- I am a Professor of Urology with the Mayo Clinic College of Medicine and Science. My clinical practice is in Jackson... moreI am a Professor of Urology with the Mayo Clinic College of Medicine and Science. My clinical practice is in Jacksonville Florida, Mayo Clinic campus. My focus is Men's Health, specifically surgical and medical management of erectile dysfunction, Peyronie's Disease, prostate enlargement (BPH), urethral strictures and male incontinence.edit
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Research Interests: Brachytherapy, Prostate Cancer, Medicine, Multivariate Analysis, Humans, and 15 moreMale, Androgen Deprivation Therapy, Clinical Sciences, Aged, Middle Aged, Adult, Hormonal Therapy, Implant, Proportional Hazards Models, JAMA, Adenocarcinoma, Insurance Medicine, Combined Modality Therapy, Prostatectomy, and Medical and Health Sciences
We retrospectively reviewed our experience with the artificial urinary sphincter in men with post-prostatectomy incontinence to determine the impact of prior collagen injection therapy on surgical outcome and overall cost of treatment.... more
We retrospectively reviewed our experience with the artificial urinary sphincter in men with post-prostatectomy incontinence to determine the impact of prior collagen injection therapy on surgical outcome and overall cost of treatment. The records and preoperative urodynamic studies of 30 men with post-prostatectomy incontinence who underwent artificial urinary sphincter placement were reviewed. Of these patients 23 (76.6%) had undergone prior collagen injection (collagen group) and 7 had not (noncollagen group). Preoperative and postoperative severity of incontinence was assessed with the American Urological Association quality of life index (scale 0 to 6) and number of pads used daily. Using a Valsalva leak point pressure of less than 60 cm. water as a predictor of failure with collagen injection, we calculated the potential savings had these patients foregone collagen injection and chosen artificial urinary sphincter primarily. Of the 30 patients 24 (80%) were incontinent following radical retropubic prostatectomy and 6 (20%) after transurethral resection. Intrinsic sphincter deficiency was the sole etiology of incontinence in most patients (83.3%) and 5 (16.7%) had concomitant detrusor instability. Six patients alternated the use of pads with the use of clamps or a condom catheter to aid in controlling leakage. Mean number of collagen treatment sessions for the injection group was 2.9 (range 1 to 7). There was a significant difference in mean time from prostatectomy to artificial urinary sphincter between the noncollagen (25.3 months) and collagen (35.8 months) groups (p = 0.04). There were no other statistically significant differences between the groups, including mean age (66.2 years, range 45 to 83), mean followup (26.2 months), mean preoperative pads daily (5.8+/-3.4), median preoperative quality of life index (6, range 3 to 6), median preoperative American Urological Association symptom score (13, range 3 to 35) and mean preoperative Valsalva leak point pressure (42.7+/-21.4 cm. water). For all patients in the study the mean postoperative pads daily was 0.8, mean quality of life index 1 and surgical complication rate 13.3%. There were no statistically significant differences between the collagen and noncollagen groups in any of these parameters. Among the collagen group 17 patients (73.9%) had a Valsalva leak point pressure less than 60 cm. water. Considering the mean additional period of incontinence (time between prostatectomy and artificial urinary sphincter) to be 12.9 months and the additional treatment costs (including pads daily and mean number of collagen syringes per patient), the direct costs of treatment for the collagen group were 85.6% higher than those for patients who chose artificial urinary sphincter primarily. Prior collagen therapy did not adversely influence the surgical complication rate or compromise effectiveness of the artificial urinary sphincter. However, patients with Valsalva leak point pressure less than 60 cm. water have lower rates of success with collagen injection therapy and could benefit from a more successful, timely and cost-effective treatment of incontinence by choosing the artificial urinary sphincter as primary therapy.
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We retrospectively reviewed our experience with the artificial urinary sphincter in men with post-prostatectomy incontinence to determine the impact of prior collagen injection therapy on surgical outcome and overall cost of treatment.... more
We retrospectively reviewed our experience with the artificial urinary sphincter in men with post-prostatectomy incontinence to determine the impact of prior collagen injection therapy on surgical outcome and overall cost of treatment. The records and preoperative urodynamic studies of 30 men with post-prostatectomy incontinence who underwent artificial urinary sphincter placement were reviewed. Of these patients 23 (76.6%) had undergone prior collagen injection (collagen group) and 7 had not (noncollagen group). Preoperative and postoperative severity of incontinence was assessed with the American Urological Association quality of life index (scale 0 to 6) and number of pads used daily. Using a Valsalva leak point pressure of less than 60 cm. water as a predictor of failure with collagen injection, we calculated the potential savings had these patients foregone collagen injection and chosen artificial urinary sphincter primarily. Of the 30 patients 24 (80%) were incontinent following radical retropubic prostatectomy and 6 (20%) after transurethral resection. Intrinsic sphincter deficiency was the sole etiology of incontinence in most patients (83.3%) and 5 (16.7%) had concomitant detrusor instability. Six patients alternated the use of pads with the use of clamps or a condom catheter to aid in controlling leakage. Mean number of collagen treatment sessions for the injection group was 2.9 (range 1 to 7). There was a significant difference in mean time from prostatectomy to artificial urinary sphincter between the noncollagen (25.3 months) and collagen (35.8 months) groups (p = 0.04). There were no other statistically significant differences between the groups, including mean age (66.2 years, range 45 to 83), mean followup (26.2 months), mean preoperative pads daily (5.8+/-3.4), median preoperative quality of life index (6, range 3 to 6), median preoperative American Urological Association symptom score (13, range 3 to 35) and mean preoperative Valsalva leak point pressure (42.7+/-21.4 cm. water). For all patients in the study the mean postoperative pads daily was 0.8, mean quality of life index 1 and surgical complication rate 13.3%. There were no statistically significant differences between the collagen and noncollagen groups in any of these parameters. Among the collagen group 17 patients (73.9%) had a Valsalva leak point pressure less than 60 cm. water. Considering the mean additional period of incontinence (time between prostatectomy and artificial urinary sphincter) to be 12.9 months and the additional treatment costs (including pads daily and mean number of collagen syringes per patient), the direct costs of treatment for the collagen group were 85.6% higher than those for patients who chose artificial urinary sphincter primarily. Prior collagen therapy did not adversely influence the surgical complication rate or compromise effectiveness of the artificial urinary sphincter. However, patients with Valsalva leak point pressure less than 60 cm. water have lower rates of success with collagen injection therapy and could benefit from a more successful, timely and cost-effective treatment of incontinence by choosing the artificial urinary sphincter as primary therapy.
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Introduction: Urethral erosion following artificial urinary sphincter (AUS) placement is hypothesized to be secondary to unrecognized intra-operative urethral injury. Intra-urethral indigo carmine solution (ICS), a blue dye, following... more
Introduction: Urethral erosion following artificial urinary sphincter (AUS) placement is hypothesized to be secondary to unrecognized intra-operative urethral injury. Intra-urethral indigo carmine solution (ICS), a blue dye, following urethral mobilization should identify intra-operative urethrotomy and prevent early post-operative cuff erosion. Methods: Retrospective review was completed of all men undergoing AUS (AMS 800 device) insertion between January 2000 and January 2005 for post prostatectomy stress incontinence at one institution. Operative reports were examined for use of intra-operative injection of ICS as well as documentation of urethral injury. Post-operative course was reviewed for evidence of early cuff erosion. All patients were followed a minimum of 6 months post-operatively. Results: Seventy-eight men underwent AUS placement during the investigative period. Forty-one men received intra-operative ICS injection following urethral mobilization and 37 men did not. ICS identified one intra-operative urethral injury. No urethral injuries were noted in the non-injection group. The ICS group suffered 3 (7.3%) early urethral erosions; the control group had one early urethral erosion (2.7%). Conclusion: Intra-operative ICS use is easy, safe, and able to identify urethral injury. However, its use did not preclude the incidence of early cuff erosion. This may postulate the existence of early urethral cuff erosion as a separate entity not dependent on intra-operative urethrotomy.
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With the immunobead antisperm antibody test a prospective study was conducted to evaluate the immune status of 55 men before and after vasectomy reversal. A third of the vasectomy patients (19 of 55) had significant serum-sperm antibodies... more
With the immunobead antisperm antibody test a prospective study was conducted to evaluate the immune status of 55 men before and after vasectomy reversal. A third of the vasectomy patients (19 of 55) had significant serum-sperm antibodies (20 per cent binding or more) detected by the indirect immunobead antisperm antibody test. Of 31 vasovasostomy patients 12 (38 per cent) had significant sperm-surface antibodies (20 per cent binding or more) by the direct immunobead antisperm antibody test. Preoperative serum assays correctly classified the antibody status of 69 per cent of the vasectomy patients. The immunological impact of spermatic granuloma formation, duration of vasal obstruction, patient age and presence of sperm in the vasal fluid at operation also were assessed. An inverse relationship between the proportion of antibody-bound sperm and the percentage of motile sperm in the ejaculate of vas reversal patients was found with videomicrographic semen analysis. The percentage motility was significantly lower among patients with greater quantities of sperm-surface antibodies. No other parameter of semen analysis showed this difference when compared for positive or negative immunobead antisperm antibody test results.
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Primary urethral carcinoma is a rare oncologic condition with limited data to support organ-sparing therapies. Herein, we present a case of primary urethral squamous cell carcinoma in situ of the bulbar urethra treated with intraurethral... more
Primary urethral carcinoma is a rare oncologic condition with limited data to support organ-sparing therapies. Herein, we present a case of primary urethral squamous cell carcinoma in situ of the bulbar urethra treated with intraurethral 5-fluorouracil (5-FU) who exhibited a complete pathologic response observed at the time of dismembered urethroplasty. The clinical features, diagnosis, and treatment course of our case are reviewed. These data may support the use of intraurethral 5-FU for similar cases in the future.
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The present study was designed to investigate the effect of various forms of stimulation on the levels of high energy phosphates (ATP + CP) in the rabbit corpora cavernosa. Prestimulation with the alpha agonist phenylephrine (200 microM)... more
The present study was designed to investigate the effect of various forms of stimulation on the levels of high energy phosphates (ATP + CP) in the rabbit corpora cavernosa. Prestimulation with the alpha agonist phenylephrine (200 microM) for five minutes caused a significant decrease in both ATP and Creatine phosphate (CP) when compared with control tissue. Field stimulation (64 Hz) of the precontracted tissue induced an immediate decrease in tension by approximately 50%. The level of ATP + CP after field stimulated-relaxation was not significantly different from that from the initial prestimulation. Field stimulation (FS) from basal tone (2 g) caused a contraction and a significant decrease in both ATP and CP. Phentolamine (10 microM) (alpha-adrenergic antagonist) induced a significant decrease in the 2 g basal tension and a significant increase in the intracellular concentrations of both ATP and CP from that of control levels. In summary, the contractile response to both neuronal and pharmacologic stimulation was similar to that of other smooth muscle, producing a decrease in high energy phosphates. Field stimulated relaxation did not change the level of high energy phosphates from that of prestimulated levels. Finally, our data indicates that in the presence of the alpha blocker phentolamine (10 microM), high energy phosphate levels (ATP + CP) increase significantly. This indicates that in the corpus cavernosum, there is significant basal tone that is linked to significant tonic alpha receptor stimulation and is maintained by a net consumption of ATP.
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ABSTRACTBackgroundIntracavernosal injections (ICI) are a well-established treatment option for men with erectile dysfunction (ED); however, the anticipation of pain with injection remains a significant barrier to the use of ICI.AimTo... more
ABSTRACTBackgroundIntracavernosal injections (ICI) are a well-established treatment option for men with erectile dysfunction (ED); however, the anticipation of pain with injection remains a significant barrier to the use of ICI.AimTo evaluate the patient-anticipated degree of pain versus the experienced degree of pain pre- and post-ICI in men undergoing their first injection with an erectile agent.MethodsWe studied 51 patients who underwent their first ICI in our men’s health clinic. Anticipated needle-associated pain was judged with a pre-injection score, and pain experienced during the injection was judged with a post-injection score. All patients graded their pre- and post-ICI pain using a standard 10-point scale (0–10).OutcomesPre- and post-ICI pain was defined with the visual analogue scale (0–10) in men undergoing their first penile injection.ResultsMedians and interquartile ranges (IQRs) of the patients’ age [65 years (54.5–68.0)], pre-injection pain [5 (4–7)], and post-injection pain [1 (1–2)] were recorded. Most men in the study had erectile dysfunction (68.6%) and/or Peyronie’s Disease (64.7%). The average pre-injection prediction pain score was 5.45 ± 2.15; the average post-injection perceived pain score was 1.20 ± 0.73. Thus, there was an average discrepancy of over 4 points in predicted pain vs perceived pain. A paired t-test was performed which showed a statistically significant difference between pre- and post-injection scores (P < .05). A Wilcoxson Signed Rank Test showed statistical significance in the difference between pre- and post-injection pain scores (P < .05).Clinical ImplicationsICI is a safe, effective treatment for patients with ED and is associated with significantly less pain than is anticipated by patients.Strengths & LimitationsThis is the first report to describe the discrepancy between pre-ICI anticipated pain and post-ICI experienced pain. Limitations include an overall small sample size.ConclusionPatients experience significantly less pain with ICI than they anticipate having. This represents an important factor to consider when counseling patients about available ED treatments.
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Laparoscopic pelvic lymphadenectomy is a satisfactory alternative to open lymphadenectomy for staging prostate cancer. Specific information obtained by endorectal coil magnetic resonance imaging may be used to predict the most likely side... more
Laparoscopic pelvic lymphadenectomy is a satisfactory alternative to open lymphadenectomy for staging prostate cancer. Specific information obtained by endorectal coil magnetic resonance imaging may be used to predict the most likely side for lymph node metastases. These criteria may be used to define side selection for performing a unilateral laparoscopic lymphadenectomy without the risk of missing contralateral nodes that may be positive. A unilateral dissection when feasible reduces operative time and morbidity.
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The introduction of phosphodiesterase-5 (PDE-5) inhibitor therapy for the treatment of erectile dysfunction (ED) marked the beginning of a much greater awareness of this condition and its effects on quality of life. Resulting research has... more
The introduction of phosphodiesterase-5 (PDE-5) inhibitor therapy for the treatment of erectile dysfunction (ED) marked the beginning of a much greater awareness of this condition and its effects on quality of life. Resulting research has provided much data on the etiologies of ED, the risk factors involved, and the connection between ED and atherosclerotic disease. With the ED patient more frequently seeking treatment from his primary care physician, it behooves both urologists and non-urologist physicians to be familiar with the properties of the PDE-5 inhibitors, as well as those of other oral, sublingual, intracavernosal, and intraurethral ED drugs. This article reviews the diagnostic approach to the ED patient and the mechanisms of PDE-5 inhibition and discusses data from trials of PDE-5 inhibitors and the erectogenic dopaminergic agonist apomorphine.
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Erection is mediated by relaxation of the smooth muscle elements within the sinusoids of the corpus cavernosum. Although cavernosal relaxation can be mediated by a variety of mechanisms including purinergic stimulation, prostoglandins,... more
Erection is mediated by relaxation of the smooth muscle elements within the sinusoids of the corpus cavernosum. Although cavernosal relaxation can be mediated by a variety of mechanisms including purinergic stimulation, prostoglandins, and beta-adrenergic stimulation the major mechanism involves the stimulated release of nitric oxide (NO) and subsequent relaxation of the corporal smooth muscle. Experimentally, NO can be released both by direct stimulation of NO-containing nerves (using field stimulation) and indirectly via cholinergic stimulation of NO release from the endothelium (using bethanechol). Preliminary studies have indicated that NO release and/or NO-stimulated relaxation of corporal smooth muscle is an active process involving both an increase in cytosolic calcium and an increase in metabolic energy utilization. Ryanodine is a pharmacological agent that can inhibit calcium-stimulated calcium release from the sarcoplasmic reticulum. The results of the current study demonstrated that ryanodine inhibited both field-stimulated relaxation and bethanechol-stimulated relaxation but did not affect relaxation induced by adenosine triphosphate (ATP) or nitroprusside. These studies strongly support the hypothesis that NO-stimulated relaxation is mediated, in part, by calcium release from the sarcoplasmic reticulum through ryanodine-sensitive channels.
Research Interests: Endocrinology, Andrology, Biology, Calcium, Medicine, and 15 moreInternal Medicine, Nitric oxide, Pubmed, Animals, Male, Endoplasmic Reticulum, Penis, Clinical Sciences, Phenylephrine, Muscle Relaxation, Adenosine Triphosphate, Intracellular Calcium, Metabolic energy, Paediatrics and reproductive medicine, and In Vitro Techniques
Continent catheterizable urinary reservoirs and orthotopic bladder substitutes are complex surgical endeavors. The goal is preservation of renal function, reliable continence, and storage intervals acceptable to the patient. The... more
Continent catheterizable urinary reservoirs and orthotopic bladder substitutes are complex surgical endeavors. The goal is preservation of renal function, reliable continence, and storage intervals acceptable to the patient. The construction requires familiarity with bowel segments and may increase operative time for radical cystoprostatectomy by 30% to 50%. Patients with continent reservoirs have improved body image, work habits, and sexual and interpersonal relationships. Experience with patients with dysfunctional neurogenic bladders previously converted to Bricker urostomies now undiverted to continent reservoirs indicates an overall increase in physical activity and self-satisfaction. These patients are tolerant of reoperations to maintain independence from wet urostomies. Undoubtedly, the expectations of bladder cancer patients will differ from those of young adults with neurogenic bladder, but we have found that when all options are presented patients will seek out therapy that least alters their body image. Therefore, patient selection becomes an important factor in determining the success of continent reservoirs. Patients must have the dexterity and motivation to catheterize the urinary reservoir, irrigate for mucus and, in cases of orthotopic bladder replacement to urethra, accept the need for artificial sphincter placement in 30% to 40% of cases. Management of the neo-bladders requires additional consideration of several practical and theoretic points for both the surgeon and medical oncologist: 1. Patients with diffuse carcinoma in situ or transitional cell carcinoma at the bladder neck or prostatic urethra should undergo simultaneous urethrectomy excluding orthotopic bladder replacement. 2. Ten percent to 40% of patients undergoing radical cystoprostatectomy for transitional cell cancer will have concomitant underdiagnosed adenocarcinoma of the prostate; patient prognosis will remain defined by the stage and grade of the bladder cancer. 3. Patients may have a tendency toward dehydration because of increased loss of free water through bowel transit. 4. Absorption of chloride, ammonium, and hydrogen ions may cause hyperchloremic acidosis, especially in face of imparied renal function. 5. Because of the potential for drug absorption across reservoir mucosa, patients receiving chemotherapy may require Foley catheterization with irrigation in addition to intravenous hydration. 6. Creatinine clearance is unsuitable for studying the renal function of reservoir patients because urine passes through the intestinal segment where creatinine is absorbed; glomerular filtration is better estimated by nuclear scanning with the reservoir emptied. 7. Most reservoirs will remain colonized with bacteria. 8. Antibiotic prophylaxis for the patient with temporary impairment of immune function during chemotherapy may be necessary. 9. Mucus may entrap bacteria serving as a host defense; its production may diminish with time from construction. All patients should be capable of performing reservoir irrigations to manage mucus obstruction.(ABSTRACT TRUNCATED AT 400 WORDS)
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Personal digital assistant (PDA)-based continuing medical education (CME) activities have become widely available. To evaluate the effectiveness of print- and PDA-based CME materials in erectile dysfunction (ED). CME materials describing... more
Personal digital assistant (PDA)-based continuing medical education (CME) activities have become widely available. To evaluate the effectiveness of print- and PDA-based CME materials in erectile dysfunction (ED). CME materials describing links between ED and comorbid medical conditions, effects of certain lifestyle modifications on ED, and treatment of ED with phosphodiesterase 5 (PDE5) inhibitors were distributed as a print supplement and as electronic modules, viewed with PDAs. We evaluated how effectively these materials improved evidence-based clinical choices, using survey questions about case vignettes and comparing responses of CME participants (N = 85) and matched nonparticipants (N = 94). Effect size, measuring the difference in evidence-based clinical scores between participants and nonparticipants. CME certificates were awarded to 3,557 participants (459 print, 3,098 PDA). Among survey respondents, significantly more CME participants recognized that ED was associated with greater risk for myocardial infarction (61% participants; 34% nonparticipants; P <or= 0.001) and was a strong marker for diabetes mellitus (37% participants; 9% nonparticipants; P <or= 0.001). In contrast, participants and nonparticipants both displayed a good understanding of the relationships of smoking, obesity, and sedentary lifestyle with ED and of using PDE5 inhibitors to treat ED in patients with prostate cancer or benign prostatic hyperplasia; this likely reflects a good baseline understanding of these topics. Participants and nonparticipants each displayed a poor understanding of the recommendations regarding nonarteritic anterior ischemic optic neuropathy and PDE5 inhibitor use. Patient reluctance to discuss sexual concerns was perceived as the most significant barrier to optimal ED management. Given patient reluctance to discuss sexual concerns, future CME activities should focus on educating health-care providers and patients that ED is a risk factor for cardiovascular disease and diabetes. Both print- and PDA-based CME on ED were effective; the large number of lesson completers suggests a trend toward on-demand, self-selected CME is positive.
Research Interests: Decision Making, Sexual Health, Medicine, Erectile dysfunction, Continuing Medical Education, and 15 moreHumans, Sexual Medicine, Female, Male, Handheld, Data Collection, Risk factors, Phosphodiesterase Inhibitors, Middle Aged, Adult, CME, Risk Factors, Clinical Competence, Psychology and Cognitive Sciences, and Medical and Health Sciences
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Purpose: Prostate brachytherapy is becoming increasingly utilized in the definitive treatment of men with early-stage prostate cancer. Others have reported a close relation between total dose to the gland and genitourinary and... more
Purpose: Prostate brachytherapy is becoming increasingly utilized in the definitive treatment of men with early-stage prostate cancer. Others have reported a close relation between total dose to the gland and genitourinary and gastrointestinal toxicity. We tested the hypothesis that 3 months of hormone deprivation would decrease gland size and decrease radioactivity implanted, which would result in less morbidity. Here, we report the toxicity associated with this novel treatment strategy. Methods: One hundred fifty-five prostate cancer patients underwent ultrasound-guided transperineal implantation of palladium-103 at the Hospital of the University of Pennsylvania between January 1994 and July 1998. All men received at least 3 months of neoadjuvant luteinizing hormone-releasing hormone (LHRH) agonist therapy and were registered in the study. This group of men were compared with 55 men treated at the Hospital of the University of Pennsylvania with brachytherapy alone between December 1991 and December 1993. Results: Compared with men treated with implant alone, men who received LHRH agonist therapy had significantly smaller glands at the time of implant (27.7 cm3 vs 36.3 cm3), required fewer seeds (47.9 vs 83.2), and had significantly less radioactivity implanted (76.3 mCi vs 117 mCi). The genitourinary and gastrointestinal morbidity in the men receiving hormone deprivation was minimal, with long-term side effects occurring in only three patients. In addition, potency was preserved in 83% of men. Discussion: Three months or more of neoadjuvant LHRH agonist therapy before transperineal brachytherapy is safe, significantly reduces the amount of radioactivity implanted, and is associated with very low rates of genitourinary and gastrointestinal toxicity. In addition, potency preservation after combined-modality therapy is excellent and is similar to that of implantation alone. Further studies of this treatment approach are warranted.
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Research Interests: Pharmacology, Endocrinology, Chemistry, Medicine, Low Frequency, and 15 moreHigh Frequency, Humans, Internal Medicine, Nitric oxide, Animals, Male, Penis, Frequency Dependence, Phenylephrine, Muscle Relaxation, Low Frequency Stimulation, nitroprusside, High Frequency Stimulation, In Vitro Techniques, and Electric stimulation
Priapism is a persistent erection which fails to subside after climax and is accompanied by penile pain and tenderness. The most common form of priapism to confront contemporary urologists is persistence of erection following... more
Priapism is a persistent erection which fails to subside after climax and is accompanied by penile pain and tenderness. The most common form of priapism to confront contemporary urologists is persistence of erection following pharmacologic stimulation. We reviewed our experience over 18 months with initial diagnostic intracavernous challenges of prostaglandin E1. Three-hundred and sixty-six new impotence patients presented to our center and underwent PGE1/color duplex Doppler assessment; 14 patients developed persistent rigidity of two or more hours accompanied by penile discomfort. Each of these patients was successfully managed with penile aspiration and direct corporal instillation of the alpha-adrenergic agonist phenylephrine. The mean PGE1 dosage injected was 6 micrograms and mean duration of erection preceding aspiration 180 minutes. Penile blood gases were obtained from the initial aspirate in all cases. The duration of pharmacologic erections were correlated with the partial pressures of oxygen, carbon dioxide, bicarbonate and the pH using linear regression analysis. There was a clear trend towards deoxygenation, acidosis, and hypercarbia with prolonged erection (105-342 minutes). The relationship between duration of pharmacologic erection and acidosis/hypercarbia was highly significant.
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Research Interests: Prostate Cancer, Medicine, Humans, Male, Prostate, and 15 moreClinical Sciences, Aged, Middle Aged, Hormonal Therapy, Hormone Therapy, Lymph Node, Prostate Specific Antigen, Diethylstilbestrol, Adenocarcinoma, Leuprolide, Combined Modality Therapy, Disease Free Survival, Flutamide, orchiectomy, and Macho
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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... more
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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A recent observational study characterized intravaginal ejaculatory latency time and single item patient reported outcome measures in a large population of males with and without premature ejaculation, as well as their female partners. In... more
A recent observational study characterized intravaginal ejaculatory latency time and single item patient reported outcome measures in a large population of males with and without premature ejaculation, as well as their female partners. In the current analysis we assessed the relative influence of those measures in identifying premature ejaculation as diagnosed by the clinician. Data were from a 4-week, multicenter, observational study of men with (207) and without (1,380) premature ejaculation (diagnosed using The Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision criteria), as well as their female partners. Estimated and measured intravaginal ejaculatory latency time, age, and responses to single item (control over ejaculation, personal distress, satisfaction with sexual intercourse and interpersonal difficulty) and multiple item (male and female Golombok-Rust Inventory of Sexual Satisfaction, male Self-Esteem and Relationship questionnaire, and Short Form 36) measures were evaluated with stepwise logistic regression analysis. Self-estimated and stopwatch measured intravaginal ejaculatory latency time were interchangeable, correctly assigning premature ejaculation status with 80% sensitivity and 80% specificity, increasing to 80% sensitivity and 96% specificity when combined with single item patient reported outcomes. Subject reported control over ejaculation and personal distress most strongly indicated premature ejaculation status. Partner personal distress was more influential in determining premature ejaculation status than estimated or measured intravaginal ejaculatory latency time, and single item measures were more influential than multiple item measures. Age was not influential in assigning premature ejaculation status. Neither self-estimated nor stopwatch measured intravaginal ejaculatory latency time alone was optimal for assigning premature ejaculation status. Subject and partner responses to single item measures, particularly control over ejaculation and personal distress, were important. Results suggest that a combination of estimated intravaginal ejaculatory latency time and the 4 single item patient reported outcome measures can adequately identify premature ejaculation status.
Research Interests: Adolescent, Medicine, Observation, Humans, Female, and 15 moreMale, Reaction Time, Interpersonal Relations, Premature Ejaculation, Mental Disorder, Clinical Sciences, Aged, Middle Aged, Self Assessment, Adult, Observational Study, Logistic Models, Clinical Diagnosis, Ejaculation, and Outcome Assessment Health Care
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Introduction Peyronie’s Disease (PD) is characterized by a fibrous scar of the tunica albuginea. PD is typically imaged with 2D ultrasound. We propose a classification system of these ultrasound findings in the evaluation of PD. Objective... more
Introduction Peyronie’s Disease (PD) is characterized by a fibrous scar of the tunica albuginea. PD is typically imaged with 2D ultrasound. We propose a classification system of these ultrasound findings in the evaluation of PD. Objective The purpose of this study is to establish a functional sonographic classification system for evaluating PD and to examine the relationship between PD grading and curvature, duration of PD, and vascular erectile status. Methods In our study, 395 patients with PD underwent intracavernosal injection with an erectile agent (ICI) followed by Color Doppler Duplex Ultrasound (CDDU). All CDDU studies were performed by a single examiner and all PD grading was done by two independent reviewers using saved images. Ultrasound findings including peak systolic velocities (PSV) and resistive indices (RIs) were recorded. PD grades of 2D images were classified into three grades: Grade 1 acoustic shadowing without calcification; Grade 2 focal microcalcifications of the tunica, pillars, or septal fibers; Grade 3 confluent calcification of the dorsal, septal, ventral tunica albuginea. Results There were 250 patients classified with Grade 1 (63%) sonographic changes, 75 with Grade 2 (19%), and 70 with Grade 3 (18%). All groups had similar median ages and body mass index (BMI): Grade 1 (59.3 yr), Grade 2 (59 yr) and Grade 3 (60.3 yr), p = 0.711; BMI 27.6, 28.2, 27.7, p = 0.813. Additionally, medical and surgical risk factors for erectile dysfunction were similar across the three groups; these included hypertension, heart disease, diabetes mellitus, hyperlipidemia, smoking history, and history of prostate surgery. Most patients had previously used PDE5-Inhibitors (293/395). History and/or physical findings of Dupuytren’s palmar contracture was noted in 30/395 (7.6%) of men. The median duration of PD was not significantly different across the three groups (12, 12, 14 months p = 0.639). Neither CDDU diagnoses (Table 1) nor curvature varied by sonographic grades (Table 2). Conclusions The scar resulting from PD seals together the outer longitudinal and inner circular layers of the tunica albuginea causing deformity of the erect shaft. PD plaques are usually palpable and associated with focal thickening of the tunica. On 2D ultrasound, the typical appearance is an acoustic shadow. Most of our patients presented with Grade I acoustic shadowing and no calcifications 250/395 (63%). On the other hand, 19% had acoustic plaque shadowing and additional findings of focal tunica or deep microcalcifications and 18% had confluent calcification of the dorsal, septal or ventral tunica. We propose a unique and reproducible classification system for Peyronie's Disease. This grading system is based on grayscale ultrasound of Peyronie’s plaques may serve the purpose of diagnostic evaluation, didactic teaching and integrated research. Disclosure No
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Introduction Peyronie’s disease (PD) is characterized by penile pain, penile deformation and curvature, sexual dysfunction, and psychological implications. Fibrosis and plaque formation are often part of PD pathophysiology. Calcified... more
Introduction Peyronie’s disease (PD) is characterized by penile pain, penile deformation and curvature, sexual dysfunction, and psychological implications. Fibrosis and plaque formation are often part of PD pathophysiology. Calcified plaques can alter treatment planning. Penile ultrasound with Doppler (PUS) is used to exclude erectile dysfunction and identify plaques. However, plaque extent and distribution can be obscured by acoustic shadowing, limiting complete plaque characterization. Non-contrast pelvis computed tomography (CT) provides a noninvasive method to identify plaques in 3 dimensions and quantify plaque Ca burden. Objective Our objective was to utilize Agatston Ca scoring measure Ca burden in patients with Peyronie's disease. Methods A retrospective database from 1/1/2017 and 6/30/2021 identified 25 men with calcified plaques on CT after PUS performed by a single urologist. Two abdominal radiologists reviewed CTs in consensus to measure calcified plaque size and distribution on Visage PACS. Semiautomated Agatston Ca scoring values were obtained with Syngo.via. Total Ca volume (mm3), total Ca score were correlated with hourglass deformity on clinical exam, plaque complexity on CT (>2 discrete calcified plaques, circumferential corpus cavernosum involvement, septal involvement), and surgical management using descriptive statistics and t-test. Results Mean Ca volume was 1417 mm3 (range 1.4-5425.7, standard deviation (SD) 1570); mean Ca score was 1691 (range 1.6-6048; SD 1862) with significantly higher Ca volume in patients with complex plaques (265 mm3 vs 472 mm3, p<0.05), and significantly longer plaque dimension for longest plaque dimension measured by CT vs US (31 vs 23, p<0.05). There was no significant difference in Ca volume for nonsurgical vs surgical (1791 vs 893, p=0.06) or for no hourglass vs hourglass deformity (1173 vs 1904, p=0.19). Conclusions CT scan and calcium scoring are useful tools in the assessment of PD. Semiautomated Ca scoring may help noninvasively identify complex calcified penile plaques to guide medical and surgical therapy for Peyronie’s disease. Disclosure No
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Introduction The presence and extent of penile calcifications is an important factor in disease management of Peyronie’s Disease (PD). Calcified plaques may necessitate plaque excision and grafting (E&G) in addition to other... more
Introduction The presence and extent of penile calcifications is an important factor in disease management of Peyronie’s Disease (PD). Calcified plaques may necessitate plaque excision and grafting (E&G) in addition to other therapies or surgeries. PD pathology such as corporal septal involvement, multifocal calcifications, and circumferential corporal calcification can be difficult to assess on color doppler ultrasound (CDDU) due to device limitations. Computed tomography (CT) can be utilized for further characterization of PD. Objective The objective of our study was to review patients who underwent CT imaging for characterization of their Peyronie's Disease. Methods Twenty-three patients with a diagnosis of PD were retrospectively evaluated between 2017 and 2021. Patients underwent CDDU examination with artificial erection and were evaluated based on erectile function, plaque dimension, hourglass deformity, plaque septal involvement, and suspected calcification status. Patients with CDDU examination suggestive of calcification or significant complexity underwent non-contrast CT scan for 3-dimensional evaluation of the plaque prior to surgical discussion. CT complexity was defined as concern for multifocal calcified plaques (>2), partial/complete circumferential corpus cavernosum involvement, or septal involvement. Results All 23 patients had concerning findings on initial examination for calcified plaque which led to their CT evaluation; 9 of 23 (39.1%) patients had exam findings with hourglass deformity. On CT evaluation, calcification was confirmed in 22 of 23 patients (95.7%). Plaque dimensions on CT scan ranged from 0.4 x 0.2 x 0.5 cm to 4.0 x 2.0 x1.7 cm. Many of these measurements were approximations due to circumferential calcified plaque. A classic “gull-wing” appearance was noted in 6 of 23 (26%) patients; 12 of 23 (52.2%) of patients had septal involvement on CT; 8 of 23 patients (34.8%) had significant multifocal disease; 8 of 23 patients (34.8%) decided to proceed with surgical correction via E&G (n = 3), IPP with E&G (n =1), or via IPP with manual remodeling via Wilson technique (n = 4). Conclusions Non-contrast penile CT scan identifies calcification well in patients with Peyronie's Disease. CT allows for increased accuracy of surgical planning especially when evaluating for multifocal disease, circumferential plaque and/or septal involvement. These elements are critical for for providing accurate surgical recommendations and preoperative discussions. Disclosure No
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ABSTRACT
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The management of male sexual dysfunction and specifically erectile dysfunction (ED) has seen major changes in each decade since the 1970s thanks to the discovery that a papaverine injection could produce erection, the NIH Consensus... more
The management of male sexual dysfunction and specifically erectile dysfunction (ED) has seen major changes in each decade since the 1970s thanks to the discovery that a papaverine injection could produce erection, the NIH Consensus Statement which defined ED in 1992, advances in minimally invasive diagnostics, and the development of orally effective erectogenic class of drugs, the phosphodiesterase type-5 inhibitors
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Introduction Ischemic priapism remains a significant cause of morbidity among men. To date, the precise time when penile ischemia results in permanent, non-reversible cavernosal smooth muscle injury, compromising subsequent erectile... more
Introduction Ischemic priapism remains a significant cause of morbidity among men. To date, the precise time when penile ischemia results in permanent, non-reversible cavernosal smooth muscle injury, compromising subsequent erectile integrity, remains ill-defined. Objectives To review the medical literature pertaining to ischemic priapism, focusing on factors that predict the exact timeline of irreversible cavernous tissue injury. Methods A comprehensive literature search was performed. Our search included both publications on animal models and retrospective clinical series through January 2022. Articles were eligible for inclusion if they contained original data regarding nonreversible tissue injury on histology and/or provided a timeline of erectile function loss or preservation and had full text available in English. Results Innovative studies in the 1990s using invitro models with strips of rabbit, rat, canine and monkey corpus cavernosal tissue demonstrated that anoxia eliminated spontaneous contractile activity and reduced tissue responsiveness to electrical field stimulation or pharmacological agents. The same models demonstrated that the inhibitory effects of field stimulated relaxation, were mediated by nitric oxide. Subsequent studies using similar models demonstrated that exposure of corpus cavernosum smooth muscle to an acidotic environment impairs its ability to contract. A pH of 6.9 was chosen for these experiments based on a case series of men with priapism, in whom a mean pH of 6.9 was measured in corporal blood after 4–6 hours of priapism. Invivo animal studies demonstrated that after erection periods of 6–8 hours, microscopy shows sporadic endothelial defects but otherwise normal cavernous smooth muscle. In these studies, greater durations of ischemic priapism were shown to result in more pronounced ultrastructural changes and presumably irreversibility. In studies involving human corporal tissues, samples were obtained from men who had experienced priapism for at least 12 hours. Overall, erectile function outcome data is deficient in priapism reporting, especially within treatment windows less than 6 hours. Some reports on ischemic priapism have documented good erectile function outcomes with reversal by 12 hours. Conclusion Based on our extensive review of animal models and clinical reports, we found that many clinical papers rely on the same small set of animal studies to suggest the time point of irreversible ischemic damage at 4–6 hours. Our review suggests an equal number of retrospective clinical studies demonstrate that ischemic priapism reversed within 6–12 hours may preserve erectile function in many patients.