Estimates of use of preferred contraceptive method in the United States: a population-based study

Background

In the U.S. and globally, dominant metrics of contraceptive access focus on the use of certain contraceptive methods and do not address self-defined need for contraception; therefore, these metrics fail to attend to person-centeredness, a key component of healthcare quality. This study addresses this gap by presenting new data from the U.S. on preferred contraceptive method use, a person-centered contraceptive access indicator. Additionally, we examine the association between key aspects of person-centered healthcare access and preferred contraceptive method use.

Methods

We fielded a nationally representative survey in the U.S. in English and Spanish in 2022, surveying non-sterile 15-44-year-olds assigned female sex at birth. Among current and prospective contraceptive users (unweighted n = 2119), we describe preferred method use, reasons for non-use, and differences in preferred method use by sociodemographic characteristics. We conduct logistic regression analyses examining the association between four aspects of person-centered healthcare access and preferred contraceptive method use.

Findings

A quarter (25.2%) of current and prospective users reported there was another method they would like to use, with oral contraception and vasectomy most selected. Reasons for non-use of preferred contraception included side effects (28.8%), sex-related reasons (25.1%), logistics/knowledge barriers (18.6%), safety concerns (18.3%), and cost (17.6%). In adjusted logistic regression analyses, respondents who felt they had enough information to choose appropriate contraception (Adjusted Odds Ratio [AOR] 3.31; 95% CI 2.10, 5.21), were very (AOR 9.24; 95% CI 4.29, 19.91) or somewhat confident (AOR 3.78; 95% CI 1.76, 8.12) they could obtain desired contraception, had received person-centered contraceptive counseling (AOR 1.72; 95% CI 1.33, 2.23), and had not experienced discrimination in family planning settings (AOR 1.58; 95% CI 1.13, 2.20) had increased odds of preferred contraceptive method use.

Interpretation

An estimated 8.1 million individuals in the U.S. are not using a preferred contraceptive method. Interventions should focus on holistic, person-centered contraceptive access, given the implications of information, self-efficacy, and discriminatory care for preferred method use.

Funding

Arnold Ventures.

Abortion Aftercare Instructions in the United States: A Content Analysis of Patient Handouts

BACKGROUND

At the clinical visit for abortion care, patients typically receive a handout with information about what to expect and how to care for themselves after the abortion. Published guidelines give little to no guidance regarding the content of postabortion instructions.

METHODS

We collected aftercare instruction handouts for first trimester procedural and medication abortion from abortion clinics throughout the United States. Instructions were coded and analyzed using conventional content analysis.

RESULTS

Of the 84 unique aftercare handouts we received, most included information about symptoms to expect (included in 98% of procedural handouts, 97% of medication handouts), how to manage symptoms (included in 100% of procedural handouts, 100% of medication handouts), and specific behaviors to avoid (included in 94% of procedural handouts, 66% of medication handouts). The most common behavioral avoidance instructions were "pelvic rest" (included in 90% of procedural handouts, 63% of medication handouts), avoiding strenuous activity (included in 61% of procedural handouts, 29% of medication handouts), and avoiding submersion in water (included in 41% of procedural handouts, 26% of medication handouts). Handouts varied with regard to the extent and duration of specific recommendations. They also varied in tone, word choice, and other characteristics.

CONCLUSIONS

There exists a wide range of abortion aftercare instructions throughout the United States. Inconsistency among instructions may reflect a lack of published, evidence-based clinical guidelines. Standardizing aftercare instruction handouts based on patient-oriented evidence could improve patient experience after abortion.

State abortion policies and Medicaid coverage of abortion are associated with pregnancy outcomes among individuals seeking abortion recruited using Google Ads: A national cohort study

OBJECTIVE

A major challenge to understanding barriers to abortion is that those individuals most affected may never reach an abortion provider, making the full impact of restrictive policies difficult to measure. The Google Ads Abortion Access Study used a novel method to recruit individuals much earlier in the abortion-seeking process. We aimed to understand how state-level abortion policies and Medicaid coverage of abortion influence individuals' ability to obtain wanted abortions.

METHODS

We employed a stratified sampling design to recruit a national cohort from all 50 states searching Google for abortion care. Participants completed online baseline and 4-week follow-up surveys. The primary independent variables were: 1) state policy environment and 2) state coverage of abortion for people with Medicaid. We developed multivariable multinomial mixed effects models to estimate the associations between each state-level independent variable and pregnancy outcome.

RESULTS

Of the 874 participants with follow-up data, 48% had had an abortion, 32% were still seeking an abortion, and 20% were planning to continue their pregnancies at 4 weeks follow-up. Individuals in restricted access states had significantly higher odds of planning to continue the pregnancy at follow-up than participants in protected access states (aOR = 1.70, 95% CI = 1.08, 2.70). Individuals in states that do not provide coverage of abortion for people with Medicaid had significantly higher odds of still seeking an abortion at follow-up (aOR = 1.80, 95% CI = 1.24, 2.60). Individuals living in states without Medicaid coverage were significantly more likely to report that having to gather money to pay for travel expenses or for the abortion was a barrier to care.

CONCLUSIONS

Restrictive state-level abortion policies are associated with not having an abortion at all and lack of coverage for abortion is associated with prolonged abortion seeking. Medicaid coverage of abortion appears critical to ensuring that all people who want abortions can obtain them.

Interprofessional Abortion Opposition: A National Survey and Qualitative Interviews with Abortion Training Program Directors at U.S. Teaching Hospitals

CONTEXT

Hospital policies and culture affect abortion provision. The prevalence and nature of colleague opposition to abortion and how this opposition limits abortion care in U.S. teaching hospitals have not been investigated.

METHODS

As part of a mixed-methods study, a nationwide survey of residency and site directors at 169 accredited obstetrics-gynecology training programs was conducted in 2015-2016, and 18 in-depth interviews with program directors were conducted in 2014 and 2017. The prevalence and nature of interprofessional opposition were examined using descriptive statistics, and regional differences were investigated using logistic regression. A modified grounded theoretical approach was used to analyze interview data.

RESULTS

Among the 91% of survey respondents who reported that they or their colleagues had wanted or needed to provide abortions in the prior year, 69% faced opposition from colleagues. Most commonly, opposition came from nurses (58%), nursing administration (30%) and anesthesiologists (30%), manifesting as resistance to participating in or cooperating with procedures (51% and 38%, respectively). Fifty-nine percent of respondents had denied care to patients in the prior year because of colleagues' opposition. Respondents in the Midwest and South were more likely than those in the Northeast to deny abortion care to patients because of such opposition (odds ratios, 3.2 and 4.4, respectively). Interviews revealed how participants had to circumvent opposing colleagues, making abortion provision difficult and leading to delays in and, infrequently, denial of abortion care.

CONCLUSIONS

Interprofessional opposition to abortion is widespread in U.S. teaching hospitals. Interventions are needed that prioritize patients' needs while recognizing the challenges hospital colleagues face in their abortion participation decisions.

Taking the provider "out of the loop:" patients' and physicians' perspectives about IUD self-removal

OBJECTIVE

This study describes the perspectives of patients and providers about intrauterine device (IUD) self-removal.

STUDY DESIGN

This qualitative study is a subanalysis of two datasets from a single project, which included semistructured individual interviews with 15 patients and 12 physicians. We derived the data for this analysis from portions of the interviews pertaining to IUD self-removal and provider removal. We analyzed data using deductive and inductive techniques to perform content and thematic analyses.

RESULTS

The majority of patients and physicians cited both concerns about and potential benefits of IUD self-removal. Patients cited concerns about safety as the reason they did not wish to remove their own IUD, but physicians did not share these concerns; instead, physicians were apprehensive about not being involved in the discussion to remove the IUD. Both patients and physicians valued having the provider "in the loop" and reported fears about hasty or coerced removal.

CONCLUSIONS

IUD self-removal is an option that some patients may be interested in. Addressing concerns about safety may make self-removal more appealing to some patients. Addressing physicians' concern about "hasty" removal may require additional training so that providers are better able to support patients' decision making around contraceptive use.

IMPLICATIONS

The option of self-removal could have a positive impact on reproductive autonomy and patient decision making.

Reproductive coercion: an under-recognized challenge for primary care patients

BACKGROUND

Reproductive coercion impacts many women of reproductive age.

OBJECTIVES

We sought to explore how reproductive coercion, including pregnancy coercion and birth control sabotage, impacts women in a primary care population.

METHODS

We administered a survey to women accessing care at a family medicine clinic in the Bronx, NY. Reproductive coercion was defined as a positive response to at least one of five questions adapted from previous studies. We assessed the association of reproductive and demographic characteristics with a lifetime history of reproductive coercion.

RESULTS

At least one form of reproductive coercion was reported by 24% of the 97 respondents. Current lack of personal safety and a history of transactional sex for money or a place to stay were significantly associated with having experienced reproductive coercion (all P ≤ 0.02).

CONCLUSIONS

Reproductive coercion was common among women of reproductive age at this urban family medicine clinic in an underserved community, and was associated with other forms of control and violence. Clinicians are advised to discuss birth control sabotage and pregnancy coercion with their patients.

"I Don't Want to Go Anywhere Else": Patient Experiences of Abortion in Family Medicine

BACKGROUND AND OBJECTIVES

Prior studies have demonstrated that most women are comfortable with the option of receiving early abortion care in the family medicine setting, and patients who received early abortion care in this context report satisfaction with their experience. There are few qualitative studies, however, that explore abortion experiences in the family medicine setting. This study aimed to better understand influential factors in women's choices and experiences of their family medicine setting for abortion care.

METHODS

We conducted semi-structured interviews with 15 women who received early abortion care at an urban federally qualified health center offering full-spectrum family medicine. Transcripts were analyzed in NVivo, using editing and immersion/crystallization approaches.

RESULTS

Women who received abortion care in this setting were highly satisfied. Though many were surprised when they learned abortion care was available, their responses were favorable, and their experiences were positive. Our results indicate that connection to the clinic setting and to the provider who performed the abortion created a context of trust and comfort. Further, women in our study appreciated the privacy offered by a general medical setting as well as the convenience and continuity of care afforded by accessing abortion care in their accustomed primary care setting.

CONCLUSIONS

Women in our study reported high levels of satisfaction with care and would recommend this setting to others. In a context of increasing restrictions on abortion, family physicians are well-positioned to increase access by including abortion care in the range of reproductive health services offered in their primary care practice settings.

What Women Want: A Qualitative Study of Contraception in Jail

OBJECTIVES

We undertook this study to understand women's perceptions of receiving contraception at Rikers Island Jail.

METHODS

We conducted semi-structured in-depth interviews in 2011 to 2012 with 32 women incarcerated at Rikers Island Jail. We analyzed the data using standard qualitative techniques.

RESULTS

Almost all participants believed that contraception should be provided at the jail. However, many said they would hesitate to use these services themselves. Reservations were caused in part by women's negative views of health care services at the jail. Fears about the safety of birth control, difficulties associated with follow-up in the community, and desire for pregnancy were other factors that influenced interest in accepting contraception.

CONCLUSIONS

Contraception at the jail must be provided by trusted medical providers delivering high quality care with the goal of allowing women to control their own fertility; this would ensure that women could access birth control and cease using birth control when desired.

Developing patient-centered teams: The role of sharing stories about patients and patient care

Research indicates that health care teams are good for staff, patients, and organizations. The characteristics that make teams effective include shared objectives, mutual respect, clarity of roles, communication, trust, and collaboration. We were interested in examining how teams develop these positive characteristics. This paper explores the role of sharing stories about patients in developing patient-centered teams. Data for this paper came from 1 primary care clinic as part of a larger Providers Share Workshop study conducted by the University of Michigan. Each workshop included 5 facilitated group sessions in which staff met to talk about their work. This paper analyzes qualitative data from the workshops. Through an iterative process, research team members identified major themes, developed a coding scheme, and coded transcripts for qualitative data analysis. One of the most powerful ways group members connected was through sharing stories about their patients. Sharing clinical cases and stories helped participants bond around their shared mission of patient-centered care, build supportive relationships, enhance compassion for patients, communicate and resolve conflict, better understand workflows and job roles, develop trust, and increase morale. These attributes highlighted by participants correspond to those documented in the literature as important elements of teambuilding and key indicators of team effectiveness. The sharing of stories about patients seems to be a promising tool for positive team development in a primary care clinical setting and should be investigated further.

A Review of Contraception and Abortion Content in Family Medicine Textbooks

BACKGROUND AND OBJECTIVES

Family physicians are critical providers of reproductive health care in the United States, and family physicians and trainees refer to textbooks as a source of clinical information. This study evaluates the coverage of reproductive health topics in current family medicine textbooks.

METHODS

We identified 12 common family medicine textbooks through a computerized literature search and through the recommendations of a local family medicine clerkship and evaluated 24 areas of reproductive health content (comprising contraceptive care, management of early pregnancy loss, and provision of induced abortion) for accuracy and thoroughness using criteria that we created based on the latest guidelines.

RESULTS

All contraceptive methods evaluated were addressed in more than half of the textbooks, though discrepancies existed by method, with intrauterine devices (IUDs), external (male) condoms, and diaphragms addressed most frequently (10/12 texts) and male and female sterilization addressed least frequently (8/12 texts). While most contraceptive methods, when addressed, were usually addressed accurately, IUDs were often addressed inaccurately. Coverage of early pregnancy loss management was limited to 7/12 texts, and coverage of early abortion methods was even more limited, with only 4/12 texts addressing the topic.

CONCLUSIONS

Family medicine textbooks do not uniformly provide correct and thorough information on reproductive health topics relevant to family medicine, and attention is needed to ensure that family physicians are receiving appropriate information and training to meet the reproductive health needs of US women.

Erectile response to transurethral alprostadil, prazosin and alprostadil-prazosin combinations

PURPOSE

Transurethral alprostadil has been shown to be efficacious in many men with erectile dysfunction. We compared transurethral alprostadil and prazosin alone, and in combination to treat this disorder.

MATERIALS AND METHODS

In this double-blind, placebo controlled study the erectile responses to transurethral alprostadil, prazosin and alprostadil-prazosin combinations were assessed in 234 men 26.8 to 81.5 years old with complete organic erectile dysfunction. Patients self-administered a random sequence of 7 doses in the clinic in 4 weeks. The erectile response was assessed using categorical and visual analog scales.

RESULTS

Full penile enlargement or rigidity was achieved by 165 of the 234 men (70.5%) after at least 1 active dose of medication. The most effective alprostadil dose (500 microg.) resulted in full penile enlargement or rigidity in 51.8% of administrations, whereas the most effective prazosin dose (2,000 microg.) and placebo resulted in a similar response in 12.7 and 2.7%, respectively (p <0.001). The 500/2,000 microg. alprostadil/prazosin combination, which resulted in full enlargement or rigidity in 58.9% of doses, was only slightly better than the most effective dose of alprostadil alone (500 microg.). However, combinations of 125/500 and 250/500 microg. alprostadil/prazosin were more effective (p <0.01) than 125 and 250 microg. alprostadil given alone, respectively. The most common side effect of therapy was penile pain, which rarely led to study discontinuation. Hypotension most commonly developed at the higher alprostadil-prazosin combination.

CONCLUSIONS

Transurethral alprostadil and alprostadil-prazosin combinations produced erections in men with complete organic erectile dysfunction. This combination therapy may be an option in patients who do not respond to transurethral alprostadil alone.

Clinical guidelines panel on erectile dysfunction: summary report on the treatment of organic erectile dysfunction. The American Urological Association

PURPOSE

The American Urological Association convened the Clinical Guidelines Panel on Erectile Dysfunction to analyze the literature regarding available methods for treating organic erectile dysfunction and to make practice recommendations based on the treatment outcomes data.

MATERIALS AND METHODS

The panel searched the MEDLINE data base for all articles from 1979 through 1994 on treatment of organic erectile dysfunction and meta-analyzed outcomes data for oral drug therapy (yohimbine), vacuum constriction devices, vasoactive drug injection therapy, penile prosthesis implantation and venous and arterial surgery.

RESULTS

Estimated probabilities of desirable outcomes are relatively high for vacuum constriction devices, vasoactive drug injection therapy and penile prosthesis therapy. However, patients must be aware of potential complications. The outcomes data for yohimbine clearly indicate a therapy with marginal efficacy. For venous and arterial surgery, based on reported outcomes, chances of success do not appear high enough to justify routine use of such surgery.

CONCLUSIONS

For the standard patient, defined as a man with acquired organic erectile dysfunction and no evidence of hypogonadism or hyperprolactinemia, the panel recommends 3 treatment alternatives: vacuum constriction devices, vasoactive drug injection therapy and penile prosthesis implantation. Based on the data to date, yohimbine does not appear to be effective for organic erectile dysfunction and, thus, it should not be recommended as treatment for the standard patient. Venous surgery and arterial surgery in men with arteriolosclerotic disease are considered investigational and should be performed only in a research setting with long-term followup available.

A double-blind, placebo-controlled evaluation of the erectile response to transurethral alprostadil

OBJECTIVES

Previous studies have indicated that the urethra may provide an effective route for administering vasoactive medication for the treatment of erectile dysfunction. We evaluated the safety and efficacy of alprostadil administered intraurethrally at home for the treatment of this disorder.

METHODS

This prospective, multicenter, double-blind, placebo-controlled study evaluated the erectile response to randomly assigned doses of transurethral alprostadil at home in 68 men with long-standing (mean 41 months) erectile dysfunction of primarily organic etiology. Patients completing the study each administered a random sequence of four different doses (125, 250, 500, and 1000 micrograms) and placebo over a 2 to 4-week period. Assessments included the couples' ability to have intercourse, patient ratings of erectile response by both categorical and visual analogue scales, penile volume measurements, and overall assessments of comfort and ease of administration.

RESULTS

Overall, 75.4% (49 of 65) of study patients achieved full enlargement of the penis and 49.2% (32 of 65) achieved an erection judged by the patient to be sufficient for intercourse. In addition, 63.6% (42 of 66) of patients reported intercourse. Efficacy was similar across etiologies. The most common side effect was penile pain, which occurred in association with 9.1% to 18.3% of alprostadil administrations, depending on dose. Mean comfort ratings ranged from 79 to 87, depending on dose, where 0 = severe discomfort and 100 = comfortable; ease of administration scores were above 90 for each dose, where 0 = difficult and 100 = easy. There were no episodes of priapism in this study.

CONCLUSIONS

Short-term treatment with transurethral alprostadil produced erections resulting in sexual intercourse in most patients with chronic erectile dysfunction. This therapy may be a useful treatment option for patients with erectile dysfunction.

Persistent müllerian duct syndrome with transverse testicular ectopia and spermatogenesis

Normal male sexual differentiation is dependent on at least 2 factors: 1) testosterone and 2) müllerian inhibiting factor. The absence of müllerian inhibiting factor is responsible for a rare form of male pseudohermaphroditism, the persistent müllerian duct syndrome or hernia uteri inguinale. Patients with this syndrome present with persistent müllerian structures and the syndrome may be associated with transverse testicular ectopia. Additionally, most patients have azoospermia. We report a case of persistent müllerian duct syndrome with transverse testicular ectopia in which sperm are documented in the ejaculate.

An improved vasoactive drug combination for a pharmacological erection program

Papaverine hydrochloride (smooth muscle relaxant), phentolamine mesylate (alpha-adrenergic blocking agent) and prostaglandin E1 (vasodilator and smooth muscle relaxant) were combined to produce a potent vasoactive drug therapy for use in a pharmacological erection program. Doses of 2.5 cc papaverine (30 mg./cc), 0.5 cc phentolamine (5 mg./cc), 0.05 cc prostaglandin E1 (500 micrograms./cc) and 1.2 cc 0.9% normal saline were combined to produce a vial of 4.25 cc for patient convenience. Twenty unit vials were made from the 1 cc vial of prostaglandin E1, the most expensive ingredient. The solution is physiologically active for at least 6 months and can be stored at room temperature although refrigeration is recommended. The pH of the solution is 4. This vasoactive drug combination has been used in 116 patients for diagnostic testing and subsequent treatment. A dose of 0.25 cc has been effective for diagnosis and treatment in the majority of patients with mild to moderate arteriogenic and/or venogenic and diabetic impotence. For patients with neurogenic dysfunction 0.1 to 0.125 cc was the usual dose. Two patients had a prolonged erection requiring irrigation, 1 on the day of initial testing and 1 on home therapy. Pain at the site of injection or during intercourse was noted in only 2 patients and to date no fibrosis or plaques have been found.

Arterial and venous surgery for vasculogenic impotence: a combined French and American experience

A multidisciplinary approach with emphasis on hemodynamic tests was used to diagnose 421 patients with arteriogenic, venogenic or mixed arteriogenic/venogenic impotence who underwent a vascular surgical procedure. With an average follow-up of nearly five years, approximately 50% of patients were cured and an additional 20% were improved.

Enhanced cavernometry: procedure for the diagnosis of venogenic impotence

A technique of cavernometry to diagnose corporovenous leakage (CVL) is described. The criterion used to define CVL was a corporeal infusion rate greater than 60 ml/min after the intracorporeal injection of 60 mg papaverine or 30 mg papaverine and 1 mg phentolamine. Alpha blockade in addition to papaverine decreased the incidence of corporovenous leakage.

Applications of microsurgery in urology

The applications of microsurgery in urology have increased in the decade since urologists first used such techniques. The primary uses for microsurgery in urology at first were vasovasostomy, vasoepididymostomy, and testicular autotransplantation. Penile revascularization has recently become another procedure for which microsurgery is used with increasing frequency. As more urologists learn the techniques, other urologic applications for microsurgery surely will develop.

Venous arterialization for erectile impotence

Revascularization of the corporal bodies in arteriogenic impotence can be accomplished by means of a venous arterialization procedure as described by Ronald Virag. This surgical approach and early results are detailed in this article.

Management of bladder stones: should transurethral prostatic resection be performed in combination with cystolitholapaxy?

We report our institutional experience and review the literature in the management of bladder stones, with particular attention to combined cystolitholapaxy and transurethral prostatectomy. Vesical calculi are associated with obstructing prostatic hypertrophy two thirds of the time. Combined cystolitholapaxy and transurethral resection of the prostate have significant morbidity.

Single ectopic ureter: unusual presentation in adult male

We present a case of an unusual and late presentation of a single ectopic ureter in an adult male. The patient presented with gross painless hematuria. The left ureter draining a dysplastic kidney terminated in the ipsilateral seminal vesicle.

Reconstructive surgery for vasculogenic impotence

A multidisciplinary approach was used to diagnose 12 patients with vasculogenic impotence. Deep dorsal vein ligation was performed in 8 men to treat venous incompetence. Venous arterialization according to the technique of Virag was used in 4 men to treat arterial inflow insufficiency. A 75 per cent success rate was noted for the correction of venous incompetence. With an average followup of 1 year, excellent success was achieved in re-establishing corporeal blood flow with the technique of venous arterialization plus creation of a venocorporeal shunt.

Reliability of gynecologic sonographic diagnosis, 1978-1984

The indications for gynecologic ultrasonography, as well as the reliability of sonographic diagnoses in gynecologic patients, remain controversial. In an effort to evaluate the reliability of the gynecologic sonographic diagnoses rendered at this institution, we analyzed 900 patients available for follow-up. The referral diagnosis was confirmed in 331 patients (36.8%). In 531 patients (59%), sonography established the diagnosis. Thirty-eight (4.2%) of the diagnoses rendered did not reveal the actual status of the patient and were deemed to be "misleading." Twenty-one of the misleading diagnoses involved the attempted diagnosis of pregnancy at less than 5 weeks' menstrual age. Sonography correctly identified 353 of 370 patients with normal pelvic anatomy. Specific clinical settings in which gynecologic sonography could be beneficial are presented.

Penile xenon (133Xe) washout: a rapid method of screening for vasculogenic impotence

The radioactive inert gas xenon (133Xe) is a well-established isotopic indicator used to assess vascular status in many organ systems. We employed xenon-133 to evaluate male impotence. Xenon-133 was injected subcutaneously at the level of the coronal sulcus in the detumescent state. Using the gamma camera, sequential images were obtained and computer-generated curves calculated. The clearance time for 50 per cent washout of the injected 133Xe (T1/2) was then calculated for each patient, as well as a control group. Preliminary findings indicate a correlation with such established techniques of evaluating erectile impotence as history, physical examination, penile pulse Doppler tracings, and brachial-penile blood pressure index. The xenon-133 washout study was a rapid, minimally invasive, reproducible, and cost-effective method of screening those impotent patients for vasculogenic etiology of their erectile impotence. We recommend the addition of this method to the surgeon engaged in the care of impotent males.

Use of single J urinary diversion stents in intestinal urinary diversion

A review of the past twenty months of intestinal-urinary diversion with use of the single J urinary diversion stents at Albany Medical Center Hospital and the Albany Veterans Administration Medical Center resulted in no ureteroileal anastomotic fistulas. Thirty-seven stented anastomoses were performed in 19 patients.

Placement of penile prosthesis during surgery for malignancies

Insertion of either a semirigid or inflatable penile prosthesis at the completion of surgery for various malignancies was performed. Twelve men had implants and were followed at least one year with excellent results. Careful preoperative sexual counseling with the patient's spouse is recommended and adds immeasureably to the mental well-being of the patient in the postoperative period. Penile prostheses can be placed easily after radical cystectomy, radical prostatectomy (perineal or retropubic), urethrectomy, and bilateral orchiectomy. Penile prosthesis placement may also be recommended for patients with less than adequate erectile function who may be undergoing pelvic lymphadenectomy with 125I implantation for prostatic carcinoma.

Pyosemia and carriage of chlamydia and ureaplasma in infertile men

Chlamydia trachomatis and Ureaplasma urealyticum have been implicated as causative organisms in infections involving the male and female urogenital tracts. Seminal fluid, anterior urethral swabs and first-voided urine specimens from men undergoing infertility evaluation, with and without pyosemia, or anterior urethritis were cultured for Chlamydia trachomatis and Ureaplasma urealyticum. The method used to isolate Chlamydia trachomatis involved cytochalasin-B treated McCoy cells, and NYC and A7 solid media were used for the isolation of Ureaplasma urealyticum. Isolation of Chlamydia trachomatis from seminal fluid has not been possible even in the face of pyosemia and the presence of Chlamydia trachomatis in urine and urethral swab material. The reasons for the inability to culture Chlamydia trachomatis will be explored.

Non-incisional therapy for priapism

During a 4-year period 7 patients with priapism were managed successfully with a non-incision treatment program. Three were treated by hypotensive anesthesia with sodium nitroprusside, 2 by the Winter procedure (creating a temporary cavernospongiosum shunt) and 2 by combining hypotensive anesthesia and the Winter procedure. Causes of the priapism were pelvic infection in 1 patient, sickle cell trait in 2 and post-hemodialysis in 2. The cause was not known in 2 cases. Of the 7 patients 5 were potent before the onset of the priapism and remained so after treatment. No complications of therapy were noted and hospitalization averaged 1.4 days, with 5 patients being discharged the day after treatment. Our experience with these 7 patients indicates that creation of a vascular shunt by an operative technique may not be necessary to alleviate priapism.

Congenital penile curvature without hypospadias

Congenital curvature of the penile shaft without hypospadias is a rare problem that poses cosmetic and functional disability. It is caused by disparate growth of the penile corpora. Surgical repair of 7 cases is reviewed, with follow-up of two to eight years. The results of these 7 cases are added to 13 other cases reported previously. The Nesbit technique was used with the modification of (1) preserving the dorsal neurovascular bundle to avoid anesthesia and lymphedema of the glans in selected cases, and (2) intraoperative use of saline-induced erections and Allis clamp " tucks" of the tunica albuginea to insure a satisfactory repair.

Idiopathic rupture of the bladder: association with methamphetamine and alcohol

We report a case of rupture of the bladder. The 2 precipitating causes for the rupture appeared to be the diuretic and obtunding effect of alcohol combined with the bladder neck constriction caused by the alpha-sympathomimetic drug, methamphetamine.

Use and abuse of retrograde pyelography

Retrograde pyelography to demonstrate the renal pelvis and ureters is a common urologic procedure. Newer contrast materials and better radiographic techniques have obviated many of the previous indications for retrograde studies were independently reviewed by two urologists and a radiologist to determine if the studies were indicated, appropriately timed, informative, and complete. Our results indicate a high percentage of these examinations are incompletely performed and uninformative and could have been replaced by noninvasive studies. What constitutes a complete retrograde study and when to utilize this examination is discussed.

The familial liver donor in renal transplantation

A survey is made of the 20-year experience with more than 300 living donors in renal transplantation at the Peter Bent Brigham Hospital. Details are given pertaining to the first transplantation of the kidney from one living person to another in December 1954. The surgical technique, the complications and the results of renal transplantation from a living donor are summarized. The philosophic and psychologic problems encountered are described. A comparison of results summarized by Murray of living, related donor transplants to cadaveric donor transplants is included. This paper constitutes a salute to the familial living donor.

Recovery of renal function after prolonged unilateral ureteral obstruction

Concepts of renal counterbalance and animal experiments have long supported nephrectomy for prolonged complete unilateral ureteral obstruction. The situation in humans has been clarified by only a few reported cases. Herein we report 3 cases with relief of obstruction after at least 28, 28 and 150 days. Evidence is presented to support renal preservation in similar cases.

Vasectomy without complication

In a four-year period 500 outpatient vasectomies were performed by the author. Bilateral scrotal incisions were used in all cases as were metal clips to occlude the vas deferens. Operating time rarely exceeded fifteen minutes. No failures and no sperm granulomas were encountered. Complications were rare and included a single scrotal hematoma and six minor infections. Unilateral absence of the vas deferens was noted in 2 patients. The technique to be described is a simple, complication-free method of vasectomy.

Bladder fistula following total hip replacement using self-curing acrylic

A case of a bladder fistula following total hip replacement is attributable to thermal injury by self-curing polymethylmethacrylate projecting into the retropubic space.