Paul’s story: How the procedure went…

Good afternoon gentlemen,

I had my procedure at 9:00 am today (1/23/03); since I have received so much help and advice from this site, I thought I’d give back a little by sharing my own experience in the hopes it may benefit someone down the line.

My whole decision to have a vasectomy came about after I learned that my wife was expecting our second child (now seven weeks old). Truthfully, I would have been happy with one, but it would have been selfish of me to deny my wife the opportunity to have a daughter (which she has always wanted) in addition to our son. We had agreed ahead of time that two children were my limit (due to both financial and time constraints) and that we would accept whatever came as our last.

Why a vasectomy?

I wasn’t comfortable with my wife taking oral contraceptives for the next 20 years (we’re both still young and have many fertile years ahead of us, the vasectomy notwithstanding). We both felt barrier methods were inadequate both in terms of efficacy and intrusiveness (the effort required to make them work). I felt that the vasectomy was much safer than a tubal ligation (which requires more invasive surgery, along with general anesthesia or a spinal block). Additionally, the success of a vasectomy can be verified via sperm count; with a tubal, you wait a few months and hope for the best. Finally, there is something to be said for sharing the burden of birth control after my wife used “pills” ever since we wed and had to experience childbirth. Yes, there are risks associated with the vasectomy, but thorough research of the birth control methods out there led me to realize that nothing is risk-free except for 100% abstinence.

The next step was looking into the procedure itself, both techniques as well as the risks of this procedure. I did lots of research and asked lots of questions (as those of you who frequent this group know). I’m the kind of guy who wouldn’t buy a TV without doing my homework (at any rate, I believe that doing anything permanent to your body without knowing all your options is INSANE!). Knowing what was out there enabled me to have a meaningful discussion with my surgeon about the risks of the different procedures (specifically, open vs. closed) and ultimately decide what was best for me.

The vasectomy day

So, after a very sleepless night, I took my Valium at 8:00 a.m. and headed out to the surgeon’s office for my 9:00 a.m. appointment. As for the procedure:

1. The doctor was very prompt. My decision as to which procedure to undergo was a “game time” decision; we actually spent the prep time reaching this decision.
2. I wound up having a closed-ended procedure. Typically, with this procedure my surgeon removes a section of the vas, sutures each end shut, and forms a loop (which is then secured with another suture). However, at my request, he also performed a fascial interposition on the prostatic ends (like with a good open-ended procedure). I decided on the closed-ended V because the very slight risk of back-pressure related PVP simply didn’t outweigh the much higher incidence of granuloma formation (usually painful) with the open procedure (my doctor reports virtually no sperm leakage with the double-tied testicular ends; no leakage generally means no granuloma). At any rate, with the interposition, a simple fix for backpressure is conversion to open-ended.
3. As it turns out, a complication/risk developed that I had neither thought of nor heard about. Specifically, this is the risk that the outpatient surgery room (at the clinic) might not have adequate resources for your vasectomy to be performed. Let me explain: it seems that my left vas was deep inside (not at the surface) and hidden among several other tissues which formed a 1/2″ thick cord-like structure. The vas was finally uncovered right before the doctor was going to close me up and schedule me for exploratory surgery under general anesthesia (he stated that he was able to perform this additional procedure, but the clinic facilities were simply inadequate). As it was, I had to endure an enlarged incision (requiring antibiotics), a hematoma (which had to be sutured shut), and extra swelling (from lots of local anesthetics). Curiously, I felt a pain in my groin and back area from this procedure, feeling much like if you find yourself straining to hold in a bowel movement.
4. Total procedure (from prep to dismissal) took about 1 hour, 40 minutes. I felt fine as soon as I was closed up. Had lunch with antibiotics and Darvocette at 11:30 a.m. and test drove my plumbing at 1:00 p.m. Everything’s fine.

I’ll post later with some post-surgery considerations and thoughts I would like to share. Right now, the Darvocet and residual Valium are taking their toll.

Later…

As I noted above, my vasectomy appeared to be significantly more difficult than most. Darvocet and Valium have worn off; I’m off to the store soon to buy lots of frozen peas, corn, baby Lima beans, whatever. While I’m not in excruciating pain, it’s definitely MUCH more than the vague achiness I’ve heard about (not pressure, just from the extent of the exploration, left side only). Incidentally, my surgeon advised that I might want to make arrangements to take Monday off of work as well, so I don’t think I’m imagining more pain than usual.

Checked in the mirror; the cut on the left side of the scrotum is close to 1″ long (twice as long as the cut on the right side). I’m apprehensive that this level of scarring will change the shape of my scrotum, but oh well.

I actually took another test drive at about 4:00 p.m.; everything still all good in the plumbing. 2 down, 18 more to go.

Interestingly enough, my doctor encouraged me to not remain sedentary all day; he says that this is not a good idea for any type of surgery. Sure enough, as long as I don’t over-exert myself, changing positions helps with the pain some. Obviously, the surgeon didn’t place any restrictions on sexual activity. As always, let your comfort level and common sense be your guide.

After all, is said and done, what would I say to someone else having a vasectomy:

1. Educate yourself. As I related earlier, I was actually able to have the surgeon modify the procedure to meet my needs and concerns. A good doctor of any specialty will respect your input if you appear to be well-informed. For me, the sense of control I felt from learning what was out there made me sure that I was making the best possible decision for myself and my family.
2. Take a pill. The Valium prescribed for my nerves was a godsend. In the right dose, it does a good job of taking the edge off your nerves but leaves you fully able to make good decisions, ask the right questions, and understand the doctor’s instructions. If you are the nervous type, have the doctor prescribe an additional Valium for the night before (I wish I had).
3. Get an experienced surgeon who you are comfortable with. As I noted earlier, my vasectomy was the closest my surgeon had come to not being able to finish in the clinic (we’re talking about a guy who has done this for 10 years and currently does 2-3 per week). I have little doubt my surgeon’s experience salvaged the procedure; with a less-experienced surgeon, I could easily be sitting here in at least as much pain (the incision and exploration are what hurts, not the actual interruption of the vas) but facing the prospect of either general anesthesia or continued fertility.
4. Listen to your doctor. After reviewing all the literature out there at great length, I realized that the incidences of complications are merely averages and generally do not compensate for differences in technique and skill level. After discussing my research with my surgeon, we ultimately made the decision for closed-ended based on his experiences and concerns with his particular technique.
5. Don’t be afraid to ask for what you want. My surgeon advises that, with the exception of NSV, all the procedures used in vasectomy (various suture techniques, interfascial positioning) are used commonly throughout many different types of surgery. My takeaway was that if your surgeon won’t accommodate you and doesn’t give a reason beyond “that’s not the way I do it”, move on.
6. Get the first appointment in the morning. You’ll be as well-rested as you can be (important for your comfort level); equally important, your surgeon will be fresh.
7. Write a list of things to ask/requirements you want met/things you need to do. It’s hard to remember everything you need to do under the best of circumstances. If you’re the nervous sort (like I am) or if you are taking a pre-operative sedative, you might find this particularly helpful. It can as involved as technical questions for the surgeon or as simple as remembering to take your jock, money, etc to the appointment.

19th February 2003 update

It’s been a while, but this is my first chance to keep up given my ongoing recovery (the vasectomy was on 1/23/03) (more on that later), and both kids battling multiple illnesses (one almost serious enough to require hospitalization).

I don’t quite remember where I left off, so I’ll start with the first post-op appointment. Basically, I have ongoing discomfort that seems to be related to difficulty in finding the left vas.

The first appointment was six days post. I was called in early after complaining of tenderness and an odd lump on my left side about 1/4″ across, 1 1/2″ long, and growing/hardening. It turned out to be scarring (about 10x more than on the right side). Was advised that this was to be expected with the complication. The surgeon removed the sutures and secured the wounds with tape. Gave me instructions for delivering the sample (at least 15 – 20 ejaculations AND one-month post-vasectomy, no activity for four days prior, must be at the lab within 1 hour). Told me to schedule an appointment in about a month, and to continue to take it easy.

1 1/2 weeks later, the tape falls off; I notice that the left is saturated with fluid. Two days later, I notice a cone-shaped scab l; incision was still raw and I did not want a cone-shaped hole 😉 Another call to Dr., he again advises to see him the next day (2/14/03, now three weeks post). The doctor removes the scab and advises me to continue using antibacterial ointment to ensure proper healing (this is working well). Expresses some concern over my continuing pain (not general ache, but localized at the bottom of the testicle) but notes correctly that I am feeling better and that we should not worry unless I cease to make progress. Was told to make an appointment for two weeks out (2/27/03). I must say that at this point I’m getting concerned over the increasing frequency of visits.

Since that last visit, the pain in the testes has been consistent. It is set off by something as minor as it contacting the seam of my pants (tight or loose, doesn’t matter). At worst, it is a sharp pain followed by a few minutes of throbbing (from thigh to abdomen). At best, it’s still enough to make me pause and suck in my breath (we’re talking little stuff like getting out of my car). I haven’t had the nerve to resume going to the gym. And just today, I noticed a new lump (left side only) that is causing the pain (a slight touch tells all). BTW, I have been taking maximum doses of anti-inflammatories (2400 mg of ibuprofen or four tablets of Aleve per day) for almost a week due to a broken tooth (when it rains it pours…).

So, my dilemma is how to approach my doctor at the next visit. The message I want to convey (tactfully) is that, at five weeks, we need to look at some options for aggressively treating this discomfort (it already affects what I do). I still trust the doctor, but need to convey the message that I’m not going to let 5 weeks of wait and see extend into 5 months, etc, and that, in case he loses interest, it will be much harder to ignore than to treat me.

I should add that I have been good about staying off my feet for the first five days (even though Dr. said that it was best to move around without heavy exertion) and didn’t do any real physical labor until some lawn work on Saturday 2/8. Additionally, while I did note some sporadic pain on the left side prior to vasectomy; it was never as severe or persistent as now, so I don’t think that’s the issue. Finally, the reason I need to get this resolved now is that I have a reconstructed knee (the left side) with a weak joint, arthritis, and ligament damage; already, walking awkwardly after the vasectomy has caused pain in the area where the ligaments are torn. I don’t want to accelerate that inevitable knee replacement!

Sorry if I rambled. Any advice is welcome (how to approach the doctor, what procedures to pursue, or stories from those who have had this issue) and will be graciously accepted. My gut tells me to get a testicular ultrasound (suggested a few weeks back as a possibility by my PCP, and logical since if I can feel the lump it should show up during the test). After that, I don’t really know how to proceed (other than to relay the above to him).

23rd March 2003 update

Saw the Urologist today, finally. The surgeon had botched the referral, had my regular MD do it on an ASAP basis. Still, 3 weeks all in all, not too bad to wait.

The lump is due to epididymitis, and the shooting pains were most likely a blowout. The Urologist said what typically happens is that the infection is pre-existing but gets exacerbated by the vasectomy since the bacteria is now trapped and cannot be flushed out.

So the prognosis is very good. It might not go down 100%, but it will be asymptomatic. The treatment is Cipro, Advil, and increased sexual activity (to force the bacteria through the rupture). I’ll be seeing him again in 4 weeks.

Incidentally, I mentioned my pre-vasectomy concerns and asked if the OE might have prevented the symptoms. He doesn’t like the OE due to the potential for painful granuloma, like if they formed around a nerve (I can believe it, this lump makes me need to pee when it gets irritated). He also claims (don’t know if this is true) that the OE has not taken off due to a significantly higher rate of failures. Finally, he says that, specifically with my issue, the OE does not leave a free enough path to prevent bacterial buildup as I have.

15th July 2003 update

I just had my follow-up visit with the urologist on 4/24/03.

At the previous visit (3/20/03) I had been diagnosed as having epididymitis with a possible rupture: treatment was 500 mg of Cipro and 600 mg of Advil, twice daily (10 days on the Cipro). This helped the sharp pains from the site of the swelling but did nothing to ease general ache or the throbbing testicular pain (left side only). Sharp pains returned a few days after finishing the Cipro; another 10 days cleared that particular discomfort up for good it seems.

At the follow-up visit, I gave a urine sample which came back clean. Then, the doctor came in and asked how I was. I told him about the benefit of the Cipro, the lingering pain, and asked for clarification on his diagnosis. I asked about the next step for treatment and he said there is none. I tried to discuss what my surgeon and I had talked about and he became condescending and defensive.

He stated “on the record” (meaning he had one of his assistants come into the room to witness what he was telling me):

1. I have epididymitis located where the epididymis meets the vas. No granuloma
2. The causes of epididymitis are poorly understood; in the vast majority of cases, a specific cause is not identifiable.
3. The Cipro was given just in case I had an infection; I should be glad that I saw any benefit from the treatment.
4. The swelling/pain should diminish, but it might remain the same or worsen. The maximum improvement would take six months. His recommendation was to do nothing and to just endure the pain.
5. The pain wasn’t as bad as I thought it would be and was completely to be expected (personally, I am most concerned about pain within the testicle itself, but the urologist couldn’t care less).
6. Reversal is an option for pain abatement (“$4,000; cash upfront”); the rate of complete pain relief is somewhere around 50%.
7. He didn’t believe in the open-ended procedure or epididectomy; if I chose to pursue this option he no longer wished to be involved in my care. In fact, he wouldn’t even discuss the merits of the procedure except to say that it might work (after I told him my surgeon’s view on the OE) but he didn’t think the risk of painful granuloma and vasectomy failure was worth assuming.
8. There is no good way to screen for this type of problem; the precautions I took (pre-vasectomy manual exam and ultrasound) are all you can do to minimize complications.

So, I have a urologist whose advice is contradicting my surgeon and is basically telling me to not waste his time unless I want a reversal and am willing to pay cash upfront. This second visit he didn’t do anything but the urine analysis. No exam. Just sitting in a chair and telling me to “suck it up”. Take my $20, bill the insurance for another $90 to $100; not bad for sitting on his ass for 15 minutes. I didn’t bother to list all my concerns, new symptoms/problems,etc. since it was obvious he wouldn’t care.

Where am I now? Talked to my PCP just today about my urologist diagnosis, demeanor and indifference, unwillingness to expend effort to evaluate my symptoms, and the conflict between the urologist advice and the surgeon’s counsel. She will get the consultation notes from the urologist and arrange for a second opinion. I’m going to get a copy of the file and add a note detailing all the symptoms I’m experiencing “for the record” (this new HIPPA law is great).

Personally, I’m pretty sure the pain is not just due to pressure buildup (although the pressure may be exacerbating an existing condition). I feel this way because I have no discomfort in the right side to speak of (and no lump), the left side happens to be the one where the surgeon had to dig around for 40 minutes to find the vas and has the incision that healed badly, and because the pain flares up when I stretch the muscles in my left leg (for example, I squatted down to at the store to look at something on a low aisle and was rewarded with a throbbing testicle for the next half-hour). The bottom line is I’m not willing to trust my health to a doctor who says “grin and bear it” without listening to what I have to say.

More to follow after my 7/28/03 appointment with a second urologist.

An interesting aside is the length of time it took to secure this second opinion. Sufficient to say that sometimes you need to raise all kinds of hell with your medical provider and the HMO organization to get what you’re entitled to.

As always, thoughts, questions, and input always welcome.

July 30 2003 update

From yesterday’s second opinion. After the customary urine sample, a PA on staff at the Uro’s office asked me some questions and spent a decent amount of time taking my history, noting pre-vasectomy medical history, the particulars of the procedure, and post-op issues. He asked questions that indicated he had some idea of the symptoms I was having (occasional pain, ache after physical exertion).

After the physical exam, the urologist prescribed 10 days of Doxycycline. His report to my regular doctor noted an epididymal mass 1 x 1.5 cm, slightly tender to direct touch, no induration. The preliminary diagnosis is epididymal cyst/spermatocele. The urologist is requesting authorization for a scrotal ultrasound and two follow-up appointments (the first of which is on 8/25). The urine sample (analyzed in-house) came back completely clean.

August 29 2003 update

I wound up taking the full 20 days of Doxycycline prescribed by the urologist; it helped quite a bit, so I suspect I had some lingering infection after the earlier Cipro.

Just had the ultrasound on 8/26 and follow up Uro visit on 8/27. The ultrasound showed no abnormal growths so that rules out spermatocele/hydrocele or any other type of cyst or mass. The Uro’s opinion is that the discomfort is persistent back pressure (the usual time for abatement is 3-4 months and I’m at 7+); although he is optimistic that the pressure and pain will subside eventually (hopefully in less than one year). He recommends Advil for any pain episodes and avoidance of activities that cause discomfort.

In case the pain doesn’t subside, I asked the Uro about the OE conversion; he also doesn’t do them, for the usual reasons. Also, the third Uro I arranged directly through the HMO doesn’t do them either (I called and asked so as not to waste my time).

I contacted the HMO to reschedule the additional consult with an Uro that does OE (so that I’m getting good advice on all my options). I explained that the surgeon offering the OE conversion doesn’t return my calls and that both Uros won’t do it. I expected a call back from the referral group but instead the quality of the care group wants to know more about my situation.

So, at this point, I feel much better (almost 100% usually with prescription NSAID) but still don’t think I’m getting the whole picture without seeing an Uro with experience with the OE procedure. So, since the HMO seems willing to find me one and arrange a referral, we’ll see what happens now.

May 8 2004 update

I had intended to update at the one year mark, so here I am three months late. Apologies to those of you seeking my input to whom I was unable to respond; sometimes life just gets in the way!

Anyways, in the last update, I’d stated that the second Uro advised waiting and that I should see relief by the one-year anniversary. I spoke with my regular M.D. who had followed up with the Uro; he reiterated that he was confident the pain would go away with time, as my body adjusted to cope with the sperm production.

My insurance had agreed to provide an additional consultation at a member Uro of my choosing, but not finding one who would consider an OE conversion, I just decided to give it some time. Just too much to do with work and two little ones to look after.

Currently, I consider myself recovered. The left (troublesome) epididymis is more swollen than the right, and the level of swelling varies throughout the day from the lump to a larger mass. But there is no pain unless I squeeze just the right spot (right up against the testicle), which is hard to do accidentally. In fact, I’ve taken some shots from the toddler (changing diapers) and it feels good as new. Back to doing lawn work pain-free (that took about nine months, however) and basically all normal activities.

I am curious about the nature of the swelling and will bring it up at my next regular checkup, but don’t intend to take any corrective measures unless recommended by my M.D. I do recall the second Uro saying that the Epi might not ever return back to its original shape, so I’m not worried about it unless pain returns.

Also, my wife isn’t pregnant (and activity has been increased at times), so I’d say I’m still sterile (yes!).

Thank you to all who were there to support me during some of the more difficult times.

Submitted by Paul