Digest of recent discussions on ISSM mail (May 2008 - Aug 2008)

In this digest we had 5 cases, 2 on orgasmic disorders, one on iatrogenic sexual dysfunction, one on penile skin lesion and the fifth discussing experts opinion on special cases performing penile implants

• Sexual Dysfunction following GnRH injection ( Dr. Mohamed Moaz)
• Fordyce spots (Dr.Rafael R. Badalyan)
• Penile prosthesis and chronic medical diseases (Dr. Ramiro Fragas)
• Orgasmic disorder after surgery for aortic aneurysm (Dr. Yoram Vardi & Dr. Ilan Gruenwald)
• Orgasmic disorder and TURP (Dr. Eduardo Bertero)  

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

Sexual Dysfunction following GnRH injection ( Dr. Mohamed Moaz)

This is a case of an azoospermic patient complaining of weak libido and ED following taking a GnRH analogue gonapeptyle 3.7 injection by a mistake as a treatment for his infertility problem.

His LH and testosterone serum levels dropped sharply post injection. He was given one IM sustanon injection 250mg. Dr. Mohamed asked about the prognosis of such a patient and when will be the best time to perform a TESE procedure for his original infertility complaint.

Dr. Buvat mentioned that Gonapeptyl is indeed a GnRH agonist that induces transient but profound hypogonadotropic hypogonadism. The patient’s sexual desire is expected to increase 2 – 3 weeks following the Sustanon injection provided it is not prolonged by the psychological stress of his taking a wrong injection. On the other hand continuing testosterone esters injections is going to prolong the hypogonadotropic hypogonadism due to the negative feed-back effect of testosterone on the hypothalamic centers. At least 3 months, may be necessary after the last sustanon injection before some spermatogenesis starts again. Dr. Buvat thought it would be better for the patient to start again chorionic gonadotropin injections (5000 international units twice a week), that will make stimulate testosterone secretion in physiological amounts without the risk of inhibiting the hypothalamic gonadotropic centers, associated from now with hMG at the same dosage as in any hypogonadotropic hypogonadism. In that case spermatogenesis should have resumed within 4 months, and testicular biopsy might be done after this period of time.

Detailed discussion

Primary infertility, repeated semen analysis revealed (Azoospermia). Clinical examination showed normal secondary sexual characters, local examination revealed moderated sized testicles. History of two Testicular Biopsy operations were done, last one at 1999 showed no sperm with spermatogenic arrest histopathology. History of Medical Treatment was taken (HMG/HCG) for 8 months followed by TESE (revealed few motile & immotile sperm in L1, L2) at Amman , Jordan . Two ICSI trials were negative. he attended our Clinic on 24/12/07, normal hormonal profile (FSH, LH, Testosterone) with Azoospermia in semen analysis. He was advised to repeat medical treatment program (HMG/HCG) for 3-6 months to be followed by TESE with microsurgical testicular biopsy with ELB lab technique . he recieved once wrong injection( given by mistake from pharmacy) in the form of (GnRh analoge , gonapeptyle 3.7 ) , he started to feel desire and sexual dysfunction after which he sent his laboratory results done 17/05/08 at , which showed: FSH: 3.7 (2-10) mIU/ml, LH: 0.00 mIU/ml (2-12), Prolactin: 4.04 ng/ml (3.2-19.6), total Testosterone: 0.16 ng/ml (1.9-11.3) , androgen therapy foolowed by HMG / HCG was advised for 3-6 months, he started to recieve one sustanone 250im but after 10 days he didnt feel any change in desire or sex. is there is any further advice for hem , when expected safely to do new biopsy for hem, and when expected to have normal sex

Dr .Mohamad Moaz

Dear Dr Moaz and El Meliegy,

Gonapeptyl is indeed a GnRH agonist that induces transient but profound hypogonadotropic hypogonadism. It is therefore normal that 2 to 3 weeks after such an injection the testosterone level of your patient is extremely low, what may result in severely reduced sexual desire. His sexual desire is probably going to increase following the Sustanon injection but such an effect of testosterone therapy requires more than 10 days. At least 2 weeks, often 3 or more. On condition that the negative impact of testosterone deficiency on his sexual desire is not prolonged by that of the psychological stress or even depression resulting from his understanding that something wrong was done with respect to his fertility.

On the other hand continuing testosterone esters injections is going to prolong the hypogonadotropic hypogonadism due to the negative feed-back effect of testosterone on the hypothalamic centers. At least 3 months, and probably more, may be necessary after the last sustanon injection before some spermatogenesis starts again. It would be better for the patient to start again chorionic gonadotropin injections (5000 international units twice a week), that will make him producing again testosterone in physiological amounts without risk of inhibiting the hypothalamic gonadotropic centers, associated from now with hMG at the same dosage as in any hypogonadotropic hypogonadism. In that case spermatogenesis should have resumed within 4 months, and testicular biopsy might be done after this period of time. In this way the negative impact of the Gonadopeptyl injection on Leydig and spermatogenetic cells would be by-passed. Lastly the negative impact of the Gonapeptyl injection would have disappeared after 4 months. A dose of 3 to 4 mg of triptoreline (gonapeptyl) completely inhibits the gonadotropic centers for 4 weeks, but then a partial inhibition may persist for 4 more weeks.

Jacques Buvat MD

Fordyce spots (Dr.Rafael R. Badalyan)

This is a case of a patient complaining of pain and discomfort in the glans penis, especially during sexual intercourse. In addition he observed the presence of red spots (Fordyce spots) on the scrotum and glans after taking treatment for hepatitis C infection.

Dr. Ashour diagnosed the case as Fordyce spots, which should not be painful. The pain might be neuralgic with advice of giving gabapentine. Spots need no treatment unless they are bleeding, hence can be cauterized.

Dr. McMahon mentioned that these spots on the glans penis are essentially the same as Fordyce spots but are called Tyson glands. They are small ectopic sebaceous glands which usually occur in middle-aged sebaceous hyperplasia. They are a natural occurrence and do not denote any disease. Best managed by reassurance.

Detailed discussion

Dear Colleagues,

I would like to ask your opinion for this case.

The patients is complaining on some pain and discomfort in the glans of penis, specially while sexual intercourse.

Also he is observing some red spots on the scrotum and glans, which in evaluation look like Fordyce spots (please see the attached photos).

As he is noting, it appeared after treatment for hepatitis C 2 years ago (with pegasis).
Now he started to note such small papules on other parts of the skin and it is very much alarming him.

What can I suggest to this guy for these papules and for the pain? Has it anything to do with his diseases?

Thank you for your time and advice in advance.

Sincerely,

Rafael R. Badalyan, MD, PhD

Dear all
This nice case is not uncommon, multiple Angikeratomata of the scrotum that has only the complication of sponteneous or traumatic induced bleeding that terrifies the pt. and treated with cautery. It appears that it increased after the development of the liver disease.-high venous pressure.

The glans Fordyce spots as appeared in the photo is very obvious only with the firm squeeze or compression. The pain assocciates is mostely neuralgic due to the fact that the pt noticed somthing strange on the precious organ. As any fordyce spots any where in the body like the lips is non-symptomatic. pls assure the pt and Gabapentine will be agood option to use for his coital induced discomfort.

Shedeed Ashour

Strictly speaking Fordyce spots were first described on the shaft of the penis. These spots on the glans penis are essentially the same but are called Tyson glands. They are small ectopic sebaceous glands which usually occur in middle-aged sebaceous hyperplasia. They are a natural occurrence and do not denote any disease. They are best managed by reassurance.

Chris G McMahon

Penile prosthesis and chronic medical diseases (Dr. Ramiro Fragas)

Dr. Fargas asked about colleagues experience with prosthetic surgery for chronic renal failure and spinal cord patients.
Dr Boiko had an experience of implanting a semi rigid device for a 28 years old, quadriplegic patient with good results.
Dr. Sydney advised proper sterilization of urine for spinal cord patients. Dr. Ashour used 1-1.5 cm smaller size when implanting a semi rigid device for a spinal cord patient. Dr. Gomez used only inflatable implants for spinal cord patients for fear of perforation.

Detailed discussion

Dear colleagues,

I need them to help with two topics:

Do you experience of Prosthetic Surgery in patient with Chronic Renal disease?. Approaches of Selection.

Do you experience of Prosthetic Surgery in patient with Spinal Lesions?. Approaches of Selection.

An affectionate greeting. Dr. Ramiro Fragas - Valdes.

Dear Ramiro Fragas,

I had a patient 28 years old with tetra pares who has been struck by electric current of 24 000 volt. We implanted to him semirigid prosthesis with a good result.
Best regards,

Mykolay Boiko MD, Prof. Andrologist, Sexopathologist

Ramiro:

I hope everything is nice with you.
I have done some implants in both group of patients. The only extra-care is to sterilize the urine of patients with spinal cord lesions before the procedure.

Sidney

Dear Ramiro
Its tricky, when it comes to sizing in patients with spinal cord injury; esp if you are implanting a semi rigid. A good care has to be applied measuring a 1-1.5 cm less than the original measurment or the perforation will be likely to occur. Sterilization and the irrigation has to be reinforced for these patients... post op longer Antibiotics and sterilization of urins is important esp if they are frequent catheter users or using a condom catheter.

Thanks

Shedeed Ashour Shedeed

Hello Ramiro:

We have some extensive experience in spinal cords.
Like Sidney says, these guys are chronically colonized so it is imperative to have sterile urine at the time of surgery. The other point is that they have impaired sensation and have a high erosion index with simirigid rods. We only use inflatable prosthesis in spinal cord patients.

Best regards,

Reynaldo Gómez

Dear friends thank you for their interesting comments.

I could see the integral management that Rey Gomez makes in spinal cord patients in the Worker's Hospital in Santiago. I congratulate you for the organization of the Meeting of Uro - Oncology of the SIU in November of the 2008 in Chile, many of us can Surely see each other in this important event.

Congratulations also for Sidney for your new number of the Arquivos

H.Ellis.

Orgasmic disorder after surgery for aortic aneurysm (Dr. Yoram Vardi & Dr. Ilan Gruenwald)

This is case of a 51 years old male who complained of anorgasmia with normal erectile function following a major surgery for a repair of an aortic aneurysm. In response to a question by Dr. Bonierbale, Dr. Yoram added that the patient does not feel any stroke enjoyment, yet his desire and mood are unaffected.
Dr. Bou Jaoude had an experience with a similar case. His patient symptoms improved partially on perineal physiotherapy, sex therapy and IM testosterone for the associated hypogonadism.
Dr. Bronner saw that even if there is no psychogenic background detected, the tension caused by the loss of some sexual sensations may deteriorate the man’s self esteem and confidence and may create marital tension and hence a good sexual counselling which aims to conserve some intimate activity would seem helpful.

Detailed discussion

I would like to share a case I had a few days ago and would appreciate the ISSM's members' opinion.

A 51 year old male, happily married, that has a normal erectile response and function but does not have any sensation of orgasm or sexual satisfaction. This patient underwent an urgent, complicated major operation – repair of a huge ruptured aortic aneurism, ending up with an implanted aortic sleeve of 10 cm length. His medical background –s/p CABG, s/p PTCA and Ischemic heart disease, he is on daily aspirin, simovil, dimitone and losec. Until the operation he had normal sexual activity and normal erectile function. Today, 8 months after the procedure he still has normal erectile function yet he lacks any sense of orgasm or satisfaction and has no pleasurable sensation when ejaculating. He senses the ejaculation and is aware of its occurrence (retrograde) yet apart from that he does not feel any sexual enjoyment or sense of relief or unloading. This phenomenon appeared immediately after the operation from his first sexual attempt. He came to the office with his wife who is very understanding and supportive and willing to cooperate in whatever is necessary in order to help him recover from this condition and to help him with his frustration. I do not suspect ant psychogenic origin, and I am quite certain that this is a neurological damage due to the traumatic surgical procedure

I would appreciate any comments or suggestions for therapy.

Ilan Gruenwald,

Dear Yoram

Can you say us if, outside of ejaculation, he is reserving stroke enjoyment, and desire?

Did his mood changed?

Thank you for these precisions

Mireille BONIERBALE, MD, HP

Thanks for your interest
This patient does not feel any stroke enjoyment but fortunately it does not affect any change in mood or desire

Regards

Yoram

Dear doctor Vardi

I had a patient presenting the same sexual symptoms after an abdominal aorta surgery.

After a period of erectile dysfunction (and 4 or 5 weeks of IPDE5 treatment) , he have normal erections, but lost the sensation of pleasure during ejaculation.

I agree with you about the neurological origin of this orgasmic dysfunction but without neglecting psycho-sexologic aspects which deteriorate symptoms.

My patient came to my office 8 months after his surgery and he was partially but significantly improved in few month by a multidisciplinary care:

• perineal physiotherapy
• sexological therapy : to lurn to be concentrate on new sensations (or remaining sensations!) rather than to focus on the lack of sensations that he knew and also to not to neglect the other sources of pleasure during the sexual intercourse...
• he had an hypogonadism which was treated by IM Testosterone

It is difficult to me to say which care play the biggest role in this partial improvement : the natural evolution (recovring of neurapraxia )?, the sex-therapy ?, psychological accompaniment ?, tesosterone ? …

This improvement was partial but sufficient to my patient and I hope it will be the case of your patient !

Best regards

Dr Gilbert Bou Jaoudé

Dear Prof. Vardi and Dr. Gruenwald,

I agree with the attitude of Dr. Gilbert Bou Jaoudé. I mean that even if there is no psychogenic background at diagnosis point, the tension caused by the loss of some sexual sensations may deteriorate the man's self esteem and confidence and may create marital tension. A good sexual counselling which aims to conserve some intimate activity, during the period needed for further diagnosis or medical treatment is essential to keep a good quality of sexual life.

The couple can find also alternative intimate & erotic activites ( temporary or permanent). The man can also find that he is capabale to remain a good sexual partner, even if some changes have occurred.

best regards

Gila Bronner

Orgasmic disorder and TURP (Dr. Eduardo Bertero)

This is a case of a 57 year old patient who after performing a TURP suffered from TURP syndrome. This was followed by a complaint of anorgasmia with preserved erectile function.
Dr. Wylie thought the complaint might be related to expansion and stretching of the posterior capsule and so the plexus of the prostate (initially by the tumour then by inflammation).
Dr. Castellani inquired about the weight of the resected prostate and the duration between the procedure and the complaint.
Dr. Fargas, Dr. Farsi and Dr. Sergej believed the complaint to be of psychogenic origin.
On the other hand Dr. Porst and Dr. Richter saw that an organic etiology was the cause, relying on the theory that the prostate is an orgasmic organ. In addition in this particular case the occurance of the TURP syndrome proves that the procedure was complicated with presumably perforation of the prostate capsule in addition to fluid inflow in the venous system.

Detailed discussion

Dear collegues,

I have a 57 year old patient who was submitted to a TURP (transurethral resection of the prostate) 18 months ago. The procedure was followed by a rare complication: TURP syndrome requiring hospitalization for more than 2 weeks.

This patient looked for our clinic complaining of “not feeling the sensation of orgasm” during intercourse. He says that knows when he ejaculates by a “sign” but not orgasm. He does not suffer erectile dysfunction. He has no comorbidities.

As he links the appearance of sexual symptoms with the surgery and there was this complication (TURP syndrome) my question is:

There could be a neurological injury related to this disorder? Is there something to do?

Dr. Eduardo Bertero

Some of the problem may be related to expansion and stretching of the posterior capsule and so the plexus of the prostate (initially by the tumour then by inflammation) but I acknowledge that this remains a serious area of debate.

Only this afternoon a patient was asking me about this very matter. In his case he had no knowledge of Ej – only his partner noticed he had ejaculated.

Kindest regards

Kevan.

Greetings to all.

Dear Eduardo I have some cases with ED post TURP(transurethral resection of the prostate) for neurological lesion, but in this case, this conserved the erection, the dysfunction of the Orgasm should be psychological

I believe that the help of a Sexologist, Specialist of Mental Health is fundamental.

Fraternally.

Dr. Ramiro Fragas.

Hi every one,

It is very unlikely that this proplem was due to TURP or the subsequent complications that occured. The most likely cause is psychogenic. Counsiling might help.

Regards,

Prof Hasan farsi

Dear all,

I am not quite sure if we can consider the orgasmic problems of this guy as psychogenic/psychological.

1stly I am wondering that he can feel ejaculation by a "sign". Usually guys with a TURP do not have any antegrade but retrograde ejaculation. Is that the case with this guy?

2ndly we should bear in mind that the prostate is an "orgasmic" organ and that the "untouched"(preserved) prostate can considerably intensify the orgasmic feelings and orgasmic pleasure in men . Having said that there is no question that the prostate can individually contribute in the range from little to very much to the orgasmic feelings of a man.This knowledge, that the prostate is an organ which, if adequately stimulated during sexual activities, can intensify man's orgasm is widely used in all these TANTRA lessons especially in India and Africa and those who have experienced well performed TANTRA lessons know what I am speaking about.

Perhaps our members from India and Africa can comment on this subject.

Unfortunately to my knowledge we do not have any objective and reliable data on to what extent surgical procedures on the prostate either because of BPH or PCA can influence orgasm in men,i.e. orgasm's intensity and feelings because we have only focused our clinical research on erectile function.

From my many patients after RRP I know quite well that RRP may have a great negative impact on their orgasmic feelings, not in everybody but in many. Unfortunately at present we do not have any validated tools/questionnaires to explore that issue but we should focus our clinical research efforts in this regard.

Because this guy has had TURP with subsequent TURP-syndrome it is proven that although the procedure was performed "only" on BPH it was a serious procedure with presumably perforation of the prostate capsule in addition to fluid inflow in the venous system.

To conclude my guess is that behind this Guy's complaints is an considerable organic component.

Regards

Prof.Dr.Hartmut Porst

I am concordant with Professors opinion

Dr. Bogolyubov Sergej

How long has been lasting the TURP ? How many grams where resected?

Renato Castellani

Dear Eduardo,

TURP syndrome usually develops after a very intense "scarification" of the Prostate gland, including capsule perforation. That means that it is most probable there has been a neurological damage. I suppose the "ejaculation sign" is a sign only. After deep TURP it is most probable that there is no ejaculate at all. Unfortunately, I do not think that the condition will normalize after 18 months.

I would suggest to talk to the patient, to explain to him that this is a rare although known complication. After a normal uncomplicated TURP there is anejaculation (retrograde ..) in many cases. Reassure him that it is very good that he kept his erectile function. I do not think there is an indication for PDE5i therapy.

Good luck and please report on follow up.

Santiago Richter, M.D.