[Practical recommendations for the management of testosterone deficiency]. / Recommandations pratiques pour la prise en charge du déficit en testostérone.

OBJECTIVES: The Francophone Society of Sexual Medicine (SFMS) and the Andrology and Sexual Medicine Committee (CAMS) of the French Association of Urology (AFU) have brought together a panel of experts to develop French recommendations for the management of testosterone deficiency (TD). METHODS: Systematic review of the literature between 01/2000 and 07/2019. Use of the method of recommendations for clinical practice (RPC) and the AGREE II grid. RESULTS: TD is defined as the association of clinical signs and symptoms suggestive of TD with a decrease in testosterone levels or serum androgen activity. Diagnosis requires a T lower than the reference values in young men on 2 successive assays. Sexual disorders are often at the forefront, and concern the whole male sexual function (desire, arousal, pleasure and orgasm). The most evocative symptoms are: decrease in sexual desire, disappearance of nocturnal erections, fatigue, loss of muscle strength. Overweight, depressed mood, anxiety, irritability and malaise are also frequently found. TD is more common in cases of metabolic, cardiovascular, chronic, andrological diseases, and in cases of corticosteroid, opioid, antipsychotic, anticonvulsant, antiretroviral, or cancer treatment. Since SHBG is frequently abnormal, we recommend that free or bioavailable T is preferred over total T. The treatment of TD requires a prior clinical (DRE, breast examination) and biological (PSA, CBC) assessment. Contraindications to T treatment are: progressive prostate or breast cancer, severe heart failure or recent cardiovascular event, polycytemia, complicated BPH, paternity project. It is possible in cases of sleep apnea syndrome, psychiatric history, stable heart disease, prostate cancer under active surveillance and after one year of complete remission of a low or intermediate risk localized prostate cancer treated in a curative manner. It includes long-term testosterone supplementation and life-style counseling. Treatment is monitored at 3, 6, 12 months and annually thereafter. It is clinical (annual DRE) and biological (total T, PSA, CBC), the most frequent side effect being polyglobulia. CONCLUSION: These recommendations should help improve the management of TD.

[An overview of the management of erectile disorders]. / Historique de la prise en charge des troubles de l'érection.

The large successive studies on the treatment of erectile disorders started with local injections of papaverine in 1982, followed by the marketing of intracavernous injections of alprostadil in 1994 and, in 1998, sildenafil, the first type 5 phosphodiesterase inhibitor. An efficient alternative to improve the quality and duration of an erection is presently represented by intra-cavernous injections of alprostadil alfadex when oral treatments are insufficient, inefficient or contraindicated.

[Erectile dysfunction in the case of cardiovascular disease]. / Dysfonction érectile en cas de pathologie cardiovasculaire.

Erectile dysfunction is frequent in those suffering from heart disease. It could be a good marker of an intra-clinical arterial disease. From a therapeutical point of view, intracavernous injections of PGE1 are efficient and safe second line in the treatment of erectile dysfunction in the cardiac population, whatever the origin. No drug interactions with the various treatment used in cardiology, notably derived nitrates, has been reported. Management of erectile dysfunction helps to reinforce patients' adherence to their other treatments.

[The opinion of patients treated with intracavernous injections: the EASY survey]. / Point de vue des patients traités par injections intra-caverneuses: l'enquête EASY.

The primary objective of the EASY survey (Evaluation de l'Acceptation deS injections dans la dYsfonction érectile) was to study the feelings of patients treated for erectile disorders with long-term intracavernous injections of prostaglandin E1. The major criteria for abandoning treatment with IPDE 5 are, in descending order, inefficacy, cost and poor tolerance. Regarding the results with intracavernous injections of Edex, around 80% of patients were satisfied; 70 to 80% of those treated for risk factors and/or cardiovascular or neurological diseases and 55% of those treated following cancer of the prostate claimed that their sex life had improved.

[Squirting and female ejaculation in 2015?]. / Que sait-on des femmes fontaines et de l'éjaculation féminine en 2015?

Since Antiquity, women who expulse a large quantity of liquid during sexual stimulation have remained a mystery. This phenomena is usually called "squirting". Many physicians have proposed different explications, however, there are very few scientific publications and their conclusions are discordant. Today, squirting is fashionable in the media, and some recent studies have brought new information. Through medical publications, we present the conclusions concerning the origin and the nature of squirting, the psychological experience of these squirting women and the feelings of their partners.

[Endoscopic study of reflux of the saphenous valve]. / Etude endoscopique des reflux valvulaires saphéniens.

Saphenous venous endoscopy, invasive and non-physiological, enables the in vivo and in situ observation of the valve system. A saphenous vein has a preferential flattening axis parallel to the outside of the skin with two walls, internal and external, and two borders. A valve is inserted on one vein wall, with the valve horns being on the borders. The free borders of a bivalve are parallel with the surface of the skin. The valve system has an antireflux function. There are three main causes of reflux in the saphenous veins: 1. Transitory functional incompetence affecting valves of normal appearance. This incompetence results from valve inertia, flattening of the valve against the sinus wall and loss of co-adaptation. Do active factors producing closure of the valve cup exist against such transitory incompetence? 2. Incongruity between the vein wall and valves. The intercorneal or commissural space allows reflux on the border of the vein. This is the commonest cause of reflux in varicose disease of the vein wall. 3. Actual valve lesions. A distinction is drawn between lesions due to thinning, elongation, stretching, splitting or tearing and those due to thickening, retraction or adhesion. Endoscopy has enabled us to discover cases of varicose disease with predominantly valvular lesions in young individuales in whom early lesions of the valve cup cannot be explained by venous wall disease and has led us to complete the classification of varicose disorders.

[Modification of the level of adenosine triphosphate in digital pulp capillary blood in patients with microcirculatory disorders following i.v. injection of coenzyme A (CoA 1000)]. / Modification du taux d'adénosine tri-phosphate (ATP) dans le sang capillaire prélevé au niveau de la pulpe digitale, dans les troubles de la microcirculation, après injection i.v. de coenzyme A (CoA 1000).

Capillary blood ATP assay was performed in 2 groups of patients (diabetic and non-diabetic) with disorders of microcirculation, before and several minutes after 2 mg I.V. of Coenzyme A (CoA 1000). Values obtained showed a significant increase in both groups. The hypothesis advanced, based on previous experimental data indicating an action of CoA on intracellular calcium movement, is that CoA 1000 acts by elevation of the membrane ATP/Ca+ ratio of red corpuscles, and possible activation of their deformability and flow rate in the microcirculation.

[Venous endoscopy]. / Endoscopie veineuse.

The miniaturization of endoscopic equipment now allows exploring the superficial venous system and visualizing the endovein in situ and in vivo. This type of venous endoscopy is an ambulatory procedure, performed during a simple outpatient consultation of angiology, after which the patient is immediately discharged. Although this examination is invasive, non-physiological and expensive, it allows the video recording of the morphology, dynamics and kinetics of the values, of the endovein and of the liquid flows (blood, washing fluid and sclerosing products). The new examination has already enabled us to propose an functional classification of the parietal valves of the great saphenous vein. It makes an intraoperative three-dimensional mapping of the vessels possible, which is sometimes difficult in such particular anatomical regions as the popliteal fossa. It allows performing sclerosis with a visual control and following up the evolution of the immediate endoparietal lesions in situ.

[Maxillary cyst of dental origin with uncommon ocular complication]. / A propos d'un kyste maxillaire d'origine dentaire avec complication oculaire inhabituelle.

A 23-year-old woman was referred for decreased vision and central scotoma. Fundus examination disclosed unilateral acute oedematous optic neuritis. A nasolabial cyst was diagnosed, probably of dental origin, because numerous apical granuloma were noticed. The abscess did not produce any fistula which explained the absence of clinical and radiological dental sinusitis. Treatment included excision of the nasolabial cyst and systemic antibiotics. The prognosis was excellent with recovery of a normal visual acuity and normal fundus appearance. There was no evidence of any recurrent episode. The nasolabial cyst was the cause likely of the neuritis. Nevertheless, multiple sclerosis must be considered. Only long-term absence of neurological signs could prove that the maxillary lesion was directly responsible for the optic disorder.

[Results and indications of curietherapy of the eustachian tube with iridium 192 in chronic otitis in the adult]. / Résultats et indications de la curiethérapie de la trompe d'eustache à l'iridium 192 dans l'otite chronique de l'adulte.

Between January 1985 and January 1988, 56 patients received radioactive implant therapy of the Eustachian tube with Iridium 192 in the context of tympanoplasty for chronic otitis with tubal dysfunction. After reviewing the method used, we present the results by category of chronic otitis and attempt to propose its indications. Tubal dysfunction was assessed on clinical and otoscopic data and tubal manometry in each patient. A randomised study would appear to be necessary to confirm the interesting results obtained in chronic mucous otitis, in the sequelae of chronic otitis, in evolving retraction pockets and finally for certain manifestly discharging cavities.

[Sexual disorders after radical prostatectomy and their treatment. Psychological aspects]. / Les troubles sexuels après prostatectomie radicale et leurs traitements. Aspects psychologiques.

Forty-one men who had undergone radical prostatectomy and their wives were interviewed in order to evaluate the erectile disorders encountered after this operation and to facilitate therapeutic impact. Twenty-three of the women stated they were satisfied with their sexual intercourse before the operation and among them, 16 (70%) stated they were unsatisfied after their husband's operation. Among these 16 couples, 10 accepted sexual counselling which led to satisfaction with sexual intercourse in 8 couples. Sexual counselling was the only therapy needed in 1 couple, 4 men received intracavernous injections and 3 used a vacuum system. These results, as well as the impact of integrating the sexual partner in the treatment protocol for erectile impairment were discussed.

[Prostaglandin E1 in the treatment of erectile insufficiency. Comparison of efficacy and tolerance based on different etiologies]. / Prostaglandine E1 dans le traitement de l'insuffisance érectile. Efficacité et tolérance comparées selon différentes étiologies.

Prostaglandin E1 (PGE1) is widely used for the treatment of impotence. We retrospectively studied 322 patients who had received injection of prostaglandin E1 from 1991 to 1993 and attempted to divide them into different subgroups as a function of the aetiology of the impotence in order to determine whether there is a difference in efficacy and tolerance. The complete work up included at least two consultations with a sex therapist, a pharmaco-Doppler examination, cavernometry, plethysmography of the nocturnal erections and blood chemistry with assay of the free testosterone in all patients. Erections compatible with penetration were observed after prostaglandin E1 injection in 85.4% of the patients (all aetiologies). Very favourable results were obtained in the group of patients with an arterial defect (n =36) since erections allowing intercourse were obtained in 83.3%. For the patients with occlusive venous dysfunction (cavernous leakage) (n = 35) the injections were less effective but led to satisfactory results in 74.3%. The results were excellent (94.7%) in the cases of psychogenic impotence (n = 113). Finally, in patients with diabetes related impotence (n = 21), the treatment was much less effective giving only 52.3% of positive results. In several cases (n = 151) we were able to compare the effectiveness of PGE1 with that of papaverine alpha blockers. For the patients with an arterial defect, PGE1 was slightly more effective. For patients with an occlusive venous dysfunction, PGE1 was always more effective than papaverine and finally, for patients with diabetes, the papaverine-alpha blocker combination was more effective than PGE1 in all cases.(ABSTRACT TRUNCATED AT 250 WORDS)

[Capillaroscopy and wound healing]. / Capillaroscopie et cicatrisation.

Capillaroscopy is a very simple examination which allows good evaluation of the superficial micro-circulation of the skin. The authors consider that this new examination constitute a method to evaluate the risks of skin necrosis after facelift and abdominoplasty and, may possibly change the strategy of operations.

[Sclerotherapy of the external saphenous vein under endoscopic control]. / Sclérose de la saphène externe sous controle endoscopique.

The contribution of investigative venous endoscopy is essential. This out-patient endoscopic technique visualises the venous endothelium, valve systems and collaterals. For example, this technique enabled J.F. Van Cleef and C. Ribreau to draw up an anatomo-physiological classification of the parietal valves of the long saphenous vein on the basis of video films. From a therapeutic standpoint, venous endoscopy has yet to show its value. We chose the short saphenous since treatment of incontinence of this vessel is difficult and controversial: difficult because of anatomical variations, notably its ending and because of its course in the popliteal fossa; controversial because of its relations with the gemellary veins. Treatment of the short saphenous, whether medical or surgical, is not always entirely satisfactory. In case of surgical treatment, together with J.P. Hugentobler, we had already noted the value of three-dimensional localisation by transcutaneous illumination of the precise course of a vein using the cold light of the distal tip of the endoscope. "Venous ligatures" which can be placed intravenously are not currently available. In case of medical treatment by sclerosing injections of the short saphenous junction under endoscopic control, the product used can be injected with great topographical precision and strictly intravenously. Large amounts of product can easily be injected. However, this technique has at least three disadvantages: it is expensive; there is no parallel between endovenous lesions immediately visible by endoscopy and the mid-term results of sclerosing injections; the relations between the gemellary veins and the short saphenous can be identified precisely only by prior ultrasonography. As a result, sclerosing injections under endoscopic control remain within the domain of research.

[Curietherapy of the Eustachian tube using Ir-192 in chronic otitis of tubal origin]. / Plésiocuriethérapie de la trompe d'Eustache par iridium 192 dans les otites chroniques d'origine tubaire.

Failure of chronic otitis surgery, especially tympanoplasty, are mainly related to Eustachian tube dysfunction. A new technique of anti-inflammatory irradiation of the Eustachian tube was designed in 1985 in Créteil to improve the Eustachian tube function. The Eustachian tube is catheterized during the tympanoplasty using a plastic tube, 1.6 mm in diameter; this tube is closed at the external end. The other end of the tube is open and goes through the opposite nasal cavity. The plastic tube is loaded 24 h later with a 4.5 cm long irridium 192 wire to deliver a dose of 3 Gy on the reference isodose, 4 mm in diameter, in approximately 3 h. The tube is then gently withdrawn through the nasal cavity. Seventy-four patients, 16 years old or more, took part in the study. The method was performed successfully in 62 patients. Fifty-six patients were followed up; mean follow-up was more than 20 months. The follow-up assessment included otoscopy, audiometry, impedancemetry and residual Rinne measurement. Otoscopy results were adequate in 86% of patients. Hearing was improved in 44% of patients. Impedancemetry was adequate in 70% of patients and residual Rinne lower than 20 dB in 56%. These results are better if compared with those of a series of 30 tympanoplasties performed without intracavitary irradiation in 1984: the tympanoplasty failure rate then was 73%. In conclusion, this new procedure proved to be safe and simple and led to an improvement of the functional results of complex tympanoplasty.

[Hormones and venous system]. / Hormones et système veineux.

Sex hormones have an effect on venous "content" and "container" according to their chemical nature, their dosage and their mode of administration: 17 beta-estradiol (endogenous): protective effect; synthetic estrogens, at normal or low doses: thrombogenic; oral natural estrogens: thrombogenic; extra-digestive natural estrogens: non thrombogenic; non steroid progestagens (androgenic): thrombogenic; non androgenic progestagens: non thrombogenic. Clinically, the venous disease si characterized by sudden episodes occurring at key-periods of the hormonal life: puberty, pregnancy, menopause, oral contraceptives intake, substitute treatments of menopause, premenstrual syndrome. Evaluation of these different situations shows that an early treatment is possible and needed, which, although not providing a new venous wall for these constitutionally fragile patients, may act effectively at two levels: 1) correction of the haemodynamic disorder (venous reflux in the saphenous arches and the perforators; 2) resorption of tissue infiltration. As primary prevention, in a patient with hormonal disorders or who must be treated with estrogens or progestagens, the objective of our treatment is to protect the venous wall and encourage the return circulation. One must: 1) reinforce the vaso-constrictive effect and the parietal tone, 2) limit collagen and elastin alteration, 3) reinforce capillary permeability and decrease the interstitial edema, 4) normalize the haemorheological constants, 5) restore the balance hemostasis-fibrinolysis. The opinion of a phlebologist seems essential before prescribing a hormonal treatment and monitoring the effects of the treatment. Cooperation between gynaecologists and phlebologists is particularly essential in the interpretation of the clinical disorders as well as discussing the venous risk, the dosage and the administration route of sex hormones.

Efficacy and safety of transurethral alprostadil therapy in men with erectile dysfunction. MUSE Study Group.

OBJECTIVE: To examine the safety and efficacy of transurethral pharmacotherapy for erectile dysfunction, involving the use of a novel therapeutic system to administer alprostadil (prostaglandin E1) to the urethral mucosa in a double-blind, randomized, parallel, placebo-controlled study conducted in five countries in Europe. PATIENTS AND METHODS: In an outpatient setting, patients with primarily organic erectile dysfunction of at least 3 months' duration were treated with transurethral alprostadil, in an open-label, dose-escalating study. Testing stopped when the dose provided an erection sufficient for intercourse, as assessed by the patient and the investigator. Patients who achieved a sufficient response were then randomized to either active medication at the selected dose or to placebo for use at home for 3 months. After each home administration, patients recorded in diaries whether or not sexual intercourse occurred and any adverse reactions to the drug. RESULTS: A total of 249 patients were treated in an outpatient setting; of these patients, 159 (64%) achieved an erection sufficient for intercourse and were randomized (1:1) to either active medication or placebo for home treatment. Of the patients randomized to alprostadil for home treatment, 69% reported intercourse at least once, compared with 11% of patients randomized to placebo (P < 0.001). The most common adverse reaction, urethral pain/burning, was reported by 7% of patients in the clinic. Most patients (83%) graded transurethral alprostadil as causing minimal or no discomfort in the clinic. No patient reported priapism or developed penile fibrosis. CONCLUSION: Alprostadil delivered transurethrally by this system was well tolerated and effective in treating erectile dysfunction.

The effect of transurethral alprostadil on the quality of life of men with erectile dysfunction, and their partners. MUSE Study Group.

OBJECTIVE: To evaluate the impact of treatment for erectile dysfunction on the quality of life of men and their partners. PATIENTS AND METHODS: The study included 249 men with organic erectile dysfunction of more than 3 months' duration who self-administered transurethral alprostadil in an open-label, dose-escalating manner in an outpatient medical setting. Patients with a sufficient response (159) were randomly assigned in a double-blind protocol to either active medication or placebo for 3 months at home. Patients and partners each completed quality-of-life questionnaires before and after treatment. RESULTS: In the clinic 159 of the 249 men (64%) had an erection sufficient for intercourse when using transurethral alprostadil. At home, 46 of 67 men (69%) reported intercourse at least once on transurethral alprostadil, compared with eight of 73 (11%) on placebo (P < 0.001). Patients on alprostadil showed a 34% improvement in their 'relationship with partner', a 5% improvement in 'personal wellness', and a 71% improvement in 'quality of erection' domains, compared with a decline of 11%, 8% and 1%, respectively, in patients on placebo (P < 0.005 for each comparison). Partners of patients on alprostadil showed a 35% improvement in the 'relationship with partner' domain, compared with a 12% improvement in the placebo group (P = 0.028). There was a trend toward improvement in other partner domains. Urogenital pain was reported by 14% of patients during home treatment. CONCLUSION: The resumption of sexual intercourse with the use of transurethral alprostadil was accompanied by an improvement in several important quality-of-life domains in patients and their partners.