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Digest of recent discussions on ISSM mail (May 2007 - August 2007)Amr El-Meliegy, M.D. - ISSM List Manager The list digest contains 9 interesting cases in diverse subjects discussing surgical, medico-legal, ethical guidelines, STDs, orgasmic and FSD topics. My deep thanks to all who enrich our list discussions with their cases or comments. I would also like to express my thanks to my colleagues, Dr. Ahmed El Guindi and Dr. Adham Zaazaa for helping me in summarizing the cases.
Penile Implant CaseDr. I. Goldstein Dr. Goldstein presented a patient with ED who had a two-piece penile implant for years and unfortunately it thinned out the corpora distally. The failed two-piece device was successfully replaced with a three-piece the implant but this hurt his wife, in part, because the tissues were too thin distally. The surgeon had subsequently been trying to bolster the tissues with #1 cadaveric fascia and #2 alloderm but both techniques failed. The patient now has a malleable on one side only and that is very thinned out distally. Dr. Goldstein asked for suggestions. Dr. Ghanem questioned whether the cause of the atrophic corpora can be due to a specific disease, repeated surgery or oversizing. Dr. Rosello argued that wrong choice of the implant or bolstering the tissues with cadaveric fascia and alloderm may have been what provoked the infection. He was not in favour of one side implantation. Instead, using a cavernotome would have facilitated insertion in a fibrotic corpora. Dr. Ashour who had a similar case advised covering the rod with a Dacron Loose cap so as to create a recess to suture to the edges of the thinned corpora from the sides as well as the proximal crescent of the corporal edge. Dr. Lopes preferred using bovine pericardium due to its low cost, inertia, elasticity, absence of transmission of diseases, low probability of retraction and good resistance to tension that allow it to cover large defects without forming protuberences. Dr. Levine commented that removing one cylinder would be a good idea when distal reconstruction is not possible but if both sides were thin the next option would be to do a distal corporoplasty via a subcoronal approach, close off the distal corporal tip and again lay in a graft preferably Tutoplast processed human pericardium to reinforce the distal closure at the level of the corona. He added that using a device such as a single cylinder 3-piece which will not present constant pressure on the distal repair may work best advising the patient not to use the devise for 10-12 weeks to allow maximum tissue healing Dr. Mulcahy used successfully a natural tissue repair in 50 similar cases. He incised the backwall of the sheath containing the implant and a new cavity for the cylinder was developed in spongy tissue more medially and dorsally. Detailed DiscussionDr. I. Goldstein Dear All, On behalf of Dr. Goldstein I am forwarding you this case for discussion. Best regards to all, Amr El-Meliegy, M.D. ISSM List Manager (( I am trying to manage a patient with ED who had a two-piece penile implant for years and unfortunately this thinned out the corpora distally. The failed two-piece device was successfully replaced with a three-piece the implant but this hurt his wife, in part, because the tissues were too thin distally. The surgeon has subsequently been trying to bolster the tissues with #1 cadaveric fascia and #2 alloderm but both techniques failed. The patient now has a malleable on one side only and that is very thinned out distally. The patient still wants to be fixed. Any thoughts of how to manage this?)) How old is the patient? Are there any diseases to explain the tissue atrophy or is it the result of repeated surgery / oversizing? If the rod is about to erode then undersizing might be considered. Good luck with this tough case! Hussein Ghanem Could you please explain how the bolstering (technically) was done ? Obviously, if the prosthesis does not fill the whole corpora cavernosa, the penis may lose girth as well as length in some cases. The choice of the prosthesis must be based on the patient’s anatomy, never on the surgeon’s preferences. If a hydraulic prosthesis proves to be the most adequate for a patient, he should not be implanted a malleable one. Concerning the fact that the three-piece implant hurt the patient’s wife, I cannot explain it unless the penis was not straight or the prosthesis not correctly placed. I think that bolstering the tissues with cadaveric fascia and alloderm may have been what provoked the infection; hence the surgeon had to take the three-piece implant out. Moreover, I cannot see the reason behind the decision to implant a malleable prosthesis on one side only. Indeed if one suspects the existence of fibrosis, the cavernotome has to be used in order to facilitate insertion after deciding which implant is best. The tissues’ evaluation as “thin” could be a subjective perception, in my opinion, and if the albuginea tunic was very thin to start off with, the surgeon should have performed a biopsy to know the origin of the anatomical anomaly. Regards Dr. Mariano Rossello Barbara Dear all In regards of the presented case of Dr. Goldestien, I am giving my opinion because I have the same pt scenario. A 66 years ld male to whom I replaced a mechanically failed Dynaflex with a maleable ACUform and after 3 month he is com planing of hurting the wife and pain. On examination the lft side rod is almost subcutaneous because of corporal thinning ? Because the pt is using only the female superior position because he has both knees replaced. My opinion is to cover the rod with a Dacron Loose cap so to has a recess to suture to the edges of the thinned corpora from the sides as well as the proximal crescent of the corporal edge. Any further thoughts will be appreciated... SHEDEED ASHOUR Dear all This is a very tough case as many of the tricks have already been tried and failed. Removing one cylinder is a good idea when distal reconstruction is not possible but if both sides are thin the next option would be to do a distal corporoplasty via a
subcoronal approach, close off the distal corporal tip and again lay in a graft9 I prefer Tutoplasrt processed human pericardium) to reinforce the distal closure at the level of the corona. Using a device such as a single cylinder 3-piece which will not
present constant pressure on the distal repair may work best and then allow no inflation or sexual activity for a minimum of 10-12 weeks to allow maximum tissue healing. I've used a natural tissue repair in such cases. The backwall of the sheath containing the implant is incised and a new cavity for the cylinder is developed in spongy tissue more medially and dorsally. I've used this in about 50 casesand have had good results with no known recurrences. Reference J Urol 1999. 161: 193-195. John Mulcahy Crural IndurationDr. Becher presented a case of a 50 y/o healthy man with a history of severe perineal pain on palpation and spontaneous constant pressure sensation over the past year. He complained of complete ED with no response to maximum doses of PDE5I and perineal induration. These symptoms started a few days after a 3 hours mountain bike journey. On physical exam he showed severely indurated and tender proximal corpora on both sides, from the ischium to the penile angle. Penile sensation was normal with a small dorsal midshaft Peyronie's plaque. Duplex US showed poor erectile response to 1 ml of trimix with a normal peak systolic flow and an elevated end diastolic flow. The arteries looked patent to the crus on both sides and both proximal corpora looked more dense on US but not calcified. MRI showed fibrosis. The pain improved on ketorolac. Dr. Becher was wondering if a biopsy or a cavernosogram would be of help. Dr. Glina suggested that it might be a segmental priapism due to the trauma. He had a past experience with a similar case for which he surgically incised the albuginea and drained the corpora. Dr. Lue and Dr. Zahran advised to try pentoxiphylline 400mg for 6 months Dr. Ghanem referred to a similar case presented by Dr. Morales 3 years. The detailed discussion could be read on http://www.issm.info/ by following ISSM List - Interesting cases / Discussions, under the priapism cases. Dr. Porst experienced 5 similar cases. All were proximal (crura) segmental priapism with pain followed by proximal fibrosis and happened either after straddle trauma or extreme biking tours. He sees no relation to Peyronie's disease. In two cases excision of the priapismic (fibrotic) tissue was done. In another 2 penile implants were inserted. Dr. Rosello recommended a high-resolution-scan. If it showed the presence of nodules, a penile implant prosthesis should be considered since the calcification of these nodules might lead to a loss of rigidity and penile shortening. Detailed DiscussionThis is a 50 y/o healthy man with a history of severe perineal pain on palpation and spontaneous constant pressure sensation over the past year. He complains of complete ED with no response to maximum doses of PDE5I and perineal induration. This
symptoms started a few days after a 3 hours mountain bike journey. Edgardo: It can be a segmental priapism due to thrauma. I had a case many years ago and we did a surgical procedure incising the albuginea and draining the corpora. Borrelli M, Glina S, Wroclawski ER, Celestino JC, Menezes de Goes G. I would suggest pentoxifylline 400 mg, three times a day for 6 months. We discussed -3 years ago- perhaps a similar case presented by Dr. Antonio Martín Morales. Please find below its digest. The detailed discussion may be read on http://www.issm.info/ by following ISSM
List - Interesting cases / Discussions. Cases are sorted by subject. We placed with priapism! Partial Thrombosis? Partial Priapism? Cavernous collagenosis? Dr. Antonio Martín Morales presented a case of a 57 years old man, who suffered sudden pain and induration in the crura of the right corpus cavernosum, not related trauma or unusual (aggressive or hard) sexual activity A "tru-cut" biopsy of the mass, was informed as "connective tissue highly collagenized". Figures may be seen on http://www.issir.org/prod/data/issirlist/cavernous.htm. Dr. Ignacio Moncada suggested probably a partial thrombosis of the corpus cavernosum. He referred to a recently published paper in European Urology by Goeman (Eur Urol 44: 119–123, 2003) describing three similar cases with similar MRI results. Dr. Andik Wijaya suggested a therapeutic trial with a corticosteroid and NSAIDs. H Ghanem suggested investigating –as in cases of venous thrombosis- to exclude a hypercoagulable state. Dr. Sidney Glina suggested partial priapism and provided a review on literature including 13 references. Dr. Shedeed Ashour suggested a trial with POTABA and Tamoxifen, while Dr. Sudhakar Krishnamurti suggested that it is not common for Peyronie's disease to invade the corpora so extensively. would endorse Dr lue suugesstion. As usually pentoxifellyine might have a better role in such early Diagnosed cases Abdel Rahman Zahran I saw in my 25 years' experience 5 such cases.All were proximal (crura) segmental priapism with pain followed by proximal fibrosis and happened either after straddle trauma or extreme biking tours. That has nothing to do with Peyronie's disease.In two cases excision of the priapismic (fibrotic) tissue was done in 2 cases penile implants. Regards Prof.Dr.Hartmut Porst As Tom Lue suggests, Pentoxifylline will expand the tissues periferically. However, let us not forget that this patient does not respond to maximum doses of PDE5I, and considering his age and the fact that the MRI shows fibrosis, I would recommend a
high-resolution-scan. If this scan shows the presence of nodules, I think a penile implant prosthesis should be considered since the calcification of these nodules might lead to a loss of rigidity and penile shortening. Contamination with PDE5 InhibitorsDr. Ira Sharlip There has been at least 2 reports showing that some food or nutritional supplements that were advertised for the use of erectile dysfunction, have been intentionally and secretly contaminated with PDE5 inhibitors. Dr Ira Sharlip thinks it would be important to know if any of the ISSM members knows of any patient who was actually harmed while using a nutritional supplement which might be contaminated with a PDE5 inhibitors. It is possible that a non-suspecting patient could be using the contaminated product and nitroglycerine at the same time. No ISSM member has heard or known of a patient that was harmed during the use of contaminated supplements, but this is probably because if there was any cases, they were not reported. Dr Gonzalez-Cadavid wondered if this could happen from endogenous PDE5-inhibitor-like substances rather than contamination with synthetic products. Dr Sharlip replied that the products that were found to be contaminated – Super –X and Stamina Rx - contained therapeutic doses of sildenafil and tadalafil. (Fleshner N, et al. Evidence for contamination of herbal erectile dysfunction products with phosphodiesterase type 5 inhibitors. J Urol 174:636-641, 2005). Detailed DiscussionContamination with PDE 5 inhibitors To all ISSM members: There are at least two reports showing that some food or nutritional supplements advertised for the treatment of ED have been intentionally and secretly contaminated with PDE5 inhibitors. It is possible that an unsuspecting patient using nitroglycerine for chest pain would unwittingly use an over-the-counter ED product which was secretly contaminated with a PDE5 inhibitor. I am interested to know if any ISSM member knows of a patient who was actually harmed by using a nutritional supplement which was contaminated with a PDE5 inhibitor. Ira Is it for sure that this reflects a contamination with synthetic products, or could this arise from endogenous PDE5-inhibitor-like substances? Nestor Gonzalez-Cadavid Ira, I'll let you know if it is the case hi ira i hope you are well i have not had any patient develop any problems take care dean Re: Communication from Nestor Gonzalez-Cadavid re: contamination of nutritional supplements with PDE5 inhibitors Dear Nestor, The products I am referring to had therapeutic doses of sildenafil or tadalafil. Of seven products tested in one study, one product called Super-X had an average of 30.2 mg of sildenafil per capsule. Another product called Stamina Rx had an average of 19.77 mg of tadalafil per capsule. I don't believe these concentrations could have been from endogenous PDE5i-like substances. The reference is: Fleshner N, et al. Evidence for contamination of herbal erectile dysfunction products with phosphodiesterase type 5 inhibitors. J Urol 174:636-641, 2005. Ira Sharlip I have not heard of any serious A?E's occurring in the Laurence A Levine Larry, Thanks for the reply. AE's may have occurred without being reported. Ira Sneezing Post EjaculationDr.Bertero presented a case of a 60 year old man complaining recently of sneezing (5 -10 times) few minutes after ejaculation. Dr. King diagnosed the case as vasomotor rhinitis, that is produced by the changes in blood vessels and nerve cells in the nasal passages. It occurs in response to irritants, including smoke, environmental toxins, changes in temperature and humidity, stress, and even sexual arousal. The biologic causes are unknown. Some research has found an association between vasomotor rhinitis and gastroesophageal reflux disorder (GERD, a common cause of heartburn), which some experts think may be due to a common defect in the nervous system that controls muscle action. Symptoms of vasomotor rhinitis are similar to most of those caused by allergies. Usually, however, they are more severe and occur predominantly on one side of the nose. Dr. Ghanem wondered if this could be a type of allergy or an association with PDE5 inhibitors. Dr. Teloken mentioned his seeing of a 7 years old boy who had an acute asthma following taking PDE5 inhibitors for pulmonary hypertension. However there was no mention of using a PDE5 inhibitor in this case as mentioned by Dr. Khaled. Detailed DiscussionDear Colleagues, I have seen today a 60 year old man with a recent history of sneezing few minutes after ejaculation. He stated that this has happened in all instances and occurs 2-3 minutes after orgasm. The number of sneezes varies from 5-10. I have not seen much in the PubMed. Your experience would be helpful, Have a nice weekend. Dr. Eduardo Bertero Dear Dr Bertero Dear Eduardo Could that be an allergy! Certain allergies -e.g. cholinergic urticaria- are precipitated by changes in weather or physical activity. PDE-5 inhibitors may induce nasal congestion but I am not aware of any reports that this congestion results in sneezing. Kind regards, Hussein I´ve seen a young fellow (around 7yo), with pulmonary hypertension, under PDE5 inhibitor, who presented "acute asthma" and sneezing during exercise test (pre-clinical study). According to the ER report "PDE5 inhibitor + exercise" could be considered a trigger for the respiratory system disability". I coudn´t find any support for the ER statement.: Claudio Teloken Dear all, this is a very interesting case,this is my first time to hear a case of bouts of sneezing following orgasm I did not find any relevant data in the literature speaking about that. all the friends who reply mentioned PD5 inhibitors but the
original message did not mention use of such blockers by this old man.if this a real case of allergy , there should be some sort of a link between the ejaculation pathway and sneeezing reflex.... Treatment of ChlamydiaDr. Iyad Emad In response to Dr. Iyad Emad’s posting that the treatment of chlamydial infection with single dose of 1g azithromycin was not always successful, Dr. Carlos Cairoli suggested that prescribing it once a week for a period of one month yields better results. Dr. Mariano Rosselló recommended combining Ofloxacin and Sulfamethoxazole when the infection was persistent. Dr.Hussein Ghanem advised doxycycline for NG and posted the revised CDC guidelines for gonococcal urethritis, in which ceftriaxone IM is the drug of choice. Spectinomycin and cephalosporin regimens are also effective. A single oral dose of azithromycin 2 g is effective against uncomplicated gonococcal infections, but its widespread use is not recommended because of concerns regarding rapid emergence of resistance. The revised CDC guidelines for gonococcal urethritis are available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5614a3.htm Detailed DiscussionDear Colleagues, Do you have a good results from treament of chlamydia trichomatis by azithromycin 1g. single dose. In my practice this treatment has not been succsessfull in many cases. I'd like to share your experince in this matter. thanx. Dr. Iyad Emad Dear Iyad I use for a long time, Azithromycin 1gr a week, for a month with success. Best regards Dr Carlos Cairoli Dear all: In my experience, treating chlamydia trichomatis with Azithromycin usually did well. However, in some cases, when the infection was persistent, I had to resort to the combination of Ofloxacin and Sulfamethoxazole. Dr. Mariano Rossello Dear Rossello you mentioned recommendations for Gonococcal urethritis have changed and Quinolones are no longer first line treatment options ,in April 2007 and so I want i know first line therapy of Gonococcal urethritis in April 2007 recommendations The revised CDC guidelines for gonococcal urethritis may be read on http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5614a3.htm Currently ceftriaxone IM is the drug of choice. Spectinomycin and cephalosporin regimens are also effective. A single oral dose of azithromycin 2 g is effective against uncomplicated gonococcal infections, but its widespread use is not recommended because of concerns regarding rapid emergence of resistance. Best regards, Post coital penile swellingDr. Mohamed Nasser In a young couple, married since 1995( male 29 female 22) ,the male complained, after 3 months of marriage, of pain in the groin for 10 hours after intercourse with enlarged tender inguinal lymph nodes, swollen penis, redness on the glans, malaise and bone aches, but no ulcers or discharge. He claimed to have had no extra marital relations and no STDS. This attack occurred twice in the first year with increased frequency until it now occurs with every intercourse. All STDs tests performed for the couple were negative. Needle aspiration from lymph nodes revealed only inflammation and the vaginal swab revealed mild streptococcal and candidal infection. The husband received augmentin 1 gm for many months and his wife was recommended vaginal douching. They claim that this, done before or after intercourse, makes the attack less aggressive. With condom use the attack never occurred. The diagnosis of post coital allergy was made. The husband was prescribed claritine orally and daktacort cream with condom use for at least one month with improvement in the penile swelling and no recurrence of attacks. Dr. Rosselló recommended an abstinence period of at least 25 days and treatment for vaginal infection until vaginal flow analysis becomes totally negative. Diprofos IM injection once monthly for 2 months was also being considered before permitting intercourse without condom. Detailed DiscussionDear Dr Hussein Dear Dr. Nasser: It would be interesting to know if you have some feedback about how is going the treatment with Claritin and Daktacort with your patient. Indeed both are recommended in the case you are telling us and in my opinion, the
patient should follow this treatment during 1 month at least. It is important that the couple does not have intercourse during a minimum of 25 days. Furthermore, his female partner should also be prescribed some treatment for vaginal infection and she
should follow the treatment until the vaginal flow analysis gets totally negative. Many thanks for you great cooperation Actually i didnt recieve feedback bec patients travelled abroad and will be back a month later. ill send you directly any informations best respect mohamad nasser moaz Dear Dr El Meligy Good day. Many thanks for your great help. Regarding the case of post coital pain , the wife attend the clinic ,she said that there was improvement in the penile swelling and pain with usage of antihistaminic for 2 weeks and daktacort and no recurrence of attacks because they used condom in all previous coital attempts . They are asking is there any treatement prevent attaks without using condom in the future because they are not happy with using it. After the husband will arrive from traveling I will examin him clinically , and advice for condom for another 2 months, with diprofos IM one every month for 2 month. I don't know is it advisible to return coitus without condom after that or not.. Waiting for further opinions .Mohamad Nasser Moaz Sexual assault caseDr. P Ramlancham A 45 year old Diabetic on oral therapy for 8 years has been charged with sexual assault of a 36 year old female. The allegation is that he had penetrated her. He denies that he was able to penetrate her as he has had Erectile Dysfunction(ED) for the last 5 years and that his wife (he says) would vouch for that. The accuser filed a report in a few days after the alleged incident and no sperm were available intravaginally at the time of the examination for DNA matching. In response to Dr. P Ramlancham’s inquiry about how this case should be argued in court, Dr.Pierre Assalian, pointed out that we should not forget the psychological power of a new relation or rape that can give an erection especially when 8 years of Diabetes II were not really enough to cause severe ED. After seeking any previous history of similar complaints, the basis of this accusation and the evidence police have, the accuser should undergo a psychiatric evaluation. Dr Ira Sharlip stressed that if in the South African legal environment the burden of proof was on the accuser; the accused is presumed innocent until proven guilty (like in the Dr. Rabinowitz recommended sending him to a sleep lab to check for nocturnal erections and that that would give “objective and verifiable medical evidence of an erectile capacity or the absence of it”, results, that in his opinion, would hold in court. However, he stated, the case was also complicated by “the possibility that penetration may have been brought about by other means as well a finger, object etc…” Detailed DiscussionDear Colleague I would be delighted if I could please have your expert opinions on a case that I am faced with at present 45 year old Diabetic on oral therapy for 8 years has been charged with sexual assualt of a 36 year old female. The allegation is that he had penetrated her. He denies that he was able to penetrate her as he has Erectile Dysfunction(ED) for the last 5 years and his wife (he says) will vouch for that. How can I prove/disprove that he had penetrated her? Kind Regards, Dr P Ramlachan Dr Ramlachan, Prithy, Regarding your case of the 45 year old diabetic man with ED who is accused of sexual assault: I, and I am sure many other American members of ISSM, have experience with this type of legal case because it comes up from time to time in the litigious I do not know of any way to prove or disprove, after the fact, that your patient had penetrated the accuser. In the past, we have used NPTR monitoring to help show that a man has ED. But there are so many limitations with Rigiscans that this test is not very reliable for proving ED. If his wife will testify that he has had ED for several years, that will probably help. And his lawyer can point out the high rate of ED in diabetic men. If you have any documentation that your patient has had ED and that you have been treating him for ED, that would probably help also. Ira Sharlip Dear Dr. Ramlachan I would recommend sending him to a sleep lab to check for nocturnal erections. This will give objective results that in my opinion would hold in court. Dave Rabinowitz Dear Dr. Ramlachan I suggest that any objective and verifiable medical evidence of an erectile capacity, or the absence thereof, would be forensically significant. However the case is also complicated by the possibility that penetration may be brought about by other means as well. (Finger, object etc) Dave Rabinowitz Dear Colleagues Thanx for the valuable input. The accuser did file a report in a few days after the incident. He did not ejaculate in her and no sperm was available at the time of the examination. The legal team have asked for input on the reliability of Rigiscan testing, nocturnal penile tumescence testing , the situational aspect of the incident and whether erection could have occurred at that time even though one could have a history of occassional early morning erections. Your input would be appreciated Kind regards Examination of Patients with Gender DysphoriaDr Kevin Wylie is seeking to find consensus on the extent of the physical examination required before prescribing hormones to patients with gender dysphoria. Previous endocrinologists and specialists and some existing published protocols have recommended full body examination including genital examination, in part to exclude intersex states, to exclude other genital pathology that may affect subsequent surgery and as good practice to record baseline measures (e.g. testicular density and size; absence of PCO) prior to giving hormones. Dr Wylie reported that many patients resent their genitals and dislike such an examination. For over 5 years, their clinic has offered the option of declining such examination by the GP or a clinic doctor. In the case of female patients they have offered transabdominal ultrasound instead of vaginal examination to exclude PCO before starting androgens. Dr Wylie and his collegues are trying to develop standards of care and guidelines in the UK and this is one area where there is difference of opinion between physicians and other clinicians and user groups. Obviously they want to offer the least invasive, yet safe and medically defensible interventions. Whilst most hormones are 'off label' use, they are standard treatment with well known side effects (wanted and unwanted) which the patient signs a consent form confirming such advice has been given. Dr. Wylie inquired about the minimum physical examination whether genital examination was necessary, or can be considered irrelevant if the patient was properly advised? Dr Moser’s opinion was that the clinician should push for a complete physical examination along with a pap smear, anal examination and STDs check. His rationale is that the patient would not talk to the clinician about previous sexual relationships – if any. Also, these individuals rarely see other physicians, so if he declines examination, probably no one else will perform it. Lastly, embarrassment over the body is not a reason other patients avoid exams, so he is not sure that we should treat our gender dysphoric patients any differently. Of course, anyone can decline an exam, but a discussion of the risks and benefits of that decision will follow. It is also suggested that attempting to perform the examination should be after the trust is built . Mild hormones can be used in the cases where no examination was done. Dr Assalian does not perform genital examination unless the patient was suspected to have an abnormality. In that case, the patient is sent to the endocrinologist for examination, hormonal and genetic assessment. If no abnormality was suspected, the patient is admitted into the program and sent to the endocrinologist for hormonal therapy and follow up after the decision to go through with the sex change is taken. Dr. Dean explained the “four principles” approach to biomedical ethics which requires us to respect patient autonomy. The patient should have the opportunity to decide whether or not to submit to examination, having received a reasonable explanation of why the physician thinks it is necessary, and what the benefits and risks of doing or not doing it might be. It may be beneficent to perform, or not to perform, an examination, depending on the individual circumstances. “Guidelines” recommending (or not) examination need to be applied after consideration of each patient as an individual. Following guidelines is not a defence against complaints of inappropriate implementation in individual cases. In the case of TS patients, there are special issues involved. Psychological issues are involved and could harm the patient and their relationship with the physician. Dr Dean’s practice is to offer examination to patients, explaining that on rare occasions, it will elicit useful data; if they agree, he will examine them. Prior to recommending hormone therapy, he would wish to perform an appropriate examination to minimise cardiovascular risk. For most patients, that would just involve assessment of pulse and blood pressure. In patients at risk of prostate and breast cancer, largely in older patients, he would be more emphatic in his recommendation for a more thorough examination to check for these specific problems. Clearly, appropriate pre-operative physical assessment is essential and patients are generally accepting this, as it is so much more task-related. Detailed DiscussionDear colleagues I am seeking consensus on the extent of the physical examination required before prescribing hormones to patients with gender dysphoria. Previous endocrinologists and specialists and some existing published protocols have recommended full body examination including genital examination. In part to exclude intersex states, to exclude other genital pathology that may affect subsequent surgery and as good practice to record baseline measures (e.g. testicular density and size; absence of PCO) prior to giving hormones. Many patients resent their genitals and dislike such an examination. For over 5 years, our clinic has offered the option of declining such examination by the GP or a clinic doctor. For FtM, we have offered transabdominal ultrasound instead of vaginal examination to exclude PCO before starting androgens. We are trying to develop standards of card and guidelines in the UK and this is one area where there is difference of opinion between physicians and other clinicians and user groups. Obviously we want to offer the least invasive, yet safe and medically defensible interventions. Whilst most hormones are 'off label' use, they are standard treatment with well known side effects (wanted and unwanted) which the patient signs a consent form confirming such advice has been given. What is the opinion about the minimum physical examination & is genital examination necessary, or can we consider it irrelevant if the patient is properly advised? Kind regards Kevan Wylie. Hi, I don't deal with such patients but on general principle physical examination is a basic part of dealing with all patients and their problems. Surely this is essential especially when one is contenplating significant treatment. David Jones Dear Dr. Wylie, I take a different approach. I think that many of these individuals rarely see other physicians, so if I do not do a complete exam no one will. These patients are often embarrassed about sex they may have had in the past (with men or women) and not will discuss it with you. This may have included penetrative sex and a pap smear, anal exam, and STD checks are appropriate. Embarrassment over the body is not a reason we let other patients avoid exams, so I am not sure that we should treat our gender dysphoric patients any differently. Of course, anyone can decline an exam, but a discussion of the risks and benefits of that decision will follow. In a harm reduction model (prevent use of black market hormones or decrease psychiatric consequences of denying the hormones), it can be appropriate to prescribe hormones with very minimal or no exam, but clearly not ideal. Nevertheless, I think the clinician should be pushing for a complete exam as the level of trust between physician and patient increases. Take care, Charles Moser, PhD, MD, FACP Dear Dr.Wylie I would be very grateful to for sending me a copy of conset form for hormone replacement therapy. Thanking you, Your sincerely Das Dear Das Do you see gender patienst for hormones or at the surgery stage? What is your opinion of my
questions? I will happily send you a copy when I am back in the office presumably to the address below? Kind regards Kevan. Dear Kevan Many thanks for your reply. I don't see gender patients and not involed in gender surgery. I do an andrology clinic. I
think your questions are very good.I would like to hear more views on this. I personally think a full body examination including genital is exetremely helpful provided pt's personality and mental state( anxiety and depression) allow it. Thank you very
much for sending me a copy at the address below at your convenience. I do not believe this was ever posted to the list, so I am sending it again. Charles Moser Dear Kevan and Colleagues We run the only service for the evaluation and treatment of gender dysphoric patients in our province. When we evaluate them we take a full history that covers what Charles is mentioning.I do not do physical exams.If a patient
mentions any thing about inter sex or he thinks there is a physical problem then he /she is sent to our Endo MD for complete evaluation that includes hormone and genetic studies. If we do not suspect any physical causes which is the majority,the
individual is taken into our programme ,until we are satisfied that the decision to go through sex changes is without risk ( at least we hope) then the person is sent to the Endo for evaluation and prescribing hormones and follow up. Dear Kevan Thank you for raising such and interesting and fundamental issue. The range of responses has also been interesting. I don’t think that arguments along the lines that “doctors always have and always should examine patients, and must do so as a routine” should go entirely unchallenged. From an ethical perspective, one should only perform a procedure on a patient if it is likely to be of benefit, or prevent a harm, to them, and the strength and likelihood of benefit must outweigh the risk and likelihood of harm, and the potential severity of the harm, that not doing the procedure might cause. The “four principles” approach to biomedical ethics requires us to respect patient autonomy. The patient should have the opportunity to decide whether or not to submit to examination, having received a reasonable explanation of why the physician thinks it is necessary, and what the benefits and risks of doing or not doing it might be. It may be beneficent to perform, or not to perform, an examination, depending on the individual circumstance. “Guidelines” recommending (or not) examination need to be applied after consideration of each patient as an individual; following guidelines is not a defence against complaints of inappropriate implementation in individual cases. An examination may cause harm and might breach the recommendation to nonmaleficence; is it really so essential to patient safety that we must insist upon it or refuse to provide care? In the case of TS patients, there are special issues involved. In the initial stages of care, the psychological impact of insisting that a patient display to us those bodily features that are at the root of their dysphoria may not only adversely affect their well-being but might also damage their relationship with their physician. They may feel able to permit examination at a later stage but many will not. Are we going to miss important medical problems that can ONLY be elicited by a physical examination and, if so, what is the prevalence of those problems in this population. My view is “yes, but only so extremely rarely that the potential benefit does not outweigh the risk”. Let us be realistic here; disorders of sexual development in this patient group are not exactly common. My own practice is to offer examination to patients, explaining that on rare occasions, it will elicit useful data; if they agree, I will examine them. Prior to recommending hormone therapy, I would wish to perform an appropriate examination to minimise cardiovascular risk. For most patients, that would involve just involve assessment of pulse and blood pressure. In patients at risk of prostate and breast cancer, largely in older patients, I would be more emphatic in my recommendation for a more thorough examination to check for these specific problems. Clearly, appropriate pre-operative physical assessment is essential and patients are generally accepting of this, as it is so much more task-related. To summarise: Offer examination to all but don’t insist unless there is the likelihood of a revealing a major management or safety problem. Don’t coerce patients into accepting the examination by presenting it as a condition of continuance of care. There are already plenty of conditions that they have to fulfil – at least these have a reasonable basis in the avoidance of likely harms from provision of inappropriate treatment. I look forward to being roasted in due course. Best wishes
I fully agree with John. Dear John I was impressed by the correspondence regarding the issue of the extent of the physical examination required before prescribing hormones to patients with gender dysphoria. As editor of "controversies in sexual medicine" In the JSM I think that this can be an excellent topic for this section The format is of at least 4 authors writing a personal approach consisting of approximately 500 words and up to 5 ref. So I would like your approval to write one approach. What you wrote seem interesting and need only some correction. Are you willing to do it I need it ASAP as it should be ready for the January issue. Regards Vaginal HyperthermiaDr. Gerard Gimenez A 44 year old female patient went to Dr Gimenez’s practice complaining of persistent elevated vaginal temperature for a period of one year. Previous gynecological assessment revealed no cause. Dr Gimenez’s first impression was that of presistant sexual arousal due to hot vagina, the heat being mild and tolerable, but there is no lubrication or sexual desire. Her husband feels the vaginal heat and both partners are uncomfortable during intercourse. As treatment, Dr Gimenez prescribed pseudoephidrene tablet, vaginal showers with cold water and criogel during the day. The patient was also told to keep an intravaginal temperature record. The first reply was concerning temperature gated receptors: hot and cold, TRPV1 and TRPV8, respectively. It was suggested that - theoretically speaking- the use of methanol could cause the activation of cold receptors. It was also suggested that intravaginal low concentration of capsacin could de-sensitize the C-fibers, but could cause intolerable sudden pain. Also gabapentin could be beneficial, by dampening the C-fibers. Dr.. Rosenbaum considered a diagnosis of neuropathic origin, such as pudendal nerve entrapement or simply, vulvodynia, but after ruling out all vulvovaginal infections and diseases. The reported decreased lubrication and dyspareunia indicates a pain syndrome, which could be treated in a multidisciplinary approach; medical – depending on chronicity - using low dose tricyclics or anticonvulsants (as gabapentin), physical therapy consisting of manual therapy and pelvic floor biofeedback to normalize tone, and sexual therapy to deal with decrease sexual desire and its effect on the relationship. He also reported that pseudoepherine could cause an increase in vaginal dryness and steroid creams – if used – could contribute to mucosal thinning, thus being useful in the short term, but not a suitable solution in the long term. Dr Rossello suggested that this case might be of psychosomatic origin. In order to determine as objectively as possible the diagnosis of this pathology, it would be helpful to take the patient’s vaginal temperature and compare it to the usual female vaginal temperatures. Also, it might be important to know exactly in which circumstances this problem started in order to try to discover what triggered it off. If the treatment recommended was doing well, then the patient should go on with it, except if it turns out to be a psyco-somatic disorder. Dr Bonierbale agreed with Dr Rossello and suggested the use of thermofeedback. Detailed DiscussionDear Colleagues: I hope everyone is OK and working hard towards sexual health in the whole world. Thanks in advance !! Dr. Gerardo Giménez I am not clinical sexual dysfunction expert but our research group have a strong interest in the temperature gated receptors: hot and cold, TRPV1 and TRPM8, respectively. Both of which exist in the bladder and vagina. I dont have any suggest but the mechanism of action is interesting. By research intravaginal low concentration capsacin could desensitize the C-fibers but acute pain could be terrible. Also I don't know of anybody who has done this. It is possible that an activation of the cool receptor, something with methanol may help but this is only research speculation. Lastly, a drug like gabapentin that dampens C-fibers may be reasonable to try. Michael Dear Dr. Giménez By "hot vagina" is your intention to describe chronic vulvovaginal burning? In that case, assuming any vulvovaginal infection or disease has been ruled out perhaps you could consider a diagnosis of neuropathic origin, such as pudendal nerve entrapment or simply, vulvodynia. Persistent genital arousal is generally characterized by chronically feeling genitally/sexually aroused in a manner unrelieved by orgasm.. As she reports decreased lubrication and dyspareunia, the burning appears to indicate a pain syndrome. These types of syndromes could be treated in a multidisiplinary fashion: medical, depending on the chronicity, low dose tricyclics or anticonvulsants (such as gabapentin) may alleviate the burning. Physical therapy consisting of manual therapy and pelvic floor biofeedback to normalize tone, and sex therapy to address decreased sexual desire, arousal and effect on relationship. Pseudoepherine can cause/ aggravate vaginal dryness and steroid creams (mentioned as treatment in another case, not your) can contribute to mucosal thinning. Both these treatments alleviate symptoms in the short term but are generally not a long term solution to a chronic condition. Talli Y. Rosenbaum, PT Dear Dr. Giménez: Indeed this case is atypical and we might be dealing with a problem of a somatogenic nature, that is to say the increase of the vaginal temperature is the body’s reaction to a psychic, maybe unconscious problem of the patient. In order to determine as objectively as possible the diagnosis of this pathology, it would be helpful to take the patient’s vaginal temperature and compare it to the usual female vaginal temperature. Furthermore, it would be interesting to know exactly in which circumstances this problem started in order to try and discover what triggered it off. If the treatment you recommended is doing well, my opinion is that the patient should go on with it, except if it turns out to be a psyco-somatic disorder. Dr. Mariano Rossello Thanks for your opinion, Dr. Rosello Dear Dr Rosello I agree with Dr Rossello; it will be interesting to use thermofeedback in this case best regards Dr Mireille Bonierbale |
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