Penile length is preserved after implant surgery.

OBJECTIVE: To investigate if there is a correlation between penile size measured preoperatively and erect penis after penile implant surgery (PI). A common cause of patient dissatisfaction after PI is caused by patients complaining that surgery has shortened the penis. It has been suggested that stretched penile length preoperatively is almost the same after surgery when the prosthesis is in erect status. However, no comprehensive data supports this theory. This prospective study was done to investigate this theory. PATIENTS AND METHODS: Standardised measurements of stretched penile length and girth were performed in theatre before PI implantation then re-measured at the end of the procedure with the penis in the erect position. We recorded type of PI, cylinder lengths and malleable rod diameters. All patients had data recorded on body mass index (BMI), hypertension (HTN), glycated haemoglobin (HbA1c ), and Peyronie's disease (PD). RESULTS: In all, 133 patients were assessed; 88 (66.2%) had a malleable penile prosthesis (MPP) and 45 (33.8%) an inflatable penile prosthesis (IPP). The median age and BMI were 56 years and 30 kg/m2 , respectively. In all, 40 (30.1%) patients had HTN, 37 (27.8%) had PD, and 89 (66.9%) were diabetic. The mean (SD) pre-implant stretched length was 12.8 (1.8) cm. The mean (SD) flaccid girth was 10.3 (1.2) cm. Postoperatively, the mean (SD) erect length and girth were 13.1 (1.7) cm and 11.3 (1.3) cm, respectively. Overall, there was a significant (P < 0.05) increase in both the mean (SD) length at +0.36 (0.63) cm, and girth at +1.04 (1.02) cm. Patients who had an IPP, had a greater increase in both length (mean [SD] 0.62 [0.72] cm) and girth (mean [SD] 1.7 [1.0] cm) compared to those who had a MPP (mean [SD] 0.22 [0.53] cm and 0.7 [0.87] cm, respectively) (P < 0.05). We investigated correlations between pre- and postoperative outcomes related to BMI, HTN, diabetes, and PD. None of these variables affected outcome. CONCLUSIONS: PI surgery does not significantly decrease penile size compared to the preoperative assessment. The outcome was not affected by co-morbidities. The preoperative length and girth correlated well with the immediate postoperative erect penis, although girth was not necessarily comparable in this series of patients measured under anaesthesia. Recording penile dimensions in the clinic and agreeing these with patients' preoperatively may be a way of improving satisfaction levels with this surgery.

Assessment of penile erection methods in rhesus macaques to model pharmacokinetics of antiretroviral drugs and penile infection with simian immunodeficiency virus.

BACKGROUND: An established macaque model to assess HIV interventions against penile transmission is currently not available. Physiological changes during penile erections may affect susceptibility to infection and drug pharmacokinetics (PK). Here, we identify methods to establish erections in macaques to evaluate penile transmission, PK, and efficacy under physiologic conditions. METHODS: Penile rigidity and length were evaluated in eight rhesus macaques following rectal electrostimulation (RES), vibratory stimulation (VS), or pharmacological treatment with Sildenafil Citrate (Viagra) or Alprostadil. RESULTS: Rectal electrostimulation treatment increased penile rigidity (>82%) and length (2.5 ± 0.58 cm), albeit the response was transient. In contrast, VS alone or coupled with Viagra or Alprostadil failed to elicit an erection response. CONCLUSION: Rectal electrostimulation treatment elicits transient but consistent penile erections in macaques. High rigidity following RES treatment demonstrates increased blood flow and may provide a functional model for penile PK evaluations and possibly simian immunodeficiency virus (SIV) transmission under erect conditions.

Penile Prosthesis Implantation in Patients with a History of Total Phallic Construction.

INTRODUCTION: Outcomes following penile prosthesis implantation in patients with a history of total phallic construction are not well described. AIM: The aim of this study was to evaluate outcomes following neophallus penile prosthesis placement. METHODS: Retrospective review penile prosthesis placement in patients with prior total phallic construction. GORE-TEX® (Gore Medical, Flagstaff, AZ) sleeve neotunica construction was utilized in all patients. MAIN OUTCOME MEASURE: Success defined as patient sexual activity with a functioning prosthesis. RESULTS: Thirty-one patients underwent neophallic prosthesis implantation at a mean 35.6 years of age. Prosthesis placement occurred at an average 56.3 months following phallic construction and follow-up was a mean of 59.7 months. Malleable prostheses were placed in 21 patients and inflatable in 10; implants were bilateral in 94%. Six percent experienced operative complications including a bladder injury (1) and phallic flap arterial injury (1). Postoperative complications occurred in 23% at a median 5.5 months following placement. Five prostheses were explanted secondary to infection or erosion and two additional required revisions. Of the explanted prosthesis two were later replaced without further complication. Eighty-one percent of patients were sexually active following prosthesis placement. CONCLUSIONS: Penile prosthesis placement is possible in patients with prior penile reconstruction/phallic construction. Although complications rates appear to be elevated in this population compared with historic controls of normal anatomic men, the majority of patients in this series were sexually active following prosthesis placement. This demonstrates the utility of prosthesis implantation in these difficult patients.

Restoring penis sensation in patients with low spinal cord lesions: the role of the remaining function of the dorsal nerve in a unilateral or bilateral TOMAX procedure.

AIMS: The recently developed TOMAX-procedure restores unilateral genital sensation, improving sexual health in men with a low spinal lesion (LSL). It connects one dorsal nerve of the penis (DNP) to the intact ipsilateral ilioinguinal nerve. We proposed bilateral neurotization for full sensation of the glans but this entails cutting both DNPs, risking patients' erection/ejaculation ability. The objective was to select patients for a bilateral TOMAX-procedure by measuring remaining DNP function, and perform the first bilateral cases. METHODS: In 30 LSL patients with no penile- but normal groin sensation selected for a unilateral TOMAX-procedure the integrity of the sacral-reflex-arc and DNP function was tested pre-operatively using bilateral needle electromyography (EMG)-bulbocavernosus reflex (BCR) measurements, and an interview about reflex erections (RE) ability. RESULTS: In 13 spina bifida- and 17 spinal cord injury patients [median age 29.5 years (range 13-59 years), spinal lesion T12 (incomplete) to sacral], seven (23%) patients reported RE, four (57%) with intact BCR, and of nine (30%) patients with intact BCR, four reported RE (44%). CONCLUSIONS: Even patients with a LSL and no penile sensation can have signs of remaining DNP function, but cutting both DNPs to restore full glans sensation in a bilateral TOMAX-procedure might interfere with their RE/ejaculation. To avoid this risk, we propose a selecting-protocol for a unilateral- or bilateral procedure using RE and BCR measurements. Using this protocol, three patients were bilaterally operated with promising preliminary results. Full sensation of the glans could lead to further improvement in sexual function.

Usefulness of Endovascular Therapy for Penile Gangrene Secondary to Calciphylaxis: A Case Report.

We here report a case of successful endovascular therapy for penile gangrene in a patient with calciphylaxis and a long history of diabetes mellitus and end-stage renal disease on dialysis. The internal iliac artery, with 75% stenosis, was treated with balloon-expandable bare metal stent implantation, whereas the inferior gluteal artery, 75% stenosis, was treated with balloon dilatation. After endovascular therapy, the intractable penile pain immediately resolved, and penile salvage with complete wound healing was achieved 6 months after the procedure.

[A case of strangulation of the penis with difficult release].

We report a case of penile strangulation by a metal ring. An 81-year-old man visited our hospital with a complaint of penile swelling and urinary retention caused by a ring placed around the penile root to control the patient's sexual desire; the ring had been placed some days prior to presentation. We could not release the penile strangulation by hand or with a ring cutter in the emergency room. We decided to cut the thick metal ring in the operating room under local anesthesia and sedation with a surgical tool used in the orthopedic department. It took approximately 2 hours to cut the ring. The patient had made a satisfactory recovery 7 days postoperatively, and no complications were observed during the postoperative period.

Prepuce: phimosis, paraphimosis, and circumcision.

Phimosis is a condition in which the prepuce cannot be retracted over the glans penis. Actually, physiologic phimosis is common in male patients up to 3 years of age, but often extends into older age groups. Balanoposthitisis a common inflammation occurring in 4-11% of uncircumcised boys. Circumcision is generally undertaken for three reasons: first, as an item of religious practice, typically neonatally although occasionally transpubertally, as a rite of passage; second, as a prophylactic measure against future ailments for the reduction in the risk of penile cancer, urinary tract infection, and sexually transmitted infection; and third, for immediate medical indication. Balanitisxeroticaobliterans is an infiltrative skin condition that causes a pathological phimosis and has been considered to be the only absolute indication for circumcision. Various kinds of effective alternatives to circumcision have been described, including manual retraction therapy, topical steroid therapy, and several variations of preputioplasty. All of these treatments have the ability to retract the foreskin as their goal and do not involve the removal of the entire foreskin. Paraphimosis is a condition in which the foreskin is left retracted. When manipulation is not effective, a dorsal slit should be done, which is usually followed by circumcision.

Early surgical repair or conservative treatment? Comparing patients with penile fracture concerning long-term sexual functions.

BACKGROUND: To compare the patients who underwent early surgical repair of penile fracture, which is one of the urological emergencies, and patients who recovered with conservative treatment concerning long-term sexual functions. METHODS: The data of 42 patients who applied to our clinic with penile fracture between January 2010 and January 2020 were retrospectively analyzed. The patients were categorized into two groups as early operated and followed-up conservatively. The preoperative and postoperative findings of the patients were compared with the International Erectile Function Scale (IIEF-6) scores in the long-term follow-up. RESULTS: The median age of the patients was 35 (20-65) years and the median follow-up period was 52 (8-120) months. The postoperative mean IIEF-6 score of the patients was 22.98±6.52. There was no significant difference between the surgical and the conservative groups concerning postoperative complications (p=0.460). In the follow-up period, the presence of palpable plaque on the rupture area was significantly higher in the conservative group (p=0.041). However, there was no significant difference between the groups concerning IIEF-6 scores (p=0.085). CONCLUSION: Although there is no significant difference in long-term IIEF-6 scores between the two groups, the rate of palpable plaque formation is higher in patients followed-up conservatively. Therefore, early surgical repair should be considered in the foreground, especially in patients with a large rupture area.

[Pathophysiology and management of Peyronie's disease in adult patients: an update]. / Physiopathologie et prise en charge de la maladie de La Peyronie.

Peyronie's disease (PD) is due to a fibrotic plaque forms in the tunica albuginea layer of the penis. It is responsible of penile pain, angulation, and erectile dysfunction. Even though the aetiology remains unknown, the knowledge of the pathophysiology has evolved in recent years. Recent studies indicate that PD has prevalence of 3 to 9% in adult men. During the initial acute phase (6 to 18 months), the condition may progress, stabilize or regress in 20%. Therefore, a conservative treatment approach has been advocated. An initial discussion about evaluation, information, and reassurance is necessary in most cases. The most commonly employed oral therapies include tocopherol (vitamin E), and para-aminobenzoate (Potaba), which have failed to demonstrate efficiency. Intralesional injection therapies with interferon alpha-2B, verapamil are frequently used as a first-line treatment modality, and can provide an improvement in decreasing penile pain and penile curvature. Current literature has shown that extracorporeal shock wave lithotripsy was only active on the pain. Regarding penile curvature, there are discrepancies in the published series. The surgical approach is restricted to men unresponsive to nonoperative therapies (i.e., 10% of patients). In such cases, plication, grafting or even penile prosthesis implantation are conceivable management options.

Floppy Glans-Classification, Diagnosis and Treatment.

INTRODUCTION: Glans hypermobility presents a rarely observed complication of penile prosthesis implantation. It may result in patient dissatisfaction because of painful intercourse, difficulties during penetrative sex, and a poor cosmetic result. This problem may prevent the patient from using an otherwise fully functional implant. AIM: To summarize current knowledge, clarify terminology, and review treatment options of multifaceted diagnosis of floppy glans. METHODS: Analysis of published literature and experience of authors' institution. MAIN OUTCOME MEASURE: We reviewed publications that outlined incidence, pathophysiology, diagnostics, and management strategies of floppy glans phenomenon. RESULTS: Floppy glans phenomenon can result from the soft glans, incorrect position, or size of the implant cylinders or the anatomy of the glans. A careful physical examination with a fully inflated implant will indicate the direction of the droop and can be very helpful in distinguishing the underlying cause of the deformity. In ambiguous cases obtaining a correct diagnosis will often involve imaging-magnetic resonance imaging or penile ultrasound scanning of the inflated device. Cooperation with an experienced uroradiologist is invaluable in such cases. The glanspexy procedure should be performed according to the surgeon's experience and preference. CONCLUSIONS: Understanding the different glans abnormalities and unified terminology is crucial for optimization of the treatment. Medical therapy can always be tried before revision surgery, as long as it is safe for the patient and function of the implant. The accuracy of the position and size of the implant should always be thoroughly assessed before a diagnosis of the real glans hypermobility is made and treatment provided. Skrodzka M, Heffernan Ho D, Ralph D. Floppy Glans-Classification, Diagnosis And Treatment. Sex Med Rev 2020;8:303-313.

Mechanisms of penile fibrosis.

INTRODUCTION: Penile fibrosis has been conceptually identified with the plaque that develops in the tunica albuginea in Peyronie's disease (PD), or with localized processes induced in the corpora cavernosa by ischemic or traumatic events. Recently, it has been proposed that a diffuse, progressive, and milder intracorporal fibrosis, which affects also the media of the penile arteries, is responsible for vasculogenic erectile dysfunction (ED) associated with aging, smoking, diabetes, hypertension, and post-radical prostatectomy. These processes differ in etiology, time course, target cells, and treatment, but have many features in common. AIM: To review the literature pertaining to fibrosis in the penis, related to PD and ED. METHODS: PubMed search for pertinent publications mainly during 2001-2008. RESULTS: This review focuses initially on PD and then deals with studies on ED in animal and cell culture models, discussing some of the pathophysiological similarities between tunical fibrosis in PD and corporal fibrosis in corporal veno-occlusive dysfunction (CVOD), and emerging therapeutic strategies. The role of profibrotic factors, the excessive deposit of collagen fibers and other extracellular matrix, the appearance of a synthetic cell phenotype in smooth muscle cells or the onset of a fibroblast-myofibroblast transition, and in the case of the corporal or penile arterial tissue the reduction of the smooth muscle cellular compartment, are discussed. This histopathology leads either to localized plaques or nodules in penile tissues, or to the diffuse fibrosis causing impairment of tissue compliance that underlies CVOD and arteriogenic ED. The antifibrotic role of the sustained stimulation of the nitric oxide/cyclic guanosine monophosphate pathway in the penis and its possible relevance to exogenous and endogenous stem cell differentiation is also briefly presented. CONCLUSIONS: Fibrotic processes in penile tissues share a similar cellular and molecular pathophysiology and common endogenous mechanisms of defense that have inspired novel pharmacological experimental approaches.

[Reconstructive surgery of penile deformities and tissue deficiencies]. / A hímvesszo görbületei, torzulatai, szövethiányos állapotai.

Penile deformities and tissue deficiencies can disturb sexual intercourse or make it impossible. The aim of the study is to summarize the different diseases according to their clinical appearance and pathological processes and to review operative methods and personal experiences. Surgical treatment of hypo- and epispadias is usually performed in childhood, but curvatures after unsuccessful operation can demand the reconstruction of urethra, skin and corpora cavernosa eventually. Peyronie's disease and curvature after penile fracture desire the reconstruction of tunica albuginea. Plaque surgery used to be performed with dermal, tunica vaginalis or venous grafts, but best results are obtained by shortening procedure on the contralateral side according to the Heinecke-Mikulitz principle. Tissue deficiencies and curvatures were observed after necrotic inflammatory processes, like Fournier's gangrene or chronic dermatitis. Skin defects were cured by flaps and grafts. Abscesses of penis, severe tissue defects and also curvatures were observed after intracavernous injection in cases of erectile dysfunction. Possibilities of reconstruction seem to be very poor. Oil granuloma of penis presents a new task for penile reconstruction. The best results of skin replacement were achieved by temporary embedding of the penis in scrotum.

Penile Girth Enlargement Strategies: What's the Evidence?

INTRODUCTION: Most men seeking penile girth augmentation have physiologically normal penises but may suffer from severe preoccupation with penis size known as penile dysmorphophobic disorder. AIM: To describe the medical, procedural, and reconstructive techniques available for penile girth enhancement and to review the success and complications of each modality. METHODS: A comprehensive review of peer-reviewed publications on the topic was performed through a PubMed search. Key search terms included penis, enhancement, enlargement, phalloplasty, reconstruction, girth, and augmentation. MAIN OUTCOME MEASURE: We wanted to summarize the motivations behind penile girth enhancement and review the outcomes for girth augmentation treatments. RESULTS: Various medical, traction, injection, prosthetic, and reconstructive modalities have been studied for penile girth enhancement, with increases in girth ranging from 0-4.9 cm. Complications were reported in a minority of patients, but they may be devastating and include penile fibrosis, sexual dysfunction, device infection, and death. CONCLUSION: A variety of penile girth augmentation techniques have been studied. Clinical guidelines are lacking, and complications of penile girth enhancement are likely underreported. Until more rigorous investigation with accurate reporting of complications is achieved, penile girth augmentation procedures should be considered experimental. Hehemann MC, Towe M, Huynh LM, et al. Penile Girth Enlargement Strategies: What's the Evidence? Sex Med 2019;7:535-547.

Shaeer's corporal rotation for length-preserving correction of penile curvature: modifications and 3-year experience.

INTRODUCTION: Correction of penile curvature by corporal rotation enabled the correction of 90 degrees ventral curvature with neither shortening nor erectile dysfunction. However, some limitations were described, and only one case was reported upon. AIM: This work described a 3-year experience with corporeal rotation, the modifications addressing and eliminating its drawbacks and limitations, as well as the long-term follow-up of 22 patients. METHODS: Modified corporeal rotation was performed in 22 patients with various degrees of curvature. Degree of deviation, erect penile length, symmetry, and erectile function were evaluated and compared pre- and postoperatively. MAIN OUTCOME MEASURES: Correction of curvature, resultant sexual function, penile length, and girth. RESULTS: Full correction of curvature was achieved in 20 out of 22 patients, with no shortening, asymmetry, or erectile dysfunction. Residual curvature in two patients was no more than 10 degrees. CONCLUSIONS: Corporal rotation can restore straightness to the penis with no loss in phallic length, asymmetry, or erectile dysfunction. While a variety of surgical techniques are feasible for the correction of milder degrees of curvature, we believe that severe degrees should be spared the shortening and corrected by corporeal rotation.

Pain Management in Penile Prosthetic Surgery: A Review of the Literature.

INTRODUCTION: The literature on perioperative pain control and management in inflatable penile prosthesis placement is not firmly established. Because inflatable penile prosthesis placement is an elective procedure, pain can be one of the many issues that influence patient decision making. Pain control also presents a unique challenge to providers in an era of widespread opiate abuse. AIM: To review published data on pain management before, during, and after penile prosthetic surgery. METHODS: Peer-reviewed literature and conference abstracts were analyzed for all relevant publications related to this issue. RESULTS: The past several decades have seen a shift from general to local anesthesia for penile prosthetic surgery. This has been well characterized and is seen as successful with different local anesthetic options and techniques. To date, only one study has provided follow-up for longer than 1 week regarding postoperative pain management for prosthetic surgery. CONCLUSION: Perioperative pain management for the patient receiving a penile prosthetic is well characterized; postoperative pain management is not. Although periprocedural local anesthesia has been well described for penile prosthesis surgery, a standardized postoperative pain management plan does not exist. This review highlights the need for further characterization of postoperative pain and the subsequent development of an algorithmic approach for management. Reinstatler L, Shee K, Gross MS. Pain Management in Penile Prosthetic Surgery: A Review of the Literature. Sex Med Rev 2018;6:162-169.

Penile Length: Measurement Technique and Applications.

INTRODUCTION: Penile size has long been an important fixation in men's lives. On the one hand, a smaller penis has been associated with anxiety and apprehension; on the other hand, a larger penis has generally been related to virility and strength. These perceptions predominate during an erection, when penile size is representative of a man's masculinity. AIM: To assess adult penile length and summarize average penile length assessments from the literature; analyze how various urologic diseases and therapies affect penile length and volume; and review how surgical treatments for Peyronie's disease, penile prosthesis implantation, and radical prostatectomy can affect penile size to appropriately counsel patients seeking such therapies and set realistic goals for patients. METHODS: To achieve the aim of this review, we analyzed the literature on penile size and volume and how these can be affected by various urologic diagnoses and therapies. We summarize common diagnoses and therapies that can affect penile size. MAIN OUTCOME MEASURE: We thoroughly discuss how the aforementioned diagnoses and therapies can negatively affect penile size. In doing so, we allow readers to understand the intricacies of penile size when faced with such diagnoses and therapies in their patients. RESULTS: Surgical treatments for Peyronie's disease, penile prosthesis implantation for refractory erectile dysfunction, and radical prostatectomy for prostate cancer can lead to a decrease in penile size. CONCLUSION: Urologists must recognize that the different therapies they offer can affect a man's penile size, often negatively. This in turn can lead to poorer satisfaction outcomes in patients. Davoudzadeh EP, Davoudzadeh NP, Margolin E, et al. Penile Length: Measurement Technique and Applications. Sex Med Rev 2018;6:261-271.

Surgical Management of Adult-acquired Buried Penis: Impact on Urinary and Sexual Quality of Life Outcomes.

OBJECTIVE: To assess postoperative patient-reported quality of life outcomes after surgical management of adult-acquired buried penis (AABP). We hypothesize that surgical treatment of AABP results in improvements in urinary and sexual quality of life. METHODS: Patients that underwent surgical treatment of AABP were retrospectively identified. The Expanded Prostate Cancer Index (EPIC) questionnaire was completed at ≥3 months postoperatively, and completed retrospectively to define preoperative symptoms. EPIC is validated for local treatment of prostate cancer. Urinary and sexual domains were utilized. Questions are scored on a 5-point Likert scale, with higher scores indicating better quality of life. Preoperative scores were compared with postoperative scores. RESULTS: Sixteen patients completed pre- and postoperative questionnaires. Mean time from surgery to questionnaire was 12.6 months. There was a significant improvement in 10 of 12 urinary domain questions and 10 of 13 sexual domain questions. Fourteen of 16 patients (87.5%) reported significant improvement in overall sexual function (median score changed from 1.5 to 5, P <.0001). Similarly, 14 of 16 patients (87.5%) reported significant improvement in overall urinary function (median score changed from 1 to 4, P <.0001). CONCLUSION: AABP is a challenging condition to treat and often requires surgical intervention to improve hygiene and function. There are limited data on patient-reported quality of life outcomes. We found that surgical management of AABP results in significant improvements in both urinary and sexual quality of life outcomes.

Photo Rounds: Painless penile ulcer and tender inguinal lymphadenopathy.

Our patient had previously been treated for syphilis. But when his symptoms persisted, further testing revealed that he was being treated for the wrong STD.