What is the best course of action for a 62-year-old male (YOM) with a small epididymal mass and painful ejaculation after vasectomy?

Management of Small Epididymal Mass with Painful Ejaculation Post-Vasectomy

For a 62-year-old man with a small epididymal mass and painful ejaculation after vasectomy, begin with scrotal ultrasound to characterize the mass, followed by conservative management with NSAIDs and scrotal support, reserving surgical intervention (epididymectomy including the distal vas and vasectomy site) only if symptoms persist beyond 3-6 months of conservative therapy. 1, 2, 3

Initial Diagnostic Approach

Obtain scrotal ultrasound with high-frequency transducer (>7.5 MHz) to:

• Confirm the mass is extratesticular (epididymal) rather than intratesticular, which fundamentally changes management 1, 4
• Characterize whether this represents an epididymal cyst, sperm granuloma, or chronic epididymal changes from post-vasectomy obstruction 5, 2
• Rule out testicular pathology, as infertile men have elevated testicular cancer risk (pooled OR 1.91) 1

Key examination findings to document:

• Exact location and size of the epididymal mass 1
• Presence of testicular enlargement or firmness 1
• Vas deferens palpability and any nodularity at the vasectomy site 2

Understanding Post-Vasectomy Epididymal Changes

Post-vasectomy epididymal masses and pain occur through a well-characterized mechanism:

• Sperm granulomas develop at vasectomy sites in up to 60% of patients, usually asymptomatic 2
• Epididymal distension from continued spermatogenesis against obstruction is common 2
• Only 3-6% of vasectomy patients develop symptomatic epididymal problems 2
• Painful ejaculation specifically suggests epididymal distension or granuloma formation 2, 3

Conservative Management (First-Line)

Initial treatment for 3-6 months should include:

• NSAIDs for pain control 2
• Scrotal support 2
• Reassurance that most episodes resolve spontaneously 2

The evidence strongly supports conservative management first, as most painful post-vasectomy epididymal conditions resolve without surgery 2.

Surgical Management (Reserved for Refractory Cases)

If conservative management fails after 3-6 months, consider epididymectomy with specific technical requirements:

• Include the entire distal vas deferens and previous vasectomy site in the excision 3
• Simple epididymectomy alone achieves cure in only 50% of post-vasectomy pain cases 3
• Histopathology typically shows long-standing obstruction, interstitial fibrosis, and perineural fibrosis accounting for pain 3

Critical surgical principle: Incomplete excision that leaves the vasectomy site or distal vas increases failure rates 3.

Important Caveats

Rule out malignancy considerations:

• While epididymal masses are usually benign (unlike intratesticular masses), ultrasound confirmation is mandatory 1, 6
• Adenomatoid tumors are the most common benign epididymal tumors but are rare 6
• Any solid intratesticular component requires inguinal orchiectomy, never scrotal approach 1, 7

Avoid these pitfalls:

• Do not perform scrotal biopsy or scrotal incision for any suspected testicular pathology 1, 7
• Do not rush to surgery for post-vasectomy epididymal pain, as <1% ultimately require surgical intervention 2
• Do not perform epididymectomy without including the vasectomy site and distal vas 3

When to Refer to Urology

Immediate referral if:

• Ultrasound shows any intratesticular mass or solid component 7, 8
• Rapidly enlarging mass 7
• Constitutional symptoms suggesting malignancy 7

Routine referral if:

• Symptoms persist beyond 3-6 months of conservative management 2, 3
• Patient desires definitive surgical treatment 3