Patient Portal Engagement Affects Postvasectomy Semen Analysis Completion.

OBJECTIVE: To identify factors that affect completion of postvasectomy semen analysis (PVSA) in men receiving telehealth prevasectomy counseling. Telehealth visits have become increasingly common for prevasectomy consultations. Prior studies have shown that men prefer telehealth vasectomy consultations over in-person options. Postvasectomy semen testing should be completed to confirm sterilization. METHODS: Three hundred and seventy-one men aged 19 and older who saw a single physician for a telehealth prevasectomy consultation and completed an in-office vasectomy were included in the study. Demographic information such as age, patient relationship status, and distance from the clinic were accessed via electronic medical record. Patients were assessed based on their engagement with electronic preprocedure instructions, and the primary outcome measured was completion of PVSA. RESULTS: 45.6% of men completed a PVSA. There was no significant difference in completion of the PVSA between those who opened their electronic instructions before their vasectomy and those who did not (46.1% vs 44.4%, P = .77). Of those who messaged the clinic for any reason at least once after their consultation, 62% completed their PVSA; 41% who did not contact the clinic completed the PVSA (P = .0009). CONCLUSION: While there was no difference in completion of PVSA in patients who opened their instructions vs those who did not, patients with a higher level of engagement with the patient portals were more likely to complete their semen test. By understanding factors influencing patient compliance with postvasectomy semen testing, healthcare professionals can develop targeted interventions to ensure safe and successful outcomes.

Money Talks: The Shifting Effect of Limiting Monetary Incentives for Urology Resident Research.

OBJECTIVE: To assess incentive changes on resident publication behavior. In 2020, we demonstrated the positive effect of an unlimited $1000 publishing incentive for Urology residents. Following this publication, institutional changes led to a limit of a single $1000 publishing incentive per resident per year. METHODS: The PubMed database was assessed to quantify average resident primary authorship and average overall publications. Average primary authorships and total PubMed listings were then compared by year before any incentive (June 2008-June 2016), during unlimited incentive (July 2016-October 2020), and after the limited financial incentive (November 2020-June 2023). RESULTS: Scholarly activity from 30 out of 30 possible residents was evaluated. The average PubMed research participation for the program per year increased significantly from 2.44 preincentive to 8.0 when the incentive was unlimited but decreased to 4.0 when the incentive was limited (P = .026). Similarly, the average PubMed primary resident authorships per year increased from 1.0 preincentive to 6.25 during the unlimited incentive period but decreased to 2.0 when the incentive was limited (P < .001). CONCLUSION: Our data showed an unlimited monetary incentive resulted in a significant increase in average primary resident authorship and average resident participation for publications to PubMed. The limited monetary incentive model resulted in a significant decrease on resident publication and participation in research compared to unlimited incentives. However, limited monetary incentives have a positive, though restricted, effect on Urology resident publication and participation in research compared to no incentive.

Attention-deficit hyperactivity disorder medication use is associated with testosterone hypofunction-results from a national claims database analysis.

Male hypogonadism is not a risk associated with attention-deficit hyperactivity disorder (ADHD) stimulant medications, but recent studies have explored this connection. Though the pathophysiologic connection remains unclear, we predicted that long-term use of ADHD stimulant medications could increase the risk of hypogonadism in post-pubertal males. Utilizing TriNetX, LLC Research Network data from January 2000 through December 2019, men older than 18 with ADHD receiving long-term stimulant medication (>36 monthly prescriptions) were selected for the study population. Two control groups were constructed: individuals with ADHD but no stimulant medication use, and individuals without ADHD or stimulant medication use. A diagnosis of testicular hypofunction (ICD-10: E29.1) within five years of long-term ADHD stimulant medication use was the chosen primary outcome. After propensity score matching, 17,224 men were analyzed in each group. Of the men with long-term ADHD stimulant medication use, 1.20% were subsequently diagnosed with testicular hypofunction compared to 0.67% of individuals with ADHD without stimulant medication use (RR: 1.78, 95% CI: 1.42-2.23) and 0.68% in men without ADHD or stimulant medication use (RR: 1.75, 95% CI: 1.39-2.19). Therefore, chronic ADHD stimulant medication use was found to be significantly associated with a subsequent diagnosis of testicular hypofunction.

New Artificial Intelligence ChatGPT Performs Poorly on the 2022 Self-assessment Study Program for Urology.

INTRODUCTION: Large language models have demonstrated impressive capabilities, but application to medicine remains unclear. We seek to evaluate the use of ChatGPT on the American Urological Association Self-assessment Study Program as an educational adjunct for urology trainees and practicing physicians. METHODS: One hundred fifty questions from the 2022 Self-assessment Study Program exam were screened, and those containing visual assets (n=15) were removed. The remaining items were encoded as open ended or multiple choice. ChatGPT's output was coded as correct, incorrect, or indeterminate; if indeterminate, responses were regenerated up to 2 times. Concordance, quality, and accuracy were ascertained by 3 independent researchers and reviewed by 2 physician adjudicators. A new session was started for each entry to avoid crossover learning. RESULTS: ChatGPT was correct on 36/135 (26.7%) open-ended and 38/135 (28.2%) multiple-choice questions. Indeterminate responses were generated in 40 (29.6%) and 4 (3.0%), respectively. Of the correct responses, 24/36 (66.7%) and 36/38 (94.7%) were on initial output, 8 (22.2%) and 1 (2.6%) on second output, and 4 (11.1%) and 1 (2.6%) on final output, respectively. Although regeneration decreased indeterminate responses, proportion of correct responses did not increase. For open-ended and multiple-choice questions, ChatGPT provided consistent justifications for incorrect answers and remained concordant between correct and incorrect answers. CONCLUSIONS: ChatGPT previously demonstrated promise on medical licensing exams; however, application to the 2022 Self-assessment Study Program was not demonstrated. Performance improved with multiple-choice over open-ended questions. More importantly were the persistent justifications for incorrect responses-left unchecked, utilization of ChatGPT in medicine may facilitate medical misinformation.

Buerger's Disease in the Testicle: A Case of Testicular Thromboangiitis Obliterans.

Thromboangiitis obliterans (TAO), otherwise known as Buerger's disease, is a rare, non-atherosclerotic inflammatory vasculopathy that typically affects small and medium-sized arteries of the distal extremities. Smoking is believed to be integral to the pathogenesis, as TAO primarily affects young male smokers. The disease is characterized by extremity pain secondary to ischemia that may progress to ulceration, gangrene, and amputation. Involvement of the reproductive system is uncommon. Here, we offer a case of TAO presenting as a testicular mass lesion.

Early Career Publication Trajectory of Male Infertility Fellows During and After Fellowship.

BACKGROUND: Improving evidence-based medicine through research contribution is an important aspect of fellowship training. Prior studies have investigated the research activity of urology fellows during and after fellowship. The main objective of this study was to specifically explore the publication productivity of male infertility fellows both during fellowship and in the first 5 years afterwards. METHODS: The 19 fellowship program directors from the Society for the Study of Male Reproduction were asked to share a list of fellows from 2004 to 2019. Publications from 87 fellows at 12 programs were analyzed. PubMed® was utilized to search for peer-reviewed publications for each fellow during their fellowship and in the first 5 years afterwards. Each publication was classified by publication type (original research, review article, editorial comment, or case report), topic (fertility, testosterone, or other), and author type (sole, first, middle, or last author). RESULTS: Some 87 male infertility fellows were analyzed, and a total of 1608 peer-reviewed publications were identified. Some 662 total publications (41.2%) were written on the topic of fertility during fellowship and in the first 5 years afterwards. Some 554 (34.5%) publications were completed during fellowship, 178 (11.1%) in year 1, 164 (10.2%) in year 2, 220 (13.7%) in year 3, 269 (16.7%) in year 4, and 223 (13.9%) in year 5. The mean number of publications during fellowship was 6.37 (range 0-57). Means for years 1-5 after fellowship were 2.12, 1.95, 2.65, 3.36, and 2.97, respectively. After fellowship, 25.3% of the fellows did not publish again. A significant difference was detected between the group mean number of publications (analysis of variance, ANOVA - p = 0.0001) during fellowship and the 5 years afterwards. There was no significant difference between the group mean number of publications between the 1st and 5th years post-fellowship (ANOVA - p = 0.5919). CONCLUSIONS: As anticipated, male infertility fellows were most productive during fellowship, with relatively stable research production thereafter. Thus, early career support and mentorship remain important to the future academic success of fellows. Future investigation of the relationship between male infertility fellow characteristics and the pursuit of an academic career is warranted.

Online Health Information for Penile Prosthesis Implants Lacks Quality and Is Unreadable to the Average US Patient.

BACKGROUND: Online health information (OHI) has become widely accessible and affects patient decisions regarding their healthcare. The purpose of this study was to assess the readability, quality, and accuracy of information available to patients online about penile prosthesis implants (PPIs). METHODS: We performed a Google search using the keywords "penile implant" and "penile prosthesis." The first 30 search results for both terms were analyzed, and advertisements, news articles, duplicates, and videos were excluded. Websites were categorized as institutional, commercial, and personal/patient support. Readability of each website was determined using the Flesch-Kincaid grade level (FKGL) readability formula within the readable tool. Quality was measured by Health On the Net (HON) certification status and the DISCERN scoring method. For website accuracy, a score of 1-4 (1=0-25%, 2=25-50%, 3=50-75%, and 4=75-100%) was assigned. RESULTS: Forty-four websites met the criteria (23 institutional, 12 commercial, and 9 personal/patient support). The mean total FKGL score was 9.55. No statistical difference was detected between mean FKGL for each website category (p=0.69). Only eight websites (18%) scored ≤8th-grade reading level (average US adult level), while 36 (82%) were >8th-grade level. Mean total DISCERN sum score was 39.74/75, with no statistical difference in mean DISCERN score between website types (p=0.08). Over half (55%) of the websites were defined as "very poor" or "poor" quality by DISCERN scoring. Mean total overall quality rating was 2.67/5. HON certification was verified for only nine websites (20%). Twenty-five percent of websites were classified as 0-25% accurate, 23% were 25-50% accurate, 30% were 50-75% accurate, and 23% were 75-100% accurate. CONCLUSION: Most information on the Internet about PPIs is reasonably accurate; however, the majority of websites are deficient in quality and unreadable to the average patient, irrespective of website type.

Cryoablation of the penile nerves for chronic penile pain.

We present a unique case of a 39-year-old male with a 20-year history of chronic penile pain. Unfortunately, there are currently very limited reports on how best to manage chronic penile pain, as chronic penile pain is a diagnosis of exclusion without any apparent disease. Here, we describe our patient's clinical presentation of chronic penile pain, history of previously failed medical and procedural treatments, and eventually completion of cryoablation of the penile nerves. In this case study, we demonstrated that targeted cryoablation of the penile nerves is a potential treatment option for chronic penile pain that failed medical management. We also discuss the anatomy and innervation of the penis as it relates to sensation of chronic penile pain and subsequent cryoablation of the penile nerves.

The Impact of Visiting Rotations on the Urology Residency Match: Insights and Perspectives From the 2021-2022 Applicants.

OBJECTIVE: To survey 2022 Urology Residency Match applicants on their away rotation experiences to better understand the impact of pandemic changes, including the one in-person away rotation limit, on interviews and match outcomes. METHODS: An anonymous post-match online survey was distributed to applicants of study-participating institutions. Data was prospectively collected regarding respondent demographics, away rotation experiences, interviews, utilization of preference signaling, and overall match outcomes. RESULTS: In total, 230 applicants completed the survey. Respondents prioritized geography (28.1%), program reputation (26.1%), and early notification (25.6%) as the top factors in determining whether to accept a rotation offer. The majority (93%) participated in a single away rotation, with nearly all respondents being offered a virtual interview from the program where they completed a visiting clerkship. Of those who declined away rotation offers, 56% were not offered an interview at the program they declined an offer from. The majority matched at either their home institution (20.8%), a program where they submitted a preference signal (22.2%), or a program where they completed an in-person away rotation (13%). Despite 46.3% of respondents reporting that their match outcome was negatively affected by the ability to rotate at only one away rotation, the majority were satisfied (70%) with their rotation selection based on match results. CONCLUSIONS: For applicants, participation in visiting rotations plays a significant role in the match process. Further research regarding mechanisms to optimize the away rotation application process is needed as the capacity to do visiting electives expands in the post-pandemic environment.

Testosterone Therapy is Associated With Depression, Suicidality, and Intentional Self-Harm: Analysis of a National Federated Database.

BACKGROUND: Long-term use of testosterone can be associated with mood destabilizing effects. Most studies investigating psychiatric complications of anabolic steroids have used small samples, but a comprehensive assessment of the risk of developing mental health disorders after testosterone use has not been performed at the population level. AIM: To determine whether testosterone therapy is associated with major depressive disorder or suicide attempts in men. METHODS: We conducted a retrospective cohort study of 70.3 million electronic health records collected from 46 healthcare organizations encompassing flagship hospitals, satellite hospitals, and outpatient clinics since 2008 to determine whether testosterone use is associated with major depressive disorder and suicide attempts in a large population. We included men 18 or older who either used testosterone or did not, defined by reported use, insurance claim, or prescription use of testosterone documented in the electronic health record. We propensity-score matched by age, race, ethnicity, obesity, and alcohol-related disorder. Additionally, a sub-group analysis was performed in testosterone deficient (<300 ng/dL) men comparing those with TD on testosterone therapy to a control group of men with TD who are not using testosterone. OUTCOMES: We determined measures of association with a new diagnosis of major depressive disorder and suicide attempt or intentional self-harm following testosterone use within 5 years. RESULTS: A total of 263,579 men who used testosterone and 17,838,316 men who did not were included in the analysis. Testosterone use was independently associated with both Major Depressive Disorder (OR 1.99, 95% CI 1.94-2.04, P < .0001) and Suicide Attempt/Intentional Self-Harm (OR 1.52, 95% CI 1.40-1.65, P < .0001). Results remained significant in testosterone deficient sub-group analysis. CLINICAL IMPLICATIONS: Men who use testosterone should be screened for and counseled about risks of depression and suicidality. STRENGTHS AND LIMITATIONS: Strengths of this study include a large sample size, the ability to account for chronology of diagnoses, the use of propensity score matching to control for potentially confounding variables, and the consistency of results with sub-group analyses. Limitations include the potential for incorrect coding within the electronic health record, a lack of granular information regarding testosterone therapy adherence, the possibility that unrecorded testosterone or anabolic steroid use were prevalent but not captured within the control group, and a lack of data regarding testosterone withdrawal. CONCLUSION: Testosterone use is independently associated with new-onset mental health disorders. Future studies are necessary to elucidate the role that androgen withdrawal plays and whether a causal relationship exists. Nackeeran S, Patel MS, Nallakumar DT, et al. Testosterone Therapy is Associated With Depression, Suicidality, and Intentional Self-Harm: Analysis of a National Federated Database. J Sex Med 2022;19:933-939.

Genetic causes and management of male infertility.

Infertility affects approximately 15% of couples. With infertility such a common problem in a generally healthy age group, complete evaluation is needed of both men and women. Infertility work up for men includes a semen analysis, the results of which suggest various supplemental studies, including karyotype. Karyotype is indicated when a patient has findings on history or physical exam concerning for chromosomal abnormalities, azoospermia, or severe oligospermia (count <5 million/mL). The most common chromosomal numerical abnormality found on karyotype is Klinefelter syndrome which is classified as redundant sex chromosomes, with the most common chromosomal arrangement being 47, XXY. If a patient is found to have a chromosomal abnormality such as Klinefelter's, there is still a chance of fertility using testicular sperm extraction and in-vitro fertilization.

Funding Peyronie's disease: funding sources for primary research literature.

The objective was to describe funding sources and publication trends for the primary literature on Peyronie's disease (PD), including direct industry research support. A search of EMBASE, PubMed, Scopus, and Web of Science was performed to identify articles published from 2006 to 2018. Articles not published in English, reviews, case reports, editorials, guidelines, and meta-analysis were excluded from analysis. Data collected included year and journal of publication, major focus, and funding sources. The US Federal Open Payments database was searched for direct industry research payments to authors. Four hundred thirty-seven articles met criteria. The median number of yearly publications was 31. The most frequent publications were Journal of Sexual Medicine (25.6%), Urology (8.9%), BJU International (7.3%), and Journal of Urology (5.7%). Plaque excision/grafting was the most common topic (16.5%) followed by pathophysiology (15.3%), and intralesional therapy (14.9%). Only 15.1% (n = 66) of articles had a funding source with only 2.3% (n = 10) articles receiving any National Institutes of Health (NIH) funding. In total, 4.1% (n = 18) of the articles were industry funded, 61.1% (n = 11) of these from Xiaflex manufacturer Endo/Auxilium. Remaining articles appeared self-funded. There were 1524 unique authors and just 13 received any direct industry funds, totaling US$718,426. Most PD research is self-funded with only a small percentage from NIH or industry.

Minimal access to male fertility prices online: an analysis of the Society for Assisted Reproductive Technology (SART) clinics.

BACKGROUND: Though insurance coverage is evolving for male infertility services, most patients continue to pay out of pocket. These costs such as semen analysis and intracytoplasmic sperm injection preparation may affect the utilization of those services. We sought to determine online price transparency specifically for male infertility services on the websites of in-vitro fertilization (IVF) clinics in the US. METHODS: In this cross-sectional analysis, pricing data was acquired from each clinic on the Society for Assisted Reproductive Technology (SART) website as of July 2019. Each website was examined for availability and cost of services. Pricing data that required applying for a quote or a phone call was excluded. Mean price was calculated for each service. Additionally, practice location in an insurance coverage mandated state (ICMS) was also analyzed to evaluate for any effect on price transparency. RESULTS: Only 24.7% (89/361) of SART clinic websites included any pricing information. Of clinics with websites (361/383), 16.3% (59/361) had ≥2 prices reported and only 5.0% (18/361) had ≥6 prices reported. Only 3.6% (13/361) reported prices for male-related infertility services. Average semen analysis price was $161 of 10 reporting clinics. Four clinics reported sperm cryopreservation or annual sperm storage price, $388 and $555, respectively. Sperm retrieval cost $244 at the two reporting clinics. ICMS did not affect male price transparency, ICMS 3.1% (6/194) vs. non-ICMS 4.2% (7/167) (P=0.576). CONCLUSIONS: Price transparency of SART clinics on websites is relatively poor with only about one-quarter of clinics providing any cost information at all. Male infertility related pricing information is even more rarely reported compared to other IVF services potentially causing a stronger barrier for males to pursue infertility treatment.

Urology Resident Involvement in Patient Safety and Quality Improvement Activities.

PURPOSE OF REVIEW: To assess current urology resident engagement in patient safety and quality improvement (PSQI) and how to improve resident involvement in PSQI. RECENT FINDINGS: Overall urology resident participation in PSQI is low, especially when compared to other non-surgical residency programs. Multiple methods have been successfully implemented to increase resident participation in PSQI. Patient safety and quality improvement are extremely important to the progression of both urology and the healthcare community. True and meaningful participation in PSQI is lacking for many urology residents. However, there are easily adopted methods to improve resident involvement in this area of healthcare. These methods include direct communication and access between residents and hospital PSQI boards, resident-led safety councils, monetary incentives, formal training, and PSQI resident support teams.

Improving the Residency Program Virtual Open House Experience: A Survey of Urology Applicants.

OBJECTIVE: To investigate the perception and value of virtual open houses for urology applicants in the COVID-19 era, since students can no longer attend subinternships and all interviews will be conducted virtually. METHODS: A Twitter survey was sent to 230 likely urology applicants connected through the UroResidency platform. It asked about the relative value of components of the virtual open house and areas for suggested improvement. RESULTS: Seventy responded. Most potential applicants valued virtual open houses that discussed strengths and weaknesses of the program, had time to interact directly with the faculty, and included resident led presentations or discussions. Most agreed programs needed to have more direct time with residents to better understand the culture of the program. CONCLUSION: In this first virtual interview season for urology, likely applicants generally engage in virtual open houses and strongly prefer time to interact directly with residents to assess the program culture.

The Positive Effect of Monetary Incentive on Urology Resident Research.

OBJECTIVE: To evaluate whether a financial incentive changed research patterns among residents over a 12-year period. METHODS: At our institution, beginning July 2016, any resident work that led to a PubMed citation was awarded $1,000. A review of the PubMed database and the regional meeting of the South Central Section of AUA (SCS/AUA) presentation itineraries were used to quantify and qualify the participation in research by these residents before and after introduction of the financial incentive. RESULTS: Scholarly activity from thirty out of thirty possible residents was evaluated. The monetary incentive resulted in increased production post-incentive (6.33) vs pre-incentive (2.44) in average total authorship participation published to PubMed per year (P = .0125). The average number of PubMed primary authorships per resident per year increased from 0 in July 2007-June 2008 to 0.7 in July 2018-June 2019, displaying upward trajectory. Average primary authorship of research produced per year presented at SCS/AUA and published to PubMed increased postincentive (9.00) vs pre-incentive (4.89) (P = .0479). More review articles and less basic science research were published after the incentive. CONCLUSION: Offering financial incentives to urology residents increased publications and meaningful participation in research.

Baseline Gonadotropin Levels and Testosterone Response in Hypogonadal Men Treated With Clomiphene Citrate.

OBJECTIVE: To investigate the role of baseline gonadotropins in predicting the biochemical response to clomiphene citrate (CC) treatment. METHODS: We conducted a retrospective review of data from hypogonadal men treated with CC in 2 high-volume fertility centers between 2013 and 2018. Patient age, body mass index, and baseline hormones (follicle stimulating hormone [FSH], luteinizing hormone [LH], and total testosterone [TT]) were obtained. Response to treatment was measured as changes in TT levels within 6 months of initiating CC treatment. Linear regression models adjusted for age, body mass index, and time on CC therapy were fitted to assess the associations between baseline LH and FSH levels with treatment response. RESULTS: A total of 332 men with mean ± standard deviation age of 36.2 ± 8.2 years were included. Median time to initial follow-up was 6 weeks (25th-75th interquartile range [IQR]: 4-9 weeks). TT levels increased significantly on CC treatment (mean change: 329.2 ng/dL, 95% CI: 307.4-351.0) with 73% of men having at least 200 ng/dL increase over baseline TT levels. In univariable linear regression models, only age was significantly associated with TT response. Neither the baseline LH nor FSH significantly predicted TT response in linear regression models. CONCLUSION: CC treatment results in significant increases in testosterone levels in most men. Baseline gonadotropins are not strong predictors for treatment response to CC. Adequate biochemical response with CC trial can be expected in most patients with normal or slightly elevated baseline gonadotropin levels.