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Introduction: The connection between abstinence times and semen round cells and pyospermia is not well understood. However, frequent ejaculation is a commonly prescribed treatment for pyospermia. Objective: We sought to identify if a correlation exists between abstinence periods and round cells and semen leukocytes. Methods: We conducted a retrospective review of men presenting to a high-volume fertility center for evaluation who had semen samples assessed for leukocytes between 2/1/2022 and 1/1/2023. Azoospermic men and men with abstinence times over 14 days were excluded. We recorded round cells, the presence of leukocytes, and days of abstinence prior to the sample. The presence of leukocytes was detected using test strips which report a positive result if the concentration of leukocytes was greater or equal to 1 million/ml. The study received IRB approval. Pearson correlations (assumes linear relationship) were used as well as generalized additive models (GAMs), which allow for a non-linear relationship between abstinence and the outcome. For analysis of semen leukocytes, a positive result was coded as 1 and a negative result was coded as 0. Round cells were log-transformed prior to calculating correlation. The estimated relationships from GAMs were plotted graphically and summarized via average marginal slopes. Results: A total of 382 semen analyses were included, with a mean abstinence period of 3.67 days (SD: 2.11). The number of round cells ranged from 0.2 to 44.0 million (mean: 4.21 million, SD: 4.68), with 19.1% (n = 73) of samples testing positive for leukocytes. Days of abstinence and round cells are significantly correlated according to a Pearson correlation (r = 0.14, p = 0.006). According to the GAM, with each day increase in abstinence, a 0.52 million increase in round cells is expected (CI 0.25-0.79 million; p<0.05). There is an increase in round cells from 0 to 5 days of abstinence before plateauing. Beyond 10 days there is a large degree of uncertainty, due to a low number of observations. When patients with negative pyospermia tests were excluded, there is no linear correlation (r = 0.11, p = 0.36), however, the GAM appears similar to the original sample (1.2; 0.2, 2.1; p<0.05). Semen leukocytes and abstinence are not significantly correlated according to the Pearson correlation (r = -0.04, p = 0.38). There is little change in the probability of leukocytes being present with respect to abstinence in the GAM (-0.001; CI 2.3-2.1; p = 0.926). There is a similar increase in the degree of uncertainty over 10 days. Conclusions: These results demonstrate a statistically significant, yet very minimal linear correlation between round cells and days of abstinence. There is an increasing number of round cells up to 5 days of abstinence before plateauing. However, there was no significant correlation between abstinence time and the presence of leukocytes in the semen in either model. Shorter abstinence times may have a role in reducing semen round cells, but it is unlikely to reduce pyospermia. Providers should be hesitant when suggesting an increased frequency of ejaculation to treat pyospermia. Disclosure: No. [ABSTRACT FROM AUTHOR]

Introduction: Successful vasectomy is confirmed with post-vasectomy semen analysis (PVSA) completed eight to sixteen weeks after the procedure. However, compliance rates remain low throughout the literature with an estimated 34% to 58% of patients never receiving a PVSA. Objective: We sought to quantify the relationship between driving time and compliance with PVSA. Methods: A retrospective chart review was conducted of vasectomies provided by urologists from an academic hospital system between 4/1/2020 and 12/31/2022. Physicians who primarily performed in-office PVSA or referred patients to outside clinics were excluded from the study. Compliance with post-vasectomy semen analysis was defined as at least 1 PVSA sample submitted. In our study we considered variables including age, virtual or in-person preoperative visit, paternity, and driving time. The shortest driving time was calculated from each patient's residence to the single PVSA drop-off site using ArcGIS. The study received IRB approval. The factors associated with compliance were analyzed via multivariable logistic regression. Driving time, age at vasectomy, paternity, and preop location were included as predictors. Driving time and age were included as continuous variables. For driving time the odds ratio reflects the change in odds of PVSA per 30 minutes of driving; for age the odds ratio reflects the change in odds of PVSA per 10 years of age. A generalized additive model was used to explore a nonlinear relationship between driving time and PVSA compliance. Results: A total of 515 patients were included in the analysis. 296 patients obtained a PVSA (57.5%). Of those who obtained a PVSA, 41% took more than 16 weeks to do so. The median driving distance for those who obtained a PVSA was 18.9 miles (11.3, 26.4) and 22.3 miles (13.9, 34.3) for those who did not (p<0.01). The median estimated driving times for those who did and did not provide PVSA were 30.6 minutes (23.0, 42.1) and 34.2 minutes (25.5, 46.8) respectively (p<0.05). Adjusted for age, paternity, and pre-op location, each 30 minutes of driving time was associated with a 48% (63%, 27%) reduction in the odds of obtaining a PVSA (p<0.001). Age at vasectomy, paternity, and pre-op location were not found to be associated with decreased PVSA compliance. (Table 1). The generalized additive model shows a similar relationship between driving distance and compliance (Figure 1). Conclusions: These results demonstrate a statistically significant correlation between longer driving time to a drop-off site and probability of PVSA non-compliance. However, factors such as paternity, age at vasectomy, and pre-op visit format were not significant. Increasing access to semen analysis drop-off centers close to patients residences may serve to increase compliance with PVSA. At-home PVSA kits and in-office semen analyses are other options for reducing this barrier. Further research is needed to see if this relationship between driving time and compliance is seen in other aspects of medical care. Disclosure: No. [ABSTRACT FROM AUTHOR]

Introduction: Varicocele may be associated with pain and subfertility which comes with a range of treatment options, from observation to pain management to surgical correction. Urologists are defendants in more malpractice suits than the average physician and litigation may be a concern when determining their management strategy. Objective: The purpose of the study was to investigate the factors associated with malpractice litigation surrounding the management of varicoceles. Methods: Using the Casetext online legal database, we searched for cases with the query "(Malpractice and (Varicocele or Varicocelectomy))." Cases were only included if they were related to varicocele management. We documented the following variables: date of case, whether the plaintiff was incarcerated, alleged breaches of duty, alleged damages, and legal outcome. Data were analyzed using descriptive characteristics. Results: Our database search yielded a total of 26 cases. Of these, 10 were related to the management of varicocele and included in our analysis. The cases occurred between the years 1931 and 2022, with 60% (6/10) having happened since 2013. 60% (6/10) of the cases involved an inmate as the plaintiff. The alleged breaches of duty included violation of the 8th Amendment (50%, 5/10), with all those cases involving inmates; negligence (40%, 4/10); and disability discrimination (10%, 1/10). The most common alleged damages included pain (80%, 8/10), infertility (30%, 3/10), and loss of testicle (30%, 3/10). A urologist was included among the defendants in half the cases. Other defendants included prison wardens, healthcare institutions, prison complexes, and other physicians. The verdict in 90% (9/10) of these cases favored the defendant. The lone case which favored the plaintiff occurred in 1951, included a urologist in the defense, and involved a retained drain inside the scrotum which led to infection and ultimately orchiectomy. 100% (6/6) of the cases involving inmates favored the defendant. Conclusions: There have been relatively few legal cases on varicoceles, and most of them involved inmates. This may reflect differences in approach or treatment of urologic issues in inmates amongst medical care facilities. Violation of the 8th Amendment, which prohibits cruel and unusual punishment, was a common breach of duty alleged by incarcerated plaintiffs. However, all those cases favored the defense, with the explanation of these decisions often stating that the act of treating the varicocele, even if not successful, was proof that sufficient efforts were made. Most of the alleged damages involved pain because of insufficient or negligent treatment. Infertility as well as loss of testicle were less common claims. A major limitation of this study is that it does not capture cases which settled prior to trial. Nonetheless, providers should be reassured that malpractice claims regarding varicoceles are uncommon and that most cases are ruled in favor of the defense. Disclosure: No. [ABSTRACT FROM AUTHOR]

Introduction: Pyospermia may be due to infection or inflammation along the male reproductive tract. Semen round cells and leukocytes can have a major impact on the management of infertility yet we have a poor understanding of the natural history of patients with seminal round cells or pyospermia. Objective: We aimed to assess the intertest reliability of seminal leukocytes and round cells within serial semen analyses in patients without treatment. Methods: We conducted a retrospective review of men presenting to a high-volume fertility center for evaluation who had multiple semen analyses assessed for leukocytes between 2/1/2022 and 1/1/2023. Men with azoospermia or who received treatment for pyospermia including antibiotics or surgery in the interval between the tests were excluded. We recorded round cells, the presence of leukocytes, and days between tests. The presence of leukocytes was detected using QwikCheck™ Test Strips which report a positive result if the concentration of leukocytes was greater or equal to 1 million/ml. A Bland-Altman assessment of agreement was conducted to assess the agreement of the number of round cells between the first and second semen analysis. The limits of agreement (LoA) represent the 95% confidence intervals between which we expect most of the differences between measurements. The number of round cells was log-transformed prior to analysis as they were positively skewed. A Cohen Kappa test was used to assess the agreement between the presence of leukocytes in the first sample and the second sample. Results: One hundred patients were included in the analysis. The mean time between tests was 75 days (SD: 68.3 days) ranging from 1 to 285 days. There was a median of 2.95 million round cells in the initial semen analysis and 2.45 million round cells in the follow-up semen analysis. Nineteen patients had positive leukocytes on the initial sample and fifteen on the second sample. Eight patients had persistently positive leukocytes. The assessment of agreement for the round cells in the initial and follow-up semen analysis shows a lower LoA of 22% and an upper LoA of 582% meaning that most measurements of round cells in the follow-up tests are estimated to be between 22% and 582% of the initial measurement. The wide range of LoAs suggests poor agreement between tests. The kappa for the presence of leukocytes in the first and second sample was 0.36 (CI 0.13-0.60) which would be considered a fair agreement. Conclusions: Round cells and semen leukocytes are poorly understood but are used to aid in the diagnosis and management of male infertility. The number of round cells and the presence of pyospermia between samples varies greatly in patients even without treatment. Providers should consider these discrepancies prior to initiating treatment of pyospermia in men presenting for infertility. Further study is needed to gain a better understanding of how round cells and semen leukocytes should influence management of men with infertility. Providers should be cautious when using the presence of round cells or pyospermia to influence treatment as there is poor consistency between tests even without pyospermia treatment. Disclosure: No. [ABSTRACT FROM AUTHOR]

Online telehealth platforms are becoming increasingly common across several areas of medicine, including those related to men's health conditions. These ventures now offer virtual services for the evaluation of testosterone deficiency and treatment via the online sale of testosterone therapy (TTh). We sought to compare the cost of undergoing virtual evaluation and treatment with TTh via online telehealth platforms, as compared to what may be offered by a board-certified urologist following the American Urologic Association (AUA) guidelines at a tertiary care center. Google was queried to identify platforms that offer an online consultation and prescription service for TTh. Platforms that did not provide transparency of services including details of the initial consultation, laboratory work, type of medication offered, and associated fees on the company website were excluded. Information regarding the type of providers used, services and laboratory work included in the initial consultation, and price for the evaluation and three months of treatment with TTh were gathered. These were compared to the services and prices that a board-certified urologist at a tertiary care center may offer while following the AUA guidelines for the evaluation and management of testosterone deficiency. Costs for services at the tertiary care center were estimated using a single institution's online cost estimator1 for a patient with no insurance, a patient with basic employee insurance, and a patient with Medicare. A total of three online platforms met inclusion criteria: Hone, Regenex Health, and TRT Nation. The services provided for the initial evaluation and for follow up of patients on TTh were similar between the online platforms and those suggested by AUA guidelines (Table 1). The cost of the initial consultation including laboratory services were lowest for the patient with Medicare at a tertiary center ($0) and via the online platform, Hone ($45.00) (Table 2). The estimated cost for three months of treatment with TRT including follow up was lowest among the patient with Medicare ($32.79) and the patient with basic employee insurance ($192.58) at the tertiary center (Table 3). The cost of three months of treatment and follow up was highest via the online platform Regenex Health ($1,059.00). While online telehealth platforms may offer a cost benefit in the initial consultation and evaluation for TRT for some patients, the cost of ongoing treatment greatly exceeds that which may be obtained at a tertiary care center for patients with basic insurance plans or Medicare. Patients without insurance may encounter a high cost of initial evaluation at a tertiary center, however, ongoing follow up and medication costs for these patients is likely similar between select online platforms and a tertiary center. No [ABSTRACT FROM AUTHOR]

Men commonly turn to the internet for information prior to seeing a physician about erectile dysfunction (ED)[1]. Reddit is a popular and influential social media platform consisting of over 52 million users engaged in discussions regarding a vast array of topics[2]. Reddit can serve as a source of information for urologic conditions[3], but social media has been shown to contain unreliable information when it comes to erectile dysfunction[4]. References: 1. Ferguson, Tom, and Gilles Frydman. "The first generation of e-patients." (2004): 1148-1149. 2. Reddit by the Numbers." Reddit, www.redditinc.com/press. 3. Du, Chris, et al. "I leaked, then I Reddit: experiences and insight shared on urinary incontinence by Reddit users." International urogynecology journal 31.2 (2020): 243-248. 4. Fode, Mikkel, et al. "Quality of information in YouTube videos on erectile dysfunction." Sexual Medicine 8.3 (2020): 408-413. We sought to identify and characterize the types of ED therapies being discussed by users of the highly influential Reddit website. Two sub-reddit pages, "Ask Men" and "erectile dysfunction", were chosen for analysis. Posts within the erectile dysfunction sub-reddit were sorted by most popular over all time, and the top 50 threads discussing ED management with at least 2 comments were chosen for analysis. Within the Ask Men sub-reddit, the posts were filtered to include the words "erectile dysfunction". Of these threads, 35 were found to contain discussions relevant to ED treatment, and were thus selected for analysis. Each thread was evaluated for any recommendations for an ED therapy made by the users within the comments, and each therapy was evaluated for congruence with the American Urologic Associated (AUA) guidelines statements for the treatment of ED. The "erectile dysfunction" and "Ask Men" sub-reddit forums consist of 8,100 and 2.7 million members, respectively. A total of 57 different ED therapies were recommended within the 85 posts that were analyzed. Recommendations for changing sexual habits were the most common (29.8%), followed by seeking assistance from a medical professional or use of medications (21.2%), lifestyle changes (17.0%), and exercise practices (13.4%) (Figure 1). Less commonly recommended therapies included the use of supplements (10.7%), herbal remedies (3.9%), and dietary changes (3.9%). Specific therapies that were recommended most often included counseling from a physician, lowering anxiety or stress reduction, reducing porn, reducing masturbation, and discussing ED openly with a partner. Of the 57 specific treatments that were discussed, only 14 (24.6%) were in line with current AUA guidelines for the treatment of ED (Table 1). ED treatments are commonly discussed on Reddit, with a wide range of therapies being self-reportedly successful among users. Most of the treatments discussed are not supported by strong clinical evidence. An understanding of commonly discussed treatments is valuable for the physician, as this may represent an opportunity to educate the population and guide patient counseling. No [ABSTRACT FROM AUTHOR]

Introduction: Recent attention has been brought to physician fertility in the last decade, most notably amongst female physicians who suffer an increased risk of infertility compared to the general population. Various factors related to a career in medicine play a role, such as a delay in pursuit of childbearing, a demanding work schedule, shift work, and stress associated with the profession. However, risk of infertility in the male physician population has yet to be studied. Objective: Therefore, we sought to evaluate the experiences and childbearing patterns of a sample of American male physicians with special attention to timing of conception and childbearing, reflections upon professional and personal decision-making, and general knowledge regarding fertility. The primary objective of this study was to determine the incidence of infertility among American male physicians. Methods: Utilizing a third party to access the American Medical Association (AMA) database, licensed US physicians registered as male and between the ages of 18-65 were identified. Within this cohort, 690 men were randomly selected and contacted via paper mail (340) or email (350) and asked to participate in the survey study. Surveys were administered electronically via REDCap (obtained through a QR code) and included questions regarding the physicians' demographics, medical specialty, and whether they have attempted to conceive. Those who have attempted to conceive were also surveyed on their work experience at the time of their first attempt at conception and their experience and partner's experience with fertility and childbearing. Internal Review Board approval was obtained for this study (STUDY 20211036). Results: Fifty-three men responded to the survey (7.7%). All respondents were cisgender males with cisgender female partners. The majority (94.3%) had attempted to conceive and occurred most during residency (46.0%). The average age when first attempting conception was 31.6 years, and this was most commonly during residency (46.0%) or after training (30.0%). During this time, many (72.0%) were responsible for night shifts, overnight call duties, or both. In addition, as many as 34 men (68.0%) had no access to paid parental leave during this time. Of 50 men who attempted conception, 14 (28.0%) of their partners experienced a miscarriage. Eight men (17.0%) underwent a fertility workup, and 6 underwent infertility treatment(s). Only 4 respondents had insurance partially covering their infertility treatments, while the other two had no insurance coverage. Conclusions: Male physicians are often exposed to long work hours, nighttime duties, and sparse paid parental leave during the time of their first attempt at conception, most commonly in residency. Our cohort shows a high rate of miscarriage (28.0%) and infertility assessment (16.0%) among this population. Future studies are needed to continue characterizing fertility amongst physicians. Disclosure: No. [ABSTRACT FROM AUTHOR]