Exploring Technology's Influence on Health Behaviours and Well-being in Type 1 Diabetes: a Review

PURPOSE OF REVIEW

Maintaining positive health behaviours promotes better health outcomes for people with type 1 diabetes (T1D). However, implementing these behaviours may also lead to additional management burdens and challenges. Diabetes technologies, including continuous glucose monitoring systems, automated insulin delivery systems, and digital platforms, are being rapidly developed and widely used to reduce these burdens. Our aim was to review recent evidence to explore the influence of these technologies on health behaviours and well-being among adults with T1D and discuss future directions.

RECENT FINDINGS

Current evidence, albeit limited, suggests that technologies applied in diabetes self-management education and support (DSME/S), nutrition, physical activity (PA), and psychosocial care areas improved glucose outcomes. They may also increase flexibility in insulin adjustment and eating behaviours, reduce carb counting burden, increase confidence in PA, and reduce mental burden. Technologies have the potential to promote health behaviours changes and well-being for people with T1D. More confirmative studies on their effectiveness and safety are needed to ensure optimal integration in standard care practices.

Systematic Review and Meta-analysis of Blood Glucose Response to High-intensity Interval Exercise in Adults With Type 1 Diabetes

OBJECTIVES

Exercise-induced hyperglycemia is recognized in type 1 diabetes (T1D) clinical guidelines, but its association with high-intensity intermittent exercise (HIIE) in acute studies is inconsistent. In this meta-analysis, we examined the available evidence of blood glucose responses to HIIE in adults with T1D. The secondary, aim was to examine predictors of blood glucose responses to HIIE. We hypothesized that there would be no consistent effect on blood glucose from HIIE, unless examined in the context of participant prandial status.

METHODS

We conducted a literature search using key words related to T1D and HIIE. Studies were required to include at least 6 participants with T1D with a mean age >18 years, involve an HIIE intervention, and contain pre- and postexercise measures of blood glucose. Analyses of extracted data were performed using a general inverse variance statistical method with a random effects model and a weighted multiple regression.

RESULTS

Nineteen interventions from 15 reports were included in the analysis. A mean overall blood glucose decrease of -1.3 mmol/L (95% confidence interval [CI], -2.3 to -0.2 mmol/L) was found during exercise, albeit with high heterogeneity (I²=84%). When performed after an overnight fast, exercise increased blood glucose by +1.7 mmol/L (95% CI, 0.4 to 3.0 mmol/L), whereas postprandial exercise decreased blood glucose by -2.1 mmol/L (95% CI, -2.8 to -1.4 mmol/L), with a statistically significant difference between groups (p<0.0001). No associations with fitness (p=0.4), sex (p=0.4), age (p=0.9), exercise duration (p=0.9), or interval duration (p=0.2) were found.

CONCLUSION

The effect of HIIE on blood glucose is inconsistent, but partially explained by prandial status.

Androgen deficiency and the aging male: new urologic perspectives

Among the most prominent health care issues of the 21st century are those relating to aging. Indeed, the elderly represent the fastest growing segment of our population. Typically, a urology practice includes a significant number of elderly males, providing the physician with both a challenge and an opportunity. Androgen deficiency in the aging male, with its detrimental effects on bone, muscle and body composition, sexual function, and psychological well-being, is an area of increasing interest in both the lay press and the medical community. The urologist must understand the pathophysiology of androgen deficiency in the male, recognize and investigate the subtle signs and symptoms of hypogonadism, determine the appropriateness of treatment, and offer informed options to the patient. Health care professionals have a responsibility to make "healthy" aging a priority.

Back-pressure testing to prevent autoinflation of penile prosthetic devices

Autoinflation of a penile prosthetic device can be a frustrating experience for the patient and surgeon alike. Although there are many causes of autoinflation, elevated reservoir pressure at the time of surgical placement is one of the more common etiologies. We describe a simple, quick technique to quantitate reservoir pressures and volume, preventing pressures that could lead to autoinflation.

Endocrine screening for sexual dysfunction using free testosterone determinations

PURPOSE

Controversy exists concerning the need for routine endocrine screening in impotent men. Debate also continues as to what hormonal studies are necessary, the role of the free fraction of testosterone and whether a history of decreased libido or testicular atrophy can predict these endocrinopathies.

MATERIALS AND METHODS

We reviewed 508 consecutive men who presented with sexual dysfunction within a 22-month period. Testosterone data were available for 268 patients (53%) and prolactin data were available for 170 (33%).

RESULTS

Hypogonadism, defined as 2 abnormal total testosterone levels, was found in 42 of our 268 patients (15.6%). A history of decreased libido by patient questionnaire and/or testicular atrophy on physical examination could not predict these cases. A normal free fraction of testosterone saved further unnecessary endocrine evaluation in 50% of patients with hypogonadism. Hypoprolactinemia was noted in 3 of 170 patients (1.8%).

CONCLUSIONS

Routine endocrine screening remains a necessary part of the evaluation for sexual dysfunction. A history of decreased libido and/or testicular atrophy on physical examination cannot predict hypogonadism. Measurement of free fraction of testosterone will further lessen unnecessary endocrine evaluations by 50% and should become standard practice in screening for hypogonadism. Prolactin levels are necessary only in patients with hypogonadism and/or a history of decreased libido.

Timing of penile color flow duplex ultrasonography using a triple drug mixture

Duplex ultrasonography is an accepted method to assess noninvasively arterial inflow to the penis. Optimal pharmacological agents as well as timing of the scan and stimulation during the scan continue to be debated. In an effort to achieve a more complete smooth muscle relaxation and capture what we perceived was a wide variation in interval to maximum arterial velocity, we revised our duplex protocol in January 1991. We report on 280 consecutive patients evaluated in this manner. Patients received 0.25 or 0.5 cc of a triple drug mixture containing 22.5 mg./cc papaverine, 0.83 mg./cc phentolamine and 8.33 micrograms/cc prostaglandin E1. Scans were performed at 0, 5, 15 and 30 minutes after injection in all patients. Any patient not having a full erection at 15 minutes performed private self-stimulation while in the standing position for at least 5 minutes before the 30-minute scan. If we conservatively define normal arterial inflow as a peak Doppler velocity of 25 cm. per second or greater in the best artery, only 35% of our patients achieved this velocity at 5 minutes. Of the remainder 26% and 22% did not reach normal velocity values until 15 and 30 minutes, respectively, after the injection. By delaying initial measurements of velocity until 5 minutes, could the highest inflow velocity be missed and patients diagnosed incorrectly? The group at risk would be those who had good tumescence at 5 minutes and who had presumably already decreased the inflow velocities. Of the 280 patients 74 (26%) had greater than 10% tumescence at 5 minutes. Only 6 of these 74 patients did not reach velocities of 25 cm. per second or more in the best artery at some time during their study. In conclusion, our study clearly supports delaying the initial scan until 5 minutes, since only 6 of our 280 patients (2.1%) may have been incorrectly diagnosed. The study also strongly argues for additional scans until 30 minutes and self-stimulation when necessary.

Experience with triple-drug therapy in a pharmacological erection program

A group of 170 impotent men achieved usable erections during a 26-month period with a combination of papaverine, phentolamine and prostaglandin E1 (triple-drug therapy) injected intracorporeally. Of the patients 146 elected to enter a pharmacological erection program using this combination. Patient age ranged from 24 to 85 years and the average duration on the program was 11.2 months. Average injection volume was 0.36 cc per injection (range 0.1 to 1). Among those patients managed by our nurse clinician, only 3 episodes of priapism were encountered (1.7%). Scarring was documented in 7 of 170 patients (4.2%) 1 week to 21 months after starting the injections. Pain was encountered in 6 of 170 patients (3.5%). A superior dose response coupled with a low incidence of priapism, pain and scarring have led us to use triple-drug therapy as our agent of choice in the pharmacological management of erectile dysfunction.

Overtraining affects male reproductive status

OBJECTIVE

To substantiate the hypothesis that strenuous exercise disrupts the hypothalamic-pituitary-gonadal axis in men.

DESIGN

Longitudinal study.

SETTING

Normal human volunteers in an academic research environment.

PATIENTS

Five endurance-trained men (maximum oxygen consumption 65.4 +/- 3.6 mL/kg per minute [means +/- SEM]) with normal spermatogenic and hormonal profiles.

INTERVENTIONS

Semen and blood samples were collected bimonthly before, immediately after, and 3 months after overtraining, which was defined as twice the previous average weekly training volume with unchanged intensity.

MAIN OUTCOME MEASURE

Testosterone, cortisol, and sperm concentration.

RESULTS

Basal T levels decreased to 5.37 +/- 67 ng/mL from 8.68 +/- 93 ng/mL (conversion factor to SI unit, 3.47) immediately after overtraining and basal cortisol levels increased to 215.3 +/- 31 ng/mL from 145.7 +/- 27 ng/mL (conversion factor to SI unit, 2.76). This inverse relationship was highly correlated (r = -0.92). Both cortisol and T levels returned to pretraining values 3 months after resumption of previous training volume. Sperm count (91 +/- 23.3 x 10(6)) decreased significantly by 43% immediately after overtraining (52 +/- 6.8 x 10(6)) and by 52% 3 months after overtraining (44.5 +/- 20 x 10(6)). However, all values remained within normal range and would not be expected to affect fertility.

CONCLUSIONS

Our results indicate that overtraining reduces T levels, which is highly correlated with an increase in levels of cortisol and possibly a subsequent decrease in sperm concentration 74 days later.

Effect of platelet-activating factor (PAF) on human spermatozoa-oocyte interactions

The effect of exogenous platelet-activating factor (PAF) on human spermatozoa was examined by monitoring acrosomal status and hamster oocyte penetration. Induction of the acrosome response by PAF was dose, and time, dependent and required capacitated spermatozoa. Addition of 10(-14) mol PAF l-1 enhanced the acrosome reaction eightfold compared with controls treated with human serum albumin (HSA). Similar concentrations of lyso-PAF failed to induce acrosomal loss and preincubation of spermatozoa with CV3988, an inhibitor of PAF, prevented PAF induction of the acrosome reaction. PAF significantly increased the number of zona-free hamster oocytes penetrated compared with controls (9.8 +/- 0.5 of 25 oocytes were penetrated by control spermatozoa compared with 23.3 +/- 0.8 out of 25 oocytes penetrated after incubation of spermatozoa with 10(-14) mol PAF l-1; 93% of all oocytes were penetrated by at least one spermatozoon following incubation with PAF), and also increased the number of decondensed spermatozoa found per egg during the sperm penetration assay (from 1.7 +/- 0.3 spermatozoa/egg with control spermatozoa to 3.3 +/- 0.5 spermatozoa/egg with PAF-treated spermatozoa). PAF-induced increases in acrosome reaction and sperm penetration assay values were similar to effects obtained with human follicular fluid and were calcium dependent. Induction of the acrosome reaction by physiological concentrations of PAF appeared to be morphologically similar to the response induced by follicular fluid as assessed by electron microscopy.

Human sperm hypo-osmotic swelling test: relationship to sperm fertilizing ability

The simple hypo-osmotic swelling test (HOS) has been proposed as a replacement for the labor-intensive sperm penetration assay (SPA), but its reliability is still controversial. To investigate the clinical correlation between results of the HOS and the SPA, we studied the subpopulation of washed "motile" and capacitated spermatozoa as well as sperm in the original sample in both a heterogeneous patient population being evaluated for infertility (n = 47) and a donor population (n = 13). In our patient population, the correlation between HOS results and conventional semen parameters, i.e., motility and vitality, was poor. Although the mean HOS values of the donor and patient populations differed significantly, the overlap in individual variation was too great for practical application. Using motile sperm tested two hours after separation from the seminal plasma, the correlation between a positive HOS and a positive SPA was good, with only a 4% false-negative rate. However, the correlation in capacitated sperm (20 hours) or semen itself was far less reliable. Although HOS tests correlated well with the SPA in individuals with normal sperm, in those with negative results on SPA the predictive value was extremely poor: divergent findings ranged from 32% using semen samples to 74% in the two-hour motile population. The events in the fertilizing process measured by the sperm penetration assay appear to be different from those assessed by the hypo-osmotic test. The HOS test, therefore, could not be used to screen or predict results of the SPA.

Screening assays for immunologic infertility: a comparison study

Because the immunobead antisperm antibody test (IBT) is difficult to learn and results are heavily operator-dependent, we compared findings on IBT with those of SpermMAR and SpermCheck in 58 patients to determine whether the latter two tests could demonstrate improved screening ability. Assays performed on both sperm and serum (i.e., direct and indirect) yielded 100% positive predictive values when IBT was used as the standard. Both SpermCheck and SpermMAR are easier to perform, and, as the former has a slightly greater sensitivity, we recommend SpermCheck for the detection of immunologic infertility.

Platelet-activating factor in sperm from fertile and subfertile men

STUDY OBJECTIVE

To examine the proposed role of platelet-activating factor (PAF) as a mediator of sperm function first by quantitating the concentration of PAF in sperm and second by incubating sperm with PAF and assessing the change in sperm motion parameters with a computerized motion analysis system.

DESIGN

Retrospective, case-control study.

SETTING

University hospital urology clinic.

PATIENTS

Concentrations of PAF were measured in sperm from 6 randomly chosen normal donors and 8 asthenozoospermic patients. The change in sperm motion parameters was assessed in sperm from 10 randomly chosen normal donors and 7 asthenozoospermic patients.

RESULTS

Platelet-activating factor concentrations were significantly higher (P less than 0.05) in spermatozoa from asthenozoospermic patients (149 +/- 18.0 fmol/10(6) sperm) than in sperm from normal donors (91.9 +/- 13.0 fmol/10(6) sperm). Exogenous PAF did not enhance the percent motility of precapacitated or capacitated sperm from either patients or donors, and computerized semen analysis revealed no enhancement of sperm motion parameters in asthenozoospermic patients after addition of PAF to either precapacitated or capacitated sperm.

CONCLUSION

Platelet-activating factor does not appear to have therapeutic value as a means of enhancing sperm motility.

Simultaneous resection of renal carcinoma and abdominal aortic aneurysm

A 62-year-old man with a 6.5 cm abdominal aortic aneurysm and coexistent left renal cell carcinoma was treated by simultaneous radical left nephrectomy and abdominal aortic aneurysm repair. Care was taken to avoid potential infection of the bypass graft by inadvertent contamination with urine. Pathologic examination of the left kidney revealed a renal cell carcinoma, clear cell type, with no evidence of invasion into the renal vein or lymph node metastases. The patient had an uncomplicated recovery and is well and free of disease four years after operation. In cases of equivalently life threatening surgical diseases, simultaneous resection is warranted.

Varicoceles. Radiologic diagnosis and treatment

The association of clinically apparent varicoceles with male subfertility and infertility has been noted in the urology literature since the late nineteenth century, and surgical ligation of varicoceles has been considered appropriate therapy in an attempt to improve semen quality and increase fertility for the past 40 years. It has been established by several authors cited herein that varicocele size does not predict prognosis after ligation reliably. Because subclinical varicoceles may affect testicular function and histologic characteristics adversely and because age at time of therapy may affect probability of successful enhancement of fertility, the interest of radiologists and urologists has been directed toward diagnosis and treatment of both clinically obvious and clinically occult varicoceles, particularly in young adult men or adolescent boys. Testicular growth after varicocele ligation in adolescent boys also suggests a benefit from early intervention. Sonographic evidence of a varicocele must be correlated with analysis of semen for sperm density, motility, and morphology, as not all patients with varicoceles are infertile. Although surgical therapy is standard for varicocele occlusion, fairly extensive evidence exists to show that percutaneous transvenous occlusion of varicoceles is feasible, safe, and effective, particularly in the setting of varicocele recurrence after conventional surgical treatment.

MR imaging of the seminal vesicles

MR imaging (0.35 and 1.50 T) was used to assess the appearance of the seminal vesicles. The size and signal intensity of normal seminal vesicles vary with the age of the subject. In general, on T2-weighted images, the signal intensity of normal seminal vesicles is lower than that of fat in prepubertal children, similar to or higher than that of fat in adults, and similar to or lower than that of fat in patients older than 70 years of age. Endocrine and radiation therapy will influence the size and signal intensity of the seminal vesicles. The purpose of the essay is to illustrate the spectrum of seminal vesicle disease, including congenital anomalies, inflammation, and neoplastic disease. Although MR imaging is helpful in depicting seminal vesicle abnormalities, it does not allow differentiation of benign from malignant disease, distinction of hemorrhage due to tumor invasion from postbiopsy changes, or distinguishing between glandular obstruction due to tumor infiltration and mechanical compression.

Subclinical varicocele: the effectiveness of varicocelectomy

To investigate the controversial concept that subclinical varicoceles are detrimental to spermatogenesis, we undertook a prospective study of the effectiveness of surgery in 56 infertile men with clinical and subclinical varicoceles. Our statistical approach specifies improvement as a change from individual baseline level. The over-all variability in sperm counts precluded the demonstration of significant changes in sperm density consequent to surgery. Improvement in sperm motility was seen in both groups, being slightly greater in the subclinical group. The changes were inversely related to baseline levels and increased with time from surgery. Therefore, it appears that the detection of subclinical varicoceles may be warranted in infertile men with abnormal semen parameters.

Hypogonadal impotence treated by transdermal testosterone

The transdermal therapeutic system for testosterone (TTS-T) (ALZA Corp.), applied to the scrotal skin for twenty-two hours daily, was tested for twelve weeks on 4 men with hypogonadal impotence; 2 of these men wore TTS-T for as long as twenty-six months. The 40 cm2 system delivered a daily dose of 2.8 +/- 0.16 (S.E.) mg (nominal dose 2.4 mg) and the 60 cm2 system delivered a dose of 3.99 +/- 0.24 mg (nominal dose 3.6 mg). Both systems promptly increased serum testosterone and dihydrotestosterone (DHT) to physiologic levels, restoring normal erectile activity with an increased frequency of ejaculation and a positive effect on both mood and energy. There were no changes in serum sex binding globulin and estradiol, prostate or breast size, hematologic or liver function measures, or urinary flow and frequency. There were no significant changes in serum cholesterol or low-density lipoproteins, but high-density lipoproteins tended to decline slightly. There were no dermatologic problems associated with the system. The tenfold increase in DHT over baseline levels was attributed to 5-alpha reduction of testosterone in the scrotal skin. The TTS-T is convenient, reliable, and mimics normal physiologic testosterone secretion and levels more closely than conventional methods of testosterone replacement.

Vacuum tumescence devices: the role of papaverine in the selection of patients

We conducted a prospective study to determine the positive predictive value of papaverine testing to select patients in whom a vacuum constriction device would be a successful alternative to operative management of impotence. A total of 30 men presenting to an impotence clinic was evaluated with a series of papaverine dosages up to 60 mg. These patients then received a physician-administered trial of a vacuum constriction device, followed by 3 months of home use and a repeat objective evaluation. Initial responses to the device were poor, with 46% of the patients (14) achieving a rigid erection. However, after 3 months of home use 83% of the patients (25) achieved a rigid erection. The positive predictive value of a good response to the papaverine trial was 94%.

In vivo human testicular function assessed with P-31 MR spectroscopy

The clinical feasibility of assessing testicular metabolic integrity with phosphorus-31 magnetic resonance (MR) spectroscopy was investigated in six healthy volunteers and 23 patients with azoospermia. MR spectroscopic findings were compared with sperm count and motility in all patients and with findings at testicular biopsy in 23 patients. Significant differences (P less than .05) were found between the P-31 spectra of normal and azoospermic testicles in the following peak area ratios: phosphomonoester (PM)/beta-adenosine triphosphate, PM/phosphodiester, and inorganic phosphate/PM. In the patients with azoospermia, there were significant differences in these same peak area ratios between patients with primary testicular failure and those with chronic tubular obstruction. Although the differences between these two groups were statistically significant, there was a large overlap in numbers, and therefore a study with a larger patient population will be required. P-31 MR spectroscopy is a sensitive tool for assessment of testicular metabolic integrity and differentiation of normal testicles from those with markedly decreased spermatogenesis.

Optimizing the sperm penetration assay with human follicular fluid

Major limitations of the conventional sperm penetration assay are the inability to assess several aspects of sperm function (zona binding and penetration) and the absence of human ovulatory products known to influence fertilization. We therefore modified the sperm penetration assay by the addition of human follicular fluid (FF) to induce the acrosome reaction in an attempt to improve the false-negative rate of the conventional technique. In 26 patients with negative results, results became positive in 20 with human FF and the acrosome reaction increased fourfold. In 19 different men, we compared the results of the conventional and modified assays with outcome of in vitro fertilization. The false-positive rate was the same, but the false-negative rate was reduced from 40% to 7% with the addition of human FF.

SpermCheck: a simplified screening assay for immunological infertility

SpermCheck (Bio-Rad Laboratories, Hercules, CA), a new screening test for regional surface antibodies on motile sperm, uses monodispersed latex microspheres of uniform size as a vehicle to link rabbit antihuman immunoglobulins (IgA, IgG, IgM) and provides both negative and positive control sera, as well as sufficient buffer for sperm preparation in ambient CO2 atmosphere. When compared with reference data available for the immunobead test (IBT), the direct protocol (semen) for SpermCheck yielded 94.4% sensitivity with 100% specificity; the indirect protocol (serum) provided a sensitivity of 100% with 94.7% specificity. The microspheres of SpermCheck maintain a nearly uniform concentration per volume, with none to negligible clumping. The greater difference between the optical densities of latex and cytoplasm allows use of a light microscope for the rapid assessment of the percent of regional binding rather than the phase-contrast microscope required for the IBT. SpermCheck eliminates many difficulties encountered with the IBT, making SpermCheck a convenient screening assay for use in the physician's office.

Immunological status of patients before and after vasovasostomy as determined by the immunobead antisperm antibody test

With the immunobead antisperm antibody test a prospective study was conducted to evaluate the immune status of 55 men before and after vasectomy reversal. A third of the vasectomy patients (19 of 55) had significant serum-sperm antibodies (20 per cent binding or more) detected by the indirect immunobead antisperm antibody test. Of 31 vasovasostomy patients 12 (38 per cent) had significant sperm-surface antibodies (20 per cent binding or more) by the direct immunobead antisperm antibody test. Preoperative serum assays correctly classified the antibody status of 69 per cent of the vasectomy patients. The immunological impact of spermatic granuloma formation, duration of vasal obstruction, patient age and presence of sperm in the vasal fluid at operation also were assessed. An inverse relationship between the proportion of antibody-bound sperm and the percentage of motile sperm in the ejaculate of vas reversal patients was found with videomicrographic semen analysis. The percentage motility was significantly lower among patients with greater quantities of sperm-surface antibodies. No other parameter of semen analysis showed this difference when compared for positive or negative immunobead antisperm antibody test results.

Semen manipulation: improved sperm recovery and function with a two-layer Percoll gradient

The authors compared a simple, two-layer Percoll density gradient technique with the swim-up technique for semen preparation in 128 men. In samples from normospermic (n = 55), oligospermic (n = 26), and asthenospermic (n = 29) men, the Percoll technique significantly improved yield, percent motility, and absolute number of motile sperm recovered, but in samples from oligoasthenospermic men (n = 18), only percent motility was improved. The Percoll density gradient also selected sperm with markedly improved function as assessed by both the sperm penetration assay and the fertility index. In 37 samples negative on the sperm penetration assay when processed with the swim-up technique, 19 (51%) became positive when processed with the Percoll technique. The Percoll density gradient is an improved method for semen manipulation as it allows greater recovery of sperm with higher motility and improved sperm function.

Assessment of male infertility: correlation between results of semen analysis and phosphorus-31 magnetic resonance spectroscopy

To evaluate the usefulness of phosphorus-31 magnetic resonance spectroscopy (31P-MRS) in assessing male infertility, we compared it with conventional semen analysis. Specimens were obtained from otherwise healthy patient groups as follows: group A, 7 fertile control subjects; group B, 12 azoospermic men after vasectomy; and group C, 11 patients presenting for infertility evaluation. Correlations between established semen analysis parameters and the 31P-MRS-derived ratio of glycerylphosphorylcholine to total phosphate (GPC/TP) were investigated. Group A controls had a mean GPC/TC ratio of 0.10 +/- 0.05, which was the same as that of group C. With the exception of significantly lowered motility and normal morphology in group C (p less than 0.001 and 0.05, respectively) semen analysis parameters in these two groups were similar. In contrast, the GPC/TP ratio in group B (0.05 +/- 0.04) was significantly different from the control (p less than 0.05), which appropriately reflected complete vasal occlusion. The results suggest that a significant portion of seminal GPC is derived from epididymal secretion and that 31P-MRS is useful for monitoring the GPC/TP levels when assessing epididymal function and male infertility.

Localization of abscess in adult polycystic kidney by indium-111 leukocyte scan

In patients with adult polycystic kidney disease (APKD) infected cysts are difficult to localize with current radiographic techniques, especially those dependent on renal function. Indium-111 leukocyte (In-WBC) imaging is both highly sensitive and effective in detecting and localizing abscesses in patients with renal failure. We report on a patient with APKD and sepsis in whom computed tomography, ultrasound, and physical examination failed to locate the renal abscess, which was found by In-WBC scanning.

Endocrine evaluation and therapy of erectile dysfunction

Recent innovative laboratory and clinical investigations have implicated an organic cause for as many as 30 to 50 per cent of cases of impotence. Understanding the clinical subtleties of hypogonadism and the reproductive hormonal axis in the male is critical to the evaluation and treatment of impotence of endocrinologic origin. Gonadotropin assays are essential for detecting elevations of FSH and LH, which will help to distinguish primary from secondary testicular failure. The goal of androgen replacement is the maintenance of physiologic testosterone levels without the potential hepatotoxic effects.

Is there a role for Chlamydia trachomatis and genital mycoplasma in male infertility?

We believe that, without evidence of inflammation (greater than 5 WBC on VB1), there is no indication for routine culture or antibiotic treatment of infertile men. In the presence of active inflammation and positive cultures for chlamydia, treatment with antibiotics is appropriate. However, active inflammation and positive chlamydial cultures were rare findings in our population (2 of 52 and 1 of 52, respectively). Thus, we find no evidence for a role of current asymptomatic mycoplasma or chlamydial infection in male infertility.

Endocrine investigation and therapy

The most commonly investigated testicular disorder is male infertility. Although endocrine causes are uncommon, they are potentially curable. A careful history and examination for subtle features of hypogonadism are important initiating steps. Understanding the appropriate use of both baseline and dynamic testing of the hypothalamic-pituitary-gonadal axis (and, in certain instances, the adrenal and thyroid glands) is extremely important.

Assessment of testicular metabolic integrity with P-31 MR spectroscopy

To evaluate the reliability of phosphorus-31 magnetic resonance (MR) spectroscopy in the assessment of acute testicular ischemia, vascular integrity, and spermatogenesis, the authors studied in vivo canine and primate testicles grouped as follows: group 1 testes (n = 8), in situ canine controls; group 2 (n = 11), canine testes subjected to warm ischemia; group 3, canine (n = 4) and primate (n = 4) testicles from hormone-treated animals. Group 1 control testicles showed high monophosphoester (MP) levels; low levels of inorganic phosphate (Pi), phosphodiester (PD), and phosphocreatine; and high levels of adenosine triphosphate (ATP). Group 2 testes revealed a time-dependent decay of MP/Pi ratios (from 2.1 to 0.70). Regeneration of ATP was noted in the acute reperfusion period. After 6 weeks of pituitary gonadotropin suppression, group 3 testes showed a significant decrease (P less than .05) in MP/PD ratios from a control level of 2.6 +/- 0.3 and a decrease in the MP/beta-ATP ratio from 2.4 +/- 0.1 to 1.8 +/- 0.3. P-31 MR spectroscopy appears to be a potential method for noninvasively assessing testicular ischemic injury and the metabolic integrity of spermatogenesis.

Diagnostic tests for impotence: a comparison of papaverine injection with the penile-brachial index and nocturnal penile tumescence monitoring

The diagnostic usefulness of nocturnal penile tumescence monitoring, penile-brachial index and intracorporeal injection of papaverine (60 mg. in 20 ml. normal saline) was compared in 43 impotent men. Intracorporeal pressure was measured with a pressure transducer. Based on turgidity, and the time of onset and duration of erection, we classified the impotence as psychogenic/neurogenic (normal vascular competence), mild or severe arteriogenic, or venogenic. The intracorporeal injection of papaverine was useful as a functional diagnostic test for impotence. The penile-brachial index, an indirect measurement of the flaccid penis, did not correlate well with the results of the papaverine test. A poor response to papaverine injection documents organic impotence and, under these circumstances, nocturnal penile tumescence monitoring is not necessary. We conclude that the intracorporeal injection of papaverine currently is the best screening technique for the differential diagnosis of vasculogenic impotence.

Scrotal ultrasound in the infertile man: detection of subclinical unilateral and bilateral varicoceles

Clinical and laboratory studies have provided convincing evidence that varicoceles are detrimental to spermatogenesis and that this effect is unrelated to their size. Thus, physicians have used diagnostic techniques other than physical examination to find these small but clinically significant varicoceles. Because scrotal sonography has proved to be invaluable to detect many intrascrotal abnormalities, and has the unique ability to visualize the testicle and surrounding structures, we used it to evaluate 50 infertile men. Of our 50 patients 22 had a clinically palpable left varicocele and 3 additional patients had bilateral varicoceles. All clinical varicoceles were confirmed by sonography. However, sonography also demonstrated a left varicocele in an additional 12 patients (34 of 50 or 68 per cent) and a right varicocele in 21 (a total of 24 or 48 per cent). Reflux on the right side always occurred in conjunction with that on the left side. Thus, among our 50 infertile men 24 of 34 (70 per cent) had bilateral varicoceles as detected by sonography, and 12 of 50 (24 per cent) had a subclinical varicocele on the left side. The high percentage of bilateral varicoceles detected by sonography may explain the pathophysiological mechanism by which what formerly was considered a unilateral anatomical abnormality may produce bilateral testicular dysfunction. It also may challenge us to change our present unilateral surgical approach to the patient with a clinically evident left varicocele.