Zhu A, Andino J, Daignault-Newton S, Chopra Z, Sarma A, Dupree JM. What is a normal testosterone level for young men? Rethinking the 300 ng/dL cutoff for testosterone deficiency in men 20-44 years old. J Urol. 2022;208(6):1295-1302.

Special thanks to Drs Grace Chen and Samuel Ohlander at the University of Illinois at Chicago.

Does it make sense to use the same value for testosterone deficiency across men of all ages? The current AUA Guidelines threshold of 300 ng/dL is based on studies of men over the age of 45 in whom testosterone deficiency and its symptoms more commonly manifest. However, testosterone levels clearly decline with age, meaning younger men who experience pathological symptoms of low testosterone but have testosterone levels just above a simple number for normal may be underdiagnosed. These authors from the University of Michigan convincingly argue that by tailoring the testosterone threshold to more accurately reflect the range of values seen in younger men, we may better serve a significantly overlooked portion of the male population.

In this study, the testosterone levels of over 1,000 healthy men from ages 20 to 44 years were collected and analyzed. This population was further stratified into cohorts at 5-year intervals. Testosterone predictably declined with age, with the optimal threshold for the 20- to 24-year-old cohort being 409 ng/dL and that for the 40- to 44-year-old cohort being 350 ng/dL. It is notable that even the lowest testosterone value collected in this population was at least 50 ng/dL above the current AUA number. It’s time for practices using a straight 300 ng/dL threshold to adjust their diagnostic criteria to better reflect age-specific changes in testosterone, with careful consideration given to the fertility desires of those reproductive-age men who merit treatment.

Hall MK, Thiel J, Dunmire B, et al. First series using ultrasonic propulsion and burst wave lithotripsy to treat ureteral stones. J Urol. 2022;208(5):1075-1082.

Special thanks to Drs Graham Hale and Daniel Garvey at the University of Illinois at Chicago.

It’s no secret that urologists love new technology, especially when it promises to be less invasive and easier to use. Portable burst wave lithotripsy and ultrasonic propulsion to treat urinary calculi augurs just that. This study asked whether the system can be used in awake and unanesthetized patients in the emergency department or in an office setting.

The authors reported the efficacy and safety of using a 10-minute burst wave lithotripsy and ultrasonic propulsion treatment cycle in 29 awake and unanesthetized patients. They observed stone displacement in 66% of patients, including 2 that were repositioned into the bladder. By 2-week follow-up, they achieved a distal ureteral stone clearance rate of 86% with a mean size of 4.8 mm in an average of 3.9 days. Stone fragmentation was confirmed in 38% of patients, although this may be underestimated. All subjects tolerated the procedure well, and adverse events were mild and self-resolved within 24 hours, including gross hematuria in 24% and skin redness in 17%.

Our future may well portend a portable ultrasound-based platform to treat ureteral stones at initial presentation without anesthesia. Excluding obvious ultrasound limitations, this modality would represent a welcome addition to stone treatment paradigms. There are those who would caution urologists to embrace this modality or risk losing it to other specialties, but I’d put my bets on the warm place new technology rests in our hearts.

Gomez-Garberi M, Sarrio-Sanz P, Martinez-Cayuelas L, et al. Genitourinary lesions due to monkeypox. Eur Urol. 2022;82(6):625-630.

Special thanks to Drs Ashraf Selim and Daniel Garvey at the University of Illinois at Chicago.

Just when there’s light at the end of the tunnel of COVID-19, along comes a disease caused by the monkeypox virus. First reported in humans in 1970, it is endemic in certain parts of Africa. But it has recently spread well beyond with 31,000 cases reported in nonendemic locales just since May 2022. This review charted the course of 14 males with the disease who had no known travel to endemic countries.

All patients presented with cutaneous or mucosal involvement with papules, vesicles, or pustules which evolved into scabs, taking as long as weeks to appear. Penile lymphedema and inguinal lymphadenopathy may also be present. In almost half the patients, the initial symptoms were related to the pubic and scrotal areas, alerting urologists to include monkeypox in the differential diagnosis of sexually transmitted diseases, and monkeypox infection coexisted with other sexually transmitted diseases in 43%. The incubation period for monkeypox is between about 4 and 17 days, and case contacts should be isolated for 21 days. Regarding transmission, two-thirds of the patients were males having sex with men, 15% from heterosexual intercourse, and a similar number having no sexual contact in the weeks before symptom onset.

The diagnosis is made by a polymerase chain reaction test from swabs of dermal lesions or the rectum if the skin is unaffected. Treatment is mainly symptomatic and with antibiotics if bacterial superinfection is found. Surgery may be required to drain collections of pus. As a large number of cases have been reported worldwide in the last few months, urologists should be on the lookout for monkeypox to diagnose, treat, and prevent its spread.