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Erectile dysfunction, which has multifactorial causes including uremia, diabetes mellitus, hypertension, vascular insufficiency, autonomic neuropathy, and psychogenic pathology, occurs in a majority of patients with end-stage renal disease. After evaluation in the Sexual Dysfunction Clinic to exclude reversible disorders that may cause erectile dysfunction, hormonal supplementation, vacuum erection devices, and a self-injection program are offered to patients. Due to concern about patient's immunocompromised status, penile prostheses have not been considered appropriate therapy for those on dialysis or for renal transplant recipients. We report our 8-year experience with penile prostheses in 12 ESRD/renal transplant patients. Eleven patients have maintained their prostheses. Three patients had prostheses with mechanical failures that required reimplantation, and one prosthesis became infected and was explanted. Penile prostheses can be successfully implanted without excessive risk of infection in patients with erectile dysfunction resulting from end-stage renal disease.
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PMID:Penile prostheses in the management of impotence in patients with end-stage renal disease. 944 84

The electrophysiologic evaluation of patients with erectile dysfunction presents an important diagnostic challenge. The bulbocavernosus reflex (BCR) latency has been commonly used to evaluate these disorders. However, it is a measure of somatic penile innervation, whereas erection is primarily dependent on autonomic function. We evaluated 195 men with erectile dysfunction over a 3 year period. Each had electrophysiologic studies, nerve conduction studies and a BCR. BCR studies were abnormal in only 7%, of which most had diabetes or pelvic trauma. The BCR was the sole electrophysiologic abnormality in only 2%. Autonomic testing (AT) was additionally performed in 19 diabetic and 23 non-diabetic patients. This included sympathetic skin responses and measurement of the Valsalva ratio and heart rate variability with 6/min breathing. In the diabetic group, AT was positive in 63%, and most often was the sole abnormality. The bulbocavernosus reflex is relatively insensitive in the diagnosis of erectile dysfunction. Brief autonomic testing may provide valuable additional data, particularly in diabetics.
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PMID:Bulbocavernosus reflex studies and autonomic testing in the diagnosis of erectile dysfunction. 954 16

Peyronie's disease is an ill-defined condition that often leads to severe penile deformity and sometimes erectile dysfunction. Penile Doppler studies indicate veno-occlusive dysfunction as the principal cause of poor rigidity in Peyronie's disease patients. Diabetes mellitus is also a known cause of impotence and its prevalence tended to be higher in patients with Peyronie's disease. We evaluated 143 patients with Peyronie's disease, also 92 impotent men (37 diabetic, 55 nondiabetic) as control group. Penile vascular studies were performed on each group. Diabetes mellitus was also investigated in patients with Peyronie's disease. Veno-occlusive dysfunction was found as the main cause of impotence in both groups (81.1% in diabetic, 89% in nondiabetic control group and 88.8% in Peyronie's disease patients). In our study group the prevalence of diabetes mellitus tended to be higher than in the control population but it did not alter the ratio of veno-occlusive dysfunction and impotence in Peyronie's disease patients. We believe there is a close relationship between diabetes mellitus and Peyronie's disease, considering our high incidence. We also conclude that diabetes mellitus is not the main cause of impotence in patients with Peyronie's disease.
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PMID:The relationship between diabetes mellitus, impotence and veno-occlusive dysfunction in Peyronie's disease patients. 956 48

Erectile dysfunction (ED) affects millions of men throughout the world. The literature is ample, but an accurate estimate of its prevalence is still difficult since figures mainly refer to the USA, and are based mostly on small selected samples of people. Caution must anyway be used in comparing data from studies conducted in the past because of possible differences in the definition and classification of ED. Many factors are believed to contribute to the development and maintenance of ED. The influence of age and of several medical conditions (diabetes, vascular disease, and chronic diseases such as hepatic failure, renal failure and dialysis) is well defined. Also well documented is the role of some drug groups, whereas the role of other pharmacological agents is still controversial because of the frequent coexistence of other pathological conditions or concomitant exposure to other drugs. Less well defined and sometimes controversial is the role of risk factors mainly related to life-style such as cigarette smoking, alcoholism, total cholesterol levels and certain types of trauma. This paper reviews the main data on the epidemiology of ED and some related risk factors.
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PMID:The epidemiology of erectile dysfunction and its risk factors. 956 24

Corpus cavernosum electromyography (EMG) and its evolution: single potential analysis of cavernous electrical activity (SPACE) seem to be promising diagnostic methods in the evaluation of erectile dysfunction and smooth muscle integrity. Our study concentrates on the role of EMG in the evaluation of corpus cavernosum smooth muscles, using it as a noninvasive technique for demonstrating autonomic erectile dysfunction through their influence on recording SPACE and consequent proper selection of patients for different therapeutic modalities. A total of 80 male patients were examined for the feasibility of transcutaneous registration of cavernous electrical activity with a 2-channel electrophysiological unit (Evamatic 2000, Dantec) with two surface electrodes bilaterally placed on the penile shaft. Ten patients had normal erectile function, but complained of other urological symptoms. They served as the controls for normal electrical activity. Fifty patients with organic impotence of nonvascular (neurogenic) or vascular (venogenic, arteriogenic) aetiologies were subjected to EMG in both the flaccid and the erect state. On the basis of the EMG patterns the patients were divided into the following groups: 34 patients having normal tracing in both the flaccid and the erect state, and 21 patients showing abnormal patterns of waves with evidence of autonomic neurogenic dysfunction and incomplete smooth muscle relaxation. Of the latter 4 had long-standing diabetes mellitus and 4 had spinal injuries.
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PMID:Evaluation of the role of corpus cavernosum electromyography as a noninvasive diagnostic tool in male erectile dysfunction. 956 16

Erectile dysfunction is commonly experienced in men with diabetes mellitus. We report that the intracavernous pressure (ICP) rise in diabetic rats was 55% of the control and returned to normal following insulin (I) or insulin plus free oxygen scavenger (I + S) treatment. Insulin-like growth factor (IGF) binding protein (IGFBP) -3, -4, and -5 messenger RNA (mRNA) levels in the major pelvic ganglia (MPG) of diabetic rats were elevated by 2-fold, 2.6-fold, and 2.5-fold, respectively. Both I and I + S returned IGFBP-4 and 5 mRNA levels to normal, whereas IGFBP-3 gene expression was severely inhibited. IGFBP-2 gene expression was greatly inhibited by diabetes and was unresponsive to treatment. In the penis of diabetic rats, IGFBP-2 and -4 mRNA levels were low, whereas IGFBP-3 mRNA levels were elevated 10-fold. These effects were reversed by I and I + S. I and I + S also corrected the IGFBP-3 expression pattern. IGF-I gene expression in the penis and MPG was not significantly increased (P < 0.05) by diabetes and returned to normal levels following I or I + S treatment. Because IGFs are potent regulatory factors in vascular tone, this newly described activity of insulin may play an important role in the improvement of erectile function seen clinically and in animal models.
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PMID:Improvement of erectile function in diabetic rats by insulin: possible role of the insulin-like growth factor system. 964 87

Do we need impotence testing? Yes, it is the clinician's obligation to establish the etiology of impotence: end organ vascular failure vs neurologic dysfunction vs psychosexual dysfunction, classify the severity of that dysfunction, and select a therapy that is not only acceptable to the patient but also addresses his pathology. The most commonly utilized diagnostic tests for erectile dysfunction are outlined in this monograph. Nocturnal erections are evaluated by tests commonly known as nocturnal penile tumescence (NPT) studies. NPT has been measured by each of the following methods: stamp test, Snap Gauges, strain gauges, NPTR (Rigiscan, Osbon Medical Systems), and sleep lab NPTR. Normal Nocturnal Penile Tumescence and Rigidity (NPTR) depends on both the integrity of the corticospinal efferents to the penis and vascular responsiveness of the penile tissues to those nerve signals. When nocturnal erections are of appropriate duration and strength the central and peripheral neuroeffectors and intra-corporal regulators of penile hemodynamics are intact. Unfortunately, abnormal NPTR is of little value in determining the etiology or classifying the severity of vascular impotence; the most prevalent kind of end organ failure. The sacral reflex arc of erection consists of somatosensory afferents via the dorsal and pudendal nerves and autonomic efferents via the pelvic and cavernous nerves. These afferents have been measured indirectly by somatosensory evoked potentials (SSEP) and bulbocavernosus reflex latency (BCR). Penile EMG's have recently been recorded, corporal cavernosal smooth muscle electrical activity: CC-EMG. This technology is far from standardized; computer-assisted interpretations of penile electrical potentials may eventually differentiate afferent nerve pathologies so long inferred in: diabetes, spinal cord injury and following radical pelvic surgery. Numerous diagnostic tests have been employed to evaluate penile hemodynamics: penile plethysmography, penile blood pressures, penile brachial index, selective internal pudendal pharmacoangiography, Doppler sonography, dynamic infusion cavernosometry/cavernosography, nuclear washout radiography, and color duplex Doppler ultrasound. Insufficient corporal veno-occlusion is implicated in up to 50% of patients. The diagnosis and demonstration of venous leakage requires complete smooth muscle relaxation. Veno-occlusive dysfunction is associated with poorly sustained erections; this pathology has traditionally been evaluated with Dynamic Infusion Cavernosometry and Cavernosography. DICC is an invasive test, and is now primarily reserved for patients considering the option of vascular reconstructive procedure. Pharmacotesting consists of intracavernous injection and visual rating of the subsequent erection; the test is the most commonly used office procedure for diagnosing erectile dysfunction. It is simple, minimally invasive, and performed without monitoring equipment. Hemodynamic investigations suggest that a positive injection test is associated with normal veno-occlusion, but not necessarily with normal arterial function. When the penile response to pharmacotesting is suboptimal or equivocal, diagnostic testing with duplex Doppler assessment should be performed. The penile blood flow study (PBFS) provides an objective, minimally invasive evaluation of a suboptimal/equivocal erectile response.
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PMID:Evidence based assessment of erectile dysfunction. 964 64

Erectile dysfunction has an incidence of 2-9% and it is seen often in general practice. But the more recent treatment methods such as intracavernous drug injections and vacuum constriction devices are not known by general practitioners and normally used drug treatment has no efficacy. The management of impotence of the general practitioner should concentrate upon internistic conditions like diabetes, hypertension, hypercholesteremia and different drugs causing impotence. The symptomatic treatment of erectile dysfunction has to be done by a specialist, who is able to offer all therapeutic options.
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PMID:[Impotence: evaluation and treatment in general practice--what is reliable?]. 965 76

The understanding of pharmacology of impotence has shown a steady improvement over the last 15 years which has resulted in a better appreciation of the neurovascular mechanisms of the erectile process especially at the level of the corpora cavernosa; however, central mechanisms which control libido and erection are not yet completely elucidated. Frequent diseases most commonly encountered in elderly patients--i.e. diabetes, hypertension, atherosclerosis, depression, etc--represent a frequent cause of erectile dysfunction (ED) and are treated with medications that can interfere with sexual functioning at the central and/or peripheral level. Antidepressants, including the tricyclics and the monoamine oxidase inhibitors, have been implicated in ED, decreased libido, and impaired ejaculation. Most antihypertensives have been associated with some erectile impairment, but diuretics seem to have little effect on erectile function. The calcium channel blockers and ACE inhibitors are associated with a low incidence of ED. Sympatholytic antihypertensives seldom cause importence but can cause retrograde ejaculation because of the relaxation of the smooth muscles in the prostatic urethra and bladder neck. The most commonly prescription drugs that can affect sexual function are briefly discussed and an integrated pharmacological approach to the patient with drug-induced ED is proposed.
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PMID:[Pharmacology of male sexual dysfunction]. 969 33

Vascular surgery or penile prosthesis implantation are the main surgical options for erectile dysfunction. In this category, penile revascularization is the only causal therapy for selected patients: males younger than 50 years of age at time of surgery, maximum of two risk factors, exclusion of diabetes mellitus. Long-term success decreased to 53% to 55% in comparison to first encouraging reports of 80% success. Venous surgery resulted in an even more distinct decline of success the longer the elapse of time after surgery. Long-term success dropped under 40%, leaving only a few indications for penile venous ligation. In contrast, penile prosthesis implantation results in high satisfaction rates. Despite this, it is not generally recommended as first choice surgical management as it is linked to irreversible damage of the cavernosal bodies. Among numerous types of penile implants, preference is nowadays mostly given to the three-piece hydraulic models. However, such complications as defective or perforated cylinders in up to 35% after 5 years have arisen, depending on the type of implant. In a selected patient group, vacuum constriction devices with a mean patient acceptance of 75% (50% to 90%) seldom result in complications and are thus considered to be a well-established therapeutical option.
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PMID:[Vascular surgery, implant surgery and vacuum erectile aids. Review-overview-prospects of 3 therapy options in erectile dysfunction]. 979 32


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