Cases/Sexual Health

Father of Three Asking About A Vasectomy Who Is Worried About Pain and Sex — Free SCA Practice Case

Father of three asking about a vasectomy who is worried about pain and sex

Station Timer

12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

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Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Stephen Mallory

Age

41 years

Consultation Type

Video

Age

Situation

Video Consultation. Routine appointment booked by the patient.

Reason for Encounter

"I'd like to talk about having a vasectomy."

Medical Records

●PMH: Appendicectomy at 19. Eczema in childhood. No scrotal or groin surgery recorded.
●Medications: None on repeat.
●Allergies: NKDA.
●Social: Married to Natalie, 39. Three children aged 13, 10 and 6. Building surveyor for a housing association. Non smoker.
●Contraception: Condoms recorded at last review 3 years ago.

Recent Notes

●No consultations in the last 12 months.

Patient Script

For the friend playing the patient role

Character Overview: You are Stephen Mallory, a 41 year old building surveyor for a housing association. You are on site visits about two days a week and at a desk or working from home the rest. You live with your wife Natalie, who is 39 and works part time as a dental nurse, and your three children: Amelia, who is 13, Harvey, who is 10, and Poppy, who is 6. Poppy was not planned. She arrived while you were using condoms, and you love her to bits, but it is part of why you and Natalie now say three is exactly right. You have talked about a vasectomy on and off for over a year and have made up your mind. You are an easygoing, practical man who likes a straight answer, and you joke when you are nervous. You are quite anxious underneath. You dislike needles, you went light headed at a blood test once, and you have heard stories that put you off. You assume it is a quick snip after which you stop worrying about contraception.

Opening Sentence: "Morning, doctor. Natalie and I have decided three is plenty, so I'd like to get a vasectomy. I'll be honest, I'm a bit nervous about it."

History if Asked (Data Gathering Phase)

●Why now: "We've been talking about it for over a year. The kids are 13, 10 and 6 and we're done. Poppy's starting to get more independent and we feel like we've got our lives back a bit. I'd like to get it sorted."
●How sure you are: "Completely sure. I've had plenty of time to think. It isn't a spur of the moment thing and nothing has happened to set it off."
●Natalie's view: "She's fully on board. She said if I had any doubt I shouldn't do it, and I haven't. She'd come to an appointment if that helped. She's at work this morning."
●Pressure: "None. It's my decision as much as hers. My mum thinks I'm daft to even talk about it, but that's her."
●The relationship: "Married for 15 years. We're solid. I know people say never say never, so I've thought about it. If anything happened to Natalie or us, I honestly can't see myself starting again with babies at my age."
●What if something changed: "I did wonder, if the worst happened, whether it can be undone. A mate told me you can just get it reversed. Is that right?" He is not put off by the answer. If told it is meant to be permanent and reversal is not reliable, he says: "Fine. I'm not planning on changing my mind, I just wanted to know."
●What you know: "I know they cut something so the sperm can't get through. I think it's quick and done with a local. That's about all."
●Where you heard stories: "Aidan from my football club had his about four years ago. He had an ache for about a year and still says he gets twinges. And a bloke at work said it 'takes the edge off' things. I don't know how much of that is banter."
●Why you and not Natalie: "She had the coil fitted after Poppy and had it taken out after three months because of the bleeding and cramps. She had a terrible time having it put in. She gets migraines with flashing lights, so she can't take the combined pill either. Her having an operation under a general anaesthetic seems a lot more than mine. It's only fair that I do it."
●Current contraception: "Condoms. We've used them for years. They're fine, just a bit of a faff, and obviously they didn't stop Poppy."
●Natalie pregnant now: "No. Her period came on time last week and we've used condoms every time."

ICE (Ideas, Concerns, Expectations)

Gating note: Stephen does not volunteer these. He shares each when the doctor asks open questions about his worries, thoughts or what he is hoping for.

●Ideas: He thinks of a vasectomy as a simple snip that makes you sterile at once, like turning off a tap. He assumes the semen tubes are cut and that is that. He half believes the friend's comment that it can dull your sex drive.
●
Concerns:
- ●Pain: "Will it hurt? I hate needles. Aidan's ache for a year has really stuck with me. Will I be awake?"
- ●Sex: "Will I still get erections, and will I still, you know, finish properly? Will there be any difference in how much comes out? Will it knock my sex drive? I don't want to stop being able to perform."
- ●Cancer: If asked what else he has heard, he says he read online that it can raise the chance of prostate cancer. He has not looked at where it came from.
●Expectations: "I'd like to be referred and get it done. I assumed we could bin the condoms straight away after it. Natalie is looking forward to that." If told he must keep using them: "Oh. I didn't know that. How long for?"

Other History

Gating note: Stephen answers each of these plainly when asked.

●Health: "I'm well. I had my appendix out at 19 and had eczema as a kid. No operations on my groin or testicles, no hernia."
●Testicles and urine: "No lumps, no pain, no swelling. No history of infections, no discharge, no burning when I pass water. I was never told I had an undescended testicle."
●Bleeding and medicines: "I take no tablets, not even aspirin, and I don't bruise easily. No family history of bleeding problems."
●Allergies: "None, including latex and anaesthetics."
●Children: "Natalie's pregnancies were all straightforward. I don't have any other children."
●Sexual health: "I've only ever been with Natalie. No sexual health concerns."
●Lifestyle: "Non smoker. A few pints on a Saturday. I play football on a Sunday morning but I'm not playing much at the moment."
●Mood: "Good, generally. A bit stressed with the kids' timetables, nothing more."

Social and Practical Circumstances

●Work: Spends about two days on site, walking building sites and climbing stairs. The rest is desk based and he could work from home. He could take a few days off if needed and does not have a money worry about it.
●Home support: Natalie's mum lives five minutes away and helps with the children. Natalie would look after him.
●When he could attend: He is flexible and can arrange a procedure on a Friday if that helps.
●His fear of the day: If asked about the procedure, he says he is mainly worried about the needle and "being awake while someone is working down there". He would be relieved to hear of sedation or other options if he is very worried. He is not asking for a general anaesthetic.

Responses to Management (The Negotiation Phase)

●
If the doctor explains that the procedure is meant to be permanent, or discusses reversal:
- ●Reaction: Thoughtful. "That's what I thought. I just wanted to hear it from someone who knows." If told reversal is complicated and does not always work, he says: "Right, so I shouldn't treat it as a back door. I'm happy with that." He is not offended if the doctor checks whether he is certain, and says again that Natalie and he have discussed it for a year.
●
If the doctor explains that it is not effective at once, or gives failure rates:
- ●Reaction: Surprised. "So it doesn't work straight away? I really thought it did." If given figures such as a small chance of persistent sperm early on and a very rare later failure: "So it's about as reliable as it gets but not a hundred percent. And if it did fail, I'd know from the test?" He accepts the answer. If the doctor gives a figure without explaining that it is small, he asks: "Is that high or low?"
●
If the doctor explains that he needs another method of contraception until a semen test is clear:
- ●Reaction: A little deflated, then practical. "So the condoms stay for a bit then. How long? What does the test involve, and how many times do I need to ... you know, before it?" If told at least 12 weeks and about 20 ejaculations, then a sample: "Fine, we'll keep them going. What if the sample still shows something?" If told another sample is taken, he accepts it. If the doctor does not mention a check, he says: "So I can bin them straight away, then?"
●
If the doctor addresses erections, desire and ejaculation:
- ●Reaction: Relieved but wants it plainly. If told there is no evidence it affects erections, hormones or desire and that semen looks the same: "Honestly? That bloke at work is a wind up merchant. That's a weight off." If the doctor is vague, he asks: "So no change at all?" If told there may be some soreness at first, including with erections, he says that is fine as long as it passes.
●
If the doctor explains the procedure, pain and risks:
- ●Reaction: Nervous but attentive. "Local anaesthetic, so I won't feel it? And Aidan's ache, how common is that?" If told long lasting troublesome pain is uncommon, in only about 1 or 2 in 100 men, he says: "That's better than I feared. I'd put that against the condoms." About prostate cancer: "I read it gives you cancer." If told it is not thought to cause cancer, he is reassured. About the needle: "Could I have something to calm me down?" He is glad to hear that his anxieties can be raised with the surgical team.
●
If the doctor offers referral, written information, a next step and warning signs:
- ●Reaction: Positive. "Yes please, I'd like to be referred. Could I have something for Natalie to read as well?" He asks: "What would worry you afterwards? What's normal and what isn't?" He repeats back clearly when given specific warning signs, such as increasing pain or swelling, a high temperature or a large bruise, and what to do. If the doctor suggests he sleeps on it, he says he is happy to proceed but is glad to have the option.

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 16 indicators checked+0−0

Positive (0/8)

Negative (0/8)

Domain 2: Clinical Management and Medical Complexity

0 / 22 indicators checked+0−0

Positive (0/11)

Negative (0/11)

Domain 3: Relating to Others

0 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Clinical Learning Points

The Core Dilemma and the Model Plan

●Stephen is a 41 year old father of three who wants a vasectomy and holds three misunderstandings: that he is sterile at once, that it may blunt his sex life, and that it will hurt for a long time. The station tests whether the candidate gives balanced, accurate counselling on permanence, failure, the contraception gap and sexual function, without talking him out of a considered decision.
●The model plan has six parts. Explore why he wants it, how settled the decision is and what Natalie thinks. Draw out his worries about pain and sex. Check suitability with a short history. Counsel on permanence, failure rates, short and long term effects and the need for other contraception until a clear semen test. Confirm he can decide, and offer written information and time. Refer to the local vasectomy service, and give specific safety netting.
●Acceptable alternatives: booking a second appointment for him and Natalie before referring, or referring today and sending written information. Mentioning alternatives for Natalie briefly is good practice, but his reasons for choosing vasectomy are sound, so a long comparison is not required.

Who Is Suitable and Assessing Readiness

●NICE Clinical Knowledge Summaries (CKS, Contraception: sterilization, last revised February 2024) advise assessing the person's understanding of the procedure, their mental capacity and the risk of later regret, and giving verbal and written information on efficacy, advantages, disadvantages and risks.
●Stephen is a good candidate: an adult, three children, the youngest aged six, a stable marriage, a decision made over more than a year, and no pressure. The British Association of Urological Surgeons (BAUS) leaflet (October 2024) says vasectomy is not recommended in men without children, and is not appropriate in pregnancy or within six months after the birth of a child. That is why Natalie not being pregnant and Poppy's age matter.
●Regret is a recognised risk that the CKS assessment is designed to identify. Commonly cited risk factors, from general practice rather than the sources above, are a young age, a decision made in a crisis, a new relationship or pressure from a partner. Asking what might change, such as a death in the family or a new relationship, tests the decision without doubting him.
●A partner's views matter and the couple's shared decision is encouraged, but the decision is his, and the GP should not make the partner's attendance or agreement a condition. Offering Natalie the chance to join or to read the information is the right balance.

Permanence and Reversal

●Vasectomy should be regarded as irreversible. BAUS states that if there is any doubt about whether it is right, a man should not go ahead. Stephen asks about reversal because a friend said it is easy. The correct answer is that the NHS does not routinely offer reversal, that reported success rates (motile sperm in a later sample) vary from 40% to over 97% and fall the longer the gap since the vasectomy, so it must not be seen as a back door.
●A good candidate says this clearly and kindly, checks that he is still certain, and moves on once he is. Repeating the point many times, or treating his question as a sign of doubt, is unhelpful.

Effectiveness and Failure Rates

●Vasectomy is the most effective method of male sterilisation, and the NHS website describes a success rate of over 99%. Counselling should distinguish two kinds of failure.
●Early failure is when sperm persist in the post operative semen test, so he is not sterile. BAUS gives about 1 in 250. It is found because the test is done, and further samples or a repeat procedure follow.
●Late failure is when the cut ends rejoin after an initial clear result, giving fertility and pregnancy later. BAUS gives about 1 in 2000. It is rare and cannot be predicted by a test.
●Candidates need not quote exact numbers, but should avoid saying vasectomy is one hundred percent reliable.

Contraception Until Clearance

●A man is not sterile at once. Sperm already beyond the point where the tubes are cut must be cleared by ejaculation. BAUS says that on average 20 to 30 ejaculations are needed, and that a semen sample is requested at least 12 weeks after the operation. The NHS website advises using another method until a doctor confirms success, usually around 12 weeks.
●If the sample shows no sperm, he receives the all clear. If a few sperm remain, a further sample is taken some weeks later.
●Stephen assumes the condoms can be put away that night. This is the most important safety point in the station. A candidate who agrees to this, or who is vague, has left a risk of pregnancy for a couple who have clearly decided not to have another child.
●CKS gives 12 weeks as the optimal time for the semen test. In a small minority, non motile sperm persist, and the service may give 'special clearance' to stop contraception when fewer than 100,000 non motile sperm per mL are found in a fresh sample at least 7 months after vasectomy.
●Sample instructions come from the service. In this station it is enough to explain that the test happens and that condoms continue until he is told it is clear.

Pain, Recovery and Complications

●Most services use local anaesthetic. Anxious men can discuss options with the surgical team, which may include sedation or, in some services, general anaesthetic. Stephen is not asking for this, but should know he can raise his fear of the needle.
●The NHS website says it is common to have testicular pain and swelling for about a week, that taking ibuprofen or paracetamol should help, and that erections may be painful at first and there may be blood in the semen, which pass quickly. Supportive underwear is advised, and heavy lifting is avoided for a short time.
●CKS advises an NSAID unless contraindicated, rest until pain permits, supportive underpants, and abstaining from sex for 2 to 7 days. CKS puts chronic post vasectomy pain (more than 3 months) at 1 to 14% depending on definition, rarely severe. BAUS lists blood in the semen the first few times in between 1 in 2 and 1 in 10 men, significant bruising or swelling needing drainage in between 1 in 10 and 1 in 50, infection or inflammation of the testicle in between 1 in 10 and 1 in 50, and troublesome chronic testicular pain in 1 to 2 in 100.
●Stephen's friend Aidan reflects this last group. A candidate who acknowledges that some men do get long lasting discomfort, but that it is uncommon, gives a truthful answer.
●Warning signs for same day review include worsening pain or swelling, a high temperature, or a large and spreading bruise.

Sexual Function and Health Myths

●The NHS website says there is no evidence that vasectomy affects long term sexual performance or enjoyment. BAUS states there is no evidence that it causes long term health risks such as testicular or prostate cancer. CKS notes an association with prostate cancer in some studies that is unlikely to be causal, and no increase in impotence, testicular cancer or heart disease.
●Vasectomy does not change testosterone, desire, erections or orgasm. The fluid that makes up most of the ejaculate is produced beyond the point where the tubes are cut, so semen looks much the same. Soreness in the first week or so is expected.
●A candidate who says that nothing will change, without acknowledging early soreness, is slightly overstating. A candidate who says that some men are affected, without a basis, is spreading the myth.
●Vasectomy does not protect against sexually transmitted infections. Condoms remain relevant with any new partner.

Alternatives and Referral

●Other options are continuing condoms, long acting reversible contraception for Natalie, or female sterilisation. Natalie has migraine with aura, so she should not use combined hormonal methods, and she did not tolerate a coil. Female sterilisation is usually done under general anaesthetic and is a bigger operation. Vasectomy is a reasonable and safe choice, and he is not wrong to prefer it.
●Referral goes to the local vasectomy service according to local pathways. Written information, such as the BAUS leaflet, should be offered, and a record made of the counselling and the plan.

Common Mistakes in This Station

●Telling him the condoms can stop after the procedure, or not mentioning the semen test at all.
●Describing vasectomy as one hundred percent effective or easy to reverse.
●Reassuring him about erections without exploring what he has heard, or dismissing the stories as nonsense.
●Missing the cancer question because it is only raised when asked.
●Insisting Natalie must agree or attend, or pressing him to decide today.
●Giving long lists of numbers without checking what he understood.
●Forgetting to ask about previous scrotal surgery, infection or bleeding problems.
●Giving no specific warning signs for after the procedure.

Mapped to the RCGP curriculum topic: Sexual Health.

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