Digest of recent discussions on ISSM mail (Sept 2009 - Dec 2009)

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IRWIN GOLDSTEIN

Post-Injection Pain & Induration

December 2, 2009: 20 Messages

1

Please, I need your help.  I have a 40 year old male who had excellent erections and some lifelong premature ejaculation - IELT 1-2 minutes - who responded to a radio advertisement by the Boston Medical Group which stated that they had a treatment better than Viagra that could allow men to have erections lasting 30-60 minutes.  This patient was of course taught self-injection therapy.  On his one and only self-injection, he experienced a 4 hour erection.  Subsequent to this one prolonged erection, he now complains of new onset significant pain in the penis during any sexually induced erection (whether nocturnal erection, masturbation erection or intercourse erection).  The pain is very distracting and lasts for hours after the erection ends.   On his exam in the office, his distal third of the penile shaft is definitely indurated.  He did not have any tenderness or evidence of Peyronie’s disease/plaques on flaccid examination.  He had an ultrasound in the flaccid state but this was not really conclusive.  The big problem now is the new onset pain during erection that wakes him up from sleep and now prevents him from sexual activity.  I have placed him on anti-inflammatory and anti-histamine agents.  He cannot tolerate pentoxifylline.  

Irwin Goldstein (dr.irwingoldstein@gmail.com)

2

Anti-inflammatory medication is worth trying. Tincture of time is needed. Perhaps during ultrasound in flaccid state you could have induced erection and seen exactly where the pain is ? Any point tenderness? Is the flow shunted ? At his relatively young age, does he have any predisposing cause for ED ? Is he mentally stable ?

Johnny Roy (docroy@aol.com)

3

I know it  might be seen as causing more discomfort but using a VCD daily often works post-trauma as a gentle way of improving the vascularity; and him being able to control the 'sore penis'; much like vulval massage is often helpful to the women with vulval pain.

                                                                                               Ruth Hallam-Jones (ruth.hallam-jones@virgin.net)

4

If it is a neurogenic pain, carbamazepine 300 mg, 3 times daily, will work.

Mario Maggi (m.maggi@dfc.unifi.it)

5

How long ago was his ICI event with near-priapism? I've seen many patients who are former Boston Medical Group patients and they have a proprietary formula that I believe includes bimix and one other substance that I can't remember. I suspect he has some diffuse corporal fibrosis/induration from the ICI and near-priapism event. We see this frequently and offer the same as you have. If this is in the early inflammatory phase (first 3-6 months) then we have suggested Vit E 400 IU qid for first 3-6 months after injury. I know the studies but anecdotally Vit E seems to help only these types of patients during this time frame. I suspect that as this matures, the pain will become less but can take a long time. The only worry is that the distal fibrosis may develop into decreased distal rigidity, decreased length/girth, buckling, hour-glassing and potentially, a curvature (less common). These patients are some of the most difficult to treat because the pain can be prolonged, it is not possible to prophylactically treat their pain, and they have sufficient erectile function; surgical intervention can only worsen it.  I have never sent these patients to interventional pain management for blocks because it seems to me to be a chemical/mechanical event that is only precipitated by an erection. Something to consider if this is incapacitating and daily NSAIDs/tramadol/SSRI/Neurontin or Lyrica are unhelpful. I have no experience with using SSRI/Neurontin or Lyrica for this type of pain pattern. 

We would follow them every 3 months. Hope this is helpful. By the way, the Boston Medical Group had a judgement of $ 9 million against them in September 2009 for ICI complications resulting in priapism.

Todd James Doran  (todd.j.doran@vanderbilt.edu)

6

I have not seen such a case, but it would most likely be inflammatory in etiology with a possible neuropathic component. My thoughts would be to try a course of steroids, rather high in dosage, and consider the adjunctive use of Neurontin and/or Elavil. Admittedly, this is not a very `scientific’ approach, but there are no negative aspects to this treatment.

Larry Lipshultz (larryl@bcm.tmc.edu)

7

I would try pregabalin (Lyrica) 100 mg to start and increase prn.  We've had success with this in men with genital pain in the CP/CPPS collaborative group.  Publication currently in press.

Michael O'Leary  (moleary1@partners.org)

8

I would treat him as a neuropathy case with neurontin 300 mg tid and increase the dose if he tolerates it. You can also use Cymbalta (60 mg qid) which is indicated in patients with diabetic neuropathy. In addition, Cymbalta is an SSRI which may also improve his PE.

Ricardo Munarriz (munarriz@bu.edu)

9

It is certainly possible that this represents the early inflammatory phase of Peyronie’s disease, in spite of there being no palpable plaque. It may also represent an inflammatory response to the injected drugs resulting in the local induration and pain.  At this point conservative management is in order and I agree that a course of an anti-inflammatory agent such as celebrex 200 mg qid for 7-10 days and a Medrol dose pack may help cool the fire. In time further evaluation is in order. I would not use any mechanical stretching at this time including VED or traction devices as this may exacerbate his pain. A good question is, `What is his mental state?’. He may benefit from some early sex therapy intervention if he appears to be becoming overly distressed by this event.

Laurence Levine (drlevine@hotmail.com)

10

I think that this patient must have a painful fibrosis secondary to intra-cavernous drugs. I would try colchicine at least for 2-3 months with doses between 1.8 - 2.4 mg daily.

Luis Alfredo Wadskier Bocaranda (lwadskier@gmail.com)

11

Please note that cymbalta is an SNRI rather than an SSRI.

Toby Shepherd (toby.shephard@boehringer-ingelheim.com)

12

Cymbalta is NOT an SSRI, hence it will have no effect on PE, but Gabapentin would.

Pierre Assalian (pierreassalian@3web.net)

13

It may be possible that the connective tissue of the shaft got overstretched and that there is perhaps even some injury to the terminal branch of the pudendal nerve. If you work with a physiotherapist who treats men, he or she can use myofascial release techniques, or even modalities such as iontophoresis or laser. It may not hurt to release some pelvic floor trigger points as well.

Talli Y. Rosenbaum  (tallir@netvision.net.il)

14

I agree with Dr. Levine that this is more suggestive of an inflammatory process and am doubtful that this is neuropathic or typical CPPS so gabapentin or lyrica may not be helpful. Certainly an SSRI or topical agent can treat his PE and if it modulates his erection penile pain then that’s an added bonus. I also agree that stretching or VED will definitely work against your desired goal to decrease penile pain. Time will tell if this is corporal fibrosis or a continuum of Peyronie’s disease. I have yet to see a patient presenting this way to develop into the CPPS that we all see.

 Todd James Doran  (todd.j.doran@vanderbilt.edu)

15

The pronounced induration and unremarkable plain ultrasound study are interesting. Was flaccid-state color flow Doppler done, to exclude an arterial fistula, induced possibly by poor injection technique?

Maurice Garcia  (MGarcia@urology.ucsf.edu)

16

There's something odd about this case.  As our neurology colleagues like to say, "Where is the lesion?" and I have to wonder whether in this case the lesion is between the ears. It is noteworthy that the trouble started with his very first self-injection. For many men this is a psychologically challenging event, and this was coupled with an erection that lasted up to the period of time (4 hr) when he was certainly counseled that damage might occur.   Even if he used his own saliva instead of alcohol to prep the injection site, it is unlikely he could have created enough inflammation to cause pain with every erection.  Once a man believes he has injured his penis, he may find a variety of everyday symptoms that will appear to support his belief.  I would withhold all medical therapy other than anti-inflammatory meds, provide reassurance that the discomfort will likely resolve with time, and re-evaluate in 3 months.

Abraham Morgentaler  (amorgent@yahoo.com)

17

Congratulations Abe for your subtle clinical sense!

Jacques Buvat (jacques@buvat.org)

18

I personally think that his priapism may have lasted for more than 4 hours and that this prolonged priapism might have caused this distal fibrosis (partial thrombosis?). Time will hopefully be his best friend. Meanwhile use anti-inflammatory drugs.

Eric Vrijhof (eric.vrijhof@home.nl)

19

Seems THE answer, or at least the most fitting one!!

Michèle Lachowsky (lachowsky@orange.fr)

20

I think it could be an inflammatory process without penile deformity which can develop into Peyronie’s disease after some months; with pain recovery. In this phase I suggest Colchicine 1 mg x 2/day for 3-4 months.  

Tiziano Scalvini  (tiscalvini@tin.it)