Evaluation and treatment of erectile dysfunction.

Erectile dysfunction has an organic etiology in most cases, with vascular disease the single most common cause. In addition to a thorough history and physical examination, clinical evaluation may include hormonal assessment, diabetes screening, nocturnal tumescence testing and color Doppler flow studies of the penile vasculature. Therapy for erectile dysfunction has progressed rapidly during the past decade, with alternatives including hormone supplements, vacuum constriction devices, penile self-injection therapy and penile prostheses. The majority of patients and their partners report satisfactory results with these treatments.

Ultrasonographic characteristics of testicular adenomatoid tumors.

PURPOSE: We determined the characteristics of testicular adenomatoid tumors which could distinguish these lesions from testicular malignancies. MATERIALS AND METHODS: Clinical presentation and ultrasonographic findings in 3 men with testicular adenomatoid tumors were compared with those in 10 men treated for testicular malignancies. RESULTS: Clinical presentation was similar for all patients. Of the 3 adenomatoid tumors 2 appeared isoechoic on ultrasound and 1 appeared normal. None of the 10 cancers appeared isoechoic or normal on ultrasound. CONCLUSIONS: Small tumors that appear isoechoic on ultrasound should be biopsied through an inguinal incision with frozen section assessment rather than immediate radical orchiectomy.

Patient satisfaction with current impotence therapy.

One hundred ninety-eight impotent men were evaluated between July 1993 and June 1994. A "patient goal-directed" approach was used in all cases. Treatment options presented to patients included: oral yohimbine, vacuum constriction devices, penile self-injection therapy, penile prostheses, and testosterone supplementation when clinically indicated. Thirty-two percent of patients declined treatment, and 67% chose nonsurgical therapy. Only two patients (1%) chose penile prostheses. In August 1994, a survey addressing satisfaction with therapy was mailed to all patients, and 99 men (50%) responded. Of the treated respondents, 80% stated that their therapy was "easy to use," and 70% reported that they were "able to have intercourse." Patients prefer nonsurgical impotence therapy, which restores satisfactory sexual function in most men.

A method of human semen centrifugation to minimize the iatrogenic sperm injuries caused by reactive oxygen species.

Current techniques of sperm preparation for in vitro fertilization or intrauterine insemination require centrifugation of human semen to separate spermatozoa from the seminal plasma. Centrifugation increases reactive oxygen species (ROS) formation in semen. Moreover, high levels of ROS are associated with sperm membrane injury through spontaneous lipid peroxidation, which may alter sperm function. We investigated the relationship between centrifugation variables (time and g-force) and ROS production to establish an optimal centrifugation protocol for sperm preparation techniques. Semen from 38 men (24 patients and 14 normal volunteers) was evaluated for the formation of ROS before centrifugation and after centrifugation at 200 g for 2 or 10 min and after 500 g for 2 or 10 min. The absence of white blood cells in semen which can also produce ROS was determined with the myeloperoxidase technique (Endtz test). All specimens were negative (< 1 x 10(6)/ml) by the Endtz test. The formation of ROS was measured by chemiluminescence. ROS formation was regarded as high (positive) when the chemiluminescence response was at least 10 x 10(4) counted photons/min (cpm). The sperm concentration in each sample was adjusted to 15-20 x 10(6) cells/ml before analysis. Eight specimens (7 patients and 1 donor) exhibited high levels of ROS before centrifugation. All 8 showed further, significant increases in ROS formation regardless of g-force or time. The increase in ROS was significantly less when semen was centrifuged for 2 as compared to 10 min (p < 0.001). Six specimens previously ROS-negative became ROS-positive after centrifugation for 10 min at 200 and 500g. We conclude that the time of centrifugation is more important than g-force for inducing ROS formation in semen. Based on these results, we recommend a shorter centrifugation period in the preparation of sperm for assisted reproductive techniques.

Clinical outcome and cost comparison of percutaneous embolization and surgical ligation of varicocele.

We reviewed the records of 81 consecutive subfertile men with oligospermia and/or asthenospermia, treated for varicocele with either percutaneous embolization or surgical ligation between 1987 and 1991, and compared the outcomes and costs of the two procedures. All men had presented with infertility of at least 6 months duration, and in most cases female factors had been previously evaluated and treated. Patients were offered a choice of embolization or ligation of the internal spermatic vein. Forty-five men (56%) underwent ligation, and 36 men (44%) opted for embolization. The mean age, serum follicle-stimulating hormone, pretreatment sperm density, motility, and concentration of motile sperm were similar for the two groups. Seminal quality improved in 65% of all patients after varicocele ablation (46 of 71). Improvements were seen in postoperative sperm density (P < 0.01), motility (P < 0.002), and concentration of motile sperm (P < 0.001). Thirty-nine percent of the assessable patients established pregnancies during the study interval (26 of 66). The two treatment groups did not differ significantly with regard to the likelihood of postoperative improvement in sperm density (P = 0.64), motility (P = 0.33), concentration of motile sperm (P = 0.11), or pregnancy rate (P = 0.83). Percutaneous embolization and surgical ligation of varicocele are equally effective in improving male infertility and cost about the same. Embolization offers the potential advantage of shorter recovery to full activity as compared to surgical ligation. Where experienced interventional radiologists are available, percutaneous embolization should be offered as an alternative to open ligation.

Experience with macroscopic vasectomy reversal at the Medical College of Wisconsin.

Thirty-two men underwent vasectomy reversal using loupe magnification at the Medical College of Wisconsin between 1984 and 1991. Semen analysis and pregnancy data were available for 27 of them, and sperm were present in the ejaculate of 24, representing a patency rate of 89%. Pregnancy was established by 11, for a pregnancy rate of 41%. These results suggest that vasovasostomy using loupe magnification provides acceptable rates of patency and pregnancy, although the pregnancy rate appears to be somewhat lower than that reported for microsurgical repair. The lower cost of macroscopic vasectomy reversal may outweigh the potential statistical advantages for some couples.

PIP: 32 men underwent vasectomy reversal using 2.0x to 4.0x loupe magnification at the Medical College of Wisconsin between 1984 and 1991. The mean patient age was 36 years. The mean interval from vasectomy to reversal was 6.4 years (range 1 to 18 years). All procedures were performed on an outpatient basis, using local anesthesia with intravenous sedation. Anastomoses were completed using a modification of the technique described by Middleton. A semen analysis was obtained 1 to 3 months postoperatively. The medical record of each patient was reviewed to determine data for semen quality. Patients were contacted by telephone to determine pregnancy status as of July 1993. Semen analysis and pregnancy data were available for 27 of the 32 men (84%) who underwent vasectomy reversal between 1984 and 1991. Sperm were present in the ejaculate of 24 men, representing a patency rate of 89%. 11 men (41%) established pregnancies during the study interval. A complete semen analysis including sperm count, percent motility, and morphology was performed in 23 patients. Semen quality was determined according to World Health Organization standards for normal. 5 men (22%) had normal postoperative semen quality in all 3 parameters. 15 (65%) men were subfertile in one or more parameters. Three patients (13%) had no sperm present in the ejaculate. Regarding pregnancy according to semen quality, 60% (3 of 5) of the men with normal postoperative semen analyses established a pregnancy, while 40% (6 of 15) of the patients with subfertile semen quality produced pregnancies. Vasovasostomy using loupe magnification provides acceptable rates of patency and pregnancy as compared to microsurgical repair, although the pregnancy rate appears to be slightly better with microsurgery. Because of the potential cost benefits to both the patient and the surgeon, the relatively simple macroscopic vasovasostomy will continue to play a role in the management of postvasectomy male infertility.

The effect of partial zona dissection on the fertilizing capacity of chronically obstructed mouse caput epididymal sperm.

PURPOSE: Having observed that sperm from the chronically obstructed caput epididymis fertilize poorly in vitro, we investigated the effect of partial zona dissection (PZD) on fertilization in a murine model of unilateral proximal epididymal obstruction. Cleavage rates were compared for zona-intact oocytes and PZD oocytes incubated with sperm from the following epididymal segments: the obstructed caput, the contralateral nonobstructed caput, the contralateral cauda, and a sperm-free preparation to control for parthenogenesis. RESULTS: Unilateral epididymal obstruction resulted in significantly higher sperm counts in the obstructed caput compared to the nonobstructed caput, although there was no difference in motility. Cleavage rates for ova incubated with sperm from the obstructed caput and the nonobstructed caput were uniformly poor and did not differ significantly from those for the sperm-free controls. Cauda sperm fertilized significantly better than all other sperm groups (P < 0.05). Partial zona dissection did not improve cleavage rates in any group. CONCLUSION: We conclude that sperm from the chronically obstructed caput epididymis, like sperm from the normal caput, are unable to fertilize ova, and PZD does not enhance this poor fertilizing capacity. Furthermore, the finding that PZD does not improve the fertilizing capacity of the presumably mature cauda sperm in our mouse model suggests that any beneficial effect of PZD may be strain-specific.

Color Doppler sonography in the evaluation of the adult acute scrotum.

Color Doppler sonography (CDS) was used to evaluate 35 adult males with acute scrotal discomfort. Correlative nuclear scintigraphy was performed in 15 patients. Surgical correlation was available in 10 patients with clinical follow-up in the remaining 25. The complete absence of intratesticular color flow was used as our criterion for testicular ischemia. This was found to be 100% sensitive and 100% specific in 8 patients with surgically confirmed testicular ischemia. Spontaneous detorsion was noted in one patient with hyperemia demonstrated by color imaging. Increased color flow was found in 20 patients with the clinical impression of scrotal inflammation. Nuclear scintigraphy and color Doppler imaging had 100% agreement in 15 patients. Color Doppler sonography is a useful and highly accurate diagnostic method in the evaluation of patients with the acute scrotal syndrome. Color flow imaging is comparable to nuclear scintigraphy in the diagnosis of testicular ischemia.

Ureteric jets: evaluation of normal flow dynamics with color Doppler sonography.

This study was designed to investigate a variety of sonographic features of ureteric jets in order to define patterns of flow and ranges of flow values in an asymptomatic population. The following features of ureteric jets were measured during a period of up to 30 min in a group of 15 asymptomatic volunteers after oral hydration (the mean value was calculated on each side): peak velocity (mean, 57 cm/sec); jet duration (mean, 4.6 sec); and number of peaks and subpeaks (mean, 2.2). Several flow patterns were observed, including discrete jets, ureteric streaming, and rest periods. For each patient the ratios of values obtained on the left and right sides were calculated for peak velocity (1.00-1.74; mean, 1.26); jet duration (1.00-4.69; mean, 1.83); and jet frequency (1.00-1.21; mean, 1.11). The interjet interval (period between jets) ranged from 2 to 150 sec. Bolus volume and jet frequency showed simultaneous moment-to-moment variation. The frequency and velocity rather than the duration ratios may be of greatest value in identifying patients with normal ureterodynamics. Our findings challenge two current concepts of renal pelvic and ureteral response to changes in urine output: (1) ureters have a fixed maximal discharge rate and (2) bolus volumes do not change until this rate is achieved. Asymmetric moment-to-moment fluctuations observed in jet frequency suggest that prolonged examination may be necessary to confirm normal symmetry of jet frequency in some patients with suspected ureteric obstruction.

A comparison of the urological complications associated with long-term management of quadriplegics with and without chronic indwelling urinary catheters.

The primary objective of this retrospective study was to compare the incidence of urological complications and renal deterioration in post-traumatic quadriplegic patients managed with or without a chronic indwelling urinary catheter. The charts of 57 consecutive patients who sustained traumatic cervical spinal cord injury between 1970 and 1980 were reviewed. All of the patients received the initial management or rehabilitation therapy at our institution. The unique features of this clinical review are that a large cohort of patients was followed for a minimum of 10 years, none of the 57 consecutive patients was lost to followup and a yearly excretory urogram provided an objective assessment of the renal units. The followup, and mechanism, level and degree of injury for the 32 patients managed with and 25 managed without a catheter were similar. Overall, the incidences of renal and bladder calculi, pyelonephritis, gross hematuria, penile/urethral erosion, urosepsis, urethral stricture, epididymitis and pyonephrosis were not significantly different in the catheterized and noncatheterized groups. The Kaplan-Meier analysis of the most recent excretory urogram demonstrated that the incidence of renal deterioration was also equivalent in the catheterized and noncatheterized groups. Our study suggests that the decision to manage quadriplegics with or without an indwelling catheter should not be based on relative risk of complications or renal deterioration. The decision to avoid an indwelling catheter in these patients should reflect patient comfort, convenience and quality of life.

Carcinoma of the sigmoid colon: an unusual cause of Fournier's gangrene.

We report a case of perforated adenocarcinoma of the sigmoid colon in an inguinal hernia presenting as Fournier's gangrene. Bowel perforation has been known to cause this disease but, to our knowledge, perforation in an inguinal hernia due to benign or malignant disease has not been reported elsewhere. Gastrointestinal tract perforation should be sought as a potential etiology in patients with necrotizing fasciitis of the genitalia. When such a perforation exists occult malignancy should be ruled out.

Color Doppler ultrasonography in the evaluation of the acute scrotum.

Color Doppler ultrasonography was used to assess 20 patients with the acute onset of scrotal pain. Patients were categorized into 3 groups according to the initial clinical impression of the examining physician: ischemia, inflammation or trauma. Color Doppler ultrasonography correctly predicted the need for surgery in 8 of 9 operated patients (89%) and correctly predicted the outcome in all 11 nonoperated patients (100%). The anatomical resolution possible, as well as information regarding blood flow made color Doppler ultrasonography a useful tool in the assessment of acute scrotal processes.