Peyronie's patients may benefit from implants

Key Points

Newer treatments for male sexual dysfunction highlighted at the 2010 AUA annual meeting are allowing urologists to improve patients' quality of life and satisfaction with treatment. Accordingly, urologists' confidence in prescribing these treatments, where indicated, is growing, said John Mulcahy, MD, PhD, a private-practice urologist in Madison, AL.

"Many men are disappointed with penile implants when the erection is a little shorter than it used to be," Dr. Mulcahy said. "When there is dissatisfaction, the number one reason is erection size."

"They work, but they tend to exaggerate curvature," Dr. Mulcahy explained.

Implants may help Peyronie's patients

However, one study shows that the vast majority of patients with Peyronie's disease who underwent implantation with a length-expanding inflatable penile prosthesis were satisfied after surgery. Postoperatively, these patients had either minimal or no curvature, and nearly all were able to have intercourse. Accordingly, Dr. Mulcahy said that because reputable researchers found these implants created no significant issues with increased curvature, urologists should not dismiss them summarily, as they previously might have.

Implants designed to provide length as well as girth will not enlarge the penis, he added. However, Dr. Mulcahy noted, "Physicians can say there's going to be less shortening than there was in the past. This will improve patient satisfaction and physician confidence."

Likewise, a multicenter European study reveals that a technique for lengthening and widening the penis simultaneously with prosthesis implantation boosted patients' length and girth. As such, nearly all patients reported satisfaction with the procedure.

However, Dr. Mulcahy cautioned that the procedure requires virtually disassembling and reassembling the penis around the implant.

"If you get too aggressive with the penis, blood only flows in one direction-from the base to the tip," Dr. Mulcahy said. "If you interrupt the blood supply, the result is a dead penis." Likewise, he says the procedure requires mobilizing the dorsal neurovascular bundle.

"If you're not careful in mobilizing the bundle, you'll produce a numb head," Dr. Mulcahy said. For these reasons, he says the average private-practice urologist should carefully consider whether to perform the procedure.

Further evidence of TRT benefits

Other research at the AUA meeting spotlights the benefits of testosterone replacement therapy (TRT)-even for some men with a history of high-risk prostate cancer. Testosterone-deficient men tend to feel lethargic, develop obesity, and experience bone mineral loss and ED, Dr. Mulcahy said. But until about 5 years ago, he added, experts believed that prescribing testosterone in men with prostate cancer histories would only fuel the cancer.

More recently, however, urologists have learned that that is not the case, he said. Small case series began to show that men who had undergone definitive radical prostatectomy could undergo TRT without incident, as could men with a low risk of recurrence.

"We're finding that replacing testosterone tends to be safe, and we're getting more courageous in treating men with prostate cancer with TRT," Dr. Mulcahy said. "There might even come a day when we're giving it to men with advanced prostate cancer."

In one study, TRT given to patients with a history of radical prostatectomy and high-risk characteristics caused no statistically significant change in PSA. Similarly, in a retrospective, multi-institution study, implantable testosterone pellets provided sustained testosterone levels, were well tolerated, and caused no significant PSA impact.

"Many urologists are using these, and they seem to be getting good results," Dr. Mulcahy said.

In another retrospective study, TRT caused no biochemical recurrence in post-prostatectomy men who had had organ-confined prostate cancer.

"The idea that TRT will negatively affect the prostate is becoming a myth. And all these papers are confirming that. Now we can more confidently prescribe TRT in hypogonadal patients who had prostate cancer," Dr. Mulcahy said.

Moreover, he said that expanded use of TRT is teaching urologists more about its side effects and which patients make good candidates. Additionally, three studies show that urologists may be able to use clomiphene citrate (Clomid) to boost testosterone levels.

"It's never been dramatically effective in improving sperm count," Dr. Mulcahy said. "But now it's been shown to improve testosterone levels."

In another area of research, papers show that a lidocaine/prilocaine spray appears effective at delaying premature ejaculation. While the use of non-prescription lidocaine/prilocaine in a cream formulation for this indication is not new, pharmaceutical manufacturers are attempting to legitimize the product through the FDA drug approval process, Dr. Mulcahy noted.

Further in the future, he said that gene therapy may show promise for treating ED.

"Gene therapy actually grows new penile cells. The penis is very easily adaptable to this because it's so accessible. You stick a needle into it and get right where the action is or isn't," Dr. Mulcahy said.

However, he noted that a highly publicized 1999 case involving fatal toxicity caused by gene therapy of the liver (Mol Genet Metab 2003; 80:148-58) temporarily dampened enthusiasm for such treatments. Gene therapy research has since resumed in earnest, Dr. Mulcahy said, but it could be a decade or more before it achieves widespread use.