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Digest of recent discussions on ISSM mail (April 2006 - July 2006)Hussein Ghanem MD Discussion DigestISSM List was active with three lively clinical discussions where many members shared their opinions. The Penile Prosthesis discussion was enlightening and highlighted the different opinions and experiences, the FTM heterosexual case shed light on this important area of sexual medicine, while the premature Ejaculation and Pelvic Floor data were interesting to explore. Penile Prosthesis Rod Rotation and Selection of Penile ProsthesesPenile Prosthesis Rod Rotation and Selection of Penile Prostheses One of most active discussions we had so far on ISSM List was initiated by Dr. Wael Zohdi who presented a case of a diabetic, middle age gentleman who received a malleable penile prosthesis that seamed well-implanted �on-table� but later (in two months time) exhibited rotation of the right rod over the left one, with resulting deviation to the left side that interfered with successful coitus. The glanular tips were adjacent. However, the crural tips were not, the right crural tip was shifted away from the ischial tuberosity. Re-implantation was performed, where a constriction ring was observed on the right side upon dilatation. The condition was rectified, but recurred in one and a half years. Dr. Ignacio Moncada suggested the phenomenon to be related to the high frequency of migration and erosion in case of implanting a malleable prosthesis in diabetic patients. He proposed that an inflatable (3-piece) as a more suitable alternative. Despite its cost, it would be more cost-effective in comparison to the probability of recurrence of the same condition for the third time in case a malleable is used or primary repair is resorted to. He recommended the mini-salvage procedure with the 7 solutions technique (Mulcahy), along with an antibiotic coated prosthesis, the length of which is determined according to that of the left (normal) corpus cavernosum. He also recommended sexual intercourse only upon sexual excitation, as an engorged glans has a protective effect on the tunica analogous to a boxer�s glove protecting the hand. Dr. Moncada discouraged the use of a perineal incision for repairing the possible tear, fixation of the prosthesis to the ischial tuberosity, and early return to sexual activity. Dr. Laurence A Levine and Dr. Antonio Morales agreed with Dr. Moncada�s view. Dr. Andy McCullough and Dr. Kew-Kim Chew recommended transurethral Alprostadil for inducing glans engorgement. Dr. Alonso Acu�a suggested PDE5 inhibitors for the same purpose, aiming at the protective effect and at higher patient satisfaction. Dr. Hussein Ghanem suggested excluding cross-perforation, or tracts that are �too medial�. He generally found implantation of malleable implants to be simple, fast, low risk, and low cost procedures. Dr. Shedeed Ashour recommended that in case the patient will not go for an inflatable, the �hang cap� technique for re-implantation, where a non-absorbable suture connects the rear tip to the corporotomy, along with irrigation with antibiotic solutions. Dr. Claudio Teloken suggested repair for crural perforation or rear-tip fixation, based on his experience with the malleable prosthesis. He attributed unpleasant experiences with the malleable implants to technique rather than the device. He also highlighted his experience and publication on the effectiveness of rifamycin in salvage procedures that match that of the expensive 7 solutions. Dr Paulo Brito Cunha and Dr. Ramiro Fragas reported similar views. Dr. Sidney Glina recommended a Dacron graft rather than primary repair for a tunical tear. Dr. Evgenios Alargof advised that �cost� should not be the factor that determines the type of prosthesis to be implanted, and does not justify -what is in his opinion- a higher complication rate. Dr. Santiago Richter also proposed that it is the surgical technique, rather than the type of prosthesis that determines success, complications, and satisfaction, and that every aspect, including cost and availability should be taken into consideration. He agreed with the cross-perforation possibility for explaining the case at hand, as well as with the use of the perineal approach whenever necessary. Dr. Andrew McCullough proposed the development of an evaluation tool for patient satisfaction after prosthesis implantation. Dr. Run Wang highlighted the importance of the prior informed consent for patient expectations and satisfaction, and proposed the standardization of a dedicated consent. Dr. Laurence A Levine agreed and suggested developing a consent committee for designing a universal consent form. Dr. Mariano Rossell� Barbar� supported the latter and suggested the addition of FAQ�s. Dr. Moncada pointed out the different (almost opposite) some standpoints are, regarding this topic, with even a country specific point of view. He also discussed the limitations of current guidelines and proposed that the ISSM Executive Committee set of a Force Task to address this issue. Dr. John Mulhall informed members that a proposal for the development of a registry for penile prosthesis cases is under consideration by the ISSM executive committee. Dr. Ira Sharlip agreed and concluded that the leadership of ISSM agrees completely that ISSM should have a task force on penile prostheses, as suggested. That would be achieved through the new ISSM Registry Committee. This committee will collect case reports and create databanks for a variety of clinical problems in sexual medicine, including penile prostheses. Many members send emails supporting this proposal. Osama Shoier, M.D. Detailed discussionAn interesting case. Forty-five years diabetic patient underwent penile prosthesis surgery for venogenic ED. Mentor acuform was inserted the dilation was easy and the 2 ends of the rods were felt at the proximal 1/3 of the glans penis. Both rods were felt at the same level. The patient discharged from the hospital on the same day. Wound healing was excellent and he was counseled to start sexual intercourse 8 weeks after surgery. The patient came with a complaint of penile deviation and failure of vaginal penetration. On examination the penis showed mild deviation to the left side and the right rod was seen rotated over the left one. The proximal ends of both rods were felt equally at the same level just below the mid glans penis. However, the proximal (crural end) of the right rod was felt 1.5 cm away from the ischial tuberosity. The patient was readmitted to the hospital again and corportomies were done together with re-dilation of the proximal corpora. A constriction ring was observed during re-dilation on the right side. Post-operative recovery was unremarkable. The patient had successful intercourse and easy vaginal penetration 10 weeks after implantation. One and half years later the patient came to my clinic with same problem. Do you have any suggestions regarding the proper management of this case? Wael Zohdy, MD Dear Dr Zolhdy, Malleable rods are not the best type of prosthesis for a young diabetic patient, I�m afraid. The risk of migration and erosion of the rods is high and invariably they become loose after some time due to the continuous pressure in the proximal and distal ends which acts as a tissue expander making too much space for the cylinders. My suggestion is to extract both rods and implant a 3-piece hydraulic prosthesis. Measure the left side, the normal one, and implant both cylinders with the same length. You can use a rear tip extender and fix it to the corporotomy with a non absorbable suture, but it is not necessary. Take into account that this is a third surgery so the risk of infection is higher (double the normal risk) so you should make a �mini-salvage� procedure with the 7 solutions technique (Mulcahy) and use an antibiotic coated prosthesis; the IV antibiotics never reach the peri-prosthetic space once the capsule has been formed and this happens a few weeks after the first surgery. Don�t try to make an incision in the perineum to repair a possible crural perforation or fix the rear tip to the periostium of the ischial tuberosity, it never works. Advise to your patient not to use the prosthesis during the first month and to make always use of the prosthesis with sexual stimulation, the engorged glans will protect the corpora from the inflated cylinders like a boxer�s glove protect the hand. Sometimes, patients don�t want to spend more money in a 3-piece prosthesis, but tell him that he needs an inflatable one otherwise you can repair the perforation and relocate the cylinders but it will happen again sooner or later, so he will save money and time doing it at once. I am sure that your patient will be much happier with the 3-piece than with the malleable one, no question. Regards, I truly enjoyed reading Dr Moncada's response to this problem pateint situation and I agree with his recommendations. I will use the "boxer's glove " analogy from now on, so long as the professor allows it. Laurence A Levine MD,FACS Dear Wael Dr. Andy McCullough suggested muse for glans engorgement Best regards Your friend Alonso Acu�a from Colombia Dear Wael thanx for the case. The explanation of the case canhelp putting the best managment for it. Most probaply the implant is too slim for the space -or it became like that - then it redilated the space for it self. -and these patients im my opinion were badely selected from the start as avenogenic ause in a diabetic young ED patient. if the pt insested for another maleable prosthesis you have to fix the rods using the hang cap technique -u saw me doing it befor- hanging the rear tip by anon-aborbable suture and making it long up to th corportomy where u ca tie it there- making less knots as much as you can. put into consideration the infection risk in a diabetic its now almost 30%. so use coated cyliners or use irregation of the multiple antibiotic solution. Small regular dose of sildenafil or PRN sucsseded in helping a similar case of havingan engorgment over the rods so, there will be no room for the rods to move. The first event as it happened early after the surgery mot probaply was due to septal cross perforation. the re-do found another tunnel for the rod on the next surgery and dilation. with best wishes for you and the Patient. Dear Dr Moncada I would like to comment yours rewiew about the Moncada`s statements. 1.The fact that the cost of malleable prosthesis is covered or not by a Gov.insurance in a country, dos not determine (and must not determine ) the choice of malleable prosthesis in such patients.The least cost (the coverage as well ) is mportant sure , but it is not the primary. So i agree with Dr. Moncada, that in the era of 2006, for a young (noncomplicated - without serious fibrosis,plaque,etc....etc. ...) diabetic patient, like this, the placement of an inflatable (for example a 3-peaces inhibizone impregnated ) prosthesis is the first choice and not the placement of malleable one .The possibility of malfunction, leakage and infection then is low and keeping out of such rods trouble. So the malleable prosthesis is first choice in case of limited dexterity from the part of the patient only ,since the physician is familiar with all type of prosthesis. Regards. Dr. Evgenios Alargof Since 1987 I have used malleable prosthesis, only. Actually, in my opinion they are the best ones. They are not expensive. As a non surgeon I am enjoying these emails tremendously,what is clear ,you should have a consensus on this subject Dr Ghanem something to look into Pierre Assalian,MD Dear friends, I agree with Dr. Richter that the final outcome of penile prosthesis surgery depends mainly on the surgeon's experience and technique. Dr. Assalian is right that there is no consensus, most probably because it is not possible to conduct a randomized controlled trial comparing both types of devices, inflatable and malleable (patients will probably not accept to receive their prosthesis at random!). I also ran a search for randomized controlled studies comparing both types of devices and found none. Thus the decision remains for the patient and implanting surgeon. Problems will occasionally occur with either type of prosthesis. In Dr. Zohdy's case the patient is fortunate that his implanting surgeon has both exeptional surgical skills and the wisdom to take the opinion of others before jumping into another procedure. I again thank Dr. Zohdy for opening this intersting discussion. Dear Friends & colleagues It is very interesting discussion and many of opinions are some addition to others' experiences. I agree with dr. Rhichter & Claudio inputs and i feel the management of such cases is individual both for the Surgeon & the case. thanks god also, we have almost Zero% infection rate and 90% of our cases choose a maleable positionable implant. Dr ghanem's paper on the out patient infection control technique is a good and easy way to decrease the rate of infection. SHEDEED ASHOUR., MD I fully agree with my very good friend Ignacio in how to manage the patient. However he made think about the exact role of the boxer's glove: To protect the boxer's hand or the contary's face?. Maybe, at the end of the day, it has to do with the position you are holding at a given time. My best wishes I agree with Claudio. In many countries you have only malleable prostheses available and they have been a good option for years with very few complications. Sidney Glina Hello to all. I have read all the comments, on the complex case that I present the Wael Zohdy MD and I have seen very interesting ideas. We place 105 prothesis among 1995 to March 2006, They had severe ED with biogenic etiology who received Penile Prosthesis Implants. In most of the case, we use a specific surgical procedure to the conservation of the erectile tissue. Three hydraulic (AMBICOR), the malleable rest (HR, AMS 600, 600M, 650, Acuform, TUBE, Olmedo, Silicub, Silimed, Small Carrion; Jonas). The main conditions leading to Erectile dysfunction were Diabetes Mellitus (No18), Arterial Risk Factors (Hypertension, smokers, cholesterol), Fibrosis post priapism (7), Peyronie�s disease and Pelvic trauma. More frequent complications of this procedure were penis edema (4), three cases with scrotum hematoma, three cases with urinary retention, two cases with lesion of penis�s septum, lesion of distal urethra in a man suffering from post priapism fibrosis, urethra erosion in two cases, forcing to take off the implant crura perforation (1 case), five cases need change of implant due to mechanical deficiency. Surgical procedure was very more difficult in patients with post priapism fibrosis, hipoplasia of cavernous bodies, patients with trauma of the pelvic and urethra, those with primary sexual dysfunction and those suffering from neuropathy, all of them with long term erectile dysfunction. I have operated 18 cases of diabetics with Severe ED, to which we Implant (17 malleable and 1 Ambicor), one had erosion (malleable), the Ambicor work well two years, but now he had mechanical failure and we should change it, he prefers a malleable one. The level of satisfaction of patient and couples was high (More than 90 %). According to our experience, penile prosthesis implant is a good therapeutic choice for patients suffering of severe erectile dysfunction who do not respond to other treatments. Complications can be avoided if technical steps for this surgery are acepted. I invite them to a Course of live Surgery (Peyronie, Prothesis Implant and other), during the 3er Ibero-American Encounter of Andrology (ANDRO 2006), of the December 3- 8, 2006 in Havana. Some of you could surely be professors of Course, many of which have already been operating with us in Havana in other courses. We will be waiting for you! A strong hug. Ramiro Fragas MD. Dear Ramiro: More than 90 % of couple�s satisfaction in penile implant is really something.... Satisfaction rate depends upon what and how patients are questioned about. Dear friends, I have really enjoyed the discussion about this interesting case, but principally because we could see how different (almost opposite) some standpoints are regarding this topic, we could see even a country specific point of view. Looks like everything is a matter of personal opinion �you think that 3-p are best, but I think malleable are best�� �You say that repairing the crural perforation never works, but I think this is the best solution for this patient�� who is right? That big is the lack of evidence based medicine to address this issue? I have read also some comments suggesting that there is no consensus about to whom, what type, when and how to implant a penile prosthesis: also on how to manage the complications. This is not completely true, there are several good reviews published. The Journal of Sexual Medicine published a Summary of the Surgery Committee during the 2nd International Consultation on Sexual Dysfunctions in Paris 2004, in Volume 1 Page 98 - July 2004 (The Penile Implant for Erectile Dysfunction by John J. Mulcahy, MD, Edouardo Austoni, James H. Barada, Hyung Ki Choi, Wayne J.G. Hellstrom, Sudhakar Krishnamurti, Ignacio Moncada, Dirk Shultheiss, Michael Sohn, and Hunter Wessells) But to tell the truth, this was not a truly Consensus Panel and no clear guidelines were adopted. On the other hand, the AUA Erectile Dysfunction Guideline Update Panel published in July 2005 in J Urol their guidelines. The penile prosthesis section was too limited (1 page), giving only three main recommendations: a)inform the patient about the available devices, techniques and complications, b)do not perform any prosthetic surgery in the presence of infection and c) administer IV antibiotic preoperatively. All these recommendations were based on panel consensus but not on a review of the literature and the available data; too little for such an important treatment option. Nobody has really published a good Meta-Analysis on penile prosthetic surgery and I am sure that many legal and ethical issues might come from this lack of consensus (what antibiotic prophylaxis, role of antibiotic coated prosthesis, role of glycosilated Hb before penile implant, placement a reservoir in a radical cystectomy patient, penile prosthesis in HIV patients and many other unresolved questions) I would like to officially propose the ISSM Executive Committee (or the SC) the implementation of a Force Task on Penile Prosthetic Surgery with the objective to review all the available data, perform a meta-analysis, reach a consensus and establish clear guidelines and recommendations for this important modality of ED treatment. I believe that ISSM should be the leader scientific society to take this responsibility; we have the best experts in sexual medicine (and surgery) and the best Journal to publish it. Who else can do it? Cairo could be the also best place in the world to start with this. All the best, Ignacio I have enjoyed your inciteful comments. With regard to addressing EBM in penile prosthetic surgery, the ISSM has commissioned a standards committee which has almost completed its task. One of the task forces has addressed penile prosthetic surgery. This was chaired by michael sohn. The purpose of this effort is to develop standards in the practice of sexual medicine and surgery. I suspect that some of the issues that you have raised will not be addressed by the task force as there is a lack of EBM. Rather than metanalyses we should be thinking of prospective analyses perhaps supported in part by ISSM. Much to my disappointment industry has not yet committed to the conduct of rigorous science in penile prosthetic surgery. Finally, a proposal for the development of a registry committee is under consideration by the ISSM executive committee and this may be able to address some of your concerns. Again thank you for your enlightening comments. John Mulhall I agree with Dr. Levine. I have been using a pre-printed consent form specifically for penile implants for many years. It really helps for patients to understand what to expect. I sometimes give this consent form to patients to take it home before they make the decision for surgery. I do believe a universal consent form may help us more since we have better implants now than anytime before and the outcomes now are much better than the outcomes 5 or 10 years ago. I will present two papers regarding penile implants outcomes at the upcoming Cairo meeting. One is to compare the satisfaction among Ambicor (2-piece), AMS 700 series (three-piece) and Mentor Titan (three-piece). One of the problem is what evaluation instrument should we use to include patient and partner assessment. Even though there were some publications regarding patient's satisfaction after penile implants, I do agree with Dr. Levine that our society is ready for more rigorous evaluation of prosthetic surgical outcomes from surgeons, patients and their partners. Run Wang, MD, FACS Interesting how this case has triggered so much discussion. Clearly our community of specialists are ready for more rigorous evalution of prosthetic surgical outcomes including patient and partner assessment. I also believe that the ISSM should be charged to design a universal penile prosthesis implantation consent form. My suspicion is that the issues/concerns that we as physicians want our patients to understand preoperatively would be similar worldwide in spite of prosthesis type preferences ( ie 2-piece, 3-piece, maleable/positionable devices). As I will not be able to attend the cairo meeting maybe one of you could suggest developing such a consent committee. I would be happy to serve on it. Larry We have not several instruments for the evaluation of the nonsurgical treatments for ED but have not moved forward with the same degree of scientific rigor in the evaluation of penile prostheses, perhaps because the outcome of rigidity is unambiguous. Unfortunately it is not the rigidity that is the postop complaint. I hear orgasmic dysfunction and penile shortening as common. I always counsel about the shortening but the orgasmic dysfunction is hard to anticipate. I would invite Ray Rosen and Stan Althof (among many others) to participate in the formation of an evaluation form as they were instrumental in the IIEF and EDITS questionnaires. Andrew McCullough Pre-op counselling and post-op evaluation are obviously very important aspects of patient management. In addition to what has been said, topics such as lack of glans tumescence and the relatively 'cold' penis with prostheses should be included in these assessments. We had discussed the use of transurethral alprostadil toenhance glans tumescence in a case report. Kew-Kim Chew Dear ISSM members, First, let me apologize for the lateness of these comments to reach you (due to internal mail problems ) .However, the penile prosthesis mail exchange was so interesting to me that I cannot help forwarding the couple of comments I did myself : Concerning the patient's consent form I definitely agree as well. Indeed, from my very first starts of performing penile prosthesis implantation in 1983, I have been thinking of the necessity to create a specific form to obtain the patient�s consent as well as a form with FAQ�s that should always be handed before the operation. It is extremely important that the patients and their partner know why they want to have the implant procedure and that they choose by themselves the type of prosthesis they want to have. They should be shown each and every kind of prosthesis that exists on the market and they should be aware of the advantages and drawbacks of each prosthesis. The most serious concerns that may be experienced after the implantation of a prosthesis are the ones that appear if all the information was not given to the patient before the operation. Of course like Dr Levine, our entire medical community wants the surgical operations to have a minimum 99.5% success for the patient and their partner. Thus, if all the complex information is given, if the choice of the prosthesis is adequate both from the medical and anatomical level, and if the surgical operation is made with the purest techniques and with the necessary instruments, the implant is generally always successful. The non-fulfilment of these requirements would unfortunately lead to a very serious issue and concern. This is the reason why I will support Dr. Levine�s statement in Cairo. I will get in touch with Run Wang and Andrew McCullough, and anyone that will support this initiative. I will also like to hear other comments on this respect, Regards to all Dr. Mariano Rossell� Barbar� Ignacio, The leadership of ISSM agrees completely with you that ISSM should have a task force on penile prostheses, as you suggested. We think the best way to do this is through the new ISSM Registry Committee. This committee will collect case reports and create databanks for a variety of clinical problems in sexual medicine, including penile prostheses. The registry idea was suggested by John Mulhall, who will chair the committee. Initially, there will be subcommittees for penile prostheses and for Peyronie's disease. There is also interest in a subcommittee which would collect data on testosterone replacement therapy in men who are hypogonadal after treatment for prostate cancer. There are many other clinical problems in sexual medicine which can be studied in this way. With an international registry to which worldwide ISSM members can contribute clinical data using the same case-report forms, we can create a global databank and collect a larger volume of data than can be done regionally or locally. We hope that when these data are collected, we may find answers to some important clinical questions such as those you pointed out in your email to ISSMList about penile prostheses. Ira Ira D. Sharlip, M.D. Premature Ejaculation and the Pelvic FloorDr Talli Rosenbaum expressed interest in any theories or actual studies regarding the possible mechanism whereby active relaxation of the bulbo and ischio-cavernous muscles can delay the ejaculation response by inhibiting the ejaculatory reflex. Dr. Gorm Wagner outlined the difficulty in applying this technique. Dr. Giuseppe La Pera mentioned that he has experience with the pelvic floor rehabilitation and routinely use it as first step in the treatment of premature ejaculation. He also pointed out his publication regarding this topic. Dr. Aksam Yassin also provided his references. Detailed DiscussionI am interested in any theories or actual studies regarding the possible mechanism whereby active relaxation of the bulbo and ischio-cavernous muscles can actually delay the ejaculation response by inhibiting the ejaculation reflex. Is this a neurophysiologically sound hypothesis? Talli Yehuda Rosenbaum, PT "Active relaxation" ??? How do you induce that?? To make a person "think into a given group of muscles" and thereby control the tension (contraction as well as relaxation) is extremely difficult and the need of special skills of the therapist as well as in the patient mandatory. Very few people work with this at a serious and documented level. Try Birthe Bonde as I do not have an e-mail address.She is treating men as well as men for such kind of problems. I have experience with the pelvic floor rehabilitation and I routinely do as first step in the treatment of premature ejaculation. In 1996 I wrote on this connection this paper La Pera G, Nicastro A. On my experience after a much higher improvement on the ejaculatory control soon after the end of treatment at 1 year the cure rate is around 30%. The younger the higher are the chance to be cured On my opinion what is very important for the success is the kinesitherapy Giuseppe La Pera Dear All, Health Journal of Gulf Medical College,Ajman UAE;Vol. 2 (2000): 36-39 by Aksam A. Yassin And in German: Yassin A., Neuraltherapi in der Urologie, Ganzheitsmedizin Zeitschrift 2-3 (1991): 13-25 And Ganzheitsmedizin, Nr. 4, 8. Jg, S. 13-19, (Dez. 1995) Sincerely Aksam A. Yassin MD PHD EdD FEBU Young Female to Male TranssexualH Ghanem presented a case of a young -18 years- FTM transsexual. There with no signs of virilization or history of use of male hormones. The main questions / concerns expressed were: Is there any advice that would help him cope until he gets or don't get the surgery? Would androgen therapy be advisable at this stage or would it just virilize a good looking girl into neither being boy or girl? The patient seems to be unaware of that option. Dr. Stanley Althof pointed out the guidelines of the Harry Benjamin International Gender Dysphoria Association www.hbigda.org set to assist clinicians in making decisions regarding initiating hormone therapy and surgery. Dr. Mireille Bonierbale agreed, provided several references and pointed out that there is a necessary period of observation of one year before Androgen therapy is approved by the psychiatrist. Dr. Cassimjee added that are so many individual variations with respect to ability to cope, emotional adjustment, etc, requiring each case to be individualized. Dr. Kevan Wylie presented a further reference and explained that within his multidisciplinary team, after some time of assessment, they often use a GnRH agonist for 6-12 months before androgen therapy (unless the adolescent team have started the latter). The first treatment is more amenable to reversal of effect of course if transition or medication has to be stopped for whatever reason. Dr. Pierre Assalian agreed with expressed opinions and cautioned that there is always a risk of depression and suicide if patients do not get help. Dr. Shedeed Ashour briefly described his experience with 4 patients and also cautioned about the risks of depression and suicide if appropriate management was not offered. Dr. Claudio Teloken mentioned that according to the law in Brazil, surgery may only be carried out after the age of 21. Under these particular circumstances, the psychiatrist, psychologist, social counselor, counselor-in-law (application for official ID changing), etc., have plenty of time to go over all individual necessities. Detailed discussionsDear colleagues An 18 years old girl presented with her mother and elder brother for evaluation. Throughout her young life the girl felt she was a boy, played mainly with boys, indulged mainly in male activities, and always wished to become a man. Physically, external & internal genitalia, as well as female secondary sex characters are normally developed and consistent with a well built athletic young lady. However he felt as a man entrapped within the body of a girl. His family brought him hoping to find a solution to his misery and after he caused a lot of embarrassment approaching girls in his conservative town. The patient doesn't wish to be a lesbian but hopes to become a man even if the results of surgery are far from ideal. There were no signs of virilization or history of use of male hormones. Despite limited education the mother and brother accepted the condition and were willing to go along with any line of therapy that was appropriate. I referred the patient to a psychiatrist interested in sexual disorders to confirm the diagnosis of FTM transsexualism. I also explained that the procedures to obtain approval for sex change surgery are lengthy (many years) and frequently not successful. My questions are: Sincerely, Hussein Dear Hussein- The Harry Benjamin International Gender Dysphoria Association has guidelines to assist clinicians in making decisions regarding initiating hormone therapy and surgery. Their website is www.hbigda.org/ and there is a tab to take you to the standards of care. Dear Hussein I am a french psychiatrist specialized in care of gender dysphoria Generaly when it is a good case there is more than 70/80% of satisfaction after the Sexual Reassigment Surgery I send you a little personnal work on this thema and you will can read in june a good work of the european specialized team of reassigment of Pr stan Monstrey ( President of HBIGDA) in our European journal of sexual health "sexologies" the references on this question are Green, R., & Fleming, D. - (1990). Transsexual surgery follow-up status in the 1990s. Annual Review of Sex Research, 1, 163-174. Pf�fflin, F. (1992). Regrets after sex reassignment surgery. In W.O. Bockting, E. Coleman, Gender Dysphoria, Interdisciplinary approaches in clinical management. Binghamton, NY : The Haworth Press. Pf�fflin, F., & Junge, A. (1992). Nachuntersuchungen nach geschlechusumwandlung : eine kemmentierte literatureubersicht 1961-1991[Follow-up studies after sex reassignment surgery : a review 1961-1991], Scahttauer, Stuttgart, 149-459. Lawrence, A.A. (2003). Factors Associated With Satisfaction or Regret Following Male-to-Female Sex Reassignment Surgery. Archives of Sexual Behavior,32, 4, 299�315 Best regards Dear Hussein, Interesting case. There are so many individual variations with respect to ability to cope, emotional adjustment,etc, requiring each case to be individualised. There are no south african studies available which could provide answers you need . I would strongly suggest to the family of seeking help in another country to avoid any further misery for this girl. Cost is always a problem. Life is about the choices we make. Families have to learn to realise this. I am aware that in many countries the public service would not offer choice of such operations. The private sector, would make available such expertise. Kind regards See also this recent article: Houk CP & Lee PA. The diagnosis and care of transsexual children and adolescents: a pediatric endocrinologists' perspective. J Pediatr Endocrinol Metab. 2006 Feb;19(2):103-9. Kind regards Dear Hussein I read with great interest your case.Interesting that transsexualism exist in all cultures and in all religions.I forgot the name but one of the pharaoh queen that was always dressed as a male was the first transsexual in the history. You may not know but I run the only service in our province that evaluate and treat TS.If you want that would be one of the topic that I can address in my talk with your group if this is still stands. Bach to your case,all the advice you were given is a good one.Usually it is recommended that she gets psychological support for at least 6 months,the you can think of hormones.I wonder hoe she will do in a restricted society that will see her as abnormal or crazy?We have followed successfully many Iranian females who immigrated to Canada and got the operation and doing very well.One would like to know the opinion of the psychiatrists in Egypt? there is always a risk of depression and suicide if they do not get help,at time in repressive societies they were even killed.There is a film called Men do not cry where id depicts a FTM ts who was killed in a small town. Dear Colleagues, Thank you all for the very useful advice and information you sent me. As for Pierre's question; I do agree that they are seen within restricted societies as "abnormal" or "crazy", that is probably the reason they appear to be tolerated, since insanity as not punishable on religious or legal grounds. I guess these unfortunate patients have acted "different" since early childhood so their surrounding communities have grown to tolerate them as individuals with mental disorders. I am not aware of any violent crimes against patients with gender dysphoria in Egypt. However, concerns about the risks of depression and suicide are obviously serious issues. Best regards, Hussein Ghanem Dear Hussein I went through our FTM cases. Hundred percent of them came to see us already under androgen management (some exuberant athletic phenotype). According to our law, surgery just can carried out after the age of 21. Under these particular circunstances, psychiatrist, psychologist, social counselor, counselor-in-law (application for official ID changing), etc., have plenty of time to go over all individual necessities. Among few cases we've done, a 9-y-follow-up case got maried 3-4 years ago. Hi Dr Hussein I'll give u my experience regarding FTM, during a period of 5 years; I saw 4 cases of young nice ladies who wish to be men. 2 of them fade-up of the procedures and the fact they sustained the procedures and one of them now received her ID papers after 3 years between psychiatric evaluation in 3 countries and 3 surgeries in 2 middle eastern countries (I have the photos for all stages ending by testicular implant). Of course after a period of role playing for the other sex with the help of the hormonal treatment. The problem I found lies if the parents are not aware of the sequellae if they hinder the process most of these girls Throughout their young life felt they were boys, played mainly with boys, indulged main male activities, and always wished to become a man. One of my patients played the male role in a sexual relation (closed) and they plan to marry in the near future. In some countries the procedure and the protocol is obvious and easy. But in some others it is tedious and lengthy up to committing suicide by the suffering young patients They feel as a man entrapped within the body of a girl. Realistic expectation of the surgery is of utmost importance or you will suffer with your team of the un-satisfaction of the pt. Refer the patient to a psychiatrist interested in sexual disorders to confirm the diagnosis of FTM transsexuals. For Medico legal aspects all papers approvals and consents must be copied and u have your personal hard copy. What is the experience or is there any literature dealing with the what becomes of these patients if they can not get sex change surgery? Specialized Society chaired by a ex-FTM pt is well known ? a report about it in ORGYN 2003 Vol.2 Would androgen therapy be advisable at this stage? or would it just virilize a good looking girl into neither being boy or girl? Androgen will be only started if the decision has been taken to proceed for the 2 years trial of role playing. Created on 10/06/2006 |
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