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Digest of recent discussions on ISSM mail (Sept 2007 - December 2007)Amr El-Meliegy, M.D. - ISSM List Manager In this digest we have 4 cases. One by Dr. Moncada which is a continuation to a case previously presented by Dr. La Pera. One case on delayed ejaculation presented by Dr. Sadeghi-Nejad. Dr. Ghanem initiated a discussion on how internet pornography can influence teenagers. Lastly a case presented by Dr. Badalyn about an abnormal penile duplex study.
Penile implants and radical retropupic prostatectomy (RRP) – Dr. Ignacio MoncadaPenile implants and radical retropupic prostatectomyDr. Moncada reinitiated the discussion about Dr. La Pera’s case posted in the digest of Jan-April 2007 Dr. Giuseppe La Pera had a patient on which he performed an AMS/700 penile prosthesis 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 prosthesis 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 were 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. Dr. Moncada presented his experience with performing a radical prostatectomy for a patient in whom he implanted an AMS 700 cx 5 years before. He moved the reservoir out of the surgical field, preserving its capsule. This made it easy to access the prostate. He deflated the prosthesis to make the reservoir smaller and used for dissection only forceps and scissors. Using this technique, there was no need to change the reservoir, which was also protected from being contaminated. (The photos in the following link demonstrate the operative steps). http://www.kodakgallery.com/I.jsp?c=y9hmlg8.8ni41qw&x=1&y=lxfwgu Dr. Palmer also had experience with these patients at the Ohio State University performing robotic radical prostatectomy. He stressed not to deflate the reservoir until dissection is completed as this facilitates it. Dear Friends, Earlier this year, Dr. La Pera from Italy posted a case of a patient with a prostatic carcinoma that had a 3-p penile prosthesis. He expressed his concerns about the reservoir and the need of replacing it or the risk of infection. I had the opportunity of performing a radical prostatectomy a few days ago in a patient in whom I had implanted 5 years ago a AMS 700 CX. The access to the prostate is easy once you move the reservoir out of the surgical field. The best way to do it is to dissect free the reservoir preserving the capsule around it, so that the reservoir's surface is covered by it avoiding its contamination during the operation. I inflated the prosthesis to make the reservoir smaller and easier to dissect; I did not use the bovie, just forceps and scissors and tried not to break the surrounding capsula. With this technique you do not need to change the reservoir and the risk of contamination is virtually null. You can see some photos of this surgery clicking http://www.kodakgallery.com/I.jsp?c=y9hmlg8.8ni41qw&x=1&y=lxfwgu You will see 7 photos, first is the deflated prosthesis; 2nd I inflate the prosthesis; 3rd I am freeing the reservoir's capsula from its attachments; 4th The reservoir is free; you can see the connection to the pump, but please note that the capsula is unbroken; 5th moving the reservoir out of the operating field; 6th at the end of the prostatectomy, the reservoir now completely full is again in the prevesical space; 7th Best regards, ignacio Ignacio Moncada MD Dear Sirs, We have also had experience with these patients at The Ohio State University performing robotic radical prostatectomy. If you have any more questions, do not hesitate to contact me. Regards, Kenneth J. Palmer, MD Ignacio: Congratulations for the slides show. Adolfo Casabé Delayed ejaculation following spinal anesthesia – Dr. Hossein Sadeghi-NejadDr. Sadeghi-Nejad presented a case of a 63 years old male who complained of delayed ejaculation after undergoing an Achilles tendon surgery under spinal anesthesia. He had a normal testosterone level. Dr. Nejad suspected the cause to be the actual puncture and not the anesthetic itself. The patient had been on the following medications: Propecia, Allopurinol, Hyzaar, ASA, Singulair, Lipitor, Advair, occasional Proventil, occasional Prevacid, occasional Prednisone (asthma), occasional antihistamine, Xalatan (ocular hypertension), and occasional Voltaren (joint pains). Dr. Nejad advised him to try a high intensity vibrator to the frenular area. Dr.Ghanem advised to stop or replace propecia due to its possible association with the patient’s complaint. However, Dr. Nejad replied that the patient had been on propecia long before the occurrence of this disorder. Dear all: I am hoping that some of you can shed some light on this scenario. The patient is a 63 y.o. physician colleague who developed moderate to severe delayed ejaculation soon after a achilles tendon surgery under spinal anesthesia. He was catheterized during the procedure. This was reportedly smooth and uncomplicated. His PMH is essentially unremarkable (see below). From what I know and understand, the typical "stick" for the spinal is at the L4-L5 level (IDEALLY) and this is way above the ejaculatory reflex center (T12). However, the chronological order of events leads me to suspect that the spinal anesthesia (the actual puncture, rather than the anesthetic itself) was most likely the culprit and affected the nerves. I checked his serum testosterone levels as hypogonadism can be associated with ejac dysfunction, but the T was normal. The chronological summary of the events is as follows: Had spinal anesthesia on November 9, 2006 for a torn Achilles tendon repair. Noted delayed ejac. sometime soon after (by Jan., 2007). PMH: Mild coronary artery disease; hypercholesterolemia; Mild-Mod asthma; Numerous kidney stones in the past. Treated with stone removal surgery once, and ultrasound once. Meds - Propecia, Allopurinol, Hyzaar, ASA, Singulair, Lipitor, Advair, occasional Proventil, occasional Prevacid, occasional Prednisone (asthma), occasional antihistamine, Xalatan (ocular hypertension) started July 2007, occasional Voltaren (joint pains), nuclear stress tests annually. I HAVE SUGGESTED THAT HE USE A HIGH INTENSITY VIBRATOR FOR STIMULATION OF THE FRENULAR AREA TO SEE IF THIS MAKES ANY DIFFERENCE. I WOULD GREATLY APPRECIATE ANY COMMENTS ABOUT THIS CASE AS I DON'T HAVE A GOOD ANSWER (OR SOLUTION) FOR HIM. Many thanks. Hossein Sadeghi-Nejad, M.D. Dear Dr. Sadeghi-Nejad I suggest trying to stop / replace propecia -if possible- as it is occasionally associated with ejaculatory disorders (1.2% vs 0.7%, placebo), according to its product information website. Kind regards, Hussein Thank you Hussein. I had suggested the exact same to him, though he told me that he has been on propecia for a long time and the chronology was more in line with his recent surgery. Effect of internet pornography on teenagers – Dr. Hussein GhanemDr. Ghanem initiated a discussion about the effects of internet pornography on the sexual health of teenagers Dr. Assalian viewed it as part of Paraphilias or Compulsive sexual behavior. For persons having a relation, it could be considered emotional infidelity as the person invests a lot of time in cybersex and not in his partner. It can create wrong perceptions about definition of a normal sexual act and size of sex organs. Dr. Bronner had seen cases were internet pornography resulted in the following sexual dysfunctions: 1. Low sexual desire in intimate relationship (inspite of frequent masturbation in front of the internet.) In treating such paraphillic disorders, Dr. Rabinowitz stressed on avoiding contact with pornographic material during treatment period. On the basis of regarding such a disorder as an OCD, SSRI’s in high doses were found to be useful. Dr. Moser argued that compulsion is not part of the DSM diagnostic criteria of Paraphilias. In addition “Emotional infidelity”, low sexual desire in relationships (but frequent masturbation), erectile dysfunction only with a partner, retarded ejaculation, and the Madonna/Prostitute dichotomy were all well known prior to the Internet. There is no indication that the Internet had changed the incidence or prevalence of these disorders. The following are 3 publications about the same topic: Dear Colleagues I am invited to a panel of a talk show about sexual health and sex education. Among other issues it will discuss the effects of internet pornography on the sexual health of teenagers. I would appreciate any data or expert opinion about this issue (preferably before Friday). Including the opinions of international experts would certainly enrich the discussion. Kind regards Hussein Ghanem, M.D. Dear Hussein In the area of Paraphilias or Compulsive sexual behaviour,clearly internet pornography or as some will call it cybersex has become part of this disorder.In this area we discuss also Infidelity ,people who resort to this will say that we are not harming any body,if they are in a relation, because there is no genital contact ,but clearly this constitutes emotional infidelity because the person invests a lot of time in cybersex and not in his partner/wife . Adolescents and adults watching pornography believes that sex and sexual acts are what we see,men can last hours before they ejaculate,big penises,large breasts in women.Pornography in general looks to women as if they are all sexually addict,it is demeaning for women. Does it give education in teenagers,may be .In a society where sex is a taboo ,does this encourage this kind of behaviour,need to be looked at. In general it gives wrong sex education. Hope this is helpful Pierre Assalian,MD Dear Dr. Ghanem, I can share with you the clinical experience of the Sexual-Medicine-Center (Dept. of Urol. Sheba Medical Center, Israel): We treat sexual problems caused by the ifluence of frequent use of interenet-porno by young men. The main symptoms that we diagnose are: 1. Low sexual desire in intimate relationship (inspite of frequent masturbation in front of the internet.) If these cases are relevat to your panel discussion, I'll expand more. with best regards Gila Bronner Dear Hussein I have treated selected cases of paraphilias over the years, in the main those who show paraphillic behaviors but retain the capacity for normative functioning, in the absence of antisocial personaity traits. Two issues seem to me to be relevant here: 1. Part of the treatment plan must be to end all contact with pornographic material, at least for the duration of the treatment, as use of pornography is a positive reinforcing factor in most paraphillics. 2. For many paraphillics, the endless preoccupation with erotic-paraphillic imagery and fantasies have an OCD (obsessive-compulsive disorder)–like quality. I have found that many respond well to SSRIs, often in higher doses that for depression. 3. Good luck and best wishes, David Rabinowitz MD I wish to thank Drs Pierre Assalian, Gila Bronner, Charles Moser, and David Rabinowitz for the very usefull information you sent me. Hussein Ghanem Dear Professor Ghanem, It's my pleasure to indicate you a paper which may help you, published in the European Journal of Sexual Health "Pornography on the net : same attraction but new options" Kind regards Dear Hussein: In my practice, which is socio-culturally distinct, I see victims of pornography presenting with severe sexual inadequacy and sexual anhedonia. These men have usually watched pornography for many years without being in a sexual relationship until they get married. Sexual inadequacy presents with feelings of body dysmorphism, especially about penis size, and an inferiority complex and low opinion about themselves as lovers in comparison with the porn stars. In the second group, we see men who have severe problems with sexual arousal and satisfaction. Normal sex seems most unexciting to them, and this leads to severe relationship problems. Many begin to abuse substances and alcohol to try and overcome this, but without success. Also, many partners of such men feel that these men are just `not there' during lovemaking. Best. Sudhakar Krishnamurti. How do you said, it's a cultural problem. In south Brazil we do not see greats alterations for the precoce exposition to porn in Internet. Whith the exceptions, that always hapens. The moral changes, but, the moral always changes. CARLOS EDUARDO CARRION VIDAL DE OLIVEIRA Dear folks, In response to Drs, Assalian and Bronner (messages below): Compulsion is not part of the DSM diagnostic criteria of Paraphilias. "Emotional infidelity," idolization of certain body features, low sexual desire in relationships (but frequent masturbation), erectile dysfunction only with a partner, retarded ejaculation, and the Madonna/Prostitute dichotomy were all well known prior to the Internet. There is no indication that the Internet has changed the incidence or prevalence of these disorders. Correlation is not causation. We do ourselves and our patients a disservice when we assume a symptom (or an observation) is the cause of a problem without scientific research. Take care, Charles Moser, PhD, MD, FACP Dear Hussein I have a colleague who has published two papers on the effect and consumption of pornography. Please find them below. Hald GM, Malamuth NM. Hald GM. Annamaria Giraldi, MD, Ph.d Dear friends, Thank you all so much for all the material you sent me on the list or directly to my email account. The different opinions were very helpful in presenting to the audience various points of views. The show was very well accepted and the producers were very appreciative of the wealth of information that I summarized in Arabic slides illustrating the opinions of experts from all over the world. The program will be broadcasted on the Dubai satellite channel. Many thanks and warm regards to all. Hussein Ghanem, M.D. hi hussien i participated in a show before about this subject "pornography effects on sexual health" and have good material will forward it to u when am back because out of office for two days good-luck Shedeed Ashour shedeed Abnormal penile duplex study – Dr. Rafael R. BadalyanDr. Badalyn presented a case of a 29 years old divorced male complaining of unsustained erections for 1.5 years. The condition did not occur during his marital life. No past history of relevant medical troubles. Hormonal profile was normal. Duplex penile vessels study showed arrhythmic velocity like stable bigemeny or some times trigemeny, with first systolic inflow velocity 39cm/sec , the second inflow was about half of the first (20-25cm/sec) , with missing third one, which was simultaneous with his brachial pulse. Dr. Piha saw it as a typical case for cardiac arrhythmia. He recommended a 24 hour Holter monitoring for the patient. He also added that that the strong autonomic sympathetic activation during sexual intercourse (for example high performance anxiety) can cause cardiac arrhythmias. Dr. Wylie referred to a similar case he presented which is listed in digest for July - December 2002. Dr Broderick advised performance of 12 lead ECG to rule out arrhythmia. He added that venous leakage was to be considered in the differential diagnosis. Dear Colleagues, I would like to share with you this clinical case and ask for your advice: Twenty nine y.o. male patient referred, complaining on ED for last one and half year. The erections in more then 50% of cases are not enough for penetration or loosing during the intercourse. From the history it seems to be psychological problem, as it starts after being divorced (was married for one year, but sex, as he says, was not the reason of divorcement). During this year he had 2 partners with relations for 2-3 months each, and the same problem occurs with both of them. Once he tried PDE5 inhibitor, with reaching sufficient erection. Blood check up for risk factors and hormones revealed no abnormalities. Three years ago he referred to cardiologist with complains on heart are, but nothing was found. We have performed a duplex Doppler of cavernous arteries: The erection after pharmacostimulation E4-E3. What was found was not typical: The MCV from left was 39cm/sec, and right MCV 35 cm/sec, with the EDV=5 from left and 0 from right. But the velocity was arrhythmic like stable bigeminy or some times trigeminy, with first systolic inflow velocity 39cm/sec , the second inflow was about half of the first (20-25cm/sec) , with missing third one. That was simultaneous with his brachial pulse, so no duplex artefact. I would like to ask if this can be a reason of erectile problems or indeed this should be viewed as psychological case? Should he treated first by cardiologist? Thanks in advance Wishing you all Marry Christmas and Happy and Prosperous New Year 2008. With regards, Rafael R. Badalyan, MD, PhD Can I suggest you have a look at the digest for July - December 2002 which may be helpful. Kevan R Wylie MB MMedSc MD Dear Dr. Badalyan, I have performed some 2000 color duplex doppler examinations of penile arteries. The finding you described is typical for patients with cardiac arrhytmias. It is obvious that frequent arhythmias, like ventricular bigemeny or atrial fibrillation have a harmful effect on penile circulation. Has the patient undergone a 24-hour Holter monitoring? If no, I strongly recommend that. The case seems not to be a psychological problem. However, it should be noted that the strong autonomic sympathetic activation during sexual intercourse (for example high performance anxiety) can cause cardiac arrhythmias. In any case those frequent arrhythmias probably are involved with erectile dysfunction of your patient. Best regards Juhana Piha, M.D., Ph.D. Dear Dr. Piha, Thank you very much for your kind and very useful response. The patient sent to cardiologist for Holter monitoring. I will keep you informed with the results and with cardio treatment outcomes. Dear Dr. Wylie, As I see, you had a patient with alike doppler results.Did you see the two pick flow as -^^- or as -^-^---? I think here should be the difference between fibrillation and bigemeny. I am interested, if you remember the outcome with that patient. Thanks once again. Yours, Rafael Dear Rafael It was -^-^--- Kind regards Kevan. Patient needs a 12 lead ECG to rule out arrythmia. What was the intracavernous dosing for the doppler. Did the patient say this was similar or worse than the erections he gets at home. I suspect venous leak, but anxiety certainly can yield false positive results. GAB |
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