Digest of recent discussions on ISSM mail (Jan - April 2004)
Hussein Ghanem MD
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Discussions on ISSIR List are taking more depth with the generous input from members dealing with several aspects of ED. It is a privilege not readily available to most practitioners to find urologists, andrologists,
psychiatrists, sex-therapists, endocrinologists and other related scientists, brainstorming a single case.
The discussions were very active during the first 4 months of 2004. |
The list of topics and responses includes:
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Dr. Amr El-Meliegy inquired if any member used baclofen for the treatment of stuttering priapism. Treatment of recurrent idiopathic priapism with oral baclofen was suggested in a recent Journal of Urology article (Dec 2002; 168: 2552) by Rourke et al.
Dr. Gregory Broderick found it effective for the suppressing nocturnal erections/stuttering priapism. However, neurologically normal patients noted unpleasant side effects. Dr. Hossein Sadeghi-Nejad tried Baclofen on 2 patients with stuttering priapism.
One did not respond while the other noted mild temporary improvement. Side effects were not a significant problem in Dr. Sadeghi-Nejad�s cases at a dose ranging from (5-40 mg qhs). Both cases were later managed by self-injection of phenylephrine. Other
treatment lines for recurrent priapism may be read on http://www.issir.org/ by clicking ISSIRList / Digest directory.
Case by Dr. Meliegy:
Dear Colleagues,
Anybody have experience as regards using baclofen in treatment of stuttering priapism?
Thanks,
Amr El-Meliegy, MD
Consultant of Andrology
Soliman Fakeeh Hospital-Jeddah-KSA
Associate Professor of Andrology & STDs-Cairo University
Reply by Dr. Broderick:
It has been written up in several journals.
There is information on management of stuttering priapism on-line: click on Publications this will give you option of AUA Guidelines.
www.auanet.org
Personally I have found it effective for the suppressing nocturnal erections/stuttering priapism; unfortunately neurologically normal patients don't like the side effects.
GABroderick
Response from Dr. Sadeghi-Nejad:
Based on the relatively recent J Urol article, I have tried Baclofen on 2 patients with stuttering priapism. One did not respond at all. The other had mild improvement for the first 2-3 weeks, but reverted back to his usual state. Started at a dose of 5mg
and gradually increased to 40 mg qhs. Side effects were not an issue with either patient at these doses. They are now both successfully managed with self-injection of phenylephrine.
Hossein Sadeghi-Nejad, M.D., F.A.C.S.
Associate Professor of Urology
UMD New Jersey Medical School
Chief of Urology
NJ Veterans Affairs Hospitals
Director, Center for Male Reproductive Medicine
Hackensack University Medical Center
20 Prospect Ave, #711,
Hackensack, NJ 07601
Telephone: (201) 342-7977
Fax: (201) 342-0623 HUMC
Fax: (973) 395-7197 VA/University
Web: www.hsadeghi.com
Dr. Kevan Wylie initiated an interesting discussion about dorsal neurotomy for the treatment of premature ejaculation. Dr. Giuseppe La Pera made a very strong case against the use of this experimental technique. Many members contributed to this very
interesting discussion that may be read online on www.issir.org
Dear colleagues
In 1994 Romero & Rebello (I think) published a paper on dorsal neurotomy for premature ejaculation. Does anyone have the reference details and any more recent experience?
Kind regards
Kevan Wylie. Sheffield. UK
Dear Dr Kevan Wylie:
Recently, in a meeting of the Spanish Andrology Association in Santo Domingo, Dr Ana Puigvert and other colleagues were presenting their experience on this matter. They have treated a large number of cases and found it usefull on some special patients.
I am sending the e mail address of Dr Puigvert, renowned andrologist from Spain, so you can contact her.
anapuigvert@hotmail.com
Best regards
Dr Oscar D�az
Cuba
Dear Kevan Wylie
here my opinion and experience regarding neurotomy .
First of all, let me apologize for not being short, in fact this subject needs time for considerations.
As many of you, I have followed the issues regarding the premature ejaculation. At the beginning of the 90's, I had the chance to observe these kind of experience. I have some doubts on the real effectiveness of the neurotomy to treat the premature
ejaculation.
Here are my doubts :
1. Since a universally accepted definition of the premature ejaculation hasn't been given yet, how is it possible to state the effectiveness of the neurotomy? How is it possible to heal something that could be healthy?
2. The tests presented during the conferences, at the beginning of the 90's, proving therapeutic effectiveness, were based on the BCR (boulbus cavernous reflex). Who is able to explain to me how a vegetative reflex can be measured by a test which explores
only the somatic pathway?
3. The tests boasted the demonstration of a supposed effectiveness were based on the wave amplitude of the BCR. Whoever has experienced these kind of tests knows that the wave amplitude does not measure anything since the wave amplitude may depend on the
thickness of the skin, the positioning of the electrode and on the sweat of the patient. How is it possible to demonstrate supposed effectiveness using a parameter which does not measure what we are looking for?
To my opinion, whoever intends to perform this operation should do it either in research centers or in the hospitals authorized to carry out no-profit research.
The procedures to be followed have to be those usually used for experimentation in man: ethical committee� good clinical practice, etc.
In the informed consensent, the patient must clearly have understood that:
1. the operation is experimental;
2. the boasted results are not evidence based;
3. there are non surgical therapy alternatives,
4. the scientific community has not published anything about this kind of surgery on the so-called indexed journals from 1966 to this day;
5. there may be serious complications such as the loss of sensibility and loss of ejaculation (according to what have been reported in a small series in early 90s)
In my opinion in 2004 to perform such kind of surgery outside this context is ethically and scientifically unacceptable since that patients could be pushed to undergo this operation only for mere economic reasons without having any advantage in change.
Giuseppe La Pera Rome Italy
Dear Kevan:
I totally agree with La Pera. I wouldn't do that operation for PE, it is totally experimental and too dangerous. Furthermore, the same result can be achieved with the use of local anaesthetics applied to the glans penis and is totally reversible; try this
to see if can be of any help in your patient before considering this aggressive operation.
Best regards,
Ignacio Moncada
Madrid, Spain
Dear Dr.La Pera: I wholeheartly share your opinion.I also congratulate you for the clarity of your statement.PE is also a variable phenomenon which an individual can experience episodically.Also it is also important to consider the placebo effect
present in ANY intervention in this condition which pathophysiology it is still poorly understood.Any ablative proedure should be considered with upmost caution.
Dr.Roberto F.Labayen
Buenos Aires -Argentina
Thanks Ignacio
I agree with the comments raised by yourself and colleagues. My reason for asking was to try and determine if this procedure was still being undertaken or had been relegated to the history books. There are now some good pharmacological options as well as
Prolong and behavioral techniques.
Best wishes
Kevan.
Dear Kavan,
I totaly agree with Dr. Moncada. This operation is experimental and at this moment should not included in arsenal of treatment for RE. Forthermore, this operation can cause unreversible damage and can damage quality of life of your patient. There are
several effective treatment for RE with reasenable results.
Juza Chen, MD
Dear Dr Kevan
I agree with other opinions about dorsal neurotomy for rapid ejaculation: it is totally experimental, no proved results, no completely accepted. And there is another point: Dr Pompeo, from Sao Paulo University, Brazil, observed patients with rapid
ejaculation before and after penectomy, and some of them persisted with their complaints. If this is a behavioural problem, why do you try to solve using a surgical procedure? It is more prudent applying psychotherapy and some medications, that are more
effective.
Carlos Da Ros
Porto Alegre, Brazil
I agree with Dr Da Ros, remembering the paper of Dr Pompeo from S�o Paulo, USP that stated the same kind of ejaculation instead the Penectomy.
Kind regards.
Dr Carlos Cairoli
HSL-PUCRS
Dr. Frederick J. Snoy presented a case of ejaculation at midday without any erotic thoughts. Dr. Pierre Assalian noted that spontaneous ejaculation has been reported in males who has been taking PROZAC and other SSRIs, as well as natural drugs like St
Johns wart and also inquired about street drugs. Dr. Zohier Murad suggested excluding a stimulating irritating factor affecting his ejaculatory neurological pathways.
The detailed discussion:
Gentlemen,
I have recently seen a patient who came in with complaints of spontaneous ejaculation. He says this happens midday usually when going about his work. He denies having an erection at the time, or any erotic thoughts or fantasies. He says its very
embarrassing, as he is fully dressed, at work, and suddenly exudes a full ejaculation. He complains that it reduces his sex drive with his wife somewhat as this happens several times a week recently. "And I feel like I've already had sex that day." He is
on no medications and doesn't seem to have psychiatric issues.
I had another patient with nearly the same complaints several years ago.
Any ideas? Source? Treatment?
I have ordered an MRI of the brain.
Frederick J. Snoy MD
Urology Group of New Mexico
4161 Montgomery Blvd. NE
Albuquerque, NM 87109
W 505 872 4090
C 505 681 6988
Dear Dr Snoy
Spontaneous ejaculation has been reported in males who has been taking PROZAC and other SSRIs,usually was accompanied by Yawning.It is not common side effects.You said he does not take any medication,but does he take any natural drugs like St Johns wart.I
have reported the occurence of delayed ejaculation in a patient who takes st john warts,so is he taking also street drugs?
I do not know why you orderd MRI. If nothing organic is found ,may be he could be put on Clomipramine(Anafranil)25 to 50 mg qd to delay his ejaculation or Paroxetine 10 mg qd.Keep us informed
Pierre Assalian,M.D
Psychiatrist and Sexologist
McGill University
President 17th World Congress Of Sexology
July 10-15,2005 Montreal
Dear Collegue
I had no similar case yet If the patient have no psychiatric disease and is not having eratic thoughts or fantasies and is not on drugs and have no apparent illnes ,then we should think of a stimulating irritating factor affecting his ejaculatory
neurological path ways either spinal or within the brain ...So kindly look into local disease affecting the nerves or even tumers affecting his neurones .
Kindly keep me informed about his final diagnosis.
Best Regards
Z.murad
F.R.C.S.Ir
Consultant Urologist
Dr. Kevan Wylie presented an unusual case of gender dysphoria where a transsexual women on anti-androgen therapy requests sildenafil to insure that her (male) partner see her aroused. Dr. Mario Maggi noted that that anti-androgen treatment strongly
decreased PDE5 gene and protein expression in human penis and therefore responsiveness to sildenafil. H Ghanem & Dr. Pierre Assalian suggested that it was atypical that patient was not upset that her partner shows interest in her male genitalia. Dr.
Charles Moser reported prescribing PDE5 inhibitors to MTF transsexuals with good results. On the other hand Dr. Shedeed Ashour reported a FTM transsexual requesting tadalafil in hope for clitoral engorgement!
The detailed discussion:
Dear colleagues
Has anyone ever read or had experience in the use of prescribing antiandrogens for trans women who at the same time complain of ED and ask for sildenaifil to ensure their (male) partner can see them aroused an sexually interested during the RLE and before
any surgery. The patient protests that they are truly gender dysphoric?
We have this dilemma in our clinic.
Regards,
Kevan R Wylie MD
Consultant in Sexual Medicine
Porterbrook Clinic, Sheffield.
P.A. Jaye Pinder 0114 271 8674
& Consultant Andrologist
Royal Hallamshire Hospital.
Secretary - Peter Zyss 0114 271 3334
Editor-In-Chief Sexual & Relationship Therapy
President EFS2004
We recently found that anti-androgen treatment strongly decreased PDE5 gene and protein expression in human penis and therefore responsiveness to sildenafil. The reference is Morelli A, Filippi S, Mancina R, Luconi M, Vignozzi L, Marini M, Orlando C,
VannellAversa A, Natali A, Forti G, Giorgi M, Jannini EA, Ledda F, Maggi M. ANDROGENS REGULATE PHOSPHODIESTERASE TYPE 5 EXPRESSION AND FUNCTIONAL ACTIVITY IN CORPORA CAVERNOSA.
Endocrinology. 2004 Feb 5 [Epub ahead of print]
Hoping that this helps
Mario Maggi
Dear Dr. Wylie,
I don't have an answer for this interesting case but I wish to raise more questions. Is the patient not upset that her partner shows interest in her male genitalia? Does her partner perceive her as a male homosexual rather than a transsexual female! It
seems to me to be an atypical presentation.
Are there other gender dysphoric females with similar complaints?
Best regards,
Hussein Ghanem MD
Professor of Andrology, Sexology & STDs
Cairo University, Cairo, Egypt
Dear Dr Ghanem
This indeed is another dilemma. We wonder that the relationship will not continue afterwards because there is no penetration of the trans lady nor any use of the trans woman's erection other than to confirm sexual interest and achievement of orgasm.
We have not had this issue in over 6 years of our clinic!
Kevan.
Dear Kevan
I agree with Dr Ghanem,This is an atipical case of Gender Dysphoria.All our cases do not want anything to do with (this),meaning thewir penis,If I am the treating psy.I will not give him a PDE5 inhibitor.
Pierre Assalian,M.D.
Mcgill University
President 17th WCS 2005
Montreal,Canada
Dear folks,
To give a different perspective, I have prescribed PDE5 inhibitors to MTF transsexuals. The reasons for the request have been varied. Some report a better orgasm, some report they are doing it only for their partner, and some are interested intercourse.
Many of these patients have gone on to have sex reassignment surgery; no regrets have been voiced. One patient did eventual break up with her boyfriend, because he could not get aroused after she lost her penis. She grieved the relationship, but was not
sorry about her experiences with sildenafil or the surgery.
I think it is worth noting that all these individuals were on antiandrogen therapy; the current data would suggest that they should not respond to PDE5 inhibitors when hypogonadal. Since they all did, I wonder if estrogen can facilitate PDE5 inhibitor
function.
I caution people not to make hard rules about how a transsexual should behave. The theories behind transsexuality are in a state of flux, there are different types of transsexuals, and the individuals in these categories are not uniform. Clearly, on-going
psychotherapy is important to the transition process. If anyone does not know, there is a professional society that deals with the problems of transsexuals, link below.
Take care,
Charles Moser, Ph.D., M.D.
Dear all
I am facing more or less the same problem of a youg virgin who is a trans sexual and came with her-his- partner to my clinic asking for Tadalafil, because the more natural long action to ensure her masculine role during the act and feel the clitoral
engorgment during arousal. she is not yet operated upon but promised by this and on the hormonal treatment now. what's your opinion.??????
Shedeed Ashour Shedeed MD.,
Lecturer of andrology, Sexology & STDs
Cairo University, Cairo Egypt
Consultant of Andrology, Erfan Hospital Jeddah.KSA
Dear Dr.Shedeed
I am the director of the Human Sexuality Unit of the McGill University Health Center Montreal,Canada and have been involved with the evaluation and treatment of Transsexuals for the last 26 years.Your case is atypical.I do not fully understand what is she
requesting?There should be evaluation from psychiatic point of you.We have no data about clitoral engorgement with Tadalafil nor any of the others.
By the way I am a graduate of Cairo University 1968 and in Canada since 1969.
Pierre Assalian,M.D.
Associate Prof.Psych.
President 17th World Congress of Sexology Montreal 2005
Dr. Nguyen Tan Trung inquired about the management of severe post-priapism penile fibrosis. Dr. Andik Wijaya suggested the trial of a vacuum suction devise. Definitive therapy appears to remain surgical by implanting a penile prosthesis by experienced
implant surgeons.
Question by Dr. Tan Trung
Dear all friends,
We must wait until Thursday October 21 to discuss this problem with I.Saenz de Tejada and E.Wespes in Buenos Aires,according to the 11thWorld Meeting Program.But I already have 2 cases of severe post-priapism penile fibrosis involving entirely the 2
C.Cavernosa,do you have any suggestion about the management ?
Thanks and Kind regards,
Nguyen Tan Trung,MD
HochiminhCity,Vietnam
Response by Rr. Wijaya
Dear Dr.Nguyen Tan Trung,
I have experience with the same condition. I've prensented the case in a poster presentation during Montreal Conference.
I use Vacuum pump (Erect aid-Osbond) to forse a sufficient blood flow to the corpus covernosum twice a day ( 15 minute ). And also give the patient 500mg Vitamine C three times a day.
Fortunately, around a month later, the fibrosis resolve, and the erection become better.
regards,
Dr.Andik Wijaya, MRepMed(Dipl)
www.drawclinic.com
Dr. Oscar D�az inquired about possible immunological reactions in relation to penile prosthesis implantation. Dr. Mustafa Usta & Dr. Gregory Broderick noted that they are not aware of any such reports. Dr. Broderick reported a paper by Dr. David
Barrett that did address this issue regarding silicone in Artificial Urinary Sphincters. The paper did note particles of silicone in remote locations from the implant site, but found no evidence of immunologic 'syndromes' as was being claimed by patients
with breast implants. Dr. Ulrich Witzsch reported that an article in the lay press mentioned a case of a patient who went to court claiming an immunologic reaction.
The detailed discussion:
Dear Members of the ISSIR:
I am the head of sexual therapists in Cuba.
We have used penile prosthesis before, but now we will star a new project for the implant of prosthesis to a bigger number of patients. As we are doing a protocol for this procedure, someone here has talk about the neccesity of including inmunological
tests to the protocol for the measure of any change in the inmunological response of these patients due to the effect of silicone.
It is there any report on the effects of penile silicone implants on inmunology?
Have you seen any patient with inmunological problems as side effect of prosthesis implantation?.
Best regards
Dr Oscar D�az
Dear Oscar
For about 10 years I have attendt as well as I performed about 150 IPP operations. I have never seen or read any information about immunological
reaction in these patients after operation
Best Regards
Mustafa F Usta M.D
I am not aware of any peer reviewed evidence demonstrating immunologic reactions early or delayed to contemporary penile prosthesis (Mentor or AMS).
More than a decade past Dr. David Barrett did address this issue regarding silicone in Artificial Urinary Sphincters. His paper did note particles of silicone in remote locations from the implant site, but found no evidence of immunologic 'syndromes' as
was being claimed by patients with breast implants.
You may want to look up that reference.
GABroderick
Professor of Urology
Residency Program Director
Mayo Clinic Jacksonville
President Elect
Sexual Medicine Society NA
Dear Dr. Dias,
some years ago there was an article in some german newspaper that a patient had immunological problems with a prostheses. He went to Court against Dow Corning if I remember right.
I do not know any scientific paper out of that time regarding that problem.
Regards
Ulrich Witzsch
Dr. Sidney Glina presented a case where he was asked for a second opinion regarding a cutaneous fistula that occurred following bovine pericardium grafting for Peyronie�s disease. Dr. Eric Meuleman suggested the graft needs to be removed while Dr.
Guillermo Guegliov inquired about culture & sensitivity testing and suggested an antibiotic trial. Dr. Ulrich Witzsch suggested power-duplex and an MRI to find out where the infection is exactly followed by removing the graft �if needed- and covering the
gap with resorbable material. Dr. Tom Lue reported his experience and suggested a Mulcahy salvage procedure, and replacing the pericardium with porcine small intestine submucosal graft. Dr. Sudhakar Krishnamurti suggested removal of the infected graft
under sensitivity-dictated antibiotic cover, irrigating the operative field well, and placing a penile dermal flap.
The detailed discussion:
I saw a patient that had been submitted to a multiple plaque incision and bovine pericardium grafting for Peyronie�s disease two months ago. At 10th day after the surgery it had been noticed a small skin lesion in base of the penis that in the
following days started to drain purulent secretion. He came to me for a second opinion and I saw a cutaneous fistula that is actively draining secretion. There is no fever or any other symptom. I presume that the graft can be infected.
Has someone seen any case like that? Any suggestion for treatment?
Sidney Glina
Dear Sidney,
my gut feeling is to remove the inlay,
yours sincerely Eric Meuleman
Dear Sidney: Before removing the graft I would try to do the maximum efforts in order to control the infection. Has the secretion been cultured ? Did he receive proper antibiotics ? It seems like there is no emergency so you can take your time. Besides
that, if you take out the pericardium, what are you going to do with the gap ? There�s nothing written about this so it looks like you will have to do your own way. Warmest regards, Guillermo
Gueglio (Buenos Aires, Argentina).
Dear Sidney,
such a case I have not seen before, might be because of mad cow desease bovine material is not used in Germany any more. If I would get an case like that I would do an powerduplex and an MRI to find out where the infection is exactly. The best images in
MRI we have with erection, this might be a problem because I would not like to incejct into an infected region. So might be oral Medication and VSS might help.
First I would try an antibiotic therapy according to the culture. If the examinations proof an infection of the graft it has to be removed in my understanding. I would cover the defect with resorbabale material like tachocomb under a broad antibiotic
therapy.
Regards
Ulrich Witzsch, Frankfurt, Germany
Dear Sidney:
I had a similar situation that may be useful for your consideration. I placed a prosthesis and pericardium graft for a patient with severe curve and ED. He got infected 3 weeks later. When I went in, the pericardim was half digested by the infection. I
did a Mulcahy salvage procedure and replaced the pericardium with porcine small intestine submucosal graft. The patient was giving cipro for 4 weeeks. He did not get an infection and the wound healed nicely. About 2 months later the prosthesis eroded when
he pumped it up but he did not have infection at that time. Since you did not placed prosthesis, I think the salvage procedure will be more helpful.
--
Regards,
Tom
Dear Dr. Glina,
Have you ever tried closing the defect with a penile dermal flap ? Why don't you try it ?
Nearly all free grafts (whatever their source) will develop at least some necrotic areas in the short and intermediate term, if they do not die altogether, which they often do eventually anyway. Such necrotic areas form great nidi for infection. This
never happens in a flap with its own, assured, good blood supply. You can perform this operation in one stage. Remove the infected graft under sensitivity-dictated antibiotic cover, irrigate operative field well, and place the penile dermal flap.
Give it a thought.
Best regards,
Sudhakar Krishnamurti.
India.
Dear Sidney:
I agree with Dr. Krhisnamurtis' suggestion but adding a Mulcahy's salvage/antibiotic coverture. In this way you get the a better receptor surgical field, "clean of infection".
Good luck anyway with this challenging case, whatever the final treatment option you choose. Please let us know.
Best regards
------------------------------------
Hospital Regional Universitario Carlos Haya
Antonio Mart�n Morales
Unidad Androlog�a, Servicio Urolog�a
AMARTINMORALES@terra.es
Plaza Hospital Civil s/n
M�laga, 29009
Espa�a
tel: +34 951030371
fax: +34 951030362
mobile: +34 670586610
Dr. Eric Meuleman presented a very interesting case of an unusual ejaculatory disorder where the ejaculate dribbles out 2 minutes after orgasm. No abnormalities were noted on physical exam, TRUS & hormone profile. Dr. Dr. Andik Wijaya suggested a
neurotransmitter disorder. Dr. Krishnamurti suggested any urethral studies - 'scopy, 'graphy etc, Dr. John dean suggested a possible urethral diverticulum or possible cyst. Dr. Santiago Richter found a discovered a Urethral Diverticulum (Cowper's
Syringocele) in a similar case. Dr. Pierre Assalian noted that this is probably a urologic disorder not a sexological one while Dr. Stacy Elliott suggested Kegel�s exercises if no physical abnormality was found. Drs Raviv, Bronner & Sarig outlined
different possible physical, psychological and behavioral factors. Dr. Zohier Murad and Dr. Antonio Morales suggested a urethral stricture and recommended a uroflowmetry. Dr. Juza Chen inquired about medications mainly antidepressants or alpha blockers.
The detailed discussion:
Please give me your opinion about the following case:
A 33 year old healthy man with active childwish, complains about anejaculation.
He is experiencing an orgasm and then 2 minutes after he reached his orgasm the ejacuate is dribbling out. On examination this appeared indeed to be semen. Examination of his postejaculatory urine: negative
Previous history: blank. Physical (neurological) examination: no abnormalities. TRUS: normal. FSH, LH, Testosterone, HbA1C, prolacine: normal.
Who has questions/suggestions?
Eric JH Meuleman MD PhD
Consultant Urologist Sexologist
Dept Urology
University Medical Center St Radboud
POBOX 9101
6500HB Nijmegen
The Netherlands
Phone: +31243613920
Fax: +31243541031
I have a few patients with similar conditions. I suppose these cases related to the low level of neurotransmitter dopamine in the brain. So I tried to resolve the condition by giving them Levodopa 50 mg/ day for 2 weeks. Fortunately, some of them
finally able to ejaculate with optimum orgasm
Dr.Andik Wijaya,MrepMed(Dipl)
Couple Clinic Indonesia
Wisma BII 16th floor / Suit 1614
Surabaya, INDONESIA
www.drawclinic,com
Has this always been the patient's ejaculatory pattern ? If yes, do we have any urethral studies - 'scopy, 'graphy etc ? If not, then what was it like earlier, or at other times ?
Sudhakar Krishnamurti
India
Hi Eric
I suppose that he might have a urethral diverticulum or perhaps a cyst or some other lesion causing obstruction. Has he had a TRUS or vasography? I saw a guy with similar symptoms last year, except that he also had some ejaculatory pain. We found on TRUS
that he had a prostatic cyst causing obstruction. He experienced orgasm and pain, and then the semen slowly oozed its way past the obstruction several minutes later. One of my urologist colleagues de-roofed the cyst and the problem resolved.
Best wishes
John Dean (UK)
Dear Eric
In my opinion it is clearly a urological etiology and not a sexological one. We should ask Marcel Waldinger s opinion. Please put in your agenda 17th World Congress of Sexology in Montreal 2005 ,july 10_15
Pierre Assalian,M.D.
President
If there is nothing anatomical going on as our colleagues have suggested, then properly done male Kegel exercises - 100 per day for 6 - 8 weeks - have helped some of my MS patients who dribble semen several minutes after orgasm.It also helps improve
their diminished orgasmic quality.
Stacy Elliott,MD
Director, BC Center for Sexual Medicine
Vancouver BC
Clinical Professor, Psychiatry and Urology
University of British Columbia
Canada
We thought of some other possibilities:
1. Physical factor: spastic pelvic floor. In such a case it will take a few minutes before his muscles relax. Surface EMG (biofeedback) may confirm that. Spastic floor may be invovled with anxiety, stress, irritable bowl syndrome, obssessive physical
training, constipation or voiding difficulties.
2. Psychological factor: if the problem exists during intercourse and not while masturbating, there might be some stress concerning his spouse or their efforts to bring a child.
3. Behavioral factor: some men hold until their spouse reach orgasm. When the moment arrives they can't ejaculate immediately.
Dr. Gil Raviv (urologist), Gila Bronner (sex therapist) - Sexual Medicine Center
Judith Sarig (physiotherapist) - Pelvic Floor Clinic
Sheba Medical Center
Tel-Hashomer, Israel
Dear college
Does the patient suffer from S T D ?
Does he have any flow problems ?
Does he have a urethral stricture ?
Z.murad
F.R.C.S.Ir
Consultant Urologis
I agree with Dr. Murat's coment. Maybe a uroflowmetry could be useful as a starting and non-invasive test.
------------------------------------
Hospital Regional Universitario Carlos Haya
Antonio Mart�n Morales
Unidad Androlog�a, Servicio Urolog�a
AMARTINMORALES@terra.es
Plaza Hospital Civil s/n
M�laga, 29009
Espa�a
tel: +34 951030371
fax: +34 951030362
mobile: +34 670586610
I had a patient with similar complaints and mild dysuria, in whom I finally discovered a Urethral Diverticulum (Cowper's Syringocele) A retrograde/voiding urethrogram may be helpful and if this is the final diagnosis, unroofing is the best and most
effective treatment.
Santiago Richter
Dept. Urology, Sapir Medical Center
Kfar Sava, Israel
Is this petient on any medication? I have seen several patients with this problem who were on antidepressive or alpha blockers. TRUS can help to exclude any obstructive etiology.
Best regards,
Juza Chen, MD
Dr. Brito Cunha presented a case of an 18 years old patient complaining of severe headaches occurring during sexual intercourse and becoming more intense at orgasm, and not responding to Beta-adrenergic blocking drugs. Interestingly, Dr. Pierre
Assalian, Dr. Prithy Ramlachan & Dr. Shedeed Ashour had similar cases that responded to non steroidal anti-inflammatory drugs.
The detailed discussion:
18 years old patient complains severe headache just before the excitatory phase of a sexual intercourse, followed by orgasm, since he was 13 years old. The headache occurs during sexual intercourse and at orgasm becomes more intense. Low-dose treatment
for two to eight weeks with beta-adrenergic blocking drugs, such as propranolol or atenolol, has been not able to suppress such headache. The painful headache is managed with TRAMAL (cl de tramadal) and lasts till two months. I need help and a wise and
experienced consultation in this one.
The work up was normal, entirely.
P. Brito Cunha.
Dear Dr.Cunha
I had a case similar which I controlled with an non steroid anti inflammatory,that be taken one hour before intercourse.
Hope that is helpful
Pierre Assalian,MD
Dear DR Cunha
Indomethacin 25-50mg one to two hours before intercourse has worked excellently.
DR Prithy Ramlachan (MBChB)
Nelson Mandela School of Medicine
Univ of KZN
South Africa
Hi all I have many cases of sexual severe headache and I found it of great help to give these people Mefenamic acid Ponstan Forte 2 tabs prior or just at the onset of the Arousal.
Another tip is that these cases start to increase with Tadalafil use "personal observation".
Shedeed ashour shedeed
Consultant Andrologist.
Lecturer of Andrology, Sexology & STDs cairo Univ.
Last update : 01/03/2004
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