New Times - San Luis Obispo

This simple procedure may hurt more than you think

BY STACEY WARDE

Kevin Hauber would love nothing more than to walk down the street without excruciating pain, or to enjoy making love to his wife without the searing stabbing sensations he sometimes feels when she touches him.

Following his vasectomy on Aug. 12, 1999, Hauber returned to his San Luis Obispo urologist several times to complain of pain and discomfort.

Finally the pain was so unbearable he asked his urologist, "OK, level with me. Why do I feel like I've been kicked in the balls all the time?"

What Hauber's urologist never told him, what he later discovered on his own, was that he was suffering from post-vasectomy pain syndrome (PVPS), a malady that he estimates afflicts 6 to 25 percent of the 50 million men in the U.S. who have had this surgical procedure. The range depends on the medical data you look at and how you define chronic pain.

Additionally, Hauber says, nearly 75 percent of men who undergo vasectomies experience autoimmune responses to sperm in their bodies. In such cases the body manufactures antibodies that attack sperm cells.

Worse, according to Hauber, was that his urologist, whom he declines to name, never informed him of these potential risks, or of links with prostate cancer, which are far more common than the unsuspecting patient realizes.

The disclosure generally given a patient by his urologist, says Hauber, is about short-term complications.

"It's no big deal. Expect a little pain and discomfort for a day or two but no adverse or long-term side affects. Complications are rare. At worst, maybe your scrotum will bleed a little, or swell up like an eggplant, but it’s nothing to get alarmed about. In a few days, everything will be fine," the doctors say, according to Hauber.

But that's not always true, Hauber claims.

Medical disclosure about the side effects of ibuprofen, contends Hauber, is more complete than it is for vasectomies. After an odyssey of more than a year through unrelenting pain, including six surgeries and nerve blocks, Hauber is determined to change that.

"There's an absolute mass of information that says there are going to be substantial consequences" for men who have a vasectomy, Hauber says. These include autoimmune responses, the formation of cysts in and around the testicles, problems with the epididymis (a long, thin duct in which sperm is accumulated prior to ejaculation), prostate cancer, and, for some men, unrelenting and devastating pain.

"These things are not discussed because, if you knew [about them going in], you wouldn't do it," Hauber says.

The critical juncture for Hauber, and for many of the men who have told him similar horror stories about vasectomies gone wrong, is in the doctor's office during the initial consultation. This is where there ought be a joining of minds between doctor and patient in communicating the substantial impact a vasectomy can have.

State law requires that patients be given the opportunity to give informed consent, says Hauber. This means men ought to have all the information they need to make an intelligent decision about vasectomy, its risks, and its possible impact on their health.

But physicians, he says, hesitate to discuss the potential risks because, as one doctor told him, "it would scare and traumatize patients."

"Well, let me tell you about scaring and traumatizing someone," Hauber adds, referring to his own experience.

Post-vasectomy pain syndrome, argues Dr. Malcolm Carruthers, a London physician who specializes in testosterone therapy for men, "can turn a previously fit man into a chronic invalid."

In an article for a medical website, Andrology Clinic, Carruthers adds, "Even if the operation was painless, and not accompanied by the bruising and immediate post-operative discomfort which is quite common, weeks, months or years after the operation, nagging pain begins at the site.

"Sometimes tender cysts, or lumps called granulomas, can arise around the cut ends of the vas, and even if further surgery is performed to cut them out, the pain persists," Carruthers said.

* * *

While discussing by telephone the ins and outs of having a vasectomy, Dr. Michael deWit Clayton offers to make an appointment for a consultation.

"Why don't you just come in and we can do it just like you're thinking about getting a vasectomy?" he suggests.

Clayton shares an office with four other urologists whose practice is Urology Associates of San Luis Obispo. It is on the second floor of a new medical building on Casa Street next to Sierra Vista Regional Medical Center.

The office is staffed by women–an unnerving prospect for a shy guy thinking about getting his testicles scissored. The receptionist asks, "May I help you?"

Clayton apparently has received an emergency call and had to run out. He'll be back shortly.

An assistant shows the way to a small room furnished with a table and some chairs. A window overlooks the parking lot. Medical books and pamphlets rest on shelves. The fluorescent blue screen of a video monitor glows, waiting for someone to press the "play" button.

On the table are a consent form for sterilization, instructions for the patient before and after surgery, and a 15-page booklet, "Understanding Vasectomy."

This is where the consultation takes place. It begins with the viewing of a five-minute video produced in 1997 by American Medical Communications as part of its "Patient Education Series" on urology procedures.

Today's topic, of course, is vasectomy.

The details are presented quickly and in no-nonsense fashion.

Vasectomy is a "safe and inexpensive procedure" that is performed on half a million men a year, we're told.

It "does not interfere with normal, healthy sexual activity." It's "highly effective, safe," and, the video informs repeatedly, "permanent."

A simplified cutaway of the male reproductive anatomy is offered. It shows how sperm travels from its place of incubation in the testes through the vas deferens up to the ejaculatory ducts, where it mixes with fluids from the prostate and seminal vesicle before being ejaculated as semen.

In theory, the beauty of this arrangement is that when the vas is cut and sealed off, the semen will still spring geyser-like during orgasm. The only thing missing will be sperm.

But, the video cautions, a man won't be sterile for at least a month or so after the procedure because some spermatic residue may find its way out. The patient instructions on the table warn, "Do not discontinue contraception until you receive a report that [your] semen contains no sperm."

Long-term complications, the video continues, have been noted in some medical studies. A 1993 study, unnamed in the video, claimed some links with increased risk of prostate cancer for men who had undergone vasectomies. But "subsequent studies," also unnamed, "contradict this."

As a precaution for men over 40 and for men whose vasectomies were done more than 20 years ago, the American Urological Association recommends an annual examination of the prostate and annual Prostate-Specific Antigen (PSA) blood tests to give advance warning of potential problems.

The procedure itself, which entails making an incision in the scrotum and slicing the vas deferens and tying it off, is described in detail. It all starts with a shave, shown plainly as a razor swipes pubic hair away from the male pouch.

The idea of being shaved isn't so scary. But the thought of what comes next is enough to make even the toughest nut a little squeamish. An antiseptic wash is applied before the doctor makes the incision. To numb the area, an anesthetic is injected into the scrotum

The viewer's knees close spontaneously, self-protectively. The doctor makes the incision and pulls a portion of the vas from its comfy pouch. He cuts the vas, ties it off, puts it back. Sealed and done.

"The whole procedure takes about 15 to 20 minutes," the narrator says with a certain glee. Simple. Like having a tooth pulled.

In fact, he says, you'll probably be able "to resume normal activities within two to three days." And, most important, you can probably have sexual relations in about one week.

The operative word for sufferers of post-vasectomy pain syndrome, of course, is "probably."

Some possible side effects of the operation are touched upon: a small amount of bleeding on the dressing, some swelling of the testicles, black-and-blue discoloration of the affected areas. The narrator says these "usually disappears without treatment."

Otherwise, vasectomies are a "safe, one-time way to prevent pregnancy."

Finally, other risks to be noted are blood clots that are "usually absorbed into the bloodstream," and, oddly enough, psychological problems in patients who have sought a vasectomy as part of a "sexual success" program rather than as a way to prevent pregnancy.

"Remember," the narrator concludes, "your health is your responsibility."

Dr. Clayton arrives winded from his return sprint. Catching his breath, seating his formidable, bear-like frame in a chair across the table, he might have just come off the football field. Dressed in smoke-gray medical duds, Clayton is an imposing but gentle presence.

He patiently and carefully describes vasectomy in detail.

The key to a safe and complication-free procedure, he points out, is all in the technique.

"I see a lot of complications from work done by other doctors," usually physicians who don’t specialize in vasectomies, he says. But it's been years since any of his own patients has returned with complaints of pain or discomfort.

About six years ago, he explains while sketching the male genitalia on a blank sheet of paper, he "started a new technique."

The vas, he says scribbling squiggly lines indicating vessels and nerves, has its own blood and nerve supplies. If either of these is disrupted in any way, there will be problems with bleeding and pain.

These must be stripped away from the vas before the cut is made. Severed blood vessels and nerves are not an option. Once stripped clean, the vas can be safely cut and tied off.

"Careful technique and absolute meticulous attention to detail will eliminate the risk of pain" and other complications, Clayton argues. "I haven't seen a guy back here for pain for years.

"You just don't change anything you don't need to change," he adds. "Even though it's a relatively simple procedure, if it's done sloppily you'll have a miserable patient." But that's true with any surgery, he adds. "If you whack a nerve, it's gonna hurt."

Complications may be attributed to primary caregivers who are not as cautious or as familiar with the procedure as urologists, he says.

"I've had primary care doctors call me and ask, ‘Can you show me what to do?’" Clayton says. "It's not a super-difficult thing to do. My staff has seen me do it enough times where they could do it themselves."

But what about all this talk of sperm granulomas and autoimmune responses?

The granulomas, which form as a result of leakage from the severed vas, can indeed cause tremendous pain, Clayton acknowledges. But again, he says, if the procedure is done properly, there should be no leakage and thus no granulomas.

Sperm produced by the testes, meanwhile, is absorbed back into the body. "What happens is that the body breaks it down."

There's no compelling evidence to show that the body has an autoimmune response to the sperm, he says. "It's very rare, probably more anecdotal" than actual.

* * *

Hauber is convinced that he's amassed enough data to contradict the claim that the incidence of adverse reactions to vasectomies is "one in a million."

"After months of research," says Hauber, "I found out that nothing could be further from the truth. I came across a wealth of research" that suggests that a vasectomy has adverse effects on a man's body.

He's found more than 150 medical journal articles discussing the problems associated with vasectomy. The articles detail more than 900 case histories of chronic pain and other complications.

Hauber, who himself suffers from chronic and debilitating pain, awakens often in pain in the middle of the night. At first he raged about it. Eventually, he began to practice meditation as part of a "mindfulness"-based stress reduction program taught by Mark Schecter, a Cayucos chiropractor.

It's the only thing that has worked, he says–and it’s more effective than the nearly 100 pain medications he’s tried in a desperate effort to find relief. Sometimes Hauber runs hot water in the bath and soaks and meditates. Early on he would write in his journal while everyone else in the house was sleeping. Then, when he couldn't get back to sleep after soaking in the tub, he started searching online for information about vasectomies. It became a constructive way to deal with his misery.

The data he compiled, along with the notes from his journal, evolved into a manuscript titled "If It Works, Don't Fix It!" Hauber is looking for a publisher for the book, which contains a 13-page bibliography of studies indicating the dangers of vasectomy.

H.J. Roberts, a Florida physician who has studied the effect of vasectomies for 30 years. has written his own book on the subject, "Is Vasectomy Worth the Risk? A Case Against Vasectomania."

Roberts read Hauber's manuscript and commented, "In view of the magnitude of vasectomania, it would be a disservice for physicians and public health officials to ignore his experience and that of many others on the grounds they are 'just anecdotes.'"

The medical literature points to something larger than anecdotal evidence, Roberts argues.

Some of that research was reported more than 20 years ago, in a 1979 article in the Fertility and Sterility Medical Journal by Edward I. Shapiro, M.D. and Sherman J. Silber, M.D. There will be definite consequences from the operation, they argue, focusing primarily on the impact on the epididymis, a long, oval-shaped structure made up mostly of the sperm ducts of the testicles.

"When a patient elects to have a vasectomy, he must understand that pressure build-up [near] the vasectomy site [on the testicular side], congestion of the epididymis, and, indeed, epididymal blowouts are inevitable consequences of this surgical procedure," Shapiro and Silber argued.

"In more than 800 vasovasostomy [vasectomy reversal] patients whom we have seen, there is always some degree of epididymal engorgement and congestion. Indeed, after one explores these post-vasectomy patients microsurgically, it becomes difficult to understand why the vast majority of such patients have no pain or discomfort."

Additionally, Roberts claims that vasectomy patients "are undergoing a procedure that causes more immunological problems than any other procedure I know of. Many men later realize they haven’t been told everything, that it’s far more serious than they realized.

By then, it’s too late.

***

Armed with his research on post-vasectomy pain syndrome, Hauber returned to his urologist to discuss his findings.

The doctor, who asked not to be named while commenting on Hauber's case, followed up Hauber's concerns with research of his own.

"Of course I looked into this after he brought it to my attention," he says. While he doesn't doubt the possibility of pain among men who have undergone vasectomy, he is still not convinced by hard evidence that it's as common or pervasive a problem as Hauber contends.

"How common is it? I really don't know. But my honest opinion is that it's pretty rare," he said. "It's probably an exceptionally unlikely event" given the number of vasectomies he and his associates have performed over the years, he added.

"We're just not getting the negative feedback" that would suggest significant numbers of men in the San Luis area suffer pain as a result of this procedure. I there was a problem, "I would think more people would be complaining," he said.

Additionally, San Luis Obispo County's medical community is a tight-knit group, says the doctor, and problems such as those described by Hauber would certainly have come to light if they were widespread.

"I wish I knew what caused this problem," he adds. "I don't think all of the answers are fully known yet. Pain syndromes, in general, frustrate all physicians."

The bottom line, contends Hauber's urologist, is that "vasectomy is still one of the safest, most effective forms of contraception available. But it's certainly not without risks, and that's what I tell my patients."

* * *

The first time Martin Yracheta answers the phone, he sounds doped. In fact, he is: He’s just taken a shot of morphine.

"I just had my testicle removed," the Nipomo resident explains. "My whole right side is messed up. I’m having very difficult problems. My whole right side is turning blue."

Yracheta begs off the phone, says he needs to see the doctor, and asks if he can talk about his vasectomy some other time.

One week later, Yracheta, a 38-year-old heavy equipment operator who’s been out of work since his vasectomy last March 10, sounds feisty. He’s got the fight back in him even though he’s on the mend from the Jan. 16 removal of his right testicle as a result of complications from his vasectomy.

"Basically, they took my damn nut out," he says.

Yracheta and his wife, Gloria, opted for vasectomy after deciding they were through having children. Married and together for 22 years, they have two children and a granddaughter.

Yracheta’s family doctor, a general practitioner, offered to perform the vasectomy. It seemed OK with Yracheta. Hell, the guy’s a doctor, Yracheta reasoned.

But from the day Yracheta left the doctor’s office, he’s been in pain. It never got better, only worse. He experienced swelling, nausea, and the seeping of blood and pus from his scrotum. His doctor, whose name Yracheta declines to disclose, "never did anything about it. He never told me nothing–he just told me to put hydrogen peroxide on it."

Yracheta spent 10 days in the hospital.

"The pain was so bad," he continues, "like someone poking you in the groin with an ice pick. Every time I did something my testicle would swell up to the size of a tennis ball or softball. I was pretty sick, too."

Yracheta, who leads an active life and enjoys camping and hunting and fishing with his family, considers himself a strong individual. But the pain of the last 10 months has put him out of commission. In his forced convalescence he’s put on 30 pounds."I think of myself as one of the toughest goddamn guys in Nipomo," he says. "But this can make a grown man cry. When a man gets sick down there, peeing blood, I don’t care how tough you are, it’s going to put you down."

Add to the pain the stress of paying bills with only two months of disability insurance left, not knowing whether he’ll be able to return to work, or whether he and Gloria can even afford to keep their home, and "I can see how a perfectly good man could go crazy and do something stupid because he can’t take it no more."

* * *

While more severe than most, Yracheta’s experience proves the real dangers of meddling with nature.

Kevin Hauber was also given the option of removing his testicles to relieve the pain of PVPS. The pain resulting from post-vasectomy complications can be so great, explains Hauber, that some men will "go to the extreme of having their testicles cut off." Hauber promptly dismissed the option.

"My decision was, ‘Put the scalpels away! I’m going to take charge of my own healing.’" Given all these seemingly insane or stupid options, Hauber says, "I’ve gotten really selective about what I’m willing to try."

But for some men there is no option. The pain is simply too great.

Stories such as Yracheta’s are more common than doctors are willing to admit, Hauber says. He’s heard plenty of them. After putting up a website–www.dontfixit.org–and making other connections through his research, Hauber has been contacted by men throughout the country seeking advice and moral support.

"If I could give a man some advice, I would say, 'Don't do it!’" writes one Joe Austin in an e-mail from Bakersfield.

"The chances of complications are understated, and the complications are bad. If you have complications, the chances are your doctor will not care. To look at you or think about you will cause him embarrassment."

Charlie Oliver, a physical therapist from Hampton, N.H., reports a near-wrestling match with his urologist.

"He injected me and put the syringe down and immediately picked up scissors and cut me open." The anesthetic hadn’t taken effect yet. "I yelled. He told me, 'Don't be a baby, that doesn't hurt.’ I protested.

"He then clamped a hemostat onto my vas deferens. It was brutal. I almost passed out. I wasn't breathing well. When I got my senses back I reached up and grabbed his left arm and squeezed it for all I was worth. 'Stop, that hurts! It’s killing me!’ At that point he yanked on the hemostat clamped onto my vas deferens."

Oliver has been in pain for more than 10 years, even after losing both testicles to subsequent surgeries.

The more Hauber hears stories like these, the more determined he is to put the word out.

One reason knowledge of PVPS isn’t more widespread, says Hauber, is because "this is a highly personal matter and men tend to be embarrassed about it. For many men, also, the pain comes and goes, and it's hard to get in to see a doctor about it.

"Often, pain or other side effects will take years to develop after the vasectomy is performed, so doctors don't connect the events, and diagnose post-vasectomy pain as something else, like epididymitis."

Additionally, men are told "it's all in their head and to go see a psychologist, [that] their pain isn’t real." Men raised to hide their pain suffer further indignities as a result.

Or the doctor may offer to remove the testicles. "These are not options most men are willing to pursue, so they stop seeing doctors and find a way to live with the pain," Hauber says.

Finally, some doctors aren’t eager to disclose their findings, Hauber argues.

* * *

One of the least discussed consequences of vasectomy is how it affects men’s partners. Men often opt for a vasectomy because it seems the only viable option when measured against the long-term risks a woman assumes in using the pill. Vasectomy also seems preferable to sterilization of the woman by tubal ligation.

But in challenging the apparent benefits of vasectomy, asking men and their physicians to reconsider its impact on men’s bodies, Hauber doesn’t want the issue of birth control to be thrown back into women’s laps.

The question of birth control shouldn’t become "a contraceptive hot potato to be tossed back and forth between the sexes," he says. Men and women should weigh all the options of birth control together and seek what is in their mutual best interest.

Meanwhile, the negative impact of the sterilization of men poses serious challenges to men and women and their families.

Martin Yracheta’s vasectomy has completely altered his family’s lives, says his wife, Gloria.

It’s not just a men’s issue, she says; "it’s like a whole household issue." She hates to see him suffer on her account. "I know that he’s done this for me. I feel really bad. I know that he hurts. I can see him in pain all the time."

Occasionally, she and her son have to leave the house to let Yracheta have his space. "We come back when we know the pain has gone down."

Pressure is mounting, she adds, especially now that Yracheta’s disability payments are about to run out.

"This is not going to break us–I just have to deal with this," Gloria says. Nonetheless, complications from her husband’s vasectomy are taking their toll. "I’m getting stressed out here pretty quick."

Neither knows whether Yracheta will be able to return to work, whether the removal of his testicle will eliminate the pain. "We’re just praying to God that the pain doesn’t come back," she says.

Kevin Hauber and his wife, Kristen, have discussed every detail of his ordeal.

"I now know more about the male anatomy than I ever thought I would," says Kristen. "It’s opened the doors of communication between us and brought us closer together."

Some couples haven’t been so lucky.

"We’ve known people who have split up over this thing," she says. Chronic pain can be like a third entity in a relationship: "It’s kind of like having another being or presence in the house."

"It’s definitely a family issue. It’s not just Kevin’s issue," Kristen says. For one thing, Hauber can’t simply run off and play or roughhouse with the kids.

"I have to think about how much do I have to medicate myself just to play with my kids," he says.

For another, he can’t have sex at the drop of a hat. "It just doesn’t happen that way when you have chronic testicular pain," Hauber explains. He must plan for sexual liaisons by taking Vicadin, a prescription painkiller, long enough beforehand that the physical contact of lovemaking won’t be excruciating.

Otherwise spontaneous expressions of love and desire must be tempered with a more judicious kind of intimacy.

"The issue of intimacy, for us, has to go beyond sex," Hauber says, even though he enjoys physical contact with his wife. The have-sex-at-the-drop-of-a-hat kind of intimacy isn’t an option for them anymore.

It’s quite possible, adds his wife, that this mindful approach to lovemaking has more depth to it.

"We’ve learned how to be together in a different way. Intimacy takes on another dimension," she says. One dimension, which many couples might find unpalatable, is learning how to curb one’s sexual urges.

"When you know you can’t do anything about it, your libido goes to sleep," Kristen says.

Yet the Haubers have learned there are plenty of opportunities for caressing, dancing, and simply being affectionate. Wild, uninhibited passionate forays into sexual desire are not as important as they might have been at one time. And that’s OK, they say; love has a deeper, fuller quality to it because each partner has matured in coming to terms with how to express love in a new way.

"If you’re 40 years old and still having sex the way you were when you were 20 that’s probably OK, but if that’s all you’re doing, it’s possible that you’re missing something very important in your love life," Kristen says.

* * *

It may be true that most men may have experienced little or no pain, and few problems with their health, as a result of vasectomy, Hauber concedes. But that doesn’t mean these problems don’t exist.

And he contends that while vasectomies may work to prevent pregnancy at the cost of few dire health consequences, there are enough men who have suffered to warrant closer scrutiny by the medical community.

"Physicians need to take ownership of the problem," he says. They’re not really paying attention to the potential risks. They need to be more aware of the problems associated with post-vasectomy pain syndrome–and they need to talk about these problems with men considering vasectomy as a birth-control option.

Meanwhile, Hauber doesn’t mind making a nuisance of himself, so long as physicians begin to address the issue more directly. Both Hauber and Yracheta are also considering pursuing legal action against their doctors.

"This problem has affected me, several of my friends, and numerous men I have come to know over the Internet. It is far too significant to sit around and not say anything." Æ

Stacey Warde is a free-lancer for New Times.