Inflammation After Vasectomy: Common Cause Of Pain After Vasectomy
October 13, 2024
Inflammation after vasectomy is a risk of any vasectomy procedure. Scrotal inflammation as a cause of pain after vasectomy happens in approximately 20% of vasectomy patients… or 1 out of 5 patients.
This scrotal inflammation is not serious, but it can be a source of discomfort or pain after the procedure.
There can be multiple causes of scrotal inflammation after vasectomy: the actual vasectomy procedure, exposure to sperm, or increased pressure in the epididymis after the vas deferens have closed.
Inflammation after vasectomy usually resolves with time and conservative treatment.
What happens to sperm after vasectomy?
All vasectomy procedures cause blockage of the vas deferens.
Sperm are made in the testicles and travel up into the body through the vas deferens tubes. During a vasectomy, each vas deferens tube is closed in a small area. After a vasectomy the sperm travel towards the closed section of the vas deferens and stop at the site of vasectomy blockage. Here the sperm collect and wait until they are slowly broken down and absorbed by the body.
After vasectomy the sperm gradually back up in the lower vas deferens and epididymis…or the ‘lower system’. This does not typically cause pain unless this increased pressure causes distention of the epididymis. The increase in pressure caused by back up of sperm is mostly unnoticed by patients.
As a result of the increased pressure in the lower system, the testicles slowly decrease sperm production.
Eventually the lower system reaches equilibrium. During equilibrium sperm production in the testicle equals sperm absorption in the vas deferens. When equilibrium is reached, the sperm in the lower section of the vas deferens are broken down and absorbed at the same the rate at which sperm are produced by the testicles.
In some patients sperm production continues indefinitely but at a much lower rate and in other patients sperm production stops completely.
If you ultimately end up looking having a vasectomy reversal, then you will hope and pray the sperm production in the lower end is not impaired and the vasectomy reversal will be more successful.
If you are like most patients and never have a vasectomy reversal, then you could care less about what is happening in the lower end as long as your are not having pain, discomfort, or sexual impairment.
Inflammation after vasectomy: Why does this happen?
What is inflammation?
Inflammation is a normal part of the body’s response to injury or infection. Inflammation occurs when the body releases chemicals that trigger an immune response to fight off infection or heal damaged tissue.
The key word is “normal” because it does means what you are experiencing is typical for many patients and not a serious complication. All surgical procedures, both major and minor, cause tissue injury. Vasectomy is a minor surgical procedure, which is technically a controlled injury to the vas deferens. The tissue injury stimulates the immune system to repair the damaged vas deferens. This repair process is more commonly known as healing.
Inflammation causing pain after vasectomy can be subacute or delayed.
Subacute inflammation usually means within the first month of the vasectomy procedure. It most commonly occurs 5 to 7 days after a vasectomy procedure but can occur anytime within the first 3 months after having an uncomplicated vasectomy procedure. Subacute inflammation can happen at either the vasectomy site or in the epididymis.
Delayed inflammation is any inflammation that happens 3 to 12 months after vasectomy. Most commonly delayed inflammation happens within the first six months of having a vasectomy. Delayed inflammation after vasectomy usually happens in the epididymis.
What is the cause of subacute inflammation after vasectomy?
Subacute typically means slightly delayed. We most commonly observe subacute inflammation 5 to 7 days after vasectomy in 1 out of every 5 vasectomy patients.
Subacute inflammation typically results in pain at the vasectomy sites and/or in the epididymis. This inflammation can be on one side or both sides. Most commonly it is confined to one side.
As patients heal from the vasectomy they can develop subacute inflammation. This happens when the body’s immune system sends white blood cells into the area to clean up and repair injured tissue. These white blood cells release prostaglandins.
Prostaglandins are hormone-like compounds that trigger many parts of the inflammatory system. Prostaglandins increase the sensitivity of nerves. This is why you experience discomfort or pain after any injury or surgical procedure.
Commonly available over the counter anti-inflammatory medication (ibuprofen and naproxen) prevent prostaglandin production. This is why these medications are the best medications to decrease pain after vasectomy.
The inflammatory/immune response can be more intense in some patients. We all respond differently. This is also why 4 out of 5 patients may not experience any inflammatory discomfort after vasectomy.
Causes of subacute inflammation at the vasectomy sites
When patients experience subacute inflammation at the vasectomy sites the pain typically occurs 5 to 7 days after vasectomy. The pain is located higher up in the scrotum at the vasectomy sites. The vasectomy sites feel large and swollen…about the size of a garbanzo bean or in some cases as large as your thumb.
Usually this pain is only experienced when you touch, examine, or otherwise grab the vasectomy sites. Sometimes pain is made worse when you squeeze your abdominal muscles because the pressure changes on the inside the abdomen causes the vas deferens to retract (pull up toward the abdomen) or release (move away from the abdomen). The movement of the vas deferens is what causes the pain. The vas deferens can move when you sit, stand up, or lift a heavy object.
Subacute inflammation at the vasectomy sites happens as response to the coagulation/cutting the vas deferens, reaction to suture, exposure to sperm. It can also be a combinations of these processes.
Coagulating and/or cutting the vas deferens. These techniques cause an insult to the vas deferens. The healing response is to repair the vasectomy sites. Some patients can have discomfort at one or both vasectomy sites after vasectomy.
Reaction to suture. Absorbable sutures are only absorbable because the white blood cells attack and dissolve the suture as part of the inflammatory process.
Chromic suture is one of the original absorbable sutures made from chemically processed animal intestines. Chromic suture can cause an intense inflammatory reaction in a minority of patients as the suture is absorbed by the body.
Silk suture was one of the original permanent sutures. Although silk suture is not absorbed it can cause an intense inflammatory reaction in some patients. Silk and chromic sutures continue to be used by many vasectomy providers.
Exposure to sperm. Small amounts of sperm can leak out of the cut lower end of the vas deferens. During the first several days after vasectomy, this leaked sperm causes an immune/inflammatory response. The body’s immune system is not normally exposed to sperm because the sperm is contained in the genitourinary system.
Although it may seem strange at first, sperm is handled by your body in much the same way as water in your house. Your living room never sees water because the water is contained in your plumbing system. This is how sperm is kept away from your immune system. When the immune system sees sperm for the first time, the white blood cells attack and dissolve the sperm. This creates inflammation.
Sperm leakage can happen with either an open ended vasectomy technique or a closed end vasectomy technique. Even if the lower end was tied off with suture or clamped there can be sperm leakage from the lower end soon after the procedure.
The vas deferens tubes are not like PVC or copper pipes. The vas deferens are human tissue. Human tissue is dynamic. Sutures or clamps, if placed too tightly, across the vas deferens cause pressure necrosis, cut through the tubes, and allow sperm to leak out within the first several days.
Regardless of what technique is used on the lower end there will be some exposure to sperm due to spillage from the lower end of the divided vas deferens.
Causes of subacute inflammation in the epididymis
Subacute inflammation can also occur in the epididymis.
When patients experience subacute inflammation in the epididymis the pain typically occurs 5 to 7 days after vasectomy but can occur during the first month after vasectomy. The pain is located lower in the scrotum in the epididymis.
The epididymis is the soft “C” shaped structure located on the back surface of each testicle. When patients have pain in the epididymis they usually have pain when they sit (back of testicles will touch the seat), walk/run (back of testicles will touch the thigh), sexual activity that results in the back of the testicles being touched, or any movement that causes the back of the testicle to come into contact with any other object.
The cause of subacute inflammation is usually from back up of sperm and increased pressure within the epididymis.
When this happens the entire back side of the testicle will feel firm and tender to the touch. Patients with this inflammation describe tenderness on the side that is having inflammation. The scrotum, especially on the side having the inflammatory reaction feels tight and drawn up against the body. This is how the body compensates.
Not all patients will experience this but approximately 20% (1 out of 5) of patients will have some degree of tenderness in the epididymis as they heal from a vasectomy.
It is possible to have this subacute inflammation at both the vasectomy site and the epididymis….or isolated to one area only….and/or on one side of the scrotum or both sides of the scrotum.
Common sense would make it seem that both sides of the scrotum would experience the same degree of inflammation after vasectomy. We are unsure why but it is very common for these more intense inflammatory reactions to involve only one side of the scrotum.
We are unsure why some vasectomy patients experience inflammation after vasectomy and others do not. Perhaps patients who have higher sperm counts are more vigorous producers of sperm? Perhaps these patients make more sperm and, as a result, are more likely to experience epididymal congestion on one or both testicles.
What causes delayed inflammation after vasectomy?
Delayed inflammation can occur 3 to 12 months after vasectomy. In some rare cases it can happen within the first 1 to 3 years after vasectomy. Delayed inflammation after vasectomy usually happens in the epididymis.
The cause of delayed inflammation is backup and congestion of sperm in the epididymis on one or both testicles. This is more commonly diagnosed on one side and does not usually involve both sides. We are uncertain why this is limited to one side in some patients.
The cause of delayed inflammation is the exact same process that occurs with subacute inflammation in the epididymis.
Sperm can back up and cause distention in the epididymis. As the epididymis becomes more distended with sperm the structure becomes tender to the touch. Patients will usually notice a gradual increase in discomfort over several days. They usually describe it more as discomfort and less as pain. Usually this will resolve with the passage of time and the use of over the counter anti-inflammatory medication.
In some patients the increased sperm pressure in the epididymis can cause a small aneurysm (or ballooning) in a weak section of the epididymis. Sperm will fill this aneurysm and the immune system will respond to the aneurysm in an attempt to contain it. This aneurysm will be tender but in most cases in no larger than the size of a dime or nickel.
The aneurysm that contains sperm is called a ‘sperm granuloma’. Sperm granulomas are tender nodules that can from after vasectomy. If sperm ‘leaks’ from the aneurysm then the body will mount a more intensive immune response and patients can experience more prolonged discomfort. Overtime this will improve and gradually become better.
The body is attempting to repair itself and accommodate the effects of the vasectomy.
How do you treat inflammation after vasectomy?
Treatment of inflammation after vasectomy is easy. In fact, if the discomfort is tolerable and not impacting your daily routine you do not have to do anything. Your body will gradually repair itself and things will gradually go back to normal.
What is gradual? Usually within 2 to 4 weeks the inflammation and pain will resolve. Nodules, or granulomas, in either the vas deferens or epididymis will get better (less painful and smaller) but some will never go away.
The following is the recommended treatment for inflammation after vasectomy:
- Over the counter anti-inflammatory medication (ibuprofen or naproxen).
- Tight firm fitting underwear or an athletic supporter
- Hot baths
The above treatments will help with discomfort but will not speed up (or slow down) healing. Healing is gradual and can only be accomplished by the body’s immune system.
Anti-inflammatory medications. The best anti-inflammatory medications are ibuprofen and naproxen. These medications decrease prostaglandin synthesis. Prostaglandins help with healing but they also cause pain. Anti-inflammatory medications interfere with prostaglandin production and decrease pain.
Ibuprofen and naproxen are better because they decrease prostaglandin synthesis in both the brain and body. A common issue with these medications is most people do not take enough.
- Ibuprofen: The best dosage of ibuprofen is 800 mg every 8 hours…this is four over the counter tablets every 8 hours. The over the counter ibuprofen tablets are each 200mg.
- Naproxen. The best dosage of naproxen is 440/500 mg every 12 hours…this is two over the counter tablet every 12 hours. The over the counter naproxen tablets usually are 220mg.
- Naproxen is probably better…if only for the fact that it last for 4 additional hours than the recommend maximal ibuprofen dosage.
Acetaminophen is not the best medication for pain. Acetaminophen does interfere with production of some prostaglandins (mainly the fever causing prostaglandins) but only in the brain. Acetaminophen also induces changes that raise the pain threshold in the brain (so tells your brain not everything is painful). Acetaminophen is a better medication for headache and fever.
We typically only recommend acetaminophen for patients who are allergic to ibuprofen or naproxen or for patients who are not getting good pain relief from these medications.
More information: NSAIDS vs acetamiophen: A nice review
Aspirin is not an ideal choice because 1) pain relief does not last as long as ibuprofen or naproxen and 2) aspirin inhibits platelets which stop bleeding. Taking aspirin could increase the risk of bleeding and/or bruising after vasectomy. Aspirin is an ingredient in many over the counter medications; ie Goody/BC powders, Excedrin, etc
Tight firm fitting underwear or an athletic supporter. This helps to keep the scrotum and testicles elevated and protected against the body. If you have inflammation in your scrotum any direct touch or movement will cause discomfort.
A tight firm fitting scrotal support will prevent the scrotum from being jostled when you walk or run and prevents the testicles from making contact with the surface of whatever you are sitting on.
Hot baths. Hot baths increase the blood flow to the external surface areas of the body, including the scrotum. This causes increased scrotal blood flow. We are not 100% certain but this increased blood flow may help to ‘flush out’ prostaglandins. It may also brings in ‘fresh’ immune cells to help with healing.
Cold packs may help with pain but they also cause vasoconstriction. In general, cold treatment is helpful with a fresh injury because it limits swelling. Cold is not usually recommended for injuries that are more than 48 hours old and it could impair the healing response.
We do not routinely recommend cold packs for scrotal inflammation.
Is pain good or a necessary part of healing?
Pain is not bad unless it limits your daily activities. We always want patients who have scrotal inflammation to be aware they do not necessarily have to do anything or take any treatment.
Pain is caused by prostaglandin release. Prostaglandins stimulate the immune system and accelerate healing but these chemical mediators also make nerves more sensitive (increase the perception of pain).
Pain helps healing because it lets you know where the damage is and makes you less likely to touch or put pressure on the area that is healing…because when you do it hurts. The pain makes you stop. The pain is your reminder to not stimulate the damaged tissue as this area is healing.
Pain is natural…but so is sickness and death. You do not always have to accept something because it is natural.
You can use the above treatments without interfering in healing. We also want to acknowledge you do not have to do any of the above treatments. These treatments will help you feel better while your body is repairing itself but will not speed up healing.
How is a His Choice Vasectomy different?
We are not trying to imply His Choice vasectomy patients have less pain or discomfort with our techniques than the techniques of other doctors but we do want to reassure you we take steps to improve your recovery after vasectomy.
More information: His Choice Vasectomy
We don’t remove tissue. During a His Choice Vasectomy, we do not cut out any of the vas deferens. By not removing large sections of the vas deferens, we cause less complications and potentially cause less pain during recovery.
Luminal coagulation of upper end. During a His Choice Vasectomy, the upper end of the divided vas deferens is lightly coagulated (burned) on the inside to accelerate closure of the upper portion. This decreases the chance of vasectomy failure. We try to coagulate only enough to accelerate closure of the upper part of the vas deferens. Extensive coagulation can only increase the inflammatory response.
Fascial interposition. The ends of the vas deferens are made to be out of alignment with a technique called fascial interposition (which is inserting healthy tissue between the two cut ends). We do this with small titanium clips (the size of a grain of rice) that are permanent and non-reactive. Fascial interposition further decreases the risk of failure.
Some patients are fearful of the titanium clips. They do not want anything foreign in their body. We like to reassure patients these clips are commonly used during vasectomy and have never been shown to cause a serious problem. The clips help hold the ends of the vas defers apart until they heal closed. The clips do not need to be removed.
The clips are titanium which is commonly used in surgery because this metal is non-reactive and is not recognized by the immune system….this means they cause less inflammation. Almost all orthopedic hardware is composed of titanium: screws, rods, artificial knees and hips, etc.
Some patients will request suture and suture is a reasonable alternative to titanium clips; however, absorbable suture is only absorbable because the immune system recognizes it as foreign and attacks the suture. This is why the suture eventually gets absorbed..because the immune system attacks and dissolves the suture material.
Some sutures (chromic and silk) can cause intense inflammatory reactions in some patients. We never use these sutures during our vasectomy procedures.
Open ended technique. We leave the lower end open and this minimizes the sudden increase of pressure in the epididymis. The lower end will eventually heal closed. This gives the lower system time to adapt. Even with an open ended vasectomy patients can experience pain in the epididymis from sperm congestion but we believe the percentage of patients experiencing this discomfort is lower.
Does open ended cause more inflammation from sperm exposure?
We do not believe an open ended vasectomy causes more inflammation. It is also important to understand when doctors commonly close the lower end with sutures or clips this does not mean that the lower end is effectively closed for most patients. What commonly happens is the suture or clips (when placed directly across the vas deferens) will cut through this tubes slowly several days after vasectomy from pressure necrosis and the lower end will effectively be open….so sperm leakage is going to occur no matter what is done to the lower end.
We do everything we can to make vasectomy easy for patients: no needle, no scalpel, single visit, no removal of anatomy, and no sutures required.
Find a His Choice Vasectomy provider near you: His Choice Vasectomy providers
