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Background The testosterone (T) status of a man is influenced by serum concentrations of sex hormone–binding globulin (SHBG). Specifically, tight binding of T to SHBG is believed to render the SHBG-bound T fraction biologically unavailable, meaning that interpretation of T levels in the clinical setting depends in part on knowledge of SHBG concentrations. Although SHBG levels have been reported in population studies, there is scant information for men presenting with clinical symptoms. Objective To report SHBG values for a large cohort of men presenting to a men’s health center. Design, setting, and participants Medical records were reviewed for 1000 consecutive patients seen at our center with a reported SHBG value. SHBG concentrations were measured by a national clinical laboratory using an immunoassay run on a Beckman Coulter DXi system. Outcome measurements and statistical analysis Patients were age-stratified and data were plotted in the form of comparative histograms. Results and limitations The mean age (± standard deviation) of the total cohort was 53.5 ± 13.5 yr (range 17–91). The mean SHBG was 31.8 ± 15.2 nmol/l (range 6-109), with a nearly 20-fold difference from the lowest to the highest values. SHBG was >60 nmol/l in 5.6% of the men. Patients were stratified according to age. A total of 535 patients were ≤54 yr old. In this younger cohort, the mean age was 40.52 ± 7.9 yr (range 17–54) and mean SHBG was 27.7 ± 13.3 nmol/l (range 6–88), and 2.2% of patients had SHBG >60 nmol/l. A total of 465 patients were ≥55 yr old. In this older cohort, the mean age was 64.8 ± 7.23 yr (range 55–91) and mean SHBG was 36.6 ± 15.8 nmol/l (range 11–109), and 9% of patients had SHBG >60 nmol/l. Mean SHBG was significantly higher in the older group ( p Conclusions A remarkably wide distribution of SHBG concentrations was observed in a clinical population of men presenting to a men’s health center, among both younger and older men. Since SHBG concentrations greatly influence test results for hormones that bind to SHBG, recognition of this large interindividual variability should be considered in the clinical interpretation of these hormone results, particularly for T. Routine SHBG testing should be considered for men suspected of T deficiency. Patient summary Sex hormone–binding globulin (SHBG) levels vary widely among both older and younger men. This may impact the interpretation of test results for hormones that bind to SHBG, such as testosterone, since the portion that binds to SHBG is believed to not be biologically available.

Introduction Penile prosthesis infections remain challenging despite advancements in surgical technique, device improvements, and adoption of antibiotic prophylaxis guidelines. Aim To investigate penile prosthesis infection microbiology to consider which changes in practice could decrease infection rates, to evaluate current antibiotic prophylaxis guidelines, and to develop a proposed algorithm for penile prosthesis infections. Methods This retrospective institutional review board–exempt multi-institutional study from 25 centers reviewed intraoperative cultures obtained at explantation or Mulcahy salvage of infected three-piece inflatable penile prostheses (IPPs). Antibiotic usage was recorded at implantation, admission for infection, and explantation or salvage surgery. Cultures were obtained from purulent material in the implant space and from the biofilm on the device. Main Outcome Measures Intraoperative culture data from infected IPPs. Results Two hundred twenty-seven intraoperative cultures (2002–2016) were obtained at salvage or explantation. No culture growth occurred in 33% of cases and gram-positive and gram-negative organisms were found in 73% and 39% of positive cultures, respectively. Candida species (11.1%), anaerobes (10.5%) and methicillin-resistant Staphylococcus aureus (9.2%) constituted nearly one third of 153 positive cultures. Multi-organism infections occurred in 25% of positive cultures. Antibiotic regimens at initial implantation were generally consistent with American Urological Association (AUA) and European Association of Urology (EAU) guidelines. However, the micro-organisms identified in this study were covered by these guidelines in only 62% to 86% of cases. Antibiotic selection at admissions for infection and salvage or explantation varied widely compared with those at IPP implantation. Conclusion This study documents a high incidence of anaerobic, Candida, and methicillin-resistant S aureus infections. In addition, approximately one third of infected penile prosthesis cases had negative cultures. Micro-organisms identified in this study were not covered by the AUA and EAU antibiotic guidelines in at least 14% to 38% of cases. These findings suggest broadening antibiotic prophylaxis guidelines and creating a management algorithm for IPP infections might lower infection rates and improve salvage success.

Limited literature exists regarding the safety of testosterone therapy in men treated for prostate cancer. We present multi-institutional data on testosterone therapy in hypogonadal men with prostate cancer treated with radiation therapy.We retrospectively reviewed the records of hypogonadal men treated with testosterone therapy after radiation therapy for prostate cancer at 4 institutions. Serum testosterone, free testosterone, estradiol, sex hormone-binding globulin, prostate specific antigen, prostate specific antigen velocity and prostate biopsy findings were analyzed.A total of 98 men were treated with radiation therapy. Median age was 70.0 years (range 63.0 to 74.3) at initiation of testosterone therapy. Median baseline testosterone was 209 ng/dl (range 152 to 263) and median baseline prostate specific antigen was 0.08 ng/ml (range 0.00 to 0.33). In the cohort the tumor Gleason score was 5 in 3 men (3.1%), 6 in 44 (44.9%), 7 in 28 (28.6%), 8 in 7 (7.1%) and 9 in 4 (4.1%). Median followup was 40.8 months (range 1.5 to 147). Serum testosterone increased to a median of 420 ng/dl (range 231 to 711) during followup (p0.001). Overall a nonsignificant increase in mean prostate specific antigen was observed from 0.08 ng/ml at baseline to 0.09 ng/ml (p = 0.05). Among patients at high risk prostate specific antigen increased from 0.10 to 0.36 ng/ml (p = 0.018). Six men (6.1%) met criteria for biochemical recurrence.Testosterone therapy in men following radiation therapy for prostate cancer was associated with a minor increase in serum prostate specific antigen and a low rate of biochemical recurrence.

For several decades any diagnosis of prostate cancer (PCa) has been considered an absolute contraindication to the use of testosterone (T) therapy in men. Yet this prohibition against T therapy has undergone recent re-examination with refinement of our understanding of the biology of androgens and PCa, and increased appreciation of the benefits of T therapy. A reassuringly low rate of negative outcomes has been reported with T therapy after radical prostatectomy (RP), radiation treatments, and in men on active surveillance. Although the number of these published reports are few and the total number of treated men is low, these experiences do provide a basis for consideration of T therapy in selected men with PCa. For clinicians considering offering this treatment, we recommend first selecting patients with low grade cancers and undetectable prostate-specific antigen following RP. Further research is required to define the safety of T therapy in men with PCa. However, many patients symptomatic from T deficiency are willing to accept the potential risk of PCa progression or recurrence in return for the opportunity to live a fuller and happier life with T therapy.

To report our initial experiences with testosterone undecanoate (TU 750) mg (AVEED) in men with testosterone deficiency.All patients receiving TU 750 mg at our center between July 1, 2014, and August 1, 2016, were identified. Clinical response was assessed through structured interviews and laboratory evaluations. Adverse events were documented, including increase in prostate specific antigen (PSA), increase in hematocrit (Hct), and the development of postinjection cough.More than 2 injections were received by 147 men, with mean age 63.2 years. Mean baseline total testosterone (T) and free T were 305 ng/dL and 0.69 ng/dL, respectively. Nadir mean results during treatment were higher for total and free T, at 413.2 ng/dL and 0.81 ng/dL, respectively (P .001 for each). Symptomatic improvement was reported by 97 of 147 patients (66.0%). Thirty patients (20.4%) discontinued therapy. Return of symptoms before the next injection was noted by 34%, managed by reduced interval between injections and/or supplemental injections of T cypionate. Three patients (2%) experienced transient cough immediately after TU injection, none requiring intervention. Mean Hct rose from 45.6% to 47.2%. Mean PSA rose from 1.7 ng/mL to 2.0 ng/mL. There were no strokes, myocardial infarctions, or deaths, and no new cases of prostate cancer.This initial clinical experience with TU 750 mg provides evidence for good patient satisfaction and persistence with treatment, together with a favorable safety profile. Optimal dosing may be less than 10 weeks for some individuals.

Objective. Computer-based immunization tracking is a routine part of many pediatric practices; however, data quality is inconsistent and entry often relies on dedicated data entry personnel and is time-consuming, expensive, or difficult. The purpose of this study was to evaluate data quality, nursing satisfaction, and reduction in documentation burden after the introduction of a point-of-service immunization entry system in an inner-city pediatric primary care center. Design. Prospective preintervention and postintervention study. Methods. Visit records from all pediatric nonurgent care visits for patients Results. One hundred forty-seven (63.6%) of 231 preintervention and 132 (51.4%) of 257 postintervention children received at least 1 immunization (immunized) during the study visit. Gender and mean age were similar for immunized children in the 2 groups. In the preintervention group, 56 (37.9%) of 147 immunized children had at least 1 dose missing (a total of 128 of 343 doses administered) from the immunization tracking database compared with none in the postintervention group. Medical record review showed that 92.6% of preintervention and 91.4% of postintervention children were on-schedule after the study visit. However, missing data lead to the misclassification of preintervention children—only 68.4% were reported by the database to be on-schedule. All 9 nurses reported using the program all the time to enter immunizations, 89% said that the program required somewhat or a lot less time, and 100% strongly recommended continued use of the program. All 9 nurses also reported that they would be somewhat or very unenthusiastic about the system if labels were not available. During the 12 months after introduction of the system, 8273 forms containing immunization information were printed, preventing nurses from having to write >101 000 dates. Conclusions. Immunization entry by nurses at the time of immunization preparation improves the quality of tracking data, reduces misclassification of immunization needs, saves time, and can be well-accepted. It is likely that poor data quality in some tracking systems has led to falsely low immunization coverage estimates. Systems such as the one in this study can improve quality and should be integrated into routine clinical practice.

Testosterone deficiency (TD) is a common clinical condition that causes sexual and non-sexual symptoms. Low serum concentrations of testosterone also predict significant health outcomes, such as diabetes, metabolic syndrome, and increased mortality. Treatment with testosterone therapy (TTh) effectively improves symptoms, and also has a positive impact on body composition and bone density. Since there is no serum testosterone value that reliably identifies men who will respond to treatment from those who will not, healthcare providers must exercise clinical judgment in making the diagnosis of TD. Multiple formulations of TTh are available, each with advantages and disadvantages. Overall, TTh is relatively safe but the risks, such as erythrocytosis, makes long-term monitoring mandatory. The evidence does not support concerns regarding cardiovascular and prostate cancer risks.

This report presents our experience with T therapy in a cohort of T-deficient men on active surveillance (AS) for Gleason 3 + 3 and Gleason 3 + 4 prostate cancer (PCa). A retrospective chart review identified 28 men with T deficiency who underwent T therapy (T group) for at least 6 months while on AS for PCa. A comparison group of 96 men on AS for PCa with untreated T deficiency (no-T group) was identified at the same institution. The AS protocol followed a modified Epstein criteria and allowed inclusion of men with a single core of low-volume Gleason 3 + 4 PCa. Mean age was 59.5 and 61.3 years, and mean follow-up was 38.9 and 42.4 months for the T and no-T groups, respectively. Of all 28 men in the T group, 3 (10.7%) men developed an increase in Gleason score while on AS. Of 22 men in the T group with Gleason 3 + 3 disease, 7 (31.8%) men developed biopsy progression including 3 men (13.6%) who developed Gleason 3 + 4 PCa. Of 6 men with Gleason 3 + 4 disease at baseline, 2 (33.3%) men developed an increase in tumor volume, and none developed upgrading beyond Gleason 3 + 4. All 96 men in the no-T group had Gleason 3 + 3 disease at baseline and, 43 (44.7%) developed biopsy progression, including 9 men (9.38%) with upgrading to Gleason 7 (3 + 4). Biopsy progression rates were similar for both groups and historical controls. Biopsy progression in men on AS appears unaffected by T therapy over 3 years. Prospective placebo-controlled trials of T therapy in T-deficient men on AS should be considered given the symptomatic benefits experienced by treated men.

Introduction The prognostic value of serum total testosterone (TT) prior to treatment has not been investigated. Aim This study was performed to determine how baseline TT influences changes in body composition in men undergoing testosterone therapy (TTh). Main Outcome Measures Response to TTh in a clinical population of men with symptomatic testosterone deficiency (TD). Methods Retrospective case series of 58 men with TD were treated with TTh. All were naive to previous TTh. Men were stratified into two groups: group 1 (N = 38) consisted of men with baseline TT > 300 ng/dL (10.4 nmol/L) and group 2 (N = 20) consisted of men with total TT Results At baseline, both groups had similar lean mass (LM) and fat mass (FM), but percentage of trunk FM and percentage of total FM were significantly higher in group 2. Both groups demonstrated similar increases in LM for arms, legs, and total body. Percentage of total FM significantly decreased in both groups. Conclusions. Baseline severity of symptomatic TD influences body composition. Similar changes in LM and FM were seen with TTh regardless of baseline severity in TD. Men with TT > 300 ng/dL demonstrated significant positive changes in body composition. The similarity in objective response to TTh in these two groups provides support for the value of FT in the assessment of men with symptoms suggestive of TD. Di Sante S, Conners WP, and Morgentaler A. Influence of baseline serum testosterone on changes in body composition in response to testosterone therapy. J Sex Med 2012;9:585–593.

Introduction Standard technique (ST) for implantation of testosterone pellets involves making a single linear track in the subcutaneous tissue of the buttock from the incision. After our initial experience with this modality, we modified this surgical technique to our current "V" technique (VT). This involves two tracks both caudally directed and emanating from the same skin incision but angulated approximately 10–15 degrees apart. While this allows additional pellets to be inserted more easily, and increased space to place those pellets further from the skin incision, it minimally increases the surgical procedure. Aim We sought to examine the impact of this technical modification on therapeutic efficacy and surgical complication rates. Methods Retrospective chart review of all patients treated with testosterone pellets at our institution. Main Outcome Measure Complication rates for infection, extrusion, hematoma, and pain. Results One hundred sixty‐eight patients underwent 281 implantation procedures (40 via ST and 241 via VT). The mode number of pellets used with ST was 8 (range 6–8) and with VT was 10 (range 10–13). Incidence of pellet extrusion was 7.5% with ST and 0.8% with VT. Infection complicated ST in 5% of cases but only 1.2% with VT. No cases of hematoma were seen with ST but 1.2% of VT cases. Pain prompting discontinuation of therapy was seen in 7.5% with ST and 1.7% with VT. Significant pain without discontinuation was seen in 5% with ST and 1.2% with VT. Only in 1 of the 3 cases of hematoma was the individual on blood thinners. Fifty‐eight other insertions were performed on blood thinners without significant hematoma. None of the individuals who developed infection or bleeding required additional surgical therapy. Conclusion VT allows successful placement of larger number of pellets, with low rates of complications, especially extrusion, even in men on anticoagulants. Conners W, Flinn K, and Morgentaler A. Outcomes with the "V" implantation technique vs. standard technique for testosterone pellet therapy. J Sex Med **;**:**–**.