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INTRODUCTION AND OBJECTIVES:Inflatable penile prosthesis (IPP) surgery is an effective, safe and satisfactory treatment option for medication-refractory erectile dysfunction. Postoperative complica...

INTRODUCTION AND OBJECTIVES:Prior to the 1970s, medicine and sexuality were considered separate entities and erectile dysfunction (ED) was thought to be a psychological disease. Throughout the past...

INTRODUCTION AND OBJECTIVES:Penile prosthesis infection is a devastating complication to both patients and surgeons. It is most commonly managed with explantation (82.7%), which results in penile f...

INTRODUCTION AND OBJECTIVES:The epidemiology of genito-urinary foreign bodies (GUFB) has been mainly reported through case reports and small series. The aim of this study is to investigate the epid...

Introduction Constraints on surgical resident training (work-hour mandates, shorter training programs, etc.) and availability of expert surgical educators may limit the acquisition of prosthetic surgical skills. As a result, training courses are being conducted to augment the prosthetic surgery learning experience. Aim To evaluate the impact of a hands-on cadaver-based teaching program on resident procedural knowledge and procedural confidence with placement of a penile prosthesis. Main Outcome Measure Changes in procedural knowledge and self-confidence following a focused training program on penile prosthetics. Methods As part of the 2017 Society of Urologic Prosthetic Surgeons and the Sexual Medicine Society of North America Annual Meeting, 31 urology residents participated in a simulation lab in prosthetic urology. The lab included didactic lectures and a hands-on cadaveric laboratory. Participants completed surveys before and after the course. Wilcoxon Signed Rank tests for matched pairs were used to compare respondents’ pre- and postcourse knowledge (% questions answered correctly) and confidence ratings. Prior implant experience was assessed. Results 31 residents participated in this study. The majority of the participants were 4th- (41.9%) and 5th-year residents (38.7%). Participants showed a significant improvement in procedural knowledge test scores (68.8±13.4 vs 74.2 ± 13.0, P < .05) and self-reported increased median surgical confidence levels (4 vs 3, P value < .001) after completion of the cadaveric course. Subgroup analysis demonstrated that residents with prosthetic surgery experience of Conclusion Simulation training in prosthetic surgery seems to improve surgical confidence and knowledge. Further research is needed to better understand the benefits and limitations of simulation training.

The purpose of this review is to critically analyze and summarize recent studies in the area of penile prosthesis surgery outcomes with a focus on infection prevention in high-risk patients. Reduction of surgical time in complex prosthesis surgery may reduce infection risk. Concomitant implant surgery is not associated with increased infection risk. Certain immunocompromised patients may be more likely to have penile implant infections, but these may not include patients with well-controlled HIV, well-controlled diabetes, or transplant recipients. Substance abuse is correlated with increased risk of infection after penile implant surgery. Careful patient selection and preoperative optimization can reduce infection risk in spinal cord injury patients. In the last 5 years, there have been several important studies investigating the risk of penile prosthesis infection in complex patients, clarifying which patient categories are at increased risk and how that risk can be mitigated.

This is a single-institution retrospective study of closed suction drain outputs in primary three-piece IPP cases performed between 2014 and 2017 by a single surgeon. The aim was to investigate the impact of closed suction drains (CSD) during penile prosthesis placement. One hundred and sixty-nine patients underwent intraoperative placement of a closed suction drain. Drain outputs were measured at 12 and 24 h, and postoperative complications were documented. There were no hematomas or infections observed within the patient cohort. The drain output decreased significantly between the first and subsequent 12 h period. Surgical time was associated with statistically significant increases in CSD output at 12 and 24 h with a near linear relationship between surgical times and CSD at 12 and 24 h. Penile prosthesis placement in patients on aspirin did not affect the CSD output volume. Closed suction drains should be considered in all patients undergoing placement of inflatable penile prosthesis, particularly in those cases with longer operative time.

The purpose of this study is to investigate the relationship between inflatable penile prosthesis (IPP) infection, time of year, climate, temperature and humidity. This is a retrospective IRB-approved analysis of 211 patients at 25 institutions who underwent salvage procedure or device explant between 2001 and 2016. Patient data were compiled after an extensive review of all aspects of their electronic medical records. Climate data were compiled from monthly norms based on location, as well as specific data regarding temperature, dew point, and humidity from dates of surgery. Rigorous statistical analysis was performed. We found that penile prosthesis infections occurred more commonly in June (n = 24) and less frequently during the winter months (n = 39), with the lowest number occurring in March (n = 11). One-hundred thirty-nine infections occurred at average daily temperatures greater than 55 °F, compared to 72 infections at less than 55 °F. The incidence rate ratio for this trend was 1.93, with a p-value of0.001. Humidity results were similar, and fungal infections correlate with daily humidity. Infected implants performed in the fall and summer were over 3 and 2.3 times, respectively, more likely to grow Gram-positive bacteria compared to implants performed in spring (p = 0.004; p = 0.039). This was consistent across geographic location, including in the Southern hemisphere. We found trends between climate factors and IPP infection like those seen and proven in other surgical literature. To our knowledge these data represent the first exploration of the relationship between temperature and infection in prosthetic urology.

Introduction Since the introduction of inflatable penile prostheses (IPPs), risk of infection has decreased. However, concurrent substance abuse has not been investigated in prosthetic urology. Aims To determine whether substance abuse would stand out as a relevant risk factor for infection in patients undergoing IPP implantation. Methods This retrospective study was conducted on charts from the past 12 years at our institution, where a single surgeon completed 602 primary IPP surgeries, with only 12 cases (2%) resulting in postoperative infection. Five of these patients (42%) were actively misusing at least one substance at the time of operation (ie, alcohol, marijuana, cocaine, heroin, other illicit substances, and prescription narcotics). Substance abuse was identified in the medical chart by International Classification of Diseases, Ninth Revision code or by clear documentation by a provider. Multivariate logistic regression analysis was used to estimate the probability of infection as a function of demographic, physical, and treatment variables. Main Outcome Measures Logistic regression analysis was used to determine statistically significant correlations between risk factors and IPP infection. Results Polysubstance abuse, poorly controlled blood sugar, and homelessness at the time of procedure positively correlated with postoperative infection. Use of the mummy wrap correlated with decreased infection. Conclusion Active polysubstance abuse, poor glycemic control, and homelessness increase infection risk at IPP implantation. We encourage other implanters to discuss active polysubstance abuse with their patients and to tread cautiously because of the increased risk of infection.

INTRODUCTION AND OBJECTIVE:Penile prostheses (PP) that are dipped in antimicrobial solutions can be specially selected by the implanter and tailored towards the patient. The best choice for antimic...

Background Ectopic placement of penile prosthesis reservoirs has become more common in patients whose space of Retzius has been compromised. Aim To describe techniques and instruments used to place penile prosthesis reservoirs ectopically. Methods We present our method of placing ectopic reservoirs and review the literature for other techniques. We also catalog the instruments used for this purpose. Outcomes Similar to traditional reservoir placement, successful ectopic reservoir implantation requires good cosmetic and functional success and low complication rates. Results Ectopic reservoir placement has been shown to be effective, to safely avoid bowel, bladder, and vascular injury, and to maintain excellent function and cosmesis. Multiple tools for ectopic placement have been described, but no data exist comparing their effectiveness and complications. Examples include dissection of the space anterior to the transversalis muscle using the surgeon's finger, a pediatric Yankauer suction tip, or a Foerster lung clamp. Instruments described to grasp and advance the reservoir include a sponge stick, a Foerster lung clamp, and the ectopic reservoir insertion tool (Sontec, Centennial, CO, USA). The effect of different instruments on the integrity of reservoir has not been extensively studied. Clinical Implications Attention to technique and the instruments used to dissect the ectopic space and grasp the reservoir are crucial to successful ectopic reservoir placement. Strengths and Limitations Reports of vascular, bowel, or bladder injuries during ectopic placement are exceedingly rare, as are reports of injury to reservoirs caused by traumatic grasping. However, no methods or tools have been compared in head-to-head trials. Conclusion Ectopic placement is safe and effective, but differences between methods and instruments have not been delineated.

Background Infra-pubic placement of an inflatable penile prosthesis (IPP) has a well-known configuration deformity from contralateral tubing that crosses the corporal bodies, resulting in tubing visibility and irritation under the penile skin. Aim To present a novel step to eliminate this tubing crossover deformity. Methods The V-neck technique was applied to five patients, two of whom underwent suprapubic fat pad excision with simultaneous infra-pubic IPP placement and three patients who underwent only infra-pubic IPP placement. The technique added an additional 1 minute of procedure time. The reservoir was placed on one (ipsilateral) side into the space of Retzius. Outcomes Primary outcome measurements were esthetic appeal at follow-up, immediate postoperative complications, and difficulty of implementation of the technique. Results The technique included the following steps. (i) The standard infra-pubic approach, as popularized by Perito (J Sex Med 2008;5:27–30), was used to place the reservoir and cylinders. The ipsilateral and contralateral cylinders and the reservoir were clamped and unconnected. (ii) Finger dissection was used to create a sub-phallic window and a U-shaped aortic clamp was used to pass the contralateral tubing. (iii) After passing the green tubing through the window, all connections were performed in the usual fashion. Tubing crossover was eliminated, as was passage of the right and left cylinder tubes down their respective gutters. Postoperative follow-up at 2 weeks showed no visible tubing. Clinical Implications This simple maneuver could help prevent the discomfort of tubing crossover deformity commonly seen after infra-pubic placement of an IPP. Strengths and Limitations This unique maneuver can be applied to all infra-pubically placed IPPs. Limitations include the small patient population and short follow-up. Whether this maneuver will make revision surgery more difficult is unclear. Conclusion This technique is a novel step to infra-pubic IPP placement that adds minimal operative time and could eliminate visible tubing.

Introduction Ischemic priapism is an uncommon urologic emergency characterized by a compartment syndrome-like ischemic insult to the corpora cavernosa of the penis. The goal of treatment in ischemic priapism is rapid detumescence to prevent long-term erectile dysfunction. Non-surgical treatment options include aspiration, irrigation, and intracavernous injections of sympathomimetic agents. At our institution, phenylephrine is used in the treatment of ischemic priapism at concentrations and doses that are higher than those recommended in established guidelines. Aim To characterize our experience with high-concentration intracavernous phenylephrine in the treatment of ischemic priapism at an urban tertiary care center. Methods A retrospective chart review identified 58 unique patients presenting to the emergency department on 136 occasions and receiving the diagnosis of ischemic priapism by urologic physicians. Patients' charts were reviewed to record the dosing of phenylephrine and the outcomes and circumstances of the presentation. Main Outcome Measures Success rates of different treatment strategies for different circumstances of presentation. Results Successful detumescence was achieved with non-surgical management in 86% of unique patients and the overall resolution rate when including repeat visits was 94%. All patients presenting within less than 36 hours of priapism were successfully treated with non-surgical management. There were no reported complications or associated symptoms related to the use of intracavernous phenylephrine during the 5-year period. Conclusion The use of high concentration and dosing of intracavernous phenylephrine demonstrates a high success rate in the treatment of ischemic priapism. Future prospective studies are needed to further characterize appropriate phenylephrine dosing for its efficacy and safety.

Introduction A single‐armed, prospective, multicenter international study evaluated the redesigned Coloplast Titan One Touch Release (OTR) pump inflatable penile prosthesis. The OTR pump has a unique release valve that permits deflation of the implant with one squeeze of opposing touch pads. Aims To assess the impact of a new penile prosthesis design, the Titan OTR, on patient ease of operation. Furthermore, to assess patient satisfaction, surgeon acceptance, and the ease with which patients were trained in device operation in the clinic setting. Methods A total of 113 eligible patients from eight centers were recruited from men presenting with erectile dysfunction without prior prosthetic implantation. The subjects had a mean age of 61 years, and had a number of comorbidities, including diabetes (31.9%), hypertension (34.5%), and Peyronie's disease (23.9%). All underwent implantation of the study device. Main Outcome Measures Questionnaires were used to capture patient satisfaction as well as physician feedback on ease of implantation and patient education. A paired analysis was completed for patient satisfaction at 6 (N = 96) and 12 (N = 90) months. Results Overall satisfaction with the device was 90.6% and 90.0% at 6 and 12 months, respectively. The primary end point, ease of deflation, was seen in 70.8% and 73.3% at these two time points, with the 12‐month value statistically better than historical controls. Physicians overwhelmingly reported straightforward/simple intraoperative product preparation (97.3%) and equivalent or easier training compared with their previous pump of choice (96.4%). Adverse events for all subjects (N = 113) included removal of the device in four cases (3.5%) for infection and one case for chronic pain (0.8%). Conclusions The Titan OTR represents an advance in penile prosthetic technology that is well accepted by patients and physicians. The study design allowed for realistic evaluation of the new technology aimed at enhancing clinical outcomes. Ohl DA, Brock G, Ralph D, Bogache W, Jones L, Munarriz R, Levine L, and Ritenour C. Prospective evaluation of patient satisfaction, and surgeon and patient trainer assessment of the Coloplast Titan One Touch Release three‐piece inflatable penile prosthesis. J Sex Med 2012;9:2467–2474.

Pharmacotherapy is the usual initial therapy for most men with erectile dysfunction.To review the current data relating to the efficacy, tolerability and safety of drugs used in the treatment of men with erectile dysfunction.A critical review of the literature relating to the use of pharmacotherapeutic agents was undertaken by a committee of eight experts from five countries, building on prior reviews.Expert opinion and recommendations were based on grading of evidence-based literature, internal committee dialogue, open presentation, and debate.Almost all currently available evidence relates to sildenafil, tadalafil, and vardenafil. Phosphodiesterase type 5 (PDE5) inhibitors are first-line therapy for most men with erectile dysfunction who do not have a specific contraindication to their use. There is no evidence of significant differences in efficacy, safety, and tolerability between the PDE5 inhibitors and apomorphine. Intracavernosal injection therapy with alprostadil should be offered to patients as second line therapy for erectile dysfunction. Intraurethral alprostadil is a less effective treatment than intracavernosal alprostadil for the treatment of men with erectile dysfunction.PDE5 inhibitors are effective, safe, and well-tolerated therapies for the treatment of men with erectile dysfunction. Apomorphine, intracavernosal injection therapy with alprostadil, and intraurethral alprostadil are all effective and well-tolerated treatments for men with erectile dysfunction. We recommend some standardization of the assessment of psychosocial outcomes within clinical trials in the field of erectile dysfunction.

Penile pain is one of the most distressing, limiting, and difficult to treat manifestations of Peyronie disease. The use of steroid injections for penile deformities associated with Peyronie disease has been ineffective. However, use of steroid injections in managing penile pain has been poorly investigated. The aim of this study was to examine the efficacy and safety of subcutaneous, nonintralesional steroid injections in patients with severe, disabling, and/or chronic penile pain associated with Peyronie disease. This was a single-institution retrospective study of 16 patients with severe, disabling, and/or chronic penile pain associated with Peyronie disease who underwent subcutaneous, nonintralesional injection of triamcinolone (50 mg) between 2004 and 2006. Preinjection and postinjection analog pain scales were used to assess treatment efficacy. All 16 patients (mean age, 47.6 ± 11.1 years) had penile pain associated with erections for an average of 13.9 months (range, 3-36 months) prior to injections. Mean preinjection and postinjection penile pain scores were 6.6 ± 2.1 and 0.5 ± 0.5, respectively. On average, patients were pain free at follow-up visits within 10.6 ± 7.6 weeks. The mean pain-free duration was 23.8 months (range, 3-52 months). The mean cumulative dose of triamcinolone was 75.0 mg (range, 50-200 mg), with a mean of 1.5 injections (range, 1-4 injections). All 16 patients had overall improvement in pain scores. There were no adverse events or geometric penile changes after injections. Subcutaneous, nonintralesional injections of triamcinolone is an effective, safe, and durable means of managing severe, disabling, and/or chronic penile pain in patients with Peyronie disease. Future studies are needed to validate these findings.

OBJECTIVE To report the experience of three highly specialized centres in the vascular evaluation of erectile dysfunction (ED) in teenagers, as there is little information on this topic, and although clinical guidelines support the use of vascular studies in selected cases, our experience is that vascular evaluation aimed at diagnosing organic ED is uncommon in teenagers, and most are designated as having psychogenic ED. PATIENTS AND METHODS In a retrospective multi-institutional analysis of three ED databases (1998–2003) we assessed males aged ≤19 years presenting with ED. The review of these databases focused on demographic characteristics, risk factors for ED, erectile function, results of vascular evaluation, and the causes of ED. RESULTS In all, 40 males aged 14–19 years were identified. The mean (range) duration of ED at presentation was 22.6 (4–84) months. The major risk factors for ED were antecedent perineal trauma (37%) and penile trauma or surgery (15%). The mean (sd) International Index of Erectile Function ‘erectile function’ domain score was 15 (4). Information obtained by history taking was not predictive of the cause of ED. Vascular studies were performed in 62% of the patients and 48% of these patients were found to have an underlying vascular pathology; 42% of the latter group were found to be possible candidates for surgical intervention and another 16% needed further angiographic evaluation. CONCLUSION ED in teenagers should not be routinely categorized as psychogenic without an adequate vascular evaluation, as a significant percentage have abnormal erectile haemodynamics consistent with vasculogenic ED.

Introduction Is cavernosometry a useful tool in treating men with erectile dysfunction? Methods Five people with expertise and/or interest in the area of cavernosometry were asked to contribute their opinions. Main Outcome Measure To provide food for thought, discussion, and possible further research in a poorly discussed area of sexual medicine. Results While one urologist feels dynamic infusion cavernosography and cavernosometry seem to have found their place in history, another believes it is time to separate these tests and look at cavernosometry alone and its relevance to the use of duplex Doppler ultrasound, both useful tools in assessing surgical candidates. Three clinicians agree that cavernosography and cavernosometry have a role in specific cases, particularly before revascularization surgery. Conclusion Cavernosometry may not be a useful tool for the average clinician treating erectile dysfunction, but serves a purpose for the specialist. Vardi Y, Glina S, Mulhall JP, Menchini F, and Munarriz R. Cavernosometry: Is it a dinosaur?

Since its introduction in 1996 Mulcahy salvage has significantly improved outcomes for the removal and replacement of infected inflatable penile prostheses. Long-term followup data of Mulcahy salvage show an infection-free rate of 82%. A multicenter retrospective analysis of the malleable implant salvage technique was conducted to assess infection outcomes and the feasibility of conversion from malleable device back to inflatable penile prosthesis.This is a retrospective, institutional review board exempt, multi-institution study of 58 patients who underwent Mulcahy salvage with inflatable penile prosthesis removal and replacement with malleable prosthesis. Patient operative notes and charts were extensively reviewed to compile study data.Between 2002 and 2014 a total of 58 patients underwent infected inflatable penile prosthesis removal and replacement with a malleable prosthesis via Mulcahy salvage. Of these patients 54 (93%) have remained infection-free postoperatively. Average patient age was 56.4 years and average operative time was 148 minutes. Postoperative followup (as of May 2015) ranged from 1 month to 84 months. Of the 54 patients 37 retained the malleable prosthesis and 17 (31%) subsequently underwent replacement with an inflatable penile prosthesis. This occurred on average 6.7 months after Mulcahy salvage. Four patients had persistent infection after Mulcahy salvage with the malleable prosthesis and underwent explantation.This retrospective analysis of Mulcahy salvage procedure and replacement of inflatable penile prosthesis with malleable prosthesis shows a high infection-free rate. Additionally, 17 of the 54 patients who remained infection-free were able to successfully undergo subsequent removal of the malleable prosthesis and replacement with an inflatable penile prosthesis. Further prospective studies are needed to compare salvage with malleable vs inflatable penile prosthesis.

Introduction The treatment of sexual dysfunction in patients with prior sexual offenses poses ethical and legal dilemmas. Sex offenders are not obligated by law to disclose this history to medical professionals. Over 20% of sex offenders experience sexual dysfunction; however, the number of sex offenders seeking evaluation for sexual dysfunction is unknown. Aims The aims of this study were to determine the incidence and characteristics of sex offenders seeking treatment in our clinic; and to review data regarding sex offender recidivism and ethics pertaining to the issue as it relates to treating physicians. Methods Sex offenders were identified via three methods: new patient screening in a dedicated sexual medicine clinic, chart review of those on intracavernosal injection (ICI) therapy for erectile dysfunction (ED), and review of patient's status-post placement of penile prosthesis. Charts were cross-referenced with the U.S. Department of Justice National Sex Offender Public Website. Patient characteristics and details of offenses were collected. Main Outcome Measures The main outcome measures used were a self-reported sexual offense and national registry data. Results Eighteen male sex offenders were identified: 13 via new patient screening; 3 by review of ICI patients; 1 by review of penile prosthesis data; and 1 prior to penile prosthesis placement. All were primarily referred for ED. Of those with known offenses, 64% were level 3 offenders (most likely to re-offend). The same number had committed crimes against children. All those with complete data had multiple counts of misconduct (average 3.6). Ninety-four percent (17/18) had publicly funded health care. Twelve (67%) were previously treated for sexual dysfunction. Conclusions Registered sex offenders are seeking and receiving treatment for sexual dysfunction. It is unknown whether treatment of sexual dysfunction increases the risk of recidivism of sexual offenses. Physicians currently face a difficult choice in deciding whether to treat sexual dysfunction in sex offenders.

Penile fracture is an uncommon urologic emergency, defined as traumatic rupture of the tunica albuginea of the corpus cavernosum. It occurs mainly in young adults during sexual activity. In the United States, urethral injury is associated with 10-38% of all penile fractures. Diagnosis can be made clinically with the classic triad of an audible crack, detumescence, and appearance of hematoma. We sought to identify characteristics associated with true penile fracture vs. other diagnoses, and determine associated morbidity and risk factors for complications. Retrospective operative chart review identified 39 patients (mean age 39.4 years) with clinical features of penile fracture presenting to Boston Medical Center from June 2004 to May 2013. Average time from injury to presentation was 76 h (range 0.5 h-9 days) and the mechanism of injury was coital in 32 (82%) patients. Thirty-two patients (82%) had confirmed penile fracture, 7 (18%) had isolated vascular injury. Of confirmed fractures, 4 (13%) had bilateral corporal injury and associated urethral injury. Imaging was utilized in a total of 21 cases, penoscrotal ultrasound (US) in 17 cases, retrograde urethrogram (RUG) in 3 cases, and magnetic resonance imaging (MRI) in 1 case. Penile exploration was carried out via degloving (n = 5, 13%) or penoscrotal (n = 34, 87%) incisions. At follow-up, six patients (15%) had complications: 2 wound infections, 2 new-onset erectile dysfunction (ED), 1 urethral stricture, 1 fistula and 1 wound dehiscence. Urethral injury increased the risk of post-operative complications (p = 0.015). Penile fracture is primarily a clinical diagnosis, however imaging may be helpful if diagnosis is uncertain. Urethral injury should be suspected in cases of bilateral corporal injury and may be associated with increased morbidity. Surgical approach does not affect morbidity, but may facilitate surgical repair.

Introduction Oral contraceptives (OCs) have been the preferred method of birth control because of their high rate of effectiveness. OC use, however, has been associated with women's sexual health complaints and androgen insufficiency. OC use is associated with a decrease of androgen ovarian synthesis and an increase in the production of sex hormone‐binding globulin (SHBG). There have been limited studies assessing SHBG values after discontinuation of OC use. Aim To retrospectively investigate SHBG levels before and after discontinuation of OC use. Main Outcome Measure Sex hormone‐binding globulin values were compared at baseline, while on the OC, and well beyond the 7‐day half‐life of SHBG at 49–120 (mean 80) days and >120 (mean 196) days after discontinuation of OCs. Methods A total of 124 premenopausal women with sexual health complaints for >6 months met inclusion/exclusion criteria. Three groups of women were defined: (i) “Continued‐Users” (N = 62; mean age 32 years) had been on OCs for >6 months and continued taking them; (ii) “Discontinued‐Users” (N = 39; mean age 33 years) had been on OCs for >6 months and discontinued them; and (iii) “Never‐Users” (N = 23; mean age 36 years) had never taken OCs. Results Sex hormone‐binding globulin values in the “Continued‐Users” were four times higher than those in the “Never‐User” group (mean 157 ± 13 nmol/L vs. 41 ± 4 nmol/L; P 120 days). Conclusion In women with sexual dysfunction, SHBG changes in “Discontinued‐Users” did not decrease to values consistent with “Never‐Users.” Long‐term sexual, metabolic, and mental health consequences might result as a consequence of chronic SHBG elevation. Does prolonged exposure to the synthetic estrogens of OCs induce gene imprinting and increased gene expression of SHBG in the liver in some women? Prospective research is needed. Panzer C, Wise S, Fantini G, Kang D, Munarriz R, Guay A, and Goldstein I. Impact of oral contraceptives on sex hormone‐binding globulin and androgen levels: a retrospective study in women with sexual dysfunction. J Sex Med 2006;3:104–113.

Introduction From 1999 to 2004, there had been 21 publications from multiple medical specialties (sexual medicine, urology, neurology, cardiology, biomedical engineering, sports medicine, emergency medicine, and officials from the National Institute for Safety and Occupational Health) investigating the relationship between bicycle riding and erectile dysfunction (ED). In the previous 18 years, there have been 14 such studies. Aim The primary aim was to summarize accumulating data on the safety of bicycle riding based on medical evidence categorized by levels of evidence, including case reports, observational studies, case control studies, mechanistic studies, and population‐based epidemiologic investigations. The secondary aim was to address the concerns of bicyclists and propose measures to minimize the risk of ED associated with bicycle riding. Methods An English‐language medical literature review was made of publications in peer review journals from 1981 to 2004, including published abstract presentations at major medical meetings. Main Outcome Measure Ranked published epidemiologic data on bicycle riding and ED. Results Bicycle riding more than 3 hours per week was an independent relative risk (RR = 1.72) for moderate to severe ED. In case control studies, the prevalence of moderate to severe ED in bicyclists was 4.2% and 4% vs. age‐matched runners 1.1% ( P ≤ 0.018) and swimmers 2% ( P = 0.05), respectively. Therefore, bicycle riders should take precautionary measures to minimize the risk of ED associated with bicycle riding: change the bicycle saddle with a protruding nose to a noseless seat, change the posture to a more upright/reclining position, change the material of the saddle (GEL), and tilt the saddle/seat downwards. Conclusions. The mechanism is hypothetically related to the rider interaction with the bicycle saddle at the perineum–saddle interface. Straddling bicycle saddles with a nose extension is associated with suprasystolic perineal compression pressures, temporarily occluding penile perfusion and potentially inducing endothelial injury and vasculogenic ED. Huang V, Munarriz R, and Goldstein I. Bicycle riding and erectile dysfunction: An increase in interest (and concern). J Sex Med 2005;2:596–604.

Purpose To investigate the differential impact of straddles (A ns and B ns ) and noseless two‐cheek seats (A ntcs and B ntcs ) on penile hemodynamics and perineal compressive forces in subjects who cycle in a stationary bicycle. Materials and Methods Subjects underwent cavernosal artery peak systolic velocity (CAPSV) measurements after intracavernosal injection of vasoactive agents while supine, sitting upright on an examination table, straddling a saddle, sitting on a seat, and again supine. Mean perineal compression pressures recorded while straddling the saddles were compared with those while sitting upright. Results No differences were found in right and left CAPSV values while supine, sitting upright on an examination table, sitting on a seat, and supine again. Right/left CAPSV (cm/second) values straddling A ns and saddle B ns (0.7 ± 2.9/1.5 ± 6.2 and 0/0, respectively) were significantly lower than values obtained while sitting on A ntcs and B ntcs (25.6 ± 13.4/23.8 ± 12.0 and 17.3 ± 6.4/18.3 ± 6.5, respectively) ( P ns and saddle B ns (315.2 ± 39 and 387.9 ± 64.3, respectively) were significantly higher than values obtained while sitting upright on an examination table (47.6 ± 5.2 and 46.0 ± 8.1, respectively) ( P Conclusions e have identified an objective test to assess if an individual bicycle rider, sitting on a certain shape of bicycle saddle or seat generates sufficient compressive forces at the perineal–saddle interface to obstruct cavernosal arterial inflow. This study also demonstrated that straddling bicycle saddles with nose extensions is associated with perineum–saddle interface compressive pressures that exceed systolic perfusion pressures, significantly diminishing penile hemodynamics. Munarriz R, Huang V, Uberoi J, Maitland S, Payton T, and Goldstein I. Only the nose knows: Penile hemodynamic study of the perineum–saddle interface in men with erectile dysfunction utilizing bicycle saddles and seats with and without nose extensions. J Sex Med 2005;2:612–619.