Search

Objective: To assess the association of common sleep disorders with female sexual dysfunction.Materials and Methods: We conducted a cross-sectional analysis using the TriNetX Diamond Network. Adult women diagnosed with insomnia, obstructive sleep apnea, or circadian rhythm sleep disorder were assessed to determine the association with female sexual dysfunction, hypoactive sexual desire disorder, female orgasmic disorder, and female sexual arousal disorder. A propensity-score matched control cohort for age, race, ethnicity, tobacco use, outpatient service utilization, obesity, hyperlipidemia, diabetes mellitus, hypertensive disease, ischemic heart disease, and surgical procedures on the female genital system was generated, excluding those with any sleep disorders, sleep deprivation, or morbid obesity with alveolar hypoventilation. All cohorts excluded those with any antidepressant or antipsychotic prescriptions.Results: Our query yielded 1,317,491 women diagnosed with sleep apnea, 1,538,567 with insomnia, and 58,902 with circadian rhythm sleep disorder. Women with sleep apnea and insomnia had higher odds of hypoactive sexual desire disorder, female sexual arousal disorder, and female orgasmic disorder compared to matched controls. Women with sleep apnea, insomnia, or circadian rhythm sleep disorder all had a significantly higher odds of female sexual dysfunction compared to matched controls.Conclusions: In this large cross-sectional analysis, sleep disorders were strongly associated with female sexual dysfunction. It is thus crucial for providers to screen for poor sleep when conducting a thorough evaluation for sexual dysfunction in women to diagnose highly prevalent sleep disorders and improve overall health. [ABSTRACT FROM AUTHOR]

Background: Secondary analyses of the Testosterone Replacement Therapy for Assessment of Long-Term Vascular Events and Efficacy Response in Hypogonadal Men (TRAVERSE) trial revealed significantly higher rates of new-onset atrial fibrillation (AF) and acute kidney injury (AKI) in the testosterone replacement therapy (TRT) cohort., Aim: To validate the secondary findings of the TRAVERSE trial., Methods: We utilized the TriNetX Research Network to identify a cohort of men ages 45-80 years old who met similar inclusion criteria to the TRAVERSE trial. We compared hypogonadal men (testosterone 100-300 ng/dL) who had a prescription for topical testosterone therapy and men who did not. Propensity score matching was used to match patient populations. Kaplan Meier survival analysis was used to determine the relative risk of new-onset AF and AKI within 3 years., Outcomes: New-onset AF and AKI within 3 years., Results: There were 2134 men included in each cohort after propensity score matching. Men on TRT had significantly lower testosterone (T) at the time of diagnosis compared to men not prescribed TRT (207 ± 66 ng/dL vs 246 ± 140 ng/dL, P < 0.001). Kaplan-Meier survival analysis showed a significantly increased risk of AKI among men on TRT (RR 1.53, 95% CI 1.07-2.18). However, TRT was not associated with a significantly increased risk of new-onset AF (RR 1.48, 95% CI 0.93-2.37)., Clinical Implications: Hypogonadal men with underlying cardiovascular risk factors or pre-existing cardiovascular disease who receive TRT may be at increased risk of AKI after starting therapy., Strengths and Limitations: We evaluated a large global research database and utilized similar inclusion and exclusion to the TRAVERSE trial. However, our results are limited by the retrospective study design and reliance on documented claims data., Conclusion: Similar to the TRAVERSE trial, our study demonstrated an increased risk of AKI among men on TRT, but did not find increased risk of AF. However, further studies are required to validate these results., (© The Author(s) 2024. Published by Oxford University Press on behalf of The International Society for Sexual Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: To study improvements in spermatogenesis in men with a history of testosterone therapy using a novel fertility treatment regimen., Design: A single-center retrospective cohort analysis., Setting: Clinic., Patient(s): Seventy-seven men with previous testosterone use seeking fertility treatment from January 2020 to March 2024., Intervention(s): A treatment regimen of 3,000 IU of human chorionic gonadotropin (hCG) and 75 IU of follicle-stimulating hormone (FSH) three times a week was used., Main Outcome Measures(s): The primary outcome measured was change in sperm concentration during hCG/FSH therapy. The secondary outcome measured was whether concurrent testosterone therapy during hCG/FSH therapy affected recovery of spermatogenesis., Result(s): Within the entire cohort (n = 77), 74% of men demonstrated improvements in their sperm concentrations. There was not a significant difference in recovery of sperm concentration in men who stayed on testosterone therapy during hCG/FSH reboot (no testosterone therapy [n = 50], 74% improved, vs. concurrent testosterone therapy [n = 27], 74% improved)., Conclusion(s): We report optimal recovery of spermatogenesis with hCG/FSH therapy in men with infertility with a history of testosterone use. Concurrent testosterone therapy does not impede hCG/FSH-mediated spermatogenic recovery., Competing Interests: Declaration of Interests B.T.S. has nothing to disclose. A.G.O. has nothing to disclose. K.J.C. has nothing to disclose. J.P.L. has nothing to disclose. T.P.K. has nothing to disclose. J.M.A. has nothing to disclose. J.B.H. has nothing to disclose. L.I.L. has nothing to disclose., (Copyright © 2024 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

While vulvar lichen sclerosus (VLS) causes intense pruritus, associated risks of mood disorders and prescription patterns and impact of concurrent sexual dysfunction are unknown. We queried TriNetX Diamond Network between 2009 and 2022, conducting three comparisons after propensity-score matching for demographics and relevant comorbidities: (1) women with lichen sclerosus (LS) sparing the vulva vs. women with VLS; (2) VLS patients who received treatment within 6 months of diagnosis vs. patients who did not and (3) VLS patients with vs. without sexual dysfunction. Outcomes included new depressive episodes, anxiety disorder, major depressive disorder (MDD), and prescriptions of antidepressants or benzodiazepines. After matching, VLS was associated with increased depressive episode [risk ratio (RR) 1.39], anxiety disorder (RR 1.93), and MDD (RR 2.00) diagnoses compared to LS sparing the vulva. Next, VLS treatment was associated with decreased risk of depressive episode (RR 0.60) and anxiety disorder (RR 0.72). Finally, concurrent sexual dysfunction was associated with increased benzodiazepine (RR 3.50), vaginal estrogen (RR 6.20), antipruritic agents (RR 3.90), and topical anti-inflammatory (RR 2.61) prescriptions. In conclusion, vulvar involvement is associated with increased risk of antidepressant and benzodiazepine prescriptions, and diagnosis of depressive episode, anxiety disorder, or MDD., (© 2023. The Author(s), under exclusive licence to Springer Nature Limited.)

It is unknown if the risk of erectile dysfunction (ED) following Coronavirus-19 (COVID-19) infection is virus-specific. Our study assessed the risk of ED in COVID-19 patients as compared to patients with other common viral infections. The TriNetX COVID-19 Research Network was queried. We examined cohorts of men aged ≥18 years infected with: COVID-19, influenza, respiratory syncytial virus, enterovirus, acute viral hepatitis, mononucleosis, and herpes zoster. Men were included if they had at least one outpatient follow-up visit within 18 months and excluded if they had one of the other viruses of interest or a prior ED diagnosis or treatment, prostatectomy, pelvis radiation, or chronic hepatitis infection. Cohorts were propensity score matched and compared for differences in new ED diagnosis and/or prescription of phosphodiesterase-5 inhibitors (PDE5i). COVID-19 positive men were less likely to develop ED or have a PDE5i prescription than men with infected with herpes zoster [Relative Risk (RR): 0.37, 95% Confidence Interval (CI) 0.27-0.49] and more likely to develop ED or have a PDE5i prescription than men with no acute viral illness (RR: 1.33, 95% CI 1.25-1.42). In this national propensity-matched cohort study comparing post-infection ED risk and PDE5i prescriptions, we found that COVID-19 was no more likely to result in a diagnosis of ED or prescription of PDE5i when compared to all acute viral illnesses except herpes zoster, which was more likely to result in a diagnosis of ED or prescription of PDE5i when compared to COVID-19. These findings suggest an inflammatory etiology (perhaps due to cytokine release, endothelial dysfunction, or blunted hormone signaling) behind any acute infection can result in a heightened ED risk; however, further studies are required to investigate the connection between other viral infections and ED., (© 2023. The Author(s), under exclusive licence to Springer Nature Limited.)

We investigated the prevalence, incidence, and rates of pharmacological treatment of delayed ejaculation using the TriNetX Diamond Network. We included all men evaluated in the inpatient, outpatient, and emergency settings. Prevalence was determined by comparing the number of men diagnosed with delayed ejaculation to the entire population. Incidence was determined by comparing the number of men diagnosed with delayed ejaculation without a prior diagnosis to the overall population without a prior diagnosis. Rates of pharmacologic treatment were calculated by comparing the number of men who received a prescription to the total number of men with delayed ejaculation. Trends in prevalence and incidence were compared using six-month intervals, while trends in pharmacologic treatment were compared using one-year intervals. A total of 23,164 adult males were diagnosed with delayed ejaculation from 2013 to 2019. During the final six-month interval (July to December 2019), 2,747 of 16,496,744 men received a delayed ejaculation diagnosis, and 1,375 of 16,488,270 men without a prior diagnosis were diagnosed with delayed ejaculation. In 2019, only 916 of 4,733 (19.4%) men diagnosed with delayed ejaculation received any prescription, with the most common being testosterone (9.5%), bupropion (6.6%), and buspirone (2.3%). Prevalence, incidence and pharmacologic treatment all had increasing trends., (© 2024. The Author(s), under exclusive licence to Springer Nature Limited.)

Male hypogonadism is not a risk associated with attention-deficit hyperactivity disorder (ADHD) stimulant medications, but recent studies have explored this connection. Though the pathophysiologic connection remains unclear, we predicted that long-term use of ADHD stimulant medications could increase the risk of hypogonadism in post-pubertal males. Utilizing TriNetX, LLC Research Network data from January 2000 through December 2019, men older than 18 with ADHD receiving long-term stimulant medication (>36 monthly prescriptions) were selected for the study population. Two control groups were constructed: individuals with ADHD but no stimulant medication use, and individuals without ADHD or stimulant medication use. A diagnosis of testicular hypofunction (ICD-10: E29.1) within five years of long-term ADHD stimulant medication use was the chosen primary outcome. After propensity score matching, 17,224 men were analyzed in each group. Of the men with long-term ADHD stimulant medication use, 1.20% were subsequently diagnosed with testicular hypofunction compared to 0.67% of individuals with ADHD without stimulant medication use (RR: 1.78, 95% CI: 1.42-2.23) and 0.68% in men without ADHD or stimulant medication use (RR: 1.75, 95% CI: 1.39-2.19). Therefore, chronic ADHD stimulant medication use was found to be significantly associated with a subsequent diagnosis of testicular hypofunction., (© 2023. The Author(s), under exclusive licence to Springer Nature Limited.)

No study has yet assessed the risk of developing erectile dysfunction (ED) after a diagnosis of long COVID, defined by the Centers for Disease Control and Prevention as the persistence or presence of new symptoms at least 4 weeks after initial SARS-CoV-2 infection, when compared to those diagnosed with acute COVID or cases in which more severe treatment is required. To assess these risks, we queried the TriNetX COVID-19 Research Network from December 1st 2020 through June 2023. Men aged ≥ 18 diagnosed with long COVID were compared to those diagnosed with acute COVID and analyses were performed to compare men who were/were not hospitalized within 1 month of acute COVID diagnosis and men who did/did not need vasopressors. Cohorts were propensity score matched and compared for differences in new ED diagnosis and/or prescription of phosphodiesterase-5 inhibitors (PDE5i). After propensity score matching, the long and acute COVID cohorts included 2839 men with an average age of 54.5±16.7 and 55.1±17.1 years respectively (p = 0.21). Men with long COVID were more likely to develop ED or be prescribed PDE5i (3.63%) when compared to men with only acute COVID infections (2.61%) [RR 1.39; 95% CI 1.04, 1.87]. There was no statistically significant risk of developing ED or being prescribed PDE5i for individuals who received vasopressors [RR 0.92; 95% CI 0.77,1.10] or were hospitalized [RR 0.93; 95% CI 0.82,1.06]., (© 2024. The Author(s), under exclusive licence to Springer Nature Limited.)

Semaglutide was approved in June 2021 for weight loss in non-diabetic, obese patients. While package inserts include sexual dysfunction as a side effect, no study has assessed the degree of this risk. The objective of our study is to assess the risk of developing erectile dysfunction after semaglutide is prescribed for weight loss in obese, non-diabetic men. The TriNetX Research database was used to identify men without a diagnosis of diabetes ages 18 to 50 with BMI > 30 who were prescribed semaglutide after June 1st, 2021. Men were excluded if they had a prior erectile dysfunction diagnosis, any phosphodiesterase-5 inhibitors prescription, intracavernosal injections, penile prosthesis placement, history of testosterone deficiency, testosterone prescription, pelvic radiation, radical prostatectomy, pulmonary hypertension, or were deceased. We further restricted our cohort to non-diabetic, obese men by excluding men with a prior diabetes mellitus diagnosis, a hemoglobin A1c > 6.5%, or having ever received insulin or metformin. Men were then stratified into cohorts of those that did and did not receive a semaglutide prescription. The primary outcome was the risk of new ED diagnosis and/or new prescription of phosphodiesterase type 5 inhibitors at least one month after prescription of semaglutide. The secondary outcome was risk of testosterone deficiency diagnosis. Risk was reported using risk ratios with 95% confidence intervals (95% CI). 3,094 non-diabetic, obese men ages 18-50 who received a prescription of semaglutide were identified and subsequently matched to an equal number cohort of non-diabetic, obese men who never received a prescription of semaglutide. After matching, average age at index prescription for non-diabetic, obese men was 37.8 ± 7.8 and average BMI at index prescription was 38.6 ± 5.6. Non-diabetic men prescribed semaglutide were significantly more likely to develop erectile dysfunction and/or were prescribed phosphodiesterase type 5 inhibitors (1.47% vs 0.32%; RR: 4.5; 95% CI [2.3, 9.0]) and testosterone deficiency (1.53% vs 0.80%; RR: 1.9; 95% CI [1.2, 3.1]) when compared to the control cohort of non-diabetic men who never received a semaglutide prescription., (© 2024. The Author(s), under exclusive licence to Springer Nature Limited.)

Purpose: This meta-analysis aimed to determine the efficacy and safety of antioxidant supplementation for treating erectile dysfunction (ED)., Materials and Methods: We systematically searched MEDLINE, Embase, and the Cochrane Library for double-blind, randomized, placebo-controlled trials of oral antioxidant supplementation in men with ED. Erectile function was assessed by the International Index of Erectile Function-Erectile Function domain (IIEF-EF) score. Using random-effects meta-analysis models, antioxidant and placebo groups were compared for erectile function using the mean difference in IIEF-EF score adjusted to a 6-30 scale and for side effects using the log risk ratio., Results: The review included 23 trials of 1,583 men (median age 51 years) treated with antioxidant supplementation or placebo for a median of 12 weeks (range, 4 weeks to 6 months). Antioxidant supplementation significantly improved erectile function compared to placebo, with a mean difference of 5.5 points (95% confidence interval [CI]: 3.7 to 7.3; p<0.001) on the IIEF-EF. In meta-regression, the treatment benefit was greater in men with more severe ED (p<0.001). Side effects were uncommon, none were serious, and the frequency was comparable between antioxidant (3.8%) and placebo (2.1%) groups (log risk ratio=0.36; 95% CI: -0.24 to 0.97; p=0.24)., Conclusions: Antioxidant supplementation appears safe and significantly improves erectile function in men with ED, particularly those with more severe symptoms. Limitations of this review included unknown long-term efficacy and safety and the inability to make specific product and dosing recommendations due to the variety of antioxidants and regimens studied., Competing Interests: RR reports consultancy with Boston Scientific., (Copyright © 2024 Korean Society for Sexual Medicine and Andrology.)

Introduction: The objective of this study was to assess the rates of surgical shunting and prosthesis placement for acute ischemic priapism using a large multi-institutional claims database., Methods: A US claims database network (TriNetX Diamond Network) was queried from 2010 to 2020. We constructed a cohort of men ages ≥ 16 years who (1) had a diagnosis of priapism and (2) underwent an irrigation of the corpora cavernosa for priapism. We assessed the number of men who then had a surgical penile shunt or penile prosthesis placement. Demographics, time to surgical procedure, and order of procedures were collected., Results: A total of 6392 men were identified with the diagnosis of priapism and the procedure of corpora cavernosal irrigation. Of these men, 693 (11%) proceeded to surgical shunt. One hundred forty-four men (2%) underwent initial penile prosthesis placement. Of the men undergoing initial penile prosthesis, only 17 of 144 (12%) cases occurred within the first month of corpora cavernosal irrigation. Finally, when assessing choice of initial shunts vs initial penile prosthesis before and after 2015, overall rates of initial shunt (10.0% vs 8.5%, P < .0001) and initial prosthesis (3.1% vs 2.1%, P < .0001) were lower after 2015 when compared with rates prior to 2015., Conclusions: In this US claims-based analysis of men presenting with ischemic priapism and treated with initial irrigation, a small percentage (11%) of men went on to receive surgical shunting, and only 2% received an initial prosthesis. Men receiving initial prostheses were more likely to have more comorbidities, and overall surgical management of priapism has decreased over time.

Our objective was to analyze the rates of erectile dysfunction and Peyronie's disease following a penile fracture using a large, multi-institutional claims database. Inclusion criteria included men ages 15 or older with a diagnosis of penile fracture and any office visit within 5 years of the penile fracture. Exclusion criteria included prior erectile dysfunction, prescription of erectile aids, or penile prosthesis placement. Our primary outcome was the diagnosis of erectile dysfunction or prescription of phosphodiesterase-5 inhibitors within 5 years. A secondary analysis assessed rates of Peyronie's disease following penile fracture. 1242 men were identified with penile fracture and subsequently matched to men without penile fracture, resulting in equal cohorts of 1227 men. Men with a history of penile fracture were more likely to receive a diagnosis of erectile dysfunction or require phosphodiesterase-5 inhibitors (RR 3.18, 95% CI: 2.30-4.40). Men who did not undergo immediate repair had higher rates of erectile dysfunction or treatment (RR: 1.84, 95% CI: 1.22-2.78). Men over the age of 45 years who had a penile fracture were more likely to develop erectile dysfunction or treatment compared to men under 45 years (RR: 1.65, 95% CI: 1.14-2.39). Rates of Peyronie's disease were higher in men with a history of penile fracture (5.8% vs 0%, p < 0.0001). Rates of Peyronie's disease were lower if immediate repair of the fracture was performed (RR: 0.20, 95% CI: 0.10-0.41). Men over the age of 45 years with penile fracture were more likely to develop Peyronie's Disease within 5 years compared to men under the age of 45 years penile fracture (RR: 3.72, 95% CI: 1.94-7.16). Penile fracture increases the risk of both erectile dysfunction and Peyronie's disease, especially those treated with conservative measures or over the age of 45 years compared to patients under 45 years with a penile fracture., (© 2023. The Author(s), under exclusive licence to Springer Nature Limited.)

Purpose: Elevated hematocrit (Hct) can result in increased risk of major adverse cardiovascular events (MACE) in men receiving testosterone therapy (TTh). However, the impact of the magnitude of the change in Hct from baseline after starting TTh has never been assessed., Materials and Methods: To assess whether an increase in Hct after initiating TTh is associated with an increased risk of MACE within 3 and 24 months of initiating TTh, we queried the TriNetX Research network database for men over the age of 18 with Hct values obtained within 6 months before starting TTh, and who had follow-up Hct measurements within 3 and 24 months after beginning TTh from 2010 to 2021. Men with and without a subsequent increase in Hct after initiating TTh were propensity matched. MACE was defined as myocardial infarction, stroke, or death., Results: After matching, 10,511 men who experienced an any increase in Hct after initiating TTh and an equal number of controls who did have an increase in Hct were included. Compared to controls who did not have an increase in Hct after starting TTh, the men who had an increase in subsequent Hct had a significantly increased risk of MACE compared to men with no change in Hct., Conclusions: We demonstrate that increases in Hct from baseline are associated with increased risk of MACE, compared to men whose Hct remains stable while receiving TTh.

The relationship between male genitourinary conditions and sleep disorders has previously only been reported in single-institution studies with small cohorts. Our objective was to assess the association of erectile dysfunction (ED) and testosterone deficiency with various sleep disorders using a large claims database. The TriNetX Diamond database was queried in June 2022. In men aged 40-70 years, insomnia, sleep apnea, and circadian rhythm sleep disorder were each independently assessed to determine the association with ED and testosterone deficiency and then followed by propensity score matching performed for age, hypertension, hyperlipidemia, diabetes mellitus, ischemic heart disease, tobacco usage, and obesity. Testosterone deficiency was more likely to be found in men diagnosed with sleep apnea (odds ratio (OR) 1.66 [95% confidence interval (CI) 1.65-1.67]), insomnia (OR 1.74 [95% CI 1.73-1.76]), and circadian rhythm dysfunction (OR 2.63 [95% CI 2.54-2.73]) compared to matched controls. ED was more likely to be found in men diagnosed with sleep apnea (OR 1.02 [95% CI 1.01-1.03]), insomnia (OR 1.30 [95% CI 1.30-1.31]), and circadian rhythm dysfunction (OR 1.54 [95% CI 1.49-1.59]) compared to matched controls. Our results emphasize the negative impact of poor sleep on diseases of the male genitourinary system by identifying these relationships in the largest cohort in the U.S. reported to date., (© 2022. The Author(s), under exclusive licence to Springer Nature Limited.)

Introduction: Bladder exstrophy (BE), cloacal exstrophy (CE), and epispadias (E) are variants of the exstrophy-epispadias complex (EEC). These children require opioids and benzodiazepines to achieve pain management and immobilization for a lifetime of surgeries. It is hypothesized that these children would be sensitized to opiates and benzodiazepines as adults. The objective was to identify incidence of opiate and benzodiazepine use in adult EEC patients., Methods: A US Health network, TriNetX Diamond was queried from 2009 to 2022. Incidence of prescriptions for benzodiazepines and opioids were calculated for adults aged 18-60 years with a diagnosis of BE, CE, or E., Results: A total of 2627 patients were identified: 337 with CE, 1854 patients with BE, and 436 with E. Of these, 55.5% of CE, 56.4% of BE, and 41.1% of E had received any opioid prescription. Non-EEC controls had lower rates of opioids at 0.3%. E had a lower likelihood than BE or CE of receiving opioids (p < 0.0001, p < 0.0001). Benzodiazepines were prescribed in 30.3% of CE, 24.4% of BE, 18.3% of E, and 0.1% of controls. CE had a higher likelihood of benzodiazepines than both BE and E (p = 0.022, p < 0.001, respectively). E group had the lowest likelihood of benzodiazepine prescription (p = 0.007 when compared to BE) and all groups were significantly higher than controls (p < 0.0001 for all comparisons). For BE, females were more likely to be prescribed opioids (p = 0.039) and benzodiazepines (p = 0.027) than males. Sub-analyses revealed BE females had higher rates of surgical procedures (general, cardiac, gastrointestinal, and maternity) and chronic diagnoses (generalized anxiety disorder, major depressive disorder, chronic pain) compared to males with BE. Older age was associated with higher likelihood of opioid or benzodiazepine prescriptions in BE (p < 0.001), CE (p = 0.004), and E (p = 0.002)., Discussion: Across the EEC, adult patients with the most severe anomalies of CE were more likely to have received opioids and benzodiazepines. Females with BE were prescribed more opioid and benzodiazepines than males with BE. Mirroring the US population, female sex and increasing age were associated with higher rates of prescriptions, chronic diagnoses, and surgical procedures. Limitations include the lack of granular data and ability to correlate results with childhood surgeries., Conclusion: Adult EEC patients have higher rates of opioid and benzodiazepine prescriptions, with a high percentage of co-prescribing when compared to healthy controls. Across the spectrum, those with more severe anomalies, female sex, and increasing age were more likely to have received prescriptions., Competing Interests: Conflicts of interest None., (Copyright © 2023 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Purpose: The aim of this study was to assess whether there is an association between vasectomy and benign prostatic hyperplasia with associated lower urinary tract symptoms (BPH/LUTS) due to inflammatory etiology., Materials and Methods: We assessed the incidence of BPH/LUTS in men who had undergone vasectomy in a matched cohort analysis using the TriNetX Research Network. We identified men aged 30 to 60 years who underwent vasectomy and had a follow-up visit within 6 months to 5 years after vasectomy from January 2010 through December 2022 and compared them with matched controls. Outcomes recorded include diagnoses of BPH (N40, N40.1), BPH-related medication prescriptions, and BPH-related procedures. We accounted for confounding variables through propensity score-matching for age; race; and history of comorbid medical conditions: hyperlipidemia (International Classification of Disease-10: E78), metabolic syndrome (E88.81), overweight or obesity (E66), testicular hypofunction (E29.1), hypertension (I10-I16), nicotine dependence (F17), and obstructive sleep apnea (G47.33)., Results: There was no significant difference in BPH diagnosis between postvasectomy men vs controls (0.84% vs 0.80%, RR: 0.95, 95% CI 0.86-1.05) or BPH/LUTS diagnosis (0.48% vs 0.44%, RR: 0.92, 95% CI 0.81-1.05) within 6 months to 5 years after vasectomy, respectively. No differences in BPH medication prescription (0.94% vs 0.84%) or rate of BPH procedures (0.022% vs 0.017%) were detected between the 2 groups., Conclusions: This study suggests that vasectomy does not increase the risk of BPH development and/or LUTS worsening compared with the general population, providing assurance to both patients and health care providers who may consider vasectomy as a safe family planning option., Competing Interests: DECLARATIONS OF INTEREST None.

Importance: Although the use of perioperative pain medications is highly investigated, limited studies have examined the usage of pain medication for post hysterectomy prolapse repair and the few that have have been restricted to smaller sample sizes., Objective: Our objective was to assess the association of perioperative opioid usage after posthysterectomy prolapse repairs with development of new persistent opioid usage., Study Design: The TriNetX Diamond Research Network was queried to create our cohorts of opioid-naive adult women with vaginal repair or laparoscopic sacrocolpopexy. The primary study outcomes were (1) the rate of perioperative opioid usage and (2) development of new persistent opioid usage. All cohorts were matched on age, race, ethnicity, chronic kidney disease, hypertensive diseases, ischemic heart disease, diseases of the liver, obstructive sleep apnea, affective mood disorders, pelvic and perineal pain, obesity, tobacco use, and utilization of office/outpatient, inpatient, or emergency department services., Results: We identified 10,414 opioid-naive women who underwent laparoscopic sacrocolpopexy and 13,305 opioid-naive women who underwent vaginal reconstruction. Rates of perioperative opioid usage were higher after laparoscopic sacrocolpopexy. Rates of developing new opioid usage were higher in both surgical-approach populations that received perioperative opioids compared with those that did not. Rates of new and persistent opioid usage did not differ by surgical approach when stratified by perioperative opioid usage., Conclusions: We identified that opioid dependence may occur after surgery if patients are given opioids within 7 days of either approach, associating opioid dependence with perioperative opioid usage rather than the approach taken., Competing Interests: The authors have declared they have no conflicts of interest., (Copyright © 2023 American Urogynecologic Society. All rights reserved.)

The symptoms of testosterone deficiency have been known throughout history with evidence dating back to the twenty-first century BCE when men were castrated to be docile and obedient servants. Experimentation ingesting mammalian testicles began during the reign of the Roman empire and continued through the nineteenth century with claims that the substance found within these testicles could improve energy, erectile function, and urination. In the twentieth century, studies transplanting animal testes onto other castrated animals suggested that a substance produced in the testicle was responsible for systemic effects. Then in 1929, Adolf Butendant was the first to isolate testosterone and shortly after synthetic formulations of testosterone were created. While testosterone therapy is an important treatment for testosterone deficiency, the history of testosterone therapy has not been without abuse from doping scandals in the twentieth century and the use of testosterone therapy for conversion therapy and treatment of psychiatric disease. Today, there are clear and appropriate clinical uses of testosterone set by the American Urological Association to treat clinically significant testosterone deficiency. Still, even with such guidelines, the potential for misuse and abuse remains high in physicians and athletes. There is a long history that has led to the development of testosterone therapy and when used appropriately can significantly improve the quality of life for men with testosterone deficiency., (© 2022. The Author(s), under exclusive licence to Springer Nature Limited.)

Hemoglobinopathies are autosomal recessive disorders that occur when genetic mutations negatively impact the function of hemoglobin. Common hemoglobinopathies that are clinically significant include sickle cell disease, alpha thalassemia, and beta thalassemia. Advancements in disease-modifying and curative treatments for the common hemoglobinopathies over the past thirty years have led to improvements in patient quality of life and longevity for those who are affected. However, the diseases, their treatments and cures pose infertility risks, making fertility preservation counseling and treatment an important part of the contemporary comprehensive patient care. Sickle cell disease negatively impacts both male and female infertility, primarily by testicular failure and decreased ovarian reserve, respectively. Fertility in both males and females with beta thalassemia major are negatively impacted by iron deposition due to chronic blood transfusions. Hematopoietic stem cell transplant (HSCT) is currently the only curative treatment for SCD and transfusion dependent beta thalassemia. Many of the conditioning regimens for HSCT contain chemotherapeutic agents with known gonadotoxicity and whole-body radiation. Although most clinical studies on toxicity and impact of HSCT on long-term health do not evaluate fertility, gonadal failure is common. Male fertility preservation modalities that exist prior to gonadotoxic treatment include sperm banking for pubertal males and testicular cryopreservation for pre-pubertal boys. For female patients, fertility preservation options include oocyte cryopreservation and ovarian tissue cryopreservation. Oocyte cryopreservation requires controlled ovarian hyperstimulation (COH) with ten to fourteen days of intensive monitoring and medication administration. This is feasible once the patient has undergone menarche. Follicular growth is monitored via transvaginal or transabdominal ultrasound, and hormone levels are monitored through frequent blood work. Oocytes are then harvested via a minimally invasive approach under anesthesia. Complications of COH are more common in patients with hemoglobinopathies. Ovarian hyperstimulation syndrome creates a greater risk to patients with underlying vascular, pulmonary, and renal injury, as they may be less able to tolerate fluids shifts. Thus, it is critical to monitor patients undergoing COH closely with close collaboration between the hematology team and the reproductive endocrinology team. Counseling patients and families about future fertility must take into consideration the patient's disease, treatment history, and planned treatment, acknowledging current knowledge gaps., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Bedrick, Kohn, Pecker and Christianson.)

Context: Penile prosthesis is a durable and effective treatment for erectile dysfunction (ED). Even as other treatment options for ED have been brought to market, penile prosthetic surgery remains a mainstay for urologists treating ED. No systematic study has yet summarized the global trends in penile prosthetic surgery., Objective: To systematically review studies of trends in penile prosthetic surgery to determine global movements in implantation rates, malleable versus inflatable prosthetic surgery, inpatient versus outpatient implantation surgery, proportion of men with ED undergoing penile prosthetic surgery, and prosthetic cost., Evidence Acquisition: A systematic review of MEDLINE, EMBASE, Cochrane Library, and ClinicalTrials.gov was performed for studies assessing trends in penile prosthetic surgeries and costs associated with penile prosthetic device and inclusive surgical costs., Evidence Synthesis: Twenty-seven studies were identified during the systematic review, comprising 447,204 penile prosthetic surgeries reported from 1988 to 2019. A trend analysis demonstrates that rates of penile prosthetic surgery declined dramatically in the late 1980s and early 1990s, but have demonstrated modest growth since the mid-2000s. Outpatient inflatable penile prosthetic surgery has strongly trended upward. Costs of penile prosthetic device have matched the rate of inflation, but inclusive surgical cost has radically outpaced inflation. Growth has mainly been seen in the USA, with a more modest global growth., Conclusions: Penile prosthesis remains a viable option for the treatment of ED. Trends such as outpatient surgery and inflatable penile prosthesis placement may be driving the recent steady growth of penile prosthetic surgeries, but surging inclusive surgical cost may present a barrier for some patients without insurance coverage., Patient Summary: Penile prostheses continue to be an important treatment for erectile dysfunction. While the volume of penile prosthetic surgeries dropped when phosphidiesterase-5 inhibitors became available, prosthetic surgery is becoming more patient centric, as seen by increases in inflatable prosthetic placement and outpatient surgery., (Copyright © 2021 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Adoption of the prostatic urethral lift (PUL) as a treatment for benign prostatic hyperplasia highlights the importance of training residents with novel technology without compromising patient care. This study examines the effect of resident involvement during PUL on patient and procedural outcomes. Retrospective chart review was conducted on all consecutive PUL cases performed by a single academic urologist between October 2017 and November 2019. Trainees in post-graduate year (PGY) 1-3 are considered junior residents, while those in PGY 4-6 are senior residents. The International Prostate Symptom Score (IPSS) and quality of life (QOL) scores were used to measure outcomes. Simple and mixed-effects linear regression models were used to compare differences. There were 110 patients with a median age of 66.4 years. Residents were involved in 73 cases (66.4%), and senior residents were involved in 31 of those cases. Resident involvement was not associated with adverse perioperative outcomes with respect to the number of implants fired, the percentage of implants successfully placed, or the postoperative catheterization rate. After adjustment for confounding factors, junior residents were associated with significantly longer case length compared to the attending alone (+12.6 min, P = 0.003) but senior residents were not (+2.4 min, P = 0.59). IPSS and QOL scores were not significantly affected by resident involvement (P = 0.12 and P = 0.21, respectively). The presence of surgeons-in-training, particularly those in the early stages, prolongs PUL case length but does not appear to have an adverse impact on patient outcomes., Competing Interests: None

Many azoospermic men do not possess mature spermatozoa at the time of surgical sperm extraction. This study is a systematic review and meta-analysis evaluating outcomes following round spermatid injection (ROSI), a technique which utilizes immature precursors of spermatozoa for fertilization. An electronic search was performed to identify relevant articles published through October 2018. Human cohort studies in English involving male patients who had round spermatids identified and used for fertilization with human oocytes were included. Fertilization rate, pregnancy rate, and resultant delivery rate were assessed following ROSI. Meta-analysis outcomes were analyzed using a random-effects model. Data were extracted from 22 studies involving 1099 couples and 4218 embryo transfers. The fertilization rate after ROSI was 38.7% (95% confidence interval [CI]: 31.5%-46.3%), while the pregnancy rate was 3.7% (95% CI: 3.2%-4.4%). The resultant delivery rate was low, with 4.3% of embryo transfers resulting in a delivery (95% CI: 2.3%-7.7%). The pregnancy rate per couple was 13.4% (95% CI: 6.8%-19.1%) and the resultant delivery rate per couple was 8.1% (95% CI: 6.1%-14.4%). ROSI has resulted in clinical pregnancies and live births, but success rates are considerably lower than those achieved with mature spermatozoa. While this technique may be a feasible alternative for men with azoospermia who decline other options, couples should be aware that the odds of a successful delivery are greatly diminished and the prognosis is relatively poor., Competing Interests: None

Recent data suggest that cystic fibrosis transmembrane conductance regulator (CFTR) gene alterations negatively impact male fertility beyond obstruction. We sought to compare gene alterations, sperm retrieval rates, and intracytoplasmic sperm injection (ICSI) outcomes among men with cystic fibrosis (CF) disease and congenital bilateral absence of the vas deferens (CBAVD) only. We retrospectively evaluated all men who underwent surgical sperm retrieval at two academic, high-volume andrology centers from 2010 to 2018. Only men with documented CFTR alterations and obstructive azoospermia from either CBAVD or CF were included. Differences between groups for CFTR abnormality, sperm retrieval, and ICSI outcomes were statistically analyzed. Overall, 39 patients were included with 10 in the CF and 29 in the CBAVD groups. Surgical sperm retrieval rates were significantly lower in the CF group for sperm concentration (14.8 × 10 [6] ml-1 vs 61.4 × 10 [6] ml -1 , P = 0.02) and total motile sperm count (2.9 million vs 11.4 million, P = 0.01). This difference was only predicted by homozygous delta F508 CFTR mutations (P < 0.05). The CF group also demonstrated a significantly higher rate of rescue testicular sperm extraction (70.0% vs 27.6%, P < 0.03) and lower fertilization rate with ICSI (32.5% vs 68.9%, P < 0.01). In conclusion, those with CF demonstrated lower sperm quality, greater difficulty with sperm retrieval, and worse ICSI outcomes compared with CBAVD-only patients. Homozygous delta F508 CFTR mutations appear to significantly impair spermatogenesis and sperm function., Competing Interests: None

Non-obstructive azoospermia is a distinct diagnosis within male infertility in which no sperm is found in the ejaculate as a result of spermatogenesis failure. Because of the increased prevalence of genetic abnormalities in men with non-obstructive azoospermia, male infertility guidelines recommend screening for karyotype abnormalities and Y chromosome microdeletions in this population. Numerous karyotype abnormalities may be present resulting in impaired spermatogenesis, including: Klinefelter syndrome, translocations, and deletions. Y chromosome microdeletions of the AZFa, AZFb, AZFc subregions all can also result in non-obstructive azoospermia with the possibility of sperm being present if only the AZFc subregion is deleted. While these are the two genetic tests recommended by the guidelines, nearly 50%-80% of non-obstructive azoospermia has no identifiable cause and is deemed idiopathic. Several other genetic defects can lead to non-obstructive azoospermia including Kallmann syndrome, mild androgen insensitivity syndrome, and TEX11. While many additional candidate genes have been proposed, many have yet to be verified or are so infrequent in the population that screening is cost-ineffective. Much research is still required in the genetics of non-obstructive azoospermia and will require multi-institutional initiatives to better understand the genetics of condition., Competing Interests: Declaration of competing interest None., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

INTRODUCTION Few studies have compared surgical outcomes after 3-piece inflatable penile prosthesis (IPP) surgery in patients exposed to pelvic radiation therapy (RT) compared to a radiation naïve control group., Materials and Methods: A total of 715 consecutive patients underwent 3-piece IPP placement between 2007-2018. There were 101 men exposed to pelvic RT before or after IPP for a variety of malignancies and 153 men met inclusion criteria for the control group, which included men undergoing IPP surgery with a history of radical prostatectomy but no exposure to pelvic RT., Results: Patients in the RT group had a higher body mass index (kg/m²) (28.7 versus 27.8, p = 0.003) and higher Charlson co-morbidity index score (6 versus 5; p < 0.001). At a median follow up of 5 years (IQR 2-8 years), there was an 18.4% surgical complication rate in the radiation group compared to 11.5% in the control group, though this was not statistically significant (p = 0.141). Timing of radiation, prior artificial urinary sphincter (AUS) status, co-implantation of an AUS, and brand of prosthesis were not associated with increased rate of complications. On multivariable logistic regression analysis, exposure to RT was not significantly associated with increased risks of complications (OR: 1.31; CI 0.55-3.12)., Conclusions: This study shows no significant increase in risk of surgical complication in patients exposed to pelvic RT and supports the use of IPP in men with a history of RT and refractory erectile dysfunction.

Men with neurogenic bladder (NGB) often have concomitant erectile dysfunction and may be considered for inflatable penile prosthesis (IPP) placement. However, it is unclear if NGB is a risk factor for complications associated with IPP placement. The aim of this study is to compare surgical outcomes after IPP placement in a contemporary cohort of patients with NGB to that of a non-neurogenic control group. To accomplish this, consecutive records of patients who underwent IPP implantation between 2007 and 2018 were retrospectively reviewed. Patients with a known neurologic lesion and documented NGB by clinical or urodynamic criteria were compared with a non-neurogenic control group of men with erectile dysfunction. We found that patients in the NGB cohort were younger (median age 48 vs. 62 years, p < 0.001) and less likely to void spontaneously prior to surgery (3% vs. 97%, p < 0.001). The most common cause for NGB was spinal cord injury (46%). There was a 24.3% overall rate of complication (infection, erosion, or mechanical failure) in the NGB cohort compared with a 7.5% rate in the non-neurogenic control group (p = 0.001). On multivariate logistic regression modeling, NGB (OR 3.47; 95% CI 1.13-10.71; p = 0.03) was independently associated with risk of IPP complication. First time penile prosthesis was associated with lower risk of IPP complication (OR 0.25 95% CI 0.09-0.71; p = 0.01). In conclusion, patients with NGB are at increased risk for complications after IPP placement. Patients should be counseled accordingly, and all efforts should be made to stabilize bladder function prior to surgery.

The COVID-19 pandemic has brought unique challenges to the delivery of undergraduate medical education, particularly for current third-year medical students who are preparing to apply to residency. In mid-March, medical schools suspended all clinical rotations for the remainder of the 2019-2020 academic year. As such, third-year medical students may not be able to complete sufficient clinical experiences to make important career choices before they have to submit their residency applications. While the decision to suspend clinical rotations was necessary to protect students, specialty organizations and residency programs must mitigate the deficits in students' clinical education caused by the COVID-19 pandemic.In this Perspective, the authors identify potential challenges for third-year medical students and advocate for solutions to improve the residency application process for students and programs. First, they propose delaying the date that programs can access applicant data through the Electronic Residency Application Service, thereby affording students more time to complete clinical experiences, solidify their specialty decision, and strengthen their residency application. Second, the authors recommend a restriction on the number of visiting rotations that students are expected to complete to allow for a more equitable distribution of these important experiences. Third, they suggest that program directors from each specialty agree on a maximum number of applications per applicant (based on historical data) to curb an upsurge in applications that may stem from the unique circumstances created by COVID-19 without causing applicants undue stress. Lastly, the authors advocate that residency programs develop infrastructure to conduct video-based interviews and engage students through virtual networking events.Amidst the unique environment created by COVID-19, the authors urge governing bodies, specialty organizations, and residency programs to consider these recommendations to improve the efficiency and reduce the stress surrounding the 2021 Match.

Objectives: Here we examine the association between shift work sleep disorder (SWSD) and erectile dysfunction (ED) in shift workers., Methods: Men presenting to a single andrology clinic between January 2014 and July 2017 completed validated questionnaires: International Index of Erectile Function (IIEF), Patient Health Questionnaire-9 (PHQ-9), and the nonvalidated SWSD Questionnaire. Men were also asked about shift work schedule, comorbidities, phosphodiesterase 5 (PDE5) inhibitor use, and testosterone use. Serum total testosterone values were determined for each visit. Linear regression was performed controlling for testosterone use, testosterone levels, PDE5 inhibitor use, age, and comorbidities to determine the effect of SWSD on ED as assessed using the IIEF., Results: Of the 754 men completing questionnaires, 204 reported nonstandard shift work (begins before 7 am or after 6 pm, regularly extends out of that frame, or rotates frequently) and 48 were found to have SWSD using a screening questionnaire. Nonstandard shift work alone did not result in worse IIEF-EF scores (P = .31), but those who worked nonstandard shifts and had SWSD demonstrated IIEF-EF scores 2.8 points lower than men without SWSD (P < .01). When assessing for the type of shift work performed, men who worked night shifts had IIEF-EF scores 7.6 points lower than men who worked during the day or evening (P < .01). Testosterone use improved IIEF-EF scores for men with SWSD by 2.9 points, ameliorating the effect of SWSD on ED. However, baseline testosterone levels were not associated with worse erectile function in this cohort., Conclusion: Men with SWSD have worse erectile function, with men who work night shifts having even poorer erectile function. These findings suggest that circadian rhythm disturbance may significantly impact erectile function. While testosterone therapy may partly reverse the effects of SWSD, shift work is a potential risk factor for ED and should be assessed for as part of the evaluation of men with ED. Rodriguez KM, Kohn TP, Kohn JR, et al. Shift Work Sleep Disorder and Night Shift Work Significantly Impair Erectile Function. J Sex Med 2020;17:1687-1693., (Copyright © 2020 International Society for Sexual Medicine. All rights reserved.)

Purpose of Review: Genetic testing in male infertility is an essential part of the process of diagnosis. Genetic abnormalities, such as Y-chromosome microdeletion, chromosomal abnormalities and mutations for cystic fibrosis, can all negatively impact a male's fertility and can be tested for during a fertility evaluation. Both Y-chromosome microdeletion and chromosomal abnormalities increase in prevalence as sperm concentrations decrease, and azoospermic men have the greatest frequency of genetic abnormalities., Recent Findings: These genetic abnormalities can also be found in oligospermic men; however, on the basis of several recent studies, the prevalence of genetic abnormalities is lower in oligospermic men than previously thought., Summary: The current screening thresholds are devised from the previously determined prevalences and have not been revised based on the emerging data; thus, in this review of the literature, we will discuss this new evidence and whether screening thresholds should be changed.

Introduction: Sexual dysfunction affects many people, with 33‒60% of women reporting sexual dysfunction and 8‒52% of men with erectile dysfunction or premature ejaculation. In an effort to determine the constellation of factors responsible for sexual dysfunction, the effect of thyroid hormone derangements has been of recent interest., Aim: To investigate the associations between thyroid hormones and sexual dysfunction in women and men., Methods: Literature was reviewed to examine the effects of hypo- and hyperthyroidism on sexual function., Main Outcome Measure: We present a summary of the effects of thyroid dysfunction on domains of sexual functioning., Results: Most studies demonstrate that men with hypo- and hyperthyroidism have increased rates of sexual dysfunction, including erectile dysfunction in men with hypothyroidism. However, studies vary on the strength of correlation between hormonal derangement and level of sexual dysfunction. In both men with hyper- and hypothyroidism, treating the thyroid disorder at least partially reverses sexual dysfunction. In contrast, the current literature provides no consensus on the effect of hypothyroidism, hyperthyroidism, or Hashimoto's thyroiditis on female sexual function. In studies that observed increased rates of sexual dysfunction in women with thyroid disorders, correction of the thyroid derangement resulted in resolution of some sexual dysfunction. Studies are also conflicted on whether there is a relationship between the degree of sexual dysfunction and the degree of hormone derangement in women. However, prior work has demonstrated a relationship between thyroid autoantibodies and sexual dysfunction in women., Conclusion: Thyroid dysfunction is an important factor in the pathogenesis of sexual dysfunction in men and possibly women. Evidence suggests a reversibility of sexual dysfunction with correction of thyroid dysfunction, although the exact pathophysiology of thyroid-mediated sexual dysfunction remains unknown. However, current evidence supports thyroid derangements rather than autoantibodies as the causative factor in men, whereas autoantibodies appear to play a more prominent role in women. Bates JN, Kohn TP, Pastuszak AW. Effect of Thyroid Hormone Derangements on Sexual Function in Men and Women. Sex Med Rev 2020;8:217-230., (Copyright © 2018 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

Our purpose was to determine if key pinch strength is predictive of patient preference for a single IPP model among three currently available models (Coloplast™ Titan, Coloplast™ Titan Touch, and the Boston Scientific AMS 700™). We prospectively recruited men without penile prostheses over 65 years old from our urology clinic. Demographic and medical history were recorded. To measure key pinch strength study participants squeezed a dynamometer between their thumb and index finger while seated with their arm resting at 90°; the strongest of three attempts was recorded. Participants were asked to operate three inflatable penile prosthesis devices installed within identical penis models. The number of pumps required to achieve erection with each device was recorded. Participants were asked to rate difficulty of inflation on a 1-5 scale. Participants ranked, from best to worst, which device they preferred based on ease of inflation. A total of 100 men completed the study. Median age and key pinch strength were 70.0 years and 19.0 pounds. Coloplast Titan was the most favored pump based on ease of inflation (58%). The median age, median key pinch strength, and median number of pumps required for erection were similar among men that favored Coloplast Titan as compared with AMS 700 and Coloplast Titan Touch. Multivariate linear regression of the 1-5 rating scale revealed lower grip strength to be associated with increased difficulty of inflation of Coloplast Titan Touch (p  = 0.045). No other factors were associated with increased difficulty of inflation. Men with below-average key pinch strength may benefit from being offered a model other than Coloplast Titan Touch. Whether these findings translate to men who have already received implants remains to be determined. Nevertheless, evaluation of pinch strength should be considered in men prior to implantation of IPP.

Background: Men with Peyronie's disease (PD) may have an increased prevalence of certain comorbidities, including malignancy. We sought to examine the clinical relationship between PD and subsequent diagnosis of malignancy., Methods: Using data from the IBM Health MarketScan claims database from 2007 to 2013, we compared men with PD to a control group of men without PD or erectile dysfunction matched for age and duration of follow-up. We compared incidence of 18 categories of malignancy between both groups using a Cox regression model., Results: In total, 48,423 men with PD and 484,230 controls were identified. The mean age within both cohorts was 50 ± 9.4 years old, and mean follow-up time was approximately 4.4 ± 2.1 years. After being controlled for age, year of evaluation, obesity, smoking, number of outpatient visits, number of urologist visits, and duration of follow-up, men with PD had an increased risk of all cancers (hazard ratio = 1.10, 95% CI = 1.06-1.14), stomach cancer (1.43, 1.06-1.14), testis cancer (1.39, 1.05-1.84), and melanoma (1.19, 1.02-1.38) when compared with controls. The strengths in using the MarketScan database are the anonymous nature of the data, accessibility, and the power provided by the large number of patient visits recorded. Limitations include a lack of detail in certain facets of patient clinical data, and the lack of long-term follow-up to assess the impact of time on other potentially associated conditions., Conclusions: This manuscript is the first to our knowledge to describe a relationship between PD and cancer. Men with PD may be at increased risk for certain malignancies compared with age-matched controls. Further investigation is needed to explore the clinical implications of these findings. Pastuszak AW, Thirumavalavan N, Kohn TP, et al. Increased Cancer Risk in Men With Peyronie's Disease: A Cohort Study Using a Large US Insurance Claims Database. Sex Med 2019;7:403-408., (Copyright © 2019 The Authors. Published by Elsevier Inc. All rights reserved.)

Purpose: To study the impact of advanced paternal age on embryo aneuploidy., Methods: This is a multicenter international retrospective case series of couples undergoing assisted reproduction via in vitro fertilization using donor eggs to control for maternal factors and preimplantation genetic testing for aneuploidy via next-generation sequencing at Igenomix reproductive testing centers. The main outcome measure was the prevalence of embryo aneuploidy in egg donor cycles. Semen analysis data was retrieved for a small subset of the male patients., Results: Data from 1202 IVF/ICSI egg donor cycles using ejaculated sperm (total 6934 embryos) evaluated using PGT-A between January 2016 and April 2018 in a global population across all Igenomix centers were included. No significant association was identified between advancing paternal age and the prevalence of embryo aneuploidy overall and when analyzing for each chromosome. There was also no significant association between advancing paternal age and specific aneuploid conditions (monosomy, trisomy, partial deletion/duplication) for all chromosomes in the genome., Conclusions: This is the largest study of its kind in an international patient population to evaluate the impact of advancing paternal age on embryo aneuploidy. We conclude there is no specific effect of paternal age on the prevalence of embryo aneuploidy in the context of embryo biopsies from egg donor cycles.

Introduction: Telemedicine video visits have been suggested as a mechanism to improve access to urological care in geographically isolated communities. However, Internet availability is not consistent across the United States. This study aims to better understand the interplay of broadband Internet, urologist density and county demographics to inform the strategic deployment of urological telemedicine., Methods: A geospatial analysis was conducted to assess associations between broadband Internet and urologist density. Adequate broadband Internet availability was determined to be greater than 50% county coverage. Data were obtained from 2015 Federal Communications Commission filings. Physician density in 2015 was obtained from 2016-2017 Area Health Resources Files. A univariate regression was performed to estimate the associations of county demographics with broadband availability and urologist density., Results: More than 10.9 million Americans lack access to local urology care and broadband Internet. Overall 31.7 million Americans lack access to a urologist but have reliable broadband Internet coverage. Counties with no urologists were associated with having less accessibility to broadband Internet and greater distance to the nearest county with a urologist. Counties without Internet availability or urologists were more likely to be rural (OR 9.93) and be designated as a whole county health professional shortage area (OR 10.05)., Conclusions: A quarter of communities that lack access to local urologists also lack access to broadband Internet. Telemedicine cannot address poor access to urology care in communities without high-speed Internet. Future studies are needed to establish whether, pending expanded access to broadband Internet coverage, telemedicine will improve patient outcomes in geographically isolated communities.

Introduction: Peyronie's disease is an acquired condition of the connective tissue of the penis that affects 0.5-20.3% of the male population and is marked by fibrotic plaques in the tunica albuginea. It can result in penile curvature/deviation, painful erections, and sexual dysfunction. Several treatment modalities have been proposed, with studies from the past decade investigating extracorporeal shockwave therapy's (ESWT) potential efficacy in Peyronie's management., Aims: To investigate the effects of ESWT on Peyronie's disease parameters such as penile curvature, plaque size, erectile function, and penile pain., Methods: We reviewed the literature examining the effects of ESWT on Peyronie's disease., Main Outcome Measures: The main outcome measures after receiving extracoporeal shockwave therapy included changes in degree of penile curvature, penile plaque size, International Index of Erectile Function-5 questionnaire score, and visual analogue scale score., Results: Randomized controlled trials examining the efficacy of ESWT in Peyronie's disease do not show a statistically significant benefit in curvature reduction, plaque size, or erectile function, although a recent meta-analysis demonstrates a benefit in plaque size reduction. A statistically significant reduction in penile pain has been observed across multiple studies., Conclusion: Extracorporeal shockwave therapy may be beneficial in the management of Peyronie's disease for refractory penile pain and plaque size reduction. However, penile pain typically resolves spontaneously over time, and shockwave therapy can pose a substantial financial burden to patients. A multi-institutional randomized controlled trial with standardization of methods and strict inclusion criteria regarding disease duration would prove beneficial in determining the true efficacy of shockwave therapy in Peyronie's disease. Krieger JR, Rizk PJ, Kohn TP, et al. Shockwave Therapy in the Treatment of Peyronie's Disease. Sex Med Rev 2019;7:499-507., (Copyright © 2019 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction: Stem cell therapy using stromal vascular fraction (SVF) is a promising treatment modality. SVF is comprised of a mixture of adipose-derived stem cells, endothelial precursor cells, and immune modulatory cells that act synergistically to facilitate angiogenesis and epithelial cell differentiation. This makes SVF an attractive option for men's sexual disorders that require reconstitution of vasculature and endothelial lining, namely erectile dysfunction (ED) and Peyronie's disease (PD)., Aim: The objective of this study was to compare and contrast the available literature regarding the use of SVF in the treatment of male sexual dysfunction., Methods: A literature review was performed in PubMed with the keywords "stromal vascular fraction" and/or "erectile dysfunction" and/or "Peyronie's disease" and/or "sexual dysfunction.", Main Outcome Measures: The main outcome measure for preclinical studies was erectile function, as measured by changes in intracavernous pressures, and results of histopathologic analysis of corporal tissue. Clinical endpoint analysis in humans included various patient questionnaires., Results: For ED, there were 5 preclinical studies included in the analysis, with 1 Phase 1 clinical trial in humans. Major limitations of both the preclinical and clinical studies included the absence of SVF component analysis, and short duration of follow-up. Despite a paucity of preclinical studies, there was a single clinical study assessing the efficacy of combination SVF and shock wave therapy in the treatment of PD. Limitations of this study included an absence of a control group and the use of subjective data., Conclusion: Preclinical and clinical data in the use of SVF for the treatment of male sexual dysfunction is deficient. Even though multiple medicinal disciplines are studying the use of SVF on a myriad of pathologies, further investigative work elucidating the mechanism and potential adverse effects of SVF need to be performed before clinical trials are undertaken. Haney NM, Gabrielson A, Kohn TP, Hellstrom WJG. The Use of Stromal Vascular Fraction in the Treatment of Male Sexual Dysfunction: A Review of Preclinical and Clinical Studies. Sex Med Rev 2019;7:313-320., (Copyright © 2018 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction: Selective androgen receptor modulators (SARMs) differentially bind to androgen receptors depending on each SARM's chemical structure. As a result, SARMs result in anabolic cellular activity while avoiding many of the side effects of currently available anabolic steroids. SARMs have been studied in the treatment of breast cancer and cachexia and have also been used as performance-enhancing agents. Here, we evaluate and summarize the current literature on SARMs., Aim: To present the background, mechanisms, current and potential clinical applications, as well as risks and benefits of SARMs., Methods: A literature review was performed in MEDLINE using the terms selective androgen receptor modulator, hypogonadism, cachexia, breast cancer, benign prostatic hyperplasia, libido, and lean muscle mass. Both basic research and clinical studies were included., Main Outcome Measure: To complete a review of peer-reviewed literature., Results: Although there are currently no U.S. Food and Drug Agency-approved indications for SARMs, investigators are exploring the potential uses for these compounds. Basic research has focused on the pharmacokinetics and pharmacodynamics of these agents, demonstrating good availability with a paucity of drug interactions. Early clinical studies have demonstrated potential uses for SARMs in the treatment of cancer-related cachexia, benign prostatic hyperplasia (BPH), hypogonadism, and breast cancer, with positive results., Conclusion: SARMs have numerous possible clinical applications, with promise for the safe use in the treatment of cachexia, BPH, hypogonadism, breast cancer, and prostate cancer. Solomon ZJ, Mirabal JR, Mazur DJ, et al. Selective Androgen Receptor Modulators: Current Knowledge and Clinical Applications. Sex Med Rev 2019;7:84-94., (Copyright © 2018 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Vasculogenic erectile dysfunction (ED) is one of the leading causes of male sexual dysfunction. In the past decade, multiple studies have examined the use of low-intensity extracorporeal shockwave therapy (Li-ESWT) for the treatment of ED., Aim: Investigate the efficacy of Li-ESWT for the treatment of ED., Methods: We reviewed the published literature, including randomized controlled trials (RCTs), meta-analyses, and select single-arm studies on the use of Li-ESWT for the treatment of ED., Outcomes: Changes in International Index of Erectile Function scores were evaluated in patients undergoing Li-ESWT., Results: There is no consensus from RCTs on the efficacy of Li-ESWT for the treatment of ED. Published meta-analyses have shown significant improvement in International Index of Erectile Function-erectile function domain scores in men undergoing Li-ESWT, especially when compared to men receiving sham treatment. However, differences in treatment protocols limit the generalizability of these findings. Li-ESWT may be more beneficial in cases of mild ED or when combined with phosphodiesterase type 5 inhibitors in men with moderate to severe ED. The role of Li-ESWT in the treatment of non-vasculogenic ED remains poorly defined., Conclusions: Li-ESWT could be beneficial in specific sub-sets of men with vasculogenic ED. However, future RCTs should attempt to optimize treatment protocols and have more stringent inclusion criteria to confirm these findings. Rizk PJ, Krieger JR, Kohn TP, et al. Low-Intensity Shockwave Therapy for Erectile Dysfunction. Sex Med Rev 2018;6:624-630., (Copyright © 2018. Published by Elsevier Inc.)

Background: More than 21 million Americans and nearly 20% of the U.S. workforce are shift workers. Non-standard shift work, defined as work that falls outside of 6 am-6 pm, can lead to poor diet, exercise, and sleep habits that lead to decreased productivity, increased workplace accidents, and a variety of negative health outcomes., Aim: To investigate the associations between shift work exposure and chronic medical conditions such as metabolic syndromes, cardiovascular disease, gastrointestinal disturbances, and depression as well as urologic complications including hypogonadism, male infertility, lower urinary tract symptoms, and prostate cancer with a focus on the effects of shift work sleep disorder (SWSD) on the severity of these negative health outcomes., Methods: We reviewed the literature examining effects of shift work and SWSD on general and urologic health., Outcomes: We produced a summary of effects of shift work on health with focus on the increased risk of negative health outcomes in non-standard shift workers, particularly those with SWSD, when compared to daytime workers or workers without SWSD., Results: Studies have associated non-standard shift work schedules and poor health outcomes, including increased risks of diabetes mellitus, dyslipidemia, hypertension, heart disease, peptic ulcer disease, and depression, in shift workers. However, few studies have focused on the role that shift work plays in men's urologic health. Current evidence supports associations between non-standard shift work and increased hypogonadal symptoms, poor semen parameters, decreased fertility, lower urinary tract symptoms, and prostate cancer. These associations are strengthened by the presence of SWSD, which affects up to 20% of shift workers. Unfortunately, interventions, such as planned naps, timed light exposure, melatonin, and sedative hypnotics, aimed at alleviating excessive nighttime sleepiness and daytime insomnia in non-standard shift workers experiencing SWSD, are limited and lack strong evidence to support their efficacy., Conclusions: Non-standard shift work has been associated with a variety of negative health outcomes and urologic complications, especially with concurrent SWSD. Recognition of these increased risks among shift workers can potentially aid in more effective screening of chronic health and urologic conditions. Non-pharmacologic treatment of SWSD focuses on behavioral therapy and sleep hygiene while melatonin, hypnotics, and stimulants are used to alleviate insomnia and excessive sleepiness of SWSD. Further research into both pharmacologic and non-pharmacologic therapies for SWSD is needed to establish more definitive guidelines in the treatment of SWSD in order to increase productivity, minimize workplace accidents, and improve quality of life for shift workers. Deng N, Kohn TP, Lipshultz LI, et al. The Relationship Between Shift Work and Men's Health. Sex Med Rev 2018;6:446-456., (Copyright © 2018. Published by Elsevier Inc.)

Background: The subsequent health risks associated with Peyronie's disease (PD) are unknown., Aim: This cohort study assesses the risk of developing auto-immune conditions and common chronic health conditions after a diagnosis of PD. We hypothesize that an increase in auto-immune disease will be evident in men with PD, as has been suggested in smaller studies., Methods: We determined the longitudinal incidence of 13 auto-immune diseases and 25 common chronic conditions in a cohort from the Truven Health Analytics (Ann Arbor, Michigan, USA) database from 2007-2013. The cohort included men with 1 of 3 exposures in 2007: (1) men with PD, (2) men with erectile dysfunction (ED) but not PD, and (3) men without PD or ED, matched on age and follow-up duration., Outcomes: To assess incidence, we utilized a Cox regression model adjusting for age, smoking, obesity, health care visits per year, urology visits per year, and years of follow-up., Results: We included 8,728 men with PD; 204,147 men with ED; and 87,280 controls. Men with PD had an increased risk of developing benign prostatic hyperplasia (hazard ratio [HR] 1.21, 95% CI 1.16-1.27), prostatitis (HR 1.21, 95% CI 1.12-1.31), and lower urinary tract symptoms (HR 1.10, 95% CI 1.05-1.16) when compared to both men with ED and age-matched controls without ED or PD even when controlling for the number of urology visits per year. Compared to controls, men with PD also had an increased risk of developing keloids. No significant risk for any auto-immune disease was observed., Clinical Implications: Clinicians should have heightened awareness for these relevant co-morbidities when treating men with PD., Strengths & Limitations: Utilizing a claims database provides one of the largest cohorts of men with PD ever published but claims databases lack some individual patient data such as risk factors and demographic information relevant to PD, including: penile injury, history of urologic procedures, and other lifestyle factors., Conclusion: Men with PD had a higher risk of benign prostatic hyperplasia, lower urinary tract symptoms, prostatitis, and keloids after a diagnosis of PD, but no increased risk of auto-immune conditions. These findings suggest a common etiology for these conditions that may manifest itself in diseases at different times in men's life cycle. Pastuszak AW, Rodriguez KM, Solomon ZJ, et al. Increased Risk of Incident Disease in Men with Peyronie's Disease: Analysis of U.S. Claims Data. J Sex Med 2018;15:894-901., (Copyright © 2018. Published by Elsevier Inc.)