Alexander Greenstein

Efficacy of sildenafil as adjuvant therapy to selective serotonin reuptake inhibitor in alleviating premature ejaculation

OBJECTIVESnTo evaluate the efficacy of sildenafil and selective serotonin reuptake inhibitor in alleviating premature ejaculation (PE) in patients in whom other treatments had failed.nnnMETHODSnHealthy men evaluated for primary PE graded their ejaculation on a scale of 0 to 8 (0 = almost never, 8 = almost always). The intravaginal ejaculatory latency time (IVELT) was graded on a scale of 0 to 3 (0 = longer than 5 minutes, 3 = shorter than 1 minute). The 138 men who scored their PE as 4 or greater and IVELT as 2 or greater comprised the study group. Psychological and behavioral counseling was provided during the study. PE was graded using the same scales 3 months after the initiation of each treatment. Topical 5% lidocaine ointment comprised the initial treatment: dissatisfied patients (PE grade 4 or greater, IVELT 2 or greater), took one tablet of paroxetine 20 mg for 30 days and then one tablet 7 hours before intercourse. Sildenafil was added to the treatment of patients dissatisfied with paroxetine alone.nnnRESULTSnThe mean initial PE grade was 5.67 +/- 0.13 and that for IVELT was 2.9 +/- 0.19 for all participants (mean age 28.7 years). Thirty-eight reported improvement (PE grade 2.0 +/- 0.8, P <0.01; IVELT 0.13 +/- 0.34, P <0.001) after local lidocaine application. Of the 100 treated with paroxetine, 42 reported improvement (PE grade 2.5 +/- 0.1, P <0.01; IVELT 0.28 +/- 0.46, P <0.001), and 56 of the remaining 58 who were treated with a combination of paroxetine and sildenafil reported improvement (PE grade 1.78 +/- 0.23, P <0.001; IVELT 0.16 +/- 0.37, P <0.001). Two patients remained dissatisfied with all treatment modalities.nnnCONCLUSIONSnSildenafil combined with paroxetine and psychological and behavioral counseling alleviated PE in patients in whom other treatments failed.

CLINICAL EFFICACY OF SILDENAFIL IN PATIENTS ON CHRONIC DIALYSIS

PURPOSEnWe evaluate the clinical efficacy of sildenafil citrate for patients who are on chronic dialysis and who have concomitant erectile dysfunction.nnnMATERIALS AND METHODSnA total of 35 men (mean age 60.7 years) on dialysis and with erectile dysfunction of various etiologies were administered 25 to 100 mg sildenafil for at least 6 months. The International Index of Erectile Function questionnaire (IIEF), a global assessment question and partner satisfaction question were used to evaluate sildenafil efficacy. Patients also reported any adverse events that occurred during treatment.nnnRESULTSnTreatment was effective for 28 of the 35 (80%) patients according to the results of the IIEF and global assessment questions. Partner satisfaction correlated with the IIEF overall response (0.79) and global assessment question results (0.86). No correlation was found between sildenafil failure and patient age, the etiology of erectile dysfunction, duration of erectile dysfunction, prior treatments, testosterone and prolactin blood levels, and the duration and etiology of renal failure. Of the 35 patients sildenafil was stopped due to intolerable headaches in 3 and because of lack of efficacy in 7.nnnCONCLUSIONSnSildenafil is an effective and safe treatment for erectile dysfunction in most patients on chronic dialysis.

Alleviating Constipation in the Elderly Improves Lower Urinary Tract Symptoms

Background: Constipation and lower urinary tract symptoms (LUTS) very frequently occur in the elderly, and several reports have suggested that dysfunction in either one of these systems may affect the other. Most studies correlating rectal and bladder dysfunction, however, have been carried out in children or young women. Objective: To examine the effect of alleviating constipation on LUTS in the elderly. Methods: Fifty-two patients aged 65–89 (mean 72 ± 13) years with chronic constipation and LUTS participated in this prospective cohort study. Before treatment of constipation was initiated and on their monthly visits, patients completed a questionnaire regarding their constipation pattern, urinary symptoms, sexual function and mood, and underwent urinalysis. Urinary tract anatomy and residual urine were evaluated by abdominal ultrasound at the commencement and completion of the study. Patients were followed up for 4 months. Results: Treatment of constipation increased the number of weekly defecations from 1.5 ± 0.9 to 4.7 ± 1.2 (p < 0.001). Patients spent less time on the toilet (25 ± 2.1 versus 63 ± 1.9 min, p < 0.0001). Fewer patients reported urgency (16 versus 34, p < 0.001), frequency (25 versus 47, p < 0.001) and burning sensation during urination (6 versus 17, p < 0.05). There was improvement in the scoring of urgency, frequency and burning sensation (from a baseline of 52 to 126, 131 and 95, respectively, p < 0.001). Urinary stream disturbances improved in 32 of the 52 patients (p < 0.001). Residual urine volume decreased from 85 ± 39.5 to 30 ± 22.56 ml (p < 0.001). There was also a significant decrease in the number of patients with bacteriurial events (5 versus 17, p < 0.001), and an improvement in sexual activity and mood (p < 0.05). Conclusions: Our data demonstrated that medical relief of constipation significantly improves LUTS in the elderly which, in turn, improves the patient’s mood, sexual activity and quality of life.

Sexual Dysfunction in Women Partners of Men With Erectile Dysfunction

We evaluated 113 female partners of men with erectile dysfunction (ED) attending a sexual dysfunction clinic in order to define sexual dysfunction among these women. In all, 51 (45%) women denied having any sexual dysfunction. The other 62 (55%) responded to questions classifying their complaint(s) according to the international classification of female sexual dysfunction (FSD) in the following topics (40/62, 65%, reported having more than one problem): decreased sexual desire (n=35, 56%), sexual aversion (none), arousal (n=23, 37%) and orgasmic disorders (n=39, 63%), dyspareunia (n=19, 31%), vaginismus (n=3, 5%), and noncoital sexual pain (none). Many female partners of men with ED report having some form of sexual disorder, mostly orgasmic problems and decreased sexual desire. Therefore, for optimal outcome of ED treatment, evaluation and treatment of male and FSD should be addressed as one unit within the context of the couple, and be incorporated into one clinic of sexual medicine.

Predicting penile size during erection

The aim of this prospective study was to identify clinical and engineering parameters of the flaccid penis for prediction of penile size during erection. Dorsal and ventral penile lengths, as well as base and tip circumferences were measured in flaccid states, gently stretched states and at full erection resulting from intracavernosal injection of prostaglandin E1 in 55 patients. The forces required to stretch the penis were measured by a specially designed gauge and regression relationships of the measured dimensions were calculated. An engineering model was developed to analyze differences between results obtained during stretching and erection, as well as to approximate the optimal force values which should be applied during the stretching part of the clinical evaluation of penile size. The ratio between the flaccid to stretched penile lengths was shown to be the best predictor for the ventral elongation from flaccid to erect penile lengths. The engineering analysis predicted that a minimal tension force of approximately 450u2005g during stretching of the penis is required to reach the potential erection length. The stretching forces exerted by the urologist in the clinical setting were experimentally shown to be significantly (P<0.01) less than this value. The values of the relative and absolute elongations of the stretched penis at its ventral aspect provide reliable estimations of its potential maximal elongation during erection. The model designed for this study may obviate the use of intracavernosal injections for estimating penile length during erection.

SILDENAFIL VERSUS THE VACUUM ERECTION DEVICE: PATIENT PREFERENCE

PURPOSEnWe evaluated the preference of patients with erectile dysfunction who had been effectively treated with a vacuum erection device and then switched to sildenafil.nnnMATERIALS AND METHODSnA total of 52 patients with erectile dysfunction who achieved satisfactory erectile function according to the International Index of Erectile Function (IIEF) while using a vacuum erection device were switched to an increasing dose of sildenafil (range 25 to 100 mg.) until satisfactory erection was maintained at least twice a week for at least 1 month. The 2 treatment methods were not used concomitantly. A total of 36 patients with a mean age of 59 years (range 35 to 77) who claimed to have achieved satisfactory erections with a vacuum erection device and sildenafil reported their preference to continue sildenafil or resume the use of a vacuum erection device, reasons for the choice and any adverse side effects.nnnRESULTSnOf the 36 participants in whom the efficacy of sildenafil was similar to that of a vacuum erection device according to the IIEF scores (mean plus or minus standard deviation 61.6 +/- 10.4 and 62.5 +/- 6, respectively), 12 (33.3%) decided to resume use of a vacuum erection device (group 1) while 24 (66.6%) preferred to continue sildenafil (group 2). There were no statistically significant differences between the groups regarding patient age or the etiology and duration of erectile dysfunction. The increase in the IIEF score while using a vacuum erection device was higher in group 1 than 2, with a mean of 66.75 versus 60.4, respectively (p = 0.002). The adverse side effects of sildenafil were the main reasons for preferring a vacuum erection device. Fewer ejaculatory difficulties, efficacy, comfort and ease of use were the main reasons for choosing sildenafil.nnnCONCLUSIONSnEven in an era of effective oral medication, the vacuum erection device remains a preferred treatment option for a substantial number of patients with erectile dysfunction.

Genito-Sensory Analysis in Women with Arousal and Orgasmic Dysfunction

INTRODUCTIONnDiagnosis and treatment of female sexual dysfunction (FSD) are currently based on subjective female reports and physical examination. The GenitoSensory Analyzer (GSA) is a quantitative sensory testing tool designed to quantify vibratory and thermal sensation in the vagina and clitoris in a reproducible manner, and may therefore contribute to the diagnosis and management of FSD.nnnAIMnTo address the question of whether women with arousal and/or orgasmic sexual disorders have genital sensory abnormalities as measured by the GSA.nnnMAIN OUTCOME MEASURESnThresholds for warm, cold, and vibratory sensation at predetermined points in the vaginal wall and clitoris.nnnMETHODSnFemale subjects complaining of arousal and/or orgasmic sexual disorders for more than 6 months were evaluated using a questionnaire based on the female sexual function index (FSFI). Women with a desire disorder, pain disorder, vulvar vestibulitis syndrome, or acute vaginal or/and introital infection were excluded. The GSA device measured thresholds for warm, cold, and vibratory sensation at predetermined points in the vaginal wall and clitoris. Eight measurements were obtained, and deviations from previously published normative values were identified.nnnRESULTSnTwenty-eight women (age 40.4 +/- 13 years) complaining of arousal and/or orgasmic FSD comprised the study cohort. Twenty-five of them (89%) had at least one pathologic genitor-sensory threshold on GSA testing and 19 (68%) had >3 pathologic thresholds. Pathologic GSA results were associated with lower arousal scores on the FSFI questionnaire, older age, and menopausal status.nnnCONCLUSIONSnMost of the study women had at least one genitor-sensory pathology on GSA testing, indicating a possible organic component in their disorder. Our findings support the incorporation of the GSA as a quantitative tool in the assessment and diagnosis of patients with FSD.

Cardiac Arrhythmias During Nonsynchronized Extracorporeal Shock Wave Lithotripsy

PURPOSEnWe evaluated the occurrence of cardiac arrhythmias during nonsynchronized extracorporeal shock wave lithotripsy.nnnMATERIALS AND METHODSnA total of 125 nonsynchronized shock wave lithotripsy treatments was performed using a spark plug lithotriptor.nnnRESULTSnAsymptomatic unifocal ventricular premature contractions occurred during 23 treatments (18.4%) and were more frequent during therapy on the right side (p < 0.05). Among patients undergoing multiple sessions only 1 exhibited ventricular premature contractions during treatment. No correlation was demonstrated between ventricular premature contractions and patient age, gender, presence of heart disease, stone size and location within the collecting system (kidney or ureter), presence of a ureteral catheter or nephrostomy tube, mode of anesthesia or number of shock waves.nnnCONCLUSIONSnNonsynchronized shock wave lithotripsy can be accomplished safely in most patients.

T Lymphocyte Subsets and Function in the Peripheral Blood of Patients with Urological Cancer

The phenotypic distribution and immune reactivity of T lymphocyte subpopulations from peripheral blood of 50 patients with urological cancer were determined. Included were 36 patients with bladder transitional cell carcinoma, 7 patients with renal cell carcinoma and 7 patients with prostatic carcinoma. Thirty-eight age-matched patients with benign urological disease served as controls. A depression in immune competence was found in the group of male patients with infiltrating bladder cancer. In more than 50% of the patients with infiltrating bladder carcinoma, the T helper (CD4) subset was reduced with a concomitant inversion in the CD4/CD8 ratio and impairment in the T cell function as determined by the ability to proliferate upon phytohemagglutinin and concanavalin stimulation. Patients with superficial bladder carcinoma, as well as those with renal cell carcinoma had an immune profile similar to that of the control group. The group of patients with prostatic carcinoma had higher mean CD4/CD8 ratios than the control group, resulting from decreased suppressor/cytotoxic cells. Our results have indicated that the characterization of T cell subset and lymphocyte activity correlated well with the histopathologic state of patients with bladder carcinoma. Thus, the determination of the CD4/CD8 ratio may prove a valuable method for monitoring patients with bladder carcinoma, in addition to serial urine cytology, random urothelial biopsies and flow cytometry.

Do reported micturition symptoms on the American Urological Association Questionnaire correlate with 24-hour home uroflowmetry recordings?

PURPOSEnPatient subjective descriptions of micturition habits using the American Urological Association (AUA) symptom index were compared with uroflowmetry recordings obtained during a 24-hour period.nnnMATERIALS AND METHODSnIn a prospective study, the AUA questionnaire was given twice to 42 men. All micturitions during a typical 24-hour period were continuously recorded by a home uroflowmetry system. Daytime frequency, strength and intermittency of the stream, and nocturia were calculated from the recorded data, which were correlated with the matching questionnaire answers.nnnRESULTSnExcept for nocturia, there was no correlation between the answers and recorded findings.nnnCONCLUSIONSnMen are unable to quantify correctly their own clinical status. The study results cast doubt on the validity of the self-administered AUA survey to reflect clinical micturition.