Digest of recent discussions on ISSM mail (May - August 2005)

Hussein Ghanem MD

Complaint of ED and �numb penis� in a young man

Dr. Luca Incrocci forwarded a case of a 25 years old male patient who contacted him though e-mail complaining of complete ED and a �numb� penis for seven years, not associated with other medical or psychological conditions, or a history of trauma. Rigiscan monitoring was reported as normal, and PGE1 intracavernous injection resulted in a rigid erection. The patient declined penile doppler as he moved from the city. Psychological counseling was not successful.

Dr. Sudhakar Krishnamurti inquired about libido and the endocrinal status. Dr. Claudio Teloken suggested autonomic neurological evaluation. Dr. Shedeed Ashour also suggested neurological testing and mentioned seeing a patient with a similar complaint and a history of sacral affection after small pox 25 years ago. Dr. Laurence Levine reported a patient with a numb penis following gunshot pudendal nerve injury and suggested evoked sensory potential evaluation. Dr. Gorm Wagner pointed out that the sensitivity of the skin and/or the glans may be evaluated by a clinical neurophysiologist and that "Space" is no longer an accepted diagnostic tool.

Dr. Mariano Rossell� advised carrying out a psycho-analytical study of the patient�s personality, and exploring psychological trauma. He also advised manual, vibratory or audio-visual stimulation with Rigidometery that the patient carries on privately, by himself, prior to undertaking arteriography and evoked potential studies. Dr. Giorgio Corretti and Dr. Andy McCullough also suggested predominantly psychogenic factors. Dr. McCullough pointed out that similar complaints are not uncommon in New York, and that these young men generally are resistant to accept a psychogenic diagnosis, and frequently end up going to someone - who has little to no experience or interest in the area of sexual dysfunction- who takes their insurance (or the parent's insurance).

The detailed discussion

Dear colleagues

I received an e-mail for help from a UK young guy. Please read it hereunder. I have not seen him but I have collected some information about his problem. I hope you can help with ideas, suggestions. I believe the best way to help him is to see an experienced specialist in the UK. Ian Eardley, Geoff Hackett, John Pryor...would one of you (or somebody else I cannot think of now) be willing to see him?
Thanks ahead.
Luca Incrocci

I'm a 25-year old male. For the past seven years, without having suffered disease, injury, or mental trauma, my penis has been completely numb and inactive. Virtually no erectile activity for the past seven years. A range of medical specialists in the UK has been unable to determine the problem.

When physical practitioners found no problem I was referred to psychological counselling, but they have also been unable to discover any explanation and feel the cause may in fact be physiological.

I was given an injection of alprostadil; a high enough dosage did cause my penis to become somewhat rigid but entirely without sensation, and afterwards became quite painful. There was not enough time with my doctor to try a Doppler Ultrasound as I moved away from my home city.

I was tested with a device called a "rigiscan. According to my doctor, this detected a normal pattern of nocturnal erections. But I have never found on waking anything resembling the erections I used to have 7 years ago.

I'd be happy to accept a psychological prognosis if it is the right one. But my own instinct is that this is entirely physical.

Luca Incrocci

Dear Dr. Incrocci:
I'd like to add the name of David Ralph to your already illustrious list of U.K. specialists, but my surmisal is that the patient could also use the help of some psychologists. Also, we have no information about his libido and endocrine status.

Best of luck !

Sudhakar Krishnamurti.
India.

I think I recognise this patient as someone who could have attended our unit which is a very integrated service!
Kevan.
Kevan R Wylie MD

Dr Kevan
I wonder if you could offer him going through a nervous autonomic evaluation. In spite of many controversial issues, particulary regarding the methodology (indeed worlwide argued), we�re in debt with Steve, Portner and others. You may call SPACE or something else but you�re responsible for this patient� health. I�ve seen a young fellow, same symptoms, altered SPACE with Hansen' disease.
Best Regards
Dr. Claudio Teloken

Dear all

I feel that this patient will benifit of a neurological assesment and my opinion it might be the 1st attack of DS, or some rarities like Hansen's disease or polyneuropathy and some more rare i have one case of same problem for the past 25 years due to sacral affection by small pox ( this patient's brothers one died of the same diagnosis and the second got blind).

SPACE and other neurophysiologic assesments are also good ideas to add for the battery of the diagnosis list of investigations.

Thanks
Shedeed Ashour Shedeed
Ass.prof. Andrology,Sexology, STDs
Cairo university, cairo EGYPT
Consultant Andrologist, Dr Erfan Hospital Jeddah, KSA

Thanks Claudio for this suggestion and potential diagnosis. Is there anyone undertaking SPACE in Europe? I do not think anyone of us in the UK is undertaking this evaluation. Any information could be passed to the patient and a referral considered from our local health group if this is recommended by international colleagues.

Kind regards

Kevan.
Kevan R Wylie MD DSM FRCPsych

"Space" is a non-existing, artificially created phenomen which wasintroduced by Stief som 12-15 years ago.
For info about cc-EMG look at Cost-action B18 (EU) and read the last years litt.and presentations (last at ISSM-meetingin Argentina).and be aware of the fact that it is the MOTORIC autonomous innervation and not the sensory part.The sensitivity of the skin and/or the glans may be evaluated by a clinical neurophysiologist.

Regards Gorm Wagner

I had a patient recently who was shot by some thieves in Mexico City through the hip. Thankfully the bullet did not hit any major structures but he notes
a nearly completely numb penis. Erections are OK but difficult to sustain as he has no sensation. I suspect he experienced an injury to the pundendal
nerve(s)- quite the shot to hit them both.

I wonder if the patient in question here from the UK has some form of  sensory neuropathy and may benefit from more sophicated evoked sensory
evaluation- if only to help identify the problem as possibly a phyical one.

Laurence A Levine MD,FACS
Professor of Urology
Rush University
Chicago,Illinois

Dear Colleague:

In our opinion it is necessary to find out if there has been any psychological trauma from the adolescence until now, therefore it is convenient to carry out psycho-analytical study of his personality. We recommend the Beck, Stai and IIEF tests.

At the same time it is important to find out if the patient has been able to obtain ANY degree of tumescence or rigidity through manual, vibratory or audio-visual stimulation. If yes, you can offer him the Rigidometer to carry out an axial rigidity test at home, in the most erotic atmosphere that he can create. With this test, one can evaluate the arterial circulatory capacity of the penis and if the corporo-veno-oclusivo mechanism is activated. It is very important that the patient carries out this test
(rigidometry) privately, by himself, because in this way he can switch on the erection mechanisms, incorporating the sensorial and psychological stimuli that he wishes avoiding the psychological inhibition that is unleashed when you make an in-clinic Doppler, which in our judgment is not the most suitable test.

If no rigidity at all is achieved, providing that the prostaglandin has caused pain and an undetermined rigidity, we think that it is convenient to practise a pelvic arteriography with the purpose of studying the arterial and venous field. We would also make an evoked potentials study and reflexometry test to evaluate the neurological and sensitivity routes.

We also recommend Dr. K. Wylie in Liverpool for sexual dysfunctions of psychogenic aetiology.

Regards,

Mariano Rossell�,M.D
Director, Centre of Urology, Andrology & Sexology
Palma de Mallorca - Madrid

a good sexual-psychical evaluation was recommend for these kind of sexual dysfunctions. I don't kwow the right person in UK, but if you want someone in Italy,
there is no problem.
Giorgio Corretti

Dear All,
This young man sounds pretty disturbed .
On one hand he had the time for a rigiscan but not a doppler.
A normal rigiscan and no erectile function??!!???
This has been going on for 7 years!
When did he become sexually active? (if he ever has) What's his family history?
I strongly doubt that he had an adequate "psychological screen".
In New York such cases are not that uncommon and the young men are usually unwilling to consult a good therapist.
They end up going to someone who takes their insurance (or the parent's insurance) who has little to no experience or interest in the area of sexual dysfunction.
I push them hard to see a competent Psychiatrist who can treat the underlying depression, anxiety or OCD.
They may not like the message but sooner or later (it can be years) if they are "hurting enough" they call me back for the name .

Andy McCullough

Child Priapism

Dr. Bruno Carvalho presented a case of a 7 year boy with high flow priapism for about a year. He initiated investigations for adrenal and testicular tumors and requested an angiogram. Dr. Sidney Glina suggested perineal trauma as a causative factor and advised a doppler study before the angiogram. Dr. Chris McMahon also advised initial penile duplex ultrasound without pharmaco-challenge to confirm the probable presence of an arterio-lacunar fistula. He also suggested an attempt at digital occlusion of the fistula during US for 4-5 minutes. He noted that most cases will require angiographic embolization by an interventional radiologist using autologous clot, platinum microcoils or latex microspheres.

Dr. Gregory Broderick agreed upon the possibility of a straddle injury that the parents might not be aware of, and advised Color Doppler examining both the pendulous shaft and the origin of the cavernous arteries through the perineum. Dr. Broderick reported a similar case where a boy fell on exercise equipment in a store, and suffered a straddle injury on a bar. Dr. Laurence A Levine advised that if a fistula or pseudoaneurysm is diagnosed, then phalloangiogram with clot embolization (not coil) or even transcutaneous clot injection may be considered, if the family elects an aggressive approach.

The detailed discussion

I have a very rare case(in my clinical experience) of a 7 year boy with high flow priapim for about a year!
his penis is hard for a year without pain or any complaint by the kid.

But his parents are very worried. i am investigating adrenal and testicular tumors an already ask for an angiogram (selective).
any other idea?
thank you all
bruno carvalho

Dr. Bruno Carvalho:
It is important to identify if the boy had any perineal trauma and ask for a penile eco-doppler before the angiogram. Probabely it is a post-trauma high
flow priapism.

Sidney

Dear Dr Carvalho

This boy needs an initial penile duplex ultrasound without pharmaco-challenge to confirm the probable presence of an arterio-lacunar
fistula. This is probably the result of blunt perineal trauma. If present the best approach is an attempt at digital occlusion of the fistula during
US for 4-5 minutes which occasionally works but most will require angiographic embolisation by an interventional radiologist using autologous
clot, platinum microcoils or latex microspheres

Dr Chris G McMahon
Australian centre for Sexual Health

Do not do an angiogram as the first study on this child.
Color Doppler examining both the pendulous shaft and the origin of the cavernous arteries through the perineum is the least invasive way to locate
a sinusoidal fistula.
You must consider the possiblility that this little boy has had a straddle injury his parents may not be aware of. I had a similar case of a child
presented to me by the late John Duckett of Children's Hospital Philadelphia. The boy fell on exercise equipment in a store, where he was
not supposed to be playing and had a straddle injury on a bar!
Greg Broderick
Professor of Urology
Mayo Clinic College of Medicine
Jacksonville, Florida
Residency Program Director
President Sexual Medicine Society NA

I agree entirely with Dr Broderick as a duplex ultrasound without pharmacostimulation may reveal the fistula or pseudoaneurysm. If it is
present and the family elects to try to be aggresive-you may consider phalloangiogram with clot embolization (not coil) or even transcutaneous
clot injection has worked in my experience. These should be considered before a direct trial of surgical ligation.

Laurence A Levine MD,FACS
Professor of Urology
Rush University
Chicago,Illinois

Last update : 09/25/2005