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Background The purpose of this study is to evaluate the prognostic factors for sperm retrieval and determine if Y chromosome deletion is associated with deleterious effects on spermatogenesis in non-mosaic Klinefelter patients. Whether Y chromosome deletion determines the sperm retrieval rate in non-mosaic Klinefelter patients has not yet been addressed. Methods We retrospectively collected medical records of azoospermic patients from Sep 2009 to Dec 2018, and enrolled 66 non-mosaic 47, XXY patients who were receiving mTESE. The predictive values of patients age, serum follicle-stimulating hormone (FSH), luteinizing hormone (LH), testosterone, prolactin, estradiol and Y chromosome deletion were assessed for successful sperm recovery. Results Testicular sperm recovery was successful in 24 (36.4%) of 66 men. The mean age (36.0 vs. 36.6 years), and levels of FSH (30.0 vs 36.9 IU/L), LH (17.7 vs 21.9 IU/L), testosterone (2.4 vs. 2.1 ng/ml), prolactin (9.1 vs. 8.8 ng/ml), and estradiol (19.4 vs. 22.3 pg/ml) did not show any significant difference when comparing patients with and without successful sperm retrieval. Partial deletion of azoospermic factor c (AZFc) was noted in 5 (20.8%) of 24 patients with successful sperm retrieval, including three b2/b3 and two gr/gr deletion cases, whereas 4 (9.5%) of 42 patients with unsuccessful sperm retrieval were noted to have AZFc partial deletion (one b2/b3, one sY1206 and two gr/gr deletion), though the difference was not statistically significant (p = 0.27). Conclusion According to present results, age and AZFc partial deletion status should not be a deterrent for azoospermic males with non-mosaic Klinefelter syndrome to undergo mTESE.

INTRODUCTION AND OBJECTIVES:Exercising and “eating better” are often associated with a myriad of health benefits such as weight loss and increased energy. Numerous studies have examined the potenti...

Introduction: For the technologically adept man, the use of online direct-to-consumer (DTC) men’s health services such as Hims® and Roman® offer convenience, accessibility, and discretion when pursuing care for sensitive issues such as erectile dysfunction Characteristics of the users of these telemedicine services have not been well described We surveyed a population of adult men to determine their perception of infertility and semen analysis, as well as their use of online men’s health services Objective: To determine the familiarity with and use of DTC men’s health services among adult men Additionally, we sought to evaluate perceptions regarding infertility, low testosterone, and semen analysis testing among these men using an online survey Methods: The survey was conducted between November 2019 to January 2020 through ResearchMatch com, a voluntary online registry of individuals interested in participating in clinical research Males age 18 and over were invited to complete an online survey with 5-point Likert items assessing concern for low testosterone, infertility, and likelihood of conducting a semen analysis test without a physician recommendation Participants were also asked about their familiarity with and use of DTC health services such as Hims®, Roman®, and 23andMe® Responses were dichotomized and logistic regression estimated the association between participant characteristics and outcomes of interest Results: Of 1,276 participants who completed the survey, 794 (62 2%) expressed some degree of concern about having low testosterone, and 277 (21 7%) were concerned about infertility Of all participants, 48 5% reported familiarity with Hims®, Roman® or similar online men’s health services but only 2 9% (n=37) reported actual use More than 85% of DTC users were under age 65 Factors associated with use of DTC men’s health telemedicine services included age < 60, (age 18-39: OR 4 20, 95% CI 1 14 to 15 56, p=0 032;age 40-59: OR 3 94, 95% CI 1 22 to 12 75, p =0 022), income between $50K and $100K ($50K to $75K: OR 4 71, 95% CI 1 01 to 21 94, p=0 048;$75K to $100K: OR 6 41, 95% CI 1 31 to 31 45, p=0 022), and concern about low testosterone (OR 3 16, 95% CI 1 15 to 8 69, p=0 026) Number of recent doctor visits, use of testosterone and other supplements, prior use of 23andMe®, and concern about infertility were not associated with increased odds of use Conclusions: Younger generation men in the middle-income bracket had higher odds of using online DTC men’s health telemedicine services than older or wealthier men Level of engagement with the traditional health care system as determined by recent doctor visits did not predict use of DTC men’s health services As telemedicine use accelerates during the COVID-19 pandemic, it is increasingly important for physicians to understand the characteristics of patients who access DTC websites, delineate the health concerns that can and cannot be comprehensively addressed through this modality, and recognize the long-term consequences for the landscape of sexual medicine care in the United States Disclosure: Work supported by industry: no

Background “Prospective Registry of Outcomes with Penile Prosthesis for Erectile Restoration” (PROPPER) is a large, multi-institutional, prospective clinical study to collect, analyze, and report real-world outcomes for men implanted with penile prosthetic devices. We prospectively correlated co-morbid conditions and demographic data with implanted penile prosthesis size to enable clinicians to better predict implanted penis size following penile implantation. We present many new data points for the first time in the literature and postulate that radical prostatectomy (RP) is negatively correlated with penile corporal length. Methods Patient demographics, medical history, baseline characteristics and surgical details were compiled prospectively. Pearson correlation coefficient was generated for the correlation between demographic, etiology of ED, duration of ED, co-morbid conditions, pre-operative penile length (flaccid and stretched) and length of implanted penile prosthesis. Multivariate analysis was performed to define predictors of implanted prosthesis length. Results From June 2011 to June 2017, 1,135 men underwent primary implantation of penile prosthesis at a total of 11 study sites. Malleable (Spectra), 2-piece Ambicor, and 3-piece AMS 700 CX/LGX were included in the analysis. The most common patient comorbidities were CV disease (26.1%), DM (11.1%), and PD (12.4%). Primary etiology of ED: RP (27.4%), DM (20.3%), CVD (18.0%), PD (10.3%), and Priapism (1.4%), others (22.6%). Mean duration of ED is 6.2¡À4.1 years. Implant length was weakly negatively correlated with White/Caucasian (r=−0.18; P

Objective To report on an early adopter series of collagenase Clostridium histolyticum (CCh) for Peyronie's disease (PD). Postapproval studies of CCh have been anticipated after recent Food and Drug Administration authorization of its use for men with PD as definitive and durable nonsurgical interventions have been long desired. Materials and Methods From May 2014 to October 2015, a database consisting of PD patients with >30° of penile curvature received CCh from a single provider at a single institution. Objective penile curvature measurements and deformity directions were assessed pre- and posttreatment. Using the validated Peyronie's Disease Questionnaire (PDQ), changes in subjective symptoms of intercourse ability, penile pain, and bother were also noted. Results We followed 49 unique PD patients treated with CCh. Mean follow-up was 183 days with a median of 6 injections over 3 cycles performed per patient. The mean pretreatment penile curvature was 49.3 degrees. Curvature was reduced by 15.4 degrees (32.4%, P P P P = .89). Five notable bleeding events (10.2%) were noted, including 1 penile fracture requiring operative exploration. Conclusion CCh use for PD yielded improvements in penile curvature, subjective intercourse, and bother symptoms. Further postanalysis studies of greater follow-up are needed to assess long-term durability, efficacy, and safety.

Erectile dysfunction (ED) has been well recognized as a marker of increased cardiovascular risk for more than 15 years, especially in younger men. Early detection of ED represents an opportunity to intervene to decrease the risk of future cardiovascular events and limit the progression of ED severity. Evidence suggests there is a window of opportunity of 3 to 5 years from the onset of ED to subsequent cardiovascular events. This opportunity is usually missed if the onus is placed on the patient to seek care for his sexual problems. Unfortunately, these clear messages have not been incorporated into routine cardiovascular care. The reasons for these disparities within specialties are discussed in this article, in addition to management algorithms. Lifestyle modification is usually recommended as the first-line treatment to correct ED and lessen cardiovascular risk, but evidence suggests that this might be effective only in men without established cardiovascular comorbidities. In men with type 2 diabetes mellitus and established cardiovascular disease, lifestyle modification alone is unlikely to be effective. Cardiovascular medications are often associated with sexual dysfunction but changes in medication are more likely to be beneficial in men with milder recent-onset ED. A balanced view must be taken related to medication adverse events, taking into account optimal management of established cardiovascular disease. Testosterone deficiency has been associated with different metabolic disorders, especially metabolic syndrome and type 2 diabetes mellitus. Testosterone deficiency syndrome has been associated with an independent burden on sexual function globally and increased cardiovascular and all-cause mortality. Testosterone replacement therapy has been shown to improve multiple aspects of sexual function and, in some studies, has been associated with a decrease in mortality, especially in men with type 2 diabetes mellitus. Recent studies have suggested that phosphodiesterase type 5 inhibitors, the first-line medications to treat ED, could decrease cardiovascular and all-cause mortality, through multiple mechanisms, predominantly related to improved endothelial function.Copyright (C) 2016, International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.

Introduction: The diagnosis, treatment, and survivorship of cancer have a profound effect on the quality of life and psychological well-being of men and women. Indeed, the perturbation of sexual function because of neoplasm has far-reaching implications. Aims: To explore the prevalence, pathophysiology, and treatment of sexual issues in persons with cancer and offer evidence-based recommendations regarding optimal prevention and treatment strategies. Methods: A committee of multidisciplinary specialists was formed as part of the larger International Sexual Medicine Consultation working with urologic and sexual medicine societies over a 1-year period to review the result of chronic-illness management on sexual function and satisfaction. The aims, goals, data collection techniques, and report format were defined by a central committee. Main Outcomes Measures: Expert consensus was based on evidence-based medical and psychosocial literature review, extensive group discussion, and an open presentation with a substantial discussion period. Results: This summary evaluates contemporary literature concerning the prevalence, pathophysiology, and psychological impact of cancer diagnosis and treatment on sexual dysfunction. Evidence-based recommendations and guidelines for evaluation and management are presented. Conclusion: The diagnosis and treatment of cancer have a significant negative impact on sexual function and satisfaction. Comprehension of baseline sexual function, role of psychological supports, and available treatment options could attenuate the heavy burden of decreased sexual function. Copyright (C) 2016, International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.

To date, the published data on patients treated with penile implantation generally consist of small series of single surgeon, retrospective experiences rather than prospective or large, multicenter evaluations. This study establishes a baseline of data collection from the PROPPER (Prospective Registry of Outcomes with Penile Prosthesis for Erectile Restoration). The PROPPER is the first large, prospective, multicenter, multinational, monitored, and internal review board approved study of real-world outcomes for patients with penile implants.Data from the PROPPER study were examined to determine patient baseline characteristics and primary and secondary etiologies before treatment of erectile dysfunction. Data include type and size of implant received, surgical steps/techniques used during implantation, and duration of hospital stay.Through April 2, 2015 a total of 1,019 patients were enrolled in the study at 11 sites, with radical prostatectomy being the predominant etiology in 285 (28%). Of those 285 patients treated with radical prostatectomy 280 (98.2%) received an AMS 700™. Of these patients 65.0% (182 of 280) had placement of the reservoir in the traditional retropubic space vs 31.8% (89 of 280) in a submuscular location. Of those patients not treated with radical prostatectomy receiving an AMS 700, fewer underwent reservoir placement in the submuscular location (17.7%, 124 of 702, vs 80.9%, 568 of 702; p0.001). Of those patients receiving an AMS 700, those treated with radical prostatectomy and those with diabetes had more outpatient admissions (less than 24 hours, 56.8% and 52.1%, respectively) compared to those with cardiovascular disease and Peyronie's disease (42.0% and 35.6%, respectively, p0.001).This first-of-its-kind, large, prospective, multicenter study reveals most penile implant cases in North America receive an inflatable penile prosthesis and that radical prostatectomy is the most common primary etiology of penile implant surgery. Moreover, patients treated with radical prostatectomy were more likely to have the reservoir placed in a submuscular location, have a longer operating room time and be admitted to the hospital overnight compared with other patient groups.

Introduction Given the number of confounders in predicting erectile function recovery after radical prostatectomy (RP), a nomogram predicting the chance to be functional after RP would be useful to patients’ and clinicians’ discussions. Aim To develop preoperative and postoperative nomograms to aid in the prediction of erectile function recovery after RP. Main Outcome Measures International Index of Erectile Function (IIEF) erectile function domain score-based erectile function. Methods A prospective quality-of-life database was used to develop a series of nomograms using multivariable ordinal logistic regression models. Standard preoperative and postoperative factors were included. Main Outcome Measures The nomograms predicted the probability of recovering functional erections (erectile function domain scores ≥24) and severe erectile dysfunction (≤10) 2 years after RP. Results 3 nomograms have been developed, including a preoperative, an early postoperative, and a 12-month postoperative version. The concordance indexes for all 3 exceeded 0.78, and the calibration was good. Clinical Implications These nomograms may aid clinicians in discussing erectile function recovery with patients undergoing RP. Strengths & Limitations Strengths of this study included a large population, validated instrument, nerve-sparing grading, and nomograms that are well calibrated with excellent discrimination ability. Limitations include current absence of external validation and an overall low comorbidity index. Conclusions It is hoped that these nomograms will allow for a more accurate discussion between patients and clinicians regarding erectile function recovery after RP.

In the population of patients with prostate cancer, survivorship has come to the forefront of continuity-of-care. In addition to urinary control, erectile function is a significant issue after radical pelvic surgery. Penile prosthesis surgery remains an excellent option for restoring erectile function to those for whom more conservative measures have failed. This review article outlines the anatomical, surgical and post-operative consideration involved in the placement of a penile prosthesis in this special patient population.

Introduction After its U.S. FDA approval in 2013, Collagenase Clostridium histolyticum (CCh) has seen increasing use as a nonoperative treatment for Peyronie's disease (PD). We review the history of CCh and trials that led to its adoption. Aim To provide a historical and contemporary context for the evolution of Collagenase Clostridium histolyticum as a treatment modality for Peyronie's disease. Methods A comprehensive search of peer-reviewed literature was performed pertaining to CCh and its biochemical and clinical significance. Main Outcome Measure The main outcome studied was the efficacy and safety profile of CCh in PD. CCh use in other diseases processes and its associated outcomes are also described. Results CCh injection yields objective improvement in penile curvature across multiple trials in PD patients. Recently, level 1 strength of evidence has emerged supporting its widespread use. As such, CCh stands as the only FDA-approved injectable therapy for PD. Adverse events were namely limited to local reactions. Serious systemic complications and need for intervention were rare. Conclusions CCh is a safe and effective treatment for PD patients with deformities and plaque configuration amenable to injectable therapy. Multiple trials have demonstrated improvements in objective and subjective metrics such as penile curvature and bother scores. However, multiyear follow-up is needed to assess durability and its sustained clinical significance. Currently, refinement in dosing and technique has established a niche for CCh in PD patients who are affected by their symptoms but are not yet committed to surgical intervention. Yang KK and Bennett N. The history of collagenase clostridium histolyticum.

Plaque incision/excision and grafting are a specialized procedure reserved for men with Peyronie’s disease, featuring severe penile curvature, near-normal erectile function, and adequate erectile length. The choice of graft material requires careful consideration of the positive and negative attributes. Grafts may be divided into three distinct categories: synthetic, autologous, and extracellular materials. A description of each is presented below with a brief relevant literature review.

In this survey sent to the members of the Sexual Medicine Society of North American (SMSNA), Yafi et al . assessed the providers’ experience with intralesional injection of collagenase clostridium histolyticum (CCh) for Peyronie’s disease (PD). The anonymous, 33-question survey was sent to 693 members of SMSNA with valid email addresses and requested responses from CCh prescribers. The 100 responders (14.4% response rate), were relatively evenly distributed in their experience administering CCh injections with 36%, 23% and 41% of responders performing injections on ≤10 patients, 10–20 patients, and >20 patients respectively.

Background Although there is a strong correlation between erectile dysfunction and Peyronie's disease (PD), there are limited data on the efficacy and satisfaction of inflatable penile prosthesis (IPP) placement in this population. Aim To assess the efficacy and overall satisfaction of IPP placement in men with erectile dysfunction and concomitant PD using the Prospective Registry of Outcomes with Penile Prosthesis for Erectile Restoration (PROPPER). Methods Data from the PROPPER study were examined to determine patient baseline characteristics and primary and secondary etiologies before IPP treatment and included type and size of implant received, presence of corporal fibrosis, and operative time. Men completed 5 validated questionnaires at baseline and annually out to 5 years. Outcomes IPP placement was performed in 250 patients with PD with comparable surgical times and outcomes as in patients without PD. Results 1,180 men underwent IPP insertion at 11 sites; of these, 250 (21.2%) were diagnosed with PD. This is an ongoing study; 1- and 2-year data are available for 177 (70.8%) and 130 (52.0%) patients, respectively. Intraoperatively, 51.2% patients with PD had corporal fibrosis, with an average operative time of 52.8 minutes. At baseline, 19.3% of men (36 of 187) with PD reported being depressed, with a decrease to 10.5% (6 of 57; P = .02) and 10.9% (5 of 46; P = .07) at 1- and 2-year follow-ups, respectively. More than 80% of patients with PD were satisfied or very satisfied at 1- and 2-year follow-ups. In addition, more than 88% of patients with PD were using their device at the 1- and 2-year follow-up visits. Clinical Implications Patients with concomitant PD and erectile dysfunction can safely and effectively have an IPP placed with similar outcomes as patients without PD. Strengths and Limitations The 1st limitation was that all participating prosthetic urologists were high-volume implanters and these results might not be representative of those of general urologists. A 2nd limitation was that none of the patients were randomized. A 3rd limitation was that although most study points were mandatory, some of the data collection, including depression data, was optional, with not all sites participating. A 4th limitation was that depression data were self-reported. Conclusion IPP can be inserted in patients with PD with acceptable patient satisfaction and usage and depressive symptoms appear to lessen in patients with PD after IPP placement.

Objective To determine the proportion of men presenting for fertility evaluation who reported having an established primary care physician (PCP). Design Retrospective, observational study. Setting Academic health center. Patient(s) All men presenting for initial male factor infertility consultation with a single reproductive urologist between 2002 and 2018. Intervention(s) Men were asked to provide the name of their PCP at the time of initial visit. Main Outcome Measure(s) Descriptive statistics characterized the proportion of men with a PCP at the time of evaluation and associations between PCP status and clinical characteristics. Result(s) Among 4,127 men presenting for initial fertility consultation, 844 (20.5%) reported having an established PCP, 480 (11.6%) reported no PCP, and 2,803 (67.9%) did not have data available. Among 1,302 men who had a prior primary care visit within our healthcare system, 414 (31.8%) had been seen within 1 year before their fertility evaluation. Men with an established PCP were slightly older than those without a PCP, with higher body mass index, and lower systolic blood pressure. Hormonal profiles were similar across groups, but men with an established PCP had a significantly higher total motile sperm count than those without a PCP, median 53 (interquartile range, 11–109) versus 35 (interquartile range, 8–98). Conclusion(s) More than one third of men presenting for fertility evaluation did not have an established PCP. Reproductive urologists are uniquely positioned to facilitate the critical relationship between young men and PCPs, which should be a key component of the male fertility treatment paradigm.

Since the original inflatable penile prosthesis in the 1970s, several enhancements to penile prosthesis implant design, implant surgical technique, and post-operative care have been developed to increase overall patient (and partner) satisfaction rates. We, in this communication, seek to discuss these advancements and the overall impact in combating erectile dysfunction. As we continue to pursue avenues of effective and definitive treatment modalities for erectile dysfunction refractory to medical therapy, rates of infection and mechanical failure will hopefully continue to decline in the perioperative setting.

The quality of functional outcome has become increasingly important in view of improvement in prognosis with colorectal cancer patients. Sexual dysfunction remains a common problem after colorectal cancer treatment, despite the good oncologic outcomes achieved by expert surgeons. Although radiotherapy and chemotherapy contribute, surgical nerve damage is the main cause of sexual dysfunction. The autonomic nerves are in close contact with the visceral pelvic fascia that surrounds the mesorectum. The concept of total mesorectal excision (TME) in rectal cancer treatment has led to a substantial improvement of autonomic nerve preservation. In addition, use of laparoscopy has allowed favorable results with regards to sexual function. The present paper describes the anatomy and pathophysiology of autonomic pelvic nerves, prevalence of sexual dysfunction, and the surgical technique of nerve preservation in order to maintain sexual function.

We studied the incidence and risk factors for the development of erythrocytosis with implantable testosterone pellets.A multi-institutional retrospective database analysis was used to evaluate men treated with testosterone pellets between 2009 and 2014. Inclusion criteria consisted of adult, hypogonadal males who had a full complement of pretreatment and posttreatment surveillance studies. Pretreatment and posttreatment values were compared with Wilcoxon signed rank tests. Multiple linear regression was used to identify potential risk factors for significant hematocrit elevation.A total of 97 patients were included in the study. The average age of the cohort was 52 years (range 24 to 80). Mean hematocrit before and after pellet implantation was 43.9% and 46.1%, respectively, corresponding to an increase of 2.2% (CI 1.4-2.9, p0.001). The average increase in testosterone was 145.3 ng/dl from an initial mean of 278.9 ng/dl (CI 105.7-184.9, p0.001). Multiple linear regression demonstrated that pretreatment hematocrit was inversely related to the expected change in hematocrit. Pretreatment comorbidity status (ie the presence of hypertension, hyperlipidemia, obesity or diabetes) was not associated with a significant increase in posttreatment hematocrit.Although the data demonstrate a statistically significant increase in hematocrit, an increment of 2.2% is unlikely to translate into clinical relevance. Thus, for this cohort of patients implantable testosterone pellets appear safe in terms of the risk of polycythemia. Pretreatment hematocrit may serve as a predictor of a significant hematocrit increase after the initiation of therapy.

Erectile dysfunction adversely affects up to 20% of all men and is the most commonly treated sexual disorder. The public health implications of this condition are significant and represent a challenge for our healthcare system. The physiological pathways responsible for erections have been extensively studied, and much advancement has been made since the introduction of phosphodiesterase 5 inhibitors. Newer agents, such as dopaminergic and melanocortin receptor agonists, which target central erectogenic pathways, are under investigation. Newer formulations and delivery methods of existing medications such as alprostadil will also be introduced in the near future. Furthermore, low-intensity shockwave lithotripsy and stem cell regenerative techniques are innovative approaches to the treatment of erectile dysfunction.