Digest of recent discussions on ISSM mail (March-July 2002)

Hussein Ghanem MD

Dr. Jacques Buvat raised again the problem of paucity of phentolamine for use in combination intracavernosal therapy.  He requested advice and references about equivalences between the doses of phentolamine and chlorpromazine, and any other hints that current users of chlorpromazine believe to be important to communicate to new users of this drug, as well as precautions or adverse effects that might be expected? 

Drs. Nguyen Tan Trung, Paulo Cunha and Sidney Glina have been using chlorpromazine for the past 4 to 9 years and appear to be satisfied with the results. Dr. Glina suggests substituting phentolamine by an equivalent dose of chlorpromazine. Results were published in the Brazilian Journal of Urology (Portuguese).  Dr. Ronald Lowis �during a limited phentolamine shortage- temporarily used a bi-mix of PGE-1 and papaverine and just left out the phentolamine. The responses to the bi-mix -in his opinion- were just as good as the tri-mix.  Dr. Hartmut Porst suggested a practical solution by adding ready mixed papaverine / phentolamine ampoules �available in Europe- to Prostaglandin E1.

The problem of Anorgasmia in elderly patients was presented by Dr. Edgardo Becher who noted this condition in a few patients in their 60's or 70's.  These patients appeared to be free from neuropathies, had normal lab works and obtained sufficient erections with sildenafil.  Dr. Andik Wijaya suggested Kegel exercises while Dr. Bechara and Dr. Casab� suggested Yohimbine and ciproheptadine, and provided related references.

Topic 1: Honey Moon Impotence

Annette Owens MD and Hussein Ghanem MD

It is interesting that Honey Moon Impotence which is a common clinical presentation in the Middle East appears to be quite rare in other countries.
Dr. Owens & I had the following communication. We decided to share it with other ISSIR members to learn what experience other colleagues have in relation to this topic (demographics, treatment options, etc.). We had previous communications when a patient from the Middle East consulted Dr. Owens about the topic.

Hussein Ghanem MD

Response from: Annette Fuglsang Owens

Dear Hussein:

I am presently preparing a presentation for next week's AASECT meeting in Miami.
I am going to mention a question about honeymoon impotency and I was wondering whether this is a relatively common concern 'in the Middle East'? Do you have any information? Any specific demographics? Are people generally well informed about psychogenic causes for ED and ED in general? What treatment options are generally available in those cultures?

Best wishes,
Annette
--
Annette Fuglsang Owens, MD PhD
Chief Medical Officer and Co-Founder
The Sexual Health Network
www.SexualHealth.com

Response from: Hussein Ghanem MD

Dear Annette,

It is estimated that 12% of visits to sexual dysfunction clinics in Egypt & Saudi Arabia are related to honeymoon impotence.

Physicians attending patients with erectile dysfunction in certain conservative societies frequently face unique situations related to the culture and family attitudes. Newly wed couples in conservative societies probably have limited premarital sexual experiences. Although this makes the wedding night a very special event, yet men with fear of failure are under a significant amount of stress. Not only do they fear embarrassment with their wives but also possible humiliation with the bride's family.

Sex therapy requires a level of understanding, cognitive ability to conceptualize the problem and challenge its basis. The cultural acceptance of joint couple therapy, which is the mainstay of sex therapy , is greatly compromised in our population and probably for many in the developing world.

Sildenafil & Intracavernosal therapy are thus quite commonly used in the Middle East in this indication. In a study published in the IJIR (1) self injections were successful in 67 (93%) of 72 patients with honeymoon impotence. The five failures were due to vaginismus. Only 6 (8 %) patients needed long-term use. Similar results -using sildenafil- were presented by Dr. Amr El Meliegy in the recent world congress of sexology, Paris 2001.

Best wishes.
Hussein

1) Short-term use of intracavernous vasoactive drugs in the treatment of persistent psychogenic erectile dysfunction. Hussein Ghanem, Tarek Sherif, Tarek Adbel-Gawad, Tarek Asaad. International Journal of Impotence Research 1998 Dec; 10(4): 211-4

Response from: Dr. Andik Wijaya

In my clinic in Surabaya, Indonesia, I found around 10 % of my patients are new couples suffer from honeymoon impotence. For these patients usually I give them zoloft 50 mg according to release their psychological distress, and ICI ( self injection ). I did not give them sildenafil citrate because, usually sildenafil did not work on nervous patients as honeymoon impotence patients. Combine of zoloft and ICI gave a good result on more than 90 % patients.

regards,
Andik Wijaya,M.D.
Couple Clinic Indonesia
www.drawclinic.com

Response from: Dr. AMR EL MELIEGY

From my own experience with honeymoon impotence cases, I found that 15% of my ED patients in Saudi Arabia have this problem. The first key to treatment is informing the patient about the nature and incidence of his disease. The presence of the wife is essential if possible. If the wife is a contributor to the problem as by having vaginismus, then referral to a psychiatrist might be needed. Sildenafil in my experience has proved to be very helpful. ICI are used if sildenafil fails. Anxiolytics like buspar 20mg/day are sometimes needed. SSRI,i restrict them to PME afraid of their effect on increasing anxiety.

DR.AMR EL MELIEGY

Topic 2: Substituting Phentolamine with Chlorpromazine for Intracavernosal Injections ?

Jacque Buvat MD

Dear colleagues,

I regularly use double or triple mixtures for intracavernosal injections in patients resistant to prostaglandin E1 alone, by associating to it phentolamine and possibly papaverine. Phentolamine is no more available in France since several years. Until now I obtained it from Belgium which is close to my city and where it was available. It seems to be no more available in Belgium since some days. I intend to test the substitution of phentolamine with chlorpromazine, since it has been reported by our Brazilian colleagues that the association of chlorpromazine with papaverine or PGE 1 works as well as that of phentolamine. I would be very grateful to them if they could give me some indications on the equivalences between the doses of phentolamine and these of chlorpromazine, and any other indication which they think important to communicate to a new user of this drug. Are there adverse effects on vigilance to be expected ? Can you communicate references of papers having reported about this association ?

Thanks ahead.

Jacques Buvat MD

Response from: Dr. Paulo Brito Cunha

I use Chlorpromazine (CLPZ) since 1993. It is not expensive . It is good .
To psicogenics : 0,5 mg per ml >> 1 ml = 100 units . Each dose = 25 units for all patients . No priapism and no fibrosis . Erection : 1 hour . I use Na Cl ( 0,9% ) .

TRIMIX

PGE1= 500 mcg ( 1 ml ) + Papaverine Cl (16 ml ) = 800mg + CLPZ ( 10 ml ) = 50 mg + Na Cl ( 53 ml ) ( 0,9 % ) = 80 ml . Each ml = 100 units = 6,25 mcg ( PGE1 ) + 10 ml ( Pap ) + 0,625 mg ( CLPZ )

How to use : Psicogenics = 3/5 units ; til 90 minutes . No priapism .
Neurogenics ( diabetic , neuropraxis etc ) = 4/8 unts .90 minutes too
Vasculogenics( MI , atherosclerosis etc ) = from 10 , till 30 unts . We can use 50 unts . No problems . Since 1993 , only 12 priapism .

Paulo Brito Cunha > Brasil > Rio de Janeiro .

Response from: Dr. Sidney Glina

According to Dr. Buvat�s question on phentolamine substitution:

We have been using clorpromazine for phentolamine substitution for the last four years, either with PGE1 or papaverine. The doses of phentolamine and clorpromazine are equivalent; for example I used PGE1 10 micrograms with 1 mg phentolamine/ ml and now I use PGE1 10 micrograms and 1 mg clorpromazine. There has been no adverse events.
We published 1 paper on the subject on the Brazilian Journal of Urology (Portuguese).

Sidney Glina

Response from: Dr. Ronald Lewis

Jacques, Several years ago we could not get phentolamine for a while as well. During that time I used a bi-mix of PGE-1 and papaverine, just left out the phentolamine. The response to the bi-mix in my opinion was just as good as the tri-mix. We now have access to tri-mix again and are using it again but I used this bi-mix for almost one year as a substitute and was just as pleased with the results. Ron Lewis

Response from Dr. Hartmut Porst

Dear Jacques,

the combination of papaverine(30 mg) and phentolamine(1mg) is available in Europe under the trade-name Androskat (2 ml ampoules with the content described).I regularly combine 1 amp. Androskat with 1 amp. Caverject which dissolves immediately and is a powerful combination.
Best regards

Hartmut

Response from Dr. Nguyen Tan Trung

I regularly use a Bi-Mix with Papaverine (10amp/1ml/40mg:400mg)
and Clorpromazine (1amp/2ml/25mg),so 1ml#33mg Pap + # 2,8mg CPZ.
My patients (and theirs partners, of course!) have found no difference
comparatively with Papaverine-Phentolamine, and it's cheaper than PGE1.
Sincerely,
Nguyen Tan Trung, MD
Vietnam

Topic 3: Anorgasmia

Edgardo Becher MD

I have a few patients in their 60's or 70's that, although happy with their ED management with sildenafil, are completely unable to reach an orgasm. They have no signs of neuropathy and labs are normal and they don't take SSRI's.
Does anyone use any drug to help these patients even empirically?

Edgardo Becher
Buenos Aires, Argentina

Response from: Dr. Andik Wijaya

I have a few experiences with the similar cases. Combined of Kegel exercise
and Madopar 250 mg 3 X 1/2 ,
are useful. As we know Dopamine is one of the key neurotransmitter in human
sexual response. Lack or decrease of dopamine level may cause unorgasmic
problem so increasing dopamine level will recover orgasm capacity. . But,
you should alert if your patient are hypertension, because it could increase
their blood pressure.

Andik Wijaya, M.D.
Couple Clinic Indonesia
www.drawclinic.com

Response from: Dr. Bechara and Dr. Casab�

sYohimbine 8 mg plus ciproheptadine 8 mg has been demonstrated by Dr. Mazza to be effectiveness to reach the orgasm in similar population.

Yohimbine 5-10 mg plus Ciproheptadine 8 mg, 2 hours before intercourse was referred by Mazza, O. and Zeller in:"Tratamiento farmacologico de la Disfunci�n Er�ctil" Editorial Panamericana. Buenos Aires, Argentina. 1997.

Ciproheptadine in the treatment of Anorgasmia was referred by Laverma, H. "The successful treatment of citalopram induced anorgasm by ciproheptadine". Acta Psychiatr Scand, 1996 (1):69-70.


Dr. Bechara and Dr. Casab�

Last update : 08/20/2002