Neurogenic Impotence Research Articles

Measurement of electrochemical conductance of penile skin using Sudoscan®: A new tool to assess neurogenic impotence

To investigate the value of electrochemical skin conductance (ESC) measurement at penile level using Sudoscan® for the diagnosis of neurogenic impotence in diabetics. The following neurophysiological parameters were assessed in 25 male diabetics who complained of impotence and 25 age-matched normal male subjects without erectile dysfunction (age range: 29-70 years): ESC, sympathetic skin responses (SSR), warm detection thresholds (WDT), and cold detection thresholds (CDT) for the penis and the feet, vibration detection thresholds (VDT) for the penis, and sensory nerve conduction study of the dorsal nerve of the penis (DNP) with sensory nerve action potential (SNAP) recording. Diabetic patients with impotence differed from controls with regard to most neurophysiological results at both penile and foot levels. Among penile innervation variables in the group of impotent diabetics, penile ESC was found to be the most frequently abnormal (80% of patients), followed by penile WDT, CDT, and DNP-SNAP amplitude (52% of patients), and then penile SSR amplitude and VDT (44% of patients). Various combinations of abnormalities were observed: penile ESC was the only abnormal test in 2 patients, while all tests were abnormal in 2 patients and remained normal in only one patient. Erectile dysfunction is common in diabetic men, but the diagnosis of a neurogenic origin is challenging. This study showed that ESC measurement using Sudoscan® is feasible and more sensitive than SSR recordings to show penile sympathetic innervation impairment. This new test should be further studied to better define its diagnostic accuracy and clinical correlates.

2017 PENILE AUTONOMIC INNERVATION: CORPUS CAVERNOSUM ELECTROMYOGRAPHY REVISITED

You have accessJournal of UrologyInfertility: Physiology, Pathophysiology, Basic Research1 Apr 20112017 PENILE AUTONOMIC INNERVATION: CORPUS CAVERNOSUM ELECTROMYOGRAPHY REVISITED Laura Leddy, Xiaogang Jiang, and Claire Yang Laura LeddyLaura Leddy Seattle, WA More articles by this author , Xiaogang JiangXiaogang Jiang Seattle, WA More articles by this author , and Claire YangClaire Yang Seattle, WA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.2245AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Electrophysiological measurement of penile autonomic nervous system electrical activity has proven difficult. Corpus cavernosum (CC) electromyography (EMG) was first described in 1989, as a method to measure penile autonomic (sympathetic) innervation. However, interest in the technique waned, in part due to concerns about the origin of the recorded signal. We revisited this technique as a possible tool for the evaluation of neurogenic impotence, which is often a diagnosis of exclusion. Our hypothesis was that the recorded spontaneous and evoked CC potentials derived from the tissue of the corpus cavernosum and not the penile skin. METHODS We recruited healthy male volunteers with normal erectile function confirmed by the International Index of Erectile Function (IIEF). A Porti electrodiagnostic system (TMS International, The Netherlands) connected to a portable computer recorded low-frequency CC-EMG signals via penile surface electrodes during 3 phases: (1) Baseline CC-EMG was recorded for 30 minutes. (2) A penile ring block was performed by injecting subdermally 20cc of 1% lidocaine, followed by 30 minutes of CC-EMG recording. (3) An intracavernosal block using 2cc of 1% lidocaine was injected into the left corporal body, followed by CC-EMG recording for 30 minutes. Alternating startling stimuli, via auditory and median nerve stimulation, were used to evoke penile autonomic signals at random time points during the 3 phases. A suprapubic electrode was used as a control to record sympathetic electrodermal activity. RESULTS Eight healthy male volunteers, ages 19–54 (mean 36) participated. All subjects demonstrated spontaneous and evoked CC-EMG complexes during Phase 1. Evoked CC complexes were preceded by a sharp spike in the penile and suprapubic electrodes. In Phase 2 all subjects had spontaneous and evoked CC complexes. The sharp spike was maintained in the suprapubic electrode but not in the penile electrodes, indicating the skin block eliminated the penile electrodermal response. In Phase 3 no spontaneous or evoked CC complexes or penile electrodermal activity were apparent in any subject, indicating the intracavernosal block eliminated the corporal-generated signal. The suprapubic electrode continued to demonstrate a sharp spike in response to evoking stimuli in all study subjects. CONCLUSIONS This study uses a penile skin block and intracavernosal block to confirm the cavernosal tissue as the source of CC-EMG. Further refinement of this technique may render it useful in the evaluation of neurogenic impotence. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e806-e807 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Laura Leddy Seattle, WA More articles by this author Xiaogang Jiang Seattle, WA More articles by this author Claire Yang Seattle, WA More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Cystometry and mictometry as tools in diagnosing neurogenic impotence.

Thirty-six males with erective impotence underwent neurological and urological examinations. Six of the patients were known to have a neurological disorder at the time of referral (four multiple sclerosis, one myelomeningocele, one diabetic polyneuropathy). Four further cases of neurological disorders were found (one multiple sclerosis, one myelopathy of unknown cause, one Shy-Drager syndrome, one sequelae of sacral herpes zoster). Five of these 10 patients gave a history of urinary troubles, but in all of them objective signs of bladder dysfunction were found at cystometry and/or mictometry. Among the 26 patients with impotence and no indication of a neurological disorder all invariably had normal cystometrograms, though some had abnormal mictiograms, probably due to local urological disorders. A neurological examination should be included in the evaluation of patients with erective impotence. Cystometry and mictometry may be of value by giving additional indications that the impotence is neurogenic. This is explained by the fact that the anatomical structures regulating sexual function lie close to corresponding structures regulating bladder function at the spinal level.

Internal fixation of traumatic diastasis of pubic symphysis: is plate removal essential?

Internal fixation of the traumatic diastasis of symphysis pubis is an integral part of the definitive management of pelvic ring injuries. Both functional outcome and long term physiological effects of plate retention have not been clearly addressed and no specific indications regarding implant removal have been proposed in the literature. We reviewed 74 patients (18 females and 56 males), with an average age of 40.6 (16-75) years, who underwent open reduction and internal fixation (ORIF) of the pubic symphysis. Except from the demographic data many other parameters like suprapubic pain, sexual disturbance, impotence and dyspareunia were taken under consideration. Furthermore, any correlation between implant failure and functional impairment was recorded and the subject of implant removal in pregnant women was examined. Health outcome was assessed according to EuroQol 5-D (EQ-5D) questionnaire. Mean follow up: 41.7 (28-89) months. Suprapubic pain was present in ten patients. Three men developed neurogenic impotence and one woman had deep dyspareunia. None of these symptoms were related to implant status. Three of the four females who had uncomplicated pregnancy in the post-stabilization period had the plate in situ. Implant failure was seen in four patients but they remained asymptomatic. EQ-5D questionnaire revealed high satisfaction scores among young women and men of all age groups. This study supports the view that routine removal of the plate is not essential. The issue of whether the implant needs to be removed in women of childbearing age requires further investigation.

Sexual Function in Chronic Kidney Disease

Endocrine abnormalities are common in patients with chronic kidney disease (CKD) and lead to sexual dysfunction, anemia, hyperparathyroidism, and altered mineral metabolism. Common clinical problems include disturbances in menstruation in women, erectile dysfunction in men, and decreased libido and infertility in both sexes. Organic factors tend to be prominent and are related to uremia and other comorbid illnesses. Psychological factors and depression may exacerbate the primary problem. Alterations in the hypothalamic-pituitary axis are seen early in CKD and tend to worsen after patients start dialysis. Hypogonadism plays a dominant role in male sexual function, whereas changes in hypothalamic-pituitary function predominate in female sexual dysfunction. In patients on dialysis, treatment strategies include optimizing dose of dialysis, correction of anemia with erythropoietin, and correction of hyperparathyroidism. Successful kidney transplantation may restore normal sexual function, especially in younger patients.

Introduction

A multidisciplinary international course on Male Erectile and Sexual Dysfunction, organized on behalf of the Educational Committee of the European Academy of Andrology, convened in Rome at the end of 2004. The goal of the meeting was increased interactions among peers leading to discussion of the latest pathophysiological and clinical efforts specifically related to male sexual function and dysfunction. All podium presenters were invited to submit manuscript to the official journal of the Academy, the International Journal of Andrology. The Editor-in-Chief, Prof. Jorma Toppari asked us to serve as Associate Editors of this Supplement, following the rules and the peer-review process of the Journal's tradition. As can seen from the size and the content of this IJA supplement, there was an overwhelming response to our invitation. In the past few years, from the marketing of the first efficacious oral treatments for erectile dysfunction, thousand of scientific articles, books, textbooks, monographies have been published on the field of male sexual medicine, which is definitively an important, if not that with the greater growth's impetus, of Andrology. However, because of this scientific ‘overgrowth’, it seems necessary to point out with timely and authoritative scholarly review articles a so complex matter. In fact, the development of male medical sexology in many medical, such as endocrinology, psychiatry, internal medicine, and surgical specialties, such as urology, calls for closer integration. Andrology, with the help of basic science, born as a multidisciplinary discipline to overcome the separation between specializations and subspecializations, which deprives patients of a holistic approach to their sexual difficulties. We hope that by providing an expanded base of literature, this Supplement will stimulate more sexological culture, further research efforts, new data to support innovative diagnostic procedures and treatment options for men with sexual medical concerns. Male sexual function and dysfunction are here dissected and up-to-date review articles describe the neuroendocrine regulation of male libido, flow charts for diagnosing premature ejaculation and vascular, endocrine, and neurogenic impotence. A particular emphasis has been used in the therapy section, giving to the reader a practical approach to the use of short-acting type-5 phosphodiesterase inhibitors, of the new long-acting as well as psychotherapy. We owe special thanks to Prof. Toppari, to the Editorial Assistant of the IJA, Ms Leena Karlsson, and to Educational Committee of the EAA for their kind offer, as well as their encouragement and support for this important scientific project. Furthermore, we are in debt with Lilly Italia and to the manager Dr Concetto Vasta for the generous and unrestricted grant which made possible this publication. We also would like to personally thank the Authors for their hard work to submit their manuscripts in a timely fashion. Sir Francis Bacon wrote in his De dignitate et augmentis scientiarum (Advancement and Proficiency of Learning) that ‘Scientia et potentia humana in idem coincidunt’, a notable sentence that can be freely translated as ‘Science and (sexual) human potency exactly coincide’. And this is our arrivederci to the reader of this IJA’ Supplement on Male Erectile and Sexual Dysfunction.

The additive erectile recovery effect of brain‐derived neurotrophic factor combined with vascular endothelial growth factor in a rat model of neurogenic impotence

To test the hypothesis that combined intracavernosal injection with vascular endothelial growth factor (VEGF) with adeno-associated virus-mediated brain-derived neurotrophic factor (AAV-BDNF) synergistically facilitates the neural regeneration and erectile function after cavernosal nerve injury. Forty Sprague-Dawley male rats were randomly divided into five equal groups: eight had a sham operation while 32 had bilateral cavernosal nerve freezing followed by an immediate intracavernosal injection with either phosphate-buffered saline (PBS), VEGF, AAV-BDNF, or AAV-BDNF + VEGF. Erectile function was assessed by cavernosal nerve electrostimulation at 3 months, and samples of the major pelvic ganglia and penile tissue were evaluated histologically. In this animal model of impotence from nerve injury, the recovery of erectile function was greatest in those receiving AAV-BDNF + VEGF; the mean (sd) maximal intracavernosal pressure in this group was 87.2 (20.78) cmH2O, compared with 37.3 (11.39) for VEGF alone and 49.8 (29.58) for AAV-BDNF alone. No erectile dysfunction was identified in the sham group, with a pressure of 100.7 (22.70) cmH2O, while all treatment groups significantly outperformed the PBS (control) group, at 29.3 (13.52) cmH2O. Furthermore, all animals receiving monotherapy or combined treatment had more NADPH-diaphorase-positive nerve fibres than controls but less than in the sham group. Bilateral cavernosal nerve freezing causes erectile dysfunction with accompanying neurological changes. Intracavernosal injection with either VEGF or AAV-BDNF alone enhances nerve regeneration, with combined therapy (VEGF and AAV-BDNF) promoting neural and erectile recovery additively.

Erectile dysfunction after fracture of the pelvis

Male sexual dysfunction after fracture of the pelvis is more common than previously supposed with rates as high as 30% reported when the complaint is specifically sought. With the increase in survival from major injuries, the long-term consequences of trauma are being seen with increasing frequency

The effect of neural embryonic stem cell therapy in a rat model of cavernosal nerve injury.

To isolate embryonic stem cells that have differentiated along the neuronal cell line, and to assess whether injecting these neural stem cells into the corpus cavernosum influences cavernosal nerve regeneration and functional status. Embryonic neural stem cells were obtained; 26 male Sprague-Dawley rats were divided into four groups: five had a sham operation; eight (controls) had a bilateral cavernosal nerve crush and injection of culture medium into the corpora cavernosa; four had an injection of neural embryonic stem (NES) cells into the major pelvic ganglion (MPG); and nine had bilateral cavernosal nerve crush and injection of NES cells into the corpora cavernosa. Erectile response was assessed by cavernosal nerve electrostimulation at 3 months, and penile tissue samples were evaluated histochemically for nitric oxide synthase (NOS)-containing fibres, tyrosine hydroxylase and neurofilament staining. The groups injected with NES cells into the MPG and corpora cavernosa had significantly higher intracavernosal pressures than the control group. Immunohistochemical staining also revealed differences in the quality of the NOS-containing nerve fibres. Neurofilament staining was significantly better in the experimental groups injected with NES cells. We were able to isolate embryonic stem cells that had differentiated along the neural cell line and, using these NES cells intracavernosally, showed improved erectile function in a rat model of neurogenic impotence.

Effect of insulin-like growth factor-1 and insulin-like growth factor binding protein-3 complex in cavernous nerve cryoablation.

The purpose of this work was to study the effect of insulin-like growth factor 1 (IGF-1) and its binding protein (IGFBP-3) on the recovery of erectile function in a rat model for neurogenic impotence. In all, 28 male Sprague-Dawley rats were divided into four groups: seven underwent a sham operation; seven underwent bilateral cavernous nerve freezing (control group); seven underwent bilateral cavernous nerve freezing followed by intraperitoneal injection of IGF-1; and seven underwent bilateral cavernous nerve freezing followed by intraperitoneal injection of IGFBP-3. Erectile response was assessed by cavernous nerve electrostimulation at 3 months, and samples of penile tissue were evaluated histochemically for nitric oxide synthase (NOS)-containing fibers. In the sham and IGF-1 group, there were significantly higher maximal intracavernous pressures compared to the IGFBP-3 complex and the control group. Correspondingly in the cavernosum, there were significantly more NOS-containing nerve fibers in the sham and IGF-1 groups. In conclusion, administration of IGF-1 can facilitate the regeneration of NOS-containing nerve fibers in penile tissue and enhance the recovery of erectile function after bilateral cavernous nerve cryoablation. The reverse effect was noted with the IGFBP-3 complex injection.

Long-Term Survival of Autotransplanted Major Pelvic Ganglion in the Corpus Cavernosum of Adult Rats

Neurogenic impotence is a common complication after radical pelvic surgery, irradiation or perineal trauma. Neuronal transplantation is a new frontier for treating neurological disorders. We investigated whether the major pelvic ganglion can survive and become functional after being implanted into the corpus cavernosum in adult rats. Adult male rats (13) were divided into 3 groups and sacrificed at 3 time points, namely 30 (4), 60 (5) and 90 (4) days. All rats underwent excision of the right major pelvic ganglion and left cavernous nerve. The right ganglion was implanted into the right crus of the penis. Electrostimulation was applied to the left major pelvic ganglion and cavernous nerve (1.5 mA.) and right crus (10 mA.) at sacrifice. The crural region and left ganglion were then excised for immunostaining of neuronal nitric oxide synthase (nNOS), protein gene product 9.5 and growth associated protein 43. Image analysis was used to calculate the area stained in pixels. Electron microscopy of the implanted area was performed to assess neuronal survival. Although the degree varied, all neuronal implants survived after transplantation. The response to electrostimulation was insufficient to produce erection. No difference was noted among the areas of nNOS staining when specimens from the 3 time points were compared. The area of expression of nNOS, protein gene product 9.5 and growth associated protein 43 was larger in the implanted area than in the surrounding cavernous tissue. Under electron microscopy most surviving implants showed normal ultrastructure, although areas of fibrotic replacement were seen in several implants. Our results show that the autotransplanted major pelvic ganglion expresses nNOS, protein gene product 9.5 and growth associated protein 43, and survived up to 90 days after implantation into the corpus cavernosum. Further studies with fetal neuronal tissue seem warranted.

LONG-TERM EFFICACY OF SILDENAFIL AND TACHYPHYLAXIS EFFECT

Purpose: We observed that patients who initially responded to sildenafil frequently became resistant to it with time. We evaluated the long-term efficacy of sildenafil.Materials and Methods: A telephone survey was conducted of patients during the first year of sildenafil usage, and another one was completed 2 years later of the same group.Results: During the first survey, the etiology of impotence included post radical prostatectomy in 25, arterial insufficiency in 26, diabetes in 19, neurogenic impotence in 12, suspected venous leak in 9, proved venous leak in 7, Peyronie’s disease in 6 and unspecified in 47 patients. The overall improvement rate, which was defined as the ability to initiate and maintain erections for successful intercourse, was 74%. The dose necessary to achieve this response was 100 mg. sildenafil in 15% of patients, 50 mg. in 83% and 25 mg. in 2%. During the second survey, information was collected on 82 patients and only 43 (52%) had continued treatment. Of the 69 patients who report...

LONG-TERM EFFICACY OF SILDENAFIL AND TACHYPHYLAXIS EFFECT

We observed that patients who initially responded to sildenafil frequently became resistant to it with time. We evaluated the long-term efficacy of sildenafil. A telephone survey was conducted of patients during the first year of sildenafil usage, and another one was completed 2 years later of the same group. During the first survey, the etiology of impotence included post radical prostatectomy in 25, arterial insufficiency in 26, diabetes in 19, neurogenic impotence in 12, suspected venous leak in 9, proved venous leak in 7, Peyronie's disease in 6 and unspecified in 47 patients. The overall improvement rate, which was defined as the ability to initiate and maintain erections for successful intercourse, was 74%. The dose necessary to achieve this response was 100 mg. sildenafil in 15% of patients, 50 mg. in 83% and 25 mg. in 2%. During the second survey, information was collected on 82 patients and only 43 (52%) had continued treatment. Of the 69 patients who reported an initial good response 41 (59%) were still using sildenafil, and of the 43 who were still using it 16 (37%) had to increase the dose by 50 mg. to achieve an adequate result. There was no significant relationship between the need to increase the dose and frequency of treatment per month. Reduction in efficacy ranged from 15% to 50% (mean 36 +/- 12%) and the time to loss of efficacy ranged from 1 to 18 months (mean 11 +/- 5). Of the 82 patients in the second surgery, 39 (48%) stopped using sildenafil. A total of 28 (74%) patients reported a good initial response on the first survey, and 6 had spontaneous erections and no longer needed treatment. However, 14 (50%) patients discontinued sildenafil because of the loss of efficacy. In this group 10 patients had side effects, mainly headache and flushing of the face and nose, and only 2 discontinued treatment because of them. Our data suggest that there is a possible tachyphylaxis effect with sildenafil. Of the patients who were followed for 2 years 20% had to increase the sildenafil dose to have the same effect and 17% discontinued use due to loss of efficacy.

The effect of adeno-associated virus mediated brain derived neurotrophic factor in an animal model of neurogenic impotence.

We tested the hypothesis that transfecting penile tissue with brain derived neurotrophic factor may facilitate neural recovery and erectile capability after cavernous nerve injury. Of the 34 Sprague-Dawley rats used 10 underwent sham operation and 24 underwent bilateral cavernous nerve freezing and intracavernous injection of adeno-associated virus-LacZ (12) or adeno-associated virus-brain derived neurotrophic factor (12). Erectile function was assessed by cavernous nerve electrostimulation at 4 and 8 weeks, and samples of penile tissue and the major pelvic ganglia were evaluated histologically. In the brain derived neurotrophic factor group mean maximal intracavernous pressure plus or minus standard deviation was significantly higher than in the LacZ group at 4 and 8 weeks (58.5 +/- 11.7 cm. water versus 28.4 +/- 5.5 and 61.3 +/- 12.5 versus 37.7 +/- 7.9, respectively). In addition, in the brain derived neurotrophic factor group reduced nicotinamide adenine dinucleotide phosphate diaphorase staining and neuronal nitric oxide synthase immunostaining revealed significantly more positive nerve fibers in the dorsal nerves and cavernous tissue than in the LacZ group at each time point and the percent of neuronal nitric oxide synthase positive neurons in the major pelvic ganglia was also significantly greater. Moreover, in the LacZ group most neurons showed a light staining pattern with irregular contours and numerous vacuoles in the cytoplasm. Intracavernous injection of adeno-associated virus-brain derived neurotrophic factor may prevent the degeneration of neuronal nitric oxide synthase containing neurons in the major pelvic ganglia and facilitate the regeneration of neuronal nitric oxide synthase containing nerve fibers in penile tissue, thus, enhancing the recovery of erectile function after bilateral cavernous nerve injury.

Relationship between penile thermal sensory threshold measurement and electrophysiologic tests to assess neurogenic impotence

Objectives. Erectile function is usually assessed by neurophysiologic tests such as the bulbocavernosus reflex or pudendal nerve somatosensory evoked potentials. These tests investigate only large nerve fibers, although erection depends on autonomic nerve fibers, which are of small diameter. Warm and cold sensory fibers have similar calibers as the autonomic nerve fibers, and their integrity can be reliably evaluated by the measurement of thermal sensory thresholds. We studied penile thermal sensory testing in parallel with standard electrophysiologic tests to assess their sensitivity in the diagnosis of penile neuropathy. Methods. Twenty-five normal male subjects without erectile dysfunction or evidence of diffuse neuropathy (group 1) and 35 diabetic patients who complained of impotence (group 2) were studied. Erectile function was quantitated using the erectile dysfunction symptom score. Warm, cold, and vibratory sensory thresholds were assessed on the dorsal aspect of the penis. In addition, penile sympathetic skin responses and pudendal nerve somatosensory evoked potentials were recorded. Results. We found a significant difference between the two groups in the erectile dysfunction symptom score ( P <0.0001), cold threshold ( P = 0.0007), and warm threshold ( P = 0.0025), but not for the other parameters. The erectile dysfunction symptom score correlated with the penile warm and cold thresholds ( P = 0.0006 and 0.002, respectively). Conclusions. Thermal thresholds assess small nerve fiber damage, which can indirectly reflect autonomic disturbances, particularly in the context of a diffuse neuropathy such as diabetic polyneuropathy. Penile thermal sensory testing correlated strongly with the clinical evaluation of erectile function and is a new and promising tool for the diagnosis of neurogenic impotence.

Efficacy of sildenafil in erectile dysfunction after radical prostatectomy.

Radical retropubic prostatectomy (RRP) is an important cause of iatrogenic erectile dysfunction (ED). While sildenafil has been widely used since its introduction as a new treatment option for ED, its efficacy in post-RRP patients has not been extensively studied. We retrospectively compared the efficacy of sildenafil in post-RRP and non-surgical patients with ED (NSED) using a subset of questions from the International Index of Erectile Function (IIEF) and correlated results with their specific etiology of ED based on penile blood flow study (PBFS). A brief questionnaire regarding satisfaction with sildenafil was administered to 72 consecutive post-RRP patients (nerve sparing status unknown) and 32 consecutive NSED patients who had previously undergone PBFS with pharmacotesting as part of their evaluation for ED. PBFS diagnoses were arterial insufficiency (AI) for peak systolic velocity (PSV) < 25 cm/sec; venogenic (CVOD) for PSV > or = 35 cm/sec, mixed vascular for PV > 25 but < 35 cm/sec and resistive index (RI) < 0.9; a vascular normal diagnosis (neurogenic impotence) required excellent rigidity sustained for 20 min. Differences in the IIEF subscores for the different groups of patients were assessed. Success with sildenafil was defined as moderate or excellent improvement (3/4 or 4/4) with ability for penetration. No differences were found among the different subgroups of RRP patients with respect to IIEF scores or success rates with sildenafil. NSED patients had both significantly higher post-treatment IIEF scores (3.6/3.4 vs 2.5/2.2; t=4.50, P<0.0001) and success rates (63% vs 31%; t=3.11, P < 0.01) with sildenafil treatment than RRP patients. We found that sildenafil is significantly less effective in impotent RRP patients than in age-matched patients with ED (31% vs 63%). We had postulated that sildenafil would be least effective among RRP patients with excellent sustained rigidity to PGE1, as this subgroup is likely to have neurogenic impotence. We found that sildenafil response rates among subgroups of RRP patients were statistically similar regardless of PBFS diagnosis. IIEF scores for the RRP subgroups were similar but statistically lower than in men with ED and no history of RRP. While individuals with normal vascular responses to PGE1 have an increased likelihood of having neurogenic impotence, in RRP patients, we were unable to demonstrate any difference in efficacy of sildenafil, regardless of the PBFS diagnosis.

Retrospective review of flow patterns following retropubic prostatectomy.

We retrospectively evaluated penile inflows in 103 previously potent individuals who underwent standard nerve sparing radical retropubic prostatectomy (RRP) for the treatment of prostate cancer. No effort to identify or spare the accessory pudendal artery (APA) was made in any case. Our goal was to investigate the role of the accessory internal pudendal artery (APA) in the maintenance of erections in this population. We hypothesize that if the APA is present in a significant number of men, and its ligation significantly contributes to post-RRP impotence, then there should be an increased incidence of asymmetry between R/L cavernous arterial flows among post RRP patients with vascular impotence. One hundred and three previously potent individuals complaining of persistent erectile dysfunction for at least six months after RRP were studied with color duplex Doppler, following age specific dosing of PGE1. Vascular assessment was performed before and after self-stimulation, measuring peak systolic velocity (PSV), end diastolic velocity (EDV), and resistive index (RI). Erections were visually rated as inadequate (INA), adequate (ADE) for penetration, or excellent (EXC) with sustained rigidity for at least 20 min. Cavernous artery asymmetry (CAA) was defined as a >10 cm/s difference between right and left sided arterial flows. Mean duration between surgery and Doppler study was 14.7 months. 27 out of 103 (26%) of patients developed excellent rigidity consistent with isolated neurogenic impotence (PSV=32.0 cm/s, mean RI=0.95); 24 out of 103 (23%) had adequate vascular responses making it impossible to infer presence or absences of neurogenic impotence; 52 out of 103 (51%) had inadequate rigidity consistent with vascular insufficiency (PSV=23.7 cm/s, mean RI=0.66). We noted that of patients with EXC response, 48% (13 out of 27) had CAA. Among patients with severe inflow disease (INA responders), CAA was seen in only 21% of cases (11 out of 52). The incidence of APA has been reported as being from 4-70%, and its significance in the maintenance of erections has been questioned. Assuming that the APA provides significant inflow in some patients, we expected an increase in CAA in individuals in whom it was sacrificed. We found a higher incidence of CAA among post-RRP patients with normal vascular erectile responses to PGE1 (48%) compared to men with true vasculogenic impotence post-RRP (21%). These data do not support the importance of the APA in the maintenance of erections in the post-RRP patient.

EVALUATION AND THERAPEUTIC APPROACHES OF VOIDING AND ERECTILE DYSFUNCTION IN NEUROLOGICAL BEHCET'S SYNDROME

Purpose Behcet's syndrome is a progressive inflammatory disease which involves multiple systems. It is characterized by 3 main symptoms of iridocyclitis, and oral and genital ulcerations. Nervous system involvement is seen rarely in this clinical entity and is known as neurological Behcet's syndrome. Inflammation usually occurs in the brain stem, cerebellum and medulla spinalis. Voiding and erectile dysfunction can be due to progressive inflammatory reactions in the nervous and vascular systems. We prospectively evaluated the dysfunctional bladder and penis, and therapeutic options were evaluated prospectively. Materials and Methods A total of 24 consecutive patients diagnosed with neurological Behcet's syndrome after neurological evaluation were enrolled in this study. Neurological involvement and localization of the nervous system were proved on evaluation. Voiding and erectile dysfunction was evaluated regardless of the presence of related symptoms, and the results were compared with those of controls. Patients with voiding dysfunction on urodynamic study were treated and reevaluated symptomatically after 3 and urodynamically after 6 months. Results The rate of erectile dysfunction in neurological Behcet's syndrome was 63%. Mixed type vasculogenic impotence, arterial insufficiency, veno-occlusive dysfunction and neurogenic impotence were identified in 7, 2, 2 and 1 patient, respectively. Detrusor instability was demonstrated in 12 patients with urgency incontinence, including 3 with detrusor-sphincter dyssynergia. Brain stem localization was determined in these patients on neurogenic evaluation. Significant improvement was observed with anticholinergic treatment and clean intermittent catheterization in 3 patients with detrusor-sphincter dyssynergia. Hypersensitive and hypocompliant detrusor was noted in patients with neurological Behcet's syndrome who had normal voiding habits. Conclusions Incontinence or irritable bladder symptoms should not be considered innocuous clinical findings in neurological Behcet's syndrome. Lower urinary tract function should be evaluated in all patients with this neurological syndrome. The incidence of erectile dysfunction is approximately 65% and the therapeutic approach should be determined according to lower urinary tract function.

Bulbocavernosus-reflex latencies and pudendal nerve SSEP compared to penile vascular testing in 669 patients with erectile failure and other sexual dysfunction.

The purpose of this current study was to find out the coincidence of pathological penile vascular supply with pathological data in Bulbocavernosusreflex latency (BCR-L) measurements and Pudendal Nerve SSEP (PudSSEP) recordings. Six hundred and sixty-nine males (642 with erectile dysfunction, 27 with different sexual disturbances) (mean age 49.3 y, range 17-76 y) underwent consecutively a battery of neurophysiological investigations together with pharmacotesting of cavernous bodies combined with duplex sonography of penile arteries. Pathological vascular findings were indicated in 286 men (43%), pathological neurophysiological findings in 264 men (39%). Normal findings in both investigations (vascular and neurophysiological) were encountered in 252 men (38%); 131 men (19%) revealed pathological data exclusively in the neurophysiological parameters, 153 (23%) exclusively in the vascular parameters and 133 (20%) in both. The highest percentages of pathological findings were observed in patients with diabetes mellitus (110 out of 131, 88%) and patients who had sustained pelvic trauma or surgery (36 out of 44, 82%), in contrast to the lowest percentage in patients with a proven psychogenic etiology (10 out of 38, 26%). Somewhat surprising was the rather high proportion of vascular impairment in patients with defined neurological diseases such as alcohol abuse (20 out of 51, 43%), polyneuropathy (PNP) of various etiology (9 out of 19, 47%), lumbosacral radiculopathies (26 out of 65, 40%), and CNS diseases (24 out of 52, 46%), about half of them coinciding with pathological neurophysiological findings. Even if the validity of BCR-L measurement and PudSSEP recordings in the assessment of neurogenic impotence was controversely discussed, we conclude that in a large number of impotent males both neurogenic and vascular factors are responsible for the onset of erectile dysfunction.

Unusual Complications of the Vacuum Erection Device

Objectives. The vacuum erection device (VED) is usually well tolerated and very effective for patients with erectile dysfunction. When used correctly, VEDs carry low morbidity and few recognized complications. We report on 5 patients who developed unusual complications associated with VED use, including two previously unreported complications of urethral bleeding and capture of scrotal tunica within the penile shaft. Methods. Patient 1: a 38-year-old diabetic man with significant peripheral neuropathy and an 8-year history of erectile dysfunction developed penile skin necrosis at the ring site after leaving the penile ring on for an excessive length of time (6 hours). Patient 2: a 76-year-old diabetic man who used a VED correctly for 3 months developed severe urethral bleeding. Patient 3: a 75-year-old diabetic man who enjoyed satisfactory erections with a VED for 14 months developed a 3 × 3-cm penile cystic mass located on the proximal right side of the penile shaft. This mass was not present in the flaccid state and was seen only with VED use. Patient 4: a 65-year-old man developed Peyronie’s disease after 4 years of correct VED use. Patient 5: a 62-year-old man with neurogenic impotence following a radical prostatectomy developed penile ecchymoses acutely following placement of a smaller constriction ring. He subsequently developed a dorsal penile plaque with mild dorsal curvature. Results. Patient 1 did well with local skin care and no longer uses a VED. Patient 2 underwent cystoscopy and was found to have prominent urethral vessels (varicosities) in the midurethra, compared with a normal cystoscopy 9 months previously. This patient no longer uses a VED and now denies any urethral bleeding at 15-month follow-up. Patient 3 underwent corpora cavernosography and contrast injection of the cystic mass. These radiographic studies showed that the mass did not communicate with either corpora cavernosa or the corpus spongiosum. A retrograde urethrogram failed to show a urethral diverticulum. The patient was surgically explored, and the penile cystic mass was found to be scrotal tunica vaginalis. Subsequently, a hydrocele repair was performed, yet postoperatively the patient developed testicular migration into the ipsilateral penile shaft. Testicular fixation was not feasible secondary to a childhood herniorrhaphy, and an orchiectomy was performed. Patient 4 underwent implantation of a penile prosthesis and is doing well at 3-year follow-up. Patient 5 experiences mild dorsal penile curvature with erections induced by transurethral prostaglandin E1. The penile curvature does not interfere with intercourse and will be managed conservatively. Conclusions. We describe unusual side effects associated with VEDs. Although thousands of men use VEDs successfully and without morbidity, the urologist must be aware of unusual complications associated with VED use.