An integrated approach to male-factor subfertility: bridging the gap between fertility specialists trained in urology and gynaecology.

Subfertile men and women are usually cared for by different clinicians, namely urologists and gynaecologists. While these doctors share each other's goals, they may not always appreciate the content or implications of their opposite number's clinical decisions; to some degree they may practice in "silos." We address this problem by reviewing the effectiveness of medical treatments for male factor subfertility in the context of female factors. The effectiveness of treatments for couples with male factor subfertility, other than IVF with ICSI, appears modest. However, data from randomized controlled trials suggest benefits from some treatments: clomiphene and tamoxifen for the male (common odds ratio for pregnancy [COR] 2.42; 95% CI 1.47 to 3.94), antioxidants (COR 4.18; 95% CI 2.65 to 6.59) and surgical management of a clinical varicocele (COR 2.39; 95% CI 1.56 to 3.66). Nevertheless, close attention to female age and the duration of subfertility help to avoid lost opportunity through delays in treatment when IVF with ICSI is indicated. Making treatment decisions squarely in the context of the couple's overall prognosis is key for optimal outcomes. Future trials of male fertility treatments should focus on pregnancy as the primary outcome, rather than less important surrogates such as sperm quality.

Les hommes et les femmes hypofertiles obtiennent habituellement leurs soins auprès de cliniciens distincts, soit des urologues et des gynécologues, respectivement. Bien que ces professionnels de la santé aient des objectifs communs, il est possible qu'ils ne comprennent pas toujours le contenu ou les implications des décisions cliniques de leurs homologues; on pourrait même en venir à affirmer qu'ils agissent de façon cloisonnée. Nous traitons de ce problème en analysant l'efficacité des traitements médicaux visant l'hypofertilité masculine dans le contexte des facteurs féminins. À l'exception de l'utilisation concomitante de la FIV et de l'IICS, l'efficacité des traitements offerts aux couples qui font face à une hypofertilité attribuable à des causes imputables à l'homme semble modeste. Toutefois, des données issues d'essais comparatifs randomisés semblent indiquer que certains traitements offrent des avantages : clomiphène et tamoxifène administrés à l'homme (rapport de cotes commun pour ce qui est de la grossesse [RCC], 2,42; IC à 95 %, 1,47 - 3,94), antioxydants (RCC, 4,18; IC à 95 %, 2,65 - 6,59) et prise en charge chirurgicale d'une varicocèle clinique (RCC, 2,39; IC à 95 %, 1,56 - 3,66). Quoi qu'il en soit, le fait de bien porter attention à l'âge de la femme et à la durée de l'hypofertilité aide à éviter les occasions manquées en raison de délais dans la mise en œuvre du traitement, dans les cas où l'utilisation concomitante de la FIV et de l'IICS s'avère indiquée. Le fait de prendre des décisions en s'assurant de tenir absolument compte du pronostic global du couple est d'une importance capitale pour l'obtention d'issues optimales. L'obtention d'une grossesse (et non des critères auxiliaires moins importants, tels que la qualité des spermatozoïdes) devrait constituer le critère d'évaluation principal des futurs essais visant les traitements contre l'infertilité masculine.

Impact of virtual education on urology education during the COVID-19 pandemic.

INTRODUCTION: The coronavirus pandemic changed the way urology education was delivered. At Dalhousie University, third-year medical students (clinical clerks) undergoing a two-week urology elective had the historic in-person seminars changed to virtual seminars with pre-recorded lectures by staff. The academic abilities of the clerks were measured via a standardized written exam and clinical score assigned by a staff preceptor. This study aimed to measure the impact of virtual education on student performance. METHODS: Clerk clinical and exam scores have been recorded since 2014. The in-person seminar (pre-COVID) cohort included students from January 2014 to March 2020 (n=109), while the virtual seminar (post-COVID) cohort was recorded from April 2020 to August 2022 (n=60). Independent t-test was used to compare clinical, exam, and total scores between the pre-COVID student groups after ensuring normality. RESULTS: Students in the virtual seminar group (mean ± standard deviation 88.69±6.50%) performed better than the in-person seminar student groups (86.32±6.33%) in terms of clinical performance gradings (p=0.02). There was no statistically significant difference in written exam scores between the in-person seminar and virtual seminar cohorts (77.34±10.94% vs. 78.75±11.37%, p=0.43). Cumulative scores were higher for virtual seminar student groups vs. in-person seminar cohort (86.70±5.40% vs. 84.52±5.44%, p=0.01). CONCLUSIONS: Clinical clerks undergoing virtual education during a two-week urology elective had improved clinical and cumulative score performances when compared to the in-personal seminar cohort; virtual seminars did not statistically negatively impact exam scores.

Canadian trends in testosterone therapy.

INTRODUCTION: Rates of testosterone therapy (TT) prescribing dropped dramatically following the U.S. Food and Drug Administration and Health Canada warning regarding potential cardiovascular morbidity in 2014. Since then, prescription rates appear to be increasing in the U.S., however, data on TT use in Canada is lacking. Current database studies suffer from incomplete prescription capture, lack of information on continued use, and confounding from concurrent population growth. Nova Scotia (NS) is a Canadian province with minimal population growth over the past decade. NS tracks every testosterone prescription and refill through their prescription monitoring program (NSPMP). All testosterone prescriptions must be written on triplicate forms, allowing for comprehensive tracking. The purpose of this study is to describe the long-term prescription trends of testosterone in a mid-sized Canadian province using a database that captures 100% of all TT prescriptions written and filled. METHODS: Data were extracted from the NSPMP database on all prescriptions and prescription refills of androgens for men over 18 years of age from 2007-2019. Population statistics were gained using publicly available data from Statistics Canada. Analysis of patterns on individual years and over time were examined for number of patients, prescriptions, and prescribers, as well as formulation. RESULTS: The male population of Nova Scotia remained relatively stable throughout the study period (2007: 455 064; 2019: 475 478; population increase of 4.3%). A total of 7883 men (1.7% of the male population) received a prescription for TT during the study period; 1673 men received only one prescription in the entire study period and 5446 men remained on TT for longer than six months. Of the 1730 men under 45 who were prescribed TT, 75% (n=1298) of them stayed on it for more than six months; 1856 men (24%) switched the type of testosterone they were on during the study period. The number of men receiving TT yearly increased by 98%, from 1235 in 2007 to 2448 in 2019. The number of men receiving TT plateaued in 2014, except for men under age 35, in whom it has steadily increased every year since 2007. Interestingly, primary care providers (PCPs) wrote 92% of all prescriptions, on average (interquartile range 90-93). CONCLUSIONS: In a mid-sized Canadian province with stable population growth, prescriptions of testosterone increased until 2014, and then either stabilized or decreased. TT prescriptions in young men have continued to increase yearly. Injectable and gel-based formulations have increased in popularity over the past decade. Future efforts to educate prescribers, especially surrounding the effects on fertility in young men, should be largely focused on PCPs.

An Examination of the Relationship between Mental Distress, Functional and Psychosocial Quality of Life Indicators in a Population Based Sample of Prostate Cancer Survivors Who Received Curative Treatment.

INTRODUCTION: Although survival rates are highest among prostate cancer survivors compared to any other forms of cancer, nearly 60% suffer from mental distress. Here we examine urinary function and psychosocial stressors and their association with poor mental health in a younger group of prostate cancer survivors who have undergone curative treatment. METHODS: The study includes 128 men (47 to 70 years old) who received active treatment for prostate cancer, and completed a survivorship online survey between 2017 and 2018. Psychological distress was assessed with Kessler Psychological Distress Scale. International Prostate Symptom Score subscales (incomplete urinary emptying, frequency, intermittency, urgency, weak stream, straining and nocturia) and number of current prostate cancer survivorship stressors were predictors. Multivariate logistic regression was used to fit the model while controlling for months of survivorship since diagnosis, the presence or absence of surgery, radiation or hormone therapy treatment, current medication for depression and demographics. RESULTS: A total of 19.5% of men scored positive for current mental health issues. Prostate cancer survivors who reported increased number of current survivorship stressors (OR 1.48, 95% CI 1.09-2.01), had higher frequency of urination (OR 2.05, 95% CI 1.15-3.64), history of radiation treatment (OR 7.15, 95% CI 1.02-50.35) and were currently on prescribed medication for depression (OR 33.47, 95% CI 3.80-294.87) had higher odds for screening positive for psychological distress compared with their counterparts. CONCLUSIONS: These results corroborate recent findings showing an intersection between urological oncology and poor mental health during survivorship, and warrant the development of multidisciplinary teams in addressing survivorship issues in this population.

Scrotal syringocystadenoma papilliferum: case report.

Syringocystadenoma papilliferum (SCAP) is a benign rare adnexal skin neoplasm, which in a third of cases arises from a nevus sebaceous and is most commonly found on the head and neck and in very rare instances found on the genitalia. We report on a 59-year-old man with SCAP on the scrotum. The clinical scenario and histopathological findings are outlined. Following excision and histological confirmation of a noninfiltrative process, the patient remains asymptomatic. To our knowledge, only three other cases of such a lesion on the scrotum have been reported in the literature.

Spermatocytic Tumor With Sarcoma: A Rare Testicular Neoplasm.

Spermatocytic tumor, formerly known as spermatocytic seminoma, is an uncommon testicular neoplasm which is a distinct clinicopathologic entity from classic seminoma. These tumors are not associated with germ cell neoplasia in situ, other germ cell tumors, or isochromosome 12p. Although typically, these tumors have an excellent prognosis occasional cases are associated with sarcoma and have a very poor prognosis. We present a case of spermatocytic tumor with sarcoma showing a chondrosarcomatous component, discuss the pathologic findings and differential diagnosis and provide follow-up information.

Sarcoid of the testis.

Sarcoidosis is a chronic disease that rarely manifests in the male reproductive tract. Due to its infrequent nature, treatment for sarcoid of the male reproductive tract is controversial. We report a case of incidentally discovered sarcoid of the testis in a white male managed with a testis sparing approach.

Natural history of urinary tract infection in a primary care environment in Canada.

OBJECTIVE: To characterize the natural history of uncomplicated urinary tract infection (uUTI) in a Canadian primary care environment from the patient's perspective. MATERIALS AND METHODS: Female patients (n = 2323) with symptoms of uUTI were recruited by 581 family physicians who collected baseline demographic and clinical data and prescribed 500 mg/day extended release ciprofloxacin (Cipro XL). Follow-up data were collected 4 and 10 days later by patient telephone interview assessing uUTI symptoms, medication compliance, time to symptom resolution, impact on usual activities and overall satisfaction. RESULTS: Patients (mean age 40) had on average 3.56 uUTI symptoms at baseline, the most common of which was frequency (94% of patients). The mean duration of symptoms was 4.9 days. Sixty-three percent of patients reported an impact of uUTI on usual activities prior to antibiotic therapy with a mean impact score of 4.33 {scale 0 to 10 (maximum)}. At day 4, uUTI symptoms had decreased to 0.74/patient, 71.5% of patients reported symptom resolution, while medication compliance was 97%. By day 10, uUTI symptoms had decreased further to 0.42/patient, 84.3% of patients had symptom resolution and only 13% reported a residual impact on usual activities (mean impact score, 0.76). Patients showed high levels of satisfaction (> 80%) with all aspects of therapy. CONCLUSIONS: Patients wait almost 5 days before seeking medical attention for uUTI and by that time symptoms can significantly impact normal activities. This assessment of symptoms and outcomes of uUTI provides physicians with a better view of the impact of infection on patient's lives.

Canadian guidelines for the management of benign prostatic hyperplasia.

OBJECTIVE: To develop the first Canadian guidelines for the management of lower urinary tract symptoms in men with benign prostatic hyperplasia (BPH). METHODS: These guidelines, developed under a mandate provided by the Canadian Urological Association (CUA), were a collaborative effort between the CUA guidelines committee and the Canadian Prostate Health Council. BPH guidelines developed by the American Urological Association, the European Association of Urology, the World Health Organization International Consultation on BPH, and similar committees from Germany, Sweden and Australia were reviewed. The committee further reviewed a systematic literature search, updated to May 2004, and systematically derived Canadian urological opinion data. RESULTS: The subsequent Canadian BPH guidelines were developed as an evidence based consensus among the committee members. Mandatory evaluation includes history, physical examination and urinalysis, while a symptom inventory and PSA in selected patients are recommended. Serum creatinine, uroflow, voiding diary, post void residual and sexual function questionnaire are optional. Unless there is an indication, other related tests are not recommended. Treatment choices should be governed by the severity of the symptoms, bother and patient preference. Guidelines for medical, surgical and minimally invasive treatment as well as special considerations are described in terms of guideline, option and recommendation. CONCLUSIONS: Diagnostic and treatment guidelines for BPH reflect the Canadian social priorities, economics, socialized medical practice, manpower issues, and medicolegal considerations.

Acute renal infarct without apparent cause: A case report and review of the literature.

Acute renal infarction is a rare clinical entity most commonly occurring as a result of a thromboembolic event in patients with predisposing risk factors. Its non-specific presentation can lead to delayed or missed diagnosis. However, modern imaging technology has allowed for the diagnosis of renal infarction to be made earlier in its clinical course. Due to its rare nature, treatment guidelines do not exist. We report a case of acute renal infarction identified on computed tomography scan in a patient with no known predisposing factors to thromboembolism that was treated through suction thrombectomy.

Broken retrieval string leads to failed self-removal of a double-J ureteral stent.

Double-J ureteral stents facilitating the drainage of urine from the kidney to the bladder are widely used. Stents designed for patient self-removal are commonplace. We report a case of urosepsis that lead to the incidental discovery of a failed self-removal of a double-J ureteral stent. The retrieval cord broke during self-removal and the patient mistook the string for the stent. Adequate patient education is essential to assure successful self-removal.

Anxiety related to sexual abuse: A case of recurrent priapism.

Recurrent priapism is notoriously difficult to treat and very distressing to the sufferer. There is little literature about emotional contributors to this condition. We report a case of a man with sexual abuse and severe anxiety who responded acutely to emotion-focused treatment with persistent cessation of severe recurrent priapism episodes. A second case treated with the same method had a similar response to treatment. Emotional factors may be relevant in certain cases of recurrent priapism and these factors warrant clinical management and formal study.

Burkholderia cepacia infection of the prostate caused by inoculation of contaminated ultrasound gel during transrectal biopsy of the prostate.

Burkholderia cepacia infection of the prostate is very rare. We report 6 cases of prostatic infection secondary to inoculation of contaminated ultrasound gel during transrectal biopsy of the prostate. All of these patients required hospitalization and were treated with intravenous antibiotics. One of these cases is the first description of chronic prostatitis with B. cepacia.

CUA Guideline: The workup of azoospermic males.

A committee was established at the request of the CUA to determine guidelines for the investigation and management of azoospermia. Members of the committee, all of whom have special expertise in the investigation and management of male infertility, were chosen from different communities across Canada. The members represent different practices in different communities.