Patricia Guhring

An Analysis of the Natural History of Peyronie’s Disease

PURPOSE Little information exists on the natural history of PD. We defined the course of PD in a group of men with this condition who received no treatment. MATERIALS AND METHODS The study population comprised patients with PD who presented within 6 months of disease onset, had no medical treatment and were followed until at least 12 months after disease onset. At baseline and followup penile abnormality was determined following intracavernous injection and by measurement at maximum penile rigidity. RESULTS A total of 246 patients met inclusion criteria. At presentation mean age +/- SD was 52 +/- 22 years and the duration of PD was 3.5 +/- 1.5 months. At baseline in men with documented curvature 72% had dorsal, 17% had ventral and 11% had lateral curvature. Mean curvature at baseline was 42 +/- 22 degrees. Mean stretched flaccid penile length was 12.2 cm. The mean duration of PD at the followup assessment was 18 +/- 7 months. At followup stretched flaccid length had decreased to 11.4 cm (p = 0.035). Of the patients 32% complained of some degree of erectile dysfunction at baseline. All patients who reported penile pain had improvement and 89% reported complete resolution at followup. Of men with curvature 12% had improved, 40% remained stable and 48% had worsened at followup. In those in whom curvature improved the mean change was 15 degrees, while in those in whom curvature worsened the mean change was 22 degrees. CONCLUSIONS To our knowledge this is the largest study to explore the natural history of PD. A minority of men experienced improvement in penile abnormality, while penile length decreased during the 1-year followup. This information will permit clinicians to provide patients with realistic expectations at presentation for the evaluation of PD.

Assessment of the Impact of Sildenafil Citrate on Lower Urinary Tract Symptoms in Men with Erectile Dysfunction

INTRODUCTION Sildenafil citrate is an effective and well-tolerated oral erectogenic medication. Through phosphodiesterase type 5 (PDE5) inhibition, it induces relaxation in penile smooth muscle, resulting in erection. Due to its mild affinity for other PDE enzymes, it may cause smooth muscle relaxation in a number of other organs. Recent data suggest an association between erectile dysfunction (ED) and lower urinary tract symptoms (LUTS). Anecdotally some patients cite improvement in LUTS while using sildenafil. AIM This study was conducted to assess the impact of Viagra on LUTS, using the International Prostate Symptom Score (IPSS) questionnaire. MAIN OUTCOME MEASURE International Index of Erectile Function (IIEF) and IPSS inventories. METHODS Men presenting to a sexual dysfunction clinic who were candidates and opted for treatment with sildenafil completed the IIEF and IPSS. Men with the IPSS scores greater than 10 were enrolled and completed the IPSS and IIEF questionnaires at least 3 months after the commencement of sildenafil. Comparisons were made between pre- and posttreatment scores in the IPSS and erectile function (EF) domain of the IIEF. RESULTS Forty-eight men were enrolled, with a mean age of 62 +/- 11 years. The mean improvement in the EF domain score was 7 points (P = 0.01). The mean improvement in the IPSS score was 4.6 points (P = 0.013) and in quality of life (QOL) score was 1.4 points (P = 0.025). In total, 60% of men improved their IPSS score, and 35% had at least a 4-point improvement in their score. The mean number of uses of sildenafil per week was 2.0 +/- 0.6. No significant correlation was seen between the degree of the IPSS improvement and baseline IPSS, baseline EF domain score, or magnitude of improvement in EF domain score. CONCLUSIONS These data indicate a positive impact of Viagra on men with mild to moderate LUTS. It is presumed, although unproven, that the medications effect is mediated through bladder neck/prostatic smooth muscle relaxation.

The Chronology of Depression and Distress in Men with Peyronie's Disease

INTRODUCTION For the practicing clinician, appreciating Peyronies disease (PD) significant negative psychological impact is apparent. Despite this, there exists not a single study using validated instruments assessing this issue. AIMS To document the effect of PD on the psychosocial status of men. MAIN OUTCOME MEASURES The Center for Epidemiological Studies Depression scale (CES-D) for evaluation of depression and the SF-36 for quality of life assessment. METHODS Men (N = 92; 54 +/- 11 years of age) presenting for PD evaluation completed the CES-D, Short Form-36 (SF-36), and an inventory regarding PD. Partners were not assessed. RESULTS A vast majority of men (88%) had a partner with a mean partner age of 49 +/- 11 years. The median duration of PD at presentation was 12 (1-360) months. As a whole, 48% were classified as depressed on the CES-D (26% moderate, 21% severe). These subjects were then placed into groups according to the length of time since diagnosis of PD. Length-of-time groups were: 0-6 months, 6-12 months, 12-18 months, and >18 months. The percent of men scoring above the CES-D cutoff for depression remained consistently high with no significant difference across time since diagnosis groups. These results are supported by data from the Mental Health subscale (MHS) of the SF-36 (lower scores indicate lower mental heath). For the entire sample, the MHS standardized mean of 46.80 was significantly lower (P < 0.05) than the general male population standardized mean of 50. The MHS means stayed consistently low (no statistical difference) across time since diagnosis groups. CONCLUSIONS Using validated instruments, we have demonstrated that 48% of men with PD have clinically meaningful depression that would warrant medical evaluation. This high level of depression stayed consistent across time since diagnosis. These data suggest that most men do not psychologically adjust to their diagnosis of PD and all men with PD should be considered appropriate mental health screening.

Determinants of patient satisfaction following penile prosthesis surgery.

PURPOSE Penile prosthetic surgery is associated with satisfaction rates >90% for the general penile implant population. It is suggested that satisfaction rates may be lower in certain populations. This study was undertaken to define potential predictors of satisfaction. METHODS Patients undergoing penile prosthesis surgery completed the International Index of Erectile Function (IIEF) prior to surgery, and the IIEF and Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) questionnaires at least 6 months postoperatively accompanied by a Global Satisfaction Question (GSQ). RESULTS A total of 114 patients constituted the study population. Subgroups evaluated included patients with Peyronies disease (PD), body mass index (BMI) > 30 kg/m2, radical prostatectomy (RP), and patient age > 70 years. The mean patient age and duration of ED were 59 +/- 14 and 3.2 +/- 1.9 years, respectively. All groups demonstrated statistically significant differences between pre- and postoperative scores for the IIEF and EDITS. Patients with PD, a history of RP, and BMI > 30 kg/m2 had significantly lower scores on the GSQ, IIEF satisfaction domain, and EDITS compared with the general implant population. Only PD impacted negatively on the postoperative IIEF erectile function domain score. On the multivariate analysis, factors associated with >or=5-point difference in the IIEF satisfaction domain score compared with the general implant population were PD (RR = 4.2), RP (RR = 2.2), and BMI > 30 (RR = 1.8). CONCLUSIONS These data suggest that men diagnosed with PD, BMI > 30, or previous RP undergoing penile prosthesis surgery have lower satisfaction rates than the general penile implant population.

Measurement of Penile Curvature in Peyronie’s Disease Patients: Comparison of Three Methods

AIM Peyronies disease (PD) may be treated in a medical or surgical fashion. Factors involved in the decision of which treatment to choose include duration of disease and magnitude of penile deformity. Curvature can be measured using at-home photography (AHP), vacuum erection device (VED), or intracavernosal injection (ICI). This study was undertaken to determine the concordance between the three methods of deformity assessment. Patients were also questioned regarding the presence of erectile dysfunction (ED) based on self-report and the International Index of Erectile Function. MATERIALS AND METHODS A total of 68 men presented to their urologist after taking penile photographs from three angles during maximal erectile rigidity. In the office, a VED was used to induce erection, and a goniometer was utilized to measure degree of curvature. ICI with trimix was then used to induce artificial erection, which was measured with a goniometer as well. RESULTS There was a statistically significant difference in self-report curvature magnitude compared with measured ICI-assisted curvature. Curvature profiles included dorsal plaques in 50 patients (73.5%), ventral plaques in 10 (15%), and lateral in eight (11%). Using ICI, the mean curvature measured was 42 degrees. Mean degree of curvature using VED was 33 degrees, while that of photography was 34 degrees. Photographic measurements differed most from ICI in men with concurrent ED (P < 0.01), while vacuum device measurements were most inaccurate in men with curvatures of >60 degrees. CONCLUSIONS Our results show that the degree of curvature measured using vacuum-assisted device and AHP is underestimated as compared with the gold standard ICI. We therefore recommend that ICI be used to most accurately determine degree of deformity. If ICI is not available, it is imperative that the same manner of measurement be used between all patients in a study group, as well as during serial evaluation in a trial.

A review of outcomes of an intracavernosal injection therapy programme

Study Type – Therapy (outcomes research)

Erectile Function Profiles in Men With Peyronie’s Disease

PURPOSE In this study we investigated the erectile function status of men presenting with Peyronies disease. MATERIALS AND METHODS Demographics of patients regarding age, duration of PD, nature of deformity and comorbidities were compared between the patients with PD, with and without erectile dysfunction. Patients with erectile dysfunction underwent dynamic infusion cavernosometry/cavernosography. The hemodynamic profile of patients presenting with combined PD and ED were analyzed and compared between those with onset of ED before and after diagnosis of PD. RESULTS Of the 222 patients 78 had ED (35%) by self-report at presentation. The mean age of patients with PD and ED was 52 +/- 22 years old. Hypertension (71.5%), hyperlipidemia (60.4%) and smoking (49.2%) were the leading comorbidities in the entire group. Statistically significant differences were found between the groups with and without ED for hypertension (p = 0.02) and cigarette smoking (p = 0.009). Of 222 patients 45 (20%) had ED that predated PD onset (group 1) and 33 (15%) had ED that postdated the onset of PD (group 2). DICC showed normal hemodynamics in 14 of 78 patients (18%), arteriogenic insufficiency in 50 (64%) and corporoveno-occlusive dysfunction in 16 (20%). CVOD was evenly distributed between groups 1 and 2, whereas arteriogenic ED was significantly higher in group 1 (82%). Site specific leak was seen in 4 of 33 (12%), all group 2 patients. CONCLUSIONS Patients in whom ED postdates the onset of PD are more likely to have normal erectile hemodynamics. Site specific leak is an uncommon contributor to PD and is seen only in the patients with PD in whom ED postdated PD onset. The leading vascular etiology of ED in PD is arteriogenic in older patients and those with greater associated comorbidities.

Can the International Index of Erectile Function distinguish between organic and psychogenic erectile function

To define the ability of the International Index of Erectile Function (IIEF) to differentiate between organic and psychogenic erectile dysfunction (ED).