





Pain after Vasectomy About 20 of every 100 men who undergo vasectomy (note, not vasectomy reversal but the original operation) develop chronic post vasectomy pain. This complication is sadly rarely mentioned when men are consented prior to surgery. Many of these men need to take analgesics to make things more comfortable and many fail to find a solution. The classical symptoms are the onset of pain after intercourse. This discomfort usually has an initial acute phase lasting for several weeks, this is often followed by several months of background ache and a pretty much permanent increase in sensitivity to trauma. The pain often re-occurs leaving some men avoiding intercourse to prevent triggering an attack. This is not quite how the procedure was meant to help with family planning! Why does it occur? The general tendency to develop aching testes after vasectomy is due to the build up of pressure in the testicle. The testes continue produce sperm and small amounts of fluid even after vasectomy, this build up of pressure is responsible for the pain. If the pressure becomes too high, often at the time of intercourse one of the tiny tubules in the epididymis can burst, this releases of sperm into the area and causes a marked reaction by the bodies immune system. It's this immune response and inflammation that causes the acute pain in the testicle and is often treated (ineffectively) with antibiotics. How can it be treated? Testicular pain, it has to be said, strikes terror into the heart of urologists. It can be very difficult to treat. Most treatments have studies which show them to be be both nearly certain cures and very probable failures. The situation for post vasectomy pain is better but still not perfect. My own approach is to use step wise management, beginning with the least invasive techniques first. Management Cascade Simple pain killers for up to 6 weeks

Neuroleptics - Amytriptaline / Gabapentin (not usually for post vasectomy patients)

Consider vasectomy reversal

Epididymectomy - removal of the epididymis

Microsurgical testicular dennervation The initial treatment is to attempt to contain the problem. A first episode of acute post vasectomy pain can simply be covered with 2-6 weeks of pain killers such as paracetamol 1g four times per day. For recurring episodes further strategies should be tried. Gabapentin works well for men with testicular pain without previous vasectomy but not so well in men who have obstructed vasa, clearly here the underlying problem is the ongoing blockage rather than a chronic pain situation. The choice is between vasectomy reversal (with its attendant risks of further pregnancy) or removal of the epididymis. Of these two procedures reversal seems to be the more likely to improve the pain. An often highly effective alternative is dennervation of the testicular cord. This is best performed microsurgically to minimise the chance of complications such as damage to the testicle. For other causes of pain and swelling check here Selected Research Papers Eur Urol. 2002 Apr;41(4):392-7 Management of chronic testalgia by microsurgical testicular denervation. Heidenreich A, Olbert P, Engelmann UH. Klinik für Urologie and Kinderurologie, Philipps-Universität Marburg, Baldingerstrasse, 35043 Marburg, Germany. heidenre@post.med.uni-marburg.de OBJECTIVES: Chronic testicular pain (CTP) is defined as uni- or bilateral, intermittent or continuous testicular discomfort of at least 3 months duration that interferes with the patient's daily activities and prompts him to seek medical advice is a rather common urological manifestation of chronic pain syndrome. Diagnosis and treatment of CTP has been a difficult and often unrewarding clinical situation. Success rates of conservative and surgical measures including epididymectomy and orchiectomy rarely exceed 55-73% and 10-40%, respectively. We report our experience on microsurgical testicular denervation as therapeutic option in CTP. PATIENTS AND METHODS: Following an extensive preoperative work-up (urine/semen cultures, transrectal ultrasound, testicular sonography, pain and orthopedic consultation) not revealing any pathologic abnormalities and a positive response to spermatic cord block, 35 patients underwent microsurgical testicular denervation. In brief, spermatic cord was dissected, vas deferens, cremasteric muscle and testicular vessels were separated. After identification of the testicular artery by application of vasodilatating agents using magnifying loops or the operating microscope, all structures besides the testicular artery, vas deferens and 1-2 lymphatic vessels were coagulated and transsected using bipolar diathermy. RESULTS: After a mean follow-up of 31.5 months 34/35 (96%) patients are completely pain-free; no intra- or postoperative complications were encountered. No case of testicular atrophy or hydrocele formation was observed during postoperative follow-up. CONCLUSIONS: Microsurgical testicular denervation results in reliable and reproducible excellent therapeutic success rates of 96% and should be integrated in the management of CTP at an early stage. High success rates require adequate and meticulous diagnostic work-up of the patients by spermatic cord block using saline as placebo and different local anaesthetics as an initial therapeutic armentarium predicting postoperative outcome. Int J Urol. 2007 Jul;14(7):622-5. Chronic orchialgia: consider gabapentin or nortriptyline before considering surgery. Sinclair AM, Miller B, Lee LK. Department of Urological Surgery, Royal Bolton Hospital, Minerva Road, Farnworth, Bolton, UK. OBJECTIVE: To establish if there is a role for gabapentin or nortriptyline in the treatment of chronic orchialgia. METHODS: Twenty-six consecutive patients with chronic orchialgia were seen in the chronic pain clinic by a multidisciplinary team. A pain questionnaire was completed prior to commencing either gabapentin or nortriptyline. They were reviewed at 3 months and a repeat questionnaire completed. A 50% improvement in pain was considered successful. RESULTS: Complete data was available for 19 patients. Overall, 61.5% of patients commenced on gabapentin and 66.6% of patients commenced on nortriptyline had a greater than 50% improvement in pain. Patients with post-vasectomy testicular pain were considered as a subgroup. None of these patients had a greater than 50% improvement in pain. However, 80% of patients in the subgroup with idiopathic chronic orchialgia had a greater than 50% improvement in pain. CONCLUSION: Although this is a small study, it appears that gabapentin and nortriptyline are effective in the treatment of idiopathic chronic orchialgia but not post-vasectomy pain.









