Core document on erectile dysfunction: key aspects in the care of a patient with erectile dysfunction.

The aim of this Core Document of the Spanish Consensus on Erectile dysfunction (ED) is to offer guidance to the nonspecialist physician in the management of patients with ED. ED is one of the most frequent chronic health problems in men older than 40 y of age and may also act as a sentinel symptom for other important underlying diseases. Its etiology can be classified into organic, psychogenic, or mixed. In most cases, the underlying cause of ED is usually a chronic health problem (such as diabetes, hypertension, atherosclerosis, and so on) or an adverse drug effect. The initial step in the management is to assess erectile function in patients with risk factors for ED. Once ED has been established, a detailed sexual, medical, and social history, including a review of medications used, is the most important aspect of a patient's assessment. Generally, examination should be limited to the cardiovascular, neurological, and urogenital systems. Fasting glucose and blood lipid profile should be performed in every man with ED, and free testosterone levels in men older than 50 y or if hypogonadism is suspected; other diagnostic tests are optional and should be requested on an individualized basis. In many cases, the most likely cause of ED can be identified based on the above information. Therapeutic intervention should be patient-oriented and based on the expectations and wishes of the patient and his partner, who should be included in discussions whenever possible. Basic interventions common to any type of ED include sexual counseling, lifestyle modifications, treatment of associated medical conditions, and switching to alternative drugs with lower risk of ED. In certain cases, an etiologic treatment may be performed (sex therapy, revascularization surgery, and hormonal therapy). Most patients with ED will benefit from symptomatic treatments; first-line therapy may be prescribed by physicians who are not specialists in ED, and includes oral agents such as inhibitors of phosphodiesterase type 5, currently considered the drugs of choice for initial treatment of ED. Intracavernous drugs are the second-line therapy, and surgical treatments, such as implantation of penile prostheses, are reserved for urologists/andrologists who specialize in ED. Referral may be appropriate where indicated by age, clinical findings, or the patient's request.

Spermatozoa selection in discontinuous Percoll gradients for use in artificial insemination.

In a preliminary study of the ejaculate of 93 men, changes in motility and hypo-osmotic swelling before and after sperm separation by discontinuous Percoll gradients were evaluated. Both parameters improved significantly (P less than 0.01) in Percoll-separated spermatozoa. In a second stage, 99 couples underwent intrauterine insemination of separated semen by Percoll gradients. The population had infertility for a mean of 5.6 years. In a 1-year period, a total of 344 intrauterine insemination cycles were completed. Failure was considered when conception did not occur within four treatment cycles. The mean number of cycles per successful couple before pregnancy was 1.52. An overall 21% pregnancy rate was achieved (16% for oligoasthenospermia and 24% for asthenospermia). Sperm separation in Percoll gradients is a useful technique for intrauterine insemination in some cases of male subfertility.

[TESE-ICSI in the treatment of secretory azoospermia secondary to cryptorchism. Report of a clinical case]. / TESE-ICSI nel trattamento della azoospermia secretoria secondaria a criptorchidismo. Descrizione di un caso clinico.

The pathogenic role of cryptorchism in male infertility is still controversial. To report a case of a 34-year-old patient consulted for primary infertility with a history of 2 years associated with prepubertal bilateral orchidopexy for cryptorchidism. The fertility studies demonstrated azoospermia and normal sperm volume. Testicular sperm extraction (TESE) and intracytoplasmic sperm injection (ICSI) were performed with success. Cryptorchism can cause primary obstructive infertility. Testicular sperm aspiration (TESA) is an alternative when spermatogenesis is preserved. In this patient TESE-ICSI was performed with success.

Role of the urological surgeon in the age of intracytoplasmic sperm injection.

In the last few years, it has been demonstrated that intracytoplasmic sperm injection is an effective procedure for treating patients with severe male infertility. Before this technique was available, the urological surgeon involved in the reproduction field dealt mainly with reconstructive (vasoepididimostomy, vasovasostomy) or endoscopic surgery of the seminal duct as well as varicocelectomy. Nowadays, the urological surgeon continues to participate in the field of reproductive surgery by applying methodologies which enable natural conception, and has to be involved in all aspects of sperm retrieval techniques.

A new device for microsurgical sperm aspiration.

A new device for microsurgical aspiration of seminal fluid is presented. It is simple to use, flexible, and watertight, allowing maximum retrieval of seminal fluid.

Clinical experience with apomorphine hydrochloride: the first 107 patients.

PURPOSE: We assessed the efficacy and safety of apomorphine hydrochloride in patients with erectile dysfunction. MATERIALS AND METHODS: A total of 107 patients who had consultations because of erectile dysfunction between July and November 2001 were assessed. The sample was randomly selected. RESULTS: Response to apomorphine hydrochloride was assessed in 107 patients complaining of erectile dysfunction, randomly selected at the office. With the 2 mg initial dose the response amounted to 23.5%, with 3 mg it amounted to 28.5% and the global response to the drug amounted to 26.1%. Positive response was obtained in 18.5% of those in whom the dose was increased from 2 to 3 mg. Obtaining an erection with enough rigidity to enable coitus satisfactory for the patient was accepted as a positive response. According to the clinical presentation of the erectile dysfunction, the highest efficacy was found in those cases with early detumescence, and the lowest one in those cases with complete affection. The overall incidence of adverse effects was 8.4%, with nausea being the most frequently reported. CONCLUSIONS: Apomorphine hydrochloride is the first central action erection inducing drug. Its use is encouraged by high tolerability, low rate of adverse effects and virtually nonexistent interaction with other drugs usually administered to patients with erectile dysfunction.

[Prolonged erections after diagnostic injection of papaverine chlorhydrate]. / Erecciones prolongadas tras inyección diagnóstica de clorhidrato de papaverina.

We analyzed the incidence of prolonged erection (PE) in 495 impotent subjects following intracavernous papaverine chlorhydrate injection to evaluate sexual dysfunction. Patient course was individually assessed. The overall the incidence of PE was 5.05%. The etiology of sexual dysfunction was psychogenic in all cases. No evidence of dose- or age-related PE was observed. Fibrosis of the corpus cavernosum, although more prevalent in PEs greater than 6 hours, was also observed in PEs of a shorter duration. This suggests that a probable predisposing factor might previously be present in some patients. None of the different methods utilized to achieve penile detumescence appears to afford any significant advantage.

[Acceptability of auto-injection of vasoactive drugs in the treatment of erectile dysfunction]. / Aceptabilidad del autoinyector con fármacos vasoactivos en el tratamiento de la disfunción eréctil.

OBJECTIVES: To study the utility of the PenInject 2.25 (SHL Medical AB), an instrument for intracavernous auto-injection of vasoactive drugs. METHODS: 61 males, aged 30-70 years, with erectile dysfunction were studied. The study comprised two groups: group A consisted of 26 patients previously treated with intracavernous injections using a syringe that were started on treatment with the self-injector, and group B consisted of 35 previously untreated patients that started treatment directly with the self-injector. Different data and questions on the facility of use and acceptance of the instrument were analyzed. Data evaluation were plotted on visual analog scales of 10 cm. A score of 5 or more showed good results and less than 5 was considered unfavorable. RESULTS: The positive aspects were facility of use, comfort, design of the self-injector, which scored higher than 7. The negative aspects were pain, fear, discomfort intensity, which scored below 4. CONCLUSIONS: The use of the PenInject self-injector in this group of patients improved the acceptability of intracavernous therapy for erectile dysfunction in comparison to the classical syringe.

[Response to intracavernous administration of 3 different drugs in the same group of patients with erectile dysfunction]. / Respuesta a la administración intracavernosa de tres fármacos diferentes en el mismo grupo de pacientes con disfunción eréctil.

OBJECTIVE: To compare the subjective and objective penile rigidity in the same group of patients with erectile dysfunction after intracavernous injection of different vasoactive drugs. METHODS: 91 impotent males were randomly assigned to three groups of intracavernous injection: A: 20 micrograms PGE1 B: 30 mg papaverine hydrochloride + 1 mg phentolamine (bimix), and C: 10 micrograms PGE1 + 15 mg papaverine hydrochloride + 0.5 mg phentolamine (trimix). Each patient was scheduled to receive the three modalities of intracavernous injection randomly with an interval of 7-10 days between injections. Penile rigidity equal to or more than 60% was considered positive. Subjective and objective penile rigidity were evaluated with callipers by the same observer. RESULTS: 82 patients completed the study and 9 dropped out after prolonged erection with one of the ICI modalities. Rigidity after treatment with C (66 +/- 15%) was significantly superior to that of B (59 +/- 15%, p = 0.0001) and A (60 +/- 13%, p = 0.0115). No differences were observed between A and B (p = 0.4644). Analysis of only the positive response showed significant differences between A and C, but not between C and B (p = 0.3323). Differences were not found between the response to PGE1 (A) and bimix (B) (p = 0.1275). The order of application of the drug had no effect on response (p = 0.026). CONCLUSIONS: A higher percentage of positive response in patients with erectile dysfunction was achieved with the trimix modality. Choice of more potent ICI regimens can improve the diagnostic and/or therapeutic efficacy in males that do not respond to PGE1 alone.

Cavernositis following intracavernous injection of vasoactive drugs.

Intracavernous injection is one of the most common treatments of erectile dysfunction. Infectious complications are rare, but hazardous. We report the case of a 44-year-old to stress the importance of patient supervision and drug prescription.

Meiotic chromosome studies and synaptonemal complex analyses by light and electron microscopy in 47 infertile or sterile males.

Mitotic and meiotic chromosome studies and synaptonemal complex analyses by light and electron microscopy have been carried out in a selected series of 47 infertile or sterile males with highly abnormal seminograms, affecting the number of spermatozoa, their morphology and/or motility. In 46 cases, the karyotype was 46,XY. One patient had a 13/14 translocation. With the exception of the patient with a 13/14 translocation, and three patients with desynapsis (8.5%), all other cases showed either normal or absent metaphase I figures. However, synaptonemal complex analysis by light and electron microscopy demonstrated the presence of pairing anomalies (desynapsis, fragmented or irregular synaptonemal complexes) in 31.9% of the patients studied. The total number of synaptic anomalies observed (40.4%) is higher than in a former light microscopy study of 111 infertile or sterile patients (28.8%) probably because the higher resolution of the electron microscope permits the characterization of some anomalies that cannot be detected with the light microscope. The electron microscope should therefore be used in all cases in which the light microscope provides doubtful results.

A new synaptic anomaly: irregular synaptonemal complexes.

In this paper we describe a new synaptic anomaly characterized by the presence of irregular synaptonemal complexes (SCs) in two sterile patients.