Psychological Impact of Peyronie's Disease: A Review

IntroductionPeyronie's disease (PD) is characterized by an accumulation of scar tissue in the tunica albuginea of the penis that causes curvature and deformity. PD can result in psychological distress, depression, or anxiety, which often goes untreated.AimsTo review the current literature on the psychological impact of PD, educate healthcare providers about the psychological components of the disease, and propose interventions that address the psychological and sexual challenges patients and their partners may encounter.MethodsWe performed a MEDLINE search, limited to English, using the terms “Peyronie's disease” AND “psychological” OR “psychosocial,” and select references were included for review.Main Outcome MeasureCritical review of the currently available English language literature.ResultsPD and its associated deformity often impairs sexual relations and frequently leads to psychological and psychosocial sequelae for affected individuals. Many men experience depression, low self‐esteem, and emotional distress; these problems markedly diminish the quality of life for affected individuals. The literature suggests that as many as 81% of men report “emotional difficulties,” 48% report clinically meaningful depression (26% moderate; 21% severe), and 54% report relationship problems due to PD. The challenges imposed by PD include alterations in sexual relationships, restrictions on intimacy, social isolation, and stigmatization, all of which are linked and reinforce each other. Physicians may be unaware of the psychological sequelae suffered by patients and their partners.ConclusionsImproved awareness and education about the psychological consequences and treatment options for PD are necessary among healthcare providers. To best help patients and optimize outcomes, a team‐based approach is needed that includes psychosocial assessment and appropriate resource referrals for the patient and his sexual partner. Nelson CJ and Mulhall JP. Psychological impact of Peyronie's disease: A review. J Sex Med 2013;10:653–660.     

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.     

Concordance Between Patient and Physician Assessment of the Magnitude of Peyronie's Disease Curvature

IntroductionThe magnitude of penile deformity is a critically important factor in Peyronie's disease, as it is associated with increased difficulty in penetrative sexual intercourse and in turn with negative psychosocial consequences. Deformity magnitude also influences treatment choice when surgical correction is indicated.AimTo determine the concordance between patient and physician assessment of magnitude of penile curvature in men with Peyronie's disease.MethodsPatient assessment of curvature was obtained at initial interview. Physician assessment was performed using intracavernosal injection-assisted erection using a goniometer applied during excellent penile rigidity.Main Outcome MeasuresPatient and physician assessments of penile curvature.ResultsThe sample consisted of 192 men with a mean age of 54 ± 12 years old. Mean curvature on patient and physician assessment was 33 ± 17 and 36 ± 18 degrees, respectively. Only 49% of patients (94) correctly assessed their curvature, whereas 35% underestimated and 16% overestimated it.ConclusionsOnly half of PD patients accurately assess their penile curvature, with more than twice as many patients underestimating it than overestimating it. These data suggest that patient self-reporting of penile curvature should not be used as a clinical marker or end point in Peyronie's disease trials. Matsushita K, Stember DS, Nelson CJ, and Mulhall JP. Concordance between patient and physician assessment of the magnitude of Peyronie's disease curvature. J Sex Med 2014;11:205–210.     

A New,Innovative, Lengthening Surgical Procedure for Peyronie's Disease by Penile Prosthesis Implantation with Double Dorsal‐Ventral Patch Graft: The “Sliding Technique”

IntroductionPeyronie's disease is the result of the formation of fibrous plaques in the tunica albuginea of the penis; typical presentations of the disease are represented by pain during erection, erectile dysfunction, and penile deformities, such as curvature, narrowing, and penile shortening. The most complex treatment is related to penile shortening.AimTo find a safe procedure in penile shortening due to Peyronie's disease providing a satisfactory lengthening, allowing an early stabilization of the penis, and preventing axial tension on the neurovascular bundles during dilation.MethodsWe describe a new lengthening surgical procedure based on a ventro‐dorsal incision of the tunica albuginea, penile prosthesis implantation, and double dorsal‐ventral patch grafting with porcine small intestinal submucosa. Three patients, affected by Peyronie's disease with penile shortening and erectile dysfunction, underwent this procedure with approval of our local ethical committee.We evaluated the penis lengthening, intraoperative and postoperative complications, patient's preoperative and postoperative sexual life satisfaction (International Index of Erectile Function [IIEF] questionnaire).ResultsThe average operative time was 2 hours and 50 minutes. No major intraoperative nor postoperative complications occurred. No significant bleedings were recorded. Patients were discharged after 48–72 hours.The average increase in length obtained was 3.2 cm. All patients resumed sexual intercourses with satisfaction; no significant loss of sensitivity or any sign of vascular distress of the glans was recorded. The follow‐up is 13 months. The average IIEF score is 60.ConclusionsThe lengthening of the penis by a double dorsal‐ventral patch graft is an innovative procedure that is based on current techniques of plaque incision and grafting, and that can easily resolve severe shortening of the penis due to Peyronie's disease. In the cases presented, this procedure resulted easily, effectively, and safely. Nevertheless, the technique proposed in this article shall be validated through prospective studies with larger samples. Rolle L, Ceruti C, Timpano M, Sedigh O, Destefanis P, Galletto E, Falcone M, and Fontana D. A new, innovative, lengthening surgical procedure for Peyronie's disease by penile prosthesis implantation with double dorsal‐ventral patch graft: The “sliding technique.” J Sex Med 2012;9:2389–2395.     

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.     

Surgical outcomes and patient satisfaction after dermal, pericardial, and small intestinal submucosal grafting for Peyronie's disease

IntroductionPeyronie's disease, a localized fibrosis of the tunica albuginea surrounding the penile corpora, results in penile curvature and sexual dysfunction. Surgical management involving grafting to straighten the penis is the treatment of choice in conditions unresponsive to conservative therapy where penile length preservation is important.AimTo determine surgical outcomes and patient satisfaction after dermal, pericardial, and small intestinal submucosal grafting for Peyronie's disease.Main Outcome MeasuresThe International Index of Erectile Function (IIEF), postoperative self-reports, patient satisfaction, and clinical characteristics were used to measure outcomes.MethodsWe retrospectively reviewed charts of 36 patients who underwent surgery for Peyronie's disease requiring grafting from 1999 to 2005. Follow-up to subjectively assess outcomes was conducted.ResultsAverage patient age at surgery was 55 ± 1 years. Body mass indexes were similar among all groups. Erectile dysfunction risk factors were comparable with 36% reporting hypertension and 22% hypercholesterolemia. Overall patient follow-up time was 673 ± 98 days. Self-reported resolution of penile curvature was noted in 60% of dermal, 100% of Tutoplast, and 76.9% of Stratasis graft recipients. Stratasis patients maintained presurgery length (54%) and rigidity (77%) more so than dermal (30%, 60%) and Tutoplast (23%, 39%) patients. Assessment of erectile dysfunction using the IIEF-5 captured significant improvements in patients receiving Stratasis grafts (preoperative: 10.1 ± 1.1 vs. postoperative: 17 ± 1.6). Overall, 89% of patients reported satisfaction following surgical intervention.ConclusionsSurgical management of Peyronie's disease results in correction of penile curvatures and high rates of patient satisfaction. Loss of penile length and decreased rigidity occurred to a lesser degree with Stratasis grafts. While detailed informed consent is essential in this patient population, novel materials such as Tutoplast and Stratasis grafts improve outcomes following surgical correction of Peyronie's disease. Kovac JR, and Brock GB. Surgical outcomes and patient satisfaction after dermal, pericardial, and small intestinal submucosal grafting for Peyronie's disease.     

Standard Operating Procedures for Vascular Surgery in Erectile Dysfunction: Revascularization and Venous Procedures

IntroductionThe impact of penile blood supply on erectile function was recognized some 500 years ago. At the turn of the 20th century first results of penile venous ligation were published and in 1973 the first surgical attempts to restore penile arterial inflow were undertaken. Numerous techniques were published in the meantime, but inclusion criteria, patient selection, and success evaluation differed extremely between study groups.AimTo develop evidence-based standard operating procedures (SOPs) for vascular surgery in erectile dysfunction, based on recent state of the art consensus reports and recently published articles in peer-reviewed journals.MethodsBased on the recent publication of the consensus process during the 2009 International Consultation on Sexual Medicine in Paris, recommendations are derived for diagnosis and surgical treatment of vascular erectile dysfunction. In addition several recent publications in this field not mentioned in the consensus statements are included in the discussion.Main Outcome MeasureThe Oxford system of evidence-based review was systematically applied. Due to the generally low level of evidence in this field expert opinions were accepted, if published after a well-defined consensus process in peer-reviewed journals.ResultsReferring to penile revascularization it may be concluded, that in the face of missing randomized trials, only recommendations grade D may be given: this kind of surgery may be offered to men less than 55 years, who are nonsmokers, nondiabetic, and demonstrate isolated arterial stenoses in the absence of generalized vascular disease.The evidence level for recommendations concerning penile venous ligations may be even lower. Too many unsolved controversies exist and universal diagnostic criteria for patient selection as well as operative technique selection have not been unequivocally established. This kind of surgery is still considered investigational but may be offered in special situations on an individualized basis in an investigational or research setting after obtaining written consent, using both pre- and postoperatively validated measuring instruments of success evaluation.ConclusionsSOPs for penile revascularization procedures can be developed, concerning a highly selected patient group with isolated arterial stenoses. Based on the available data it is not yet possible to define SOPs for surgical treatment of corporal veno-occlusive dysfunction. Sohn M, Hatzinger M, Goldstein I, and Krishnamurti S. Standard operating procedures for vascular surgery in erectile dysfunction: Revascularization and venous procedures. J Sex Med 2013;10:172-179.     

Is Kelami's Method Still Useful in the Smartphone Era? The Virtual 3-Dimensional Reconstruction of Penile Curvature in Patients With Peyronie's Disease: A Pilot Study

BackgroundPeyronie's disease is an idiopathic fibrotic disease affecting the penile tunica albuginea. Among other resulting deformities, the more common penile curvature should be assessed preferentially with in-office goniometric estimation after pharmacologically induced erection, although clearly invasive and uncomfortable.AimIn the present pilot study, we investigated the usefulness for the patient and the surgeon of a 3-dimensional (3D) reconstruction of the penile curvature obtained through photogrammetry software in clinical evaluation and surgical planning.MethodsEnrolled patients received alprostadil 10 μg by intracavernous injection. Then, the medical personnel took a sequence of up to 50 photographs in orthostatism via a smartphone and processed them to obtain a 3D model of the whole groin area with 3DF Zephyr free software (3Dflow SRL, Verona, Italy), to take measurements of the penile curvature with MeshLab software (National Research Council of Italy, Rome, Italy) and to simulate the results after corporoplasty with Blender software (Blender Foundation, Amsterdam, the Netherlands). Finally, we submitted a 1–5 Likert scale to patients and surgeons investigating their satisfaction with the use of the 3D model during preoperative counseling, surgical planning, and the esthetic results after surgery.OutcomesWe investigated the patient and surgeon satisfaction with the use of the 3D model in understanding/evaluating the pathology and the surgical planning during the preoperative visit and the satisfaction with the final esthetic results in relation to the preoperative model itself.Results4 patients were included. The median photographs acquisition and computer processing time were 39 seconds and 347.5 minutes, respectively. All the patients and surgeons involved gave a score of ≥4 to all the items investigated.Clinical implicationsThe 3D model of the penile curvature is very useful both to the patient and the surgeon to understand the severity of the disease and the possible surgical management.Strength & LimitationsThis is a pilot study including only 4 cases, but it is the first experience in which the patients with Peyronie's disease had the possibility to see a virtual 3D model of their penile curvature and final esthetic results after corporoplasty, based on 3 freely available computer applications.ConclusionOur pilot study has shown that it is possible to quickly obtain a sequence of photographs to create an accurate virtual 3D model of the penis of patients with Peyronie's disease, helping the patients and the surgeon during preoperative counseling and surgical planning.Pavone C, Abrate A, Altomare S, et al. Is Kelami's Method Still Useful in the Smartphone Era? The Virtual 3-Dimensional Reconstruction of Penile Curvature in Patients With Peyronie's Disease: A Pilot Study. J Sex Med 2021;18:209–214.     

Continuing Medical Education: Incision and Grafting for Severe Peyronie's Disease (CME)

BackgroundPeyronie's Disease is a wound healing disorder involving growth of fibrous plaques in the tunica albuginea, and often results in abnormal penile curvature and subsequent development of erectile dysfunction. A 59-year-old man with a history of untreated penile trauma who presented with a 6-year history of worsening penile curvature that interfered with sexual functioning and resulted in associated erectile dysfunction.MethodsThe patient's Peyronie's Disease was evaluated in clinic with a focused physical exam and a penile vasculature study using a color duplex Doppler ultrasound. Since the patient did not have proper insurance coverage for an inflatable penile prosthesis, but did have normal arterial flow with only boderline veno-occlusive disease, he instead underwent an incision and grafting procedure. After degloving the penis, a lateral approach parallel to the corpus spongiosum was used to enter Buck's fascia and isolate the neurovascular bundles. The fibrous plaque was incised with a residual tunical defect of 4 × 5 cm, and covered with a pericardial graft.ResultsPreoperatively, artificially induced erection during the patient's Doppler study demonstrated dorsal curvature greater than 80 degrees. Intraoperatively, after completing the incision and grafting procedure, artificial erection demonstrated minimal (less than 15 degrees) residual curvature. At his 1-week postoperative visit, he reported spontaneous erections and minimal pain. One month postoperatively, his incisions were well healed and an artificially induced erection continued to demonstrate minimal curvature.DiscussionManagement of severe Peyronie's Disease with significant penile curvature is a challenging clinical problem. In extreme cases, placement of an inflatable penile prosthesis with ancillary techniques usually gives the best clinical outcome. Although more difficult to execute in severe cases, incision and grafting represents an acceptable alternative in the appropriately selected patient. Richardson B, Pinsky MR, and Hellstrom WJG. Incision and grafting for severe peyronie's disease. J Sex Med 2009;6:2084–2087.     

Examining Postoperative Outcomes after Employing a Surgical Algorithm for Management of Peyronie's Disease: A Single-Institution Retrospective Review

AimSurgery remains the gold standard treatment for men with stable Peyronie's disease (PD). In an attempt to guide operative selection, we report our series of penile-straightening procedures for PD, using a surgical algorithm that recommended tunica albuginea plication (TAP), partial plaque excision and grafting (PEG) or inflatable penile prosthesis (IPP) placement. With this study, we attempt to further refine surgical approach, define realistic surgical outcomes, and help establish reasonable postoperative expectations for treatment of PD.MethodsWe retrospectively reviewed all patients who underwent surgery for PD at our institution between 2007 and 2013. Work-up involved a history, physical exam, and a duplex ultrasound. Several questionnaires were employed to assess bother and distress associated with PD. Objective outcomes and patient satisfaction were assessed postoperatively. Primary outcomes include postoperative patient satisfaction with rigidity, curvature, and ability to engage in intercourse. Secondary outcomes include comparing emotional, relationship, and psychological distress to severity of disease.ResultsA total of 390 patients underwent penile-straightening procedures for correction of PD. Of these patients, 29%, (n = 114) underwent TAP, 41% (n = 159) PEG, and 30% (N = 114) IPP. Mean follow-up was 17 months. The three surgical modalities showed no significant difference in satisfaction with penile rigidity, presence of bothersome residual curve, or ability to engage in intercourse. Preoperatively, 80% of men reported a negative effect of PD on their emotional status. Postoperatively, 88.4% of men were able to engage in penetrative intercourse, while only 70% were satisfied with rigidity and 84.9% were satisfied with curvature correction.ConclusionPatient experience with postsurgical rigidity, ability to engage in intercourse, and residual bothersome curve was not statistically different across the three groups, supporting the use of this surgical algorithm. The majority of patients with PD experience some degree of emotional and psychological distress, which may compromise patient satisfaction. Papagiannopoulos D, Yura E, and Levine L. Examining postoperative outcomes after employing a surgical algorithm for management of Peyronie's disease: A single-institution retrospective review. J Sex Med 2015;12:1474–1480.     

Collagenase Clostridium histolyticum for the Treatment of Peyronie's Disease: The Development of This Novel Pharmacologic Approach

IntroductionThe conception of collagenase Clostridium histolyticum (CCH) as treatment for Peyronie's disease (PD) was a vital first step in providing a nonsurgical, minimally invasive FDA-approved treatment for men with PD.AimTo review the origins, clinical research history, and ultimately FDA approval of collagenase as PD treatment.MethodsA PubMed search using (Peyronie's or Peyronie) AND collagenase, and limited to clinical research studies, returned nine papers that were examined in the current review.ResultsCollagenase as a PD treatment arose in response to a lack of effective nonsurgical treatments and the incomplete understanding of underlying PD etiology. Awareness of dense collagen in PD scarring and parallel initial exploration of collagenase to treat herniated lumbar discs coincided with and inspired laboratory-based investigation of collagenase effects on excised PD plaque tissue. The foundational conceptual work and the critical development of purified injectable collagenase allowed the pursuit of clinical studies. Progression of clinical studies into large-scale robust trials culminated in two important outcomes: development of the first validated, PD-specific measure of psychosexual function, the Peyronie's Disease Questionnaire, and the first FDA-approved treatment for PD.ConclusionsCollagenase therapy began as an attempt to modify the structure of PD-related tunica albuginea scarring, despite the lack of a fundamental understanding of the scar's origin. If we wish to advance PD treatment beyond this first effective step, the future needs to bring us full circle to the starting point: We need a greater understanding of the control of collagen deposition and wound healing in men with PD. Gelbard MK, Chagan L, and Tursi JP. Collagenase Clostridium histolyticum for the treatment of Peyronie's disease: The development of this novel pharmacologic approach. J Sex Med 2015;12:1481–1489.     

Peyronie's Disease Plaque Calcification—Prevalence,Time to Identification,and Development of a New Grading Classification

IntroductionPeyronie's disease (PD) is a connective tissue disorder of the penis in which a fibrous scar in the tunica albuginea can result in multiple penile deformities.AimThe study aims to investigate the prevalence and time to identification of plaque calcification (PC) in our PD patient population and whether stratification of calcification based on severity seen on ultrasound would serve as a predictor of treatment progression to surgery.MethodsA retrospective review of 1,041 men presenting with PD from 1993 to 2009 was performed. Eight hundred thirty‐four underwent penile duplex ultrasound.Main Outcome MeasuresPC was graded as: grade 1 (<0.3 cm), grade 2 (>0.3 cm, <1.5 cm), grade 3 (>1.5 cm; or ≥2 plaques >1.0 cm). A matched control group with noncalcified plaques (n = 236) was selected for comparison.ResultsTwo hundred eighty‐four men (34%) were found to have PC noted on ultrasound, and 98 had fully documented dimensions of the PC. Forty‐one percent were found to have grade 1, 28% grade 2, and 32% grade 3. When analyzed by grade and progression to surgery, 23% of grade 1, 32% of grade 2, and 55% of grade 3 patients had surgery. Those with grade 3 PC were more likely to undergo surgical intervention for PD (OR 2.28 95% CI 1.07–4.86) and more likely to undergo a grafting procedure than control patients (P < 0.0001).ConclusionsMen with PC are not more likely to undergo surgery than those without PC (OR 0.95, 95% CI 0.58–1.57). PC is not uncommon, as it was found in 34% of our cohort. PC does not appear to be an indication of mature or stable disease, as it was identified by ultrasound in 37% of patients less than 12 months after onset of symptoms. Men with grade 3 PC have an increased likelihood of progression to surgical intervention and a higher likelihood of undergoing a grafting procedure. Levine L, Rybak J, Corder C, and Farrel MR. Peyronie's disease plaque calcification—prevalence, time to identification, and development of a new grading classification. J Sex Med 2013;10:3121–3128.     

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.     

Characteristics of Men With Peyronie's Disease and Collagenase Clostridium Histolyticum Treatment Failure: Predictors of Surgical Intervention and Outcomes

BackgroundA subset of patients with Peyronie's disease (PD) treated with collagenase clostridium histolyticum (CCH) experience persistent bother and some require surgery.AimWe characterize patients experiencing persistent bother after CCH treatment and identify associations and predictors of surgical intervention/outcomes.MethodsWe retrospectively identified patients with PD from October 2014 to October 2019 and identified those presenting with persistent bother after CCH treatment by other urologists. Intracavernosal injection and penile Doppler ultrasonography were performed, and subsequent interventions/outcomes were recorded. Baseline characteristics were compared with Student t-test and chi-square test. Predictors of surgical intervention and complications were assessed using multivariable logistic regression.OutcomesThe primary outcome was surgery after CCH treatment. Secondary outcomes included worsened erectile function, sensory deficits, and penile length change.ResultsOf 573, 67 (11.7%) patients with PD had undergone prior CCH treatment with median 6 injections (range 2–24). Mean post-CCH PD Questionnaire bother score was 10.1 (SD: 3.1), and total International Index of Erectile Function-5 was 15.3 (SD: 8.7). Mean PD duration was 27.8 (SD: 35.7) months, with a mean composite curvature (MCC) of 69.0° (SD: 33.8) measured after injection. Of 67, 44 (65.7%) patients had MCC >60°. Of 67, 52 (77.6%) patients had indent, narrowing, or hourglass and 26 (38.8%) had hinge effect (buckling of the erect penis with axial pressure) on examination. Calcification was identified in 26 of 67 (38.8%) patients, with grade 3 calcifications comprising 6 of 23 (26.1%) patients. Of 67, 33 (49.3%) patients underwent surgery, with 20 (60.1%) undergoing partial plaque excision and grafting with/without tunica albuginea plication, 6 (18.2%) undergoing tunica albuginea plication alone, and 7 (21.2%) undergoing penile prosthesis with plaque incision and grafting. Surgical patients had greater mean curvature (82.6 vs 55.4, P = .001) and were more likely to have hinge (54.5% vs 20.6%, P = .005). On multivariable analysis, MCC ≥60° predicted patient’s decision for surgery (odds ratio: 2.99, P < .01, 95% confidence interval: 1.62–4.35). There were no associations between surgical complications and number of injections or CCH-associated adverse events.Clinical ImplicationsPatients presenting with persistent bother after CCH treatment often have narrowing and calcifications (despite calcifications being a contraindication to CCH treatment), and those who have hinge or severe curvature are more likely to undergo surgery with low rates of complications.Strengths/LimitationsThis study's generalizability is limited by selection bias, but useful data are provided for patient counseling.ConclusionPatients with persistent bother after CCH treatment had high rates of indentation/narrowing, plaque calcifications, and MCC >60° at completion of CCH treatment. Surgical intervention is more common with hinge and is safe and feasible in these patients, with low rates of complications. These findings suggest possible negative prognostic factors for CCH treatment, which merit further investigation.Bajic P, Wiggins AB, Ziegelmann MJ, et al. Characteristics of Men With Peyronie's Disease and Collagenase Clostridium Histolyticum Treatment Failure: Predictors of Surgical Intervention and Outcomes. J Sex Med 2020;17:1005–1011.     

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.     

The Management of Peyronie's Disease: Evidence-based 2010 Guidelines

IntroductionThe field of Peyronie's disease is evolving and there is need for a state-of-the-art information in this area.AimTo develop an evidence-based state-of-the-art consensus report on the management of Peyronie's disease.MethodsTo provide state-of-the-art knowledge regarding the prevalence, etiology, medical and surgical management of Peyronie's Disease, representing the opinion of leading experts developed in a consensus process over a 2-year period.Main Outcome MeasuresExpert opinion was based on grading of evidence-based medical literature, widespread internal committee discussion, public presentation, and debate.ConclusionsThe real etiology of Peyronie's disease and the mechanisms of formation of the plaque still remain obscure. Although conservative management is obtaining a progressively larger consensus among the experts, surgical correction still remains the mainstay treatment for this condition. Ralph D, Gonzalez-Cadavid N, Mirone V, Perovic S, Sohn M, Usta M, and Levine L. The management of Peyronie's disease: Evidence-based 2010 guidelines.     

Standard Operating Procedures in the Disorders of Orgasm and Ejaculation

IntroductionEjaculatory/orgasmic disorders are common male sexual dysfunctions and include premature ejaculation (PE), inhibited ejaculation, anejaculation, retrograde ejaculation, and anorgasmia.AimTo provide recommendations and guidelines of the current state-of-the-art knowledge for management of ejaculation/orgasmic disorders in men as standard operating procedures (SOPs) for the treating health care professional.MethodsThe International Society of Sexual Medicine Standards Committee assembled over 30 multidisciplinary experts to establish SOPs for various male and female sexual medicine topics. The SOP for the management of disorders of orgasm and ejaculation represents the opinion of four experts from four countries developed in a process over a 2-year period.Main Outcome MeasureExpert opinion was based on grading of evidence-based medical literature, limited expert opinion, widespread internal committee discussion, public presentation, and debate.ResultsPE management is largely dependent upon etiology. Lifelong PE is best managed with PE pharmacotherapy (selective serotonin reuptake inhibitors and/or topical anesthetics). The management of acquired PE is etiology specific and may include erectile dysfunction (ED) pharmacotherapy in men with comorbid ED. All men seeking treatment for PE should receive basic psychosexual education. Graded behavioral therapy is indicated when psychogenic or relationship factors are present and is often best combined with PE pharmacotherapy in an integrated treatment program. Delayed ejaculation, anejaculation, and/or anorgasmia may have a biogenic and/or psychogenic etiology. Men with age-related penile hypoanesthesia should be educated, reassured, and instructed in revised sexual techniques which maximize arousal. Retrograde ejaculation is managed by education, patient reassurance, and pharmacotherapy.ConclusionsAdditional research is required to further the understanding of the disorders of ejaculation and orgasm. McMahon CG, Jannini E, Waldinger M, and Rowland D. Standard operating procedures in the disorders of orgasm and ejaculation. J Sex Med **;**:**–**.