Gender disparities among publications within international sexual medicine urology journals and the impact of blinding in the review process.

BACKGROUND: While female urologists are known to publish at less frequency than their male peers, The Journal of Sexual Medicine was reported to have among the highest growth in female authorship from 2002 to 2020 in urology journals. AIM: We sought to assess the frequency of female authorship in sexual medicine journals worldwide and the factors that affect this, including the blinded/unblinded review process. METHODS: Eleven sexual medicine journals were assessed for geographic location, peer review method, and SCImago Journal Rank citation index (a metric of citation frequency and prestige). Journals were grouped into top, middle, and bottom quartiles based on metric score. Web of Science was used to access the publications' first, second, last, and corresponding authors from the past 5 years. An internet search or Gender-API.com was used to determine the gender identities of authors. Univariate and multivariable logistic regression models were performed. OUTCOMES: Outcomes included the likelihood of female authorship (first, second, last, and corresponding) based on journal location and ranking, the clustering of female authors, the journal's peer review process, and the frequency of female editorial board members. RESULTS: Overall, 8938 publications were identified. Women represented 30.7%, 31.3%, 21.3%, and 18.7% of the first, second, last, and corresponding authors, respectively; gender was unable to be assessed for 2.6%, 17.2%, 7.3%, and 2.7%. On univariate analysis, journals from North America, in the top quartile, and with a double-blind review process were more likely to have female authors (P < .001). On multivariate analysis, articles were more likely to have a female first author if they had a double-blind peer review process (odds ratio [OR], 1.20; 95% CI, 1.02-1.40), a female second author (OR, 2.54; 95% CI, 2.26-2.85), or a female corresponding author (OR, 7.80; 95% CI, 6.69-9.10). CLINICAL IMPLICATIONS: Gender-concordant mentoring and universal double-blind manuscript review processes may minimize the impact of gender bias and increase female authorship rates, in turn producing more diverse research. STRENGTHS AND LIMITATIONS: This is the first study assessing female authorship in sexual medicine journals. Limitations include not assessing every author listed on articles and being unable to determine gender identities for some authors. CONCLUSION: Female authorship rates are higher than reported rates of practicing female urologists but still lower than their male peers. Female authors were more likely to be published in journals with double-blind peer review processes and when publishing with additional female authors.

The impact of male infertility faculty on urology residency training.

The objective of this study was to determine the impact of having male infertility on urology residents' infertility training experience, surgical confidence, and In-Service-Exam Infertility/Sexual Medicine subscores. We electronically surveyed urology residents throughout the United States querying exposure to infertility faculty and fertility knowledge. Univariable and multivariable analysis was performed to determine predictors of higher In-Service Exam Infertility/Sexual Medicine sub-scores and self-rated infertility competency. Fifty-four of 72 respondents (75%) reported that male infertility comprises ≤10% of their training. Of the 63 residents who have a reproductive urologist on faculty, 66.7%, 47.6%, and 49.2% have scrubbed/observed a microsurgical varicocelectomy, vasectomy reversal and testicular sperm extraction, respectively. Residents exposed to infertility faculty are more likely to self-rate their infertility understanding as "excellent" or "good" (p = 0.04 and p = 0.02, respectively), and 14.4× more likely to feel confident performing infertility procedures, versus residents lacking faculty (p < 0.001). Residents having formal microsurgical training have better self-rated infertility understanding (p < 0.001), non-obstructive azoospermia management (p = 0.01), and competency performing infertility procedures (p < 0.001). Residents exposed to fertility faculty are more likely to feel confident performing fertility procedures after residency (p = 0.001). In conclusion, infertility comprises a minority of residency training. Most residents anticipate performing infertility procedures in practice, despite two-thirds lacking confidence performing these. Having an infertility faculty and formal microsurgical training improves residents' surgical confidence, non-obstructive azoospermia management, and global male infertility understanding. A structured educational curriculum may improve resident infertility training.

How far will they go? Distance and driving times that north American men travel to see a reproductive urologist.

Male factor infertility affects about 50% of infertile couples. However, male factor infertility is largely under-evaluated due to multiple reasons. This study is to determine the time men travel for fertility evaluation, and factors associated with driving longer. Data from the Andrology Research Consortium were analysed. Driving distance and time were calculated by comparing "patient postal code" with "clinic postal code", then stratified into quartiles. Patients with the longest driving times (> 75th percentile [Q4]) were compared with those having shorter driving times. Logistic regression analysis was used to identify factors associated with longer driving times. Sixteen clinics and 3029 men were included. The median driving distance was 18.1 miles, median driving time was 32 min, and Q4 driving time was 49 min. Factors correlated with having Q4 driving time were age > 30 years, native Indian and Caucasian race, body mass index (BMI) > 30 kg/m2 , history of miscarriage, children with previous partner, self-referral, prior vasectomy, and prior marijuana use. On logistic regression, males aged < 30 years were more likely to be in Q4 for driving time versus older males. Blacks and Asians were less likely to travel further than Caucasians. Overweight/obese men, those having children with previous partner, and with prior vasectomy were more likely to be in Q4 travelling time. Factors correlated with longer driving times include younger age, native Indian and Caucasian race, higher BMI, children with prior partner, and prior vasectomy. These may reflect groups that drive long distances for reproductive care. The study provides an opportunity to better access these groups and minimise their barriers to fertility care.

Sperm granulomas: Predictive factors and impacts on patency post vasectomy reversal.

The objective of this study was to identify factors that predict for sperm granuloma formation and the impact of sperm granuloma presence and quantity on vasectomy reversal (VR) outcomes. A cross sectional retrospective review of prospectively collected data, on the impact of granuloma on VR outcomes from a single academic center was performed. The impact of age, obstructive interval, intraoperative vasal fluid findings, anastomosis type, body mass index, tobacco use and total motile count (TMC) was determined. A total of 1550 men underwent VR between January 2000 and August 2019. Granulomas were present unilaterally in 23.3% (n = 361) and bilaterally in 14.2% (n = 220). On univariate analysis, increasing patient age negatively correlated with a larger number of granulomas (p = .011). Granuloma presence was associated with finding intact and motile sperm from the vasal stump intraoperatively (p = .001), and vasoepididymostomy anastomosis (p < .001). However, granuloma presence (and quantity) did not correlate with obstructive interval or maximum TMC. Tobacco use and body mass index (BMI) were not associated with granuloma presence. On multivariate analysis, granuloma quantity was not associated with TMC. Obstructive interval and vasovasostomy anastomosis were associated with higher TMC, while BMI was negatively associated with TMC. In conclusion, increasing age was negatively correlated with granuloma formation. Granuloma presence was associated with more favourable intraoperative fluid findings and anastomosis type, but not post-VR TMC, suggesting men with and without granulomas undergoing skilled microsurgery will have similar patency rates. Heavier men should be encouraged for weight loss prior to vasectomy reversal as increasing BMI was associated with lower TMC.

National opioid prescription patterns and patient usage after routine vasectomy.

Routine prescription of opioids after outpatient surgery is common. The main objective of this study was to determine urologist opioid prescribing patterns and patients' pain control medication regimens (opioid and anti-inflammatory) after vasectomy. We designed an anonymous seven-question electronic survey of urologists to assess vasectomy practice and post-vasectomy opioid prescriptions using the American Medical Association Physician Masterfile database. We then performed a retrospective internal telephone survey of men who had undergone vasectomy by a single surgeon (MKS). This telephone survey queried men about opioid prescription filling, opioid use and ibuprofen use. We received 136 (4.5%) electronic survey responses. 51.5% of urologists routinely prescribed opioids for post-vasectomy analgesia, despite 50.4% having 'no idea' how many patients actually used these. On internal telephone survey, 52.6% of patients who used opioids reported using ibuprofen as their primary pain medication, versus 92.6% of patients who did not use opioids (p = .004). Ibuprofen use was associated with using fewer opioid tablets (p = .003). Using ≥1 opioid tab was associated with increased odds of not using ibuprofen as the primary pain medication (OR 11.2, 95% CI 2.39-83.0, p = .005). In conclusion, integration of practice guidelines may help standardise and minimise potentially unnecessary post-vasectomy opioid prescriptions.

The effect of trainee involvement on surgical outcomes and complications of male infertility surgical procedures.

In this study, we sought to determine the effect of trainee (resident or fellow physician) involvement in male infertility surgical procedures on patient surgical outcomes and complications. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was retrospectively reviewed for fertility surgical procedures from 2006 to 2012. The procedures included were as follows: epididymectomy, spermatocelectomy, varicocelectomy ± hernia repair, ejaculatory duct resection, vasovasostomy, vasoepididymostomy and 'unlisted procedure male genital system' (to capture sperm retrieval procedures). A variety of peri- and post-operative outcomes were examined. Trainee and nontrainee-involved groups were compared by Wilcoxon rank sum tests, followed by logistic regression, univariate and multivariate analyses. 924 cases were included: 309 with trainees and 615 without. The median post-graduate trainee year was 3 (range: 0-10). Patients in the trainee-involved cohort had higher rates of chronic obstructive pulmonary disease, steroid usage and black race. Mean operative time was 42.5% longer in trainee-involved cases, even after controlling for other covariates (76.2 vs. 49.5 min, p = .00). Hospital stay length was also longer in trainee-involved cases (0.41 vs. 0.35 days, p = .02). There were no differences in superficial infections (p = 1.00), deep wound infections (p = 1.00), urinary tract infections (p = .26), or reoperations (p = .23) with or without trainee involvement.

Effect of antidepressant medications on semen parameters and male fertility.

Antidepressant medications are commonly used in males of reproductive age for long-term treatment of depression, as well as other disorders. Although antidepressants are known to be associated with sexual side-effects, their effects on semen parameters and other markers of male fertility have been less thoroughly described. The majority of available studies have focused on selective serotonin reuptake inhibitors, which have been shown to negatively impact semen quality in in vitro, animal and human studies. Fluoxetine, in particular, has been the subject of multiple studies and has been associated with gonadotoxic effects, including decreased sperm concentration and motility, increased deoxyribonucleic acid fragmentation, and decreased reproductive organ weights. Studies of several other selective serotonin reuptake inhibitors have yielded similar results. Reassuringly, this effect does seem to be reversible. The data regarding serotonin-norepinephrine reuptake inhibitors, norepinephrine-dopamine reuptake inhibitors, tricyclic antidepressants, monoamine oxidase inhibitors and atypical antidepressants are sparse, varied and conflicting. Given the widespread and often long-term use of antidepressant medications, there is a clear need for further data regarding their impact on semen quality and male fertility.

Sperm Morphology: History, Challenges, and Impact on Natural and Assisted Fertility.

PURPOSE OF REVIEW: The classification of morphologically normal sperm has been progressively redefined. Concurrently, our understanding of the significance of sperm morphology in relation to male factor infertility has evolved. In this review, we will discuss the evolution of sperm morphology assessment and factors that contribute to its measurement variability. We will examine the impact of sperm morphology on natural pregnancy, IUI, IVF, and ICSI outcomes. RECENT FINDINGS: There is a lack of consensus on sperm morphology classification, technique, and inter-observer grading variability. Current evidence suggests sperm morphology has low predictive value for pregnancy success, for both natural and assisted reproduction. Additionally, the threshold for what is considered an adequate percentage of morphologically normal sperm has changed over time. These variables have called into question the relevance of this variable in predicting fertility outcomes. Our understanding of the impact of sperm morphology on reproductive outcomes continues to evolve and seems to play less of a role than initially thought.

Analysis of online discussion boards for male infertility.

We aimed to identify what information patients and partners are seeking on male infertility forums. Online discussion boards were identified. Posts were analysed in three steps: open coding, axial coding and selective coding, to determine common themes. A total of 1,118 posts were analysed. The majority of posts (20.2%) were related to "Questions about male fertility diagnosis and testing", with 47.8% asking for assistance interpreting semen analysis results. About 15.7% of posts were about "Feelings associated with male infertility", with 26.7% expressing anger or frustration, 26.1% encouraging hope, 21% seeking hope and 12.5% expressing fear. About 15.4% of posts were about "Lifestyle factors to improve male fertility", 24.4% of which were about vitamins and 6.4% about intercourse timing. About 15.4% of posts were about "Male infertility conditions", with 43% about semen parameters. Other themes included "Questions about male factor treatments", "Questions about assisted reproductive technologies (ART)", "Relationship issues", "Asking for advice", "Financial concerns" and "Information sharing". About 63.6% of posts were written by female partners [t(1,117) = 9.451, p < .001]. The most common posts posed questions about male fertility diagnosis and testing. Users discussed feelings involved in infertility, and counselling should be integrated. About 63.6% of posts were by partners, highlighting the importance of partners having access to infertility information.

Anatomical Targeting Improves Delivery of Unconjugated Nanoparticles to the Testicle.

PURPOSE: Nanoparticles, which are submicroscopic particles typically ranging from 100 to 300 nm, are interesting as potential treatment of testicular disorders because they can be engineered to allow delivery to privileged tissues, such as across the blood-brain barrier or theoretically the blood-testis barrier. We compared the effects of anatomical and/or ligand targeting on testicular nanoparticle uptake in a rat model. MATERIALS AND METHODS: A total of 48 rats were divided into 6 groups, including a control group and groups that received intra-arterial injection of unconjugated nanoparticles with and without saline flush, intravenous injection of unconjugated nanoparticles, intra-arterial injection of follicle stimulating hormone conjugated nanoparticles, intravenous injection of follicle stimulating hormone conjugated nanoparticles and intra-arterial injection of transactivating transcriptor conjugated nanoparticles. A dose response curve was assessed for intra-arterially injected unconjugated nanoparticles. Using high performance liquid chromatography and histological analysis we determined nanoparticle uptake by the testicle at 4 hours. RESULTS: Intra-arterial injection resulted in a 5.8-fold increase in uptake compared to intravenous injection at 35 mg/kg of unconjugated nanoparticles (3.7 vs 0.6 µg nanoparticles per gm testicle, p = 0.04). Anatomical targeting failed to improve testicular uptake in FSH conjugated nanoparticles (intra-arterial vs intravenous injection 0.33 vs 0.38 µg FSH nanoparticles per gm testicular tissue, p = 0.73). On fluorescence microscopy nanoparticles were noted in the testicular interstitium and seminiferous tubules, and absent from the testicular vasculature. CONCLUSIONS: Arterial injection for anatomical targeting of nanoparticles to the testis is feasible, improves unconjugated nanoparticle delivery to testicular tissue and enables nanoparticles to cross the gonadal vascular endothelium and the blood-testis barrier.

Human Fetal Testicular Tissue Xenotransplantation: A Platform to Study the Effect of Gonadotropins on Human Germ Cell Development In Utero.

PURPOSE: We examined the effects of long-term hCG stimulation on germ cell maturation, and Sertoli and Leydig cell function in a xenotransplantation model of the human fetal testis. MATERIALS AND METHODS: A total of 20 human fetal testes were ectopically xenografted on 20 castrated NCr male nude mice. Grafts were collected for analysis 24 weeks later. Mice were treated with saline as the control or with hCG beginning 4 weeks after the grafts were transplanted. RESULTS: Of the grafts 65% survived at 24 weeks. In contrast to untreated pregrafted samples, hCG stimulated xenografts showed significantly increased density of seminiferous tubule formation with Sertoli cell migration to the basement membrane. Germ cell proliferation and differentiation from gonocytes (M2A(+)) to prespermatogonia (MAGE-4A(+)) were observed in graft samples recovered from the hCG and nonhCG treated groups at 24 weeks of treatment. Leydig cells in hCG treated grafts produced significantly more testosterone than nonhCG treated grafts. Although further studies are required to investigate the potential for further differentiation and maturation of xenografted human fetal testes, normal in utero testicular development was reproduced under long-term hCG stimulation. CONCLUSIONS: This model represents a means to study long-term effects of gonadotoxins or hormonal stimulation on the maturation of human fetal testes.

The relationship between sperm viability and DNA fragmentation rates.

BACKGROUND: In humans, sperm DNA fragmentation rates have been correlated with sperm viability rates. Reduced sperm viability is associated with high sperm DNA fragmentation, while conversely high sperm viability is associated with low rates of sperm DNA fragmentation. Both elevated DNA fragmentation rates and poor viability are correlated with impaired male fertility, with a DNA fragmentation rate of >30% indicating subfertility. We postulated that in some men, the sperm viability assay could predict the sperm DNA fragmentation rates. This in turn could reduce the need for sperm DNA fragmentation assay testing, simplifying the infertility investigation and saving money for infertile couples. METHODS: All men having semen analyses with both viability and DNA fragmentation testing were identified via a prospectively collected database. Viability was measured by eosin-nigrosin assay. DNA fragmentation was measured using the sperm chromosome structure assay. The relationship between DNA fragmentation and viability was assessed using Pearson's correlation coefficient. RESULTS: From 2008-2013, 3049 semen analyses had both viability and DNA fragmentation testing. A strong inverse relationship was seen between sperm viability and DNA fragmentation rates, with r=-0.83. If viability was ≤50% (n=301) then DNA fragmentation was ≥ 30% for 95% of the samples. If viability was ≥75% (n=1736), then the DNA fragmentation was ≤30% for 95% of the patients. Sperm viability correlates strongly with DNA fragmentation rates. CONCLUSIONS: In men with high levels of sperm viability≥75%, or low levels of sperm viability≤ 30%, DFI testing may be not be routinely necessary. Given that DNA fragmentation testing is substantially more expensive than vitality testing, this may represent a valuable cost-saving measure for couples undergoing a fertility evaluation.

Vasectomy as a reversible form of contraception for select patients.

INTRODUCTION: To provide an effective form of birth control, men may choose a reversible or permanent form of contraception. Vasectomy is presently offered as a permanent option for male contraception. We have had patients who were interested in vasectomy and reversal as a temporary birth control option. The purpose of this paper is to determine if vasectomy should be offered for selected couples as a temporary form of contraception and under which circumstances. MATERIALS AND METHODS: A literature review was conducted to determine the available reversible contraceptive options, risks, failure rates and contraindications to each, and the risks and success rates of vasectomy and vasectomy reversal. RESULTS: Reversible contraceptives include hormonally based methods for women, non-hormonal anatomic barrier devices and spermatocidal agents. Hormone based therapies may be contraindicated in women with cardiovascular disease, hypertension, and some cancers. Non-hormonal contraceptives are generally less effective and may be unacceptable for some couples due to higher failure rates, difficulty of use and lack of acceptance. Both vasectomy and vasectomy reversal are low risk procedures. Reversal may be performed with a high degree of success, particularly with a short obstructive interval (97% patency if performed < 3 years following vasectomy). CONCLUSION: While vasectomy should be considered a permanent form of sterilization for most couples, there are select couples, unable or unwilling to use other forms of birth control, who would benefit from an informed discussion about using a vasectomy as a reversible form of contraception.

Untreated hypogonadism and testosterone replacement therapy in hypogonadal men are associated with a decreased risk of subsequent prostate cancer: a population-based study.

We sought to understand the relationship between hypogonadism and testosterone replacement therapy (TRT) in hypogonadal men on the risk of developing localized and metastatic prostate cancer. We used the Merative MarketScan database of commercial claims encounters to identify men diagnosed with hypogonadism. These men were matched to eugonadal men who served as controls. Multivariate negative binomial regression analysis of prostate cancer diagnoses, hypogonadism, and TRT in hypogonadal men adjusting for various known confounding factors was used to understand the impact of hypogonadism and TRT on prostate cancer risk. We identified 3,222,904 men who met inclusion criteria, of which 50% were diagnosed with hypogonadism (1,611,452) and each were matched to a control (1,611,452). The incidence of prostate cancer was 2.16%, 1.55%, and 1.99% in eugonadal controls, hypogonadal men on TRT, and hypogonadal men without TRT, respectively (p < 0.001). Untreated hypogonadism was independently associated with a decreased risk of localized prostate cancer (IRR 0.46, 95% CI 0.43-0.50, p < 0.001) compared to eugonadal controls. Hypogonadal men on TRT also had a significantly decreased risk of localized prostate cancer (IRR 0.49, 95% CI 0.45-0.53, p < 0.001). Furthermore, hypogonadal men on TRT (IRR 0.21, 95% CI 0.19-0.24, p < 0.001) or without TRT (IRR 0.20, 95% CI 0.18-0.22, p < 0.001) both had significantly decreased risk of metastatic prostate cancer, respectively. Our population-based analysis suggests that untreated hypogonadism in men is associated with a 50% decreased incidence of localized prostate cancer and an 80% decreased incidence of metastatic prostate cancer. TRT in hypogonadal men was also associated with a decreased risk of subsequent prostate cancer. Further research is needed to better understand the relationship between hypogonadism and TRT in hypogonadal men on the risk of subsequent prostate cancer.

Uncovering the Association Between Complete AZFc Microduplications and Spermatogenic Ability: The First Reported Series.

Purpose This article aims to report the first series of men with complete AZFc microduplications and their clinical and reproductive characteristics. Methods We sampled 3000 men who presented for reproductive urology evaluation from 2012-2020, of which 104 men underwent high-resolution Y-chromosome microarray testing, and five men were identified to have complete AZFc microduplications. Medical, surgical, and reproductive histories were obtained. Semen and hormonal parameters as well as response to fertility therapies were recorded. Results Five men were identified as having complete AZFc microduplications. The mean age was 33.75 years, representing 0.2% (5/3000) of men presenting for fertility investigation, 4.8% (5/104) of men undergoing microarray testing, and 21% (5/24) of men with AZFc abnormalities. Two of the men had prior undescended testicles and one had several autoimmune processes. The mean follicle-stimulating hormone (FSH) was 5.5 IU/L, luteinizing hormone (LH) 3.6 IU/L, and testosterone 14.56 nmol/L. One man was azoospermic, one man alternated between severe oligospermia and rare non-motile sperm, one had variable parameters, with one semen analysis demonstrating azoospermia and a second demonstrating a total motile sperm count (TMSC) of 4 ×106, one man was persistently oligospermic with TMSCs ranging 3.96-12.6 ×106, and one man initially had severe oligospermia, with a mean TMSC of 1.5 ×106, which increased to 21.7 ×106 after intervention (varicocele embolization, clomiphene citrate). This last man then fathered a spontaneous pregnancy. Conclusion AZFc complete microduplications are a rare cause of spermatogenic failure but not an uncommon form of AZFc abnormality. Clinically, they represent a heterogeneous group, having a variable reproductive potential. Cases should be managed on an individual basis.

Clustering of UPOINT domains and subdomains in men with chronic prostatitis/chronic pelvic pain syndrome and contribution to symptom severity.

PURPOSE: The UPOINT (Urinary, Psychosocial, Organ specific, Infection, Neurologic/systemic and Tenderness of skeletal muscle) system characterizes men with chronic prostatitis/chronic pelvic pain syndrome according to 6 domains. Some domains have multiple possible criteria but to our knowledge grouping these criteria have never been validated. Domain clustering may provide clues to the etiology or treatment of individual phenotypes. We examined domain clustering patterns and the contribution of individual domains and subdomains to symptom severity. MATERIALS AND METHODS: We reviewed the records of 220 patients with chronic prostatitis/chronic pelvic pain syndrome. Of the patients 120 were characterized by UPOINT alone and 100 were characterized by subdomain, including urinary (voiding and storage), psychosocial (catastrophizing and depression), organ specific (bladder and prostate), infection (prostate and urethra) and neurologic/systemic. The NIH-CPSI (National Institutes of Health-Chronic Prostatitis Symptom Index) was used to measure symptom severity. RESULTS: The urinary, psychosocial, infection and neurologic/systemic subdomains had a similar incidence but organ specific-prostate was more common than organ specific-bladder (51% vs 33%). On cluster analysis with multidimensional scaling urinary, organ specific and tenderness clustered together, as did neurologic, infection and psychosocial. Of the subdomains organ specific-prostate and organ specific-bladder diverged but the others clustered together. The domains that significantly contributed to the total NIH-CPSI score were urinary, psychosocial and tenderness. Only psychosocial contributed independently to the quality of life subscore. CONCLUSIONS: UPOINT domain criteria capture a homogeneous group for each domain except organ specific, in which bladder and prostate diverge. Clustering of domains specific to the pelvis (urinary, organ specific and tenderness) vs systemic domains (neurologic, infection and psychosocial) implies 2 patient populations that may differ in pathophysiology and treatment response. The primary drivers of pain in patients with chronic pelvic pain syndrome are pelvic floor tenderness, depression and catastrophizing.

Complete testicular-epididymal dissociation presenting as adult chronic orchialgia.

Complete testicular epididymal dissociations are exceedingly rare conditions where the epididymis and the vas deferens are completely dissociated from the testicle. We present the case of a 46-year-old male with a history of chronic, intermittent and severe left testicular pain who was found to have a complete testicular epididymal dissociation at the time of surgical exploration and bilateral orchidopexy. Microsurgical approximation of the tail of the epididymis to the tunica albuginea of the testis with reapproximating the muscularis of the spermatic cord to the epididymal appendage was performed with subsequent relief of symptoms.