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Vasectomy: Etiology of Infectious Complications*
Vol. 33, No.1, January 1980 Printed in U.8A.
FERTILITY AND STERILITY Copyright 0 1980 The American Fertility Society
VASECTOMY: ETIOLOGY OF INFECTIOUS COMPLICATIONS*
RODNEY A. APPELL, M.D. t PAUL R. EVANS
Department of Urology, Yale University School of Medicine, New Haven, Connecticut 06510, and London Hospital Medical College, London, England
Semen was cultured prior to vasectomy for voluntary sterilization. Postvasectomy infectious complications occurred only in patients with positive preoperative semen cultures. The offending pathogen was the same organism found in the semen culture. This evidence for an endogenous cause of postoperative vasectomy infections suggests that a semen culture and antimicrobial sensitivity be obtained prior to vasectomy. In this manner the correct antimicrobial agent can be instituted as an aid to rapid resolution of a postvasectomy infection. Fertil Steril33:52, 1980
tients under local anesthesia (1% lidocaine hydrochloride) on shaven genitalia prepared with chlorhexidine. The genitalia were draped with sterile linen. The surgeon wore sterile gloves, but was not masked and gowned. A separate scrotal incision was made over each vas deferens. Meticulous attention was paid to all bleeding points, which were ligated with 3-0 plain catgut. A 2.0-cm segment of vas was excised, and each end was ligated with 3-0 chromic catgut. Contact between the two cut ends was avoided by Hanley's method of folding the ends of the vas back so that they faced in opposite directions. 9 Contact between the cut ends was further avoided by Strode's technique of burying the proximal end in the surrounding fascia. lo The skin was also closed with 3-0 chromic catgut. A scrotal support was immediately placed over a small dressing, and the patient was advised to apply ice packs to the genitalia for 24 hours. Each patient was evaluated 1 week after surgery or earlier if he required or requested medical attention.
The popularization of vasectomy as a means for voluntary sterilization has led to several retrospective studies concerning morbidity associated with the procedure. l -8 A review of the literature reveals over-all postvasectomy infection rates starting at less than 3% 7 and ranging as high as 12%.6 These infectious complications can be divided into two main categories-wound infection and epididymitis. There have been attempts to affect the rate of infection by the prophylactic use of antibiotics, with no significant reduction. 2 ,5 This study has been limited to immediate postoperative infectious complications with the view of helping to explain the etiology of postvasectomy infections. MATERIALS AND METHODS
Serum from 134 fertile prevasectomy patients was obtained by masturbation into sterile, inert plastic containers 1 to 3 hours prior to operation. The semen was cultured on blood agar, and antibiotic disc sensitivities were determined. The surgical procedure was performed on outpa-
RESULTS
Significant bacterial growth (> 105 colonies/mD was found in the semen of 5 of 134 patients undergoing vasectomy. Postvasectomy complications (Table 1) occurred in six patients (4.5%); however, only three patients (2.3%) had infectious complications-two patients with bacterial epididymitis
Received August 24,1979; accepted September 17, 1979. *ACMI Prize Paper. Presented at the Thirty-Fifth Annual Meeting of The American Fertility Society, February 3 to 7, 1979, San Francisco, Calif. tPresent address and address for reprint requests: Department of Urology, LSU Medical Center, 1542 Tulane Avenue, New Orleans, La. 70112.
52
Vol. 33, No.1
VASECTOMY: ETIOLOGY OF INFECTIOUS COMPLICATIONS
TABLE 1. Postvasectomy Complications in 134 Patients
53
and 1 patient with a superficial wound infection. Urine cultures from the two patients with epididymitis and a wound culture in the third patient were obtained, and the organism grown in each case corresponded to that found in the preoperative semen cultures of these patients (Table 2). These three patients responded rapidly to the appropriate antimicrobial agent determined by the antibiotic sensitivities derived from the preoperative semen cultures. Other complications encountered in these 134 patients included small scrotal hematoma formation (2 patients) and nonbacterial epididymitis (1 patient). Two patients who had had positive preoperative semen cultures had an unremarkable postoperative course.
demonstrates that postvasectomy infectious complications are most probably endogenous in origin. No patient with a negative preoperative semen culture was found to have a postoperative bacterial infection. Therefore, the presence of bacteria in the genital tract placed a patient at risk for a postoperative infectious complication. It should be noted that postoperative testicular discomfort with epididymal swelling does not necessarily mean that bacterial infection is present, as this symptom complex may occur in the absence of infection and, is probably congestive in nature. The low incidence of postvasectomy infections in this study and in the literature indicates that the use of prophylactic antibiotics is probably not warranted. However, the evidence in this study for an endogenous cause of infection following vasectomy indicates that a semen culture with antibiotic disc sensitivities be obtained prior to vasectomy, especially in those patients with a history of urogenital tract infections. In this wayan appropriate antimicrobial agent can be given early to thosepatients who may develop a postvasectomy infection.
DISCUSSION
REFERENCES
No. of patients
2 (1.5%) 1 (0.7%) 3 (2.2%) 1 (0.7%)
2 (1.5%)
Postoperative complications
Scrotal hematoma Nonbacterial epididymitis Bacterial infection Superficial wound infection Epididymitis
This study confirms the safety of performing outpatient vasectomies. The over-all morbidity rate of 4.5% is acceptable, and the infectious complication rate of 2.2% is lower than that in most published series,1-8 including two in which prophylactic antibiotics wereused. 2 , 5 This study also TABLE 2. Semen Cultures and Relation to Postvasectomy Bacterial Infections in 134 Patients Organism in positive pr:h:r~t~N ~~~n
1. Enterococcus 2. Escherichia coli
3. Proteus mirabilis 4. Escherichia coli 5. Enterococcus
Corresponding bacterial complication (N = 3)
Culture and type of organism postvasectomy
Wound infection Wound: Enterococcus Epididymitis Urine: Escherichia coli Epididymitis Urine: Proteus mirabilis None None
1. Schmidt SS: Technics and complications of elective vasectomy. Fertil Steril17:467, 1966 2. Livingston ES: Vasectomy: a review of 3200 operations. Can Med Assoc J 105:1065, 1971 3. Esho JO, Cass AS, Ireland GW: Morbidity associated with vasectomy. J Urol 110:413, 1973 4. Leader AJ, Axelrad SD, Frankowski R, Mumford SD: Complications of 2711 vasectomies. J Urol 111:365, 1974 5. Gould RS: Vasectomy-discomfort and complications in 1100 patients studied: the role of steroids in the prevention of swelling and discomfort. J Urol 112:224, 1974 6. Sobrero AJ, Kohli KL: Two years' experience of an outpatient vasectomy service. AmJ Public Health 65:1091,1975 7. Bennett AH: Vasectomy without complication. Urology 7:184,1976 8. Squires JW, Pinch LW: The morbidity of vasectomy. Surg Gynecol Obstet 143:237, 1976 9. Hanley HG: Vasectomy for voluntary sterilization. Lancet 2:207,1968 10. Strode JE: A technique of vasectomy for sterilization. J Urol 37:733, 1937
FERTILITY AND STERILITY Copyright 0 1980 The American Fertility Society
VASECTOMY: ETIOLOGY OF INFECTIOUS COMPLICATIONS*
RODNEY A. APPELL, M.D. t PAUL R. EVANS
Department of Urology, Yale University School of Medicine, New Haven, Connecticut 06510, and London Hospital Medical College, London, England
Semen was cultured prior to vasectomy for voluntary sterilization. Postvasectomy infectious complications occurred only in patients with positive preoperative semen cultures. The offending pathogen was the same organism found in the semen culture. This evidence for an endogenous cause of postoperative vasectomy infections suggests that a semen culture and antimicrobial sensitivity be obtained prior to vasectomy. In this manner the correct antimicrobial agent can be instituted as an aid to rapid resolution of a postvasectomy infection. Fertil Steril33:52, 1980
tients under local anesthesia (1% lidocaine hydrochloride) on shaven genitalia prepared with chlorhexidine. The genitalia were draped with sterile linen. The surgeon wore sterile gloves, but was not masked and gowned. A separate scrotal incision was made over each vas deferens. Meticulous attention was paid to all bleeding points, which were ligated with 3-0 plain catgut. A 2.0-cm segment of vas was excised, and each end was ligated with 3-0 chromic catgut. Contact between the two cut ends was avoided by Hanley's method of folding the ends of the vas back so that they faced in opposite directions. 9 Contact between the cut ends was further avoided by Strode's technique of burying the proximal end in the surrounding fascia. lo The skin was also closed with 3-0 chromic catgut. A scrotal support was immediately placed over a small dressing, and the patient was advised to apply ice packs to the genitalia for 24 hours. Each patient was evaluated 1 week after surgery or earlier if he required or requested medical attention.
The popularization of vasectomy as a means for voluntary sterilization has led to several retrospective studies concerning morbidity associated with the procedure. l -8 A review of the literature reveals over-all postvasectomy infection rates starting at less than 3% 7 and ranging as high as 12%.6 These infectious complications can be divided into two main categories-wound infection and epididymitis. There have been attempts to affect the rate of infection by the prophylactic use of antibiotics, with no significant reduction. 2 ,5 This study has been limited to immediate postoperative infectious complications with the view of helping to explain the etiology of postvasectomy infections. MATERIALS AND METHODS
Serum from 134 fertile prevasectomy patients was obtained by masturbation into sterile, inert plastic containers 1 to 3 hours prior to operation. The semen was cultured on blood agar, and antibiotic disc sensitivities were determined. The surgical procedure was performed on outpa-
RESULTS
Significant bacterial growth (> 105 colonies/mD was found in the semen of 5 of 134 patients undergoing vasectomy. Postvasectomy complications (Table 1) occurred in six patients (4.5%); however, only three patients (2.3%) had infectious complications-two patients with bacterial epididymitis
Received August 24,1979; accepted September 17, 1979. *ACMI Prize Paper. Presented at the Thirty-Fifth Annual Meeting of The American Fertility Society, February 3 to 7, 1979, San Francisco, Calif. tPresent address and address for reprint requests: Department of Urology, LSU Medical Center, 1542 Tulane Avenue, New Orleans, La. 70112.
52
Vol. 33, No.1
VASECTOMY: ETIOLOGY OF INFECTIOUS COMPLICATIONS
TABLE 1. Postvasectomy Complications in 134 Patients
53
and 1 patient with a superficial wound infection. Urine cultures from the two patients with epididymitis and a wound culture in the third patient were obtained, and the organism grown in each case corresponded to that found in the preoperative semen cultures of these patients (Table 2). These three patients responded rapidly to the appropriate antimicrobial agent determined by the antibiotic sensitivities derived from the preoperative semen cultures. Other complications encountered in these 134 patients included small scrotal hematoma formation (2 patients) and nonbacterial epididymitis (1 patient). Two patients who had had positive preoperative semen cultures had an unremarkable postoperative course.
demonstrates that postvasectomy infectious complications are most probably endogenous in origin. No patient with a negative preoperative semen culture was found to have a postoperative bacterial infection. Therefore, the presence of bacteria in the genital tract placed a patient at risk for a postoperative infectious complication. It should be noted that postoperative testicular discomfort with epididymal swelling does not necessarily mean that bacterial infection is present, as this symptom complex may occur in the absence of infection and, is probably congestive in nature. The low incidence of postvasectomy infections in this study and in the literature indicates that the use of prophylactic antibiotics is probably not warranted. However, the evidence in this study for an endogenous cause of infection following vasectomy indicates that a semen culture with antibiotic disc sensitivities be obtained prior to vasectomy, especially in those patients with a history of urogenital tract infections. In this wayan appropriate antimicrobial agent can be given early to thosepatients who may develop a postvasectomy infection.
DISCUSSION
REFERENCES
No. of patients
2 (1.5%) 1 (0.7%) 3 (2.2%) 1 (0.7%)
2 (1.5%)
Postoperative complications
Scrotal hematoma Nonbacterial epididymitis Bacterial infection Superficial wound infection Epididymitis
This study confirms the safety of performing outpatient vasectomies. The over-all morbidity rate of 4.5% is acceptable, and the infectious complication rate of 2.2% is lower than that in most published series,1-8 including two in which prophylactic antibiotics wereused. 2 , 5 This study also TABLE 2. Semen Cultures and Relation to Postvasectomy Bacterial Infections in 134 Patients Organism in positive pr:h:r~t~N ~~~n
1. Enterococcus 2. Escherichia coli
3. Proteus mirabilis 4. Escherichia coli 5. Enterococcus
Corresponding bacterial complication (N = 3)
Culture and type of organism postvasectomy
Wound infection Wound: Enterococcus Epididymitis Urine: Escherichia coli Epididymitis Urine: Proteus mirabilis None None
1. Schmidt SS: Technics and complications of elective vasectomy. Fertil Steril17:467, 1966 2. Livingston ES: Vasectomy: a review of 3200 operations. Can Med Assoc J 105:1065, 1971 3. Esho JO, Cass AS, Ireland GW: Morbidity associated with vasectomy. J Urol 110:413, 1973 4. Leader AJ, Axelrad SD, Frankowski R, Mumford SD: Complications of 2711 vasectomies. J Urol 111:365, 1974 5. Gould RS: Vasectomy-discomfort and complications in 1100 patients studied: the role of steroids in the prevention of swelling and discomfort. J Urol 112:224, 1974 6. Sobrero AJ, Kohli KL: Two years' experience of an outpatient vasectomy service. AmJ Public Health 65:1091,1975 7. Bennett AH: Vasectomy without complication. Urology 7:184,1976 8. Squires JW, Pinch LW: The morbidity of vasectomy. Surg Gynecol Obstet 143:237, 1976 9. Hanley HG: Vasectomy for voluntary sterilization. Lancet 2:207,1968 10. Strode JE: A technique of vasectomy for sterilization. J Urol 37:733, 1937