Background: Direct-to-consumer (DTC) Internet-based prescription and pharmacy platforms offer electronic consultation for evaluation and pharmacologic treatment of erectile dysfunction (ED) without a physical exam or in-person visit, presenting a potentially dramatic shift in care for this condition. Aim: To characterize the extent to which DTC prescribing sites for ED generate traffic and attract individual users. Methods: Using SEMRush, a marketing software platform that provides analytics regarding website traffic, we examined online site visits to 6 major DTC prescribing websites offering ED evaluation and treatment from October 2017 through December 2019. Outcomes: We recorded trends in the number of unique visitors over time, visitor referral patterns, and the proportion of overall visitors to individual sites. Results: During the study period, the total number of unique, quarterly visitors increased by 1,688% from 655,733 in the 4th quarter (Q4) 2017 to over 11 million in Q4 2019. In 2019, there were on average 4,971,674 visits to all sites combined each month. For the 2 largest sites (Hims and Roman), visitors predominantly reached the site via direct web address (27.3%) or search engine referral (27.3%). Clinical implications: An increasingly large number of potential patients are utilizing DTC prescribing platforms for the diagnosis and treatment of ED, which do not require physical exams or treatment of other comorbid conditions. Strength & Limitations: Demonstrates high demand for ED DTC prescribing services using independent market research software and characterizes the number of visits for the first time. Limitations include the lack of individual demographics and lack of information regarding what proportion of unique visits lead to evaluation and treatment using the services. Conclusion: The dramatic increase in visits to DTC prescribing sites that treat ED represents a paradigm shift in ED care, and it is imperative that clinicians and researchers work to understand how patients utilize online telemedicine, the safety and efficacy of online management of ED, and the potential downstream implications of its widespread use.

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We present the case of a penile fracture involving the proximal corpus cavernosum, presenting as a hematoma extending into the scrotum. The presentation, diagnosis, and surgical approach, which differ from the more typical penile shaft fracture, are delineated.

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Chronic Kidney Disease (CKD), it remains unclear which factor has much more worse effects on renal function. We accessed the influence of hyperuricemia on impaired renal function in patients with UA stone components in comparison with community-dwelling population.METHODS: Between 2010 and 2014, we treated 1793 consecutive patients with urolithiasis in our hospital, and identified stone components available 473 patients. Of those, 123 patients with UA stone were included in the present study. Age, sex, and serum UA concentration adjusted control subjects were selected from 3089 community-dwelling population in each group by propensityscore matching (2:1). Subjects were divided into two groups; hyperuricemia or non-hyperuricemia groups according to the serum UA concentrations (UA-low: < 7.0 or UA-high: ¼7.0 mg/mL). We compared renal function between the UA stone and control subjects in each group. The renal function was evaluated as estimated glomerular filtration rate (eGFR). The independent risk factor for impaired renal function were investigated by multivariate logistic regression analysis.RESULTS: We selected pair-matched 166 control subjects and 83 UA stone patients for serum UA-low group. Similarly, 68 control subjects and 34 UA stone patients for serum UA-high group. UA stone patients had significantly lower in eGFR (P<0.01) compared with control subjects regardless of serum UA concentrations. Multivariate logistic regression analysis revealed that age, past-history of cardiovascular disease, serum UA, and stone former were significant factors for stage 3 CKD. UA stone component had 3-fold chance to develop stage 3 CKD than serum UA concentration.CONCLUSIONS: Uric acid stone components may strongly influence on renal function deterioration than hyperuricemia.

Non-obstructive azoospermia (NOA) is classified upon histology. However, significant heterogeneity exists within each testis. We hypothesize that histological evaluation misdiagnoses numerous men based upon a more comprehensive genetic phenotype. The objective of this study was to evaluate the discrepancies among histologic and genetic phenotyping of NOA patients.METHODS: In a prospective blinded study, 54 men presenting with NOA underwent testis biopsy at the time of surgical sperm retrieval. Tissue was sent for histology or RNA sequencing. Histological classification was performed by examining 9 discrete regions by 2 fellowshiptrained GU pathologists, at a tertiary care facility. RNA libraries were created and bulk next-generation RNA sequencing was performed using an Illumina HiSeq 2000 platform. Reads were mapped using TopHat (v2.0.8), quantified with Cufflinks, and normalized as FPKMs. Results underwent principal component analysis (PCA), and hierarchical clustering analysis using iDEP 0.42 to evaluate the relatedness of genomic phenotypes compared to histologic phenotypes.RESULTS: 21879 transcripts were mapped among the specimens. PCA demonstrated that Sertoli Cell Only (SCO) patients group tightly together, while early and late maturation arrest (MA) both group together. However, Klinefelter Syndrome (KS) grouped between SCO and normal (NL) while hypospermatogenesis (HS) was extremely variable, and was distributed among SCO, NL and MA groupings. Hierarchical clustering demonstrated significant heterogeneity between and within histologic classes. 4 second order hierarchical branches were identified. The first cluster contained 9 normal specimens, 3 HS and 1 late MA. The second cluster was comprised of 1 KS and 1 HS patient. The third cluster was predominantly SCO and was comprised of 10 SCO, 6 KS, and 3 HS patients. The fourth cluster was largely defined by maturation arrest with 11 early MA, 4 late MA, 3 HS, 1 normal and 1 SCO.CONCLUSIONS: Our results suggest that NOA subtypes broadly cluster together; however, a significant number of discrepancies exists between genomic clustering compared to conventional histologic classification. These findings identify the need for further research in refining the precision and reproducibility of sub-classification in NOA.