The effect of aging on spermatogenesis and pregnancy outcomes.

Until fairly recently, it had been assumed that paternal age had only a minor impact on reproductive outcome. Several recent provocative studies have raised the specter of a causal association between paternal age and significant medical conditions in the offspring. However, the observational nature of these studies leaves open the possibility that factors other than age itself may be responsible for observed results. This article reviews the available data on this topic, with an eye toward providing a basis for clinical counseling of the older man who wishes to have a child.

Subjective sexual response to testosterone replacement therapy based on initial serum levels of total testosterone.

INTRODUCTION: Testosterone replacement therapy (TRT) has been shown to be beneficial for men with hypogonadism. However, it is unknown how well hypogonadal men respond to TRT based on the severity of testosterone deficiency. AIM: To determine subjective sexual response rates to TRT based on initial serum testosterone values, with particular interest in men with "low-normal" levels of total testosterone (TT). MAIN OUTCOME MEASURES: Subjective responses to TRT in the domains of erectile dysfunction, libido, orgasm, and morning erections. METHODS: A retrospective study was performed of 211 men with sexual symptoms of hypogonadism who underwent TRT. All men had either low values of TT (<300 ng/dL) or free testosterone (FT) (<1.5 ng/dL). The cohort was divided into three groups based on initial TT levels: Group 1: 0-200 ng/dL (N = 26; 12.3%); Group 2: 201-300 ng/dL (N = 64; 30.3%); Group 3: 301 ng/dL or greater (N = 121; 57.3%). Improvement in erectile function was determined prior to addition of any other treatment (e.g., phosphodiesterase type 5 inhibitors). The mean follow-up was 9 months (range 3-36 months). RESULTS: The mean age was 55.2 years. Testosterone gel was used in approximately two-thirds of each group. Improvement in libido was reported in 61.5%, 96.6%, and 29.8% for Groups 1, 2, and 3, respectively (P < 0.001). Improvement in erectile function was noted in 46.2%, 45.3%, and 73.6% for Groups 1, 2, and 3, respectively (P < 0.001). At time of last follow-up, the percentage of men continuing with TRT was 73.1%, 57.8%, and 58.7% for Groups 1, 2, and 3, respectively (P = nonsignificant). CONCLUSIONS: These preliminary data suggest that men with sexual symptoms of hypogonadism respond well to TRT across a wide range of initial TT values, including men with low-normal TT levels. These men may have low bioavailable levels of testosterone that are not reflected in TT values.

Wide variability in laboratory reference values for serum testosterone.

INTRODUCTION: The laboratory determination of testosterone levels consistent with a diagnosis of hypogonadism is complicated by the availability of multiple testosterone assays and varying reference ranges. AIM: To assess current laboratory practices regarding availability of testosterone assays and use of reference values. METHODS: A telephone survey of 12 academic, 12 community medical laboratories, and one national laboratory. MAIN OUTCOME MEASURES: Types of androgen assays offered and determination of reference values. RESULTS: All of the academic and eight of the community centers performed total testosterone testing. Free testosterone was performed in-house by six of the 12 academic and one community center. Testing for bioavailable testosterone, free androgen index, and percent free testosterone was performed in-house by no more than two centers. There were eight and four different assays used for total and free testosterone, respectively. One national laboratory offered equilibrium dialysis measurement of free testosterone. Of the 25 labs, there were 17 and 13 different sets of reference values for total and free testosterone, respectively. The low reference value for total testosterone ranged from 130 to 450 ng/dL (350% difference), and the upper value ranged from 486 to 1,593 ng/dL (325% difference). Age-adjusted reference values were applied in four centers for total testosterone and in seven labs for free testosterone. All reference values were based on a standard statistical model without regard for clinical aspects of hypogonadism. Twenty-three of the 25 lab directors responded that clinically relevant testosterone reference ranges would be preferable to current standards. CONCLUSIONS: Laboratory reference values for testosterone vary widely, and are established without clinical considerations.

Technical advances in penile prostheses.

Despite the introduction of oral phosphodiesterase inhibitors, penile prostheses continue to be an important form of treatment for erectile dysfunction (ED). Penile prostheses are associated with high satisfaction rates due to their ease of use, reliability, and ability to provide excellent rigidity. Advances over the last decade include steps to reduce mechanical failures and surface coatings to prevent prosthetic infections. These advances make the penile prosthesis an excellent option for the treatment of ED, particularly for men who fail oral therapy.

Phleboliths in varicoceles presenting as spermatic cord mass.

OBJECTIVE: To discuss the diagnosis and management of phleboliths in the dilated veins of a varicocele. DESIGN: Case report. SETTING: Two healthy patients in an academic andrology center. PATIENT(S): Two healthy patients undergoing evaluation and treatment of male factor infertility. INTERVENTION(S): Ultrasonography and varicocele repair. MAIN OUTCOME MEASURE(S): Improvement in male factor infertility. RESULT(S): One patient had a phlebolith diagnosed ultrasonographically by echogenicity and acoustic shadowing within a dilated vein of a varicocele. Another patient had a hard mass found within a dilated vein of a varicocele at the time of surgical repair. CONCLUSION(S): A hard rounded mass within a spermatic vein identified at surgery or sonographically within the veins of the spermatic cord should be considered a phlebolith. Decisions regarding treatment depend on clinical presentation.

Hypogonadism in the man with erectile dysfunction: what to look for and when to treat.

Hypogonadism (low serum testosterone) is commonly associated with erectile dysfunction (ED). However, many urologists may lack appreciation of the relative merits of treating hypogonadism compared with oral phosphodiesterase inhibitors for sexual dysfunction. Testosterone-replacement therapy (TRT) may be the best treatment for men with ED when the presentation includes diminished libido or other sexual symptoms or when non-sexual symptoms such as depressed mood, decreased sense of vitality, and increased fatigue also exist. The health benefits of TRT also include improvements in body composition, bone density, cognition, and sense of well-being. Thus, there may be good reasons to use TRT as first-line therapy for the man with ED. Concerns regarding prostatic and cardiovascular risks of TRT have not been supported by the literature. Nevertheless, men receiving TRT must be monitored at regular intervals with digital rectal examination and blood testing for prostate-specific antigen. Hematocrit or hemoglobin also should be obtained regularly due to the risk of erythrocytosis. Awareness of the benefits of TRT in the man with ED may improve clinical outcomes.

Ureteric obstruction requiring nephrectomy after uterine fibroid embolization.

To our knowledge, there have been no reported cases of ureteric obstruction resulting in a non-functioning hydronephrotic kidney after uterine fibroid embolization. We report a case of a patient who required surgical intervention for management of symptoms.

A case of transitional cell carcinoma seeding of small bowel anastomosis after radical cystoprostatectomy.

We present a case in which a man developed transitional cell carcinoma of the small bowel 6 months after having undergone a cystoprostatectomy and ileal conduit urinary diversion.

Renal colic and torsion: case report and review.

Acute ureteric colic and acute scrotum are among the most commonly seen urological emergencies. We present a case in which a male patient presented with simultaneous right flank pain and ipsilateral scrotal pain.