Male Infertility Update
Philip Werthman, M.D. Director, Center for Male Reproductive Medicine Los Angeles, CA
Dr. Werthman has edited a textbook on male infertility published by W.B. Saunders, the leading medical publisher, and was the male fertility consultant to the popular book, Staying Fertile Longer.
Dr. Werthman and Dr. Rothman have also given a myriad of lectures over the years at international and national fertility society and urology meetings as well as to local and regional physician and patient groups.
Introductions and Objectives:
Post-vasectomy pain syndrome is a nebulous term for chronic and sometimes debilitating scrotal pain following vasectomy. The syndrome and treatments have been poorly characterized. We report on a single surgeon’s 10-year experience treating patients with vasectomy reversal for chronic post-vasectomy pain.
We reviewed the charts of 45 men (vasectomized elsewhere) who presented with the complaint of chronic pain after their vasectomy. Data was collected as to time of onset of pain, years since the vasectomy, prior treatments, nature and quality of the pain, physical findings, surgical findings and outcomes of vasectomy reversal and requirement for additional treatment.
45 men were evaluated for post-vasectomy pain. 63% stated their pain began during the vasectomy, 8% within the first week thereafter, 13% within the first 5 months and remainder within six years. Median age of the vasectomy was 3.7 years with a range on 0.4-18 years. Twenty patients (45%) complained of pain after ejaculation, 45% complained of a dull testicular ache, 15 % had sharp and burning pain radiating up to their abdomen, and 10% complained of a tender lump. Two patients complained of constitutional symptoms. Sixty-seven percent of patients were initially treated by their local urologist with antibiotics and anti-inflammatory drugs and had no response. Two patients had excision of sperm granulomas with conversion to open ended vasectomy and 2 patients had failed vas reversals. Seventy percent of patients elected to undergo a microsurgical vasectomy reversal with excision of the vasectomy scar/granuloma. At the time of surgery, 40% were found to have a sperm granuloma, 15% had generalized inflammation around the vas, 29% had no unusual post-vas findings and one patient had large neuromas. Seventy-five percent of reversal patient’s experienced complete resolution of their symptoms, 10% had greater than 30% reduction in their symptoms and 10% had no change in symptoms. Two patients had only temporary relief of symptoms after reversal. Two patients went on to have microsurgical spermatic cord denervation after failed reversal and one patient ultimately elected to have a unilateral orchidectomy. One cord denervation was ultimately successful.
Post-vasectomy pain syndrome continues to be a problem plaguing a small number of vasectomized men. Pain appears to vary in its time to onset, is inconsistent in nature and quality, and probably has multiple pathologic etiologies. Adequate anesthesia for the vasectomy is crucial since most patients began experiencing pain during the procedure. Vasectomy reversal has a very high likelihood of producing a symptom-free outcome. Sperm granulomata, inflammatory/scar tissue, and foreign bodies should be excised at the time of reversal surgery. Open-ended vasectomy should be avoided as it made subsequent reversal surgery more difficult to perform.
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