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A case of loclaised penile corporeal fibrosis is described in a psychogenically impotent diabetic, following a short course of self-injection therapy with papaverine. The possible aetiology and implications of this complication are discussed together with the need to obtain informed written consent from patients undergoing this form of treatment.
29 individuals with venous impotence underwent transsection of the deep dorsal penile vein, of the superficial and ectopic veins, if any. 19 patients responded initially with either spontaneous erections or increased sensitivity of the cavernous bodies to intracorporeal papaverine. 1 patient developed postoperative priapism. The majority of patients who failed to respond had major leakage into the cavernous veins or abnormal connections between the spongious and cavernous bodies. An intraoperative decrease of flow rates to induce and maintain erection was found to be indicative for response. 10 individuals developed secondary erectile dysfunction 4-24 months after the initial response. A more extensive surgical approach should be considered to improve long-term success rates.
In a group of 472 impotent patients who were evaluated with pharmacologic duplex sonography, 117 patient (24.8%) had a history of hypertension, 26 of them (22.2%) for more than 10 years. Objective data about the changes in pulsation, diameter and blood flow velocity of the penile arteries after papaverine injection and the resulting erectile response allowed indirect assessment of the penile venous function. Varying degrees of impaired arterial function were diagnosed in 85% of the patients. The duration of hypertension had less deteriorating effects on the penile arterial system than second risk factors such as diabetes mellitus (n = 31) or smoking (n = 26). Patients on antihypertensive medication (n = 88, 75.2%) demonstrated a worse arterial response to papaverine than those without medication (n = 29, 24.8%). The best vascular response to papaverine injection was found in patients taking a combination of beta-blockers and vasodilators (n = 6), whereas thiazides either taken alone or in combination (n = 51, 60%) seem to have a deteriorating effect on arterial function. However, the arterial response did not correlate with the ability to achieve 'full erection' after intracavernous papaverine injection. Clinical experience confirms that certain antihypertensive drugs affect not only the blood pressure, but also compliance of the erectile tissue resulting in a functional venous leak. This may impair erectile function as much as arteriosclerotic changes of the vascular system secondary to hypertension.
In 17 patients percutaneous transpenile venous occlusion was performed for the treatment of so-called venous leak impotence. Because of primary failure, the procedure was repeated in 5 patients. On four occasions, it was combined with a retrograde venous occlusion via the internal iliac vein. Within a rather short follow-up period of 23 months maximum, the overall success rate is 65%. Six patients are able to have intercourse and 5 others need additional intracavernous injections. Complications of the procedure were not observed.
Colour Doppler imaging and cavernosometry are the optimal means for objective assessment of pharmacologically induced penile erections. 21 impotent patients were assessed by both methods independent of the information derived from the other modality. The diagnosis obtained was found to be immediately consistent in only 10 cases, 7 of which had venous leakage. 6 of the remaining 11 patients had a diagnosis of mixed arterial and venous disease in one or the other modality, but only arterial or venous disease alone in the other. The remaining 5 patients had completely inconsistent diagnoses. However, knowledge of the clinical picture and awareness of the pitfalls in the diagnostic procedures allows most of the discrepancies to be explained. Colour Doppler imaging is subject to operator error but allows selection of patients for cavernosography.
Corporeal veno-occlusive dysfunction is an important cause of organic impotence and is characterized by increased flow rates to create and to maintain erection during artificial erection produced by intracavernous saline infusion. Sixty-seven patients with this erectile insufficiency underwent penile ligature-resection of deep dorsal vein between 1982 and 1986, and were evaluated by nocturnal plethysmography, pharmacocavernometry as well as a questionnaire about their sexual life for long-term follow-up. The surgical procedure was controlled in the operating room by reduction of the erectile flow rates. Thirty-one patients were potent postoperatively and were able to have satisfactory intercourse. Results after resection were slightly better than after simple ligation of the deep dorsal vein. Four patients had penile glans insensibility resulting from the surgical dissection. There were 7 relapses several months after the procedure due to leakage through other deeper veins. Eight failures were due to additional psychogenic disorders or to neurologic disease not accurately diagnosed before the treatment because they all developed normal papaverine-induced erection after venous surgery while before it they only developed a slight tumescence. Reduction of the erectile flow rates within normal values was impossible during surgery in 3 patients. Eleven failures were due to concomitant arterial disease. Resection of the deep dorsal vein can restore penile erection in patients with cavernovenous leakage in about 50% of well-selected patients.
Vasoactive intestinal peptide (VIP), a key penile neurotransmitter, induces erection after local injection in man. To augment the therapeutic potential of VIP for impotence treatment and circumvent difficulties of direct penile injections, a strategy was designed to increase peptide hydrophobicity. This was accomplished by the synthesis of a conjugate of VIP and stearic acid (stearyl-VIP). Upon penile topical application, stearyl-VIP, in contrast to native VIP, significantly increased sexual function as measured by copulatory activity and penile reflexes (erections) in testosterone-treated, castrated rats. In addition, stearyl-VIP penetrated the body in amounts severalfold greater than VIP. Pharmacokinetic studies demonstrated 10-fold higher penile concentrations of stearyl-VIP, as compared with that measured in the blood 15 min after application, with a gradual decrease thereafter. The peak of incorporation into peripheral tissues that was observed 30 min after administration was 1,000-fold less than that found in the penile tissue. Tissue extraction and chromatographic analysis revealed that stearyl-VIP remained essentially intact for greater than or equal to 15 min and was cleared after 1 h. Thus, topically administered stearyl-VIP had increased bioavailability in comparison with VIP without apparent toxicity, suggesting significant therapeutic potential.
Clinical material is presented on a single case of impotence in a middle-aged black man. The symbolic meanings of the symptom in terms of the patient's aggression, feelings about his racial self-image, and the options that allow for male identity are discussed, along with some aspects of an interracial treatment situation in these changing times.
The retrospective study of 38 male patients undergoing aorto-iliac reconstructive and abdominal aortic aneurysm surgery was carried out. The study demonstrates the deficiency in the pre-operative, intra-operative, and post-operative evaluation of these patients regarding the factors affecting impotence. Recommendations are made, and a flow sheet is compiled to assist the vascular surgeon in the evaluation and management of these patients.
A case of traumatic arteriovenous (AV) communication between the internal iliac artery and vein presented with impotence and buttock claudication simulating the iliac artery steal syndrome. Surgical resection of the AV fistula resulted in satisfactory coitus and abolishment of the claudications.
Eleven patients presenting over the last three years with erectile impotence who have been treated by the insertion of the Jonas Silicon-Silver penile prosthesis are reviewed. The insertion of this prosthesis is a minor procedure. It has a simple design, low cost, no permanent erection or mechanical problems and an excellent cosmetic and functional result.
Intracavernosal injection of phenoxybenzamine or papaverine has been tried on 127 men suffering from erectile impotence. In 113 of them it caused an erection which should have sufficed for coitus. Seventy-three men have used such injections, given at home by themselves or their wives, fortnightly or less often, to make coitus possible after each injection; 54 of them still do so.
Tissue available (bioavailable) testosterone (T) includes circulating free T (FT) and albumin-bound T. A reasonable assessment of bioavailable T can be made by using 50% ammonium sulfate to precipitate sex hormone-binding globulin (SHBG)-bound T. The supernatant non-SHBG-bound T (non-SHBG-T) correlates well with physiological androgen activity. To assess bioavailable T in normal aging men, we analyzed serum samples from seven healthy aged men (65-83 yr old) and compared the results to samples from 13 young men (22-39 yr old). Mean serum T, FT, and LH concentrations were not significantly different in the 2 groups. However, the mean absolute non-SHBG-T level was significantly lower (P less than 0.005) in the older group. In a separate population of 20 impotent but otherwise healthy men (5 27-37 yr old, 10 48-64 yr old, and 5 66-69 yr old), the mean absolute non-SHBG-T concentration was lower in middle-aged (P less than .01) and elderly men (P less than 0.001) than in young men. The absolute FT was lower only in the elderly group (P less than 0.05), while mean LH and T levels were similar in all 3 age groups. These data suggest that serum concentrations of tissue available T are decreased in aged men and that non-SHBG-T measurement is a more sensitive indicator of this decrease than are serum T or serum FT measurements. These changes appear to begin by middle age.
This article looks at the current treatment of impotence and recent developments in the pharmacological treatment of erectile dysfunction. Sildenafil (Viagra) threatens to become the most costly drug treatment within the NHS, but its value may be overestimated and its effectiveness under-researched. This oral treatment has received a lot of recent press attention and is perhaps overshadowing the value of established treatment regimens. Pharmacological treatment may also fail to tackle the important psychological problems often associated with this distressing condition.
In 15 impotent patients, the effect of visual sexual stimulation was evaluated by measuring their urinary levels of adrenaline and noradrenaline, before and after stimulation. Both adrenaline and noradrenaline increased in the urine over the base levels in response to the visual sexual stimulation. The average increases were 1.5 times for adrenaline, and 1.4 times for noradrenaline. There was an evident correlation between the degree of sexual excitation and the excretion of adrenaline and noradrenaline into urine.
A rapid, practical diagnostic scheme is the key to selecting proper candidates for treatment with bromocriptine. The evaluation centres around assays for prolactin and follicle stimulating hormone, polytomography and computerised axial tomography of the sella turcica and parasellar regions, and the ergot alkaloid, bromocriptine. Additionally, bromocriptine is of significant value in the treatment of men and women with hypogonadotrophic hypogonadism. Approximately 80% of patients with hypogonadotrophic hypogadism and hyperprolactinaemia will respond favorably to bromocriptine therapy. In women who conceive during such treatment there appears to be no increase in the rate of spontaneous abortion, of multiple gestations or of congenital anomalies. Bromocriptine appears to be of little value in the treatment of male impotence unless hyperprolactinaemia is a component of the disease. Side affects are usually mild and transient. Following the discontinuation of therapy most patients have a recurrence of hyperprolactinaemia and hypogonadism.
Recent innovative research into the physiology and pharmacology of erection and the introduction of intracavernous injection of vasoactive agents have revolutionised our approach to the diagnosis and treatment of impotence. A thorough understanding of the rationale, indications, precautions and potential complications of intracavernous self-injection is essential for successful management. The commonly used drugs for injection are papaverine, either alone or in combination with phentolamine, and alprostadil (prostaglandin E1). The major adverse effects include priapism, prolonged erection, and fibrosis of the erectile tissue. With the proper technique and appropriate dosage, this is a safe, minimally invasive, and highly effective treatment.
A hydraulic four-part prosthetic device to enable penile erection is being implanted into selected patients with organic or psychogenic impotence. By controlling a pump mechanism implanted into the scrotum, the patient can cause penile erection and its subsidence. Complications of the procedure are related to the surgery and the mechanics of the prosthesis. Radiography is invaluable in detecting cylinder ballooning, cylinder buckling, fluid leaks from the system, and tube kinking. Radiographic evaluation of the device is done with a single, carefully monitored film with the penis in the oblique position and, if necessary, additional films in the anteroposterior position with the prosthesis inflated or deflated.