Microsurgical vasovasostomy for the treatment of intractable chronic scrotal pain after vasectomy.

Dear Editor, We present herein two rare cases of intractable chronic scrotal pain after vasectomy. The patients were effectively treated with microsurgical vasovasostomy (MVV). We also discuss the possible aetiologies of the pain and other surgical options. Vasectomy was once the most common method of permanent contraception for men in both China and worldwide. One particularly distressing complication after vasectomy is chronic scrotal pain, which is defined as intermittent or constant, unilateral or bilateral scrotal pain for o3 months. The pain is intense enough to interfere with the patient’s daily activities and prompts him to seek medical attention. Although its aetiology remains unclear, epididymal congestion, painful sperm granulomas, vascular stasis and nerve impingement have been postulated as possible aetiologic factors. Non-surgical options have been used successfully to treat chronic scrotal pain after vasectomy, including scrotal support, thermal therapy, limiting activity, non-steroidal anti-inflammatory drugs, narcotic analgesics, antibiotics, neuroleptics, spermatic cord nerve block, biofeedback and psychiatric evaluation. Surgical options include reversal of the vasectomy, microsurgical spermatic cord denervation, granuloma excision, epididymectomy and orchidectomy. The microsurgical techniques used for vasectomy reversal have changed significantly in the past decade, culminating in the standard surgical procedures used today, and its indications include a desire to have more children (remarriage or after the death of a child), treatment of post-vasectomy pain and treatment of obstructive azoospermia due to traumatic or iatrogenic injury of vas deferens. To our knowledge, we report the first cases of the use of MVV for the treatment of intractable chronic scrotal pain after vasectomy in a Chinese hospital. The 72-year-old and 49-year-old men presented with a more than 20-year history of intractable, chronic scrotal pain after vasectomy. They had consulted various urologists and had undergone numerous attempted therapies in other hospitals. They reported a history of vasectomy more than 30 years and 20 years previously, respectively. They did not have any histories of haematuria, haematospermia, lower urinary tract symptoms, epididymitis, prostatitis or testicular trauma. Their physical examination was unremarkable, and both the secondary sexual characteristics and genital examination were normal. The testes were descended bilaterally and normal in size and consistency. The caput epididymides exhibited dilatation and tenderness. The vasa deferentia were palpated for painful lumps at the vasectomy sites. Digital rectal examination was unremarkable for prostatic abnormalities. Each patient underwent Doppler ultrasonography of the testes and urinary tract, urinalysis, urine culture and spermiogram to exclude primary or secondary causes of pain, including intratesticular infection, tumours and ureteral lithiasis. At our initial consultation, the patients were asked to complete a pain and psychological questionnaire, which included pain, depression and anxiety scores. The pain score (Visual Analogue Scale) was in the form of an 11-point numerical rating score with 0 representing ‘no pain’ and 10 representing the ‘worst possible pain’. The patients’ preoperative pain scores were 5 and 6 points, respectively. The depression scores (Self-rating Depression Scale) were in the form of an 80-point numerical rating score; a score less than 50 indicated ‘normal’, and a score greater than 50 indicated ‘depression’. The depression scores of the two patients were 35 and 38 points, respectively. The anxiety scores (Self-rating Anxiety Scale) were in the form of an 80-point numerical rating score; scores less than 50 were considered to indicate ‘normal’, whereas scores greater than 50 indicated ‘anxiety’. The anxiety scores of the two patients were 33 and 32 points, respectively. Spermatic cord block was performed once for each patient with 6 ml of 1% lidocaine and 1 ml of methylprednisolone (40 mg). The patients had 3 and 7 days of complete pain relief after the blockade, respectively. The study protocol was approved by the Ethical Committee of the First Affiliated Hospital of Sun Yat-Sen University, and informed consent was signed by the patients. The patients were offered MVV as a more permanent solution in March and July 2012, respectively. Scrotal exploration was performed with the patients under combined spinal–epidural anaesthesia. The left-side incision (3 cm) of the scrotum through the tunica vaginalis was made, and the left vas deferens was delivered through this incision. The painful lumps and nerveimpinging tissue at the vasectomy site were thoroughly resected by electrocautery. Distal patency was confirmed by infusing diluted methylene blue through the abdominal side of the vas deferens, resulting in blue colouring of the urine. A 123 to 153 operating microscope (Leica Microsystems (Schweiz) AG, Heerbrugg, Switzerland) was used