How common is chronic pain after vasectomy?

(For more on this topic, check out www.reddit.com/r/postvasectomypain for hundreds of stories written by men dealing with chronic pain caused by their vasectomy.)

Your doctor will probably admit that chronic pain is a possible complication resulting from vasectomy, but most will say that it happens rarely, or even very rarely.

What exactly does very rarely mean?

Before you decide to have a vasectomy, stop and ask yourself what odds of chronic pain you are willing to sign up for. To get some idea of what this would be like, just imagine being mildly nauseated every day and not knowing whether or not it would ever stop.

Here are the chances for chronic pain caused by vasectomy given by several national level health organizations. These are the professional societies and experts that the urologists are supposed to be getting their statistics from:

• Canadian Urology Association give the chronic pain outcomes for vasectomy at between 1–14% (Link)
• American Urological Association says chronic pain serious enough to impact quality of life occurs after 1–2%of vasectomies. (Link)
• British Association of Urological Surgeons, patient advice reports troublesome chronic testicular pain which can be severe enough to affect day-to-day activities in 5–14% of vasectomy patients. (Link)
• UK National Health Service says long-term testicular pain affects around 10% of men after vasectomy. (Link)
• 11th edition of Campbell Walsh Urology (2015) cites 10% incidence of chronic scrotal pain caused by vasectomy. (Link)
• European Association of Urology (2012) cites 1–14% incidence of chronic scrotal pain caused by vasectomy, usually mild but sometimes requiring pain management or surgery (Link)
• Royal College of Surgeons of England says significant chronic orchalgia may occur in up to 15% of men after vasectomy, and may require epididymectomy or vasectomy reversal. (Link)
• Journal of Andrology cites large studies that find Post Vasectomy Pain Syndrome 2–6% of the time (Link)
• UpToDate says “surveys have found that the incidence of “troublesome” post-vasectomy pain is reported by approximately 15% of men, with pain severe enough to affect quality of life in 2%. However, survey respondents may not have been representative of all men who have had a vasectomy.” (Link)
• European Association of Urology says “Post-vasectomy scrotal pain syndrome is a scrotal pain syndrome that follows vasectomy. Post-vasectomy scrotal pain syndrome is often associated with negative cognitive, behavioural, sexual or emotional consequences, as well as with symptoms suggestive of lower urinary tract and sexual dysfunction. Post-vasectomy pain may be as frequent as 1% following vasectomy, possibly more frequent.” (Link)
• American Family Physician says “Recent studies estimate the incidence of severe postvasectomy pain syndrome to be between 1% and 6%” (Link)
• International Journal of Environmental Research and Public Health published a meta-analysis in March 2020 to determine the incidence of PVPS, which examined 559 peer-reviewed studies and concluded that “Post-vasectomy pain syndrome occurred in 5% of subjects” (Link) The authors determined that “the overall incidence of post-vasectomy pain is greater than previously reported.”

What do “rare” and “very rare” normally mean when describing side effects of a medical intervention?

The World Health Organization provides specific definitions for using these words when discussing medical side effects:

• Very Common = Greater than 10%
• Common = 1% to 10%
• Uncommon = 0.1% to 1%
• Rare = 0.01% to 0.1%
• Very Rare = Less than 0.01%

(Link 1) (Link 2)

Based on these definitions, chronic pain is not a very rare, or rare side effect of vasectomy. It isn’t even uncommon.

Rather, chronic pain is a common side effect of vasectomy. Sometimes it is called Post Vasectomy Pain Syndrome (PVPS). This pain may go away after several months or years, or it may be permanent.
Before they modify your body, your surgeon should make sure that you:

• Know about Post Vasectomy Pain Syndrome
• Understand the impact it would have on your life
• Understand that it may be permanent
• Know that the risk is at least 1%
• Explicitly accept the risk

If your surgeon does not communicate the above points to you, they are operating on you without your informed consent.

Vasectomy works out well for most men. Those who have an uncomplicated vasectomy may be back to feeling normal in as little as a week and are quick to encourage others to “get the snip.” They may reject stories about men who have chronic pain or other permanent complications as exaggerations. Sometimes they make the mistake of reasoning that if a bad outcome did not happen to them, then it must never happen to anyone. Health providers market the procedure as quick, effective, and safe. Men who worry that their health or sexual function may be permanently damaged by a vasectomy are repeatedly assured that after a few weeks they will feel and function exactly as they did before the surgery. Reports about the downsides of vasectomy are frequently dismissed as unreliable. They are disparaged as exaggerations, products of hypochondriac imagination, or myths being promoted by fear-mongers. Men are told that not only is it practically impossible for vasectomy to harm their sex lives, it is likely that their sex lives and even their orgasms will improve because of the surgery.

Unfortunately, the science shows that negative health impacts of vasectomy can happen and they are not rare. That might not surprise you after you consider a few key facts:

• Before vasectomy, sperm is kept separated from the immune system. After vasectomy, the immune system typically creates antibodies that cause it to seek out and kill sperm. In other words, men commonly become allergic to their own sperm, and a chronic auto-immune response can cause inflammation, making the area feel swollen and raw on the inside.
• After vasectomy, the testes continue producing sperm, but since the sperm cannot escape, they can create pressure inside the epididymis and vas deferens. In fact, the pressure can get high enough to rupture these tissues, releasing the sperm and allowing it to form a bubble in the scrotum called a granuloma. Anyone who has experienced epididymitis will immediately recognize the nagging ache of a swollen epididymis. If you haven’t had this experience, you can compare it to the painful pressure an ear infection can cause.
• Nerves severed during the procedure sometimes heal poorly and interact with scar tissue and auto-immune inflammation, irritating the nerves and causing pain called neuralgia, which in PVPS is usually described as a burning sensation that is hard to localize but centered in the groin.
• The vas deferens is not just a passive tube — it is lined with muscles that contract during ejaculation to move sperm along. Vasectomy disrupts the function of these muscles.
• The groin is a very complex region of the body, constantly under mechanical stress whether you are sitting, standing or walking. Multiple organ systems work in close proximity, so that problems in one system can spill over to cause problems in other systems. Nerves that enter the inguinal canal can refer pain to the inner thigh, stomach and lower back — disrupting the normal functioning of muscles in those areas. For a point of comparison, surgery to repair an inguinal hernia results in chronic pain even more frequently than vasectomy. 16% of the time based on this study. Another study puts chronic pain at 28% post hernia surgery, with 11% saying it interfered with work or leisure activity. Chronic pain is not unique to groin surgery — it is a common complication of many kinds of surgery, which is why you should avoid surgery unless you need it!

Given these facts, perhaps the real surprise should be that the percentage of men who suffer from long term health problems as a result of this surgery is so low.

For the unlucky minority, vasectomy opens a Pandora’s box. Part of the pleasure of sex is taken away and replaced with pain. The constant discomfort reduces their quality of life, interferes with the activities they previously enjoyed and may frequently intrude on their thoughts. They try one therapy after another before finally giving up in exasperation. As months pass with no relief, they come to grips with the fact that pelvic pain is their new constant companion and may never leave. There are few opportunities to warn others about the danger. Bringing up the topic in conversation results in a social penalty and has no benefit — even among close friends. They may feel reluctant to express their feelings to their partner, fearing it could have a negative impact on their relationship. Some men worry that by telling their partner that sex has become painful or disappointing, they could irreparably damage the attraction and desire their partner feels toward them. Instead, they pretend like nothing has changed.

Men initially complain to their doctors, who are reluctant to attribute the problems to the vasectomy and who are unwilling to warn the public that a problem worth taking seriously may exist.

In many ways, PVPS manages to have just the right properties to help it hide in plain sight.

Doctors who have not personally experienced PVPS seem dismissive of the scope and seriousness of the problem. They grudgingly acknowledge the published rates of chronic pain but claim it doesn’t match their own observations. Even if they have done thousands of vasectomies, they claim they have only seen PVPS once or twice in their career.

Vasectomized men may be hesitant to continue to pester their doctor about discomfort that is not going away, especially if it is the same doctor who performed the vasectomy. When they do seek help, they are seldom diagnosed as having a chronic pain syndrome that is a complication of their surgery. Instead, they are given various therapies and admonished that healing can sometimes take many months. Urologists avoid discussing the possibility that the problem is a chronic pain syndrome, preferring to focus on the symptoms and making it difficult for men to realize that what they are experiencing is part of a pattern that many others have experienced. After several fruitless doctor visits, men who are nevertheless still in pain may view further appointments as a waste of time and money. When they stop making appointments, doctors are tempted to assume that the problem has been resolved successfully.

For men whose symptoms appear months or years after their surgery, nothing can persuade a urologist to conclude that the vasectomy was the ultimate cause. The symptoms sound similar to age-related problems that begin to afflict men in their 40’s and 50’s, which gives doctors who want to avoid blaming vasectomy a convenient scapegoat. There is no specific medical code with which to classify and track PVPS. The failure to gather statistics, low incidence rate, long time-spans and confounding age-related factors make scientific investigation into PVPS tricky and expensive.

Men who are notified about the risk of PVPS before their surgery are often reassured that residual pain would be a trivial inconvenience and that few who have PVPS pursue surgery to cure it. They are not made to understand that none of the the surgical remedies are guaranteed to work, and all of them have the potential to make the chronic pain worse. The option with the best results, vasectomy reversal, is very expensive, usually not covered by health insurance, painful to recover from, likely to restore the unwanted fertility, and fails to fix the problem about 20% of the time. Many men are emotionally traumatized by their vasectomy and too afraid to take the risk of having more surgery, choosing instead to cope with the pain indefinitely.

One of the factors that blinds practitioners and the public to the danger is that vasectomy has a lot of good things going for it. The majority of men recover very quickly and do not have residual pain or any noticeable change to their sexual function. They can have spontaneous sex without any fear of causing unwanted pregnancy. They protect their partner from all of the pain and risk of pregnancy. It seems like an almost ideal solution to many serious problems. The majority of men who have had vasectomies consider it one of the best decisions they have ever made and are pleased to boast about how little pain was involved and how quickly they returned to their normal activities.

Vasectomy is understandably seen as an indispensable tool to reduce the disproportionate risks women face. Vasectomy is viewed by many as an essential brake on a human population that is growing far too rapidly. In light of all this, the existence of PVPS is a very unwelcome fact, provoking in many a reflexive and unshakable assumption that PVPS cannot be a serious problem.

The lack of enthusiasm for discovering the truth about PVPS has lead to a situation where widely published figures for PVPS have been incorrect by at least factor of 10 and have only been recently corrected:

Example 1: Uptodate

Example 2: Campbell Walsh Urology textbook

Both of these sources were corrected in 2013. Urologists have not made it a priority to disseminate the correction and many still quote older, incorrect statistics.

Vasectomy is unusual, in that it is a surgery that is not performed to make the patient healthier. In fact, the patient’s health can only be harmed by this procedure. Vasectomy is performed to protect the health of the patient’s partner. Part of the reason it is labeled “safe” is because pregnancy and tubal ligation are more dangerous. Many in our culture see vasectomy as a man’s obligation to his partner. A man who will not endure (what is thought to be) the trivial pain and risk of a vasectomy is often judged to be selfish or cowardly. A doctor who is advising a man on the risks of this surgery is thus placed in a delicate situation. Say too much, or say it the wrong way, and a man might decide to protect his own health at the expense of the health of his partner.

Doctors who believe PVPS has a psychosomatic component may feel that warning men in plain language could harm the man by creating a self-fulfilling prophesy. When telling people the naked truth has so much potential downside, what is a doctor to do? Most doctors choose to thread the needle by using the written and verbal equivalent of fine print to discharge their obligation without raising any undesirable alarms.

Doctors are not the only ones who treat facts about vasectomy complications as a kind of “hazardous information.” Other examples include:

• Women who hope their partner will have a vasectomy: “Don’t tell my husband about that, I’ll never get him to go.”
• Men deciding whether or not to get a vasectomy: “I stayed away from the horror stories. Didn’t want to freak myself out.”
• Men who are experiencing PVPS: “I need to focus on the positive.”
• Men considering whether to warn another man who is getting a vasectomy: What happened to me was a one-in-a-million freak accident, and not relevant to his decision.

As a result of the risk and impact of PVPS being downplayed by virtually everyone, including trusted authorities and the very men who suffer from PVPS, men with this disease find themselves in a situation that many find difficult to fully acknowledge as real. The mismatch between the pain in their own bodies and the public consensus about vasectomy can be a source of significant frustration. Their partners, hearing ubiquitous assurances that vasectomy is safe and cannot affect sexual function, are left to wonder if there is some other explanation as to why their man has become less emotionally available and suddenly ambivalent toward sexual contact.

The widespread misunderstanding about vasectomy also hampers the ability of doctors and scientists to improve the situation. How can you study a problem, such as diminished ejaculation sensation caused by vasectomy, if you don’t dare admit that the problem exists? How can you recommend getting a vasectomy reversal to a man who is suffering without admitting that there is something fundamental about vasectomies that makes getting them reversed curative? In other words, you are admitting that getting a vasectomy is risky not just because it is surgery — it is risky because it permanently changes the body to function in a way that sometimes causes disease. Many men report that their doctors do not mention reversal as a treatment option unless the man specifically asks them about it.

At the age most men seek a vasectomy, most do not have any experience with chronic pain, and cannot appreciate what an enormous psychological stress it can be. For some it feels like being trapped and subjected to torture in slow motion over many years. Social media has provided a rare forum in which some men feel comfortable talking candidly and in detail about their experience with PVPS. Their stories have many similarities and common themes. By reading them you can get a detailed picture of what it is like to lose this bet. There are hundreds of stories available at www.reddit.com/r/postvasectomypain . I do my best to avoid posting the same person’s story twice.

More study needs to be done so that we can know the rate of this complication with more precision. Men who are still sore 3 months after their vasectomy want to know what to expect and what to do. Should they get additional surgery? How long should they wait before making this decision? They deserve to be taken seriously and given advice that is well-grounded in scientific study.

Finding and testing new birth control techniques for men and for women should be made a higher priority. Exaggerating the safety of the currently available options makes it harder to be motivated to search for real improvements. Perhaps a technique like Vasalgel could be seen as a better risk trade-off since it may have a lower incidence of PVPS or be easier to reverse if the man ends up with chronic problems. Perhaps the choice of vasectomy technique (open/closed, scalpel/no-scalpel, bilateral/midline) makes a difference in how likely chronic pain is to result.

The subreddit is a place to post stories or links to stories about what it is like to have PVPS. Scientists and doctors have not yet done an adequate job of measuring this problem and communicating it to the public, so the task falls to the people who have the most reason to care about the issue — the people whose lives have been negatively impacted.

I have no ideological problem with vasectomy. In fact, before I had a vasectomy, I thought it was easy to see that it was the best choice for my family. I didn’t investigate the procedure at all before having it done, trusting that my urologist would advise me of any relevant risks. My urologist did not give me an accurate idea of the frequency and impact of chronic pain. Unfortunately, I have been in pain every day since my surgery. My motive for working on the subreddit is that I want men to get a proper warning about the risks, and to disrupt the complacency that surrounds our attitude toward vasectomy so that we will be interested in developing a technique that is actually as safe as most people erroneously believe vasectomy to be.

Men who are willing to step up and voluntarily risk surgery that benefits others, including their partners, doctors and all of society deserve better than to be mislead about how safe it is. They deserve better than to have their complications remain understudied and poorly understood. We need to see effort put into understanding how common chronic pain is after vasectomy, and into learning what can be done to prevent it, and what the best treatment protocol should be.

If you had a vasectomy in the last 12 months and are still in pain, I would not recommend getting additional surgery right away. I think it’s better to wait it out and take some time to educate yourself about the alternatives, both surgical and non-surgical. See how you feel at 1 year. Waiting won’t make things worse, and many guys experience improvement for a year or more.

If you want to get a vasectomy and minimize your chances of developing PVPS, here is some advice from Dr. Sheldon Marks:

Any good urologist should be fine. When you go in for your pre-vasectomy consultation be sure to ask about your concerns — explain you have done you reading and ask him or her to explain the technique they use — then you can ask that small piece only be removed, as high up the vas as they can away from the testicle, minimize cautery, no clips, no ties and use plenty of long acting local anesthetic. Some will say sure, others will tell you they want to do it the way they do it…It may take a few doctors visits to find a urologist that does vasectomies the way you want. Don’t be in a hurry and don’t go to the first urologist you see if you have bad feelings. It would be great if you could call around and ask but I cant imagine anyone giving you that information or assurances as a nonpatient over the phone.

https://www.postvasectomypain.org/t/minimizing-risk-of-post-vasectomy-pain/77/5

Other long-term complications of vasectomy

Vasectomy is correlated with an increased rate of prostate cancer. Scientists argue about why this is the case. For a long time, the consensus view has been that vasectomy does not cause prostate cancer. However, recent studies strongly suggest that a little more than 1% of vasectomies result in prostate cancer.

https://ascopubs.org/doi/full/10.1200/jco.2013.54.8446

https://www.ncbi.nlm.nih.gov/pubmed/31119294

https://pubmed.ncbi.nlm.nih.gov/32772072/

If these studies are correct, then prostate cancer is another *common* complication of vasectomy. The studies show a “relative risk” of at least 1.1 for prostate cancer, with similar numbers for the aggressive, lethal type.

A recent study found that although vasectomy does cause men to have prostate cancer more often, men with a vasectomy nevertheless are less likely to die of the disease. I would presume that this is because the type of man that is more likely to get a vasectomy is also the type of man that is more likely to show up for his prostate exam.

A fact that tends not to get counted when comparing vasectomy with the female alternative salpingectomy is that salpingectomy can reduce a woman’s risk of ovarian cancer — possibly by 30% to 64% (Link)

Vasectomy also raises your risk for kidney stones by about 10% if you are under 46 years old:

https://pubmed.ncbi.nlm.nih.gov/9016891/

https://pubmed.ncbi.nlm.nih.gov/2891890/

Vasectomy may be a simple, quick snip, but long term negative consequences can extend far beyond the scrotum and affect many other parts of the body, including the prostate and kidneys, in surprising ways.