Etiology of azoospermia in a military population.

PURPOSE: Male infertility is commonly seen at urology clinics and 10% to 20% of infertile males are found to be azoospermic. Azoospermia is classically categorized as nonobstructive or obstructive. This classification tailors the evaluation, diagnosis and proper treatment. We performed a retrospective study to provide an updated etiology of azoospermia in patients in the United States in a universal health care model. MATERIALS AND METHODS: We retrospectively reviewed the records of men with azoospermia who presented to our institution between 2004 and 2012. Laboratory data were analyzed, included semen analysis, follicle-stimulating hormone, luteinizing hormone, testosterone, semen fructose and genetic studies. Patients underwent scrotal exploration as indicated for testis biopsy and sperm extraction. RESULTS: We reviewed 139 outpatient records. Nonobstructive azoospermia was diagnosed in 99 men (71%), including 33 (34%) identified with Sertoli-cell only syndrome. Other etiologies included an idiopathic cause in 25 cases (26%), Klinefelter syndrome in 9 (9%), maturation arrest in 9 (9%), Y chromosome microdeletion in 5 (5%), cryptorchidism in 4 (4%), trauma in 4 (4%), exogenous testosterone supplementation in 4 (4%) and other genetic disorders in 6 (6%). Obstructive azoospermia was identified in 40 men (29%), of whom 16 (40%) had congenital bilateral absence of the vas deferens. Other etiologies included an idiopathic cause in 11 cases (28%), an iatrogenic condition due to a surgical cause in 5 (13%), ejaculatory duct obstruction in 3 (8%), trauma in 1 (3%), retrograde ejaculation in 1 (3%), vas deferens occlusion in 2 (5%) and unilateral absence of the vas deferens in 1 (3%). CONCLUSIONS: This study delineates the etiology of azoospermia in men with universal access to care.

Lower prevalence of varicoceles in obese patients found on routine scrotal ultrasound.

PURPOSE: Research shows that obese patients have a lower incidence of varicoceles. Increased adipose tissue, which makes physical examination difficult, was hypothesized to be the cause. We evaluated the varicocele incidence on routine scrotal ultrasound to see whether difficult physical examination was causative. MATERIALS AND METHODS: We reviewed all scrotal ultrasounds from the last 2 years for men 18 to 40 years old who had a recorded body mass index. Physical examination findings and the indication for ultrasound were included. We used standard criteria for ultrasound detected varicoceles. National Institutes of Health criteria was used to classify patients as normal-body mass index less than 25 kg/m(2), overweight-25 to 30 or obese-greater than 30. RESULTS: Of the 1,079 patients 330 (30.6%) had an ultrasound detected varicocele. Mean ± SD body mass index in those with vs without a varicocele was 26.7 ± 3.8 vs 26.0 ± 3.7 kg/m(2) (p = 0.04). On physical examination 171 patients (16.0%) had a varicocele. Mean body mass index in those with vs without a varicocele on physical examination was 26.6 ± 3.7 vs 26.4 ± 3.9 kg/m(2) (p = 0.09). We calculated varicocele frequency by body mass index for ultrasound detected varicoceles only. Of 374 normal weight patients 129 (34.5%) had a varicocele while in the overweight and obese groups 163 of 535 (30.6%) and 43 of 170 (25.6%), respectively, had a varicocele. The difference between normal and obese patients was statistically significant (p = 0.04). CONCLUSIONS: Obese patients have a lower prevalence of varicoceles detected by ultrasound. The lower prevalence is independent of physical examination and more likely due to another factor.

Survey of Sexual Function and Pornography.

INTRODUCTION: We aimed to explore and describe the pornography habits of young men and women. Given recent upward trends in pornography use and erectile dysfunction, along with a plausible pathophysiology, we hypothesized that pornography use would correlate with sexual dysfunction. MATERIALS AND METHODS: Institutional Review Board approval was obtained. Surveys were distributed to 20-40 year old men and women presenting to a urology clinic. Information was collected on demographics and medical history. Sexual function was evaluated with the International Index of Erectile Function (IIEF) in men and the Female Sexual Function Index in women. Extent of potential addiction to pornography was measured with the pornography craving questionnaire and the obsessive passion scale. Pornography use was measured based on both frequency and duration, and analyzed relative to sexual dysfunction. RESULTS: Men used pornography significantly more frequently than women (81.1% vs. 39%). Computer and cellular phone image viewing were the most popular modalities in both sexes. There was no association between IIEF and craving for, or obsessive passion for, pornography. Preference for pornography with masturbation was found to be significantly associated with erectile dysfunction (p = 0.001). Rates of erectile dysfunction were lowest in those preferring partnered sex without pornography (22.3%) and increased significantly when pornography was preferred over partnered sex (78%). No correlation was found between any variables and female sexual dysfunction. CONCLUSIONS: Pornography and sexual dysfunction are common among young people. No clear relationship exists between extent of addiction to pornography and sexual dysfunction in either gender. However, men who prefer masturbation with pornography to partnered sex have a significantly increased risk of sexual dysfunction. Given sexual dysfunction may be associated with mental health concerns, further evaluation of its causes and impact on military operational readiness are warranted.

Transureteral saline perfusion to obtain renal hypothermia: potential application in laparoscopic partial nephrectomy.

BACKGROUND: Partial nephrectomy for resection of renal tumors often requires renal artery clamping and external renal cooling using ice-slush. Laparoscopic surgery precludes traditional ice-slush cooling. To facilitate renal cooling during laparoscopic partial nephrectomy, we investigated a method of intrarenal cooling by retrograde transureteral iced saline perfusion. METHODS: Open laparotomy was performed in 6 pigs. After atraumatic renal artery clamping, one kidney was cooled externally by using standard ice-slush; the other was cooled transureterally. For transureteral cooling, the ureter was cannulated with a double lumen 12 Fr catheter. Chilled saline (4 degrees C) irrigation was flushed through the catheter into the renal pelvis (16.7 mL/min) and allowed to drain via the second lumen of the catheter. Using a 30-gauge hypodermic thermometer, kidney temperatures were measured at 5-minute intervals for 30 minutes at 3 locations and 2 depths (0.5 cm and 1.5 cm). The animals were euthanized, and the kidneys were harvested for histologic examination. RESULTS: Renal cooling was achieved with both external and transureteral cooling. However, lower (5.0 versus 26.1 degrees C, P<0.001) parenchymal temperatures were achieved more rapidly with external renal cooling. During transureteral cooling, medullary (1.5 cm) temperatures were lower than cortical (0.5 cm) temperatures were; this difference did not reach statistical significance. CONCLUSIONS: Although renal hypothermia can be achieved by transureteral iced saline infusion, external cooling by using ice-slush appears to be more efficient in the porcine model. With refinement of the technique, intrarenal cooling via a transureteral approach may allow more effective cooling of the renal medulla, and limit warm ischemia during laparoscopic partial nephrectomy.

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

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

Operating characteristics of follicle-stimulating hormone in azoospermic men.

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

Demographics of Men Receiving Vasectomies in the US Military 2000-2009.

BACKGROUND: We hypothesize that there is a higher incidence of vasectomy within the military at a younger age based on this equal access health care system. MATERIALS AND METHODS: A review of the CHAMPS military database was conducted for men receiving vasectomies from 2000 to 2009. Age at vasectomy, number of children, race, religion, and marital status were recorded and incidence was computed. RESULTS: Total of 82,945 vasectomies was performed. The overall incidence to have a vasectomy was approximately 7.10 per 1000 men. The highest rate of occurrence was 14.4 per 1000 men in men 30-34 years old. Whites had a higher rate than blacks at 10.03 per 1000 men compared to 6.27 per 1000 men. Protestants had the highest rate at 8.44 per 1000 men, and Jewish people had the lowest at 1.86 per 1000 men. Married men had a rate of 12.3 per 1000 men, whereas single men were 1.03 per 1000 men. CONCLUSIONS: The incidence to have a vasectomy in the military was 7.10 per 1000 men, with an age adjusted rate at 8.66 per 1000 men. This information may assist primary care providers in discussing vasectomies as a permanent form of contraception.

Bilateral testicular infarction and orchiectomy as a complication of polyarteritis nodosa.

We report an unusual case of a 28-year-old male with constitutional symptoms and bilateral testicular pain. After diagnosis of cytomegalovirus (CMV) hepatitis, his constitutional symptoms and testicular pain worsened despite treatment for epididymoorchitis. Ultrasound was concerning for infarction. Exploration in the operating room revealed bilateral testicular infarction requiring bilateral orchiectomy with subsequent androgen hormone replacement. Pathologic diagnosis was polyarteritis nodosa (PAN). PAN is a rare systemic vasculitis that affects multiple organs. There are no previous reports of PAN-induced vasculitis leading to bilateral testicular infarction and bilateral orchiectomy.

Practice patterns in vasectomy reversal surgery: results of a questionnaire study among practicing urologists.

PURPOSE: Although vasectomy reversal surgery is a common procedure for male factor infertility, little is written on the common practice patterns of the practicing urologist. We designed a questionnaire to assess the practice patterns of community and academic urologists with respect to surgical technique, followup care, patient selection and the definition of success. MATERIALS AND METHODS: A 20-question survey pertaining to vasectomy reversal surgery was mailed to members of the Western Section, American Urological Association and to members of the Society of Government Service Urologists. Survey results were tabulated in a computer data base and statistical analysis was performed. RESULTS: A total of 1,508 questionnaires were mailed and 622 completed questionnaires were returned. Of the respondents 367 (59%) indicated that they perform vasectomy reversals, including 29 (8%) who were fellowship trained in infertility, 86 (23%) who were affiliated with residency training and 252 (69%) who practiced in a community setting. As expected, on average fellowship trained urologists performed more reversals yearly than academic or community urologists (26.4, 12.2 and 7, respectively). Patient selection criteria varied. Of fellowship trained urologists 12.5% would elect not to operate if it were greater than 15 years since vasectomy compared with 41.9% for academic and 57.1% of community urologists. Just more than half (50.2%) of respondents indicated they did not recommend routine gynecologic evaluation of the patient partner. When comparing fellowship, academic and community practitioners, an operating microscope was used in 93%, 65% and 56% of procedures (p <0.001), and vasal fluid was examined in 83%, 75% and 67%, respectively. Fellowship trained urologists also used finer suture material (p <0.001). An average of 8 anastomotic sutures were placed in 2 layers but significant differences existed between fellowship trained urologists, and their academic and community counterparts. Most urologists (71%) defined their success by the presence of sperm in the ejaculate. Only 10.9% of urologists recommended sperm cryopreservation at surgery and 90% recommended postoperative sexual abstinence (average 3 weeks). All urologists recommended postoperative semen analysis done at an average of 3 months. CONCLUSIONS: The practice of vasectomy reversal varies among urologists. Differences in surgical technique, postoperative care and selection criteria exist. Knowledge of these variations may assist practicing urologists to tailor their practice patterns in the selection for and performance of vasectomy reversal.

Palliative transurethral prostate resection for bladder outlet obstruction in patients with locally advanced prostate cancer.

PURPOSE: The outcome of patients with advanced prostate cancer undergoing palliative transurethral resection of the prostate (TURP) is not well defined in the literature. We determined the preoperative characteristics, operative morbidity and postoperative outcomes of patients with advanced prostate cancer undergoing palliative TURP and compared these outcomes to those of patients undergoing TURP for benign prostatic hyperplasia (BPH). MATERIALS AND METHODS: A retrospective review of all patients with prostate cancer undergoing palliative TURP at a single institution between 1994 and 2001 was performed. Operative reports, and outpatient and inpatient records were reviewed. Serum prostate specific antigen, and cancer grade and stage at cancer diagnosis were compared with findings at TURP. Operative statistics, postoperative outcomes and complication rates were compared between the palliative prostate cancer TURP group and a large cohort of 520 patients undergoing TURP at our institution for BPH during the same period. The Fisher exact and 1-sample t test were used to determine statistical differences in outcomes between these 2 groups. RESULTS: A total of 24 palliative TURPs were performed in 19 patients. At prostate cancer diagnosis mean patient age was 68.7 years (range 49 to 87) and median prostate specific antigen +/- SD was 39.7 +/- 78.3 ng/ml (range 1.5 to 334). Radiation therapy was the initial treatment in 11 patients (58%) and the remainder received initial hormonal therapy. Mean age at TURP was 74.2 years (range 50 to 91) with an average time from prostate cancer diagnosis to TURP of 49.7 months (range 1 to 196). While only 22.7% of the patients had high grade cancer (Gleason score 8 to 10) at cancer diagnosis 67% were determined to be high grade at palliative TURP (p = 0.001). After TURP the mean urinary flow rate decreased from 9.6 to 7.3 cc per second (p = 0.453) and the International Prostate Symptom Score improved from 21.1 to 11 (p = 0.002). Compared with patients undergoing TURP for BPH those treated with palliative TURP were more likely to have failure of the initial voiding trial (p <0.001), and require reoperation (p <0.001), chronic drainage (p = 0.001) and re-catheterization for bleeding or obstruction (p = 0.056). CONCLUSIONS: Palliative TURP can be performed safely in patients with advanced prostate cancer with significant improvement in urinary symptoms. However, the rates of postoperative urinary retention and reoperation are higher than in patients undergoing TURP for BPH.

A prospective, randomized pilot trial of acupuncture of the kidney-bladder distinct meridian for lower urinary tract symptoms.

PURPOSE: We performed a pilot trial to assess the response of lower urinary tract symptoms and prostate specific antigen (PSA) to acupuncture in a population of patients biopsy negative for prostate cancer. MATERIALS AND METHODS: A total of 30 patients were randomly assigned to 1 of 3 study groups, including observation for 3 months with 6 blood samples for PSA at set intervals, 9 sessions of acupuncture in 3 months to points of the kidney-bladder distinct meridian expected to treat the prostate with 6 blood samples for PSA at set intervals and 9 sessions of acupuncture in 3 months to points not expected to treat the prostate with 6 blood samples for PSA at set intervals. The effect of acupuncture on lower urinary tract symptoms was assessed monthly using the International Prostate Symptom Score. RESULTS: Trend analysis (repeated measures ANOVA) revealed no significant changes in the 3-month period in the randomized arms. Statistical analysis showed p = 0.063 for the International Prostate Symptom Score, p = 0.945 for PSA and p = 0.37 for the free-to-total PSA ratio. CONCLUSIONS: Acupuncture to the kidney-bladder distinct meridian neither relieves lower urinary tract symptoms nor impacts PSA.