Jonathan P. Jarow

Evaluation of the azoospermic patient.

Azoospermia is found in up to 10 to 20 per cent of the men who present to an infertility clinic. The main causes are testicular failure and ductal obstruction. Testicular biopsy remains the definitive test used to differentiate these 2 disorders. A retrospective study of 133 azoospermic men was performed to determine the accuracy and limitations of noninvasive variables in predicting testicular failure in an effort to limit the need for diagnostic testicular biopsy. Of 49 patients (37 per cent) with ductal obstruction a third had bilateral vasal agenesis. The remaining 84 azoospermic patients (63 per cent) had testicular failure. The results of the complete evaluation of these patients are described. Among the 101 patients with a testicular biopsy confirmed diagnosis there was a significant difference in testicular size (p less than 0.001), ejaculate volume (p less than 0.001) and serum follicle-stimulating hormone (p less than 0.001) between patients with testicular failure and those with ductal obstruction. The sensitivity and specificity of various parameters were determined. The best criteria to predict ductal obstruction preoperatively are a serum follicle-stimulating hormone level of less than 2 times greater than normal and the absence of bilateral testicular atrophy (100 per cent sensitivity and 71 per cent specificity). An algorithm for evaluation of the azoospermic patient is described such that all men with ductal obstruction and a minimal number with testicular failure undergo testicular biopsy.

Effect of diabetes mellitus upon male reproductive function.

D iabetes leads to metabolic abnormalities involving regulation of carbohydrate metabolism. These abnormalities produce pathology in a variety of organ systems; ophthalmopathies, neuropathies, nephropathies, and vasculopathies, among many other medical derangements, may be present. Insulin-dependent diabetics are believed to have a genetic predisposition activated by environmental events, which results in an autoimmune reaction to insulin-producing cells. Islet-cell antibodies are formed that deplete the B-cell population within the pancreas, leading to deficiencies in insulin secretion.’ The pathogenesis of noninsulin-dependent diabetes mellitus (NIDDM) is less understood, but it is thought that insulin resistance precedes the disease and that a positive family history is the most important risk factor for developing the disease. Researchers are unsure whether insulin resistance is sufficient for the development of NIDDM or whether it simply unmasks a primary B-cell defect2 Most of the attention and information concerning sexual function in the male diabetic has overwhelmingly been focused upon the diagnosis, incidence, etiology, and therapeutic intervention of impotence. Although diabetes is one of the major etiologies of organic impotence, our review seeks to define the effects of diabetes upon male reproductive function, which is distinct from potency. The male reproductive system can be divided into three components analogous to renal physiology: pretesticular (hypothalamic-pituitary-gonadal axis, endocrine control), testicular (spermatogenesis), and posttesticular (ejaculation). Diabetes mellitus may have a deleterious effect upon any or all of these aspects, and the available data from

PENILE TRAUMA: AN ETIOLOGIC FACTOR IN PEYRONIE'S DISEASE AND ERECTILE DYSFUNCTION

PURPOSEnIt has been postulated that trauma to either the partially or fully erect penis is a potential cause of Peyronies disease. In addition, it has been proposed that engaging in sexual relations with a partial erection due to mild impotence is a risk factor for the development of Peyronies disease. This study was performed to determine whether patients with either Peyronies disease or non-Peyronies disease impotence had an increased rate of penile trauma compared with potent controls.nnnMATERIALS AND METHODSnWe mailed surveys to 207 men who had been seen for management of Peyronies disease, 250 impotent men without Peyronies disease, and 275 age-matched urologic patients without a history of either impotence or Peyronies disease. The survey inquired whether the individual had a history of penile trauma to the flaccid or erect phallus or injury during sexual intercourse. In addition, patients were questioned whether they had been engaging in sexual relations with a partial erection.nnnRESULTSnThe mean age of the impotent patients was slightly less than both the Peyronies disease patients and controls. A similar response rate to the survey was found among the 3 groups. The mean duration of illness was 6 years for Peyronies disease and 10 years for impotence. The frequency of penile trauma of any kind was significantly greater in both the Peyronies disease (40%) and impotence (37%) patients than in the controls (11%). There was no significant difference between the Peyronies disease and impotence groups. However, the Peyronies disease patients had a lower frequency of attempting sexual relations with a partial erection than the 2 other groups.nnnCONCLUSIONSnThe results of this survey demonstrate a significantly higher incidence of penile trauma in both impotent patients and patients with Peyronies disease compared with controls. This study demonstrates an association between penile trauma and both Peyronies disease and impotence. The reduced incidence of engaging in sexual relations with a partial erection among the Peyronies disease patients implies that partial impotence is not a predisposing factor for Peyronies disease.

RISK FACTORS FOR PENILE PROSTHETIC INFECTION

PURPOSEnWe determined the risk factors for penile prosthesis infections.nnnMATERIALS AND METHODSnThe records of 156 men undergoing 167 procedures for insertion of a penile prosthesis were reviewed. The device was implanted during a primary uncomplicated procedure in 114 cases. Simultaneous penile reconstruction was performed in 23 cases. A malfunctioning penile prosthesis was replaced or repaired immediately following removal in 30 cases. Minimum followup was 1 year.nnnRESULTSnThe infection rate was 1.8% after insertion of a penile prosthesis in 114 men without previous penile surgery compared to 21.7% for procedures requiring reconstruction of the corpora, which was significantly different (p < 0.01). The infection rate after revision of a penile prosthesis was 13.3%, which was significantly greater than that following primary uncomplicated implantation (p < 0.05) but not different from that for patients requiring reconstruction (p = 0.5). There was no difference in patient age, etiology of impotence or associated medical disorders among the 3 groups. Operative time was significantly longer for patients requiring penile reconstruction than for the other 2 groups (p < 0.01).nnnCONCLUSIONSnThe risk of infection is significantly greater when penile reconstruction is required, and appears to be related to increased duration of surgery. The increased risk of infection associated with revision of a penile prosthesis cannot be explained by patient characteristics or operative time.

Puboprostatic Ligament Sparing Improves Urinary Continence After Radical Retropubic Prostatectomy

OBJECTIVESnTo determine whether a puboprostatic ligament-sparing technique of prostatic apical dissection provided improved urinary continence after radical retropubic prostatectomy.nnnMETHODSnA total of 43 men with clinically localized prostate cancer underwent radical retropubic prostatectomy (standard apical dissection in 25, puboprostatic ligament-sparing technique in 18). Patients were evaluated by independent observer questionnaire to determine their continence status. The questionnaire was tested in a control group of 25 men who had not undergone prostate surgery. The overall continence rate and time to achieve continence was compared between the two surgical groups. In addition, the clinical and pathologic stages and both the rate and location of positive margins were assessed.nnnRESULTSnMean patient age and serum prostate-specific antigen values were not significantly different between the two groups. Clinical and pathologic stages were also similar. The mean follow-up period for the puboprostatic ligament-sparing group was 35 weeks compared with 57 weeks for the standard group (P < 0.05). The median time until continence was achieved after surgery was significantly shorter (P = 0.01) for the puboprostatic ligament-sparing group than for the standard method (6.5 and 12 weeks, respectively). However, the overall continence rate at 1-year follow-up for the two groups was similar (100% and 94%, respectively). The positive margin rate and location of positive margins were not different with the puboprostatic ligament-sparing technique.nnnCONCLUSIONSnThe puboprostatic ligament-sparing technique improves the rapidity of return of urinary continence after radical prostatectomy without significantly enhancing overall continence or interfering with the therapeutic efficacy of the procedure.

Seminal improvement following repair of ultrasound detected subclinical varicoceles.

PURPOSEnWe determined whether repair of subclinical varicoceles detected by scrotal duplex ultrasonography results in significant seminal improvement and identified the best ultrasonographic criteria to use in the selection of patients for subclinical varicocelectomy.nnnMATERIALS AND METHODSnOf 256 consecutive infertile men being evaluated by physical examination and color duplex scrotal ultrasonography 76 underwent varicocele repair and were followed with serial semen analyses. All subclinical varicoceles were confirmed by venography. The outcome of varicocelectomy was determined by changes in total motile sperm count and compared among patients with different clinical grades of varicoceles and ultrasonographically measured in veins sizes.nnnRESULTSnA significant overlap was observed between ultrasonographically measured venous diameter and clinical grade of varicocele. There was no correlation between venous diameter and postoperative outcome when controlled for clinical grade. Significant postoperative improvement in semen parameters was noted in 67% of patients with clinical and only 41% with subclinical varicocelectomy (p<0.05). The best ultrasonographic cutoff to predict a positive outcome after subclinical varicocelectomy was venous diameter greater than 3mm. Patients with larger clinical varicoceles had greater postoperative seminal improvement than those with small or subclinical varicoceles regardless of baseline sperm count.nnnCONCLUSIONnVaricocele size has a direct impact on the probability and amount of seminal improvement after varicocelectomy. Outcome following subclinical varicocelectomy is significantly less than after repair of clinical varicoceles. Although 41% of patients with subclinical varicoceles had significant postoperative improvement in semen parameters, an equal number were worse postoperatively and, thus, mean sperm count was unchanged for the group. The results of our study suggest that subclinical varicocelectomy is of questionable benefit.

Outcome Analysis of Goal Directed Therapy for Impotence

PURPOSEnWe assessed patient preference, satisfaction and overall outcome of goal directed management of erectile dysfunction.nnnMATERIALS AND METHODSnThe results of goal directed therapy of impotence were assessed by an independent telephone survey of 377 consecutive men who had not received prior therapy and who were followed for a minimum of 2 years.nnnRESULTSnPatients preferred medical to surgical therapies despite significantly higher satisfaction rates achieved with surgery. Average number of treatment modalities chosen by each patient was 2 (range 0 to 5). Ultimately, only 40% of the patients achieved a long-term satisfactory result with goal directed therapy. The remainder were not satisfied with the last treatment but chose no further therapy, were lost to followup or refused therapy from the outset.nnnCONCLUSIONSnOur results clearly demonstrate a patient preference for the least invasive forms of therapy. Patients avoid significantly more effective but also more invasive treatment options despite unsatisfactory results with less invasive methods. Future research efforts should be concentrated on the development of new medical therapies to enhance overall patient satisfaction.

Ipsilateral Testicular Hypotrophy is Associated With Decreased Sperm Counts in Infertile Men With Varicoceles

PURPOSEnThe presence of ipsilateral testicular growth retardation (hypotrophy) is the most common indication for prophylactic varicocele repair in adolescents in an effort to prevent future infertility. We examined the relationship between semen parameters and ipsilateral versus contralateral testicular size in men with unilateral varicoceles to determine whether testicular size is an appropriate parameter for predicting future fertility.nnnMATERIALS AND METHODSnWe studied the records of consecutive patients with palpable unilateral left varicoceles for whom a history, physical examination and semen analysis were available. Total motile sperm counts of men with and without ipsilateral testicular hypotrophy were compared.nnnRESULTSnWe identified 611 patients with unilateral clinical left varicoceles, including 305 (50%) with ipsilateral testicular hypotrophy. Mean total motile sperm counts plus or minus standard error of mean were significantly less in the patients with than without testicular hypotrophy (80 +/- 5.2 versus 126 +/- 7.8 x 10(6) sperm, p = 0.0018). Hypotrophy was more common in patients with large varicoceles (73%) than in those with medium (53%) or small (43%) varicoceles.nnnCONCLUSIONSnInfertile patients with testicular hypotrophy associated with unilateral varicoceles have worse semen parameters than those without hypotrophy. These data support the practice of varicocele repair in adolescents with varicocele associated testicular growth retardation.

Transrectal ultrasonography of infertile men

OBJECTIVEnTo determine normal transrectal ultrasonographic anatomy in young men and the frequency of abnormalities in the infertile population.nnnDESIGNnTransrectal ultrasonography was performed upon 30 fertile volunteers and 150 consecutive men referred for male factor infertility.nnnSETTINGnA male fertility center.nnnRESULTSnTransrectal ultrasonography was normal in 60% of controls and 53% of infertile group. The frequency of hyperechoic lesions within the prostate was similar in controls (40%) and infertile men (39%). Müllerian duct cysts were present in 11% of the infertile men and none of the volunteers. Rectal exam was normal in all of the men.nnnCONCLUSIONSnTransrectal ultrasonography is more sensitive at detecting abnormalities of the seminal vesicles and prostate than rectal exam. Hyperechoic lesions within the prostate is frequently a normal finding. Müllerian duct cysts are more frequently observed in infertile men and may be a cause of ejaculatory duct obstruction.

Seminal Vesicle Aspiration in the Management of Patients with Ejaculatory Duct Obstruction

Ejaculatory duct obstruction is a rare but significant cause of male factor infertility. Vasography is the current gold standard for the diagnosis of complete obstruction of the ejaculatory ducts. However, there is currently no reliable method to diagnose partial obstruction. We performed seminal vesicle aspiration under transrectal ultrasonographic guidance in 11 infertile men to assess the use of this diagnostic test in the evaluation and management of patients with ejaculatory duct obstruction. The absence of sperm within the seminal vesicle aspirate from 8 patients who had sperm in the ejaculate demonstrates that sperm are not normally present within the seminal vesicles. Numerous motile sperm were observed in the seminal vesicle aspirate from an azoospermic patient in whom vasography documented complete ejaculatory duct obstruction, demonstrating that sperm can reflux into the seminal vesicles in patients with distal obstruction. Two patients with suspected partial ejaculatory duct obstruction had sperm in the seminal vesicles. In conclusion, sperm are not normally present within the seminal vesicles and ejaculatory duct obstruction should be suspected in any patient with numerous sperm within the seminal vesicles.