Low Testosterone Has a Similar Prevalence among Men with Sexual Dysfunction Due to Either Peyronie's Disease or Erectile Dysfunction and Does Not Correlate with Peyronie's Disease Severity

IntroductionLow testosterone (T) has been suggested as a risk factor for Peyronie's disease (PD) that may correlate with disease severity. Low T is common in men with sexual dysfunction but its role in the pathogenesis of PD remains unclear.AimThe aim of this study was to compare the prevalence of low T (<300 ng/dL) in patients presenting with PD or erectile dysfunction (ED), as well as disease severity between men with PD and either low T or normal T (≥300 ng/dL).MethodsRetrospective review of 300 men with either PD or ED was conducted. Men were excluded for combined PD and ED, psychogenic ED, or prior T use. For men with PD, plaque size, degree of curvature, and surgical correction rate were compared.Main Outcome MeasuresThe main outcome measures were (i) mean T levels in men with PD or ED and (ii) plaque size, degree of curvature, and surgical correction rates among men with PD and either low T or normal T.ResultsEighty‐seven men with PD and 98 men with ED were identified. Men with PD had mean total T and free T of 328 ng/dL and 11.5 ng/dL, while men with ED had mean levels of 332 ng/dL and 12.1 ng/dL, respectively (P > 0.05). Of PD men, 52.9% had low T, compared with 45.9% of men with ED (P = 0.35). T levels did not correlate with plaque size or degree of curvature in the PD group (P > 0.05).ConclusionsMen with sexual dysfunction characterized by either PD or ED had similarly low T levels, and low T did not correlate with PD severity or surgical correction rate. The comparable prevalence of low T in men with PD or ED suggests the high rate of low T in PD men may be related to a common process among men with abnormal erectile physiology and not specifically causative in plaque formation. Kirby EW, Verges D, Matthews J, Carson CC, and Coward RM. Low testosterone has a similar prevalence among men with sexual dysfunction due to either Peyronie's disease or erectile dysfunction and does not correlate with Peyronie's disease severity. J Sex Med 2015;12:690–696.     

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 **;**:**–**.     

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.     

Evaluating the Impact of Penile Girth Discrepancy on Patient Bother in Men With Peyronie's Disease: An Observational Study

BackgroundMen with Peyronie's disease (PD) may experience penile narrowing. Little data on penile girth changes and their psychosocial impact exist.AimTo assess girth discrepancy in men with PD and its association with patient bother.MethodsThis was a retrospective observational study. All patients with PD at our institution who were seen in the sexual medicine clinic and who completed 3 validated instruments the PD questionnaire (PDQ), Self-Esteem and Relationship (SEAR) questionnaire, and a depression questionnaire, the Center for Epidemiologic Studies Depression Scale (CES-D), and a curvature assessment were included. Patient and PD characteristics are described. Associations of instability and bother to girth differences are assessed. 2 outcomes for girth differences are classified as (i) girth difference of ≥ 1 cm vs less and (ii) girth differences of ≥10% vs less. Unadjusted and adjusted effects of PD and patient characteristics are assessed on the outcome of high bother using logistic regression models.OutcomesThe main outcomes of this study were penile girth changes, instability, and questionnaire scores. High bother was defined as a PDQ bother score of ≥9.ResultsA total of131 men had midshaft curvature and were the focus of the study. Their mean age was 59 ± 9 (range 31–78) years. PD duration was 16 ± 25 (range 1–180) months, with a mean degree of primary curvature of 37 ± 20^o. Mean girth difference between base and point of maximum curvature was 0.78 ± 0.53 cm equating to a mean girth difference at point of maximum curvature of 6 ± 4%. Instability was present in 53% of men. There were 54 men with a girth difference of ≥ 1 cm and 23 men with a ≥10% change in girth. There was no difference in CES-D, SEAR, or PDQ domain scores or high bother in men with significant girth changes. Univariable analysis of predictors of high bother included the degree of curvature (odds ratio [OR]: 1.06; P < .001), instability (OR 6.62; P < .001), CES-D sum (OR 1.09; P = .002), and SEAR score (OR 0.96; P = .001). On multivariate analysis, only the degree of primary curvature was predictive of high bother (OR 1.06; P < .001).Clinical ImplicationsPenile girth changes have little impact on overall psychosocial well-being. The degree of penile curvature is the primary predictor of patient bother.Strengths and LimitationsStrengths include a large patient population and use of validated questionnaires. Limitations include single-center, retrospective study and subjective instability grading.ConclusionsPenile girth discrepancy in men with PD has limited psychosocial impact. Clinically significant bother was associated with the degree of primary curvature.Salter CA, Nascimento B, Terrier, JE, et al. Evaluating the Impact of Penile Girth Discrepancy on Patient Bother in Men With Peyronie's Disease: An Observational Study. J Sex Med 2020;17:1560–1565.     

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.     

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.     

The Cumulative Effects of Medication Use,Drug Use,and Smoking on Erectile Dysfunction Among Men Who Have Sex with Men

IntroductionErectile dysfunction (ED) is highly prevalent among human immunodeficiency virus‐seropositive (HIV+) men who have sex with men (MSM). There is a need for additional research to determine the correlates of HIV+ and HIV‐seronegative (HIV?) MSM, especially regarding nonantiretroviral medication use.AimsThis study examined the prevalence of ED and the sociodemographic, medical conditions, medication use, and substance use correlates of ED among HIV+ and HIV? MSM.MethodsA modified version of the International Index of Erectile Function (IIEF) for MSM was self‐administered by participants enrolled in the Multicenter AIDS Cohort Study, an ongoing prospective study of the natural and treated histories of HIV infection among MSM in the United States. The study sample included 1,340 participants, including 612 HIV+ and 728 HIV? men. Poisson regression with robust error variance was used to estimate prevalence ratios of ED in multivariable models in combined (HIV+/?) and separate analyses.Main Outcome MeasureED was determined by the summed scores of a modified version of the IIEF validated among MSM.ResultsTwenty‐one percent of HIV+ MSM and 16% of HIV? MSM reported ED. Being >55 years of age, black race, cumulative pack years of smoking, cumulative antihypertensive use, and cumulative antidepressant use had significant positive associations with the prevalence of ED in the total sample. Among HIV+ men, duration of antihypertensive use and antidepressant use were significantly associated with increasing prevalence of ED. Among HIV? men, being >55 years of age, black race, and cigarette smoking duration were associated with increased prevalence of ED.ConclusionPredictors of ED may differ by HIV status. Although smoking cessation and effective medication management may be important as possible treatment strategies for ED among all MSM, there may be a burden on sexual functioning produced by non‐HIV medications for HIV+ men. Hart TA, Moskowitz D, Cox C, Li X, Ostrow DG, Stall RD, Gorbach PM, and Plankey M. The cumulative effects of medication use, drug use, and smoking on erectile dysfunction among men who have sex with men. J Sex Med 12;9:1106–1113.     

Continuing Collagenase Clostridium Histolyticum Injections Among Initial Nonresponders Results in Significant Curvature Improvements in the Majority of Peyronie's Disease Men

BackgroundIt is currently unclear if men with Peyronie's Disease (PD) who achieve minimal benefits with the first 2 series of Collagenase Clostridium Histolyticum (CCH) injections should continue with additional injections.AimTo analyze curvature improvements from the final two series of CCH injections based on amount of improvement during the first 2 series.MethodsA prospective registry was analyzed of all men undergoing CCH injections for PD at a single institution. Men were included if they had completed a full 4 series (8 injections) of CCH and had baseline, interval (after 2 series), and/or final (after 4 series) curvature assessments available. Men were stratified into cohorts using baseline-to-interval assessments of ≤10° (or ≤20%) and >10° (or >20%), and improvements were compared using interval-to-final assessments.OutcomesThe primary outcome was interval-to-final curvature improvements stratified by ≤10°/>10° or ≤20%/>20% improvements achieved during the baseline-to-interval period. Secondary outcomes included analyses of demographic and pathophysiologic variables to determine associations with significant improvements during the final 2 CCH series.ResultsA total of 296 PD men were identified as receiving at least one CCH injection, of whom 175 had baseline-to-interval, 84 interval-to-final, and 115 with baseline-to-final measurements. Mean age was 56.6, PD duration 28.6 months, baseline curvature 63.4°, hourglass deformity 36.2%, and calcification 20%. Mean overall curve improvement was ?21.5° (33.1%). Among men who experienced ≤20% improvements after 2 series, the mean subsequent curvature change was -24.6% during the final two series (vs +4.3% of those with >20% initial improvement, P< .001), and they were 2.7x more likely to experience >20% subsequent curve improvements. Thirty-one percent of those who achieved >10° during the first 2 series experienced benefits during the final 2 series compared to 70% of men who had ≤10° improvement initially. No demographic or pathophysiological variables predicted likelihood for improvements during the final 2 series of injections.Clinical ImplicationsMen who fail to achieve significant benefits with 2 series of CCH injections may benefit from completing the final 2 series.Strengths and LimitationsStrengths including a relatively large, prospective series. Limitations include a single center, nonrandomization, nonblinded assessments, and restriction to men who completed eight injections.ConclusionsIn the current series, approximately 2/3 of men who fail to achieve >10° or 20% curve improvements with an initial 2 series of CCH injections achieved >10° or 20% improvements with the subsequent 2 series.Alom M, Burgon H, Ziegelmann M, et al. Continuing Collagenase Clostridium Histolyticum Injections Among Initial Nonresponders Results in Significant Curvature Improvements in the Majority of Peyronie's Disease Men. J Sex Med 2021;18:1092–1098.     

A Pilot Study of HIV/STI Risk among Men Having Sex with Men Using Erectile Dysfunction Medications: Challenges and Opportunities for Sexual Medicine Physicians

IntroductionA growing literature suggests relationships between erectile dysfunction medications (EDM) and riskier sexual behavior among men who have sex with men (MSM). Questions remain concerning EDM use and related HIV/sexually transmitted infections (STI) risk among older MSM, particularly those 40 years and over, for whom EDM may be medically warranted.AimThis exploratory pilot study explores the relationship between EDM and risky sexual behavior in a convenience sample of MSM using EDM and attending historic sex‐on‐premises venues.MethodsWe examined anonymous surveys from 139 MSM. Bivariate relationships were examined. We then fit a multiple logistic regression model to determine predictors of engaging in unprotected anal intercourse (UAI) at last EDM, using variables identified as being significantly related to UAI in the bivariate analyses. Potential predictors entered the model in a stepwise fashion.Main Outcome MeasuresThe primary outcome measure was engaging in UAI at last EDM use.ResultsMSM participating in the study ranged from 27 to 77 years and averaged 52.0 years (standard deviation = 10.73 years). These participants were primarily older MSM; fewer were younger MSM (12.12%), under age 40. Participants reporting UAI at last EDM use (N = 41) were significantly younger (P < 0.01). Men visiting bars within the last 6 months reported less UAI (P < 0.01). Both variables were independent predictors of UAI in the logistic regression model (P < 0.01).ConclusionSimilar to reports from younger MSM, our findings suggest older MSM using EDM and reporting UAI are also recreational drug users. We include recommendations for urologists and other sexual medicine physicians treating MSM who may be at elevated risk for HIV/STI infection because of joint EDM and club drug use. Goltz HH, Coon DW, Catania JA, and Latini DM. A pilot study of HIV/STI risk among men having sex with men using erectile dysfunction medications: Challenges and opportunities for sexual medicine physicians. J Sex Med 2012;9:3189–3197.     

Impact of Prostate Cancer Treatment on the Sexual Quality of Life for Men‐Who‐Have‐Sex‐with‐Men

IntroductionWith earlier prostate cancer (PCa) diagnosis and an increased focus on survivorship, post‐treatment sexual quality of life (QoL) has become increasingly important. Research and validated instruments for sexual QoL assessment based on heterosexual samples have limited applicability for men‐who‐have‐sex‐with‐men (MSM).AimWe aimed to create a validated instrument for assessing sexual needs and concerns of MSM post‐PCa treatment. Here we explore post‐PCa treatment sexual concerns for a sample of MSM, as the first part of this multi‐phase project.MethodsIndividual semi‐structured interviews were conducted with 16 MSM face‐to‐face or via Internet‐based video conferencing. Participants were asked open‐ended questions about their experiences of sexual QoL following PCa. Interviews were recorded, transcribed verbatim, uploaded to NVivo 8^TM, and analyzed using qualitative methodology.Main Outcome MeasureWe have conducted semi‐structure qualitative interviews on 16 MSM who were treated for PCa. Focus was on post‐treatment sexual concerns.ResultsThe following themes were inductively derived: (i) erectile, urinary, ejaculation, and orgasmic dysfunctions; (ii) challenges to intimate relationships; and (iii) lack of MSM‐specific oncological and psychosocial support for PCa survivorship. Sexual practices pre‐treatment ranked in order of frequency were masturbation, oral sex, and anal sex, an ordering that prevailed post‐treatment. Sexual QoL decreased with erectile, urinary, and ejaculation dysfunctions. Post‐treatment orgasms were compromised. Some single men and men in non‐monogamous relationships reported a loss of confidence or difficulty meeting other men post‐treatment. Limited access to targeted oncological and psychosocial supports posed difficulties in coping with PCa for MSM.ConclusionsThe negative impact on sexual QoL can be severe for MSM and requires targeted attention. Penile–vaginal intercourse and erectile function have been the primary focus of sexual research and rehabilitation for men with PCa, and do not adequately reflect the sexual practices of MSM. Our findings suggest that future research dedicated to MSM with PCa is needed to incorporate their sexual practices and preferences specifically into treatment decisions, and that targeted oncological and psychosocial support services are also warranted. Lee TK, Handy AB, Kwan W, Oliffe JL, Brotto LA, Wassersug RJ, and Dowsett GW. The impact of prostate cancer treatment on the sexual quality of life for men‐who‐have‐sex‐with‐men. J Sex Med 2015;12:2378–2386.     

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.     

Curvilinear Relationship Between Depression and Unprotected Sexual Behaviors among Men Who Have Sex with Men

IntroductionThe relationship between depressive symptomatology and risky sexual behaviors has been controversial in literature.AimThe current study aims to reexamine the relationship between depression and sexual behaviors among men who have sex with men (MSM) using different sets of analytical assumption.MethodsSix hundred twenty MSM were recruited in a lesbian, gay, bisexual, and transgender community center in Taiwan to participate in a cross‐sectional survey. An additional variable of squared depressive symptomatology was used to detect nonlinearity between depressive symptomatology and logit‐transformed unprotected anal intercourse (UAI) and unprotected oral sex (UOS). Multivariable logistic regression was applied to further estimate the relationship among the three variables.Main Outcome MeasuresDepressive symptomatology was measured by the Beck Depression Inventory (BDI), UAI, and UOS.ResultsDepressive symptomatology had a nonlinear relationship with unprotected anal and oral sex. While linear BDI scores of MSM were not associated with unprotected sexual behaviors in the logistic model, their scores were significantly associated with unprotected sexual behaviors in the model that included both the linear (UAI, odds ratio [OR] = 1.087; P < 0.01; UOS, OR = 1.099, P < 0.01) and quadratic BDI scores (UAI, OR = 0.998, P < 0.01; UOS, OR = 0.997, P < 0.01). The relationship between BDI scores and the probability of unprotected sexual behaviors corresponded to an inverted U‐shaped curve, as opposed to a straight line.ConclusionsOur findings suggest that depressive symptomatology has a significant curvilinear relationship with unprotected sexual behaviors. MSM with moderate levels of depression may be at elevated risk of engaging in unprotected sexual behaviors in comparison to their peers who exhibit either significantly higher or lower depression scores. Shiu CS, Chen YC, Tseng PC, Chung AC, Wu MT, Hsu ST, and Ko NY. Curvilinear relationship between depression and unprotected sexual behaviors among men who have sex with men. J Sex Med 2014;11:2466–2473.     

Is There a Relationship Between Chronic Periodontitis and Erectile Dysfunction?

IntroductionChronic periodontitis (CP) is characterized with inflammation of the gingival tissues, which causes endothelial dysfunction in different organs.AimIn this study, we investigated the association of CP with the erectile dysfunction (ED).MethodsThe study group included 80 male patients with ED and 82 male patients without ED (control), aged between 30 and 40 years. The International Index of Erectile Function (IIEF) questionnaire was used to assess male sexual function, particularly the presence or absence of ED.Main Outcome MeasuresThe patients in the study and control groups were statistically compared according to their plaque index (PI), bleeding on probing (BoP), probing depth (PD), and clinical attachment level (CAL).ResultsIn the non‐ED and the ED groups, the mean age was 35.7 ± 4.8 and 34.9 ± 4.9 years, respectively. Patients' characteristics including body mass index, household income, and education status were similar in both groups (P > 0.05). Nineteen patients (23%) had severe CP in the non‐ED group; 42 patients (53%) had severe CP in the ED group. Logistic regression analysis showed a significantly high association between ED and the severity of CP (odds ratio: 3.29, 95% confidence interval: 1.36–9.55, P < 0.01). The mean values of PI, BoP, and the percentages of sites with PD >4 mm and sites with CAL >4 mm were significantly higher in the ED group than in the control group (P < 0.05). The mean values of PD and CAL were not significantly different in the two groups (P > 0.05). The decayed, missing, filled teeth scores were also significantly higher in the ED group than in the non‐ED group (P < 0.05).ConclusionOur results have suggested that CP had a high association with ED in young adults at 30–40 years. We think that it will be of benefit to consider periodontal disease as a causative clinical condition of ED in such patients. O?uz F, Eltas A, Beytur A, and Akdemir E. Is there a relationship between chronic periodontitis and erectile dysfunction? J Sex Med 2013;10:838–843.     

A Retrospective Comparative Study of Traction Therapy vs. No Traction Following Tunica Albuginea Plication or Partial Excision and Grafting for Peyronie's Disease: Measured Lengths and Patient Perceptions

IntroductionLoss of penile length is a recognized and common consequence of Peyronie's disease (PD). Traction therapy (TT+) has been reported to decrease post‐op length loss as well as increase stretched penile length (SPL) prior to surgery.AimThe aim of this study was to study patient outcomes with penile length change and patient satisfaction after surgery following tunica albuginea plication (TAP) and partial plaque excision and grafting (PEG) with or without postoperative TT.MethodsRetrospective analysis was performed from our cohort of Peyronie's reconstructive surgery between 2007 and 2010. SPL was measured dorsally from pubis to corona and recorded at the initial office visit and then compared to most recent postoperative visit. Patients were then stratified by procedure and whether TT was used (TT+ and TT?; TAP N = 52 [27 TT+ and 25 TT?] and PEG N = 59 [36 TT+ and 23 TT?). Traction therapy was initiated for >2 hours a day for 3 months typically starting 3–4 weeks postoperatively. A non‐validated mailed questionnaire assessed patient perceptions.ResultsMean length change seen in TAP (TT+) was 0.85 cm (0.25–1.75) vs. ?0.53 cm (?1.75 to 0.5) in TAP (TT?) (P < 0.001). The mean length change seen in PEG (TT+) was 1.48 cm (0–6) vs. PEG (TT?) 0.24 cm (?1 to 2.5 cm) (P < 0.001). Sixty‐one percent of surveys were returned; 85% lost length prior to the initial office evaluation, with an average of ?2.5 cm lost. Importantly, in those who used traction, there was no perceived length loss, 58% reported a mean erect length gain of 1.1 cm. However, only 54% of all patients were satisfied with their current erect length.ConclusionsLoss of length in men with PD remains a serious concern. It appears that postoperative TT can result in length preservation, and in many, a measured and perceived length gain following correction of the curvature. Rybak J, Papagiannopoulos D, and Levine L. A retrospective comparative study of traction therapy vs. no traction following tunica albuginea plication or partial excision and grafting for Peyronie's disease: Measured lengths and patient perceptions. J Sex Med 2012;9:2396–2403.     

Factors Influencing Prostate‐Specific Antigen Response among Men Treated with Testosterone Therapy for 6 Months

IntroductionFactors influencing prostate‐specific antigen (PSA) changes in men undergoing testosterone (T) therapy have not been well studied.AimThe aim of this study was to assess the influence of selected variables on PSA changes in hypogonadal men administered with 1.62% testosterone gel (T‐gel) for 6 months.MethodsA double‐blind, placebo‐controlled study of 274 (234 T‐gel, 40 placebo) hypogonadal men >18 years of age, with baseline T concentrations <300 ng/dL, PSA ≤2.5 ng/mL, and negative digital rectal examination. Subjects received once‐daily T‐gel for T therapy.Main Outcome MeasuresChanges in mean serum PSA, percentage of free PSA (%fPSA), and T from baseline to 6 months (182 days).ResultsMean age was 53.5 years and baseline mean values were total T 247 ng/dL, PSA 0.9 ng/mL, and %fPSA 24.6%. Among men treated with T‐gel, T increased to 499 ng/dL and PSA increased by 0.1 ng/mL (P = 0.0012). PSA increased ≥0.3 ng/mL in 26.3%, <0.3 ng/mL in 73.7%, including a decline from baseline in 33.0%. In the placebo group, T increased 29 ng/dL to 274 ng/dL, and PSA decreased 0.1 ng/mL, compared with baseline. A greater increase in PSA was noted in men ≥60 years old than in men <60 years old (0.4 vs. 0.05 ng/mL, respectively; P = 0.0006). Mean PSA did not change in men with baseline serum T >250 ng/dL, whereas it increased by 0.2 ng/mL in men with T ≤250 ng/dL (P = 0.0031). PSA increased 0.3 ng/mL in men with baseline %fPSA <20% and 0.1 ng/mL in men with %fPSA ≥20%.ConclusionsOverall, T‐gel treatment was associated with a minor increase in PSA, of questionable clinical significance. Factors predicting greater PSA increases included age ≥60 years, baseline T ≤250 ng/dL, and %fPSA <20%. Men with T >250 ng/dL and age <60 years demonstrated minimal or no PSA change. Morgentaler A, Benesh JA, Denes BS, Kan‐Dobrosky N, Harb D, and Miller MG. Factors influencing prostate‐specific antigen response among men treated with testosterone therapy for 6 months. J Sex Med 2014;11:2818–2825.     

Condom Use during Most Recent Anal Intercourse Event among a U.S. Sample of Men Who Have Sex with Men

IntroductionRecent nationally representative data documenting event‐level condom use have included samples that are predominantly heterosexual, resulting in limited information on rates of condom use for penile‐anal intercourse (PAI) among men who have sex with men (MSM).AimThis study sought to document the demographic and event‐specific situational factors associated with condom use during most recent PAI among MSM.MethodsData were collected via an Internet survey from 14,750 MSM (ages 18–87 years) from 50 U.S. states and the District of Columbia.Main Outcome MeasuresMeasures included items related to sociodemographics, recent sexual behavior history, event characteristics, condom use, and items associated with ejaculation during the event.ResultsParticipants' median age was 39.0 years; race/ethnicities included white (83.2%), Latino (7.2%), and African American (3.9%), and most men (85.3%) identified as homosexual. Age (P ≤ 0.001), race/ethnicity (P ≤ 0.001), partner status (P ≤ 0.001), and location of sexual event (P ≤ 0.001) were all significantly related to the likelihood of condom use during men's most recent PAI with another man. In total, only 2.5% of the entire sample reported that ejaculation occurred in their own or their sexual partner's anus without a condom during most recent PAI.ConclusionsThis study provides a large‐scale assessment of condom use during the most recent PAI among MSM in the United States. Findings from this study highlight diversity in condom use behaviors and demonstrate varying degrees of potential risk for human immunodeficiency virus and other sexually transmitted infections. Future prevention efforts should consider contextual components of condom use, including partner type, location of the sexual event, and semen exposure, to more accurately develop individualized risk reduction strategies. Rosenberger JG, Reece M, Schick V, Herbenick D, Novak DS, Van Der Pol B, and Fortenberry JD. Condom use during most recent anal intercourse event among a U.S. sample of men who have sex with men. J Sex Med 12;9:1037–1047.     

WNT2 Locus Is Involved in Genetic Susceptibility of Peyronie's Disease

IntroductionPeyronie's disease (PD) is a fibromatosis of the penis, with a pathology very similar to what is seen in the hand (palmar fascia) in Dupuytren's disease (DD). Recently, we performed a genome‐wide association study and identified nine genetic loci containing common variants associated with DD. Seven of these loci mapped within or near genes of the canonical WNT pathway and each locus yielded relatively large odds ratios (ORs) for DD disease status.AimGiven the clinical overlap between PD and DD, we examined whether the nine DD susceptibility loci are also involved in PD.MethodsAn association study was performed using a case/control design. From 2007 to 2010, we prospectively included 111 men who had been clinically diagnosed with PD. Control subjects (N = 490 males) were randomly drawn from a population‐based cohort from the same region of the Netherlands. Allele frequencies in the 111 PD cases and 490 controls were compared using a 1‐degree‐of‐freedom basic chi‐square test. A P value < 0.05 after Bonferroni correction for the nine tested single nucleotide polymorphisms (SNPs) was considered statistically significant (i.e., P < 0.0056).Main Outcome MeasureAssociation of genetic markers (SNPs) with PD.ResultsWe observed significant association with SNP rs4730775 at the wingless‐type MMTV integration site family member 2 (WNT2) locus on chromosome 7 (P = 0.0015, OR 0.61), but found no evidence for the other eight loci being involved with PD despite the large effect size seen for some of these variants in DD. The WNT2 association was even more significant after we removed 15 patients with comorbid DD.ConclusionsWNT2 is a susceptibility locus for PD and our finding provides evidence for a partly shared genetic susceptibility between PD and DD. Dolmans GH, Werker PM, de Jong IJ, Nijman RJ, LifeLines Cohort Study, Wijmenga C, and Ophoff RA. WNT2 locus is involved in genetic susceptibility of Peyronie's disease. J Sex Med 2012;9:1430–1434.     

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.     

Risk Factors of Peyronie's Disease. What Does Our Clinical Experience Show?

IntroductionPeyronie's disease (PD) is a localized fibrosis that affects the tunica albuginea of the penis. Its origin can be associated with coital penile trauma in men with autoimmune hypersensitivity and a presumed genetic predisposition.AimTo identify clinical and traumatic risk factors in a patient population with PD, when compared to a control group.MethodsFrom November 2007 to March 2010, 317 patients sought medical attention for PD. As control group, 147 consecutive patients, who came for a prostate exam, were studied. Clinical, traumatic, and sexual history of these patients was gathered. Risks factors were considered only if they had been present before the onset of PD symptoms.Main Outcome MeasureThe International Index of Erectile Function and the International Prostate Symptoms Score. A univariate logistic regression model (chi‐square) (odds ratios [ORs] and 95% confidence intervals [CI] ) was used to estimate the association of risk factors with PD; and the Student's t‐test was implemented for age.ResultsThe mean age of patients with PD and control group was 56.7 and 58.8, respectively (P < 0.923). The mean evolution time of the disease was 17.7 months (2–48). Erectile dysfunction (ED) and coital trauma constituted the only two independent risk factors for PD compared to the control group (P < 0.05 and 0.002, respectively) with an OR of 1.5 (95% CI 1.0–2.3) and 2.69 (95% CI 1.41–5.21), respectively. Patients with ED and diabetes mellitus and with a mild‐to‐moderate ED also presented a higher predisposition (P = 0.008 and 0.00001), with an OR of 3.64 (95% CI 1.33–10.79) and 5.58 (95% CI 3.03–10.42), respectively.ConclusionErectile dysfunction and coital trauma have proven to be independent risk factors for the development of PD. Casabé A, Bechara A, Cheliz G, De Bonis W, and Rey H. Risk factors of Peyronie's disease. What does our clinical experience show? J Sex Med 2011;8:518–523.