Quality of life and functional outcome following anterior or abdominoperineal resection for rectal cancer

AIMS

The aims of the study were (1) to evaluate quality of life (QoL) and functional outcome in patients following anterior resection (AR) or abdominoperineal resection (APR) for rectal cancer, and (2) whether these outcomes were dependent on the level of anastomosis.

METHODS

Patients who were without recurrent or metastatic disease were identified from the Norwegian Rectal Cancer Registry. QoL was assessed by the EORTC questionnaires QLQ-C30 and QLQ-CR38, and rectal function by a short questionnaire. Of 319 patients studied, 229 had undergone AR and 90 APR. The median age was 73 years, and the median time since surgery was 64 months.

RESULTS

Mean QoL scores for body image and male sexual problems were better following AR than APR (P<0.01), also in patients with a low (< or = 3 cm) anastomosis. Patients who had undergone AR had higher mean scores for constipation (P<0.001) and more often used anti-diarrhoeal medication (P=0.005), than patients who had undergone APR. Patients with a low anastomosis (< or = 3 cm) had more incontinence for gas and solid stools (P<0.05), and had more incontinence (P=0.006) compared with patients with higher anastomosis, but there was no difference in QoL. Subgroup analysis showed that irradiated patients (n=34) had worse rectal function in terms of frequency, urgency, and incontinence (P<0.01).

CONCLUSIONS

Although rectal function was impaired in patients with low anastomosis, patients who had undergone AR had better QoL than patients who had undergone APR.

A study of finger lengths, semen quality and sex hormones in 360 young men from the general Danish population

BACKGROUND

It has been suggested that finger length may correlate with function or disorders of the male reproductive system. This is based on the HOXA and HOXD genes' common embryological control of finger development and differentiation of the genital bud. The objective of this study was to explore the association between the ratio of 2nd to 4th finger length (2D:4D ratio) and testis function in a sample of young Danish men from the general population.

METHODS

Semen samples and finger measurements were obtained from a total of 360 young Danish men in addition to blood samples for sex hormone analysis to describe the possible association between 2D:4D and semen and sex-hormone parameters.

RESULTS

A statistically significant inverse association with the 2D:4D was found only in relation to hormone levels of FSH in the group of young men with a 2D:4D >1 (P = 0.036) and a direct association with the total sperm count in the group of young men with a 2D:4D < or = 1 (P = 0.045).

CONCLUSION

The statistically significant results may be 'false positives' (type I error) rather than representing true associations. This relatively large study of young, normal Danish men shows no reliable association between 2D:4D finger ratio and testicular function. Measurements of finger lengths do not have the power to predict the testicular function of adult men.

A subfertile patient diagnosed with testicular carcinoma in situ by immunocytological staining for AP-2γ in semen samples: Case report

The incidence of testicular cancer is rising. Despite a high cure rate, efforts should be made to obtain diagnosis at the pre-invasive intratubular carcinoma in situ (CIS) stage, as the disease is potentially lethal and treatment has severe side-effects, especially regarding reproductive function. CIS diagnosis is presently only possible by a surgical biopsy of the testis. Immunocytological staining for transcription factor activator protein (AP-2gamma), previously identified as a marker for neoplastic germ cells, was performed in centrifuged samples of ejaculates obtained from 104 andrological patients, including patients with testicular cancer and subfertility. Cells positive for AP-2gamma were found only in semen samples from patients diagnosed a priori with testicular neoplasms and, surprisingly, in a 23 year old control subject with oligozoospermia and no symptoms of a germ cell tumour. Testicular biopsies performed during the follow-up of this patient revealed widespread CIS in one testicle, thus proving a potential diagnostic value of the new marker. For the first time, a patient without clinical symptoms of testicular neoplasia was diagnosed at the pre-invasive CIS stage using a new, simple method based on immunocytological staining of a semen sample for AP-2gamma, a novel marker for CIS. The value of this method for diagnostic use in the clinic requires further careful validation in a large series of patients and controls, but the preliminary results are promising.

[Surgery and stenting for oesophageal cancer]

BACKGROUND

The purpose of this study was to evaluate the results of surgery and stenting for operable and inoperable oesophageal cancer.

MATERIAL AND METHODS

Retrospective patient materials with resection (n = 65, 1983-2002) or stenting (n = 59, 1994-2003) for primary oesophageal cancer.

RESULTS

Mortality after surgery was 11% and 15% of the patients were re-operated. 36 (55%) had complications such as respiratory failure (n = 33), anastomotic dehiscence/perforation (n = 4), chylothorax (n = 1), haemorrhage (n = 3), wound rupture (n = 1), septicaemia (n = 2), arrhythmia (n = 4) and wound infection (n = 5). Median survival after surgery was 11 months. Survival after three years was 17%, after five years 8%. The stent procedure was without mortality but haemorrhage (n = 1) and stent dislocation (n = 2) occurred. 8 patients (14%) were re-stented for tumour stenosis (n = 6), fistula (n = 2) and dislocation (n = 1). Median survival after stenting was 78 days. Survival after 30 days was 80%, after one year 7%.

INTERPRETATION

Resectable oesophageal cancer should be operated in fit patients, as survival is improved and some patients can be cured. Stenting is the main option in inoperable patients.

[Internal rectal invagination treated with rectopexy and sigmoid resection]

BACKGROUND

Internal rectal intussusception, usually occurring in women, causes constipation and incomplete evacuation of stool.

MATERIALS AND METHODS

Twenty-one women and one man (median age 48) were operated with suture rectopexy and sigmoid resection. The patients were examined with anoscopy and defecography, and symptomatic outcome, patients' satisfaction and morbidity were evaluated. Outcome was based mainly on the validated KESS score for constipation.

RESULTS

There was a significant reduction in all ten symptoms. Faecal incontinence improved in the two afflicted patients after operation. The number of patients with constipation was reduced from 20 to 8 (p < 0.01); none became constipated. Mean (95 % CI) colonic transit times in ten constipated patients was reduced from 5.3 (4.1-6.4) to 4.0 (2.6-5.4) days (p = 0.08); seven of these patients had a reduction of transit time as well as constipation score.

INTERPRETATION

Rectopexy with sigmoid resection improved symptoms, including constipation and feeling of incomplete rectal emptying.

[Surgical treatment of anal fissure]

BACKGROUND

Anal fissure is very painful; surgery is warranted when medical treatment fails.

MATERIAL AND METHOD

We present a retrospective study of 34 patients (median age 42; 19-63) treated by subcutaneous lateral internal sphincterotomy (n = 27) and anal dilatation (n = 7) from 1992 to 2002, carried out by a questionnaire on pain, anal incontinence, and treatment result.

RESULTS

There were no complications or treatment for recurrence of anal fissure. Median pain score before surgery was 7.3 on a scale from 0 (no pain) to 10 (worst imaginable pain), median 73 months (4-124) after surgery the median score was 0 (0-5) (p = 0.00). For sphincterotomy (n = 27), the median score was 7.8 before surgery and 0 (0-5) after (p = 0.00), for anal dilatation 6 (3-10) before surgery and 2 (0-2) (p = 0.01) after. All patients had reduced pain scores after surgery but their incontinence scores remained unchanged. Two patients (7%) who had previously been dilated or irradiated developed faecal incontinence after sphincterotomy. More patients became asymptomatic after sphincterotomy (n = 18; 67%) than after anal dilatation (n = 4; 57%).

INTERPRETATION

Compared to anal dilatation, sphincterotomy offers better pain relief for anal fissure. Doing a shorter sphincterotomy corresponding to length of the fissure reduces the risk of anal incontinence.

[Secondary anterior sphincteroplasty for anal incontinence after delivery]

BACKGROUND

The prevalence of anal sphincter rupture at vaginal delivery is from 0.5 to 2.5 %. More than 50 % of these patients may need a secondary anterior sphincteroplasty because of anal incontinence.

MATERIALS AND METHODS

We present prospective series of 29 women (median age 45 years) operated with an overlapping anterior sphincteroplasty from 1996 to 2001. The patients were examined with anal ultrasonography (n = 23), manometry (n = 19) and neurophysiologically (n = 13), and divided into group 1 (n = 19) with anal sphincter rupture and group 2 (n = 10) with sphincter rupture as well as pudendal neuropathy. All patients (n = 29) were examined with the Cleveland Clinic incontinence score before and median eight (2-64) months after operation.

RESULTS

Median incontinence score before and after operation was 11.0 (0-22) versus 5.0 (0-16) (p = 0.002) for group 1; 18.0 (15-24) versus 15.5 (11-24) (p = 0.034) for group 2. There was also a significant difference between the groups concerning incontinence scores both preoperatively (p = 0.045) and postoperatively (p = 0.028). An improvement of continence was seen in 15 (79 %) of the patients in group 1 compared to 4 patients (40 %) in group 2. In group 1 a significant increase of median resting and squeeze pressures was seen.

INTERPRETATION

Anterior sphincteroplasty improves anal continence considerably in patients with isolated sphincter rupture. However, patients with evidence of pudendal neuropathy must be informed that they should expect only a minor improvement in continence after operation.

Early evaluation of bowel symptoms after primary repair of obstetric perineal rupture is misleading: an observational cohort study

PURPOSE

This study was conducted to investigate the long-term development of anal and urinary incontinence and to investigate the clinical value of electromyography and pudendal nerve terminal motor latency after obstetric anal sphincter rupture.

METHODS

One hundred females with obstetric anal sphincter rupture were evaluated by an anal incontinence questionnaire at 5 and 18 months postpartum and by a urine incontinence questionnaire at 18 months postpartum. Pudendal nerve terminal motor latency and electromyography examinations were performed on 68 and 67 females, respectively, at 10 months postpartum.

RESULTS

Fecal incontinence increased from 7 to 17 percent between 5 and 18 months (P = 0.04). At 18 months, the incidence of anal incontinence in females working outside the home (42/70 (60 percent)) was greater than that for females still at home with their child (12/30 (40 percent); P = 0.05). Anal incontinence at 18 months was significantly higher (P = 0.01) in subjects with pathologic electromyographic findings (76 percent) than in those with normal electromyography (45 percent; observed differences, 31 percent (95 percent confidence interval, 9 to 54 percent)). Thirty percent of the subjects had urinary stress incontinence. The risk of fecal urgency was greater in females with urinary urgency (difference, 44 percent; 95 percent confidence interval, 18 to 69 percent) and urinary stress incontinence (difference, 24 percent; 95 percent confidence interval, 3 to 44 percent) than in those without.

CONCLUSION

Fecal incontinence symptoms worsen with increased follow-up time, and the change in working status is the most likely explanation; therefore, early evaluation of bowel symptoms is misleading. Denervation injury of the anal sphincter is an independent risk factor for anal incontinence but has no association with urinary incontinence. Urinary urgency and stress incontinence symptoms are strongly associated with fecal urgency.

Resection rectopexy for internal rectal intussusception reduces constipation and incomplete evacuation of stool

OBJECTIVE

To study the effect of rectopexy and sigmoid resection (resection rectopexy) on symptoms in patients with internal rectal intussusception.

DESIGN

Retrospective and prospective study.

SETTING

University hospital, Norway.

PATIENTS

22 patients with internal rectal intussusception.

INTERVENTIONS

Resection rectopexy by an open (n = 13) or laparoscopically-assisted (n = 9) technique.

MAIN OUTCOME MEASURES

Symptomatic outcome, patients' satisfaction, and morbidity. Outcome was based mainly on the validated KESS score, which covers 10 symptoms included in the definiton of constipation.

RESULTS

There was a significant reduction in all 10 symptoms. Two patients complained of incontinence which improved after operation. The number of patients with constipation was reduced from 20 to 8 (p = 0.000) and none became constipated. Mean (95% CI) colonic transit times before and after operation in 10 patients with constipation were 5.3 (4.1 to 6.4) and 4.0 (2.6 to 5.4) days (p = 0.083). Seven of these 10 patients had a reduction of both transit time and constipation score. Six patients had complications after open operations. These included one damaged ureter, reoperations for bleeding, incomplete intestinal obstruction, and 2 wound infections.

CONCLUSION

Rectopexy with sigmoid resection resulted in improvement in symptoms, including constipation and feeling of incomplete rectal evacuation, and acceptable morbidity.

Is there any correlation between objective anal testing, rupture grade, and bowel symptoms after primary repair of obstetric anal sphincter rupture?: an observational cohort study

PURPOSE

The purpose of this study was to investigate the relationships between the grade of anal sphincter rupture, anal sphincter defect, manometry variables, and anal incontinence.

METHODS

A total of 132 females with first-time obstetric sphincter rupture were evaluated by transanal ultrasound, manometry, and scoring of bowel symptoms five months after delivery.

RESULTS

Anal sphincter rupture and transanal ultrasound grade correlated with each other ( rs= 0.427, P= 0.001). Both rupture and transanal ultrasound grade correlated with soiling grade ( rs= 0.2, P= 0.03 for both), but in a multiple regression analysis, only transanal ultrasound grade was significant ( P= 0.001) as an independent variable. Anal incontinence score correlated with all the manometry variables, but in a multiple regression analysis, only squeeze pressure was significant ( P= 0.001, beta = -0.4) as an independent variable. Both anal sphincter rupture and transanal ultrasound grade were correlated with manometry variables, but only transanal ultrasound grade was significant as an independent variable after multiple regression analysis. The frequency of transanal ultrasound-verified extensive defect of anal sphincter was higher in rupture Grade 3B (25; 95 percent confidence interval, 12-38 percent) and Grade 4 (45; 95 percent confidence interval, 24-66 percent) than in Grade 3A (2.8; 95 percent confidence interval, -1 to -6.6 percent).(s) (s)CONCLUSION Manometry variables are significantly lower in incontinent females than in continent females, and the Wexner incontinence score was correlated with manometry variables. Both anal sphincter rupture and transanal ultrasound grade correlated with soiling grade and with manometry variables, but in both cases only the transanal ultrasound grade was a significant independent variable.

Do occult anal sphincter injuries, vector volume manometry and delivery variables have any predictive value for bowel symptoms after first time vaginal delivery without third and fourth degree rupture? A prospective study

BACKGROUND

The aim of this study was to determine whether there exists a correlation between anal incontinence, occult sphincter injuries, anal manometry values, and delivery variables in primiparous women after first time vaginal delivery.

METHODS

Eighty-six primigravida women were recruited for this study. Transanal ultrasonography (TAUS) and vector volume manometry (VVM) was performed and bowel symptoms were recorded at 25 weeks of pregnancy and 5 months after labor. Incontinent women at 5 months after vaginal delivery were interviewed again at 12 months.

RESULTS

Nineteen women (25%) experienced flatus incontinence postpartum. After 12 months, only one-third of the women were still incontinent. Fourteen women (19%) showed abnormal TAUS of the anal sphincter. Of the delivery variables, only baby head circumference was significantly associated with flatus incontinence (p = 0.01). There was no correlation between flatus incontinence or delivery variables and anal sphincter injuries; VVM values were not associated with either anal sphincter injuries or flatus incontinence at 5 months, but VVM values were negatively associated with flatus incontinence at 12 months after labor.

CONCLUSIONS

At 5 months after labor, flatus incontinence is relatively common, and is not associated with reduced VVM values. Two-thirds of women recover from flatus incontinence during the first year. Women who had flatus incontinence persisting for a minimum of 1 year had reduced VVM values. Anal sphincter injuries as seen by TAUS are not associated with either VVM values or any delivery variable. Baby head circumference is the only delivery variable significantly associated with flatus incontinence.

A national strategic change in treatment policy for rectal cancer--implementation of total mesorectal excision as routine treatment in Norway. A national audit

INTRODUCTION

Rectal cancer surgery has been characterized by a high incidence of local recurrence, an occurrence which influences survival negatively. In Norway there was a growing recognition that local recurrence rates were related to surgeon performance and that surgeons applying a standardized surgical technique in the form of total mesorectal excision could achieve better results. This contrasts with the prevailing argument voiced by many opinion leaders that local recurrence rates and possibly survival rates can only be improved by adjuvant or neoadjuvant treatment strategies. The Norwegian Rectal Cancer Project-initiated in 1993-aimed at improving the outcome of patients with rectal cancer by implementing total mesorectal excision as the standard rectal resection technique.

METHODS

This observational national cohort study covers all new patients (3,319) with rectal cancer from a population of 4.5 million treated between November 1993 and August 1997. The main outcome measures were local recurrence, survival, and postoperative mortality and morbidity rates. The technique of total mesorectal excision was compared with conventional surgery.

RESULTS

The proportion of patients undergoing total mesorectal excision was 78 percent in 1994, increasing to 92 percent in 1997. The observed local recurrence rate for patients undergoing a curative resection was 6 percent in the group treated by total mesorectal excision and 12 percent in the conventional surgery group. Four-year survival rate was 73 percent after total mesorectal excision and 60 percent after conventional surgery. Postoperative mortality rate was 3 percent and the anastomotic dehiscence rate was 10 percent. Radiotherapy was given to 5 percent and chemotherapy to 3 percent of the patients in the curative resection group.

CONCLUSION

A refinement of the surgical resection technique for rectal cancer can be achieved on a national level, the technique of total mesorectal excision can be widely distributed, and surgery alone can give good results.

Design, organization and management of a controlled population screening study for detection of colorectal neoplasia: attendance rates in the NORCCAP study (Norwegian Colorectal Cancer Prevention)

BACKGROUND

In the past three decades, the incidence of colorectal cancer (CRC) in Norway has doubled, surpassing all other Nordic countries for both men and women to become the most frequently diagnosed cancer. A small-scale, randomized study on flexible sigmoidoscopy (FS) screening in Telemark, Norway, has shown a reduction in accumulated CRC incidence after 13 years. The aim of our study was to evaluate the effect on CRC mortality and morbidity by screen detection of CRC and removal of precursor lesions (polypectomy), and to test out the management and organization mimicking a countrywide screening service. A total of 13,823 men and women (1:1), age 55-64 years, were drawn randomly from the population registries in Oslo (urban) and the county of Telemark (mixed urban and rural) and invited to have a screening examination. The rest of the relevant age cohorts constituted the control groups. In the screening group, 535 individuals were excluded according to exclusion criteria, rendering 13,288 individuals eligible for screening examination.

METHODS

A once only screening model was used. In the screening group, individuals were randomized to have a once only FS or a combination of FS and faecal occult blood test (FOBT).

RESULTS

The overall attendance rate was 8,849 out of 13,288 (67%); 73% in Telemark and 60% in Oslo. Attendance for FS only was 68% and 65% for combined FS&FOBT.

CONCLUSIONS

The present FSIFS&FOBT screening study obtained a high acceptance rate for both screening modalities. The attendance rate was stable throughout the trial, suggesting an acceptable model for management of future countrywide screening.

[Perforated ulcer]

BACKGROUND

We wanted to review patients operated for perforated peptic ulcer at Ullevål University Hospital, Oslo, Norway in the period 1992-1997.

MATERIAL AND METHODS

Data from 84 operated patients (43 men) were obtained retrospectively from patient and hospital files. Median age was 69 years (range 20-92 years).

RESULTS

41 patients had perforated duodenal ulcer and 43 had perforated gastric ulcer (pylorus included). Median time from start of symptoms until admission to hospital was 5 hours (range 2-24 hours; n = 40) and from admission to start of surgery 5 hours (range 1 1/2-48 hours; n = 69). 64 out of 74 patients had pneumoperitoneum on preoperative abdominal X-ray examination. 77 patients were operated with rafi and/or tegmentation of the perforation; six patients with Billroth II or Billroth I; one patient was treated with percutaneous drainage. Median duration of surgery was 68 minutes (range 40-240 minutes). Thirteen patients died in hospital. Post-operative complications were recorded in 30 patients.

INTERPRETATION

Early surgical intervention is important to reduce lethality from ulcus perforatum. A patient with clinical peritonitis and suspected perforated peptic ulcer should be operated without time-consuming examinations.

[Functional outcome after reservoir surgery in ulcerative colitis]

BACKGROUND

The aim of this study was to examine whether the functional result of restorative proctocolectomy for ulcerative colitis deteriorated by postponing follow-up from three to eight years after pouch surgery.

MATERIAL AND METHODS

All patients (n = 58) operated for ulcerative colitis from 1984-97, who still had intact reservoir, responded to a questionnaire on defecating pattern, stool leakage, perianal irritation, urinary function, workload, sexual life, social life, and the patient's opinion on outcome. The results for the first 29 patients were compared to last 29 patients operated. Median follow-up was eight for the first 29 patients and three years for the last 29.

RESULTS

There were no significant difference in functional outcome and patient opinion after pouch surgery between the first 29 and last 29 patients (n = 58). Respective figures for median 24-hour stool frequency were 7.0 and 6.3, leakage of stool 48% and 38%, ability to defer defecation 86% and 97%, perianal irritation 59% and 48%, use of antidiarrhoeal medication 55% and 52%, and wearing of pad 28% and 38%. Sexual life (n = 57) had improved for 11 (19%) and deteriorated for seven patients (12%). Potency was reduced in five (15%) and ejaculation in four patients (12%), one of whom (3%) had retrograde ejaculation. Three (5%) had received a disability pension and five (9%) had reduced workload. After the pouch operation 48 (91%) felt better and three (6%) felt worse because of frequent bowel emptying (n = 3), perianal eczema (n = 1) and pouch fistula (n = 1).

INTERPRETATION

The results do not demonstrate any significant deterioration of functional outcome after pouch surgery for ulcerative colitis by postoperative increase of follow-up from three to eight years.

Morbidity and functional outcome after restorative proctocolectomy for ulcerative colitis

OBJECTIVE

To find out whether a threefold increase in follow up (median 108 compared with 36 months) influenced major morbidity and functional outcome between the first 32 and the last 32 patients consecutively operated on with J-pouch ileoanal anastomosis for ulcerative colitis from 1984 to 1997.

DESIGN

Retrospective and prospective study.

SETTING

University hospital, Norway.

PATIENTS

64 patients with ulcerative colitis who had proctocolectomy and ileal pouch-anal anastomoses.

INTERVENTIONS

The pouches were mainly hand anastomosed (n = 61) to the dentate line after mucosectomy or anastomosed by double stapling technique without mucosectomy (n = 3). The 58 patients who still had their pouches responded to a questionnaire on functional outcome and satisfaction.

MAIN OUTCOME MEASURES

Morbidity, functional outcome, and patients' satisfaction.

RESULTS

Major morbidity in these 64 patients comprised pelvic sepsis in 3 (5%), operation for intestinal obstruction in 5 (8%), pouchitis in 12 (19%), fistulas in 7 (11%) and pouch excision in 6 (9%). Thirteen patients (20%) had 35 reoperations and 11 patients (17%) had 22 re-laparotomies. There were more complications among the first 32 patients with the longest follow up than among the last 32 patients, but this difference was significant only concerning the rate of reoperations (31% compared with 9%) because of the higher number of pouch excisions (5 compared with 1) in this group. There were no significant differences in the functional outcome and degree of patient satisfaction between the first 29 and the last 29 patients. Respective values for 24 hour median stool freqency were 7.0 and 6.3, leakage of stool 48% and 38%, ability to defer defaecation 86% and 97%, perineal irritation 59% and 48%, use of antidiarrhoeal medication 55% and 52%, and wearing of pad 28% and 38%. Sexual life (n = 57) was improved in 11 (19%) and reduced in 7 (12%). Potency was reduced in 5 (15%) and ejaculation in 4 (12%), one of whom (3%) had retrograde ejaculation. Three (5%) received disability pensions and five (9%) had reduced workload. After the pouch operation 48 (91%) felt better and 3 (6%) felt worse because of frequent bowel emptying, perineal eczema, or pouch fistula.

CONCLUSION

Continence-preserving proctocolectomy carries considerable morbidity, but the long term functional outcome is satisfactory and does not seem to deteriorate substantially.

Should we watch what we eat and drink? Report on the International Workshop on Hormones and Endocrine Disrupters in Food and Water: possible impact on human health, Copenhagen, Denmark, 27-30 May 2000

The aim of this Workshop was to bring together scientists with different backgrounds, including clinical endocrinologists, basic researchers and epidemiologists, to discuss the complex and controversial topic of endocrine disrupters, and their impact on human health. Nearly 250 scientists attended the Workshop, and 50 lectures and 90 posters were presented and discussed. The most important scientific findings and reviews are to be published in Human Reproduction and Human Reproduction Update. Some of the highlights are presented here.

Inter-observer variation in the results of the clinical andrological examination including estimation of testicular size

Inter-observer variation in andrological examination by 10 clinical investigators from five Nordic and Baltic countries was investigated. In addition, information on intra-observer variation was obtained for six of the 10 investigators. Testicular size was measured using Prader's orchidometer and one of the investigators also performed an ultrasound estimate of testicular size. A highly significant difference (p < 0.001) between observers was found with an inter-observer error of 16% in estimating testicular size in 23 young men. The difference in the estimate tended to increase with increasing testicular size. There was no significant intra-observer difference in two measurements performed on consecutive days. Only differences in median testis size, which were greater than 31% between measurements by two investigators, were found to be significant at the 5% level. The ultrasound estimate of testicular size was significantly lower than the orchidometer estimate, with a mean difference of 3.6 mL for the left testis and 4.3 mL for the right testis. Tanner staging of genitalia and diagnosis of a varicocele was subject to great inter-observer variation, and for the diagnosis of varicocele only one-third of the investigators was able to reproduce their results on a second examination. In conclusion, it was found that the clinical andrological examination of young men is subject to great inter-observer variation. This should be kept in mind when results from different studies are compared as well as in daily clinical practice.

High frequency of sub-optimal semen quality in an unselected population of young men

Male reproductive function seems to have deteriorated considerably during the past 4-5 decades. However, studies of the reproductive function in unselected populations have not previously been reported. As the large majority of young men in Denmark are subjected to a compulsory medical examination for military service, this provided a unique opportunity to study the reproductive function in an unbiased population. Altogether 891 young men delivered a blood sample in which reproductive hormones were measured. From 708 of these men data were also obtained on semen quality and testis size. The median sperm concentration was 41 x 10(6)/ml (mean 57.4 x 10(6)/ml). Men with ejaculation abstinence above 48 h had slightly higher sperm concentrations (median 45 x10(6)/ml, mean 63.2 x 10(6)/ml), but even in this subgroup, 21 and 43% respectively had sperm counts below 20 x 10(6)/ml and 40 x 10(6)/ml. Among men with no history of reproductive diseases and a period of abstinence above 48 h, as many as 18 and 40% respectively had concentrations below 20 and 40 x 10(6)/ml. Sperm counts were positively correlated with testis size, percentage normal spermatozoa and inhibin B, and negatively correlated with percentage immotile spermatozoa and follicle stimulating hormone. Possible causes for this high frequency of young men with suboptimal semen quality are obscure and need to be explored. Whether these findings apply for young male populations of comparable countries remains to be seen.