Characteristics and Long Term Follow up of Men Who Suffer Ischemic Priapism Secondary to Recreational Use of Intracavernosal Injectable Medications.

OBJECTIVE: To better understand patient experience, risk factors, culture, and ED outcomes surrounding recreational ICI use that led to ischemic priapism. METHODS: After IRB approval, men presenting for ischemic priapism secondary to recreational ICI use from January 2010 to December 2018 were contacted by mail and then via telephone. Standardized questions were asked of all study participants on the topics of erectile function (IIEF-5), sexual practices, and at-risk behavior at the time of priapism. Qualitative data analysis was performed using grounded theory methodology. RESULTS: 14 men age 24-59 were successfully recruited. All men described themselves as men having sex with men (MSM) and one (7.1%) as having both male and female sexual partners. Average follow up IIEF-5 among participants was 13 (SD 4.0). Eleven men (78.6 %) described illicit drug use at the time of priapism. Qualitative data analysis yielded several preliminary themes: concomitant drug use, naivety, peer pressure, and delay in seeking treatment. Men frequently reported illicit drug use in group sex scenarios and ICI use under pressure to perform sexually or to counteract effects of illicit substances. CONCLUSIONS: Recreational ICI in this cohort was part of a lifestyle of risky behavior. Methamphetamine use and group sex encounters strongly motivate recreational ICI use. Substance abuse centers may offer an entry point into this population for counseling and primary prevention.

The Complex Relationship Between Lower Urinary Tract Symptoms and Sexual Health.

PURPOSE OF REVIEW: Lower urinary tract symptoms (LUTS) and sexual health have common links. Medical and surgical treatments for LUTS can significantly affect various domains of sexual health including erectile function, ejaculatory function, and libido. This review summarizes recent findings. RECENT FINDINGS: Current literature demonstrates a strong association between LUTS, sexual health, and metabolic syndrome. The role of miRNA is also being investigated. Combination medical therapy with phosphodiesterase 5 inhibitors (PDE5-I) shows promise but needs further investigation. Newer surgical therapies for benign prostatic hyperplasia (BPH) aim to preserve sexual function without sacrificing efficacy and durability. Although we are beginning to acknowledge the link between LUTS and sexual health, a better understanding of the underlying biochemistry is needed. Only then can more effective therapies be developed. Further prospective studies should focus on the long-term durability and safety of treatments for both conditions.

Bladder perforation secondary to primary systemic amyloidosis.

Amyloidosis is a disorder of protein folding characterized by extracellular aggregation and deposition of amyloid protein fibrils. Light-chain amyloidosis, also known as primary systemic amyloidosis, is the most common form of the disease. We present a case of an 84-year-old male with a history of systemic primary amyloidosis causing genitourinary, cardiac, and autonomic dysfunction who presented with hematuria and hypotension secondary to bladder perforation. He underwent open repair of a large extraperitoneal bladder defect. He ultimately died as a result of medical complications from his disease.

A novel sorting technology allows for highly efficient selection of sperm without chromatin damage.

Sperm chromatin damage has been associated with male infertility, increased risk for spontaneous abortion, and poor embryo development. Available methods for detecting chromatin damage render the sperm no longer suitable for clinical use. Early apoptotic events resulting in chromatin damage are associated with increased permeability of the cell membrane to large ions. We propose the use of a large fluorescent organic cation, proprietary fluorochrome (PF-1), for fluorescence-activated cell sorting (FACS) for negative selection of sperm without chromatin damage. Sperm with chromatin damage are PF-1 positive. Performance of cell sorting by PF-1 was verified with terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) after FACS on PF-1(+) and PF-1(-) subpopulations. Whereas 19.5% of PF-1 positive sperm were TUNEL positive only 1.5% sperm in the PF-1(-) fraction were TUNEL positive (p < 0.00001). TUNEL values below 1.9% were considered background fluorescence. Post-sorting motility and vitality were 49.4% (SD: 12.5) and 65.0% (SD: 14.99), respectively. Proprietary fluorochrome activated sperm sorting may decrease or most likely eliminate all of TUNEL positive sperm without adverse effects on viability, providing a new therapeutic avenue for men with a high percentage of TUNEL positive sperm. Further research is needed to determine if the reduction in TUNEL positive sperm using PF-1 will improve in vitro fertilization (IVF) outcomes.

Flow cytometric characterization of apoptosis and chromatin damage in spermatozoa.

Apoptosis has been implicated in sperm chromatin damage; it is unclear whether apoptosis occurs through cytoplasmic or mitochondrial pathways. Sperm has minimal volume of cytoplasm but prominent mitochondria. Propidium iodide (PI), annexin V (AV), DiIC1(5) and proprietary fluorochrome (PF-1) were used to investigate apoptosis activation in human sperm using multichannel flow cytometry. There was a time-dependent increase in staining of spermatozoa with both AV and PF-1 and decrease in mitochondrial staining with DiIC1(5). These results strongly suggest that the drop in mitochondrial potential precedes changes in membrane phospholipids, and thus suggest apoptotic activation through mitochondrial pathway in human spermatozoa.

The Shang Ring device for adult male circumcision: a proof of concept study in Kenya.

OBJECTIVE: To assess safety, preliminary efficacy, and acceptability of the Shang Ring, a novel disposable device for adult male circumcision in Kenya. METHODS: Forty HIV-negative men were recruited in Homa Bay, Kenya. Circumcisions were performed by a trained physician or nurse working with 1 assistant. Follow-up was conducted at 2, 7, 9, 14, 21, 28, 35, and 42 days after circumcision. Rings were removed on day 7. Pain was assessed using a visual analog scale (VAS) (0 = no pain, 10 = worst possible). Men were interviewed at enrollment and on days 7 and 42. RESULTS: All 40 procedures were completed successfully. Mean procedure and device removal times were 4.8 (SD ± 2.0) and 3.9 (SD ± 2.6) minutes, respectively. There were 6 mild adverse events, including 3 penile skin injuries, 2 cases of edema, and 1 infection; all resolved with conservative management. In addition, there were 3 partial ring detachments between days 2-7. None required treatment or early ring removal. Erections with the ring were well tolerated, with a mean pain score of 3.5 (SD ± 2.3). By day 2, 80% of men were back to work. At 42 days, all participants were very satisfied with their circumcision and would recommend the procedure to others. CONCLUSIONS: Our results demonstrate that the Shang Ring is safe for further study in Africa. Acceptability of the Shang Ring among participants was excellent. With short procedure times, less surgical skill required, and the ease with which it can be used by nonphysicians, the Shang Ring could facilitate rapid roll-out of male circumcision in sub-Saharan Africa.

Microsurgical spermatocelectomy: technique and outcomes of a novel surgical approach.

PURPOSE: A microsurgical approach to spermatocelectomy theoretically minimizes the risk of injury to the epididymis and testicular blood supply. We present the technique of microsurgical spermatocelectomy and report our perioperative and recurrence outcomes. MATERIALS AND METHODS: In a 15-year period 23 men with a total of 36 epididymal cystic masses underwent microsurgical resection with confirmation of spermatocele diagnosis by intraoperative identification of sperm in the cyst fluid. We reviewed pathology reports for resected epididymal tissue in the spermatocele specimen. Postoperative outcome measures included complications, sperm count changes, improvement in pain and fertility, and cyst recurrence. RESULTS: Mean spermatocele size was 5.0 cm (range 1 to 15). Common indications for surgery included pain in 35% of cases, infertility in 30% and the 2 conditions in 13%. A total of 13 patients (57%) underwent simultaneous procedures for concomitant varicocele and/or hydrocele with a mean overall surgical time of 152 minutes. A single scrotal hematoma managed conservatively was the only postoperative complication. There was no case of infection. Avoidance of inadvertent epididymal resection was shown by absent epididymal tissue in each of the 36 spermatocele pathology specimens. Also, no patient with preoperative and postoperative semen analyses available experienced a decreased sperm count, confirming the avoidance of iatrogenic epididymal tubule obstruction. At a mean followup of 17.3 months no man had cyst recurrence or testicular atrophy and all with preoperative pain reported improvement. One patient with preoperative infertility achieved pregnancy 12 months after surgery. CONCLUSIONS: Microsurgical spermatocelectomy is safe and effective with a minimal risk of epididymal injury, testicular atrophy and recurrence.

Male circumcision: Africa and beyond?

PURPOSE OF REVIEW: Male circumcision has become an important component of HIV prevention strategies in Africa. Results of recent trials have renewed interest in this ancient procedure and its potential application in the reduction of sexually transmitted infections (STIs). With renewed interest comes controversy, which has always been a close companion to circumcision. RECENT FINDINGS: Following the three randomized trials in Africa demonstrating the protective effects of male circumcision on HIV infection, studies have reported other benefits of circumcision including protection from certain STIs, including human papillomavirus and herpes simplex virus 2. With data accumulating on the public health benefits of circumcision and the endorsement of circumcision from WHO, investigators have begun to evaluate the feasibility, safety and cost of implementation of large-scale circumcision programs. Limitations of circumcision have also been explored. SUMMARY: Male circumcision will likely play an important role in HIV/STI prevention programs in Africa; the inclusion of circumcision in the health policy of developed countries will require further investigation.

[A recommendable standard protocol of adult male circumcision with the Chinese Shang Ring: outcomes of 328 cases in China].

OBJECTIVE: Standardization of and training in adult male circumcision can significantly reduce its complication rate. Currently no such program exists for its standardization and training, making it difficult to guarantee the quality of male circumcision services. We therefore established a standardized surgical protocol for adult male circumcision in China using the Shang Ring, and applied it to a clinical study examining the performance of the Shang Ring in adult male circumcision. METHODS: A total of 328 adult men aged 18-58 (mean 27.8) years, 25 with phimosis and 303 with redundant prepuce, underwent circumcision with the Shang Ring, and evaluation of the operation time, pain scores (using the visual analog scale), postoperative complications, time for wound healing, and their satisfaction with the postoperative appearance. RESULTS: The operation time was 4.7 +/- 1.3 minutes. The pain scores were 0. 2 +/- 0.6 during the surgery, 1.6 +/- 1.0 twenty hours postoperatively, 1.7 +/- 1.1 twenty hours prior to the ring removal, and 2.7 +/- 1.4 during the ring removal. Complications included infection in 2 (0.6%), bleeding in 2 (0.6%), and wound dehiscence in 2 (0.6%) of the patients. None of the patients with wound dehiscence required postoperative suturing and all were managed conservatively instead. Sixteen of the patients (4.9%) experienced penile edema. The time for complete wound healing after circumcision was 20.3 +/- 6.7 days. The rate of the patients'satisfaction was 99.7% (327/328). CONCLUSION: The standard protocol of adult male circumcision with the Shang Ring has the advantages of short operation time, slight pain, low rate of complications, and high satisfaction and acceptance of the patients. Strict standardization of the surgical protocol can maximize its clinical advantages for adult male circumcision.

History of vasectomy reversal.

Vasectomy reversal has come a long way since the first anastomosis of the vas deferens and epididymis. Although its history is not as politically charged as that of vasectomy, the progress of reversal surgery has had its share of brilliant discoveries and missteps. In the early part of the twentieth century, vasovasostomy and vasoepididymostomy were esoteric procedures, but by the 1970s, a majority of urologists had some experience with reversal surgery. With the advent of microsurgical technique, reversal surgery has become once more a specialist's undertaking. The history of vasectomy reversal is an excellent case study in the evolution of surgery.

The (+)- and (-)-gossypols potently inhibit both 3beta-hydroxysteroid dehydrogenase and 17beta-hydroxysteroid dehydrogenase 3 in human and rat testes.

Androgen deprivation is commonly used in the treatment of metastatic prostate cancer. The (-)-gossypol enantiomer has been demonstrated as an effective inhibitor of Bcl-2 in the treatment of prostate cancer. However, the mechanism of gossypol as an inhibitor of androgen biosynthesis is not clear. The present study compared (+)- and (-)-gossypols in the inhibition of 3beta-hydroxysteroid dehydrogenase (3beta-HSD) and 17beta-HSD isoform 3 (17beta-HSD3) in human and rat testes. Gossypol enantiomers were more potent inhibitors of rat 3beta-HSD with IC(50)s of approximately 0.2microM compared to 3-5microM in human testes. However, human 17beta-HSD3 was more sensitive to inhibition by gossypol enantiomers, with IC(50)s of 0.36+/-0.09 and 1.13+/-0.12 for (-)- and (+)-gossypols, respectively, compared to 3.43+/-0.46 and 10.93+/-2.27 in rat testes. There were species- and enantiomer-specific differences in the sensitivity of the inhibition of 17beta-HSD3. Gossypol enantiomers competitively inhibited both 3beta-HSD and 17beta-HSD3 by competing for the cofactor binding sites of these enzymes. Gossypol enantiomers, fed orally to rats (20mg/kg), inhibited 3beta-HSD but not 17beta-HSD3. This finding was consistent with the in vitro data, in which rat 3beta-HSD was more sensitive to gossypol inhibition than rat 17beta-HSD3. As the reverse was true for the human enzymes, gossypol might be useful for treating metastatic prostate cancer.

High complication rates challenge the implementation of male circumcision for HIV prevention in Africa.

This commentary discusses the study by Bailey and colleagues, who aimed to assess the safety of male circumcision practices in both clinical and traditional settings in Bungoma, Kenya. The study evaluated 1,007 males who underwent circumcision in a clinical (n = 562) and traditional (n = 445) setting. All young men who underwent circumcision were interviewed after surgery to assess their satisfaction and complication rates, and a sample of the practitioners who performed the circumcisions were interviewed to determine their circumcision training and experience. Additionally, 24 circumcision procedures (12 each in the clinical and traditional settings) were directly observed by the study investigators. The study found complications rates of 17.7% and 35.2% in the clinical and traditional groups, respectively. Furthermore, the study revealed shortcomings in practitioner knowledge, training and resources in both groups. Before scaling up male circumcision services in countries with a high prevalence of HIV, a careful strategy to minimize unnecessary morbidity, and fundamental improvements on current circumcision techniques, are required.

Adult varicocele.

PURPOSE OF REVIEW: Adult varicocele presents a challenge for male reproductive specialists. We have yet to fully elucidate the pathophysiology of varicocele. The enigma of the varicocele, although a source of frustration for clinicians, has been a siren call for researchers as attested to by the substantial, if flawed body of literature on the topic. We critically review recent publications on varicocele. RECENT FINDINGS: Although yielding mixed results, studies this year have explored the potential relationship between oxidative stress and varicocele-associated infertility. In clinically focused research, one group tackled the contentious question of efficacy of surgical varicocele management. Building on the errors of prior meta-analyses, this study takes a fresh view on an old but vital topic. Finally, it is becoming clearer that varicocele affects Leydig cell function as well as seminiferous tubular function, and is a risk factor for androgen deficiency. SUMMARY: With exceptions, recent studies support a role for varicocelectomy in the management of infertile couples. In addition, evidence is accumulating that early repair of varicoceles, especially large varicoceles, may be effective in preventing future infertility and may be an effective treatment for androgen deficiency.

Endocrine manipulation in male infertility.

Endocrine therapy for male infertility is broadly categorized as specific or nonspecific therapy. Although uncommon, primary endocrine diagnoses in infertile men are amenable to targeted therapy. The efficacy of empiric endocrine therapy for idiopathic male infertility, however, has not been demonstrated conclusively by clinical trials. With better understanding of the underlying pathophysiology of idiopathic male infertility, careful evaluation of endocrine therapy in well-selected treatment groups and well-designed randomized, controlled trials is warranted. Although empiric endocrine therapy for idiopathic male infertility has been largely replaced by assisted reproductive techniques, both treatment modalities could play a role, perhaps as combination therapy.

Use and outcomes of intracytoplasmic sperm injection for non-male factor infertility.

OBJECTIVE: To determine whether intracytoplasmic sperm injection (ICSI) is associated with improved outcomes for non-male factor infertility. DESIGN: We examined the patient characteristics associated with treatment choice-ICSI and conventional in vitro fertilization (IVF)-among patients without a diagnosis of male factor infertility and compared outcomes between the two groups, adjusting for patient characteristics using multivariate regression models. SETTING: Academic fertility center. PATIENT(S): We evaluated 696 consecutive assisted reproductive technology (ART) cycles performed for couples with normal semen analysis at the Stanford Reproductive Endocrinology and Infertility Center between 2002 and 2003. We compared patient characteristics, cycle details, and outcomes for ICSI and IVF. MAIN OUTCOME MEASURE(S): Fertilization, pregnancy, and live birth rates. RESULT(S): Patient characteristics were similar between the two groups, except the proportion of patients with unexplained infertility (IVF 15.1% vs. ICSI 23.5%), previous fertility (IVF 62.6% vs. ICSI 45.5%), and previous ART cycle (IVF 41.2% vs. ICSI 67.7%). More oocytes were fertilized per cycle for the IVF group (6.6 oocytes versus 5.1 oocytes). Fertilization failure, pregnancy, and live birth rates did not differ between IVF and ICSI. Using logistic regressions, having had previous ART was found to be positively associated with ICSI. Treatment choice of ICSI was not associated with fertilization, pregnancy, or live birth rates. CONCLUSION(S): No clear evidence of improved outcomes with ICSI was demonstrated for non-male factor infertility.