Inflatable Penile Prosthesis Placement in Men with Peyronie's Disease and Drug-resistant Erectile Dysfunction: A Single-Center Study

IntroductionErectile dysfunction (ED) frequently accompanies Peyronie's disease (PD) and changes the therapeutic approach.AimTo evaluate a single-center experience with inflatable penile prostheses (IPP) in men with medication refractory ED and PD.MethodsNinety men underwent placement of an IPP with straightening maneuvers as necessary to address their deformity and ED.Main Outcome MeasuresPreoperative assessment included International Index of Erectile Function-erectile function domain (IIEF-EF) and duplex ultrasound to confirm ED and measure erect deformity. Postoperative assessment included a modified Erectile Dysfunction Index of Treatment Satisfaction (EDITS) questionnaire, as well as office visits at 1, 6, and every 12 months thereafter.ResultsComplete chart review was performed with mean follow-up of 49 months. Mean preoperative IIEF-EF score was 11. Full rigidity was not obtained in any patient during duplex ultrasound. Mean curvature at maximum erection was 53°. There were seven mechanical failures requiring device replacement, two revision surgeries for pump or reservoir malposition, one infected device, and two corporoplasties for distal tunica erosion. Postoperative office assessment revealed a functionally straight (i.e., <20°) erect penis and a properly positioned as well as operational device in all patients. The modified EDITS questionnaire was returned by 56 (62%). Overall, 84% of patients were satisfied with their outcome, yet only 73% were satisfied with their straightness. Patient perceived postoperative curvature correction stabilized quickly and was complete by 3 months in 84% of patients. Satisfaction with ease of inflation, deflation, and concealability was 84%, 71%, and 91%, respectively. Coital activity was reported by 91% of men in this group.ConclusionIn men with PD and ED, IPP placement allowed reliable and satisfactory coitus for the great majority of men. Mechanical failure was 7%. Men with PD undergoing IPP placement should be counseled regarding potential penile length loss and residual curvature, neither of which appeared to interfere with coitus but may reduce satisfaction. Levine LA, Benson J, and Hoover C. Inflatable penile prosthesis placement in men with Peyronie's disease and drug-resistant erectile dysfunction: A single-center study.     

ORIGINAL RESEARCH—PEYRONIE'S DISEASE: Testosterone Deficiency and Peyronie's Disease: Pilot Data Suggesting a Significant Relationship

IntroductionAs testosterone (T) has been shown to influence wound healing, and serum T declines in the age group at risk for Peyronie's disease (PD), we explored the possibility that low serum T may be associated with PD.AimThe purpose of this study was to evaluate the relationship between serum T concentrations and features of PD.MethodsMedical records were reviewed for 121 consecutive patients with PD seen over a 2-year period. All patients were assessed for sociodemographic data, medical history, comorbid medical conditions, findings on physical examination, and severity of curvature. Laboratory testing included serum concentrations of total testosterone (TT) and free testosterone (FT). Testosterone deficiency (TD) was defined as TT values less than 300 ng/dL and/or FT less than 1.5 ng/dL.Main Outcome MeasuresPrevalence of TD in men with PD and correlation of TT and FT with severity of curvature and plaque size.ResultsMean patient age was 53.9 ± 10.6 years (range 28–77). Penile curvature was 50.2 ± 23.6 degrees (range 10–120). Mean TT was 411.6 ± 203.6 ng/dL (range 69–877), and mean FT was 1.12 ± 0.58 ng/dL (range 0.13–5.06). Low T was identified in 29.5% by TT alone and in 74.4% overall. Severity of curvature was greater for men with TD compared with men with normal T (54.3 vs. 37.1 degrees, P = 0.006). Men with low FT had greater penile curvature than men with normal FT (37.5 vs. 55.9 degrees, respectively, P = 0.003). Severity of penile curvature correlated significantly with FT (r = ?0.314, P = 0.016) and estradiol/T (r = 0.476, P = 0.0001) but not TT (r = ?0.199, P = 0.138).ConclusionsThis pilot study suggests a possibly important relationship between low T and PD. Further prospective studies are needed to confirm this relationship. Moreno SA, and Morgentaler A. Testosterone deficiency and Peyronie's disease: Pilot data suggesting a significant relationship. J Sex Med 2009;6:1729–1735.     

Radiation Therapy in Peyronie's Disease

IntroductionPeyronie's disease (PD) is characterized by fibrotic plaque formation within the tunica albuginea, leading to penile deformity, angulation, painful erections, and often, erectile dysfunction. There is limited knowledge of its etiology and pathophysiology. Currently, there is no standardization for reporting the evaluation and treatment outcomes. No consensus exists on the ideal management of PD.AimThe aim of this study is to review the use of radiation therapy (RT) for the treatment of PD.MethodsThis study used a review of the literature and informed expert opinion.Main Outcome MeasuresThe main outcome measures are the reported improvement with regard to pain, curvature, plaque size, and erectile function as well as a review of the safety profile of RT.ResultsRadiation has been used for the empirical treatment of PD with mixed results throughout the literature. Low‐dose RT in the early stages of PD seems to be effective in patients with painful erections not improving with time or with the use of oral or intralesional therapies. Comparison with other current medical therapies is difficult due to the absence of criteria for therapeutic success and the absence of randomized, controlled trials. Multiple studies have demonstrated varied results in terms of curvature reduction, plaque volume, and sexual functioning. The absence of the use of validated means of measuring penile deformity and sexual function, the limited relevance of plaque and pain improvement combined with the potential negative consequences of radiation on erectile tissue structure and function lead us to make a recommendation that RT not be used for the management of PD.ConclusionsIn clinical practice, mixed success for RT has led to the recommendation against its use as a treatment modality for PD. Mulhall JP, Hall M, Broderick GA, and Incrocci L. Radiation therapy in Peyronie's disease. J Sex Med 2012;9:1435–1441.     

Extracorporeal Shockwave Therapy in Peyronie's Disease: Systematic Review and Meta-Analysis

BackgroundPeyronie's disease (PD) is associated with penile pain, deviation, and sexual dysfunction. Up till now, there is no conservative standard treatment for PD. However, the role of Extracorporeal Shock Wave Therapy (ESWT) is gaining increasing interest.AimTo evaluate the effect of ESWT on penile deviation, plaque size, erectile function, pain scale, and the rate of complications in PD patients.MethodsPubMed database was searched for articles published from January 2000 to November 2020, using related keywords and including randomized controlled trials (RCTs) only. Meta-analysis and forest plots were carried out using RevMan, and outcomes were reviewed by 2 authors independently. PRISMA guidelines were used in this article to achieve the quantitative and qualitative synthesis of data.OutcomesChanges in penile deviation, plaque size, erectile function, pain scale, and the rate of ESWT related complications.ResultsThe search yielded 73 articles. Three RCTs, including 117 patients in the ESWT group and 121 patients in the placebo group, were reviewed. ESWT is associated with reduction in plaque size (OR = 2.59, 95% CI (1.15–5.85), P= .02). No significant difference in reduction of penile deviation angle or rate of bruises were detected in post ESWT group when compared to placebo. No evidence was found to show an effect of ESWT on erectile function or pain scale.Clinical ImplicationsBased on the available RCTs, ESWT fails to improve penile curvature or pain in men with PD.  Although ESWT may reduce plaque size, this remains of questionable clinical significance.Strengths & LimitationsRCTs used different metrics to report the same outcome. Missed data were imputed to match the requirements of meta-analysis. However, there is still much data that cannot be estimated.ConclusionThe current data suggest that ESWT fails to improve penile curvature or pain in men with PD.  Although ESWT may reduce plaque size, this remains of questionable clinical significance, and further studies are required to confirm findings.Bakr AM, El-Sakka A. Extracorporeal Shockwave Therapy in Peyronie's Disease: Systematic Review and Meta-Analysis. J Sex Med 2021;18:1705–1714.     

High Patient Satisfaction of Inflatable Penile Prosthesis Insertion with Synchronous Penile Plication for Erectile Dysfunction and Peyronie's Disease

IntroductionTwenty to thirty percent of patients with Peyronie's disease (PD) have erectile dysfunction (ED) refractory to medical therapy and may benefit from a combined procedure addressing both conditions.AimThe aim of this study was to show the efficacy of inflatable penile prosthesis (IPP) insertion and synchronous penile plication for correcting penile curvature and ED in patients with PD.MethodsA retrospective review was performed of all patients who underwent IPP insertion with synchronous penile plication at our tertiary care center between 2010 and 2013. All patients received an intraoperative saline intracorporal injection to induce an artificial erection. After the tunica albuginea was exposed via a standard transverse scrotal incision over the proximal penile shaft, the incision was retracted distally and/or laterally as needed for plication suture placement. Plication sutures were placed in parallel opposite the angle of greatest curvature. The incision was returned proximally to the standard penoscrotal junction for IPP insertion. Demographic and surgical data were collected from the patients' medical records. Patient satisfaction was assessed postoperatively using a nonvalidated questionnaire.Main Outcome MeasuresThe focus of this study was surgical outcomes, both technical and patient-reported satisfaction.ResultsEighteen patients with a mean age of 63 years underwent IPP insertion with synchronous penile plication. Patients presented with dorsal (n = 11), lateral (n = 2), and biplanar curvature (n = 5). Mean preoperative curvature was 39 degrees (range 30–60) and was corrected on average to <5 degrees (range <5–12) using a median of four plication sutures (range 3–6). Among 15 patients completing a postoperative satisfaction survey at a mean of 11 months, all reported improvement in their overall condition and penile curvature; one with biplanar deformity reported minor residual curvature. None reported continued pain or required suture release.ConclusionsIPP insertion with synchronous penile plication for the correction of ED and PD is effective and results in high patient satisfaction. Chung PH, Scott JF, and Morey AF. High patient satisfaction of inflatable penile prosthesis insertion with synchronous penile plication for erectile dysfunction and Peyronie's disease. J Sex Med 2014;11:1593–1598.     

Trans-corporal incision of Peyronie's plaques

IntroductionPatients presenting with Peyronie's disease (PD) curvature and erectile dysfunction (ED) can achieve straightening and rigidity through penile prosthesis implantation and manual modeling and, if necessary, a relaxing tunical incision with or without grafting. Unfortunately, this maneuver will not correct PD‐induced shortening. In addition, incision and grafting after the prosthesis has already been implanted adds to operative time and risk, and may indicate mobilization of the neurovascular bundle and, possibly, a secondary skin incision.AimThis work describes trans‐corporal incision (TCI), a minimally invasive endoscopic approach for plaque incision from within the corpora cavernosa, restoring straightness and length to the penis, before calibration of the corpora cavernosa, allowing implantation of a longer prosthesis in a straight penis, with neither mobilizing the neurovascular bundle nor a secondary incision.MethodsSixteen patients with PD deformity and refractory ED were operated upon. Intra‐operative artificial erection demonstrated the deformity. Through a penoscrotal incision, the corpora were dilated. TCI was performed to incise Peyronie's plaques at the point of maximum deformity. Artificial erection was re‐induced and correction of curvature evaluated. Length was measured before and after TCI. Implantation proceeded as usual.Main Outcome MeasuresPenile straightness and length.ResultsFollowing implantation, the penis was straight in all cases. Pre‐TCI length of the corpora was unequal on either side. Post‐TCI, both corpora were of equal length with an average increase of 2.5 cm (11.9%) on the right side and 1.9 (9.1%) on the left.ConclusionTCI; corporoscopic incision of Peyronie's plaques upon implantation of penile prosthesis is a minimally invasive approach that restores both straightness and length to patients with PD and ED, with neither mobilization of the neurovascular bundle nor plaque incision and grafting. Shaeer O. Trans‐corporal incision of Peyronie's Plaques. J Sex Med 2011;8:589–593.     

Correlation of Degree of Penile Curvature between Patient Estimates and Objective Measures among Men with Peyronie's Disease

IntroductionAmong men with Peyronie's disease (PD), the degree of penile curvature has significant implications on psychological well-being, sexual function, treatment planning, and posttherapy evaluations.AimThe primary objective of the current study was to correlate patients' estimates of penile angulation with objective measures.Main Outcome Measures(i) Proportion of patients over- or underestimating their actual degree of curvature; and (ii) degree differences between patient estimates and objective measures of penile curvature.MethodsAt baseline, patients with established PD were asked to provide a “best estimate” of their degree of penile curvature. Objective measures of penile angulation were then performed using standardized photographs and protractor-based measurement of penile curvature during full erection. Correlations were performed between patient estimates of penile curvature and objective measures of penile angulation.ResultsEighty-one men with established PD and a mean age of 52 years (range: 20–72 years) were prospectively evaluated. Mean duration of disease was 33 months (range: 6–276 months), and mean plaque size was 1.4 cm ± 0.1 standardized error (SE). The proportion of patients with dorsal, lateral, and ventral curvatures was 39%, 57%, and 4%, respectively. Patient estimates of baseline penile curvature (mean 51 degrees ± 3.1 SE) differed significantly from objective measurements (mean 40 degrees ± 2.4, P = 0.001). A significantly higher proportion of patients overestimate their actual degree of penile curvature (54% overestimate, 26% underestimate, and 20% are accurate within 5 degrees, P = 0.002). Compared with objective measures, patients' estimates of degree of penile curvature differed by an average of 20 degrees ± 2.2 SE.ConclusionsPatients with PD tend to overestimate their degree of penile curvature. Objective measurement of penile angulation is necessary to accurately counsel patients regarding disease severity, recommend appropriate treatment strategies, and objectively evaluate outcomes following therapy. Bacal V, Rumohr J, Sturm R, Lipshultz LI, Schumacher M, and Grober ED. Correlation of degree of penile curvature between patient estimates and objective measures among men with Peyronie's disease. J Sex Med 2009;6:862–865.     

Predicting erectile dysfunction following surgical correction of Peyronie's disease without inflatable penile prosthesis placement: vascular assessment and preoperative risk factors

IntroductionSurgical therapy remains the gold standard treatment for Peyronie's Disease (PD). Surgical options include plication, grafting, and placement of inflatable penile prosthesis (IPP). Postoperative erectile dysfunction (ED) is a potential complication for PD surgery without IPP. We present our large series follow‐up to evaluate preoperative risk factors for postoperative ED.AimsThe aim of this study is to evaluate preoperative risk factors for the development of ED following surgical correction of PD taking into account the degree of curvature, graft size, surgical approach, hypertension, hyperlipidemia, diabetes, smoking history, preoperative use of phosphodiesterase 5 inhibitors (PDE5), and preoperative duplex ultrasound findings including peak systolic and end diastolic velocities and resistive index.MethodsWe identified 218 men undergoing either tunica albuginea plication (TAP) or partial plaque excision with pericardial grafting for PD following a previously published algorithm between November 1992 and April 2007. Preoperative and postoperative erectile function, curvature characteristics, presence of vascular risk factors, and duplex ultrasound findings were available on 109 patients.Main Outcome MeasuresOur primary outcome measure is the development of ED after surgery for PD.ResultsTen percent of TAP and 21% of plaque excision with grafting patients developed postoperative ED. Neither curve direction (P = 0.76), graft area (P = 0.78), surgical approach (P = 0.12), chronic hypertension (P = 0.51), hyperlipidemia (P = 0.87), diabetes (P = 0.69), nor smoking history (P = 0.99) were significant predictors of postoperative ED. No combination of risk factors was found to be predictive of postoperative ED. Preoperative use of PDE5 was not a significant predictor of postoperative ED (P = 0.33). Neither peak systolic, end diastolic, nor resistive index were significant predictors of ED (P = 0.28, 0.28, and 0.25, respectively).ConclusionThis long‐term follow‐up of a large published series suggests that neither preoperative risk factors nor preoperative duplex ultrasound findings are predictive of postoperative ED, thus reinforcing the use of previously published preoperative treatment algorithms. Taylor FL, Abern MR, and Levine LA. Predicting erectile dysfunction following surgical correction of peyronie's disease without inflatable penile prosthesis placement: Vascular assessment and preoperative risk factors. J Sex Med 2011;9:296–301.     

Penile Duplex Ultrasonography in Men with Peyronie's Disease: Is it Veno‐Occlusive Dysfunction or Poor Cavernosal Arterial Inflow that Contributes to Erectile Dysfunction?

IntroductionAt least 20% of men with Peyronie's disease (PD) suffer from erectile dysfunction (ED). The fundamental mechanism is thought to arise from the progression of penile fibrosis, which was initially limited to the PD plaque within the tunica albuginea. However, recent studies have highlighted the possibility of fibrosis of the cavernosal vessel media wall leading to impairment of arterial inflow.AimTo evaluate the penile duplex ultrasonographic findings in PD of impotent men and to determine whether early features of PD might predict clinical progression.Main Outcome MeasuresPatient demographic, comorbidities, International Index of Erectile Function‐5 scores, surgical intervention, and physical findings were documented. Penile curvature, plaque size, and peak systolic velocity (PSV) and end‐diastolic velocity (EDV) on color duplex ultrasonography (CDU) were recorded.MethodsWe performed a retrospective review of all men presenting with penile curvature and length loss who underwent penile CDU between January 2001 and January 2010.ResultsA total of 1,120 men underwent penile CDU during the 10‐year period. Complete information was obtained in 810 men; 250 men complained of decreased penile rigidity, while 150 men were unable to sustain erection. Comorbidities were similar between men with PD with and without ED. Tunical thickening (65%) was the most common CDU feature, and mean cumulative calcifications was 24.2 mm² (1–360 mm², standard deviation 76). The PSV and EDV on the right cavernosal artery were 14.2 cm/second and 3.5 cm/second, while the left cavernosal artery measurements were 15.1 cm/second and 3.2 cm/second. Multivariate logistic regression model showed strong correlation between plaque size and development of ED. Both veno‐occlusive dysfunction and impaired cavernosal arterial inflow were associated with ED.ConclusionsVeno‐occlusive dysfunction and impaired cavernosal arterial inflow contributed to the development of ED, and larger plaque size is a strong predictor of surgical intervention. Chung E, De Young L, and Brock GB. Penile duplex ultrasonography in men with Peyronie's disease: Is it veno‐occlusive dysfunction or poor cavernosal arterial inflow that contributes to erectile dysfunction? J Sex Med **;**:**–**.     

Surgical Correction of Persistent Peyronie's Disease Following Collagenase Clostridium Histolyticum Treatment

IntroductionCollagenase clostridium histolyticum (CCH) is an Food and Drug Administration‐approved intralesional injection for treatment of Peyronie's disease (PD) that has been shown to reduce penile curvature deformity and PD symptom bother in phase 2b and phase 3 placebo‐controlled clinical trials. For some patients, nonsurgical treatment with CCH may not sufficiently improve penile curvature, and surgical correction may be pursued following CCH therapy.AimThis study aims to examine intraoperative and postsurgical outcomes of surgical correction of persistent penile curvature in patients with PD who had previously received CCH.MethodsRetrospective chart review was used to identify patients with PD who had received CCH intralesional injection within either the phase 2b or phase 3 CCH clinical trials and then underwent surgical correction due to remaining penile curvature. Surgical techniques used were partial plaque excision and grafting (PEG) and/or tunica albuginea plication (TAP).Main Outcome MeasuresPrimary assessments included pre‐ and postsurgery penile curvature, erectile rigidity, stretched penile length, intraoperative time, and occurrence of adverse events.ResultsSeven men were identified who underwent surgical straightening with TAP or PEG following CCH treatment. Mean number of days from the final CCH injection to surgery was 182 (standard deviation 118; median 127 days). Average penile curvature prior to surgical straightening was 58°. No anatomical difficulties or complications secondary to the effects of prior CCH treatment occurred during surgery. Intraoperative time was representative of standard TAP and PEG surgeries (range 88–146 minutes). All men reported penile curvature <20° postsurgery. One patient experienced a postsurgery subgraft hematoma that required aspiration. There were no postsurgery reports of decreased penile sexual sensation and no occurrence of vascular compromise or decreased penile rigidity.ConclusionThis initial case series supports the hypothesis that prior CCH treatment is not a contraindication to PEG or TAP surgery in the treatment of penile curvature in patients with PD. Levine LA and Larsen SM. Surgical correction of persistent Peyronie's disease following collagenase clostridium histolyticum treatment. J Sex Med 2015;12:259–264.     

Erectile dysfunction after plaque incision and grafting: short-term assessment of incidence and predictors

IntroductionPlaque incision and grafting (PIG) surgery for Peyronie's disease (PD) is a recognized management strategy. One of the recognized complications of PIG surgery is the development of postoperative erectile dysfunction (ED).AimTo determine the incidence of ED after PIG surgery and attempt to define predictors of ED development.MethodsAll patients underwent preoperative cavernosometry. Grafting was performed with either cadaveric pericardium (Tutoplast) or intestinal submucosa (Surgisis). Prior to 2006, the procedure used an H‐type incision, whereas after this date, the Egydio approach has been used.Main Outcome MeasuresMen undergoing PIG completed preoperative and 6‐month postoperative International Index of Erectile Function (IIEF) questionnaires.Results56 patients were analyzed. Mean patient and partner ages were 57 ± 22 and 54 ± 18 years, respectively. Mean duration of PD at the time of PIG was 22 ± 9 months. Seventy‐five percent had curvature alone, 11% had hourglass/indentation deformity, and the remainder had combined curvature/indentation. Mean preoperative curvature was 52 ± 23°. Fifty‐two had grafting with Tutoplast, while four had grafting with Surgisis. All men at baseline were capable of generating a penetration rigidity erection. Preoperatively, 50% of men had cavernosal insufficiency and 21% had venous leak (baseline and postoperative erectile function [EF] domain scores were 23 ± 4 and 17 ± 9, respectively [P < 0.01]). Forty‐six percent of men experienced a ≥6‐point decrease in EF domain score after PIG. The predictors of a ≥6‐point reduction in IIEF‐EF domain score on multivariable analysis were degree of preoperative curvature, type of plaque incision, patient age, and baseline venous leak.ConclusionsAlmost one‐half of men had significant reduction in their erectile rigidity after PIG. Reduction was predicted by larger baseline curvature, the Egydio plaque incision technique, older patient age, and the presence of venous leak at baseline. Based on these data, we discourage older men, those with venous leak, and those with profound curvature from considering PIG surgery. Flores S, Choi J, Alex B, and Mulhall JP. Erectile dysfunction after plaque incision and grafting: Short‐term assessment of incidence and predictors. J Sex Med 2011;8:2031–2037.     

Predictors of Depression in Men With Peyronie's Disease Seeking Evaluation

BackgroundPeyronie's disease (PD) has negative impacts on the psychosocial status of men including depression warranting clinical evaluation in up to 50% of men.AimTo examine predictors of depression in patients with early PD seeking evaluation.MethodsAll PD patients at a high-volume PD practice underwent screening and curvature assessment after intracavernosal injection. Complex deformity was defined as any degree of multiplanar curvature, curvature >60 degrees, or presence of hourglass deformity. Men completed the PD questionnaire (PDQ), a validated depression questionnaire (CES-D) as well as the Self-Esteem and Relationship (SEAR) questionnaire. Scores of ≥16 on CES-D were considered indicative of moderate/severe depression. Predictors of the presence of depression were defined using univariable and multivariable logistic regression.OutcomesDemographic, bother and curve related predictors of depression in men with PD.Results408 men completed all questionnaires. Mean age was similar between depressed and nondepressed groups (57 ± 10 years overall, P = .60 between groups). Proportions of erectile dysfunction were similar between groups (P = .96). Mean PD duration was similar between groups (19 ± 35 months overall, P = .46 between groups). Mean degree of curvature was 38 ± 2 degrees in the depressed vs 33 ± 1 degrees in the nondepressed groups (P = .03). A complex deformity was seen in 64.5% in the depressed vs 61.5% in the nondepressed (P = .56). A total of 110 (27%) patients had CESD scores ≥16. 74% depressed men were in relationships compared to 84% nondepressed men (P < .01). Other characteristics including bother, pain, duration of disease, curve complexity and instability were similar between the two groups. On univariable analysis, factors protective against depression included being partnered (OR 0.42, 95%CI 0.24–0.75, P < .01) and higher total SEAR scores (OR 0.95, 95%CI 0.94–0.97, P < .01). Elevated PDQ domain scores were associated with depression (Psychologic Symptoms 1.05, 95%CI 1.02–1.10, P < .01; Pain 1.08, 95%CI 1.03–1.12, P < .01; Bother 1.11, 95% CI 1.05–1.68, P < .01) as well as baseline history of depression (OR 2.93, 95%CI 1.67–5.14, P < .001). On multivariable analysis, only total SEAR score remained protective against depression (OR 0.96, 95%CI 0.94–0.97, P < .001).Clinical ImplicationsProviders must recognize that men with PD seeking evaluation have meaningful rates of depression for which early recognition is necessary.Strengths and LimitationsRetrospective review of a large prospectively collected dataset from a single center of men with PD utilizing a validated screening tool for depression.ConclusionWhile no significant demographic, bother or curve related factors predicted depression in early PD men seeking evaluation, it remains a significant problem warranting further prospective evaluation.P. Nahid, N. Bruno, S. Carolyn, et al. Predictors of Depression in Men With Peyronie's Disease Seeking Evaluation. J Sex Med 2021;18:783–788.     

The Prevalence of Peyronie's Disease in Japan: A Study in Men Undergoing Maintenance Hemodialysis and Routine Health Checks

IntroductionThe incidence of Peyronie's disease (PD) in the general population is believed to be as high as 20%. However, most of the data concerning the prevalence of PD have been obtained from Caucasian populations.AimThe aim of this study was to examine the prevalence of PD in Asia and among men undergoing hemodialysis and discuss the pathophysiology of PD.MethodsA total of 1,090 men who received a routine health check at our hospital (control group) as well as 130 male patients undergoing maintenance hemodialysis were enrolled. The diagnosis of PD was based on a palpable penile plaque.Main Outcome MeasuresHemodialysis patients were asked about their sexual activity and completed the International Index of Erectile Function‐5 questionnaires. The differences between patients' and hemodialysis‐associated factors, comorbidities, and medications were statistically assessed for patients with and without PD.ResultsThe prevalence of PD was significantly increased among hemodialysis patients (12 patients: 9.2%) relative the control group (six men: 0.6%) (P < 0.0001, odds ratio: 18.4). In both groups, the plaques were primarily allocated dorsally. In the hemodialysis patients with PD, the frequency of masturbation (P < 0.05) and the incidence of moderate or severe erectile dysfunction (P < 0.01) were significantly higher than those among hemodialysis patients without PD. In comparison with patients without PD, the number of acetate dialysate users was significantly higher among patients with PD (P < 0.05), and none of the PD patients used angiotensin‐related antihypertensive drugs (P < 0.05).ConclusionsThe prevalence of PD in healthy Japanese men is low (0.6%), which suggests the existence of racial differences in the prevalence of PD. Moreover, these results indicate that hemodialysis increases the incidence of PD. The differences in the characteristics between male hemodialysis patients with and without PD provide new insights into the pathophysiology and therapeutic window of PD. Shiraishi K, Shimabukuro T, and Matsuyama H. The prevalence of Peyronie's disease in Japan: A study in men undergoing maintenance hemodialysis and routine health checks. J Sex Med **;**:**–**.     

Erectile Dysfunction Might Be Associated With Chronic Periodontal Disease: Two Ends of the Cardiovascular Spectrum

IntroductionBoth chronic periodontal disease (CPD) and erectile dysfunction (ED) are associated with cardiovascular disease and its risk factors, including smoking and diabetes mellitus. However, the association between ED and CPD has never been studied.AimTo study the association between ED and CPD.Main Outcome MeasuresPrevalence of ED, prevalence of CPD, ED severity.Methods:The study population consisted of 305 men who filled the Sexual Health Inventory for Men (SHIM) questionnaire in order to detect ED and assess its severity, and underwent a pair of standardized posterior dental bitewing radiographs in order to detect CPD. SHIM questionnaire scores 21 or less represented ED. Alveolar bone loss of ≥6 mm represented CPD.ResultsThe mean age of included men was 39.5 ± 6.7 years. Overall, 70 (22.9%) men had ED and 13 (4.3%) had CPD. CPD was significantly more prevalent among men with mild ED (P = 0.004) and moderate to severe ED (P = 0.007) in comparison to men without ED.ConclusionsED might be associated with CPD. These preliminary findings are consistent with theories that associate these conditions with systemic inflammation, endothelial dysfunction, and atherosclerosis. Zadik Y, Bechor R, Galor S, Justo D, and Heruti RJ. Erectile dysfunction might be associated with chronic periodontal disease: Two ends of the cardiovascular spectrum. J Sex Med **;**:**–**.     

Vitamin D and Erectile Dysfunction

IntroductionEndothelial dysfunction has been demonstrated to play an important role in pathogenesis of erectile dysfunction (ED) and vitamin D deficiency is deemed to promote endothelial dysfunctions.AimTo evaluate the status of serum vitamin D in a group of patients with ED.MethodsDiagnosis and severity of ED was based on the IIEF‐5 and its aetiology was classified as arteriogenic (A‐ED), borderline (BL‐ED), and non‐arteriogenic (NA‐ED) with penile‐echo‐color‐Doppler in basal condition and after intracaversous injection of prostaglandin E1. Serum vitamin D and intact PTH concentrations were measured.Main Outcome MeasuresVitamin D levels of men with A‐ED were compared with those of male with BL‐ED and NA‐ED.ResultsFifty patients were classified as A‐ED, 28 as ED‐BL and 65 as NA‐ED, for a total of 143 cases. Mean vitamin D level was 21.3 ng/mL; vitamin D deficiency (<20 ng/mL) was present in 45.9% and only 20.2% had optimal vitamin D levels. Patients with severe/complete‐ED had vitamin D level significantly lower (P = 0.02) than those with mild‐ED. Vitamin level was negatively correlated with PTH and the correlation was more marked in subjects with vitamin D deficiency. Vitamin D deficiency in A‐ED was significantly lower (P = 0.01) than in NA‐ED patients. Penile‐echo‐color‐Doppler revealed that A‐ED (PSV ≤ 25 cm/second) was more frequent in those with vitamin D deficiency as compared with those with vitamin >20 ng/dL (45% vs. 24%; P < 0.05) and in the same population median PSV values were lower (26 vs. 38; P < 0.001) in vitamin D subjects.ConclusionOur study shows that a significant proportion of ED patients have a vitamin D deficiency and that this condition is more frequent in patients with the arteriogenic etiology. Low levels of vitamin D might increase the ED risk by promoting endothelial dysfunction. Men with ED should be analyzed for vitamin D levels and particularly to A‐ED patients with a low level a vitamin D supplementation is suggested. Barassi A, Pezzilli R, Colpi GM, Corsi Romanelli MM, and Melzi d'Eril GV. Vitamin D and erectile dysfunction. J Sex Med 2014;11:2792–2800.     

Predictors of Curvature Improvement in Men With Peyronie's Disease Treated With Intralesional Collagenase Clostridium Histolyticum

IntroductionPenile curvature is the most common abnormality that is observed by men with Peyronie's disease (PD). Collagenase Clostridium histolyticum (CCH) has become a standard treatment for PD patients.AimTo identify predictor factors associated with improvements of penile curvature outcomes in men with PD treated with CCH.MethodsWe retrospectively collected the data of patients with PD treated with CCH up to 8 injections divided into 4 cycles between January 2014 and July 2020. Per protocol, penile curvature was assessed at baseline, and after the second and ford CCH cycle. If after cycle 2, curvature demonstrated no improvement, or penile curvature was significantly improved and the patient was happy, no further treatment was recommended. However, if penile curvature was significantly improved and the patient remained dissatisfied, 4 cycles were completed. Three categories of response were evaluated: improvement (≥10 degrees or ≥20%, either 1 happens), unchanged (±10 degrees or ±20%) or worsened (≥10 degrees or ≥20%, either 1 happens). Logistic regression analyses were performed to evaluate predictive factors associated with penile curvature improvements.OutcomesDegrees of the curvature changes between the baseline and after the cycles of CCH.ResultsA total of 114 patients underwent CCH treatment. Median age was 57 years. Median PD duration was 11 months. At baseline, mean curvature was 47 degrees, 65% had dorsal curvature, 53% mid-shaft location, and 15% calcification. After CCH treatment, the mean final curvature was 40 degrees. A total of 44% improved the curvature, 39% had no change while 17% worsened after CCH treatment. Of men who had penile curvature improvement with CCH treatment, the mean curvature decreasing in degrees and percentage were 22 degrees and 41%, respectively. Men with baseline curvature ≤ 30, 31–59, and ≥ 60 degrees, the percentage curvature improvement were 29%, 43%, and 60%, respectively. Baseline curvature was the only significant predictor of penile curvature improvement after CCH (OR 1.33, 95% CI = 1.1, 1.7).Clinical ImplicationsWe confirmed baseline penile curvature is the most important predictive factor, and this is the first report describing proportions of penile curvature improvement with CCH treatment.Strengths and LimitationsThis study has several strengths, including the use of validated instruments. Nonetheless, there are limitations: the retrospective nature of the study, a single institution; and modelling device was not controlled.ConclusionPenile curvature improvement was significantly more common in patients with greater baseline curvature, reaching up to 60% for patients with ≥ 60 degrees.Flores JM, Nascimento B, Punjani N, et al. Predictors of Curvature Improvement in Men With Peyronie's Disease Treated With Intralesional Collagenase Clostridium Histolyticum. J Sex Med 2022;19:1680–1686.     

ORIGINAL RESEARCH—PEYRONIE'S DISEASE: Peyronie's Disease Following Radical Prostatectomy: Incidence and Predictors

IntroductionBoth prostate cancer and Peyronie's disease (PD) are prevalent in men after their fifth decade of life. The evidence to support or refute a link between radical prostatectomy (RP) and PD is limited.AimsTo define the incidence of PD in men who had RP and determine possible predictors of PD development after RP.MethodsA review of a prospectively built sexual medicine database, years 2002–2008, looking at subjects who had RP as a monotherapy for localized prostate cancer. We identified and characterized subjects who developed PD within 3 years after RP and compared them with subjects who did not.Main Outcome MeasuresThe incidence of PD among men who attended a sexual medicine clinic after they had RP, predictors of PD development after RP.ResultsThe study population included 1,011 subjects, and PD incidence in this population was 15.9%. Mean time to develop PD after RP was 13.9 ± 0.7 months. Mean curvature magnitude was 31 + 17 degrees. On univariate analysis, younger age (mean age of 59 + 7 in men with PD vs. 60 + 7 years in men without PD, P = 0.006) and white race (vs non-white, 18% vs. 7%, P < 0.001) were predictive of PD development after RP, but post-op erectile function was not a predictor of PD development. On multivariate analysis, younger age (odds ratio (OR) = 1.3, for 5-year decrease in age) and white race (OR = 4.1, vs. non-white) remained independent significant predictors.ConclusionsMen presenting with sexual dysfunction after RP have higher PD incidence then the general population. Therefore, they should be routinely evaluated for PD. Younger men and men of white race are at increased risk for PD. Prospective controlled studies are needed to elucidate the incidence of PD following RP and to conclude if RP has a causative role in the pathogenesis of PD. Tal R, Heck M, Teloken P, Siegrist T, Nelson CJ, and Mulhall JP. Peyronie's disease following radical prostatectomy: Incidence and predictors.     

Standard Operating Procedures for Peyronie's Disease

IntroductionPeyronie's disease (PD) refers to a penile deformity that is associated with sexual dysfunction.AimTo provide recommendations and Standard Operating Procedures (SOPs) based on best evidence for diagnosis and treatment of PD.MethodsMedical literature was reviewed and combined with expert opinion of the authors.Main Outcome MeasuresRecommendations and SOPs based on grading of evidence–based medical literature.ResultsPD is a fibrotic wound-healing disorder involving the tunica albuginea of the corpora cavernosa. The resulting scar is responsible for a variety of deformities, including curvature, shortening, narrowing with hinge effect, and is frequently associated in the early phase with pain. Patients frequently experience diminished quality erections. All of these conditions can compromise sexual function for the affected male. The etiopathophysiology of PD has yet to be clarified and as a result, effective, reliable, mechanistic directed non-surgical therapy is lacking.ConclusionsThe management of PD consists of proper diagnosis and treatment, ranging from non-surgical to surgical interventions. The main state of treatment for PD rests at this time on surgical correction that should be based on clear indications, involve surgical consent, and follow a surgical algorithm that includes tunica plication, plaque incision/partial excision and grafting, and penile prosthesis implantation. Levine LA and Burnett AL. Standard operating procedures for Peyronie's disease. J Sex Med 2013;10:230-244.     

ORIGINAL RESEARCH—PEYRONIE'S DISEASE: Penile Sonographic and Clinical Characteristics in Men with Peyronie's Disease

IntroductionUltrasonography of the penis is readily available to the urologist and gives good anatomic detail of soft tissue structures. It has not been widely utilized in the assessment of Peyronie's disease (PD).AimsTo describe the sonographic characteristics of the penis in PD and the relationship between clinical and sonographic features.MethodsThis cross-sectional study enrolled patients from a single clinical practice. A PD-specific questionnaire was administered and sonographic evaluations were performed.Main Outcome MeasuresSonographic characteristics of men with PD.ResultsTunical thickening, calcifications, septal fibrosis, and intracavernosal fibrosis, were observed at initial clinical evaluation in 50%, 31%, 20%, and 15% of men, respectively. Men aged 40–49 (OR 2.4, P = 0.02) and men aged 50–59 (OR 2.4, P = 0.004) were more likely to have sub-tunical calcifications relative to men under age 40. Men with septal fibrosis had fewer chronic medical conditions such as diabetes (OR 0.3, P = 0.04), hypertension (OR 0.5, P = 0.03), and coronary artery disease (OR 0.2, P = 0.05), and presented within 1 year of disease onset (OR 2.1, P = 0.001). Men with septal fibrosis were less likely to have lost penile length (OR 0.5, P = 0.04) and more likely to be able to have intercourse (OR 1.9, P = 0.05). Men with intracavernosal fibrosis were less likely to have penile pain (OR 0.5, P = 0.05), but more likely to have penetration difficulty during intercourse (OR 1.9, P = 0.008), an additional penile deformity (OR 1.8, P = 0.02), or rapid onset of disease (OR 1.7, P = 0.04). Tunical thickening was associated with a decreased ability to have intercourse (OR 2.3, P < 0.001).ConclusionPD is a clinically and sonographically heterogeneous condition. Sonography is a safe, low-cost, and rapid means of objectively characterizing lesions in this condition. This may help track the evolution of the condition in individual patients and in the future may be useful for tailoring treatment strategies. Smith JF, Brant WO, Fradet V, Shindel AW, Vittinghoff E, Chi T, Huang YC, Davis CB, Conti S, and Lue TF. Penile sonographic and clinical characteristics in men with Peyronie's disease. J Sex Med 2009;6:2858–2867.     

Treatment of Peyronie's Disease With Collagenase Clostridium histolyticum and Vacuum Therapy: A Randomized,Open-Label Pilot Study

BackgroundCollagenase Clostridium histolyticum (CCH) is indicated for the treatment of penile curvature in adult men with Peyronie's disease (PD) with palpable plaque and curvature deformity of at least 30° at the start of therapy.AimTo evaluate the efficacy and safety of CCH plus vacuum-pump therapy with and without penile modeling for the management of PD.MethodsAdult men with PD and penile curvature of at least 30° were randomly assigned to receive CCH 0.58 mg plus vacuum therapy alone (n = 15) or with penile plaque modeling (n = 15). Patients received no more than four treatment cycles (cycle = ∼6-week duration), each consisting of two intralesional injections of CCH administered 24 to 72 hours apart. Vacuum therapy was applied twice daily from 14 days after the second injection of each cycle until the following cycle. Modeling was performed 24 to 72 hours after the second injection of each cycle.OutcomesThe primary end point was change in penile curvature from baseline to week 36; additional end points included changes in Peyronie's Disease Questionnaire (PDQ) domain scores, composite response (≥20% decrease in penile curvature and decrease in PDQ bother score ≥ 1 point), and global response (small but important, moderate, or much improvement in the Global Assessment of PD).ResultsAt week 36, improvement in penile curvature from baseline was similar in the two groups (mean change from baseline = −23.7° [SD = 10.9] for CCH + vacuum + modeling and −23.3° [SD = 7.2] for CCH + vacuum; between-group difference = −0.3°, 95% CI = −7.3 to 6.6). Improvements in most PDQ domains, including bother, were observed from baseline to week 36 in the two groups. Most patients were composite (66.7% and 84.6% with CCH + vacuum + modeling and CCH + vacuum, respectively) and global (86.7% and 92.3%, respectively) responders. The most common adverse events were penile contusion, penile swelling, and penile pain.Clinical ImplicationsVacuum-pump therapy administered alone or in combination with modeling after CCH treatment could improve PD symptoms.Strengths and LimitationsThis was a pilot study with a small sample and limited follow-up duration.ConclusionCCH and vacuum-pump therapy (alone or combined with modeling) could be an appropriate consideration for men with PD and warrants further investigation.Ralph DJ, Abdel Raheem A, Liu G. Treatment of Peyronie's Disease With Collagenase Clostridium histolyticum and Vacuum Therapy: A Randomized, Open-Label Pilot Study. J Sex Med 2017;14:1430–1437.