This page examines the page entitled "Post-Vasectomy Treatment Options".

Option

Analysis

Inigual Orchiectomy. "This is a form or castration where the doctor cuts your groin and pulls out the testicles along with the cords."

He later says that "Patients often can be insistent about having testes removed for persistent pain but clearly, they must be counseled that Orchiectomy may not provide relief."

This is removal of one testicle - bilateral Orchiectomy is removal of both, but lets get beyond the melodramatic description and look at the facts.

The quote he attributes to Davis et all.¹ However, the words opposite do not appear in the version of the study available from the National Library of Medicine. The study itself is not vasectomy related. It looks at orchiectomy as a means of treating chronic testicular pain. CTP is a fairly common urological complaint. The results were that between 50% and 73% of patients did have relief from pain. So bizarre though it may seem, removing the testicles doesn't necessarily stop the pain there!

It also has to be pointed out that there are no studies in the National Library of Medicine on the effectiveness of this being used as a treatment for post vasectomy pain syndrome. Nor do any of the peer review studies mention it. Christian & Sandlow³ is one of the more thorough peer review articles on post vasectomy pain - they don't mention it as a cure either. If there aren't any studies that prove it is likely to work as a cure for post vasectomy pain syndrome, doctors are very unlikely to use it as a treatment method. However, in the course of research I did find one study into the use of epididymectomy as a cure for pvp that mentions an isolated case of orchiectomy being used when epididymectomy failed⁸. I'm sure that this reference will appear in the next edition of the book!

Inigual Orchiectomy is in the main a treatment for testicular cancer, and is sometimes used in cases of prostate cancer². The same article states that "If a man has one healthy testicle, he should not notice any negative change in his quality of life. In the majority of cases, Orchiectomy does not result in long-term sexual side effects or infertility, though it may increase these problems if they were present before the surgery."

Scrotal Orchiectomy

Again, another treatment used in the main for treating testicular cancer. No studies at the National Library of Medicine, or any mention of this being used as a treatment method for post vasectomy pain by the peer review studies either.

Epididymectomy. "Studies have been mixed... with many showing about 50% success rate. Unfortunately he will only keep his testicles a short while after an Epididymectomy since the blood flow to the testicles can be damaged during the procedure causing testicular atrophy".

It is true that all surgical treatment options have varied results based on a variety of factors. With Epididymectomy and microsurgical denervation the best results are achieved when patients have undergone a meticulous diagnosis to see if it is suitable in their case. Therefore it is correct to say that studies have mixed results. Sweeney et all⁶ in their general review of Epididymectomy state that "We do not advocate Epididymectomy for all patients who complain of pain after vasectomy. The present group included only those with tender swollen epididymes who had persistent symptoms. Those with nonspecific orchialga an no significant findings would not be expected to benefit from epididymal surgery."

As regards effectiveness of Epididymectomy in treating post vasectomy pain syndrome, West et all⁷state that "Of the 16 patients, 14 had excellent initial symptomatic benefit from Epididymectomy. At 3-8 years afterward, nine of 10 patients interviewed had a sustained improvement of their scrotal pain." Other studies typically report in the 70% + range. I have not found any study that reports results less than this. Other studies also report that Epididymectomy is not indicated as a treatment unless the epididymes are swollen and tender. As in West⁷, nonspecific pain indicates that Epididymectomy is not suitable.

Pollock¹³ suggests that epididymectomy may be indicated if the original vasectomy has been performed too close to the epididymis, and the patient hasn't responded to medication.

The claim that post Epididymectomy the patient will lose his testicles is clearly false. No studies in the National Library of Medicine that look at Epididymectomy report this happening in the follow up studies. Doing a Google search reveals a couple of personal web pages that make the claim without references. Sweeney⁶ did note one case of atrophy in their general study into the use of Epididymectomy, but at the same time stated they did not asses the effect of Epididymectomy on the testis, and suggest further scientific studies into this. They did not mention of the individual was in the vasectomy group or not.

Neurectomy, or surgical denervation. "This may be OK if being numb from the groin down through the testicles and into the inner thigh doesn't bother you."

Oddly enough no medical reference to back up that statement, and oddly enough there aren't any studies that back it up anyway! So what's new???

But looking beyond the made up statement, how effective is this as a treatment? In properly selected patients it's very effective. "Microsurgical testicular denervation results in reliable and reproducible excellent therapeutic success rates of 96%"⁹. In an earlier study, the same team achieved a similar success rate. They monitored the patients for between 4 and 62 months (average of 20.6 months) and found that none of the patients suffered from intra or postoperative complications¹⁰.

As with other treatment options, the studies make the point that it's suitable for use in specific instances, and that accurate diagnosis is crucial to success of the procedure :- "Based on our experience microsurgical testicular denervation should be performed in patients with CTP and no underlying organic disease. However, the high success rate of our surgical procedure can only be maintained if the selection of suitable patients is performed very carefully and a specific organic origin of CTP has been excluded prior to surgery".

Vasectomy reversal - vasovasostomy or vasoepididymostomy. "The medical community in general wants to warn against a panic that would cause a rush to get reversals."

Make of that statement what you will.

He also says that vasectomy reversal has good results in some, but not others. That is a true statement. Nangia et all¹⁰, whilst reporting a success rate of 69% of men becoming completely pain free after vasectomy reversal, they also point out that "No histological features aid in identifying a cause of pain or provide prognostic value for subsequent pain relief." In other words, despite reporting a high success rate, predicting who it works for is difficult. It's regarded as a general purpose method where epididymectomy and microsurgical denervation are not specifically indicated. It's probably the most used method too, though no statistics are available to prove this.

Myers et all¹¹ report a success rate of 75%.

As mentioned by Hauber, there are two types of reversal procedure. There are indicators that determine which version may be more suitable. Kolettis¹³ looked at how effective epididymal fullness was as an indicator. It's not a pvp study, but a general one into vasectomy reversal. He concludes that in the absence of epididymal fullness vasovasostomy is indicated, and "epididymal fullness may suggest, but cannot predict, unfavorable vasal fluid that requires vasoepididymostomy."

Open-ended conversion (Re-doing the vasectomy as an open-ended vasectomy).

There are no published case histories or studies at the National Library of Medicine. However, one Canadian specialist in treating pvp¹⁴ reports "excellent results in relieving pain doing the conversion of closed-ended vasectomy to open-ended vasectomy. This is also a much simpler procedure than carrying out a vasectomy reversal."

Removal of potentially painful granulomas may be proposed.

Although spermatic granulomas typically occur in some 60% of cases, they are mostly small and asymptomatic (patient is unaware they are there). And of the men that do develop granuloma's they are only painful in a very small percentage of cases¹⁵. The role of the spermatic granuloma is fully discussed on the "Cut to the chase" page on this site.

The main treatment for granuloma's is time - they mostly resolve themselves given time. Surgical removal is sometimes done, but injecting them with steroids works well too¹⁴.

"A spermatic nerve block and or an epidural may be proposed."

An epidural is generally regarded as a short-lasting local anaesthetic used mainly in childbirth administered into the epidural space in the spinal column. However, in this context he's referring to a steroid injection into the epidural space as opposed to anaesthesia. Steroid injections are mainly used for lower back pain, and provide relief from pain for one week up to one year. It's effective in significantly reducing pain for approximately 50% of patients.¹⁶ There aren't any studies that deal specifically with post vasectomy pain, but Hauber quite rightly says that a series of nerve blocks may break the pain cycle. Spine-health.com¹⁶ lists a series of contra-indications and potential side effects of steroids and the epidural procedure. In essence, a nerve block is similar to the epidural in that it's an injection of anaesthetic agents and / or steroids but the injection is in the spermatic cord.

Although nerve blocking is only a temporary measure, a positive response to spermatic cord block is an indicator that microsurgical denervation may successfully provide permanent relief.¹⁰ Therefore nerve blocking may be used as a diagnostic aid in the quest for a permanent solution.

"Conservative measures are likely to be suggested before any of the above procedures are undertaken. This probably means medications aplenty. Anti depressants, anti seizure medications, anti convulsants, various pain killers, hormone therapy, anti-inflammatories".

Conservative measures will always be tried first, the reason being that in the majority of cases, conservative measures resolve the problem. In one study that looked at the incidence of chronic pain post vasectomy¹⁷, 82% of those that complained of testicular pain post vasectomy could not be classed as having pvp as the period of pain was brief and didn't last more than 3 months after the vasectomy. Analgesics were sufficient to control the pain in many cases.

As to the "Probably" statement, there isn't any probability of being issued most of the medicines on the list. Conservative measures specifically means a short course of analgesics, routine pain killers or in some cases antibiotics. Anti depressants are not routine, nor are anti seizure, anti convulsant medications or hormone therapy. It's possible that in individual cases hormone therapy may be used - I have heard of a couple of cases of this myself.

Acupuncture.

Reference 2 of the Hauber page is from a Chinese medical journal, and deals with acupuncture post vasectomy. I have heard of other people who have tried acupuncture, and had some measure of success. Therefore as it's not going to cause harm, and may be of benefit, it's a solution many people would say is worth trying. After giving the first bit of sensible advice so far, it's a shame he had to ruin the effect with a stupid cartoon.

Other conservative therapies including warm baths, swimming, therapeutic massage, chiropractic, diet and nutrition.

All good, sound advice. Basically, anything that relieves tension or stress has to be a positive help.

Time.

Hauber offers good advice here regarding time, also pain and stress management.

Finding out if you are having any autoimmune reactions.

Pollock¹⁴ suggests certain diagnostics that can help to determine the cause of post vasectomy pain. Finding out if you have antisperm antibodies is on the list. Pollock also states that "Some speculate that post vasectomy pain could be mediated by an immune reaction. It is known that antibodies to sperm are produced by the body after vasectomy. It is possible that these antibodies can react with testicular epididymal and or scrotal tissue to cause an inflammatory reaction."

He goes on to state that "Some advocate the use of a steroidal anti-inflammatory for 1-2 weeks. This treatment may be particularly helpful in treating an antibody/immune mediated cause of the pain. Hormone treatment with testosterone, +/- progesterone may also be effective in suppressing the production of the antigen (sperm) and therefore may help in treating an antibody-mediated immune reaction."

Testicular self-examination

This is something we ALL should be doing anyway! What relevance he thinks it has to pvp is not particularly clear.

Testicular massage

Again, something that can't do harm and may well help some.

"If you are concerned about the prostate cancer risk of vasectomy, or just about the general risk of prostate cancer there are a number of simple preventative measures you can take. Nutritional factors, especially meat, fat and dairy intake have been linked to greater risk of disease. Higher consumption of selenium, vitamin E, fruit and tomatoes all have been associated with reduced occurrence of prostate cancer." Attributed to Chan et all⁴

He then says that the Chan article mentions vasectomy as a risk factor. Surprise surprise.

Well, I guess that the big surprise (or not by this time) is that the Chan et all article does not mention vasectomy as a risk factor in any way, shape or form. Check the link below to the original to see for yourself. Out of the 16 bullet points on this page, this is only the third published medical study he's referred to - and he's added his own sentences that don't exist in the original.

Vasectomy and prostate cancer do not have a relationship. This is discussed elsewhere on this site. Saying "If you are concerned about the prostate cancer risk of vasectomy" is a typical scare tactic, and should be treated as such.

For an informed article on prostate cancer and the history of the prostate cancer and vasectomy scare read Prostate cancer and vasectomy. Realities and myths.⁵