==inizio objective==

The penile prosthesis option presently suffers a paradox: despite being for the patient with severe ED the solution that scores the highest in terms of satisfaction, the vast majority of patients that qualify for it do not have access to it. Several are the barriers to the penile prosthesis solution: patients are not informed / misinformed about this option, costs of penile implants are significant, no reliable figures on the dimensions of penile implant field are available. Two key interventions appear accordingly needed: to produce reliable data on the phenomenon “penile implant surgery” at National level, and to correctly inform the general population of the benefits and limits of the penile prosthesis option.
For these purposes a prospective Registry for penile implants and a Institutional informative website aimed to popularize the potentials of the penile prosthesis option to the lay public have been launched on December 2014 by the Italian Society of Andrology (S.I.A.) (1).

==fine objective==

==inizio methodsresults==

The “INSIST-ED REGISTRY” (Italian Nationwide Systematic Inventarisation of Surgical Treatment for ED) is a prospective Registry of penile prostheses (all brands, all models) open to all implanting surgeons operating in Italy. Registry surgeons agree to provide anonimous patient, device, surgical procedure, outcomes, follow-up data, for both first and revision surgeries. The impact of penile implants on recipients quality of life at 1 year f.u. is to be assessed by the QOLSPP questionnaire (2). S.I.A. concurrently created an Institutional website (www.androprotesi.it) aimed to provide lay public with sound information on the penile prosthesis option; only implanting surgeons adhering to the Registry and active on it are present in such website with a personal page.

==fine methodsresults==

==inizio results==

As February 2016, 44 implanting surgeons joined the Registry, and 326 surgical procedures have been entered in the Registry database. We report analysis of the first 300 consecutive cases entered in the Registry; they comprise: 252 (84%) new implants, 37 (12,3%) prosthesis substitutions, 10 (3,3%) device removal without substitution, 1 simple surgical revision. Geographic distribution: 121 (40,3%) procedures were performed in North Italy, 115 (38,3%) in Centre Italy, 64 (21%) in South Italy. Chief ED etiologies of the Registry cases were: 107 (35,6%) iatrogenic (radical pelvic surgery), 62 (20,6%) Peyronie’s cases, 31 (10,3%) diabetes. The overall 289 implanted devices are represented by: 235 (81,3) three-component devices, 18 (6,2) two-component devices, 36 (12,4%) non hydraulic devices. Surgical settings: 79% of all the performed procedures took place in public hospitals, the remaining 21% in private settings. Waiting time from indication to surgery for new implants: 12 months in public hospitals, 1,4 months in private settings.

==fine results==

==inizio discussions==

Penile prosthetic surgery has potentials to become both: more acknowledged by the ED population, and more accessible. This project moves in the direction to promote the realization of such potentials through the “INSIST-ED” Registry, and the Institutional informative website www.androprotesi.it. Our Registry is the first experience of this kind in Europe. In the rest of the world another Registry only is ongoing, in the U.S.A.: “PROPPER” (3), launched in 2011. It differs from our Registry in the following aspects: it is a Company-devised study that evaluates only the devices produced by that Company, and with the Company itself having direct access to data and planning their analysis. Conversely, in the “INSIST-ED” Registry the Scientific Society S.I.A. has devised the study (opened to devices of all Companies), owns the database, and plans data analysis.
We will soon start collecting data on the impact of penile prostheses on recipients quality of life through the only validated tool for this purpose: the QOLSPP (2).

==fine discussions==

==inizio conclusion==

The INSIST-ED Registry represents the first European experience of penile prosthesis Registry. The first data analysis at one year since its start is providing for the first time objective data on the landscape of penile implantology in Italy. We hope that such data will be instrumental also to negotiate with Health Authorities better policies for the penile implant surgery area (for instance, more favourable reimbursements and more devices available in public hospitals). We also expect that our project will induce a more appropriate request of access to the “penile prosthesis option” by the severe ED population, now correctly informed by the Institutional website www.androprotesi.it .

==fine conclusion==

==inizio references==

1. Pescatori E, Franco G:
 Introducing the first Registry for penile implants: the INSIST-ED Registry (Italian Nationwide Systematic Inventarisation of Surgical Treatment for ED). J Sex Med 2015;12(suppl 3):216–240 HP-06-005
2. Caraceni E, Utizi L: A questionnaire for the evaluation of quality of life after penile prosthesis implant: quality of life and sexuality with penile prosthesis (QoLSPP): to what extent does the implant affect the patient’s life? JSM 2014; 11: 1005-12
3. Henry GD et al: The Who, How and What of Real-World Penile Implantation in 2015: The PROPPER Registry Baseline Data. J Urol. 2016;195(2):427-33

==fine references==

==inizio objective==

Abnormalities of the penis are infrequent, troublesome situations for both patients and urologists. Moreover a small penis can provoke anxiety and depression in prepuberal patients’ parents (1). The incidence of real small genitalia is unknown (2). In almost all cases who underwent an andrological consultation there was no real genital insufficiency, but only an excess of expectations or an eunuchoid habitus, typical of the obese children. What is the correct strategy to reassure parents or require a diagnosis of second level in order to identify endocrine or genetic damages that cause hypogenitalism?
We report our series and diagnostic flow chart used in cases of real micropenis.

==fine objective==

==inizio methodsresults==

From January 2008 to December 2015, 86 children (7-12 years) with suspected hypogenitalism underwent an andrological consultation at our department. In all patients a physical examination with evaluation of scrotal contents and evaluation of the stretched penile length was performed. Only patients with pathological length (according to Aaronson’s tables (3); 1994) were admitted to the assessment of the second level. Our protocol includes the evaluation of FSH, LH, total testosterone (T), prolactin, DHT (Dihydro-testosterone), and genetic study of androgen receptor to evaluate congenital or acquired disorders of the hypothalamus, pituitary gland, gonads or an alpha reductase deficit or peripheral androgen insensitivity (4).

==fine methodsresults==

==inizio results==

73 patients had not real genitalia abnormalities. In 68 patients we documented an excess of expectations from parents, in 5 cases an eunuchoid habitus due to childhood obesity. Diagnosis of micropenis has been confirmed in 13 patients. Micropenis can be defined as a penile length smaller than 2.5 standard deviations (SD) below the mean. 5 patients were diagnosed with hypogonadotropic hypogonadism, 1 case with panhypopituitarism associated with consensual deficit of TSH, ACTH and GH, 2 cases with deficit of 5 alpha reductases, 2 cases with deficiency of androgen receptor. In 3 patients it was not possible to find endocrine abnormalities and it has been hypothesized partial insensitivity of the genital skin to androgens.

==fine results==

==inizio discussions==

The reassuring attitude toward the parents worried about the size of genitals is justified in most cases, but this attitude must be endorsed by an accurate assessment of the real stretched penile length. A meticulous physical examination could help to identify the true cases of genital anomalies from the false ones. In pathological cases the diagnostic flow chart should be properly completed. As a consequence we stretch the usefulness of a careful assessment of the T/DHT rate (normal value: 4.9 + 2), that can be related with a deficit of 5-alpha reductase (5). 51 of the 86 patients were first-born child and the parents were alarmed by the difference with the other sons.

==fine discussions==

==inizio conclusion==

Penile abnormalities have a varied etiology and require a flexible approach. An adequate physical examination may allow a first assessment, useful to exclude cases of “false” small genitalia. In our series the majority of cases of “real” small genitalia are due to micropenis, whose diagnosis is related on correct measurement. Congenital or acquired disorders of the Hypothalamic-Pituitary-Gonadal axis are more rare instead. Endocrinological assessment helps in determining the etiology of small genitalia. A careful assessment of the T/DHT rate is useful for evaluating a possible deficit of 5-alpha reductase in cases with unknown etiology. Finally, an appropriate counseling with parents can reduce their anxiety and can improve the diagnosis and the therapy of this rare pathology.

==fine conclusion==

==inizio references==

1 Suorsa KI , Mullins AJ. Characterizing Early Psychosocial Functioning of Parents of Children with Moderate to Severe Genital Ambiguity due to Disorders of Sex Development. J Urol. 2015 Dec;194(6):1737-42. doi: 10.1016/j.juro.2015.06.104. Epub 2015 Jul 18.

2 Wang MH, Baskin LS. Endocrine disruptors, genital development, and hypospadias. J Androl. 2008 Sep-Oct;29(5):499-505. doi: 10.2164/jandrol.108.004945. Epub 2008 May 22.

3 Aaronson IA. Micropenis: Medical and surgical implications. J Urol. 1994 Jul;152(1):4-14.

4 Hatipoğlu N, Kurtoğlu S. Micropenis: etiology, diagnosis and treatment approaches. J Clin Res Pediatr Endocrinol. 2013;5(4):217-23. doi: 10.4274/Jcrpe.1135.

5 Gad YZ, Nasr H, Mazen I, Salah N, el-Ridi R. 5 alpha-reductase deficiency in patients with micropenis. J Inherit Metab Dis. 1997 Mar;20(1):95-101.

==fine references==

==inizio objective==

Erectile dysfunction (ED) is a common complication of priapism. ED can be irreversible if erectile tissue damage has occurred, above all in case of priapism lasting longer than 24 hours (1). However ED was reported also in patients with RIP (recurrent ischemic priapism) in which durations of priapism episodes are shorter (2). The basis of ED in RIP with briefer priapism duration is unex-plained. In a previous retrospective evaluation of clinical outcomes associated with the use of phosphodiesterase type 5 inhibitors in a very small number of RIP patients, the rate of ED was higher in the group of patients with sick cell disease (SCD) (3). The aim of this study was to evaluate the risk factors associated with EP in patients with RIP in our series.

==fine objective==

==inizio methodsresults==

We enrolled 78 patients with an history of RIP presenting to the urology and hematology department at our institution between January 2007 and January 2015. Erectile dysfunction was evaluated using priapism-specific IIEF and SHIM questionnaires. We definied RIP as having >= 2 episodes of ischemic priapism within the past six months, with the majority (>75%) of episodes lasting <5 hours. Almost all patients underwent phosphodiesterase type 5 inhibitors (PDE5i) therapy. The patients who underwent surgical shunts, penile prostheses or androgen ablative therapy were excluded from the study. Categorical data were collected in a database and they were compared using pearson's chi-squared test (χ2). ==fine methodsresults== ==inizio results== 35 out of 78 patients (44,9%) with RIP had an history of SCD. Overall, 27 out of 35 patients (77,1%) were identified as having mild or severe ED. 43 out of 78 patients (55,1%) with RIP had an idiopathic and drug-related etiologies. Overall, 21 out of the 43 (48,8%) patients were identified as having mild or severe ED. Patients with SCD had a significative higher rate of ED than those without SCD (p=0,0106). SCD patients were also more likely to have ED than non-SCD patients among all patients with episodes lasting <= 2 hours (p=0,0136) or those occurring weekly (p=0,0002). ==fine results== ==inizio discussions== ED is a common complication of priapism but there is little evidence in scientific literature about its relationship with RIP. In this study we confrimed RIP to be a risk factor for ED in particular for patient affected by SCD. Moreover the duration of priapism episodes and episode frequency affected the patients with SCD more than the patients without SCD. Patients with SCD may have an increased susceptibility to the reversible ischemic tissue injury associated with RIP episodes. It can be related to a chronically decrease of nitric oxide (NO) biovailability (4), an aberration in NO regulatory signaling (5) and an elevated oxidative stress resulting from reactive species generated chronically in SCD. Moreover these episodes can have a cumulative effect in producing cavernosal damage independent of major episodes. ==fine discussions== ==inizio conclusion== In our series we confirmed that ED is strongly associated with RIP, in particular in patients with SCD. The same strong association is also seen in some subcategory of patients with SCD (episodes regularly lasting <=2 hours or occurring weekly) compared to non-SCD. SCD is one of the most common etiology of RIP. As a consequence it is imperative to discover early this dangerous condition, in order to prevent severe erectile dysfunction in this patients with a properly therapeutic scheme. Despite of significant advancements in the understanting and in the management of priapism, identification of new pathophysiologic mechanisms may suggest new strategy to treat and prevent SCD priapism-associated ED. ==fine conclusion== ==inizio references== 1-Broderick GA. Priapism and sickle-cell anemia: diagnosis and nonsurgical therapy. J Sex Med. 2012 Jan;9(1):88-103. doi: 10.1111/j.1743-6109.2011.02317.x. Epub 2011 Jun 23. 2-Emond AM, Holman R, Hayes RJ, Serjeant GR. Priapism and impotence in homozygous sickle cell disease. Arch Intern Med. 1980 Nov;140(11):1434-7. 3-Burnett AL, Bivalacqua TJ, Champion HC, Musicki B. Feasibility of the use of phosphodiesterase type 5 inhibitors in a pharmacologic prevention program for recurrent priapism. J Sex Med. 2006 Nov;3(6):1077-84 4- Akinsheye I, Klings ES Sickle cell anemia and vascular dysfunction: the nitric oxide connection. J Cell Physiol. 2010 Sep;224(3):620-5. doi: 10.1002/jcp.22195. 5- Bivalacqua TJ, Ross AE, Strong TD, Gebska MA, Musicki B, Champion HC, Burnett AL. Attenuated RhoA/Rho-kinase signaling in penis of transgenic sickle cell mice. Urology. 2010 Aug;76(2):510.e7-12. doi: 10.1016/j.urology.2010.02.050. Epub 2010 Jun 9. ==fine references==

==inizio objective==

Fibrosis in the corpora cavernosa, is usually related with well known anamnestic risk factors. Causes of corporal fibrosis include complications from an infected implant such as explantation, priapism, penile trauma, Peyronie’s disease, and prolonged use of an intracavernosal injection agent (1-2-3).
Despite this, in our experience we have found significant fibrosis in the corpora cavernosa of patients without any well know risk factors. The aim of our study was to investigate the causes of significant penile fibrosis in our penile prosthesis implantation experience.

==fine objective==

==inizio methodsresults==

We enrolled 132 patients whose underwent a penile prosthesis implantation from January 2010 to December 2015. We classified the patients according to the indication for the implantation and to the intraoperative discovery of significant corpora cavernosa fibrosis. We classified the patients in two groups. In “group A” we enrolled 43 patients with high risk of prevedible significant fibrosis and In “group b” we enrolled 89 patients with low risk of prevedible significant fibrosis. We considered “significant fibrosis” if during the surgery we needed the help of additional straightening procedures like incision or excision of the scar, multiple corporotomies with or without grafting, the use of the Rossello dilator, implant downsizing, and transcorporeal resection (4). Arduos dilatation has not been considered as a paremeter of “significant fibrosis” because it can be related to the surgeon experience. Categorical data were collected in a database and they were compared using pearson’s chi-squared test (χ2).

==fine methodsresults==

==inizio results==

In our series 47 out of 132 (35,6%) patients experienced significant fibrosis. 14 out of 43 patients (32,6%) were in group A and 33 out 89 patiens (37,1%) in group B (p=0,6112). Table 1 shows in details anamnestic features of the patients who underwent a penile prosthesis implantation and the rate of significant fibrosis. The most important rate (60%) of significant fibrosis was found in the group of patients with an history of radical prostatectomy. Significant fibrosis was found in 31,8% of diabetic patients, in 20% of patients with cardiovascular disease, in 44,4% of paraplegic patients, in 25% of patients with Peyronie’s disease, in 22,2% of patients who underwent radiotherapy for prostate cancer, in 27,8% of patients with an history of priapism, in 23% of patients with veno-occlusive dysfunction, in 20% of the patients who underwent a previous penile prosthesis implantation and 5 patients had no clear causes of fibrosis.

==fine results==

==inizio discussions==

The primary pathophysiological event in the development of penile fibrosis is over-expression of plasminogen activator inhibitor 1, TGF β1, and reactive oxygen species that lead to the increased activity of myofibroblasts and the elevated production, deposition and accumulation of collagen (5). As expected, significant fibrosis was found frequently in priapism and in patients affected by peyronie’s disease. Significant fibrosis was surprisingly found in a big rate of patients with veno- occlusive disfunction, paraplegia and others no well know risk factors. 4 out of the 20 patients (20%) in the group of previous radical prostatectomy underwent continuative therapy with intracavernosal injection agent. All these patients experienced significant fibrosis. In more than a quarter of patients who are waiting for a penile prosthesis implantation without important risk factor for significant fibrosis, addictional straightening procedures can be necessary to permorm a correct implantation.

==fine discussions==

==inizio conclusion==

In conclusion, during a penile prosthesis implantation procedure, we can found significant fibrosis in the corpora cavernosa also in patients with no well know risk factors related to fibrosis. As a consequence it is imperative to have all needful surgical instrumentary (like the Rossello dilator) in simple clinical cases too. Last but not least it is imperative to have a good property of management of these complex cases. This preliminary study can suggest the use of a chronic preventive medical therapy with phosphodiesterase-5 inhibitors or pentoxifylline in this new risk categories of patients who are waiting for a penile prosthesis implantation.

==fine conclusion==

==inizio references==

1-Kabalin JN Corporeal fibrosis as a result of priapism prohibiting function of self-contained inflatable penile prosthesis. Urology. 1994 Mar;43(3):401-3.
2-Wilson SK Reimplantation of inflatable penile prosthesis into scarred corporeal bodies. Int J Impot Res. 2003 Oct;15 Suppl 5:S125-8.
3- Bilgutay AN, Pastuszak AW. Peyronie’s disease: a review of etiology, diagnosis, and management. Curr Sex Health Rep. 2015 Jun 1;7(2):117-131.

==fine references==

==inizio objective==

To evaluate the safety and efficacy of deep dorsal vein embolization using aethoxysklerol in the treatment of erectile dysfunction resulting from venous leakage, in patients not responders to the maximum dosage of various phosphodiesterase type 5 inhibitors (PDE5i).

==fine objective==

==inizio methodsresults==

The study enrolled 171 consecutive (age 21-39 years old) patients from March 2006 to June 2015. International Index of Erectile Function-Erectile Function Domain (IIEF-EF) questionnaire, medical history, physical examination, routine blood analysis, hormonal analysis, penile dinamic doppler ultrasound with volumetric analysis of the penis were checked in all patients. Venus leak was diagnosed by penile doppler and confirmed by dynamic infusion cavernosometry (DIC) using flow-to-maintain (FTM) measurement as the defining parameter.
Venous leak was diagnosed based upon a FTM value > 5 mL/minute. All patients underwent CT cavernosography to study the site of venous leakage. After penile block with carbocaine, a short penile dorsal midline incision was made at the corona of the glans penis. The superficial dorsal vein was ligated. The deep dorsal vein was identified and isolated under the Buck´s fascia. The distal end was ligated with 3-0 Vicryl™ and circumflexed veins were also ligated with 3-0 Vicryl™. The proximal end was catheterized with a 20 gauge steel needle after placing a tourniquet at the root of the penis and 3 ml aethoxysklerol foam 3% was injected for venoablation. We do not use an air block technique and Valsalva maneouvre. The patients were evaluated six months after surgery. Statistical analyses were conducted using SAS version 9.3 software (SAS Institute, Inc., NC). Mean values with standard deviations (±SD) were computed and reported for all items. Statistical significance was achieved if p-value was ≤0.05 (two-sides).

==fine methodsresults==

==inizio results==

The procedure did not cause any intraoperative complications. Postoperative minor hematomas occurred in 13 patients. Painful erections lasting at least 3 months occurred in 21 patients. At 6-month follow-up 132 out of 171 patients (77,2%) reported to have erections sufficient to permit vaginal penetration without the use of any drugs or additional devices. 23 out of 171 (13,45%) reported to have erections sufficient to permit vaginal penetration with the use of low dose of PDE5i. 16 out of 171 (9,4%) patients did not report any improvement. Preoperative IIEF-EF scores changed significantly at 6-month follow up (9±6 vs 21±7; p<0,001). Volumetric analysis of the penis showed a significant increase (Pre-op: 122.63% ± 65.66% vs 6-month post-op: 263.74% ± 90.20%; p<0,001) at 6-month follow up. ==fine results== ==inizio discussions== Nowadays PDE5i (inhibitors) are the first-line standard therapy in erectile dysfunction. The success rate of the therapy with PDE5i is about 70%(1). Moreover this type of medication is not indicated in patients taking nitrates or with other contraindication. DVO is one of the most common causes of vasculogenic erectile dysfunction. In the past, deep dorsal vein ligation have been performed to correct DVO with a low succes rate (2), probably due to the opening-up of some collateral veins. Embolization of the deep dorsal vein using aethoxysklerol has been previously described (3). Aeroblock techique in Valsalva maneouvre seems to maintain the sclerosing agent at place and can lead to a sufficient sclerosing of the deep dorsal vein network, including small veins. We perform a modified technique achieving results similar to others previously reported series in literature (3). ==fine discussions== ==inizio conclusion== DVO is one of the most common causes of vasculogenic erectile dysfunction above all in young patients. In our experience, this technique was effective, minimally invasive, and cost-effective in young patients with veno-occlusive dysfunction. We do not use an air block technique and Valsalva maneouvre. Despite this only 9,4% patients did not report any improvement after this procedure. It can be an alternative procedure to the simple penile vein ligation and to the penile prosthesis implantation after PDE5-inhibitor failure or in patients who cannot use this therapeutic option. Our study limitation is short follow-up period and our result should be followed-up in the future. ==fine conclusion== ==inizio references== 1-Nam Cheol Park, Tae Nam Kim, Hyun Jun Park Treatment Strategy for Non-Responders to PDE5 Inhibitors-World J Mens Health. 2013 April; 31(1): 31–35. Published online 2013 April 23. doi: 10.5534/wjmh.2013.31.1.31. 2-Henriet, JP. Value of sclerotherapy in the treatment of certain types of impotence caused by venous leakage. Phlebologie. 1987; 40:975-980. 3-Herwig R, Sansalone S. Venous leakage treatment revisited: pelvic venoablation using aethoxysclerol under air block technique and Valsalva maneuver. Arch Ital Urol Androl. 2015 Mar 31;87(1):1-4. doi: 10.4081/aiua.2015.1.1. ==fine references==

==inizio objective==

Priapism is a persistent penile erection that continues greater than four hours and can be not related to sexual stimulation. Ischemic priapism is a nonsexual, persistent erection characterized by little or no cavernous blood flow and hypoxic, hypercarbic, acidotic corporal blood gas. It is an urological emergency because it is associated with progressive fibrosis of the corpora cavernosa and erectile dysfunction (1). Recurrent ischemic priapism (RIP) is a form of ischemic priapism characterized by episodes of prolonged sleep-related erections (SRES) or transitory attacks of priapism. The aim of our study was to perform a retrospective study of our series of RIP reporting our classification and our management.

==fine objective==

==inizio methodsresults==

We retrospectively analyzed 135 patients with a history of RIP presenting to the urology and hematology department at our institution between January 2007 and May 2015. We usually classify our patients with RIP in three group: “prolunged sleep-related erections (SRES) with spontaneous resolution” (group 1), “minor RIP: transitory attacks of priapism with conservative management and resolution in two-five hours” (group 2), “major RIP: episodes of priapism with conservative management and resolution after 5 hours” (group 3). In this study we describe our management strategy in prevention of RIP according to some socio-demographic characteristics of the patients. We show the results of our series.

==fine methodsresults==

==inizio results==

72 out of 135 (53,3%) patients were enrolled in group 1, 35 out 135 (25,9%) patients were enrolled in group 2, 28 out 135 (20,7%) patients were enrolled in group 3. Finasteride has been used in 18 out of 135 (13,3%) patients. Only 8 out of 18 (44,4%) patients experienced zero episodes of priapism per month, another 3 (16,7%) experiencede 1-15 recurrences per month, and the remainging men with over 15 priapic episodes. The mean age of this group of patients was 38,2 (range 35-42). Ketoconazole has been used in 46 out of 135 (34%) patients. Prednisone was coadministered in all patients. 42 out of 46 (91,3%) patients experienced complete resolution of episodes of prolonged SRES. Moreover 33 patients (78,6%) did not need to resume ketoconazole after the therapy was discontinued an average duration of 6 month. The mean age of this group of patients was 23,4 (range 15-28). Phosphodiesterase type 5 inhibitors (PDE5i) has been used in 54 out of 135 patients. 35 out 54 (64,8%) patients had a sickle cell disease, 10 out 54 (18,5%) patients had thalassemia and 2 out 54 (3,7%) patients had glucose-6-phosphate dehydrogenase deficiency. The other 7 patients (13%) had idiopathic priapism. 46 out 54 (85,2%) patients alleviating (at least a 50% reduction in number and in severity of episodes) or solved (no more episodes) priapism at a mean follow-up of six months. Self-administered intracavernosal injections (ICI) were used by 17 out of 135 (12,6%) patients.

==fine results==

==inizio discussions==

After the acute episode is resolved, with or without any invasive procedure, the preferred management strategy of RIP would be prevention of future episodes. Current medical option for prevention of RIP are supported with level 3 or 4 evidence (2). The therapeutic approach should be well tolerated, safe and effective (3). Our management strategy is usually related to some socio-demographic characteristics of the patient. Antiandrogens are not recommended in young virile men. Ketoconazole may be a potentially effective treatment for prepuberal men or those desidering fertility with testosterone monitoring and dose tritation. PDE5i are usefull in men with idiopathic priapism and in priapism assoaciated with blood diseases, without affecting normal erectile capacity. The costs of this therapy does not allow its widespread use. ICI was not used in order to prevent the episodes of priapism but in order to treat episodes once they occur. It can be usefull in patients who are resilient to a self-injection approach, with sporadic episodes of priapism and witouth significant cardiovascular disease.

==fine discussions==

==inizio conclusion==

Despite of a large number of therapy described in scientific literature for the prevention of future episodes in RIP, there is not a therapy supported with an high evidence level (level 3 or 4 evidence). In our preliminary experience ketoconazole and PDE5i are safe and useful in prevention of priapism episodes in patients affected by RIP. The other described therapies can be useful only in specific categories of patients or in case of important contraindications to the use of PDE5i or ketoconazole. Despite this a randomized multi-center study will be needed and our result should be followed-up in the future.

==fine conclusion==

==inizio references==

1-Montague DK, Jarow J, Broderick GA, Dmochowski RR, Heaton JP, Lue TF, Nehra A, Sharlip ID; American urological association guideline on the management of priapism. J Urol. 2003 Oct;170(4 PT 1):1318-24.

2- Salonia A, Eardley I, Giuliano F, Hatzichristou D, Moncada I, Vardi Y, Wespes E, Hatzimouratidis K; European association of urology guidelines on priapism. Eur Urol. 2014 Feb;65(2):480-9. DOI: 10.1016/J.EurUro.2013.11.008. Epub 2013 NOV 16.

3- Hoeh MP, Levine LA. Prevention of recurrent ischemic priapism with ketoconazole: evolution of a treatment protocol and patient outcomes. J Sex Med. 2014 Jan;11(1):197-204. DOI: 10.1111/JSM.12359. Epub 2013 Nov 27.

==fine references==