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Background “Prospective Registry of Outcomes with Penile Prosthesis for Erectile Restoration” (PROPPER) is a large, multi-institutional, prospective clinical study to collect, analyze, and report real-world outcomes for men implanted with penile prosthetic devices. We prospectively correlated co-morbid conditions and demographic data with implanted penile prosthesis size to enable clinicians to better predict implanted penis size following penile implantation. We present many new data points for the first time in the literature and postulate that radical prostatectomy (RP) is negatively correlated with penile corporal length. Methods Patient demographics, medical history, baseline characteristics and surgical details were compiled prospectively. Pearson correlation coefficient was generated for the correlation between demographic, etiology of ED, duration of ED, co-morbid conditions, pre-operative penile length (flaccid and stretched) and length of implanted penile prosthesis. Multivariate analysis was performed to define predictors of implanted prosthesis length. Results From June 2011 to June 2017, 1,135 men underwent primary implantation of penile prosthesis at a total of 11 study sites. Malleable (Spectra), 2-piece Ambicor, and 3-piece AMS 700 CX/LGX were included in the analysis. The most common patient comorbidities were CV disease (26.1%), DM (11.1%), and PD (12.4%). Primary etiology of ED: RP (27.4%), DM (20.3%), CVD (18.0%), PD (10.3%), and Priapism (1.4%), others (22.6%). Mean duration of ED is 6.2¡À4.1 years. Implant length was weakly negatively correlated with White/Caucasian (r=−0.18; P

Introduction Penile prosthesis implantation has emerged as a definitive treatment to restore sexual function to the motivated man with erectile dysfunction. Substantial improvements in the design of inflatable devices have been made since they first became available more than four decades ago. Aim To review the history of the penile prosthesis, the indications, preoperative evaluation, and patient and partner satisfaction. The current approaches to addressing intra- and postoperative complications, provide an understanding of prosthesis infection, and placement of these devices will be reviewed. Methods A committee of worldwide experts in this field was assembled during the 2015 International Consultation on Sexual Medicine (ICSM) and performed a systematic review of the peer-reviewed published medical literature pertaining to penile prosthesis. Particular attention was given to higher level trials when available. Recommendations are based upon the Oxford Criteria. Main Outcome Measures Unfortunately there is limited level 1 and 2 evidence, and where expert opinion was utilized, the decision was unanimous within the committee with a goal of presenting a clinically relevant guideline pertaining to penile prostheses. Results Penile prosthesis has undergone an evolution over the past 40 years resulting in a more effective and reliable treatment for advanced erectile dysfunction not responding to less invasive methods including oral treatment with PDE5 inhibitors, vacuum erection device, and intracorporal injection therapy. It should be considered an appropriate treatment option for the man who wishes to restore erectile function and who understands the potential risk of mechanical failure and infection, both of which are less common now as a result of improvements made in device design as well as surgical protocols adhered to in the operating room. Patients must be clearly informed of the risks associated with penile prosthesis including mechanical failure, infection, shortening of the penis, change in sensation and configuration of the penis, as well as injury to local structures. Intraoperative complications are unusual but do occur and can usually be addressed intraoperatively to allow placement of the device at the time of initial surgery. Postoperative complications may also be addressed when they occur but may require more advanced reconstructive surgical techniques. Men with Peyronie's disease, corporal fibrosis due to infection, trauma, prior prosthesis explantation, priapism, and men who have undergone construction of a neophallus may require additional advanced maneuvers to obtain optimum results with a penile prosthesis. Conclusion Penile prosthesis remains as an important, viable, and effective treatment for male erectile dysfunction that does not respond to other less invasive approaches or when these approaches are contraindicated or not acceptable to the patient. These devices provide the patient with the ability to engage in penetrative sexual activity without interfering with urination, ejaculation, sensation, or orgasm. Although mechanical failure can occur, the current devices are more reliable as a result of design modifications. Infection remains the most dreaded complication but since the introduction of antibiotic and hydrophilic coatings, infection is less common. Overall, patient and partner satisfaction appear to be reasonably high when a penile prosthesis is used to restore erectile function.

Peyronie’s disease (PD) is a highly prevalent condition that affects the physical and psychosocial well-being and quality of life (QoL) for thousands of Canadian men. The specific etiology of PD remains poorly understood and there remains a paucity of randomized placebo-controlled trials evaluating treatment interventions.1-3 PD can be found in up to 8.9% of men, a remarkable increase in cited prevalence that is attributable to growing awareness (as historical data suggested a rate of less than 1%); the burden of disease is significant, and PD is often present in otherwise healthy men. The following guidelines were crafted by the committee with a full awareness of the limitations of the literature, and sought to provide actionable recommendations to guide PD care in the Canadian health system.

To date, the published data on patients treated with penile implantation generally consist of small series of single surgeon, retrospective experiences rather than prospective or large, multicenter evaluations. This study establishes a baseline of data collection from the PROPPER (Prospective Registry of Outcomes with Penile Prosthesis for Erectile Restoration). The PROPPER is the first large, prospective, multicenter, multinational, monitored, and internal review board approved study of real-world outcomes for patients with penile implants.Data from the PROPPER study were examined to determine patient baseline characteristics and primary and secondary etiologies before treatment of erectile dysfunction. Data include type and size of implant received, surgical steps/techniques used during implantation, and duration of hospital stay.Through April 2, 2015 a total of 1,019 patients were enrolled in the study at 11 sites, with radical prostatectomy being the predominant etiology in 285 (28%). Of those 285 patients treated with radical prostatectomy 280 (98.2%) received an AMS 700™. Of these patients 65.0% (182 of 280) had placement of the reservoir in the traditional retropubic space vs 31.8% (89 of 280) in a submuscular location. Of those patients not treated with radical prostatectomy receiving an AMS 700, fewer underwent reservoir placement in the submuscular location (17.7%, 124 of 702, vs 80.9%, 568 of 702; p0.001). Of those patients receiving an AMS 700, those treated with radical prostatectomy and those with diabetes had more outpatient admissions (less than 24 hours, 56.8% and 52.1%, respectively) compared to those with cardiovascular disease and Peyronie's disease (42.0% and 35.6%, respectively, p0.001).This first-of-its-kind, large, prospective, multicenter study reveals most penile implant cases in North America receive an inflatable penile prosthesis and that radical prostatectomy is the most common primary etiology of penile implant surgery. Moreover, patients treated with radical prostatectomy were more likely to have the reservoir placed in a submuscular location, have a longer operating room time and be admitted to the hospital overnight compared with other patient groups.

Introduction Although clinical evidence supports an association between cardiovascular/metabolic diseases (CVMD) and erectile dysfunction (ED), scientific evidence for this link is incompletely elucidated. Aim This study aims to provide scientific evidence for the link between CVMD and ED. Methods In this White Paper, the Basic Science Committee of the Sexual Medicine Society of North America assessed the current literature on basic scientific support for a mechanistic link between ED and CVMD, and deficiencies in this regard with a critical assessment of current preclinical models of disease. Results A link exists between ED and CVMD on several grounds: the endothelium (endothelium-derived nitric oxide and oxidative stress imbalance); smooth muscle (SM) (SM abundance and altered molecular regulation of SM contractility); autonomic innervation (autonomic neuropathy and decreased neuronal-derived nitric oxide); hormones (impaired testosterone release and actions); and metabolics (hyperlipidemia, advanced glycation end product formation). Conclusion Basic science evidence supports the link between ED and CVMD. The Committee also highlighted gaps in knowledge and provided recommendations for guiding further scientific study defining this risk relationship. This endeavor serves to develop novel strategic directions for therapeutic interventions.

Introduction Erectile dysfunction is a major complication of radical prostatectomy, commonly associated with penile neuropathy. In animal models of peripheral nerve injury, glial growth factor-2 (GGF2), a member of the neuregulin family of growth factors, has neuroprotective and neurorestorative properties, but this potential has not been established after cavernous nerve (CN) injury. Aims The effectiveness of GGF2 in preserving axonal integrity and recovering erectile function in a rat model of radical prostatectomy-associated CN injury. Methods Adult male Sprague-Dawley rats underwent bilateral CN crush injury (BCNI) or sham surgery. Rats were administered GGF2 (0.5, 5, or 15 mg/kg) or vehicle subcutaneously 24 hour pre and 24-hour post-BCNI, and once weekly for 5 weeks. Erectile function was assessed in response to electrical stimulation of the CN. CN survival was assessed by fluorogold retrograde axonal tracing in major pelvic ganglia (MPG). Unmyelinated axons in the CNs were quantitated by electron microscopy. Main Outcome Measures Erectile function recovery, CN survival, and unmyelinated CN axon preservation in response to GGF2 treatment following BCNI. Results Erectile function was decreased (P < 0.05) after BCNI, and it was improved (P < 0.05) by all doses of GGF2. The number of fluorogold-labeled cells in the MPG was reduced (P < 0.05) by BCNI and was increased (P < 0.05) by GGF2 (0.5 and 5 mg/kg). The percentage of denervated Schwann cells in the BCNI group was higher (P < 0.05) than that in the sham-treated group and was decreased (P < 0.05) in the GGF2-treated (5 mg/kg) BCNI group. In the BCNI + GGF2 (5 mg/kg) group, the unmyelinated fiber histogram demonstrated a rightward shift, indicating an increased number of unmyelinated axons per Schwann cell compared with the BCNI group. Conclusions GGF2 promotes erectile function recovery following CN injury in conjunction with preserving unmyelinated CN fibers. Our findings suggest the clinical opportunity to develop GGF2 as a neuroprotective therapy for radical prostatectomy.

Alternative reservoir site placement has become an accepted technique for patients who require an inflatable penile prosthesis. To our knowledge there has been no prospective evaluation of this technique, which is currently off label. We performed a prospective, multicenter, multinational, internal review board approved study to evaluate the effectiveness and safety of alternative reservoir site placement.PROPPER initiated in June 2011, is a database containing patient outcomes of inflatable penile prosthesis implantation. Patients with AMS® penile prostheses continue to be enrolled at 13 North American sites. We examined PROPPER study data to determine surgical implantation use patterns for the AMS 700™ series. We evaluated reservoir implantation site and complications by implantation site.A total of 759 patients had been implanted with an AMS 700 series implant by the time of evaluation. Mean patient followup was 17.8 months (range 0 to 36). There was no reported case of revision surgery for a palpable reservoir and no report of vascular or hollow viscous injury associated with alternative reservoir site placement. Two cases of reservoir herniation in the alternative reservoir site placement group and 2 in the space of Retzius group were treated with reservoir reimplantation. Patients with 1-year assessment available were satisfied or very satisfied with the device and reported a frequency of use of more than once per month.Alternative reservoir placement in the submuscular location is an option in patients who undergo inflatable penile prosthesis surgery. Implant surgeons should consider alternative reservoir site placement a safe, effective alternative to reservoir placement in the space of Retzius.

Background The molecular mechanisms responsible for the survival and preservation of function for adult parasympathetic ganglion neurons following injury remain incompletely understood. However, advances in the neurobiology of growth factors, neural development, and prevention of cell death have led to a surge of clinical interest for protective and regenerative neuromodulatory strategies, as surgical therapies for prostate, bladder, and colorectal cancers often result in neuronal axotomy and debilitating loss of sexual function or continence. In vitro studies have identified neurturin, a glial cell line-derived neurotrophic factor, as a neuromodulator for pelvic cholinergic neurons. We present the first in vivo report of the effects of neurturin upon the recovery of erectile function following bilateral cavernous nerve crush injury in the rat. Methods In these experiments, groups (n = 8 each) consisted of uninjured controls and animals treated with injection of albumin (blinded crush control group), extended release neurotrophin-4 or neurturin to the site of cavernous nerve crush injury (100 μg per animal). After 5 weeks, recovery of erectile function (treatment effect) was assessed by cavernous nerve electrostimulation and peak aortic pressures were measured. Investigators were unblinded to specific treatments after statistical analyses were completed. Results Erectile dysfunction was not observed in the sham group (mean maximal intracavernous pressure [ICP] increase of 117.5 ± 7.3 cmH2O), whereas nerve injury and albumin treatment (control) produced a significant reduction in ICP elevation of 40.0 ± 6.3 cmH2O. Neurturin facilitated the preservation of erectile function, with an ICP increase of 55% at 62.0 ± 9.2 cmH2O (p < 0.05 vs control). Extended release neurotrophin-4 did not significantly enhance recovery of erectile function with an ICP change of 46.9 ± 9.6. Peak aortic blood pressures did not differ between groups. No significant pre- and post-treatment weight differences were observed between control, neurotrophin-4 and neurturin cohorts. All animals tolerated the five-week treatment course. Conclusion Treatment with neurturin at the site of cavernous nerve crush injury facilitates recovery of erectile function. Results support further investigation of neurturin as a neuroprotective and/or neuroregenerative agent facilitating functional recovery after cavernous or other pelvic autonomic nerve injuries.

Introduction There are several contraceptive methods to prevent pregnancy, reversible as well as nonreversible ones. The sexual satisfaction of couples is affected by many types of contraceptives used. Aim The aim of this study was to evaluate prospectively the effect of vasectomy on the sexual life and satisfaction of couples. Methods Seventy‐six couples took part in this evaluation and filled out respective questionnaires before and after vasectomy. All the questionnaires were evaluated statistically for differences in the respective sexual domain scores. Main Outcome Measures Standardized questionnaires were used. The International Index of Erectile Function (IIEF) as well as postoperative pain score were completed by men. Female Sexual Function Index (FSFI) was completed by the female partner. For statistical analysis, the T‐Square Test was used. Results The average age of couples, who chose the vasectomy procedure, was 37 years for women and 39 years for men. The contraception method most frequently used prior to the vasectomy was the birth control pill. For the male partner, the IIEF showed no significant change in the respective domains. Out of the 76 couples, 93% of the males and 96% of their female partners would recommend and do vasectomy again. The postoperative pain score was 3.5 on 0–10 scale, and there were no postoperative complications reported. The best improvement of the sexual function was noticed for the female partners. The FSFI showed a significant improvement in the domains desire ( P P P P P Conclusion This is the first report to our very best knowledge that showed the positive impact of vasectomy on sexual satisfaction of couples. Vasectomy is a safe operation with minimal complication rates. Mohamad Al‐Ali B, Shamloul R, Ramsauer J, Bella AJ, Scrinzi U, Treu T, and Jungwirth A. The effect of vasectomy on the sexual life of couples. J Sex Med 2014;11:2239–2242.

Introduction: There has been a long history of man's fascination with better and stronger sex drive and performance across different cultures. Several literature texts from the Hindu, Egyptian, Chinese and Roman civilizations document the human endless search for substances that can enhance sexual experiences and/or treat erectile dysfunction. Aim: This review will discuss the current research done on the most popular plant aphrodisiacs and provide evidence to support or discourage the use of any of them to enhance sexual desire and/or function in men. Methods: We review the current evidence on the use of natural substances as aphrodisiacs. Results: We found very little evidence to support the use of plant aphrodisiacs in the treatment of male sexual dysfunction. The vast majority of studies were conducted on animals with very few clinical studies. Available data suggest a beneficial effect of ginseng as a pro-sexual supplement and not an independent treatment for male sexual dysfunction. Conclusions: Trans-culturally, many herbal therapies show some potential benefits in improving men's sexual function; however, adequate studies on the specific benefits and health risks associated with their use are needed. We strongly recommend the design and execution of well-controlled clinical studies to determine the efficacy and safety of plant aphrodisiacs. Copyright © 2013 John Wiley & Sons, Ltd.

Objective To issue a consensus document on the prevention, management, and research of infection associated with penile prostheses, as neither professional associations nor governmental entities have issued guidelines that are specific to this infection. Methods Sixteen North American experts on infection of penile prostheses were identified and assembled to select and discuss certain issues related to infection of penile prostheses. After performing an extensive search of clinically important issues in published reports, the 16 experts met twice in person to finalize the selection, discuss the issues that were deemed most important, and issue pertinent recommendations. Results Although many subjects relevant to infection of penile prostheses were initially identified, the experts selected 10 issues as currently being the most important issues and for which there exists some support in the published data. The examined issues involved prevention, management, or research of infections associated with penile prostheses. Conclusion In the absence of pertinent guidelines, the consensus document issued by experts in the field of prosthetic urology is anticipated to improve the quality of patient care, streamline the prevention and management of infected penile prostheses, and stimulate collaborative research. Although this consensus document could serve as best practice recommendations, the lack of adherence to these recommendations would not indicate improper care.

Background Although there is a strong correlation between erectile dysfunction and Peyronie's disease (PD), there are limited data on the efficacy and satisfaction of inflatable penile prosthesis (IPP) placement in this population. Aim To assess the efficacy and overall satisfaction of IPP placement in men with erectile dysfunction and concomitant PD using the Prospective Registry of Outcomes with Penile Prosthesis for Erectile Restoration (PROPPER). Methods Data from the PROPPER study were examined to determine patient baseline characteristics and primary and secondary etiologies before IPP treatment and included type and size of implant received, presence of corporal fibrosis, and operative time. Men completed 5 validated questionnaires at baseline and annually out to 5 years. Outcomes IPP placement was performed in 250 patients with PD with comparable surgical times and outcomes as in patients without PD. Results 1,180 men underwent IPP insertion at 11 sites; of these, 250 (21.2%) were diagnosed with PD. This is an ongoing study; 1- and 2-year data are available for 177 (70.8%) and 130 (52.0%) patients, respectively. Intraoperatively, 51.2% patients with PD had corporal fibrosis, with an average operative time of 52.8 minutes. At baseline, 19.3% of men (36 of 187) with PD reported being depressed, with a decrease to 10.5% (6 of 57; P = .02) and 10.9% (5 of 46; P = .07) at 1- and 2-year follow-ups, respectively. More than 80% of patients with PD were satisfied or very satisfied at 1- and 2-year follow-ups. In addition, more than 88% of patients with PD were using their device at the 1- and 2-year follow-up visits. Clinical Implications Patients with concomitant PD and erectile dysfunction can safely and effectively have an IPP placed with similar outcomes as patients without PD. Strengths and Limitations The 1st limitation was that all participating prosthetic urologists were high-volume implanters and these results might not be representative of those of general urologists. A 2nd limitation was that none of the patients were randomized. A 3rd limitation was that although most study points were mandatory, some of the data collection, including depression data, was optional, with not all sites participating. A 4th limitation was that depression data were self-reported. Conclusion IPP can be inserted in patients with PD with acceptable patient satisfaction and usage and depressive symptoms appear to lessen in patients with PD after IPP placement.

The prognostic significance of capsular incision (CapI) into tumor during radical prostatectomy (RP) with otherwise organ-confined disease remains uncertain.To evaluate the impact of CapI into tumor on oncologic outcome.A retrospective review of 8110 consecutive patients with prostate cancer treated at Ottawa Hospital and at Memorial Sloan-Kettering Cancer Center, both tertiary academic centers, between 1985 and 2008.All patients underwent an open, laparoscopic or robotic RP.Patients were divided into four pathologic categories: group 1 (CapI group), positive surgical margins (PSMs) without extraprostatic extension (EPE); group 2, negative surgical margins (NSMs) without EPE; group 3, NSM with EPE; group 4, PSMs with EPE. Estimates of recurrence-free survival were generated with the Kaplan-Meier method. Recurrence was defined as a prostate-specific antigen (PSA)0.2 ng/ml and rising. Cox proportional hazards regression was used to estimate the hazard ratio (HR) for recurrence controlling for pretreatment PSA, RP date, RP Gleason sum, seminal vesicle invasion, and lymph node involvement. Pathologic categories were defined in the model by including the variables EPE and surgical margins (SMs) as well as their interaction.Median follow-up was 37.3 mo. The 5-yr recurrence-free probability after RP for the CapI group was 77% (95% confidence interval [CI], 72-83). This was not only inferior to patients with NSMs and no EPE (log rank p0.0001) but also to those with NSMs and EPE (log rank p=0.0002). In multivariate analysis the interaction between EPE and SM was not significant (p=0.26). In the adjusted model excluding the interaction term, patients with EPE had an increased risk for recurrence (HR: 1.80; 95% CI, 1.49-2.17; p0.0001) as did those with positive margins (HR: 1.81; 95% CI, 1.51-2.15; p0.0001). This was a retrospective study.CapI into tumor has a significant impact on patient outcome following RP. Patients, who otherwise would have organ-confined disease, will now have a higher probability of recurrence than those with completely resected extraprostatic disease.

Peyronie’s disease (PD) is an acquired inelastic scar of the tunica albuginea of the penis, resulting in penile pain, curvature and other deformities, and sexual dysfunction, as well as significant psychological morbidity and relationship/partner issues. Contemporary data suggest an incidence of one in 20 men, with peak occurrence between ages of 50–55 years. Initial diagnosis of PD is made by thorough medical history and examination of the external genitalia; early referal to an urologist experienced in PD management is recommended. Evidence for nonsurgical treatment options is limited; the most commonly used, vitamin E, has not been shown to have benefit over placebo. Recent double-blinded placebo-controlled evidence suggests a role for oral pentoxifylline as a first-line agent. Intralesional injection therapy with verapamil is a frequently utilized option, as first- or second-line treatment, or in combination with other modalities. IFN-β2b injections into the penile plaque have also shown benefit over placebo in decreasing penile curvature, plaque size, penile pain and plaque density. Penile traction is currently under investigation for a potential role in PD management. The gold standard treatment for clinically significant deformity after PD has stabilized remains surgery. Several surgical options are available, including minimally invasive plication procedures, incision of the plaque and grafting or a penile prosthesis (when concurrent treatment-resistant erectile dysfunction is present).

Introduction Genital morphology (especially male) among the animal kingdom is characterized by extensive differences that even members of closely related species with similar general morphology may have remarkably diverse genitalia. Aim To present the sexual medicine specialist with a basic understanding of the current hypotheses on genital evolution with an emphasis on the sexual selection theories. Methods A review of current literature on the theories of genital evolution. Main Outcome Measures Analysis of the supporting evidence for the sexual selection theories of genital evolution. Results Several theories have been proposed to explain genital evolution. Currently, the sexual selection theories are being considered to present valid and solid evidence explaining genital evolution. However, other theories, including sexual conflict, are still being investigated. All theories of genital evolution have their own weaknesses and strengths. Conclusions Given that many complex biological mechanisms, mostly unknown yet, are involved in the process of genital evolution, it is thus reasonable to conclude that not one theory can independently explain genital evolution. It is likely that these mechanisms may prove to have synergistic rather than exclusive effects. Shamloul R, El-Sakka A, and Bella AJ. Sexual selection and genital evolution: An overview.

OBJECTIVE To investigate the neurotrophic effect of brain-derived neurotrophic factor (BDNF) and vascular endothelial growth factor (VEGF) in cultured major pelvic ganglia (MPG) derived from young and aged rats. MATERIALS AND METHODS The dorsocaudal region of the MPG was isolated from 12 6-month-old male rats and 12 24-month-old male rats. The MPGs were treated with BDNF, VEGF, or both, at 0, 12.5, 25, 50, 100 and 150 ng/mL to determine the effective concentration for 50% activity (EC50) and optimum dosage for promoting neurite growth. Neurite outgrowth from treated MPGs was measured by microscopy. NADPH diaphorase and tyrosine hydroxylase (TH) staining was used to characterize neurites. RESULTS Both BDNF and VEGF promoted neurite sprouting from MPG. Neurite growth was more robust in MPGs derived from young rats (6 months) than from aged rats (24 months). The EC50 for BDNF, VEGF and combined treatment were 10.6, 11.9 and 52 ng/mL in young rats, and 11.3, 12 and 0.75 ng/mL in old rats, respectively. The optimum dosage of both factors for promoting MPG neurite growth in all groups was 25–50 ng/mL. VEGF appeared to favour NADPH diaphorase-positive neurites, whereas BDNF favoured TH-positive neurites. CONCLUSION BDNF and VEGF promote neurite growth from cultured MPG; combined treatment produced the most robust neurite outgrowth. Neurite growth from MPGs derived from aged rats was not as robust as it was from MPGs from younger rats. Further studies on the effect of neurotrophins after cavernous nerve injury are warranted.

Conservative management of prolonged ischemic priapism is rarely effective. Interventions include corporal aspiration/irrigation, injection of vasoconstrictive agents or surgical procedures. We describe a technique that fulfills several important criteria in the surgical management of ischemic priapism in that immediate resolution of ischemic pain is achieved, a wide area, reliably patent shunt is created, the procedure is technically simple and it may be performed with the patient under a local anesthetic.We reviewed the records of 13 patients treated with the T-shunt for whom followup, including erectile function, was available.Records were available for review for 13 men who underwent the T-shunt procedure from April 2006 to January 2008. In most cases priapism had lasted for more than 24 hours and previous irrigation/intracorporal administration of sympathomimetics had been unsuccessful. Of these 13 men 6 had undergone unsuccessful distal or proximal shunt procedures before presentation to our service. All procedures were performed using local anesthetic only. Cavernous blood flow was restored in all but 1 patient and another required a second procedure. T-shunts resulted in resolution of penile pain in all patients and all but 2 had recovery of erectile function.The T-shunt technique results in immediate resolution of ischemic penile pain and rigidity. Ultrasonography confirms that blood flow is usually restored to the previously ischemic corpora cavernosa after the procedure. The T-shaped shunt is simple and reliable, and access also allows for proximal trans-shunt dilation. We observed surprisingly excellent recovery of erectile function. This procedure may facilitate recanalization of corporal circulation and could make proximal shunts obsolete.

Introduction The management of Peyronie's disease (PyD) presents several challenges to the clinician. Despite progress in the understanding of PyD on several fronts, it remains a physically and psychologically devastating condition for the affected patient and partner. Aim The purpose of this Continuing Medical Education article is to review contemporary knowledge of the epidemiology, pathophysiology, evaluation, and management of PyD, thus enabling best-practice management. Methods An English-language MEDLINE review was performed from 1990 to present-day for PyD. Main Outcome Measure Current state of, and new developments in, PyD. Results Recent studies have established a new paradigm for the natural history and epidemiology of PyD. Prevalence approaches 5%, while less than 20% of men report spontaneous resolution of deformity. The psychological sequelae on both patient and partner are underrepresented in literature; data gleaned from select Internet websites have better established Peyronie's effects on psyche and relationships. For the majority of patients, evaluation, information, and reassurance is sufficient. Few medical treatment options are supported by data from well-designed placebo-controlled trials. For men unresponsive to nonoperative therapies, plication, grafting, or implantation of a penile prosthesis are surgical management options. Conclusions PyD does not invariably progress to a complete loss of the ability for sexual intercourse. Should deformities preclude intercourse, well-established medical or surgical options may be considered; indeed, using one or more of the treatment approaches outlined can, in most cases, result in adequate restoration of sexual function. Bella AJ, Perelman MA, Brant WO, and Lue TF. Peyronie's disease.

Objectives Although the discovery of phosphodiesterases (PDEs) was made soon after the identification of cyclic adenosine monophosphate nearly half a century ago, their true importance in medicine has taken many decades to be realised. The recognition of the important role PDE enzymes play and the impact of altering intracellular cyclic nucleotide levels became significant for most urologists and clinicians in the early 1990s with the discovery of sildenafil, a PDE5 inhibitor (PDE5-I). Once approved around the world, on-demand use of PDE5-Is became the gold standard. Recently, the potential beneficial effects of PDE5-Is on the pulmonary, vascular, and other systems has led to examination of alternative dosing regimens. In this review, we have synthesised the available published peer-reviewed literature to provide a critical contemporary view of evolving indications for PDE5-Is and how alternative dosing regimens may impact on sexual and other functions. Methods MEDLINE search of all peer-reviewed English literature for the period 1990–2007. Results The plethora of articles detailing potential uses of PDE5-I in multiple fields of medicine was uncovered. Use of alternative dosing regimens shows great promise across a number of clinical indications, including post–radical retropubic prostatectomy, pulmonary hypertension, endothelial dysfunction, and salvage of on-demand PDE5-I nonresponders. Conclusions Use of PDE5-I on a daily basis may evolve into a major form of drug administration both for men with erectile dysfunction and for those with a myriad of other conditions shown to benefit from this approach.

This article reviews contemporary treatment strategies for the aging male who does not demonstrate a satisfactory response to first-line oral phosphodiesterase-5 inhibitor agents for erectile dysfunction. More than half of men aged 40–70 years are unable to attain or maintain a penile erection sufficient for satisfactory sexual performance, with the prevalence of erectile dysfunction climbing to more than 75% among those aged over 70 years. However, the aging male may fail to respond to or express dissatisfaction with oral on-demand treatment. Clinically effective phosphodiesterase-5 inhibitor salvage strategies include patient re-education, lifestyle changes, correction of risk factors, dose adjustment, agent switching, androgen replacement and/or psychosexual or relationship counseling. Important new data supporting the safe and efficacious use of daily phosphodiesterase-5 inhibitor dosing schedules are reviewed. If required, progression to second- and third-line treatments is appropriate for most men, and may include intracavernous penile injections, vacuum erection devices, multimodality therapy or implantation of a penile prosthesis.

Increasing attention is being focused on identifying novel approaches to recover cavernous nerve (CN) function after injury or secondary to disease states such as diabetes mellitus. We examined penile brain-derived neurotrophic factor (BDNF) and neurotrophin-3 (NT-3) expression, and activation of the Janus kinase (JAK)/signal transducer and activator of transcription (STAT) molecular pathway in the major pelvic ganglion (MPG) after CN injury in the rat.Five groups of eight male Sprague-Dawley rats (4 mo, 250-300 g) were used in this study. The penis and MPG with attached CN segment were harvested at 0 h (controls), 12, and 24 h, as well as at 5 and 12 d after CN axotomy, for protein, messenger RNA (mRNA), and immunohistochemical analysis.mRNA and protein expression of BDNF was upregulated in the penis after injury (p0.05). Levels of NT-3 were unchanged. The JAK/STAT pathway was activated in the MPG after transection, as evidenced by increased STAT1 (peak: 24 h) and STAT3 (peak: 5 d) phosphorylation (p0.01 vs. controls).This study demonstrates increased expression of penile BDNF and upregulation of phosphorylated STAT1 and STAT3 in the MPG in response to CN transection. Activation of the JAK/STAT pathway after injury represents a promising new molecular target for modulating CN survival and regeneration.

A wide variety of medications, devices, and surgical interventions are available to patients who have ED. These range from first-line oral agents to second-line therapy with injections or vacuum devices to third-line options, such as penile prosthesis implantation. In this article, we cover available treatments for erectile dysfunction, ranging from first-line to third-line therapies.

Management of patient expectations in correcting penile curvature is paramount. As in other plication-based therapies, penile length already lost to underlying disease cannot be reclaimed. Additionally, indentations or hourglass deformities cannot be corrected with this technique. There are, however, some very compelling advantages to this procedure. It may be performed under a local anesthetic, there is essentially no risk of de novo erectile dysfunction, and it can often be performed using a longitudinal incision, which is particularly helpful in an uncircumcised patient wishing to retain his prepuce. Before surgery, it is important to try to get an objective view of the penile deformity, conducted by patient self-photography or with a pharmacologic injection in clinic, although both methods have disadvantages. When the patient is brought to the operating room, he is injected with 60-mg papavarine to induce erection. Pharmacologic erection is preferable to saline infusion, because the compression on the corpora cavernosa necessary for saline infusion often masks the full proximal extent of the curvature. © 2007 International Society for Sexual Medicine

Introduction Men with nonpalpable isolated septal scars (ISS) identified with color duplex ultrasonography (CDU) comprise a group of previously unrecognized patients with wide‐ranging sexual concerns. Aim We aim to identify the clinical characteristics of patients presenting with this atypical form of Peyronie’s disease characterized by the absence of palpable deformity. Materials and Methods Of 482 consecutive patients who presented to a tertiary care erectile dysfunction (ED) clinic and underwent CDU after satisfying inclusion criteria, 27 (5.6%) men with nonpalpable ISS and no dorsal or ventral plaque were identified. Main Outcome Measures International Index of Erectile Function (IIEF), CDU, and clinical characteristics. Results The median age of the men with nonpalpable ISS was 49 years. The length of time from onset of symptoms to presentation was 22 months, and the pretreatment IIEF score was 14. The remaining 455 men who underwent CDU were of similar age (48 years) but had a markedly lower IIEF score of 9.5 (statistical median). ISS patients presented with decreased penile rigidity (20), penile shortening (13), chronic pain with erection (13; mean 33 months), and the inability to maintain an erection (7). Fourteen men had failed phosphodiesterase‐5 inhibitor therapy, and four reported unsatisfactory results. Management options included retrial with oral agents, intracavernous pharmacotherapy, verapamil injections, and surgery. Conclusions The clinician should be suspicious for nonpalpable ISS in men with sexual concerns who present with decreased penile rigidity, length loss, and chronic pain with erection. Our findings support the use of CDU for this patient group, particularly when previous treatment has failed, because men with ISS had a greater likelihood of having no palpable deformity or curvature and ongoing penile pain. Bella AJ, Sener A, Foell K, and Brock GB. Nonpalpable scarring of the penile septum as a cause of erectile dysfunction: An atypical form of Peyronie’s disease. J Sex Med 2007;4:226–230.

Introduction The advent of the penile prosthesis revolutionized the treatment of erectile dysfunction (ED), resulting in near-complete treatment efficacy and high patient satisfaction rates. While several types of penile prosthesis are available, the inflatable penile prosthesis (IPP) is the most commonly used device in the United States. Aims To describe the key modifications to IPPs from the two major manufacturers—American Medical Systems (AMS) and Coloplast—since the invention of the IPP, and to relate these changes to improvements in prosthesis function and patient outcomes based on available literature. Methods Review and evaluation of the literature between 1973 and present describing modifications in IPP design and the influence of these modifications on IPP durability and patient-related factors. Main Outcome Measures Data describing the impact of iterative improvements in three-piece IPP design on device function, durability, and patient outcomes. Results There were progressive improvements in IPP technology from both major manufacturers not only on the durability of the prosthesis but also on patient outcomes, with fewer device failures and lower infection rates. Notable improvements include incorporation of kink-resistant tubing, changes in the weave or addition of shear- and infection-resistant coatings to cylinder layers, pump and tubing connection modifications, the addition of rear tip extenders, and the incorporation of lockout valves to prevent autoinflation. Conclusions Numerous incremental modifications to the IPP from both major manufacturers since its invention have increased its durability and improved patient outcomes.

Neoplasms of perivascular epithelioid cells (PEComas) have in common the coexpression of muscle and melanocytic immunohistochemical markers. Although this group includes entities with distinct clinical features, such as angiomyolipoma, clear cell sugar tumor of the lung, and lymphangioleiomyomatosis, similar tumors have been documented in an increasing diversity of locations. The term PEComa is now generally used in reference to these lesions that are not angiomyolipomas, clear cell sugar tumors, or lymphangioleiomyomatoses. While most reported PEComas have behaved in a benign fashion, malignant PEComas have occasionally been documented. We present a case of hepatic PEComa with benign histologic features, which nonetheless presented with metastases to multiple sites nearly 9 years later. This case represents the second documented malignant PEComa of the liver, as well as the longest follow-up of a surviving patient with a malignant PEComa, emphasizing both the need for criteria that more accurately predict the behavior of PEComas and the necessity of long-term follow-up of patients with PEComas.

With the introduction of phosphodiesterase type-5 inhibitors as a first-line, oral treatment for erectile dysfunction, intracavernous injection of vasoactive agents is regarded as a secondary therapy for most patients. However, clinicians evaluating the aging male must be aware of this important group of safe and effective therapies, since patients may be more appropriately treated for their erectile dysfunction with intracavernous prostaglandin E-1, papaverine or phentolamine (alone or in combination) owing to the presence of absolute contraindications to phosphodiesterase type-5 use, a failure to respond to these agents or patient preference. Ongoing research continues to define new options for the intracavernous treatment of erectile dysfunction, including gene transfer therapy. These efforts will probably result in the introduction of novel therapies with greater efficacy, tolerability and a more rapid onset of action, as an ever-expanding number and combination of agents is investigated. Until then, contemporary intracavernous vasoactive treatments will continue to successfully restore erectile function among patients with diverse erectile dysfunction etiologies and a variety of comorbidities.

Oral phosphodiesterase type-5 inhibitors are the contemporary choice for first-line treatment of erectile dysfunction in most men. Due to its efficacy, safety and ease-of-use, tadalafil is preferred by many men suffering from erectile dysfunction of varying severity and etiology. In this review, pharmacodynamic and updated clinical data from integrated analyses and postmarketing surveillance of tadalafil are reported, including efficacy results for specific patient subpopulations, treatment guidelines and compiled safety data including a review of nonarteritic anterior ischemic optic neuropathy and possible links to the use of phosphodiesterase-5 inhibitors.

Introduction Erectile dysfunction (ED) is a highly prevalent and often untreated condition. It may be a marker of underlying chronic illness and negatively impacts quality of life. Penile arterial insufficiency, frequently found in association with hypertension, dyslipidemia, diabetes mellitus, pelvic irradiation, trauma, and smoking, is the most common cause of ED. Aim This study was designed to measure the effect of penile hypoperfusion‐induced alteration and injury on erectile tissue at the cellular and protein level. Methods Eighteen 4‐month‐old male Sprague Dawley rats were placed into three groups (n = 6): sham surgery, unilateral internal iliac artery ligation (UIIAL), and bilateral internal iliac artery ligation (BIIAL). Main Outcome Measure Erectile function was assessed 4 weeks following arterial ligation surgery as measured by a rise in intracavernosal pressure induced by cavernosal nerve stimulation. Penile tissue alterations were characterized by immunohistochemistry, protein content measured by western blot, and “global” protein expression profile carried out by using surface‐enhanced laser desorption/ionization time‐of‐flight mass spectrometry (SELDI‐TOF‐MS) ProteinChip technology. Results Significantly lower intracavernous pressures were demonstrated in animals subjected to UIIAL surgery, which correlated to the extent of artery ligation. The intensity and quantity of immunohistochemical staining for neuronal nitric oxide synthase, endothelial cell integrity, smooth muscle cell α‐actin, and vascular endothelial growth factor (VEGF) receptor flk1 were decreased in the BIIAL group compared to sham controls. SELDI‐TOF‐MS analysis revealed changes in molecular expression of a ∼6,560 Da protein relative to a 7,720 Da protein (peak ratio = 1.34 ± 0.3, BIIAL; 0.36 ± 0.1 controls, P Conclusions In this report, an animal model of vascular penile insufficiency demonstrates altered protein expression associated with cavernosal tissue injury and reduced erectile function. Although the clinical significance of these observations is currently undefined, this model may allow greater insight into the complex biologic changes associated with arteriogenic ED in man.

A 44 year-old female, known to have Li-Fraumeni syndrome, was discovered to have a retroperitoneal mass on surveillance ultrasound. Computerized tomography revealed a 2.0 cm non-cystic, enhancing soft tissue mass abutting the postero-superior margin of the right kidney. She underwent radical nephrectomy, adrenalectomy and en bloc resection of the tumor. Pathology showed a grade I, well-differentiated retroperitoneal liposarcoma with negative surgical margins. She recovered well from surgery and continues to remain recurrence free at 12 months based on serial CT imaging.