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PubMed2000

Embolization of the deep dorsal vein for the treatment of erectile impotence due to veno-occlusive dysfunction.

PURPOSE: We evaluate the effectiveness of deep dorsal vein embolization for the treatment of venous impotence. MATERIALS AND METHODS: A total of 32 impotent patients with veno-occlusive dysfunction underwent deep dorsal vein embolization. The condition was suspected based on findings of penile Doppler ultrasonography and cavernosometry. The diagnosis was confirmed with pharmacocavernosography that appeared to delineate venous leakage. During the procedure we isolated and cannulated the deep dorsal vein through a small dorsal penile incision with the patient under local anesthesia. We used a mixture of the tissue glue, N-butyl cyanoacrylate, and lipodol for embolization, with a total volume of 5 ml. injected antegrade into the previously catheterized dorsal vein under fluoroscopic control. As soon as we observed the occluded veins we performed repeat pharmacocavernosography. At 3-month followup patients were reassessed with history and cavernosometry. Followup ranged from 12 to 36 months (median 25). RESULTS: Of 32 patients 22 (68.7%) regained sexual activity, which was confirmed by cavernosometry. The remaining 10 patients (31.3%) experienced little if any clinical response, which correlated with cavernosometry. There were no significant side effects. CONCLUSIONS: Deep dorsal vein embolization for venogenic impotence is simple, effective and safe, and appears to be cost-effective. The results obtained in this limited number of patients are promising and justify trials in larger groups.

Adult↗
PubMed1995

The use of duplex ultrasound in the assessment of arterial supply to the penis in vasculogenic impotence.

Impotence may be caused by arterial disease affecting the vessels supplying the corpora cavernosa. Color duplex ultrasound was used to measure the peak systolic velocity and systolic rise time in the deep penile arteries in 22 impotent men following papaverine stimulation. The results were compared with the findings of selective internal pudendal pharmaco-arteriography. A further comparison was made using color duplex ultrasound with 37 impotent men who all responded well to papaverine. A systolic rise time of 110 msec. or more was found to be the best discriminant of disease in the arteries supplying the corpora giving a positive predictive value of 0.92. A long systolic rise time in a papaverine responder may indicate that the arterial supply is borderline or that the arterial flow is maximal and that the problem lies on the sinusoidal-venous side. It appears that in the absence of a pathological condition there is a large surplus arterial supply.

Adult↗
PubMed1996

Correlation of ultrastructural alterations in cavernous tissue with the clinical diagnosis vasculogenic impotence.

Cavernous tissues of 27 impotent and 4 potent men were evaluated in order to determine the ultrastructural changes in patients with vasculogenic impotence. Tissue samples were obtained during penile prosthesis insertions and surgical repairs of penile fractures in impotent and potent patients, respectively. For the clinical evaluation (pharmacologic color Doppler ultrasound, dynamic pharmacocavernosometry and nocturnal penile tumescence monitoring) patients were divided into three groups: slight/moderate arterial dysfunction (n = 5), severe arterial dysfunction (n = 9) and purely cavernous erectile dysfunction (n = 9). No significant ultrastructural alteration was noticed in the group with moderate arterial dysfunction; decrease and deterioration of smooth muscle cells was the prominent finding in the severe arterial and venogenic dysfunction groups. Preliminary examination of cavernous tissue may be a part of routine evaluations in the approach to the management of erectile dysfunction.

Adult↗
PubMed1997

Is diabetic neuropathy responsible for diabetic impotence?

It is well known that diabetes mellitus is accompanied by complications of sexual dysfunction and it is believed that diabetic neuropathy may cause impotence. In our study, we found that not all the patients who visited our center with the chief complaint of diabetic impotence were suffering from organic impotence, and diabetes mellitus per se served as a means of psychological stress in a substantial number of cases. Probably because no method has been available to provide precise information on the state of the penile-controlling nerves, we found that a larger number of patients than expected were suffering from a vascular disorder.

Algorithms↗
PubMed1994

Effects of papaverine and prostaglandin E1 on corpus cavernosum smooth muscle of arteriogenically and diabetically impotent men.

Relaxant effect of prostaglandin E1 (PGE1) and papaverine (PAP) were measured in strips of corpus cavernosum smooth muscle taken from a healthy control group of men (A; n = 5), from arteriogenically impotent men (B; n = 6) and from additionally diabetic impotent men (C; n = 5) with venous leakage. Maximal relaxant effect was achieved with PAP at a mean of 10(-4) mol/l and PGE1 at a mean of 5.8 x 10(-6) mol/l. PAP induced complete relaxation in all strips. There was no difference in relaxant effects between groups. Relaxant effect was less pronounced and depended significantly on etiology: phenylephrine-induced tension was reduced by 76 +/- 8% (A), 54 +/- 14% (B) and 23 +/- 18% (C), respectively. In conclusion, our data suggest degradation of PGE1 receptors depending on the cause of erectile dysfunction. Furthermore, relaxant capacity of cavernous smooth muscle per se seems not to be impaired in impotence. Therefore, pathophysiology of venous leakage cannot sufficiently be explained by a lack of relaxation.

Alprostadil↗
PubMed1994

A new approach to the pharmacologic treatment of impotence.

A new approach to the use of topical medications to induce penile erections is suggested. Many impotent patients treat erectile dysfunction with injected vasoactive drugs like papaverine, phentolamine and PGE-1. However, many patients fear using needles and the possible side effects from injections are well known (pain, ecchymosis, priapism, fibrosis of corpora cavernosa). In six patients with erectile impotence who sought an alternative to pharmacologic injection therapy, a 1 cm square window was created in Buck's fascia and tunica albuginea and covered with a piece of the deep dorsal vein of the penis. The penile skin overlying the window was marked with India ink and vasoactive medication was applied to this area. The goal of this procedure was to enable the topical erection-inducing medication to pass through the skin of the penis, through the window and into the corpus. All of the patients experienced a satisfactory erectile response after application of nitroglycerin cream as documented by penile Doppler ultrasound evaluation. Two of the six patients currently use only the nitroglycerin cream to induce erections satisfactory for sexual intercourse. Three patients alternate the use of the cream and injections. One patient prefers injection. This procedure may offer a desirable alternative to injection therapy for selected patients with impotence.

Administration, Topical↗
PubMed1994

[Diagnosis and treatment of impotence. Indications of intracavernous injections].

Based on progress in our understanding of the physiology of erection, intracavernous injections of vasoactive substances have completely changed the treatment of impotence. Essentially, erection results from the effect of smooth muscle relaxation in the vascular walls leading to local fall in vascular resistance and increased arterial flow combined with smooth muscle relaxation within the sinusoid spaces of the cavernous bodies. Smooth muscle cell tone is regulated not only by the classical norepinephrine and acetylcholine neurotransmitters, but also by other non-adrenergic and non-cholinergic neurotransmitters released locally. Although the "erectile neurotransmitter" has not been identified parasympathetic nerve terminaisons release nitric oxide (NO) a powerful myorelaxant agent. NO is also synthetized by the endothelial cells on the internal surface of the sinusoidal spaces. These recent findings have led to the use of papaverin to reduce the level of intracellular calcium, alpha-blockers to antagonize alpha-receptor and prostaglandin to inhibit norepinephrine release. Vasoactive intestinal polypeptide, a myorelaxing agent, and linsidomine which favours NO release have also been used. Diagnostic tests by intracavernous injections are indicated as part of the complete work-up in patients consulting for impotence. Therapeutic indications for auto-injections require careful choice of the agent and the dosage to inject depending on the cause of the impotence and the patient's demands and capacity to learn the technique. Papaverin or prostaglandin E1 alone or in combination with phentolamine give good results. Rigid erections can be obtained in over 60% of the patients. Alpha-blockers appear to be the least active in terms of rigidity. Mid-term results of intracavernous fibroses have been reported after papaverine injections. Priapism is the main secondary effect of intracavernous injections.

Humans↗
PubMed1996

[Intra-cavernous collagen analysis in impotence].

The role of the different components of the corpus cavernosum is very important in the physiopathology of erectile dysfunction. The precise function of collagen fibers in erectile physiology is controversial. We measured the different types of collagen (I, III, IV) in the corpus cavernosum of 26 impotent and potent men using cell image analysis and immunohistochemistry. We found differences in the distribution of collagen I, III, IV in each pathological group (arterial, caverno-venous, psychogenic). The augmentation of collagen I and the light diminution in collagen III makes the corpus cavernosum less compliant which translates clinically as an alteration in the filling of the vascular spaces and by dysfunction of the veno-occlusive mechanism. The diminution in collagen IV shows an alteration in the function of endothelial cells. The fact that in the psychogenic group we found also a diminution in collagen IV content, makes us infer that psychogenic impotence could be the first stage of an organic impotence.

Adult↗
PubMed1996

Dynamic infusion cavernosometry and cavernosography (DICC) in the evaluation of vasculogenic impotence.

BACKGROUND: This study was conducted to find more accurate physiological assessment of the penile vascular status in impotent patients. METHODS: Twenty-two males, aged 25-76 years (mean 54.0 years) with possible underlying vascular causes of impotence, had dynamic infusion cavernosometry and cavernosography (DICC) examination to ascertain the arterial and/or venous insufficiency in the penis. Prostaglandin E1 20 micrograms was injected intracavernously in this 4-phase study. RESULTS: No side effect or complication was noted during or after the examination in all 22 patients. During the phase 1 test, the mean resting intracavernous pressure (ICP) was 6.8 +/- 3.6 mmHg and the mean plateau ICP after PGE1 injection was 47.2 +/- 23.9 mmHg. The mean ratio of plateau ICP to mean arterial pressure was 50.2 +/- 23.4%. In the phase 2, the mean ICP determined 30 seconds after cessation of saline infusion without and with perineal compression was 65.3 +/- 26.8 mmHg and 129.1 +/- 26.2 mmHg, respectively. The mean ICP decay from 150 mmHg was 84.7 +/- 26.8 mmHg. The mean systolic pressure of each cavernous artery, 87.6 +/- 18.9 mmHg and 93.6 +/- 17.6 mmHg in left and right side, respectively, was found during phase 3 evaluation. The mean ratio of systolic pressure of each cavernous artery to brachial artery (cavernous-brachial index, CBI) was 70.1 +/- 12.7% and 75.1 +/- 11.5% in left and right side, respectively. Six patients with CBI greater than 75% had normal Doppler duplex sonography (diameter of cavernous artery greater than 0.9 mm and peak flow velocity greater than 25 cm/sec). Cavernosography in phase 4 evaluation showed venous leakage in 20 of 22 patients (90.9%) with ICP decay greater than 60 mmHg. Two patients with ICP decay less than 45 mmHg were found to have no venous leakage. CONCLUSIONS: The cavernous-brachial index is usually less than 75% in penile arterial insufficiency. The patients with ICP decay from 150 mmHg greater than 60 mmHg would have penile venous leakage demonstrated in the cavernosography. The results of cavernosometry are highly correlated with cavernosography. Our results suggest that DICC may provide a good examination for more physiological assessment and accurate diagnosis of vasculogenic impotence.

Adult↗
PubMed1995

Permanent open shunt as a reason for impotence or reduced potency after surgical treatment of priapism in 26 patients.

A permanent open shunt as a cause of impotence or impaired potency after a shunt operation for priapism is an unusual situation. In this series we studied the persistence of an open shunt in 26 patients who had developed impotence or impaired potency after operative treatment for priapism. All patients had been examined by cavernosography on the suspicion of an open shunt, giving a positive finding in five of 26 cases, in all of which impotence was cured by closure of the shunt. In five patients without a permanent open shunt potency returned to normal only after 6-12 months.

Adult↗
PubMedDate not supplied

[Diagnostic methods and therapeutic options in vasculogenic impotence].

Until a few years ago, the main cause of men's genital impotence was reputed to be psychogenic. On the other hand, the development of diagnostic techniques has been in aid in isolating the most frequent cause of impotence among the organic forms, and in particular those of vascular origin. The authors herein examine the diagnostic methods of vasculogenic impotence and evaluate the therapeutic options in relation to the various causes identified.

Humans↗
PubMed1998

Intracavernosal endothelin levels of impotent men before and after papaverine induced penile erection.

OBJECTIVES: Endothelin and nitric oxide (NO) are modulating factors of vascular tonus. Recent data have given support to the assumption that penile erection is the consequence of competition of vasodilator NO and vasoconstrictor endothelin on penis. Reported that atherosclerotic vascular disease is presented with increased endothelin and decreased NO release, this study was designed to search for a similar endothelin alteration in corpus cavernosum of penis. METHODS: Intracavernosal entothelin levels of 33 important men with arteriogenic impotence before and after papaverine-induced penile erection were examined by using radioimmunoassay kits. RESULTS: The intracavernosal endothelin levels of arteriogenic impotent men in our study were not altered both in the flaccid and papaverine-induced erectile state. CONCLUSIONS: The lack of alteration was concluded to be the possible result of cavernosal damage in arteriogenic impotence leading to diminished release of NO and increased release of endothelin.

Adult↗
PubMed1985

Internal iliac artery revascularization in the treatment of vasculogenic impotence.

Five impotent men underwent internal iliac artery revascularization in conjunction with end-to-side aortobifemoral bypass after preoperative testing suggested a vasculogenic cause for impotence. All patients had abnormal preoperative penile/brachial arterial pressure indices (mean, 0.42 +/- 0.12). Following operation, all patients regained erectile capability and had normal postoperative penile/brachial indices (mean, 0.80 +/- 0.06). One patient developed retrograde ejaculation, emphasizing the need for meticulous nerve-sparing dissection with this operation. Internal iliac artery revascularization in conjunction with end-to-side aortobifemoral bypass is effective in relieving vasculogenic impotence in properly selected patients.

Aorta↗
PubMed1985

Interstitial compartment pathology and spermatogenic disruption in testes from impotent diabetic men.

Studies utilizing animal models of diabetes suggest that diabetic complications of impotence involve structural lesions in the testis as part of an overall defect in the pituitary-testicular axis. In the present study testicular biopsies from ten oligospermic and/or impotent men with diabetes were evaluated by light and electron microscopy. One biopsy was judged normal. The remaining tissue showed variable testicular pathology ranging from minimally to grossly affected. Seminiferous tubules had decreased tubule diameters, hyalinized tubule walls, and occluded lumina owing either to epithelial encroachment or cellular debris and exfoliated round germ cells. Sertoli cells were vacuolated and showed a high degree of apical cell membrane redundancy and degeneration. Although Sertoli-Sertoli cell junctional complexes appeared normal, Sertoli junctional specializations associated with spermatids were structurally abnormal or absent. All tubules were variably depleted of adluminal compartment germ cell types. The interstitial compartment was filled with a collagen-rich extracellular matrix concentrated around small blood vessels and seminiferous tubule walls. Capillaries and lymphatic endothelia appeared structurally abnormal and compromised by the interstitial "matrix expansion." Some Leydig cells contained a variable number of small to large lipid droplets, vacuoles, and secondary lysosomes. Results indicate the presence of tissue pathology in testes of impotent diabetic men. Discrete ultrastructural lesions in apical Sertoli cell cytoplasm are associated with spermatogenic disruption and morphological changes in the interstitial compartment suggest microvascular complications.

Adult↗
PubMed1982

Increased penile perfusion and reversal of vasculogenic impotence following femoro-femoral bypass.

This study assessed the effect of femoro-femoral bypass on penile perfusion and impotence. Twelve patients with femoro-femoral grafts had Doppler pressure measurements and penile/brachial indices (PBI) recorded at both dorsal penile arteries, first with the graft open and then with the inflow portion of the graft temporarily occluded by manual external compression. Doppler pressure measurements and PBI did not change significantly in the dorsal penile artery on the donor (inflow) side of the graft when the graft was temporarily occluded. Patients who were potent both pre- and postoperatively (n = 5) had no significant change in pressure or PBI on the recipient (outflow) side of the graft with graft occlusion. In those patients who experienced reversal of impotence following bypass (n = 4) the mean dorsal penile artery pressure on the recipient side decreased from 101 mmHg with the graft open to 30 mmHg with the graft occluded (P less than 0.05). Review of arteriograms revealed that patients most likely to experience increases in penile perfusion have either (a) recipient side common iliac artery occlusion and a patent internal iliac system which is perfused in a retrograde fashion or (b) recipient side proximal internal iliac occlusion with well-developed collateral circulation between the profunda femoris and the distal internal iliac arterial systems. Femoro-femoral bypass can increase penile perfusion and alleviate vasculogenic impotence in selected patients.

Adult↗
PubMedDate not supplied

Psychological factors involved in impotence. A review of the literature.

Recent developments in the treatment of impotence and studies on the results of psychological methods for its treatment seem to indicate that the number of individuals who suffer from impotence of purely psychogenic origin is less than was reported in literature of the last decade. It is undoubtedly true, however, that psychological factors play an important role in the pathogenesis of this disorder. This review looks at psychological factors involved in impotence from three perspectives. Beginning with a historical review, those theoretical bases which formed the premise for psychological therapies are described. Second, diagnostic issues are explored in some detail. Finally, the variety of treatment modalities which have been used, with varying degrees of success, is described. It appears that whatever psychological treatment method is used, the patients who have the best prognosis are those in whom the disorder has lasted for less than two years, who have a strong motivation for psychotherapy, persisting sexual desire, and who are without significant psychopathology.

Behavior Therapy↗
PubMed1994

Clinical reliability of multi-drug intracavernous vasoactive pharmacotherapy for diabetic impotence.

The aim of this study was to assess the effectiveness and safety of intracavernous injections of a four-drug vasoactive mixture in diabetic patients with organic impotence. A group of 60 diabetic patients with either pure neurogenic, pure vasculogenic or mixed neurovasculogenic impotence were treated with intracavernous injections of a combination of 12.1 mg/ml papaverine hydrochloride, 1.01 mg/ml phentolamine mesylate, 10.1 micrograms/ml prostaglandin E1 and 0.15 mg/ml atropine sulphate ('full-dose' mixture). A mixture of the same drugs but at one-third concentrations ('reduced-dose' mixture) was also used. The mean (+/- SEM) volumes of the full-dose and reduced-dose mixtures used were 0.21 +/- 0.03 ml and 0.31 +/- 0.02 ml, respectively. All the patients were able to sustain a rigid erection at the end of the titration phase of the study. At a mean follow-up of 18 months, 48 patients (80%) were successfully using the mixture, 6 patients (10%) were using the mixture at a dose lower than the initial dose and 6 patients (10%) had dropped out from the injection therapy. No major complications were seen. The association of multiple vasoactive drugs which use different mechanisms of action, thus exerting a pharmacological synergism, is an effective and safe procedure in intracavernous pharmacotherapy for diabetic patients with organic impotence.

Adult↗
PubMed1979

Pituitary gonadal system function in patients with erectile impotence and premature ejaculation.

The pituitary testicular system was studied in men with psychogenic impotence. Eight patients with primary erectile impotence age 22--36 years, eight men with secondary erectile impotence age 29--55 years, and 16 men with premature ejaculation age 23--43 years were studied. The last group was further divided into two subgroups: E1 (n = 7) patients without and E2 (n = 9) patients with anxiety and avoidance behavior toward coital activity. Sixteen normal adult men age 21--44 served as a control group. Diagnosis was made after psychiatric and physical examinations. Patients complaining primarily of loss of libido were not considered in the study. Ten consecutive blood samples were obtained over a period of 3 hr from each patient. Luteinizing hormone (LH), total testosterone, and free (not protein-bound) testosterone were measured. Statistical analysis revealed no significant differences between patients and normal controls.

Adult↗