There are many options to prevent pregnancy; abstinence, withdrawal method, condoms, spermicidal solutions, diaphragm, cervical cup, intrauterine device, oral contraceptive pills, long-acting hormonal implants, depo injections, lactation amenorrhea method, emergency contraception, vasectomy, and tubal ligation. This activity is an overview of vasectomy and its role and technique in the prevention of pregnancy. Vasectomy is the only form of permanent male sterilization, a procedure where the vas deferens are transected, ligated, and separated in fascial planes. Urologists perform about 75% of vasectomies while the remainder gets performed by general surgeons and family medicine physicians. The success rate for vasectomy is high, 99.7%, and typically low complication rates ranging between 1 to 2%.
The majority of the pertinent anatomy encountered during a vasectomy is within the scrotum. Multiple layers of the scrotum must be entered to gain access to the vas deferens. The tissues that will be encountered, superficial to deep, include the skin, Scarpa’s fascia, dartos, external spermatic fascia (continuation of external oblique), cremaster muscle (continuation of internal oblique), internal oblique fascia (continuation of transversalis fascia), tunica vaginalis (derived from peritoneum), tunica albuginea, testicle. The epididymis is on the posterior aspect of the testicle with the head on the superior aspect and the tail on the inferior aspect of the testicle. The epididymal body is between the head and tail. The vas deferens or ductus deferens is connected to the tail of the epididymis and runs superiorly with the spermatic cord through the external inguinal ring, through the inguinal canal, and into the peritoneum through the internal inguinal ring. The vas deferens is on the medial side of the spermatic cord. The vas deferens enters the ejaculatory duct where it meets with the seminal vesicles. It then travels through the prostate and enters the urethra at the seminal colliculus. It is covered by vas sheath, with arterial blood supplied by the artery of the vas deferens, venous drainage through the pampiniform plexus, with innervation by short adrenergic neurons.
Vasectomy is an elective procedure for male sterilization and pregnancy prevention. Therefore, the performing physician must talk about the risks, benefits, and alternatives. The decision should not be made lightly or hastily. When discussing with patients, the permanency of the procedure needs to be stressed. Generally, the recommendation is that both the patient and partner should be involved in this decision, but ultimately, only the consent of the patient undergoing vasectomy is necessary.
There are no absolute contraindications for a vasectomy. There are relative contraindications to an office vasectomy, but these can be mitigated by performing the vasectomy in the operating room. Contraindications to an office vasectomy include difficultly isolating vas deferens during the scrotal exam at initial evaluation, coagulopathy, previous scrotal surgery, chronic orchialgia, testicular pathology such as malignancy. Some patients may present an ethical dilemma to the physician (young age, no children, lack of agreement with the partner, current pregnancy, and possibility of fetal loss), which the physician will need to consider during a consultation.
Generally, there two medical professionals involved in performing a vasectomy: the performing physician and an assistant.
It is imperative for the provider who will be performing the vasectomy to meet and discuss the vasectomy with the patient before the procedure. This consultation should begin with a complete medical and social history. The medical history should focus on genitourinary problems, scrotal pain, trauma to genitals, surgery to genitals, testicular malignancy. Hematologic issues, including anticoagulation or medical coagulopathy, require discussion. Social history should include consideration of their partner and pregnancy potential, prior pregnancies, and previous difficulties with pregnancy.
Next, a physical exam should follow, focusing on the genitalia. The scrotum gets evaluated with a focus on the tolerability of the exam, the vas deferens mobility, hernias, varicoceles, spermatoceles, testicular masses, or testicular tenderness.
After provider evaluation, discussion regarding the risks, benefits, and alternatives to vasectomy should be performed, allowing informed consent. The following are key concepts that require consideration :
The risk of hematoma and infection is about 1 to 2%, with rare cases of Fournier gangrene. The risk of chronic scrotal pain is believed to be about 1% requiring further management, and the risk of epididymitis approximately 1%. Sperm granulomas occur less than 5% of the time, and even fewer are symptomatic. Men require instruction that they will continue to produce ejaculate but will be devoid of sperm and that generally, no difference is noted in the ejaculate volume as sperm only make up about 10% of the ejaculate. Testosterone and libido following vasectomy has been studied and has been shown to be unaffected. Alternative types of vasectomies; operating room, scalpel technique, laparoscopic, and open, which are typically associated with another abdominal surgery. Alternatives forms of pregnancy prevention include abstinence, withdrawal, condoms, spermicidal solutions, diaphragm, cervical cup, IUD, OCP, implants, depot injections, lactation amenorrhea method, emergency contraception, tubal ligation.
Prepping and draping:
Typically, the patient shaves the scrotum before or has it shaved at the time of the procedure. Then, he gets prepped with an antimicrobial solution, and the surgical field gets set with a fenestrated drape. The scrotum is exposed through the opening of the drape, with the penis isolated posteriorly to drape. We generally ask the patient if they would like a narration of the procedure. Most men prefer narration, but a select few prefer silence. Music is often a distraction technique.
Note: There are numerous ways to perform vasectomies – the two basic requirements are the isolation of the vas deferens and occlusion of the vas lumen. This procedure description is very general and represents just one of many ways to perform a vasectomy, and any method is acceptable, as long as it accomplishes isolation and occlusion.
The vas deferens are identified and isolated through the scrotal skin. Vas mobility is evaluated to determine if both vas deferens can be brought up through a single incision or if two incisions are needed. The vas deferens is grasped and brought up to just below the skin with the first and third digit, while the second digit creates tension behind the vas deferens.
The skin is infiltrated with lidocaine, as well as the peri-vasal issue. Either a scalpel or a single tip on the sharp dissector is used to puncture the skin. Both tips are then inserted into the puncture, and the dissector tips are separated, creating an opening within the skin. The vas deferens is then grasped with the vas tenaculum.
The vas deferens and peri-vasalar tissue are grasped with the vas tenaculum to provide traction as the sharp dissector is used to remove the peri-vasal tissue; this is done by again spreading the tips of the sharp dissector while within the peri-vasal tissue. There are times when the vas tenaculum is used to regrasp the vas deferens because as more tissue has been released, the vas deferens becomes more isolated. Generally, a length of about 2 cm of vas deferens is exposed through the puncture wound. At this point, the vas deferens has been ISOLATED from the peri-vasal tissue. The vas deferens is then partially transected with either scissor or cautery, to allow control of the distal and proximal ends. This action is performed a second time along the vas, in either direction, about 1 cm from the other transection site. The lumen of the stay sides of the vas deferens undergo occlusion with cautery, and then the vas deferens is completely transected in those two locations, excising about a 1 cm segment of vas deferens tissue.
One end is allowed to retract while the other end is maintained using forceps, allowing us to perform fascial interposition. The vas sheath is reapproximated with either a clip or suture. Hemostasis requires review. The vas is allowed to retract into the scrotum. The surgeon performs the same procedure on the opposite side. The dartos and skin are reapproximated with electrocautery, suture, or nothing if small enough and hemostatic. The wound gets covered with antibiotic ointment, and gauze is placed over the ointment to prevent the fouling of undergarments.
The patient is slowly cleaned up and prepared to discharge. We generally have patients stay for a short time following to ensure they are not feeling faint or experiencing significant bleeding.
Post vasectomy semen analysis (PVSA):
A semen analysis is generally performed 8 to 16 weeks following vasectomy. PVSA is necessary within 2 hours of ejaculation. The sample should be moved at room temperature and kept undiluted and uncentrifuged. Microscopic evaluation hopes to reveal azoospermia or rare non-motile sperm. Rare non-motile sperm has been defined as fewer than 100000 per ml, more practically if 2 or more sperm per high powered field (100x) in 20 fields or if motile sperm are present, this represents failure. If over 100000 per ml non-motile sperm or motile sperm are visible, a repeat semen analysis will be required at 6 months post-vasectomy as 30 to 50% will achieve azoospermia within 6 months. If sperm are again present, this is a failure, and the patient will require repeat vasectomy.
Post-procedure care will require discussion and written instructions. Following the procedure, patients will experience pain. Pain should be controlled in a multimodal way, utilizing ice, supportive undergarments, acetaminophen, ibuprofen, and possible narcotics. Patients may have some blood from the wound and local erythema, but after 2 days, this should improve. The recommendation is to limit activity and aggressive sexual activity for approximately 3 to 5 days. Showering can resume post-procedure, day 0, but the patient should delay submerging incision with bathing or swimming for 5 to 7 days. Generally, no follow up is required except for the semen analysis or if complications or patient concerns arise.
Common patient experiences during the vasectomy include pain at the surgical site and pain and pressure within the abdomen. Select patients can become nauseous and experience lightheadedness. The proceduralist can encounter bleeding or difficulty isolating the vas deferens.
Early: Hematospermia is infrequent and resolves without intervention. The risk of hematoma and infection is about 1 to 2%, with rare cases of Fournier's gangrene. The risk of epididymitis approximately 1%.
Late: The risk of chronic scrotal pain is believed to be about 1% requiring further management. Sperm granulomas occur less than 5% of the time, and even fewer are symptomatic. With azoospermia or under 100000 per ml of non-motile sperm, the risk of pregnancy is around 1 in 2000. There is also a 0.24% possibility of failure of vasectomy, requiring a repeat procedure.
Vasectomy is the fourth most common contraceptive method behind condoms, oral contraceptives, and tubal ligation, in descending order. Vasectomy is faster, equally effective, and one-fourth the cost of tubal ligation.
Vasectomy can take place in a variety of clinicians with technique variations of performing safe and effective vasectomies. The two main requirements of a vasectomy are isolation and occlusion. A thorough history and physical exam need to be performed, and the patient needs clear instructions as to the risks, benefits, alternatives, and expectations of vasectomies.
Vasectomy is generally an office procedure requiring a trained clinician but also an assistant. Pain is typically minimal but can cause patients to become faint during the procedure. The role of the nurse is instrumental in the monitoring of the patient during the surgery and providing post-operative care. Patients require education about the postoperative course, pain control, wound care, diet, sexual activity, showering, and physical activity; the surgeon or the nurse can provide this counsel.
Best outcomes occur when patients are adequately informed about vasectomy. A vasectomy is an excellent form of birth control, but before intercourse, post-vasectomy patients require PVSA to ensure azoospermia or rare non-motile sperm.
Nursing generally assists with the procedure; they do this by presenting instruments, calming the patient, and assisting with teaching the patient. They also are the initial individuals that patients contact with questions or concerns.
Nurses monitor the patient following the procedure to ensure they are safe to discharge. They also typically are the first individuals to receive phone calls from patients with questions or complications from the procedure.
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