Self-injection Therapy Research Articles

High attrition rate with intracavernousinjection of prostaglandin E1 for impotency

Objective To determine if intracavernosal pharmacotherapy utilizing prostaglandin E1 (PGE1) injections is a well accepted and durable treatment modality for impotency. Method We reviewed the charts of 110 consecutive men who underwent a thorough impotency evaluation and were considered acceptable candidates for intracavernosal pharmacotherapy with PGE1. Results Forty patients opted not to initiate treatment with PGE1 (16 due to loss of interestin sex), while 60 patients pursued home self-injection therapy; 10 patients were lost to follow-up. Thirty-six (60%) of those who initiated therapy discontinued the use of PGE1 with a mean follow-up of six months; 18 terminated PGE1 usage due to loss of interest in sexual activity and 3 due to return of spontaneous erections. However, many who lost interest in sexual activity in both groups directly attributed this to the required intracavernosal route of administration for PGE1. Thus, only 24 of the original 100 (24%) patients continued to use PGE1 as impotency therapy for an attrition rate of 76 percent. Conclusion Our study indicates that intracavernosal pharmacotherapy using PGE1 injectiontherapy is not a satisfactory long-term therapeutic modality for many patients with erectile dysfunction. The diverse reasons for this high attrition rate are discussed.

The Negative Pressure Device for Erectile Disorders: When Does it Fail?

Of 74 men with erectile dysfunction who used a vacuum device at home only 20 were satisfied with the erections achieved. The device was offered only to men who had not been helped by sexual counseling, self-injection therapy or venous surgery, and to 8 patients who had had problems with a penile implant. Fibrosis reduces the chances of success with the vacuum device, and only 2 of 14 such patients used it successfully. In all 9 patients with psychogenic impotence the device failed. Although 9 men did achieve erections with the device, they disliked it so much that they did not begin regular use. Our disappointing overall result was probably due to negative patient selection.

Four-Drug Intracavernous Therapy for Impotence Due to Corporeal Veno-Occlusive Dysfunction

Although veno-occlusive dysfunction is a frequent cause of impotence, a definitive therapeutic strategy has not yet been clearly defined. A total of 56 patients with corporeal veno-occlusive dysfunction diagnosed by dynamic infusion cavernosometry-cavernosography (flow to maintain erection greater than 10ml. per minute and rate of corporeal pressure decrease after interruption of intracavernous infusion greater than 50mm. Hg for 30seconds) not considered suitable candidates for surgery underwent self-injection therapy. A vasoactive mixture composed of 12.1mg./ml. papaverine hydrochloride, 10.1 µgm/mh prostaglandin E1, 1.01mg./ml. phentolamine mesylate and 0.15mg./ml. atropine sulfate was used. After dose titration of the drug mixture 54 patients (95%) were able to obtain sustained rigid erections that guaranteed satisfactory sexual activity. Mean (plus or minus standard error of mean) volume of injected mixture was 0.42 ± 0.09ml. (range 0.25 to 0.90ml.). Four patients (7%) reported transient hypotension that did not recur after the application of a penile rubber band before injection. At a mean followup of 16 months 6 patients (11%) discontinued use of injections, 37 (69%) were satisfied and using the mixture, and 11 (20%) maintained rigid erections using a lower than initial dose. No major complications were encountered. The association of drugs with different mechanisms of action caused a synergism that potentiated the therapeutic activity and reduced side effects by decreasing the total drug dose.

Combination of Psychosexual Therapy and Intrapenile Injections in the Treatment of Erectile Dysfunctions: Rationale and Predictors of Outcome

In view of high drop-out rates from auto-injection therapy for impotence, a treatment strategy was established that combined psychosexual therapy with intracavernous self-injections. Sixty-eight men (mean age: 52 years, s = 11, 7) were included into an integrated psycho-somatic evaluation and treatment program. The comprehensive psychological evaluation consisted of a self-developed, multidimensional questionnaire and a thorough clinical interview. In 52% of the cases the partner could be included in the evaluation process. The somatic evaluation consisted of the oscillometric (DINAMAP® 1846SX) assessment of the penisbrachialis index, doppler study of penile arteries (both before and after intracavernous injection), and the intracavernous injection of a vasoactive substance (papaverine, papaverine/phentolamine, if required). The etiology was rated as somatogenic in 13%, as mixed in 31%, and as psychogenic in 56% of cases. All patients were offered a trial of sexual therapy. In addition, 46% were instructed in self-injection therapy. The patients who accepted and employed auto-injection therapy were older, rated their sexual pleasure and satisfaction significantly higher, had no diminished or lost sexual desire, reported less partner problems but complained of a lack of desire in their partners. In a 1-year follow-up 37% of our sample were classified as not improved, 19% as slightly improved, and 44% as improved. The predictors of outcome were determined by means of discriminant and logistic regression analyses. The results show that the following variables significantly contribute to the outcome of the the combined treatment program: partner problems (negative predictor), premature ejaculation (negative predictor), predominantly organogenic impotence (positive predictor), employment of auto-injection therapy (positive predictor), reduction of sexual desire (negative predictor), adequate sexual stimulation by partner (positive predictor), and smoking (negative predictor). The results of our study indicate that a combination of psychosexual and self-injection therapies can be a promising therapeutic option. Patients with psychogenic impotence, however, can only benefit from this integrative therapy if they have no serious partner problems and no premature ejaculation.

Influence of Cause on Choice of Therapy in 174 Patients with Erectile Dysfunction

In 174 impotent patients consistent application of modern diagnostic methods, including dynamic color duplex sonography, pharmacocavernosography, nocturnal penile tumescence monitoring and psychological exploration, led to invasive therapy in 38 and to self-injection therapy in 76. Analysis of patients who received penile implants and those who performed self-injection did not show an important effect of etiology of impotence on the choice of treatment. Therefore, if penile vascular surgery is excluded, diagnostic procedures can be limited to a simplified goal-directed panel. Once psychogenic impotence is excluded through nocturnal penile tumescence monitoring, application of vasoactive drugs serves only to select patients to be considered for self-injection therapy. Implant surgery will be reserved for patients who fail to respond to any drug applied.

Through the Eyes of Women: The Sexual and Psychological Responses of Women to their Partner’s Treatment with Self-Injection or External Vacuum Therapy

We prospectively delineated and contrasted the sexual, marital and psychological responses of women to their partner’s use of 2 treatments for erectile dysfunction: 1) self-injection of papaverine and phentolamine, and 2) vacuum tumescence therapy. The women were assessed at 5 points during a 12-month period with psychometric questionnaires and clinical interviews. Statistical analysis indicated that the women responded equally well to both treatments. They demonstrated significant increases in frequency of intercourse, sexual arousal, coital orgasm and sexual satisfaction. No significant changes were noted on the psychometric questionnaires. The women reported feeling more at ease in their relationships and characterized sex as more leisurely, relaxed and assured. Negative responses focused on the lack of spontaneity and hesitation about initiating sex. Selfinjection and vacuum pump therapy restore potency in men and secondarily facilitate improved sexual function in women.

Pharmacologically Induced Erections Among Geriatric Men

Intracavernous injection of vasoactive drugs for the treatment of erectile impotence has become a standard therapeutic technique. Previous reports detailing experience with this treatment are based on patient populations significantly younger than most patients who suffer from impotence. The geriatric population, which comprises the majority of patients with impotence, is unique due to the physical, psychological and social changes associated with the aging process. To characterize better elderly men with impotence, and determine whether intracavernous injection therapy is safe and effective in this age group, a retrospective analysis was performed upon patients attending the male sexual dysfunction clinic at our university medical center who received a standard papaverine and phentolamine mixture (30mg. papaverine and 1.0mg. phentolamine per ml.). The etiology of impotence, degree of patient satisfaction and complication rate of 65 patients 65 years or older (mean age 70 years) undergoing papaverine plus phentolamine self-injection therapy were compared to a similar sized group of impotent men approximately 20 years younger (mean age 47 years). Significant differences in etiology of impotence were evident between the 2 groups. Treatment response rates were equal for the 2 age groups although elderly patients required a higher dose of papaverine and phentolamine to obtain an erection, and used the medication less frequently. Complications were few, of minimal consequence and occurred with equal frequency between the 2 age groups.

Intracavernous pharmacotherapy inpsychogenic impotence

Twenty-five men with psychogenic impotence but without serious psychopathology were considered for intracavernosal therapy with papaverine hydrochloride and phentolamine mesylate. A total of 20 proved suitable and began self-injection in conjunction with sex therapy; 8 patients had return of spontaneous erections without pharmacotherapy, although one of them needs to keep the medication in his refrigerator. The other 12 patients are continuing self-injection therapy. Psychotherapy with self-injection may be helpful in the management of psychogenic erectile impotence.

Enteral Hyperalimentation with Continuous Subcutaneous Insulin Infusion Improved Severe Diarrhea in Poorly Controlled Diabetic Patient

Little is known about effective treatment for severe diarrhea in the insulin-dependent diabetic patient. A 41-year-old woman was admitted to our hospital because of hyperglycemia and dysuria. She had stopped insulin self-injection therapy for 2 years and diarrhea had become worse, resulting in malnutrition. Following enteral alimentation by elemental diet (ED) with continuous subcutaneous insulin infusion (CSII), frequency of diarrhea remarkably decreased and general nutritional condition was improved. At the first step, the patient was given 600 kcal/d ED through the tube sustained in the jejunum. Total calorie intake for 24 hours was gradually increased to the level of 2400 kcal/d and this therapy continued for 5 months. During this period, blood glucose level was kept in almost normal range (between 100 and 200 mg/dL) through the continuous insulin infusion of regular insulin (1.0-1.5 U/h). Thereafter, general conditions were improved and frequency of diarrhea gradually decreased. When this treatment was stopped, watery diarrhea, steatorrhea, and hypoalbuminemia completely disappeared and she gained 12 kg of body weight. Furthermore, spontaneous urination appeared following this treatment. This case suggests that the enteral hyperalimentation combined with strict control of blood glucose, using the CSII, may be an effective therapy for such severe diarrhea with malnutrition in diabetes.

Intracavernous Self-Injection of Vasoactive Drugs in the Treatment of Impotence: 8-Year Experience with 615 Cases

Of 615 patients with impotence of varying etiologies who were followed from 12 to 96 months after the institution of intracavernous self-injection therapy with vasoactive drugs (papaverine alone, papaverine and α-blockers, and Ceritine, a new multilevel acting drug) 87% (533 patients) returned for followup visits or were regularly contacted. Of these patients sexual activity was restored in 91%. The dropout rate was 11.25%. The 114 episodes of prolonged erections among 51 patients (4.57%) represented less than 3 per 1,000 of the 34,875 recorded injections. All patients were treated without complications. The percentage of patients suffering from nodules or permanent deformations was 2.8%. There were no cases of intracavernous fibrosis. The percentage of satisfied patients (satisfaction index 7 or greater) was 84.8%. Improvement in spontaneous erections during sexual intercourse was obtained in 65% of the cases: 15% no longer needed self-injections and 50% only used them occasionally while 35% remained entirely dependent.

Intracorporeal Self-Injection with Epinephrine as Treatment for Idiopathic Recurrent Priapism

Intracorporeal papaverine self-injection therapy has gained widespread acceptance in the treatment of impotence. Treatment for the opposite, recurrent priapism, is also possible with the same technique using a vasoconstrictive drug. We report a patient with idiopathic recurrent priapism successfully managed by intracorporeal self-injection with epinephrine.

Why do so many people drop out from auto-injection therapy for impotence?

Although intracavernous injection of vasoactive substances has been shown to be a reasonable and reliable method of reversing impotence, studies assessing patient acceptance of this new technology are lacking. By prospectively following patients and willing partners over a 2-year period, this study sought to document patient utilization rates and the reasons why patients decline or discontinue injection therapy. The cumulative dropout rate was 46%, with patients being most at risk for leaving the program after evaluation or during the trial dose phase. Patients decline treatment because they are unable to accept the idea of injecting themselves or because of potential side effects. Patients discontinue treatment because of perceived lack of efficacy. Patient and programatic obstacles to utilization of self-injection therapy are analyzed.

Vasoactive Intracavernous Pharmacotherapy—The Nursing Role in Teaching Self-Injection Therapy

Our physician-nurse team management of a program in vasoactive intracavernous pharmacotherapy to treat male impotence has provided a high degree of patient and partner satisfaction. Nurses participate in the assessment of the ability of a patient or partner to master the self-injection technique, and the potential of a couple for compliance with and commitment to the program, all of which are key factors for successful home therapy. A nurse also teaches the self-injection technique. Audiovisual materials and handouts are used as teaching aids to ensure that complete and consistent information is given. The patient or partner is required to perform a self-injection under nursing supervision before a prescription for home use is written. Initial followup visits are scheduled with a nurse at 1 to 2-week intervals. At these visits the nurse identifies possible patient errors in self-injection technique, dose or frequency, and answers questions about the therapy. After the couple has mastered and is comfortable with home injection, followup appointments are scheduled with the physician at 4-week intervals to monitor for possible changes in response to treatment and for an examination of the phallus.

Intracorporal injection of papaverine and phentolamine in the management of impotence.

Intracorporal injection of 0.5 ml papaverine (30 mg/ml) and phentolamine (2.5 mg/ml) was given to 144 patients presenting with various types of impotence. The high response rate (97%) precluded the use of this test to differentiate between types of impotence but provided patients with the choice of embarking on a self-injection programme. Of the 101 patients entering the programme 78 are continuing self-injection therapy with a mean follow-up of 6.5 months. The incidence of complications is low and patients are generally very satisfied with the treatment.