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PubMed1988

The diagnosis of venogenic impotence: dynamic or pharmacologic cavernosometry?

In an attempt to refine the diagnosis of venogenic impotence, we evaluated different techniques of cavernosometry in 10 dogs. Saline was perfused intracavernously in five dogs to induce erection. Regardless of the amount required for induction, a mean flow rate of 23.4 ml./min. was necessary to maintain an intracavernous pressure level of 110 cm. H2O. In seven dogs, a leak was created by intracavernous insertion of a 19-gauge needle. When erection was induced by either cavernous nerve stimulation or a combination of papaverine injection and saline perfusion, the mean flow through the needle was significantly less than when erection was induced by saline perfusion alone (1.73, 1.78, and 8.77 ml./min., respectively). Sympathetic trunk stimulation at the level of L5 could reduce the intracavernous pressure by 90% in erections induced by neural stimulation or papaverine plus perfusion but had no effect on erection induced by saline perfusion alone. Our findings show that cavernosometry after intracavernous injection of papaverine will provide more valuable information in patients in whom venogenic impotence is suspected.

Animals↗
PubMed1988

Papaverine testing of impotent patients following nerve-sparing radical prostatectomy.

To investigate the etiology of impotence following nerve-sparing radical retropubic prostatectomy we performed papaverine testing on 23 patients who did not regain erections sufficient for vaginal penetration. Intervals from surgery to testing ranged from 3 to 30 months, with an average of 9 months. All patients achieved some degree of tumescence. In response to intracavernous papaverine injection only 1 patient (5 per cent) obtained an erection equivalent to the preoperative state. Of 18 patients who were fully potent preoperatively 8 (44 per cent) achieved an erection less than normal but judged to be sufficient for intercourse by the examining physician. Twelve patients, including 2 who were not fully potent preoperatively, had erections of poor quality insufficient for vaginal penetration. The results suggest that in most of these patients postoperative erectile dysfunction is predominantly vasculogenic in origin. Thus, factors other than injury to the neurovascular bundles may be responsible for postoperative impotence.

Erectile Dysfunction↗
PubMed1987

Intracavernous self-injection with phentolamine and papaverine for the treatment of impotence.

To evaluate the efficacy and safety of intracavernous self-injection of phentolamine and papaverine for the treatment of impotence, 30 patients were enrolled in a prospective, randomized, double-blind, placebo-controlled cross-over study of papaverine and phentolamine versus normal saline. A total of 29 patients completed the study. The phentolamine plus papaverine combination resulted in erection in 24 patients (82.8 per cent) and no erection occurred after injection of saline. Of the patients 12 (41.4 per cent) experienced technical difficulties with the injection. Ecchymosis of the penis at the site of injection was common and 1 patient experienced priapism that resolved spontaneously. No other side effects occurred. Intracavernous self-injection with phentolamine and papaverine appears to be a safe and effective treatment of impotence but long-term effects must be determined.

Aged↗
PubMed1987

Penile prosthesis surgery in the treatment of impotence in the immunosuppressed man.

Thirteen male diabetic patients on immunosuppressive therapy following organ transplantation underwent implantation of 14 penile prostheses for treatment of organic impotence. Except for extended parenteral antibiotic therapy and increased steroid coverage postoperatively, the preoperative, perioperative and postoperative management in all 13 patients was similar to that of routine penile implantation procedures. No infections or erosion complications were encountered. We conclude that the penile prosthesis should be included in the armamentarium for the treatment of impotence in the immunosuppressed man.

Adult↗
PubMed1985

Venous leakage: surgical treatment of a curable cause of impotence.

While the arterial aspects of erectile impotence recently have received considerable attention, the venous component of normal and impaired erection has been ignored. In this study venous leakage was demonstrated by inducing passive erections using a controlled perfusion of the corpora cavernosa with continuous pressure monitoring. In 20 patients with impaired erectile activity under a standardized flow (80 to 120 ml. per minute) no rigid erections were obtained and the perfused liquid was demonstrated to escape through the deep dorsal vein of the penis. After ligation of this vein the erections improved sufficiently to allow satisfactory intercourse in 16 of the 20 patients. The 4 failures had serious arterial lesions. In patients with organic impotence the venous pathological condition should be assessed routinely, since it represents an easily correctable anomaly if arterial inflow is not severely impaired.

Contrast Media↗
PubMed1984

Neuroanatomy of penile erection: its relevance to iatrogenic impotence.

The neuroanatomy of erection in men is not well defined. Recently, we isolated successfully the cavernous nerves for acute and chronic neurostimulation to induce penile erection in dogs and monkeys. We then investigated the anatomy of these nerves in humans by cadaveric dissection and serial histologic sectioning. Our experience in tracing the spinal nuclei responsible for vesical and urethral function by transportation of horseradish peroxidase enabled us to explore the location and organization of the spinal center for erection. Thus, systemic knowledge of the neuroanatomy of erection was accumulated. The spinal nuclei for control of erection are located in the intermediolateral gray matter at the S1 to S3 and T12 to L3 levels in dogs, and the S2 to S4 and T10 to L2 levels in humans. From these sacral nuclei axons issue ventrally and join the axons of the nuclei for the bladder and rectum to form the sacral visceral efferent fibers. These fibers emerge from the anterior root of S2 to S4, and join the sympathetic fibers to form the pelvic plexus, which then branches out to innervate the bladder, rectum and penis. The fibers innervating the penis (cavernous nerves) travel along the posterolateral aspect of the seminal vesicle and prostate, and then accompany the membranous urethra through the genitourinary diaphragm. These fibers are located on the lateral aspect of the membranous urethra and ascend gradually to the 1 and 11 o'clock positions in the proximal bulbous urethra. Some of the fibers penetrate the tunica albuginea of the corpus spongiosum, while others spread to the trifurcation of the terminal internal pudendal artery and innervate the dorsal, deep and urethral arteries. Shortly before the 2 corpora cavernosa merge the cavernous nerves penetrate the tunica albuginea along with the deep artery and cavernous vein. The terminal branches of these nerves innervate the helicine arteries and the erectile tissue within the corpora cavernosa. Because of the intimate relationship of the cavernous nerves to the rectum, prostate and urethra, they can be damaged easily during urological and pelvic procedures. This systemic knowledge of the human cavernous nerves from the spinal center to the erectile tissue should permit a better understanding of erection and impotence. Furthermore, with the aid of intraoperative neurostimulation, the cavernous nerves may be identified and preserved, thereby preventing iatrogenic impotence.

Animals↗
PubMed1984

Evaluation of the urological assessment in impotence: findings with a new diagnostic rating scale.

We report the findings of a critical evaluation of urological assessment in impotence. Initially, a rating scale (Q scale) was developed, which included the individual elements of the urological assessment, such as testicular size, serum testosterone level and so forth. The items in the scale were derived from the files of patients with erectile dysfunction and were scaled according to predetermined categories. Following this, the rating scale was applied to 67 impotent patients in whom the etiology had been established clearly using criteria that were independent of the urological assessment (that is a psychiatric interview and nocturnal penile tumescence evaluation). Statistical analysis of the results indicated that the 2 diagnostic groups differed significantly on a number of the individual scale items. However, no single item by itself could be used as a reliable indicator of etiology. Further analysis indicated that when the items were considered in combination, rather than singly, etiology was identified correctly in 95 per cent of the patients in the sample. Replication of these findings in a cross-validation study will help to standardize the urological assessment and to promote the development of a common language to facilitate communication in this field.

Adult↗
PubMed1983

Etiology of diabetic impotence.

We evaluated 31 male diabetics for sexual dysfunction. Patients were examined by an endocrinologist, psychologist or psychiatrist, urologist and neurophysiologist. Evaluation was done by penile blood pressure, pudendal nerve latency, psychologic testing and laboratory tests, including serum testosterone levels. Mean patient age was 53 years and the average onset of sexual dysfunction was 6 years after the diagnosis of diabetes. Results showed that 68 per cent of the patients had evidence of vascular occlusion, 26 per cent had neurologic abnormalities, 19 per cent had low plasma testosterone levels and 38 per cent had relevant psychological problems, although the condition was considered primarily psychogenic in only 19 per cent. Of those patients with abnormal nerve latencies 86 per cent had abnormal Doppler penile systolic pressures, while only 28 per cent of the patients with abnormal penile pressures had abnormal neurologic findings. These data suggest that vascular occlusion is the most prevalent abnormality in impotent diabetics and may predate neurologic abnormalities. The diabetics were divided into 2 groups, insulin-dependent and insulin-nondependent patients. A higher incidence of vascular lesions was found in insulin-dependent diabetics (83 versus 57 per cent), suggesting that vascular pathological conditions are related to severity of the diabetes. Although most diabetics have a vascular etiology for impotence one must remember that other causes may be present and that a thorough investigation is necessary.

Adult↗
PubMed1983

Reactions to the implantation of an inflatable penile prosthesis among psychogenically and organically impotent men.

We evaluated 17 nondepressed and psychologically stable recipients of an inflatable penile prosthesis who had been either organically or psychogenically impotent and 12 of their sexual partners several months after surgical implantation. The men were evaluated for changes in general psychological adjustment, sexual satisfaction and sexual activity. The partners were assessed separately on similar instruments. Two scales of the Minnesota Multiphasic Personality Inventory were found to have potential for initially discriminating organic and psychogenic impotence. The hypothesis that psychogenic recipients would manifest more psychological difficulties and would be less satisfied was only partially supported. While neither group suffered significant disturbance in psychological adjustment a consistent pattern was noted in which psychogenic patients were somewhat less satisfied with the results and experienced more postoperative complications. However, over-all reactions were positive, including increases in frequency of sexual over-all reactions were positive, including increases in frequency of sexual intercourse and duration of sexual play for patients and their partners.

Coitus↗
PubMed1982

Vasculogenic impotence: role of the pelvic steal test.

A new dynamic pelvic flow test is described that measures differential right and left corporeal artery blood pressure changes with exercise. Previous penile blood flow measurements have been made at rest. It is well known that exercise may unmask vascular pathological conditions not apparent at rest. Furthermore, cases have been reported that document potency at rest and impotence following exercise. As a result exercise was used to stress the pelvic vasculature in 97 patients chosen from vascular and urology clinics. A decrease of 0.15 or more in penile-brachial index with exercise was found to be statistically abnormal. A total of 23 patients (27 per cent) fulfilled the criteria for positive pelvic steal testing. In this group there were high incidences of smoking (52 per cent), hypertension (52 per cent) and diabetes (30 per cent). Although 70 per cent of these patients had at least occasional morning erections 78 per cent complained of loss of erection with exercise. The pelvic steal test detected vascular pathological conditions in 17 patients (20 per cent) previously missed by resting penile-brachial index measurements. Nocturnal penile tumescence studies in these patients demonstrated poor quality erections and correlated with the intermediate penile-brachial index values. Angiographic data performed in 5 of 23 patients corroborated the pathophysiology of a pelvic steal condition in each case. The pelvic steal test is simple to perform and markedly improves the sensitivity and yield of penile blood pressure measurements. The test appears to have better results in patients with suspected vasculogenic impotence and intermediate resting penile-brachial index values.

Adult↗
PubMed1981

Single implants in the treatment of erectile impotence.

A total of 12 patients with erectile impotence underwent implantation of a Finney flexirod penile prosthesis in 1 corpus cavernosum only. This procedure has a special advantage in developing countries since the cost of the operation in reduced by approximately 50 per cent. The penis is less rigid and longer, and in case of failure the other corpus cavernosum is readily available. This procedure is the method of choice in cases of psychogenic impotence since there is a considerable amount of super erection present in all of the cases.

Adult↗
PubMed1980

Comprehensive laboratory evaluation of impotent men.

A thorough diagnostic evaluation was done on 27 impotent men. In addition to a detailed history and physical examination each patient underwent a psychiatric interview, Doppler penile blood pressure determination and measurement of the bulbocavernosus reflex latency time. Abnormalities in penile blood pressure were detected in 67 per cent of the patients, neurologic abnormalities were found in 41 per cent and psychiatric disorders were noted in 35 per cent. Of the 27 patients 48 per cent had a combination of neurologic, psychiatric and vascular abnormalities. A definite cause-and-effect relationship between these abnormalities and impotence has not been established.

Doppler Effect↗
PubMed1979

Sexual impotence: the overlooked complication of a second renal transplant.

The incidence of sexual impotence in 20 men who have received at least 2 kidney transplants was 65% compared to 10% after the first transplant. The importance was transient (2 to 4 months) in both affected men after the first transplant but permanent (2 to 10 years) in 6 men after the second operation. We attribute this increased percentage of impotence to the second end-to-end arterial anastomosis that requires division of the internal iliac arteries. We suggest that the second transplant be placed end-to-side into the common iliac artery.

Adult↗
PubMed1978

Impotence: a diagnostic approach.

A diagnostic approach to erectile impotence using a sexual function questionnaire, nocturnal penile plethysmography, penile blood pressure measurement, cavernosograms, cystometrograms and plasma testosterone levels is presented. Case examples demonstrate the clinical value of these diagnostic tools. Psychogenic impotence should be diagnosed only after nocturnal penile plethysmography has demonstrated the presence of complete erections.

Adult↗
PubMed2001

Relationship between penile thermal sensory threshold measurement and electrophysiologic tests to assess neurogenic impotence.

OBJECTIVES: Erectile function is usually assessed by neurophysiologic tests such as the bulbocavernosus reflex or pudendal nerve somatosensory evoked potentials. These tests investigate only large nerve fibers, although erection depends on autonomic nerve fibers, which are of small diameter. Warm and cold sensory fibers have similar calibers as the autonomic nerve fibers, and their integrity can be reliably evaluated by the measurement of thermal sensory thresholds. We studied penile thermal sensory testing in parallel with standard electrophysiologic tests to assess their sensitivity in the diagnosis of penile neuropathy. METHODS: Twenty-five normal male subjects without erectile dysfunction or evidence of diffuse neuropathy (group 1) and 35 diabetic patients who complained of impotence (group 2) were studied. Erectile function was quantitated using the erectile dysfunction symptom score. Warm, cold, and vibratory sensory thresholds were assessed on the dorsal aspect of the penis. In addition, penile sympathetic skin responses and pudendal nerve somatosensory evoked potentials were recorded. RESULTS: We found a significant difference between the two groups in the erectile dysfunction symptom score (P <0.0001), cold threshold (P = 0.0007), and warm threshold (P = 0.0025), but not for the other parameters. The erectile dysfunction symptom score correlated with the penile warm and cold thresholds (P = 0.0006 and 0.002, respectively). CONCLUSIONS: Thermal thresholds assess small nerve fiber damage, which can indirectly reflect autonomic disturbances, particularly in the context of a diffuse neuropathy such as diabetic polyneuropathy. Penile thermal sensory testing correlated strongly with the clinical evaluation of erectile function and is a new and promising tool for the diagnosis of neurogenic impotence.

Adult↗
PubMed1998

Possible molecular mechanisms of cryoablation-induced impotence in a rat model.

OBJECTIVES: Cryoablation of the prostate has been reported to induce impotence as a consequence of cavernosal nerve injury. This study is designed to investigate the early and late effects of cavernosal nerve cryoablation on growth factor expression and erectile function in a rat model. METHODS: Forty male rats were divided into two groups (n=20 each). The first group underwent unilateral cavernosal nerve freezing (experimental group). Before their euthanization at 1 and 3 months (10 rats each), erectile function was assessed by electrostimulation of the cavernous nerves. The second group served as the control and was killed at the same time points. Western blot and reverse transcriptase-polymerase chain reaction (RT-PCR) techniques were used to identify protein and gene expression of nerve growth factor (NGF), transforming growth factor-alpha (TGF-alpha), epidermal growth factor (EGF), and insulin-like growth factor-1 (IGF-1) in the rat penis and pelvic ganglia. RESULTS: Electrostimulation of the frozen nerve after 3 months revealed a significantly higher maximal intracavernosal pressure and a shorter latency period than in the 1-month group. At 3 months, immunoblot showed upregulation of NGF, TGF-alpha, and the precursor form of IGF-1 protein expression in the penile tissue; RT-PCR showed downregulation of NGF gene expression in the pelvic ganglia of the frozen side. CONCLUSIONS: The results show that erectile function decreased at 1 month and then partially recovered 3 months after cavernosal nerve freezing. This alteration in erectile function was associated with differential gene and protein expression of the growth factors (NGF, TGF-alpha, EGF, and IGF-1). Further studies are required to elucidate the potential role of these growth factors in the prevention and treatment of cryoablation-induced impotence.

Animals↗
PubMed1988

Nocturnal penile tumescence monitoring with stamps in impotent diabetics.

The usefulness of nocturnal penile tumescence (NPT) monitoring with stamps was evaluated in diabetic males with impotence. The stamps, which were similar in paper and size to Japanese 10-yen postage stamps, were wrapped around the penis before sleep and the stamp ring was checked for breakage the next morning. Clinical features of the subjects were investigated by penile blood pressure index (PBPI), neurological examinations, psychological tests, and hormonal measurements. Nineteen out of 37 patients with impotence had a breakage of the stamp rings on one or more of 3 nights. The patients with non-breakage of stamp rings had significantly more serious diabetic neuropathy (peripheral and autonomic), depressive tendency, loss of libido, and a higher prevalence of heavy smoking than those with breakage of the stamp rings. PBPI and hormonal findings showed no difference between the breakage and non-breakage patients. These results show that the diagnostic value of this method is nearly the same as that of NPT recording with a strain gauge.

Adult↗
PubMed1997

[The psychiatrist and the impotent patient].

Psychiatrists may face impotence in two circumstances: the patient complains of his impotence, or suffers from depression or another psychiatric condition. It is in the way in which the patient and the symptom are approached by the psychiatrist that a confident and beneficial relation may be established.

Depressive Disorder↗