Elroy D. Kursh

Side Effects of Self-Administration of Intracavernous Papaverine and Phentolamine for the Treatment of Impotence

Beginning October 1985, 111 men agreed to enter a prospective study of the side effects of low dose papaverine/phentolamine therapy. A total of 46 men dropped out, 30 during the initial phase. The percentage of men with painless nodules almost consistently doubled from one followup examination to the next: 8 per cent at 1 month, 17 per cent at 3 months, 32 per cent at 6 months and 57 per cent at 12 months. The average injection frequency of those with nodules was 2 1/2 times higher than those without nodules. Of the men 41 per cent required an increased dose of medications during followup, and 40 per cent of 50 men had at least 1 abnormality of liver function, most of these involving mild to moderate elevations of alkaline phosphatase and lactic dehydrogenase. Priapism was not encountered during self-injection but it did occur twice in 329 physician-administered injections. Careful regular monitoring of patients should continue as some patients enter the second year of treatment.

Spontaneous Rupture of the Kidney with Perirenal Hematoma

Spontaneous rupture of the kidney involves either the collecting system or parenchyma, the latter being associated with a subcapsular or perirenal hematoma. A review was made of 78 cases of spontaneous parenchymal rupture with perirenal hematoma, including 4 of our own. One of these cases is the first description of spontaneous rupture of the kidney secondary to renal vein thrombosis. The patients are usually in the fourth decade of life and present with an acute onset of flank pain, a tender mass and commonly symptoms and signs of shock. Hematuria is often present and generally urography reveals a mass, distorted collecting system and/or non-visualization of the kidney. Tumors are the most common cause followed by vascular diseases, infection, nephritis and blood dyscrasias. Nephrectomy when possible should be performed expeditiously since conservative therapy is uniformly unsuccessful.

Why do so many people drop out from auto-injection therapy for impotence?

Although intracavernous injection of vasoactive substances has been shown to be a reasonable and reliable method of reversing impotence, studies assessing patient acceptance of this new technology are lacking. By prospectively following patients and willing partners over a 2-year period, this study sought to document patient utilization rates and the reasons why patients decline or discontinue injection therapy. The cumulative dropout rate was 46%, with patients being most at risk for leaving the program after evaluation or during the trial dose phase. Patients decline treatment because they are unable to accept the idea of injecting themselves or because of potential side effects. Patients discontinue treatment because of perceived lack of efficacy. Patient and programatic obstacles to utilization of self-injection therapy are analyzed.

Synergistic gangrene of the scrotum and penis secondary to colorectal disease.

We recently encountered 5 patients with synergistic gangrene of the genitalia secondary to colorectal disease. This number of cases suggests that there may be an increasing incidence of this entity that has been reported only several times in the past. Pseudomonas was one of the organisms cultured in all cases. Because of the high mortality rate we advocate aggressive therapy, consisting of early and repeated radical débridement into normal tissues and appropriate management of the colorectal source of contamination. Our experience indicates that the lower gastrointestinal tract should be considered as a possible cause of infection in all cases of synergistic gangrene of the scrotum and penis.

Through the Eyes of Women: The Sexual and Psychological Responses of Women to their Partner’s Treatment with Self-Injection or External Vacuum Therapy

We prospectively delineated and contrasted the sexual, marital and psychological responses of women to their partners use of 2 treatments for erectile dysfunction: 1) self-injection of papaverine and phentolamine, and 2) vacuum tumescence therapy. The women were assessed at 5 points during a 12-month period with psychometric questionnaires and clinical interviews. Statistical analysis indicated that the women responded equally well to both treatments. They demonstrated significant increases in frequency of intercourse, sexual arousal, coital orgasm and sexual satisfaction. No significant changes were noted on the psychometric questionnaires. The women reported feeling more at ease in their relationships and characterized sex as more leisurely, relaxed and assured. Negative responses focused on the lack of spontaneity and hesitation about initiating sex. Self-injection and vacuum pump therapy restore potency in men and secondarily facilitate improved sexual function in women.

The Application of Intracavernous Injection of Vasoactive Medications for Erection in Men with Spinal Cord Injury

Obtaining and sustaining an erection that is firm enough and adequate for vaginal penetration and satisfactory completion of intercourse are common problems for the male spinal cord injury patient. Intracavernous injection of vasoactive substances offers a new treatment option but it must be approached with caution in this population. During the last year we placed 20 spinal cord injury men (16 paraplegics and 4 quadriplegics) on self-injection of papaverine alone or with phentolamine. Of the patients 19 were able to obtain an erection adequate for penetration. The patient who did not obtain an adequate erection had anomalous penile venous drainage. Six episodes of priapism occurred in 3 patients: 1 had a surgical shunt placed elsewhere before he entered our program, and 2 were treated with aspiration of the corpora and injection of epinephrine. All 3 patients subsequently have been able to obtain satisfactory erections with use of lower doses of papaverine alone.

Treating Erectile Dysfunction with External Vacuum Devices: Impact Upon Sexual, Psychological and Marital Functioning

We evaluated prospectively the medical, sexual and psychosocial outcome of external vacuum devices in the treatment of erectile dysfunction. A total of 29 men regularly used such a device for 6 months and reported statistically significant improvements in erectile quality, frequency of intercourse attempts, frequency of orgasm and sexual satisfaction, as well as decreased psychiatric symptomatology, increased self-esteem and a trend toward improved marital satisfaction. Of the partners 18 reported improved sexual functioning, including increased frequency of orgasm, decreased masturbation and greater sexual satisfaction, with no changes in psychosocial parameters. The vacuum device was effective in producing erections in 89% of the men. Dropout, only 19% within 6 months, was primarily due to insufficient or pivoting erections and bruising. The most frequent adverse effects were blocked ejaculation and physical discomfort. Vacuum devices appear to provide a safe, effective, inexpensive, noninvasive treatment for erectile failure that enjoys high patient and partner acceptance.

Intracavernosal injection in the treatment of impotence: A prospective study of sexual, psychological, and marital functioning

This study assessed the sexual, psychosocial, and medical impact of intracavernosal injection of papaverine hydrochloride and phentolamine mesylate in the treatment of impotence. Ninety-six percent of patients initially achieved satisfactory erections with injections. Common side effects of self-injections included bruising (26%), nodule development (21%), abnormal liver function tests (7%), and pain (5%). No nodules resulted in penile bending or pain, and no patient discontinued treatment due to nodule development. Dropout rate to date was 35%. Self-injection treatment was associated with increases in erection quality, intercourse frequency, and sexual satisfaction, and decreases in masturbation frequency for patients. Partners also reported increases in intercourse frequency, coital arousal, and satisfaction. Decreases in general psychiatric symptomatology and increases in relationship satisfaction and self-esteem were apparent for patients, but not for partners.

CT and MR imaging in staging bladder neoplasms

Thirteen patients with bladder carcinoma were examined by magnetic resonance (MR) imaging and CT to determine the relative accuracy of the modalities in staging bladder carcinoma. Magnetic resonance correctly identified the presence or absence of extravesical spread of carcinoma in 10 of 13 patients (77%). Two patients were understaged and one was overstaged. Computed tomography correctly staged nine of 13 patients (69%), with three patients understaged and one patient overstaged. Neither MR nor CT was able to determine depth of invasion of the bladder wall in the absence of extravesical spread.

Twelve-month comparison of two treatments for erectile dysfunction: Self-injection versus external vacuum devices

This study directly compared two nonsurgical treatments for erectile dysfunction, self-injection of papaverine/phentolamine and external vacuum devices, in terms of usage rates, effectiveness, side effects, dropout rates, and impact on patient sexual and psychologic functioning. Both alternatives were regularly, successfully, and safely used by patients, though dropout rates were higher for self-injection. Both produced erections of improved quality, and effected sustained improvements in frequency of intercourse, orgasm, and sexual satisfaction. Spontaneous erections also improved with both treatments. General psychiatric symptomatology was decreased, and anxiety was improved. There were no differences between the two treatments in sexual or psychologic impact. Relative contraindications and esthetic considerations are presented.