Holly Tanner, PT, DPT, MA, OCS, WCS, PRPC, LMP, BCB-PMB, CCI is a faculty member and the Director of Education at Herman & Wallace. She owns a private practice that focuses on pelvic rehabilitation and on chronic myofascial pain. Along with H&W faculty member Stacey Futterman, she co-authored the Male Pelvic Floor course.
In the US, vasectomy is one of the most common procedures performed, and it is often completed in an outpatient setting with a local anesthetic. Fortunately for most folks, it’s well-tolerated and the advice to rest and ice is enough to allow full recovery. Unfortunately, there are those who don’t recover with ease and are left with chronic pain complications. This is a population that is often left out of the clinical rehabilitation setting, and there is not yet robust literature to catch up with the positive clinical results pelvic rehab providers observe when treating post-vasectomy pain.
The goal of a vasectomy is typically contraception. The tube known as either the vas deferens or the ductus deferens is interrupted so that sperm does not travel to its typical destination outside the body via the urethra. This disruption in the tube takes place within the spermatic cord as it passes through the scrotum as this area is easily accessible. There are several techniques that can disrupt the tube where the sperm travels including, but not limited to, clamping, cauterization, or excision. The procedure leaves a small incision in the scrotal tissue.
Complications of a vasectomy may include bleeding and hematoma, infection, sperm granuloma (discussed below), chronic scrotal pain, seminal vesicle abscess (rare), and early or late canalization. (Sihra et al., 2007) Interestingly, some patients report less pain after vasectomy. (Leslie et al., 2007) Theories about the cause of post-vasectomy pain include interstitial fibrosis in the epididymal duct and perineurial fibrosis. (Lee et al., 2012) When we consider the anatomy, within the canal there may also be nerve irritation from the genitofemoral nerve, for example, or other connective tissues. If a patient had pain prior to the procedure in the low back, lower abdomen, or groin, the patient’s system may have been vulnerable to complications due to a sensitized system.
Examination & Rehab Efforts
When a patient presents with pain post-vasectomy, symptoms may worsen with prolonged sitting, with pressure from clothing, or in association with sexual or fitness activities. Because there has been a local insult to the tissues, it is logical to check the site of the procedure for any breakdown, signs of significant inflammation, swelling, and to examine for signs of infection such as fever. (Most patients have returned to their medical provider once pain develops, but if they haven’t, a referral is appropriate.) If the pain can be reproduced locally at the site of the procedure, the pain can often be managed by local treatment. You might find benefit in exam procedures such as a trunk or hip extension for the soft tissue tensioning as well as mechanical loading; palpation to the abdominal wall as well as within the spermatic cord. Treatment can address guarding of the area, general wellness (nutrition, movement, mental health), simple modalities such as heat, and gentle self-mobilization to the painful area.
Granulomas can form following a vasectomy, and while usually asymptomatic, a granuloma may be responsible for post-vasectomy pain. They are described as a “bag-like” structure with disintegrating spermatozoa that form at the cut ends of a vasectomy. (Chatterjee et al., 2001) If the granuloma is painful, very light manual mobilization of the thickened area may be done to alleviate pain (see image below). Mobilization of the spermatic cord itself via the testicle or more proximally may also prove helpful. Local modalities such as ultrasound or heat may improve symptoms as well, but clinically I have found that gentle manual therapy and movement exercises are enough to resolve the pain within a few weeks. Patients can be instructed to complete self-mobilization to the area of the granuloma, and as they often are scared to touch the area, helping alleviate this fear is useful in healing.
Post-vasectomy syndrome is very challenging for patients to manage, as they are often dismissed once the procedure is completed. Patients will share that they have been told “everything looks healed” and that the pain should go away on its own. Most providers are unaware of the role of pelvic rehab clinicians, and many pelvic rehab providers are less knowledgeable about conditions related to the scrotum and spermatic cord. For patients who do not respond to conservative intervention, vasectomy reversals have been found to be significantly helpful in reducing pain, though it’s often undesired due to the goal of contraception that inspired the vasectomy. (Herrel et al., 2015; Polackwith et al., 2015). Ideally, patients will be provided with an early recommendation to pelvic rehab so that further procedures or undoing of the vasectomy is avoided.
If you’d like to learn more about post-vasectomy syndrome and many other conditions that can go unrecognized and under-treated, the next opportunity to take the Male Pelvic Floor course is coming up July 9-10,2021!
Megan Pribyl, PT, CMPT is a practicing physical therapist at the Olathe Medical Center in Olathe, KS treating a diverse outpatient population in orthopedics including pelvic rehabilitation. Megan’s longstanding passion for both nutritional sciences and manual therapy has culminated in the creation of her remote course, Nutrition Perspectives for the Pelvic Rehab Therapist, designed to propel understanding of human physiology as it relates to pelvic conditions, pain, healing, and therapeutic response. She harnesses her passion to continually update this course with cutting-edge discoveries creating a unique experience sure to elevate your level of appreciation for the complex and fascinating nature of clinical presentations in orthopedic manual therapy and pelvic rehabilitation.
As a course developer and instructor for the Herman & Wallace Pelvic Rehab Institute, it is a privilege to continue sharing my passion for nutrition and pelvic rehabilitation with professionals nationwide. Interest in the topic continues to grow, and many pelvic rehab providers have identified nutrition as the “missing link” in their clinical practice. Nutrition Perspectives for the Pelvic Rehab Therapist has helped hundreds of pelvic rehab professionals integrate nutrition-related information into their clinical practice since 2015.
In the realm of nutrition, few questions provoke discussion with the same fervor as our title question: Organic Food vs. Conventional: Is There Any Difference? This question deserves a multi-dimensional answer - not unlike many topics in nutrition - including accessibility concerns, ethical factors for farmers, socio-economic factors, and our unique agricultural construct here in the United States. But the question about organic vs. conventional might just be the most important one deserving a thoughtful discussion to unravel the complexities around the topic of food.
You see, the answer to this question has profound implications for us. As we expand our ability to identify potential root contributors to conditions commonly encountered in pelvic rehabilitation, we must factor in nutrition. At first glance, it might be a stretch to see how one might link organic foods and potential effects on conditions such as constipation, inflammatory bowel diseases, IBS, PBS, and endometriosis for example. However, looking at food in a functional way, we acknowledge there may be under-appreciated qualitative differences between foods grown organically or produced conventionally.
Take, for example, the recent article by Kesse-Guyot et.al., 2020. which discusses the prospective association between organic food consumption and the risk of type 2 diabetes. In this study of over 30,000 participants, those with the highest quintile of organic food consumption compared to those with the lowest quintile had a 35% lower risk of having type 2 diabetes. The conclusion made by the authors was that organic food consumption was inversely associated with the risk of type 2 diabetes.
Said a different way, the study described a phenomenon where, for example, you might eat an organic bowl of oatmeal for breakfast and I might eat the same serving size conventional bowl of oatmeal for breakfast. If we extrapolate the comparison over our entire dietary intake pattern, you would have a 35% lower risk for developing type 2 diabetes compared to me…..despite you and I “eating the same foods”. How can this be possible? And might this begin to explain the sheer exasperation and frustration that can evolve in persons trying to make positive dietary changes - only to find they have no notable effect? How many times do you hear someone say “I am trying to eat healthily but it doesn’t seem to make a difference”.
Keeping in the context of type 2 diabetes, it is very well established that reductions in the richness and diversity of healthy microbes inhabiting the large intestine (gut dysbiosis) are correlative to metabolic syndrome. In those with type 2 diabetes, microbiomes showed a decrease in anti-inflammatory, probiotic, and other [beneficial] bacteria that could be pathogenic. (Das et al, 2021) Appreciating the differences between organic vs conventional - it is also well established that organic foods do carry less residue of herbicides and pesticides. These residues - which are found in higher concentration in conventionally produced foods - have been implicated in the same reduction in richness and diversity of microorganisms in the gut - which is contributory to dysbiosis. (Rueda-Ruzafa et all, 2019) Therefore it now seems not just plausible - but probable that there is a distinguishable difference between organic and conventional diets - to a degree at which all health care providers would do well to take notice.
In a report on the history of organic agriculture, author George Kuepper points out that:
“Pioneers of the organic movement believed that healthy food produced healthy people and that healthy people were the basis for a healthy society.”
And if organic foods can be a part of that, our patients deserve to know that these scientifically documented differences exist.
As our awareness of the connection between nutrition and health grows, so does the need to follow the science to share evidence-based and evidence-informed information. It is now more important than ever to have a working knowledge of nutrition basics as a pelvic rehabilitation professional. Plan to join us at one of our upcoming remote offerings of “Nutrition Perspectives for the Pelvic Rehab Therapist”: June 19-20 where we will explore this and many additional - and fascinating facets of the nutrition discussion.
Das, T., Jayasudha, R., Chakravarthy, S., Prashanthi, G. S., Bhargava, A., Tyagi, M., . . . Shivaji, S. (2021). Alterations in the gut bacterial microbiome in people with type 2 diabetes mellitus and diabetic retinopathy. Sci Rep, 11(1), 2738. doi:10.1038/s41598-021-82538-0
Kesse-Guyot, E., Rebouillat, P., Payrastre, L., Alles, B., Fezeu, L. K., Druesne-Pecollo, N., . . . Baudry, J. (2020). Prospective association between organic food consumption and the risk of type 2 diabetes: findings from the NutriNet-Sante cohort study. Int J Behav Nutr Phys Act, 17(1), 136. doi:10.1186/s12966-020-01038-y
Kuepper, George. (2010) A Brief Overview of the History and Philosophy of Organic Agriculture. Kerr Center for Sustainable Agriculture. http://kerrcenter.com/wp-content/uploads/2014/08/organic-philosophy-report.pdf Accessed May 14, 2021.
Rueda-Ruzafa, L., Cruz, F., Roman, P., & Cardona, D. (2019). Gut microbiota and neurological effects of glyphosate. Neurotoxicology, 75, 1-8. doi:10.1016/j.neuro.2019.08.006Images: