Post Vasectomy Pain (PVP)
The Dawson Microsurgery assessment and experience.
What is PVP?? The Dawson Microsurgery definition
• A chronic relapsing testicular ache whose onset may be as little as 8 weeks to as long as 5 years or more post vasectomy.
• PVP may occur immediately after ejaculation or the pain may be of insidious onset over subsequent days.
• The pain is chronic, lasting for years with relapses usually lasting 1-4 days though very variable in frequency
• Often the pain is unilateral or at least more severe on one side than the other.
• PVP should, where possible, be a diagnosis of exclusion after investigation has failed to identify any other lumbar of urological abnormality’.
We advise exclusion of lumbar spinal problems, prostatic disease, and varicocoele.
Spectrum of severity
As with other diseases there is a spectrum of severity with symptoms varying from trivial and short lived, to severe and persistent. At its most severe PVP can affect the patient’s everyday life leading to irritability, depression and relationship problems. GPs, urologists and ultrasound departments will all be familiar with vasectomy patients reporting post vasectomy discomfort. Most PVP suffers will be reassured by the exclusion of testicular malignancy by a normal US Scan but some will require intervention.
Examination generally shows a completely normal testis but a swollen, often tender epididymis in which there can be firm swellings, possible concretions due to sperm stasis. On the vas, sperm granuloma may be present but in our experience does not cause PVP.
Various suggestions have been made, neurological damage at the site of vasectomy, epididymal distension and formation of sperm granuloma. Investigation has shown that there are no histological correlations post vasectomy changes in the vas, epididymis or testis so the presence of PVP is an individual response to the vasectomy. At Dawson Microsurgery we believe that PVP is caused by pressure build up in the epididymis leading to distension of this delicate structure and its overlying fascia. Over the last 10 years we have performed reversal of vasectomy for approximately 24 PVP sufferers. We also have experience PVP as an incidental finding (over 100 cases) in men requiring return of fertility. Overall, reversal in this clinic leads to complete resolution of pain in over 90% of cases.
Various teatments have been devised for PVP. These include excision of the epididymis, converting the vasectomy to open ended and reversal of vasectomy. In our view reversal is the best option as this is a simple day case procedure without risk of significant complication and has a proven high success rate. Reversal of the vasectomy allows the accumulted sperms and fluid to drain freely thus allowing the epididymis to deflate and return to normal One word of caution, if the connection scars and closes the pain will return, so excellence of technique, quality and accuracy of microsurgery, is all important.
Dr Andrew Dawson Urological microsurgeon
Choosing a vasectomy reversal clinic – follow the doctors!
Get a few doctors together and ask them about their last operation. Maybe it was a slipped disc, gall stones, arthritis of the hip, maybe even a cheeky tummy tuck. No matter what it was you can be sure they did their research because they know that complications and operation failures do happen. Problems are not an act of God, problems are avoidable.
So how do doctors choose a doctor?
They talk to colleagues, read up on the subject often published articles on the internet then draw up a three point list;
1) what is the best technique, the goldstandard or benchmark?
2) who is specially trained in this specific method?
3) how many procedures does he do every year?
This almost always leads to ‘the man’ for the job!
Using the internet
The ‘web is a funny thing! For any given subject, it’s all there. The good, the bad, the ugly, the misleading the fraudulent and the excellent!! There is ‘hard’ and soft information. Hard facts from research papers and soft information, usually cuddly feel good pictures and unattributable quotes.
So here are my suggestions for reading between the lines of the UK vasectomy reversal web sites. It works for reversal but of course applies to most medical procedures.
Technique – getting the facts, knowing what standard to expect.
Nearly all the research on reversal on vasectomy reversal has been done in the USA and that is where to go to find the facts. No doubt in my mind that the American surgeons Dr Sherman Silber and Professor Marc Goldstein (famous for the multi layer microdot technique) are the ‘best of the best’. Their web sites give masses of reliable information, see www.infertile.com and www.maleinfertility.com . Both these centres have described techniques that have been tried and tested and shown to be the ‘best techniques’. If you want to see these same techniques, Drs Silber and Goldstein show their operations on Youtube, they are not grisly!
Check your UK surgeon uses a technique similar if not exactly the same as the best guys and has received the training in this technique. Look for a certificate!
Number of procedures
there is no doubt that focussing on this procedure brings experience and competence. As an example an orthopaedic surgeon may well super specialise say in knee joints and almost never do any other operation so he knows that procedure inside out which gives you best the patient results.
So, how many procedures is good and how many is enough? The good guys, our benchmark will perform one to two reversals per day taking around 3-4 hours per case and perform maybe 4 cases per week, 150 per year. However, more than this may not mean better! Some web sites in the UK claim their surgeon performs 6-8 reversals per day and 500 per year. OK, so that’s 500 cases per year and a throughput of 6- 8 cases per day means our surgeon is spending 12 to 16 hours of operating per day and that’s without a lunch break, toilet break or rest. He is doing this for 80 working days a year as well as holding down a full time urologist job, maybe being a prostate expert as well. Does this allow enough time to provide you with the results you expect?
What about technique?
There are a variety of techniques out there all of which aim to do the same job. They are not all the same, some are designed for quickness and some aim to avoid the technical difficulty of performing real microsurgery. So your surgeon should tell you exactly what he does. Choose a surgeon who uses a proven (published in the medical journals) technique and be wary of the individual surgeon doing his own thing. If his way is best you can be sure he would let us all know and we would all use his method! And what about the size of the stitches used? Our benchmark surgeons use proper micro stitches, sometimes 9-0 but usually 10-0 (higher numbers, smaller stitches). So what of claims such as the use of cardiac stitches? Sounds good? Well, cardiac stitches are at their smallest 7-0, not microsurgery stitches at all.
The web sites mention ‘success rates’, what does this mean?
It’s all about the babies!
Success in this context means simply that at some time after the reversal some of the tests showed some sperms for however short a time. This is the same as ‘patency’, so that the join was open at least a bit for a while.
But real vasectomy reversal success is about getting pregnant because getting pregnant means that the reversal has produced enough sperms that are motile enough to get through and do the job!
Many reversal sites hide behind the excuse that fertility involves the female which is an unknown factor. But that simply is not good enough! The published results on reversal manage to quote pregnancy rates and these are valid because over a large sample (say over 100 cases) the fertility of the females averages out. So my advice is ask to for pregnancy rates and don’t accept excuses because pregnancy is the only success you are interested in!
So, good luck with your research. Please do give us a call (on 01429 282800) or visit www.vasectomyreversals.co.uk for our impartial advice, but only about your vasectomy reversal! If it’s a tummy tuck you need, follow the other doctors!
Andrew Dawson Director Dawson Microsurgery Vasectomy Reversal Clinic
Couples are faced with the choice of IVF or reversal when they want to add to the family after vasectomy. Where do they turn for advice on what to do next? Maybe the GP, their friends and acquaintances, the internet? Many go to a fertility clinic for guidance. Continue reading →
Contact Us: 01429 282800
We're always happy to discuss and help with individual cases