14.4 Erectile Dysfunction, Peyronie Disease, Priapism & Gender-Affirming Surgery

Erectile Dysfunction, Peyronie Disease, Priapism & Gender-Affirming Surgery

Penile and andrological disorders sit at the intersection of vascular biology, neural signaling, and micro-reconstructive surgery. Board examinations rigorously evaluate the pathophysiological cascades of corporal tumescence, cardiovascular risk stratification for erectile dysfunction, reconstructive mechanics for Peyronie deformities, the emergent triage of acute ischemic priapism, and the surgical anatomy and urological complications of genital gender-affirming reconstructive surgery.

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1. Erectile Dysfunction (ED): Pathophysiology & Cardiovascular Predictor

Physiology of Normal Erection & Detumescence

Normal physiological erection is a neurovascular event initiated by psychological and sensory sexual stimuli:

1. Nitric Oxide Release: Non-adrenergic, non-cholinergic (NANC) parasympathetic autonomic nerves (cavernous nerves from the pelvic plexus) and vascular endothelial cells release Nitric Oxide (NO).
2. cGMP Activation: NO diffuses into adjacent trabecular cavernosal smooth muscle cells and binds to soluble guanylyl cyclase (sGC), catalyzing the conversion of GTP into cyclic guanosine monophosphate (cGMP).
3. Intracellular Calcium Depletion: cGMP activates protein kinase G (PKG), which phosphorylates ion channels, sequestering free intracellular calcium (Ca2+) into the sarcoplasmic reticulum and expelling it extracellularly.
4. Sinusoidal Engorgement & Veno-Occlusion: Smooth muscle relaxation allows arterial inflow into the lacunar spaces from the paired cavernosal arteries. As the sinusoids expand against the rigid, non-compliant tunica albuginea, the subtunical venular plexus is mechanically compressed, arresting venous outflow (corporal veno-occlusive mechanism).
5. Detumescence: Phosphodiesterase type 5 (PDE5) hydrolyzes cGMP into inactive 5'-GMP, restoring intracellular calcium, contracting cavernosal smooth muscle, and restoring venous outflow.

+-------------------------------------------------------------------------------------------------------+
| PRINCETON IV: CARDIOVASCULAR ASSESSMENT IN ED                                                         |
| Artery-size hypothesis: similar vascular disease may become symptomatic earlier in smaller arteries.  |
| Typical diameters: penile 1–2 mm; coronary 3–4 mm; carotid 5–7 mm; femoral 6–8 mm.                    |
| Vasculogenic ED can precede symptomatic coronary disease by 2–5 years; assess cardiovascular risk.    |
| For men without known CVD: assess ASCVD risk; consider coronary calcium testing when appropriate.     |
| For known CVD, assess the safety of sexual activity and ED treatment:                                 |
| LOW RISK: successful revascularization, controlled hypertension, mild valvular disease,               |
| or NYHA I–II heart failure with ≥ 5 MET exercise capacity and no ischemia on recent testing.          |
| INDETERMINATE: mild/moderate stable angina, MI 2–8 weeks ago without intervention, NYHA III,          |
| or peripheral arterial disease/prior stroke or TIA. Exercise or pharmacological stress testing        |
| helps reclassify risk before resuming sexual activity.                                                |
| HIGH RISK: unstable/refractory angina, uncontrolled hypertension, NYHA IV heart failure,              |
| recent MI < 2 weeks without intervention, or high-risk arrhythmias. Stabilize before sexual activity. |
+-------------------------------------------------------------------------------------------------------+

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2. Stepped Management Ladder for Erectile Dysfunction

+--------------------------------------------------------------------------------------------+
|                             STEPPED MANAGEMENT LADDER FOR ED                               |
|                                                                                            |
|  FIRST-LINE:  Oral PDE5 Inhibitors & Lifestyle Modifications                               |
|               --> Sildenafil, Tadalafil, Vardenafil, Avanafil                              |
|               --> Weight reduction, smoking cessation, glycemic and lipid control          |
|                                                                                            |
|  SECOND-LINE: Intracavernosal Injections (ICI) & Vacuum Erection Devices                   |
|               --> Alprostadil (PGE1) monotherapy or Bimix / Trimix injections              |
|               --> Vacuum Erection Devices (VED) with base constriction ring (<30 min)      |
|               --> Intraurethral Alprostadil (MUSE)                                         |
|                                                                                            |
|  THIRD-LINE:  Surgical Implantation of Penile Prosthesis                                   |
|               --> Inflatable 3-piece penile prosthesis (IPP) vs Malleable / semirigid rods |
|               --> Salvage washout protocol (Mulcahy protocol) for prosthesis infection     |
+--------------------------------------------------------------------------------------------+

Treatment choice also depends on patient preference, efficacy and tolerability; injections or devices can be chosen without exhausting every oral option.

First-Line: Oral Phosphodiesterase Type 5 (PDE5) Inhibitors

• Mechanism: Competitively inhibit the catalytic site of the PDE5 isoenzyme, preventing cGMP degradation and augmenting the natural nitric oxide-mediated erectile response during sexual arousal. They do not initiate erections without sexual stimulation.
• Pharmacological Profiles:
  • Sildenafil: 25–100 mg on demand; taken 60 min before coitus; fatty meals delay absorption; duration 4–8 hours.
  • Tadalafil: 10–20 mg on demand or 5 mg once daily; half-life 17.5 hours ("the weekend pill"); absorption unaffected by food; also approved for concurrent BPH/LUTS.
  • Vardenafil: 10–20 mg on demand; similar kinetics to sildenafil; minor QT prolongation.
  • Avanafil: 50–200 mg; rapid onset (15–30 min); highly selective for PDE5.
• Common Adverse Effects: Headache, facial flushing, nasal congestion, dyspepsia. Sildenafil can inhibit PDE6 in the retina, causing transient blue-tinted vision (cyanopsia). Tadalafil can inhibit PDE11 in skeletal muscle, causing lower back and myalgic pain.

Second-Line: Intracavernosal Injections (ICI) & Vacuum Devices

• Intracavernosal Injection (ICI): The patient self-injects vasoactive agents directly into the lateral aspect of the corpus cavernosum (avoiding the dorsal neurovascular bundle and ventral urethra):
  • Alprostadil (Prostaglandin E1, PGE1): Stimulates adenylate cyclase, increasing intracellular cyclic AMP (cAMP) and depleting intracellular calcium independently of the nitric oxide pathway. Highly effective in neurogenic ED (e.g., post-radical prostatectomy).
  • Bimix / Trimix: Blends of Papaverine (non-selective PDE inhibitor), Phentolamine (alpha-adrenergic antagonist), and Alprostadil. Offers superior rigidity at lower individual doses.
  • Risks: Prolonged erection / priapism, pain (alprostadil activates sensory pain receptors), and corporal fibrosis.
• Vacuum Erection Devices (VED): An external acrylic cylinder creates a vacuum, drawing venous blood into the corpora. A constricting elastic ring is placed at the base of the penis to maintain rigidity. The ring must be removed within 30 minutes to prevent ischemic penile injury.

Third-Line: Penile Prosthesis Implantation

• Indicated in men with refractory ED who have failed, cannot tolerate, or have contraindications to oral and injectable therapies.
• Three-Piece Inflatable Penile Prosthesis (IPP): Gold standard. Comprises two fluid-filled intracorporal cylinders, a scrotal control pump, and a preperitoneal fluid reservoir. Yields the highest patient and partner satisfaction rates (>90%) by mimicking natural flaccidity and rigidity.
• Malleable / Semirigid Rods: Simpler, paired bendable rods. Preferred in elderly patients with impaired manual dexterity or extensive pelvic fibrosis.
• Infection Management & The Mulcahy Salvage Protocol: Suspected implant infection needs prompt specialist assessment, antibiotics and usually removal of infected components. Selected patients can undergo complete explantation, thorough washout and immediate replacement, often with a malleable device, to preserve corporal space and length. Others need explantation with delayed reimplantation. Immediate salvage is not compulsory for every infection; tissue condition, systemic illness and surgical expertise determine suitability.

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3. Peyronie's Disease (PD)

Peyronie's disease is an acquired connective tissue disorder of the tunica albuginea, characterized by localized fibrous plaque formation leading to penile curvature, deformity, shortening, and erectile dysfunction.

Pathophysiology & Natural History

Repetitive microvascular buckling trauma during intercourse causes microtears in the inner and outer layers of the tunica albuginea. In genetically susceptible men, defective wound healing triggers persistent fibrin extravasation, local inflammatory cell influx, and marked upregulation of Transforming Growth Factor-beta 1 (TGF-β1). Fibroblasts transform into myofibroblasts, depositing abnormal, disorganized collagen and elastin that coalesce into dense, non-distensible, and often calcified plaques.

+-------------------------------------------------------------------------------------------------------------------------+
|                             PEYRONIE'S DISEASE: THE TWO CLINICAL PHASES                                                 |
|                                                                                                                         |
|  ACTIVE (ACUTE) PHASE (Typically lasts 6 to 18 months):                                                                 |
|  --> Clinical hallmarks: Evolving / dynamic penile curvature, painful erections, soft palpable                          |
|      plaque tissue                                                                                                      |
|  --> Management: STRICTLY CONSERVATIVE                                                                                  |
|      - Oral NSAIDs for pain; treat concomitant ED; pentoxifylline is not recommended                                    |
|      - Penile traction therapy to preserve length                                                                       |
|      - INVASIVE SURGERY IS STRICTLY CONTRAINDICATED during the active phase                                             |
|                                                                                                                         |
|  STABLE (CHRONIC) PHASE:                                                                                                |
|  --> Clinical hallmarks: Resolution of coital pain, STABLE DEFORMITY FOR ≥ 3–6 MONTHS, USUALLY ≥ 9–12 MONTHS FROM ONSET |
|  --> Management: RECONSTRUCTIVE SURGERY indicated if deformity prevents coitus                                          |
|      - Choice of procedure governed by: curvature degree, penile length, and baseline ED                                |
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Reconstructive Surgical Selection Algorithm

                                +----------------------------------+
                                | STABLE PEYRONIE'S DEFORMITY     |
                                | (Painless, stable >= 3-6 months) |
                                +----------------------------------+
                                                 |
                                                 v
                       +----------------------------------------------------+ 
                       | Does the patient have concurrent ED refractory     |
                       | to oral phosphodiesterase type 5 inhibitors?       |
                       +----------------------------------------------------+ 
                                 /                                  |
                                / YES                                | NO
                               v                                      v
             +----------------------------------+     +----------------------------------+
             | INFLATABLE PENILE PROSTHESIS     |     | Assess Curvature Severity &      |
             | IMPLANTATION (IPP)               |     | Penile Length                    |
             | +/- Intraoperative Modeling      |     +----------------------------------+
             | +/- Plaque Incision / Grafting   |                       |
             +----------------------------------+                       |
                                                                        v
                        +-----------------------------------------------------------------+
                        |  Curvature < 60 degrees?                                        |
                        |  Adequate baseline penile length?                               |
                        |  Absence of severe hourglass / hinge defect?                    |
                        +-----------------------------------------------------------------+
                                          /                             |
                                         / YES                           | NO
                                        v                                 v
                      +----------------------------------+ +----------------------------------+
                      | TUNICAL PLICATION                | | PLAQUE INCISION & GRAFTING (PIG) |
                      | (Nesbit or 16-Dot Procedure)     | | (Lengthening Procedure)          |
                      | --> Shortens convex side         | | --> Incises plaque on concave    |
                      | --> Slight loss of penile length | |     side & applies graft tissue  |
                      | --> LOW RISK OF DE NOVO ED       | | --> Carries 20-30% risk of de    |
                      |                                  | |     novo postoperative ED        |
                      +----------------------------------+ +----------------------------------+

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4. Priapism: Emergency Classification & Management

Priapism is a pathological, prolonged, involuntary penile erection lasting > 4 hours unrelated to sexual interest or stimulation. Ischemic priapism is a time-critical emergency; confirm the subtype promptly because non-ischemic priapism is managed differently.

Pathophysiological Classification

Stuttering Priapism (Recurrent Ischemic Priapism)

Recurrent, transient, self-limiting ischemic episodes occur particularly with sickle cell disease. A prolonged episode requires the same emergency treatment as acute ischemic priapism. Specialist prevention may use low-dose daily PDE5 inhibitors started while flaccid, or selected adrenergic/hormonal therapy; evidence is limited. Hormonal suppression can impair sexual maturation, libido and fertility: avoid it before sexual maturation and counsel men seeking conception. Preventive PDE5 inhibition is not treatment for an acute ischemic erection.

Stepwise Management Ladder for Ischemic Priapism

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| ISCHEMIC PRIAPISM: IMMEDIATE DECOMPRESSION AND STEPWISE ESCALATION                                     |
| 1. ANALGESIA AND ASPIRATION: penile block if needed; use lateral proximal corporal access              |
| at 3 or 9 o’clock with a 16–18 G needle, avoiding the dorsal neurovascular bundle and ventral urethra. |
| Aspirate stagnant blood; irrigate with sterile 0.9% saline as needed.                                  |
| 2. PHENYLEPHRINE: selective alpha1 agonist contracts cavernosal smooth muscle.                         |
| Give 200 mcg intracavernosally every 3–5 minutes; maximum 1 mg within 1 hour.                          |
| Example dilution: 200 mcg/mL gives a 1 mL dose. Check units and final concentration.                   |
| Use lower doses in children/severe CVD; review contraindications, including malignant or               |
| poorly controlled hypertension and MAO inhibitors. Monitor BP and pulse during treatment               |
| and every 15 minutes for 1 hour afterward; use ECG monitoring as clinically indicated.                 |
| Repeat aspiration/injection if necessary; failure prompts surgical decompression.                      |
| 3. DISTAL SHUNT±TUNNELLING: Winter (biopsy needle), Ebbehoj (#11 blade), Al-Ghorab                     |
| (open distal tunical window) or T-shunt. No single distal shunt has proven superior.                   |
| 4. REFRACTORY CASES: select further decompression with specialist judgment. Historical                 |
| proximal options include Grayhack (cavernosaphenous) and Quackels (cavernospongiosal) shunts;          |
| benefit is uncertain and complications include ED; venous shunts carry thromboembolic risk.            |
| 5. DELAYED/REFRACTORY PRESENTATION: after > 48 hours, counsel about the poor erectile prognosis        |
| and discuss early prosthesis. Viability assessment, including MRI/biopsy in selected cases,            |
| can inform management. Detumescence may still relieve pain; do not assume all shunts futile.           |
| IF A SHUNT HAS BEEN PERFORMED, DELAY IMPLANTATION to reduce implant infection and erosion.             |
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5. Transgender Surgical Procedures & Urological Complications (ETR p. 54)

Gender-affirming surgery (GAS) represents an integral component of multidisciplinary transgender care. Urologists are frequently called upon to perform primary genital reconstructive surgeries and, crucially, to manage acute and long-term reconstructive and functional urological complications per the European Training Requirements (ETR) in Urology (2026, p. 54).

+--------------------------------------------------------------------------------------------------+
|                    GENDER-AFFIRMING GENITAL RECONSTRUCTION: CLASSIFICATION                       |
|                                                                                                  |
|  1. TRANSFEMININE (MALE-TO-FEMALE) SURGICAL PROCEDURES:                                          |
|     --> Bilateral orchiectomy                                                                    |
|     --> Penile Inversion Vaginoplasty (Gold standard / most frequent)                            |
|     --> Peritoneal Flap Vaginoplasty (Davydov-type / robotic pull-down)                          |
|     --> Intestinal Vaginoplasty (Pedicled rectosigmoid or ileal segment)                         |
|     --> Clitoroplasty (Preserves dorsal glans neurovascular bundle)                              |
|     --> Labiaplasty (Constructed from scrotal skin and redundant prepuce)                        |
|     --> Urethral shortening and spatulated meatoplasty                                           |
|                                                                                                  |
|  2. TRANSMASCULINE (FEMALE-TO-MALE) SURGICAL PROCEDURES:                                         |
|     --> Metoidioplasty (Using clitoris hypertrophied by systemic testosterone therapy)           |
|     --> Phalloplasty (Vascularized free or pedicled tissue transfer: RFFF, ALT, MLD)             |
|     --> Urethral Lengthening (Neo-urethra constructed via vascularized skin flap / buccal graft) |
|     --> Scrotoplasty with paired silicone testicular prostheses                                  |
|     --> Vaginectomy with colpectomy                                                              |
|     --> Staged Inflatable Penile Prosthesis (IPP) implantation                                   |
+--------------------------------------------------------------------------------------------------+

Transfeminine (Male-to-Female) Genital Reconstructive Surgery

• Operative Principles of Penile Inversion Vaginoplasty:
  1. Bilateral Orchiectomy & Funiculectomy: Complete excision of testes and spermatic cords up to the external inguinal rings.
  2. Corporotomy & Radical Corporal Resection: The paired corpora cavernosa are dissected from the overlying neurovascular bundle, transected near their crural attachments at the ischial rami, and closed securely for hemostasis and to limit residual erectile tissue.
  3. Neurovascular Clitoroplasty: A sensate clitoris is fashioned from a trimmed portion of the dorsal glans penis, meticulously maintaining its continuity with the dorsal penile neurovascular bundle (dorsal nerves and dorsal penile arteries passing beneath the pubic arch), preserving erogenous tactile sensation.
  4. Neovaginal Cavity Dissection: A neo-vaginal cavity is dissected in the prostatorectal plane, anterior to the rectum and posterior to the prostate/urethra, up to the peritoneal reflection.
  5. Lining the Neovagina: The inverted penile skin tube retains its epithelial lining and is frequently augmented with a full-thickness scrotal skin graft; it is introduced into the cavity and anchored to the sacrospinous ligaments or pelvic floor.
  6. Urethral Shortening & Spatulated Meatoplasty: The bulbar urethra is shortened, mobilized, spatulated ventrally, and sutured flush with the neo-vulvar introitus inferior to the neo-clitoris.
• Alternative Vaginoplasty Techniques:
  • Peritoneal Flap Vaginoplasty: Utilizes vascularized peritoneal flaps (via open or robotic transabdominal mobilization) to line the neo-vaginal vault; can augment limited penile/scrotal skin in primary or revision surgery. Peritoneum is mesothelial tissue; natural vaginal mucosal lubrication should not be promised.
  • Intestinal Vaginoplasty: Employs an isolated, pedicled segment of sigmoid colon (or ileum); provides self-lubricating mucus secretion and excellent canal depth, but carries risks of continuous foul-smelling excessive discharge, diversion colitis, and bowel anastomotic leak.

Transfeminine Urological Complications

• Urethral Meatal Stenosis (15% to 20%): The most common urological complication following vaginoplasty. Resulting from excessive circumferential cicatricial scar contracture, devascularization, or inadequate spatulation of the neo-meatus. Patients present with urinary spraying, straining, post-void dribbling, or acute/chronic urinary retention. Managed by dorsal or ventral meatoplasty or Y-V plasty.
• Rectovaginal Fistula (1% to 4%): A devastating surgical complication caused by inadvertent intraoperative rectal buttonhole injury during deep pelvic dissection, thermal injury from electrocautery, or delayed ischemic necrosis from excessive posterior vaginal packing pressure. Manifests with fecal soiling or flatus discharging through the neovagina. Obtain specialist assessment for infection, tissue injury and fistula extent. Fecal diversion is selected when needed, rather than automatic. Definitive repair may use layered closure with a vascularized flap, such as gracilis, after inflammation and tissue conditions permit.
• Neovaginal Stenosis & Loss of Depth/Caliber: Contracture of the canal occurs in up to 10% of cases, related to scarring, tissue loss, pelvic-floor dysfunction and inadequate dilation. Follow the surgeon’s dilation schedule: frequent early dilation is usually tapered to long-term maintenance. Persistent pain or loss of depth needs assessment rather than forceful dilation.
• Hair-Related Complications: Hair-bearing skin in a reconstructed urethra can promote urinary encrustation, stones and recurrent UTI. Hair inside a neovagina instead causes local irritation, retained debris and discharge. Plan preoperative hair removal for skin used internally. Treat urinary stones and residual hair follicles with specialist endoscopic or surgical techniques; these are distinct anatomical problems.

Transmasculine (Female-to-Male) Genital Reconstructive Surgery

• Metoidioplasty vs. Phalloplasty:
  • Metoidioplasty: Uses testosterone-induced clitoral enlargement when this accords with the patient’s goals. Timing follows achieved growth and individualized assessment; a universal 12–24 month hormone minimum is not a current adult requirement. Involves surgical division of the clitoral suspensory ligament and ventral fibrous chordee, mobilizing the hypertrophied clitoris into a microphallus (typically 4 to 8 cm in length). The neo-urethra is extended to the tip of the microphallus using vaginal mucosal grafts or labia minora flaps. Scrotoplasty is performed using labia majora flaps with testicular implants.
    • Advantages: Preserves normal erogenous sensation, low complication profile, enables voiding while standing in most cases, does not require microvascular free flap transfer.
    • Limitation: The small dimensions of the phallus generally preclude penetrative sexual intercourse.
  • Phalloplasty: The surgical creation of an adult-sized phallus (12 to 15 cm) using free or pedicled vascularized tissue transfer:
    1. Radial Forearm Free Flap (RFFF): The recognized gold standard. Provides thin, supple skin for "tube-within-a-tube" simultaneous neo-phallus and neo-urethral construction, reliable vascularity via the radial artery and cephalic/venae comitantes, and superior sensory innervation via the medial and lateral antebrachial cutaneous nerves (coapted to the ilioinguinal and dorsal clitoral nerves).
    2. Anterolateral Thigh (ALT) Flap: Pedicled or free flap based on the lateral circumflex femoral perforators; minimizes conspicuous forearm scarring, but flap thickness in Western populations often requires secondary surgical thinning, and sensory nerve coaptation yields less erogenous innervation.
    3. Latissimus Dorsi (MLD) Flap: Provides substantial muscular bulk, indicated when forearm and thigh donor sites are unsuitable.
  • Urethral Lengthening: May be staged or combined. The native urethra is extended through a fixed perineal segment (pars fixa) to the phallic segment (pars pendulans), using suitable vascularized flaps and, in selected reconstructions, grafts.
  • Inflatable Penile Prosthesis (IPP): Implantation is performed as a delayed, final stage (typically 9 to 12 months after phalloplasty) after adequate wound healing, flap perfusion and protective sensation have developed; timing is individualized.

Transmasculine Urological Complications

Transmasculine genital reconstruction can carry substantial reconstructive morbidity, primarily involving the neo-urethra and prosthetic devices:

• Urethrocutaneous Fistula (20% to 50%): The most frequent complication following phalloplasty. Fistulas commonly involve the junction of the reconstructed pars fixa and pars pendulans, but can occur elsewhere along the reconstructed urethra, where perfusion transitions between two distinct tissue beds and high hydrostatic voiding pressures occur. Small fistulas often heal spontaneously with conservative management (continuous suprapubic catheter urinary diversion for 4–6 weeks). Persistent or large fistulas require operative multi-layered closure utilizing vascularized interposition flaps (e.g., suitable local fasciocutaneous tissue or a gracilis flap).
• Urethral Strictures (25% to 40%): Common sites include the fixed-to-phallic urethral junction and neo-meatus. During early healing, severe obstruction may require suprapubic drainage; defer incision/urethroplasty until at least 6 months after neophalloplasty. Selected short, non-obliterative anastomotic strictures may undergo endoscopic incision, but avoid repeated attempts beyond two. Longer, recurrent or phallic strictures often need graft/staged urethroplasty.

Summary Reference Tables: Andrology, Priapism & Gender Surgery

Table 1: Erectile Dysfunction Diagnostic & Management Framework

Table 2: Priapism Differential Diagnosis & Emergency Action Protocols

Table 3: Gender-Affirming Genital Surgery: Techniques & Specific Urological Complications

Premature Ejaculation

Premature ejaculation combines an abnormally short ejaculation latency, poor control and associated distress. Classify it as lifelong or acquired and assess consistency, relationships, erectile function, drugs and relevant genitourinary symptoms. A short duration alone is insufficient; self-estimated latency is usually adequate clinically.

For acquired symptoms, address causes such as ED, prostatitis, LUTS, anxiety or hyperthyroidism first. For lifelong PE, EAU first-line pharmacological options are on-demand dapoxetine or lidocaine/prilocaine spray. Daily SSRIs or clomipramine are off-label second-line alternatives. Discuss adverse effects and expectations; psychological/behavioural treatment can complement medication. Avoid transferring topical anaesthetic to the partner by following the product instructions.

Worked decision: A man reports newly rapid ejaculation after developing difficulty maintaining erections. Assess and treat the ED rather than immediately assuming lifelong PE or recommending a destructive penile operation.

Primary references: EAU Disorders of Ejaculation and EMA Fortacin product information.