CONCERNS IN THE MALE
| WHAT’S NEW IN MALE INFERTILITY ?—Victor M. Brugh, III, MD, Assistant Professor of Urology, Eastern Virginia
Medical School, Norfolk
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| Components of medical history: evaluate couple to determine—how long couple has tried to conceive; whether
couple ever achieved conception with each other or other partners; past use of assistive reproductive techniques; sexual
history; frequency and timing of intercourse, ie, during ovulation; whether spermicidal lubricant used; assess patient’s
disease history—look for chronic medical conditions and acute illnesses, eg, febrile illness, occurring within previous 6
mo; identify all medications used by patient; testosterone replacement—used to treat hypogonadal men; can halt spermatogenesis;
use frequently unreported to physician; men receiving testosterone therapy often do not—consider over-
the-counter dehydroepiandrosterone (DHEA) or androstenedione (Andro) to be medicine; understand exogenous testosterone
causes infertility; ask about previous—exposure to chemicals, toxins, or radiation; infections (eg, sexually
transmitted diseases [STD], mumps, or orchitis); genitourinary (GU) trauma; GU procedures performed during childhood
that can cause infertility (eg, orchidopexy, testicular torsion, V-Y plasty of bladder neck); hernia repair with mesh during
young adulthood—key concern; produces dense scarring in inguinal region that frequently involves vas deferens;
when damaged vas cannot be repaired, pregnancy may be achievable using in vitro fertilization (IVF) with testicular
sperm extraction
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| Physical examination: determine whether patient well virilized; check for—inguinal scarring from previous surgery;
varicoceles; congenital absence of vas deferens; small and abnormally positioned testes; testicular cancer
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| Laboratory work-up: DNA damage assays clinically unreliable; obtain 2 semen analyses at IVF center (white blood
cell assay and strict morphology sufficient for evaluation); to detect endocrinopathies that might impair sperm production,
assess follicle-stimulating hormone (FSH), testosterone, leuteinizing hormone (LH), prolactin, and estradiol levels
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| Intracytoplasmic sperm injection (ICSI): used with IVF; forces fertilization by injecting sperm cell directly into
egg; can use ejaculate with low sperm count or sperm from epididymis and testis to achieve pregnancy; avoids testicular biopsy
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| Obstructive azoospermia: patient has normal hormonal studies, testes, and sperm production; obstruction occurring
at—prostate caused by ejaculatory duct or müllerian duct cysts; vas deferens caused by prior vasectomy, inguinal hernia repair
with mesh, prior scrotal surgery, or congenital absence of vas deferens; epididymis caused by scrotal surgery or chronic
epididymitis
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| Semen analysis: analyzing single drop of liquified ejaculate associated with marked sampling error; semen pellet approach
critical for evaluating azoospermia
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| Genetic evaluation: essential before referring man to reproductive endocrinologist; helps couple determine whether to
proceed with IVF; Y chromosome microdeletions—genes along Y chromosome affect sperm production; number of
microdeletions increases with severity of infertility; microdeletions in azoospermia factor (AZF) region—on long
arm of Y chromosome; occur only in azoospermic men; AZFc region contains DAZ gene commonly deleted in infertile
men; high-resolution banding karyotype and Y chromosome-microdeletion assays—indicated in men with nonobstructive
azoospermia or testicular failure with <5 million sperm/mL concentrations when no other treatable cause of infertility
identified; avoid passing genetic defects to offspring; predict outcome of sperm retrieval; educate couple on
cause of male infertility; avoid IVF and ICSI failure
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| Hormonal manipulation: testosterone/estradiol (T/E) ratio—low (ie, <10) in men with elevated FSH and estradiol
levels and low to low normal testosterone levels; ≥10 in fertile males; elevated estradiol—develops as testosterone
aromatized by aromatase; harm spermatogenesis by reducing LH and FSH secretion or poor secretion of testosterone
in testes
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 | Aromatase inhibitors: now used to treat male infertility on off-label basis; men with T/E ratio <10 treated with low
doses of anastrozole (Arimidex) experienced—increase in testosterone to normal ranges; suppression of estradiol;
normalization of T/E ratio; doubling of semen concentration; improved morphology and motility of sperm cells;
point—after treatment, some men use less complex and expensive forms of assistive reproduction
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| Microscopic epididymovasostomy (EV): required in men who developed—epididymal blowout following vasectomy;
iatrogenic occlusion following previous scrotal surgery; epididymal obstruction associated with epididymitis; end-
to-side anastomosis—achieved patency rate of ≈70% and pregnancy rate of ≈40%; technically challenging; modified
intussusception—facilitates suture placement; increased patency rate to 90%; equalled paternity rate with traditional
end-to-side technique
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| PENILE AND SCROTAL DISORDERS IN ADOLESCENCE —Jack Elder, MD, Carter Kissell Professor of Urology,
Case Western Reserve University School of Medicine; Director of Pediatric Urology, Rainbow Babies and Children’s Hospital,
Cleveland, OH
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| Testicular torsion: common cause of testicular pain; usually intravaginal; associated with abrupt onset of severe pain
and previous history of intermittent testicular pain during adolescence; physical findings—exquisite tenderness on palpation;
scrotal swelling and erythema; cremasteric reflex usually absent (patients with 180° to 360° torsion may have reflex);
pain may be minimal or absent with intermittent torsion/detorsion; operative intervention—early on, usually
leads to salvage; delayed >12 hr after onset, often results in testicular necrosis; point—if torsion 360°, arterial perfusion
may persist 1 to 2 days; establishing blood flow to testis—ultrasonography (US; easiest test to perform; operator-dependent;
absent or reduced blood flow suggestive of torsion); radionuclide testis scan (takes longer to obtain); imaging
studies for testicular pain— false-negative rate 3% to 5%; US or radionuclide scans may appear normal in patients with
≤360° or intermittent torsion; exquisite tenderness—key clue that torsion exists with presence of arterial perfusion; proposed
pathogenesis—fairly thin spermatic cord produces rapid cutoff of arterial blood flow; with thick cord, 360° torsion
will not entirely eliminate perfusion
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| Management of testicular torsion: if torsion obvious, explore scrotum (US unnecessary); imaging
recommended—if diagnosis uncertain; to confirm suspected torsion of appendix testis, epididymitis, or to confirm diagnosis
when patient has prolonged testicular pain and marked swelling; options—detorsion (attempt if pain lasts <4 hr;
turning testis outward appropriate in two thirds of cases; in one third of cases, testis must be turned inward); emergency
scrotal exploration; bilateral scrotal orchiopexy
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| Technical aspects: evaluate one side and, when appropriate, perform detorsion; repair contralateral side; if involved testis
viable, perform orchiopexy; remove nonviable testis (antisperm antibodies may adversely affect contralateral testis);
testicular prosthesis requested primarily by boys who lose testis to torsion or tumor
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| Torsion of appendix testis: most common cause of testicular pain in prepubertal boys; onset insidious, ie, patients appear
comfortable until physical examination detects point tenderness at upper pole; scrotal erythema may be present;
caveat— reactive hyperemia can lead to misdiagnosis of epididymitis on US; management—bed rest for 24 hr; ibuprofen
tid for 5 days; reevaluation if pain or scrotal swelling worsens
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| Epididymitis: typically seen in sexually active boys or boys with known GU abnormalities
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| Hydroceles: usually noncommunicating in adolescents, unless patient has symptoms and/or physical examination suggestive
of hernia; diagnostic laparoscopy indicated when questions exist about hydrocele type; if patient has—patent
processus vaginalis, perform groin incision; closed processus vaginalis, explore scrotum; when larger hydrocele recurs
after initial repair—incise along superolateral border of scrotum; drain hydrocele; perform repair; use Dartos pouch to
reduce risk for recurrence
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| Varicoceles: usually small and asymptomatic; underdiagnosed (most pediatricians do not check for varicoceles); may
cause testicular growth arrest; with repair, affected testis can eventually equal size of contralateral testis; testicular
assessment—calipers measure testis in 3 dimensions (preferred approach); US correlates poorly with caliper data; monitor
patients annually and document testis size; indications for varicocele repair—disparity in testicular size; testicular pain
(uncommon); abnormal right testis; grade 3c varicocele (ie, varicocele twice as large as left testis); abnormal semen specimen
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| Varicocele repair: retroperitoneal laparoscopy—minimally invasive; artery often distinct from veins in older adolescent;
recovery relatively rapid; operating time reduced with experience; disadvantages include transperitoneal approach,
risk for injury to abdominal viscera; risk for postoperative hydroceles, cost, difficulty encountered in operating on obese
patients, and learning curve; angiographic approach—requires general anesthesia; radiation exposure significant; may
be useful for managing varicocele recurrence or persistent varicocele following open repair; subinguinal approach
without microscope—advantages (avoids opening inguinal canal; requires small incision; promotes rapid recovery;
procedure can be extended into inguinal canal when necessary); disadvantage (artery may be more difficult to identify);
pointers on approach— place patient in reverse Trendelenberg position; use loupe magnification; pulse Doppler can
identify artery; microscopic varicocelectomy—generally provides no clear benefit over loupe dissection; reasonable
option for managing large varicocele with higher recurrence rate
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| Undescended testis: rare in adolescents; usually end up in superficial inguinal pouch; orchiopexy—acceptable; role of
biopsy to detect cancer focus remains unclear, ie, underlying malignancy generally palpable; orchiectomy—not routinely
recommended, unless difficulty encountered in bringing testis down; risk for infertility or malignancy minimal if
testis can be brought down easily; prescrotal orchiopexy—relatively short procedure; proven effective
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| Penile disorders of adolescence: phimosis—families want to avoid circumcision; administration of 0.1% triamcinolone
cream tid loosens phimotic ring in ≥75% of cases; preputioplasty surgical alternative; hypospadias—advise patient
and family that higher surgical complication rate in adolescents associated with increased blood flow to penis and erections;
postoperative erections eliminated by administering ketoconazole; surgical complications include fistula and
meatal stenosis; “hidden” penis in obese boys—weight loss often ineffective; penile degloving may be required; when
necessary, perform liposuction and fix scrotum to base of penis
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| OSTEOPOROSIS IN MEN —J. Lisa Tenover, MD, PhD, Professor of Medicine, Division of Geriatric Medicine and Gerontology,
Emory University School of Medicine, Atlanta, GA
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| Osteoporosis in men: despite high peak bone mass, lifetime fracture risk significant among men; older men more likely
to die ≤6 mo following hip fracture than women (mortality related in part to coexisting illness); among osteoporotic
men—≈35% have primary idiopathic osteoporosis; ≈65% have osteoporosis due to secondary causes, including chronic
glucocorticoid use, alcohol abuse, hypogonadism, low physical activity, and hyperthyroid and calcium disorders
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| Bone mineral density (BMD) evaluation: predicts fracture risk; screening tools—dual energy x-ray absorptiometry
(DEXA; preferred); quantitative US (poor); reimbursement—most insurance plans do not reimburse cost of BMD screening
in men; diagnostic function must be used as reimbursement qualifier; situations requiring diagnostic BMD that qualify
for Medicare reimbursement—osteopenia detected on x-ray; chronic glucocorticoid use; hypogonadism;
nephrolithiasis; preparation for initiation of androgen deprivation therapy (ADT)
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| When osteoporosis discovered: unless hypogonadism present, rule out other causes of osteoporosis, including parathyroid
disease, urinary calcium abnormalities, myeloproliferative disorders, and hypo- and hyperthyroidism
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| Osteoporosis during ADT for prostate cancer: bone contains androgen and estrogen receptors; estrogen receptors
more important for bone formation; data show—chemical or surgical orchiectomy renders men “menopausal,” with
rapid bone loss and increased fracture risk; recommendations for managing men starting ADT—determine osteoporosis
risk; initiate resistance exercises; stop smoking; limit alcohol consumption; administer calcium and vitamin D; determine
BMD; man with T score—>0.1 not osteoporotic and requires repeat BMD test at ≈2 yr; between 1 and 2.5,
requires repeat BMD test at 1 yr; >2.5 osteoporotic and requires immediate therapy
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| Treatment: if patient osteopenic—minimize risk for osteoporosis by administering calcium and vitamin D, and keep
patient active; with proper care, osteoporosis preventable
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| Hypogonadal men: require calcium and vitamin D; can receive—testosterone or oral bisphosphonates; subcutaneous
teriparatide (Forteo) for severe bone density problems; combination of testosterone, calcium, and vitamin D—with
or without finasteride increases BMD of hip and spine; with oral bisphosphonate improves BMD of spine, femoral
neck, and trochanter in men with severe hypogonadism
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| 5α-reductase inhibitors: do not affect BMD; dihydrotestosterone (DHT) not important factor in bone
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| Men receiving ADT: who are—osteoporotic before receiving ADT require immediate treatment; osteopenic or normal
before ADT must be monitored (once osteoporosis develops, initiate treatment, including calcium and vitamin D); options
not approved by Food and Drug Administration (FDA)—raloxifene (Evista) exerts protective effect similar
to estrogen on bone; bisphosphonates (pamidronate [Aredia] given intravenously on cyclic basis prevented bone loss
from leuprolide [Lupron] therapy)
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| Monitoring options: 25-hydroxyvitamin D levels (essential); spot urine evaluation at 3 mo (elevated N-telopeptide indicates
inadequate suppression of bone breakdown); BMD analysis (wait 2 yr if patient already osteoporotic)
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Educational Objectives
| The goal of this program is to educate the listener about some common problems affecting male patients. After hearing and
assimilating this program, the clinician will be better able to:
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| 1. Diagnose factors causing male infertility.
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| 2. Select appropriate medical and surgical options for managing male infertility.
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| 3. Diagnose and repair scrotal disorders in adolescents.
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| 4. Manage penile disorders in adolescents.
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| 5. Prevent and manage osteoporosis in men.
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Discussed on This Program
Alendronate sodium [Fosamax]
Anastrozole [Arimidex]
Betamethasone [Celestone]
Calcium (several trade names and formulations)
Dehydroepiandrosterone (DHEA) [Fidelin]
Finasteride [Propecia, Proscar]
Ibuprofen (several trade names and preparations)
Ketoconazole [Nizoral]
Letrozole [Femara]
Leuprolide acetate [Lupron, others]
Pamidronate disodium [Aredia]
Raloxifene [Evista]
Risedronate sodium [Actonel]
Teriparatide acetate (rDNA origin; parathyroid hormone) [Forteo]
Testolactone [Teslac]
Testosterone (several trade names and preparations)
Triamcinolone (several trade names and preparations)
Vitamin D
Suggested Reading
Alibhai SM et al: Prevention and management of osteoporosis in men receiving androgen deprivation therapy: a survey
of urologists and radiation oncologists. Urology68:126, 2006; Amory JK et al: Exogenous testosterone or testosterone
with finasteride increases bone mineral density in older men with low serum testosterone. J Clin Endocrinol Metab
89:503, 2004; Brugh VM 3rd , Lipshultz LT: Male factor infertility: evaluation and management. Med Clin North
Am 88:367, 2004; Brugh VM 3rd et al: Male factor infertility. Endocrinol Metab Clin North Am 32:689, 2003; Duncan
GG et al: GU radiation oncologists consensus on bone loss from androgen deprivation. Can J Urol 13:2962, 2006;
Herndon CD et al: Long-term outcome of the surgical treatment of concealed penis. J Urol 170:1695, 2003; Schalamon
J et al: Management of acute scrotum in children—the impact of Doppler ultrasound. J Pediatr Surg 41:1377,
2006; Zilberman D et al: Torsion of the cryptorchid testis—can it be salvaged? J Ur.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial relationship
with the manufacturer or provider of any commercial product or service discussed. For this issue, the faculty reported
nothing to disclose.
Dr. Brugh gave his scientific presentation at State of the Art Urology 2005, presented September 16-17, 2005, in Virginia
Beach, VA, by Eastern Virginia Medical School; Drs. Elder and Tenover gave their scientific presentations at
Advances in Urology 2005, presented December 2-3, 2005, in Atlanta, GA, by Emory University School of Medicine.
The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.
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