Since the late 1970s the definition and etiology of chronic testicular pain following vasectomy has been evolving, as have the names for this syndrome, including postvasectomy orchalgia (Shapiro and Silber, 1979), late postvasectomy syndrome (Selikowitz and Schned, 1985), congestive epididymitis (Schmidt and Free, 1978), chronic testicular pain (McMahon et al, 1992), and postvasectomy pain syndrome (McCormack and LaPointe, 1988). Today, the syndrome is generally recognized by the term postvasectomy pain syndrome (PVPS). Although the mechanism has not been proven, a number of studies have shown changes in the histology of the epididymis and the testis following vasectomy. Patients with PVPS generally present with orchalgia; pain with intercourse, ejaculation, or both; pain with physical exertion; and tender or full epididymides (Nangia et al, 2000). The theory that these symptoms are caused by infection has long since been discarded, due to the lack of response to antibiotics in these patients and absence of acute infection when epididymal and vasal sections are removed during surgery and analyzed histologically (Selikowitz and Schned, 1985; Chen and Ball, 1991). Instead, histologic studies of samples collected during vasovasostomy or epididymectomy have demonstrated a chronic inflammatory process that begins to explain the development of PVPS. (Journal of Andrology, Vol. 24, No. 3, May/June 2003)
“Post-vasectomy pain syndrome is a chronic pain syndrome that follows vasectomy. The cause of this syndrome and its incidence are unclear. It is generally treated with anti-inflammatory agents. Occasionally, patients will elect to undergo vasectomy reversal in an attempt to alleviate this syndrome. Unfortunately, the response to surgical intervention is unpredictable.” The AUA vasecomy information page goes on to say that ejaculation and orgasm are not affected by vasectomy with this caveat, “The only exception to this is the occasional patient who has developed post-vasectomy pain syndrome.”
The incidence of post-vasectomy pain can be estimated, the symptoms are well described by affected patients and in the medical literature, and there are effective treatments. Chronic genital pain that affects sexual function and quality of life is a catastrophic outcome for the affected men. Information on this issue should be presented at the time of vasectomy. Acute post-vasectomy problems with bleeding or infection have an incidence of approximately 2 to 5%. The incidence of chronic pain that can affect sexual enjoyment or function is also around 2 to 5%. This information is not always listed on the consent forms for vasectomy and may not be covered by the physician. There are many different vasectomy techniques, but the "no scalpel", "open" technique seems to yield lower rates of congestive epididymitis (though any vasectomy technique carries a risk of chronic testicular pain).
What I wish my surgeon had said before the procedure: "Besides the acute post-operative pain, swelling, and bruising that we have spoken about, which most men find are very time-limited, fairly trivial, and manageable with ice and Tylenol, I need to tell you about the risk of chronic testicular or epididymal pain after vasectomy. It may be as high as twenty percent or as low as 1 to 2%. Some men find it “troubling”, while others find it to be a “nuisance”. A small percentage of men develop severe pain and find it affects their quality of life or causes pain during sex or diminishes the sensation of orgasm or pleasure from sex. Between 1 in 30 and 1 in 60 men regret having the vasectomy due to chronic genital pain. If you end up in this latter group, your treatment options will include warm soaks, Motrin, and time. If it does not resolve, you may need a vasectomy reversal and it may not be covered by insurance and could cost $4000 to $12,000. You have an approximate 70% chance of responding to the reversal. Of course if you have a reversal, you will likely be fertile again. If the reversal is ineffective, you might have to consider further surgery that could include removal of your epididymus (a mushy organ connected to the testicle) or removal of the testicle itself. Now, step through here and we will get you ready for your procedure…
The problems with being told this are below:
1)The information would be hard to agree on as it varies widely from study to study and 2) some men would change their mind after reading this info and walk out of the appointment or cancel the planned procedure. 3) Some surgeons have better outcomes than others, perhaps due to experience or skill. They would likely object to using worldwide statistics for outcomes. Clearly, they could use their own, if they knew them, but follow-up after vasectomy is frequently poor. Many men suffer in silence and fear further surgery. Nonetheless, statistics aside, this statement or another with similar intent should be included on all vasectomy consent forms with the statistics reflected in the medical literature or those consistent with the surgeon’s own practice at the very least. This is currently not required in the United States. Any practitioner can use any consent form he or she wishes to augment the usual pre-operative counseling that should precede all vasectomies.
I know there are those out there that have had a vasectomy and did not have chronic pain, sexual problems, or regrets. Over 70% of men have none of these issues. In fact, some surveys list 90% satisfaction rates. Please don't email me with success stories. I am trying to help the smaller group who developed problems or reach others before they decide to make sure their eyes are open prior to the procedure.
It should be obvious from the content of this post that I am anti-vasectomy. I consider it an intellectually flawed procedure with an unacceptable long-term complication rate, primarily chronic pain. It is an elective procedure that leaves 15% of patients with chronic genital pain. This information should be made available to vasectomy candidates before their procedure and should require the signing of a chronic pain disclaimer as part of the pre-operative counseling for vasectomy. The long term implications of compromising the blood testes barrier and the subsequent development of anti-sperm antibodies are also largely unknown.