Dennis J. Krauss

Risks of blood volume changes in hypogonadal men treated with testosterone enanthate for erectile impotence

Administration of anabolic steroids carries many risks. We present a series of 15 patients with primary hypogonadism who as a group had statistically significant increases in whole body hematocrit and red blood cell volume while on testosterone therapy of 300 mg. intramuscularly every 3 weeks. A small decrease in plasma volume over-all was not significant. Subsequent analyses compared subgroups whose whole body hematocrit during testosterone therapy was either 48% or greater (9) or less than 48% (6). Interaction effects indicated that the subgroups were similar when off testosterone but when on testosterone the former group exhibited an increase in red blood cell volume and a decrease in plasma volume, while the latter group had little change in either measurement. Subsequent to stopping testosterone therapy 2 patients in the whole body hematocrit 48% or greater group suffered strokes and 1 had transient ischemic attacks while on therapy. No one in the whole body hematocrit less than 48% group has had any cerebrovascular symptoms. Clinical implications, as well as cost-effective and practical suggestions for detecting possible dangerous hemoconcentration are discussed.

Transcutaneous Electrical Nerve Stimulator for Stress Incontinence

It has been shown that some patients with stress incontinence after prostatectomy may have significant improvement with electrical anal stimulation. The use of a transcutaneous stimulator is the easiest and least invasive method to try initially. Results may be quite satisfying whether the mechanism is physiologic or placebo. This is the first report of the use of transcutaneous electrical nerve stimulation in patients with stress incontinence.

Does a mid-lumbar block level provide adequate anaesthesia for transurethral prostatectomy?

In this prospective, randomized study, 23 patients having spinal anaesthesia for transurethral prostatectomy (TURP) were evaluated for the adequacy of their block using a visual analog pain score (V4 PS). Each patient with a “standard”(≥T10) block level (n = 5) or “intermediate” (L1 or T12) block level (n = 5) found the block adequate. Sixty-two percent (8/13) of patients with a “low”-L3) block level found their block adequate. The VAPS was assessed every five minutes or whenever pain abruptly increased during TURP; an “inadequate block” was defined as a V4 PS ≥ 5 /10 during prostatic resection. Intravesical pressure was monitored and kept <15 mmHg to distinguish between pain from bladder distension and from prostatic resection. “Low” block patients (LBP) who found their block inadequate (n = 5) received supplemental intrathecal local anaesthetic given through a spinal catheter. The subsequent L1 block level was adequate for TURP. In LBP, who found their block adequate (n = 8), a higher (P < 0.01) VAPS was observed than in patients with a “standard” block level. However, a smaller (P < 0.05) maximum percent decrease in diastolic blood pressure was found in LBPs, than in “intermediate” or “standard” block patients. It is concluded that a spinal block ≥L1) is adequate during TURP when bladder pressure is monitored and kept low. Mid-lumbar block levels should be reserved for patients in whom the benefit of minimizing haemodynamic changes outweighs the risk of a “less complete” anaesthetic.RésuméAu cours de cette étude prospective randomisée, l’efficacité de la rachianesthésie est évaluée sur une échelle visuelle analogique (EVA) chez 23 patients soumis à une résection transuréthrale de la prostate (RTUP). Chaque patient (n = 5) bloqué au niveau « standard » (≥T10) ou « intermédiaire » (L1ou T12) a trouvé le bloc suffisant. Soixante-deux pourcent (8/13) des patients avec un niveau « bas » (≤L3 ont trouvé le niveau suffisant. Le score d’EVA a été évalué aux cinq minutes à chacun des moments où la douleur a augmenté subitement pendant la RTUP; le bloc a été considéré comme insuffisant lorsque l’EVA ≥ 5/10 pendant la résection. La pression intravésicale a été monitorée et maintenue < 15 mmHg pour distinguer la douleur de la distension vésicale de celle de la résection prostatique. Les patients à niveau « bas » (PNB) qui ont trouvé le bloc insuffisant (n = 15) ont reçu un supplément d’anesthésique local par un cathéter intrarachidien. Le niveau à L1,a été par la suite considéré comme suffisant pour la RTUP. Chez les PNB qui ont trouvé le bloc suffisant (n = 8), un EVA plus élevé (P < 0,01) a été rapporté que chez les patients avec un niveau « standard ». Cependant, une plus petite baisse maximale (P < 0,05) de la pression artérielle diastolique a été constatée chez les PNB que chez les patients à bloc « standard » ou « intermédiaire ». En conclusion, un bloc rachidien ≥L1 est adéquat pendant la RTUP en autant que la pression vésicale est gardée basse. Les niveaux mid-lombaires devraient être réservés aux patients chez qui le bénéfice d’atténuer les modifications hémodynamiques est supérieur au risque d’une anesthésie moins complète.

Male Erectile Disorder

Male erectile disorder involves a persistent and recurrent difficulty in which a man cannot attain or maintain an erection that is sufficient for intromission and subsequent sexual activity. Expressions such as “I can’t get it up anymore,” “I’ve lost my manhood,” and “It’s dead down there” all capture the typical client’s view of this disorder.

Use of the Malleable Penile Prosthesis in the Treatment of Erectile Dysfunction: A Prospective Study of Postoperative Adjustment

Much of the research on the postoperative adjustment of penile prosthesis recipients and their partners has been hampered by retrospective designs, unreliable assessment procedures and other methodological limitations. To address these shortcomings and to increase current knowledge regarding postoperative adjustment, we completed a prospective, longitudinal study of 19 implant recipients and their partners. Our results suggest that most patients and partners were satisfied with the prosthesis 1 year postoperatively, although use of the prosthesis sometimes was accompanied by short-term complications. Satisfaction tended to be lower among spouses than patients. Frequency of sexual intercourse increased during the followup period but there were no changes in sexual desire. Neither marital nor psychological adjustment changed significantly during this period.

Incapacitating flank pain of questionable renal origin

Local anesthetics can play a significant role in the diagnosis, and possible definitive treatment, of previously intractable flank pain. Numerous patients may thus be spared unnecessary physical and mental anguish, as well as unnecessary surgery.

The Failed Penile Prosthetic Implantation Despite Technical Success

Successful implantation of a penile prosthesis involves more than an operation. Psychological factors can be crucial before, during and after the operation. If these issues are not addressed the true goal of restoring the pleasure of sexual intercourse will not be achieved, regardless of the type of prosthesis used or the technical success of the procedure.

Prostate Biopsy in Patients after Proctectomy

Until the discovery of prostate specific antigen as a tool to detect prostate carcinoma, the rectum has always been necessary to allow the best evaluation and biopsy of the prostate, whether by digital examination or transrectal ultrasound. We describe a simple, accurate, computerized tomography-guided method to biopsy the prostate in men who have undergone proctectomy.

Fulminating hypercalcemia and markedly increased nephrogenous cyclic AMP in a patient with transitional cell carcinoma of the bladder

Refractory hypercalcemia developed suddenly in a patient who had undergone a radical cystectomy for an anaplastic transitional cell carcinoma of the bladder. A normal serum parathyroid hormone (PTH) value was obtained by immunoassay while the patient had hypercalcemia and unimpaired renal function. This normal PTH value in the presence of hypercalcemia was consistent with his hypercalcemia being secondary to excessive amounts of circulating PTH. The finding of increased nephrogenous cyclic AMP, however, provided the definitive diagnosis of hyyperparathyroidism. Since autopsy revealed that there was no residual tumor in the bladder area, only evidence of metastatic disease, and since the parathyroid glands were not hyperplastic or adenomatous, we attributed this patients hypercalcemia to hyperparathyroidism due to the ectopic production of PTH by a metastasis from the transitional cell carcinoma of the bladder.

Repeat male genital self-mutilation precipitated by urinary complications of prior repair.

Male genital self-mutilation is uncommon, with repeat mutilation even more rare. Our case is unique in that a urological complication of the first mutilating act (meatal stenosis) helped to precipitate the second incident. This case underscores the need not only for immediate urological and psychiatric care at the time of initial mutilation but also for close, combined followup care as well. In the majority of cases, when properly monitored, the men do not repeat the mutilating act.