Evaluation of the impact of marijuana use on semen quality: a prospective analysis.

AIMS: To assess if marijuana consumption - prevalent among men of reproductive age and becoming widespread due to decriminalization - is associated with changes in semen parameters. Marijuana's active metabolite, tetrahydrocannabinol, can alter signaling pathways within spermatozoa, affecting spermatogenesis and fertility. METHODS: We prospectively evaluated semen analyses (SA) from men presenting for infertility evaluation at one institution from July 2017 to April 2018. Participants completed a reproductive health questionnaire including items regarding marijuana consumption. SA was performed in accordance with World Health Organization (WHO) 5th Edition criteria. SA parameters included volume (ml), concentration (million/ml), motility (%), progressive motility (%), and Tygerberg strict morphology (%). RESULTS: A total of 409 patients completed the questionnaire; 174 (43%) men reported marijuana use (ever-users). Current and past users comprised 71 (17%) and 103 (25%), respectively. Compared with never-users, current and past users had a significantly higher likelihood of abnormal sperm strict morphology (33.1% versus 50.7% and 53.4%, respectively; p < 0.001). However, sperm motility was more likely to be less than WHO reference values in never-users than current and past-users (38.3% versus 21.1% and 27.2%, respectively; p = 0.01). In multivariate logistic regression analyses, current use was associated with increased odds of abnormal strict morphology [odds ratio (OR) 2.15, 95% confidence interval (CI): 1.21-3.79] and semen volume less than WHO reference value (OR 2.76, 95%CI: 1.19-6.42), while odds of less than WHO reference value sperm motility were reduced (OR 0.47, 95%CI: 0.25-0.91). CONCLUSION: Marijuana use is common among men presenting for fertility evaluation, and may have a detrimental effect on semen quality, particularly morphology and volume, but may be protective against abnormal sperm motility. Large, prospective studies of both semen quality and fertility in this growing, at-risk population are warranted.

Association of the 2012 American Urological Association Vasectomy Guidelines with National Trends in Vasectomy Followup in the United States.

INTRODUCTION: The American Urological Association Vasectomy Guidelines published in 2012 defined vasectomy success as either azoospermia or rare nonmotile sperm (≤100,000 nonmotile sperm/ml). We sought to characterize nationwide practice patterns surrounding vasectomy followup before and after publication of the guidelines. METHODS: Data were collected using the MarketScan® database. We identified men 18 to 64 years old undergoing vasectomy between 2007 and 2015 with at least 12 months of followup to track post-vasectomy semen analysis claims. Demographic data including age, vasectomy provider type and regionality were also queried. We compared the likelihood of men obtaining multiple post-vasectomy semen analyses before vs after the guidelines release with multivariate logistic regression. Linear regression was used examine time to first post-vasectomy semen analysis association with observed post-vasectomy semen analysis frequency trends. RESULTS: We identified a total of 87,201 patients who underwent vasectomy between 2007 and 2015 and had at least 1 post-vasectomy semen analysis claim. Men undergoing vasectomy in the post-guideline years of 2013 to 2015 were at lower risk for requiring any repeat post-vasectomy semen analysis (OR 0.68, 95% CI 0.66-0.71) and less likely to have had ≥3 post-vasectomy semen analyses (OR 0.82, 95% CI 0.77-0.88) than those in the pre-guideline (2007 to 2012) cohort. Mean time to first post-vasectomy semen analysis was shorter in men who submitted multiple analyses (p <0.001). CONCLUSIONS: Within a nationally representative patient cohort, men required fewer repeat post-vasectomy semen analyses after publication of the 2012 guidelines. Further research on patient and provider characteristics affecting variations in vasectomy followup patterns and guideline adherence is needed.

The vasal fluid proteomic profile and microscopic sperm presence at time of vasectomy reversal.

BACKGROUND: The microscopic characteristics of vasal fluid at time of vasectomy reversal (VR) guide operative decision making and predict fertility outcomes. The proteomic profile of this vasal fluid has not been described or correlated with the microscopic fluid appearance. To characterize the vasal fluid proteome at time of VR and evaluate the variation of the vasal fluid proteome with respect to microscopic presence of sperm. METHODS: A prospective cohort study was conducted enrolling twenty-five men undergoing VR for infertility and/or pain at a University-affiliated hospital. Vasal fluid samples obtained at time of VR were grouped based on presence of sperm on light microscopy at time of VR. Proteomic profiles were generated using liquid chromatography/ tandem mass spectrometry, and MS/MS protein spectral counts compared between individuals and treatment groups, controlling for less than 5% protein false discovery rate (FDR). Proteins were matched with the human swissprot database using the Comet search engine, and categorized by Gene Ontology (GO) terms. RESULTS: There was large variability between the 46 vasal fluid samples collected, with 1,692 unique proteins detected. The three most abundant proteins were Lactotransferrin, Cysteine-rich secretory protein 1, A-kinase anchor protein 4. There was no correlation between the proteome and microscopic sperm presence. Prevalent GO terms included viral process, signal transduction, innate immune response, protein folding and spermatogenesis. CONCLUSIONS: We describe the proteome and the most common proteins in vasal fluid at time of VR. Numerable sperm, testis and epididymis specific proteins were present even in the absence of sperm on microscopy. Further evaluation is needed to determine if a protein biomarker may better guide operative decision making and predict VR fertility outcomes.

Treatment Trends and Cost Associated With Peyronie's Disease.

INTRODUCTION: Providers may use several treatment options for patients with Peyronie's disease; however, it is unclear whether practice patterns have evolved over recent years and if this has impacted cost. AIMS: To investigate trends in the treatment of Peyronie's disease over time and the associated costs using a national, commercial insurance claims database. METHODS: A retrospective cohort study was conducted using claims from the Truven MarketScan database from 2007 to 2018 for men with Peyronie's disease. Cost was estimated as either the sum of prescription oral or injectable treatment costs or as the single net cost associated with the operative procedure. MAIN OUTCOME MEASURES: Frequency of use of various treatments for Peyronie's disease and associated costs were assessed as trends over the timeline by year. RESULTS: The estimated annual incidence of Peyronie's disease in this population rose from 61 to 77 per 100,000 patients over the included years, and the percent annual treatment rate rose from 17.8% to 26.2%. Colchicine was the most commonly prescribed oral agent in 2007 used in 22% of treated individuals; by 2018, pentoxifylline was the most common prescribed oral agent used in 33%. In 2007, 11% of treated patients received intralesional verapamil; however, by 2018, 24% received injectable collagenase, whereas <1% received intralesional verapamil. The mean annual, per-individual cost of Peyronie's disease treatment increased from $1,531 in 2007 to $10,339 in 2018. The cost increase was greatest for injectable therapies, which rose from $811 per individual in 2007 to $16,184 in 2018, a 19-fold increase. CONCLUSIONS: Diagnosis and treatment of Peyronie's disease is increasing over time. Pentoxifylline has become the most common oral prescription, whereas injectable collagenase has become most common injection. The mean cost associated with Peyronie's disease treatment increased more than 5 times from 2007 to 2018 corresponding with Federal Drug Administration's approval of injectable collagenase. Loftus CJ, Rajanahally S, Holt SK, et al. Treatment Trends and Cost Associated With Peyronie's Disease. Sex Med 2020;8:673-678.

Comparison of clinician and patient users of a mobile phone application to assess penile curvature in Peyronie's disease.

Assessment of Peyronie's disease with penile injection is invasive and uncomfortable. We developed a smartphone application (UWPEN) to assess penile angulation in the home environment. The purpose of this study was to compare clinician and patient measurements and assess the patient experience with UWPEN in a clinical setting. We prospectively enrolled patients with Peyronie's disease undergoing intracavernosal injection of alprostadil. Penile angulation and narrowing were then assessed by patients and clinicians using UWPEN and compared to values obtained via a goniometer and a ruler (gold standard). Measurements were compared using the Pearson correlation test. Upon completion of measurements, patients were surveyed regarding the ease of use, confidence with use, and measurement preferences. Twenty patients were enrolled in the study; two patients were excluded for poor penile turgidity after a maximum dosage of intracavernosal alprostadil. Correlation between UWPEN and gold standard measurements by patients and clinicians was R = 0.55 (p = 0.01) and R = 0.87 (p < 0.01) for dorsal measurements, R = 0.62 (p = 0.01) and R = 0.77 (p < 0.01) for lateral measurements, and R = 0.73 (p < 0.01) and R = 0.64 (p < 0.01) for girth measurements, respectively. Prior evaluation of correlation suggests a strong correlation at R = 0.8, and good correlation at R = 0.5. Overall, patients preferred using UWPEN to traditional measurements, and 75% reported UWPEN as their first preference for measurements. UWPEN enables patients to assess their disease severity with good correlation to gold standard measurements. Patients prefer mobile platforms for disease monitoring, and development of technology for disease monitoring should be a priority within the Peyronie's disease research community.

Perspectives on Priapism Education in Emergency Medicine.

INTRODUCTION: Priapism is a urologic emergency managed by both emergency medicine (EM) providers and urologists. Attitudes regarding its management and understanding of education of non-urology trainees in this area are poorly defined. AIM: The aim of this study was to describe attitudes toward priapism management among multiple stakeholders and define the current state of priapism education among EM residency programs. METHODS: Surveys were developed and distributed online to EM residency leadership, EM residents, and urology providers. Each solicited attitudes and preferences regarding independent priapism management by EM providers. EM residents were further queried about their educational and clinical experiences in priapism management, and EM residency leadership were surveyed about their educational curricula. Responses among all 3 groups were compared using Fisher's exact tests. MAIN OUTCOME MEASURE: Quantitative and descriptive responses were solicited regarding EM providers' management of acute ischemic priapism and current priapism curricula for EM residents. RESULTS: 91 EM residency program directors and assistant program directors (31.6% of programs), 227 EM residents (14.7% of programs), and 94 urologists (6.3% of survey recipients) responded. All geographic regions and all years of EM training were represented. Over 90% of all surveyed groups felt that EM providers should independently manage priapism in practice. 17% of senior EM residents felt "not at all" confident in managing priapism; and 25.5% had never primarily managed this entity in training. 81% of programs had a formalized priapism curriculum, of which 19% included treatment simulation. However, 36% of residents felt that current curricula were insufficient. CLINICAL IMPLICATIONS: Widespread approval from both EM providers and urologists support EM-based management for uncomplicated cases of acute ischemic priapism. Current educational curricula for EM trainees may not be sufficient to prepare them to manage this entity in practice. STRENGTHS & LIMITATIONS: This is the first study to examine provider attitudes toward EM-based management of priapism and assess the current state of education in this area with input from all key stakeholders. This survey was limited in its scope and the response rate was lower than desired. CONCLUSION: Urologists support independent priapism management by EM providers, but an educational gap remains for EM trainees who do not feel adequately trained to manage this independently in practice. Dai JC, Franzen DS, Lendvay TS, et al. Perspectives on Priapism Education in Emergency Medicine. J Sex Med 2020;17:159-162.

Reconsidering vasectomy reversal over assisted reproduction in older couples.

OBJECTIVE: To provide pregnancy and live birth rates from a contemporary series of vasectomy reversals in men with female partners aged ≥35 years and to correlate the results with IVF. SETTING: Tertiary academic referral center. DESIGN: Retrospective comparative study of prospectively collected database. PATIENT(S): Two hundred forty-six men who underwent vasectomy reversal for fertility with female partner aged ≥35 years. INTERVENTION(S): Vasovasostomy or vasoepididymostomy. MAIN OUTCOME MEASURE(S): Correlation of pregnancy and live birth rate of this cohort by age groups with most recently published pregnancy and live birth rate per IVF cycle. RESULT(S): One hundred thirty-six men who underwent vasectomy reversal between 2006 and 2014 met our inclusion criteria. Overall pregnancy and live birth rates were 35% and 30%, respectively. Subgroup analysis by female age groups (35-37, 38-40, >40 years) demonstrated pregnancy and live birth rates comparable to those per IVF cycle by age groups according to a recently published (2015) national report. CONCLUSION(S): Vasectomy reversal should be strongly considered in men with a partner aged ≤40 years. Additionally, vasectomy reversal can be considered in carefully selected patients even with a partner aged >40 years.

Evaluation of Vasectomy Trends in the United States.

OBJECTIVE: To use the Truven Health MarketScan database to better approximate the annual rate of vasectomies performed in the US population, to determine changes over time, regional differences, providers performing this, and to know if there is any monthly variation in vasectomy rates. MATERIALS AND METHODS: Claims data were evaluated from 2007 to 2015 to determine the annual prevalence of vasectomy by patient age and region in the United States. The cohort included men aged 18-64 years with at least 1 claim in any given year in Truven Health MarketScan. Provider type and place of service were evaluated in 2014 and 2015. Monthly evaluation of vasectomy prevalence compared with total claims was performed. RESULTS: The prevalence of vasectomies decreased from 2007 to 2015, across all age groups and in all locations of the country (P <.001). Using these data and the most recent US census data, an estimated 527,476 vasectomies were performed in the United States in 2015. The North Central and West regions (0.64% and 0.60%, respectively) had the highest annual prevalence of vasectomies. The month of March and the end of the year had the highest proportion of vasectomies performed. In both 2014 and 2015, a urologist in the office setting performed 82% of vasectomies. CONCLUSION: An estimated 527,476 vasectomies were performed in the United States in 2015. From 2007 to 2015 there was a decrease in the proportion of vasectomies performed in all age groups and in all locations of the country. The end of the year and the month of March are when the most vasectomies are performed.

Factors and practice patterns that affect the decision for vasoepididymostomy.

INTRODUCTION: To determine the factors used to make the decision between vasovasostomy (VV) and vasoepididymostomy (VE) by leaders performing microsurgical vasectomy reversal using a questionnaire. MATERIALS AND METHODS: An online questionnaire was sent to all members of the Society for the Study of Male Reproduction (SSMR), a male reproduction subspecialty society of the AUA, using the SurveyMonkey platform. RESULTS: Sixty-seven surgeons responded to the questionnaire (27% of SSMR members). Of which 72% of members performed less than 50 vasectomy reversals per year. Also, 71% of members stated that less than 20% of their vasectomy reversals are vasoepididymostomies. When evaluating epididymal fluid at the time of reversal, 87% would perform a VE for pasty fluid, 66% with creamy fluid without sperm heads and 55% with no or scant fluid. With respect to banking sperm, 36% take sperm or testicular tissue at the time of VE while 37% sometimes take sperm mostly depending on the couple's preference. The Berger end-to-side with intussusception VE technique is used by the majority of members (78%). The presence of intact sperm or sperm parts determined the location in the epididymis for anastomosis for 55% and 19% of members respectively. Postoperative semen testing after a VE is evaluated first between 6 weeks to 3 months for 64%. The procedure is considered a failure between 6 to 12 months for 34% and 12 to 18 months for another 48% if no sperm is seen on semen analysis. CONCLUSIONS: Most members perform a VE with pasty fluid or creamy fluid without sperm heads. Three out of four members are using the Berger end-to-side intussusception technique to perform their VE. More studies are needed to determine the optimal circumstances to perform a VE as there is significant variation in responses even among members of the SSMR.

A review of the epidemiology and treatment of Peyronie's disease.

INTRODUCTION: Peyronie's disease (PD) has significant effect on patients and their partners. We provide a current review of the epidemiology as well as the nonsurgical and surgical treatment of PD. MATERIALS AND METHODS: Review of literature pertaining to PD with focus on epidemiology and treatment options. CONCLUSION: PD is common and likely underreported. The availability of new and highly effective treatment options will catalyze patient awareness and subsequently the prevalence of disease.

Bone Saw for Calcified Peyronie's Disease Plaques.

OBJECTIVES: To determine the incidence of calcified Peyronie's disease plaque that cannot be cut with a blade in a 100-case series and to describe the use of a soft tissue-protecting bone saw for plaque incision. METHODS: Chart reviews were done of all surgically treated Peyronie's disease patients at our center between October 1996 and December 2012. 100 cases were included. We evaluated our novel technique of tissue-protecting bone saw surgical use. RESULTS: 100 consecutive patients underwent surgery for Peyronie's disease, and 6 required transverse bone saw plaque incision due to the severity of calcification that could not be cut with a blade. Four of those 6 underwent grafting procedures with porcine submucosal intestinal substance (SIS) and 2 underwent placement of inflatable penile prosthesis (IPP) after plaque incision. There were no surgical complications. Both IPP patients had functioning prosthesis 4 and 7.3 years after surgery. One SIS-graft patient required re-operation for more proximal curvature 11 months later and ultimately required multiple plaque incisions and an IPP. CONCLUSION: Densely calcified plaques occurred in 6% of a surgical series of Peyronie's disease patients. The vibrating bone saw is a novel technique to incise calcified plaques before grafting or IPP placement.

Vasectomy Reversal for Postvasectomy Pain Syndrome: A Study and Literature Review.

OBJECTIVE: To review our institution's experience and success with vasectomy reversal to treat postvasectomy pain syndrome (PVPS) over the last 20 years. MATERIALS AND METHODS: A single surgeon (E.F.F.) performed all the vasectomy reversals. We identified 123 procedures done for PVPS treatment and were able to contact 76 patients. We sent surveys or conducted phone interviews inquiring about satisfaction, levels of pain preoperatively and postoperatively, and the need for additional procedures for pain. Thirty-one patients completed phone or written surveys. In addition, we compared the location of vasectomy among patients presenting for pain to that of fertile patients. RESULTS: Thirty-one men had vasectomy reversal for postvasectomy pain, with median age of 38 years (range, 31-55 years), of which 26 underwent vasovasostomy (VV). Seven patients required epididymovasostomy (EV) on at least 1 side based on intraoperative findings. Eighty-two percent of patients reported improvement in their pain at 3.2 months (±3.4 months) after vasectomy reversal. Thirty-four percent patients had complete resolution of all pain. Mean pain score before procedure was 6.4 (±2.4), decreasing to a median of 2.7 (±2.7) afterward. There was a 59% improvement in pain scores (P <.001). Two patients required additional procedures for continued pain, one orchiectomy and one epididymectomy. Four patients required an additional reversal procedure, one a repeat VV at 1 year and 3 an EV at 1, 5, and 9 years, respectively. Follow-up ranged from 1 to 19 years, with a mean follow-up of 8.4 years. We found no relationship between vasectomy location and pain. CONCLUSION: Vasectomy reversal, through the use of both VV and EV, can provide long-term relief from PVPS.

Infertility with Testicular Cancer.

Testicular germ cell cancer is one of the most curable cancers. Most patients are treated during their reproductive years, making infertility a significant quality of life issue after successful treatment. This focused review evaluates the factors that contribute to infertility and specific fertility risks with the various testicular cancer treatments. Timing of patient discussions and current fertility treatments are reviewed.

Impact on Pregnancy of Gross and Microscopic Vasal Fluid during Vasectomy Reversal.

PURPOSE: We compared fertility outcomes with gross and microscopic fluid findings at vasectomy reversal at a high volume vasectomy reversal center. MATERIALS AND METHODS: A retrospective study of a prospective database was performed. All vasectomy reversals were performed by a single surgeon (EFF) between 1978 and 2011. The clinical pregnancy rate was self-reported or determined via patient mailers. Patient and operative findings were determined through database review. We classified vasal fluid as opalescent, creamy, pasty or clear. Intraoperative light microscopy was used to determine if sperm or sperm parts were present and if they were motile. Multivariate analysis was performed evaluating patient age, partner age, years after vasectomy, type of surgery, and gross and microscopic fluid analysis. RESULTS: A total of 2,947 microsurgical vasectomy reversals were reviewed after we excluded reversals performed for post-vasectomy pain. We determined the pregnancy status of 902 (31%) cases. On univariate analysis with respect to pregnancy the presence of motile sperm at vasovasostomy neared statistical significance (p=0.075) and there was no difference between bilateral vs unilateral motile sperm. Gross fluid appearance was not statistically significant but we found the order of pregnancy success to be opalescent, creamy, clear then pasty fluid. On multivariate analysis only female partner age and sperm heads only or no sperm seen on light microscopy had statistical significance (p <0.05). CONCLUSIONS: The presence of motile sperm at vasectomy reversal approaches statistical significance on univariate analysis as a factor that affects clinical pregnancy rates. On multivariate analysis female partner age and microscopic findings of sperm heads only or no sperm are inversely related to pregnancy rates. These data will help counsel couples after vasectomy reversal and reinforce the importance of female partner age.

Higher outcomes of vasectomy reversal in men with the same female partner as before vasectomy.

PURPOSE: We reviewed fertility outcomes of vasectomy reversal at a high surgical volume center in men with the same female partner as before vasectomy. MATERIALS AND METHODS: We retrospectively studied a prospective database. All vasectomy reversals were performed by a single surgeon (EFF). Patients who underwent microsurgical vasectomy reversal and had the same female partner as before vasectomy were identified from 1978 to 2011. Pregnancy and live birth rates, procedure type (bilateral vasovasostomy, bilateral vasoepididymostomy, unilateral vasovasostomy or unilateral vasoepididymostomy), patency rate, time from reversal and spouse age were evaluated. RESULTS: We reviewed the records of 3,135 consecutive microsurgical vasectomy reversals. Of these patients 524 (17%) who underwent vasectomy reversal had the same female partner as before vasectomy. Complete information was available on 258 patients (49%), who had a 94% vas patency rate. The clinical pregnancy rate was 83% by natural means compared to 60% in our general vasectomy reversal population (p <0.0001). On logistic regression analysis controlling for female partner and patient ages, years from vasectomy and vasectomy reversal with the same female partner the OR was 2 (p <0.007). Average time from vasectomy was 5.7 years. Average patient and female partner age at reversal was 38.9 and 33.2 years, respectively. CONCLUSIONS: Outcomes of clinical pregnancy and live birth rates are higher in men who undergo microsurgical vasectomy reversal with the same female partner. These outcomes may be related to a shorter interval from vasectomy, previous fertility and couple motivation.

Testosterone replacement therapy and prostate health.

There is an emerging evolution in the understanding of the relationship between the prostate and testosterone. It has long been generally believed that with testosterone replacement therapy (TRT), increasing serum testosterone levels led to prostatic growth and worsening of voiding dysfunction and associated complications. A new theory, the Saturation Model of Testosterone and its effect on the Prostate has gained attention. This theory suggests that the prostate's response to increasing levels of serum testosterone reaches a limit beyond which there is minimal effect. This model predicts that testosterone replacement therapy occurs above this saturation point, and replacing testosterone to eugonadal levels should not worsen prostate related benign disease. We evaluated the recent published data, with an emphasis on clinical studies done within the last 3 years, for the effects of testosterone supplementation on benign prostatic disease.