Digest of recent discussions on ISSM mail (Jan 2008 - April 2008)

Amr El-Meliegy, M.D. - ISSM List Manager

The list digest contains 10 interesting cases in diverse subjects discussing surgical, priapism, Peyronie’s disease, weak libido, ejaculation, 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.

• Excessive lubrication and FSD (Dr. Gila Bronner)
• Nocturnal paraphimosis (Dr. Kevan Wylie)
• Anejaculation (Dr. Emad Salem)
• Penile prosthesis erosion (Dr. Eduardo Bertero)
• Priapism and Tamsulosin (Dr. Sidney Glina)
• Post orgasmic vomiting (Dr. Shedeed Ashour)
• Post vasectomy pain (Dr Peggy Kleinplatz)
• Priapism wih failed puberty and HRT (Dr. Hussein Ghanem)
• Weak libido with high testosterone (Annette Owens)
• Peyronie with penile shortening (Dr. Eduardo Bertero)

Excessive lubrication and FSD (Dr. Gila Bronner)

A  32 year old single healthy woman, complaining  of excessive lubrication points out that her present partner -a 39 year old single man- loses his erection shortly after penetration, saying that “He doesn't feel anything”. He is a premature ejaculator (1-2 min after penetration). In the past she had good sexual relationships, with many partners who were satisfied, but she describes several cases of men who lost their erections. She is easily aroused and reaches orgasm by manual, oral, vibrator stimulations. She has tried to have sex with a tampon inside her vagina. He functioned better and she could feel his penis moving inside her for the first time.

While Dr.Louise-Andrée Saulnier reported satisfactory results, in similar cases, after combining Kegel exercices with Biofeedback for both partners, Dr. Pierre Assalian suggested a more simplistic approach. It consisted of changing the sexual position or instructing the woman to raise her legs during intercourse as well as prescribing a PDE5 inhibitor to the male partner to increase penile girth. He diagnosed the case as "floating penis", resulting from the high arousal of the female partner.

Dr. Hussein Ghanem pointed out that it shouldn’t be taken for granted that excessive vaginal lubrication was the cause of the ED and PE.  The male partner should therefore be evaluated and prescribed a PDE5 inhibitor & an SSRI if necessary. Dr. Sudhakar Krishnamurti emphasized the added value of using studded or ribbed condoms by the male, or even a female condom.

Dr. Dave Rabinowitz pointed out that since vaginal lubrication was an exudation-resorbtion phenomenon and that no glands were involved, anti-cholinergic and nor-epinephrinergic interventions were unlikely to make a significant difference.  This excess vaginal lubrication was probably due to an excess local production of the hormone “VIP”. Dr. Kevan, on the other hand reported success with Baclofen, while Dr. Patrice Cudicio advised the use of pseudo ephedrine to reduce lubrication.

Israeli sex therapists and physicians recommended a multi-disciplinary approach. It consisted of treating the male partner's PE and ED and using a condom. The condom would delay ejaculation whilst ruling out the cause of absent sensations; being either the excessive lubrication or a vaginal muscles problem. They also advised that a colposcopy be performed to check for any cervical pathology.  Other, rather empirical, suggestions were made: Using “Transderm” (for sea-sickness), which contains Scopolamine and has an effect on mucous membranes; switching to progesterone-only or low-estrogen contraceptive pills and finally; inserting a tampon imbibed with adrenergic nasal drops.

Dear Friends,

I would appreciate your professional advice on the following case:

A  32 year old single healthy woman, complains of excessive lubrication.

She points out that her present partner (39 year old single man) loses his erection shortly after penetration, saying that he doesn't feel anything.

He is a premature ejaculator (1-2 min after penetration).

In the past she had good sexual relationships, with many partners who were satisfied, but she describes several cases of men who lost their erections.

She is easily aroused and reaches orgasm by manual, oral, vibrator stimulations.

She has tried to have sex with a tampoon inside her vagina. He functioned better and she could feel his penis moving insode her for the first time.

thanks for your kind attention

gila

Gila Bronner

Dear Gila,

in my practice, I had few cases like the one you describe. The best results I had came from the prescription of the Kegel exercices in order to improve the PC muscle strenth for the two partners. If you have access to BIOFEEDBACK services, il helps to reach better results.

Let me know if you need more information.

Good luck,

Louise-Andrée Saulnier

Dear Louise-Andrée:

Could you explain what is the phisiopathological mechanism in where Kegel exercise or Biofeedback device could reduce vaginal lubrication.?

Regards

Adolfo Casabé

Dear Friends,

In my practice pseudo ephedrine is often effective to reduce lubrication

Docteur Patrice CUDICIO

Dear Gila,

I suggest evaluating the male partner and possibly a therapeutic trial using a PDE5 inhibitor and an SSRI to treat the ED and Premature ejaculation (PE).

Some experts believe that 1-2 minutes is not PE.  I believe we shouldn't take it for granted that excessive vaginal lubrication is the cause of the ED and PE.

Best regards,

Hussein

Dear Louise-Andrée, Patrice and Hussein,

Thank you for yr good advice.

I wish to share with you some of the suggestions received by Israeli sex therapists and physicians:

1. Treat the male partner's PE and ED- he seems a main part of the presenting problem.

2. Use of condom will enable differentiate if the absence of sensation is due to too much lubrication or due to vaginal muscles problem. Condom might also delay ejaculation.

3. Colposcopy of cervix to check possible pathology

4. There were a few suggestions that have no scientific evidence, but have some logical basis:

   Transderm (for sea-sickness), which has Scopolamine and has effect on mucous membranes

   Change her contaceptives to progesterone only pills or low level estrogen pills

   Insert a tampon lubricated with adernergic nasal drops.

best regards

gila

Dear Gila:

In addition to the treatment of the male partner for PE and ED as has already been suggested on this board, the use of a studded or ribbed condom by the male, and even a female condom, might help.

Sudhakar Krishnamurti

Dear Gila ,

I have heard of this problem anecdotally but have no experience in managing it. I would like to put to you some thoughts: vaginal lubrication is an exudation- resorbtion phenomenon and no glands are involved, thus anticholinergic and norepinephrinergic interventions are unlikely to make a significant difference. A local hormone called VIP increases vaginal lubrication, and it raises a thought as to whether it may be useful to consult with a physician well versed in this hormone, and to check as to whether she may have an excess.

See the references below.

Best wishes,

Dave Rabinowitz

I have had success with baclofen.

Kevan.

Dear Gila

Salutations to you and to all from Thailand where Betty and I spending vacation time.

Regarding your case,she seems highly aroused,and it causes what is called"floating penis".

In my practise I will not prescribe any medication to her,I doubt that Kegel excercise or biofeed back will do anything,what works is the changing position in intercourse or have the women raises her legs while making love.A PDE5 inhibitor may give the man increase in the girth or circumference.

Pierre

Nocturnal paraphimosis (Dr. Kevan Wylie)

Dr. Wylie presented a case of a diabetic man  in his fifties who awakens with regular ‘painful non - rigid erections’. Priapism was ruled out. The patient claims that his penis grew in size by over 100%. Photographs taken at the time of the incident appeared to represent a partial paraphimosis except that the patient was circumcised 20 years ago for phimosis. No infection in the glans was noted.

I have a gentleman who is in his fifties who awakens with regular ‘painful erections’. We thought this to be nocturnal priapism but the usual management and treatment options did not work. I then got him to clarify matters further and he described that his penis grew in size by over 100%. He eventually brought some photographs for me to look at and these appear to represent a partial paraphimosis except that he is circumcised. This surgery was 20 years ago for phimosis. I appreciate that full surgery beyond the ridges may not take place with adult circumcision and so may help to explain the situation. There is not rigidity of the penis for the duration of the swelling and it can take 48 hours to subside. He is diabetic but the glans is not infected and there is no Candida.

Is there an alternative diagnosis to consider? Has anyone ever encountered this phenomenon and if so, do you have any advice for management?

Kevan Wylie.

Anejaculation (Dr. Emad Salem)

A male patient presented to Dr. Emad Salem complaining of anejaculation during sexual intercourse with his wife. He has been married for 5 years. Retrograde ejaculation was excluded and he reported experiencing normal nocturnal emissions. His wife is extremely cooperative, they underwent exercises to prolong excitement and foreplay with no positive outcome. The couple underwent an IVF that resulted in pregnancy, but unfortunately aborted during the 4th month.

The patient gave history of extremely strict upbringing and no attempts of masturbation before marriage. The patient used to apply inhibitory procedures when getting severely excited before marriage, he even tried to suppress his nocturnal emission if he was semiconscious. After marriage, he used to get severely excited but without ejaculation or orgasm and it gets harder to reach severe excitement now. Masturbation before intromission by himself or when aided by the wife did not result in ejaculation either. After intercourse the patient experiences tingling sensation and desire to urinate. The patient is extremely dissatisfied with his inability to orgasm, while his wife experiences good orgasms.

Dr Claudio Teloken suggested the use of oxytocin before sex or L-DOPA – which needs a couple of weeks. He suggested transrectal ultrasonographic examination and hormonal profile assessment. Dr Charles Moser also suggested nasal oxytocin.

Dr Pierre Assailan reported that the patient was typical of psychological etiologies and should explore sexual trauma, fear of impregnating his wife, latent homosexuality and paraphilias before starting any medication.

Dr Hussein Ghanem reported that primary absolute anorgasmia fits the patient’s case, although this topic is poorly addressed in literature. Dr Hussein reported that most patients don’t respond to treatment but he had a recent success with a 24 year old single male by advising him to masturbate regularly while focusing on the pleasure on his fantasies while forgetting the ejaculation. He also reported that Dr Medhat Amer had some success with vibratory stimulation. Dr Hussein also mentioned that psychological factors for failure include obsessive-compulsive personalities, fears, performance anxiety trap, but could also be a combination of factors as there is rarely a clear cut case. Other physical factors could include narcotics and alcohol abuse, nerve disorders and spinal cord injury. Absent bulbocavernosus reflex could also have a role although many healthy male have absent reflex. He suggested that the patient should not concentrate on ejaculation but relax and enjoy giving and receiving stimulation. Sensate focus exercise, desensitization by ejaculation outside and vibratory stimulation/fantasies could be attempted. He then addressed the fertility side of this issue in which sperm retrieval can be done by electrovibratory stimulation, transrectal electroejaculation and fine needle aspiration. Occasionally collection of semen during nocturnal emission could be done.

Dr Shedeed Ashour suggested deep psychoanalysis because of the inhibition he practiced, religious orthodoxy like syndrome or deep conflict dating back to his very early life.

Dear all:

I've a patient who has anejaculation ( proved not to be retrograde ejaculation), He has also normal nocturnal emission, History of overstrict bringing up.

He has followed all advices regarding intensive trial to increase his excitement and prolong the foreplay periods with his cooperative wife, with no results.

Trials os IVF ----> his wife got pregnant for 4 months then abortion.

Past history:

1- He has never tried to masturbate before marriage.

2- Before marriage he has times of severe excitment (about to ejaculate), but he used to perform an intense inhibition on this feeling . He even used to try inhibition on nocturnal emission if he was semiconsious at time of ejaculation.

After marriage:--> he has been married for 5 years

1- at the begining he was feeling severe excitment after getting out of the vagina, but when he tried the intrumission again --> no ejaculation.

2- Diagnostic masturbation after marriage, even with his wife's hand , did not bring him to excitment or ejaculation.

3- later on, in his marriage life , it was getting much infrequent for him to feel this severe excitment.

Although his wife has a very good orgasm while praticing sex with him.

But, usually after sexual act he is unhappy with his anejaculation which is conflicted with his satisfied wife.

4-  After sexual act, he is almost always feeling tingling sensation and that he strongly want to pee.

Emad Salem, MD

Dear Emad

We´ve been using nasal Oxytocin just before sexual intercourse. Occasionally, some patients will be given oral L-DOPA too. However, L-Dopa benefit demands couple of weeks.

Best regards

PS: According to our protocol, all individuals before been treated should undergo blood hormonal tests and trans rectal ultrasonography

                                                               Claudio Teloken  MD  PhD

Dear Claudio Teloken,

How long you have made use of this protocol. What is the dosage? Why blood hormonal tests and trans rectal ultrasonography? I have been using nasal Oxytocin, too. But without much success

Go to.

 J Sex Med. 2007 Dec 14 [Epub ahead of print]

Male Anorgasmia Treated with Oxytocin.

Ishak WW, Berman DS, Peters A.

Cedars-Sinai Medical Center—Psychiatry, Los Angeles, CA, USA.

Introduction. This is a case report on male anorgasmia that was successfully treated with oxytocin. Oxytocin is increased during arousal and peaks during orgasm. More recently, a study on humans published in Nature has shown its value in social bonding, increasing trust, and enhancing the sense of well-being. Aim. To test the effectiveness of administering oxytocin in a case of treatment-resistant anorgasmia. Methods. The patient underwent a biopsychosocial evaluation by a psychiatrist trained in sexual medicine and sex therapy for male orgasmic disorder, acquired type. Medical conditions, effect of substances, and psychological issues were ruled out. The patient was properly consented to using oxytocin as an off-label trial. Oxytocin was administered using a nasal spray intracoitally because of its ultra-short half-life. Results. Oxytocin was effective in restoring ejaculation. Conclusions. A case of treatment-resistant male anorgasmia was successfully treated with intracoital administration of intranasal oxytocin.

PMID: 18086171 [PubMed - as supplied by publisher]

Dear Dr. Teloken,

As far as I know, we do not have nasal Oxytocin in the US, can you tell me the dose and your success rate with this. 

Sincerely,

Charles Moser, PhD, MD, FACP

Emad

These cases ,are typical of psychological etiologies ,once you rule out organic which in this case seems not present.

There are many reasons,having no time to enumerate as I am away on vacation,.You have to explore sexual trauma,fear of impregnating his wife,latent homoseuality,paraphilias etc.I will not jump in giving him medication.We can talk later.

Pierre Assalian,MD

Dear Emad

Almost all patients that I've seen with primary absolute anorgasmia - Young healthy men who had never been able to reach orgasm and ejaculation during any kind of sexual activity, in spite of normal erections and night emissions- fit the description you gave, strict upbringing, significant inhibitions and NEVER Masturbated!  Very little literature addresses this specific presentation.  I had one recent success with an unmarried 24 years old young man by advising him to masturbate regularly while focused on the pleasure and fantasies when forgetting about the ejaculation.

Medhat Amer had success with a similar case using vibratory stimulation.  However, most cases do not respond to such treatments.

Several factors might interfere with reaching full sexual excitement and thus failure to reach orgasm. Suggested psychological factors include obsessive-compulsive personality, interpersonal factors and various fears.

However, in many cases there is no clear cut cause.

Patients might fall into a performance anxiety trap. Instead of relaxing and enjoying the sexual experience they might focus on their performance and on reaching orgasm.

Performance anxiety would thus inhibit sexual excitement and orgasm.

Suggested physical factors include hypnotic abuse, narcotic & alcohol abuse and nerve disorders or spinal cord injuries. An absent glandipudendal ('bulbocavernosus') reflex has been correlated with treatment failure.

However, many healthy men have an absent 'bulbocavernosus' reflex.

Various treatment approaches have been used with varying success. Reduction of performance anxiety and providing a high level of stimulation might be achieved through the sensate focus exercises.

If the patient is able to ejaculate outside the vagina, sex therapists attempt desensitization by prescribing a series of exercises where the patient masturbates up to ejaculation on his own first, then with his wife, then outside the vagina, and finally intravaginally.

Vibratory stimulation and sexual fantasies might be helpful as with the cases mentioned above. The general advice given to patients with primary or secondary failure of reaching orgasm is not to concentrate on the outcome of the sexual experience but rather to relax and enjoy giving and receiving stimulation.

The other aspect of the Anorgasmia problem is infertility.

Several approaches for sperm retrieval and assisted reproduction have been successful. These include electrovibratory stimulation, transrectal electroejaculation, and testicular sperm fine needle aspiration.

Occasionally patients were able to collect sperm after night emissions and deliver it to the Andrology laboratory for freezing (this worked with 2 of my patients).  They need a collection cup near by.

Good luck with this difficult case

Hussein

Hussein Ghanem, M.D.

Dear all

Hi Emad

from the history of your pt i can recommend deep psychoanalysis because it seems to me from the intense inhibition he practiced that he has a relegious orthodoxy like syndrome or deep conflict dating back to his very early life.... family, parent,...etc..

thank u

SHEDEED ASHOUR SHEDEED

Penile prosthesis erosion (Dr. Eduardo Bertero)

This is a case of a 64 year old man who had a malleable implant put 15 years ago.  During the last year he noticed that the tip of the right cylinder was protruding through the urethra but not yet perforating the mucosa. The patient was not in favour of installing an inflatable implant. Dr. Bertero asked whether he should replace it before it perforates and whether he should perform the Carsons Windsock reinforcement with Gortex or just rerouting .

All the opinions emphasized immediate interference. Dr. Love advised to repair the distal corpora with some allograft material as Pelvicol and to replace the rod with a 0.5 cm shorter one. According to Dr. Richter  if there is no infection, one could repair the Corpora only and leave the rod. He preferred to avoid the use of artificial material, to lessen chance of infection. In case of a reimplantation, he advised using a shorter rod which is to be pulled back as much as possible and to suture it through the corpora, catching the tunica and the proximal end of the rod preventing it to migrate distally. Dr. Gueglio recommended to remove the rod and reoperate after 3 months if immediate implantation and rerouting were not possible. Tip reinforcement by interpositioning of a dermal graft was suggested by Dr. O.Shaeer. However Dr. Levine and Dr. Ashour were not in favour of using a dermal graft which increases the risk of infection. Dr. Levine prefers Tutoplast processed pericardium. Dr. Lopez suggested to use bovine pericardium. Dr. Edgardo advised to perform a hemi coronal incision, reroute the cyllinder as dorsal and lateral as possible, and close with at least 3 layers. Dr. Glina was for Carsons Winsock reinforcement.

Dear colleagues I would like your input:

A 64 year old man had a malleable implant 15 years ago.  During the last year he noticed that the tip of the right cylinder was protruding through the urethra.  He came in the office last week.

The tip is really very superficial through the meatus however has not perforated the mucosa as yet.

Should I replace it right away, before the perforation happens?

Should I perform the Carsons Windsock reinforcement with Goretex? Or just a rerouting?

Regards,

PS: He does not want a inflatable.

Dr. Eduardo Bertero

Dr Bertero,

Was there pain before this happened? - I wonder about occult infection.

Is he diabetic? - Poor tissue strength and healing

I would replace the cylinder as soon as possible, before it erodes. I would repair the distal corpora with some allograft material, ? Pelvicol.

If he does not want an inflatable implant I would consider going 0.5 cm shorter on the replacement

Dr Chris Love

Dear Dr. Bertero,

I agree with Dr. Love. You should explore the patient ASAP.

Regarding what to do, it depends on the intraop findings. If you are comfortable with the idea that there is no infection, you could repair the Corpora only and leave the rod. In any case you should take a culture from the open corpora and provide good antibiotic therapy. You could build a windsock, although if you can save the use of artificial material, there is less chance of infection.

Since the patient does not want an inflatable PP, there is another trick you could use if you must implant a shorter rod. This is pull back the rod as much as possible and suture it through the corpora, catching the tunica and the proximal end of the rod. So you prevent the shorter rod to migrate distal and repeat the problem.

In any case, I advise you to operate now in order to prevent perforation.

Good luck and please report us of your decision and results,

Santiago Richter, M.D.

Eduardo: I would definitely  implant a new cylinder, rerouting it, without waiting for the perforation to happen. If this is not possible I would explant the cylinder and then come back after 3 months. Good luck and best regards, Guillermo Gueglio.

Dear All,

I recommend replacement and tip reinforcement if impending perforation is confirmed. I have a description of a reinforcement technique in press at the JSM. The glans is dissected off of the tip of the corpus cavernosum which is enforced by an interposition dermal graft. Waiting until actual perforation and extrusion occur may necessitate delayed replantation with the possible consequent fibrosis.

 All the best,

                    Osama Shaeer, M.D.

Dear Eduardo,

He needs to be explored ASAP. I would perform a hemi coronal incision, reroute the cyllinder as dorsal and lateral as possible, and close with at least 3 layers.

Good Luck!

Edgardo

Dear Dr.Bertero

I would recomened replacing the old one before it erodes completetly. You do not have to perform the Carsons Windsock  reinforcement with Goretex. Just a rerouting might be a good idea. If the other cylinder is good you might consider a slightly shorter one for reinsertion.

Good luck.

Prof. Hasan farsi

I agree that immediate attention is in order before perforation and I agree that some distal reenforcement is in order but I would not recommend use of a dermal draft given the increased risk of infection (minute foci of bacteria in the dermis. Instead i use Tutoplast processed pericardium.

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

Dear all

Yes the best for this pt is reenforcement after finding out any cause for this condition>

-Review his file if its longer from the start-= reinforce +shorten

- Bad sexual technique has to be excluded and if any Pt education needed after surgery.

- New DM or Uncontrolled

- Bad general health

- trivial dormant infection re-activated.

I also diagree with the dermal graft ? seb cyst , hair follicles even rudimentary will invite for the risk of infection (FB). but i agree with the re-enforcement>

thanks

SHEDEED ASHOUR SHEDEED

Eduardo and Colleagues,

I recommend replacement and tip reinforcement before perforation. I prefer to use bovine pericardic. Probably in cases like that we have infection associated with isquemic tissue secondary prosthesis implanted too tightly.

Years ago I had a case with uretrhal perforation and extrusion (Int Braz J Urol. 2007 Jan-Feb;33(1):74-6). In a delayed replantation, if necessary, I use bovine pericardic too.

Eduardo Lopes

Eduardo:

I would do a repair right way using Carsons Winsock reinforcement.

Sidney Glina

Priapism and Tamsulosin (Dr. Sidney Glina)

Dr. S. Glina presented a case for a 32 years old male who developed low flow priapism after intake of 0.4gm tamsulosin. Dr. Yasusuke noted that there was a similar case in the literature. Dr. Nejad published a paper recently about terazocin and occurance of priapism . Dr. Serjei also have seen a 76 year old patient who developed priapism after taking 4mg tamsulosin.

Dear friends:

Have you ever seen a patient that developed priapism after taking tamsulosin 0,4 mg?

A 32 yo gentleman came to my office for a surgical repair of congenital penile curvature. He complained of some degree of urgency and at the end of the evaluation I prescribed tamsulosin 0.4g.

After taking 1 pill he developed a typical low-flow priapism that I was able to treat with irrigation and adrenalin.

Sidney Glina

Dear Sidney:

I checked the database of Pharmaceuticals and Medical

Devices Agency of Japan.

I found one case of priapism in 2003. Details are unknown.

In Japan the dose of tamsulosin is 0.2mg.

Regards,

Yasusuke

Hello Sidney. Please see our recent report about terazosin and priapism.

J Sex Med. 2007 Nov;4(6):1766-8. Epub 2007 Apr 19.

New-onset priapism associated with ingestion of terazosin in an otherwise healthy

man.

There is a reference to tamsulosin. (ref #3 in our paper). It has been reported.

Best,

Hossein

Dear Sidney !

I have one patient 76 year ago with BPH, who recived 4 mg tamsulosin and he had prolonged painful erection. This situation are finished, when we changed a-blokers.

Dr. Bogolyubov Sergej

Hossein:

Thank you.

I know the relationship of terazosin and priapism, but I was not aware taht tamsulosim ( a more specific alpha-blocker) could have the same consequence.

Sidney Glina

Post orgasmic vomiting (Dr. Shedeed Ashour)

Dr. S. Ashour presented a case of newly married 32 years old man complaining of vomiting which occurs upon orgasm. The patient gave no past history of any medical troubles.

Dear professors and colleagues

 thank you in advance for your comments.

We all know about the sexual headache but........ Recently, I received and gave care to a newely married couple, complaining of Severe attack of vomiting upon orgasm- ejaculation. the male partner is an indian 32 and the wife is Saudi 36 years old. they are relatives and have no other complaints or comorbidities. now they avoid making love because of the antiception of the occurrence of vomiting.

Is there any cases like that faced in your daily practice?? and if any, how you managed them? what is the explanation behind?

Shedeed Ashour Shedeed..MD

Post vasectomy pain (Dr Peggy Kleinplatz)

Dr Peggy Kleinplatz asked for any recommendations or suggestions regarding a loving sexually compatible couple in their early forties. During 2003, after their 3rd child, the male underwent a vasectomy in a walk-in clinic in which the doctor was certainly not a urologist. During the procedure the male could feel pain in the left testicle, before which he didn’t feel any pain in the right side. After the procedure, the left testicular pain was excruciating –especially on contact- it needed 9 months of disability leave. He was seen by an excellent urologist who diagnosed the case as post-vasectomy pain syndrome as a result of a botched vasectomy and prescribed celebrex for 4 – 6 months. The pain decreased after the treatment but was not gone. By then celebrex was all over the news, so he stopped it. The husband failed to see his urologist again. In 2007, his new urologist ordered an ultrasound examination which revealed nothing, but the genital examination lead to 2 weeks off work. Both the husband’s urologist and family doctor agreed that the pain will probably never resolve. The pain is localized to the left bottom of the left testicle and is slowly diminishing to the extent where he can walk comfortably, but any “giggling” like in jogging is out of the question. Local examination or jiggling led to swelling of the entire left hemi-scrotum. The husband requested the removal of his left testicle but his urologist would not accept the suggestion and the patient agreed with his doctor. Recently it came to Dr. Kleinplatz’s attention that the pain increased significantly after ejaculation. The patient tried going a month without ejaculation which led to severe pain afterwards. Also ejaculating every day was un bearable, ejaculating every 2-3 days was his best option. The ejaculate was of normal color and volume.

Dr Shedeed Ashour suggested persistent post-vasectomy orchalgia due to congestive epididymitis, low grade infection of epididymal tail, vasal pathology as blow outs , cyst or partial ligation of vasal nerve leading to a neuroma. After exclusion of other pathologies, Gabapentine could be tried or the recently approved Cymbalta, antidepressants, local anesthetic injection in the spermatic cord and if all else fails, orchidectomy.

Dr Hussein Ghanem’s opinion was that epididymectomy was less drastic than orchiectomy, after exclusion of psychosomatic and physical etiologies. Dr Lopes and Dr Ira agreed with this opinion.

A vasal reversal was also suggested.

Dr John Mulhall said that this case is probably neural trauma mediated post-vasectomy pain syndrome and may also include epididymal pressure pain or a chronic pelvic pain syndrome variant. He also pointed out the need to identify if the pain is intrascrotal and if there is a psychosomatic element. He performs a series of spermatic cord blocks in a blinded fashion using bupivacaine versus saline in 3 sessions. If the pain improves with the local anesthetic injection alone, then microsurgical spermatic cord denervation is suggested. Epididymectomy could also be done, but will not give positive result if the pain is due to perivasal neuroma. Lastly, orchiectomy and spermatic cord excision could be done.

If spermatic cord injection responses are equivocal, then a pain management team should be consulted and treatment for chronic pelvic pain could be considered.

Dr Laurence Levine reported that this was a typical case of post-vasectomy pain syndrome. He reported that it is not necessarily due to a botched vasectomy. Increased pain after ejaculation maybe due to back pressure as a result of an obstructive component. He advised removal of the left testis if no pathology was found, but the pain had a 10 – 40% chance of persisting. Sensitization may occur causing the involved nerves to fire at lower thresholds with shorter refractory periods and in time could happen spontaneously, without any stimuli. If the pain responds due spermatic cord block, microdenervation at the level of the pubic tubercle should be done. In Dr Levine’s experience of over 100 cases with this procedure, 71% chance of complete and durable pain in 14 years of follow up, 18% in which pain decreased by at least 50% and 12% in which no improvement occurred. Two of his patients had testicular atrophy and the pain ceased.

GAB’s opinion was to re-do ultrasound to check for sperm granuloma, in which a vaso-vasostomy is the only solution, attempt ilio-inguinal nerve block and to exclude subclinical varicocele using duplex.

Dr Ramiro Fargas-Valdes advised oral dexamethasone 0.75 mg daily for 20 days , to be repeated for another 20 days after re-examination. If this failed injection of local anesthesia in the spermatic cord would be recommended.

Dear Colleagues:

I recently began to see a loving, sexually compatible couple in their early 40’s. When they completed having their 3rd child in 2003 they decided he should have a vasectomy. He had a “no scalpel” vasectomy performed  4 ½ years ago in a walk-in clinic, an almost literally fly-by-night clinic long since closed, by a physician he believes was a GP and most assuredly was not a urologist. He blames himself for not having sought out a urologist from the outset. During the surgery he immediately felt “the freezing didn’t work” and felt considerable pain as the physician worked on the left side of his scrotum. There had been no pain prior to that  during the surgery on the right side.

Following the surgery, the pain continued in the left testicle. Any contact was excruciating. The pain was severe enough to require 9 months of disability leave. For 2 years, this very involved father was unable to even let his children sit on his lap. He was eventually referred to an excellent urologist (with a long waiting list) and was seen by her 1 ½ years later. She acknowledged a botched vasectomy and diagnosed post-vasectomy pain syndrome. She prescribed Celebrex for 4-6 months. This seemed to help noticeably but the pain was far from gone. When he returned for follow up, Celebrex was very much in the news and she took him off this drug to see how he would fare without meds. When he attempted to return to her, she was on maternity leave and subsequently closed her practice. (I can attest to her extraordinary work.)

The next urologist, in 2007, ordered an ultrasound. Results showed no remarkable findings. He reports that even having a testicular examination is excruciating to the point where he ends up off work for 2 weeks. His family physician and the second urologist advised that he will probably never be rid of the pain. The pain is localized to “the left, bottom of the left testicle”. The pain has slowly diminished to the point where he can walk comfortably but anything that causes “jiggling” (e.g., running, playing basketball, coitus if he is on top) remain out of the question. (Coitus where she is on top is OK.) Jiggling and testicular exams also cause swelling of the entire left side of the scrotum. Given that he is (otherwise) a very healthy, athletic man, this is most distressing.

He recently requested that the left testicle be removed.

His latest (third) urologist has refused this request, agreeing that nothing can be done to alleviate the pain of a botched vasectomy but that it makes no sense to remove the testicle when there are no signs of pathology on ultrasound or palpation (except for reports of extreme pain). The patient has accepted this decision.

However, the patient never thought to mention to any of these physicians (given the focus on post-vasectomy pain) that the pain is worst after ejaculating. He attempted to go one month without ejaculating to “give it a rest” but that made the pain of ejaculating one month later much more severe. He then tried to ejaculate daily.

This too was very painful. He has figured out that he can manage the pain best by ejaculating every 2-3 days. This is still very painful but the lesser among the other evils. The ejaculate is apparently of normal colour and volume.

I have referred him back to his family physician and urologist to deal specifically with the post-ejaculatory pain. In the interim, I would welcome any insights or recommendations for this gentleman.

Thank you.

Sincerely,

Peggy J. Kleinplatz, Ph.D.

Hi all

In my opinion, your poor pt is now having a persistent post-vasectomy Orchalgia, that is severe enough to keep him off his work for long. I feel he has either congestive epididymitis or even low-grade infection at the tail of this epididymis ( bad technique). Or he has a pathology at the convoluted part of the vas ? blow-outs, cyst or else. or lastly, like a phantom syndrome if the vasal nerve was partially tied making a neuroma, which is painful on touch and movement.

After excluding any pathology, trial of Gabapentine or the newer generations, or the recently approved Cymbalta,lilley, antidepressant might be of help. or injection of an anesthetic in the cord. Orchidectomy has to be last resort.

Thank you

SHEDEED ASHOUR SHEDEED

Dear Dr. Kleinplatz

Epididymectomy would be much less radical than orchiectomy and would probably resolve the pain.  Obviously psychosomatic and physical disorders need to be excluded first.

Please update us about the progress.

Hussein

Dear Dr. Kleinplatz:

Has a vasectomy reversal been considered? This can be successful in a subset of patients with this problem and is certainly preferable to an orchiectomy.

The following reference may be of help:

J Urol. 2000 Dec;164(6):1939-42.

Vasectomy reversal for the post-vasectomy pain syndrome: a clinical and histological evaluation.

Nangia AK, Myles JL, Thomas AJ JR.

Regards,

HSN

Dear all,

I agree with Dr. hussein.

Epididymectomy would be enough to resolve this case.

Sincerely,

Eduardo Lopes, M.D.

Peggy,

If I thought that this man’s pain is not primarily psychological, I would do an epididymectomy to include all of the tissue from the proximal epididymis up to and including the vasectomy site before considering orchiectomy.

Ira

While he likelihood is that he has a neural trauma mediated post-vasectomy pain syndrome he may also have epididymal pressure pain or a variant of chronic pelvic pain syndrome (especially given the exacerbation after orgasm). The primary goal is to define whether this pain is solely mediated by intrascrotal pathology or whether there is a significant psychosomatic component.

In such patients I challenge them with a series of blinded spermatic cord blocks (bupivicaine versus saline) where the patient returns to the office on three occasions and has the administration of either 0.5% bupivicaine or saline (2 of one and one of the other) in a blinded fashion.

If the patient has clear improvement or eradication of pain with local anesthetic but no improvement with saline, I believe a presumptive diagnosis of intrascrotal pathology can be made. In this circumstance, my preference iis spermatic cord denervation. This has been very successful when performed microsurgically. When this is unacceptable or ineffective epididymectomy may be considered but this will not address the pain if it is mediated by a perivasal neuroma.

Where all else fails an orchiectomy with spermatic cord excision will almost certainly work.

In cases where the response to the course of blinded spermatic cord blocks is equivocal then one needs to be cautious about a surgical approach to management and consultation with a pain management team may be useful or the use of strategies employed for chronoic pelvic pain disorders may benefit the patient.

John Mulhall MD

This is a typical case of post-vasectomy pain syndrome which does not necessarily occur as a result of a “botched vasectomy”. In fact it can simply occur as a result of tethered nerves which are readily aggravated by any activity. The fact that the pain is worse after ejacualtion is likely due to an obstructive component resulting in back pressure within the obstructed segment (ie the prox vas and epididymis). If there is no identifiable pathology the testicle need not be removed and in fact there is a 10-40% chance that the pain will persist.

The pathophysiology of chronic pain has made interesting strides over the past several years such that it is now recognized that a process known as sensitization can occur which over time allows the involved nerves to fire at lower thresholds, at faster intervals, with shorter refractory period and in time can simply fire spontaneously without any obvious noxious stimuli. I have found that when a man presents with chronic genital/scrotal contents pain (of any etiology)that if they respond with temporary relief of pain following a spermatic cord block where 20cc of 0.5% bupivacaine is injected into the cord at the pubic tubercle level, that they are then a candidate for a microdenervation of the spermatic cord. My experience with this procedure in over 100 cases is a 71% chance of complete and durable pain with follow-up now up to 14 years, 18% had at least a 50% drop in pain and 12% had no improvement, but none were worse. Only 2 men in that series have testicular atrophy and both were free of pain. My current series is currently under review at J Urology and I have 2 previous smaller series published in J Urology. I think it is definitely worth considering in this individual.

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

Tough case.

Lots of thoughts:

1. Sperm granuloma, especially with post ejaculatory pains. Re-do ultrasound and search for this along cord. Sometimes vaso-vasostomy only way to improve.

2. Consider ilio-inguinal nerve block, does it eliminate pain.  If yes consider TENS unit or series of nerve blocks.

3. Pain with exercise consider subclinical varicocele, again a repeat sono with lying and standing views using color doppler may help.

GAB

Hello to all. 

I agree with injection of an anesthetic in the cord for this case, but before I treat him with Dexametasona oral 0.75 mg x day, for 20 days, I see him and I repeat the treatment for other 20 days. I have had very good results with this treatment in similar cases. He doesn’t improve, I would consider the Blockades (lido 1% and Bupivacaine 0.5 %),  Exceptionally I have had to make epididymecyomy.

Best Regard.

Ramiro Fragas-Valdes. MD. MSc.

Dear Colleagues,

Thank you all for your very helpful replies. The patient was seen by his family physician on Friday.Consistent with the suggestions of Dr. Shedeed and Dr. Moser, Lyrica (Pregabalin 25 mg., increasing to 75 mg. over the next 3 weeks) was prescribed by her in the interim while waiting to get an appointment for the patient with his urologist.

I will be sure to update you on the case. Again, thank you.

Sincerely,

Peggy J. Kleinplatz, Ph.D.

Hello to all. 

I agree with injection of an anesthetic in the cord for this case, but before I treat him with Dexametasona oral 0.75 mg x day, for 20 days, I see him and I repeat the treatment for other 20 days. I have had very good results with this treatment in similar cases. He doesn’t improve, I would consider the Blockades (lido 1% and Bupivacaine 0.5 %),  Exceptionally I have had to make epididymecyomy.

Best Regard.

Ramiro Fragas-Valdes. MD. MSc.

Priapism wih failed puberty and HRT (Dr. Hussein Ghanem)

A 21 years old hypogonadal male, who was started on hormone replacement therapy (HRT) for failed puberty since 2 weeks, using HCG 2500 I.U. twice weekly, presented with ischaemic priapism of 30 hours duration. Priapism developed 2 days after the fourth injection. The length of the erect penis was 7 cm from tip to pubic bone, most of which was hidden in infrapubic fat.  The patient is short, obese, looks like a 12 years old and weighs 80 Kg (176 pounds).  Aspiration revealed dark blood but fortunately the episode resolved after 90 minutes of aspiration/ irrigation. A complete blood count and haemoglobin electrophoresis were requested and the patient was advised to stop the HCG for the time being.

Laurence A Levine MD, who had personally encountered similar cases, explained that this phenomenon appeared to prove the fundamental value of testosterone (T) on erectile function; that there was a threshold below which erections don't occur. He elucidated, referring to Bud Burnett's work, that initially, there was no T to stimulate NOS. Once NOS was activated via the new circulating T, penile vasodilatation occurred but with no PDE5 around to degrade cGMP; vasodilatation persisted; priapism ensued. Laurence A Levine MD recommended a slower introduction of T so the PDE5 could “catch up”.

Dr. Shedeed Ashour elaborated on the previously proposed “slow introduction”: A smaller dose of daily Testosterone e.g. 40 mg/day T undecanoate tablets; a smaller dose of HCG i.e. 750 I.U. weekly and a regular PDE5 for preventing attacks of priapism. Dr. Shedeed advised against performing a shunt operation, in order to preserve future function and recommended adding anti-phospholipids to the investigations.

Dr. Gregory Broderick suggested using a cream or gel preparation to better modulate the level of T by keeping it at an effective yet lower level and possibly monitoring it via serum samples. He also recommended prescribing a 5mg daily dose of Cialis to prevent stuttering priapism and its potential molecular and structural damaging effects on corporal smooth muscles.

Dr. Hussein Ghanem noted that teaching the patient and his parents self injections –suggested by Dr. Broderick- using thereby available ephedrine 30 mg ampoules, saved them multiple long trips to the clinic. The episodes of prolonged erections seized a few days after stopping the HCG. A recommendation of injecting the patient for any persistent morning erection was made. The AUA Priapism Guidelines of 2003* recommends phenylephrine as “the safest agent” regarding the risks of cardiovascular side effects.

Dear Colleagues,

A 21 years old male presented (yesterday) with ischemic priapism of 30 hours duration.  He also suffers hypoganadotrophic hypogonadism and was started on Hormone Replacement therapy using HCG 2500 IU twice weekly 2 weeks ago for failed puberty.  Priapism developed 2 days after the fourth injection. The length of the erect penis is 7 cm from tip to pubic bone but is mostly hidden in the infrapubic fat.  The patient is short, obese and looks like a 12 years old, weight 80 Kg (176 pounds).

Aspiration revealed dark blood but fortunately the episode resolved after 90 ms of aspiration / irrigation.  We requested a complete blood count and Hemoglobin electrophoresis, and advised stopping the HCG for the time being.

My questions are:

·         Suggestions for further management.

·         Management if priapism recurs.  Is it safe to perform a shunt procedure on an infantile penis, if aspiration / irrigation fail? I consulted a pediatric urologist who was quite concerned and agreed to join in a shunt procedure only if absolutely necessary.

·         If we reinitiate HRT there might be a risk of recurrence of priapism, if we don’t secondary sex characters would not develop and the patient will not reach puberty.  Any suggestions about further management of the hypogonadism after the priapism problem resolves?

·         Phenyl epherine is frequently not available.  Any information about the maximum dose of ephedrine ampoules we can use safely for intracavernous injection in priapism.

  I would appreciate your comments / suggestions.

Hussein

It appears you have proven the fundamental value of testosterone on erectile function. That there is a threshold level below which erections don't occur and when you administered the HCG the previously unexposed tissue responded to generate an unopposed erectile response resulting in priapism. This may simply be a variant of Bud Burnett's work with sickle cell  or NOS-/NOS-mice where there is down regulation of PDE5 as in this case there was virtually no testosterone to stimulate NOS. Once NOS was activated with the new circulating T penile vasodilation occurred but with no PDE5 around to degrade cGMP, vasodilation persists. I have also seen this and recommend slow introduction of testosterone so the PDE5 can catch up. There may be other more creative techniques too.

Laurence A Levine MD

Prof.Ghanem H.

The super sensitivity of the unprimed tissue of the penile organ can be alleviated using very small dose of testosterone-esp if pt's height is ok and he did not receive before-and smaller dose of hcg -750iu weekly- for attacks prevention a regular PDE5 I will be beneficial. I have a similar case who responded well to this regimen. Shunt operation will not be needed in my opinion for the preservation of this young man in the future.

i recommend doing him investigation:

CBC, Hb electophoresis, and anti-phospholipids.

shedeed Ashour

I think Trinity has hit the 'nail on the head' with pulsatile release of T from HCG or depo injection of T, levels are very high.

  Using a cream or gel preparation the level of T may be better modulated (kept at an effective but lower level). You can also draw blood levels to confirm T,

and reduce the cream/gel dose.

Unfortunately I am of the belief that stuttering priapism may initiate first molecular and then subsequently structural changes in the corpus cavernosum. The latter may be irreversible corporal smooth muscle damage and forever subject the patient to episodes of priapism.

What would really be convincing in the stuttering priapism patients is NPTR before and after institution of daily PDE-5 inhibitor - we now have an approved product - Cialis 5mg.

GAB 

Thank you all very much for sharing your knowledge & expertise.  The adviceto teach the patient and parents self injections using phenyl ephedrine saved them multiple trips to Cairo (they are from Kanater, a neighboring city).  I used ephedrine 30 mg ampoules because it's available.

The patient informed me that the episodes of prolonged erections seized a few days after stopping the HCG.

The PDE-5inhibitor suggestions and starting with a low dose of testosterone are great ideas.  I don't think the patient will afford testosterone gel; it's currently quite expensive in Egypt, so I plan to start with a low dose of Testosterone undecanoate tablets.  It's not hepatotoxic and the dose can be easily controlled.  I plan to use 40 mg / day instead of the standard dose of 160 mg /day.

Best wishes,

Hussein

Weak libido with high testosterone (Annette Owens)

This is a case of a 64 year old male complaining of sudden loss of libido, accompanied by decrease in muscle mass and testicular size. The patient was on vitamins, amino acids, saw palmetto and nettle root extract to treat BPH. He was suffering of depression long before he started to complain of weak libido. His total testosterone was elevated with normal Free T, estradiol, progesterone, DHEA-S and DHT.

Dr. Teloken asked if the patient complained of snoring or apnea. From his own experience he suggested that this might be related to an abnormal serum levels of T3, T4 and TSH or due to high BMI , high serum microprolactin or depression.

Dr. Beshara  recommended stopping the extract for BPH treatment. He advised repeating the testosterone profile including a bioavailable testosterone and a referral to a sex therapist.

Dear colleagues:

Does anyone have suggestions for why this man¹s total T is elevated, his free T in the normal range, but his main complaint is total lack of libido?

This client is a 64-year-old white male complaining about sudden lack of libido over the past year. Despite many years of depression, sex always used to be an important part in his life. He still feels depressed but his loss of libido was significant and motivated him to have his blood levels of various hormones tested.

Lab values                               (referenceinterval)
His total T:       1051 ng/dL            (241-827) ELEVATED
Free T:            15.5 pg/mL            (6.6-18.1)
Dihydrotestosterone: 57 ng/dL            (30-85)
Estradiol:           30 pg/mL            (0-530)
DHEA-S:              89 ug/dL            (42-290)
Progesterone:       0.7 ng/mL            (0.3-1.2)

He takes a variety of vitamins and amino acids (incl.glycine, glutemic acid, glutamine, tyrosine, phenylalanine) as well as saw palmetto and nettle root extract to treat BPH.

His desire decreased soon after he started taking nettle root extract, but this could be a coincidence. The only relevant side effect

I could find is that saw palmetto can lower libido.

He has noted decreased testis size and reduced volume of ejaculate over the past few months and he claims to have very low muscle mass despite regular exercise.

They did not measure his SHBG, nor LH levels.

I welcome any suggestions.

Warmly,

Annette Owens, MD PhD

I´m missing comments on sleep profile: snoring, apnea.

I´ve seen patients like this under the following circunstances:

- abnormal serum levels of T3, T4 and particularly TSH or

- high BMI as well as high serum microprolactin or

- depression.

Regards

Claudio Teloken  MD  PhD

Dear Annette,

This man has definite signs and symptoms of androgen deficiency.

If he has a rare case of androgen resistance syndrome, hi SHBG would be normal and his LH elevated

If his free T is to be believed, it is relatively low for the level of total T.......so he may have an elevated SHBG.....from liver disease or anti-epileptics....even though his estradiol seems normal

He definitely has a low DHT, which seems to be the hormone that regulates prostate, and sexual functions (but not bone). He would therefore would appear to have a deficiency of 5 alpha reductase. There is no mention of him taking propecia for hair loss or proscar for the enlarged prostate. I have seen weird metabolic abnormalities from otc herbals, so although I don't know anything specific about nettle root extract, I would get an LH and SHBG, take him off the nettle root, and repeat his pattern a month later.

Andy Guay

My suggestions are

1) To evaluate drop out the extact to treat BPH if is possible

2) To repeat the hormonal testosterone dosaje including biodisponible testosterone

3) Referal the patient to the sex terapist in order to found psycological factors causing loss of libido

Best regards

Amado Bechara, MD, PhD

Peyronie with penile shortening (Dr. Eduardo Bertero)

Dr. Bertero presented a case of a 46 year old married man, having Peyronie’s disease.  His only complaint was 60% shortening. The question was whether to do nothing or to interfere with any kind of surgery such as relaxing incision and grafting.

Some experts were in favour of surgery with caution taken to try to preserve the patient’s potency.  Dr. Baldassare suggested plaque incisions and grafting  with fascia lata. Dr. Krishnamurti used successfully penile dermal flaps with similar cases. Dr. Cairolli advised for relaxing incision and crural grafting.

Dr. Martinez-Salamanca and Dr. Moncada were in favour of non invasive treatment using a penile extendor for 6 months. Dr. Rosello preferred the use of the vacuum device. From his point of view, it would be more comfortable to the patient in addition to providing adequate oxygenation to the corpora.

However Dr. Krishnamurti and Dr. Levine were against the use of the vacuum device as they saw it would not help stretching a fibrotic and calcified plaque. Dr. Krishnamurti raised the issue that the trapped blood from the vacuum is mostly venous. They saw that the vacuum use might even worsen the condition.

Dear collegues,

I have a 46 year old married man, with a history of having Peyronies Disease for 3 years.  No pain, no erectile dysfunction or deformity.  His only complain is of 60% shortening.  Today, rigid state measured 10 cm long.  He is very unpleasant and dissatisfied with this length.  During physical exam I can feel at least 3 plaques and the US confirms it Each side of corpora and on the middle .

My question: Worth doing a penile surgery as relaxing incision + graft?  Other technique? Worth doing nothing?

 Regards,

Dr. Eduardo Bertero

Difficult case.

The age of the patient is too important for a non surgical treatment.

I would perform a plaque incisions and grafting (with fascia lata) considering the opportunity of a circular grafting also. The patient must know about the possibility of prosthetic implant.

The post operative period should include sildenafil therapy associated with penile extension and vacuum device.

Regards

Dott.

Roberto Baldassarre

Dear Dr. Bertero:

It is definitely worth trying to conserve (restore) this man's natural erectile function before rushing to insert prostheses. I normally perform a penile dermal flap operation in such patients, with very good results. This can be performed both in the uncircumcised and circumcised. For operative steps (videos) and original article PDF, please go to www.PeyroniesDisease.org.

Best.

Sudhakar Krishnamurti.

Dear Eduardo, very interesting case

If the patient does have not any deformity and the mayor complaint is penile shortening another options could be penile extender for at least 6 hours a day during 3 months and see

You can measure penile lenght and girth and follow-up him for the improvement

Thanks a lot

Keep us posted

Juan I. Martinez-Salamanca

Dear Eduardo

I thing the best you can do is relaxing incision plus albuginea from crura graft.

Best regards

Dr Carlos Cairoli

Juan,

Completely agree. Do not operate this patient, may be end up with further shortening. The extender is harmless and effective if the patient is constant with the use of it.

Best regards,

Ignacio

Dear Colleagues,

I would recommend a vaccuum treatment: in my experience the use of vacuum as a therapy (not as a functional device for obtaining an erection for intercourse only) has proven good results. Apply every morning an aspiration force during 50 seconds to achieve maximum erection, hold it for 50 seconds, until feeling slight discomfort and then release for 10 seconds. Repeat exercise 20 times approx.

This will mantain the elasticity and penile elongation capacity, augmenting it through a forced aspiration by allowing the penis to fill with arterial blood provoking an oxygenation of the tissues.

Repeat routine twice a day: 20 times in the morning and 20 more in the evening. I believe this is more confortable for the patient than wearing an extensor during 6 hours a day plus you achieve an oxygenation of the corpora cavernosa. The routine should be mantained throughout at least two months.

Eduardo, let us know how this patient evolves, it will be interesting to see how he does.

Best regards,

Mariano Rossellَ, MD

Dear Dr. Rossello:

It is not clear to me how the vacuum device will help in end stage Peyronie's disease, where the plaque is fully fibrosed/ calcific. Also, to my knowledge, the blood sucked in by the vacuum device is usually venous rather than arterial, and more in the integument than in the cavernosal cylinders. Please clarify.

Thanks.

Sudhakar Krishnamurti.

Dear friend Rossello:

I do have the same Sudhakar question. In addition what´s the physiopathology of stretching fibrotic/ischaemic tissue for such period of time. Does it ameliorate or ... may be make it worse  the situation.

Thanks for your comments on this difficult subject.