"Blue balls" and sexual coercion: a survey study of genitopelvic pain after sexual arousal without orgasm and its implications for sexual advances.

Background: Blue balls/vulva has received increasing interest from the public in recent years, sparking debate about genital physiology, controversy around "sexual release" as a treatment for this type of pain, and sexual consent. Aim: This cross-sectional, mixed-methods online study aimed to evaluate the general understanding and frequency of blue balls/vulva and whether individuals have ever been pressured to continue sexual activity because of a partner's fears of experiencing pain without orgasm. Methods: A total of 2621 individuals with a penis (n = 1483) or vagina (n = 1138) were recruited for an online survey on the experience of "blue balls/vulva." Quantitative analyses consisted primarily of descriptive statistics and chi-square analyses. Between-group differences were analyzed (based on whether respondents reported having a penis or vagina), and responses to open-ended questions were examined via thematic analysis. Outcomes: The primary outcomes of interest were reports of the belief in blue balls/vulva, the frequency and pain characteristics of blue balls/vulva, and the incidence of being pressured to continue sexual activity due to a partner's fears of experiencing pain without orgasm. Results: Results indicated that significantly more individuals with a penis than a vagina reported believing that blue balls are real, endorsed experiencing pain when they approached orgasm but did not ejaculate, and reported moderate and severe pain. Significantly more individuals with a vagina than a penis reported being pressured into a sexual act due to a partner's fear of experiencing pain without orgasm. Results from the thematic analysis indicated that participants recognized that those with a vagina are expected to act sexually to prevent their partners' experience of blue balls, despite agreement that this phenomenon should not be used to coerce or manipulate partners into engaging sexually. Clinical Implications: Education on the frequency of this phenomenon and methods to relieve pain alternative to partnered sexual activity should be addressed in patients who present with this condition. Strengths and Limitations: Although the survey was brief, it provided information from a relatively large sample about whether people believe that this phenomenon exists, how many experience it, how painful it is, and how often it has been used as an excuse for a partner to continue sexual activity. Conclusion: Results indicated that severe pain exists in a minority of individuals, that solitary sexual and nonsexual activities can help to alleviate the discomfort, and that this pain is not a valid reason to continue unwanted sexual activity.

Hydrodissection for improved microsurgical denervation of the spermatic cord: prospective blinded randomized control trial in a rat model.

Microsurgical denervation of the spermatic cord (MDSC) can provide up to an 86% improvement in pain in patients with chronic orchialgia (CO) who have failed conservative management. Failures in MDSC could be due to small diameter nerves (≤1 mm) left behind on the spermatic cord. The objective of this study was to assess if hydrodissection (HD) of the spermatic cord after MDSC could decrease the number of residual nerve fibers without compromising blood flow. Prospective blinded randomized control trial: bilateral MDSC was performed on 22 adult rats (44 cords). HD of the spermatic cord was performed on one side of each rat (side randomized) using the ERBEJET2. The contralateral cord (no HD) was the control for each animal. Blood flow through the vessels was monitored using a micro-Doppler probe. After completion a cross-section of the residual cord was sent to pathology (blinded to technique) to assess for small diameter nerves and signs of damage in vascular integrity. Blood flow had been maintained in the vessels when the ERBEJET2 was set to 6 bar (87 psi). The cord where HD had been performed had a significantly lower total median residual nerve count of 5 (0-10), compared to 8 (2-12) on the non-HD side (p = 0.007). No structural damage was seen in the vessels in the spermatic cord that had undergone HD (gross exam and histology). HD of the spermatic cord significantly decreases residual nerve density without compromising vascular integrity in a rat model.

Prospective control trial: flexible CO2 laser vs. monopolar electrocautery for robotic microsurgical denervation of the spermatic cord.

Microsurgical denervation of the spermatic cord (MDSC) is a treatment option in patients with chronic orchialgia. This procedure requires precise care to avoid any thermal damage to crucial adjacent tissues (arteries, veins, and lymphatics). Monopolar electrocautery is the standard ligation energy source, but may cause extensive collateral damage to the tissues. However, CO2 laser is known to produce a very predictable tissue penetration and minimal collateral spread. The goal of this study was to compare the extent of collateral thermal damage in both monopolar electrocautery and CO2 laser ablation in the spermatic cord during a robotic assisted MDSC (RMDSC) procedure as well as the feasibility for utilizing the flexible fiber-optic CO2 laser probe after "RMDSC" procedure. RMDSC was performed using standard monopolar electrocautery on the spermatic cord of one side of a fresh human male cadaver (randomly selected) and then compared to RMDSC using the CO2 laser on the contralateral spermatic cord. Nine histological cross-sections from each cord were measured for depth of collateral thermal/cautery injury. The mean collateral thermal injury with CO2 laser was 0.17 ± 0.031 mm (range: 0.15-0.25 mm), and with standard electrocautery 0.72 ± 0.046 mm (range: 0.60-0.75 mm). CO2 laser resulted significantly less collateral thermal injury than standard electrocautery (p < 0.0001). The CO2 laser probe was easy to manipulate with the Black Diamond micro-forceps (Intuitive Surgical, CA) and allowed for convenient tissue plane dissection. Human cadaveric targeted RMDSC using a flexible CO2 laser energy results in significantly decreased collateral thermal injury compared to standard monopolar electrocautery. These initial findings suggest potential advantages of the CO2 laser over traditional monopolar cautery in cases requiring minimal collateral tissue damage. Future studies are needed to assess its clinical potential in microsurgery.

Salvage Ultrasound-guided Targeted Cryoablation of The Perispermatic Cord For Persistent Chronic Scrotal Content Pain After Microsurgical Denervation Of The Spermatic Cord.

OBJECTIVE: To assesses the efficacy of ultrasound-guided targeted cryoablation (UTC) of the perispermatic cord as a salvage treatment for patients who failed microsurgical denervation of the spermatic cord. METHODS: Retrospective review of 279 cases (221 patients: 58 bilateral) undergoing UTC between November 2012 and July 2016, performed by 2 fellowship trained microsurgeons. UTC was performed using a 16-gauge cryo needle (Endocare, HealthTronics, Austin, TX). Branches of the genitofemoral, ilioinguinal, and inferior hypogastric nerves were cryoablated medial and lateral to the spermatic cord at the level of the external inguinal ring. Level of pain was measured preoperatively and postoperatively using the visual analog scale and Pain Index Questionnaire-6 (QualityMetric Inc., Lincoln, RI). RESULTS: Median age was 43 years, operative duration 20 minutes, and postoperative follow-up 36 months (24-60). Subjective visual analog scale outcomes: 75% significant reduction in ain (11% complete resolution and 64% ≥50% reduction in pain). Objective Pain Index Questionnaire-6 outcomes: 53% significant reduction at 1 month (279 cases), 55% at 3 month (279 cases), 60% at 6 month (279 cases), 63% at 1 year (279 cases), 65% at 2 years (275 cases), 64% at 3 years (232 cases), 59% at 4 years (128 cases) and 64% at 5 years (53 cases) post-op. COMPLICATIONS: 2 wound infections, 4 penile pain cases (resolved in a few months). CONCLUSION: UTC of the perispermatic cord is a safe potential treatment option for the salvage management of persistent chronic scrotal pain in patients who have failed microsurgical denervation of the spermatic cord.

Review of the role of robotic surgery in male infertility.

OBJECTIVES: To present the current state of the art in various robot-assisted microsurgical procedures in male infertility and review the latest literature, as the technology in infertility procedures has substantially developed since the incorporation of the Vinci® robotic platform (Intuitive Surgical, Inc., Sunnyvale, CA, USA). MATERIALS AND METHODS: The search strategy in this review was conducted in accordance with Cochrane guidelines and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A search strategy was conducted in MEDLINE, PubMed and the Cochrane electronic databases (from 2000 to present) to identify studies that included both robotic and male infertility. RESULTS: In all, 23 studies were found, 12 of which met our inclusion criteria. Articles were excluded if the study did not include both male infertility and robotics. CONCLUSIONS: Robotic assistance for microsurgical procedures in male infertility appears to be safe and feasible. It has several advantages including elimination of tremor, multi-view magnification, additional instrument arms, and enhanced dexterity with articulating instrument arms. It also has a short learning curve with a small skin incision. However, larger, prospective studies are needed to establish the clinical benefits over standard microsurgery.

Targeted Robotic Assisted Microsurgical Denervation of the Spermatic Cord for the Treatment of Chronic Orchialgia or Groin Pain: A Single Center, Large Series Review.

PURPOSE: Microsurgical denervation of the spermatic cord is a treatment option for chronic orchialgia refractory to conservative treatment. A recent study showed specific nerve fibers as the possible cause of chronic orchialgia. Our goal was to present the outcomes of ligation of these nerves using a technique of targeted robotic assisted microsurgical denervation of the spermatic cord. MATERIALS AND METHODS: We retrospectively reviewed the records of 772 patients who underwent targeted robotic assisted microsurgical denervation of the spermatic cord from October 2007 to July 2016. Selection criteria were chronic testicular pain more than 3 months in duration, failed conservative treatments, negative neurological and urological workup, and temporary resolution of pain with a local anesthetic spermatic cord block. Targeted robotic assisted microsurgical denervation of the spermatic cord was performed. Pain was assessed preoperatively and postoperatively using a subjective visual analog scale and objectively with the standardized and validated PIQ-6 (Pain Impact Questionnaire-6) score. RESULTS: Followup data were available on 860 cases. During a median followup of 24 months (range 1 to 70) 718 cases (83%) showed a significant reduction in pain and 142 (17%) had no change in pain by subjective visual analog scale scoring. Of cases with a significant reduction in pain 426 (49%) had complete resolution and 292 (34%) had a 50% or greater reduction. Objective PIQ-6 analysis showed a significant reduction in pain in 67% of patients 6 months postoperatively, in 68% at 1 year, in 77% at 2 years, in 86% at 3 years and in 83% at 4 years. CONCLUSIONS: Targeted robotic assisted microsurgical denervation of the spermatic cord is an effective, minimally invasive approach with potential long-term durability in patients with refractory chronic orchialgia.

Chronic Testicular and Groin Pain: Pathway to Relief.

The management of patients suffering with chronic testicular and groin pain is very challenging. With increased awareness of men's health, more patients and clinicians are open to talk about this complex problem that affects over 100,000 men/year. The pathogenesis of chronic orchialgia is still not clear, but there are several postulated theories. Treatment options include conservative medical therapy with NSAIDs, antidepressants, anticonvulsants, and narcotics. Surgical options such as targeted microsurgical denervation and microcryoablation can provide permanent durable pain relief. The goal of this article is to review and discuss the management of patients with chronic orchialgia using currently available literature.

Robot-assisted microsurgery for chronic orchialgia.

Chronic orchialgia is one of the most common complaints seen in the urologists office and has traditionally been considered a very difficult diagnostic and therapeutic challenge for the clinician. First line management of chronic orchialgia is conservative treatment; however, in men who fail conservative therapy, surgical intervention may be indicated. Microsurgery has been the mainstay for surgical treatment of chronic orchialgia, but the implementation of robotics to microsurgery lends itself particularly to surgical treatment of chronic orchialgia. PubMed was used to perform a current literature search on chronic orchialgia with robotic microsurgery, robotic spermatic cord denervation, robotic varicocelectomy, and robotic vasectomy reversal. Although conservative therapy is considered the first line treatment for chronic orchialgia, reported outcomes are moderate to poor, with the need to proceed to surgical intervention in select cases. Current surgical therapies in which robot assistance have been applied to microsurgery include microsurgical denervation of the spermatic cord, varicocelectomy, and vasectomy reversal. As further studies have assisted in the understanding of surgical treatment of chronic orchialgia, the application of robot assistance to this level of microsurgery has been shown to be feasible and safe with comparable outcomes to traditional microsurgery and may provide potential advantages.

Genital pain: algorithm for management.

Chronic testicular pain although becoming very common in our patient population poses a challenge to the physician, the patient and his family. The pathogenesis of chronic orchialgia (CO) is not well understood. The objective of this paper is to review the current literature on chronic testicular pain and its management and to propose an algorithm for its treatment. Abstracts, original papers and review articles were reviewed during a literature search using words such as testicular pain, CO, and microsurgical anatomy of spermatic cord. Chronic scrotal content pain (CSP) is a difficult condition to treat and could be idiopathic or secondary. Conservative therapy is the first line of treatment attempted to allow the patient to return to his routine activities. When conservative treatment fails, patients can now turn toward surgical options such as microsurgical denervation of the spermatic cord (MDSC) which has a success rate published in the 60-85% range and/or minimally invasive therapies such as microcryoablation of the spermatic cord, Botox or Amniofix injection. There is an increase in referrals for CO. The true pathogenesis is still unclear and the road to complete recovery is unsure for certain patients. This paper proposes an algorithm for the management of patients suffering with CO.

Chronic orchialgia: Review of treatments old and new.

INTRODUCTION: Chronic orchialgia is historically and currently a challenging disease to treat. It is a diagnostic and therapeutic challenge for physicians. Conservative therapy has served as the first line of treatment. For those who fail conservative therapy, surgical intervention may be required. We aim to provide a review of currently available surgical options and novel surgical treatment options. METHODS: A review of current literature was performed using PubMed. Literature discussing treatment options for chronic orchialgia were identified. The following search terms were used to identify literature that was relevant to this review: Chronic orchialgia, testicular pain, scrotal content pain, and microsurgical denervation of the spermatic cord (MDSC). RESULTS: The incidence of chronic orchialgia has been increasing over time. In the USA, it affects up to 100,000 men per year due to varying etiologies. The etiology of chronic orchialgia can be a confounding problem. Conservative therapy should be viewed as the first line therapy. Studies have reported poor success rates. Current surgical options for those who fail conservative options include varicocelectomy, MDSC, epididymectomy, and orchiectomy. Novel treatment options include microcryoablation of the peri-spermatic cord, botox injection, and amniofix injection. CONCLUSION: Chronic orchialgia has been and will continue to be a challenging disease to treat due to its multiple etiologies and variable treatment outcomes. Further studies are needed to better understand the problem. Treatment options for patients with chronic orchialgia are improving. Additional studies are warranted to better understand the long-term durability of this treatment options.

Robot-assisted microsurgery in male infertility and andrology.

Use of the operative microscope marked a new era for microsurgery in male infertility and andrology in the 1970s. More than a decade has passed since the initial description of the first robotic-assisted microsurgical vasovasostomy. Large single-center series have recently been published on robotic-assisted microsurgery for vasectomy reversal, especially in the past few years. Multicenter studies are also beginning to be reported, and the potential for this new platform for microsurgery is starting to become more apparent. This article describes the basic technical details of robotic-assisted microsurgery in male infertility and andrology, and reviews the latest literature.

Robotic microsurgery optimization.

The increased application of the da Vinci robotic platform (Intuitive Surgical Inc.) for microsurgery has led to the development of new adjunctive surgical instrumentation. In microsurgery, the robotic platform can provide high definition 12×-15× digital magnification, broader range of motion, fine instrument handling with decreased tremor, reduced surgeon fatigue, and improved surgical productivity. This paper presents novel adjunctive tools that provide enhanced optical magnification, micro-Doppler sensing of vessels down to a 1-mm size, vein mapping capabilities, hydro-dissection, micro-ablation technology (with minimal thermal spread-CO2 laser technology), and confocal microscopy to provide imaging at a cellular level. Microsurgical outcomes from the use of these tools in the management of patients with infertility and chronic groin and testicular pain are reviewed. All these instruments have been adapted for the robotic console and enhance the robot-assisted microsurgery experience. As the popularity of robot-assisted microsurgery grows, so will its breadth of instrumentation.

Medical management of male infertility in the absence of a specific etiology.

Idiopathic male infertility can be diagnosis in approximately one-third of infertile males. The empirical medical treatment with or without assisted reproductive techniques appears common in male infertility practice. This type of management can be classified as hormonal treatment including gonadotropins, antiestrogens, and aromatase inhibitors and support with antioxidant supplements such as carnitine, lycopene, glutathione, and vitamin E. This review investigates the evidence of commonly used empirical medical management of male infertility when there is no demonstrable diagnosis.

Robotic-assisted microsurgery for an elective microsurgical practice.

Robotic-assisted microsurgery can be utilized for either intracorporal or extracorporeal surgical procedures. Three-dimensional high-definition magnification, a stable ergonomic platform, elimination of physiologic tremor, and motion scaling make the robotic platform attractive for microsurgeons for complex procedures. Additionally, robotic assistance enables the microsurgeon to take microsurgery to challenging intracorporeal locations in a minimally invasive manner. Recent adjunctive technological developments offer the robotic platform enhanced optical magnification, improved intraoperative imaging, and more precise ablation techniques for microsurgical procedures. The authors present the current state-of-the art tools available in the robotic-assisted microsurgical platform.

Robotic microsurgery in male infertility and urology-taking robotics to the next level.

The initial reports of robotic assisted microsurgery began to appear in the early 1990s. Animal and early human studies were the initial publications. Larger series papers have recently been published from a few institutions. The field of robotic assisted microsurgery is still in evolution and so are adjunctive tools and instruments. It is clearly a different and unique skill set-is it microsurgery or is it robotic surgery, or both. It is clear from history that the art of surgery evolves over time to encompass new technology as long as the outcomes are better for the patient. Our current robotic platforms may not be ideal for microsurgery, however, the use of adjunctive tools and instrument refinement will further its future potential. This review article presents the current state of the art in various robotic assisted microsurgical procedures in male infertility and urology. Some novel applications of taking microsurgery to areas not classically accessible (intra-abdominal vasovasostomy) and adjunctive tools will also be presented.

Trifecta nerve complex: potential anatomical basis for microsurgical denervation of the spermatic cord for chronic orchialgia.

PURPOSE: We identified structural abnormalities in the spermatic cord nerves that may explain how microsurgical denervation of the spermatic cord provides pain relief in patients with chronic orchialgia. MATERIALS AND METHODS: We retrospectively reviewed a prospective database to compare spermatic cord biopsy specimens from 56 men treated with a total of 57 procedures for microsurgical denervation of the spermatic cord for chronic orchialgia vs a control group of men without pain treated with cord surgery, including varicocelectomy in 4 and radical orchiectomy in 6. Tissue biopsies were obtained from mapped regions of the spermatic cord in all cases. Biopsies stained with hematoxylin and eosin were examined by an independent pathologist. Three human cadaveric spermatic cords were dissected to confirm localization of the nerve distribution identified on pathological mapping. RESULTS: We identified a median of 25 small diameter (less than 1 mm) nerve fibers in the spermatic cord. Of the 57 procedures for orchialgia 48 (84%) showed wallerian degeneration in 1 or more of these nerves but only 2 of 10 controls (20%) had such degeneration (p = 0.0008). In decreasing order of nerve density the 3 primary sites (trifecta nerve complex) of these changes were the cremasteric muscle fibers (19 nerves per patient), perivasal tissues and vasal sheath (9 nerves per patient), and posterior cord lipomatous/perivessel tissues (3 nerves per patient). Cord nerve distribution mapped by the biopsies was confirmed by cadaveric dissection. CONCLUSIONS: In men with chronic orchialgia there appears to be wallerian degeneration in reproducible patterns in the spermatic cord nerve fibers. Transection of these nerves may explain the effect of the denervation procedure.

Robotic assisted versus pure microsurgical vasectomy reversal: technique and prospective database control trial.

Microsurgical vasectomy reversal is a technically demanding procedure. Previous studies have shown the possible benefit of robotic assistance during such procedures. Our goal was to compare robotic assisted vasovasostomy and vasoepididymostomy to standard microsurgical vasovasostomy (MVV) and vasoepididymostomy (MVE). The use of robotic assistance for vasectomy reversal may provide the microsurgeon with improved visualization, elimination of tremor, and decreased fatigue and obviate the need for a skilled microsurgical assistant. This study provides the first clinical prospective control trial of robotic assisted versus pure microsurgical vasectomy reversal. The use of robotic assistance in microsurgical vasovasostomy and vasoepididymostomy may have benefit over MVV and MVE with regards to decreasing operative duration and improving the rate of recovery of postoperative total motile sperm counts based on our study.

Robotic approaches for male infertility and chronic orchialgia microsurgery.

PURPOSE OF REVIEW: Since its inception in early 2000, robotic assistance with urologic procedures continues to expand. The magnification, three-dimensional visualization, and surgical control offered by the latest daVinci Si-HD system has led to its integration into microsurgical procedures for male infertility. The addition of robotic assistance may allow an improvement in outcomes similar to when the operating microscope was introduced in microsurgery. Though the use of robotics in microsurgery is still in its early phases, initial findings are encouraging. RECENT FINDINGS: This review covers robotic microsurgical procedures and tools for infertility and chronic orchialgia/testicular pain such as vasovasostomy, vasoepididymostomy, varicocelectomy, testicular sperm extraction and targeted denervation of the spermatic cord. Preliminary human clinical studies appear to show improved operative efficiency and comparable outcomes. The use of robotic assistance during robotic microsurgical vasovasostomy appears to decrease operative duration and improve the rate of return of postoperative sperm counts compared to the pure microsurgical technique. SUMMARY: Long-term prospective controlled trials are necessary to assess the true benefit for robotic-assisted microsurgery. The preliminary findings are promising, but further evaluation is warranted.

Giant organ confined prostatic adenocarcinoma: a case report.

INTRODUCTION: Giant prostatic adenocarcinoma represents a rare and challenging treatment dilemma. CASE PRESENTATION: We describe a case of an otherwise healthy 71-year-old African male who presented with a PSA of 5800 ng/ml and a prostate volume of over 1000cc. Unique aspects of this case include the size of the prostate, the apparent absence of distant metastases, and the safe usage of transabdominal biopsy of this mass. CONCLUSION: We present this case report and review of literature to generate further discussion amongst readers as to management options for this difficult case.

EMMPRIN mediates beta-adrenergic receptor-stimulated matrix metalloproteinase activity in cardiac myocytes.

Extracellular matrix metalloproteinase inducer (EMMPRIN) expression is increased in myocardium from patients with dilated cardiomyopathy and animal models of heart failure. However, little is known about the regulated expression or functional role of EMMPRIN in the myocardium. In rat cardiac cells, EMMPRIN is expressed on myocytes but not endothelial cells or fibroblasts. Therefore, we tested the hypothesis that EMMPRIN expression regulates matrix metalloproteinase (MMP) activity in rat ventricular myocytes in vitro. In adult rat ventricular myocytes (ARVM), beta-adrenergic receptor (betaAR) stimulation and H(2)O(2) (24 h) each increased EMMPRIN expression as assessed by immunoblotting. Pretreatment with a catalase/superoxide dismutase mimetic or adenoviral-mediated expression of catalase or a dominant-negative c-jun N-terminal kinase-1 (JNK) mutant inhibited the betaAR- and H(2)O(2)-stimulated increases in EMMPRIN expression suggesting that EMMPRIN expression is regulated via a reactive oxygen species-dependent JNK pathway. To determine whether EMMPRIN expression regulates matrix metalloproteinase (MMP) activity, EMMPRIN activity was inhibited by adenoviral expression of an inhibitory mutant of EMMPRIN. Expression of mutant EMMPRIN inhibited the betaAR-stimulated increases in MMP2 expression and zymographic MMP activity. Thus, in cardiac myocytes betaAR stimulation induces the expression of EMMPRIN via the ROS-dependent activation of JNK. The resulting increase in EMMPRIN activity stimulates MMP expression and activity. These findings suggest that in the myocardium the regulated expression of EMMPRIN is a determinant of MMP activity and may thus play a role in myocardial remodeling.