Archive for the ‘vasectomy’ Category

No-Scalpel, No-Needle Vasectomy-The Prime Cut

December 8, 2014

Most practices are impacted at the end of the year by the rush of patients who have met their deductibles. In Urology, aside from patients wanting to get stones busted (Lithotripsy), scrotal issues addressed, and an occasional prostate; by far and away, the number of vasectomies that are done in December is at least 4-5 times the number that our offices perform during any of the other months. The following is intended for any questions that you may have regarding vasectomy and is based on more than 5,000 vasectomies I have performed over 30 years of urologic practice.

Vasectomy Facts

1. Average time for the procedure is 6-8 minutes.

2. Patients are not given any narcotics as Aleve or Advil are sufficient for any discomfort. Less than 1 in 100 patients require a narcotic prescription.

3. Patients are offered the option of Valium 20 mg. to take prior to the procedure with instructions to have a driver.

4. 95% of the men who come in for a vasectomy consult go on to have the procedure.

5. The biggest fear is of someone they do not know holding sharp instruments and working on their scrotum while they are awake. Because of proper education, including an article given to all patients prior to have the procedure, men need not worry about the vasectomy impacting their sexual function.

6. The sperm make up only 5% of the ejaculatory volume so no noticeable change in the semen volume.

7. Rarely men will be seen following the procedure for some discomfort and typically, it is related to some inflammation or small hematoma and Tylenol or Advil are more than adequate.

8. Because of the way the procedure is performed, it is very rare to see a scrotal hematoma, which can occur and creates a small swelling of the scrotum. This occurs most often in men who do not heed the advice of going home, lying down and keeping ice on the incision.

10. Occasionally, a question is asked regarding sperm banking and this can be done in a facility in one of the infertility clinics in the area.

11. Vasectomy reversal is a formal surgical procedure that can take anywhere from 1-1/2 to 2 hours to perform. Through a scrotal incision, the testicle and spermatic cords are brought into the surgical field. The ends of the vas identified, freshened up and scar tissue removed and an operating microscope is used to perform a surgical closure using typically anywhere from 7-0 to 9-0 permanent suture. Success rates for vasectomy reversal is approximately 75% within the first 10 years and drops to about 30% after 10 years.

Anatomy

The vas deferens is a small tube approximately 3 mm (1\8 inch) in diameter that carries sperm from the testicle up into the body where it unites with the seminal vesicles and stores the sperm until ejaculation when the semen is deposited in the vagina in order to fertilize an egg and start the process of conception.

No Scalpel Procedure

Following anesthetizing the skin in the mid-section of the scrotum with a device that deposits the anesthetic without the use of a needle. Then a single puncture is made about 1\4 of inch in length in the middle of the scrotum. Each vas is occluded with very small titanium clip. No sutures or stitches are required. The patient lies on the table for a few minutes and then goes home and lays flat in bed for a few hours using ice over the scrotum for 45 minutes out of every hour until going to sleep.

Office visits

A vasectomy consultation is always performed before the procedure for a number of reasons:

1. To explain the procedure to the patient.

2. To allay fears, address misconceptions, and put the patient at ease.

3. To ensure anatomically that there are no problems with performing the vasectomy which include an extremely large patient with small scrotum, prior evidence of infection, and to screen for extremely anxious patients who probably would not tolerate the procedure being performed in the office under local anesthesia.

4. Pre-procedure instructions are given including the need to shave all the hair on the scrotum preferably the night before.

5. Men are given a prescription for Valium, which they should take 30-45 minutes before the procedure. If the man takes the Valium pill, then he will need a ride home as he should not drive a car after using Valium.

6. Post-procedure instructions are given including the need to go home and stay off his feet and keep ice on for two days. Sexual intercourse can begin typically 3-4 days post- procedure. Additionally the men are instructed to return for a follow-up visit. It takes approximately 15 ejaculations to clear all sperm from the portion of the vas above the legation of the vas.

6. Typically, a man makes a follow-up appointment at 6-8 weeks although the record is one week, but he wasn’t married! They are also informed of the 1 in 1500 chance of reconnection of the vas.

Summary

The majority of men have the procedure performed on Thursday or Friday, spend the weekend resting with ice, return to work on Monday and are back to regular activity including intercourse by Wednesday or Thursday of the following week.

Bottom Line: Having done more than 5,000 vasectomies, I can think of very few men who would not be willing to undergo the procedure again or recommend it to a friend. Certainly, in comparison to tubal ligation, which requires general anesthetic, it is a much simpler, less costly and less painful form of sterilization.
Don’t hesitate to give me a call if you have any questions about vasectomy or go to my website to view a video on vasectomy: http://neilbaum.com/videos/vasectomy

Issues To Consider Regarding Vasectomy

October 12, 2014

Men who consider a vasectomy often ask questions about the risks involved. This blog will discuss the risks and the consequences of vasectomy and what every man needs to know before proceeding with the procedure.

There are three main concerns regarding the long-term consequences or general health hazards of vasectomy. These concerns have arisen mainly from isolated studies over the past 50 years. Remember that it is important to show that several things be true when trying to link two medical conditions: a) that the link makes physiological sense and that this is shown in either animal models or in humans, and b) there should be excellent evidence of this link in populations of humans.

Heart Disease Risk

In 1979 a study was published that suggested that atherosclerosis or coronary artery disease might occur prematurely after vasectomy in monkeys. In this small study, monkeys fed high cholesterol diets were found to have what appeared to be increased amounts of atherosclerosis following vasectomy. Subsequent animal studies did not agree with these initial findings, and large epidemiological studies, including an extensive study of U.S physicians followed for 259,000 person-years have concluded that neither early atherosclerosis nor heart attacks or strokes occur more frequently in men who have had vasectomies compared to men who have not.

It is true is that after vasectomy, approximately 60-70% of men develop a form of allergy to their sperm in the form of antisperm antibodies. The body, either during the vasectomy or after, is exposed to sperm proteins that it commonly does not see and antibodies against these proteins can be observed in some patients. However, it has not been shown conclusively that the presence of these antibodies has any significant effect on other organs.

Prostate Cancer Risk

There has been much discussion over the past 15 years about whether vasectomy is associated with the development of prostate cancer later in life. The Journal of the American Medical Association published 2 reports suggesting that men who have had a vasectomy may be at risk for developing prostate cancer. Both studies were coauthored by Dr. Edward Giovannucci. One study evaluated men married to female nurses: men with vasectomies were compared to men without. The second study evaluated men in the health professions (veterinarians, pharmacists etc) who had had a vasectomy, and, again compared them with other male health professionals who had not had vasectomies. In both studies, there appeared to be an increased risk of developing prostate cancer in men who had a vasectomy more than 20-22 years before. On the contrary, several other studies, including several in the U.S showed no statistically significant increase in the risk of prostate cancer following vasectomy. Indeed, it was suggested in the same JAMA issues that a true cause-and-effect relationship could occur by chance alone, or because of biases (selectivity) or other unaccounted variables in these two studies.

Concerns raised from these studies include the fact that the men in the study might not represent the larger population of all men who get vasectomies. This means that the study cannot be used with certainty to predict a similar occurrence in the general population. It is also possible that the men who had had vasectomies in these studies would be more likely to see a urologist rather than an internist or family practice physician for later evaluation of a urologic problem than the men who had not had vasectomies. Urologists are better at finding prostate abnormalities than other kinds of physicians and therefore cancer might have been detected earlier than it would have otherwise. This is called “detection bias.” It has also been suggested this study design makes it impossible to identify all of the factors that might contribute to this end result with two events (vasectomy and cancer) occurring several decades apart. A prospective study is really necessary here to answer the question. A prospective study evaluates groups of patients at the time they have the vasectomy and follows them regularly for years to see, if indeed, cancers do occur. This is the most powerful way to study this relationship, but was not used in the Giovannucci papers. In addition, no study has ever established that there is an increased risk of death after prostate cancer following vasectomy.

Because the question of a relationship between vasectomy and prostate cancer was raised, the American Urological Association first recommended that men who had a vasectomy more than 20 years ago or who were > 40 years of age at the time of vasectomy have an annual examination of their prostates as well as a blood test for prostate cancer (serum Prostate Specific Antigen or PSA). However, given the recent lack of support for this relationship between vasectomy and prostate cancer, this recommendation has been revoked. Finally, no mechanism is known, nor is there any animal model proof of the plausibility of the link between these conditions.

Dementia Risk

There is a recent, single, small paper that has linked vasectomy to the later development of a rare form of Alzheimer’s disease. The issue is that a researcher found that, among a group of patients suffering a form of dementia called primary progressive aphasia (PPA) that is often confused for Alzheimer’s disease, the men had a higher percentage of vasectomy than was thought normal. The study found that 40% of 47 men with PPA had had a vasectomy, while among another 57 men from the community without PPA there was a vasectomy rate of 16%. What this means is simply that the rate of vasectomy among PPA patients is a little over 2 fold higher than in otherwise healthy patients. This study did not find an increased rate of vasectomy in patients with Alzheimer’s.

The most common form of dementia caused by brain deterioration in individuals over age 65 is Alzheimer’s disease. A very unusual form of Alzheimer’s disease is called primary progressive aphasia. This condition robs people of their ability to speak and understand language, but they are still able to maintain their hobbies and perform other complicated tasks for a long time. By contrast, Alzheimer’s patients lose their memory, interest in hobbies, family life and become idle.

A “mechanism” for the association between PPA and vasectomy was also proposed in the study. It involves the fact that men can have antibodies form to sperm after having a vasectomy (see above risks) and these antibodies may somehow cross-react with the brain and cause PPA. There is no animal model data to support this theory, however.

Problems with this study are similar to that described for prostate cancer risk and vasectomy. How unique were these patients that they gathered from all over the US twice annually to participate in a support group with such rare disease? We really need a prospective study to show this relationship as retrospective studies have too much “bias” or too many uncontrolled issues that could produce the same result. In addition, the study groups were very small: fewer than 20 PPA patients had a vasectomy and fewer than 10 healthy patients had a vasectomy. It is hard to generalize at all from so few patients in a study. Also, the study methods were faulty in that the vasectomy condition should have been confirmed by reviewing the medical charts on the PPA patients, since their disease alters their ability to understand, hear and remember what has happened to them! Indeed, like the issue of prostate cancer and vasectomy, this issue will take at least a decade or two to confirm or disprove.

Bottom Line: Vasectomy remains an effective method of sterilization. Certainly there are risks with any procedure and the risks of prostate cancer, dementia, and heart disease need to be considered by every man who wishes to proceed with the vasectomy.

The Safety of Vasectomy Using No Scalpel, No-Needle Technique

October 12, 2014

Vasectomy remains one of the most effective and safest methods of contraception. The only technique that would be cheaper is the diaphragm and abstinence. Both of which have a high failure rate. The next few blogs will discuss the safety of vasectomy.

Besides the fact that a vasectomy is very popular, one must remember that there is no form of fertility control, except abstinence, which is completely free of potential complications. In all, vasectomy remains one of the safest and best forms of permanent contraception, provided that the patient is aware of and understands the potential risks associated with the procedure. The side effects and complications of vasectomy are divided into “early” and “late” categories, depending on when they occur. The risks and complications of the procedure, including potential vasectomy pain, are examined below in greater detail.

Vasectomy and Pain

Men worry about pain and discomfort during and after the procedure. In my practice less than 5% of respondents said they had pain, much lower than the well-recognized and commonly published rate. In addition, seldom do any of the men require post operative pain medication. I suggest bed rest and ice over the scrotum the day of the procedure and non-steroidal anti-inflammatory medication such as Tylenol or Aleve for post operative pain.

Early Complications

Shortly after the procedure there may be mild discomfort, and most men are able to return to work in 1-2 days. A small amount of oozing (light bleeding, less than the size of a quarter) and swelling in the area of the tiny opening are not unusual. This should subside within 72 hours. Occasionally, the skin of the scrotum and base of the penis turn black and blue. This is not painful, lasts only a few days, and goes away without treatment. For a period of 7 days following the vasectomy, sex should be avoided. Strenuous exercise (for example climbing, riding motorcycles or bicycles, playing tennis or racquetball) should also be avoided for 7 days, and nothing heavier than 8-10 pounds should be lifted after the procedure until day 7 when all activities including heavy lifting can begin.

Rarely (less than 1%), a small blood vessel may bleed into the scrotum and continue to bleed and form a clot of blood (hematoma). A small clot will be reabsorbed by the body with time, but a large one usually requires drainage through a surgical procedure.

Importantly, the vasectomy procedure is not always 100% effective in preventing pregnancy because, on rare occasions, the cut ends of the vas may rejoin. This occurs very infrequently; the published rate is about 1 in every 600 vasectomies. My vasectomy failure rate, defined as either persistent motile sperm in the ejaculate or a pregnancy after the procedure, is less than 1/1000 cases.

Since sperm can survive for several months in the vas deferens above the point where they were interrupted, it is very important that another form of contraceptive is used until sterility is assured. To determine whether the ejaculate is devoid of sperm, an ejaculate must be brought in for formal microscopic examination after the procedure. Since “clearing the tubes” through ejaculation is a relatively inefficient process, it make take 15 ejaculations to empty the system entirely of sperm. In terms of time after the procedure, roughly 90% of men will have no sperm in the ejaculate 3 months later. This is the reason we ask men to provide us with a semen sample after 15 ejaculations or 3 months after the vasectomy. Occasionally, it may take 6 months or longer after the procedure to flush out all the sperm. The semen specimen must demonstrate no sperm before unprotected intercourse is permitted.

Bottom Line: Vasectomy is a safe form of sterilization and there are few complications.  Each man who considers proceeding with a vasectomy needs to weigh the benefits vs. the risks and complications associated with the procedure.  Most men will find that the procedure is the best way to proceed with contraception.

What Happens After A Vasectomy?

October 10, 2014

A vasectomy, using the no-scalpel, no needle technique takes just a few moments to accomplish in the doctor’s office. However, there are some precautions that are necessary after the procedure.

Most often, men are concerned about the pain involved in a vasectomy procedure as well as having a healthy, functional sex life afterwards. The no needle technique using a local anesthetic and the no-scalpel procedure which allows the procedure to be accomplished through a quarter inch opening without requiring an incision, causes minimal or no pain during or after the procedure.

Post Vasectomy Advice

  • The vasectomy procedure lasts anywhere from 10-12 minutes.
  • Patients do not require any general anesthesia and often take a Valium tablet before the procedure to remove the anxiety often associated with the procedure.
  • A bag of frozen peas or ice should be placed on top of the underwear over the scrotum to help reduce any swelling. Instead of frozen peas, you can place a few ice cubes in a zip lock bag and place this over the scrotum for a few hours after the procedure.
  • You may feel an ache in your testicles which is treated with extra strength Tylenol or Aleve.
  • You will need to have a ride home if you take the Valium.
  • It is recommended that vasectomy patients abstain from sex for 3 days.
  • You should have no activity the day of the procedure and minimal activity for 2-3 days after the procedure. You can resume all activity including heavy lifting and bike riding seven days after the procedure.
  • You will need to use some form of contraception until your semen is examined under the microscope to be certain that all sperm are absent from the ejaculate. I suggest that you have 15 ejaculations using contraception and then bring in a specimen for me to examine. If no sperm is seen, I will ask for a second specimen a few days later and if the second specimen is without sperm, you will be considered sterile and can stop using contraception.

Bottom Line: While pain tolerance varies from person to person, the pain following a vasectomy is generally a mild discomfort as long as instructions are followed. Avoid heavy lifting and strenuous exercise, take pain medication when necessary and place ice on the scrotum to speed up recovery time.   Finally, a vasectomy is not a protection against sexually transmitted diseases (STD).

Vasectomy For Male Contraception-What Are the Alternatives?

October 10, 2014

A vasectomy is a method of male birth control that should be considered carefully as it is, for the most part, a permanent form of sterilization. The procedure using the no-scalpel, no needle technique can be done in minutes. However, reversing the vasectomy takes several hours in the operating room and is usually not covered by insurance. Before you move forward with a vasectomy, it is important to review vasectomy alternatives that are available.  If you have any doubts about having children in the future, you should explore temporary birth control options.

Tubal ligation, commonly referred to as getting your ‘tubes tied,’ is a procedure used for female sterilization. The fallopian tubes, the small tubes that transport the egg or ovum from the ovary to the uterus, are closed off by various methods (severed, sealed or pinched) to block the eggs from reaching the uterus.

Essure

Essure is a permanent method of birth control where small metal coils are placed in the fallopian tubes. The coils cause scar tissue to form, which blocks the eggs from reaching the uterus. The coils are inserted vaginally during a hysteroscopy procedure. Unlike tubal ligation, there are no incisions or anesthesia used. Birth control is needed for several months after the procedure until the scar tissue has completely formed.

Bottom Line: Vasectomy should be considered a permanent form of contraception. If there is a possibility that you might want more children in the future, I suggest that you consider temporary forms of birth control that are non-surgical. There are a variety of options available including condoms, birth control pills, cervical cap, diaphragm and, yes, abstinence!

Vasectomy And Prostate Cancer-What’s the Risk

July 10, 2014

I often receive calls about the relationship between prostate cancer and vasectomy. There have been many studies that have looked into this relationship and this blog will shed some light on the issue and help men make an informed decision on having a vasectomy, one of the best methods of permanent contraception.

Men who had a vasectomy had a significantly greater risk of developing aggressive, potentially fatal prostate cancer, according to data from a 50,000-patient cohort study.
A recent study in the Journal of Clinical Oncology stated that the overall association between vasectomy and prostate cancer was modest.

The lead authors was quoted as saying, “I think we need to tell men that vasectomy has some risk with prostate cancer, may be linked, but we don’t know. It’s something they need to be aware of and monitored, but really, to me, this is not something that is such a strong association that we need to be changing the way we practice, either prostate cancer screening or vasectomy.”
Studies dating back to the early 1990s have yielded conflicting results about the association between vasectomy and prostate cancer. Some studies have shown as much as a twofold increase in the risk of prostate cancer after vasectomy, whereas others showed no association, the authors noted.

During follow-up through 2010, 6,023 participants had newly diagnosed prostate cancer, including 811 lethal cases. The data showed that 12,321 of the men had vasectomies. The primary outcomes were the relative risk (RR) of total, advanced, high-grade, and lethal prostate cancer, adjusted for a variety of possible confounders.

Vasectomy did not have a significant association with low-grade or localized prostate cancer.

The study adds information to the discussion and controversy surrounding vasectomy and prostate cancer but leaves many questions unanswered. Use of transurethral resection of the prostate, statins used to treat elevated cholesterol levels, selenium, and a number of other factors can influence prostate cancer risk.

The study added little information that goes beyond what previous studies had shown, said Gregory Zagaja, MD, of the University of Chicago. The study suffered from the same limitations of studies that came before it.

Multiple experts state that no consensus exists about potential biological explanations for reported associations between vasectomy and prostate cancer or whether the association is biologically plausible.

Bottom Line: There is a modest risk of prostate cancer in men who undergo a vasectomy. All men, whether or not they have had a vasectomy, need to have a regular PSA and digital rectal exam. For more information on this topic and the relationship between prostate cancer and vasectomy, speak to your doctor.

Vasectomy and Other Medical Issues-Prostate and Testicular Cancer

November 14, 2013

There isn’t a day that goes by that men ask me about the consequences of having a vasectomy.
These reports were prompted by concerns that vasectomy, which involves surgery to cut the tubes that carry sperm, could lead to inflammation in the pelvic region. Prolonged inflammation in certain circumstances can increase cancer risk.

There has been some uncertainty surrounding this question, but recent studies have demonstrated that having a vasectomy has NO effect on the risk of prostate or testicular cancer.
Older data – from studies tracking disease rates across broad population groups – suggested a modest connection, while other studies found no such link.

More recent studies from researchers at institutions such as Boston University and the University of Washington showed no convincing association between vasectomy and prostate cancer. The Boston University group and researchers in Denmark found no link between vasectomy and testicular cancer.

Bottom Line: Today, we can say with confidence that vasectomy does not increase or decrease the likelihood of developing prostate or testicular cancer.

Vasectomy-The Prime Cut, Most Men Are Satisfied With The Decision and the Procedure

June 22, 2013

I have performed nearly 6000 vasectomies in my career and I have found very few men are disappointed with the procedure or the results. The majority of men don’t have any reservations after the procedure.
Often men will ask if the procedure is reversible and the answer is that the vasectomy can be reversed. However, men should make the decision to have a vasectomy only if their family is complete or they don’t plan to ever have children. The cost of the vasectomy is less than $1000 but the cost of the reversal can be north of $20,000. The vasectomy is done with a local anesthetic only takes 10-15 minutes and a reversal requires a general anesthesia and can take 2-3 hours to complete.

A study conducted at the University of Iowa reported half of the men said they considered a vasectomy for a year or less before having the procedure; 85 percent had a high level of certainty they made the right decision. The most common reason for the sterilization was that a man didn’t want additional children and felt a vasectomy was the best birth-control option. Over 90 percent were married, and had two or more children.

Almost a third of the men had some anxiety about the procedure, primarily concern about possible pain and “fear of the unknown.”
Bottom Line: Vasectomy remains one of the best forms of permanent sterilization. Most men are satisfied with the procedure and the results and would do it again and recommend it to others.

No Sperm, No Baby, No Problem

March 29, 2013

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Women have received a bad rap.  The assumption that most problems associated with the difficulty to conceive and have a baby is the fault of the female partner.  However, let the truth be told, 1\3 are a result of female problems, 1\3 are a male issue, and 1\3 are linked to both male and female problems. 

That’s the bad news.  The good news is that two-thirds of couples treated are ultimately able to conceive.

Part of the issue today is that many women are waiting much later in life to have children.  As women get older they’re going to see more problems trying to conceive. Men are capable of fathering children later in life, certainly into their 40s and 50s. They don’t have the same fertility issues that women have at that age.  That is, the biologic clock of men ticks longer than for women.

Common causes of men’s infertility can be hormonal problems, injuries, illness, medications, or a previous vasectomy. Lifestyle issues like smoking and alcohol use may affect sperm production, but are secondary factors.

A common cause of infertility in men is varicocele, an enlargement of the veins in the scrotum that heats the testicles, affecting the number and shape of sperm.  A varicocle is a common problem and up to 30 percent of all men have a varicocele.

Varicocele can develop in adolescence, and may be discovered by a pediatrician. Because of the long-term effects that can lead to infertility, a pediatric surgeon or urologist may recommend a procedure to correct the problem, depending on the severity. The purpose of the surgery is to seal off the affected vein and route blood flow into normal veins.

Another cause of male infertility is vasectomy.  Men are having a vasectomy, which is a reasonably permanent form of sterilization at an earlier age, and then have a change of heart when they get divorced and then marry a younger partner and want to have children and start a second family.  A vasectomy reversal is now quite successful and can be done as an outpatient in an ambulatory treatment center.

More recently, the public has been bombarded with advertisements for medications aimed at correcting low testosterone or low T. These popular medications for hormone replacement for low testosterone may affect a man’s future fertility.  Men should talk with their doctors about medications if they are trying or may be planning to achieve a pregnancy in the future.

Bottom line: Infertility is just as much a man’s problem as it is for the woman.  Help is available and the place to start is a semen examination to be sure that the man has all the ammunition he needs to father a child. 

When You Have A Tack In Your Sack-Chronic Testicular Pain

June 15, 2012
When It Hurts Down There

Chronic Testicular Pain

Chronic testicular pain is a common malady causing havoc in men with this problem. The pain can be so debilitating that men lose productivity in the work place, have sexual problems and even depression that requires treatment. Men often have anxiety about cancer. Chronic testicular pain is also called orchialgia, orchidynia, chronic pelvic pain syndrome, or chronic scrotal pain syndrome. These are all terms used to describe intermittent or constant testicular pain.

Chronic testicular pain occurs at any age but the majority of the patients are in their mid to late thirties. The pain can involve one or both testicles. The pain can remain localized in the scrotum or radiate to the groin, perineum, back or legs. On clinical examination the testis may be tender but in the majority of men is otherwise unremarkable.

Causes of orchialgia include infection, tumor, testicular torsion, varicocele, hydrocele, spermatocele, trauma and previous surgical procedures such as a vasectomy.

Any organ that shares the same nerve pathway with the scrotal contents can present with pain in this region. Pain arising in the kidney, hip, prostate gland or back pain caused by a herniated disc can present as testicular pain. Injury to nerves following a hernia repair can cause chronic testicular pain. Chronic testicular pain has been recognized as a feature of diabetic. Some men attribute the start of their chronic testicular pain to some form of blunt injury to the testicles. Unfortunately in a large proportion of patients the cause of their pain remains unknown.

Post vasectomy chronic pain syndrome
It is not common but there is a possibility that following a vasectomy an obstruction or congestion of the vas or in the epididymis may be the cause of the pain.
If the man has an injection of local anesthetic, such as xylocaine, prior to cutting the vas, this may reduce both immediate and long term post vasectomy pain.

The formation of spermatic granuloma following a vasectomy has been well documented but its protective or causative role as been controversial.

Testing
Scrotal ultrasonography is usually part of the evaluation of patients with scrotal pain. However, in the absence of significant clinical findings during physical examination and in the presence of negative urinalysis, the only real benefit of scrotal ultrasound is reassurance to the patient worried about cancer

Treatment
Surgery is to be avoided if possible. Even if infection has not been identified a small number of patients may respond to a combination of antibiotics and non-steroidal anti-inflammatory drugs. Tricyclic antidepressants, such as imipramine, sometimes relieve the pain. Those with intractable symptoms may benefit from a multidisciplinary team approach involving a urologist and a pain clinic specialist including a psychologist. Transcutaneous electrical stimulation or TENS analgesia often have favorable results. This works on the principle that transcutaneous electrical stimulation causes release of endorphins in the nerves of the spinal cord that supply the scrotum.

A spermatic cord block with a local anesthetic such as xylocaine can be done in the doctor’s office. The procedure, if successful, can be repeated in regular intervals.

For patients who fail to respond to conservative management and wish to avoid the surgical options that are available in treating chronic orchialgia, a trial with an alpha blocker might be an option.

For patients in whom all medical treatments have failed and testicular pain continues to impair their quality of life, surgical intervention may be indicated as a last resort. A number of surgical strategies have been described.

Microsurgical denervation of the spermatic cord may provide relief of chronic testicular pain. Another technique is to divide the ilioinguinal nerve and its branches.

Removal of the epididmymis or epididymectomy should be performed only if the patient had been counselled regarding the likelihood of poor results.

Vasectomy reversal
Putting the vas back together or a vas reversal has helped a number of men with chronic testicular pain.

Unfortunately a small number of patients who fail to respond to medical or more invasive treatment will ultimately undergo removal of the entire testicle for pain relief. This procedure must be the last resort.

Bottom Line:
Chronic testicular pain remains a challenge to doctor as well as the patient.
Help is usually available with medication, nerve stimulation with TENS, and only surgery as a last resort.


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