Phosphodiesterase type 5 inhibitors as treatment for erectile dysfunction: a webinar-based poll unveiling perceptions of healthcare professionals.

Aim: Erectile dysfunction (ED) is marked by a recurring incapacity to achieve or uphold a satisfactory erection during sexual activities. The study aims to increase awareness about male reproductive health, dispel misconceptions about ED and encourage physician-patient discussions. Materials & methods: A live online poll was conducted during a 3-day webinar titled "Turning the Tide of Men's Health" organized by Viatris™ in collaboration with the Saudi Society of Family and Community Medicine and attended by healthcare professionals (HCPs) from diverse specialties. The attendees voluntarily responded to nine poll questions on adherence to ED medication, use of phosphodiesterase type 5 inhibitors (PDE5is) as cure versus management of ED and patients' challenges. The responses to the poll questions were recorded and assessed to understand the perceptions of HCPs. Results: The poll garnered 10,423 responses from 5831 attendees on the second day of the webinar. The key findings included HCPs' perceptions that PDE5is contribute to ED management not complete cure. The respondents acknowledged that adherence to ED medications might decline on days without planned sexual activity, and long-term adherence on a daily PDE5i is exhibited by a relatively modest percentage of ED patients. The consensus among respondents was that PDE5is do not enhance or generate sexual desire, and the daily schedule of ED treatment may be burdensome for some patients. Conclusion: The findings from this poll offer insights into the perspectives of HCPs regarding the usage of PDE5is to treat ED. Responders of the poll generally agreed that PDE5is can help manage ED without affecting desire, though adherence may be lower on days without planned sexual activity. Furthermore, most respondents acknowledged that adhering to a daily pill regimen posed a greater burden than waiting for the medication to take effect.

Sequence Variants in PSMB8/PSMB9 Immunoproteasome Genes and Risk of Urothelial Bladder Carcinoma.

BACKGROUND: The PSMB8 and PSMB9 immunoproteasome genes are essential in cell processes, such as decisions on cell survival or death, the cell cycle, and cellular differentiation. Because recent evidence has demonstrated an immunological role for proteasomes in various malignancies, including urothelial bladder carcinoma (UBC), we evaluated single nucleotide polymorphisms (SNPs) in PSMB9 and PSMB8. We determined any associations between these SNPs and susceptibility to UBC in the Saudi community. METHODS: Samples of genomic DNA were taken from buccal cells of 111 patients with UBC and 78 healthy controls. TaqMan Real-Time PCR was used to determine genotype distributions and allele frequencies for the PSMB9 rs17587 G>A and PSMB8 rs2071543 G>T SNPs. We used SNPStats (https://www.snpstats.net) to choose each SNP's best interactive inheritance model. RESULTS: The PSMB9 rs17587 SNP was associated with the risk of UBC (odds ratio [OR] = 5.21, P < 0.0001). In contrast, the PSMB8 rs2071543 SNP showed no association with UBC risk (OR = 1.13, P = 0.7871). In terms of genotypic distribution, the rs17587 G>A SNP was more frequent in UBC cases than controls in both the dominant (OR = 7.5; 95% confidence interval, 3.7-15.1; P = 0.0051) and recessive (OR = 17.11, 95% confidence interval 5.1-57.4; P = 0.0026) models. Genotypic distribution of the PSMB8 rs2071543 G>T SNP was not significantly different between cases and controls in any interactive inheritance models (P > 0.05). CONCLUSION: These results suggest a potential role for PSMB9 as a biomarker for increased UBC risk. Discovering more genetic variants within immunoproteasome genes related to antigen presentation could help further our understanding of this risk.

Solitary incidental primary Kaposi's sarcoma of the glans penis in a patient with no risk factors.

Kaposi's sarcoma (KS) is an endothelial neoplasm, originally reported by Moritz Kaposi in 1872. It most commonly involves the lower extremities. Its clinical presentation and course can be quite variable. We present a rare case of solitary incidental primary KS of the glans penis in a circumcised, immunocompetent male who is human immunodeficiency virus seronegative. The lesion was discovered incidentally when the otherwise asymptomatic male presented to our outpatient department for an unrelated issue and was given a physical examination. To our knowledge, this is the first incidentally discovered case of primary penile KS.

Urological knowledge among primary health care physicians in Saudi Arabia.

OBJECTIVES: To evaluate the general knowledge among primary health care (PHC) physicians regarding the management of common urological problems in Saudi Arabia. METHODS: This is an observational prospective study, where a self-administered questionnaire was distributed to practicing PHC physicians in the western region of Saudi Arabia on January 2017. The questionnaire consisted of 21-item questions, inquiring about demographics and general urological knowledge and skills. The management of common urological problems was assessed by case scenarios for specific urological condition, including urethral catheterization, definition and evaluation of hematuria, recognition of age-specific increase in prostatic specific antigen (PSA), and management of lower urinary tract symptoms. Results: A total of 148 questionnaires were distributed, with a response rate of 75.7%, where 112 respondents completed the questionnaires,  including 54.3% residents, 39% general practitioners, and 5.4% specialists. Fifty-seven percent of respondents were males and 68% were Saudi practitioners. A higher number of respondents expressed that they were able to catheterize a male than female patient (56.5% versus 34.3%). Only 6.4% of respondents defined microscopic hematuria accurately. Knowledge about hematuria, serum prostate specific antigen and overactive bladder was low in all groups. Apart from hematuria, seeking urological consultations was less than 35% for all other disease entities. CONCLUSION: Urological knowledge among PHC physicians seems to be insufficient. Significant percentages of the participants were unable to catheterize a female patient, did not know the definition of hematuria; and whether to ask for urological consultations in cases of hematuria, increased PSA, and overactive bladder.

Challenges to Practicing Sexual Medicine in the Middle East.

INTRODUCTION: The Middle East is a vast region that includes the Arabian Peninsula, Turkey, Iran, the Levant, and North Africa. Some of the world's earliest civilizations appeared in this region and major religions such as Judaism, Christianity, and Islam originated there. It is an influential region in politics, economy, and resources, but it remains largely enigmatic to those outside the region. The various ethnicities, religions, traditions, and customs in the region have made it unique and diverse at the same time. Among the most controversial topics that have emerged about the Middle East is sex and sexuality. Images of women wearing veils and black abayas come to mind. However, in this region, sexual freedoms such as polygyny are permitted. It is in these settings that are unlike anywhere else that regional sexual medicine physicians must practice and produce results. AIMS: To present some factors challenging to the practice of sexual medicine in the Middle East. METHODS: The literature was reviewed for studies that addressed sexual medicine in the Middle East. This was supplemented by studies that investigated certain patterns of practice and behaviors that are often encountered in medical practice in the region. MAIN OUTCOME MEASURES: Factors contributing to the difficulties in practice faced by sexual medicine physicians in the Middle East. RESULTS: Several societal, environmental, and patient- and physician-related factors were identified. CONCLUSION: It can be particularly challenging to practice sexual medicine in the Middle East. However, the region needs qualified sexual medicine specialists to debunk many myths concerning sexuality and sexual health, in addition to the day-to-day practice of this specialty.

Sexual Health in Undergraduate Medical Education: Existing and Future Needs and Platforms.

INTRODUCTION: This article explores the evolution and current delivery of undergraduate medical education in human sexuality. AIM: To make recommendations regarding future educational needs, principles of curricular development, and how the International Society for Sexual Medicine (ISSM) should address the need to enhance and promote human sexuality education around the world. METHODS: The existing literature was reviewed for sexuality education, curriculum development, learning strategies, educational formats, evaluation of programs, evaluation of students, and faculty development. MAIN OUTCOME MEASURES: The prevailing theme of most publications in this vein is that sexuality education in undergraduate medical education is currently not adequate to prepare students for future practice. RESULTS: We identified components of the principles of attitudes, knowledge, and skills that should be contained in a comprehensive curriculum for undergraduate medical education in human sexuality. Management of sexual dysfunction; lesbian, gay, bisexual, and transgender health care; sexuality across genders and lifespan; understanding of non-normative sexual practices; sexually transmitted infections and HIV, contraception; abortion; sexual coercion and violence; and legal aspects were identified as topics meriting particular attention. CONCLUSION: Curricula should be integrated throughout medical school and based on principles of adult learning. Methods of teaching should be multimodal and evaluations of student performance are critical. To realize much of what needs to be done, faculty development is critical. Thus, the ISSM can play a key role in the provision and dissemination of learning opportunities and materials, it can promote educational programs around the world, and it can articulate a universal curriculum with modules that can be adopted. The ISSM can create chapters, review documents, slide decks, small group and roleplay topics, and video-recorded materials and make all this material easily available. An expert consensus conference would be needed to realize these recommendations and fulfill them.

Holmium laser enucleation versus photoselective vaporization for prostatic adenoma greater than 60 ml: preliminary results of a prospective, randomized clinical trial.

PURPOSE: To our knowledge we report the first single center, prospective, randomized study comparing holmium laser enucleation and high performance GreenLight™ prostate photoselective vaporization as surgical treatment of prostatic adenomas greater than 60 ml. MATERIALS AND METHODS: A total of 80 patients with a large prostatic adenoma were randomly assigned to surgical treatment with holmium laser enucleation or photoselective vaporization. International Prostate Symptom Score, International Index of Erectile Function-15, maximum flow rate, post-void residual urine, serum prostate specific antigen and transrectal ultrasound volume were recorded. RESULTS: Patient baseline characteristics were similar for holmium laser enucleation and photoselective vaporization. Operative time and catheter removal time were almost equal in the 2 groups (p = 0.7 and 0.2, respectively). Eight vaporization cases were converted to transurethral prostate resection or holmium laser enucleation intraoperatively due to bleeding. A significantly higher maximum flow rate and lower post-void residual urine were noted in holmium laser cases during the entire followup (at 1 year each p = 0.02). However, no significant difference in International Prostate Symptom Score, quality of life or International Index of Erectile Function-15 was detected. Prostate volume and serum PSA decreased 78% and 88% in the holmium laser group, and 52% and 60% in the vaporization group, respectively. CONCLUSIONS: Holmium laser enucleation and photoselective vaporization are effective for lower urinary tract symptoms due to a large prostatic adenoma. Early subjective functional results (maximum flow rate and post-void residual urine) of holmium laser enucleation appear to be superior to those of photoselective vaporization. In our hands cases intended to be treated with photoselective vaporization were at 22% risk of conversion to another modality. This could reflect our determination to vaporize to the capsule in all vaporization cases.

Varicocele and male factor infertility treatment: a new meta-analysis and review of the role of varicocele repair.

CONTEXT: Varicocele is a common condition, found in many men who present for infertility evaluation. OBJECTIVE: To assess the effect of varicocelectomy on male infertility. EVIDENCE ACQUISITION: A literature search was performed using Embase and Medline. Literature reviewed included meta-analyses and randomized and nonrandomized prospective (controlled and noncontrolled) studies. In addition, a new meta-analysis was performed. EVIDENCE SYNTHESIS: Four randomized controlled trials reporting on pregnancy outcome after repair of clinical varicoceles in oligozoospermic men were identified. Using the random effect model, the combined odds ratio was 2.23 (95% confidence interval [CI], 0.86-5.78; p=0.091), indicating that varicocelectomy is moderately superior to observation, but the effect is not statistically significant. We identified 22, 17, and 5 prospective studies reporting on sperm concentration, total motility, and progressive motility, respectively, before and after repair of clinical varicocele. The random effect model combined improvement in sperm concentration was 12.32 million sperm per milliliter (95% CI, 9.45-15.19; p<0.0001). The random effect model combined improvement in sperm total and progressive motility were 10.86% (95% CI, 7.07-14.65; p<0.0001) and 9.69% (95% CI, 4.86-14.52; p=0.003), respectively. These results indicate that varicocelectomy is associated with a significant increase in sperm concentration as well as total and progressive motility. Prospective studies also show that varicocelectomy reduces seminal oxidative stress and sperm DNA damage as well as improving sperm ultramorphology. Studies indicate that a microsurgical approach to a varicocele repair results in less recurrence and fewer complications than other techniques. CONCLUSIONS: Although there is no conclusive evidence that a varicocele repair improves spontaneous pregnancy rates, varicocelectomy improves sperm parameters (count and total and progressive motility), reduces sperm DNA damage and seminal oxidative stress, and improves sperm ultramorphology. The various methods of repair are all viable options, but microsurgical repair seems to be associated with better outcomes.

Anti-sperm antibodies are not associated with sperm DNA damage: a prospective study of infertile men.

Infertile men have poorer sperm DNA integrity than do fertile men, and this damage may contribute to reducing male reproductive potential. However, the etiology of this damage has not been fully characterized. We sought to examine the relationship, if any, between anti-sperm antibodies and sperm DNA damage in a consecutive series of non-azoospermic, infertile men in order to determine whether anti-sperm antibodies (ASAs) may contribute to sperm DNA damage. We conducted a prospective study on consecutive semen samples obtained from men (n=75) presenting for infertility evaluation. Sperm concentration, motility, strict morphology, ASA levels (by direct mixed agglutination reaction, expressed as the percentage of spermatozoa with IgG or IgA antibodies) and sperm DNA damage (by sperm chromatin structure assay) were evaluated. Mean (+/-SD) sperm concentration and progressive motility were significantly lower in ASA-positive (>40% of sperm coated with ASAs) compared to ASA-negative samples (23.4+/-13.1 x 10(6)/mL and 27+/-15% vs. 74.6+/-61.2 x 10(6)/mL and 46+/-18%, respectively, P<0.05). Sperm progressive motility was inversely correlated with the percentage of IgG-bound (r=-0.33) and IgA-bound spermatozoa (r=-0.25). In contrast, sperm %DNA fragmentation index and percent normal forms were not significantly different in ASA-positive compared to ASA-negative samples (17.5+/-17.9% and 7.5+/-3.0% vs. 17.4+/-13.5% and 6.5+/-2.6%, respectively). The data indicate that ASAs are not associated with sperm DNA damage and suggest that ASAs are unlikely to have a significant direct or indirect effect on sperm DNA integrity.

Microanatomy of the left and right spermatic cords at subinguinal microsurgical varicocelectomy: comparative study of primary and redo repairs.

OBJECTIVES: To examine and compare the left and right spermatic cord arterial and lymphatic anatomy identified at primary and redo microsurgical subinguinal varicocelectomy. METHODS: We reviewed the operative reports of 335 consecutive microsurgical varicocelectomies performed by a single surgeon: 325 primary repairs and 10 reoperations. We recorded number of testicular arteries (internal and external spermatic) and lymphatic channels preserved at subinguinal microsurgical varicocelectomy, and evaluated the relationship between the right and left vascular anatomy at bilateral varicocelectomy. RESULTS: A total of 235 left-sided and 90 bilateral primary repairs were performed. A mean (+/-standard deviation) number of 2.4+/-1.0 arteries and 4.6+/-1.5 lymphatics were identified during the left-sided repairs. For bilateral repairs, there were 2.4+/-0.9 arteries and 4.4+/-1.2 lymphatics on the left and 2.2+/-0.9 arteries and 4.2+/-1.3 lymphatics on the right with a significant correlation between the number of right and left internal spermatic arteries (r=0.42). For the cohort of secondary (redo) varicocelectomies, we identified 2.3+/-0.6 arteries and 4.8+/-1.6 lymphatic channels (not significantly different from the primary varicocelectomy cohorts). CONCLUSIONS: The number of arteries and lymphatics preserved at microsurgical varicocelectomy is highly variable, but there is some similarity in the microanatomy of the right and left spermatic cords at the level of the external inguinal ring. The data also suggest that the number of arteries and lymphatic channels identified at a redo varicocelectomy is comparable to that observed during a primary varicocelectomy.

Identification of spermatozoa in archived testicular cancer specimens: implications for bench side sperm retrieval at orchiectomy.

OBJECTIVES: To evaluate the patterns of spermatogenesis in the normal testicular parenchyma of primary testicular cancers and estimate the feasibility of sperm retrieval at the time of radical orchiectomy. METHODS: We reviewed the archived histologic sections of 39 consecutive patients who had undergone radical orchiectomy for primary testicular cancer at 3 university-affiliated hospitals. We examined all areas of normal (noncancerous) testicular parenchyma to evaluate the level of spermatogenesis and presence of mature spermatozoa in these sections. A minimum of 100 seminiferous tubules were scored per case. We also evaluated the epididymal tubules for the presence of mature spermatozoa. A review of the clinical chart was performed to evaluate the relationship between clinical data and histologic findings. RESULTS: In nearly 40% of the cases evaluated (15/38), the predominant histologic pattern was full spermatogenesis. Mature spermatozoa were identified in nearly 80% (30/38) of the testicular histologic sections and in 50% (14/28) of the evaluable epididymal sections. Clinical stage (presence of extranodal disease) and tumor marker levels were related to the probability of identifying mature spermatozoa in the testis. CONCLUSIONS: The data suggest that sperm retrieval at the time of radical orchiectomy is a feasible fertility option, with a 40% probability of recovering spermatozoa by random biopsy of the noncancerous testicular parenchyma and an 80% probability of recovering spermatozoa with a more extensive dissection. In 50% men, spermatozoa may be recovered by epididymal aspiration alone.

Antioxidants and sperm DNA damage: a clinical perspective.

PURPOSE: Infertile men possess substantially more sperm DNA damage than do fertile men, damage that may impact negatively on reproductive outcomes. In this era of assisted reproductive technologies there is mounting concern regarding the safety of utilizing DNA-damaged spermatozoa in this setting. Therefore, it is important to identify strategies that may reduce sperm DNA damage. The purpose of this review is to discuss the rationale for antioxidant therapy in men with sperm DNA damage and to evaluate the data on the efficacy of dietary and in vitro antioxidant preparations on sperm DNA damage. METHODS: We reviewed the literature on antioxidants and sperm DNA damage. RESULTS: To date, the data suggest that dietary antioxidants may be beneficial in reducing sperm DNA damage, particularly, in men with high levels of DNA fragmentation. However, the mechanism of action of dietary antioxidants has not been established and most of the clinical studies are small. A beneficial effect of in vitro antioxidant supplements in protecting sperm DNA from exogenous oxidants has been demonstrated, however, the effect of these antioxidants in protecting sperm from endogenous ROS, gentle sperm processing and cryopreservation has not been established.

Microsurgical varicocelectomy for infertile men with oligospermia: differential effect of bilateral and unilateral varicocele on pregnancy outcomes.

OBJECTIVES: To evaluate the pregnancy outcomes of two groups of oligospermic men with varicocele, one having a varicocelectomy (group 1) and the other electing not to have surgery (group 2), as varicocele represents the most common factor associated with male infertility and most reports indicate that varicocelectomy has a beneficial effect on male fertility and pregnancy outcome. PATIENTS AND METHODS: We retrospectively reviewed consecutive oligospermic men who had microsurgical varicocelectomy (233, group 1) between September 1996 and January 2002 and a consecutive group of oligospermic men with varicoceles who elected not to have surgery (127, group 2). The outcome measures included changes in semen variables, partner pregnancy rates (assisted and unassisted) and use of assisted reproductive technologies (ART). RESULTS: The mean sperm concentration and motility increased significantly after varicocelectomy (P < 0.05). The natural pregnancy rate in group 1 (38%) was higher than in group 2 (30%). The use of ART was significantly greater in group 2 than group 1. In the subset of couples with bilateral varicocele, the natural pregnancy rate was significantly higher in group 1 than group 2 (48% vs 15%, respectively, P = 0.008). CONCLUSIONS: This study suggests that the natural pregnancy rate is higher after varicocelectomy than in those not having surgery, although the difference was not statistically significant. However, in the subset of couples with bilateral varicocele, the spontaneous pregnancy rates were significantly higher after surgery.

Semen analysis and sperm function assays: what do they mean?

Appropriate laboratory testing is an integral component of the proper evaluation of the male presenting with infertility. This article reviews the semen analysis and sperm function assays. Sperm function testing is used to determine if the sperm have the biologic capacity to perform the tasks necessary to reach and fertilize ova and ultimately result in live births. For a sperm to be fertile in vivo, it must be able to traverse the cervical mucus and reach the ova. The sperm must undergo capacitation and the acrosome reaction, fuse with the oolemma, and incorporate into the ooplasm. Proper embryo development requires that functional DNA be delivered to the ooplasm. Defects in any of these steps may result in infertility. A variety of tests are available to evaluate different aspects of these functions. To accurately use these functional assays, the clinician must understand what the tests measure, what the indications are for the assays, and how to interpret the results to direct further testing or patient management.

Sperm head morphology is related to high deoxyribonucleic acid stainability assessed by sperm chromatin structure assay.

OBJECTIVE: To examine the relationship between sperm strict morphology and sperm chromatin integrity. DESIGN: Prospective study. SETTING: Infertility clinic. PATIENT(S): Eighty-seven consecutive semen samples from non-azoospermic men presenting for infertility evaluation and 6 samples from fertile donors. INTERVENTION(S): Assessment of standard semen parameters and sperm chromatin structure assay (SCSA) parameters (%DFI [DNA fragmentation index] and %HDS [high DNA stainability]). Evaluation of %HDS and %DFI after treatment with dithiothreitol (a thiol-reducing agent used to decondense sperm nuclei) was also undertaken. MAIN OUTCOME MEASURE(S): Relationship between sperm strict morphology defects and SCSA parameters (%DFI and %HDS). RESULT(S): We observed significant relationships between the percentage of normal sperm forms and both %HDS (r = -0.40) and sperm motility (r = 0.32). We also found significant relationships between sperm head defects and both %HDS (r = 0.40) and sperm concentration (r = -0.39). Sperm tail, midpiece, and neck defects were not significantly related to the SCSA parameters. Treatment of spermatozoa with dithiothreitol (to induce decondensation) resulted in a substantial increase in %HDS but no measurable change in %DFI. CONCLUSION(S): The observed relationship between sperm head defects and %HDS suggests that sperm head abnormalities may, in part, be due to incomplete sperm chromatin condensation.

Surgical management of benign prostatic hyperplasia: current evidence.

Benign prostatic hyperplasia (BPH) is one of the most common male urological disorders. The surgical management of BPH is evolving at a rapid rate, with several new procedures available that challenge transurethral resection of the prostate as the standard treatment in the surgical management of small to medium sized glands. The new procedures aim to achieve results comparable to transurethral resection of the prostate while minimizing morbidity and cost. In this Review, we discuss some of the current surgical options for the treatment of BPH that seem popular in the literature.

Varicocelectomy for infertile couples with advanced paternal age.

OBJECTIVES: To evaluate the reproductive outcomes of infertile couples with a clinical varicocele and advanced paternal age. METHODS: We reviewed the clinical records of 581 consecutive, non-azoospermic men presenting with a clinical varicocele and infertility. RESULTS: We identified 115 men aged 40 years and older and 466 men younger than 40 years with a clinical varicocele and infertility. The proportion of men with secondary infertility was significantly higher in the group of men aged 40 years and older compared with the men younger than 40 years (43% [50 of 115] versus 19% [87 of 466], respectively; P <0.001). There were no significant differences in baseline sperm parameters and in spontaneous pregnancy rates after varicocelectomy in couples with advanced paternal age (40 years or older) compared with the younger couples (49% versus 39%, respectively). However, the spontaneous pregnancy rate in couples with advanced paternal age (40 years or older) who underwent varicocelectomy was significantly greater than that of the age-matched control group who did not undergo surgery (49% versus 21%, respectively; P <0.05). CONCLUSIONS: The results of this study suggest that paternal age does not adversely influence pregnancy outcome after varicocelectomy. The data support the practice of varicocelectomy for treatment of clinical varicocele and infertility in older men.