Direct-To-Consumer Internet Prescription Platforms Overlook Crucial Pathology Found During Traditional Office Evaluation of Young Men With Erectile Dysfunction.

OBJECTIVE: To determine comorbidities in young men with erectile dysfunction (ED) who are increasingly targeted by direct-to-consumer (DTC) internet platforms that sell phosphodiesterase-5 (PDE-5) inhibitors without comprehensive clinical evaluation; and, further, to characterize the portrayal of DTC platforms by popular news media. METHODS: We retrospectively reviewed all men age ≤40 evaluated for ED at an andrology clinic during January 2016-March 2019 to obtain demographics, exam and lab findings, and treatments. Five news sources were analyzed during the study period to characterize whether articles about DTC platforms were positive, critical, or balanced/neutral. RESULTS: We identified 388 patients, with age 29.5 ± 5.0 years, 15% rate of obesity, 20% prediabetes or diabetes, 54% dyslipidemia, and 20% hypogonadism. Serum lab findings associated with subfertility were found in 11%. Semen analysis was conducted in 64 men, of whom 40% were abnormal. Varicoceles were found in 35%. PDE-5 inhibitor was prescribed to 328 men (88%). Off-label empiric therapies included clomiphene (32.9%) or aromatase inhibitor (12.1%). Testosterone replacement was initiated in 9.7%. Analysis of news coverage revealed 18 articles, of which 61% portrayed DTC platforms exclusively in a positive light. CONCLUSION: Office consultation identified young men with significant comorbidities that would be missed by DTC platforms, which employ only questionnaires for health screening. DTC platforms present themselves as medical authorities without following AUA Guidelines, yet garner mostly positive press coverage. Patients engaging these platforms may falsely believe they are receiving adequate medical assessment. Urologists may do well to incorporate telemedicine to enfranchise young men with evidence-based evaluation.

Discontinuation from Collagenase Clostridium histolyticum Therapy for Peyronie's Disease: Review and Single-Center Cohort Analysis.

INTRODUCTION: Intralesional injection therapy with collagenase Clostridium histolyticum (CCh) is an effective treatment option for Peyronie's disease (PD), but it carries risks, costs, and the need for multiple visits, which may cause patients to discontinue therapy prematurely. AIMS: To identify and summarize the current literature on CCh discontinuation and present our experience with CCh discontinuation. METHODS: We performed a PubMed review of existing literature on discontinuation from CCh therapy and retrospectively analyzed our prospectively maintained Institutional Review Board-approved CCh database for January 2016-December 2018. Demographic information, clinical outcomes, and communication logs were collected. Reasons for discontinuation of therapy were assessed. A logistic regression to identify factors influencing dropout was performed. MAIN OUTCOME MEASURES: Documentation of discontinuation statistics in published literature, and rates of and reasons for discontinuation in a single-institution cohort. RESULTS: Our literature review identified 15 studies with specified cohort sizes. Of these, 10 specifically quantified discontinuation rates, which ranged from 13% to 56%. Combined, these studies show a 20% dropout rate. Dissatisfaction with therapy was the most common reason for dropout. In our cohort, 100 men completed a course of 8 CCh injections. Twelve men (10.7%) discontinued therapy, including 4 due to relocation, 3 due to cost, 1 due to a hematoma, 1 due to early satisfaction, 2 due to no perceived improvement, and 1 due to a demanding work schedule. Hematoma formation was a predictor of dropout in our cohort (odds ratio 8.74; P = .037). CONCLUSION: Additional focus must be placed on quantifying and evaluating CCh discontinuation. Our findings show that a majority of men complete a full course of 8 injections; most of the few men who dropped out of therapy did so due to relocation. Counseling to reduce CCh discontinuation should focus on initial sexual function, adverse events, and expectations. Amighi A, Eleswarapu SV, Mendhiratta N, et al. Discontinuation from Collagenase Clostridium histolyticum Therapy for Peyronie's Disease: Review and Single-Center Cohort Analysis. Sex Med Rev 2019;7:690-698.

Verumontanum Cyst Associated With Lower Urinary Tract Symptoms in an Adolescent.

Urinary tract polyps occur anywhere from the renal pelvis to the anterior urethra. Lower tract polyps occur less frequently than upper tract polyps and are a rare finding in children. Symptoms include obstruction, dysfunctional voiding, or hematuria. We report the case of a 17-year-old male who presented with persistent leakage of urine following voiding. Ultrasound demonstrated a small cystic lesion in the posterior aspect of the prostate and a voiding cystourethrogram was suggestive of a utricular cyst or polyp. He underwent a cystoscopy that demonstrated a large cystic structure originating from the verumontanum, nearly obstructing the prostatic urethra.

Youth varicocele and varicocele treatment: a meta-analysis of semen outcomes.

OBJECTIVE: To study youth who have a varicocele or are undergoing varicocele treatment, in relation to changes in semen, as measured by semen analysis (SA). DESIGN: Meta-analysis of studies identified via a search of PubMed, Medline, and the Cochrane Library covering the last 40 years. SETTING: Not applicable. PATIENT(S): Youth from studies that assessed the presence and/or treatment of varicocele with SA. INTERVENTION(S): Selected studies were analyzed in two separate meta-analyses: one for the effect of varicocele on semen, as measured by SA (hypothesis #1), the other for the effect of treatment on semen, as measured by SA (hypothesis #2). MAIN OUTCOME MEASURE(S): A random-effects model was used to calculate weighted mean difference (WMD) of semen outcomes. Heterogeneity was calculated. Bias was assessed with funnel plots and Egger's test. RESULT(S): The initial literature search returned 1,180 potentially relevant articles. For hypothesis #1, 10 studies with a total of 357 varicocele and 427 control subjects were included. Sperm density, motility, and morphology were significantly decreased when associated with a varicocele, with a WMD of -24.0×10(6)/mL (95% confidence interval [CI; -39.5 to -8.6]), -7.5% (95% CI [-12.3% to -2.7%]), and -1.7% (95% CI [-2.4% to -1.1%]), respectively. Another 10 studies with 379 treated and 270 untreated subjects were analyzed for hypothesis #2. Sperm density and motility were significantly improved following treatment, with a WMD of 14.6×10(6)/mL (95% CI [7.1-22.1]) and 6.6% (95% CI [2.1%-11.2%]), respectively. CONCLUSION(S): The presence of varicocele in youth appears to negatively affect sperm density, motility, and morphology. Treatment appears to result in moderate improvement of sperm density and mild improvement in sperm motility.

Operating characteristics of follicle-stimulating hormone in azoospermic men.

OBJECTIVE: To validate factors predictive of nonobstructive azoospermia (NOA) and to determine the operating characteristics of FSH for predicting NOA. DESIGN: Retrospective cohort study. SETTING: Tertiary care military treatment facility. PATIENT(S): One hundred forty azoospermic males undergoing infertility evaluation. INTERVENTION(S): Standard evaluation included history and physical, hormonal workup, and genetic evaluation. Diagnostic testicular biopsy was offered to characterize patients as obstructive azoospermia (OA) or NOA. MAIN OUTCOME MEASURE(S): Semen volume, semen fructose, FSH, T, E2, PRL, testicular atrophy. RESULT(S): Seventy-eight of 140 azoospermic patients underwent a biopsy. The ability to predict NOA based on logistic regression was statistically significant for FSH and testicular atrophy. On multivariate analysis, only FSH remained predictive of NOA. The area under the FSH receiver operating characteristic curve was 0.847, which is significant. The cut point of FSH with the highest likelihood ratio of predicting NOA on biopsy was ≥12.3 mIU/mL. CONCLUSION(S): FSH remains the best predictor of NOA. With full knowledge of the operating characteristics of FSH in this population, a patient can be properly educated and treatment can be individualized, based on the specific risk associated with that subject's measured FSH.