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334 Challenging Concepts in Urological Surgery
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The patient returns 7 years later to our clinic with worsening ED, occasional
nocturia, urgency, slow stream, and decreased libido despite utilizing 20 mg
on- demand tadalafil. He has since been diagnosed with HTN and hyperlipidaemia
and is on lisinopril and simvastatin. Repeat blood work reveals an early- morning total
testosterone level of 8.3 nmol/ L, prostate- specific antigen level of 1.7 ng/ mL, and appropriate control of his diabetes and lipids.
Evidence base Hypogonadism
● Testosterone therapy in hypogonadal men with ED can improve certain sexual characteristics,
possibly including ED; PDE5is may have improved efficacy in a eugonadal state.
● It is important to check testosterone on a morning fasted sample, along with sex hormone- binding
globulin to obtain an accurate reading of free and total testosterone and avoid over- diagnosing
hypogonadism. An early- morning fasted sample can be 20% higher than an improper sample.
● Treatment of hypogonadism has secondary benefits of improved lethargy, depression, limits
osteoporosis, and helps build lean muscle mass.
● Tadalafil has been shown to decrease LUTS and improve ED in men when taken as a 5 mg daily
31
dose.
The patient was switched to tadalafil 5 mg daily and started on testosterone gel.
One month later his early- morning testosterone level was 19.5 nmol/ L. He noticed an
improvement in his erection quality, energy, sexual desire, and LUTS. Six months later
his DRE, prostate- specific antigen, haemoglobin, cholesterol, liver function test profile,
Expert comment
Testosterone replacement
Testosterone replacement is
not felt to be associated with
cardiac risk. However, side effects
include increased haematocrit,
concerning for an elevated risk
of deep vein thrombosis; mild
fluid retention, which can worsen
heart failure; worsening sleep
apnoea; breast enlargement; and
LUTS. Haemoglobin, cholesterol,
prostate- specific antigen, and
testosterone levels; liver function;
and digital rectal examination
require intermittent monitoring
while on therapy.
and total testosterone remained in the normal range.
Four years later, the patient returns with worsening ED despite tadalafil and testos-
terone. He has started two additional medications to keep his blood sugars controlled.
A penile Doppler is performed revealing a peak systolic velocity (PSV) of 25 mL/ s and
retrograde flow in diastole after a second 10 mcg injection of alprostadil was given due
to the initial dose not producing an adequate erection.
Expert comment Specific investigations
More specific evaluations are reserved for non- responders to oral medications, candidates for penile
implant, Peyronie’s disease, post priapism or traumatic ED, lifelong ED, concern for psychogenic ED,
and medicolegal situations.
A penile Doppler with intracavernosal alprostadil is the most useful functional test. A PSV >30 cm/ s
is normal. A PSV of ≤25cm/ s is indicative of arteriogenic ED. A reversal of flow in diastole is expected
and the end- diastolic velocity should be <3 cm/ s. A reading of >5 cm/ s is indicative of a continued
outflow from the cavernosal space and is sometimes referred to as a ‘venous leak’ phenomenon.
However, the results must be correlated with the clinical picture. High stress during the test can lead
to an artificially poor erection during the test. One cannot diagnose venous leak if an inadequate
erection is achieved. Always ask the patient if the erection they achieved during the ultrasound scan
was representative of their normal state. If they achieved a better erection when back in the changing
room after the test was completed, this can be indicative of an anxiety related suppression of the
effect of alprostadil during the test, and puts the poor vascular dynamics readings into the correct
perspective.
Additional tests can be used in this situation and include nocturnal penile tumescence testing if
psychogenic ED is suspected. Other specialised tests used to investigate ED include a magnetic
resonance imaging if there has been significant trauma, priapism, or anatomical abnormality and
angiography in cases of pelvic trauma. Dynamic infusion cavernosometry and cavernosography are
very rarely indicated.
29
30
After being counselled on further treatment options, the patient chose intracavernosal
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injections with alprostadil and was started at a 10 mcg dose after a test dose of 5mcg
was performed and taught in clinic. He given instructions for dose escalation at home.
Learning point Second- line treatments
Alprostadil is a prostaglandin- E1 analogue that induces cyclic adenosine monophosphate (cAMP)
signalling thereby decreasing intracellular calcium to bolster erections.
Intraurethral alprostadil deposits come in pellets (Medicated Urethral System for Erection, MUSE) or
cream (Vitaros).
● Pellet dosages are 250– 1000 mcg with 43% total efficacy and 65% in those who responded to an
office trial. Penile pain and erythema were reported in 32%.
● Cream dosages are 200– 300 mcg showing significant improvement of ED.
● Other side effects occur in 2– 5% and include dizziness, hypotension- induced syncope, sweating,
priapism, and urethral bleeding.
Intracavernosal injection (ICI) of alprostadil monotherapy at dosages of 5– 40 mcg has an efficacy
35,36
of >70%.
Other formulations of ICI include bimix (papaverine + phentolamine), trimix (papaverine
34
+ alprostadil + phentolamine), or quadmix (which includes atropine) but require a compounding
pharmacy.
● ICI carries the highest risk of priapism of all ED treatments at 0.3– 7% with alprostadil ICI
monotherapy carrying the least risk.
● Other complications include varying levels of pain in 7– 34% that often decreases over time, 1– 12%
develop nodules or fibrosis, and haematoma in 6– 25%.
Vacuum erection devices are a non- pharmacological therapy that can be highly effective, safe, and
less expensive in the long term.
● These devices use negative pressure to draw blood into the corporal sinusoids and are made of
three components: a cylinder that is placed around the penis, a pump to draw air out of cylinder,
and a compression ring to limit venous outflow.
● Although 92% of patients achieve erections firm enough for intercourse,
of the vacuum devices range from 35% to 70%.
● The most common side effects are discomfort, petechiae, ejaculatory difficulty due to the
compression ring, penile coldness, and numbness.
32
33
35,36
37– 39
long term satisfaction
40
335Case 34 Erectile dysfunction
Clinical tip Use of second- line therapies
Intraurethral alprostadil is used after micturition, 15– 30 minutes before sexual activity:
● To place, lift the penis straight up and place the pellet applicator 3 cm into urethra, depress the
button, and move the applicator from side to side to separate the pellet before removing the
applicator, and ‘rolling the urethra’ to aid absorption. The cream is squeezed into the opened
urethra without needing to insert an applicator, and any excess cream is rubbed over the glans to
allow it to absorb. An initial trial in clinic should be done to assess for syncope and need for dose
escalation.
41
Intracavernosal injection produces on- demand erections within 5– 10 minutes:
● A ½ inch 27- or 30- gauge needle is placed into the corporal space lateral to the dorsal nerve
complex. An initial dose should be administered in clinic to assess the technique and response.
Dose titration can occur at home.
● Special ‘dual chamber’ applicators are available for alprostadil monotherapy.
● Injections may be given by patients or their partner.
● The site of injection should be massaged for 30 seconds unless the patient is anticoagulated. Then
pressure should be placed for 5– 10 minutes.
● Patients need to be made aware of the risk of priapism and be provided with a treatment algorithm
for it. Terbutaline and pseudoephedrine have been studied to facilitate detumescence in ICIinduced priapism.
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● If in 3– 4 hours there is no detumescence, an emergency room visit is required for immediate
attention to prevent lasting and irreversible damage to the cavernosal tissue.
Vacuum erection devices produce on- demand, immediate erections:
● Patients should be instructed about a learning curve with vacuum erection devices.
● The open end of the cylinder is placed over the penis against the pubis to create an airtight seal with
lubricant used to facilitate the seal. Devices come with single- hand operation attached to the end of the
cylinder. The constriction ring should be placed over the cylinder before beginning so it can be rolled onto
the base of the penis immediately after negative pressure is released and before removal of the cylinder.
● A constriction band should not be left on for >30 minutes as this may lead to ischaemia.
After 5 years, the patient returns to our clinic for further refractory ED despite 40
mcg alprostadil ICI. One year ago, cardiac ischaemic changes were found on a stress
test. Angiography revealed two- vessel CAD and he had drug- eluting stents placed with
a good outcome. He continues on aspirin and has initiated insulin. On a follow- up
stress test, he completed a 4- minute protocol without any changes. Over the last 9
months, he tried using a vacuum erection device but was unsatisfied. He wants to
know if there is anything else that can be done.
Clinical tip Counselling for penile implants
● Penile prosthesis has the highest level of patient satisfaction (up to 90%) for severe ED.
● On- demand erections are achieved with preserved sensation and ejaculation.
● Placement irreversibly inhibits the ability to have or stimulate a natural erection.
● Devices change the feel of the flaccid penis.
● The erection does not replicate a natural erection and lacks glans engorgement. These factors can
lead to a perception of decreased size.
● Glans engorgement can be improved with co- use of PDE5is or topical alprostadil.
● There are semi- rigid, two- and three- piece inflatable devices.
● Infection rate has been reported as 1% in virgin and 2– 3% with revision cases.
increased in patients with poor diabetic control or extensive fibrosis post priapism.
● If infection occurs, a hastened explant of the infected device must be performed.
● Prothesis salvage for infection was reported by Mulcahy et al. as 80– 90% successful after explant,
thorough washout, and immediate reimplantation of a new device. This is not appropriate in the
setting of a severe local infection, sepsis, or a resistant organism.
● Other complications include erosion (1– 6%), mechanical failure rates (approximately 10% at 5 years,
20% at 10 years, 30% at 15 years), pump or reservoir displacement (1– 2%), auto- inflation (1%), scrotal
swelling and bruising, chronic pain, new or worsening curvature, transient difficulty with ejaculation or
retention, phimosis, sensory change, cylinder aneurysm, inguinal hernia, and supersonic transporter
(SST) deformity (i.e. glans tilt or droop) which can cause difficulty with penetration.
● Reoperation rates range from 5% to 15% at 5 years.
● Predictors of satisfaction include realistic expectations, BMI <30 kg/ m2, and no Peyronie’s disease or
history of prostatectomy.
● Predictors of dissatisfaction are perceived loss of length, decreased glanular engorgement, altered
sensation, and partner dissatisfaction.
53
51,52
44– 46
47
48,49
The risk is
50
Learning point Types of devices
● Two main vendors: Coloplast and Boston Scientific.
● Three main prosthesis options: malleable/ semi- rigid, two- piece or three- piece inflatable.
● Boston Scientific three- piece inflatable devices include the AMS 700™ CX, CXR, and LGX. The
700™ CX is considered the base standard and expands in girth. The 700™ CXR does not expand as
greatly and thus is used for scarred corporal bodies or small penis size. The 700™ LGX expands in
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girth (18 mm) and length (15%).
● Boston Scientific’s three- piece inflatable device is coated with an antibacterial coating known as
InhibiZone™ that consists of rifampicin and minocycline, has the Momentary Squeeze™ pump, and
the reservoir is called the Conceal™.
● Boston Scientific has a two- piece inflatable device (Ambicor™) that is used when reservoir
placement places a patient at undo risk (e.g. renal transplant/ neobladder/ bilateral mesh hernia
repairs), but the patient declines a malleable device. This device does not come coated in
InhibiZone™.
● Boston Scientific also has the Spectra™ malleable device. It is non- antibiotic coated and comes in
girths of 9.5, 11, and 13 mm.
● Coloplast’s three- piece device is the Titan® Touch. It has a narrow base and standard cylinders that
expand in girth to 21 mm.
● Coloplast devices have hydrophilic coating allowing for tailored antibiotic solution to be
impregnated into device, have the one- touch release pump, and the reservoir is the CL
(Cloverleaf) design.
● Coloplast’s malleable device is the Genesis® which also has a hydrophilic coating, and comes in
9.5, 11, and 13 mm girths.
● Both companies’ three- piece devices have lock- out valves limiting auto- inflation.
● Both pumps allow detumescence without the need to hold the deflate button while compressing
the penis/ cylinders to empty.
Expert comment Which device to recommend
The most important thing when deciding on an implant is to involve the patient and ideally their
partner. They should have the opportunity to see the devices in person, learn how the mechanism
works, watch videos about the devices, and ideally speak to a patient who has had one before. This
should be done over more than one consultation to allow the patient to make a considered and
informed choice. With all the information on board, the patient should choose the device that suits
them best. This will lead to better satisfaction. Except in cases where there may be a particular medical
reason why one type of implant may not be suitable, all should be considered. Implant counselling is
often best done by a specialist nurse to allow more time for an unbiased consultation.
337Case 34 Erectile dysfunction
Clinical tip Preoperative considerations
● No device should be placed in the presence of a systemic, cutaneous, or urinary infection.
Untreated voiding dysfunction due to either bladder outlet obstruction or neurogenic bladder is a
contraindication.
● Good diabetic control is important. A recent correlation between HbA1c and infection rate was
published revealing an infection rate of 1.3% with HbA1c level of <6.5%, 1.5% for 6.5– 7.5%, 6.5%
for 7.6– 8.5%, 14.7% for 8.6– 9.5%, and 22.4% for >9.5% (p <0.001). A HbA1c threshold level of 8.5%
predicted infection with sensitivity of 80% and specificity of 65%.
● Intravenous anti- Gram positive and negative coverage is required for preoperative induction and
recommended for 24 hours postoperatively. Regimens include an aminoglycoside + vancomycin or
first- or second- generation cephalosporin.
● Shaving should be done immediately prior to incision so small cuts do not become infected ahead
of time. Patients should be instructed to not shave themselves prior to surgery.
● Chlorhexidine decreases skin flora compared to povidone- iodine.
Clinical tip Operative considerations
● A no- touch technique has been advocated by some experts.
● Incision options include subcoronal, infrapubic, and penoscrotal, each with their own benefits and
limitations.
● A ventral scrotoplasty after placement may improve perceived length.
54
55
56
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● There is a 4.5% risk of proximal perforation, which is more common than lateral and distal
perforations and is often caused by smaller dilators.
● Risk of proximal perforation increases in revision surgery but can be readily repaired at the time of
surgery with a rear tip extender sling anchored to the corporal body.
● If perforation is not recognized and repaired an extrusion can occur.
● Use a clank test to assess for crossover.
● If a crossover does occur, place a large dilator into the receiving side of the crossover and re- dilate
the side that caused the septum perforation.
● Urethral injury most commonly occurs during distal dilation, scrotal dissection, or penile
modelling.
● If a distal urethral injury occurs during dilating, the urethra should be repaired via a distal counter
incision and the case delayed for 3 months. However, if the opposite cylinder is in position already,
it can be left in place.
● A Foley catheter is used to drain the bladder to avoid injury during reservoir placement.
● If the space of Retzius is obliterated, as in a post- prostatectomy setting, ectopic placement of the
reservoir is an established option.
● A Gibson- type counter- incision can be made to ensure safe placement of the reservoir.
● If a bladder injury is identified, as by blood in the catheter, make a counter incision, explore, and
close the bladder, then place the reservoir on the opposite side.
● Lastly, when modelling for curvature, ensure extra support to the distal corpora to minimize risk of
distal perforation.
Clinical tip Postoperative considerations
● Perform a wound check at 2 weeks post surgery.
● Patients can then be taught to cycle the device from 3 weeks.
● Patients should perform daily cycling to expand the capsule during its maturation.
● Intercourse should be delayed for 6 weeks.
● Distal erosion is more common in those with impaired sensation and can be repaired using a
fibrous capsule cap or graft cap through a distal incision and re- dilating the distal space through the
medial wall of the capsule.
● Twenty per cent of patients rarely or never use their device, but despite this the satisfaction rate
approaches 90%.
58,59
60
The patient elected to have a three- piece inflatable device placed. His HbA1c level
was checked preoperatively and was elevated at 92 mmol/ mol (10.6%). His procedure
was postponed until he optimized his glycaemic control and his HbA1c dropped to 56
mmol/ mol (7.3%). The device was then placed without complication. At 3 months
after surgery, he was satisfied with the quality of his erection and happy he could initiate a more routine sexual relationship with his partner again.
A final word from the expert
ED is common problem. The key steps are to differentiate psychogenic from organic ED, to
identify any potentially reversible causes, and to identify any coexisting pathological risk factors.
Given the common aetiological factors for atherosclerosis and endothelial dysfunction leading
to both ED and CAD, development of the former is often a warning sign of future cardiovascular
disease, and gives an opportunity to change the course of the individual’s future health and
outcome. The management of ED has been transformed by PDE5is, which have become more
accessible as the post- patent costs have dropped significantly. For those who fail to respond to
this first line, a stepwise approach to management as outlined here moving through injectable
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agents and vacuum devices and leading up to penile prosthesis can effectively manage ED, an
important element of a man’s life and psychological well- being.
339Case 34 Erectile dysfunction
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341Case 34 Erectile dysfunction
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35
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CASE
Peyronie’s disease
Sarah Prattley
Expert commentary Rowland Rees
Case history
A 51- year- old gentleman was referred to the andrology clinic with a 2- year history of
penile curvature. The curvature had been stable for approximately 18 months and
no longer caused painful erections. This resulted in him being unable to have sexual
intercourse; however, his erectile function was not impaired.
Questioning and photographic evidence revealed a marked dorsal curvature of 70°.
His erectile function was satisfactory, without the need for adjunctive therapy. The
patient had recently started a new relationship, but had been unable to achieve penetrative intercourse due to the curvature. This was affecting his psychosexual health
which subsequently led to mild depression. The patient had a past medical history of
asthma, and took a combination budesonide and formoterol 160/ 4.5 mcg inhaler. He
was also a smoker with a 20 pack- year history. He had no evidence of Dupuytren’s
contracture or Ledderhose disease.
On examination and self- taken photograph depicting degree of curvature, the patient was found to have a 70° dorsal curvature at tumescence with associated waist
deformity, with a stretched penile length of 11 cm. There was palpable plaque disease
on the dorsal aspect of the penis which was non- tender.
Learning point Phases of Peyronie’s disease
There are two distinct phases of Peyronie’s disease (PD), and it is important to identify which
phase the patient is in as this will help guide management, advice, and monitoring.
Active disease
This is characterized by active symptoms that are dynamic and changing. Pain related to inflammation
can be experienced along the active area of disease in the tunica albuginea. Deformity at this stage
may not be fully developed and may change over the subsequent months. The natural history of PD
is that plaque- related pain improves or resolves in approximately 90% of patients in the first 12– 18
months. However, improvement in curvature is limited to 3– 13%, with predictors of progression versus
resolution unclear.
worsens in 30– 50%.
but can be intact. During this stage, conservative and medical therapy can be considered to attempt
to limit symptoms and progression.
Stable disease
Stable disease is characterized by a lack of symptom change or progression for >3 months, and is
typically 1 year following the onset of symptoms.4 Pain may still be present but is less common. There
1,2
Stabilization of plaque disease and curvature occurs in 47– 67% of patients and
2,3
Erectile function during this stage may be compromised by pain or deformity
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