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PubMed1990

Clinical significance of ultrastructural findings in the corpora cavernosa of normal and impotent men.

Corpora cavernosa of 5 normal and 11 impotent living men were studied by electron microscopy. Of the smooth muscle cells 42.3% from corporeal tissues of impotent men showed a pronounced thickening of the basal lamina, a paucity of dense bodies and contractile filaments, minimal or no glycogen and fewer vesicles on the cell surface, whereas only 5.4% of the smooth muscle cells from normal men showed similar alterations. These differences were statistically significant (p less than 0.003). The percentage of altered smooth muscle cells in corporeal tissues of impotent men was proportional to the severity of symptoms and clinical findings. Morphometric analysis revealed no significant differences in the relative proportions of the major components of corporeal tissue (smooth muscle cells, extracellular matrix, vascular lumina and endothelial cells). These findings suggest the need for early detection of corporeal tissue degeneration by preoperative biopsy to assist in better selection of candidates for a penile vascular operation. They also may contribute to the development of new therapeutic modalities for erectile dysfunction.

Adult↗
PubMed1990

Comparison of penile duplex ultrasonography with nocturnal penile tumescence monitoring for the evaluation of erectile impotence.

A total of 50 patients with erectile dysfunction underwent comprehensive evaluation, including vascular evaluation with penile duplex ultrasonography and papaverine injection, as well as nocturnal penile tumescence monitoring. The latter was performed in a sleep laboratory setting in all patients. The results of penile duplex ultrasonography with papaverine injection were classified as 18 patients with normal vascular findings, 22 with arterial insufficiency, 3 with the pelvic steal syndrome and 7 with isolated venous leakage. Of the patients 15 had normal ultrasonographic and nocturnal penile tumescence findings, 29 had abnormal ultrasonographic vascular and nocturnal penile tumescence findings, 3 had abnormal ultrasonographic vascular findings and normal nocturnal penile tumescence (including 1 with the pelvic steal syndrome as evidenced by penile brachial index) and 3 had normal ultrasonographic vascular findings and abnormal nocturnal penile tumescence (including 2 with neurogenic erectile dysfunction). Penile duplex ultrasonography with papaverine injection appears to be a useful objective method to evaluate vasculogenic impotence and to correlate favorably with nocturnal penile tumescence monitoring. It also may have a higher yield than nocturnal penile tumescence monitoring in patients with the pelvic steal syndrome. While nocturnal penile tumescence is impaired in patients with neurogenic impotence, penile duplex ultrasonography with papaverine injection reveals, as expected, normal findings in patients with neurogenic impotence and normal vascular systems.

Adult↗
PubMed1989

Impotence evaluated by the use of prostaglandin E1.

We screened 80 patients at our hospital for the differential diagnosis of impotence using intracavernous injection of prostaglandin E1 (20 micrograms). The rate of positive response was 78.8 per cent (63 patients). Neither systemic reactions nor priapism occurred. However, a considerable incidence (23.8 per cent, 19 of 80 patients) of tolerable injection pain was encountered. The 133xenon penile washout study was conducted routinely in impotent men for hemodynamic evaluation of penile vascularity. In 80 patients a positive correlation between the response of intracavernous prostaglandin E1 injection and the result of the washout study was found (r equals 0.381, p less than 0.0002). We selected 14 subjects randomly to receive additional intravenous infusions of prostaglandin E1 (6 ampules, 120 micrograms total) for 3 days, after which another 133xenon washout study was done. The washout studies before and after intravenous prostaglandin E1 infusion were compared, and 10 patients (71.4 per cent) appeared to obtain improvement in half-time clearance and penile blood flow. However, only 3 patients noticed improvement subjectively. We suggest that prostaglandin E1 could be a desirable alternative for the diagnosis and treatment of impotence.

Adult↗
PubMed1988

Intracavernous self-injection for impotence: a long-term therapeutic option? Experience in 78 patients.

A total of 78 patients 17 to 84 years old reported their experience via questionnaire with the papaverine-phentolamine injection technique for impotence. The mean number of injections used was 30.7. Penile induration occurred in 13 patients (16 per cent) and it was generally of limited extent. A higher incidence of induration was observed in those with vasculogenic impotence. Prolonged erection was reported by 23 per cent of the patients, 8 per cent of whom experienced erection for more than 12 hours. Priapism occurred exclusively in diabetic patients and patients with a neurological etiology of impotence. A total of 22 per cent of the patients reported moderate to severe pain with injection, 35 per cent indicated decreased quality of erection with time in response to the vasoactive agents and 28 per cent believed this therapy to be unsatisfactory. Among those who discontinued the injections 5 cited variability of erectile response (duration or quality) as the reason for discontinuation. A decrease in the effectiveness of the injections with time may be anticipated among some patients. For patients who face a penile implant without other options penile self-injection with vasoactive drugs is a reasonable alternative in that complications do not prevent successful prosthetic implantation.

Consumer Behavior↗
PubMed1988

Treatment of impotence due to perineal venous leakage by ligation of crura penis.

Perineal venous leakage is a cause of impotence that is demonstrated easily by dynamic cavernosography. Perineal ligation of the crura penis was done in 13 patients with this type of impotence. Nine patients achieved satisfactory intercourse and 3 had sufficient erection after intracavernous self-injections of papaverine. Implantation of a penile prosthesis was required in only 1 patient. Ligation of the crura penis is a simple operation that seems to be efficient in the treatment of impotence owing to perineal venous leakage.

Adult↗
PubMed1987

Bulbocavernosus reflex to somatic and visceral nerve stimulation in normal subjects and in diabetics with erectile impotence.

Bulbocavernosus reflex to stimulation of the vesicourethral junction and glans penis was recorded in 14 normal controls and 24 diabetic men complaining of erectile impotence. In all normal subjects the bulbocavernosus reflex to stimulation of these sites could be obtained, and mean latencies were 59.2 +/- 8.0 msec. and 33.3 +/- 3.7 msec., respectively (p less than 0.00001). A total of 66 per cent of the diabetics (16 patients) exhibited abnormal (delayed or absent) bulbocavernosus reflex to stimulation of the vesicourethral junction, while only 12.5 per cent (3 patients) had delayed response to glans penis stimulation. The latter tended to remain within normal limits, although the mean latency was significantly different from that of normal subjects (p less than 0.05). Abnormalities of the bulbocavernosus reflex to stimulation of the vesicourethral junction correlated strongly with the presence of peripheral and autonomic neuropathy, diabetes and organogenic impotence. Our results indicate that this is an informative test for the evaluation of visceral afferents arising from the bladder neck and, hence, in the differential diagnosis of organogenic versus psychogenic erectile impotence.

Adult↗
PubMed1987

The erectile angle: objective criterion to evaluate the papaverine test in impotence.

Intracavernous papaverine injection may be the first diagnostic step in the assessment of the impotent patient. However, the appreciation of its effect must rely on the evaluation of penile rigidity. Since measurement of rigidity requires a sophisticated procedure that may not be available to the majority of practitioners, we attempted to find a simple and objective method to evaluate the results of this common test. We tested 50 patients complaining of impotence with intracavernous injection of 60 mg. papaverine. The length and circumference of the penis were measured before and after papaverine injection. The rigidity was determined by measuring the angle between the penis and the legs with the patient in the standing position. Afterwards, each patient underwent vascular (Doppler ultrasound and cavernometry) and neurological examinations. A total of 27 patients with no vascular abnormalities had an erectile angle of 96 degrees (range 90 to 130 degrees), while 23 patients had some vascular disorders (9 arterial lesions, 8 venous leakage and 6 combined lesions) and an erectile angle of 36 degrees (range 0 to 60 degrees). There was no significant difference between the groups in the increase of length and circumference of the penis after intracavernous injection of papaverine. The papaverine test can distinguish between patients with vascular and psychogenic problems. A negative papaverine test associated with a normal Doppler examination is characteristic of venous leakage. Measurement of the erectile angle after intracavernous injection of papaverine with the patient in the standing position is a simple, objective and reliable method to evaluate patients with vascular impotence.

Adult↗
PubMed1987

Pharmacoarteriography in the evaluation of impotence.

Progress in diagnosis and therapy of impotence is handicapped by the absence of a validated and objective method for evaluating the vascular system; a gold-standard for vasculogenic impotence is needed. Prior experience has indicated that conventional arteriography in unanesthetized patients is unreliable in evaluation of the penile arterial supply. We have improved our arteriographic methods by the routine application of selective pudendal injections, vasodilation pharmacoangiography with nitroglycerin and papaverine, and direct magnification. Experience in 37 impotent patients demonstrates marked improvement in the quality of visualization of distal vessels, and the frequent presence of functional vasoconstriction of medium and small arteries that can be distinguished from organic disease only with vasodilators. We believe these angiographic methods will improve the criteria against which other diagnostic and therapeutic methods can be objectively assessed.

Adult↗
PubMed1987

Penile pharmacocavernosography and cavernosometry in the evaluation of impotence.

Within the past few years, veno-occlusion of the corpora cavernosa has become generally recognized as an essential prerequisite for adequate penile erection. Veno-occlusive incompetence is suspected to be a frequent cause of impotence. Our recent experience with cavernosography in two normal volunteers and 36 impotent patients indicates that angiography is reliable in evaluating the competence of the veno-occlusive mechanism only if both pharmacocavernosography (PCG) and pharmacocavernosometry (PCM) are applied. Twenty minutes after intracavernosal (IC) injection of a mixture of 60 mg. papaverine and one mg. phentolamine (regitine), 100 ml. of diluted radiographic contrast medium are infused at the rate of one or two ml./sec. while pressure is recorded, and radiographic films are exposed at the rate of one every eight to 15 seconds. PCM and PCG of the corpora cavernosa indicated the overall degree of competence of the cavernosal veno-occlusive mechanisms, and the sites of veno-occlusive incompetence; non-pharmacologic studies were unreliable in these regards. During non-pharmacologic infusion in normals, pressures rose to 40 to 45 mm. Hg, and free efflux could be visualized from multiple venous systems. After pharmacologic injection in normals, all venous channels closed, and pressures rapidly rose toward or above 200 mm. Hg, at which time the infusion was stopped. Veno-occlusive incompetence was defined angiographically when more than minimal efflux occurred during pharmacocavernosography from any venous system. The incompetence could involve the deep penile system, the deep dorsal system, or the spongiosal system, alone or in combination. Severe veno-occlusive incompetence was considered diagnostic of venogenic impotence, and was defined manometrically when IC pressures failed to exceed 100 mm. Hg during infusion of 100 ml. of fluid at 2 mm./second after IC papaverine and phentolamine injection. We believe these angiographic methods will improve the criteria against which other diagnostic and therapeutic methods can be assessed.

Adult↗
PubMed1987

Penile electrodiagnosis. Value of bulbocavernosus reflex latency versus nerve conduction velocity of the dorsal nerve of the penis in diagnosis of diabetic impotence.

The nerve conduction velocity of the dorsal nerve of the penis was evaluated with a direct measuring technique in impotent men with and without diabetes mellitus. The average nerve conduction velocity was 37 M. per second in impotent diabetics and 45 M. per second in nondiabetics. The latency of the bulbocavernosus reflex showed no significant difference between the groups and was within normal limits. The measurement of the nerve conduction velocity of the dorsal nerve of the penis is a valuable test for assessment of impotence in patients with diabetes mellitus.

Adult↗
PubMed1987

Changes in the VIPergic, cholinergic and adrenergic innervation of human penile tissue in diabetic and non-diabetic impotent males.

Penile tissue (consisting of corpus cavernosum and tunica albuginea) was obtained from 19 patients undergoing surgery for the implantation of penile prostheses. The tissue was examined for vasoactive intestinal polypeptide-like immunoreactivity in nerves, acetylcholinesterase-positive staining in nerves and noradrenaline content. Impotence was due to a variety of causes; 11 patients were classified as a 'non-neuropathic' group on the basis of their clinical history which included Peyronie's disease, vascular disease, hypertension and psychogenic impotence. Vasoactive intestinal polypeptide-like immunoreactive and acetylcholinesterase-positive nerves were present and the pattern and distribution were similar in each patient in this group. The noradrenaline content of the tunica albuginea was significantly lower than the corpus cavernosum (p less than 0.02), although there was a linear relationship between the noradrenaline contents of the two regions (r = 0.95, p less than 0.01). By comparison, a complete absence of vasoactive intestinal polypeptide-like immunoreactivity in nerves was observed in a patient with a cauda equina lesion. Five out of six diabetic patients studied revealed a marked reduction in vasoactive intestinal polypeptide-like immunoreactivity in nerves associated with the cavernous smooth muscle, while acetylcholinesterase-positive staining was reduced in three out of five diabetic patients studied. The noradrenaline content of the corpus cavernosum from diabetic patients was significantly lower (p less than 0.02) than that of the 'non-neuropathic' group. The noradrenaline content of the tunica albuginea, however, was similar in both groups. The results provide evidence that VIPergic, cholinergic and adrenergic nerves in the penis are affected in diabetes mellitus and thus may contribute to the development of impotence in diabetic patients.

Acetylcholinesterase↗
PubMed1986

Is intracavernous injection of papaverine a reliable screening test for vascular impotence?

To determine whether intracavernous injection of papaverine can discriminate vascular versus psychogenic impotence 80 mg. papaverine were injected intracorporeally into 27 impotent patients without any hormonal or neurological abnormality. The patients also underwent dynamic cavernosography, the artificial erection test and selective internal iliac arteriography. In addition, 21 of the patients underwent nocturnal penile tumescence monitoring. The response to intracavernous papaverine injection was noted as positive (fully rigid erection), intermediate or negative (soft or absent erection). Among 14 patients with severe arterial lesions and/or severe venous leakage the response was negative in 11 and positive in none. Among the remaining 13 patients (moderate or absent vascular abnormalities) the response was positive in 4 but negative in 4. Of 15 patients with an abnormal nocturnal penile tumescence test the response to intracavernous papaverine injection was negative in 12 and positive in none. However, of 6 patients with a normal nocturnal penile tumescence test the response was positive in only 1. Over-all, the results of the intracavernous papaverine injection test are correlated only fairly with those of the nocturnal penile tumescence test and the vascular investigations. This test could be useful to save some nocturnal penile tumescence tests in cases of suspected vascular impotence. However, the safety of this procedure must be confirmed in larger series. Indeed, 1 of our patients suffered priapism after a second intracavernous papaverine injection performed for a therapeutic purpose.

Adult↗
PubMed1984

Endocrine dysfunction in impotence: incidence, significance and cost-effective screening.

A comprehensive evaluation of impotence includes assessment of the functional integrity of the hypothalamic-pituitary-gonadal axis. However, little is known about the incidence or significance of hormonal abnormalities in an unselected group of men with erectile failure. A systematic multidisciplinary, multidimensional assessment of 256 impotent men showed clearly an organic etiology in 35.9 per cent, psychogenic in 38.3 per cent and mixed or uncertain in 25.8 per cent. The incidence of hypothalamic-pituitary-gonadal axis abnormalities in the entire group was 17.5 per cent but in only 12.1 per cent did they contribute clearly to erectile dysfunction. A cost-effective screening of the endocrine system in impotent men includes a thorough history and physical examination, and a serum testosterone determination. More sophisticated and expensive investigations should be reserved for patients with a history of drug use known to induce hormonal abnormalities or with somatic evidence of hypogonadism and a depressed serum testosterone level.

Adult↗
PubMed1978

Urological and behavioral approach to the treatment of secondary impotence.

Psychogenic impotence is far more common than organic impotence and may co-exist with or be a result of it. Psychological principles of therapy may be needed for all impotent patients treated by the urologist. These principles include 1) re-education in sexual function, 2) removal of pressure for male performance, 3) bringing existing performance fears to the surface for therapy, 4) teaching patients techniques to deal with the fears, 5) teaching the partner proper cooperation and 6) improving the communications between the 2 partners.

Anxiety↗
PubMed1994

Effect of yohimbine-trazodone on psychogenic impotence: a randomized, double-blind, placebo-controlled study.

OBJECTIVES: The aim of this study was to determine the effectiveness and safety of yohimbine and trazodone used together for the treatment of pure psychogenic impotence. METHODS: Sixty-three patients who had psychogenic impotence diagnosed on the basis of sexual history, results of physical examination, laboratory analysis, polysomnographic recording of nocturnal erections, and dynamic color Doppler sonography of the cavernosal arteries were entered into a randomized, double-blind, placebo-controlled, partial crossover study comparing placebo with yohimbine (15 mg per day orally) and trazodone (50 mg per day orally) used together. Treatment consisted of two 8-week courses. Patients who initially received placebo for 8 weeks were then switched to the 2-drug combination for 8 weeks. Erectile function, ejaculation, interest in sex, and sexual thoughts were investigated at the end of drug treatment and at 3- and 6-month follow-up. For statistical analysis chi-square, McNemar, and Student's t test for unpaired data were used. RESULTS: Fifty-five patients (87%) completed the whole treatment schedule. Positive clinical results (complete and partial responses) were obtained in 39 (71%) patients at the end of the drug treatment phase. These results were significantly better than those obtained with placebo (p < 0.01). Positive results were maintained in 32 (58%) and 31 (56%) patients at 3- and 6-month follow-up, respectively. Minor drug-related adverse effects occurred in 6 (11%) of the patients in the yohimbine-trazodone group and in 2 (4%) in the placebo group. CONCLUSIONS: The combination of yohimbine and trazodone is a safe and effective first-line treatment for psychogenic impotence.

Administration, Oral↗
PubMed1994

High attrition rate with intracavernous injection of prostaglandin E1 for impotency.

OBJECTIVE: To determine if intracavernosal pharmacotherapy utilizing prostaglandin E1 (PGE1) injections is a well accepted and durable treatment modality for impotency. METHOD: We reviewed the charts of 110 consecutive men who underwent a thorough impotency evaluation and were considered acceptable candidates for intracavernosal pharmacotherapy with PGE1. RESULTS: Forty patients opted not to initiate treatment with PGE1 (16 due to loss of interest in sex), while 60 patients pursued home self-injection therapy; 10 patients were lost to follow-up. Thirty-six (60%) of those who initiated therapy discontinued the use of PGE1 with a mean follow-up of six months; 18 terminated PGE1 usage due to loss of interest in sexual activity and 3 due to return of spontaneous erections. However, many who lost interest in sexual activity in both groups directly attributed this to the required intracavernosal route of administration for PGE1. Thus, only 24 of the original 100 (24%) patients continued to use PGE1 as impotency therapy for an attrition rate of 76 percent. CONCLUSION: Our study indicates that intracavernosal pharmacotherapy using PGE1 injection therapy is not a satisfactory long-term therapeutic modality for many patients with erectile dysfunction. The diverse reasons for this high attrition rate are discussed.

Adult↗
PubMed1997

Is high-dose yohimbine hydrochloride effective in the treatment of mixed-type impotence? A prospective, randomized, controlled double-blind crossover study.

OBJECTIVES: To determine the effectiveness and safety of high-dose yohimbine for the treatment of mixed-type impotence. METHODS: Twenty-nine patients who had mixed-type impotence diagnosed on the basis of a sexual history, results of a physical examination, laboratory analysis, assessment of the sensory pain threshold of the dorsal nerve of the penis, and dynamic color Doppler sonography of the cavernosal arteries were entered into a randomized, double-blind, placebo-controlled, crossover comparison of a placebo with high-dose yohimbine hydrochloride (36 mg per day orally). The treatment consisted of two 25-day courses; after a 14-day washout period, the patients who initially received the placebo for 25 days were switched to yohimbine hydrochloride for 25 days. Erectile function, ejaculation, interest in sex, physical examination findings, blood pressure, pulse rate, weight, and audiovisual sexual stimulation test were investigated before treatment and at the end of each drug period. The Mann-Whitney test was used for the statistical analysis. RESULTS: Twenty-seven patients (93%) completed the whole treatment schedule. Positive clinical results (complete and partial responses) were obtained in 12 cases (44%) at the end of the yohimbine phase and in 13 (48%) after the placebo period. No statistical difference was indicated. Drug-related adverse effects occurred in 2 patients in the yohimbine group (7%). CONCLUSIONS: Yohimbine is no better than placebo as a first-line treatment for mixed-type impotence.

Adrenergic alpha-Antagonists↗
PubMed1997

[Surgical treatments of erectile impotence].

Impotence affects 10 to 15% of the male population. Organic factors are recognized in 80% of cases. Intracavernosal injections of vasoactive agents (Virag) have provided advances in the physiopathologic understanding of impotence and provide new ways of treating this incapacity. However this option is inaffective in most organic cases: arteriogenic, venogenic or disorders of smooth cavernous muscle. Vasoactive injections for many reasons are abandoned in about 40% of the cases. Two kinds of surgical management can be performed: microrevascularization in order to restore the arterial penile flow or to reduce penile venous flow during erection; implantation of penile prosthesis when other therapeutic possibilities are exhausted. Arterialization of the deep dorsal vein (DDV) appears to be the best procedure in arteriogenic and principally venous impotence. Erectile function in theses case is restored in 60% of our patients. Two types of prostheses can be implanted: semi-rigid with an axial permanent rigidity and inflatable or hydraulic devices with a flaccid aspect after intercourse. These prostheses are technically successful in 75 to 90% of cases, but partner satisfaction does not match surgical success rates.

Arteriovenous Shunt, Surgical↗