Phenomenal work was done in sexual medicine this year. While there were many excellent presentations across the board, the highlights of the AUA Annual Meeting in 2023 in sexual medicine can be categorized into 4 broad topics: Peyronie’s disease (PD), penile prosthetics, pelvic floor physical therapy, and regenerative therapies.

Nonsurgical options for treatment of PD are of increasing interest. This, combined with the lack of availability of collagenase Clostridium histolyticum in Canada, prompted Feng et al to evaluate actinidin, which is found in kiwi fruit, as a potential treatment for PD.¹ They demonstrated in vitro reduction of cellular bound collagen and subsequent reduction of cellular viability in human PD models. This may represent an exciting, novel therapeutic agent for PD.

There were numerous presentations on the utility of collagenase. One standout was presented by Wu et al, who described the use of collagenase in atypical presentations of PD patients² who would have been excluded from the IMPRESS trials.³ They demonstrated safety and efficacy in men with hourglass deformities, ventral curve, multiplanar curve, and calcified plaques. The therapeutic response was similar in the atypical and typical groups (18.3° vs 20.9°, P = .294). Complication rates, as well as decreases in psychosocial symptoms and bother score, were also similar in both groups, suggesting we may be able to reduce exclusion criteria without sacrificing efficacy.

Dr Landon Trost presented modifications to the IMPRESS trial protocol, which included injections on 2 consecutive days, injections to the erect penis, favoring the point of maximal curvature over the plaque itself, and the utilization of aggressive modeling.⁴ With this protocol, he describes significantly greater curve improvements, averaging an additional 10°, and an increase in overall responders to the treatment, varying from 78%-94%, compared to 62%-66% prior to incorporation of the protocol changes. Rather than take these modifications as the new gold standard, this work should spark further optimization of a useful therapeutic tool. Dr Trost does advise caution in incorporating aggressive modeling into a PD practice.

Several studies discussed the use of chlorhexidine gluconate in infection prevention for inflatable penile prosthesis patients. Karpman et al presented a series of cases in which a Coloplast Titan implant was dipped into Irrisept (0.05% chlorhexidine solution) and exposed to various pathogens.⁵ The chlorhexidine exposed implants demonstrated a 3-10–log reduction in cell counts in all species tested, while the saline control demonstrated no reduction in cell counts. Fuselier et al examined excised capsule cultures before and after irrigation with chlorhexidine irrigation in patients undergoing revision penile prosthetic surgery.⁶ They found that no patients (0%) had positive cultures after washout, compared to 14% of patients with positive cultures prior to washout.

There were multiple opinions presented regarding partial component exchange in the management of malfunctioning inflatable penile prostheses. Barham et al presented a multicenter retrospective study in which they found that men undergoing partial exchange of their device had a higher infection rate, higher rate of noninfectious complications, and shorter time to revision than patients who had an exchange of the entire device.⁷ However, a counterpoint was presented by Dr Morey’s group out of UT Southwestern, who found that there was no difference in complications between patients who had their reservoir completely removed and replaced, those who had their original reservoir deactivated and left in situ, and those who had their original reservoir validated and reconnected to new components.⁸ Ongoing research should clarify this discrepancy.

Expanded indications for pelvic floor physical therapy offer hope for several difficult-to-treat conditions. Pastore et al investigated the long-term outcomes of pelvic floor muscle training in males with lifelong premature ejaculation.⁹ These patients completed a 12-week program of physiokinesiotherapy, electrostimulation, and biofeedback with 3 sessions per week. Patients reported a 3-fold increase in latency time, and 67% of patients reported maintenance of ejaculatory control at 72 months of follow-up. In general, pelvic floor physical therapy was recommended by a variety of presenters as a low-morbidity, but potentially effective, option for many difficult-to-treat problems in sexual medicine, including hard flaccid syndrome, ejaculatory pain, painful nocturnal erections, and chronic scrotal contents pain.

Perhaps the most discussed, and controversial, topic at this year’s meeting was regenerative therapy. Goldstein et al presented a sham-controlled, randomized, prospective trial using low-intensity shock wave therapy (LiSWT) in men with erectile dysfunction.¹⁰ They found a statistically significant decrease in end diastolic velocity in the treatment group vs the sham controls. Notably, there were 2 different treatment arms with varying protocols and varying outcomes, reinforcing the need to identify an optimal protocol. Owens-Walton et al reported a durable 4-point improvement in IIEF in men undergoing LiSWT at 1, 3, and 6 months posttreatment when compared to sham treatment.¹¹ Both studies support the use of LiSWT in properly selected patients with erectile dysfunction.

Dr Yafi summarized the state of regenerative therapies, which are promising but certainly require further investigation. Radial waves, which patients can purchase online, are consistently ineffective. There is a growing body of evidence that LiSWT may produce benefit in a subgroup of patients, though both patient selection and treatment protocols need to be optimized, as noted previously. Given the novelty and lack of standardization of protocols, there are ethical concerns regarding charging patients for therapy at this time. Regarding platelet rich plasma and stem cell therapy, there were multiple presentations which spoke to the safety of these treatments; however, efficacy data are still forthcoming.

Ongoing research will build on the breakthroughs presented this year, with new developments sure to come. With certainty we can conclude: the future of sexual medicine is bright.