Citations

Abstract Introduction Erectile Dysfunction (ED) is becoming increasingly recognized as a potential marker of chronic medical conditions. Recent research has examined the association between ED and Parkinson’s disease. In fact, recent findings indicate that men with ED have upwards of a fourfold higher risk of developing Parkinson’s disease compared to those without a diagnosis of ED. Objective Our research investigates associations between self-reported ED severity and neurobiological factors, including measures of cognitive function and neuroimaging of dopaminergic integrity. Methods We performed a retrospective analysis of 93 male research participants with ED extracted from an observational cohort study of aging and Parkinson’s disease biomarkers. Though some patients experienced some age-related mild cognitive changes, all participants were classified as clinically neurologically healthy. Patients received cognitive testing through the Montreal Cognitive Assessment (MoCA), with scores ranging from 0-30. Neuroimaging of the bilateral caudate and putamen, components of the striatum implicated in Parkinson’s disease pathology and dopaminergic binding, was measured through dopamine transporter SPECT imaging (DaTScan) binding ratios. ED was self-reported using questions 22-23 on the Scales for Outcomes in Parkinson’s Disease – Autonomic Dysfunction (SCOPA-AUT). Question 22 stated “In the past month, have you been impotent (unable to have or maintain an erection?)” and question 23 stated “In the past month, how often have you been unable to ejaculate?”. SCOPA-AUT scores ranged from 0 (sometimes) to 3 (often) and were averaged across both questions. Patients taking dopaminergic Parkinson’s disease medications or PDE5 inhibitors at baseline were excluded due to potential confounding. Due to violations of normality assumption, numerical associations utilized an age-adjusted partial spearman correlation coefficient. Descriptive statistics are displayed as median (IQR). Results Of the 93 selected participants, one individual was excluded due to incomplete neuroimaging DaTScan data. Therefore, 92 patients were included in our analysis. The median age of participants was 67.3 years (61.4 – 73.0) and the median MoCA score was 27.2 (26.0, 28.7) which represents minimal cognitive impairment. Age-adjusted spearmen correlation coefficient showed no association between MoCA measured cognitive performance and ED severity (r = -0.116, p = 0.275). Age-adjusted associations of striatal DaTScan showed a significant, mild relationship between ED severity and both right caudate dopamine binding ratios (r = 0.236, p=0.0242) and left putamen dopamine binding ratios (r = 0.262, p = 0.0121). However, associations between ED severity and both left caudate (r = 0.150, p = 0.155) and right putamen (r = 0.143, p = 0.176) dopamine binding ratios did not reach statistical significance. Conclusions Although no association was observed between ED severity and cognitive function, greater ED severity was significantly associated with increased striatal dopaminergic binding. This positive, age-adjusted association may reflect a compensatory dopaminergic response similar to that seen in the early stages of Parkinson’s disease. Overall, our findings suggest that ED could serve as a potential marker of central dopaminergic and autonomic alterations, even in the absence of clinically evident neurological disease. Disclosure No

Abstract Introduction Penile plication is the gold standard operation for Peyronie’s disease with preserved erectile function but is associated with persistence of hourglass shaft deformity and palpable, permanent plication sutures that may be bothersome in some patients. A novel technique utilizing extratunical grafting overlying plication sutures in the tunica albuginea may improve patient discomfort, increase penile girth, and improve overall satisfaction. Objective We aim to analyze patient centered outcomes and satisfaction scores associated with this operation. Methods We retrospectively evaluated 13 patients who underwent Peyronie’s correction with penile plication with extratunical onlay grafting with biological Dura substitute graft performed by a single surgeon at a tertiary academic center. The graft was placed over 2-0 Ethibond Lue plication sutures in a circumferential fashion sparing the neurovascular bundle and secured with chromic suture. Primary endpoints of interest were patient satisfaction scores (1-10), presence of hourglass, palpability of sutures as well as associated discomfort, and sexual activity. Results Median follow up was 15.4 months. 100% of patient were sexually active at time of follow up. Mean patient reported post operative satisfaction was 8.9 out of 10. No patients endorsed palpability of plication sutures, coital discomfort at site of repair, or persistence of hourglass or concavity deformity. In patients who reported less than a 10 in satisfaction, areas of dissatisfaction include persistence of curvature, albeit decreased pre-operatively, as well as enhanced girth associated with dyspareunia of the receptive partner during intercourse in a single patient. Conclusions We present excellent post operative satisfaction and patient centered outcomes utilizing extratunical grafting overlying penile plication sutures in Peyronie’s disease repair. This novel technique may meaningfully improve patient satisfaction is patients with Peyronie’s disease undergoing plication alone. Disclosure No

Abstract Introduction Peyronie’s disease (PD) and ED can coexist, affecting the patient’s perception of erectile function. The AUA guidelines recommend intracavernosal injection, with or without doppler ultrasound, prior to invasive interventions. Our objective was to assess vascular erectile integrity in patients with PD. Objective The objective of our study was to assess vascular erectile integrity in patients with PD. Methods We retrospectively reviewed 2309 patients who underwent color doppler duplex ultrasound (CDDU) at our institution. CDDU findings such as peak systolic velocities and resistive indices were recorded following injection of low dose Alprostadil and again after a period of privacy and visual sexual stimulation. Among patients diagnosed with PD, comparisons of patient characteristics between those with PD only and those with PD and ED were made using ANOVA (continuous characteristics) or Chi-squared test (categorical characteristics). Results Of men that underwent CDDU, 1468/2452 (63%) were diagnosed with PD. Among those with PD, 327 (14%) were diagnosed with PD only and 1141 (49.4%) were diagnosed with both PD and ED. Those with PD only had lower BMI (27.1 vs 28.4), were less likely to have hypertension (37% vs 46%), less likely to have Diabetes Type 2 (16% vs 31%), less likely to have used PDE-5 inhibitor (39% vs 82%), and less likely to have failed to a PDE-5 inhibitor (30% vs 73%) compared to men with both PD and ED, all p<0.005. Average SHIM scores were higher among those with PD only compared to PD and ED (18 vs 12). CDDU diagnoses for men with PD and ED were: AI (32%), CVOD (43%), mixed vascular ED (26%). Conclusions In a large cohort of men with PD we identified multiple potential risk factors for erectile dysfunction. CDDU of men with PD demonstrates that three-quarters of patients have some form of vascular erectile dysfunction. Counselling for surgical interventions should include a Doppler assessment to ensure patients are appropriately triaged to PD-corrective surgery versus penile implant. Future AUA Guidelines should reclassify the recommendation for evidence-based testing prior to surgical interventions from ‘Expert Opinion’ to ‘Clinical Principle’. Disclosure No

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 Introduction Vasectomy is a highly effective, permanent method of contraception. Vasectomy is commonly performed in the outpatient urology clinic with the patient awake. There is clearly anticipation of pain as well as anxiety associated with the procedure. Objective The objective of our study was to evaluate anticipated versus experienced pain associated with office-based vasectomy. Methods We studied men who underwent vasectomy in May and June of 2022. Men who had no history of scrotal surgery of any kind were asked to score the anticipated pain associated with an office based vasectomy with a score of 0-10. After the vasectomy, patients were asked to rate the pain they perceived with the vasectomy on the same scale (0-10). Results A total of 17 men were asked to rate their pain as discussed in the method section. The median age of men sampled was 38 years of age. All men we treated were given 15 mg of Valium before the procedure and instructed to take the medication 30 minutes prior to their procedure. The average pre vasectomy prediction pain score was 7.5+/- 1.9; the average post-injection perceived pain score was 2.9+/- 1.9. Thus there was an average decrease of over 4 points in the predicted pain versus perceived pain. A two-sample T test was performed; in addition Wilcoxson Signed Rank Test was performed. Both tests showed a statistical significance in the difference between pre and post vasectomy pain scores (p<0.001). Conclusions We found that patients who are undergoing office based vasectomy for the first time have a significantly higher perception of pain versus perception of pain after the injection. We have utilized this data in our clinic to explain to patients that while most patients will predict a high pain score associated with the vasectomy, the vast majority of patients report minimal pain after the procedure. Our study can be particularly helpful in patients who have had significant anxiety about office based vasectomy and for those patients who are deciding between office based vasectomy and vasectomy performed under general anesthesia. Disclosure No

Abstract Introduction Over 500,000 men undergo vasectomy in the U.S. annually. Although found to be 99.7% successful, the cost of vasectomy failure that results in an unplanned pregnancy far outweighs the cost of follow up semen analysis to ensure success. Despite the cost-benefits of post-vasectomy semen analysis (PVSA), compliance ranges only 30%-87%. Challenges include access to care, cost, and inconvenience of time4. Mail-in PVSA may help address these challenges and improve compliance, particularly in socially vulnerable and rural communities. Objective To examine geographic and socioeconomic community-level factors linked to mail-in PVSA completion in Texas. Methods We prospectively analyzed data from Texas men after undergoing vasectomy who received a Fellow mail-in PVSA kit between 2021–2024. Home ZIP codes were linked to the Distressed Community Index (DCI), a measure of economic well-being across US communities. The primary outcome-mail in PVSA completion within 40 weeks of being provided a test kit-was evaluated against region, DCI, and kit ordering setting. Chi-square tests and multivariable logistic regression were used, and statistical significance was assessed at the 0.05 level. Results Of 4,744 men included, 81.1% (3,849) completed mail-in PVSA testing. Compliance rates were lower among individuals living in urban areas, in the North Texas region, those residing in communities “at-risk” of socio-economic distress, and those who received their kit in a clinic (Table 1). On multivariate analysis, residence in a rural area was associated with higher completion rates (OR 1.50, 95% CI 1.12–2.04), and men who ordered their kits direct-to-consumer where significantly more likely to be compliant than those receiving their kits in a clinic (OR 10.33, 95% CI 5.01–26.26). Conclusions Men in rural areas of Texas were 74% more likely to complete mail-in PVSA, even after adjusting for social determinants of health. Direct-to-consumer users were also more likely to complete testing than clinic-ordered users. Mail-in PVSA shows higher adherence than historical clinic-affiliated methods (30–50%). Further research is needed to explore regional factors influencing completion, such as cultural attitudes, access to postal services, health literacy around male infertility, and insurance policy. In summary, mail-in PVSA testing may dramatically improve compliance for men in rural areas, and potentially decrease the risk of unplanned pregnancies. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Fellow

Abstract Introduction Infertility insurance benefits remain a key concern for individuals pursuing medical training during peak reproductive years. While urologists play a central role in managing male infertility, the availability and visibility of fertility benefits during urology residency remain poorly characterized. Delays in family building are common among male trainees, often paralleling those of their partners. By the time individuals pursue fertility care, partners may already be within or approaching advanced reproductive age. Additionally, male infertility is increasingly recognized as a marker of systemic health conditions, underscoring the importance of adequate evaluation and support. Objective To assess the prevalence, scope, and accessibility of infertility treatment coverage across U.S. urology residency programs. Methods A total of 148 accredited U.S. urology residency programs were identified and evaluated from the American Urologic Association that participated in last year’s match. Each program's public-facing urology department website, affiliated graduate medical education (GME) website (with linked benefits booklet if applicable), and program details were reviewed. Programs were assessed for the availability of information regarding infertility treatment benefits, gender-specific coverage (male, female, or unspecified), institutional details describing benefit access, and available data such as lifetime coverage limits and cycle caps. Data were descriptively analyzed. Results Out of 148 programs, 40 (27%) provided available information regarding infertility treatment benefits while 140 programs (95%) provided information on general medical benefits. Among these 40 programs, 22 (55%) specified coverage for female fertility services, 16 (40%) included male-specific benefits, and 18 (45%) referenced fertility coverage without specifying sex. Six programs (15%) included information on female-only benefits, whereas none exclusively listed male-specific benefits. (Table 1) Male fertility services were variably represented among the 40 programs with fertility benefit information. There were 6 programs (15%) specified sperm cryopreservation, 4 programs (10%) that included sperm extraction, and 1 program (2.5%) mentioned covering vasectomy reversal. Among programs that disclosed cost-related information, the average lifetime medical fertility benefit was $17,500 (n=8), with an additional $7,800 for pharmacy benefits (n=10). The average of total lifetime fertility coverage maximum was $28,375 (n=20). Only 4 programs (10%) specified a cycle limit, averaging 2.75 cycles. Regional variation in the availability of fertility benefit information was observed, with the Western, North Central, and South Central regions demonstrating the highest proportions of programs providing infertility treatment benefit information (56%, 31%, and 29%, respectively), and the New York region the lowest (5.9%). However, these differences did not reach statistical significance (p = 0.092). Conclusions Fewer than one-third of U.S. urology residency programs provide accessible information regarding infertility treatment coverage. Male-specific services, despite the specialty’s clinical focus and the growing recognition of infertility as a systemic health concern, remain underrepresented. The limited transparency of fertility benefits, almost always requiring indirect access through GME resources, may hinder informed reproductive planning. As many male trainees delay childbearing alongside their partners, timely and visible support for infertility coverage is essential. Improving the availability and clarity of these benefits may help address both reproductive and broader health needs for future urologists. Disclosure No

Abstract Introduction While microdeletions in the azoospermia factor (AZF) regions of the Y chromosome are a well-recognized cause of genetic male infertility, reproductive outcomes and broader health profiles among affected men remain poorly characterized. Objective We explore the distribution of AZF deletion subtypes and evaluate comorbidities and fertility management patterns in this unique population. Methods We performed a multi-institutional retrospective cohort study of men diagnosed with AZF deletions following evaluation by a reproductive urologist and genetic testing. The primary exposure variable was the AZF subtype (AZFa, AZFb, AZFc, or multilocus [e.g., AZFabc]).Clinical data were extracted to assess the presence of comorbidities, including hypertension, diabetes mellitus, hyperlipidemia, liver disease, and cardiac disease. Descriptive statistics were used to characterize the distribution of AZF subtypes, comorbidity profile, and outcomes of sperm retrieval procedures within our cohort. Results Among 40 men with confirmed AZF microdeletions across three academic centers, four patients with SRY translocations were excluded. Of the remaining 36, AZFc was the most common subtype (75%), followed by multilocus (16.6%), AZFa (5.5%), and AZFb (2.7%). The median age was 32.8 years (IQR: 29.2–33.6) and median BMI was 28.6 kg/m2 (IQR: 25.6–32.8). Comorbid conditions were identified in 8% of the cohort, with hyperlipidemia (13.9%), hypertension (11%), and diabetes (11%) most commonly reported. Sperm retrieval was attempted in 31% (n=11) of patients, exclusively among those with AZFc (n=10) andAZFb (n=1) deletions. Microscopic testicular sperm extraction (mTESE) was the predominant technique (91%). Sperm was successfully retrieved in 46% of these cases, all within the AZFc subgroup. Conclusions This study advances limited literature on AZF microdeletions by characterizing systemic health profiles and post-diagnosis infertility management. Our results support a broad phenotype associated with genetic causes of male infertility. In this cohort of men with YCMD, AZFc was the most prevalent subtype. Compared to national estimates for similarly aged men, our findings suggest that men with YCMD may have a distinct comorbidity profile compared to the general population, with an elevated prevalence of metabolic disease. Our findings reinforce male infertility as a heterogeneous condition that may serve as an early marker for broader metabolic disease. In addition, nearly all patients who underwent sperm retrieval were within the AZFc group. Fertility management trends favored mTESE, with moderate success rates in sperm retrieval, particularly among AZFc patients. Our results highlight provider preferences in surgical fertility management in patients withYCMD. Our findings underscore the need for a holistic approach to men with YCMD, addressing both surgical fertility management and systemic health risks. Clear patient counseling on sperm retrieval success rates and early identification of comorbidities may redefine outcomes for this unique population. Our results support a broad phenotype associated with genetic causes of male infertility. Disclosure No

Abstract Introduction Fertility preservation is an essential component to cancer survivorship. One third of male survivors experience infertility following gonadotoxic treatments, and expeditious preservation prior to therapy is recommended by oncology guidelines. However, this can be challenging given time constraints, lab expertise, and financial considerations. Objective We describe national practice patterns and identify barriers and facilitators regarding inpatient male fertility preservation. Methods An anonymous 34-item Qualtrics survey was sent to reproductive Urologists in the United States. Email addresses were obtained from public membership databases. Respondents were queried across several domains, including provider demographics, specific inpatient cryopreservation scenarios, and fertility preservation procedures. Results Thirty-nine (21%, n=39/189) responses were received. The majority of respondents were fellowship-trained reproductive urologists 89.7% (35). The majority (97.4%) of respondents offer microdissection testicular sperm extraction (mTESE) for fertility preservation, and many offer conventional TESE (71.8%), traditional ejaculated sperm cryopreservation (71.8%), or microsurgical epididymal sperm aspiration (59%). Only 30.8% of respondents offer electroejaculation. Respondents rate non-urology provider awareness of male cancer fertility preservation options at 5.05/10 on a Likert scale. Many (65%) respondents provide formal materials or education to nonurology providers to address this deficit. On average, respondents reported 2.6 inpatient oncofertility preservation consults per month (range 0-25, median=1). Most (60%) of respondents reported that <25% of these patients ultimately complete inpatient preservation. Financial burdens (97%), logistical hurdles (97%), limited awareness (97%), and concern for delay of oncologic care (92%) were identified as the most common barriers for patients precluding fertility preservation. In addition, 85% of respondents also listed difficulty coordinating with other specialists as a barrier. On free-text queries, respondents identified facilitators of fertility preservation as automatically triggered consults, use of an urgent cryopreservation pager, formal fertility preservation pathway within the order set, and utilization of an inpatient coordinator as facilitators that aid in achieving timely fertility preservation prior to gonadotoxic therapies. Conclusions Despite all reproductive urologists offering cryopreservation services and education regarding the urgency and priority of inpatient fertility preservation, less than a quarter of patients complete this process during hospitalization prior to initiation of treatment. This remains the consequence of numerous patient, provider, and facility level barriers, even in systems with robust referral processes. Inpatient fertility preservation remains an underutilized and often missed opportunity. Multidisciplinary interventions are needed to address ongoing barriers. Disclosure No

Abstract Introduction Sperm cryopreservation is becoming increasingly accessible and cost-effective. One of the most common indications for cryopreservation remains prior to gonadotoxic therapies and surgeries. However, it may be used by patients undergoing vasectomy as an alternative to potential future more invasive procedures including reversal or sperm retrieval. Objective To characterize demographic and individual factors associated with the utilization of cryopreservation prior to vasectomy. Methods We conducted a retrospective review of all patients from January 2023 to May 2025 at a single academic medical center who underwent a vasectomy. All 186 patients who completed the pre-vasectomy questionnaire were included in our analysis. At the time of vasectomy consultation, patients were informed of the procedure’s permanent nature and, per guidelines, were educated on future fertility options, including vasectomy reversal and sperm retrieval for use with in vitro fertilization. All patients were also separately offered sperm cryopreservation. Demographic and questionnaire data was collected and analyzed. Pre-vasectomy questionnaire information included age, relationship information, familial information, and reason for vasectomy, among other factors. Numerical variables were described as medians with interquartile range and categorical variables were described in counts. Due to violation of the normality assumption, Fisher’s Exact test was used for categorical variables and the Kruskal-Wallis rank sum test was used for numerical variables. Results 186 patients completed the pre-vasectomy questionnaire and were used in our analysis. Of these individuals, 5.4% (n=10) utilized cryopreservation at the time of vasectomy. Individuals utilizing cryopreservation had a median age 5 years younger than those who did not utilize the same service (p = 0.046). Moreover, 40.0% (n=4) of individuals in the cryopreservation group had children compared to 83.5% (n=147) in the no cryopreservation group (p=0.004). Current relationship length was significantly longer for individuals who did not utilize cryopreservation, with a median reported relationship length of 11 years as compared to a median length of 5 years for individuals utilizing cryopreservation (p=0.025). The shorter relationship length is likely related to an additional finding that the percentage of individuals who utilized cryopreservation were married approximately 30% less often than individuals who did not use the same service (p=0.039). Conclusions While only a small proportion of patients undergoing vasectomy choose to pursue cryopreservation despite counselling at their visit, significant differences in demographic and individual characteristics were observed for those who did. These individuals tended to be younger, married at lower rates, without children, and in shorter relationships. With improved access to reproductive services, further work is needed to understand decision choices for men offered sperm cryopreservation prior to permanent sterilization. Disclosure No