Question 1
What would be the diagnostic work-up in this patient?

1. Autophotography: 34%
2. Intracavernous injection of vasoactive agents: 9%
3. Color Doppler Ultrasonography: 23%
4. Penile MRI: 27%
5. Dynamic Infusion Cavernosometry and Cavernosography (DICC): 7%

Comments:

An autophotography is necessary to document the penile curvature. Alternatively, an intracavernous injection of vasoactive agents could be used to document this curvature in the office. This patient has normal erectile function, so it is not necessary to include color Doppler ultrasonography and DICC in the diagnostic work-up. A duplex ultrasonography is able to provide information on the size and location of the plaque and it is useful compare the results of the possible treatment. Furthermore, it can provide information on the calcification status of the plaque that is important to select between conservative and surgical treatment.

Question 2
How would you manage this patient?

1. No treatment-watchful waiting: 4%
2. Medical therapy (colchicine, vitamin E, tamoxifen, POTABA, etc): 48%
3. Plication surgery: 23%
4. Incision and vein patch surgery: 21%
5. Penile prosthesis: 4%

Comments:

This patient experiences pain during erection suggesting that the disease is not yet stabilized. My choice would be to start oral treatment with Colchicine 2mg/day approximately 3-6 months depending on decrease in plaque size and pain during erection and reevaluate the patient at the end of 3 months and then 6 months. Surgery should be considered only when the curvature is stable for at least 6 months.

Question 1
What would be the diagnostic work-up in this patient?

1. Rigiscan: 2,27%
2. Triplex ultrasonography: 9,09%
3. Hormonal profile: 29,54%
4. All the above: 40,91%
5. None of the above: 18,19%

Comments:

This is a typical case of organic ED due to diabetes and hypertension. This man reports progressive loss of normal erections and did not respond to tadalafil 10mg. Most of the website visitors suggested that this man should have a complete diagnostic evaluation while about 20% suggested that no specific evaluation was necessary. The latter strategy reflects current guidelines suggesting no specific evaluation in such a typical case proceeding directly to treatment. Hormonal profile is recommended in almost every case with ED since it is quite common in elderly and represents a common cause of non-response to drug therapy. Certainly there is no clear answer and clinicians should individualize diagnostic evaluation in a patient-centred approach.

Question 2

1. Suggest him to try tadalafil 20mg at least 4 times: 9,09%
2. Try another PDE5i. If he still is a PDE5i non responder, suggest intracavernosal injections: 13,64%
3. Prescribe testosterone gel in combination to tadalafil: 15,91%
4. Take a careful medical and sexual history identifying possible reasons for inappropriate use of tadalafil and provide counseling: 38,64%
5. None of the above. The management strategy would be based on the results of diagnostic work-up: 22,72%

Comments:

Most of the answers suggest that this man needs a careful medical history in order to identify reasons for inappropriate use of tadalafil and provide counselling. This man is not a true non-responder. He tried only 10mg of tadalafil instead of the highest recommended dose (20mg) for only 3 times (at least 4 at the highest dose are recommended). Furthermore, no information is given on proper use administration before sexual intercourse (time to T-max is 2 hours) or the presence of adequate sexual stimulation. Addressing these factors are important before considering this man as a non-responder and suggesting another treatment modality

Question 1
What will be your working diagnosis?

1. Infection after intracavernosal injection: 11%
2. Infection after penile augmentation: 34%
3. Infection after penile bite: 23%
4. Infected oil granulomas (Paraffinoma): 28%
5. Subcutaneal fungal infection: 4%

Comments:

Penile paraffinoma is the result of subcutaneal injection of mineral-oil for the purpose of penile enlargement. It may occur months or many years following the injection of the oil, and is characterized with single or multiple irregular masses with painful or painless ulcer, skin indurations and penile edema. Usually patients are febrile but in acute fazes some patients may suffer from high temperature and have problems in sexual function. Most patients have a history of penile dysmorphophobia and some of them have problems in urination.

Infection after penile augmentation usually occurs close to the operation, associated with significant local pain, fluctuation and purulent discharges from the operation scar.

Infection after penile bite is a localized infection associated with limited penile edema, pain and high temperature.

Question 2
How do you treat this patient?

1. Treat with antibiotics and derange: 28%
2. Treat with antibiotics followed excision of all infected granulomas: 30%
3. Treat with antibiotics followed wide excision of all involved skin and skin graft: 13%
4. Treat with antibiotics followed wide excision and delayed skin graft: 9%
5. Perform two stage operation: wide excision of all involved skin and skin graft: 20%

Comments:

The treatment of choice for paraffinoma is aggressive excision of all effected areas and of the scrotal skin flap or skin mesh graft in one stage. Pre and post operative antibiotic therapy is essential. Once a patient is treated with the appropriate antibacterial therapy and all effected areas are excised, the chances of infection are insignificant.

A two-stage operation and or delay grafting is not recommended by most authors.

Treatment with antibiotics and drainage is not sufficient.

Treatment with antibiotics following the excision of all granulomas is related with significant morbidity.