Urinary catheter alleviation navigator protocol (UCANP): Update to the hospital-wide implementation at a single tertiary health care center.

BACKGROUND: Catheter-associated urinary tract infections are commonly reported health care-associated infections. It was demonstrated that the urinary catheter alleviation navigator protocol (UCANP) pilot resulted in a reduction of catheter utilization and catheter days. METHODS: Quality improvement initiative that was implemented at a single urban, tertiary health care center, focusing on early discontinuation of indwelling urinary catheters (IUCs) and avoidance of reinsertion. The protocol was expanded hospital-wide from September 2020 to April 2022. We compared IUC utilization, IUC standardized utilization ratio (SUR), and catheter-associated urinary tract infection standardized infection ratio in the preintervention period (March 2020 to August 2020) to the postintervention period (May 2022 to October 2022). RESULTS: Preimplementation, 2 patients with IUC removal were placed on UCANP. Postimplementation, 835 (45%) patients with IUC removal participated in the protocol. The number of patients requiring IUC reinsertion did not differ among the 2 groups. IUC utilization was significantly decreased from 0.28 to 0.24 with a 14% reduction (P = .025). SUR decreased by 11% from 0.778 to 0.693 (P = .007) and standardized infection ratio by 84% from 0.311 to 0.049 (P = .009). CONCLUSIONS: Our protocol significantly reduced IUC utilization and SUR after hospital-wide implementation. UCANP is a safe and effective strategy that can potentially decrease unnecessary IUCs in patients with transient urinary retention.

Impact of epigenetic reprogramming on antitumor immune responses in glioma.

Epigenetic remodeling is a molecular hallmark of gliomas, and it has been identified as a key mediator of glioma progression. Epigenetic dysregulation contributes to gliomagenesis, tumor progression, and responses to immunotherapies, as well as determining clinical features. This epigenetic remodeling includes changes in histone modifications, chromatin structure, and DNA methylation, all of which are driven by mutations in genes such as histone 3 genes (H3C1 and H3F3A), isocitrate dehydrogenase 1/2 (IDH1/2), α-thalassemia/mental retardation, X-linked (ATRX), and additional chromatin remodelers. Although much of the initial research primarily identified how the epigenetic aberrations impacted glioma progression by solely examining the glioma cells, recent studies have aimed at establishing the role of epigenetic alterations in shaping the tumor microenvironment (TME). In this review, we discuss the mechanisms by which these epigenetic phenomena in glioma remodel the TME and how current therapies targeting epigenetic dysregulation affect the glioma immune response and therapeutic outcomes. Understanding the link between epigenetic remodeling and the glioma TME provides insights into the implementation of epigenetic-targeting therapies to improve the antitumor immune response.

Urinary catheter alleviation navigator protocol (UCANP): Overview of protocol and review of initial experience.

BACKGROUND: Given the associated morbidity, mortality, and financial consequences of catheter associated urinary tract infections (CAUTIs), efforts should be made to mitigate the risk. We sought to describe, and report results for a post-catheter removal bladder management protocol focused on decreasing catheter reinsertion, catheter days, and overall CAUTI risk. METHODS: This was a quality improvement initiative implemented over a 3-month period at a single urban, tertiary health care center. Patients with an indwelling urinary catheter deemed eligible for removal were followed and cared for according to the study protocol. Rates of catheter reinsertion, catheter days, and assessment of CAUTI risk were compared between cohorts. RESULTS: A total of 173 patients were eligible for protocol enrollment. Catheter reinsertion rate was 16% during the pilot, compared to 21% and 27% for the historical cohorts, (P = .02). The mean number of catheter day's during the study was 1.4 days, compared to 9.5 and 5.6 days in the historical cohorts (P = .004). Catheter hours (OR 1.010 95% CI 1.005 - 1.015 P < .0001.) was a predictor of catheter reinsertion during the pilot. CONCLUSIONS: Our protocol resulted in a reduction of catheter reinsertion rates and number of catheter days. Expansion of this protocol to a larger patient cohort is required.

COVID-19 Infection in Men on Testosterone Replacement Therapy.

BACKGROUND: Men who contract coronavirus disease 2019 (COVID-19) appear to have worse clinical outcomes compared with women which raises the possibility of androgen-dependent effects. AIM: We sought to determine if testosterone replacement therapy (TRT) is associated with worse clinical outcomes. METHODS: Through a retrospective chart review, we identified 32 men diagnosed with COVID-19 and on TRT. They were propensity score matched to 63 men diagnosed with COVID-19 and not on TRT. Data regarding comorbidities and endpoints such as hospital admission, intensive care unit admission, ventilator utilization, thromboembolic events, and death were extracted. Chi-square and Kruskal-Wallis tests examined differences in categorical and continuous variables, respectively. Logistic regression analysis tested the relationship between TRT status and the study endpoints. RESULTS: There were no statistically significant differences between the 2 groups, and TRT was not a predictor of any of the endpoints on multivariate analysis. CONCLUSION: These results suggest that TRT is not associated with a worse clinical outcome in men diagnosed with COVID-19. Rambhatla A, Bronkema CJ, Corsi N, et al. COVID-19 Infection in Men on Testosterone Replacement Therapy. J Sex Med 2021;18:215-218.

Outcomes of Surgery in Peyronie's Disease Following Intralesional Collagenase Clostridium Histolyticum Injections.

PURPOSE OF REVIEW: To explore the potential hurdles surgeons may encounter when preforming surgical correction of penile curvature in patients with Peyronie's Disease following intralesional collagenase clostridium histolyticum injections. RECENT FINDINGS: Although limited data exists, retrospective analysis of surgeon experiences in surgical treatment of refractory penile curvature in patients with Peyronie's disease appears to not result in more post-operative complications and may only slightly increase intra-operative difficulty. As the use of intralesional collagenase clostridium histolyticum continues to increase and patients who demonstrate persistent curvature despite treatment seek further management, the role of investigating the feasibility of surgery demonstrates significant importance. Although limited data exists, it appears that surgery following intralesional collagenase clostridium histolyticum is safe without added post-operative complications. At the present time, however, further data on intra-operative findings and post-operative outcomes remain necessary, and as the use of this intralesional therapy continues to rise, further information should become readily available.

Penile Lymphangioma: review of the literature with a case presentation.

BACKGROUND: Penile lymphangiomas are rare manifestations of lymphangiomas or lymphatic malformations which are more commonly found in the head or neck region of the body. Lymphangiomas are further categorized as lymphangioma circumscriptum, cavernous lymphangioma, cystic hygroma, or acquired lymphangiomas (also known as lymphangiectasia), based on their depth and etiology. RESULTS: A literature review revealed only 30 cases of penile lymphangioma between 1947 and March 30, 2018. Several causes were attributed to the acquired penile lymphangiomas, including trauma, phimosis, and infection. While penile lymphangiomas can be initially mistaken for an infection, a thorough history and physical examination is sufficient to clinically diagnose a lymphangioma of the penis. Historically, surgical excision has been the gold standard of treatment for this condition. When asymptomatic, patients may opt for conservative management with avoidance of mechanical trauma alone. Other physicians have revealed novel treatment plans to rid patients of their penile lymphangioma such as a staged laser procedure. CONCLUSION: In this article, we elucidate the causes, symptoms, treatments, and outcomes associated with penile lymphangiomas found in the literature while also presenting the case of a 30-year-old African-American man diagnosed with acquired penile lymphangioma.

CONTEXTE: Les lymphangiomes du pénis sont des manifestations rares des lymphangiomes ou des malformations lymphatiques qui sont plus fréquemment observés dans les régions de la tête ou du cou au niveau du corps. Les lymphangiomes sont aussi classés en lymphangiome circumscriptum, lymphangiome caverneux, hygroma kystique, ou en lymphangiomes acquis (aussi connus sous l'appellation lymphangiectasie), selon leur profondeur et leur étiologie. RÉSULTATS: Une revue de la littérature ne révèle que 30 cas de lymphangiomes du pénis rapportés entre 1947 et Mars 2018. Plusieurs causes ont été attribuées aux lymphangiomes acquis du pénis, parmi lesquelles les traumatismes, le phimosis et les infections. Bien que les lymphangiomes péniens puissent être initialement pris pour une infection, une recherche des antécédents et un examen clinique minutieux sont suffisants pour diagnostiquer cliniquement un lymphangiome du pénis. L'excision chirurgicale a toujours constitué le gold standard du traitement de cette maladie. Lorsqu'elle est asymptomatique, les patients peuvent choisir un traitement conservateur en évitant les seuls traumatismes mécaniques. D'autres médecins ont proposé de nouveaux traitements ayant pour objectif de débarrasser les patients de leurs lymphangiomes péniens, comme la procédure au laser par étapes. CONCLUSION: A partir des données de la littérature, nous avons clarifié dans cet article les causes, symptômes, traitements et résultats associés aux lymphangiomes du pénis ; nous avons aussi présenté le cas d'un homme afro-américain âgé de 30 ans diagnostiqué comme porteur d'un lymphangiome pénien acquis. MOTS-CLÉS: Caverneux, Circumscriptum, Kystique, Hygroma, Lymphangiome, Lymphangiectasie, Pénien, Pénis.

Diagnosis and Management of Gynecomastia for Urologists.

PURPOSE OF REVIEW: Our aim is to review the steps of diagnosis and management of gynecomastia with a special focus on treatment of gynecomastia associated with androgen deprivation therapy for prostate cancer. RECENT FINDINGS: Recent studies investigating tamoxifen and radiation therapy for both therapy and prophylaxis of bicalutamide-induced gynecomastia are reviewed. Gynecomastia is a common clinical problem, affecting between one and two thirds of middle-aged men. Diagnosis is typically made by history and physical exam. Common causes include chronic medical conditions and medications; however, unexplained gynecomastia should prompt laboratory work-up, followed by appropriate imaging studies to evaluate for hormone producing cancers. For patients taking bicalutamide for treatment of prostate cancer, tamoxifen or radiation therapy for gynecomastia are excellent options.

30-day adverse event rates following penile prosthesis surgery: an American College of Surgeons National Surgical Quality Improvement Program based evaluation.

BACKGROUND: Commonly utilized as a third-line therapy for erectile dysfunction (ED) management, the penile prostheses have become a staple treatment for ED refractory to pharmacological interventions. There is however a paucity of data in the literature pertaining to short-term adverse outcomes following penile prosthesis surgery. We thus sought to leverage the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) to evaluate such outcomes within 30 days of surgery in these patients. We hypothesized that such data will lead to a more informed patient-physician consultation. METHODS: Relying on the ACS-NSQIP database [2005-2013], patients undergoing penile prosthesis placement were identified utilizing the Current Procedural Terminology (CPT) codes: 54400, 54401, 54405, 54406, 54407, 54408, 54410, 54411, 54416 and 54417. Outcomes assessed included system-wise categorized complications, length-of-stay (LOS), and re-intervention, readmission and 30-day mortality rates. Descriptive statistics were used to analyze available data. Multivariate analysis could not be performed due to small sample size. RESULTS: Overall, 98 cases of patients who underwent surgery for penile prosthesis placements between the years 2005 and 2013 were reported by the ACS-NSQIP affiliated hospitals. The median age was 65 years (interquartile range, 58-70 years). The overall 30-day complication rate was 11.3% (n=11); 5 of the 11 complications were infectious in etiology, and three were a postoperative blood transfusion event. The median LOS was 1 day. One (1.0%) patient needed to return to the operating room, two patients (2.6%) were readmitted and there was one (1.0%) death within 30 days of the original surgery. CONCLUSIONS: Surgery for penile prosthesis appears to be a safe operation despite the routinely advanced age of the patients requiring it. Complications in the immediate postoperative setting are usually infectious. This data can be used in the clinical setting for a more informed patient-physician discussion and patient expectation management.

Literature review of vaccine-related adverse events reported from HPV vaccination in randomized controlled trials.

BACKGROUND: The human papilloma virus (HPV) infections were addressed with two FDA-approved HPV vaccines: quadrivalent and bivalent vaccine. The objective of this manuscript is to determine the safety of the HPV vaccine. RESULTS: A search of PubMed articles for "human papillomavirus vaccine" was used to identify all-type HPV clinical studies prior to October 2014. A refined search of clinical trials, multicenter studies, and randomized studies were screened for only randomized controlled trials comparing HPV vaccine to controls (saline placebo or aluminum derivatives). Studies were limited to the two FDA-approved vaccines. Following PRISMA guidelines, the literature review rendered 13 publications that met inclusion/ exclusion criteria. Gender was limited to females in 10 studies and males in 1 study. Two studies included both males and females. Of the 11,189 individuals in 7 publications reporting cumulative, all-type adverse events (AE), the AE incidence of 76.52 % (n = 4544) in the vaccinated group was statistically significantly higher than 67.57 % (n = 3548) in the control group (p < 0.001). The most common AE were injection-site reactions. On the other hand, systemic symptoms did not statistically significantly differ between the vaccination cohort (35.28 %, n = 3351) and the control cohort (36.14 %, n = 3198) (p = 0.223). The pregnancy/ perinatal outcomes rendered no statistically significant difference between the vaccine group and control group. CONCLUSION: Because the statistically significantly higher incidence of AE in the HPV vaccine group was primarily limited to injection-site reactions, the vaccinations are safe preventative measures in both males and females.

CONTEXTE: Les infections dues au papillomavirus humain (HPV) ont été prises en compte par deux vaccins HPV approuvés par la FDA (Food and Drug Administration: Agence américaine des Produits Alimentaires et Médicamenteux): les vaccins quadrivalent et bivalent. L'objectif de cet article est de déterminer la sécurité du vaccin HPV. RÉSULTATS: Une recherche dans PubMed des articles sur "human papillomavirus vaccine" a été utilisée pour identifier tout type d'études cliniques sur HPV antérieures à Octobre 2014. Une recherche affinée des essais cliniques, des études multicentriques et des études randomisées n'a été menée que pour les essais randomisés avec groupe témoin comparant le vaccin HPV à un témoin (solution saline comme placébo ou dérivés de l'aluminium). Seules les études utilisant les deux vaccins approuvés par la FDA ont été retenues. En suivant les recommandations PRISMA, la revue de la littérature a retrouvé 13 publications conformes aux critères d'inclusion/exclusion. Dix études impliquaient les femmes et une les hommes. Deux études incluaient à la fois des femmes et des hommes. Sur les 11 189 personnes de 7 articles rapportant tout type d'effets indésirables (EI) cumulés, l'incidence d'EI de 76,52% (n=4544) dans le groupe vacciné était significativement plus élevée que l'incidence de 67,57% dans le groupe témoin (p<0,001). Les réactions sur le site d'injection étaient l'EI le plus courant. D'autre part, les symptômes systémiques ne différaient pas significativement entre la cohorte vaccinée (35,28%; n=3351) et la cohorte témoin (36,14%; n=3198) (p=0,223). Les issues des grossesses et les issues périnatales n'étaient pas significativement différentes entre groupe vacciné et groupe placébo. CONCLUSION: Comme l'incidence significativement plus élevée d'EI dans le groupe vacciné se limitait principalement aux réactions sur le site d'injection, les vaccinations sont des mesures préventives sans danger pour les hommes et les femmes.

When is a varicocele repair indicated: the dilemma of hypogonadism and erectile dysfunction?

In the past, the indications for varicocelectomy are primarily for infertility with abnormal semen parameters, testicular hypotrophy/atrophy in adolescents, and/or pain. The surgical treatment of varicocele for hypogonadism is controversial and debated. Recently, multiple reports in the literature have suggested that varicocele is associated with hypogonadism and varicocele repair can increase testosterone levels. Men with hypogonadal symptoms should have at least two serum testosterone levels. Microsurgical varicocelectomy may be beneficial for men with clinically palpable varicoceles with documented hypogonadism. In this review, we summarize the most recent literature linking varicocele to hypogonadism and sexual dysfunction and the impact of repair on serum testosterone levels. We performed a search of the published English literature. The key words used were "varicocele and hypogonadism" and "varicocele surgery and testosterone." We included published studies after 1998. We, also, evaluated the effect of surgery on the changes in the serum testosterone level regardless of the indication for the varicocele repair.

Possible germ cell-Sertoli cell interactions are critical for establishing appropriate expression levels for the Sertoli cell-specific MicroRNA, miR-202-5p, in human testis.

BACKGROUND: To examine human microRNA expression in fertile men and subsequently to compare expression patterns of miRNAs in fertile and infertile men, specifically men with Sertoli Cell Only (SCO) histopathology. METHODS: Testicular tissues from men with azoospermia and SCO, as well as those of men with normal spermatogenesis, were analyzed. MicroRNA was isolated using the miRCURY™ RNA Purification Kit. A miRCURY LNA™ Universal RT system was used for detection of microRNA by quantitative real-time PCR. MicroRNA localization was performed by in situ hybridizations (ISH) on formalin-fixed paraffin embedded (FFPE) tissue utilizing miRCURY LNA™ microRNA ISH technology. Statistical analysis was performed by GenEx V5.0. RESULTS: MicroRNA expression was determined for 13 normal fertile men and 5 men with the confirmed diagnosis of diffuse SCO. MiR-202-5p expression was reduced by 17-fold (P < 0.00001) in tissue from SCO men compared to normal. MiR-34c-5p was reduced by 346-fold (P < 0.00001), miR-10b was reduced 18-fold (P < 0.00001), miR-191 was reduced 20-fold (P = 0.001) and miR-126 was reduced 40-fold (P < 0.00001)) in tissues from SCO compared to normal fertile men. Using ISH, miR-202-5p was localized to Sertoli cells of men with normal spermatogenesis, but not in the Sertoli cells of men with SCO. CONCLUSION: Number of miRNAs are differentially expressed in normal fertile men compared to men with SCO. MicroRNA-202-5p is localized to Sertoli cells and its expression dramatically differs between fertile men and men whose germ cells are depleted, suggesting a novel interaction for regulating microRNA expression between the somatic and germ cell components of the seminiferous epithelium.

OBJECTIFS: Evaluer l'expression des microARN chez des hommes féconds puis comparer les profils d'expression de ces miRNAs chez des hommes féconds et des inféconds qui présentent plus particulièrement un syndrome de Sertoli seules (SCO) à l'histologie testiculaire. MATÉRIEL ET MÉTHODES: Ont été analysés des tissues testiculaires d'hommes avec azoospermie et SCO ainsi que ceux d'hommes avec spermatogenèse normale. Les miRNAs ont été isolés avec la trousse de Purification miRCURY™ RNA. Le système miRCURY LNA™ Universal RT a été utilisé pour la détection quantitative de miARNs par PCR en temps réel. La localisation des miARNs a été réalisée par hybridation in situ (HIS) sur des tissus fixés au formol et inclus en paraffine en utilisant la technologie miRCURY LNA™ microRNA ISH. Les analyses statistiques ont été faites avec GenEx V5.0. RÉSULTATS: L'expression des microARNs a été faite chez 13 hommes féconds et 5 hommes avec un diagnostic confirmé de SCO diffus. L'expression de miR-202-5p est réduite d'un facteur 17 (P < 0.00001) dans le tissu des hommes SCO par rapport au tissu des hommes à spermatogenèse normale. L'expression de miR-34c-5p est réduite d'un facteur 346 (P < 0.00001), celle de miR-10b d'un facteur 18 (P < 0.00001), celle de miR-191 d'un facteur 20 (P = 0.001) et celle de miR-126 d'un facteur 40 (P < 0.00001) dans les tissus des hommes SCO comparés à ceux des hommes à spermatogenèse normale. MiR-202-5p a été localisé par HIS dans les cellules de Sertoli des hommes à spermatogenèse normale, mais pas dans les cellules de Sertoli des hommes SCO. CONCLUSIONS: Nombre de miARNs sont exprimés différentiellement chez les hommes féconds par rapport aux hommes SCO. MicroARN-202-5p est localisé dans les cellules de Sertoli et son expression diffère de façon marquée entre les hommes féconds et ceux dont les cellules germinales sont absentes; ceci suggère une nouvelle interaction ­ entre les cellules somatiques et germinales constitutives de l'épithélium séminifère ­ impliquée dans la régulation de l'expression des microARNs.

Testis sperm extraction.

The last 20 years have produced developments in the treatment for patients with non-obstructive azoospermia (NOA) who were once considered to be infertile. The combination of intracytoplasmic sperm injection together with various testicular sperm retrieval techniques, including conventional testicular sperm extraction (TESE), microdissection TESE (micro-TESE) and fine needle aspiration (FNA), have revolutionized treatment for these men. In men with NOA, isolated regions of spermatogenesis within the testis are common. The goal for all types of sperm retrieval procedures is locating the focal region(s) of spermatogenesis, and harvesting the sperm for assisted reproduction. This review article explores the surgical management of men with NOA and describes all techniques that can be used for testicular sperm retrieval. A PubMed search was conducted using the key words: "sperm extraction", "NOA", "testicular FNA", "testicular mapping", "TESE", and "testicular biopsy". All articles were reviewed. Articles were included if they provided data on sperm retrieval rates. The methods for performing sperm retrieval rates and outcomes of the various techniques are outlined. Micro-TESE has a higher sperm retrieval rates with fewer postoperative complications and negative effects on testicular function compared with conventional TESE.

The effect of hypogonadism and testosterone-enhancing therapy on alkaline phosphatase and bone mineral density.

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 <350 ng/dL undergoing testosterone-enhancing therapy and followed for 2 years. Follicle-stimulating hormone, luteinising hormone, free testosterone, total testosterone, sex hormone binding globulin, calcium, AP, vitamin D, parathyroid hormone, and dual-energy X-ray absorptiometry (DEXA) scans were analysed. A subgroup of 36 men with one DEXA scan before and one DEXA 2 years after initiating treatment was performed. RESULTS: Analysis of the relationship between testosterone and AP at initiation of therapy using stiff linear splines suggested that bone turnover occurs at total testosterone levels of <250 ng/dL. In men with testosterone levels of <250 ng/dL, there was a negative correlation between testosterone and AP (R(2) = -0.347, P < 0.001), and no correlation when testosterone levels were between 250 and 350 ng/dL. In the subgroup analysis, the mean (sd) testosterone level was 264 (103) ng/dL initially and 701 (245), 539 (292), and 338 (189) ng/dL at 6, 12, and 24 months, respectively. AP decreased from a mean (sd) of 87 (38) U/L to 57 (12) U/L (P = 0.015), 60 (17) U/L (P < 0.001), and 55 (10) U/L (P = 0.03) at 6, 12, and 24 months, respectively. The BMD increased by a mean (sd) of 20 (39)% (P = 0.003) on DEXA. CONCLUSION: In hypogonadal men, the decrease in AP is associated with an increase in BMD on DEXA testing. This result suggests the use of AP as a marker of response to therapy.

A critical analysis of candidacy for penile revascularization.

INTRODUCTION: Penile revascularization (PR) is a potentially curative procedure for young men with isolated arteriogenic erectile dysfunction. Standard preoperative evaluation is erectile hemodynamics (HDX) using duplex Doppler penile ultrasound (DUS) and/or cavernosometry (DIC) and assessment of cavernosal arterial anatomy by selective internal pudendal arteriography (SIPA). AIM: The aim of this study was to review our experience with men who sought a second opinion from us regarding their candidacy for PR. METHOD: Study population consisted of men (i) who presented to us for a second opinion regarding PR; (ii) who had DUS/DIC and SIPA; and (iii) had been advised by outside surgeon to undergo PR. Review of the HDX study and SIPA was conducted. Discrepancies between these studies resulted in repeating the DIC in men with normal SIPA or repeating the SIPA in men with normal HDX studies. MAIN OUTCOME MEASURES: Discrepancies between HDX and SIPA and the results of repeat HDX or SIPA were the main outcome measures. RESULT: Forty-five patients participated in the study; mean age was 33 years with 4% ≥50 years old. Median vascular risk factor number was 1 (ranged 0-3). A credible trauma history was present in 11%. Thirty-three percent had prior DIC and 49% of patients had a significant discrepancy between HDX study and SIPA, including all patients seen by a community urologist. Thirty-eight percent had a discrepancy between side of abnormality on HDX and SIPA where both studies were abnormal (group A). Seven percent had abnormal HDX and normal SIPA (group B). Four percent had a normal HDX study with an abnormal SIPA (group C). Repeat DIC (n = 20) was conducted in groups A + B and was normal in 70% of cases. Repeat SIPA (n = 2) was conducted in group C and was normal in both patients. CONCLUSION: Almost one half of patients had a significant discrepancy between HDX and SIPA. Of these, 73% had normal repeat studies, making them no longer candidates for penile revascularization.

Bulbocavernosus muscle area measurement: a novel method to assess androgenic activity.

Serum testosterone does not correlate with androgen tissue activity, and it is critical to optimize tools to evaluate such activity in males. Ultrasound measurement of bulbocavernosus muscle (BCM) was used to assess the relationship between the number of CAG repeats (CAGn) in the androgen receptor (AR) and the BCM size; the changes in the number of CAGn over age were also evaluated. Transperineal ultrasound measurement of the BCM was also performed. AR CAGn were determined by high performance liquid chromatography, and morning hormone levels were determined using immunoassays. Forty-eight men had CAG repeat analysis. Twenty-five were <30 years of age, mean 23.7 years (s.d. = 3.24) and 23 were >45 years of age, mean 53 years (s.d. = 5.58). The median CAGn was 21 (13-29). BCM area was greater when the number of CAGn were <18 as compared to the number of CAGn >24 (P = 0.04). There was a linear correlation between the number of CAGn and the BCM area R 2 = 16% (P = 0.01). In the 45 to 65-years-old group, a much stronger negative correlation (R 2 = 29%, P = 0.01) was noticed. In the 19 to 29-years-old group, no such correlation was found (R 2 = 4%, P = 0.36). In older men, the number of CAGn increased with age (R 2 = 32%, P = 0.01). The number of CAGn in the AR correlates with the area of the BCM. Ultrasound assessment of the BCM is an effective surrogate to evaluate end-organ activity of androgens. The number of CAGn may increase with age.

When to ask male adolescents to provide semen sample for fertility preservation?

BACKGROUND: Fertility preservation in adolescents undergoing sterilizing radiation and/or chemotherapy is the standard of care in oncology. The opportunity for patients to provide a semen sample by ejaculation is a critical issue in adolescent fertility preservation. METHODS: Fifty males with no medical or sexual developmental abnormalities were evaluated. The subjects were screened for evidence of orgasmic, erectile, and ejaculatory dysfunction. A detailed sexual development history was obtained under an Institutional Review Board (IRB)-approved protocol. RESULTS: Fifty males, aged 18-65 years (mean 39±16.03 years) volunteered to be part of this study. The mean reported age for the onset of puberty was 12.39 years (95% CI, 11.99-12.80 years), 13.59 years (95% CI, 13.05-14.12 years) for the first ejaculation, 12.56 years (95% CI, 11.80-13.32 years) for the start of masturbation, and 17.26 years (95% CI, 16.18-18.33 years) for the first experienced intercourse. Seventy-five percent of the cohort reached puberty by the age of 13.33, experienced masturbation by 14.5, first ejaculated by the age of 14.83, and had intercourse at age of 19.15 years. The first experienced ejaculation fell 1.5 years after the onset of puberty in 80% present of the cohort, and 84% starts masturbation 1.5 years after the onset of puberty. The mean response between the younger and the older subject was not statistical significance. CONCLUSIONS: It is appropriate to consider a request for semen specimens by masturbation from teenagers at one year and six months after the onset of puberty; the onset age of puberty plus 1.5 years is an important predictor of ejaculation and sample collection for cryopreservation.

Medical treatment of male infertility.

The majority of male infertility is idiopathic. However, there are multiple known causes of male infertility, and some of these causes can be treated medically with high success rates. In cases of idiopathic or genetic causes of male infertility, medical management is typically empirical; in most instances medical therapy represents off-label use that is not specifically approved by the FDA. Understanding the hypothalamic-pituitary-gonadal (HPG) axis and the effect of estrogen excess is critical for the assessment and treatment of male infertility. The use of certain medical treatment has been associated with an increase in sperm production or motility, and primarily focuses on optimizing testosterone (T) production from the Leydig cells, increasing follicle-stimulating hormone (FSH) levels to stimulate Sertoli cells and spermatogenesis, and normalizing the T to estrogen ratio.

Microdissection testicular sperm extraction: an update.

Patients with non-obstructive azoospermia (NOA) were once considered to be infertile with few treatment options due to the absence of sperm in the ejaculate. In the last two decades, the advent of intracytoplasmic sperm injection (ICSI), and the application of various testicular sperm retrieval techniques, including fine needle aspiration (FNA), conventional testicular sperm extraction (TESE) and microdissection testicular sperm extraction (micro-TESE) have revolutionized treatment in this group of men. Because most men with NOA will have isolated regions of spermatogenesis within the testis, studies have illustrated that sperm can be retrieved in most men with NOA, including Klinefelter's syndrome (KS), prior history of chemotherapy and cryptorchidism. Micro-TESE, when compared with conventional TESE has a higher sperm retrieval rate (SRR) with fewer postoperative complications and negative effects on testicular function. In this article, we will compare the efficacy of the different procedures of sperm extraction, discuss the medical treatment and the role of testosterone optimization in men with NOA and describe the micro-TESE surgical technique. Furthermore, we will update our overall experience to allow counseling on the prognosis of sperm retrieval for the specific subsets of NOA.