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.