Digest of recent discussions on ISSM mail (May 2009 - Aug 2009)

III

PIERRE ASSALIAN

Rare Impotence...Help!                                                                                 

                                                                                                              21 May 2009: 9 messages

1

This is an email I received from a patient. I have not seen him. It is rather long; hope you can give me an idea.

Pierre Assalian (pierreassalian@3WEB.NET)

 “Hi: I have a strange case of impotence no urologist has heard of. Please, I need someone’s help ! When I get an erection, at the base of my penis it gets very hard, VERY, like it’s going to blow. But it cuts like a ring and the rest of the penis is soft but long as if the blood is going in but there’s no pressure. Also, the pelvic floor gets really hard, like there’s a back flow. When I did the penile Doppler, the hard lump or mass didn’t show up. So the urologists are puzzled. They say everything seems to be normal. So I thought that the best way to see it would be to stimulate myself and then perform an ultrasound on the penis. The radiologist told me it’s not circulatory, it is a muscle contraction ! She had never seen this before. So I used magnesium orally and topical, with oil..no steady results! My ACTH is 14.8 – high: My Testosterone is 9.7  - low: Aldosterone standing is 413 – normal: PSA is normal: Prolactin – high normal. I feel tired all the time, sometimes experience heart palpitation, and hot flashes many times a day (early male menopause?). My sperm count is low with low viability. I feel less masculine and also old. The penile mass like a ring at base of penis is hard and the organ is like a flask, but they say `No Peyronie’s’. I have no erection in my sleep. Only this hard mass at the base of my penis. The trouble is that sometimes I get a perfect erection with no hard mass at the base, but that is rare. Now most of the time the problem is there. But it’s not psychological because in the night in my sleep most of the time it does the same thing and also in the morning. Why? And I wake up with this hard mass at the base, the root of the penis again ! I don’t understand. I'm a lost cause. I've seen 7 urologists, done a penile Doppler, and they say everything is ok, circulation of blood is good ?!  It’s been like this for 3 1/2 years now. No HIV, no syphilis, hepatitis or diabetes. My blood pressure and sugars are normal too. There’s no Peyronie’s or fibrosis anywhere. Not even in the pancreas, liver! I had an operation for a varicocele about 15 years ago. The bulb of the penis is exactly where the hard mass comes, only on stimulation. There’s nothing on palpation at rest. Please help. All the urologists I’ve seen here don’t have a clue. I've tried acupuncture, medicinal plants, TCM and Tibetan medicine, osteopathy, massage therapy....Should I go to a sleep clinic for erection monitoring and sleep apnea? Can hypnosis help??? Do you know a specialist for this type of problem, a hypnotist?

Thanks for anything you can throw my way , a reference or a phone number. I'll go anywhere. I need to see the best specialist, because the urologists here are very knowledgeable but...

I express my full gratitude for your time.

Sxxxxx.”

2

Over quite a few years now, I have been treating impotent men (non responders to PDE5-I, e.g. post RP) with intracavernosal injections. Each patient is given a test dose injection as part of the assessment. Occasionally one will see a deformity:hourglass, bend, even similar to the one described in your e-mail. The interesting thing is that occasionally there is nothing to palpate clinically prior to the test injection, or on subsequent assessment. I call this condition `Non-palpable Peyronie’s’ and I think that is what your man has.

                                                                               Mensclinic (Contact@MENSCLINIC.NET)

3

Indeed this is an interesting phenomenon. I’d like to propose a hypothesis for the above scenario.

As S has never got the penile erection and the lump at the base of the penis together, I suggest that there is an either/or situation. Also, as he only gets this lump upon stimulation, this lump indeed is related to the sexual response. Therefore, considering the two above statements, the most probable site of this reversibility should be at the level of the blood supply. The only way to test this hypothesis is by visualizing the blood supply to this area by an arterio-venogram.

                                                                     Shavindra Dias (shavindra17@YAHOO.CO.UK)

4

It is probably Peyronie’s associated with a psychogenic ED that explains this. It might be interesting to perform a high frequency echography of the `ring’ in order to have the diagnosis.

                                                                                Patrice CUDICIO (tabacar@MAC.COM)

5

I would agree that a dynamic MRI with intracavernosal PGE1 and contrast will help delineate any areas of fibrosis, AVM, or 'muscular' abnormality that may not be apparent on Doppler. It is somewhat puzzling that he sometimes has `a perfect erection’: therefore, before proceeding much further, Nocturnal Penile Tumescence testing would be instructive. It would also be interesting to know of his age, any history of trauma, and his response to the PGE1, but if he has true distal flaccidity secondary to Peyronie’s that does not respond to PDE5-I or injections, then the prognosis is not that great, and he may end up requiring an inflatable prosthesis,

                                                                               Rowland Rees (rowlandrees@AIM.COM)

6

I agree with your opinion and your suggestion. I too saw a few cases with the same problem. Sonography showed hyperechoic lesions inside the corpora cavernosa.

Giovanni Colpi (gmcolpi@YAHOO.COM)

7

Dear all, I think that this case needs to be summarized, re-encapsulated before giving any further suggestions: This might be a mere hour-glass deformity. But is that getting worse by any additional factors ? A DICC and an MRI would be great. No sleep testing will be needed because the Rigiscan will give dissociative recordings between base and tip.

  Shedeed Asahour Shedeed (shedeedash@YAHOO.COM)

8

I recommend DICC. According to the Giessen Group, the best way to diagnose plaques is palpation rather than ultrasonography or MRI. I treat cases like yours with propionyl L-carnitine 500 mg, pentoxyfyllin 400 mg, and PABA, as recommended by evidence-based medicine. The following are also recommended but I haven’t tried them:

 Khaled M Othman (khaledbenothman@YAHOO.COM)

9

The initial history is described with such anxiety, I wonder if there is a psychogenic input to the way things are descriptively reconstructed and recited to us by the patient. Need photos to understand this condition. It is unlikely that so many urologists who have evaluated this gentleman could all have missed the same pathology.

Alan Sadah (uro95@YAHOO.COM)