|Digest of recent discussions on ISSM mail (May - August 2004)|
Digest of recent discussions on ISSM mail (May - August 2004)
Hussein Ghanem MD
Dr. Antonio Martín Morales presented a case of a 57 years old man, who suffered sudden pain and induration in the crura of the right corpus cavernosum, not related trauma or unusual (aggressive or hard) sexual activity A "tru-cut" biopsy of the mass, was informed as "connective tissue highly collagenized". Figures may be seen on http://www.issir.org/prod/data/issirlist/cavernous.htm. Dr. Ignacio Moncada suggested probably a partial thrombosis of the corpus cavernosum. He referred to a recently published paper in European Urology by Goeman (Eur Urol 44: 119–123, 2003) describing three similar cases with similar MRI results. Dr. Andik Wijaya suggested a therapeutic trial with a corticosteroid and NSAIDs. H Ghanem suggested investigating –as in cases of venous thrombosis- to exclude a hypercoagulable state. Dr. Sidney Glina suggested partial priapism and provided a review on literature including 13 references. Dr. Shedeed Ashour suggested a trial with POTABA and Tamoxifen, while Dr. Sudhakar Krishnamurti suggested that it is not common for Peyronie's disease to invade the corpora so extensively.
I'd appreciate very much your input on this case.
57 yo man, who present with a sudden pain and induration in the crura of the right corpus cavernosum, 20 days on duration. Neither trauma nor unusual (aggressive or hard) sexual activity took place at any time and the last sexual intercourse was 15 days prior to this event. He complains of HBP (Rx ACEi) and is on PDE5i. Last standard dose 5 days prior to the event with a very hard erection and no ejaculation. He doesn't explain the reason for this action, although denies any manipulation or stress over the penis. Since onset he has consulted with many urologists and underwent MRI, showing an slightly enlarged and solid crura of the right corpus cavernosum, well delimitated, anyhow and a respected urethra (see figures at: http://www.issir.org/prod/data/issirlist/cavernous.htm ). A penile Doppler ultrasound, without vasoactive drugs was also performed, which showed normal arteries and no veins, concluding cavernous thrombosis. A "tru-cut" biopsy of the mass, was informed as "connective tissue highly collagenized", suggestive of Peyronie's disease. Currently he's on colchicine and vit E, the pain is slowly going down but the hardness of the corpus cavernosum remains almost the same. No signs of acute inflammation are visible and the crura can be easily recognized through palpation, I mean, penile structures are respected and the process seems to be confined to the crura itself. Erections are good but still slightly painful. No problems with voiding. I've recommended him watchful-waiting because he can cope with the discomfort/pain.
Any suggestion regarding etiology or any treatment apart what he's currently receiving?
My best regards
Antonio Martín Morales
Hospital Carlos Haya
Unidad Andrología, Servicio Urología
This case is probably a partial thrombosis of the corpus cavernosum. There is a brilliant paper recently published in European Urology by Goeman (Eur Urol 44 : 119–123, 2003) describing three cases like yours with nice MRI of the penis. They suggested conservative treatment although they recommended systemic anticoagulation. In all three cases, the thrombosis resolved spontaneously over several months without complications.
I suggest you to use Kenacord (corticosteroid) injection and Feldene (Pyroxicam) ointment.
Dr. Andik Wijaya, MRepMed(Dipl)
Couple Clinic Indonesia
The thrombosis appeared to have occurred without any known risk factor like stasis or a history of endothelial injury. I suggest investigating –as in cases of venous thrombosis- to exclude a hypercoagulable state as occurring with lung cancer and other malignancies associated with increased fibrinogen or thrombocytosis; deficiency of antithrombin 3 as a result of nephrotic syndrome or liver failure; systemic LE; or inflammatory bowel disease(Lange Current Surgical Diagnosis & Treatment, 2003).
I also wish to thank you all for your kind remarks about the ISSIR List Digest.
This patient must had a partial priapism. In most cases the treatmen should be conservative. I attached a quick review on literature about the subject.
1: Ptak T, Larsen CR, Beckmann CF, Boyle DE Jr.
Idiopathic segmental thrombosis of the corpus cavernosum as a cause of partial
Abdom Imaging. 1994 Nov-Dec;19(6):564-6.
PMID: 7820037 [PubMed - indexed for MEDLINE]
2: De Zan A, Gamba P, Piana P, Squintone L, Vottero M, Tizzani A.
[A case of priapism of the proximal corpora cavernosa]
Minerva Urol Nefrol. 1993 Mar;45(1):29-30. Review. Italian.
PMID: 8322115 [PubMed - indexed for MEDLINE]
3: Burkhalter JL, Morano JU.
Partial priapism: the role of CT in its diagnosis.
Radiology. 1985 Jul;156(1):159.
PMID: 4001404 [PubMed - indexed for MEDLINE]
4: Roa Rico M, Roa Luzuriaga M.
[Partial priapisms. Proximal priapism. Report of a case]
Arch Esp Urol. 1981 Jul-Aug;34(4):297-300. Spanish.
PMID: 7294904 [PubMed - indexed for MEDLINE]
5: Johnson GR, Corriers JN Jr.
J Urol. 1980 Jul;124(1):147-8.
PMID: 7411706 [PubMed - indexed for MEDLINE]
6: Llado J, Peterson LJ, Fair WR.
Pripism of the proximal penis.
J Urol. 1980 May;123(5):779-80.
PMID: 7420578 [PubMed - indexed for MEDLINE]
7: Gottesman JE.
Recurrent partial priapism.
Urology. 1976 May;7(5):519-20.
PMID: 1274013 [PubMed - indexed for MEDLINE]
8: Goeman L, Joniau S, Oyen R, Claes H, Van Poppel H.
Idiopathic partial thrombosis of the corpus cavernosum: conservative management
is effective and possible.
Eur Urol. 2003 Jul;44(1):119-23. Review.
PMID: 12814686 [PubMed - indexed for MEDLINE]
9: Pegios W, Rausch M, Balzer JO, Wolfram M, Bentas W, Jonas D, Vogl TJ.
MRI and color-coded duplex sonography: diagnosis of partial priapism.
Eur Radiol. 2002 Oct;12(10):2532-5. Epub 2002 Feb 21.
PMID: 12271395 [PubMed - indexed for MEDLINE]
10: Lewis JH, Javidan J, Keoleian CM, Shetty SD.
Management of partial segmental priapism.
Urology. 2001 Jan;57(1):169.
PMID: 11164175 [PubMed - indexed for MEDLINE]
11: Schneede P, Schmeller N, Muller-Lisse UG, Reiser MF, Hofstetter AG.
[Partial priapism. Case report and review of the literature of diagnostic and
Urologe A. 1999 Mar;38(2):179-83. Review. German.
PMID: 10231940 [PubMed - indexed for MEDLINE]
12: Machtens SA, Kuczyk MA, Becker AJ, Stief CG, Jonas U.
Partial unilateral penile thrombosis: magnetic resonance imaging and
J Urol. 1998 Aug;160(2):494-5. No abstract available.
PMID: 9679908 [PubMed - indexed for MEDLINE]
13: Thiel R, Kahn T, Vogeli TA.
Idiopathic partial thrombosis of the corpus cavernosum.
Urol Int. 1998;60(3):178-80.
PMID: 9644790 [PubMed - indexed for MEDLINE]
Regarding this case i have my own opinion, as the tru-cut bx revealed a picture of peyronie's disease this case might benifit to much of POTABA and Tamoxifen as anti fibrosis and EGF.
Also regarding the possible aetiology that might be a non noticible trauma like cycling or other perineal trauma.
thanks for these nice cases
Shedeed Ashour shedeed
Cairo university Cairo Egypt.
It is not common for Peyronie's disease to invade the corpora so extensively.
I lost the patient for follow-up, because of that I didn't provide you with the outcome of the process.
Thanks everybody for the inputs.
Antonio Martín Morales
Hospital Carlos Haya
Unidad Andrología, Servicio Urología
Dr. Kevan Wylie presented a case of complete loss of libido in a 30+ man after T2 sympathectomy. Dr. Ben-Zion suggested a depressive disorder and advised treatment with ZYBAN (Bupropion HCl). Dr. Pierre Assalian also suspected psychological etiologies, whether individual or relational issues. Dr. Francisco Costa Neto also agreed that if Testosterone (total and free)and Prolactine levels remain normal, then a psychogenic dysfunction would be most probable. He advised a trial with a PDE5 inhibitor.
I have a patient who had a T2 sympathectomy and is now free of facial flushing, Goosebumps and sweating in the upper limbs. However, he also claims complete loss of libido. How can this be the case and has anyone any suggestions for ,managing this man in his early 30’s?
His adrenal and pituitary function is normal other than a raised growth hormone of 34 (IGF-1 normal).
Kevan R Wylie MD
Consultant in Sexual Medicine
Porterbrook Clinic, Sheffield.
Sometimes it may me depressive disorder- i have good experience with ZYBAN (Bupropion HCl) with a similar patient.
I.Z. Ben-Zion MD
Soroka Medical Center
POB 151 Beer-Sheva ISRAEL 84101
I am sure you have not overlooked psychological etiologies, whether individual or relational issues.
Dear Dr. Wylie,
If Testosterone (total and free)and Prolactine levels remains normal, I
believe that he has a psychogenic dysfunction. I would try a PDE5 and see
how it works.
Francisco Costa Neto. MD.
Dr. Eric Meuleman presented a case of a 56 years old male complaining of reduced penile length (erect length10 cm) after implantation of a hydraulic penile prosthesis for ED associated with diffuse cavernous fibrosis, DM, ischemic heart disease & renal impairment. Juza Chen strongly advised not touch functional, well-located prosthesis only for penile size, due to the risks of re-operation and over-sizing. Dr. Mustafa F Usta suggested educating the patient about normal penile dimensions (8cm or above) and suspects the patient would still be unsatisfied if the prosthesis was replaced with a longer size. Dr. John Mulhall referred to his research where the stretched penile length was measured preoperatively and serially postoperatively up to 6 months. The data (presented at ISSIR in Montréal and yet to be published) is that most men have no significant length changes, much of this is perceptual. He outlined other measures including suspensory ligament division, losing weight or a consideration of a prepubic lipectomy or liposuction if the patient is obese. Dr. Roberto Labayen also suggested suspensory ligament division. Dr. John Mulcahy advised against any surgical intervention since cutting into the penis creates more scar tissue and further shortening. Dr. Wayne Hellstrom advised a trial with a vacuum suction devise suggesting that the slightly increased penile girth and glans enlargement can make a significant difference. Dr. Ignacio Moncada’s recommendations are to measure penile length only with complete sexual stimulation to make use of glans’ engorgement, and to advice the patient to exercise inflating the cylinders up to the maximum 15 minutes twice a day. Dr. This attempts to expand the tissue little by little allowing for a slight (but measurable) length gain. Dr. Gregory Broderick also advised 'cycling' the device: inflating before the shower and leaving it up for the entire shower.
He also suggested a PDE5 inhibitor with sex to enhance the flaring of the glans. Dr. Alonso Acuña gave another perspective inquiring about the condition of the vaginal and perineal muscles of the wife.
Could you give me your advice on the following:
56 years old male with therapy resistant ED, diffuse cavernous fibrosis and DM type 2, cardiac angina, mild renal insufficiency got a penile implant (AMS 700 CXM, cylinders: 14 X 9.5 cm) in september 2003.
Now he complaints about the fact that his penis is to short to penetrate. The sexual relationship with his wife, who is having a body mass index of 24.5 kg/m2 is functional. On examination the device is functional, the cylinders are nicely filling the corpora into the glans and the length of the erect penis is 10 cm.
What to do?
Eric JH Meuleman MD PhD
Consultant Urologist Sexologist
University Medical Center St Radboud
Do not touch functional, well-located prosthesis only for penile size. You cannot grantee that new prosthesis will make his penis longer. From other side if you put to long prosthesis in patient with diabetes it can cause decubitus on the glans penis and can penetrate easily, and all this, in addition of probably higher infection rate of re-operation in diabetic patients.
Juza Chen, MD
Don't do anything to risk the current implant.. He has cavernous fibrosis+ DM and a functional, uncomplicated prosthesis. He is lucky.
Usually, Best is the enemy of Good.
Dear Dr Meuleman
Complaints related to penile lenght is comonly seen in patients who underwent IPP implamntations, especially if they have systemic disease such as DM or CRF. I would suggest to try to convince the guy that the lenght of his penis is long enough to have satisafactory sexual intercourse. (As you know the penis should be at least 8cm for satisfactory sexual intercourse).
I do not believe that this guy will be more happy than the present, if you will replace the IPP with a longer size.
Mustafa F Usta M.D., Assistant Professor
Akdeniz University School of Medicine
Department of Urology, Section of Andrology
Dumlupinar Bulvari Kampus 07070
This kind of case is always a challenge. i spend a lot of time with men prior to such surgery giving them realistic expectations. I measure their stretched penile length preoperatively and serially postop out to 6 months. our data (presented at issir in montreal and yet to be published) is that most men have NO significant length changes. much of this is perceptual i believe. it is often so long since they have seen their erect penile length that they do not realize that their penis has already shortened prior to you making an incision )especially in the setting of DM and corporal fibrosis). I concur with all the comments that have been made thus far regarding the current implant and avoiding a secondary operation on it.
Fernando Borges from florida has previously presented data (although not yet published) on suspensory ligament division for length enhancement for such cases. it may be worth contacting him if this patient would be interested in such an approach. once other question ... what is HIS body habitus. is he obese? how big a prepubic fat pad or pannus does he have? if large, then losing weight or consideration of a prepubic lipectomy or liposuction may be indicated.
John P. Mulhall
Erik; Give him a try with a VCD.The slightly increased penile girth and glans enlargement can make a world of difference from my experience for some patients with these complaints.Surprisingly it is the partner who is often the complainer and the man is only secondarily passing on her dissatisfaction.
I see about one patient a week with this complaint following a well sized penile implant. After my 20 minute lecture to him about scar tissue and loss of elasticity, I ask him why did he heal so short. He used to be called "Big Bob"-his new nick-name is "Bob". Pre operatively I give all such patients a booklet I composed about penile implants whish has an extensive discussion about size and scar tissue. I would not do anything surgical since cutting into the penis creates more scar tissue and further shortening. Wayne's suggestion of a VED is worth offering as it will draw blood into the remnant spongy tissue around the cylinders under the tunica. This type of guy, however, would not be happy with the vacuum ring.
Eric, this is the everyday case.
Patients frequently complain of shortened penis after implantation. One common reason is because they inflate the prosthesis without sexual stimulation to measure and re-measure and become obsessed with the length; but they miss the glans' engorgement secondary to sexual stimulation which is important to add up a couple of centimetres to the total length. So, first recommendation would be to measure penile length only with complete sexual stimulation.
Second recommendation would be to tell the patient to exercise inflating the cylinders up to the maximum during 15 minutes twice a day (morning and night, after a hot shower or bath), trying to pump it up with progressively more fluid. This will expand the tissue little by little allowing for a
slight (but measurable) length gain. I like this approach because you are transferring the responsibility of the treatment to the patient (you can always say that he didn't do it appropriately or with enough energy or duration if it doesn't work), secondly because is slow and sometimes they get used to current length; but finally because it works, everyone has seen patients with a broken prosthesis and when you have to replace it you need cylinders a couple of cm longer than the original measurement.
So, exercise and measure only in erection.
Dear Dr.Meuleman: Did you consider the division of the Suspensory ligament of the penis? I suspect that you could get more usable lenght, by this,than trying to replace the cilinders,with its possible risks of infection and/or erosion.
Roberto Labayen,M.D.-Buenos Aires-Argentina
I would like to second Ignacio's recommendation.
I have these patients 'cycle' the device: inflate before the shower and leave it up for the entire shower.
Try a PDE5 inhibitor with sex to enhance the flaring of the glans.
Steve Wilson has written about 'upsizing' the prosthesis if serial exam reveals that after a year of cycling, you can pull the prosthesis distally and show some additional strecthed length, basically demonstrate an SST deformity.
I agree with Ignacio's and Greg's suggestion.
Antonio Martín Morales
Hospital Carlos Haya
Unidad Andrología, Servicio Urología
I think is good to know about the vagional conditions of the wife and how much is her ability for contraction the perineal muscles, etc..
Dr. Jacques Buvat requested recent references on the Persistent Arousal Syndrome in Women and its possible relationship with the use of Serotonin Reuptake Inhibitors (SSRIs). Dr. Kevan Wylie referred to his case report and the work of Sandy Leiblum. Dr. Pierre Assalian pointed out that the literature and the few cases he saw occurred during the use or the discontinuation of SSRIs. He added that this condition is also known as Clitorism, where women complained of this persistent feeling of being constantly aroused. It is described as the equivalent of Priapism, The difference is that it does not cause any damage to the clitoris and subsides in couple of days.
I would be very happy if somebody was able to give me some recent references on the Persistent Arousal Syndrome in Women and its possible relationships with the use of Serotonin Reuptake Inhibitors.
Jacques Buvat MD
Sandy Leiblum has written several papers. We also published a case report cited below.
Sexual and Relationship Therapy, Vol. 16, No. 4, 2001
Traditional dance—a treatment forsexual arousal problems?
RUTH HALLAM-JONES & KEVAN R. WYLIE
Kevan Wylie. Sheffield. UK
Would you be kind enough to furnish us with some references and name of journal Sandy published her papers,as all sexual journals are not available to us.
Prof M H Cassimjee
Dear Dr Buvat
In response to your question, and a comment about Sandra Lieblum. What Sandra described weas not related to SSRIs. What have been reported in the literature and I saw few cases were while they are on the SSRIs or while we were discontinuing the SSRIs.As you know we call this condition Clitorism, where women complained of this persistent feeling of being constantly aroused,it is said it is the equivelant of Priapism,the difference that it does not cause any damage to the clitoris and it subsides in couple of days
Hope this is helpful
17th WCS Montreal 2005
Dr. Eric Meuleman presented an interesting case of a 30 years old patient complaining of episodes of urethral blood loss when his erect penis is compressed or bended. The blood loss can be so severe that it leads to a clot retention that needs bladder rinsing. The bleeding is not related to ejaculation. MRI Pelvis, TRUS, Urethrocystoscopy and IVU were all normal. He did not respond to an empirical trial of finasteride. Dr. Adolfo Casabé, Dr. Santiago Richter & Dr. Irvin Fishman suggested a repeat Urethrocystoscopy during induced erection with electrocoagulation of vascular abnormalities, if detected. Dr. Dr. Ramiro Fragas recommended an empirical trial of Vitamin C and Rutin (Rutascorbín). Dr. Shedeed Ashour and Dr. Ronald Lewis suggested a Cavernosography -after induction of erection with a vasoactive agent & penile bending or compression- to exclude a cavernoso-spongiosal shunt.
please advise me on the following complicated case:
Thirty years old computer technician, who since 1997 experiences episodes of urethral bloodloss when his erect penis is compressed or bended . The bloodloss can be so severe that it leads to a clot retention that needs bladder rinsing. Strange enough the haemoragghe is not related to ejaculation. Because of fear of this event, he is having no more sexual intercourse with his beautiful wife.
MRI Pelvis: No indication for an arteriovenous malformation nor other abnormalities.
Trial of treatment with finasteride: no improvement
Eric JH Meuleman MD PhD
Consultant Urologist Sexologist
University Medical Center St Radboud
Have you done the uretrhocystoscopy in erection?
Because sometime we have seen vascular alterations only during erectal situation
In this case,it must be electrocoagulated.
Buenos Aires Argentina
Dear Dr. Meuleman.
I would like to recommend him what I have used in cases of sperm bleeding recurrent and many times it is possible to control. (Vitamin C, 500 mg / day or Rutascorbín (Rutin + Vitamin C), during 3 months and to observe their evolution).
Dr. Ramiro Fragas.
University Hospital "Manuel Fajardo."
if the bleeding appears only while compressing or bending the erected penis, that means that the source of the bleeding is most probably from the anterior urethra. One cannot bend or compress the "invisible" part of his penis. For that reason, I think a flexible urethrocystoscopy during erection may be a good diagnostic method, as suggested by another colleague. There may be a superficial submucosal blood vessel ( not necessarily A-V fistula) that becomes engorged due to corporeal maximal filling. Similar to a superficial nasal blood vessel that bleeds whenever one sneezes or coughs. You could cauterize the vessel.
Finasteride will not help if the problem does not come from the prostate.
Kfar Sava, Israel
Hi Dr. Meuleman
Long time no see. My suggestion for the case of bleeding per urethra upon erection, esp with bending that; it must be a corporosopngiosal shunt (most propably traumatic), which is very small and not detected except on erection. When the lacunar spaces widen and accomodate blood it increases in size to the level of passing the blood to the spongiosum. It has been a subclinical fracture penis caused by tucking the penis. and this is why the patient especially used the bending to ellicit the bleeding. Also, the place very rarely can be placed in the glandular portion and filling the navicular fossa and just expelled on bending the penis.
Cavernosography on full erection with penile manipulations and bending will be diagnostic in my opinion.
Shedeed Ashour Shedeed
Consultant andrologist, Erfan hospital Jeddah, Saudi Arabia.
The mystery of the senile bleeding may be resolved by inducing an erection with a vasodilator such as caverject and then examining te urethra with a flexible scope. One may bend or compress the penis at the same time to detect the source of the bleeding.
Best of luck and let us know what you find.
Since the urethral blood loss occurs with erection, why not perform cavernosography before and after induction of erection with a vasoactive agent. The penis can be compressed during the imaging studies. I suggest without agent first for then a communication between the corpora cavernosa and the urethra may be visualized without the need for vasoactive agent, but to demonstrate whatever the etiology is might occur only when the intracavernosal pressure of erection is present.
Dr. Chris McMahon presented a case of a 43 years old man intractable glans and penile pain. Pain is present at rest, is worsened by pressure and interferes with intercourse. No abnormal physical or laboratory findings were detected apart from a history of epididymitis and stone disease. Dr. Edgardo Becher suggested empirical treatment for prostatitis with minocycline or macrolids 4 weeks, plus Permixon or an alpha blocker. Dr. Gerald Brock advised excluding neuropathies, diabetes, and suggested penile US to exclude non-palpable intra-septal scars. Dr. James H. Barada advised a HSV-II titer to identify a post-herpetic neuralgia and supportive treatment as a "chronic pain" patient. He suggested NSAIDs plus Neurontin (Gabapentin: Pfizer/Parke-Davis), beginning with 300 mg daily and increasing to 900-1200 mg. Dr. Shedeed Ashour suggested excluding Tyson it’s. Dr. Zohier Murad also suggested excluding prostatitis. Dr. McMahon’s extensive evaluation did exclude neuropathies, scaring, prostatitis & accessory gland infection. The case apparently remains as a "chronic pain" disorder. Dr. Frederick Snoy presented a similar case of a 70 years old patient that has had pain on erections in the right side of the glans penis since he was a teenager ((July - December 2002 ISSIR List digest).
Comments/assistance with the following case is invited
A 43 yo man presents with a history of intractable glans and penile pain - the pain is localised to the left ventrolateral aspect of the corona and extends along the ventral surface of the distal 1/3 of the shaft. Pain is present at rest, is worsened by pressure or palpation but not with tumescence/erection - completion of intercourse is difficult due to pain. There is no dysuria, LUTS, penile deformity, nodule or ED. Past history includes hypertension, epididymitis April 03 which settled with AB and renal stone disease with ESWL and a double J stent 12/12 ago. No physical findings or skin lesions apart from penile tenderness on palpation - MSU, urethral swab, clamydia PCR all negative
Comments are invited and, in fact, anticipated
Dr. Chris McMahon M.B.,B.S.
Sometimes the pain is referred from the prostate, he has a history of epididimytis
so I would certainly treat him at least empirically for prostatitis with
minocyline or macrolids 4 weeks, plus Permixon or an alpha blocker. Many
times cultures are negative but they are still infected.
Any neuropathy? diabetes?
I'd do a penile US as I have a couple of these guys who are otherwise well and have nonpalpable intra-septal scars.
I have a couple who have been treated with intralesional verapamil with some degree of success.
In some other cases the nonpalapble scar does become evident many months later.
Normal prostate on DRE with no response to several different AB and NSAIDs but prostatodynia is a possibility
No neuropathy - helathy young chap. Normal penile duplex with no intracavernous, septal or tunical fibrosis and normal glans
First of all the pain is "real" and your evaluation is extensive in an effort to determine its etiology. The only thing I would add is a HSV-II titer to identify a post-herpetic neuralgia.
In many cases no etiology is identified and the patient must be treated supportively as a "chronic pain" patient.
I have seen some benefit [and one or two dramatic responders](anecdotally in a varied population) with a combination of NSAIDs + Neurontin (Gabapentin:Pfizer/Parke-Davis), beginning @ 300 mg daily and increasing to 900-1200 mg.
This drug has an indication for post-herpetic neuralgia and diabetic neuropathy but I have also used it "off-label" for intractable pain/discomfort (measured by QOL impact) in ilioinguinal neuritis and chronic orchalgia.
I look forward to other thoughts. Thank you for utilizing ISSIR-List for the presentation of this interesting and difficult case.
James H. Barada, MD, FACS
Albany Center for Sexual Health
1365 Washington Ave. #102
Albany, New York USA
Dear Dr. McMahon
Dr. Frederick Snoy presented a similar case of a 70 years old patient that has had pain on erections in the right side of the glans penis since he was a teenager ((July - December 2002 ISSIR List digest). Dr. Emre Akkus & Dr. Shedeed A Shedeed suggested MRI & US evaluation while I suggested evaluation regarding a psychosomatic disorder if a physical lesion is ruled out.
The detailed discussions may be read on www.issir.org/ under ISSIRList/Discussions.
I am pasting the details of the previous discussion for your convenience.
HIV, Hep B & C, HSVI & II serology all -ve.
my opinion was as dr jame (Atypical HSV presentation) with the exception of verifying that this pain is either allodynia-or parasthesias is very important in the dosing and duration of the use of gabapentin. second somtimes its related to a post Fixed drug erpution So, is ther any tinge of violaceous brwon hyperpigmentation? Also, think about Tysonitis, or wait and see as it may evolve into a peyronie's disease. In the last case you can start colchicine with the gabapentin.
Shedeed Ashour Shedeed
Thanks for your comments
There are no tender peri-urethral boggy lumps suggestive of periurethral abscesses or beads of pus emerging from the opening of the ducts of the tysons glands on either side of the frenulum to suggest suggest tysonitis. His HSV I & II serology is -ve and their is no glans penis rash consistent with a fixed drug eruption
Kindly evaluate the prostate (DRE ,US ,Secretions analysis and culture ) as the patient has a positive past history of epidedimitis .
Dr. Sheldon Burman presented a case of a 42 year-old paraplegic male patient. He responds inadequately to Cialis 20mg and Viagra 100mg taken appropriately. He responds well to 20mg of intracavernous PGE1, but does not want to inject himself every time he wants sexual intercourse. The use of an external vacuum device is not acceptable to this patient. Dr. Burman inquired about the experience of other members with penile prostheses in paraplegics. In his own experience with over 2300 penile prosthesis insertions, he had 4 anterior extrusions, one of which was a paraplegic who had multiple procedures. Two other paraplegics healed uneventfully. In a series of 90 prostheses infection in spinal cord injury patients, Dr. Yasusuke kimoto reported 3 extrusions and 9 surgical removals due to (Paraplegia 32:336-339, 1994).
Dr. Juhana Piha suggested trying high doses of tadalafil or sildenafil (Cialis 40 mg or Viagra 200 mg). Dr. John Dean and Dr. Francisco Costa Neto also suggested high doses of sildenafil, tadalafil or vardenafil. Dr. Carlos Moreira pointed out that the concensus of the World Diabetes Mellitus Association is that intracavernous Prostaglandin E1 has to be the first choice for Sildenafil non responder. Dr. Pedro Ramon Gutierrez referred to his work that was presented in the last Montreal ISSIR meeting. His group concluded that combination therapy involving oral and intracavernous injections is a good option, at least before implanting a penile prosthesis. Dr. Shedeed Ashour pointed out that the outcome of surgery would also be affected by the technique and co-morbid conditions (e.g. Diabetes Mellitus).
Dear Fellow Members of the Issir:
I have a 42 year-old male patient, paraplegic since 1976 due to a motor vehicle accident. He has a supra-pubic catheter and has no problem with bowel movements. He gets no spontaneous erections and has no sensation below the level of his umbilicus. He takes Mandelamine for urinary tract infections 2-3 times per year; otherwise, he is in excellent health. He is an activity director at a rehab facility. He spends his life in a wheelchair. He desperately wants as normal a heterosexual relationship as possible. His libido is high as well as his testosterone level. In 1998, following too long riding a tractor, he developed ischial breakdown corrected by construction of a flap, which healed uneventfully. He responds inadequately to Cialis 20mg and Viagra 100mg taken appropriately. He responds well to 20mg of Caverject intracavernosally, but does not want to inject himself every time he wants sexual intercourse. The use of an external vacuum device is not acceptable to this patient.
What has been your experience with penile prostheses in paraplegics? Do they tend to heal well? Are complications such as extrusions more common than usual? In twenty years and over 2300 penile prosthesis insertions, I have had 4 anterior extrusions, one of which was a paraplegic who had had multiple procedures. Two other paraplegics healed uneventfully.
Your response would be deeply appreciated.
Sheldon O. Burman, M.D.
Male Sexual Dysfunction Clinic
3401 N. Central Avenue
Chicago, IL 60634
We reported a long term follow-up study for penile prosthesis in spinal cord injury patients ( Paraplegia 32:336-339, 1994).
In our series, we experienced 3 extrusions and 9 surgical removals due to infection out of 90 prostheses during average 4 year follow-up.
However, Perkash reported infection rate as low as 2% (Paraplegia 30:327-332, 1992).
I hope these information is helpful.
Dear Dr Burman
Have you tried Cialis 40 mg or Viagra 200 mg? I have several patients with severe erectile dysfunction (for example diabetics with poluneuropathy) who do not respond sufficiently to normal doses of PDE5-inhibitors, but quite well to high doses.
Docent, Chief physician
Erectile Dysfunction Laboratory
Mehilainen Co, Turku, Finland
My experience is the same as that of Dr Piha and it often worthwhile exploring unlicensed higher doses of PDE5-i drugs, particularly if the only acceptable alternative is surgery. The dose/response curve for sildenafil and tadalafil may flatten off above the maximum recommended doses but certainly isn’t flat. I think that it is worth trying vardenafil before proceeding to surgery, too. The “evidence” may not be there to support these suggestions, but there is very little to refute them, either.
Invicorp (VIP+phentolamine) may be available in a “Relia-ject” device again soon, which is as simple to use as a biro. No drug-related pain, no mixing, just place it against the skin and press the button. It fires the needle through the skin and injects the drug automatically. It can take less than 20 seconds to administer, from the fridge to the disposal bin. It is as yet unlicensed but it is probably only a matter of time before it is available and it certainly won’t be an option after an implant.
John Dean, Sexual Physician, UK
Dear Dr. Piha,
I have a at least 50 patients that use 200 mg of Viagra and have being tryied 40 mg of Ciallis, all of them with a diagnosis of Pheriferic Neuropathy from Diabetes at most, seventy-eight percent of these patients did´nt achieved a Response 3 with oral drugs. But, TRIMIX (Phent., PGE1, Papav.) and 0,25 cc´s Dose I.C..eighty-three percent achieved a Response 3.
Thus, I think it happens because the Neuropathy itself.
Francisco Costa Neto, MD.
Santa Izabel Hospital
Department of Urology
Prof. of Andrology
The consens of the World Diabetes Mellitus Ass. points that Prostaglandin E1 as ICD has to be the first choice for Sildenafil non responders diabetic patients. And that is the way it works for our patients.
Doses over 100 mgrs of Sildenafil increase adverse effects with no improvement of erection.
Dear Dr. S. O. Burman:
Our group reported, in last Montreal ISSIR meeting, partial results in a prospective study combining Sildenafil 50 mg on demand plus PGE1 IIC 20mcg programme each two weeks, in non responder to Sildenafil 100 mcg and we save 67% of them. We expect to present final results in Buenos Aires. We think this combining treatement could be a good option in this case, at least before implant penile prothesis, because "your patient do not need to inject himself every time he wants sexual intercourse".
We hope to help with this information.
Thank you and regards.
Pedro Ramon Gutierrez. CESEX. Tenerife. C.I. Spain
Dear Dr sheldom
There is a paper by Padama Nathan for the usage of what's called salvage procedure for those non responders to the usual dosage of PDEIs. but still what you can get for the erection is far less than the rate of adverse events increament. The prothesis outcome in paraplgeics depends upon the technique and the comorbid diseases(DM, PVD), so if the patient is suitable for the best solution which is the ICI (Caverject), he will be suitable to try the combination of 2 or 3 drugs working on multiple level before going to prosthesis as a last option.
Shedeed Ashour Shedeed MD
Dr. Emre Akkus presented a case of a 16 years old patient with aspermia consistent with retrograde ejaculation as confirmed by post-ejaculatory urine analysis. TRUS revealed a small defect at the bladder neck. No other pathology was identified at the verumontanum or seminal vesicle. No diabetes mellitus nor any other endocrinal abnormality was identified. Dr. Drogo K. Montague agreed on the management plan, confirming TRUS findings with cystourethroscopy. This is to be followed by a V-Y bladder-neck plasty. Dr. Ralf Herwig suggested a micturition cytourethrogram -addition to the cystoscopy- as well as further evaluation of neurological status of the patient. He also outlined other treatment options including alpha mimetic agents & injection of bulking agents into the bladder neck. For reproduction and sperm retrieval purposes Dr. Herwing suggested a trial of ejaculation with a filled bladder or micturition of preinstalled sperm buffer media, after ejaculation. Dr. Edgardo Becher also suggested an alpha agonist such as pseudoephedrine. Dr. Eric Meuleman inquired about orgasm which appears to be occurring normally.
I need your advice and suggestions for an interesting case:
16 years old a young adolescent man. His main complaint is he does not have semen fluid with masturbation nor during sleep ejaculations.
His hormone levels are normal, no major disease like Diabetes.
His genitals and physical appearance are normal like a young man.
TRUS revaled a small defect (an opening) at the bladder neck. No other pathology like a verumontanum or seminal vesicle cyst.
Urine analyses after masturbation revealed plenty of spermatozoa which supports retrograde ejaculation.
I am planning to perform urethrocystoscopy and try to see whether such an opening at the bladder neck or whether any other pathology?? exist.I also asked to investigate whether Zinc appears in the urine after masturbation.
Questions: What other diagnostic tools should I perform?
If it is a congenital bladder neck opening what procedure should I perform?
Can Anybody who has any experience on such a case make any other suggestions?
Dear Dr. Akkus
Of course the TRUS findings should be confirmed by cystourethroscopy as you plan. Then you should perform a V-Y bladder neck plasty. This is the reverse of the usual procedure that is performed to treat bladder neck contracture. I wish you success.
Drogo K. Montague, M.D.
Glickman Urological Institute
Cleveland Clinic Foundation
I suggest in addition to a cystoscopy to perfor a Micturation cyto urethrogram to ensure that a bladderneck insufficiency / filling of the prostate before micturation can be seen. This seems to me as a proof of bladder neck insufficiency. I whould also check the neurological status of the patient.
My first choice in therapy whould be an alpha mimetic agent (in Austria Gutron Trp.). If no improvement can be seen there might be an option for bulcing agent injetion into the bladder neck.
Another option can be ejaculation with filled bladder for reproduction or sperm asservation after ejaculation (micturation of preinstilled solution after ejaculation.
Dr.Ralf Herwig, M.D.
Dept. of Urologie,
I would try with an alpha agonist such as pseudoephedrine 120 mg 2 hours before masturbation.
Is he experiencing an orgasm?
Yes Eric, He has orgasms.
Last update : 09/09/2004