[Testosterone therapy]. / Testosterontherapie.

Hormone replacement therapy with testosterone has become well-established over the course of time. The initial substantial concerns with respect to complications and potential adverse events, particularly in older patients, were proven to be unfounded over time. Testosterone therapy has therefore gradually become a regular treatment modality in urological practice. It has also been shown to represent a valuable tool as supportive treatment for patients with erectile dysfunction and hypogonadism. A variety of testosterone preparations are available for treatment. Recent pharmaceutical developments have greatly improved the practicability and ease of administration for patients. Several guidelines have been developed that provide clearly formulated standards and instructions for indications, contraindications, application, risk factors and monitoring of testosterone therapy. Adverse events affecting the cardiovascular system and especially diseases of the prostate gland are of great importance, thus making the urologist the primary partner in the treatment of patients with testosterone deficiency.

[Biopsies of the kidney, prostate and urinary bladder]. / Biopsie der Prostata und Punktion der Niere und Blase.

BACKGROUND: Biopsies of the kidney, prostate and urinary bladder are amongst the most frequent interventions in urology. A correct indication, preparation and performance are important to achieve good results and low complication rates. OBJECTIVES: In this review complication management in biopsies of the kidney, prostate and urinary bladder are discussed. MATERIALS AND METHODS: A selective search of the literature, with emphasis on systematic reviews and larger cohort studies was performed. RESULTS: Complication rates are generally low. However, certain factors such as coagulation disorders, anatomical malformations, accompanying morbidities or antibiotic resistance may play a significant role and increase rates of complications. Especially complications such as hematuria and injury of contiguous organs are described in the literature. DISCUSSION: Biopsies of the kidney, prostate and urinary bladder can be performed with low complication rates if general and specific factors in the planning of the intervention and prevention of complications are considered.

Validation of the German version of the 'Hypogonadism Related Symptom Scale' (HRS) in andrological patients with infertility, HIV infection and metabolic syndrome.

As commonly used self-reported screening instruments for male hypogonadism demonstrated lack of specificity, a Hypogonadism Related Symptom Scale (HRS) was developed in 2009 as a novel self-rating screening tool. As the questionnaire has not been validated, the purpose of our study was to perform a validation in patients presenting with different disorders (e.g. infertility, HIV infection or metabolic syndrome) and disease-related risk to develop hypogonadism. Two hundred and eighteen patients aged 19-71 years (40.1 ± 9.5) who completed the HRS and other common questionnaires [International Index Of Erectile Function (IIEF), National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI), Hospital Anxiety and Depression Scale (HADS), short form (SF)-12] were included. In all patients, blood levels of total testosterone, luteinizing hormone, follicle-stimulating hormone, oestradiol and sex hormone-binding globulin were determined and free testosterone was calculated. Cronbach's α for the scale was 0.896, split-half 0.871 for the 1st half and 0.807 for the 2nd half. Spearman-Brown coefficient was 0.767, and Guttman split-half coefficient was 0.759. Consistent correlations were found between HRS and IIEF5 (ρ = 0.57, P < 0.001), and HADS (ρ = -0.6, P < 0.001). In addition, HRS was significantly correlated with total testosterone (ρ = 0.135, P < 0.05), free testosterone (ρ = 0.148, P < 0.05) and oestradiol (ρ = -0.134, P < 0.05). Our validation study confirms the data from the initial development of the HRS questionnaire. Clinicians might have an additional advantage from the HRS when investigating males with suspected hypogonadism.

Acute epididymitis in ultrasound: results of a prospective study with baseline and follow-up investigations in 134 patients.

OBJECTIVES: To perform a comprehensive follow-up analysis of ultrasonographic scrotal features and associated signs in patients with acute epididymitis. METHODS: Between 2007 and 2012, 134 adults (median age 54 years) with acute epididymitis underwent scrotal ultrasonography and palpation at first presentation and after 2 weeks and 3 months. RESULTS: At first presentation, 61 patients (45.5%) had hydrocele, 63 (47.0%) concomitant orchitis, and 8 (5.9%) epididymal abscess. Epididymitis was predominantly located in 24 cases (17.9%) in the head, 52 cases (38.8%) in the tail, and 58 cases (43.3%) in both. On the affected side, testicular volume was 16.9 ± 6.8 ml and peak systolic velocity of the testicular artery was 23.7 ± 7.5 cm/s, compared to the healthy side with 12.3 ± 4.4 ml and 9.5 ± 3.6 cm/s respectively (P<0.001). Concomitant orchitis was associated with hydrocele, testicular enlargement and pain (P<0.01). Orchiectomy due to secondary testicular infarction was necessary in four cases, while in all other patients ultrasound parameters normalized. Only 16/90 patients (17.8%) showed a persistent epididymal swelling after 3 months. CONCLUSIONS: Common ultrasound features include hydrocele, epididymal enlargement, hyperperfusion, and testicular involvement. Under conservative treatment, ultrasound parameters normalize without evidence of testicular atrophy even in patients with epididymal abscess or concomitant orchitis.

[Current therapeutic options for Peyronie's disease]. / Aktuelle Therapieoptionen der Induratio penis plastica.

Peyronie's disease is a heterogeneous disorder with typical symptoms of plaque formation, penile pain, deviation, penile shortening and erectile dysfunction. The etiology is unknown. Repetitive microtraumatic lesions with the formation of inelastic scar tissue at the level of the tunica albuginea are discussed as a trigger mechanism for a questionable genetic disposition. A non-surgical therapy based on a clear pathophysiology does not exist although several conservative treatment regimes are practiced. In the stable stage of the disease surgical therapy of penile angulation is the most frequent operation. Depending on the deviation angle, penile length and erectile dysfunction, different types of straightening surgery can be offered. This article provides an overview of conservative management and commonly used surgical techniques.

Prostatitis and andrological implications.

AIM: The prostatitis syndrome is a frequent disease affecting men in their reproductive age. The prostatitis syndrome is classified according to the National Institutes of Health (NIH) definition. Andrological implications of the prostatitis syndrome might encompass fertility issues, sexual dysfunctions and endocrinological alterations and influences. METHODS: A medline query using the terms prostatitis AND andrological implication, fertility, sexual dysfunction or endocrinology was performed. RESULTS: Acute bacterial prostatitis and andrological implications have not been adequately addressed. Patients with chronic bacterial prostatitis and chronic pelvic pain syndrome have been investigated evaluating sperm parameters. Some studies showed impaired sperm parameters. In chronic bacterial prostatitis, half of the patients reveal significant bacteriospermia with still debatable deleterious effects on sperm quality. Few interventional studies have addressed fertility issues in those patients. Anti-inflammatory treatment perhaps could have a positive impact on sperm parameters. Sexual dysfunction can be described by different components such as erectile, ejaculatory, orgasmic and sexual desire dysfunctions. Sexual dysfunction in chronic prostatitis adds to the number of positive symptom phenotypes and correlates therefore with increasing symptom scores in patients with chronic prostatitis syndromes. However, prospective interventional studies on the role of sexual dysfunctions are missing. Hormones have been found to modulate the inflammatory response via different receptors, particularly via estrogen receptor alpha. This evidence, however, is mainly limited to pre-clinical studies currently. CONCLUSION: Andrological implications are heterogenous and frequently described in patients with chronic prostatitis syndrome. Nonetheless, andrological factors have not been routinely addressed as primary variables in the different studies, which makes further research necessary.

[Seminal cytokines: is quantification useful in urogenital disorders?]. / Zytokine im Ejakulat : Ist die Bestimmung bei urogenitalen Erkrankungen sinnvoll?

Cytokines are cellular messengers which play a key role in many biological conditions such as immune defence and reproduction. During recent years analysis of seminal cytokines has become of increasing interest in various pathologies. To evaluate the current role of seminal cytokines we performed a systematic literature search within the framework of our focus group "Male Infertility during Infection and Inflammation - MIBIE". Out of 581 manuscripts we identified 124 original articles which investigated a total of 31 different cytokines. These studies can be categorized according to the following three topics: infertility, infections and chronic prostatitis. The current analysis demonstrates that seminal cytokine profiles are not associated with either semen quality or fertility; however, cytokines might be beneficial for diagnosis and monitoring therapy in patients with urogenital infections/inflammation. Further studies are needed to clarify if a single cytokine or a combination of different cytokines is necessary to evaluate different pathologies.

Guía clínica de la Asociación Europea de Urología sobre la vasectomía / European Association of Urology Guidelines on Vasectomy

Contexto: La Asociación Europea de Urología presenta su guía clínica para la vasectomía. La vasectomía es muy eficaz, pero pueden surgir problemas que están relacionados con la falta de información preoperatoria del paciente, el procedimiento quirúrgico y el seguimiento postoperatorio. Objetivo: Esta guía clínica tiene por objeto proporcionar información y recomendaciones para los médicos que realizan vasectomías y promover el suministro de información adecuada al paciente antes de la operación para evitar expectativas poco realistas y procedimientos legales. Adquisición de la evidencia: Se llevó a cabo una revisión exhaustiva de la literatura mediante Medline, Embase y la Base de Datos Cochrane de Revisiones Sistemáticas de 1980 a 2010. La atención se centró en los ensayos controlados aleatorizados (ECA) y los metaanálisis de los ECA (nivel 1 de evidencia) y en los estudios bien diseñados sin aleatorización (nivel 2 y 3 de evidencia). Un total de 113 registros únicos fueron identificados para su consideración. Se excluyeron las publicaciones que no estaban en lengua inglesa, así como los estudios publicados como resúmenes solamente o informes de las reuniones. Síntesis de la evidencia: La guía clínica debate las indicaciones y contraindicaciones de la vasectomía, la información y el asesoramiento preoperatorio del paciente, las técnicas quirúrgicas, los cuidados postoperatorios y el posterior análisis del semen y las complicaciones y consecuencias finales. Conclusiones: La vasectomía tiene la intención de ser un método anticonceptivo permanente; No hay contraindicaciones absolutas para la misma. Las contraindicaciones relativas pueden ser la ausencia de hijos, edad < 30 años, una enfermedad grave, ninguna relación actual y dolor en el escroto. El asesoramiento preoperatorio debe incluir métodos alternativos de anticoncepción, tasas de complicación y fracaso y la necesidad de análisis del semen postoperatorio. Se debe obtener consentimiento informado antes de la operación. Aunque el uso de cauterio de la mucosa y la interposición fascial han demostrado reducir el fracaso temprano en comparación con la ligadura simple y resección de un segmento de vaso pequeño, no hay datos sólidos que muestren que una técnica de vasectomía en particular es superior en cuanto a prevención de la recanalización tardía y espontánea del embarazo después de la vasectomía. Tras el análisis del semen se puede dar el alta en caso de azoospermia documentada y en el caso de espermatozoides inmóviles en la eyaculación por lo menos 3 meses después del procedimiento (AU)

Context: The European Association of Urology presents its guidelines for vasectomy. Vasectomy is highly effective, but problems can arise that are related to insufficient preoperative patient information, the surgical procedure, and postoperative follow-up. Objective: These guidelines aim to provide information and recommendations for physicians who perform vasectomies and to promote the provision of adequate information to the patient before the operation to prevent unrealistic expectations and legal procedures. Evidence acquisition: An extensive review of the literature was carried out using Medline, Embase, and the Cochrane Database of Systematic Reviews from 1980 to 2010. The focus was on randomised controlled trials (RCTs) and meta-analyses of RCTs (level 1 evidence) and onwell-designed studies without randomisation (level 2 and 3 evidence). A total of 113 unique records were identified for consideration. Non-English language publications were excluded as well as studies published as abstracts only or reports from meetings. Evidence synthesis: The guidelines discuss indications and contraindications for vasectomy, preoperative patient information and counselling, surgical techniques, postoperative care and subsequent semen analysis, and complications and late consequences. Conclusions: Vasectomy is intended to be a permanent form of contraception. There are no absolute contraindications for vasectomy. Relative contraindications may be the absence of children, age < 30 yr, severe illness, no current relationship, and scrotal pain. Preoperative counselling should include alternative methods of contraception, complication and failure rates, and the need for postoperative semen analysis. Informed consent should be obtained before the operation. Although the use of mucosal cautery and fascial interposition have been shown to reduce early failure compared to simple ligation and excision of a small vas segment, no robust data show that a particular vasectomy technique is superior in terms of prevention of late recanalisation and spontaneous pregnancy after vasectomy. After semen analysis, clearance can be given in case of documented azoospermia and in case of rare non motile spermatozoa in the ejaculate at least 3 mo after the procedure (AU)

[European Association of Urology guidelines on vasectomy]. / Guía clínica de la Asociación Europea de Urología sobre la vasectomía.

CONTEXT: The European Association of Urology presents its guidelines for vasectomy. Vasectomy is highly effective, but problems can arise that are related to insufficient preoperative patient information, the surgical procedure, and postoperative follow-up. OBJECTIVE: These guidelines aim to provide information and recommendations for physicians who perform vasectomies and to promote the provision of adequate information to the patient before the operation to prevent unrealistic expectations and legal procedures. EVIDENCE ACQUISITION: An extensive review of the literature was carried out using Medline, Embase, and the Cochrane Database of Systematic Reviews from 1980 to 2010. The focus was on randomised controlled trials (RCTs) and meta-analyses of RCTs (level 1 evidence) and on well-designed studies without randomisation (level 2 and 3 evidence). A total of 113 unique records were identified for consideration. Non-English language publications were excluded as well as studies published as abstracts only or reports from meetings. EVIDENCE SYNTHESIS: The guidelines discuss indications and contraindications for vasectomy, preoperative patient information and counselling, surgical techniques, postoperative care and subsequent semen analysis, and complications and late consequences. CONCLUSIONS: Vasectomy is intended to be a permanent form of contraception. There are no absolute contraindications for vasectomy. Relative contraindications may be the absence of children, age <30 yr, severe illness, no current relationship, and scrotal pain. Preoperative counselling should include alternative methods of contraception, complication and failure rates, and the need for postoperative semen analysis. Informed consent should be obtained before the operation. Although the use of mucosal cautery and fascial interposition have been shown to reduce early failure compared to simple ligation and excision of a small vas segment, no robust data show that a particular vasectomy technique is superior in terms of prevention of late recanalisation and spontaneous pregnancy after vasectomy. After semen analysis, clearance can be given in case of documented azoospermia and in case of rare nonmotile spermatozoa in the ejaculate at least 3 mo after the procedure.

[Peyronie's disease: diagnostics and therapy]. / Induratio penis plastica (IPP) : Diagnostik und Therapie.

Peyronie's disease is a benign disorder of the penis but the etiology is still unknown. A wound healing disorder after repetitive microtraumatic lesions with inelastic scar formation of the tunica albuginea potentially leads to the typical symptoms of penile plaque formation, penile pain, deviation and erectile dysfunction. A non-surgical therapy based on a clear pathophysiology does not exist although the benefit of several conservative treatment options is under discussion. In the stable stage of the disease patients with Peyronie's disease frequently undergo penile surgery. Depending on the deviation angle, the penile length and the erectile dysfunction different straightening surgery can be performed. This article provides an overview of the natural history of the disease and describes present conservative management strategies and common surgical techniques for penile straightening.

[Treatment of azoospermia: surgical sperm retrieval (MESA, TESE, micro-TESE)]. / Therapie der Azoospermie : Operative Spermiengewinnung (MESA, TESE, Mikro-TESE).

The introduction of intracytoplasmic sperm injection (ICSI) into the spectrum of assisted reproductive technologies has offered men who suffer from severe disorders of spermatogenesis and azoospermia the possibility of fathering a child. Different surgical techniques can be used to extract spermatozoa from these men from either the epididymis and/or the testis. Surgical sperm retrieval offers a treatment for patients with testicular and/or obstructive azoospermia in cases where microsurgical refertilization is not an option or has already failed. Among surgical techniques that have been explored over the years, microsurgical epididymal sperm aspiration (MESA) and testicular sperm extraction (TESE) have become the most popular. Percutaneous techniques (such as TEFNA) are available but have disadvantages versus open surgical procedures. Together with cryopreservation of extracted spermatozoa, these techniques facilitate retrieval of spermatozoa for several ICSI attempts by a single surgical intervention.

[Testosterone and erectile dysfunction]. / Testosteron und erektile Dysfunktion.

Primary hypogonadism represents a classic but rare cause of erectile dysfunction (ED) in men. Therapy with testosterone as monotherapy is therefore unlikely to cure ED in the typical ED patient. However, recent developments indicate a much greater role of testosterone in erectile function than has been supposed in the past. Serum testosterone levels decline in men with increasing age. Aging men might develop late-onset hypogonadism (LOH) associated with characteristic symptoms. Typical symptoms of LOH are represented by decreased libido and sexual function, osteoporosis, altered distribution of body fat, overall reduction in physical strength, and alterations in the general mood. Experimental and clinical studies over the last few years have also pointed out that hypogonadism results in characteristic alterations of the erectile tissue of the penis. These alterations might be reversible in response to hormone therapy with testosterone. Particularly testosterone might be a helpful supportive therapy in cases where PDE-5 antagonists have tended to lose their effectiveness on the erectile tissue in the treatment of ED.

Impact of infection on the secretory capacity of the male accessory glands.

INTRODUCTION: Studies that compare the impact of different infectious entities of the male reproductive tract (MRT) on the male accessory gland function are controversial. MATERIALS AND METHODS: Semen analyses of 71 patients with proven infections of the MRT were compared with the results of 40 healthy non-infected volunteers. Patients were divided into 3 groups according to their diagnosis: chronic prostatitis NIH type II (n = 38), chronic epididymitis (n = 12), and chronic urethritis (n = 21). RESULTS: The bacteriological analysis revealed 9 different types of microorganisms, considered to be the etiological agents, isolated in different secretions, including: urine, expressed prostatic secretions, semen and urethral smears: E. Coli (n = 20), Klebsiella (n = 2), Proteus spp. (n = 1), Enterococcus (n = 20), Staphylococcus spp. (n = 1), M. tuberculosis (n = 2), N. gonorrhea (n = 8), Chlamydia tr. (n = 16) and, Ureaplasma urealyticum (n = 1). The infection group had significantly (p < 0.05) lower: semen volume, alpha-glucosidase, fructose, and zinc in seminal plasma and, higher pH than the control group. None of these parameters was sufficiently accurate in the ROC analysis to discriminate between infected and non-infected men. CONCLUSION: Proven bacterial infections of the MRT impact negatively on all the accessory gland function parameters evaluated in semen, suggesting impairment of the secretory capacity of the epididymis, seminal vesicles and prostate. These findings were associated with an infectious related significant increase of semen pH. None of the semen parameters evaluated can be suggested as a diagnostic tool for infection.

Impact of infection on the secretory capacity of the male accessory glands

INTRODUCTION: Studies that compare the impact of different infectious entities of the male reproductive tract (MRT) on the male accessory gland function are controversial. MATERIAL AND METHODS: Semen analyses of 71 patients with proven infections of the MRT were compared with the results of 40 healthy non-infected volunteers. Patients were divided into 3 groups according to their diagnosis: chronic prostatitis NIH type II (n = 38), chronic epididymitis (n = 12), and chronic urethritis (n = 21). RESULTS: The bacteriological analysis revealed 9 different types of microorganisms, considered to be the etiological agents, isolated in different secretions, including: urine, expressed prostatic secretions, semen and urethral smears: E. Coli (n = 20), Klebsiella (n = 2), Proteus spp. (n = 1), Enterococcus (n = 20), Staphylococcus spp. (n = 1), M. tuberculosis (n = 2), N. gonorrhea (n = 8), Chlamydia tr. (n = 16) and, Ureaplasma urealyticum (n = 1). The infection group had significantly (p < 0.05) lower: semen volume, alpha-glucosidase, fructose, and zinc in seminal plasma and, higher pH than the control group. None of these parameters was sufficiently accurate in the ROC analysis to discriminate between infected and non-infected men. CONCLUSION: Proven bacterial infections of the MRT impact negatively on all the accessory gland function parameters evaluated in semen, suggesting impairment of the secretory capacity of the epididymis, seminal vesicles and prostate. These findings were associated with an infectious related significant increase of semen pH. None of the semen parameters evaluated can be suggested as a diagnostic tool for infection.

[Male adnexitis]. / Adnexitis beim Mann.

The term male adnexitis summarizes acute and chronic infections of the male urogenital tract. Chronic infections and inflammatory conditions are difficult to diagnose and the therapy has not been standardized. Therapy and management of complications has been clearly defined for acute urogenital infections. To date, antibiotic treatment in chronic infections and inflammatory conditions is only indicated when pathogenic bacteria can be retrieved from urogenital secretions.The usefulness of treatment with anti-inflammatory drugs is still debatable. One of the major concerns is the effect of urogenital infection on the fertility of the male. Although associations between urogenital infections and infertility have been shown for some entities, a general negative outcome of infectious events on male fertility appears to be unlikely.

Antisperm antibodies detected by mixed agglutination reaction and immunobead test are not associated with chronic inflammation and infection of the seminal tract.

The association between chronic inflammatory/infectious diseases of the male reproductive tract and the presence of antisperm antibodies (ASA) in semen is still controversial. We compared the results of the mixed agglutinin reaction (MAR) test and immunobead test for detecting ASA type IgG and IgA in 133 patients attending our special outpatient department for andrological infections and evaluated the differences in the detection rate of ASA. Patients were divided into three groups: a study group that included 79 patients with symptomatic nonacute inflammatory/infectious diseases of the seminal tract, a control group (n = 44) and a third group of men with a history of successful vasectomy reversal (n = 10). The two tests correlated in a statistically significant manner for the detection of IgG and IgA in all groups. The overall positive detection rate of clinical significant levels of IgG and IgA was 2.5% and 1.3% (respectively) in the patients with inflammation/infection of the seminal tract. No statistical significant difference in the detection rate of ASA levels between the inflammatory/infectious group and the controls was detected. The results of the MAR test and immunobead test have a statistical significant correlation and their results provide evidence that there is no association between inflammatory/infectious diseases of the male reproductive tract and the presence of ASA in semen.

[TESE and mTESE. Therapeutic options in male infertility due to testicular azoospermia]. / TESE und M-TESE. Therapieoption bei infertilen Männern mit testikulärer Azoospermie.

Modern techniques of testicular sperm extraction (TESE) make it possible for an infertile man to father a child. The operations are standardized to a large extent and the underlying morphological alterations of spermatogenesis also appear to be sufficiently known. Current research is focused on prognostic factors for the testicular material that determine the sperm retrieval rate and success rates after in vitro fertilization/intracytoplasmic sperm injection (IVF-ICSI).TESE and microTESE are accepted standard operations for testicular sperm retrieval for IVF/ICSI. Predictions for effective sperm recovery are addressed.

Chronic bacterial prostatitis (NIH type II): diagnosis, therapy and influence on the fertility status.

In only approximately 10% of men with symptoms of chronic prostatitis/chronic pelvic pain syndrome bacterial infection of the prostate can be demonstrated by the Meares and Stamey 4-glass or the pre- and post-prostate massage (PPM) two-glass test. Chronic bacterial prostatitis is mainly caused by Gram-negative uropathogens. The role of Gram-positives, atypicals and anaerobes is still debatable. For treatment, fluoroquinolones are considered the drugs of choice because of their favourable pharmacokinetic properties and their antimicrobial spectrum. As relapse and re-infection are a major problem in chronic bacterial prostatitis, only the results of studies with a follow up period of at least 6 months are meaningful. Analysing the concentrations of various fluoroquinolones in prostatic and seminal fluid as well as in prostatic tissue, it becomes, however, obvious that fluoroquinolones differ not only in plasma concentrations, but also in their penetration ability to these sites. Nevertheless, the concentrations at the site of infection of most fluoroquinolones with this indication should be sufficient for the treatment of chronic bacterial prostatitis caused by susceptible pathogens. On the other hand, male accessory gland infection has been linked to male infertility. However, there is still a lack of evidence showing that bacterial prostatitis would have a negative impact on sperm quality.