Gender Bias in Letters of Recommendation: Relevance to Urology Match Outcomes and Pursuit of Fellowship Training/Academic Career.

OBJECTIVE: To review applications to a single urology residency program to determine application characteristics predictive of (1) successful match into urology residency and (2) pursuit of fellowship training and/or academic practice after completion of residency. Our principal variables of interest were gender bias as assessed in letters of recommendation (LOR), personal statements, Medical Student Performance Evaluation (MSPE), race, and gender. MATERIALS AND METHODS: Applications submitted to our urology residency program in the 2014 cycle were reviewed. Twenty-three variables were analyzed, including applicant demographics, application materials, and gender bias. Deidentified text from LOR, personal statements, and MSPE was evaluated for gender bias using an open-source gender bias calculator. A subanalysis of applicants who matched at a top 25 urology program was performed. Logistic regression analysis was performed to identify applicant variables associated with (1) match success and (2) fellowship training or academic employment as of September 2021. RESULTS: Two hundred and twenty-two completed applications were analyzed. First authorship of a published manuscript was significantly associated with greater odds of matching. Female gender and top 25 medical school attendance were both significant predictors of matching at a top 25 urology program. The number of first-author publications was associated with completion of fellowship training or current employment in an academic position. CONCLUSION: First-author publications are the most important preinterview determinant of match success and subsequent pursuit of academic practice/fellowship training. Certain applicant characteristics are associated with matching at highly ranked programs. Gender bias in application materials (including LOR) does not appear to exert a significant influence on match and early career outcomes.

Pharmacotherapy for Erectile Dysfunction in 2021 and Beyond.

Erectile dysfunction (ED), defined as the inability to develop or maintain an erection firm enough for satisfactory sexual intercourse, is a common urologic condition that increases in prevalence with age but can affect men of any age. As the discovery of the role of the nitric oxide pathway in inducing and maintaining erections, there have been numerous pharmacologic advancements for the treatment of ED. Here, we will review the mainstays of the pharmacologic treatment of ED: OTC/herbal supplements, phosphodiesterase type V inhibitors (PDE5I), intraurethral suppositories (MUSE), and intracorporal injections (ICI).

Disorders of Ejaculation: An AUA/SMSNA Guideline.

PURPOSE: Men who ejaculate before or shortly after penetration, without a sense of control, and who experience distress related to this condition may be diagnosed with premature ejaculation (PE), while men who experience difficulty achieving sexual climax may be diagnosed with delayed ejaculation (DE). The experience of many clinicians suggest that these problems are not rare and can be a source of considerable embarrassment and dissatisfaction for patients. The role of the clinician in managing PE and DE is to conduct appropriate investigation, to provide education, and to offer available treatments that are rational and based on sound scientific data. MATERIALS AND METHODS: The systematic review utilized to inform this guideline was conducted by a methodology team at the Pacific Northwest Evidence-based Practice Center. A research librarian conducted searches in Ovid MEDLINE (1946 to March 1, 2019), the Cochrane Central Register of Controlled Trials (through January 2019) and the Cochrane Database of Systematic Reviews (through March 1, 2019). An update search was conducted on September 5, 2019. Database searches resulted in 1,851 potentially relevant articles. After dual review of abstracts and titles, 223 systematic reviews and individual studies were selected for full-text dual review, and 8 systematic reviews and 59 individual studies were determined to meet inclusion criteria and were included in the review. RESULTS: Several psychological health, behavioral, and pharmacotherapy options exist for both PE and DE; however, none of these pharmacotherapy options have achieved approval from the United States Food and Drug Administration and their use in the treatment of PE and DE is considered off-label. CONCLUSION: Disturbances of the timing of ejaculation can pose a substantial impediment to sexual enjoyment for men and their partners. The Panel recommends shared decision-making as fundamental in the management of disorders of ejaculation; involvement of sexual partner(s) in decision making, when possible, may allow for optimization of outcomes.

Sexual Wellness in Cisgender Lesbian, Gay, and Bisexual People.

Cisgender sexual minority persons have sexual wellness needs that go well beyond disease prevention. Despite historical asymmetries in research and clinical attention to sexual wellness in cisgender lesbian, gay, and bisexual persons, a growing body of evidence exists on how to optimally care for these populations. Additional research and development is warranted.

Prostate cancer and sexual consequences among men who have sex with men.

Prostate cancer and its treatment frequently lead to sexual side effects that negatively impact personal identity, sexual function, and intimate relationships. The sexual consequences of prostate cancer treatment on men who have sex with men (MSM) differ in some ways from what is observed in heterosexual men. This review summarizes literature from the past two decades exploring how MSM are affected by, and adapt to, prostate cancer treatment. The evidence on whether prostate cancer has a lower prevalence in MSM is unclear but lower screening rates are well-documented within this population. Prostate cancer treatment affects urinary, bowel, and sexual function in both MSM and heterosexual men. These changes may have different sexual and psychological ramifications in MSM when compared to heterosexual men. A common concern among MSM treated for prostate cancer is absence of support, both from the medical profession and in some cases from their own communities. Many MSM with prostate cancer have developed coping strategies and altered sexual practices to accommodate side effects. Lessons learned from this population may have relevance to sexual wellness in non-MSM prostate cancer survivors. Concise recommendations for caring for MSM with prostate cancer are provided.

Evaluating the impact of a medical school cohort sexual health course on knowledge, counseling skills and sexual attitude change.

BACKGROUND: Sexual health is generally considered an integral part of medical and allied healthcare professional training. However, many medical schools do not offer this as a mandatory curriculum, or minimize it. Sexual health as an academic area was introduced in the 1970s, but there have been few cohort evaluations of its impact. This was limited by the availability of few psychometric scales for evaluation. We evaluated the full, mandatory, sexual health course in year 1 medicine at a large state university in the Midwest US, including the course with lectures; panels and tutorials; a video app to give students feedback on their sexual history taking skills; and a 3-station sexual history OSCE at the end of the course. RESULTS: Seventy-four medical students (43% of the course cohort) volunteered, for an incentive, to complete evaluation materials pre- and post-course. We used the Sexual Health Education for Professionals Scale (SHEPS), designed and with appropriate psychometric standardization for such evaluation. The SHEPS data covers 7-point Likert scale ratings of 37 patient situations, asking first how well the student could communicate with such a patient, and on the second part how much knowledge they have to care for such a patient. The third subscale examines personal sexual attitudes and beliefs. Data indicated that the matched pretest-posttest ratings for skills and knowledge were all statistically significant and with very large effect sizes. Few of the attitude subscale items were significant and if so, had small effect sizes. Sexual attitudes and beliefs may be well-formed before entry into medical school, and sexual health teaching and learning has minimal effect on sexual attitudes in this US sample. However, using the 3 sexuality OSCE cases scores as outcomes, two of the 26 attitude-belief items predicted > 24% of the variance. CONCLUSIONS: The sexual health course produced major changes in Communications with patients sexual health skills and Knowledge of sexual health, but little change in personal Attitudes about sexuality. These data suggest that personal attitude change is not essential for teaching US medical students to learn about sexual health and sexual function and dysfunction, and comfortably take a comprehensive sexual history.

Predictive Factor of Preresidency Publication on Career Academic Achievement in Urologists.

INTRODUCTION: Publications at any point in training can impact future academic interest and achievement. Implications of publishing scholarly work prior to residency on accomplishments during and after residency are understudied. METHODS: We obtained publication output before, during and after residency for urologists graduating between 2002 and 2008 from the 36 training programs affiliated with a top 50 urology hospital nationwide. Additional collected information included fellowship training, current appointment, total and R01 National Institutes of Health grants, and h-index. We compared urologists' preresidency scholarship with residency and career achievements. RESULTS: We retrieved data from 543 urologists, of whom 161 (29.7%) and 92 (16.9%) published 1 or more total and first author manuscripts before residency, respectively. A total of 269 (49.5%) urologists went on to pursue fellowship and 183 (33.7%) entered academic practice. Urologists with a first author publication before residency had increased odds of entering academics (OR 1.9, 95% CI 1.2-3.1), obtaining National Institutes of Health grants (OR 2.2, 95% CI 1.1-4.3) and acquiring National Institutes of Health R01 grants (OR 4.1, 95% CI 1.7-9.7). Those with more first author manuscripts prior to residency were also more likely to pursue fellowship (p=0.0002), have a higher h-index (p <0.0001) and publish more during (p <0.0001) and after residency (p=0.0002). However, those with more total publications before residency were only associated with greater h-index (p=0.002) and publications in residency (p=0.001). CONCLUSIONS: Preresidency scholarly endeavors, particularly first author publications, are associated with future scholarly achievement, which may inform both resident selection procedures and medical education curricular development.

Clinical Outcomes of Periprocedural Antithrombotic Therapy in Ischemic Priapism Management.

BACKGROUND: Priapism is a urologic emergency consisting of a painful erection lasting greater than 4 hours; antithrombotic therapy (ATT) have recently been recommended as an adjunct in the treatment of ischemic priapism. AIM: To determine the short- and long-term outcomes of periprocedural ATT in the management of acute ischemic priapism. METHODS: A retrospective review of patients seen at the University of California, San Francisco, from 2008 to 2019 was carried out to identify those evaluated for acute priapism. Information regarding duration of priapism, etiology, treatment, periprocedural and postprocedural ATT type and dose, and follow-up data was collected. OUTCOMES: ATT use was the exposure of interest; outcome variables included priapism resolution, repeat episodes, long-term complications, and follow-up. RESULTS: 70 patients with at least 1 detailed record of an acute priapism episode between 2008 and 2019 were identified. Of the 70 patients who underwent management for an acute episode of priapism, 59 (84%) received intracavernous injection of phenylephrine with or without corporal aspiration. Of the 4 patients who received ATT at the same time as intracavernous injection, none had additional priapism episodes. In the 55 patients who did not receive immediate ATT, 22 (40%) required at least 1 shunting procedure. The 9 patients who received ATT concurrently with shunting experienced less recurrence than the 13 patients who did not receive ATT (11% vs 69%, respectively P = .012). There were no significant differences in long-term erectile dysfunction (P = .627), fibrosis (P = .118), genitourinary pain (P = .474), and urinary issues (P = .158) between those who received ATT and those who did not. CLINICAL IMPLICATIONS: Our findings suggest that ATT has a role in preventing priapism recurrence; we observed that long-term repeat priapism episodes are less frequent in those who received periprocedural ATT compared with those who did not and that ATT may especially reduce recurrence in cases when shunting was required STRENGTHS & LIMITATIONS: This is the first study looking at the clinical outcomes of periprocedural ATT in the management of ischemic priapism. It is limited by the fact that it is a single-center study, types of ATT were heterogenous, and the exact timing of priapism management could not be measured for everyone. CONCLUSION: In spite of its limitations, these preliminary findings are promising and warrant further exploration of the use of ATT in the management of ischemic priapism. Ramstein JJ, Lee A, Cohen AJ, et al. Clinical Outcomes of Periprocedural Antithrombotic Therapy in Ischemic Priapism Management. J Sex Med 2020;17:2260-2266.

The future of penile prostheses for the treatment of erectile dysfunction.

Penile prostheses (both inflatable and malleable) are standard care in the management of erectile dysfunction (ED). Introduced over 45 years ago, modern penile implants have evolved greatly during that period of time and now represent the cutting edge in materials science and function. Despite the introduction of highly effective oral pharmacotherapy for ED, these devices have remained relevant and will almost certainly remain so for the foreseeable future. Despite their high degree of efficacy, there is always potential for further improvements in both implants themselves and the surgical techniques and processes used for their placement. In this manuscript we speculate on the future of penile implants, based in large part on the historical perspective and recent developments in the implant surgery space. We include recommendations on future technical innovations, post-operative management, and novel implant designs that may revolutionize the future management of ED.

Management Options for Premature Ejaculation and Delayed Ejaculation in Men.

INTRODUCTION: Many men experience distressing issues regarding the timing of orgasm and ejaculation, such as premature ejaculation (PE) and delayed ejaculation (DE). Despite being highly prevalent, both PE and DE are poorly understood and present a management challenge for sexual medicine specialists. AIM: To summarize existing data on the medical management of PE and DE. METHODS: A comprehensive literature review pertaining to the management of PE and DE was conducted using PubMed and clinicaltrials.gov for data published up until May 2019. Our focus was on double-blind, placebo-controlled trials and meta-analyses of such studies. MAIN OUTCOME MEASURE: Peer-reviewed studies on treatment options for PE and DE were critically analyzed for results and methodological rigor. RESULTS: The peer-reviewed data on PE management continue to evolve. Psychotherapy, pharmacotherapy, and procedural interventions have all been associated with some degree of efficacy. A strong evidence base supports the off-label use of selective serotonin reuptake inhibitors and local anesthetics in PE given consistent increases in ejaculation latency time. Education and mental health assessments remain important components of PE management despite a dearth of peer-reviewed data on these interventions. Numerous treatment strategies have been evaluated for DE; limited data support psychotherapy, pharmacotherapy, and/or penile vibratory stimulation as management options. CONCLUSION: A number of management options for PE or DE exist but none has been formally approved by the US Food and Drug Administration. New and novel treatments would be of great value in managing issues regarding the timing of ejaculation/orgasm. Martin-Tuite P, Shindel AW. Management Options for Premature Ejaculation and Delayed Ejaculation in Men. Sex Med Rev 2020; 8:473-485.

Anejaculation: Relevance to Sexual Enjoyment in Men and Women.

INTRODUCTION: Ejaculation and orgasm are important components of sexual response in men. Our understanding of both phenomena is limited. Anejaculation can be a source of substantial distress, even when procreation (ostensibly the only purpose of ejaculation itself) is not a priority. AIM: To present an opinion on male perceptions of ejaculation disorders (specifically anejaculation) based on a variety of data sources, including peer-reviewed literature. METHODS: A non-systematic review of literature on anejaculation and other impairments of ejaculatory and orgasmic response was conducted. Relevant articles were critically analyzed and reported MAIN OUTCOME MEASURE: An opinion is presented, based on existing data sources, on how and why ejaculation is deemed important to men and their sexual partners. RESULTS: The peer-reviewed literature on disorders of ejaculation is scant; existing reports oftentimes do not adequately distinguish between orgasm and ejaculation in assessment. Men's perceptions of ejaculation quality appear to be positively associated with satisfaction with sexual response, particularly regarding orgasm. Based on very limited data, female sexual partners of men appear to often (but not always) value the orgasmic experience of their partner; only a minority prioritize actual ejaculation. There is evidence that disorders of ejaculation may be particularly troublesome for men who have sex with men. CLINICAL IMPLICATIONS: The influence of medical conditions and treatments on ejaculation should be considered in the clinical context. Psychological adaptations and interventions may be of value in some cases. STRENGTHS & LIMITATIONS: Data on the clinical relevance of anejaculation outside the context of concomitant orgasmic dysfunction are sparse. Men's experience of orgasm is at least partially associated with ejaculation-specific variables; whether this association is mediated by psychological, physical, or a combination of factors remains unclear. CONCLUSIONS: Ejaculation, orgasm, and sexual satisfaction are closely intertwined but distinct phenomena. Shindel AW. Anejaculation: Relevance to Sexual Enjoyment in Men and Women. J Sex Med 2019;16:1324-1327.