Association between Hidradenitis Suppurativa and Abnormalities in Semen Parameters and Sexual Function: A Pilot Study.

Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease affecting patients of reproductive age. Although HS shares risk factors with male infertility, only 1 epidemiological study has evaluated this association. To further evaluate this potential association, findings on semen and hormonal analysis, testicular ultrasound, and the International Index of Erectile Function (IIEF-15) were compared between 28 men attending a tertiary HS clinic during the period April 2019 to April 2021, and 44 healthy controls, spouses of infertile women undergoing semen evaluation before in vitro fertilization. Patients with HS were divided based on the absence or presence of gluteal and genital lesions. Patients with HS were younger than controls (median 27 vs 34 years, p < 0.0004) and had a higher proportion of smokers (86% vs 33%, p < 0.0001). Semen parameters in patients with gluteal-genital lesions, specifically those with severe scrotal involvement necessitating surgery, were lower than the WHO reference values and significantly lower than in patients without gluteal-genital lesions and controls. Erectile dysfunction was reported by 93% of patients with HS. These findings suggest that spermatogenesis and sexual function may be impaired in young men with HS. Therefore, multidisciplinary management of HS should include their evaluation to identify patients who might benefit from semen cryopreservation and sexual treatment.

Prostate-specific antigen level association with COVID-19 infection and vaccination.

INTRODUCTION: The associations among SARS-CoV-2 infection, vaccination and total serum prostate serum antigen (PSA) levels in men undergoing screening for prostate cancer are unknown. METHODS: A retrospective analysis of data from a large health maintenance organization. Records of individuals aged 50 to 75 years with two serum PSA tests taken between March 2018 and November 2021 were included. Individuals with prostate cancer were excluded. Changes in PSA levels were compared between individuals who had at least 1 SARS-CoV-2 vaccination and/or infection between the two PSA tests and individuals who did not have an infection and were not vaccinated between the two PSA tests. Subgroup analyses were performed to assess the impact of the elapsed time between the event and the second PSA test on the results. RESULTS: The study and control groups included 6,733 (29%) and 16 286 (71%) individuals, respectively. Although the median time between PSA tests was shorter in the study vs. the control group (440 vs. 469 days, P<.001), PSA elevation between the tests was higher in the study group (0.04 vs. 0.02, P<.001). The relative risk for PSA elevation ≥1 ng/dL was 1.22 (95% CI 1.1, 1.35). Among individuals who were vaccinated, PSA increased by 0.03 ng/dL (IQR -0.12, 0.28) and 0.09 ng/dL (IQR -0.05, 0.34) after 1 and 3 doses, respectively (P<.001). Multivariate linear regression showed that SARS-CoV-2 events (ß 0.043; 95% CI 0.026-0.06) were associated with a greater risk for PSA elevation, after adjusting for age, baseline PSA and days between PSA tests. CONCLUSION: SARS-CoV-2 infection and vaccinations are associated with a slight increase in PSA, with the third anti-COVID vaccine dose having a more prominent impact, but its clinical significance is unknown yet. Any significant increase in PSA must be investigated and cannot be dismissed as secondary to SARS-CoV-2 infection or vaccination.

Sexual dysfunction among adolescent and young adult cancer patients: diagnostic and therapeutic approach.

PURPOSE OF REVIEW: We present a review for healthcare professionals, formulated by a multidisciplinary team, for screening and interventions, describing common sexual impairments encountered by adolescent and young adult cancer patients (AYACP), and suggest a comprehensive evidence-based assessment approach and interventions for treatment of sexual dysfunction (SD). RECENT FINDINGS: We discuss the various aspects of SD in AYACP, including causes, challenges and etiologies, and then go on to recommend increased awareness and guidance in healthcare workers, in order to optimize diagnosis and treatment of SD. SUMMARY: Although the extent of SD among AYACP is widely recognized, oncological clinicians rarely address SD in their routine practice, lacking a clear approach of interdisciplinary diagnostic and therapeutic interventions. Here, we suggest guiding clinical management to optimize treatment quality.

Trends in urological emergencies in the Era of COVID-19

ABSTRACT Purpose: To evaluate trends in emergency room (ER) urological conditions during COVID-19 pandemic lockdown. Materials and Methods: Retrospective analyses of renal colic, hematuria, and urinary retention in ER's admissions of a tertiary hospital during the lockdown period (March 19 to May 4, 2020) in Israel. Patient's demographics and clinical characteristics were compared to those in corresponding periods during 2017-2019, with estimated changes in ER arrival and waiting times, utilization of imaging tests, numbers of hospitalizations, and urgent procedure rates. Results: The number of ER visits for renal colic, hematuria, and urinary retention decreased by 37%, from an average of 451 (2017-2019) to 261 patients (2020). Clinical severity was similar between groups, with no major differences in patient's age, vital signs, or laboratory results. The proportion of ER visits during night hours increased significantly during lockdown (44.8% vs. 34.2%, p=0.002). There was a decrease in renal colic admission rate from 19.8% to 8.4% (p=0.001) without differences in urgent procedures rates, while the 30-day revisit rate decreased from 15.8% to 10.3% during lockdown (p=0.02). Conclusions: General lockdown was accompanied by a significant decrease in common urological presentations to the ER. This change occurred across the clinical severity spectrum of renal colic, hematuria, and urinary retention. In the short term, it appears that patients who sought treatment did not suffer from complications that could be attributed to late arrival or delay in treatment. The long-term implications of abstinence from seeking emergent care are not known and require further investigation.

The absence of spermatogenesis in radical orchiectomy specimen is associated with advanced-stage nonseminomatous testicular cancer.

BACKGROUND: To assess if clinical, pathological, and spermatogenesis factors are associated with clinical staging in patients with testicular germ cell tumors. PATIENTS AND METHODS: We retrospectively reviewed the pathology reports and slides from 267 men who underwent radical orchiectomy for testicular cancer at our institution during 1998-2019. Histologic slides were reviewed and the presence of mature spermatozoa was documented. Clinical, laboratory and radiographic characteristics were recorded. Logistic regression analyses were used to identify factors associated with advanced disease stage at diagnosis. RESULTS: Of 267 male patients, 115 (43%) patients had testicular non-seminomatous germ cell tumors (NSGCT) and 152 (57%) seminomatous germ cell tumors (SGCT). Among NSGCT patients, those presenting with metastatic disease had a higher proportion of predominant (>50%) embryonal carcinoma (64% vs. 43%, respectively, P = 0.03), and lymphovascular invasion (45.8% vs. 26.6%, respectively, P = 0.03) than non-metastatic patients. Spermatogenesis was observed in 56/65 (86.2%) and 36/49 (73.5%) of non-metastatic and metastatic NSGCT patients, respectively (P = 0.09). On semen analysis, severe oligospermia (<5 million/ml) was more common in metastatic than in non-metastatic NSGCT (26.5% vs. 8.3%, respectively, P = 0.04). On multivariate analysis, predominant embryonal carcinoma and lack of spermatogenesis in pathological specimens were associated with metastatic disease. CONCLUSION: The absence of spermatogenesis and a high proportion of embryonal carcinoma was associated with advanced disease in patients with NSGCT. Whether it may also translate as a predictor of oncologic outcome needs further evaluation.

Trends in urological emergencies in the Era of COVID-19.

PURPOSE: To evaluate trends in emergency room (ER) urological conditions during COVID-19 pandemic lockdown. MATERIALS AND METHODS: Retrospective analyses of renal colic, hematuria, and urinary retention in ER's admissions of a tertiary hospital during the lockdown period (March 19 to May 4, 2020) in Israel. Patient's demographics and clinical characteristics were compared to those in corresponding periods during 2017-2019, with estimated changes in ER arrival and waiting times, utilization of imaging tests, numbers of hospitalizations, and urgent procedure rates. RESULTS: The number of ER visits for renal colic, hematuria, and urinary retention decreased by 37%, from an average of 451 (2017-2019) to 261 patients (2020). Clinical severity was similar between groups, with no major differences in patient's age, vital signs, or laboratory results. The proportion of ER visits during night hours increased significantly during lockdown (44.8% vs. 34.2%, p=0.002). There was a decrease in renal colic admission rate from 19.8% to 8.4% (p=0.001) without differences in urgent procedures rates, while the 30-day revisit rate decreased from 15.8% to 10.3% during lockdown (p=0.02). CONCLUSIONS: General lockdown was accompanied by a significant decrease in common urological presentations to the ER. This change occurred across the clinical severity spectrum of renal colic, hematuria, and urinary retention. In the short term, it appears that patients who sought treatment did not suffer from complications that could be attributed to late arrival or delay in treatment. The long-term implications of abstinence from seeking emergent care are not known and require further investigation.

Male infertility - The other side of the equation.

BACKGROUND: A male factor contributes to infertility in approximately 50% of couples who fail to conceive, causing significant psychosocial and marital stress. OBJECTIVE: This article reviews the general practitioner's (GP's) evaluation of male infertility and indications for referral to a male infertility specialist, and gives an overview of the specialist management of male infertility. DISCUSSION: Male infertility can result from anatomical or genetic abnormalities, systemic or neurological diseases, infections, trauma, iatrogenic injury, gonadotoxins and development of sperm antibodies. When a couple fails to achieve pregnancy after 12 months of regular, unprotected sexual intercourse, a screening evaluation of both partners is essential. For the male partner this includes history, physical examination, endocrine assessment and semen analysis. Several lifestyle and environmental factors can have a negative impact on male fertility, and the GP has a pivotal role in educating patients about modifiable factors.

Much more than prescribing a pill - Assessment and treatment of erectile dysfunction by the general practitioner.

BACKGROUND: Erectile dysfunction is a common but often neglected condition. Prevalence increases with age, but is not insignificant in younger men. OBJECTIVE: This article will broadly describe the epidemiology, classification and risk factors of erectile dysfunction. It will also discuss assessment and current treatment modalities, with a particular focus on the unique role of the general practitioner (GP). DISCUSSION: Erectile dysfunction may be classified as vasculogenic, neurogenic, endocrinological, drug-related, psychogenic or mixed. Commonly, erectile dysfunction is a cause of anxiety and even depression. Risk factors, such as smoking and hypertension, and reversible causes, such as hypogonadism or offending medications, should be addressed. At present, oral pharmacotherapy represents the first-line option for most patients with erectile dysfunction. It is of utmost importance to evaluate and treat comorbidities, such as depression, metabolic syndrome and cardiovascular disease, that often accompany erectile dysfunction. Patients will undoubtedly benefit from comprehensive management by a dedicated GP. Occasionally, referral to a urologist, psychologist or sexual health physician may be required.

Urolithiasis - Ten things every general practitioner should know.

BACKGROUND: Upper urinary tract stones are a common problem in Australia, with an incidence of 0.13% per year, and a lifetime prevalence of up to 15% in males and 8% in females. Many of these patients first present to general practitioners (GPs), so a thorough understanding of the diagnosis, treatment and prevention of stone disease is an important part of any GP's arsenal. OBJECTIVE: In this article, we present evidence-based guidelines regarding urolithiasis, from diagnosis, through to conservative and operative management, and prevention, as a reference for GPs and other primary care physicians. DISCUSSION: The majority of urolithiasis cases can be conservatively managed. However, prior to conservative management, adequate imaging must be obtained and emergent conditions must be excluded. Conservative management should not be initiated without a plan in the event the management fails, and adequate analgesia and medical expulsive therapy should be prescribed. Should surgery be necessary, the majority of operations can be performed as minimally invasive day procedures.

Peyronie's disease - Watch out for the bend.

BACKGROUND: Peyronie's disease is a relatively common condition in urological practice, but is still poorly identified and understood in the wider medical community and by most of the public. Identifying the condition and appropriate referral for expert opinion can significantly lessen the physical and psychological effect on patients. OBJECTIVE: The objective of this article is to provide general practitioners with a concise and updated review of Peyronie's disease, with the aim of helping them to provide appropriate advice to their patients. DISCUSSION: Peyronie's disease is an aberrant wound healing process culminating in excess scar formation in the penis, which may cause penile pain, shortening and curvature. It is often accompanied by erectile dysfunction, and can result in progressive and severe impairment of penetrative intercourse. The course of the disorder is divided into active inflammatory and chronic stable phases. Oral therapy is usually of limited efficacy, while penile traction may only be beneficial in motivated patients. Intralesional injections of collagenase were recently introduced as a non-surgical measure to decrease penile curvature. Surgery remains the most effective treatment for Peyronie's disease and is considered the gold standard.

Post-thaw recovery of rare or very low concentrations of cryopreserved human sperm.

OBJECTIVE: To analyze cases in which no sperm could be identified after thawing among cryopreserved samples of rare or very low concentrations of sperm. DESIGN: Retrospective, single-institution, cross-sectional. SETTING: Male infertility clinic. PATIENT(S): We identified couples that underwent intracytoplasmic sperm injection (ICSI) with the use of either ejaculated or testicular cryopreserved-thawed sperm. Inclusion criteria were men with <100,000 total ejaculated sperm or men with azoospermia due to spermatogenic dysfunction who underwent microsurgical testicular sperm extraction with similarly low pre-cryopreservation sperm counts. Pre-cryopreservation specimens were categorized as "rare sperm only" (Group 1) or <100,000 total sperm (group 2). "Rare sperm only" applied to cases in which only one to three sperm were identified in a search of >20 high-power fields. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Cases in which no sperm were able to be found post-thaw (i.e., complete cellular loss) for use at the time of a programmed IVF cycle. RESULT(S): We analyzed 55 men (83 ICSI cycles). There were five ICSI cycles (6.0%) among five different couples in which no sperm could be identified post-thaw. Of these, four cases were from group 1 (8.5%) and one from group 2 (2.8%). Complete cellular loss occurred in 5.8% of testicular sperm samples and 7.1% of ejaculated sperm samples. There were no statistical associations between the ability to locate sperm post-thaw and the pre-cryopreservation parameters or sperm source. CONCLUSION(S): Failure to retrieve any sperm after thawing of rare or very low concentrations of cryopreserved sperm is an infrequent event and largely limited to those patients with rare quantities of sperm.

Outcomes of anastrozole in oligozoospermic hypoandrogenic subfertile men.

OBJECTIVE: To determine whether the change in sperm parameters in subfertile hypoandrogenic men treated with anastrozole is correlated to the magnitude of increase in testosterone (T) to estrogen ratio in men responding to treatment. DESIGN: Retrospective study. SETTING: Male fertility clinic. PATIENT(S): The study group consisted of 86 subfertile hypoandrogenic men with low T/estradiol (E2) ratio (n = 78) or a prior aversive reaction to clomiphene citrate (n = 8). INTERVENTION(S): All patients were treated with 1 mg anastrozole daily, administered orally. MAIN OUTCOME MEASURE(S): Hormone analysis and semen analysis before and after treatment were performed. Hormone analysis included measurements of total T, E2, sex-hormone binding globulin, albumin, FSH, and LH, and bioavailable T was calculated. Total motile sperm count was calculated from the semen analysis. RESULT(S): In all, 95.3% of patients had an increased serum T and decreased serum E2 after treatment with anastrozole. Sperm concentration and total motile counts improved in 18 of 21 subfertile hypoandrogenic oligozoospermic men treated with anastrozole. In these men the magnitude of total motile count increase was significantly correlated with the change in the T/E2 ratio. No improvement was seen in semen parameters of men with azoospermia, cryptozoospermia, or normozoospermia at presentation. CONCLUSION(S): Approximately 95% of men with hypoandrogenism responded with improved endocrine parameters, and a subset of oligozoospermic men (approximately 25% of all patients) displayed significantly improved sperm parameters. In that subset, increase in sperm parameters was correlated with the change in the T/E2 ratio, which argues for a physiologic effect of treatment.

Predictors of spermatogenesis in radical orchiectomy specimen and potential implications for patients with testicular cancer.

OBJECTIVE: To assess the ability of semen analysis and other patients' characteristics to predict the presence of spermatozoa in radical orchiectomy pathological specimen, and describe potential implications for patients with azoospermia and testis cancer. DESIGN: Retrospective cohort study. SETTING: Tertiary hospital. PATIENT(S): A total of 214 consecutive patients with testicular cancer who underwent radical orchiectomy between 1997 and 2015. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Histologic slides were reviewed and the presence of mature spermatozoa was documented. Clinical, laboratory, and radiographic characteristics were recorded. Logistic regression analyses were used to identify factors associated with the presence of spermatozoa in the noninvolved ipsilateral testicular parenchyma. RESULT(S): Spermatozoa were found in the pathological specimen of 145 patients (67.8%). At multivariate analysis, increased tumor size was the only factor associated with lower rates of spermatozoa in the specimen. Mean tumor diameter was 4.06 cm, and spermatozoa were found in 83% and 49% of testes with tumor diameters <4 and ≥4 cm, respectively. Preoperative semen analysis records were available for 107 patients. Oligozoospermia, severe oligozoospermia, azoospermia, and cryptozoospermia were observed in 17 (16%), 18 (17%), 9 (8%) and 3 (3%) patients, respectively. Sperm concentration and motility were not associated with complete spermatogenesis. Seven of 12 patients (58%) with either azoospermia or cryptozoospermia had mature sperm in their pathological sections. CONCLUSION(S): Larger testicular cancers are associated with lower rates of spermatozoa in the ipsilateral testis. Given the substantial likelihood (∼60%) of spermatozoa to be present in the cancerous testis of patients with azoospermia and cryptozoospermia, concomitant oncologic testicular sperm extraction (TESE) can be considered in these selected patients.

Percutaneous nephrolithotomy for infection stones: what is the risk for postoperative sepsis? A retrospective cohort study.

The purpose of this study was to compare the postoperative course of patients with positive stone culture (SC) to patients with sterile SC, and to analyze the predictors for post percutaneous nephrolithotomy (PCNL) sepsis; and to describe the type and resistance patterns of bacteria responsible for post PCNL sepsis. From a cohort of 206 consecutive patients undergoing PCNL, we identified 45 patients with a positive SC (group A) and compared them to patients with a sterile SC (group B). Association between different groups was assessed using Chi square, two-tailed Student's t test and Mann-Whitney U test, as appropriate. Twenty-three patients had postoperative sepsis and regression analysis was performed to identify clinical variables associated with sepsis. Demographics, stone load and hospitalization time were similar in both groups. Postoperative sepsis developed in 31.1% of patients in group A compared to 5.9% in group B. In multivariate analysis, only positive SC was an independent risk factor for postoperative sepsis (OR 6.894, 95% CI 2.31-20.59, P = 0.001). All patients responded well to treatment with no septic complications. Enterococci were the prevalent organism (29.4%) in patients with a positive SC. Quinolone resistance was high in both gram negative and gram positive bacteria. Patients with an infected stone are at high risk to develop postoperative sepsis despite standard preoperative antibiotic preparation. SC is important to direct further treatment as almost half of patients with positive SC have a discordant or sterile urine culture. Determining the prevalent bacteria and resistance patterns in SC can aid the selection of empiric antibiotic therapy in high-risk patients.

Neutrophil-to-lymphocyte ratio predicts progression and recurrence of non-muscle-invasive bladder cancer.

OBJECTIVE: Neutrophil-to-lymphocyte ratio (NLR) predicts advanced stage disease and decreased survival in patients undergoing radical cystectomy for urothelial carcinoma of the bladder. The predictive value of NLR in non-muscle-invasive bladder cancer (NMIBC) has not been well studied. We aimed to evaluate whether NLR predicted disease recurrence and progression in NMIBC. MATERIALS AND METHODS: The medical records of 122 consecutive, newly diagnosed, patients with NMIBC treated with transurethral tumor resection, between the years 2003 and 2010, were reviewed. Patients with hematological malignancies (n = 4) and without preoperative NLR (n = 11) were excluded. Cutoff points for NLR were tested separately for recurrence and progression using the standardized cutoff-finder algorithm. Univariate and multivariate Cox regression analyses were used to evaluate the association between NLR and disease recurrence and progression. RESULTS: The study cohort comprised 91 men and 16 women at a median age of 68 years. The median NLR was 2.85 (interquartile range: 2-3.9). In total, 68 patients (64%) had an NLR>2.41. Patients with NLR>2.41 were more often men (P = 0.02) and had T1 category tumors (P = 0.034). Analyzed as a continuous variable, higher NLR showed a weak positive association with high tumor grade (R = 0.21, P = 0.028). The median follow-up for patients without disease recurrence was 40 months (interquartile range: 23-51). The estimated 3-year progression-free survival rate in patients with an NLR>2.41 was 61%, compared with 84% in patients with an NLR≤2.41 (P = 0.004). On multivariate analysis, an NLR>2.41 (hazard ratio [HR] = 3.52; 95% CI: 1.33-9.33; P = 0.012) and high-risk tumors compared with low-intermediate-risk tumors (HR = 4.83; 95% CI: 1.31-17.77; P = 0.018), as defined by the European Organization for Research and Treatment of Cancer risk tables, were associated with disease progression. An NLR>2.43 (HR = 1.75; 95% CI: 1.05-2.92; P = 0.032) and treatment with intravesical instillations (HR = 0.49; 95% CI: 0.28-0.85; P = 0.011) were associated with disease recurrence on multivariate analysis. CONCLUSIONS: NLR is an independent predictor of disease progression and recurrence in patients with NMIBC without hematological malignancies. Prospective studies are required to validate the role of NLR as a prognostic marker in NMIBC.

Presence of detrusor muscle in bladder tumor specimens--predictors and effect on outcome as a measure of resection quality.

OBJECTIVES: To identify predictors of the absence of detrusor muscle in bladder tumor specimens and analyze its effect on clinical outcome as an indicator of resection quality. METHODS: The bladder cancer database of a tertiary medical center was queried for patients who underwent complete transurethral resection of bladder tumor (TURBT) between 2008 and 2009. Study end points were absence of detrusor muscle in the surgical specimen and its association with disease recurrence/progression. RESULTS: Detrusor muscle in the surgical specimen was found in 265 of the 332 study patients (79%). The likelihood of finding muscle increased with higher clinical stage (Odds Ratio [OR]-1.8), higher tumor grade (OR-3), larger tumor size (OR-3.2), multifocal disease (OR-1.7), and nonpapillary morphology (OR-2.3). History of bladder cancer, surgeon's experience, and tumor location in the bladder had no effect. In the whole study population, neither tumor recurrence nor disease progression was associated with absence of detrusor muscle. In patients with T1 tumors, absence of detrusor muscle in the specimen was associated with higher early recurrence rate but not worse long-term outcome. CONCLUSIONS: Absence of detrusor muscle in TURBT specimens is not determined by the technical difficulty of the procedure or surgical experience. Surgeons are more prone to obtain deep muscle in large, nonpapillary-appearing tumors, likely reflecting efforts to attain accurate staging in these cases. The presence or absence of detrusor muscle may serve as a surrogate of resection quality in patients with T1 tumors, but its general applicability to the overall population of patients undergoing TURBT remains questionable.

Resection of ureteral orifice during transurethral resection of bladder tumor: functional and oncologic implications.

PURPOSE: We assessed the risk of upper urinary tract obstruction and tumor recurrence following ureteral orifice resection during transurethral resection of bladder tumor. MATERIALS AND METHODS: We reviewed the medical records of patients treated with transurethral resection of bladder tumors involving the ureteral orifice from 2008 to 2011. Patients with preoperative hydronephrosis or prior ipsilateral nephrectomy and those in whom a ureteral stent was placed during the procedure were excluded from analysis. Study end points were clinical or radiographic evidence of upper urinary tract obstruction and disease recurrence. RESULTS: The study group included 65 men (82%) and 14 women (18%) in whom a total of 84 orifice resections were performed. Hydronephrosis was observed in 11 patients (13%) during a median followup of 15 months (IQR 7-26). Hydronephrosis was secondary to muscle invasive disease in 5 patients (6%) and it resolved spontaneously in 3 (4%). In the remaining 3 patients (4%) overt stricture was detected at the ureterovesical junction, requiring endoscopic intervention. One patient was diagnosed with recurrent tumor in the upper urinary tract. The estimated bladder disease recurrence rate was 28% at 1 year and 54% at 2 years. Corresponding disease progression rates were 4% and 12%, respectively. CONCLUSIONS: Ureteral orifice resection during transurethral resection of bladder tumor is rarely associated with detrimental renal obstruction or an increased risk of tumor recurrence in the upper urinary tract. New onset hydronephrosis is mostly attributable to muscle invasive disease or temporary obstruction. However, the few cases of overt stricture underscore the importance of meticulous followup with imaging.