Vasectomy: A Simple Operation?
By William P. Pannell, MD, FACS
A vasectomy is the logical procedure for family planning in a stable relationship and certainly the ideal solution for the man who simply does not want to be responsible for bringing another child into the world. The female equivalent, the tubal ligation, is a procedure that must be completed in an operating room under general anesthesia and involves traversing the peritoneal cavity. Vasectomies are performed in a doctor’s office under local anesthesia without exposure to any intra-corporeal organs. The costs of tubal ligations are many times that of vasectomies and the work time lost is also significantly longer. So why are there more tubal ligations performed than vasectomies?
Obviously there are misconceptions about vasectomies that prevent men from undergoing the procedure. Every experienced vasectomy surgeon realizes his first objective is to make sure the patient understands what a vasectomy does, and does not, do. Religious and cultural barriers may prevent men from having vasectomies. Many men, and women, still feel that family planning is the responsibility of a woman. As vasectomies have become popular and our society had become more open regarding the discussion of such matters the discussions about successful operations that were performed with minimal discomfort or disability have been a deciding factor for many men. Unfortunately, in a similar manner, the discussions of significant problems that developed or operations that failed have discouraged men from seeking the procedure.
The procedure sounds simple. After a local anesthetic is injected the scrotal skin is opened exposing the firm rubbery vas deferens. This duct, through which the sperm flow, is ligated, clipped, cauterized or cut in such a manner to prevent the sperm from flowing. Although no research is available to substantiate the observation, it does appear that the flow of sperm is related to a supply and demand mechanism. There are reports of sperm leaking from the testicular end of the vas deferens creating sperm granulomas but such occurrences are rare. This process has to be repeated for both of the ducts coming from both of the testicles. The incision is closed or sometimes left to heal without a suture.
Vasectomies have two unique problems that are related to the nature of the tissue being manipulated and the tubes that are cut. Scrotal tissue is elastic. In most of the other parts of the body an incision can be made, tissue can be manipulated and the wound can be closed with little fear of continued bleeding or swelling. The inelastic tissue creates a tamponade effect where any bleeding or swelling is slowed by the inability of that tissue to stretch. Pressure builds within the incised area and this pressure prevents further bleeding or swelling. The scrotal tissue simply continues to stretch however and the resultant bleeding and swelling can cause the scrotum to become very large and painful. It is the difference between blowing up a small balloon and a small plastic bag. The biggest mistake made by young surgeons who first encounter this problem is to think that the scrotum must be re-explored or drained. The bleeding and swelling does not collect nicely into a single pocket but disperses through the tissue making such drainage impossible. Re-opening the wound invites infection and does not provide any relief. Fortunately even with a tremendous amount of swelling there is no permanent damage. In thirty years of dealing with the complications related to vasectomies (mine and those referred to me) I have never seen a testicle die or anyone develop chronic pain. Admittedly the healing does require an extended period of time-up to three months.
The second problem unique to vasectomies relates to the almost uncanny ability of the severed ends of the vas deferens to re-unite. At a designated time after a vasectomy is performed men are asked to collected a semen specimen to make sure that no sperm are present in the ejaculate. This period of time should be long enough to have allowed all of the sperm to have passed from the system distal to the point of interruption and also time for any healing to have occurred. If sperm persist, theoretically even a few sperm instead of the millions that are usually present, then the operation is a failure. The man has not been sterilized. Depending on the ego of the surgeon a number of reasons can be used to explain the lack of sterility. Although “accessory” vas deferens (three instead of two) have been described we have never seen the extra duct in our practice. We have seen instances where only one duct could be found and ligation of that single duct resulted in a successful operation. Other structures within the scrotum may be mistakenly transected even though the vas deferens is a large firm tubular structure that certainly feels different than any other structure in the scrotum. The fact that articles have been written suggesting that extra tissue be mobilized and placed between the severed ends of a vas deferens substantiates the probable origin of most failures as being the healing of the severed ends in such a manner as to allow the re-establishment of sperm flow. The only problem in mobilizing this tissue is that the extra dissection must be completed in an area where tissue handling and dissection should be minimized to prevent the bleeding and swelling.
These complications also affect the surgeons who are trying to master the vasectomy procedure. It is not unusual for a young surgeon to completely abandon the procedure after a few episodes of massive swelling or failed sterilizations. Even experienced vasectomy surgeons occasionally have these problems develop.
The swelling and failures still do not compare to the complications that can be associated with female sterilizations. Today, the monitoring associated with general anesthetics has made it possible to recognize improper intubations long before brain damage can occur but there are still problems that can develop related to difficulties encountered during the intubation and aspiration problems following extubation of the trachea. The entrance into the peritoneal cavity leaves a certain amount of scar tissue that can cause small bowel obstructions later. In comparison, the complications associated with vasectomies are relatively minor when compared to female tubal ligations. Every man who develops some swelling or discomfort following a vasectomy should remember that his anguish is still far less than it would be if he lost the mother of his children or his mate. Vasectomies remain the procedure of choice for family planning.
The experience of a surgeon in performing successful uncomplicated vasectomies is very important. In the end it is, as usual, the faith that a patient has in a surgeon’s ability that determines whether or not the operation will be performed. The surgeon who resents your questions as to his experience, who refuses to talk to you about possible complications or who does not want you talking to other men on whom he has performed the procedure should be avoided. The surgeon who will relate the number of times he has done the procedure and who will tell you about the types of problems he has encountered should be sought. Beware of the doctor whose ego refuses to allow him to admit he has ever had a complication or who is insulted when you seek a second opinion. I think I can safely say that every experienced vasectomy surgeon has at least one complication develop from a vasectomy procedure that he performed.
Post Vasectomy Activities: What Can I Do?
The activities of a man after the procedure can, in a small way, lessen the discomfort related to the operation. Informed with the understanding regarding the elasticity of the scrotum, men should avoid any type of strenuous activity for days or even weeks. A well deserved few days lounging on the couch is appropriate especially during the week-ends of non-stop sports activities. It is doubtful that ice packs offer any true protection but they are often recommended. Surgical incisions actually are closed by the clotted blood elements that fill the defect within a few hours and are probably impervious to any type of outside infection. Still some doctors ask patients to avoid bathing for several days. If you need an excuse not to bathe then certainly avoiding soap and water is okay. Otherwise cleaning the wound in a shower, with soap, is appropriate and probably helpful at any time following the surgery. If the wound is closed with sutures, especially absorbable sutures, some inflammation may appear around the entrance and exit sites. Topical antibiotics that are bought over the counter offer very little protection but they do prevent the wound from “sticking” to underwear and thus may be somewhat helpful. Generally letting the wound stay as dry as possible is preferable. Infection, which is surprisingly rare in the scrotum, involves hard reddened areas that are extremely painful to touch and usually even cause a low grade fever. The doctor should be contacted. If you have one of these infections there will not be a question. You will know something is wrong. You will know something has changed for the worse. If you have a little drainage and a few little red spots that really don’t bother you then there is not a significant problem. Often with absorbable sutures the wound may actually appear to “open” slightly. Again, this is not a problem. Nothing is going to fall out. The skin was probably rolled in with the closure and is now relaxing.
If sex is painful then don’t do it. You can resume sexual activities when you are safely beyond the period of avoiding strenuous activity if you realize you are not sterile until you have documented that there are no sperm in the ejaculate. Remember that the interruption in the vas deferens is completed at a point close to the testicle. There is a significant amount of ductal tissue winding up through the inguinal canal and prostate gland that is still full of sperm. These sperm must be evacuated before sterility is achieved. The method of clearing the tubes is left to the imagination of the patient. It appears to me that the bulk of the ejaculate comes from the prostate gland which is totally unaffected by a vasectomy so consequently a person has no way of determining is sperm are present in his ejaculate. There is no “drying up”. The resumption of sexual activities will be a natural part of the healing process and the period of discomfort will pass quickly.
Don’t be discouraged if the sperm count has to be repeated. Depending on sexual activity and other ill-defined factors the complete clearing of the ducts may take as much as three months. Persistent sperm beyond that point may indicate a problem, an unsuccessful procedure, but there is no harm in repeating the counts beyond this period and hoping that scar tissue will seal off the last bit of flow. The reproduction of our species is a tremendous force of nature and our body seems to have an amazing ability to overcome any efforts to stifle the delivery of sperm. In thirty years I have never seen a third vas deferens but such an abnormality may occur. Unless a surgeon is certain that one side has been interrupted both vas deferens will have to be divided again. If the surgeon can actually feel the vas deferens and palpates a gap between the severed ends on one side then the other side must have healed and reunited. If he can feel such a gap on both sides then there must be a third duct but if he cannot palpate this third duct from the outside there is little chance he will find it through a surgical exploration of the scrotum.
Supportive underwear, even an athletic supporter, does provide some degree of comfort when normal walking activities are resumed. Attempts to apply any type of dressing to that area of the body is usually futile but if there is any drainage then using underwear that facilitate the placement of a pad is appropriate and will prevent staining of clothing.
Bill Pannell is a practicing general surgeon, and a fellow of the American College of Physicians