Erectile Dysfunction: A Primer for in Office Management.

Introduction: Optimizing erectile dysfunction (ED) remains a clinically significant endeavor as insufficient outcomes from oral, injectable and even surgical approaches to treatment remain less than ideal. In this report, we integrate evolving knowledge and provide an algorithmic approach for the clinician to fine-tune management. Methods: We performed a PubMed and Medline search of Erectile Dysfunction treatment optimization, enhanced patient efficacy for ED, and why men fail ED treatment. All relevant papers for the past two decades were reviewed. Results: Establishing the goals and objectives of the patient and partner while providing detailed instructions for treatment can minimize failures and create an environment that allows treatment optimization. A thorough work-up may identify reversible or contributing causes. We identified several areas where treatment of ED could be optimized. These include; management of associated medical conditions, lifestyle improvements, PDE5 inhibitor prescription strategies, management of hypogonadism and the initiation of intracavernosal injection therapy (ICI). Conclusions: In our view, once a man presents for help to the clinician, use of the simple strategies identified in this review to optimize the tolerability, safety and effectiveness of the selected treatment should result in enhanced patient and partner satisfaction, with improved outcomes.

Physical examination of the epididymis made easy: a novel, reproducible and structured approach.

The epididymis is the most common source of acute and chronic scrotal pain in the outpatient setting, yet there are no standardized methods for proper palpation of this organ. We describe a novel scrotal examination technique that is reproducible and easy to learn. Our technique utilizes a maneuver we call testicular 'framing', and in our experience this maneuver almost invariably leads to proper diagnosis of epididymal pathology by facilitating successful palpation of the epididymal head, body and tail.

Success rates of patients with poor emptying on clean intermittent catheterization.

INTRODUCTION: Clean intermittent catheterization (CIC) theoretically reduces incontinence, urinary tract infections (UTIs) and lower urinary tract symptoms (LUTS) in the face of poor emptying. It is unclear whether all patients realize these benefits or if CIC is only helpful for some. MATERIALS AND METHODS: A retrospective review of 321 patients all of whom underwent urodynamic study prior to starting CIC for impaired emptying. Success was considered to be no incontinence, no UTIs, and no LUTS while performing CIC. Patients who did not meet these criteria or who stopped CIC for whatever reason were classified as failures. RESULTS: The mean duration of follow up was 4.3 years (+/- 4.4 years). Overall 51% of the cohort was classified as a success. Among those patients started on CIC to treat incontinence, recurrent UTIs or LUTS the success rate was 43%. We identified the comorbidity of diabetes mellitus, the use of anticholinergic medications, the need for a homecare nurse to perform the CIC, and a post-void residual (PVR) of <300 cc at initial urodynamics to be independently associated with failure on CIC. CONCLUSIONS: CIC resolved incontinence, recurrent UTIs, and LUTS in some but not all patients with impaired emptying. We identified characteristics associated with failure on CIC. Our study has provided some direction as to those individuals most and least likely to benefit from adopting this mode of bladder management for poor emptying.