The Affects of Post Vasectomy Pain on Sexuality and Quality of Life

Several post-vasectomy surveys document chronic scrotal or testicular pain that can interfere with sexual function or enjoyment and causes some men to regret their vasectomy decision (McMahon et al 1992, Choe and Kirkemo, 1996, Ahmed et al, 1997, Morris et al, 2002, Manikandan et al 2004, Leslie et al 2007). A study by Choe and Kirkemo concluded that chronic scrotal pain was the most common post-vasectomy complication that could adversely affect quality of life (Choe and Kirkemo, 1996). The very nature of the affect of chronic genital pain on a patient’s quality of life necessitates its inclusion in pre-operative dialogue and written consent. Several studies have concluded that a discussion of chronic post-vasectomy testicular pain should be included in the pre-vasectomy informed consent process (Morris et al 2002, Manikandan et al, 2004). Post-vasectomy pain syndrome (PVPS) is usually characterized by chronic or intermittent testicular and/or epididymal pain and is frequently worsened by intercourse or ejaculation. PVPS can be exacerbated by vigorous physical activity, and is frequently accompanied by tender or full epididymides (Nangia et al, 2000). Symptoms can be unilateral or bilateral and the pain can radiate into the groin or abdomen along the course of the spermatic cord structures. There are no studies in the literature that explore the specific sexual effects of post-vasectomy pain (pain associated decrease in libido, changes in orgasmic response or ejaculation, decrease in sexual enjoyment, or pain related erectile potency issues). It seems likely that any significant genital pain associated with sex could affect sexual response, potency, or sexual enjoyment, and in this way affect libido and mood. The psychological morbidity of chronic genital pain after vasectomy is not well represented in either the psychiatric or urological literature. This paper explores the psychological and sexual symptoms of PVPS and their affects on quality of life.

There are several studies that describe the location of and characteristics of chronic genital pain after vasectomy. In a series of thirteen cases discussing vasectomy reversal to treat chronic post-vasectomy pain by Nangia et al, the patients had a variety of genital pain complaints: nine had testicular pain, epididymal pain was present in two, four had pain on ejaculation, and eight had pain during intercourse (Nangia et al, 2000). In a similar series of thirty-two patients, all of the patients complained of unilateral or bilateral testicular pain characterized as a dull ache that increased with sexual arousal, intercourse or ejaculation (Myers et al, 1997). In a retrospective postal study of 172 post-vasectomy patients, 56 (33%) had chronic testicular discomfort and 26 of these considered it to be “troublesome”. In this series, the pain was primarily described as an intermittent and unilateral “dull ache”, but some described a “sharp severe pain”. Five percent of the patients surveyed had pain associated with intercourse (McMahon et al, 1992). Other patients with post-vasectomy pain have required epididymectomy for relief of pain. In a series of ten patients, nine had constant pain in either the testes or epididymides. Four of ten had pain with activity, and three had pain during intercourse (Chen and Ball, 1991).

This association between pain and intercourse or orgasm must have effects on libido, arousal, sexual enjoyment, and potency, but no studies exist that specifically address this outcome for vasectomized men. Other chronic pain entities are represented in the literature. In a controlled study of 72 men with CPPS (chronic pelvic pain syndrome) the authors concluded: “CPPS subjects differed from controls by reporting significantly less frequent sexual desire or thoughts, less frequent sexual activities, less arousal/erectile function, less orgasm function, and higher frequencies of genital pain during/after intercourse.” (Tripp et al, 2006) There are studies in the literature regarding female pelvic or genital pain conditions and their effects on sexual function. In a study of women with Vulvar Vestibulitis Syndrome (VVS) and a control group, VVS sufferers reported hypervigilance for coital pain and also exhibited a selective attention bias towards pain stimuli (Payne et al, 2005). Sufferers of VVS have also been shown to have lower levels of desire and arousal even after watching erotic materials and have reported higher levels of hypervigilance and fear of pain (Payne et al, 2007). In a study of chronic pain of any type, only 44% of patients experienced normal arousal during intercourse and most were dissatisfied with their orgasmic function. (Monga et al, 1998). In another study of sexual function in chronic pain patients, 73% had pain-related sexual issues that often correlated with decreased sexual frequency (Ambler et al, 2001).

Given the location of the pain in PVPS patients (testicular, epididymal, scrotal, or radiating into the groin) it seems likely that PVPS patients could develop problems with libido, arousal, orgasm, or potency issues. In an attempt to document the sexual side effects and quality of life changes related to chronic genital pain after vasectomy, patients who complained of either testicular, epididymal, or scrotal pain after vasectomy were located via websites or online support groups for men with post-vasectomy pain. Their complaints included: chronic testicular pain, epididymal pain or swelling, pain on ejaculation, pain after sex that could last hours or days, pain under the scrotum in the tail of the epididymides bilaterally that stopped them from riding bicycles or pain on erection. Some men reported difficulty with pain after any physical activity, pain that made them “guard” their laps such that they could not allow their children onto them, or pain that interfered with their ability to work around the house or in their vocation.

Representative quotes:

“The discomfort started immediately after the procedure. It is worse with standing or sitting to long on hard surface. I am sore after sex. I went back few times for nerve blocks. . Sometimes feels like a deep groin pain with a sensation up to the lower right abdominal area.”

“After weeks of excruciating pain, the epididymitis infection ran its course. The doctor mentioned that vigorous exercise and extreme straining could cause flare-ups and has implied that In order to live pain free, I may require an additional surgery to remove the epididymus. A younger less experienced doctor advised not to consider any corrective surgery at this time. He said that he wouldn’t consider removing of the epididymus unless I’ve lived in pain for at least a year. I am now four months post vasectomy. I still have the constant heavy dragging feeling and pressure like my testicle is being squeezed and/or pulled. The left testicle hangs lower and appears larger/longer than the right one. Upon closer inspection there’s swelling at the lower end. It is almost difficult to tell where the testicle ends and the grape sized, mushy, very sensitive mass begins. Any contact or movement of the testicle is uncomfortable.

“I had my vasectomy on March 16 and I am still experiencing a constant feeling of backpressure and soreness that is impossible to not think about, disrupts my sleep, and makes daily life very difficult. The locus of the pain seems to have settled into the upper rear area of the scrotum, and is particularly painful on the left side. Sitting produces a feeling of tightness and nausea.”

“Sometimes my pain is severe and I miss work. Other times I just grind it out. My ultrasound indicated some swelling in the right testicular region. My blood test was positive for autoimmunity to my on sperm. PVP has changed my life. I have two kids that I can’t play with, I can’t do any housework or yard work. I can no longer work out or golf. I cannot walk or sit for an extended time. Everything I do revolves around PVP. This has not only affected me, but my family as well.”

“Within a couple of weeks, I developed a lot of discomfort related to what I felt to be pressure in my testicles which was centered in the epididymus. I went back for my post-vasectomy checks and the urologist told me not to worry about it, that the pressure would “eventually” go away. I tried to find information about the pain I was experiencing, but there was nothing in the local university’s library, and very little information on the web. The only references I could find to post vasectomy pain on the web indicated that it was “extremely rare” and “usually” went away after six months. Over a period of months, this pressure developed into almost constant pain. The epididymus on both testicles swelled to almost ten times their normal size – the epididymus on my left testicle swelled to the point that it was almost the size of the testicle itself. I felt that I had clamps attached to the back of my testicles.”

Pains near the lower part of the testicles or in the tail of the epididymus – This had been there for at least 10 to 12 months and had stopped me from riding my bike. It was a localized sharp needle or ground glass sensation under my scrotum bilaterally. Even by itself this would have required surgical treatment have as it affected sleep and made long car rides a challenge. (I commute an hour each way to and from work.) This pain has not resolved with vasectomy reversal.”

“A constant dull ache in the testes, similar to what many men feel if they have no sex for weeks but more intense. The reversal center spokesperson I contacted said their facility had seen some men who got a reversal just for this “weird full feeling” in the genital region, mostly in the testicular area. This sensation was not tolerable to me and is a distraction at the least. It began in the week after surgery and sometimes seemed less noticeable if I took Motrin. Taking Motrin on a long-term basis every day adds risks that I was not willing to take with my stomach and kidneys, however. In addition, chronic discomfort in the testes tends to affect ones mood, quality of life, and sexual function.”

Discussion

It seems clear from the narratives of affected men that post-vasectomy pain is very distressing and has broad affects on libido, sexual function, physical activities, and quality of life. Due to the high impact of these symptoms, a discussion of post-vasectomy pain syndrome is imperative prior to vasectomy despite its relatively low incidence.

The American Urological Association has addressed this issue in their patient information for prospective vasectomy candidates: “Post-vasectomy pain syndrome is a chronic pain syndrome that follows vasectomy. The cause of this syndrome and its incidence are unclear. It is generally treated with anti-inflammatory agents. Occasionally, patients will elect to undergo vasectomy reversal in an attempt to alleviate this syndrome. Unfortunately, the response to surgical intervention is unpredictable.” It goes on to say that ejaculation and orgasm are not affected by vasectomy with this caveat, “The only exception to this is the occasional patient who has developed post-vasectomy pain syndrome.”

The quality of life and sexual affects of PVPS should also be mentioned in the discussion of side effects and complications with prospective vasectomy candidates. Citing the incidence and existence of the syndrome alone does not allow an informed decision. The sexual affects of the symptoms should be discussed as they are in the AUA website information noted above. If a man is not told of PVPS and its potential affects on sexual function, then a life altering outcome could occur without any warning. The current consent process tends to emphasize only the best outcome: no pain, no sexual side effects and no quality of life issues. Given the known incidence and subsequent impact of PVPS, it would seem fair to caution men about both incidence and the affects of this tragic vasectomy outcome.