What the editors are reading? Adolescent urology

Abstract

The Diagnosis and Management of Priapism: an AUA/SMSNA Guideline (2022) https://www.auanet.org/guidelines-x15197.Trinity J. Bivalacqua; MD PhD; Bryant K. Allen, MD; Gerald B. Brock, MD; Gregory A. Broderick, MD; Roger Chou, MD; Tobias S. Kohler, MD; John P. Mulhall, MD; Jeff Oristaglio, PhD; Leila L. Rahimi, MHS; Zora R. Rogers, MD; Ryan P. Terlecki, MD; Landon Trost, MD; Faysal A. Yafi, MD; Nelson E. Bennett, Jr., MD.Editorial comment: This guideline report was ultimately created using 203 articles and is based on best evidence. Treatments were assigned a strength rating of A (high), B (moderate), or C (low), and evidence-based statements of Strong, Moderate, or Conditional Recommendation were developed. Clinical Principle and Expert Opinions were developed when the panel found insufficient evidence. Of particular interest to pediatric urologists are the guidelines for the operative therapy of priapism and guidelines for the treatment of boys and men with sickle cell disease (SCD).No optimal distal corporoglanular shunt (e.g., T-Shunt, Winter's, Al Gorab, Ebbehoj) was identified. Additionally, the Panel was unable to find studies comparing shunting alone versus shunting with tunneling, where a dilator is placed into the corpora. However, the Panel does recommend tunneling when ischemia persist after distal shunting (Evidence Level C). It found no evidence for the benefits of proximal shunting after distal shunting for persistent acute ischemic.For men presenting with acute ischemic priapism lasting over 36 h or those who have failed distal shunting, the Panel recommends consideration for early (i.e., within 2 weeks) placement of a penile prosthesis. As an alternative, these men can be managed with conservative therapies such as pain control and outpatient follow-up, knowing that it is unlikely that erectile function will be restored using shunting procedures.Similar to the general population, standard management for priapism in boys and men with SCD and other hematologic and oncologic disorders should not be delayed. Even in pre-pubertal boys, the same initial interventions are recommended and are well outlined in the Guidelines. Important and sickle cell disease specific recommendations regarding the use of intravenous hydrations, supplemental oxygen, pain management, exchange transfusion, ice packs, monthly transfusion and hydroxyurea are outlined.Take home message: Given the poor results of intervention after ischemic priapism lasting over 36 h, prompt, attentive and sometimes aggressive intervention is warranted even in pre-pubertal boys. Patient education regarding priapism in high-risk groups such as boys with SCD should not be underestimated.Erectile Dysfunction in a Sample of Sexually Active Young Adult Men from a U.S. Cohort: Demographic, Metabolic and Mental Health Correlates.Calzo JP, Austin SB, Charlton BM, Missmer SA, Kathrins M, Gaskins AJ, Chavarro JE. J Urol. 2021 Feb;205(2):539–544. https://doi.org/10.1097/JU.0000000000001367. Epub 2020 Sep 16.PMID: 32935616.Editorial comment: The authors examined cross-sectional survey data from 2,660 sexually active men, aged 18–31 years, from the Growing Up Today Study (GUTS). GUTS includes the children of women in the Nurses’ Health Study II who were enrolled at ages 9–16 years between 1996 and 2004. These children were subsequently followed to adolescence and adulthood.Sexual activity, marital status, body mass index and comorbidities potentially affecting erectile dysfunction (ED) including diabetes, hypertension, hypercholesterolemia, depression, anxiety, antidepressant and tranquilizer use were evaluated. Subjects self-reported the use of ED medication and supplements. Eleven percent of sexually active men reported mild ED and 2.9% reported moderate-to-severe ED. ED was less common in married/partnered men compared to single men. Antidepressant use, tranquilizer use and anxiety were associated with greater odds of moderate-to-severe ED. While few men (2%) reported using ED medication or supplements, 29.7% of them misused prescription ED medication.Take-home message: While this sample has limited racial/ethnic and socioeconomic diversity, it finds that ED is not uncommon in sexually active young adult men and is associated with relationship status and mental health. Healthcare providers should screen for ED in young men, and monitor use of prescription ED medications and supplements for sexual functioning.Masculinizing surgery in disorders/differences of sex development: clinician- and participant-evaluated appearance and function.van de Grift TC, Rapp M, Holmdahl G, Duranteau L, Nordenskjold A; dsd-LIFE group. BJU Int. 2022 Mar;129(3):394–405. doi: 10.1111/bju.15369. Epub 2021 Mar 31.PMID: 33587786.Editorial comment: This paper is from the dsd-LIFE consortium that consists of 16 European partners from Germany, France, the Netherlands, Poland, Sweden and the UK. One thousand forty adolescents (≥16 years) and adult participants with diagnoses including Klinefelter's syndrome (n = 57), severe (isolated) hypospadias (n = 25), partial androgen insensitivity syndrome (PAIS) (n = 17), partial 46, XY or mixed 46,XY/45, X0 gonadal dysgenesis (n = 38), and 13 with other diagnoses (e.g. ovotestes, steroid synthesis errors, congenital adrenal hyperplasia) were included in the study. These subjects who live “other than the female gender” and who have had some form of masculinizing surgery: hypospadias repair (n = 84), orchidopexy (n = 86), breast reduction (n = 32) and/or gonadectomy (n = 52) were studied. The main indication for gonadectomy was dysgenesis.Long-term outcomes of these surgeries were evaluated. Sixty percent of men had revisionary surgery after hypospadias with most related to urethral strictures. Urine dribbling and urogenital infections was reported in 27%. One hundred ten patients had urologic examinations. Overall, the examiner deemed 11% had poor appearance after hypospadias surgery and this was worse in PAIS. Of the participants, dissatisfaction was greatest in the PAIS (4.6 ± 2.1 cm) who had shorter penis length than the whole group (7 ± 2.7 cm). Patients with and without a history of hypospadias repair reported similar satisfaction with their sex life. Additionally, satisfaction with the timing of surgery was studied and the participants were generally satisfied with early surgery for hypospadias and cryptorchidism.Take-home message: Esthetic and functional outcomes vary among patients based on specific diagnoses, initial anatomy and surgeries performed. Differences of sexual development are varied, and though many diagnoses are considered to demonstrate differences in development, we should focus on specific diagnoses and avoid clustering groups.Endocrine outcome and seminal parameters in young adult men born with hypospadias: A cross-sectional cohort study.Tack LJW, Spinoit AF, Hoebeke P, Riedl S, Springer A, Tonnhofer U, Hiess M, Weninger J, Mahmoud A, Tilleman K, Van Laecke E, Juul A, Albrethsen J, De Baere E, Van De Velde J, Verdin H, Cools M. EBioMedicine. 2022 Jun 24;81:104119. https://doi.org/10.1016/j.ebiom.2022.104119. Online ahead of print.PMID: 35759917.Editorial comment: In this multi-center study, the authors assess the endocrine function and reproductive potential of 193 men ages 16–21 years with non-syndromic hypospadias (NSH) who had undergone spontaneous puberty and compare them to 50 healthy male peers. Subject evaluation included physical examination including Tanner staging, height, weight, stretched penile length, testicular examination with focus on presence of varicocele, semen analysis, hormone assays and exome-based gene panel analysis (474 genes). Birth history including whether the boy was small for gestational age (SGA) and the severity of hypospadias were noted.In young men with NSH, LH and INSL3 (a more novel marker for Leydig cell function) levels were higher than in men without hypospadias. Overall oligo- or azoospermia was observed in 18.6% of NSH men. However, these abnormalities were noted in 31.3% of complex NSH men and 59% of those with NSH who were born small for gestational age. Gene panel analysis identified no likely pathogenic coding. Suboptimal growth in stature was identified in almost 35% of men born SGA with NSH.Take home message: Spermatogenesis is compromised in men with NSH. Those with NSH born SGA and those with complex NSH are most affected. The care of men with hypospadias goes beyond attention to the urologic consequences of hypospadias and hypospadias repair and should include attention to somatic growth, endocrine function and reproductive goals.