Digest of interesting cases discussed on ISSM mail

Hussein Ghanem MD

Case 1: Nocturnal Priapism

(Presented by Jacques Buvat MD)

Dr Bjarne Kromann, from the department of Urology, National Hospital, Rigshospitalet, Copenhagen, Denmark, has a difficult case with nocturnal priapism and penile pain for almost two years. You will find here after the patient's history. He will be very interested in knowing your opinion, and will like to read your comments on ISSIR List. You will also find my reply to his initial mail, and his own reply to my comments.

Best regards, Jacques Buvat MD

Patient's history:

Twenty-three year old man, during the year of 1999, he had for six months intermittent longstanding erections for two to four hours without sexual stimulation, occasionally more than ten hours of spontaneous priapism. In June 1999 he was referred to Department of Urology for fourteen hours of priapism; but no penile pain. Puncture of the corpus cavernosum was performed with injection of vasoconstrictor (Ephedrine) with no effect, an operative procedure ad modum Ebbeh�j (Winther) was performed. This was effective for one month.

August 1999 presenting with painful nocturnal erections. For three weeks he had had this problem, waking up during the night with painful erection, in the morning it was difficult for him to achieve detumescence, and he went to work with a semirigid penis. He was treated with Ephedrine 25 milligram i.c. as self injection, and inhalation Bricanyl (Terbutalin 7,5 milligram at night) as beta-receptor stimulator. This treatment had limited effect.

Ultrasound investigation of the corpora showed high flow in the deep cavernous arteries and the helicine arteries. Blood analysis showed arterial values of pO2 and saturation of 95%, pH 7,43.

September 1999 selective arteriography and embolisation of the left internal pudendal artery was performed with an autolog coagulum. This has limited success.

MR-scanning September 1999 of the columna cervicalis, thoracalis et lumbalis and spinalcord was normal.

He was treated for a few months with Digoxin 250 �g x 1, self injection of Ephedrine and terbutaline inhalations - all without effect.

Since October 1999 he has been treated with an antiandrogen, cyproteronacetate (Androcur) 50 milligrams twice a day; for periods only 50 milligrams a day, and for shorter periods of one or two months no medical treatment.

The patient still has longstanding nocturnal erections which wakes him up during the night due to penile pain. The patient is quite depressed due to the medical treatment with antiandrogen and his sexual desire is low due to this treatment.

I would like to know what kind of treatment you would offer this type of patient?

Sincerely Yours

Bjarne Kromann

Reply from J. Buvat

Dear Mr Kromann,

I apologize for the delay of this reply but I was on leave. Regarding your patient, has some fibrosis, possibly with penile angulation, resulted from his prolonged erections ? Have you been able to confirm the present reality of persisting prolonged erections on sympathico-mimetics or antiandrogens ? Have you tried combining both types of treatments ? May be chlorimipramine could be of some help due to both its antidepressive, anti-algic, and in some extent anti-erectile activities.

Best regards, Jacques Buvat MD

Reply from B. Kromann

Dear Mr.Buvat

Thank you for your reply on my patient with longstanding painful nocturnal erections.
The patient has a juvenile penile angulation of 30 degrees to the left, and there has been no changes (worsening) since this "priapism problem" started 2 years ago.

On examination the corpora feels with some resistance - oedema of the cavernous tissue? For 2 years he has not experienced a normal flaccid penis, and on all his visits to the clinic the penis has been in the same state with full tumescence and this resistance on palpation.

There is no palpable fibrosis in the corpora.
I have no Rigid-scan device available, and have not been able to record the nocturnal erections/priapism; neither before nor during the medical treatment.
But the ultrasound investigation shows a high flow and arterial flow into the helicine arteries when the penis is non-erect as he comes walking into the clinic.
I have tried combining sympatico-mimetics and antiandrogens with little success.
I have not tried chlorimipramine.
Yes- you may introduce the patient history on ISSIR-list.
I am a member of ISSIR.
I look forward for these comments and advices.

Thank you for your time, yours
Bjarne Kromann,M.D.
Dept of Urology
Rigshospitalet, National Hospital
Copenhagen, Denmark

Response from: Hartmut Porst MD

In terms of this indeed difficult case I suggested to evaluate the hormone levels especially the T and DHT as well as a sonography of the testicles and adrenals. I have had 2 guys with elevated T and DHT and longstanding painful erections, one of these two with a Leydig cell tumor.

Response from: Mauro Dimitri MD

I will suggest you to perform on your patient a cavernosography, to study the deep venous system for possible obstructions. After genital infections (prostatitis) I observed the onset of venous leakage in some cases. Moreover, a superficial and deep thrombophlebitis due to toxins could alter the endothelial layer of the veins resulting in venous occlusion (remember the thrombosis secondary to trauma and inflammation during sexual intercourse at the level of the superficial retro glandular vein ). In my knowledge these data are not supported in the literature until now , but a deep venous damage could cause a high back pressure ( the system cannot void rapidly).

You mentioned that the patient developed a progressive priapism after six months of intermittent longstanding erections. In my opinion a cautious corporeal-glans shunt could be performed.

Response from: Sidney Glina MD

I would try finasteride 5md/day. It has less side effects than antiandrogens. There has been one case to be published at the Brazilian Journal of Urology where they used this drug in a case of stuttering priapism due to falciform anemia with success for more than two years.

Response from: Hussein Ghanem MD

Dr. Kromann presents us with quite a challenging case of idiopathic recurrent priapism. A similar case was presented a few months ago and self injection with vasoconstrictors were also suggested.

I do not have an answer to this problem but rather wish to raise more questions. What are the long-term side-effects of self-injection with sympathomimetics? Should this patient have routine cardiac check-ups? Since treatment is only symptomatic and this is a young patient, would we expect the condition to only deteriorate with repeated insult to the cavernous tissue? If so, would a penile prosthesis now be a fair option to resolve the problem?

Case 2 : Hodgkin's Disease & ED

I received the following inquiry by e-mail. I would be grateful for any thoughts about this case. Are there any other factors being overlooked, related to Hodgkin�s disease or its treatment, that might lead to ED.

I am posting the patient's questions and my suggested answers.
Case in the patient�s own -quite intelligent- words:

I am going to give you some background about myself. I was diagnosed with Hodgkin's when I was 15 and received radiation treatment to the chest area. Since then, things seemed to be fine. However, lately I was diagnosed with Hypothyroidism and my doctor prescribed synthroid which has helped bring my TSH level back to normal level. This is my medical record in short. As to my social/sexual record, well I had some girlfriends but I have never had a sexual intercourse due to religious/cultural reasons. My libido was excellent until a couple of years ago and then it started declining.

1. How can I be totally sure that the problem is psychogenic and not physical in nature? I have conducted the following tests (free Testosterone, FSH, LH, TSH Prolactin) all with normal results. Penile duplex was normal and intracavernous injection resulted in a five-hour erection that resolved spontaneously. Biothesiometry was normal; nevertheless, I feel that the problem is physical and that my body NOT my mind is the problem.
   Suggested answer: It appears that your problem is primarily psychogenic but you need to keep your thyroid insufficiency under control. The only remaining test is night erection monitoring.

2. Are there any aphrodisiac (food or herbs) that can help improve the sexual desire? If yes, can you suggest some?
   Suggested answer: I suggest maintaining a normal healthy diet. I am not aware of any specific food substance that would increase the sexual desire.

3. Would practicing sex with a partner improve my sexual desire? In other words would having sex induce the desire to have more sex?
   Suggested answer: Performance anxiety (fear of failure) improves with success and worsens with failure. I do not advise you to do anything that contradicts your personal beliefs. That would only lead to guilty feelings. Unprotected sexual intercourse can lead to STDs. Having sex just to test or treat yourself is disrespectful to women and in my view could only complicate matters by adding to the performance anxiety.

4. Does practicing sports help in having a more healthy sex drive (by stimulating the blood circulation I guess)?
   Suggested answer: Certainly, that would help you both physically & psychologically, and could very well improve your desire. However, start exercise in a proper-programmed manner to avoid injury.

5. If my problem is psychogenic? How can I solve it? How does Trazodone help ? And what do I do to avoid those headaches cause by taking Trazodone?
   Suggested answer: As long as your thyroid problem is under control, you do not appear to have a physical factor for the dysfunction. Trazodone is an antidepressant that has been shown by some studies to improve sexual function. You should probably go to a lower starting dose. Treatment for psychogenic erectile dysfunction is basically through psychosexual therapy that could be assisted with erectogenic medications according to severity of the disorder.

I would appreciate your thoughts and comments.
Kind regards,

Hussein Ghanem MD
Department of Andrology, Cairo University

Response from: Luca Incrocci MD

As regarding the case of the man who has sexual problems after a treatment for a Hodgkin's disease years ago, I can tell you the following.

I am a radiation oncologist and a sexologist and I do a lot of research in this field.
If this man (how old is he now?) did not receive any chemotherapy for his lymphoma, it is not possible to understand his problem as a consequence of chest radiotherapy. After chemotherapy it is known (and it has been published) that vascular damage is found in the corpora cavernosa.

Of course because of radiation he got hypothyroid, but if this is controlled with drugs he should be OK.

I found in most of my patients psychological problems in accepting cancer and its treatment.
His libido or desire problem is likely not organic.
I would suggest psycho-sexological counseling and, why not, try Yohimbine as a (mild) aphrodisiacum.
If he really has ED he might try Viagra or apomorphine.

If he likes he may email to me to chat about his problem. I am interested to keep informed about the evolution of his problem.

Luca Incrocci, M.D.
l.incrocci@erasmusmc.nl

Last update : 01/03/2002