Rigid Erection Research Articles

274 Outcomes Of Intralesional Collagenase Clostridium Histolyticum (CCH) In Peyronie’s Disease

The IMPRESS trials estimated that 75% of men will experience 25% curvature improvement with a mean of a 30% curvature improvement. To describe our experience and define predictors of improvement. We retrospectively reviewed records of men with PD who underwent CCH treatment. Men received up to 8 injections of CCH, divided into 4 cycles. Patients underwent a baseline, interim (between cycles 2 and 3) and end-of-treatment (EOT) curvature assessment (CA). CA were performed in the office using goniometry after a pharmacologically-induced rigid erection. 2 hours of daily traction therapy was used to standardized mechanical therapy. Patient demographics, PD characteristics and outcomes were recorded. Two different definitions of curvature improvement were used: absolute change (10o) and percentage change (>25%). Three categories degrees of response were evaluated: improvement (>10o), unchanged (±10o) or worsened (>10o). Multivariable analysis (MVA) was performed to explore predictors of improvement. Sub-group analysis was performed to evaluate improvement rates in groups with different baseline curvature: group A <30°, B 30–60° and C >60°.

MP43-19 A CONTEMPORARY ASSESSMENT OF NORMAL ERECTION PHYSIOLOGY

You have accessJournal of UrologySexual Function/Dysfunction: Basic Research & Pathophysiology I1 Apr 2018MP43-19 A CONTEMPORARY ASSESSMENT OF NORMAL ERECTION PHYSIOLOGY Katherine Cockerill, Ram Pathak, Ciarra Boyne, and Gregory Broderick Katherine CockerillKatherine Cockerill More articles by this author , Ram PathakRam Pathak More articles by this author , Ciarra BoyneCiarra Boyne More articles by this author , and Gregory BroderickGregory Broderick More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.1418AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Classic studies using invasive caversonometry have associated a rigid erection with sustained intracavernous pressures > 80-90 mm Hg with erection pressures reaching supra-diastolic pressures during activation of bulbocavernous muscle contraction associated with pelvic stimulation. The contemporary assessment of erectile complaints relies on non-invasive color duplex Doppler ultrasound imaging (CDDU). The CDDU parameters associated with rigid erection are End Diastolic Flow Velocity = 0 (EDV0) or EDV reversed (EDVr), when intracavernous pressures equals or exceeds the diastolic blood pressure, respectively. The aim of our study is to identify age-specific diastolic blood pressure (DBP) parameters for patients who achieved normal rigidity following penile injection of Alprostadil associated with EDV0 or EDVr during CDDU. METHODS We retrospectively reviewed 97 men complaining of erectile dysfunction (ED) who demonstrated normal/sustained rigidity. Blood pressure measurements were recorded at the time of CDDU. Other parameters recorded were Peak Systolic Velocity, Resistive Index, EDV, age, BMI, co-morbidities and duration of erectile dysfunction complaints. RESULTS A total of 97 patients with a median age of 57 years and a mean BMI of 26.6 underwent CDDU. All patients achieved rigid erection following PGE1 injection; all but three patients required alpha-adrenergic injection for erection reversal at 60 minutes. Fourteen patients were classified as EDV0 (18.5%) and 83 patients were classified as EDVr (85.5%). Twenty-nine patients (29.9%) had a diagnosis of hypertension. The mean DBP at time of CDDU was 76.7 mm Hg (with SD = 10.7). The mean diastolic blood pressure between men with EDV0 and EDVr was not significantly different (79.7 vs. 75.8 mm Hg, p = 0.13). For patients age <50 years with EDV0, the median DBP was 79 with interquartile range (71, 83). For patients age > 50 years with EDV0, the median DBP was 85 with IQR (73, 89). For patients age < 50 years with EDVr, the median DBP was 76 with IQR (70, 81). For patients age > 50 years with EDVr, the median DBP was 78 with IQR (66, 84). CONCLUSIONS Our study suggests that the previously established parameters for intracavernous pressure >80-90 mm Hg for normal erection may be too high. We found mean diastolic blood pressures of 75-79 mmHg in men complaining of ED who had vascular normal erections following intracavernous Alprostadil. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e586 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Katherine Cockerill More articles by this author Ram Pathak More articles by this author Ciarra Boyne More articles by this author Gregory Broderick More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Correlation between peak systolic velocity and diameter of cavernosal arteries in flaccid versus dynamic state for the evaluation of erectile dysfunction

Previous studies have suggested that parameters measured in the flaccid state (FS) by penile duplex Doppler ultrasound (PDDU) may predict the outcome after intracavernosal injection (ICI). The aim of this study was to evaluate the association between peak systolic velocity (PSV) and cavernosal artery diameter (CAD) in the FS with PSV and clinical assessment of erection hardness (CAEH) after ICI. Fifty patients who underwent PDDU for erectile dysfunction were prospectively enrolled. PSV and CAD were measured in FS and then correlated with PSV and CAEH after ICI of 20 μg of e1 prostaglandin (PGe1). Even though PSV in FS demonstrated a significant correlation with PSV after ICI (P=0.04, r=0.21), none of the cutoff values tested (10, 13 and 15 cm s-1 in FS) had a combined sensitivity and specificity >80% to predict a PSV after ICI ⩾30 cm s-1. No correlation was observed between CAD in FS and PSV after ICI. Also, no association was observed between PSV in FS and development of a complete full rigid erection after ICI. Although PSV in FS statistically correlates with PSV after ICI, predictive values are low, making it non-reliable to predict accurately the response to ICI of 20 μg PGe1.

MP84-02 UTILITY OF 2D PHOTOGRAPHY IN THE ASSESSMENT OF PENILE CURVATURE IN MEN WITH PEYRONIE's DISEASE (PD): THE GOSOFT STUDY

You have accessJournal of UrologySexual Function/Dysfunction: Evaluation II1 Apr 2017MP84-02 UTILITY OF 2D PHOTOGRAPHY IN THE ASSESSMENT OF PENILE CURVATURE IN MEN WITH PEYRONIE's DISEASE (PD): THE GOSOFT STUDY Jean-Etienne Terrier, Leonardo Florez Valencia, Maciej Orkisz, Christian J Nelson, Lawrence C Jenkins, Phil Vu Bach, Eduardo P Miranda, Bruno Nascimento, and John P Mulhall Jean-Etienne TerrierJean-Etienne Terrier More articles by this author , Leonardo Florez ValenciaLeonardo Florez Valencia More articles by this author , Maciej OrkiszMaciej Orkisz More articles by this author , Christian J NelsonChristian J Nelson More articles by this author , Lawrence C JenkinsLawrence C Jenkins More articles by this author , Phil Vu BachPhil Vu Bach More articles by this author , Eduardo P MirandaEduardo P Miranda More articles by this author , Bruno NascimentoBruno Nascimento More articles by this author , and John P MulhallJohn P Mulhall More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.2643AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Curvature assessment (CA) in Peyronie's disease (PD) is a critical step in the evaluation of the PD patient. Assessment using combined intracavernosal injection and goniometry (IG) is the standard approach. Aim: to evaluate the utility of novel software (GoSoft) for the measurement of the PD deformity. METHODS Population: men with PD, who had a CA using IG. A rigid erection was an inclusion criterion for inclusion in this analysis. Degree of curvature was measured with a goniometer, simultaneously a photograph was taken. The photo was analyzed using GoSoft software by three observers at different time points, each being blinded to the goniometer assessment. The primary outcome was to compare the inter-observer and intra-observer reliability of GoSoft. We also aimed to compare the concordance between GoSoft and goniometry. We compare correlation for curvature ≤ 45 degrees and for > 45 degrees. We accepted a variability of 5 degrees and considered an under and over-estimation if the difference was >5 degrees. RESULTS 53 subjects were included. The intra-observer reliability was excellent, representing a high correlation ( r=0.96 to 0.98, p<0.001) with a variance between means of 1.3±0.6 degrees. The inter-observer reliability was also high (r=0.89 to 0.95, p<0.001) (Figure 1) with a variance between means of 2.2±1 degrees. The Pearson correlation coefficients (r) between the goniometer and GoSoft for each rater were: Rater 1: r=0.75, p<0.001; Rater 2: r=0.73, p<0.001; and Rater 3: r=0.80, p<0.001. This indicates strong agreement, but also suggests variability between the types of measurement. For the three raters, when comparing GoSoft to the goniometer, GoSoft accurately measured (within ±5 degrees) 45% of the curvatures, underestimated it by >5 degrees in 25% of the curvatures, and overestimated it by >5 degrees in 30% of the curvatures. The correlation appears to be higher for greater curvatures. For curvature ≤ 45 degrees, the correlations between goniometer and GoSoft ranged from: r=0.41-0.47, p=0.03; while, for curvatures > 45 degrees, the correlations ranged from: r=0.59-0.65, p<0.01. CONCLUSIONS GoSoft assessment is consistent with goniometry. The excellent reliability and reproducibility might provide a more standardized instrument for CA in men with PD. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e1138-e1139 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Jean-Etienne Terrier More articles by this author Leonardo Florez Valencia More articles by this author Maciej Orkisz More articles by this author Christian J Nelson More articles by this author Lawrence C Jenkins More articles by this author Phil Vu Bach More articles by this author Eduardo P Miranda More articles by this author Bruno Nascimento More articles by this author John P Mulhall More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Chromatographic fingerprinting as a strategy to identify regulated plants in illegal herbal supplements

Erectile dysfunction (ED) is a sexual disorder characterized by the inability to achieve or maintain a sufficiently rigid erection. Despite the availability of non-invasive oral treatment options, many patients turn to herbal alternatives. Furthermore, herbal supplements are increasingly gaining popularity in industrialized countries and, as a consequence, quality control is a highly important issue. Unfortunately, this is not a simple task since plants are often crushed and mixed with other plants, which complicates their identification by usage of classical approaches such as microscopy. The aim of this study was to explore the potential use of chromatographic fingerprinting to identify plants present in herbal preparations intended for the treatment of ED. To achieve this goal, a HPLC-PDA and a HPLC-MS method were developed, using a full factorial experimental design in order to acquire characteristic fingerprints of three plants which are potentially beneficial for treating ED: Epimedium spp., Pausinystalia yohimbe and Tribulus terrestris. The full factorial design demonstrated that for all three plant references a C8 column (250mm×4.6mm; 5µm particle size) is best suited; methanol and an ammonium formate buffer (pH 3) were found to be the best constituents for the mobile phase. The suitability of this strategy was demonstrated by analysing several self-made triturations in three different botanical matrices, which mimic the influential effects that could be expected when analysing herbal supplements. To conclude, this study demonstrates that chromatographic fingerprinting could provide a useful means to identify plants in a complex herbal mixture.

Penile vascular diagnostic categorization using penile duplex Doppler ultrasound: Differences in vascular hemodynamics parameters by differences in anatomic sampling location.

In 2013 the International Society for Sexual Medicine(ISSM) published the guidelines regarding the standard operating procedure (SOP) for penile duplex Doppler ultrasound (PDDU). Although ISSM-SOP have given important strides in reducing interobserver variability in PDDU by procedural protocol and parameters these guidelines do not address the anatomic location along the penis at which hemodynamic measurements have to be done. In our opinion a "double sampling" may be interesting to detect the arteriogenic or venogenic nature of the erectile dysfunction (ED). In particular sampling measurements at the "crus" (at the level of the peno-scrotal junction) may be significative for detection of veno-occlusive dysfunction (VOD),whereas an evaluation at "mid penis" (1/2 distance between peno-scrotal junction and coronal sulcus), may be useful to diagnose an arterial insufficiency (AI). We evalued 90 men, mean age 56.3, affected with ED of medium degree, responder to PDE5-I that urdergone to PDDU and also responder after pharmacologic intracavernosal injection (PII)of prostaglandin E1 20 mcg, with rigid erection and normal maintenance. We moreover evalued 90 men in youthful age (mean 35.2), in absence of vascular risk factors, no responder to PDE5-I that undergone to PDDU by PII at high dosage (bimix: prostaglandin E1 20 mcg, papaverine 20 mg). In the first pool the sampling at "mid penis" resulted significative for arterial insuffciency (AI) in 81% (73), in presence of normal or borderline end diastolic velocity (EDV). Sampling at the "crus" resulted negative for VOD in 90% (81). In the second pool, 66.6% (60) resulted responder with rigid erection and normal maintenance in presence of normal hemodynamic parameters: peak systolic velocity (PSV) and end diastolic velocity (EDV) both at the "crus" and at "mid penis" sampling. 33.4% (30) responded with a semirigid erection and manifested a constant deficit of maintenance; at the "crus"and at "mid penis" the hemodynamic arterial parameters resulted normal. At the "crus" the EDV resulted significantly augmented (VOD index) in 96.6% (29); at "mid penis" augmented EDV was founded in 50% (15). These observational data would be able to confirm the utility of a routinary "double sampling" procedure, at the "crus" and at "md penis", during PDDU in order to better distinguish between VOD or AI or in any case to be useful to stimulate a future more precise standardization in execution of PDDU examination.

Tunical Outer Layer Plays an Essential Role in Penile Veno-occlusive Mechanism Evidenced from Electrocautery Effects to the Corpora Cavernosa in Defrosted Human Cadavers

To determine the exact anatomical structure for establishing penile veno-occlusive function, we sought to conduct a hemodynamic study on defrosted human cadavers. Thirteen penises were used for this experiment, and 11 intact penises were allocated into the electrocautery group (EG, n = 6) and the ligation group (LG, n = 5). A circumcision was made on the penis to access the veins. Two #19 scalp needles were fixed in the 3 and 9 o'clock positions in the distal penis for colloid infusion and intracavernous pressure (ICP) monitoring, respectively. For the EG, the deep dorsal vein and cavernosal vein trunks were freed for 3-5 cm where at least 3 emissary veins were identified via opening Buck's fascia; these veins underwent electrocautery at 45 watts, while the ICP was maintained at 0, 50, 75, 100, 125, and 150 mmHg, respectively. For control, venous ligation was made but at the ICP of 150 mmHg. A tissue block including the emissary vein was then obtained for histological analysis. Except all in the EG and those whose ICP exceed 125 mmHg in the EG, the sinusoids of the corpora cavernosa sustained varied fulgurated fibrosis in every specimen and the severity appeared reversely commensurate with the ICP regarding sinusoidal clumping and darkish bands (P <.02 and .01 respectively). We conclude that the tunica albuginea can prevent the electrocautery damage to intracavernous sinusoids once the ICP reached a level corresponding to a rigid erection. The outer tunica plays an essential role in fulfilling the veno-occlusive mechanism.

Excision and Patch Grafting of a Lateral Peyronie's Plaque-Utilizing a Longitudinal "Window" Approach.

IntroductionPeyronie’s disease (PD) is a debilitating disorder in which collagen deposition, fibrosis, and plaques in the tunica albuginea result in penile curvature, shortening, and pain. For severe curvatures requiring plaque incision or excision with grafting (PIEG), a subcoronal circumcising incision with penile degloving has historically been used.AimsThe aim of this study was to report our unique approach to PIEG via a longitudinal “window” incision for the correction of PD, minimizing the surgical manipulation and dissection accompanying the traditional circumcising incisional approach that may lead to increased postoperative edema, pain, and prolonged healing time.MethodsA patient presented with a stable, painless, 90-degree midshaft leftward curvature causing penetration difficulties and painful intercourse for his partner. His Sexual Health Inventory for Men (SHIM) score was 23. The patient opted for surgical correction with plaque excision and grafting via a 4-cm longitudinal incision overlying the point of maximal curvature along the left lateral penile shaft. This direct access to the left corpus cavernosum and plaque, along with dissecting skin, dartos, and Buck’s fascia, created a window with sufficient exposure for excision and patch grafting.Main Outcome MeasuresThe main outcome measures were objective data and subjective data in men undergoing PIEG via lateral longitudinal “window” incision for PD repair.ResultsThe plaque was excised and a porcine small intestinal submucosa graft was sewn in. Intraoperative artificial tumescence at the end of surgery revealed complete correction of the curvature. The patient experienced painless rigid erections by postoperative day three with minimal penile edema. By postoperative week four, he could successfully partake in coitus. His SHIM score remained unchanged. At maximum follow-up 6 months postoperatively, he still endorsed excellent cosmetic and functional outcomes with spontaneous unassisted erections and no recurrence of his curvature.ConclusionA lateral longitudinal incision for PIEG is a feasible technique and may reduce the postoperative morbidity and dissection required with traditional circumcising incision with penile degloving. Larger comparative studies are necessary for further evaluation.

MP51-19 COLOR DUPLEX DOPPLER ULTRASOUND (CDDU): CAN WE CATEGORIZE CAVERNOUS VENOUS OCCLUSIVE DISEASE (CVOD) AS MILD, MODERATE AND SEVERE?

You have accessJournal of UrologySexual Function/Dysfunction/Andrology: Evaluation II1 Apr 2015MP51-19 COLOR DUPLEX DOPPLER ULTRASOUND (CDDU): CAN WE CATEGORIZE CAVERNOUS VENOUS OCCLUSIVE DISEASE (CVOD) AS MILD, MODERATE AND SEVERE? Ram Pathak, Russell Chavers, Bhupendra Rawal, and Gregory Broderick Ram PathakRam Pathak More articles by this author , Russell ChaversRussell Chavers More articles by this author , Bhupendra RawalBhupendra Rawal More articles by this author , and Gregory BroderickGregory Broderick More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1756AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Cavernous venous occlusive disease (CVOD) is defined as a failure to maintain adequate erections despite appropriate arterial inflows and can be non-invasively diagnosed with Color Duplex Doppler Ultrasound (CDDU). The key to making this diagnosis is to identify men with normal cavernous arterial inflows, who fail to achieve rigid erection. The aim of our study was to evaluate the relationship between arteriogenic risk factors of ED and CVOD and determine if it is possible to grade the severity of CVOD with non-invasive Doppler metrics. METHODS A retrospective review was conducted on patients who underwent analysis by CDDU from January 2010 to June 2013. Resistive Indices (RI) were calculated using Peak Systolic Velocity (PSV) and End Diastolic Velocity (EDV) values by the following formula: RI=(PSV-EDV)/PSV. Patients were sub-classified based on the following CDDU parameters: Pure-group (Right and Left pre- and post-PSV≥35cm/s), Intermediate group (Right and Left pre- or post-PSV≥35cm/s), and mixed group (Right or Left pre- or post- PSV≥35cm/s). RESULTS A total of 89 patients, with a mean age of 60 (19-86), mean BMI of 26.5 (19-39.3), and a mean age of ED onset of 52 (13-80) satisfied the criteria of pure and intermediate group (n=75 and n=14). Of the pure and intermediate groups, arteriogenic risk factors were not well represented: hypertension (10%), diabetes mellitus (12%), heart disease (10%), smoking (16%), and hyperlipidemia (44%). When comparing the pure group to the intermediate group plus the mixed group, the median age and median age of ED onset favored younger patients in the pure group (60 vs. 63, p=0.043 and 52 vs. 56, p=0.017). When sub-stratifying the pure group into tertiles, the following RI cutoffs were discovered: mild (81.6-94.0), moderate (72.6-81.5) and severe (59.5-72.5). With these three group's comparison, co-variates such as post-PSV right (p = 0.032), post- PSV left (p= 0.003), average post-PSV (p = 0.002), and SHIM score categories (SHIM scores: 1-10 vs. 11- 20, P = 0.030) were statistically significantly different. CONCLUSIONS Unlike arteriogenic ED, the etiology and risk factors for CVOD remain indeterminate and further research into this field is critical. The data does support a correlation between CVOD and age, with younger patients more likely exhibiting CVOD. The pure group analysis supports a correlation between SHIM score and RI value and provides an evidence-based classification of CVOD as mild, moderate or severe. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e627 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ram Pathak More articles by this author Russell Chavers More articles by this author Bhupendra Rawal More articles by this author Gregory Broderick More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Improvement in erection hardness and intercourse success with first dose of sildenafil citrate 100 mg

PurposeTo determine, in men with erectile dysfunction (ED), the extent of improvement in erection hardness and in the rate of successful sexual intercourse (SSI) during the final intercourse attempt using sildenafil 50 mg compared with the subsequent initial attempt after a dose increase to 100 mg.Patients and methodsThis post hoc analysis used data from two randomized, double-blind, placebo-controlled studies of flexible-dose sildenafil for the treatment of men with ED, who were given sildenafil 50 mg or matching placebo, to be taken as needed before sexual intercourse. After 2 weeks, those with no tolerability concerns were titrated up to 100 mg, forming the subgroup of this analysis. The main outcome measures were event log data, including an Erection Hardness Score (EHS) and a question on SSI (“Did your erection last long enough for you to have successful sexual intercourse?”), for each attempt at sexual intercourse, analyzed by study and treatment group (sildenafil or placebo). Statistical comparisons were conducted by using the Fisher’s exact test.ResultsIn both studies, the sildenafil group had a larger proportion of EHS4 (completely hard and fully rigid) erections (P < 0.001) and SSI (P < 0.005) compared with the placebo group, both before and after the dose increase. Between the final 50 mg sildenafil dose and the initial 100 mg sildenafil dose, the outcomes improved and significantly so in the larger study.ConclusionThe improved efficacy with sildenafil 100 mg versus 50 mg, which occurs rapidly, suggests that patients should be encouraged to use 100 mg if they are unable to achieve completely hard and fully rigid erections or SSI with the 50 mg dose.

Erectile function, erection hardness and tolerability in men treated with sildenafil 100 mg vs. 50 mg for erectile dysfunction

To compare efficacy and tolerability between 100-mg and 50-mg sildenafil doses in five double-blind, placebo-controlled (DBPC) fixed-dose studies. Doses were compared for the change (baseline to end of 8-12 weeks of DBPC treatment) in score on the Erectile Function (EF) domain of the International Index of Erectile Function (IIEF; from five fixed-dose studies, > 1500 men); the per-patient estimated percentage of occasions that a specified Erection Hardness Score (EHS; from two of the five fixed-dose studies, > 500 men) was achieved, computed from logistic regression; the odds ratio (OR) of achieving EHS3 (hard enough for penetration, but not completely hard) and EHS4 (fully hard and completely rigid); and the adverse event incidence by treatment (from all five fixed-dose studies). For the 100-mg vs. 50-mg dose, IIEF-EF score improvement was consistently greater across the five studies and was statistically significant when data from two studies with similar design were pooled (10.7 ± 0.64 vs. 8.9 ± 0.83, p = 0.0287); and during the first 2 weeks of treatment, the odds of achieving EHS4 erections were almost doubled in one study (OR = 1.77, p = 0.0398). Sildenafil was generally well tolerated at either dose. Men with erectile dysfunction treated with 100-mg compared with 50-mg sildenafil may be more likely to achieve a greater improvement in erectile function and, within the first 2 weeks, completely hard and fully rigid erections, with little or no greater risk to tolerability.

Colour duplex ultrasound and simplified corporoglanular shunting procedures with and without tunnelling in contemporary management of priapism

Colour duplex ultrasound and simplified corporoglanular shunting procedures with and without tunnelling in contemporary management of priapism

Does Anatomy of the Pubic Arch Interfere with the Maintaining of Erection?

There are men who suffer from unsustainable erections without any identified cause of erectile dysfunction, raising the question if anatomical alterations could be involved. Since early anatomical studies, it has been proposed that to achieve full penile rigidity, the blood must be blocked inside the penis by compression of the deep dorsal vein (DDV), the main venous collector under pubic symphysis. Using a recently developed caverno computed tomography (CT) scan technique, allowing the evaluation of the venous drainage of the corpora cavernosa (CC) during erection, we have studied some anatomical conditions of this important part of the erectile phenomenon. Puboischial rami angles were measured in axial CT images and calculated strictly on the upper insertion point of the CC, using axial submillimeter slices in 37 patients divided into 3 groups depending on the results of the caverno CT scan: (i) no leak; (ii) superficial veins leaking; and (iii) drainage through the DDV and/or preprostatic plexus. In addition same angles were measured in two randomly unselected populations of men (N = 30), and women (N = 23) who underwent pelvic CT scan for various reasons, unrelated to their sexual or genital condition. The angles made by both puboischial rami were measured in patients with and without veno-occlusive dysfunction and in unselected samples of men and women. There is a significantly wider angle made by both puboischial rami in men without complete erection and without evidence of anomalous venous drainage (group 3) (72.2° ± 4.7° standard deviation [SD]), compared with both men with normal erection (group 1) (57.5 ± 5° SD) P < 0.00001, and men with incomplete erection and evidence of anomalous drainage (group 2) (57.7 ± 6° SD) P < 0.00001. If confirmed in larger samples, these results raise new questions on the mechanism and the role of these significant anatomical variations, yet unknown, in maintaining or not full rigid erections.

Sexual outcomes after organ potency-sparing surgery and glans reconstruction in patients with penile carcinoma.

Introduction:Radical surgery is the “gold standard” for treatment of invasive penile carcinoma but very poor aesthetic, functional and psychological outcomes have been reported. Our purpose was to assess the impact of organ potency-sparing surgery in locally confined carcinoma of the penis.Materials and Methods:We evaluated retrospectively 42 patients with early penile cancer (Ta,T1,T2), treated with glandulectomy and glanduloplasty with urethral mucosa and sparing of cavernosal apexes, or glandulectomy and limited apical resection in cases of Stage T2. Sexual function, ejaculation and libido were evaluated with an IIEF-15 questionnaire before the appearance of neoplasia (about three months before the surgery) and six months after surgery. Quality of life was evaluated by the Bigelow-Young questionnaire. The scores relating to two weeks prior to the surgery have been compared to those obtained six months after surgery. The statistical analysis was conducted using t-Student for repeated measures and analysis of variance.Results:Six months after surgery 73% of patients reported spontaneous rigid erections, 60% coital activity while 76% of the group treated with urethral glanduloplasty reported normal ejaculation and orgasm, regained an average of 35 days after surgery. The average IIEF-15 scores reported in the entire series in the domains of erection, libido and coital activity of the pre-cancer period were not statistically different than those recorded six months after surgery. In the group treated with glandular reconstruction, pre-and postoperative IIEF-15 mean scores related to ejaculation and orgasm domains were not significantly different. Mean scores of Bigelow-Young questionnaires related to sexual pleasure, familial, social and professional relationships showed significant improvement after surgery.Conclusions:Potency sparing-sparing surgical treatments have a positive impact on a wide spectrum of the patient's life including family relationships, and social and working conditions.

Standardization of Vascular Assessment of Erectile Dysfunction

ABSTRACT Introduction In-office evaluation of erectile dysfunction by color duplex Doppler ultrasound (CDDU) may benefit the decision-making process in regard to choosing the most appropriate therapy. Unfortunately, there is no uniform standardization in performing CDDU resulting in high variability in data expression and interpretation when comparing results among various centers, especially when conducting multicenter trials. Establishing standard operating procedures (SOPs) is a major step that will help minimize such variability. Aim This SOP describes CDDU procedure with focus on establishing uniformity and normative parameters. Main Outcome Measure Measure intra-arterial diameter, peak systolic velocity, end-diastolic velocity, and resistive index for each cavernosal artery. Methods After initial discussion with the patient about his history and International Index of Erectile Function evaluation describe procedural steps to the patient. Perform the CDDU in a relaxed state, scanning the entire penis (in B-mode image) using a 7.5- to 12-MHz linear array ultrasound probe. An intracorporal injection of a single or combination of vasoactive agents (e.g., prostaglandin E1, phentolamine, and papaverine) is then administered and CDDU performed at various time points, preferably with audiovisual sexual stimulation (AVSS). Results Monitor penile erection response (tumescence and rigidity) near peak blood flow. Self-stimulation or AVSS leaving the patient alone in room or redosing may be considered to decrease any anxiety and help achieve a maximum rigid erection. Conclusion Considering the complexity and heterogeneity of CDDU evaluation, this communication will help in standardization and establish uniformity in such data interpretation. When indicated, invasive diagnostic testing involving (i) penile angiography and (ii) cavernosography/cavernosometry to establish veno-occlusive dysfunction may be recommended to facilitate further treatment options.

Optimal strategy for penile rehabilitation after robot‐assisted radical prostatectomy based on preoperative erectile function

WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Removing of prostate for the treatment of localized prostate cancer is associated with a variable loss of erectile function due to injury of the nerves of erection during operation. Some researchers have reported that after nerve-sparing radical prostatectomy (RP), the natural recovery time of erectile function is at least 2 years. Factors such as thermal damage, ischaemic injury, mechanically induced nerve stretching and the local inflammatory effects of surgical trauma may also impair the cavernous nerves during RP. The concept of penile rehabilitation was first studied by Montorsi et al. in 1997. They showed that the use of any drug or device at or after RP could maximize the recovery of erectile function. Penile rehabilitation programmes (PRPs) with vasoactive agents, such as oral phosphodiesterase-5 inhibitors (PDE5Is), intraurethral and intracavernosal vasoactive agents, and vacuum erection devices (VEDs) can protect erectile tissue integrity and prevent corporal smooth muscle atrophy and diminish collagen formation. The present findings are consistent with previous reports that PRPs have a significant beneficial effect on early erectile function recovery and that preoperative erectile function is one of the important predictors of erectile function after RP. Patients can be referred for penile rehabilitation if they have any degree of erectile function (mild, moderate or normal) before operation. We also showed that the combination of PDE5Is and VEDs for PRPs offers the shortest erectile function recovery period. To define the optimal penile rehabilitation programme (PRP) based on preoperative Sexual Health Inventory for Men (SHIM) scores after robot-assisted radical prostatectomy (RARP). The medical records of 203 patients who underwent bilateral nerve-sparing RARP between 2007 and 2011 were reviewed for the present retrospective study. According to patients' preoperative erection status, group 1 (SHIM = 8-16), group 2 (SHIM = 17-21) and group 3 (SHIM = 22-25) were defined. After bilateral nerve-sparing RARP, phosphodiesterase-5 inhibitors (PDE5Is), a vacuum erection device (VED), the combination of PDE5Is and a VED, or none of them were utilized by all patients for penile rehabilitation. Treatment success was defined as a rigid erection suitable for successful sexual intercourse. The numbers of patients in groups 1, 2 and 3, respectively, were 9, 22 and 73, and the mean erectile function recovery periods (EFRPs) were 15.44 ± 7.73, 12.31 ± 8.12 and 8.73 ± 5.67 months (P < 0.05). Group 3 offered the best results for EFRP. Only PDE5Is or the combination of PDE5Is and VED use had a beneficial effect on EFRP (P < 0.05). Using PDE5Is and VED together provided the best result, but there was no difference between PDE5Is and a VED (P ≥ 0.05). After bilateral nerve-sparing RARP, PRP with PDE5Is, including the combination of PDE5Is and VED, has a beneficial effect on erectile function recovery across all levels of baseline erectile function. Further large randomized control studies are needed to validate these findings.

Penile Veins Are the Principal Component in Erectile Rigidity: A Study of Penile Venous Stripping on Defrosted Human Cadavers

The human erectile mechanism is an intricate interplay of hormonal, vascular, neurological, sinusoidal, pharmacological, and psychological factors. However, the relative influence of each respective component remains somewhat unclear, and merits further study. We investigated the role of venous outflow in an attempt to isolate the key determinant of erectile function. Dynamic infusion cavernosometry and cavernosography was conducted on 15 defrosted human cadavers, both before and after the systematic removal and ligation of erection-related penile veins. Preoperatively, an infusion rate of more than 28.1 mL/min (from more than 14.0 to 85.0 mL/min) was required to induce a rigid erection (defined as intracavernosal pressure [ICP] exceeding 90 mmHg). Following surgery, we were able to obtain the same result at a rate of 7.3 mL/min (from 3.1 to 13.5 mL/min) across the entire sample. Thus, we witnessed statistically significant postoperative differences (all P ≤ .01), consistently elevated ICP, lower perfusion volumes, and a general reduction in time taken to attain rigidity. The cavernosograms provided further evidence substantiating the critical role played by erection-related veins, whereas histological samples confirmed the postoperative integrity of the corpora cavernosa. Given that our use of cadavers eliminated the influence of hormonal, arterial, neurological, sinusoidal, pharmacological, and psychological factors, we believe that our study demonstrates that the human erection is fundamentally a mechanical event contingent on venous competence.

Physiology: Clinical implications for physicians and surgeons

SummaryRecent studies substantiate a model of the tunica albuginea of the corpora cavernosa as a bi-layered structure with a 360° complete inner circular layer and a 300° incomplete outer longitudinal coat spanning from the bulbospongiosus and ischiocavernosus proximally and extending continuously into the distal ligament within the glans penis. The anatomical location and histology of the distal ligament invites convincing parallels with the quadrupedal os penis and therefore constitutes potential evidence of the evolutionary process. In the corpora cavernosa, a chamber design is responsible for facilitating rigid erections. For investigating its venous factors exclusively, hemodynamic studies have been performed on both fresh and defrosted human male cadavers. In each case, a rigid erection was unequivocally attainable following venous removal. This clearly has significant ramifications in relation to penile venous surgery and its role in treating impotent patients. One deep dorsal vein, 2 cavernosal veins and 2 pairs of para-arterial veins (as opposed to 1 single vein) are situated between Buck’s fascia and the tunica albuginea. These newfound insights into penile tunical, venous anatomy and erection physiology were inspired by and, in turn, enhance clinical applications routinely encountered by physicians and surgeons, such as penile morphological reconstruction, penile implantation and penile venous surgery.

New Topical Formulation of Isosorbide Dinitrate in the Treatment of Male Impotence

The effect of a topical formulation of isosorbide dinitrate (2% w/w) in a lipophilic vehicle has been studied in 16 men (mean age 56 years, range 32–73) presenting impotence due to organic causes. Penile response occurred after a mean time of 20 min (range 15–35 min) and lasted for 65–85 min. Eight of the 16 patients developed a rigid erection which enabled them to achieve sexual intercourse. Tumescence occurred in six of the patients and no response was seen in two of the men. In the patients who achieved rigid erection, no side-effects were seen in either themselves or their partners. These data indicate that isosorbide dinitrate, with an appropriate vehicle, is a promising therapeutic approach to male impotence.

Satisfaction Profiles in Men Using Intracavernosal Injection Therapy

Intracavernosal injection therapy (ICI) is a well-established second-line therapy used in the treatment of erectile dysfunction (ED). Controversy exists as to whether oral phosphodiesterase type 5 inhibitors (PDE5i) or injection therapy lead to higher satisfaction. This study addressed ICI satisfaction in a modern cohort of patients in the PDE5i era. Patients on ICI for at least 6 months were included in our study. Patients were administered the International Index of Erectile Function (IIEF) at the initial visit. On subsequent visits, patients were administered the IIEF and the Erection Hardness Scale (EHS). Study end points were change in baseline scores in the satisfaction domains (SD) of the IIEF, type of injection medication used, and predictors of satisfaction. Multiple logistic regressions were performed for predictors of satisfaction. One hundred twenty-two patients met inclusion criterion. Mean time to follow-up was 25±12 months (range 6-106 months). Sixty-five percent of patients continued injections at the time of follow-up. When SD scores were examined, intercourse SD scores increased from 4.8±1.7 at baseline to 12.3±3.1 (P<0.01); overall SD scores increased from 4.1±1.8 to 7.2±2.0 (P<0.05). On multivariate analysis, predictors of satisfaction included older age (odds ratio [OR]=2.1), younger partner age (OR=2.5), clinically significant increase in the erectile function domain score (OR=3.1), and attainment of a "fully rigid" erection (EHS 4) (OR=6.8). We have evaluated satisfaction in a modern cohort of ICI patients. While dropout rates are significant, for those patients who continue to inject, we have found high levels of satisfaction using the IIEF, the gold standard for evaluation of erectile function. On multivariate analysis, we found that older age, younger partner age, and fully rigid erections were predictors of increased satisfaction. ICI remains a robust second-line therapy in the treatment of ED even in the era of PDE5i.