Doron S. Stember

Reproductive Sequelae of Diabetes in Male Patients

Diabetes mellitus (DM) is an increasingly prevalent public health concern. A recent study projected the number of people worldwide with DM to increase from 171 million in 2000 to 366 million in 2030. Although DM is a systemic disease that often leads to end-organ dysfunction of multiple body systems, the effects of the condition on male fertility are often not fully appreciated. DM is associated with multiple risk factors for reduced male fertility potential, including erectile dysfunction, various manifestations of ejaculatory dysfunction, and hypogonadism.

Preoperative Erectile Function Is an Independent Predictor for Decision to Spare Cavernous Nerves During Radical Prostatectomy

INTRODUCTIONnCavernous nerve sparing (NS) is critical for recovery of erectile function (EF) as well as erectile tissue preservation following radical prostatectomy (RP). Clinical experience suggests that surgeons may opt for non-NS RP in patients with impaired baseline EF.nnnAIMnThis study was performed to define if baseline EF is an independent predictor of NS status during RP.nnnMETHODSnA total of 2,323 mean (mean age 59u2009±u20097 years) who underwent RP at a tertiary referral academic medical center were retrospectively evaluated. Patients who underwent preoperative radiation therapy or androgen deprivation treatment were excluded.nnnMAIN OUTCOME MEASURESnPreoperative parameters evaluated included biopsy pathological characteristics, prostate-specific antigen (PSA) level, patient age, and EF. Baseline EF was graded on a validated five-point patient reported scale. NSS was graded intraoperatively by the surgeon, using a four-point NS score assigned to each nerve where 1u2009=u2009fully preserved, 2u2009=u2009partially preserved, 3u2009=u2009minimally preserved, and 4u2009=u2009resected. NS surgery was defined as NSS of 1 or 2 on both sides, and nerve resection surgery was defined as NSS of 3 or greater on both sides.nnnRESULTSnOn univariate analysis, factors related to nerve resection surgery included (all Pu2009<u20090.01): increasing age (ru2009=u20090.16), Gleason score (ru2009=u20090.19), EF score (ru2009=u20090.21), percentage biopsy cores positive (ru2009=u20090.11), higher preoperative PSA (relative risk [RR] 1.72, 95% confidence interval [CI] 1.23-2.40), and clinical stage ≥T2 (RR 2.17, 95% CI 1.68-2.78). On multivariable analysis, factors independently predicting for non-NS surgery included (all Pu2009<u20090.01): baseline EF (odds ratio [OR] 1.50, 95% CI 1.33-1.68), biopsy Gleason sum (OR 1.95, 95% CI 1.65-2.36), clinical T stage ≥T2 (OR 1.59, 95% CI 1.15-2.20), patient age (OR 1.07, 95% CI 1.04-1.09), and percentage of biopsy cores positive (OR 1.01, 95% CI 1.00-1.02).nnnCONCLUSIONSnWhile unfavorable clinical and prostate biopsy characteristics predict less NS, we have shown that poorer baseline EF also independently predicts for nerve resection RP. For every point increase in EF score (that is, worsening EF) the odds of not receiving NS during surgery increase by a factor of 1.5. Although NS is not associated with worse cancer outcomes in appropriately selected patients, failure to spare nerves is associated with poor post-operative EF, urinary continence, and increased severity of cavernous venous leak. Patient anxiety related to cancer diagnosis and impending treatment may lead to falsely-worsened apparent EF when recent erections are assessed during a pre-operative planning visit. For these reasons prostatectomists should consider NS based solely on factors other than patients baseline EF, even when it is impaired.

Aggressive angiomyxoma of the scrotum

INTRODUCTIONnAggressive angiomyxoma (AAM) is a rare, benign mass with propensity for local invasion and recurrence after resection. Infrequently, this tumor can be found arising from the scrotum or cord structures in males.nnnAIM/METHODSnA case report is presented followed by a review of relevant literature addressing the diagnosis, imaging, management and follow-up for aggressive angiomyxoma of the scrotum.nnnRESULTSnImaging can assist in further characterization of masses noted on physical exam. Scrotal sonography is typically the primary imaging modality utilized and magnetic resonance imaging is able to provide further anatomic detail. Treatment mainstay is surgical resection with necessary long term surveillance.

Sexual medicine disparities between Asia and North America: commentary on male sexual dysfunction in Asia

In a recently published article in Asian Journal of Andrology, Ho et al.1 examine prevalence, attitudes, and treatment patterns related to sexual dysfunction in Asia and contrast them with those of Western society. They highlight the relative paucity of data with respect to erectile dysfunction (ED), premature ejaculation, and hypogonadism in the Asian population. Although the authors make a commendable attempt to characterize sexual dysfunction in Asia, there are multiple factors that complicate interpretation of published prevalence rates. Confounding factors affecting interpretation of these studies include the methodology of identification of the studied cohorts, ages of study participants, survey response rates, definitions of ED, and strategies and lengths of time for data collection. n nBoth Asia and North America are comprised of diverse urban and rural communities and populations of widely varying educational backgrounds and socioeconomic classes. There is little doubt, therefore, that heterogeneous cultural factors influence reporting and treatment of sexual dysfunction on both continents. The rate of ED in the United States is commonly estimated to be 35%–50% of men aged 40–70 years.2, 3 In a review of epidemiologic studies of sexual dysfunction involving Asian countries (including several world studies that included Asian data and allowed for comparison between nations), Lewis demonstrated a wide variation in reported prevalence rates.4 For example, men in Thailand had an overall ED rate of 38%, compared with 20% for China, 15% for Korea and 2% for Malaysia. In all studies, however, prevalence rates increased with age. There was a 7%–15% overall ED prevalence in Asian studies for the 40–49 years age group, which increased to 39%–49% for men aged 60–70 years. North American, Latin, and Australian populations had similar age-related increases. n nThe authors of the present review focus on differences in attitudes and treatment between Asian and Western men with ED. They note that many Asian men are ‘suffering (sexual dysfunction) in silence in contrast to men living in Western societies, and suggest that cultural differences related to perception of masculinity may be a root cause. That being said, these same influences affect men and reporting of sexual dysfunction in all cultures. In New York City, we have the privilege to provide care to an exceptionally diverse patient population, including men from across the Asian continent. As in Asia, we routinely encounter patients who are primarily employing alternative and traditional medicine instead of, or along with, so-called “Western” medicine. Men may access these non-traditional therapies because they can be obtained in an anonymous way without divulging embarrassing sexual ‘failures. By definition, alternative medicines have not been subjected to standards of evidence-based demonstration of efficacy and are therefore minimally discussed during medical school and residency training in the United States. Accordingly, North American physicians are typically under-educated with respect to traditional medicine and tend to be skeptical regarding herbal therapy.5 Nevertheless, many patients in Asia and the United States rely on herbal medications. Xu and Levine reported that 11–30% of their patients were taking herbal medicines. They reported that when asked the question, ‘How useful do you consider herbal remedies to be in the treatment of your patients?, physicians responded with a median answer of 2 on a 5 point scale, with 5 valued as ‘very useful treatment of patients and 1 as ‘not at all useful.6 Given an increasingly diverse society with high levels of continued Asian immigration, we believe that Western physicians would benefit from more concrete and formal training with respect to alternative medicine and that these therapies should be subject to more rigorous evaluation and, perhaps, regulation. n nThe authors of the review cite cost, availability, lack of documented side effect profile, quality control, and inconsistent effects as important factors related to the ubiquitous utilization of alternative medications in Asia. In Western countries, as in Asia, a myriad of ‘natural products come with claims of improved sexual vitality and growth of the phallus. In a publication by MacKay, L-arginine, yohimbine, Panax ginseng, Maca, Ginkgo biloba, DHEA, and Tribulus terrestris were reviewed for efficacy in treating ED.3 The papers authors concluded that, although evidence-based trials were scarce, the treatments may yield some beneficial effects on penile endothelial tissue, although concern about potential side effects and drug interactions remains. Within the field of urology, there appears to be consensus regarding the need for more clinical and bench research into the efficacy and safety profiles of herbal and traditional medications. n nPerhaps the most intriguing disparity that exists between Asian and American cultures is the cultural differences in male health seeking behavior. These differences may persist even among Americans of Asian descent. It has been reported that Asian Americans felt that they were insufficiently involved in the decision making of their own care, perceived that the doctor did not spend enough time with them, and were less likely to agree that ‘physicians treat them with respect and dignity as compared with Caucasian Americans.7 In a study examining health beliefs among Chinese students in America, females were more likely than their male counterparts to obtain regular check-ups. The study further delineated the students perception of their parents in regard to accessing healthcare, and it was reported that the mothers were ‘more likely to seek preventive care and to get regular check-ups than their fathers.8 This alarming disparity in gender among Asian Americans reflects conclusions reached by the authors of the current review regarding Asians in Asia. n nThere is clearly a need for healthcare providers to gain the trust of Asian male patients and recognize perceived or real shortcomings regarding mutual respect and shared decision-making responsibilities. Greater understanding of alternative therapies for sexual dysfunction is important for patients outcomes and safety. Ongoing efforts by dedicated organizations in Asia, such as the Asia Pacific Society for Sexual Medicine, will be instrumental in removing cultural taboos and facilitating rational therapeutic approaches so that Asian men no longer have to suffer in silence.

Erectile Dysfunction: Treatment

The willingness to pursue treatment for xaderectile dysfunction (ED) is dependent on many factors but associated patient bother and distress is a key factor. Other relevant factors to consider include the presence of contraindications to therapy, the absence of partner, lack of willingness of partner to participate in sexual relations, and cost of treatment. As outlined in the other ED algorithms, some patients will have undergone extended evaluation and others will have forgone further assessment. While 50 % of men over 40 years of age have some degree of ED, less than 10 % ever seek treatment, presumably because many of them are not bothered by the ED and are capable of having satisfactory sexual relations despite their ED.

Azoospermia: Surgical Sperm Retrieval

Recent advances in techniques for surgical sperm retrieval and the advent of intracytoplasmic sperm injection (ICSI) allow for biological paternity in azoospermic men for whom the only xadavailable treatments a mere 20 years ago were use of donor sperm or adoption. Many procedures are available with which sperm may be retrieved from the epididymis and testis. These procedures vary significantly in efficacy, invasiveness, requirement for technical expertise, and indication. Informed procedure selection and proper technical performance are critical for achievement of optimal reproductive outcomes. The least traumatic method that yields sufficient high quality sperm to meet the couple’s immediate and future reproductive goals should be selected. Communication with the reproductive endocrinologist is critically important for delivery of optimal care to the couple. Sperm retrieval may either be performed electively with cryopreservation of retrieved sperm for ICSI to be performed at a later date (frozen approach), or it can be coordinated so that fresh sperm are available immediately following oocyte retrieval (fresh approach). The frozen approach has significant logistical advantages and is the xadpreferred approach by most experts for men with obstructive azoospermia, in whom an abundance of sperm are anticipated to be retrieved. Expert consensus varies when the patient has nonobstructive azoospermia. The literature suggests that fertilization rates and pregnancy outcomes of ICSI cycles using cryopreserved sperm are at least equivalent to outcomes in cycles using fresh sperm. However, there is a theoretical chance that no viable sperm will survive the freeze-thaw process, especially when very few sperm are retrieved.

Penile Deformity: Peyronie’s Disease

Peyronie’s disease (PD) is an acquired localized connective tissue disorder of the penile tunica albuginea. PD is characterized by changes in the collagen composition and the formation of fibrous plaques in the surrounding vascular tissue of the corpora cavernosum.

Low Semen Volume

Low semen volume refers to the consistent finding of low volume of ejaculated fluid on semen analysis. This is usually defined as a semen volume consistently less than 1.5 mL. It is important to remember that this semen parameter is highly variable and depends critically upon an appropriate abstinence period of at least 2 days prior to sample collection. Low semen volume (or perceived low semen volume) may be a bothersome symptom for which a man seeks clinical evaluation and treatment, or may be discovered during evaluation for subfertility.

Erectile Dysfunction: Extended Evaluation

In the ED: Initial Evaluation algorithm the patient had a thorough history, physical examination, and laboratory testing performed. At this stage the patient is ready to be treated (see ED Treatment algorithm). The purpose of the extended evaluation is twofold: (1) to define if the patient has underlying pathology that will impact upon the clinician’s management and (2) to attempt to give the patient a prognosis for his ED (i.e., to determine if the patient is curable or not.) The classic example of the former is a patient diagnosed with venous leak who has used PDE5i without much success. In this scenario, we would move this patient directly to penile injections and not reeducate him about PDE5i use or attempt any other PDE5i. Another example of this concept, based on the recent finding that ED is a harbinger of occult or future coronary artery disease, is the middle-aged healthy man who presents without overt vascular risk factors but has underlying arteriogenic ED revealed on testing. We would suggest to this patient that he seek cardiologic consultation. There is evidence that such men are at greater risk for having an abnormal cardiac stress test. From a prognostic standpoint, the classic example is someone who the clinician believes may have psychogenic ED, as all of such patients are potentially curable. From a causation standpoint, the vast majority of patients with ED have primarily organic ED and this is usually vasculogenic in nature. It is estimated that about 70 % of all men with primarily organic ED have underlying vascular risk factors such as diabetes, hypertension, dyslipidemia, cigarette smoking, or the metabolic syndrome. Such patients sometimes, although not always, have a prior history of vascular disease (myocardial infraction, peripheral vascular disease, or stroke). Other major causes of organic ED include (with approximate estimates) medications (10 %), pelvic surgery (10 %), endocrine problems (3 %), neurological problems (2 %), and other conditions (5 %, lower urinary tract symptoms related to BPH, sleep apnea syndrome, collagen vascular diseases). Thus, a good history and physical examination, combined with judicious use of laboratory testing, will help make most of the nonvascular diagnoses.

Azoospermia: Indeterminate Etiology

In some cases it may be difficult to xaddistinguish between obstructive and nonobstructive azoospermia based on the initial clinical evaluation. These indeterminate cases include patients with borderline clinical findings such as mild serum FSH elevations and mildly low testicular xadvolumes, as well as patients in which discrepancies exist between the clinical history, physical examination, and serum hormone evaluation. The classic approach in these cases has been performance of diagnostic testicular biopsy for direct histologic assessment of spermatogenesis and remains the gold standard for diagnostic evaluation. However, most experts (including the authors) advocate directly proceeding to exploratory surgery without performance of a separate testicular biopsy. The advantage of this approach is that it is both diagnostic and therapeutic, allowing for management of the patient with indeterminate azoospermia with a single procedure.