Early use of vacuum constriction device following radical prostatectomy facilitates early sexual activity and potentially earlier return of erectile function.

To assess the efficacy of vacuum constriction devices (VCD) following radical prostatectomy (RP) and determine whether early use of VCD facilitates early sexual activity and potentially earlier return of erectile function. This prospective study consisted of 109 patients who underwent nerve-sparing (NS) or non-nerve-sparing (NNS) RP between August 1999 and October 2001 and developed erectile dysfunction following surgery. The patients were randomized to VCD use daily for 9 months (Group 1, N=74) or observation without any erectogenic treatment (Group 2, N=35). Treatment efficacy was analyzed by responses to the Sexual Health Inventory of Men (SHIM) (abridged 5-item International Index of Erectile Function (IIEF-5)), which were stratified by the NS status. Patient outcome regarding compliance, change in penile length, return of natural erection, and ability for vaginal intercourse were also assessed. The mean patient age was 58.2 years, and the minimum follow-up was 9 months. Use of VCD began at an average of 3.9 weeks after RP. In Group 1, 80% (60/74) successfully used their VCD with a constriction ring for vaginal intercourse at a frequency of twice/week with an overall spousal satisfaction rate of 55% (33/60). In all, 19 of these 60 patients (32%) reported return of natural erections at 9 months, with 10/60 (17%) having erections sufficient for vaginal intercourse. The abridged IIEF-5 score significantly increased after VCD use in both the NS and NNS groups. After a mean use of 3 months, 14/74 (18%) discontinued treatment. In Group 2, 37% (13/35) of patients regained spontaneous erections at a minimum follow-up of 9 months after surgery. However, only four of these patients (29%) had erections sufficient for successful vaginal intercourse and rest of patients (71%) sought adjuvant treatment. Of the 60 successful users, 14 (23%) reported a decrease in penile length and circumference at 9 months (range, 4-8 months) compared to 12/14 (85%) among the nonresponders. However, in control group 22/35 reported decrease in penile length and circumference. Early use of VCD following RP facilitates early sexual intercourse, early patient/spousal sexual satisfaction, and potentially an earlier return of natural erections sufficient for vaginal penetration.

Experience with Jonas malleable penile prosthesis.

Experience with the use of the Jonas penile prosthesis in 69 patients is presented, and the implantation of this prosthesis through a penoscrotal incision is described. Use of this prosthesis generally allows the penis to hang in a dependent position or to project outward from the body when coitus is desired. A malleable prosthesis such as the Jonas also has an additional advantage when it is used for treatment of impotence due to Peyronie disease, since its implantation allows the penis to be straightened without performing a simultaneous corporoplasty.

Intracavernous injections of papaverine and phentolamine: correlation with penile brachial index.

Eighty-two patients were evaluated for erectile failure with a comprehensive history, physical examination, hormonal testing, noninvasive Doppler examination (PBI), and nocturnal penile tumescence (NPT). After these studies all patients received intracavernous injection with a combination of papaverine (50 mg) and phentolamine (1.66 mg), and both tumescence and rigidity were monitored. Rigidity response was compared with the PBI. The number of patients with a poor rigidity response in each PBI category were: 3 of 5 with a PBI of less than 0.6 (vasculogenic), 7 of 11 with a PBI of 0.6-0.75 (ambiguous), and 25 of 66 with a PBI of 0.75-1.0 (normal). These results indicate only a marginally significant association between PBI and intracavernous injection. The procedure was safe with no long-term sequelae from injection observed, and no surgical intervention was required. Complications of injections included reversible priapism in 11 patients (13.4%), transient dizziness in 10 patients (12.2%), and hematoma in 5 patients (6.2%). This study suggests that intracavernous injection with a drug combination may be a more sensitive screening test for vasculogenic impotence than noninvasive Doppler studies because it more closely simulates the erectile response.

Accessory urethral channel communicating with the seminal vesicle.

A rare variety of accessory urethra communicating with the left seminal vesicle is reported. Communication was demonstrated between the prostatic urticle and the right seminal vesicle, but not the left. Infection of the accessory channel was managed conservatively with antibacterial therapy. The classification, diagnosis, and treatment for this anomaly are discussed.

Psychogenic urinary retention.

Six cases (5 females and 1 male) of unexplained urinary retention are reported. The diagnosis of psychogenic urinary retention was considered after negative medical, urologic, urodynamic, and neurologic evaluations. This diagnosis was then confirmed by psychiatric consultation. Urinary retention was managed by combining biofeedback-monitored relaxation and specific imagery techniques with intermittent self-catheterization on a fixed schedule. Psychotherapy, pharmacotherapy, and behavior therapy were also utilized with good to excellent short-term results.

Routine endocrine screening in impotence.

Routine hormonal screening (serum testosterone and prolactin) of 300 men presenting with a primary complaint of impotence resulted in detection of endocrine dysfunction in 5 men (1.7%). Four patients had hypogonadism, and 1 patient had a prolactin-secreting pituitary adenoma. The cost of screening these men for endocrine dysfunction was $34,722.00. Despite this cost and the low yield of endocrine disease detection, routine determination of serum testosterone and prolactin provides useful information to the clinician evaluating impotent men and when abnormal, indicates the need for thorough endocrine evaluation.

Cost-effective evaluation of impotence.

Two hundred consecutive men presenting with a chief complaint of impotence have been evaluated with a protocol involving one or two outpatient visits. The initial evaluation for all patients consisted of a history taken in a conventional manner and supplemented by a patient-completed sexual function questionnaire, physical examination, serum testosterone and prolactin, and two-night nocturnal penile tumescence studies. Following the initial evaluation the patients were placed in one of three categories: (1) organic impotence, (2) functional impotence, (3) ambiguous impotence (mixed functional and organic impotence or organic impotence of undetermined etiology). Patients in the latter group underwent additional testing including penile vascular studies, two-hour oral glucose tolerance test, and psychiatric consultation. With this protocol, patients can be efficiently and effectively evaluated as outpatients with costs ranging from +250 to +450.

Endoscopic transurethral suspension of bladder neck and urethra. Experimental trials of new procedure in dogs.

An endoscopic, transurethral suspension of the female urethra and bladder neck is achieved by placing sutures through the anterior urethral wall up to the anterior abdominal fascia. The sutures are placed under direct endoscopic vision using a specially designed suture passer. In 8 female dogs a mean increase in urethral length of 1.81 cm (SEM 0.21 cm) was obtained immediately postoperatively. Reevaluation three months postoperatively demonstrated the mean increase to be 1.56 cm (SEM 0.11 cm). Cystoscopy and postmortem dissection demonstrated integrity of the repair in all 8 dogs. A clinical trial in stress incontinent women is suggested.

Erectile dysfunction in men with diabetes mellitus.

During a fourteen-month period, 497 men were evaluated for a primary complaint of erectile dysfunction. The initial evaluation consisted of a history taken in a conventional manner and supplemented by a patient-completed sexual function questionnaire, a physical examination, and serum testosterone, serum prolactin, and nocturnal penile tumescence studies. When appropriate, additional evaluations, including penile vascular studies, two-hour oral glucose tolerance tests, and psychiatric consultation were obtained. Abnormal glucose metabolism was present in 161 men (32%). Five men (1%) had insulin-dependent diabetes mellitus (IDDM), 80 men (16%) had noninsulin-dependent diabetes mellitus (NIDDM), 55 men (11.1%) had newly diagnosed noninsulin-dependent diabetes mellitus, and 21 men (4.2%) had impaired glucose tolerance tests. One hundred forty-seven of these men (91.3%) had organic pattern impotence, and 14 (8.7%) had psychogenic pattern impotence.

Primary erectile dysfunction in a man with congenital isolation of the corpora cavernosa.

We report on a 33-year-old man with primary erectile dysfunction, isolated cavernous bodies, corporeal veno-occlusive dysfunction, and hypoplastic cavernous arteries. To our knowledge, this is only the second reported case of absence of communication between the corpora cavernosa.

Efficacy of the vacuum constriction device in patients with corporeal venous occlusive dysfunction.

OBJECTIVES: The vacuum constriction device (VED) is an effective nonsurgical treatment for erectile dysfunction. Its efficacy in specific patient groups, however, has not been extensively studied. Only one study to date has examined the use of the VED in patients with corporeal veno-occlusive dysfunction (CVOD). This study used a mailed questionnaire and no statistical analysis of the data. The purpose of this study was to examine the efficacy of the VED in patients with documented CVOD. METHODS: From 1989 to 1992, 294 patients chose to use a VED as treatment for erectile dysfunction. All patients were evaluated with a thorough history and physical examination, hormonal testing, glucose tolerance testing, and nocturnal penile tumescence studies. Ninety-eight patients underwent additional vascular testing. When seen in follow-up, patients were asked to assess erection quality and overall satisfaction with the device. RESULTS: Fifty patients had documented CVOD (33 by cavernosometry, 16 by ultrasound, and 1 by cavernosography). Twenty-eight patients (56%) were satisfied, 13 patients (26%) were unsatisfied, and in 9 patients (18%) satisfaction could not be determined. Thirty-eight patients (76%) achieved an erection of at least 7 on a scale of 1 to 10. There was no relationship between the severity of disease (as measured by cavernosometry) and the rating of erection (Kruskal-Wallis test, P = 0.77) or satisfaction with the device (Fisher's exact test, P = 0.95). CONCLUSIONS: The VED is an acceptable nonsurgical treatment for patients with erectile dysfunction secondary to CVOD regardless of severity. Its success rate is comparable to other therapeutic modalities such as injection therapy.

Treatment of organic impotence with penile prosthesis in renal transplant patients.

Seven patients were identified who underwent both renal transplantation and penile prosthesis implantation at our institution between June 1980 and June 1990, and their charts were retrospectively reviewed. A total of nine penile prostheses were placed in these patients, five prior to transplantation and four following transplantation. One patient received two prostheses prior to transplantation. One patient received a prosthesis both before and after transplantation. No complications were seen in the four prostheses placed following transplantation with a follow-up of one to forty months (mean 18 months). Of the five prostheses placed prior to transplantation, two were removed due to periprosthetic infections, a cylinder leak developed in one, and one was complicated by penile and scrotal erythema with sepsis.

Diagnostic evaluation, classification, and treatment of men with sexual dysfunction.

During a two-year period, 165 men were evaluated for sexual dysfunction. Most evaluations were conducted on an outpatient basis and required two separate visits. Fifty-one per cent, 47 per cent, and 2 per cent of the patients were found to have functional disorders, organic disorders, and incomplete evaluations, respectively. Treatment recommendations were tailored to each patient using information gathered during the diagnostic evaluation.

Future considerations: advances in the surgical management of erectile dysfunction.

As treatment options for erectile dysfunction (ED) continue to expand, and with more attractive alternatives such as effective systemic treatment becoming available, the number of men presenting for treatment of ED is increasing exponentially. Since a subset of these men continue to require surgical therapy, there is a potential for the number of operations for the treatment of ED and related disorders to actually increase. Areas in the surgical treatment of ED where improvements are needed are identified, including: measures to prevent penile prosthesis infections, better penile implants, improved penile augmentation procedures, better surgical procedures for the treatment of Peyronie's disease, improved penile revascularization procedures, and new motor and sensory penile nerve grafting procedures. International Journal of Impotence Research (2000) 12, Suppl 4, S140-S143.

Cylinder sizing: less is more.

In penile prosthesis implantation traditional cylinder-sizing techniques frequently result in penile cylinders that are too long for the corpora cavernosa. This can result in premature cylinder wear leading to cylinder aneurysm or fluid loss. Additionally, in the case of the length expanding Ultrex penile prosthesis, cylinders that are too long can result in an S-shaped cylinder deformity. We describe a cylinder measurement technique that avoids the problem of oversizing.

Surgical approaches for penile prosthesis implantation: penoscrotal vs infrapubic.

Surgical approaches for implantation of three-piece inflatable penile prostheses include the infrapubic and the penoscrotal. The penoscrotal approach avoids possible injury to the dorsal sensory nerves, provides easier and more complete corporeal exposure, and allows the pump to be anchored in the scrotal pouch. A variant of the penoscrotal approach, the transverse penoscrotal incision, is described.

Penile prosthesis infections.

In this retrospective review we looked at infection rates and risk factors in penile prosthesis recipients. Computer registry records of patients implanted with three-piece inflatable prostheses from April 1986 to March 1999 were reviewed. Bacteriological culture report data were obtained from the medical records. There were 491 three-piece inflatable penile prosthesis recipients with follow-up ranging from 1 to 168 months (mean 83). All patients were implanted more than 1 y ago. There were 10 infections in 491 recipients (2.0%). In 285 primary prosthesis recipients there were seven infections (2.5%). In 206 secondary prosthesis recipients there were three infections (1.5%). Seven infections occurred in 354 non-diabetics (2.0%) and three infections occurred in 137 diabetics (2.2%). None of these differences were statistically significant. Explants for infection were performed in 8 weeks or less following implantation in eight patients. In two patients explants occurred at 17 and 26 months following implantation. Cultures from the periprosthetic space grew E. coli (four), Proteus mirabilis (two), Staph. aureus (two), and bacteroides (two). Infections occurred in 2.0% of three-piece inflatable penile prosthesis recipients. There were no statistically significant differences in infection rates between first time and repeat prosthesis recipients and between diabetic and non-diabetic recipients. Eight of the 10 infections occurred 8 weeks or less following implantation.

Long-term efficacy and compliance of intracorporeal (IC) injection for erectile dysfunction following radical prostatectomy: SHIM (IIEF-5) analysis.

Baseline and follow-up data from 102 patients using intracorporeal (IC) injection for erectile dysfunction (ED) following RP were retrospectively collected. We compared baseline International Index for Erectile Function (IIEF) questionnaires with the abridged IIEF-5 questionnaires, referred to as the Sexual Health Inventory of Men (SHIM) to determine drug efficacy. The mean presurgery SHIM score was 21.75+/-5.23, which decreased to 4.23+/-3.48 after surgery and increased to 19.46+/-8.78 post-treatment. Overall, 68% (69/102) of patients achieved and maintained erections sufficient for sexual intercourse and 48% (49/102) of patients continued long-term therapy with a mean use of 3.7+/-1.9 y. In all, 52% (53/102) patients discontinued IC therapy. However when excluding patients who switched to oral therapy, had loss of partner or return of normal erections; the compliance to IC injections was 70.6% (71/102). There was no difference in the SHIM analysis between the nerve sparing (NS) and the non-NS or between the types of medications used. IC injections can provide excellent long-term efficacy and compliance in up to 70% of the patients. This study suggests that IC injections are an excellent salvage option in NS patients who fail oral therapy and a first option in patients with non-NS procedures.

Report of the American Foundation for Urologic Disease (AFUD) Thought Leader Panel for evaluation and treatment of priapism.

PURPOSE: Patients with priapism often develop permanent erectile dysfunction and personal sexual distress. This report is intended to help educate the public by reviewing the varied definitions and classifications of priapism and limited literature reports of pathophysiology, diagnosis and treatment outcomes of priapism. The AUA priapism guidelines committee is responsible for creating consensus as to appropriate individual patient management of priapism by physicians. MATERIALS AND METHODS: A multidisciplinary panel, consisting of 19 thought leaders in priapism, was convened by the Sexual Function Health Council of the American Foundation for Urologic Disease to address pertinent issues concerning the role of the urologist, primary care providers and other health care professionals in the education of the public regarding management of men with priapism. The panel utilized a modified Delphi method and built upon the peer review literature on priapism. RESULTS: The Thought Leader Panel recommended adoption of the definition of priapism as a pathological condition of a penile erection that persists beyond or is unrelated to sexual stimulation. Priapism is stressed to be an important medical condition that requires evaluation and may require emergency management. The classification system is categorized into ischemic and non-ischemic priapism. Essential elements of the ischemic classification are the inclusion of: (i) clinical characteristics of pain and rigidity; (ii) diagnostic characteristics of absence of cavernosal arterial blood flow; (iii) pathophysiological characteristics of a closed compartment syndrome; (iv) a time limit of 4 h prior to emergent medical care; and (v) a description of the potential consequences of delayed treatment. Essential elements of the non-ischemic classification are the inclusion of: (i) clinical characteristics of absence of pain and presence of partial rigidity; (ii) diagnostic and pathophysiological characteristics of unregulated cavernosal arterial inflow; and (iii) the need for evaluation but emphasizing the lack of a medical emergency. The panel recommended adoption of a rational management algorithm for the assessment and treatment of priapism where the cornerstone of initial assessment includes a careful clinical history, a focused physical examination and selected laboratory and/or radiologic tests. The panel recommended that specific criteria and clinical profiles requiring specialist referral should be identified. The panel further recommended that patient (and partner) needs and education concerning priapism should be addressed prior to therapeutic intervention, however only in the case of chronic management or post acute presentation evaluation should this delay intervention. Treatment goals to be discussed include management of the priapism with concomitant prevention of permanent and irreversible erectile dysfunction and associated psychosocial consequences. The panel recommended that when specific therapies for priapism are required, a step-care treatment approach based upon reversibility and invasiveness should be followed. CONCLUSIONS: The Thought Leader Panel calls for research to expand our understanding of the prevalence and diagnosis of priapism and education to create awareness among the public of the potential urgency of this condition. Critical areas to be addressed include the multiple pathophysiologies of priapism as well as multi-institutional trials to objectively assess safety and efficacy in the various treatment modalities.

Penile prostheses. An overview.

Penile prosthesis implantation in selected patients can achieve very gratifying results. Satisfactory surgical results can be obtained in a high percentage of cases, and if the patient and his partner are well informed preoperatively, patient and partner satisfaction can also be very good.