Effect of Penile Traction and Vacuum Erectile Device for Peyronie’s Disease in an Animal Model

BackgroundPenile traction therapy with the use of a traction device (TD) or vacuum erectile device (VED) has been studied as local modalities for Peyronie’s disease (PD).AimTo identify changes of penile curvature, erectile function, and possible cellular and molecular mechanisms between the TD and VED in a rat model of PD.MethodsPeyronie’s plaque was induced in 30 adult male rats. Then, rats were randomly divided into control (PD without treatment), VED, and TD groups. In the VED group, vacuum pressure was applied to the cylinder to induce penile engorgement inside the cylinder for 1 minute. The penis was allowed to deflate completely for another 1 minute. This was repeated for five cycles (inflate and deflate). In the TD group, the rat penis was straightened by a suspended tension gauge at the same tension by clamping the prepuce. This was performed three times per day at 20 minutes per session, with 5-minute intervals between sessions. The entire treatment duration was 4 weeks.OutcomesPenile curvature, intracavernosal pressure, and mean arterial pressure were measured. Immunohistochemistry for α-smooth muscle actin, transforming growth factor-β1 and mothers against decapentaplegic homolog 2/3 were performed.ResultsThe TD and VED groups had less penile curvature compared with the control group (15.3 ± 5.3° for TD, 28.4 ± 6.8° for VED, 38.6 ± 10.5° for control; P < .001 for TD vs control, P < .05 for VED vs control). The TD group also had less penile curvature compared with the VED group (P < .05). The VED group had a higher ratio of intracavernosal pressure to mean arterial pressure compared with the two other groups (0.56 ± 0.10 for VED, 0.38 ± 0.06 for TD, 0.32 ± 0.07 for control; P < .001). The immunohistochemistry results showed the VED group had more preserved α-smooth muscle actin with less transforming growth factor-β1 and mothers against decapentaplegic homolog 2/3 than the TD and control groups in the corpus cavernosa.Clinical TranslationVarious benefits can be observed with the TD and VED for the treatment of PD.Strengths and LimitationsThis study explored the mechanism and benefits of TD and VED therapies for the treatment of PD. The rat model might not represent the human condition.ConclusionPenile traction therapy with the TD or VED is beneficial to decrease penile curvature in animal models of PD. The underlying mechanism could be related to antiapoptosis, antifibrosis, and smooth muscle preservation.Lin H, Liu C, Wang R. Effect of Penile Traction and Vacuum Erectile Device for Peyronie’s Disease in an Animal Model. J Sex Med 2017;14:1270–1276.     

Penile Sensory Changes After Plaque Incision and Grafting Surgery for Peyronie’s Disease

Introduction

Plaque incision and grafting (PIG) for Peyronie’s disease (PD) is not devoid of complications such as erectile dysfunction and penile sensory changes.

Penile Size Restoration With Nondegloving Approach for Peyronie’s Disease: Initial Experience

Introduction

The sliding technique (ST), commonly done with a subcoronal circumcising incision with penile degloving, has been used to restore penile size in patients with severe Peyronie’s disease (PD) and erectile dysfunction, but with a potential risk of ischemic injury to the glans penis.

Testosterone Levels Are Not Associated With Magnitude of Deformity in Men With Peyronie’s Disease

IntroductionThere are some data suggesting that there is a relationship between the magnitude of Peyronie’s disease (PD)–associated penile curvature and low serum testosterone.AimTo evaluate the relationship between PD associated penile deformity and total testosterone (TT) and free testosterone (FT) levels.MethodsWe identified patients diagnosed with PD who had early morning TT measurements. Because laboratories have different reference values, we analyzed testosterone values 2 ways, as raw values and as standardized values (TT and FT values converted into z-scores for each laboratory). Deformity assessment was conducted during an intracavernosal injection–induced rigid erection. The association between T levels and magnitude of penile curvature was analyzed in a number of ways. First, an independent measure t-test tested differences in curvature degree by TT groups (low T: <300 ng/dL; normal T: ≥300 ng/dL). Second, an association was sought between T levels based on quartiles of the normal range (<300, 300–450, 450–600, and >600 ng/dL). These analyses were conducted for both TT and FT levels and using both raw and standardized T values. Third, multivariable analysis using multiple linear regression was performed in an attempt to define predictors of the degree of penile curvature. Factors entered into the model included: TT level, FT level, patient age, race (white vs other), number of co-morbidities, body mass index, presence of erectile dysfunction, duration of PD, and prostatectomy (yes vs no).Main Outcome MeasuresThe relationship between T levels and the magnitude of penile curvature.Results184 subjects met all study criteria. Average age was 54 ± 12 years. Mean TT level was 425 ± 176 ng/dL, and mean curvature magnitude was 35° ± 19°. The percent of subjects in the first through fourth TT quartiles was 26%, 34%, 24%, and 16%. As a continuous variable, there was no association between TT levels (r = ?0.01, P = .95) or FT levels (r = ?0.08, P = .30) and the curvature magnitude. When examining TT groups, there was no difference in mean curvature between the low TT group and the normal TT group (35.4° ± 17° vs 34° ± 20°, P = .70). When analyzing the TT and FT levels standardized into z-scores, there was no association between degree of curvature and TT z-scores (r = ?0.003, P = .95) and FT z-scores (r = ?0.08, P = .43). There was also no association between testosterone levels and degree of curvature in the multivariable model.ConclusionsThere does not appear to be any association between testosterone levels and the magnitude of PD-associated penile deformity.Mulhall JP, Matsushita K, Nelson CJ. Testosterone Levels Are Not Associated With Magnitude of Deformity in Men With Peyronie’s Disease. J Sex Med 2019;16:1283–1289.     

Efficacy of Combined Collagenase Clostridium histolyticum and RestoreX Penile Traction Therapy in Men with Peyronie’s Disease

BackgroundPrevious studies of penile traction therapy (PTT) devices have demonstrated limited/no efficacy when combined with intralesional therapies for Peyronie’s disease (PD). Recently, randomized data have demonstrated the efficacy of a novel PTT device, RestoreX, developed in cooperation with the Mayo Clinic, in men with PD.AimTo assess the safety and efficacy of treatment with the RestoreX device plus collagenase Clostridium histolyticum (CCH) compared with CCH alone and CCH with other PTT devices.MethodsA prospective registry has been maintained of all men undergoing CCH injections for PD between March 2014 and January 2019. Assessments were performed at baseline, during each series, and after completion of treatment. Those completing therapy (8 injections or sooner if satisfied) were categorized into group 1 (CCH alone), group 2 (CCH plus any PTT device other than RestoreX), or group 3 (CCH plus RestoreX).OutcomesChanges in penile length, curvature, and subjective perception and the occurrence of adverse events.ResultsOf 287 men with data on PTT use, 113 had completed therapy with all objective data available and compose the current cohort. Baseline demographic and pathophysiological variables were similar among the 3 groups except penile length and previous PD medications. Following treatment, group 3 demonstrated significantly greater improvements in curvature (mean, 20.3°/31% for group 1, 19.2°/30% for group 2, and 33.8°/49% for group 3), length (-0.7 cm/-4%, -0.4 cm/-2%, and +1.9 cm/+17%, respectively), and subjectively estimated curvature improvement (44%, 32%, and 63% respectively), despite shorter daily PTT use (0.9 vs 1.9 hours/day). Group 3 was more likely than the other groups to experience ≥20°, ≥20%, and ≥50% curvature improvements, ≥1 cm length gain, and ≥20% length improvement. All results were statistically significant for group 3 versus groups 1 and 2, but not between groups 1 and 2, even after controlling for baseline features and isolating a subset of ≥3 hours/day PTT use (group 2). Group 3 was 6.9 times more likely to achieve ≥20° curvature improvement, and 3.5 times more likely to achieve ≥50% curvature improvement, and 10.7 times more likely to experience ≥20% length improvement. Adverse events were similar among the 3 groups.Clinical ImplicationsUse of the RestoreX device enhances mean curvature outcomes by 71% and increases penile length in men with PD receiving CCH therapy.Strengths & LimitationsStudy strengths include a prospective registry, consistent assessments, the largest single-site series with complete posttreatment outcomes reported to date, the largest PTT series reported to date, and a true-to-life clinical design. Limitations include the nonrandomized methodology and single-site setting.ConclusionThe combination of RestoreX and CCH is associated with significantly greater curvature and length improvements compared with CCH alone or CCH with other PTT devices.Alom M, Sharma KL, Toussi A, et al. Efficacy of Combined Collagenase Clostridium histolyticum and RestoreX Penile Traction Therapy in Men with Peyronie’s Disease. J Sex Med 2019;16:891–900.     

Safety and Efficacy of Collagenase Clostridium histolyticum in the Treatment of Acute-Phase Peyronie’s Disease

BackgroundPeyronie’s disease (PD), defined as the abnormal formation of fibrous plaque(s) in the tunica albuginea of the penis, is a chronic condition that afflicts 3% to 13% of the US male population; there is no current research on the efficacy and safety of collagenase Clostridium histolyticum (CCH) in the treatment of acute phase PD.AimTo examine the efficacy and safety of CCH in the treatment of acute-phase PD.MethodsWe retrospectively reviewed the records for all patients treated with CCH for PD from April 2014 through April 2017. Patients who reported penile pain and duration of PD no longer than 12 months at presentation qualified as being in the acute phase of PD. The primary outcomes of interest were final changes in curvature after CCH treatment regardless of the number of CCH cycles received and frequency of treatment-related adverse events.OutcomesParameters of efficacy and safety were compared between acute- and stable-phase PD.ResultsA total of 162 patients were included in the study, of which 36 (22%) qualified as having acute-phase PD (group 1) and the remaining 126 (78%) qualified as having stable-phase PD (group 2). Median duration of PD was 8.5 months (range = 1–12) for group 1 and 18 months (range = 1–492) for group 2. There was no significant difference in final change in curvature between the acute and stable phases of PD (16.7° vs 15.6°; P = .654). There was no statistically significant difference in frequency of treatment-related adverse events between the acute phase (4 patients, 11%) and the stable phase (12 patients, 10%; P = .778).Clinical ImplicationsCCH therapy is as safe and efficacious in acute-phase PD as it is in stable-phase PD.Strengths and LimitationsThis is the first report that assesses the safety and efficacy of CCH therapy focusing on acute-phase PD. This study was composed of a large cohort of patients receiving CCH therapy in acute- and stable-phase PD. Limitations include bias associated with retrospective studies, a small sample, and a single-center setting.ConclusionsAlthough CCH is not clearly indicated for treatment during the acute phase of PD, these results suggest that CCH use during this phase can be effective and safe. There was no statistically significant difference in final change in curvature or treatment-related adverse events after CCH therapy delivered between the acute and stable phases of PD.Nguyen HMT, Anaissie J, DeLay KJ, et al. Safety and Efficacy of Collagenase Clostridium histolyticum in the Treatment of Acute-Phase Peyronie’s Disease. J Sex Med 2017;14:1220–1225.     

Outcomes of RestoreX Penile Traction Therapy in Men With Peyronie’s Disease: Results From Open Label and Follow-up Phases

BackgroundA randomized, controlled clinical trial evaluating the efficacy of RestoreX traction therapy in men with Peyronie’s disease (PD) has been completed, with the 3-month results previously reported. The present study presents outcomes from the open-label and follow-up phases of the original trial.AimTo report 6-month (open-label phase) and 9-month (follow-up phase) outcomes from a randomized, controlled trial (NCT03389854).MethodsA randomized controlled trial was performed from 2017 to 2019 in 110 all-comer men with PD. Men were randomized 3:1 to RestoreX (PTT) or no therapy (control) for 3 months, followed by 3-month open-label and follow-up phases. Key outcomes included adverse events (AEs), changes in penile curvature and length, erectile function, and standardized and nonstandardized assessments of PD.OutcomesThe primary outcomes are safety, penile length, penile curvature, Peyronie’s Disease Questionnaire, International Index of Erectile Function, and satisfaction.Results6-month (n = 64) and 9-month (n = 63) outcomes were reported, with a mean duration of PTT use of 31.1 minutes. No significant AEs were reported, with temporary erythema and discomfort being most common and resolving within minutes. On intent-to-treat analysis, control-to-PTT men experienced significant length (1.7–2.0 cm) and curvature improvements (18–20%). PTT-to-PTT men also achieved additional length (0.6–0.8 cm) without further curvature improvements. An as-treated analysis of PTT use ≥15 minute/day demonstrated 2.0- to 2.3-cm length gains (largest of any PTT to date) and 18–21% curve improvement. All sexual function domains of the International Index of Erectile Function and Peyronie’s Disease Questionnaire were significantly improved (except orgasmic domain). 95% of men treated for 6 months experienced length gains (mean 2.0–2.2 cm), and 61% had curve improvements (16.8–21.4° [32.8–35.8%]). RestoreX was preferred 3–4:1 over all other PD treatments, and 100% preferred it over other PTT devices.Clinical ImplicationsUse of RestoreX 30 minutes daily results in significant length and curve improvements in PD men without significant AEs.Strengths & LimitationsStrengths include largest randomized study of PTT, blinded assessments, and inclusion of all-comers with few restrictions; limitations include sample size that precludes comparisons between treatment cohorts and lack of long-duration (>3–9 hours) treatment arm.ConclusionPTT with RestoreX results in significant improvements in length, curve, and subjective and objective measures of sexual function without significant AEs. RestoreX PTT represents a safe, conservative, low-cost option for managing men with PD.Joseph J, Ziegelmann M, Alom M, et al. Outcomes of RestoreX Penile Traction Therapy in Men With Peyronie’s Disease: Results From Open Label and Follow-up Phases. J Sex Med 2020;17:2462–2471.     

Peyronie’s Disease and the Female Sexual Partner: A Comparison of the Male and Female Experience

BackgroundPeyronie’s disease (PD) is characterized by penile pain, deformity, and sexual dysfunction, often resulting in an impaired sexual experience and significant psychological bother for the patient. However, there are limited data on the impact of PD on female sexual partners (FSPs).AimTo compare the psychosexual experience of men with PD and their FSPs.MethodsWe retrospectively reviewed all prospectively enrolled men and their FSPs who presented for initial PD evaluation to our sexual health clinic from July 2018 to February 2020. All men completed a PD-specific survey and the PD questionnaire (PDQ). If the patient was accompanied by an FSP during initial evaluation, she completed the PDQ for Female Sexual Partners and Female Sexual Function Index. We further queried our database that included information on patient demographics and clinical characteristics.OutcomesThe main outcome of this study is retrospective comparison of responses with the PDQ and PDQ for Female Sexual Partners.ResultsData were available for 44 men with PD (median age, 56 years; interquartile range, 49–63) and their FSPs (median age, 54 years; interquartile range, 50–61). The majority of men presented in the chronic phase (35 of 44, 79.5%), and median objective composite curvature was 75° (interquartile range, 50–90°). Owing to PD, female and male partners reported similar difficulty with vaginal intercourse (VI) (74.3% vs 81.5%, P = .555), decreased frequency of VI (70.6% vs 85.2%, P = .228), and at least moderate discomfort/pain with VI (48.6% vs 33.3%, P = .232). FSPs were “very” or “extremely” bothered by the appearance of their partner’s erect penis less often than male partners (20.0% vs 59.3%, P < .001). FSPs were “very” or “extremely” bothered by their partner’s PD during VI less often than men with PD (32.3% vs 65.2%, P = .017). Few FSPs (22.9%) had “severe” or “very severe” concern with damaging their partner’s penis during VI.Clinical ImplicationsThe sexual experience for men with PD and their FSPs differs, thus emphasizing the importance of active engagement of both men with PD and FSP during initial PD evaluation.Strengths and LimitationsThis initial study draws data from a single, high-volume men’s health clinic with a limited sample size. Survey responses may have been shared by patients with PD and their FSPs.ConclusionPD impacts the sexual experience for both men and FSPs. A similarly large proportion of men with PD and FSP noted decreased frequency of and difficulty with vaginal intercourse. Yet, FSPs were less bothered by the appearance of the erect penis and the deformity during VI compared with men.Farrell MR, Ziegelmann MJ, Bajic P, et al. Peyronie’s Disease and the Female Sexual Partner: A Comparison of the Male and Female Experience. J Sex Med 2020;17:2456–2461.     

Shaeer’s Punch Technique: Transcorporeal Peyronie’s Plaque Surgery and Penile Prosthesis Implantation

BackgroundPenile prosthesis implantation in cases of severe Peyronie’s disease may require plaque excision/incision and grafting, which may require mobilization of the neurovascular bundle or urethra, posing the risks of penile hyposensitivity or urethral injury, and is time-consuming, possibly increasing infection risk.AimEvaluating transcorporeal debulking of Peyronie’s plaques by “Shaeer’s punch technique.”MethodsPenile prosthesis implantation and punch technique (PPI-Punch) was performed for 26 patients. After corporotomy and dilatation, Peyronie’s plaques were punched out from within the corpora cavernosa using the punch forceps, and then a penile prosthesis was implanted. Comparison to a matching retrospective group of 18 patients operated upon by plaque excision-grafting and penile prosthesis implantation was performed.OutcomesThe study outcomes were straightness of the erect penis, complication, satisfaction with length on a 5-point scale, the International Index of Erectile Function-5, and the Erectile Dysfunction Inventory of Treatment Satisfaction questionnaire.ResultsAverage preoperative curvature angle was 58.1 ± 11.7 in the Punch group and 58 ± 14.8 in the excision-grafting group, p=0.99. After surgery, all patients had a straight penis. No tunical perforations, urethral injuries, or extrusions were noted. Average additional operative time for Punch technique ranged from 5 to 10 minutes (7.3 ± 1.7), in contrast to the excision-grafting group where plaque surgery duration was 50.8 minutes ± 11.1, an 85% difference, p < 0.0001. Septal plaques in the latter group could not be removed. In the PPI-Punch group, penile sensitivity was preserved in all patients, compared with the excision/grafting group, with 7 of 18 patients reporting hyposthesia of the glans. Infection occurred in 1 of 26 patients in the PPI-Punch group, compared with 2 of 18 patients in the excision/grafting group. Satisfaction with length on a 5-point scale was 3.8 ± 0.9 in the punch group, versus 3.1 ± 1.1 in the excision-grafting group, p=0.009.Clinical ImplicationsThe proposed technique is minimally invasive and prompt, possibly decreasing the known complications of plaque surgery and PPI including sensory loss.Strengths & LimitationsOne limitation is the inability to accurately measure preoperative erect length in patients with erectile dysfunction with poor response to intracavernous injections.ConclusionShaeer’s punch technique is a minimally invasive procedure for transcorporeal excavation of Peyronie’s plaques before penile prosthesis implantation, omitting the need for mobilization of the neurovascular bundle or spongiosum, and hence, there is low or no risk for nerve or urethral injury and brief plaque surgery time.Shaeer O, Soliman Abdelrahman IF, Mansour M, et al. Shaeer’s Punch Technique: Transcorporeal Peyronie’s Plaque Surgery and Penile Prosthesis Implantation. J Sex Med 2020;17:1395–1399.     

Comparative Cost-effectiveness of Surgery,Collagenase Clostridium Histolyticum,and Penile Traction Therapy in Men with Peyronie’s Disease in an Era of Effective Clinical Treatment

BackgroundTraditionally, surgery has been considered the gold standard treatment for Peyronie’s disease (PD). Less-invasive alternatives, such as collagenase Clostridium histolyticum (CCH) and traction therapy, have been proposed and proven effective.AimTo compare cost-effectiveness of management options for PD.MethodsA Markov analytic model was created to compare the cost-effectiveness of treatment with a novel traction device, RestoreX (RXPTT), vs CCH vs surgery. Outcomes were derived from single-institution, prospective data of 63 men treated with RXPTT, 115 with CCH, and 23 with plication or incision and grafting. Costs were based on 2017 Medicare reimbursement and utility values from the literature.Main Outcome MeasuresModel outcomes included complications for each treatment arm, as well as the probability of success, which was defined as ≥20% improvement in curvature. Univariable and multivariable sensitivity analyses were performed to test the robustness of the model.ResultsOverall success rates were 96% (surgery), 66% (CCH), and 48% (RXPTT). At 10 years after treatment, RXPTT was the most cost-effective, with mean costs per patient of $883 (RXPTT), $11,419 (surgery), and $33,628 (CCH). CCH and surgery both resulted in a gain of quality adjusted life years (QALYs) relative to RXPTT (9.44 and 9.36 vs 9.27, respectively). Sensitivity analysis demonstrated greater cost-effectiveness for surgery if lower (≤46%) rates of postoperative erectile dysfunction or length loss (≤3%). CCH became more cost-effective at lower costs (≤$16,726) or higher success rates (≥76%). On multivariable sensitivity analysis at a willingness to pay threshold of $100,000/QALY, the most cost-effective strategy was RXPTT in 49%, surgery in 48%, and CCH in 3% of simulations. At a willingness to treat threshold of $150,000/QALY, the most cost-effective treatment option was RXPTT in 33%, surgery in 55%, and CCH in 12% of simulations.Clinical ImplicationsIn an era of value-based care, this model can guide cost-effective treatment selection on the basis of provider, patient, and payer characteristics.Strengths & LimitationsThe current study represents the first cost-effectiveness comparison of treatment modalities for PD and is strengthened by prospective data collection, large CCH and traction sample sizes, and robust sensitivity analyses. Consistent with cost-effective models, the model is limited by assumptions and may not apply to all scenarios.ConclusionsRXPTT represents a more cost-effective method for achieving ≥20% curvature improvement compared with surgery or CCH. Depending on treatment goals, rate of surgical complications, and willingness to pay threshold, surgery and CCH may become more cost-effective in select scenarios.Wymer K, Kohler T, Trost L. Comparative Cost-effectiveness of Surgery, Collagenase Clostridium Histolyticum, and Penile Traction Therapy in Men with Peyronie’s Disease in an Era of Effective Clinical Treatment. J Sex Med 2019;16:1421–1432.     

The Surgical Treatment of Peyronie’s Disease in the Older Man: Patient Characteristics and Surgical Outcomes in Men 65 and Older

IntroductionSurgery remains the gold standard for the correction of penile deformities secondary to Peyronie’s disease (PD). Nevertheless, there is no published data on the surgical treatment of PD in older men.AimConsidering the aging national and international population, we sought to evaluate the pre-operative characteristics and surgical outcomes of men aged 65 or older who underwent surgical treatment for PD at our tertiary care institution.MethodsWe retrospectively reviewed the charts of all men 65 years or older who underwent surgery for PD from January 2010 to September 2017. We compared men who underwent penile prosthesis implantation with straightening maneuvers (PP+SMs), tunica albuginea plication (TAP), and plaque partial excision with grafting (PEG).Main Outcome MeasureThe main objective of this study was to find the baseline pre-operative patient characteristics and postoperative patient-reported outcomes.ResultsA total of 86 men with a median age of 68 years underwent surgery during the study period. 39 men underwent PP+SM (45%), 25 men a TAP (29%), and 22 men a PEG (26%). The mean curvature for all men was 59.9 ± 22.0° (range 0?105°). Those who underwent a PEG had a mean ± SD degree of curvature of 78.6 ± 16.6°, significantly higher than those who underwent PP+SM or TAP (49.1 ± 20.2° and 61.4 ± 17.4°, respectively; P < .001). Moreover, men who underwent a PEG had significantly more complex penile deformities (eg, narrowing with hinge effect) and better reported baseline erectile function compared with men who underwent PP+SM or TAP. Overall, 95% of all men reported having a functionally straight penis postoperatively with 94% engaging in penetrative intercourse at last follow-up. Overall, patient-reported satisfaction was 85% with a median follow-up of 43.5 months.Clinical ImplicationsOur findings suggest that the surgical treatment of PD in older men is safe, effective, and associated with high patient satisfaction. Although this represents a surgical series susceptible to selection bias, it underscores the importance of patient selection and counseling in achieving good surgical outcomes.Strengths & LimitationsOur study is the first to report on outcomes of surgical treatment of PD in an elderly patient population with relatively long-term follow-up. Our limitations include a small sample size, single operating surgeon, and the lack of a younger comparison group.ConclusionDespite an aging global population, surgery remains a viable and reliable option for the properly selected and counseled older men with PD.Abdelsayed GA, Setia SA, Levine LA. The Surgical Treatment of Peyronie’s Disease in the Older Man: Patient Characteristics and Surgical Outcomes in Men 65 and Older. J Sex Med 2019;16:1820–1826.     

Penile Sonoelastography for the Localization of a Non‐Palpable,Non‐Sonographically Visualized Lesion in a Patient with Penile Curvature from Peyronie's Disease

IntroductionSonoelastography is an emerging ultrasound‐based technique that allows characterization of tissue stiffness.AimThe aim of this report is to present a case of significant penile curvature with a non‐palpable, non‐sonographically visualized plaque that was demonstrable with sonoelastography.MethodsA 60‐year‐old male presented with significant left penile curvature during erections. The penis was evaluated with physical exam followed by B‐mode and color Doppler ultrasound. No evidence of plaque was identified with these modalities. Shear wave sonoelastography was pursued to further characterize the patient's Peyronie's disease.ResultsAn area of increased tissue stiffness that correlated with the site of maximum curvature was identified with shear wave sonoelastography and used to target intralesional injection therapy.ConclusionSonoelastography provides an additional way to characterize, localize, and deliver therapy to a lesion in patients with Peyronie's disease and is particularly useful when palpation and B‐mode ultrasonography have failed to demonstrate a plaque. Richards G, Goldenberg E, Pek H, and Gilbert BR. Penile sonoelastography for the localization of a non‐palpable, non‐sonographically visualized lesion in a patient with penile curvature from P eyronie's disease. J Sex Med 2014;11:516–520.     

Increased Risk of Incident Disease in Men with Peyronie’s Disease: Analysis of U.S. Claims Data

Background

The subsequent health risks associated with Peyronie’s disease (PD) are unknown.

Preparation for an elective surgical procedure in a Jehovah’s Witness: a review of the treatments and alternatives for anemia

Anemia in a Jehovah’s Witness can be a challenging situation for the general obstetrician and gynecologist. With today’s multicultural society, this issue is not as uncommon as previously thought. The following article reviews the alternatives to heterologous blood transfusion available to those patients who will not accept blood. A review of perioperative management is discussed, including cell salvage systems, normovolemic hemodilution, and controlled hypotensive anesthesia. Strategies for pre- and postoperative management are also presented. These include iron, erythropoietin, and nutrition. There are many options available, so management can be tailored to each specific situation.