Vasectomy Article in a GP medical magazine, 2001

I have been doing vasectomies for the last 5 years.  I was originally taught by two local NHS Consultant Surgeons and they taught me the standard hospital technique where a segment of vas is cut out, the ends are tied, folded back and the skin is closed with catgut sutures.  I found, however, with this technique that however carefully one did it, the catgut sutures tended to become infected or were sore, and patients typically took a good fortnight to heal up.  There were also an unacceptable incidence of haematoma, swelling and bruising.  When I had the opportunity to retrain in the Marie Stopes method using cautery, I seized it enthusiastically and switched over completely to this method.  I was also keen to make the operation as pleasant and relaxing and as pain-free as possible and over the years I have been adapting it and experimenting with various adjustments to this end.  The most important change was a suggestion I read in a book that anaesthetic should be injected high in the scrotum at the very beginning of the whole procedure and given a good 5-10minutes to work.  This then anaesthetised the vas and testis before the skin is even cut through.   The anaesthetic is put in using a dental syringe and the very fine needles that go with it (30 gauge).  This injection is virtually painless and I can vouch for this from my own experience.  Doing it on yourself is a little worrying if you are not used to injecting yourself, but these ultra fine needles certainly cause minimal discomfort.  In fact it is a lot less painful than having a simple blood sample taken from your arm.    

Unfortunately these fine 30 gauge needles are not readily available on the NHS so we buy them privately ourselves.  I also use them for all minor surgery to the skin as I find the hospital orange needles is really quite thick.  For instance when I do tennis elbow injections, I use a 30 gauge Dickson needle which is about the size of an acupuncture needle.  This means that tennis elbow injections are so painless they can be repeatedly injected in a fanwise manner to ensure that the exact tender spot is hit.  Similarly, for carpal tunnel injections, I use a 27 gauge long needle and this has rendered this procedure almost completely painless. 

I put in the high up initial injection at the very beginning when the patients come in, telling them that this is as bad as it gets and if they can put up with this, then they can relax for the rest of the procedure.  As this is virtually painless, it has quite a beneficial effect on the patient’s morale and they tend to settle back and relax much more.  The next stage is simply to swab down the scrotum with some Chlorhexidine, scrub up and prepare to proceed.

We play music in the background as a relaxation, we encourage patients to bring their own music and if they don’t, they are liable to get the Bee Gees…

Another trick we do in the winter months is to put a hot water bottle in the patient’s lap for 5-10 minutes which makes the scrotum very loose.  When the scrotum is tight and contracted it is really quite a tricky operation to do a vasectomy.  When it is loose then the testicles hang down, this gives you an extra inch or so of room to manoeuvre and speeds up the whole procedure.

Further anaesthetic is put under the scrotal skin and a very short incision of about ½ cm long is made through the skin and deeper layers.  Using special fine forceps the vas is pulled through this incision and cleared of surrounding tissue.  I then check the sensation in the vas to make sure it has gone completely numb by squeezing it gently with artery forceps.  Should there be any residual sensation in it, the patient gets a further injection of local anaesthetic before the next step.

For the next step of cautery the fans have to be turned on as it smells rather unpleasant and using a Surgitron, the vas is then cauterised for approximately 1½cm.  With the Surgitron the setting can be turned down to a much lower power and then any small bleeding vessels can be picked off.  As a result of this, the average blood loss during one of these procedures would only be enough to cover an area the size of perhaps one postage stamp on the swab.

The vas is then popped back into the scrotum and a further incision is made on the left side and the whole procedure is repeated.  I used to do the vasectomy through one incision on the right side as it is possible to reach over to the left side and pull the vas through the right side incision. However, looking at results, I found that this caused an unacceptable amount of bruising and I think it is because the midline septum of the scrotum is being cut without direct vision and a vessel may be opened and would then bleed without me being able to cauterise it.  Certainly since doing 2 incisions, the amount of bruising has been dramatically reduced. 

When I operated on myself I was quite amazed in the following day or so how little bruising there was and how little discomfort I had.  The wounds heal up extremely quickly without stitches and for myself they were fully closed within 2 days and 4 days later I could scarcely even see where the incision had been.   We often suggest to patients that when they go home they put something cold such as frozen peas in their lap as this makes the scrotum contract, cuts down on any chance of bleeding and helps the incisions close.  My son had an operation for a hydrocoele when he was younger which because it was a rather major thing needed a large incision, and this was closed by catgut stitches in the scrotum.  I can vouch from the experience of this that stitches in the scrotum always get slightly infected.  They go soft and nasty in bathwater and they take at least a week to two weeks to dissolve and disappear.   If it is possible to close the skin without them and this method allows this, then the healing is altogether dramatically faster and less troublesome. 

The wounds are covered with powder (a surgery secret) to stimulate fast wound healing and a couple of gauze swabs are placed over the scrotum and tight underwear is worn.  The patient is then able to drive himself home.  We draw the line at walking or cycling home, but driving is perfectly acceptable.  They are given a very full set of instructions on aftercare and I always personally phone them the next morning to check everything is fine.  We give them a sheet of Co-Proxamol tablets in case they get discomfort and some of them do get a sort of aching pain deep in the stomach.  I had a bit of this after I did myself but it wasn’t bad enough to warrant needing a painkiller.  We also give our patients one tablet of antibiotic in case they developed a haematoma, to prevent it getting infected.  As a result of this, we have only ever had one infection post operatively and that came on about 10 days later and responded to a couple of days of antibiotics.  We have had almost no cases of swelling in the testicles or of haematoma using this technique.

I believe this method of vasectomy is about as minimalist and as kind as it is possible to do.   It does, however, have one draw back, which is that the failure rate can be about 0.5%.  About 1 in 200 men fail to block off the vas completely and when we check them in 3 months they still have live sperm.  Occasionally these will then disappear over the next few months, but we have had to re-operate on a couple of men.  They don’t seem to mind too much, because a) they know it doesn’t hurt, b) they know it heals very quickly and doesn’t interfere with their life and c) they have the distinction of being so virile that my technique was unable to stop the sperm.  They seem to enjoy dining out on this bit of prowess.  We of course don’t charge anyone who needs a re-do.

The money that we make from doing vasectomies all goes to a local charity, the Wey and Arun Canal Trust, WACT, and I make the patients sign a gift aid form so the £150 fee is worth about £180 to the charity.  I have been involved for the last 7 years with them, trying to restore this derelict canal that links the English canal network to the channel.  It is a long term project and we don’t expect to finish it for another 20-30 years.   Recently I have been taking mentally ill and retired patients with me and we do the work as a form of exercise and therapy (Green Gym).

While I would not condone doctors treating themselves, there are times when you feel confident about a procedure such as this and it seems natural to do it yourself. The procedure was not painful in the slightest. Although it made me sweat a bit with anxiety, I never felt faint once and the nurse was extremely kind in helping me and I think she was probably more anxious than I was.  I was quite amazed by the interest showed by the National Press in this story, but I suppose it was rather a dry time for the newspapers in the middle of August.  I am pleased that it has had this publicity because I am keen to reassure men that vasectomy can be a very mild, painless procedure.  I am sure many more of them would come forward if they could be assured that it was not a horrifying experience that men are so fond of recounting.  I am also intrigued by the fact that it is illegal in France and my secret wish would be to be able to do vasectomies for French men in Paris.  I believe Marie Stopes have been trying to break into this market but have run into legal trouble with the French authorities.  If this story could make it through to the French media, then it may well help change the situation over there.