Erectile Dysfunction

Penile Erections And Deep Dorsal Veins

Blood drained off from the sinusoidal spaces or directly from arteriovenous shunts is collected in the distal two thirds of the corpora cavernosa via a direct subtunical venous plexus, and is then transported further via the oblique emissary veins that perforate the tunica albuginea. Several emissary veins open into a circumflex vein, which originates ventrally between the corpus spongiosum and the corpus caver-nosum, and surrounds the corpus cavernosum like a hoop, finally opening into the...

Neurologic diseases

ED can occur as a result of various neurologic diseases or lesions. The hippocampus and paraventricu-lar nucleus and medial preoptic area are considered as the main centers regulating sexual drive and behavior 37,38 . Lesions at these areas may result in ED, depending on their severity. Central neurologic disorders frequently associated with ED include disorders at the level of the brain (e.g. multiple sclerosis, temporal lobe epilepsy, Parkinson's disease, stroke or Alzheimer's disease), or at...

References

Vorrichtung zur k nstlichen erektion des penis. Patentschrift Nr. 268874, Klasse 30d, Gruppe 15. Kaiserliches Patentamt 1914. Available from European patent office, Den Haag, The Netherlands, 1914. 2 Nadig PW, Ware JC, Blummof R. Noninvasive device to produce and maintain an erection-like state. Urology 1986 27 126-131. 3 Tan HL. Economic cost of male erectile dysfunction using a decision analytic model for a hypothetical managed-care plan of 100,000 members. Pharmacoeco-nomics...

Diagnosis and Evaluation

Although no clear operationalized criteria exist for IE, given that most sexually-functional men ejaculate within about three to eight minutes following intromission, a clinician might assume that men with latencies beyond 20 or 30 minutes (and who experience consequent distress), or men who simply cease sexual activity due to exhaustion or irritation, qualify for this diagnosis 39 . Such symptoms, together with the fact that a man and or his partner decide to seek help for the problem, are...

Penile erection

Erectile Dysfunction Images

Experimental research on penile erection dates from at least the 19th century, with the work of pioneer physiologists such as Eckhardt, Langley and Anderson. Subsequently, during the 20th century significant advances were achieved thanks to the work of Semans and Langworthy in the 1930s, veterinary researchers performing experiments in conscious bulls and stallions in the 1970s, Sjostrand using plethys-mography to quantify penile erection in the rabbit, and then work by Lue's and Goldstein's...

Experimental investigation of female sexual function

GABAergic drugs and sexual motivation, receptivity and exploratory behaviors in the female rat. Psychopharmacol (Berl) 1997 129 372-381. Giuliano F, Allard J, Compagnie S, Alexandre L, Droupy S, Bernabe J. Vaginal physiological changes in a model of sexual arousal in anesthetized rats. Am J Physiol Regul Integr Comp Physiol 2001 281 R140-149. Erskine MS. Solicitation behavior in the estrous female rat A review. Horm Behav 1989 23 437-502. McKenna KE, Chung SK, McVary KT. A...

Biochemical diagnosis

What hormone should be measured The laboratory reference values of T and FT show a wider range than those for most other hormones (for instance, thyroid hormones), which makes it difficult to establish whether measured values of T in patients are normal or abnormal. Is a patient whose plasma levels of T fall from the upper to the lower range of normal T levels (a drop of as much as 50 ), T deficient T levels may well remain within the reference range but may be inappropriately low for that...

Poor Physical and Psychological Health

In a recently published report involving 447 men Table 5.1 Etiology and risk factors of ED. Lifestyle factors and individual health conditions Possible factors obesity, sleep deprivation, general poor health Coronary artery disease (CAD) Peripheral arterial occlusive disease (PAOD) Cavernous veno-occlusive dysfunction Cavernous fibrosis after priapism Hypoprolactinemia and prolactinoma Drug induced (see Table 5.3) LUTS (lower urinary tract symptoms) and BPH Other medical disorders Respiratory...

Partner evaluation

The partners of men with ED are affected, to a lesser or greater degree by the ED, as is the male. As alluded to by Dr Wagner and colleagues 21 , quality of life (QoL) has become one of the important parameters in the evaluation of treatment and assessment of medical conditions, and it may be an important tool in determining the urgency of the need for therapeutic intervention for ED. It is important to evaluate the QoL of the couple, because men and women alike will suffer as a result of male...

Efficacy

The efficacy of the three PDE-5 inhibitors was investigated world wide in large-scale trials, both in mixed ED populations as well as in subpopulations, like patients with diabetes, and after nerve-sparing radical prostatectomy (Table 7.4). To interpret Table 7.4 correctly it has to be mentioned that SEP 2 and SEP 3 diary data were available in all the tadalafil and var-denafil trials, whereas in the early sildenafil trials SEP 2 and 3 were not available, the tool successful intercourse was...

Nonresponders to PDE5 inhibitors

Of course there are real non-responders to PDE-5 inhibitors. Real non-responders mostly have a severe end-organ failure, which means that the cavernosal tissue has lost a considerable portion of its functional smooth musculature 99 . In the clinical setting these PDE-5 inhibitor non-responders show severe veno-occlusive dysfunction, with many of them also non-responding to intracavernosal injection of va-soactive drugs such as alprostadil or the trimix combination. Quite frequently this...

Topical alprostadil Alprox

Topical alprostadil (Alprox -TD) in doses of 100, 200 and 300 g was investigated against a placebo in two multicenter pivotal phase 3 trials involving 1732 patients with mild to severe ED 20 . The demographics of the study population showed diabetes in 21 , hypertension in 44 , RRP in 12 , CAD in 21 , and nitrate or a-blocker medication in 16 . The SEP 3 data obtained after 12 weeks of treatment as shown in Fig. 9.3, indicate a clearly inferior efficacy if compared to PDE-5 inhibitors, whose...

Responsibility of hypogonadism

Sexual function of men with severe organic hypogonadism Data accumulated in such men show that T is required for pubertal acquisition of gender characteristics as well as adult sexual behavior and functional capacity, including libido, ejaculation, and spontaneous erections. Administration of T during placebo-controlled studies demonstrated that sexual desire and arousal are T-dependent 13,29,30 and represent the main impact of T on sexual function of men. The frequency of sexual activity...

Cardiovascular function

Steroids and vascular risk factors Premenopausal women suffer significantly less from cardiovascular disease than men, and traditionally it has been thought that the relationship between sex steroids and cardiovascular disease is predominantly determined by the relatively beneficial effects of estrogens, and by the relatively detrimental effects of androgens on lipid profiles 101 . Nevertheless, the vast majority of cross-sectional studies in men are not in agreement with this assumption they...

Alternatives to testosterone therapy

Vat Calculations And The Vat Returns

Another potential method of the treatment of hypogonadism is the use of agents that increase the endogenous production of T in men with hypog-onadotropic hypogonadism. Shabsigh et al. reported on a study on 36 men with hypogonadism defined as serum T level less than 3ng mL. Each patient was treated with a daily dose of 25 mg clomiphene citrate, and followed prospectively. The mean age was 39 years with the mean pretreatment T and estrogen levels of 2.47 0.39ng mL and 32.3 10.9pg mL,...

Pathophysiology

The main pathophysiologic factors related to ED in diabetes revolve around the main abnormalities of the disease that is, vascular and neuropathic factors. ED, however, has both psychologic and organic factors associated with it, and this is also true in diabetes. Buvat etal. found that the psychologic factors were additive to the vascular and neuropathic factors that are prevalent in diabetes 356 . Veves et al. studied 110 men with diabetes, and found that psychogenic factors were the only...

Patient and Implant Selection

It is of critical importance to offer this treatment only to properly selected patients, and furthermore to Fig. 12.2 (a) AMS 700CX InhibiZone . (b) Mentor-Alpha 1. (c) Mentor Titan with ResistTM-Coating (here, colour-enhanced with methylene-blue). Fig. 12.2 (a) AMS 700CX InhibiZone . (b) Mentor-Alpha 1. (c) Mentor Titan with ResistTM-Coating (here, colour-enhanced with methylene-blue). select the model that best fits the patient's needs and anatomy. Patients who are eligible for a penile...

Neurophysiology of erection

Erectile Dysfunction And Spinal Cord

Parasympathetic nerve supply Initiation of erection Pro-erectile impulses are generated in the parasympathetic erection centers of the limbic system and the hypothalamus, in particular in the paraventricular nucleus and the medial preoptic area, which are the key regions for the central regulation of erection 17 . Perception of visual, auditory, imaginary, tactile or other erotic stimuli activate a variety of receptors which, in turn, stimulate via oxytocinergic, dopaminergic neurons the spinal...

Pharmacokinetic issues of the three PDE5 inhibitorsonset and duration of clinical efficacy

The pharmacokinetic profile of a drug comprises all the different steps between its entry into the body and its elimination. In this regard of special interest is the speed of absorption, which is best defined by the Tmax (time needed to reach the maximum plasma concentrations Cmax) and T1 2 (half-life), defined as the time it takes for the fall of the plasma-concentrations of a drug to half of its Cmax values. In the clinical setting the Tmax corresponds quite well with the speed of clinical...

Vasoactive substances used in the intracavernous injection test

In practice, PGE1 (alprostadil) is the substance of choice for diagnostic purposes. It is available worldwide in 10 or 20 g ampoules under the names of Caverject (manufactured by Pharmacia) or Viridal Edex (manufactured by Schwarz Pharma). The crucial advantage of PGE1 is that it causes priapism requiring treatment in only approximately 0.5-1 of cases, as compared to other, older substances such as papaverine or papaverine phentolamine, which cause priapism requiring treatment in up to 10 of...

Alprostadil PGE1Caverject Edex Viridal

Alprostadil Mechanism Action

The effect of PGE1 on the human corpus cavernosum (CC) was first described in 1975 by Karim & Adaikan 3 . Of more than 30 prostaglandins tested in vitro on the human CC, PGE1 is the only compound that produced relaxation conducive for erection 4 . All other prostaglandins produced either a dual effect (contraction and relaxation) or contraction only. The relaxant effect of PGE1 on the human CC has been further demonstrated in vitro 5,6 . Initial studies on the effectiveness and mechanism by...

Transurethral alprostadil PGE1 with MUSE Medicated Urethral System for Erection

A new alprostadil preparation using transurethral application with a small single-use applicator was introduced in 1994, and later on developed as MUSE (Medicated Urethral System for Erection) for market approval in US, 1996 (VIVUS, USA) followed by many other countries worldwide 70 . Although the transurethral application route seemed at first glance to be preferable to self-injection therapy the outcome and especially direct comparative trials to intracavernously-applied alprostadil...

Prostaglandins From Euroform Healthcare

Intracavernous injection of papaverine for erectile failure Lancet 1982 2(8304) 938 2 Virag R, Frydman D, Legman M, Virag H. Intracavernous injection of papaverine as a diagnostic and therapeutic method in erectile failure. Angiology 1984 35(2) 79-87. 3 Karim SMM, Hillier K. Physiological roles and pharmacological actions of prostaglandins in relation to human reproduction. In Karim SMM, ed. Prostaglandins and Reproduction. Lancaster MTP Press Ltd, 1975, pp. 23-75. 4 Adaikan PG....

Ejaculation and male orgasm

Most of the experimental work done so far for the investigation of ejaculation is based on behavioral experiments. Ejaculations in rats can be studied much the same way they are studied in humans, with the latency from first mount or intromission to ejaculation being the key variables (Fig. 1.3). Male rats typically ejaculate following several penile intromissions, and can ejaculate several times before becoming sexually exhausted, in which the male no longer responds to estrous odors or female...

Neurophysiology of ejaculation

Both the central and peripheral neural system is involved in the ejaculatory process. Central Nervous System The brain, brainstem and lumbospinal cord contain various areas that are involved in ejaculation. These areas have been identified in male rat studies. Specific information on areas in the human brain leading to ejaculation is mostly lacking. However, one positron electron tomography (PET) scan study in normal male volunteers has shown that during ejaculation a dopamine-rich area, the...

Sexual Medicine

And the Standards Committee of the International Society for Sexual Medicine Standard Practice in Sexual Medicine Chairman Hartmut Porst (Germany) Co-Chairman Jacques Buvat (France) Sub-Committee Preclinical Research and Animal Models in Sexual Medicine (Male and Female) Chairman Fran ois Giuliano (France) Members James G. Pfaus (Canada), Kevin McKenna ( USA), Balasubramanian Srilatha (Singapore) Sub-Committee Psychobehavioral and Couple Aspects Chairmen Stanley E. Althof (USA), Raymond Rosen...

Etiology and Risk Factors Lifelong PE

For about a century it was thought that lifelong PE is mainly caused by psychologic factors. Several different psychologic mechanisms have been proposed. Psychoanalytic theory Karl Abraham (1917) postulated that PE is due to unconscious hostile or anxious feelings towards women 16 . Psychosomatic theory In 1943 Bernard Schapiro suggested that PE be considered a psychosomatic disorder in which psychologic problems influence the activity of the genitals, which are thought to be weak in men with...

Rectification of terms

In humans, sexual dysfunctions form around the categories of sexual arousal, desire, orgasm, and pain. Arousal may be separated into physiologic genital arousal (sometimes referred to as potency) and subjective or psychologic arousal that denotes a conscious awareness of the genital sensations. However, this psychologic arousal may be an important component of sexual desire (sometimes referred to as libido or motivation). Sexual arousal and desire sum into behavioral responses of copulation...

Corpus Cavernosum Electromyography CCEMG

This procedure is used in the measurement of the reflex latency time of the BCR and pudendal, somatosensory-evoked potentials. This method has a considerable shortcoming in that it only checks the integrity of the somatic penile nervous system and does not allow any statement in terms of auto-nomic penile innervation, the system that is mainly responsible for the induction of erection (parasym-pathetic nervous system) and detumescence (sympathetic nervous system). The greatest obstacle to...

Psychogenic

Multiple psychosocial explanations have been offered for IE, with unconscious aggression, unexpressed anger, malingering, and fear of pregnancy, recurring as themes in the psychoanalytic literature. Religious orthodoxy may be a factor in some instances, the idea being that certain beliefs may limit the sexual experience necessary for developing the knowledge necessary to learn to ejaculate, or may result in an inhibition of normal function 11 . Although religious orthodoxy may play a role for...

Pathophysiology of DHEA deficiency

DHEA deficiency can be seen in several disease states. Regardless of the etiology, patients with pri mary adrenal insufficiency manifest signs and symptoms associated with a deficiency or absence of all adrenal cortical hormones including cortisol, DHEA, and aldosterone 283,284 . Women with panhypopituitarism have severe androgen deficiency due to a lack of both ovarian and adrenal androgen production 248 . Pituitary insufficiency can lead to a deficit of DHEA as the zona reticularis of the...

Types of Penile Prosthesis

Penile implants are currently available in a variety of forms, which can be categorized into two major types semi-rigid, or inflatable, with a silicon or polyurethane jacket. Details of the available length and diameters can be found on the websites of the two manufacturing companies American Medical Systems at www.visitams.com and the Mentor Corporation at www.mentorcorp.com. When implanted into the corpora cavernosa, they can be manipulated by the patient to fit his needs. The Jonas implant,...

Guanylate cyclase GC activators

Several research groups were focusing in the past couple of years on guanylate cyclase, on the GC-B, a membrane bound enzyme in particular involved in the physiologic process of erection by promoting the cleavage of cGMP from GTP 23,24 . At least two GC activators, i.e. YC-1 and BAY 41-2272, ( ) 100 90 80 70 60 50 40 30 20 10 0 Fig. 9.2 Results (SEP 3) of the multicenter trial with the PDE-5 inhibitor DA 8159 (udenafil 18 ) N 319. Placebo 100 g Alprox 200 g Alprox 300 g Alprox Fig. 9.3 Results...

Male Sexual Function

Peripheral sexual reflexes (erection and ejaculation), copulatory behaviour (mounts, intromissions, Fig. 1.1 Incentive sequences for human and rat sexual behaviors. This model provides a conceptual way to denote classes of homologous or analogous behaviors between the species (and sexes). The behavioral stream moves from left to right, through appetitive, precopulatory, and consummatory phases of behavior. This conforms to the movement of animals from distal to proximal to interactive with...

Models of male sexual dysfunctions

Male rats that do not perform sexually are typically taken out of behavioral studies, so there is very little known about their actual erectile responsiveness. This proportion is generally low, especially if the males are pre-exposed to the test chambers prior to their initial sexual experiences. Some of these males do not display any interest in the female, and do not initiate any kind of sexual activity. However, other males display sexual interest and mount repeatedly, but do not achieve...

Female Sexual Function

Gonadally-intact female rats of reproductive age go into sexual heat every four to five days immediately after ovulation. This process is initiated by the sequential actions of estrogen and progesterone (and possibly also androgens) in the brain and periphery, so that sexual behaviour shows an estrous cycle. Although women (and certain other primate females) can engage in sexual activity throughout their menstrual cycle, there is a peak rise in female-initiated sexual activity around the time...

Female orgasm the urethragenital reflex and the consequences of paced copulation

It is not known whether female rats experience anything like orgasm during sex. However, like males, they display a genital reflex, called the urethro-genital reflex that is reminiscent of the orgasmic response in women. This reflex can be induced and studied in isolation by applying a mechanical stimulation to the urethra of anesthetized, spinalized female rats. The urethro-genital reflex includes rhythmic contractions of the vagina, uterus, and the anal sphincter, as well as the striated...

Hypogonadismagonadism and hypoactive sexual desire

Although there are currently no established models of female sexual dysfunction in rats, there are several reasons to believe that such models could exist. The most obvious would be the consequences of hypogonadism induced by ovariectomy followed by maintenance with different doses of estrogen alone, or estrogen and progesterone. Ovariectomized rats treated with estrogen and progesterone display a complete pattern of procep-tive and receptive behaviors, whereas those treated with estrogen alone...

Endothelial factors

Angiotensin The angiotensin I II system and the an-giotensin-converting enzyme play a role in the regulation of the cavernous smooth muscle tone 37,38 . Angiotensin II causes a dose-dependent contraction of the cavernous musculature, which can be blocked by specific AT1-receptor antagonists such as losartan, but not by AT2-antagonists. In patients with severe organic impotence in whom a penile implant was inserted, hypertrophied cells secreting angiotensin II have been detected in the corpus...

Hepatic insufficiency

ED has been reported in up to 50 of patients with Table 5.2 Pathogenesis of ED in diabetes mellitus. Macroangiopathy (rarely) Iliac arteries Microangiopathy (frequently) Penile arteries and microcirculation Polyneuropathy Somatic nervous system Pudendal and dorsal penile nerve Autonomic nervous system Parasympathetic pelvic and cavernous nerves (Impairment of erection) Sympathetic pelvic and cavernous nerves (Loss of emission and ejaculation) Impairment of neurotransmitter synthesis release...

Routine laboratory tests

These should include a blood sugar and a fasting lipid profile in all men with ED without a diagnosis of diabetes mellitus or dyslipidemia, respectively. A PSA should be determined in the case of abnormal findings during palpation of the prostate, or as per the physicians' PSA screening protocol. A urinalysis is also helpful to look for glucose, ketones and protein-uria, as well as blood and white blood cells. Blood pressure, weight and waist circumference should be measured as a part of the ED...

Intracavernous injection test combined with Dopplerduplex ultrasound

This specific diagnostic test in the hands of the urologist (or perhaps radiologist) should be thought of as an optional part of the evaluation. It is the optimal method of reliably diagnosing relevant disturbed arterial blood supply to the penis, and of obtaining an approximate idea of the relaxation capacity and thus cavernous function in practice. In addition, the drug-induced erection reveals possible cavernous deformations in Peyronie's disease such as cavernous notches, or deviations that...

Self Injection Therapy

The demonstration by Virag in 1982 that intracav-ernous (IC) injection of papaverine produced a fully-rigid erection in normal males, introduced a new route of administration in the clinical management of pharmacologic agents for the treatment of erectile failure 1,2 . Intracavernous injection of a vasoac-tive agent that readily produces erection has greatly simplified the multidisciplinary diagnostic investigations and management of erectile dysfunction (ED). Three groups of drugs are...

Drug combinations for selfinjection therapy

Penile Self Injections Demonstration

PGE1 is still the first line option for patients who either do not respond or show contraindications for oral phosphodiesterase-5 inhibitors. Besides PGE1 mono therapy, several potentially useful combinations have been used for self-injection therapy as second line options. The vasoactive agents most commonly used in combination therapy, were phen-tolamine, papaverine, PGE1, and VIP. Potential advantages of the use of combination therapies over mono therapy may depend on the number of drugs...

Topical Therapies

Provided topical application can be as effective as oral or injection therapy, it would certainly have a greater popularity and acceptance, particularly for those patients with needle phobia fearing injection therapy, or those with contraindications for the use of PDE-5 inhibitors. Ideally, topical applications are considered to be non-invasive and have minimal systemic side effects that are commonly associated with oral pharmacotherapies. Currently, the application sites for topical therapy...

Penile Length Alterations

There are a total of three analyses on this issue in the literature. Fraiman et al. studied 100 men less than six months after radical prostatectomy, and took preoperative and postoperative flaccid and erect measurements and demonstrated an overall mean reduction in erect penile length of 9 but a mean reduction in volume of 22 1 . Munding et al. studied 31 men and measured penile length in the stretched flaccid state (accepted as equivalent to erect length) and showed that 71 had a decrease in...

Penile rehabilitation

The relationship between hypoxia and cavernosal fibrosis has been documented in at least two in vitro studies 9,57 . It is thought that hypoxia induces TGF-P1 expression that in turn accelerates collage- nization of the corpus cavernosum smooth muscle, while at the same time decreasing the level of PGE1, which may help protect from fibrosis. Since hypoxia of cavernous tissue is related to the blood supply, and the greatest blood supply occurs at time of erection, any neural damage that results...

Intracavernosal injections

The use of intracavernosal injections to treat post-RP ED was first proposed by Dennis and McDougal in 1988 81 . They reported a success rate of 85 (12 14 patients) with a mixture of papaverine and phentolamine. Intracorporeal injection therapy with alprostadil alone is effective in the majority of post-RP ED patients regardless of the status of their cavernosal nerves 82 . Gontero et al. evaluated the best regimen for starting intracavernosal injections in a series of patients who had...

Nocturnal Penile Tumescence NPT Testing

This method is useful for select individuals. NPT testing takes advantage of the fact that men with normal erectile function have 4-6 episodes of involuntary, nocturnal erections lasting 20-50 minutes during a 6-8 hour sleep cycle. These erections occur mostly during REM (rapid eye movement) sleep. NPT testing in the diagnosis of ED has been described and is known worldwide 50 . NPT is best used to distinguish between organic and psychogenic ED. Other simple and inexpensive methods such as the...

Cavernosometry and Cavernosography

Prior to 1998, cavernosometry and cavernosography 38,39 were widely used for the diagnosis of male erectile dysfunction. However, with the launch of a new oral drug treatment sildenafil Viagra , 40 , the need to diagnose cavernous insufficiency has changed greatly. What was the reason for this Quite simply stated, the treatment of ED was no longer a function of any testing. Rather, the introduction of the oral phosphodiesterase type 5 inhibitors PDE-5i changed the diagnostic and treatment...

Cavernsography

Non-ionic contrast agent is then added via a three-way stopcock, and after 50-100 mL of contrast agent, X-ray is performed in four different planes. This includes two anterior posterior projections with the penis bent upwards and downwards, as well as two lateral oblique projections using the urethrogram technique. Infusion is then stopped and 300-500 g of phenylephrine is injected intracavernosally to achieve detumescence. The butterfly cannula are removed after detumescence has occurred and...

Tissue Engineering and ED

Various surgical techniques have been developed to restore genital abnormalities, e.g. epispadias, micropenis, penile carcinoma, genital trauma, corporal fibrosis, and Peyronie's disease. In many of these cases there is a limited amount of cavernosal tissue and surgeons have relied on prosthetic devices to recover the patient's erectile function 2 . Reconstruction of normal erectile tissue using autologous cells, derived from the patient's own body, is an intriguing concept for the treatment of...

Complications of penile revascularization

Complications occur in up to 25 of patients after penile revascularization 4,37,39 . Glans hyperemia is the most common complication after these procedures. Inguinal hernia formation and postoperative hematoma have occurred in up to 25 of patients as well 4 . Venous ligation procedures rationale and technical considerations The previous terms venous leakage, venous vasculo-genic dysfunction or venogenic ED have been replaced by the more precise term CVOD 11 . CVOD may be due to structural...

Postoperative management

Once the patient has exited the operating room, it is essential that repeated evaluation be conducted to ensure that the shunt remains patent. It is recommended that the patient be re-evaluated prior to leaving the recovery (post-anesthesia care) unit. Once the patient has been discharged to the surgical floor ward, he needs to be re-evaluated in a serial fashion for the next 24 hours. At each assessment, shunt patency or corporal blood oxygenation needs to be defined. Relying on the degree of...

Complications of penile prosthetic surgery and their management

Erectile Radiology

The typical complication that may occur during dilation of the corpora cavernosa is perforation of the tunica albuginea. Typically the perforation occurs during the initial step of dilatation if this is the case, interrupting the dilatation on that side and completing the same procedure contralaterally will show the real length of the crus. With a size nine Hegar dilator in place in the corpus cavernosum contralateral to the perforation, the surgeon should go back to the crus affected by the...

Technique and complications of selfinjection therapy

In order to overcome the reservations and to increase the acceptance of patients on the one hand, but to decrease at the same time the complications of self-injection therapy on the other hand, a thorough instruction of the patients in a proper technique and use of ultra-thin needles is mandatory. According to the experiences of the authors it takes, in many patients, at least two teaching sessions before the patient is sure that he has mastered this technique correctly and avoids potential...

Treatment of Hypoactive Sexual Desire

Treatment of HSD is directed to the putative cause of the condition. There are no effective symptomatic treatments for HSD, as there are for erectile dysfunction (i.e. phosphodiesterase-5 (PDE-5) inhibitors). Bupropion, an antidepressant medication that has an effect in the re-uptake of dopamine and norepinephrine 41 , has been studied, and it has shown a modest effect on women with HSD when compared to placebo (using the slow-release form starting 150 mg day for one week and then 300 mg day)...

General Conclusion

Real progress has been made in understanding the neuroanatomical and neurochemical mechanisms of erection, ejaculation, solicitation, and other sexual responses, and in the design of rational pharmacologic treatments for certain sexual dysfunctions. We have begun to examine the mechanisms that underlie desire, and how sexual stimulation and reward impact on endpoints like sexual arousal, desire, attractiveness, and even mate choice. Progress in these areas could not have been made without the...

Genital sexual arousal

Upon sexual arousal, the blood supply to the vagina is rapidly increased and at the same time the venous drainage is reduced, thus creating vasocongestion and engorgement with blood. Such an increase in blood flow combined with an enhanced permeability of the capillary tufts induces a neurogenic transu-date, which results in vaginal lubrication. From left Female (right) makes a headwise orientation toward the male (left) characteristic of a solicitation. Top right Female hops over the male to...

Cardiovascular Risk Factors

More than 20 years ago the vascular surgeon Vaclav Michal from Prague recognized that chronic arterial disease, compromising the blood flow in the cavernous arteries, can be a significant cause of ED 11 . Atherosclerosis appears to be the most common cause of vasculogenic erectile dysfunction. Smoking, hypertension, diabetes mellitus and dyslipidemias have been shown to initiate the cascade of events resulting in atherosclerosis. These include endothelial injury, cellular migration, and...

Lower Urinary Tract Symptoms LUTS

There has been a recent increased interest in the association between LUTS and ED, both conditions being prevalent among older men. Recent epidemiologic data support such a link. El Sakka recently studied 476 male patients with ED and reported that 77 suffer from LUTS of those, 22.8 had mild, 42 had moderate, and 35.2 had severe grades of ED. Significant associations between LUTS and both the longer duration and the increased severity of ED, were also observed 69 . Suggested mechanisms for the...

Body composition

Body composition is seriously affected by the aging process. Aging is almost universally accompanied by an increase in abdominal fat mass and a decrease of muscle mass. Androgens have a substantial impact on muscle mass and on fat distribution, and therefore the relationship between these signs of aging and T levels has been assessed. Several studies have convincingly documented an inverse correlation between abdominal fat mass and FT levels and this appears to be independent of age 82-84 ....

DHEA therapy

DHEA replacement in adrenal insufficiency and pan-hypopituitarism Traditionally, adrenal insufficiency, resulting from Addison's disease, has been treated with glucocorti-coids and mineralocorticoids, while secondary adrenal insufficiency, resulting from pan-hypopitu-itarism, has been treated with glucocorticoids alone, as aldosterone production is regulated separately by the renin-angiotensin system 298 . However, management of the adrenal androgen deficiency associated with both conditions...

Metabolic syndrome

The metabolic syndrome comprises a group of risk factors that consist of endothelial dysfunction and atherosclerosis, which can lead to cardiovascular disease 398 . Although the definition of the various components of the metabolic syndrome has varied somewhat, there is now good consensus using the NCEP ATP-III criteria 399 . The criteria are 1 Triglyceride level > 150mg dL 4 Fasting blood sugar > 100mg dL 5 Waist circumference > 40 inches (102 cm) in men, or BMI > 28.8 Any three of the...

Postoperative ED

Surgery may lead to ED, either by compromising the vascular or nerve supply, or by hormonal deprivation (e.g. post castration, due to advanced prostate cancer or post pituitary surgery). Transurethral and open prostate adenomectomy may result in ED in between 5 and 40 of patients depending on the se ries reported 51-53 . Procedures frequently resulting in the manifestation of ED include radical pelvic surgery, such as radical prostatectomy (non nerve sparing), or cystectomy, abdominoperineal...

Psychic functions

There is some evidence to suggest that T may influence performance on cognitive tasks 132,133 , which is supported by the finding that T administration to older men enhances performance on measures of spatial cognition. The correlation between T levels and cognitive performance, such as spatial abilities or mathematical reasoning 134,135 , has been confirmed in Western and non-Western cohorts of healthy males 135 . In a cross-sectional analysis of the MMAS data, while older age was associated...

Risks of androgen therapy

Recent reports suggesting increased risks associated with hormone replacement in women 174,175 have aroused concern that men receiving hormone replacement may also be vulnerable to increased health risks. However, no large-scale, long-term studies have yet been initiated to assess the benefits and risks of T therapy in men. It is well recognized that the development of benign prostatic hyperplasia requires the presence of andro-gens and that the marked reduction in serum T caused by chemical or...

Hartmut Porst

The overwhelming success of sildenafil in the management of male erectile dysfunction (ED) encouraged both researchers and the pharmaceutical industry to enforce their endeavors in this special field of medicine. Meanwhile two further PDE-5 inhibitors tadalafil and vardenafil have joined sildenafil. Because they are not really distinguishable from sildenafil in terms of efficacy and side effects, but only from the pharmacokinetic profile, they are now directly competing with this very first...

Nature and prevalence of late onset hypogonadism

In late onset hypogonadism (LOH) there is a variable decline predominantly involving non-SHBG-bound T. Several studies document that androgen levels decline with aging (for review see 75 ). Longitudinal studies 76-78 have documented a statistical decline of serum T by approximately 30 in healthy men between the ages of 25 and 75 years. Since serum levels of SHBG increase with aging, plasma T not bound to SHBG decreases even more, by about 50 , over that period. Studies in twins have shown that...

Psychologic

The man who presents with inhibited ejaculation, in whom organic and pharmacologic causes have been eliminated by careful medical assessment and investigation, requires thorough psychosexual assessment. If he is in a relationship, his partner, and the quality of the relationship, also require evaluation. Numerous psychotherapeutic processes are described for the management of inhibited ejaculation, but none has been properly evaluated 11,18,89,93 . Therapists generally devise their own therapy...

Epidemiology

Inhibited ejaculation (IE) is less common than PE. The prevalence of IE in the general male population was found to be 1.5 in 1000 73 . The prevalence of acquired IE in men below the age of 65 years was 3 to 4 73 . IE can be classified as either lifelong or acquired. It may be global, occurring with every sexual encounter and all sexual partners, or it may be intermittent and situational. Some men with acquired IE can masturbate to orgasm, whereas others will or cannot. Approximately 75 of a...

Guidelines for Research in the Surgical Management of Peyronies Disease

Defining surgical outcomes has been hampered by a number of factors including studies containing small patient numbers, lack of standardization of patient populations being studied, lack of a uniform definition of successful outcome, and absence of comparative outcomes between procedures. The committee suggests that every effort be made to define the patient population being studied in detail in particular, defining the magnitude of baseline deformity, pres ence of associated deformities, and...

Peyronies Disease

While not viewed as a classic risk factor of the development of Peyronie's disease, radical prostatectomy is being increasingly recognized as a potential correlate of acquired penile curvature. There is only a single report in the literature suggesting that men with ED following RP may also have Peyronie's disease 4 . Analyzing 100 men who presented with post-RP ED, 11 had what the authors termed fi-brotic changes. Three-quarters of this latter group had palpable plaques. At 24 months after...

What is required for a good animal model

Predictive validity is the most important requisite of an appropriate animal model. In addition to this, Recording of intracavernous pressure increases in anesthetized or conscious animals Penile reflex tests Ex copula erections In vitro studies of cavernosal strips penile artery reactivity (organ baths) Cavernosal smooth muscle cells culture Biochemical studies of erectile tissue Mating test latency to ejaculate Urethrogenital reflex (anesthetized) PCA-induced ejaculation (anesthetized or...

Introduction

Ejaculatory dysfunction (EjD) is one of the most common male sexual disorders. The spectrum of EjD extends from premature or rapid ejaculation, through delayed ejaculation to a complete inability to ejaculate, anejaculation, and includes retrograde ejaculation and painful ejaculation. The sexual response cycle comprises four interactive, non-linear stages desire, arousal, orgasm, and resolution. In males, the fourth stage of orgasm is usually coincident with ejaculation, but represents a...

Organogenic

In the discussion of organogenic causes of IE, it is essential to distinguish between physiologic and pathophysiologic factors. Physiologic refers to those that are biologically inherent to the system, perhaps hardwired through genetic and normal maturational processes. Pathophysiologic refers to Table 16.2 Correlation of erection, ejaculation and intercourse with level and severity of spinal cord injury 81 . Cord lesion ( ) ( ) coitus ( ) ( ) Upper motor neuron Lower motor neuron Complete...

Diagnosis

The diagnosis of RE can be often made obviously with a history of previous surgical procedure. Retrograde ejaculation can be confirmed by demonstration of sperm in an analysis of a post-ejaculation urine sample 114 . Patients with absent and even low-volume ejaculate should be evaluated with a post-ejaculation urine specimen as retrograde ejaculation is frequently combined with antegrade ejaculation 117 . Examination of the post ejaculation urine is performed by centrifuging the specimen for 10...

Ejaculation

Chronic fluoxetine inhibits sexual behavior in the male rat Reversal with oxytocin. Psychopharmacol 1999 144 355-362. Coolen LM, Allard J, Truitt WA, McKenna KE. Central regulation of ejaculation. Physiol Behav 2004 83 203-215. Johnson RD, Hubscher CH. Brainstem microstimulation differentially inhibits pudendal motoneuron reflex inputs. Neuroreport 1998 9 341-345. McKenna KE. Ejaculation. In Knobil E, Neill J.D, eds. Encyclopedia of Reproduction. Academic Press,...

Mechanisms of action

It has been well described that the physiologic effects of DHEA are related to its peripheral conversion to the downstream sex steroid hormones, which then act on nuclear steroid receptors to exert their effects 270,273,274 . The ability for the conversion of active hormones in the peripheral tissues, where the hormone will be active, is called intracrinology. This phenomenon has been outlined for sex steroids very well by the work of Labrie 275,276 . Different peripheral tissues are able to...

Neuromodulatory drugs

The term nerve sparing essentially means that the surgeon using his experience and expertise defines if the nerves are anatomically and macroscopically intact. This may have less than perfect correlation with the actual functional integrity of the cavernous nerves. In animal models there is a plethora of literature associating cavernous nerve injury with corpus cavernosal smooth muscle structural damage. Maximum dose PDE5i x4 over 2-4 weeks PLUS PDE5i prescription at time of catheter removal...

Painful ejaculation

Painful ejaculation or odynorgasmia is a poorly- characterized syndrome and may be associated with benign prostatic hypertrophy BPH , infection, or inflammation from acute prostatitis, chronic pro-statitis chronic pelvic pain syndrome, seminal vesi-culitis, seminal vesicular calculi, or ejaculatory duct obstruction, a treatable cause of male infertility 122-125 . Nickel reported that 18.6 of men with lower urinary tract symptoms LUTS diagnosed with clinical benign prostatic hyperplasia reported...

Psychotherapy

A number of different psychotherapeutic approaches to PE have been described, but their efficacy have not been evaluated in properly controlled and adequately powered trials, and the different therapeutic modalities have not been compared in formal studies. It is likely that only some men seeking treatment for PE require in-depth psychotherapy. In spite of hard evidence on the efficacy of psychotherapy, behavioral retraining is still often practiced by sexologists. Behavioral treatment is...

Side effects and contraindications

The side effects commonly observed with yohimbine can mostly be traced back to the partially increased sympathetic activity anxiety, nausea, restlessness, agitation, sleeplessness tachycardia, palpitations, rarely diarrhea, manic symptoms 4,7,9 . In addition, after yohimbine, either increases or more infrequently decreases in blood pressure were reported, which may become of clinical relevance if hypertensive patients are taking this medication. In 25 hypertensive patients who had not been...

Populations for combination therapy and screening

Testosterone efficacy as monotherapy for ED is limited, because of the multifactorial nature of the pathophysiology of ED. Combination therapy with T and other ED treatments, such as PDE5i, may be valuable in certain subpopulations of patients. There is increasing evidence that combination therapy is effective in treating ED in patients where treatment failed with testosterone or PDE5i alone. Combination therapy may be particularly useful in men with type 2 diabetes and metabolic syndrome, who...

Sympathetic Skin Response SSR

Measurement of heart beat variation and the sympathetic skin response are generally accepted and now standardized investigation methods to demonstrate involvement of the autonomic nervous system, e.g. in diabetes, although the SSR method evaluates the sympathetic nervous system. SSR is infrequently used in the diagnostic evaluation of male ED, or in planning treatment for male ED. The method makes use of a somatic afferent sympathetic reflex, via which the activation of sweat gland secretion in...

Penile Angiography

Until the mid 1980s, penile angiography was regarded as the gold standard in the diagnosis of arteriogenic impotence. This technique was mainly developed at the end of the 1970s by Ginestie and Romieu, whose standard work on this topic remains valid today 44 . As a result of standardization of vascular diagnostic in erectile dysfunction, using non-invasive Doppler and duplex ultrasound, penile angiography is no longer a standard diagnostic test 45 . The only remaining indications for penile...

Copulatory behavior and measures of female sexual motivation or desire

As in males, female sexual behavior can be divided into sequential appetitive and consummatory components (Fig. 1.1). In the female rat, these aspects of sexual behavior are also referred to as proceptive and receptive components, two different aspects of sexual behavior displayed by estrous females in the presence of sexually-active males. To solicit attention and approach of the male, the female displays a variety of active proceptive behavioral patterns, including solicitations, hops and...

Epidemiology of Erectile Dysfunction

The scale and potential social impact of erectile dysfunction may be best understood by an appreciation of its international frequency. In 1995, it is estimated that there were 152 000 000 men worldwide suffering from erectile dysfunction. Because of the accelerating aging of the world population, coupled with the high prevalence of erectile dysfunction in men over 50, the world population of men with erectile dysfunction is expected to increase to 322 000 000 by the year 2025 21 . With this...

Alterations in Orgasm

Most of the post-radical prostatectomy sexual dysfunction literature has focused specifically on erectile dysfunction, and changes in orgasm have been reported in post-prostatectomy patients 14-16 . Orgasm, which is often considered to be a goal and reinforcer of sexual behavior, remains the least understood phase of the sexual response cycle. Alterations in orgasm, and in particular its absence, are associated with significant reductions in emotional and physical satisfaction, which in turn...

Embryology of the Penis

The penis develops from the genital tubercles and the urethra from the genital folds (in the female labia minora). The genetic sex (XY) induces testicular development, with the help of the sex-determining factor located on the Y chromosome 1 . Differentiation of the external genitals (male phallus female clitoris) from the genital tubercles occurs when testosterone production begins in the Leydig cells in the 8th 9th embryonal week. The penis grows very rapidly and is fully developed along with...

Mechanism of action and conversions

The testis has a dual function spermatogenesis and the production of T. The latter takes places in the Leydig cells. The daily production of T in adulthood is about 5-7 mg. T diffuses passively into cells of the target organs of androgens. To exert its biologic action, it must bind to the androgen receptor, though there are also a number of biologic actions of T that do not require receptor activation. For some of its biologic actions T is a prohormone. After diffusion into the cell, T may be...

Future therapies

Selective androgen receptor modulators The discovery and development of selective androgen receptor modulators (SARMs) provides the opportunity to design molecules that are not only orally active, but that target androgen receptors in different tissues to elicit the specific desired activity 223 . The desired activity profile of novel SARMs is described in Table 18.5. An ideal SARM for the treatment of primary or secondary male hypogonadism would have the following profile orally active, with a...

Apomorphine SL

The history of apomorphine dates back to 1869 when its first synthesis from morphine was reported by Mathiessen 15 . The dopaminergic activities of apo-morphine were first published in the mid 1960s when it was successfully administered in Parkinson's disease to suppress refractory motor oscillations 16 . Apomorphine was formerly used as an emetic in the treatment of poisoning to prevent absorption of orally ingested poisons. The erection-inducing effect of apomorphine in humans was first...

Surgical options

The primary purpose of shunt surgery is oxygenation of the corpus cavernosal smooth muscle CCSM . Shunts do not always result in immediate detumescence, as the CCSM may remain paralyzed for some time and, depending upon the duration of the priapism event, significant tissue edema may be present, which will masquerade as penile tumescence rigidity. Shunt procedures are subdivided into four groups 1 Percutaneous distal shunts Winter, Ebbehoj 2 Open distal shunt Al-Ghorab 3 Open proximal shunt...

The role of anxiety in sexual dysfunction

Anxiety played a significant role in early psychody-namic formulations of sexual dysfunction and later became the foundation for the etiologic concepts of sex therapy established by Masters and Johnson 3 and Kaplan 4 . Kaplan believed that sexually related anxiety became the final common pathway through which multiple negative influences led to sexual dysfunction. More recent studies have suggested that it may not be the subjective role of anxiety, per se, that causes and maintains sexual...

Psychotherapy of erectile dysfunction

Men with lifelong and acquired erectile dysfunctions typically achieve significant gains initially and over the long term, following participation in sex therapy. Men with acquired disorders tend to fare better than those with lifelong problems. Masters and Johnson 3 reported initial failure rates of 41 and 26 for lifelong (primary) and acquired (secondary) erectile dysfunction, respectively. Their 2-5 year follow-up of this cohort indicated sustained gains. Masters and Johnson's initial...

History and Epidemiology of Male Sexual Dysfunction

It seems paradoxical that among the physiologic functions of the human body, sexual function has generated the greatest popular awareness and curiosity, but the least scientific inquiry. Despite the considerable human behavior, both virtuous and evil, that has been motivated by human sexuality, restrictive social attitudes and taboos have severely inhibited scientific investigation of human sexual function. Working within a restrictive social environment, a few irrepressible investigators and...

Treatment of men with sexual dysfunction and hyperprolactinemia

The literature contains some observations of marked improvement of sexual dysfunctions associated with HPRL following non-specific treatments such as psycho- or sex-therapy 250 or, as concerns ED, sildenafil 241,253 . However, PRL-lowering dopamine-agonists (bromocriptine, lisuride, quina-golide, and cabergolide, the latter one being effective following a single administration per week) 254 most often not only normalize all aspects of sexual function, but also shrink the possible pituitary ade...

Depression and Sexual Function

The relationship between depression and sexual functioning is of considerable interest to clinicians and researchers since both affective and sexual disorders are highly prevalent, are believed to be co- morbid, and may even share a common etiology 7,8 . It is generally agreed that the relationship between depressive mood and sexual dysfunction is bi-directional and further complicated by the sexual side effects of antidepressant medication 9 . The empirical evidence confirms a prominent role...

The importance of receptivity

Many of the changes associated with aging, such as loss of bone and muscle mass, increased fat mass, and deterioration of physical, cognitive, and sexual capacities, are similar to the symptoms of classical hypogonadism in younger men. The decline in circulating T is not universal in elderly men and is of a lesser magnitude than in classical hypogonadism. To explain the androgen deficiency-like symptoms in aging in the presence of relatively mildly reduced T levels, it has been hypothesized...