An overview of the management of post-vasectomy pain syndrome

Post-vasectomy pain syndrome remains one of the more challenging urological problems to manage. This can be a frustrating process for both the patient and clinician as there is no well-recognized diagnostic regimen or reliable effective treatment. Many of these patients will end up seeing physicians across many disciplines, further frustrating them. The etiology of post-vasectomy pain syndrome is not clearly delineated. Postulations include damage to the scrotal and spermatic cord nerve structures via inflammatory effects of the immune system, back pressure effects in the obstructed vas and epididymis, vascular stasis, nerve impingement, or perineural fibrosis. Post-vasectomy pain syndrome is defined as at least 3 months of chronic or intermittent scrotal content pain. This article reviews the current understanding of post-vasectomy pain syndrome, theories behind its pathophysiology, evaluation pathways, and treatment options.

Perceived Interest in Vasectomy among Latina Women and their Partners in a Community with Limited Access to Female Sterilization

The low prevalence of vasectomy among Latino men in the United States is often attributed to cultural characteristics despite limited evidence supporting this hypothesis. We assessed male partners' perceived willingness to undergo vasectomy through surveys with 470 Mexican-origin women who did not want more children in El Paso, Texas. Overall, 32% of women reported that their partner would be interested in getting a vasectomy. In multivariable analysis, completing high school (OR=2.03 [1.05, 3.95]), having some college education (OR=2.97 [1.36, 6.48]) or receiving US government assistance (OR=1.95 [1.1, 3.45]) was associated with partners' perceived interest. Additionally, we conducted two focus groups on men's knowledge and attitudes about vasectomy with partners of a subsample of these women. Despite some misperceptions, male partners were willing to get a vasectomy, but were concerned about cost and taking time off work to recover. Health education and affordable vasectomy services could increase vasectomy use among Mexican-origin men.

Male contraception: a clinically-oriented review

Despite the variety of available female contraceptive methods, many pregnancies (~50%) are still undesired. Many men (>60%) want to participate equally with their partner in family planning; however, male contraceptive methods (MCMs) account for only 14% of those used worldwide and no pharmaceutical MCM is available so far. The only two MCMs currently available are condoms, which despite protecting against sexually transmitted diseases have high failure rates (~19%), and vasectomy, which though very efficient (99%) is poorly reversible (<50%). Among MCMs under investigation, male hormonal contraceptives (MHCs) are those that have come closest to commercialization. The action of MHCs relies on the disruption of spermatogenesis that exogenous androgen administration evokes by suppressing the hypophyseal-gonadal axis. Various regimens of androgens as monotherapy or in combination with progestins have been tested in clinical trials achieving a Pearl Index <1.0 (equal to that of the female oral contraceptive pill); however, concerns regarding the variable response rates observed (non-responders: 5-20%), the impracticality of parenteral administration and long-term prostate-associated or cardiovascular morbidity have deflected the interest of the pharmaceutical industry from further research. Non-hormonal contraception methods may be, at least theoretically, more specific by selectively disrupting spermatogenesis and sperm transport or fertilizing ability. Nevertheless, only a few have been tested in clinical trials (Reversible Inhibition of Sperm Under Guidance, RISUG, and Intra Vas Plugs); most of them are still in pre-clinical development or have been abandoned due to toxicity (gossypol). Consequently, until a reliable, safe and practical MCM is developed, women will continue to bear most of the contraception burden.

[Dynamic changes of the epididymal size after vasectomy: An ultrasonographic observation]

OBJECTIVE

To investigate the dynamic changes of the epididymal size 1 year after vasectomy.

METHODS

Fifty male volunteers received vasoligation. Before and at 1, 2, 3, 6, and 12 months after operation, we measured the size and detected the internal echoes of the epididymis using color Doppler ultrasonography.

RESULTS

The bilateral epididymides were both thickened post-operatively in all the 50 cases, with statistically significant differences between the baseline and the 1st month, the 1st and the 2nd month, the 2nd and the 3rd month, or the 3rd and the 6th month after surgery (all P < 0.01), but not between the 6th and the 12th month (P > 0.05).

CONCLUSION

Within 6 months after vasectomy, the bilateral epididymides manifested a progressive thickening, but basically restored their balance of secretion-absorption after 6 months.

Brdt Bromodomains Inhibitors and Other Modern Means of Male Contraception

Compared to efficient and secure female contraception, a vasectomy and condoms are the only options for men. The choice of male contraceptive methods is limited, so contraception mainly rests on the shoulders of women. Several concepts are considered: testosterone administration--inhibiting pituitary secretion of lutropin (LH) and follicle stimulating hormone (FSH), progestogen--affecting the secretion of gonadotropin and gonadoliberin (GnRH) antagonists. New potential targets for non-hormonal male contraception were discovered: glyceraldehyde-3-phosphate-dehydrogenase (GAPDHS)--specific to male germ cells and voltage-gated cation channel (CatSper). Both are responsible for sperm motility. Drugs such as thioridazine used in schizophrenia treatment and phenoxybenzamine (antihypertensive activity) exhibit a contraceptive effect. Similar action exhibits an analogue of lonidamine--adjudin and an antagonist of retinoic acid receptors (BMS-189453). Researchers are working on a contraceptive vaccine, whose active ingredient is epididymal protease inhibitor (Eppin). Another promising method acts by blocking Bromodomain testis-specific proteins (Brdt) involved in the process of spermatogenesis. JQ1-the Brdt inhibitor causes reversible infertility without affecting the endocrine signaling pathways. A recent discovery of Juno as the binding partner for Izumo1 identifies these proteins as the cell-surface receptor pair, essential for gamete recognition and this interaction can be inhibited by an anti-Juno monoclonal antibody. Our review shows that the situation of men can change and investigators are close to the optimal solution. In the near future men will be able to choose the best contraceptive suited to their needs.

Scrotal pain: evaluation and management

Scrotal pain is a common complaint in a urological practice. Its diagnosis can prove challenging in both acute and chronic forms and requires a thorough and complete history and physical examination. This article discusses the evaluation and management of several entities of scrotal pain, including testicular torsion, epididymitis, postvasectomy pain, varicocele, and chronic orchialgia.

What's a Guy To Do?: Contraceptive Responsibility, Confronting Masculinity, and the History of Vasectomy in Canada

Despite the growing popularity of vasectomy in recent years, historians have largely ignored the history of the procedure. The current article provides a preliminary examination of voluntary male sterilization in Canada and, in so doing, challenges the gendered paradigm scholars have often applied to the history of contraception. State-sponsored Medicare and late decriminalization of contraception are discussed as factors that slowed widespread adoption of vasectomy in Canada while evolving surgical techniques are highlighted for their role in increasing acceptability of the procedure. The article explores how evolving definitions of hegemonic masculinity have both hindered and encouraged acceptance of vasectomy over time.

Comparative effects of vasectomy surgery and buprenorphine treatment on faecal corticosterone concentrations and behaviour assessed by manual and automated analysis methods in C57 and C3H mice

Establishing effective cage-side pain assessment methods is essential if post-surgical pain is to be controlled effectively in laboratory animals. Changes to overall activity levels are the most common methods of assessment, but may not be the most appropriate for establishing the analgesic properties of drugs, especially in mice, due their high activity levels. Use of drugs that can affect activity (e.g. opioids) is also a problem. The relative merits of both manual and automated behaviour data collection methods was determined in two inbred mouse strains undergoing vasectomy following treatment with one of 2 buprenorphine dose rates. Body weights and the effects of surgery and buprenorphine on faecal corticosterone were also measured.

Surgery caused abnormal behaviour and reduced activity levels, but high dose buprenorphine caused such large-scale increases in activity in controls that we could not establish analgesic effects in surgery groups. Only pain-specific behaviour scoring using the manual approach was effective in showing 0.05 mg/kg buprenorphine alleviated post-vasectomy pain. The C57 mice also responded better to buprenorphine than C3H mice, indicating they were either less painful, or more responsive to its analgesic effects. C3H mice were more susceptible to the confounding effects of buprenorphine irrespective of whether data were collected manually or via the automated approach. Faecal corticosterone levels, although variable, were higher in untreated surgery mice than in control groups, also indicating the presence of pain or distress.

Pain-specific scoring was superior to activity monitoring for assessing the analgesic properties of buprenorphine in vasectomised mice. Buprenorphine (0.01 mg/kg), in these strains of male mice, for this procedure, provided inadequate analgesia and although 0.05 mg/kg was more effective, not completely so. The findings support the recommendation that analgesic dose rates should be adjusted in relation to the potential severity of the surgical procedure, the mouse strain, and the individual animals' response.

[Efficacy of microsurgical vasectomy reversal on patients after vasectomy]

OBJECTIVE

To evaluate the efficacy of microsurgical vasectomy reversal on patients after vasectomy.

METHODS

In the study, 41 patients after vasectomy were admitted for microsurgical vasectomy reversal. The mean (range) age was 45 (29 to 66) years for the men. The mean duration of obstruction was 12 years. All the patients were seen by the surgeon for a complete history and physical examination. Semen analyses proved azoopermia, and their serum levels of sexual hormone were normal. They were all offered scrotal exploration. Microvasovasostomy was performed if the sperm was found in the material coming from the proximal vas lumen. The decision for microvasoepididymostomy was made during surgery, if the fluid was creamy, containing only debris or there was no fluid whatsoever when the vas was milked toward the cut end. Microvasovasostomy was performed in 40 patients, of whom 6 were with lateral microvasoepididymostomy and 1 with bilateral microvasoepididymostomy. The initial semen analysis was then done after usually 3 months postoperatively. Patency was arbitrarily defined as>10 000 sperm/mL in ejaculate in at least one semen analysis after surgery. Postoperative patency rate and postoperative impregnation rate were followed.

RESULTS

The 41 patients were followed up for 3 to 72 months, and 5 cases were lost. In the 28 patients who had obstructions for less than 15 years, 3 were lost. Sperm was found by semen analysis in 21 patients. Their sperm density was 2×10(6) to 46×10(6) sperms/mL and motility was 0% to 60%. The semen analysis revealed azoospermia in 2 patients after 12 months, who were advised to undergo intracytoplasmic sperm injection. Natural conception occurred in 6 patients followed for more than 12 months. The overall patency rate was 84% (21/25). Among the patients with a follow-up of >6 months, the natural paternity rate was 29% (6/21). In the 13 patients who had obstructions for more than 15 years, 2 were lost. The patency and pregnancy rates were 64% (7/11) and 14% (1/7) respectively. Their sperm density was 0.02×10(6) to 30× 10(6) sperms/mL and motility was 0% to 43%.

CONCLUSION

Microsurgical vasectomy reversal is an effective method to treat vasal obstruction due to vasectomy. The patency and pregnancy rates are related to the time of vasectomy. The patency and pregnancy rates are higher in patients with obstruction for less than 15 years than those for more than 15 years.

[Long-term effect and safety of non-occlusive intra-vas device for male contraception]

OBJECTIVE

To assess the long-term effect and safety of non-occlusive intra-vas device (IVD) for male contraception in comparison with no-scalpel vasectomy (NSV).

METHODS

We conducted a follow-up investigation on 100 males who had received IVD and another 50 who had undergone NSV 6 years before. We compared the rates of sperm absence and complications between the two groups.

RESULTS

Follow-up visits were successfully performed on 95 males (95%) of the IVD group and 44 (88%) of the NSV group. Pregnancy was not found in any of the cases. Spermatozoa (> or = 5 x 10(6)/ml) were not detected in 87 cases (91.58%) in the IVD group and in 44 cases (95.45%) in the NSV group, with no significant differences between the two groups (P > 0.05). The rate of postoperative complications in the IVD group (11.58%) showed no significant difference from that of the NSV group (4.55%) (P > 0.05).

CONCLUSION

IVD is as effective and safe as NSV for male contraception.

Effect of Vasectomy on Sperm Nuclear Chromatin Condensation in the Rabbit

Histone-to-protamine exchange in haploid spermatids is known to play a central role for male fertility. The present study investigates, for the first time, the effects of vasectomy on the expression of protamines in the rabbit. During normal spermatogenesis, protamine-1 and protamine-2 mRNA were expressed from step 5 round spermatids to step 11 elongated spermatids. In unilaterally vasectomized animals, control testes revealed normal spermatogenesis with normal protamine expression, while vasectomized testes exhibited both normal spermatogenesis and spermatogenic arrest. Some testes with normal spermatogenesis revealed delayed expression of both protamine-1 and protamine-2. Furthermore, multinucleated round spermatids were a regular finding in these testes. In both treated and untreated animals, a higher percentage of spermatozoa from the cauda epididymis had highly condensed chromatin when compared with those from the testis. The percentage of spermatozoa with highly condensed chromatin from testes and epididymides from the vasectomized side of treated animals remained unchanged from controls. As the integrity of nuclear chromatin is important for oocyte fertilization, especially in intracytoplasmic sperm injection (ICSI), where most of the natural selection mechanisms are bypassed, our data add valuable information for the treatment of infertility by ICSI, showing that vasectomy may affect nuclear chromatin integrity of testicular spermatids but not epididymal spermatozoa. Microsurgical epididymal sperm aspiration (MESA), therefore, may be superior to testicular sperm extraction (TESE) in vasectomized patients.

Vasectomy Influences Expression of HE1 but not HE2 and HE5 Genes in Human Epididymis

Epididymal roles include protection and transport, maturation, and storage of the sperm cells. It is known that these functions are altered under vasectomy, but the consequences of excurrent duct obstruction on the pattern of gene expression along the human epididymis are poorly documented. In order to understand how excurrent duct occlusion affects different epididymal regions, the expression pattern of genes known to be expressed in specific epididymal segments was investigated along the epididymides of vasectomized men. Selected human epididymal complementary DNAs (cDNAs) identified by differential library screening were studied because of their unique messenger RNA (mRNA) distribution along the different epididymal segments. In situ hybridization as well as immunohistologic studies were undertaken to investigate the effect of vasectomy on a gene expressed all along the epididymis (HE1) or more selectively in the proximal (HE2) or distal (HE5) segment. The HE1 transcript was affected by the obstruction of the epididymis with little or no mRNA detectable along the epididymis. The HE1-related antigen was shown by immunohistochemical methods to be reduced within the epithelium of the epididymis of vasectomized men. By contrast, HE5 mRNA and protein, expressed in epithelial cells of the distal epididymis, were not affected by the obstruction of the vas deferens. Similarly, HE2 transcriptional and translational products normally expressed in the caput epididymidis were not affected by vasectomy. These results show that excurrent duct obstruction differentially affects the expression pattern of some specific transcripts and their encoded proteins, probably impairing their fundamental roles in the physiology of the epididymis.

The Ratio of Second to Fourth Digit Length in Azoospermic Males Undergoing Surgical Sperm Retrieval: Predictive Value for Sperm Retrieval and on Subsequent Fertilization and Pregnancy Rates in IVF/ICSI Cycles

The differentiation of the urogenital system and the appendicular skeleton in vertebrates is under the control of Homeobox (Hox) genes. It has been shown that this common control of digit and gonad differentiation has connected the pattern of digit formation to spermatogenesis and prenatal hormone concentrations in males. We wished to establish whether digit patterns, particularly the ratio between the lengths of the second and fourth digit in males (2D : 4D), was related to spermatogenesis and, more specifically, the presence of spermatozoa in testicular biopsies from azoospermic men undergoing surgical sperm retrieval. Forty-four men were recruited, of whom 16 were diagnosed with nonobstructive azoospermia and 4 with congenital bilateral absence of the vas deferens, and 24 previously fertile men were azoospermic after previous vasectomy. Our results show that men with previous fertility or of an acquired form of azoospermia had significantly lower 2D : 4D ratios than men with nonobstructive azoospermia. In nonobstructive azoospermia, there was a significantly lower 2D : 4D ratio on the left side in men who had successful retrieval than those with unsuccessful retrieval. For these men who had a successful retrieval, none had a 2D : 4D ratio more than 1 on the left side, whereas 4 of 7 men in whom sperm was not found had a 2D : 4D ratio greater than 1. On successful sperm retrieval, subsequent fertilization and clinical pregnancy rates were unaffected by 2D : 4D ratios.

[Perspectives of male contraception]

The principle of suppressive methods of male contraception is to repress the sperm production and its functions by hormonal, chemical, physical, immunological or other ways. Of hormonal methods, the most perspective seems to be the steroid blockade of spermatogenesis. In horizon of ten years, it might be expected that the first male hormonal contraception will be available in form of injections or implants, however the "male pill" will not become a reality in the near future. Blockade of calcium channels by means of pharmacological inhibitors seems to be another promising mechanism of sperm functions inhibition. Based on the results of research of last two decades, the method of "reversible vasectomy" might be accessible, too.

[Pregnancy by a man with severe oligospermia after vasectomy: a case report]

OBJECTIVE

To analyze the risk of pregnancy in the woman whose husband has severe oligospermia after vasectomy.

METHODS

A woman was found pregnant, whose husband, a 35-year-old man, had received vasectomy two years before. Two seminal examinations at the interval of 7 days showed the total number of motile sperm to be 0.047 x 10(6) and 0.044 x 10(6), respectively. DNA analysis after miscarriage exhibited a 99.9996% relative chance paternity (RCP).

RESULTS

DNA analysis proved the biological paternity of the man with severe oligospermia after vasectomy.

CONCLUSION

A man with severe oligospermia after vasectomy could make his wife pregnant.

Morphological alterations and distribution of occludin in rat testes after bilateral vasectomy

The aim of study was to investigate the fate and the morphology of the cells which constitute the spermatogenic line, and to determine the distribution of occludin in the testis in adult vasectomized Wistar rats. The rats were divided into two groups: control group (sham-operated) and vasectomized group. One, 3 and 6 months after sham and vasectomy operations, testis samples were examined. The weight of the testes was found to be reduced 3 and 6 months after vasectomy. There was vacuolization in the seminiferous tubules one month after vasectomy. The tubules showed severe atrophy 3 and 6 months after vasectomy. The occludin immunolabeling in the 3- and 6-month groups was weak and diffuse, and the density of the protein was found to be decreased. The increase in the number of apoptotic cells was accompanied by a time-dependent decrease in the number of haploid, diploid and tetraploid cells. This study demonstrated that vasectomy causes degeneration in the seminiferous tubules with alterations in occludin distribution with a decrease in the number of spermatogenic cells. Moreover, these alterations increase in a time-dependent manner.

The assessment of post-vasectomy pain in mice using behaviour and the Mouse Grimace Scale

BACKGROUND

Current behaviour-based pain assessments for laboratory rodents have significant limitations. Assessment of facial expression changes, as a novel means of pain scoring, may overcome some of these limitations. The Mouse Grimace Scale appears to offer a means of assessing post-operative pain in mice that is as effective as manual behavioural-based scoring, without the limitations of such schemes. Effective assessment of post-operative pain is not only critical for animal welfare, but also the validity of science using animal models.

METHODOLOGY/PRINCIPAL FINDINGS

This study compared changes in behaviour assessed using both an automated system ("HomeCageScan") and using manual analysis with changes in facial expressions assessed using the Mouse Grimace Scale (MGS). Mice (n = 6/group) were assessed before and after surgery (scrotal approach vasectomy) and either received saline, meloxicam or bupivacaine. Both the MGS and manual scoring of pain behaviours identified clear differences between the pre and post surgery periods and between those animals receiving analgesia (20 mg/kg meloxicam or 5 mg/kg bupivacaine) or saline post-operatively. Both of these assessments were highly correlated with those showing high MGS scores also exhibiting high frequencies of pain behaviours. Automated behavioural analysis in contrast was only able to detect differences between the pre and post surgery periods.

CONCLUSIONS

In conclusion, both the Mouse Grimace Scale and manual scoring of pain behaviours are assessing the presence of post-surgical pain, whereas automated behavioural analysis could be detecting surgical stress and/or post-surgical pain. This study suggests that the Mouse Grimace Scale could prove to be a quick and easy means of assessing post-surgical pain, and the efficacy of analgesic treatment in mice that overcomes some of the limitations of behaviour-based assessment schemes.

Ultrasound diagnosis of three cases of Mondor's disease

OBJECTIVE

To describe clinical features and ultrasound findings of three cases of a little-known and relatively infrequent entity in daily clinical activity, which is often unnoticed and under-reported: penile Mondor's disease or superficial penile veins thrombophlebitis.

METHODS

We are reporting the cases of three patients aged 33, 25 and 39 years who were referred to our department, the first case with suspicion of inguinal hernia, the second one to rule out testicular pathology because of pubic and perineal discomfort, and the third one for painful induration of the dorsal region of the penis. The three patients underwent Doppler-ultrasound examination (Toshiba®, using a 13-18MHz linear transducer) to establish definitive diagnosis, and had a favorable evolution with conservative management.

RESULTS

Ultrasound examination revealed: Case 1. Penile superficial dorsal vein and lateral superficial veins thrombosis. Case 2. Thrombosis of the right branch of the superficial dorsal vein and its perineal distal connections. Case 3. Penile superficial dorsal vein thrombosis. Definitive diagnosis of the three cases was Mondor's disease.

CONCLUSIONS

Mondor's disease is an often under-reported entity in daily clinical activity. Doppler-ultrasound findings (echogenic material within veins, lack of any response after compression by the transducer and absence of color flow) confirm de diagnosis. This disease has a favorable evolution and functional prognosis. Knowledge of Mondor's disease by echographists is basic to avoid false-negative results in radiologic examination.

Gene expression in the epididymis of normal and vasectomized men: what can we learn about human sperm maturation?

Anatomically, the human epididymis is unusual when compared with the excurrent duct of other eutherian mammals. Furthermore, clinical observations suggest that it may not be as important for sperm maturation as is the case for laboratory animals. In contrast, hierarchical clustering of microarray data of epididymides from normal men revealed 2274 modulated qualifiers between the epididymal segments, 1184, 713, and 269 of them being highly expressed in the caput, corpus, and cauda, respectively. The organization of qualifiers according to their similarities by gene ontology indicated that caput transcripts are dedicated to cell-cell adhesion, whereas the corpus is characterized by genes involved in response to other organisms (ie, defense mechanisms) and the cauda transcriptome is specialized in muscle contraction and establishment of localization. A region-specific gene expression pattern thus characterizes the human epididymis as in animal models. In humans, vasectomies have consequences on the epididymal transcriptome. Cluster analysis revealed that 1363 genes are expressed in both normal and vasectomized epididymides, whereas 911 and 660 of them are specifically expressed in normal and vasectomized epididymides, respectively. Three of the affected genes are particularly interesting because of their involvement in sperm biochemical remodeling during epididymal transit: dicarbonyl/l-xylulose reductase, Niemann-Pick disease, type C2, and cysteine-rich secretory protein 1. In some vasovasostomized men, these modifications in gene expression induced by vasectomy are irreversible, thus affecting the biochemical parameters, and potentially, the function of their ejaculated sperm. This may explain the discrepancies between a surgically successful vasovasostomy and fertility recovery.