Biomedical subjects
Publications and source records attributed to I Goldstein.
A case of neglected pessary is presented. After erosion through the anterior vaginal and bladder walls the device came to rest entirely within the bladder. Surgical management of removal of the pessary and repair of the resulting vesicovaginal fistula are described. Appropriate use of supportive pessaries as well as complications of misuse and neglect are discussed.
Impotence in the diabetic man may be secondary to a neuropathic condition of the autonomic penile nerves. The relationship between autonomic neuropathy and impotence in diabetes was studied in human corporeal tissue obtained during implantation of a penile prosthesis in 19 impotent diabetic and 15 nondiabetic patients. The functional status of penile cholinergic nerves was assessed by determining their ability to accumulate tritiated choline (34), and synthesize (34) and release (19) tritiated-acetylcholine after incubation of corporeal tissue with tritiated-choline (34). Tritiated-choline accumulation, and tritiated-acetylcholine synthesis and release were significantly reduced in the corporeal tissue from diabetic patients compared to that from nondiabetic patients (p less than 0.05). The impairment in acetylcholine synthesis worsened with the duration of diabetes (p less than 0.025). No differences in the parameters measured were found between insulin-dependent (11) and noninsulin-dependent (8) diabetic patients. The ability of the cholinergic nerves to synthesize acetylcholine could not be predicted clinically with sensory vibration perception threshold testing. It is concluded that there is a functional penile neuropathic condition of the cholinergic nerves in the corpus cavernosum of diabetic impotent patients that may be responsible for the erectile dysfunction.
The binding characteristics of the muscarinic acetylcholine receptor antagonist, [3H]quinuclidinyl benzilate, to isolated membranes of human corpus cavernosum and endothelial cells, cultured from this tissue, were investigated. [3H]quinuclidinyl benzilate bound to membranes of human corpus cavernosum and endothelial cells with high affinity and limited capacity. Analysis of the binding data by Scatchard plot revealed the presence of one class of binding sites. The ligand binding specificity was determined by competitive binding assay. The data obtained show that [3H]quinuclidinyl benzilate was displaced by unlabeled competitors in the following order of efficacy in both membrane preparations: quinuclidinyl benzilate greater than scopolamine greater than atropine greater than 4-diphenylacetoxy-N-methyl-piperidine methiodide, M3 antagonist greater than pirenzepine, M1 antagonist greater than oxotremorine greater than (4-hydroxy-2-butynyl)trimethylammonium chloride m-chlorocarbanilate, M1 agonist greater than carbachol greater than hexamethonium. Solubilization of the muscarinic acetylcholine receptors from human corpus cavernosum and endothelial cells, with 1% digitonin and 0.02% cholate and subsequent analysis on sucrose density gradients, demonstrated the presence of a macromolecule specifically bound to [3H]quinuclidinyl benzilate sedimenting at the 6.2 S region of the gradient. These results demonstrate the presence of muscarinic acetylcholine receptors in human corpus cavernosum and in endothelial cells cultured from this tissue.
To determine the presence, location and pattern of arterial occlusive disease within the hypogastric-cavernous arterial bed in impotent men following blunt perineal and pelvic trauma, we reviewed the selective internal pudendal arteriograms of 20 patients with a history of blunt perineal and 7 with blunt pelvic trauma who had immediate development of impotence. Arteriographic studies of 104 other impotent patients also were reviewed and compared. Patients with persistent impotence immediately after blunt pelvic and perineal trauma had significantly different patterns of arteriographically demonstrated occlusive disease within the distal hypogastric-cavernous arterial bed consistent with the site of the traumatic injury. Those who sustained blunt pelvic trauma and complained of immediate impotence revealed arterial occlusive lesions mainly in the internal pudendal, common penile, cavernous and dorsal arteries. The incidence of arterial lesions in the distal internal pudendal or common penile artery was significantly higher (p less than 0.01) in patients with blunt pelvic trauma (92%) than in those with blunt perineal trauma (35%). Patients who sustained blunt perineal trauma and complained of immediate impotence demonstrated a more focal pattern of pathological arterial occlusion primarily in the cavernous and dorsal arteries. The incidence of a solitary arterial lesion in the cavernous artery without proximal disease was significantly higher (p less than 0.05) in patients with blunt perineal trauma (48%) than in those with blunt pelvic trauma (8%). It is hypothesized that blunt trauma without immediate impotence may be a potential risk factor for later development of arterial vasculogenic impotence, and that unrecognized or seemingly innocuous trauma may be a factor in cases of idiopathic impotence. Patients without trauma and with vascular risk factors have a more diffuse pattern of arteriographically demonstrated arterial lesions.
Trazodone hydrochloride is an oral antidepressant agent which has been associated with the improvement of erections in impotent men and the development of prolonged erections or priapism in potent men. An in vivo study in animal and human subjects was performed to gain experience with the effect of intracavernosal trazodone. In the anesthetized New Zealand White rabbit, intracavernosal trazodone or its major metabolite m-chlorophenylpiperazine (m-CPP) produced full penile erection in 76% and 84% of animals studied respectively with doses ranging from one to 15 mg. On the other hand, intracavernosal administration of five mg. papaverine resulted in a prolonged erection in 90% of animals studied. In 13 selected volunteer patients, intracavernosal trazodone caused tumescence but not full penile erection with corporal body pressures of 28.2 +/- 5.8 mm. Hg. Intracavernosal papaverine or papaverine and phentolamine in these subjects resulted in significantly higher corporal body pressures of 58 +/- 18 mm. Hg (p less than .05). Intracavernosal administration of alpha adrenoceptor agonists but not normal saline resulted in complete detumescence of trazodone- or m-CPP-induced prolonged erection in the animal studies. Intracavernosal trazodone results in erectile activity that appears in part based on its local alpha blocking activity but like other intracavernosal alpha-blocking agents is not as effective in initiating penile erections as are intracavernosal agents that directly induce smooth muscle relaxation.
Two forms of priapism are known to occur. The more common type, veno-occlusive priapism, presents with a prolonged painful erection, and it is characterized by ischemia and pooling of blood within the corpora cavernosa. The less common form, high flow priapism, is characterized by lack of pain and ischemia. The pathophysiology of this disorder is poorly understood and the treatment is unclear. We report 2 cases of nonischemic priapism, one of which occurred after blunt perineal trauma and the other after intracavernosal self-injection with papaverine and phentolamine. Based on our 2 cases as well as a review of the literature (5 cases), we propose that the pathophysiological mechanism of this disorder is unregulated arterial inflow into the corpora, classify it as arterial priapism, and describe a diagnostic and therapeutic algorithm for its management.
A prospective ultrasound study was conducted in 160 normal pregnant women with gestational ages ranging from 14 to 40 weeks. Several fetal biometric measurements were obtained, including the posterior horn width (PHW) and the cerebroposterior horn distance (CPHD) of the lateral ventricles. Curvilinear relationships were found between the gestational age and the ratio of the PHW/CPHD (r = 0.665, p less than 0.0001); and the PHW/hemispheric width (HW), (r = 0.716, p less than 0.0001) and also between the biparietal diameter and the PHW/CPHD ratio (r = 0.649, p less than 0.0001), and the PHW/HW ratio (r = 0.732, p less than 0.0001). A correlation in growth was also observed between the femur length and the PHW/CPHD (r = 0.660, p less than 0.0001), and the PHW/HW (r = 0.734, p less than 0.0001). Nomograms of the PHW, CPHD, and the ratio of PHW/CPHD against gestational age were generated. The establishment of normal indices of the posterior horn provides new, precise, and comprehensive data that will serve as a standard against which the evaluation of early abnormal ventricular growth and anomalous development of the central nervous system may be compared.
Selective internal pudendal angiography was performed in 195 men (average age, 35.4 years +/- 10.3) who were suspected of having arteriogenic impotence. In the majority of patients, disease was localized to the cavernosal arteries. A previous series that involved older patients had demonstrated significant disease in the hypogastric and internal pudendal arteries. When controlled for trauma, the data revealed no significant difference (X2 test, P greater than .10) in the distribution of hemodynamically significant penile arterial disease. However, in patients who had sustained major pelvic trauma, the common penile artery was frequently hemodynamically compromised. There is a great deal of variation in the origin of the internal pudendal artery. An accessory pudendal artery was demonstrated in 7% of the patients. If a selective internal pudendal artery injection fails to demonstrate the penile arterial anatomy, a less selective injection should be performed. Bilateral injections should always be performed, as unilateral arterial disease was present in 15% of the patients.
Hemodynamically, most cases of priapism occur as a result of venous outflow obstruction producing engorgement of the corpora cavernosa. In a small number of patients, however, the cause is uncontrolled arterial inflow, often from direct arterial trauma. The authors report two cases of arterial or "high-flow" priapism that were successfully treated with selective transcatheter embolization with autologous clot.
Relaxation of the smooth muscle of the corpora cavernosa of the penis is necessary for penile erection. To determine the relation of impaired relaxation to impotence in diabetic patients, we performed an in vitro examination of corpus cavernosum tissue obtained at the time of implantation of a penile prosthesis in 21 diabetic and 42 nondiabetic men with impotence. Contraction was induced in isolated strips of corporal smooth muscle by norepinephrine; then relaxation was assessed with electrical stimulation of autonomic nerves and with the administration of three agents: acetylcholine, which is known to be mediated by endothelium-derived relaxing factor; papaverine; and sodium nitroprusside. The latter two act directly on smooth muscle (i.e., they are endothelium-independent). Autonomically mediated relaxation with electrical stimulation was less pronounced in the smooth muscle from diabetic men (n = 18) than in the smooth muscle from nondiabetic men (n = 24; P = 0.001). The degree of impairment increased with the duration of diabetes (r = 0.61, P = 0.007). Endothelium-dependent relaxation was also impaired, as evidenced by a lower degree of muscle relaxation after the administration of acetylcholine in the tissue from diabetic men (n = 16) than in that from nondiabetic men (n = 22; P = 0.001). The adverse effects of diabetes persisted after we controlled for smoking and hypertension. Endothelium-independent relaxation after the administration of nitroprusside and papaverine was similar in tissue from the diabetic and nondiabetic men. We conclude that diabetic men with impotence have impairment in both the autonomic and the endothelium-dependent mechanisms that mediate the relaxation of the smooth muscle of the corpora cavernosa. These findings may provide a rationale for the treatment of diabetic men with impotence by intracavernosal injection of vasodilators to induce endothelium-independent relaxation of the smooth muscle.
A method for culturing endothelial cells (HCC-EC) from surgical specimens of human corpus cavernosum has been developed. The approach involves selective endothelial outgrowth from explants and may be generally applicable to tissues whose endothelium is not amenable to isolation by routine mechanical or enzymatic methods. The tissue is minced into pieces which are placed onto gelatin- or fibronectin-coated tissue culture plastic, and grown in medium suitable for microvascular endothelial cell growth (Carson and Haudenschild, In Vitro 22:344-354, 1986). By Days 5 to 7 EC colonies are found. Within a day or two after the appearance of the EC colonies, a non-EC cell type appears and, if undisturbed, quickly overgrows the EC. An exploitable temporal separation between the emergence of EC and non-EC is obtained when both conditioned medium (from bovine aortic endothelium) and retinal extract are present during the outgrowth period. Explants are removed by pipetting at the first sign of the emergence of the non-EC cell type. Once isolated, HCC-EC do not require conditioned medium but do require either retinal extract or acidic fibroblast growth factor for survival and growth. Approximately 60% of the first passage cultures are at least 80% EC as judged by DiI-Ac-LDL labeling. One corpus (0.3 x 0.3 x 0.5 cm) usually produces 120 cm2 of primary culture within 2 wk. These EC form contact-inhibited monolayers and stain positively for Factor VIII. They have a doubling time at 6th passage of 48 h and a plateau density of 5 to 7 x 10(4) cells/cm2. The availability of such cultures should facilitate the study of endothelium-mediated responses which play an important role in the erectile function of human penile corpus cavernosum.
A prospective ultrasonographic study was conducted in 100 normal pregnant women with gestational ages that ranged from 36 to 42 weeks in which multiple biometric measurements were obtained. Dimensions of the distal femoral, proximal tibial, and proximal humeral epiphyseal ossification centers, as well as the placental and colonic grades, were also evaluated. A high statistical correlation was found between gestational age and each of the five variables (p less than 0.001). With a stepwise linear logistic regression analysis, we determined that gestational ages (36 to 39 weeks and 40 to 42 weeks) could be ascertained with a high probability with the use of a combination of the proximal humeral epiphysis and colonic grades. Probability estimates were not significantly affected by the addition of the distal femoral, proximal tibial epiphyses, placental grade, or amniotic fluid volume. From these data, probability prediction tables were generated. The results of this study provide an alternate method by which gestational age may be estimated in late pregnancy.
The regulation of adrenergic activity in the penis was investigated by studying human and rabbit corpus cavernosum strips in organ chambers and measuring the release of norepinephrine from adrenergic nerve terminals. Electrical field stimulation of corporal strips caused frequency-dependent contractions which were potentiated by cocaine and attenuated by the alpha 1 adrenoceptor antagonist prazosin (10(-7) M), but not by the alpha 2 adrenoceptor antagonist rauwolscine (10(-7) M). Norepinephrine caused concentration-dependent contractions of corporal strips, which were attenuated by prazosin and rauwolscine. Acetylcholine and physostigmine attenuated adrenergic nerve mediated contractions and also significantly reduced electrically-induced norepinephrine release. These effects were reversed by atropine. Atropine alone enhanced electrically-induced norepinephrine release. Rauwolscine inconsistently enhanced adrenergic nerve mediated contractions but augmented norepinephrine release caused by electrical stimulation. The alpha 2 adrenoceptor agonist clonidine inhibited electrically-induced norepinephrine release. Vasoactive intestinal polypeptide (VIP) attenuated adrenergically-mediated contractions, but had no effect on electrically-induced release of norepinephrine. It is concluded that: 1) contraction of corporal smooth muscle is mediated by postjunctional alpha 1 adrenoceptors; 2) adrenergic activity is modulated by prejunctional alpha 2 adrenoceptors and cholinergic nerves via prejunctional muscarinic receptors; and 3) the putative nonadrenergic noncholinergic neurotransmitter, VIP, has no apparent role in the regulation of adrenergic nerves.
Body stalk anomaly results in a severe body wall defect, maldevelopment of the hindgut, and the presence of a very rudimentary umbilical cord. A case of prenatally diagnosed body stalk anomaly is presented along with the discussion of the essential diagnostic criteria.
A prospective ultrasound study was conducted on 171 normal pregnancies ranging in gestational age from 15 weeks to term to evaluate the developmental anatomy of the atria of the lateral ventricles. The atrial width showed no significant modifications throughout gestation, remaining fairly constant. Significant linear relationships were found between the cerebroatrial distance and gestational age (R2 = 0.88; P less than .0001) and between the cerebroatrial distance and the biparietal diameter (R2 = 0.936; P less than .0001), with a first- and second-order regression equation being the best fit, respectively. From these data, growth of the atria was characterized both biologically and mathematically, providing a comprehensive evaluation of the atrioventricular system throughout pregnancy. Such data offer the potential for early prenatal diagnosis of various types of developmental abnormalities of the fetal ventricular system.
Although the subject has been the focus of a large body of obstetric literature, premature rupture of the membranes and its pathogenesis, management, and incidence of sequelae remain confused and controversial. The origins of this disquieting state of affairs can be traced to the lack of a specific, narrow definition of the condition, and resultant variations both in gestational age and maternal epidemiology in the populations assessed.
Intracavernosal self-injection of smooth muscle relaxants, primarily papaverine admixed with phentolamine, have been used to treat impotence in over 300 patients. The program is effective in a large fraction of this group. Selection of patients, adjustment of dose, methods for monitoring, clinical efficacy, and complications are discussed.