Digest of recent discussions on ISSM mail (January 2007 - April 2007)
Amr El-Meliegy, M.D. - ISSM List Manager
ISSM List Digest Jan � April 2007
The ISSM List discussions reached a record of 13 cases discussing very diverse, and interesting topics. The new filtering system was installed in April, which will prevent unwanted and personal emails to bother you anymore. I would like to express my thanks for my colleagues, Dr. Ahmed El Guindi and Dr. Ali Abderrasoul for helping me in summarizing the cases.
Cases
A 65 year old patient complaining of erectile dysfunction for many years came to Dr Ira Sharlip�s office. He had a history of well controlled hypertension and hypercholesterolemia. Otherwise, he was in a good physical condition. According to Dr Sharlip, he was psychologically normal and was not prone to complaining about pain unnecessarily.
The patient tried PDE5 inhibitors, which worked effectively for several years. After which he tried intra-corporeal injection therapy and was not satisfied. On 09 Aug 2005, the patient underwent a Mentor malleable prosthesis implantation through a subcoronal incision.
The implanted prosthesis� measurements were as follows; 13mm cylinders with a length of 20 cm including the rear tip extenders. Dr Sharlip reports that both corpora dilated easily to 13mm and the total corporal measurement was 20 cm. The procedure went very smoothly and the cylinders were a good fit in terms of length and width. Dr Sharlip considered shortening the cylinders by 0.5 � 1 cm but the fit seemed excellent and his judgement was to use the 20 cm length. Irrigating fluid of 80 mg Gentamycin in 500ml saline was used throughout the implantation.
The patient was doing very well till the 3rd day, when he started complaining of severe pain in the penile shaft. On examination there were no signs of infection and minimal edema and ecchymosis. On the 4th post-operative day, the pain was intolerable, even with the use of narcotics as analgesia. Upon the patient�s request, the prosthesis were removed on the 5th post-operative day, during which there was no unusual findings. The pain resolved 2 to 3 days after the removal of the prosthesis.
The patient refused to consider an inflatable prosthesis. He was told that the re-implantation of a shorter and narrower prosthesis might not cause the pain experienced before, after the previous implantation, since other forms of treatment continue to be inadequate. Dr. Sharlip asked if reimplantation of a shorter and narrower malleable prosthesis would work for this patient?
There seems to be a disagreement concerning the cause of the post operative pain experienced by this patient. On one side, there is the opinion that it�s either the length or the girth of the implant, while on the other hand, there is the opinion that the pain was psychosomatically induced.
Those in favor of the measurements of the prosthesis being the cause of pain suggested that either the length or the girth or both should be reduced during re-implantation.
There was also some suggestions regarding performing some procedures before re-implantation; to soften the corporal tissue, prevent shortening and allow easier subsequent dilatation. These recommendations include the use of vaccum device, drugs as alprosatidil , pentoxiphilline , and L arginine. Also suggested was performing of optical corporotomy combined with trans-corporal resection in the case of extensive fibrosis, difficult dilatation or shortening.
As to the cause of post-operative pain, it was suggested that it was due to ischaemia of the compressed corporal tissue after the implantation of the cylinders .
Those in favor of the psychosomatic etiology of the pain, thought that the patient�s expectations for the operation were not meet, as he was not ready for the operation. They recommended for such cases a one stage replacement by an inflatable prosthesis without delay, otherwise the same consequences will follow.
Detailed discussion
I have a 69 year old patient who has had ED for many years. He has a history of well-controlled hypertension and hypercholesterolemia but he is otherwise in good health and he leads a vigorous lifestyle. He is psychologically "normal" and he is not prone to complaints about pain.
He tried PDE5 inihibitors, which worked initially for several years, and then intracavernous injection therapy. He was not satisfied with these treatments. On 09 Aug 2005, I implanted a Mentor malleable prosthesis through a subcoronal incision. The total corporal measurements were 20 cm and the corpora dilated easily to 13 mm. I implanted a pair of 13 mm cylinders which were cut to 20 cm length including standard rear-tips. The procedure went very smoothly and the cylinders fit very well in terms of length and width. I considered shortening the cylinders by 0.5-1.0 cm but the fit seemed excellent and my judgement was to use the 20 cm length. During the surgery, I used my usual irrigating fluid of 80 mg Gentamicin in 500 mL of saline.
The patient did very well for 2 days and then began to complain of severe pain in the shaft of the penis. There was no suggestion of infection and there was minimal penile edema and ecchymosis. By the 4th postoperative day, the patient could not tolerate the pain, even with narcotics for analgesia. He requested removal of the prosthesis, which I did on the 5th postoperative day. At the explantation, there were no unusual findings. The pain resolved in 2-3 days after explantation.
Other forms of treatment for ED continue to be inadequate for this patient. I have told him that reimplantation with a shorter and narrower malleable prosthesis might not cause the pain he experienced with the previous implantation. He refuses to consider an inflatable prosthesis.
My question to surgeons among the ISSM membership is: What are the chances that reimplantation of a shorter and narrower malleable prosthesis will work for this patient?
Thank you in advance for your opinions.
Ira
Ira D. Sharlip, M.D.
Ira I had a similar problem several years ago with an Ambicor. I was of course concerned about sub-clinical infection as there were no overt signs of infection. Ultimately I explored and shortened the device by 1 cm by removing the RTE. I did do a mini-salvage as been my practice for many years. Regardless the intraop cultures came back clean. He did very well thereafter and is still doing well 4 years later. So a smaller device may work for him. But now you've got fibrosis in there.
Good luck.
Larry
Laurence A Levine MD,FACS
Professor of Urology
Rush University
Chicago,Illinois
Dear Ira: I am reasonably confident that a pair of 11mm prostheses will bypass the problem. I am not sure shortening the length will help, especially because the pain was mainly in the shaft. I am also concerned that if you downsize the length too much, you may end up with an SST deformity in the future. I have seen this a few times when 13mm devices are used. In the few cases I recall, the pain resolved after approx 2 weeks, but the pain was not as intolerable as in your case. I had wondered in the past if the pain (in my cases, transient) was due to a degree of tissue ischemia secondary to pressure/compression from the wide prostheses. Although the corpora dilate to 13 or 14 easily on each side, the combination can be too much of a good thing in some patients :-)
Hope this helps with your final decision.
Hossein
Dear Ira
We had experience with 2 cases that we published in the IJIR, 1999. Please find the details below quoted from our paper.
"Two patients were reoperated upon for severe post-operative pain persisting from day one to day 17 post operatively (duraphase) and prolonged post operative pain 11 weeks post operatively (omniphase). In the first case (a juvenile diabetic patient) infection was suspected, but no purulence was found and gram stains and cultures were negative. The 12mm * 22cm device was removed and replaced two months later with a 10mm * 19cm prosthesis with no difficulty dilating the corpora symmetrically. We now suggest it was an oversizing problem.
In the second case, the provisional diagnosis was an oversized prosthesis and pain resolved gradually after cutting 1cm off the proximal cap of the omniphase prosthesis".
Ghanem H, Fahmy I, Fallon B. Infection control in outpatient unicomponent penile prosthesis surgery. IJIR. 1999 Feb; 11(1): 25-7
Hope this is useful
Hussein
Dear Ira,
I agree with Prof. Ghanem.
On my experience, after I implanted a few Mentor Acuform, 13 mm, I realized that it is quite painful, it is very bulgy, the patient has serious difficulty in concealing and even bending his penis with two such rods inside. Unless the man has a really big penis, I try to convince my patients to accept an 11 mm PP.
It is not a matter of length but of girth. It is a pity your patient does not accept an inflatable, even an Ambicor PP.
Best regards,
Santiago
Ira,
One of my patient had similar severe pain with AMS prosthesis and downsizing of the prosthesis girth solves the problem. If the patient is not diabetic the prosthesis length should be not problematic.
For your convenience, I am enclosing two of our publications related to the pain issue in cases of inflatable prosthesis (not malleable) implantation.
Best regards,
Juza Chen, MD
Ira: I have seen persistent post-implant pain in diabetic men and as others have suggested this can be a sign of subclinical infection. In the diabetics I have seen post implant penile pain without infection; I have had success using Neurontin for the pain.
For this patient I would recommend a period of 6 months 'rehabilitation'.
1. Three times per week using VED; pump but no band; done for five to ten minutes repeatedly after his shower.
2. Once weekly injection of alprostadil followed by a VED session.
This I have found softens the corporal tissues, prevents shortening and makes subsequent surgical dilation easier. With this regimen some men will be able to penetrate (using the alprostadil-VED + band), but I don't promise them that.
Given his terrible pain without infection, I would not reimplant with rigid rods but would encourage him to have inflatable IPP.
Greg Broderick
Dear DR Ira
Dear colleagues and Friends, Hope for all of you the best of the best in all you wish , Thank you all for the useful information and sharing the experiences , for this case I am with the most of the colleagues that the problem in the diameter (13mm) as the pain in the shaft not the glans or crural (but can i know from DR Ira the nature of the pain ( dull aching , throping ,...etc) ,the course ( progressive, stationary , regressive ) , the lab result ( CBC,ESR, culture ..etc) also i belive that you should wait longer ( post operative complication in 1,207 cases Transient problems, such as pain or penile edema lasting longer than 4weeks, occur in 10 to 15 per cent of patients , and serious complications such as infection or prosthesis erosion occur in 1 to 5 per cent.of cases )
it is interesting using the vacuum post opertive for increasing the flexibility of tissue but PGE injection i am disagree with using pain mediator in this cases , but one of the interesting study done by Merrill DC.
Transcutaneous electrical nerve stimulation (TENS) was employed to reduce postoperative pain in 40 patients who had either radical nephrectomy, radical prostatectomy, or implantation of an inflatable penile prosthesis. These patients used 68 per cent less pain medication and made 84 per cent fewer requests for meperidine hydrochloride (Demerol) injections than did 40 control patients who had similar surgical procedures. The TENS units were easy to use, and there were no complications to electroanalgesia. The TENS program also was costeffective. TENS provided a simple, safe method of reducing postoperative pain in the three surgical procedures tested. Electroanalgesia may have application in other types of urologic surgery, and TENS should be particularly useful in patients who have outpatient surgery.
PMID: 3495062 [PubMed - indexed for MEDLINE]
i think there is away to wait by different kinds of support ( oral , systemic and local injections ) for 4-6 weeks after discation the percents of possibility of pain disappear with the patient before .......... as the dilatation was very easy without any resistance as you informe as .
thank you
Prof .Dr Khaled othamn
M.D andrology
ABS sexology
UAE
Dear dr Ira:
i would suggest recounselling of the pateint as regard that reimplantationis the best chance for him ,this will alleviates a part his bad expirence as regard the interactable pain he suffered from before,.
down sizing is mandatory by 1 -2 cm,together with a mid penile incision.
I would agree with dr g. brodreick suggestions to minimize the alerady present fibrosis& I would suggest, daily night dosing of pentoxyfilline to softens the fibrosis.
you can try to use vancomycin with the irrigating solution in the revision state.
regards.
Abdel Rahman Zahran M.D
ISSM members -Dr Abdel-Rahman zahran suggests the use of pentoxifylline to exhance penile blood flow following explantation. I, in fact ,use the same agent with L-arginine for my patients with Peyronie's disease for their presumed anti-fibrotic properties. The question is-Is there any real evidence of either effect- enhanced blood flow or reduced fibrosis from these agents??
Larry
Laurence A Levine MD,FACS
Hi Larry:
In experimental models, for PD we tested pentoxyfilline in Valente EG, Vernet D, Ferrini MG, Qian A, Rajfer J, Gonzalez-Cadavid NF (2003) PDE L-arginine and PDE inhibitors counteract fibrosis in the Peyronie's fibrotic plaque and related fibroblast cultures. Nitric Oxide, 9:229-244. and it worked tin this rat model in reducing fibrosis.
Best regards
Dr. Nestor Gonzalez-Cadavid
Dear colleagues!
The patient had most likely psychogenic pain. Operation caused a stress decompensation. The expectations of the patient did not correlate with the result of operation. He was not ready to implantation. It was a cause of natural postoperative pains. For organic pain (an ischemia, excess of the implant size, infection) it is not absolutely typical, as there were no changes locally and infection was not revealed. In this case I would suggest the following:
1. Do not remove the prosthesis immidiately (4 days are not enough to understand the reason)
2. If there is a decision on reoperation it was necessary to make one-stage replacement by an inflatable prosthesis, that would clear the reason of pain. In this situations delayed implantation, even an inflatable prosthesis can lead to a similar clinical presentation. It is risk for the patient and for the doctor.
It seems to me that in this situation, when we do not have the reason of pain and psychologist`s and the psychiatrist`s consultation, reimplantation is not appropriate.
Prof. Peter A. Scheplev.
What Prof. Scheplev is pointing at ,the need to consult a psychiatrist,psychologist, or a sexual medicine specialist before fitting somebody with pp,at least in certain cases.
Pierre Assalian.MD
Hi Everybody !
Lots of good opinions and conjectures floating around there already on this subject, but I'd like to ride mine on this one from Peter Scheplev, who makes a good case for a psychosomatic etiology. I too have seen this syndrome in some patients where there has been no intra-op sizing ambiguity whatsoever, and no evidence at all of post-op infection either. Such cases are hard to forecast even by good pre-op psychological screening and counselling. Re-operation can make the situation much worse, especially if rushed. Prudence, not just clinical, but also medico-legal, is paramount.
Sudhakar Krishnamurti
Hyderabad, India
Dear Ira, dear friends,
I have seen this situation with some of the younger patients who received the maximum girth for their caliber, and came to believe that it is related to engorgement of the remaining cavernous tissue I set aside at dilatation, against the rods in a tight space. This distention is possibly the cause of pain especially considering that it coincides with sexual excitation and nocturnal erection (naturally, this does not imply that the patient has normal cavernous tissue, as excluded by preoperative therapeutic trials and investigations).
I therefore warn the patient before hand, advise refraining from sexual excitation and may even prescribe anti-erectogenic medications in addition to analgesics and antibiotics. The pain will disappear in 4 weeks time on average as the cavernous tissues gradually atrophy. This worked for my patients and I still go for the maximum girth feasible.
Hope this helps.
As for re-implantation, let me suggest a trial at optical corporotomy and trans-corporal resection, in case you face difficult dilatation or shrinkage of the corpora:
Corporoscopic Excavation of the Fibrosed Corpora Cavernosa for Penile Prosethesis Implantation: Optical Corporotomy and Trans-Corporeal Resection, Shaeer�s Technique.O.K.Z. Shaeer and A.K.Z. Shaeer J Sex Med 2007;4:218�225
All the best,
Sincerely,
Osama Shaeer
Dr.Osama Shaeer
Dear Prof Ira
From a long list of maleable prosthesis we implanted, I feel it a problem of sizing and if tip pain + it equals over length and rear tip pain is somtimes temorary cz of dilation. but if persisted its the girth more than the length because the girth is proportionate to the rear end of the prothesis. Infection mostely showed a tender and somwhat swollen corpora and somtimes on one side.
but the problem of persistent severe intractable pain points to 1-overgirth 2- psychological
if you tried Gabapentine it it failed or Tegretol does not work. The only solution is to remove the implant and implant another one with smaller diammter. hoping it is not the psychic pain or it will persist.
wish u good luck
shedeed Ashour shedeed
Dear Ira and dear members,
I mainly agree with Dr Levine�s opinion and I would like to give some additional precisions. It is important that the subcoronal incisions, the lateral ones as well as the incisions made at the end of the corpora cavernosa, should not be superior to 1,5 cm .
The prosthesis should be half centimetre shorter than the corpora cavernosa because the corporotomy�s suture point reduces the length of the corpora cavernosa. In the case we are commenting upon, I am quite sure that the prosthesis was too long and, in the absence of infection, I would have shortened the prosthesis in the same surgical act or I would have swapped it by a new one that would be half centimetre shorter.
If this is not done during the same surgical act, the patient starts having a bad experience of the prosthesis and most probably will not be willing to undergo a second surgery.
Ambicor prostheses are not adequate if the patient has a conical-shaped penis. Indeed the distal part of the Ambicor prosthesis is 30 mm and is very hard: this may cause pain when the albuginea is sutured, due to internal pressure. I suggest that in this case and for patients with conical penis, the Mentor Excell Resist prosthesis is much better since the distal part of it is very soft.
Dr. Mariano Rossell�
Urology, Andrology and Sexual Medicine Centre
Dear Dr. Ira:
Probably you�ve enough suggestions regarding this particular case. However I�d like to include another situation. A 55 yo caucasian gentelman (diabetes, hypertension, obese and dyslipedemia) underwent to malleable PPI, 13 diameter, as outpatient elsewhere. I saw him at the ER about 24 h after procedure, complaining about "uncontrolled pain". A penile doppler US has been carried out followed by intracavernous Caverject 20 micrograms. Cavernous arteries could not be demonstrated. Selective pudendal arteriography was done and both cavernous arteries were obliterated. Considering ischemia one rode vas withrawn and doppler US did demonstrate cavernous artery flow. Pain was controlled and patient is not interested in implant a second rod. Ischemia, edema...
Regards
Claudio Teloken
Dear Dr Ira,
I am much attracted to the opinions expressed by
Dr.scheplev---- I think
that the complaint of your patient is largely psychosomtic
due to improper
or inadequate pre-operative counselling of the patient or
the usual
unrealistic expectations of many patients about PP
surgery(some patients
have unstable or hysterical personality). although you
already explanted the
PP but I suggest the following for similar cases :
1. four days is a short time to consider
explantation,better to consider
reassurance,recouncilling and potent pain killers provided
the possibility
of overt or subclinical infection is remote.
2. giving drugs that could possibly reduce penile fibrosis.
3. in this particular case I think the idea of
re-implantation would be
disastrous and it is much better to consider a non-surgical
approach.
thanks
Dr.hesham nabil khaled
A 24 year old male came to Dr. Chris McMahon presenting with �soft glans syndrome�. In this case the patient�s glans failed to expand sufficiently and showed instability on full erection thus interfering with penetration.
His erection was excellent with no significant past history . A penile duplex/ultrasound showed normal cavernosal arteries, normal veno-occlusive mechanism, normal corporal morphology, no distal corporal fibrosis and normal expansion/extension of corporal tips into the glans penis.
In hope of improving distal corporal perfusion and exaggerated corporal tip expansion, the patient underwent a trial of daily tadalafil. No improvement was noted. Dr. McMahon believed in the presence of a significant psychogenic component.
There is a variety of advice given in this interesting case. The majority agreed upon the use of trans-urethral alprostadil (MUSE), in order to improve penile glandular tumescence. A rubber band could also be used with MUSE.
The theory of a very early Peyronie�s disease, causing abnormal vascular communication between the corpus cavernosum and the spongiosum was suggested. An arteriogram or cavernosography could be done to shed more light. In this case, the course of action would be microsurgical arterial by-pass between the inferior epigastric and the dorsal artery. Also suggested was dorsal vein ligation, either with the previous procedure mentioned or as a solitary procedure.
The presence of a psychogenic etiology was also thought of. Education of the patient was advised, in order to avoid the presence of a wrong idea considering what is normal and what is not, according to the patient. Start and stop technique was referred to, in order to increase genital congestion.
The use of a vaccum device was recommended, in order to increase the blood flow to the distal part of the corpus spongiosum.
Detailed discussion
Dear Colleagues,
Can I ask for some assistance in this patient?
He is a 24 year old male who presents with a �soft glans syndrome� where his glans penis failed to adequately expand and is unstable at full erection causing some problems with penetration. There is no significant past history and his erections are excellent. A penile duplex ultrasound demonstrates normal cavernosal arteries, a normal veno-occlusive mechanism, normal corporal morphology, no distal corporal fibrosis and normal expansion/extension of corporal tips in to the glans penis. He has failed to respond to a trial of daily tadalafil in the hope that this will promote improved distal corporal perfusion and exaggerated corporal tip expansion. There is no doubt a significant psychogenic component
Any advice will be appreciated
Chris G McMahon
Dear Chris,
can I understand that this phenomenon was vanished upon
intracavernosal
injection, while performing the penile duplex ultrasound?
Pharmaco-dynamic cavernosography could bring more insights
in regard to
penile opacification and structure! What do you think?
Sincerely
Aksam A. Yassin
Dear Chris,
have you tried MUSE? It is known to improve the tumescence
of glans
penis at least in patients with penile prosthesis.
Regards
Juhana Piha
Dear Colleague
What are the psychogenic components?
- Psychic manifestations ( depression , anxiety, OC..)?
- Relational difficulties?
- Life events?
- Personal Sexual History?
Sincerely
Mireille BONIERBALE, MD, HP
Dear Chris,
Transurethral alprostadil (MUSE) is worth trying. We had
previously reported
on the use of transurethral alprostadil (MUSE) to improve
glans tumescence
after penile implant surgery.
Kind regards,
Kim Chew
Dear Chris
I would like to suggest a treatment approach from non-medical sexology, which essentially bypasses questions of etiology, but would be interesting and informative if it helps. It is an approach borrowed from "Tantric sex" in which patients are instructed to stimulate to the plateau phase of orgasm and then withhold stimulation until recession of the acute phase of the orgasm. They then repeat several times before ejaculating. This is known colloquially as "edging", and also as "stop-start" stimulation. I recommend this technique in sex therapy in certain ED patients and in women with arousal disorders. As this approach increases genital congestion it may produce an effect on the glans. It may be useful to begin as masturbation exercises. They should do this as much as is comfortable for them, and of course only if acceptable to the person. Certainly no harmful side effects can accrue, and perhaps could be considered before more invasive techniques.
Best wishes,
Dave
David Rabinowitz MD
Dear Chris,
According to the findings you describe, it seems the problem to involve the Corpus Spongiosum only, with no involvement of the Corpus Cavernosum. It is hard to believe that someone can have a psychologic problem concerning the CS only. On my opinion, the psychologic component is secondary to ... and not the cause of...
Is the problem present on the Glans only, or along the urethra too (also part of the CS).
In any case, the most probable diagnosis at this stage is a very early Peyronie's disease involving the vascular communications between CC and CS
Regarding treatment, I agree with Dr. Kim Chew's suggestion of MUSE, or any other topic vasodilator.
What about the use of a rubber ring at the base of the penis after MUSE? - Use of VED?
Good luck and keep us updated
Best regards,
Santiago
Dear Chris,
Thanks for this interesting uncommon case. I enjoy reading great suggestions.
Can his erect penis stand for buckling pressure? It may not be abnormal if it does.
It seems that this patient is gifted with very good development of glans penis and lucky with good erectile function, but may, unfortunately, be without knowledge of doing adequate lubrication of sexual attempt or most possibly misunderstanding of the nature of glans penis.
The glans penis is a very interesting structure in the entire organ of the penis which is a man�s symbol. Its distal ligament (attached) acts functionally and structurally as a bone in lower species on mammalians. It ought to be regarded as an umbrella rather than an airbag. Similarly an open-umbrella shall not be rigid as a spur which is rigid everywhere. In 1993 I had a 24-year-old similar case (I do not believe that they own the same genes which will not contribute in anatomical aspect if so ). Eventually he got the right anatomy after he had strived to put his glans into the urethral orifice of his partner for some eight months because insufficient knowledge.
This patient might be normal but just requires reeducation. It will be worthy of being studied for genome if there is no distal ligament (Still no excetion).
Would you please keep us update?
Geng-Long Hsu
Dear Chris,
I agree with Santiago Richter and I do not think that this guy has a psychological problem. His problem is clearly a physical one: lack of tumescence and engorgement of the glans while having a normal erection in the cavernosal bodies is just impossible. The main arteries supplying the glans are the dorsal arteries of the penis, the urethral and bulbar arteries irrigate the corpus spongiosum and are responsible for the tumescence of the spongiosum but not for the erection of the glans which depends on the dorsal arteries. This patient may have an insuffiency of the dorsal arteries, probably traumatic in origin in a young person without significant past history (forced stretching during masturbation, distal vascular lesion during circumcision, congenital?). My suggestion in this case would be to perform an arteriogram of the penile arteries (dorsal arteries can be seen quite easily) and if you confirm the blockage of these arteries an option would be to offer the patient a microsurgical by-pass from the epigastric to the dorsal artery.
Best regards,
Ignacio Moncada MD
Madrid, Spain
I agree with Dr Moncada altho I doubt there will be a
recontructable
vascular lesion. The use of MUSE may allow engorgement and
possibly with
regualr use provide some rehabilitation for a more
spontaneous vascular
response. It's worth a try.
Laurence A Levine MD,FACS
Professor of Urology
Rush University
Chicago,Illinois
I agree with Larry and Ignacio:
I have several young patients with soft glans syndrome and vasculogenic ED secondary to traumatic cavernosal artery insufficiency (no leak) who I have performed a microarterial bypass surgery from the inferior epigastric artery to the dorsal artery with or without ligation of the dorsal vein with excellent results. Both conditions (ED and soft glans ) improved after surgery, however I don't know if the improvement of the soft glans syndrome is psychological or due to increase in inflow or decrease outflow. Base in my anecdotal experience, I think that well selected patients with a normal psycological evaluation may benefit from bypsas surgery with or without ligation of the dorsal vein. In addition, Muse has been helpfull in several patients.
Ricardo
Ricardo Munarriz, M.D.
Dear colleagues,
the case of soft glans syndrome is quite interesting,I
totally agree with Dr
moncada and I think such cases are mostly organic and
cannot be
psychological by anyway
DrHesham Nabil Khaled,MD
Dear colleagues:
I agree with many answers that were already given and since Dr McMahon indicates that the tests seem to be normal, excepting for the soft glans penis, I wish to point out that there are quite a lot of patients who believe that the glans has to be in erection and it is necessary to explain to them that it is not the case: the glans permits to obtain the necessary tumescence since it has to act as a �cushion� in order not to hurt itself during penetration and not to hurt his partner. I agree with Moncada and with Munariz: there might have an arterial injury although it is not common in young patients with no past history. I also agree with Dr Levine and my other colleagues who recommend the use of MUSE and patient psychotherapy.
Best Regards
Dr. Mariano Rossell� Barbar�
I agree with most doctor , i think it is not psychogenic cause rather than organic cause in the C.S may be early preutheral fibrosis with medical treatment trial after penile dupplex study i recommend topeglan gel ( PGE &SEPA) insted of muse with pentoxiphlyin oral treatment to increases the peripheral circulation with anti anxiety , sildenafile as PDE5 inhibitor more rigidity ,Kgel exercises and ozone therapy for 3 months trial before rearterialization
KHALED OTHMAN
I agree with this organic explanation - the only other population I have seen this in is spinal cord injury ( where there was normal glans filling before injury) suggesting a neurogenic cause of the vascular deficit
Stacy Elliott, MD
His dorsal arteries had excellent systolic flow on duplex US.
Chris G McMahon
Dear Mariano, dear all,
I enjoy the discussion about this entity ,entitled "soft glans syndrome " and I agree with Mariano Rosello Barbara that there are guys complaining that there glans is not as stiff as the cavernous bodies and that these guys principally have a completely wrong perception
of what is physiological and what is not during erection and that naturally the glans must become tumescent but not rigid.
But there are also rarely these other guys who are complaining that there glans has lost the ability of tumescence what is also often reported by their partners provided they have had a comparison with the status before the loss of glans' tumescence occurred. I see those guys about three to five times per year and in some of them I was not able to figure out any neurological or vascular etiology. Of course in some of them you will find a history such as trauma (for example penile fracture without hematoma or situation after perineal or pelvic trauma or surgery etc.), neurological or metabolic diseases.
But in some of them the history is completely uneventful and nobody can aswer the question why in these men all of a sudden the glans has lost its tumescence while erection occurs (perhaps in some it may be due to a latent penile trauma).May be it's a local neurovascular pathological process which is not well understood to date.
Unfortunately in the majority of these cases there is no real diagnostic means available to objectify soft glans syndrome and neither cavernosography nor color doppler nor intracavernosal injection test is able to prove soft glans during physilogically occuring erection ,(except VSS) e.g. the diagnosis is settled mostly by history.
Principally MUSE is the therapy of choice for the majority of these cases what also applies for penile constriction rings such as the previous actis rubber band provided with MUSE or any other rubber rings/bands etc.
But according to my experience in some of these guys dorsal penile vein ligature(superficial and deep veins) - this entity of soft glans syndrome is in my hands the only exception where I do rarely this procedure - may work quite well and may be considered in failures to conservative managment. I recall quite well a meanwhile 45 year old gentlemen who presented at my office with this soft glans syndrome over 15 years ago and in whom I did such a dorsal penile vein procedure which worked very well for roughly 10 years. Then he presented once more because of recurrence of soft glans and I ligated once more newly built dorsal penile veins and up to now he is satisfied with his glans tumescence.No doubt these are exceptions and the majority of these guys can be managed conservatively and by counselling if unrealistic expectations about "glans erection" are obvious.
Regards
Prof.Dr.Hartmut Porst
Chris
A rare case like this draw the old horses out of the
stables.The
Copenhagen Impotence Study Group (CISG:
Ebbehoj,Metz,Uhrenholdt,Wagner)worked intensively with many
new
aspects of penile function and dysfunction.
The lack of tumescence of the glans during erection is
rather
special to look at as it resembles a cloche hat (sun hat)on
the tip
of the erect shaft.
Ebbehoj and Metz have described their first case in 1985
(1)where
they performed an Ebbehoj procedure(2) The normal blod flow
pattern
of the glans is discussed by me in 1981(3)
Since then Ebbehoj and Metz have surgically treated foor
patients
either by shunting or by closing (too) abundant venous
drainage in
the sulcus area, all depending of the underlying pathology.
Metz reports that he just a week ago saw one of these
patients
(unrelated to this problem) who was operated upon in 1992
and still
fully satisfied with his penile erectile ability.
1)EBBEHOJ J, METZ P Lacking Tumescence of Glans During
Penile
Erection.
J UROL 1985 134 1220
2)EBBEHOJ J A NEW OPERATION FOR PRIAPISM SCAND J PLAST
RECONSTR
SURG 1974
8 241-242
3) WAGNER G GREEN R 1981 IMPOTENCE NEW YORK PLENUM PRESS
p29-30
Greetings GORM
Dear Chris
In addition to MUSE, we have also found the use of penoscrotal rings and sometimes also a vacuum device (with a retaining ring) has helped increase overall engorgement of the soft glans. This is all augmented by regular supportive counselling in a way similar to the �ineffective� doses of sildenafil, etc. which improve with support and sustained use of the treatment. The penoscrotal rings are underused but are the most aesthetically acceptable �medical� intervention especially with the younger men.
Best wishes
Kevan.
Dear Colleagues:
I am totally agree with every word by Dr.Hartmut Porst , Also with Santiago Richter that the most probable diagnosis at this stage is a very early Peyronie's disease involving the vascular communications between CC and CSProf. recomended the suggestion of Ignacio Moncada in this case would be to perform an arteriogram of the penile arteries (dorsal arteries can be seen quite easily) and if you confirm the blockage of these arteries an option would be to offer the patient a microsurgical by-pass from the epigastric to the dorsal artery. I think topiglan gel with band or vcd , trental ,bulpocavernous exercises , after being sure that the patient without hyochondriases psychological focus , revascularization is very good solution but after failure of medical trial and probable diagnosis
Best regards
khaled othman
Dear Chris
most of thesepatient are exaggerating and somtimes anxious and Dysmorphic. But anyway they are beniiting too much of Minoxidil Spray on the glans (2-3 puffs to guard aanist the most common side effect which is headace) befor coital attempt by 10-20 mins.
yours
shedeed Ashour MD
Dear Colleagues
A very interesting discussion but i worry about too firm a glans not allowing ejaculation to occur/
Regards
Dr Prithy Ramlachan
And what about the spial arteries? Did he underwent to a pudendal arteriography?
Claudio Teloken
Dear Dr.Othman:
I have highlightened and rendered bold two phrases in your earlier email message (vide infra). Is there anything in the existing international literature on this ? Thanks in advance for the elucidation.
Sudhakar Krishnamurti
Hyderabad, INDIA
Dear all
I would like to add my voice to Dr.Sudhakar.I would like to
know if there is
anything in the literature about very early peyronie
disease involving the
vascular commiunication between CC and CS ?? as far as I
know nothing
exists. thanks
Dr.hesham nabil
Dear all
Thanks for this very interesting case and discussion
I agree that the suggestion that this entity is due to peyronie disease involving the
vascular communications between CC and CS seem to me unlikely.
In order to better understand this phenomenon you can insert a needle in the glans and inject contrast material through the glans and visualized spongiosal communication to the corpora. This technique is published in - Vardi Y, Saenz de Tejada I: Functional and radiologic evidence of vascular communication between the spongiosal and cavernosal compartment of the penis. Urology 49: 749-752, 1997.
Regards
Yoram Vardi
DR. Eugen Plas presented a patient complaining of symptoms of late onset hypogonadism (LOH) for 7 months. His serum testosterone was 48nmol/l (normal 8.4-28.7) normal SHBG 92nmol/l, LH, prolactin, DHEAS, cortisol, HCG, thyroid and general blood samplings were all normal.
He denied taking any medications or anabolics. He only took some vitamins a year ago for approx. 3 months. His major complaints are lack of libido, fatigue, absent nocturnal erections and ED which improved on CIALIS.
As regards this case some doctors suggest that the medications he took (vitamins) were nothing but hormones which is probably the cause of his hypertestosteronemia.
Others suggest that these symptoms are non specific for the LOH and that psychogenic factors must be ruled out.
Detailed discussion
Dear members,
I have a 40 year old athletic male computer technician who has LOH symptoms since 7months but at repeated measurements a serum testosterone of 48nmol/l (normal 8,4-28,7) or higher, normal SHBG 92nmol/l, LH, prolactin, DHEAS, Cortisol, HCG, thyroid and general blood samplings were all normal. Imaging controls of the hypohysis, adrenal and testes were repeatedly normal.
He denied taking any medications or anabolics, just recently he mentioned that he took some vitamins a year ago for general health for approxy. 3months. His major complaints are lack of libido, fatigue, no nocturnal erections and ed which works well when taking cialis.
Unfortunately I do not have a clue of the pathogenesis of his hypertestosteronemia and would be pleased I could recieve some suggestions.
Thank you in advance, yours sincerely
Eugen Plas
Hi.
From my experince many so called "Vitaminis" this guys take have hormons and pre-hormons. I siggest he stops taking any materials for a while and then re-check.
Itzahk Z Ben-Zion , MD
Hypertestosteronemia suggestions requestedDear Dr. Plas
Very interesting case, I agree with Dr. Ben-Zion that many
athletes take
Androgens disguised as vitamens. Occasionally we see
Hypertestosteronemia
with androgen resistance disorders. Were all the
testosterone evaluations
done in the same lab? if so it might be worthwhile to
repeat it in a
different lab.
As regards the Late-onset hypogonadism (LOH) symptoms, I
also suggest ruling
out psychogenic factors since these symptoms are
non-specific, and the
patient has high rather than low testosterone.
Please update us about your findings,
Hussein
I have seen high testosterone levels associated with
"natural vitamin" preps but as might be expected, there is a
concommittent low LH level. I suspect psychogenic causes.
Andy McCullough
Dear Dr. Plas
your case is seen every now and then,I agree that the so
called vitamins he
had recieved before are nothing but hormone - rich or
anabolic - rich OTC
preparations found in all pharmacies.this explains
hypertestosteronemia you
have found which is not matching with LOH symptoms you
mentioned which are
very non specific as hussein said,most probably they are
non organic in
origin in the light of high serum testosterone level found
Hesham Nabil,MD
About hypertestosteronemia patient
I had few patients who after taking medications like clomid 4 to 8 months before ,had hypertestosteronemia but without LOH symptoms. I suggest ruling out psychogenic disorders and consider androgen resistance.
Dr Claudio Terradas
Dr Sharlip initiated a discussion about the link of circumcision and HIV infection.
The possible benefits of circumcision mentioned were: protection from harmful bacteria, guarding against cervical cancer, avoidance of penile cancer , and protection from UTI.
It is viewed as an easy outpatient procedure with minimal surgical risks, particularly in infants. In adults, transient premature ejaculation due to a more sensitive glans was reported by Dr. Richter. However, Dr Moncada reported decreased sensation post circumcision with patients even asking for reconstruction. He also advised plasty to be done for cases failing to retract their prepuce.
Dr Sharlip mentioned that 2 studies done in South Africa and Kenya showed that complications post circumcision is 1.7 - 3.8% ; whereas HIV infection in these countries affects 1 of every 3 men and hence circumcision in countries with high risk of HIV infection could be very beneficial. Others agreed that circumsicion should be done in countries with high prevalence of HIV infection , under proper hygienic settings, by trained physicians taking every precaution to avoid complications, particularly the very rare but disastrous complication of amputation of the glans penis.
Dr. Sadeghi-Nejad added that the two large African randomized trials in South Africa and Kenya were terminated earlier than scheduled as interim analysis of the data revealed signficant ( 60% ) relative risk reduction in favor of circumcision.
Dr. McCullough raised the question of whether the association was causal or due to some socioeconomic or cultural factor in circumcised men. Dr. Wisniewski added that since there is no epidemiologic study that has shown that circumcision should be a public health funded procedure with equivocal benefits, then funds would be better spent on sex education and condoms.
Detailed discussion
Dear ISSM Members,
Androlog is a website for experts in male infertility who wish to exchange information online. On 06 Mar 07, Dr. Craig Niederberger, Interim Chairman of Urology at the University of Illinois in Chicago, wrote the following email. I am very interested to know what ISSM members think about the issue of circumcision and HIV infection.
Ira
Dear Ira,
This is a most interesting issue.
I have no experience regarding the effect of circumcision on the incidence of HIV transmission.
On the other hand, we do have here in Israel a great experience on Circumcision in adult males, mainly for traditional/religious purposes.
I mean Jews who immigrated to Israel, not being circumcised as children, due to political limitations in their Country of origin, wishing to fulfill this tradition.
This is an office procedure, performed under local anesthesia. I dare to say that there are almost no surgical complications, keeping the man out of sexual activity for about 7-10 days. Some men complain of transient Premature Ejaculation, probably due to a more sensitive glans, uncovered by the prepuce.
In summary, there is no doubt that the surgical risk/benefit balance goes far in favor of the benefit of less HIV transmission.
Best regards,
Santiago
Dear Ira,
Concerning circumcision there is a growing evidence about its various benefits as
1. Protection from urinary tract infection (UTI)
2. Guarding against cervical cancer
3. Avoidance of penile cancer
4. Reduction of harmful bacteria
These are the list of papers in literature confirming its benefits
1. J. A. Lohr, �The foreskin and urinary tract infections,� Journal of Pediatrics, March 1989, Vol. 114, No. 3, pp. 502�504.
2. J. A. Roberts, �Does circumcision prevent urinary tract infections?�, Journal of Urology, May 1986, Vol. 135, No. 5, pp. 991�992.
3. Thomas E. Wiswell, W. E. Hachey, �Urinary tract infections and the circumcision state: An update,� Clinical Pediatrics, March 1993, Vol. 32, No. 3, pp. 130�140.
4. J. Winberg, I. Bollgren, L. Gothefors, M. Herthelius, K. Tullus, �The prepuce: A mistake of nature?�, Lancet, March 1989, Vol. 1, No. 8638, pp. 598�599.
5. H. G. Rushton, M. Majd, �Pyelonephritis in male infants: How important is the foreskin?�, Journal of Urology, August 1992, Vol. 148, No. 2, pp. 733�736.
6. C. M. Ginsburg, G. H. McCracken, �Urinary tract infections in young infants,� Pediatrics, April 1982, Vol. 69, No. 4, pp. 409�412.
7. L. W. Herzog, �Urinary tract infections and circumcision. A case-control study,� American Journal of Diseases of Children, March 1989, Vol. 143, No. 3, pp. 348�350.
8. E. F. Crain, J. C. Gershel, �Urinary tract infections in febrile infants younger than 8 weeks of age,� Pediatrics, September 1990, Vol. 86, No. 8, pp. 363�367.
9. K. N. Shaw, M. Gorelick, K. L. McGowan, N. M. Yakscoe, J. S. Schwartz, �Prevalence of urinary tract infection in febrile young children in the emergency department,� Pediatrics, August 1998, Vol. 102, No. 2, e 16.
10. T. L. Stull, J. J. LiPuma, �Epidemiology and natural history of urinary tract infections in children (Review),� Med Clin North America, March 1991, Vol. 75, No. 2, pp. 287�297.
11. F. Serour, Z. Samra, �Comparative periurethral bacteriology of uncircumcised and circumcised males,� Genitourinary Medicine, August 1997, Vol. 73, No. 4, pp. 288�290.
12. �Male Circumcision, Penile Human Papillomavirus Infection, and Cervical Cancer in Female Partners,� New England Journal of Medicine, April 2002, Volume 346:1105�1112, Number 15, http://content.nejm.org/cgi/content/abstract/346/15/1105.
13. Laura Johannes, The Wall Street Journal, Thursday, April 11, 2002, p. D8.
14. Thomas E. Wiswell, �Neonatal Circumcision: A Current Appraisal,� Mosby Year Book, Inc., Focus & Opinions: Pediatrics, 1995, Vol. 1, No. 2.
15. E. J. Schoen, �The relationship between circumcision and cancer of the penis,� CA Cancer J Clin, September�October 1991, Vol. 41, No. 5, pp. 306�309.
16. U.S. News & World Report, May 1988, p. 68.
17. B. Morris, �Medical benefits from circumcision,� March 1999, p. 4.
In addition, it is a minor procedure which carries small risks.
Best regards,
Amr El-Meliegy, M.D.
Dear Ira,
In communities where circumcised men are in monogamous partnerships the incidence of HIV is almost none existent. The problem is comparing such groups to those where sexual practices include polygamy, unprotected sex, activity during menses, anal penetration etc. as culturally accepted. To believe that circumcision alone would protect men and their partners in such environs has never been proven. There is no Epidemiologic Study that has shown that Circumcision should be a Public Health funded procedure with unequivical benefit to all males. The public purse would be better spent on sex education and condoms.
Stan Wisniewski Perth West Australia. Best Wishes to you Ira.
Concerning the benefit of circumcision in reducing HIV infection vs. surgical risks of circumcision:
Two recent careful studies in Africa have shown that circumcision reduces risk of HIV infection. These studies have received much publicity.
Auvert et al, PLoS Med 2005; Nov;2(11):e298
Bailey et al, Lancet 2007; 369: 643-656
In some areas of Africa, 1 in 3 men are HIV+ and therefore at risk for AIDS and premature death. My guess is that even if circumcisions are done by inexperienced healthcare workers, the fraction of men who would be exposed to risk of serious surgical complications from circumcision would be far less than 1 in 3.
In the South African study by Auvert et al, 60 surgically-related adverse events occurred in the 1,568 men (3.8%) who received circumcision. In the Kenyan study by Bailey et al, 24 surgically-related adverse events occurred in 23 of the 1334 men (1.7%) who received circumcision. None of the adverse effects were life-threatening. In these studies, the circumcisions were performed by a small number of doctors who had a special interest in circumcision. If there were to be a widespread campaign to perform circumcision in a broad population of men, the circumcisions would probably have to be done by less well-trained surgeons and the rate of adverse events would probably be higher. Still, I would not expect the rate of surgical adverse events to come close to off-setting the benefit of the reduced HIV rate found in circumcised men. In the Auvert and Bailey studies, the protective effect of circumcision on HIV infection was 53-60%.
Should nations which have a high rate of HIV infection encourage their male citizens to have circumcision?
Ira D. Sharlip, M.D.
Dear all
i agree with dr Ira that tose nations with high prevalence of HIV infected people should encourage the performance of circumcision. Its really protective.
the fact that by circumcision we reduce the surface area of the vulnerble mucus membrane exposed to the source during coitus, lies bebind this rational.
Shedeed Ashour Shedeed
I just wish to point out that circumcision should only be performed in proper hygienic settings by trained physicians taking every precaution to avoid complications, particularly the very rare but disastrous complication of amputation of the glans penis. Over-circumcision and buried penises are not uncommon and need to be avoided.
Hussein
Dear Ira
Congratulation for bringing up this very interesting topic
and the excellent discussion in ISSMList
As responsible for the controversies in sexual medicine for
JSM I thought that this can be an excellent topic for the
next issue of JSM
This section generally include 4--5 experts that need to
write about 500 words and 5 ref
First can you write one of them and second can you
recommend
othe possible experts wit differents opinions
Hoping to see you soon probably in Berlin
Yoram
Dear colleagues:
In my opinion, circumcision should be performed to all men who cannot retract their prepuce and see their glans penis, as well as to those men who cannot cover the glans penis after having an erection, without the help of the hands. The 2 main benefits of circumcision clearly are that it improves both the glans penis hygiene and sexual activity. Penile hygiene is easier to a circumcised man, avoiding thus at the same time bacterial and viral infections. However, I am not sure of this so-called protective effect of circumcision on HIV infection.
Regards to you all
Mariano Rossell� Barbar�, MD.
I agree with those who think that circumcision is an
interesting topic.
To argue that circumcison may protect from HIV can be a
dangerous message, prophylactic measures are the most
important and this should be a strong statement.
There are also disadvantages with circumcision, mainly the
decrease in sensation that many patients refer after it. I
see more and more patients asking for a reconstruction of
the foreskin, particularly those who had the circumcision in
the adult age feel very much this decreased sensation
during sexual intercourse. It is like the quest for the lost
prepuce.
If the retraction of the prepuce is the problem, a plasty
should be the solution. I am not sure to propose
circumcision for prevention of HIV infection or penile cancer.
Best regards,
Ignacio
Sent from my Blackberry
Ignacio Moncada MD
Dear colleagues :
No doubt that Male circumcision provides a degree of protection against acquiring HIV infection, equivalent to what a vaccine of high efficacy would have achieved. Male circumcision provide an important way of reducing the spread of HIV infection in sub-Saharan Africa. (Preliminary and partial results were presented at the International AIDS Society 2005 Conference, on 26 July 2005, in Rio de Janeiro, Brazil.).
The results of two randomized clinical trials of male circumcision in Kenya and Uganda are interest, however male circumcision should be carefully considered as a potential public health tool in preventing HIV acquisition. Implementation of this surgical procedure will need to be carefully scaled up and integrated into other prevention programs with emphasis on surgical training, aseptic techniques, acceptability, availability and cultural considerations and this can be provided through different societies as ISSM and foundations by guidelines in practice circumcision with the less complication as well as helping the high risk area in providing the services of circumcision to children ,adolescent and adult in a healthy environment well coast less than the budget in treatment with parallel ongoing researches in this field of treatments the end result well can be measured easily for its benefit .
The report from the randomized clinical trial of male circumcision in South Africa demonstrating a 60% protective effect in preventing HIV acquisition provided the first clinical trial evidence of efficacy of male circumcision in protecting men against HIV infection. This protective effect was consistent with both ecological and epidemiologic studies which also show a protective effect of 50-70% in men at high risk for HIV infection
khaled Othman
Dear Ira,
Excellent elaboration. Only I like to add that,
although circumcision is a relatively minor surgery,
however I have seen very drastic post operative
consequences "such as partial amputation of the glans,
bad infection and bleeding� especially in infants and
children. My point is, we have to have clear
guidelines and proper settings to start practicing
circumcision in a wide scale.
Ahmed
Dear all
It is well known that the incidence of HIV in circumscised
males are much
lower than those who are circumscised ,that is also true
for other STDs.
therefore it is healthier ,safer and effective strategy to
combat HIV in
heavily contaminated areas of the world if it is applicable
there
Dr hesham nabil
Dear Ira:
In response to the email re. the risks and benefits of circumcision in preventing HIV disease, the two large African randomised trials in South Africa and Kenya were terminated earlier than scheduled as interim analysis of the data revealed signficant (in one case 60% ) relative risk reduction in favor of circumcision. Another similar study from Uganda corroborates the findings and I think it is fair to say there is widespread agreement re. the beneficial effects of circumcision in decreasing (not preventing) HIV infection (i.e. becoming infected).
The more difficult issue is policy implementation in countries where the resources may not allow for circumcision to be done under ideal or even semi-ideal circumstances. It is my understanding that circumcision in the neonatal period is associated with a signficantly decreased incidence of adverse events as compared to the adult (or even teenage) population and should therefore be recommended in areas where HIV infection is an epidemic. This recommendation should be combined with resources to educate the parents (who may normally not have opted for circumcison based on cultural or religious preferences) about the risks and benefits so they can make an informed decision.
Similarly , in the adult population, resources should be geared toward provision of a clean environment for performing the surgery, optimization of the technical skills of those who will be performing the procedure, and educating the public about the risks and benefits of the procedure.
I once saw a fascinating program about the amazing positive effect of a group of health care workers in Africa who pioneered the concept of motorcycle delivery of protease inhibitors to pregnant women and other HIV infected patients in remote areas with no access to modern healthcare. Perhaps a similar effort can be undertaken to bring patients from remote areas to better equipped facilities or at least to set up educational programs in those areas. (The last point is especially critical when a "new breakthrough" therapy comes along, since many are quick to embrace the procedure at the cost of forgetting the basic rules: in this case, safe ("safer") sex and remembering that we do not know if circumcision will actually prevent transmission.
Hossein Sadeghi-Nejad, M.D., F.A.C.S.
One must ask the question whether the association is causal
or due to some socioeconomic or cultural factor in men who
might be circumcized. Association does not mean a causal
link.
Andrew McCullough
Dear Dr Ira ,Dear all Colleagues :
Can we say that we approve in this data based points , also please visit the sites recommended .
1) The majority of men who are HIV positive have been infected through the penis .
2)There is conclusive epidemiological evidence to show that uncircumcised men are at a much greater risk of becoming infected with HIV than circumcised men .
3)The inner surface of the foreskin contains Langerhans' cells with HIV receptors; these cells are likely to be the primary point of viral entry into the penis of an uncircumcised man .
4) Male circumcision should be seriously considered as an additional means of preventing HIV in all countries with a high prevalence of infection .
5)The development of HIV receptor blockers, which could be applied to the penis or vagina before intercourse, might provide a new form of HIV prevention
See : Journal Of Infectious Deseases, Jan 20, 2005 "Male Circumcision Reduces Risk Of HIV Transmission From "Women To Man" http://www.geocities.com/HotSprings/2754/hivjan20-2005.htm
Tue 6 April, 2004 Epidemiology. Reuters Health "Circumcision Found to Reduce HIV Risk, Again http://www.geocities.com/HotSprings/2754/042004hiv.htm
USA Today, April 12, 2002 Women Have Less Cervical Cancer Risk If Their Sex Partners Are Circumcised http://www.geocities.com/HotSprings/2754/hiv2052002.htm
The BBC News, April 10, 2002 Circumcision Curbs Cervical Cancer Risk http://www.geocities.com/HotSprings/2754/cervical042002.htm
The Canadian Press, April 10, 2002 Circumcised Men Less Likely To Spread Cancer Causing Virus http://www.geocities.com/HotSprings/2754/hiv2052002.htm
Ivanhoe Newswire, Nov,2004 Study shows male circumcision may help prevent AIDS transmission http://www.geocities.com/HotSprings/2754/new2004hiv.htm
Journal Of Clinical Pathology, January, 2004: 57:77-78. Circumcision May Help Prevent HIV Spread http://www.geocities.com/circ-online/healthHIV2004.html.htm
Emma Hitt, PhD ORLANDO, Florida (Reuters Health) Tue May 28, 2002. Clues Found to Circumcision's HIV-Protective Effect http://www.geocities.com/HotSprings/2754/hiv052002.htm
Robert Szabo Roger V Short, professor How does male circumcision protect against HIV infection? British Medical Journal 2000;320:1592-1594 http://bmj.bmjjournals.com/cgi/content/full/320/7249/1592 and http://bmj.bmjjournals.com/cgi/content/full/321/7274/1467/a
May, 2000: The Case for Circumcision. East Bay Express. Gordy Stalk Interviews Dr. Edgar J. Schoen and Dr. Daniel Halperin http://www.circumcisioninfo.com/slack_eastbayexpr.htm
Khaled Othman
Yoram,
I will be glad to write 500 words and give 5 key references on this subject. Let me think about other experts. I will get back to you.
Ira
Dr McCullough's points to what is otherwise known as
surrogate marker(s) for a factor which was not or cannot be
measured directly.
Dr Chris Carmody
Dr. La Pera presented a case of a 25 y. o. man who became impotent after a post traumatic �cauda syndrome�. One year after the traumatic event, the patient continues to complain of paresthesia in the genital area, and perineum. He is completely impotent. His neurosurgeon stated that there is no chance to improve the neurological situation. Peak systolic velocity of his cavernosal arteries was greater than 50 cm/s. Selective pudendal arteriography did not show any pathological findings. Hormonal profile was normal.
Dr. Kera advised trail of half dose PDE5 inhibitors and watch for side effects as priapism. Dr. Nabil advised to safely use PDE5 inhibitors or smaller dose of PGE1 under strict supervision due to its neurogenic origin.
Detailed discussion
Dear Friends,
I would like to report the case of a 25 y. o. man who
became impotent after a post traumatic �cauda syndrome�.
After one year from the traumatic event he still have
paresthesia in the genital area, perineum and his penis is
always tumescent.
The neurosurgeon who is in charge for the neurological
lesions stated that there is no chance to improve the
neurological situation.
The case is particular unusual because although the penis
is not in priapism with a full rigidity the basal pick
systolic velocity of cavernosal arteries is greater than 50
cm/s.
The patient has also performed a selective pudendal
arteriography which did not show any pathological findings.
Hormonal and metabolic pattern are normal.
The patient is completely impotent since the trauma and
split from his partner because the impotence. I wonder if
would be correct to treat him with PDE 5 inhibitors and or
PGE1.
Thanks to all for any suggestion and advise you would like
to give me
Giuseppe La Pera
Dear Prof. La Pera,
Although systolic pressures are high, I can see it still isn't enough for full rigidity. I can also see that is has influenced negatively this patient's sexual life.
I think a trial with half the dose of a PDE5 inhibitor is in order and monitor the changes closely for any side effects, systemic or local (priapism).
Kind regards,
Kenneth
Dear Dr la Pera
your case is apparently categorised as a case of neurogenic
impotence, in
such a case you can use safely PD5I or using a smaller dose
of PGE1 under
strict supervision as they are very liable to get prolonger
erection or
priapism.
Dr hesham Nabil
Dr. Mulhall presented a case of a 48 year old man complaining of crashing upon ejaculation for 2 days. He feels flu like symptoms, extremely achy, heavy, very sluggish cognitively, and sometimes even sore throat. He avoids ejaculation. Apart from that he is cardiac free with normal testosterone and cortisol. He suffers from hypothyroidism. His libido is normal.
Dr. Mulhall found nothing in literature except a single paper (case report on 2 patients) by Dr. Marcel Waldinger and hence was asking about any ideas as regards the pathophysiology and management of this problem.
Dr. Kevan tried for such cases a number of analgesics including gabapentin and pregabalin as well as many of the classic treatments for 'prostatitis'. Distraction techniques and other non ejaculatory (but orgasmic) Taoist type sexual activity, he thought might be useful. He also added that for some cultures and many couples, there are a number of psychosomatic or relational factors to considered.
Dr. Moser suggested success with Buproprion having anti-anxiety properties with no negative effects on sexual functioning. Dr. Ashour had success with Tramal 50mg PRN. Dr.Dave wrote about a study which tried an opioid antagonist (Naloxone ) given to a group of atheletes having similar symptoms post exercising and questioned if this syndrome could be related to endorphin deficit.
Dr. Krishnamurti stated that in some countries some guys believe that loss of semen (vital fluid) causes weakness. Many of these develop post-ejaculatory symptoms to varying degrees, sometimes severe.
Detailed discussion
Dear ISSM Members:
Please read below an email from a man who seems to have
post-orgasmic illness syndrome. other than a single paper
(case report on 2 patients) by marcel waldinger I have not
found any other useful literature. I would value your thoughts
as to the pathophysiology and management of this problem.
John Mulhall
"My symptoms became apparent about 8 years ago. They are
very simple really. Upon ejaculation I crash. By that I
mean, completely (and I mean completely) drained of energy
for about 2 days. I feel flu-ish, extremely achy, heavy,
very sluggish cognitively, sometimes even sore throat.
Needless to say, I avoid ejaculation. Other than that I am
(according to my doctor) a normal, healthy, 48 year old male
although I have hypothyroidism. I just had a physical and all
blood tests and heart are normal. I have had testosterone
and cortisol tested and those are normal. Also, libido is
normal."
Dear Dr. Mulhall:
I am currently seeing a client with the same syndrome. I
recommend
contacting Marcel D. Waldinger, MD, PhD at
md@waldinger.demon.nl.
He was able to give me some insights into my case. He is
currently
conducting another study on this topic but his results have
not been
published yet.
Annette Owens, MD PhD
Dear John & Annette
I am currently trying to help another man with these symptoms in my andrology clinic who avoids ejaculation at all costs. To date he has tried a number of analgesics including gabapentin and pregabalin after trails of many of the classic treatments for 'prostatitis'. Other men I have treated with similar symptoms are often resistant to medical interventions.
Distraction techniques and �prescribing� non-ejaculatory (but orgasmic) Taoist type sexual activity may be useful but the aftermath of loss of ejaculatory control for many of these men is too overwhelming and they cannot be persuaded to become sexually active again.
Of course for some cultures and many couples there are a number of psychosomatic or relational factors to consider.
Kevan.
Dear folks,
I have had several patients like this as well. I have also noted that they are resistant to medical interventions. My best success is with buproprion XL, but patients often choose to discontinue it, even after it has �helped.�
Take care,
Charles Moser, PhD, MD, FACP
Charles
what is the rational for Wellbutrin?????
Pierre Assalian
I saw this as an anxiety disorder, at least in my patient.
Buproprion does
have anti-anxiety properties (though many people do not
believe the data)
and it has no negative effects on sexual functioning. It
also tends to
energize people, so I thought it might help the feelings of
fatigue after
orgasm.
The patient was seen back 2 in weeks; he took 150 mg QD for
a week then 300
mg QD for a week. He felt his fatigue was less severe
after orgasm and his
girlfriend thought everything was better in their
relationship. He was seen
after another month on 300 mg a day and reported that the
fatigue and other
symptoms were better and were still improving, but were not
yet resolved.
He then decided to travel for 6 months and did not want to
take the pills
with him. Also of note, he broke up with his girlfriend.
Pt was lost to
follow-up at that point.
Take care,
Charles Moser
Dear All:
Is it possible to prove that this syndrome is NOT functional in etiology ? What is the scientific explanation for this symptom complex ? In this part of the world, there are millions of guys who believe that loss of semen (vital fluid) causes weakness. Many of these develop post-ejaculatory symptoms to varying degrees, sometimes severe.
If there's conjecture about possible organic etiology, it has to be established unambiguously.
Sudhakar Krishnamurti
It is possible, but the patients I have seen did not seem preoccupied with semen loss or overly worried about it. They just noted this response.
See reference below.
Take care,
Charles Moser, PhD, MD, FACP
Dear Annette and all
i had one case of the same symptoms who failed any treatment but what found of geat help is to use Tramadol-Tramal 50 mg as PRN thrapy.
Shedeed Ashour Shedeed
Dear colleagues,
The syndrome described is reminiscent of a study I recall in which physically fit volunteers were given an opioid antagonist (Naloxone I think) and then asked to exercise. Rather than experiencing the "high" well known to exercisers after an aerobic session they experienced a response similar �it seems to me- to that described in the post-ejaculatory syndrome: fatigue, anhedonia, etc. So the question: could this be a syndrome of endorphin deficit??
Dave
Dr. Fragas was inquiring if anyone had experience with using Propoleum in treating Peyronie�s disease. He presented a paper by him which showed good results with this kind of oral therapy as regards decrease in curvature and plaque size.
Dr. Larry was still investigating the drug in the laboratory, with no results yet observed.
Detailed discussion
Dear Larry.
Would I like to know if our friends of the ISSM have some experience with this medication in the Peyronie and which your opinion of its future is?
Greetings to all.
Ramiro Fragas.
Havana, Cuba.
Archivos Espa�oles de Urolog�a (Ed. impresa)
Print ISSN 0004-0614
Arch. Esp. Urol. vol.58 no.9 Madrid Nov. 2005
�download article in PDF format
How to cite this article
________________________________________
Androlog�a
________________________________________
ENFERMEDAD DE PEYRONIE. EVALUACI�N DE TRES MODALIDADES TERAP�UTICAS:
PROP�LEO, L�SER Y PROP�LEO + L�SER.
Manuel Lemourt Oliva1, Ramiro Fragas Vald�s2, Rafaela Bordonado Ram�rez3, Jos� Luis Santana4,
Elizabeth Gonz�lez Oramas5 y Alberto Merino6.
Servicio de Urolog�a1. Cl�nica Central Cira Garc�a.
Servicio de Urolog�a2. Hospital Cl�nico Quir�rgico Manuel Fajardo,
T�cnico Farmacia Hospitalaria3 C.Quir�rgico Freyre de Andrade.
Radi�logo Instituto Nacional de Oncolog�a4,
Bioestad�stica5 Hospital C. Quir�gico Freyre de Andrade.
Cl�nica del Dolor6. Hospital Fajardo. Ciudad Habana. Cuba.
Summary.- OBJECTIVES: To compare the results of treatment of peyronie�s disease with propoleum, laser, and simultaneous propoleum-laser.
METHODS: Prospective research. Twenty-eight patients with Peyronie�s disease from the hospitals Freyre de Andrade, Fajardo, Cl�nico Quir�rgico y Habana Campo were studied between May 2002 and August 2003. They were divided into three groups:1) treatment with propoleum: 10 patients; 2) treatment with laser: 8 patients; and 3) treatment with propoleum + laser: 10 patients. A registered formula of Propoleum powder was employed in daily 900 mg capsules over six months. 30 sessions of laser were applied to the plaque divided in periods of 10 sessions every 2 months. Study variables: age, race, date of disease start/clinical improvement correlation, beginning of improvement after treatment. Data were processed in a statistical software (Epinfo-6) and multivariate analysis with non parametric methods was employed.
RESULTS: Mean age was between 4th and 7th decade in all groups. Caucasian race was predominant. The propoleum-laser group achieved the greater diminishment of the plaque among those with one or two years of disease evolution. Pain was not the main symptom in these patients. The greater diminishment of the curvature was obtained in the propoleum groups, with a mean diminishment of 10.8 (propoleum only) and 10.3 (Propoleum+ laser) in comparison to the laser group with a mean decrease of 8 and mean increase of 12.6. Mean plaque diminishment measured clinically was 2.3 cm and 1.5 cm in the propoleum groups, respectively, and 1.2 cm in the laser group. Ultrasound measurement mean diminishment was 2.3 mm and 12.16 mm in the propoleum groups. The laser results were not comparable due to the low number of patients in relation to the other groups.
CONCLUSIONS: 1-best results appeared in the groups treated with propoleum in patients with 1-2 years of disease. 2-Diminishment of the curvature angle, physical or ultrasound measurement of the plaques was greater in the propoleum groups. 3-After the start of treatment, the propoleum-laser group referred early improvements, and the propoleum group referred continuous progressive improvement; only a few patients in the laser group referred improvement. 4- Treatment with propoleum was more effective and laser increased its action, being propoleum in monotherapy less complex in its application and with a better cost-benefit ratio.Keywords: Propoleum. Peyronie�s disease
. Ramiro- delighted to see that you have put together a
report on your
experience with propoleo. As my Spanish is poor I could not
appreciate the
fullness of the results and how you assessed and measured
the changes in
penile deformity. We did do some preliminary in vitro
studies in our lab in
Chicago with the propoleo that I received from Dr Lemourt.
We were looking
for changes in fibroblast proliferation, MMP/collagenase
and TIMP's level.
We did not see any changes as we had trouble dissolving the
agent and
controlling for drug concentration. As a result most of the
cells did not
survive. We are cuurently performing more analyses and I
will let you know.
As of right now I'm not a big believer in the efficacy of
any oral therapy
for PD as I wonder whether we can get adequate levels into
the hypovascualr
and hypocellular plaque via the systemic circulation. But
we need to keep up
our efforts and report as carefully and reliably as
possible the physical
changes in the clinical trials- including measured change
in curvature (best
with in office protractor/goniometer), and in girth,
stretched length and if
possible assess change in sexual function- right now the
IIEF is our best
tool but hopefully a validated PD questionnaire will be
available in the
near future.
Keep up the good work
Larry
Dr. Belen presented a case of a 46 years old man who had low flow priapism occuring right after cardiac catheterization. The patient was seen 53 hours post priapism. Dr. Belen underwent cavernospongiosus shunt (Ghorab procedure). Pain disappeared but the penis was still detumescent. He was wondering if the patient needed a cavernosafenous shunt.
Dr. Ghanem and Dr. Chen found there was no need as their was no pain and the penis was expected to remain detumescent for few days. Testing the patency of the shunt can be done by applying moderate pressure/message by the fingers on the penile shaft and observe if the penis empties and refills with release of pressure. Or by testing the presence of flow in the cavernosal arteries by color doppler ultrasound or testing for oxygenated blood by cavernosal blood aspiration. PDE5 inhibitors or a penile implant is an option should the patient suffer from ED.
Detailed discussion
Dear Friends,
I would like to report the case of a 46 years, man
The case is particular unusual because the penis is in
low-flow priapism
post heart catheterism ,that he appeared immediately, they
call me to the
consultation when he had fifty three hours of evolution .
They had made him
treatment prescribe with etilefrina at the twenty-four
hours, without
result.
immediately make surgery in the form of a
cavernospongiosus shunt
(Al-Gorab) and conventional perineal cavernospongiosus
shunt and take
biopsy of both cavernous bodies.
The corpora cavernosa were irrigated with normal saline
until bright blood
was seen to exit, but continuous with priapism now without
pain.
I wonder if would be correct to treat him with
cavernosafeno shunt
(Grayhack)
Thanks to all for any suggestion and advise you would like
to give me
Ra�l Alberto Bel�n.
Prof. Raul Alberto Belen
Dear Dr. Belen
A successful shunt drains the corpora to limit the ischemic
damage, fibrosis
and pain, but doesn't always lead to immediate
detumescence. I suggest you
test the patency of your shunts by applying moderate
pressure/message by the
fingers on the penile shaft and observe if the penis
empties and refills
with release of pressure. You can also test the presence of
flow in the
cavernosal arteries by color doppler ultrasiound or test
for oxygenated
blood by cavernosal blood aspiration. If the shunt is
patent -which is quite
possible since the pain resolved- then no further surgery
is indicated.
Best wishes with this case, please inform us about the
progress.
Hussein
Dear Raul,
Thanks to bring up this interesting case.
Your successful treatment turns this patient from low flow
to high flow
priapism and he doesn't need any other treatment, unless he
will continue
suffering from pain. His erection will become flossed in
several days. If
this will not happen, than you will need reassess this
patient.
If the erection is a problem and he is not responding to
the PDE5i,
insertion of penile prosthesis probably will be the best
solution for him.
Juza Chen, MD
Dr. Giuseppe La Pera had a patient on which he performed an AMS/700 penile prothesis implantation, some years earlier. This patient came to his office recently with prostatic carcinoma. He is a candidate for RRP. Dr. La Pera expressed some concerns regarding the implant�s reservoir during the surgery. He was mainly concerned about whether he should remove the reservoir at the beginning of the RRP, and if so, should he replace it at the end of the operation or afterwards. He was also concerned about the drain, as a source of contamination? Accidental rectal perforation, was also one of his concerns.
The general consensus in this case was to inflate the penile prothesis before the surgery, thus emptying the reservoir and leaving it occupying the least space possible, and hence minimizing the risk of damage to the reservoir.
Another point that was agreed upon by the majority, was that the presence of the dense capsule that is expected to surround the reservoir will isolate it from the proceedings.
Another suggestion was to clamp the tubings at the beginning of the operation and replace the reservoir at the end of surgery.
Pre-operative bowel preparations was suggested, to allow easy repair in case of accidental rectal perforation.
Avoiding use of cutting current diathermy was suggested, also the placing of the suction drain on the side opposite to that of the reservoir was recommended.
Another idea was to perform a perineal approach so as to stay as far from the implant as possible.
Detailed discussion
Dear Friends,
I have a patient who, several years ago, have been
implanted with AMS /700 penile prosthesis. Now he came to my
office for a prostatic cancer and is candidate for radical
retropubic prostatectomy (RRP).
I have some concern regarding the reservoir for the RRP. I
wonder if
1. should the reservoir be removed at the begining of the
surgery and reimplated at the end of the same session or at
the later date?
2. what about the drain that is left for several days and
which can contaminate the reservoir
3. what in case of accidental rectal perforation
thanks
Giuseppe La Pera
Consider a perineal approach as you won't have to bother
with the device at
all.
Larry
Herb Lepor and I had a similar case and we inflated the
prosthesis during the case to empty the reservoir. He did
fine. In our case the reservoir had been placed through a
counter incision instead of through the groin. If the reservoir
is problematic in its location you can clamp the tubing
remove it and replace it at the end of the case with a new
one.
Andrew McCullough NYU
giuseppe
if the reservoir has been placed in the space of Retzius
whether blindly through the inguinal ring or via a
counter-incision, after 3 months there should be a dense capsule
around the reservoir excluding it from the field of vision
during a RRP. i would do as andy mccullough has suggested and
inflate the prosthesis to empty the reservoir. be careful
with your anastomotic sutures and ensure that the device is
fully functional at the end of the case just in case the
capsule/reservoir was perforated during the RRP. i have done
this several times without incident.
john
Dr La Pera,
I have done several of these and find that the reservoir is
in a capsule and
isn't seen at the time of the RRP.
The fluid in the reservoir inside the capsule can be a
problem as it
occupies the space in the pelvis, but, as suggested,
inflating the implant
will help to empty the reservoir.
Buona fortuna,
Dr Christopher Love,
Dear Lap�ra
We�ve done a couple of RRP in 3 volume pp patients. As was mentioned by Dr. Muhlal, there is a capsule surrounding the reservoir. No problems regarding the drainage: it�s not going to cause any problem. Do not remove the reservoir. I do not know about rectal perforation.
By the way, someone familiar with prostate cancer individuals undergoing to IMRT and prreviously 3 volume inflatable penile prosthesis? Shortening device survival? Does anynone want to join for putting togheter some fw data
Claudio Teloken
Dear Giuseppe:
The reservoir does not need to be removed. Inflating the
cylinders intra-op is a good idea to give you more room to
work in the deep pelvis. I recommend avoiding the cutting
current when using diathermy (coag is OK) to minimize chances
of damage to the reservoir. Although many have moved away
from using bowel preps, I still routinely give bowel preps
when doing RRPs so a rectal injury (this should be a very
rare occurrence) can be repaired in layers. In this
particular case, I highly recommend it. Placement of a closed
suction drain on the side contralateral to the reservoir should
also be OK.
Hope this helps.
HSN
Dear Giuseppe,
I had one case of IPP in patient with CaP. Before the
operation we inflated
the prosthesis and during the operation found a nice dense
capsule around
the reservoir. We were able to finish the prostatectomy
without the need
removal of the reservoir.
Insertion of the drain to the area of anastomosis did not
change the
outcome. The Idea to clamp the tubing is and replace the
reservoir at the
end of the operation is very useful, but depends on the way
of prosthesis
insertion. The risk of rectal perforation in this case is
not higher that
usually and preoperative bowel preparation in this specific
case may be
helpful.
Juza Chen,
Dear Dr La Pera and friends,
I would not either remove the reservoir since it is
normally not in contact
with the bladder. Indeed inflating the prosthesis in order
to empty the
reservoir will make the surgery easier.
Mariano Rossell�
Dr. Perelman was preparing for a review lecture about the treatment of retarded ejaculation for the world sexology meeting in Sydney. He was asking about any suggestions or experiences to add in his review.
Dr. Dave commented that he uses Buproprion 150mg x 2 or x 3 daily off label, which seems more consistently to improve arousal and interest over time, with additional sex therapy techniques in a couple based task-oriented format wherever possible, or masturbation tasks in single patients, taking care of the epileptogenic effect of Buproprion.
Dr. Elliott mentioned that his experience with sympathomimetics such as pseudoephedrine has only been successful in the neurogenic population (taking care of blood pressure increase). He have not found PDE5i helpful unless there was altered genital sensation. Minor improvement with PDE5i was observed among women with multiple sclerosis). He added that the other often missed etiology of delayed ejaculation especially with aging, is lowered testosterone, which had good results on replacement.
Dr. Kevan found bupropion, buspirone and yohimbine valuable in anorgasmia in clinical practice, while the use of sympathomimetics were valuable in inhibited/delayed ejaculation. He added that any cause of peripheral neuropathy must be excluded in both conditions.
Detailed discussion
Dear Colleagues,
The WAS Scientific Program Committee Chairs invited me to review "How Successful is the Treatment of Inhibited Ejaculation--from Authority to Evidence Based Medicine?" for a symposium at the April, World Congress of Sexual Health meeting in Sydney, Australia.
I am eager to include any of your new data, experiences, submitted articles, manuscripts, etc, to make this review as up to date as possible. In particular, your use of any new devices, compounds, or off-label meds uses that impact ejaculatory latency, and/or increase ejaculatory force, intensity, volume or sensation, would be very interesting. I have already reviewed and prepared information on this topic through November, 2006
If you have a new approach, please send a MS ppt slide or two, summarizing your perspective, along with a peer reviewed/submitted journal article attached as back-up for your view (MS Word .doc or pdf). Please let me know your affiliation and how you prefer to be cited for your work. Of course, any way you choose to communicate to me would be fine. My contact info is provided below.
Look forward to hearing from you and hope to see many of you in Australia.
Best�Mike
Dear Dr. Perelman ,
I have noted with interest your forthcoming presentation in the domain of the treatment of inhibited ejaculation. I provide a sexology consultation service to our urodynamics department and over the years I have found that more and more such cases are dominating the clinical agenda, so much so that most of my work is now in the realm of anorgasmia in men (and sometimes in women), and libido problems. I have generally found that the literature has not provided clear pharmacologic answers and I have yet to come across a medication that consistently ( or even tending to) shortens latency time to orgasm. For a time I related to the problem using a working hypothesis of realative parasympathetic dominance, or sympathetic non-dominance in the arousal phase, and even had one patient trying epinephrine nasal spray during arousal, but to no avail. I have used norepinephrinergic antidepressant medication off-label with some improvement in libido and responsiveness but no consistent results. Currently I am using Buproprion 150mg x 2 or x 3 daily off label, which seems more consistently to improve arousal and interest over time, and I build on that with additional sex therapy techniques in a couple based task-oriented format wherever possbile, or masturbation tasks in single patients.
Buproprion should be used with caution as it has epileptogenic potential.
I think that this area remains one for much more research and collaboration. I would be most interested in your thoughts on the matter, as I will be unable to attend the Sydney meeting
Best wishes,
Dave
Hi Michael,
RE: inhibited orgasm. My experience with sympathomimetics such as pseudoephedrine has only been successful in the neurogenic population - and BP increases must be watched for ( ie can make autonomic dysreflexia in spinal cord injury worse). I have not found PDE5i helpful either unless there is altered genital sensation and some minor improvement with that after PDE5i has made orgasm easier in some ( ie women with multiple sclerosis).
The other often missed etiology of delayed ejaculation( non- neurogenic) , especially with aging, is lowered testosterone.Replacement of hypogonadal men has made a big difference for many of my patients to increase the frequency or orgasmic attainment.
Stacy Elliott, MD
Hi Dave,
Thank you for taking the time to prepare your thoughtful remarks. I will send you some materials subsequent to the Sydney meeting per your request.
Best--Mike
Dear colleagues
I have certainly found bupropion, buspirone and yohimbine valuable in anorgasmia in clinical practice.
The use of sympathomimetics is valuable in inhibited/delayed ejaculation.
Of course, as stated any cause of peripheral neuropathy must be excluded in both conditions.
Kind regards
Kevan.
Dr Serge Carrier had a 46 year old patient referred to him that underwent a male to female gender transformation surgery in 1990. Before the surgery the patient had normal male anatomy, but felt more as a woman than as a man.
7 years post-surgery the patient started regretting the sex reversal procedure. The resentment increased until in 2004 the patient switched from female hormonal replacement to male hormonal replacement. During the same year, the patient underwent breast liposuction.
Then he went back to consult the surgeon who performed the initial sex transformation surgery, but the surgeon refused to help.
The patient was sent to Dr. Carrier for his opinion.
On examining the patient, Dr Carrier reported that the genitalia were obviously of a female, although there was a small part of the glans left. Penectomy was performed at the pubic level. A small vagina was constructed using the scrotum. The patient claims that when sexually aroused, the penis elongates to 5 centimeters.
Dr Carrier asked for opinions and suggestions.
All agreed that the biggest mistake in this particular case was performing the gender transformation surgery in the first place. Full psychological and psychiatric assessment is mandatory in gender re-assignment candidates, a step that was not thoroughly performed in this case. Hormonal treatment and real life experience also, before the initial surgery, would have been of huge benefit.
Full psychological assessment for the patient was seen a must, before embarking on a new course of action. The surgical opinions, available now, did not seem optimistic.
Dr Sudhakar Krishnamurti suggested insertion of prosthesis into the existing corpus cavernosum after a first stage tubed phalloplasty, as an option, if at all possible.
Dr Stacy Elliott questioned whether it was feasible to perform the urethral reconstruction procedure or not.
Detailed discussion
Hi to all,
I was referred for opinion a 46 year old patient with a
very special
situation.
The patient was a male until 1990. He had a normal anatomy.
However he felt
more like a woman than as a man. In 1990, the patient
underwent a male to
female genital transformation. 6 to 8 years after this
surgery, he started
to regret it to the point that in 2004, he stopped the
female hormone and
was given testosterone replacement. He underwent breast
liposuction as well
in 2004. Of course now he would like to recover his male
genital as much as
possible. He saw the plastic surgeon that did the surgery
initially and
refused to help him.
My questions are:
Does anybody has experience with this kind of situation?
And if so, what are
the option for this now gentleman?
Physically, the genitalia looks obviously female. There is
a small gland
left (part of it) and the penis was cut at the pubic level.
There is a small
vagina (done with the scrotum). When the patient is
sexually aroused, the
penis elongates up to 5 cm according to him.
Let me know.
Serge Carrier
Dear Serge
There are a number of cases of regret post gender
reassignment surgery.
You are asking about surgical experience of reversal.
It is also imperative that substantial assessment of
suitability for further
surgery is undertaken, not least because of the major
surgery involved.
Standards of care are unclear but recent communications I
have had with experts
in the field would suggest a real life experience and multi
professional
assessment be undertaken over a 12 month period before
embarking on gender
re-change surgery.
Kind regards
Kevan.
Serge - we have a plastic surgeon out here in Vancouver (
Cam Bowman)
who has a lot of training in this - also the Montreal
group Yvon Menard
- but will need to combine with urology to look at whether
urethral
repair possible ( always a nightmare). I assume he's been
reassessed by
psychiatry?
Stacy Elliott, MD Vancovuer
Yes and Thanks.
Serge
Dear Dr. Carrier/ All:
It is quite obvious here that surgery was hastily and wrongly performed on this patient without heed to established protocols and guidelines. The regret here is not that the patient wants to `undo' the operation. The regret here is that the operation was done in the first place. Even that does not seem to have been done properly. I wonder what penectomy technique it is that leaves 5 cm of penis behind, given that complete removal of the corpora cavernosa is an important desideratum in MTF surgery. It is now only possible, if at all, to insert prostheses into the (fortuitously !) existing corpora cavernosa after a first stage tubed phalloplasty. Without clinical photographs and examination, it's hard to tell though.
The whole situation is quite abominable really, and no `salvage' procedure, however well-performed now, can hope to truly salvage the situation.
For the umpteenth time in the arena of gender reassignment surgery, once again, there is a big lesson here for all amongst us who are involved with this kind of work.
Sudhakar Krishnamurti
Was it a wrong diagnosis at the first place? The patient
was not transexual,
or is the gender identity not as fixed as we believe it is?
Perhaps our
psychiatry collaegues could update us about the status of
knowledge in this
area.
Hussein
Dear all,
This is very good example why we should be very careful
before decision
making performing this kind operation and how much we need
to evaluate
psychological-psychiatric status of the candidates. Now we
face a patient
who will be not happy with any kind of reconstruction, if
is any.
Juza Chen
Tel-Aviv
Dear all,
It is clear here that there is a very bad selection of this
candidate for
MTF surgery,he was not 100% psychologically ready and fit
for such surgery.I
wonder what can be done for him now !!!
Dr/hesham nabil
Dear all
I think the main problem was inadequate psychiatric
assessment in the
first place. I do not think this patient was a true
transsexual. These
patients, by definition, would never ever want to change
back to their
original sex. We have never encountered any of our patients
ever coming
back for repeat assignment.
Technically, I would imagine it to be a very difficult
surgery.
I am not sure whether he will change his mind again!!!
Ganesh
Dear colleagues
I have been assessing transsexuals for years prior to surgery. This realy a most unusual case and I agree that it represents a clear warning as to the critical importance of a most careful diagnosis. It is my practice to conduct a full psychiatric assessment, psychodiagnostic testing and a full social worker intake before even considering a recommendation for hormonal treatment. I insist upon the standard two years of life under hormonal care and living as a member of the opposite sex, before finally writing out a recommendation for surgery.If I detect ambivalence I refer for psychotherapy and follow up before making any decisions.
I would like to recommend to surgical colleagues not to agree to any irreversible surgical interventions unless they are satified that a highly professionalized psychiatric assessment has been carried out.
There is an extensive literature on this subject but useful guidelines may be found at http://www.tc.umn.edu/~colem001/hbigda/hstndrd.htm
Best wishes
Dave Rabinowitz
Thanks for your comments. I agree with you that the surgery
should not have been done in the first place.
Serge
Dr Jaswinder asked about the value of rigidometer (DIR) in diagnosing ED.
Dr. Ghanem answered that he DIR might be useful in research centers interested in having a precise measurement of axial rigidity or in studying geometrically based ED. However, for everyday practice DIR indications might not be that frequent. He refered to 2 publications about the importance of specialized diagnostic tests for ED (1, 2). He also added that there are 2 main questions to be answered in the diagnosis of ED
� Does the patient have ED and what is the severity? (usually answered through Validated questionnaires e.g. SHIM).
� What is the Etiology & Risk factors? (achieved through a detailed medical (exploring risk factors), sexual history, a focused physical examination, lab tests & selected diagnostic tests ordered only as needed, if they would alter the management plan or point to a potentially life threatening condition) (2).
On the other hand, no publications mentioned the positive predictive value of the DIR. It is important that once a diagnostic test has been ordered, the physician must be aware and educate the patient about the accuracy of a test. A diagnostic test with frequent false positive results (low specificity) ; as is the case with tests depending upon the response to the Intracavernous injections, could lead to a serious psychological setbacks as seen with many cases performing cavernosometry. He illustrated his comment giving an example a young man being informed erroneously that his ED was primarily physical, requiring lifetime therapy or surgery (3).
1. Lue TF. Impotence: a patient goal directed approach to treatment. World J Urol 1990; 8: 67-74
2. Model for Evaluation and Treatment of Erectile Dysfunction. The Process of Care Consensus Panel. Int J Impot Res 1999; 11: 59 -74
3. Ghanem & Shamloul. Evidence based medicine in the diagnosis of ED. PASSM 3rd biannual meeting, Dubai Feb 2007
Detailed discussion
Could the members please guide me regarding the instrument rigidometer as I am planning to buy one.The manufactures claim it to be very helpful in diagnosis of ED
Dr Jaswinder
Dear Jaswinder:
Go to www.uroan.com for info on the rigidometers. It's nice to note that you have become a member of the ISSM. Or have you ?
Best.
Sudhakar Krishnamurti
Thanks
I have already talked to them but i want opinion of the doctors who are using it since it is about rupee 2 lakhs investment for me . Is it worth that ?Are you using it in your centre ?
regards
Dr Jaswinder
Dear Dr. Jaswinder
Thank you for bringing the topic of specialised diagnostic tests for discussion on the ISSM List.
The DIR might be useful in research centers interested in having a precise measurement of axial rigidity or in studying geometrically based ED. However, for everyday practice DIR indications might not be that frequent. I wish to refer you to 2 excellent publications before ordering any specialized diagnostic tests for ED (1, 2).
Generally there are 2 main questions to be answered in the diagnosis of ED
� Does the patient have ED and what is the severity? That is usually answered through Validated questionnaires e.g. SHIM.
� What is the Etiology & Risk factors? This is achieved through a detailed medical (exploring risk factors), sexual history, a focused physical examination, lab tests & selected diagnostic tests ordered only as needed, if they would alter the management plan or point to a potentially life threatening condition (2).
Are you aware of any publications mentioning the positive predictive value of the DIR? It is important that once a diagnostic test has been ordered, the physician must be aware and educate the patient about the accuracy of a test. A diagnostic test with frequent false positive results (low specificity) � as is the case with tests depending upon the response to the Intracavernous injections- could lead to a serious psychological setbacks. We have seen many of these problems with cavenosometry. An example to this problem is that of a young man being informed �erroneously- that his ED is primarily physical, requiring lifetime therapy or surgery (3).
4. Lue TF. Impotence: a patient goal directed approach to treatment. World J Urol 1990; 8: 67-74
5. Model for Evaluation and Treatment of Erectile Dysfunction. The Process of Care Consensus Panel. Int J Impot Res 1999; 11: 59 -74
6. Ghanem & Shamloul. Evidence based medicine in the diagnosis of ED. PASSM 3rd biannual meeting, Dubai Feb 2007
Hussein
Dr. Bertero had a patient who had undergone an AMS urinary sphincter 2 months ago. He was questioning if it was safe to to implant a semi-rigid or better an inflatable penile prosthesis and whether there should be any problem with the cuff?
The majority agreed that either implants was safe taking care not to violate the pseudo capsule of the sphincter during surgery to guard against infection.
Dr. Chen and Dr. Cairolli were in favor of a semirigid one.
Dr. Rosello recommended, for future occasions, to implant both sphincter and prosthesis in the same sitting.
Detailed discussion
Dear collegues,
Is there any trouble to implant a semi-rigid penile prosthesis in a patient who had undergone an AMS urinary sphincter 2 months ago? Should there be a problem with the cuff? Should I implant just an inflatable penile prosthesis?
Have a nice week,
Dr. Eduardo Bertero
Eduardo,
I have not encountered any problems with either inflatable or semirigid.
Andy McCullough
Dear Eduardo
I don't think that you will have any problem. My point of view is that a semi-rigid penile prosthesis in that particular case is better.
Best regards
Dr Carlos Cairoli
Dear Eduardo,
There is no problem with insertion of semirigid prosthesis.
I have no experience with inflatable in such cases.
Regards from Tel-Aviv,
Juza Chen, MD
Bertero
Either one will be fine. I�ve done before
Claudio Teloken
I agree with the others. Any prosthesis should not create
new problems. There is no need for the pseudocapsule of
the sphincter to be violated during the procedure, leaving it
protected from infection.
Dana Ohl
University of Michigan
Dear Bertero:
I think both options are valids. Of course the patient must be informed about the risks.
Pompeo
Indeed, any of the prosthesis will do since it does not
affect the cuff at
all. I would even recommend, for future occasions, to
implant both sphincter
and prosthesis during the same surgery. Dr Steve Wilson is
the major expert
in that field and we also have very good satisfaction level
in our Centres.
Dr. Mariano Rossell� Barbar�
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