CURRENT OPTIONS FOR MANAGING SEXUAL DYSFUNCTION
From the Annual Florida Urological Society Meeting
Educational Objectives
| The goal of this program is to improve the surgical and pharmacologic management of sexual dysfunction. After hearing and
assimilating this program, the clinician will be better able to:
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 | 1. Evaluate the risk for erectile dysfunction (ED) after prostatectomy and describe surgical, radiation, and other treatment
options for prostate cancer.
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| 2. Analyze the data and choose among the various methods used to minimize postsurgical ED.
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| 3. Compare the benefits of surgical vs pharmacologic methods of treating Peyronie’s disease and identify candidates for
tunica plication surgery and penile prosthesis.
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| 4. Recognize the congenital causes of fertility and disorders of sexual function and determine the optimal method and
timing of surgery to correct these conditions in boys and girls.
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| 5. Assess the potential for recovery of fertility and sexual function after surgical correction of congenital conditions.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning
committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts
of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health
care and not a proprietary business or commercial interest. For this program, Drs. Donatucci and Erhard and the planning
committee reported nothing to disclose.
Acknowledgements
Lectures given by Drs. Donatucci and Erhard were recorded at the 2007 Florida Urological Society Annual Meeting,
held August 30 to September 2, 2007, in Miami Beach, FL. The Audio-Digest Foundation thanks the speakers and the
Florida Urological Society for their cooperation in the production of this program.
| PENILE REHABILITATION IN THE POSTPROSTATECTOMY PATIENT —Craig F. Donatucci, MD, Associate Professor,
Department of Surgery, Division of Urology, Duke University School of Medicine, Durham, NC
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| Erectile dysfunction (ED): high incidence after prostatectomy and major factor in therapy decision; study—male patients
without cancer asked to rate survival vs potency in choosing hypothetical treatment regimen; found 22% would not
trade any survival advantage for potency; 68% would trade 10% survival advantage at 5 yr; second study—128 men with
localized prostate cancer asked to trade among various side effects, assuming 5-yr life expectancy; found patients would
trade 1.9 mo of survival to avoid swelling of breasts; value of ED depended on age of patient (ie, patients <70 yr of age
traded twice as much survival advantage to retain erections as those >70 yr of age); third study—among 31 patients at 3
mo after undergoing radical prostatectomy (RP), size of penis decreased >1 cm in 48%, but one patient gained 1 cm in
length; another 64-yr-old patient, who did not respond to phosphodiesterase-5 (PDE-5) inhibitors 4 yr after RP, responded
with full erection to 10 µg injected prostaglandin E1 (PGE1 ); individuals vary
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| Incidence of Peyronie’s disease: estimated incidence in men with prostate cancer 10%, but study of 110 men after RP
showed incidence 41%; 92% of patients had curve, 69% had palpable plaque, and 24% had hour-glass-shaped deformity
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| Treatments: meta-analysis of studies from 1970 to 1999 looked at patients with known erectile function before treatment
who underwent irradiation, RP, or newer therapies; >3500 patients had RP (most without nerve-sparing), 1343 had external
beam irradiation, 172 had brachytherapy, and 261 had cryotherapy; found slight advantage in potency with radiation
therapy at 2 yr; rate of potency nearly same, whether nerve-sparing or standard RP procedure performed
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| Irradiation study: 268 patients underwent 3-dimensional conformal radiation therapy at doses of 68 to 78 Gy; 28% had
ED at baseline; among potent patients, 27% developed ED at 1 yr (rate rose to 36% and remained stable at 2 yr); study
weakness—nonstandard instrument used to measure erectile function
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| Brachytherapy study: among 226 patients, 128 potent before therapy, as defined by International Index of Erectile Function
(IIEF)-5 score; potency after treatment defined as IIEF score of 13 (normal score 25); at 3 yr, 50% of 128 remained
potent (score of 20 on average vs score of 3 for impotent patients), with mean time of ED onset, 5.4 mo
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| Intensity-modulated radiation therapy (IMRT): 69 patients studied using validated Sexual Health Inventory for Men
(SHIM); 52 patients potent before treatment (SHIM score >10); among 32 patients followed for 36 mo after treatment,
8 had SHIM score of 22, 3 had mild ED (SHIM score 17-21), 16% had mild to moderate ED (SHIM score 12-16);
>50% had either moderate or severe ED
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| Postsurgical ED: differs from other forms (eg, acute onset, associated with life-changing event, severe injury, most refractory
to therapy with PDE-5); speaker considers age and potency status most important predictors of outcome after RP; patients
>60 yr of age experience significant change in sexual function, regardless of choice of therapy; patients potent before
surgery more likely to retain potency; recovery of erectile function gradual
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| Minimizing ED: nerve-sparing surgery and intraoperative neurostimulation not effective
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| Pharmacologic approach: study results for therapy with PGE1 —among 27 men after radical retropubic prostatectomy
(RRP), 12 received PGE1 3 times weekly starting 1 mo after surgery, 15 did not receive PGE1 ; 67% of patients who received
PGE1 had spontaneous erections, compared to 25% with no PGE1 ; optimal time for therapy—among 73 patients
who had RP, 36 received PGE1 within 3 mo and 37 after 3 mo; 72% of patients who had early PGE1 reached end
point of good erection, compared to 40% who had therapy later; study results for therapy with PDE-5—patients underwent
nerve-sparing prostatectomy with normal IIEF score (>24) and real-time Regiscan monitoring before surgery; patients
treated for 36 wk with 50 mg sildenafil (Viagra) nightly, then no sildenafil for 8 wk before reevaluation; potency
defined as return to baseline IIEF score and Regiscan results; 27% of patients on sildenafil returned to baseline, compared
to 4% on placebo; tadalafil chosen as alternative (lasts longer in serum); second study—132 patients undergoing
surgery for prostate cancer received sildenafil; patients could choose injection therapy if 4 oral doses of 100 mg of
sildenafil ineffective; 74 patients received no therapy after surgery; after 18 mo, 64% of patients who received sildenafil
(with or without injection) had unassisted erections, compared to 18% receiving no therapy; in treatment group,
IIEF scores on average 22.6 (in nontreatment group, average score 12); time to response 9.4 mo (13.3 mo with no treatment);
immunophilins—hypothesized that pretreatment could help nerve regeneration; effect of pretreatment with immunophilin
ligands (eg, FK506) being evaluated
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| Penile rehabilitation after cryotherapy: study of 325 patients, 127 of whom were potent before therapy; patients treated
with vacuum device beginning at 6 wk after surgery; oral PDE-5 added after 6 mo; no patients potent immediately after
therapy; 29% recovered potency at 1 yr, 48% at 2 yr, and 52% at 3 yr; study weaknesses—no control group; poor definitions
of erectile function; only 58 patients evaluated at 2 yr, 42 at 3 yr, and 19 at 4 yr
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| Current investigational trials: treatment with sildenafil after radiation and hormone therapy for prostate cancer; nerve-
sparing RP with and without nerve grafting; effects of immunophilin GP1485—patients received oral GP1485 4 times
daily before surgery, with or without sildenafil; initial analysis at 12 mo showed no difference in level of function or
time to return of function; trial of tadalafil in patients with radiotherapy terminated because of slow recruitment
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| PEYRONIE’S DISEASE: CURRENT AND FUTURE MANAGEMENT —Dr Donatucci
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| Treatment: no therapies approved by Food and Drug Administration (FDA); treatment options include observation, oral,
injected, and topical therapies, and surgery; speaker rarely uses nonsurgical therapies because of poor efficacy
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| Oral therapy: speaker uses vitamin E 400 IU bid; antioxidant may prevent progression of condition; aminobenzoate (Potaba;
vitamin B-derivative) has no proven benefit; considered safe, but expensive and causes gastrointestinal (GI) side
effects; colchicine inexpensive and may benefit patients, but can cause GI distress and (in high doses) aplastic anemia;
speaker uses 0.6 to 1.2 mg colchicine in patients who have severe debilitating pain (does not use published dose of 2.4
mg long-term); tamoxifen has no proven benefit and unacceptable side effects (eg, alopecia); carnitine of no proven
benefit
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| Intralesional therapy: steroids have no benefit and increase risk for tissue atrophy, which can complicate subsequent surgery;
no data to support use of orgotein; verapamil—collagenase; causes less fibroblast proliferation, decreases extracellular
matrix; conflicting data on efficacy from controlled trials; interferon—showed slight (insignificant) benefit in
controlled trial; significant adverse events (eg, acute flu-like syndrome); study results—121 of 1000 patients treated
with intralesional verapamil; all had duplex ultrasonography (US) before and after therapy; no improvement in arterial
function; decreased curve (mean 30°) in 60%; after 23 mo, improvement reported in curvature, rigidity, and sexual
function, regardless of Kelami classification of severity; verapamil 10 mg injected into plaque after penile block
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| Study of electromotive (iontophoresis) administration of verapamil and steroid (dexamethasone) into tunica albuginea;
unclear whether effects due to verapamil or dexamethasone; found 43% of patients experienced decrease in curvature;
girth increased in 43% of treated patients; study weakness—small number of patients
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| Topical verapamil (gel): off-label use; reported 90% efficacy, but no placebo-controlled trials; study to determine whether
drug penetrated plaque—verapamil gel used in patients 12 hr before surgery to place penile prosthesis; no verapamil
found in biopsies of tunica albuginea taken during surgery
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| Extracorporeal shock wave therapy: popular in Europe, but interpretation of results difficult, due to variation in techniques
and measurement of outcomes
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| Controlled clinical trial of collagenase planned for Dupuytren's contracture may provide data
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| Surgical options: plication procedure to reduce curvature, incision and/or excision with graft, or placement of prosthesis;
patient expectations—important to discuss realistic outcomes before surgery (eg, good outcome defined as 70%
improvement in function); patient should not expect return to previous length; preoperative vascular work-up (eg, duplex
US) important for all patients to predict outcome; patients with significant arteriovenous dysfunction candidates
for prosthesis
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| Tunica plication: indicated if adequate rigidity, simple curve <60°, no hourglass or hinge effect, and adequate length;
speaker favors excision over incision grafting procedures for patients with complex bidimensional curves, or destabilizing
or hourglass hinging; plication simple, minimally invasive, has less risk for ED, and does not cause shortening of penis;
can cause nodules under skin when performed without incision; methods—result acceptable when performed in
dorsal curve with ventral incision and plication suture; Schroeder procedure good for incision and plication (no resection
of tunica albuginea as in Nesbit plication) using absorbable (eg, 2-0 PDS or 2-0 Maxon) sutures in patients >40 yr of
age; for patients <40 yr of age, speaker recommends use of proline in center flanked by 2 absorbable sutures to avoid
formation of aneurysm; incise longitudinally and close transversally using 3-mm incisions to avoid palpable abnormalities
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| Excision and graft procedure: required for patients with severe disease (curvature >60°); graft materials—no ideal material
available; vein, dermis, tunica, and artificial grafts tested; solvent-dehydrated human dura mater (Tutoplast) and
SurgASSIST grafts used most often; results better when all of defect excised and large graft inserted; early mobilization
important after surgery using vacuum device and adjunctive anti-inflammatory agents
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| Placement of penile prosthesis: best for patients with inadequate rigidity and without pharmacotherapy; perform incision
over prosthesis using SurgASSIST graft to allow straightening
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| New treatments: stretching of tunica albuginea using device to extend penis; no data supporting efficacy
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| LONG-TERM SEXUAL FUNCTION IN PATIENTS WITH CONGENITAL CONDITIONS —Michael Erhard, MD,
Chair, Department of Surgery, Division of Pediatric Urology, Nemours Children’s Clinic, Jacksonville, FL
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| Congenital conditions affecting boys: gonadal failure, eg, male intersexes (rare), abdominal muscle deficiency
(prune-belly syndrome) and undescended testis, Klinefelter’s syndrome (affects 1 in 500); transport failure, eg, disruption
caused by surgery, congenital absence of vas, posterior urethral valves
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| Congenital conditions affecting girls: gonadal failure, eg, intersex conditions, Turner’s syndrome; XO, mosaic pattern;
genital tract failure—eg, spina bifida, exstrophy, uterine malformations (bicornuate uterus, uterus didelphys, septated
uterine malformations), vaginal atresia (midline müllerian abnormalities, Mayer-Rokitansky-Küster-Hauser
syndrome lacking midline structure and proximal two-thirds of vagina); patients cannot have children but can have good
sexual function after bowel vaginoplasty
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| Cryptorchidism: affects 2% to 3% of boys (<1% by 1 yr of age); surgery best before 1 yr of age; 20% to 30% of patients
with proximal hypospadias and nonpalpable gonads have intersex status and need chromosomal evaluation; unilateral
cases—incidence of infertility 8% to 10% (similar to normal population); surgery indicated to prevent future
problems (eg, hernia); bilateral cases—19% have normal sperm count, 50% to 60% infertile or subfertile; patients with
bilateral intra-abdominal undescended testes at most risk; treat by orchidopexy, with or without adjuvant gonadotropin-
releasing hormone (GnRH) analogues to stimulate germ cells
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| Prune-belly syndrome: includes intra-abdominal undescended testicles; germ cell neoplasias may occur; most have
Sertoli cells only; if fertility possible, consider early surgery
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| Hypospadias and epispadias: key issues include amount of urethroplasty needed and degree of curvature of penis
(surgical issues similar to those in Peyronie’s disease, eg, correction of chordee by bagging nerves and dorsal venous
complex can affect erectile function); often significant dorsal curvature associated with epispadias, but outcomes usually
good if long urethra successfully closed; mapping of nerves—imaging studies of fetal clitoris and penis show similar
placement of nerves and corporeal ultrastructure, with absence of nerves at 12 o’clock position, so plication procedure for
hypospadias performed in dorsal midline (eg, Heineke-Mikulicz fashion); location of nerves (eg, splayed toward glans)
also important during plication and reduction surgery for congenital adrenal hyperplasia; studies also provided more stable
vascular pedicles for improved urethroplasty
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| Functional disorders in girls: congenital adrenal hyperplasia and female pseudohermaphroditism; fertility not impaired,
but vagina and urethra confluent with urogenital sinus going to apparent hypospadias with male phallus; case example
had bilateral nonpalpable gonads, suggesting congenital adrenal hyperplasia, rather than presence of palpable
gonad, suggesting male patient with mosaic pattern causing ambiguous genitalia, hypospadias, and undescended testicle
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| Clitoral virilization: may regress with treatment; timing and number of stages for total reconstruction controversial;
speaker favors single-stage procedure performed early; procedure includes vaginoplasty, with or without clitoroplasty
and labioplasty; vaginoplasty uses flap or V-Y advancement flap and mobilization of urogenital sinus; high rate of vaginal
stenosis requiring revision if procedure performed early (3-6 mo of age); reevaluate patient at 6 to 12 wk after procedure
and before puberty; clitoroplasty performed to reduce erectile tissue; avoid damaging nerve supply to glans and
dorsal skin; dorsal skin reconstructed in labioplasty
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| Spina bifida: lower potential for orgasm in female patients if lesion above T10; patients fertile; many have premature labor
and cesarean deliveries; male patients may have erections (similar dependence on location of lesion above or below
T10); therapy—PDE inhibitors and vacuum devices work well; fertility depends on location of lesion (lower lesions
more likely to be fertile); patients may have had reconstructive bladder-neck surgery that disrupts ejaculatory ducts or
may be azospermic
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| Exstrophy: omphalocele most severe; testicles generally normal in boys, but may be undescended intra-abdominal; difficult
to reconstruct epispadias and bladder neck, due to lack of musculature; dorsal erectile deformities found; girls fertile
but have anatomic problems, eg, uterine prolapse
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| Lack of penis: few treatment options
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Suggested Reading
Goddard et al: Development of feminizing genitoplasty for gender dysphoria. J Sex Med 4(4Pt1):981, 2007; Henry
GD, Wilson SK: Updates in inflatable penile prostheses. Urol Clin Norht Am 34:535, 2007; Hsieh MH et al: Associations
among hypospadias, cryptorchidism, anogenital distance, and endocrine disruption. Curr Urol Rep 9:137, 2008; Jordan
GH: Peyronie’s disease: update on medical management and surgical tips. Can J Urol 14Suppl1:69, 2007; Kadioglu
A et al: Graft materials in Peyronie’s disease surgery: a comprehensive review. J Sex Med 4:581, 2007; Kim DF et al:
Subjective patient-reported experiences after surgery for Peyronie’s disease: corporeal plication versus plaque incision with
vein graft. Urology 71:698, 2008; Kumar R, Nehra A: Dual implantation of penile and sphincter implants in the post-
prostatectomy patient. Curr Urol Rep 8:477, 2007; Lean WL et al: Clitoroplasty: past, present and future. Pediatr Surg Int
23:289, 2007; Lee YS et al: Genital anomalies in Klinefelter’s syndrome. Horm Res 68:150, 2007; Levine LA, Newell
MM: Fast Size Medical Extender for the treatment of Peyronie’s disease. Expert Rev Med Devices 5:305, 2008; Lorenzo
AJ: The “perfect” hypospadias repair: Are we there yet? Can Urol Assoc J 2:115, 2008; Madeb R et al: Patient-reported
validated functional outcome after extraperitoneal robotic-assisted nerve-sparing radical prostatectomy. JSLS 11:443, 2007;
Markiewicz MR et al: The oral mucosa graft: a systematic review. J Urol 178:387, 2007; McCullough AR: Rehabilitation
of erectile function following radical prostatectomy. Asian J Andorl 10:61, 2008; Mulhall JP et al: Artery sparing
radical prostatectomy—myth or reality? J Urol 179:827, 2008; Rambhatla A et al: Rationale for phosphodiesterase
5 inhibitor use post-radical prostatectomy: experimental and clinical review. Int J Impot Res 20:30, 2007; Russell S et al:
Systematic evidence-based analysis of plaque infection therapy for Peyronie’s disease. Eur Urol 51:640, 2007; Snodgrass
WT: Management of penile curvature in children. Curr Opin Urol 18:431, 2008; Taylor Fl, Levine LA: Peyronie’s
Disease. Urol Clin North Am 34:517, 2007; Wilt TJ et al: Systematic review: comparative effectiveness and harms of
treatments for clinically localized prostate cancer. Ann Intern Med 148:435, 2008; Zippe CD, Pahlajani G: Penile rehabilitation
following radical prostatectomy: role of early intervention and chronic therapy. Urol Clin North Am 34:601, 2007.
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