National opioid prescription patterns and patient usage after routine vasectomy.

Routine prescription of opioids after outpatient surgery is common. The main objective of this study was to determine urologist opioid prescribing patterns and patients' pain control medication regimens (opioid and anti-inflammatory) after vasectomy. We designed an anonymous seven-question electronic survey of urologists to assess vasectomy practice and post-vasectomy opioid prescriptions using the American Medical Association Physician Masterfile database. We then performed a retrospective internal telephone survey of men who had undergone vasectomy by a single surgeon (MKS). This telephone survey queried men about opioid prescription filling, opioid use and ibuprofen use. We received 136 (4.5%) electronic survey responses. 51.5% of urologists routinely prescribed opioids for post-vasectomy analgesia, despite 50.4% having 'no idea' how many patients actually used these. On internal telephone survey, 52.6% of patients who used opioids reported using ibuprofen as their primary pain medication, versus 92.6% of patients who did not use opioids (p = .004). Ibuprofen use was associated with using fewer opioid tablets (p = .003). Using ≥1 opioid tab was associated with increased odds of not using ibuprofen as the primary pain medication (OR 11.2, 95% CI 2.39-83.0, p = .005). In conclusion, integration of practice guidelines may help standardise and minimise potentially unnecessary post-vasectomy opioid prescriptions.

Routine Prescription of Opioids for Post-Vasectomy Pain Control Associated with Persistent Use.

PURPOSE: The AUA (American Urological Association) Position Statement on opioid use recommends using opioids only when necessary. We sought to determine if routine prescribing of opioids is necessary for pain control after vasectomy, and if an association exists with persistent use. MATERIALS AND METHODS: We retrospectively reviewed the charts of patients who underwent vasectomy in clinic between April 2017 and March 2018. Patients were stratified into 2 groups, including those initially prescribed opioids and those not receiving opioid prescriptions at the time of vasectomy. The initial pain medication regimen depended on the standard prescription practice of each provider. Encounters with a medical provider for scrotal pain within 30 days, subsequent opioid prescriptions and new persistent opioid prescriptions between 90 and 180 days were compared between the 2 groups using the Fisher exact test. RESULTS: Between April 2017 and March 2018 a total of 228 patients underwent clinic vasectomy as performed by 8 urologists. At the time of vasectomy 102 patients received opioid prescriptions and 126 received no opioid prescriptions. There was no statistically significant difference between the opioid and nonopioid groups in encounters for scrotal pain (12.7% vs 18.4%, p = 0.279). The incidence of new persistent opioid use was 7.8% in the opioid cohort compared to 1.5% in the nonopioid cohort (p = 0.046). CONCLUSIONS: Opioids, which do not appear to be necessary in men who undergo vasectomy, were associated with persistent use in 7.8% of patients at 3 to 6 months. In the face of an opioid epidemic urologists should take action to limit over prescription of opioids after vasectomy.

Bringing men to the table: sterilization can be for him or for her.

Sterilization, male and female combined, is the most common use of contraception in the United States. Despite the lower risk, higher cost-efficacy, and high efficacy of vasectomy compared with female sterilization, more US women rely on female sterilization than male sterilization. Reasons for low use of vasectomy include lack of knowledge and misconceptions about the procedure, lack of access, provider bias, and patient preferences. This article will provide a basic overview of male and female sterilization, an exploration of vasectomy barriers, and ways obstetrician-gynecologists can increase vasectomy uptake including regular recommendation of vasectomy to patients in long-term committed relationships considering sterilization.

Who chooses vasectomy in Rwanda? Survey data from couples who chose vasectomy, 2010-2012.

BACKGROUND: Vasectomy is safe and highly effective; however, it remains an underused method of family planning (FP) in Africa. In view of this, three Rwandan physicians were trained in no-scalpel vasectomy with thermal cautery and fascial interposition on the prostatic end as vasectomy trainers in 2010, and this initiative has resulted in over 2900 vasectomy clients from February 2010 to December 2012. STUDY DESIGN: This cross-sectional descriptive study describes vasectomy clients (n=316) and their wives (n=300) from 15 randomly selected hospitals in Rwanda. RESULTS: The vasectomy clients were mainly over age 40, had young children (age <3) and were married and cohabiting. Limited financial resources, satisfaction with existing family size and avoiding side effects from hormonal methods (wives') were key motivators for vasectomy uptake. High rates of previous FP use and high degree of interspousal communication are known correlates of higher FP use. CONCLUSIONS: Future and current Rwandan FP programs and other interested parties will benefit from understanding which couples elect vasectomy, their motivations for doing so and their service utilization experiences. Better integration of vasectomy counseling and postvasectomy procedures will benefit the program. IMPLICATIONS: Until this project, vasectomy projects in sub-Saharan Africa were viewed as unrealistic. This study confirms factors influencing vasectomy uptake identified in earlier research, but does so within a robust sample of vasectomy users and their wives and provides a strong understanding of who likely vasectomy users are in this context. Promotion of vasectomy services should be considered as an essential element of a healthy contraceptive method mix.

Vasectomy demographics and postvasectomy desire for future children: results from a contemporary national survey.

OBJECTIVE: To describe the longitudinal demographics and family planning attitudes of vasectomized men with the use of the National Survey for Family Growth (NSFG). DESIGN: Retrospective cohort analysis of the NSFG with the use of national projections and multivariable regressions. SETTING: In-home survey. PATIENT(S): The NSFG sampled 10,403 men aged 15-45 years from 2006 to 2010 regarding family planning attitudes. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Vasectomy and desire for children. RESULT(S): There were 3,646,339 (6.6%) vasectomized men aged 18-45 years in the U.S. On multivariable regression the following factors increased the odds of having a vasectomy: currently married (odds ratio [OR] 7.814), previously married (OR 5.865), and increased age (OR 1.122) and income (OR 1.003). The odds of having a vasectomy increased with number of children. The following factors decreased the odds of having a vasectomy: immigrant status (OR 0.186), African American (OR 0.226), Hispanic (OR 0.543), Catholic (OR 0.549), and other non-Protestant religion (OR 0.109). Surprisingly, an estimated 714,682 (19.6%) vasectomized men in the U.S. desire future children. Men practicing a religion (OR 8.575-15.843) were more likely than atheists to desire children after vasectomy. 71,886 (2.0%) vasectomized men reported having a vasectomy reversal. CONCLUSION(S): This study highlights the importance of preoperative counseling for permanency of vasectomy and reveals an opportunity to counsel couples about vasectomy versus tubal ligation.

Current and future role of voluntary surgical contraception in increasing access to and utilization of family planning services in Africa.

BACKGROUND: Voluntary surgical contraception is the most widely utilized method of contraception in the world. High effectiveness, low complication rates and reduced cost in the long term make them the ideal contraceptive choice to diverse group of clients including clients from low resource settings. OBJECTIVE: To assess the current status of utilization and effectiveness of voluntary surgical contraception in Africa and suggest possible future roles in contraceptive method choice. METHODS: A review of available literature on voluntary surgical contraception and synthesis of information under relevant headings. RESULTS: Despite very high total fertility rates in most countries of Africa, surgical contraceptives still contribute to a very small proportion ofcontraceptive method choice in the continent. Client profile and acceptability studies indicate a large unmet need for permanent contraception in the continent. Lack of information, misconceptions and weak health systems (particularly surgical care) are the major impediments to increasing availability of surgical contraception. Lack of knowledge and low levels of motivation among health care providers may also be significant barriers to access. CONCLUSIONS: Ihcreasing availability of information on the safety and effectiveness of these methods to both health care providers and the general population can increase demand and acceptability. Delegating service provision to appropriately trained non-physician providers at primary care settings can assist in increasing accessibility of these important family planning methods.

Fascial interposition technique for vasectomy: is it justified?

PURPOSE: To assess the feasibility of the fascial interposition (FI) technique to improve the results of non-scalpel vasectomy (NSV) through a cost-effective modification. PATIENTS AND METHODS: The outcome of the FI technique for NSV in 954 consecutive candidates treated by two surgeons was evaluated retrospectively. 726 (76%) of the clients had undergone NSV with FI (FI group) and for the other 228 (24%) NSV by simple ligation and excision (LE) without FI (NFI group) was performed. Demographic data, operative time and complications as well as vasectomy failures were analyzed between the two groups. RESULTS: The two groups were age-matched and there were no significant differences between the two procedures regarding operative complications and operative time. 13 cases of vasectomy failures (5.7%) were detected after 3 months of follow-up, all in the NFI group. No vasectomy failure was recognized in the FI group. CONCLUSION: Combined use of FI with simple LE could be considered a simple effective method for NSV with a high success rate that allows the NSV to remain as a reliable option for contraception.

Vasectomy. A safe, effective, economical means of sterilization.

Vasectomy is a common office procedure that is a permanent, safe, and effective form of birth control. It is less expensive and safer than tubal ligation. Physicians who wish to perform the procedure should be aware of the potential complications and explain them to the patient. Physicians also should perform the procedure often enough to have a low complication rate.

Sterilization and its consequences.

UNLABELLED: The purpose of this review is to analyze critically the two techniques of sterilization (bilateral tubal ligation [BTL] and vasectomy) so that a physician may provide informed consent about methods of sterilization. A MEDLINE search and extensive review of published literature dating back to 1966 was undertaken to compare preoperative counseling, operative procedures, postoperative complications, procedure-related costs, psychosocial consequences, and feasibility of reversal between BTL and a vasectomy. Compared with a vasectomy, BTL is 20 times more likely to have major complications, 10 to 37 times more likely to fail, and cost three times as much. Moreover, the procedure-related mortality, although rare, is 12 times higher with sterilization of the woman than of the man. Despite these advantages, 300,000 more BTLs were done in 1987 than vasectomies. In 1987, there were 976,000 sterilizations (65 percent BTLs and 35 percent vasectomies) with an overall cost of $1.8 billion. Over $260 million could have been saved if equal numbers of vasectomies and BTLs had been performed, or more than $800 million if 80 percent had been vasectomies, as was the case in 1971. The safest, most efficacious, and least expensive method of sterilization is vasectomy. For these reasons, physicians should recommend vasectomy when providing counseling on sterilization, despite the popularity of BTL. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians LEARNING OBJECTIVES: After completion of this article, the reader will be able to predict the failure rates and likelihood of successful reversal of tubal ligation and vasectomy; to recall the difference in cost between the two sterilization procedures, and to describe the short-term and long-term complications associated with each of the two methods of sterilization.

The incidence of post-vasectomy chronic testicular pain and the role of nerve stripping (denervation) of the spermatic cord in its management.

OBJECTIVE: To assess the incidence of chronic postvasectomy testicular pain (CPTP) and evaluate the use of denervation of the spermatic cord in its management. PATIENTS AND METHODS: A retrospective postal survey of 560 patients (mean age 36 years, range 25-55; mean time since vasectomy 19 months, range 8-39) who underwent vasectomy between July 1992 and December 1994 was carried out to determine the incidence of CPTP. A prospective study was conducted in a further group of 17 patients (mean age 43 years, range 34-60), who had had CPTP for at least one year, to evaluate the effectiveness of nerve stripping of the spermatic cord in relieving pain. RESULTS: Of 396 replies, 108 (27.2%) patients complained of some testicular pain following their vasectomy operation. In 88 (82%) of these 108 patients the pain was brief and was not defined as CPTP, while 20 (19%) patients had pain for > 3 months; 33 (31%) patients required analgesics to control the pain. Of the 17 patients who underwent spermatic cord denervation, 13 reported complete relief of pain at their first follow-up visit and were discharged. Four patients had a significant improvement in the symptom score and were satisfied with the results. CONCLUSIONS: There is a small but significant incidence of CPTP and patients should be warned of this possibility when counselled before operation. Denervation of the spermatic cord seems to be a viable surgical option for patients with CPTP who fail to respond to conservative measures.

Twenty years of epidemiology in fertility regulation.

This paper summarizes findings from epidemiological research in fertility regulation which have helped in formulating policies nationally and internationally, without pretending to be all-encompassing; rather, it should help in demonstrating the usefulness and importance of epidemiological research and in discussing outstanding issues of public health relevance.

PIP: Epidemiological research serves to continue surveillance of fertility regulation agents once phase 3 clinical trials have been completed and the contraceptives have been marketed. Epidemiologic research conducted during the past 20 years has had a major impact on family planning program policies and clarified many concerns about contraceptive side effects that emerged in the early 1970s. Central has been the reassessment of the risk of malignant neoplasms associated with use of hormonal contraception. Data from large-scale studies such as the Cancer and Steroid Hormone Study in the US and the World Health Organization Collaborative Study involving 9 developing and 2 developed countries suggest that combined oral contraceptives (OCs) decrease the risk of ovarian and endometrial cancer, especially in long-term users. Although there is emerging evidence that OC use exceeding 5 years is associated with a modest increase in cervical cancer risk, the causality of the association is questionable given the probable influence of confounding factors such as sexually transmitted diseases. Moreover, epidemiologic studies launched in the 1980s confirmed that the previously noted association between OCs and cardiovascular diseases has been reduced as a result of lower doses of ethinyl estradiol and revised prescribing practices. Other foci of epidemiologic investigations have included possible side effects associated with natural family planning, the impact of modern IUDs on pelvic inflammatory disease and ectopic pregnancy risks, and the association between vasectomy and testicular and prostate cancer. Given the observational nature of epidemiologic research and the potential for bias, findings from several studies addressing the same research question with different methodological approaches are generally assessed.

Vasectomy and prostate cancer: a case-control study in a health maintenance organization.

A case-control study was conducted within Group Health Cooperative of Puget Sound to evaluate the relation between prior vasectomy and the risk of prostate cancer. Cases consisted of 175 men newly diagnosed with histologically confirmed prostate cancer during 1989-1991. A total of 258 controls, matched to cases on birth year and membership status, were randomly selected from the general membership of the plan. Information was collected from mailed questionnaires and medical records on medical history, including prior vasectomy, anthropometric measures, family history of prostate cancer, personal habits, and medical care utilization, and demographic factors. Conditional logistic regression analyses showed that the odds ratio for prostate cancer associated with vasectomy was 0.86 (95% confidence interval 0.57-1.32) after adjustment for confounders. The odds ratio estimate did not differ substantially by age at vasectomy or time since vasectomy. However, the odds ratio estimate for prostate cancer associated with vasectomy tended to be increased among men who had a father or brother with prostate cancer. Nevertheless, the increased risk may be related to detection bias or differential participation rates due to both vasectomy status and a family history of prostate cancer. These results suggest no overall association between vasectomy and prostate cancer.

PIP: A case-control study was conducted at Group Health Cooperative of Puget Sound, a health maintenance organization, to evaluate the relation between prior vasectomy and the risk of prostate cancer. Cases were 175 men newly diagnosed with histologically confirmed prostate cancer during 1989-91. 258 controls, randomly selected from the general membership of the plan, were matched to cases by birth year and membership status. Information was collected from mailed questionnaires and medical records on medical history, including prior vasectomy, anthropometric measures, family history of prostate cancer, personal habits, medical care utilization, and demographic factors. Conditional logistic regression analysis identified a 0.86 odds ratio for prostate cancer associated with vasectomy after adjustment for confounders. The odds ratio estimate did not differ substantially by age at vasectomy or time since vasectomy. However, the odds ratio estimate for prostate cancer associated with vasectomy tended to be increased among men who had a father or brother with prostate cancer. This increased risk may be related to detection bias or differential participation rates due to both vasectomy status and a family history of prostate cancer. Study results suggest the existence of no overall association between vasectomy and prostate cancer.

Questionnaire-based outcomes study of nononcological post-vasectomy complications.

PURPOSE: We conducted an outcomes analysis to determine the incidence of post-vasectomy complications. MATERIALS AND METHODS: A questionnaire (154 questions) addressing post-vasectomy complications, incidence of post-vasectomy scrotal pain and quality of life issues was sent to 470 patients. Followup telephone surveys were made. RESULTS: A total of 182 patients (42.3%) responded. Mean follow-up was 4.8 years. The most common complication was post-vasectomy scrotal pain in 34 men (18.7%), which adversely affected the quality of life in 4 (2.2%). In retrospect, 71.4% of the men were satisfied with the decision for vasectomy, 19.3% had equivocal feelings and 9.3% were dissatisfied. CONCLUSIONS: Chronic scrotal pain is the most common post-vasectomy complication that may adversely affect quality of life in men undergoing vasectomy.

PIP: 500,000 to 1 million vasectomies are performed annually with only a 2-3% complication rate. However, despite the low complication and failure rates of the procedure, vasectomy is a leading cause of urological litigation. The authors conducted an outcomes analysis to determine the incidence of post-vasectomy complications, particularly the incidence of chronic scrotal pain related to vasectomy and its impact upon quality of life. A questionnaire of 154 questions addressing post-vasectomy complications, incidence of post-vasectomy scrotal pain, and quality of life issues was sent to 470 patients selected from the Henry Ford Hospital database who underwent vasectomy between January 1988 and November 1992. Follow-up telephone surveys were conducted. 182 patients responded to the questionnaires. The participants were followed for a mean period of 4.8 years. The most common complication was post-vasectomy scrotal pain in 34 men, which adversely affected the quality of life in four. 71.4% of the men were, however, satisfied with having decided to undergo vasectomy, 19.3% had equivocal feelings, and 9.3% were dissatisfied.

Objective assessment of spermatogenesis in men with functional and anatomic obstruction of the genital tract.

Experimental rodent models simulating the condition of neurogenic infertility have drawn attention to the role of potential epididymal dysfunction as an underlying cause. This functional obstruction of the genital tract is comparable to the outcome of genital tract obstruction after vasectomy, and may explain the common finding of asthenospermia in both groups following either stimulated semen recovery or vasovasostomy, respectively. Since spermatogenic dysfunction has been reported in spinal cord injury, the relative roles of defective sperm production and sperm transport remain to be determined in men with neurogenic infertility. The objective of this study was to compare the levels of spermatogenesis in groups of vasectomized men and those with spinal cord injury, using objective measurement criteria for spermatogenesis. Groups of 10 spinal cord-injured and six vasectomized men matched for age and duration of disease, underwent incisional testicular biopsy. The specimens were divided equally for parallel quantitation of spermatogenesis by both quantitative cytometry and DNA flow cytometric analysis. Quantitative parameters showed similar values for both groups with reference to mean tubular wall thickness, mean tubular concentration of spermatids and Sertoli cells, as well as the mean spermatid: Sertoli cell ratio per tubule. Additionally, similar percentages of 1N, 2N and 4N cells, were found in both groups. Based on these preliminary findings this study provides a clinical correlation supporting the experimental observation that both anatomical and functional obstruction of the male genital tract exert a similar although minor spermatogenic insult, and that in both the putative cause for neurogenic infertility is more likely to be at the post-testicular level.

Vasectomy: preliminary report on 25 cases.

Preliminary data on 25 men who underwent vasectomy for contraception between June 1986 and May 1988 at the Marie Stopes Clinic--Nairobi is presented. The majority (76.0%) of the subjects were aged between 25 and 39 years. 68.0% had 4 living children or less. Professionals including lecturers, lawyers, teachers, engineers etc, formed 88.0% of the total. Three clients(12.0%) had documented complications; one had aseptic wound, one had haematoma and the last one had a failed vasectomy. All were treated successfully. Complications of vasectomy and the need for follow-up of vasectomised men are discussed.

PIP: Preliminary data on 25 men who underwent vasectomy for contraception between June 1986 and May 1988 at the Marie Stopes Clinic - Nairobi is presented. The majority (76%) of the subjects were aged between 25 and 39 years. 68.0% had 4 living children or less. Professionals including lecturers, lawyers, teachers, and engineers formed 88.0% of the total. 3 clients (12.0%) had documented complications; one had aseptic wound, one had hematoma, and the last one had a failed vasectomy. All were treated successfully. Other complications that may occur include orchitis, epididymitis, disturbed sexual function, granuloma, and antibody or arterio-venous fistula formation. Follow-up is a necessary process since patients may not return, even if there is a problem. In this study only 4 (16.9%) of the men reported back after 6 weeks. The other 3 (12.0%) returned because of their complications.

Vasectomy and health: cardiovascular and other diseases following vasectomy in Sichuan province, People's Republic of China.

The long-term sequelae of vasectomy were studied in a retrospective cohort study of 4596 vasectomized and 4340 nonvasectomized farmers from eight rural communes in Sichuan, People's Republic of China. The mean duration since the operation was 14.5 years with a range of 10 to 25 years. At the time of evaluation the vasectomized men were generally healthier than the non-vasectomized for a wide range of health indicators including clinical signs of cardiovascular disease, resting ECG changes, positive ECG changes following a maximal stress test, or fundus abnormalities. The lack of association between vasectomy and cardiovascular disease noted in Europe and the USA is supported by the present study conducted in a population with a low prevalence of cardiovascular disease and risk factors.

PIP: A study was conducted in Sichuan, China to further determine if any correlation exists between vasectomy and the risk of heart disease. In a retrospective analysis of 4596 men who had received vasectomies and 4340 who had not been vasectomized, it was found that the cardiovascular status of men who had had a vasectomy was actually better that those who had not. The mean duration since the operation was 14.5 years with a range of 10-25 years. The results confirmed past conclusions that vasectomy is not linked with coronary disease. Testing for other endpoints and areas such as stomach ulcer and hypertension indicated that men who had received a vasectomy were in general in better health. Resting ECG changes and positive ECG changes following a stress test further confirmed the results. Mortality associated with vasectomy was also examined with no negative connection found. Vasectomy has been extensively studied and has been proven repeatedly to be a safe procedure that is not linked to adverse effects.

Open-ended vasectomy: an assessment.

Leaving open the testicular end of vas at vasectomy could reduce symptoms of epididymal congestion and improve the success rate of vasovasostomy but might have the disadvantage of increasing the incidence of painful sperm granulomas and spontaneous recanalization. In 4330 open-ended vasectomies the rate of epididymal congestion was significantly less than in 3867 standard vasectomies. The rate of painful sperm granulomas was not increased: it was significantly reduced. Spontaneous recanalization was rare in both groups. Whether or not open-ended vasectomy improves the success rate of vasovasostomy, it represents an improvement in technique because it reduces the rate of complications after vasectomy. Closure of the sheath over the prostatic end of vas is essential if recanalization is to be prevented.