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Partial impotence in a twenty-year-old was found, on angiography, to be the result of an arteriovenous fistula of the internal pudendal artery. This condition was corrected by corpus cavernosum revascularization.
A radioisotope technique to estimate penile blood flow is described. The radioisotope penogram is noninvasive and gives a dynamic evaluation of the arterial supply, venous drainage, and blood flow in the corporeal bodies. The penogram is a valuable adjunct in evaluation of patients with vasculogenic impotence.
The bulbocavernosus reflex and pudendal evoked responses were obtained in a group of control patients and impotent men in an attempt to assess their reliability and objectivity in diagnosing neurogenic erectile dysfunction.
One hundred impotent men were evaluated with Doppler pulse-wave analysis and intracavernous papaverine. Fifty-four men with normal Doppler study response had abnormal responses to papaverine. A normal Doppler study response failed to predict the inability of papaverine to induce an erection in 54 per cent of cases. Twenty-seven patients had abnormal Doppler study responses, and only 2 of these men had a normal response to papaverine. An abnormal Doppler study response was highly predictive of a vascular abnormality.
This study compares the findings of multidisciplinary evaluation to the two-night use of the Snap-Gauge band in 100 impotent men. An organic etiology was diagnosed in 52 percent of those evaluated. The Snap-Gauge band proved accurate as a screening device for organic disease. If no elements were broken over the two-night period, this finding correlated with multisystemic diagnosis of organic etiology in 86 percent of cases. Among the 52 patients in whom an organic etiology was diagnosed, 32 broke no elements for a 62 percent sensitivity. When more than one element was broken, the predictive value as to etiology of the erectile dysfunction diminished.
We designed acute and chronic animal models to evaluate a new procedure of arterialization of the cavernous vein. In the acute study, arteriogenic impotence was induced in 6 dogs by bilateral ligation of the penile arteries just proximal to the crus of the penis. The cavernous vein and penile artery were anastomosed proximal to the site of ligation, and the pudendal vein was ligated proximally to prevent the diversion of arterial blood away from the penis. Erection was induced either by electrostimulation of the cavernous nerves or by intracavernous injection of papaverine, and the erectile response was studied before and after cavernous vein arterialization. Four dogs were followed up for two months to evaluate the long-term effects of the procedure. Shortly after arterialization of the cavernous vein, the basal flow rate in the internal pudendal artery increased dramatically to almost six times the control rate, and the erectile response to neurostimulation was approximately 85 percent of control. Selective pudendal arteriography at two months confirmed the patency of all arteriovenous anastomoses. However, scanning electron microscopy and histologic examination revealed sinusoidal damage most probably consequent to the chronically elevated arterial flow.
The transdermal therapeutic system for testosterone (TTS-T) (ALZA Corp.), applied to the scrotal skin for twenty-two hours daily, was tested for twelve weeks on 4 men with hypogonadal impotence; 2 of these men wore TTS-T for as long as twenty-six months. The 40 cm2 system delivered a daily dose of 2.8 +/- 0.16 (S.E.) mg (nominal dose 2.4 mg) and the 60 cm2 system delivered a dose of 3.99 +/- 0.24 mg (nominal dose 3.6 mg). Both systems promptly increased serum testosterone and dihydrotestosterone (DHT) to physiologic levels, restoring normal erectile activity with an increased frequency of ejaculation and a positive effect on both mood and energy. There were no changes in serum sex binding globulin and estradiol, prostate or breast size, hematologic or liver function measures, or urinary flow and frequency. There were no significant changes in serum cholesterol or low-density lipoproteins, but high-density lipoproteins tended to decline slightly. There were no dermatologic problems associated with the system. The tenfold increase in DHT over baseline levels was attributed to 5-alpha reduction of testosterone in the scrotal skin. The TTS-T is convenient, reliable, and mimics normal physiologic testosterone secretion and levels more closely than conventional methods of testosterone replacement.
Eight married men with secondary impotency on a nonorganic, non-psychiatric disease basis injected themselves with placebo subcutaneously (SC) twice a day (b.i.d.) for the first week in a single blind design followed by two periods of four weeks with LHRH (3 mg b.i.d. for four weeks) and placebo (b.i.d. for four weeks) in a double blind crossover design. Outcome was assessed by daily questionnaires. There were no significant differences between the effects of LHRH and placebo on frequency of intercourse, spontaneous erections, and wife's rating of her husband's libido. On these measurements, small, non-significant, trends toward improvement were associated with LHRH. The patients' rating of their own libido was higher (p less than 0.05) during the first week on LHRH compared to the first week of the four weeks of placebo, but the magnitude of the differences was minimal. Frequency of masturbation did not increase with LHRH. In contrast to other studies, men with premasturbatory activity improved less and there was no improvement in potency in the two month follow-up after LHRH. Baseline LH, FSH, testosterone and prolactin were all within normal limits. The LH and FSH response to LHRH decreased over the 28 days but testosterone levels and response to LHRH increased. Since there was a small trend toward improvement after LHRH, clinical trials with LHRH analogs should be explored.
Uncollected data must be filled in after the fact in many epidemiological studies. We compared several methods for constructing a surrogate variable for erectile potency, based on responses to related questions, in the Massachusetts Male Aging Study (MMAS). Quadratic discriminant analysis performed best among the procedures tested, achieving high rates of correct classification in cross-validation of training data and (according to posterior estimates) in classification of MMAS subjects. Two versions of the surrogate variable were constructed, one involving a discrete classification and the other involving a set of continuous probabilities. The two versions were used to investigate medical correlates of impotence in MMAS and produced similar results, although the continuous version appeared to provide higher statistical power. We conclude that construction of a surrogate variable is a viable and potentially beneficial option in epidemiological investigations.
Nuclear medicine techniques may be used to test fallopian tube patency and penile vascular inflow and outflow. Radionuclide hysterosalpingography (HSP) is a readily performed method of evaluating fallopian tube patency, and is believed to be more physiologic and functionally informative than the accepted radiologic method of contrast HSP. The test is simple to perform and interpret and offers an accurate alternative to the contrast examination. For scintigraphic evaluation of impotence, blood pool studies are most useful in assessing the integrity of arterial inflow, but may also be used to generate indices of venous leak. Washout of xenon after subcutaneous injection, in the flaccid state, has been used as a measure of baseline penile perfusion, as has intracavernosal injections in the flaccid penis. Intracavernosal xenon washout during erection seems the most useful method of testing venous integrity. Washout using technetium-99m (99mTc)-labeled red blood cells (99mTc-RBC) may emerge as a convenient alternative to the more technically difficult xenon examinations.
OBJECTIVE: To compare subjective assessments of erectile function with results obtained from nocturnal penile tumescence and rigidity (NPTR) monitoring in patients with spinal cord injury (SCI). DESIGN: A prospective study. SETTING: Erectile function questionnaires were completed by each patient. NPTR monitoring was performed at the patient's home with the Rigiscan system. PATIENTS: Thirty SCI patients (8 cervical, 16 thoracic, 5 lumbar, 1 sacral) were between 22 and 75 (mean 48) years old. Twenty patients (67%) had complete SCI and 10 patients (33%) had incomplete SCI with mean duration since injury of 14 years. MAIN OUTCOME MEASURES: The results from two consecutive nights of NPTR monitoring were compared with each patient's own response to our erectile function questionnaire. RESULTS: Twenty-three patients (77%) reported normal erectile function: 16 had normal NPTR studies and the remaining 7 had abnormal NPTR studies. Seven patients (23%) reported poor-to-absent erectile function: 3 had normal NPTR studies and 4 had abnormal NPTR studies. All 10 patients (100%) with incomplete SCI had NPTR studies that corroborated their own assessment of erectile function, compared to 11 of 20 patients (55%) with complete SCI. NPTR studies in the remaining 9 patients (45%) with complete SCI were inconsistent with their own assessment of erectile function. CONCLUSION: A direct correlation (p<.05) existed between incomplete SCI patients' NPTR studies and their own assessment of erectile function. Complete SCI patients demonstrated significant discrepancy between their own assessments of erectile function and results from NPTR studies. Incomplete SCI patients tended to maintain normal erectile function, as opposed to complete SCI patients. Ten percent of SCI patients who reported erectile dysfunction may actually be suffering from psychogenic impotence.
There have not been studies assessing the effects of chronic testosterone cypionate (TC) therapy on circulating levels of testosterone (T), estradiol (E2), free T, bioavailable T (BAT), luteinizing hormone (LH), and sexual function in impotent men with low T levels. This study was a double-blind crossover using 200 mg of TC or placebo given intramuscularly every 14 days for six injections and the other medication given for six doses. Blood was drawn before each injection. Mean concentrations of T, E2, free T, and BAT were the same on TC or on placebo, but serum LH was significantly suppressed during intramuscular TC. With TC statistically significant improvements in libido and in potency were noted. Five of the men were able to have vaginal sex while taking TC. TC injections every 14 days do not appear to maintain increased T concentrations for 2 full weeks, and other dosage/injection schedules are being evaluated, but there were improvements in libido and potency.
On the basis of reports describing nitric oxide as a form of endothelium-derived relaxing factor and on our own experience with intracavernous use of nitric oxide-releasing substances in animal models, we undertook an approved human study of intracavernous sodium nitroprusside as a treatment for impotence. We report our early experience in which severe hypotension and only mild tumescence in our first 3 patients caused us to discontinue the trial.
We describe a patient who initially presented with impotence followed by progressive lethargy and visual disturbances. Endocrine and radiological evaluation was suggestive of pituitary adenoma but pathological evaluation after transsphenoidal hypophysectomy revealed renal cell carcinoma metastatic to the pituitary. The etiology of this unusual presentation and prior reports of renal cell carcinoma spread to the pituitary are reviewed.
Endothelial injury in a deep dorsal vein graft may result from thermal, ischemic or mechanical trauma during surgical preparation or following exposure to systemic blood pressures and flow. We removed a functioning in situ deep dorsal vein graft section 10 months after microvascular arterial bypass surgery due to glans hyperemia. This section was compared and contrasted histomorphologically with a preoperative deep dorsal vein section that was procured for routine histological examination before the arteriovenous anastomosis. Detailed examination of the vein graft tissues by light microscopy, computer morphometrics and immunological staining demonstrated no evidence of vascular pathology. In the normal, healthy deep dorsal vein graft exposure to systemic arterial blood pressures and flow for 10 months did not result in myointimal proliferative lesions. Such histological changes seem more likely to be attributable to endothelial injury following iatrogenic surgical trauma. In situ vein grafts offer the opportunity to use "no-touch" endothelium preserving vascular techniques. Use of these grafts may improve long-term clinical results in penile microvascular arterial bypass surgery for impotence as it has in other vascular beds.
We performed routine diagnostic evaluations in 160 consecutive patients from our impotence clinic. After the diagnostic studies were completed, the results of RigiScan* monitoring during visual sexual stimulation before and after intracavernous injection of vasoactive drugs were compared to the results of standardized pharmacological testing, single potential analysis of cavernous electrical activity and pharmacocavernosometry. The results suggest RigiScan monitoring to be a highly accurate method to evaluate and document objectively the erectile response after intracavernous injection of vasoactive drugs. Although pathological monitoring after intracavernous injection is significantly associated with pathological findings in the specific evaluation, the predictive value of RigiScan monitoring for specific organogenic etiologies is not satisfactory, since normal monitoring showed no convincing correlation to single potential analysis of cavernous electrical activity or cavernosometry.
Color coded duplex sonography, regarded as the gold standard in penile vascular evaluation, does not yield data on cavernous oxygenation itself. In addition to using color coded duplex sonography to measure peak flow velocity in cavernous arteries after injection of 20 micrograms. prostaglandin E1 in 34 unselected patients with impotence, we monitored cavernous oxygen tension with oxygen-sensitive Eppendorf needle electrode. During flaccidity the mean cavernous oxygen tension of 38 mm. Hg increased to 61 mm. Hg after injection of prostaglandin E1. Peak flow shown with color coded duplex sonography and maximal oxygen tension correlated well in 24 men (71%). However, in 10 men (29%) normal peak flow did not result in a cavernous oxygen tension of greater than 65 mm. Hg, so this might have been isolated cavernous perfusion defects. In contrast, there was no case of impaired arterial inflow and high oxygen tension. Monitoring of cavernous oxygen tension allows for characterization of patients with cavernous perfusion deficiency. This new and simple diagnostic method might help to improve diagnosis and followup after penile vascular surgery. However, more data on patients and controls will be required to define normal ranges.
Although veno-occlusive dysfunction is a frequent cause of impotence, a definitive therapeutic strategy has not yet been clearly defined. A total of 56 patients with corporeal veno-occlusive dysfunction diagnosed by dynamic infusion cavernosometry-cavernosography (flow to maintain erection greater than 10 ml. per minute and rate of corporeal pressure decrease after interruption of intracavernous infusion greater than 50 mm. Hg for 30 seconds) not considered suitable candidates for surgery underwent self-injection therapy. A vasoactive mixture composed of 12.1 mg./ml. papaverine hydrochloride, 10.1 micrograms./ml. prostaglandin E1, 1.01 mg./ml. phentolamine mesylate and 0.15 mg./ml. atropine sulfate was used. After dose titration of the drug mixture 54 patients (95%) were able to obtain sustained rigid erections that guaranteed satisfactory sexual activity. Mean (plus or minus standard error of mean) volume of injected mixture was 0.42 +/- 0.09 ml. (range 0.25 to 0.90 ml.). Four patients (7%) reported transient hypotension that did not recur after the application of a penile rubber band before injection. At a mean followup of 16 months 6 patients (11%) discontinued use of injections, 37 (69%) were satisfied and using the mixture, and 11 (20%) maintained rigid erections using a lower than initial dose. No major complications were encountered. The association of drugs with different mechanisms of action caused a synergism that potentiated the therapeutic activity and reduced side effects by decreasing the total drug dose.