Expert: Arthur Goldstein, M.D. - 6/24/2007

Question
34 yrs old, male, Tennessee, USA.

After sex I have cramps in lower ab region - kind of painful around groin area also - all like a gas cramp pain. I had a vasectomy about two years ago. This started about 1 year after the vasectomy  - also I have a felt a small nodule in my scrotum near the incision scar - not on testicle. I have also developed since the Vasectomy is premature ejaculation, if I try to control it (hold back) the cramping pain is much worse. But if I don't try and hold back the cramping pain is not as severe, but thats helping my wife's sex life.

Answer
Rick, it is quite common to develop a small nodule at the site of vasectomy.  This is either just scar tissue or a benign lesion called a spermatic granuloma.  The former is painless and of no significance while the latter is often tender.  There is often some leakage of sperm from the vas at the time of surgery.  In some men, the body recognizes the sperm in this locale as a foreign substance (as sperm are only supposed to reside in the vas) and walls the area off with inflammatory cells producing the nodule.  This is totally benign but if uncomfortable enough, it can be easily cured by excision.

I think it highly unlikely hat your pain is related to the vasectomy.  The discomfort is most likely due to an inflammation of the prostate gland, so called prostatitis.  Symptoms that might occur with prostatitis include frequency of urination, slowing of the urinary stream, burning with voiding or ejaculation, burning in the penile tip unrelated to voiding, sexual dysfunction (such as difficulty with erection), aching in the penis, testicles, and discomfort in the lower abdomen, low back, groin, rectum or perineum (the area between the scrotum and rectum – between the “wind and the rain”). The passage of blood at the initiation or termination of urination or in the semen can also be noted.  During sexual arousal the prostate gland manufactures fluid that accounts for about 2/3 of the volume of ejaculate.  The seminal vesicles are paired structures located behind the prostate gland that also manufacture fluid.  Sperm from the testicles (which account for only 1-2% of the semen) travel up a series of tubes (epididymis and vas deferens) on each side to join the seminal vesicles forming the paired ejaculatory ducts. These structures empty into the prostatic portion of the urethra. At the time of ejaculation, fluid is discharged into the urethra (urinary canal) from the prostate gland and ejaculatory ducts forming the semen.  The semen volume is in the 2-6 cc range.     It is not uncommon for inflammation and/or infection to spread in a retrograde manner into the vas and epididymis.  Even without such spread, prostatic discomfort is often referred into the testicle.  Too frequent or too infrequent ejaculation, sexual arousal without ejaculation, withdraw at the time of ejaculation, aggressive bike or horse back riding, and excessive spicy foods, alcohol, and caffeine in the diet can predispose you to this.  Sitting for long periods of time, especially in an automotive vehicle, can put undo pressure on the prostate and aggravate the condition.  For the latter, it is best not to sit more than 2-3 hours at a time.  Stop the vehicle periodically, take a short walk and go to the bathroom to urinate.  A thick pad or piece of sponge rubber on your seat will also help to cushion the prostate.  One should avoid any of the above that apply.  Eliminating all of these factors that apply to you are just as important, if not more so, than taking medication!  Ejaculation beyond the tolerance of the prostate to fill and empty may also cause discomfort.  Likewise if one does so infrequently, fluid still builds up from thoughts, dreams, fantasies, etc. and has to be released periodically to decompress the gland and relieve the symptoms.  For most men, ejaculation in moderation, perhaps 1-2 times a week, is reasonable.  A daily warm bath for 10-15 minutes 1-2 times daily also lessens the discomfort.  Attention to sexual activity and warm bathes should be utilized regardless of the type of prostatitis and whether or not medications are prescribed.
There are several types of prostatitis.  Sometimes prostatitis can be due to an infection of the gland with bacteria.  This usually requires an initial 4 week course of an appropriate antibiotic (the commonest prescribed are the fluoroquinolones, but tetracyclines, sulfas and other agents can also work).  Typically, pus cells and bacteria are found in the prostatic fluid.  
Abacterial prostatitis has several varieties.  In one, the prostatic fluid demonstrates pus cells but no bacteria.  In the other, called prostadynia, there are neither pus cells nor bacteria in the fluid, just the symptoms.  In all types of prostatitis, the urinalysis generally is normal unless the infection spreads into the bladder.   Abacterial prostatitis usually responds to the general measures mentioned above.  Medications that sometimes help include the over-the-counter natural supplement saw palmetto 320 mgm daily and alpha-blockers (such as Flomax, Hytrin, Cardura & Uroxatral).  The latter require a prescription from you physician if he thinks it is indicated.  Prostatitis may also be classified as acute (severe), subacute (mild), or asymptomatic.  It may also occur as a single episode, be recurrent or chronic.  
In cases refractory to treatment, there is another condition that can produce similar symptoms. This disorder is ejaculatory duct obstruction. Usually the   doctor will find the seminal vesicles to be very swollen on rectal examination. The patient will notice either absence or a markedly diminished semen volume. The diagnosis is made by doing a transrectal ultrasound of the prostate and seminal vesicles. Therefore, if symptoms persist, consultation with a urologist should be scheduled.  In cases with recurrent prostatitis or hematuria, it sometimes is necessary to study the urinary tract more completely.  A man should learn to listen to his body.   

The premature ejaculation was not caused by your vasectomy.  Premature ejaculation is a common condition.  It refers to men who ejaculate prior to intromission or within a minute or two after insertion.  It is more common in younger men and tends to spontaneously improve with age.  In general, it occurs more often in those men who ejaculate relatively infrequently.   The commonly used treatments are:

EMLA cream, a prescription drug that contains a potent relative of novocaine is used to numb the skin of  the glans penis. I have not had much success with it. There is also the potential of becoming allergic to "caines" making them unsafe for you to use in the future.

2.  Certain antidepressants (ie Prozac, Anafranil, Zoloft, etc.) can be used successfully in delaying ejaculation.   However, they also have possibly harmful side effects. They are prescription drugs and should not be taken without medical supervision.

3.  The "squeeze technique" of behavioral modification is successful and safe. It is well described in most books on sexual therapy and dysfunction. However, it requires frequent practice and a cooperative partner.

4.  The use of condoms decreases sensation and helps some individuals.

5.   Having sexual intercourse a second time in the same session usually produces a greater time to ejaculation. If one can't get aroused again, the use of Viagra may help. However, Viagra does not treat the  premature ejaculation per se. It is best to see a urologist skilled in the evaluation and treatment of sexual dysfunction for more information about the above options. Good luck!