Webmaster's note:- This literature review was written by two researchers from the Netherlands as a commissioned article for a website that is no longer in existence. The article was last updated on January 16, 1998. The original text is on this site as public domain information on the grounds that this article has been/is the source of general comments widely available on the web such as "The Dutch study", "Research from Holland" etc. As webmaster, I feel that people may wish to read the original source of these comments and references.
It should be noted that this is NOT research on men in the Netherlands - it is a literature review of predominantly US research by two men who happen to live in the Netherlands.
It should also be noted that the reviewers comments in the Conclusions section on the incidence of PVP in Dutch men is NOT a finding of any research, but an mathematical extrapolation of a US study4 that had a response rate of 42%, and a final sample size of 182 men.
This article is now considerably out of date. There are other much more recent review articles available in the medical journals section of this website, along with the research they are based on.
Introduction
In the Netherlands over 700.000 men
underwent vasectomy. Short term complications comprise hematomas
and wound infections. Long term effects have been analyzed in
several studies. In particular complaints varying from scrotal
discomfort during intercourse to continuous scrotal pain are
still ill understood. Here the literature on this problem is
reviewed and suggestions for treatment and patient information
are given.
Incidence
Several studies report on the incidence of
post-vasectomy scrotal pain and different names for these pain
complaints were mentioned. Dependent on the way of documentation
and patient population, recurrence rates vary from 0.9% in a
cohort of 10590 men studied by Massey et al (1984)1
within one year after vasectomy up to 54% in a group of patients
with post-vasectomy scrotal granuloma2. McMahon et al
(1992)3 reported on questionnaire evaluation of 172
men 4 years after vasectomy. Chronic testicular discomfort was
present in 56 (33%) patients. Twenty-six patients (15%)
experienced their complaints troublesome. In this series 9
patients (5%) sought further medical consultation3.
Choe and Kirkema (1996)4 recently reported on the
outcome after vasectomy with a mean follow up of 4.8 years.
Unfortunately, a response rate of only 42.3% to a mailed
questionnaire was obtained. Chronic scrotal pain was reported by
34 of 182 responding patients (18.7%). Occasional, not
troublesome discomfort was found in 24 (70.6%) whereas minor
nuisance and more severe pain effecting quality of life were
found in 17.6% and 11.8% respectively. The majority of patients
complain of unilateral pain3,5,6, but up to 50%
bilateral complaints were reported by Chen and Ball
(1991)7. The time interval between vasectomy and
chronic scrotal pain ranges largely. In the study by Chen and
Ball (1991)7 the interval of patients surgically
treated for the complaint ranged from 2 months to 20
years.
Causes
Chen and Ball (1991)7
distinguished two differented causes of post vasectomy pain.
First, obstruction of the efferent epididymal duct system
resulting in dilatation of the caput epididymis and interstitial
fibrosis5. This event takes place mainly in the first
year following vasectomy as confirmed by serial ultrasonographic
evaluation8. A second cause may be perineural
inflammation. This predominantly occurs at the proximal
transsected vas or at the cauda of the ruptured cauda epididymis
due to leakage of spermatozoa in the surrounding tissue. At
histological evaluation Chen and Ball (1991)7 found
neural entrapment in a fibrotic sheath and lymphocytic
infiltration around the nerves reflecting a chronic inflammation.
McMahon et al (1992)3 found no correlation between
early postoperative complications such as infection or hematoma
and chronic pain complaints. Sperm granulomas, however, a
frequent finding after vasectomy were associated with pain
complaints in 54% of patients2. Schmidt
(1985)2 postulated that sperm granulomas, associated
with chronic inflammatory reaction may be causing chronic pain
complaints. However, several studies propagate non-ligation of
the epididymal side of the vas deferens stimulating sperm
granuloma formation and thereby decreasing pressure buildup in
the epididymis9, 10. Shapiro and Silber
(1979)6 found in a prospective study less epididymal
pain after an "open-end" vasectomy. Similar results were obtained
by Moss (1992)11 who performed over 3000 closed- and
open-ended vasectomies and found significant difference in
post-vasectomy pain respectively (6% and 2%). That method of
surgery does play a role in post-vasectomy pain was also
suggested by the studies conducted by Schmidt and Free
(1979)12. They found congestive epididymitis rates of
5.6%, 3.8%, and 2.8% for ligation, bipolar and monopolar
cauterization of the vasal ends respectively12.
Whether the no-scapel method of vasectomy will result in less
chronic pain remains to be
established13.
Diagnosis
A constant pain was reported in 9 of 10
patients in a study by Chen and Ball (1991)7. The
majority of pain complaints were located to the epididymis
7. Pain is often exacerbated during intercourse and
ejaculation2, 3.
Treatment
Initially conservative measures should be
considered. Reassurance forms an important element. In particular
scrotal pain during intercourse and ejaculation can be bothersome
to the patient. Antibiotics should be applied in case of
bacterial infection, manifested in hyperaemia, fever, and extreme
local tenderness. Intermittent use of pain medication or NSAIDs
may be considered when pain is occurring only incidently. Local
anesthesia infiltration have been applied
successfully14. Surgical treatment should only be
considered in pain resistent to conservative measures.
Epididymectomy only effective in approximately half the patients
7. It was suggested that due to the fact that the
perineural chronic inflammation remains when only the epididymis
is removed, proper treatment should be to resect both epididymis
and the tissue surrounding the original vasectomy region5,
7. Even complete resection appeared not to be sufficient
for pain relief in the study of Chen and Ball (1991)7.
They offered orchiectomy to 5 of 10 patients with unsuccessful
surgical treatment of post vasectomy pain. From their data,
success rates of this radical treatment option were not
mentioned.
Conclusions
In the Dutch population 700.000 males are
vasectomized over the past years. Considering chronic scrotal
pain to be present in up to 10% of these patients the prevalence
of the syndrome would be approximately 1% of the male Dutch
population. Since the major reason for dissatisfaction after
vasectomy was reported to be chronic pain4,
pre-vasectomy counselling of the patient on this problem should
take place.
References
[1]. Massey FJ, Bernstein GS, O'Fallon
WM, Schuman LM, Coulson AH, Crozier R, Mandel JS, Benjamin RB,
Berendes HW, Chang PC, Detels R, Emslander RF, Korelitz J,
Kurland LT, Lepow IH, McGregor DD, Nakamura RN, Quiroga J,
Schmidt S, Spivey GH, Sullivan T: Vasectomy and health: results
from a large cohort study. JAMA 252:1023, 1984.
[2]. Schmidt SS: Spermatic granuloma: an often painful lesion.
Fertil Steril 31:178, 1985.
[3]. McMahon AJ, Buckley J, Taylor A, Lloyd SN, Deane RF, Kirk D:
Chronic testicular pain following vasectomy. Br J Urol 69:188,
1992.
[4]. Choe JM, Kirkemo AK: Questionnaire-based outcomes study of
nononcological postvasectomy complications. J Urol 155:1284,
1996.
[5]. Selikowitz SM, Schned AR: A late post-vasectomy syndrome. J
Urol 134:494, 1985.
[6]. Shapiro EI, Silber SJ: Open-ended vasectomy, sperm
granuloma, and postvasectomy orchialgia. Fertil Steril 32:546,
1979.
[7]. Chen TF, Ball RY: Epididymectomy for post-vasectomy pain:
histological review. Br J Urol 68:407, 1991.
[8]. Jarvis LJ, Dubbins PA: Changes in the epididymis after
vasectomy: sonographic findings. Am J Roentgenol 152:531,
1989.
[9]. Denniston GC, Kuehl L: Open-ended vasectomy: approaching the
ideal technique. J Am Board Fam Pract 7:285, 1994.
[10]. Schmidt SS: Vasectomy by section, luminal fulguration and
fascial interposition: results from 6248 cases. Br J Urol 76:373,
1995.
[11]. Moss WM: A comparison of open-end versus closed-end
vasectomies: a report on 6220 cases. Contraception 46: 521,
1992.
[12]. Schmidt SS, Free MJ: The bipolar needle for vasectomy. 1.
experience with the first 1000 cases. Fertil Steril 29:676,
1979.
[13]. Liu X, Li S: Vasal sterilization in China. Contraception
48:255, 1993.
[14]. Paxton LD, Huss BK, Loughlin V, Mirakhur RK: Intra-vas
deferens bupivacaine for prevention of acute pain and chronic
discomfort after vasectomy. Br J Anaesth 74: 612, 1995.
[15]. McCormack M, Lapointe S: Physiological consequences and
complications of vasectomy. Can Med Assoc J 138: 223,
1988.