Safety and efficacy of botulinum neurotoxin in the treatment of erectile dysfunction refractory to phosphodiesterase inhibitors: Results of a randomized controlled trial.

BACKGROUND: There has been recent interest in the use of botulinum neurotoxin (BoNT) in the field of Andrology, whereby it has been investigated in the treatment of penile retraction and premature ejaculation. OBJECTIVES: To evaluate the safety and efficacy of intracavernosal BoNT-A injection in the treatment of patients with erectile dysfunction (ED) refractory to oral phosphodiesterase inhibitors (PDE5Is). PATIENTS AND METHODS: A double-blind randomized placebo-controlled prospective comparative study conducted at one center and involved 70 patients with ED refractory to PDE5Is. At baseline, the following data were collected: erection hardness score (EHS), peak systolic velocity (PSV), end diastolic velocity (EDV), sexual health inventory for men (SHIM), and the sexual encounter profile 2&3 (SEP-2&3) questionnaires. Treatment group (n = 35) received a single ICI of 100 units of BoNT-A in 2 ml of saline and control group (n = 35) received a single ICI of 2 ml of saline. EHS, PSV, and EDV were assessed at 2 weeks post treatment. SHIM, SEP-2, SEP-3, and global assessment questionnaire (GAQ-Q1&Q2) were completed at 2-, 6-, and 12-weeks post treatment. RESULTS: Two weeks post treatment, the treatment group showed a statistically significant improvement in the mean EHS, PSV, EDV, and GAQ-Q1 positive responders (p < 0.001) compared to the control group. At 6- and 12-weeks post treatment, the treatment group showed a statistically significant improvement in the SHIM scores, SEP-2, and GAQ-Q1&Q2 positive responders compared to the control group. At 6 weeks, where there was a 5-point improvement in the mean SHIM score of the treatment group (10±5.9 from 5.4±1.7 at baseline) versus no improvement in the placebo group, 18 patients in the treatment group (53%) were able to have an erection hard enough for vaginal penetration versus only one patient in the control group. CONCLUSION: BoNT-A is safe and effective as a potential treatment for ED refractory to PDE5I therapy.

Urethral instillation of chlorhexidine gel is an effective method of sterilisation.

Objective: To examine the effectiveness of preoperative urethral sterilisation with chlorhexidine gel in rendering the urethra as sterile as the skin of the genital area, with the skin sterilised as per the International Society for Sexual Medicine guidelines for penile prosthesis implantation. Patients and methods: A total of 111 male patients undergoing sterile andrological surgical procedures were divided into a control group (N = 61) and a chlorhexidine gel group (N = 50). Patients in the chlorhexidine group received urethral instillation with 6 mL of chlorhexidine preoperatively and on table. Patients from both groups received on-table skin preparation using povidone iodine and chlorhexidine povidone iodine. At the end of surgery, swabs were obtained from urethra and the penile skin. Skin and urethral swabs were compared for bacterial colonisation by culture and sensitivity. Results: Of the 111 patients, 16 had urethral colonisation and 10 had skin contamination, and they were all in the control group. The most common organism detected in both the urethral and skin samples was coagulase-negative Staphylococcus aureus. Urethral colonisation was significantly greater in the control group compared to the chlorhexidine group, at 16/61 vs 0/50 (P = 0.001). Similarly, skin colonisation was significantly greater in the control group compared to the chlorhexidine group, at 10/61 vs 0/50, (P = 0.002). Conclusion: Chlorhexidine gel is a powerful sterilising agent that will render the urethra sterile.

The Impact and Management of Gynaecomastia in Klinefelter Syndrome.

Gynecomastia is defined as a palpable enlargement of the male breast, secondary to an increase in the glandular and stromal breast tissue. Gynecomastia is encountered in up to 80% of Klinefelter syndrome cases. The pathophysiology involves testosterone/estrogen imbalance. This review article will further explore the pathophysiology of gynecomastia along with the different lines of management.

The efficacy of the T-shunt procedure and intracavernous tunneling (snake maneuver) for refractory ischemic priapism.

PURPOSE: The current management of ischemic priapism that is refractory to conventional medical therapy is a form of shunt procedure that diverts blood away from the corpus cavernosum. We assessed the outcome of the T-shunt and intracavernous tunneling for the management of ischemic priapism. MATERIALS AND METHODS: During a 36-month period 45 patients presented with prolonged ischemic priapism. Patients were divided into subgroups according to the duration of priapism. All patients had an unsuccessful primary treatment, and underwent a T-shunt and intracavernous tunneling with cavernous muscle biopsies. All patients completed an IIEF-5 (International Index of Erectile Function-5) questionnaire preoperatively and 6 months postoperatively. RESULTS: Resolution of the priapism using a T-shunt and snake maneuver occurred in all patients with a priapism duration of less than 24 hours and in only 30% of those with priapism lasting more than 48 hours. After a 6-month median followup the IIEF-5 score was significantly reduced from a mean of 24 (range 23 to 25) preoperatively to 7.7 (range 5 to 24), which was related to the duration of the priapism (p <0.0005). All patients with priapism for more than 48 hours had necrotic cavernous smooth muscle on biopsy and had severe erectile dysfunction requiring the insertion of a penile prosthesis. Those patients with moderate and mild erectile dysfunction were treated with phosphodiesterase type 5 inhibitors. CONCLUSIONS: The success of the T-shunt with snake tunneling is dependent on the duration of priapism. When it is less than 24 hours the results are favorable, although erectile dysfunction is still present in 50% of patients. In those with a priapism duration greater than 48 hours the technique usually fails to resolve the priapism and all patients end up with erectile dysfunction due to smooth muscle necrosis.

Penile fracture and penile reconstruction.

The past decade has seen a significant development in penile reconstruction techniques, and the management of penile fracture has progressively shifted from a conservative approach to early surgical repair. The radial artery-based free flap phalloplasty now represents the gold-standard procedure for total phallic reconstruction both in men and in female-to-male transsexuals.

An update on penile reconstruction.

Penile reconstruction still represents a formidable challenge for the urologist. In this review, the most recent advances in penile reconstruction after trauma, excision of benign and malignant disease and in patients with micropenis, aphallia or female to male gender dysphoria are reported.

The role of vacuum pump therapy to mechanically straighten the penis in Peyronie's disease.

OBJECTIVE: to assess the efficacy of vacuum therapy in mechanically straightening the penile curvature of Peyronie's disease (PD). PATIENTS AND METHODS: Modelling of the tunica albuginea has been shown to be possible during penile implant surgery and this principle has been applied as an alternative conservative therapy. In all, 31 patients with PD (mean duration 9.9 months; mean age 51 years, range 24-71) completed the study. Over a 12-week period, the patients used a vacuum device (Osbon ErecAid, MediPlus, High Wycombe, UK) for 10 min twice daily. The assessment at study entry and at completion after 12 weeks included the International Index of Erectile Function questionnaire, a perceived pain intensity score, stretched penile length measurement and the angle of penile deformity after an intracavernous injection with prostaglandin E1. RESULTS: there was a clinically and statistically significant improvement in penile length, angle of curvature and pain after 12 weeks of using the vacuum pump. Of the 31 patients, 21 had a reduction in the angle of curvature by 5-25 degrees, three had worsening of the curvature and there was no change in the remaining seven. The curvature was corrected surgically in 15 patients while the remaining 16 (51%) were satisfied with the outcome. CONCLUSION: vacuum therapy can improve or stabilize the curvature of PD, is safe to use in all stages of the disease, and might reduce the number of patients going on to surgery.