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Chronic scrotal pain after vasectomy is possibly the most troublesome and vexing complication of vasectomy. Chronic pain has no association with immediate postoperative complications such as infection, or hematoma . Chronic scrotal pain, also known as post vasectomy pain syndrome, can persist for months to years, and is defined as constant or intermittent testicular pain for 3 months or longer with a severity that interferes with daily activities prompting the patient to seek medical attention . The pathophysiology leading to post vasectomy pain is unclear, and felt to be potentially related to inflammation resulting in damage and fibrosis of spermatic cord nerves . While 1–2% of patients after vasectomy experience this complication, conservative management with NSAIDS and scrotal support help avoid need for more invasive interventions. The majority of men with post vasectomy scrotal pain can be managed conservatively .

However, men with pain refractory to conservative measures may potentially benefit from surgical intervention. When pain is localized to the site of a sperm granuloma, excision of the granuloma can relieve pain and prevent recurrence . Men who experience pain with ejaculation can be offered vasectomy reversal, with upwards of 84% experiencing improvement after vasovasostomy . Conversely, if these patients desire to maintain surgical sterility, epididymectomy can be performed with good results . In patients with chronic pain not clearly confined to epididymis or granuloma, microsurgical spermatic cord denervation can be considered. These men, who previously experienced temporary pain relief from a spermatic cord block and subsequently undergo microsurgical cord denervation, experience complete pain relief in 76% of cases, and significant improvement in an additional 9% . Men who experience continued pain despite surgical measures may be best managed with referral to pain clinic for additional pain management instruction. Lastly, in men with chronic pain who fail to respond to surgical and medical intervention, inguinal orchiectomy may be required. Unfortunately, pain relief is not guaranteed, with 27% reported to have continued pain post-orchiectomy , and should only be considered as a last resort for refractory post vasectomy pain. It is the authors’ experience that much of the chronic pain is due to inflammation. Therefore, we have found it useful to have patients wear scrotal support or compression shorts for 1–2 weeks following the procedure in order to minimize pulling of the spermatic cord. This appears to have lessened the number of calls and postoperative visits. We have also stressed the need for no heavy lifting for the first 5–7 days in order to reduce the likelihood of scrotal hematoma. While this still occurs infrequently, most are small hematomas secondary to the administration of local anesthesia (rather than capillary oozing), and can be managed conservatively.