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During 1964 through 1973, 76 men underwent abdominoperineal resection as part of or subsequent to resection for inflammatory bowel disease. No instance of permanent impotence was found. Proctectomy should not be deferred because of the risk of impotence.
Vascular problems represent the most frequent cause of organic impotence. Abnormal venous drainage from the corpora cavernosa is now widely accepted as the major cause of vasculogenic impotence. Based on our experience with more than 450 radiologic procedures, we describe the technique of cavernosography and cavernosometry, the effect of papaverine injection, and we review the literature.
The past decade has seen a remarkable expansion of understanding of erection and the treatment of impotence. This has been brought about, in part, by improvements in radiographic techniques for selective pudendal arteriography and dynamic cavernosography, which, in turn, have made possible development of surgical techniques for the management of penile vascular insufficiency and corpus spongiosum venous leakage that yield good short-term results in restoring the capacity for penetration in impotent patients.
PURPOSE: We aimed to assess objectively the integrity of the parasympathetic neural pathway that controls the inflow choke vessels to the corpora cavernosa in a group of male patients with postproctectomy erectile dysfunction. METHODS: The study group was male patients with erectile dysfunction after proctectomy for rectal cancer and inflammatory bowel disease identified by sexual function questionnaire. The group underwent two consecutive nights of home nocturnal penile tumescence monitoring with the Nocturnal Electrobioimpedance Volumetric Assessment device. The control group was also monitored. It comprised preoperative potent patients with rectal cancer and inflammatory bowel disease who had not yet undergone a variety of surgical procedures. Demographics and nocturnal penile tumescence parameters were recorded, including number, duration, and percentage increase in penile volume of tumescent events. RESULTS: Thirty-four impotent study group and 28 potent control group patients underwent nocturnal penile tumescence monitoring. The groups were well matched for mean age (difference, 1.4 years; 95 percent confidence interval, -5.8 to 8.6 years) and proportion with rectal cancer (difference, 6 percent; 95 percent confidence interval, -1 to 13 percent). The number of nocturnal penile tumescent events was greater for the potent group than for the control group (mean rank, 40.4 vs. 24.2; P = 0.0004). There was no significant difference between the mean duration (difference, 2.6 minutes; mean rank, 27.9 vs. 34.4; P = 0.16) or the mean penile volume increase (difference, 5.4 percent increase; mean rank, 30.6 vs. 32.6; P = 0.66) for tumescent events between the study and control groups. Mean age was significantly higher in complete than in partial impotence (60.9 vs. 53.1 years; difference, 7.8 years; 95 percent confidence interval, 0.1 to 15.5 years). There was a nonsignificant trend to a lower mean number of tumescence events among sildenafil responders than among nonresponders (3.5 vs. 4.8 events; mean rank, 11.2 vs. 17.3; P = 0.14). CONCLUSION: Nocturnal penile tumescence activity is diminished but not ablated by the trauma of surgical dissection. This suggests that some of the cavernous nerves that govern inflow to the corpora cavernosa are intact after surgery and that the nerve lesion responsible for erectile dysfunction is partial, and it explains why the response to sildenafil in such patients is surprisingly high.
Simultaneous monitoring of penile diameter and penile arterial pulse during laboratory-based erotic stimulation with film and fantasy, has been used to compare diabetic and non-diabetic impotent men with non-impotent controls. The degree of erection to erotic film distinguished between organic and psychogenic aetiologies. The diabetic group showed smaller penile pulse amplitude changes than the other two groups. Amongst the diabetics, severe autonomic neuropathy was associated with impaired erectile and penile pulse amplitude responses. Severe retinopathy was associated with smaller baseline penile pulse amplitude as well as smaller amplitude response. Blood pressure response to erotic stimuli did not differ between the three groups. An analysis of the temporal relationship between penile diameter change and pulse amplitude change revealed differences between the groups that may prove to have diagnostic as well as theoretical implications.
The VCD is a mechanical device that produces an erection by creating a vacuum of up to 250 mm Hg. Up to now, it has been used in patients with organic impotence (mainly diabetic) with a high level of success and minimal side effects. This study reports preliminary findings on the application of the VCD in both organic (e.g. diabetics) and psychogenic cases of impotence. All subjects were able to develop an adequate erection with the instrument making intercourse possible. However, the frequency of use dropped sharply as the study progressed and some subjects and their sexual partners expressed reservations about continuing with it. Mild numbness in the penis was experienced by several users.
We evaluated the effect of the opioid antagonist nalmefene on the HPG axis and on food consumption in 14 older impotent men. These patients had low to low normal mean serum testosterone values and normal gonadotrophin levels on screening evaluation. Normal response to GnRH was demonstrated in all the men. The protocol called for 24 hours of evaluation before and during administration of nalmefene 2.0 mg IV every 8 hours for 3 doses. During each 24 hour period, the following determinations were made: serum testosterone, FSH, and LH by five separate determinations between 8 AM and noon; 8 AM and 11 PM serum cortisols; 24 hour urine collections for free cortisol; and nocturnal penile tumescence (NPT). Food consumption was measured from 4 PM to 10 AM during the two periods. Nalmefene resulted in significant rises in testosterone, LH, and FSH. Nalmefene significantly elevated morning and evening cortisol measurements in all the patients. Nalmefene decreased total calorie consumption, principally by decreasing fat consumption. There was no effect on NPT. We conclude that in older impotent men, nalmefene acutely increases activity of the HPG axis and decreases calorie intake predominantly by decreasing fat consumption.
A critical review of the literature on psychogenic impotence is undertaken with special reference to recent advances in objective evaluation of erectile function and radiographic visualization of the penile arteries. Standardization of nomenclature, subclassification of acute versus insidious erectile dysfunction, insistence on objective criteria for declaring erectile dysfunction or a cure of the same, and the reestablishment of psychogenic impotence as a diagnosis of exclusion are to be encouraged.
A case of impotence with significantly impaired nocturnal penile tumescence (NPT) following transurethral resection of the prostate (TURP) is described. The patient was studied with polysomnographic recording including measurements of NPT for three consecutive nights at nine months after surgery and showed a total absence of full erections. Possible causes of his impotence are discussed. It is concluded that the total clinical picture strongly suggests that the erectile dysfunction was a result of physiologic complications of the surgery. Methodologic problems in past work are discussed, and the need for detailed diagnostic studies is stressed. The sleep studies that should be a part of this comprehensive evaluation are described.
Intraurethral penile body temperature measurement is a simple, inexpensive procedure designed for screening impotent patients which can be done in the physician's office. The results give a reliable index of penile arterial circulation and can suggest possible organic impairment, which can be verified further by other noninvasive vascular studies. In our experience, patients having more than 3 degrees F. difference between sublingual and internal penile temperature are most likely to have significant penile arterial obstruction. This method is recommended as a diagnostic procedure to help detect possible vasculogenic causes of impotence.
The authors describe a multidisciplinary approach to the assessment of impotence that includes the recording of nocturnal penile tumescence and analysis of the patient's MMPI profile. Ten patients were studied who, on the basis of physical and psychiatric assessment, were identified as being organically or psychogenically impotent. In each case, the application of decision rules based on either nocturnal penile tumescence or the MMPI would have led to misdiagnosis.
The inflatable penile prosthesis was used to manage impotence of neurogenic origin secondary to spinal cord injury. The female partners were also interviewed. Analysis of the results indicated that this was an eminently satisfactory method of managing this distressing complication of spinal cord injury. Both men and women indicated satisfaction with the prosthesis. The incidence of complications was the same as in those patients with non-neurogenic impotence. Erosion of the prosthesis due to pressure necrosis of denervated tissue did not occur.
Since 1974, 900 patients with erectile dysfunction from various causes underwent implantation of a semi-flexible prosthesis, generally of the Small-Carrion type. The largest group had arteriosclerotic or hypertensive cardiovascular disease. The second largest group was composed of patients with diabetes mellitus. Those in the third group had undergone prostatectomy, cystectomy, or abdominal-perineal resection. For a large number of patients a diagnosis of psychogenic impotence was reached, mainly from the results of the history questionnaire and the Minnesota Multiphasic Personality Inventory. Complications were rare (8.1%). Preoperative, intraoperative, and postoperative considerations include correct selection of prosthesis, rigorous antibiotic coverage, prevention or care of perforation, and possible need for reoperation. The results were almost uniformly successful. Psychogenic cases and instances of infertility related to the impotence are reviewed.
The author presents the view that there is a real need to diagnose impotence in more detail as demand for physiologic solutions to erectile dysfunction make inroads into the simplistic solution offered by penile implantation. Penile blood pressure measurements are diagnostic of vascular insufficiency only when values are low, since it is possible to demonstrate obstructive disease of the internal pudendal artery and its branches with selective arteriography of the presence of normal penile blood pressure. A rational approach to the workup of impotence is called for and practitioners are asked to weigh the ultimate usefulness of each test in the context of the individual patient's needs.
Review of recent implantations of penile prostheses done at Duke University Medical Center reveals 6 patients implanted for impotence secondary to priapism. Of these 6 patients, 5 had sickle cell anemia-induced priapism and 1 had idiopathic priapism. One patient had implantation of an inflatable prosthesis later followed by a semirigid prosthesis, 3 had implantation of a semirigid prosthesis, and 1 had an unsuccessful attempt at implantation of a semirigid prosthesis. The 5 patients with successful implantation have obtained satisfactory postoperative coital function. We believe that penile prostheses are beneficial in patients with impotence secondary to priapism. The degree of fibrosis encountered suggests that a semirigid prosthesis is more favorable, since the inflatable prosthesis may not overcome corporeal rigidity.
Vibratory stimuli were used for diagnostic evaluation of 130 impotent patients. The stimuli were applied to the glans penis, and erectile response was measured and displayed on a recorder. The erectile response to vibration was compared with nocturnal penile tumescence (NPT) monitoring and to artificially produced full erection. At the present time vibratory stimuli do not represent an alternative diagnostic method to NPT. However, the two methods are complementary. Erectile activity during vibration was detected in 43 of 130 patients. For these 43 patients further evaluation with NPT monitoring would not be necessary. Because vibration evaluation is performed as an outpatient procedure, it can contribute to a significant cost reduction in the evaluation of impotent patients.
Fifty-six type II diabetic males (mean age 52) were studied. Nineteen (33.9%) were diagnosed as having secondary impotence (SI); there was no correlation with age, diabetic control, and the use of insulin versus oral antidiabetic agents. Positive correlation was found between slow (less than 42 M/sec) motor nerve conduction velocity (MNCV) and SI at p less than 0.02, amounting to 58 per cent of the 19 cases. SI did not correlate with a standard list of peripheral neuropathic symptoms alone in the absence of slow MNCV. Correlation with SI was greatest when slow MNCV coexisted with neuropathic symptoms (p less than 0.04). MNCV testing may improve diagnosis and cost-effectiveness in assessing diabetic men with impotence.
In an attempt to develop as objective a method for the evaluation of impotence as possible, the authors assigned numerical values to four parameters considered essential to sexual function, namely, libido, erection, ejaculation, and orgasm, and used the sum totals of these scores, collected before and after initiation of therapy, as indicators of overall sexual function. Numerical values were assigned according to a logarithmic scale, in four stages from 0 to 10, i.e., 0, 1, 3, and 10; a score of 0 signified "normal" and a score of 10, "abnormal." By comparing sum totals of scores computed before and after initiation of therapy, the authors were able to evaluate therapeutic efficacy on the basis of changes in these sum totals. Using this method, the mean total score for a control group of 24 normal subjects was 1.67 +/- 0.26 (mean +/- standard error). For the test group, which consisted of 24 patients of psychogenic impotence, the mean total score prior to initiation of therapy was 16.46 +/- 3.55, an extremely high score in comparison with the control group. After four weeks of therapy, the mean total score dropped to 9.37 +/- 1.77, indicating a statistically significant (p less than 0.05) decrease over the pre-therapy mean total score.