A study to assess the prevalence of chronic testicular pain in post-vasectomy men compared to non-vasectomised men

Incidence of Post-Vasectomy Pain: Systematic Review and Meta-Analysis

This is the first systematic review and meta-analysis to ascertain incidences of post-vasectomy pain following traditional scalpel, or non-scalpel vasectomy. Electronic databases PubMed, Embase and PsycINFO were searched up to 1 July 2019 for peer-reviewed articles recording post-vasectomy pain. We identified 733 publications, screened 559 after removal of duplicates and excluded 533. Of the remaining 26 full-text articles, 8 were excluded with reasons, leaving 18 for detailed analyses. Meta-analysis was performed on 25 separate datasets (11 scalpel, 11 non-scalpel, 3 other/combined). Study follow-up ranged from 2 weeks to 37 years and sample sizes from 12 to 723 patients. The overall incidence of post-vasectomy pain was 15% (95% CI 9% to 25%). The incidences of post-vasectomy pain following scalpel and non-scalpel techniques were 24% (95% CI 15% to 36%) and 7% (95% CI 4% to 13%), respectively. Post-vasectomy pain syndrome occurred in 5% (95% CI 3% to 8%) of subjects, with similar estimates for both techniques. We conclude that the overall incidence of post-vasectomy pain is greater than previously reported, with three-fold higher rates of pain following traditional scalpel, compared to non-scalpel vasectomy, whereas the incidence of post-vasectomy pain syndrome is similar.

Salvage Ultrasound-guided Targeted Cryoablation of The Perispermatic Cord For Persistent Chronic Scrotal Content Pain After Microsurgical Denervation Of The Spermatic Cord

OBJECTIVE

To assesses the efficacy of ultrasound-guided targeted cryoablation (UTC) of the perispermatic cord as a salvage treatment for patients who failed microsurgical denervation of the spermatic cord.

METHODS

Retrospective review of 279 cases (221 patients: 58 bilateral) undergoing UTC between November 2012 and July 2016, performed by 2 fellowship trained microsurgeons. UTC was performed using a 16-gauge cryo needle (Endocare, HealthTronics, Austin, TX). Branches of the genitofemoral, ilioinguinal, and inferior hypogastric nerves were cryoablated medial and lateral to the spermatic cord at the level of the external inguinal ring. Level of pain was measured preoperatively and postoperatively using the visual analog scale and Pain Index Questionnaire-6 (QualityMetric Inc., Lincoln, RI).

RESULTS

Median age was 43 years, operative duration 20 minutes, and postoperative follow-up 36 months (24-60). Subjective visual analog scale outcomes: 75% significant reduction in ain (11% complete resolution and 64% ≥50% reduction in pain). Objective Pain Index Questionnaire-6 outcomes: 53% significant reduction at 1 month (279 cases), 55% at 3 month (279 cases), 60% at 6 month (279 cases), 63% at 1 year (279 cases), 65% at 2 years (275 cases), 64% at 3 years (232 cases), 59% at 4 years (128 cases) and 64% at 5 years (53 cases) post-op.

COMPLICATIONS

2 wound infections, 4 penile pain cases (resolved in a few months).

CONCLUSION

UTC of the perispermatic cord is a safe potential treatment option for the salvage management of persistent chronic scrotal pain in patients who have failed microsurgical denervation of the spermatic cord.

Osteopathic Manipulative Treatment as a Novel Way to Manage Postvasectomy Pain Syndrome

Postvasectomy pain syndrome (PVPS) can be debilitating and is notoriously difficult to treat, often requiring a multidisciplinary approach. In this case report, osteopathic manipulative treatment (OMT) was used to treat a patient with PVPS. After vasectomy, an otherwise-healthy man experienced chronic right testicular pain, aggravated by exercise, touch, and sexual intercourse, resulting in marital strain and an inability to perform routine fitness activities. Symptoms persisted for 8 years, despite lifestyle modifications, orally administered pain regimens, pelvic floor physical therapy, nerve blocks, steroid injections, epididymectomy, spermatic cord denervation, and counseling. After the patient's urologist suggested orchiectomy, his family medicine physician referred him for OMT. The OMT interventions, applied over a 4-month period, were directed at the lumbar spine, pelvis, pelvic floor, and lower abdomen. After treatment, the patient reported absence of testicular pain most of the time and described his quality of life as "10 times better." Literature review revealed no reports of OMT used to manage PVPS.

Long-term safety, health and mental status in men with vasectomy

Vasectomy is an efficient male contraceptive method, but the long-term effects of this technology in a large population are unclear. To investigate the influence of vasectomy on long-term health effects, we recruited 485 men with a vasectomy and 1940 men without vasectomy in China. After obtaining basic information from the Aging Males’ Symptoms (AMS) scale and other questionnaires, peripheral blood was drawn to assess the hormone levels, prostate specific antigen (PSA) and blood biochemistry. Using multiple linear regression analysis, these factors had no relationship with vasectomy except for four factors including the Somatic score (0.31, 0.02 and 0.61) in AMS, SF-36 score (−18.8, −32.00 and −5.60), “Role emotional” (−6.28, −10.34 and −2.22) and “Mental health” (−1.55, −3.08 and −0.02). A stratified analysis showed that with increased age, smoking and drinking, residence in township or a higher level of education, the mental health of men was worse. Vasectomy had no long-term effect on the level of sexual hormones in men, and it did not increase the level of PSA. The impact of the vasectomy on quality of life in men were mainly reflected in psychological effects, which suggests that men with vasectomy groups many benefit from professional psychological counseling.

Targeted Robotic Assisted Microsurgical Denervation of the Spermatic Cord for the Treatment of Chronic Orchialgia or Groin Pain: A Single Center, Large Series Review

PURPOSE

Microsurgical denervation of the spermatic cord is a treatment option for chronic orchialgia refractory to conservative treatment. A recent study showed specific nerve fibers as the possible cause of chronic orchialgia. Our goal was to present the outcomes of ligation of these nerves using a technique of targeted robotic assisted microsurgical denervation of the spermatic cord.

MATERIALS AND METHODS

We retrospectively reviewed the records of 772 patients who underwent targeted robotic assisted microsurgical denervation of the spermatic cord from October 2007 to July 2016. Selection criteria were chronic testicular pain more than 3 months in duration, failed conservative treatments, negative neurological and urological workup, and temporary resolution of pain with a local anesthetic spermatic cord block. Targeted robotic assisted microsurgical denervation of the spermatic cord was performed. Pain was assessed preoperatively and postoperatively using a subjective visual analog scale and objectively with the standardized and validated PIQ-6 (Pain Impact Questionnaire-6) score.

RESULTS

Followup data were available on 860 cases. During a median followup of 24 months (range 1 to 70) 718 cases (83%) showed a significant reduction in pain and 142 (17%) had no change in pain by subjective visual analog scale scoring. Of cases with a significant reduction in pain 426 (49%) had complete resolution and 292 (34%) had a 50% or greater reduction. Objective PIQ-6 analysis showed a significant reduction in pain in 67% of patients 6 months postoperatively, in 68% at 1 year, in 77% at 2 years, in 86% at 3 years and in 83% at 4 years.

CONCLUSIONS

Targeted robotic assisted microsurgical denervation of the spermatic cord is an effective, minimally invasive approach with potential long-term durability in patients with refractory chronic orchialgia.

Vasectomy reversal for post-vasectomy pain syndrome

Post-vasectomy pain syndrome (PVPS) is a rare, but devastating outcome following vasectomy. Given the widespread utilization of vasectomy for permanent contraception, with more than 500,000 procedures performed annually in the United States, it can be a significant challenge for both patients and providers. Vasectomy reversal is a surgical option for men who fail conservative or medical management. Despite improvements in technique, vasectomy carries some inherent risks making pre-procedure counseling regarding the risks of PVPS paramount. Chronic post-operative pain, or PVPS, occurs in 1-2% of men undergoing the procedure. This review will examine the utility of vasectomy reversal as a means of addressing PVPS.

Chronic orchialgia: epidemiology, diagnosis and evaluation

Chronic orchialgia is a vexing condition defined as chronic or intermittent scrotal pain lasting at least three months that significantly interferes with daily activities. There are currently no guidelines regarding the diagnosis and management of this condition despite it being the cause of 2.5-4.8% of urologic clinic visits. Men often present with chronic orchialgia in their mid to late 30s, although the condition can present at any age. A broad differential diagnosis of chronic orchialgia includes epididymitis, testicular torsion, tumors, obstruction, varicocele, epididymal cysts, hydrocele, iatrogenic injury following vasectomy or hernia repair, and referred pain from a variety of sources including mid-ureteral stone, indirect inguinal hernia, aortic or common iliac artery aneurysms, lower back disorders, interstitial cystitis, and nerve entrapment due to perineural fibrosis; approximately 25-50% of chronic orchialgia is idiopathic in nature. In such cases, it is reasonable to consider psychological and psychosocial factors that may be contributing to chronic pain. Invasive testing is not recommended in the work-up of chronic orchialgia.

Diagnosis and Surgical Management of Male Pelvic, Inguinal, and Testicular Pain

Pain occurs in the male genitourinary organs as for any organ system in response to traumatic, infectious, or irritative stimuli. A knowledge and understanding of chronic genitourinary pain can be of great utility to practicing nonurologists. This article provides insight into the medical and surgical management of subacute and chronic pelvic, inguinal, and scrotal pain. The pathophysiology, diagnosis, and medical and surgical treatment options of each are discussed.

Chronic orchialgia: Review of treatments old and new

Introduction:

Chronic orchialgia is historically and currently a challenging disease to treat. It is a diagnostic and therapeutic challenge for physicians. Conservative therapy has served as the first line of treatment. For those who fail conservative therapy, surgical intervention may be required. We aim to provide a review of currently available surgical options and novel surgical treatment options.

Methods:

A review of current literature was performed using PubMed. Literature discussing treatment options for chronic orchialgia were identified. The following search terms were used to identify literature that was relevant to this review: Chronic orchialgia, testicular pain, scrotal content pain, and microsurgical denervation of the spermatic cord (MDSC).

Results:

The incidence of chronic orchialgia has been increasing over time. In the USA, it affects up to 100,000 men per year due to varying etiologies. The etiology of chronic orchialgia can be a confounding problem. Conservative therapy should be viewed as the first line therapy. Studies have reported poor success rates. Current surgical options for those who fail conservative options include varicocelectomy, MDSC, epididymectomy, and orchiectomy. Novel treatment options include microcryoablation of the peri-spermatic cord, botox injection, and amniofix injection.

Conclusion:

Chronic orchialgia has been and will continue to be a challenging disease to treat due to its multiple etiologies and variable treatment outcomes. Further studies are needed to better understand the problem. Treatment options for patients with chronic orchialgia are improving. Additional studies are warranted to better understand the long-term durability of this treatment options.

Chronic scrotal pain caused by Mild Epididymitis:Report of a series of 44 cases

Objectives: Patients with idiopathic chronic scrotal pain are challenging to both the general practioner and urologist. In this study, we tried to recognize mild epididymitis as an underrecogniczed cause of idiopathic chronic scrotal pain.

Methods: We described a consecutive series of 44 patients with idiopathic chronic scrotal pain characterized by mild scrotal pain, mild to moderate tenderness of epididymis without abnormal swelling of epididymis. We obtained a detailed history and physical examination along with routine urinalysis and Doppler ultrasound to identify the characteristics of this new clinical entity.

Results: A consecutive series of 44 patients who were primarily diagnosed as "idiopathic chronic scrotal pain" came to our hospital. All had the sign of mild to moderate tenderness on the affected epididymis without epididymis enlargement. Doppler ultrasound showed the affected epididymis with normal size and no abnormal change. We treated them with antibiotics orally along with cessation of strenuous activity and all fully recovered from scrotal pain.

Conclusion: In this study, we recognized mild epididymitis as an underrecogniczed cause of idiopathic chronic scrotal pain. It was characterized by mild scrotal pain, mild to moderate tenderness of epididymis without abnormal enlargement of epididymis.

Trifecta nerve complex: potential anatomical basis for microsurgical denervation of the spermatic cord for chronic orchialgia

PURPOSE

We identified structural abnormalities in the spermatic cord nerves that may explain how microsurgical denervation of the spermatic cord provides pain relief in patients with chronic orchialgia.

MATERIALS AND METHODS

We retrospectively reviewed a prospective database to compare spermatic cord biopsy specimens from 56 men treated with a total of 57 procedures for microsurgical denervation of the spermatic cord for chronic orchialgia vs a control group of men without pain treated with cord surgery, including varicocelectomy in 4 and radical orchiectomy in 6. Tissue biopsies were obtained from mapped regions of the spermatic cord in all cases. Biopsies stained with hematoxylin and eosin were examined by an independent pathologist. Three human cadaveric spermatic cords were dissected to confirm localization of the nerve distribution identified on pathological mapping.

RESULTS

We identified a median of 25 small diameter (less than 1 mm) nerve fibers in the spermatic cord. Of the 57 procedures for orchialgia 48 (84%) showed wallerian degeneration in 1 or more of these nerves but only 2 of 10 controls (20%) had such degeneration (p = 0.0008). In decreasing order of nerve density the 3 primary sites (trifecta nerve complex) of these changes were the cremasteric muscle fibers (19 nerves per patient), perivasal tissues and vasal sheath (9 nerves per patient), and posterior cord lipomatous/perivessel tissues (3 nerves per patient). Cord nerve distribution mapped by the biopsies was confirmed by cadaveric dissection.

CONCLUSIONS

In men with chronic orchialgia there appears to be wallerian degeneration in reproducible patterns in the spermatic cord nerve fibers. Transection of these nerves may explain the effect of the denervation procedure.

Microdenervation of the spermatic cord for chronic scrotal content pain: single institution review analyzing success rate after prior attempts at surgical correction

PURPOSE

Microdenervation of the spermatic cord is an effective treatment for men with intractable scrotal content pain. We evaluated a single center experience, analyzing patients in whom prior surgical attempts had failed to correct pain who subsequently underwent microdenervation of the spermatic cord.

MATERIALS AND METHODS

A retrospective chart review of 68 patients who underwent microdenervation of the spermatic cord from 2006 to 2010 was performed. Prior ipsilateral surgical procedures with the intent to correct scrotal content pain were selected, identifying 31 testicular units.

RESULTS

Chart review was performed on 68 men with mean age of 42 years at presentation and a mean followup of 10 months. Patients in whom prior surgical correction had failed and who subsequently had microdenervation of the spermatic cord had a mean postoperative pain score of 3 (range 0 to 10) with an average decrease in pain of 67%. Those who had not undergone a prior attempt at surgical correction had a mean post-microdenervation of the spermatic cord pain score of 2 (range 0 to 10) and an average pain decrease of 79% which did not differ statistically from those in whom prior surgery failed. In addition, 50% of men who had undergone surgery before microdenervation of the spermatic cord had complete relief of pain after microdenervation of the spermatic cord vs 64% of those who had not undergone previous surgery.

CONCLUSIONS

Men with chronic scrotal content pain in whom prior attempts to correct pain have failed have similar, albeit lower, success rates as those without prior surgical intervention. Therefore, men with chronic scrotal content pain in whom prior surgical management has failed and who have a positive spermatic cord block should be considered candidates for microdenervation of the spermatic cord.

Update on vasectomy protocol

Vasectomy is a commonly practiced form of male contraception with over half a million procedures performed annually. Among urologists who perform the procedure, there is considerable variation in pre-procedure patient counseling, vasectomy technique, and post-procedure practices regarding confirmation of sterility. We report an overview of the vasectomy literature published within the past year with a focus on guidelines that have been recently published by two major organizations, the American Urological Association (AUA) and the European Association of Urology (EAU).

Advances in male contraception

Despite significant advances in contraceptive options for women over the last 50 yr, world population continues to grow rapidly. Scientists and activists alike point to the devastating environmental impacts that population pressures have caused, including global warming from the developed world and hunger and disease in less developed areas. Moreover, almost half of all pregnancies are still unwanted or unplanned. Clearly, there is a need for expanded, reversible, contraceptive options. Multicultural surveys demonstrate the willingness of men to participate in contraception and their female partners to trust them to do so. Notwithstanding their paucity of options, male methods including vasectomy and condoms account for almost one third of contraceptive use in the United States and other countries. Recent international clinical research efforts have demonstrated high efficacy rates (90-95%) for hormonally based male contraceptives. Current barriers to expanded use include limited delivery methods and perceived regulatory obstacles, which stymie introduction to the marketplace. However, advances in oral and injectable androgen delivery are cause for optimism that these hurdles may be overcome. Nonhormonal methods, such as compounds that target sperm motility, are attractive in their theoretical promise of specificity for the reproductive tract. Gene and protein array technologies continue to identify potential targets for this approach. Such nonhormonal agents will likely reach clinical trials in the near future. Great strides have been made in understanding male reproductive physiology; the combined efforts of scientists, clinicians, industry and governmental funding agencies could make an effective, reversible, male contraceptive an option for family planning over the next decade.

The incidence of chronic scrotal pain after vasectomy: a prospective audit

OBJECTIVE

To assess the extent of scrotal pain in men before and after vasectomy, to produce accurate data for the benefit of men considering this procedure, and hence improved informed consent about the outcomes, as chronic scrotal pain after vasectomy is a poorly quantified clinical problem.

PATIENTS AND METHODS

Between November 2004 and January 2006 nine surgeons carried out vasectomies in 625 men (mean age 39.9 years, sd 5.6) under local anaesthesia. A questionnaire was devised to establish the presence of any scrotal or testicular pain, and to characterize this discomfort; 6 months after the procedure a modified version of the same questionnaire was administered.

RESULTS

In all, 593 (94.7%) men returned the preoperative questionnaires and were entered into the study; 488 (82.2%) of these completed the follow-up questionnaire, giving a mean (sd) follow-up of 6.8 (1.6) months. In all, 65 men reported new-onset scrotal pain at 7 months (14.7%). The mean visual analogue score for this pain was 3.4/10. Four men (0.9%) in the responding group described pain after vasectomy as 'quite severe and noticeably affecting their quality of life'.

CONCLUSION

At 7 months after vasectomy about 15% of previously asymptomatic men have some degree of scrotal discomfort. These early data indicate that chronic scrotal pain after vasectomy is a genuine entity, but a longer-term follow-up in this group will be important to allow further evaluation of how this pain develops with time.