Lawrence S. Hakim

DIABETIC SEXUAL DYSFUNCTION

Although the overall incidence of erectile dysfunction in the general population between the ages of 40 and 70 years is 52%, men with diabetes mellitus have impotence at an earlier age and with a significantly higher prevalence, ranging as high as 75%. Numerous advances have been made in understanding the physiologic and biochemical mechanisms controlling penile erection. Improved clinical techniques for the diagnosis and treatment of impotence, including dynamic vascular testing, intracavernosal pharmacotherapy, and microsurgical revascularization, have allowed us to enter a new and exciting era in the quest for a more complete understanding of erectile dysfunction.

Single-Blind, Multicenter, Placebo Controlled, Parallel Study to Assess the Safety and Efficacy of Intralesional Interferon α-2b for Minimally Invasive Treatment for Peyronie’s Disease

PURPOSE We investigated the efficacy and safety of intralesional interferon alpha-2b for the treatment of Peyronies disease. MATERIALS AND METHODS A total of 117 consecutive patients with a mean age of 55.1 years who had Peyronies disease were enrolled in a single-blind, multicenter, placebo controlled, parallel study to determine the efficacy and safety of intralesional interferon alpha-2b therapy (Schering, Kenilworth, New Jersey), including 62 who received placebo and 55 who received interferon alpha-2b. Saline (10 ml) in controls and interferon alpha-2b (5 x 10(6) U) were administered biweekly for 12 weeks. Each patient was evaluated for penile curvature, plaque size and density, penile pain, erectile function and penile hemodynamics before and after study completion. Improvement in these parameters was statistically compared between the groups. RESULTS A total of 53 patients in the control arm and 50 in the interferon alpha-2b arm completed the study. Improvement in penile curvature, plaque size and density, and pain resolution was significantly greater in patients treated with interferon alpha-2b vs placebo. The increase in mean International Index of Erectile Function scores was not significantly different between the groups. Penile blood flow improvement was observed in interferon alpha-2b treated patients but not in those who received placebo. The decrease in the number of penile vascular pathologies was significantly higher in interferon alpha-2b cases. Side effects, mostly flu-like symptoms, which were frequently noted in patients on interferon alpha-2b, were mild to moderate in degree and of short duration. CONCLUSIONS This single-blind, multicenter, placebo controlled, parallel study demonstrates that intralesional interferon alpha-2b at a dose of 5 x 10(6) units biweekly for 12 weeks is effective and safe as minimally invasive therapy for Peyronies disease.

Peyronie’s Disease: AUA Guideline

PURPOSE The purpose of this guideline is to provide a clinical framework for the diagnosis and treatment of Peyronies disease. MATERIALS AND METHODS A systematic review of the literature using the PubMed®, EMBASE® and Cochrane databases (search dates 1/1/1965 to 1/26/15) was conducted to identify peer-reviewed publications relevant to the diagnosis and treatment of PD. The review yielded an evidence base of 303 articles after application of inclusion/exclusion criteria. RESULTS The systematic review was used to create guideline statements regarding treatment of PD. When sufficient evidence existed, the body of evidence for a particular treatment was assigned a strength rating of A (high quality evidence; high certainty), B (moderate quality evidence; moderate certainty), or C (low quality evidence; low certainty). Evidence-based statements of Strong, Moderate, or Conditional Recommendation were developed based on benefits and risks/burdens to patients. Additional consensus statements related to the diagnosis of PD are provided as Clinical Principles and Expert Opinions due to insufficient published evidence. CONCLUSIONS There is a continually expanding literature on PD; the Panel notes that this document constitutes a clinical strategy and is not intended to be interpreted rigidly. The most effective approach for a particular patient is best determined by the individual clinician and patient in the context of that patients history, values, and goals for treatment. As the science relevant to PD evolves and improves, the strategies presented here will be amended to remain consistent with the highest standards of clinical care.

Evidence-Based Management Guidelines on Peyronie's Disease.

INTRODUCTION Despite recent advances in our knowledge and treatment strategies in Peyronies Disease (PD), much remained unknown about this disease. AIM To provide a clinical framework and key guideline statements to assist clinicians in an evidence-based management of PD. METHODS A systematic literature search was conducted to identify published literature relevant to PD. The search included all relevant articles published up to June 2015, including preclinical studies and published guidelines. References used in the text were assessed according to their level of evidence, and guideline recommendations were graded based on the Oxford Centre for Evidence-Based Medicine Levels of Evidence. Owing to the paucity of larger series and randomized placebo-controlled trials with regard to surgical intervention, guideline statements are provided as clinical principle or expert opinion. MAIN OUTCOME MEASURES This literature was discussed at a panel meeting, and selected articles with the highest evidence available were used to create consensus guideline statements for the Fourth International Consultation on Sexual Medicine guidelines on PD. RESULTS In addition to existing Third International Consultation on Sexual Medicine guidelines on PD, seven new summary recommendations were created. CONCLUSION A greater understanding of the scientific basis of PD is greatly needed to address our understanding of the pathophysiology, clinical epidemiology, psychosocial, and diagnostic assessment as well as treatment strategies.

North American Consensus Document on Infection of Penile Prostheses

OBJECTIVE To issue a consensus document on the prevention, management, and research of infection associated with penile prostheses, as neither professional associations nor governmental entities have issued guidelines that are specific to this infection. METHODS Sixteen North American experts on infection of penile prostheses were identified and assembled to select and discuss certain issues related to infection of penile prostheses. After performing an extensive search of clinically important issues in published reports, the 16 experts met twice in person to finalize the selection, discuss the issues that were deemed most important, and issue pertinent recommendations. RESULTS Although many subjects relevant to infection of penile prostheses were initially identified, the experts selected 10 issues as currently being the most important issues and for which there exists some support in the published data. The examined issues involved prevention, management, or research of infections associated with penile prostheses. CONCLUSION In the absence of pertinent guidelines, the consensus document issued by experts in the field of prosthetic urology is anticipated to improve the quality of patient care, streamline the prevention and management of infected penile prostheses, and stimulate collaborative research. Although this consensus document could serve as best practice recommendations, the lack of adherence to these recommendations would not indicate improper care.

Office-based management of impotence and Peyronie's disease.

Erectile dysfunction (ED) impacts more than 50% of men older than 40 years; Peyronie disease (PD) affects up to 10% of men, with an adverse impact on normal sexual function and overall well-being. ED can also be the first sign of other underlying disease. The office-based evaluation of ED and PD is the first step in the management of these devastating conditions of mens health. New and exciting nonsurgical therapies are now available to help treat these conditions and restore sexual function and quality of life.

Erectile Dysfunction: AUA Guideline

Purpose: The purpose of this guideline is to provide a clinical strategy for the diagnosis and treatment of erectile dysfunction. Materials and Methods: A systematic review of the literature using the Pubmed, Embase, and Cochrane databases (search dates 1/1/1965 to 7/29/17) was conducted to identify peer‐reviewed publications relevant to the diagnosis and treatment of erectile dysfunction. Evidence‐based statements were based on body of evidence strength Grade A, B, or C and were designated as Strong, Moderate, and Conditional Recommendations with additional statements presented in the form of Clinical Principles or Expert Opinions. Results: The American Urological Association has developed an evidence‐based guideline on the management of erectile dysfunction. This document is designed to be used in conjunction with the associated treatment algorithm. Conclusions: Using the shared decision‐making process as a cornerstone for care, all patients should be informed of all treatment modalities that are not contraindicated, regardless of invasiveness or irreversibility, as potential first‐line treatments. For each treatment, the clinician should ensure that the man and his partner have a full understanding of the benefits and risk/burdens associated with that choice.

Lower extremity above-knee prosthesis-associated erectile dysfunction.

Blunt pelvic and perineal trauma has been previously reported to result in site-specific veno-occlusive dysfunction and/or site-specific cavernosal artery insufficiency. We herein describe a case of erectile dysfunction in a young previously potent amputee. We postulate that the erectile dysfunction is associated with a newly described form of blunt trauma, that is, site-specific compression from a perineal weight-bearing lower extremity above-knee prosthetic device. It is hypothesized that when the force exerted by the above-knee prosthesis is directed medially towards the ischiopubic ramus, the penile crura and common penile arterial blood supply become susceptible to crush-like injury, since they are in fixed anatomic locations in the perineum sandwiched between the compressive force and the bone. Clinical evaluation of the erectile dysfunction in this patient revealed site-specific corporal veno-occlusive dysfunction and site-specific common penile arterial occlusive pathology in the precise region of the contact of the above-knee prosthesis with the perineum. Further research is needed in above-knee prosthesis design to prevent erectile dysfunction.

Testosterone replacement therapy

It is a pleasure to present this introduction to a very special issue of Translational Andrology and Urology ( TAU ) that is focused on “testosterone replacement therapy” (TRT). As editors, we strove to present a current, state-of-the-art and global perspective on this very common and important medical condition. Established national and international experts as well as rising stars were invited to contribute and the response to our invitations to provide manuscripts on this timely subject has been overwhelming and allowed for the inclusion of numerous outstanding original articles, comprehensive review articles, as well as important opinions from many of the world leaders in the area of andrology. The papers in this issue of the TAU journal provide insightful updates and perspectives on our current understanding of the epidemiology, pathophysiology and important role of TRT in clinical practice.

MP56-12 CONCERNS OF FEMALE PEYRONIE′S DISEASE PARTNERS: A NARRATIVE ANALYSIS

INTRODUCTION AND OBJECTIVES: Peyronie0s Disease (PD) is known to have a significant negative impact on the psychosocial and relationship functioning of male patients, with studies finding increased depression, distress, and sexual dysfunction in men with PD. In just the past year, researchers have also begun to attend to the female partners of these men, studying their own sexual function, relationship satisfaction, and mood. However, these few studies are flawed: by using the male patient as a gateway to access his female partner, they limit their access to women whose partners are comfortable making such a referral; by using surveys that emphasize sexual function, they restrict the opportunity for the partners to define their own concerns. This study seeks to address these problems, using narrative content analysis of Internet posts made by female PD partners to describe and rank the concerns expressed by these women, independent of their interactions with researchers and male partners. METHODS: This is a qualitative study, analyzing the content of Internet posts made by female PD partners on two patient-centered and member-operated, English-language PD support forums. In deference to ethical concerns regarding consent to research, only those posts within the public domain and readily accessible to non-members via Google search were analyzed. A Grounded theory process was used, with open coding to identify themes of concern. RESULTS: From 2/2005-10/2016, a total of 793 posts were published online, by 48 female PD partners. The primary concern expressed by these women related to difficulty communicating with their partners about PD, with 24/48 (50%) posting about this issue. Secondary concerns were partners0 emotional (18/48 (38%)) and physical (12/48 (25%)) pain. Only 10/48 (21%) expressed concern about their own diminished sexual pleasure, with 4/48 (8%) describing how their partners0 curvature enhanced their sexual experience. CONCLUSIONS: When evaluated through the nonintrusive method of Internet narrative analysis, female PD partners are most concerned with poor communication, followed by their partners0 emotional and physical pain. While their sexual needs do merit attention, this study suggests that interventions targeting the psychosocial needs of patients and their partners would be most meaningful for this population.