Reconfiguration of the severely fibrotic penis with a penile implant

PURPOSE

Using evidence based methods we prospectively evaluated the impact of a new surgical procedure on penile deformity caused by severe cavernous fibrosis.

MATERIALS AND METHODS

In 10 patients with severe penile curvature, shortening and impaired penile rigidity due to fibrosis of the corpora cavernosa we made multiple relaxing incisions of the tunica albuginea and subsequently placed a 3-piece inflatable penile implant. Patients were evaluated before and after the procedure by the International Index of Erectile Function and several general assessment questions. Preoperatively and postoperatively we measured flaccid and erect penile length.

RESULTS

At the 6-month followup all International Index of Erectile Function domains were significantly improved compared with preoperative values. Average penile length was increased 2.3 and 3 cm. while flaccid and erect, respectively, compared with before surgery. Complete penile straightening was achieved in 9 of 10 cases (90%). Surgical reoperation was performed in 1 patient (10%) in whom the implant was removed due to scrotal infection and in another (10%) in whom a further single relaxing incision of the fibrotic plaque was needed to attain complete penile straightening.

CONCLUSIONS

Patients with severe penile curvature, shortening and impaired penile rigidity due to penile fibrosis may be offered this surgical alternative, which proved to be effective and safe in our preliminary series.

Vulvodynia: the challenge of "unexplained" genital pain

Vulvodynia is a clinical syndrome that may include unexplained vulvar pain, sexual dysfunction, and psychological disability. It is a multifactorial syndrome that should be diagnosed, if possible, with an intradisciplinary approach. This article discusses the diagnosis and treatment of vulvodynia, starting with a summary of the complex nervous system within the pelvis. Different clinical pictures and different subtypes of the syndrome have been described in order to identify the etiologic aspects that are essential for diagnosis and subsequent treatment. Clinical evaluation should stress attention to detailed "pain-mapping" and evaluation of past and present history. The gynecological examination should be an overall patient evaluation, incorporating global physical impression, change in posture due to pain and careful examination of the pelvic floor. Examination of the pelvic floor is frequently omitted. Leading to an incorrect diagnosis of psychogenic pain. Such a misdiagnosis can result in the dismissal of appropriate treatment. Proper evaluation requires a comprehensive, multidisciplinary approach that includes medical, rehabilitative, and psychological issues.

A randomized open trial for comparison of proton pump inhibitors, omeprazole versus rabeprazole, in dual therapy for Helicobacter pylori infection in relation to CYP2C19 genetic polymorphism

BACKGROUND AND AIM

The genetic polymorphism of cytochrome P450 (CYP) 2C19 has been shown to influence the efficacy of Helicobacter pylori eradication therapy with a proton pump inhibitor (PPI) and amoxicillin (so-called dual therapy). Omeprazole, a widely used PPI, and rabeprazole, a new PPI, are metabolized in different pathways in terms of CYP2C19 genetic polymorphisms. In this study, we compared the efficacy of omeprazole and rabeprazole in a 2-week dual therapy in relation to CYP2C19 polymorphism.

METHODS

One hundred and ninety-nine patients with peptic ulcer disease were randomly assigned to receive one of the following regimens: 500 mg t.i.d. amoxicillin together with either 20 mg b.i.d. omeprazole or 10 mg b.i.d rabeprazole. The eradication of H. pylori was evaluated by using a bacterial culture and a [(13)C]-urea breath test at 1--2 months after completion of treatment. Cytochrome P4502C19 polymorphism was analyzed by using polymerase chain reaction-restriction fragment length polymorphism.

RESULTS

Intention-to-treat-based cure rates for the omeprazole or rabeprazole regimens were 66.3% (95% CI, 56--75) and 62.4% (95% CI, 52--71), respectively, without significant difference. Cytochrome P4502C19 genetic polymorphism did not influence the cure rates in either of these regimens. We analyzed various factors associated with treatment failure (PPI, CYP2C19 genotype, and smoking habit) by using multiple logistic regression; smoking was the only significant independent factor for treatment failure.

CONCLUSION

Omeprazole and rabeprazole were equally effective in combination with amoxicillin in eradicating H. pylori, irrespective of the PPI used (omeprazole or rabeprazole) and CYP2C19 genetic polymorphism. Smoking significantly decreased the cure rate of H. pylori infection in the dual therapy.

Malignant fibrous histiocytoma of soft tissue producing granulocyte colony-stimulating factor

We treated a rare case of malignant fibrous histiocytoma (MFH) of soft tissue that produced granulocyte colony-stimulating factor (G-CSF). The patient, an 80-year-old woman, was admitted because of a feeling of abdominal fullness and leg edema. An elastic, hard, tender tumor was palpated in the right thigh. Histopathological examinations of the tumor revealed atypical and prominent pleomorphic spindle-shaped cells with funicular arrangement, which were compatible with the diagnosis of MFH. Prominent leukocytosis (up to 84,300/microl), a high serum G-CSF concentration (82 pg/ml) and positive immunohistochemical staining of the tumor tissue for G-CSF indicated that G-CSF was produced by the MFH.

Sildenafil taken at bedtime significantly increases nocturnal erections: results of a placebo-controlled study

OBJECTIVES

Nighttime erections occur at all ages and contribute to the maintenance of the morphodynamic integrity of smooth muscle cells within the corpora cavernosa. This study was aimed at evaluating the effect on nocturnal erections of sildenafil versus a placebo taken at bedtime.

METHODS

A double-blind, crossover, placebo-controlled study design was used to examine the effects of sildenafil and placebo on sleep-related erectile activity. Thirty selected patients with erectile dysfunction (vasculogenic etiology, 22 patients [73%]; psychogenic etiology, 8 patients [27%]) were submitted to a polysomnographic recording of nocturnal erections, using a RigiScan device during 3 consecutive nights. After a first night of adaptation, the 2 following nights were used to study patients after the administration of sildenafil (100 mg) or a placebo taken at bedtime.

RESULTS

Twenty-three patients (77%) showed a significantly improved nocturnal erectile activity (according to the calculation of rigidity and tumescence activity units) after the administration of sildenafil (P <0.01), 5 patients (17%) showed comparable nocturnal erections with sildenafil and placebo, and 2 patients (6%) showed a significantly improved nocturnal erectile activity after taking the placebo (P <0.05). Overall, mean rigidity and tumescence activity values at the tip and base of the penis were significantly improved after sildenafil rather than placebo administration (P <0.001). The duration of tip rigidity greater than 60% was significantly longer during the night with sildenafil (P <0. 001). Although the number of erectile episodes was greater during the sildenafil night, this did not reach statistical significance.

CONCLUSIONS

In most patients with good sleep efficiency and who have erectile dysfunction, sildenafil, rather than a placebo, taken at bedtime produces a significantly improved nocturnal erectile activity. Further studies are needed to verify whether this preliminary finding may constitute the basis for the use of sildenafil as a tool for preventing erectile dysfunction.

Evidence based assessment of long-term results of plaque incision and vein grafting for Peyronie's disease

PURPOSE

We assessed the long-term outcome of plaque incision and vein grafting in select patients with Peyronie's disease by extensive preoperative and postoperative subjective and objective analysis.

MATERIALS AND METHODS

From January 1995 to June 1998, 50 men 28 to 62 years old (mean age 44) underwent surgery. Patients were evaluated preoperatively, 3 months after surgery and at a mean long-term followup of 32 months by sexual history, physical examination, determination of penile length and degree of curvature, dynamic color power Doppler sonography of the penile vessels and nocturnal RigiScan* evaluation for 3 nights. Study inclusion criteria were penile curvature 45 degrees or greater that made vaginal intromission impossible, stable disease for at least 6 months, patient reported normal penile rigidity, normal penile hemodynamics on color power Doppler ultrasound, normal nocturnal penile rigidity with at least 1 erection nightly (including base and tip rigidity greater than 60%, and a duration of 10 minutes) and absent base-tip discrepancies. Plaque was usually approached via a combined subcoronal and midline sagittal scrotal incision. Maximal rigidity was created intraoperatively and 1 to 3 plaque incisions were made. Saphenous vein patches were then grafted at the incision sites. Postoperatively patients were systemically treated with neurotrophic factors and low molecular weight heparin. Local vacuum supported corporeal stretching was done and weekly alprostadil injections were given to optimize corporeal oxygenation.

RESULTS

At long-term followup complete penile straightening was achieved in 40 cases (80%), minor residual curvature of 30 degrees or less persisted in 7 (14%) and significant disease recurred in 3 (6%). Penile rigidity was equal to that preoperatively in 47 patients (94%), while 3 (6%) reported clinically significant decreased potency. Penile length was equal to that preoperatively in 30 patients (60%), while 20 (40%) noticed slight penile shortening. Postoperatively penile color power Doppler sonography showed vascular impairment in 5 men (10%) and nocturnal RigiScan testing revealed a significant decrease in nightly erections in 5 (10%). Surgical complications included penile hypoesthesia in 1 case (2%), penile hematoma in 2 (4%), wound infection in 1 (2%) and glandular ischemia in 1 (2%).

CONCLUSIONS

Plaque incision and vein grafting achieved satisfactory clinical results in the majority of patients with severe and stable Peyronie's disease, intact penile rigidity preoperatively, normal penile color power Doppler ultrasound and normal nocturnal RigiScan testing.

Functional anatomy of cavernous helicine arterioles in potent subjects

PURPOSE

We investigated the morphological and functional features of cavernous helicine arterioles in male potent subjects.

MATERIALS AND METHODS

Ten young men reporting normal rigid erections which were confirmed by polysomnographic recording underwent power Doppler sonography of the cavernous helicine arterioles during flaccidity, after intracavernous injection of alprostadil, and after subsequent genital and audiovisual sexual stimulation.

RESULTS

During flaccidity the helicine arterioles were never detected by power Doppler imaging while they became evident in all cases after alprostadil injection. They usually originated from the cavernous artery forming an acute angle and showed 3 orders of ramifications. Systolic and diastolic flow was present. After genital and audiovisual sexual stimulation, and achievement of maximum rigidity, the helicine arterioles were still evident but with only 1 or 2 orders of distal ramifications. Only systolic flow was present. During penile tumescence the helicine arterioles disappeared in all cases.

CONCLUSIONS

Using power Doppler sonography it is possible to investigate the functional anatomy of the cavernous helicine arterioles during the various phases of the erectile cycle. Our preliminary study suggests that the helicine arterioles are functionally inactive during penile flaccidity while they are activated during penile tumescence and continue to supply blood to the corpora also during maximum penile rigidity.

Assessment of UDP-galactosyl-transferase activity in gastric mucosa of patients with chronic liver disease using an enzyme-linked peanut agglutinin binding assay

Gastric mucin plays an important role in protecting mucosa from irritants such as acids and pepsin, and UDP-galactosyltransferase is a key enzyme in mucin synthesis. In order to study the synthesis of gastric mucin in patients with chronic liver disease, we developed a new assay using a peanut agglutinin lectin to measure this enzyme in human gastric mucosa obtained by endoscopic biopsy. Enzyme activity correlated well with that determined with a previous method using radiolabeled galactose. The enzyme activity in gastric mucosa of cirrhotic patients was significantly lower than in patients with chronic hepatitis or in normal controls and correlated with the amount of mucin in surface epithelial cells. Our findings suggest that the synthesis of gastric mucin is impaired in patients with liver cirrhosis.

Geranylgeranylacetone and cetraxate hydrochloride increase UDP-galactosyltransferase activity in rat gastric mucosa

UDP-galactosyltransferase (UDP-Gal-T) is a key enzyme in the synthesis of mucus glycoprotein which plays an important role in gastric mucosal defensive mechanisms. Analysis of gastric UDP-Gal-T activity should clarify the mechanisms of the action of antiulcer drugs regarding gastric defensive factors. Here, we examined UDP-Gal-T activity in rat gastric mucosa treated with the antiulcer drugs geranylgeranylacetone (GGA) and cetraxate hydrochloride (CET). The effects of coadministration of indomethacin and exogenous administration of prostaglandins (PGs) were also studied. GGA and CET significantly increased UDP-Gal-T activity, and coadministration of indomethacin inhibited the increase of enzyme activity. UDP-Gal-T activity level with GGA was significantly higher than the control level, even in the presence of indomethacin. With CET, however, this was not the case. Among PGs, PGE1 significantly increased enzyme activity. Concomitant administration of PGE1 and GGA or CET increased UDP-Gal-T activity even with indomethacin to the levels achieved when these antiulcer drugs were administered without indomethacin. Our findings suggest that GGA and CET exert antiulcer effects by increasing mucus glycoprotein synthesis and that endogenous PG synthesis may be involved in this process. However, mechanisms not mediated by endogenous PGs may also exist in the stimulatory action of GGA on UDP-Gal-T activity.

AMS 700 CX inflatable penile implants for Peyronie's disease: functional results, morbidity and patient-partner satisfaction

This study was designed to clarify the functional results, morbidity and the patient-partner satisfaction observed with, the American Medical System 700 CX three-piece inflatable prosthesis in the treatment of impotence associated with Peyronie's disease. Thirty-three patients were treated and additional plaque surgery was performed in 13 cases (40%). Within 10 days of surgery, four patients (12%) developed a wound infection which was treated conservatively and one patient (3%) experienced glandular ischemia. At the 6-week follow-up, complete penile straightening was achieved in 23 patients (70%), while penile rigidity was considered optimal by all patients. On the contrary, the penis was considered short by 10 patients (30%). Five diabetic patients (15%) complained of severe scrotal and penile pain during full activation of the implant and in one of these patients (3%) the implant had to be removed. Due to spontaneous erections occurring after implant activation one patient (3%) required replacement of the reservoir from the Retzius space into the peritoneum. At the long-term follow-up (mean +/- SE: 17 +/- 2.2 months), 23 patients were evaluated and all found to be engaging in intercourse with the prosthesis. However, five patients (21%) and three of the 13 partners (25%) assessed were not yet completely satisfied. The American Medical System CX700 inflatable penile prosthesis obtains complete penile straightening in 70% and rigidity in 100% of impotent patients with Peyronie's disease. Patients should be fully informed about possible surgical morbidity and actual post-operative penile length.

Analysis of galactosyltransferase activity in rat gastric mucosa using crude mucosal homogenate

Mucus glycoprotein is one of the major components of gastric mucus which plays an important role in mucosal defensive mechanisms as a mucus-bicarbonate barrier. Analysis of the mucus glycoprotein synthesis is a useful tool for evaluating gastric mucosal defensive factors. UDP-galactosyltransferase (UDP-Gal-T) is one of the regulating enzymes for the synthesis of the mucus glycoprotein. In the present paper, we studied assay methods for UDP-Gal-T activity in rat gastric mucosa using radiolabeled UDP-galactose and two different kinds of acceptor proteins, namely ovomucoid and asialomucin, and analyzed effects of antisecretory agents on the UDP-Gal-T activity. We used crude supernatants of homogenized scrapings of the fundic part of rat stomach as an enzyme preparation and determined optimal conditions. In each acceptor, Mn2+ and the non-ionic detergent Triton X-100 were required for the enzyme activity. With each acceptor molecule, the type of glycosidic linkages of galactose was beta-type linkage. With asialomucin as an acceptor, UDP-Gal-T activities of rat gastric mucosa decreased after intraperitoneal administration of antisecretory agents, while change of the enzyme activity was not observed with ovomucoid as an acceptor.