vasectomy
Doctor Information
Peter Southern age 31
No PMH
No regular medication of allergies
No PMH
No regular medication of allergies
Patient Information
Pete Southern age 31
History: Your wife has sent you in to get the snip. You have four kids (12, 8, 6 and 4) and neither of you want anymore. She is tired of taking the pill so its your turn now. You had a chat about it a couple of times and she is pretty clear this is going to happen. Initially you thought she could get her tubes tied but her doctor told her it is a bigger surgery and not as successful so she wont have it now.
If asked only: You would rather not have an operation because you are terrified of being put to sleep. You had your appendix out when you were 12 and you have awful memories of it. To be honest, the thought of being put to sleep is giving you sleepless nights now, but you dont want to be a coward. You children are fab but there is no way you are having anymore. You are a refuse collector and your wife is a beautician so money is quite tight at the minute and you genuinely could not afford to have another child. You have not had much luck with contraception - Jill your wife got pregnant on the pill and on the coil. She still takes a pill but you are both always a bit worried it might fail again. Jill has heard about something called a mirena, but she isn't keen on getting another coil.
You have no idea what is involved with the snip. You have assumed that they knock you out and then cut something down there. You do have a friend, Jim who went through it, and wanted it reversed later, and he was told that its not available on the NHS, so you are aware that it is essentially irreversible.
You are usually fit and well, with no medical problems, no medication or allergies
Ideas: you need the snip
Concerns: you are scared to be put to sleep and don't know if you can got through with it
Expectations: to get a referral to see a specialist
If the doctor explains the procedure to you, you are relieved to know it can be done under local anaesthetic, and this does make you more likely to got through with it. You are a bit apprehensive about some of the side effects an risks with the procedure (especially long term testicular pain), but if you are given a good explanation and how those aspects can be dealt with, you will go through with it. You are fully aware it is not reversible on the NHS, and although you are young, you are sure you do not want anymore children.
History: Your wife has sent you in to get the snip. You have four kids (12, 8, 6 and 4) and neither of you want anymore. She is tired of taking the pill so its your turn now. You had a chat about it a couple of times and she is pretty clear this is going to happen. Initially you thought she could get her tubes tied but her doctor told her it is a bigger surgery and not as successful so she wont have it now.
If asked only: You would rather not have an operation because you are terrified of being put to sleep. You had your appendix out when you were 12 and you have awful memories of it. To be honest, the thought of being put to sleep is giving you sleepless nights now, but you dont want to be a coward. You children are fab but there is no way you are having anymore. You are a refuse collector and your wife is a beautician so money is quite tight at the minute and you genuinely could not afford to have another child. You have not had much luck with contraception - Jill your wife got pregnant on the pill and on the coil. She still takes a pill but you are both always a bit worried it might fail again. Jill has heard about something called a mirena, but she isn't keen on getting another coil.
You have no idea what is involved with the snip. You have assumed that they knock you out and then cut something down there. You do have a friend, Jim who went through it, and wanted it reversed later, and he was told that its not available on the NHS, so you are aware that it is essentially irreversible.
You are usually fit and well, with no medical problems, no medication or allergies
Ideas: you need the snip
Concerns: you are scared to be put to sleep and don't know if you can got through with it
Expectations: to get a referral to see a specialist
If the doctor explains the procedure to you, you are relieved to know it can be done under local anaesthetic, and this does make you more likely to got through with it. You are a bit apprehensive about some of the side effects an risks with the procedure (especially long term testicular pain), but if you are given a good explanation and how those aspects can be dealt with, you will go through with it. You are fully aware it is not reversible on the NHS, and although you are young, you are sure you do not want anymore children.
Examination Findings
Normal external genitalia, vas deferens clearly identifiable, no testicular swellings. No infection / inflammation of the scrotal skin.
Abdomen soft and non tender
Mark scheme
Data Gathering
|
POSITIVE INDICATORS
Organised and systematic in gathering information from history taking, examination Data gathering does appears to be guided by the probabilities of disease Undertakes physical examination competently |
NEGATIVE INDICATORS
Makes immediate assumptions about the problem Intervenes rather than using appropriate expectant management Is disorganised/unsystematic in gathering information Appears disorganised/unsystematic in the application of the instruments or the conduct of physical examinations |
Clinical Management Skills
|
POSITIVE INDICATORS
Develops a management plan (including referral) that is appropriate and in line with current best practice Management approaches reflect an appropriate assessment of risk `Discusses procedure and alternatives to vasectomy Refers appropriately & co-ordinates care with other healthcare professionals Manages risk effectively, safety netting appropriately |
NEGATIVE INDICATORS
Does not suggest how the problem might develop or resolve Fails to make the patient aware of relative risks of different approaches, unable to discuss procedure Decisions on whether & where to refer are inappropriate. Follow-up arrangements are absent or disjointed |
Inter Personal Skills
|
POSITIVE INDICATORS
Identify patient’s agenda, health beliefs & preferences Works with the patient to develop a shared management plan Uses explanations that are relevant and understandable to the patient Shows sensitivity for the patient’s feelings in all aspects of the consultation including physical examination Does not allow own views/values to inappropriately influence dialogue |
NEGATIVE INDICATORS
Doesn't enquire about patients ICE Takes a doctor centered approach towards management Uses an explanation that is filled with jargon, or forgets to explain at all Doesn't show any sympathy / empathy towards the patient's situation Inappropriately influences patient interaction through own views/values |
Management
This case is fairly straight forward (there are a few without any major hidden agendas or complications!) if you know about vasectomy. Firstly a basic history to establish their reproductive background and reasons for wanting sterilisation, and an examination of the external genitalia to ensure there are no obvious abnormalities or barriers to surgery. Check their level of understanding about vasectomy and ensure they are competent to make the decision. With the advent of long-acting reversible female contraceptives, it may be worth checking whether they and their partner have considered this as an alternative.
Certain factors pose higher risks for regret post-procedure. A reversible is possible but it is not NHS funded, and is only successful in approximately 50% of cases. Men under age 30, those without children, or those for whom the decision is made during an event (e.g. after a pregnancy, a relationship breakdown, or following partner coercion) are more likely to regret the decision. Its worth emphasising that they consider this an irreversible procedure, and prior to undertaking it they should consider all possible future events (ones that patients usually haven't considered, such as the tragic loss of their children / family to illness / accident, or finding themselves in a different relationship in future) and are still happy they want to proceed.
The following is a list of advantages and disadvantages taken form the NICE CKS website
Advantages
Disadvantages
How would you explain the procedure? The area around the testicles is numbed. The cord that goes up from the testicle to the penis is cut just above the testicle, and each end is stitched up. At two months afterward the surgery you need to provide two semen samples approximately 4 weeks apart. If these are clear from sperm, your vasectomy is considered a success. Until that point you will need additional contraception.
Compared to a female having tubal occlusion for sterilisation, which has a failure rate of 1/200, male vasectomy has a failure rate of 1/2000. There are also less risks associated with the latter. Some of the possible complications include bleeding, bruising, pain and infection. Longer term there is the risk of chronic testicular pain and sperm granuloma. Chronic testicular pain can be quite common with around 10% of patients experiencing to some degree, although for most it won't be severe enough to come back to see their GP about. The procedure can (and is usually) performed under local anaesthetic, and in many areas, is performed by consultant urologists in a primary care setting.
Once they have had the procedure they need to continue using contraception until they have had two semen samples showing azoospermia. These samples are usually taken at 2 and 3 months post op, but does vary depending on local protocol.
Certain factors pose higher risks for regret post-procedure. A reversible is possible but it is not NHS funded, and is only successful in approximately 50% of cases. Men under age 30, those without children, or those for whom the decision is made during an event (e.g. after a pregnancy, a relationship breakdown, or following partner coercion) are more likely to regret the decision. Its worth emphasising that they consider this an irreversible procedure, and prior to undertaking it they should consider all possible future events (ones that patients usually haven't considered, such as the tragic loss of their children / family to illness / accident, or finding themselves in a different relationship in future) and are still happy they want to proceed.
The following is a list of advantages and disadvantages taken form the NICE CKS website
Advantages
- Very effective in preventing pregnancy.
- The lifetime failure rate is approximately 1 in 2000 men following negative semen testing.
- It is (for practical purposes) permanent.
- Sex need not be interrupted to use contraception.
Disadvantages
- It requires a minor surgical procedure.
- It takes a while for a vasectomy to be effective.
- Effective contraception is required until azoospermia is confirmed, and this could be 2 or 3 months after the procedure.
- People may regret having had the procedure:
- The assessment process is designed to ensure that people at risk for regret are identified and fully informed about alternative long-acting reversible contraceptive methods.
- Vasectomy cannot easily be reversed, and the NHS rarely provides reversal procedures.
- Vasectomy does not protect against sexually transmitted infections.
- There is a small risk of haematoma and infection after the procedure.
- Rarely, the procedure fails after clearance has been given that there are no spermatozoa in the ejaculate.
How would you explain the procedure? The area around the testicles is numbed. The cord that goes up from the testicle to the penis is cut just above the testicle, and each end is stitched up. At two months afterward the surgery you need to provide two semen samples approximately 4 weeks apart. If these are clear from sperm, your vasectomy is considered a success. Until that point you will need additional contraception.
Compared to a female having tubal occlusion for sterilisation, which has a failure rate of 1/200, male vasectomy has a failure rate of 1/2000. There are also less risks associated with the latter. Some of the possible complications include bleeding, bruising, pain and infection. Longer term there is the risk of chronic testicular pain and sperm granuloma. Chronic testicular pain can be quite common with around 10% of patients experiencing to some degree, although for most it won't be severe enough to come back to see their GP about. The procedure can (and is usually) performed under local anaesthetic, and in many areas, is performed by consultant urologists in a primary care setting.
Once they have had the procedure they need to continue using contraception until they have had two semen samples showing azoospermia. These samples are usually taken at 2 and 3 months post op, but does vary depending on local protocol.