Hussein Ghanem

Priapism: pathogenesis, epidemiology, and management.

INTRODUCTION Priapism describes a persistent erection arising from dysfunction of mechanisms regulating penile tumescence, rigidity, and flaccidity. A correct diagnosis of priapism is a matter of urgency requiring identification of underlying hemodynamics. AIMS To define the types of priapism, address its pathogenesis and epidemiology, and develop an evidence-based guideline for effective management. METHODS Six experts from four countries developed a consensus document on priapism; this document was presented for peer review and debate in a public forum and revisions were made based on recommendations of chairpersons to the International Consultation on Sexual Medicine. This report focuses on guidelines written over the past decade and reviews the priapism literature from 2003 to 2009. Although the literature is predominantly case series, recent reports have more detailed methodology including duration of priapism, etiology of priapism, and erectile function outcomes. MAIN OUTCOME MEASURES Consensus recommendations were based on evidence-based literature, best medical practices, and bench research. RESULTS Basic science supporting current concepts in the pathophysiology of priapism, and clinical research supporting the most effective treatment strategies are summarized in this review. CONCLUSIONS Prompt diagnosis and appropriate management of priapism are necessary to spare patients ineffective interventions and maximize erectile function outcomes. Future research is needed to understand corporal smooth muscle pathology associated with genetic and acquired conditions resulting in ischemic priapism. Better understanding of molecular mechanisms involved in the pathogenesis of stuttering ischemic priapism will offer new avenues for medical intervention. Documenting erectile function outcomes based on duration of ischemic priapism, time to interventions, and types of interventions is needed to establish evidence-based guidance. In contrast, pathogenesis of nonischemic priapism is understood, and largely attributable to trauma. Better documentation of onset of high-flow priapism in relation to time of injury, and response to conservative management vs. angiogroaphic or surgical interventions is needed to establish evidence-based guidance.

SOP Conservative (Medical and Mechanical) Treatment of Erectile Dysfunction

INTRODUCTION Erectile dysfunction (ED) is the most frequently treated male sexual dysfunction worldwide. ED is a chronic condition that exerts a negative impact on male self-esteem and nearly all life domains including interpersonal, family, and business relationships. AIM The aim of this study is to provide an updated overview on currently used and available conservative treatment options for ED with a special focus on their efficacy, tolerability, safety, merits, and limitations including the role of combination therapies for monotherapy failures. METHODS The methods used were PubMed and MEDLINE searches using the following keywords: ED, phosphodiesterase type 5 (PDE5) inhibitors, oral drug therapy, intracavernosal injection therapy, transurethral therapy, topical therapy, and vacuum-erection therapy/constriction devices. Additionally, expert opinions by the authors of this article are included. RESULTS Level 1 evidence exists that changes in sedentary lifestyle with weight loss and optimal treatment of concomitant diseases/risk factors (e.g., diabetes, hypertension, and dyslipidemia) can either improve ED or add to the efficacy of ED-specific therapies, e.g., PDE5 inhibitors. Level 1 evidence also exists that treatment of hypogonadism with total testosterone < 300 ng/dL (10.4 nmol/L) can either improve ED or add to the efficacy of PDE5 inhibitors. There is level 1 evidence regarding the efficacy and safety of the following monotherapies in a spectrum-wide range of ED populations: PDE5 inhibitors, intracavernosal injection therapy with prostaglandin E1 (PGE1, synonymous alprostadil) or vasoactive intestinal peptide (VIP)/phentolamine, and transurethral PGE1 therapy. There is level 2 evidence regarding the efficacy and safety of the following ED treatments: vacuum-erection therapy in a wide range of ED populations, oral L-arginine (3-5 g), topical PGE1 in special ED populations, intracavernosal injection therapy with papaverine/phentolamine (bimix), or papaverine/phentolamine/PGE1 (trimix) combination mixtures. There is level 3 evidence regarding the efficacy and safety of oral yohimbine in nonorganic ED. There is level 3 evidence that combination therapies of PDE5 inhibitors + either transurethral or intracavernosal injection therapy generate better efficacy rates than either monotherapy alone. There is level 4 evidence showing enhanced efficacy with the combination of vacuum-erection therapy + either PDE5 inhibitor or transurethral PGE1 or intracavernosal injection therapy. There is level 5 evidence (expert opinion) that combination therapy of PDE5 inhibitors + L-arginine or daily dosing of tadalafil + short-acting PDE5 inhibitors pro re nata may rescue PDE5 inhibitor monotherapy failures. There is level 5 evidence (expert opinion) that adding either PDE5 inhibitors or transurethral PGE1 may improve outcome of penile prosthetic surgery regarding soft (cold) glans syndrome. There is level 5 evidence (expert opinion) that the combination of PDE5 inhibitors and dapoxetine is effective and safe in patients suffering from both ED and premature ejaculation.

Combination Clomiphene Citrate and Antioxidant Therapy for Idiopathic Male Infertility: A Randomized Controlled Trial

OBJECTIVE To assess the effect of treatment with a combination of clomiphene citrate as an antiestrogen and vitamin E as an antioxidant on the incidence of pregnancy and sperm variables in men with idiopathic oligozoospermia and infertility. DESIGN Prospective, randomized, placebo-controlled trial. SETTING The outpatient andrology clinic at a university hospital. PATIENT(S) Sixty infertile men with idiopathic oligoasthenozoospermia. INTERVENTION(S) Patients were randomly assigned to two treatment groups: a group receiving the combination of clomiphene citrate (25 mg/day) and vitamin E (400 mg/day; n = 30) against a placebo group (n = 30). Treatment was maintained for 6 months. MAIN OUTCOME MEASURE(S) Pregnancy incidence and variations in semen parameters. RESULT(S) A significantly higher pregnancy rate was found among the combination treatment group in comparison to the control group. The odds ratio was 3.76 and the 95% confidence interval was 1.03-13.64, with a 36.7% pregnancy rate (11/30) in the combination treatment group compared with 13.3% pregnancy rate (4/30) in the control group. The trial showed a significantly higher increase in sperm count and progressive sperm motility with nonsignificant changes in total sperm motility, percentage of abnormal forms and semen volume in the combination treatment group as compared to the control group. CONCLUSION(S) The combination of clomiphene citrate as an antiestrogen and vitamin E as an antioxidant can significantly increase the pregnancy rate and improve sperm count and progressive sperm motility in cases of idiopathic oligoasthenozoospermia.

Validity of the Arabic version of the sexual health inventory for men among Egyptians

The objective of this study is to assess the validity of Arabic version of the abridged International Index of Erectile Function among a sample from the Egyptian populace. Two groups were included in this study. Group A included 68 patients complaining of erectile dysfunction (ED) >1 y, who failed oral treatment and accepted intracavernous self-injection. All patients of group A were previously clinically diagnosed as having ED. Group B included 68 men not complaining of ED and not suffering from any major chronic or acute illness. The mean (s.d.) age of all 136 patients was 52±5.7 y. Candidates of both groups were requested to complete the Sexual Health Inventory for Men (SHIM) questionnaire. Cronbachs alpha coefficient was used to assess the internal consistency of the SHIM. The items of maintenance ability, erection confidence, maintenance frequency, erection firmness and intercourse satisfaction showed an overall ICC of 0.92. Internal consistency for the whole scale was 0.91. In conclusion, the Arabic version of the SHIM administered to 136 Egyptian men proved to be reliable and valid. It also showed a high degree of specificity and sensitivity among the Egyptian population.

Correlation between penile duplex findings and stress electrocardiography in men with erectile dysfunction

The aim of this work is to assess the association between vasculogenic erectile dysfunction (ED) and coronary artery disease in men above the age of 40 y. The study included 40 patients above 40 y of age with vasculogenic ED of more than 3 months duration. A dynamic duplex study after intracavernosal injection of a bimix solution (60 mg papaverine+2 mg phentolamine mesylate) was carried out using a color ultrasound machine. The patients underwent a stress ECG test, carried out on a motor-driven treadmill according to the ‘Bruce Protocol’. A total of 12 patients were diagnosed with positive ischemic heart disease (IHD). Their mean peak systolic velocity (PSV) was PSV=19.58 cm/s. In all, patients were diagnosed with negative IHD; their mean PSV was 36.21 cm/s. A statistically significant difference was observed between patients with positive IHD and patients with negative IHD regarding PSV (P=0.003). The sensitivity of a PSV of less than 35 cm/s in predicting IHD was 50% with a specificity of 100%. Positive predictive value for abnormal stress ECG to predict a PSV of less than 35 cm/s was 100%. In conclusion, the PSV of cavernosal arteries is a reliable measure for predicting IHD in patients with vasculogenic ED. Patients with a PSV of less than 35 cm/s should be referred for cardiologic assessment as they carry a real risk of having silent IHD.

SOP: Physical Examination and Laboratory Testing for Men with Erectile Dysfunction

INTRODUCTION Physical examination and laboratory evaluation of men with erectile dysfunction (ED) are opportunities to identify potentially life-threatening etiologies and comorbid conditions. AIM To review genital anatomy, identify any physical abnormalities, assess for comorbid conditions, and reveal significant risk factors for ED. METHODS Expert opinion was based on evidence-based medical literature and consensus discussions between members of this International Society for Sexual Medicine (ISSM) standards committee. RESULTS For men with ED, a general examination including blood pressure and pulse measurements and a focused genital exam are advised. Fasting blood sugar, serum total testosterone, prolactin levels, and a lipid profile may reveal significant comorbid conditions. CONCLUSIONS Though physical examination and laboratory evaluation of most men with ED may not reveal the exact diagnosis, these opportunities to identify critical comorbid conditions should not be missed.

Position Paper: Management of Men Complaining of a Small Penis Despite an Actually Normal Size

INTRODUCTION With the worldwide increase in penile augmentation procedures and claims of devices designed to elongate the penis, it becomes crucial to study the scientific basis of such procedures or devices, as well as the management of a complaint of a small penis in men with a normal penile size. AIM The aim of this work is to study the scientific basis of opting to penile augmentation procedures and to develop guidelines based on the best available evidence for the management of men complaining of a small penis despite an actually normal size. METHODS We reviewed the literature and evaluated the evidence about what the normal penile size is, what patients complaining of a small penis usually suffer from, benefits vs. complications of surgery, penile stretching or traction devices, and outcome with patient education and counseling. Repeated presentation and detailed discussions within the Standard Committee of the International Society for Sexual Medicine were performed. MAIN OUTCOME MEASURE Recommendations are based on the evaluation of evidence-based medical literature, widespread standards committee discussion, public presentation, and debate. RESULTS We propose a practical approach for evaluating and counseling patients complaining of a small-sized penis. CONCLUSIONS Based on the current status of science, penile lengthening procedure surgery is still considered experimental and should only be limited to special circumstances within research or university institutions with supervising ethics committees.

Comparing Penile Measurements in Normal and Erectile Dysfunction Subjects

INTRODUCTION With the increase in penile augmentation procedures it becomes important to assess what is the normal erect penile size in both potent men and men with erectile dysfunction (ED). AIM The aim of this work is to define the average stretched penile size in normal men and ED patients. MAIN OUTCOME MEASURES Penile length and girth. METHODS This study included 1,027 adult men presenting to a university hospital outpatient clinic. Two groups of patients were included in this research work. Group I comprises normal adult men (949) and Group II, ED patients (78). There were no differences of race, age, height, and weight. Penile length and girth were measured using a tape measure and rigid ruler in the fully stretched states in both groups. All penile measurements were performed by the same physician. RESULTS In normal men (Group I) the mean of the fully stretched length was 12.9 +/- 1.9 cm and the mean of the fully stretched girth was 8.9 +/- 0.9 cm. In ED patients (Group II), the mean of the fully stretched length was 11.2 +/- 1.5 cm and the mean of fully stretched girth was 8.8 +/- 0.8 cm. Comparing the mean of fully stretched penile lengths in both groups revealed statistical significant difference (P < 0.001) between them, whereas comparing the mean of fully stretched penile girths in both groups revealed statistical nonsignificant difference (P = 0.474) between them. There were significant positive correlations between fully stretched penile lengths and fully stretched penile girths in both groups. CONCLUSION The average of fully stretched penile length in normal potent men is 12.9 cm, whereas the patients with ED tend to have significantly shorter penises (11.2 +/- 1.5 cm).

Clinical and sonographic assessment of the side effects of intracavernous injection of vasoactive substances

The objective of this study is to evaluate the side effects of intracavernous vasoactive agents on clinical and sonographic basis. Two groups of patients were included, group I included 168 ED patients trained on self-injection therapy using one of the three protocols. Protocol A: papaverine; protocol B: PGE1; and protocol C: trimix (papaverine, phentolamine and PGE1). Patients were followed up clinically, sonographically and by laboratory investigations for 6 months to evaluate the occurrence of side effects. Group II included 21 patients presenting to our department for the first time with a complication of intracavernous injection pharmacotherapy (ICI) initiated elsewhere. In all, 168 patients of group I completed the study. Patients on papaverine had the highest incidence of complications concerning prolonged erection, subcutaneous hematoma and penile fibrosis. Postinjection penile pain was observed more with groups B and C than group A. No systemic side effects were reported. Duplex ultrasound was beneficial in detecting mild clinically impalpable fibrosis. In total, 10 patients of group II presented with prolonged erection, seven with penile fibrosis, three with cavernositis and one with intracavernous needle breakage. We conclude that although ICI therapy is an effective second-line treatment option, patients on a self-injection program should be followed up both clinically and sonographically both at the initiation phase and on regular follow-up visits.

An Evidence-Based Perspective to the Medical Treatment of Male Infertility: A Short Review

Introduction: Evidence-based medicine (EBM) is the integration of best research evidence with clinical expertise and patient preferences and values. Aim: This narrative review aims to assist the physicians to make informed decisions based on the best available evidence in the area of male infertility and the patients’ own preferences and values. Methods: In this review we present the current state of knowledge and uncertainties about the medical management of male infertility. We describe the best available evidence from systematic reviews, randomized controlled studies and observational studies where appropriate. Results: Data from the literature suggest that gonadotropin treatment of male infertility can lead to a significant increase in pregnancy rates, however larger studies are needed to confirm such findings. Studies including combinations of antiestrogens, antioxidants and androgens are promising but need confirmation with further research. Conclusions: Most current combination therapies consist of orphan medications without industry support. Andrology research centers and other dedicated departments and units need to conduct randomized controlled trials of sufficient duration, sample number and robust design for groups most likely to benefit from antiestrogens, L-carnitine, antioxidants, and combination therapy. The ease of administration, low cost and mild side effects of antiestrogens justify their utility despite insufficient evidence of effect as monotherapies. Randomized controlled trials assessing other forms of medical therapy and combination therapy are available but are still in the preliminary stages.