Analysis of diurnal variation in serum testosterone levels in men with symptoms of testosterone deficiency.

BACKGROUND: Testosterone (T) plays a crucial role in various physiological functions in men, and understanding the variations in T levels during the day is essential for diagnosing and treating testosterone deficiency (TD). AIM: We sought to evaluate the reduction in serum total T (TT) levels throughout the day in men with symptoms of testosterone deficiency and to determine the variables having an impact on the extent of this decline. METHODS: The study population consisted of a group of men who within 3 months of each other had all undergone both early morning and afternoon TT level measurements. We did not include patients with a history of a prior orchiectomy, testosterone levels below 100 ng/dL or above 1000 ng/dL, a history of androgen deprivation therapy, or patients on T therapy. Statistical analyses were conducted using descriptive statistics, t-tests, chi-square tests, and correlation calculations. Liquid chromatography-tandem mass spectrometry was used to measure TT, and a change in TT levels greater than 100 ng/dL was considered significant. Using multivariable and univariable analysis, we attempted to define predictors of a decrease in afternoon TT levels. OUTCOMES: The majority of men showed no significant difference in T levels between morning and afternoon. RESULTS: In total, 506 men with a median age of 65 years were analyzed. The most common comorbidities were hypertension and hyperlipidemia. Levels of TT were measured in the morning and afternoon, and no significant differences in mean T levels based on the time of the test were found. Age was not significantly associated with T levels. CLINICAL IMPLICATIONS: There was a weak negative correlation between age and the difference between morning and afternoon T levels, with younger men showing more significant variations in T levels. The most considerable differences in T levels were observed in men younger than 30 years. There were no predictors of the magnitude of the T decrease in the afternoon. STRENGTHS AND LIMITATIONS: Strengths of the study include the number of subjects and the use of liquid chromatography-tandem mass spectrometry for T measurement. Limitations include failure to measure morning and afternoon T levels on the same day, the retrospective nature of the study, and a smaller sample size of patients younger than 30 years. CONCLUSION: In this study we found no strong link between age and daily T fluctuation, but we observed a decrease in the magnitude of variation with aging. The group experiencing the most significant decline in daily T had higher morning and consistently normal afternoon T levels.

Predictors of Worsening Erectile Function in Men with Functional Erections Early After Radical Prostatectomy.

BACKGROUND: Prior studies suggest that men with good erectile function shortly after radical prostatectomy (RP) can subsequently have worsened erectile function. AIM: To determine the prevalence and predictors of early erectile function recovery post-RP and of worsening erectile function after initial erectile function recovery. METHODS: We retrospectively queried our institutional database. Men who underwent RP during 2008-2017 and who completed the International Index of Erectile Function erectile function domain both pre-RP and serially post-RP, constituted the population. Functional erections were defined as International Index of Erectile Function (IIEF)-6 erectile function domain scores ≥24. We analyzed factors predicting functional erections at 3 months post-RP as well as factors predicting a decrease in functional erections between 3 and 6 months, defined as ≥2-point drop in the erectile function domain. Multivariable logistic regression models were used to identify predictors of early erectile function recovery and also of subsequent decline. OUTCOMES: Erectile function recovery rates at 3 months post-RP and predictive factors; rates of erectile function decline between 3-6 months and associated predictors. RESULTS: Eligible patients comprised 1,655 men with median age of 62 (IQR 57, 67) years. Bilateral nerve-sparing (NS) surgery was performed in 71% of men, unilateral NS in 19%, and no NS in 10%. Of this population, 224 men (14%; 95% CI 12%, 15%) had functional erections at 3 months post-RP. On multivariable analysis, significant predictors of early erectile function recovery included: younger age (OR 0.93, P < .001), higher baseline erectile function domain score (OR 1.14, P < .001) and bilateral NS (OR 3.81, P = .002). The presence of diabetes (OR 0.43, P = .028) and a former smoking history (OR 0.63, P = .008; reference group: never smoker) was associated with the erectile dysfunction at 3 months post-RP. Of the men with early functional erections, 41% (95% CI 33%, 48%) had a ≥ 2-point decline in erectile function between 3 and 6 months. No factors were identified as predictors for this decline. CLINICAL IMPLICATIONS: Only a small proportion of men have functional erections at 3 months post-RP and a notable number of them will experience a decline in erectile function between 3 and 6 months. STRENGTHS AND LIMITATIONS: Strengths: large patient population and the use of validated questionnaire. LIMITATIONS: single-center retrospective study. CONCLUSION: A minority of men had functional erections 3 months post-RP, about half of whom had a decline in erectile function by month 6. We recommend appropriately counseling post-RP patients on the risk of such a decline in erectile function. Salter CA, Tin AL, Bernie HL, et al. Predictors of Worsening Erectile Function in Men with Functional Erections Early After Radical Prostatectomy. J Sex Med 2022;19:1790-1796.

Luteinizing Hormone Suppression Profiles in Men Treated With Exogenous Testosterone.

BACKGROUND: Due to the negative feedback mechanism involved in the hypothalamic-pituitary-gonadal axis, testosterone therapy (TTh) may result in suppression of luteinizing hormone (LH) secretion, but clinical experience demonstrates the level of LH suppression is variable. AIM: We sought to define the relationship between TTh and LH levels, specifically predictors of LH suppression in men on TTh. METHODS: We performed a retrospective analysis of a prospectively maintained database of patients with testosterone deficiency (TD) treated with TTh. Patient demographic and clinical data including vascular risk factor (VRF) status were collected. Serum total T and LH levels before TTh and after ≥3 months (m) were recorded. LH suppression was defined as serum LH level <1.0 IU/ml. MAIN OUTCOME MEASURES: Predictors of LH suppression were searched though a series of logistic regression models assessing suppression status at the final observation, and then a series of Cox proportional hazards models assessing time to first suppression were performed. RESULTS: A total of 227 patients with mean age of 58±14 years at time of TTh initiation were included in our analysis. Just under half of subjects received transdermal T as the only modality (n = 101, 44%), while one third (n = 77, 34%) received intramuscular only, and the remainder (n = 49, 22%) received both modalities during follow-up. The mean baseline LH level was 10 ± 12 IU/ml. The percent of men who had baseline LH level above 1 IU/ml and at any given point of TTh was 84% and 78%, respectively, thus 22% of men had suppressed LH levels on TTh considering the definition of LH <1 IU/ml. Most men (73%) had a suppressed LH level of <1 IU/ml at least once during follow-up. In the final adjusted model for LH suppression, intramuscular route (OR = 2.44), baseline LH (OR = 0.94), estradiol (OR = 1.05) remained significant. CLINICAL IMPLICATIONS: LH suppression profiles may be relevant for dose titration during TTh and perhaps to minimize testicular atrophy. STRENGTHS & LIMITATIONS: A strict definition for TD was applied using LCMS for T measurements and patients had long-term follow-up. CONCLUSION: While 73% of patients had at least one LH <1 IU/ml during TTh, only 22% maintained suppressed throughout the treatment. Miranda EP, Schofield E, Matsushita K, et al. Luteinizing Hormone Suppression Profiles in Men Treated With Exogenous Testosterone. J Sex Med 2022;19:1359-1365.

Micro-testicular sperm extraction outcomes for non-obstructive azoospermia in a single large clinic in Victoria.

AIMS: To evaluate the results of microdissection testicular sperm extraction (micro-TESE) and intracytoplasmic sperm injection (ICSI) for treatment of non-obstructive azoospermia (NOA). MATERIALS AND METHODS: We retrospectively analysed data of 88 consecutive patients with clinical NOA who were treated with micro-TESE by a single surgeon, between August 2014 and September 2020, in Melbourne, Victoria. Upon a successful sperm retrieval, sperm was either used fresh for ICSI, frozen for future use or both. The outcome measures were sperm retrieval rate (SRR), and in vitro fertilisation (IVF)/ICSI results. Furthermore, SRR was calculated for the predominant causes and histopathological patterns. RESULTS: The overall SRR was 61.2%. It was significantly higher in patients with a history of cryptorchidism and other childhood diseases (100%) than in the other NOA groups (P < 0.05). Patients with Klinefelter syndrome had a 75% SRR. Among the different types of testicular histology, the highest SRR were noted in patients with complete hyalinisation (100%) and hypospermatogenesis (92.9%), and low with Sertoli cell-only syndrome (46.3%). The SRR has significantly increased from 33.3% in 2015-2016 to 73.6% in 2019-2020 (P = 0.009). Of the 52 patients with SSR, 47 underwent IVF/ICSI. Fertilisation rate was 42.4%. Twenty-nine couples achieved at least one good-quality embryo and had embryo transfer. Nineteen achieved pregnancy (40.4%), and in three patients a miscarriage resulted. CONCLUSIONS: This is the first report from Australia showing that micro-TESE is an effective treatment for NOA with high SRR. The increasing success rates over several years indicate the importance of surgical skill and laboratory staff experience.

Detection of chlamydia infection within human testicular biopsies.

STUDY QUESTION: Can Chlamydia be found in the testes of infertile men? SUMMARY ANSWER: Chlamydia can be found in 16.7% of fresh testicular biopsies and 45.3% of fixed testicular biopsies taken from a selection of infertile men. WHAT IS KNOWN ALREADY: Male chlamydial infection has been understudied despite male and female infections occurring at similar rates. This is particularly true of asymptomatic infections, which occur in 50% of cases. Chlamydial infection has also been associated with increased sperm DNA damage and reduced male fertility. STUDY DESIGN, SIZE, DURATION: We collected diagnostic (fixed, n = 100) and therapeutic (fresh, n = 18) human testicular biopsies during sperm recovery procedures from moderately to severely infertile men in a cross-sectional approach to sampling. PARTICIPANTS/MATERIALS, SETTING, METHODS: The diagnostic and therapeutic biopsies were tested for Chlamydia-specific DNA and protein, using real-time PCR and immunohistochemical approaches, respectively. Serum samples matched to the fresh biopsies were also assayed for the presence of Chlamydia-specific antibodies using immunoblotting techniques. MAIN RESULTS AND THE ROLE OF CHANCE: Chlamydial major outer membrane protein was detected in fixed biopsies at a rate of 45.3%. This was confirmed by detection of chlamydial DNA and TC0500 protein (replication marker). C. trachomatis DNA was detected in fresh biopsies at a rate of 16.7%, and the sera from each of these three positive patients contained C. trachomatis-specific antibodies. Overall, C. trachomatis-specific antibodies were detected in 72.2% of the serum samples from the patients providing fresh biopsies, although none of the patients were symptomatic nor had they reported a previous sexually transmitted infection diagnosis including Chlamydia. LIMITATIONS, REASONS FOR CAUTION: No reproductively healthy male testicular biopsies were tested for the presence of Chlamydia DNA or proteins or Chlamydia-specific antibodies due to the unavailability of these samples. WIDER IMPLICATIONS FOR THE FINDINGS: Application of Chlamydia-specific PCR and immunohistochemistry in this human male infertility context of testicular biopsies reveals evidence of a high prevalence of previously unrecognised infection, which may potentially have a pathogenic role in spermatogenic failure. STUDY FUNDING/COMPETING INTEREST(S): Funding for this project was provided by the Australian NHMRC under project grant number APP1062198. We also acknowledge assistance from the Monash IVF Group and Queensland Fertility Group in the collection of fresh biopsies, and the Monash Health and co-author McLachlan (declared equity interest) in retrieval and sectioning of fixed biopsies. E.M. declares an equity interest in the study due to financing of fixed biopsy sectioning. All other authors declare no conflicts of interest. TRIAL REGISTRATION NUMBER: N/A.

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.

Adult male stress and urge urinary incontinence - A review of pathophysiology and treatment strategies for voiding dysfunction in men.

BACKGROUND: Male urinary incontinence adversely affects health-related quality of life and is associated with significant psychosexual and financial burden. The two most common forms of male incontinence are stress urinary incontinence (SUI) and overactive bladder (OAB) with concomitant urge urinary incontinence (UUI). OBJECTIVE: The objectives of this article are to briefly review the current understandings of the pathophysiological mechanisms in SUI and OAB/UUI, and offer a set of practical, action-based recommendations and treatment strategies. DISCUSSION: The initial evaluation of male urinary incontinence usually occurs in general practice, and the basic work-up aims to identify reversible causes. First-line treatment is conservative management, such as lifestyle interventions, pelvic floor muscle training with or without biofeedback, and bladder retraining. Treatment options include male slings and artificial urinary sphincter surgery for men with persistent SUI, and medical therapy, intravesical botulinum toxin, sacral neuromodulation or surgery in refractory cases for those with predominant OAB/UUI.

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.

Predicting biochemical response to clomiphene citrate in men with hypogonadism.

INTRODUCTION: Clomiphene citrate (CC) is as an effective treatment for men with hypogonadism (HG). Identifying the ideal candidate for this strategy has to date largely relied upon a patient's interest in preservation of testicular volume and spermatogenesis. AIM: This analysis was undertaken to define if predictors existed of robust elevation in serum testosterone (T) levels in response to CC. METHODS: Seventy-six men with a diagnosis of HG (two separate early morning total T levels <300 ng/dL) opting for CC therapy constituted the study population. Demographic, comorbidity data, and physical and laboratory characteristics were recorded. Laboratory tests were conducted 4 weeks after commencement and every 6 months thereafter. Multivariable analysis was conducted to define if predictors of biochemical response could be identified. Parameters included in the model were patient age, mean testicular volume, varicocele presence, and baseline total T, free T, and luteinizing hormone (LH) levels. MAIN OUTCOME MEASURE: Successful biochemical response to CC, defined as an increase of ≥200 ng/dL in total T level at ≥6 months after commencing CC, was the main outcome measure. RESULTS: Mean age was 46 ± 22 years. Mean pretreatment testicular volume was 16 ± 8 mL. Mean baseline T and LH levels were 179 ± 72 ng/dL and 7.2 ± 5.6 IU/mL, respectively. Mean total T on CC was 467 ± 190 ng/dL. Forty-seven patients (62%) met the responder definition, with a mean increase in total T levels of 302 ± 76 (204-464) ng/dL. In CC responders, the mean LH rise was 5.6 ± 3.1 IU/mL. On multivariable analysis, factors predictive of CC response included: mean testicular volume (adjusted [adj.] r = 0.32, P < 0.01), mean testicular volume ≥14 mL (hazard ratio [HR] 2.2, P < 0.01), LH level (adj. r = 0.48, P < 0.001), and LH level ≤6 IU/mL (HR 3.5, P < 0.001). CONCLUSION: These data indicate that two thirds of men with HG meet a robust responder definition and that pretreatment testicular volume and LH levels (in continuous and dichotomized fashions) are predictors of response.

Direct-to-Consumer Telemedicine Practices in the Health and Fertility of Men: A Systematic Review of the Literature.

PURPOSE: Men are increasingly turning toward online direct-to-consumer (DTC) men's health platforms to fulfill their health needs. Research surrounding these platforms is lacking and the motivations and predictors underlying this online health-seeking behavior is largely unknown. This review scopes the existing literature concerning DTC men's health and identifies factors influencing engagement, as well as health outcomes of this platform. MATERIALS AND METHODS: A structured search was performed following PRISMA guidelines. CINAHL via EBSCO, Embase, MEDLINE via Ovid, PsycINFO, PubMed and Web of Science were searched. RESULTS: Peer-reviewed quantitative and qualitative studies with a focus on demographics and characteristics of those using DTC men's health platforms, as well as studies related to patient outcomes using such platforms, were included. Ten of the 3,003 studies identified met the inclusion and exclusion criteria. Four cross-sectional descriptive studies evaluated the motivations behind men's engagement with DTC platforms. Convenience, embarrassment and health motivation were identified as predominant factors associated with DTC platform use. The review identified a lack of qualitative studies, and major limitations were noted in the quantitative studies that impacted the accuracy of findings. Six further quantitative studies explored the quality of care provided by DTC platforms. DTC platforms were found to have a varying level of adherence to established clinical guidelines, but appeared to provide satisfactory patient outcomes with low levels of patient-reported side effects and adverse events. CONCLUSIONS: There is a lack of research within the DTC men's health space given the infancy of the field. Important predictors and motivations underlying men's choices in accessing these platforms have been noted across several studies. However, further studies need to be conducted to investigate the psychosocial underpinnings of this behavior. Studies across a wider variety of male health conditions treated by these platforms will also help to provide insights to guide patient-centered care within the DTC landscape.

Surgical management of male infertility: An overview.

BACKGROUND: The general practitioner is often the first to assess couples with infertility. In up to half of all infertile couples, a male factor may be found as a contributing cause. OBJECTIVE: The aim of this article is to provide a broad understanding of the options available for surgical management of male infertility to assist couples in navigating their treatment journey. DISCUSSION: Treatments may be classified into four categories: surgery for diagnostic purposes, surgery to improve semen parameters, surgery to improve sperm delivery and surgery to retrieve sperm for in vitro fertilisation. Assessment and treatment of the male partner by urologists trained in male reproductive health, working collaboratively within a team, can maximise fertility outcomes.

Psychological, social, and sexual challenges affecting men receiving male infertility treatment: a systematic review and implications for clinical care.

In recent years, social research surrounding the consequences of infertility has increasingly focused on the male perspective; however, a gap exists in the understanding of men's experiences of male infertility treatment. This review aims to synthesize the existing evidence concerning the psychological, social, and sexual burden of male infertility treatment on men, as well as patient needs during clinical care. A systematic search identified 12 studies that are diverse in design, setting, and methods. Psychological evaluations have found that urological surgery may have a lasting impact on infertility-specific stress, and treatment failure can lead to feelings of depression, grief, and inadequacy. Men tended to have an avoidant coping mechanism throughout fertility treatment, and their self-esteem, relationship quality, and sexual functions can be tied to outcomes of treatment. Partner bonds can be strengthened by mutual support and enhanced communication; couple separation, however, has been noted as a predominant reason for discontinuing male infertility treatment and may be associated with difficult circumstances surrounding severe male infertility. Surgical treatments can affect the sexual functioning of infertile men; however, the impact of testicular sperm extraction outcomes appears to be psychologically driven whereas the improvements after microsurgical varicocelectomy are only evident in hypogonadal men. Clinically, there is a need for better inclusion, communication, education, and resource provision, to address reported issues of marginalization and uncertainty in men. Routine psychosocial screening in cases of severe male infertility and follow-up in cases of surgical treatment failure are likely beneficial.

Outcomes of clomiphene citrate treatment in young hypogonadal men.

UNLABELLED: Study Type - Therapy (case series) Level of Evidence 4. What's known on the subject? and What does the study add? Hypogonadism is a prevalent problem, increasing in frequency as men age. It is most commonly treated by testosterone supplementation therapy but in younger patients this can lead to testicular atrophy with subsequent exogenous testosterone dependency and may impair spermatogenesis. Clomiphene citrate (CC) may be used as an alternative treatment in these patients with hypogonadism when maintenance of fertility is desired. This study shows that CC is a safe and efficacious drug to use as an alternative to exogenous testosterone. Not only have we validated previous findings of other papers but have proven our findings over a much longer period (mean duration of treatment 19 months). This prospective study is the largest to date assessing both the objective hormone response to CC therapy as well as the subjective response based on a validated questionnaire. OBJECTIVE: • To prospectively assess the andrological outcomes of long-term clomiphene citrate (CC) treatment in hypogonadal men. PATIENTS AND METHODS: • We prospectively evaluated 86 men with hypogonadism (HG) as confirmed by two consecutive early morning testosterone measurements <300 ng/dL. • The cohort included all men with HG presenting to our clinic between 2002 and 2006 who, after an informed discussion, elected to have CC therapy. CC was commenced at 25 mg every other day and titrated to 50 mg every other day. The target testosterone level was 550 ± 50 ng/dL. • Testosterone (free and total), sex hormone binding globulin, oestradiol, luteinizing hormone and follicle stimulating hormone were measured at baseline and during treatment on all patients. Once the desired testosterone level was achieved, testosterone/gonadotropin levels were measured twice per year. • To assess subjective response to treatment, the androgen deficiency in aging males (ADAM) questionnaire was administered before treatment and during follow-up. RESULTS: • Patients' mean (standard deviation [sd]; range) age was 29 (3; 22-37) years. Infertility was the most common reason (64%) for seeking treatment. The mean (sd) duration of CC treatment was 19 (14) months. • At the last evaluation, 70% of men were using 25 mg CC every other day, and the remainder were using 50 mg every other day. • All mean testosterone and gonadotropin measurements significantly increased during treatment. • Subjectively, there was an improvement in all questions (except loss of height) on the ADAM questionnaire. More than half the patients had an improvement in at least three symptoms. • There were no major side effects recorded and the presence of a varicocele did not have an impact on the response to CC. CONCLUSION: • Long-term follow-up of CC treatment for HG shows that it appears to be an effective and safe alternative to testosterone supplementation in men wishing to preserve their fertility.

Clomiphene citrate is safe and effective for long-term management of hypogonadism.

OBJECTIVE: To assess the efficacy and safety of long-term clomiphene citrate (CC) therapy in symptomatic patients with hypogonadism (HG). PATIENTS AND METHODS: Serum T, oestradiol and luteinizing hormone (LH) were measured in patients who were treated with CC for over 12 months. Additionally, bone densitometry (BD) results were collected for all patients. Demographic, comorbidity, treatment and Androgen Deficiency in Aging Men (ADAM) score data were also recorded. Comparison was made between baseline and post-treatment variables, and multivariable analysis was conducted to define predictors of successful response to CC. The main outcome measures were predictors of response and long-term results with long-term CC therapy in hypogonadal patients. RESULTS: The 46 patients (mean age 44 years) had baseline serum testosterone (T) levels of 228 ng/dL. Follow-up T levels were 612 ng/dL at 1 year, 562 ng/dL at 2 years, and 582 ng/dL at 3 years (P < 0.001). Mean femoral neck and lumbar spine BD scores improved significantly. ADAM scores (and responses) fell from a baseline of 7 to a nadir of 3 after 1 year. No adverse events were reported by any patients. CONCLUSIONS: Clomiphene citrate is an effective long-term therapy for HG in appropriate patients. The drug raises T levels substantially in addition to improving other manifestations of HG such as osteopenia/osteoporosis and ADAM symptoms.

Perioperative prevention of penile prosthesis infection: practice patterns among surgeons of SMSNA and ISSM.

INTRODUCTION: Anecdotally, there is great variation in the use of strategies to prevent postoperative penile implant infection. AIM: To evaluate the perioperative practice patterns of surgeons who insert penile prostheses focusing on their respective infection control routines. METHOD: An anonymous Web-based survey was sent to members of the Sexual Medicine Society of North America (SMSNA) and the International Society of Sexual Medicine (ISSM). MAIN OUTCOME MEASURES: Thirty-nine questions were asked pertaining to the strategies used during the pre-, intra-, and postoperative phases of penile implant surgery to prevent infection. RESULTS: One hundred twenty-nine surgeons responded to the survey (SMSNA 84; ISSM 45). Most surgeons considered themselves sexual medicine specialists. More SMSNA respondents had inserted >100 prosthesis (SMSNA 69%, ISSM 50%). Routine urine culture is not performed by 40% and 50% of SMSNA and ISSM members, respectively. Similar percentages of surgeons from each society request a daily preoperative antimicrobial scrub. About two-thirds of ISSM members use razors for the preoperative shave compared with one-third of SMSNA members. Most ISSM surgeons preferred povidone-iodine for hand and skin preparation while most SMSNA surgeons chose this only for skin preparation. Two-thirds of SMSNA members prepared the skin for at least 10 minutes compared with 34% of ISSM surgeons. There were considerable differences in all aspects of antibiotic usage not only between members of both societies but also among individual members of each society. Most surgeons prefer not to place a drain (SMSNA 70%, ISSM 81%). Discharge timing differs between the two groups. CONCLUSIONS: There is great variation in perioperative strategies utilized to prevent penile implant infections including some key differences between surgeons from SMSNA and ISSM. It is unknown if these variations result in changes in the postoperative infection rate; however, the study data may assist in the formation of practice guidelines and form the basis of future prospective studies.

Novel extraction technique to remove a penile constriction device.

INTRODUCTION: Penile strangulation can be a challenging clinical situation and usually requires prompt treatment. The clinician should be aware of the various techniques to remove such devices. AIM: The aim of this article was to describe a new noninvasive technique, the "pseudo-pulley" method, to remove a penile constriction device. METHODS: During an episode of medication-induced hypersexuality, a 63-year-old man presented to the emergency department with a cast iron locking nut of a vehicle towbar lodged at the base of the patient's penis. RESULTS: The utilization of the "pseudo-pulley" method to remove the constriction device negated the need for more invasive measures. We outline a step-by-step description on this new technique. The patient's recovery was complete and uneventful. CONCLUSION: The current case report describes a noninvasive technique for removing a penile constriction device that does not rely on specialized equipment and industrial drills that can cause iatrogenic injury.