Digest of recent discussions on ISSM mail (January - April 2005)

Hussein Ghanem MD

Diagnosing Psychogenic Erectile dysfunction

Background

Sexologists in conservative societies are frequently faced with the dilemma of diagnosing psychogenic ED in young men who have recently been married and failing to consummate their marriages, or who are postponing their marriages indefinitely out of fear of failure. Meliegy (2004) 1 reported an alarming (17%), presentation of Honeymoon impotence among 2375 ED patients seen within a sexual dysfunction clinic in Saudi Arabia. Shamloul (2004) 2 found that most such complaints were of psychogenic etiology and resolved with short treatment courses of a PDE-5 inhibitor. We reported similar findings in the pre PDE-5 inhibitors era using short courses of intracavernous injections3.

Question Posted

Since diagnostic tests frequently have false positive results, and an erroneous diagnosis of organic ED is devastating to a young man who wishes to understand the etiology of his problem, we initiated a discussion to obtain the advice of ISSM members about the criteria we should use to establish the diagnosis of psychogenic ED in this age group. Our typical patient is a young men reporting rigid morning erections or demonstrated normal Rigiscan results but still diagnosed with a physical etiology (e.g. venous leakage) on the basis of elevated end diastolic velocities or abnormal resistivity indices on penile color Doppler studies, or abnormal cavernosometry / cavernosography results. Our bias on experience and published literature 1,2,3 is that such cases are usually psychogenic in nature.

Opinion of ISSM members

ISSM members generously contributed their opinions. Dr. Sidney Glina agreed that young patients with ED but with rigid morning erections and normal NPT are unquestionably psychogenic. He explained that Cavernosography, cavernosometry or color Doppler studies depend on the response to intracavernous vasoactive drugs which is highly impacted by anxiety and adrenergic state, and most of those tests are abnormal due to insufficient relaxation because of anxiety and stress.

Dr. Hartmut Porst suggested criteria for the diagnosis of organic "venous leakage�. These include no episodes at all of completely rigid erections while performing sexual activities, and no complete erections after intracavernosal injection of the maximum dose of the trimix mixture (40 �g PGE 1 + 30 mg Papaverine + 1 mg Phentolamine). The diagnosis of functional (psychogenic or better sympathetic ) "venous leakage" is made if there are in the history episodes of complete erections during sexual activities but on the other hand the high-dose intracavernosal injection test is not resulting in a complete erection for at least 20 min.

Dr. Pierre Assalian agreed that this is an important question and needs to be discussed.
In his practice as a psychiatrist dealing with sexual problems, he has to obtain a history that ED is situational and not global, He also elicits a history of high levels of Performance Anxiety and utilizes the PASS which is Performance Anxiety Sexual Scale which is a validated scale that he developed and recently presented at the ISSM meeting in Buenos Aires.

Dr. Charles Moser made an interesting remark that psychogenic patients often respond to medical and surgical interventions and organic patients often respond to psychotherapy. In his opinion it is rare to see a pure case of either psychogenic or organic erectile dysfunction, and the distinction does not affect the treatment plan or the approach to the patient. Dr. Moser suggested that all patients complaining of erectile dysfunction should be offered a complete medical work-up and a referral to a sex therapist for evaluation. The diagnosis is usually erectile dysfunction, multiple etiologies.

Dr. Oscar D�az noted that this question is difficult to answer at this time because there is not a �standardized model of the kind of sexual therapist needed� in many countries. He suggested a model involving sex therapists working closely with urologists to provide a comprehensive service for the patient.

Dr. Mariano Rossell� suggested a screening protocol that involves history, examination, specific diagnostic tests as well as several tools and questionnaires to evaluate the psychogenic condition, including STAI (anxiety levels), BECK (existence of depression) and the IIEF. He also discussed the potential benefits and shortcomings of various diagnostic procedures including the Rigidometer, Rigiscan, Doppler, Cavernosometry and Cavernosography.

Dr. Shedeed Ashour stressed the impotence of a good history taking, experience, and again pointed out that anxiety could influence the results of various investigations dependant on maximal smooth muscle relaxation. Dr. Pbrito Cunha reminded us about the entity of geometrically based erectile dysfunction.

Reference

1. A. El-Meliegy. A retrospective study of 418 patients with honeymoon impotence in an andrology clinic in Jeddah, Saudi Arabia. Europ J of Sexol; Sexologies (2004) 13 (47): 1-4
2. R Shamloul. Management of Honeymoon Impotence. Journal of Sexual Medicine. 2005 In press (personal communication).
3. Ghanem H, Sherif T, Adbel-Gawad T, Asaad T. Short term use of intracavernous vasoactive drugs in the treatment of persistent psychogenic erectile dysfunction. . Int J Impot Res 1998 Dec; 10(4): 211-4

Urethral Manipulation Syndrome

Dr. Bilal Gumus requested brought into discussion the rare urethral manipulation syndrome (Kelami Syndrome). This is a condition resulting from fibrosis and scarring of corpus spongiosum after any kind of urethral manipulation, and leads to ventral penile curvature.

H Ghanem provided literature about this unusual condition and reported seeing a patient with severe ventral penile curvature following multiple complicated urethral surgeries. The discussed options were either a Nesbit or a modified corporoplasty procedure (but the penis was quite shortened so these would probably have been unsatisfactory), or urethral reconstruction. He was quite afraid of further surgery and was lost to follow-up.

Detailed Discussion

Dear Colleagues,
I would be grateful for your coorperation ,if you can send me any information (literature and experience) that you have got about Kelami Syndrome ( urethral manipulation syndrome).My e-mail adress is: bhgumus@hotmail.com.
Thanks for all your interest.

Bilal Gumus MD.

Dear Dr. Gumus,

Thank you for bringing up this rare syndrome ( urethral manipulation syndrome) into discussion.
I did see a patient with severe ventral penile curvature following multiple complicated urethral surgeries. The discussed options at that time were either a Nesbit or a modified corporoplasty procedure (but the penis was quite shortened so these would probably have been unsatisfactory), or urethral reconstruction. The patient was involved in law-suits against the physicians who attended his case before us. He was quite afraid of further surgery and was lost to follow-up

I hope the following literature search would be helpful.

Best regards,

Hussein Ghanem, M.D.
Professor of Andrology, Sexology & STD's
Cairo University

• Urol Int. 1984;39(6):352-4.

Urethral manipulation syndrome. Description of a new syndrome.
Kelami A.

For the first time in the literature, a syndrome that leads to ventral penile deviation is described-urethral manipulation syndrome (UMS, Kelami). This condition is due to fibrosis and scarring of corpus cavernosum urethrae (spongiosum) after any kind of urethral manipulation. In cases of impossible penetration, reconstructive surgery straightens the penis.

• Urology. 1995 Nov;46(5):707-9.

Ventral penile curvature following radical pelvic surgery: a variant of urethral manipulation syndrome.
Grossfeld GD, Ginsberg DA, Boyd SD.
Department of Urology, University of Southern California School of Medicine, Los Angeles, USA.

OBJECTIVES. Urethral manipulation syndrome (UMS) describes ventral penile curvature and urethral stricture disease that develop following repeated episodes of urethral manipulation. We describe a variant of this syndrome, in which the presence of an indwelling catheter following radical pelvic surgery led to a marked penile curvature without clinically apparent urethral stricture disease. METHODS. We identified 4 patients in whom ventral penile curvature developed following radical pelvic surgery. Three patients underwent radical retropubic prostatectomy and the fourth patient underwent radical cystoprostatectomy with creation of a neobladder to the urethra. All were treated with 3 weeks of catheter drainage postoperatively. Each patient reported straight erections prior to surgery. RESULTS. These patients came to prosthesis surgery between 7 months and 3 years after their pelvic procedure. Each patient was noted to have ventral penile curvature when artificial erection was induced. Curvature was secondary to scarring between the anterior corpus spongiosum and the overlying ventral tunica albuginea in the mid- to proximal penile shaft. It was necessary to mobilize the urethra off the corpora and to incise the scarred tunica to obtain a satisfactory result at the time of prosthesis placement. In 3 cases, GoreTex was needed to bridge the corporeal defect. CONCLUSIONS. These cases represent a variant of UMS in which catheter drainage leads to scarring of the ventral tunica albuginea, resulting in ventral penile curvature. In view of the increasing number of radical pelvic procedures being performed, this potential complication must be recognized, as aggressive corporeal reconstruction with urethral mobilization is needed if subsequent prosthesis surgery is undertaken.

• Arch Esp Urol. 1993 Jul-Aug;46(6):510-2.

[Urethral manipulation syndrome. A new case]
Amat Cecilia M, Romero Perez P.

Hospital Comarcal Marina Alta, Denia, Alicante, Espana.

The so-called "urethral manipulation syndrome" is distinct from the other andrological conditions of penile deviation. Unlike Peyronie's disease, the urethral manipulation syndrome is always secondary to any type of endourological instrumentation of the urethra. The deviation is always ventral and no tissue structural changes are demonstrable by ultrasound. Diagnosis is based on inspection and principally on a previous history of endoscopic exploration. If the condition does not resolve spontaneously, treatment is by surgical correction of the deviation.

• Arch Ital Urol Nefrol Androl. 1992 Dec;64(4):349-51.

Urethral manipulation syndrome (Kelamy syndrome): acquired ventral penile deviation.
Afsar H, Sozduyar N.
Department of Urology, Medical Faculty, Gaziantep University, Turkey.

Fibrosis of the corpus spongiosum penis, caused by urethral manipulation and the resulting ventral penile deviations are known as the urethral manipulation syndrome (Kelami Syndrome). This condition is due to fibrosis and scarring of the corpus spongiosum penis after any kind of urethral manipulation. We have observed 4 urethral manipulation syndromes developing after urethrocystoscopy and presented them.

• Br J Urol. 1989 Dec;64(6):629-31.

Acquired ventral penile curvature: spongiofibrosis caused by urethral manipulation.
Yachia D.
Department of Urology, Hillel Yaffe Memorial Hospital, Hadera, Israel.

Fibrosis of the corpus spongiosum, caused by urethral manipulation, and the resulting ventral penile curvatures are known as the urethral manipulation syndrome. This acquired, largely iatrogenic deformity is noticed only be sexually active patients. Partial, gradual disappearance of glans engorgement and irregularities palpable along the penile urethra associated with ventral curvature are constant findings. The post-manipulative ventral curvature can be transient, disappearing when the inflammatory process subsides or the repeated urethral manipulation ceases. Since fibrosis of the corpus spongiosum begins with urethral inflammation, patients in whom irregularities of the penile urethra are observed during urethrography should be questioned about any erectile deformity. Surgical treatment is indicated when the deformity interferes with sexual intercourse or is accompanied by severe urethral strictures.

Last update : 05/10/2005