Impotent Patients Research Articles

Impotence and Chronic Renal Failure: A Study of the Hemodynamic Pathophysiology

A retrospective multi-institutional study was performed to document and characterize the arterial vascular disease in the hypogastric-cavernous arterial bed and/or veno-occlusive dysfunction of the corpora cavernosa in patients with end stage renal disease. We evaluated 20 impotent patients (mean age 40 ± 9 years) with chronic renal failure using pharmaco-cavernosometry and pharmacocavernosography (4 also underwent pharmaco-arteriography). Patients were divided into groups based on the treatment (14 with renal transplantation and 6 with hemodialysis or peritoneal dialysis), as well as by history of vascular risk factors (16 with and 4 without risk factors). Of the patients 19 revealed abnormal intracavernous pressure responses to repeated intracavernous injections of vasoactive agents implying vascular disease of the penis. Cavernous artery occlusive disease was found in 78% of the patients. All patients who underwent arteriography had diffuse atherosclerotic disease of the distal penile arteries. Corporeal veno-occlusive dysfunction was found in 90% of the patients, of whom 60% had diffuse pan-cavernous leakage involving the dorsal, cavernous and crural veins, glans penis and corpus spongiosum. This renal failure-associated vascular disease of the penis was found to occur independently of the presence of known systemic atherosclerotic vascular risk factors. Patients who underwent early treatment of the uremia by renal transplantation had vasculogenic impotence only in the case of rejection of the renal transplant, suggesting that early renal transplantation may delay or prevent the development of the penile vasculopathy. The most likely pathophysiology of the vascular impairment includes renal failure-associated atherosclerosis, and renal failure-associated hypoxia changes of the contractile (smooth muscle) and structural (collagen/elastin) components of the erectile tissue. Strategies for future research and clinical therapies are suggested.

Mentor alpha 1 inflatable penile prosthesis: Patient satisfaction and device reliability

Objective. This report describes a study of patient satisfaction and device reliability in 50 organically impotent males who were implanted with a Mentor Alpha 1 inflatable penile prosthesis. Method. Data were obtained from review of medical records, and patient-completed structured questionnaires. Results. The average patient age was fifty-nine years (range: 25 to 90 years). Thirty-one patients (62%) had underlying medical conditions, and all tried at least one other treatment prior to implantation. All patients received perioperative prophylactic antibiotics, and all were drained with a closed suction drain for twenty-four hours. Follow-up ranged from two to forty-one months (av. 15 mos). Complications occurred in 2 patients (4%), including 1 periprosthetic infection and 1 intraoperative cylinder aneurysm. An average of one office visit was required for teaching inflation/deflation. Ninety-eight percent of the patients and 96 percent of their partners were satisfied with the device. Ninety-four percent and 96 percent thought the device was easy to inflate and deflate, respectively. Two patients (4%) reported partial cylinder inflation related to physical activity. All were satisfied with the girth and rigidity, but only 92 percent were satisfied with the length. Ninety-eight percent said they would undergo the procedure again and would recommend this implant to other impotent patients. Conclusions. These data indicate that the Mentor Alpha 1 device has good short-term mechanical reliability, and yields a high level of patient and partner satisfaction.

Il penogramma radioisotopico dinamico con nitroglicerina sublinguale nella diagnostica non invasiva dell'impotenza

Nuclear medicine techniques may be used to test vasculogenic impotence. Dynamic radioisotope penogram with 0.3 mg sublingual nitroglycerin was performed in 50 impotent patients. The penogram index (Ip) and the time required to reach peak activity (Tp) was calculated. Ip was useful to differentiate vasculogenic and psychogenic impotence. The radioisotope penogram is a simple, less invasive and valuable screening test in the identification of vasculogenic impotence.

Microstructural Disorders of Tunica albuginea in Patients Affected by Impotence

The role played by the tunica albuginea in the erection mechanism seems to be very significant in promoting the constriction of sub-albugineal venous reticulum and trans-albugineal effluent veins, as well as providing an inextensible protective structure to the arteriolae and to the intracavernous nerves. The passive function exerted by the tunica albuginea is a result of its structure, which is rich in collagenic fibers, linked by elastic fiber bridges. The presence of structural disorders in the tunica albuginea of 16 patients suffering from psychogenic, arteriogenic and venogenic impotence is evaluated. The results obtained show a significant decrease in elastic fibers in the tunica albuginea of impotent patients compared to a control group of 5 patients with normal erection activity. This structural disorder could result in tunica albuginea alteration and, therefore, in erection insufficiency.

Comparison of Thymoxamine Permeation between Hairless Rat and Horse Penile Mucous Membrane Using an in vitro Diffusion Model

Moxisylyte (or thymoxamine) administered intracavernously is known to improve erection in organically impotent patients. Prior to drug administration by percutaneous route, we have to define its in vitro permeation parameters after application of thymoxamine on both rat skin and horse penile mucous membrane. 24 h after drug application, the percentages of thymoxamine which diffused through the penile mucous and the rat skin were 88 and 75%, respectively. Thymoxamine flux varied according to the biological membrane tested. With regard to the penile mucous membrane, a maximal flux (1,774 nmol.h-1.cm-2) was observed 2.5 h after drug application, whereas for the rat skin a maximal flux (657 nmol.h-1.cm-2) was noted at 3.5 h. Thymoxamine flux decreased rapidly in the penile mucous membrane. This decrease was slower when thymoxamine penetrated the rat skin; the difference could be due to a different morphology of the tested biological membranes. In contrast to the rat skin, the external keratinized layer was absent in the penile mucous membrane. In conclusion, the ability of thymoxamine to penetrate easily and rapidly the biological membrane, and particularly the penile mucous membrane, suggests that thymoxamine could reach the pharmacological target represented by the corpus cavernosum of the penis.

Significance of Full Nocturnal Erections with Short Duration

The aim of the study was to clarify the pathophysiologic significance of full but short-lived nocturnal erections observed in some impotent men. Penile circulation was assessed by color Doppler sonography and pharmacocavernosometry in 35 impotent patients who underwent polysomnographic recording of nocturnal erections. In each case, there were at least 3 erectile episodes with a complete rigidity (always > 700 g) but with a short duration (mean duration of the maximum level of full erection = 4 min; always < 6 min). All patients demonstrated a normal arterial inflow with mean +/- SEM right and left cavernosal peak flow velocities of 39.5 +/- 1.8 and 41.3 +/- 1.5 cm/s, respectively. Pharmacocavernosometry detected a dysfunction of the cavernous veno-occlusive mechanism (mean +/- SEM maintenance flow: 45 +/- 8 ml/min and mean +/- SEM corporal pressure decay over 30 s: 82.5 +/- 9 mm Hg) in 18 patients (51%). In these patients, this finding may be a possible explanation for the short duration of nocturnal erectile episodes. In the remaining 17 patients (49%) with normal penile vascular status, a dysfunction of the adrenergic system could play a role in the pathophysiology of this picture. Full but short-lived nocturnal erections, as assessed by polysomnographic recording, are indicative of a normal arterial status and should encourage further assessment of the corporal veno-occlusive mechanism.

Computerized Measurement of Penile Elastic Fibres in Potent and Impotent Men

Intracavernous elastic fibres may play a role in human erectile tissue compliance and elasticity. Using computerized image analysis we have measured objectively the percentage of elastic fibres in corpus cavernosum tissues in both potent and impotent men. Twenty-two penile biopsies were performed in 5 potent and 17 impotent patients due to vascular disease. The mean percentage of elastic fibres was 9% in normal patients. In 12 patients with venous leakage a significant decrease in the amount of elastic fibres of 5.1% was observed and in 5 patients with arterial disease it was 4.3%. No correlation between the reduction of the elastic fibre quantification and age was observed. Change in elastic fibre content may alter the relaxation properties of cavernosal tissue and play a role in the development of erectile dysfunction.

Intracavernous Vasoactive Pharmacotherapy: The Impact of a New Self-Injection Device

The clinical effects of a new self-injection pen were investigated in 160 impotent patients undergoing intracavernous vasoactive pharmacotherapy. Of the patients previously using insulin syringes for self-injection 90% switched to the pen, since it was considered easier to use and several injections could be performed with the same drug cartridge, thus avoiding the preparation necessary before every single injection with the syringe. Dropout rates were 36% and 12% for patients using the syringe and the pen, respectively (p < 0.05). This self-injection pen can be used for any drug, either singly or in combination with others. It is well accepted by patients, and greatly increases acceptance of and satisfaction with intracavernous pharmacotherapy.

Poststroke Impotence in China

Poststroke impotence patients are encountered frequently in clinical practice, but the literature and research about them are limited in our country. This paper presents a preliminary investigation of the sexual functioning of 82 poststroke survivors.

Ultrastructural features of penile tissue in impotent men.

Penile erection is related to the integrity of penile tissue. In order to study the ultrastructural histopathological changes in penile erectile tissue in impotent men, biopsies were taken from 29 impotent and 5 normal patients during surgical treatment. Light microscopy revealed insignificant histological changes and various degrees of fibrotic change in the corpora cavernosa of impotent men, and electron microscopy revealed severe myopathic, fibrotic changes in the penile tissue. These non-specific changes could not be used to determine the aetiology of impotence, and the relationship between the ultrastructural appearances, the causes of impotence and the results of treatment was unclear. Further studies are required to establish the value of intracorporeal biopsy in selecting treatment for impotent patients.

Dynamic echography of the penis in the follow-up of impotent patients treated with intracavernous injections.

Dynamic echography of the penis (DEP) after pharmacological stimulation of erection has been designed to evaluate the albugineal wall thickness (AWT), the cavernosal appearance in the normal penis and corporeal changes in patients treated with intracavernous injections presenting with haematomata, hyperechoic images, prolonged erection and Peyronie's disease. DEP was performed in 973 patients who had had an average number of 89 (+/- 16) intracavernous injections for 16.7 +/- 11.7 months. A total of 1424 DEP examinations were performed. Transducer positioning, erectile condition, clinical recording and computer retrieval methods were adapted to gather ultrasonography data. The standard average AWTs recorded in patients free from Peyronie's disease and who were untreated were 0.11 cm at the septum, 0.17 and 0.15 cm at the dorsal root and the tip of the albuginea respectively, 0.14 cm ventrally and the diameter of the corpus cavernosum averaged 1.61 cm. Intracavernous therapy brought an increase in AWT of 15.38% to the septum, 11.76% and 10.53% to the dorsal tip and root respectively and 12.5% ventrally. Frequent haematomata induced greater increase, while prolonged erections did not. Patients with untreated Peyronie's disease were found to have greater AWT which decreased after treatment with intracavernosal injections. Before treatment abnormal penile hyperechoic images were found in 3.18% (intracavernous images) and 3.31% (albugineal nodules) of DEP, and in 7.09% and 7.54% respectively post-treatment.

Morphodynamic assessment of penile circulation in impotent patients: the role of duplex and color Doppler sonography.

Duplex and color Doppler sonography were used to assess the vascular status of 240 impotent patients. The tests were performed before and after intracorporal injection of a standard dose of a vasoactive mixture and measurements were done both at the crura and at the midshaft of the penis. Particular care was taken in the evaluation of cavernosal arteries diameter, wall pulsatility, morphology of spectral waveform, blood flow acceleration, systolic and diastolic flow velocity and flow volume. Resistance and pulsatility indexes of the cavernosal arteries were also measured. Flow along the deep dorsal vein was quantified when possible. Cavernosal artery peak systolic flow velocity, flow volume and acceleration were the best indicators of arterial penile circulation. Persistently elevated (> 10 cm/s) diastolic flow in the cavernosal arteries positively correlated with a diagnosis of venogenic impotence obtained by dynamic infusion cavernosometry--cavernosography in almost 80% of cases. Duplex and color Doppler sonography permit to thoroughly evaluate cavernosal arteries function and seem to have a promising role in the study of the veno-occlusive mechanism of the corpora cavernosa.

Electromyography of Cavernous Smooth Muscle during Flaccidity: Evaluation of Technique and Normal Values

Objective evaluation of the penile innervation in impotent patients is mostly restricted to examination of the somatic pudendal pathways. These tests provide little information on the pelvic-cavernous autonomic innervation of the corporeal bodies. Electromyography of the flaccid penile smooth muscle is a reproducible and non-invasive method of evaluating these autonomic pathways and the status of intrinsic smooth muscle. Examination techniques and normal values have been studied in 15 young and potent volunteers. Recordings in 13 patients with neuropathology and 57 impotent patients are discussed.

Simultaneous Inflatable Penile Prosthesis Insertion and Corporoplasty for Septal Chordee Attributed to Peyronieʼs Disease

Impotent patients with Peyronie's disease who qualify for penile prosthesis surgery may pose a reconstructive challenge that can best be resolved at the time of exploration. Restrictive plaques, especially septal chordee, that persist after prosthesis insertion deserve resection. The surgical technique, pathophysiology, and management of postoperative edema facilitated by percutaneous access to the Resipump are described.

Duplex Doppler Scanning with Prostaglandin E1 in the Diagnosis of Cavernovenous Leakage

The aim of this study was to find out the normal response of the duplex Doppler (DD) parameter resistance index (RI) during a high dose prostaglandin E1 (40 micrograms) induced erection and to evaluate the clinical usefulness of DD scanning in the diagnosis of cavernovenous leakage (CVL). The results of DD scanning and cavernometry were compared in 10 potent control subjects and 82 impotent patients RI was > or = 1 in all control subjects later than 10 min after the intracavernous injection and RI at 20 min after the injection (RI20) was chosen as a clinical parameter. An inverse correlation (r = -0.69, p < 0.001) between RI20 and the maintenance flow (MF) at 150 mm Hg (MF150) was demonstrated. Sensitivity and specificity of RI20 (values < 1 indicating CVL) as a test of CVL (MF150 > 18 ml/min) were 89% and 86%, respectively. In conclusion, the measurement of RI20 in DD scanning after an adequate pharmaco-stimulation is a reliable, noninvasive method in the diagnosis of CVL.

Drug-Induced Male Sexual Dysfunction

Impotence, defined as the consistent inability to maintain an erect penis of sufficient rigidity for sexual intercourse, has been estimated to affect 10 million American men. An age dependence has been shown to exist, with 25% of men over age 65 affected. A large body of clinical experience and published reports in the literature link many commonly prescribed drugs with sexual dysfunction. Drugs can affect sexual function at a variety of points such as inhibition of ejaculation or sedation/depression leading to reduced libido. Antihypertensive drugs have been most commonly associated with impotence. There have been reports of sexual dysfunction with almost all classes of antipsychotics, but little clinical investigation has been performed. Other drugs associated with sexual dysfunction include digoxin, clofibrate, cimetidine and various hormonal agents and antineoplastics. An important first step in approaching all impotent patients is the taking of a detailed medical, surgical, sexual and drug/substance abuse history. The least invasive form of therapy should be employed. Recent studies have shown intracavernous injections of alprostadil (prostaglandin E1) to be safe and effective for long term use. Vacuum constriction devices may also be of help. Better and more durable prostheses are now available should other treatment be unsuccessful.

Intracavernous Pharmacotherapy for Impotence: Selection of Appropriate Agent and Dose

We performed a retrospective analysis of 101 impotent patients using intracavernous self-injections as primary therapy for vasculogenic impotence. A total of 70 patients used an average of 5.58μg. prostaglandin E1 (95% confidence interval 4.83 to 6.34μg.) as a single agent, and 31 injected 0.40ml. (95% confidence interval 0.342 to 0.457ml.) of a combination of papaverine (12mg./ml.), phentolamine (1mg./ml.) and prostaglandin E1 (9μg./ml.). We describe the procedure to establish the dosage for home use and discuss the implications of the low dosages relative to previous reports.

Efficiency and Side Effects of Intracavernous Injections of Moxisylyte in Impotent Patients: A Dose-Finding Study Versus Placebo

We assessed the efficiency and tolerance of the «-blocking agent moxisylyte in 2 double-blind studies versus placebo performed in 12 neurogenic patients with spinal cord lesions and in 61 patients presenting with either psychogenic impotence (30) or erectile dysfunction that was predominantly neither psychogenic, hormonal nor neurogenic (31). In each etiological group patients were randomized (according to latin square method) to receive 3 single doses (10, 20 and 30mg.) of moxisylyte and a placebo. The erectile response was determined 5, 10, 15, 20 and 30 minutes after each injection. Whatever etiology of impotence and dosage tested, the erectile response induced by moxisylyte was significantly higher than the placebo-induced response. No difference occurred among the 3 doses. In 93% of the patients moxisylyte induced an erectile response, including tumescence in 6, partial rigidity in 16 and complete rigidity in 46. Thus, in 62 of 73 patients (85%) the drug allowed initiation of erection adequate for intercourse. Placebo induced such erection in only 25% of the cases and in 55% there was no response. Tolerance was good and no priapism occurred. Only 4 patients (5%) reported mild pain during injection but erections were never painful, 1 presented with moderate and transient hypotension at the 20mg. dose and a painless prolonged erection was observed in 1 case after the lowest dose. Drugs such as moxisylyte should be given before less well tolerated drugs.

Corporeal blood gas changes according to duration of drug-induced prolonged erection.

The corporeal blood gas changes in accordance with the duration of the prolonged erection which developed after intracorporeal pharmacotherapy with papaverine and phentolamine were investigated in 62 impotence patients. The picture of the corporeal blood taken from 15 psychogenic impotence patients (a control group) at 10 minutes after intracavernous injection when they showed full erections was arterial but there was pCO2 rise and pH drop compared to femoral artery blood taken simultaneously. As the erection lasted longer, significant gas changes of the cavernous blood began to appear (p < 0.0001): increase in pCO2 and decrease in pO2 from 4 hours, decrease in pH from 5 hours, decrease in O2 saturation from 6 hours. Erections lasting for more than 16 hours showed significantly worse hypoxia (p < 0.05). Therefore, to prevent hypoxia and metabolic acidosis, drug-induced prolonged erection would be better decompressed before it lasts for more than 4 hours.

Velocity and Flow Volume Gradients along the Cavernosal Artery: A Duplex and Color Doppler Sonography Study

Duplex and color Doppler sonography were used to assess 130 impotent patients and 8 potent controls. Cavernosal artery diameter, peak flow velocity and volume flow rate were evaluated at the level of the crura of the corpora cavernosa and 1 cm proximal to the corona penis. Potent controls and nonarteriogenic impotent patients showed a 20% reduction in hemodynamic parameters at the periphery of the cavernosal arterial tree. In patients with occlusive disease, involving either the upper arterial tree or the entire course of the cavernosal artery, the gradient was maintained. In patients with selective occlusive disease of the distal segment of the cavernosal artery the hemodynamic gradient almost doubled. Hemodynamic gradients can be identified along the cavernosal artery and provide additional information to arteriographic data for the selection of candidates for penile vascular reconstructive surgery.