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Congenital defect in sinusoidal smooth muscles: a cause of organic impotence.

We report 2 cases of primary impotence due to a congenital defect in the compliance of the sinusoidal spaces secondary to fibrosis and atrophy of the smooth muscles. Both patients were young adults at presentation. Diagnosis of this rare entity was achieved by penile Doppler ultrasound and cavernosometry/cavernosography of the cavernous bodies. Both patients underwent placement of a penile prosthesis, during which biopsy samples of the cavernous tissue were obtained, and diagnosis was confirmed by light and electron microscopy.

Adult↗

Preoperative and postoperative dynamic cavernosography and cavernosometry: objective assessment of venous ligation for impotence.

A total of 11 men (mean age 51.4 years, 1-year followup) with venous leakage impotence underwent surgical venous ligation. Of the men 8 had erections twice per week immediately after the procedure but at 3 months only 2 remained potent. Dynamic pharmacological cavernosography and cavernosometry were repeated 3 months postoperatively and 6 of the 11 men had venous leakage. These men with venous leakage underwent percutaneous embolization with platinum coils and 4 had successful results. Three additional men became potent after embolization. Of the 11 men 9 are documented to have normal dynamic cavernosography and cavernosometry findings after the combination of an operation and embolization, and 5 are potent. The postoperative and post-embolization dynamic cavernosometry data show that all 11 men have a marked decrease in the flow to maintain erection. Eight men have erections with papaverine or prostaglandin E1 intracorporeal injections. Postoperative dynamic cavernosography and cavernosometry can be diagnostic as well as therapeutic with embolization.

Adult↗

Microsurgical arteriovenous revascularization in the treatment of vasculogenic impotence.

We studied 35 patients with vasculogenic impotence who underwent an operation since 1986 and who were followed postoperatively for a minimum of 1.5 years. In all patients a microsurgical anastomosis was performed between the inferior epigastric artery and the arteriovenous shunt of the dorsal penile vessels. Potency was restored or improved in 77% of the patients during the long-term observation. Doppler or duplex sonography confirmed the same percentage of patent anastomoses. Through microsurgical modifications of the Hauri procedure and the interposition of free venous grafts, it was possible to operate further in 3 patients with short epigastric arteries and to treat intraoperative complications effectively in 1.

Abdominal Muscles↗

Calcitonin-gene-related peptide: a possible role in human penile erection and its therapeutic application in impotent patients.

A functional study was done to examine a possible role of calcitonin-gene-related peptide in human penile erection and its possible therapeutic applications for patients with erectile dysfunction. In the determination of an effective dosage, 5 ng. (2 patients), 50 ng. (2 patients), 500 ng. (4 patients), 5 micrograms (4 patients) and 25 micrograms (7 patients) were injected intracavernously, and pulse and blood pressure were monitored. Arterial inflow was measured by Doppler sonography, smooth muscle relaxation was determined by the analysis of cavernous electrical activity and cavernous outflow occlusion was recorded by cavernosometry. In 12 patients the erectile response of prostaglandin E1 was compared to the response of an equal (6 patients) or decreased dose of prostaglandin E1 combined with an equal weight of calcitonin-gene-related peptide. In 14 patients the erectile response to the combination of calcitonin-gene-related peptide and prostaglandin E1 was compared to the response of prostaglandin E1 alone, and with a combination of 15 mg./ml. papaverine and 0.5 mg./ml. phentolamine. Calcitonin-gene-related peptide induced an increase in the penile arterial inflow, cavernous smooth muscle relaxation and cavernous outflow occlusion. Histochemical results indicated nerve fibers positive for calcitonin-gene-related peptide within the cavernous bodies. A dose-dependent erectile response to calcitonin-gene-related peptide was observed at doses of 500 ng. to 25 micrograms. Systemic side effects were first observed at a dose of 25 micrograms in 2 of 7 patients. The combination of calcitonin-gene-related peptide and prostaglandin E1 was more effective in inducing a full erection than either prostaglandin E1 alone or the combination of papaverine and phentolamine. Pain was reported in 4% of the patients who received the combination of calcitonin-gene-related peptide and prostaglandin E1, whereas 42% of those who received prostaglandin E1 alone reported pain. Our results suggest that calcitonin-gene-related peptide may be a possible neurotransmitter for penile erection. A combination of calcitonin-gene-related peptide and prostaglandin E1 seems to be an effective alternative combination in the treatment of impotence.

Adult↗

Intracavernous self-injection of vasoactive drugs in the treatment of impotence: 8-year experience with 615 cases.

Of 615 patients with impotence of varying etiologies who were followed from 12 to 96 months after the institution of intracavernous self-injection therapy with vasoactive drugs (papaverine alone, papaverine and alpha-blockers, and Ceritine, a new multilevel acting drug) 87% (533 patients) returned for followup visits or were regularly contacted. Of these patients sexual activity was restored in 91%. The dropout rate was 11.25%. The 114 episodes of prolonged erections among 51 patients (4.57%) represented less than 3 per 1,000 of the 34,875 recorded injections. All patients were treated without complications. The percentage of patients suffering from nodules or permanent deformations was 2.8%. There were no cases of intracavernous fibrosis. The percentage of satisfied patients (satisfaction index 7 or greater) was 84.8%. Improvement in spontaneous erections during sexual intercourse was obtained in 65% of the cases: 15% no longer needed self-injections and 50% only used them occasionally while 35% remained entirely dependent.

Adrenergic alpha-Antagonists↗

Effect of apomorphine on penile tumescence in men with psychogenic impotence.

In a double-blind study using physiological recording of penile tumescence, brachial subcutaneous apomorphine hydrochloride injections elicited penile erections in men with psychogenic impotence. This observation is compatible with the hypothesis of central dopaminergic involvement in human penile erection. Since apomorphine is believed to induce erections by its effect on brain monoamine pathways, apomorphine response may have diagnostic use in evaluating the etiology of erectile failure.

Apomorphine↗

Hyperprolactinemia and impotence: why, when and how to investigate.

The contribution of hyperprolactinemia to erectile disorders has not been clarified. Modest elevations of serum prolactin occur after administration of drugs that by themselves affect erectile function. Prolactinomas produce marked elevations of the hormone and invariably are accompanied by hypogonadotropic hypogonadism. Among 1,236 consecutive impotent patients investigated at our center 5.3% had serum levels of prolactin greater than normal. Only 34 of the 66 hyperprolactinemic patients were available for analysis. The etiology of the hyperprolactinemia in this group was pituitary adenoma in 14.7%, drug-induced in 29%, chronic renal failure in 6%, laboratory error in 2.9% and idiopathic in 47.1%. Medical management has a high degree of success but simply lowering the levels of prolactin is not invariably accompanied by restoration of function.

Adenoma↗

Topical glyceryltrinitrate causes measurable penile arterial dilation in impotent men.

The current understanding of the intracavernous changes that cause or accompany penile erections has encouraged the use of vasodilators as therapy for erectile dysfunction. An established vasodilator, glyceryltrinitrate, was selected for in vivo study because of its rapid transdermal absorption. Color coded duplex ultrasound was used to assess penile vascular response. In a large group of men with erectile dysfunction significant dilation was noted in response to a small amount of nitroglycerine paste applied to the penis. There is a measurable vasodilatory response that can be induced by synthetic nitrates in penile tissue in impotent men.

Blood Flow Velocity↗

Bulbocavernosus reflex: its validity as a diagnostic test of neurogenic impotence.

Measurement of the bulbocavernosus reflex is used widely to diagnose underlying neurogenic disorders in erectile dysfunction. A prolonged bulbocavernosus reflex latency (that is more than 45 msec.) or the absence of a reflex response of the bulbocavernosus muscles during electrical stimulation of the glans penis is considered a sign of neurological disease. Since only a few experimental studies have been performed in man related to the neurophysiological mechanism of erection, and since the results of these studies were contradictory the diagnostic validity of bulbocavernosus reflex measurement was reassessed. We determine whether men with abnormal bulbocavernosus reflex latencies have concomitant organic erectile dysfunction as confirmed by nocturnal plethysmographic and rigidity recordings. The bulbocavernosus reflex was recorded in 90 subjects and 19 had abnormal bulbocavernosus reflex latencies. Of these 19 subjects 8 had normal nocturnal erections, thus, confirming a diagnosis of psychogenic impotence. These results cast some doubts on the validity of bulbocavernosus reflex measurement for the diagnosis of organic erectile dysfunction due to a neurological disease.

Adult↗

A prospective double-blind trial of intracorporeal papaverine versus prostaglandin E1 in the treatment of impotence.

A randomized prospective, double-blind clinical trial was performed comparing intracorporeal injections of papaverine (30 mg. per ml.) with prostaglandin E1 (10 mcg. per ml.) as pharmacological treatment of impotence. A total of 15 men completed the study, receiving papaverine and prostaglandin E1 in a crossover design. Over-all, 9 of 15 evaluable patients had a full erection with either 1 or both drugs: 3 secondary to papaverine only, 2 to prostaglandin E1 only, and 4 to both drugs. No major complications were observed. We conclude that intracorporeal prostaglandin E1 may be used successfully to stimulate pharmacological erections and that it might be useful in patients not responding to intracorporeal papaverine.

Adult↗

Effect of yohimbine hydrochloride on erectile impotence: a double-blind study.

A double-blind, partial crossover study on the therapeutic effect of yohimbine hydrochloride on erectile dysfunction was done in 82 sexually impotent patients. All patients underwent a multifactorial evaluation, including determination of penile brachial blood pressure index, cavernosography, sacral evoked response, testosterone and prolactin determination, Derogatis sexual dysfunction inventory and daytime arousal test. After 1 month of treatment with a maximum of 42.0 mg. oral yohimbine hydrochloride daily 14 per cent of the patients experienced restoration of full and sustained erections, 20 per cent reported a partial response to the therapy and 65 per cent reported no improvement. Three patients reported a positive placebo effect. Maximum effect takes 2 to 3 weeks to manifest itself. Yohimbine was active in some patients with arterial insufficiency and a unilateral sacral reflex arc lesion, and in 1 with low serum testosterone levels. The 34 per cent response is encouraging, particularly in a Veterans Administration population presenting with a high incidence of diabetes and vascular pathological conditions not found in regular office patients. Only few and benign side effects were recorded, which makes this medication worth an attempt, often as a first line of treatment even at a dose of 8 tablets.

Adult↗

Reconstructive surgery for vasculogenic impotence.

A multidisciplinary approach was used to diagnose 12 patients with vasculogenic impotence. Deep dorsal vein ligation was performed in 8 men to treat venous incompetence. Venous arterialization according to the technique of Virag was used in 4 men to treat arterial inflow insufficiency. A 75 per cent success rate was noted for the correction of venous incompetence. With an average followup of 1 year, excellent success was achieved in re-establishing corporeal blood flow with the technique of venous arterialization plus creation of a venocorporeal shunt.

Adult↗

Another surgical approach for vasculogenic impotence.

Until recently, a defect in the capability of blood to be trapped in the corpus cavernosum so that adequate penile turgidity can be maintained for successful intercourse has not been considered a major etiology for impotence. A diagnostic test called dynamic cavernosography was developed that consists of a cine-taped cavernosogram in conjunction with intracavernous pressure measurements at 3 different cavernous infusion rates. The results of 104 of these tests are presented. More recently, 17 of these patients also have undergone papaverine tests. Of the patients 59 per cent had no or only partial erections at all infusion rates and pressure did not increase to greater than 50 mm. Hg. The papaverine test showed only partial or no tumescence when 60 mg. were injected into the corpora. As a result, 25 patients underwent a penile operation to remove some venous outflow channels. Of the patients who underwent an operation for absent tumescence at any flow rate and who had a large number of venous channels draining the corpora cavernosa on the cavernosogram 59 per cent were potent postoperatively.

Adult↗

The unreliability of nocturnal penile tumescence recording as an outcome measurement in the treatment of organic impotence.

We investigated the degree of congruence between outcome measures used to evaluate pharmacological treatment of impotence. After a comprehensive multidisciplinary assessment 17 patients were treated with an adrenergic blocker during an 8-week interval. Nocturnal penile tumescence recordings were made before treatment (as part of the assessment procedure) and at its conclusion. As part of a larger study the use of nocturnal penile tumescence monitoring has been examined as a possible outcome measure. Patient and partner self-reports also were used to evaluate treatment outcome. A comparison of patient and partner self-reports with nocturnal penile tumescence records showed little agreement between the 2 measures. These findings suggest that despite its intuitive appeal as an index of erectile function nocturnal penile tumescence recording is not a reliable index of therapeutic effectiveness. Furthermore, these findings lend support to the hypothesis that nocturnal penile tumescence and sexual erections may be separate phenomena, perhaps under the control of different mechanisms.

Adult↗

Papaverine-induced penile blood flow acceleration in impotent men measured by duplex scanning.

We assessed the value of penile blood flow acceleration as a parameter in the evaluation of the penile arteries. Duplex sonography and pulsed Doppler analysis with papaverine were performed in 50 impotent men. Measured parameters included cavernous artery diameters before and after papaverine, post-papaverine peak blood flow velocity and blood flow acceleration. Erections were graded subjectively on a scale of 1 to 4, with 4 being a full erection. Penile blood flow acceleration appeared to correlate with vessel dilatability and poor erectile response, and was subjectively more discriminating than peak blood flow velocity. This parameter provides additional measurable data about arterial function and should be obtained in addition to the other 2 parameters.

Adult↗