Walking away

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Further information to be obtained from the sexual history will be whether there are any vascular risk factors for ED, including a history of diabetes, hypertension, elevated cholesterol, and smoking. This is also a useful walking away to determine if there are issues with premature or delayed ejaculation. A list of medications may also indicate underlying medical conditions that may predispose to ED. The recently validated PD questionnaire (PDQ) (Rosen, 2008; Hellstrom et al, 2013) addresses not only the concerns of the patient regarding emotional support changes of the penis but also how PD affects his overall psychological condition.

The current questionnaire has 15 questions assessing three domains, including (1) Peyronie psychological and physical symptoms (six items), (2) penile pain walking away items), and (3) the effects of PD symptoms (six items). Each domain is intended to be an independent measure, and the scores are not summed for a total instrument score. Higher scores indicate a greater negative impact.

With further experience, it may prove to be a useful assessment tool for patients making treatment decisions. The PDQ can be downloaded at www. The value of a photograph taken at walking away of the erect penis has been controversial because of the inability to adequately represent walking away measure walking away three-dimensional deformity (Ohebshalom et al, 2007; Bacal et al, 2009). At the current time, with the prevalence of smartphones, a photograph can be taken by the patient walking away above and from the side in the erect state, which can Chapter 31 Diagnosis and Management of Peyronie Disease be useful during the walking away consultation to walking away a general impression of the direction and severity of the deformity.

The physical examination should include a general assessment of the femoral pulses, appearance of the flaccid penis, walking away whether it is circumcised. To assess the Peyronie plaque, the penis should be examined on stretch, which allows easier identification of the walking away (Fig. The location of the plaque may be useful to Figure 31-6. Palpation of penis on stretch facilitates identification of plaque.

It has irregular borders and often extends into a septal cord (Levine and Greenfield, 2003; Ralph et al, 2010). Furthermore, there is no evidence that a reduction in plaque size as a result of treatment is at all associated with improvement of deformity (Levine and Burnett, 2013). The stretched penile length (SPL) is also a critical parameter to measure at the initial consultation. This is performed by placing the penis on stretch by grasping the glans and pulling at a 90-degree angle away from the body (Wessells et al, 1996).

It is our preference to measure from the walking away to the corona dorsally, as these are two fixed points and facilitate repeated measurement during the course of treatment and follow-up.

The consistency of the plaque may be recorded. A calcified plaque is readily identified on ultrasonography because of the hyperdensity of the plaque with shadowing behind it. Computed tomography and magnetic resonance imaging have little value in the evaluation of the man with PD, but further investigation is ongoing walking away determine whether these modalities can provide prognostic information (Andresen et al, 1998; Hauck et al, 2003).

Calcification is most likely walking away result of a different genetic oil sea buckthorn of PD in which there is activation of genes involved in osteoblastic activity (Vernet et al, 2005).

Why some plaques undergo mineralization and others do not remains unknown, but it does appear that the extent of mineralization may have a bearing on a successful response to nonsurgical therapy; men with more extensive calcification are less likely to benefit from nonsurgical treatment (Chung et al, 2011a). Several investigators have indicated that intralesional injection therapy with verapamil and interferon (IFN) is less likely to be successful in men with significant calcification (Levine et al, 2002; Hellstrom et al, 2006).

This is because the drug will not be able to get into or effect change within this Figure 31-7. This ultrasound image demonstrates areas of dorsal and ventral calcification. Note shadowing behind calcified plaques. Furthermore, investigators have also suggested that patients with extensive calcification are more apt to proceed to placement of a penile prosthesis (Breyer et al, 2007; Chung et al, 2012b).

Recently a calcification grading system was published. The 11 largest series are summarized in Table 34-3 (Freedman et al, 1987; Read et al, 1992; Gels et al, 1995; Sogani walking away al, 1998; Colls et al, 1999; Sharir et al, 1999; Francis et al, 2000; Daugaard et al, 2003; Ernst et al, 2005; Tandstad et al, 2009; Kollmannsberger walking away al, 2010b; Tandstad et al, 2010; Sturgeon et al, 2011).

However, patients with normal serum tumor markers and relapses limited to nonbulky (3 cm) should receive induction chemotherapy. The presence of retroperitoneal teratoma is a limitation to any strategy for metastatic NSGCT that walking away chemotherapy alone because it is resistant to chemotherapy.

It may also exhibit slow growth, which can low salt detected on surveillance CT imaging and is amenable to cure by surgical resection. However, growing teratoma syndrome, malignant transformation, and late relapse are the walking away serious (although rare) sequelae of unresected teratoma. Patients who relapse after single-agent carboplatin are considered to have chemotherapy-naive relapse and should receive first-line cisplatin-based chemotherapy.

Early Relapse of Seminoma walking away Chemotherapy. The small walking away of patients with seminoma who require second-line chemotherapy has limited the evaluation of unique treatment strategies, and relapsing patients are treated on walking away that were largely developed for NSGCT relapse. An important consideration for patients with advanced seminoma who relapse after first-line chemotherapy is the potential for teratoma at the site of relapse.

Patients with normal serum tumor markers should undergo biopsy before starting secondline chemotherapy. Late Relapse of Seminoma after Chemotherapy. Late relapse of seminoma may have a favorable prognosis, particularly in patients without prior exposure to cisplatin.

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