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PubMed1999

The causes of patient dropout from penile self-injection therapy for impotence.

PURPOSE: Penile self-injection therapy, a second line treatment for erectile dysfunction, is the most efficacious means of reestablishing functional erections when first line therapies fail and the patient wants to avoid penile prosthesis implantation. Despite high efficacy rates, injection therapy has high dropout rates. To our knowledge studies to date analyzing patient attrition have reviewed small numbers of patients followed for only short periods. We elucidate the main reasons for patient dropout in a large penile self-injection program with long-term followup. MATERIALS AND METHODS: A questionnaire was mailed to 1,424 patients who completed the office training and home use phases of a penile self-injection program. RESULTS: The overall attrition rate was 31% of the 720 men who completed the questionnaire, with a mean followup of 38 months. The main reasons for dropout were cost of therapy, patient and partner problems with the concept of penile injection, lack of partner availability and spontaneous improvement in erections. Lack of efficacy of therapy was the primary reason for only 1 of 7 dropouts. Furthermore, adverse effects of penile injections (priapism, penile nodules, pain) appeared to be only minor contributors to dropout. CONCLUSIONS: To our knowledge this study is the largest published, single center cohort of patients treated with injection and followed for an analysis of dropout rates. Based on study data a reduction in dropout rates may be achieved by keeping the cost of therapy low, and ensuring patient and partner education as well as continued support throughout treatment.

Adult↗
PubMed1999

[Transurethral alprostadil (MUSE) in erectile dysfunction].

The ideal therapy for erectile dysfunction should be easy, non invasive, painless, with a high success and a low side effects rate. Alternative methods of delivery drugs to the erectile body, instead of intracavernosal injection of vasoactive drugs such as prostaglandin, have been evaluated. Vasoactive agents can be administered topically into the urethral mucosa for absorption into the corpus spongiosum and transfer into the corpora cavernosa via small communicating veins. We report data from the literature and our experience with MUSE (Medicated Urethral System for Erection) for the treatment of erectile dysfunction. Penile pain or discomfort is the common adverse effect reported, while no priapism of fibrotic complication is reported. But local discomfort, limited efficacy, and cost are to be considered.

Administration, Topical↗
PubMed1999

[Metastatic carcinoma of the penis: clinical assessment, treatment, and review of the literature].

OBJECTIVE: To review the pathogenesis, clinical features, diagnosis and treatment of metastatic carcinoma of the penis. METHODS: We report four cases of metastatic carcinoma of the penis with special reference to the clinical features, diagnosis and treatment. RESULTS: Two cases were due to prostatic cancer and the rest were secondary to bladder cancer and colorectal cancer. All patients received palliative treatment and survival has been poor. CONCLUSIONS: Penile metastases are rare and are usually secondary to other genitourinary primaries, priapism is the most frequent symptom, although increased penile size, ulceration and nodes formation have also been described. Diagnosis must be established by biopsy of the lesion to rule out other benign disease. Treatment is generally palliative; the options of surgery, radiotherapy and chemotherapy are available. Hyperthermia in combination with radiation therapy has been shown to be an effective modality in the treatment of penile metastases. Prognosis, however, is very poor.

Aged↗
PubMed2000

[Peroperative erection in lower urologic surgery].

Erection is a rare event during lower urinary tract surgery. When it is extremely refractory, endoscopy is impossible and the lower urinary tract surgery may need to be deferred. The development of erection during spinal anaesthesia is due to manipulations before complete installation of sensory block or incomplete blockade of sacral segments (S2 to S4) supplying the nervi erigentes. The mechanism of erection during general anaesthesia remains poorly elucidated. General anaesthesia may suppress central or peripheral sympathetic control of flaccidity. The peripheral target could be the smooth muscle of the cavernous tissue, either by a direct action or via alpha-adrenergic receptors. Psychogenic and reflexogenic stimuli have also been proposed, possibly facilitated by amplification of sensations during stage II anaesthesia. The various treatments are based on experience acquired in the field of priapism. Systemic treatments such as ketamine an beta 2 mimetics or benzodiazepines are not always effective and are associated with considerable adverse effects. Intracavernous injections of alpha-adrenergic drugs constitute the treatment of choice. Phenylephrine and etilefrine are preferred because of their rapid efficacy and particularly their only moderate cardiovascular adverse effects.

Anesthesia↗
PubMed2000

[Treatments with alpha-stimulants in urology].

Neuropharmacology is a rapidly expanding field due to the regular discovery of new neurotransmitters or neuroreceptors. Hopes have now been raised for the treatment of vesicosphincteric disorders by developing molecules with a potential selective clinical action on the detrusor or the urethra. After a brief review of the neuroanatomy and general neuropharmacology of the sympathetic nervous system, the current indications for alpha agonists are reviewed and discussed. These indications include the treatment of priapism, retrograde ejaculation, and incontinence due to sphincter incompetence. The more recent use of agents with a central mechanism of action is also discussed (detrusor hyperactivity of spinal cord injury patients). The authors review the current indications and note that, although the use of these drugs is very specific and limited in the field of urology, it is nevertheless based on an interesting concept. Like molecules at the stage of clinical trials for peripheral or central targets, the mechanism of action of these molecules on the sympathetic adrenergic system needs to be more fully elucidated. Their adverse effects remain the limiting factor for use on peripheral targets.

Adrenergic alpha-Agonists↗
PubMed2000

Intraoperative pharmacological erection as an aid to pediatric hypospadias repair.

PURPOSE: The intraoperative evaluation of erection is a major advance in hypospadias surgery. We determined the advantages of erections induced pharmacologically over those induced by intracorporeal saline injection for evaluating chordee during hypospadias surgery. MATERIALS AND METHODS: During the repair of hypospadias or chordee without hypospadias 56 boys 6 months to 13 years old underwent pharmacological erection induced by 14 microg. alprostadil administered intracavernously. Phenylephrine (40 microg. ) was given for detumescence. We monitored the adequacy of erection and detumescence, changes in blood pressure and pulse, and in 3 cases intracorporeal pressure. Intraoperative artificial erection was also induced in 30 patients. RESULTS: Erection occurred within 1 minute of injection. It was judged to be excellent in 47 cases and adequate in 6, while it failed in 3 probably due to injection outside of the corpora. Erection involved the whole penis, in contrast to artificial erection when tourniquet placement altered the erection and left the penile base flaccid. The degree of chordee remained stable during evaluation compared to artificial erection when curvature varied with the force of the saline injection. Erection persisted during chordee repair as long as the corpora were not opened. Detumescence occurred within seconds in all cases in which phenylephrine was given. There were no cases of priapism, and systemic blood pressure and pulse did not change. Intracorporeal pressure during pharmacological erection was 47 to 70 mm. Hg, whereas during artificial erection pressure was 50 to 250 mm. Hg depending on how much saline was injected and how rapidly fluid drained through the tourniquet. Chordee was induced by over injection. CONCLUSIONS: Pharmacological erection in hypospadias repair is effective and reliable with no significant complications. It is especially valuable in severe hypospadias and in patients with a large suprapubic fat pad. Artificial erection with saline injection should be performed with only moderate force since over filling is unphysiological and may falsely induce chordee.

Adolescent↗
PubMed2000

[Clinical features of essential thrombocythemia in three children].

Essential thrombocythemia (ET) is one of the quite rare myeloproliferative disorders in children. The natural course and outcome of this disease have been reported to vary. We report three children (two boys and one girl, mean age at diagnosis 12 yr) with ET who showed different clinical courses. The girl was asymptomatic, but the boys had ankle pain and priapism, respectively. The platelet count ranged between 2300 and 2900 x 10(9)/L, and the diagnoses were made according to the criteria of the Polycythemia Vera Study Group. The serum thrombopoietin level reached 0.33 and 0.47 fmol/ml in two patients. All three children were administered aspirin or dipyridamole orally. Normalization of the platelet count was observed in two patients, and stable disease persisted in one. The 12 pediatric patients with ET reported previously in Japan demonstrated a low incidence of serious thrombohemorrhagic complications and a favorable outcome, none developing acute leukemia. Careful continuous observation and conservative treatment may be preferable in pediatric patients who do not have cardiovascular symptoms, avoiding the use of potential leukemogens such as alkylating agents and hydroxyurea.

Aspirin↗
PubMed2000

The predictive value of white cell count in assessing clinical severity of sickle cell anaemia in Afro-Caribbeans patients.

The relationship between each of haemoglobin concentration (Hb), red cell count (RCC), white cell count (WBC), platelet count (PLT), mean corpuscular volume (MCV), red cell width difference (RWD), and average number of acute admissions per year (AVEADM), were determined in a cross-sectional study of 128 Afro-Caribbean sickle cell anaemia patients attending the Sickle Cell Disease Clinic of Central Middlesex Hospital in London for a mean of 7.6 patient-years. The diagnosis of sickle cell anaemia was made by both haematological and DNA analyses. The haematological parameters were determined using Coulter S automated counter during the steady state periods while the AVEADM was computed from all admissions for painful crisis, acute anaemia and acute chest syndrome, priapism, and acute stroke. Haemoglobin F level was determined by HPLC. Analysis was done in the paediatric and adult patients separately. There were no significant correlations between any of the parameters and AVEADM in the paediatric group. In adult patients, there was significant positive correlation (P < 0.05) between WBC and AVEADM. WBC has a negative correlation with Hb concentration and HbF level. WBC 10 x 10(9)/L and above is associated with Hb and HbF level below the mean for the group. WBC is lower but not significantly, in patients with single alpha-gene deletion than in those without deletion (P = 0.06). This study suggests that higher WBC count may suggest possible increased hospital admission, lower Hb concentration, and lower HbF level, in adult patients, and that, as a single parameter it can be of value in the assessment of patients with sickle cell anaemia. Possible mechanisms for these findings are also suggested.

Adolescent↗
PubMed2001

Profile of the Nigerian sickle cell anaemia patients above 30 years of age.

OBJECTIVE: To examine the haematological profiles of patients with sickle cell anaemia above the age of 30 years. DESIGN: Prospective cross sectional study. SETTING: Department of Haematology University College Hospital, Ibadan, Nigeria. SUBJECTS: 98 patients with sickle cell anaemia above the age of 30 years. MAIN OUTCOME MEASURES: Clinical and haematological profiles of the patients. RESULTS: There were 75 females and 23 males. The steady state packed cell volume was 21 to 28% with a median of 24% Haemoglobin F (HbF) level in 33 patients was greater than 3% but less than 5%. Thirty six patients had a HbF which was greater than 5% but less than 10%. Twenty three patients had a HbF level which was greater than 10% but less than 15%. Five patients had a HbF level greater than 15% and only one patient had a HbF level of 22%. The severe complications of sickle cell anaemia were not observed in 87 patients (88.8%), though some age related complications like Grade 4 ischaemic necrosis of the femoral head, chronic inflammatory liver changes and ophthalmic complications were observed. Eighty six patients had never had a blood transfusion, while 76 had never been admitted into hospital. Thirty four patients had a mild to moderate degree of splenomegaly while 64 patients had mild to moderate degree of hepatomegaly. Seven of the patients had chronic ulcers which spanned five to 12 years before the study. Five patients, however, had had cerebrovascular accidents. The cohort of patients with HbF level greater than 10% had not experienced priapism, acute chest syndrome, cerebrovascular accidents or chronic leg ulcer. All the patients have had a form of Western education, have a good knowledge of the disease and possible outcome. CONCLUSION: The study strongly suggests that for the survival of the sickle cell anaemia patient, educational background of patients and their parents, awareness of hospital treatment and early presentation in hospital are major contributory factors. Also, adequate medical care, maintenance of disciplined life styles, stable or sedentary occupation and good family support, prompt and effective treatment of complications, all contribute to better health and hence a longer life span.

Adult↗
PubMed2002

The efficacy, safety and tolerability of intracavernous PNU-83757 for the treatment of erectile dysfunction.

PURPOSE: Despite the introduction of sildenafil citrate many men with erectile dysfunction remain dependent on intracavernous therapy. While the majority achieves satisfactory results with currently available intracavernous preparations, all preparations have undesirable side effects, including priapism, fibrosis and post-injection pain. We determined the efficacy, safety and tolerability of the erectogenic potassium channel opener PNU-83757. MATERIALS AND METHODS: We selected 66 men with erectile dysfunction of vascular etiology for intracavernous injection of PNU-83757 in a single dose, single blind, placebo controlled study. Of the 6 patients allocated into each of 11 dose groups 5 received active drug and 1 received placebo. Groups received progressive doses of PNU-83757 or placebo. Holter monitoring was performed at scheduled intervals. Heart rate, and systolic, diastolic and mean blood pressure were assessed at scheduled intervals. Blood samples were obtained for pharmacokinetic study. Patients were evaluated at regular intervals for adverse events. Investigators and patients evaluated efficacy. RESULTS: The first complete erection was observed at 10 mcg. Of the 25 patients receiving active drug in the 60 to 140 mcg. groups only 1 had no erectile response, 15 had partial erection and 9 had complete erection. No serious adverse events or cardiovascular effects were noted. CONCLUSIONS: The minimum effective dose for complete erection was 10 mcg. The erectile response reached a plateau between 60 and 140 mcg., suggesting minimal improvement in efficacy at higher doses. Patient evaluation of erectile quality corresponded well with that of investigators. PNU-83757 was efficacious and extremely well tolerated, and the only adverse events were mild. No cardiovascular side effects were observed at any dose. PNU-83757 intracavernous injections caused no post-injection pain in any patient, which may make PNU-83757 superior to alprostadil in a select group. Further study is required to evaluate the efficacy of PNU-83757 combined with other drugs and with sexual stimulation.

Adolescent↗
PubMedDate not supplied

Perioperative management in children with sickle cell disease undergoing laparoscopic surgery.

OBJECTIVE: The aim of this study was to evaluate our experience with laparoscopic surgery in children with sickle cell disease. METHODS: A retrospective chart review was performed to analyze the indication for surgery, perioperative management, surgical technique, complications, duration of hospitalization, and outcome. One pediatric surgeon performed all procedures. RESULTS: Thirteen children underwent laparoscopic surgery for the following indications: symptomatic cholelithiasis/cholecystitis in 9; recurrent splenic sequestration in 3; and hypersplenism/symptomatic cholelithiasis in 1. The 7 boys and 6 girls had a median age of 7.8 years. Patients undergoing splenectomy only were younger than those undergoing cholecystectomy (median age, 3.6 years versus 11.5 years, respectively). Four children underwent endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy because of common bile duct dilatation and stones. Twelve patients received packed red blood cell transfusions prior to surgery. The median operative time was 150 minutes, and the median hospitalization was 3 days. Four patients suffered postoperative complications (2 with acute chest syndrome, 1 with recurrent abdominal pain, and 1 with priapism). The patient with abdominal pain was found to have a retained stone in the common bile duct, which was retrieved via endoscopic retrograde cholangiopancreatography and sphincterotomy. All complications resolved with medical management. CONCLUSIONS: Laparoscopic surgery is safe in children with sickle cell disease. Meticulous attention to perioperative management, transfusion guidelines, and pulmonary care may decrease the incidence of acute chest syndrome.

Anemia, Sickle Cell↗
PubMed2002

Penile metastases from urogenital primaries.

Metastatic tumors of the penis are rare. They are usually secondary to primaries of the genitourinary and gastrointestinal tracts. This entity is usually accompanied by distressing symptoms like dysuria, pain, induration, swelling of the penis and priapism, making immediate intervention necessary. Different methods of treatment are used to achieve the palliative effect: local surgical excision, penis amputation, radiotherapy or chemotherapy. Nevertheless, the prognosis is poor, because the disease is already disseminated and in most cases other metastases will occur soon.

Aged↗
PubMed2002

[Role of power Doppler in the differential diagnosis between organic and functional cavernovenous insufficiency in patients with erectile maintenance deficiency].

Dynamic penile eco colorDoppler (ECDP) shows limits of specificity in case of differential diagnosis between functional (adrenergic hypertone) and organic cavernovenous incompetence. The aim of this study is the evaluation of a new flow chart for venogenic erectile dysfunction diagnosis, including power Doppler (PD), avoiding the repetition of ECD with higher concentrations of PGE1. In fact this procedure is invasive, often painful and burdened by a consistent risk of priapism. Patients suspected of caverno-venous incompetence underwent PD during the ECD. 85 of them showed high telediastolic velocity but normal systolic peak flow. All these patient underwent PGE1 redosing, to a maximum of 40 micrograms. Patients with still suspicious ECD were administered RigiScan. 63 patients over 85 had good PD, while 22 had bad PD. Of the 63 patients with good PD, 60 (95%) had normal ECD after redosing, while in 3 (5%) of them the telediastolic velocity remained high. In these 3 patients RigiScan showed normal nocturnal rigidity in 2 cases, abnormal in 1. 18 patients (82%) of the 22 with bad PD never showed improvement of ECD and RigiScan resulted altered in 15. In our opinion concordance between 10 micrograms ECD and PD avoids redosing in demonstrating organic venogenic erectile dysfunction. If PD is good but ECD is altered, 10 micrograms re-dosing could help in differentiating organic or functional erectile dysfunction. The diagnostic flow chart, then, should always include PD.

Adolescent↗
PubMed2002

Principles of blood transfusion in sickle cell anemia.

Sickle cell anemia (SCA) is one of the commonly inherited hemoglobinopathies in the Kingdom of Saudi Arabia. It is characterized by periods of remissions and exacerbations called crises as well as certain pathological phenomenon such as acute chest syndrome, priapism, hepatopathy, and cerebrovascular stroke. Blood transfusion (BT) as therapy and prophylaxis in SCA, although was advocated as early as the 1940's, there are still debates regarding its benefits and risks. This is a review of the value of BT in patients with SCA with emphasis on the risks and benefits as well as guidelines towards safe BT.

Anemia, Sickle Cell↗
PubMed1999

[Mode of action of sildenafil].

Sildenafil is the first oral therapeutic agent for erectile dysfunction. Sildenafil is a selective inhibitor of cGMP-specific phosphodiesterase (PDE-5). Penile erection involves relaxation of the corpus cavernosum, an event mediated by NO and cGMP. The biological actions of cGMP are terminated by phosphodiesterase enzymes and PDE-5 is the major cGMP metabolising enzyme in this tissue. Sildenafil is relatively safe compared to erection injectables because it does not relax on isolated human corpus cavernosum, and does not cause priapism. Due to the tendency of abuse of sildenafil, its adverse cardiovascular associations with myocardial infaraction, ventricular arrhythmia and hypertension need to be alerted.

Erectile Dysfunction↗
PubMed1992

[Prostaglandin E1 in the long-term treatment of erectile dysfunction].

Intravenous injections of Prostaglandin E1 were administered to 65 men suffering from erectile dysfunction. Later on, 59 of them administered the substance to themselves. Our experience as well as literary data have confirmed the efficacy of prostaglandin E1 administered intracavernously in the therapy of different forms of impotence, including the so-called psychogenic form. Its advantage is that it metabolizes directly in the cavernous tissue. Virtually no significant systemic side reactions were recorded and neither priapism nor fibrosis of the corpora cavernosa were observed after long-term treatment. Prostaglandin E1, a product of Léciva Praha, was used within the clinical study of this preparation.

Alprostadil↗
PubMed1992

[Effects of PGE1 on penile blood flow].

From February to July in 1989, 47 patients came to our O.P.D. with the chief complaint of impotence. The average age was 48.3 +/- 10.7 y/o. We applied intracoporeal injection of prostaglandin PGE1 (20 mg); and evaluated its penile blood flow effect by color duplex scanning (Acuson 128). The erectile responses of the test showed that: 6 patients (12.8%) had normal response: and 16 patients (34%) had imperfect response. Altogether, the total positive response rate was 46.8%, and 25 patients (53.2%) showed impaired response. The onset of response was 9.1 +/- 3.6 minutes and the duration of erection was 59.2 +/- 24.7 minutes. The percentage of diameter change of both deep arteries after injection was Rt: 58.1 +/- 41.5%; left: 52.3 +/- 35.6%. The peak velocity of right cavernosal arterial flow after intracoporeal injection was 35.5 +/- 15.9 cm/sec; and that of the left side was 33.2 +/- 16.9 cm/sec. There was no correlation between the increment of peak velocity of the deep arterial flow and the erection grade. The same phenomenon was also found between the increased change in the diameter of the deep artery and the erection grade. 16 patients (34.1%) experienced tolerable pain during the procedure. Two patients (4.3%) experienced dizzines and discomfort due to venous leakage. No priapism was found. This study suggests PGE1 may be an excellent potential alternative to other vasoactive drug with less complication in the diagnosis and treatment of impotence. But the cost and stability were its shortcoming.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1992

[Non-surgical therapy of impotence: infiltration, iontophoresis, ultrasound, laser].

Surgical therapy is the only useful correction in congenital fibrosis or in hypoplasia of the 'corpora cavernosa', associated with hypospadia or not. On the contrary in not congenital fibrosis of the 'corpora cavernosa' (Peyronie's disease, consequences of priapism, or trauma, complications of pharmaco-prosthesis) are allowed pharmaco-physical treatments (infiltrations, ionophoresis, ultrasound, laser). Pharmaco-physical therapy can be used as the only treatment, which is often resolutive, but it is also useful before or after the surgical operation of the 'corpora cavernosa'. These diseases can give disorders of the erection, until complete impotence is reached. In fact the erectile tissue can't expand, because of the rising fibrosclerosis. Among acquired fibrosis of corpora cavernosa I.P.P. has surely the greatest recurrent: the consistency of our series made possible to achieve significant results with a unified therapeutical protocol. The same management was applied in other, less frequent, penile fibrosis, always with full positive results even if on a small number of patients. We are evaluating a new drug (defibrotide) in the treatment of cavernosal vasculitis. Another one (hyaluronidase) associated to orgotein, could improve its effect against inflammation especially in chronic evolutions. Besides new treatments, we emphasize the prevention of iatrogenic fibrosis with particular regard to cavernous pharmaco-infusions by autoinjections: the training of the patient and the safety of the autoinjectors must be carefully checked by the andrologist to decrease a large amount of complications.

Erectile Dysfunction↗