Alom, Mulham

Abstract Introduction Discrimination and sexual harassment within the workplace have a negative impact on well-being and productivity and are often underreported due to lack of comfortability in confronting the offender. Objective We aim to assess the prevalence of these abusive behaviors within a urology department and the impact of a dedicated training session on comfortability reporting/confronting discrimination and harassment. Methods Employees within a urology department at a single institution were invited to take a survey regarding discrimination and harassment both before and after a dedicated training session on reporting and confronting these behaviors. Statistical analyses were performed between pre- and post-survey groups, genders, and roles within the department. Results A total of 166 employees completed the pre-training survey, while 79 (47.6%) completed the post-training survey. 116 (69.9%) respondents identified as female. Roles within the department included physician (48/166, 28.9%), advanced practice provider (21/166, 12.7%), nurse (42/166, 25.3%), and nonclinical staff (51/166, 30.7%). The training demonstrated a positive impact in respondent comfort level with addressing gender discrimination, where 19/23 (82.6%) people who answered neutral/ disagree/strongly disagree changed their answer to agree/strongly agree compared to 7/56 (12.5%) who changed their answers in the opposite way (p=0.02). More women reported experiencing sexual harassment at least once a year compared to men (38.6% vs. 16.7%, p<0.0001). Patients were the most commonly reported offenders of abusive behaviors towards staff. Conclusions Specific training on strategies for addressing abusive behaviors can help employees feel empowered to confront gender discrimination by both patients and their peers. Disclosure No

Abstract Introduction Collagenase clostridium histolyticum (CCH, Xiaflex®; Endo Pharmaceuticals) is the only FDA-approved non-surgical therapy for Peyronie’s Disease (PD). CCH is an effective alternative to surgery for patients with PD who have a palpable plaque and a curvature deformity of ≥30°. Clinicians who administer CCH must complete risk mitigation training, and access to specialists varies by region across the US. Identifying areas with low provider availability may improve patient access to this and other treatments for PD. Objective To review the availability of clinicians offering CCH for the treatment of Peyronie’s Disease in the conterminous United States. Methods We utilized a publicly available search tool on a website provided by Endo Pharmaceuticals to identify certified providers offering CCH in the conterminous United States. We created a list of 23 zip codes that, when surrounded by a 500-mile radius, encompass the entire conterminous United States. We then utilized the search tool to identify providers within those radii. The data gathered included the provider’s name, specialty, and practice address. Duplicate addresses were removed, but a single provider offering CCH at 2 different locations was considered 2 different data points. We compared the data relative to the American Urological Association’s “The State of the Urology Workforce and Practice in the United States” and 2021 State Population Estimates from the US Census Bureau. Results In total, 1948 locations offering CCH were identified (Figure 1a). The mean number of locations offering CCH per 100,000 state residents was 0.61 [SD 0.27] (Figure 1b). Wyoming had the highest number of locations per 100k residents with 1.39. New Mexico had the lowest with 0.05. The 10 states with the highest ratio of clinicians/locations (from high-low) per capita were Wyoming, Georgia, Rhode Island, Nebraska, Maryland, New Jersey, Kansas, North Carolina, South Carolina, and Alabama. The 10 states with the lowest were New Mexico, Delaware, Maine, Mississippi, Minnesota, Vermont, Missouri, Indiana, New Hampshire, and Idaho. The mean proportion of urologists providing CCH to total urologists (Figure 1c) was 0.15 [SD 0.07]. Wyoming had the highest proportion of 0.40 and New Mexico had the lowest of 0.02. The 10 states with the highest proportion (from high-low) were Wyoming, Georgia, Utah, Nebraska, Kansas, Alabama, Nevada, Arizona, South Carolina, and Oklahoma. The 10 states with the lowest proportion (from low-high) were New Mexico, Delaware, Maine, Vermont, New Hampshire, Minnesota, Missouri, South Dakota, and Mississippi. Conclusions There are notable differences in the relative availability of CCH providers across the US. These discrepancies may impact access to care, supporting an opportunity to expand training efforts. States with low numbers of treatment locations offering CCH per 100k residents relative to other states also had a low total proportion of urologists offering CCH as a treatment. There is room for current practicing urologists in these states and others to expand their practice to offer CCH and improve patient access to this important non-surgical treatment option. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Endo Pharmaceuticals.

Abstract Introduction There is no agreed-upon definition for acute/chronic phases of Peyronie’s Disease (PD). Collagenase Clostridium histolyticum (CCH) is the only FDA-approved treatment for PD, but original phase-3 trials included patients with symptom duration > 12 months (“chronic phase”). Objective Here, we sought to evaluate the influence of time between symptom onset and starting CCH on treatment outcomes. Methods Men receiving CCH from 2014-2021 were included in an IRB-approved database. Pertinent data were reviewed, including demographics and curvature assessments. The duration between symptom onset and starting treatment with CCH was assessed to determine if the time from symptom onset to treatment impacted objective outcomes. Results One hundred forty-five patients completed the entire series of 8 injections and had complete data for review. Mean baseline curvature 53.2o (SD 18). The mean time between symptom onset and CCH was 14.8 months (SD 18). Mean absolute and percentage improvements were 20.3o (SD 16) and 39.4% (SD 35). Symptom duration did not significantly impact curvature improvement (Figure 1). Similarly, symptom duration did not significantly impact the risk for CCH-related side effects. Conclusions The time between symptom onset and treatment did not significantly impact outcomes with CCH. Our findings support the utility of using CCH early in the course of PD and emphasize the opportunity to delay if necessary without compromising efficacy. Disclosure No

Abstract Introduction Intralesional Collagenase Clostridium histolyticum (CCH) is approved for men with Peyronie’s Disease (PD). Most studies use curve improvement ≥ 20% to define treatment success. Objective Here, we sought to further characterize objective and subjective treatment outcomes with CCH. Methods We reviewed our prospectively maintained database for all patients who underwent CCH at our institution from 2013 through the present. We specifically identified those who completed four series of CCH (or elected to discontinue prior to completing four series due to satisfactory penile straightening or lack of results) and had available curvature assessment data. Treatment outcomes were broken down by level of curve improvement (0%, 10%, 20%, 30%, and > 40% improvement). Treatment success was also evaluated by improvements in the ability to engage in penetrative sexual intercourse and perceived surgery avoidance. Statistical analyses were performed using JMP Pro 14.1.0 (SAS Institute, Cary, NC). Results 127 patients had complete data available. The mean age was 57 years (SD 8.4). The mean PD duration was 27 months (SD 59). The mean baseline curvature was 66.1O, and the mean post-treatment curvature was 45.1O (p<0001). The mean curvature improvement was 32% (SD 33). 68% of patients achieved a 20% or greater improvement in penile curvature, including 38% who achieved ≥ 40% improvement. 72% (n=48/67) felt that CCH prevented the need for surgery, and 68% reported CCH restored the ability to penetrate. Stretched flaccid penile length (SPL) increased by ≥ 1 cm in 50% of patients who used concurrent penile traction (PTT) and CCH, including 28% of patients who experienced ≥ 2 cm of length gain. In contrast, only 16% of patients who did not perform concurrent PTT had a ≥ 1 cm increase in SPL (p<0.0001). Conclusions CCH may restore the ability to penetrate with intercourse, and most patients feel that CCH prevents the need for surgery. Almost 40% of patients experienced a 40% or greater curvature improvement. However, 13% of patients may go through the entire series with minimal improvement. Concurrent PTT allows for simultaneous penile length gain in some patients. These data are helpful when counseling patients on expected outcomes. Disclosure No

Abstract Introduction Women in healthcare are faced with unique challenges that may increase the risk of infertility including irregular work hours, occupational hazards due to radiation or chemicals, and advanced maternal age. Objective We therefore sought to investigate live birth rates of female healthcare workers presenting with infertility compared to their non-healthcare counterparts. Methods After obtaining IRB approval, a retrospective review of hospital employees and partners presenting for a fertility evaluation between 2013-2019 was conducted. Patient age, BMI, history of previous live birth, occupation, use of assisted reproductive technology and female fertility factor were recorded. Couples with at least 12 months of follow up from initial presentation as well as a documented semen analysis were included in the study. Normal semen parameters were defined by the World Health Organization 2010 criteria. Logistic regression analysis was conducted to identify factors associated with increased likelihood of live birth. Results Of the 934 female partners identified, 445 were healthcare workers and 489 non-healthcare workers. Female age, BMI, smoking status, and history of previous live birth were not statistically significant between groups. No differences in male partner age, BMI, semen parameters and presence of male factor were noted. As an overall group, female age, male age, and abnormal concentration were noted to impact live birth rates (p<0.016). Live birth rates were higher in female health care workers compared to non-healthcare workers, 76.1 vs. 69.6%, respectively, p=0.042. The cohort was then further analyzed to determine if there was a difference in between females holding a Doctor of Medicine (MD) and other medical occupations (91 MDs vs 357 other occupations). Live birth rates, pregnancy complications, and preterm labor were not statistically significant, however MDs were found to have higher rates of use of assisted reproductive technologies (IUI or IVF) and were more likely to be older at time of evaluation (p=0.0015). After controlling for age at delivery, female physicians were still more likely to utilize ARTs, but this was no longer statistically significant (p=0.0806). Conclusions In this cohort of hospital employees, female healthcare workers had a higher live birth rate despite no differences in age, BMI, female factor infertility, use of assisted reproductive technology, or male partner factors. However, when the subgroup of female hospital employees was further analyzed, MDs were noted to have higher use of assisted reproductive technologies and older age. This indicates increased difficulty achieving pregnancy, likely a reflection of advanced maternal age. Further research is needed to identify subgroups within the healthcare population that may be at greater risk for infertility. Disclosure No

Abstract Introduction Physicians may be subjected to grueling work hours, sleep deprivation, and a stressful work environment during their prime reproductive years. While attention to fertility among female physicians has garnered interest in recent years, little is known about the fertility of their male colleagues. Objective In this study we sought to compare semen parameters of male physicians presenting for a fertility evaluation compared to their non-physician counterparts. Methods Upon IRB approval, a retrospective review of all hospital employed individuals (or their partners) who underwent a semen analysis between 2013-2019 was performed. Post-vasectomy semen analysis patients were excluded. Baseline patient demographics including age, comorbidities, occupation, and BMI were recorded. Normal semen parameters were defined by the World Health Organization 2010 criteria. A comparison analysis of semen analysis parameters, baseline characteristics, and comorbidities was conducted with a significant p-value defined as <0.05. Results Of the 169 physicians and 438 non-physicians identified, physicians were more likely to have a lower BMI (median 25.8 vs. 28.0, p<0.0001) when compared to their non-physician counterparts. Physicians were less likely to have ADHD, depression, obstructive sleep apnea, malignancy, alcohol abuse, and history of smoking (p<0.05). Physicians had better semen parameters including pH, concentration, motility, volume, and morphology (p<0.05), with a greater sperm concentration (68.4 vs. 52.2 million/mL, p<0.0001) and higher total motile sperm count (125 vs. 86.4 million, p<0.0001) compared to non-physicians. However, male physicians were more likely to be older at time of semen analysis (33.8 versus 32.7 years, p<0.05), more likely to utilize assisted reproductive technology (IVF and IUI, p=0.0277), have older female partners (p=0.0053), and have older female partners at time of delivery (p=0.0124). Conclusions In this study we report, for the first time, semen parameters of physicians compared to non-physicians. Physicians had a significantly higher total motile sperm count and sperm concentration; however, they were older at time of semen analysis, more likely to utilize ART, and more likely to have older female partners. While physicians may be healthier, this may indicate increased difficulty achieving pregnancy. Patient care is directly impacted by the health and safety provided to their physicians. As the paradigm in the medical field shifts from caring only for our patients to caring for ourselves, fertility amongst male physicians warrants further investigation. Disclosure No

Abstract Introduction Collagenase Clostridium Histolyticum (CCH) is an FDA-approved treatment for Peyronie’s Disease (PD). Based on phase-3 trials, the recommended treatment course consists of 8-injections over the course of roughly 18-20 weeks. While its efficacy has been established, less is known about patient-specific reasons for electing to discontinue CCH injection therapy. Objective To evaluate patient-reported factors associated with premature CCH discontinuation. Methods We queried a database of all patients (n=406) who underwent CCH at a single institution from 2014-2021. Patients who did not complete the recommended 8 injections were identified, and a detailed review was undertaken to determine causes of discontinuation. Patients were excluded from our analysis for the following reasons: deceased at the time of chart review, declined to participate, or could not be reached in 3 phone calls. Results Out of 406 patients who underwent Xiaflex treatment at our single institution, 133 did not complete 8 injections (32.8%). The mean number of CCH injections was 4.42 (SD 1.65). The most common reasons for discontinuing Xiaflex were satisfactory curve reduction (27%), unsatisfactory curve reduction (21%), bothersome side effect (15%), and decision to pursue surgery (12%) [Figure 1]. Other less common reasons included other health concerns, pausing treatments due to the Covid-19 pandemic, high treatment cost, transferring care elsewhere, and lack of awareness that more injections were indicated. Conclusions In our single institution study, we find that nearly 1/3 of patients who begin Xiaflex injections will not complete the full recommended treatment course. Understanding the reasons for discontinuation can help providers better stratify patients for Xiaflex treatment versus other modalities. In addition, given previous studies that indicate that 2/3 of men who fail to achieve a 20% curve reduction after their first 4 injections will go on to achieve this curve reduction after their final 4 injections, our data points to the potential impact of improved patient education for the 21% of individuals who discontinue due to unsatisfactory curve reduction (Alom et al 2021). Disclosure No

Abstract Introduction Independently performed procedures by well-trained advanced practice providers (APP) facilitate access to specialized care. We sought to compare outcomes between physicians and APPs with intralesional collagenase clostridium histolyticum (CCH). Objective Compare outcomes of CCH injections based on injection provider. Outcomes included curvature improvement and adverse events. Methods Men receiving CCH between 2014-2021 at our institution by four physicians and four APPs were included in an IRB-approved database. CCH was delivered as a series of 8 injections per protocol. Patient demographics, procedural-related adverse events, and curvature changes were recorded. The “APP-ratio” is defined as percentage of total injections administered by an APP per patient. Results After excluding patients who did not complete the entire CCH course or return for final assessment, 150/406 patients were analyzed. Mean baseline penile curvature was 66.2° (SD 23). Mean absolute and percent improvements in curvature were 21.7° (SD 18) and 33% (SD 27). The mean APP ratio was 69%, and 133 patients (89%) had at least 25% of their injections performed by an APP. There was no significant difference (p=0.65, p=0.39) in absolute or relative curvature improvement based on the APP-ratio [Figure 1]. There was also no difference in adverse events (pain, swelling, and hematoma). Conclusions In our high-volume CCH practice, APPs achieve the same outcomes and safety compared to physicians. Greater training efforts expand access to care for patients with PD. Disclosure No

ABSTRACT Introduction Covid-19 has helped drive all forms of medicine away from traditional brick and mortar medical interactions. Given the availability of online services to obtain treatments for ED, we developed a website to facilitate patient education, triage and men's health appointment scheduling. Objective We sought to assess characteristics of men who utilized a novel website to treat their ED. Methods We report on 50 patients who ultimately booked and attended appointments (video or in person) for erectile dysfunction. Patients found our website through our institution's main informational ED pages or through youtube links from our men's health video playlist library. Patients create an institutional account and are then asked a series of MD created questions designed to streamline patient triage and complete the majority of chart documentation ahead of the appointment. Patients are then sent videos relevant to their condition and future appointment options. Results 2300 users investigated the ED portion of the website with 1.8% of patients ultimately following through with an appointment. 13% of patients who explored the ED portion of the site created a user account that allows a questionnaire to be taken. 90% of men who began the ED questionnaire completed with a mean time of 11 minutes. 52% of men offered an appointment based on their responses completed the patient scheduling form. 71% of traffic was on mobile devices with 29% on desktop/tablet. Site use by time of day is shown in figure 1. Mean age of patients was 53. 92% of patients had ED that occurred > 6 months. Mean SHIM score was 8.2 (IQR 4-12). 80% of participants had both desire and opportunity for sexual activity, 20% did not meet both criteria and thus SHIM scores were less valid for these men. Of the users 28% had never tried pde5s, 32% had partial success with pde5s, 24% could not tolerate or afford pde5s and 42% had unsatisfactory results with pde5s. PDE5 naïve patients were seen by an internal medicine MD specializing in men's health, 10 were seen by surgeons as they requested IPPs and the rest were seen by a combination of men's health APPS and urology attendings for second line treatments and penile doppler. Interestingly, 66% of men were interested in undergoing penile doppler to better understand the etiology of their ED. Hypertension (40%) and diabetes (22%) were the most common medical comorbidities. 36% of the cohort had a strong family history of cardiac disease. Conclusions Men with ED can be effectively triaged through a website application. Most men with pde5 refractory ED wish to pursue penile doppler. The majority of patients seen had watched educational video material ahead of time, facilitating a more sophisticated and streamlined patient interaction. Disclosure No