Varicocele and epididymitis in Behcet disease

Uncovering the link between inflammatory rheumatic diseases and male reproductive health: a perspective on male infertility and sexual dysfunction

Inflammatory rheumatic diseases (IRDs) refer to a range of persistent disorders that have a major influence on several physiological systems. Although there is much evidence connecting IRDs to sexual dysfunction and fertility problems, research specifically focusing on male infertility in relation to these diseases is sparse. This review addresses the complicated connection between IRDs and male infertility, emphasising the physiological, psychological, and pharmacological aspects that influence reproductive health outcomes in men with rheumatic conditions. We explore the effects of IRDs and their treatments on many facets of male reproductive well-being, encompassing sexual functionality, semen characteristics, and hormonal balance. Additionally, we present a comprehensive analysis of the present knowledge on the impact of several categories of anti-rheumatic drugs on male reproductive function. Although there is an increasing awareness of the need of addressing reproductive concerns in individuals IRDs, there is a noticeable lack of research especially dedicated to male infertility. Moving forward, more comprehensive research is needed to determine the prevalence, risk factors, and mechanisms driving reproductive difficulties in males with IRDs. We can better assist the reproductive health requirements of male IRD patients by expanding our understanding of male infertility in the setting of rheumatic disorders and implementing holistic methods to care.

Update on the Diagnosis of Behçet's Disease

Behçet's disease (BD) is a systemic inflammatory disease with unknown etiology. It is characterized by recurrent mucocutaneous lesions and major organ disease such as ocular, neurologic, vascular, and gastrointestinal manifestations. The diagnosis of BD is mainly based on clinical manifestations after ruling out other potential causes. There are no specific laboratory, histopathologic, or genetic findings for the diagnosis of BD. The International Study Group (ISG) criteria set is still the most widely used set for the diagnosis. The main limitation of this criteria set is the lack of major organ manifestations such as vascular, neurologic, and gastrointestinal involvement. The ICBD 2014 criteria are more sensitive, especially in early disease. However, patients with such as spondyloarthritis can easily meet this criteria set, causing overdiagnosis. Diagnosing BD can be a big challenge in daily practice, especially in patients presenting with only major organ involvement such as posterior uveitis, neurologic, vascular, and gastrointestinal findings with or without oral ulcers. These patients do not meet ISG criteria and can be diagnosed with "expert opinion" in countries with high BD prevalence. The pathergy test is the only diagnostic test used as diagnostic or classification criteria for BD. Our recent studies showed that common femoral vein (CFV) thickness measurement can be a valuable, practical, and cheap diagnostic tool for BD with sensitivity and specificities higher than 80% for the cut-off value of 0.5 mm. However, the diagnostic accuracy of CFV measurement should be investigated in other disease groups in the differential diagnosis of BD and in also different ethnic populations.

The effects of autoimmune rheumatic-related diseases on male reproductive health: A systematic review

Autoimmune rheumatic-related diseases (ARRDs) have physical and psychological impact on patients, including their sexual life. While many studies have investigated fertility problems in females, data on males-related fertility are scarce, which explains the lack of guidance. The main objective of this systematic review was to evaluate the reproductive health in males with ARRDs. This systematic review followed the preferred reporting items for systematic reviews guidelines. Original articles from Pubmed and Scopus, published until September 16, 2021, and tackling the effects of ARRDs and/or ARRDs treatments on male fertility and/or pregnancy outcomes, were included. A total of twenty-five studies met the inclusion criteria. They were published between 1981 and 2018. The studied ARRDs were spondyloarthritis (n = 9), systematic lupus erythematosus (SLE, n = 6), Behcet disease (BD, n = 5), rheumatoid arthritis (RA, n = 5), antiphospholipid syndrome (n = 1), and dermatomyositis (n = 1). The most reported effects of ARRDs on fertility are i) high levels of reproductive hormones, mainly in RA and SLE; ii) impaired semen quality in SLE, spondyloarthritis, and BD; and iii) higher rate of varicocele in BD and spondyloarthritis. Regarding the treatments effects, i) conventional synthetic disease-modifying anti-rheumatic drugs (e.g.; methotrexate and salazopyrine) increase testosterone level, ii) cyclophosphamide impairs fertility, iii) anti-tumor necrosis factor agents are associated with improvement in semen quality, and iv) no increased number of miscarriages or congenital abnormalities in children fathered by BD was reported. To conclude, both ARRDs and their treatments alter fertility in males with ARRDs. In practice, in addition to the conventional semen analysis, screening for infertility seems legitimate in males with ARRDs.

Sexual function and reproduction can be impaired in men with rheumatic diseases: A systematic review

BACKGROUND

Information about the possible effect of rheumatic diseases on male sexual function and reproduction (sexual health) is scarce and difficult to summarize. Factors known to impair sexual health, such as inflammation, medication use and hypogonadism can be present in a significant proportion of male patients with rheumatic diseases.

OBJECTIVES

The objective of our study was to systematically review the literature for the influence of paternal rheumatic disease on sexual health, such as sexual function, reproductive hormones, male fertility, pregnancy and offspring outcomes.

DATA SOURCES

English language articles identified through Embase, MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, Google Scholar and the Clinical trial registries of Europe and the USA published until February 2019.

STUDY APPRAISAL AND SYNTHESIS METHODS

Literature was synthesized in narrative form and in summary tables. Outcomes were categorized as: sexual function, reproductive hormones, fertility and pregnancy and offspring outcomes. Results are presented per category and per disease.

RESULTS

9735 articles were identified with our search strategy. After removal of duplicates, excluding articles by screening titles and abstracts and assessing eligibility by reading 289 fulltext articles, 87 articles fulfilled the eligibility criteria. All included studies enrolled patients diagnosed with a rheumatic disease and had results at least on one of the outcome categories. Sexual function was the most common category, followed by reproductive hormones, fertility and pregnancy and offspring outcomes. Sexual function is impaired in a high proportion of patients with rheumatic diseases. This was statistically significant in most of the studies where a control group was available. Clinically relevant abnormalities in reproductive hormones were mainly identified in patients with rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) and a positive correlation with disease activity were reported. Semen quality in men with rheumatic diseases can be impaired in patients with SLE, SpA, sarcoidosis, BD and MWS. Sperm count and motility were the most common semen quality parameters affected. No negative effect of paternal RA and vasculitis on pregnancy outcomes were reported in 3 studies. No studies reporting the effect of paternal disease on offspring outcomes were identified.

LIMITATIONS

Most of the studies included in this review suffer from an inconsistent methodological quality, definitions of outcomes varied in several studies, a wide variety of screening questionnaires and/or diagnostic tools were used and results might only apply to the specific populations that were studied.

CONCLUSIONS

This systematic review suggests that sexual health is impaired in men with rheumatic diseases. The degree and extent of sexual health impairment vary per disease. More research is needed to fully understand the link between rheumatic diseases and impaired male sexual health. Meanwhile, rheumatologists should be aware of this association and discuss it with their patients.

IMPLICATIONS OF KEY FINDINGS

Sexual health of men with rheumatic diseases can be impaired by the disease itself. Especially in men trying to conceive, information on sexual function, reproductive hormones and sperm quality are needed to identify these problems. Treatment resulting in lower disease activity can improve overall sexual health in man with rheumatic diseases and facilitate their journey to fatherhood.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO 2018 CRD42018099845.

Acute Hepatic Failure and Epididymitis in a Hispanic Patient With Active Systemic Lupus Erythematosus

Systemic lupus erythematosus (SLE) is an autoimmune disease known to affect a variety of organ systems. Patients with SLE are more prone to developing common infections that can mimic the complications of SLE. As such, it is essential to differentiate complications of SLE from infection to ensure appropriate management and to improve morbidity and mortality of this patient population. Here we present a 24-year-old, Hispanic male, with SLE complicated by dialysis-dependent end-stage renal disease and dilated cardiomyopathy. The patient presented to the emergency room with nausea, vomiting, and abdominal pain and admitted to the medicine service. Initial evaluation showed hypoalbuminemia coupled with elevated transaminases, INR, and total bilirubin consistent with acute liver failure. Further evaluation was negative for viral, toxic, metabolic, or vascular causes of acute failure. The patient was diagnosed with lupus hepatitis and associated acute hepatic failure, and started on high dose prednisone (60 mg daily). Complete resolution of liver function and symptoms was observed within 1 week at follow-up. The patient was readmitted 2 weeks after discharge with left scrotal pain and swelling after abruptly decreasing the prescribed prednisone dose 3 days after discharge. Physical exam and scrotal ultrasound in the emergency department were consistent with epididymitis. Urinalysis, urine culture, and gonorrhea and chlamydia PCR were all negative. Without evidence of infection, and upon reconfirmation of low serum complement levels, the patient was diagnosed with lupus epididymitis and restarted on high dose prednisone. Complete resolution of symptoms was attained within 1 week at follow-up. This case emphasizes the importance of differentiating the clinical manifestations of SLE from infection and the complexity of disease presentation in Hispanic patients.

No appreciable decrease in fertility in Behçet's syndrome

OBJECTIVES

Behçet's syndrome (BS) follows an active course during the childbearing years in both men and women. We formally surveyed the infertility rate and the effect of drugs and types of organ involvement on fertility in BS.

METHODS

We compared fertility among BS patients with and without major organ involvement with those with FMF, AS and healthy controls. A structured interview was performed and the medical records of the patients were reviewed to confirm the sites of involvement and drugs they used during their entire follow-up.

RESULTS

The number of female patients who were not able to ever conceive, who were not able to conceive before or after disease onset or who were able to conceive late or only with assisted reproductive technology was not increased among the BS group. The same was true for the male patients to successfully achieve a conception and/or father a child. The average number of children, miscarriages, terminations and ectopic pregnancies were similar among the groups. Infertility was more common in BS patients with major organ involvement who used cyclophosphamide (CYC) compared with those who did not (P = 0.009).

CONCLUSION

Infertility is not appreciably increased among BS patients attending a dedicated outpatient clinic. Major organ involvement does not increase the risk of infertility and CYC is the only drug that seems to compromise fertility in BS.