Search

Purpose: The purpose of this white paper is to educate health care professionals about the evolution of telemedicine (TM) and to propose a hybrid model that leverages the strengths of traditional in-person medicine as well as virtual medicine while maximizing the safety and quality of men's sexual health care. Literature Search Strategy: A literature search focused on the use of TM in urology and men's health was performed through PubMed/MEDLINE, Embase, and Web of Science (January 1, 2012–April 26, 2022). Keywords included all known permutations of the terminology used to refer to virtual health, care as well as the terminology used to refer to urologic diseases, issues specific to men's health, and men's sexual health concerns. Publications that emerged after the literature search that met this criterion also were incorporated. Opinion pieces, letters to the editor, meeting abstracts, and conference proceedings were excluded. Additional resources were retrieved, such as governmental technical reports, legislative updates and reviews, and blogs. This search strategy yielded 1684 records across databases after removal of duplicates. Abstracts from the retrieved records were reviewed for relevance. Relevant publications were defined as those that reported data on any aspect of TM use specific to urology, men's health, and/or men's sexual health. If relevance was unclear from the abstract, then the full text of the article was retrieved for a more detailed review. In addition, the published evidence-based practice guidelines relevant to care for erectile dysfunction, Peyronie's disease, ejaculatory dysfunction, and hypogonadism were retrieved. The most common reasons for article exclusions were a focus on TM use in disciplines other than urology and the absence of data (ie, opinion pieces). After exclusions, a total of 91 publications remained and constituted the evidence base for this paper. [ABSTRACT FROM AUTHOR]

Introduction: Unconsummated marriage (UCM) is the inability of the heterosexual married couple to have penovaginal sexual intercourse. Objective: To systematically review current evidence regarding the etiological factors and clinical management of UCM. Methods: A comprehensive bibliographic search on the MEDLINE, Scopus, Web of Science, and Cochrane Library databases was performed in June 2023. Studies were selected if they described married couples (S) who never had sexual intercourse (PI) in case report or case series (D) evaluating the related causes and/or management (E) and reporting data with qualitative, quantitative or mixed methods (R). Quantitative data were reported as found in the original studies. Evaluation of level of evidence and quality of studies were based on Oxford Centre for Evidence-Based Medicine 2011 and Murad scale, respectively. The review was reported according to PRISMA statement and registered in PROSPERO with ID CRD42023433040. Results: A total of 27 studies including 1,638 males and 1,587 females were selected (Fig 1). Eight articles (29.6%) were case-report involving a single couple and 19 studies (70.4%) were case series. Mean (range) Murad score was 4.1 (1–8) showing low-intermediate overall study quality. All articles had a level of evidence of 4. Most of the studies were reported from Egypt (5, 18.4%), Israel (4, 14.9%), and USA (4, 14.9%) (Fig 2). Mean age of males and females varied between 24.2 and 37.6 years and from 21 to 27.4 years, respectively. The reasons for the medical visit that led to the diagnosis of UCM were inability to consummate in 23 studies (85.2%), inability to conceive in 1 article (3.7%), and mixed in 3 papers (11.1%). The mean duration of UCM before a medical visit varied from 7 days to 3.5 years. Eight studies involving both men and women showed that vaginismus (8.4–81%) and ED (10.5–61%) were the most common causes of UCM. Three articles reported that 16.6–26% of all UCM cases were due to both male and female factors. Basic sex education was advised in all treatment programs. A multidisciplinary therapeutic approach involving urologist, gynecologist, psychiatrist, and physiotherapist was applied to 135 patients, achieving a consummation rate of 97%. Sildenafil 50 mg on demand for 1–3 months was used in the management of ED leading to a consummation rate of 84.6–100%. Tadalafil was prescribed both on-demand and daily, achieving consummation rates of up to 91%. Vaginismus was treated with desensitization sessions and graded vaginal dilators, leading to penetrative intercourse in 66.6–100% of cases after 1 month-5 years of therapy. Strengths & Limitations: The first systematic review covering the entire spectrum of UCM. The low quality of most of the included papers and the large percentage of UCM cases are probably not published. Conclusions: ED and vaginismus are the most reported causes of UCM; however, a strong psychological component certainly underlies a significant number of cases. A multidisciplinary approach based on strategic integration of sex education, medical therapy, psychosexual support, and surgical treatment would seem the most suitable option to manage couples with UCM. Disclosure: No. [ABSTRACT FROM AUTHOR]

Introduction: Unconsummated marriage (UCM) is the inability of the heterosexual married couple to have penovaginal sexual intercourse. Objective: To systematically review current evidence regarding the etiological factors and clinical management of UCM. Methods: A comprehensive bibliographic search on the MEDLINE, Scopus, Web of Science, and Cochrane Library databases was performed in June 2023. Studies were selected if they described married couples (S) who never had sexual intercourse (PI) in case report or case series (D) evaluating the related causes and/or management (E) and reporting data with qualitative, quantitative or mixed methods (R). Quantitative data were reported as found in the original studies. Evaluation of level of evidence and quality of studies were based on Oxford Centre for Evidence-Based Medicine 2011 and Murad scale, respectively. The review was reported according to PRISMA statement and registered in PROSPERO with ID CRD42023433040. Results: A total of 27 studies including 1,638 males and 1,587 females were selected (Fig 1). Eight articles (29.6%) were case-report involving a single couple and 19 studies (70.4%) were case series. Mean (range) Murad score was 4.1 (1–8) showing low-intermediate overall study quality. All articles had a level of evidence of 4. Most of the studies were reported from Egypt (5, 18.4%), Israel (4, 14.9%), and USA (4, 14.9%) (Fig 2). Mean age of males and females varied between 24.2 and 37.6 years and from 21 to 27.4 years, respectively. The reasons for the medical visit that led to the diagnosis of UCM were inability to consummate in 23 studies (85.2%), inability to conceive in 1 article (3.7%), and mixed in 3 papers (11.1%). The mean duration of UCM before a medical visit varied from 7 days to 3.5 years. Eight studies involving both men and women showed that vaginismus (8.4–81%) and ED (10.5–61%) were the most common causes of UCM. Three articles reported that 16.6–26% of all UCM cases were due to both male and female factors. Basic sex education was advised in all treatment programs. A multidisciplinary therapeutic approach involving urologist, gynecologist, psychiatrist, and physiotherapist was applied to 135 patients, achieving a consummation rate of 97%. Sildenafil 50 mg on demand for 1–3 months was used in the management of ED leading to a consummation rate of 84.6–100%. Tadalafil was prescribed both on-demand and daily, achieving consummation rates of up to 91%. Vaginismus was treated with desensitization sessions and graded vaginal dilators, leading to penetrative intercourse in 66.6–100% of cases after 1 month-5 years of therapy. Strengths & Limitations: The first systematic review covering the entire spectrum of UCM. The low quality of most of the included papers and the large percentage of UCM cases are probably not published. Conclusions: ED and vaginismus are the most reported causes of UCM; however, a strong psychological component certainly underlies a significant number of cases. A multidisciplinary approach based on strategic integration of sex education, medical therapy, psychosexual support, and surgical treatment would seem the most suitable option to manage couples with UCM. Disclosure: No. [ABSTRACT FROM AUTHOR]

Introduction: The clitoris is a crucial structure for sexual arousal and orgasm in people with gynecological anatomy. Despite its functional importance, the innervation of the clitoris has historically been understudied. The innervation of the clitoris includes somatic afferents of the dorsal nerve of the clitoris, a branch of the pudendal nerve and sacral plexus, and autonomic afferents of the cavernous nerve, a branch of the inferior hypogastric plexus. Although we have identified these structures, there remains a paucity of research on surgical techniques to avoid clitoral innervation during pelvic surgery, despite the importance of these nerves in gynecological sexual function. Objective: This paper aims to summarize the current literature on clitoral innervation with special attention paid to the anatomical locations of nervous structures within the pelvis to inform future pelvic surgeons and reduce sexual side effects related to clitoral nerve damage. Methods: We performed a PubMed search from inception through June 14, 2023 utilizing the Medical Subject Headings (MeSH) search terms "(clitor*)) AND (innerv* OR nerv*) AND (surg*)" and imported this search into Covidence software. Included in the literature search were observational studies, clinical trials, review articles, correspondence, and communications, and only articles in English were included. Results: An initial abstract screen of 200 articles resulted in 87 articles that were fully screened and 53 articles that were utilized as within the scope of this paper. 45 papers discussed the dorsal nerve of the clitoris, while 15 papers explored autonomic afferents via the cavernous nerve. The anatomical location of the dorsal nerve of the clitoris has been tracked in 29 papers, most of which utilize cadaver dissection, with at least six anatomic variations identified. The cavernous nerve's exact location, however, has not been traced as extensively as has the location of the dorsal nerve of the clitoris, perhaps due to its smaller diameter and shorter length. Additional innervation to the clitoris was proposed in 12 studies as well. Many studies suggested that commonly performed procedures, including midurethral sling placement for stress urinary incontinence, labiaplasty, clitoral hood reduction, clitoroplasty, and urogenital sinus repair may interfere with clitoral innervation if not otherwise modified. Two studies discussed sensory mapping techniques prior to pelvic surgery to account for anatomic variation in clitoral innervation. Conclusions: The clitoris is a vastly innervated structure with both somatic and autonomic afferents whose locations and anatomic variations should be considered when performing pelvic surgery. Failure to consider not only the dorsal nerve of the clitoris but the cavernous nerve as well may have consequences that negatively impact clitoral sensitivity, engorgement and erection, orgasmic ability, and overall sexual function. Disclosure: No. [ABSTRACT FROM AUTHOR]

Introduction: Clitoral adhesions occur when the epithelial skin surfaces of the prepuce and glans clitoris become adherent. The severity of clitoral adhesions is best documented during full prepucial retraction using vulvoscopy with photography; mild, moderate, and severe clitoral adhesions occur when there is >75%, 25-75%, and <25% visualization of the glans clitoris, respectively. Clitoral adhesions are associated with a closed compartment with inadequate clearance of keratinaceous sloughed material from the epithelial surfaces of the prepuce and glans clitoris. This trapped material may form keratin pearls resulting in local inflammation and glans hypersensitivity/pain. In one study of 614 evaluable individuals with vulvas who presented to a sexual medicine clinic for various sexual dysfunctions, 23% demonstrated clitoral adhesions based on vulvoscopy with photography (mild 44%, moderate 34%, and severe 22%) of which 14% complained of clitoral hypersensitivity/pain. We observe symptomatic and asymptomatic clitoral adhesions occurring in women presenting with entry dyspareunia, severe allodynia and hyperalgesia, who are clinical suspected and pathologically conformed to have neuroproliferative vestibulodynia (NPV). Surgical management of the NPV involves complete vestibulectomy with vaginal advancement flap. For those patients who also have clitoral adhesions, lysis of clitoral adhesions may be performed at the time of vestibulectomy. Objective: To examine the association between clitoral adhesions and NPV. Methods: A retrospective chart review of patients with NPV who underwent vestibulectomy and lysis of clitoral adhesions concomitantly between January 1, 2021 and October 31, 2023 was performed. History, physical examination, pre-op vulvoscopy with photographs, operative records and patient outcome data were collected. Results: Sixty-three patients with NPV, (mean age 29, range 19 – 64 years), underwent vestibulectomy surgery. A total of 34 (54%) of these patients underwent concomitant lysis of (mild (38%), moderate (50%), or severe (12%) clitoral adhesions. Multiple keratin pearls were removed in 91% of cases. More than half (53%) of these patients with NPV and clitoral adhesions complained of glans hypersensitivity/pain during pre-op vulvoscopy. The majority (88%) of this cohort reported "somewhat better" or "very much better" on PGI-I after lysis of adhesions. No negative side effects following the lysis of clitoral adhesions were noted. Conclusions: There is a high prevalence of symptomatic clitoral adhesions in patients with NPV (53%) compared to women who presented to a sexual medicine clinic for other sexual concerns (14%). While clitoral adhesions are not always symptomatic, we hypothesize the high prevalence in patients with NPV may be due any of the following: i) pain/stress resulting in peripheral nerves releasing neurotransmitters that stimulate proliferation/differentiation of prepucial sebaceous glands and upregulate prepucial sebaceous cell lipid synthesis, ii) infrequency of clitoral tissue engorgement from sexual activity, iii) limitation or aversion to touching or retracting clitoral prepucial tissue, iv) increased frequency of wearing menstrual pads rather than tampons, v) severe genital pain perceived as co-existing in both vestibule and clitoris and vi) the patient is already scheduled for surgery under anesthesia so the patient conveniently agrees to also undergo lysis of adhesions. Clinicians should be aware of this high association. Disclosure: No. [ABSTRACT FROM AUTHOR]

Introduction: Decreased libido is a distressful symptom during and after cancer treatment. This is the first prospective longitudinal study that investigates the use of flibanserin to treat decreased libido in breast cancer patients on endocrine therapy. Objective: This study evaluates the efficacy of flibanserin as measured by change in desire, sexual function, and distress from sexual dysfunction. These outcomes are measured using the following validated instruments: Female Sexual Function Index (FSFI) both desire and total scores, Patient-reported Outcomes Measurement Information System Sexual Function Instrument (PROMIS-SF) and patient distress via FSDS-R. Methods: Forty-three women with stage 0-III ER+ breast cancer on endocrine therapy for at least 3 months who reported HSDD as defined by the DSM-IV and ISSWH consensus paper were enrolled on an IRB-approved prospective, longitudinal trial from both an academic center and an alliance community site. All patients took flibanserin 100mg nightly for 24 to 36 weeks. Patients were monitored closely for 52 weeks for adverse events, with medical exams and questionnaires at baseline, week 4, 8, 16, 24, 52 with optional week 36 appointments. Given the small sample size, descriptive, graphical, and nonparametric paired tests for pairwise comparisons of a measure were performed. Results: Participants reported improved libido and sexual satisfaction as demonstrated by both the PROMIS-SF and FSFI data (see Table 1). 35/43 (83.3%) patients completed the FSFI and 25/43 (58.1%) completed the PROMIS-SF. The mean overall total FSFI score increased from 11 at baseline, to 17 at week 8 and 24 at week 36. The PROMIS data for interest in sexual activity improved from a baseline mean score of 43 to 51 at 8 weeks, to 54 at 24 weeks and 55 at 36 weeks. Similarly, the FSFI data in the domains of desire and arousal improved respectively from 1.90 and 1.56 at baseline to 3.03 and 3.05 at 8 weeks, 3.30 and 3.17 at week 16 and 3.53 and 4.01 at week 36. Satisfaction with sex life also improved from PROMIS baseline of 46 to 49 at week 8 and 55 at week 36. FSFI data for the domain of satisfaction indicate parallel trends with a baseline score of 2.36, increasing to 3.15 at week 8 and 4.45 at week 36. Furthermore, vaginal discomfort scores improved on both the PROMIS and FSFI. FSFI data on lubrication also showed improvement with a baseline mean score of 1.85 increasing to 2.84 by week 8, 3.24 at week 24 and 4.01 at week 36. However, the PROMIS suggests a decrease in lubrication from baseline to week 8. Patient distress also decreased throughout the study as measured on the FSDS-R and distress thermometer. There were no severe adverse events. The most common adverse events were nausea, somnolence and dizziness. Conclusions: Flibanserin improves libido and overall sexual function as measured by the PROMIS-SF and FSFI in breast cancer patients on endocrine therapy. The exciting data from this pilot study is currently informing a larger randomized placebo-controlled study evaluating the efficacy of flibanserin in women with breast cancer. Disclosure: Yes, this is sponsored by industry/sponsor: Sprout Pharmaceuticals Clarification: Industry funding only - investigator initiated and executed study Any of the authors act as a consultant, employee or shareholder of an industry for: Ms. Medicine, NanOlogy LLC, Paxman Cooling Ltd, Procter and Gamble, Rejoy, Revision Skincare, Sermonix, Shook, Hardy and Bacon, Spectrum Pharmaceuticals, Sprout Pharmaceuticals, TerSera. [ABSTRACT FROM AUTHOR]

Introduction: Krabbe Disease (KD) or globoid cell leukodystrophy is a rare autosomal recessive lysosomal storage disorder affecting approximately 1 in 100,000 people worldwide. GALC gene mutations associated with KD involve a galactosylceramidase deficiency, which damages the oligodendrocytes and Schwann cells. Therefore, nervous system demyelination is a hallmark of KD. While only a few infants survive beyond two years in early-onset Krabbe disease, patients with late-onset Krabbe Disease exhibit a milder phenotype and longer life expectancy. Late-onset KD symptoms include progressive muscle weakness and stiffness, developmental regression, behavioral changes, dementia, hearing loss, vision problems, and seizures. Only a few cases of sexual dysfunction associated with KD have been reported in literature but they highlight the wide-ranging impact of this condition on young adults and adults. Objective: This review aims to examine sexual dysfunction in KD, as reported in literature. We employ a broad definition of sexual dysfunction (erectile dysfunction, dyspareunia, orgasmic disorder, muscle weakness, etc.) and its incidence in both sexes with KD. A comprehensive review of this topic has not yet been conducted, and we offer here preliminary information for healthcare providers when addressing sexual concerns in patients with lysosomal storage disorders. Methods: A literature search was conducted by two separate investigators who independently screened studies and abstracted data. Data sources included peer reviewed publications from the following databases: PubMed, Scopus, Web of Science, EMBASE, Cochrane, Google Scholar and Clinical trials.gov. There were no restrictions on language nor date of publication. The search algorithm utilized to generate the review list was: (Globoid cell leukodystrophy OR Galactosylcerebrosidase deficiency OR Galactosylceramidase deficiency OR Krabbe disease OR Late-onset Krabbe disease OR GALC mutation). Results were further filtered by article type, restricting articles to Case Reports, Clinical Trials, Reviews, and Systematic Reviews. Results were then screened for reports containing data on sexual dysfunction in patients with KD. Results: A total of four case reports and one review paper contained reports of sexual dysfunction in KD patients. All cases involved late-onset Krabbe disease, characterized by a milder and more insidious presentation. Genitourinary symptoms reported included urinary incontinence (N=3) and erectile dysfunction (N=2), however, there were no reports (N=0) of symptoms related to female sexual dysfunction. Other symptoms commonly reported in late-onset KD that might be linked to sexual function were ataxia, spasticity and weakness of lower limbs (N=3), and sensory dysfunction due to peripheral neuropathy (N=4). Conclusions: This pioneering review reveals that patients with KD experience symptoms of sexual dysfunction. While the rarity of KD makes it challenging to study it clinically, sexual dysfunction may be consistent with the known pathophysiology of late-onset KD. This review also highlights that sexual dysfunction in female patients with KD is an under-investigated component of the disease presentation. Future clinical research into this important comorbidity, especially in female patients where the literature is lacking, may improve the care of patients with KD. Disclosure: No. [ABSTRACT FROM AUTHOR]

Introduction: Patient recollection of details discussed during medical consultation is often limited (Figure 1a). For genital gender-affirming surgery (gGAS) consultations, lengthy discussions and deep contemplation surrounding surgical options are critical. Inadequate communication can result in patient complaints and medico-legal action, whereupon issues such as a lack of discussion or poor documentation can lead to medico-legal liability against the care provider and hospital system. As a result, strategies must be developed to ensure that information discussed during complex medical consultations are made available so patients can properly weigh out the care options presented. Objective: 1) Assess medico-legal incidents in Urologic and surgical specialties in the UK, US, and a Californian quaternary care center, 2) evaluate the advantages and feasibility of offering audio-recordings of patient consultations, and 3) create a user-friendly smartphone app for recording healthcare consultations. Methods: A literature review evaluated current evidence on medical liability claims in the UK and US was conducted. Additionally, our center's Department of Risk Management provided information pertaining to medico-legal cases against our institution. Separately, gGAS patients consented to audio-record their consultation. Copies were provided to patients and kept in their medical records. A follow-up survey assessed its usefulness, and based upon patient feedback, a smartphone application was developed. Results: A PubMed search yielded 921 results on "medical malpractice claims" from 2013–2023. In Urologic Surgery, 32 papers addressed medical malpractice, with 2 providing data over the last 15 years. In the UK, 660 claims were made from 2010–2020, of which 8.2% were due to poor communication (37 = informed consent; 17 = lack of follow-up). In the US, from 2020–2022, 38.3% of Urologists faced at least one legal proceeding in their career, and 5.3% were sued within 1 year for any reason. Our institution's Department of Risk Management reported 32% of lawsuits were related to surgical care. Informed consent involved 8% of cases and had a component in 32%. The average financial settlement for medical malpractice was $125,000.00 USD, and trial costs averaged $75,000.00 USD. 50/71 patients completed an anonymized, online survey post-audio recording. Positive results were noted regarding recording quality, comfort whilst being recorded, and wishes for future consultation recordings (Figure 1b). In addition, most patients felt less anxiety, and had greater confidence in their treatment choice (Figure 1c) Based upon patient responses, we developed a smartphone App which records 90 minutes of audio, allows for file and hyperlink attachments to be sent to patients before immediately deleting all information (Figure 1d). Routine use of audio-recordings led to a reduction in patient queries to our office. Conclusions: Routine audio recording of patient consultations provides significant benefits with minimal cost to providers. As per our institution's Office of Risk Management, it offers protection against medico-legal risks. Adequate discussion, good documentation and providing adjuncts for patients can help prevent a large proportion of medicolegal complaints in addition to optimizing patient care. Considering that patients face similar challenges across different disciplines and regions, a larger study (multi-center, international, multi-language) is warranted. Disclosure: No. [ABSTRACT FROM AUTHOR]

Introduction: Krabbe Disease (KD) or globoid cell leukodystrophy is a rare autosomal recessive lysosomal storage disorder affecting approximately 1 in 100,000 people worldwide. GALC gene mutations associated with KD involve a galactosylceramidase deficiency, which damages the oligodendrocytes and Schwann cells. Therefore, nervous system demyelination is a hallmark of KD. While only a few infants survive beyond two years in early-onset Krabbe disease, patients with late-onset Krabbe Disease exhibit a milder phenotype and longer life expectancy. Late-onset KD symptoms include progressive muscle weakness and stiffness, developmental regression, behavioral changes, dementia, hearing loss, vision problems, and seizures. Only a few cases of sexual dysfunction associated with KD have been reported in literature but they highlight the wide-ranging impact of this condition on young adults and adults. Objective: This review aims to examine sexual dysfunction in KD, as reported in literature. We employ a broad definition of sexual dysfunction (erectile dysfunction, dyspareunia, orgasmic disorder, muscle weakness, etc.) and its incidence in both sexes with KD. A comprehensive review of this topic has not yet been conducted, and we offer here preliminary information for healthcare providers when addressing sexual concerns in patients with lysosomal storage disorders. Methods: A literature search was conducted by two separate investigators who independently screened studies and abstracted data. Data sources included peer reviewed publications from the following databases: PubMed, Scopus, Web of Science, EMBASE, Cochrane, Google Scholar and Clinical trials.gov. There were no restrictions on language nor date of publication. The search algorithm utilized to generate the review list was: (Globoid cell leukodystrophy OR Galactosylcerebrosidase deficiency OR Galactosylceramidase deficiency OR Krabbe disease OR Late-onset Krabbe disease OR GALC mutation). Results were further filtered by article type, restricting articles to Case Reports, Clinical Trials, Reviews, and Systematic Reviews. Results were then screened for reports containing data on sexual dysfunction in patients with KD. Results: A total of four case reports and one review paper contained reports of sexual dysfunction in KD patients. All cases involved late-onset Krabbe disease, characterized by a milder and more insidious presentation. Genitourinary symptoms reported included urinary incontinence (N=3) and erectile dysfunction (N=2), however, there were no reports (N=0) of symptoms related to female sexual dysfunction. Other symptoms commonly reported in late-onset KD that might be linked to sexual function were ataxia, spasticity and weakness of lower limbs (N=3), and sensory dysfunction due to peripheral neuropathy (N=4). Conclusions: This pioneering review reveals that patients with KD experience symptoms of sexual dysfunction. While the rarity of KD makes it challenging to study it clinically, sexual dysfunction may be consistent with the known pathophysiology of late-onset KD. This review also highlights that sexual dysfunction in female patients with KD is an under-investigated component of the disease presentation. Future clinical research into this important comorbidity, especially in female patients where the literature is lacking, may improve the care of patients with KD. Disclosure: No. [ABSTRACT FROM AUTHOR]

Introduction: Patient recollection of details discussed during medical consultation is often limited (Figure 1a). For genital gender-affirming surgery (gGAS) consultations, lengthy discussions and deep contemplation surrounding surgical options are critical. Inadequate communication can result in patient complaints and medico-legal action, whereupon issues such as a lack of discussion or poor documentation can lead to medico-legal liability against the care provider and hospital system. As a result, strategies must be developed to ensure that information discussed during complex medical consultations are made available so patients can properly weigh out the care options presented. Objective: 1) Assess medico-legal incidents in Urologic and surgical specialties in the UK, US, and a Californian quaternary care center, 2) evaluate the advantages and feasibility of offering audio-recordings of patient consultations, and 3) create a user-friendly smartphone app for recording healthcare consultations. Methods: A literature review evaluated current evidence on medical liability claims in the UK and US was conducted. Additionally, our center's Department of Risk Management provided information pertaining to medico-legal cases against our institution. Separately, gGAS patients consented to audio-record their consultation. Copies were provided to patients and kept in their medical records. A follow-up survey assessed its usefulness, and based upon patient feedback, a smartphone application was developed. Results: A PubMed search yielded 921 results on "medical malpractice claims" from 2013–2023. In Urologic Surgery, 32 papers addressed medical malpractice, with 2 providing data over the last 15 years. In the UK, 660 claims were made from 2010–2020, of which 8.2% were due to poor communication (37 = informed consent; 17 = lack of follow-up). In the US, from 2020–2022, 38.3% of Urologists faced at least one legal proceeding in their career, and 5.3% were sued within 1 year for any reason. Our institution's Department of Risk Management reported 32% of lawsuits were related to surgical care. Informed consent involved 8% of cases and had a component in 32%. The average financial settlement for medical malpractice was $125,000.00 USD, and trial costs averaged $75,000.00 USD. 50/71 patients completed an anonymized, online survey post-audio recording. Positive results were noted regarding recording quality, comfort whilst being recorded, and wishes for future consultation recordings (Figure 1b). In addition, most patients felt less anxiety, and had greater confidence in their treatment choice (Figure 1c) Based upon patient responses, we developed a smartphone App which records 90 minutes of audio, allows for file and hyperlink attachments to be sent to patients before immediately deleting all information (Figure 1d). Routine use of audio-recordings led to a reduction in patient queries to our office. Conclusions: Routine audio recording of patient consultations provides significant benefits with minimal cost to providers. As per our institution's Office of Risk Management, it offers protection against medico-legal risks. Adequate discussion, good documentation and providing adjuncts for patients can help prevent a large proportion of medicolegal complaints in addition to optimizing patient care. Considering that patients face similar challenges across different disciplines and regions, a larger study (multi-center, international, multi-language) is warranted. Disclosure: No. [ABSTRACT FROM AUTHOR]

Introduction: The American College of Obstetricians and Gynecologists (ACOG) reports 43% of American women experience sexual health problems, including Female Sexual Interest and Arousal Disorder, Female Orgasmic Disorder, Genito–Pelvic Pain and Penetration Disorder, and Substance or Medication-Induced Sexual Dysfunction. Objective: At Women's Ambulatory Health Services (WAHS), an inner-city clinic associated with Hartford HealthCare, at which UConn Health ObGyn residents work, there is no routine screening in place for sexual dysfunction. This project aimed to implement the Female Sexual Function Index (FSFI) for screening for sexual dysfunction at this clinic to identify patients who may benefit from treatment. Methods: We implemented the FSFI-short version, a six-question screening tool for sexual dysfunction that has been validated in English and Spanish and utilized in many countries on July 1st, 2022. Patients presenting for a new gynecologic visit or an annual gynecologic exam were asked to complete the screening tool. Patients who scored equal to or less than 18 on the FSFI-short version were identified as at risk for female sexual dysfunction and were offered referral to a health psychologist specializing in sexual dysfunction. We utilized the RE-AIM framework for implementation science to guide the implementation evaluation. We collected data on patients from July 1 through December 1, 2022. We collected patient demographics and implementation outcomes, including rate of survey completion, candidacy for referral and referral completion. Results: 196 surveys were reviewed between July 1st and December 1st of 2022. 44 surveys were excluded for various reasons, including not meeting study inclusion criteria or invalid responses. 152 screening forms were included and 45 patients screened positive. Subjective patient barriers were gathered from comments written directly onto the paper survey as well as quotes documented by their providers in the visit note. These subjective barriers included hesitancy to discuss sexual health and lacking knowledge that the gynecologist provider offers assessment and management for these disorders. Conclusions: The introduction of the FSFI-sv at WAHS has both expanded the resources offered to patients, enhanced the environment surrounding topics of women's health both between staff members as well as within the patient-provider relationship, and has unearthed multiple opportunities for improving the screening process, referral selection and work flow for sexual dysfunction amongst the patient population. Disclosure: No. [ABSTRACT FROM AUTHOR]

Introduction: Erectile Dysfunction (ED) is a common male sexual disorder that is caused by various conditions including vascular dysfunction. Different treatment options can be implemented, like lifestyle modifications, pharmacological intervention, or surgical procedures. In select ED cases, vascular procedures such as penile revascularization and venous ligation could be an alternative option. Objective: We herein evaluated the current evidence and outcomes of penile revascularization, venous ligation and other vascular surgery with specific emphasis on complications and patients' satisfaction. Methods: A literature search was conducted using PubMed and Google Scholar to examine papers from 1993 to present day. Keywords, such as, "Erectile dysfunction", "ED vascular surgery", "Penile venous ligation", "Penile revascularization", and "Arterial bypass surgery", were used in this search. All the papers were in the English language. Results: A total of four studies met inclusion criteria for penile arterial bypass and dorsal penile venous ligation procedures with erectile function, clinical outcomes, satisfaction rates and post operative complications. Regarding penile arterial bypass, two studies identified. First study reported inferior epigastric artery (IEA) to the penile dorsal artery of 1500 patients reported success rates of erectile function were 67% and satisfaction rates of 89%. Postoperative complications were anastomotic disruption, penile skin sensation loss and pain. Regarding venous ligation of penile dorsal vein, two studies identified. First study of 100 patients reported success rates of erectile function were 62% at 1 year. Second study of 26 patients reported success rates of erectile function were 42.3% and satisfaction rates of 57.7% at 3.7 years. Postoperative complications were painful erections, skin necrosis, and penile shortening (Table 1). Conclusions: Vascular therapies including penile arterial bypass and penile dorsal venous ligation for ED could provide improved clinical outcomes and satisfactions in select patients' population. Future studies are warranted to further evaluate its surgical outcomes and long-term safety and efficiency. Disclosure: No. [ABSTRACT FROM AUTHOR]

Introduction: The clitoris is a crucial structure for sexual arousal and orgasm in people with gynecological anatomy. Despite its functional importance, the innervation of the clitoris has historically been understudied. The innervation of the clitoris includes somatic afferents of the dorsal nerve of the clitoris, a branch of the pudendal nerve and sacral plexus, and autonomic afferents of the cavernous nerve, a branch of the inferior hypogastric plexus. Although we have identified these structures, there remains a paucity of research on surgical techniques to avoid clitoral innervation during pelvic surgery, despite the importance of these nerves in gynecological sexual function. Objective: This paper aims to summarize the current literature on clitoral innervation with special attention paid to the anatomical locations of nervous structures within the pelvis to inform future pelvic surgeons and reduce sexual side effects related to clitoral nerve damage. Methods: We performed a PubMed search from inception through June 14, 2023 utilizing the Medical Subject Headings (MeSH) search terms "(clitor*)) AND (innerv* OR nerv*) AND (surg*)" and imported this search into Covidence software. Included in the literature search were observational studies, clinical trials, review articles, correspondence, and communications, and only articles in English were included. Results: An initial abstract screen of 200 articles resulted in 87 articles that were fully screened and 53 articles that were utilized as within the scope of this paper. 45 papers discussed the dorsal nerve of the clitoris, while 15 papers explored autonomic afferents via the cavernous nerve. Fourteen papers discussed both somatic and autonomic innervation to the clitoris. The anatomical location of the dorsal nerve of the clitoris has been tracked in 29 papers, most of which utilize cadaver dissection, with at least six anatomic variations identified. The cavernous nerve's exact location, however, has not been traced as extensively as has the location of the dorsal nerve of the clitoris, perhaps due to its smaller diameter and shorter length. Additional innervation to the clitoris was proposed in 12 studies as well. Many studies suggested that commonly performed procedures, including midurethral sling placement for stress urinary incontinence, labiaplasty, clitoral hood reduction, clitoroplasty, and urogenital sinus repair may interfere with clitoral innervation if not otherwise modified. Two studies discussed sensory mapping techniques prior to pelvic surgery to account for anatomic variation in clitoral innervation. Conclusions: The clitoris is a vastly innervated structure with both somatic and autonomic afferents whose locations and anatomic variations should be considered when performing pelvic surgery. Failure to consider not only the dorsal nerve of the clitoris but the cavernous nerve as well may have consequences that negatively impact clitoral sensitivity, engorgement and erection, orgasmic ability, and overall sexual function. Disclosure: No. [ABSTRACT FROM AUTHOR]

Introduction: Hypersexuality or Compulsive Sexual Behavior Disorder (CSBD) is characterized by a spectrum of sexual behaviors and fantasies marked by compulsion, obsession, and impulsivity. The pathophysiology of CSBD remains poorly understood despite the arousing of articles exploring the potential biomarkers associated with hypersexuality. Objective: We aimed to review the literature regarding the investigation on CSBD pathophysiology from a neuroimaging, neuroendocrine and molecular perspective. Methods: We raised papers related on neuroimaging, neuroendocrine and molecular biomarkers investigated in individuals that reached diagnosis of CSBD or similar, written in English language in the last 10 years, through PubMed, Scopus, and Web of Science with biomarkers and compulsive sexual behavior/hypersexuality key terms. Results: Neuroimaging studies revealed the activation of the anterior cingulate cortex, ventral striatum, and amygdala, in individuals with CSBD. Neuroendocrine markers revealed abnormalities in the hypothalamic-pituitary-adrenal (HPA) axis, including elevated adrenocorticotropic hormone (ACTH) levels and non-suppression of dexamethasone. Findings concerning the hypothalamic-pituitary-gonadal (HPG) axis, responsible for sexual function regulation, varied among CSBD individuals, including testosterone and luteinizing hormone (LH) levels. Oxytocin levels have been noted to rise in CSBD individuals and subsequently decrease following psychotherapy. Genetic and epigenetic markers associated with CSBD suggest involvement of addiction-related genes and epigenetic modifications near the corticotropin-releasing hormone (CRH) gene. Conclusion: Most of the findings point to HPA axis alterations. Molecular analysis is in the beginning, as well as more research on the HPG axis is needed. The exploration of CSBD biomarkers potentially will provide insights into its pathophysiology, diagnosis, and treatment. Financing: FAPESP. [ABSTRACT FROM AUTHOR]

Introduction: Sexual dysfunctions remain inadequately addressed in medical education, despite their prevalence and adverse impact on quality of life. In Brazil, there are scarce university-affiliated healthcare centers that focus on sexual health. These services play a critical role in diagnosing and managing sexual disorders and can be pivotal in the training of healthcare professionals, as well as in the advancement of research and outreach in sexual medicine. Objective: To describe the experience of establishing two sexual health centers in university-affiliated hospitals in Northeastern Brazil. Method: This is an experiential report detailing the establishment of two distinct sexual health services. Results: Both sexual health services started in different general hospitals in 2021, founded by a male and a female psychiatrists, authors of this paper. The initiative was prompted by the lack of dedicated sexual health services and the awareness of substantial patient distress stemming from sexual issues. Activities include patient consultations, case discussions, sexology seminars, and research project development, involving medical students and resident physicians, integrated into the psychiatry residency curriculum Referrals come mainly from other hospital specialties, but external referrals are also accepted. Collaboration with other healthcare professionals occurs through the analysis of clinical cases. Conclusion: The establishment of sexual health services within university-affiliated hospitals has a positive impact on patient care and contributes to the study of sexual medicine, an area often overlooked in medical education. Improvements are needed in patient recruitment, counter-referral procedures, and the systematic incorporation of medical student rotations. While these services hold promise, they require greater integration with other healthcare services and a closer collaboration with undergraduate medical education. Financing: No conflict. [ABSTRACT FROM AUTHOR]

Introduction and Objetives: Hydroceles are abnormal collection of fluid between the parietal and visceral layers of the tunica vaginalis. Traditionally, surgical excision and or repair under general anaesthesia has been the standard of care, but sclerosant therapy can be used safely and with efficacy for hydrocele's treatment. This study aims to review and elucidate the current literature sclerotherapy for hydrocele. Methods: We searched for articles in Pubmed, Embase and Cochrane evaluating aspiration and sclerotherapy for hydrocele treatment. Search terms were "hydrocele" and "sclerotherapy". Relevant papers references were full reviewed searching for new articles. The sclerosing agents considered eligle were phenol, tetracycline, sodium tetradecyl sulfate, phenol and alcohol. Results: We included 1554 patients from 26 studies. Mean aspirative hydrocele volume was 238,3 mL. Cure rate was seen in 58,3% to 76% after a single procedure in STDS studies and 70% to 94,11% overall success. Phenol's studies demonstrated a 47.5% to 70% cure rate with one sclerotherapy and 96.5% to 100% overall success. In Sclerotheraphy with tetracycline cure rate after a single procedure was 57% to 100% and overall success was 77% to 100%. Of the polidocanol group, cure rate was 42.3% to 62.1% after one sclerotherapy and overall success was 51.7% to 94%. Finally, in alcohol's group we found 50% to 76.12% after one procedure and 80% to 97.62%. Conclusion: A better cure rate after one procedure was observed with tetracycline and overall success after multiples procedures was seen with phenol. Due to heterogeneity and biases of the studies, more controlled clinical trials must be done to elucidate the best sclerosant agents. Financing: No conflict. [ABSTRACT FROM AUTHOR]

Introduction: The penis is a vital organ of perception that transmits perceived signals to ejaculation-related centers. The penis consists of the glans penis and penile shaft, which differ considerably in both histology and innervation. Objective: This paper aims to investigate whether the glans penis or the penile shaft is the main source of sensory signals from the penis and whether penile hypersensitivity affects the whole organ or only part of it. Methods: The thresholds, latencies, and amplitudes of somatosensory evoked potentials (SSEPs) were recorded in 290 individuals with primary premature ejaculation using the glans penis and penile shaft as the sensory areas. Results: The thresholds, latencies, and amplitudes of SSEPs from the glans penis and penile shaft in patients were significantly different (all P < 0.0001). The latency of the glans penis or penile shaft was shorter than average (indicating hypersensitivity) in 141 (48.6%) cases, of which 50 (35.5%) cases were sensitive in both the glans penis and penile shaft, 14 (9.9%) cases were sensitive in the glans penis only, and 77 (54.6%) cases were sensitive in the penile shaft only (P < 0.0001). Conclusions: There are statistical differences in the signals perceived through the glans penis and the penile shaft. Penile hypersensitivity does not necessarily mean that the whole penis is hypersensitive. We classify penile hypersensitivity into three categories, namely, glans penis, penile shaft, and whole-penis hypersensitivity, and we propose the new concept of penile hypersensitive zone. Disclosure: No. [ABSTRACT FROM AUTHOR]

Introduction: The penis is a vital organ of perception that transmits perceived signals to ejaculation-related centers. The penis consists of the glans penis and penile shaft, which differ considerably in both histology and innervation. Objective: This paper aims to investigate whether the glans penis or the penile shaft is the main source of sensory signals from the penis and whether penile hypersensitivity affects the whole organ or only part of it. Methods: The thresholds, latencies, and amplitudes of somatosensory evoked potentials (SSEPs) were recorded in 290 individuals with primary premature ejaculation using the glans penis and penile shaft as the sensory areas. Results: The thresholds, latencies, and amplitudes of SSEPs from the glans penis and penile shaft in patients were significantly different (all P < 0.0001). The latency of the glans penis or penile shaft was shorter than average (indicating hypersensitivity) in 141 (48.6%) cases, of which 50 (35.5%) cases were sensitive in both the glans penis and penile shaft, 14 (9.9%) cases were sensitive in the glans penis only, and 77 (54.6%) cases were sensitive in the penile shaft only (P < 0.0001). Conclusions: There are statistical differences in the signals perceived through the glans penis and the penile shaft. Penile hypersensitivity does not necessarily mean that the whole penis is hypersensitive. We classify penile hypersensitivity into three categories, namely, glans penis, penile shaft, and whole-penis hypersensitivity, and we propose the new concept of penile hypersensitive zone. Disclosure: No. [ABSTRACT FROM AUTHOR]

Introduction: Novel technologies utilizing artificial intelligence (AI) have shown their potential to reduce provider workload and improve task efficiency in certain clinical settings. ChatGPT is an AI-powered chatbot which utilizes natural language processing (NLP) technology to provide human-like responses to open-ended questions posed by users. Recent studies have shown ChatGPT's ability to provide diabetes counseling in lieu of trained educators, and effectively communicate technical research papers in layman's terms to patients. Vasectomy is a common urologic clinic procedure that can be a source of anxiety for patients, many of whom desire the opportunity for further pre-operative counseling. Objective: The objective of this preliminary study was to evaluate the ability of ChatGPT to respond to common patient questions on vasectomy encountered by sexual medicine specialists. Methods: We composed a list of 20 questions commonly asked by patients pertaining to vasectomy. The questions were submitted to ChatGPT Plus with the prompt: "Answer the following questions in 50 words or less". 3 fellowship-trained sexual medicine specialists then rated the accuracy of ChatGPT's responses on a scale from 1-5 (1 representing a completely inaccurate response and 5 representing a response in line with what they would recommend to patients). Scores were tabulated and summarized (Table 1). Descriptive statistics were performed. Weighted Cohen's kappa was calculated to assess for interrater reliability. Results: Median score across all 20 responses from 3 raters was 4.1 (IQR 1.3). The most common rating was 5, indicating a high level of agreement between ChatGPT's responses and those of sexual medicine specialists. The lowest score assigned was 2 (indicating poor accuracy), and was received by 6 responses. Weighted Cohen's kappa was 0.49, implying moderate agreement amongst raters. Overall, ChatGPT was able to provide relatively accurate and concise responses to these common questions. Conclusions: Our results demonstrate the capability of using ChatGPT as a potentially reliable source of information for patients desiring vasectomy counseling. Given the high clinical volume faced by many vasectomy providers, ChatGPT could possibly improve patient satisfaction and reduce provider burden. Further collection of real-world data is needed to better assess the accuracy and reliability of ChatGPT's responses. Sexual medicine specialists should be aware of the strengths and limitations of emerging AI technologies as a medium for providing accurate health information to patients. Disclosure: Any of the authors act as a consultant, employee or shareholder of an industry for: Fellow, Posterity Health, Coloplast, Hims, Genentech. [ABSTRACT FROM AUTHOR]

Introduction: Previous studies have evaluated surgical outcomes and aesthetic results of Genital Gender Affirming Surgery (GGAS) while few studies have examined sexual outcomes after GGAS. Objective: We sought to systematically review the literature on sexual health outcomes of metoidioplasty in the transmasculine population. Methods: PubMed, Embase, and Web of Science was used to identify studies through April 29, 2022 based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Figure 1 shows search terms, inclusion, and exclusion criteria. Results: Fourteen papers were included. Findings on arousal/desire ranged from 86% (n=48) reporting desire for sex to 100% (n=1455) reporting no difficulty in arousal. Preserved erogenous sensation and no issues with masturbation was reported in 100% of people across studies (n=1164;1455). Orgasm ability ranged from 66-70% (n=115) who were able to orgasm during sexual activity or masturbation to 100% (n=1455) who had no problems with orgasm. Orgasm satisfaction was found to be 100% (n=48). A study found that 80% (n=15) had challenges with erections, with 83% (n=18) of Erection Hardness Scores were 'larger but not hard' or 'hard but not hard enough for penetration.' Earlier studies reported 100% of people had an erection (n=1599), and ratings of 'satisfied' or 'partially satisfied' in 94% (n=145). Across studies, 87-100% were unable to have penetrative sex (87% unable, n=15; 100% unable, n=737). For some, the inability to penetrate was the most dissatisfactory aspect of the metoidioplasty for 39% of patients (n=28). Conclusions: Current literature on transmasculine people undergoing GGAS shows high ratings of arousal/desire, preservation of erogenous sensation, masturbation, and ability to orgasm following metoidioplasty. Data on the ability and adequacy of erection is less definitive. Overall ratings of sexual health appear high, but inability to have penetrative sex remains a source of persistent dissatisfaction for some. Further studies using surveys validated in transmasculine populations are needed to definitively describe sexual function after GGAS. Disclosure: No. [ABSTRACT FROM AUTHOR]

Introduction: Surgical castration has been present throughout human history, dating back at least earlier than 1000 BC. Eunuchs, or men who have been castrated, served as royal guards, government officials and choir singers among other professions. Objective: We sought to review the early surgical castration techniques of historical Eurasia. Methods: Literature review for male surgical castration techniques was performed using Pubmed and Google Scholar. Results: The Ottoman Empire first started enlisted eunuchs as palace servants in Constantinople as early as 500 AD. By the 16th century, the Ottomans had institutionalized eunuchs as the harem guards. Castration was routinely performed by priests. After restraining the child in a chair, a cord was tied around both the penis and scrotum, and the genitals were excised en bloc with a razor. Hemostasis was achieved with boiling oil and wax or hot sand followed by acacia bark extract. Mortality was as high as one in three patients. Following castration, a nail was placed in the urethra to prevent urethral stricture formation. Within China castration has occurred throughout history, however the procedure was described in greatest detail during the 19th century Qing dynasty. The patient was physically restrained, and the genitalia anesthetized with a "secret agent," known only to the surgeon, colloquially called "knifers." The surgeon would firmly grasp both the penis and scrotum with one hand, hovering a curved knife in opposite hand. The surgeon would then ask for consent to proceed. The genitalia were removed with one cut. The wound was washed thrice with boiled pepper solution and covered with moistened paper. A pewter urethral plug was placed to prevent stricture formation. The patient was disallowed hydration and his urethra remained obstructed for three days post-operatively. On the fourth day the plug was removed, and the patient was allowed to void. Mortality was dubiously estimated at 2%. The Skoptsky were a Christian religious sect of Eunuchs within 18th century Russia. As the practice was rooted in religion the majority of Skoptsky men volunteered for castration. Men were encouraged to accept the "greater seal," i.e. removal of penis, scrotum and testicles, rather than the "lesser seal," i.e. sparing the penis. The genitalia were variously removed with a combination of hot iron rods, glass, razors, and knives. Again, a nail was placed in the urethra to prevent stricture. In 16th to 18th century Italy the famed Castrati Singers underwent prepubertal castration to preventing lengthening of the thyroid cartilage. The singers were highly desired in choirs and operas for their high pitch. Castration typically occurred between ages 6 and 9. Patients were placed in a hot bath and provided a "potent drink," often containing opium. The carotid arteries were compressed until the patient became lethargic, and the spermatic cords were then severed. Conclusions: Surgical castration was performed for a variety of reasons throughout human history. The techniques, anesthesia, and tools used to perform castration reflected resources and education available to the surgeon at time of castration. Disclosure: No. [ABSTRACT FROM AUTHOR]

Introduction: Epididymal cysts (EC) are an incidental finding on scrotal ultrasounds (SUS), with an anecdotal prevalence from 5-20% with peaks at age 2 and in puberty. A recent survey at a children's hospital in Michigan found that up to 35% of boys 15 or older had ECs. While adult men often demonstrate EC, comparatively few papers characterize the prevalence of ECs in adults. It is presumed that ECs most commonly develop during their 20s-40s but no clear prevalence by age has been established in the general adult population. Objective: This present research will investigate within the same geographic region the prevalence of ECs in adult men. Methods: A retrospective review was conducted for men 18-years-of-age and older who underwent a Michigan hospital-based SUS between 2010 – 2015. Patients without EC and EC patients were compared using two-sample t test, associations between age and presence of ECs were evaluated by chi-square test, and associations between age and TTV were evaluated by one-way ANOVA and Pearson's correlation coefficient. Results: 357 out of 801 men (44.6%) were found to have sonographic evidence of ECs. When separated into age groups, the prevalence of ECs significantly increased (p=0.041) with increasing age. In men with only ECs, their TTV did not significantly decrease with age (r = 0.06, p=0.684), unlike men without EC (r = 0.18, p=0.028). Conclusions: This geographic cohort of men have the highest prevalence of ECs reported in the global literature. Two novel observations are that ECs frequency increases with age and TTV is preserved with age in men with ECs. TTV correlates significantly with FSH, LH, testosterone, and sperm health – further investigation should examine how preserved TTV may correlate with these values. Future studies should also examine the link between endocrine disrupting compound exposure and development of ECs. Disclosure: No. [ABSTRACT FROM AUTHOR]

Introduction: Recent attention has been brought to physician fertility in the last decade, most notably amongst female physicians who suffer an increased risk of infertility compared to the general population. Various factors related to a career in medicine play a role, such as a delay in pursuit of childbearing, a demanding work schedule, shift work, and stress associated with the profession. However, risk of infertility in the male physician population has yet to be studied. Objective: Therefore, we sought to evaluate the experiences and childbearing patterns of a sample of American male physicians with special attention to timing of conception and childbearing, reflections upon professional and personal decision-making, and general knowledge regarding fertility. The primary objective of this study was to determine the incidence of infertility among American male physicians. Methods: Utilizing a third party to access the American Medical Association (AMA) database, licensed US physicians registered as male and between the ages of 18-65 were identified. Within this cohort, 690 men were randomly selected and contacted via paper mail (340) or email (350) and asked to participate in the survey study. Surveys were administered electronically via REDCap (obtained through a QR code) and included questions regarding the physicians' demographics, medical specialty, and whether they have attempted to conceive. Those who have attempted to conceive were also surveyed on their work experience at the time of their first attempt at conception and their experience and partner's experience with fertility and childbearing. Internal Review Board approval was obtained for this study (STUDY 20211036). Results: Fifty-three men responded to the survey (7.7%). All respondents were cisgender males with cisgender female partners. The majority (94.3%) had attempted to conceive and occurred most during residency (46.0%). The average age when first attempting conception was 31.6 years, and this was most commonly during residency (46.0%) or after training (30.0%). During this time, many (72.0%) were responsible for night shifts, overnight call duties, or both. In addition, as many as 34 men (68.0%) had no access to paid parental leave during this time. Of 50 men who attempted conception, 14 (28.0%) of their partners experienced a miscarriage. Eight men (17.0%) underwent a fertility workup, and 6 underwent infertility treatment(s). Only 4 respondents had insurance partially covering their infertility treatments, while the other two had no insurance coverage. Conclusions: Male physicians are often exposed to long work hours, nighttime duties, and sparse paid parental leave during the time of their first attempt at conception, most commonly in residency. Our cohort shows a high rate of miscarriage (28.0%) and infertility assessment (16.0%) among this population. Future studies are needed to continue characterizing fertility amongst physicians. Disclosure: No. [ABSTRACT FROM AUTHOR]

Introduction: Per and polyfluoroalkyl substances (PFAS) are commonly used in industrial and consumer products and are environmental and health contaminants. The most common PFAS chemicals, perfluorooctane sulfonate (PFOS) and perfluorooctanic acid (PFOA), are used in firefighting foam, nonstick bakeware, water-resistant fabrics, grease-resistant paper and fire-resistant materials. PFAS is a known endocrine disruptor and can reduce testosterone and lower semen quality. The impact of PFAS exposure on erectile physiology is unknown. Objective: Our study will assess the effect of PFOS and PFOA on erectile function in Sprague-Dawley rats. We hypothesize that PFOS and PFOA will decrease erectile function. Methods: Adult male Sprague-Dawley rats were divided into three groups (n=10/group): 1) Control; 2) PFOS (10mg/kg/day); and 3) PFOA (10mg/kg/day). PFOS/PFOA was dissolved in 0.05% Tween 20 and administered in drinking water for 28 days. Controls received 0.05% Tween 20 in drinking water. The study was carried out in two different cohorts of rats (n=4 and n=6/group). Following 28 days of PFOS/PFOA exposure, rats were placed on regular drinking water for 2 weeks. Body weights were collected weekly and terminal organ weights of liver, testes, spleen, heart, lungs, brain, seminal vesicles, kidneys, bladder, and thymus were recorded. Erectile function was assessed prior to PFAS exposure and every 2 weeks thereafter via apomorphine-induced behavioral erections and yawns. Nerve-stimulated intracavernosal pressure and mean arterial pressure (ICP/MAP) was measured 2 weeks after exposure stopped. Results: Four weeks of PFOS exposure significantly decreased body weight while PFOA exposure did not impact body weight (Con: 588±63.5g; PFOS: 453±16.3g; PFOA: 535±29.9g, p<0.01). The PFOS dose in the second cohort was overtly toxic with 5/6 rats dying following 3-4 weeks of exposure. Two weeks following PFOS/PFOA exposure, livers were markedly enlarged (Con: 19.4±2.85g; PFOS: 25.4±0.16g; PFOA: 20.2±3.77g, p<0.01), spleens were smaller (Con: 0.93±0.12g; PFOS: 0.65±0.03g; PFOA: 0.88±0.12g, p<0.05), and testes were larger in PFOS rats (Con: 1.8±0.07g; PFOS: 2.0±0.06g; PFOA: 1.8±0.07). No other organ weights were different across exposure groups. PFOS/PFOA exposed animals had similar numbers of apomorphine-induced erections throughout the 6 week period. Two weeks post-exposure, ICP/MAP was unchanged between all groups (n=5-10/group). Ongoing studies will assess testosterone levels. Conclusions: A sub-chronic PFOS exposure markedly decreased body weight, increased liver size, decreased spleen weight, and increased testes weight. PFOA exposure did not impact body or organ weights. Following PFOS or PFOA exposure, there was no change in apomorphine-induced behavioral erections or ICP/MAP. Additionally, the dose of PFOS assessed was quite toxic to the second cohort of animals. Future studies will assess if a more chronic exposure will impact erectile function. Disclosure: No. [ABSTRACT FROM AUTHOR]

Introduction: Patient recollection of details discussed during medical consultation is often limited (Figure 1a). For genital gender-affirming surgery (gGAS) consultations, lengthy discussions and deep contemplation surrounding surgical options are critical. Inadequate communication can result in patient complaints and medico-legal action, whereupon issues such as a lack of discussion or poor documentation can lead to medico-legal liability against the care provider and hospital system. As a result, strategies must be developed to ensure that information discussed during complex medical consultations are made available so patients can properly weigh out the care options presented. Objective: 1) Assess medico-legal incidents in Urologic and surgical specialties in the UK, US, and a Californian quaternary care center, 2) evaluate the advantages and feasibility of offering audio-recordings of patient consultations, and 3) create a user-friendly smartphone app for recording healthcare consultations. Methods: A literature review evaluated current evidence on medical liability claims in the UK and US was conducted. Additionally, our center's Department of Risk Management provided information pertaining to medico-legal cases against our institution. Separately, gGAS patients consented to audio-record their consultation. Copies were provided to patients and kept in their medical records. A follow-up survey assessed its usefulness, and based upon patient feedback, a smartphone application was developed. Results: A PubMed search yielded 921 results on "medical malpractice claims" from 2013-2023. In Urologic Surgery, 32 papers addressed medical malpractice, with 2 providing data over the last 15 years. In the UK, 660 claims were made from 2010-2020, of which 8.2% were due to poor communication (37 = informed consent; 17 = lack of follow-up). In the US, from 2020-2022, 38.3% of Urologists faced at least one legal proceeding in their career, and 5.3% were sued within 1 year for any reason. Our institution's Department of Risk Management reported 32% of lawsuits were related to surgical care. Informed consent involved 8% of cases and had a component in 32%. The average financial settlement for medical malpractice was $125,000.00 USD, and trial costs averaged $75,000.00 USD. 50/71 patients completed an anonymized, online survey post-audio recording. Positive results were noted regarding recording quality, comfort whilst being recorded, and wishes for future consultation recordings (Figure 1b). In addition, most patients felt less anxiety, and had greater confidence in their treatment choice (Figure 1c) Based upon patient responses, we developed a smartphone App which records 90 minutes of audio, allows for file and hyperlink attachments to be sent to patients before immediately deleting all information (Figure 1d). Routine use of audio-recordings led to a reduction in patient queries to our office. Conclusions: Routine audio recording of patient consultations provides significant benefits with minimal cost to providers. As per our institution's Office of Risk Management, it offers protection against medico-legal risks. Adequate discussion, good documentation and providing adjuncts for patients can help prevent a large proportion of medicolegal complaints in addition to optimizing patient care. Considering that patients face similar challenges across different disciplines and regions, a larger study (multi-center, international, multi-language) is warranted. Disclosure: No. [ABSTRACT FROM AUTHOR]

Introduction: Female sexual dysfunction (FSD), as recognized by the American Foundation for Urologic Disease, consists of low libido, problems with sexual arousal, inability to achieve orgasm, and dyspareunia. Sexual function is an important aspect of life for many women and is closely correlated with overall well-being. This dysfunction is often underrepresented in the academic space when compared to male sexual disorders, such as erectile dysfunction (ED). As FSD spans the fields of Urology, Gynecology, Psychology, and Endocrinology, bibliometric analyses are an important resource to understand the vast body of knowledge by highlighting landmark papers. Objective: The objective of this study was to identify key articles about FSD using citation number and bibliometric analysis to facilitate future scholarly efforts into more research on FSD through a multidisciplinary perspective. Methods: We searched for articles in the Web of Science Core Collection between 1900 to 2023 using terms specific to FSD. We identified relevant FSD articles and selected the top 50 most cited (T50). A bibliometric analysis was performed to collect and analyze data about title, authorship, publication year, citation number, journal and impact factor, country and institution, study type, citation index, specialty, and conflict of interest. Citation index was calculated as citations/years since publication to determine citations per year. Results: 6,858 results were identified and T50 articles were published between 1997-2014 in 12 countries, across 32 different institutions, and in 20 journals. Most articles were published in 2007 while most citations occurred in articles published in 1999. The most cited article (4020 citations), The Female Sexual Function Index (FSFI): A multidimensional self-report instrument for the assessment of female sexual function by R. Rosen, also had the most citations per year (174.78 citation/year). The USA produced the most articles, specifically through University of Medicine and Dentistry of New Jersey. Journal of Sexual Medicine published the most articles. The mean number of citations per article was 351.64. Observational studies were most common while reviews were least common. Less than half were sponsored. Of all the specialties that FSD spans, most articles were published in Urology & Nephrology, then Psychology, then Obstetrics and Gynecology. Research about FSD has been less impactful and influential than research about male sexual dysfunction, which is evidenced in the lower median citation number (209.00 vs. 364.00 citations, respectively) and total number of articles in WoS (6,858 vs 24,941 articles, respectively) for FSD compared to ED. Since FSD and male sexual dysfunction have about equal prevalence, this disparity may be due to the reluctance of female patients to discuss sexual issues due to shame. Conclusions: This is the first bibliometric analysis to identify the characteristics of T50 articles in FSD. This list emphasizes the lack of attention that FSD has had in medical research and underscores the obvious discrepancy between research into FSD and male sexual dysfunction. We hope to provide healthcare professionals with a valuable resource to understand the vast body of knowledge and trajectory of FSD to guide future research and education. Disclosure: No. [ABSTRACT FROM AUTHOR]