Micro-Denervation of the Spermatic Cord for Post-Vasectomy Pain Management

[Male contraception]

CONTEXT

Contraception is a major global health issue, which is still dominated by female contraception. Developments in male contraception could help redistribute the contraceptive burden.

METHODS

A literature search was carried out to review the existing options and the criteria for optimal contraception, to establish the principles of a male pre-contraception consultation, and to review the various research avenues with their advantages and disadvantages.

RESULTS

The new male contraception options are detailed, whether hormonal (androgen therapy, combination of progestins and testosterone) or non-hormonal, particularly thermal, with current results and avenues for improvement. Condom use and vasectomy remain the only 2 validated options. The recent development of minimally invasive vasectomy without the need for a scalpel and of occlusion techniques has simplified the procedure, minimised the risk of complications (pain, haematomas, post-vasectomy pain syndrome) and improved efficacy. The issues of regret and the possibility of repermeabilisation are also raised.

CONCLUSION

The question of male contraception will become increasingly important in consultations with urologists. The urologist will have to inform the patient, as required by law, before the vasectomy is performed, and provide the best possible advice on the technique, which will often be minimally invasive without the need for a scalpel. New reversible options should also broaden the range of options available on a routine basis, with a view to gradually moving towards contraceptive equity.

[Recommendations of the Committee of Andrology and Sexual Medicine of the AFU concerning the management of Vasectomy]

OBJECTIVES

To answer the main clinical questions asked by practitioners and men consulting for a vasectomy request.

METHOD

The CPR method was used. The clinical questions were formulated according to the PICO methodology. A Pubmed literature search for the period 1984-2021 identified 508 references, of which 79 were selected and analyzed with the GRADE grid.

RECOMMENDATIONS

Vasectomy is a permanent, potentially reversible contraception. It is a safe procedure. A second vasectomy is necessary in only 1 % of cases. Surgical complications (hematoma, infection, pain, etc.) are rare. The frequency of prolonged scrotal pain after vasectomy is about 5 %, and less than 2 % describe a negative impact of this pain on their quality of life. Vasectomy does not have negative consequences on sexuality. The only contraindication to vasectomy is the minor patient. Patients at increased risk of remorse are single, divorced or separated men under the age of 30. Sperm storage may be particularly appropriate for them. Whatever the reason, the law allows the surgeon to refuse to perform the vasectomy. He must inform the patient of this at the first consultation. The choice of the type of anesthesia is left to the discretion of the surgeon and the patient. It must be decided during the preoperative consultation. Local anesthesia should be considered first. General anesthesia should be particularly considered in cases of anxiety or intense sensitivity of the patient to palpation of the vas deferens, difficulty palpating the vas deferens, or a history of scrotal surgery that would make the procedure more complex. Concerning the vasectomy technique, 2 points seem to improve the efficiency of the vasectomy: coagulation of the deferential mucosa and interposition of fascia. Leaving the proximal end of the vas deferens free seems to reduce the risk of post-vasectomy syndrome without increasing the risk of failure or complications. No-scalpel vasectomy is associated with a lower risk of postoperative complications than conventional vasectomy. Regarding follow-up, it is recommended to perform a spermogram at 3 months post-vasectomy and after 30 ejaculations. If there are still a few non-motile spermatozoa at 3 months, it is recommended that a check-up be performed at 6 months post-vasectomy. In case of motile spermatozoa or more than 100,000 immobile spermatozoa/mL at 6 months (defining failure), a new vasectomy should be considered. Contraception must be maintained until the effectiveness of the vasectomy is confirmed.

Chronic scrotal pain: Pathogenesis, clinical phenotypes and modern treatment concept (clinical lecture)

Chronic scrotal pain (CSP) is a general term, which defines variety of problems causing discomfort or pain in the scrotum, which can be caused by the problems with testicles and other structures of the scrotum: epididymis, vas deferens, paratesticular structures. For a practicing urologist, the diagnosis and treatment of chronic scrotal pain is always a difficult task due to the many reasons for its appearance and the variety of clinical symptoms. CSP is a widespread but poorly understood condition, the etiology of which often can not be identified. Pain localized in the scrotum makes up 38.8 % of all cases of chronic men’s pelvic pain. From 2.5 to 4.8 % of all visits to the urologist relate to CSP syndrome. Primary scrotal pain syndrome is not associated with infection or other local pathological processes that could cause pain. The treatment of chronic scrotal pain is challenging because the pain often does not react to the traditional treatments.

The purpose of this lecture is to draw the attention of urologists, general practitioners, and everyone who is interested in the problem of treating chronic scrotal pain to the possibilities of modern medicine in solving this multidisciplinary problem.

Postvaricocele Embolization Pain Syndrome: A Case Series Report and Review of Current Treatment Strategies

BACKGROUND

Orchialgia is not an uncommon complaint among men with varicocele, but postvaricocele embolization-related testicular pain has not been widely investigated. This study evaluates the phenomenon of postvaricocele embolization pain (PVEP) syndrome and examines the current strategies to treat this unusual complication.

METHODS AND MATERIALS

A prospectively collected database of patients with PVEP who presented to a tertiary center was analyzed between January 2011 and January 2020 following internal ethics approval. Patient demographics, including other complications related to embolization, analgesic requirements, and pain scores (on a 10-point visual analog score), treatment strategies, Patient Global Impression of Improvement (PGI-I) score and overall satisfaction score (on a 5-point scale), were reviewed. All patients were reviewed for a minimum of 12 months.

RESULTS

A total of 20 men with a mean age of 33.8 (18-45) years old, presented with PVEP over 10 years. Most men received embolization on an average of 26.6 (18-48) months. The reasons for varicocele embolization include either isolated or combined orchialgia (15 men), subfertility (5 men), and cosmesis (6 men). Eighteen (90%) men underwent microscopic spermatic cord denervation (MSCD) and 2 patients elected for conservative measures. The average pain scores pre-MSCD and post-MSCD were 6.9 (4-9) and 1.4 (0-4) (p<0.001) with a significant reduction in analgesia requirements. Immediate improvement in pain score was reported in all the patients and this persisted at the 12 months review. Most men reported a high satisfaction score (of 4/5) and only one patient reported no change in symptoms after MSCD.

CONCLUSION

PVEP is a unique complication and patients should be counseled on the potential risk of persistent orchialgia following embolization for varicocele. The MSCD appears to be an effective treatment option with high success and satisfaction rates.

Microsurgical Denervation of the Spermatic Cord: A Historical Perspective and Recent Developments

INTRODUCTION

The management of chronic scrotal pain is long and varied, with historical treatment algorithms typically ending with orchiectomy. Microsurgical denervation of the spermatic cord (MDSC) is a testicle-sparing option for patients who have failed conservative treatment options and over its forty-year history has seen many technical refinements.

OBJECTIVES

To review the history and development of MDSC and discuss the outcomes of different surgical techniques.

METHODS

A literature review using PubMed and Google Scholar was conducted to identify studies pertaining to surgical treatment of CSP, MDSC, and outcomes. Search terms included "chronic," "scrotal pain," "orchialgia," "spermatic cord," "denervation," and "microsurgery."

RESULTS

We included 21 case reports and series since the first seminal paper describing MDSC technique in 1978. Additional studies that challenged existing conventions or described novel techniques are also discussed. The current standard procedure utilizes a subinguinal incision and a surgical microscope. Open, robotic, and laparoscopic approaches to MDSC have been described, but access to minimally invasive instruments may be limited outside of developed nations. Pain reduction following preoperative spermatic cord predicts success of MDSC. Methods for identifying and preserving the testicular and deferential arteries vary depending on surgeon preference but appear to have comparable outcomes. Future developments in MDSC involve targeted denervation, minimizing collateral thermal injury, and alternative techniques to visualize arterial supply.

CONCLUSION

For patients suffering from CSP, MDSC is a well-studied technique that may offer appropriately selected patients' relief. Future investigation comparing targeted vs full MDSC as well as in vivo study of new techniques are needed to continue to improve outcomes. Sun HH, Tay KS, Jesse E, et al. Microsurgical Denervation of the Spermatic Cord: A Historical Perspective and Recent Developments. Sex Med Rev 2022;XX:XXX-XXX.

Seminal exosomes - An important biological marker for various disorders and syndrome in human reproduction

BACKGROUND

Exosomes are nano-sized membrane vesicles, secreted by different types of cells into the body's biological fluids. They are found in abundance in semen as compared to other fluids. Exosomes contain a cargo of lipid molecules, proteins, phospholipids, cholesterol, mRNAs, and miRNAs. Each molecule of seminal exosomes (SE) has a potential role in male reproduction for childbirth. Many potential candidates are available within the seminal exosomes that can be used as diagnostic markers for various diseases or syndromes associated with male reproduction. Also these seminal exospmes play a major role in female reproductive tract for effective fertilization.

AIM

The aim of this review is to focus on the advancement of human seminal exosomal research and its various properties.

METHODS

We used many databases like Scopus, Google scholar, NCBI-NLM and other sources to filter the articles of interest published in exosomes. We used phrases like "Exosomes in human semen", "Composition of exosomes in human semen" and other relevant words to filter the best articles.

RESULTS

Seminal exosomes play a major role in sperm functions like cell-to-cell communication, motility of the sperm cells, maintaining survival capacity for the sperm in the female reproductive tract and spermatogenesis. Also, seminal exosomes are used as a carrier for many regulatory elements using small RNA molecules. miRNAs of the seminal exosomes can be used as a diagnostic marker for prostate cancer instead of prostate specific antigen (PSA). Epididymosomes can be used as a biomarker for reproductive diseases and male infertility.

CONCLUSION

Seminal exosomes could be used as biological markers for various reproductive disorders, male infertility diagnosis, and it can be used in anti-retroviral research for the identification of novel therapeutics for HIV-1 infection and transmission.

Gold Standard Care of Chronic Scrotal Pain

INTRODUCTION

Chronic scrotal pain (CSP) can be a debilitating condition for patients and is often difficult to characterize.

METHODS

A review of literature was performed using Embase, Cochrane and Medline databases in the period 1.January 2010 to 1.January 2021. We found 132 articles, and the authors screened abstract and references. Thirty-seven articles are included after removing duplicates.

RESULTS

This review presents a variety of medical and surgical treatment options for CSP such as spermatic cord blocks (36-80% success rate), microsurgical denervation of the spermatic cord (76-100% success rates), Botox (56% success rate), targeted ilioinguinal and iliohypogastric peripheral nerve stimulation, and radical orchiectomy (55-75% success rate).

CONCLUSION

An overview of various treatment options, both non-surgical and surgical are provided, with the aim of establishing what may be the best treatment option for CSP.

Vasectomy: a guidelines-based approach to male surgical contraception

Except for condom use, vasectomy is the only approved form of male contraception. The American Urological Association published guidelines on vasectomy in 2012, which clearly outlined patient counseling, vasectomy techniques to maximize successful occlusion, and postvasectomy care. However, there are certainly areas of further improvement to be addressed. Vasectomy is severely underutilized compared with tubal ligation for sterilization, likely due to lack of patient awareness. Although the majority of vasectomies are performed in the office with local anesthesia, some patients are still routinely prescribed narcotics for postprocedural pain, despite the well-described opioid pandemic. Finally, although patients are counseled on the necessity of a postvasectomy semen analysis to confirm sterility prior to the discontinuation of alternative contraceptives, more than 50% of men do not complete this test. Therefore, alternative strategies must be pursued to improve patient compliance.

Chronic Scrotal Content Pain: a Review of the Literature and Management Schemes

PURPOSE OF REVIEW

Chronic scrotal content pain (CSCP) is a complex condition with multiple etiologies that requires a thorough understanding of its pathophysiology, workup, and treatment options. We performed a comprehensive and contemporary review to augment our current understanding of CSCP.

RECENT FINDINGS

We discuss new advances in CSCP-specific pain questionnaires, modern studies of microscopic spermatic cord denervation and its variations, and novel techniques including electric nerve stimulation and cryoablation in addition to randomized control trials with significant negative findings. We also present literature focusing on the prevention of CSCP secondary to surgical iatrogenic causes. The constantly evolving literature of CSCP has led to the significant evolution in its diagnosis and treatment, from oral medications to salvage options after microscopic spermatic cord denervation. With each advance, we come closer to developing a more thorough, evidence-based algorithm to guide urologists in treatment of CSCP.

Arteriovenous haemangioma of the vas deferens: a case report and literature review

Arteriovenous haemangioma of the vas deferens is an extremely rare entity in clinical practice. To date, there have been no clinical or pathological cases reported in Medline, Embase or other published English literature. Herein, a 50-year-old male who presented with right scrotal pain for 4 years after vasectomy was admitted to our hospital. One painful nodule was palpable in the right scrotum on physical examination. Color Doppler ultrasound merely showed dilation of the epididymis and no additional information concerning the painful nodule in the right scrotum. Moreover, the laboratory test results were all within normal limits. Ibuprofen was administered to the patient for 2 months with a poor effect, and then spermatic cord block significantly relieved his symptoms. This patient underwent resection of the right painful nodule of the vas deferens under medical advice. Postoperative pathological examinations showed arteriovenous haemangioma of the vas deferens. There were no obvious complications after arteriovenous haemangioma excision, and the right scrotal pain was significantly relieved 1 month later. This article reminds urologists and oncologists that haemangioma can involve the vas deferens and, in addition to spermatic granuloma, might be a cause of post-vasectomy pain syndrome. Cauterization of the vas deferens might have a potential relationship with haemangioma.

Targeted Microsurgical Denervation of the Spermatic Cord for Chronic Orchialgia: the Current Standard of Care

PURPOSE OF REVIEW

This paper reviews the pathophysiology, current literature, techniques for full microsurgical denervation (MDSC) and targeted microsurgical denervation (TMDSC) of the spermatic cord, and outcomes for these treatment options for patients with chronic scrotal content pain (CSCP) or orchialgia.

RECENT FINDINGS

Significant reduction in pain (77-100%) is reported across various studies for CSCP patients with minimal patient morbidity. The testicular atrophy/loss risk is less than 1%. Testosterone levels do not appear to be affected by TMDSC/MDSC. The outcomes between TMDSC and MDSC are comparable (not statistically significantly different). However, TMDSC is significantly more efficient and a lot less tedious to perform. TMSCD had a shorter microsurgical operative time (21 min vs 53 min, P = 0.0001) than MDSC. Targeted or full microsurgical denervation of the spermatic cord is a safe and effective treatment option that is well published across several studies. The targeted MDSC approach is a more efficient and potentially less risky approach with similar outcomes to full MDSC.

Management of Chronic Orchialgia: Challenges and Solutions - The Current Standard of Care

INTRODUCTION

Chronic scrotal content pain (CSP) or chronic orchialgia can be debilitating for patients and difficult to treat. There is a paucity of structured treatment algorithms to approach this difficult condition.

METHODS

A review of the literature was performed. Conservative treatment options are presented and then targeted surgical interventions that the urologist may perform are then presented in a structured algorithm format. Many of these patients may obtain a significant reduction in pain with some of these treatments.

RESULTS

This review presents the pathophysiology, a new assessment tool, and various treatment options available for CSP patients, such as targeted spermatic cord blocks, targeted and standard microsurgical denervation of the spermatic cord (77-100% success rates), ultrasound-guided peri-spermatic cord and ilioinguinal cryoablation (59-75% success rates), scrotox (botox) (56-72% success rates), targeted ilioinguinal and iliohypogastric peripheral nerve stimulation (72% success rate), radical orchiectomy (20-75% success rate), targeted robotic-assisted intra-abdominal denervation (71% success rate) and vasectomy reversal (69-100% success rates).

CONCLUSION

A structured and evidence-based approach to help urologists manage patients with chronic orchialgia or scrotal content pain is presented.

Development of a clinically relevant symptom index to assess patients with chronic orchialgia/chronic scrotal content pain

Background

The purpose of this study was to develop a candidate symptom index for men with an established diagnosis of chronic orchialgia.

Methods

Based on interviews with patients and providers, we developed a 70-item questionnaire that focused on seven areas of orchialgia symptoms: pain, location, urinary symptoms, sexual dysfunction, medical history and quality of life (QOL) impact. The questionnaire was completed by patients at two medical centers. Cluster analysis was performed with the software package R (3.2.1).

Results

A total of 113 men completed the survey. Median symptom duration was 12 months (range, 3-336 months). Outside the testicle, pain was felt in the spermatic cord (66%), groin (66%), penis (24%), suprapubic region (38%), flank (31%), thigh (32%), abdomen (36%) and perineum (35%). Bother scores were high only for testicle and spermatic cord pain. Urinary frequency was common (54%) but not bothersome. Sexual dysfunction was common: 55% had erectile dysfunction, 56% had decreased libido and 39% had painful ejaculation with high bother for all. By cluster analysis, QOL parameters clustered tightly with minimal pain level, pain at night, burning pain, distribution to spermatic cord and groin, erectile dysfunction and premature ejaculation.

Conclusions

Men with chronic orchialgia have a high incidence of associated symptoms. Most bothersome symptoms with highest QOL impact include burning pain, pain at night, radiation to groin and spermatic cord, erectile dysfunction and low libido. Based on these findings, we have created a candidate orchialgia symptom index with domains of pain, sexual symptoms and QOL that will undergo prospective validation.

What Can We Do for Chronic Scrotal Content Pain?

Chronic scrotal content pain remains one of the more challenging urological problems to manage. This is a frustrating disorder to diagnose and effectively treat for both the patient and clinician, as no universally accepted treatment guidelines exist. Many patients with this condition end up seeing physicians across many disciplines, further frustrating them. The pathogenesis is not clearly understood, and the treatment ultimately depends on the etiology of the problem. This article reviews the current understanding of chronic scrotal content pain, focusing on the diagnostic work-up and treatment options.