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Gender dysphoria can present as a positive symptom of schizophrenia. Completion of gender affirmation surgeries should not occur as a result of male genital self‐mutilation via a deferral of emergent surgical reconstruction. Instead, gender affirmation should be considered after a full workup and assessment for resolution of any acute psychosis.

Summary Ganciclovir (GCV) inhibits spermatogenesis in preclinical studies but long‐term effects on fertility in renal transplant patients are unknown. In a prospective, multicenter, open‐label, nonrandomized study, male patients were assigned to Cohort A [valganciclovir (VGCV), a prodrug of GCV] (n = 38) or B (no VGCV) (n = 21) by cytomegalovirus prophylaxis requirement. Changes in semen parameters and DNA fragmentation were assessed via a mixed‐effects linear regression model accounting for baseline differences. Sperm concentration increased post‐transplant, but between baseline and treatment end (mean 164 days Cohort A, 211 days Cohort B), the model‐based change was lower in Cohort A (difference: 43.82 × 106/ml; P = 0.0038). Post‐treatment, sperm concentration increased in Cohort A so that by end of follow‐up (6 months post‐treatment) changes were comparable between cohorts (difference: 2.09 × 106/ml; P = 0.92). Most patients’ sperm concentration improved by end of follow‐up; none with normal baseline concentrations (≥20 × 106/ml) were abnormal at end of follow‐up. Changes in seminal volume, sperm motility/morphology, DNA fragmentation, and hormone levels were comparable between cohorts at end of follow‐up. Improvement in semen parameters after renal transplant was delayed in men receiving VCGV, but 6 months post‐treatment parameters were comparable between cohorts.

INTRODUCTION AND OBJECTIVE:ChromaSelect is a highly sensitive and specific method of identification and isolation of intact and live human sperm from ejaculate, epididymal or testis specimens with ...

Background Ejaculation consists of the emission of semen from seminal vesicles and prostate, followed by expulsion. Ejaculatory dysfunction may take several forms including premature ejaculation, delayed or anejaculation, retrograde ejaculation, and painful ejaculation. Ejaculation is what we can see whereas orgasm is what we feel. The presence of ejaculate does not indicate the ability to experience orgasm. Hence, for the purpose of this work we consider orgasm and ejaculation as 2 separate neurobiological phenomena. Aim To review the role of advanced investigative techniques such as perineal ultrasound in the diagnosis and management of ejaculation and ejaculatory dysfunction. Methods We performed a PubMed search for key words individually and in combination: “ejaculation,” “ejaculatory dysfunction,” “delayed ejaculation,” “painful ejaculation,” “retrograde ejaculation,” “perineal ultrasound,” and “transrectal ultrasound.” We also share our local experience using perineal ultrasound in assessing ejaculation. Outcomes Perineal ultrasound can be used as an aid in the investigation of ejaculatory dysfunction. Results Evaluation of ejaculatory function hinges on a detailed psychosexual history and appropriate physical examination. Function of the ejaculatory center in the spine is androgen dependent; thus, hormonal evaluation is an important aspect of the workup. Disorders of ejaculation and orgasm require evaluation of neuromuscular reflexes activated during sexual activity. Dynamic ultrasonographic (US) ejaculatory-orgasmic studies allow for reproducible and detailed descriptions of the sexual response. Transrectal ejaculatory studies are useful in uncovering reasons for lack of antegrade semen emission, especially in men with poor sperm production or after vasectomy. Dynamic US studies contribute clinical utility in its non-invasive nature and can provide insight to the dynamic processes surrounding pelvic floor functioning in men. Conclusions Perineal US for men with delayed ejaculation or anejaculation, painful ejaculation, or retrograde ejaculation may be helpful in select cases. Further research using this modality may help advance our understanding of ejaculatory dysfunction. Forbes CM, Flannigan R, Paduch DA. Perineal Ultrasound: a Review in the Context of Ejaculatory Dysfunction. Sex Med Rev 2018;6:419–428.

Objective To evaluate whether varicocelectomy improves both serum testosterone and sexual function, as assessed by the Male Sexual Health Questionnaire (MSHQ). Methods A retrospective chart review of patients who have undergone varicocelectomy and had both pre- and postoperative MSHQ was performed. The MSHQ is a clinically validated questionnaire that assesses erectile function, ejaculatory function, and sexual satisfaction, with higher scores indicating better function. Clinical parameters pre and postvaricocelectomy were compared with paired t test. Results Thirty-four patients met study criteria. Seventeen patients (50%) presented for infertility, and the remaining 13 had symptomatic varicocele associated with hypogonadism. Average postsurgical follow-up was 20.6 ± 12.5 months. The majority of men in the study had bilateral varicoceles and left grade III varicoceles. Significant improvements in the total MSHQ score (3.9 ± 8.7, P = .027), the MSHQ erectile function (1.2 ± 2.3, P = .007), and the MSHQ ejaculatory function (1.4 ± 3.1, P = .018) domains were seen. Fifteen (44%) men saw improvement in their erectile function and 18 (53%) saw improvement in ejaculatory function. The improvement in serum testosterone was also significant (136.0 ± 201.3 ng/dL, P = .007). Conclusion Microsurgical repair of varicocele not only improves testosterone, but also improves patient-reported erectile and ejaculatory functions. Patients can confidently be counseled that varicocelectomy has the potential to improve sexual function along with serum testosterone.

To assess the efficacy of time-resolved MR angiography (MRA) in evaluating penile vasculature in patients with clinically suspected vascular anomalies contributing to their erectile dysfunction correlating with penile doppler ultrasound (PDUS) findings and clinical outcomes after surgical intervention. Men (n = 26) with signs of early vascular shunting on PDUS underwent time-resolved, contrast-enhanced (0.1 mMol/kg gadobutrol at 1 ml/s followed by saline flush) 3-dimensional spoiled gradient echo T1-weighted MRA sequence performed over 3 min with 4.6 s frame rate after intracavernosal injection of an erectogenic agent. Additional T1- and T2-weighted sequences were performed for anatomic co-localization and tissue characterization. MRA images were evaluated for early filling of draining veins as well as arteriovenous malformations and fistulas and correlated with findings at surgery. 29 MRA examinations on 26 patients (mean age 39 years) demonstrated abnormal early venous drainage (n = 22) as well as diminutive/delayed cavernosal enhancement (n = 3), incomplete tumescence (n = 2), and combined arterial inflow/venous outflow disease (n = 1). The MRA had a concordance of 85.2% at determining the presence, or lack thereof of a shunt/AVM when compared to PDUS. Time-resolved MRA allows for both temporal and spatial resolution with visualization of both arterial and venous abnormalities which may be suggested with a screening PDUS examination. This technique allows us to provide detailed anatomic information prior to any surgical intervention.

INTRODUCTION AND OBJECTIVES:Chromatin-modifying complexes (CPCs) play a critical role in epigenetic gene regulation and are thought to implement global genetic programs. Several long non-coding RNA...

INTRODUCTION AND OBJECTIVES:Our group has previously demonstrated that men with Sertoli Cell Only Syndrome (SCO) demonstrate a 17x downregulation of miR-202-5p compared to testis biopsies from norm...

Background Mechanisms underlying delayed orgasm (DO) are poorly understood; however, known effects of psychotropic medications on sexual function provides a rationale for aberrant central nervous system signaling as a cause. Aim To compare brain activation between men with normal orgasm and those with lifelong DO during sexual stimulation using brain fMRI algorithms. Methods 3 subjects with self-reported life-long DO and 6 normal controls were included in this study. The International Index of Erectile Function, Male Sexual Health Questionnaire, and self-reported time to orgasm were used to assess sexual function. Subjects underwent a 3-T fMRI study while viewing 3 video clips: a neutral control (NC), a positive emotional control (EC), and a sexual condition (SC). Each video sequence was repeated 5 times, with 50-second clips presented in a randomized fashion. fMRI data were analyzed in a block design manner to determine areas of differential brain activation between groups. The Allen Brain Atlas of gene expression in the human brain was used to identify signaling pathways in the areas of differential fMRI activation between the DO and control groups. Outcomes The primary outcome was differential activation of fMRI neural activation between groups. Results Analysis of differential activation in the SC compared with the NC and EC revealed increased activation in the right frontal operculum (P = .003), right prefrontal gyrus (P = .003), and inferior occipital gyrus (P = .003). Increased activation in the right fusiform gyrus of the occipital lobe and the right hippocampus (P = .0004) was seen in the DO group compared with controls. Using the Allen Atlas of Human Brain Expression, we identified corresponding neurotransmitter receptors to this region, including adenosine receptors, muscarinic and nicotinic cholinergic receptors, cannabinoid receptors, and dopamine receptors, among others. Clinical Implications Lifelong DO in men may be due to abnormal neurotransmitter signaling leading to poor progression of arousal due to aberrant processing of sexual cues. Identification of neurotransmitter pathways by fMRI will aid the development of pharmacotherapeutic agents. Strengths & Limitations Strengths of this study include the novel application of functional neuroimaging to investigate the pathogenesis of DO. Limitations include the small sample size, making this study exploratory in nature. Conclusion This study revealed differences in brain activation on visualization of sexual stimuli in men with a history of DO compared with controls. Identified regions are rich in numerous neurotransmitter receptor subtypes and may be amenable to pharmacologic targeting to identify novel therapies for these men.

Introduction Penile transplantation, in its infancy, has the potential to reestablish functional outcomes for men with penile loss and disfigurement. However, significant bioethical considerations are pertinent, and systematic discussions are necessary to safely progress implementation. Aim To determine the attitude of health practitioners toward the penile transplant and identify the key aspects of concern pertinent to the operation and clinical care. Methods Health care professionals from the United States responded to either email invitation, web link, or social media post on Facebook to complete a questionnaire investigating perceptions and attitudes toward penile transplantation. Main Outcome Measures Respondents' attitude toward penile transplantation, their own perceived important functions of the penis, and concerns about performing a penile transplantation. Respondents' previous exposure to visceral transplants, to penile disfigurement, and information about penile transplants were used as independent factors in analysis. Results Among 412 health care professionals who responded to the questionnaire, 95.9% were in favor of visceral organ transplant, but only 64.3% were in favor of penile transplantation. The results showed that 61.3% of respondents first learned about the penile transplant from mass media, whereas only 37.5% had been exposed through a scientific journal, formal lecture, or a professional colleague. Younger health professionals and those exposed through professional forums surrounding penile transplantation were more likely to be in favor of the procedure (P < .001). The most important functions of the penis were identified by respondents as being sexual function (role in sexual activity) and gender identity (being a man) with rates of 86.4% and 85.3%, respectively (P < .001). Barriers identified by respondents included the use of immunosuppression and the potential subsequent effect on healthcare resource utilization. Reading an excerpt about penile trauma in war during the questionnaire improved acceptance of penile transplantation (P = .05). Conclusion Penile transplantation is accepted by most health professionals surveyed. Younger respondents and those informed through professional outlets are more favorable toward penile transplantation. Anticipated limitations include the risk of immunosuppression, lack of available donors, and the effect on healthcare utilization.

Objective To evaluate the relationship of testosterone-enhancing therapy on alkaline phosphatase (AP) in relation to bone mineral density (BMD) in hypogonadal men. Patients and Methods Retrospective review of 140 men with testosterone levels of

Introduction Klinefelter syndrome (KS) is the result of sex chromosome aneuploidy most often characterized as 47,XXY. The typical features of KS include tall stature, gynecomastia, small firm testicles, hypergonadotropic hypogonadism, and infertility. However, abnormalities in neurodevelopment, cognition, and social and behavioral functioning also can be present. The abnormalities in neurodevelopment are believed to be due in part to androgen deficiency during early development and puberty. Aim To discuss the role of androgens in normal adolescent development; discuss the cognitive, behavioral, and social functioning of children with KS; evaluate the evidence for early androgen therapy in men with KS; and discuss management strategies in the development of boys with KS. Methods A systematic review of early androgen therapy and KS was performed using PubMed-Medline and Scopus databases. Relevant articles commenting on social, behavioral, cognitive, and physical outcomes among infants, children, and adolescents were included for reporting and discussion. Main Outcome Measures Social and behavior functioning; cognitive outcomes; adverse effects associated with androgen therapy. Results 3 retrospective articles and 2 randomized controlled trials addressing early androgen therapy in boys with KS were reviewed. These studies showed an improvement in several aspects of social and cognitive functioning based on validated questionnaires. Treatment strategies, potential negative effects, and limitations of the literature on early androgen therapy in boys with KS are discussed. Conclusion Our findings indicate that early androgen supplementation in children with KS combined with specific educational, family, and social support improves behavioral functioning. The optimal timing of hormonal therapy might require prospective studies, but based on our data and review of the literature, the benefit of early hormonal and therapeutic intervention in KS is very encouraging. Flannigan R, Patel P, Paduch DA. Klinefelter Syndrome. The Effects of Early Androgen Therapy on Competence and Behavioral Phenotype. Sex Med Rev 2018;6:595–606.

We investigated the safety and tolerability of testosterone replacement therapy in adolescents with Klinefelter syndrome.We reviewed the medical records of all consecutive adolescents with Klinefelter syndrome evaluated between 2007 and 2012. Patients receiving testosterone replacement and aromatase inhibitor therapy were identified. Data on demographics, physical characteristics, medical history and serum hormone concentrations were collected for each patient. We evaluated longitudinal changes in serum testosterone, luteinizing hormone and follicle-stimulating hormone as well as changes in body mass index after the initiation of testosterone replacement therapy.We identified 151 adolescents with Klinefelter syndrome. Mean age at presentation was 11.6 years. Testosterone replacement therapy and aromatase inhibitors were initiated in 110 and 75 patients, respectively, at an average age of 13 to 14 years. Topical testosterone replacement therapy was used in 95% of patients with good clinical efficacy and compliance based on serial serum testosterone values. After the initiation of testosterone replacement therapy average serum testosterone improved from 240 to 650 ng/ml. Serum luteinizing hormone and follicle-stimulating hormone increased with the progression of puberty from 2.6 to 16.6 and 7 to 42 mIU/ml, respectively. No adverse outcomes related to testosterone replacement therapy were reported.Hormone supplementation with testosterone and aromatase inhibitors in adolescents with Klinefelter syndrome appears to be safe and effective for maintaining serum testosterone within the normal range. Compliance with topical formulations is high. Topical testosterone replacement therapy is not associated with the suppression of endogenous serum luteinizing hormone or follicle-stimulating hormone.

What's known on the subject? and What does the study add? Disorders of ejaculation and orgasm are common, even in men with only mild erectile dysfunction (ED). Treatment with the phosphodiesterase type-5 inhibitor tadalafil was associated with improvements in ejaculatory and orgasmic function. Patients with residual ejaculatory or orgasmic dysfunction experience reduced sexual satisfaction. These findings need to be corroborated in further clinical trials involving men without ED. Objectives To compare effects of tadalafil on ejaculatory and orgasmic function in patients presenting with erectile dysfunction (ED). To determine the effects of post-treatment ejaculatory dysfunction (EjD) and orgasmic dysfunction (OD) on measures of sexual satisfaction. Patients and Methods Data from 17 placebo-controlled 12-week trials of tadalafil (5, 10, 20 mg) as needed in patients with ED were integrated. EjD and OD severities were defined by patient responses to the International Index of Erectile Function, question 9 (IIEF-Q9; ejaculation) and IIEF-Q10 (orgasm), respectively. Satisfaction was evaluated using the intercourse and overall satisfaction domains of the IIEF and Sexual Encounter Profile question 5. Analyses of covariance were performed to compare mean ejaculatory function and orgasmic function, and chi-squared tests evaluated differences in endpoint responses to IIEF-Q9 and IIEF-Q10. Results A total of 3581 randomized subjects were studied. Treatment with tadalafil 10 or 20 mg was associated with significant increases in ejaculatory and orgasmic function (vs placebo) across all baseline ED, EjD, and OD severity strata. In the tadalafil group, 66% of subjects with severe EjD reported improved ejaculatory function compared with 36% in the placebo group (P < 0.001). Similarly, 66% of the tadalafil-treated subjects (vs 35% for placebo; P < 0.001) with severe OD reported improvement. Residual severe EjD and OD after treatment had negative impacts on sexual satisfaction. Limitations of the analysis include its retrospective nature and the use of an instrument (IIEF) with as yet unknown performance in measuring treatment responses for EjD and OD. Conclusions Tadalafil treatment was associated with significant improvements in ejaculatory function, orgasmic function and sexual satisfaction. Proportions of subjects reporting improved ejaculatory or orgasmic function were ≈ twofold higher with tadalafil than with placebo. These findings warrant corroboration in prospective trials of patients with EjD or OD (without ED).

Aim: To establish norms for reproductive hormones in healthy males with normal urologic and sexual function, and to assess the change in reproductive hormone levels with respect to age among healthy males. Methods: Healthy volunteers aged 18 - 29 (group 1) and 45 - 65 (group 2) were recruited for enrollment in a prospective study. Inclusion criteria comprised normal urinary, ejaculatory, orgasmic, and erectile function, as determined by IPSS, MSHQ, and IEFF-15. Men with history of chronic medical illnesses or chronic medication use were excluded. Fifty men met the study criteria. Each participant underwent physical examination and standardized serum hormone evaluation using ELISA and EIA methods. Statistical analysis was performed using JMP 8.0 software (SAS Institute Inc., Cary, NC), to compare hormone levels between the two groups of men. Results: There were 25 men each in groups 1 (mean age 26) and 2 (mean age 51). Overall, 46% were Caucasian, 31% African American, 15% Hispanic, and 8% Asian. There was no statistically significant difference in serum total T, SHBG, E2, or LH between groups 1 and 2. Notably, the 95% CI for serum T levels for both groups of men were considerably higher than commonly accepted lower-end cut-off limits. Conclusion: Serum T levels do not vary significantly with age, in otherwise healthy men with normal sexual and urologic function. Furthermore, healthy men have much higher serum total and free T levels than the lower-end reference limits provided by commercial laboratories.

Urologists and reproductive endocrinologists have become the first contact physicians for young men of reproductive age and have the unique opportunity to positively affect men’s health and quality of life. Growing evidence indicates that a significant proportion of men presenting with infertility or sexual dysfunction are hypogonadal. One hundred ninety nine men were enrolled in our center, and mean total testosterone was = 122, 57%), osteopenia (n = 69, 39%) and osteoporosis (n = 8, 4%). There were no differences in the mean age (p 0.64), height (p 0.99) and weight (p 0.02). Our results indicate that hypogonadism is one of the main risk factors for osteopenia and osteoporosis which can be found in 8% of hypogonadal men younger than 50 years of age. Testosterone replacement therapy may be indicated in most men with hypogonadism and low bone mineral density (BMD); however the benefits of testosterone treatment in eugonadal men are unproven. Selective estradiol and androgen receptor modulators expand our treatment modalities in men of reproductive age when suppression of gonadotropins may interfere with reproductive plans. Early detection of hypogonadism and osteoporosis may lower the risk of hip and vertebral fractures in some men. Further prospective RCTs are needed to prove cost-effectiveness of detection and the best treatment of osteoporosis in hypogonadal men of reproductive age. Urologists have the opportunity to be at the forefront of greater awareness of this clinical problem due to their frequent contact with this population of patients.

INTRODUCTION AND OBJECTIVES: Sertoli cell-only syndrome (SCOS) is one of the most severe forms of male factor infertility and is classically thought to be devoid of germ cells. However, evidence from microsurgical testicular sperm extractions (TESE) on patients with SCOS has revealed the presence of rare focal areas of spermatogenesis, thereby suggesting the presence of spermatogonial stem cells (SSC) in at least some patients with SCOS. We hypothesize that SSCs are present in most patients with SCOS and that it is abnormal differentiation of the SSC into spermatogonia (SPG) A and/or B that leads to SCOS. METHODS: Testicular samples were obtained from 5 men with pure SCOS on biopsy during TESE and from 5 cadaveric men with normal spermatogenesis. Specimens were assessed for mRNA markers of SSC, SPG A, and SPG B by RNA sequencing. Immunofluorescence was then used to visualize SSCs and SPG A in the testicular samples. Finally, flow cytometry using known markers for SSC (SSEA4) and SPG A (GFRa1) was used to provide quantitative evidence of cellular presence in testicular samples. RESULTS: On RNA sequencing, mRNA markers for SSC and SPG A are expressed in similar numbers in men with normal spermatogenesis and in those with SCOS. On the other hand, there was a dramatic overexpression of mRNA markers for differentiated cells, such as spermatocytes, in men with normal spermatogenesis (Table 1). Immunofluorescence showed increased expression of GFRa1 in the testes of men with SCOS when compared to the testes of men with normal spermatogenesis. Flow cytometry analysis of four testicular samples from men with SCOS and four samples from those with normal spermatogenesis showed a similar number of SSEA4+ cells (0.11%), but a nearly four-fold increase in the number of GFRa1+ cells in men with SCOS compared to those with normal spermatogenesis (0.7% versus 0.18%, respectively). CONCLUSIONS: These findings suggest that SSCs are present in patients with SCOS in similar numbers as in those with normal spermatogenesis. However, there is a surprising accumulation of SPG in SCOS patients. Rather than differentiating and proceeding down the spermatogenesis pathway, the SSCs proliferate, but remain undifferentiated. The azoospermia seen in men with SCOS appears to be secondary to a defect in SSC differentiation and entry into meiosis. Source of Funding: The project was supported by The Frederick J. and Theresa Dow Wallace Fund of the New York Community Trust. This project was also supported by grant number T32HS00066 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality.

INTRODUCTION AND OBJECTIVES: Penile prosthesis (PP) reoperations include removing or replacing a previously placed PP. PP are now more commonly utilized in older men with more comorbidities, which may influence the rate of reoperation. We assessed national trends in reoperations for PP surgery and factors associated with reoperation. METHODS: Data were obtained from the Centers of Medicare and Medicaid Services using the Public Use files for the years 2002 to 2010. For national trends in PP placement and reoperation, the total numbers of men undergoing each of these procedures were used for analysis. Man men undergoing reoperation had their initial PP placement prior to enrollment in Medicare. For the analysis of characteristics associated with reoperation after PP placement, only men whose initial PP placement was captured by the Medicare dataset were analyzed. RESULTS: The overall rate of PP replacements or removals has remained relatively steady at an average of about 1,200 replacements (IQR 1,140-1,300) and 500 removals (IQR 460-580) per year. Each year, an average of 2.5% (IQR 1.4-2.7%) of the men undergoing a PP placement eventually underwent a reoperation for the prosthesis, with either a PP replacement (median 1.1%, IQR 0.81.3%) or PP removal (1.3%, IQR 0.8-1.6%) (Table 1). The degree of comorbidity as measured by the Charlson Comorbidity Score was found to be a predictor for reoperation (OR 2.3-3.5, p-value

of EVs in prostate cancer (PCa). We aimed to investigate the prognostic potential of prostate-specific EVs in PCa patients. METHODS: Plasma and prostate tissue were collected from patients who underwent surgery for PCa (n1⁄482) or benign prostatic hyperplasia (BPH, n1⁄428). To analyze the quantity of EVs in prostatic tissue, we performed transmission electron microscopy (TEM), immuno-TEM with CD63 and prostate-specific membrane antigen (PSMA) antibodies, and immunofluorescence staining. After EV isolation from plasma using an aqueous two-phase system, CD63 and PSMA concentration was measured using ELISA kits. Relationship between plasma EV concentration and clinicopathologic outcomes were analyzed. RESULTS: PSMA-positive areas in prostate tissue differed in patients with BPH, and low-, intermediate-, and high-risk PCa (2.4, 8.2, 17.5, 26.5%, p

OBJECTIVE • To investigate orgasmic outcomes in patients undergoing robotic-assisted laparoscopic radical prostatectomy (RALP) and the effects of age and nerve sparing on these outcomes. PATIENTS AND METHODS • Between January 2005 and June 2007, 708 patients underwent RALP at our institution. • We analysed postoperative potency and orgasmic outcomes in the 408 men, of the 708, who were potent, able to achieve orgasm preoperatively and available for follow-up. RESULTS • Of men aged ≤60 years, 88.4% (198/224) were able to achieve orgasm postoperatively in comparison to 82.6% (152/184) of older men (P < 0.001). • Of patients who received bilateral nerve sparing (BNS) during surgery, 273/301 (90.7%) were able to achieve orgasm postoperatively compared with 46/56 (82.1%) patients who received unilateral nerve sparing and 31/51 (60.8%) men who received non-nerve-sparing surgery (P < 0.001). • In men ≤60 years who also underwent BNS, decreased sensation of orgasm was present in 3.2% of men, and postoperative orgasmic rates were significantly better than men ≤60 years who underwent unilateral or no nerve sparing (92.9% vs 83.3% vs 65.4%, respectively; P < 0.001). • Potency rates were also significantly higher in men ≤60 years and in those who underwent BNS. CONCLUSIONS • Age and nerve sparing influence recovery of orgasm and erectile function after RALP. • Men ≤60 years old and those who undergo BNS are most likely to maintain normal sexual function.

The phenotypic effects of the gr/gr partial azoospermia factor c deletion vary geographically and to our knowledge have not been reported in the American population. We evaluated the clinical characteristics of infertile American men with the gr/gr deletion.We retrospectively reviewed clinical data on 1,410 infertile men tested for the gr/gr deletion. We analyzed sperm concentration and the outcome of microdissection testicular sperm extraction with respect to gr/gr status.We identified 73 men with gr/gr deletions, including 43 of 989 (4.3%) with azoospermia, 18 of 317 (5.7%) with severe oligospermia (less than 5 million sperm per ml), 6 of 61 (9.8%) with oligospermia (5 to less than 20 million sperm per ml) and 6 of 43 (14%) infertile men with normospermia (greater than 20 million sperm per ml). A gr/gr deletion correlated with higher sperm production. The gr/gr deletion rate was higher in men with normospermia than in those with a sperm concentration of less than 20 million and less than 5 million per ml (p = 0.021 and 0.006, respectively). Microdissection testicular sperm extraction was done in 22 azoospermic men with gr/gr deletions and sperm were retrieved in 14 (64%). This retrieval rate was similar to that at our center in men with idiopathic nonobstructive azoospermia (p = 0.13).Diagnosis of the gr/gr deletion did not predict impaired sperm production in our patient population and did not appear to alter the prognosis for surgical sperm retrieval. Despite the established modulatory impact of the gr/gr deletion on sperm production in some populations at this time the clinical value of testing infertile American men for the gr/gr deletion is not clear.

Evaluation of potential candidates for testosterone replacement therapy (TRT) includes a complete medical history, physical examination, and hormonal screening. The choice of testosterone assay is important in clinical decision making. TRT should, in theory, approximate natural endogenous production of the hormone. There is no apparent association between TRT and the development of prostate cancer. The administration of exogenous testosterone is not a means of reversing the aging process in men with normal testosterone levels, but it may offer considerable benefit for those with hypogonadism.

Purpose of review Recent findings in the physiology and neurobiology of ejaculation have expanded our understanding of male sexual function and have allowed the development of new instruments to investigate ejaculatory and orgasmic disorders. Recent findings The evidence-based definition of lifelong premature ejaculation has set a model in the evaluation and treatment outcome of sexual dysfunction. New instruments to objectively assess arousal, orgasm and the expulsion phase of ejaculation such as functional MRI, dynamic pelvic ultrasound, PET scans and validated questionnaires have lead to a better understanding of sexual dysfunction in men. Animal models, developments in neurobiology and clinical experience have transformed a purely psychoanalytical approach to ejaculatory and orgasmic function into a novel multidisciplinary, scientifically sound and evidence-based discipline of medicine. Summary Ejaculation is an integral part of normal sexual function. Ejaculatory dysfunction is common and may cause substantial disruption to the quality of a patient's life. A better understanding of the epidemiology, pathophysiology, neuroscience and genetics of ejaculatory and orgasmic function will eventually lead to the development of new, effective methods of treatment of disorders of ejaculation and orgasm in men.

Male pelvic pain syndrome (MPPS) is marked by chronic pain in the genitoanal and lower abdominal areas, often involving chronic prostatitis/chronic pelvic pain syndrome, pain upon ejaculation, erectile dysfunction, and painful bladder syndrome/interstitial cystitis. Studies of chronic pain patients have shown that the objective assessment of progress and resolution of symptoms rely on evaluation focused on complete physical examination and history taking with standardized and validated questionnaires. Because MPPS and sexual dysfunction are not life-threatening conditions, bother score of symptoms, global impairment of function, and underlying diagnosis should direct therapy. Furthermore, treatment should be multimodal, escalating, and aimed at decreasing recurrence rates. This article reviews the evaluation and treatment of MPPS and sexual dysfunction in men.

Introduction Radical prostatectomy (RP) is associated with erectile dysfunction (ED). A single, placebo-controlled, human study has assessed the effects of regular sildenafil use after RP and demonstrated an increased chance of preservation of preoperative erectile function. Aim This study was undertaken to define the effects of such a regimen in an animal model. Methods Using the cavernous nerve (CN) crush injury model, animals were divided into a number of groups: no CN injury (sham), bilateral CN injury exposed to either no sildenafil (control) or sildenafil at two doses (10 and 20 mg/kg) subcutaneously daily for three different durations (3, 10, 28 days). Main Outcome Measures At these time points, CN electrical stimulation was used to assess erectile function by mean intracavernosal pressure (ICP)/mean arterial pressure (MAP) ratio. For the structural analyses, whole rat penes were harvested. Staining for Masson's trichrome was utilized to calculate the smooth muscle-collagen ratio. Immunohistochemical antibody staining was performed for endothelial (CD31 and eNOS) and neural (GAP43, NGF, and nNOS) factors and immunoblotting was performed to analyze the AKT/eNOS pathway. Terminal deoxynucleotidyl transferase biotin-dUTP nick end labeling (TUNEL) assay was used for the assessment of apoptotic indices and the CN architecture was evaluated by transmission electron microscopy (TEM). Results Erectile function was improved with sildenafil in a time- and dose-dependent fashion with maximization of erectile function recovery occurring with daily 20 mg/kg at the 28-day time point. Sildenafil use resulted in smooth muscle-collagen ratio protection and CD31 and eNOS expression preservation. Sildenafil reduced apoptotic indices significantly compared with control. Animals exposed to sildenafil had increased phosphorylation of akt and eNOS. Tem demonstrated distinct differences in architecture between control and sildenafil groups toward an increased amount of myelinized nerve fibers. Conclusions Sildenafil use in the CN crush injury model preserves erectile function that appears to be mediated predominantly through preservation of smooth muscle content and endothelial function as well as through reduction in apoptosis. Mulhall JP, Muller A, Donohue JF, Mullerad M, Kobylarz K, Paduch DA, Tal R, Li PS, Cohen-Gould L, and Scardino PT. The functional and structural consequences of cavernous nerve injury are ameliorated by sildenafil citrate.

Lower urinary tract infections (UTIs) are common among the general population and are most often caused by bacterial pathogens. Viruses are an uncommon cause of UTIs in an immunocompetent host; however, viruses are increasingly recognized as the cause of lower UTI, especially hemorrhagic cystitis, among immunocompromised patients. BK virus, adenovirus, and cytomegalovirus are predominant pathogens involved in hemorrhagic cystitis after stem cell and solid organ transplantation, and their early diagnosis and treatment may prevent significant morbidity of hemorrhagic cystitis. The diagnosis of viral lower UTI is based on molecular techniques, and real-time polymerase chain reaction is often the method of choice because it allows for quantification of viral load. Cidofovir is becoming a drug of choice in viral UTIs because it is active against the most common viral pathogens. This review discusses the epidemiology, pitfalls in diagnosis, and current treatment of viral UTIs.

Hypogonadism is defined as decreased testosterone levels in men. Hypogonadism can be accompanied by erectile, orgasmic, and ejaculatory dysfunction.To evaluate whether treatment with testosterone solution 2% (testosterone) could improve ejaculatory function in a cohort of hypogonadal men.Sexually active, hypogonadal men at least 18 years old (total testosterone300 ng/dL) were randomized to receive testosterone or placebo for 12 weeks.Effects of testosterone on primary outcomes were evaluated using the International Index of Erectile Function (IIEF) and the Men's Sexual Health Questionnaire, Ejaculatory Dysfunction, Short Form (MSHQ-EjD-SF) questionnaires. Treatment differences were calculated using analysis of covariance.In total, 715 men (mean age = 55 years) were randomized to placebo (n = 357) or testosterone (n = 358). Most sexually active men who reported IIEF scores had some degree of erectile dysfunction (IIEF erectile function score26). Although ejaculatory function score (MSHQ-EjD-SF) improved in the testosterone group compared with placebo (P.001), improvement on the "bother" item did not reach statistical significance. Treatment-related adverse events in the testosterone group affecting at least 1% of patients were increased hematocrit, upper respiratory tract infection, arthralgia, burning sensation, fatigue, increased prostate-specific antigen, erythema, and cough. Few patients in either treatment group developed at least one adverse event leading to discontinuation (testosterone = 1.98% vs placebo = 3.09%; P = .475).Hypogonadal men receiving testosterone solution 2% therapy experience significantly greater improvement in ejaculatory function, compared with placebo, as assessed by the MSHQ-EjD-SF. However, improvement in "bother" was not statistically different between the two groups. Testosterone therapy was generally well tolerated.

Low T levels have been associated with ejaculatory dysfunction (EjD) in cross-sectional studies; however, the efficacy of T replacement in improving EjD has not been studied in a randomized controlled trial.To evaluate the efficacy of T replacement in androgen-deficient men with EjD.A multicenter, double-blind, randomized, placebo-controlled, 16-week trial with T solution 2% versus placebo.Medical centers in the United States, Canada, and Mexico.Seventy-six men with one or more EjD symptoms, including delayed ejaculation, anejaculation, reduced ejaculate volume, and/or reduced force of ejaculation, and two total T levels300 ng/dL (10.41 nmol/L) measured with liquid chromatography tandem mass spectrometry.Sixty milligrams of T solution 2% or placebo applied to the axillae for 16 weeks.The primary outcome was a change in the score of the three-item Male Sexual Health Questionnaire-Ejaculatory Dysfunction-Short Form (MSHQ-EjD-SF); secondary outcomes included measured ejaculate volume, scores of the bother/satisfaction item of the MSHQ-EjD-SF, the orgasmic function domain of the International Index of Erectile Function Questionnaire, and the sexual activity log.Seventy-six participants were randomized; 66 completed the study. Baseline demographic and clinical characteristics were comparable between the treatment arms. T replacement improved the MSHQ-EjD-SF score (mean score change, +3.1); however, this effect was not statistically different from placebo (mean score change, +2.5; P = .596). No differences were seen in any of the secondary outcomes or frequency of adverse events.T replacement was not associated with significant improvement in EjD in androgen-deficient men.

Background The utilization of penile prosthesis (PP) insertion in the general population for medically refractory erectile dysfunction (ED) has not been well-characterized. This study assessed the national temporal trends in the surgical management of ED utilizing PP. Materials and Methods An analysis of the 5% Medicare Public Use Files from 2001 to 2010 was performed to assess the use of PP. Regression analysis was performed to identify factors associated with PP placement, type of PP utilized, and factors associated with revisions. Results A total of 1,763,260 men were diagnosed with ED, 3% (53,180) of whom underwent PP insertion. The utilization of PP for ED decreased from 4.6% in 2002 to 2.3% in 2010 (P 1 were more likely to have a PP inserted for ED (P Conclusions The surgical management of ED with PP changed significantly between 2001 and 2010. The overall utilization of PP decreased, but its use in patients with significant medical comorbidities increased. Age >65, ethnicity, and geography influenced the likelihood of PP placement, prosthesis type, as well as the likelihood of prosthesis removal or revision.