Identifying the cause of testicular pain

Post-vasectomy pain is a well recognised, poorly publicised condition, write Dr Jonathan Pinnell and Dr Lorna MacColl.

This problem often develops months or even years after a vasectomy (Photograph: SPL)
This problem often develops months or even years after a vasectomy (Photograph: SPL)

A 43-year-old man attended the surgery due to a three-month history of pain in his right testicle. While it was not usually troublesome it would become excruciating on achieving an erection and engaging in sexual activity.

On several occasions the pain was so severe that it caused him to lose his erection. After an episode of severe pain it persisted as a dull ache in the right testicle for about a week.

He was previously fit and well and his only prior medical history was for a vasectomy he had undergone three months prior to the onset of symptoms. This time delay initially led to the vasectomy being dismissed as a potential cause.

Examination identified moderate tenderness at the lower pole of the right testicle but was otherwise unremarkable. A course of antibiotics was issued even though he was felt to be at a low risk of infection.

Four weeks later the pain was still as severe as before. We consulted the literature and each search we performed based on the patient's symptoms pointed to the same cause and led to his diagnosis of post-vasectomy pain syndrome. He was commenced on a trial of NSAIDs.

Well-recognised complication
Post-vasectomy pain syndrome is a well-recognised, but poorly publicised complication of vasectomy. As is exemplified by this case, it is an intermittent or constant, unilateral or bilateral testicular pain that occurs for longer than three months and interferes with daily activities prompting the individual to seek medical advice.

Intermittent pains are often triggered by physical exertion, sexual activity or ejaculation. It may occur immediately postoperatively but more commonly develops months to years later.1

This delay is due to a gradual rise in pressure within the epididymis caused by continued production of sperm that are released into a system now closed by ties or clips on the vas deferens.

The painful build-up of sperm may be prevented or relieved by an 'epididymal blowout' or by recruitment of macrophages into sperm-destroying granulomas within the epididymis.2

Providers of vasectomy, both NHS and private, are encouraged by 2004 guidance from the Royal College of Obstetricians and Gynaecologists (RCOG) to inform men of the risk of chronic pain. However, general awareness of the complication remains low and information regarding the level of risk is often ambiguous.

The risk of chronic pain is commonly described as affecting 'some men' or 'a very small number of men'. However, multiple UK-based studies of post-vasectomy pain have demonstrated that the proportion of men who develop pain after a vasectomy is almost 15%.

The number of men who seek medical advice or rate their pain as severe, and therefore qualify for a diagnosis of post-vasectomy pain syndrome, is up to 6%.3 This does not correlate with the level of risk described to patients and it may influence their decision.

Difficult to manage
Post-vasectomy pain, a chronic problem, is often difficult to manage. It is therefore very important to improve the general awareness of the condition so that men are counselled appropriately regarding the risk and GPs recognise it as a potential cause of scrotal pain.

Initial treatment is often with antibiotics, as in this case, out of fear of epididymitis. When this fails, and the condition is recognised, some men are successfully managed with simple analgesia, particularly NSAIDs.

However, if pain persists it may be necessary to seek support from pain and urology services. Non-surgical options include stronger analgesia, TENS or nerve infiltration. Surgical options include epididymectomy, denervation of the spermatic cord and reversal of vasectomy.

  • Dr Pinnell is an FY2 and Dr MacColl is a GP at Gnosall Surgery, Stafford.

References
1. Tandon S, Sabanegh E. Chronic pain after vasectomy: a diagnostic and treatment dilemma. BJU Int 2008; 102(2): 166-9.

2. Christiansen CG, Sandlow JI. Testicular pain following vasectomy: a review of postvasectomy pain syndrome. J Androl 2003; 24(3): 293-8.

3. Leslie TA, Illing RO, Cranston DW et al. The incidence of chronic scrotal pain after vasectomy: a prospective audit. BJU Int 2007; 100(6): 1330-3.

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