When to Use the Knife with Post-Vasectomy Pain

Gordian knot
Post-vasectomy pain: A Gordian knot or not? (Courtesy: lawsociety.org.uk)

The case is an actual patient from The Turek Clinic
After having 3 kids in 5 years, he was more than ready to have his tubes tied. So, he did, by a colleague, and he did quite well thank you…for a while. “The procedure seemed to go OK, Doc, but lately my balls have been achy,” he told me 6 months after the vasectomy. He’d been cleared from using other contraception by that time. “It’s not bad enough to take anything, and I can’t tell what makes it worse or better, but I’m not ready to live like this forever.”
On physical exam, everything looked great. No lumps or bumps, no varicocele, hernia or tenderness. Everything in its rightful place down there. The only finding of note was that the vasectomy sites were quite low in the scrotum, behind each testis.

Uncommonly Common Pain

Although rare in my practice, post-vasectomy pain syndrome appears to be more common than many vasectomists are willing to admit, occurring in up to 15% of men after the procedure. Even more commonly, both vasectomists and patients shrug their shoulders when it comes to evaluating causes and using effective treatments for this debilitating condition.
In my experience, you must first listen to the patient and learn about the pain. Having done this for years, I realized that this “syndrome” is actually compromised of 4 very different problems, but all knowable and treatable.

Break it Down

Granuloma: Acutely tender mass at the vasectomy site resulting from leakage of sperm either at surgery or soon afterwards. Usually resolves with anti-inflammatories and time and only rarely needs to be removed surgically.
Epididymitis. Acute tenderness near the testicle that can occur any time (but generally years) after the procedure. It may be that increased back pressure in the system behind the vasectomy causes a “blowout” in the delicate tubes of the epididymis. It is not an infection and generally resolves with time and a short course of anti-inflammatories. It rarely recurs.
Neurogenic. Chronic pain in the spermatic cord or testis area often without any physical exam findings that begins early on after the procedure and sticks around, relentless and bothersome. Usually associated with a difficult vasectomy procedure. This pain is best treated with weeks to months of anti-inflammatories, neuromodulators and pain therapy. If spermatic cord blocks relieve the pain, then microdissection of the spermatic cord can be used to desensitize the area.
Congestion. Low level tenderness, or simply a “heaviness” in the testis, that occurs months after an otherwise unremarkable vasectomy procedure. Typically represents increased “pressure” from backed up fluid and sperm in the system and “stretching” of the tubular organs behind it to the point of annoyance. Treatment can include time, removal of the epididymis (rarely) and vasectomy reversal to restore natural anatomy and sperm flow, thereby reducing back pressure. I have also successfully used testosterone replacement therapy to “turn off” sperm production, decompress the system, and eliminate the discomfort.
Which of these did my patient have?  Well, with low level, chronic pain, and no mass, it was a classic case of congestion. After conservative treatment with anti-inflammatories, the low-level discomfort persisted. I performed a straightforward vasectomy reversal and he felt better immediately. Happy to be pain-free, he and his partner are now considering other contraceptive choices.
As a dedicated men’s health guy and microsurgeon, what I have learned about post-vasectomy pain syndrome is to listen to the patient, dissect out the problem, and only pull out the knife when you have to.
 

31 thoughts on “When to Use the Knife with Post-Vasectomy Pain

  1. Good evening Dr. Turek,
    My husband was diagnosed with azoospermia in April. We then tested all hormone levels, did genetic screening, and tested for the karyotype and Y Chrosome microdeletion. All tests came back completel normal. His FSH was 3.0, LH was 2.8 and testosterone 502 with normal testicular size. All signs pointed to OA, but when PESA was performed, no sperm were found so they diverted to a testicular biopsy which showed maturation arrest. We are getting results back and meeting with the urologist tomorrow. Is there any hope for us? We know our only options at this point for genetic children are doing either FNA mapping or mTESE. We are preparing for the worst, as early MA has low chances of success for mTESE, low chance for success with ICSI, and high risk for genetic abnormalities. Is there any insight you might have to our case by any chance? We would appreciate your expertise!! Thank you for your time!

    1. Dear Grace, you are certainly well educated on the nuances of testis pathology! Yes, early or late maturation arrest can mimic the look of a blockage testis but is actually much more common than a blockage. Since the testis tubules in this condition appear normal, mTESE is often very difficult to do and unsuccessful at finding sperm. FNA mapping might be a good choice as it, by nature, is different and doesn’t rely on testis tubule size to find sperm. It simply finds the sperm.

  2. Dear Dr. Turek
    I got a vasectomy one month ago. I had a small internal bleeding, but after a month my scrotum is still larger than before vasectomy. But my problem is the pain that appeared one day after the procedure. I still feel that the testicles are painful and sore, sticking around, the skin under scrotum is burning, and all of these get worse with minimal activities like just walking. I am taking anti-inflammatory pills and paracetamol. There is no infection or granuloma.
    I feel best when I lie down at night.
    Am I in the Neurogen or Congestion group? What is your suggestion? Is there any hope for me?
    thank you very much

    1. Dear Sam B. Swelling and residual pain can be normal 4 weeks after a vasectomy. Still too early to call it congestion or neurogenic pain. Sounds like you had a hematoma after the procedure which itself can take 4-6 weeks to heal. Things might be fine but check in with your vasectomist regarding your concerns.

  3. Dear Dr. Turek,
    I had a torsion event as a teen which resulted in a left orchiectomy and a right orchiopexy. I am now 31 in a stable relationship with two kids and am looking to get a vasectomy. My doctor attempted the procedure a week ago, but had a difficult time getting things into position and we stopped short due to pain. We are rescheduling to complete the procedure under general anesthesia. I am quite bruised and very tender near the incision and my epiditimus/spermatic cord.
    After searching around I’ve learned a bit more about PVPS and am now reconsidering getting a vasectomy. My doctor didn’t provide the 15% statistic you quoted and I’ve seen elsewhere, nor did he discuss any possible complications due to my history. I’m attempting to make an informed decision about the risks of PVPS and candidacy for vasectomy given my prior trauma, but haven’t found anything useful. Are there any studies or statistics you are aware of associating prior orchiopexy and PVPS or vasectomy candidacy for torsion survivors?
    Thanks for your time and I appreciate your candidness about the risks and possible complications of a vasectomy!

    1. Dear Jon A, you are wise to take a step back and reconsider the vasectomy. In cases of orchidopexy, there may be excessive scar tissue around the cord that forms a “rind” and makes the vasectomy a bit harder. You should move forward with care, as you only have 1 testis to work with for the rest of your life. I am not so much worried about PVPS as testis injury in a man with only one jewel left.

  4. I had a vasectomy 5 weeks ago. I have pain on my left side — not debilitating but also not something I would want to accept as a long-term thing.
    For the first couple of days after the vasectomy, I had nothing more than tenderness at the incision site. Then, after that, for about a week, I was 100% fine. Then, at about day 12, after a couple of ejaculations, I started to feel dull pain in one testicle, and in the groin on the same side — about the same as the pain one feels after a light impact on normal testicles.
    I am uncomfortable on chairs (constantly moving around trying to find the right position) and very conscious of my one testicle in walking.
    It doesn´t look particularly enlarged (although it is hanging a little lower than the other). I do not feel any noticeable bumps or lumps.
    I am taking ibuprofen and paracetomol, but it doesn’t help much, if at all.
    What might my problem be?
    Thanks.

    1. Dear Shawn, A great question for your vasectomist! Pain 5 weeks from vasectomy could be either infection or inflammation. Congestion typically starts later and is preceding by a period of painfree-ness.

  5. Hello, I am writing on behalf of my husband. He had a vasectomy done 3 months ago then placed on keflex for about 5 days. After that his right testicle swelled up, then placed on cipro for 3 weeks, as soon as he came off of it right testicle swelled up again, then got an ultrasound show: right epidymitis, small vericocele and small hyrdocele. Prior to vasectomy Had no urologic issues. They placed him in flagyl for 3 weeks. During the time he takes antibiotics and Ofcourse nsaid 600mg. Testicles return to normal. As soon as he stops then r testicle swelled up again. So needless to say again R testicle swollen. Urologist says this is crazy and does not know what is going on. He is getting another ultrasound on Thursday and they want to start him on another antibiotic combo. 2 diff antibiotics. I have been reading a lot maybe too much on this topic and have an concerned and blame myself a little bc I told him to look into this bc we have 3 beautiful kids and and don’t want to risk getting pregnant again. Anyways, in my gut I have a feeling that after this antibiotic round same thing gonna happen. I am at the point that I want to look into a reversal and pray to god it is an option bc life long pain like this I feel would cause depression to anyone. Please let me know your thoughts from your experience.

    1. Dear Liz, I’m sorry that you and the hubby are going through this! Since it is only 3 mos out from the procedure it is most likely inflammation from sperm spillage and not a real bacterial infection. Typically antibiotics don’t help but long courses of antiinflammatories do. He could have a “leaky” vasectomy or epididymitis but most likely only inflamed and not infected. A reversal would be difficult to do well during a period of active inflammation. Be happy to see him!

  6. Boy, do I need some new diagnostic ideas and FAST! Here’s my PVPS situation, and I’m at a loss as to which of the four categories I fall into. I had a vasectomy about three years ago, and during the procedure the doctor asked, “hmm…you’re bleeding a lot…any ideas why?” (Um, nooooo, do you, doc?) Despite that bizarre and ominous beginning, recovery wasn’t too bad. But a year later I began feeling aches and twinges of pain in my right testicle, and at completely random times. Swelling too. Since then, the pain has come and gone, sometimes with strong generalized aches, but also a stabbing pain that will come and quickly go, perhaps ten times a day. It’s an excruciating flash of white-hot pain, but then is gone the next second. I’ve been treated by the original doctor with steroid shots to the scrotum, anti-inflammatories, antibiotics, but the pain always comes back. And it seems it’s getting worse in the last few weeks. As I write tonight, the stabs are coming every few minutes again, and are so painful that my body flinches. I work as a psychotherapist and the fear of having one of these flinching/grimacing episodes while I’m listening to a client unburden their lives is a huge stressor, (“Oh, don’t mind me, it’s just that my balls are on fire. Please continue.”) Thank you for any thoughts!

    1. Dear Brian Kay, Love the response you wrote when you’re doctor asked you why you might be bleeding!! Honestly, it doesn’t sound like the treatments that you have received have worked to date. This means that a) the pain is entirely unrelated to the vasectomy (i.e. look for other causes, hernia, pelvis, back etc) or b) the relationship to the vasectomy is complex. Be happy to see you!

  7. Paul,
    Just had a vasectomy about a week ago. The first few days were actually not too bad, and feeling better each day. About 3 or 4 days later, wash showering and cleaning in that region, when I started to experience left testicular pain (which had been the side that was feeling better). Few days since then and pain has been constantly there with activity, and absent at rest. Tender to palpation, especially posterior to the left testes, and I notice the left epididymis seems enlarged compared to right, and is most tender to palpation. Otherwise, no signs of infection I notice. What potential causes come to mind?

    1. Dear Matt, pain within a week of vasectomy can be inflammatory or congestive. It’s a little too early to call it. If it continues, please contact your vasectomies to followup.

      1. I had the same issue pain in left testi lump above it went in to office on day 6 they put me on antibiotics doxycycline. Now I’m on day 13 five days on antibiotics swelling of Epididymitis is on and off very uncomfortable I’ve been taking Aleve

  8. Dear Dr. Turek
    I had my vasectomy 3 months ago. About 6 weeks ago I started having pain from my left testicle up to behind my pubic hair. I went to see my doctor, had a subsequent ultrasound scan on my scrotum and was diagnosed with a granuloma. I’ve been taking anti-inflammatory (sodium diclofenac) for the last 6 weeks but have just run out of them. I have less pain in my testicles, my pain is mostly situated behind my pubic hair.
    Do you think this pain locality is consistent with a granuloma?
    Could I take the anti-inflammatories for longer?
    Is there anything else I could be trying or doing?

    Thanks so much.

    1. Dear Chris, that diagnosis sounds about right. Stay on the treatment plan and keep in touch with your vasectomist!

  9. Dear Dr. Turek,
    I had vasectomy 10 months ago. The first couple weeks were not to bad, I immediately had some aching pain in lower abdomen and some small aches at the site. Things started to go downhill 2-3 weeks later, with soreness and then shooting pains typically starting from upper scrotum and moving up into the lower abdomen.
    I was told I had a small pea size granuloma on the left side, during the first 3 months it could often be quite painful to touch. At 3 months I switched to a lot of burning pain and the shooting pain attacks became rarer. I had a sense of pressure mostly on the left side that often made it difficult to sit. During this period touching the upper part of my testicles often resulted in intense pain. This is much rarer now but still occasionally happens.

    I’ve made some amount of progress since then. For a week I had an intense building pain/ache with ejaculation on my *right* side, then milder right side pain occasionally after that bad week. I still seem to switch between different things I’ve felt, sometimes bad always going on.

    For the past couple months, I seem to go through bouts of different things I’ve experienced, but they are typically less intense., sometimes its mostly burning. Sometimes its generalized soreness in the groin, sometimes the shooting/throbbing pains return, sometimes aches in lower abdomen. The pressure/tightness on left side unfortunately re-intensified in the last week. I feel like I’ve plateaued on progress and while never feeling normal, I have bad flare ups.

    I’m going to try a cord block soon. The urologist I’m going to seemed perplexed by my up and down progress state but only seems to be offering denervation as a path forward and I’m unsure of that. I mentioned reversal but he seems to think it could make things worse? I mentioned try TRT to test and he seemed to think the potential side effects aren’t worth it.

    All I have really tried at this moment are an unsettling amounts of NSAIDs, papaya seed extract and waiting.

    Thank you for your time and sorry for rambling.
    Jesse

    1. Dear Jesse, this is unfortunate that you have had such a drawn-out pain experience after a simple procedure. My sense from the migrating pain is that something else is going on or that you are so focused on pain that the “microphone” is set on 10/10 volume. I would encourage a dual approach to the pain: treat it locally and also centrally, possibly with neuromodulators.

  10. Dear Dr Turek,

    Thank you for your thoughts, I appreciate it. I’m not familiar with neuromodulators. Searching leaves me a little lost, do you mean like acupuncture or electrical pulses?

    I have had a couple back pain incidents (a very old injury that was dormant flared up, the first time with a burning pain similar to that I was suffering in the groin) and have lingering hip pain on my left side. My primary said the hip pain was muscle tightness, I suspect from how tight I tend to hold that side.

    If I could ask you to speculate, I have bouts of pulsing throbbing pain, that have somewhat lost their intensity. Do you know what that might be?
    Thank you again,
    Jesse

  11. Dear Dr. Turek,
    I had vasectomy more than one year ago (15 july 2108) and I’m with intermitent pain after that day. The pain intensity it’s diferent but never enogh to take analgesics (0-4 of 10). My doctor says its just time question and this pain its going to disapear but here I am with the same pain. I’m not sure what make it better or worst but sometimes I feel If I got many ejaculatios (the same or consecutive days) I feel the pain increases but not inmediatly. Cold it’s the other thing that maybe increasses the pain. I can say too that my left testicle was quite lower than right one before operation and I feel more pain in the right side often. Ultrasound find on me fisiologic hidrocele bilateral, varicocele in left side and a 8.6mm lump on the right testicle (inside epididimys). The doctors do not worry about this things and they say everything its fine, they dont find anything wrong. The doctor touch epididimus and can’t focalize the pain in that side and find it normal. I’m trying to find if my pain its because “congestion” and go reversal but they dont agree because the pain can get worse. The only recomended thing is to remove epididimus if the pain get worse or get analgesics pills for the rest of my life. I apologyze for my bad english, but you are currently the only hope I have.

    1. Dear Adrian, I am sorry that you have had a painful year after your vasectomy. To me this sounds like congestion but could be residual inflammation. Some treat congestion with removal of the epididymis but I typically do not. Either Reversal or testosterone replacement to “turn off” sperm production and decongest the system work well for me.

  12. Hey Dr. Turek,
    I had my procedure done 6/26, so I’m nearing 3 months since the procedure now. Immediately following the procedure I noticed the pain in my left testicle was much greater than that of the right. Based on reading the “normal” post procedure pain expectations my right side seemed to fit in. The left side had a strong dull ache, like someone was squeezing the testicle constantly, and this slowly decreased in intensity over roughly 4 weeks post surgery. After the 4 month mark this dull ache seemed to disapear best I can remember. It would come back for short periods of time, normally it seemed if I was doing something active or putting pressure on my testicles like sitting wrong or something, but it was not 100% constant throughout the day. Then at the 2 month mark the pain returned as a constant pain. It is very dull, like 2/10, and feels like a light pressure like something is just barely squeezing my left testicle. I have been reading various articles online (this can be good or bad I suppose) but read about the granuloma and noticed I do appear to have a small lump that could be this on the left side. Note, I have been just fine on the right side, maybe some small twinges of pain once every other day for like 5 seconds, but nothing noteworthy really.

    I reached out to my Dr. roughly 10 days ago and he recommended anti-inflammatory and ice and a follow up at my 3 month mark to see if conditions have improved, suggesting we’ll do an ultrasound if not. I have followed his recommendations, taking 600mg ibuprofen every 6 hours (except in the night) for the last 10 days and haven’t noticed any improvement, maybe even a slight worsening (although this could be more psychological I suppose).

    Now for my questions, if you don’t mind.
    Based on my symptoms, do you think it is possible I have a granuloma and it is causing the pain I feel?
    Can a granuloma form this quickly? Can it cause these symptoms? If so, can an extended period of time of ibuprofen fix this, as in disintegrate the granuloma I guess?

    Lastly, I am with Kaiser and I am local to you so I would be interested in getting a second opinion. I think I’d get more value out of the second opinion if you can help me do some initial troubleshooting if you will, and then I can bring the results to you for discussion. So please let me know if there is anything else you would suggest for me to ask my provider to check as I try to follow up with this ultrasound.

    I appreciate your time and thanks for helping us all out on this forum here, very valuable stuff!

    1. Dear Matt, You’re a good historian. First fact is that a vasectomy is really two procedures and each side can heal up differently. You have experienced this. Second is that the timeframe of the pain you have is classic for inflammation/granuloma. It just may take a little longer. If low grade discomfort continues without evidence of inflammation/granuloma then it may be congestion but this takes longer to sort out. Happy to see you anytime!

      1. Thanks for the info Doc. Based on some of your other responses, sounds like I should give it at least 2 months of regular anti-inflammatory usage before I rule out the granuloma/inflamation diagnosis?

        Also, I just realized it auto-filled my whole name in, would you mind editing the name on original post back to just Matt D. for privacy reasons?

  13. Howdy Dr. Turek,

    I appreciate your informative article on this difficult subject. In my opinion there is not enough awareness of this issue, and there is a lot of room for improvement in how doctors talk about and attempt to treat PVPS.

    I have had pain ever since my vasectomy in December, 2017. As I sit here right now I have a mild burning sensation in the general area of my epididymides and perineum. Sexual intercourse with my wife has gotten less and less frequent since the vasectomy.

    You may find my little hobby interesting. I have been looking on online social media for men describing their experience with PVPS.
    Here is a timeline linking to 338 social media “case studies” of men with persistent pain and/or sexual dysfunction after vasectomy:
    https://www.reddit.com/r/postvasectomypain/wiki/timeline

    I have been adding a new story every day for almost a year now. I find it a refreshing counterpoint to being told by authorities that my condition is all in my head, or very rare, or that it will surely resolve on its own any day now.

  14. Hi Dr. Turek. I had a vasectomy 3.5 months ago, and I’m still in discomfort. My main areas of discomfort area as follows:
    1) Still sore/tender by the incision site, which was higher up closer to the base of the penis than low in the scrotum. No granuloma present. Feels like a sensitive nerve, if I press on it.
    2) Can’t sit for very long, and tenderness in the perineum.
    3) General discomfort/tingling in the testes/scrotum (low on the pain front, but very annoying).
    The pain/discomfort seems to come and go at times. My urologist, who I’m seeing tomorrow, made a comment that maybe he nicked a nerve during the incision. Don’t know what to believe. When the discomfort subsides, I feel like myself. Any thoughts? Thanks so much for your time.

    1. Dear Mark, post vasectomy pain is usually not that hard to figure out, at least in my practice. However, an in-office visit is usually required so that I can carefully examine you.

  15. Hi! I am writing because my husband and I are trying to figure out what’s causing his pain. He had a vasectomy a little over 3 years ago. Then, about 11 months ago he started feeling a lot of pain in one testicle and had swelling. An ultrasound showed increased blood flow to one are (near the epididymis). They treated him with ice, Ibuprofen and 2 different antibiotics (dox, ceph). They didn’t help. The pain is not as bad as it was, the swelling went away, and the doctors said to just wait it should go away with time. But, he still has mild-moderate achy (sometimes sharp) pain. He got another ultrasound a couple months ago and it showed nothing abnormal. Do you think this is congestion, and if so, what would the treatment be? Also, have you seen this article https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4048522/
    and do you think another antibiotic could be helpful if used longer? Thanks for listening! It’s hard to find a dr. who does!

    1. Dear Keri, acute pain more than 1 year after a vasectomy is typically inflammation or epididymitis from a “blow out” of the system (under pressure). The treatment is NSAIDs (Ibu) for 4 weeks or more; antibiotics typically don;t help as there is no true infection. Residual granulomas can occur from this which can be bothersome though. Congestion typically is slow onset of nagging, “heavy” feeling testicles and is generally not acute. I can usually tell what’s going on with a detailed physical exam (no ultrasound). Consider a visit!

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