AndrologyHigh-yieldUpdated Aug 202630 min read

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Priapism

Definition: erection persisting > 4 hours beyond, or unrelated to, sexual stimulation
Classification (3): ischemic · non-ischemic · recurrent (stuttering)

Ischemic vs Non-ischemic

Feature	Ischemic (veno-occlusive, low-flow)	Non-ischemic (arterial, high-flow)
Frequency	Majority	Rare
Pain	Yes, fully rigid + tender	No, tumescent but not rigid
Blood gas	Hypoxic, hypercarbic, acidotic	Normal
Etiology	Non-traumatic	Trauma (straddle injury → cavernosal artery laceration)
Emergency?	Yes — emergency	No — not emergent

Stuttering = recurrent ischemic episodes with confirmed ischemia; most commonly sickle cell disease (also the most common cause in children/adolescents)
EF recovery by time to reversal: <12h ≈100% → 12–24h ≈75% → 24–36h ≈50% → ≥36h ≈0%
- Duration is the key driver of future ED — the most significant complication of prolonged ischemic priapism

Risk factors

Hematologic: SCD (priapism in 23–89% of homozygous males by age 18), thalassemia, hemolytic anemias, leukemia, myeloma
Medications (9 classes): α-blockers, trazodone/antipsychotics, anticoagulants, antihypertensives, hydroxyzine, ADHD agents, recreational (cocaine, alcohol, marijuana), hormones (testosterone, GnRH), intracavernosal erectile agents
Other: GU/pelvic trauma, thrombophilia, metabolic (Fabry, amyloid), neurogenic, malignant infiltration

Diagnosis

Mandatory: H&P + corporal blood gas (aspiration)
Optional: CBC, Hgb electrophoresis, tox screen; penile duplex US only when ischemic vs non-ischemic is indeterminate (not the primary diagnostic test)

History — the elements that change management

Duration of the erection · presence of pain · previous episodes and how they were treated · baseline erectile function · use of erectogenic therapies · medications and recreational drugs · sickle cell disease, hemoglobinopathies, hypercoagulable states · trauma to the pelvis, perineum or penis

Investigations to consider — cavernosal blood gas (mandatory) · CBC · PT/PTT · urine toxicology · hemoglobin electrophoresis · penile duplex (only if ischemic vs non-ischemic is unclear)

Source	PO₂	PCO₂	pH
Normal arterial	>90	<40	7.40
Mixed venous	40	50	7.35
Ischemic priapism	<30	>60	<7.25

Gas results are sometimes reported in kPa — 1 kPa = 7.5 mmHg.

Management — Ischemic

Conservative measures are NOT recommended — observation, oral agents and cold packs have no role in established ischemic priapism, and cold compresses are contraindicated in sickle cell disease. Do not delay transfer.

Initial measures — monitored bed · IV access · hydration and oxygen · analgesia · ± hematology consult

(Oral terbutaline and pseudoephedrine are described for injection-induced prolonged erection, but are not recommended in established ischemic priapism — go to aspiration.)

First-line: corporal aspiration ± irrigation ± intracavernosal phenylephrine (aspiration alone resolves ~36%)

Aspiration technique

Penile nerve block first — infiltrate around the entire base of the shaft with 1% lidocaine WITHOUT epinephrine, or bupivacaine without epinephrine
19-gauge needle on a large syringe. Insert laterally through the shaft — this avoids the corpus spongiosum and urethra ventrally, and the neurovascular bundle dorsally
Aspirate 20–30 mL from the 2 or 10 o'clock position while milking the shaft. Because the corpora communicate, aspiration on one side is usually enough
If the initial aspirate is bright red rather than dark venous blood, suspect an arterial cause and treat as high-flow
Aspirate first to fill the corpora with fresh oxygenated blood before injecting
Once detumescence is achieved, apply an elastic bandage around the shaft to keep the corpora empty and compress the puncture site

Phenylephrine

Dilute to 100–500 mcg/mL; supplied as 10 mg in 1 mL, so dilute before use
Inject at 3 or 9 o'clock near the base, 0.5–1.0 mL per dose, doses ≥5 min apart, continue up to 1 hour
Max ~1 mg (hypertensive stroke reported at cumulative 2 mg); monitor BP/HR
α-agonist of choice (α1-selective, fewest cardiac effects); off-label
AE: hypertension + reflex bradycardia (most common), headache, dizziness, arrhythmia
Have atropine ready (0.02–0.05 mg/kg) for reflex bradycardia — involve the ER physician
Second line epinephrine; third line methylene blue
If persistent > 1 hour despite injection + aspiration → surgical shunting
Surgical shunting (only after BOTH α-agonist AND aspiration/irrigation attempted)
Consider for events ≤72 hours; forego shunt if > 72 hours
Distal first (corporoglanular), with or without tunneling — optimal type undefined

Distal (preferred)	Proximal (historical)
Percutaneous (WET): Winter (needle, least effective), Ebbehoj (No.11 blade), T-shunt (No.10 blade) +/- Snake maneuver (tunneling)	Quackles (cavernosum→spongiosum)
Open (ATC): Al-Ghorab (5-mm distal tunica cone), Tunneling (Hegar dilator), Combined	Grayhack (→saphenous vein)
	Barry (→deep dorsal vein)

AE of shunting (6): penile edema, hematoma, infection, urethral fistula, penile necrosis, PE
Acute ischemic priapism > 36 h → options: observation/pain control · distal shunt ± tunneling · early penile prosthesis (within 2 weeks) — infection rate <10%; corporal fibrosis not yet established so length preserved

Management — Stuttering (recurrent ischemic) prevention

Children should receive alpha agonists (oral and intracavernosal) plus a PDE5 inhibitor
Adults — 5α-reductase inhibitors · antiandrogens · GnRH agonists · intracavernosal alpha agonists · baclofen · pseudoephedrine · PDE5i · home self-injection α-agonist · ketoconazole + prednisone
Use alpha agonists with caution in hypertensive patients
SCD-specific: hydroxyurea, chronic exchange transfusion (reduces episodes — not primary treatment of an acute episode)

Management — Non-ischemic (not an emergency)

First-line: observation (spontaneous/conservative resolution up to 62%); reasonable 4-week trial → Second-line: percutaneous fistula embolization — detumescence ~85%, ~80% retain erections, recurrence ~30% (offer a 2nd attempt); bilateral embolization ↑ ED risk → Surgical ligation last resort (transcorporal; most urologists inexperienced)
Compression therapy may work, especially in children — continuous compression with a strap-on dressing
Surgical ligation carries a risk of long-term impotence
Prolonged erection (≤4 h) after ICI: distinct from priapism; conservative ± in-office phenylephrine; treat as ischemic only if > 4 h

Peyronie's Disease

Definition: acquired fibrosis of the tunica albuginea (TGF-β1) ± pain, deformity (curvature/indentation/hinge/shortening), ED, distress
Plaque location: dorsal in 60–70% (deviates toward the affected/scarred side)

Things commonly got wrong

Peyronie's is not rare
Once it has stabilized, there is usually no further progression
It does not have a high likelihood of spontaneous resolution
It is not a disease of only middle-aged men, nor only of white men
Trauma to the flaccid AND the erect penis can activate the scarring process
ED is frequently found in men with Peyronie's
Plaque calcification is NOT an indication of mature, chronic-phase disease

Risk factors — "IT DRAG A Crooked Wand"

Infection · Trauma · Diabetes · Radical prostatectomy (11–16%) · increasing Age · Genetic · Autoimmune · Collagen disorders (Dupuytren, plantar fascia/Ledderhose, tympanosclerosis) · aberrant Wound healing

Hypogonadism → more severe disease; PDE5i are not associated
Associated conditions: aging · diabetes · ED in 37–58% · psychological distress · radical prostatectomy · hypogonadism · collagen disorders

Natural history

Pain resolves in ≈90%
Curvature: improves only 12–13%, worsens ≈45%, stable ≈42%
Active (acute): changing symptoms ± pain, up to 18 months
Stable (chronic): unchanged ≥3 months

Diagnosis

Mandatory: H&P (penis examined on stretch; baseline stretched length)
Recommended before invasive treatment: assess erect deformity — ICI ± duplex US (gold standard) or home photographs/protractor

What a complete duplex assessment gives you

Identification and measurement of plaque calcification
Objective measurement of the erect deformity — curvature, girth irregularity, hinge effect
Identification of corporal fibrosis
Observation of the erectile response to vasoactive injection
Penile vascular parameters — PSV, EDV, resistive index

PDQ questionnaire — 15 questions, 3 domains: psychological and physical symptoms (6 items) · penile pain (3 items) · effects of symptoms (6 items)

Management — Non-surgical

Active phase: NSAIDs for pain

Stable phase

Penile traction — first-line non-invasive; wear ≥3 h/day
Intralesional + modeling: collagenase · verapamil · interferon α-2b
ESWT — conditional, for pain only (do NOT use to reduce curvature — may worsen it)
Oral agents largely ineffective (vitamin E, tamoxifen, procarbazine not recommended)

Oral agents

Agent	Mechanism	Outcome
Pentoxifylline	Blocks the TGF-β1 inflammatory pathway; prevents type-I collagen deposition	Decreased curvature in 33%, mean 23°; IIEF increase vs placebo — the only oral with a positive signal
Potaba	Raises monoamine oxidase activity → antifibrotic	Decreased plaque size, no curvature change
Vitamin E	Antioxidant	No benefit
Tamoxifen	Induces TGF-β in an estrogen-receptor-independent fashion	No benefit
Colchicine	Microtubule depolymerization	No benefit
Carnitine	Increases mitochondrial respiration	No benefit

Intralesional agents

Agent	Mechanism	Outcome
Clostridial collagenase	Selectively degrades collagen I & III	Curvature ↓ 34% (mean 17°) vs 18% (mean 9.3°) placebo
Interferon α-2b (withdrawn from the European and US markets in 2021; no longer carries an EAU recommendation)	↓ fibroblast proliferation and collagen production, ↑ collagenase	Curvature ↓ 27% (13.5°) vs 9% (4.5°) placebo
Verapamil	CCB — inhibits fibroblast proliferation and ECM protein synthesis; ↑ collagenase activity	Reduced curvature and plaque-associated narrowing
Nicardipine	Dihydropyridine CCB — more effective than verapamil in vitro at reducing glycosaminoglycan synthesis	Reduced pain, improved IIEF-5, smaller plaque — no benefit in curvature

Poor candidates for verapamil: extensive calcification, curvature > 90°, or ventral curvature — the plaque cannot be adequately infiltrated
Predictors of verapamil success: age under 40 and curvature > 30°

External force

Modality	Outcome
Penile traction	Length +0.5–2.0 cm, girth +0.5–1.0 cm, curvature ↓ mean 20°, plaque softening; satisfaction 85%
Electromotive drug administration	Verapamil alone: no benefit. Verapamil + dexamethasone: curvature 43° → 21°
ESWT	Improves pain, IIEF-5 and QoL — no curvature reduction
Vacuum	Angle ↓ 5–25° in 21 of 31 patients; AEs include urethral bleeding, skin necrosis, penile ecchymosis
Radiotherapy	No clinical benefit; possible malignant change, increased ED risk in the elderly

Collagenase (Xiaflex) — degrades collagen I & III; reduces curvature + plaque, does not treat pain or ED

Candidates: curvature >30° and <90°, intact EF, single dorsal/lateral plaque, no hourglass/calcification, no ventral curvature
IMPRESS: 17° improvement
AE: corporal rupture (penile fracture), bruising, pain, swelling, hematoma
Plication or grafting can be performed after collagenase without added technical difficulty

Management — Surgical

Indications (4): stable disease (≥1 yr from onset + ≥3–6 mo stable) · deformity preventing intercourse (>30°) · failed non-surgical · desire for rapid/reliable result

Choice depends on erectile function + deformity severity:

Option	Use when	Notes
Plication (Nesbit, Yachia, 16-dot)	Simple curvature <60°, adequate length, no hourglass or hinge effect, anticipated length loss <20% of total erect length	Preserves rigidity; causes shortening; recurrence >30° ≈10%
Plaque incision/excision + grafting	Complex curves >60°, large plaques, hourglass, shaft narrowing, extensive calcification, short penis	Better length; higher ED/rigidity-loss risk; needs strong pre-op erections
Penile prosthesis	Refractory ED + deformity	Gold standard when ED coexists; IPP preferred

Pre-operative consent — set these expectations

Goal is "functionally straight" — residual curvature under 30°
Length: more likely shorter with plication than with grafting
Diminished rigidity: ≥5% in all studies (grafting more than plication); ≥30% if pre-operative erectile quality was suboptimal
Decreased sensation: typically resolves in 1–6 months; rarely compromises orgasm or ejaculation

Technique notes

Historically the plaque was totally excised — this produced large graft onlays with an unacceptably high ED rate. Plaque incision replaced it: a modified-H or double-Y incision at the point of maximum curvature
Plaque excision and grafting is preferable when the area of maximum deformity is excised, particularly with severe indentation
Ventral curvatures repaired with grafting have a much higher rate of complete ED
Prosthesis + significant residual curvature (>30°) → manual modeling (full inflation, force opposite max curvature 90 sec); urethral injury = most common AE of modeling
- If residual curvature still exceeds 30° after modeling, make a relaxing incision in the tunica over the maximum curvature. If the incisional defect is > 2 cm, place a biograft (pericardium or SIS) to prevent cicatrix contracture or prosthesis herniation
- Post-operative prolonged cylinder inflation — keep the device inflated 10–30 minutes daily for 3 months, starting 6 weeks after surgery
- AMS 700 CX and Titan have the best intrinsic rigidity and best correct curvature associated with tunical scarring

Predictors of post-operative ED

Age > 55 · corporeal veno-occlusive dysfunction with RI < 0.80 · large tunica defect and graft size · ventral curvature · curvature > 60°

Graft material

The ideal graft approximates the strength and elasticity of normal tunica albuginea; minimal morbidity and tissue reaction; readily available; not too thick; pliable and easy to size and suture; inexpensive; infection-resistant; preserves erectile capacity.

Class	Examples	Notes
Autologous (historical)	Fat, dermis, tunica vaginalis, dura mater, temporalis fascia, saphenous vein, buccal mucosa	—
Synthetic	PETE (Dacron)	No longer recommended — infection, inflammatory response, fibrosis
Pericardium (human/bovine)	—	Thin, strong, do not contract; no reports of infection or rejection
Small intestinal submucosa (porcine)	—	Similar advantages, but graft contraction — especially one-ply — with recurrent curvature in 37–75%; subgraft hematoma 26%, infection 5%
Tachosil	—	No suturing needed; usable for hourglass deformity

Post-operative rehabilitation — massage and stretch, nightly PDE5i, traction therapy: to prevent shortening and possibly recover length, encourage straight healing, preserve vascular integrity, and encourage partner participation

Counsel: residual curvature, shortening, ↓rigidity, ↓sensation

Erectile Dysfunction

Physiology

Parasympathetic S2–S4 (cavernosal) → erection/tumescence · Sympathetic T10–L2 → detumescence + emission · Somatic pudendal (Onuf, S2–S4) → sensation + ischio-/bulbocavernosus contraction
NO = principal erectile neurotransmitter (nNOS → initiation, eNOS → maintenance) → ↑cGMP → smooth-muscle relaxation; PDE5 degrades cGMP
Norepinephrine = principal neurotransmitter of flaccidity (and is high in psychogenic ED)

How the smooth muscle actually relaxes

Flaccidity — NE plus endothelin-derived factors (endothelin, PGF2α) raise intracellular calcium → increased smooth-muscle tone
Erection — NO raises cGMP and cAMP, which activate protein kinases producing three effects:
1. Opening of K⁺ channels → hyperpolarization
2. Sequestration of intracellular calcium into the endoplasmic reticulum
3. Blockade of calcium influx by inhibiting voltage-gated calcium channels
The event that initiates detumescence after a normal erection is a transient rise in intracorporal pressure
Endothelin-1 is the most potent vasoconstrictor
PGE1 → erection · PGF2α + endothelin + NE → flaccidity

Psychogenic vs reflexogenic erection

Psychogenic — audiovisual or fantasy. Pathway: brain → T11–12 and S2–4
- A lesion above T9 abolishes psychogenic erection
- Psychogenic stimulation alone is not enough for penetration
Reflexogenic — tactile stimuli to the penis. One tract ascends to the sensory perception area; the other goes to the autonomic nuclei in the cord, then the cavernous nerve
- Rigidity comes mainly through somatic pathways
- Preserved in 95% of complete upper-cord lesions vs 25% of lower-cord lesions
- In a complete injury above T12: reflex erection, but no emission and no ejaculation
- Patients with sacral cord injury retain psychogenic erectile ability even though reflexogenic erections are abolished

Central neurotransmitters

Neurotransmitter	Effect
Dopamine	D1 and D4 enhance erection; D2 enhances seminal emission
Serotonin (5-HT)	Inhibits sex drive and the spinal sexual reflex; 5-HT1A inhibits erection and facilitates ejaculation; 5-HT2C enhances erection
Norepinephrine	Enhances sexual function centrally — peripherally it drives flaccidity
GABA	Inhibits erectile signals
Opioids	Inhibit penile erection
Cannabinoids	Inhibit sexual function
Oxytocin	Enhances the appetitive and reinforcing effects of sexual activity
Nitric oxide	Mediates erection at the paraventricular nucleus
Melanocortins	MCR4 enhances erection
Prolactin	Suppresses sexual function

Testosterone

Enhances sexual interest, frequency of sexual activity and frequency of nocturnal erection; relaxes penile artery and cavernous smooth muscle
The threshold for normal erection is 300 ng/dL (≈10.4 nmol/L)

Classification

Organic — "ED VAN": Endocrinologic · Drug-induced · Vasculogenic · Anatomic · Neurogenic · vs psychogenic vs mixed
Psychogenic clues: present nocturnal/masturbatory erections, situational, recent stress, performance anxiety

Pathophysiology in three failures

Failure	Type	Marker
Failure to initiate	Neurogenic	(yohimbine, an α2 antagonist, targets this)
Failure to fill	Arterial	PSV < 25
Failure to store	Venous leak	EDV > 5

Risk factors, by adjusted odds ratio

Condition	Odds ratio
Antidepressant use	9.1
Antihypertensive use	4.0
Diabetes mellitus	2.9
Obstructive urinary symptoms	2.2
Hypertension · smoking · BPE	1.6
BMI > 30 · physical inactivity	1.5
Cardiovascular disease	1.1

93% of men with ED develop it about 24 months before the onset of ischemic heart disease — ED is a sentinel symptom
Acebutolol (β1-selective) causes less ED; α1-blockers and ARBs enhance erection

Diagnosis

Mandatory: H&P + morning total testosterone
diabetes screen (fasting glucose/HbA1c) + lipid panel + questionnaires: SHIM/IIEF-5 (5 items, score 1–25, assesses the past 6 months, >21 = normal erectile function), IIEF (15 items, 5 domains), EHS
Further labs where indicated: bioavailable testosterone, TFT, LFT, LH, FSH, prolactin, PSA

History — what to cover

Partner interview · onset and duration · number of partners · difficulty generating vs maintaining · global vs situational · constant vs intermittent · morning and nocturnal erections · rigidity · last satisfying intercourse · curvature · physical capacity · desire · ejaculation · orgasm · PMHx, PSHx, medications, family and social history

Sexual activity imposes a cardiac stress equivalent to

Walking 1 mile in 20 minutes · briskly climbing 2 flights of stairs in 10 seconds · 4 minutes of the Bruce treadmill protocol

Princeton classification — cardiac risk before resuming sexual activity

Low risk	Intermediate	High risk
Asymptomatic, < 3 CAD risk factors; mild stable angina; uncomplicated previous MI; LVD/CHF NYHA I–II; post-successful revascularization; controlled hypertension; mild valvular disease	≥ 3 CAD risk factors; moderate stable angina; recent MI > 2 but < 6 weeks; LVD/CHF NYHA III; non-cardiac sequelae of atherosclerosis	High-risk arrhythmias; unstable or refractory angina; recent MI < 2 weeks; LVD/CHF NYHA IV; hypertrophic obstructive cardiomyopathy; uncontrolled hypertension; moderate-to-severe valvular disease

Vascular evaluation, in sequence

Combined intracavernosal injection and stimulation (CIS) — first line
Penile duplex US — second line, and the most accurate vascular test. Assess at 5, 10, 15 and 20 minutes

Parameter	Normal	Abnormal
PSV	> 35 cm/s	< 25 = arterial insufficiency; 25–35 is equivocal
EDV	< 5 cm/s	> 5 = veno-occlusive dysfunction
RI = (PSV − EDV) ÷ PSV	> 0.8	< 0.8 = veno-occlusive dysfunction

A patient with an arteriovenous fistula will NOT have a negative end-diastolic velocity
Indications for penile duplex: priapism (persistent or partial erection after treatment for ischemic priapism) · young patient with ED · trauma with ED · refractory ED · Peyronie's disease · endocrinopathy
Dynamic infusion cavernosometry and cavernosography — for suspected vasculogenic leak from trauma, or lifelong ED; usually precedes penile vascular surgery
Penile angiography — young patient with ED secondary to traumatic arterial disruption
NPTR — reserved for when it will change management

Management ladder

1st: PDE5 inhibitors → 2nd: ICI / intraurethral alprostadil / vacuum device → 3rd: surgery (prosthesis) Plus conservative throughout: psychosexual counseling, medication change, lifestyle/exercise (~+3 IIEF-EF)
Treatment is shared decision-making — a patient may decline any non-surgical line and go straight to a prosthesis

PDE5 inhibitors — augment but do not induce erection

PDE5i	Onset	Duration (T½)	Food effect
Sildenafil	30–60 min	~12 h (4 h)	High-fat ↓ efficacy
Vardenafil	30–60 min	~10 h (4 h)	High-fat ↓ efficacy
Tadalafil	60–120 min	~36 h (17.5 h)	Not affected
Avanafil	15–30 min	~6 h (5 h)	Not affected

Absolute CI: nitrates (precipitous hypotension, no antidote — avoid nitro 24 h sildenafil/vardenafil, 48 h tadalafil, 12 h avanafil), hypersensitivity
Relative CI: severe renal/liver disease, severe cardiac (MI <6 mo), NYHA class II, non-selective α-blockers, anti-arrhythmics (vardenafil — QT), hereditary retinal disorders (retinitis pigmentosa), history of priapism
AE: headache, flushing, dyspepsia, nasal congestion, visual disturbance
Cross-reactivity: sildenafil and vardenafil hit PDE6 (vardenafil is the most selective); tadalafil hits PDE11
- Sildenafil is the most likely to cause visual disturbance — blue vision, color blindness — via PDE6; NAION (sudden vision loss) is the serious one
Initial response rate is 70% — but only 50% in diabetics
After 7–10 days of daily tadalafil the serum level is maintained
Drug interactions: ketoconazole, itraconazole and protease inhibitors (ritonavir) block CYP3A4 → reduce the PDE5i dose; rifampin induces CYP3A4 → higher doses needed

Indications for regular (daily) dosing

The patient wants spontaneity
Coexisting LUTS — tadalafil only
Before prostatectomy, to familiarize the patient — the rationale is anti-fibrotic, since the cavernous nerves undergo neuropraxia post-operatively

Post-operative ED rates

Operation	ED
Radical prostatectomy	43–100%
Nerve-sparing RP	30–50%
Abdominoperineal resection	15–100%
Nerve-sparing rectal surgery	< 10%
Pelvic fracture — early realignment	34%
Pelvic fracture — late	42%

Intracavernosal injection: trimix = alprostadil + papaverine + phentolamine (more pain); bimix = papaverine + phentolamine (more priapism); limit 10 injections/month (fibrosis); CI = MAOI, poor dexterity, psych instability, coagulopathy/unstable CV, priapism risk

Regimen	Success
Monotherapy	70%
Bi-therapy (either agent + phentolamine)	90%
Trimix	90%

Alprostadil (PGE1) is the only FDA-approved agent — raises cAMP; most common side effect is pain; expensive; 10–20 µg
Papaverine — vasodilator and non-specific PDE inhibitor (2, 3, 5) → raises cGMP and cAMP; priapism 35%, fibrosis, impaired LFTs
Phentolamine (α-blocker) maintains the erection — must not be given alone
The principle of bimix/trimix: lower the dose of each agent to cut side effects, while gaining synergy

MUSE (intraurethral alprostadil)

Useful for floppy glans syndrome; lower incidence of prolonged erection than ICI
Contraindicated in urethral stricture, meatal stenosis, balanitis
AE — pain, minor urethral bleeding, priapism, hypotension/hypersensitivity
Must not be used during unprotected intercourse with a pregnant partner — it may induce uterine contractions — and not in couples trying to conceive

Vacuum device — the constriction ring must not be left in place longer than 30 minutes

Arterial revascularization — candidate criteria

Under 55 years · non-smoker · non-diabetic · no venous leakage · radiographic confirmation of internal pudendal artery stenosis
Highest success in men under 30 with isolated arterial stenosis after perineal or pelvic trauma
Venous reconstructive surgery remains investigational

Penile Prosthesis

Types

Type	Subtypes	Notes
Non-inflatable	Malleable	Cheap, easy, low failure; more erosion ,constant rigidity, no girth ↑
Inflatable	2-piece, 3-piece	Most physiologic; 3-piece reservoir in space of Retzius

Limited dexterity → semirigid; prior pelvic surgery (RP, cystectomy, APR) → submuscular reservoir
2-piece when pelvic surgery has restricted the space of Retzius
Pre-op: stretched penile length ≈ maximal post-op length (counsel re: shortening + glans softening)
Indications: refractory ED · refractory ED with Peyronie's · priapism lasting > 36 hours

Approaches

Approach	Advantages	Disadvantages
Peno-scrotal (commonest)	Easier to bury the tubing; easier pump placement	Challenging reservoir placement
Infrapubic	Easier reservoir placement	Nerve bundle injury; very challenging pump placement
Subcoronal	—	—

Preparation

Good glycemic control — one meta-analysis put the cut-off at HbA1c 11
Ask the patient NOT to shave
10-minute alcohol-based skin prep
Gentamicin + vancomycin, or cefazolin + gentamicin, or cefazolin alone
Post-operative antibiotics for 24 hours only [EAU, AUA]

Operative principles

Penoscrotal incision → good exposure of the corporotomy sites
Dilate to 13 mm distally, 12 mm proximally
Malleable girths: 13, 11, 9.5 mm. Inflatable: standard 18 mm if dilated to 13; narrow base if dilated only to 10
Reservoir — usually the space of Retzius, after piercing transversalis fascia
- After radical prostatectomy, placing the reservoir through the inguinal canal into Retzius has caused bowel compression on inflation, requiring surgical intervention
- Ectopic alternative — submuscular suprafascial, between rectus above and transversalis fascia below. A finger through the inguinal canal creates a space pointing toward the umbilicus; a long nasal speculum, then a double-hinged or ring clamp, develops the cavity 3–4 inches inside the internal inguinal ring
Pump — anterior sub-dartos, in the most dependent area
Water-tight corporal closure → drain → pressure dressing → keep the catheter

Intra-operative troubleshooting

Cross-over

Remove both cylinders; place a large dilator in the common cavity; redilate the opposite cavity pointing laterally and place a cylinder in it; remove the dilator and place the second cylinder in the original common cavity
Test by inflating — the Foley should sit midline with both cylinders symmetrical either side

Corporal perforation

	Recognition	Management
Proximal	> 1 cm difference in measurement	Windsock (foreign material — a possible infection source, hard to remove) or a suture sling securing the exit tubing of the ipsilateral cylinder
Distal	A visible dilator, or fluid leak, with an intact urethra	Remove the cylinder. A Foley is not mandatory — urine will not enter, by the Bernoulli principle. A cylinder may go in the opposite crus to maintain length. Re-implant after 5–6 months
Urethral	Blood at the meatus	Abort placement on that side and repair; leave a Foley ~10 days and re-attempt at ~6 weeks

The most likely site of corporal perforation during placement is the septum

Curved erection after cylinder placement

< 20° is acceptable and should permit intercourse
> 20° → manual modeling for 90 seconds after clamping the pump tubing with shodded clamps, to protect the pump from back-pressure. Repeatable. Alternatively a Nesbit/plication, or plaque incision and grafting

Post-operative complications

Penile necrosis — at risk: severe cardiovascular disease, diabetes, chronic smoking, previous prosthetic implants, prior pelvic radiation. Counsel pre-operatively, especially with two or more. When ischemic necrosis is detected, remove the cylinders promptly to take pressure off the penis; conservative debridement.

Cylinder erosion / extrusion — remove the cylinder; place a spacer cylinder in the opposite corporal body to maintain patency and preserve length; replace after 5–6 months, once solid scar has obliterated the erosion tract.

Autoinflation — in the obese patient, keep the implant completely deflated during healing so the capsule forms around a larger space. If the cylinders are partially filled, the reservoir is not completely full and the smaller capsule limits future expansion → autoinflation.

Infection — two options

Leave the implant out. Irrigation drains in each corporal body, wound closed; antibiotic solution instilled every 8 hours for 3 days. Return in 2–6 months to replace — cylinders are harder to place because of corporal scarring, and the erection will be noticeably shorter
Salvage — remove the infected prosthesis, wash out, immediately replace the device. Successful in 80%

Delayed re-implantation causes secondary corporal fibrosis, decreased penile size and a harder reinsertion — minimize by re-operating 6–12 weeks post-op
Salvage is contraindicated in: enterococcus, tissue necrosis, sepsis, diabetic ketoacidosis, or cylinder erosion into the urethra

Antiseptic washes during salvage

Dilute povidone-iodine 0.35–3.5% in the implant cavities, left 3 minutes; wash out with saline or antibiotic solution
Eliminate hydrogen peroxide — no antiseptic advantage over povidone-iodine and it can be cytotoxic
Chlorhexidine may be more effective but the data are insufficient; pressure irrigation optional

SST deformity — conservative first, pulling the penile skin toward the scrotum. If that fails, glans pexy — tack the glans to the distal tunica albuginea with a non-absorbable 3-0 suture.

The commonest post-operative complaint after prosthesis placement is length loss

Ejaculatory & Orgasmic Dysfunction

Emission (sympathetic T10–L2) → seminal fluid into prostatic urethra + bladder-neck closure (α-sympathetic)
Ejection (somatic pudendal S2–S4) → rhythmic bulbocavernosus contraction, antegrade expulsion

SCI level	Ejaculation potential
Above T12	No (may have reflex ejaculation)
T12–L1	Possible (± retrograde)
L2–L4	Likely
Sacral	High

Unlike erectile capacity, the ability to ejaculate increases with descending levels of spinal injury. Fewer than 5% of complete upper motor neuron lesions retain the ability to ejaculate.

Premature Ejaculation (PE)

Definition (ISSM 2013): ejaculation ≤1 min (lifelong) or bothersome reduction to ≤3 min (acquired) + inability to delay + negative personal consequences
Lifelong PE is neurologic in etiology. Acquired PE — performance anxiety, psychosocial problems, ED, chronic prostatitis, recreational drugs, hyperthyroidism
Treat comorbid ED first. 1st: psychosexual therapy (squeeze, stop-start)
2nd: pharmacotherapy — "PASTA" (all off-label):
- PDE5i (only if comorbid ED)
- Anesthetic topical — 2.5% lidocaine/prilocaine, 20–30 min pre-intercourse, wipe before penetration
- SSRIs — dapoxetine on-demand

Drug	Dose	Timing	Evidence
Dapoxetine	30–60 mg	On demand, 1–3 h before	High — the only approved oral agent, in > 60 countries
Paroxetine	10–40 mg	Once daily	High
Sertraline	50–200 mg	Once daily	High
Fluoxetine	20–40 mg	Once daily	High
Citalopram	20–40 mg	Once daily	High
Clomipramine	12.5–50 mg	Daily, or on demand 3–4 h before	High
Topical lignocaine/prilocaine	Titrated	On demand, 20–30 min before	High
Tramadol	25–50 mg	On demand, 3–4 h before	Low — risk of opiate addiction
PDE5i	Sildenafil 25–100 · tadalafil 10–20 · vardenafil 10–20 · avanafil 50–200 mg	30–50 min before	Low; moderate combined with an SSRI
Alprostadil	5–20 µg intracavernosal	5 min before	Very low — priapism and corporal fibrosis risk

Paroxetine gives the strongest delay — IELT increases about 8.8-fold. But dapoxetine is the only approved oral drug — EAU 2026 carries a Strong recommendation for either dapoxetine or a lidocaine/prilocaine spray as first-line in lifelong PE.
The delay usually appears within 5–10 days of starting treatment
SSRIs and tramadol are all contraindicated with MAOIs
Attempt graduated withdrawal of drug therapy after 6–8 weeks

Delayed Ejaculation / Anejaculation / Anorgasmia

Causes: psychogenic; aging (DM — afferent nerve degeneration); endocrine (hypothyroidism, hyperprolactinemia); neurogenic
- Radical prostatectomy → no ejaculate, orgasm preserved
- RPLND → anejaculation in non-nerve-sparing; nerve-sparing preserves antegrade in 80–100%
- SSRIs → ejaculatory dysfunction in ~60%
Management: psychosexual therapy, lifestyle, pharmacotherapy, vibratory stimulation/electroejaculation for SCI (risk of autonomic dysreflexia)

Causes — of retrograde ejaculation, delayed ejaculation, anejaculation and anorgasmia

Category	Causes
Aging male	Degeneration of penile afferent nerves
Psychogenic	Inhibited ejaculation
Congenital	Müllerian duct cyst · Wolffian duct abnormality · prune-belly syndrome
Anatomic	TURP · bladder-neck incision
Neurogenic	Diabetic autonomic neuropathy · MS · SCI · radical prostatectomy · proctocolectomy · bilateral sympathectomy · abdominal aortic aneurysm surgery · para-aortic lymphadenectomy
Infective	Urethritis · genitourinary tuberculosis · schistosomiasis
Endocrine	Hypogonadism · hypothyroidism
Medication	Alpha-methyldopa · thiazides · TCA and SSRI antidepressants · phenothiazine · alcohol abuse

The diagnostic algorithm — start with: is there orgasm?

Never → either failure of emission (neurogenic, metabolic, drug side effect → disease-specific management) or inhibited male orgasm (→ psychosexual therapy)
Sometimes → inhibited male orgasm with nocturnal/masturbatory emissions (→ psychosexual therapy), or age-related degeneration (→ reassure, alter technique)
Always → then ask: is there ejaculation?
- No → are sperm present in the urine after orgasm?
  - No → aspermia — think ejaculatory duct obstruction
  - Yes → retrograde ejaculation — reassure/educate, pharmacotherapy, surgery
Orgasm without any antegrade ejaculate is called aspermia, anejaculation, or dry ejaculation

Drug therapy for delayed ejaculation / anejaculation

Drug	As needed	Daily
Cabergoline	—	0.5–2.0 mg every 3 days
Pramipexole	—	0.125–0.25 mg
Amantadine	100–400 mg, two days before coitus	100–200 mg bid
Bupropion	—	150 mg daily or bid
Reboxetine	—	4–8 mg
Buspirone	—	5–15 mg bid
Cyproheptadine	4–12 mg, 3–4 h before	—
Oxytocin	24 IU intranasal during coitus	—

Pseudoephedrine does NOT help delayed ejaculation — it is only for retrograde ejaculation

Retrograde Ejaculation

RF: bladder-neck surgery (TURP), diabetes
Dx: post-orgasmic urinalysis for sperm and fructose (vs failure of emission) — indicated when the ejaculate volume is < 1 mL
Rx: α-agonists (pseudoephedrine, ephedrine, midodrine), imipramine
- Pseudoephedrine 120 mg every 6 hours the day before coitus, and twice on the day of coitus, produced antegrade ejaculation in 58% of a predominantly diabetic group
- Imipramine 25 mg BID

Other

Painful ejaculation: treat underlying cause (urethritis, BPH, prostatitis/CPPS, seminal vesiculitis, seminal vesicular calculi, EDO)
- Occurs in 17–23% of men with LUTS/BPH
Ejaculatory anhedonia: sufferers may be male or female; aware of orgasm and ejaculation but experience little or no pleasure
- Assess total and free testosterone, pituitary gonadotropins and prolactin. If there is hyperprolactinemia or secondary hypogonadism, get a pituitary MRI
- Pharmacotherapy and psychotherapy — cabergoline 0.5–3 mg every 3 days
Post-orgasmic illness syndrome (POIS): flu-like myalgia/fatigue within 30 min of orgasm; proposed type-1 hypersensitivity; trial autologous-semen desensitization