1. Differentiate presentations of ischemic and nonischemic priapism during patient history and evaluation.

2. Explain the medical and surgical options for, and cite the recommended treatment approaches to, ischemic, nonischemic, and stuttering priapism.

3. Compare the efficacy of current methods used for retrieving sperm in men with nonobstructive azoospermia.

4. Review the technical aspects of vasectomy.

5. Discuss controversial aspects of vasectomy, and detail possible positive and negative outcomes associated with the procedure.

Up or Down: A Refined Approach to all Three Types of Priapism
Tom F. Lue, MD, Professor and Vice Chair of Urology, and Emil Tanagho Endowed Chair in Clinical Urology, University of California, San Francisco, School of Medicine

Priapism: definition—pathologic penile erection that persists beyond or is unrelated to sexual stimulation (duration >4 hr); classification—ischemic (no flow); nonischemic (high flow)

Evaluation of patient: >95% of nonischemic priapism due to trauma; on physical examination (PE), nonischemic priapism usually not 100% rigid and 95% of time not painful (reverse in ischemic priapism); cavernous blood gases and color duplex ultrasonography (US) help differentiate ischemic from nonischemic priapism; if obtaining cavernous blood gases, inform laboratory that blood obtained from penis

Medical management: effective if performed within 24 hr (if treated properly, majority of patients managed with α- adrenergic medications); first step evacuation of old blood; then intracavernous injection of diluted α-adrenergic agonist given (speaker prefers 1 mL of phenylephrine [Neo-Synephrine] diluted with 9 mL of saline)

Surgical shunts: Winter shunt—uses biopsy needle placed through glans penis into corpora cavernosa; success rate 50%; results in edema in area; when condition recurs, more difficult to treat; Ebbehoj procedure—uses #11 blade scalpel; Al-Ghorab procedure—excision of tip of corpus cavernosum; speaker recommends longitudinal (rather than transverse) incision; cavernosum-venous—saphenous vein (Grayhack shunt); deep dorsal vein (Barry shunt); proximal (spongiosum-cavernosum)—Quackels shunt (1964), Sacher shunt (1972); advantage of better proximal saturation; disadvantage time-consuming; complications include urethral obstruction, cavernositis, and fistula; least desirable surgical option

Differentiating between recurrence and postischemic hyperemia: best method color duplex US (immediately shows whether penis has blood circulation); cavernous blood gases (takes several hours to change from normal blood circulation to ischemic situation); if no blood flow on US, recurrence present; high blood flow indicates normal response to ischemic insult

Treatment of ischemic priapism: within 24 hr—evacuation of old blood and injection of diluted α-adrenergic agonist; <2 days—T-shaped shunt; >3 days—T-shaped shunt and tunneling (T-T shunt); speaker uses #10 blade scalpel (insert into penis, turn laterally, and remove to create T-shaped shunt); done on one side; blood flows out of opening; wait 5 to 10 min before suturing; if erection recurs, do shunt on other side (not performed if partial erection present); absence of blood flow after shunt made indicates presence of edema; place dilator completely to base of penis to create channel for blood to flow from proximal to distal area and reestablish circulation; data suggest type of procedure performed not as important as duration of priapism; if priapism treated within 2 days, most patients recover; treatment algorithm—in patients with sustained erection, obtain cavernous blood gases or perform PE; evacuate blood and give diluted α-adrenergic agent; if necessary, perform shunt procedure (T shunt if <2 days); if Winter shunt performed and not effective, recurrence worse; if >2 days, perform T-T shunt

Nonischemic priapism: majority due to blunt perineal straddle injury; onset usually delayed until nocturnal or sexual erection (blood flow bursts injured arterial wall)

Treatment of nonischemic priapism: angiographic embolization of ruptured cavernous artery—treatment option; done with coils, gelatin sponge, or autologous blood clots (coils most effective but migration possible); using gel or blood clot much less effective and must be performed several times); suture ligation of ruptured artery—with US guidance in operating room (OR); performed only when problem persists >6 mo, with well-defined capsule; embolization and suture ligation possibly no longer necessary; better treatment to give antiandrogen (eg, Flutamide) or gonadotropin-releasing hormone (GnRH) agonist (eg, Lupron) for 3 to 6 mo; prevents almost all nocturnal erections, allowing ruptured blood vessel to close by itself

Stuttering (recurrent) priapism: possible mechanism of action—down-regulation of Rho-kinase pathway (important for muscle contraction); treatment options—include diluted α-andrenergic agent, antiandrogen, GnRH agonist, and ketoconazole; some data suggest that small doses of phosphodiesterase type 5 (PDE5) inhibitor effective in treating priapism (counteracts loss of Rho-kinase); however, speaker not certain of clinical efficacy, except in patients with underlying sickle cell disease

Is There a Best Way to Retrieve Sperm in Men with Testis Failure?
Paul J. Turek, MD, Professor and Endowed Chair in Education, Departments of Urology, Obstetrics-Gynecology, and Reproductive Sciences, University of California, San Francisco, School of Medicine

Introduction: 5% of infertile men have azoospermia, either obstructive or nonobstructive; patients with obstructive azoospermia can undergo repair; although sperm absent in ejaculate, possibly present in testicle (threshold effect of sperm production)

Finding sperm in testicles of patients with nonobstructive azoospermia (NOA): Belgian study found sperm recoverable from most patients who are normal or who have hypospermatogenesis; in 50% of men with abnormalities (ie, NOA), sperm found

Whether presence of sperm predictable in men with NOA: speaker says no; testicular size as predictor acceptable (but not highly predictive); history of ejaculated sperm helpful, but regression of germ line in stem cells of testis possible, especially in genetic infertility, diabetes, or systemic disease; follicle-stimulating hormone (FSH) levels not helpful; inhibin levels better but not formally predictive; probably best predictor biopsy of testis; clinicians encouraged to obtain biopsy in patients with NOA; normal pattern progression of stem cells toward middle, becoming sperm nuclei; in maturation arrest, germline stem cells present, but stopped at meiosis; in Sertoli cell-only syndrome, no germ cells present (difficult to treat); disadvantages—only provides information on biopsied area; invasive; 30% sampling error

Approaches to patient with NOA: simultaneous diagnostic and therapeutic biopsies with “up front” cryopreservation of sperm; real-time multiple biopsy techniques or deep biopsy (microdissection), with or without diagnostic biopsy; mapping of testes; insufficient evidence to suggest any of these procedures better than any other

Mapping technique: done in office under local anesthesia (takes 30 min); if sperm found, proceed to IVF or intracytoplasmic sperm injection (ICSI), directing biopsy to area(s) that showed sperm on map (highly successful); if no sperm found, speaker advises patients to consider other options, eg, sperm donor, adoption; speaker believes mapping has 5% false-negative rate

Microdissection: done in OR at time of IVF and ICSI; in best hands, 60% chance of finding sperm; concept behind procedure that seminiferous tubules containing sperm “thicker” and more opaque than tubules that do not contain sperm; involves systematic examination of testis (entire parenchyma) under microscope under local anesthesia; study—Schlegel retrospectively compared multibiopsy approach to microdissection and reported 50% improvement in retrieval of sperm with microdissection; subsequent studies confirmed that microdissection 50% better than performing multiple biopsies; overall, procedure associated with 50% success rate; if man has cryptorchidism, good chance that sperm present; characteristics—requires operating microscope, general anesthesia, expertise, and good laboratory; long-term effects unclear (testosterone levels in bilateral cases fall at ≈3 mo; however, ≈85% of men return to normal at ≈1 yr; ≈2% lose ability to produce testosterone and reduced to castrate levels); little data on whether procedure repeatable

Systematic mapping: conducted under local anesthesia; speaker tries to concentrate on hilum; provides cytologic (rather than histologic) view; cytologic specimens evaluated for presence of motile sperm; leaves marks on testicle used to map sites where sperm found; studies show procedure ≈50% successful in finding sperm in azoospermic infertile men; characteristics—no operating microscope necessary; requires local anesthesia, expertise in FNA; no long-term effects; in cases in which speaker locates only one site with sperm, he proceeds with microdissection (≈86% successful in recovering enough sperm to fertilize every egg); in cases with ≥2 sperm sites, ≈99% successful; procedure repeatable (speaker performed ≤5 times in some patients); when compared to biopsy, almost 30% of men who had biopsy with no sperm have sperm on mapping; variability within testicles in 1 in 4 men; variability between testicles present

Mapping as archival tool: determines presence of germ cells in testis; identifies presence of any other pathology (eg, lymphomas); enables better patient phenotyping; replaces standard biopsy

Metabolic imaging of testis with nuclear magnetic resonance (NMR) spectroscopy: comparison of normal fertile to azoospermic men shows that normal patients have high levels of phosphocholine and phosphatidylcholine, while azoospermic men do not; goal to obtain “metabolic fingerprint” of testicle; suggested that repeated use of NMR spectroscopy and analysis of ratios of phosphocholine and phosphatidylcholine possible non-invasive way to identify presence and location of spermatogenesis in men with failed testis

Controversies with Vasectomy
Jay Sandlow, MD, Associate Professor and Vice Chair, Department of Urology, Froedtert and Medical College of Wisconsin, Milwaukee

Technical aspects: preparation—preprocedural sedation (all patients given ≈10 mg of diazepam (Valium) ≈1 hr before procedure); scrotum shaved in room (infection rate lower if scrotum shaved at time of surgery); keep room and preparation solution warm; local anesthesia—combination of 1% lidocaine and 0.5% bupivicaine; procedure—some controversy over using 1 incision vs 2 (speaker prefers 2) and conventional vs no-scalpel technique (studies show patients do better postoperatively with no-scalpel technique)

Procedure: isolate vas deferens (grasp vas); separate vas from surrounding structures and vasal vessels; remove segment; block ends; repeat on other side; occlusion technique—clips vs ties (clips shown to distribute pressure more evenly across ends of vas, resulting in less necrosis); cautery (intraluminal most effective); fascial interposition (shown to reduce incidence of recanalization); compressive dressing and jock strap for scrotal support

Results: efficacy—most studies estimate failure rate (pregnancy after successful procedure) 1 in 2000 to 1 in 4000; recanalization rates vary; rate of early recanalization (within first 6 wk) quite high, but drops close to zero by 2 to 3 mo; complications—rare; include hematoma (most common), sperm granuloma, and failure

Follow-up: all patients must wait 8 wk and should continue previous contraception method; getting 2 azoospermic semen samples recommended (however, most patients do not return after first sample); controversy over whether necessary to centrifuge sample vs evaluation of neat sample (speaker no longer centrifuging samples)

Controversies: 1 incision vs 2 incisions—advantage of 1 incision, 1 hole; among disadvantages, may get same side twice, and may be unable to go as far away from testis (likely increases chance of postvasectomy pain); sending piece of vas deferens to pathology department—pros (confirms that vas deferens removed); cons (pathology cannot identify sides; extra cost; no protection against failure due to recanalization); number of postoperative specimens necessary to confirm results—many recommend 2 azoospermic samples; however, several longitudinal studies show that once one azoospermic or severely oligospermic sample obtained, likelihood of patient being sterile extremely high, so need for second sample probably not necessary; whether necessary to see complete azoospermia in sample (vs low numbers of nonmotile sperm)—typically, standard of care azoospermia, but studies show that if <100,000 nonmotile sperm seen, likelihood of eventually progressing to full azoospermia high; increasingly, patients being cleared without strict azoospermia; long- term effects—over past 40 yr, studies reported systemic effects on men’s health, including cardiovascular (CV) disease, autoimmune disorders, and testicular and prostate cancer; in addition, recent paper suggests link between vasectomy and early-onset dementia; however, all such reports disproved due to lack of biologic evidence or poor study methodology; presently, no proven long-term effects with vasectomy; incidence of pain—true incidence of postvasectomy pain unknown (reports of significant pain from 17% to 1 in 10,000); 2 types (neuropathic and obstructive); most men report resolution of pain over time (however, amount of time for full resolution of pain unclear); occasionally see patient with chronic pain that requires treatment (speaker prefers to manage these cases nonoperatively)

Conclusions: adequate counseling key to successful vasectomy (important to spend time with couples explaining pros and cons of procedure; need to be certain that couple truly desires); no technique 100% effective in rendering patient sterile; speaker thinks no difference how procedure performed as long as clinician uses technique he or she comfortable with and does careful patient follow-up (most important to ensure that no motile sperm in patient’s ejaculate); open-ended vasectomy has lower chance of postvasectomy pain (theoretically) but higher failure rate (due to greater likelihood of recanalization); long-term effects of vasectomy not likely serious; however, true incidence of postvasectomy pain currently unknown only