Article

Managing penile shortening after Peyronie's Disease Surgery

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Abstract

Introduction and Objective: Loss of penile length is a common complaint of patients undergoing surgical correction of penile curvature for Peyronie's (PD) disease. Penile extenders have been developed to increase penile length by regular application on the penis based on their tissue expansion properties. We assessed the value, in terms of increasing penile length, of the application of a penile extender (Andropenis ®) in men who have undergone tunica albuginea plication or grafting for PD. We also studied the impact of this treatment on the health related quality of life (HRQoL) Methods: 40 men, aged between 54 - 64 (mean 58 y.o.), undergoing PD surgery constituted the study population; 12 patients were submitted to a grafting procedure while the rest (n=28) undergone a plication technique. 20 consecutive patients were treated with a penile extender device (Andropenis ® ) while the previous 20 served as a control group. The extender was applied when the circumcision had healed (2 to 3 weeks after surgery) with a traction force of 900 to 1200 gr 8 to 12 hours daily during at least 4 months. Parameters studied were penile length before, after surgery and after the continued use of the device. HEQoL using the SF-36 questionnaire was also assessed to compare both groups of patients. Results: Penile shortening after surgery ranged from 0.5 cm to 4 cm. Shortening was slightly less relevant in patients undergoing a grafting procedure but this difference was not statistically significant. Treatment with the device produced a length increase ranging from 1 to 3 cm, this increase was proportional to the number of hours per month the patient was using the extender. There were significant differences in several of the SF-36 parameters in the patients under the device when compared to those not using the extender (p

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... Only 2 articles investigated the role of PTT after PD surgery; 21,22 however, in both studies, the traction was not applied immediately after the end of the surgery but several weeks later. ...
... Moncada-Iribarren et al 21 reported the use of a traction device (Andropenis, Andromedical SL, Madrid, Spain) after penile grafting or plication. PTT was applied when the circumcision had healed (2 to 3 weeks after surgery), 8 to 12 hours daily during at least 4 months. ...
Article
Background Some studies showed encouraging results on the efficacy and safety of penile traction therapy after Peyronie's disease (PD) surgery. The early traction therapy (ETT) could be an effective and safe approach to minimize penile shortening in patients undergoing PD surgery. Aim To evaluate the feasibility, efficacy, and safety of a novel penile splint as ETT in patients with PD undergoing grafting techniques. Methods Patients with PD underwent plaque incision and grafting technique; at the end of the procedure, a novel penile splint (ETT) was applied to all patient. The device consisted of 2 10CH intubating stylets, self-adapted to each patient, that kept the penis stretched with the aid of non-absorbable sutures. The total expense for the materials needed to build each penile splint was less than 15 euros. This active traction was maintained for 1–3 weeks; then, we removed the stitches leaving the device on-site for a passive traction. Within 3–4 weeks from surgery, the penile splint was replaced by a standard penile traction device. Outcomes The main outcomes evaluated at 6 months included stretched penile length (SPL), penile curvature, International Index of Erectile Function-erectile function (IIEF-EF) domain, patient satisfaction, and time to first satisfactory sexual intercourse. Results A total of 46 patients were enrolled. The median preoperative IIEF-EF, penile curvature, and SPL were 27 points, 70°, and 13 cm, respectively. The median follow-up was 15 months. The median postoperative IIEF-EF was 25 points (P < .001). The median residual penile curvature was 10° (P < .001). The median postoperative SPL was 13 cm (P = .269). 8 patients (17.4%) lost 1 cm of SPL; no shortening greater than 1 cm was recorded. The median time to first satisfactory sexual intercourse and patient satisfaction score was 6 weeks and 9 points, respectively. Clinical Implications Our results could pave the way for a new line of research, which in turn could lead to an improvement in the postoperative management of the patient undergoing surgery for PD. Strength & Limitations This is the first study evaluating the ETT after PD surgery. The main limitation of this study is the lack of a randomized control group. Other weaknesses are the small sample size and the short follow-up time. Conclusion Our novel penile splint is inexpensive, easy to assemble, and adaptable to the patient. ETT using this novel device, followed by standard traction therapy, seems to be feasible, effective, and safe. Fernández-Pascual E, Manfredi C, Cocci A, et al. A Novel Penile Splint as Early Traction Therapy After Grafting Techniques for Peyronie's Disease. J Sex Med 2020;XX:XXX–XXX.
... There is some early data suggesting that a penile extension device may increase length, prevent graft contraction and minimize postoperative penile shortening. 22,23 Lastly, congenital micropenis results from a number of biochemical etiologies, and it is lifelong. By definition, micropenis is 'a normally formed penis that is at least 2.5 s.d. ...
... Lastly, the micropenis can result from embryonic testis failure causing insufficient masculinization. 22 Bladder exstrophy and epispadias also can result in penile shortening, thought to be related to a congenitally shortened anterior corporal length. 26 ...
Article
Penile size is a considerable concern for men of all ages. Herein, we review the data on penile size and conditions that will result in penile shortening. Penile augmentation procedures are discussed, including indications, procedures and complications of penile lengthening procedures, penile girth enhancement procedures and penile skin reconstruction.
... Hinsichtlich des postoperativen Managements der Patienten gibt es derzeit kein allgemeingültiges evidenzbasiertes Konzept. Akzeptierter Standard ist eine etwa zwei Wochen nach OP beginnende Dehnung des Penis mit einer Vakuumpumpe (Moncada-Iribarren et al. 2007). Zudem scheint die postoperative Einnahme von PDE-5-Hemmern eine verbesserte Transplantat-Einheilung zu ermöglichen und das Risiko einer postoperativen erektilen Dysfunktion zu verringern (Levine et al. 2005;Lue und El-Sakka 1998). ...
Article
Zusammenfassung Einleitung Die Induratio penis plastica (IPP) ist eine erworbene chronische Erkrankung der Tunica albuginea und/oder des Septums der Corpora cavernosa, die zu Deformitäten und Verkrümmungen des Penis führen und die Sexualität der Betroffenen stark beeinträchtigen kann. Darüber hinaus kann die IPP bei den betroffenen Patienten zu emotionalen Problemen und zu Beziehungsproblemen führen. Forschungsziele Die vorliegende Übersichtsarbeit gibt einen Überblick über die konservativen und chirurgischen Therapieoptionen der IPP, geht detailliert auf die psychischen Besonderheiten und Probleme der Betroffenen ein und stellt mögliche psycho- und sexualtherapeutische Interventionen dar. Methoden Es handelt sich um eine nicht-systematische narrative Übersichtsarbeit. Mithilfe einer Pubmed-Datenbankanalyse wurden Original- und Übersichtsarbeiten zur IPP identifiziert und im Hinblick auf Methodik und Ergebnisse ausgewertet. Überlegungen zur interdisziplinären Integration einer unterstützenden Psychotherapie werden angestellt. Ergebnisse Die konservative und die chirurgische Therapie stellen keine kausale, sondern eine symptomatische Behandlung dar. Die Effektivität der konservativen Therapie ist eingeschränkt. Die chirurgische Therapie stellt den Goldstandard zur Behandlung der schweren IPP dar, kann aber Nebenwirkungen wie erektile Dysfunktion und Längenverlust des Penis zur Folge haben. Die IPP führt häufig zu psychischen Belastungen, die im Rahmen einer interdisziplinär integrierten Psychotherapie adressiert werden sollten. Ein entsprechend kombiniertes Vorgehen wird vorgeschlagen. Schlussfolgerung Um die Erwartungen an die konservative und chirurgische Therapie nicht zu überhöhen, müssen die Patienten über die Möglichkeiten und Limitationen realistisch und ausführlich aufgeklärt werden. Die psychischen Spezifika und Belastungen sollten bei der Therapie der IPP interdisziplinär integriert berücksichtigt werden.
... There, Moncada and colleagues reported on the use of PTT after PD surgery for length shortening. 37 A total of 40 men who underwent PD surgery (12 PEG and 28 plication) were randomized to have PTT versus observation. Patients were instructed to use PTT daily postoperatively for 8-12 h for a total of 4 months. ...
Full-text available
Article
Peyronie’s disease is a disorder of abnormal and dysregulated wound healing leading to scar formation in the tunica albuginea of the penis. Penile traction therapy has emerged as an attractive therapeutic option for men with Peyronie’s disease in both the acute and chronic phases. Currently, clinical studies are limited by lack of randomization, small cohorts, and lack of patient compliance with therapy. Despite these shortcomings, studies have shown a potential benefit with minimal morbidity. Specifically, penile traction may help to preserve or increase penile length and reduce penile curvature when used as monotherapy or as adjuvant therapy for surgical and intralesional treatments. Further study is necessary to define patient characteristics that are predictive of improved outcomes, determine the duration of treatment needed for clinical effect, and improve patient compliance.
... Major changes were seen in the psychological and physical symptom domain of the PDQ (PS-PDQ) as well as the bother and distress domain (BD-PDQ), whereas there was no impact on the penile pain domain (PP-PDQ) score as patients were included in the stable phase of the disease with no pain. The PDQ-PS changed significantly (P < 0.001) from 12.3 to 7.8 (4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19) compared with baseline, and compared with the NIG in which there were no changes compared with baseline. In addition, the mean (range) PDQ-BD score improved significantly from 13.8 to 7.2 (5-16) Fig. 7. ...
Article
Objectives To evaluate the efficacy and safety of a new penile traction device (PTD) ‘Penimaster PRO’ in a group of patients with stable Peyronie's disease (PD) compared to a non‐intervention group in a multicentre study trial. Material and Methods 93 patients with chronic stable PD (without ED, no significant pain, and with a unidirectional curvature of at least 45 degrees being stable for more than 3 months) were recruited and followed for a 12‐week period. 47 patients were randomly assigned to ‘PeniMaster PRO’ group (PG) and 46 assigned to the non‐intervention group (NIG). Patients were asked to apply the PTD 3‐8 hours a day for 12 consecutive weeks with specific instructions regarding the progressive increase of traction force applied to the penis over time. The primary outcome of the study was to assess the change in the degree of curvature measured in the fully erect state after intracavernosal injection of Alprostadil at baseline, 1, 2 and 3 months. Other parameters such as the type of curvature, stretched penile length (SPL), Peyronie's Disease Questionnaire (PDQ), International Index of Erectile Function (IIEF‐EF) and adverse events were also assessed in each visit. Results 41 patients in PG and 39 in NIG completed the study. There was an overall reduction in curvature of 31.2 degrees (p<0.001) at 12 weeks compared to baseline in the PG, representing a 41.1% improvement from the baseline which significantly correlated with the number of daily hours the device was applied in a dose‐dependent manner. Those patients using the device less than 4 hours a day experienced a reduction of 15‐25 degrees (mean 19.7 degrees, 28.8% improvement, p<0.05), while patients using the device more than 6 hours a day experienced greater curvature reduction ranging from 20 to 50 degrees (mean of 38.4 degrees, 51.4% improvement, p<0.0001). In contrast, no significant changes in curvature were observed in the NIG. Furthermore, SPL increased significantly in PG compared to baseline and compared to the NIG, ranging from 0.5 to 3.0 cm (mean 1.8 cm, p<0.05 IIEF‐EF also improved in patients of the PG (mean of 5 points). Mild adverse events occurred in 43% of patients such as local discomfort and glans numbness. Conclusion The use of ‘Penimaster PRO’ PTD, a non‐invasive treatment should be offered to patients with stable PD for three consecutive months before performing any corrective surgery, as this provided a significant reduction of the curvature, increase in penile length and a significant improvement of the symptoms and bother induced by PD. This article is protected by copyright. All rights reserved.
... Finally, loss of penile length following surgery for PD is a major complaint for most patients irrespective of surgical technique. The use of PTT has, however, been associated with a 13 cm gain in SPL when used as a pre-operative ( Levine & Rybak, 2011) or post-operative ( Moncada-Iribarren et al., 2007) modality in conjunction with definitive surgical therapy for PD. Overall, PTT is an underused tool which, when used diligently, may provide a clinically significant benefit in penile length. ...
Article
Peyronie's disease (PD) is an under-diagnosed condition with prevalence in the male population as high as 9%. It is a localized connective tissue disorder of the penis characterized by scarring of the tunica albuginea. Its pathophysiology, however, remains incompletely elucidated. For the management of the acute phase of PD, there are currently numerous available oral drugs, but the scientific evidence for their use is weak. In terms of intralesional injections, collagenase clostridium histolyticum is currently the only Food and Drug Administration-approved drug for the management of patients with PD and a palpable plaque with dorsal or dorsolateral curvature >30°. Other available intralesional injectable drugs include verapamil and interferon-alpha-2B, however, their use is considered off-label. Iontophoresis, shockwave therapy, and radiation therapy have also been described with unconvincing results, and as such, their use is currently not recommended. Traction therapy, as part of a multimodal approach, is an underused additional tool for the prevention of PD-associated loss of penile length, but its efficacy is dependent on patient compliance. Surgical therapy remains the gold standard for patients in the chronic phase of the disease. In patients with adequate erectile function, tunical plication and/or incision/partial excision and grafting can be offered, depending on degree of curvature and/or presence of destabilizing deformity. In patients with erectile dysfunction non-responsive to oral therapy, insertion of an inflatable penile prosthesis with or without straightening procedures should be offered. © 2015 American Society of Andrology and European Academy of Andrology.
... 11 Moncada-Iribarren et al found further evidence of the benefit of PTT in a randomized controlled trial of daily PTT after definitive surgical management for PD. 12 In a cohort of 40 patients the authors showed that 8 to 12 hours of daily stretching for at least 4 months resulted in a 1 to 3 cm increase in SPL. More recently Levine et al examined the role of PTT for 2 to 8 hours daily for 6 months in 11 patients with chronic PD (more than 2 years). ...
Article
The concomitant use of penile traction therapy (PTT) with interferon alpha-2b (IFN) has been previously described. We present an update on our clinical experience to assess the benefit and duration of daily traction. A retrospective review of patients who underwent IFN therapy between 2001 and 2012 was performed. Charts were reviewed and data collected regarding various patient demographics, vascular parameters, objective length and curvature measurements and use of PTT. PTT was further stratified according to duration of daily use. One-hundred and twelve patients underwent a median of 12 IFN injections (range 6-24). Daily use of PTT was reported by 31% of patients. There were no differences in patient demographics, initial vascular status, pre-treatment stretched penile length (SPL), erect circumference and curvature between patients who followed a PTT regimen and those who did not. Overall use of PTT did not impact change in penile circumference (PTT +3.2mm [SD 6.5] vs. no PTT +2.1mm [SD 7.4], p=0.45), change in curvature (PTT -8.1 degrees [SD 16.0] vs. no PTT -9.9 degrees [SD 11.8], p=0.49), or change in SPL (PTT +2.4mm [SD 0.9] vs. no PTT +1.3mm [SD 0.8], p=0.56). Men who used PTT ≥3 hours/day gained significantly greater SPL compared to those not using PTT (4.4mm [SD 0.5] vs. 1.3mm [SD 0.8], p=0.04). Routine use of PTT during intralesional injections (ILI) with IFN for PD may provide a small but subjectively meaningful improvement in SPL, without affecting curvature, if used for at least 3 hours a day. Copyright © 2015 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.
... Postoperatively, patients may be advised to use a penile stretching device on a daily basis, possibly with oral medications such as a low-dose PDE5 inhibitor.13,91,111 The use of a PDE5 inhibitor hypothetically increases penile blood flow. ...
Full-text available
Article
Peyronie's disease (PD) is a condition of the penis, characterized by the presence of localized fibrotic plaque in the tunica albuginea. PD is not an uncommon disorder, with recent epidemiologic studies documenting a prevalence of 3-9% of adult men affected. The actual prevalence of PD may be even higher. It is often associated with penile pain, anatomical deformities in the erect penis, and difficulty with intromission. As the definitive pathophysiology of PD has not been completely elucidated, further basic research is required to make progress in the understanding of this enigmatic condition. Similarly, research on effective therapies is limited. Currently, nonsurgical treatments are used for those men who are in the acute stage of PD, whereas surgical options are reserved for men with established PD who cannot successfully penetrate. Intralesional treatments are growing in clinical popularity as a minimally invasive approach in the initial treatment of PD. A surgical approach should be considered when men with PD do not respond to conservative, medical, or minimally invasive therapies for approximately 1 year and cannot have satisfactory sexual intercourse. As scientific breakthroughs in the understanding of the mechanisms of this disease process evolve, novel treatments for the many men suffering with PD are anticipated.
... Moncada-Iribarren and colleagues presented the first noncontrolled randomized study on the use of PTT in men who underwent PD surgery [Moncada-Iribarren et al. 2007]. A total of 40 men who had PD surgery (12 men with graft and 28 men with penile plication only) were randomized to penile traction versus observation. ...
Full-text available
Article
In recent years, penile traction therapy (PTT) has gained considerable interest as a novel nonsurgical treatment option for men with Peyronie’s disease (PD) and short penises. The current published literature suggests that selected cases of PD may benefit from a conservative approach with PTT, resulting in increased penile length and reduction of penile deformity. It appears to be safe and well tolerated but requires a great deal of patient compliance and determination. This article reviews the current literature pertaining to the use of PTT in men with PD, short penises and in the setting of pre- and postprosthesis corporal fibrosis.
... Investigators have recommended the use of nocturnal PDE5 inhibitors so as to enhance postoperative vasodilation, which may help support graft take as well as reduce cicatrix contraction [70]. Finally, external penile stretching devices have been encouraged and have been recently shown to actually enhance the likelihood of further length gain with both grafting and plication procedures, but will at a minimum reduce length loss postoperatively [93,94]. ...
Article
Introduction: Peyronie's disease (PD) refers to a penile deformity that is associated with sexual dysfunction. Aim: To provide recommendations and Standard Operating Procedures (SOPs) based on best evidence for diagnosis and treatment of PD. Methods: Medical literature was reviewed and combined with expert opinion of the authors. Main outcome measures: Recommendations and SOPs based on grading of evidence-based medical literature. Results: PD is a fibrotic wound-healing disorder involving the tunica albuginea of the corpora cavernosa. The resulting scar is responsible for a variety of deformities, including curvature, shortening, narrowing with hinge effect, and is frequently associated in the early phase with pain. Patients frequently experience diminished quality erections. All of these conditions can compromise sexual function for the affected male. The etiopathophysiology of PD has yet to be clarified and as a result, effective, reliable, mechanistic directed non-surgical therapy is lacking. Conclusions: The management of PD consists of proper diagnosis and treatment, ranging from non-surgical to surgical interventions. The main state of treatment for PD rests at this time on surgical correction that should be based on clear indications, involve surgical consent, and follow a surgical algorithm that includes tunica plication, plaque incision/partial excision and grafting, and penile prosthesis implantation.
... Typically a patient is seen 2 weeks after surgery, at which point, massage and stretch therapy is initiated. 72,73 The patient is instructed to grasp the penis by the glans and gently stretch it and then with his other hand massage the shaft of the penis for 5 min twice per day for 2-4 weeks. The massage and stretch can be performed by the patient's Surgery for Peyronie's disease LA Levine and SM Larsen 30 partner for the second 2 weeks if possible. ...
Full-text available
Article
Peyronie's disease (PD) is most simply referred to as a fibrotic wound-healing disorder of the tunica albuginea. It is both a physically and psychologically devastating disorder that causes penile deformity, curvature, hinging, narrowing and shortening, which may compromise sexual function. Although a variety of non-surgical treatments have been suggested, none to date offer a reliable and effective correction of the penile deformity. As a result, surgery remains the gold standard treatment option, offering the most rapid and reliable treatment which will be the focus of this article. We review the preoperative evaluation, surgical algorithm, graft materials and postoperative management of PD. Outcomes for tunical shortening, tunical lengthening and penile prosthesis placement for penile straightening are reviewed. Tunica albuginea plication is the preferred method of straightening for men with adequate rigidity and less severe disease defined as curvature less than 70° without narrowing/hinging. Men who have more severe, complex deformity, but maintain strong preoperative erectile function should be considered candidates for straightening with plaque incision or partial excision and grafting. Finally, for those men who have inadequate rigidity and PD, penile prosthesis placement with straightening is the best approach to address both problems.Asian Journal of Andrology advance online publication, 26 November 2012; doi:10.1038/aja.2012.92.
... However, this study involved a very small cohort of patients with no control group. Several years later, Moncada-Iribarren and colleagues [11] reported on the use of a traction device to treat penile shortening that had occurred after PD surgery. A total of 40 men participated in this study, with 12 undergoing a grafting procedure while the remaining 28 underwent plication only. ...
Full-text available
Article
Penile traction therapy has traditionally been implemented to increase penile length but has recently been investigated for reducing the curvature associated with Peyronie's disease. The results of a few initial investigations have been conflicting, and further research is needed to confirm the true benefit of such therapy and its potential role in treating Peyronie's disease as both a monotherapy and in combination with other therapeutic options.
... Sexual activity is allowed 6 weeks postoperatively. Based upon the recent report by Moncada and colleagues [106] , for patients undergoing surgical reconstruction, the use of an external penile traction device is recommended beginning 2 to 3 weeks postoperatively. It should be applied daily for up to 12 hours for 3 months to reduce postoperative shortening. ...
Article
Peyronie's disease is a psychologically and physically devastating disorder that is manifest by a fibrous inelastic scar of the tunica albuginea, resulting in palpable penile scar in the flaccid condition and causing penile deformity, including penile curvature, hinging, narrowing, shortening, and painful erections. Peyronie's disease remains a considerable therapeutic dilemma even to today's practicing physicians.
Article
Introduction Penile traction therapy (PTT) and vacuum erection devices (VED) are nonsurgical conservative treatment options that have been used in the treatment of various urologic and sexual disorders such as Peyronie's Disease (PD) and Erectile Dysfunction (ED). Recently expanded uses for these therapies now include penile lengthening and with surgical interventions such as penile prosthesis surgery (PPS) and radical prostatectomy (RP). These devices can be used as both monotherapy or combination therapy. Objectives To review the indications and clinical studies for PTT and VED. Methods A literature search was conducted using PubMed to identify relevant studies addressing PTT, VED, and their indications. Searched terms included penile traction therapy, penile traction device, vacuum erection device, Peyronie's disease, penile prosthesis, radical prostatectomy, subjectively small penis, penile lengthening, erectile dysfunction. Results PTT with dynamic traction devices has shown favorable benefits for PD in many studies. The benefits of VED for PD cannot be confirmed due to limited studies with poor quality. In posterior urethroplasty, VED shows promise postoperatively, with additional trials also needed. In PPS, both PTT and VED have had positive findings in pre- and postoperative treatment. In RP patients, VED use has had positive outcomes while new literature shows beneficial effects of dynamic PTT and provides a basis for future studies. VED use does not show great benefit in patients with small penis, however PTT does have some positive findings. In ED, VED has a history of successful use and PTT has promising new data available. Conclusion PTT and VED have been utilized in urologic and sexual conditions with various success. Several promising areas utilizing both PTT and VED are being studied, however, more research needs to be done in these areas prior to becoming a standard treatment. Mehr J, Santarelli S, Green TP, et al. Emerging Roles of Penile Traction Therapy and Vacuum Erectile Devices. Sex Med Rev 2021;XX:XXX–XXX.
Article
Rationale Penile Prosthesis Implantation (PPI) is the definitive treatment for Erectile Dysfunction not responsive to conservative management strategies. Furthermore, it is a staple of surgical treatment of severe Peyronie's Disease (PD) and phallic reconstruction. Expert implantologists occasionally face disastrous complications of penile implant surgery which can prove to be very challenging. In this article we present a selected number of case reports which exemplify this kind of situations and discuss management strategies while also commenting on plausible aetiologies. Patients’ concerns The first case describes a PPI performed in end-stage fibrotic corpora after multiple instances of implantation/explant. The second and third cases show two diametrically opposed approaches to the management of glans necrosis after PPI in post-radical cystectomy patients. The fourth case describes the history of a diabetic patient suffering from glandular, corporal and urethral necrosis after a complicated PPI procedure. The fifth case reports the surgical treatment of a case of recurring PD due to severe scarring and shrinking of a vascular Dacron patch applied in a previous operation. Diagnosis Complication diagnosis in all patient was mainly clinical, intra- and postoperative, with Penile Color Doppler Ultrasonography performed when needed in order to demonstrate penile blood flow. Interventions The patients underwent complex surgical procedures that addressed each specific complication. Complex penile implants with fibrosis-related complications, penile prosthesis explant with and without surgical debridement of necrotic areas, penile prosthesis explant with necrotic penile shaft and urethral amputation with perineostomy, and complex corporoplasty with scar tissue excision and patch application with PPI were performed in the five patients. Outcomes Penile anatomy and erectile function with PPI was achieved in 4 out of 5 patients. 1 of 5 patient is scheduled to undergo a total phallic reconstruction procedure at the time of this writing. Lessons Management of disastrous complications of penile implant surgery can be very challenging even in expert hands. In-and-out knowledge of possible PPI and PD complications is required to achieve an acceptable outcome. Bettocchi C, Osmonov D, van Renterghem K, et al. Management of Disastrous Complications of Penile Implant Surgery. J Sex Med 2021;18:1145–1157.
Article
Surgery is the golden standard for the treatment of patients with Peyronie's disease in chronic phase (12–18 months). Learning risk factors for post‐surgical curvature (>20°) would aid both surgeon and patient in their decision‐making process. The aim of this study was to investigate the risk factors for residual/recurrent curvatures. The clinical data of the patients, who underwent reconstructive surgery for PD between 1997 and 2016, were retrospectively reviewed. Follow‐ups were performed via physical examination, surveys and phone calls. For shortening surgery (Nesbit/plication), initial bi‐planar curvature was proved to be a predictor of post‐operative curvature (p = .05). Lateral and ventral curvatures were associated with higher recurrence rates in patients who underwent grafting surgery (p = .01). In terms of baseline comorbidities, only diabetes mellitus had an association with curvature nonrecurrence for both shortening and lengthening surgeries (p < .05). Grafting surgery may be suggested to patients who had bi‐planar curvatures instead of Nesbit surgery. Nesbit plication surgery may be preferred for patients with lateral and ventral curvatures instead of grafting surgery. Higher cavernosal blood pressures and more nocturnal erections of nondiabetic young patients might impede plication sutures and grafts and therefore increase penile curvature recurrence.
Article
Background A subset of patients with Peyronie's disease (PD) treated with collagenase clostridium histolyticum (CCH) experience persistent bother and some require surgery. Aim We characterize patients experiencing persistent bother after CCH treatment and identify associations and predictors of surgical intervention/outcomes. Methods We retrospectively identified patients with PD from October 2014 to October 2019 and identified those presenting with persistent bother after CCH treatment by other urologists. Intracavernosal injection and penile Doppler ultrasonography were performed, and subsequent interventions/outcomes were recorded. Baseline characteristics were compared with Student t-test and chi-square test. Predictors of surgical intervention and complications were assessed using multivariable logistic regression. Outcomes The primary outcome was surgery after CCH treatment. Secondary outcomes included worsened erectile function, sensory deficits, and penile length change. Results Of 573, 67 (11.7%) patients with PD had undergone prior CCH treatment with median 6 injections (range 2–24). Mean post-CCH PD Questionnaire bother score was 10.1 (SD: 3.1), and total International Index of Erectile Function-5 was 15.3 (SD: 8.7). Mean PD duration was 27.8 (SD: 35.7) months, with a mean composite curvature (MCC) of 69.0° (SD: 33.8) measured after injection. Of 67, 44 (65.7%) patients had MCC >60°. Of 67, 52 (77.6%) patients had indent, narrowing, or hourglass and 26 (38.8%) had hinge effect (buckling of the erect penis with axial pressure) on examination. Calcification was identified in 26 of 67 (38.8%) patients, with grade 3 calcifications comprising 6 of 23 (26.1%) patients. Of 67, 33 (49.3%) patients underwent surgery, with 20 (60.1%) undergoing partial plaque excision and grafting with/without tunica albuginea plication, 6 (18.2%) undergoing tunica albuginea plication alone, and 7 (21.2%) undergoing penile prosthesis with plaque incision and grafting. Surgical patients had greater mean curvature (82.6 vs 55.4, P = .001) and were more likely to have hinge (54.5% vs 20.6%, P = .005). On multivariable analysis, MCC ≥60° predicted patient’s decision for surgery (odds ratio: 2.99, P < .01, 95% confidence interval: 1.62–4.35). There were no associations between surgical complications and number of injections or CCH-associated adverse events. Clinical Implications Patients presenting with persistent bother after CCH treatment often have narrowing and calcifications (despite calcifications being a contraindication to CCH treatment), and those who have hinge or severe curvature are more likely to undergo surgery with low rates of complications. Strengths/Limitations This study's generalizability is limited by selection bias, but useful data are provided for patient counseling. Conclusion Patients with persistent bother after CCH treatment had high rates of indentation/narrowing, plaque calcifications, and MCC >60° at completion of CCH treatment. Surgical intervention is more common with hinge and is safe and feasible in these patients, with low rates of complications. These findings suggest possible negative prognostic factors for CCH treatment, which merit further investigation. Bajic P, Wiggins AB, Ziegelmann MJ, et al. Characteristics of Men With Peyronie's Disease and Collagenase Clostridium Histolyticum Treatment Failure: Predictors of Surgical Intervention and Outcomes. J Sex Med 2020;XX:XXX–XXX.
Article
Introduction: Penile Traction Therapy (PTT) is increasingly being recognized as a viable non-surgical approach to Peyronie's Disease (PD). The goal of this article is to review the current literature on PTT with attention to traction protocols, devices, and outcomes. Areas Covered: Literature on the pathophysiology of PD, PTT as primary and adjunctive treatment for PD, perioperative use of PTT, and Vacuum Erection Devices are all reviewed. Pertinent literature was obtained from the PubMed database. The key words: "penile traction," "mechanotransduction," and "Peyronie's Disease" were searched and results were narrowed down based on relevance to the review. Expert Commentary: PTT appears beneficial but the true magnitude of effect is difficult to discern. Most studies are not randomized, have small sample sizes, lack control arms, or have varying traction protocols. Patient compliance is critical and new devices and traction protocols are needed to maximize the benefit of PTT.
Article
Objectives: To evaluate the outcomes in men undergoing Collagenase Clostridium histolyticum (CCH) with concurrent penile traction therapy (PTT) for the treatment of Peyronie's Disease (PD). Methods: We identified patients treated with CCH between March 2014 and July 2016. Patients were recommended to perform modeling and PTT between injection series. A final curve assessment was performed after patients completed CCH. A prospective database was maintained, including patient reported frequency and duration of PTT. Statistical analysis was performed to evaluate outcomes based on use and duration of PTT. Results: 51 patients completed CCH and had complete objective data available for analysis. Mean(SD) baseline curvature was 66.7 (25.0) degrees, and mean(SD) improvement post-CCH was 20.9 (17.3) degrees (p<0.0001). Thirty-five (69%) men reported daily PTT for a mean(SD) of 9.8 (6.3) hours per week. No significant difference was identified in the degree of curve improvement based on frequency or duration of PTT (p=0.40). Similarly, no associations between PTT and functional outcomes including intercourse restoration and surgery prevention were identified. Stretched penile length (SPL) increased non-significantly by a mean(SD) of +0.4 (1.5) cm in the PTT group, compared with -0.35 (1.5) in the non-PTT group (p=0.21). Conclusions: The current series represents a "true to life" experience, wherein utilization patterns, attrition, and compliance issues are relevant factors impacting efficacy.PTT utilization with the Andropenis? declined in both frequency and duration with subsequent injection series, and there was no significant difference in curve improvement or SPL with a mean 10 hours of weekly concurrent PTT.
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Paintings and records of the ancient Greeks indicate that they believed a small penis was superior [1]. However, as time passed and with various sexual revolutions, many men started to believe that a larger penis is better and that having a large penis in comparison with the penises of rest of the male population is important. Penis size has been a source of anxiety for men throughout history, as evidenced by the use of the terms “phallic identity” and “phallocentrism” in historical accounts. “Phallic identity,” as described by Vardi, is the concept of a man seeking his identity in his penis, with a focus on bigger is better. Similarly, “phallocentrism” is the concept that the penis is central to a man’s identity [2, 3].
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The purpose of this chapter is to introduce the measurements of penile dimension, summarize the available literature on penile size, discuss conditions that contribute to penile shortening, and highlight the indications of penile augmentation surgery. A physical examination should involve an assessment of body habitus, detailed genital examination (significant suprapubic fat pad, testis, and secondary sexual characteristics) with careful exclusion of genuine penile anomalies. Careful measurements of flaccid length, stretched length, erect length, flaccid circumference, and erect circumference are essential. The definition of a normal penile size has become of increasing interest to perform correct diagnostic assessment and therapeutic choice in patients with concerns regarding penile adequacy. By definition, micropenis is “a normally formed penis that is at least 2.5. S.D. below the mean in size.” Penile shortening is a phenomenon that is associated with certain medical and surgical conditions, including penile cancer, penile trauma, excessive skin loss, prostate cancer treatment modalities, buried penis, Peyronie’s disease, and congenital anomalies (epispadias, hypospadias and intersex disorders.
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Article
Penile traction therapy (PTT) is a new therapeutic option for men with Peyronie's disease (PD). However, it has a long history of use in other fields of medicine including bone, skin, skeletal muscle, and Dupuytren's. Mechanotransduction, or gradual expansion of tissue by traction, leads to the formation of new collagen tissue by cellular proliferation. As a molecular result, continuous extension of the fibrous plaque causes significant increases in collagenase and metalloproteinases, and, ultimately, to fibrous plaque softening and extension. This hypothetical knowledge has been supported by recent well designed experimental studies. Furthermore, several clinical papers have provided promising results on the use of PTT in PD patients. It has been shown in some series that the use of PTT significantly increases flaccid and stretched penile lengths and results in significant penile curvature improvement when compared to baseline. Furthermore, the use of PTT concomitantly with either verapamil or interferon α-2b has also been shown to be an effective therapy. Additionally, the beneficial effect of PTT on penile length before or after penile surgery in men with corporal fibrosis has been described. Finally, as a minimally invasive alternative treatment option to penile augmentation surgery in men with dysmorphophobia, PTT use has shown promising results by several experts. Studies have shown that PTT provides an acceptable, minimally invasive method that can produce effective and durable lengthening of the penis in men complaining of a small/short penis. There are, however, several criticisms related to the designs of the reported studies, such as small sample size and selection bias. Well-designed studies with larger numbers of patients and longer follow-up periods are, however, needed to establish the true benefits of PTT.
Chapter
Peyronie’s disease (PD) is a psychologically and physically devastating disorder that is manifest by a fibrous inelastic scar of the tunica albuginea, resulting in palpable penile lesion in the flaccid condition and causing penile deformity including penile curvature, hinging, narrowing, shortening, and painful erections. In spite of multiple treatment options offered since Francois de la Peyronie described PD in 1743 [1]. PD remains a considerable therapeutic dilemma even to today’s practicing physicians.
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Penile curvature can be caused by a congenital chordee (also termed congenital curvature), or it may be an acquired deformity as a result of Peyronie's disease. Although the surgical treatment for congenital chordee is similar to that performed for mild to moderate Peyronie's disease, it is a different clinical entity. If the dorsal aspect of the penis has more tissue and/or elasticity it will result in a ventral bend in the erect state. If the curvature is severe, this can interfere with vaginal penetration, making coitus difficult or in some cases impossible. This chapter discusses various surgical techniques for penile curvatures, namely tunica albuginea plication, nesbit and plication procedures, plaque incision with grafting, and partial plaque excision with pericardial grafting.
Article
Objetivo: Informar sobre los principios de la cirugía reconstructiva de diferentes deformidades del pene causadas por la enfermedad de Peyronie: restauración de la longitud, perímetro y forma con o sin implante de prótesis de pene. Métodos: En el período comprendido entre febrero 2007 y marzo de 2009, se realizó cirugía con parche por enfermedad de Peyronie en 98 pacientes con edades comprendidas entre 24 y 72 años (media 52 años). Las deformidades en el pene eran diferentes: curvatura dorsal en 54 (55%) pacientes, lateral en 7 (7%), ventral en 11 (11%), y curvatura combinada en 21 (21%); 24 pacientes presentaban estrechamiento en el cuerpo cavernoso (reloj de arena) (24 %). Cuatro (4%) pacientes presentaban acortamiento de pene aislado, sin otras deformidades, y en dos (2%) pacientes se encontró un estrechamiento cavernoso difuso aislado sin acortamiento. La gravedad de la curvatura varió de 60o-90o, media 72. Treinta y un (31%) pacientes padecían disfunción eréctil asociada. Las opciones quirúrgicas para los casos graves de enfermedad de Peyronie fueron: injerto simple en 26 (26%) pacientes, injertos complejos incluyendo incisión circular de la túnica albugínea en 36 (36%), y los mismos procedimientos en pacientes con disfunción eréctil combinados con implante de prótesis de pene en 37 pacientes (38%). La corrección quirúrgica se basó en la medición del defecto de la túnica y el cálculo preciso del tamaño del injerto y la forma. El enderezamiento y alargamiento del pene se logró, mediante la nivelación del lado/s acortados del pene con el más largo (convexo) y el injerto. El ancho del pene se restablece con incisión/es longitudinal/es adicionales e injertos; el ancho del injerto se determina mediante la medición de la diferencia en la circunferencia entre las partes normal y reducida del cuerpo cavernoso. En todos los casos, se utilizó InteXen LP (AMS) como material de injerto. Resultados: El seguimiento medio fue de 15 meses (6-25). El incremento de longitud del pene fue de 2,8 cm sin prótesis (1,5-4,2 cm) y 3,2 cm (2-4,5cm) con prótesis. En 5 pacientes (<15 grados), la corrección de la curvatura fue insuficiente, debido a que el haz neurovascular fue un factor limitante. Veinticuatro pacientes informaron de hipoestesia y sensibilidad orgásmica reducida que se recuperó espontáneamente al cabo de 3-6 meses. Seis pacientes presentaron una disfunción eréctil de novo y 6 pacientes progresión de la enfermedad. Sólo un paciente con implante de prótesis de pene sufrió infección. El índice de satisfacción general de los pacientes fue del 95%. Conclusiones: La reconstrucción de la túnica albugínea completa en la enfermedad de Peyronie puede realizarse como un procedimiento seguro por medio de injertos transversales, longitudinales y circulares con o sin implante simultáneo de prótesis de pene. Se puede lograr, mediante el cálculo geométrico, la longitud máxima del pene, el grosor y la recuperación de la forma, independientemente del tipo de deformidad.
Article
Background: Peyronie's Disease is a wound healing disorder involving growth of fibrous plaques in the tunica albuginea, and often results in abnormal penile curvature and subsequent development of erectile dysfunction. A 59-year-old man with a history of untreated penile trauma who presented with a 6-year history of worsening penile curvature that interfered with sexual functioning and resulted in associated erectile dysfunction. Methods: The patient's Peyronie's Disease was evaluated in clinic with a focused physical exam and a penile vasculature study using a color duplex Doppler ultrasound. Since the patient did not have proper insurance coverage for an inflatable penile prosthesis, but did have normal arterial flow with only boderline veno-occlusive disease, he instead underwent an incision and grafting procedure. After degloving the penis, a lateral approach parallel to the corpus spongiosum was used to enter Buck's fascia and isolate the neurovascular bundles. The fibrous plaque was incised with a residual tunical defect of 4 x 5 cm, and covered with a pericardial graft. Results: Preoperatively, artificially induced erection during the patient's Doppler study demonstrated dorsal curvature greater than 80 degrees. Intraoperatively, after completing the incision and grafting procedure, artificial erection demonstrated minimal (less than 15 degrees) residual curvature. At his 1-week postoperative visit, he reported spontaneous erections and minimal pain. One month postoperatively, his incisions were well healed and an artificially induced erection continued to demonstrate minimal curvature. Discussion: Management of severe Peyronie's Disease with significant penile curvature is a challenging clinical problem. In extreme cases, placement of an inflatable penile prosthesis with ancillary techniques usually gives the best clinical outcome. Although more difficult to execute in severe cases, incision and grafting represents an acceptable alternative in the appropriately selected patient.
Article
Introduction: The field of Peyronie's disease is evolving and there is need for a state-of-the-art information in this area. Aim: To develop an evidence-based state-of-the-art consensus report on the management of Peyronie's disease. Methods: To provide state-of-the-art knowledge regarding the prevalence, etiology, medical and surgical management of Peyronie's Disease, representing the opinion of leading experts developed in a consensus process over a 2-year period. Main outcome measures: Expert opinion was based on grading of evidence-based medical literature, widespread internal committee discussion, public presentation, and debate. Conclusions: The real etiology of Peyronie's disease and the mechanisms of formation of the plaque still remain obscure. Although conservative management is obtaining a progressively larger consensus among the experts, surgical correction still remains the mainstay treatment for this condition.
Article
Introduction. Pilot experiences have suggested that tension forces exerted by a penile extender may reduce penile curvature as a result of Peyronie's disease. Aim. To test this hypothesis in a Phase II study using a commonly marketed brand of penile extender. Methods. Peyronie's disease patients with a curvature not exceeding 50° with mild or no erectile dysfunction (ED) were eligible. Fifteen patients were required to test the efficacy of the device assuming an effect size of >0.8, consistent with an “important” reduction in penile curvature. Changes in penile length over baseline and erectile function (EF) domain scores of the International Index of Erectile Function (IIEF) constituted secondary end points. Main Outcome Measures. Patients were counselled on the use of the penile extender for at least 5 hours per day for 6 months. Photographic pictures of the erect penis and measurements were carried out at baseline, at 1, 3, 6, and 12 months (end of study). The IIEF-EF domain scores were administered at baseline and at the end of study. Treatment satisfaction was assessed at end of study using a nonvalidated institutional 5-item questionnaire. Results. Penile curvature decreased from an average of 31° to 27° at 6 months without reaching the effect size (P = 0.056). Mean stretched and flaccid penile length increased by 1.3 and 0.83 cm, respectively at 6 months. Results were maintained at 12 months. Overall treatment results were subjectively scored as acceptable in spite of curvature improvements, which varied from “no change” to “mild improvement.” Conclusions. In our study, the use of a penile extender device provided only minimal improvements in penile curvature but a reasonable level of patient satisfaction, probably attributable to increased penile length. The selection of patients with a stabilized disease, a penile curvature not exceeding 50°, and no severe ED may have led to outcomes underestimating the potential efficacy of the treatment. Gontero P, Di Marco M, Giubilei G, Bartoletti R, Pappagallo G, Tizzani A, and Mondaini N. Use of penile extender device in the treatment of penile curvature as a result of Peyronie's disease. Results of a phase II prospective study. J Sex Med 2009;6:558–566.
Chapter
The objective of surgical treatment for Peyronie’s disease is to restore a painless, straight, and natural erection that is sufficient for intercourse. Plication procedures are associated with penile shortening, especially in cases of excessive curvature or rotation. Grafting procedures may prevent penile shortening, but they are often associated with poor postoperative anatomical and functional results caused by graft shrinkage and postoperative graft-associated corporeal veno-occlusive dysfunction. Surgical straightening of penile curvature with tunica plication and tunica albuginea free grafts is a simple and highly efficacious treatment modality with excellent functional results. It is associated with minimal postoperative shortening and eliminates major immediate and late complications, including recurrent curvature. It preserves erectile capacity in men with preoperative normal erectile function. Initial long-term patient satisfaction data, with lasting cosmetic and functional results, indicate that the proposed technique may be used as the indicated procedure for successful surgical treatment of excessive congenital or acquired penile curvature malformation.
Article
Limited publications exist regarding long-term outcomes of surgical correction for Peyronie's Disease (PD). To report on long-term postoperative parameters including rigidity, curvature, length, sensation, function, and patient satisfaction in men with PD treated surgically via Tunica Albuginea Plication (TAP) or Partial Plaque Excision with Tutoplast Human Pericardial Grafting (PEG). Objective and subjective data regarding patients who underwent either TAP or PEG. We report on 142 patients (61 TAP and 81 PEG) with both objective data and subjective patient reports on their postoperative experience. Patients underwent either TAP or PEG following our previously published algorithm. Data was collected via chart review and an internally generated survey, in which patients were asked about their rigidity, straightness, penile length, sensation, sexual function and satisfaction. Average follow up for TAP patients was 72 months (range 8-147) and 58 months (range 6-185) for PEG patients. At survey time, 93% of TAP and 91% of PEG patients reported curvatures of less than 30o. Rigidity was reportedly as good as or better than preoperative in 81% of TAP and 68% of PEG patients, and was adequate for coitus in 90% of TAP and 79% of PEG patients with or without the use of PDE5i. Objective flaccid stretched penile length measurements obtained pre and postoperatively show an average overall length gain of 0.6 cm (range -3.5-3.5) for TAP and 0.2 cm (range -1.5-2.0) for PEG patients. Sensation was reportedly as good as or better than preoperative in 69% of both TAP and PEG patients; 98% of TAP patients and 90% of PEG are able to achieve orgasm. 82% of TAP patients and 75% of PEG patients were either very satisfied or satisfied. Our long-term results support both TAP and PEG as durable surgical therapy for men with clinically significant PD.
Article
To report the principles of penile resculpturing of different deformities caused by M. Peyronie: restoration of penile length, girth and shape with or without penile prosthesis implantation. In the period between February 2007 and March 2009, we performed grafting surgery for M. Peyronie in 98 patients aged between 24 and 72 years (mean 52 years). Penile deformities were diferent: dorsal curvature in 54 (55%), lateral in 7 (7%), ventral in 11 (11%), and combined curvature in 21 (21%) associated corporal narrowing was present in 24 patients (24%). Four (4%) patients presented isolated penile shortening without other deformity. Isolated diffuse corporal narrowing without shortening was found in two (2%) patients. Severity of curvature ranges from 60 to 90 degrees, mean 72. Thirty one (31%) patients had associated ED. Surgical options for severe Peyronie's disease were: single grafting in 26 pts (26%), complex grafting including circular tunical incision in 36 pts (36%), and in patients with ED the same procedures combined with penile prosthesis implantation (37 pts, 38%). Surgical correction was based on measurement of the tunical defect and precise calculation of graft size and shape. Penile straightening and lengthening was achieved by equalizing of shortened penile side/s with the longest one (convex) and grafting. Penile width is reestablished with additional longitudinal incision/s and grafting; graft width is determined by measurement of difference in circumference between normal and narrowed part of the corpora. We used Intexen LP (AMS) as a grafting material in all cases. The mean follow-up was 15 months (6-25). Mean penile length gain without prosthesis was 2.8cm (1.5-4.2) and with prosthesis 3.2cm (2-4.5cm). Insuficient straightening was in 5 patients (>15 degree) where Neuro Vascular Bundle (NVB) was limiting factor. Twenty four patients reported hypoesthesia and reduced orgasmic sensitivity that recovered spontaneously after 3-6 months. De-novo ED occurred in 6 pts and progression of disease in 6 patients. Infection occurred only in one patient with penile prosthesis implantation. Overall patients' satisfaction was 95%. Complete tunical reconstruction in IPP can be performed as a safe procedure by transversal, longitudinal and circular grafting with or without simultaneous penile prosthesis implantation. Maximum penile length, girth and shape restoration can be achieved using geometrical calculation, regardless of type of deformity.
Article
It has been suggested that the application of penile-extender devices increases penile length and circumference. However, there are a few scientific studies in this field. The aim of this study was to assess the efficacy of a penile-extender (Golden Erect(®) , Ronas Tajhiz Teb, Tehran, Iran) in increasing penile size. This prospective study was performed on subjects complaining about "short penis" who were presented to our clinic between September 15, 2008 and December 15, 2008. After measuring the penile length in flaccid and stretched forms and penile circumference, patients were instructed to wear Golden Erect(®) , 4-6 hours per day during the first 2 weeks and then 9 hours per day until the end of the third month. The subjects were also trained how to increase the force of the device during determined intervals. The patients were visited at the end of the first and third months, and penile length and circumference were measured and compared with baseline. The primary end point of the study was changes in flaccid and stretched penile lengths compared with the baseline size during the 3 months follow-up. Twenty-three cases with a mean age of 26.5 ± 8.1 years entered the study. The mean flaccid penile length increased from 8.8 ± 1.2 cm to 10.1 ± 1.2 cm and 10.5 ± 1.2 cm, respectively, in the first and third months of follow-up, which was statistically significant (P < 0.05). Mean stretched penile length also significantly increased from 11.5 ± 1.0 cm to, respectively, 12.4 ± 1.3 cm and 13.2 ± 1.4 cm during the first and second follow-up (P < 0.05). No significant difference was found regarding proximal penile girth. However, it was not the same regarding the circumference of the glans penis (9.3 ± 0.86 cm vs. 8.8 ± 0.66 cm, P < 0.05). Our findings supported the efficacy of the device in increasing penile length. Our result also suggested the possibility of glans penis girth enhancement using penile extender. Performing more studies is recommended.
Article
Penile shortening following radical prostatectomy and straightening procedures for Peyronie's disease can be a devastating and unwelcome side effect of these operations. The majority of men undergoing radical prostatectomy for prostate cancer have a measured loss of penile length, which also can occur in men with Peyronie's disease and may be exacerbated by surgery. Recent studies have investigated the mechanisms resulting in penile shortening, and various treatments have emerged to prevent and treat postoperative penile shortening. This article reviews the recent literature on penile length loss after radical prostatectomy and following correction of penile deformity for Peyronie's disease.
Full-text available
Article
Peyronie's disease (PD) is a fibrotic disorder of the tunica albuginea of the penis. It is characterized by different degrees of penile curvature and sexual dysfunction. Several medical treatments have been employed to manage the disorder, with variable success rates. Surgical therapy is reserved for patients with severe penile deformity that fails to improve with medical treatment and impedes coital function. The advantages and disadvantages of various surgical approaches have long been debated. Herein, we describe the evolving surgical techniques for PD using knowledge obtained from the contemporary literature. In addition, we discuss the emerging data regarding the role of phosphodiesterase 5 inhibitors in the management of PD.
Article
Peyronie's disease (PD) is a relatively common disorder affecting middle aged men. Conservative nonsurgical treatments include oral, topical, and intra-lesional pharmacotherapies, vacuum stretching, and mechanical traction. Four people with expertise and/or interest in the area of PD were asked to contribute their opinions with regard to the safety and efficacy of nonsurgical conservative treatments. To provide food for thought, discussion, and possible further research in a poorly discussed area of sexual medicine. Of the four experts writing on the topic, one believes a combination of medical therapy and penile traction has positive potential for curvature. Another feels that although medical therapies have potential to alleviate pain, there is little evidence to show that they help with curvature or that penile traction helps. A third expert proposes dividing the disease into phases, where patients in the acute phase may benefit from conservative therapy, whereas patients whose disease is stable require surgical intervention. The last expert agrees that the therapy should depend on the stage of the disease, but believes like the first expert that there is a role for traction therapy for patients with stable disease. There is a need for guidelines for nonsurgical therapies for patients with PD, but there is a paucity of evidence as to their efficacy.
Article
Pilot experiences have suggested that tension forces exerted by a penile extender may reduce penile curvature as a result of Peyronie's disease. To test this hypothesis in a Phase II study using a commonly marketed brand of penile extender. Peyronie's disease patients with a curvature not exceeding 50 degrees with mild or no erectile dysfunction (ED) were eligible. Fifteen patients were required to test the efficacy of the device assuming an effect size of >0.8, consistent with an "important" reduction in penile curvature. Changes in penile length over baseline and erectile function (EF) domain scores of the International Index of Erectile Function (IIEF) constituted secondary end points. Patients were counselled on the use of the penile extender for at least 5 hours per day for 6 months. Photographic pictures of the erect penis and measurements were carried out at baseline, at 1, 3, 6, and 12 months (end of study). The IIEF-EF domain scores were administered at baseline and at the end of study. Treatment satisfaction was assessed at end of study using a nonvalidated institutional 5-item questionnaire. Penile curvature decreased from an average of 31 degrees to 27 degrees at 6 months without reaching the effect size (P = 0.056). Mean stretched and flaccid penile length increased by 1.3 and 0.83 cm, respectively at 6 months. Results were maintained at 12 months. Overall treatment results were subjectively scored as acceptable in spite of curvature improvements, which varied from "no change" to "mild improvement." In our study, the use of a penile extender device provided only minimal improvements in penile curvature but a reasonable level of patient satisfaction, probably attributable to increased penile length. The selection of patients with a stabilized disease, a penile curvature not exceeding 50 degrees, and no severe ED may have led to outcomes underestimating the potential efficacy of the treatment.
Article
To assess a commonly marketed brand of penile extender, the Andro-Penis(R) (Andromedical, Madrid, Spain), widely used devices which aim to increase penile size, in a phase II single-arm study powered to detect significant changes in penile size, as despite their widespread use, there is little scientific evidence to support their potential clinical utility in the treatment of patients with inadequate penile dimensions. Fifteen patients were required to test the efficacy of the device, assuming an effect size of >0.8. Eligible patients were counselled how to use the penile extender for at least 4 h/day for 6 months. Penile dimensions were measured at baseline and after 1, 3, 6 and 12 months (end of study). The erectile function (EF) domain of the International Index of EF was administered at baseline and at the end of the study. Treatment satisfaction was assessed using an institutional unvalidated five-item questionnaire. After 6 months the mean gain in length was significant, meeting the goals of the effect size, at 2.3 and 1.7 cm for the flaccid and stretched penis, respectively. No significant changes in penile girth were detected. The EF domain scores improved significantly at the end of study. Treatment satisfaction scores were consistent with acceptable to good improvement in all items, except for penile girth, where the score was either 'no change' or 'mild improvement'. Penile extenders should be regarded as a minimally invasive and effective treatment option to elongate the penile shaft in patients seeking treatment for a short penis.
Article
Peyronie's disease (PD) is a fibrotic disorder of the penis whose etiopathophysiology remains unclear. At this time, there is no known reliable nonsurgical treatment. This study reviews our experience with external penile traction therapy to correct the deformity associated with this disorder. To evaluate prolonged external penile traction as a nonsurgical treatment for PD. Ten men with PD completed this noncontrolled pilot study of traction therapy using the FastSize Penile Extender. Nearly all (90%) had failed prior medical therapy. Traction was applied as the only treatment for 2-8 hours/day for 6 months. All subjects underwent pre- and post-treatment physical examination including measurement of stretched flaccid penile length (SPL) and biothesiometry. Curvature and girth were measured during erection before and after treatment with dynamic duplex ultrasound. Assessment of erectile and sexual function was further assessed with the International Index of Erectile Function and Quality of Life Specific to Male Erection Difficulties (QOL-MED) questionnaires. At 3 and 6 months post-treatment, SPL was measured and subjective assessment of deformity by the patient was recorded. Subjectively all men noted reduced curvature estimated at 10-40 degrees, increased penile length (1-2.5 cm) and enhanced girth in areas of indentation or narrowing. Objective measures demonstrated reduced curvature in all men from 10-45 degrees; average reduction for the group was 33% (51-34 degrees). SPL increased 0.5-2.0 cm and erect girth increased 0.5-1.0 cm with correction of hinge effect in four out of four men. International Index of Erectile Function-erectile function domain increased from 18.3-23.6 for the group. Changes in quality of life by QOL-MED were not found to be statistically significant in this small series. There were no adverse events including skin changes, ulcerations, hypoesthesia or diminished rigidity. Prolonged daily external penile traction therapy is a new approach for the nonsurgical treatment of PD. Further study appears warranted given the response noted in this pilot study.
Article
This paper reports on the scientific principles, treatment protocol and initial trial results of the FastSize Medical Extender, a new medical device developed for the treatment of Peyronie's disease and phalloplasty utilizing controlled periodic stretching of the penis; other uses of the device are also mentioned. Initial Institutional Review Boards monitored clinical trials of the device indicate that significant (10-45 degrees ) improvement in curvatures are achievable and that larger scale trials are therefore justified. The device appears to meet a previously unmet need within the population of Peyronie's disease sufferers for a noninvasive, nonsurgical first-option treatment modality. The device works by holding the penis in a cradle and subjecting it to gentle stretching, the tension being provided by small metal extensions that are added to the cradle frame to provide traction against internal springs. Patient education is minimal for the device, but patient compliance with the extended daily treatment procedure is critical for significant curvature change. While a review of appropriate reimbursement codes has not been conducted, the pricing of the device makes it easily affordable. Although it has not yet been formally studied, the device also appears to have applications beyond Peyronie's disease; such as offering potential for offsetting penile shortening prior to implant surgery, preventing shortening following PD penile reconstruction and after radical prostatectomy where loss of penile length is commonly reported. The recent trial noted that, over a 6-month period, patients reported increases in penile length of 1-2.0 cm, with an accompanying increase in girth. There are no alternative devices available that have proven efficacy as a result of a clinical trial and, given reproducible results, the device will begin to play an important role in treatments that require penile tissue remodeling. Future developments should include larger scale, multicenter trials aimed at reproducing the results of the initial study on Peyronie's disease, also trials in conjunction with pharmacological treatment involving plaque remodeling agents such as verapamil and interferon, and trials that will investigate the possible benefits of the device for penile enlargement that may help pre- and postsurgical candidates for penile implants and penile reconstruction following prostatectomy.
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