[Functional electromyostimulation of the penile corpus cavernosum (FEMCC)]. Initial results of a new therapeutic option of erectile dysfunction]. / Funktionelle Elektromyostimulation des Corpus cavernosum penis (FEMCC). Erste Ergebnisse einer neuen therapeutischen Option bei erektiler Dysfunktion.

Transcutaneous application of low-frequency electric current in the treatment of partially or temporarily denervated striated muscles is widely used to prevent or treat muscular atrophy. Due to the high regenerative capacity of smooth muscle cells, this approach should be beneficial in the treatment of diseases with smooth muscle degeneration due to partial denervation. Our study was done to evaluate the possible beneficial effect of transcutaneous application of low-frequency electric current to the corpus cavernosum penis in the treatment of erectile dysfunction. After a comprehensive work-up, 22 patients with chronic erectile dysfunction (21/22 vasoactive nonresponders) received daily (3-5 x 20 min) transcutaneous functional electromyostimulation of the corpus cavernosum smooth muscles (FEMCC; zero line symmetric impulses of trapezoid shape, two-channel device with alternating stimulations, f = 10-20 Hz for channel I and 20-35 Hz for channel II; t(i) = 100-2000 microseconds, approx. 12 mA, rise time 0.5 s, stimulation time 5 s per channel, interval between stimulations 0.5 s). Five of 22 patients (23%) regained full spontaneous erections and another three (14%) responded to vasoactive drugs after FEMCC. Fourteen were FEMCC failures, including two who subjectively 'improved'. In a similar group of patients evaluated during the same period but receiving no therapy, no spontaneous improvement of the erectile function was observed. Our preliminary results suggest that FEMCC is feasible and results in an improvement of the erectile capacity in a significant proportion (37%) of patients. Further studies will be carried out to corroborate our results, to improve stimulation parameters and to evaluate selection criteria for FEMCC.

[Fournier's gangrene. Experiences and changes in the disease picture since its initial description]. / Die Fournier'sche Gangrän. Erfahrungen und Veränderung des Krankheitsbildes seit der Erstbeschreibung.

Fournier's disease mostly occurs in immunosuppressed men in the 5th to 7th decade of life. Bacteria from the urogenital or colorectal tract lead to a rapid spreading soft tissue infection. Painful scrotal or perineal swelling and a black spot as a sign of beginning necrosis are guiding symptoms. Involved bacteria are grampositive cocci, enterobacteriaceae and anaerobes. Main principles of therapy are immediate radical debridement and broad spectrum antibiotics. Sepsis renders the prognosis more infaust.

Functional electromyostimulation of the corpus cavernosum penis--preliminary results of a novel therapeutic option for erectile dysfunction.

Transcutaneous application of low-frequency electric current in the treatment of partially or temporarily denervated striated muscles is widely used to prevent or treat muscular atrophy. Due to the high regenerative capacity of smooth-muscle cells, this approach should be beneficial in the treatment of diseases with smooth-muscle degeneration due to partial denervation. Our study was done to evaluate the possible beneficial effect of transcutaneously applied low-frequency electric current on the corpus cavernosum penis in the treatment of erectile dysfunction. After a comprehensive workup, 21 patients with chronic erectile dysfunction (20/21 vasoactive nonresponders) received daily (3-5 x 20 min) transcutaneous functional electromyostimulation of the corpus cavernosum smooth muscles [FEMCC; zero-line symmetric impulses of trapezoid shape, 2-channel device with alternating stimulations; frequency (f), 10-20 Hz for channel I and 20-35 Hz for channel II; impulse duration (ti), 100-150 microseconds; approx. 12 mA; rise time, 0.5 s; stimulation time, 5 s/channel; pause between stimulations, 0.5 s. In all, 4/21 patients (19%) regained full spontaneous erections and another 3/21 (14%) responded to vasoactive drugs after FEMCC. Overall, 14/21 were FEMCC failures, including 2 who subjectively "improved." In a similar group of patients who were evaluated during the same period but received no therapy, no spontaneous improvement in erectile function was observed.(ABSTRACT TRUNCATED AT 250 WORDS)

Bilateral metachronous testicular germ cell tumors occurring in two non-twin brothers. Case report and review of the literature.

We report here the familial occurrence of bilateral testicular germ cell tumors in 2 non-twin brothers, developing after an interval of 16 and 4 years, respectively. To our knowledge, this is the first report on the occurrence of metachronous and bilateral testicular tumors in non-twin brothers.

Role of the nitric oxide donor linsidomine chlorhydrate (SIN-1) in the diagnosis and treatment of erectile dysfunction.

OBJECTIVES: Recently, nitric oxide was shown to be a mediator of penile erection in men and the nitric oxide donor linsidomine chlorhydrate (SIN-1) was introduced as a novel treatment option in patients with erectile dysfunction. We now present our follow-up results with the intracavernous application of SIN-1. METHODS: One hundred thirteen patients with erectile dysfunction of various etiologies and 10 normal control subjects underwent intracavernous pharmacotesting with 1 mg SIN-1. Of the 113 patients, 71 (62.8%) underwent additional pharmacotesting with a mixture of papaverine (15 mg/mL) and phentolamine (0.5 mg/mL) (P/P). Forty-eight responders to SIN-1 were enrolled in an autoinjection program with this substance. RESULTS: All normal control subjects had full rigid erections lasting 40 to 70 minutes. Of 113 patients, 78 (69%) had responses sufficient for intercourse with SIN-1, and the other 35 patients (31%) demonstrated inadequate responses. All 44 responders to SIN-1 who also received P/P had erections sufficient for intercourse with P/P in doses of 0.25 to 2 mL (mean, 0.6 +/- 0.3 mL). Six patients (13.6%) had prolonged erections with minimal to moderate doses of P/P. From the total of 27 patients who had erections insufficient for intercourse with SIN-1, 20 (74.1%) had good responses with 0.25 to 2.0 mL P/P (mean, 1.5 +/- 0.5 mL). One patient (4%) had a prolonged erection with 1.0 mL P/P: After 10 to 150 injections/patient (total of 1160 injections; mean, 24.1 injections), no significant side effects were noted with SIN-1. CONCLUSIONS: Our data suggest that intracavernous SIN-1 is safe and efficacious in the majority of patients with erectile dysfunction; however, it has a lower smooth muscle relaxing effect than a combination of P/P. The absence of severe side effects, including priapisms, may be explained by the use of a physiologic pathway for induction of the erectile response and the rapid intracavernous decomposition of SIN-1.

Prognostic factors for the postoperative outcome of penile venous surgery for venogenic erectile dysfunction.

Since penile venous surgery is usually associated with a poor postoperative outcome, a study was done to evaluate possible prognostic factors for this procedure. A total of 77 patients with erectile dysfunction underwent ligation of all dorsal penile veins and resection of the deep dorsal penile vein for venous incompetence. In all patients a comprehensive evaluation was done preoperatively. All patients did not respond to pharmacotherapy and had a venous leak. After a followup of 6 months, patients were classified as having full spontaneous erections, failure and response to pharmacotherapy. Of the 77 patients 31 (40.3%) had full spontaneous erections, 8 (10.3%) were currently responding to pharmacotherapy and 38 (49.4%) failed. The maintenance flow was 75 +/- 45 ml. per minute in the group with spontaneous erections and 103 +/- 60 ml. per minute in the failure group (p = 0.20). Mean patient age was 49.8 +/- 11.7 and 49.1 +/- 10.2 years, respectively (p = 0.23). Of the 41 patients wih normal single potential analysis of cavernous electrical activity 28 had full erections postoperatively, 5 responded to pharmacotherapy and 8 failed, compared to 3, 3 and 30, respectively, of the 36 patients with abnormal single potential analysis of cavernous electrical activity. After a mean followup of 21 months (range 6 to 47 months), 4 patients with full erections at 6 months postoperatively currently require intracavernous pharmacotherapy. Our results indicate that single potential analysis of cavernous electrical activity seems to be an important prognostic factor for the postoperative outcome of penile venous surgery for venogenic impotence.

[Modulith SL 20. One-year urologic experience with a lithotripter of the third generation]. / Modulith SL 20. Urologische Erfahrungen über ein Jahr mit einem Lithrotripter der dritten Generation.

The MODULITH SL20 combines on-line ultrasound and optional X-ray in series. In addition to highly simplified patient positioning and the possibility of handling the machine as a multipurpose lithotripter for disintegration of urinary-, gallbladder and bile duct stones and for treatment of pancreatic concrements this appliance can be used in cases of sialolithiasis and as a workplace for all urological purposes, so that the design is very modern. As the energy level in f2 can be extremely high, a disintegration rate of about was achieved for 70% ureteral stones in the middle and distal sections of the ureter. However, this good disintegration rate was not achieved for ureteral stones lying in the upper ureter or in cases of nephrolithiasis treated with a prototype of the machine. In our opinion, this reflects a problem with nonexistent on-line X-ray stone localization, but an overall disintegration rate of about 77% in preselected patients (1.8 stones/patient) confirms that this is a highly sophisticated and powerful machine.

Orchitis following mumps vaccination in an adult.

An acute epididymo-orchitis, followed by a viral arthritis of the left hand, occurred as complications of a mumps vaccination. In the last 17 years 4 certain cases of orchitis following vaccination have been published in Germany. We describe an additional case and discuss the possible consequences.

Intracavernous calcitonin gene-related peptide plus prostaglandin E1: possible alternative to penile implants in selected patients.

The implantation of a penile prosthesis is still the ultima ratio for patients with erectile dysfunction who fail other treatment options such as pharmacotherapy and penile venous surgery. Despite mostly favorable results regarding restoration of erectile capacity, penile allografts are often not accepted for various reasons. Therefore, pharmacotesting with a mixture of calcitonin gene-related peptide and prostaglandin E1 (CGRP/PGE1) was offered to different selected patients populations: 28 patients with erectile dysfunction and venous leakage who failed penile venous surgery, 28 patients with erectile dysfunction and venous leakage (who refused penile venous surgery) and 12 patients without venous leakage, but poor response to maximum doses of papaverine/phentolamine, received 5 micrograms CGRP plus 10 micrograms PGE1. Erections sufficient for intercourse were noted in 19/28 (67.9%), 20/28 (71.4%) and 11/12 (91.7%) patients, respectively. Our data show that a combination of CGRP and PGE1 may be an alternative to penile implants in selected patients.

[Results of surgical therapy for venous insufficiency as a cause of erectile disorders]. / Ergenbnisse der operativen Therapie des venösen Lecks als Ursache von Erektionsstörungen.

Since penile vein ligation is usually associated with a poor postoperative outcome, a study was undertaken to evaluate possible prognostic factors for this procedure. A total of 44 patients with erectile dysfunction underwent ligation of all dorsal penile veins and resection of the deep dorsal penile vein for venous impotence. A comprehensive study of all patients was made. All patients did not respond to pharmacotherapy and had a venous leak. With a minimum follow-up period of 6 months, patients were categorized as follows: full spontaneous erections, those patients responding to pharmacotherapy and those showing no improvement. Out of 44 patients, 13 had full spontaneous erections postoperatively, 5 now responded to pharmacotherapy and 26 showed no improvement. The maintenance flow was 89 +/- 50 ml/min in the group with spontaneous erections and 85 +/- 49 ml/min in those showing no improvement (P = 0.78). Out of the 20 patients with normal single potential analysis of cavernous electric activity (SPACE), 12 had full erections postoperatively, 4 showed no improvement and 4 responded to pharmacotherapy. Of the 24 patients with abnormal SPACE, 1 developed full erections, 1 now responds to pharmacotherapy and 22 showed no improvement. Our results indicate that SPACE seems to be an important prognostic factor for the postoperative outcome of penile vein ligations for venous impotence.

Predictive value of real-time RigiScan monitoring for the etiology of organogenic impotence.

We performed routine diagnostic evaluations in 160 consecutive patients from our impotence clinic. After the diagnostic studies were completed, the results of RigiScan* monitoring during visual sexual stimulation before and after intracavernous injection of vasoactive drugs were compared to the results of standardized pharmacological testing, single potential analysis of cavernous electrical activity and pharmacocavernosometry. The results suggest RigiScan monitoring to be a highly accurate method to evaluate and document objectively the erectile response after intracavernous injection of vasoactive drugs. Although pathological monitoring after intracavernous injection is significantly associated with pathological findings in the specific evaluation, the predictive value of RigiScan monitoring for specific organogenic etiologies is not satisfactory, since normal monitoring showed no convincing correlation to single potential analysis of cavernous electrical activity or cavernosometry.

Followup results of a combination of calcitonin gene-related peptide and prostaglandin E1 in the treatment of erectile dysfunction.

Recent human and animal studies have shown a possible role for calcitonin gene-related peptide in penile erection and a therapeutic benefit in combination with prostaglandin E1 for autoinjection therapy. The ethical committee approved calcitonin gene-related peptide-prostaglandin E1 combination for cases of nonresponse or cavernous fibrosis to papaverine-phentolamine. Since June 1990, 65 patients (59 nonresponders and 6 with fibrosis) were injected with 5 micrograms. calcitonin gene-related peptide plus 10 micrograms. prostaglandin E1. Of the 59 nonresponders to papaverine-phentolamine 31 and of the 6 patients with fibrosis 5 had full erectile response. Of these 36 patients 2 experienced pain during the pharmacologically induced erection. A total of 39 patients who had had at least 20 autoinjections of calcitonin gene-related peptide plus prostaglandin E1 was available for minimum followup. There were no side effects, such as pain (the 2 patients with pain mentioned previously were not included in the autoinjection therapy group), systemic side effects or (increased) fibrosis. Our results show that a combination of calcitonin gene-related peptide and prostaglandin E1 may be beneficial to the treatment of impotence in carefully selected patients.

Single potential analysis of cavernous electrical activity (SPACE). Experiences, limitations and perspectives.

Cavernous electromyography was first introduced by Wagner and Gerstenberg in 1989. The authors developed a refined method of cavernous electromyography by means of single potential analysis in introduced this method into clinical Urology as a diagnostic procedure for the evaluation of patients presenting with erectile dysfunction. To date, our experience with single potential analysis of cavernous electrical activity (SPACE) includes more than 500 patients with erectile dysfunction of various etiologies and 92 normal control subjects. Several technical modifications and refinements have been adopted during the last 4 years. In normal control subjects, SPACE shows a regular pattern of activity with long phases of electrical silence at the usual amplification interrupted by synchronous low frequency, high amplitude potentials. In patients with disruption of the peripheral autonomic supply, typical asynchronous potentials with higher frequencies and irregular shape are observed. In complete spinal cord lesions, abnormal as well as normal electrical activity is found. In patients with a long history of insulin-dependent diabetes and presumably cavernous smooth muscle degeneration, SPACE recordings show irregular potentials with low amplitudes and slow depolarization speed. Synchronization of electrical activity is usually absent. Recent studies on patients with venous leakage show that SPACE provides independent clinical information about the cavernous smooth musculature. The recording of cavernous electrical activity is possible and reproductible. In the future, a new software for one-line date processing, storage and interpretation of SPACE signals will be available.

Single potential analysis of cavernous electrical activity. Four years' experience in more than 500 patients with erectile dysfunction.

Since the recent introduction of cavernous electromyography by Gerstenberg and Wagner, a new too for the study of erectile dysfunction in man is available. The refinement of this method, single potential analysis of cavernous electrical activity (SPACE), offers a straightforward approach to the diagnosis of cavernous autonomic neuropathy and smooth muscle myopathy by minimal invasive means. SPACE was done in more than 500 consecutive patients with erectile dysfunction and in 85 normal control subjects. With increasing experience the methodology was refined with respect to the used hardware as well as cut-off frequencies. In normal control subjects, SPACE showed a reproducible regular activity with potentials of low frequency and electrical silence inbetween. The potentials were synchronous throughout the cavernous bodies. In patients with peripheral autonomic denervation, asynchronous potentials with higher frequencies and irregular shape were found. Normal and abnormal potentials were found in patients with upper spinal cord lesions. Recordings obtained with surface electrodes showed similar characteristics when compared with recordings obtained with needle electrodes. Recent studies show that SPACE provides independent information about the autonomic and myogenic intactness of the cavernous tissue. Currently, a computerized expert system and a graded classification for easier interpretation is being developed with first results. We conclude that cavernous electrical activity can be recorded. SPACE is a reproducible diagnostic tool for erectile dysfunction.

Significant obliteration of the urethral lumen after Wallstent implantation.

The permanently implanted self-expandable urethral stent (Wallstent) has found increased use in patients with recurrent urethral strictures because of its simple implantation technique. To date there have been no reports of serious complications. At 6 weeks after stent implantation our patient had complete luminal obstruction. This complication demonstrates the need for short-term controls after implantation of a urethral stent.

Preliminary results with the nitric oxide donor linsidomine chlorhydrate in the treatment of human erectile dysfunction.

Recent experimental studies showed an important role of endothelium derived relaxing factor for cavernous smooth muscle relaxation. Since nitric oxide seems to account for the biological actions of endothelium derived relaxing factor, a study was done to examine a possible role of the nitric oxide donor linsidomine chlorhydrate (SIN-1) in the treatment of erectile dysfunction. To determine a therapeutically useful dose 0.1, 0.2, 0.5 and 1 mg. SIN-1 were injected intracavernously in patients with erectile dysfunction. Each dose was given to 2 patients. Then, 63 patients received 1 mg. SIN-1, including 7 who had prolonged erections to minimal doses of papaverine plus phentolamine and 4 who did not respond with a full erection to other pharmacological agents. Intracavernous injection of SIN-1 induced a dose-dependent erectile response by increasing the arterial inflow and relaxing cavernous smooth muscles. Of the patients 29 had a full, 21 an almost full and 13 a moderate erection to 1 mg. SIN-1. There were no systemic or local side effects. In the patients with prolonged erections to papaverine plus phentolamine the mean duration of a full erectile response to SIN-1 was 57 minutes. Compared to the responses to a papaverine (15 mg./ml.) and phentolamine (0.5 mg./ml.) mixture, the erection induced by SIN-1 was superior in 10, comparable in 47 and inferior in 6 patients. Our data suggest a possible role for SIN-1 in the treatment of erectile dysfunction. Possible advantages may be that erection is induced by a mechanism similar to that occurring physiologically, a decreased risk of inducing prolonged erections and low therapy costs.

A new therapeutic concept for long-lasting iatrogenic priapism: a case report.

In a therapeutic attempt on an 18-year-old patient with iatrogenic priapism lasting for more than 2 weeks after internal urethrotomy, intracavernous lysis was commenced with 80,000 IU streptokinase per hour. Following a dosage of 300,000 IU streptokinase the lysis was stopped because of severe bleeding from the urethrotomy scar. At 4 weeks after the patient was discharged from the hospital he reported normal erections and intercourse, while single potential analysis of cavernous electrical activity and ultrasound returned to normal. Provided there are no contraindications, intracavernous lysis seems to be an effective treatment for long-lasting priapism induced by intracavernous thrombosis.

[ESWL in hemophilia B]. / ESWL bei Hämophilie B.

One of the most dramatic dangers in treating nephrolithiasis by ESWL is the development of intra- and perirenal bleeding, which requires therapeutic intervention. Even in patients whose blood parameters suggest they are healthy, hematomas are found in up to 80%. Therefore, ESWL must be regarded as contraindicated in patients with blood disorders. A case of a patient suffering from hemophilia B and from a large renal pelvic stone is reported, whom we treated by ESWL twice after sufficient substitution. X-ray revealed that the patient was stone-free on the 25th day after the first ESWL session. ESWL. A review of the literature is presented.

Transcutaneous registration of cavernous smooth muscle electrical activity: noninvasive diagnosis of neurogenic autonomic impotence.

Registration of cavernous electrical activity was shown to be a possible method for the evaluation of cavernous autonomic innervation. Recent studies in patients with normal erectile function showed that cavernous electrical activity is synchronous throughout the entire cavernous bodies. Therefore, we examined the feasibility of transcutaneous registration of cavernous electrical activity in 8 normal and 62 impotent patients. In the sitting patient cavernous electrical activity was recorded with a 2-channel electrophysiological unit. Recording was done with a coaxial needle electrode in the proximal left cavernous body and with surface electrodes bilaterally on the penile shaft. In 7 of 8 normal patients swelling of the penile shaft after circumcision resulted in a dramatically decreased amplitude of the potentials. In 41 of 62 impotent patients recordings were similar. In 10 of 62 patients no recording or markedly decreased amplitudes were noted with the surface electrodes and in these patients a small penis or penile retraction with consecutive electrode displacement was found. Careful repositioning of the surface electrodes with the patient in the supine position resulted in similar recordings in 9 (inconsistently in 4). In 11 of the 62 patients more information was obtained with the surface than with the needle electrode. Our results show that recording of cavernous electrical activity can be done in a completely noninvasive manner using surface electrodes with similar or even better information obtained than with needle electrodes.

Single potential analysis of cavernous electrical activity in impotent patients: a possible diagnostic method for autonomic cavernous dysfunction and cavernous smooth muscle degeneration.

Cavernous electrical activity was recorded in 214 patients with erectile dysfunction and in 39 normal patients. In 34 of the 39 normal patients potentials of a uniform shape were recorded during flaccidity. At cutoff frequencies of 0.5 to 500 Hz. the duration was 8 to 18 seconds (mean 12.8 +/- 2.8, seconds, standard deviation), the amplitude was 250 to 750 microv. (mean 444 +/- 109 microv.) and the polyphasity was 8 to 22 (mean 13.8 +/- 3.3). With increasing tumescence and rigidity during audiovisual sexual stimulation, high frequency potentials of low amplitude and short duration were found in the normal patients. In impotent patients with an upper motor neuron or peripheral lesion specific types of potentials were observed. In 11 of 14 impotent patients with insulin-dependent diabetes for more than 20 years and with clinical findings of cavernous myopathy the potentials showed low amplitude, irregular shape and slow depolarizations. Abnormal findings of cavernous electrical activity were recorded in 51.6% of the consecutive impotent patients. Our clinical study suggests that single potential analysis of cavernous electrical activity may be useful in the diagnosis of cavernous autonomic neuropathy and cavernous smooth muscle myopathy.