Evaluation of a progressive treatment program for erectile dysfunction in patients with diabetes mellitus.

The aim was to evaluate the effectiveness of a progressive program, starting with simple methods and, when not effective, moving to more complex methods, to treat erectile dysfunction (ED) in patients with diabetes mellitus. A total of 284 diabetic patients with ED entered into a 6-phase program starting with sildenafil citrate (Viagra). Those with contraindications, side effects, or negative response (erection insufficient for vaginal penetration) were switched to the vacuum erection device (VED), and then progressively (for failures) to intracavernous injection (ICI), sildenafil citrate+ICI, ICI+VED, and penile prosthesis. Patients were followed for 2 y. Of the 284 patients 276 patients were eligible for sildenafil citrate and 147 (53.3%) responded positively, but 25 (9.1%) patients stopped it soon due to adverse effects. Of 162 patients (129 nonresponders, eight noneligible for the sildenafil and 25 patients who dropped out due to adverse effects), treated with VED, 114 (70.4%) responded well, however, only 19 (11.7%) patients agreed to continue its use. Of the remaining 143 patients (nonresponders, noneligible for the previously mentioned treatments and patients who dropped out due to adverse effects), 103/143 (72%) responded to ICI, 27/40 (67.5%) to sildenafil+ICI, and 9/13 (69.2%) to ICI+VED. Four patients received a penile implant. At the 2 y follow-up, 81 of 284 patients who entered the study (28.5%) were still responding to sildenafil, seven (2.5%) to VED, 113 (39.8%) to ICI, 24 (8.5%) to sildenafil+ICI, two (0.7%) to ICI+VED; 15 (5.3%) had a penile implant. In all 17 (6%) patients reported spontaneous erections, 11 (3.9%) stopped the treatment due to family reasons and 14 (4.9%) failed the treatment. In conclusion, the progressive treatment program for ED seems to be very effective for diabetic patients, yielded a complete response for short-term and 91.2% rate of success at the end of 2 y follow-up.

Evaluation of the relationship between semen parameters, pregnancy rate of wives of infertile men with varicocele, and gonadotropin-releasing hormone test before and after varicocelectomy.

OBJECTIVES: To determine whether the gonadotropin-releasing hormone (GnRH) test can serve as an indicator for the need and timing of surgery in infertile men with varicocele. METHODS: The GnRH test was performed in 121 infertile men with varicocele before surgical correction and 4 to 6, 9 to 12, and 16 to 18 months after. Levels of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) were evaluated immediately before the test and 45 minutes after intravenous injection of 100 jig Relisorm L (a synthetic GnRH analogue). Eighteen fertile men with normal semen parameters served as control patients for defining the preoperative hormone levels. A more than twofold increase in FSH and a more than fivefold increase in LH was considered a positive result. Findings were correlated with semen parameters and rate of pregnancy in the patients' wives at 18 months postoperatively. RESULTS: Of the 121 patients, 89 (73.5%) had a positive GnRH test result, and 32 had a negative result. Semen parameters were improved postoperatively in 72 of the GnRH-positive patients (80.9%) and in only 6 of the GnRH-negative patients (1 8.7%). Corresponding pregnancy rates at 18 months in the two subgroups were 60 (67.4%) and 3 (9.3%), respectively. CONCLUSIONS: A positive preoperative GnRH test is a good predictor of improvement in semen parameters and pregnancy after varicocele surgery. We suggest that the GnRH test can serve as an additional indicator for varicocelectomy.

Can the vacuum test be used as a diagnostic method for determining the degree of severity of erectile dysfunction?

We performed the vacuum test (VT) using the Osbon Erec Aid System on 224 patients with erectile dysfunction (ED). The age range was 26-78 years. The vacuum procedure was performed three times at intervals of 2-8 days, using the negative pressure device (NPD). Negative pressure was created for 3-5 minutes, followed by the removal of the cylinder; the tension ring was left in place for an additional 1-2 minutes. During each procedure, we observed color and temperature changes in the glans penis and changes in the tumescence and maximal rigidity of the penis (MRP); dynamic changes in MRP were noted again 1-2 minutes after the procedure. For comparison and verification, we carried out parallel tests: nocturnal penile tumescence (NPT), penile brachial index (PBI), and Doppler penile ultrasound (DPU). On completion of the investigation, we found that 10.3% had mild ED, 38.5% moderate ED, and 41.5% severe ED. The parallel tests confirmed the diagnosis reached by VT. Thus, changes after vacuum procedures together with local symptoms can serve as criteria for determining the degree of severity of ED.

Progressive treatment of erectile dysfunction with intracorporeal injections of different combinations of vasoactive agents.

To account for severity of disease in patients with erectile dysfunction, we introduced a progressive treatment technique using four protocols of drug injections. The study group consisted of 452 men aged 26-85 gamma with erectile dysfunction. Protocol I. All patients began with a combination of papaverine and Regitine in doses adjusted to the estimated severity of dysfunction and to age, up to a maximum dose of 25 mg papaverine and 1.5 mg of Regitine. Protocol II. Patients who could not achieve sufficient rigidity on protocol I were switched to prostin VR, to a maximum of 25 mcg. Protocol III. Patients who failed protocol II received papaverine, Regitine and prostin VR. Protocol IV. Patients who failed protocol III received atropine sulfate (0.02-0.06 mg) in addition to papaverine, Regitine and prostin. Sufficient rigidity was achieved as follows: Protocol I=305 (67.4%) of the original cohort; Protocol II= 61 of the 147 failures with Protocol I (41.5%); Protocol III = 55 of the 86 failures with Protocol 11 (63.9%); Protocol IV = 20 of the remaining 31 patients (64.5%). Overall, sustained rigidity was achieved in 441 of the 452 patients (97.5%). Eleven patients (2.5%) failed all four protocols and were offered a penile prosthesis. Therefore, using our progressive method, by starting with the most available and inexpensive drugs, patients with erectile dysfunction can be given optimal treatment according to the severity of their disease. The success rate is high while costs are kept to a minimum.

Intracavernous injections for erectile dysfunction in patients with cardiovascular diseases and failure or contraindications for sildenafil citrate.

The aim of this study was to evaluate the effectiveness of a progressive program for the treatment of erectile dysfunction in patients with cardiovascular disease in whom sildenafil citrate (Viagra) was not an option. The study population included 106 patients selected from 267 with cardiovascular disease. The intracavernous injection program consisted of three protocols of increasingly complex combinations of vasoactive drugs, papaverine, phentolamine, prostaglandin E1 and atropine sulfate. Patients who failed the first protocol were switched to the second, and those who failed the second were switched to the third. A positive response was defined as an erection sufficient for vaginal penetration. A positive response was achieved on protocol I in 61 of the 106 patients (57.5%); protocol II in 32 of the remaining 45 patients (71.1%); and protocol III in seven of the remaining 13 patients (53.8%); the total success rate was 94.3%. These 100 patients were included in the 1-year follow-up, and 90 reported successful coitus at the end of that period: 79 patients (87.8%) with intracavernous injection and 11 (12.2%) without injection. The remaining 10 patients (10%) dropped out of the program, seven (7.0%) for health or marital reasons and three (3.0%) because of treatment failure. We conclude that a progressive program of intracavernous injections of vasoactive drugs may be a good alternative for the treatment of erectile dysfunction in patients with cardiovascular disease.

[Treatment of erectile dysfunction with vacuum constriction device].

The vacuum constriction device (VCD) is a noninvasive mechanical device which may produce an erection by creating a vacuum of up to 250 mm Hg and with a rubber ring to maintain this state by constricting the base of the penis. We tested the VCD on 150 men who presented with organic and psychogenic impotence in our outpatient clinic between the years 1986 and 1992. Of the 150 men, 113 (75%) achieved an adequate erection with the VCD. However, only 72 patients agreed to buy the device and use it regularly. During follow-up of from 3 months to 5 1/2 years (mean 25 months), 65 men were using the VCD regularly and reported satisfying intercourse at least once every 2 weeks. Complications were minimal and consisted of mild numbness of the penis in 7 patients, mild cyanosis in 17, and 10 cases of painless ecchymoses and petechiae which disappeared without any treatment. From our experience, the VCD appears to be a safe, inexpensive, and easy method for impotent men to engage in sexual intercourse without, of course, eliminating other therapeutic options, including surgery.

[Psychotherapy combined with use of the vacuum constrictive device for erectile impotence].

Psychotherapy and the vacuum constriction device were used to treat 125 men with different types of erectile impotence. 58 came with their wives (Group 1), the wives of 49 did not agree to come (Group 2), and 18 men did not want to inform their wives of their condition (Group 3). Age ranges and means for the 3 groups were, respectively: 26-82 (56.2 +/- 2.8); 24-80 (53.1 +/- 2.2); and 25-76 (59.3 +/- 2.7). All groups received 6-10 combined treatments, and in all 3 groups there was improvement in the objective parameters of sexual function (nocturnal penile tumescence, penile brachial index, maximal penile rigidity). But only in Group I was there improvement in subjective parameters (spontaneous erection, adequate coitus without the vacuum device). After treatment, successful coitus, with or without use of the device, was achieved in 91.3% of Group I, 69.3% of Group II and 50.0% of Group III. These results indicate that regardless of type of erectile impotence, the greatest degree of success is achieved when the patient comes for treatment together with his wife.

[Gonadotropin-releasing hormone (GnRH) in selecting patients for varicocelectomy].

The gonadotropin-releasing hormone (GnRH) test was performed on 182 patients with various degrees of varicocele before and after low, inguinal, spermatic vein ligation, and on 18 controls. The levels of follicle-stimulating hormone (FSH) and luteinizing hormone, a synthetic GnRH (LH), were evaluated before and 45 minutes after intravenous injection of 100 mcg relisorm L. FSH levels increased more than 2-fold in 118 patients [64.8%] and LH levels increased more than 5-fold in 135 patients [74.1%]). In the control group the increase was less in all cases. Therefore, whenever FSH increased more than 2-fold and LH more than 5-fold, we considered the test positive (pathologic); On this basis the GnRH test was positive in 126 (69.2%) and negative (normal) in 56 (30.7%). Of the 126 with positive tests, only 32 (27.3%) still had a positive result 5-6 months after operation. There was correlation between a positive GnRH test and significant improvement in sperm parameters after varicocelectomy: of the 126 with positive tests before operation, sperm parameters improved in 87 patients (69%), while in the 56 patients with negative tests before operation, in only 7 (12.5%) was there improvement after correction. We conclude that a positive GnRH test indicates impairment of the hypothalamic-pituitary-gonadal axis caused by varicocele and could serve as a marker for surgical intervention with good prediction of outcome.

[Evaluation of 452 patients with erectile dysfunction treated by combinations of vasoactive agents by penile injection].

In the past 15 years there has been continuous increase in the use of injections into the corpora cavernosa of different vasoactive drugs for treatment of erectile dysfunction (ED). However, some of these drugs are very expensive, are not available everywhere, and have side effects. We therefore compared the success rate of the most widely used compounds, papaverine and regitine, in 452 patients (age range 26-85) with different types of ED. Each patient received in the clinic injections of papaverine, 6-25 mg, and regitine, 0.05-1.5 mg. When maximal rigidity of the penis (MRP) was > 80%, we instructed the patient to self-inject the drug at home, 5-30 minutes before coitus. If after 3 injections MRP was not > 80%, prostaglandin E1 (PGE1) in an average dose of 10-25 mcg was added. If there was no response, papaverin + regitine + PGE1 were given in higher dosage, and atropine sulfate, 0.02 + 0.06 mg, was added if necessary. Of 452 patients, 305 (67.4%) had MRP > 80% after 3 injections of papaverine plus regitine. The other patients received PGE1 in addition. This was helpful in 61 patients (41.5%), while 55 (63.9%) required papaverine + regitine + prostin in higher doses. Of these, only 31 received papaverine + regitine + PGE1 + atropine sulfate. Of these, 20 (64.5%) reached MRP > 80%, and 11 (2.4%) MRP < 60. For these 11 patients, we recommended a penile prosthesis. Thus in 67.4% of the 452 patients, papaverine + regitine injections were effective; in 41.5%, PGE1; in 63.9%, papaverine + regitine + prostin + atropine sulfate. Only 11 (2.4%) did not react to intracorporeal injection. This progressive method of treatment enabled us to select the optimal dosage and combinations of compounds in 441/452 patients (97.5%) according to the severity of their dysfunction. During follow-up of 6 months, spontaneous erections without injection were achieved in 115 (26.0%).

[Effect of drug preparations in vitro on the morphofunctional status of spermatozoa]. / Vliianie nekotorykh lekarstvennykh preparatov in vitro na morfofunktsional'noe sostoianie spermatozoonov.

The effect was studied of different drugs (aloe extract, penicillin, vitreous body and lidase) in 20 specimens of the ejaculate with established normozoospermia and in 20 specimens with oligozoospermia, asthenozoospermia and hypozoospermia. Experiments were carried out at +4 degrees C to -38 degrees C, every 2 hours for 72 hours. It was established that depending on the time, temperature and drugs there was an essential difference between the percent of mobility and ultrastructure of spermatozoa. The most favourable effect on spermatozoa was produced by temperature ranges from 11 to 18 degrees C, lidase and penicillin.

[Risk factors for the development of infertility in men]. / O faktorakh riska razvitiia besplodiia u muzhchin.

The age and health condition at the time birth were evaluated in fathers of males suffering of sterility. Of 500 of them 4% presented no complaints while the rest suffered different diseases. Of 160 fathers of the second group referred for sterile marriage with normozoospermia 90% were healthy while the remaining showed diseases of circulatory and nervous systems. Of 40 patients whose fathers were 18-25 years during birth of their sterile sons, azoospermia was revealed in 12.5%, oligozoospermia of grade III--in 42.4% and correspondingly 25-40 years--in 5.1% and 12%; 40-50 years--in 13.1% and 45.3%; over 50 years--in 27.9% and 64.5%. Consequently, the age and health conditions of the fathers during their birth may be risk factors of sterility of their sons.

[Local hyperthermia in the combined treatment of patients with chronic bacterial urethroprostatitis]. / Lokal'naia gipertermiia v kompleksnom lechenii bol'nykh khronicheskim bakterial'nym uretroprostatitom.

Ninety patients with chronic urethroprostatitis have been followed up. The patients were divided into two groups. Group 1 (50 patients), besides general treatment, have been treated with local hyperthermia: the temperature in the urethra has been gradually increased to reach 40-60 degrees C and maintained so for 20-60 min. The temperature elevation depended on the patient's tolerance. Group 2 patients have been administered local therapy with various instillations. Good results in Group 1 recommend a smooth warming of the urethra to 40-60 degrees C as a rational and effective method of local therapy in combined treatment of patients with chronic urethroprostatitis.

Vacuum therapy combined with psychotherapy for management of severe erectile dysfunction.

We used vacuum therapy in combination with psychotherapy in 145 patients with different types of erectile dysfunction (ED). The age range was 24-82 years (average 53.4 +/- 2.7 years). The patients were divided into 3 groups according to the type of ED: 26.2% psychogenic, 36.5% organic, 37.2% mixed. All received the same treatment. Improvement in sexual function parameters, both subjective (adequate erection, spontaneous erection) and objective (penile brachial index, maximal rigidity of penis) were compared among the groups. The best results were noted in the psychogenic and organic ED patients. Of the 38 patients with psychogenic ED, 12 (31.5%) had coitus after treatment without any intervention, 23 (60.5%) had coitus with help of the vacuum constriction device (VCD). Of 53 patients with organic ED, 11 (20.7%) had coitus without any intervention, and 39 (73.5%) had coitus with help of the VCD. Of the total study population (n = 145), 31 (21.3%) had coitus without any intervention, 98 (67.5%) had coitus with help of the VCD. In 16 (11%) cases, there was no improvement in either subjective or objective parameters of sexual function.

Comparative evaluation of treatments for erectile dysfunction in patients with prostate cancer after radical retropubic prostatectomy.

OBJECTIVE: To assess the effectiveness of a progressive local treatment protocol for erectile dysfunction (ED) in patients after undergoing radical retropubic prostatectomy (RRP) for prostate cancer. PATIENTS AND METHODS: The study included 85 patients (mean age 59.5 years, range 50--75) with ED after RRP. Treatment was offered in four progressive phases, with patients passing to the next phase only if they failed the previous one: in phase I patients used a vacuum erection device; in phase II, sildenafil; in phase III, intracorporal injection; and in phase IV, intracorporal injection plus the vacuum erection device. The patients were followed for 1 year. RESULTS: Of the 85 patients, 78 (92%) responded to the vacuum erection device (with an erection sufficient for vaginal penetration), but only 11 (14%) agreed to continue with it at home. Of the remaining 74 patients, 69 with no contraindications were given sildenafil and 14 (20%) had a positive response. Sixty patients were then treated with intracorporal injection and 51 (85%) had a positive response; four of the nine failures in phase III responded to intracorporal injection plus vacuum therapy. Five patients failed all four protocols. After 1 year of follow-up, 76 of the 80 patients were successfully continuing treatment at home; seven (9%) used the vacuum erection device, 11 (14%) sildenafil, 54 (71%) intracorporal injection and four (5%) intracorporal injection plus the vacuum erection device. CONCLUSION: Overall, this progressive treatment method gave a positive response in 80 of the 85 patients (94%). After 1 year of follow-up, 76 of the 80 patients (95%) continued to respond well. Of all the methods used, intracorporal injection was the most effective for ED after RRP.

Three-year outcome of a progressive treatment program for erectile dysfunction with intracavernous injections of vasoactive drugs.

OBJECTIVES: To perform a comparative evaluation and follow-up of patients with erectile dysfunction (ED) who were treated with intracavernous injection of vasoactive drugs, starting with simple drugs and advancing to complex combinations. METHODS: The study included 625 patients, 26 to 85 years old, with ED. Four intracavernous injection protocols were used: protocol 1, papaverine plus phentolamine; protocol 2, prostaglandin E(1); protocol 3, papaverine, phentolamine, and prostaglandin E(1); and protocol 4, atropine sulfate, papaverine, phentolamine, and prostaglandin E(1). A positive response was defined as an erection sufficient for penetration. Patients for whom the basic protocol failed were successively switched to the more advanced protocols until a positive response was achieved. RESULTS: A positive response was achieved by 415 (66.4%) of the 625 patients given protocol 1; 75 (36%) of the remaining 210 patients given protocol 2; 98 (72.6%) of the 135 patients given protocol 3; and 22 (59.5%) of 37 patients given protocol 4. All four protocols failed in only 15 patients (2. 4%). At the 3-year follow-up visit (n = 610), 349 had achieved coitus, 65 (10.6%) without an injection and 202 (33.1%) with an injection. Eighty-two patients sometimes performed coitus without an injection. Sixty-three patients (10.3%) abandoned the program because of marital or health problems; 198 asked to be switched to Viagra during the follow-up period, and 120 returned to the program. CONCLUSIONS: Overall, our progressive treatment yielded a high positive response rate (97.6%), with 57.2% achieving successful coitus on follow-up. The main advantage of the program is that it spares patients who are responsive earlier from using more complex, painful, and costly drugs.

Sexual function in 131 patients with benign prostatic hyperplasia before prostatectomy.

OBJECTIVE: The aim of the present study was to ascertain the frequency of sexual dysfunction in patients with benign prostatic hyperplasia (BPH) before prostatectomy. METHODS: The study population included 131 patients aged 55-74 years (mean 61.4+/-2.7) with BPH. The patients had been complaining of daytime urgency and nocturia for the last 1-14 years (average 4.5+/-1.5 years). The diagnosis of BPH was based on the anamnestic data, the International Prostate Symptom Score (IPSS(0-35)) and quality of life assessment (L(0-6)), and results of digital rectal examination, transrectal ultrasound, and uroflowmetry. Sexual dysfunction was determined by retrospective analysis of the psychosexual history (with and separately from the spouse), penile brachial index (PBI), nocturnal penile tumescence (NPT), and blood hormone levels (testosterone). RESULTS: The patients were divided into two groups by severity of the urinary disorder: group I, severe (IPSS(0-35)-L(6); n = 70); and group II, mild relative to group I (IPSS(32-34)-L(4-5); n = 61). In group I, 15 patients (21.4%) performed normal coitus, 24 (34.2%) had weak coitus with incomplete penetration, and 21 (44.2%) had unsuccessful coitus because of a weak erection. In group II, 28 patients (45.9%) had normal coitus, 25 (40.9%) incomplete penetration, and 8 (13.1%) unsuccessful coitus. There was no significant correlation between sexual function and the patients' general health condition. The quantitative assessment of sexual dysfunction yielded the following results in groups 1 and 2, respectively: negative NPT in 32.4+/-1.8 and 24.4+/-2.1% (p<0.05); PBI <0.6 in 33.4+/-1.7 and 22.3+/-1.2% (p<0.001); and testosterone decrease to <12 nmol/l in 36.4+/-1.2 and 28.5+/-1.2% (p<0.05), respectively. The differences between the groups were significant (p<0.05) for all three parameters. CONCLUSIONS: Considering the 44. 2% rate of unsuccessful coitus in the patients with a severe urinary dysfunction compared to only 13.1% in those with a milder dysfunction and the significant correlation between severe urinary dysfunction and measures of sexual dysfunction, we suggest that BPH may be a risk factor for sexual dysfunction.

Correlation between semen parameters and retrograde flow into the pampiniform plexus before and after varicocelectomy.

OBJECTIVE: To compare, before and after repair of varicocele, the semen parameters (SP) in relation to the persistence of retrograde vein flow. MATERIAL AND METHODS: We examined the correlation between semen characteristics and retrograde flow (RF) into the pampiniform plexus in 158 patients with varicocele, before and after low inguinal spermatic vein ligation. RESULTS: The results of the investigation before surgery showed that all patients had RF and also a decrease in quantitative and qualitative SP. After surgery an improvement was observed in SP and there was a decrease in RF as a function of time elapsing from surgery. One year after surgery, an improvement in SP in 136 (86.1%) patients was observed. In 14 (8.8%) no change was noted and in 8 (5.1%) there was a deterioration in SP. Comparison between increased SP and persistence of RF 1 year after surgery revealed that of the 136 patients who showed improvement in SP, 124 (91.1%) did not have RF. Of the 14 patients with no improvement in SP, 12 (85.7%) were free of RF and 9 patients with deteriorated SP and bilateral RF. Amongst 132 infertile men, the wives of 55 (41.6%) became pregnant. None of these 55 men demonstrate RF. CONCLUSIONS: These results revealed a significant correlation between the improvement of SP, pregnancy in patients' wives and disappearance of RF. These results may be considered as a parameter of successful varicocelectomy.

[Urethral electrothermal stimulation in treating patients with chronic non-gonococcal urethro-prostatitis]. / Elektrotermouretrostimuliatsiia v lechenii bol'nykh khronicheskim negonokokkovym uretroprostatitom.

Two groups of patients with chronic urethral electrothermal stimulation [correction of electrothermoureterostimulation] were singled out. Group 1 (50 patients) received traditional treatment plus urethral electrothermal stimulation [correction of electrthermoureterostimulation] while group II only traditional treatment. The ejaculate in these groups receiving different treatment revealed significant qualitative and quantitative differences. Treatment including urethral electrostimulation [correction of electroureterostimulation] stimulates the mucosa and surrounding tissues of the urinary canal, prostatic part of the urethra [correction of ureter] and prostate, increase of its blood flow. This favoured resolution of the inflammatory process, opens the obstructed ducts of the urethral [correction of ureteral] process and alveoli of the prostate.