Prevalence and Predicting Factors for Commonly Neglected Sexual Side Effects to External-Beam Radiation Therapy for Prostate Cancer

Epigenetics as a Key Factor in Prostate Cancer

Nowadays, prostate cancer is one of the most common forms of malignant neoplasms in men all over the world. Against the background of increasing incidence, there is a high mortality rate from prostate cancer, which is associated with an inadequate treatment strategy. Such a high prevalence of prostate cancer requires the development of methods that can ensure early detection of the disease, improve the effectiveness of treatment, and predict the therapeutic effect. Under these circumstances, it becomes crucial to focus on the development of effective diagnostic and therapeutic approaches. Due to the development of molecular genetic methods, a large number of studies have been accumulated on the role of epigenetic regulation of gene activity in cancer development, since it is epigenetic changes that can be detected at the earliest stages of cancer development. The presence of epigenetic aberrations in tumor tissue and correlations with drug resistance suggest new therapeutic approaches. Detection of epigenetic alterations such as CpG island methylation, histone modification, and microRNAs as biomarkers will improve the diagnosis of the disease, and the use of these strategies as targets for therapy will allow for greater personalization of prostate cancer treatment.

Long-term follow-up suggests high satisfaction rates for bulbomembranous radiation-induced urethral stenoses treated with anastomotic urethroplasty

PURPOSE

To analyze patients who underwent anastomotic urethroplasty for radiationinduced bulbomembranous urethral stricture/stenosis (RIS) due to prostate cancer treatment with up to 19 years of follow-up and assess long-term patient reported outcomes (PROMs). Long-term follow-up with the inclusion of urethroplasty specific PROMs is lacking in the available research.

METHODS

Patients who underwent anastomotic urethroplasty for RIS were identified from 2002 to 2020. Inclusion criteria included completion of 4-month post-operative cystoscopy and PROMs including IPSS, SHIM, MSHQ-EF, 6Q-LUTS, and global satisfaction queries at 4 months. PROMs were assessed annually thereafter, and cystoscopy was performed for adverse change in PROMs or worsening uroflow/PVR parameters. PROMs were compared at pre-op, post-op, and most recent follow-up.

RESULTS

23 patients met inclusion criteria. Short-term anatomic success was 95.7%. At a mean follow-up of 73.1 months (9.1-228.9), one late recurrence occurred for an overall success of 91.3%. Significant and sustained objective improvement was identified in voiding scores, quality of life, and urethroplasty specific PROMs. Satisfaction was 91.3% despite sexual side effects, and 95.7% of patients stated they would have surgery again knowing their outcome at a mean of over 6 years' follow up.

CONCLUSIONS

RIS are challenging problems, but durable symptomatic relief is achievable in well-selected patients. Patients with bulbomembranous RIS should be appropriately counseled regarding the risk of urinary incontinence and sexual side effects after anastomotic urethroplasty. However, long-term success is high, and overall QoL will have sustained subjective improvement in most cases.

Sexual health and treatment-related sexual dysfunction in sexual and gender minorities with prostate cancer

Prostate cancer treatment has substantial effects on sexual health and function. Sexual function is a vital aspect of human health and a critical component of cancer survivorship, and understanding the potential effects of different treatment modalities on sexual health is crucial. Existing research has extensively described the effects of treatment on male erectile tissues necessary for heterosexual intercourse; however, evidence regarding their effects on sexual health and function in sexual and gender minority populations is minimal. These groups include sexual minority - gay and bisexual - men, and transgender women or trans feminine people in general. Such unique effects in these groups might include altered sexual function in relation to receptive anal and neovaginal intercourse and changes to patients' role-in-sex. Sexual dysfunctions following prostate cancer treatment affecting quality of life in sexual minority men include climacturia, anejaculation, decreased penile length, erectile dysfunction, and problematic receptive anal intercourse, including anodyspareunia and altered pleasurable sensation. Notably, clinical trials investigating sexual outcomes after prostate cancer treatment do not collect sexual orientation and gender identity demographic data or outcomes specific to members of these populations, which perpetuates the uncertainty regarding optimal management. Providing clinicians with a solid evidence base is essential to communicate recommendations and tailor interventions for sexual and gender minority patients with prostate cancer.

Pain prevalence and characteristics in survivors of solid cancers: a systematic review and meta-analysis

PURPOSE

The latest systematic review on the prevalence of pain in cancer survivors was published 5 years ago. The current review aims to provide an extended overview on the prevalence of pain, pain mechanisms, pain characteristics, and assessment methods in cancer survivors.

METHODS

A systematic research was conducted on 17th of April 2020 using MEDLINE, Embase, Scopus, Web of Science, and Cochrane looking at studies from 2014 to 2020. Studies had to report pain prevalence rates in cancer survivors with a solid tumor who finished curative treatment at least 3 months ago. Methodological quality was assessed by two independent reviewers using the Joanna Briggs Institute quality appraisal tool. Characteristics of the included studies, participants and reported pain prevalence rates were extracted. The reported prevalence rates of the individual studies were pooled within a meta-analysis. Meta-regressions were performed to identify possible determinants of the pooled pain prevalence.

RESULTS

After deduplication, 7300 articles were screened, after which 38 were included in the meta-analysis. Risk of bias was rated low in 26 articles and moderate in 12 articles. The pooled pain prevalence was 47% (95%CI 39-55), with a heterogeneity of 98.99%.

CONCLUSION

This meta-analysis suggests that nearly half of cancer survivors report pain after completing curative treatment at least 3 months ago. However, substantial unexplained heterogeneity warrants cautious interpretation of these results. Meta-regression using cancer type, treatment location, pain measurement, and follow-up time as a covariate could not explain influencing factors explaining the high heterogeneity.

Adequacy of sexual care information given to prostate cancer patients receiving radical external beam radiotherapy

Background:

Despite the acknowledged value of providing prostate radiotherapy patients with sexual dysfunction (SD) information, there is little evidence related to patient perceptions of this or the extent to which information is provided to them. This study aimed to critically evaluate the quality and format of SD information given to patients before, during and after radical EBRT to treat prostate cancer.

Method:

Members of UK prostate cancer support groups were asked to complete an anonymous online survey tool seeking opinions of the SD information they were given before, during and after external beam radiotherapy (EBRT).

Results:

There were 56 responses to the survey with over 42% of respondents reporting that they had not received any SD information. Of those who did, 78·1% (25/32) received information before the start of EBRT. Physicians were the most involved in the provision of SD information, with nurses and therapeutic radiographers being underutilised. Responses were mostly negative, or neutral regarding the quality of SD information and the information received about impact on relationships, psychological and emotional health. Many participants wanted more information and support.

Conclusion:

This study demonstrates that prostate cancer patients who have undergone radical EBRT have not received adequate information relating to potential sexual function side effects and the psychological and emotional effects of SD. This information should be included in verbal and written information provided at all stages of the radiotherapy pathway.

A modified Delphi study to identify screening items to assess neglected sexual side-effects following prostate cancer treatment

Background

Neglected sexual side effects (NSSE) are a group of less common sexual side effects that may present after Prostate Cancer (PCa) treatment. There is currently no valid and reliable tool to identify these side effects. A modified Delphi study is an effective way of developing the content of such a screening tool.

Methods

A modified Delphi study was used to obtain consensus from a multi-disciplinary group of experts over 3 rounds during a 12 week period. Ten statements were presented containing 8 closed-ended statements on individual NSSEs, and 2 open-ended statements on psychosocial impact related to NSSE. Consensus was defined as a 75% strongly agree achievement on each statement, or the final statement evolution at the end of 3 rounds. Statement support in each round was determined by mean, standard deviation and range, after a numerical value was allocated to each statement during specific rounds. All three rounds were structured and suggestions and additions were incorporated in the statement evolution of the three rounds.

Results

Thirty-five participants were invited, and 27 completed Round 1 (RD 1), 23 participants completed RD2, and 20 participants completed RD3. All 3 rounds were completed in 12 weeks. Statement 1 (sexual arousal incontinence), statement 2 (climacturia) and statement 3 (orgasm intensity) reached consensus after RD2, and statement 9 (sexual dysfunction impact) and statement 10 (experiences) were removed after RD3. Statement 4 (orgasmic pain), statement 5 (anejaculation), statement 6 (sensory disturbances), statement 7 (penile length shortening) and statement 8 (penile curvature) were finalised after the conclusion of RD3. Statements 1–3 were the most stable statements with the most support and least amount of disagreement. Statements 4–8 were less stable, but support for them improved over the 3 rounds. Statements 9–10 both had good stability, but the support indicated that they needed to be removed from the set of statements. Statement 5 had the poorest range due to an outlier opinion.

Conclusions

Consensus was reached on the items making up the NSSE screening tool. Health care practitioners will be able to use this tool to identify the evidence of NSSE after PCa treatment. Further testing will be undertaken to confirm the reliability and validly of the tool.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12894-022-00982-0.

Pharmacologic Management of Persistent Pain in Cancer Survivors

Improvements in screening, diagnosis and treatment of cancer has seen cancer mortality substantially diminish in the past three decades. It is estimated there are almost 20 million cancer survivors in the USA alone, but some 40% live with chronic pain after completing treatment. While a broad definition of survivorship that includes all people living with, through and beyond a cancer diagnosis—including those with active cancer—is often used, this narrative review primarily focuses on the management of pain in people who are disease-free after completing primary cancer treatment as adults. Chronic pain in this population needs a different approach to that used for people with a limited prognosis. After describing the common chronic pain syndromes caused by cancer treatment, and the pathophysiologic mechanisms involved, the pharmacologic management of entities such as post-surgical pain, chemotherapy-induced neuropathy, aromatase inhibitor musculoskeletal syndrome and checkpoint inhibitor-related pain are described. The challenges  associated with opioid prescribing in this population are given special attention. Expert guidelines on pain management in cancer survivors now recommend a combination of pharmacologic and non-pharmacologic modalities, and these are also briefly covered.

Mapping the prevalence and use of questionnaires to detect the neglected sexual side effects after prostate cancer treatment: a scoping review

BACKGROUND

Early prostate cancer (PCa) treatment interventions may leave men with debilitating sexual side effects, especially when not diagnosed or present at initial follow-up treatment. Men are often embarrassed to disclose their sexual dysfunction. This may lead to sexual side effects related to PCa treatment remaining untreated, adding to their burden of disability. This study was conducted to map the evidence on the prevalence of neglected sexual side effects (NSSE) after radical prostatectomy (RP) surgery or radiation treatment (RT) for PCa treatment and the reported use of questionnaires to identify such side effects.

METHODS

This systematic scoping review's search strategy involved searching MEDLINE/PubMed, Science Direct and Google Scholar databases. Guided by eligibility criteria, two independent reviewers conducted title, abstract and full-text screening. Data from the included studies were extracted. The review team explored the implications of the findings in relation to the research question and aims of the study. The Mixed Method Appraisal Tool was used to appraise the quality of the included studies. This review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines.

RESULTS

Searches of the databases identified 1369 articles, with 23 eventually included for review. The prevalence of NSSE ranged between 0 and 78% in studies reporting on early PCa treatment of RP and RT patients. Orgasmic dysfunction (5-78%), penile curvature changes (10-15.9%) and penile length shortening (0-55%) similarly showed a low to moderate prevalence. Climacturia had low prevalence (4-5.2%) after RT and moderate prevalence (21-38%) after RP, whilst anejaculation had low to high prevalence (11-72%) after RT. No validated questionnaire was used to detect any NSSE after early PCa treatment. Studies mainly modified other questionnaires, and two studies used non-validated questionnaires to identify some NSSE. Participants in the included studies reported being inadequately informed about the possible sexual side effects of their treatment.

CONCLUSION

This study showed a low to a high prevalence of NSSE in men after RP and RT for early PCa treatment. Questionnaires helped detect individual NSSEs after PCa treatment but there is currently no evidence of a valid, reliable and comprehensive questionnaire to detect the NSSE collectively.

SCOPING REVIEW REGISTRATION

N/A.

Communicating about Sexual Problems

Sexual side effects of cancer treatment are common and, unfortunately, often not discussed with patients and their partner. This may be due to personal factors of the health care provider, fear of offending the patient or lack of knowledge, time constraints, and perception of the importance to the patient based on age and severity of the cancer. Despite the barriers to communication about a sensitive topic, oncology care providers are well situated to initiate the conversation. This article will identify key issues related to communication about sexuality by oncology care providers with individuals with the most common kinds of cancer. Models for assessing sexuality in these patients are presented to facilitate communication about this important aspect of quality of life that is impacted by cancer treatment.

Climacturia: a comprehensive review assessing pathophysiology, prevalence, impact, and treatment options regarding the "leak of pleasure"

Aim of this review is to summarize and evaluate the current literature on the pathophysiology, prevalence, sociosexual impact, and potential treatment options of climacturia. Climacturia, defined as orgasm-associated urinary incontinence and characterized by great prevalence variability, ranging between 15.7 and 93% was, so far, a relatively neglected post-radical prostatectomy functional side-effect. Recent studies have shown that it can significantly impact the quality of life of couples after prostate cancer treatment. A knowledge gap characterizes the pathophysiologic pathways while treatment is based on empirically chosen treatment options (condom use, presexual intercourse urination) or on therapeutic modalities proposed by low-quality studies (pelvic floor muscle training, penile applied devices). Evidence regarding efficacy of surgical techniques (artificial urinary sphincter, male sling, or dual implantation of penile prosthesis with a sling) for climacturia treatment are limited but with an increasing trend of relevant published data in the last 5 years. The mini-jupette sling plus inflatable penile prosthesis placement is a promising surgical technique that has been studied in a multi-institutional cohort with encouraging results regarding climacturia, erectile dysfunction, and mild-incontinence control. However, future studies with longer follow-up and larger sample sizes are certainly needed to confirm the long-term safety and benefits of this intervention.

Sexual aspects of shared decision making and prehabilitation in men diagnosed with prostate cancer

This article addresses sexual aspects of two related HCP-roles in the period between a diagnosis of prostate cancer (PC) and the start of treatment. First, the 'lovemap-perspective' is used to fine-tune the process of shared decision making. Then sexual prehabilitation is explored in detail, in the belief that better sexual function before starting treatment is more likely to lead to better post-treatment outcomes. Recommendations will be shared on further development of sexual prehabilitation approaches.

Sexual function and rehabilitation after radiation therapy for prostate cancer: a review

The treatment of prostate cancer is partly guided by patient preferences. Radical prostatectomy and radiation therapy are the standard radical therapies for localized disease and render comparable oncologic outcomes. Considering that survival is high regardless of the chosen treatment, factors such as treatment-related toxicities affecting the patients' quality of life play an important role in their decision. Notably, post-treatment sexual dysfunction, which includes decreased libido, erectile dysfunction, and ejaculatory dysfunction has been shown to be an important and prevalent concern of prostate cancer survivors. In this literature review, we sought to characterize the sexual complications associated with radiation therapy and map the available sexual rehabilitation options for prostate cancer survivors experiencing sexual dysfunction as a result of radiation therapy. We identified medical, non-biomedical, counseling, and lifestyle modification options for prostate cancer survivors seeking sexual rehabilitation. Future research in this area should address the standardization of sexual side-effect reporting and investigate sexual outcomes and rehabilitation in more diverse groups and of transgender and nonheterosexual prostate cancer survivors.

Neglected side effects to curative prostate cancer treatments

In this narrative review we summarize neglected side effects of curative intended treatment for prostate cancer. They include climacturia, arousal incontinence (AI), orgasmic disturbances such as altered orgasmic sensation, anorgasmia, and orgasm-associated pain (dysorgasmia), ejaculatory dysfunction, and morphological penile alterations in the form of shortening and deformity. Even though they have not received as much interest as erectile dysfunction (ED) or urinary incontinence, these side effects have been shown to negatively impact patient's quality of life. They are common and rates of climacturia after radical prostatectomy (RP) range from 20% and 45%, less after external beam radiation therapy (EBRT). Decreased orgasmic sensation ranges from 3.9% to 60% after RP and between 36-57% after EBRT. Dysorgasmia ranges from 9.5-15% for both RP and EBRT. Anejculation after EBRT ranges from 11-71% and rates of penile shortening are reported between 0 and 100%. There are no internationally validated questionnaires that adequately asses these side effects. This is necessary if we are to align patient and partner expectations properly and consequently manage them optimally. Neglected side effects should be discussed with patients and their partners preoperatively, as they are associated with bother and may lead to patient's avoiding sexual activity.

Mapping the prevalence of the neglected sexual side effects after prostate cancer treatment and the questionnaires used in their screening: a scoping review protocol

BACKGROUND

Interventions to treat early prostate cancer (PCa) can leave men with debilitating sexual side effects. The cluster of side effects referred to as the neglected sexual side effects (NSSE) may remain permanent, undiagnosed and untreated because men are hesitant to disclose them. Questionnaires offer a discreet way into the discussion, subsequent diagnosis and possible treatment of the NSSE. This study will be conducted to map the evidence about the prevalence of the neglected sexual side effects (NSSE) after PCa treatment, and use of questionnaires in its diagnosis and screening.

METHODS

This systematic scoping review will involve searching the following electronic databases: PubMed, Science Direct and Google Scholar. Following title searching, two-independent reviewers will conduct screening of abstracts and full articles. Eligibility criteria will guide the screenings. Data will be extracted from the included studies, and the emerging themes will be analysed. The review team will analyse the implications of the findings concerning the research question and aim of the study. The mixed method appraisal tool (MMAT) will be employed for quality appraisal of included studies.

DISCUSSION

We anticipate finding a number of studies that describe the prevalence of NSSE after early PCa treatment and that report on using questionnaires to screen for the presence of symptoms including orgasm-associated incontinence, urinary incontinence during sexual stimulation, altered perceptions of orgasm, orgasm associated pain, penile shortening and penile deformity. The study findings will be disseminated through publication in a peer-reviewed journal, peer presentations and presentations at relevant conferences.

Prostatic irradiation-induced sexual dysfunction: a review and multidisciplinary guide to management in the radical radiotherapy era (Part I defining the organ at risk for sexual toxicities)

Prostate cancer is the most common malignancy and the second leading cause of cancer-related death in men. Radiotherapy is a curative option that is administered via external beam radiation, brachytherapy, or in combination. Erectile, ejaculatory and orgasm dysfunction(s) is/are known potential and common toxicities associated with prostate radiotherapy. Our multidisciplinary team of physicians and/or scientists have written a three (3) part comprehensive review of the pathogenesis and management radiation-induced sexual dysfunction. Part I reviews pertinent anatomy associated with normal sexual function and then considers the pathogenesis of prostate radiation-induced sexual toxicities. Next, our team considers the associated radiobiological (including the effects of time, dose and fractionation) and physical (treatment planning and defining a novel Organ at Risk (OAR)) components that should be minded in the context of safe radiation treatment planning. The authors identify an OAR (i.e., the prostatic plexus) and provide suggestions on how to minimize injury to said OAR during the radiation treatment planning process.

Prostate cancer in sexual minorities and the influence of HIV status

Prostate cancer is the second most common cause of cancer-related death in men in the USA, but the effect of prostate cancer diagnosis and treatment on men in a sexual minority group, including men who have sex with men and transgender women, is poorly understood. Efforts to study this population are complicated, as cancer registries do not routinely collect information on sexual orientation. As a result, epidemiological data regarding this population have come from small studies that have included disparate rates of prostate cancer screening, diagnosis and treatment. Qualitative studies indicate that prostate cancer is experienced differently by sexual minorities, with distinct health-care needs that arise owing to differences in sexual practices, social support systems and relationships with the medical community. Notably, sexual minorities have been reported to experience poorer health-related quality of life outcomes than heterosexual men, and tend to have less robust social support systems, experience increased psychological distress caused by sexual dysfunction (areas of which are unmeasured after treatment), experience isolation within the health-care system and express increased levels of dissatisfaction with treatment. The incidence of prostate cancer actually seems to be decreased in men from sexual minorities living with HIV, despite there being no differences in screening and treatment, with poor cancer-specific mortality. Although the literature on patients with prostate cancer in men from sexual minority groups has historically been sparse, peer-reviewed research in this area has grown considerably during the past decade and has become an important field of study.

Sexual function outcomes following interventions for prostate cancer: are contemporary reports on functional outcomes misleading?

Patients with primary localised prostate cancer (PCa) have a wide choice of curative therapeutic interventions, including active surveillance, surgical, focal and radiation therapies. Based on clinical and oncological characteristics, treatment decisions entail consideration of oncological and functional outcomes with important effects on quality of life. We aimed to highlight evidence surrounding present inconsistencies, the problems this presents to clinicians and patients alike and the rationale for using return to baseline as a more realistic and objective functional outcome measure for assessing sexual function in this particularly sensitive group of men. We performed a non-systematic literature review of numerous non-validated, arbitrary thresholds employed in evaluation of sexual function outcomes in men undergoing intervention for primary localised PCa. The literature presents much heterogeneity in measurement methods and outcome measures, which lack context and present difficulties when counselling patients to make informed, autonomous decisions. These include findings from the most widely used internationally validated tools, such as the International Index of Erectile Function (IIEF), UCLA prostate cancer index and European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core-30 (QLQ-C30). There is a need for standardisation of reporting outcomes following PCa treatment to facilitate evaluation of existing and emerging technologies.

Treatment-Related Sexual Side Effects From the Perspective of Partners of Men With Prostate Cancer

A cross-sectional survey was performed among partners and men who received treatment for prostate cancer to investigate whether demographic and clinical characteristics are associated with the extent of how difficult partners found it dealing with sexual side effects and the degree of having experienced sexual problems after treatment. Moreover, an aim was to determine whether sexual side effects have an impact on the relationship. A total of 171 partners were included. In all, 104 men (70.7%) experienced an increase in erectile complaints after treatment. Almost half of partners of men with an increase in erectile complaints (63.6%, n = 63) found it difficult to deal with sexual side effects and 63.5% (n = 66) experienced sexual problems. Partners with lower education levels experienced fewer sexual problems than partners with higher education levels (p < .001). Furthermore, no significant associations were found on demographic characteristics, number of comorbidities, clinical characteristics (prostate-specific antigen level; tumor, node, and metastasis staging; Gleason grading), and type of treatment. The majority of men (58.4%, n = 59) and partners (62.5%, n = 65) indicated to not have experienced the impact of sexual side effects on their relationship.

Penile dimensions: What are surgeons measuring?

Penile dimensions and related dissatisfaction, may have significant impact upon patients whom undergo andrological surgeries. Whilst penile dimension assessment is performed as part of the andrological evaluation, little is known regarding the surgeons' opinions nor contemporary practices. This study was designed to gain further insights into the opinions and practices of clinicians regarding penile measurement and is the first paper in the literature of its kind. The study was performed by inviting clinicians at andrological/urological conferences to participate in a voluntary 10 point survey concerning penile dimensions. Of 126 responses recorded, 56% (71/126) were andrologists. Of the responders, 45% (56/122) did not routinely perform penile measurement prior to treatment nor were they aware of the standardised method (93/123). The majority 64%(81/126) would measure the penile length from the pubic bone to the tip (79/123) with the penis in a stretched position (99/125). A goniometer was the most common way of assessing penile curvature (37/73) and the length would be measured mostly on the convex side (46/119). Responders felt that, from the patients perspective, a combination of length, girth and shape (51/123), or length only (50/123), were the more important aspects of penile dimensions. As responders were recruited based on their interest in andrological aspects of urology, it may not be representative of the general urological community. In conclusion, attitudes and methods of penile measurement are quite varied amongst surgeons, thus further discussion and investigation of this aspect of andrological care ought to occur.

Delayed Ejaculation: Pathophysiology, Diagnosis, and Treatment

Delayed ejaculation (DE) is a poorly defined and uncommon form of male sexual dysfunction, characterized by a marked delay in ejaculation or an inability to achieve ejaculation. It is often quite concerning to patients and their partners, and sometimes frustrates couples' attempts to conceive. This article aims to review the pathophysiology of DE and anejaculation (AE), to explore our current understanding of the diagnosis, and to present the treatment options for this condition. Electronic databases were searched from 1966 to October 2017, including PubMed (MEDLINE) and Embase. We combined “delayed ejaculation,” “retarded ejaculation,” “inhibited ejaculation,” or “anejaculation” as Medical Subject Headings (MeSH) terms or keywords with “epidemiology,” “etiology,” “pathophysiology,” “clinical assessment,” “diagnosis,” or “treatment.” Relevant sexual medicine textbooks were searched as well. The literature suggests that the pathophysiology of DE/AE is multifactorial, including both organic and psychosocial factors. Despite the many publications on this condition, the exact pathogenesis is not yet known. There is currently no single gold standard for diagnosing DE/AE, as operationalized criteria do not exist. The history is the key to the diagnosis. Treatment should be cause-specific. There are many approaches to treatment planning, including various psychological interventions, pharmacotherapy, and specific treatments for infertile men. An approved form of drug therapy does not exist. A number of approaches can be employed for infertile men, including the collection of nocturnal emissions, prostatic massage, prostatic urethra catheterization, penile vibratory stimulation, probe electroejaculation, sperm retrieval by aspiration from either the vas deferens or the epididymis, and testicular sperm extraction.