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To evaluate the effect of the transition from IMPACT, a disease-focused treatment program, to comprehensive health insurance under Medicaid through the Affordable Care Act (ACA) on general and prostate cancer-specific quality of life (QoL) on a cohort of previously uninsured low-income men. We hypothesize that general QoL would improve and prostate cancer-specific QoL would remain the same after the transition to comprehensive health insurance.We assessed and compared general QoL using the RAND SF-12v2™ (12-Item Short Form Survey, version 2) and prostate cancer-specific QoL using the UCLA PCI (Prostate Cancer Index) one year before, at, and one year after the transition between 30 men who transitioned to comprehensive insurance (newly insured/Medicaid group) and 54 men who remained in the prostate cancer program (uninsured/IMPACT group). We assessed the independent effects of Medicaid coverage on QoL outcomes using repeated-measures regression.Our cohort was composed primarily of Hispanic men (82%). At transition, patient demographics and clinical characteristics were similar between the groups. General and prostate cancer-specific QoL did not differ between the groups and remained stable over time, Radical prostatectomy as primary treatment and shorter time since treatment were associated with worse urinary and sexual function across both groups and over all three time points.Those who transitioned to full-scope insurance and those who remained in the free prostate cancer-focused treatment program had stable general and prostate cancer-specific QoL. High-touch navigation aspects of a disease-focused program may have contributed to stability in outcomes.

BackgroundThe effects of male circumcision on sexual function remain controversial. Heterogeneity across previous studies and low-quality scientific evidence have resulted in poor understanding of the effects of circumcision on erogenous sensation of the penis and orgasm function.AimIn this study we sought to describe and assess differences in erogenous genital sensation and reported orgasm function in circumcised compared with uncircumcised men.MethodsAdult male subjects who were recruited on a paid anonymous online survey platform were shown illustrations of 12 anatomic regions of the penis. Subjects were prompted to designate regions as pleasurable when touched during partnered sex and to rate each on a 1-10 scale, with higher erogeneity scores correlating with greater pleasure. Subjects were also asked to characterize their orgasms across 6 experiential domains.OutcomesOutcomes were differences between circumcised and uncircumcised men in the probabilities that regions would be designated as pleasurable, average pleasure scores, and self-reported orgasm parameters.ResultsIn total, 227 circumcised (mean [SD] age 46.6 [17.7] years) and 175 uncircumcised men (47.8 [18.1] years) completed the survey. There were no significant differences in average ratings across all regions between circumcised and uncircumcised men. However, significantly more circumcised men reported preferences for the tip of the penis (38% vs 17%, P = .02) and the middle third of the ventral penile shaft (63% vs 48%, P = .04). Additionally, there were no significant differences in orgasm quality and function across all queried domains between circumcised and uncircumcised cohorts.Clinical implicationsOur findings suggest that circumcision does not change how men describe erogenous genital sensation or how they experience orgasm.Strengths and limitationsIn this study we expanded upon existing literature regarding comparison of sexual function in circumcised and uncircumcised men in its scale and investigation of diverse domains. Limitations include the survey format of data collection.ConclusionWe found no differences in reported erogenous ratings or orgasm function between circumcised and uncircumcised men. These findings suggest that male circumcision does not negatively impact penile erogeneity or orgasm function.

BackgroundIn the original clinical trials evaluating intralesional collagenase Clostridium histolyticum for Peyronie disease (PD), treatment protocols were limited to 8 injections.AimWe sought to describe our single-center experience with the use of multiple rounds (>8 injections) of intralesional collagenase in patients with PD.MethodsWe conducted a retrospective analysis of all patients with PD receiving intralesional collagenase injections at our institution from October 2015 through December 2020. Some patients who completed 1 round of treatment elected to undergo additional rounds (16 or 24 injections) based on persistent curvature and presence of penile plaque. Clinical improvement was defined as a 20% reduction in penile curvature from the start of a given round of treatment to the end of that round of treatment. We measured erect penile curvature before and after each round and collected demographics, medical and surgical history, curvature outcomes, and treatment-related adverse events.OutcomeThe primary outcome was the reduction in penile curvature after multiple rounds of treatment with intralesional collagenase injections in patients with PD.ResultsA total of 330 patients underwent intralesional collagenase injections for PD, of whom 229 completed at least 8 injections and underwent pre- and posttreatment erect penile goniometry. An overall 42.8% (98/229), 38.6% (22/57), and 12.5% (1/8) of patients achieved clinical improvement after 1 round of therapy (8 injections), 2 rounds (16 injections), and 3 rounds (24 injections), respectively. Mean degree and mean percentage improvement of penile curvature for the start and end of each round of treatment were 8.3° and 16.4% (after 1 round), 7.2° and 16.8% (after 2 rounds), and 3.3° and 8.1% (after 3 rounds). Bruising was the most common complication, with an incidence of at least 50% in each round.Clinical ImplicationsKnowledge of patient responses to multiple rounds of intralesional collagenase injections may help guide physicians in management and counseling of patients regarding PD treatment options.Strengths and LimitationsThis is the first study to evaluate multiple rounds (>8 injections) of intralesional collagenase for PD. Limitations include retrospective analysis and smaller sample size among patients undergoing 3 rounds (24 injections).ConclusionFor patients who did not achieve clinical improvement after 1 round of treatment, an additional round may be beneficial. However, no real improvement was observed for patients undergoing a third round.

OBJECTIVE: To compare health-related quality of life in men who underwent surgical versus medical castration for metastatic prostate cancer. METHODS: We analyzed data from a prospective cohort of men enrolled in a statewide public health program that provides care for prostate cancer among low-income, uninsured men from 2001–2020. Outcome measures included the RAND SF-12 and the UCLA Prostate Cancer Index (PCI) at baseline and every six months. We used generalized estimating equations to assess the independent impact of surgical versus medical castration on health-related quality of life. RESULTS: Among men with metastatic prostate cancer, 27 underwent orchiectomy, and 274 underwent medical castration. Median cohort age at enrollment was 61.3 years (IQR 56–65); 239 (79%) men had less than a high school education. Average follow-up was 8 months (range 0–45) since study enrollment. Seventy percent of patients within the surgical castration group had their orchiectomy prior to study enrollment (median months since orchiectomy at study enrollment was 9 months, IQR 1–43). Similarly, 59% of patients within the medical castration group had begun ADT prior to study enrollment (median months since ADT initiation at study enrollment was 4 months, IQR 1–12). The majority (66%) had metastatic disease at diagnosis. The two groups did not differ in age, race/ethnicity, education, monthly income, baseline PSA, Gleason score, or percent metastatic at diagnosis. SF-12 domains did not differ between those who underwent surgical versus medical castration (on average throughout follow-up, physical component difference −2.0, 95% CI −8.0—3.9 and mental component difference −1.0, 95% CI −5.4—+3.4). Patients treated with orchiectomy reported better urinary function than those who underwent medical castration (+16 point, 95%CI 5.3–26). CONCLUSIONS: Surgical castration did not negatively impact general or disease-specific quality of life. The finding of improved urination after orchiectomy merits further inquiry. This may inform urologists’ discussion of surgical versus medical options for men with castration-sensitive metastatic prostate cancer.

BACKGROUND: Transgender and gender-diverse individuals are particularly vulnerable to healthcare discrimination and related health sequelae. OBJECTIVE: To demonstrate diversity in demographics and explore variance in needs at the time of intake among patients seeking care at a large, urban gender health program. DESIGN: We present summary statistics of patient demographics, medical histories, and gender-affirming care needs stratified by gender identity and sexual orientation. PARTICIPANTS: We reviewed all intake interviews with individuals seeking care in our gender health program from 2017 to 2020. MAIN MEASURES: Clients reported all the types of care in which they were interested at the time of intake as their “reason for call” (i.e., establish primary care, hormone management, surgical services, fertility services, behavioral health, or other health concerns). KEY RESULTS: Of 836 patients analyzed, 350 identified as trans women, 263 as trans men, and 223 as non-binary. The most prevalent sexual identity was straight among trans women (34%) and trans men (38%), whereas most (69%) non-binary individuals identified as pansexual or queer; only 3% of non-binary individuals identified as straight. Over half of patients reported primary care, hormone management, or surgical services as the primary reason for contacting our program. Straight, transgender women were more likely to report surgical services as their primary reason for contacting our program, whereas gay transgender men were more likely to report primary care as their reason. CONCLUSIONS: Individuals contacting our gender health program to establish care were diverse in sexual orientation and gender-affirming care needs. Care needs varied with both gender identity and sexual orientation, but primary care, hormone management, and surgical services were high priorities across groups. Providers of gender-affirming care should inquire about sexual orientation and detailed treatment priorities, as trans and gender-diverse populations are not uniform in their treatment needs or goals. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s11606-021-06791-9.

To determine the predictive value of voiding efficiency on acute urinary retention after discharge from BPH surgery.We performed a prospective observational cohort study of three surgeons' practices from 2019 to present. All men included underwent trial of void on post-operative day one after transurethral resection of prostate or Holmium enucleation of prostate . Active filling void trials were performed on all patients and voiding efficiency (percent of bladder volume emptied) was calculated. Multivariable logistic regression was performed to determine predictors of developing acute urinary retention.During the study period, 188 men met inclusion criteria. 110 (59%) men underwent Holmium enucleation of prostate , and 78 (41%) underwent transurethral resection of prostate. The median age of our cohort was 70 (IQR 65-75). The median prostate size was 100g (IQR 61-138g). Nineteen patients (10%) returned after discharge with acute urinary retention requiring catheterization. On post-operative day one, the median voiding efficiency was 75% (IQR 55%-94%). On multivariable analysis, patients with a voiding efficiency less than 50% were 3.8 times more likely (95% confidence interval 1.1-12.8) to develop subsequent retention compared to a voiding efficiency of greater than 75%. Increasing pre-operative prostate size was associated with lower risk of urinary retention after discharge (aOR 0.8, 95%CI 0.6-0.9).Voiding efficiency after an active void trial helps stratify risk of urinary retention in patients undergoing benign prostate surgery. High-risk patients include those with voiding efficiencies less than 50% and smaller pre-operative prostate sizes (80g).

Peyronie's disease (PD) can be subdivided into acute and chronic phases. Intralesional collagenaseAll men receiving intralesional collagenase for PD from October 2015 through December 2020 at a single academic institution were retrospectively assessed for patient demographics and comorbidities, pre- and post-treatment curvature, and adverse events. Two definitions of acute phase were used: (I) acute phase duration ≤6 months, chronic phase duration6 months; and (II) acute phase duration ≤12 months with penile pain, chronic phase duration12 or no penile pain.Of 330 patients identified, 229 underwent intralesional collagenase treatment with pre- and post-treatment erect penile goniometry. 65 (28%) met criteria for definition 1 of acute phase, 37 (16%) met criteria for definition 2, and 76 (33%) met criteria for either. Percent change in penile curvature was not significantly different between acute and chronic phases using definition 1 (16.0%This single-center, retrospective cohort analysis suggests that intralesional collagenase is both safe and effective for the treatment of men with acute phase PD. Limitations exist inherent to retrospective review, since many men did not return for post-treatment goniometry, possibly skewing our cohort toward incomplete responders. Prospective, randomized studies will be required to confirm these findings.

INTRODUCTION AND OBJECTIVE:Ritual male circumcision is common to multiple religions and cultures, and is one of the most common surgeries worldwide. The impact of circumcision on male sexual functi...

PurposeVarious disparities exist in HIV transmission among men who have sex with men (MSM). Pre-exposure prophylaxis (PrEP) has been shown to decrease the acquisition of HIV, but there is variation in uptake within the MSM population. We aim to characterise PrEP use and correlates of self-reported PrEP use in a large national sample of urban MSM in the USA.MethodsUsing data from a geosocial-networking application, a national sample (n=3744) from the largest 50 metropolitan centres in the USA was obtained.ResultsWe found 18.1% (95% CI 16.8 to 19.3) of profiles reported using PrEP, with decreased reported PrEP use in younger MSM aged 18–24 years (adjusted OR (aOR)=0.5, 95% CI 0.3 to 0.7), obese MSM (aOR=0.5, 95% CI 0.3 to 0.9), black MSM (aOR=0.6, 95% CI 0.4 to 0.9) and MSM in the South (aOR=0.7, 95% CI 0.5 to 0.9).ConclusionSignificant disparities exist in PrEP reporting by age and among black, Southern US and obese MSM. More research is needed to better understand these disparities.

Background Sexual dysfunction is common among adults and takes a toll on quality of life for both men and women. Aim To determine whether higher levels of weekly cardiovascular exercise are protective against self-reported sexual dysfunction among men and women. Methods We conducted an international online, cross-sectional survey of physically active men and women between April and December 2016, assessing exercise activity categorized into sextiles of weekly metabolic equivalent-hours. Odds ratios (ORs) of sexual dysfunction for each activity sextile compared with the lowest sextile were calculated using multivariable logistic regression, controlling for age, body mass index, diabetes mellitus, tobacco/alcohol use, sport, and marital status. Main Outcome Measures Female sexual dysfunction was defined as a score ≤26.55 on the Female Sexual Function Inventory and erectile dysfunction (ED) was defined as a score ≤21 on the Sexual Health Inventory for Men. Results 3,906 men and 2,264 women (median age 41–45 and 31–35 years, respectively) met the inclusion criteria for the study. Men in sextiles 2–6 had reduced odds of ED compared with the reference sextile in adjusted analysis (Ptrend = .03), with an OR of 0.77 (95% CI = 0.61–0.97) for sextile 4 and 0.78 (95% CI = 0.62–0.99) for sextile 6, both statistically significant. Women in higher sextiles had a reduced adjusted OR of female sexual dysfunction (Ptrend = .02), which was significant in sextile 4 (OR = 0.70; 95% CI = 0.51–0.96). A similar pattern held true for orgasm dissatisfaction (Ptrend < .01) and arousal difficulty (Ptrend < .01) among women, with sextiles 4–6 reaching statistical significance in both. Clinical Implications Men and women at risk for sexual dysfunction regardless of physical activity level may benefit by exercising more rigorously. Strengths & Limitations Strengths include using a large international sample of participants with a wide range of physical activity levels. Limitations include the cross-sectional design, and results should be interpreted in context of the study population of physically active adults. Conclusion Higher cardiovascular exercise levels in physically active adults are inversely associated with ED by self-report in men and protective against female sexual dysfunction in women.

Author(s): Gaither, Thomas W; Fergus, Kirkpatrick; Sutcliffe, Siobhan; Cedars, Benjamin; Enriquez, Anthony; Lee, Austin; Mmonu, Nnenaya; Cohen, Stephanie; Breyer, Benjamin | Abstract: BackgroundPubic hair grooming has been correlated with a self-reported history of sexually transmitted infections (STIs). We examined this relationship further in a cross-sectional survey of patients attending an urban STI clinic in San Francisco in 2018.MethodsPubic hair grooming practices and detailed sexual histories were obtained. Sexually transmitted infections were confirmed via laboratory diagnosis or physical examination by a licensed provider.ResultsA total of 314 individuals completed the survey. The median age of participants was 31 years. In total, there were 247 (80%) men, 58 (19%) women, and 5 (2%) transgender participants. Of the 247 men, 177 (72%) identified as gay or bisexual. Twenty-five (82%) of 314 patients reported pubic hair grooming within the past 3 months. Seventy-eight (25%) patients were diagnosed with a new STI during their visit. There were no significant associations between reporting any anal or genital grooming and being diagnosed with an STI. However, anal groomers were 3 times as likely to be diagnosed with a rectal STI after adjustment (adjusted odds ratio, 3.0; 95% confidence interval, 1.2-7.5) compared with genital only groomers and nongroomers. Participants who report removing all of their pubic hair more than 6 times within the past year had higher prevalence of genital STIs (33.3%, 6-10 times; 28.6%, g10 times) compared with participants who never groom all of their pubic hair (15.3%, P = 0.01).ConclusionsWe found no association between recent grooming and genital STIs. Anal grooming was associated with rectal STIs in gay and bisexual men.

Alterations in the urinary microbiome have been associated with urological diseases. The microbiome of patients with urethral stricture disease (USD) remains unknown. Our objective is to examine the microbiome of USD with a focus on inflammatory USD caused by lichen sclerosus (LS).We collected mid-stream urine samples from men with LS-USD (cases; n = 22) and non-LS USD (controls; n = 76). DNA extraction, PCR amplification of the V4 hypervariable region of the 16S rRNA gene, and sequencing was done on the samples. Operational taxonomic units (OTUs) were defined using a 97% sequence similarity threshold. Alpha diversity measurements of diversity, including microbiome richness (number of different OTUs) and evenness (distribution of OTUs) were calculated and compared. Microbiome beta diversity (difference between microbial communities) relationships with cases and controls were also assessed.Fifty specimens (13 cases and 37 controls) produced a 16S rRNA amplicon. Mean sample richness was 25.9 vs. 16.8 (p = 0.076) for LS-USD vs. non-LS USD, respectively. LS-USD had a unique profile of bacteria by taxonomic order including Bacillales, Bacteroidales and Pasteurellales enriched urine. The beta variation of observed bacterial communities was best explained by the richness.Men with LS-USD may have a unique microbiologic richness, specifically inclusive of Bacillales, Bacteroidales and Pasteurellales enriched urine compared to those with non-LS USD. Further work will be required to elucidate the clinical relevance of these variations in the urinary microbiome.

Studies of surgical complications of penile inversion vaginoplasty are limited due to small sample sizes. We describe postoperative complications after penile inversion vaginoplasty and evaluated age, body mass index and years on hormone replacement therapy as risk factors for complications.We retrospectively reviewed the records of male-to-female patients who presented for primary penile inversion vaginoplasty to a high volume surgeon (MLB) from 2011 to 2015. Complications included granulation tissue, vaginal pain, wound separation, labial asymmetry, vaginal stenosis, fistula formation, urinary symptoms including spraying stream or dribbling, infection, vaginal fissure or vaginal bleeding. We classified complications by Clavien-Dindo grade. Multivariable logistic regression was performed to determine the independent effects of age, body mass index and hormone replacement therapy on postoperative surgical complications.A total of 330 patients presented for primary penile inversion vaginoplasty. Median age at surgery was 35 years (range 18 to 76). Median followup in all patients was 3 months (range 3 to 73). Of the patients 95 (28.7%) presented with a postoperative complication. Median time to a complication was 4.4 months (IQR 1-11.5). Rectoneovaginal fistulas developed in 3 patients (0.9%). A total of 30 patients (9.0%) required a second operation. There were no complications greater than Clavien-Dindo grade IIIB. Age, body mass index and hormone replacement therapy were not associated with complications.Penile inversion vaginoplasty is a relatively safe procedure. Most complications due to this surgery develop within the first 4 months postoperatively. Age, body mass index and hormone replacement therapy are not associated with complications and, thus, they should not dictate the timing of surgery.

We explored the relation of cycling to urinary and sexual function in a large multinational sample of men.Cyclists were recruited to complete a survey through Facebook® advertisements and outreach to sporting clubs. Swimmers and runners were recruited as a comparison group. Cyclists were categorized into low and high intensity cyclists. Participants were queried using validated questionnaires, including SHIM (Sexual Health Inventory for Men), I-PSS (International Prostate Symptom Score) and NIH-CPSI (National Institutes of Health Chronic Prostatitis Symptom Index), in addition to questions about urinary tract infections, urethral stricture, genital numbness and saddle sores.Of 5,488 complete survey responses 3,932 (72%) were included in our analysis. On multivariate analysis swimmers/runners had a lower mean SHIM score than low and high intensity cyclists (19.5 vs 19.9 and 20.7, p = 0.02 and0.001, respectively). No significant differences were found in I-PSS or NIH-CPSI scores, or urinary tract infection history. Cyclists had statistically higher odds of urethral stricture compared to swimmers/runners (OR 2.5, p = 0.042). Standing more than 20% of the time while cycling significantly reduced the odds of genital numbness (OR 0.4, p = 0.006). Adjusting the handlebar higher or even with the saddle had lower odds of genital numbness and saddle sores (OR 0.8, p = 0.005 and 0.6, p0.001, respectively).Cyclists had no worse sexual or urinary functions than swimmers or runners but cyclists were more prone to urethral stricture. Increased time standing while cycling and a higher handlebar height were associated with lower odds of genital sores and numbness.

PURPOSE:Efforts have been made to reduce use of computerized tomography in children with blunt abdominal injury. Computerized tomography may be overused in pediatric patients with renal trauma. MATERIALS AND METHODS:We performed a retrospective chart review of all renal trauma patients younger than 18 years old treated at 2 urban trauma centers from 2002 to 2016. We collected demographic and clinical characteristics, renal trauma grades, urological interventions, and timing and use of computerized tomography and renal ultrasound. RESULTS:During the study period 145 patients presented with blunt renal trauma. During hospitalization 46 patients (32%) underwent repeat computerized tomography. About 20% of repeat computerized tomograms were performed less than 48 hours after the first scan. After controlling for center, isolated injury (yes/no), stent placement, age and surgical interventions (yes/no) patients who underwent delayed imaging on their first scan had decreased odds of undergoing a second computerized tomogram (adjusted OR 0.2, 95% CI 0.05-0.9, p = 0.04). Number needed to treat to prevent 1 repeat scan in high grade renal trauma patients was 3 (95% CI 2-4). Estimated sensitivity and specificity for ultrasound monitoring to detect an abnormality requiring urological intervention are 50% and 94%, respectively. CONCLUSIONS:Repeat computerized tomography in pediatric patients with renal trauma is common. Obtaining delayed imaging on the initial scan in patients with high grade renal trauma may prevent repeat scans. Renal ultrasound provides diagnostic usefulness in monitoring kidney injuries and should be considered before repeating computerized tomography.

IntroductionEmergency department visits and hospital admissions resulting from adult bicycle trauma have increased dramatically. Annual medical costs and work losses of these incidents last were estimated for 2005 and quality-of-life losses for 2000.MethodsWe estimated costs associated with adult bicycle injuries in the USA using 1997–2013 non-fatal incidence data from the National Electronic Injury Surveillance System with cost estimates from the Consumer Product Safety Commission's Injury Cost Model, and 1999–2013 fatal incidence data from the National Vital Statistics System costed by similar methods.ResultsApproximately 3.8 million non-fatal adult bicycle injuries were reported during the study period and 9839 deaths. In 2010 dollars, estimated adult bicycle injury costs totalled $24.4 billion in 2013. Estimated injury costs per mile bicycled fell from $2.85 in 2001 to $2.35 in 2009. From 1999 to 2013, total estimated costs were $209 billion due to non-fatal bicycle injuries and $28 billion due to fatal injuries. Inflation-free annual costs in the study period increased by 137% for non-fatal injuries and 23% for fatal injuries. The share of non-fatal costs associated with injuries to riders age 45 and older increased by 1.6% (95% CI 1.4% to 1.9%) annually. The proportion of costs due to incidents that occurred on a street or highway steadily increased by 0.8% (95% CI 0.4% to 1.3%) annually.ConclusionsInflation-free costs per case associated with non-fatal bicycle injuries are increasing. The growth in costs is especially associated with rising ridership, riders 45 and older, and street/highway crashes.

Urinary diversion (UD) remains the last option for improving quality of life in patients with treatment-refractory urinary incontinence (UI) or voiding dysfunction after cancer treatment. We aim to critically review the utility of UD for UI and voiding dysfunction in patients previously treated for malignancy. UD patients are at high risk given their oncologic treatment and multiple procedures prior to UD. The severe impact of UI and voiding dysfunction on quality of life is significant. Despite the risk of complications after UD, men reported significant improvement of their urinary symptoms and were confident that they would have sought UD sooner. UD remains a last option for some men dealing with severe urinary symptoms after treatment of pelvic malignancy in both men and women. Further investigation is needed to better characterize the burden of disease and potential gains surrounding management of these men.

We evaluated the short and long-term surgical outcomes of urinary diversion done for urinary adverse events arising from prostate radiation therapy. We hypothesized that patient characteristics are associated with complications after urinary diversion.We performed a retrospective cohort study of 100 men who underwent urinary diversion (urinary conduit or continent catheterizable pouch) due to urinary adverse events after prostate radiotherapy from 2007 to 2016 from 9 academic centers in the United States. Outcome measurements included predictors of short and long-term complications, and readmission after urinary diversion of patients who had prostate cancer treated with radiotherapy. The data were summarized using descriptive statistics and univariate associations with complications were identified with logistic regression controlling for center.Mean patient age was 71 years and median time from radiotherapy to urinary diversion was 8 years. Overall 81 (81%) patients had combined modality therapy (radical prostatectomy plus radiotherapy or various combinations of radiotherapy). Grade 3a or greater Clavien-Dindo complications occurred in 31 (35%) men, including 4 deaths (4.5%). Normal weight men had more short-term complications compared to overweight (OR 4.9, 95% CI 1.3-23.1, p=0.02) and obese men (OR 6.3, 95% CI 1.6-31.1, p=0.009). Hospital readmission within 6 weeks of surgery occurred for 35 (38%) men. Surgery was needed to treat long-term complications after urinary diversion in 19 (22%) patients with a median followup of 16.3 months.Urinary diversion after prostate radiotherapy has a considerable short and long-term surgical complication rate. Urinary diversion most often cannot be avoided in these patients but appreciation of the risks allows for informed shared decision making between surgeons and patients.

Objective STIs are the most common infections among adults. Concurrently, pubic hair grooming is prevalent. Small-scale studies have demonstrated a relationship between pubic hair grooming and STIs. We aim to examine this relationship in a large sample of men and women. Design We conducted a probability survey of US residents aged 18–65 years. The survey ascertained self-reported pubic hair grooming practices, sexual behaviours and STI history. We defined extreme grooming as removal of all pubic hair more than 11 times per year and high-frequency grooming as daily/weekly trimming. Cutaneous STIs included herpes, human papillomavirus, syphilis and molluscum. Secretory STIs included gonorrhoea, chlamydia and HIV. We analysed lice separately. Results Of 7580 respondents who completed the survey, 74% reported grooming their pubic hair, 66% of men and 84% of women. After adjusting for age and lifetime sexual partners, ever having groomed was positively associated with a history of self-reported STIs (OR 1.8; 95% CI 1.4 to 2.2), including cutaneous STIs (OR 2.6; CI 1.8 to 3.7), secretory STIs (OR 1.7; CI 1.3 to 2.2) and lice (OR 1.9; CI 1.3 to 2.9). These positive associations were stronger for extreme groomers (OR 4.4; CI 2.9 to 6.8) and high-frequency groomers (OR 3.5; CI 2.3 to 5.4) with cutaneous STIs, and for non-extreme groomers (OR 2.0; CI 1.3 to 3.0) and low-frequency groomers (OR 2.0; CI 1.3 to 3.1) with lice. Conclusions Among a representative sample of US residents, pubic hair grooming was positively related to self-reported STI history. Further research is warranted to gain insight into STI risk-reduction strategies.

Author(s): Baradaran, Nima; Awad, Mohannad; Gaither, Thomas W; Fergus, Kirkpatrick B; Ndoye, Medina; Cedars, Benjamin E; Balakrishnan, Ashwin S; Eisenberg, Michael L; Sanford, Tom; Breyer, Benjamin N | Abstract: OBJECTIVE:To assess the association of genital numbness and erectile dysfunction in male cyclists. SUBJECTS AND METHODS:Cyclists were recruited through Facebook advertisements and outreach to sporting clubs. This is a secondary analysis of a larger epidemiological population-based study that examined sexual and urinary wellness in athletes. We queried cycling habits and erectile function using Sexual Health Inventory for Men (SHIM). RESULTS:A total of 2 774 male cyclists were included in the analysis. Amongst cyclists, there was a statistically significant increase in the trend of genital numbness presence with more years of cycling (P = 0.002), more frequent weekly cycling (P l 0.001), and longer cycling distance at each ride (P l 0.001). Less frequent use of padded shorts (odds ratio [OR] 0.14, P l 0.001) and lower handlebar (OR 0.49, P l 0.001) were associated with numbness, but body mass index (BMI) (OR 1.1, P = 0.33) and age (OR 1.2, P = 0.15) were not. In a multivariate logistic regression model, after adjusting for age, BMI, and lifetime miles (calculated by average daily cycling mileage × cycling days/week × cycling years.), there were no statistically significant differences in mean SHIM score between cyclists with and cyclists without numbness (20.3 vs 20.2, P = 0.83). However, interestingly, the subset of cyclists who reported numbness in the buttock reported statistically significantly worse SHIM scores (20.3 vs 18.4, P l 0.001). This association was not present in cyclists who reported numbness in the scrotum, penis, or perineum and remained significant after adjusting for overall biking intensity. CONCLUSION:Cyclists report genital numbness in proportion with biking intensity but numbness is not associated with worse sexual function in this cohort.

PurposePerineal urethrostomy is a viable option for many complex urethral strictures. However, to our knowledge no comparison with anterior urethroplasty regarding patient reported outcome measures has been published. We compared these groups using a large multi-institution database.Materials and methodsWe performed a retrospective study of anterior urethroplasty in the TURNS (Trauma and Urologic Reconstructive Network of Surgeons) database. The anterior urethroplasty cohort was defined by long strictures greater than 6 cm. We compared demographic, clinical, urinary and sexual characteristics using validated patient reported outcome measures between patients treated with long stricture anterior urethroplasty and those who underwent perineal urethrostomy.ResultsOf the 131 patients 92 treated with long stricture anterior urethroplasty and 39 treated with perineal urethrostomy met study inclusion criteria. The cumulative incidence of failure at 2 years was 30.2% (95% CI 18.3-47.3) for long stricture anterior urethroplasty and 14.5% (95% CI 4.8-39.1) for perineal urethrostomy (p = 0.09). Compared to baseline metrics, patients who underwent long stricture anterior urethroplasty and perineal urethrostomy had similar improvements in urinary function and stable sexual function after surgery.ConclusionsPatients reported improvement in urinary function after perineal urethrostomy with no deleterious effect on sexual function. These patient reported outcome measures were comparable to those of long stricture anterior urethroplasty. Perineal urethrostomy failure rates were similar to those of long stricture anterior urethroplasty.

INTRODUCTION AND OBJECTIVES:Perineal urethrostomy is a viable option for many complex urethral strictures; however, no comparison with anterior urethroplasty (AU) or complex AU regarding patient re...

Objective To estimate the cost-effectiveness of routine, screening renal bladder ultrasound (RBUS) for children age 2-24 months after a first febrile urinary tract infection (UTI), as recommended by the American Academy of Pediatrics. Study design We developed a decision analytic model that simulates a population of children after a first febrile UTI. The model incorporates the diagnostic utility of RBUS to detect vesicoureteral reflux and genitourinary anomalies. We adopted a health-system perspective, 5-year horizon, and included 1-way and 2-way sensitivity analyses. Costs were inflated to 2018 US dollars, and our model incorporated a 3% discounting rate. We compared routine RBUS after first, febrile UTI compared with routine RBUS after second UTI (ie, control arm). Our main outcomes were recurrent UTI rate and incremental cost per quality-adjusted life-year (QALY). Results Among children 2-24 months after a first febrile UTI, RBUS had an overall accuracy (true positives + true negatives) of 64.4%. The recurrent UTI rate in the intervention arm was 19.9% compared with 21.0% in the control arm. Thus, 91 patients would need to be screened with RBUS to prevent 1 recurrent UTI. RBUS increases QALYs by +0.0002 per patient screened, corresponding to an incremental cost-effectiveness ratio of $803 000/QALY gained. In the RBUS arm, 20.6% of children would receive unnecessary voiding cystourethrograms compared with 12.2% of children in the control group. Conclusions Screening RBUS after a first, febrile UTI in children age 2-24 months does not meet cost-effectiveness guidelines. Our findings support deferred screening until a second UTI.

IntroductionWorkforce disparities in medicine have been well documented. Early medical school exposures have been shown to highly influence career choice. We hypothesized that gender and racial disparities exist in early medical school exposures to urology.MethodsWe surveyed urology residency applicants who interviewed at our institution from 2016 to 2017. Student demographics were collected in addition to forms of urology exposures (clinical and research). Early urology exposure was defined as occurring before the 3rd year of medical school. Early exposures were compared by gender and racial/ethnic groups underrepresented in medicine.ResultsDuring the study period 72 interviewees were invited to participate and 71 completed the survey (response rate 98.6%). The majority of participants were male (54, 76%). Thirteen participants (18%) met the criteria for underrepresented in medicine. Fewer female applicants discovered urology (41% vs 75%, p=0.01), first shadowed a urologist (35% vs 68%, p=0.02), first operated with a urologist (29% vs 60%, p=0.03) and began research (0% vs 49%, p

PURPOSE:To assess the functional Queryoutcome of patients with cystoscopic recurrence of stricture post-urethroplasty and to evaluate the role of cystoscopy as initial screening tool to predict future failure. METHODS:Cases with cystoscopy data after anterior urethroplasty in a multi-institutional database were retrospectively studied. Based on cystoscopic evaluation, performed within 3-months post-urethroplasty, patients were categorized as small-caliber (SC) stricture recurrence: stricture unable to be passed by standard cystoscope, large-caliber (LC) stricture accommodating a cystoscope, and no recurrence. We assessed the cumulative probability of intervention and the quality of life scores in association with cystoscopic recurrence 1-year post-urethroplasty. Patients with history of hypospadias, perineal urethrostomy, urethral fistula, and meatal pathology were excluded. RESULTS:From a total of 2630 men in our cohort, 1054 patients met the inclusion criteria: normal (n = 740), LC recurrence (n = 178), and SC recurrence (n = 136) based on the first cystoscopic evaluation performed at median 111 days postoperatively. Median follow-up was 350 days (IQR 121-617) after urethroplasty. Cystoscopic recurrence was significantly associated with secondary interventions (2.7%, 6.2%, 33.8% in normal, LC, and SC groups, respectively). Quality of life variables were not statistically significantly different among the three study groups. CONCLUSIONS:Many patients with cystoscopic recurrence do not need an intervention after initial urethroplasty. Despite good negative predictive value, cystoscopy alone may be a poor screening test for stricture recurrence defined by patient symptoms and need for secondary interventions.

Introduction Implications of lubricant use in men having sex with men (MSM) are poorly characterized, particularly associations with sexual behavior and rectal sexually transmitted infection (STI) risk. Aim We sought to clarify covariates associated with lubrication type including differing sexual preferences and rectal STI prevalence. Methods Primary English-speaking individuals ≥18 years old visiting San Francisco City Clinic (SFCC) between April and May of 2018 who endorsed lubricant use during receptive anal sex within the last 3 months were studied. Associations between lubrication type used and collected covariates were assessed using Kruskal-Wallis analysis of variance for continuous variables and Chi-squared test for categorical variables. We used logistic regression to examine the association between lubrication type and rectal STI test result. Main Outcome Measures Rectal STI test positivity. Results From all enrolled participants, 179 completed the survey and endorsed use of a lubricant during receptive anal sex within the last 3 months. Silicone lubricant users had the most sexual partners in the last 3 months (13 [mean] ± 30 [SD], P= .0003) and were most likely to have a history of gonorrhea. Oil-based lubricant users had the most partners with whom they had receptive anal sex in the last 3 months (7 ± 6, P= .03). Water-based lubricant users most commonly used a condom in their last sexual encounter and had the fewest sexual partners in the last 3 months (4 ± 4, P= .0003). Spit/saliva lubricant use was associated with positive rectal STI result. Conclusion Silicone and oil-based lubricant users were more likely to report condomless receptive anal sex and to have a history of gonorrhea while spit/saliva lubricant use associated with positive rectal STI acquisition.

ProblemSystems-based practice focuses on the organization, financing, and delivery of medical services. The American Association of Medical Colleges has recommended that systems-based practice be incorporated into medical schools' curricula. However, experiential learning in systems-based practice, including practical strategies to improve the quality and efficiency of clinical care, is often absent from or inconsistently included in medical education.InterventionA multidisciplinary clinician and nonclinician faculty team partnered with a cardiology outpatient clinic to design a 9-month clerkship for 1st-year medical students focused on systems-based practice, delivery of clinical care, and strategies to improve the quality and efficiency of clinical operations. The clerkship was called the Action Research Program. In 2013-2014, 8 trainees participated in educational seminars, research activities, and 9-week clinic rotations. A qualitative process and outcome evaluation drew on interviews with students, clinic staff, and supervising physicians, as well as students' detailed field notes.ContextThe Action Research Program was developed and implemented at the University of California, San Francisco, an academic medical center in the United States. All educational activities took place at the university's medical school and at the medical center's cardiology outpatient clinic.OutcomeStudents reported and demonstrated increased understanding of how care delivery systems work, improved clinical skills, growing confidence in interactions with patients, and appreciation for patients' experiences. Clinicians reported increased efficiency at the clinic level and improved performance and job satisfaction among medical assistants as a result of their unprecedented mentoring role with students. Some clinicians felt burdened when students shadowed them and asked questions during interactions with patients. Most student-led improvement projects were not fully implemented.Lessons learnedThe Action Research Program is a small pilot project that demonstrates an innovative pairing of experiential and didactic training in systems-based practice. Lessons learned include the need for dedicated time and faculty support for students' improvement projects, which were the least successful aspect of the program. We recommend that future projects aiming to combine clinical training and quality improvement projects designate distinct blocks of time for trainees to pursue each of these activities independently. In 2014-2015, the University of California, San Francisco School of Medicine incorporated key features of the Action Research Program into the standard curriculum, with plans to build upon this foundation in future curricular innovations.

PurposeAmerican minority groups have been historically underrepresented in phase III prostate cancer clinical trials despite often having higher risk disease. We analyzed enrollment trends of major racial/ethnic groups in the United States in phase III prostate cancer trials between 2003 and 2014 compared to SEER (Surveillance, Epidemiology and End Results) incidence data.Materials and methodsPhase III prostate cancer trials primarily enrolling patients from the United States were identified in the ClinicalTrials.gov database. Enrollment trends were analyzed for major racial/ethnic groups. Prostate cancer incidence data from the SEER registry were used to identify enrollment targets. The enrollment difference was determined by calculating the absolute difference between the percent of a racial/ethnic subgroup in the SEER registry population and the percent of that subgroup in the phase III prostate cancer trial population.ResultsAmong 39 studies identified African American enrollment in therapeutic trials increased across the study period (p

Background Genital numbness and erectile dysfunction in cyclists may result from repeated perineal impacts on the bicycle saddle (micro-trauma) that occur during routine cycling. Aim To evaluate the relationship between oscillation forces and perineal pressures among cyclists in a simulated laboratory setting. Methods Participants were fit to a study bicycle to ensure all cyclists had the same torso angle (60 ± 1 degree) and maximum knee angle (150 ± 1 degree). A lever system was used to generate oscillation events of 3 progressively increasing magnitudes. Perineal pressure was continuously measured using a pressure sensor on the bicycle saddle. This process was carried out in each of the following conditions: (1) stationary (not pedaling) with the standard seatpost, (2) pedaling with standard seatpost, (3) stationary with seatpost shock absorber, and (4) pedaling with seatpost shock absorber. Outcomes We compared perineal pressure changes during oscillation events in the stationary and pedaling states, with and without the seatpost shock absorber. Results A total of 39 individuals were recruited (29 men and 10 women). As the amount of oscillation increased from an average of 0.7g (acceleration due to Earth’s gravity) to 1.3g, the perineal pressure increased from 10.3% over baseline to 19.4% over baseline. There was a strong linear relationship between the amount of oscillation and increase in pressure (r2 = 0.8, P < .001). A seatpost shock absorber decreased the impact of oscillation by 53% in the stationary condition. Men and women absorbed the majority of shock in areas corresponding to pelvic bony landmarks. Conclusion This study represents one of the first characterizations of cycling-associated perineal micro-trauma in a laboratory setting. We found a strong linear relationship between oscillation magnitude and perineal pressure during cycling, which was mitigated by a seatpost shock absorber. The use of shock absorption in bicycle design may reduce perineal micro-trauma and potentially improve cycling-associated perineal numbness and erectile dysfunction.

Author(s): Porten, Sima P; Gaither, Thomas W; Greene, Kirsten L; Baradaran, Nima; Anger, Jennifer T; Breyer, Benjamin N | Abstract: ObjectiveTo further explore the issue of work parity between male and female urologists in the context of demographics, practice characteristics, subspecialty affiliation, and planned retirement.Materials and methodsWe analyzed data from the 2014 American Urological Association census, which is a specialty wide survey distributed to the entire urology community in the United States. A total of 2204 census samples were weighted to represent 11,703 urologists who practiced in the United States in 2014. We compared clinical and nonclinical hours worked by gender after adjusting for age, practice setting, fellowship type, and whether or not the urologist performed inpatient operations.ResultsOf the 11,703 practicing urologists in the United States, female urologists make up approximately 7.7% of the workforce (n ~ 897). Female practicing urologists were younger (66.4%, l45 years old), had shorter training intervals, and a younger planned retirement age than their male counterparts (63 years vs 68.5 years, P l.001). More women were fellowship-trained in a urologic subspecialty (54.9% vs 34.9%, P l.001) and more were in academic practices (33.2% vs 21.9%, P = .03). After adjusting for age, practice type, subspecialty, and inpatient operations performed, there was no difference in hours worked between women and men (beta-coefficient -2.8, 95% confidence interval -6.4 to 0.7, P = .12).ConclusionGender does not appear to drive the number of hours urologists work per week. There is work hour parity between women and men practicing urologists in both clinical and nonclinical hours. Women are proportionately more likely to pursue fellowship training and hold academic positions.

INTRODUCTION AND OBJECTIVES: To describe the epidemiology of genital burns in the U.S. and investigate the underlying etiology. METHODS: The National Electronic Injury Surveillance System database was queried for individuals who sustained genital burns from 2000 to 2016. We collected data on age, gender, injury diagnosis, disposition, and causative agents. Multivariate analysis was performed to determine predictors of hospitalization. RESULTS: We estimate 17,026 (95% CI 16,649–17,404) cases of genital burns presented to emergency departments nationally. Genital burns occurred more in males than females (12,295 vs 4,731). Scalding (57.9%) was the most common mechanism of injury and hot water (35.7%) the most common causative agent. Significant predictors of hospitalization on multivariate analysis were multi-surface (OR 4.4), scalding (OR 11.5) and thermal burns (OR 27.9). Children ages 0–2 had the highest prevalence of genital burns, and children ages 0–12 comprised 37.1% of the study. For children

There is a growing body of evidence in health disparity research that racial concordance between patient and physician can contribute to patient’s trust, satisfaction, resource utilization, and decision-making participation. To compare the current racial/ethnic characteristics of practicing urologists to the U.S. population by American Urological Association (AUA) census geographic region. We compared urologist demographics from the 2014 AUA census to U.S. census data. Underrepresented in medicine (URM) status was defined as African-American (AA) or Hispanic race/ethnicity. Percent differences by AUA section were calculated by subtracting weighted frequencies of race/ethnicity for urologists from the general population. A negative percent difference denotes underrepresentation of urologists relative to the general population; positive percent difference denotes overrepresentation. URM urologists (n=728, 6.5%) were younger and more often female than non-URM counterparts. Overall, AA and Hispanic urologists were underrepresented in most sections while Caucasian and Asian urologists were overrepresented. AA urologists were most underrepresented in the East South-Central section (−34.4%). Hispanic urologists (−38%) were most underrepresented in the Pacific section (−38%). Overall, the percentage of URM urologists, compared to non-URM urologists, were highest in the South Atlantic [37.9% (276/728) vs . 19.2% (1,984/10,319), P vs . 11.1% (1,143/10,319), P

Objective To determine if traumatic renal injuries or computed tomography (CT) findings are predictive of hypertension (HTN) development following injury. Methods A retrospective review of a renal trauma database was performed from 1995 to 2015. Renal injuries were graded by the American Association for the Surgery of Trauma system, with high-grade defined as IV or V. Nonrenal genitourinary trauma (ie bladder, penile, urethral, and testicular) patients were selected as controls. Patients with a diagnosis of HTN before their trauma or those lacking follow-up were excluded. Risk factors associated with HTN following trauma were identified using multivariable regression with propensity scoring. Results In total, 163 patients had a renal injury and 60 had nonrenal, genitourinary injuries. The median age was 31 years (interquartile range 23-43) with median follow-up of 4.7 years (interquartile range 1.9-8.5). Twenty-three (14%) patients with renal trauma were newly diagnosed with HTN on follow-up, compared with 2 (3%) in the control groups. (P = .02) After propensity quartile adjustment, patients with high-grade trauma had higher odds of developing HTN compared with low-grade renal trauma patients and controls (adjusted odds ratio 3.5, 95% confidence interval 1.3-9.3, P = .01). Patients with a midpole medial laceration and medial blood on CT had higher odds of developing HTN compared with patients without these characteristics (odds ratio 5.36, 95% confidence interval 1.3-22.6, P = .02). Conclusion Increasing renal trauma grade is a risk factor for future development of HTN. CT findings at trauma presentation may be useful in stratifying patients who are at increased risk.

Summary Background The association between obesity and urinary dysfunction in childhood has been described, albeit through retrospective analysis, making temporal relationships difficult to establish. Objective The objective of this study was to determine risk factors for significant weight gain in children at risk for recurrent urinary tract infections. Study design A secondary analysis of the Randomized Intervention for Children with Vesicoureteral Reflux and Careful Urinary Tract Infection Evaluation trials was conducted. The outcome of interest in these children was significant increase in body mass index (BMI) percentile (>85th BMI percentile for sex and age) in previously normal-weight children. Multivariable logistic regression was used to determine the independent effects of predetermined risk factors. Results In total, 446 patients were included in the study. Most patients aged less than 1 year at study entry (229, 51%), and 399 (89%) of patients were female. Eighty-four patients (17%) became clinically overweight. Patients assigned to prophylactic antibiotics were not more likely to gain significant BMI percentiles (adjusted odds ratio [aOR] = 1.1, 95% confidence interval [CI] = 0.6–1.8). Significant BMI percentiles were gained in Hispanic/Latino patients compared with whites (aOR = 3.3, 95% CI = 1.7–6.4), in children who were infants at study enrollment compared with non-infants (aOR = 2.1, 95% CI = 1.2–3.8), and in those with persistent reflux during the study period (aOR = 2.1, 95% CI = 1.0–4.3). Neither patients assigned to prophylactic antibiotics (aOR = 1.1, 95% CI = 0.6–1.8) nor patients with bladder and bowel dysfunction (BBD) (aOR = 1.2, 95% CI = 0.6–2.3) were more likely to gain significant BMI percentiles. Discussion Significant BMI percentile gain is common in patients at risk for UTIs. Hispanic/Latino ethnicity, persistent reflux, and younger age, specifically infants than non-infants, were identified as independent risk factors for becoming overweight in this population. Exposure to prophylactic antibiotics and BBD were not associated with becoming overweight. Conclusion Risk for becoming overweight should be discussed when managing patients at risk for UTIs, especially in the subpopulations identified. Summary Table . Multivariable analysis of associations with significant BMI percentile gain in the RIVUR/CUTIE studies. Clinical variables Study estimate persistent reflux n = 446 Study arm No antibiotic prophylaxis 1.0 (reference) Antibiotic prophylaxis 1.1 (0.6–1.8) Age Non-infant 1.0 (reference) Infant 2.1 (1.2–3.8) a Sex Female 1.0 (reference) Male 1.5 (0.7–3.2) Race/ethnicity White 1.0 (reference) Black 1.3 (0.4–3.7) Asian 0.5 (0.1–4.2) Hispanic/Latino 3.3 (1.7–6.4) a Mixed/other 1.2 (0.5–2.9) BBD ever 1.2 (0.6–2.3) Persistent reflux None/resolved 1.0 (reference) Persistent 2.1 (1.0–4.2) a BMI, body mass index; BBD, bladder and bowel dysfunction; CUTIE, Careful Urinary Tract Infection Evaluation; RIVUR, Randomized Intervention for Children with Vesicoureteral Reflux. a P-value

Background Female genital self-image is an important aspect of psychosocial and sexual health. The Female Genital Self-Image Scale (FGSIS) is a validated instrument that has been used to characterize women’s level of genital dissatisfaction. Aim In this report, we assess genital dissatisfaction using the FGSIS in a nationally representative sample of U.S. women. Methods We conducted a nationally representative survey of non-institutionalized adults aged 18–65 years residing in the United States. The survey included questions about demographics, sexual behavior, and the FGSIS. Outcomes Demographic characteristics were found to significantly correlate to women's perceived genital dissatisfaction. Results In total, 3,372 women completed the survey and 3,143 (93.2%) completed the FGSIS. The mean age was 46 years, and there was broad representation across the United States in terms of age, education, and location. On bivariate analysis, women’s genital dissatisfaction was significantly correlated to their age, race, location, and education. Women who were sexually active were less likely to report genital dissatisfaction than women who were not sexually active (76% vs 62%, respectively, P < .001). The frequency of sexual activity was negatively correlated with genital dissatisfaction (P = .002). Women who reported genital dissatisfaction were less likely than those who reported satisfaction to engage in receptive vaginal sex (83% vs 88%, respectively, P = .03). There were no other significant associations between genital dissatisfaction and types of sexual activity. On multivariate analysis, women were less likely to report genital dissatisfaction if they were older, of black race, had an education level of high school or above, and/or lived in the Northeastern or Midwestern United States. There was no association between genital dissatisfaction and relationship status or gender of sexual partner. Clinical Translation Female genital dissatisfaction may be related to age, race, education, and geography. Conclusions This is the first nationally representative sample of U.S. women focusing on genital and self-image and dissatisfaction. These data may not apply outside the United States. These data may help providers who provide information for women and manage concerns related to genital self-image.