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PubMed1981

The multidisciplinary approach to vasculogenic impotence.

The proper assessment of erectile dysfunction can be objectively accomplished only by examining the vascular, hormonal, neurologic, and psychologic components. The vascular surgeon today requires the ability to participate in multidisciplinary approach to diagnosis and needs an understanding of pelvic hemodynamics to design aortoiliac reconstructions that optimize pelvic blood flow. We perform a history and physical examination carefully designed to evaluate erectile ability and detail vascular involvement. Outpatient serum samples are obtained for hormonal analysis. In the noninvasive vascular laboratory, we measure the penile blood pressure using a 2.5 cm cuff and a 10 MHz Doppler probe. We feel strongly that measuring the right and left cavernosal artery pressures directly and determining the penile/brachial index (PBI) most accurately reflects penile flow. A PBI less than 0.6 is diagnostic of vasculogenic impotence, and a PBI greater than 0.75 is normal. We perform our pelvic steal test by exercising the thigh and buttock muscle groups, and comparing the PBI before and after exercise. A decrease of 0.1 or more represents a positive steal test. Measurement of nocturnal penile tumescence is valuable in cases where history, physical examination, and noninvasive vascular laboratory evaluations do not correspond. A neurologic evaluation may include cystometrography or sacral latency testing when indicated. Psychological screening is performed in all patients. We screened 54 vascular clinic patients and found 81% to be symptomatic of erectile dysfunction. In this group, 79% had a PBI less than 0.75, and 38% had a positive pelvic steal test. Illustrative cases are presented herein and the implications in aortoiliac surgery are discussed.

Adult↗
PubMed1978

Single session psychotherapy in secondary male impotence.

The feasibility of re-achieving sexual potency in males suffering from secondary impotence of nonorganic origin by the use of brief psychotherapy is demonstrated. Four cases are presented in which this result was achieved in a single session, as well as two others in which some further work had to be done. The importance of intervening psychotherapeutically as early as possible is stressed. Some of the prevalent dynamic features found in these cases are discussed.

Adult↗
PubMed1994

Experience with buccal phentolamine mesylate for impotence.

Satisfactory erection with penetration can be obtained in impotent men by the oral or buccal administration of the alpha-adrenergic antagonist, phentolamine. This agent is also used in conjunction with papaverine HCl for intracavernous injection. The previous observation by Gwinup, that 50 mg of phentolamine HCl po, 1.5 hours before coitus resulted in erection in 11/16 patients, is confirmed. This study, using phenoxybenzamine as the placebo, was repeated with success in 36/85 (42.3%) patients. Because of cost and to decrease the waiting time, a buccal form of phentolamine mesylate was administered (20 mg) with erection and penetration in 21/69 (31.8%). There was no correlation between the degree of penile vascular insufficiency or age and the effectiveness of phentolamine. Buccal phentolamine is shown to increase flow velocity in the dorsal penile artery. Phentolamine produces minimal side effects, including hypertension in the subjects.

Administration, Buccal↗
PubMed1995

Comparison of RigiScan and sleep laboratory nocturnal penile tumescence in the diagnosis of organic impotence.

PURPOSE: We evaluated the relative use of RigiScan measurement of radial rigidity compared to sleep laboratory measurement of axial rigidity and trained observer determination of erectile function in the diagnosis of organic impotence. MATERIALS AND METHODS: A total of 28 patients underwent simultaneous 2-night formal sleep laboratory nocturnal penile tumescence and RigiScan monitoring. Standard normal values for radial rigidity and axial rigidity were tested for accuracy in predicting normal nocturnal penile tumescence compared to trained observer determination of the adequacy of an erection for penetration. RESULTS: RigiScan tip measurements correlated poorly with buckling pressure, while base measurements strongly correlated (p = 0.0005). Observer determination of a functional erection was strongly associated with tip (p = 0.002), base (p = 0.0005) and buckling pressure measurements (p = 0.0005). Using observer determination as the gold standard receiver operating curves were generated to select RigiScan base and buckling pressure measurements that predicted functional erections with the highest sensitivity and specificity. CONCLUSIONS: RigiScan is a useful tool for measuring nocturnal penile tumescence. However, base measurements are more accurate than tip measurements for evaluating erectile function. The currently accepted level of rigidity used to define a normal erection (70% or greater) overestimates organic erectile dysfunction.

Adult↗
PubMed1995

Does compression of the base of the penis improve the efficacy of intracavernosal injection of prostaglandin E1 for impotence? A randomized controlled study.

The objective of this study was to evaluate the effect on erections of impeding venous blood flow following intracavernosal injections of prostaglandin E1. Dispersion of injected X-ray contrast medium indicated that application of the RMRI penile clamp to the base of the penis retarded venous outflow. The clamp was then tested in impotent men to determine whether their erectile response was enhanced. Erectile response was assessed using a Rigiscan monitor, palpation of the penis by a staff nurse and the patient's subjective impression. The results demonstrate that there is no significant improvement in erectile response following venous compression.

Adult↗
PubMed1995

Effect of blood sampling on apomorphine-induced penile tumescence in erectile impotence: a case report.

Apomorphine HCl (Apo) (0.5 mg sc), but not placebo, induced an erectile response (monitored with a mercury strain gauge) lasting 40 min in an impotent hyperprolactinemic patient. Serial blood sampling modified the 40 min erectile response. Prompt detumescence followed by complete or partial restoration of tumescence occurred each time blood was drawn. This observation points to the sensitivity of the Apo-erectile response to experimental procedures subjectively perceived as anxiogenic.

Apomorphine↗
PubMed1994

Love and sex after 60: how to evaluate and treat the impotent older man. A roundtable discussion: Part 2.

In the medical evaluation of older men with erectile dysfunction, obtain a detailed history to determine whether the dysfunction is organic or psychogenic. Determine if there are underlying pathologic processes--most notably vascular diseases--or other factors responsible for the dysfunction, such as medications or nerve or arterial damage from surgery. Lifestyle changes in mid-life (regular exercise, a low-fat diet, and smoking cessation) increase a man's chances of remaining potent as he grows older. Treatments for impotence include injection therapy, vacuum devices, and implants. Each therapy has advantages and disadvantages, and the informed patient plays an important role in choosing the therapy that is right for him.

Aged↗
PubMed1994

[Neurological evaluation of erectile impotence].

The diagnostic approach to neurologic evaluation of erectile impotence in neurologic subjects differs from non neurologic subjects; in particular in this last group of patients the aim of diagnosis may drive to point out or exclude an hidden or underestimated neurologic lesion. Authors report the different diagnostic approach.

Erectile Dysfunction↗
PubMed1994

HIV-1 associated neuropathies in males; impotence and penile electrodiagnosis.

Value of the bulbocavernosus reflex latency versus nerve conduction velocity of the dorsal nerve of penis and penile brachial index was evaluated in HIV-1 infected asymptomatic and symptomatic men with and without an objective evidence of neuropathy. These studies revealed striking results in neuropathic group. Both asymptomatic and symptomatic patients with neuropathy exhibited a significant decrease (P < 0.0005) in the values of the nerve conduction velocity of the dorsal nerve of penis as well as penile brachial index in comparison with the controls of the same age group. However both types of non neuropathic patients showed a non significant difference in the above mentioned parameters with their respective controls. The latency of bulbocavernosus reflex showed no significant difference between the groups and was within the normal limits. A non significant association in the values of the study parameters among asymptomatic and symptomatic patients with and without neuropathy was also observed. These findings suggest an exclusively apparent sexual pathway for the penile dorsal nerve conduction and penile brachial index in both HIV-1 infected asymptomatic and AIDS positive men affected by neuropathic conditions, irrespective of their disease state. We thus conclude that a primary defective neuropathic mechanism may play an etiological role in the pathogenesis of erectile impotence in these patients.

Acquired Immunodeficiency Syndrome↗
PubMed1994

Neurogenic impotence: diagnostic value of nerve conduction studies, bulbocavernosus reflex, and heart rate variability.

In a group of 10 neurogenic impotent patients the diagnostic sensitivities of peripheral nerve conduction, bulbocavernosus reflex latency, and heart rate variability have been compared. The bulbocavernosus reflex latency appears as the least affected parameter, while nerve conduction and heart rate variability-measured during hyperventilation and expressed as the percentage of the RR interval variation-show similar diagnostic yields.

Adolescent↗
PubMed1993

[Penile erection using vacuum devices: our experience with 100 impotent patients with organic etiology].

The aim of this study was to determine the efficacy and acceptability of the erection suction device in patients with erectile dysfunction from organic causes. One hundred patients suffering from impotence due to different organic etiologies were evaluated following a protocol which included patient history, physical examination, general blood tests, hormonal tests, erection (Rigiscan) study and vascular and neurological tests. In 87% of the patients, a correct erection was achieved when the suction device was used for sexual intercourse. However, only 28.7% accepted to use this method routinely.

Adult↗
PubMed1993

Penile angiography in impotence: local experience.

Vasculogenic causes of impotence and especially venous leakage are now considered to be significantly worthwhile to be evaluated in the light of new developments and changes in the treatment of erectile dysfunction. The investigations of cavernosography and penile arteriography are gaining importance. In 32 months, from August 1990 to March 1993, 126 cavernosograms and 11 bilateral internal pudendal arteriograms have been performed on patients from Toa Payoh Hospital. Smooth muscle relaxants are helpful in both procedures. Nearly three-quarters of the cavernosograms showed deep venous leakage. The use of arteriograms is still very restricted. The many variations of the arterial supply to the penis pose problems in the interpretation of the arteriograms and hence, recognition of the numerous variations besides the knowledge of the normal basic vascular anatomy is of paramount importance.

Adult↗
PubMed1993

[Complications of intracavernous pharmacologic infusion in impotence. Long-term results].

The large scale employment in recent years of vasoactive drugs in the treatment of impotence forms the basis for a significant statistical study on incidence of complications and collateral effects. We studied 658 patients submitted to ICF (intracavernous pharmacoinfusion) diagnostic and therapeutic in the last 6 years (1986-1992). The patients have been shared groups according to the period and the treatment: in 226 cases we have utilized papaverine, in 224 cases phentolamine-papaverine association and in 208 cases prostaglandin E1. In the last group the complications have been lower: echymosis and haematoma 0.5%, priapism 1.5%, intracavernous fibrosis 1%, fibrotic knots 0.5%. In conclusion we confirm the validity of treatment with PGE1 intracavernous infusion.

Adult↗
PubMed1993

[Treatment of sexual impotency by intra-cavernous injections of prostaglandin E1. Report of 180 patients].

As already reported, PGE1 induces a valid erection, when administered intracavernously, without causing prolonged erection or general side effects. We have tested PGE1 (< 20 micrograms) in 180 patients suffering from organic erectile impotence, a complete erection was observed in 130 (72.2%), while incomplete erection was noted in 37 (20.5%). In both groups (92.7%) erection was sufficient for sexual intercourse. Among the best results, 41 patients had previously received high doses intracavernous injection of papaverine, without any benefit, and 15 patients have cavernosal venous leakage documented by cavernosometry and cavernosography before prostaglandin E1 test. Tumescence without rigidity was noted in 13 (7.2%). Of these 167 patients, 95 entered an autoinjection protocol for treatment of erectile dysfunction, using special device. In our series neither systemic reaction nor prolonged erection occurred. No fibrosis of cavernous tissue or scar formation was observed after up to 125 injections. However, 19 patients (10.5%) reported burning sensations during the entire period of erection and one patient (0.5%) had an haematoma at the site of the injection. PGE1 is effective in inducing artificial penile erection and it has a role in the diagnosis and treatment of erectile dysfunction, it is considered to be a more suitable agent than other vasoactive drugs.

Adult↗
PubMed1993

The success of microsurgical penile revascularization in treating arteriogenic impotence.

The treatment of arteriogenic erectile dysfunction with revascularization techniques has been controversial both in terms of its use and the type of surgical repair. Success rates reported in the literature are based almost exclusively on patient testimonial, without the use of objective post-operative criteria. At our institution from 7/88 through 8/91, 18 patients were treated for arteriogenic impotence using microsurgical penile revascularization. The patient population ranged in age from 23 to 64 years, and each patient underwent a complete history and physical examination, serum hormone testing, psychological evaluation of patient and partner, biothesiometry, penile plethysmography, nocturnal penile tumescence/rigidity testing with a Rigiscan device, and selective pudendal arteriography. One patient was status post a pelvic fracture, 2 lacked identifiable risk factors, 2 had diabetes, 6 were heavy smokers, and 7 had hypertension. Pre-operatively each patient had a suspicious medical history, abnormal plethysmography, abnormal Rigiscan testing, and a hemodynamically significant lesion on angiography. Revascularization was done by anastomosing the inferior epigastric artery to the deep dorsal veing and dorsal artery, or the deep dorsal vein alone if both arteries were atretic. Postoperatively, all 18 patients underwent a personal interview, repeat penile plethysmography, and repeat Rigiscan testing. Six patients reports successful coitus and an additional four were having coitus with the aid of intracavernous pharmacotherapy. Seventy-eight percent (14/18) had improved tracings on penile plethysmography, and 56% (10/18) had normal erectile capability by Rigiscan testing.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1993

[Color Doppler echography of the cavernous bodies after F.I.C. in the study of erectile impotence of vascular origin].

Study with the Doppler method has been associated with "cavernometrics" and "cavernography" in erection pathologies for some time. But this enquiry is burdened not only be technical inaccuracies such as the lack of knowledge of the angle of incidence of the doppler wave and the diameter of the explored vessel etc, but also by intrinsic difficulty method itself. Therefore, the authors have used a color Doppler to individuate and study the cavernous arteries, and present the results obtained from a group of 21 patients, all affected by erectile deficits, who were selected on the basis of anamnestica and clinical criteria. They individualized 21 patients in whom the vasculogenic nature of their affection appeared probable, out of the 125 who were under their observation for their sexual inadequacy. In three patients the clinical suspicion of a venous incompetency was confirmed by dynamic "cavernometrics with cavernography". The study of the four phases of erection (flaccidity, tumescence, erection, detumescence) was carried out after an intracavernous injection of 20 micrograms of PGE/1. The parameters considered were: systolic velocity of the hematic wave, diastolic speed, the index of resistance and range. In cases of vasculogenic impotence with an arterial base the systolic wave in the 2nd and 3rd phases presented a speed inferior to the norm of standard values, the resistance index altered by the lacking of physiological increment due in the erectile beyond the closing of venous "polsters", also to the rigidity of the albuginea.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1993

Impotence.

Impotence is a clinical problem that patients and doctors are becoming more prepared to discuss. To advise patients with confidence a knowledge of causes, investigations and treatments is necessary. The treatment options include sex counseling, intracorporeal injection, external vacuum devices and penile implants.

Erectile Dysfunction↗
PubMed1993

[A program of intracavernous drug-induced erection for the treatment of impotence].

The study includes 138 patients with erectile dysfunction, all of them previously treated with intracavernous injections. Following study and classification of the type of impotence, they were all included in one of the four following groups. The drugs used were, in group I (73 patients) Prostaglandins E1, in group II (37 patients) Papaverine, in group III (6 patients) a combination of Papaverine and Phentolamine and in group IV (22 patients) a combination of Papaverine and Prostaglandins E1. We found a good treatment response in 59.3% cases (60.3% in group I, 51.3% in group II, 66.7% in group III, and 69% in group IV). We outline the better results obtained in group IV, as well as the reduced number of complications in our series.

Administration, Topical↗