Investigating the risk factors of penile arterial insufficiency and veno-occlusive dysfunction in patients with erectile dysfunction.

Objective: To investigate the risk factors for penile arterial insufficiency (PAI), which is a known cause of erectile dysfunction (ED). Methods: Patients who attended our urology clinic complaining of ED for more than 6 months were prospectively enrolled in this study over 1-year period. Patient consent was taken and ethical committee approval. Complete medical history and thorough general and local examination including body mass index (BMI), Peyronie's disease (PD) and penile size measurements (length and girth) were done for all of them. Laboratory tests included testosterone, lipid profile and glycated haemoglobin (HA1c). A penile duplex ultrasound study (PDU) was done for all patients after intracavernosal injection (ICI) with alprostadil. Peak systolic velocity (PSV) and end-diastolic velocity (EDV) were measured after 15 min. Statistical analysis was done using SPSS. Results: A total of 440 patients were enrolled in this analysis. The mean age was 48(23-81), and the mean BMI was 30 (18-51). Older patients had lower PSV (r = -0.361, P = 0.000) and higher EDV (r = 0.174, P = 0.001), and both correlations were highly statistically significant. Diabetics had lower PSV (r = -0.318, P = 0.000) and higher EDV (r = 0.139, P = 0.008), which were also highly statistically significant. Smokers had lower PSV (r = -0.140, P = 0.008) and higher EDV (r = 0.178, P = 0.001), which were highly statistically significant. Men with larger penises measured skin to tip had lower EDV (r = -0.119, P = 0.024), which was less significant. Interestingly, there was neither a significant correlation between BMI and PSV (0.16, P = 0.745) nor a significant correlation between testosterone and PSV (0.029, P = 0.552). Also, there was no correlation between PSV and both dyslipidaemia and penile PD. Conclusions: Ageing, tobacco consumption, DM and hypertension seem to have a negative impact on penile haemodynamics, which was statistically significant. In our patients, there was no statistically significant effect on penile haemodynamics in patients with increased BMI, low testosterone or PD or according to the size of the penis.

Recreational use of oral erectile dysfunction medications among male physicians - A cross-sectional study.

Introduction: Erectile dysfunction (ED) is defined as the persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance. Bypassing health-care providers and obtaining ED medications (EDM) without a prescription are an issue that is faced globally. Aim: We attempt to assess erectile function (EF) among a local sample of physicians, the psychological effects of recreational EDM use, and compare EF among different user groups. Methods: This is a cross-sectional study done solely on physicians in Saudi Arabia. A self-designed questionnaire including demographics, sexual characteristics, use of ED medication, sexual satisfaction, and the validated international index of EF (IIEF). Outcome: Physicians misused EDM. Results: A total of 503 physicians completed the questionnaire. Among participants reporting sexual problems, only 23% received counseling and 3.4% were professionally diagnosed with ED. Among users, 71.2% were using EDM recreationally, 14.4% prophylactically, and 14.4% were prescribed. Participants aged 20-29 IIEF-5 score was significantly lower than participants aged 30-39 years. Prescribed users had a lower IIEF-5 score compared to both recreational users and nonusers. Clinical Implications: Many healthy sexually active men use EDMs recreationally to increase sexual performance. Strengths and Limitations: One of the limitations of our study is that we did not use standardized tools to determine the diagnosis of some important disorders like premature ejaculation. Our study strengths include the very high response rate, with our results truly showing a nationwide self-assessment of sexual dysfunction. Conclusion: Recreational use of oral EDMs may adversely impact the psychological aspects of sexual function. In our study, physicians misused EDM. We recommend labeling EDMs as restricted medication that requires a prescription to use by a licensed physician.

Malleable Penile Implant Rod Diameter Predicts Complications and Patient Satisfaction.

BACKGROUND: One of the most common complaints after malleable prosthesis implantation (MPI) is thinning of the penis and decreasing girth. Some surgeons try to insert the largest diameter they can to improve patient satisfaction AIM: To investigate if malleable rod diameter (MRD) has an impact on outcome and patient satisfaction METHODS: Consecutive malleable prosthesis implantation (MPI) was assessed in a high-volume center over 1 year. The same preoperative, intraoperative, and postoperative protocols were used for all patients and one brand of the malleable device was used only. We recorded MRD and length for all patients. All patients had data on comorbidities including glycated hemoglobin (HbA1c) and clinical Peyronie's disease (PD). Revision cases and those who lost for follow-up were excluded from the study. We also excluded patients operated on by low-volume surgeons. All complications, minor (edema, ecchymosis, pain), and major (infection and erosion) were recorded. After 1-year, patients were assessed and given a Likert scale from 1 to 5 where 5 is most satisfied with their MPI. We stratified patients according to MRD into 2 groups: group A for diameter 9.5 and 11 mm and group B for 13 mm. OUTCOME: Larger diameter of malleable penile implants may be associated with more complications RESULTS: 183 patients had full data and filled the questionnaire after 1-year follow-up. All patients had Coloplast, Genesis penile implants. Major complications rate (infection, erosion, and removal) was significantly higher in group B 11% vs 1.2% in group A (P = .016). At 4 weeks postoperative visit, 90 % of group A showed no complications vs 60% only in group B that was statistically significant (P = .0003). Satisfaction rate was more in patients in group A (88.6%) compared to patients in group B (75.7%) but this did not reach to be statistically significant (P = .0519) CLINICAL IMPLICATIONS: MRD predicts outcome. STRENGTHS & LIMITATIONS: The strengths of our study include that it is the first prospective study with good number of malleable implants. Limitations include: no validated satisfaction instrument and MRD choice was based on surgeon preference. CONCLUSIONS: Larger diameter of malleable penile implants are not associated with a higher rate of patient satisfaction Habous M, Omar M, Farag M et al. Malleable Penile Implant Rod Diameter Predicts Complications and Patient Satisfaction. Sex Med 2022;10:100486.

Prevalence and Predictive Factors of Female Sexual Dysfunction in a Sample of Saudi Women.

INTRODUCTION: Female sexual dysfunction (FSD) is a common health problem that is inadequately investigated in Saudi Arabia. AIM: To assess the prevalence and predictors of FSD in a sample of Saudi women attending the primary care and gynecology clinics. METHODS: A cross-sectional clinic-based survey involved Saudi women attending primary care and gynecology clinics in a teaching hospital in Riyadh during the period from January to June 2019. Data were collected using a structured interview questionnaire. Female sexual function has been evaluated by the Arabic version of the Female Sexual Function Index. MAIN OUTCOME MEASURES: The main outcome measure of this study was female sexual function using the Arabic version of the Female Sexual Function Index. RESULTS: 200 Saudi women were included in this study. Their age ranged from 18 to 50 years. Most of the participants (88.5%) were fairly satisfied or satisfied with their spouse's sexual ability and 120 (60%) had a risk of FSD. Participants with FSD reported the lowest scores for arousal and desire domains (3.03 ± 1.3 and 3.12 ± 1.1, respectively) followed by orgasm domain (3.48 ± 1.4). Predictive factors for risk of FSD in our participants were age greater than 40 years (P = .012), unemployment (P = .035), low/moderate family income (P = .014), dissatisfaction with the spouse's sexual ability (P = .005), and higher weight (P = .010) and height (P = .043). Only age greater than 40 years (P = .041), low family income (P = .007), and dissatisfaction with spouse's sexual ability (P = .011) sustained independent significance in a multivariate logistic regression analysis. CONCLUSION: A high prevalence of FSD was encountered in our sample of Saudi women. Desire and arousal were the most significantly affected domains followed by orgasmic problems. Age greater than 40 years, low socioeconomic level, and dissatisfaction with the spouse's sexual ability are the most significant predictors. Madbouly K, Al-Anazi M, Al-Anazi H, et al. Prevalence and Predictive Factors of Female Sexual Dysfunction in a Sample of Saudi Women. Sex Med 2021;9:100277.

Management of severe complications following penile surgery for erectile dysfunction and Peyronie disease: Three case reports.

RATIONALE: Erectile dysfunction (ED) and Peyronie's disease (PD) are conditions commonly observed in andrology. Despite the surgical refinement and the technical improvement in this field, even in expert hands, detrimental consequences have been reported and it can be related to patient's comorbidities or misconduct in the postoperative period. In this article we report anecdotal cases of severe complications following penile surgery for ED and PD in high volume centers, describe the strategies adopted to treat it and discuss the options that would have helped preventing these events. PATIENTS' CONCERNS: The first case describes a patient with history of ED and PD causing penile shortening and a slight dorsal deviation of penile shaft. In the second case it is described a corporeal necrosis and urethral fistula following inflatable penile prosthesis implant. In the last case it is described the migration of reservoir into the abdomen after inflatable penile prosthesis implantation post-radical prostatectomy. DIAGNOSIS: All 3 patients were investigated with a penile doppler ultrasound with PGE1 intracorporeal injection for ED and PD diagnosis. An abdominal computed tomography scan and magnetic resonance imaging were ordered for patient of case three. INTERVENTIONS: The patients underwent different combined procedures depending on the case and including: glansectomy, penile prosthesis implantation associated with a penile elongation with double dorsal-ventral patch graft ("sliding technique"), penile urethroplasty with buccal mucosa graft, and laparotomy for reservoir removal. OUTCOMES: No further serious complications were reported after the procedures described. LESSONS: Penile surgery in patients with concomitant PD and systemic comorbidities can be at high risk of complications. As shown in this series there are possible dramatic evolution of these complications that may cause irreversible consequences to the patient. For this reason, a dedicated surgical and nursing team is necessary to reduce the chances that it happens. When this event occurs, a team trained in their management can improve the patient outcome.

Peyronie's Disease is common in poorly controlled diabetics but is not associated with the Metabolic Syndrome.

PURPOSE: The purpose of the study is to investigate if metabolic syndrome (MS) and other comorbidities are associated with Peyronie's disease (PD). METHODS: A total of 1833 patients retrospectively investigated and divided into two groups: Group A - PD patients (n = 319) and Group B - non-PD patients (n = 1303). The two groups were fully evaluated for diabetes mellitus (DM) with the glycated hemoglobin (HbA1c), hypertension (HTN), dyslipidemia (DL), obesity by measuring body mass index, total testosterone (T), penile vascular circulation measuring Peak systolic velocity (PSV) as indicator of arterial supply, end-diastolic velocity (EDV) as indicator of venous output, and finally, smoking. RESULTS: The presence of diabetes was significantly correlated with PD (P = 0.005). Patients with diabetes had a 7% higher incidence of PD. However, patients with the highest HbA1c level of >8.5 had an increased odds ratio of 1.6 (P = 0.025, confidence interval [CI] =1.061-2.459) of having PD. Increased age was significantly correlated with PD (P = 0.025). For each year of life, the likelihood of having PD increases by an odds ratio of 1.019, or 2% per year (P = 0.001, CI = 1.004-1.027). Unexpectedly, DL (P = 0.006) and smoking (P = 0.041) were associated with lower incidences of PD. Patients with DL or smoking had a 5%-7% lower incidence of PD with an odds ratio of 0.6 (P = 0.006, CI = 0.410-0.864). HTN (P = 0.621) and the total number of comorbidities (P = 0.436) were not correlated with PD. Mean serum T values were statistically (P = 0.43) but not clinically significant among patients with Peyronie's versus patients without Peyronie's (4.62 vs. 4.38 ng/ml). Neither low PSV (Fisher's exact test P = 0.912) nor abnormal EDV (Fisher's exact test P = 0.775) was correlated with the finding of PD. CONCLUSIONS: While MS was not associated with PD, diabetes, particularly poorly controlled diabetes, was associated with an increased rate. Further research into the interaction of PD and metabolic disease is warranted.

Prevalence and awareness of varicocele among athletes in Riyadh, Saudi Arabia.

PURPOSE: To evaluate the prevalence and awareness about symptoms, and complications of varicocele among athletes (bodybuilding and aerobics exercises) in Riyadh, Saudi Arabia. PATIENTS AND METHODS: A cross-sectional study of male athletes aged between 18 and 48 years old was carried out in multiple branches of fitness centers over a period of 13 months in Riyadh, Saudi Arabia. A total of 382 face-to-face interviews using a predesigned questionnaire were conducted to identify the levels of knowledge, attitude, and practice. A randomly selected 48 subjects were examined. Varicocele was diagnosed and graded based on clinical examination and Doppler ultrasonography. RESULTS: Of the participants, 157 (41%) lacked knowledge and awareness regarding varicocele, its symptoms and complications. Of the examined participants, 22 (46%) were found to have varicocele. No difference in varicocele was found among bodybuilders and aerobic athletes (P=0.249). Similarly, no difference was related to duration of exercise session whether for 1 hour or more (P=0.131). However, our study revealed a higher rate of varicocele among athletes who exercised more than three times per week (P=0.009). Testicular volume was neither significantly different among respondents with and without varicocele nor between the left or right sides within each group. CONCLUSION: Knowledge about varicocele, its symptoms and complications is poor among male athletes in Riyadh, Saudi Arabia. Varicocele is more common in athletic men who are frequently exercising. Efforts to increase knowledge and enhance awareness of varicocele in young males, in general, are strongly warranted.

Penile length is preserved after implant surgery.

OBJECTIVE: To investigate if there is a correlation between penile size measured preoperatively and erect penis after penile implant surgery (PI). A common cause of patient dissatisfaction after PI is caused by patients complaining that surgery has shortened the penis. It has been suggested that stretched penile length preoperatively is almost the same after surgery when the prosthesis is in erect status. However, no comprehensive data supports this theory. This prospective study was done to investigate this theory. PATIENTS AND METHODS: Standardised measurements of stretched penile length and girth were performed in theatre before PI implantation then re-measured at the end of the procedure with the penis in the erect position. We recorded type of PI, cylinder lengths and malleable rod diameters. All patients had data recorded on body mass index (BMI), hypertension (HTN), glycated haemoglobin (HbA1c ), and Peyronie's disease (PD). RESULTS: In all, 133 patients were assessed; 88 (66.2%) had a malleable penile prosthesis (MPP) and 45 (33.8%) an inflatable penile prosthesis (IPP). The median age and BMI were 56 years and 30 kg/m2 , respectively. In all, 40 (30.1%) patients had HTN, 37 (27.8%) had PD, and 89 (66.9%) were diabetic. The mean (SD) pre-implant stretched length was 12.8 (1.8) cm. The mean (SD) flaccid girth was 10.3 (1.2) cm. Postoperatively, the mean (SD) erect length and girth were 13.1 (1.7) cm and 11.3 (1.3) cm, respectively. Overall, there was a significant (P < 0.05) increase in both the mean (SD) length at +0.36 (0.63) cm, and girth at +1.04 (1.02) cm. Patients who had an IPP, had a greater increase in both length (mean [SD] 0.62 [0.72] cm) and girth (mean [SD] 1.7 [1.0] cm) compared to those who had a MPP (mean [SD] 0.22 [0.53] cm and 0.7 [0.87] cm, respectively) (P < 0.05). We investigated correlations between pre- and postoperative outcomes related to BMI, HTN, diabetes, and PD. None of these variables affected outcome. CONCLUSIONS: PI surgery does not significantly decrease penile size compared to the preoperative assessment. The outcome was not affected by co-morbidities. The preoperative length and girth correlated well with the immediate postoperative erect penis, although girth was not necessarily comparable in this series of patients measured under anaesthesia. Recording penile dimensions in the clinic and agreeing these with patients' preoperatively may be a way of improving satisfaction levels with this surgery.

Whole genome mRNA expression profiling revealed multiple deregulated pathways in stromal vascular fraction from erectile dysfunction patients.

Background: Stem-cell-based therapies have recently been explored in the field of erectile dysfunction (ED). However, the cellular and molecular phenotype of adipose derived stem cells (ADSCs) stromal vascular fraction (SVF) from ED patients remains largely unknown. Herein we compared the global gene expression profile in the SVF from ED patients and healthy individuals and identified altered signaling pathways between the two groups.Methods: Samples (2-5 g) of abdominal adipose tissue from ED patients (n = 6) and healthy individual controls (n = 3) undergoing elective cosmetic liposuction were collected. Immediately after removal, SVF was separated using Collagenase type I and type IV protocol. RNA was isolated and microarray experiments were conducted using the Agilent platform. Data were normalized and pathway analyses were performed using GeneSpring software.Results: Our data revealed multiple differentially expressed genes between the ED and control group. Hierarchical clustering based on differentially expressed mRNAs revealed clear separation of the two groups. The distribution of the top enriched pathways for the up-regulated genes indicated enrichment in inflammatory response and T-cell receptor signaling, while pathway analysis performed on the down-regulated genes revealed enrichment in mitogen-activated protein kinase, TGF-ß, senescence, FAK, adipogenesis, androgen receptor, and EGF-EGFR signaling pathways in SVF from ED patient.Conclusion: Our data revealed the existence of multiple altered signaling pathways in the SVF from ED patients, which could potentially play a role in the etiology of this disease. Therefore, therapeutic strategies targeting these pathways might provide novel therapeutic opportunity for ED patients.

Predictors of Satisfaction in Men After Penile Implant Surgery.

INTRODUCTION: Despite the high satisfaction with penile implant (PI) surgery reported in the literature, a significant proportion of patients remain dissatisfied. AIM: To evaluate satisfaction after PI surgery, using a single question and a scoring system. Furthermore, we attempted to define factors that predicted high patient satisfaction. METHODS: The study population consisted of all patients undergoing PI surgery between 2009 and 2015. Comorbidity, demographic, and implant information were recorded. Complications recorded included: minor (requiring no re-operation) such as penile or scrotal hematoma, superficial wound breakdown; major (requiring hospitalization or re-operation) such as device infection, erosion, and mechanical malfunction. Patient satisfaction was defined using a single question posed to the patient 6 months after surgery using a 5-point Likert scale (5 being the most satisfied). Descriptive statistics were used to define complication rates and multivariable analysis (MVA) was performed to define predictors of high satisfaction (score ≥ 4), including presence and degree of complications, Peyronie's disease (PD), diabetes mellitus (DM), number of vascular comorbidities, body mass index (BMI) > 30, and patient age. MAIN OUTCOME MEASURE: Patients with a major complication, with or without an additional minor complication, had a higher likelihood of being dissatisfied (25%) compared to patients with no complication or only minor complication 1.9% (no complications) and 3.7% (only minor complications), P < .001. RESULTS: 902 patients were analysed. Mean age was 56.6 ± 10.6 years. Mean BMI was 30 ± 5. Comorbidity profile was diabetes 75%, dyslipidaemia 44%, hypertension 33%, cigarette smoking 32%, and PD 34%. 76% had a malleable implant (MPP) and 24% an inflatable implant (IPP). 31% had a minor complication and 9% a major complication. 93% had high satisfaction (score ≥4). Patients with any complication had a reduced rate of high satisfaction (97.5% vs 87.7%; P < .001) and even more pronounced with a major complication (96.7% vs 64.2%; P < .001). On MVA, only the absence of a major complication was a significant predictor of high satisfaction (OR 20, 95% CI 9-50, P < .001). CONCLUSION: A high percentage of men are satisfied after penile implant surgery. Only the presence of a major complication is linked to a lower likelihood of achieving high satisfaction. Habous M, Tal R, Tealab A, et al. Predictors of Satisfaction in Men After Penile Implant Surgery. J Sex Med 2018;15:1180-1186.

Clomiphene citrate and human chorionic gonadotropin are both effective in restoring testosterone in hypogonadism: a short-course randomized study.

OBJECTIVES: To compare serum testosterone response and symptom improvement in men with hypogonadism in response to treatment with clomiphene citrate (CC), human chorionic gonadotropin (hCG), or a combination of both therapies. PATIENTS AND METHODS: A total of 282 men with hypogonadism, wishing to preserve their fertility, were randomized to one of three treatment arms: CC 50 mg (n = 95); 5000 IU hCG injections twice weekly (n = 94); or a combination of both therapies (CC + hCG; n = 94). All participants had complete medical history and had undergone thorough physical examination, including body mass index (BMI) assessment. Laboratory tests included serum total testosterone and glycated haemoglobin (HbA1c) measurements. Quantitative Androgen Deficiency in the Aging Male (qADAM) questionnaire scores were also recorded. Morning samples of total serum testosterone levels were assessed at three time points: baseline, 1 and 3 months. RESULTS: Testosterone levels increased at 1 and 3 months in all three groups. The mean baseline testosterone level was 2.31 ± 0.66 nmol/L, BMI was 30.8 ± 6.2 kg/m2 , and qADAM score was 20.5 ± 3.8. Testosterone levels increased in all groups at all time points, with a final mean value of 5.17 ± 1.77 nmol/L (223% increase) with no statistically significant difference among the groups. qADAM scores had increased in all groups at 1 month (CC group: 6.36; hCG group: 5.08; CC + hCG group: 7.26) and at 3 months (CC group: 12.73; hCG group: 11.82; CC + hCG group: 15.13) with a significant difference in intergroup analysis for the CC + hCG group compared with the other two groups (P < 0.01). CONCLUSIONS: All three treatments were equally effective in restoring testosterone levels. Single-agent CC is simple, cheap and may be used as treatment for hypogonadism when maintenance of fertility is desired. This approach seems to be as effective as either hCG alone or a combination of hCG and CC.

Malleable Penile Implant Is an Effective Therapeutic Option in Men With Peyronie's Disease and Erectile Dysfunction.

BACKGROUND: The inflatable penile prosthesis (IPP) is typically the preferred implant for Peyronie's disease (PD) and malleable penile prostheses (MPPs) have been discouraged. AIMS: To evaluate the effectiveness and patient satisfaction of the MPP vs IPP in patients with PD. METHODS: Men with PD and erectile dysfunction who elected for penile implant surgery constituted the study population. Preoperatively, demographic and comorbidity parameters were recorded. Curvature was measured with a goniometer at maximum rigidity after intracavernosal injection of a vasoactive agent. Postoperatively, overall satisfaction was measured at 3, 6, 12, and 24 months on 5-point Likert scale from 1 (dissatisfied) to 5 (very satisfied). RESULTS: 166 men with a mean age of 59 ± 10 years were analyzed. The mean preoperative curvature in the entire cohort was 65° (range = 30-130°). 94% of patients with MPP had total resolution of their curvature at the end of the operation, whereas 8 patients (6%) had residual curvature (25-40°). In the IPP group 25 of 30 (83.3%) had a straight penis at the end of surgery, whereas 5 of 30 (16.7%) had residual curvature, with the mean magnitude being 33° in the MPP group and 30° in the IPP group. 86% of all patients had diabetes. There were no differences between the 2 implant groups in age, hemoglobin A1c, body mass index, or smoking status. The mean patient satisfaction was 4.42 ± 0.70 (range = 2-5) and there was no difference between the 2 groups. The mean follow-up period was 23.4 months (range = 6-29 months). CONCLUSION: We found that the MPP is as effective as the IPP in curvature correction in patients with PD, with similar patient satisfaction for the 2 groups. Habous M, Farag M, Tealab A, et al. Malleable Penile Implant Is an Effective Therapeutic Option in Men With Peyronie's Disease and Erectile Dysfunction. Sex Med 2018;6:24-29.

Defining a glycated haemoglobin (HbA1c) level that predicts increased risk of penile implant infection.

OBJECTIVES: To re-evaluate the role of diabetes mellitus (DM) as a risk factor for penile implant infection by exploring the association between glycated haemoglobin (HbA1c) levels and penile implant infection rates and to define a threshold value that predicts implant infection. PATIENTS AND METHODS: We conducted a multicentre prospective study including all patients undergoing penile implant surgery between 2009 and 2015. Preoperative, perioperative and postoperative management were identical for the entire cohort. Univariate analysis was performed to define predictors of implant infection. The HbA1c levels were analysed as continuous variables and sequential analysis was conducted using 0.5% increments to define a threshold level predicting implant infection. Multivariable analysis was performed with the following factors entered in the model: DM, HbA1C level, patient age, implant type, number of vascular risk factors (VRFs), presence of Peyronie's disease (PD), body mass index (BMI), and surgeon volume. A receiver operating characteristic (ROC) curve was generated to define the optimal HbA1C threshold for infection prediction. RESULTS: In all, 902 implant procedures were performed over the study period. The mean patient age was 56.6 years. The mean HbA1c level was 8.0%, with 81% of men having a HbA1c level of >6%. In all, 685 (76%) implants were malleable and 217 (24%) were inflatable devices; 302 (33.5%) patients also had a diagnosis of PD. The overall infection rate was 8.9% (80/902). Patients who had implant infection had significantly higher mean HbA1c levels, 9.5% vs 7.8% (P < 0.001). Grouping the cases by HbA1c level, we found infection rates were: 1.3% with HbA1c level of <6.5%, 1.5% for 6.5-7.5%, 6.5% for 7.6-8.5%, 14.7% for 8.6-9.5%, 22.4% for >9.5% (P < 0.001). Patient age, implant type, and number of VRFs were not predictive. Predictors defined on multivariable analysis were: PD, high BMI, and high HbA1c level, whilst a high-volume surgeon had a protective effect and was associated with a reduced infection risk. Using ROC analysis, we determined that a HbA1c threshold level of 8.5% predicted infection with a sensitivity of 80% and a specificity of 65%. CONCLUSION: Uncontrolled DM is associated with increased risk of infection after penile implant surgery. The risk is directly related to the HbA1c level. A threshold HbA1c level of 8.5% is suggested for clinical use to identify patients at increased infection risk.

Outcomes of variation in technique and variation in accuracy of measurement in penile length measurement.

Accurate data regarding the size of the erect penis is of great importance to several disciplines working with male patients, but little data exists on the best technique to measure penile length. While some previous small studies have suggested good correlation between stretched penile length, others have shown significant variability. Penile girth has been less well studied, and little data exist on the possible errors induced by differing observers and different techniques. Much of the published data report penile length measured from the penopubic skin junction-to-glans tip (STT) rather than pubic bone-to-tip (BTT). We wished to assess the accuracy of different techniques of penile measurements with multiple observers. Men who achieved full erection using dynamic penile Doppler ultrasound for the diagnosis of sexual dysfunction or a desire for objective penile measurement were included in the study. Exclusion criteria were penile scarring, curvature, or congenital abnormality. In each case, the penis was measured by one of the seven andrology specialists in a private air-conditioned (21 °C) environment. Each patient had three parameters measured: circumference (girth) of the penile shaft, length from suprapubic skin-to-distal glans (STT), and pubis-to-distal glans (BTT). The three measurements were recorded in the stretched flaccid state, and the same three measurements were then repeated in the fully erect state, following induction of full erection with intracavernosal injection. We analyzed the accuracy of each flaccid measurement using the erect measurements as a reference, for the overall patient population and for each observer. In total, 201 adult men (mean age 49.4 years) were included in this study. Assessing the penis in the stretched and flaccid state gave a mean underestimate of the erect measurement of ~20% (STT length 23.39%, BTT length 19.86%, and circumference 21.38%). In this large, multicenter, multi-observer study of penis size, flaccid measurements were only moderately accurate in predicting erect size. They were also significantly observer dependent. Measuring penile length from pubic bone to tip of glans is more accurate and reliable, the discrepancy being most notable in overweight patients.

Association of the modified frailty index with adverse outcomes after penile prosthesis implantation.

OBJECTIVES: To investigate frailty as a predictor of surgical outcome in elderly patients undergoing penile prosthesis implantation. MATERIAL AND METHODS: A total of 54 elderly patients, above 60 years of age, underwent penile prosthesis implantation between 2012 and 2014. Their data were collected and retrospectively analyzed. A modified frailty index (mFI) was calculated for each patient based on 11 risk factors from the Canadian Study of Health and Aging Frailty Index. The 1-year adverse outcomes were correlated with mFI, patients' and procedure's risk factors. RESULTS: Mean age was 64.9 ± 5.2 years. No mortality was reported in our patients, however, one-year adverse outcomes were encountered in 43 (79.6%) patients. Among all studied variables, the 1-year adverse outcomes was not significantly association with mFI, but with preoperative glycosylated hemoglobin A1c (HbA1c) (p = 0.031) and associated Peyronie's disease (PD) (p = 0.000). HbA1c, dyslipidemia, hypertension, PD and duration of the procedure were predictive of infection complications (p < 0.05). Only PD and HbA1c sustained an independent significant impact. CONCLUSIONS: mFI is not a predictive of post-penile prosthesis implantation adverse outcomes in elderly patients with impotence. Degree of diabetic control and association with PD was associated with the 1-year adverse outcomes and infection complications.

Glans Necrosis Following Penile Prosthesis Implantation: Prevention and Treatment Suggestions.

OBJECTIVE: To examine possible etiology and treatment outcomes in 21 patients with glans necrosis following penile prosthesis implantation. METHODS: Glans necrosis typically presented with a dusky glans on the first postoperative day following prosthesis implantation. RESULTS: The blood supply to the glans penis consists of the dorsal arteries and the terminal branches of the spongiosal arteries. Using the cohort in our study, we compiled preoperative comorbidities and adjunctive surgical maneuvers that might compromise glans vascularity, leading to glans necrosis. Preoperative risk factors were arteriosclerotic cardiovascular disease (90%), diabetes mellitus (81%), smoking (81%), previous prosthesis explantation (57%), and previous radiation therapy (48%). The most prevalent intraoperative and postoperative factor was subcoronal incision for reasons as simple as coincident circumcision or as complex as for penile degloving (86%). Other factors detected were penile wrapping with an occlusive elastic bandage (62%), use of a sliding technique for penile lengthening (33%), and coincident distal urethral injury repair (29%). Seventeen patients (81%) managed expectantly with preservation of implanted prosthesis sustained significant glandular loss. Four patients managed with immediate prosthesis removal healed without sequelae. CONCLUSION: Patients with preoperative risk factors undergoing penile prosthesis implantation should avoid high-risk adjunctive surgical maneuvers. Upon development of signs of glans necrosis postoperatively, in the setting of these high-risk factors, immediate implant removal may prevent subsequent glans necrosis.

Postwash total motile sperm count: should it be included as a standard male infertility work up.

INTRODUCTION: Pregnancy rates after intrauterine insemination (IUI) varies greatly. We aimed to identify pre and post processing semen analysis parameters that may be predictive of successful pregnancy in couples undergoing IUI. MATERIALS AND METHODS: A retrospective study of the records of all couples underwent IUI for a 2 year period at our infertility center. Different characteristics of female subjects, pre and post processing semen parameters and treatment parameters were compared statistically. RESULTS: Thirty-two clinical pregnancies followed 526 IUI cycles in 294 couples, for a clinical pregnancy rate of 6.1% per cycle and a 10.9% per couple. The mean age of the women at IUI was 31.14 ± 6 years (range 19-45 years). Neither maternal age, body mass index, number of mature follicles, maximum day 3 follicle stimulating hormone level, presence or absence of previous children, number of previous miscarriages, nor prewash semen parameters had any impact on pregnancy rate post IUI. Postwash total motile sperm count (TMSC) (p = .027) and number of cycles (p = .042) were independent predictors of successful pregnancy after IUI. CONCLUSIONS: A postwash TMSC of 5 million sperm or more is significantly associated with a high pregnancy rate. After ruling out medically or surgically correctable male factors that may contribute to infertility, we recommend including a pretreatment sperm processing during routine male fertility work up for proper patient counseling and direction to the suitable assisted reproduction technique.

Gender differences in perception of psychosocial distress and coping mechanisms among infertile men and women in Saudi Arabia.

The objective of the study was to evaluate the differences in psychosocial distress and coping mechanisms among infertile men and women in Saudi Arabia (SA). We performed a cross-sectional study of infertile patients (206 women and 200 men) attending infertility clinics in three referral hospitals in Riyadh, SA. A semi-structured questionnaire was developed to assess socio-demographic, clinical and psychosocial variables. Infertility-related psychosocial pressures were reported in 79 (39.7%) male and 97 (47.3%) female participants (p = 0.123). Males suffered more from intrusive questions and pressure to conceive, remarry or get divorced, while females were stressed more from psychological and emotional exhaustion, marital discord, attitudes of mothers-in-law or society, and persistent desire by the husband to have children. To cope with infertility, females engaged more in religious activities (p < 0.001) and spoke more to someone regarding their problems (p < 0.001). To solve their infertility problems, 50% tried to find solutions via the internet, and 38.5% of males and 51% of females reported using alternative medicines (p = 0.012). The patients with infertility in SA face multiple psychosocial stressors related to their infertility, and cope differently based on the gender and culture-specific knowledge of infertility. The female participants were significantly more affected from psychosocial stressors and the persistent desire by their spouse to have children.

Noninvasive treatments for iatrogenic priapism: Do they really work? A prospective multicenter study.

OBJECTIVES: Intracorporeal injections (ICIs) of vasoactive substances during penile Doppler ultrasound (PDU) are a common investigation for erectile dysfunction (ED) diagnosis. ICI can be responsible of priapism, a pathological condition of prolonged penile erection not related to sexual stimulation. The aim of our study is to investigate the effectiveness of physical exercise and medical treatment as noninvasive therapy to restore detumescence in prolonged erections after ICI. MATERIALS AND METHODS: Data were prospectively collected on men undergoing PDU in three urological centers. Three hundred and sixty-nine patients underwent PDU for the investigation of ED. All the participants received an ICI of quadrimix; prostaglandine E1, papaverine, phentolamine, and atropine. The data of the patients have been analyzed to record their comorbidities, results of PDU, and the complications encountered. RESULTS: Fifty-three patients (14.4%) developed prolonged erections. Physical exercise alone was successful in reversing prolonged erection within 30 min in 21 (39.6%) patients. Out of the remaining 32 patients, oral salbutamol induced detumescence in 18 (34%) within the observation period of 60 min. Nonresponders were managed successfully with aspiration and irrigation of corpora with saline (11 patients, 20.75%) or with Phenylephrine (three patients, 5.66%). CONCLUSIONS: Physical exercise and oral salbutamol are safe and effective in restoring detumescence of pharmacologically-induced priapism. Noninvasive therapy may save a significant number of these patients an invasive treatment.

Conservative Therapy is an Effective Option in Patients With Localized Infection After Penile Implant Surgery.

INTRODUCTION: Traditionally, penile implant (PI) infections have been managed by removal with immediate or delayed replacement. Recently, interest has been focused on conservative therapy (CT) using antibiotic therapy. AIM: To investigate the success rate and predictive factors affecting the outcome of CT in PI infection patients. METHODS: Patients diagnosed with early, localized PI infection were considered candidates for CT. Exclusion criteria included temperature >37.5°C, WBC >13,000/µL, and appearance of any sign of sepsis. In patients with purulent drainage, culture swabs were taken and an antibiotic was chosen based on sensitivity results. Oral antibiotics were used until the local infection was completely resolved. Patients were evaluated weekly during this process. RESULTS: Thirty-seven patients were retrospectively reviewed and constituted the study population. Mean age was 58.1 (range 37-85; SD 9.9) years. All were diabetic. Mean BMI was 31.8 (range 24-47; SD 5.0). PI was malleable in 33 cases and inflatable in 4 cases. Culture results (n = 19) included Staphylococcus epidermidis (42 %), pseudomonas (21%), Escherichia coli (21%), and S aureus (16%). Four of 37 patients needed the PI removed due to CT failure and onset of systemic symptoms, at a mean time-point of 75 ± 1.8 days after CT commencement. In men who were cured, mean time to complete healing was 49 (range 29-97; SD 15.8) days. Two of 37 patients (5%) had PI removal because of persistent penile pain despite complete wound healing, at a mean time point of 128 ± 2.5 days after CT commencement. All men managed conservatively resumed sexual intercourse. CONCLUSION: CT of localized PI infection appears to be a viable option for such patients, with the majority of patients retaining their implant and resuming sexual activity.