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Proceed with Confidence: Vasectomies

Paul Simmons, MD and Lyrad Riley MD, MPH
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 Do you automatically refer to a urologist when a patient asks about a vasectomy? Have you ever considered that this procedure can actually be done in the primary care office? Our own Paul Simmons discusses this with Dr. Lyrad Riley in the first installment of a new series on procedural tips and tricks called: “Proceed with Confidence.” 

 

Pearls:

  • Before performing vasectomy, make sure the patient is 100% certain they want it and are a good candidate.

  • The most important part of the procedure is being able to palpate the vas deferens and bring it to the skin surface.

  • Good counseling about post-vasectomy care and the semen test after 3 months, 20 ejaculations to ensure success.

 

  • Vasectomy:

    • Permanent method of sterilization for males that involves interrupting the vas deferens as it leaves the testicle

    • Half a million are done each year

    • Of couples that go the surgical route of sterilization, 10% are using vasectomies

    • Much simpler, safer and less expensive than a tubal ligation

      • Same day

      • Not intraabdominal

      • Home the same day

      • Return to work in a couple of day

  • Risks:

    • Small risk of infection, scrotal hematoma

    • About 20% have a small knot at the end of the vas deferens where the body’s making a immunologic reaction to the sperm that are now exposed

    • Congestive epididymitis - aching thought to be due to some back pressure in the epididymis

    • Failure rate (pregnancy) is 1 in 200 and lower once you have a negative post vas deferens semen analysis

    • 1-2% risk of chronic scrotal pain

  • Good candidates:

    • Never had surgery

    • No anatomic abnormalities

    • No anticoagulants

    • Chronic opioid use or chronic pain

    • 100% certain because even if conception is possible afterwards, not always successful and is expensive

  • Procedure:

    • Preparation:

      • If Medicaid need 30 days wait and less than  6 months after signing consent

      • Need a ride home because of the medication

      • Clip hairs on scrotum but don’t shave it to lower risk of infection

      • No need to fast but don’t have a large meal prior to procedure

      • No antibiotics necessary

      • Bring athletic support or snug-fitting briefs to support scrotum for a couple of days post procedure

    • Pre-medication:

      • Vary widely by provider

      • Dr. Riley uses diazepam 10mg and Percocet as anxiolytic and to relax the cremaster muscles

    • Procedure details:

      • Sterile area of the fenestrated drape and skin prepped with disinfectant like betadine or chlorhexidine

      • Grasp vas deferens through the skin with middle finger and thumb. It feels like al dente spaghetti

      • Make a bleb in the skin with lidocaine 1%

      • Stretch open the skin with special forceps to 6-8mm rather than a scalpel to make an incision

      • Use the vas clamp to grasp the vas deferens through the incision

      • Put additional lidocaine right along course of spermatic cord to try and take out the two nerves that travel along spermatic cord

      • Clean layers off around the vas deferens until you see the smooth, shiny white serosa on the vas deferens for a 2cm segment

      • Grasp the vas deferens about 2cm apart and excise about 1cm with an iris scissor

      • Use small battery-operated electrocautery unit to go into the vas deferens lumen and cauterize each tip

    • Post-procedure:

      • Tuck a little gauze  right over the scrotum underneath the athletic supporter

      • Escort out to their ride

      • Rest for a couple of days

      • No sex/ejaculation for a week

      • Ice or frozen bag of vegetables for 10-15 minutes the first couple of a days

      • 3 months and about 20 ejaculations to flush out any remain sperm before checking with a sperm test to make sure it worked

      • Post-op exam is usually unnecessary unless there is significant pus/discharge, swelling, pain, fever

      • +/- pathology to make sure you got the vas deferens

 

REFERENCES:

  1. Rayala BZ and Viera AJ. Common questions about vasectomy. Am Fam Physician. 2013 Dec 1; 88(11):757-761.

  2. Dassow P and Bennett JM. Vasectomy: an update. Am Fam Physician. 2006 Dec 15;74(12):2069-2074.

  3. Sharlip I, Belker A, Honig S, et al. Vasectomy: American Urological Association (AUA) guideline. AUA 2012 May, updated 2015.

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