Vasectomy – what exactly did they do and what was done wrong?
As the author of these posts I have taken the liberty with my very first article to change the agenda of what I offered. This first piece is on the vasectomy itself and questions I am frequently asked. Again these are my opinions, based on experience and my own thoughts. Take everything I say and what everyone says, yes even the experts, with a grain of salt. I may be wrong and am always open to being corrected or learning other’s thoughts.
Vasectomy technique. First of all vasectomies are a simple surgery designed to disrupt the flow of sperm through the vas. We all do vasectomies using the same basic concepts, but often in our own unique way. The technique we use is based on how we were taught, what works for us over the years and anything new we learned along the way. No one has any secret magic technique that is better than anyone else. A standard vasectomy involves cutting, clipping, tying, cauterizing or excising a segment of vas - and usually a combination of any or all the above. Sometimes this is done through a single midline incision and sometimes through small incisions or defects created on either side. Many use the no scalpel technique or variations of that, while there are still some that prefer small incisions. The key point is that there is no hard and fast absolute technique, and no specific technique that one can say causes PVPS or doesn’t.
Because I do vasectomy reversals daily and often for PVPS, many men are rightfully worried that additional surgery will exacerbate the problem. They often ask how will my reversal be different from the vas and why will the reversal not make things worse. My answer is that there is a world of difference. A vasectomy is a quick, in and out, seek and destroy, shock and awe type of a focus traumatic procedure. Get in - find the vas - do the damage - get out and move on to the next patient. It is a destructive procedure that causes instant obstruction of a system not designed to be obstructed. The reversal is the exact opposite. It is a very precise, delicate, microsurgical reconstruction that takes several hours under a high-power surgical microscope. The goal of a correctly perform reversal is to reconnect the ends of the vas, restore the flow, all while doing the absolute least trauma to the delicate tissues of and around the vas.
A lot of men with PVPS want to know what was done wrong at the time of their vasectomy to cause such horrible and debilitating pain. In our world of absolute cause and effects, it only makes sense that something had to have been done wrong. Clearly, it seems, there must be someone or something to blame and hold accountable for this horrible pain and all the devastating consequences. Unfortunately that’s not the case. Though we are always looking for clues that might explain who’s at risk, or what we can do to minimize the chances, the likelihood of developing this kind of destructive pain is still very rare. Most urologists I have talked to have never had a patient with severe PVPS, that they can recall, that had this kind of pain that did not resolve soon and respond to normal anti-inflammatory treatments. I really don’t think that anything specific was done unique to the men with this pain different from the many thousands of men in their practices who didn’t get the horrible pain. When I talk with my colleague, the way too smart Dr. Peter Burrows, though we have never really checked this through our database, it seems that the majority of men with PVPS have several metal clips at the vasectomy site. As much as I’d like to blame the absolute occlusion of these clips, I also know that probably hundreds of thousands of vasectomies are performed using these clips without the subsequent pain. The other common finding is that the vasectomy is often done way down low in the vas. My thought is that by doing the vasectomy down low, there is less vas to allow for the build up of pressure, and so the pressure builds up and back into the delicate tubules of the epididymis. When a vasectomy is performed higher up away from the testicles, there is more vas to handle and dissipate the pressure that builds up.
I know of one very bright PVPS expert (that I have tremendous respect for) who believes that there is an immunological response that plays a role, but as of this moment in my heart I am not sure that is right. Of course, if a treatment works, then that is great and I will add that to my list of possible causes and treatment choices. We learn new things every day and so this is one area where I may be totally wrong. We see many men with antibodies that we have shown play zero role in subsequent fertility and seem to have no clinical signs of symptoms of the antibody response.
As I will discuss in a later piece expanding on my thoughts as to what causes PVPS, there are five basic findings that I usually see in men with this pain. Almost all the patients had at least one and many a combination or all of these findings. These include
- Significant buildup of fluid under pressure, often on one or both sides
- Sperm granuloma, very small to large
- Dense extensive scarring at the vasectomy site (dramatically more than I usually see every day with my reversals for fertility)
- Metal clips as previously discussed (not sure of the cause and effect but they are often there)
- Vasectomy low in the vas
Of course, because of the nature of medicine, I can almost guarantee you that my next reversal patient with PVPS will have absolutely none of these.
So in summary, I really don’t think there’s anything specific that a doctor does at the time of vasectomy that we can consistently predict will cause pain. Rather I think it’s that person’s unique healing response to the technique of the vasectomy that’s responsible for the pain. The good news is that for the vast majority of men with PVPS, there are a variety of conservative and invasive treatments that are usually effective in dramatically reducing or eliminating the pain. If there are any of the many brilliant urologists that have an opinion, I would love to hear them.