World Meeting on Sexual Medicine Postponed to 2021
JSM Methodology Update Series: Dr. Joana Carvalho
Dear Members and Colleagues:
After careful and deliberate consideration, we have decided to postpone the 22nd World Meeting on Sexual Medicine (WMSM) to November 15-17, 2021, in relation to the coronavirus (COVID-19) outbreak that is established to be a global pandemic.
Until recently, we felt optimistic that September was still far enough away to confidently proceed with our plans. However, the potential reach of COVID-19 has changed significantly over the last weeks with a rapid increase of cases worldwide and with increasing restrictions, which makes it very difficult to accurately assess its risks.
While this is not a decision we have taken lightly, our Board of Directors felt strongly that making a proactive and timely decision on this matter is beneficial to all parties involved.
The health and safety of all attendees and the patients they care for is our first priority. In addition, we are already seeing the impact of the travel restrictions issued by countries, academic institutions, hospitals, and industry partners on the attendance of delegates, faculty, and sponsors/exhibitors for our originally planned dates.
Therefore, at this time, we find ourselves unable to guarantee the most important thing our attendees and industry partners trust us above all else to deliver – a well-attended, high-quality, premier global sexual medicine meeting.
We would like to thank you for your patience. We are confident that with your continued support we will make the 22nd World Meeting on Sexual Medicine possible and as successful as always. Additional information regarding hotel reservation cancellations, registration refunds, and meeting logistics is available on the FAQ page of the meeting website.
We appreciate your commitment and flexibility and look forward to seeing you in Yokohama, Japan next year!
On behalf of the ISSM Board of Directors,
Luiz Otavio Torres, President
JSM Methodology Update Series: Dr. Laurence Levine
The fifth publication of the Journal of Sexual Medicine’s methodology update series will be Dr. Joana Carvalho’s “Measuring Pedophilic Sexual Interest," which was published in JSM’s March 2020 issue (https://doi.org/10.1016/j.jsxm.2019.12.008). Joana Carvalho, PhD, is an Assistant Professor at the Universidade Lusófona de Humanidades e Tecnologias in Lisbon, Portugal, with research focusing on various areas including paraphilias, sexual addiction, and sexual desire.
To get a more in-depth understanding of the thoughts behind her paper, we conducted a text interview with Dr. Carvalho:
1. What can the reader learn from the paper?
“This work is a narrative review on assessment methods aimed at measuring pedophilic sexual interest. The reader can find a set of key methods, along with their general application procedures and discussion on the strengths and limitations of each method. The reader may further learn on the main challenges in this field of assessment, and eventually apply such methods within the specificities of his/her country and legal system.”
2. What are the limitations with the present methods to measure pedophilic sexual interest?
“Most of these methods lack solid validation. In addition, their application and interpretation of data lack standardized procedures. Accordingly, some of the current methods aimed at measuring pedophilic sexual interest may actually miss the basic principles of psychological assessment. In some countries, such methods would not be recognized as a clinical or forensic assessment tool, and hence, would not be accepted for clinical or legal decisions. Even if there were standardized procedures for application and interpretation of data, countries vary a lot in terms of legal regulation, determining what kind of assessment convicted sexual offenders may go through. Even so, improving these assessment strategies is a first step for the wide spreading and acceptance of the assessment of pedophilic sexual interest.”
3. How is the field developing?
“This field of assessment is clearly more developed in countries such as U.S.A or Canada. Still, there’s been joint efforts to extend this type of assessment to other countries and legal systems. This is obviously a complex process that requires a dialog between science and law. In the meantime, new assessment tools, based on indirect measurement and supported by novel technology are emerging.”
4. What are the challenges within different cultures?
“Cultures present distinct legal systems, and some are not adapted to consider this kind of assessment as a formal assessment tool. In such countries, professionals may use some of these methods for research, but not for legal or clinical purposes. Besides, cultures vary in the way they appraise pedophilia. Moral judgments on clinical entities such as pedophilia may shape how the assessment of pedophilic sexual interest is conducted in a given culture.”
5. Why is it important to measure pedophilic sexual interest?
“Pedophilic sexual interest is a key risk factor in sexual offender recidivism. We may measure pedophilic interest as a means to establish risk and adjust clinical interventions aimed at managing such risk. Ultimately, we are preventing new crimes by working directly with offenders or individuals at risk of offence.”
The sixth publication of the Journal of Sexual Medicine’s methodology update series will be Dr. Laurence Levine’s “Peyronie's Disease Intervention Studies: An Exploration of Modern-Era Challenges in Study Design and Evaluating Treatment Outcomes," which was published in JSM’s March 2020 issue (https://doi.org/10.1016/j.jsxm.2019.11.271).
Laurence A. Levine, MD, is a Professor of Urology in the Department of Urology at Rush University Medical Center in Chicago, with research focusing on various areas including the treatment of erectile dysfunction and Peyronie’s disease.
To get a more in-depth understanding of the thoughts behind his paper, we conducted a text interview with Dr. Levine:
1. In the current COVID-19 environment, what role does telemedicine play in the evaluation of the PD patient?
“For years, I have been providing fee-for-service telephone consultations mostly for patients calling from a distance away from my office in Chicago. I believe the same process can be quite useful especially during the COVID-19 crisis where patients may be sheltered at home and yet worried about their PD. During the interview, I would be able to get a general idea of the onset of disease symptoms, subjective estimate of deformity, their erectile function, and review the current treatment options. These interviews are useful as oftentimes these men have obtained a good deal of misinformation about Peyronie’s disease with respect to etiology and treatment options. As we all know there is a good deal of 'voodoo' on the internet and unfortunately our own literature is wrought with difficult to interpret information, albeit less voodoo. Although these interviews can be quite useful to get an
initial idea of the patient’s condition as well as provide some reassurance that treatment is available, it is clearly not enough. In my opinion, the man with PD needs a physical examination and direct evaluation of his erection. In my practice, I routinely perform Doppler duplex ultrasound (PDDU) evaluation of all men with PD in the flaccid and erect state following vasoactive injection. Having said that, the ability to offer a telemedicine consultation does provide the patient an opportunity to gain useful information and possibly to initiate non-surgical therapy, such as oral medications and traction therapy before they can come to the office for a full evaluation.”
2. Could you give us a sense of the role auto-photography plays in your PD practice?
“I feel it is critical to directly examine the penis for the following reasons: It allows me to assess tunical elasticity, measure stretched length, palpate the scar, and to compare the erectile response to an intracavernosal drug injection during PDDU to the patient’s erection at home, as well as to objectively measure curvature and indentation deformity. On the other hand, I find that auto-photography has limited value. We know that the 2D representation of the erect penis in a photograph oftentimes underestimates the true deformity and will fail to provide accurate information about severity of curvature and indentation, as well as whether there is a hinge effect or buckling that occurs with application of axial forces. We also know that the patient’s report of deformity is oftentimes either over or underestimated. Therefore, in my practice accurate assessment of deformity is critical
and auto-photography is frequently inaccurate. Auto-photography’s primary value may be to provide remote follow-up of the patient’s progress following or during treatment once the deformity has been properly assessed in the office.”
3. What are the key components of penile length measurement in the PD patient, flaccid and erect?
“The key components in the flaccid state include measurement of stretched flaccid penile length which I measure with a rigid ruler (preferably supine) from the pubis by pushing down on the skin and pubic fat pad with the penis on full stretch perpendicular to the body plane, to the beginning of the corona. These are two fixed points which are essential to measure at the initial consultation and at subsequent visits, particularly after any intervention. I also like to assess the elasticity of the penis, which is more of a gestalt appreciation for the lack of 'give' that one feels when gently pulling the penis away from the body. In most men with PD, there will be loss of elasticity. This seems to correlate with the patient’s perception of lost erect length and provides an opportunity to discuss how the scar tissue results in the loss of elasticity and subsequent deformity.
"In the erect state, the most important measurements will be assessment of curvature with a goniometer, which is infrequently a simple sharp (elbow-like) curve with a straight component from the base to the point of maximum curvature and then a straight shaft thereafter. More commonly, there is a more crescent-like curve which can make accurate assessment of deformity difficult. It should be recognized that the accuracy obtained with a goniometer, even in the simple sharp curve, has an intra- & inter-observer error of at least 5 degrees in any direction. This is why I do not believe that anything less than a measured 10-degree reduction of curvature is likely to be a meaningful change in deformity. As to indentation deformity, we are now routinely evaluating this, during maximum erection, with a string and a ruler to compare the circumference at the point of most severe
indentation relative to the girth at the base and distal shaft.”
4. You question the role of PDDU in the evaluation of the PD patient, but when does abnormal erectile hemodynamics impact upon your care, medical and surgical?
“The question I have with respect to the role of PDDU in patients with PD is why any physician evaluating these men would not want to perform it. It provides a substantial amount of information including whether there is calcification present, which is critical, particularly if Xiaflex is being considered. It also provides the most objective opportunity to measure curvature and indentation deformity. All of this can be obtained following intracavernosal pharmacological injection (ICI). PDDU also allows for assessment of penile hemodynamics, which is useful to some degree, but I think provides the least amount of valuable information with respect to clinical decision making. The real question is whether the patient does or does not obtain a full erection following ICI and whether that erection is similar to or better than what they can obtain at home. The actual measurement of
hemodynamics is clearly operator, time, and environmentally dependent and the actual accuracy of the numbers obtained are questionable as one can find different flow characteristics at different locations along the shaft as well as at different time points throughout the study. The basic question is whether the patient can obtain a full erection adequate for intromission and whether that is equal to, better, or worse than what they would obtain at home. In my opinion, hemodynamics is most useful when the patient does not obtain a full erection and this is similar to their home erection, we can then document that there is arterial and/or venous insufficiency present which may be most useful for insurance and coverage purposes. In men who have poor quality erections at home and during PDDU, they should be considered candidates for placement of a prosthesis with straightening maneuvers so
that they can resume sexual activity as soon as possible, even if they are in the acute phase. On the other hand, if they do get a strong erectile response during the PDDU, which is similar to what they attain at home and they are in the stable phase, these measurements will guide selection of the surgical approach to correct the deformity (i.e., plication vs grafting). In other words, if the patient had a very strong erectile response, similar to home, and had a severe curve and/or severe indentation with hinge effect, they would be someone who might be a candidate for a grafting procedure without an IPP, whereas the man with borderline erectile response who would not accept a prosthesis, here a plication procedure would be a better choice for that individual. Therefore, the combination of the erectile response and deformity measurements, as well as the presence of calcification, can all
be useful in terms of surgical decision making. For the man who is not in the stable phase, identification of grade 2 or 3 calcification, in the area of maximum deformity, should rule out the use of Xiaflex.”
5. What is your opinion on the prognosis of future RCTs being done in the PD space?
“RCTs have proven to be very difficult to perform for men with PD for several reasons. First, any single site rarely has enough patients to power such a study. Multi-center studies are hard to control and surely not all men with PD have similar presenting deformity or underlying comorbidities, as well as a plethora of other difficult to control variables. But RCTs are the foundation upon which we can build evidence to support or debunk emerging therapies. They most likely need to be multi-center in design to be able to have an adequate number to power the trial and to have the best possible controls so that we can offer our patients reasonable hope of honest treatment outcomes. Unfortunately, but realistically, RCTs are also very expensive to conduct. Sponsoring pharmaceutical or device companies will want to know that they have an opportunity to recoup their investment in these studies.
Finally, given our current failure to understand the basic pathophysiology of PD will make the likelihood of a finding a magic bullet as a reliable treatment in the near future unlikely.”