D

espite advances in oral, intracavernosal, topical pharmacotherapy, and even the use of vacuum mechanisms, there is a large group (approximately 15% of men seeking treatment for their erectile dysfunction) of patients refractory to all types of therapy who have severe and irreversible damage of their mechanism of erection and that requires a surgical treatment option.

Penile prostheses are mechanisms designed to produce a similar phenomenon to the tumescence produced by the influx of blood to the cavernous trabeculae and that in normal conditions are produced by various types of stimuli.

There is not an “ideal implant” to date, but one of the primary objectives is to be as close as possible to the normal penis in its erect and flaccid state; so it is relevant the information granted to the patients and their partners, as well as the selection of the patient and the most appropriate device type for the surgery.

It is important to emphasise that there are countless articles that try to approach the theme of satisfaction in patients receiving treatment for erectile dysfunction. Without a doubt, it is a condition that directly impairs the quality of life of the patients. Although there are many factors that influence the sexual environment of the individual and alter the results of many of these studies, it is clear that it is necessary to standardise specific evaluation parameters to objectify the results of these studies.

In conclusion, penile prostheses are mechanisms designed to produce a tumescence and enough penile stiffness for activity sexual and try to improve the quality of life of patients suffering from erectile dysfunction that do not respond to other treatments. The satisfaction rates reported in the literature exceed 75% in most studies, which makes them an excellent alternative for patients with a surgical indication.

P

eyronie’s disease is a connective tissue disorder that affects the tunica albuginea of the penis. Recent studies suggest that this pathology is due to an inflammatory process with abnormal cicatrization in the tunica albuginea caused by microtraumas during intercourse.

It presents as indurations or plaques, particularly painful with the erection, and also causes a retraction and curvature of the penis. Peyronie’s disease prevents or hinders sexual activity in its late stage, either by significant curvature or by erectile dysfunction.

The evolution of the disease has two phases: The first is the early or inflammatory phase manifests itself with pain and curvature of the penis during erection, It also presents a palpable nodule or induration. This stage of the disease will last approximately 12 to 24 months. In recent studies, it was shown that in 94% of the patients, there was a resolution of coital pain at 18 months. A small percentage of patients present a resolution without sequelae at the end of the inflammatory process.

In the next phase, if the inflammation does not resolve, the tissue involved becomes calcified. This phase is characterized by stability of the curvature, pain and in many cases the presence of sexual dysfunction.

Diagnosis

Currently, the interrogation and physical examination provide valuable information to be able to diagnose the disease. Every patient should be evaluated with a broad clinical history where it is essential to know how the symptoms started, the time of evolution, associated factors, and the family and psychosexual history detailed.

The physical examination is the most important tool, the penis in a state of flaccidity appears completely normal to inspection. in most cases. It is the palpation, which allows doctors to determine the size, position, consistency, and number of indurations. Approximately one-third of patients will develop scarring or calcified plaque that can be observed by ultrasound or simple radiography.

S

ince the cause of bent penis (Peyronies disease) is different from one man to another and in some cases an improvement without treatment is experienced, the initial therapeutic recommendation is to wait and see what happens. For this purpose, the evolution of the plaque, curvature of the penis and erectile function are checked periodically for about 12 months before the treatment is considered. Some treatments may increase the risk of erectile dysfunction in the patient.

Non-surgical methods

If Peyronie’s disease does not improve without treatment, the use of some of the following may be tried:

–Vitamin E: Research has shown improvement in the disease when vitamin E is administered orally, although efficacy has not been demonstrated in controlled clinical studies. 

–Intralesional injections: Medications can be injected directly into the inside of the plate. For example collagenase, verapamil or other calcium antagonists. These drugs try to destroy the deposits of scar tissue to return it to normal. For this, several injections are administered for a period of up to three months. Its effectiveness is variable. Intralesional injections of corticosteroids, such as cortisone, have produced important side effects in healthy tissues of the penis.

Surgical methods

If there is no improvement with medical treatments or if the curvature of the penis persists, you can opt for surgery. It is usually indicated when the aesthetic aspect of the penis is unacceptable, when the intercourse is painful or there is a poor-quality erection. Surgery is often effective in restoring a normal erection, although each method can produce undesirable side effects such as partial loss of erection or shortening of erection penis length.

U

rinary incontinence is defined as the involuntary loss of demonstrably objective urine that constitutes a social or hygiene problem for the person who suffers it. It is a frequent problem and an incidence of 5 to 15% is estimated in men older than 60 years, with important implications in the quality of life of the individuals who suffer it.

Different epidemiological studies show that a significant percentage of people who suffer from it (up to 50%) do not show it; it is mistakenly assumed as a situation proper to adulthood. Overall, urinary incontinence is more prevalent in women. Only in the pediatric age, it is more frequent in men, and the incidence is equal for both sexes in the geriatric age, affecting up to 70-80% of the elderly with severe mental deterioration.

The causes of urinary incontinence in men according to age are: nocturnal incontinence in childhood (15-20% of children aged 4-10 years); Bladder hyperreflexia after spinal cord injury in young men and the elderly, where the incidence is significantly higher.

The most frequent causes of incontinence in men are: bladder overactivity (hyperreflexia-instability), iatrogenic sphincter insufficiency (up to 30% of patients who have undergone radical prostatectomy), overflow incontinence, infravesical obstruction, and bladder urinary incontinence. Due to this multicausality and the peculiarity of each patient, the design of the interventions must be individualized. The completion of a care plan with strict follow-up of these patients modifies the evolution of urinary incontinence and its complications.

Anatomically, men are more protected against the possibility of presenting incontinence. There are circumstances and risk factors for urinary incontinence, such as cerebrovascular accidents, dementia, bladder cancer, diabetes, limitation of mobility, faecal impaction, medications and aging, very prevalent pathologies in medical consultations. Incontinent patients suffer more urinary infections and more depression due to loss of self-esteem and isolation, as well as feelings of guilt with reaction from insecurity and apathy. It can affect sleep and rest, mobility, emotional behavior and the activities of playtime.

Treatment

In men with stress incontinence, urge incontinence or incontinence of effort / mixed urgency, initial treatment should include counseling
adequate on the habits of life, physiotherapy, programmed voiding patterns, behavioral therapies and medication.

Varicocele Treatment

V

aricocele is an anatomoclinical syndrome characterized by dilation of the venous plexus and clinically by spermatic venous reflux into the veins of the pampiniform plexus that drain the blood from the testicles. The presence of these testicular varices has been related to male infertility, more specifically, with a decrease in the number of spermatozoa, their mobility, morphology, and capacity for fertilization.

Treatment
The aim of varicocele correction is to improve the reproductive capacity of the patient, improve the production of androgens and in cases of testicular pain, its suppression.
In the cases of men with infertility and varicocele surgery is not always necessary.
Assisted Reproduction Techniques such as ICSI, intrauterine insemination can be the way to achieve a pregnancy. But in most cases, the correction allows a greater chance of getting this.

The treatment for varicocele can be surgical or by embolization. To decide
what kind of access is going to be carried out, it is necessary to keep in mind the three types of varicocele formation pathways: failure of the internal spermatic vein, hyperpressure of the primitive iliac vein and anomalies of the venous plexuses.
Regarding the embolization of the testicular veins, it can be of two forms: antegrade by scrotal via or retrograde via the femoral vein. Other forms of intervention are sclerotherapy and surgery for laparoscopy, which has a high cost, and the microscopic, which is the lowest rate of recurrence presents.

The prognostic factors in the adult are related to the age of the couple and their fertility status, the presence of other associated pathologies such as infections, obesity, toxic consumption, etc., the time of infertility, the degree of spermogram and the levels of FSH, LH and androgens.
Among the most important beneficial changes of the varicocele correction is the recovery of testicular volume, which occurs in 70-80% of adolescents in which the testicular size was inferior to normal. It has also been found an increase in testosterone concentration and in the quality of the semen when they are compared with the non-operated patients.