[Peyronie's disease. Conservative and surgical therapy]. / Induratio penis plastica. Konservative und operative Therapie.

Peyronie's disease is characterized by the formation of a plaque of the tunica albuginea that leads to a mainly dorsally directed penile curvature and penile shortening due to scarification. The exact ethiopathology remains unclear. The natural history of the disease is variable, ranging from spontaneous remissions to chronic, and including severe penile curvature. Therapy should be conservative in the early, painful, progressive phase. No conservative medical or semi-invasive treatment modality, such as extracorporeal shock wave therapy or radiation therapy, is currently available for curing all of the symptoms of this disorder in all patients. All studies with a controlled design showed poor therapeutic outcomes that are frequently identical to the natural course. Surgical therapy should only be performed in the stable stage of the disease. This means that Peyronie's disease should have been present for at least 12 months, and the patient should not have suffered from pain or the progression of symptoms for at least 6 months. The surgical treatment modalities comprise plication procedures (Essed-Schroeder, Nesbit), plaque-incisions with grafting, and the insertion of penile implants with simultaneous correction of the curvature by "penile cracking" or incisions of the plaque.

[Cost of fertility and erectile dysfunction therapy: who has to pay what in the GVK?]. / Kosten einer Fertilitäts- und ED-Therapie Wer zahlt was in der GKV?

From 1 January 2004 new legislation changed the liability of the public health insurance regarding diagnostic and therapy both of erectile dysfunction and infertility. Before 2004 medical therapy of erectile dysfunction (autoinjection therapy, PDE5 inhibitors) was included in the coverage of the general health insurance; however, it is now excluded by law. Before 2004 sterilization was covered by public health insurance only if medically indicated. The costs of vasovasostomy or artificial fertilization after sterilization were only covered by health insurance if the sterilization was carried out for medical reasons. In the field of infertility the liability of statutory health insurance has only been restricted concerning artificial fertilization. Since 2004 there have been restrictions concerning the age of the insured person, and 50% of the costs have to be payed by the patient herself. Moreover, for the different methods of artificial fertilization, the number of trials and the indications have been defined by the Federal Committee. The statutory health insurance is not liable if the number of trials exceeds the limit.

Metanephric adenoma of the kidney: case report and review of the literature.

Metanephric adenoma is a rare tumor of the kidney. So far metanephric adenomas were considered to be benign, slowly growing and non-metastasizing tumors with an excellent prognosis. Only recently two cases of metastasized metanephric adenomas were published. Therefore, diagnostic work up, therapy and follow up of this tumor have to be reassessed. We report the case of a 42 year old male with metanephric adenoma. Current literature concerning metanephric adenoma is reviewed.

[Diagnosis of erectile dysfunction]. / Diagnostik der erektilen Dysfunktion.

Erectile dysfunction is a disorder with multifactorial causes. The pathophysiological origin can be severe general disease. Consequently each patient has to undergo a general diagnostic procedure so that severe disease is not missed. The diagnostic work-up of erectile dysfunction follows a three-step scheme of increasing invasiveness. The non-invasive step is the most important. These investigations comprise taking an extensive general history including a detailed sexual history, psychological diagnosis, physical examination, and laboratory tests. The semi-invasive procedures include the intracavernous injection test, colour-coded duplex sonography and optional neurophysiological examinations. The invasive investigations include dynamic infusion pharmacological cavernosography and cavernosometry, and penile angiography. The extensiveness of the diagnostic procedures should be adapted to the complexity of the history and the therapeutic expectations. However, if there is any suspicion of a severe disease remaining undiagnosed, the diagnostic procedures should be adequately comprehensive.

[Therapy of the "aging male"]. / Therapie des "Aging male".

Serum testosterone levels decline in men with increasing age. Late-onset hypogonadism with its characteristic symptoms can occur in men as they age. Typical symptoms of late-onset hypogonadism are decreased libido and sexual function, osteoporosis, altered distribution of body fat, overall reduction in physical strength, and alterations in general mood. Late-onset hypogonadism can be treated with testosterone, and different forms of testosterone have become available for this indication. The aim of testosterone replacement therapy is to produce serum testosterone levels within the physiological range avoiding levels above and below this range. Although hormone replacement therapy has become accepted in aging males, careful consideration of the indications and therapy monitoring are still required since there are major concerns about the long-term outcome of this therapy and particularly its effects on the prostate gland.

[Assessment among German urologists of various conservative treatment modalities for Peyronie's disease. Results of a survey]. / Einschätzung der verschiedenen konservativen Therapieverfahren der Induratio penis plastica unter deutschen Urologen. Ergebnisse einer Umfrage.

BACKGROUND: The aim of this study was to evaluate the frequency and the assessment of the different conservative modalities of treatment in Peyronie's disease. A representative survey among 3187 German urologists was performed using a standardized questionnaire comprising currently used concepts of therapy, their efficacy, and their tolerability. MATERIAL AND METHODS: A total of 636 urologists participated in the study. Altogether they had treated 6019 patients with Peyronie's disease in 2003. The majority of urologists treated between 3 and 15 patients per year. The most frequent treatment modality was the administration of potassium paraaminobenzoate, followed by vitamin E and extracorporeal shock wave therapy. Other oral drugs and intralesional drug administrations were used considerably less frequently. RESULTS: The most commonly used treatment modalities were assessed for the best results in terms of efficacy and tolerability. However, this outcome is contradictory to the few controlled studies regarding the efficacy of the different drugs. CONCLUSIONS: The large number of patients treated demonstrates the importance of conservative therapy for Peyronie's disease. Therefore, it is unfortunate that no conservative treatment modality is currently available that cures the symptoms of this disorder in all patients affected.

Correlations between hormones, physical, and affective parameters in aging urologic outpatients.

OBJECTIVE: To determine the relationship between sex hormones, physical complaints, depression, sexuality, and life satisfaction in aging men. METHODS: 263 outpatients aged 40 years and above (M=56.2; 40-84 years) were recruited from 6 andrological outpatient departments in Germany to evaluate "aging male" symptoms. Subjects were assessed by standardised self-report questionnaires, physical, and endocrinological examination. RESULTS: Total and free testosterone as well as DHEA-S (dehydroepiandrosterone-sulfate) levels decreased significantly with age. SHBG (sex hormone binding globulin) and LH (luteinizing hormone) increased; estradiol remained unchanged. Inactivity, lower urinary tract symptoms, erectile and orgasmic dysfunction also increased significantly with age. A low testosterone level was significantly associated with a reduced motivation and a lack of sexual desire. In addition to reduced testosterone levels, a reduced motivation was also predicted by depression and an impaired physical self-concept. Reduced activity, erectile dysfunction, and low testosterone levels contributed significantly to the lack of sexual desire. CONCLUSIONS: Aging men are frequently afflicted with a wide range of physical complaints (e.g. fatigue, prostate symptoms), erectile and orgasmic dysfunction, reflected in a reduced physical self-concept. Assessment and treatment of age-related physical and affective alterations must consider their close interplay with hormonal and lifestyle variables.

Apoptosis in non-tumorous adult human testis tissue. Comparison of so-called 'normal' testis tissues.

INTRODUCTION: Apoptosis seems to play an important role in tumorigenesis, prognosis and therapy of testicular tumors. To understand its biological significance, it is important to quantify the amount of apoptosis and to compare the rate of apoptosis to that of a normal, unaffected reference tissue. Usually tissue from the unaffected site of the testis in patients with testicular cancer or testis tissue from patients who underwent surgical castration due to prostate cancer is used as the reference tissue. However it is not known, if both tissues are equivocal with respect to their apoptotic index. The purpose of the study was to compare the two most often used reference tissues for the quantification of apoptosis in testicular tissues with regard to their apoptotic index. MATERIALS AND METHODS: The apoptotic indices of both tissues were compared, using two standard apoptosis detection methods, i.e. in situ end labeling and a morphological approach. RESULTS: The apoptotic index in testis tissue from patients who were surgically castrated for anti-hormonal treatment of prostate cancer was shown to be significantly higher than the apoptotic index of tumor free but tumor-associated testicular tissue of testis cancer patients. There was a strong relationship between the apoptotic index and the age of the patients. CONCLUSION: Although there might be genetic changes in the tumor-associated testicular tissue influencing the apoptotic index, it seems advisable to use tumor-associated tissue rather than testis tissue of patients with prostate cancer as the reference tissue, due to the significant age dependence of the apoptotic index.

Investigation on interaction between tacrolimus and sildenafil in kidney-transplanted patients with erectile dysfunction.

OBJECTIVE: Sildenafil may provide an effective treatment for erectile dysfunction, frequently observed in uremic patients and after kidney transplantation. Pharmacokinetic interactions between sildenafil and tacrolimus are to be expected due to a common elimination pathway via cytochrome P450 3A4. Therefore, the pharmacokinetics during combined use of these agents were studied over 9 days. MATERIAL AND METHODS: Nine male patients (age 29-52 years) were included, who had previously participated in a recent interaction study with sildenafil given as a single dose. Comedication remained unchanged in order to avoid introducing confounding factors. In the previous study in the patients, tacrolimus blood levels with and without sildenafil were measured for pharmacokinetic analysis. In the present study, 25 mg sildenafil were coadministered daily over 9 days and tacrolimus levels were assessed at sampling times optimized using simulation. In addition, laboratory parameters and blood pressure changes were measured and adverse effects monitored. RESULTS: Terminal half-lives of tacrolimus did not differ significantly and trough levels did not change when sildenafil was coadministered daily over 9 days. Mean arterial blood pressure was lower after sildenafil intake. Two patients had to reduce their antihypertensive treatment, 6 patients reported mild side effects. In 1 case, there was an asymptomatic, temporary increase in the serum concentration of gamma-GT. CONCLUSIONS: There was no evidence obtained for a change in elimination half-life or average concentration of tacrolimus during repeated coadministration of sildenafil. Since blood pressure decreased, a starting dose of 25 mg sildenafil and, if necessary, adjustment of the dose of antihypertensive drugs on days when sildenafil is given has to be considered. With respect to the observed blood pressure changes, pharmacokinetic/pharmacodynamic interaction studies with other antihypertensive drugs are of critical importance in these patients.

Possible hemodynamic pathways of intraurethral prostaglandin-E1 (MUSE).

Intraurethral application of prostaglandin-E1 (MUSE) is a well-tolerated pharmacotherapy for erectile dysfunction. However, the physiological mechanisms of drug transfer into the cavernous bodies are not completely clear. Using spongiosography in 35 patients, our study tried to elucidate existing shunt mechanisms. The X-rays show venous drainage through the deep dorsal vein up to the plexus Santorini. The circumflex veins are also contrasted and the cavernous bodies show opacification in their distal portion only. Structures shunting directly between the corpus spongiosum and the cavernous bodies were not demonstrable. Retrograde filling of the cavernous bodies through the deep dorsal vein and its circumflex braches seems to be the most relevant way of drug transfer after intraurethral application of prostaglandin-E1. Diffusion into the cavernous bodies or a systemic mechanism of action does not seem probable.

Urogenital infection and sperm motility.

Male accessory sex gland infections are considered as potential hazards to male fertility. Various pathophysiological concepts have evolved from experimental and clinical studies that begin to explain the effects of bacteria and immunological events on the function of spermatozoa and sperm motility in particular. Besides direct influences of pathogenic bacteria on spermatozoa whose impact on the motility of human spermatozoa is reviewed herein, recent studies have identified and evaluated infectious mediators that appear to be responsible for specific molecular processes in infections that particularly affect the motility of spermatozoa. This review will focus in detail on direct bacterial effects of sperm motility, the role of seminal leucocytes and the impact of pro-inflammatory cytokines on the motility of spermatozoa.

Epithelioid sarcoma of the penis--a rare differential diagnosis of Peyronie's disease.

We report on a case of penile epithelioid sarcoma in a 29-year-old man presenting with a dorsal penile plaque that primarily was misdiagnosed as Peyronie's disease. Although the initial clinical findings of these two different entities appear similar, the consequence for the patient is severe. The only way of differentiating these disorders are histological findings. The principal microscopic characteristics of epithelioid sarcoma are the distinctive nodular arrangement, central degeneration and necrosis of the tumor cells with epithelioid appearance and eosinophilia. Immunohistochemical data (cytokeratin, epithelial membrane antigen, vimentin, CD 34, desmin) confirm the diagnosis. We conclude that in cases with slightest doubts on the diagnosis of Peyronie's disease, especially in younger men suffering from a fast-growing penile induration, a bioptic clarification of the entity should be performed to exclude a high malignant disease that can be only treated as far as it is localized by radical surgery.

[New Insights into the Etiological Pathogenesis of Peyronie's Disease]. / Neue Aspekte zur Atiopathogenese der Induratio penis plastica.

This paper reviews the current knowledge of the etiological pathogenesis of Peyronie's disease. De la Peyronie himself supposed a connection with venereal diseases. Herein, infectious, traumatic, autoimmune and genetic causes are discussed. An important hypothesis is that the recurrent microtraumatisation of the tunica albuginea during sexual intercourse leads to small lesions that activate processes of wound healing and development of fibrotic plaque. According to recent data, an association with the antigens of the HLA-system could be ruled out. Transforming growth factor beta (TGF-beta) seems to have an important impact due to its increased expression in the plaque. Furthermore it is possible to induce a condition similar to Peyronie's disease by intratunical injection of cytomodulin - a substance with TGF-beta-like activity - in an animal model. As in other fibrotic diseases, an imbalance between nitric oxide (NO) and reactive oxygen species (ROS) seems to be of importance. The most important new insights were gained from cell-culture models in which increased expression of basic fibroblast growth factor (bFGF), as well as a change in cell cycle regulation (p53) and cytogenetic instability were observed.

Validation of the German version of the International Index of Erectile Function (IIEF) in patients with erectile dysfunction, Peyronie's disease and controls.

The objective of this study was to validate the German translation of the International Index of Erectile Function (IIEF). The IIEF was administered to 59 patients with erectile dysfunction (ED), to 38 patients with Peyronie's disease and to 33 controls. All patients were investigated by standardized German versions of international questionnaires of anxiety, depression, social desirability, quality of partnership, physical complaints and life-satisfaction. The five subscales of the English version, however, could not be replicated. Internal consistency for the complete questionnaire of 15 items was high (Cronbach's alpha=0.95). Based on the total scale and two subscales, we were able to discriminate sexual function between the ED group and the comparison groups. There was no significant correlation between the IIEF scores and anxiety, depression, somatic complaints and life-satisfaction. The German version of the IIEF has found good comprehension, and acceptance by the majority of patients. Its use is somewhat limited by its focus on sexual activity in partnership. In contrast to the English version, it mainly addresses a single factor of sexual function.

Blunt renal trauma: biomechanics and origination of renal lesions.

OBJECTIVES: Computer-assisted simulation of trauma is supposed to improve protective systems in traffic and risky leisure activities. In case of blunt renal injury biomechanical data being concerned with kidneys as a whole are extremely sparse. To enable three-dimensional simulations this study should supply important data of the renal biomechanics and elucidate the relationship between force distribution and origination of renal lesions. MATERIALS & METHODS: The present study investigated 66 isolated uninjured porcine kidneys using a drop impactor. Changes in deformation, brake force of power, deceleration and intrapelvic pressure are depicted while varying energy application between 1.4 and 14.2J. Lesions were detected by cross-dissecting the organs into slices. RESULTS: The measured values reflect a high correlation between load energy or brake force of power and deformation. Except the intrapelvic pressure all biomechanical parameters rise under increasing energy load. Comparing the different parameters over time a simultaneous concurrence of maximum brake force of power, deceleration and intrarenal pressure can be shown, the peak of deformation was reached belatedly. CONCLUSIONS: The paths of biomechanical curves prove a viscoelastic behaviour of the kidney. In contrast to the literature the region principally bearing the load seems to be the collision zone between renal pelvis and cortex where first lesions appear. This is mainly caused by the fluid filled pelvis, an incompressible support, that is supposed to change its shape after exceeding energy application of about 4J.

Long-term results of Essed-Schroeder plication by the use of non-absorbable Goretex sutures for correcting congenital penile curvature.

This study evaluated the long-term outcome of the Essed-Schroeder procedure for correcting congenital penile curvature using non-absorbable Goretex sutures. The Essed-Schroeder procedure was performed in 35 patients with congenital ventral penile curvature (minimum 30 degrees ). Follow-up included a standardized interview with measurement of angulation. Twenty-three of 35 patients were available for complete long-term follow-up (average 34.3 months). The mean preoperative ventral curvature was 54 degrees. In 17/23 patients, the penis remained straightened. Recurrent curvature (average 23 degrees ) was observed in six of 23 patients. Fifteen of 23 patients complained of penile shortening (average 1.8 cm). Two of 23 patients reported disturbing side effects that were caused by plication nodes. In most cases, the results of penile straightening by the Essed-Schroeder procedure are excellent with a high grade of subjective satisfaction. Regarding the main problem, that is recurrent curvature, there is no decisive advantage of applying Goretex sutures. Discomfort caused by plication nodes can be reduced to a minimum by using a combination of soft Goretex sutures with the 'inverting stitch-technique'.

Interactions of sildenafil and tacrolimus in men with erectile dysfunction after kidney transplantation.

OBJECTIVES: To study the pharmacokinetics of the combined use of sildenafil (which may provide an effective treatment for patients with erectile dysfunction after kidney transplantation) and tacrolimus, as interactions between them are expected because of a common elimination pathway. METHODS: Ten male patients (age 29 to 52 years) were included. Because of its importance in transplant recipients, medication remained unchanged. On day 1, tacrolimus was administered routinely, and blood samples for tacrolimus assays were drawn at predefined times. On day 2, sildenafil was added and blood was collected for assays of tacrolimus, sildenafil, and the sildenafil metabolite UK103,320 (UK) at the indicated times. Blood pressure was monitored on both study days. Sildenafil and UK were assessed by high-pressure liquid chromatography and tacrolimus was assessed by microparticle enzyme immunoassay. RESULTS: No effects of sildenafil on the tacrolimus pharmacokinetics were found. However, in the patients studied, the sildenafil and UK pharmacokinetics were altered compared with the results of previous studies. The mean peak concentration of sildenafil was higher by 44% and the area under the concentration-time data increased by 90%. The elimination half-life was prolonged (4.7 hours compared with 3 hours in healthy volunteers). The area under the concentration-time data for UK was about threefold larger than in healthy volunteers, and the half-life was prolonged from 3.8 hours to 11.4 hours. Pronounced blood pressure drops were observed. CONCLUSIONS: Tacrolimus or the concomitant medication or the disease itself might have altered the sildenafil and UK pharmacokinetics. Because of the drop in blood pressure, sildenafil therapy should start at the lowest dose and any antihypertensive medication should be adjusted.

Heparin-induced priapism.

Heparin-induced priapism constitutes a special form of pharmaco-induced prolonged erection, but the pathophysiological principles are not yet definitely clear. Heparin-induced antiplatelet-antibodies may lead to the aggregation of thrombocytes and thus alter the penile blood flow leading to low-flow priapism. Alternatively, this condition may be explained by initial high-flow priapism that later turns into ischemic priapism. The question remains whether hemorrhage with subsequent organisation of the hematoma and late fibrosis constitutes a pathogenetic factor. Besides this pathogenetic discussion, this paper presents the differential diagnosis of priapism as well as diagnostic and therapeutic procedures.