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Purpose: Urethral reconstruction is performed for urethral stricture or hypospadias correction. Research on urethral tissue engineering is increasing. Because the corpus spongiosum is important to support the urethra, urethral tissue engineering should ideally be combined with reconstruction of a corpus spongiosum. We describe a method to visualize and measure the architecture of the corpus spongiosum, which is needed for scaffold design., Materials and Methods: The penis was dissected from 2 unembalmed male cadavers. One penis was flaccid and the other was erect, as induced by saline infusion. Both were frozen in ice. At 6 sites sections were obtained in the transverse and frontal directions. After digitalizing the stained sections the images were edited, area measurements were taken and a 3-dimensional reconstruction was made., Results: In transverse sections the mean area of the vascular lumen was 60% and 77% in the flaccid and the erect corpus spongiosum, and in frontal sections it was 53% and 74%, respectively. This indicated a 129% transverse increase and a 140% longitudinal increase in erection. Section sites did not essentially differ except in the glans penis. Frontal sections showed larger vascular cavities and more incomplete septae than transverse sections., Conclusions: This study provides what is to our knowledge novel information on corpus spongiosum architecture, which is relevant for scaffold design in tissue engineering. The study protocol can be used in future research with a larger number of specimens and more extensive analyses., (Copyright © 2016 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: Voluntary medical male circumcision decreases the risk in males of HIV infection through heterosexual intercourse by about 60% in clinical trials and 73% at post-trial followup. In 2007 WHO and the Joint United Nations Programme on HIV/AIDS (UNAIDS) recommended that countries with a low circumcision rate and high HIV prevalence expand voluntary medical male circumcision programs as part of a national HIV prevention strategy. Devices for adult/adolescent male circumcision could accelerate the pace of scaling up voluntary medical male circumcision. Detailed penile measurements of African males are required for device development and supply size forecasting., Materials and Methods: Consenting males undergoing voluntary medical male circumcision at 3 health facilities in the Iringa region, Tanzania, underwent measurement of the penile glans, shaft and foreskin. Age, Tanner stage, height and weight were recorded. Measurements were analyzed by age categories. Correlations of penile parameters with height, weight and body mass index were calculated., Results: In 253 Tanzanian males 10 to 47 years old mean ± SD penile length in adults was 11.5 ± 1.6 cm, mean shaft circumference was 8.7 ± 0.9 cm and mean glans circumference was 8.8 ± 0.9 cm. As expected, given the variability of puberty, measurements in younger males varied significantly. Glans circumference highly correlated with height (r = 0.80) and weight (r = 0.81, each p <0.001). Stretched foreskin diameter moderately correlated with height (r = 0.68) and weight (r = 0.71, each p <0.001)., Conclusions: Our descriptive study provides penile measurements of males who sought voluntary medical male circumcision services in Iringa, Tanzania. To our knowledge this is the first study in a sub-Saharan African population that provides sufficiently detailed glans and foreskin dimensions to inform voluntary medical male circumcision device development and size forecasting., (Copyright © 2013 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: Studies of the outcome of hypospadias repair must document quality, including assessment of complications and appraisal of appearance. To our knowledge the Pediatric Penile Perception Score is the first validated instrument for the outcome assessment of hypospadias repair in prepubertal males by surgeons and patients. We validated the instrument for adult genitalia., Materials and Methods: Standardized photographic documentation was prepared for 19 men after hypospadias repair and 3 with normal genitalia after circumcision. This was sent to 21 urologists, who rated the outcome with a questionnaire comprising items on the penile meatus, glans, shaft skin and general appearance. Each item was rated with a 4-point Likert scale. The Penile Perception Score is a sum score of all items. Patients were asked to provide a self-assessment with the same instrument., Results: When calculated with the ICC and the rank correlation using Kendall W, concordance among urologist scores was fair and good (0.46 and 0.64, respectively, p <0.001). Instrument stability was 0.78, indicating good reproducibility. Using the Spearman rank correlation coefficient general appearance correlated well with single items, including the meatus (r = 0.93, p = 0.000), glans (r = 0.92, p = 0.000) and shaft skin (r = 0.89, p = 0.000). No significant differences were found between patient and urologist Penile Perception Scores., Conclusions: The Penile Perception Score is a reliable instrument for urologist assessment and self-assessment of postpubertal genitalia after hypospadias repair. The instrument can be recommended for all age groups because it was previously validated for the pediatric population., (Copyright © 2013 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: Genital development is affected by pubertal process to a great extent, and puberty is a complex phenomenon that is influenced by multiple factors resulting in individual differences. We studied penile length and its relationship to pubertal stage in boys 13 to 15 years old., Materials and Methods: Healthy boys who were candidates for military high school were evaluated between June and July 2011. Age, residence and body mass index were recorded. Stretched penile length was measured. Pubic hair was assessed according to Tanner and Marshall staging. Genital puberty stage was defined by measurement of testicular volume with Prader orchidometer. Relationship of penile length to age, residence, pubertal stages and body mass index was evaluated statistically., Results: A total of 1,539 boys were included in the study. Mean ages and number of patients according to genital stage were as follows. Mean age was 14 years for genital stage 1 (5 patients), 13.9 years (range 13 to 15) for stage 2 (194), 14.07 years (13 to 15) for stage 3 (965) and 14.11 years (13 to 15) for stage 4 (375). Linear regression analysis revealed a significant effect of body mass index, genital stage and pubic hair stage on penile length (p <0.001) but no significant effect of age or residence. Mean penile length was significantly different among different age groups and among pubertal stages. However, mean penile lengths of different age groups within the same pubertal stage were similar., Conclusions: Penile length during puberty should be evaluated individually according to the current pubertal stage. Our study offers a reliable reference table of penile length for pubertal age group., (Copyright © 2012 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: Cryptorchidism is a common finding in infants and young boys. Early repair lessens the extent of testicular injury. We hypothesized that anatomical and socioeconomic factors affect the timing of consultation and treatment for boys with cryptorchidism., Materials and Methods: Under an institutional review board approved protocol we reviewed the records at a single institution of children who underwent exploration for unilateral or bilateral cryptorchidism. Demographic and anatomical factors were recorded., Results: The median age of 677 boys at consultation and surgery was 20.3 and 28.9 months, respectively. Median age at consultation for boys with nonpalpable and palpable testicles was 12.3 and 20.9 months, respectively (p = 0.03). Boys with a concomitant penile anomaly had a younger median age at consultation than boys without a penile anomaly (8.5 vs 20.3 months, p <0.01). Demographic factors did not vary with respect to time to consultation and surgery (p >0.05). Multivariate analysis showed that abdominal site and concomitant penile anomaly were associated with earlier time to consultation (p = 0.02 and <0.01, respectively)., Conclusions: The timing of consultation for boys with undescended testicles does not vary in regard to race, language or insurance type at this tertiary care institution. Instead, anatomical factors influenced age at consultation for boys with cryptorchidism. This suggests that in some geographic regions access to care is not restricted for minorities or noncommercially insured children., (Copyright © 2011 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: We assessed penile and bulbospongiosus measurements to develop a quantitative guide to select the surgical approach (perineal vs transscrotal vs transcorporeal) to artificial urinary sphincter cuff placement., Materials and Methods: We retrospectively reviewed the intraoperative records of 100 men who underwent artificial urinary sphincter placement (43) or anastomotic urethroplasty (57) from February 2008 to June 2009. Correlations between penile (stretched length and circumference at the shaft base) and bulbospongiosus (distal and proximal circumference) measurements were assessed. Cases were analyzed according to 2 penile circumference groups, including group 1-8.0 cm or less and group 2-8.5 or more., Results: Mean proximal bulbospongiosus circumference was uniformly larger than distal bulbospongiosus circumference (4.5 vs 3.9 cm). It was about 50% of the penile shaft circumference (mean 8.9 cm, r = 0.70). In group 1 men the average distal bulbospongiosus circumference was 3.4 cm. They were more likely to undergo transcorporeal artificial urinary sphincter cuff placement than those in group 2, who had an average distal bulbospongiosus circumference of 4.1 cm (8 of 22 or 36% vs 1 of 21 or 5%, OR 11.4). Penile length correlated less robustly with distal and proximal bulbospongiosus circumference (r = 0.39 and 0.43, respectively). Patients with urethroplasty had significantly larger urethral measurements than those with the artificial urinary sphincter (proximal and distal bulbospongiosus circumference 4.9 vs 3.7 and 4.1 vs 3.2, respectively) but were significantly younger (47 vs 67 years), and less likely to have erectile dysfunction (11 of 57 vs 34 of 43) or to have undergone radical prostatectomy (0 of 57 vs 37 of 43)., Conclusions: Bulbospongiosus circumference appears to be proportional to penile circumference. The distal bulbospongiosus is uniformly smaller than the proximal bulbospongiosus. The potential need for a perineal or transcorporeal approach to artificial urinary sphincter placement can be anticipated by penile circumference measurements and a combination of clinical factors, such as older patient age, history of radical prostatectomy and impotence., (Copyright (c) 2010 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: We determined penile length alterations in men treated with androgen suppression plus radiation therapy for local or locally advanced prostate cancer., Materials and Methods: From November 2000 to November 2005, 47 patients were enrolled in this prospective study. After clinical staging all patients received hormonal therapy (luteinizing hormone releasing agonist, leuprolide acetate or goserelin every 3 months for a total of 3 injections) and at month 7 of hormonal therapy radiation therapy was begun (total 70 Gy) for 7 weeks. Stretched penile length measurements were performed before starting androgen suppression therapy and every 3 months thereafter with a paper ruler., Results: With the initiation of therapy a gradual decrease in stretched penile length was observed. Penile shortening was statistically significant at a mean followup of 18 months (mean 14.2 to 8.6 cm, p <0.001)., Conclusions: Our findings support observations of decreased penile length after neoadjuvant hormonal therapy plus external beam radiation therapy for local or locally advanced prostate cancer. Patients should be counseled before therapy that penile shortening may occur.

Purpose: Most hypospadias repairs performed in the United States involve the removal of any foreskin that is not used in the repair, resulting in a circumcised penis. Occasionally, the wishes of the parents or the child are for the final appearance to be that of a normal uncircumcised penis. We report our collective experience from 4 institutions in the reconstruction of the foreskin during penile surgery., Materials and Methods: A total of 58 patients underwent penile surgery with reconstruction of the foreskin during a 6-year period. Of the patients 49 underwent hypospadias repair, 8 underwent phalloplasty for chordee correction without hypospadias and 1 underwent reconstruction of the foreskin for a dorsal hood without hypospadias or chordee. Of the 49 hypospadias repairs 46 were distal, 2 mid shaft and 1 proximal shaft. The technique for foreskin reconstruction consisted of a multilayered reapproximation of the lateral margins of the dorsal hood after completion of the urethroplasty and glanuloplasty., Results: Among 49 hypospadias repairs 2 patients had dehiscence of the reconstructed foreskin, with development of a urethral fistula in 1. Of the 58 total patients undergoing penile surgery 56 had retractable foreskin, of whom 4 required postoperative steroid application. Three patients/parents requested a secondary circumcision, 2 for an unacceptable cosmetic result and 1 based on personal preference., Conclusions: Foreskin reconstruction in association with penile surgery can be performed safely and with a low complication rate in appropriately selected patients. Cases with a higher risk of complications include those involving more proximal hypospadias and those requiring complete degloving of the penile shaft. Of the reconstructions resulting in phimosis most can be salvaged with the application of steroids.

Purpose: Loss of length is a common postoperative complaint of the patient who undergoes surgical correction of penile curvature. We investigate the factors influencing complications in patients who have undergone TAP for PD and chordee., Materials and Methods: A total of 102 patients underwent TAP for PD (68) or chordee (34) between 1997 and 2004. Data were gathered on each patient's preoperative complaints, physical examination, Doppler ultrasound, operative data and postoperative complaints. For the purposes of this study penile length was measured from pubis to corona along the dorsal surface of the stretched phallus., Results: Mean ages at surgery for men with PD and chordee were 53 and 24, respectively. A range of 1 to 6 plications were performed on each patient (mean 3) with an acceptably straight penis (curve less than 20 degrees) being achieved in 99% of patients. Mean followup for our patient population was 29 months and revealed only 1 patient with residual curvature. The mean loss in length after TAP was 0.36 +/- 0.5 cm with a range of 0 to 2.5 cm. When calculated as a percent of length lost from preoperative length, the postoperative percent length lost was 2.4%. When stratified into groups based on direction of curvature, the patients with ventral or ventrolateral curve had the highest percent loss of length. A 1-way ANOVA of these groups proved the differences between each group to be statistically significant (p = 0.04). Length change also significantly correlated with preoperative stretched penile length and the severity of curvature as measured in degrees in the operating room at time of surgery. Parameters that did not demonstrate a statistically significant impact on penile shortening included patient age, number of plications performed, plaque size, and hinge/narrowing effect due to a PD plaque., Conclusions: The TAP procedure is a safe and effective means of correcting penile curvature, with similar overall outcomes between patients with PD and chordee. Shortening of the penis does commonly occur but is dependent on direction and degree of curvature, as well as the length of the phallus.

Purpose: Surgical treatment of the common urogenital sinus phallus has been one of the most challenging areas in pediatric urology. To better understand the neuroanatomy of the common urogenital sinus phallus, we evaluated an animal model naturally having this condition, the spotted hyena, Crocuta crocuta. We compared the neuroanatomy of male and female humans and spotted hyenas using anatomical, immunohistochemical and 3D reconstruction techniques. We also examined the implications of the pattern of clitoral innervation for the unique challenges faced by female spotted hyenas, the only extant species of mammal that mates and gives birth through the clitoris., Materials and Methods: Three adult male and 3 female spotted hyenas were studied. With the animals under anesthesia gross anatomical examination was performed before and after artificial erection. Histological analysis was performed on one 95-day fetal male and female spotted hyena specimens, and on 18 human male and female fetal external genitalia specimens using antibodies raised against the neuronal marker S-100. Three-dimensional computer reconstruction using serial sections allowed analysis of the neuroanatomy of the penis, clitoris and common urogenital sinus of the fetal spotted hyena and human., Results: Compared to other mammals, the clitoris and penis of spotted hyenas were remarkably similar in size and configuration in the flaccid and erect states. Male and female hyenas had a single opening on the tip of the glans penis/clitoris. The basic anatomical structures of the corporeal bodies in both sexes of humans and spotted hyenas were similar. As in humans, the dorsal nerve distribution was unique in being devoid of nerves at the 12 o'clock position in the penis and clitoris of the spotted hyena. Dorsal nerves of the penis/clitoris in humans and male spotted hyenas tracked along both sides of the corporeal body to the corpus spongiosum at the 5 and 7 o'clock positions. The dorsal nerves penetrated the corporeal body and distally the glans in the hyena. In female hyenas the dorsal nerves fanned out laterally on the clitoral body. Glans morphology was different in appearance in both sexes, being wide and blunt in the female and tapered in the male., Conclusions: The neuroanatomy of the male and female external genitalia in the spotted hyena, Crocuta crocuta, although grossly similar, has distinct anatomical and functional characteristics. The clitoris of the spotted hyena is a classic example of a natural animal model of a common urogenital sinus. The neuroanatomical characteristics of the spotted hyena may be a useful model to simulate the anatomy of common urogenital sinus anomaly in humans.

Purpose: The structure and function of the lower urinary tract are still a subject of controversial discussion. Experiments in various animals, including rhesus monkeys, are often performed to improve the understanding of human physiology without adequate knowledge of anatomical differences. Therefore, a detailed study of the lower urinary tract of the male rhesus monkey (Macaca mulatta) was performed to elucidate anatomical correspondences in rhesus monkeys and humans., Materials and Methods: Lower urinary tract anatomy and histomorphology were investigated in male rhesus monkeys on serial sections. To differentiate striated and smooth muscle immunohistochemical staining was done. Three-dimensional reconstructions were developed to demonstrate the topography of the muscle systems., Results: We identified certain systems, including detrusor musculature extending on the bladder neck, a ventral longitudinal muscle system of the bladder neck, continuation of the musculature of the ureters to the verumontanum, a urethral sphincter consisting of a striated and a smooth muscle part, musculature between the urethra and rectum, and a striated longitudinal muscle system ventral to the urethral sphincter. The prostate gland of the rhesus monkey does not encircle the urethra but is attached dorsolateral. The internal sphincter (musculus sphincter vesicae) of humans does not exist in the rhesus monkey. The longitudinal systems of the urethra differ significantly from those in humans., Conclusions: Due to significant differences in lower urinary tract anatomy the suitability of the male rhesus monkey seems limited as an animal model for humans. It is not suitable for studying the longitudinal muscle systems of the human bladder neck.

Purpose: Because decreased trabecular smooth muscle content is reportedly associated with vasculogenic impotence in men, we performed a rodent study to investigate the effect of aging on trabecular smooth muscle content and caveolin-1 protein expression in penile smooth muscle cells., Materials and Methods: In 6 young (age 3 months) and 6 old (age 24 months) rats erectile function was evaluated by cavernous nerve stimulation. At sacrifice penile tissue samples were collected for Western blot analysis, Masson's trichrome staining, caveolin-1 immunostaining and electron microscopy. The percent of smooth muscle in the trabecular tissue was assessed by computer assisted image analysis., Results: In the aged rats mean intracavernous pressure plus or minus standard deviation was decreased (70 +/- 8.8 versus 107 +/- 12.3 cm. water) and the latency period was increased (7.8 +/- 1.2 versus 4.5 +/- 0.5 seconds) significantly compared to values in the young rats (p <0.001). The mean ratio of trabecular smooth muscle-to-connective tissue was also significantly altered in old versus young rats (27% +/- 2.9% versus 42.1% +/- 5.1%, p <0.001). Immunostaining for caveolin-1 was noted in each group in the sarcolemma of smooth muscle cells and endothelium of trabecular sinusoids but the staining pattern was less intense and the percent of smooth muscle positive for caveolin-1 was decreased in aged versus young rats (17.9% +/- 2.5% versus 27.5% +/- 3.6%, p <0.001). Moreover, young trabecular smooth muscle cells had more caveolae in the sarcolemma on electron microscopy and a higher expression of caveolin-1 protein on Western blot analysis. In contrast, higher endothelial nitric oxide synthase protein expression was noted in the penile tissue of old rats., Conclusions: In these aged rats the decreased ratio of trabecular smooth muscle-to-collagen and the reduced expression of caveolin-1 may contribute to erectile dysfunction.

Purpose: We have previously defined the anatomy of the neurovascular bundle in the normal and hypospadiac penis. These studies were based on analysis of the fetal penis distal to the pubic arch without total inclusion of the crural bodies. To our knowledge the neuroanatomy beneath the pubic arch has not been well described. We defined the nerve distribution under the pubic arch and the relationship of the nerves to the crural bodies, corporeal bodies and urethra of the penis., Materials and Methods: Eight normal human fetal penile specimens (at 17.5 to 29 weeks of gestation and 1 hypospadiac specimen at 32 weeks were serially sectioned and stained with Masson's trichrome, and the neuronal markers protein gene product 9.5 and S-100. These specimens were unique in that they contained the whole penis from the glans to the crural bodies beneath the pubic arch. Older specimens were decalcified before fixation. Computer reconstruction with commercially available graphics software allowed 3-dimensional analysis of the nerves and crural bodies in relation to the pubic arch and surrounding structures., Results: The nerves of the penile shaft and glans surrounded the corporeal bodies, extending from the junction of the urethral spongiosum to the classic 11 and 1 o'clock positions with a paucity of nerves at the 12 o'clock position in the dorsal midline. Beneath the pubic arch the nerves to the penis were an extension of the dorsal neurovascular bundle of the prostate. The nerves formed 2 bundles following a path just under the pubic arch in close proximity to the bone, superior to the urethra and medial to the origin of the crural bodies. The nerve bundles joined the corporeal bodies at the proximal origin, where the 2 crural bodies fused together. At this point perforating branches into the corporeal bodies from the cavernous nerves were documented. As the dorsal nerves joined the dorsal aspect of the corporeal bodies, they immediately began to fan out along the surface of the corporeal tissue to the junction of the urethral spongiosum. Three-dimensional reconstruction showed the relationship of the nerves to the pubic arch and urethra in multiple views., Conclusions: A precise understanding of penile anatomy beneath the pubic arch and at the origin of the crural bodies is important for preserving neuronal structures. This anatomy is especially germane in children undergoing posterior urethral reconstruction secondary to trauma, intersex requiring feminizing genitoplasty and severe hypospadias.

Purpose: We evaluated the long-term results of penile prosthesis implantation during the last 10 years. Special considerations were examined concerning Asian corporeal diameter, device survival and sociocultural factors influencing patient-partner satisfaction., Materials and Methods: We followed 331 patients who underwent penile prosthesis implantation from December 1985 to May 1996. Surgical data, postoperative complications and information from a survey on satisfaction are reported., Results: The most prevalent corporeal diameter in our patients was 11.0 to 11.5 cm. Postoperatively wound infection was the most serious surgical complication. The 5-year device survival was similar in the malleable and inflatable types except for a poorer outcome with the self-contained inflatable Hydroflex penile prosthesis. Overall patient satisfaction with surgery was 86.6%., Conclusions: Penile prosthesis implantation still has its place as definitive therapy in some patients with uncorrectable erectile dysfunction. In Taiwanese society more consideration of prosthesis selection, surgical preparation and patient-partner counseling is the basis for further success in the future.

Purpose: We attempted to determine whether the penis in adulthood after exstrophy reconstruction is short because of a congenital defect in the size of the corpora cavernosa., Materials and Methods: Pelvic magnetic resonance imaging was performed on 10 men who underwent exstrophy reconstruction in childhood, and 10 age and race matched controls. Measurements of penile and pelvic anatomy were compared., Results: The corpora cavernosa in men after exstrophy reconstruction were shorter than normal. Dividing total corporeal length into an anterior and posterior segment revealed that the anterior segment was short but the posterior segment attached to the pubic ramus was normal. However, the diameter of the posterior corporeal segment was greater than in controls. Although diastasis of the symphysis pubis increased the intersymphyseal and intercorporeal distances, the angle between the corpora cavernosa was unchanged, presumably because the corporeal bodies were separated in a parallel fashion., Conclusions: After exstrophy reconstruction the penis is short in adulthood, at least partially due to a congenital deficiency of corporeal tissue. Since diastasis of the pubic symphysis and chordee decrease penile visibility, approximation of the pubic symphysis and procedures to straighten the penis may improve cosmesis. However, because the corpora cavernosa are short, after exstrophy reconstruction the penis will always be shorter than normal in adulthood.

Purpose: We studied the fine architecture of the tunica albuginea of the penis., Materials and Methods: The study included 6 human male cadavers and 10 surgical patients (5 with Peyronie's disease and 5 with normal penile anatomy)., Results: The tunica albuginea of the corpora cavernosa is a bi-layered structure with multiple sub layers. Inner layer bundles support and contain the cavernous tissue and are oriented circularly. Radiating from this layer are intracavernous pillars acting as struts, which augment the septum and provide essential support to the erectile tissue. Outer layer bundles are oriented longitudinally. These fibers extend from the glans penis to the proximal crura, where they insert into the inferior pubic ramus. There are no outer layer fibers between the 5 and 7 o'clock positions. Elastic fibers normally form an irregularly latticed network on which collagen fibers rest. In Peyronie's disease the well ordered appearance of the collagen layers is lost: excessive deposits of collagen, disordered elastic fibers and fibrin are found within the region of the plaque., Conclusions: The normal 3-dimensional structure of the tunica affords great flexibility, rigidity and tissue strength to the penis, which are lost consequent to structural changes in Peyronie's disease.

Purpose: Special attention has been focused on the contribution of the ischiocavernosus muscles to intracorporeal pressure during erection., Materials and Methods: Length of the ischiocavernosus muscles and corpora cavernosa was studied in 30 cadavers., Results: A biomechanical model for calculating interference of the ischiocavernosus muscles in rigidity during the initial phase of penile erection is proposed., Conclusions: We found that, among other things, intracorporeal pressure can be influenced by the ischiocavernosus muscles during erection.

Purpose: We provide guidelines of penile length and circumference to assist in counseling patients considering penile augmentation., Materials and Methods: We prospectively measured flaccid and erect penile dimensions in 80 physically normal men before and after pharmacological erection., Results: Mean flaccid length was 8.8 cm., stretched length 12.4 cm. and erect length 12.9 cm. Neither patient age nor size of the flaccid penis accurately predicted erectile length. Stretched length most closely correlated with erect length., Conclusions: Only men with a flaccid length of less than 4 cm., or a stretched or erect length of less than 7.5 cm. should be considered candidates for penile lengthening.

The high incidence (70%) of anterior hypospadias, mostly without penile curvature, in our pediatric hypospadias patients led us to study the meatal location in normal men to investigate if meatal advancement in all patients with anterior hypospadias can be justified when the wide variation of meatal locations in normal men is considered. The location of the external meatus was analyzed in 500 men (mean age 57 years) with classification of the meatal position in relation to the tip of the glans and corona. Quality of erections and sexual intercourse, presence or absence of penile curvature, urinary stream and ability to void in a standing position were assessed in an interview. Of the 500 men only 275 (55%) were normal with the meatus in the distal third of the glans, while 65 (13%) had anterior hypospadias (glanular in 49, coronal in 15 and subcoronal in 1). In 160 men (32%) the urethral meatus was located in the mid third of the glans. Analyzing coronal and subcoronal hypospadias further, all but 6 patients were not aware of any penile anomaly, all but 1 homosexual patient have fathered children and only 1 had penile curvature (subcoronal hypospadias). However, all patients participated in sexual intercourse without problems and were able to void in a standing position with a single stream. In our study of 500 "normal" men the meatal location varied widely with only 55% of all meatus at the tip of the glans and significant hypospadias in patients without complaints about cosmetic or functional aspects. We believe that these observations might question the need for meatal advancement in cases of anterior hypospadias without associated penile curvature.

Previous studies have established normal penile length for patient age and stage of sexual development. To our knowledge penile length has only been determined to date by measuring the stretched distance from the symphysis to the glans tip. Pilot studies at our institution showed that ultrasound corpora cavernosa length determinations were possible using a 7.5 MHz. linear transducer probe. To determine whether ultrasound is a more accurate modality in assessing penile length, male subjects 0 to 24 months old with normal penile anatomy and palpably descended testicles were enrolled in a prospective analysis. Longitudinal ultrasound images of the flaccid penis were obtained from the dorsal surface. The whole corporeal bodies were easily imaged and measured. In a blinded fashion a separate investigator performed a conventional stretched penile length determination. A total of 27 male subjects 1 week to 22 months old was evaluated and 2 were excluded. Corpora cavernosa measurements using ultrasound revealed a mean length of 32.3 +/- 4.7 mm. (range 22.4 to 44.9). Stretched penile lengths of the same subjects revealed a mean length of 46.8 +/- 8.2 mm. (range 31 to 63). Circumcision status (p = 0.036) and age (p < 0.001) significantly correlated with stretched length determinations. Ultrasound measurements did not significantly vary with patient circumcision status or age. Penile length and race were not correlated when using stretched or ultrasound measurements. Ultrasound determination of corporeal body length is possible in young subjects. From infancy to age 22 months ultrasound measurements are not significantly affected by age or the presence of foreskin. Our experience suggests that corporeal body evaluation by ultrasound may offer a more accurate assessment of functional penile length.

The relaxing effects of several specific and nonspecific inhibitors of phosphodiesterases (PDE) on rabbit isolated corpus cavernosum (CC) and spongiosum (CS) were investigated. Preparations were mounted in organ baths, and isometric tension was recorded. The results were compared with the effects of direct administration of analogs of the second messenger cyclic nucleotides and the effects of forskolin, a direct stimulator of adenylate cyclase, and the nitric oxide donor 3-morpholinosydnonimine (SIN 1). All drugs relaxed the phenylephrine-induced contractions in CC and CS in a dose-dependent fashion. In CC and CS, type III (SK&F 95654) and type V (zaprinast and dipyramidole) PDE inhibitors, as well as the nonspecific inhibitors papaverine and trequinsin, showed no differences in IC50. The type IV inhibitor rolipram relaxed CC and CS at significantly lower concentrations (p < 0.005) than any other PDE inhibitor, and in CC the type III and IV inhibitor zardaverine was more potent (p < 0.05) than SK&F 95654. SIN 1 stimulates guanylate cyclase and effectively inhibits contractions in CC and CS. Activation of adenylate cyclase by forskolin also was highly effective (p < 0.005). It is concluded that PDE inhibition constitutes an effective relaxing mechanism in rabbit CC and CS. The marked effects of the different types of PDE inhibitors support the importance of cyclic guanosine 3',5'-monophosphate and cyclic adenosine 3',5'-monophosphate in smooth muscle relaxation in erectile tissue.

In 7 male cadavers the anatomical structure, thickness and tensile strength of the tunica albuginea of the penis, measured at specific locations, were determined. The tunica is composed of inner circular and outer longitudinal layers made up of collagen bundles. The outer layer appears to determine, to a large extent, the variation in thickness and strength of the tunica. The ventral groove (found between the 5 and 7 o'clock positions), which houses the corpus spongiosum, lacks outer bundles and appears vulnerable to perforation. The thickness of the tunica measured at the 7, 9 and 11 o'clock positions was 0.8 +/- 0.1 mm, 1.2 +/- 0.2 mm and 2.2 +/- 0.4 mm, respectively. Differences in the thickness of the tunica at specific locations were statistically significant (all p < or = 0.018). Symmetrical measurements were nearly identical in a mirror image arrangement (3, 5 and 1 at the 9, 7 and 11 o'clock positions, respectively). The stress on the tunica at penetration (breaking point pressure) measured at the 7, 9 and 11 o'clock positions was 1.6 +/- 0.2 x 10(7) N/m.2, 3.0 +/- 0.3 x 10(7) N/m2 and 4.5 +/- 0.5 x 10(7) N/m.2, respectively. The strength and thickness of the tunica correlated in a statistically significant manner with location (r = 0.911 and p = 0.0001). The most vulnerable area is on the ventral aspect (which lacks the longitudinally directed outer layer bundles), where most prostheses tend to extrude. This finding supports our belief that prosthesis extrusion often has an anatomical basis and is not merely a phenomenon caused by infection or compression.

In an attempt to define the hemodynamic and radiographic parameters of normal erectile function 6 patients 20 to 41 years old (mean age 30.3 years) with erectile dysfunction that spontaneously resolved after a comprehensive evaluation were reviewed. The results included normal hormonal assays, normal penile biothesiometry and normal penile brachial index. The sleep tumescence and rigidity tracings were abnormal according to the criteria that sleep erections occur every 90 minutes, are associated with penile rigidity of greater than 550 gm. plus an increase in penile circumference of greater than 1.5 cm. and last longer than 15 minutes. High resolution ultrasonography, pulse wave Doppler ultrasound, dynamic pharmacocavernosometry and dynamic cavernosography were performed. After testing the patients were informed that no organic abnormalities had been detected. No medical or surgical treatment was given. The hemodynamic values are presented as suggested normal parameters: maintenance rate (mean 11 +/- 3 cc per minute), initial decompression rate (mean 59 +/- 17 mm. Hg/30 seconds) and radiographic findings (visualization of the cavernous, external pudendal and deep dorsal veins during pharmacocavernosography, performed at intracorporeal pressures of 100 mm. Hg). All 6 patients had maintenance rates of greater than 5 cc per minute. Of these 6 patients 5 had initial decompression rates of greater than 48 mm. Hg/30 seconds and 4 had 5-minute, post-infusion steady state values of less than 50 mm. Hg, criteria that have been used to define corporovenous dysfunction.

The aim of this study was to determine the tensile strength and the elasticity of the tunica albuginea (TA), and describe morphological structures in the tissue before and after mechanical deformities. Twenty cadavers of men aged between 33 and 83 were examined. Cavernosometry was performed in all specimens. Afterwards in five cadavers the flow rate was increased until a herniation of the TA appeared. A strength about 1500 mm. Hg was found. Similar results were found in four who had an inflatable prosthesis (AMS 700) inserted, and the intraprosthetic pressure increased until a deformity was noted. Slices of TA (thickness 1.3 to 3.3 mm.) from 11 specimens were tested in a tensiometer. The elasticity coefficient was found to be around 10(8) N/m2, and the tensile strength to be 600 to 750 mm. Hg (10(4) to 10(5) N/m2). The difference between the tensile strength achieved in the tensiometer and during saline infusion is possibly caused by the intracavernous framework. Microscopy showed that TA is mainly composed of collagen fibres which are situated in an undulating arrangement, with a few elastic fibres arranged longitudinally which connect the undulating bundles of collagen fibres. When the tissue is overstretched, the elastic fibres are destroyed and the undulating arrangement disappears.

The anatomical location of the branches of the pelvic plexus that innervate the corpora cavernosa has been identified previously in stillborn male neonates and fetuses. Based upon these observations, the techniques of radical retropubic prostatectomy and cystectomy have been modified to avoid injury to the autonomic innervation of the corpora cavernosa. However, the exact anatomical relationships of these nerves to the prostate, urethra and other pelvic structures in adults are unclear, since the initial anatomical studies of the pelvic plexus were performed in stillborn neonates in whom the accompanying vessels and fascia had been removed. Because these nerves are microscopic in size and can only be identified by their association with other pelvic structures, it was believed that a more refined understanding of the anatomy was necessary. In an effort to identify precisely the relationship of the cavernous branches of the pelvic plexus to the lateral pelvic fascia and the branches of the prostatovesicular arteries and veins, the following study was performed. Shortly after death a 60-year-old man was perfused completely with Bouin's fixative solution. The entire bladder, prostate, urethra, penis, corpora cavernosa, rectum, and pelvic sidewall fascia and musculature were removed en bloc. The specimen was serially sectioned transversely at 10 mu thickness, and every tenth section was stained with hematoxylin and eosin. An anatomical reconstruction in 3 dimensions was performed and illustrated. Thus, the specific location of the nerves that innervate the corpora cavernosa and their important relationships to the urethra, prostatic capsule, Denonvilliers' fascia and pelvic floor vasculature have been identified.

The cavernous body of monkeys was studied by light and electron microscopy. The intima of the deep artery contained longitudinal muscle cells, but cushions or valve-like structures were not found. Some branches of the deep artery directly connected to subtunical veins. Only the helicine arteries which drained into the cavernous sinuses displayed subendothelial cushions. The "epitheloid cells" forming the cushions unequivocally were smooth muscle cells. It is suggested that the helicine arteries open during tumescence, thereby diverting blood from the shunt vessels into the dilating sinuses, and that the rising intracavernosal pressure eventually occludes the shunt vessels. The endothelium of the sinuses contained many intermediate filaments, but there was no morphological evidence for the hypothesis that the cells are contractile.

A total of 58 men with organic erectile dysfunction underwent penile blood flow studies with a 10 MHz. high resolution ultrasonogram and pulsed Doppler analysis after papaverine injection. The average volume increase for the entire group was 52.62 cc (445.9 per cent). No statistical differences in volume increase were noted among 3 groups separated by age. The average volume increase in 23 patients with venous insufficiency was greater than that in 20 patients with primary arterial insufficiency (p less than 0.033). Eleven patients who had erections satisfactory for vaginal penetration after papaverine injection had a statistically greater increase in penile length but no difference in volume increase than those with a poor response. The 10 MHz. high resolution sonogram provides the most accurate assessment of penile volume, which if measured at specific intervals after papaverine injection should allow an accurate assessment of penile flow. Patients with venous insufficiency may have weakness of the tunica, allowing greater volume expansion. A satisfactory erection is not associated with a significant increase in volume.

Five patients were treated with gonadotropin and topical testosterone for micropenis associated with hypothalamic hypogonadotropic hypogonadism. All patients received 1,000 units of gonadotropin weekly for 3 weeks, with a 6-week interval followed by 10% topical testosterone cream twice daily for 3 weeks. Serum testosterone levels were measured and remained equivalent for both modes of therapy. Average penile growth response with gonadotropin was 14.3% increase in length and 5.0% increase of girth. Topical testosterone produced an average increase of 60% in penile length and 52.9% in girth. The greatest growth response occurred in prepubertal male subjects with a minimal response in postpubertal male subjects. This study suggests that 10% topical testosterone cream twice daily will produce effective penile growth. The response appears to be greater in younger children, which is consistent with previously published studies of age-related 5 reductase activity.

Total phallic reconstruction presents the genitourinary reconstructive surgeon with one of the most difficult surgical challenges. The development of microsurgical techniques and free tissue transfers have advanced phallic reconstruction by reducing the number of surgical procedures and by allowing more selectivity in choosing the best innervated donor tissue. During the last 5 years 16 patients underwent total phallic reconstruction using free tissue transfers from distant donor sites. The pudendal nerve was coapted routinely to the major sensory nerves of the donor free flap. The most accurate objective baseline parameters of penile sensibility are pressure and vibratory thresholds, and electrically evoked potentials. We examined 30 normal subjects and 7 patients at least 1 year postoperatively for penile (phallic) sensibility. A pressure aesthesiometer, a biothesiometer and electrodiagnostic studies were used for testing. The 7 postoperative patients (in all of whom the pudendal nerve was incorporated into the reconstruction) had an encouraging return of tactile and erogenous sensibility compared to normal subjects. This is a promising advance in phallic reconstruction.

In 10 formalin-preserved adult male cadavers, dissection of the penile veins, arteries and nerves revealed information of clinical importance. The main venous drainage of the corpora cavernosa is via the cavernous veins, with additional drainage through the circumflex, deep dorsal, and crural veins. The arterial supply of the cavernous bodies varied remarkably, and the incidence of an accessory internal pudendal artery was high. The cavernous nerves, previously believed to be microscopic structures, were in fact identifiable grossly, and we were able to follow them from the region of the hilum of the penis to the prostate. The nature of these nerves was then confirmed by serial histologic sectioning. This detailed knowledge of the venous drainage and arterial and nervous supply of the penis, as well as of the relationships among the cavernous structures in the hilum of the penis, can elucidate the cause of erectile dysfunction and provide a valuable guide for surgical correction of vasculogenic and neurogenic impotence.

During a 2-month period all male newborns were examined prospectively to determine the normal characteristics of the penis. Of the 274 neonates examined 3 were excluded because of hypospadias with chordee. The spontaneous direction of the shaft was in the midline in 76.8 per cent, to the left side in 15.5 per cent and to the right side in 7.7 per cent. Partial absence of the prepuce was observed in 10 per cent of the patients, while an unretractable foreskin was seen in 23.2 per cent. The mean meatal aperture was 2.6 plus or minus 0.8 mm. Deviation of the median raphe was present in 10 per cent of the newborns and was associated with deviation of the meatus in 2.2 per cent. Mild torsion of the penis was noted in 1.5 per cent, while isolated torsion of 90 degrees was seen in 0.7 per cent of the patients. Early diagnosis and followup of these newborns might be helpful in determining further treatment.

The effects of subatmospheric pressure on the simian penis were studied in nine monkeys under anesthesia. A plastic cylinder was placed over the penis and suction applied until the gauge pressure was -100 to -200 cm. H2O. The intracavernous pressure decreased within one to three seconds to between -60 and -120 cm. H2O followed by a gradual increase as a result of blood flow into the corpora cavernosa. The intracavernous pressure recovery was 50% after 17 seconds and 100% by 30 to 60 seconds. These effects could also be observed when the penile base was partially constricted with a rubber band before applying the partial vacuum. Tumescence resulting from suction disappeared immediately when suction was terminated unless the base of the penis was constricted before and after the application of vacuum. In the latter case tumescence was prolonged (cavernous pressure between 60 and 120 cm. H2O) after suction. The cross-sectional area of the penis expanded to more than 150% of the flaccid state. The increase of intracavernous pressure from intracavernous papaverine injection was similar to that after suction with a constricting rubber band in place at the base of the penis. Subatmospheric pressure induces an expansion of the penis followed by increased blood inflow. The additional volume can be kept in the penis only if a constriction device is placed at the base of the penis. The tumescence induced by suction is passive, occurring without evidence of smooth muscle relaxation or release of neurotransmitters.

An erectometer for the measurement of sleep erections is described. Comparative studies using simultaneously strain gauges and the new device indicate that it possesses a significant potential for valid measurement of the circumferential increase that may occur during sleep. Because of its reliability, simplicity and low cost the erectometer is proposed as a screening procedure or as a diagnostic alternative when sleep laboratory facilities are not feasible.