Review of Ischemic and Non-ischemic Priapism.

PURPOSE OF REVIEW: Priapism is a rare condition that has different presentations, etiologies, pathophysiology, and treatment algorithms. It can be associated with significant patient distress and sexual dysfunction. We aim to examine the most up-to-date literature and guidelines in the management of this condition. RECENT FINDINGS: Priapism is a challenging condition to manage for urologists, since the etiology is often multi-factorial and the suggested treatment algorithms are based on small studies and expert anecdotal experience, perhaps due to the rarity of the disorder. Ischemic priapism of less than 24 h can be managed non-surgically in most cases with excellent results. Ischemic priapism of more than 36 h is frequently associated with permanent erectile dysfunction. Management of prolonged priapism with penile shunting still may result in poor erectile function, so penile prosthesis can be discussed in these scenarios.

A Multicenter Investigation Examining American Urological Association Recommended Antibiotic Prophylaxis vs Nonstandard Prophylaxis in Preventing Device Infections in Penile Prosthesis Surgery in Diabetic Patients.

PURPOSE: American Urological Association (AUA) antibiotic prophylaxis recommendations may be insufficient for covering organisms commonly found in penile prosthesis infections. In this study we assess the difference between AUA recommended antibiotic prophylaxis and nonstandard prophylaxis in preventing device infections in penile prosthesis surgery performed in diabetic patients. MATERIALS AND METHODS: A multicenter, retrospective cohort study of diabetic patients undergoing primary penile prosthesis surgery was performed between April 2003 and August 2018. Eighteen institutions from the United States, Europe and Korea contributed. The association between antibiotic prophylaxis type and postoperative penile prosthesis infections, device explantations and revision surgeries was assessed. RESULTS: Standard AUA antibiotic prophylaxis was followed in 48.6% (391) of cases while nonstandard prophylaxis was used in 51.4% (413). Common nonstandard antibiotic prophylaxis included vancomycin-gentamycin-fluoroquinolone, clindamycin-fluoroquinolone, and vancomycin-fluoroquinolone among other combinations. Patients who received AUA prophylaxis had significantly more postoperative device infections (5.6% vs 1.9%, p <0.01) and explantations (8.3% vs 2.0%, p <0.001) compared to those who received nonstandard prophylaxis. Patients who received AUA prophylaxis had significantly higher odds of a postoperative device infection (OR 2.8, 95% CI 1.1-7.3) and explantation (OR 3.6, 95% CI 1.4-9.1) compared to those who received nonstandard prophylaxis. CONCLUSIONS: Diabetic men with erectile dysfunction who received standard AUA prophylaxis for penile prosthesis surgery had significantly greater odds of experiencing a postoperative device infection and device explantation compared to patients who received nonstandard prophylaxis. Our study provides a strong rationale for a prospective investigation to establish the most appropriate prophylaxis strategy in penile prosthesis surgery.

The Future of Penile Prosthetic Surgical Training Is Here: Design of a Hydrogel Model for Inflatable Penile Prosthetic Placement Using Modern Education Theory.

BACKGROUND: There is a significant need for a non-biohazardous, educational platform to equip and maintain the surgical skills required by urology trainees and low-volume implanters for inflatable penile prosthetic (IPP) placement. AIM: To design and develop an anatomic, hydrogel-based simulation platform for training and evaluate IPP placement using modern education theory. METHODS: The backward design concept was used as a framework in the design and development of an IPP simulation platform. Steps included delineating requirements from a physicians' perspective, translating requirements into engineering tasks (deliverables), developing a prototype, and pilot validation. Using a combination of 3-dimensional printing and hydrogel casting, a genitourinary tract model was constructed to replicate the appropriate steps of IPP placement guided by expert feedback. Full-immersion IPP simulations were performed through both infrapubic and penoscrotal approaches by 4 expert surgeons under operative conditions. Questionnaires evaluating the simulation's realism, value as a training tool, and further recommendations were completed. OUTCOMES: Using backward design educational pedagogy, a high-fidelity, full-procedural IPP simulation was fabricated and verified as an adequate educational tool for training and assessment. RESULTS: An expert consensus on the anatomic landmarks, steps and substeps, instruments, and errors to be included in the model was reached using a hierarchical task analysis and was successfully translated into a prototype hydrogel model. Experts performed all appropriate steps of IPP surgery and rated the simulation highly in terms of its realism and value as a training tool. On average, experts agreed that the model could function as a training tool, assessment tool, prerequisite for IPP accreditation, and requirement before live surgery. Experts stated they would have their trainees ideally complete an average of 1.75 models before live surgical training. All experts believed an operative checklist would be an ideal assessment tool. Witthaus MW, Saba P, Melnyk R, et al. The Future of Penile Prosthetic Surgical Training Is Here: Design of a Hydrogel Model for Inflatable Penile Prosthetic Placement Using Modern Education Theory. J Sex Med 2020;17:2299-2306.

Impact of Antimicrobial Dipping Solutions on Postoperative Infection Rates in Patients With Diabetes Undergoing Primary Insertion of a Coloplast Titan Inflatable Penile Prosthesis.

BACKGROUND: Modern-day penile prostheses use infection retardant coating to decrease rates of postoperative infection, subsequently reducing explantation and revision rates as well. The Coloplast Titan models are dipped into antimicrobial solutions right before implantation, and the components used for dipping can be tailored toward the patient. AIM: To compare infection, explantation, and revision rates among different dipping solutions used before implantation for patients with diabetes receiving a Coloplast Titan implant. METHODS: We systematically reviewed 932 patients with diabetes receiving a primary penile implant across 18 different centers from the period April 2003 to August 2018. Of those patients, 473 received a Coloplast device, whereas 459 received an AMS device. Data regarding the type of antimicrobial solution used before implantation were recorded for 468 patients receiving a Coloplast Titan, including whether or not they suffered a postoperative infection and if they underwent explantation and/or revision. Outcome rates were compared using Fisher's exact and Pearson's chi-square tests, and logistic regression modeling was performed to account for covariates. OUTCOMES: The main outcome measures of this study were postoperative infection, explantation, and revision rates. RESULTS: Of the total 932 patients reviewed, 33 suffered a postoperative infection. Of 468 patients receiving Coloplast implants, there was a 3.4% infection rate. The most commonly used antibiotic combination before dipping was vancomycin + gentamicin (59.0%). There was a significantly lower rate of postoperative infection, explantation, and revision when vancomycin + gentamicin was used than those associated with the use of all other dipping solutions ([1.4% vs 6.4%; P = .004], [1.1% vs 8.3%; P < .001], and [2.5% vs 12.5; P < .001], respectively). After adjusting for age, body mass index, preoperative blood glucose level, and hemoglobin A1c, the use of other dips was an independent predictor of postoperative infection (odds ratio: 0.191; P = .049). The inclusion of rifampin in the dipping solution trended toward being a significant risk factor for infection (P = .057). Including antifungals in the dipping solution did not affect infection (P = .414), explantation (P = .421), or revision (P = .328) rates. CLINICAL IMPLICATIONS: Vancomycin + gentamicin was the most efficacious combination of antibiotics used for dipping in terms of preventing postoperative infection and subsequent explantation and revision. STRENGTHS AND LIMITATIONS: Data were sampled across multiple institutions providing a large sample that may be more representative of the population of interest. A key limitation of the study was its retrospective nature, which prevented us from controlling certain variables. CONCLUSION: The use of rifampin did not provide the same type of protection, possibly representing a shift in resistance patterns of common bacteria responsible for device infection. Towe M, Huynh LM, Osman MM, et al. Impact of Antimicrobial Dipping Solutions on Postoperative Infection Rates in Patients With Diabetes Undergoing Primary Insertion of a Coloplast Titan Inflatable Penile Prosthesis. J Sex Med 2020;17:2077-2083.

Epidemiology of Penile Fractures in United States Emergency Departments: Access to Care Disparities May Lead to Suboptimal Outcomes.

INTRODUCTION: The epidemiology of penile fractures in the emergency setting is not well described. AIM: Examine the incidence, evaluation, management, risk factors predicting surgical repair or hospital transfer, and use of financial resources in patients presenting with penile fractures to the emergency departments (ED) nationwide in the Unites States. METHODS: ED visits with a primary diagnosis of penile fractures (International Classification of Diseases, Ninth Edition codes) between 2010-2014 were abstracted from the Nationwide Emergency Department Sample. MAIN OUTCOME MEASURE: Penile fracture incidence, disposition, hospital, and clinical factors which were associated with immediate surgical repair or transfer to another institution, and cost were investigated. RESULTS: 8,029 ED visits for penile fracture in the United States were observed, which represents a national incidence of 1.02 per 100,000 male subjects per year. No meaningful trends in incidence were observed over the 5-year period. 63.9% were treated non-surgically or discharged from the ED, 25.7% underwent surgical repair, and 10.3% were transferred to other institutions. Hospital factors which predicted surgical repair included Northeast region, teaching hospital status, trauma hospital status, high volume ED, and urban location. Clinical risk factors which predicted surgical repair included hypertension, smoking, alcohol dependence, drug abuse, erectile dysfunction, hematuria, urethral injury, and urinary retention. Factors leading to patient transfers included non-academic, rural and non-trauma hospitals, low economic income and low emergency department volume. In addition, weekend and spring presentation were associated with higher transfer rates, while summer presentation was associated with surgical repair. CLINICAL IMPLICATIONS: A large proportion of penile fractures are discharged from the ED, indicating possible health care access disparity. STRENGTHS & LIMITATIONS: This is one of the first population-based study of penile fracture incidence, disposition, risk factors which predict surgery or transfer, and cost in the US ED setting. The unexpected high number of discharges may be a result of misdiagnosis; alternatively these data may reveal previously under-reported management patterns in the community. CONCLUSION: This large retrospective study of penile fractures in the US ED setting demonstrates a stable incidence of penile fractures presenting to the US emergency departments. A quarter of patients undergo immediate surgical repair, 10% are transferred to other institutions and 63.9% of patients are discharged home. The high proportion of ED discharges may be due to access to health care disparities. Rodriguez D, Li K, Apoj M, et al. Epidemiology of Penile Fractures in United States Emergency Departments: Access to Care Disparities May Lead to Suboptimal Outcomes. J Sex Med 2019;16:248-256.

The Use of Antiseptic Solutions in the Prevention and Management of Penile Prosthesis Infections: A Review of the Cytotoxic and Microbiological Effects of Common Irrigation Solutions.

INTRODUCTION: The Mulcahy salvage fundamentally altered the management of penile prosthesis infections (PPI). Central to this procedure is a sequence of antiseptic irrigations that aims to remove and eradicate pathogenic microflora from the infected field, thus preparing for immediate reimplantation. The antiseptic solutions and their respective concentrations, however, have never been evaluated for efficacy. AIM: This review critically examines 3 commonly used antiseptic irrigation solutions (povidone-iodine [PVI], hydrogen peroxide [H2O2], and chlorhexidine gluconate [CHG]) in terms of their antimicrobial activity, cytotoxicity, and clinical use. METHODS: A PubMed literature review was performed on articles published between 2003 and 2018. Both preclinical as well as clinical studies from various surgical disciplines were included in this review. MAIN OUTCOME MEASURE: The original salvage protocol selected for irrigation solutions at concentrations that are likely detrimental to native tissue. RESULTS: All 3 agents demonstrate in vitro cytotoxic effects at subclinical concentrations, but H2O2 is associated with the most significant deleterious properties. It does not seem to broaden antimicrobial coverage beyond what is covered by PVI. Dilute PVI (0.35-3.5% with exposure time of at least 3 minutes) possesses the most robust clinical evidence as an intraoperative adjunct, reducing the incidence of postoperative infectious complications. chlorhexidine gluconate is a promising new agent but lacks clinical data. CLINICAL IMPLICATION: Improvements in the salvage protocol are warranted based on current evidence. Careful selection of lavage solution and usage of the lowest necessary concentration will help achieve desired antimicrobial activity while avoiding native tissue cytotoxicity. Strength and limitation: The study is limited by its retrospective nature, and the heterogeneity of literature reviewed precluded a formal meta-analysis. Furthermore, future studies will need to address the roles of normal saline and antibiotic irrigations as intraoperative adjuncts for infection prevention. CONCLUSION: Diluted PVI (0.35-3.5% for 3 minutes) may be beneficial in the prevention of PPI. Evidence supports its use both in the setting of primary implantation as well as salvage of infected hardware. An improved, evidence-based protocol may increase positive outcomes of urologic prosthetic surgery. Pan S, Rodriguez D, Thirumavalavan N, et al. The Use of Antiseptic Solutions in the Prevention and Management of Penile Prosthesis Infections: A Review of the Cytotoxic and Microbiological Effects of Common Irrigation Solutions. J Sex Med 2019;16:781-790.

Multicenter Investigation of Fungal Infections of Inflatable Penile Prostheses.

BACKGROUND: Fungal infections of inflatable penile prostheses (IPPs) are inadequately understood in the literature. AIM: To review a multi-institution database of IPP infections to examine for common patient and surgical factors related to IPP fungal infections. METHODS: This is a retrospective Institutional Review Board-approved analysis of 217 patients at 26 institutions who underwent salvage or device explant between 2001 and 2018. Patient data were compiled after an extensive record review. OUTCOMES: 26 patients (12%) with fungal infections were identified. RESULTS: 23 of 26 patients (83%) with a fungal IPP infection were either diabetic or overweight. 15 patients had undergone primary IPP implantation, and the other 11 had previously undergone an average of 1.7 IPP-related surgeries (range 1-3; median 2). The average age at implantation was 63 years (range 31-92; median 63). 18 of the 26 patients with fungal infection had diabetes (69%), with a mean hemoglobin A1c (HbA1c) value of 8.4 (range 5.8-13.3; median 7.5). Twenty-two patients (85%) were overweight or obese. The mean body mass index for all patients was 30.1 kg/m2 (range 23.7-45 kg/m2; median 28.4 kg/m2), and that for diabetic patients was 30.8 kg/m2 (range 24.1-45 kg/m2, median 29.7 kg/m2). Ninety-one percent of implants were placed with intravenous antibiotics, consistent with current American Urological Association guidelines: an aminoglycoside plus first- or second-generation cephalosporin or vancomycin or ampicillin/sulbactam or piperacillin/tazobactam. 65% (17 of 26) of infected IPPs had only fungal growth in culture. No patient had concomitant immunosuppressive disease or recent antibiotic exposure before IPP implantation. CLINICAL IMPLICATIONS: More than two-thirds of the fungal infections occurred in diabetic patients and 85% occurred in overweight or obese patients, suggesting that antifungal prophylaxis may be appropriate in these patients. STRENGTHS & LIMITATIONS: This is the largest series of fungal infections reported to date in the penile prosthesis literature. The overall number of such cases, however, remains small. CONCLUSION: Fungal infections represent 12% of all penile prosthesis infections in our series and were seen mostly in diabetic or overweight patients, who may benefit from antifungal prophylaxis. Gross MS, Reinstatler L, Henry GD, et al. Multicenter Investigation of Fungal Infections of Inflatable Penile Prostheses. J Sex Med 2019;16:1100-1105.

Infection Prevention Considerations for Complex Penile Prosthesis Recipients.

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

Surgical management of retained needle in a transgender woman's phallus.

Intracavernosal self-injection (ICI) is an effective treatment for erectile dysfunction. A rare but serious complication is needle breakage. We report an unusual case of a 51-year-old transgender female patient who did not desire gender-affirming surgery, and used ICI to treat her longstanding erectile dysfunction. She presented to the emergency department 2 months after needle breakage during ICI, and was subsequently successfully treated with intraoperative fluoroscopy and needle fragment extraction. It is important to recognize transgender patients may desire to preserve sexual function, and for providers to engage in discussion surrounding sexual health throughout treatment for gender dysphoria.

Bibliometric Analysis of Erectile Dysfunction Publications in Urology and Sexual Medicine Journals.

INTRODUCTION: Scientific literature has experienced a significant growth in the number of authors per publication each year. Erectile dysfunction (ED) is one of the most common urologic conditions, accounting for over 2.9 million outpatient visits per year. Given the prevalence of ED and the large literature base available on this condition, bibliometric analysis of the ED literature could provide urologists and sexual medicine specialists with a better understanding of publication trends in this topic area. AIM: The purpose of this study was to investigate trends in authorship, citations, and impact score for ED original and review articles published in urology and sexual medicine journals. METHODS: We analyzed ED original research and review articles indexed in MEDLINE between January 1, 2006, and December 31, 2016. Descriptive statistics were used to evaluate the mean number of authors for articles by journal type and time period (2006 vs 2016). Linear regression was used to examine the relationship between number of authors, number of citations, and relative citation ratio (RCR). MAIN OUTCOME MEASURE: The primary outcomes of interest included mean number of authors, citations, and RCR per manuscript by journal type and time period. RESULTS: A total of 3,516 articles were analyzed, 2,938 (83.6%) original and 578 (16.4%) review articles. The mean number of authors among ED publications increased from 4.8 in 2006 to 6.4 in 2016, a 34.4% increase. Original articles had a greater mean number of authors compared to review articles (6.0 vs 4.3, P < .001). The mean number of authors for original articles significantly increased from 5.0 in 2006 to 7.0 in 2016 (P < .001), an increase of 38.9%. A positive linear relationship was observed between mean number of authors and number of citations per manuscript (r = 0.015, P < .01) as well as RCR (r = 0.37, P < .0001). The largest authorship increases were observed in European Urology (78.8%), BJU International (78.6%), and Journal of Sexual Medicine (58.1%). CLINICAL IMPLICATIONS: Authorship trends should be taken into consideration when urologists and sexual medicine experts review ED articles for the purpose of informing patient care. STRENGTH AND LIMITATIONS: Primary strengths include a large literature base spanning multiple years for analysis and a systematic literature search to identify relevant ED literature. Findings are limited to ED literature published in the urology and sexual medicine journals analyzed. CONCLUSION: The number of authors per ED manuscript has significantly increased over time, most notably among original research articles. Increasing authorship was associated with more citations and higher RCR in the ED literature. Rezaee ME, Johnson HA, Munarriz RM, et al. Bibliometric Analysis of Erectile Dysfunction Publications in Urology and Sexual Medicine Journals. J Sex Med 2018;15:1426-1433.

Techniques of Ectopic Reservoir Placement and Their Pitfalls.

BACKGROUND: Ectopic placement of penile prosthesis reservoirs has become more common in patients whose space of Retzius has been compromised. AIM: To describe techniques and instruments used to place penile prosthesis reservoirs ectopically. METHODS: We present our method of placing ectopic reservoirs and review the literature for other techniques. We also catalog the instruments used for this purpose. OUTCOMES: Similar to traditional reservoir placement, successful ectopic reservoir implantation requires good cosmetic and functional success and low complication rates. RESULTS: Ectopic reservoir placement has been shown to be effective, to safely avoid bowel, bladder, and vascular injury, and to maintain excellent function and cosmesis. Multiple tools for ectopic placement have been described, but no data exist comparing their effectiveness and complications. Examples include dissection of the space anterior to the transversalis muscle using the surgeon's finger, a pediatric Yankauer suction tip, or a Foerster lung clamp. Instruments described to grasp and advance the reservoir include a sponge stick, a Foerster lung clamp, and the ectopic reservoir insertion tool (Sontec, Centennial, CO, USA). The effect of different instruments on the integrity of reservoir has not been extensively studied. CLINICAL IMPLICATIONS: Attention to technique and the instruments used to dissect the ectopic space and grasp the reservoir are crucial to successful ectopic reservoir placement. STRENGTHS AND LIMITATIONS: Reports of vascular, bowel, or bladder injuries during ectopic placement are exceedingly rare, as are reports of injury to reservoirs caused by traumatic grasping. However, no methods or tools have been compared in head-to-head trials. CONCLUSION: Ectopic placement is safe and effective, but differences between methods and instruments have not been delineated. Thirumavalavan N, Gross MS, Munarriz R. Techniques of Ectopic Reservoir Placement and Their Pitfalls. J Sex Med 2017;14:1451-1454.

V-Neck Technique: A Novel Improvement to the Infra-Pubic Placement of an Inflatable Penile Implant.

BACKGROUND: Infra-pubic placement of an inflatable penile prosthesis (IPP) has a well-known configuration deformity from contralateral tubing that crosses the corporal bodies, resulting in tubing visibility and irritation under the penile skin. AIM: To present a novel step to eliminate this tubing crossover deformity. METHODS: The V-neck technique was applied to five patients, two of whom underwent suprapubic fat pad excision with simultaneous infra-pubic IPP placement and three patients who underwent only infra-pubic IPP placement. The technique added an additional 1 minute of procedure time. The reservoir was placed on one (ipsilateral) side into the space of Retzius. OUTCOMES: Primary outcome measurements were esthetic appeal at follow-up, immediate postoperative complications, and difficulty of implementation of the technique. RESULTS: The technique included the following steps. (i) The standard infra-pubic approach, as popularized by Perito (J Sex Med 2008;5:27-30), was used to place the reservoir and cylinders. The ipsilateral and contralateral cylinders and the reservoir were clamped and unconnected. (ii) Finger dissection was used to create a sub-phallic window and a U-shaped aortic clamp was used to pass the contralateral tubing. (iii) After passing the green tubing through the window, all connections were performed in the usual fashion. Tubing crossover was eliminated, as was passage of the right and left cylinder tubes down their respective gutters. Postoperative follow-up at 2 weeks showed no visible tubing. CLINICAL IMPLICATIONS: This simple maneuver could help prevent the discomfort of tubing crossover deformity commonly seen after infra-pubic placement of an IPP. STRENGTHS AND LIMITATIONS: This unique maneuver can be applied to all infra-pubically placed IPPs. Limitations include the small patient population and short follow-up. Whether this maneuver will make revision surgery more difficult is unclear. CONCLUSION: This technique is a novel step to infra-pubic IPP placement that adds minimal operative time and could eliminate visible tubing. Shah BB, Baumgarten AS, Morgan K, et al. V-Neck Technique: A Novel Improvement to the Infra-Pubic Placement of an Inflatable Penile Implant. J Sex Med 2017;14:870-875.

Multicenter Investigation of the Micro-Organisms Involved in Penile Prosthesis Infection: An Analysis of the Efficacy of the AUA and EAU Guidelines for Penile Prosthesis Prophylaxis.

INTRODUCTION: Penile prosthesis infections remain challenging despite advancements in surgical technique, device improvements, and adoption of antibiotic prophylaxis guidelines. AIM: To investigate penile prosthesis infection microbiology to consider which changes in practice could decrease infection rates, to evaluate current antibiotic prophylaxis guidelines, and to develop a proposed algorithm for penile prosthesis infections. METHODS: This retrospective institutional review board-exempt multi-institutional study from 25 centers reviewed intraoperative cultures obtained at explantation or Mulcahy salvage of infected three-piece inflatable penile prostheses (IPPs). Antibiotic usage was recorded at implantation, admission for infection, and explantation or salvage surgery. Cultures were obtained from purulent material in the implant space and from the biofilm on the device. MAIN OUTCOME MEASURES: Intraoperative culture data from infected IPPs. RESULTS: Two hundred twenty-seven intraoperative cultures (2002-2016) were obtained at salvage or explantation. No culture growth occurred in 33% of cases and gram-positive and gram-negative organisms were found in 73% and 39% of positive cultures, respectively. Candida species (11.1%), anaerobes (10.5%) and methicillin-resistant Staphylococcus aureus (9.2%) constituted nearly one third of 153 positive cultures. Multi-organism infections occurred in 25% of positive cultures. Antibiotic regimens at initial implantation were generally consistent with American Urological Association (AUA) and European Association of Urology (EAU) guidelines. However, the micro-organisms identified in this study were covered by these guidelines in only 62% to 86% of cases. Antibiotic selection at admissions for infection and salvage or explantation varied widely compared with those at IPP implantation. CONCLUSION: This study documents a high incidence of anaerobic, Candida, and methicillin-resistant S aureus infections. In addition, approximately one third of infected penile prosthesis cases had negative cultures. Micro-organisms identified in this study were not covered by the AUA and EAU antibiotic guidelines in at least 14% to 38% of cases. These findings suggest broadening antibiotic prophylaxis guidelines and creating a management algorithm for IPP infections might lower infection rates and improve salvage success. Gross MS, Phillips EA, Carrasquillo RJ, et al. Multicenter Investigation of the Micro-Organisms Involved in Penile Prosthesis Infection: An Analysis of the Efficacy of the AUA and EAU Guidelines for Penile Prosthesis Prophylaxis. J Sex Med 2017;14:455-463.

The Malleable Implant Salvage Technique: Infection Outcomes after Mulcahy Salvage Procedure and Replacement of Infected Inflatable Penile Prosthesis with Malleable Prosthesis.

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

Use of High-Dose Phenylephrine in the Treatment of Ischemic Priapism: Five-Year Experience at a Single Institution.

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

External Mechanical Devices and Vascular Surgery for Erectile Dysfunction.

INTRODUCTION: The field of sexual medicine is continuously advancing, with novel outcomes reported on a regular basis. Given the rapid evolution, updated guidelines are essential to inform practicing clinicians on best practices. AIM: To summarize the current literature and provide clinical guidelines on penile traction therapy, vacuum erection devices, and penile revascularization. METHODS: A consensus panel was held with leading sexual medicine experts during the 2015 International Consultation on Sexual Medicine (ICSM). Relevant literature was reviewed and graded based on Oxford criteria to develop evidence-based guideline and consensus statements. MAIN OUTCOME MEASURES: The development of clinically relevant guidelines. RESULTS: Penile traction therapy is a viable therapy to modestly improve penile length as a primary therapy, before penile prosthesis placement in men with decreased penile length or after surgery for Peyronie's disease. It also might have a role in the acute phase of Peyronie's disease but has inconsistent outcomes in the long-term phase. Vacuum erection devices are effective in creating an erection satisfactory for intercourse, even in difficult-to-treat populations. They also might be used in the post-prostatectomy setting to maintain penile length but have insufficient evidence as a penile rehabilitation therapy. For vasculogenic erectile dysfunction, men with suspected arterial insufficiency can be evaluated with penile Duplex Doppler ultrasonography and confirmatory angiography. Penile revascularization procedures have consistently demonstrated benefits in very select patient populations; however, inadequate data exists to suggest the superiority of one technique. Men with vascular risk factors are likely poor candidates for penile revascularization, although veno-occlusive dysfunction and age are less significant. Therapies for treating primary veno-occlusive dysfunction are not recommended and should be reserved for clinical trials. CONCLUSIONS: Since the prior ICSM meeting, multiple developments have occurred in external mechanical devices and penile revascularization for the treatment of erectile and sexual dysfunction. Sexual medicine clinicians are encouraged to review and incorporate recommendations as applicable to their scope of practice.

Active Polysubstance Abuse Concurrent With Surgery as a Possible Newly Identified Infection Risk Factor in Inflatable Penile Prosthesis Placement Based on a Retrospective Analysis of Health and Socioeconomic Factors.

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

Sex Offenders Seeking Treatment for Sexual Dysfunction--Ethics, Medicine, and the Law.

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