Update on male hormonal contraception: is the vasectomy in jeopardy?

Traditionally, male contraception has consisted of either barrier methods, such as condoms, or vasectomy. However, in recent years, we have made great strides in the basic science and clinical medicine to better understand the feedback mechanisms and physiology of the male reproductive system. These advances have enabled the development of several nonsurgical, hormonal, reversible, well-tolerated alternatives for male contraception. Men are more likely now than ever to participate in the choice of contraceptive techniques. This review will discuss the current status and recent developments in nonsurgical hormonal male contraception, a field that has been historically limited by social, financial and physiological challenges.

Penile size and penile enlargement surgery: a review.

Penile size is a considerable concern for men of all ages. Herein, we review the data on penile size and conditions that will result in penile shortening. Penile augmentation procedures are discussed, including indications, procedures and complications of penile lengthening procedures, penile girth enhancement procedures and penile skin reconstruction.

The prevalence of cystic abnormalities of the prostate involving the ejaculatory ducts as detected by transrectal ultrasound.

PURPOSE: To determine the prevalence of cystic lesions of the prostate involving the ejaculatory ducts using transrectal ultrasound (TRUS). MATERIALS AND METHODS: The prevalence of cystic lesions of the prostate involving the ejaculatory ducts was determined in a prostate cancer screening group and also in an "at risk" population of men with infertility. RESULTS: Cystic lesions of the prostate involving the ejaculatory ducts as detected by TRUS were detected in 5.0% (20 of 400 consecutive men) in a prostate cancer screening population. In contrast, these abnormalities were present in 17.0% (23/135) of the "at risk" infertile men who had TRUS performed. CONCLUSIONS: This is the largest series to date defining the prevalence of TRUS-identified cystic lesions of the prostate in a non-infertility population. While cystic lesions of the prostate involving the ejaculatory duct are uncommon in an otherwise healthy and fertile male, their prevalence increases in infertile men whose examination and semen analyses make them "at risk" for having ductal obstruction.

Priapism: etiology and management.

Priapism is a urologic emergency. All patients should receive prompt urologic consultation. Management is based on prompt recognition, differentiation between low- and high-flow priapism, reversal of any potential precipitating factors, and the use of corporal aspiration/irrigation combined with intracavernosal alpha-agonist injection therapy. It cannot be over-emphasized that severely prolonged erections are associated with the development of irreversible problems with erectile function and, therefore, immediate and aggressive management is mandatory.

Significant medical pathology uncovered by a comprehensive male infertility evaluation.

OBJECTIVE: To determine if there was a specific screening regimen that could identify all patients with significant medical pathology found during a comprehensive male infertility evaluation. DESIGN: A retrospective study. SETTING: Two university-based male infertility clinics. PATIENTS: Thirteen patients with male factor infertility identified with significant medical pathology. MAIN OUTCOME MEASURES: Initial presentation, history, physical examination, semen analysis, and hormone profile. RESULTS: The identification of significant medical pathology was uncovered in 13 of 1,236 patients (1.1%) presenting to a male infertility clinic. The pathology was identified with a thorough history in 4 of 13 patients (30.8%) and by a complete physical examination in 8 of 13 patients (61.5%). Semen analyses were available on 12 patients, and 1 patient was anejaculatory. Two patients were azoospermic. Of the patients with sperm present, the mean sperm concentration was 8.6 x 10(6)/mL (range, 0.8 to 27), and the mean sperm motility was 32.0% (range, 0% to 65%). In 5 patients, endocrine abnormalities were specifically related to the subsequent pathology identified. A tumor was identified in 10 patients (6 testicular tumors, 3 brain tumors, and 1 spinal cord tumor). Two patients had ejaculatory dysfunction as a result of mesonephric duct anomalies affecting the ejaculatory duct or bladder neck closure. One patient had Klinefelter's syndrome. CONCLUSIONS: There was no pathognomonic finding on history, physical examination, semen analysis, or hormone profile that identified all patients with significant medical pathology. The significant medical pathology identified was represented in all semen quality groupings, that is, azoospermia, severe oligospermia, mild oligospermia, and normospermia. We recommend a comprehensive urologic evaluation for all male partners of infertile couples with a male factor or unexplained infertility in an attempt to identify significant and potentially treatable medical pathology before engaging in a series of therapies with assisted reproductive techniques.

New diagnostic techniques in the evaluation of anatomic abnormalities of the infertile male.

New diagnostic imaging modalities have taken on a major role in the diagnosis of disease entities related to male infertility. Ultrasonography, MR imaging, and new operative diagnostic maneuvers will continue to define anatomy, physiology, and pathology of the male reproductive system. When any disease process affects the male in the reproductive or prereproductive years, potential repercussions on subsequent male factor fertility should always be addressed in the treatment plans of such patients. Scrotal ultrasonography is extremely helpful in identification of abnormalities of the testis parenchyma, paratesticular structures, and blood flow in the region of the testes. TRUS has replaced the vasogram as the initial diagnostic test for evaluation of the prostate, ejaculatory duct, and seminal vesicles in the infertile male. It may also be used as an adjunct to treatment in these patients. MR imaging may become a useful adjunct to TRUS in defining male genital ductal anatomy prior to surgical exploration. Vasal exploration, including subjective vasal injection pressure, vasal fluid examination, and vasography, is an important diagnostic tool in the diagnosis and treatment of male genital disorders.

Non-Hodgkin's lymphoma can mimic renal adenocarcinoma with inferior vena caval involvement.

Genitourinary involvement in both Hodgkin's and non-Hodgkin's lymphomas is common and can be confused with other benign and malignant urologic conditions. While lymphoma commonly produces vascular and ureteral encasement, intraluminal vascular involvement is rare. Indeed, there are no previous reports of renal lymphoma with tumor thrombus extending into both the renal vein and inferior vena cava. We describe the first reported case of lymphoma mimicking a Stage IIIA renal adenocarcinoma with tumor thrombus in the renal vein and the inferior vena cava. Renal lymphoma should be considered in the differential diagnosis even when tumor thrombus is present in the renal vein or vena cava.

Reassessment of male-factor infertility, including the varicocele, sperm penetration assay, semen analysis, and in vitro fertilization.

Evaluation of the male factor in infertility is becoming increasingly important as new diagnostic techniques and therapeutic options become available. Varicoceles are among the most common treatable cause of male infertility. Varicoceles are present in 10% to 20% of all males but are found in as many as 30% to 40% of men who present to an infertility clinic. Of men who have treatment for varicoceles, 50% to 75% will show some improvement in semen quality, and 30% to 40% will initiate a pregnancy. We review some controversial issues related to the diagnosis and treatment of varicoceles. In vitro fertilization, originally developed for the female with irreversible tubal damage, is now being evaluated as a possible therapy for severe male-factor infertility that has failed to respond to routine surgical or medical treatment. In vitro fertilization for the oligospermic male, however, is further complicated by the fact that men with poor sperm production frequently have poorly functioning sperm as well. Consequently, we discuss the value of the sperm penetration assay, with and without enhancement techniques to prospectively evaluate couples entering in vitro fertilization programs. We also discuss the role of strict criteria for determination of sperm morphology and quantitation of leukocytospermia in the evaluation of the infertile male. Finally, evaluation of the predictive value of "failure to fertilize" at in vitro fertilization for future in vitro fertilization success is discussed.

Use of ultrasonography in the evaluation of the infertile man.

Transrectal ultrasonography (TRUS) is a modality that most urologists are familiar with in the interpretation of prostate anatomy and pathology. Understanding the anatomy and pathology of the genital ductal system will help in the diagnosis of disease entities related to male infertility. Familiarity with both scrotal and transrectal ultrasound is vital to the understanding and diagnosis of treatable causes of male infertility.

The role of fine-needle aspiration biopsy of the prostate in staging adenocarcinoma.

Stage A prostate cancer is defined as the incidental finding of cancer in specimens obtained by transurethral resection of the prostate (TURP) in a clinically benign gland. A low-to-moderate grade tumor involving less than 5% of the TURP specimen has been termed Stage A1; a high-grade tumor or tumor involving more than 5% of the TURP specimen is termed Stage A2. Most investigators agree that Stage A1 disease has a significantly better prognosis than Stage A2 disease and may not warrant radical prostatectomy. However, the problem of correctly differentiating A1 and A2 disease remains. The authors prospectively studied 100 consecutive patients undergoing TURP for outlet obstruction without clinical suspicion of prostate cancer by digital examination. Each patient underwent fine-needle aspiration biopsy (FNAB) of each side of the prostate immediately before TURP. These data show that the addition of preprostatectomy FNAB increased the incidence of finding adenocarcinoma of the prostate from 10% to 14%. An additional 3% had FNAB results that were highly suspicious. A positive correlation between cytologic and histologic findings was seen in 83% of patients. Of three patients with Stage A2 prostate cancer, none had malignant cytologic findings. Of seven patients with Stage A1 disease, five (71%) had suspicious or malignant cytologic findings. Seven patients (7%) had suspicious or malignant cytologic findings with no histologic evidence of tumor. In conclusion, preprostatectomy FNAB cannot differentiate Stage A1 from Stage A2 prostate cancer. However, the procedure does increase the yield of finding incidental prostate cancer. The therapy of patients with either (1) malignant cytologic findings alone (Stage A0 disease), or (2) Stage A1 histologic and malignant cytologic findings (Stage A1+) is unclear at present.

Adrenal hemangioma: an unusual adrenal mass delineated with magnetic resonance imaging.

Adrenal hemangioma should be included in the differential diagnosis of any large calcified adrenal mass. We report to our knowledge the eighth surgically removed lesion and describe its appearance on magnetic resonance imaging. This imaging includes features seen in hemangiomas elsewhere, in particular a heterogeneous mass with enhancing peripheral high intensity foci on T1 images.