A shared care approach to the management of erectile dysfunction in the community

Erectile dysfunction (ED) affects men of all ages and results in considerable distress and impact on quality of life for those who suffer from it. As ED is associated with a wide variety of under-lying conditions and cardiovascular co-morbidities, there is a requirement for diversity of treatment options and several factors must be considered to customise and optimise therapy. In the ideal holistic approach to management of the ED patient, both primary care and specialist physicians have an important role to play. This article reports on a sequential approach for the diagnosis and treatment of ED, with an emphasis on 'shared care'. The deliberations are based on a pan-European inter-disciplinary group that met at the Lygon Arms, UK on 22 February 2002.

Intracavernosal alprostadil is effective for the treatment of erectile dysfunction in diabetic men

The efficacy and safety of intracavernosal alprostadil was evaluated for the treatment of erectile dysfunction in men with type I or type II diabetes mellitus. This was an open-label, flexible dose-escalating study involving 336 men (77% of whom were Asian/Oriental) enrolled by 15 centres in Australia, Canada and seven countries in Asia. The effective alprostadil dose, ie the dose producing penile rigidity adequate for intercourse and lasting up to 60 min, was established by titration at the clinic prior to entry into the 6 month self-treatment home phase. All men were fully trained in the self-injection technique before entry into the home phase. Efficacy and safety were assessed using patient and partner diaries and by interview at clinic visits during the titration phase and after 1, 3 and 6 months of treatment. An effective home dose was established by titration for 94% of the 336 men (median dose 20 microg, range 2.5-60 microg). Of 278 (83%) men who entered the home phase, 277 men (247 with type II diabetes and 30 with type I diabetes) had evaluable data for alprostadil dosage and clinical response. During the home phase, a satisfactory erectile response was achieved after 99% of injections, and the median alprostadil dose remained unchanged. The initial home dose and clinical response were similar in type I and type II diabetic men. Treatment was generally well tolerated with a low incidence of penile pain (24%) In conclusion, intracavernosal alprostadil was effective and well tolerated in type I and type II diabetic men with erectile dysfunction of mixed aetiology.

Andropause: coming of age for an old concept?

Sex hormones have a broad range of actions in regulating very diverse systems through life as well as critical reproductive and growth processes. Sex hormone biology in its satisfaction of the early demands of species survival and reproductive advantage may be leading a destructive process resulting in frailty and the less desirable aspects of aging that may, in men, be termed andropause. One important system associated directly with aging is interleukin-6, which increases as androgens decline. This may be taking place regardless of androgen receptor activity. It is currently acknowledged that androgens are the first but not the only possible treatment for andropause. There is an acute appreciation of the potentially undesirable impact of androgens on the biology of prostate cancer, as well as, possibly, the cardiovascular system. Most authors agree that careful evaluation and surveillance of the prostate must attend androgen therapy in aging men.

Antihypertensive drugs induce structural remodeling of the penile vasculature

PURPOSE

There is a strong association between hypertension and erectile dysfunction. Studies of the treatment of hypertension have shown that some pharmacological agents are capable of inducing regression of the vascular structure during treatment. We determined whether penile vascular structure is as susceptible as other vascular beds to regression during antihypertensive drug treatment.

MATERIALS AND METHODS

Adult spontaneously hypertensive rats were treated for 1 or 2 weeks with 30 mg./kg. enalapril daily, or for 2 weeks with 45 mg./kg. hydralazine daily. Structurally based vascular resistance was determined in isolated penile and skeletal muscle vascular beds perfused with Tyrode-dextran. A cumulative alpha1-adrenoceptor concentration constrictor response curve to 1 to 100 microg./ml. methoxamine was constructed and the maximum constrictor response (vasopressin, methoxamine and angiotensin II) indicating the tissue yield point (that is the average medial bulk of vascular smooth muscle) was determined. The hearts were excised and the ventricles were separated and weighed.

RESULTS

Enalapril treatment progressively regressed cardiac and vascular structure during the 1 and 2-week treatment periods with a mean tissue yield point plus or minus standard deviation of -5.91% +/- 5.1% (p <0.05) and -12.1% +/- 6.0% (p <0.05), and a mean left ventricle mass of -11.8% +/- 2.2% (p <0.05) and -13.6% +/- 3.2% (p <0.05), respectively. Hydralazine treatment for 2 weeks was less effective on vascular regression with a mean yield of -7.3% +/- 2.9% (p <0.05) and it did not alter left ventricle hypertrophy compared with controls (3.7% +/- 5.0%).

CONCLUSIONS

The data suggest that renin-angiotensin system inhibition may at least partially normalize penile vascular structure. The impact of these changes on erectile function must be determined.

Characterising the benefit of apomorphine SL (Uprima) as an optimised treatment for representative populations with erectile dysfunction

The clinical profile for apomorphine sublingual (SL), a new centrally active agent for the management of the erectile dysfunction (ED) patient, is described in this article. Apomorphine SL is shown to be rapid in onset (71% of patients within 20 min) with a consistent, predictable response that is independent of severity (mild, moderate or severe), the underlying aetiology or the presence of significant co-morbidities (coronary artery disease, hypertension, etc). Importantly, there is also consistent long-term clinical benefit (>90% of attempts being successful over 18 months), for patients who respond to therapy and a benign side effect profile (<13.4% patients with adverse events). This formulation of apomorphine has a speed of onset and overall clinical profile that may offer particular advantages to the patient in terms of spontaneity and predictability of response. ED is a complex disease of varying aetiologies and severities often associated with a number of co-morbidities that require diverse solutions. Given the need for customisation of therapy to individual patient needs, the clinical profile of apomorphine SL would indicate that it will make a most welcome addition to the physician's armamentarium against ED.

Severe erectile dysfunction is a marker for hyperprolactinemia

The need for routine prolactin (PRL) measurement in the initial evaluation of erectile dysfunction (ED) has been questioned because of the low rate of hyperprolactinemia (HP) in these men and the costs involved. In addition, it is widely thought that sexual desire problems are a good clinical marker for HP and/or low testosterone in men with ED. Within a 15-month period, 844 consecutive PRL and sexual hormone determinations were conducted in men at the Kingston General Hospital. Of these patients, 138 were comprehensively evaluated at the first visit for ED and completed the International Index of Erectile Function (IIEF). In the 138 patients, 2.2% had severe hyperprolactinemia (>35 ng/ml), within the range of 1-5% previously reported. No correlation between initial prolactin value and the sexual desire domain or the erectile function domain (EFD) of the IIEF was found for this population. However, all cases of severe HP were found to occur in men who scored less than 10 in the EFD of the IIEF. Low libido is widely accepted as a marker of HP. In this study, HP was found in patients not reporting major problems with a desire disorder. Clinically significant HP may be reliably found with routine biochemical evaluation and in this series was not detected in patients with EFD scores above 10. A routine PRL measurement is inexpensive and early detection of a serious and treatable disease may afford greater therapeutic success.

Hormonal erectile dysfunction. Evaluation and management

The clinical diagnosis of hypogonadism in the adult is difficult to establish on the basis of a history and physical examination and universally requires biochemical investigations. A serum testosterone determination is justified in men complaining of erectile dysfunction with or without alterations in sexual desire. Among the causes of erectile dysfunction, hypotestosteronemia rates are low. The prevalence of erectile dysfunction particularly is common at a period in life when alterations occur in male hormonal environment. The treatment of hypogonadal erectile dysfunction, regardless of age, is readily available, safe, and effective. The positive impact of treatment on the overall quality of life can be significant. The presence of erectile dysfunction in an aging man (> 55 years) does not imply the presence of hypogonadism, and, even if the two conditions are present, the indications for treatment require good clinical judgment. Persistent low testosterone levels may have significant detrimental effects in other organ systems; therefore, a timely diagnosis of androgen deficiency and appropriate treatment may have significant effects outside the narrow field of sexual performance.

Andropause--a multisystem disease

The syndrome of androgen deficiency with aging has important biochemical and clinical manifestations. Whether this is called the andropause or by another name the patients with this condition appear to be suffering an accelerated form of aging and some will have individual or clinical reasons to receive treatment. The changes usually attributed to androgen deficiency have been recognized more recently to be due to a broader problem with a number of interlinked hormonal systems (including growth hormone, IGF-I, melatonin, leptin). Several clinical domains can be identified comprising the andropause: Substance (lean body mass, visceral fat, bone mineral density and hematopoiesis); Surface (hair and skin alterations); Central Nervous System (intellectual capacity, mood and sleep patterns); Sex (desire and erection); Prostate. Investigation is directed at the presenting complaints and measuring the serum bioavailable testosterone. Treatment is currently by testosterone replacement using one of a number of routes (parenteral, oral, transdermal). The object of treatment is improvement in the index clinical domains and biochemical normalization. Contraindications include known or suspected prostate or breast cancer.

Key issues from the clinical trials of apomorphine SL

The central nervous system has the capacity to enhance the activity of dysfunctional penile tissue in men with erectile dysfunction (ED). Phase III clinical trials have been conducted using Apomorphine SL (TAP Pharmaceuticals, Deerfield, IL) as a centrally acting treatment for ED. Apomorphine SL has been administered to over 3,000 men in over 75,000 doses. In three phase III crossover double blind studies 854 patients were given a total of 8,263 tablets of apomorphine SL in 2 and 4 mg doses. The patients were between 18 and 70 years old and had multiple co-morbid conditions. Outcome measures included intercourse rates and erection rates on a per attempt basis as well as psychometric instruments and partner response evaluations. The results show that 74.1% of patients had moderate or severe grades of ED on inclusion into the studies, 31% had hypertension, 16% had documented coronary artery disease, 16% had dyslipidemia, and 16% had diabetes. Erections occurred rapidly (10-25 min). In 54.4% of attempts at 4 mg (vs 33.8% placebo, P < 0.001) erections suitable for intercourse were documented. A majority of the attempts at intercourse (50.6%, P < 0.001) were successful at 4 mg a doubling of baseline rates. Mild nausea was the most common but infrequent side effect and the rare occurrence of syncope was the most significant. No cardiac deaths were attributed. It is concluded that the clinical trials of apomorphine SL demonstrate a safe and significant rate of restoration of erectile function by means of a central mode of action. Efficacy has been shown in men with cardiovascular disease and severe grades of ED.

Apomorphine: an update of clinical trial results

Apomorphine SL (TAP Holdings, Deerfield, IL) is a centrally acting treatment for erectile dysfunction (ED) that has been undergoing phase III trials. Over 3000 men have received apomorphine SL and over 75,000 doses have been taken. In the first three phase III parallel arm cross-over double-blind studies 854 patients were given a total of 8263 tablets of apomorphine SL in 2 and 4 mg doses. The patients were between 18 and 70 y old and outcome measures included per attempt rates of intercourse and erections firm enough for intercourse as well as psychometric instruments and partner responses. The majority (74.1%) had moderate and severe grades of ED on admission to the studies, 31% had hypertension, 16% had documented coronary artery disease, 16% had dyslipidemia and 16% had diabetes. Erections occurred rapidly (10-25 min) and in 54.4% of attempts at 4 mg (vs 33.8% placebo). A majority of the attempts at intercourse (50.6%) were successful at 4 mg in patients when recorded on a per-attempt basis. The most common but infrequent and mild side effect of nausea decreases with use. The phase III trials of apomorphine SL show that there is a clinically important restoration of erectile function from this new formulation of apomorphine. It has a rapid and safe effect through action in the central nervous system. Apomorphine SL brings a new choice to the management of ED that will further benefit the millions of couples affected. International Journal of Impotence Research (2000) 12, Suppl 4, S67-S73.

Central neuropharmacological agents and mechanisms in erectile dysfunction: the role of dopamine

Central nervous system processes are fundamental to sexual function. Considerable progress has been made in our understanding of the neuroanatomical and neuropharmacological bases for erection. Based largely on rat models, there is adequate understanding presently of the general anatomical areas of the brain that relate to sexual function, including the medial amygdala, medial preoptic area, paraventricular nucleus, the periaqueductal gray, ventral tegmentum and others. There is also a burgeoning body of evidence implicating nitric oxide, dopamine, serotonin and oxytocin as critical central neurotransmitters involved in various aspects of sexual function. The role of dopamine, in particular, appears fundamental in the mediation of erectile responses in both animals and man. Additionally, clinical research with apomorphine, a D1/D2 agonist, has shown significant promise in improving erections in men with a wide range of erectile difficulties. Finally, a new classification matrix has been proposed for existing treatments for erectile dysfunction based upon the putative site and mechanism of action. Implications for the further development of neuropharmacological agents in this area are discussed.

Pre-penile arteries are dominant in the regulation of penile vascular resistance in the rat

The amount of blood flow into the penis that will produce an erection is dependent on the sum of inflow resistance from the feeder arteries, arterioles and the intra-penile vasculature. In the present study, our objective was to determine quantitatively the contribution to inflow resistance of these different components of the rat penile vasculature. Using methods developed previously, we determined the resistance properties of the isolated perfused whole penis in situ, both in an intact system and after serial transactions of the vessels. These cuts eliminated progressively larger distal segments of the vascular bed. Perfusion pressures were recorded at different flow rates (0.5-3 ml/min/kg body weight) under conditions of maximal dilatation and maximal vasoconstriction induced by methoxamine (MXA, 40 microg/ml). Regardless of the level of vascular tone, the pudendal artery contributes approximately 70% of the total resistance of the penile vasculature. In contrast, the vasculature within the penis (tip, shaft, crus) contributes only about one quarter of the resistance. Penile arterial inflow resistance properties both at maximal vasodilation and maximal alpha1-adrenergic constriction are dominated by the extra-penile vasculature in the rat. The implications of these findings are that alterations in the pudendal-artery (eg vasodilation, vasoconstriction, stenosis) would have primary control of arterial inflow and suggest an important role for pharmacological agents which can promote a more generalized vasodilation (eg phosphodiesterase inhibitors) in contrast to selective corpus cavernosal agents.

Effects of an environmental anti-androgen on erectile function in an animal penile erection model

PURPOSE

Erectile function is testosterone dependent. For example, interference with either the levels or receptor binding of this steroid hormone may induce erectile dysfunction. Several environmental contaminants can interfere with the actions of endogenous hormones and have been termed 'endocrine disrupters.' p,p-DDE, a prominent and persistent metabolite of the insecticide DDT, has been shown to be an androgen receptor antagonist. The objective was to determine whether endocrine disrupters, as exemplified by p,p-DDE, are factors in the etiology of erectile dysfunction.

MATERIALS AND METHODS

Using the established rat model of apomorphine-induced (80 microg./kg, s.c.) erections we assessed the dose-response effects of p,p-DDE in comparison to the known androgen receptor antagonist flutamide in acute (0.5 to 12 hours) and short-term (up to 8 weeks) experiments in both intact (Study 1) and castrated (Study 2) rats. As a follow up (Study 3), castrated rats treated with p,p-DDE were given increasing doses of testosterone (0.48 to 2.4 mg./kg., i.p.), eight weeks after p,p-DDE administration, to assess reversibility of p,p-DDE effect.

RESULTS

A single dose of flutamide (50 mg./kg., i.p.) was found to significantly decrease apomorphine-induced erections to less than 50% over 12 hours following flutamide administration with recovery of erectile response within 48 hours. In comparison, a single dose of p,p-DDE (500 mg./kg., i.p.) decreased apomorphine-induced erections for at least two weeks (1.15+/-0.3 versus 2.5+/-1.1). Castration significantly decreased apomorphine-induced erections to approximately 0.5 erections/30 minutes. Flutamide (50 mg./kg.; i.p.) or p,p-DDE (50 mg./kg.; i.p.) did not further suppress the apomorphine erections in castrated rats. Testosterone supplementation (480 microg./kg; s.c.) in vehicle treated castrated rats recovered erectile response to pre-castrated levels, whereas p,p-DDE treated castrated rats required 4 times the dose of testosterone (2 mg./kg.; s.c.) given to vehicle treated rats to recover erections.

CONCLUSIONS

The endocrine disrupter p,p-DDE can markedly interfere with erectile function and demonstrates persistence after a single dose. This supports our novel concept that environmental hormones may cause erectile dysfunction.

The conditioned response erection (CRE)--a new approach to modelling erectile responses in the rat

Several animal models are currently used in erectile (dys)function research; these models fail to account for the conditions involving the more spontaneous erections in humans. Recently, we observed an increase in the number of 'spontaneously' occurring erections in rats with previous exposure to apomorphine (APO), a centrally acting drug that initiates penile erections and yawns. Based on this observation, we designed a series of experiments to characterize the development of enhanced, non-apomorphine-induced erections or 'spontaneous' erectile responses to vehicle administration in rats with previous exposure to APO. We further examined the effects of castration on these conditioned erections. Naive (ie never received APO) rats were administered vehicle (1 ml/kg saline) to determine the frequency of baseline erections and yawns. An alternating series of APO (80 microg/kg s.c.) and vehicle administrations were performed over several days and subsequent erectile and yawning responses were recorded. Following 3 sets of 3 APO administrations (with vehicle administered between sets), and the 3rd vehicle administration, these rats were then surgically castrated and allowed 30 days to recover. Following this, APO was administered 3 times to determine erectile and yawning responses post-castration, followed by vehicle administration to determine the effects of castration on conditioned APO responses. The major findings were: (1) that although naive rats had a basal spontaneous erectile response (0.75 +/- 0.88; 4 of 8 rats with at least one erection), repetitive administration (up to 22 treatments) of the central initiator apomorphine significantly increased the number of erections (1.8 +/- 0.7; 7 of 8 rats with at least one erection) and yawning (2.5 +/- 2.47) responses to vehicle administration; and (2) both spontaneous yawning and erectile responses were found to be androgen dependent since castration dramatically lowered the number of erections (0.13 +/- 0.35; 1 of 8 rats with at least one erection) and yawns (0). Therefore, this method of producing erections without a pharmacological manipulation provides an additional animal model which can be used in conjunction with the APO-induced erections in characterizing the physiology and pathophysiology of erectile function in conscious rats.

Andropause: a misnomer for a true clinical entity

PURPOSE

A progressive decrease in androgen production is common in males after middle age. The resulting clinical picture has been erroneously named male menopause or andropause. A more appropriate designation is androgen decline in the aging male (ADAM). The syndrome is characterized by alterations in the physical and intellectual domains that correlate with and can be corrected by manipulation of the androgen milieu. We review the epidemiological aspects of aging and endocrinological manifestations of ADAM, and provide recommendations for treatment and monitoring of these patients.

MATERIALS AND METHODS

We performed MEDLINE, Pubmed, Current Contents and Pharmaceutical Abstracts searches of relevant peer reviewed publications on andropause, male climacteric, adult hypogonadism and aging. In addition, conference proceedings were researched to provide a more complete review of the literature. Information was scrutinized and collated, and contributory data were reviewed and summarized.

RESULTS

ADAM is a clinical entity characterized biochemically by a decrease not only in serum androgen, but also in other hormones, such as growth hormone, melatonin and dehydroepiandrosterone. Clinical manifestations include fatigue, depression, decreased libido, erectile dysfunction, and alterations in mood and cognition.

CONCLUSIONS

The onset of ADAM is unpredictable and its manifestations are subtle and variable, which has led to a paucity of interest in its diagnosis and treatment. Urological practice commonly includes a large proportion of men older than 50 years. Therefore, it is important for urologists to recognize the manifestations of and be familiar with evaluations necessary to document ADAM as well as its treatment and monitoring.

The prevalence and influence of significant psychiatric abnormalities in men undergoing comprehensive management of organic erectile dysfunction

Psychiatric factors are etiologically important in a proportion of patients with erectile dysfunction. We determined the prevalence of psychopathology and the impact it has on current erectile dysfunction (ED) assessment and management. A group of 120 consecutive men with ED presenting to the Human Sexuality Clinic for the first time was prospectively investigated. All patients participated in a standardized evaluative protocol, including history, physical exam, assessment by a psychiatrist (using DSM-IV criteria), selective hormonal screen, and diagnostic intracavernosal injection. Follow-up appointments were to discuss diagnostic findings and, eventually, treatment choices. The prevalence of significant psychiatric pathology, excluding interview stress, was 33%. Only 16 of 40 cases were recognized and highlighted in the initial assessments by urological staff. There was no significant difference in the modalities of treatment choices between patients with psychiatric problems and those without. 10% of the patients had multiple organic risk factors, normal ICI, and significant psychiatric pathology. Psychopathology or emotional factors play a significant role in the etiology of ED and they are difficult to identify in a non-directed assessment. Even in the face of significant vascular risk factors, psychological abnormalities may be the primary etiology. Treating the 'phallodynamically challenged' individual without adequately addressing the possible presence of psychopathology, will account for treatment failures and have the potential for leaving untreated serious emotional problems.

Infiltration of the abdominal wall with local anaesthetic after total abdominal hysterectomy has no opioid-sparing effect

We have measured the effect of infiltration of the deep and superficial layers of the abdominal wound on morphine consumption and pain for 48 h after operation, in 40 patients undergoing total abdominal hysterectomy, in a double-blind randomized study. Patients received wound infiltration with 0.9% normal saline 40 ml or 40 ml of 0.25% bupivacaine with epinephrine 1:200,000. There were no significant differences between groups in morphine consumption, linear analogue scores for pain at rest or on movement, nausea or sedation during the first 48 h after operation. We conclude that infiltration of the deep and superficial layers of the wound of a Pfannenstiel incision with local anaesthetic solution did not confer additional analgesia in patients undergoing major gynaecological surgery.

The penis is not protected--in hypertension there are vascular changes in the penis which are similar to those in other vascular beds

In hypertension, small arteries in a variety of vascular beds undergo structural changes that increase resistance. To assess whether there are differential structural changes in the penis that accompany hypertension, we began with determining structurally-based vascular resistance properties in penile and hindlimb vascular beds of adult spontaneously hypertensive rats (SHR) and Sprague-Dawley (SD) rats. In anesthetized SHR, the penile and hindlimb vasculature were isolated and perfused, maximum dilation was induced, and a flow-pressure assessment and alpha 1-adrenoceptor agonist concentration-response curves were generated. Both the baseline and maximum constrictor responses were similar in the two beds of each strain, and overall the maximum structurally-based vascular resistance in SHR was higher than in SD rats. Our data suggests that the penile vasculature is not protected from the structural changes that take place in the other vascular beds in hypertension. There does not appear to be an underlying functional control mechanism that protects the penile vasculature from structural changes that may have a negative impact on penile blood flow.

Neural and pharmacological determinants of erection

An integrative analysis of the determinants of erection will reveal that almost all the common actions of smooth muscle and endothelial cells found in normal vascular biology (NVB), and some neural mechanisms, have roles in supporting erectile function. Many of these cellular mechanisms have been harnessed to create drugs that are or will be used to treat erectile dysfunction. Without standard diagnostic or therapeutic methods, or classifications, it is difficult to compare drugs, and difficult to target the specific deficiencies causing erectile dysfunction. A classification is suggested here that hinges on the identification of two main characteristics. Firstly, there is a fundamental difference between initiating an erection (initiators) and facilitating or enhancing an erection already initiated by other processes (conditioners), and secondly, there are different implications for adverse effects and drug delivery that arise from targeting central nervous system or peripheral systemic processes. These properties suggest a classification of treatments based on a two-by-two matrix. Within each class drugs will be more equivalent enabling better comparisons and more standardized evaluative strategies. By observing the characteristics of patients benefiting from drugs of an identified class it may be possible to develop a physiologically based classification of diagnoses. There may be logical combinations of drugs that will be assembled in clinical practice, taking suitable agents from one of two or more classes. No single mechanism will stand out as overwhelming and no single drug will treat all erectile dysfunction.

A therapeutic taxonomy of treatments for erectile dysfunction: an evolutionary imperative

AIM OF THE STUDY

A functional classification of treatments for erectile dysfunction is important but none exists at present. Advances in the understanding of the mechanisms of drug action and of the mechanisms of penile erection suggest that there is now a rational basis for a therapeutic classification, with the expectation that a logical diagnostic classification will follow.

METHODS

The currently available treatments for erectile function and the known relevant basic science were reviewed and assessed. From this, and analysis of classification systems in other fields, a classification was proposed and evaluated with respect to existing treatments.

RESULTS

The treatments for erectile dysfunction were classified into five major classes by their mode of action: (I) Central Initiators, (II) Peripheral Initiators, (III) Central Conditioners, (IV) Peripheral Conditioners and (V) Other. Drugs in these classes are further subdivided by the routes of administration and the mechanisms of specificity.

CONCLUSIONS

It is possible to analyze all known treatments using this classification. The principles of this scheme should be sufficiently clear as to enable knowledgeable specialists to arrive at similar conclusions about a drug. The classification proposed is general enough such that most new drugs should fall within a class. However, it should be modified if necessary, if new therapeutic agents can not be appropriately classified. It is our conclusion that with such endeavours the specialty itself and national regulatory bodies will find it easier to define and control how to apply new drugs, how to evaluate new drugs, and how to establish reasonable equivalences among agents and in whom these drugs and devices should be used.

An uncommon urologic presentation of a supernumerary breast

Polythelia and polymastia are common developmental abnormalities of the breast and nipple which usually present as small lesions along the mammary line, an embryologic line that extends bilaterally from the axillary regions to the inguinal ligaments. These lesions have been reported in various locations outside the mammary line. We report an unusual location of polymastia in the perineum of a newborn male. A brief discussion of the clinical relevance of such lesions is also included.

Vascular control mechanisms in penile erection: phylogeny and the inevitability of multiple and overlapping systems

A co-ordinated series of vascular events underlie the generation of a penile erection. The control and regulation of this simple event is, in fact, a complex of interactions occurring at multiple levels. Many of these individual pathways and responses have been studied extensively. The understanding of the necessity of the integration between the individual pathways into a complex of series and parallel coupled mechanisms provides a rationale for the development of a framework of multiple and overlapping systems. This paper sets out some of the principles of integrated and balanced control of vasodilation and vasoconstriction in the penis. In addition, the role of growth induction and regression and the importance of time as a factor in studying penile structure and function is discussed.

Testosterone supplementation for hypogonadal impotence: assessment of biochemical measures and therapeutic outcomes

PURPOSE

Although hypogonadism is a rare cause of erectile failure, impotent men are frequently treated with supplemental androgens. The results of such treatment and the individual merits of available formulations remain controversial. A series of hypogonadal men participated in a trial of oral testosterone undecanoate to assess the effectiveness of the medication, and use of biochemical and clinical outcome measures.

MATERIALS AND METHODS

A consecutive sample of 23 hypogonadal impotent men received testosterone undecanoate orally for no less than 60 days. Serum levels of gonadotropins, testosterone, estrogens and sex hormone-binding globulin were measured before, during and after the trial. Sexual response and feeling of well-being were measured by daily diaries and visual analogue scales.

RESULTS

Testosterone undecanoate produced restoration of plasma testosterone levels in all patients but a measurable improvement in sexual attitudes and performance in only 61%. Visual analogue scores were effective discriminants of the therapeutic response but none of the conventional biochemical measures predicted or correlated with clinical outcome.

CONCLUSIONS

Testosterone undecanoate is an effective agent for treating hypogonadism. In hypogonadal impotent patients the most appropriate outcome measure for androgen supplementation is individual response to therapy, while conventional biochemical hormone determinations lack predictive value and fail to correlate with response.

Enhancement of erectile responses to vasoactive drugs by a variable amplitude oscillation device

The limitations of intracavernosal injection (ICI) of vaso-active drugs as a diagnostic tool in the evaluation of erectile dysfunction are well recognized and, prominently, include the artifacts induced by the unfamiliar environment on the patient. We report on the benefits of adding a vibratory stimulus to ICI to improve the sensitivity of this test in a population of 170 patients with erectile dysfunction who were evaluated using a standard protocol. Intracavernosal pressure was measured following ICI alone and ICI with vibratory stimulation of the penis. A statistically significant improvement in intracavernosal pressure (ICP) with the addition of vibration was observed in 87% of the subjects as compared to ICI. In 52% the improvement in ICP was greater than 20% over that achieved by ICI. This study showed that the addition of vibration to intracavernosal administration of vaso-active drugs significantly increases the erectile response in a controlled and reproducible manner. Vibratory stimulation provides a better reflection of erectile potential than the pharmacological challenge alone.

Coronary artery bypass graft surgery and its impact on erectile function: a preliminary retrospective study

Erectile function is markedly affected by acute alterations in circulatory homeostasis of which coronary artery bypass graft surgery is an excellent model. A group of consecutive patients who had undergone coronary artery bypass surgery 6-12 months previously were selected for detailed review by questionnaires that scored their pre-operative and post-operative sexual function and erectile ability and aspects of the quality of life. Thirty patients were evaluable. 10 men (33.3%) had poor erectile function before surgery. Eleven out of 30 men reported an improvement in erectile function while 10 men experienced a decrease or cessation of erectile function. Four of the five patients reporting new post-operative erectile function had had good pre-operative function suggesting that the surgery was directly associated with the impotence in these men. This pilot study suggests that coronary artery bypass surgery can have a significant impact in erectile function.

Surgical treatment of penile veno-occlusive dysfunction: is it justified?

OBJECTIVES

Veno-occlusive dysfunction is a commonly diagnosed cause of impotence. Surgical removal of the intermediate (deep dorsal vein and its tributaries) venous system of the penis has been advocated as an effective treatment but recurrence of the dysfunction is common after a few months. We studied prospectively the first 100 cases of veno-occlusive dysfunction undergoing surgical treatment at our institutions.

METHODS

One hundred consecutive patients undergoing penile venous ligation surgery were evaluated. All patients had a comprehensive workup prior to therapy. Surgery involved excision of the intermediate venous drainage. Short-term results were investigated by personal interview, and long-term outcome was determined by separate telephone interview of patients and their partners when available.

RESULTS

Short-term success (3 months) was 62%, and long-term success (45 months) was 31%. Historical factors, preoperative testing results, and histologic assessment of the surgical specimens were not found to be helpful in predicting outcome.

CONCLUSIONS

Despite the mediocre long-term results of the surgical procedure and lack of preoperative predictive factors, we believe that venous leak surgery could be offered to well-selected patients in whom the only other available alternative would be a prosthetic device.

Oral and topical treatment of erectile dysfunction. Present and future

A great deal of progress has been made in the pharmacological treatment of erectile dysfunction. At present, however, the most effective therapies require intracavernosal injections with a number of associated drawbacks. An increasing number of oral and transdermal agents have been introduced clinically or are at various phases in their development. It is evident that severe end-organ disease probably will not result in successful systemic therapy. Nevertheless, in men with intact or mildly dysfunctional erectile mechanisms, noninvasive treatments can offer some measure of success. Further study of individual and synergistic activity of available compounds is underway.

Isolation and perfusion of the pudendal vasculature in male rats

PURPOSE

The present study outlines a novel in situ technique to assess the regulation of vascular resistance in the penile vascular bed of the Wistar rat.

MATERIALS AND METHODS

The isolation and perfusion of the pudendal artery were achieved by ligating all branches of the external iliac artery not directly connected to the internal pudendal artery.

RESULTS

A linear flow-perfusion pressure curve was generated to ensure a viable preparation. A cumulative concentration-vascular response curve to the alpha 1-adrenoceptor agonist methoxamine (0.5-64 micrograms./ml.) was obtained.

CONCLUSIONS

This novel methodology will allow reproducible and consistent quantitative assessments of the numerous factors (both neural and hormonal) that are proposed to govern the flow of blood in the penile vascular bed.

Radiofrequency thermal ablation of the prostate: the TUNA technique

Radiofrequency (RF) needle ablation has been developed for use in treating the symptoms caused by benign prostatic hyperplasia. The transurethral needle ablation (TUNA) device permits accurate needle placement in the prostate and the RF generator has been designed to create reproducible lesions in prostate tissue. The procedure may be done on an outpatient basis using topical anesthesia only. Fifteen patients were studied prospectively as part of a Canadian multicenter trial. Significant improvements in peak flow (7.4-8.9 ml/s), A.U.A. Symptom Score (21-16) and Quality of Life score (4.6-3.1) have been documented in early follow-up, mirroring the improvements found in other series. The technique was well tolerated and resulted in a 20% retention rate. TUNA is a minimally invasive technique that has been shown to create lesions in the prostate and is suitable for outpatient application. Early results show a clinical effect. The ultimate indications and role for this technique will be established by randomized controlled study.

Recovery of erectile function by the oral administration of apomorphine

OBJECTIVES

Apomorphine has been reported to be effective in causing erections in animals and man when administered parenterally. The side effects, notably nausea, have seriously limited its clinical usefulness. We formulated apomorphine for controlled sublingual absorption and herein report on four preliminary studies evaluating efficacy and side effects in men with no documentable organic cause of erectile dysfunction.

METHODS

Patients complaining of erectile dysfunction underwent a careful evaluation. Those with measurable organic dysfunction or known organic factors were excluded. Men with primarily psychogenic impotence were tested with one of four protocols of an apomorphine preparation (preliminary sublingual liquid, preliminary 5 mg tablet, aqueous nasal spray, and new 3 and 4 mg controlled absorption tablets). The erectile response of these men to the drug with visual erotic or sexually neutral stimulation was studied with the Rigiscan.

RESULTS

Seven of 10 evaluable patients responded to the sublingual liquid preparation but the majority experienced significant nausea. The preliminary 5 mg tablet and aqueous forms did not produce useful responses free of side effects. The newly formulated controlled absorption 3 and 4 mg tablets were tested in 12 men. Eight of 12 (67%) developed erections in response to apomorphine. Erectile activity was seen during sexually neutral visual stimulation to a significantly greater extent than with placebo. Home trial use was found to be successful and sustained by 7 of 11 (64%) patients.

CONCLUSIONS

We have shown that apomorphine will act as an erectogenic agent when absorbed through the oral mucosa. In a carefully selected group of impotent patients with no documentable organic causes of erectile dysfunction, but with proven erectile potential, 67% will experience significantly durable erections with a dose of 3 or 4 mg of apomorphine when formulated for controlled absorption. The results in these small groups appear to justify larger clinical studies of this proprietary formulation.

Diurnal penile tumescence recording in the etiological diagnosis of erectile dysfunction

Rapid eye movement sleep occurs during napping. We investigated the appearance of penile tumescence during periods of day napping in a population of 18 impotent men who, in addition, underwent a comprehensive sleep investigation for impotence, including polysomnographic recording and nocturnal penile tumescence monitoring. Of the subjects 16 (88%) had rapid eye movement sleep during the night. Four patients who did not have erections on 2 separate sessions of nocturnal sleep recording also did not experience penile tumescence during the day. Of the 12 patients with documented erections at night 9 (75%) also exhibited erectile episodes during napping. Diurnal penile tumescence recording is less cumbersome, less expensive and more convenient to perform than its nocturnal counterpart. Diurnal penile tumescence appears to be a summary reflection of nocturnal penile tumescence episodes. The consistency between nocturnal and diurnal penile tumescence suggests that further study of this new technique is worthwhile. Validation of diurnal penile tumescence may offer a viable alternative to the comprehensive assessment of impotent men.

Video-assisted perineal and open surgery

The use of a laparoscope as a light source and close-up camera has been helpful in acquiring and teaching the techniques of radical perineal prostatectomy. The concept is simple and is applicable to a wide range of problems with surgical visualization and demonstration.

Effects of castration and exogenous testosterone supplementation in an animal model of penile erection

The dependence of erectile behavior on androgen functioning is well established. Castration produces loss of both libido and potency in man and animals. The present study, using an animal model for potency, demonstrates the dependence of centrally induced erectile behavior on an intact androgen milieu. Castrated rats failed to produce an erection in response to apomorphine, an agent shown to produce erection in nearly all normal rats. Administration of exogenous testosterone propionate in dosages exceeding 60 micrograms./kg. produced a significant increase in erectile behavior. Yawning, an essentially parallel phenomenon to the stimulation of the erectile response, was also decreased following castration and responded similarly to increasing amounts of exogenous testosterone, demonstrating the influence of androgen functioning on the central nervous system. It was concluded that testosterone is a necessary prerequisite for the maintenance of a centrally induced erectile and yawning response. In an animal model of penile erection, testosterone increases the number of erections in a dose-dependent manner in castrated rats. The dependence of the erectile response on testosterone is, at least in part, centrally mediated.

Effects of streptozotocin-induced diabetes on dopaminergic functioning in the rat: analysis of yawning behavior

Apomorphine, a dopamine receptor agonist, causes yawning in rats. It has been suggested that the analysis of yawning behavior provides an index of dopamine autoreceptor function. Dopamine turnover in the substantia nigra of diabetic rats has been shown to be decreased following administration of amphetamine or apomorphine (17,21). Yawning behavior after 4 weeks of streptozotocin (STZ)-induced diabetes in Wistar rats was significantly lowered when compared with their age-matched normal controls. Yawning behavior was not further diminished after an 8-week duration of diabetes mellitus; however, a significant recovery in yawning was seen by 20 weeks of diabetes. Yawning in rats after 20 weeks of STZ-induced diabetes mellitus is not significantly different from that seen in normal control rats. The results suggest that in STZ-induced diabetes of only 4 weeks duration a measurable change in the substrate for yawning has occurred.

Age-related changes in apomorphine-induced erections

Advancing age produces a noticeable and well-documented decline in erectile function in humans. The effects of aging on the ability of apomorphine to stimulate erection and yawning behavior in rats was studied in our bioassay for potency. At the age of seven months, rats failed to respond to the same dose of apomorphine which, just one month earlier, produced erections. Erectile function was then tested in thirty-two seven-month-old rats naive to apomorphine injections, and these rats also failed to respond. Experimentally naive rats of six months of age were then tested and apomorphine produced reliable erections. It is felt that an alteration in dopamine autoreceptor function may be occurring in the central nervous system of rats at approximately seven months of age rendering them incapable of responding to apomorphine with penile erections.

The characterization of a bio-assay of erectile function in a rat model

The investigation of biological phenomena in impotence using an animal system requires a determination of the erectile capabilities of the animal. Rats respond reliably to apomorphine by the exhibition of a phenomenon of erections and yawns. This property has been used to form the basis of a bio-assay of erectile integrity in the rat. We compared rats treated with placebo alone, sham operated rats, rats rendered surgically impotent and castrated rats with and without testosterone. Rats did not respond to placebo. The sham operated rats remained normal in all measured respects (2.66 erections/rat/30 minutes). Surgically impotent rats yawned normally but had no erections. Castrated rats did not have erections and had diminished yawning (3.21 yawns/rat/30 minutes vs. 7.7 for controls p less than .001) but responded normally after testosterone administration. The bio-assay is useful as a standard test of erectile function in the rat.

Metoclopramide decreases apomorphine-induced yawning and penile erection

Acute administration of metoclopramide, a dopamine (D2) antagonist, reduced both apomorphine-induced yawning and penile erections. Metoclopramide, prominent in clinical use as an effective antiemetic, has been shown to be associated with decreased erectile function in humans. Experimentally naive rats were given a standardized dose of apomorphine and one of a range of doses of metoclopramide. The study shows that metoclopramide decreases the erectile response to apomorphine and suggests that the erectile difficulties experienced in humans after metoclopramide treatment may be a result of interference with a central dopaminergic mechanism(s).

Topical glyceryltrinitrate causes measurable penile arterial dilation in impotent men

The current understanding of the intracavernous changes that cause or accompany penile erections has encouraged the use of vasodilators as therapy for erectile dysfunction. An established vasodilator, glyceryltrinitrate, was selected for in vivo study because of its rapid transdermal absorption. Color coded duplex ultrasound was used to assess penile vascular response. In a large group of men with erectile dysfunction significant dilation was noted in response to a small amount of nitroglycerine paste applied to the penis. There is a measurable vasodilatory response that can be induced by synthetic nitrates in penile tissue in impotent men.

Synthetic nitrovasodilators are effective, in vitro, in relaxing penile tissue from impotent men: the findings and their implications

Normal penile erectile function is dependent on arterial adequacy, appropriate venous occlusion, neurohumoral factors, and finally the relaxation of penile cavernous trabecular smooth muscle. The present experiments were designed to test whether compounds related to endothelium-derived relaxing factor have a role in penile smooth muscle relaxation and whether this role is preserved in clinically impotent tissue. Isometric tension experiments were conducted using strips of human tissue (appropriately obtained) from patients found to be impotent by clinical criteria. Glyceryl trinitrate and isosorbide dinitrate produced maximal relaxations of 66 and 63%, respectively, in tissues contracted with norepinephrine: 50% relaxation was observed at 6 x 10(-7) and 8 x 10(-5) M, respectively. The finding of a relaxant response to synthetic nitrovasodilators in "impotent" tissue implies that (i) complete end organ (smooth muscle) failure is not always, if ever, seen, (ii) endothelium-derived factors probably play a role in erectile tissue parallel with their role in other vascular tissues, (iii) more proximal factors may be responsible for clinical impotence, and (iv) synthetic nitrovasodilators may have a role in the therapy of clinical impotence.

Bladder neck suspension for stress incontinence as an outpatient procedure

Simplified but effective operative techniques have made surgery for stress incontinence less hazardous and traumatic and more acceptable to these patients. Transvaginal needle vesical neck suspensions, by avoiding splitting of the fascia of the abdominal wall, decrease postoperative discomfort and convalescence. Various modifications of the original Pereyra needle vesical neck suspension are currently in use. Probably the simplest and most effective is a technique reported by Raz, which the authors employ as an outpatient procedure and describe here.

Pseudoxanthoma elasticum and its urological implications

We describe a ureteral disruption in a patient with pseudoxanthoma elasticum. Pseudoxanthoma elasticum is characterized by major changes in the physical properties of tissues that indicate a need for modifications in classical tissue handling techniques. In particular, low elasticity and tensile strengths make dilation a more hazardous procedure in patients with pseudoxanthoma elasticum.

Improved neurologic function following repair of type I aortic dissection with an intraluminal prosthesis

Repair of type I dissection of the aorta by suturing is often complicated by intraoperative and postoperative bleeding. To avoid these complications, the authors use a sutureless ringed intraluminal prosthesis. They describe the case of a 62-year-old woman who had paralysis of the lower extremities with acute type I dissection of the aorta. Emergency surgical intervention 14 hours after onset of symptoms and repair with the intraluminal graft resulted in minimal aortic insufficiency and almost complete functional recovery. An aggressive surgical approach to patients with profound neurologic deficits due to aortic dissection is justified. Repair with the sutureless intraluminal prosthesis is simple and safe and may allow recovery of neurologic function.

Kidney transplantation. Rational approach to vascular anastomoses

A simple technique for performing the vascular anastomoses in renal transplantation is presented. It utilizes ipsilateral side-to-end vascular anastomoses using the external iliac arteries and punch anastomoses. Using this method, transplantation of kidneys is simplified despite short, multiple, or unequal caliber of renal arteries or calcified recipient iliac arteries.