Use of Testosterone in the Treatment of Chronic Postvasectomy Pain Syndrome: Case Report and Review of the Literature, The

Military Medicine, Jun 2007 by Pienkos, Edward Joseph

The purpose of this article is to describe a simple, intellectually reasonable, initial treatment for all subacute and chronic postvasectomy scrotal pains. The use of intramuscular testosterone cypionate in a dose of 400 mg monthly for 3 months is described for patients suffering from painful sperm granuloma at the vasectomy site or in the epididymis, circumventing the need for other medical or surgical approaches. Excellent results have been achieved in patients and a representative case is illustrated. The rationale for this approach based on endocrinological and immunological mechanisms is described.

Introduction

It is estimated that 500,000 to 1,000,000 vasectomies are performed for male sterilization annually in the United States representing a solution for 12% of all married couples. Excluding infidelity, early unprotected intercourse, or technical failure, the pregnancy rate following vasectomy is less than 0.1 per 100 women-years.1 Its applicability to the office setting and performance under local anesthesia lends itself to wide acceptance. Nevertheless, despite its advantages and acceptance, vasectomy has some well-known complications and remains an intellectually flawed procedure. Some complications of vasectomy are related directly to the surgical technique and include postoperative hemorrhage, vagovasal reactions, postoperative infection, persistent motile or nonmotile sperm, poor patient selection resulting in intraoperative difficulty finding the vas, termination of the procedure due to pain, and rapid request for re-establishment of fertility through vasovasostomy.

Another complication, which is composed of a number of symptoms and physical findings, could best be grouped under the title of chronic postvasectomy pain syndrome (CPVPS). In older reviews of vasectomy outcomes, CPVPS has not been mentioned as a complication.2 However, in more recent articles regarding complications of vasectomy, chronic scrotal pain is now considered to be a negative factor in surgical outcome. In addition to various medical therapies, several inventive surgical procedures have been described to address this complication. Yet, the use of intramuscular (IM) testosterone to treat this condition is not mentioned in the literature and this shortcoming is difficult to explain given the nature of the problem, namely, the continued production of antigenic spermatozoa. Therapies which do not address this core issue are ineffective, misdirected, and possibly injurious. In military and civilian practices alike, chronic scrotal pains from a variety of sources are a frequent presenting symptom to the physician's office. A thorough diagnostic approach to all such pains is necessary, and, since the perplexing and contradictory solutions frequently overlap, they are included in this article.

Case Report

A 36-year-old patient presented with a history of having a vasectomy performed 6 years earlier. Approximately 6 months following his operation, he returned to the original urologist with complaints of a painful lump in the upper portion of the left side of the scrotum. After a course of antibiotics was unsuccessful, he sought the opinion of a second urologist who recommended excision of the mass. This second procedure of excision of a presumed sperm granuloma resulted in a pain-free state for approximately 5 years. The patient then developed pain in the left side of the scrotum and he returned to the second urologist who, after an unsuccessful course of antibiotics, recommended a left epididymectomy. At this point, the patient sought another option. On presentation, the patient had a slightly tender and enlarged left epididymis and slightly tender testicle and spermatic cord. On scrotal ultrasound, there was no evidence of varicocele, testicular tumor, or hydrocele. A course of testosterone cypionate 400 mg monthly IM for 3 months was recommended. The patient reported decrease in pain within 2 weeks and has been pain-free for more than 1 year after receiving the course of three injections.

Discussion

The incidence of CPVPS is reported to range from 0.1% to 54% depending on definitions of severity and duration. Choe and Kirkemo3 found 25.3% of patients to have chronic scrotal pains and epididymitis following vasectomy, of whom 70.6% reported occasional pain and 2.2% reported pain as sufficiently severe to cause an impact on the quality of life. They also emphasized the necessity of inclusion of chronic, postoperative pain in their vasectomy consent since pain has been the subject of litigation.3 The pain is due to the interruption of the efferent sperm ducts with continued sperm production resulting in either sperm granuloma at the vasectomy site and/or epididymal obstruction and granuloma.4

A thorough history should be taken since CPVPS is defined as intermittent or constant; unilateral, bilateral, or alternating; and lasting more than 3 months. On initial presentation, the history of previous surgery is essential, for CPVPS is one possibility in the more generalized condition of various inguinal and scrotal pains. Troublesome pains preceding and following inguinal herniorrhaphy, varicocelectomy, spermatocelectomy, and hydrocelectomy are well-known. In addition to previous surgery, a history should include symptoms related to infections due to epididymitis, prostatitis, and seminal vesiculitis, and inflammatory conditions such as interstitial cystitis. A history of trauma, possibly on the job injury, back pain, other chronic pain, and psychiatric disorders should be elicited. Chronic intermittent torsion, tumor, retroperitoneal flbrosis, periarteritis nodosa, epilepsy, self-palpation orchitis, aneurysms of the common iliac artery, intervertebral disc protrusion, diabetic neuropathy, gout,5 and pudendal nerve entrapment6 have been listed as potential causes of orchialgia. Vasectomy may have been performed long ago and questions should be asked directly to establish a possible cause.