Digest of recent discussions on ISSM mail (July - December 2003)

Hussein Ghanem MD

Dr. John Pryor stressed that proper preoperative evaluation by 2 psychiatrists is crucial preoperatively, noting that when surgery is subsequently regretted, it is a tragedy and impossible to rectify. H. Ghanem mentioned that in a joint a joint Psychiatry / Andrology conference in Cairo University, it was agreed that the patient would be followed up in the psychiatry clinic for a period of 6-12 months before a final decision about surgery is made.

Dr. Cunha initiated an interesting discussion about any effect of skin-diving (without equipment) on erectile function, an apparently virgin topic. No literature appears to be available concerning this topic. Comments included looking into explanations related to endothelial function or oxygen concentration changes. Psychological factors were also suggested by H Ghanem as changes in Oxygen or Nitrogen tissue & blood concentrations occur mainly when scuba diving using compressed air.

Dr. Juza Chen inquired about the best animal model for implantation of a penile prosthesis for research purposes. Dr. tom Lue suggested that animals with good size penis (e.g. dog or monkey) would be appropriate.

The discussion initiated by Dr. Bertero -about HIV & ED therapy- was among the most active on ISSIRList for the past 2 years. The initial concern presented by Dr. Bertero was how to avoid prejudice and unfairness towards a patient with HIV requesting penile prosthesis surgery, while preventing disease spread if the patient was promiscuous. The majority of responses were in favour of doing the surgery while counselling & educating the patient about the risk of transmitting the disease to sex partners. A second question posted by H. Ghanem was whether we were always obliged to operate even if the issue we were uncomfortable with was not HIV. The majority of responses seemed to favour the notion that the surgeon is not obliged to perform a surgery he / she is not comfortable with, and the patient is free to chose another surgeon with a different point of view. Members favouring different points of view made very strong -and often quite heated- arguments.

Dr. Costa Neto inquired if any member had experience with the use of ESWL to treat Peyronie�s disease. Dr. Ben-Zion�s had experience with two patients that underwent ESWL for moderate to severe Peyronie�s disease. It gave much pain and had no result. Dr. Witzsch also found ESWL to have no influence on the curvature. These were just personal observations. Data and references would be helpful to clarify this area further.

Dr. Kevan Wylie inquired about a patient requesting a non-surgical treatment for a tight foreskin problem. Dr. Juza Chen listed the surgical options. Dr. Emre Akkus suggested applying a clamp between the foreskin in a closed position and opening it slowly to free the foreskin. He however stressed that this may be a temporary and painful solution and agreed with Dr. Chen that the definitive treatment would be surgical.

Currently a very active discussion is going on about the name of the society�s new Journal and the evolvement and training of Sexual Health Professionals.

Tanssexualism with borderline IQ

Dr. Amr Abd El Rehiem prepared an interesting case where Transsexualism was associated with Klinefelter�s syndrome (mosaic type) and borderline IQ. The main question was: Are there any specific precautions in performing sex change on a patient with borderline intelligence? Dr. John Pryor stressed that proper preoperative evaluation by 2 psychiatrists is crucial preoperatively, noting that when surgery is subsequently regretted, it is a tragedy and impossible to rectify. H. Ghanem mentioned that in a joint a joint Psychiatry / Andrology conference in Cairo University, it was agreed that she would be followed up in the psychiatry clinic for a period of 6-12 months before a final decision about surgery is made.

Case by Dr. Amr Abd Rehiem

I wish to forward this case that was prepared by Dr. Amr Abd El Rehiem, resident of Andrology, Cairo University. It is interesting that Transsexualism was associated with Klinefelter�s syndrome (mosaic type) and borderline IQ. The process of obtaining approval for sex change in Egypt is lengthy and complicated, but might be approved in this case due to the presence of physical factors and the XXY karyotype. On the other hand a borderline intelligence complicates the situation. Our questions are: Are there any specific precautions in performing sex change on a patient with borderline intelligence? Is there any literature about similar cases where gender identity disorders were associated with physical abnormalities?

A 35 years old, single, patient living in Suez City works as a cleaner at a club of an oil Company. She has a male phenotype and was reared as a male. She attended the Andrology outpatient clinic, Cairo University requesting sex re-assignment surgery to a female.

The condition was noticed since early childhood & manifested by a strong preference for girls as playmates and an intense desire to participate in stereotypical games and pastimes of girls with consistent a desire to be the other sex. Although patient preferred cross-dressing, masculine clothes were imposed on her by her parents.

At the age of 13 years, she started cross-dressing, tried to simulate female attitudes and always preferred the company of females. She was preoccupied with getting rid of her penis, feeling disgusted about it. Her family criticized her behaviour, especially her brother who abused her physically several times but the patient insisted that she was a female and never changed her attitude. He finally accepted the condition and she now lives with him after her parents died. Her parents were very upset by the condition but accepted it as an incurable disease. Her family call her Nasser (a boys name), but her neighbors and friends call her Nasra (a girls name). She dropped out of school at age of the age of twelve. As the patient was growing up, she had an intense and persistent discomfort with her sex, a sexual attraction towards males, and an intense desire to undergo sex re-assignment surgery.

When she was 22 years old, she sought medical advice in a private clinic where hormonal treatment was prescribed for her but she refused to take it, then she was referred to El Hussein University Hospital but nothing was done.

Three months ago, she sought medical advice again in Heliopolis hospital from where she was referred to our department in Kasr El Aini hospital. Physical examination revealed a small-penis of 7 cm and small testicles 2 cm volume. No secondary sexual characters in the form of beard, moustache, hoarseness of voice and having only scanty pubic and axillary hair.

Her karyotype is that of mosaic Klinefelter's syndrome 47 XXY (10%) 46 XY (90%)
Hormonal profile revealed an elevated FSH and low Testosterone.

FSH: 30.9 mU/ml (1.5-13)
LH: 11.2 mU/ml (0.8-7.6)
PRL: 7.6 ng/mL(2.5-17)
Total Testosterone: 0.5 ng/mL (2.6-13.5)
Estradiol: 9.8 (0-56)
Cortisol: 23.8 ug/dL (5-25)

Psychiatric assessment confirmed the diagnosis of Transsexualism associated with a low IQ (85). The patient fears traveling from Suez to Cairo on her own as she �gets lost� and seeks the help of her neighbors. Several ladies were kind enough to bring her over. She appears to be amazingly popular in her neighborhood where she is treated as a female and is invited to all weddings as she is known to be quite loud singing, dancing, and cheering up the atmosphere! Within the hospital she is very vocal and ready to express her dissatisfaction and frustration with lengthy procedures. The borderline IQ appears to be out of line with her conversational skills that seem to be quite well developed.

Any advice or precautions regarding the management of this case would be appreciated.

Hussein Ghanem, M.D.
Professor of Andrology, Sexology & STDs
Cairo University
hghanem@gawab.com

Comment By Dr. Pryor

Is she living and dressing as a woman? I would not consider operating unless she had been assessed by two psychiatrists who had experience of looking after patient's with gender dysphoria. When surgery is subsequently regretted, it is a tragedy and impossible to rectify. I have seen it.
John Pryor.

Comment By Dr. Ghanem

I would like to thank Dr. Pryor for his advice regarding our unusual case of gender dysphoria associated with a borderline IQ. The patient has been living as a woman for several years. She was evaluated in the Psychiatry department, Cairo University, by several staff members, and her case was presented in a joint Psychiatry / Andrology conference.

The general agreement was that it is a true case of Transsexualism. It was agreed that she would be followed up in the psychiatry clinic for a period of 6-12 months before a final decision about surgery is made. As mentioned in Dr. Pryor�s letter, it would be a tragedy if surgery was performed but subsequently regretted, I suppose this would be particularly true in our case where the patient is mentally challenged.

Hussein Ghanem, M.D.
Professor of Andrology, Sexology & STDs
Cairo University

Painful Penis Followup

In a previous discussion, Dr. Frederick Snoy presented a case of a 70 years old patient that has had pain on erections in the right side of the glans penis since he was a teenager. Dr. Emre Akkus & Dr. Shedeed A Shedeed suggested MRI & US evaluation while Hussein Ghanem suggested evaluation regarding a psychosomatic disorder if a physical lesion is ruled out

Dr. Snoy was kind to update us about the outcome of this case. He suggests that this problem appears to be a neurologically based event. Neurontin (gabapentin) 100 mg 2 hours prior to sex has completely resolved the problem. Dr. Shedeed reported similar findings with a HSVII patient and a patient on intracavernosal therapy.

Update by Dr. Snoy

Ladies and Gentlemen,

Some time back I solicited suggestions about a patient who had a life long complaint about severe right sided glanular pain on ejaculation. The patient avoided this event because of the severity of the pain. Physical exam was normal, as was neuro exam, and prostate US as well as a MRI of the penis -- suggested on this list. ( It was the only MRI of the penis at our facility.)

I finally suggested to the patient that he take Neurontin (gabapentin) 100 mg 2 hours prior to sex and this has completely resolved the problem. He is enjoying a sexual relationship for the first time in his life. A nice trick that I will remember!

Apparently this problem was a neurologically based event triggered by ejaculation.
Comments?

Frederick J. Snoy MD
Urology Group of New Mexico
4161 Montgomery Blvd. NE
Albuquerque, NM 87109
W 505 872 4090
C 505 681 6988

Response from Dr. Shedeed
Hi Dr Sony
I have few patients like yours, but two of them revealed to be HSVII, with active viral shedding after coital trauma. one was related to a small subtunical plaque of Peyronie's on the same side (improved dramaticly on Colchecine). one was on chronic self injection prgram for ED and propably he hit the dorsal nerve of the same side. the rest they improved on Neurontin.
Thanks
Shedeed Ashour Shedeed, M.D.
Consultant and Lecturer of andrology,
Cairo university.

Non-Surgical Stretching Techniques In Men With A Tight Foreskin

Dr. Kevan Wylie inquired about a patient requesting a non surgical treatment for a tight foreskin problem. Dr. Juza Chen listed the surgical options. Dr. Emre Akkus suggested applying a clamp between the foreskin in a closed position and opening it slowly to free the foreskin He however stressed that this may be a temporary and painful solution and agreed with Dr. Chen that the definitive treatment would be surgical.

Question by Dr. Wylie

Does anyone have any experience of non surgical stretching techniques in men with a tight foreskin who cannot retract the foreskin when erect? I have a patient very distressed by this who has read about use of steroid cream being used. He has read work by Michel Beauge.

Any advice or thoughts would be appreciated.

Kind regards

Kevan.

Kevan R Wylie MD
Consultant in Sexual Medicine
Porterbrook Clinic, Sheffield.
P.A. Tania Ferreyra 0114 271 8674
& Consultant Andrologist
Royal Hallamshire Hospital.
Secretary - Kim Monk 0114 271 3334
Editor-In-Chief Sexual & Relationship Therapy
President EFS2004

Response By Dr. Chen

Dear Kevin,
Several surgical options can be reasenable solutions for this patient:
1. Circumcision.
2. Z -plasty of the foreskin.
3. Dorsal split incision.
Best regards,
Juza Chen, MD

Response by Dr. Akkus

Dear Kevin,
What I understand from your words is a phimosis like condition. Because of the secretion from the Tyson glands (+) infection, foreskin may be tightly and in adhesion like situation to the penis.
If the patient wants a non-surgical approach you can apply a clamp between the foreskin and the the penis in close position and open it slowly and the foreskin may be free in few seconds.
BUT this may be a temporary solution and painful as well.
The real solution is surgical and the alternatives are clearly stated by Juza Chen.
Happy new year
Emre Akkus

HIV infection and Penile Implants

The discussion initiated by Dr. Bertero was among the most active on ISSIRList for the past 2 years. It is thus difficult to address all points raised in this digest. More than thirty responses were obtained. Around 10% of the ISSIR list members were contributed to this discussion.

The initial concern presented by Dr. Bertero was how to avoid prejudice and unfairness towards a patient with HIV requesting penile prosthesis surgery, while preventing disease spread if the patient was promiscuous. The majority of responses were in favor of doing the surgery while counseling & educating the patient.

A second question posted by H. Ghanem was whether we were always obliged to
operate even if the issue we were uncomfortable with was not HIV. The majority of responses so far seem to favor the notion that the surgeon is not obliged to perform a surgery he / she is not comfortable with, and the patient is free to chose another surgeon with a different point of view.

Members favoring different points of view made very strong -and often quite heated- arguments.

ESWL and Peyronie�s disease

Dr. Costa Neto inquired if any member had experience with the use of ESWL to treat Peyronie�s disease. Dr. Ben-Zion�s had experience with two patients that underwent ESWL for moderate to severe Peyronie�s disease. It gave much pain and had no result. Dr. Witzsch also found ESWL to have no influence on the curvature. These were just personal observations. Data and references would be helpful to clarify this area further.

Question by Dr. Neto

Dear coleagues, does any of you have the experience with ESWL to treat
Peyronie�s desease.

best regards,

Costa Neto
..................
Francisco Costa Neto. MD.
Associate Prof.
Santa Izabel Hospital
Dep.of Urology/Andrology

Response by Dr. Ben-Zion

I had two patients that underwent ESWL for moderate to severe Peyronie - it gave much pain and had no result. I see no much of Vit E amd or PABA- only operations gave good results.
Best regards

I.Z. Ben-Zion MD
Head
Sex Clinic Soroka Medical Center
POB 151 Beer-Sheva 84101
Tel:+972-8-6400783/351
Fax:+972-6403080

Response by Dr. Witzsch

Dear Coleagues,

ESWL reduces pain, sometimes plaques are smaller or gone after the treatment. I t seams not to have an influence on curvature at least in our hands.

Regards

U. Witzsch

Diving and Erectile Dysfunction

Dr. Cunha initiated an interesting discussion about any effect of skin-diving (without equipment) on erectile function, an apparently virgin topic. No literature appears to be available concerning this topic. Comments included looking into explanations related to endothelial function or oxygen concentration changes. Psychological factors were also suggested by H Ghanem as changes in Oxygen or Nitrogen tissue & blood concentrations occur mainly when scuba diving using compressed air. I wish to thank Dr. Cunha as it was refreshing to discuss diving amidst our every-day routine work.

Question from Dr. Cunha

Could anybody inform, why after diving for long periods in a same day (medium depth of 20 meters) without help of equipments, do some patient ones improve the erectile functions?

Paulo Brito Cunha

Comment by Dr. Murad
Dear
I am a diver yet i notised no differanse , if u have data please inform us.
best regards

Z.murad
F.R.C.S.Ir
Consultant Urologist

Comment by Dr. Moreira

Dear Paulo:1)I am 57 and dive for 40 years.It s exceptional someone could dive 20 meters without equipment.
2)I never realize changes in my erectile functions nor in my peers divers.

Dr.Carlos Moreira
Clinica Masters
Uruguay

Comment by Dr. Belen

Paulo:
It's exceptional could dive 20 meters without equipment. Probably in themolecular biology finding the answer.
Dr. Raul A. Belen. Cordoba Argentina.

Comment by Dr. Witzsch

Dear all,
this not strange to me even I do not have detailed data. This is like oxygen therapy in a high pressure chamber. Oxygen supply to any tissue is increased. So this might help in mild organic ED.

Ulrich Witzsch

Comment by Dr. Cunha


Dears
Actually, I would like to know if exists dive and endothelium association. Would it be beneficial? Would it be deleterious? I don't have answer(the true) for three patients that tell improvement of erectile function with the act of diving. I need scientific data, besides the personal opinion, for reply or not( the patients ).

Best regards

P Brito Cunha

Comment by Dr. La Pera

Dear Friends, I do not have the answer to this dilemma but I can report that I treated a men with E.D. who worked as professional diver . He was 42 y.o. and I did not discover any risk factor or reason to explain his E.D. . Sincerely Yours
Giuseppe La Pera

Comment by Dr. Ghanem

Dr. Cunha inquired about a patient reporting improved sexual function after skin-diving 20 meters (without equipment). Changes in Oxygen or Nitrogen tissue & blood concentrations occur when scuba diving using compressed air. Such changes are unlikely without the use of diving gear and air tanks. Thus a physical explanation to altered sexual function after skin-diving is difficult. I'm not aware of any literature discussing this topic.

A simple explanation to the patient's improved sexual function in Dr. Cunha' s case might be a better psychological mood, or feeling of well being after practicing a hobby that the patient enjoys, and is obviously very good at, a
"holiday-like effect". As for the remarkable diving depth of 20 meters, the patient might be mistaken. It is my understanding that most depth gauges and dive planners are calibrated in feet not meters.

Hussein Ghanem, M.D.
Professor of Andrology, Sexology & STDs
Cairo University

Animal Model For Penile Implants

Dr. Juza Chen inquired about the best animal model for implantation of a penile prosthesis for research puposes. Dr. tom Lue suggested that animals with good size penis (e.g. dog or monkey) would be appropriate.

Email from Dr. Chen
Talking about penile prosthesis, does anybody have suggestion which animal model is the best model for insertion of penile prosthesis for research purposes?
Thanks for advice.
Juza Chen, MD

Comment from Dr. Ghanem
Dear Colleagues,

Dr. Juza Chen inquired about which animal model is the best model for insertion of penile prostheses for research purposes.

Anatomically, the morphology of primate genital organs is closest to that of man, keeping in mind the diversity of genital organs of primates. It appears that man is fortunate to have the most well-developed erectile mechanism resulting in complete loss of the penile bone which has been described as characteristic of other primates and placental mammals (1).

I understand that much of the research work on penile hemodynamics done by Dr. Tom Lue's group in San Francisco was conducted on primates.

It might also be noteworthy that the first procedure for implanting intracavernous polyethylene rods was performed in the Fifties, apparently without prior animal work (2).

1) Philippe Bernot. Male Impotence. A historic perspective. L'Esprit Du Temp, 1994. ISBN 2-908206-37-4
2) Beheri G.E., 1960: The Problem of Impotence Solved by a New Surgical Operation. Kasr El-Eini, J. Surg. 1:50-56

Hussein Ghanem, M.D.
Professor of Andrology, Sexology & STDs
Cairo University, Cairo, Egypt
hghanem@gawab.com

Comment from Dr. Lue
Dear All:

A minor correction of Dr. Ghanem's comments.

1. For hemodynamics, we started with dog then expanded to monkey, rabbit and rat with the intention to prove that the erectile response was the same no matter the animal has os penis or not.

2. For penile prosthesis, you will need animals with good size penis (e.g. dog or monkey) unless you are working on penile prosthesis for children.
--
Regards,
Tom

Comment from Dr. Sharlip
Re: Email of Hussein Ghanem, M.D. on penile prosthesis research.

Dr. Ghanem commented, "It appears that man is fortunate to have the most well-developed erectile mechanism resulting in complete loss of the penile bone..."

I wonder sometimes if it wouldn't be better to have an os penis. Then we wouldn't have to worry about loss of penile rigidity. I also wonder what Darwinian survival advantage there might be in evolving out of the os penis.

Ira Sharlip, M.D.

Comment from Dr. Lue
In response to Ira's comment.

When men became bipedal and upright, the penis has to be flaccid when not involved in reproductive activity. Just imaging how many times you will be called to ER to fix a broken OS PENIS after any contact sport events (soccer, American football, waterpolo, etc). Also think about bicycling with an OS PENIS between the pubic-ischial bone and the damn seat!!
--
Regards,
Tom

Comment from Martin-Morales
I really enjoyed this debate. The list is absolutely fresh and full of
knowledge. Congratulations to the panel.

Antonio Martin-Morales, MD
Las Palmeras 37, Pinares de San Anton
29018, Malaga
Spain

Comment from Dr. Krishnamurti
Dear Dr. Sharlip,
The purpose behind the loss of the os penis in humans might be an evolutionary biological and eugenic one. Many of the causes of erectile dysfunction are hereditofamilial. Restoring erectile function in patients suffering from such predisposing (underlying) disorders is probably dysgenic and helps perpetration of these conditions when such patients reproduce.
So, therefore, while we may be doing service to a man's recreative sex life by `curing' him, we are probably doing a disservice to the species in general by propagating the survival of the `not the fittest'. Since nature does not distinguish between procreative and recreative sex, maybe we should. This might make a strong case for counselling of such patients about such matters.
Sudhakar Krishnamurti
Andromeda Andrology Center
Hyderabad, India

Comment from Dr. Cellek
I find Dr Krishnamurti's comments a bit difficult to believe. Maybe could he explain what he means with:
"The loss of os penis has a eugenic purpose".
"Many causes of ED are hereditofamilial". These are very strong statements and need to be supported with references (if any).
Regards,
S Cellek

Comment from Dr. Krishnamurti
Dear Dr. Cellek,
I was just thinking aloud and hypothesising loosely in response to the last line in Dr. Sharlip's message, viz., "I also wonder what Darwinian survival advantage there might be in evolving out of the os penis." Diabetes, hypertension, the lipid disorders, ? multiple sclerosis - very common causes of organic E.D. - can be hereditofamilial (again, the term is being used broadly). So I was just wondering whether nature inflicts E.D. on such afflicted men in order to stop them from reproducing, thus encouraging survival of the fitter (non-afflicted) ones. If so, then that might be an `eugenic' purpose. I did not imply that all E.D. is heredito-familial or that there can be no other explanation for the disappearance of the os penis.
The whole idea was just to brain-storm with colleagues. Naturally, therefore, I didn't think of the bibliography !
Best regards,
Sudhakar Krishnamurti.

Last update : 01/03/2004