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Male hypogonadism is a congenital or acquired disorder that exerts a negative influence on various organ functions and can massively impair the quality of life through the relative or absolute deficiency of testosterone. A variety of preparations are available for substitution treatment, which differ in administration form and intake interval. For the execution of testosterone treatment various guidelines exist with clear and practical instructions on the indications, contraindications, treatment procedure and monitoring. Of particular importance are cardiovascular aspects and diseases of the prostate gland, which underlines the central position of the urologist in the treatment.Beim männlichen Hypogonadismus handelt es sich um eine kongenitale oder erworbene Erkrankung, die durch den vorliegenden relativen oder absoluten Testosteronmangel einen negativen Einfluss auf verschiedene Organfunktionen ausübt und die Lebensqualität massiv beeinträchtigen kann. Zur Substitutionsbehandlung stehen verschiedene Präparate zur Verfügung, welche sich in der Darreichungsform und den Einnahmeintervallen unterscheiden. Zur Durchführung der Testosterontherapie existieren mehrere Leitlinien mit klaren und praktischen Handlungsanweisungen zu Indikationsstellung, Kontraindikationen, Therapiedurchführung und -monitoring. Hierbei sind insbesondere kardiovaskuläre Aspekte und Erkrankungen der Prostata von Bedeutung, was die zentrale Stellung des Urologen in der Behandlung verdeutlicht.

Sexual health is becoming increasingly important for many HIV-positive men undergoing highly effective antiretroviral therapy (ART) but remains frequently unaddressed in routine clinical consultation.To comprehensively evaluate sexual health in male patients with HIV on stable ART over a 12-month period.The prospectively registered cohort study comprising 87 HIV-positive men on stable ART (median age: 43 years) was conducted between 2011 and 2015 at a university hospital. Patients were enrolled from the outpatient infectious disease unit and underwent an extensive andrological workup to assess parameters of sexual health (questionnaires, sex hormones, ultrasound, 2-glass urine test including semen analysis with microbiological and viral diagnostics). The study period per patient lasted 12 months.The primary endpoint was the impact of chronic HIV infection on sexual health.Although, on average, sexual health was fine at baseline, 56% of the patients reported erectile dysfunction, 28% experienced reduced libido, 5% had hypogonadism, 36% showed at least 1 atrophic testicle with a volume of10 ml, 8% suffered bacterial sexually transmitted infections, 35% had seminal inflammation, and up to 47% showed reduced sperm quality. Sexual satisfaction was linked to mental health (12-Item Short Form Health Survey questionnaire) and International Index of Erectile Function scores. During the study period, the collected parameters on sexual health were generally stable. However, 35% of patients had new sex partners (median: 5 partners), 7% had fathered a child or were planning procreation, 47% reported changed libido, 17% suffered bacterial sexually transmitted infections in the urogenital tract, 16% revealed a positive HIV viral load in blood, 11% had a positive HIV viral load in semen, and 28% were treated for andrological disorders.Sexual ill-health exists in about one third of patients. This manifests itself in sexual dysfunction, sexually transmitted infections, urogenital tract inflammation, and abnormal sperm parameters, all of which require adequate counseling and therapy.The strength of this study is its comprehensive analysis of male sexual health over a 12-month period of stable ART treatment. Limitations are a heterogeneous patient cohort and a rather small percentage of patients with a positive HIV viral load in blood or semen, which prevented multivariate risk analysis.Our study provides evidence that sexual health should be actively taken into account in the routine consultation by infectious disease specialists, and an interdisciplinary approach is desirable in the case of symptoms or signs of sexual ill-health. Pilatz A, Maresch CC, Discher T, et al. Sexual Health in HIV-Positive Men Under Stable Antiretroviral Therapy During a 12-Month Period. J Sex Med 2021;18:284-294.

Although the evolutionary history of the X chromosome indicates its specialization in male fitness, its role in spermatogenesis has largely been unexplored. Currently only three X chromosome genes are considered of moderate-definitive diagnostic value. We aimed to provide a comprehensive analysis of all X chromosome-linked protein-coding genes in 2,354 azoospermic/cryptozoospermic men from four independent cohorts. Genomic data were analyzed and compared with data in normozoospermic control individuals and gnomAD. While updating the clinical significance of known genes, we propose 21 recurrently mutated genes strongly associated with and 34 moderately associated with azoospermia/cryptozoospermia not previously linked to male infertility (novel). The most frequently affected prioritized gene, RBBP7, was found mutated in ten men across all cohorts, and our functional studies in Drosophila support its role in germ stem cell maintenance. Collectively, our study represents a significant step towards the definition of the missing genetic etiology in idiopathic severe spermatogenic failure and significantly reduces the knowledge gap of X-linked genetic causes of azoospermia/cryptozoospermia contributing to the development of future diagnostic gene panels., This work was funded by Spanish Ministry of Health Instituto Carlos III-FIS (grant numbers PI17/01822 and PI20/01562) and the Fanconi Research Fund awarded to C.K. and A.R.-E.; the German Research Foundation Clinical Research Unit “Male Germ Cells” (DFG CRU326), grants to F.T. and C.F.; the National Institutes of Health (R01HD078641), awarded to D.F.C., L.N., and K.I.A.; the Netherlands Organisation for Scientific Research (918-15-667) as well as an Investigator Award in Science from the Wellcome Trust (209451) to J.A.V.; and the MICINN (BFU2015-65082-P and PGC2018-094538-B-I00), the Generalitat de Catalunya (SGR2009-1023 and SGR2014-204), and the European Community FEDER program to F.A.

International audience; Sperm develop from puberty in the seminiferous tubules, inside the blood-testis barrier to prevent their recognition as "non-self" by the immune system, and it is widely assumed that human sperm-specific proteins cannot access the circulatory or immune systems. Sperm-specific proteins aberrantly expressed in cancer, known as cancer-testis antigens (CTAs), are often pursued as cancer biomarkers and therapeutic targets based on the assumption they are neoantigens absent from the circulation in healthy men. Here, we identify a wide range of germ cell-derived and sperm-specific proteins, including multiple CTAs, that are selectively deposited by the Sertoli cells of the adult mouse and human seminiferous tubules into testicular interstitial fluid (TIF) that is "outside" the blood-testis barrier. From TIF, the proteins can access the circulatory- and immune systems. Disruption of spermatogenesis decreases the abundance of these proteins in mouse TIF, and a sperm-specific CTA is significantly decreased in TIF from infertile men, suggesting that exposure of certain CTAs to the immune system could depend on fertility status. The results provide a rationale for the development of blood-based tests useful in the management of male infertility and indicate CTA candidates for cancer immunotherapy and biomarker development that could show sex-specific and male-fertility-related responses.

Objectives: We developed the first German evidence- and consensus-based clinical guideline on diagnosis, treatment, and follow-up of germ cell tumours (GCT) of the testes in adult patients. We present the guideline content in 2 separate publications. The present second part summarizes therecommendations for the treatment of advanced disease stages and for the management of follow-up and late effects. Materials and Methods: An interdisciplinary panel of 42 experts including 1 patient representative developed the guideline content. Clinical recommendations and statements were based on scientific evidence and expert consensus. For this purpose, evidence tables for several review questions, which were based on systematic literature searches (last search in March 2018), were provided. Thirty-one experts, who were entitled to vote, rated the final clinical recommendations and statements. Results: Here we present the treatment recommendations separately for patients with metastatic seminoma and non-seminomatous GCT (stages IIA/B and IIC/III), for restaging and treatment of residual masses, and for relapsed and refractory disease stages. The recommendations also cover extragonadal and sex cord/stromal tumours, the management of follow-up and toxicity, quality-of-life aspects, palliative care, and supportive therapy. Conclusion: Physicians and other medical service providers who are involved in the diagnostics, treatment, and follow-up of GCT (all stages, outpatient and inpatient care as well as rehabilitation) are the users of the present guideline. The guideline also comprises quality indicators for measuring the implementation of the guideline recommendations in routine clinical care; these data will be presented in a future publication.

Introduction: This is the first German evidence- and consensus-based clinical guideline on diagnosis, treatment, and follow-up on germ cell tumours (GCTs) of the testis in adult patients. We present the guideline content in two publications. Part I covers the topic’s background, methods, epidemiology, classification systems, diagnostics, prognosis, and treatment recommendations for the localized stages. Methods: An interdisciplinary panel of 42 experts including 1 patient representative developed the guideline content. Clinical recommendations and statements were based on scientific evidence and expert consensus. For this purpose, evidence tables for several review questions, which were based on systematic literature searches (last search was in March 2018) were provided. Thirty-one experts entitled to vote, rated the final clinical recommendations and statements. Results: We provide 161 clinical recommendations and statements. We present information on the quality of cancer care and epidemiology and give recommendations for staging and classification as well as for diagnostic procedures. The diagnostic recommendations encompass measures for assessing the primary tumour as well as procedures for the detection of metastases. One chapter addresses prognostic factors. In part I, we separately present the treatment recommendations for germ cell neoplasia in situ, and the organ-confined stages (clinical stage I) of both seminoma and nonseminoma. Conclusion: Although GCT is a rare tumour entity with excellent survival rates for the localized stages, its management requires an interdisciplinary approach, including several clinical experts. Quality of care is highly related to institutional expertise and can be reassured by established online-based second-opinion boards. There are very few studies on diagnostics with good level of evidence. Treatment of metastatic GCTs must be tailored to the risk according to the International Germ Cell Cancer Collaboration Group classification after careful diagnostic evaluation. An interdisciplinary approach as well as the referral of selected patients to centres with proven experience can help achieve favourable clinical outcomes.

Die Induratio penis plastica (IPP) ist ein typisches, aber heterogenes Krankheitsbild mit den klassischen penilen Symptomen Plaquebildung, peniler Schmerz, Deviation, Verkurzung des Penis und erektile Dysfunktion. Die Atiologie ist unklar. Mikrotraumen werden als Ursache einer nachfolgenden, evtl. genetisch bedingten atypischen Wundheilung mit Bildung eines fibrotischen unelastischen Narbengewebes im Bereich der Tunica albuginea diskutiert. Eine kausale medikamentose Therapie ist deshalb nicht moglich, obwohl vielfaltige konservative Therapieoptionen klinisch eingesetzt werden. Die chirurgische Korrektur einer Penisverkrummung ist in der Phase der stabilen Erkrankung das primare Operationsziel. Unterschiedliche Operationsverfahren werden abhangig von Deviationsgrad, Penislange und erektiler Funktion durchgefuhrt. Dieser Artikel gibt eine Ubersicht uber den aktuellen Stand der Diagnostik sowie konservativer und chirurgischer Therapieoptionen.

Androgene sind fur die sexuelle Differenzierung der Geschlechtsorgane sowie die Ausbildung des mannlichen Phanotyps essenziell. Im Hoden spielt Testosteron eine wesentliche Rolle bei der Spermatogenese. Uber diese androgene Wirkung hinaus werden Sexualverhalten und -aktivitat beim Mann beeinflusst. Dementsprechend vielgestaltig ist die klinische Auspragung eines Testosteronmangels. Die Substitutionsbehandlung mit Testosteronpraparaten ist in der Praxis fest etabliert. Therapienutzen und Risiken mussen jedoch je nach Indikation sorgfaltig abgewogen werden.

The objective of this study was to assess whether CCDS might improve the outcome of testicular sperm retrieval in patients with azoospermia. Furthermore, we evaluated potential sonographic alterations of the testis before and after trifocal and Micro-TESE. 78 patients were enrolled prospectively: 24 with obstructive azoospermia (OA) and 54 with non-obstructive azoospermia (NOA). 31 of 54 patients in the NOA group had negative surgical sperm retrieval. Testicular volume, hormonal parameters and sonographical findings were compared before and after TESE. The spermatogenetic score was determined for all retrieval sites. CCDS was performed at the upper, middle and lower segment of the testis. Ultrasound parameters and peak systolic velocity (PSV) were measured pre- and post-operatively. Testicular volume and epididymal head size were significantly increased in OA patients compared to NOA patients. Ultrasound parameters were comparable between NOA patients with and without successful sperm retrieval. A higher intratesticular PSV was significantly correlated with a better spermatogenic score in the corresponding sonographic position. However, after adjustment for other clinical confounders, PSV does not show a significant influence on the spermatogenic score. Testicular volume decreased significantly in all patients post-operatively after 6 weeks (p

Androgene sind fur die sexuelle Differenzierung der Geschlechtsorgane sowie die Ausbildung des mannlichen Phanotyps essenziell. Im Hoden spielt Testosteron eine wesentliche Rolle bei der Spermatogenese. Uber diese androgene Wirkung hinaus werden Sexualverhalten und -aktivitat beim Mann beeinflusst. Dementsprechend vielgestaltig ist die klinische Auspragung eines Testosteronmangels. Die Substitutionsbehandlung mit Testosteronpraparaten ist in der Praxis fest etabliert. Therapienutzen und Risiken mussen jedoch je nach Indikation sorgfaltig abgewogen werden.

Considering infection/inflammation to be an important risk factor in male infertility, the aim of this study was to make a comprehensive evaluation of the prevalence of urogenital tract infection/inflammation and its potential impact on sperm retrieval in azoospermic patients. In this prospective study, 71 patients with azoospermia were subjected to an extensive andrological workup including comprehensive microbiological diagnostics (2‐glass test, semen, testicular swab and testicular tissue analysis) and testicular biopsy/testicular sperm extraction (TESE). Medical history suggested urogenital tract infection/inflammation in 7% of patients, 11% harboured STIs, 14% showed significant bacteriospermia, 15% had seminal inflammation, 17% fulfilled the MAGI definition, and 27% had relevant pathogens. At the testicular level, 1 patient had a swab positive for bacteria, no viruses were detected, tissue specimens never indicated pathogens, whereas histopathology revealed focal immune cell infiltrates in 23% of samples. Testicular sperm retrieval rate was 100% in obstructive and 46% in nonobstructive azoospermia. None of the infection/inflammation‐related variables was associated with the success of sperm retrieval or inflammatory lesions in the testis. The high prevalence of urogenital infection/inflammation among azoospermic men underpins their role as significant aetiologic factors in male infertility. However, this observation does not refer to the chances of sperm retrieval at the time of surgery/TESE.

Context Empiric use of medical and nutritional supplements to improve semen parameters and pregnancy rates in couples with idiopathic infertility has reached global proportions, although the evidence base for their use in this setting is controversial. Objective We systematically reviewed evidence comparing the benefits of nutritional and medical therapy on pregnancy rates and semen parameters in men with idiopathic infertility. Evidence acquisition A literature search was performed using MEDLINE, Embase, LILACS, and the Cochrane Library (searched from January 1, 1990 to September 19, 2017). using the methods detailed in the Cochrane Handbook. Grading of Recommendations Assessment, Development and Evaluation (GRADE) was used to assess the certainty of evidence. Evidence synthesis The literature search identified 5663 citations, and after screening of abstracts and full texts, 61 studies (59 randomised controlled trials and two nonrandomised comparative studies) were included. Pooled results demonstrated that pentoxyfylline, coenzyme Q10, L-carnitine, follicle-stimulating hormone, tamoxifen, and kallikrein all resulted in improvements in semen parameters. Individual studies identified several other medical and nutritional therapies that improved semen parameters, but data were limited to individual studies with inherent methodological flaws. There were limited data available on live birth and pregnancy rates for all interventions. The GRADE certainty of evidence for all outcomes was very low mainly owing to methodological flaws and inconsistencies in study design. Some outcomes were also downgraded owing to imprecision of results. Conclusions There is some evidence that empiric medical and nutritional supplements may improve semen parameters. There is very limited evidence that empiric therapy leads to better live birth rates, spontaneous pregnancy, or pregnancy following assisted-reproductive techniques. However, the findings should be interpreted with caution as there were some methodological flaws, as a number of studies were judged to be either at high or unclear risk of bias for many domains. Patient summary This review identified several medical and nutritional treatments, such as pentoxyfylline, coenzyme Q10, L-carnitine, follicle-stimulating hormone, tamoxifen, and kallikrein, that appear to improve semen parameters. However, there are limited data suggesting improvements in pregnancy and live birth rates. The lack of evidence can be attributed to methodological flaws in studies and the low number of pregnancies reported.

Purpose: We prospectively evaluated the results of microsurgical spermatic cord denervation in a series of patients with chronic scrotal content pain in a multicenter study, including 1 center in Germany and 3 centers in Chile.Materials and Methods: A total of 50 patients with chronic scrotal content pain more than 3 months in duration were prospectively selected for standardized operative microsurgical spermatic cord denervation as pain treatment. In all patients preoperative management included a positive response to a spermatic cord block test with local anesthesia. Pain severity was assessed using an analog visual pain scale (range 0 to 10) for 30 consecutive days. A total of 52 testicular units were operated on using a subinguinal approach. In all cases a surgical microscope was used to identify the arteria testicularis.Results: No intraoperative complications were observed and no testicular units were lost. Two reoperations were performed, including 1 for hematocele and 1 for hydrocele. Six months a...

Aim The aim of this official guideline published by the German Society of Gynecology and Obstetrics (DGGG) and coordinated with the German Society of Urology (DGU) and the German Society of Reproductive Medicine (DGRM) is to provide consensus-based recommendations, obtained by evaluating the relevant literature, on counseling and fertility preservation for prepubertal girls and boys as well as patients of reproductive age. Statements and recommendations for girls and women are presented below. Statements or recommendations for boys and men are not the focus of this guideline. Methods This S2k guideline was developed at the suggestion of the guideline commission of the DGGG, DGU and DGRM and represents the structured consensus of representative members from various professional associations (n = 40). Recommendations The guideline provides recommendations on counseling and fertility preservation for women and girls which take account of the patient's personal circumstances, the planned oncologic therapy and the individual risk profile as well as the preferred approach for selected tumor entities. Ziel Das Ziel dieser offiziellen Leitlinie, die von der Deutschen Gesellschaft für Gynäkologie und Geburtshilfe (DGGG) publiziert und zusammen mit der Deutschen Gesellschaft für Urologie (DGU) sowie Deutschen Gesellschaft für Reproduktionsmedizin (DGRM) koordiniert wurde, ist es, durch die Evaluation der relevanten Literatur konsensbasierte Handlungsempfehlungen für die Beratung und den Einsatz von fertilitätserhaltenden Maßnahmen bei präpubertären Mädchen und Jungen sowie für Patienten/-innen im reproduktiven Alter zu geben. Im Folgendem werden die Statements und Empfehlungen für Mädchen und Frauen dargestellt. Die Statements und Empfehlungen für Jungen und Männer sind nicht Inhalt dieser Publikation. Methoden Diese S2k-Leitlinie wurde durch einen strukturierten Konsens von repräsentativen Mitgliedern verschiedener Fachgesellschaften (n = 40) im Auftrag der Leitlinienkommission der DGGG, DGU und DGRM entwickelt. Empfehlungen Es werden Empfehlungen zur Beratung und dem Einsatz von fertilitätserhaltenden Maßnahmen bei Patientinnen unter Berücksichtigung der Lebensumstände, der geplanten onkologischen Therapie und des individuellen Risikoprofils dargestellt sowie über das Vorgehen bei ausgewählten Tumorentitäten.

There is a consensus on the diagnostic and therapeutic manage¬ment of bacterial prostatitis (acute and chronic). However, increas¬ing antimicrobial resistance rates for quinolones pose problems for the future, especially for therapy of chronic bac¬terial prostatitis. In chronic prostatitis/chronic pelvic pain syndrome, the diag¬nostic approach currently points more and more to an individu¬alized phenotypic assessment, in an effort to direct multimodal management towards improvement of specific symptom domains. Most therapy trials for single agents in CP/CPPS have been nega¬tive, therefore stratification by phenotype followed by individu¬alized multimodal treatment seems to be a promising strategy, although good evidence-based data are not available currently to substantiate this. Consensus regarding the need and option for treatment of asymptomatic prostatitis is far from being achieved. Therefore, taking the high prevalence of infections and inflammations in different asymptomatic conditions into consideration, further research is urgently needed to address this important field.

Sperm retrieval for in vitro fertilization/intracytoplasmic sperm injection is the only medical procedure that enables a man with testicular azoospermia to father a child. In obstructive azoospermia after failed refertilization, microsurgical epididymal sperm aspiration is the gold standard, with retrieval rates up to 100%. In nonobstructive azoospermia (NOA), testicular spermatozoa (spermatids) can be recovered by testicular sperm extraction (TESE) in approximately half of the men. No parameters are available to definitively predict a successful recovery individually, but genetic factors, reduced testicular volume, and high serum follicle-stimulating hormone levels are associated with an unfavorable outcome. Retrieval surgery is well standardized, chiefly performed with microsurgical assistance and without severe local complications. Microsurgically assisted TESE (M-TESE) and TESE that is not microscopically supported in low-chance NOA patients may result in hypogonadism in the long term. In patients with Klinefelter syndrome, the outcome is worse with increasing age. For children before chemotherapy, M-TESE for stem cell preservation must be performed with minimal damage to the testicles.

OBJECTIVES: To investigate semen quality in HIV patients under stable antiretroviral therapy (ART) compared with WHO 2010 reference values and on the sperm proteome level. DESIGN: Between 2011 and 2013, we prospectively enrolled 116 HIV-positive men without hepatitis B or C co-infections from our outpatient department for infectious diseases. METHODS: Patients received a comprehensive andrological work-up. Complete semen analysis was performed according to WHO 2010 recommendations, with each semen variable of the study population being compared with the WHO reference group (n~2000). Correlation analysis was done to investigate the influence of HIV surrogate parameters on semen quality. Two-dimensional gel electrophoresis and subsequent protein identification was performed to determine any differences in the sperm protein composition of the 15 HIV-positive patients and that of 15 age-matched healthy men. RESULTS: Median values of all assessed semen parameters were within a normal range. However, for each semen variable, about 25% of patients had values below the fifth percentile of the WHO 2010 reference group. Disease-related parameters (CD4þ cell count, viral load, CDC stage, duration of disease, duration of ART, number and type of antiretroviral drugs) were not significantly correlated with any sperm parameter. Sperm proteome analysis identified 14 downregulated proteins associated with sperm motility and fertility. CONCLUSION: This is the first study that compares all standard semen parameters in HIV positive patients under ART to WHO 2010 reference values. It provides evidence of impaired conventional semen parameters and altered sperm protein composition. Finally, HIV surrogate parameters are not suitable for predicting semen quality.

Summary As commonly used self-reported screening instruments for male hypogonadism demonstrated lack of specificity, a Hypogonadism Related Symptom Scale (HRS) was developed in 2009 as a novel self-rating screening tool. As the questionnaire has not been validated, the purpose of our study was to perform a validation in patients presenting with different disorders (e.g. infertility, HIV infection or metabolic syndrome) and disease-related risk to develop hypogonadism. Two hundred and eighteen patients aged 19–71 years (40.1 ± 9.5) who completed the HRS and other common questionnaires [International Index Of Erectile Function (IIEF), National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI), Hospital Anxiety and Depression Scale (HADS), short form (SF)-12] were included. In all patients, blood levels of total testosterone, luteinizing hormone, follicle-stimulating hormone, oestradiol and sex hormone-binding globulin were determined and free testosterone was calculated. Cronbach's α for the scale was 0.896, split-half 0.871 for the 1st half and 0.807 for the 2nd half. Spearman–Brown coefficient was 0.767, and Guttman split-half coefficient was 0.759. Consistent correlations were found between HRS and IIEF5 (ρ = 0.57, P

The prostatitis syndrome is classified into bacterial prostatitis (acute and chronic), chronic pelvic pain syndrome and asymptomatic prostatitis. The aim of this report is to review current management standards for bacterial prostatitis.A research was performed on literature dealing with acute and chronic bacterial prostatitis.There is a consensus on diagnostic management of bacterial prostatitis comprising microbiological sampling of midstream urine in acute bacterial prostatitis and performance of a bacterial localisation test in chronic bacterial prostatitis. Approximately 10 % of acute bacterial prostatitis cases eventually develop into chronic bacterial prostatitis and further 10 % into chronic pelvic pain syndrome. Bacterial isolates causing acute bacterial prostatitis are highly virulent strains comprising an array of different virulence factors. Presumably, the additional ability of isolates to form biofilms might be one factor amongst others to facilitate development of chronic bacterial prostatitis. Therapy for infectious prostatitis is standardised with antibiotics as the primary agents, empirically administered in acute prostatitis and after susceptibility testing in chronic bacterial prostatitis. Fluoroquinolones exhibit more favourable pharmacological properties; therefore, fluoroquinolones have been recommended as first-line agents in the treatment for chronic bacterial prostatitis. Antibiotic resistance to fluoroquinolones, however, is increasing and is posing significant clinical problems. Further studies on alternative antibiotics active within the prostate are therefore needed both for prophylaxis in transrectal prostate biopsy, for example, and for therapy of chronic bacterial prostatitis.Bacterial prostatitis has developed into well-managed entities with increasing antimicrobial resistance being the most severe drawback of yielding therapeutic success.

The most common pathologies of the seminal tract are persistent hematospermia, seminal vesicle stones, and seminal duct obstruction. Endoscopic diagnostic work-up of the seminal tract is impeded by complex anatomy and lack of technical equipment. To date, there is no standardized endoscopic approach. The purpose of this study was to investigate the applicability and feasibility of a flexible microoptical device for atraumatic endoscopy of the seminal tract in a male human cadaver.The transurethral endoscopic examination was performed on a male cadaver. No premortal interventions or diseases of the genitourinary tract had been reported. The seminal orifice was identified via cystoscopy and accessed by the Seldinger technique using a hydrophilic guidewire and ureteral catheter. Retrograde endoscopic inspection of the distal seminal tract was performed using a miniaturized flexible endoscope. An antegrade endoscopic inspection of the seminal tract was carried out via high scrotal access to the vas deferens.Structures of the seminal tract, such as the ejaculatory duct, seminal vesicles, and distal portion of the ductus deferentes, were visualized using the miniaturized endoscope. Image quality allowed identification of anatomical structures and characterization of tissue properties. The technical limitations we observed involved the system's maneuverability.Initial results of this novel endoscopic approach to the seminal tract using a flexible microoptical system are encouraging. However, considerable anatomical limitations of the targeted organs necessitate further refinements of the technical equipment. This approach might improve diagnostics and treatment of genitourinary diseases. Future surgical techniques may include intraseminal laser therapy or endoocclusion to monitor fertility in men.

Resumen Contexto La Asociacion Europea de Urologia presenta su guia clinica para la vasectomia. La vasectomia es muy eficaz, pero pueden surgir problemas que estan relacionados con la falta de informacion preoperatoria del paciente, el procedimiento quirurgico y el seguimiento postoperatorio. Objetivo Esta guia clinica tiene por objeto proporcionar informacion y recomendaciones para los medicos que realizan vasectomias y promover el suministro de informacion adecuada al paciente antes de la operacion para evitar expectativas poco realistas y procedimientos legales. Adquisicion de la evidencia Se llevo a cabo una revision exhaustiva de la literatura mediante Medline, Embase y la Base de Datos Cochrane de Revisiones Sistematicas de 1980 a 2010. La atencion se centro en los ensayos controlados aleatorizados (ECA) y los metaanalisis de los ECA (nivel 1 de evidencia) y en los estudios bien disenados sin aleatorizacion (nivel 2 y 3 de evidencia). Un total de 113 registros unicos fueron identificados para su consideracion. Se excluyeron las publicaciones que no estaban en lengua inglesa, asi como los estudios publicados como resumenes solamente o informes de las reuniones. Sintesis de la evidencia La guia clinica debate las indicaciones y contraindicaciones de la vasectomia, la informacion y el asesoramiento preoperatorio del paciente, las tecnicas quirurgicas, los cuidados postoperatorios y el posterior analisis del semen y las complicaciones y consecuencias finales. Conclusiones La vasectomia tiene la intencion de ser un metodo anticonceptivo permanente; No hay contraindicaciones absolutas para la misma. Las contraindicaciones relativas pueden ser la ausencia de hijos, edad

Context Sperm retrieval in combination with IVF/ICSI is the only medical procedure for an azoospermic man to father a child. Different techniques, especially testicular sperm extraction (TESE), have evolved over time and have dramatically improved the outlook for men with testicular azoospermia. However sperm retrieval rates are associated not only with the operation proposed but especially with a distinct pattern of prognostic factors that must be effectively managed for all these infertile patients for their best benefit. Objectives To review the etiology, clinical work-up including operative techniques, and prognostic factors for testicular sperm retrieval in azoospermic men to maximin clinical benefit by these procedures. Evidence Acquisition Data from basic and clinical studies with a defined, standardized approach pre- and postoperatively were analyzed. Evidence Synthesis Different standardized surgical techniques can be offered to extract spermatozoa of azoospermic men from either the epididymis and/or the testis for ICSI. Sperm retrieval offers a treatment for both patients with testicular azoospermia and men with obstructive azoospermia in cases where microsurgical refertilization is not an option or has already failed. Among surgical techniques testicular sperm extraction (TESE) and microsurgical epididymial sperm aspiration (MESA) have become the most popular techniques. However, also percutaneous techniques are employed due their easy feasibility and low costs. By utilizing these techniques together with kryopreservation of extracted spermatozoa a single surgical intervention is able to provide spermatozoa for several ICSI attempts. Extensive surgical interventions in the testis of azoospermic patients have raised concerns about the potential influence on the endocrine compartment of the testis, particularly in patients with small testes and low levels of testosterone. Conclusions Testicular sperm retrieval is a feasible and successful procedure. Testicular spermatozoa can be retrieved from the testis in up to 70% of patients, even in cases with testicular azoospermia and severe disorders of spermatogenesis. However, surgical damage of the testis might also compromise the interstitial compartment of the testis with testosterone deficiency as a consequence. Conclusively, endocrine follow-up can be considered mandatory.

Moderne Techniken der testikularen Samenzellentnahme ermoglichen es bisher unfruchtbaren Mannern, Vater eines Kindes zu werden. Die Operationen sind weitgehend standardisiert, auch die zugrunde liegenden morphologischen Veranderungen der Spermatogenese erscheinen ausreichend bekannt. Im Fokus der Forschung stehen derzeit prognostische Faktoren, die die Ausbeute des „sperm-retrievements“ und die Fertilisierungsraten nach In-vitro-Fertilisation (IVF-ICSI) fur das testikulare Material bestimmen. Die testikulare Spermatozoenextraktion (TESE) und die Mikro-TESE (M-TESE) sind standardisierte operative Verfahren zur testikularen Spermiengewinnung fur die IVF/ICSI. Praoperative Faktoren, die die Spermatozoenausbeute bestimmen, werden dargestellt.

The association between chronic inflammatory/infectious diseases of the male reproductive tract and the presence of antisperm antibodies (ASA) in semen is still controversial. We compared the results of the mixed agglutinin reaction (MAR) test and immunobead test for detecting ASA type IgG and IgA in 133 patients attending our special outpatient department for andrological infections and evaluated the differences in the detection rate of ASA. Patients were divided into three groups: a study group that included 79 patients with symptomatic nonacute inflammatory/infectious diseases of the seminal tract, a control group (n = 44) and a third group of men with a history of successful vasectomy reversal (n = 10). The two tests correlated in a statistically significant manner for the detection of IgG and IgA in all groups. The overall positive detection rate of clinical significant levels of IgG and IgA was 2.5% and 1.3% (respectively) in the patients with inflammation/infection of the seminal tract. No statistical significant difference in the detection rate of ASA levels between the inflammatory/infectious group and the controls was detected. The results of the MAR test and immunobead test have a statistical significant correlation and their results provide evidence that there is no association between inflammatory/infectious diseases of the male reproductive tract and the presence of ASA in semen.

Mit der Einfuhrung der intrazytoplasmatischen Spermatozoeninjektion (ICSI) in das Behandlungsspektrum reproduktionsmedizinischer Therapien Mitte der 90er-Jahre bot sich auch zum 1. Mal die Gelegenheit einer Vaterschaft von Mannern, die unter schwersten Spermatogenesestorungen bis hin zur Azoospermie litten. Diesen Mannern konnen heute mit unterschiedlichen Techniken operativ Spermatozoen fur die Durchfuhrung einer ISCI-Behandlung entnommen werden. Die operative Spermatozoenentnahme bietet sich auch bei Mannern mit Verschlussazoospermie mit mikrochirurgisch nicht rekonstruierbaren Verhaltnissen an. Verschiedene technische Moglichkeiten der Spermatozoenentnahme sind uber die Jahre entwickelt worden, wobei die mikrochirurgische epididymale Spermatozoenasservierung (MESA) und die testikulare Spermatozoenextraktion (TESE) die heute verbreitetsten Techniken darstellen. Basierend auf der Moglichkeit der Kryokonservierung von entnommenen Spermatozoen, konnen durch einen einzigen chirurgischen Eingriff Spermatozoen fur diverse ICSI-Zyklen entnommen werden.

Objectives The development of fibrotic diseases is associated with alterations in the transforming growth factor β (TGF-β) pathway. We have investigated the expression and activity of Smad transcription factors of the TGF-β pathway in primary tunical fibroblasts derived from patients with Peyronie's disease and from controls. Methods Primary fibroblasts were established from biopsies obtained from plaques of 16 patients with Peyronie's disease or the tunica albuginea of 8 control patients. The expression and activity of Smad transcription factors in control and TGF-β–stimulated primary fibroblasts were investigated at the RNA and protein level by reverse transcription-polymerase chain reaction, Western blotting, and immunofluorescence. Results RNA expression levels of Smad3 and Smad4 were significantly increased in fibroblasts from patients with Peyronie's disease. When stimulated with TGF-β1, fibroblasts showed rapid nuclear translocation of Smad2/3, as soon as 15min after stimulation. This effect was more pronounced and exhibited an earlier onset in fibroblasts from patients with Peyronie's disease, compared with controls. In addition, an increased nuclear retention time of Smad4 was observed in fibroblasts from patients with Peyronie's disease. Conclusions The expression and activity of Smad transcription factors of the TGF-β pathway is increased in fibroblasts of patients with Peyronie's disease. Alterations in the TGF-β pathway seem to be a pathogenetic factor in the development of Peyronie's disease.

Background Infections of the genital tract are considered common causes of male fertility disorders, with a prevalence of 6-10%. Most of the affected men are asymptomatic. The diagnostic evaluation is based mainly on laboratory testing. Inconsistent diagnostic criteria have been applied to date, and this may explain the controversial debate about the role of infection and inflammation in the genital tract as a cause of infertility. The risk of an irreversible fertility disorder should not be underestimated. Methods This review is based on pertinent publications retrieved by a selective literature search in PubMed, including guidelines from Germany and abroad and systematic review articles. Results The main causes of inflammatory disease of the male genital tract are ascending sexually transmitted infections (STIs) and uropathogens. Chronic prostatitis has no more than a limited influence on ejaculate variables. By contrast, approximately 10% of men who have had acute epididymitis develop persistent azoospermia thereafter, and 30% have oligozoospermia. Obstruction of the excurrent ducts can ensue, as can post-infectious disturbances of spermatogenesis. The differential diagnostic evaluation includes the determination of testicular volumes, hormone concentrations, and ejaculate variables. Epidemiological data are lacking with regard to infertility after primary orchitis of infectious origin; however, up to 25% of testicular biopsies obtained from infertile men reveal focal inflammatory reactions. Multiple studies have suggested a deleterious effect of leukocytes and inflammatory mediators on sperm para - meters. On the other hand, the clinical significance of bacteriospermia remains unclear. Conclusion Any suspicion of an infectious or inflammatory disease in the male genital tract should prompt a systematic diagnostic evaluation and appropriate treatment. For patients with obstructive azoospermia, the etiology and site of the obstruction determine the surgical approach to be taken. In the near future, the elucidation of underlying pathophysiological mechanisms and the identification of suitable biomarkers may enable new strategies for conservative treatment.

The first and rate-limiting step in the biosynthesis of steroid hormones is the transfer of cholesterol into mitochondria, which is facilitated by the steroidogenic acute regulatory (StAR) protein. Recent study of Leydig cell function has focused on the mechanisms regulating steroidogenesis; however, few investigations have examined the importance of mitochondria in this process. The purpose of this investigation was to determine which aspects of mitochondrial function are necessary for acute cAMP-stimulated Leydig cell steroidogenesis. MA-10 cells were treated with 8-bromoadenosine 3',5'-cyclic monophosphate (cAMP) and different site-specific agents that disrupt mitochondrial function, and the effects on acute cAMP-stimulated progesterone synthesis, StAR mRNA and protein, mitochondrial membrane potential (Deltapsim), and ATP synthesis were determined. cAMP treatment of MA-10 cells resulted in significant increases in both cellular respiration and Deltapsim. Dissipating Deltapsim with carbonyl cyanide m-chlorophenyl hydrazone resulted in a profound reduction in progesterone synthesis, even in the presence of newly synthesized StAR protein. Preventing electron transport in mitochondria with antimycin A significantly reduced cellular ATP, potently inhibited steroidogenesis, and reduced StAR protein levels. Inhibiting mitochondrial ATP synthesis with oligomycin reduced cellular ATP, inhibited progesterone synthesis and StAR protein, but had no effect on Deltapsim. Disruption of intramitochondrial pH with nigericin significantly reduced progesterone production and StAR protein but had minimal effects on Deltapsim. 22(R)-hydroxycholesterol-stimulated progesterone synthesis was not inhibited by any of the mitochondrial reagents, indicating that neither P450 side-chain cleavage nor 3beta-hydroxysteroid dehydrogenase activity was inhibited. These results indicate that Deltapsim, mitochondrial ATP synthesis, and mitochondrial pH are all required for acute steroid biosynthesis. These results suggest that mitochondria must be energized, polarized, and actively respiring to support Leydig cell steroidogenesis, and alterations in the state of mitochondria may be involved in regulating steroid biosynthesis.

Spermatogenesis, as well as the synthesis of testosterone in the human testis, is a lifelong process that persists in aging men. However, spermatogenic efficiency, estimated by the number of spermatozoa produced/day/g of testicular parenchyma (the spermatogenic index), apparently declines with age. This decline is the result of an increase in germ-cell degeneration throughout spermatogenesis, as seen in all cell types of the germ-cell line. The clinical significance of these phenomena may be questioned, since aging men still appear to be rare in infertility clinics, although parental age has increased in industrialized countries. In this context, alterations in the endocrine system are of more significance, since serum testosterone levels also appear to decrease with age. These alterations can be associated with clinical symptoms known as late-onset hypogonadism. Men suffering from this disorder can be successfully treated with testosterone; however, a broad discussion has begun regarding the necessity, usefulness, cost and risks of such a therapy in older men.

Die erektile Dysfunktion (ED) ist eine Erkrankung multifaktorieller Genese. Unter Umstanden konnen schwere Allgemeinerkrankungen die Ursache sein. Daher benotigt jeder Patient eine allgemeinmedizinische Diagnostik der ED, die verhindert, dass gravierende Erkrankungen ubersehen werden konnen.

Chronic inflammatory disease and acute infection are well known to inhibit gonadal steroidogenesis. Previous studies have demonstrated that immune activation in response to lipopolysaccharide (LPS) results in reductions in serum testosterone, and this is a direct effect on the Leydig cell. We hypothesize that during the early onset of LPS endotoxemia in vivo, testicular macrophages produce reactive oxygen species (ROS) leading to perturbation of Leydig cell mitochondria and an inhibition in steroidogenesis. To investigate the mechanism of LPS inhibition of Leydig cell steroidogenesis, alterations in mitochondria and markers of oxi-dative stress were assessed in vivo and in Leydig cell pri- mary culture. After a single injection of mice with LPS, serum testosterone was significantly decreased within 2 h. LPS injection of mice resulted in significant reductions in steroidogenic acute regulatory protein (StAR) and 3beta-hydroxysteroid dehydogenase-Delta4-Delta5 isomerase (3beta-HSD) proteins. LPS significantly increased lipid peroxidation of Leydig cell membranes, indicating that LPS results in oxidative damage in vivo. Mitochondria in Leydig cells isolated from LPS-injected mice were disrupted and showed a marked reduction in the mitochondrial membrane potential (DeltaPsim). Similar to the effects of LPS, treatment of Leydig cells with hydrogen peroxide acutely inhibited steroidogenesis, reduced StAR and 3beta-HSD protein levels, and disrupted DeltaPsim. These results suggest that LPS acutely inhibits Leydig cell function by ROS-mediated disruption of Leydig cell mitochondria. Taken together, these results demonstrate the necessity of having respiring mitochondria with an intact DeltaPsim to facilitate StAR function and Leydig cell steroidogenesis. The acute effects of LPS demonstrate how sensitive Leydig cell mitochondrial steroidogenesis is to inflammation-induced oxidative stress.

We report a case of giant multilocular cystadenoma of the prostate in a 43-year-old man. This is a rare benign entity of the prostate imitating symptoms of benign prostatic hyperplasia and originates from the prostate with extensive spread into the pelvis. Histologically, prostatic glands and cysts lined by cuboid to columnar epithelial cells with basally located nuclei are characteristic. Immunohistochemical staining is positive for prostate-specific antigen in the epithelial cells. Giant multilocular prostatic cystadenoma should be taken into account in the differential diagnosis in any case of a large cystic mass originating from the prostate.

During the last years tremendous changes have occurred in the epidemiologic knowledge and the diagnostic process of the prostatitis syndrome. A new worldwide-accepted classification system has become the gold standard in contemporary literature. The aim of this study was to compare the inflammatory and infectious status of men with prostatitis syndrome with results from our study cohort from 1992. A total of 168 symptomatic men (mean age 43.2 years; range 18-79) attending the Giessen prostatitis outpatient department were included. All men underwent a standard four-glass-test including leucocyte analysis in all specimens. A routine search for Ureaplasma urealyticum and Chlamydia trachomatis was performed. Ejaculate analysis following World Health Organization (WHO) criteria has been performed including the evaluation of increased number of peroxidase-positive leucocytes (PPL). Men were classified according to the National Institutes of Health (NIH) prostatitis classification. The distribution of patients according to NIH criteria is as follows: NIH II (4.2%), NIH IIIA (31.5%), NIH IIIB (50.0%) and urethroprostatitis (14.3%). Chlamydial infection was present in one man (0.6%). Only two men with increased leucocytes in prostatic secretions demonstrated ≥10 6 million ml -1 PPL in semen. As compared with our cohort study 10 years ago, the proportion of the different subtypes of the prostatitis syndrome have remained stable. The aetiological spectrum of chronic bacterial prostatitis has not changed whereas, in contrast, the prevalence of C. trachomatis now is found to be strikingly reduced. Using the WHO cutpoints for leucocytospermia the inclusion of seminal leucocytes to the diagnostic process has not influenced the distribution between inflammatory (type NIH IIIA) and noninflammatory (type NIH IIIB) chronic pelvic pain syndrome.

We report on a case of penile epithelioid sarcoma in a 29-year-old man presenting with a dorsal penile plaque that primarily was misdiagnosed as Peyronie's disease. Although the initial clinical findings of these two different entities appear similar, the consequence for the patient is severe. The only way of differentiating these disorders are histological findings. The principal microscopic characteristics of epithelioid sarcoma are the distinctive nodular arrangement, central degeneration and necrosis of the tumor cells with epithelioid appearance and eosinophilia. Immunohistochemical data (cytokeratin, epithelial membrane antigen, vimentin, CD 34, desmin) confirm the diagnosis. We conclude that in cases with slightest doubts on the diagnosis of Peyronie's disease, especially in younger men suffering from a fast-growing penile induration, a bioptic clarification of the entity should be performed to exclude a high malignant disease that can be only treated as far as it is localized by radical surgery.

The impact of defined urogenital inflammations on standard ejaculate parameters is still a matter of controversial debate. Basic spermiogram parameters has been analysed in patients with inflammatory and noninflammatory chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS-NIH IIIA/IIIB) with regard to indicators of inflammation in prostatic secretions and/or the ejaculate. A total of 112 consecutive patients symptomatic for chronic pelvic pain were included in the study. All of them underwent a 'four glass-test' including leukocyte determination in expressed prostatic secretions followed by ejaculate analysis according to WHO. The analysis included pH, volume, total sperm count, sperm density, motility, morphology (Shorr stain), vitality (eosin stain), and counting of peroxidase positive leukocytes (PPL). Patients were first subgrouped according to elevated leukocyte counts in prostatic secretions, and then according to the number of PPL in semen. Leukocytes neither in the prostatic secretions nor in the ejaculate were associated with reduced standard semen parameters. Our data supports previous results that elevated leukocyte counts in prostatic secretions and in ejaculate, as indicators of inflammation have no negative impact on total sperm count, sperm density, motility, morphology, and sperm vitality in patients with CP/CPPS.

Urogenital infections are considered important factors in male infertility. In this in vitro study we have evaluated the impact of leucocytes in association with an artificial infection with Escherichia coli on the motility of human spermatozoa. Ejaculates and blood samples were obtained from healthy donors with normal semen parameters. Ejaculates were prepared by swim-up technique and five fractions were isolated for incubation. Leucocyte subtypes were separated from blood samples by gradient centrifugation. Purified sperm suspensions were adjusted to a concentration of 20 x 106 ml-1 and incubated with lymphocytes/ monocytes, polymorphonuclear granulocytes (PMN), and E. coli. Samples were incubated for up to 6 h at 37 degrees C. Motility analysis was performed using a computer-assisted sperm analyzer (CASA). Spermatozoa incubated with 3 x 106 PMN ml-1 revealed a significant (P=0.003) decrease in progressive motility after 2 h. This decrease remained weakly significant (P=0.024) after 4 and 6 h. Lymphocytes and monocytes had no effect on sperm motility. Spermatozoa incubated with granulocytes and E. coli demonstrated highly significant alterations in motility after 4 and 6 h of incubation (P < 0.001). The PMN indicate an effect on motility of spermatozoa under experimental conditions. However, the results suggest that bacteria are the primary agents that interfere with sperm motility.