Vasculogenic erectile dysfunction in teenagers: a 5-year multi-institutional experience

Emergent Penile Venous Stripping for Treating Adolescent Impotence

INTRODUCTION

Traditional anatomy-based penile venous surgery is deemed inadequate. Based on revolutionary insights into penile vasculature, penile venous stripping (PVS) shows promise in treating adolescent erectile dysfunction (AED). We aimed to report on this novel approach.

METHODS

We conducted a retrospective analysis of 223 individuals under 30 diagnosed with veno-occlusive dysfunction (VOD) between 2009 and 2023. Among them, 83 were diagnosed with AED and divided into the PVS (n = 37) and no-surgery (NS, n = 46) groups. All participants had been dissatisfied with conventional therapeutic options. Dual pharmaco-cavernosography was the primary diagnostic modality. PVS involved stripping the deep dorsal vein and two cavernosal veins after securing each emissary's vein with a 6-0 nylon suture. Erection restoration was accessed using the abridged five-item version of the International Index of Erectile Function (IIEF-5) score system and the erection hardness scale (EHS). Statistical analysis was performed using IBM SPSS 21.0.

RESULTS

There were significant differences (both p < 0.001) between the preoperative and postoperative IIEF-5 scores in the PVS and NS groups (9.8 ± 3.0 vs. 20.4 ± 2.2; 9.9 ± 2.5 vs. 9.5 ± 2.1), as well as in the EHS scores (1.7 ± 0.7 vs. 3.5 ± 0.6 and 1.8 ± 0.5 vs. 1.3 ± 0.4). The satisfaction rate was 87.9% (29/33) in the PVS group and 16.7% (17/41) in the NS group.

CONCLUSIONS

AED can be effectively treated using physiological methods, although larger patient cohorts are needed for validation.

Investigating the prevalence of erectile dysfunction among men exposed to organophosphate insecticides

INTRODUCTION

Erectile dysfunction (ED) poses a significant disease morbidity and contributor to male infertility, where an estimated 20-40% of men are affected annually. While several risk factors have been identified in the etiology of ED (e.g., aging, heart disease, diabetes, and obesity), the complete pathogenesis remains to be elucidated. Over the last few decades, the contribution of environmental exposures to the pathogenesis of ED has gained some attention, though population studies are limited and results are mixed. Among environmental contaminants, organophosphate (OP) insecticides represent one of the largest chemical classes, and chlorpyrifos is the most commonly used OP in the U.S. OP exposure has been implicated in driving biological processes, including inflammation, reactive oxygen species production, and endocrine and metabolism disruption, which have been demonstrated to adversely affect the hypothalamus and testes and may contribute to ED. Currently, studies evaluating the association between OPs and ED within the U.S. general population are sparse.

METHODS

Data were leveraged from the National Health and Nutrition Examination Survey (NHANES), which is an annually conducted, population-based cross-sectional study. Urinary levels of 3,5,6-trichloro-2-pyridinol (TCPy), a specific metabolite of the most pervasive OP insecticide chlorpyrifos, were quantified as measures of OP exposure. ED was defined by responses to questionnaire data, where individuals who replied "sometimes able" or "never able" to achieve an erection were classified as ED. Chi-square, analysis of variance (ANOVA), and multivariable, weighted linear and logistic regression analyses were used to compare sociodemographic variables between quartiles of TCPy exposure, identify risk factors for TCPy exposure and ED, and to analyze the relationship between TCPy and ED.

RESULTS

A total of 671 adult men were included in final analyses, representing 28,949,379 adults after survey weighting. Approximately 37% of our cohort had ED. Smoking, diabetes, aging, Mexican-American self-identification, and physical inactivity were associated with higher ED prevalence. Analysis of TCPy modeled as a continuous variable revealed nonsignificant associations with ED (OR = 1.02 95% CI [0.95, 1.09]). Stratification of total TCPy into quartiles revealed increased odds of ED among adults in the second and fourth quartiles, using the first quartile as the reference (OR = 2.04 95% CI [1.11, 3.72], OR = 1.51 95% CI [0.58, 3.93], OR = 2.62 95% CI [1.18, 5.79], for quartiles 2, 3, and 4, respectively).

CONCLUSIONS

The results of our study suggest a potential role for chlorpyrifos and other OPs the pathogenesis of ED. Future studies are warranted to validate these findings, determine clinical significance, and to investigate potential mechanisms underlying these associations.

Association of high LDL concentrations with erectile dysfunction from a Mendelian randomization study

Lipid metabolism plays a key role in erectile dysfunction. Our purpose was to evaluate the influence of lipid-lowering drugs on erectile dysfunction employing a two-sample Mendelian randomization (MR) study. Genetic instruments were employed to represent the exposure of lipid-lowering drugs. Inverse variance-weighted MR (IVWMR) was employed to calculate the estimation of effects. IVW-MR analysis showed that the positive relationship between the expression of HMGCR and the risk of erectile dysfunction (odds ratio [OR] = 1.27, 95% confidence interval [CI] 1.03-1.57; p = 0.028). No significant relationship was detected between NPC1L1, PSK9 expression and erectile dysfunction. This MR study suggested that HMGCR inhibitors are a more desirable treatment modality for patients with ED.

Role of shear wave elastography measured in the flaccid state in predicting arteriogenic erectile dysfunction

The gold-standard method for diagnosing arteriogenic erectile dysfunction (AED) is the penile Doppler ultrasonography. We proposed a novel method for predicting AED using ultrasonic shear wave elastography (SWE) considering that the former was invasive and variable. A total of 98 male patients were enrolled in our study, referred for ED between December 2018 and October 2020. For comparison, we also included 42 volunteers from the Healthy Physical Examination Center of our hospital. The Penile Doppler Ultrasonography (PDU) and SWE were performed for all patients with the intracavernosal injection (ICI). We named three groups as AED group, nonvascular ED group and healthy controls group. No statistically significant differences were found among the three groups in terms of demographic and clinical characteristics. There were no significant differences in IIEF-5 between AED and nonvascular ED. A significant (r = 0.642, p < 0.0001) positive correlation between flaccid and erectile SWE was observed. With a cut-off value of 13.45 KPa, the area under curve, specificity, and sensitivity of the SWE values under the flaccid state in distinguishing AED from healthy subjects were 0.867, 0.786 and 0.896 respectively. The SWE value in the flaccid state can distinguish the AED from healthy subjects.

Erectile Dysfunction Resistant to Medical Treatment Caused by Cavernovenous Leakage: An Innovative Surgical Approach Combining Pre-operative Work Up, Embolisation, and Open Surgery

OBJECTIVE

Thirty per cent of cases of erectile dysfunction (ED)/male impotence are resistant to oral treatment. Half of these cases are due to blood drainage from the corpora cavernosa occurring too soon, due to cavernovenous leakage (CVL). The aim of this study was to report on an innovative treatment scheme combining pre- and post-operative haemodynamic assessment, venous embolisation, and open surgery for drug resistant ED caused by CVL.

METHODS

An analysis of prospectively collected data, with clinical and haemodynamic pre- and post-operative assessment, was carried out. Forty-five consecutive patients operated on for drug resistant ED caused by CVL were evaluated pre-operatively and three months post-operatively by pharmacologically challenged penile duplex sonography (PC-PDS), pharmacologically challenged Erection Hardness Score (PC-EHS), and pharmacologically challenged computed caverno tomography (PC-CCT). Follow up consisted of patient interview, PC-PDS, PC-EHS and if needed PC-CCT.

RESULTS

Mean patient age was 43.9 ± 12.0 years (range 20-67). Forty-nine per cent of patients had primary ED. Patients with diabetes, a smoking habit, hypercholesterolaemia, and hypertension were 18%, 11%, 9%, and 4%, respectively. Three months post-operatively, PC-EHS increased from 2.0 ± 0.7 to 3.1 ± 0.74 (p < .001), with an EHS of 3 being the threshold allowing for penetration. Deep dorsal vein velocity, a haemodynamic marker of CVL, decreased from 14.2 ± 13.0 to 0.9 ± 3.5 cm/s (p < .001). After a 14.0 ± 10.7 month follow up, the primary success rate (clinical EHS ≥ 3, possible sexual intercourse with penetration, no vascular re-operation, no penile prosthesis implant) was 73.3%. Four patients (9%) underwent successful re-operation for persistent ED and CVL. Accordingly, compared with a possible penetration rate of 8.9% before surgery, 37 patients (secondary success rate: 82.2%) were able to achieve sexual intercourse with penetration. Type of ED (primary vs. secondary) and diabetes had no influence on the results. Thirty-two per cent of patients with secondary success achieved penetration with no medication.

CONCLUSIONS

After a 14 month follow up, pre-operative work up, embolisation, and open surgery during the same procedure allowed patients with ED resistant to oral medical to achieve intercourse with penetration.

Evaluation of the effects of chronic stress applied from the prepubertal to the adult stages or only during adulthood on penile morphology in rats

The present study aimed to evaluate the effects of chronic stress from the prepubertal to the adult stages or during adulthood on penile morphology in rats. The animals were immobilized in a cylinder for 2 h daily for a total of six weeks to simulate stress. Ten rats were exposed to stress stimulus beginning from the prepubertal age, while nine rats were exposed to stress stimulus only during adulthood. Animals were killed at 24 h after the last stress session for short-term evaluation (SP-S and SA-S), while other age-matched rats were sacrificed at 6 weeks after the last stress session for long-term evaluation (SP-L and SA-L). Age-matched animals were used as controls (CP-S, CA-S, CP-L and CA-L). After treatment, serum testosterone levels and areas of cavernosum structures were evaluated. We observed no changes in serum testosterone levels after stress treatment. Results revealed that the area of the corpus cavernosum without the tunica albuginea in animals in the SA-S group was 16% lower than that in the CA-S group. The smooth muscle was 31% lower in the SP-L group than in the SP-S group and 42% lower in the SA-S group than in the CA-S group. The elastic fiber system was 48% lower in the SP-L group than in the CP-L group and 59% lower in the SA-S group than in the CA-S group. Chronic stress promoted morphological changes in the rat penis and was significantly more pronounced when the stress occurred throughout the adulthood. Chronically applied single stress stimulus caused greater damage to the penis when induced directly during adulthood than when introduced before puberty to adulthood and could be associated with erectile dysfunction.

Peyronie's disease in teenagers

INTRODUCTION

Peyronie's disease (PD) is commonly seen in middle-aged men, and little is known about this condition in teenagers.

AIM

To investigate the characteristics of PD in teenagers.

METHODS

The findings were compared between patients with the disease who were teenagers with those over 40 years of age. Statistical analyses were conducted to define differentiating features between these two groups.

MAIN OUTCOME MEASURES

The demographics, clinical features, and associated comorbidities of patients with PD were reviewed.

RESULTS

Thirty-two teenaged males were evaluated for PD in a single institution over a 10-year period. The median age for our cohort was 18 (15-19) years. Forty-five percent of patients had already been seen by another urologist, and 28% had been told they did not have PD. The mean duration of PD before seeking medical care in our cohort was 3 ± 1 months. Sixteen percent of patients reported antecedent penile trauma, half of which happened during coitus or masturbation, and 18% of patients had hemoglobin (Hb) A1c levels > 5%. Dupuytren's contracture was not seen in this population. Twenty-two percent of patients presented with penile pain. Subsequent ED was seen in 37% of patients. Multiple noncontiguous plaques were seen in 37% of patients. Twelve percent were previously treated with vitamin E, while another 12% had previous intralesional verapamil. High distress was reported by 94% of patients. Thirty-four percent sought medical attention for anxiety/mood disorder, and 28% had a negative encounter with a sexual partner related to PD. All of the 32 patients had penile curvature with a mean of 32 ± 12 degrees. Seventy-two percent of the patients had dorsal curvature while 22% had an associated deformity. Using duplex Doppler ultrasound, 12% had a calcified plaque, while none of the patients had abnormal hemodynamics. When compared with PD in adults, teenagers had greater than seven times the prevalence of multiple noncontiguous plaques (37% vs. 5%). Also, the prevalence of HbA1c level > 5% was higher in the teenagers as well (18% vs. 5%).

CONCLUSIONS

PD does occur in teenagers often causing high distress levels. Compared to older adults, teenagers often present earlier, and more commonly have elevated HbA1c level and increased number of plaques at presentation.