Variability in methodology of erectile dysfunction regenerative therapy trials on ClinicalTrials.gov.

OBJECTIVES: To evaluate the variability in the criteria of erectile dysfunction (ED) regenerative therapy trials registered on ClinicalTrials.gov. METHODS: Interventional trials on ClinicalTrials.gov with the keywords "erectile dysfunction" and variations of "shockwave," "platelet rich plasma," "stem cell," "regenerative," and "restorative" were examined. Inclusion/exclusion criteria and primary/secondary outcomes were compared between extracorporeal shockwave therapy (ESWT), platelet rich plasma and stem cell injections (PRP/SC), and other regenerative therapies (ORT) groups. RESULTS: Of the 92 trials analyzed, International Index of Erectile Function (IIEF) score was the most common primary outcome (72%), with a higher prevalence in ESWT trials than PRP/SC or ORT trials (89% vs 44% and 58%, p<.001). Safety/tolerability was a primary outcome for 44% of PRP/SC trials and 25% of ORT trials but no ESWT trials (p<.001). ESWT trials more frequently had sexual/romantic relationship-based inclusion criteria and cancer treatment-related exclusion criteria than PRP/SC and ORT trials. CONCLUSIONS: There is substantial variability in the inclusion/exclusion criteria and outcome measures among ED regenerative therapy trials. ESWT trials most frequently utilized IIEF and had the strictest inclusion/exclusion criteria, suggesting more rigorous and functional outcome-based studies. Conversely, PRP/SC and ORT trials, but not ESWT trials, had safety/tolerability as a primary outcome, likely due to the experimental nature of these therapies. The variability in inclusion/exclusion criteria and outcome measures limits comparison of the various ED regenerative therapies.

Stripping versus ligation of vas deferens in microscopic denervation of spermatic cord in men with chronic orchialgia: A multicenter study.

BACKGROUND: Microdenervation of the spermatic cord (MSCD) is an effective treatment modality for men with intractable scrotal content pain. For patients not interested in preserving fertility, some centers advocate ligation of the vas during denervation, while others prefer stripping of the vas deferens to preserve the vasal artery, hence preserving vasculature to the testis and possibly decreasing post-operative congestion pain. OBJECTIVE: To compare outcomes of patients with chronic orchialgia, who underwent MSCD by either stripping or ligating the vas deferens. MATERIALS AND METHODS: A retrospective chart review of 85 patients who underwent MSCD from 2017-2023 was performed. Patients' demographics including history of prior surgical procedures were recorded. Response to surgery was evaluated as either complete resolution of pain, partial resolution of pain, or no improvement in pain. RESULTS: Eighty-five patients underwent MSCD with a median (interquartile range, IQR) age of 36 (25.5-46.5) years and median duration of pain of 16 (6-31) months. Thirty-seven patients underwent stripping of vas, while 48 underwent ligation of vas during MSCD. Median follow up was 12 months. Twenty-one (43.5%) patients had prior inguinal scrotal surgery in the ligation group compared to 5 (13.5%) in the stripping group, p = 0.003. The etiology of pain was similar between the groups. The response to MSCD between the two groups was similar, 67.6% of patients who underwent stripping had complete resolution of pain versus 66.7% of those who had ligation (p = 0.968), with similar rates of post-operative complications (p-value = 0.132). CONCLUSIONS: In men with intractable chronic scrotal content pain with no interest in preserving fertility, ligation, or stripping of the vas deferens yields similar outcomes with regard to pain resolution. Both techniques are safe with no reports of any testicular atrophy.

Cosmetic penile enhancement procedures: an SMSNA position statement.

BACKGROUND: Penile cosmetic enhancement procedures have been performed for many years with varying success. However, they have historically been relegated to niche areas of sexual medicine, with limited data, and have not achieved mainstream adoption. More recently, the topic has been increasingly discussed within academic congresses due to availability of novel techniques, therapies, and procedures. Given their distinctive nature, the Sexual Medicine Society of North America (SMSNA) felt that it was pertinent to develop formal position statements to help guide both patients and sexual medicine providers on the current state of the scientific literature and to give recommendations for future research. AIM: The study sought to provide an evidence-based set of recommendations for injection and surgical procedures designed to lengthen, augment, or otherwise cosmetically enhance the penis. METHODS: A review was performed of all scientific literature listed in PubMed from inception through December 2023 relating to penile cosmetic enhancement procedures. Only invasive (injection/surgery) therapies were included due to their distinct risk-benefit profile compared with more conservative treatments (eg, vacuum erection devices, penile traction devices). Similar therapies were categorized, with pertinent data summarized and used to help create relevant position statements. All statements were expert opinion only and were based on analyses of the potential risks and benefits of the specific therapies. OUTCOMES: A total of 6 position statements were issued relating to 5 distinct sexual medicine cosmetic enhancement procedures. RESULTS: A consensus opinion was reached by SMSNA leadership on the state of injection/surgical penile cosmetic enhancement procedures as of 2024. Key topic areas addressed included injectable soft tissue fillers, suspensory ligament division, graft-and-flap procedures, silicone sleeve implants, and sliding/slicing techniques. Distinct recommendations were tailored to each therapy and were based solely on the current state of the literature. It is anticipated that future studies will further inform position statements and will lead to ongoing modifications. CLINICAL IMPLICATIONS: The current position statements provide both patients and clinicians evidence-based, expert recommendations on best practices relating to penile cosmetic enhancement procedures. STRENGTHS AND LIMITATIONS: Strengths include the use of an expert panel of sexual medicine clinicians, consensus design, and summary of existing literature. Limitations include expert opinion and limited research on the topic. CONCLUSION: The current SMSNA position statements provide evidence-based, consensus opinions on the appropriate role for penile augmentation and cosmetic procedures in 2024.

Does climate impact inflatable penile prosthesis infection (IPP) risk? Assessment of temperature and dew point on IPP infections.

BACKGROUND: Variations in climate have been associated with a greater risk of surgical site infections, urinary tract infections, and changes in the skin microbiome; however, limited data exist on the impact of climate on inflatable penile prosthesis (IPP) infections. AIM: We sought to evaluate the impact of climate on the risk of IPP infections in a large international, multicenter cohort. METHODS: We performed a multi-institutional, retrospective study of patients undergoing IPP surgery. We then evaluated whether the month or season, during which surgery was performed, affected device infections. Implant infections were defined as infections requiring device explantation. A univariate logistic regression analysis was undertaken. OUTCOMES: Our primary outcome was implant infection. RESULTS: A total of 5289 patients with a mean age of 62.2 ± 10.8 years received IPP placement. There was a fairly even distribution of implants performed in each season. A total of 103 (1.9%) infections were recorded. There were 32 (31.1%) IPP infections in patients who underwent surgery in the summer, followed by 28 (27.2%) in the winter, 26 (25.2%) in the spring, and 17 (16.5%) in the fall. No statistically significant differences were recorded in terms of season (P = .19) and month (P = .29). The mean daily temperature (P = .43), dew point (P = .43), and humidity (P = .92) at the time of IPP placement was not associated with infection. CLINICAL IMPLICATIONS: These findings provide reassurance to prosthetic urologists that infection reduction strategies do not need to be tailored to local climate. STRENGTHS AND LIMITATIONS: Climate data were not directly recorded for each hospital, but rather based on the monthly averages in the city where the surgery was performed. CONCLUSION: The climate at time of IPP placement and time of year of surgery is not associated with IPP infection risk.

Glans hypermobility scale (GHS): A simple grading scale and description of a modified glanspexy technique.

Glans hypermobility (GH) is a well-described clinical entity that can have significant implications for cosmesis and function, resulting in sexual dissatisfaction, penile pain, and early device erosion, with an estimated incidence of 0.04% to 10%. We developed a novel grading scale to assess GH severity intraoperatively during primary inflatable penile prosthesis (IPP) placement and describe a modified glanspexy technique to correct GH when encountered during IPP placement. 530 patients who underwent primary IPP placements from two high-volume prosthetic surgeons between February 2018 - November 2019 were retrospectively reviewed in order to identify the incidence of GH. Of these, 139 (26.2%) had hypermobility. Employing our new scaling system, grade 1, 2, and 3 GH was seen in 86 (16.2%), 29 (5.5%), and 24 (4.5%) cases, respectively. Increased implant size correlated with a decreased likelihood of GH incidence. Each increase in implant size by 1 cm decreased the incidence of detecting GH by 11.0% (OR = 0.89; p = 0.015). 11 patients underwent primary GH repair using our described technique. At one-year follow-up, one patient required repeat glanspexy for recurrent bothersome GH and a second patient developed a suture granuloma at the glanspexy incision requiring unilateral cylinder explant. Our modified glanspexy technique can be used to correct GH in any direction and is a useful tool for the prosthetic surgeon's armamentarium.

Optimal timing of surgical intervention for penile fracture: a narrative review of the modern literature.

INTRODUCTION: Penile fracture is traditionally considered a surgical emergency warranting immediate repair with the goal to maximize long-term erectile function and minimize penile curvature. Nonetheless, consensus on the optimal timing for penile fracture repair remains to be elucidated and is the subject of continued research efforts. OBJECTIVES: This review aims to summarize the contemporary literature pertaining to optimal timing of penile fracture repair and associated outcomes. METHODS: We queried PubMed/MEDLINE and Google Scholar for relevant articles published between 2012 and 2022 to evaluate the most recent literature on the queried topic of early vs delayed intervention for penile fracture. All examined review articles were published within the last decade but may have included analyses of studies published prior to 2012. Reference lists of articles and reviews were manually reviewed to identify additional relevant articles. RESULTS: We identified 16 articles that met inclusion criteria: 12 primary articles and 4 systematic reviews or meta-analyses. Importantly, definitions of early and delayed intervention varied greatly among studies, making quantitative comparison challenging. In summary, 6 primary studies and 2 systematic review articles favored early intervention. There were also 6 primary studies and 2 systematic review articles suggesting equivocal outcomes between early and delayed repair. No articles demonstrated improved outcomes with delayed repair relative to early intervention. CONCLUSION: Surgical intervention for penile fracture remains the gold standard, with superior long-term sexual and functional outcomes when compared with conservative management. Optimal timing of penile fracture repair remains to be elucidated with data limited by low incidence, resulting in small case series and a lack of randomized controlled trials. Nonetheless, recent data suggest that a brief delay in surgical intervention for patients presenting with penile fractures does not affect long-term sexual and functional outcomes.

Changes in Point of Maximal Curvature During Collagenase Clostridium Histolyticum Injections for Peyronie's Disease.

OBJECTIVE: To determine change in the point of maximal curvature (POMC) during Collagenase Clostridium histolyticum (CCH) injections for Peyronie's disease (PD). METHODS: A prospective database has been maintained of all men undergoing CCH injections since March 2014. For the current study, data were abstracted on the POMC with each curve assessment and correlated with demographic and clinical factors. Maximal changes were defined as the largest change in POMC from baseline. RESULTS: Six hundred and eighteen men underwent ≥1 series of CCH, with 313 having a baseline and subsequent POMC measurements available. Median baseline curvature was 60.0° and POMC 2.8 cm. Among 189 men who were satisfied or completed 8 CCH injections, the median improvement in penile curvature was -27.5° (40.9%). The median maximal change in POMC during CCH treatment was 1.0 cm (interquartile range, 0.5, 1.8). Overall, 55.6% had changes in POMC of ≥1 cm, 23.6% ≥2 cm, 8.9% ≥3 cm, and 3.8% ≥4 cm. Multivariate logistic regression identified ventral curvature as a predictor of larger change in POMC, after controlling for other variables. Study limitations included the observational, non-randomized study design and potential for intra- and inter-individual measurement variability. Strengths are the inclusion of an all-comer population, large series, prospective database, and routine objective assessments. CONCLUSION: Approximately half of men with PD undergoing CCH experience ≥1 cm of change in POMC during the treatment course, with nearly 1/4 experiencing ≥2 cm. Findings suggest that patients may benefit from repeat curvature assessments with each CCH series to optimize accuracy of drug administration.

The Discontinuation Rate With Collagenase Clostridium histolyticum for Peyronie's Disease in a High-volume Practice Is Unexpectedly High: Identifying Opportunities for Patient Care Improvement.

OBJECTIVE: To elucidate reasons for premature discontinuation of Collagenase Clostridium histolyticum (CCH) injections for the treatment of penile curvature associated with Peyronie's disease. METHODS: A database of men who underwent CCH injections at a single institution was queried to identify men who completed fewer than 8 injections. Chart review was conducted to identify reasons for treatment discontinuation. When this could not be identified, patients were contacted first via the online patient portal and next by phone. RESULTS: Of 406 patients who underwent CCH treatment, 133 did not complete 8 injections (32.8%). The most common reasons for discontinuation were satisfactory curve reduction (27%), unsatisfactory curve reduction (21%), bothersome side effect (15%), and pursuit of surgery (12%). Other less common reasons included other health concerns, pausing treatment due to the COVID-19 pandemic, high cost, transferring care elsewhere, and lack of awareness that more injections were indicated. CONCLUSION: We present the largest series of patients to date dedicated to evaluation of CCH discontinuation. We find that up to 1/3 of patients who begin CCH injections will not complete the full treatment course. Understanding the reasons for discontinuation can help providers better stratify patients for CCH treatment vs other modalities. In addition, as previous studies indicate curvature improvements are equally likely to be seen in the final four injections as the first four, our data points to the potential impact of improved patient education for individuals who discontinue due to unsatisfactory curve reduction.

Outcomes of collagenase Clostridium histolyticum in men with ventral curvatures: an updated series.

BACKGROUND: The efficacy and safety of collagenase Clostridium histolyticum (CCH) have been demonstrated in the treatment of men with Peyronie's disease (PD); however, the pivotal clinical trials excluded men with ventral penile curvature. AIM: The study sought to evaluate outcomes of CCH treatment in men with ventral curvatures secondary to PD. METHODS: Men with PD treated with CCH were identified from a prospective database. Patients received up to 4 series of CCH injections using a progressively modified protocol over time. Results were compared between those with baseline ventral vs nonventral penile curvatures. OUTCOMES: Changes in penile curvature, Peyronie's Disease Questionnaire scores, International Index of Erectile Function scores, nonstandardized assessments, and adverse events. RESULTS: A total of 560 men with PD (85 ventral curvature, 475 nonventral curvature) were included in the analysis. Baseline median curvature was 60.0° (interquartile range, 48.8°-75.0°) in the ventral cohort and 65.0° (interquartile range, 45.0°-80.0°) in the nonventral cohort. Median change from baseline penile curvature was -25.0° in the ventral cohort vs -24.0° in the nonventral cohort (P = .08, between-group comparison), which corresponded to curvature reductions of 44.7% and 33.6%, respectively (P = .03). In the subset of patients who completed CCH treatment (ie, received 8 injections or discontinued early because of patient satisfaction with curvature reduction), median change from baseline was -35.0° in the ventral cohort vs -25.0° in the nonventral cohort (P < .05); median percent improvement was 48.3% and 37.5%, respectively (P = .11). Median change from baseline in Peyronie's Disease Questionnaire and International Index of Erectile Function domain scores and adverse events were similar between cohorts, with the exception of possibly higher hematoma rates in the nonventral group (50% vs 37%; P = .05). No urethral injuries were sustained in either cohort. CLINICAL IMPLICATIONS: Data support the use of CCH for the treatment of ventral as well as nonventral penile curvatures in men with PD. STRENGTHS AND LIMITATIONS: Study strengths are the inclusion of a general clinical population of men with PD, the prospective design, and the relatively large series of men with ventral curvature. Limitations include the single-center and observational nature of the study. CONCLUSION: CCH was safe and effective in the treatment of both ventral and nonventral penile curvatures in men with PD.

Assessing psychiatric risk with a focus on optimizing patient satisfaction with penile prosthesis placement-a narrative review.

Background and Objective: Treatment for medication-refractory erectile dysfunction (ED) is based on a shared decision-making model. The gold standard treatment for medication refractory ED is penile prosthesis (PP) placement. Patient satisfaction rates with PP are high with adequate counseling and expectation-setting. However, as with any elective surgery, patient selection is key to minimizing complications and ultimately patient dissatisfaction. Psychological well-being is an important consideration in the preoperative evaluation and postoperative management of patients undergoing PP placement. Methods: We performed a PubMed literature review to identify pertinent studies for this narrative review. Specifically, we sought describe preoperative evaluation including appropriate counseling and patient selection as well relevant intraoperative and postoperative factors for patients undergoing PP placement with a specific focus on optimizing preoperative psychiatric factors and treatment-related patient satisfaction to identify pertinent articles describing ways to optimize patient satisfaction with PP. Key Content and Findings: A patient's psychological state can influence the degree of understanding of their condition, affect perception of their treatment team, and limit their ability to cope with complications. All patients should undergo a thorough medical history and physical examination to screen for psychiatric health disorders, substance abuse, and chronic pain conditions. Establishing patient expectations with regards to treatment-related outcomes during the preoperative consultation will ensure congruency between the patient and performing surgeon. Patients with a more significant psychiatric distress related to their underlying sexual dysfunction may require additional evaluation and counseling preoperatively. Conclusions: PP placement is associated with high levels of overall satisfaction in appropriately screened patients. Specific considerations during preoperative counseling and careful patient selection, intraoperative decision making to avoid or anticipate possible complications, and postoperative cares are necessary to ensure the best result for an individual patient.

Significant Geographic Variation in Access to Certified Collagenase Clostridium histolyticum Injectors for Peyronie's Disease Throughout the United States.

INTRODUCTION: We characterize the geographic distribution of providers trained to inject Clostridium histolyticum and identify areas with low provider availability. METHODS: We utilized a publicly available search tool to identify clinical sites offering Clostridium histolyticum in the US The data gathered included the provider's name, specialty, address, and whether the site was considered high-volume (ie, administer ≥20 Clostridium histolyticum injections per year). Data were compared to the AUA Census. RESULTS: In total, 2,388 clinical sites offering Clostridium histolyticum were identified. A total of 894 sites (37%) were high-volume sites. The mean number of locations offering Clostridium histolyticum per 100,000 state residents was 0.69 (SD 0.27). Georgia (1.28), Rhode Island (1.13), and Alaska (1.10) had the highest number, whereas New Mexico (0.10), Maine (0.22), and Delaware (0.30) had the lowest. The mean proportion of urologists providing Clostridium histolyticum to total urologists was 0.17 (SD 0.07). The 3 states with the highest proportion were Georgia (0.37), Alaska (0.31), and Utah (0.30), whereas New Mexico (0.03), Maine (0.05), and Vermont (0.06) had the lowest. CONCLUSIONS: States with low numbers of clinical sites offering Clostridium histolyticum per 100,000 residents relative to other states also had a low total ratio of urologists offering Clostridium histolyticum as a treatment. There is room for urologists in these states and others to expand their practice to offer Clostridium histolyticum and improve patient access to this important nonsurgical treatment option.

Do patients with Peyronie's disease perceive penile curvature in adults and children differently than the general population?

BACKGROUND: As perception of penile curvature varies widely, we sought to understand how adults perceive curvature and how these opinions compare with those of patients with curvature, specifically Peyronie's disease (PD). AIM: To investigate the perspectives of curvature correction from adults with and without PD, as well as differences within demographics. METHODS: A cross-sectional survey was administered to adult patients and nonpatient companions in general urology clinics at 3 institutions across the United States. Men, women, and nonbinary participants were recruited. Patients were grouped as having PD vs andrology conditions without PD vs general urology conditions plus companions. The survey consisted of unlabeled 2-dimensional images of penis models with varying degrees of curvature. Participants selected images that they would want surgically corrected for themselves and their children. Univariable and multivariable analyses were performed to identify demographic variables associated with willingness to correct. OUTCOMES: Our main outcome was to detect differences in threshold to correct curvature between those with and without PD. RESULTS: Participants were grouped as follows: PD (n = 141), andrology (n = 132), and general (n = 302) . Respectively, 12.8%, 18.9%, and 19.9% chose not to surgically correct any degree of curvature (P = .17). For those who chose surgical correction, the mean threshold for correction was 49.7°, 51.0°, and 51.0° (P = .48); for their children, the decision not to correct any degree of curvature was 21.3%, 25.4%, and 29.3% (P = .34), which was significantly higher than correction for themselves (P < .001). The mean threshold for their children's correction was 47.7°, 53.3°, and 49.4° for the PD, andrology, and general groups (P = .53), with thresholds no different vs themselves (P = .93). On multivariable analysis, no differences were seen in demographics within the PD and andrology groups. In the general group, participants aged 45 to 54 years and those who identified as LGBTQ (lesbian, gay, bisexual, transgender, queer) had a higher threshold for correction as compared with their counterparts when factoring other demographic variables (63.2° vs 48.8°, P = .001; 62.1° vs 50.4°, P = .05). CLINICAL IMPLICATIONS: With changing times and viewpoints, this study stresses the importance of shared decision making and balancing risks and benefits to correction of penile curvature. STRENGTHS AND LIMITATIONS: Strengths include the broad population surveyed. Limitations include the use of artificial models. CONCLUSION: No significant differences were seen in the decision to surgically correct curvature between participants with and without PD, with participants being less likely to choose surgical correction for their children.

Complications and troubleshooting in primary penile prosthetic surgery-a review.

Penile implant surgery is the gold standard to treat erectile dysfunction with success rates of over 90%. The first penile implants were developed in the early 1900s. Since then, several types of implants have been developed including malleable implants, two-piece inflatable implants, and three-piece inflatable implants. The three-piece inflatable penile prosthesis, which was introduced in 1973, is the most widely used type of penile implant in the United States. Penile implant surgery has undergone numerous advancements over the years, improving outcomes and patient satisfaction. However, as with any surgical procedure, there are risks and complications associated with penile implant surgery. It is important for surgeons to understand these potential complications and to have strategies in place to manage and prevent them to achieve the best possible outcomes for their patients.

Postoperative Opioid Prescribing Following Outpatient Male Urethral Surgery: Evidence for Change.

INTRODUCTION: Surgeons play a central role in the opioid epidemic. We aim to evaluate the efficacy of a standardized perioperative pain management pathway and postoperative opioid requirements in men undergoing outpatient anterior urethroplasty at our institution. METHODS: Patients undergoing outpatient anterior urethroplasty by a single surgeon from August 2017 to January 2021 were prospectively followed. Standardized nonopioid pathways were implemented based on location (penile vs bulbar) and need for buccal mucosa graft. A practice change in October 2018 transitioned (1) from oxycodone to tramadol, a weak mu opioid receptor agonist, postoperatively and (2) from 0.25% bupivacaine to liposomal bupivacaine intraoperatively. Postoperative validated questionnaires included 72-hour pain level (Likert 0-10), pain management satisfaction (Likert 1-6), and opioid consumption. RESULTS: A total of 116 eligible men underwent outpatient anterior urethroplasty during the study period. One-third of patients did not use opioids postoperatively, and nearly 78% of patients used ≤5 tablets. The median number of unused tablets was 8 (IQR 5-10). The only predictor for use of >5 tablets was preoperative opioid use (75% vs 25%, P < .01). Overall, patients using tramadol postoperatively reported higher satisfaction (6 vs 5, P < .01) and greater percentages of pain reduction (80% vs 50%, P < .01) compared to those using oxycodone. CONCLUSIONS: For opioid-naïve men, 5 tablets or less of opioid medication with a nonopioid care pathway provides satisfactory pain control following outpatient urethral surgery without excessive overprescribing of narcotic medication. Overall, multimodal pain pathways and perioperative patient counseling should be optimized to further limit postoperative opioid prescribing.

Incremental Treatment Response by Cycle With Collagenase Clostridium Histolyticum for Peyronie's Disease: A Pooled Analysis of Two Phase 3 Trials.

OBJECTIVE: To evaluate cumulative and incremental changes in penile curvature after each treatment cycle of collagenase clostridium histolyticum (CCH) in men with Peyronie's disease (PD). METHODS: Data from 2 phase 3, randomized, placebo-controlled trials were analyzed post hoc. Treatment was administered in up to 4 treatment cycles (per cycle: 2 injections, 1-3 days apart, of CCH 0.58 mg or placebo; subsequent penile modeling) at 6-week intervals. Penile curvature was measured at baseline and after each treatment cycle (weeks 6, 12, 18, and 24). Successful response was defined as ≥20% reduction from baseline penile curvature. RESULTS: Overall, 832 men (CCH, n = 551; placebo, n = 281) were included in the analysis. After each cycle, mean cumulative percent reduction from baseline penile curvature was significantly greater with CCH vs placebo (P <.001). Following one cycle, 29.9% of CCH recipients exhibited a successful response. Among nonresponders, additional cycles of injections led to further successful responses: 60.8% of first cycle failures achieved response after fourth cycle (8 injections), 42.7% of cycle 1-2 failures achieved response after fourth cycle, and 23.5% of cycle 1-3 failures achieved response after fourth cycle. CONCLUSION: Data showed incremental benefits from each of the 4 CCH treatment cycles. Completion of a full series of 4 CCH treatment cycles may optimize improvements in penile curvature in men with PD, including among those who did not clinically respond to previous treatment cycles.

Efficacy of collagenase Clostridium histolyticum in men with congenital penile curvature.

BACKGROUND: Collagenase Clostridium histolyticum (CCH) has been proven effective in multiple subpopulations of PD men; however, no studies have evaluated its role with congenital penile curvature (CPC). AIM: To evaluate the safety and efficacy of CCH in men with CPC. METHODS: A prospective registry was queried of men undergoing CCH injections at our institution. Beginning in 2016, CCH was administered to CPC men using a similar protocol to PD. A comparative analysis was performed between cohorts to evaluate the safety and efficacy of therapy. OUTCOMES: Objective measures included penile length and curvature, while subjective outcomes included standardized (International Index of Erectile Function and Peyronie's Disease Questionnaire) and non-standardized assessments. Curvature outcomes were categorized as follows: 1 - included all men, with the most recent assessment considered final, and 2 - only men who had completed eight CCH injections or stopped early due to satisfaction. RESULTS: From 2014 to Oct 2021, a total of 453 men (408 PD, 45 CPC) underwent one or more CCH injections. In comparing cohorts, CPC men were younger (33 vs 58 years, p<0.0001), had lesser baseline curvatures (52.5 vs 65°, p<0.01), more ventral curves (25.7 vs 9.2%, p<0.01), and longer penile lengths (12.5 vs 12.0 cm, p=0.04). Following treatment, both cohorts experienced similar curvature improvements. Specifically, PD men experienced 20-25° or 33-35% improvements depending on definition compared to 25-30° or 40-50% in CPC men (all p-values >0.05). CPC and PD men also demonstrated similar changes on standardized questionnaires, with the exception of the Psychological and Physical subdomain, which was more improved in CPC men (-11 vs -4, p<0.01). Baseline curvature was positively correlated with greater absolute (degree) and relative (percent) improvements. Adverse events were similar between groups after controlling for confounders. CLINICAL IMPLICATIONS: CCH may be safely and effectively administered in men with CPC. These data provide the first evidence for the efficacy of a non-surgical therapeutic option in this cohort. STRENGTHS AND LIMITATIONS: Strengths - large, prospective series with standardized assessments; Limitations - non-randomized study, short-term follow-up, and lack of standardized method to differentiate CPC from PD. CONCLUSIONS: CCH may be safely and effectively administered to men with CPC, with similar success rates compared to PD. Increasing curvature was associated with greater absolute (degree) and relative (percent) improvements, supporting the role for CCH in men with mild, moderate, or severe curvatures. External validation is warranted prior to routine implementation.

Testicular Pain - Not Always What it Seems: A Cross-Sectional Assessment of Patients Presenting for Chronic Scrotal Content Pain at a Tertiary Care Center.

OBJECTIVE: To review historical and examination findings in patients presenting to a tertiary care center for evaluation of Chronic Scrotal Content Pain (CSCP) defined by persistent/bothersome pain present for > 3-months. METHODS: We performed a retrospective chart review of all patients presenting to our medical center for evaluation of CSCP. Pertinent information collected included historical data, physical examination findings, laboratory and imaging results, and treatments recommended by the assessing physician. The data was summarized to present a cross-sectional representation of patients presenting for CSCP. RESULTS: 110 patients were identified. 80 patients (73%) had seen at least one prior urologist. 26 patients (24%) had undergone a prior unsuccessful surgical intervention for CSCP. Reproducible tenderness was present in 67% of patients including testicular tenderness in 50 (45%), epididymal tenderness in 60 (55%), and spermatic cord tenderness in 31 patients (28%). 33% of patients did not have any reproductible scrotal content tenderness on physical examination. Surgery was recommended in 57/110 patients (52%), including microdenervation in 22%. Musculoskeletal etiologies were suspected based on specific aspects of the history and physical examination in 43 patients (39%), prompting additional evaluation and/or referrals. CONCLUSION: CSCP presents with a wide array of symptoms and many patients do not have reproducible findings on examination, suggesting alternative sources of pain such as referred pain from musculoskeletal causes. The history and physical examination should include assessments for concurrent abdominal, back, hip, and other genital/pelvic pain that may suggest alternative diagnoses and referrals for appropriate treatment.

The clinical significance of imperfection: is idiopathic corporal asymmetry related to curvature during penile prosthesis placement?

Patient satisfaction after inflatable penile prosthesis (IPP) has been linked to preexisting curvature; however the association with intraoperative asymmetric corporal measurements (ACM) has not been well described. We sought to identify incidence of ACM during IPP surgery, and relationship to penile curvature. A retrospective review of all patients undergoing primary IPP placement between 6/2019 and 6/2021 was performed. Logistic regression analysis was performed to identify factors associated with ACM and need for adjunct straightening techniques. A total of 273 patients underwent primary IPP. 27.8% had Peyronie's disease (PD) diagnosed preoperatively or detected intraoperatively. ACM was identified in 20.1% (55/273) patients. There was no significant difference in ACM in PD versus non-PD patients (p = 0.55). Most patients with ACM (78.2%, 43/55) underwent placement of asymmetric device. ACM did not predict need for invasive straightening maneuvers (p = 0.12). However ACM patients were significantly more likely to have mild residual curvature than those with symmetry (p < 0.0001). Our study is first to address management of idiopathic ACM and association with curvature, providing new insight into a common situation. While ACM was detected in 20%, it did not predict need for adjunct straightening techniques. Our findings may provide reassurance to urologists troubleshooting idiopathic ACM during corporal dilation during IPP surgery.