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Using NPT monitoring, we have evaluated the complaints of impotency in 11 patients with chronic renal insufficiency. Eight of these 11 demonstrated objective evidence of sexual dysfunction. These findings support a predominant role for organic factors in the etiology of sexual dysfunction in this group of patients.
Since male impotence may be caused by a variety or non vascular factors, more precise techniques for identifying potential operative candidates must be developed. Our protocol includes nocturnal penile plethysmography, Döppler velocity at 8 levels, penile systolic pressure, electromagnetic blood flow measurement, penile reactive hyperemia. This non-invasive protocol applied on 21 patients aims to select those who would benefit from direct penile revascularization procedures. We are studying the venous emptying rate for more complete physiologic approach.
The wide range of factors that may contribute to impotence is reviewed in an attempt to establish a systematized approach for assessing etiologic factors. The effects on potency of ageing, general fitness, weight, debilitating disease, use of therapeutic and other drugsincluding alcohol and neurogenic, vasculogenic, endocrine/metabolic, urogenital and psychogenic factors are considered and discussed. The review also affords a rationale for the methodology employed.
Every time we see a patient who is complaining of erectile failure we have to evaluate with proper exams the possible organic causes of this dysfunction. After having excluded the organic etiology we can speak of psychogenic impotence. The Authors describe a mixed type case and point out that a strict division between organic and psychological causes it's not always possible; besides it's better to try to understand the patient in his total structure.
Clinical employment of selective hypogastric arteriography has been instrumental in the detection of stenosing and obliterating lesions of the pudendal arteries and their penile branches capable of giving rise to impotentia erigendi as the sole symptom. Differentiation of psychogenic and vascular impotence is now possible through non-invasive instrumental examinations such as the nocturnal penile tumescence test, and Doppler ultrasonography of the penile arteries. Arteriography to clinch the diagnosis was only employed when a suspicion was aroused by these two examinations. An account is given of technique employed for selective hypogastric arteriography and the angiographic results obtained.
Vascular pathology is responsible for about 25% of male impotence, the arterial investigation is now classical. In our experience a great number of patients showed a normal arterial condition, requiring further venous exploration. Cavernographies and pressure flow dynamics were used to evaluate 45 patients. The cavernograms allowed visualization of structural abnormalities within the cavernous tissues and their venous drainage. The heparinized and diluted contrast medium is infused at 80 to 120 ml/minute until the appearance of an erection, in normal condition the intracavernous pressure rise at greater than or equal to 80 mmHg as long as the erection last. The venous leak is characterized by the absence of erection, no increase of the intra-cavernous pressure and a rapid opacification of venous plexus under a normal perfusion flow.
Pulse volume recordings were obtained in 60 normal subjects and 74 patients with a history of impotence using a technique that is simple, reliable, inexpensive, reproducible and capable of standardisation. It measures the contributions of all vessels in the penis. The components of the electronic package are described. The pulse volume amplitudes, pulse contours and other measurements in normal subjects are defined. The results give a reliable index of penile blood flow. Pulse volume recordings were also found to correlate with the severity of pelvic angiographic patterns of occlusive disease. Further investigation is necessary to determine the precision with which the method can detect penile blood flow in patients with early vascular disease.
The injection of 80 mg of Papaverine into one of the corpora cavernosa of the penis produces an erectile response which is proportional to the local haemodynamic conditions. On the basis of this test, the investigation of penile rigidity coupled with Doppler velocity studies permit cases of impotence due to vascular disease to be differentiated from other abnormalities of erection. The intensity of the response is proportional to the quality of the local vascular reaction. The intense vaso-dilatation of the cavernous arteries leads the author to propose the use of this drug and this route of administration in the treatment of certain cases of poor erection due to arterial disease.
Treatment of 138 patients with sexual impotence of vascular origin involved revascularization of the dorsal and/or cavernous arteries of the penis by means of a venous auto or homograft branched on the external iliac or femoral arteries. Arteries requiring revascularization can be clearly detected by peroperative arteriography. Two or three shunts are usually necessary. The branches of the venous graft are firstly anastomosed microsurgically (under a 25 to 30 magnification) to the dorsal and/or cavernous arteries of the penis after their microsurgical dissection. The origin of the graft is then joined to the femoral or terminal iliac arteries. Results were generally excellent and there were very few complications: thrombosis during the first 30 postoperative days in 9 cases, hemorrhage in only one case during the last 3 years, frequent but rapidly regressing edema of the foreskin, and obturation of the shunt after the first month (between the 6th and 32nd months) in 4 patients. Postoperative priapism was never noted. This technique, in contrast to that employing direct implantation of the epigastric arteries into the corpus cavernosum, ensures the return of normal physiological erections. Follow-up after a minimum of 6 months showed that recovery was total in 78.6%, the condition being made worse in only 8.8%.
Counseling toward restoration of sexual potency was provided in twenty-eight years to 388 impotent men by one urologist. Most were in the fifty to fifty-nine-year age group. Many had histories of serious trauma, major surgical procedures, vascular diseases, diabetes mellitus, and alcoholism. Clinical judgment rather than elaborate testing was the basic approach to differentiate psychogenic from organic etiology. Strict criteria were used to classify success and failure of response to counseling. The success rate was 75 per cent, generally within three sessions at weekly intervals. Age alone did not preclude restoration of sexual competence. The highest success rate was in the fifty to fifty-nine-year age range for all three groups (white, black, and Asian).
Basal prolactin, FSH, LH and testosterone levels were determined in 47 patients presenting with impotence. Clinical history, physical examination, general analysis and personality questionnaire were normal. In two patients taking medications (imipramine and dogmatil), prolactin levels were high. The other patients had normal hormone levels. The authors discuss the various mechanisms which play a role in the secretion of prolactin and the various means available to assess changes therein.
This study emphasizes the role of the socio-cultural status and consequently of psychologic factors in sexual impotence of the black African in Senegal: --role of age, related to the perception of a dual status; --role of the ethnic group giving or not preeminence to sex; --rank in the brotherhood which may raise a conflict with ancestor; --matrimonial situation having significance of an acceptance of the cultural code about sex; --somatizations expressing the sexual potentialities; --non structured neurosis as expression of psychic and sexual inhibition; --religious behaviour with opportunities of conflicts with the religious authorities.
This article documents a vascular cause of erectile dysfunction in a patient with ligation of both internal iliac arteries after bilateral renal transplantation. The diagnosis was made by the noninvasive measurement of the penile arterial systolic pressure and confirmed by pelvic arteriography. Correction of the patient's impotence was accomplished by restoration of penile blood flow by a saphenous vein bypass graft between the external iliac and internal iliac arteries.
Two simple methods of assessing the presence and likely cause of impotence are described. The mechanism of sexual dysfunction is discussed with particular relevance to the surgical patient.
Erectile impotence is a common complaint, and competent management demands a systematized approach to diagnosis and treatment. The purpose of this article is to offer a practical schema for evaluating and treating a patient who presents complaining of this difficulty.
Only in the past decade have surgeons been able to offer men with impotence due to organic disease procedures that have good success rates. Between 1976 and 1979 the authors implanted paired silicone penile prosthesis in 35 such men, in most cases following cancer surgery. The procedure described is technically not difficult. Thirty-three of 35 patients have a functioning prosthesis. There were four complications but these should be rare if patients are properly selected. Patient satisfaction is high. No patient requested removal of the prosthesis.
The fashionable assumption that most cases of impotence are due to psychological problems is rooted in myth and often leads physicians to miss a wide range of possible physical causes. Since many metabolic, neurologic or cardiovascular disorders may cause sexual impairment, sexual and general history have to be done with utmost care and are the key to further work-up. Each systemic disorder has to be tested in regard to its significance for the sexual dysfunction. Since many drugs have a negative effect on sexual function the patient has to be asked for the medicaments he uses. A minimal laboratory work-up is required in order to get an idea of the patient's general condition.
With the aim of identifying the arterial origin of secondary sexual impotence, a velocimetric study by Döppler effect of the arteries involved in erection, was carried out in 132 patients aged between 32 and 58 years, and collected in a cardio-vascular department. 46 of these patients showed evidence of disturbance in arterial irrigation of the penis, as demonstrated by: -- flattening or disappearance of the special rate curve (46 cases out of 46); -- decreased pressure in the cavernous arteries (43 cases out of 46); -- prolongation of the time taken by the pulsatile wave (40 cases out of 46); Arterial involvement was confirmed in all 46 cases by aortography, completed in 35 cases out of 46 by selective angiography.