UNIVERSITY OF WISCONSIN MEDICAL FOUNDATION
CLINICAL POLICY AND PROCEDURE
Effective Date: January, 2005 Approval: See Authorization
Supersedes Protocol: None Contact: Clinical Staff Education
Reviewed November 2007 April 2010 March 2012
PURPOSE: To provide guidelines for preparation and follow-up of a patient undergoing a vasectomy at a UWMF Clinic.
DEFINITION: A vasectomy is a urologic procedure completed for the purpose of elective sterilization.
POLICY: The clinical staff will utilize the following guidelines to prepare for a patient undergoing a vasectomy.
SUPPLIES: Provider’s order, Patient’s record, hand controlled cautery unit with cord
Sterile vasectomy instrument pack, Sterile seven towel pack
Lidocaine 2% plain, 1 10cc syringe, Disposable razor
1 19G 1 ½” safety needle, 1 25G 5/8” safety needle
sutures per provider preference, grounding pad or patch
2 – 3 pack cottonballs, betadine soap-per provider preference
Chlorhexidine Gluconate 4% soap-per provider preference
#15 disposable scalpel, 2 pairs of sterile gloves
2 pairs of biogel gloves, 1 pair of non-sterile gloves
Antibiotic ointment or sterile Vaseline per MD preference, 1 biohazard bag, Mayo stand, 2 small formalin
containers and lab slip for vas deferens samples per provider preference
1 small brown bag—2 specimen cups and lab slips for post vas samples
2 biohazard bags, post vasectomy instruction sheet
Blank prescription paper with patient label for pain medication
Scrotal support( provider preference),
Vasectomy consent form signed at least 72 hrs prior to procedure (30 days prior for MA patients and a
MA sterilization form needs to be signed by patient and MD at least 30 days prior to procedure)
1. Room patient using standard procedure.
2. Identify the patient by date of birth and verify procedure that is to be done.
3. Verify patient has arranged for transportation post vasectomy as he may not drive home himself.
4. Verify allergies, specifically to betadine, lidocaine, chlorhexidine gluconate, latex, antibiotic ointment
5. Instruct patient to undress from the waist down and lie supine on table.
Prior to Procedure
1. Verify provider order.
2. Wash hands and gather equipment.
3. Create a sterile field on Mayo stand.
Open up pre-packaged vasectomy pack and place on Mayo stand
4. Set up according to provider preference.
5. Using sterile technique draw up 10 cc of Lidocaine 2% with 19G needle.
6. Change to the 25G safety needle.
7. Place small to medium amount of antibiotic ointment or sterile vaseline on sterile 3x3, and place on sterile field.
8. Cover items on Mayo stand with sterile towel.
1. Wash hands
2. Apply cautery pad to patient’s thigh.
3. Turn cautery machine on and set according to provider preference.
4. Put on non sterile gloves.
5. Prep scrotum and shaft of penis with Chlorhexidine Gluconate 4% soap or Betadine on cottonballs. Per provider
6. Shave scrotum with disposable razor (if necessary).
7. Prep scrotum and shaft of penis with antiseptic solution on cottonballs.
8. Remove gloves and wash hands.
9. Put on sterile gloves and drape patient according to provider preference with sterile towel pack.
10. Place hand held cautery unit on sterile field and plug cord into cautery unit.
11. Place Mayo stand by patient according to provider preference.
12. Turn on overhead surgical light.
13. Ensure patient comfort and assist provider as needed during procedure
1. Assist patient with sitting up and dressing (use scrotal support if provider orders)
NOTE: Observe for vasovagal reaction.
2. Go over post vasectomy instructions, including collection of post vas semen specimens.
(if provider has not already done so). Provide patient with two labeled specimen containers and instructions for
drop off of specimens at designated labs only.
NOTE: Patient will also be given a written copy of these instructions.
NOTE: Patient should not drive following this procedure. Assure that patient has transportation home.
3. Assist with follow-up appointment (if needed).
4. Label formalin specimen containers with at least 2 patient identifiers (full name, MRN, DOB), and place in
biohazard bags. Enter order in computer per provider preference (some MDs do not send specimens to pathology
post vas), and send specimens to lab.
5. Clean counter, Mayo stand, and table with Dispatch
6. Soak and clean instruments in Metriclean for 20 minutes.
7. Package instruments in green towel for autoclave sterilization.
8. Documentation (in Progress Notes section of HealthLink) in the patient’s record:
the procedure performed, date & time completed
name and amount of any medications given (using SmartPhrase: .medinclinic)
how patient tolerated procedure
discharge instructions, transportation method
follow-up appointment (if any)
WRITTEN BY: Deb Brausen, R.N., Manager, Department of Urology
Terry Ridderbusch, R.N., Department of Urology
Gail Jahnke, R.N., N.P., Department of Urology
REVIEWED BY: Donnette Kelly, R.N., Department of Urology, 2012
Carol Decker, RN, MSN, Clinical Staff Educator, 2012
Department of Surgery, Urology Date
Medical Director Date