A preliminary investigation of a novel method to manipulate penis length to measure female sexual satisfaction: a single-case experimental design.

OBJECTIVES: To investigate a novel methodology and explore whether artificially reducing the depth of penetration during intercourse matters to women. STUDY DESIGN AND METHODS: A study with a single-case experimental design ('n of 1'), in which a heterosexual couple act as their own control and the study is then replicated in subsequent couples, was conducted. Thirty-five couples were assessed for eligibility to participate. Twenty-nine couples without any sexual problems were randomized and 12 submitted sufficient data to analyse. As a proxy for reducing penis length, we artificially reduced the depth of penetration by using different sizes of silicone rings around the base of the man's erect penis. The main outcome measures were provided by the female partner on a scale of 0-100 and comprised: degree of (i) overall sexual pleasure; (ii) sexual pleasure from intercourse alone; and (iii) emotional connection to the male partner. The female partner was also asked before the experiment began to rate the degree of positive or negative change that would be personally meaningful for her. RESULTS: On average, reducing the depth of penetration led to a statistically significant 18% reduction of overall sexual pleasure with an average 15% reduction in length of the penis. The longer the erect penis, the less likely the rings were to have an impact on sexual pleasure. There was a range of individual responses, however, with a minority of women reporting that reducing the depth of penetration was more pleasurable on some occasions. CONCLUSIONS: Size may matter in women in a healthy stable relationship when there is penile shortening. Because of the small number of couples and the inclusion of men with an apparently long penis, our results are preliminary, and we welcome replication in a larger sample with a more diverse range of penile lengths. Our results should not be misinterpreted as meaning that increasing penile length will increase sexual pleasure in women.

A Review on Penile Length and Girth Issues in Penile Prosthetic Surgery.

PURPOSE OF REVIEW: The goal of this paper is to understand the reasons behind penile length and girth issues after penile prosthesis surgery and review the literature for current strategies employed to decrease these issues. RECENT FINDINGS: Measurement inconsistencies triggering further studies have shown there is a real loss of penile length and girth after prosthesis surgery. There have been varying hypotheses of why this happens, and numerous approaches have been proposed to help combat this in the preoperative, intraoperative, and postoperative settings. Erectile dysfunction prevalence is expected to increase; therefore it is important for urologists to understand the treatment options, including prosthesis surgery. Numerous techniques have been hypothesized and studied in smaller settings in the preoperative, intraoperative, and postoperative settings with regard to prosthetics surgery. However, larger studies are still needed to confirm these findings in order to help to counsel and educate patients preoperatively in addition to employing tactics to help minimize penile shortening.

Augmentation Phalloplasty for Acquired Penile Shortening: A Systematic Review of Techniques, Outcomes, Patient Satisfaction, and Limitations.

INTRODUCTION: Although an infrequent cause of small penile size in adult men, acquired penile shortening represents a particular reconstructive challenge due to preexisting penile anatomic deformities. AIM: With numerous techniques being performed, the purpose of our study is to assess available literature on length enhancement procedures used for acquired penile shortening deformities. METHODS: A systematic review was performed using the guidelines outlined in the Preferred Reporting Items for Systematic reviews and Meta-analyses. Medline/PubMed, Scopus, and Cochrane Databases were used to identify papers on augmentation Phalloplasty in non-transgender males with acquired penile shortening from 1990 to 2018. MAIN OUTCOME MEASURE: Outcomes, complications, and patient-reported satisfaction were analyzed. RESULTS: 12 articles, involving 931 patients and 8 primary procedures, met our inclusion criteria. The majority of articles had level of evidence of 4 (83%) and Newcastle Ottawa Scale score of 6 (92%, moderate risk of bias). All studies reported mean penile length gain; however, inconsistent methodology was used when measuring penile dimensions. Mean length gain ranged from 0.6 to 6.4 cm. Overall, the mean complication rate for all techniques ranged from 0% to 50%. Post-operative satisfaction was reported in 10 (83%) studies, 7 of which used a validated scale. Patients were generally satisfied, with reported satisfaction rates ranging from 77% to 100%. CLINICAL IMPLICATIONS: While numerous procedures have been described, the significant limitations in the available data preclude identifying a single superior procedure. STRENGTHS & LIMITATIONS: The significant heterogeneity in the reported literature is a limitation of this study and highlights the need for standardized reporting. However, this study is the first to analyze augmentation phalloplasty literature in the setting of acquired penile shortening. CONCLUSION: Augmentation phalloplasty techniques for acquired penile shortening are evolving and are continuously being modified; best-practice guidelines are crucial to achieve safe and satisfactory outcomes in this population. Abu-Ghname A, Banuelos J, Davis MJ, et al. Augmentation Phalloplasty for Acquired Penile Shortening: A Systematic Review of Techniques, Outcomes, Patient Satisfaction, and Limitations. J Sex Med 2020;17:331-341.

A Novel Penile Splint as Early Traction Therapy After Grafting Techniques for Peyronie's Disease.

BACKGROUND: Some studies showed encouraging results on the efficacy and safety of penile traction therapy after Peyronie's disease (PD) surgery. The early traction therapy (ETT) could be an effective and safe approach to minimize penile shortening in patients undergoing PD surgery. AIM: To evaluate the feasibility, efficacy, and safety of a novel penile splint as ETT in patients with PD undergoing grafting techniques. METHODS: Patients with PD underwent plaque incision and grafting technique; at the end of the procedure, a novel penile splint (ETT) was applied to all patient. The device consisted of 2 10CH intubating stylets, self-adapted to each patient, that kept the penis stretched with the aid of non-absorbable sutures. The total expense for the materials needed to build each penile splint was less than 15 euros. This active traction was maintained for 1-3 weeks; then, we removed the stitches leaving the device on-site for a passive traction. Within 3-4 weeks from surgery, the penile splint was replaced by a standard penile traction device. OUTCOMES: The main outcomes evaluated at 6 months included stretched penile length (SPL), penile curvature, International Index of Erectile Function-erectile function (IIEF-EF) domain, patient satisfaction, and time to first satisfactory sexual intercourse. RESULTS: A total of 46 patients were enrolled. The median preoperative IIEF-EF, penile curvature, and SPL were 27 points, 70°, and 13 cm, respectively. The median follow-up was 15 months. The median postoperative IIEF-EF was 25 points (P < .001). The median residual penile curvature was 10° (P < .001). The median postoperative SPL was 13 cm (P = .269). 8 patients (17.4%) lost 1 cm of SPL; no shortening greater than 1 cm was recorded. The median time to first satisfactory sexual intercourse and patient satisfaction score was 6 weeks and 9 points, respectively. CLINICAL IMPLICATIONS: Our results could pave the way for a new line of research, which in turn could lead to an improvement in the postoperative management of the patient undergoing surgery for PD. STRENGTH & LIMITATIONS: This is the first study evaluating the ETT after PD surgery. The main limitation of this study is the lack of a randomized control group. Other weaknesses are the small sample size and the short follow-up time. CONCLUSION: Our novel penile splint is inexpensive, easy to assemble, and adaptable to the patient. ETT using this novel device, followed by standard traction therapy, seems to be feasible, effective, and safe. Fernández-Pascual E, Manfredi C, Cocci A, et al. A Novel Penile Splint as Early Traction Therapy After Grafting Techniques for Peyronie's Disease. J Sex Med 2020;17:1819-1824.

Prevalence and Predicting Factors for Commonly Neglected Sexual Side Effects to External-Beam Radiation Therapy for Prostate Cancer.

INTRODUCTION: Changes in sexual function other than erectile dysfunction are sparsely investigated after radiation therapy for prostate cancer. AIM: To investigate orgasmic dysfunction, urinary incontinence during sexual activity, changes in penile morphology, and sensory disturbances in the penis in patients with prostate cancer treated with external-beam radiation therapy (EBRT). METHODS: In February 2015, men treated with EBRT at our center 3 months to 5 years previously (N = 519) received a study-specific questionnaire. This was developed from purpose-built questions and validated tools including the Erection Hardness Scale. All patients had received a radiation dose of 78 Gy. Androgen deprivation therapy was administered according to disease characteristics. MAIN OUTCOME MEASURES: Outcome measurements were prevalence rates and predictors of these side effects as identified by multivariate logistic regression analyses. RESULTS: One hundred nine patients were eligible (sexually active and had completed androgen deprivation therapy) for inclusion. Twenty-four percent reported anorgasmia, 44% reported a decreased intensity of their orgasms, and 40% reported that the time it took to reach orgasm had increased. Eleven percent reported anejaculation. Fifteen percent reported orgasm-associated pain. Only 4% reported urinary incontinence during sexual activity. Subjective penile length loss in excess of 1 cm was reported by 42%. Twelve percent reported an altered curvature of their penis after EBRT. Six percent reported painful erections. Twenty-seven percent reported decreased sensitivity in the penis after EBRT, 2% reported a cold sensation, and 2% reported paresthesia. Increasing time since final treatment increased the risk of penile sensory disturbances (odds ratio = 1.05; P = .028). CONCLUSION: Orgasmic dysfunction, changes in penile morphology, and sensory disturbances in the penis are common side effects of ERBT. Patients should be properly informed of the occurrence of these side effects before deciding which treatment to pursue. Frey A, Pedersen C, Lindberg H, et al. Prevalence and Predicting Factors for Commonly Neglected Sexual Side Effects to External-Beam Radiation Therapy for Prostate Cancer. J Sex Med 2017;14:558-565.

Prevalence and predicting factors for commonly neglected sexual side effects to radical prostatectomies: results from a cross-sectional questionnaire-based study.

INTRODUCTION: Altered perception of orgasm, orgasm-associated pain, penile sensory changes, urinary incontinence (UI) during sexual activity, penile shortening (PS), and penile deformity following radical prostatectomy (RP) have received increasing attention from researchers. AIM: The aim of this study is to describe the prevalence and predictors of the above-mentioned side effects. METHODS: This was a cross-sectional questionnaire-based study among men who had undergone RP between 3 and 36 months prior to study inclusion. Predicting factors were identified through logistic regression analyses. MAIN OUTCOME MEASURES: The primary outcome measures were prevalence rates of the above-mentioned side effects. RESULTS: Overall, 316 questionnaires were available for analyses. Of the sexually active patients (n = 256), 12 (5%) reported anorgasmia, whereas 153 (60%) reported decreased orgasm intensity. Delayed orgasms were reported by 146 (57%). Twenty-three patients (10%) had experienced pain during orgasm. UI during sexual activity were reported by 99 patients (38%). Out of the whole population, 77 patients (25%) reported sensory changes in the penis. A total of 143 patients (47%) reported a subjective loss of penile length of >1 cm. An altered curvature of the penis was reported by 30 patients (10%). Patients had increasing risk of UI during sexual activity (odds ratio [OR] 1.17; 95% confidence interval [CI] 1.10-1.25) and orgasmic dysfunction (OR 1.09; 95% CI 1.01-1.16) with increasing International Consultation on Incontinence Questionnaire scores. Erectile dysfunction (OR 1.81; 95% CI 1.07-3.10) and a high body mass index (OR 1.10; 95% CI 1.02-1.19) increased the risk of PS after RP. Nerve-sparing (OR 0.32; 95% CI 0.16-0.95) reduced the risk of PS. CONCLUSIONS: Orgasm-associated problems, UI during sexual activity, penile sensory changes, PS, and penile deformity are common side effects to RP. Daytime UI, erectile dysfunction, and nerve-sparing status can help identify patients at risk.

Prevalence and predicting factors for commonly neglected sexual side effects to brachytherapy for prostate cancer: a cross-sectional observational study.

Background: Low-dose-rate brachytherapy (LDR-B) is an established treatment for localized prostate cancer. However, while erectile function is relatively well documented, other changes in sexual function are sparsely investigated. Aim: The study sought to investigate orgasmic dysfunction, urinary incontinence during sexual activity (UIS), changes in penile morphology, and sensory disturbances in the penis following LDR-B. Methods: A cross-sectional questionnaire-based study in patients who underwent LDR-B at our center from 2010 to 2020. The questionnaire included the International Index of Erectile Function-Erectile Function Domain (IIEF-EF) and questions on orgasm, UIS, changes in penile morphology, and penile sensory disturbances. Outcomes: Outcomes were prevalence rates of altered perception of orgasm, orgasm associated pain, anejaculation, UIS, alterations in penile morphology, penile sensory disturbances, and predictors of these side effects. Results: Overall, 178 patients responded to the questionnaire. The median age was 70 years (range, 51-83 years), and the median time since LDR-B was 93 months (range, 21-141 months).Overall, 142 (80%) were sexually active and 126 (70.8%) had erectile dysfunction (ED). Of the sexually active patients, 8 (5.6%) reported anejaculation and 7 (4.9%) reported anorgasmia. Another 67 (46.9%) had decreased orgasmic intensity, while 69 (49.3%) reported an increased time to orgasm. Twenty-six (18.3%) patients had experienced orgasm-associated pain with a median visual analog pain score of 2. Considering overlap, 44 (31.0%) patients had an unchanged orgasmic function. Six (3.3%) patients had experienced UIS at least a few times. Penile length loss was reported by 45 (25.2%) patients. Seventeen (9.6%) patients reported an altered curvature of their penis and 9 (5%) had experience painful erection. Thirty-three (18.5%) patients had experienced decreased penile sensitivity. On multivariate analyses, ED was the only independent risk factor for altered perception of orgasm (odds ratio [OR], 6.6; P < .0001), orgasmic pain (OR, 5.5; P = .008), and penile shortening (OR, 4.2; P < .0056). No independent risk factors were identified for UIS or sensory penile disturbances. Clinical implications: Patients undergoing LDR-B should be adequately informed about possible side effects, and clinicians should inquire about these during follow-up visits. Strength and Limitations: We are the first to comprehensively explore the previously neglected side effects of LDR-B for prostate cancer. Limitations are the cross-sectional design assessing the cohort at different time points following their treatment and the response rate. Conclusions: Orgasmic dysfunction, changes in penile morphology, and sensory disturbances in the penis are common side effects of LDR-B for prostate cancer. UIS is only experienced by a small minority.

Expanding the Limits-Improving Penile Length With Inflatable Penile Prosthesis Implantation: A Review.

INTRODUCTION: Erectile dysfunction is a multifactorial disorder that increases in prevalence as men age. When medical therapy fails or when men are unwilling to try it, surgical intervention becomes the urologist's next best tool. However, the loss of penile length is of great concern to many patients, and there have been a myriad of ways to try to combat this fear from both patients and the surgeons themselves. In this review, we evaluate the current literature of these various approaches to improve penile length in penile prosthesis surgery. OBJECTIVES: To review novel techniques in penile prosthesis implantation surgery. METHODS: A literature search using PubMed was conducted to identify relevant peer-reviewed studies to penile prosthesis surgery. Search terms included penile prosthesis, penile shortening, sliding technique, Peyronie's Disease, erectile dysfunction, nondegloving, penile length, and Multiple Slice Technique. RESULTS: Novel techniques included preoperative techniques such as use of vacuum-assisted erection device, intraoperative techniques of aggressive dilatation and maximal sizing, ventral phalloplasty and/or scrotoplasty, suprapubic fat pad excision, relaxing tunica albuginea incisions, a sliding or slicing technique, or the postoperative use of penile rehabilitation. In addition, recognizing recall bias or inconsistencies in measurement techniques is important when evaluating men with possible penile shortening after penile prosthesis surgery. CONCLUSIONS: Advancements in surgical techniques and managing patient expectations can be crucial in the success of penile prosthesis surgery. Panuganti S, Kannady C, Wang R, Expanding the Limits-Improving Penile Length With Inflatable Penile Prosthesis Implantation: A Review. Sex Med Rev 2021;9:498-506.

Analysis of preoperative and postoperative expectations of penile implant candidates. / Evaluación de las expectativas preoperatorias y postoperatorias del candidato a prótesis peneana. Estudios de satisfacción.

Penile prosthesis implantation is a good option for the treatment of refractory erectile dysfunction. However, the patient's expectations, among other factors, condition his satisfaction after surgery. This review article aims to present the scientific evidence available concerning patient satisfaction with penile prosthesis surgery.

Mapping the prevalence of the neglected sexual side effects after prostate cancer treatment and the questionnaires used in their screening: a scoping review protocol.

BACKGROUND: Interventions to treat early prostate cancer (PCa) can leave men with debilitating sexual side effects. The cluster of side effects referred to as the neglected sexual side effects (NSSE) may remain permanent, undiagnosed and untreated because men are hesitant to disclose them. Questionnaires offer a discreet way into the discussion, subsequent diagnosis and possible treatment of the NSSE. This study will be conducted to map the evidence about the prevalence of the neglected sexual side effects (NSSE) after PCa treatment, and use of questionnaires in its diagnosis and screening. METHODS: This systematic scoping review will involve searching the following electronic databases: PubMed, Science Direct and Google Scholar. Following title searching, two-independent reviewers will conduct screening of abstracts and full articles. Eligibility criteria will guide the screenings. Data will be extracted from the included studies, and the emerging themes will be analysed. The review team will analyse the implications of the findings concerning the research question and aim of the study. The mixed method appraisal tool (MMAT) will be employed for quality appraisal of included studies. DISCUSSION: We anticipate finding a number of studies that describe the prevalence of NSSE after early PCa treatment and that report on using questionnaires to screen for the presence of symptoms including orgasm-associated incontinence, urinary incontinence during sexual stimulation, altered perceptions of orgasm, orgasm associated pain, penile shortening and penile deformity. The study findings will be disseminated through publication in a peer-reviewed journal, peer presentations and presentations at relevant conferences.

Long-term penile morphometric alterations in patients treated with robot-assisted versus open radical prostatectomy.

Neglected side effects after radical prostatectomy have been previously reported. In this context, the prevalence of penile morphometric alterations has never been assessed in robot-assisted radical prostatectomy series. We aimed to assess prevalence of and predictors of penile morphometric alterations (i.e. penile shortening or penile morphometric deformation) at long-term follow-up in patients submitted to either robot-assisted (robot-assisted radical prostatectomy) or open radical prostatectomy. Sexually active patients after either robot-assisted radical prostatectomy or open radical prostatectomy prospectively completed a 28-item questionnaire, with sensitive issues regarding sexual function, namely orgasmic functioning, climacturia and changes in morphometric characteristics of the penis. Only patients with a post-operative follow-up ≥ 24 months were included. Patients submitted to either adjuvant or salvage therapies or those who refused to comprehensively complete the questionnaire were excluded from the analyses. A propensity-score matching analysis was implemented to control for baseline differences between groups. Logistic regression models tested potential predictors of penile morphometric alterations at long-term post-operative follow-up. Overall, 67 (50%) and 67 (50%) patients were included after open radical prostatectomy or robot-assisted radical prostatectomy, respectively. Self-rated post-operative penile shortening and penile morphometric deformation were reported by 75 (56%) and 29 (22.8%) patients, respectively. Rates of penile shortening and penile morphometric deformation were not different after open radical prostatectomy and robot-assisted radical prostatectomy [all p > 0.5]. At univariable analysis, self-reported penile morphometric alterations (either penile shortening or penile morphometric deformation) were significantly associated with baseline international index of erectile function-erectile function scores, body mass index, post-operative erectile function recovery, year of surgery and type of surgery (all p < 0.05). At multivariable analysis, robot-assisted radical prostatectomy was independently associated with a lower risk of post-operative penile morphometric alterations (OR: 0.38; 95% CI: 0.16-0.93). Self-perceived penile morphometric alterations were reported in one of two patients after radical prostatectomy at long-term follow-up, with open surgery associated with a potential higher risk of this self-perception.

Penile traction therapy for Peyronie's disease-what's the evidence?

Penile traction therapy (PTT) is a new therapeutic option for men with Peyronie's disease (PD). However, it has a long history of use in other fields of medicine including bone, skin, skeletal muscle, and Dupuytren's. Mechanotransduction, or gradual expansion of tissue by traction, leads to the formation of new collagen tissue by cellular proliferation. As a molecular result, continuous extension of the fibrous plaque causes significant increases in collagenase and metalloproteinases, and, ultimately, to fibrous plaque softening and extension. This hypothetical knowledge has been supported by recent well designed experimental studies. Furthermore, several clinical papers have provided promising results on the use of PTT in PD patients. It has been shown in some series that the use of PTT significantly increases flaccid and stretched penile lengths and results in significant penile curvature improvement when compared to baseline. Furthermore, the use of PTT concomitantly with either verapamil or interferon α-2b has also been shown to be an effective therapy. Additionally, the beneficial effect of PTT on penile length before or after penile surgery in men with corporal fibrosis has been described. Finally, as a minimally invasive alternative treatment option to penile augmentation surgery in men with dysmorphophobia, PTT use has shown promising results by several experts. Studies have shown that PTT provides an acceptable, minimally invasive method that can produce effective and durable lengthening of the penis in men complaining of a small/short penis. There are, however, several criticisms related to the designs of the reported studies, such as small sample size and selection bias. Well-designed studies with larger numbers of patients and longer follow-up periods are, however, needed to establish the true benefits of PTT.