Free
Case Report  |   April 2019
Osteopathic Manipulative Treatment as a Novel Way to Manage Postvasectomy Pain Syndrome
Author Notes
  • From the Family Health Clinic at the Yokota Air Base in Japan and the Ehrling Bergquist Family Medicine Residency at Offutt Air Force Base in Nebraska. 
  • Disclaimer: The views expressed herein are those of the authors and do not necessarily reflect the official policy or position of the Department of the United States Air Force, the Department of Defense, or the US Government. 
  • Financial Disclosures: None reported. 
  • Support: None reported. 
  •  *Address correspondence to Richard E. Gray, DO, PSC, 78 Box 1404 APO, AP 96326. Email: nomadicgray@yahoo.com
     
Article Information
Osteopathic Manipulative Treatment / Pain Management/Palliative Care / Psychiatry / Urological Disorders
Case Report   |   April 2019
Osteopathic Manipulative Treatment as a Novel Way to Manage Postvasectomy Pain Syndrome
The Journal of the American Osteopathic Association, April 2019, Vol. 119, 263-267. doi:https://doi.org/10.7556/jaoa.2018.162
The Journal of the American Osteopathic Association, April 2019, Vol. 119, 263-267. doi:https://doi.org/10.7556/jaoa.2018.162
Abstract

Postvasectomy pain syndrome (PVPS) can be debilitating and is notoriously difficult to treat, often requiring a multidisciplinary approach. In this case report, osteopathic manipulative treatment (OMT) was used to treat a patient with PVPS. After vasectomy, an otherwise-healthy man experienced chronic right testicular pain, aggravated by exercise, touch, and sexual intercourse, resulting in marital strain and an inability to perform routine fitness activities. Symptoms persisted for 8 years, despite lifestyle modifications, orally administered pain regimens, pelvic floor physical therapy, nerve blocks, steroid injections, epididymectomy, spermatic cord denervation, and counseling. After the patient's urologist suggested orchiectomy, his family medicine physician referred him for OMT. The OMT interventions, applied over a 4-month period, were directed at the lumbar spine, pelvis, pelvic floor, and lower abdomen. After treatment, the patient reported absence of testicular pain most of the time and described his quality of life as “10 times better.” Literature review revealed no reports of OMT used to manage PVPS.

Vasectomy is performed to provide permanent contraception to more than half a million men annually in the United States and has a low complication rate.1-3 Possible complications include infection, bleeding, sperm granuloma, and postvasectomy pain syndrome (PVPS). 
In 2012, the American Urological Association reported that after vasectomy, 1% to 2% of men experience PVPS.2 Notoriously difficult to treat, PVPS (characterized as at least 3 months of intermittent or chronic scrotal or testicular pain, which may occur months to years after vasectomy,4 has numerous surgical and nonsurgical management options that are inconsistently successful, with no standardized protocol for evaluation and treatment,5 and it frequently persists despite a multidisciplinary approach to treatment. 
Osteopathic manipulative treatment (OMT) involves the application of direct and indirect techniques to various body regions to improve the function of the circulatory and neuromusculoskeletal systems, thereby promoting health.6 The following case is, to our knowledge, the first reported (and apparently successful) use of OMT to manage PVPS. We hypothesize a myofascial or musculoskeletal contribution to some cases of chronic pain after vasectomy, making OMT a reasonable treatment component in a multidisciplinary approach to patients with PVPS . 
Report of Case
The patient was an otherwise-healthy 38-year-old active-duty male service member who had undergone no-scalpel vasectomy 8 years earlier. His initial postoperative period was pain free, but after several months the patient experienced right posterior testicular pain and tenderness, as well as erectile dysfunction. He underwent right epididymectomy 1 year after vasectomy, after a small epididymal cyst was seen on ultrasonography; his symptoms were initially improved after this procedure, but his right testicular pain recurred during the next 7 months. He described a persistent throbbing pain that he rated as 5 to 7 on a 0-to-10 scale of severity, occasional radiation to the ipsilateral groin, with flares lasting 1 to 2 weeks and occurring about 4 times per year. Pain interfered with his sleep and was exacerbated by ambulation, transfers, exercise, touch, erections, intercourse, and ejaculation. He had no left-sided testicular symptoms or urinary symptoms, and results of testing for sexually transmitted infection, urinalyses, and cultures were consistently negative. Six years after the vasectomy, ultrasonography findings were unremarkable except for postsurgical changes, absence of right epididymis, and minimal right-sided hydrocele. 
Attempts to alleviate the patient's symptoms included activity modification, antibiotics, several oral pain regimens (including nonsteroidal anti-inflammatory drugs, muscle relaxants, pregabalin, gabapentin, and narcotics), pelvic floor physical therapy, transcutaneous electrical nerve stimulation, spermatic cord block, spermatic cord denervation, and repeated genitofemoral nerve steroid injections. He also received counseling for psychological symptoms and marital strain stemming from his chronic pain. 
Despite the above interventions, the patient's symptoms persisted, and his quality of life declined. With potential disqualification from continued military service due to his chronic pain and resultant inability to pass a military physical fitness test, his urologist offered orchiectomy as a possible definitive treatment, but the patient was hesitant to proceed and sought alternatives. 
After consultation with his primary care physician (an allopathic physician) 8 years after vasectomy, the patient was referred for OMT. 
The initial osteopathic examination of the patient revealed a taut and tender right bulbospongiosus muscle and perineal body, tenderness to palpation of the posterior superior pole of the right testicle, myofascial trigger points of the levator ani muscle on the right (palpated via digital rectal examination), pelvic malalignment, poor sacral mobility, and tender points over the right inguinal ligament, right hip flexors, and lower abdomen. 
The OMT interventions included treatment of the lumbar spine, pelvis, pelvic floor, and lower abdomen during a period of 4 months (10 visits). Specifically, maneuvers included sacral rocking with respiratory assist; high-velocity, low-amplitude lumbar roll; pelvic floor release; myofascial release of the lower abdomen and proximal right thigh; muscle-energy technique; a contract-relax technique of the right hip flexors and quadriceps; and strain-counterstain techniques. Interventions varied between sessions, based on the patient's presentation that day. The perineum was never directly treated. Rectal examinations were required only as part of initial evaluation and periodic reassessments and were not part of the treatment. 
Repeated osteopathic examination after 10 visits revealed complete resolution of the pain and tension over the right perineal body, decreased right testicle tenderness, improved sacral mobility, and decreased tender points of the abdomen and inguinal ligament. There was a persistent levator ani trigger point. The patient's postejaculatory pain, which had lasted several days before starting OMT, now did not last beyond 30 minutes. Erections were now painless, but sexual intercourse remained challenging owing to pain. After this course of treatment, the patient described his testicular pain and quality of life as “10 times better” and reported frequently being pain free, which he had not experienced since the onset of PVPS. 
Literature Search
A literature search was completed in September 2016. PubMed and Google Scholar were searched with combinations of the following search terms: “vasectomy,” “vasectomy complications,” “post vasectomy pain syndrome,” “postvasectomy pain syndrome,” “OMT,” “osteopathic manipulative,” “osteopathic manipulation,” “pelvic floor,” “pelvic pain,” “pelvic floor therapy,” “male,” and “men.” A total of 763 citations were reviewed for relevance to the above case, and applicable articles were retrieved; additional sources were identified by reviewing references within the articles, as well as related citations suggested by PubMed. Results were used to provide background information and refine a hypothesis that OMT can be a valuable part of a multidisciplinary approach to managing PVPS, which may sometimes be due to pelvic floor dysfunction. We found no studies or reports of OMT use for the management of PVPS. 
Discussion
Specific symptoms vary but most often include orchalgia, painful intercourse, painful ejaculation, tender or full epididymis, or tender vas deferens.7 The severity of PVPS may be minimal to debilitating. Most estimates of its incidence range from 1% to 6% of men who undergo vasectomy,1,8 and its pathophysiologic mechanism remains a topic of debate, with some theories ascribing PVPS to obstruction, dilatation, or possible rupture of epididymal ducts.3,9,10 
The differential diagnosis for chronic testicular pain after vasectomy is broad and includes epididymitis, infection, psychogenic pain, local neuropathy, nerve impingement, and referred pain9,11; pelvic floor dysfunction (muscle dysfunction or myofascial trigger points) is infrequently considered.4 
Treatment options for PVPS abound, although treatment failure commonly frustrates patients, their families, and physicians. Nonpharmacologic approaches include activity limitations, supportive undergarments, heat and cold therapy, pelvic floor physical therapy, acupuncture, biofeedback, and mental health treatment. Pharmacologic options include nonsteroidal anti-inflammatory drugs, narcotics, antibiotics, neuroleptics, tricyclic antidepressants, spermatic cord nerve blocks, and locally administered steroids. Sperm granuloma excision, epididymectomy, spermatic cord denervation, vasectomy reversal, and orchiectomy are surgical options that may also be considered.4,10 
The pelvic floor supports the pelvic organs through complex mechanics of muscles, ligaments, and connective tissue, while also playing a role in urinary and fecal continence, sexual arousal, and orgasms. Trigger points in the puborectalis, pubococcygeus, and rectus abdominis muscles refer penile pain, and trigger points in the external oblique muscles refer suprapubic, testicular, and groin pain.12 Pelvic floor muscle spasms can also result in sexual dysfunction.13,14 
Pelvic floor dysfunction is a cause of chronic pelvic pain syndrome (CPPS), which has not been commonly associated with vasectomy, if at all. Like PVPS, CPPS presents heterogeneously with a similar array of symptoms and commonly affects young or middle-aged men, causing genital or pelvic pain that is often associated with voiding or sexual dysfunction. Previously called “chronic prostatitis” because an inflamed or infected prostate was suspected, evidence suggests that CPPS may be related to pelvic floor musculoskeletal pain or dysfunction, myofascial pain syndromes, or functional somatic syndromes.15-17 It can be successfully managed with a multidisciplinary treatment approach, including manual pelvic floor physical therapy, relaxation training, and flexibility and aerobic exercises,12,18-20 lending further credence to theories of musculoskeletal and myofascial contributions to pain in the groin and genitals, as well as to sexual dysfunction. 
Manual therapy of the pelvic floor has been beneficial in treating CPPS and pelvic floor dysfunction,12,19,20 suggesting that OMT may also be effective for PVPS. Although pelvic floor physical therapy was unsuccessful in our patient, OMT was better able to target his suspected pelvic floor dysfunction, as well as somatic dysfunction in his lumbar spine, pelvis, and abdominal musculature. 
Because PVPS is defined by its symptoms in relation to vasectomy and not its pathophysiologic mechanism (which is still debated), our patient definitively had PVPS. Pelvic floor dysfunction may develop in some patients with symptoms refractory to more traditional treatment, placing them on the spectrum of CPPS. We hypothesized that pelvic floor dysfunction may occur via a pain-spasm-dysfunction cycle (Figure), wherein the initial surgical insult and discomfort result in pelvic floor contractions or guarding, which in turn lead to painful spasms, which compress nerves, compromise local blood flow, and, ultimately, cause pelvic floor dysfunction. The OMT techniques applied in our patient probably relaxed these soft tissues, increased local blood flow, and improved joint alignment, thereby alleviating pain and dysfunction. His pain relief seemed to be directly correlated with the start of OMT, even though his concurrent multidisciplinary treatments make it more difficult to interpret this result. 
Figure.
Hypothesized pain-spasm-dysfunction cycle in patients with postvasectomy pain syndrome that may be disrupted by osteopathic manipulative treatment (OMT).
Figure.
Hypothesized pain-spasm-dysfunction cycle in patients with postvasectomy pain syndrome that may be disrupted by osteopathic manipulative treatment (OMT).
Conclusion
To our knowledge, this is the first reported use of OMT for PVPS. We hypothesized that PVPS may ultimately lead to pelvic floor dysfunction in some patients, and thus manual treatments such as OMT may offer benefit. Given the heterogeneity of PVPS and the unknown prevalence of pelvic floor dysfunction as the source of chronic pain after vasectomy, an evaluation by an osteopathic physician to assess and treat the pelvic floor and surrounding structures may be useful for symptoms refractory to more traditional treatments. Further research should investigate the prevalence of pelvic floor dysfunction in men with PVPS, the best candidates for OMT in this population, and the specific techniques and long-term outcomes of OMT for PVPS. 
References
Rayala BZ, Viera AJ. Common questions about vasectomy. Am Fam Physician. 2013;88(11):757-761. [PubMed]
Sharlip ID, Belker AM, Honig S, et al Vasectomy: AUA guideline. J Urol. 2012;188(6 suppl):2482-2491. doi: 10.1016/j.juro.2012.09.080 [CrossRef] [PubMed]
Schwingl PJ, Guess HA. Safety and effectiveness of vasectomy. Fertil Steril. 2000;73(5):923-936. [CrossRef] [PubMed]
Valencic M. Re: Granitisiotis P, Kirk D. Chronic testicular pain: an overview. Eur Urol 2004;45:430-436 [letter]. Eur Urol. 2005;47(5):720. doi: 10.1016/j.eururo.2004.10.023
Tan WP, Levine LA. An overview of the management of post-vasectomy pain syndrome. Asian J Androl. 2016;18(3):322-337. doi: 10.4103/1008-682X.175090
Franke H, Franke JD, Fryer G. Osteopathic manipulative treatment for nonspecific low back pain: a systematic review and meta-analysis. BMC Musculoskel Disord. 2014;15:286. doi: 10.1186/1471-2474-15-286 [CrossRef]
Nangia AK, Myles JL, Thomas AJJr. Vasectomy reversal for the post-vasectomy pain syndrome: a clinical and histological evaluation. J Urol. 2000;164(6):1939-1942. [CrossRef] [PubMed]
Morris C, Mishra K, Kirkman RJ. A study to assess the prevalence of chronic testicular pain in post-vasectomy men compared to non-vasectomised men. J Fam Plann Reprod Health Care. 2002;28(3):142-144. [CrossRef] [PubMed]
Christiansen CG, Sandlow JI. Testicular pain following vasectomy: a review of postvasectomy pain syndrome. J Androl. 2003;24(3):293-298. [CrossRef] [PubMed]
Tandon S, Sabanech EJr. Chronic pain after vasectomy: a diagnostic and treatment dilemma. BJU Int. 2008;102(2):166-169. doi: 10.1111/j.1464-410X.2008.07602.x [CrossRef] [PubMed]
Granitsiotis P, Kirk D. Chronic testicular pain: an overview. Eur Urol. 2004;45(4):430-436. doi: 10.1016/j.eururo.2003.11.004 [CrossRef] [PubMed]
Anderson RU, Sawyer T, Wise D, Morey A, Nathanson BH. Painful myofascial trigger points and pain sites in men with chronic prostatitis/chronic pelvic pain syndrome. J Urol. 2009;182(6):2753-2758. doi: 10.1016/j.juro.2009.08.033 [CrossRef] [PubMed]
Rosenbaum TY. Pelvic floor involvement in male and female sexual dysfunction and the role of pelvic floor rehabilitation in treatment: a literature review. J Sex Med. 2007;4(1):4-13. doi: 10.1111/j.1743-6109.2006.00393.x [CrossRef] [PubMed]
Makovey I, Dolinga R, Shoskes DA. ‘Spousal revenge syndrome’—description of a new chronic pelvic pain syndrome. Can J Urol. 2016;23(1):8176-8178. [PubMed]
Potts JM. Chronic pelvic pain syndrome: a non-prostatocentric perspective. World J Urol. 2003;21(2):54-56. doi: 10.1007/s00345-003-0327-2 [CrossRef] [PubMed]
Potts JM. Male pelvic pain: beyond urology and chronic prostatitis. Curr Rheumatol Rev. 2016;12(1):27-39. [CrossRef] [PubMed]
Magistro G, Wagenlehner FM, Grabe M, Weidner W, Stief CG, Nickel JC. Contemporary management of chronic prostatitis/chronic pelvic pain syndrome. Eur Urol. 2016;69(2):286-297. doi: 10.1016/j.eururo.2015.08.061 [CrossRef] [PubMed]
Cohen D, Gonzalez J, Goldsetein I. The role of pelvic floor muscles in male sexual dysfunction and pelvic pain. Sex Med Rev. 2016;4(1):53-62. doi: 10.1016/j.sxmr.2015.10.001 [CrossRef] [PubMed]
Alstyne LS Van, Harrington KL, Haskvitz EM. Physical therapist management of chronic prostatitis/chronic pelvic pain syndrome. Phys Ther. 2010;90(12):1795-1806. doi: 10.2522/ptj.20090418 [CrossRef] [PubMed]
Rosenbaum TY, Owens A. The role of pelvic floor physical therapy in the treatment of pelvic and genital pain-related sexual dysfunction (CME). J Sex Med. 2008;5(3):513-523. doi: 10.1111/j.1743-6109.2007.00761.x [CrossRef] [PubMed]
Figure.
Hypothesized pain-spasm-dysfunction cycle in patients with postvasectomy pain syndrome that may be disrupted by osteopathic manipulative treatment (OMT).
Figure.
Hypothesized pain-spasm-dysfunction cycle in patients with postvasectomy pain syndrome that may be disrupted by osteopathic manipulative treatment (OMT).