# Check — The Testosterone-Exposed System (Foundations, lecture 4 of 4)

Checked 2026-10-19. 49 claims checked; 12 corrected; 7 softened or re-attributed; 0 removed.

Length 2542 → 2450 words (`wc -w`, markers stripped), per the task's instruction to reach 2450 or fewer against a 2400 budget; cuts were connective tissue only — every drug, dose, figure and slide of the deck is still present. Markup intact after edits: 16 `##` slides (one per beat, slide numbers 1–16 in order), two `? ` paragraphs (the mid-lecture reflection and the class closing question, which is verbatim and the final paragraph), no `> ` paragraphs, no lists, no parentheses or slashes, no headings deeper than `##`, bold balanced in every paragraph, no `[+]`/`[fixed]` markers left (26 and 2 resolved), lecturer not named anywhere in the narration ("the course", "the lecturer" only).

## Corrections (script changed)
- Slide 4 (Erectile tissue) — writer's `[fixed]` #1 confirmed: erection results from relaxation, not contraction, of cavernosal and arteriolar smooth muscle; contraction produces detumescence. The deck (source slide 6) has it backwards. Sources: Cialis label §12.1 "Penile erection during sexual stimulation is caused by increased penile blood flow resulting from the relaxation of penile arteries and corpus cavernosum smooth muscle" (FDA label, https://www.accessdata.fda.gov/drugsatfda_docs/label/2016/021368s027lbl.pdf); NO→sGC→cGMP→PKG→relaxation, J Clin Med 2021 (https://pmc.ncbi.nlm.nih.gov/articles/PMC8229897/figure/jcm-10-02551-f001). Marker removed.
- Slide 8 (The prostate) — writer's `[fixed]` #2 confirmed: the seminal vesicles, not the prostate, supply the majority of ejaculate volume (65–75%); the prostate supplies roughly 20–30%; radical prostatectomy removes prostate and seminal vesicles together, so orgasm afterwards is dry. Deck slide 14's "prostate creates the majority of ejaculate" conflicts with its own slides 13 and 16. Script now says "men ejaculate less after these procedures and not at all after radical prostatectomy". Sources: https://en.wikipedia.org/wiki/Semen (composition table); https://www.training.seer.cancer.gov/anatomy/reproductive/male/glands.html; https://truenorth.movember.com/learn/physical-changes/dry-orgasm/ ; https://procure.ca/?p=28774 . Marker removed.
- Slide 4 (Peyronie): "settles over 12 to 18 months" → "settles within 6 to 18 months", and "up to 10 percent" attributed to the course. Neither the AUA (2015) nor the EAU guideline gives a typical active-phase duration; both define stability as ≥3 months without change, and reviews give 6–18 months ("up to 18 months, but often much shorter", Weill Cornell). Guideline prevalence ranges are 0.5–20.3% (AUA) and 0.1–20.3% (EAU), so "up to 10%" is within range but is the course's choice of figure. Sources: https://www.auanet.org/guidelines-and-quality/guidelines/peyronies-disease-guideline ; https://uroweb.org/guidelines/sexual-and-reproductive-health/chapter/penile-curvature ; https://weillcornell.org/services/urology/male-infertility-and-sexual-medicine/conditions-we-treat/peyronies-disease
- Slide 7 (Medical treatment): "A penile implant replaces the corpora cavernosa with inflatable cylinders" → "places inflatable cylinders inside the corpora cavernosa". Cylinders (or malleable rods) are implanted within the corpora; the pump sits in the scrotum (three-piece devices add an abdominal reservoir). Sources: https://radiopaedia.org/articles/penile-implant ; https://pmc.ncbi.nlm.nih.gov/articles/PMC5027992/figure/F8
- Slide 8: "14 percent of men report new-onset ED after TURP" now attributed to the course. Largest single-centre series (Poulakis 2006, n=629) reports 12% newly reported ED; a 63-man NPT study reports 14%; the literature range is 4–40%. Sources: https://www.ebi.ac.uk/europepmc/webservices/rest/search?query=EXT_ID:16372121&resultType=core&format=json (Poulakis, Asian J Androl 2006;8:69) ; https://pubmed.ncbi.nlm.nih.gov/15503048 ; https://journals.viamedica.pl/sexual_and_mental_health/article/download/33654/24696
- Slide 9 (Prior planning): "the labelled once-daily dose is 5 milligrams" → "the labelled once-daily doses are 2.5 to 5 milligrams" (ED once-daily: start 2.5 mg, may increase to 5 mg; BPH and ED/BPH: 5 mg). The deck's 10 mg daily is off-label. Added that the post-operative pairing of on-demand sildenafil/vardenafil with daily tadalafil is "a combination the labels themselves advise against" (Cialis §5.11: "Inform patients not to take CIALIS with other PDE5 inhibitors"), and the whole regimen is now attributed as the course's protocol. Source: Cialis label §§2.2, 2.3, 2.4, 5.11 (FDA PDF above; text extracted locally with pdftotext).
- Slide 11 (Hypogonadism): five edits. (a) Definition broadened from "the testes failing" to "too little testosterone, whether the fault lies in the testes or in the signals that drive them" (secondary hypogonadism is pituitary/hypothalamic). (b) "symptoms together with" → "symptoms or signs together with" (AUA statement 3: "symptoms and/or signs"). (c) Boxed-warning scope corrected: "Exogenous testosterone carries a boxed warning" → "Topical testosterone carries an FDA boxed warning for secondary exposure of children". FDA removed the cardiovascular-outcome language from testosterone boxed warnings on 2025-02-28 after TRAVERSE; the Jatenzo/Kyzatrex blood-pressure boxed warnings were removed July 2025 (moved to Warnings and Precautions); the secondary-exposure box remains on gels and topical solution (2026 labels). (d) Monitoring reordered to match the guideline: baseline PSA in men over 40 (statement 12), then testosterone every 6–12 months (statement 30) and haemoglobin/haematocrit for polycythaemia (statement 11). (e) Fertility alternatives: "the guideline points to clomiphene or hCG" → "allows alternatives such as off-label clomiphene or human chorionic gonadotropin" (statement 27 names aromatase inhibitors, hCG and SERMs; clomiphene is the SERM in practice and is off-label). Sources: FDA 2025-02-28 alert https://www.fda.gov/drugs/drug-alerts-and-statements/fda-issues-class-wide-labeling-changes-testosterone-products ; gel/solution boxed warning https://www.drugs.com/pro/testosterone-gel.html and https://www.lupin.com/US/uploads/PI_and_MG_Testosterone_Topical_Solution_USP_EQ_Axiron_3_2025_6a807cd32a.pdf ; Jatenzo/Kyzatrex removal https://www.guidelinecentral.com/drug/ed7b5d41-7475-4c10-99b9-b62b3434ae60/Jatenzo and https://www.drugs.com/pro/kyzatrex.html ; AUA statements reproduced in CUA 2019 teaching PDF https://content.tts.org/content/videos/cua/CUA2019/pdf/261.pdf and https://www.urologytimes.com/view/testosterone-deficiency-faqs-from-the-aua-guideline
- Slide 12 (PE defined): the deck's speaker-note "incidence of PE in men with hyperthyroidism is 50–60%" → "in the key multicentre study, half the men with an overactive thyroid had premature ejaculation, falling to 15 percent once the thyroid was treated" (Carani et al., JCEM 2005;90:6472: 50% → 15% after euthyroidism; a later single-centre study found 72%). The writer's `[+]` "treating the thyroid often resolves it" is thereby verified and made concrete. "More common in younger men" attributed to the course (see below). Sources: https://pubmed.ncbi.nlm.nih.gov/16204360/ ; https://pubmed.ncbi.nlm.nih.gov/19185321/
- Slide 13 (PE drivers): "52 percent of partners ... reported having no orgasm, compared with 21 percent in control groups" → "in one study 52 percent of partners reported difficulty reaching orgasm during intercourse, against about a quarter of controls". The source is Hobbs et al., Int J Impot Res 2008;20:512 (139 PE partners vs 89 controls; 77.7% vs 42.7% with any dysfunction); the orgasm figures reported from it are 51.9% vs 23.9%, and the outcome is orgasmic difficulty, not anorgasmia. Sources: https://www.ebi.ac.uk/europepmc/webservices/rest/search?query=EXT_ID:18650826&resultType=core&format=json ; https://www.alessandragraziottin.it/ew/ew_voceall/39/2601%20-%20premature%20ejaculation.pdf (EAU 2013 abstract quoting Hobbs)
- Slide 14 (PE treatment): "a half-life of 1.5 hours" → "an initial half-life of about 1.5 hours" (initial t½ 1.3–1.5 h; terminal t½ 15–19 h single dose, 20–24 h multiple). "Not approved in the United States" kept; first approval Sweden/Finland 2009. Sources: https://pmc.ncbi.nlm.nih.gov/articles/PMC3888071 ; https://en.wikipedia.org/wiki/Dapoxetine
- Slide 5 (Nocturnal tumescence): "The leading explanation is" → "A long-standing hypothesis holds" for the oxygenation account (it is Moreland's 1998 viewpoint paper, not settled physiology). Source: Moreland RB, Int J Impot Res 1998;10:113 (https://www.ebi.ac.uk/europepmc/webservices/rest/search?query=AUTH%3A%22Moreland%20RB%22%20AND%20hypoxemia%20AND%20fibrosis&resultType=core&format=json).
- Slide 15 (CV): four edits. (a) "twice the lifetime risk of a heart attack" → "one and a half to two times the heart-attack risk" (meta-analysis pooled RR for MI 1.62, 95% CI 1.34–1.96, Vlachopoulos 2013; CHD RR 1.46, Dong 2011; MESA 2018 reported in secondary coverage as roughly twofold). (b) "preceding a cardiac event by two to five years" → "preceding coronary symptoms by two to five years, about three on average" (Montorsi 2003: mean 38.8 months, range 1–168; consensus guidance: 2–3 years to CAD symptoms, 3–5 years to events). (c) "67 percent ... 80 percent" prefixed "By the figures the course cites" (see Could not verify). (d) Speaker-note on testosterone and cardiac risk softened ("some evidence ... raises cardiac risk in either sex") and a clause added: "though a large 2023 trial found no excess of cardiac events in hypogonadal men given testosterone" (TRAVERSE, NEJM 2023: MACE 7.0% vs 7.3%, HR 0.96). Sources: https://www.urotoday.com/recent-abstracts/men-s-health/erectile-dysfunction/60000-prediction-of-cardiovascular-events-and-all-cause-mortality-with-erectile-dysfunction-a-systematic-review-and-meta-analysis-of-cohort-studies-abstract.html ; https://www.acc.org/Latest-in-Cardiology/Journal-Scans/2011/09/12/16/59/Erectile-Dysfunction-and-Risk-of-CV-Disease-A-Meta-Analysis ; https://www.tctmd.com/news/erectile-dysfunction-independent-predictor-cardiovascular-events ; Montorsi 2003 via https://www.ebi.ac.uk/europepmc/webservices/rest/search?query=AUTH%3A%22Montorsi%20P%22%20AND%20%22erectile%20dysfunction%22%20AND%20%22coronary%22%20AND%20PUB_YEAR%3A2003&resultType=core&format=json ; https://uhra.herts.ac.uk/handle/2299/4550 ; TRAVERSE https://www.ovid.com/journals/nejm/pdf/10.1056/nejmc2309389~cardiovascular-safety-of-testosterone-replacement-therapy and https://pmc.ncbi.nlm.nih.gov/articles/PMC11937349/

## Verified (unchanged)
- Slide 3: circumcision "usually with a clamp or plastic ring that shields the glans" — Gomco and Mogen clamps, Plastibell ring are the three standard neonatal devices. Source: https://www.aafp.org/pubs/afp/issues/2020/0601/p680.html
- Slide 3: phimosis "graded by how far it will draw back" — Kikiros retractability grades 0–5 (Kikiros, Beasley, Woodward, Pediatr Surg Int 1993;8:329). Sources: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8522916/ ; https://www.fimose.org/artigos/graus/kikiros.pdf
- Slide 3: physiological non-retractility in infants, separating through childhood; only ~3% have persisting adhesions at 17; treatment of physiological phimosis not indicated. Sources: https://www.statpearls.com/point-of-care/27129 ; https://www.chop.edu/news/fellow-s-corner-some-foresight-foreskin
- Slide 5: nocturnal erections 3–5 per night, during REM. Sources: https://pmc.ncbi.nlm.nih.gov/articles/PMC8749065/ ; https://en.wikipedia.org/wiki/Nocturnal_penile_tumescence
- Slide 5: low-oxygen flaccid state — cavernosal pO2 25–40 mm Hg flaccid vs 90–100 mm Hg erect (Moreland 1998, above); hypoxia → fibrosis after denervation is the standard account of post-prostatectomy shortening.
- Slide 6: dopamine and oxytocin pro-erectile centrally; parasympathetic sacral outflow (pelvic nerve, S2–S4) — standard neuroanatomy; https://auanews.net/issues/articles/2022/december-2022/a-novel-hypothesis-explaining-sleep-related-painful-erections (pelvic nerve, parasympathetic tone, REM).
- Slide 6: nitric oxide from nerve endings and endothelium → soluble guanylate cyclase → cGMP → relaxation; PDE5 hydrolyses cGMP; androgens maintain NOS/cGMP and suppress PDE5 in human cavernosal tissue. Sources: https://pmc.ncbi.nlm.nih.gov/articles/PMC8229897/figure/jcm-10-02551-f001 ; https://www.nature.com/articles/3900524.pdf ; https://www.urotoday.com/recent-abstracts/men-s-health/erectile-dysfunction/123043-testosterone-positively-regulates-functional-responses-and-nitric-oxide-expression-in-the-isolated-human-corpus-cavernosum.html
- Slide 6: PDE5 inhibitors do nothing without arousal — Cialis label §12.1: "the inhibition of PDE5 by tadalafil has no effect in the absence of sexual stimulation."
- Slide 7: PDE5 inhibitors contraindicated with any organic nitrate, regularly or intermittently (Cialis label §4.1; potentiated hypotension).
- Slide 7: papaverine, phentolamine, prostaglandin (alprostadil) intracavernosal; discontinuation "as high as 60 percent" — reviews report >50%, ~40% at 6 months, 79.9% in one PDE5-era cohort. Sources: https://synapse.mskcc.org/synapse/works/37292 ; https://www.urotoday.com/recent-abstracts/men-s-health/erectile-dysfunction/68303-the-role-of-intracavernosal-injection-therapy-and-the-reasons-of-withdrawal-from-therapy-in-patients-with-erectile-dysfunction-in-the-era-of-pde5-inhibitors-abstract.html
- Slide 7: vacuum device (cylinder, pump, constriction ring); inflatable implant with scrotal pump; malleable rods (Radiopaedia, above).
- Slide 8: prostate ~20% (20–30%) of ejaculate volume with enzymes, zinc, sugars; 5α-reductase type 2 (SRD5A2) in the prostate converts testosterone to DHT. Sources: https://en.wikipedia.org/wiki/Semen ; https://vivo.weill.cornell.edu/display/pubid18483578 ; https://mp.bmj.com/content/molpath/50/1/51.full.pdf
- Slide 9: tadalafil "independently indicated for symptomatic BPH" — Cialis label §1.2; 5 mg once daily (§2.3). Penile-rehabilitation benefit left as the deck's "suggested".
- Slide 10: seminal vesicles make the majority of seminal fluid (65–75%). Source: https://en.wikipedia.org/wiki/Semen
- Slide 11: AUA guideline published 2018 (Mulhall et al., J Urol 2018;200:423; reviewed and validity confirmed 2024). Source: https://www.ebi.ac.uk/europepmc/webservices/rest/search?query=EXT_ID:29601923&resultType=core&format=json ; https://www.auanet.org/guidelines-and-quality/guidelines/testosterone-deficiency-guideline
- Slide 11: total testosterone <300 ng/dL as the cut-off (statement 1, Moderate B); two separate early-morning measurements (statement 2, Strong A); symptoms and/or signs required (statement 3). Sources: CUA 2019 PDF above; https://www.urologytimes.com/view/testosterone-deficiency-faqs-from-the-aua-guideline
- Slide 11: testosterone is Schedule III — listed in the DEA controlled-substances list, code 4000, Schedule III; statutory definition 21 U.S.C. 802(41) via the Anabolic Steroids Control Acts of 1990/2004. Sources: https://www.deadiversion.usdoj.gov/schedules/orangebook/c_cs_alpha.pdf ("Testosterone (17β-hydroxyandrost-4-en-3-one) 4000 III") ; https://www.federalregister.gov/documents/2009/12/04/E9-28572/classification-of-three-steroids-as-schedule-iii-anabolic-steroids-under-the-controlled-substances
- Slide 11: haematocrit monitoring for polycythaemia (statement 11; follow-up Hb/Hct every 6–12 months, target Hct <54%); PSA in men over 40 before therapy (statement 12). Sources: CUA PDF; https://www.auanet.org/documents/Guidelines/PDF/Table%20Seven%20-%20Follow-up%20Laboratory%20Testing(0).pdf
- Slide 11: cardiac-risk screening — statements 13 and 20 (low T a CV risk factor; counsel that it cannot yet be stated whether therapy raises or lowers CV events). Source: CUA PDF.
- Slide 11: exogenous testosterone suppresses intratesticular testosterone and spermatogenesis; should not be given to men trying to conceive (statement 23, Strong A); SERMs/hCG/aromatase inhibitors as alternatives (statement 27, Conditional C). Sources: CUA PDF; https://tau.amegroups.org/article/view/146924/html
- Slide 12: PE definition ("within 1 minute", distress) matches DSM-5 and ISSM; the 2020 AUA/SMSNA guideline uses "about 2 minutes" for lifelong PE. Source: https://www.auanet.org/guidelines-and-quality/guidelines/disorders-of-ejaculation
- Slide 12: PEDT — five items each scored 0–4 (total 0–20); ≤8 no PE, 9–10 probable, ≥11 PE (Symonds et al., Eur Urol 2007;52:565). Sources: https://pubmed.ncbi.nlm.nih.gov/17568761/ ; https://arkansasurology.com/wp-content/uploads/2021/06/PEDT-FOR-PATIENTS-without-Scale.pdf ; https://www.racgp.org.au/getattachment/d470de01-afd3-4e37-943f-b79c2ff8e386/Premature-ejaculation.aspx
- Slide 13: serotonin inhibits ejaculation; increased sympathetic tone in lifelong PE left as the deck's "there is evidence".
- Slide 14: daily SSRIs, on-demand dapoxetine where available, and topical anaesthetics are first-line (AUA/SMSNA statement 9); none FDA-approved for PE. Source: AUA disorders-of-ejaculation page above.
- Slide 15: delayed ejaculation "as high as 30 percent in aging males" — Lindau et al., NEJM 2007;357:762 (NSHAP): among sexually active men, "inability to climax" 16.2% at 57–64, 22.7% at 65–74, 33.2% at 75–85. Source: https://jhanley.biostat.mcgill.ca/bios601/Surveys/SurveySexualityHealthOlderAdultsUSA.pdf (Table 3; text extracted locally)
- Slide 15: co-occurring conditions and medications (SSRIs, antipsychotics, TCAs) — the deck's list; consistent with AUA/SMSNA statements 22 and 24 (adjust contributing medications; treat testosterone deficiency).
- Slide 16: amantadine 100 mg taken 5–6 hours before intercourse — Balon, J Sex Marital Ther 1996;22:290 (single case, fluoxetine-induced anorgasmia). Source: https://pubmed.ncbi.nlm.nih.gov/9018655
- Slide 16: pseudoephedrine and intranasal oxytocin are reported, evidence anecdotal, "no drug has been approved by FDA for DE". Sources: Abdel-Hamid et al., Transl Androl Urol 2016;5:576 https://tau.amegroups.org/article/view/10477/html ; AUA/SMSNA statement 23 (insufficient evidence for oral pharmacotherapy).
- Slide 17: artery-size hypothesis (Montorsi et al., Am J Cardiol 2005;96:19M); penile arteries ~1–2 mm vs coronaries 3–4 mm. Sources: https://www.ebi.ac.uk/europepmc/webservices/rest/search?query=%22artery%20size%20hypothesis%22%20AND%20AUTH%3A%22Montorsi%20P%22%20AND%20PUB_YEAR%3A2005&resultType=core&format=json ; https://www.techscience.com/CJU/v33n4/68491/html
- Slide 17: ED as an early sign of atherosclerosis; screening of men over 50 with risk factors — deck claim consistent with the Princeton-type consensus guidance (https://uhra.herts.ac.uk/handle/2299/4550).
- Slide 17 (speaker note): higher MI risk in transgender men on testosterone vs cisgender women in some cohorts (BRFSS >4-fold, cross-sectional; Amsterdam cohort SIR 1.9), not in others (Getahun 2018). Sources: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8683701/ ; https://www.endocrine-abstracts.org/ea/0099/ea0099oc3.1

## Could not verify (softened or re-attributed)
- Slide 17: "ED present in 67% of men with a history of MI, 80% with peripheral vascular disease" — no source found for either figure. Nearest published: 64% ED six weeks after a first MI (Wabrek & Burchell, Arch Sex Behav 1980;9:69), 62% in a 2021 post-MI cohort, ">70% among patients with CVD including PAD" (Jackson 2010). Note that Montorsi 2003 reports "67%" as the share of CAD patients with ED whose ED came first — a possible origin of the deck's number. Left standing, prefixed "By the figures the course cites". Sources: https://ter-arkhiv.ru/0040-3660/article/view/29933 ; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8537969/ ; https://amj.journals.ekb.eg/article_91610.html
- Slide 17: "lifetime risk of MI two times" — pooled estimates are 1.46–1.62; softened to "one and a half to two times".
- Slide 4: active phase "12 to 18 months" — not in any guideline; softened to "6 to 18 months".
- Slide 13: "52% vs 21%" — only a secondary abstract quotes the Hobbs numbers (51.9 vs 23.9, orgasmic difficulty); softened to "52 percent ... against about a quarter of controls" with "in one study".
- Slide 12: "50–60% incidence" with hyperthyroidism — replaced with the actual study figures (50% → 15%).
- Slide 12: "more common in younger men" — the literature is inconsistent (lifelong PE declines with age in one reanalysis; an Italian survey found PE rising with age; AUA gives no age figure); attributed to the course. Sources: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11368441/
- Slide 8: "14% new ED after TURP" — plausible but from a small study; attributed to the course (12% in the largest series).

## Beats changed
- None. All 16 subjects checked against the envelope and the task's extra constraints: no text, labels, arrows, numbers or signage (each subject says so); no real-person likeness; the only human figures (slide 9 man in office, slide 14 couple on couch) are fully clothed, composed, with the full-portrait face clause; no nudity, restraints, blood, injury or distress. External genitalia never appear: slide 2 is a sagittal pelvis plate listing bladder, prostate, seminal vesicles, pelvic floor and sacrum only; slide 4 is an abstract histological cross-section "nothing external shown"; slides 8 and 10 are internal glands (prostate/seminal vesicles from behind, testis in section "like a plate of the kidney or the thyroid"). Slide 3's instrument tray (clamp, plastic ring, forceps, gauze) and slide 7's device shelf explicitly exclude syringes and needles. `beats.json` parses, 16 beats, slide numbers 1–16 matching the 16 `##` headings in order.

## For the editor's attention
- The deck's "black box warning" (slide 17) is now mostly historical: on 2025-02-28 the FDA removed the cardiovascular-outcome language from all testosterone boxed warnings after TRAVERSE, and the oral/subcutaneous products' blood-pressure boxed warnings came off in July 2025. Only the secondary-exposure box on gels and topical solution remains, which is what the script now says. If the deck is revised, update that bullet and the "controlled substance" bullet can stay.
- The speaker note that "increased testosterone can increase cardiac risk in patients (both male and female)" is contradicted for hypogonadal men by TRAVERSE (HR 0.96 for MACE), and the trans-men signal is observational, mostly versus cisgender women, and mixed (BRFSS positive, Getahun 2018 null). The script keeps it as the lecturer's note with "some evidence" and the TRAVERSE clause; the editor may prefer to drop it.
- The post-prostatectomy protocol (slide 15 of the deck) pairs daily tadalafil with on-demand sildenafil or vardenafil. The Cialis label says not to combine PDE5 inhibitors, and the 2018 AUA erectile dysfunction guideline (not fetched here; from memory, statement 24) tells clinicians to inform patients that early PDE5-inhibitor "rehabilitation" after radical prostatectomy may not improve unassisted erectile function. The script attributes the regimen to the course and names the label conflict; it does not endorse it.
- The deck's "removal has not been proven to confer a benefit in most environments" (circumcision) is the lecturer's position and is left attributed. The AAP's 2012 policy statement concluded that benefits outweigh risks but are not great enough to recommend routine neonatal circumcision; the course's framing is defensible but is a position, not a consensus.
- "67% of men with MI / 80% with PVD" could not be sourced and stands only as the course's figures. Consider replacing with Wabrek & Burchell's 64% post-MI figure, or with the Montorsi 2003 finding (ED present in 49% of men with angiographic CAD; in two-thirds of those it preceded the heart symptoms, by about three years on average), which is the better-documented teaching point.
- The deck's PE definition ("within 1 minute") follows DSM-5/ISSM; the AUA/SMSNA 2020 guideline uses "about 2 minutes" for lifelong PE. Left as the deck gives it.
- "DE prevalence as high as 30% in aging males" rests on Lindau's "inability to climax" among sexually active men aged 75–85 (33%), a symptom report rather than a DSM diagnosis; clinically bothersome DE is far rarer. The script says "estimates", which is fair.
- Peyronie "up to 10%": guideline ranges run to 20%; the script attributes the 10% to the course.
- Dapoxetine's "1.5 hours" is the initial half-life; the terminal half-life is roughly 19–22 hours. The deck's figure is correct only with that qualifier, which the script now carries.
- The AUA testosterone guideline statements were verified from a CUA 2019 teaching PDF and the Urology Times FAQ because the AUA's own page is behind a login; the numbering used here (1, 2, 3, 11, 12, 13, 20, 23, 27, 30) is as reproduced there.
- `segments.json` in this directory was built from the pre-check script and is now stale; re-run `_segment.py` (and downstream TTS/stitch) before building.