Penis strangulation caused by a steel ring: A Case Report

==inizio objective==

To describe a man with penis strangulation caused by a steel ring and its successful removal.

==fine objective==

==inizio methodsresults==

A 33 year-old man presented to our emergency department with a 3-hour history of a grossly swollen and painful penis due to a stainless steel ring located at the base of the penis for erection enhancement during intercourse. After intercourse, he was unable to remove the ring and the penile pain and swelling progressively worsened.
At presentation, the patient also complained of pain in his lower abdomen and hypoesthesia in his genitalia. He had no comorbidities and no history of mental illness or substance abuse.
On examination, the patient was anxious and distressed. Abdominal bulging was absent, although guarding and tenderness were present in the lower abdomen. A 2.5-cm-diameter, 2-cm wide and 2-mm-thick ring was positioned tightly at the base of the penis.
The incarcerated penile shaft was grossly edematous and bluish with areas of exudation, cool and diminished in sensation.
The small diameter of the ring and edematous tissue made it impossible to pull out the ring from the shaft.
Hence, the fire department was contacted to obtain assistance; after consultation with them, the decision was made for the fire personnel to remove the steel ring using their hydraulic cable cutter. After disinfection, 1% lidocaine was injected at the base of the patient’s penis. The ring was sheared in two places and successfully removed without injury to skin and other tissue. After removal of the ring, circulation and skin color of the penis and scrotum were restored. At follow-up 2 weeks later, the edema had resolved and the skin had completely healed. Urination, skin sensation, and erectile function had returned to normal after 1 week. Urinalysis results were normal. On examination, a discontinuous circumferential scar was evident at the base of the penis.

==fine methodsresults==

==inizio results==

The hydraulic cable cutter avoided thermal injury and shortened removal time compared with other procedures described. The patient’s recovery was uneventful, with erectile function restored after 1 week.

==fine results==

==inizio discussions==

Ring-shaped objects are placed on the penis often to enhance sexual performance and for autoerotic purposes or curiosity.(1,2). The ring hinders venous return and leads to swelling, followed by arterial and lymphatic blockage and ischemia distal to the ring (3, 4) Timely removal of the offending object is paramount for full recovery of circulatory and urinary functions and in most cases further management is unwarranted. Delay in removal can lead to penile necrosis, urethrocutaneous fistula, and even septic shock and death (3, 4, 5, 6).
Management depends on the type and size of the constricting object, time after incarceration, degree of injury, available instruments, and experience of the physicians (2). The literature describes four approaches for removal of the object: string technique, aspiration, cutting, and surgery (2, 5, 7, 8). Special implements are often needed, which are not always available in the emergency and urology departments (1, 3, 4, 9, 10). Indeed, management delay is typically caused by locating an appropriate tool (2). However, their use introduces the risk of thermal burn or mechanical damage to genitalia tissue. Furthermore, a protective device needs to be inserted between the edematous genitalia and the ring, which can increase pressure and pain (5). The Winter procedure can be attempted, but the surgery is lengthy and poses a risk of injury (2).
We believe that ours is the second report of a hydraulic cable cutter being used to shear a constricting object. The cutter posed no risk of thermal injury and was capable of directional and power adjustments. We also did not need to insert a protective device between the ring and genitalia; thus, no ensuing injury occurred.

==fine discussions==

==inizio conclusion==

Genital incarceration is an urgent clinical situation requiring prompt treatment. However, suitable tools for removing the foreign object are not readily available in emergency and urology departments. Cooperation with other disciplines, even non-medical disciplines, can result in creative and timely measures for removal of the object.

==fine conclusion==

==inizio reference==

1. Efthimiou I., Kazoulis S., Christoulakis I. Penile and scrotal strangulation caused by a steel ring: a case report. Cases J. 2008;1:45.

2. Wu X., Batra R., Al-Akraa M. Penoscrotal entrapment: a safe, innovative technique for removing metal constricting devices. BMJ Case Rep. 2012;2012

3. Kyei M.Y., Asante E.K., Mensah J.E. Penile strangulation by self-placement of metallic nut. Ghana Med J. 2015;49:57–59.

4. Sathesh-Kumar T., Hanna-Jumma S., De Zoysa N. Genitalia strangulation—fireman to the rescue! Ann R Coll Surg Engl. 2009;91:W15–W16.

5. Osman I., Muñoz A.M., Lozano J.M. Penile incarceration secondary to a ring. Urol Int. 2010;85:245–246.

6. Morentin B., Biritxinaga B., Crespo L. Penile strangulation: report of a fatal case. Am J Forensic Med Pathol. 2011;32:344–346.

7. Santucci R.A., Deng D., Carney J. Removal of metal penile foreign body with a widely available emergency medical-services-provided air driven grinder. Urology. 2004;63:1183–1184.

8. Yousef I., Ismail E., Gomaa M. A ring constriction of the penis: an emergency presentation of an aged man. J Sex Med. 2015;12(Suppl 1):62.

==fine reference==

A strange case of transverse testicular ectopia and testicular fusion due to iatrogenic cause

==inizio objective==

Transverse testicular ectopia (TTE) is a rare anomaly in which both the testes descend through a single inguinal canal and lie in the same hemiscrotum or inguinal region. It is usually found incidentally in patients operated for inguinal hernia or undescended testicles. In the literature, less than 100 cases of TTE have been reported (1). Standard treatment of TTE is mainly surgery, including inguinal hernia repair, transseptal orchiopexy, and the repair of congenital anomalies (2). In this case study, we report the case of a iatrogenic transverse testicular ectopia in a 16 years-old r man who had previously undergone left orchiopexy for testicular torsion. After the procedure the patient complained the absence of the left testis and abnormal enlargement in the right hemiscrotum.

==fine objective==

==inizio methodsresults==

A 16 years-old male patient was admitted to our hospital complaining a left empty hemiscrotum and an enlarged right testis. On the physical examination it was noted the absence of the left testis whereas the right testis was enlarged, with normal texture and without sign of inflammation.
The urethral meatus was in normal localization, and there were no findings related to the hernia in both inguinal canals. Ultrasound scan revealed the presence of both testicles, apparently fused together, located in the right hemiscrotum; left hemiscrotum was empty. Surgical exploration was planned. Through a transverse scrotal incision right hemiscrotum was entered; both testes were located in the right side and partially fused together. The right vas and vascular elements had the conventional course from the right inguinal ring through the right hemiscrotum to the testis; the left cord originated from the ipsilateral inguinal ring going through the scrotal septum to reach the left testis.
The testicles were easily separated each other avoiding any lesion to the tunica albuginea; hence the scrotal septum was partially opened in order to move the left testicle to the proper side.
Bilateral orchiopexy was then performed by using an absorbable suture joining the caudal pole of the testis to the ipsilateral pouch of the scrotum and the septum rebuilt.

==fine methodsresults==

==inizio results==

Post-operative course was uneventful and the patient was discharged the day after the procedure. Follow-up with ultrasound at 6 months after surgery showed both testes properly placed in the scrotum with normal homogeneous granular echotexture and vascularity.

==fine results==

==inizio discussions==

TTE was first reported by von Lenhossek in 1886 (3). The various theories to suggest the etiopathogenesis are: dysfunction of the genitofemoral nerve, true crossover of the testis, both the testis arising from the same genital ridge or both lying in the same processus vaginalis before descent. Management is orchidopexy, either trans-septal or extraperitoneal transposition orchidopexy (4). Laparoscopy better delineates the anatomy and enables us to see the crossing over of the spermatic cord towards the opposite side. It helps assess the testis and its side, vas, and vessels for length. The management depends upon the length of the vas and vessels. If length is severely inadequate, both the testes are fixed in the same hemiscrotum and if the length is adequate, then transseptal orchidopexy is recommended. In cases, where there is inadequate or just adequate length, transseptal contralateral orchidopexy can be done (5).
In the case reported, the transverse testicular ectopia was not due to a congenital abnormal migration of the left testis through the contralateral inguinal canal, but it resulted from the unfortunate consequences of the surgical procedure the patient had been submitted some months earlier.
Scrotal orchiopexy had been performed for left testicular torsion; it is usually a simple procedure with few surgical steps. In this case, the surgeon probably accidentally damaged the scrotal septum so that the left testis could migrate contralaterally then adhering to the right testis in a diminished space available.
Our surgical procedure was simple and effective especially if you consider that the spermatic cords in this case originated from the ipsilateral inguinal ring as usual and did not have a common origin from one side only.

==fine discussions==

==inizio conclusion==

The transverse testicular ectopia should be considered as an extremely rare complication of scrotal surgery; the integrity of the scrotal septum should be respected in order to avoid this occurrence.

==fine conclusion==

==inizio reference==

1. Fourcroy JL, Belman AB. Transverse testicular ectopia with persistent müllerian duct. Urology. 1982;19:536–8
2. M.W. Gauderer, E.R. Grisoni, T.A. Stellato, J.L. Ponsky, R.J. Izant Jr. Transverse testicular ectopia J. Pediatr. Surg., 17 (1982), pp. 43-47
3. Von Lenhossek MN. Ectopia testis transversa. Anat Anz. 1886;1:376–81.
4. Pandey A, Gupta DK, Gangopadhyay AN, Sharma SP. Misdiagnosed transverse testicular ectopia: A rare entity. Hernia. 2009;13:305–7.
5. Raj V, Redkar R, Krishna S, Tewari S. Rare case of transverse testicular ectopia – Case report and review of literature. Int J Surg Case Rep. 2017;41:407–10

==fine reference==

MEGAPENE ACQUISITO: corporoplastica riduttiva con rinforzo in pericardio bovino

==inizio abstract==

Si descrive correzione chirurgica di raro caso di cedimento strutturale dell’albuginea di entrambi i corpi cavernosi, esteso per pressochè tutta l’asta con risparmio di pochi centimetri alla base, con risultante incremento circumfereziale del pene tale da rendere fortemente disagevole l’ attività sessuale penetrativa.
Caso clinico: paziente di 55 anni con sviluppo senza causa apparente di deformazione simil-aneurismatica del pene con circonferenza massima di 21 cm. Rigidità conservata. Iter diagnostico: cavernosometria/-grafia dinamica e RNM basale e dinamica, con conferma di dilatazione aneurismatica di entrambi i corpi cavernosi.
Tecnica chirurgica: incisione circumferenziale e degloving dell’asta, estrusione dell’asta tramite incisione scrotale. Bilateralmente incisioni parauretrali a tutta lunghezza della fascia di Buck e completo scollamento della stessa – con nel suo contesto il fascio neurovascolare dorsale – dai corpi cavernosi. Erezione indotta: albuginea assottigliata nell’area di cedimento strutturale. Misurazioni circumferenziali seriate e calcolo della riduzione circumferenziale da ottenere. Conseguente asportazione bilaterale di losanghe di albuginea. Punti di ancoraggio introflettenti in Biosyn rinforzati da continua incavigliata in PDS. Confezionamento di patch in pericardio bovino (Supple Peri-Guard, Synovis) a coprire l’intera circonferenza dell’albuginea denudata, ad eccezione del corpo spongioso uretrale, fissata con punti di ancoraggio all’albuginea.
Ricostruzione di fascia di Buck. Reinserimento dell’asta nel proprio involucro cutaneo.
Circoncisione formale.

==fine abstract==

MINI-JUPETTE nella climacturia dopo prostatectomia radicale: caveat dopo prima esperienza

==inizio abstract==

Descrizione di sling uretrale “Mini-Jupette” eseguito in corso di impianto protesico penieno idraulico tricomponente per trattare incontinenza ad orgasmo (“climacturia”) e deficit erettile severo dopo prostatectomia radicale.
Caso clinico: paziente di 71 aa status/post prostatectomia radicale robotica e successiva radioterapia di salvataggio, fortemente motivato a ripresa attività coitale penetrativa, nonostante modica incontinenza e climacturia.
Si esegue intervento di Mini-Jupette sec. Andrianne. Incisione scrotale trasversa come da impianto protesico con accesso penoscrotale; esecuzione di corporotomie latero-caudalmente rispetto a impianto standard. Misurazione di distanza tra i margini mediali delle corporotomie e confezionamento di mesh in polipropilene (Pro-Lite, ATRIUM) di misure corrispondenti. Sutura dello stesso in continua alle due corporotomie (margini mediani) e verifica di appropriata tensione. Inserimento standard di protesi idraulica tricomponente. Chiusura corporotomie in continue. Protesi lasciata disattivata.
In prima giornata: rimozione catetere e drenaggio, e dimissione.
Follow-up precoce: completa risoluzione di incontinenza, e ripresa di attività coitale senza climacturia.
A termine video vengono illustrati i principali caveat di questa procedura, alla luce della limitata letteratura disponibile e della prima esperienza personale.

==fine abstract==

Single-institution experience with “penile patches” in patients with Peyronie’s disease and Erectile Dysfunction

==inizio objective==

Multiple guidelines endorse the use of surgery in the treatment of penile deformity as a result of Peyronie’s disease. Penile prosthesis implantation is a treatment choice in patients with erectile dysfunction (ED) and concomitant penile curvature due to Peyronie’s disease1. Residual curvature correction during inflatable penile prosthesis (IPP) implantation in patients with Peyronie’s disease (PD) is common. The aim of this single-institute analysis was to compare surgical outcomes between hemostatic patches and pericardium patches in patients with Peyronie’s diseas and ED managed with inflantable penile prosthesis (IPP) and plaque incision with grafting in case of persistent curve more than 30° after manual modelling.

==fine objective==

==inizio methodsresults==

From January 2015 to December 2018, 62 patients with Peyronie’s diseas and ED received inflantable penile prosthesis implantation and tunical incision and patch graft for persistent curve more than 30° after manual modelling. Tunical defects were more than 2 cm and graft used were Permacol™ (Covidien) or hemopatches [TachoSil® (Takeda) or more recently Hemopatch (Baxter AG)]. All data were collected in a prospectively maintained database and retrospectively analysed.

==fine methodsresults==

==inizio results==

Hemopatches were used in 38 patients (Group A) while Permacol™ was used in 24 patients (Group B). Mean operative time was significantly shorter in the group A (94.16±18.07) than the group B (122.14±28.8) [p10° was present in 3 out of 38 patients of Group A and in 4 out of 24 patients of Group B (p=0.2878). There were no complications due to material used or herniation of IPP trough the tunical defect.

==fine results==

==inizio discussions==

A lot of patches are commonly used for surgical correction of Peyronie’s disease (autologous dermis, tunica vaginalis, dura mater, fascia, saphenous vein, tunica albuginea, buccal mucosa, porcine intestinal submucosa, pericardium, TachoSil®, Hemopatch and synthetic material). The ideal patch should be traction‐resistant, easy to suture and manipulate and flexible, although not to the extent that it allows aneurysmatic dilatation or interferes with the veno‐occlusive function of the albuginea. The cost should also be reasonable2. Nowadays the ideal patch has yet to be determined. Permacol™ (Covidien) was commonly used for ventral hernia repair and abdominal wall reconstruction while TachoSil® and Hemopatch are commonly used for surgical haemostasis.
In our experience the time of procedures with the use of hemopatches was significantly lower probably because it does not require to be suturing to the albuginea. With the use of Permacol we assisted to a more proportion of residual curvature even if it does not reach the statistical significance. Moreover in our experience hemopatch is better than tachosil in adherence to tunica albuginea and appear more stable than Tachosil that is easily fragmentable e it is not stable during the suturing of superficial penile layers. A limitation of this study was the low number of patients and the monocentric nature of the analysis.

==fine discussions==

==inizio conclusion==

In our experience hemopatches [in particular the Hemopatch (Baxter AG)] are better than the Permacol™ in management of patients with ED and Peyronies’ disease. Despite this, nowadays , the final decision will depend on the surgeon’s experience, the patient’s preferences, economic considerations and the characteristics of the plaque.

==fine conclusion==

==inizio reference==

1-Carson CC. Penile prosthesis implantation in the treatment of Peyronie’s disease and erectile dysfunction. Int J Impot Res. 2000 Oct;12 Suppl 4:S122-6.

2- Garcia-Gomez B, Ralph D, Levine L, et al. Grafts for Peyronie’s disease: a comprehensive review. Andrology. 2018 Jan;6(1):117-126.

==fine reference==

VAC-THERAPY IN UROLOGICAL SURGERY: PRELIMINARY EXPERIENCE

==inizio objective==

A review of the literature does not currently have reports on the use of Vac-Therapy in Urology. This therapy has instead been used successfully for years in general surgery, orthopedics, dermatology and burn centers. The aim of this work is to present our experience with Vac Therapy, unique in its kind in the post-surgical management of a complex case of massive abscess of scrotal integuments and cavernous bodies. The Vac-Therapy was born on the basis of the concept borrowed from the doctor Louis Argenta, a scholar of diabetic pathology and diabetic sores and from the bioengineer Michael Morykwas of negative pressure exercisable by an aspiration device. The negative pressure is a pressure lower than the normal atmospheric one, that is 760 mmHg. To obtain the negative pressure it is necessary to remove the gaseous molecules from the affected area (for example a wound) using a suction system. This technique, which involved the use of polyurethane foam and a mechanical vacuum, was called “vacuum-assisted closure (VAC) therapy system” and developed in 1995 with the first marketing after FAD approval. Until 2005, VAC therapy was the only one available on the market to provide suitable negative pressure therapy in the world. The fundamental substrate of Vac Therapy is polyurethane foam, a polymer with large holes (400-600 micrometers) as it ensures, while maintaining porosity, a uniform pressure distribution over the entire site of action. In addition, the volume of the foam undergoing a depressurized reduction determines 3 substantial phenomena: a) stretching of the cells, b) contraction of the wound from the margins to the center with facilitation of the closure of itself, c) total elimination of the fluids present on the site that may favor infections and healing delay. The inert dressing, positioned on the wound and connected to the aspiration source, exerts on it a localized and controlled negative pressure, such as to induce cellular proliferation. Dressings generally need to be replaced every 48 to 56 hours. In the presence of site infection the most frequent medication is recommended. Too long dressing time causes discomfort to the patient by incorporating the granulation tissue into the polyurethane foam.

==fine objective==

==inizio methodsresults==

On 2 July 2019 a 72-year-old diabetic and cardiopathic patient in poor general conditions came to our observation in emergency, for severe post-circumcision complications, in a feverish state, with severe tenderness of the entire genital region, bladder anuria from about 12 hours, with complete swelling of scrotal integuments and supra-pubic region, without signs of cutaneous fistulization, incarceration of the penis of which only the extremity of the glans was recognized. The laboratory framework laid down for mild neutrophilic leukocytosis, with no evidence of PCR and PCT modifications. He was immediately catheterized with RUA resolution and subjected to echocolordoppler examination followed by extemporaneous integration with echocontrastographic survey after bolus administration of 2.4 ml of ecodedicated contrast that confirmed the diagnostic suspicion of a large abscess localized to the scrotal sac and the corpus cavernosum to peno-scrotal angle, where caverno-scrotal fistula was located with saving didymas. On admission the patient was subjected to combination antibiotic therapy with Cefazolin and Metronidazole. A few hours after the observation, the patient underwent an urgent scrototomy surgery with a complete toilet on the intrascrotal and suprapubic abscess caves, identification of incarcerated cavernous bodies and bilateral corporotomy, fistulectomy with subsequent toilet and a wide excision of cutaneous margins; finally two suprapubic and scrotal aspiration drains were positioned. In the postoperative period there was a stabilization of the symptoms but a progressive loss of substance from the surgical site and progressive necrosis of the scrotal suture margins, despite the meticulous dressings with hydrogen peroxide and chlorhexidine. After 5 days it was decided to subject the patient to a new operation this time to remove the necrotic tissue, scarify the scrotal surgical bed and place the Vac-Therapy.

==fine methodsresults==

==inizio results==

The wound was healed using “Vac white foam Small” as a polyurethane foam-based dressing for the treatment of exposed noble structures and with the installation of “Vac Veraflo Medium” instrumentation to obtain negative pressure. Medications were followed twice weekly for 10 days, during which the pressurization device was temporarily deactivated, using only physiological saline and sterile gauze. On 19 July the patient presented a wound with a vital bed, absolutely free of signs of infection and / or contamination with correct granulation. Therefore the Vac Therapy was interrupted and it was decided to proceed with a third surgical intervention aimed at grafting the INTEGRA dermal matrix substitute and at discharge the following day. The patient checked at 90 days was in perfect clinical condition, with complete regeneration of the neoderm and realignment of the scrotal margins on the prosthetic graft which is no longer visible.

==fine results==

==inizio discussions==

==fine discussions==

==inizio conclusion==

VAC is a non-invasive integrated therapeutic system that uses negative pressure, localized and controlled, continuous or intermittent to promote the wound healing process and is particularly effective in the treatment of complex wounds such as: burns, ulcers, diabetic lesions and abscess caves, guaranteeing them a correct asepsis, favoring an early juxtaposition of the margins and an early formation of the granulation tissue. Vac Therapy is contraindicated in the suspicion of cancer cells in the lesion and in the following cases: untreated osteomyelitis, non-enteric and unexplored fistulas, necrotic tissue with eschar. If until now the use of Vac Therapy was almost exclusive at orthopedic, abdominal surgical and dermatological level, our favorable experience on a complex case of scrotum-cavernous abscess allows us to propose the use of Vac Therapy also in urological and andrological surgery.

==fine conclusion==

==inizio reference==

1) Negative pressure wound therapy with saline instillation: 131 patients case series. D. Brinkert, M.Ali, M. Naud, N. Maire, C. Trial, L. Teot. International wound journal ISSN 1742-4801 (2012)
2) Negative pressure wound therapy with instillation, a cost-effective traetment for abdominal mesh exposure. E. Deleyto, A. Garcia-Ruano, J.R. Gonzalez-Lopez. Aest Plast Surg (2017) Hernia DOI 10.1007/s10029-017-1691-y.
3) Platelet-rich plasma, bilareyed acellular matrix grafting and negative pressure wound therapy in diabetic foot infection. W. Deng, J. Boey, B. Chen, S. Byun, E. Lew, Z. Liang, D.G. Armstrong. Jpurnal of Wound Care vol. 25 no 7 July 2016.
4) A new method of salvaging breast reconstruction after breast implant using negative pressurewound therapy and instillation. Ju Yong Cheong, David Goltsman, Sanjay Warrier. Aest Plast Surg (2016) 40:745-748.
5) Negative Pressure Wound Therapy with Instillation and dwell time used to treat infected orthopedic implants: a 4 patients case series. R. Dettmers, W. Brekelmans, M. Leijnen, B. Borger van der Burg, E. Ritchie. US Tomy Wound Management september 2016
6) Sterile-Water negative pressure instillation therapy for complex wounds and NPWT failures. S. Fluieraru, F. Bekara, M. Naud, C. Herlin, C. Faure, C. Trial, L. Teot. 2013 MA Healthcare.
7) L’apport d’une nouvelle mousse dans la therapie par pression negative avec instillation dans la detersiondes plaies. S. Fluieraru, F. Boissiere, C. Faure, L. Teot. Revue francophone de cicatrisation n.2 avril-juin 2017.
8) The impact of negative pressure wound therapy with instillation compared with standard negative-pressure wound therapy: a retrospective, historical, cohort, controlled study. Paul J. Kim, Christopher E. Attinger, John S. Steinberg, Karen K. Evans, Kelly A. Powers, Rex W. Hung, Jesse R. Smith, Zinnia M. Rocha, Larry Lavery. Plastic and reconstructive surgery. March 2014.
9) Vacuum -assisted closure ulta with Veraflo Instillation for the healing of diabetic foot wounds. A. Nather, Wong Le Yi Joy, Chua Chui Wei Mae, Claire Chan Shu-Yi. Scientia Ricerca Vol 1 Issue 1 2016.
10) Novel Foam dressing using negative pressure wound therapy with instillation to remove thick exudate. L. Teot, F. Boissiere, S. Fluieraru. International Wound Journal ISSN 1742-4801 march 2017.
11) The Use of Negative pressure wound therapy with an automated , volumetric fluid administration: an advancement in wound care. Tom Wolvos. Wounds 2013;25(3):75-83.

==fine reference==

ABSCESS OF PENILE’S CAVERNOSIS BODIES: ROLE OF THE “CEUS” IN DIAGNOSIS AND IN POST-OPERATIVE CONTROL OUR EXPERIENCE IN TWO CASES

==inizio objective==

The abscess of cavernous bodies is a rare urological problem. The literature review highlights only a few sporadic reports. The primary symptomatology is swelling, pain and fever. Most penile abscesses are anatomically localized in the cavernous body and are often secondary to intracavernous injections of drugs for erection, perineal and / or perianal abscesses, and trauma to the penis. Immunodeficiency and immunosuppression constitute predisposing factors. The gold standard treatment is early surgery and followed by medical therapy. Often, however, severe postoperative complications occur, such as: penile curvature and erectile deficit. The ecocolordoppler is today the first-level investigation in the study of penile pathology. The ultrasound study of the penis is performed using high frequency linear transducers with longitudinal and transverse scans on the ventral aspect of the shaft. Cavernous bodies in transverse scans appear as two relatively hypoechoic symmetrical structures with fine homogeneously distributed echoes; inside the corpora cavernosa it is possible to identify the cavernous arteries in the form of small roundish images with hyperechoic walls. The albuginea is recognizable as a hyperechogenic interface that envelops the corpora cavernosa and continues in the central part with the intercavernous septum, which presents itself with a hypo-anechoic band with posterior attenuation of the beam. The spongy body appears as a median and ventral oval structure with echogenicity similar to that of the cavernous body. In longitudinal scans the vessels appear as tubular structures running parallel to the probe. Basal ultrasound does not always allow a precise identification of a possible abscess collection. In more advanced cases the abscesses can appear as hypoechoic collections, with irregular profiles with mobile echoes, located in the internal erectile bodies or between the connective sheaths. Such situations are often associated with swelling of the mucosa and subcutaneous tissue and with a marked hyperemia of the corpora cavernosa. The ecocontrastographic study underlines in physiological conditions a mild homogeneous and progressive impregnation of the cavernosal arteries, of the hilarine arteries and of the sinusoids of the cavernous tissue. The objective of this work of ours is to show the semiology and to propose the role of CEUS in the diagnosis and post-therapeutic follow-up in cases of abscesses of cavernous bodies.

==fine objective==

==inizio methodsresults==

Between June and August 2019 two cases of cavernous corpse abscess reached our observation of the PS. The first appeared as a very rare case of spontaneous abscess of the left cavernous body in a 49-year-old patient, in apparent good general condition, arrived in PS in a febrile state and with severe pain, due to marked swelling and pain in the penis and scrotum associated with the appearance of alkaline pyuria and gland-preputial and caverno-preputial multiple fistulas in the previous 24 h from clinical observation. The laboratory framework was positive for massive neutrophil leukocytosis and increase in PCR. The second case, a 72-year-old patient, diabetic and cardiopathic in poor general conditions, arrived in PS following severe post-circumcision complications, in a feverish state, bladder-like anuria for about 12 hours, with complete swelling of scrotal integuments and suprapubic region, without signs of cutaneous fistulization, incarceration of the penis of which only the extremity of the glans was recognized. The laboratory framework laid down for mild neutrophilic leukocytosis, with no evidence of PCR and PCT modifications. In both cases, ECD examinations were performed using a LA533 multi-frequency linear probe on Esaote My Lab Classic C device followed by extemporaneous integration with ecocontrastographic investigations following bolus administration of 2.4 ml of ecodedicated contrast medium (Sonovue-Bracco-Switzerland) followed by flush of SF 10 ml with real time acquisitions up to 6 minutes.

==fine methodsresults==

==inizio results==

In accordance with the data present in the literature, in the two cases we observed the basal ultrasound examination did not allow a precise identification of the abscess collection that appeared only in a slightly hypoechoic manner, therefore suspected but hardly stadibile for entity and characterization; however, it showed the fistulous hypoechoic directed to the glans towards the balano-prepuzial sulcus in the first case and the fistulously highly hypoechoic cavernous scrotal via contained in the dartos in the second case. At the evaluation after contrast injection CEUS in correspondence with the basal hypoechogenicity, in the two cases the suspected abscesses collections were on one hand characterized with certainty presenting themselves as areas of absent central perfusion delimited by irregular rims with discrete, early and non-fleeting peripheral enhancement, from another has allowed us to document the wider distribution and extent of the abscess compared to the baseline suspicion. The fistulous tract has been well documented in both cases after CEUS as a perfusion free tubuliform area. Patients were initially treated with combination antibiotics Cefazolin 2 g every 12 hours and Metronidazole 500 mg every 8 hours and subsequently after 24 hours they underwent exploratory surgeries with left corporotomy followed by toilet in the first case and scrototomy with toilet complete of the intrascrotal and suprapubic abscess caves, identification of incarcerated cavernous bodies and bilateral corporotomy with subsequent toilet. Postoperative controls at 30 days showed no post-surgical sequelae, showing a physiological mild homogeneous and progressive impregnation of the cavernous arteries, the helicine arteries and the sinusoids of the cavernous tissue.

==fine results==

==inizio discussions==

==fine discussions==

==inizio conclusion==

The CEUS is a non-invasive method, “bed-side” executable, which in the cases presented, allowed to obtain a more precise assessment on the localization, characterization, staging of abscess of the corpora cavernosa, allowing the patient to be directed to the most appropriate therapy. The CEUS control in post-operative follow-up allowed to exclude possible sequelae or complications.

==fine conclusion==

==inizio reference==

[1] Shamloul R, Kamel I: Early treatment of cavernositis resulted in erectile function preservation. J Sex Med 2006;3:320–322.
[2] Vives A, Collado A, Ribe N, Segarra J, Ruiz Castane E, Pomerol JM: Cavernositis following intracavernous injection of vasoactive drugs. Urol Int 2001;67:111–112
[3] Maitê Aline Vieira Fernandes,1 Luis Ronan Marquez Ferreira de Souza,2 and Luciano Pousa Cartafina Ultrasound evaluation of the penis. Radiol Bras. 2018 Jul-Aug; 51(4): 257–261
[4] M. Bertolotto, C. Gasparini, L. Calderan, A. Lissiani, M.A. Cova 1 L’eco-color Doppler penieno: stato dell’arte Giornale Italiano di Ecografia 2005; 8(2): 113-127
[5] Dugdale CM, Tompkins AJ, Reece RM, Gardner AF. Cavernosal abscess due to Streptococcus anginosus: a case report and comprehensive review of the literature. Curr Urol. 2013 Aug;7(1):51–56
[6]Topsoee JF. Investigation of Penile Conditions by Ultrasound and Contrast-Enhanced Ultrasound – Presentation of Three Clinical Case. Ultrasound International Open 2015

==fine reference==

Preliminary results of treatment with Autologous Platelet-Rich Plasma and Polydeoxyribonucleotide for male genital lichen sclerosus

==inizio objective==

Genital lichen sclerosus (LS) is a chronic lymphocyte-mediated inflammatory dermatosis that has a predilection for the genital skin in both sexes. In males LS affect mainly the foreskin, the glans and the meatus. It can cause phimosis and symptoms such as burning and pain due to scarring, atrophy, erosions and edema. It is a relatively common disease but true incidence is unknown and likely underestimated. Current guidelines suggest treating patients with a continuous administration of topical corticosteroids. The aim of this study was to investigate the efficacy of a conservative treatment for LS with a combined use of autologous platelet-rich plasma (PRP) and polydeoxyribonucleotide (PDRN). Both PRP and PDRN are successfully use in many branches of medicine (trichology, dermatology, aesthetic medicine, etc.) thanks to their high tolerability and handling.

==fine objective==

==inizio methodsresults==

16 patients aged 49.44±12.64 affected by LS who fulfilled the following criteria were enrolled in the study:
-hystopathological diagnosis of LS resulting from 4 mm punch biopsy;
-negative past medical history for coagulopathies and autoimmune diseases;
-no treatments with anticoagulants, corticosteroids, nonsteroidal anti-inflammatory drugs (NSAIDs), disease-modifying anti-rheumatic drugs (DMARDs).
The protocol included a total of 7 intra-dermal or submucosal injections to any affected areas, made with “micro-papule” technique:
-first cycle: 3 infiltrations of PRP (4 ml every 15 days);
-second cycle: 4 infiltrations of PDRN (1 vial of 5,625 mg / 3 ml every 7 days).
For the injections have been used needles for mesotherapy – intradermotherapy 27G x 4 mm and insulin syringes with Luer Lock. It was never necessary to use local anesthetics.
After providing written informed consent, at blood bank Department of our hospital, the venous whole blood (about 20 ml every time) taken from the patient was centrifuged at 6000 rpm for 6 minutes. Infiltrations of PRP occurred within 30 minutes from blood processing. After each session, patients were verbally interviewed about their symptoms (eg, pain and discomfort) and lesions were evaluated by digital penoscopy. The patients remained under observation for a short time in our Andrology Unit to assess the presence of any complications or side effects.

==fine methodsresults==

==inizio results==

At three months after the seventh infiltration (ie the fourth PDRN injection), all patients exhibited clinical improvement in the size of their lesions. 11 of the 16 patients (68.75%) had become symptom-free and no longer needed to use steroids. 4 patients (25%) had a reduction of symptoms and continued to use topical steroid intermittently. Only one patient (6.25%) reported moderate pain and did not benefit from therapeutic protocol. There were no evidence of local adverse events (p.e. bleeding, infection or hematoma) during the clinical study.

==fine results==

==inizio discussions==

The PRP infiltration is a simple, safe and immunologically biocompatible procedure. PRP works via the degranulation of the a-granules in platelets, which contain synthesized and pre-packaged growth factors. PRP induces tissue building capacity thanks to platelet derived growth factor (PDGF) – isoforms AB and BB, vascular endothelial growth factor (VEGF), transforming growth factor β (TGF-β), insulin like growth factor-1 (IGF-1). Moreover, PRP activates neoangiogenesis and improves blood flow and tissue oxygenation.
PDRN, instead, is a drug belonging to the official Italian pharmacopoeia. It is indicate in the treatment of cutaneous and connective lesions associated with dystrophic and dystrophic-ulcerative pathologies. It is used in off-label ways for skin bioregeneration. PDRN, consisting of several deoxyribonucleotides joined together by phosphodiester bonds, reaches the phlogistic site with high tropism, interacting with elements such as platelets and fibronectin and defining the formation of molecular complexes capable of facilitating cell regeneration. However, the inducing action on the cell cycle seems to be associated with the ability of the active principle to activate alternative signal pathways, capable of supporting gene expression, optimizing DNA synthesis and the subsequent process of cell proliferation and tissue regeneration.

==fine discussions==

==inizio conclusion==

Currently, steroids are the most used treatment but can cause side effects such as fibrosis and in some cases it is contraindicated, such as in diabetes. Use of PRP-PDRN integrated therapeutic protocol significantly improves the overall conditions in patients affected by LS with a significant reduction in lesions, inflammation and associated symptoms. Many research studies have been published on the use of PRP and PDRN for the treatment of LS. Currently, there are no clinical studies on the combined PRP-PDRN protocol to exploit the synergism of both infiltrative procedures.
Further clinical trials are necessary to evaluate long-term results, as well as what could be the best protocol for the combined treatment of LS with PRP and PDRN.

==fine conclusion==

==inizio reference==

o Arena S, Romeo C. Polydeoxyribonucleotide Treatment in Genital Lichen Sclerosus in Males. Urol Int. 2017;98(1):111. doi: 10.1159/000449017. Epub 2016 Sep 13.
o Casabona F, Gambelli I, Casabona F, Santi P, Santori G, Baldelli I. Autologous platelet-rich plasma (PRP) in chronic penile lichen sclerosus: the impact on tissue repair and patient quality of life. Int Urol Nephrol. 2017 Apr;49(4):573-580. doi: 10.1007/s11255-017-1523-0. Epub 2017 Feb 4.
o Kim S, Kim J, Choi J, Jeong W, Kwon S. Polydeoxyribonucleotide Improves Peripheral Tissue Oxygenation and Accelerates Angiogenesis in Diabetic Foot Ulcers. Arch Plast Surg. 2017 Nov;44(6):482-489. doi: 10.5999/aps.2017.00801. Epub 2017 Oct 26.
o Laino L, Suetti S, Sperduti I. Polydeoxyribonucleotide Dermal Infiltration in Male Genital Lichen Sclerosus: Adjuvant Effects during Topical Therapy. Dermatol Res Pract. 2013;2013:654079. doi: 10.1155/2013/654079. Epub 2013 Dec 30.
o Polito F, Bitto A, Galeano M, Irrera N, Marini H, Calò M, Squadrito F, Altavilla D. Polydeoxyribonucleotide restores blood flow in an experimental model of ischemic skin flaps. J Vasc Surg. 2012 Feb;55(2):479-88. doi: 10.1016/j.jvs.2011.07.083. Epub 2011 Nov 3.
o Samadi P, Sheykhhasan M, Khoshinani HM. The Use of Platelet-Rich Plasma in Aesthetic and Regenerative Medicine: A Comprehensive Review. Aesthetic Plast Surg. 2019 Jun;43(3):803-814. doi: 10.1007/s00266-018-1293-9. Epub 2018 Dec 14. Review.
o Tedesco M, Pranteda G, Chichierchia G, Paolino G, Latini A, Orsini D, Cristaudo A, Foddai ML, Migliano E, Morrone A. The use of PRP (platelet-rich plasma) in patients affected by genital lichen sclerosus: clinical analysis and results. J Eur Acad Dermatol Venereol. 2019 Feb;33(2):e58-e59. doi: 10.1111/jdv.15190. Epub 2018 Sep 19.
o Veronesi F, Dallari D, Sabbioni G, Carubbi C, Martini L, Fini M. Polydeoxyribonucleotides (PDRNs) From Skin to Musculoskeletal Tissue Regeneration via Adenosine A2A Receptor Involvement. J Cell Physiol. 2017 Sep;232(9):2299-2307. doi: 10.1002/jcp.25663. Epub 2017 Mar 3.
o Zucchi A, Cai T, Cavallini G, D’Achille G, Pastore AL, Franco G, Lepri L, Costantini E. Genital Lichen Sclerosus in Male Patients: A New Treatment with Polydeoxyribonucleotide. Urol Int. 2016;97(1):98-103. doi: 10.1159/000443184. Epub 2016 Feb 2.

==fine reference==

“What do our boys know about sex?” Preliminary data of a new questionnaire for the evaluation of the knowledge of sexuality among adolescents

==inizio objective==

Adolescents under age 18 are underrepresented in sexual health research, resulting in a lack of data about the consciousness of young people about these issues. The aim of this study was to assess the knowledge about sexuality of adolescents under the age of 18.

==fine objective==

==inizio methodsresults==

The participants were enrolled during a cultural exchange project in September 2019. Adolescents were aged between 13 and 18 years. They come from four different countries: Italy, Portugal, Romania end Greece. The questionnaire was administered anonymously. The parents of the participants had previously signed a specific informed consent. Instructions were as follows: “We are conducting research on adolescent knowledge about sexuality. We invite you to answer as sincerely as possible after having read the instructions carefully. The information collected will not be subject to any merit assessment and will be considered strictly confidential. We thank you for the collaboration.” The survey consisted of three parts. The first part concerned generic anthropometric data and a subjective evaluation of the personal knowledge of sexuality and sexual health. The second part contained questions concerning knowledge of the male and female genitourinary system, physiology of reproduction, meaning of terms concerning the sexual sphere, contraceptive methods and sexually transmitted infections. The third part questioned the participants about personal sexual habits.

==fine methodsresults==

==inizio results==

The sample was comprised of 80 participants (M age = 16.33 years, SD = .97), 55% of whom identified as female, 45% male. Additional sample characteristics are presented in Table 1. 12.5 % of the participants believed they had insufficient knowledge of sexuality; 38.75 % scarce; 35 % sufficient; only 13.75 % believed they had a large knowledge of the subject. The main form of information was represented by internet (51.2%), followed by friends (28.75%). Only the 5% of the adolescents who completed the study stated that they had obtained information from doctors or scientific books. The other sources of information are summarized in Table 2. The percentage of correct and incorrect answers for each questions of Part 2 is shown in Table 3. Analyzing the data of part 3, we noticed that only the 10% had a stable partner. The 27.5 % of the participants has had a complete sexual intercourse. The 41.3 % had a regular masturbatory activity. 95.5 % of sexually active subjects used contraceptive methods; of these, the most common was the condom (85.7%), followed by the pill (14.3%). The other information is summarized in Table 4. 55 % of the participants had never talked to somebody about sexuality. Among those who had spoken with someone (45%), the preferred interlocutors were friends (61 %), followed by family members (22.2 %) and teachers (8.3). Additional data are presented in Table 5.

==fine results==

==inizio discussions==

Adolescents are at elevated risk for adverse sexual and reproductive health outcomes relative to their habits, including HIV, sexually transmitted infections (STIs) and unplanned pregnancy (1). The importance of sexual education is often underlyed in schools. Data from the first part indicated that young people did not believe they had sufficient knowledge of sexuality. In fact, 12.5 % of the participants believed they had insufficient knowledge of sexuality; 38.75 % scarce. Moreover, the first source of information was represented by internet for the 51.25% of the adolescents. Unfortunately, the web could be a source of distorted and misleading contents, especially in inexperienced hands. Although the participants declared to have a sufficient (35%) or large (13.75%) knowledge of the subject, we noticed that the percentage of correct answers was of only of 66.7%. Most errors were concentrated in the questions concerning the physiology of reproduction and in those concerning specific terminology. The results of questions concerning the anatomy of the genitourinary system and contraceptive methods and sexually transmitted infections were better. Data of the third part showed how the percentage of sexually active subjects was of 27.5%. Of these, only the 10% had a stable relationship. Teenagers had difficulty talking about sexuality, in particular, with family and doctors. About 55% of participants declared that they never discussed this topic with someone. Often confidants were represented by friends. This could increase confusion and misinformation, leading to incorrect behaviors and lifestyles. Our study has some limitations, first of all the sample size. However, it represents a preliminary experience which, if implemented on a larger scale, could be useful to assess the knowledge of sexual health among European adolescents.

==fine discussions==

==inizio conclusion==

We strongly encourage European nations to spread the importance of studying sexual health among adolescents in schools, creating targeted educational programs (2). Improving adolescents’ knowledge of these issues could help reduce the number of sexual health problems, such as sexually transmitted infections or unplanned pregnancies.

==fine conclusion==

==inizio reference==

1. Axinn WG et al.; Mixed method data collection strategies; New York: Cambridge University Press; 2006
2. Brian Dodge, Michael Reece, Debby Herbenick et al. School-based Condom Education and Its Relations With Diagnoses of and Testing for Sexually Transmitted Infections Among Men in the United States. Am J Public Health, 99 (12), 2180-2 Dec 2009

==fine reference==

PHYSIOTHERAPY AND UROANDROSEXOLOGY TOWARDS ORGASMIC CONSCIOUSNESS AFTER RADICAL PROSTATECTOMY: AN INTEGRATED APPROACH

==inizio objective==

role of physiotherapy and sexology in the development of a new orgasmic consciousness after radical prostatectomy in order to identify individual and couple sexual well-being

==fine objective==

==inizio methodsresults==

Integrated physiotherapeutic and uroandrosexological pathway which includes: a) physiotherapy pathway: activation and relaxation of the perineal floor in both individual and group sessions, electrostimulation of the perineal floor and biofeedback, b) urosandrosessuological pathway: first individual visit one month after surgery with progressive awareness of the new body configuration, clinical evaluation of erectile dysfunction and first interview about the new orgasmic configuration, followed by a first therapeutic pharmacological approach; continuation of the relational path with first individual then couple scheduled visits

==fine methodsresults==

==inizio results==

January 2018 October 2019, 90 single incision videolaparoscopic prostatectomies were performed ; 71 (78.8%) of them presented for the first visit in the uroandrosexological path . 15 of them (21.1%) followed the full relational path with particular attention to the climacturia
16 patients were subjected to physiotherapy for stress incontinence: 6 were evaluated to the integrated approach with concomitant uroandrosessuological pathway.
Of the 10 patients who did not follow the uroandrosessuological path : 5 drop out, out of the remaining 5: 4 problems of anxiety inherent to the disease, 1 relationship problems with division by the Partner; out of the 6 enrolled in the integrated approach: only 1 case (16%) reported climacturia ; the remaining 5 patients without climacturia 2 reached full orgasmic consciousness with satisfaction reporting “orgasm as if ejaculating” and 1 patient had a new partner. All 6 patients experienced penetrative success not necessarily mandatory for patient satisfaction. Only in 1 case the partner was involved
Out of the total 15 cases subjected to the uroandrosexologiac pathway The climacturia was referred in 46.6%

==fine results==

==inizio discussions==

The percentage of patients who accepted the uroandrosusuological path is still low, demonstrating that there are still resistances in communications in sexology.
Patients undergoing physiotherapy had a lower incidence of climacturia.
Patients undergoing an integrated approach showed a better quality of life with the goal of “orgasmic consciousness”

==fine discussions==

==inizio conclusion==

The sample is initial and small, but the successes obtained are the basis for the continuation of the experience

==fine conclusion==

==inizio reference==

Neglected Side Effects After Radical Prostatectomy: A Systematic Review
lA. Ullmann, FJ Sønksen M Fode Jou Sex Med Volume 11, Issue 2, February 2014, Pages 374-385

==fine reference==