Flaccid State Research Articles

The feasibility study of shear wave elastography in the diagnosis of erectile dysfunction.

The aim of this study was to explore the value of Shear wave elastography (SWE) in evaluating vascular and nonvascular erectile dysfunction. In this study, erectile dysfunction (ED) patients enrolled (n = 114) received SWE and Doppler ultrasonography (PCDU) exams. The peak systolic velocity (PSV) and end-diastolic velocity (EDV) were used as the classification standard. The performance of the SWE was assessed with the receiver operating characteristic curve, sensitivity and specificity. The rigidity alterations of corpus cavernosum penis with age was also investigated. SWE values of corpus cavernosum penis (CCP) before intracavernosal injection (ICI) negatively correlated with age of patients in vascular ED group (r = -0.288, P < 0.05). In erectile or flaccid state, the SWE value of vascular ED was significantly larger than non-vascular ED. When the cut-off value for SWE values of CCP 0.88m/s in erectile state and 2.32m/s in flaccid state, the areas under the receiver operating characteristic (ROC) curve were 0.700 (sensitivity: 77.78%, specificity: 60.00%) and 0.612(sensitivity: 68.52%, specificity: 51.67%) in erectile or flaccid state, respectively. This study provides preliminary evidence that SWE in flaccid state could be non-invasive methods used to moderate predict vascular ED.

The value of shear wave elastography combined with red blood cell distribution width in evaluating arterial erectile dysfunction

PurposeA retrospective study was conducted to determine the value of shear wave elastography (SWE) and red blood cell distribution width (RDW) in the diagnosis of various forms of erectile dysfunction (ED).MethodsWith the method of Nocturnal Penile Tumescence and Rigidity (NPTR) and the screening method of Color Duplex Doppler Ultrasound (CDDU), hematological data were collected from 131 individuals, among whom 24 are with psychogenic ED, 48 are with non-arterial ED(NAED) and 59 are with arterial ED(AED) with erectile dysfunction. SWE value of penile corpus cavernosum(CCP) and cavernous arterial flow velocity were measured before (flaccid state) and after (erect state) intracavernous injection (ICI) in all patients.ResultsAmong the AED patients and other types of ED patients, there were statistically significant differences in the abridged five-item International Index of Erectile Function (IIEF-5), red blood cell distribution width-coefficient of variation (RDW-CV), red blood cell distribution width-standard deviation (RDW-SD), and SWE values (all P < 0.01). In the AED patients, the IIEF-5 scores had a significant negative relationship with RDW-CV, RDW-SD, and SWE values, with SWE values having the strongest correlation. (p < 0.001, r=-0.638).ConclusionThe combination of RDW level and SWE value demonstrated the greatest performance in diagnosing AED, according to the receiver-operator characteristic(ROC) curve analysis (AUC = 0.870, p < 0.0001, cut-off value of 0.75, sensitivity of 74.6%, specificity of 91.7%).RDW and SWE value may develop into an incredibly simple, practical tool for predicting and diagnosing AED.Trial registrationretrospectively registered.

Acute Phase Peyronie's Disease: Where Do We Stand?

Peyronie's disease (PD) is a common benign condition characterized by superficial fibrosis and scar formation at the tunica albuginea of the penis, eventually leading to penile curvature. It is believed that penile micro-traumas during intercourse and subsequent activation of inflammatory processes constitute the pathogenetic basis of the disease. Routinely, PD is divided into acute and chronic phases, with pain during erection or flaccid state being the hallmark of the former. Surgical intervention should be avoided during the acute phase, as the risk of recurrence or progression of penile deformity during this stage might affect the optimal outcomes of the procedure. During this stage, many conservative treatment options have been suggested, including oral, topical, and intralesional therapies, extracorporeal shock wave therapy (ESWT), and penile traction therapy (PTT). Currently, the optimal treatment consists of a combined treatment strategy with phosphodiesterase type 5 inhibitors (PDE5Is), ESWT for pain management, PTT, and intralesional therapies. Large, well-designed randomized controlled trials (RCTs) are necessary to further elucidate the most efficient treatment option for acute phase PD.

(156) Morphometrix Tissue Segmentation Technology as a Diagnostic Aid in the Evaluation of Vasculogenic Causes of Erectile Dysfunction

Abstract Introduction Morphometrix Imaging Technologies Inc. (MPX) Tissue Segmentation Technology (TST) isolates and processes the component of ultrasound reflective signals associated with coherent specular reflection at the liquid spaces in living tissue. The software identifies and quantifies the hypoechoic structures in B-Mode Ultrasound Scans produced by these reflections and thereby profiles liquid spaces in the tissue created by blood and lymphatic vessels as a proxy for vascular intensity. It then derives tissue segment counts (TSC) as a final quantification step. Unlike SHIM Scores, TST provides a quantitative assessment of the vascular health of the erectile tissue. Objective The goal of the study was to determine whether TSC can predict a response to regenerative treatments for ED. We retrospectively studied the efficacy of MPX TST in assessing the vascularity of the corpus cavernosa (CC) and compared the findings to SHIM scores before and after Shockwave therapy (SWT). MPX can assess penile vascularity in the flaccid state using TSC and can calculate cross-sectional area and volume. Methods Retrospective study of 57 men, average age 54.9 with ED. B-mode Ultrasound video scans were performed on the penis in the flaccid state before and after treatment completion and processed through MPX to obtain the TSC which were compared to IIEF-5 SHIM scores. A typical treatment involved multiple sessions of SWT and PRP penile injection. Subjects were divided into three groups based on response to treatment and correlation with SHIM Scores: Group 1 – Good Responders &amp; Good Correlation with SHIMs, Group 2 – Poor &amp; Non-Responders &amp; Good Correlation with SHIMs, Group 3 – Good &amp; Poor Responders &amp; Non-Correlation with SHIMs. Results Overall we had an 80.7% correlation between TSC and the SHIM Score results. The average SHIM score increased to 15.9 from 10.6, (p&amp;lt;0.006). The average TSC in the left CC increased to 25 from 17.3, (p&amp;lt;0.002). The average TSC in the right CC increased to 24.7 from 17.9, (p&amp;lt;0.002). 54.9% (34 patients) were good responders and the SHIM scores correlated well with TSC. The average SHIM score increased to 17.5 from 10.8, (p&amp;lt;0.001). The average TSC in the left CC increased to 28.1 from 15.3, (p&amp;lt;0.001). The average TSC in the right CC increased to 31.2 from 17.1, (p&amp;lt;0.003). 21.1% (12 patients) were poor responders and the SHIM scores correlated well with TSC. The average SHIM score increased 10.3 from 9.4, (p&amp;lt;0.554). The average TSC in the left CC declined to 13.5 from 15.5, (p&amp;lt;0.559). The average TSC in the right CC declined slightly to 14.9 from 12.5, (p&amp;lt;0.268). 19.3% (11 patients) were a mixture of good and poor responders and the SHIM scores did not correlate well with TSC. The average SHIM score increased to 15.1 from 11.3, (p&amp;lt;0.103). The average TSC in the left CC declined to 25.5 from 26.8, (p&amp;lt;0.919). The average TSC in the right CC declined to 25.5 from 25.7, (p&amp;lt;0.975). Conclusions MPX tissue segmentation software can provide quantitative information about the vascularity of the corpus cavernosa and can differentiate responders to treatment from non-responders. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Morphometrix.

(152) Energy Absorption Simulation During Low Intensity Shockwave Therapy

Abstract Introduction Low intensity shockwave therapy (LiSWT) has been used to treat erectile dysfunction since 2010 by inducing mechanotransduction. The greater the shockwave energy absorbed in cavernosal erectile tissue, the greater the opportunity for mechanotransduction regenerative mechanisms to occur and improve erectile function. Effectiveness of LiSWT depends, in part, on applied energy (mJ/mm2) and number of applications (total shocks). Although intensity of LiSWT energy cannot be arbitrarily increased due to side effects, energy absorption may be improved by performing treatment to an erect vs flaccid penis. Intracavernosal pressure and penile volume are both determinants of velocity of the energy wave in tissue and therefore absorption of shockwave energy in tissue. Intracavernosal penile pressure when erect (100 mmHg) is 16-fold higher than flaccid (6 mmHg), and blood volume when erect (142.6 cm3) is &amp;gt;2 times more than flaccid (62.18 cm3), therefore LiSWT in the erect state with larger blood-filled lacunar spaces should be associated with greater shockwave energy absorption. Use of a symmetry-matched secondary reflector can further increase the energy absorption of each applied shockwave by reflecting the wave back. Objective The aim of this study was to perform a simulation of energy absorption during LiSWT with a reflector in both the flaccid and erect penis. Methods This energy model used the MTS UroGold electrohydraulic shockwave device [Softwave TRT]. When sound waves pass through an interface between 2 media with different impedances, sound propagation can be significantly altered. If impedances of the media are different, part of the sound energy is reflected into the incident medium; the rest of the sound energy is transferred to the second medium. Sound propagation in tissue can be illustrated via computer simulation by mathematically calculating the damping and deflection of the sound wave by different tissue structures. Finite Element Method (FEM) simulation models are particularly suitable for the mathematical description of complex processes of shockwave propagation, such as in the flaccid and erect penis. Based on results, a “prediction” of propagation of LiSWT in tissue is possible. This patient-specific procedure is based on consideration of individual anatomical structures: corporal lacunar spaces and physical-acoustic laws. For FEM modeling of LiSWT propagation, program systems ANSYS, MATLAB and PZFLEX/ONSCALE were used. Results Using the FEM calculation model of the simulation analyses, the shockwave pulse is applied at the bottom edge of the model (Fig 1). It propagates through the erect (Fig 2a) and flaccid (Fig 2b) states, with the most energy absorption in the erect penis, shown in red. The effect of increased penile pressure on energy absorption with a constant volume is shown in Fig 3. Conclusions More energy is absorbed in cavernosal tissue during erection than in the flaccid state, with a further increase in absorption with use of a symmetric reflector. This provides greater opportunity for beneficial mechanotransduction regenerative mechanism due, in part, to increased intracavernosal pressure and tissue volume with larger blood-filled lacunar spaces during erection. LiSWT to treat erectile dysfunction should be more effective when performed in the erect state utilizing a reflector. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: MTS Medical, Softwave TRT.

(126) Application of HIFEM Therapy Improves Orgasmic, Urinary and Erectile Function by Stimulation of Pelvic Floor Muscles

Abstract Introduction The weak pelvic floor in men contributes to various urological disorders. Treatment can be accomplished by strengthening the pelvic floor muscles (PFM) through pelvic floor muscle training. Nevertheless, such development of PFM is time-consuming and heavily dependent on the subject's ability to perform selective muscle contractions. An advantageous approach is the targeted stimulation of PFM which can be accomplished via electromagnetic stimulation. Particularly, the pelvic floor muscles can be non-invasively and selectively stimulated via the HIFEM field. This results in the natural development and rehabilitation of PFM, which, among other functions, plays a vital role in facilitating orgasmic, urinary and erectile function. Objective The aim of this study is to assess the safety and efficacy of the HIFEM pelvic procedure for the treatment of erectile dysfunction. Methods In this study, 28 males with a median age of 56 (30-72 years) were enrolled. The treatment was composed of ten weekly 28-minute sessions. Outcome measurements were collected via questionnaires and ultrasound imaging prior to and after the last treatment. To assess changes in erectile and sexual function, and prostate-related symptoms, the International Index of Erectile Function (IIEF) and International Prostate Symptom Score (IPSS) were used. Transverse B-Mode ultrasound video scans were recorded along the long axis of the penile shaft from the tip to the base with the penis in a flaccid state. A linear transducer was used, the depth was set at 2 cm, and the frame rate was approximately 30 frames per second. Separate video recordings of the left and right cavernosum were taken. The ultrasound scans were processed by the Morphometrix cloud-based algorithm. Adverse events were monitored during the study. Results All evaluation methods proved the efficiency of treatment on a statistically significant level. A significant improvement was detected in the majority (4 of 5) of the domains of IIEF, with the overall score improvement from a baseline value of 45.14±2.42 to 48.75±2.86 (+3.61 points). The most exceptional improvement was found in Sexual desire (+18.78%; p=1.06x10-3), Erectile dysfunction (+13.03%; p=5.7x10-4), and Orgasmic function (+10.69%; p=7.04x10-5) domains. The mean difference in the total score of the IPSS questionnaire reached -3.04 points (p=5.1x10-6), exceeding the corresponding minimal clinical difference (MIC=3 points). Overall, subjects, on average, shifted from moderately symptomatic (9.57±1.37 points) to mildly symptomatic (6.54±0.91 points). An increase in vascularity of both cavernosal was measured within 57% of patients who underwent ultrasound examination; specifically, a significant improvement was recorded in tissue segment count (TSC; +104%; p=1.17x10-4) and density (TSD; +81% p=2.20x10-3), pointing to better blood flow and delivery in examined tissues. No adverse event was observed. Conclusions The therapy administering HIFEM technology of the pelvic floor for selective PFM stimulation demonstrated significant improvement of erectile and orgasmic function and urinary symptoms. The questionnaire results corresponded with ultrasound measurements using a novel algorithm, identifying positive changes in the penile vascular system. Overall, the treatment may be considered a safe and a possible first-line solution for male patients suffering from dysfunctions linked to weakened pelvic floor muscles. Further investigation is needed. Disclosure Yes, this is sponsored by industry/sponsor: BTL. Clarification: Industry funding only - investigator initiated and executed study. Any of the authors act as a consultant, employee or shareholder of an industry for: AFFIRM Science.

(225) Hard-flaccid Syndrome: A Survey of Sexual Medicine Practitioners’ Knowledge and Experience

Abstract Introduction Hard-flaccid syndrome (HFS) is a condition of male sexual dysfunction (MSD) that has become a relatively new focus in online forums and urologic conferences. It is a poorly understood syndrome characterized by chronic pain, a partially rigid penis while in a flaccid state, and erectile dysfunction. HFS primarily affects men in their second and third decade of life, but its exact pathophysiology remains uncertain, with hypotheses suggesting a combination of physical and psychological factors. Consequently, an evidence-based understanding of HFS is lacking within the sexual medicine community. Objective Identify and quantify the current level of understanding of HFS in the sexual medicine academic society. Methods A survey was provided to sexual medicine practitioners at the 2023 American Urological Association (AUA) who attended a plenary focusing on sexual medicine. Each survey form included a screening question to determine familiarity with HFS. If they were familiar with HFS, there were multiple additional questions querying experience with HFS in their patients, modalities of diagnosis, preferred therapy options, in addition to others. These answers were then extracted onto a spreadsheet and analyzed. Results According to the registration reports from the 2023 AUA conference, there were 37 attendees at the sexual medicine plenary. A total of 36 survey responses were submitted. Of these, 35 were urologists and 1 responder was a mental health professional. Among the respondents, 8 (35%) acquired knowledge about HFS through colleagues, 6 (26%) mentioned medical journals, 4 (17%) mentioned conferences, 4 (17%) mentioned patients, and 1 (5%) stated that they first heard about it from an online pelvic floor therapist. Regarding the diagnostic approach for HFS in their practice, 17 responders considered clinical history, 16 relied on patient self-diagnosis, and 1 utilized imaging, although the specific imaging modality was not specified. Most respondents (74%) indicated that they had seen 1-10 patients with HFS, with 4 and 2 respondents reporting 11-20 and 21-50 patients, respectively. In terms of their beliefs about HFS as a legitimate condition, 12 responders expressed confidence in its existence, while 7 remained uncertain. Most respondents (11) suggested pelvic floor therapy as the optimal approach, with 10 recommending combination therapy. Conclusions This analysis highlights the ongoing lack of familiarity with HFS among professionals. This project provides valuable insights into the current understanding of this complex condition. The outcome emphasizes the critical need for continued education and research on HFS to improve diagnostic accuracy, enhance patient care, and develop effective treatment strategies. Disclosure No.

(149) Prevalence of Lumbosacral Annular Tears in Individuals with Hard Flaccid Syndrome

Abstract Introduction Hard flaccid syndrome (HFS), characterized by the penis in an unwanted persistent semi-rigid flaccid state, is an acquired, painful, and bothersome sexual dysfunction that is poorly understood. We have previously postulated that HFS is, in part, a consequence of pathological activation of a somato-visceral and/or a viscero-visceral reflex that we term the “pelvic/pudendal-hypogastric” reflex. In patients with HFS, physical examination reveals a hypercontracted flaccid penis that feels hard on palpation. Biological complaints include penile morphometric changes such as wrinkles or indents; cold-feeling glans with decreased penile sensation; urinary symptoms such as decreased force of stream; constipation; high tone pelvic floor; perineal and penile pain during ejaculation; and erectile dysfunction. Since there is limited understanding of HFS and its pathophysiologic triggers, men with these complaints often seek help from online support groups. Objective To assess the prevalence of lumbosacral annular tears in individuals participating in an HFS online support group and compare this to the prevalence reported in asymptomatic individuals in the peer-reviewed literature. Methods A sexual medicine clinic patient with HFS likely from a lumbosacral annular tear causing sacral radiculopathy who leads an HFS online support group shared his information regarding the suspected pathophysiology. Consequently, other members of the group contacted the sexual medicine clinic to share lumbar MRI images for the spine surgeon to read. All lumbar MRIs had been performed within the last year. They were uploaded to an image sharing service for the spine surgeon to read the sagittal and axial views to assess for the presence of lumbosacral annular tears. For comparison, the literature was reviewed regarding the prevalence of lumbosacral spine disease in asymptomatic individuals. Results A total of 21 individuals, mean age 28 (range 19-42) years, with symptoms consistent with HFS contacted our sexual medicine clinic. Symptoms were verified during the courtesy triage call after which a lumbar MRI was submitted by each individual for evaluation. 16/21 (76%) had surgically treatable annular tears, the most common location being L5-S1 and L4-L5. In addition to HFS symptoms, 38% had concomitant complaints of low back pain and lower extremity sciatica. In a systematic review of 33 peer-reviewed articles reporting imaging findings for &amp;gt;3000 asymptomatic individuals, the prevalence of lumbosacral annular tear varied from 19% to 29% in individuals aged 20 to 80 years [Brinjikji et al, 2015]. Conclusions There is a higher prevalence of lumbosacral annular tears among HFS individuals in this support group who had a lumbar MRI compared to the rate in asymptomatic individuals from peer-reviewed literature. This further supports our hypothesis that HFS is the result of a hyperactive “pelvic/pudendal-hypogastric” reflex. In those men with lumbosacral annular tears, HFS may be triggered by the cauda equina pathology causing sacral radiculopathy that reflexively induces excess sympathetic activity in the efferent hypogastric nerve causing the unwanted HFS symptoms. Disclosure No.

(055) LRRC8A-VRAC Controls Superoxide Anion Flux in Diabetic Vasculogenic Erectile Dysfunction

Abstract Introduction Erectile dysfunction (ED) may be an early marker for cardiovascular diseases, and it is often associated with an hypercontractility of the corpus cavernosum (CC) as a consequence of increased reactive oxygen species (ROS), which favors the flaccid state of the penis. Leucine Rich Repeat Containing 8 (LRRC8A) Volume Regulated Anion Channels (VRACs) regulates Nox1 and modulates the extracellular production of superoxide anion (O2•-). Downregulation of LRRC8A is associated with decreased production of O2•- and we have demonstrated improved relaxation and reduced contraction of the pudendal artery in LRRC8A knockout mice. Objective We hypothesized that the role of LRRC8A in contractile responses to phenylephrine (PE) and electrical field stimulation (EFS) in the CC of diabetic mice would be exaggerated compared to that in normal mice. Methods To test this hypothesis, the CC of diabetic (dbdb-/-) mice was mounted in a myograph, and contraction elicited by PE or EFS was performed in the presence of apocynin (non-selective NOX inhibitor), GKT137831 (NOX1/4 inhibitor) and montelukast (LRRC8A inhibitor). In LRRC8A KO dbdb-/- mice, contractions to PE and EFS were obtained in the absence or in the presence of GKT137831. Results In the CC, the maximal contraction to PE was increased in diabetic animals, and in the presence of 3 mM of apocynin, the contractile response was markedly diminished in both control and diabetic mice. The LRRC8A inhibitor, montelukast, significantly reduced PE-induced contraction of the CC reaching maximal contraction of 69 + 7% and 65 + 10% in the control and diabetic group, respectively, compared to the contraction in the absence of the inhibitor. In the presence of the Nox1/Nox4 inhibitor, GKT137831, the contraction elicited by PE was reduced only in the diabetic group (68 + 9% of the maximal contraction), whereas in the control group this reduction was not significant (82 + 14% of the PE-maximal contraction). In the LRRC8A KO dbdb-/- mice, the contraction to EFS was similar to dbdb-/-, however, GKT137831 reduced the contraction to EFS with lesser magnitude of inhibition in the LRRC8A KO dbdb-/- mice (35% of inhibition) compared to dbdb-/- mice (50% of inhibition), suggesting that the participation of O2•- in the contractile response was reduced by the lack of functional LRRC8A. Conclusions LRRC8A modulates the contractile response of the CC induced by α-adrenergic stimulation and in diabetes, this may be associated with O2•- production, which plays a role in the development of ED. Inhibition of LRRC8A may be a therapeutic target to prevent hypercontractility of arteries and CC in vasculogenic ED. Disclosure No.

(313) Low-Intensity Extracorporeal Shockwave Therapy May Result in Improvements in Flaccid Cavernosal Artery Peak Systolic Velocity

Abstract Introduction Low-intensity extracorporeal shockwave therapy (LiESWT) is thought to treat erectile dysfunction (ED) by stimulating neovascularization and nerve regeneration. Studies suggest subjective improvements following treatment, but objective measures are sparse. Objective We aimed to objectively assess the efficacy of LiESWT in the treatment of ED using penile Doppler in men with ED following LiESWT therapy. We hypothesized that LiESWT results in demonstrable increases in penile blood flow. Methods Patients were prospectively enrolled in a clinical trial examining objective and subjective changes in erectile function following LiESWT. Patients underwent baseline examination with penile Duplex ultrasound in both the flaccid and rigid states following intracavernosal injection of alprostadil. Patients received 12 bi-weekly LiESWT treatments of 0.2mJ/mm2 at 5Hz, 1500 shocks delivered per treatment, with follow up Duplex at 1-2 weeks, 4-6 weeks, 3 months and 6 months post-treatment. Highest peak systolic velocity (PSV) and lowest end diastolic velocity (EDV) were reported. Results Twenty-five patients completed all five study visits. The mean highest PSV in the flaccid state prior to treatment was 7.86 cm/s (± 1.47), which significantly increased to 11.31 cm/s (± 1.81, p &amp;lt; 0.05) immediately following completion of treatments. This increase was sustained at 4-6 weeks with a mean PSV of 12.74 cm/s (± 1.80, p &amp;lt; 0.05), followed by 10.74 cm/s (± 1.43, p &amp;lt; 0.05) at 3 months, and 9.87 cm/s (± 1.14, p=0.11) at 6 months (Figure 1). No significant improvements were noted in flaccid lowest EDV or rigid peak PSV/lowest EDV. Conclusions Our results suggest that LiESWT may improve baseline penile vascularity. Overall, the clinical significance of the noted improvement in flaccid PSV after LiESWT remains to be determined and more work needs to be done to define the mechanism of action of LiESWT at a tissue level in human subjects. Disclosure No.

Experience With Extra-Tunical Grafting and Tunica Albuginea Plication for Correction of Indentation Deformity in Men With Peyronie's Disease

To further evaluate extra-tunical grafting (ETG), a relatively new surgical option to treat corporal indentation in those with Peyronie's disease without buckling or hinge effect, we report our experience, patient satisfaction, and surgical outcomes. Retrospective review of patients following ETG, including pre-operative deformity, type of graft, graft location (under or over Buck fascia), patient characteristics, and satisfaction. Overall cosmetic satisfaction with deformity correction between patients undergoing 2 different ETG locations and 3 different types of grafts, as well as perceived bother of graft visibility and palpability were assessed. From 2018-2023, 35 patients underwent ETG and tunica albuginea plication (TAP) with 89.6% of patients having persistent correction on office examination at a median (interquartile range) follow-up of 23.5 (15.2) months. Overall satisfaction with penile appearance by grafting location via patient-reported questionnaires showed no statistical difference (P=.47). Patients undergoing TAP and ETG were satisfied with their erect appearance regardless of graft material. Patients reported grafting tissue was palpable (74.3%) and visible (48.6%) in the flaccid state as compared to the erect state (8.6% and 5.7%). ETG presents a less invasive surgical option than traditional approaches to correct indentation deformities not associated with instability. Our experience shows high patient satisfaction rate following correction of indentation using graft tissue when placed under or over Buck fascia. At a median follow-up of almost 2years, patients had persistent correction, and while some report visibility of the graft and palpability in the flaccid state, this tends to disappear in the erect state.

Is size in the eye of the beholder? Visual estimation of penis size among transgender and cisgender people and implications for genital gender-affirming surgery and sexual medicine.

Transgender men (TM) seeking gender-affirming phalloplasty and transgender women (TW) seeking vaginoplasty and desiring insertive intercourse must consider penis size. Evidence has shown that, at least among cisgender men (CM), penile dimensions tend to be poorly estimated. In transgender patients desiring gender-affirming surgery, inaccuracy in estimation of penis dimensions may lead to unnecessary morbidity: for TW, trauma to the neovagina; for TM with excess girth, an inability to insert. Studies on the accuracy with which transgender and cisgender patients estimate penis size are limited. To assess the degree of accuracy with which CM and CW, as well as TM and TW, visually estimate the size of the human penis, including length, width, and girth. There were 142 participants included (25 TM, 47 TW, 30 CM, and 40 CW; net mean ± SD age, 36.6 ± 11.2 years). Participants were shown these models and asked to estimate length, width, and midshaft girth by visual inspection of 6 realistic models of a penis and scrotum of varying lengths and widths. We evaluated the accuracy of the visual measurements by comparing mean perceived dimensions with the actual dimensions of each model. We used a multivariate model of all 3 bias dimensions to test for differences in average bias among gender groups (CM, CW, TM, and TW). TM significantly overestimated length across the longest models. TW significantly overestimated length in the longer 3 models. All groups except for TM significantly underestimated girth in at least 1 model. No groups significantly underestimated width. CM, CW, and TM significantly overestimated width in all 6 models. When transgender patients use numbers to express penis size (either in neophallus or vaginal depth based on perceived partner size), the result is likely to be larger than expected. Use of realistic penis models as a decision-making tool may help manage patient expectations and surgery decision making preoperatively and improve postoperative patient satisfaction and safety. To our knowledge, this is the first study to assess visual estimation in penis size in TM and CM, as well as TW and CW. The penile models in our study were shown side by side and in the flaccid state despite having dimensions more consistent with an erect penis, which may have influenced estimations across all dimensions. Men and women (cisgender and transgender) tend to significantly overestimate penis length and width.

Penile fracture: a case series of 18 patients

Introduction: Penile fractures are a rare urological emergency. It is defined as ‘rupture of the tunica albuginea of one or both corpora cavernosa. The corpus spongiosum and the urethra may also be involved in this process.’ The tunica albuginea is stiff and significantly thinner during erection than in the flaccid state, which is when injury generally happens. Method: This case series was completed between January 2018 and January 2023 at the Department of General Surgery. Eighteen patients suspected of having penile fractures participated in were included this study. All patients were thoroughly evaluated upon hospital admission to identify the diagnosis, length of time since the accident, the site of the fracture, the extent of the penile hematoma, occurrence of blood at the external meatus, presence of urine retention, and intraoperative outcomes. Results: The patients were between the ages of 24 and 70, with a mean age of 37. The duration before the presentation ranged from 7 h to 1 month (the median was 22 h). Sexual intercourse was the cause in 12 (66%) cases, rolling in the bed in three cases (16%), and blunt trauma in three cases (kicking and the edge of the bed) (16%). Pain and swelling were present in all of the patients. In 15 patients (or 83%), there was evidence of penile deviation. At presentation, 15 (72%) patients reported experiencing rapid detumescence, discomfort, and penile swelling after hearing a cracking (popping) sound. None of these individuals experienced urine retention or urethral hemorrhage, and all were emptied on their own following the episode. Physical examination showed penile ecchymosis, swelling, and substantial discomfort when the penile shaft was examined. All but three patients had an evident penile deformity. Surgery was performed under spinal anesthesia in 14 (77.7%) patients. Four patients with a delayed presentation (more than 1 week) were managed conservatively. Conclusion: As a true urologic emergency, penile fractures should be treated immediately to reduce pain and swelling and ensure better functional and esthetic outcomes. Despite taking more time, a subcoronal circumcising degloving incision is the ideal method because it is exploratory and esthetically pleasing.

Abstract P189: Hypercontractility Of Pudendal Artery And Corpus Cavernosum Is Associated With LRRC8A-VRAC And Superoxide Anion Production In Diabetic Vasculogenic Erectile Dysfunction

Erectile dysfunction (ED) may be an early marker for cardiovascular diseases and it isoften associated with an hypercontractility of the corpus cavernosum (CC) and pudendalartery (PA) in consequence of increased reactive oxygen species (ROS), which favorsthe flaccid state of the penis. Leucine Rich Repeat Containing 8 (LRRC8) VolumeRegulated Anion Channels (VRACs) regulates Nox1 and modulates the extracellularproduction of superoxide anion (O2 •- ). Downregulation of LRRC8 is associated withdecreased production of O2 •- and we have demonstrated improved relaxation andreduced contraction of the pudendal artery in LRRC8A knockout mice. In this study, wehypothesize that inhibition of Nox or LRRC8A decreases phenylephrine (PE)-inducedcontraction in the CC and PA of diabetic mice. To test this hypothesis, the CC and PA ofdiabetic (dbdb-/-) mice were mounted in myographs, and the contraction elicited by PEwas performed in the presence of apocynin (non-selective NOX inhibitor), GKT137831(NOX1/4 inhibitor) and montelukast (LRRC8A inhibitor). In the PA, the potency of PE wasincreased in diabetic mice, and apocynin (1 mM) restored the contraction of PE to thenormal levels. In the CC, the maximal contraction of PE was increased in diabetic animals,and in the presence of 3 mM of apocynin, the contractile response was markedlydiminished in both control and diabetic mice. The LRRC8A inhibitor, montelukast,significantly reduced PE-induced contraction of the CC reaching maximal contraction of69 + 7% and 65 + 10% in the control and diabetic group, respectively, compared to thecontraction in the absence of the inhibitor. In the presence of the Nox1/Nox4 inhibitor,GKT137831, the contraction elicited by PE was reduced only in the diabetic group (68 +9% of the maximal contraction), whereas in the control group this reduction was notsignificant (82 + 14% of the PE-maximal contraction). In the CC and PA, LRRC8Amodulates the contractile response induced by α-adrenergic stimulation and in diabetes,this may be associated with O2 •- production, which plays a role in the development of ED.Inhibition of LRRC8A may be a therapeutic target to prevent hypercontractility of arteriesand CC in vasculogenic ED.

Penis Girth Augmentation Using SEPA Flap and Dermofat Grafts.

Men of various ages feel that an increase in penile size would give them and their sexual partners an increased confidence. There are a variety of methods for increasing penile girth, such as injection therapies and surgery. All of these methods have a high complication rate which must be emphasized to the patients. In this article, the techniques used for increasing penile girth using dermofat grafts and SEPA (superior external pudendal artery) flaps are highlighted along with their complications and their management thereof. Ten patients were operated for penile girth augmentation between June 2016 and March 2022. Of these, six patients had augmentation using dermofat grafts and four patients had SEPA flaps. Patients were chosen as per the Augmentation Phalloplasty Patient Selection and Satisfaction Inventory (APPSSI) score which was between 2 and 6 in the pre-operative period. The age range of the patients were between 25 and 57 years. The mid-penile girth in the flaccid state ranged from 8.8 to 12.3 cm. Post-operatively, after 6 months, the final girth increase varied from 1.9 to 2.6 cm. The complication rate was 50% and included skin loss, urinary obstruction, fat necrosis, and so on. The post-operative APPSSI score ranged from 2 to 12. Complications were more in uncircumcised patients and in those who desired excessive augmentation. Penis girth augmentation using SEPA flaps and dermofat grafts is indicated in patients who fulfill the criteria and give appreciable girth increase, but patients need to be aware of the potential complications of these surgeries.

(432) Efficacy of Low-Intensity Shockwave Therapy on Hard Flaccid Syndrome: Initial Report of Three Cases

Abstract Introduction Hard flaccid syndrome (HFS) is characterized by chronic pain in the penis and perineum and firmness or rigidity of the penis even while not erect and may have a devastating impact on patient sexual quality of life. Although this syndrome has been discussed in myriad patient forums, there is no established evidence-based definition nor specific standard established treatment modalities in the literature. Current treatment options may include a combination of medical pain management, pelvic floor physical therapy, biofeedback, and stress reduction. In patients with other chronic pain conditions who fail traditional therapies, low-intensity shock wave therapy (LiSWT) has been increasingly utilized as management with positive response. We report a series of three patients with managed with LiSWT. Objective To report our initial experience of men with HFS managed with LiSWT. Methods Three patients, aged 36, 24, and 20 diagnosed with HFS were treated with LiSWT for a course of six sessions. In each session, LiSWT settings were: energy flux density of 0.13 mJ/mm2 and frequency of 3 Hz. While penis was held in stretched position, 600 shocks were delivered to each of the dorsum, left, ventral, and right aspects of penis along the shaft. The scrotum was then held up, and 600 shocks were delivered to each of the right and left crural areas, adding up to 3600 total number of shocks that were allocated evenly. All patients answered a questionnaire to assess improvement in symptoms after completion of the treatment sessions (Table 1). Results All patients reported initially alleviated symptoms after 3 treatment sessions, particularly with respect to penile rigidity in the flaccid state. Patient 1 elected for a combination of LiSWT and tadalafil. 5 months after treatment completion, Patient 1 has had complete resolution of HFS symptoms. Patient 2 had no response with tadalfil alone before he elected for LiSWT only, and patient 3 opted for LiSWT alone. After each LiSWT session, patient 2 reported relieved symptoms for 3-4 days, while patient 3 reported significant improvement lasting for 24 hours. Both patients 2 and 3 reported gradually returning to their pre-treatment baseline in 5 months’ follow-up. Conclusions While HFS is becoming increasingly recognized amongst sexual medicine clinicians, there are currently no established efficacious treatment options. LiSWT shows potential as a treatment modality and may have increased efficacy if used in combination with PDE5 inhibitors, as demonstrated in this pilot study. Nevertheless, a larger case series is necessary to establish LiSWT as a standardized treatment option and may require a more comprehensive approach to properly manage this condition. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast, Clarus Therapeutics, Antares Pharma, Acerus.

(231) Endogenous Vasoactive Peptides in the Control of Human Penile Erectile Tissue: Is There a Significance of the Neuropeptide Y (NPY)?

Abstract Introduction Aside from the neurotransmitters of the sympathetic adrenergic system, vasoconstrictor peptides may also play a role in mediating the constant tone of the erectile tissue during penile flaccidity and in returning the erect penis to the flaccid state. Neuropeptide Y (NPY) is present in high concentrations in the male genital tract. The peptide has been shown to induce contraction of isolated human penile tissue (corpus cavernosum, penile arteries) and potentiate its response to noradrenaline. Objective The purpose of our study was to measure in the cavernous and systemic blood of healthy male volunteers the course of NPY through different stages of sexual arousal. Methods Whole blood was drawn from the corpus cavernosum and the cubital vein of 15 healthy male volunteers during penile flaccidity (Fl), tumescence (Tu), rigidity (Ri) and detumescence (Det). Penile tumescence and erection were induced by applying audiovisual and tactile stimulation. Plasma levels of NPY (given in pmol/L) were determined by means of an enzyme-linked immunoassay (ELISA, IBL GmbH, Hamburg, Germany). Results NPY significantly decreased in the cavernous blood with the beginning of sexual arousal, when the flaccid penis became tumescent and finally rigid (Fl: 88.8 ± 35.8, Tu: 62.4 ± 22.7, Ri: 62.3 ± 19.7). In the phase of detumescence, only a slight increase was noted (64.8 ± 23). In the systemic circulation, no pronounced alterations in the concentration of NPY were registered through the different penile stages (Fl: 64.4 ± 27, Tu: 65.8 ± 19, Ri: 59.6-25, Det: 67.6 ± 29.3). Conclusions Our findings are in favor of the hypothesis that NPY could contribute to the maintenance of the resting state of cavernous smooth muscle. It remains to be elucidated whether the peptide may play a role in the pathophysiology of erectile dysfunction. Disclosure No

(085) Montelukast, a LRRC8A Inhibitor Decreases the Contractile Response to Phenylephrine in the Corpus Cavernosum of Diabetic Mice

Abstract Introduction Increased reactive oxygen species are often correlated with erectile dysfunction (ED) by enhancing contractility and favoring the flaccid state of the penis (which is mainly mediated by α-adrenergic innervation) and decreasing the relaxation of the corpus cavernosum (CC) associated with decreased nitric oxide (NO) bioavailability. Leucine Rich Repeat Containing 8 (LRRC8) Volume Regulated Anion Channels (VRACs) regulates Nox1 and modulates the extracellular production of superoxide anion (O2•-). Downregulation of LRRC8 is associated with decreased production of O2•- and we have demonstrated improved relaxation and reduced contraction of the pudendal artery in LRRC8A knockout mice. Objective In this study, we aim to test the hypothesis that inhibition of Nox or LRRC8A decreases phenylephrine (PE)-induced contraction in the CC of diabetic mice. Methods To test this hypothesis, the CC of diabetic (dbdb-/-, 16-week-old) mice were mounted in myographs, and the contraction elicited by PE was performed in the absence and repeated in the presence of the LRRC8 inhibitor, montelukast or Nox1/Nox4 inhibitor, GKT137831. The maximal contraction in the absence of the inhibitor was taken as 100%, and the contraction in the presence of the inhibitor was calculated as a percentage of the maximal contraction attained in the absence of the inhibitor. Results Contraction induced by phenylephrine in the CC of diabetic mice (1.27 + 0.2 mN) was similar to that observed in the control mice (1.26 + 0.4 mN). In the presence of the LRRC8 inhibitor, montelukast, PE-induced contraction of the CC was significantly reduced, reaching maximal contraction of 69 + 7% and 65 + 10% in the control and diabetic group, respectively. In the presence of the Nox1/Nox4 inhibitor, GKT137831, the contraction elicited by PE was reduced only in the diabetic group (68 + 9% of the maximal contraction), whereas in the control group this reduction was not significant (82 + 14% of the maximal contraction). Conclusions This is the first study demonstrating that, in the CC, LRRC8 modulates the contractile response induced by α-adrenergic stimulation and this may be associated with O2•- production, which plays a role in the development of ED. Since a great number of diabetic patients are not benefited by phosphodiesterase 5 inhibitors therapy, LRRC8 might be a potential therapeutic target for the development of new drugs to improve sexual function in diabetes. Disclosure No

The Effect of Spinal Anesthesia on Penile Length and Erectile Function in Patients Underwent Endoscopic Urological Surgeries: A Double-Blinded Randomized Clinical Trial

Background: Evidence shows that spinal anesthesia can alter the penile length and penile engorgement and the fact that patients undergoing spinal anesthesia may experience erectile dysfunction. We hypothesized that spinal anesthesia would not result in altered penile length; however, it can lead to temporary erectile dysfunction. Methods: A total of 73 patients referred to our hospital for endoscopic urological surgeries underwent either spinal anesthesia (SA, n = 37) or general anesthesia (GA, n = 36). We measured patients’ penile length in both stretched and flaccid states during surgery and compared changes in penile length between the SA and GA groups. We assessed erectile function in patients through a standard questionnaire one month and three months after the surgery. Results: No significant difference was observed in penile length during and two weeks after surgery between the SA and GA groups (P &gt; 0.05). Regarding erectile function, we observed a significant difference in the international index of erectile function (IIEF)-5 score between the two study groups one-month after surgery (P &lt; 0.05). However, there was no significant difference between the SA and GA groups three months after the surgery. Spinal anesthesia had no significant effect on penile length during and two weeks after surgery compared to general anesthesia. Conclusions: Patients undergoing SA may experience transient erectile dysfunction one month after surgery; however, they may develop transient erectile dysfunction, which is recovered three months after surgery.

From a Single Penile Suspensory Ligament to a Penile Suspensory Apparatus: Application to the Buried Penis Surgery

Abstract Goals/Purpose The ligamentous system supporting the penis is widely called « penile suspensory ligament ». It supports and attaches the penis to the abdominal wall and the pubic bone. However, the complexity of the anatomy of the penile suspensory system was underestimated. The aim of this anatomical study was to describe the different ligamentous (features, insertion sites, path) and their functions. Methods/Technique The first step consisted in a description of the different components of the penile suspensory apparatus on two cadavers embalmed by the Thiel method. The second part was an evaluation of the function of each ligament on freshly dead cadavers. In the third stage, we applied those findings to an exploratory cohort of patients undergoing a penile lengthening surgery for buried penis. Results/Complications The penile suspensory apparatus consisted in four ligaments from anterior to posterior : the fundiform ligament, the suspensory ligament, dense vertical ligament and the arcuate ligament. The first two were loose, non-stabilizing and the two posterior ones were dense and stabilizing. In our cohort, 12 patients were included. The mean BMI was 38. The mean pre-operative flaccid length was 4.1 cm [2.2 cm – 7 cm] and at 6 months 8.2 cm [5.2 cm - 11.5 cm] which represents a mean augmentation of 100%. The mean pre-operative circumference at a flaccid state was 8.2 cm [2 cm – 11.5 cm] and at 6 months post-operative was 12.6 cm [8.3 cm - 16 cm] which represents a mean augmentation of 85.7%. The most common complication was a phimosis. Conclusion We have described the detailed anatomy of the penile suspensory apparatus. It is the first time that the dense vertical ligament was brought to light. To avoid instability in penile lengthening, the posterior part of the dense vertical ligament and the arcuate ligament must be spared.