Post-Vasectomy Pain Syndrome (PVPS, PVP, CPTP, CPVSP) is a long-term chronic pain condition that affects between 5% to 33% of vasectomized men.[1][2][3] The pain syndrome is caused by a combination of testicular backpressure, chronic inflammation, fibrosis, sperm granulomas, nerve entrapment, and electrical activity changes in the vas deferens. When pain in the epididymides is the primary symptom, Post-Vasectomy Pain Syndrome is also known as congestive epididymitis. This pain can be present in several fashions: orchialgia (chronic testicular or scrotal pain); pain during intercourse, ejaculation or physical exertion; pain due to full or tender epididymides.
One survey found that 2.2% of vasectomized men experience pain that significantly affects quality of life and causes them to regret their vasectomy decision because of the pain.[2]
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Mechanisms of Pain
Backpressure and Distension
There is a marked increase in pressure within the vas on the testicular side following vasectomy.[4] The epididymides of vasectomized men are often swollen and distended from backpressure effects.[4] The efferent ducts and seminiferous tubules of the testes are also impacted by backpressure, leading to an increase in area and thickness.[5] The backpressure caused by blocking the vas deferens will cause what is called an "epididymal blowout" in over half of vasectomy patients.[6]. These lesions, which occur at a rate of 10% unilaterally in patients within 10 years and more likely (50%) bilaterally in patients over ten years, are benign and asymptomatic, and PVPS is more prevalent in patients who did not have these lesions ("epididymal blowouts").
Inflammation and Fibrosis
As part of the reaction of the body to the injury of vasectomy, the body produces hard scar-like tissue. Clamping the vas deferens can produce muscle disruption and fibrosis.[7] As the diameter of the vas lumen is less than the thickness of the wall, the thick muscle layers can easily become disrupted, leading to sperm accumulation and extravasation. Cysts often form from the fluid that spreads between the muscle layers.[7]
Escaping sperm and sperm granulomas
Sperm leak from the vas deferens and epididymides of vasectomized men, forming lesions in the scrotum known as sperm granulomas. Some sperm granulomas can be painful.[8] Interestingly, sperm granulomas can actually reduce the likelihood of PVPS by serving as a pressure valve.[9] The findings so far that open-ended vasectomies result 97% of the time in these lesions compared to 4% in closed vasectomies, yet open-ended vasectomies had a roughly 2% rate of PVPS compared to the 6% of closed: the early conclusion being that it is unlikely that sperm granulomas are a primary cause of PVPS.
Nerve Entrapment
Nerves can become trapped in the fibrous tissue caused by vasectomy. This pain is often heightened during intercourse and ejaculation because, with arousal and ejaculation, muscles elevate the testis. A large number of nerves that run parallel to the vas are easily cut or damaged during vasectomy.[10]
Depression
Undiagnosed depression can cause a somatization disorder that results in pain.[11]
Electrical Activity Changes
According to Ahmed Shafik of the Department of Surgery and Experimental Research, Faculty of Medicine, Cairo University, the vas deferens has two forms of electrical activity, pacesetter potentials and action potentials, and after vasectomy, while the action potentials are completely diminished, the pacesetter potentials on the testicular side exhibit an irregular rhythm, or vasoarrhythmia.[5].
Treatment
Treatment depends on the proximate cause. In one study, 9 of 13 men who underwent vasectomy reversal in an attempt to relieve the pain did indeed become pain-free.[12] Nerve entrapment is treated with surgery to free the nerve from the scar tissue, or to cut the nerve.[10] Inflammation is treated with anti-inflammatory drugs.
See also
References
- ^ Ahmed I, Rasheed S, White C, Shaikh N. "The incidence of post-vasectomy chronic testicular pain and the role of nerve stripping (denervation) of the spermatic cord in its management." British Journal of Urology. 1997; 79:269-270. PMID 9052481
- ^ a b McMahon A, Buckley J, Taylor A, Lloyd S, Deane R, Kirk D. "Chronic testicular pain following vasectomy." British Journal of Urology. 1992;69:188-191. PMID 1537032
- ^ Choe J, Kirkemo A. "Questionnaire-based outcomes study of nononcological post-vasectomy complications." The Journal of Urology. 1996; 155:1284-1286. PMID 8632554
- ^ a b Jarvis L, Dubbins P. "Changes in the epididymis after vasectomy: sonographic findings" American Journal of Roentgen. 1989;152:531-534. PMID 2644777
- ^ a b Shafik A. "Electrovasogram in normal and vasectomized men and patients with obstructive azoospermia and absent vas deferens." Archives of Andrology. 1996; 36:67-79. PMID 8824668
- ^ Christiansen C, Sandlow J (05/01/2003). "Testicular Pain Following Vasectomy: A Review of Postvasectomy Pain Syndrome". Journal of Andrology 24 (3): 293. PMID 12721203. http://www.andrologyjournal.org/cgi/content/full/24/3/293.
- ^ a b Shandling B, Janik J. "The vulnerability of the vas deferens." Journal of Pediatric Surgery. 1981;16(4):461-464. PMID 7277139
- ^ Schmidt S. "Spermatic granuloma: an often painful lesion." Fertility and Sterility. 1976;27(3):271-274. PMID 761679
- ^ Shapiro E, Silber S. "Open-ended vasectomy, sperm granuloma, and postvasectomy orchialgia." Fertility and Sterility. 1979;32(5):546-550. PMID 499585
- ^ a b Pabst R, Martin O, Lippert H. "Is the low fertility rate after vasovasostomy caused by nerve resection during vasectomy?" Fertility and Sterility. 1979;31(3):316-320. PMID 437166
- ^ "Vasectomy - Post Vasectomy Pain Syndrome". http://www.vasectomymedical.com/vasectomy-post-pain.html. Retrieved 2008-06-20.
- ^ Nangia AK, Myles JL, Thomas AJ JR (December 2000). "Vasectomy reversal for the post-vasectomy pain syndrome: a clinical and histological evaluation". J. Urol. 164 (6): 1939–42. doi:. PMID 11061886.
External links
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