Bulbospongiosus Research Articles

The Effect of Physiotherapy on Erectile Dysfunction Secondary to Prostatic Adenectomy: A Randomized Control Trial Study.

The objective of this randomized controlled trial was to investigate the impact of manual therapy (friction massage) and pelvic floor muscle (PFM) training on erectile dysfunction (ED), pelvic floor muscle thickness, and blood flow in the penile arteries and veins in men who have undergone prostatic adenectomy (PA). This study employed a randomized, double-blinded, controlled trial design. Forty patients participated and were divided into two groups: intervention and control (n=20 per group). The intervention group received 10 sessions of pelvic floor muscle training and manual therapy, while the control group solely underwent pelvic floor muscle training. The recovery rate was measured using the International Index of Erectile Function 15 (IIEF-15) questionnaire and Erection Hardness Score (EHS). Sonographic factors were assessed using simple and Doppler ultrasound. The intervention group exhibited significantly higher erectile function scores (F(1,37)=158.04, P < 0.001, η2 P = 0.810) and a higher average total (IIEF-15) score (20.52) (F(1,37)=136.76, P < 0.001, η2 P = 0.787) compared to the control group in the post-test assessment. Comparison between the two groups revealed an increase in ultrasonic parameters such as the thickness of the ischiocavernosus and bulbospongiosus muscles, maximum systolic velocity, and minimum diastolic velocity of the cavernosal artery in the intervention group. However, the maximum blood flow velocity in the posterior vein decreased. PFM training and friction massage play a significant role in managing ED following PA, positioning them as the primary treatment approach for men experiencing ED post-prostatectomy.

The development of the external genitals in female human embryos and foetuses. Part 2: Vaginal vestibule, anal canal, perineal raphe and perineal cutaneous muscles.

Concomitant with the rupture of the cloacal membrane, the perineal skin epithelium thickens (see accompanying article). In this study, we establish in female embryos and foetuses that the thick skin area divides into ventral and dorsal areas at ~14 weeks and gradually becomes restricted to the vaginal vestibule and anal canal thereafter. The dense mesenchymal core of the labia minora, which forms at ~8 weeks, extends dorsally to the anal canal as a midline reinforcement. The skin epithelium overlying this reinforcement is much thinner than the flanking 'thick skin', and is supported by an interrupted basement membrane, which implies epithelial-mesenchymal transformation of the thin midline epithelium and the subsequent establishment of the perineal raphe by the merging of the adjacent thick epithelium. Meanwhile, the anogenital distance in the perineum increases rapidly in length. Perhaps as a consequence, the labia minora cover only the ventral third of the vaginal vestibule at 20 weeks. The endodermal ducts of Bartholin's glands are identifiable at 7 weeks, while acini form at ~12 weeks. The vestibular bulbs become identifiable at ~10 weeks and form vascular networks after ~14.5 weeks. After the rupture of the cloacal membrane, the diameter of the junction of the dorsal cloaca with the anal canal is just a pinhole but widens dorsoventrally after the 7th week. The cutaneous muscles of the perineal area form as a ventrally open U-shaped mesenchymal mass, from which the anal sphincter and bulbospongiosus muscle develop. In conclusion, our findings show that thick skin epithelium persists in the vaginal vestibule and anal canal.

Castration Levels of Testosterone Results in Atrophy of Androgen-Sensitive Perineal Muscles: A Potential Biomarker for Male Hypogonadism

ObjectivesTo evaluate MRI-based measurements of androgen-sensitive perineal/pelvic muscles in men with prostate cancer before and after androgen deprivation therapy (ADT) as a novel imaging marker for end-organ effects of hypogonadism. Diagnosing hypogonadism or testosterone deficiency (TD) requires both low serum testosterone and clinical symptoms, such as erectile dysfunction and reduced libido. However, the non-specific nature of many TD symptoms makes it challenging to initiate therapy. Objective markers of TD help to better identify patients who may benefit from testosterone supplementation; however, current markers, such as low bone mineral density, lack sensitivity. Previous studies suggest that decreased bulbocavernosus-muscle (BCM) thickness may be associated with TD, although it remains unclear if this is a correlative relationship. MethodsData was prospectively collected for patients with intermediate/high-risk localized prostate cancer enrolled in a phase II trial (NCT02430480). Patients received ADT before prostatectomy and underwent prostate MRI pre-/post-ADT. BCM, ischiocavernosus-muscle (ICM), and levator-ani-muscle (LAM) measurements were made using T2W-MRI. Paired t-tests evaluated changes in BCM/ICM/LAM width, and linear regression analyses evaluated relationships between changes in testosterone and muscle width. ResultsThirty-eight consecutive patients with pre-/post-ADT MRIs were analyzed. Baseline testosterone was 286.5ng/dl, and 36/38 patients had post-ADT testosterone <50ng/dL. Pre-ADT and post-ADT measurements of the bilateral BCM/ICM/LAM width were 7.16mm/7.95mm/5.53mm and 5.68mm/6.71mm/4.89mm, respectively (p<0.001). Decreases in testosterone predicted reduction in combined perineal muscle (BCM+ICM) width (p=0.032). ConclusionsAndrogen deprivation led to significant and relatively rapid decreases in BCM/ICM/LAM thickness. This objective biomarker of low testosterone states may help identify patients who will potentially benefit from testosterone replacement.

303 - Artificial urinary sphincter implantation preserving the bulbospongiosus muscle: an interesting option in patients with frail urethra

303 - Artificial urinary sphincter implantation preserving the bulbospongiosus muscle: an interesting option in patients with frail urethra

Rectovaginal fistulas : Differentiated diagnostics and treatment

Rectovaginal fistulas (RVF) represent less than 5% of anorectal fistulas. The classification of RVF is based on the localization (low vs. high) and the etiology. The most frequent causes of RVF are birth trauma, Crohn's disease, previous surgery and pelvic irradiation. In most cases a clinical diagnostic assessment is sufficient. Additionally, endosonography is areliable tool to detect sphincter defects. Computed tomography (CT) and magnetic resonance imaging (MRI) are reserved for special situations (e.g., RVF related to anastomotic leakage, after pelvic irradiation or associated with complex perianal fistulizing Crohn's disease). The surgical treatment is primarily oriented to the localization and etiology. Surgical techniques range from local procedures (e.g., endorectal advancement flap repair, transvaginal or transperineal closure) up to more invasive tissue interposition (e.g., bulbocavernosus muscle fat tissue flap or transposition of the gracilis muscle). In "high" RVF transabdominal approaches such as coloanal anastomosis, pull through procedures or omental interposition are indicated. All surgical procedures show high recurrence rates. Several operations are mostly necessary and a stoma creation is often required.

Investigating the Effects of Manual Therapy and Pelvic Floor Training on Erectile Dysfunction: A Case Study

Introduction: Erectile dysfunction (ED) is a common issue in men, often associated with various factors, such as obesity, diabetes, and more. This case study examines the impact of friction massage combined with pelvic floor exercises on ED in three patients, linked to prostatic adenectomy, aging, and diabetes. Case Description: Patients followed a one-month regimen of pelvic floor exercises and techniques. The technique’s progress was monitored via video calls twice a week. Exercises lasted for 10 min daily, along with a 10-min massage. We assessed improvement using the international index of erectile function 15 (IIEF15) questionnaire and erection hardness score (EHS), as well as ultrasound scans. Results: Following treatment, all three patients showed increased EHS and IIEF15 15 scores. Muscular thickness increased in the ischiocavernosus and bulbospongiosus muscles, while the cavernosal artery exhibited higher systolic velocity and lower diastolic velocity, although maximum blood flow velocity in the posterior vein decreased. Treatment had the most significant impact on the adenectomy patient, followed by the elderly patient and then the diabetic patient. Conclusion: Combining friction massage and pelvic floor exercises led to improved erection- related indicators and increased patient satisfaction.

(022) A NOVEL SURGICAL TECHNIQUE TO CREATE A NATURAL-APPEARING RECESSED VAGINAL INTROITUS WITH GENDER-AFFIRMING VULVOPLASTY (“SHALLOW-DEPTH VAGINOPLASTY”) UTILIZING A PEDICLED ADVANCEMENT FLAP

Abstract Introduction Feminizing genital gender-affirming surgery options include vaginoplasty with neovaginal canal creation (“full-depth vaginoplasty”), or vaginoplasty without creation of a neovaginal canal, referred to as “vulvoplasty” or “shallow-depth vaginoplasty”. If a transgender woman does not require a vaginal canal for sexual intercourse, shallow-depth vaginoplasty is an excellent option for women as it does not carry the additional requirements of lifelong dilation and douching and lower risk of complications as compared to the full-depth vaginoplasty procedure. As with either of these procedures, achieving “normal appearing” feminine anatomy is critical for patients. Currently, techniques for shallow-depth vaginoplasty have relied on the use of a separate full thickness skin graft utilizing a portion of scrotal skin to delineate Objective 1) To better understand decision-making factors when choosing to undergo shallow-depth vaginoplasty. 2) To describe a novel technique used to create a recessed vaginal introitus. 3) To evaluate patient perceptions of appearance as compared to cisgender vulvae. Methods Patients undergoing feminizing genital gender-affirming surgery between 04/2017-07/2022 were included in this study. Of the patients undergoing shallow-depth vaginoplasty, an anonymous electronic survey querying decision-making factors and overall post-operative satisfaction were undertaken. In addition, our novel technique is described. Results A total of 110 patients underwent feminizing genital gender-affirming surgery. Of these, 35 (32%) underwent shallow-depth vaginoplasty, whilst 75 (68%) underwent full-depth vaginoplasty. Priorities: Achieving an appearance which was “comparable to” cisgender vulvae was ranked second highest after “elimination of male genital anatomy” (Figure 1a). Technique: To achieve a recessed skin-lined introitus, gathering sutures were used to create a “dimple” from penile/scrotal skin, which is tethered to the tendon of the bulbospongiosus muscle, and the diffuse perineal body tissue behind the urethral bulb (Figure 1, b-d). Attractiveness: When comparing their vulva to cisgender women’s of similar age and weight, all 26 (100%) patients reported that their vulvas had “similar” or “somewhat similar” appearance to cisgender vulvae. 24/26 (92%) of patients found their vulvas to be either “similarly or more attractive”, and 2/26 (8%) found their vulvas to be “less attractive” as compared to cisgender vulvae. Conclusions Women option for shallow-depth vaginoplasty greatly consider the cosmetic appearance which must be indistinguishable from cisgender female anatomy, which appears to be offered by this surgical technique. In addition to this, this technique offers transgender women the opportunity to have external anatomy in line with their gender identity, and for women who are not interested in using a vaginal canal for sexual experiences (i.e. receptive vaginal intercourse), this option foregoes the added risks and commitment to lifelong dilation and douching which is required for women opting to undergo full-depth vaginoplasty. Disclosure No.

Rectal Injury During Penile Inversion Vaginoplasty

ObjectiveTo evaluate the incidence, management and outcomes of rectal injury (RI) and subsequent rectovaginal fistula (RVF) during gender-affirming vaginoplasty (GAV) at a high-volume transgender surgery center. MethodsWe performed a retrospective review of pre-operative, intra-operative and post-operative findings of all patients with RI during GAV from January 2016-September 2022. Descriptive statistics were calculated using Microsoft Excel. ResultsRI occurred in nine of 1011 primary GAV and colorectal surgery (CRS) consulted in five cases, which included sigmoidoscopy with an air leak test in four and with temporary bowel diversion in two. Of the nine, six proceeded with full depth GAV, and three were converted to minimal depth vaginoplasty. Two had bulbospongiosus muscle interposition and none had a concomitant urethral injury. 1/9 with RI developed a RVF which occurred in a patient with prior perineal surgery and no intraoperative sigmoidoscopy. Three (50%) with full depth GAV developed vaginal stenosis postoperatively. ConclusionsRI during primary GAS in experienced hands is uncommon with an incidence of 0.89% in our series of 1011. Unusual tissue dissection planes were a risk factor. If injuries were identified intraoperatively, repaired with multilayer closure and evaluated by CRS, patients did well without the development of RVF despite completion of full depth GAV. It is reasonable to complete the full depth vagina, but patients should be advised of a significant risk of post-operative vaginal stenosis.

Clinical observation of male bulbar urethral strictures resulting from straddle injuries associated with falling from heights and riding activities

ObjectivesTo retrospectively investigate and analyze the characteristics of male bulbar urethral strictures or occlusions resulting from straddle injuries caused by falling from heights and riding activities.MethodsThe study included 56 patients with a history of straddle injury, who were divided into two groups: the falling group (n = 29) and the riding group (n = 27). All patients underwent urethroscopy and X-ray urethrography, followed by urethrotomy and anastomotic procedure. Both urethral and suprapubic catheters were retained for one month postoperatively. Subsequent follow-up assessments were conducted within one month to one year after surgery.ResultsThe clinical data of two groups were analyzed. The average ages were 40.1 ± 11.2 (falling group, aged 18–59) and 26.8 ± 4.4 (riding group, aged 19–35), P < 0.05. In the falling group, 21 cases (72.4%) had offspring, while in the riding group, only 3 cases (11.1%) had offspring, P < 0.05. The stricture segments in the falling group were predominantly located in the proximal part of the bulbar region (89.7%), whereas in the riding group they mainly found in the distal part (96.3%), P < 0.05. In terms of urethrography results, the average lengths of stricture segments were measured as 17.6 ± 2.8 mm and 15.5 ± 4.6 mm respectively, P < 0.05. During surgery, the average lengths of stricture segments were recorded as 19.0 ± 2.5 mm and 17.4 ± 6.1 mm, P > 0.05. In the falling group, 20 cases (69.0%) involved bulbocavernosus muscle injury, P < 0.05. In the riding group, 5 cases (18.5%) involved corpus cavernosum injury, P < 0.05. After one month of the operation, all cases were able to pass through the 16Fr urethroscope without any apparent urethral strictures or complications observed in urethrography results. The maximum urinary flow rate for all cases exceeded 15 ml/s. Two months and one year after the operation, all cases experienced smooth urinary flow and ejaculation without any disorders reported. 3 cases (10.3%) in the falling group and 7 cases (25.9%) in the riding group complained of urethral stretching pain during erection, P > 0.05.ConclusionsMale bulbar urethral strictures or occlusions resulting from straddle injuries associated with falling from heights and riding activities exhibit distinct characteristics, necessitating the development of a comprehensive surgical plan tailored to the specific features of each condition and the diverse age groups affected.

Perineoplasty for anal incontinence after obstetric anal sphincter injury repair: a case report

BackgroundThe rectal and vaginal walls are typically sutured if severe perineal lacerations with rectal mucosal damage occur during vaginal delivery. In case of anal incontinence after the repair, re-suturing of the anal sphincter muscle is standard procedure. However, this procedure may not result in sufficient improvement of function.Case presentationA 41-year-old woman underwent suture repair of the vaginal and rectal walls for fourth-degree perineal laceration at delivery. She was referred to our department after complaining of flatus and fecal incontinence. Her Wexner score was 15 points. Examination revealed decreased anal tonus and weak contractions on the ventral side. We diagnosed anal incontinence due to sphincter dysfunction after repair of a perineal laceration at delivery. We subsequently performed sphincter re-suturing with perineoplasty to restructure the perineal body by suturing the fascia located lateral to the perineal body and running in a ventral–dorsal direction, which filled the space between the anus and vagina and increased anal tonus. One month after surgery, the symptoms of anal incontinence disappeared (the Wexner score lowered to 0 points), and the anorectal manometry values increased compared to the preoperative values. According to recent reports on the anatomy of the female perineal region, bulbospongiosus muscle in women does not move toward the midline to attach to the perineal body, as has been previously believed. Instead, it attaches to the ipsilateral surface of the external anal sphincter. We consider the fascia lateral to the perineal body to be the fascia of the bulbospongiosus muscle.ConclusionsIn a case of postpartum anal incontinence due to sphincter dysfunction after repair of severe perineal laceration, perineoplasty with re-suturing an anal sphincter muscle resulted in improvement in anal sphincter function. Compared to conventional simple suture repair of the rectal wall only, this surgical technique may improve sphincter function to a greater degree.

Is bulbospongiosus muscle botox injection safe and effective in treating lifelong premature ejaculation? Randomized controlled study

PurposeTo evaluate the safety and efficacy of botulinum-A toxin injections into the bulbospongiosus muscle for cases of lifelong drug-resistant premature ejaculation (PE).MethodsNinety-eight outpatients diagnosed with lifelong PE were randomly assigned to two groups: the botulinum-A toxin group comprising forty-nine patients and the placebo (saline) group also consisting of forty-nine patients. A 100 U botulinum-A toxin was diluted into 10 cc of saline, with 5 cc injected into one side of the muscle (botulinum-A toxin group) guided by ultrasound to distribute across most muscle fibers. The same technique was applied using the same volume of saline injected into the bulbospongiosus muscle. Intravaginal ejaculatory latency time (IELT), scores from the premature ejaculation profile (PEP), Premature Ejaculation Diagnostic Tool (PEDT), International Index of Erectile Function (IIEF), and recording of any complications were obtained. Follow-ups occurred at 1-, 3-, and 6-month post-procedure.ResultsCases receiving injections of botulinum-A toxin into the bulbospongiosus muscle showed notably extended intravaginal ejaculatory latency times compared to their initial performance after treatment. In addition, there were enhancements in PEP scores, and notably, no significant complications were reported. Conversely, the bilateral injection of saline into the bulbospongiosus muscle did not demonstrate any impact on ejaculation latencies.ConclusionOur study demonstrated that the injection of botulinum-A toxin into the bulbospongiosus muscle can serve as a safe and effective option for treating PE. Nonetheless, its clinical application warrants further studies involving larger sample sizes and longer follow-up periods.

Возможности магнитно-резонансной томографии в диагностике воспалительных изменений парауретральных желез у женщин.

Introduction. Inflammation of the paraurethral glands (skеneitis) is a complex urological disease, often hidden under the guise of other pathological conditions and causing recurrent lower urinary tract infection (UTI) in women. A significant problem for the diagnosis of skineitis at present is the absence or extremely low sensitivity and specificity of available laboratory, instrumental and radiation methods. Thus, the search for new ways to examine patients with recurrent UTI caused by chronic inflammation of the Skene’s glands is an important clinical and socio-economic task of modern healthcare. Materials and methods. The study involved 30 patients aged from 24 to 51 years who underwent magnetic resonance imaging (MRI) of the pelvis with contrast enhancement and targeted examination of the urethra and periurethral area using a device with a 3T fi ld strength. To study the MR semiotics of chronic inflammation of the gallbladder, in addition to standard MR protocols, high-resolution T2-weighted images with a slice thickness of 2 mm and T2-weighted Space 3D images in a sagittal projection with a slice thickness of 1 mm were used. The first group consisted of 16 urologically healthy women without complaints of dysuria, who underwent an assessment of the MRI anatomy of the normal female urethra. MRI of 14 respondents with chronic infl mmation of the paraurethral glands (second group) was performed to search for recurring (natural) changes characteristic of this disease. Such parameters as the diameter of the urethra, the separate thickness of its anterior and posterior walls, clarity at the boundary of the layers, and the presence of pathological changes and formations were studied. Results. Analysis of the obtained tomograms showed that urologically healthy respondents are characterized by symmetrical thickness of the walls of the urethra without pathological formations in it, as well as evenness and clarity of the contour at the boundary of the layers. When studying the results of examination of patients with chronic skeneitis, all of them (100%) noted the following recurring changes: an increase in the diameter of the urethra due to thickening of its posterior wall, in particular the submucosal layer, impaired differentiation at the border of the submucosal and muscular layers, the presence of small cystic changes in the structure of the posterior wall of the urethra (85.7%) or fragmentarily dilated ducts of the urinary tract (14%). Hypertrophy of the bulbospongiosus muscles, detected in 85.7% of respondents in the second group, is likely an indicator of frequent exacerbations and duration of the disease, and can be considered as an additional nonspecific criterion for this disease. Conclusions. These changes can tentatively, given the small sample, be considered pathognomonic MR signs of chronic skineitis. Thus, MRI of the pelvis with a targeted examination of the urethra and periurethral area can help in the differential diagnosis of patients with suspected inflammation of the paraurethral glands, establishing the correct diagnosis and prescribing adequate treatment.

(067) The Outcome of Bulbospongiosus Muscle Injection with Botulinum-A Toxin for Treatment of Lifelong Premature Ejaculation; A Randomized Controlled Trial

Abstract Introduction Lifelong premature ejaculation (PE) is considered one of the commonest sexual disorder affecting men with an estimated prevalence of 2–5%. [1,2] Many definitions have been proposed for lifelong PE, the most accepted is the ISSM’s which consider PE “ejaculation which always or nearly always occurs prior to or within about 1 minute of vaginal penetration from first sexual experiences (lifelong premature ejaculation) + Negative personal consequences such as distress, bother, frustration, and/or the avoidance of sexual intimacy”.[3] However, there is no doubt that lifelong PE negatively affects the quality of life of the patient and his partner. [2] Proper assessment of this problem in an objective validated way has always been a challenge. [4] Treatment also varied from behavioral techniques, SSRIs and local anaesthetics with very variable outcome, unsatisfactory for many patients. [5] New lines have been always evolving trying to address this resistant category of patients such as injection of the glans penis with filler [6] or neurectomy of the dorsal nerve of the penis. [7] Herein; we assess a new line of treatment for lifelong PE which theoretically can inhibit the stereotyped rhythmic contractions of the bulbospongiosus muscle during the reflex of ejaculation using botulinum-A toxin; in a prospective, randomized, placebo-controlled study. Objective This study aimed to assess a new line of treatment for lifelong premature ejaculation (PE) which is botulinum-A toxin injection into the bulbospongiosus muscle. Methods It was conducted at the Andrology Unit of Tanta University in Egypt between November 2020 and November 2022. Patients with lifelong PE were considered for this study. Those suffering from PE secondary to erectile dysfunction, genital infection or psychic stress were excluded. Patients have been asked to stop any medical treatment that could affect their sexual function eg PDE5i and medications for lifelong PE; for at least 1 month before injection as well as 6 months thereafter. Sixty patients with lifelong PE have been prospectively enrolled and randomized into 2 groups; the test group (group A) was injected with 100 U botulinum-A toxin at 10 U/ml and the control group (group B) which was injected with the same volume of saline into the bulbospongiosus muscle. Injection was done in lithotomy position, using a fanning technique, under US guidance using the superficial probe to localize the site of injection. Fifty-seven patients of 60 completed the follow up protocol. Results Fifty-seven patients of 60 completed the follow up protocol. The IELT, PEP score and female satisfaction showed no statistically significant difference between both groups at the 1, 3 and 6 months post intervention. However, in the treatment group, the median (IQR) PEP score increased significantly after 1 and 3 months with a mean difference of 1.6 and 95 % CI of (0.7–2.5), P=0.001 and 0.9 and 95% CI of (1.07–1.69), P=0.02 respectively. Whereas insignificant change was noted at 6 months, with a mean difference of 0.13.In the control group however, there was no significant change of any of the tested parameters at any the 3 time points. Adverse reactions were minor and observed only in 3 cases (5%). Conclusions botulinum A injection into the BS muscle seems to be safe, but failed to prove efficacy when compared to placebo in treatment of lifelong PE Disclosure No.

(342) Glans Augmentation and Glans – Bulbospongiousus Reflex

Abstract Introduction The creation of a barrier at the level of glans by the bulking agents blocking accessibility and inhibiting the tactile stimuli to reach the dorsal nerve of penis (branch of pudendal nerve) receptors is the theory behind the effect of hyaluronic acid in the field of premature ejaculation. Clinically there is a doubt about that as filler injection in frenular delta (most sensitive area in penis) and in G-spot at female accelerates time of ejaculation, some cases with history of failed dorsal neurectomy my response to hyaluronic acid injection, filler or fat injection in penis shaft doesn’t improve ejaculation time, in the opposite side implants like Elist`s implant (pneuoma) or other solid inner condoms improves premature ejaculations. The cause is that the hard implant masks pressure on the corona thus inhibits glans – bulbospongiosus reflex which delays the second phase of ejaculation, ring application at coronal sulcus delays ejaculation for the same reason, filler or fat is not solid and doesn’t resist pressure and compressed due to pressure. In glans area compression is not possible due to tight space at glans mucosa. Objective Explanation why glans augmentation by filler delays ejaculation. Methods Seven patients with history of previous glans penis augmentation (hyaluronic acid) with good response (12-14 months ago) instead of re-injection, Alaa Aglan operation was done, cutting of bulbospongiosus muscles bilaterally plus frenular delta excision 4 months post-operative all patients were injected by hyaluronic acid at glans. Results All patients were satisfied by the operation, 3 months post-operative the gained time was calculated for each patient (by himself) then hyaluronic acid injection was done. No change in time was reported in all patients and they reported that it was still the same time gained after surgery despite all patients reported satisfactory results after previous injection one year ago. Conclusions Inhibition of glans – bulbospongiosus reflex is the main cause to delay ejaculation after glans augmentation. Disclosure No.

(062) The Physiological Health of the Penile Fibro-Vascular Assembly Requires the Integrity of Ten Fibro-ligaments in the Human Penis

Abstract Introduction Although the human penis has existed on earth for 3000 centuries and extensive studies have been conducted for many recent centuries, there is still room for improvement, particularly in the fibro-ligaments' role in maintaining physiological sexual health. Thus far, there needs to be more interpretation concerning these ligaments. Objective We aimed to explore the penile fibrous ligaments thoroughly to fill this research gap. Methods We excluded cadaveric penises that had both sides of the corpora cavernosa (CC) and corpus spongiosum (CS) damaged. However, penises with one undamaged side of the CC, including the Colles' fascia and the corpus spongiosum, were included. A total of 15 out of 46 penises were meticulously examined. Dissection findings were supplemented with 101 cadaveric photos and data from 263 penile vascular surgeries, 11 CT imaging scans, 8 MRI imaging scans, eight hypospadias surgeries, and eight penile elongation surgeries performed elsewhere internationally. Results Bilaterally, the penile CC is primarily anchored to the pelvis wall through the unilateral cavernosal ligament bilaterally (CL=2), while the CS is connected to the urinary sphincter. The suspensory, fundiform, and arcuate pubic ligament (two anatomically and one functionally) assist in stabilizing and holding the penile shaft to the pelvic wall. Distally, a distal ligament (DL=1) and spongiosal ligament (SL=1) extend the CC and CS to the glans penis and frenulum, ensuring urethra patency when required. The CC is encircled by a bi-layered tunica consisting of a 360° inner circular tunica and a 300° outer longitudinal coat. The ischiocavernosus muscle wraps around the penile crus and envelops the CL connecting to the ischial tuberosity. The CS is partially secured by the bulbospongiosus muscle proximally and receives the SL distally. The entire penis interconnects with the skeletal muscle of the urogenital diaphragm eventually. Conclusions The physiologically sexual health of the human penis's hydraulic system relies on the integrity of ten anatomically and six functionally fibro-muscular ligaments. Disclosure No.

(243) Frenular Delta Excision with Neurectomy of Ventro – Lateral Branches of Penile Dorsal Nerves (Alaa Aglan4 Operation)

Abstract Introduction Neurectomy is one of the surgical options used for treatment of premature ejaculation, variable degrees of neurectomy could be done, aggressive neurectomy may cause severe demenishion in sensations as occurs in cases of perovic technique for penis elongation or in cases of sliding techniques used in treatment of peyronie`s disease also it increases the risk of erectile dysfunction. In our old trials in phalloplasty and penile implantation we were doing neurectomy routinely with few exceptions, the success rate at that time was 78% and some side effects were reported e.g neuroma, numbness, and recurrence. After application of prediction test (spraying local anesthesia procomail at frenular area (temporary excision) and local injection around the chosen nerve/s) the picture has been changed. as we could predict the expected gained time post-surgery. The classic neurectomy is related to neural supply of glans. once we was doing classic Alaa Aglan operation (cutting bulbospongiosus muscles bilaterally plus frenular delta excision) but we found the muscles congenitally absent so we excised part of frenular delta with neurectomy to neural supply to the same area (i.e. ventro – lateral branches of dorsal nerves) the results were satisfactory to the patient. Many patients were afraid of muscles cutting at our early trials, so this operation was the alternative option, dorsal neurectomy could be done with it according to prediction tests in some cases (usually with implants). Objective Presentation of new operation for treatment of premature ejaculation (Alaa Aglan4). Methods Study was done between 3/12/2011 – 8/2/2017 (5 years following up), 247 patients were operated (after prediction test), partial excision of frenular delta plus neurectomy to ventral branches of RT and LT penile dorsal nerves. Neurectomy was done at middle third of penile shaft before branching. Dissection of proximal part till penis root and retraction of the proximal end and placing it at penis root area (to avoid reunion or recurrence). Results Numbness was reported in 13 patients disappeared within 3 months, neuroma was obvious in 7 patients treated by vitamin B injection in 5 patient’s. Re-excision of 2mm of proximal neural end (under local anesthesia) in 3 patients. No recurrence was reported. The dissection of nerves and covering the proximal end with inverted skin graft or silicone cap as a barrier between the nerves ends to prevent reunion and recurrence was done outside this study, but this technique is simple and easy. Erectile dysfunction was not reported in all patients. after 4 months all patients were satisfied by the ejaculation time. Conclusions Alaa Aglan4 operation is simple, effective, safe and permanent treatment for premature ejaculation guided by prediction test. Disclosure No.

Effect of bulbospongiosus muscle injection with botulinum-A toxin for treatment of lifelong premature ejaculation; a randomized controlled trial.

This study aimed at assessing a new line of treatment for lifelong premature ejaculation which is botulinum-A toxin injection into the bulbospongiosus muscle. Sixty patients with lifelong premature ejaculation were independently randomized into 2 groups; group I, 100 U botulinum-A toxin at 10 U/ml saline was injected with ultrasound guidance into the bulbospongiosus muscle and group II which was injected with similar volume of saline. The primary outcome was to compare both groups for changes in the Premature Ejaculation Profile (PEP), Intravaginal Ejaculatory Latency Time (IELT) and partner's satisfaction at 1, 3 and 6 months after intervention. The second outcome was to compare the adverse events in both groups. Fifty-seven patients completed the study. In group I, the mean PEP increased significantly at 1- (P = 0.02) and 3- months (P = 0.04) with insignificant increase at 6-month (P = 0.6) of follow-up. Also, no significant changes had been noted in IELT or partner's satisfaction scores throughout the study duration (P > 0.05). In group II, no significant changes had been noted in the PEP, IELT and partner's satisfaction scores throughout the study duration (P > 0.05). There were insignificant differences in the changes in the mean PEP (P = 0.7, 0.6 and 0.4), IELT (P = 0.6,0.6 and 0.5) and partner's satisfaction scores (P = 0.5,0.7 and 0.3) in comparison to the baseline values at 1-, 3- and 6- months, respectively between both groups. Adverse events were observed in only 3 patients (5.3%). In group I, mild erectile dysfunction and post micturition dribbling were reported in one patient each. Where in group II, one patient reported bleeding per urethra (P = 0.5). To conclude, injection of botulinum-A toxin into bulbospongiosus seems to be safe but failed to prove clinical efficacy for treatment of lifelong premature ejaculation when compared to placebo.

Zephyr 375 urinary sphincter implant by unical perineal incision. Initial experience.

The treatment of male severe stress incontinence (MUI) after surgery is the implantation of an artificial urinary sphincter (AUS). Traditionally you need two incisions: perineal and inguinal. Our objetive is present a series of patients treated with the Zephyr 375 EUA implant through a single perineal incision. We present six men operated on for MUI after Transuretral resection of the prostate (TURP) (1) and radical prostatectomy (5). Preoperatively we perform Pad-Test and cystoscopy. Under epidural anesthesia, a vertical perineal incision was made and dissection up to the bulbospongiosus muscle was divided and we dissected the bulbar urethra. After removing the probe, we place the cuff, checking that it reaches the appropriate pressure, leaving it deactivated. To place the pump-reservoir, we digitally develop a scrotal dartos pocket from the perineum that we close with Vicryl 3/0. After closing the muscle with 3/0 Vicryl, we left a suction drain and a bladder catheter. The mean age was 63 years (55-72). Mean surgical time was 68 minutes (60-85). All were discharged the next day without catheter and drain. All patients comfortably palpated the scrotal reservoir-pump. After activation, all patients were continent without needing additional adjustment, using 3 a safety pad. The degree of satisfaction was very high, all of them affirmed that they would undergo the same intervention again. The Zephyr 375 urinary sphincter allows placement through a single perineal incision, reducing surgical time, simplifying the technique, and reducing morbidity without compromising the functional outcome.

Sucrose consumption modifies the urethrogenital reflex and histological organization of the bulbospongiosus muscle in the male rat

Disorders of the bulbospongiosus muscle (Bsm) are associated with male sexual dysfunction, such as premature ejaculation. We determined the effect of sucrose-water consumption during pregnancy-lactation and postnatal on reflex responses and morphology of Bsm fibers in adult male Wistar rat offspring. Female rats were mated and grouped into consumed tap water mothers and sucrose-water (5 %) mothers during pregnancy-lactation to obtain experimental groups. Male pups were weaned and assigned into four groups (n = 12; each group). Those from control mothers who continued drinking tap water (CM–CO group) or sucrose water (CM–SO group), and those from sucrose mothers who drank tap water (SM–CO group) or continued drinking sucrose water (SM–SO group) until adult life. In male rat offspring (n = 6 per group) was recorded the electrical activity of Bsm was recorded during penile stimulation and urethrogenital reflex (UGR). Other male rat offspring were designated for histological analysis (n = 6 per group). Sucrose consumption during prenatal stages increased the frequency of the Bsm during UGR, while pre and postnatal consumption modified muscle fiber cross-sectional area and increased the collagen content, suggesting that a combination of a diet with pre- and postnatal sucrose changes the Bsm morphophysiology possibly causing male sexual dysfunctions.

Anatomical and histological investigation of the area anterior to the anorectum passing through the levator hiatus

Objective: To document the anatomical structure of the area anterior to the anorectum passing through the levator hiatus between the levator ani slings bilaterally. Methods: Three male hemipelvises were examined at the Laboratory of Clinical Applied Anatomy, Fujian Medical University. (1) The anatomical assessment was performed in three ways; namely, by abdominal followed by perineal dissection, by examining serial cross-sections, and by examining median sagittal sections. (2) The series was stained with hematoxylin and eosin to enable identification of nerves, vessels, and smooth and striated muscles. Results: (1) It was found that the rectourethralis muscle is closest to the deep transverse perineal muscle where the longitudinal muscle of the rectum extends into the posteroinferior area of the membranous urethra. The communicating branches of the neurovascular bundle (NVB) were identified at the posterior edge of the rectourethralis muscle on both sides. The rectum was found to be fixed to the membranous urethra through the rectourethral muscle, contributing to the anorectal angle of the anterior rectal wall. (2) Serial cross-sections from the anal to the oral side were examined. At the level of the external anal sphincter, the longitudinal muscle of the rectum was found to extend caudally and divide into two muscle bundles on the oral side of the external anal sphincter. One of these muscle bundles angled dorsally and caudally, forming the conjoined longitudinal muscle, which was found to insert into the intersphincteric space (between the internal and external anal sphincters). The other muscle bundle angled ventrally and caudally, filling the gap between the external anal sphincter and the bulbocavernosus muscle, forming the perineal body. At the level of the superficial transverse perineal muscle, this small muscle bundle headed laterally and intertwined with the longitudinal muscle in the region of the perineal body. At the level of the rectourethralis and deep transverse perineal muscle, the external urethral sphincter was found to occupy an almost completely circular space along the membranous part of the urethra. The dorsal part of the external urethral sphincter was found to be thin at the point of attachment of the rectourethralis muscle, the ventral part of the longitudinal muscle of the rectum. We identified a venous plexus from the NVB located close to the oral and ventral side of the deep transverse perineal muscle. Many vascular branches from the NVB were found to be penetrating the longitudinal muscle and the ventral part of rectourethralis muscle at the level of the apex of the prostate. The rectourethral muscle was wrapped ventrally around the membranous urethra and apex of the prostate. The boundary between the longitudinal muscle and prostate gradually became more distinct, being located at the anterior end of the transabdominal dissection plane. (3) Histological examination showed that the dorsal part of the external urethral sphincter (striated muscle) is thin adjacent to the striated muscle fibers from the deep transverse perineal muscle and the NVB dorsally and close by. The rectourethral muscle was found to fill the space created by the internal anal sphincter, deep transverse perineal muscle, and both levator ani muscles. Many tortuous vessels and tiny nerve fibers from the NVB were identified penetrating the muscle fibers of the deep transverse perineal and rectourethral muscles. The structure of the superficial transverse perineal muscle was typical of striated muscle. These findings were reconstructed three-dimensionally. Conclusions: In intersphincteric resection or abdominoperineal resection for very low rectal cancer, the anterior dissection plane behind Denonvilliers' fascia disappears at the level of the apex of the prostate. The prostate and both NVBs should be used as landmarks during transanal dissection of the non-surgical plane. The rectourethralis muscle should be divided near the rectum side unless tumor involvement is suspected. The superficial and deep transverse perineal muscles, as well as their supplied vessels and nerve fibers from the NVB. In addition, the cutting direction should be adjusted according to the anorectal angle to minimize urethral injury.