Effect of bulbospongiosus muscle injection with botulinum-A toxin for treatment of lifelong premature ejaculation; a randomized controlled trial.

This study aimed at assessing a new line of treatment for lifelong premature ejaculation which is botulinum-A toxin injection into the bulbospongiosus muscle. Sixty patients with lifelong premature ejaculation were independently randomized into 2 groups; group I, 100 U botulinum-A toxin at 10 U/ml saline was injected with ultrasound guidance into the bulbospongiosus muscle and group II which was injected with similar volume of saline. The primary outcome was to compare both groups for changes in the Premature Ejaculation Profile (PEP), Intravaginal Ejaculatory Latency Time (IELT) and partner's satisfaction at 1, 3 and 6 months after intervention. The second outcome was to compare the adverse events in both groups. Fifty-seven patients completed the study. In group I, the mean PEP increased significantly at 1- (P = 0.02) and 3- months (P = 0.04) with insignificant increase at 6-month (P = 0.6) of follow-up. Also, no significant changes had been noted in IELT or partner's satisfaction scores throughout the study duration (P > 0.05). In group II, no significant changes had been noted in the PEP, IELT and partner's satisfaction scores throughout the study duration (P > 0.05). There were insignificant differences in the changes in the mean PEP (P = 0.7, 0.6 and 0.4), IELT (P = 0.6,0.6 and 0.5) and partner's satisfaction scores (P = 0.5,0.7 and 0.3) in comparison to the baseline values at 1-, 3- and 6- months, respectively between both groups. Adverse events were observed in only 3 patients (5.3%). In group I, mild erectile dysfunction and post micturition dribbling were reported in one patient each. Where in group II, one patient reported bleeding per urethra (P = 0.5). To conclude, injection of botulinum-A toxin into bulbospongiosus seems to be safe but failed to prove clinical efficacy for treatment of lifelong premature ejaculation when compared to placebo.

Evaluation of the sexual function of female partners of men with erectile dysfunction receiving different treatment modalities: An observational study.

OBJECTIVE: To evaluate sexual functions of patients with erectile dysfunction (ED) and their female partners. METHODS: A total of 90 consecutive ED patients who received different ED therapies and their partners and 90 consecutive controls and their partners were divided into four groups. All participants were evaluated by the 15-item international index of erectile function and the Arabic version of female sexual function index (Ar-FSFI). RESULTS: All ED patients who received sildenafil demonstrated significant improvements of their erectile function compared to baseline. Their partners did not demonstrate improvements in frequency of pain during vaginal penetration (3.86 ± 0.58, 3.93 ± 0.45, p = 0.477), confidence of becoming aroused (3.86 ± 0.58, 3.93 ± 0.45, p 0.477), frequency of satisfaction with arousal (3.07 ± 0.37, 3.03 ± 0.49, p 0.712), and maintenance of lubrication (4.37 ± 0.49, 4.23 ± 0.73, p 0.354). All ED patients who received quadmix demonstrated significant improvements of their erectile function compared to baseline. Their partners did not demonstrate improvements in desire level (2.6 ± 0.67, 2.63 ± 0.85, p = 0.869) and lubrication maintenance (3.53 ± 0.82, 3.47 ± 0.82, p = 0.423). Finally, All ED patients who underwent semi rigid penile implant demonstrated significant improvements of their erectile function compared to baseline. Their female partners demonstrated significant improvements in all items of FSFI-19 compared to baseline except the frequency of pain during vaginal penetration (3.86 ± 0.58, 3.93 ± 0.45, p = 0.477), confidence of becoming aroused (3.86 ± 0.58, 3.93 ± 0.45, p = 0.477), frequency of satisfaction with arousal (3.07 ± 0.37, 3.03 ± 0.49, p = 0.712), and maintenance of lubrication (4.37 ± 0.49, 4.23 ± 0.73, p = 0.354). CONCLUSIONS: Sexual functions of ED males significantly improved after ED therapies. Nevertheless, some sexual functions of their partners were not positively impacted.

Safety and efficacy of botulinum neurotoxin in the treatment of erectile dysfunction refractory to phosphodiesterase inhibitors: Results of a randomized controlled trial.

BACKGROUND: There has been recent interest in the use of botulinum neurotoxin (BoNT) in the field of Andrology, whereby it has been investigated in the treatment of penile retraction and premature ejaculation. OBJECTIVES: To evaluate the safety and efficacy of intracavernosal BoNT-A injection in the treatment of patients with erectile dysfunction (ED) refractory to oral phosphodiesterase inhibitors (PDE5Is). PATIENTS AND METHODS: A double-blind randomized placebo-controlled prospective comparative study conducted at one center and involved 70 patients with ED refractory to PDE5Is. At baseline, the following data were collected: erection hardness score (EHS), peak systolic velocity (PSV), end diastolic velocity (EDV), sexual health inventory for men (SHIM), and the sexual encounter profile 2&3 (SEP-2&3) questionnaires. Treatment group (n = 35) received a single ICI of 100 units of BoNT-A in 2 ml of saline and control group (n = 35) received a single ICI of 2 ml of saline. EHS, PSV, and EDV were assessed at 2 weeks post treatment. SHIM, SEP-2, SEP-3, and global assessment questionnaire (GAQ-Q1&Q2) were completed at 2-, 6-, and 12-weeks post treatment. RESULTS: Two weeks post treatment, the treatment group showed a statistically significant improvement in the mean EHS, PSV, EDV, and GAQ-Q1 positive responders (p < 0.001) compared to the control group. At 6- and 12-weeks post treatment, the treatment group showed a statistically significant improvement in the SHIM scores, SEP-2, and GAQ-Q1&Q2 positive responders compared to the control group. At 6 weeks, where there was a 5-point improvement in the mean SHIM score of the treatment group (10±5.9 from 5.4±1.7 at baseline) versus no improvement in the placebo group, 18 patients in the treatment group (53%) were able to have an erection hard enough for vaginal penetration versus only one patient in the control group. CONCLUSION: BoNT-A is safe and effective as a potential treatment for ED refractory to PDE5I therapy.

An Open Prospective Study on Whether Intracytoplasmic Morphologically Selected Sperm Injection (IMSI) Offers a Better Outcome Than Conventional Intracytoplasmic Sperm Injection (ICSI).

Objective To differentiate the in vitro fertilization (IVF) outcomes between the two procedures, intracytoplasmic morphologically selected sperm injection (IMSI) and intracytoplasmic sperm injection (ICSI) in terms of relation to chemical pregnancy percentage, clinical pregnancy, live birth, miscarriage, and fertilization rates, respectively. Patients and methods This Open Prospective clinical trial was conducted during the period between Jan 2016 and Dec 2017 at one IVF unit. A total of 446 ICSI cycles and 79 IMSI cycles were conducted. Females were divided into four subgroups according to age. Results The study involved 525 couples (446 first trial ICSI cycles) and (79 first trial IMSI cycles). ICSI was statistically better than the IMSI in relation to the chemical pregnancy, clinical pregnancy (CPR), live birth (LBR), and fertilization rates, respectively (p < 0.05). However, there were no statistically significant differences between the ICSI and IMSI in relation to the miscarriage rate. There were statistically significant differences favoring ICSI in all subgroups except 35-37, in relation to chemical pregnancy; and in the 38-40 and >40 subgroups in relation to CPR. There were no statistically significant differences in these subgroups regarding the live birth, miscarriage, or fertilization rates. Conclusions This study showed that IMSI is not superior to conventional ICSI at the first attempt. Based on the findings in this study, we would not advise couples to choose IMSI at their first treatment attempt.

Urethral instillation of chlorhexidine gel is an effective method of sterilisation.

Objective: To examine the effectiveness of preoperative urethral sterilisation with chlorhexidine gel in rendering the urethra as sterile as the skin of the genital area, with the skin sterilised as per the International Society for Sexual Medicine guidelines for penile prosthesis implantation. Patients and methods: A total of 111 male patients undergoing sterile andrological surgical procedures were divided into a control group (N = 61) and a chlorhexidine gel group (N = 50). Patients in the chlorhexidine group received urethral instillation with 6 mL of chlorhexidine preoperatively and on table. Patients from both groups received on-table skin preparation using povidone iodine and chlorhexidine povidone iodine. At the end of surgery, swabs were obtained from urethra and the penile skin. Skin and urethral swabs were compared for bacterial colonisation by culture and sensitivity. Results: Of the 111 patients, 16 had urethral colonisation and 10 had skin contamination, and they were all in the control group. The most common organism detected in both the urethral and skin samples was coagulase-negative Staphylococcus aureus. Urethral colonisation was significantly greater in the control group compared to the chlorhexidine group, at 16/61 vs 0/50 (P = 0.001). Similarly, skin colonisation was significantly greater in the control group compared to the chlorhexidine group, at 10/61 vs 0/50, (P = 0.002). Conclusion: Chlorhexidine gel is a powerful sterilising agent that will render the urethra sterile.

Male Sexual Dysfunctions in the Infertile Couple-Recommendations From the European Society of Sexual Medicine (ESSM).

INTRODUCTION: Sexual dysfunctions (SDs) have been frequently reported among male partners of infertile couples due to psychogenic, relational and/or organic issues related with the inability to conceive. Likewise, male infertility (MI) could be a consequence of sexual dysfunctions. AIM: To review the evidence on the prevalence and treatment of male SDs in men of infertile couples and provide clinical recommendations on behalf of the European Society of Sexual Medicine (ESSM). METHODS: The MEDLINE database was searched in September 2019 for randomized clinical trials (RCTs), meta-analyses and open-label prospective or retrospective studies investigating the presence of erectile dysfunction (ED) and/or ejaculatory dysfunctions (EjDs) and/or low sexual desire (LSD) in conjunction with infertility. MAIN OUTCOME MEASURE: The panel provided statements on: (i) Prevalence and association between SDs and MI; (ii) Treatment of male SDs in men of infertile couples. RESULTS: ED has been reported in 9% to 62% of male partners of infertile couples, with severe impairment observed in only 1% to 3% of ED cases. Moreover, worse semen parameters have been associated with greater ED severity. Phosphodiesterase type 5 inhibitors (PDE5is) can be safely used to treat ED among patients seeking fatherhood. Male partners of infertile couples are at higher risk of premature ejaculation (PE). Retrograde ejaculation (RE) and anejaculation are a cause of MI and can be managed with electroejaculation (EEJ) or penile vibratory stimulation (PVS) or, alternatively, with oral treatments, however the latter with limited documented success. Low sexual desire has been reported by one third of men of infertile couples. CONCLUSION: ED could significantly affect male partners of infertile couple; PDE5is should be suggested to ensure an effective and satisfactory sexual relationship of the couple. Anejaculation and RE should be considered as a possible cause of MI and treated accordingly. Low sexual desire is frequently reported among men of infertile couple and could be a symptom of other systemic conditions or psychological distress. Capogrosso P, Jensen CFS, Rastrelli G, et al. Male Sexual Dysfunctions in the Infertile Couple-Recommendations From the European Society of Sexual Medicine (ESSM). J Sex Med 2021;9:100377.

How Successful Is Surgical Sperm Retrieval in Klinefelter Syndrome?

Klinefelter Syndrome (KS) is characterized by the presence of an extra X chromosome. It was first diagnosed in 1942 in a group of azoospermic men. KS is the most common chromosomal abnormality encountered in infertile men and accounts for more than 10% of the causes of azoospermia. Men who are azoospermic may still father children via testicular sperm extraction followed by intracytoplasmic sperm injection (ICSI). This review article summarizes the success rates of the available techniques for surgical sperm retrieval (SSR) in KS including conventional testicular sperm extraction (cTESE) and micro testicular sperm extraction (mTESE), as well as the risks of these procedures for future fertility. The evidence indicates that the SSR rate is as successful in non-mosaic men with KS as those with normal karyotypes, with retrieval rates of up to 55% reported. The influence of different factors that affect the chances of a successful outcome are discussed. In particular, the impact of aneuploidy rate, physical characteristics, co-morbidities, reproductive endocrine balance and the use of different hormone management therapies are highlighted. Evidence is presented to suggest that the single most significant determinant for successful SSR is the age of the patient. The success of SSR is also influenced by surgical technique and operative time, as well as the skills of the surgeon and embryology team. Rescue mTESE may be used successfully following failed TESE in KS patients in combination with hormone stimulation.

The Impact and Management of Gynaecomastia in Klinefelter Syndrome.

Gynecomastia is defined as a palpable enlargement of the male breast, secondary to an increase in the glandular and stromal breast tissue. Gynecomastia is encountered in up to 80% of Klinefelter syndrome cases. The pathophysiology involves testosterone/estrogen imbalance. This review article will further explore the pathophysiology of gynecomastia along with the different lines of management.

Dorsal phalloplasty accompanying penile prosthesis implantation minimizes penile shortening and improves patient satisfaction.

Many patients complain of shortened length following penile prosthesis implantation. Dorsal phalloplasty (DP) can accompany prosthesis placement to mitigate this complaint by resulting in more visible penis outside the plane of the patient's body. DP is done through the same incision. A nonabsorbable suture approximates the under surface of the skin where the penis meets the pubis to the periosteum of the pubic bone. This adjunctive procedure results in more visible proximal penile shaft. We compared penile visible length (pubic skin surface to tip) in patients who had the adjunctive procedure with prosthesis insertion to patients who had only the penile prosthesis. Totally, 66 patients had DP and 60 did not. All patients were operated through a penoscrotal incision. The tacking suture of # 5 nonabsorbable braided polyester was passed through the pubic periosteum then into the subcutaneous tissue and dermis of the under surface of the pubic skin. The suture was tied after prosthesis insertion. Efficacy of DP was evaluated by measured gain in erect visible length in the DP group, maintenance of that length gain until final follow up at 3 years, as well as by the difference in subjective evaluation criteria between both groups. The DP group had a 23% increase in visible length compared to pretacking (p < 0.0001) that was durable to 36 months. Subjectively, 80% of patients in the prosthesis alone group reported a shorter penis in contrast to 6.1% in the DP group. The DP group reported 28.4% higher satisfaction with length, compared to the control group (p < 0.0001). In conclusion, DP accompanying prosthesis insertion improved visible length, minimized the impression of shortening, and enhanced satisfaction with length.

An analysis of the frequency of Y-chromosome microdeletions and the determination of a threshold sperm concentration for genetic testing in infertile men.

OBJECTIVE: To describe the prevalence of Y-chromosome microdeletions in a multi-ethnic urban population in London, UK. To also determine predictive factors and a clinical threshold for genetic testing in men with Y chromosome microdeletions. PATIENTS AND METHODS: A retrospective cohort study of 1473 men that were referred to a tertiary Andrology centre with male factor infertility between July 2004 and December 2016. All had a genetic evaluation, hormonal profile and 2 abnormal semen analyses. Those with abnormal examination findings also had targeted imaging performed. RESULTS: The prevalence of microdeletions was 4% (n = 58) in this study. These microdeletions were partitioned into the following regions: Azoospermia factors (AZF); AZFc (75%), AZFb+c (13.8%), AZFb (6.9%), AZFa (1.7%), and partial AZFa (1.7%). A high follicle-stimulating hormone level (P < 0.001) and a low sperm concentration (P < 0.05) were both found to be significant predictors for the identification of a microdeletion. Testosterone level, luteinising hormone level and testicular volume did not predict the presence of a microdeletion. None of the men with an AZF microdeletion had a sperm concentration of >0.5 million/mL. Lowering the sperm concentration threshold to this level retained the high sensitivity (100%) and increased the specificity (31%). This would produce significant cost savings when compared to the European Academy of Andrology/European Molecular Genetics Quality Network and European Association of Urology guidelines. The surgical sperm retrieval (SSR) rate after microdissection testicular sperm extraction was 33.2% in men with AZFc microdeletion. CONCLUSIONS: The prevalence of Y-chromosome microdeletions in infertile men appears to vary between populations and countries. A low sperm concentration was a predictive factor (P < 0.05) for identifying microdeletions in infertile males. A threshold for genetic testing of 0.5 million/mL would increase the specificity and lower the relative cost without adversely affecting the sensitivity. The rate of SSR was lower than that previously described in the literature.

Collagenase clostridium histolyticum: a novel medical treatment for Peyronie's disease.

INTRODUCTION: Peyronie's disease (PD) affects up to 9% of the male population. PD causes scarring of the tunica albuginea of the penis which leads to penile deformity making sexual intercourse difficult or impossible. PD also causes significant psychological, emotional and relationship difficulties for both patient and partner. Up until the licencing of Collagenase clostridium histolyticum (CCH) (Xiapex®, Xiaflex®), surgical correction of the penile deformity was the mainstay of treatment. Many conservative treatment options had been previously tried, however, the safety and efficacy of these options has not been demonstrated in large well-designed clinical trials. Intra-lesional CCH is now the gold standard option for the non-surgical management of PD. It is the first and only treatment approved by the Food and Drug Administration and the European Medicines Agency for PD. In this review article, we will discuss the pharmacology, clinical efficacy, safety and future of CCH intralesional injection. EVIDENCE ACQUISITION: MEDLINE and PubMed search (from 1946). The search terms ("Collagenase Clostridium Histolyticum" OR "Xiapex" OR "Xiaflex") AND "Peyronie's disease" were used. EVIDENCE SYNTHESIS: The safety and efficacy of intra-lesional CCH in the management of PD has been demonstrated in 2 large-scale multicenter, randomized, double-blind placebo-controlled clinical trials; the investigation for Maximal Peyronie's Reduction Efficacy and Safety Studies I and II (IMPRESS I and IMPRESS II). A new study published by our group suggests a new modified shortened protocol that will reduce the cost and duration of treatment without compromising the safety or efficacy of treatment. CONCLUSIONS: CCH is the gold standard non-surgical option in the management of PD. The safety and efficacy of CCH has been demonstrated in large well-designed clinical trials. The new modified protocol, developed by our group, reduces the cost and inconvenience to patients whilst maintaining the efficacy. This will allow more men to benefit and will reduce the number of men undergoing surgical correction for their PD.

Poorly Controlled Homocystinuria: A Rare Cause of Ischemic Priapism?

We report on the 1st case of ischemic priapism secondary to poorly controlled homocystinuria. Homocystinuria is a rare, autosomal recessive, inherited disorder of metabolism that is caused by a deficiency of cystathionine synthase, leading to marked hyperhomocysteinemia. Arterial and/or venous thromboemboli are a major cause of mortality and morbidity in patients with homocystinuria. Untreated patients have a 50% chance of having a vascular event by 30 years of age. Increased homocysteine levels have been reported to upregulate prothrombotic factors and downregulate antithrombotic factors; in particular, increased homocystinuria has been found to downregulate nitric oxide (NO). Mice that are deficient in NO synthase in the cavernosal smooth muscles have a higher incidence of priapism. Decrease in NO synthase causes downregulation of cyclic guanosine monophosphate, phosphodiesterase type 5A, and Rho A/Rho-kinase. Because persistently increased homocysteine also downregulates NO, a similar mechanism could be proposed for priapism secondary to homocystinuria. In patients presenting with priapism, specific features of homocystinuria should be sought; in selected patients, screening with plasma total homocysteine might be appropriate. Ischemic priapism secondary to homocystinuria appears to respond well to the standard treatment options of aspiration, intracavernosal injection with phenylephrine, and, if required, a shunting procedure. Johnson M, Murphy E, Raheem A, Ralph D. Poorly Controlled Homocystinuria: A Rare Cause of Ischemic Priapism? Sex Med 2018;6:171-173.

Abnormal deep dorsal vein resulting in veno-occlusive erectile dysfunction.

A 59-year-old man with a 6-year history of erectile dysfunction presented to the andrology outpatient clinic. Multimodality assessment with ultrasound, MRI venography and fluoroscopic venography demonstrated an aberrant emissary vein arising from the corporal bodies causing venogenic erectile dysfunction. Selective coil embolisation of the collateral vein resulted in an almost immediate and sustained improvement in his erections.

Botulinum Neurotoxin and Its Potential Role in the Treatment of Erectile Dysfunction.

INTRODUCTION: Botulinum toxin type A (BoNT-A) has been used to treat several striated and smooth muscle disorders. During the past year, human and animal studies conducted in Egypt and Canada by two different groups of investigators have suggested a possible role for the intracavernosal injection of BoNT-A in the treatment of erectile dysfunction (ED). AIM: To discuss BoNT-A and its current medical uses, the rationale for its new potential use in the treatment of ED, and the available evidence and concerns. METHODS: A literature search was conducted. This review was based on the available studies presented at the European Society for Sexual Medicine, Sexual Medicine Society of North America, and International Society for Sexual Medicine meetings in 2016 by the two groups. MAIN OUTCOME MEASURES: Sinusoidal diameter; penile color Doppler study; Erection Hardness Score; Sexual Health Inventory for Men questionnaire; and Sexual Encounter Profile questions 2 and 3. RESULTS: Two human studies conducted by the authors and two animal studies (one from the authors' group and one from Canada) were reviewed. These seemed to suggest generally favorable outcomes with the use of BoNT-A in the treatment of ED. CONCLUSION: BoNT-A could be a potential therapy for ED. In addition to the findings of the three pilot studies, larger multicenter trials need to be conducted to further explore the true therapeutic efficacy and clinical safety of BoNT-A in the treatment of ED. Ghanem H, Raheem AA, AbdelRahman IFS, et al. Botulinum Neurotoxin and Its Potential Role in the Treatment of Erectile Dysfunction. Sex Med Rev 2018;6:135-142.

Treatment of Peyronie's Disease With Collagenase Clostridium histolyticum and Vacuum Therapy: A Randomized, Open-Label Pilot Study.

BACKGROUND: Collagenase Clostridium histolyticum (CCH) is indicated for the treatment of penile curvature in adult men with Peyronie's disease (PD) with palpable plaque and curvature deformity of at least 30° at the start of therapy. AIM: To evaluate the efficacy and safety of CCH plus vacuum-pump therapy with and without penile modeling for the management of PD. METHODS: Adult men with PD and penile curvature of at least 30° were randomly assigned to receive CCH 0.58 mg plus vacuum therapy alone (n = 15) or with penile plaque modeling (n = 15). Patients received no more than four treatment cycles (cycle = ∼6-week duration), each consisting of two intralesional injections of CCH administered 24 to 72 hours apart. Vacuum therapy was applied twice daily from 14 days after the second injection of each cycle until the following cycle. Modeling was performed 24 to 72 hours after the second injection of each cycle. OUTCOMES: The primary end point was change in penile curvature from baseline to week 36; additional end points included changes in Peyronie's Disease Questionnaire (PDQ) domain scores, composite response (≥20% decrease in penile curvature and decrease in PDQ bother score ≥ 1 point), and global response (small but important, moderate, or much improvement in the Global Assessment of PD). RESULTS: At week 36, improvement in penile curvature from baseline was similar in the two groups (mean change from baseline = -23.7° [SD = 10.9] for CCH + vacuum + modeling and -23.3° [SD = 7.2] for CCH + vacuum; between-group difference = -0.3°, 95% CI = -7.3 to 6.6). Improvements in most PDQ domains, including bother, were observed from baseline to week 36 in the two groups. Most patients were composite (66.7% and 84.6% with CCH + vacuum + modeling and CCH + vacuum, respectively) and global (86.7% and 92.3%, respectively) responders. The most common adverse events were penile contusion, penile swelling, and penile pain. CLINICAL IMPLICATIONS: Vacuum-pump therapy administered alone or in combination with modeling after CCH treatment could improve PD symptoms. STRENGTHS AND LIMITATIONS: This was a pilot study with a small sample and limited follow-up duration. CONCLUSION: CCH and vacuum-pump therapy (alone or combined with modeling) could be an appropriate consideration for men with PD and warrants further investigation. Ralph DJ, Abdel Raheem A, Liu G. Treatment of Peyronie's Disease With Collagenase Clostridium histolyticum and Vacuum Therapy: A Randomized, Open-Label Pilot Study. J Sex Med 2017;14:1430-1437.

Collagenase Clostridium histolyticum in the Treatment of Peyronie's Disease-A Review of the Literature and a New Modified Protocol.

INTRODUCTION: Peyronie's disease (PD) is a common condition that results in penile deformity, which makes sexual intercourse difficult or impossible, and causes psychological, emotional, and relationship difficulties for the man affected and his partner. Collagenase Clostridium histolyticum (CCH; Xiapex, Xiaflex) is the first licensed non-surgical treatment option for PD. The safety and efficacy have been demonstrated in two large phase III randomized controlled trials (IMPRESS I and IMPRESS II). AIM: To review the safety and efficacy of CCH and to introduce a new shortened modified protocol for CCH that was developed by the authors to decrease the cost and duration of treatment. METHODS: A review of the medical literature on CCH for inclusion in this review was obtained by searching the PubMed (from 1946) and Medline (from 1946) medical databases and from the screening of relevant bibliographies. The search terms Xiapex, Xiaflex, collagenase Clostridial histolyticum, and Peyronie's disease were used. Clinical trials in men with PD and scientific articles relating to pharmacologic data were included in the review. When possible, large, randomized, and well-designed trials were selected. MAIN OUTCOME MEASURES: Changes in the angle of penile curvature and in the Peyronie's Disease Questionnaire domains. RESULTS: The clinical trials demonstrate the safety and efficacy of CCH in the treatment of PD. The new modified protocol developed by the authors is as safe and effective as the protocol used in the clinical trials. CONCLUSION: CCH is the first licensed non-surgical treatment for PD. Its safety and efficacy have been demonstrated in large well-designed clinical trials. The new shortened modified protocol decreases the cost and duration of the treatment without compromising the safety and efficacy of the drug. This alteration will allow more patients to benefit from CCH. Abdel Raheem A, Johnson M, Abdel-Raheem T, et al. Collagenase Clostridium histolyticum in the Treatment of Peyronie's Disease-A Review of the Literature and a New Modified Protocol. Sex Med Rev 2017;5:529-535.

Sleep disorders in patients with erectile dysfunction.

OBJECTIVE: To assess the prevalence of obstructive sleep apnoea (OSA) in men presenting with erectile dysfunction (ED) at a single centre. PATIENTS AND METHODS: All men attending a specialised andrology outpatient department with a new diagnosis of ED were included in this prospective study. All patients completed three questionnaires: the International Index of Erectile Function (IIEF) and two sleep questionnaires [the Obstructive Sleep Apnoea Screening questionnaire and the Insomnia Severity Index (ISI)]. Their ED management was subsequently undertaken in accordance with local and European guidelines. An OSA diagnosis was made based on a score of ≥3 on the Obstructive Sleep Apnoea Screening questionnaire and those patients were referred for specialist management. RESULTS: Between February and September 2016, 129 patients with ED completed the study questionnaires. In all, 71 patients (55%) had a score of ≥3 on the Obstructive Sleep Apnoea Screening questionnaire, indicating a need for specialist sleep referral. Men who scored ≥3 on the Obstructive Sleep Apnoea Screening questionnaire were significantly older (61.4 vs 46.5 years; P < 0.001) and had a significantly higher body mass index (29.4 vs 26.7 kg/m2 ; P < 0.001) when compared to the control group (OSA score of <3). The sleep apnoea group (OSA score of ≥3) had significantly worse IIEF-ED scores (6.2 vs 9.1; P = 0.018) and ISI scores (7.9 vs 5.5; P = 0.061). CONCLUSION: Men presenting to the andrology clinic with ED are at significant risk of having undiagnosed sleep disorders. This has serious adverse health consequences, as well as being associated with potential dangers at work and travel. The patient compliance was high with 78% completing all three questionnaires. It is feasible to screen this population for sleep disturbance and this should be part of the ED assessment.

Safety and effectiveness of collagenase clostridium histolyticum in the treatment of Peyronie's disease using a new modified shortened protocol.

OBJECTIVES: To evaluate the efficacy and safety of collagenase clostridium histolyticum (CCH; Xiapex® , Xiaflex® ) in the treatment of Peyronie's disease (PD) using a new modified treatment protocol that aims at reducing the number of injections needed and reducing patient visits, thus reducing the duration and cost of treatment. PATIENTS AND METHODS: A prospective study of 53 patients with PD who had treatment with CCH at a single centre using a new modified protocol. The angle of curvature assessment after an intracavernosal injection of prostaglandin E1, the International Index of Erectile Function (IIEF) and Peyronie's Disease Questionnaire (PDQ) were completed at baseline and at week 12 (4 weeks after the last injection). The Global Assessment of Peyronie's disease (GAPD) questionnaire was completed at week 12. Under a penile block of 10 mL plain lignocaine 1%, a total of three intralesional injections of CCH (0.9 mg) were given at 4-weekly intervals using a new modified injection technique. In between injections patients used a combination of home modelling, stretching and a vacuum device on a daily basis to mechanically stretch the plaque. Investigator modelling was not performed. RESULTS: The mean (range) penile curvature at baseline was 54 (30-90)°. Of the 53 patients in the study, 51 patients (96.2%) had an improvement in the angel of curvature by a mean (range) of 17.36 (0-40)° or 31.4 (0-57)% from baseline after three CCH injections. The final mean (range) curvature was 36.9 (12-75)° (P < 0.001). There was an improvement in each of the IIEF questionnaire domains, all three PDQ domains and the GAPD. CCH was well tolerated by all patients with only mild and transient local adverse events. CONCLUSION: The new shortened protocol using CCH treatment is safe, effective, and cost efficient. The results of using only three CCH injections according to this modified protocol are comparable to those of the clinical trials that used eight CCH injections.

Functional outcomes following immediate repair of penile fracture: a tertiary referral centre experience with 76 consecutive patients.

OBJECTIVE: The aim of this study was to report surgical and functional outcomes in patients who underwent immediate penile fracture repair following location of the tunical tear with ultrasonography. METHODS: Patients' clinical notes from September 2005 to October 2015 were reviewed. The inclusion criteria were the documented presence of an albugineal laceration at the preoperative ultrasonography and during surgical exploration. In total, 76 patients were enrolled in the study. The aetiology, presentation, imaging results, intraoperative findings, functional outcomes and complications of surgical repair were retrospectively extrapolated from the clinical notes. Patients were questioned about their erectile and urinary function 12 months after the traumatic event. Validated questionnaires were administered to enquire about sexual and urinary function. Finally, the accuracy of the ultrasound in detecting the site of the tunical defect was evaluated. RESULTS: The mean age was 39.5 years (range 21-72 years) and the median follow-up was 13 weeks. The aetiology of the fracture was sexual intercourse in 70 patients, the taqaandan manoeuvre in three and trauma while sleeping in three. The intraoperative findings showed a ventral and transverse tear in 93.5% of cases. Urethral injuries were evident in one-quarter of the patients. Ultrasonographic findings were confirmed intraoperatively in all patients. Worsening of the quality of erections was reported by 5% of patients, and 5.2% reported a penile curvature postoperatively. CONCLUSION: Penile fracture is a rare urological emergency and requires early surgical exploration and repair. Ultrasonography is a cheap and readily available investigation that allows confirmation of the diagnosis, and identification of the location of the tear and the associated urethral injury.

Total Phallic Reconstruction Using the Radial Artery Based Forearm Free Flap After Traumatic Penile Amputation.

INTRODUCTION: Although genital injuries in civilian centers are rare, the scenario is completely different in the battlefield. If the penile distal stump is not adequate for primary reimplantation or it cannot be found, then delayed penile reconstruction needs to be considered. AIM: To report a single-center experience with total phallic reconstruction using radial artery based forearm free flap (RAFFF) after penile traumatic loss. METHODS: We retrospectively reviewed the clinical records of 10 patients who underwent total phallic reconstruction with the use of the RAFFF from September 2001 through August 2015 after traumatic amputation of the penis. MAIN OUTCOME MEASURES: Patients' baseline features, surgical outcomes, complications, and satisfaction are reported. RESULTS: The average age at the time of penile reconstruction was 36 years (range = 27-52 years). The causes of penile loss were self-amputation owing to an acute schizophrenic episode (n = 2), road traffic accident (n = 3), blast injury (n = 3), donkey bite (n = 1), and Fournier gangrene (n = 1). The average time from the trauma to reconstruction with the RAFFF was 7 years (range = 2-15 years). The urethral stump was adequate for primary anastomosis, with phallic neourethra construction in six patients. The remaining patients had complete avulsion of the penis and were voiding though a perineal urethrostomy. In consequence, they required a two-stage urethroplasty. An acute arterial thrombosis of the microsurgical anastomosis occurred in two patients and was managed successfully with immediate exploration. A neourethra stricture and fistula occurred in one patient, which needed revision. All patients who underwent complete urethral reconstruction could void and ejaculate from the tip of the phallus. After a median follow-up of 51 months (range = 1-114 months), all patients were satisfied with the size, cosmetic appearance, and sensation of the phallus. Six patients underwent inflatable penile prosthesis implantation and could engage in penetrative sex. However, revision surgery was needed in three patients (infection, n = 2; mechanical failure, n = 1). CONCLUSION: Despite the high incidence of postoperative complications and the possible need for multiple operations, in expert hands and in large-volume centers, penile reconstruction with the RAFFF after traumatic loss of the penis yields excellent results and allows patients to regain sexual and urinary functions.