Seyer, A

Abstract Introduction Chronic orchialgia is a common urologic complaint, and is estimated to make up 2.5 to 5% of urology clinic consultations. Hyperactive cremaster reflex is an often under-diagnosed source of chronic testicular pain, wherein patients experience vigorous muscular retraction of the testicles up to the external inguinal ring. This has been related to possible anatomic thickening of the cremaster muscles, or an attenuated external oblique aponeurosis. Objective To report a unique etiology and subsequent treatment of chronic orchialgia. Methods We present a case of an individual who developed new onset of hyperactive cremaster reflex after hamstring and rectus abdomonis tear during a sporting injury. Results Patient is a 37-year-old male who presented with new onset of bilateral testicular pain and chronic testicular retraction. 6 weeks prior to presentation, while playing soccer, he sustained a complete tear in the right hamstring, and partial tearing of the right rectus abdominis-adductor aponeurosis at the pubic symphysis. He completed conservative therapy with heat and ice, an extended course of anti- inflammatory medications, and physical therapy without relief. On exam, testicles were bilaterally high riding, and cremasteric muscles were noted to be in tonic spasm. Testicles would be brought into the scrotum, but were noted to rapidly ascend. He was offered injection of neuromodulator into the cremasteric muscles versus bilateral microsurgical cremaster release, and opted for the latter treatment. Bilateral cremasteric muscle fibers were ligated and excised from the external ring down to the testicle proper, and testicles were pexied in place. At follow-up, he reported complete resolution of pain and tonic retraction. Testicles were found to have normal anatomic lie within the dependent portion of the scrotum. Conclusions In patients with chronic testicular pain refractory to conservative measures, the cremasteric muscles may play a role in potentiating pain signaling through chronic, unprompted muscular spasm. This should especially be considered after regional musculoskeletal injuries affecting pelvic and inguinal muscle groups. In this select group of patients, excision of the cremasteric muscles to release cremasteric tension may be a viable treatment option for resolution of chronic pain. Disclosure No

Abstract Background Multiple guideline-based surgical treatment options for Peyronie’s disease (PD) exist, including penile plication and plaque incision or excision and grafting. Surgical incision type may differ depending upon location and severity of curve, planned concomitant procedures, and surgeon preference. Aim To evaluate postoperative wound complications comparing outcomes between ventral and subcoronal incisions in patients undergoing tunica albuginea plication (TAP) and plaque incision or partial excision and grafting (PG) for PD. Methods A single-surgeon, single-center retrospective chart review was conducted on all patients undergoing TAP or PG from 2019 to 2023. Patient demographics, including previous PD treatments, were recorded. A Mann–Whitney U test was utilized to determine differences in wound complication rate, median curvature improvement, and remaining postoperative curvature between ventral and subcoronal approaches. Outcomes Wound complication was classified as any dehiscence and/or wound exudate suspicious for infection within the first 3 months postoperatively. A secondary analysis was performed comparing these outcomes between TAP and PG. Results In the analysis, 189 patients were included, including PD straightening surgery, including 125 patients who underwent TAP (66%) and 64 patients (34%) who underwent PG. Among all cases, 49.7% underwent ventral incision (N = 94) and 50.3% (N = 95) underwent subcoronal incision. A total of 12 patients (6.3%) experienced a wound-related complication postoperatively (range 3-23 days), including 9/94 (9.6%) in the ventral incision cohort and 3/95 (3.2%) in the subcoronal cohort (P = 0.081). All the patients were treated with oral antibiotics and two patients required closure under local anesthesia (both in the ventral incision cohort). Secondary analysis did not reveal any significant difference in outcomes between TAP and PG cohorts with respect to wound complications. Clinical Implications While we did not identify a statistically significant difference, most of our wound complications, including infection and/or dehiscence, were seen in those undergoing a ventral penile raphe incision. Despite this, the rate of wound complications with either incisional approach as low. Strengths and Limitations Our report represents a large cohort of patients treated with surgical straightening for PD, and to our knowledge is one of the first to compare wound complications between ventral and subcoronal incisions. Limitations include the retrospective single-surgeon series without randomization, lack of power analysis, and heterogenous classification of wound complications. Conclusion Both ventral penile raphe and subcoronal (degloving) incisions can be considered for penile straightening procedures to correct PD curvature deformity with a low risk for serious wound-related complications.

Abstract Introduction Surgical treatment options for Peyronie’s disease (PD) include penile plication, plaque excision with grafting, and penile prosthesis placement with straightening maneuvers. Choice of surgical incision depends on location and severity of curve, concomitant procedures, and surgeon preference. Objective To assess risk of wound complications after PD surgery stratified by ventral versus subcoronal incision type. Methods A single surgeon retrospective chart review was conducted for all patients undergoing PD tunica albuginea plication (TA) or plaque excision with grafting (PEG) from Aug 2019 to June 2023. Wound complication was classified as any dehiscence or physical examination finding suspicious for infection within 30d of surgery. A Mann–Whitney U Test was used to compare demographic variables and wound complication rate based on ventral and subcoronal approaches. Results Of the 161 patients included, 105 underwent TAP and 56 underwent PEG. All patients who underwent PEG had at least one plication suture performed to correct mild residual curvature after grafting. A ventral midline penile incision was used in 81 patients (50%) and subcoronal in 80 patients (50%). Wound complications within 30d of surgery were found in 10 patients (6%), including 8 (10%) with ventral incisions versus only 2 (3%) subcoronal (OR 4.27; 95% CI 0.87-20.79; p = 0.09). There was no significant difference in wound complications between TAP and PEG cohorts. Wound complications included dehiscence requiring repeat closure (n = 1) and superficial wound infection necessitating antibiotic therapy (n = 9). In a subgroup analysis of patients who underwent TAP only, 8 patients (7.6%) with a ventral approach experienced a 30d wound complication compared with 1 patient (3.4%) with a subcoronal approach. Conclusions Penile straightening surgeries are associated with a low rate of significant wound infections. While not statistically significant, a ventral incision may have a slightly higher risk than subcoronal for wound complications within the first 30d of surgery. Both ventral and subcoronal incisions can offer excellent exposure and may be considered for patients requiring plication and/or grafting approaches. Disclosure No.

Abstract Introduction Male masturbation is a scarcely discussed topic in male sexual health. In the context of trying to conceive, male masturbation may impact overall sexual function and ultimately fertility outcomes. Objective To evaluate the relationship between masturbation frequency and sexual function amongst men undergoing fertility testing. Methods We performed a review of a prospectively maintained database of men utilizing a mail-in semen analysis test system developed by Fellow Health, Inc. Men ≥18 years were included if they consented to participate in research and completed survey questionnaires on both their quality of life and sexual function. Men reported their typical weekly masturbation frequency (0, 1-2, 3-4, 5-6, or ≥ 7 times per week) as part of the sexual function questionnaire. Descriptive statistics were reported and chi-squared tests were used to determine statistical significance at the 0.05 alpha level. Results Of the 2,034 men included, most reported masturbating one to two times per week (41.2%). Nearly one-fourth (21.6%) reported never masturbating, and only 14.2% reported a frequency of more than four times per week. Mean semen volume did not differ significantly by masturbation frequency (p = 0.07). Of note, patients were instructed to abstain from ejaculation for 48 hours prior to sample collection. Men who reported masturbating most frequently (≥7 times per week) were least likely to report ejaculatory dysfunction (12.0% vs. 21.0% for all others combined; p = 0.04), but most likely to report orgasmic dysfunction (12.0% vs. 5.7% for all others combined; p = 0.02). Interestingly, men who reported masturbating most often (≥7 times per week) were both most likely to report having sex less than once per week and most likely to report having sex ≥7 times per week when compared to other strata of masturbation frequency. Conclusions Those with higher masturbation frequency also had better ejaculatory function, but worse orgasmic function. Men who masturbate most frequently (>7 times per week) were most likely to report having sex less than one time per week and also most likely to report having sex >7 times per week, which may be reflective of differences in libido in this group. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Fellow Health.

Abstract Introduction Undergoing fertility testing can be a stressful event in a couple's life. This can impact multiple aspects of life, including sex. Objective To evaluate the relationship between stress and sexual function in men undergoing fertility testing. Methods We performed a review of a prospectively maintained database of men utilizing a mail-in semen analysis test system developed by Fellow Health, Inc. Those included consented to participate in research, were 18 or older, and completed survey questionnaires on both their quality of life and sexual function. Stress level (low, moderate, or high stress) was determined using the validated Perceived Stress Scale (PSS) 10-question survey. The sexual function survey assessed libido, orgasmic and ejaculatory dysfunction, intercourse frequency, Erection Hardness Score, and IIEF-5 score. Descriptive statistics were reported and chi-squared and t-tests were used to determine statistical significance at the 0.05 alpha level. Results A total of 2077 men undergoing fertility testing were included in this study. 50.2% reported moderate stress levels and 2.6% reported high stress levels. Those with low stress were older than those with moderate or high stress (average 35.4 vs. 34.3 and 34.0 years, respectively; p < 0.01). Men with high stress levels were more likely to report a “poor” or “terrible” libido (31.4%) compared to those with moderate or low stress, 17.2% and 9.5%, respectively (p < 0.01). Stress was highly associated with weekly intercourse frequency (p < 0.01): among men with high levels of stress, 25.5% reported having sex less than once a week compared to 6.0% of men with low stress. Likewise, no highly stressed men reported having sex more than six times per week compared to 2.8% of men with low stress. Whereas 80.4% of men with low stress were evaluated to have “No signs of ED” by the IIEF-5, the same was true for only 62.3% of moderately stressed men and 56.0% of highly stressed men (p < 0.01). Conclusions More than half of men undergoing fertility testing report increased levels of stress, which is negatively associated with libido and erectile function. In men seeking fertility evaluation, lifestyle factors such as stress levels should be assessed to identify patients who may benefit from stress management strategies. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Fellow Health.

Abstract Introduction Depression is a common mental health disorder affecting men of reproductive age. Depression or depressive symptoms may impact a variety of health factors, including sexual function. Trying to conceive may contribute to additional stress and negative emotions for the couple. Objective To determine the rate of sexual dysfunction in men with depression who are undergoing fertility testing. Methods A review was performed of a prospectively maintained database of men utilizing a mail-in semen analysis test system developed by Fellow Health, Inc. Men ≥18 years were included if they consented to participate in research and completed survey questionnaires on both their quality of life and sexual function. Depression level (normal, mild, moderate, or severe) was derived via the short-form depression assessment developed by the Patient Reported Outcomes Measurement Information System (PROMIS). The sexual function survey assessed libido, orgasmic and ejaculatory dysfunction, intercourse frequency, Erection Hardness Score, and IIEF-5 score. Descriptive statistics were reported and chi-squared tests were used to determine statistical significance at the 0.05 alpha level. Results Of the 2125 men included, 15.2% reported mild depression and 12.8% moderate or severe depression. The presence of depression was negatively associated with libido, with 11.2% of men with normal levels of depression reporting terrible or poor libido compared to 18.7% with mild depression and 22.2% with moderate or severe depression, p < 0.001. Compared to men without depression, those with moderate or severe depression were nearly twice as likely to report ejaculatory dysfunction (17.2% vs. 29.7%) and three times as likely to report orgasmic dysfunction (3.9% vs. 13.0%), p < 0.001 for all. Severity of depression was also predictive of an erection sufficient for penetration: whereas 96.8% of those with normal levels of depression reported an erection sufficient for penetration, the same could be said for only 94.5% of those with mild depression and 92.5% of those with moderate or severe depression (p < 0.001). Only 53.1% of men with moderate or severe depression had an IIEF-5 score greater than 21 (i.e., “No signs of ED”), compared to 60.9% with mild depression and 75.8% without depression, p < 0.001. Importantly, men with moderate to severe depression were more than twice as likely to report intercourse frequency less than once weekly (18.0%) as opposed to men without depression (7.4%), p < 0.001. Conclusions The presence of depression in men undergoing fertility testing is negatively associated with libido, ejaculatory, orgasmic, and erectile function. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Fellow Health.

Abstract Introduction Sleep disorders can negatively impact multiple facets of health including sexual function. In men undergoing fertility testing, optimization of general health is of utmost importance to maximize fertility outcomes. Objective To determine the relationship between sleep disturbance and sexual function in men undergoing fertility testing. Methods This study evaluated men undergoing fertility testing who completed an at-home semen analysis kit developed by Fellow Health, Inc. Men ≥18 years were included if they consented to participate in research and completed survey questionnaires on both their quality of life and sexual function. Sleep disturbance level (normal, mild, moderate, or severe) was derived using a validated survey assessment, developed by the Patient-Reported Outcomes Measurement Information System (PROMIS), which queried sleep quality, sleep depth, and restoration associated with sleep. The sexual function survey assessed libido, orgasmic and ejaculatory dysfunction, Erection Hardness Score, and IIEF-5 score. Descriptive statistics were reported and chi squared tests were used to test for independence of categorical variables with statistical significance reported at the 0.05 alpha level. Results Of the 1919 men included in this analysis, 7.7% were assessed to have a mild level of sleep disturbance and 4.4% had moderate to severe sleep disturbance. Compared to those with “normal” levels of sleep disturbance, those with mild to severe levels more often reported low libido (20.7% vs. 13.8%; p = 0.01), ejaculatory dysfunction (31.3% vs. 19.9%; p < 0.01), and orgasmic dysfunction (15.3% vs. 5.1%; p < 0.01). Of men with mild to severe sleep disturbance, 28.3% reported pursuing treatment for erectile dysfunction compared to those with normal levels of sleep disturbance (17.8%; p < 0.01). Further, only 57.2% of men with mild to severe sleep disturbance were assessed to have “No signs of ED” compared to 71.0% of men without elevated levels of sleep disturbance (p < 0.01). Conclusions Sleep disturbance is associated with reduced libido, ejaculatory, orgasmic, and erectile function in men undergoing fertility testing. Providers should assess for sleep-related symptoms during initial evaluation to optimize fertility potential. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Fellow Health.

Abstract Introduction Concerns exist when inflatable penile prosthesis (IPP) surgery is performed following transcorporal artificial urinary sphincter (TC-AUS) due to risk of damaging the AUS cuff during proximal corporal dilation and device placement. Aside from rare case reports, no data exists on outcomes and complications in patients who undergo IPP surgery with existing TC-AUS in place. Objective We aim to describe perioperative complications, infections, revision rates, and device longevity when IPP surgery is performed with existing TC-AUS in place. Methods A retrospective search was conducted to identify all patients who had undergone TC-AUS placement at a single institution from 2015-2023. Patients who had undergone IPP placement following TC-AUS at the same institution were identified. Operative technique for IPP placement was similar to standard IPP surgery with additional care taken to avoid the AUS device and preferential use of electrocautery over sharp dissection. Operatives notes and all patient encounters were reviewed, and data on demographics, operative details, perioperative complications, infections, revision rates, and device longevity were recorded. Results 727 patients underwent TC-AUS placement from 2015-2023. Of these, 13 patients underwent subsequent IPP placement (fig. 1). All patients had history of prostatectomy, and 6 (46%) patients had prior radiation. The median follow-up after IPP was 31.7 months and the time gap between AUS and IPP averaged 18.3 months (range 2.3 to 56.7 months). Average operative time for IPP was 85 minutes (range 53 to 202 minutes). Reservoirs were all placed contralateral to the AUS reservoir to minimize risk of injury to the AUS device. 8 patients had a 12 Fr catheter left post-operatively for less than 24 hours. Proximal dilation was noted to be difficult in 2 patients (15%), both of which were successfully dilated without perforation or damage to the AUS cuff. No infections or erosions occurred. 3 patients (23%) developed mechanical failure at a mean time of 28.7 months following IPP placement (36.5 months after AUS). Cuff leak was identified in 2 patients and the third has yet to undergo revision surgery to determine etiology. Conclusions IPP placement appears safe and effective in men who have previously undergone TC-AUS without increased risk of infection or device erosion. Care should be taken when dilating proximally, though proximal dilation was uneventful in most patients. Mechanical failure rates may be slightly higher compared to patients who have either device alone, and patients should be counseled accordingly. Disclosure No.

Objectives To characterise the prevalence of impostor phenomenon (IP; tendency for high‐achieving individuals to perceive themselves as fraudulent in their successes) amongst attending staff in urology, to identify variables that predict more severe impostorism, and to study the association of IP with burnout. Subjects and Methods A survey composed of the Clance Impostor Phenomenon Scale (CIPS), demographic information, practice details, and burnout levels was e‐mailed to urologists via urological subspecialty societies. Survey results were analysed to identify associations between IP severity, survey respondent characteristics, and symptoms of professional burnout. This study was conducted in the United States of America. Results A total of 614 survey responses were received (response rate 11.0%). In all, 40% ( n = 213) of responders reported CIPS scores qualifying as either ‘frequent’ or ‘intense’ impostorism (i.e., scores of 61–100). On multivariable analysis, female gender, fewer years in practice (i.e., 0–2 years), and lower academic rank were all independently associated with higher CIPS scores (adjusted P < 0.05). Regarding burnout, 46% of responders reported burnout symptoms. On multivariable analysis, increase in CIPS score was independently associated with higher odds of burnout (odds ratio 1.06, 95% confidence interval 1.04–1.07; P < 0.001). Conclusion Impostor phenomenon is prevalent in the urological community and is experienced more severely in younger and female urologists. IP is also independently associated with burnout. Increased female representation may improve IP amongst our female colleagues. More work is needed to determine strategies that are effective in mitigating feelings of IP and professional burnout amongst urologists, particularly those earlier in their careers.