Efficacy and safety of three different analgesic methods for patients undergoing transrectal ultrasound-guided prostate biopsy: a prospective, randomized controlled trial.

BACKGROUND: Recent evidence suggests that additional analgesic regimens to periprostatic nerve block (PPNB) anesthesia provide substantial pain relief during transrectal ultrasound-guided prostate biopsy. In this regard, we investigated the efficacy and safety of tramadol alone or in combination with parecoxib as adjunct regimens to PPNB anesthesia. MATERIAL AND METHODS: A total of 51 participants were randomly allocated into three study groups: Group 1 received PPNB anesthesia, Group 2 received tramadol and PPNB anesthesia, whereas Group 3 received both tramadol and parecoxib as adjunct regimens to PPNB anesthesia. The pain was evaluated at three different time points during biopsy: at the time of probe insertion (NRS1), at the time of PPNB anesthesia (NRS2), and at the time of the actual biopsy itself (NRS3), using a numeric rating scale (NRS) of pain. Safety was evaluated by the occurrence of complications and adverse effects. RESULTS: The mean NRS1 score was statistically significantly different in Groups 2 and 3 than in Group 1 (2.4 ± 1.3 and 1.1 ± 1.2 vs. 4.5 ± 1.8; p <0.0167). We found a statistically significant difference regarding NRS 2 score in Groups 2 and 3 than in Group 1 (2.6 ± 1.4 and 1.1 ± 1.3 vs. 4.1 ± 1.3; p <0.0167). The mean NRS1 and NRS2 scores were found to be statistically significantly different in Group 3 than in Group 2 (1.1 ± 1.2 vs. 2.4 ± 1.3 as well as 1.1 ± 1.3 vs. 2.6 ± 1.4; p <0.0167). Also, a statistically significant difference was found between Groups 2 and 3 regarding hematuria episodes [0 (0.0) vs. 5 (29.4); p <0.0167]. CONCLUSION: Tramadol as an adjunct regimen to PPNB anesthesia is a safe and straightforward technique that provides a significant analgesic effect. The effectiveness is even higher when tramadol is combined with parecoxib. HIPPOKRATIA 2020, 24(4): 166-172.

Intratesticular Angiolipoma: A Rare Case of Adipose Tissue Presence in the Testis.

INTRODUCTION: Solid, fat-containing tumors of the testes are extremely rare with only a few cases having been reported so far, contrary to the more frequent occurrence of paratesticular lipomatosis. Testicular angiomyolipomas and gonadal involvement in Cowden's disease, although infrequently occurring, are known examples of fat-bearing testicular lesions. Hereby, we present an extremely rare case of intratesticular angiolipoma. Angiolipomas are benign tumors of the subcutaneous tissue commonly occurring in the trunk and the extremities. Histologically, they are characterized by ample vascularity and an excess of mature adipocytes. Definitive diagnosis is established by biopsy of the lesion. PRESENTATION OF THE CASE: A 35-year-old patient presented to our andrology outpatient clinic for fertility assessment. Physical examination of external genitalia revealed no significant pathology. Testicular ultrasound however depicted an isoechoic lesion on the upper pole of the right testis measuring 1.8 cm × 0.8 cm × 1 cm and exhibiting intense arterial flow. After sonographic and MRI investigation, the patient was referred for semen analysis and cryopreservation. Subsequently, the patient underwent testicular biopsy (frozen section biopsy) and right partial orchiectomy. Final histology reported a noninfiltrating testicular angiolipoma. No recurrences have been observed in the follow-up period. DISCUSSION: Angiolipomas, which mainly occur in the trunk and extremities, are classified as infiltrating and noninfiltrating. The diagnosis is based on both clinical and histologic criteria, and the main method of treatment for both types is by surgical excision. The infiltrating type exhibits higher recurrence rates. CONCLUSION: Angiolipomas commonly occur in the subcutaneous tissue and have been invariably treated by radical excision. Hereby, we report the first case of an intratesticular, noninfiltrating type angiolipoma which was treated by partial orchiectomy.

What is the profile of patients thinking of litigation? Results from the hospitalized and outpatients' profile and expectations study.

BACKGROUND: Patients vary considerably in their intentions to pursue legal action following a medical error. The aim of this study was to explore predictors of litigious intentions in both hospitalized patients and outpatients, determining the relative influences of patients' characteristics, help-seeking behavior, information-seeking attitudes and general health status factors. METHODS: A representative cross-section of the urologic clinic of a general academic hospital and the associated outpatient clinic was used (a total of 226 patients, 145 outpatients). Data were gathered using in-person interviews conducted by trained psychologists. Attitudes were assessed by "General statements about medical errors", while expectations for information by "Krantz's Health Opinion Survey" (KHOS). RESULTS: A single multivariate model explained 21.5% of the variance of litigious intentions. Younger age (explained 7.6% of the variation, p=0.04), weaker relationship with religion (4%, p=0.02), less than 15 visits/year to any physician (7.2%, p=0.001), outpatient status (2.4%, p=0.02), and higher expectations for information were associated with higher possibility to consider suing their physician (7.6%, p=0.002). Patients' desire for disclosure of a medical error (agreement in 82.2%) exceeded their expectations for financial compensation, particularly in less severe cases (agreement in 24.1%). CONCLUSIONS: This is the first report on the profile of patients with high potential for malpractice suits as predicted by patients' age, relationship with religion, health-seeking and information-seeking behavior. Respecting patients' need for information during clinical consultations and proceeding to disclosure of medical errors, when they occur, seems to be not only the more patient-centered approach, but also the best way to lessen the likelihood of a claim. Hippokratia 2014; 18 (2):139-143.

Psychosocial outcomes after initial treatment of erectile dysfunction with tadalafil once daily, tadalafil on demand or sildenafil citrate on demand: results from a randomized, open-label study.

Initiation of ED treatment with a particular PDE5I may influence treatment-adherence and other outcomes. In this multicenter, open-label study, men with ED, naïve to PDE5I, were randomized to tadalafil 5 mg once-a-day (OaD; N=257), 10 mg on demand (PRN; N = 252) or sildenafil-citrate (sildenafil) 50 mg PRN (N = 261) for 8 weeks (dose adjustments allowed), followed by 16 weeks of pragmatic treatment (switching between PDE5I allowed). Primary outcomes (treatment-adherence) were reported previously. Here, we report effects on: Psychological and Interpersonal Relationship Scales, Self-Esteem and Relationship (SEAR) questionnaire, ED Inventory of Treatment Satisfaction (EDITS), International Index of Erectile Function (IIEF), Sexual Encounter Profile (SEP) and Global Assessment Questions (GAQ). Mixed-model for repeated measures and analysis of covariance were used to analyze changes from baseline; GAQ-responses were evaluated by logistic regression. Analyses were adjusted for treatment, country, ED-severity, baseline and baseline-by-treatment interaction. Patients randomized to tadalafil OaD or PRN reported greater improvement (least-square mean (s.e.) change) in Sexual Self-Confidence (OaD +0.90 (0.048), PRN +0.93 (0.050), vs +0.73 (0.049); P=0.006 and P=0.001) and Spontaneity (OaD +0.11 (0.035), PRN +0.13 (0.035), vs +0.02 (0.035); P = 0.044 and P = 0.010) compared with sildenafil. Improvements in GAQ and SEP responses, IIEF-EF, orgasmic function, sexual desire, overall satisfaction domains, SEAR and EDITS scores did not differ significantly between treatment groups.

Hexaminolevulinate-guided transurethral resection of non-muscle-invasive bladder cancer does not reduce the recurrence rates after a 2-year follow-up: a prospective randomized trial.

PURPOSE: To assess the impact of hexaminolevulinate (HAL) on the long-term recurrence rate of NMIBC. METHODS: A total of 130 patients with bladder tumour were randomized into two groups. The patients in one group had a HAL instillation before surgery, and they first had a white-light and after that a blue-light cystoscopy (BL group) and resection. The second group had only white-light cystoscopy (WL group) and resection. They have been followed up with cystoscopy every 3 months for a period of up to 40 months. RESULTS: The recurrence-free period was not significantly different between the two groups (BL and WL groups) (long-rank test p = 0.202). The use of HAL helped detect four flat lesions and 28 papillary lesions with cancer that would have been missed under WL only, on 16 out of the 54 patients (29.6 % CI 95 % 11.1-33.3). The use of HAL changed the proposed postoperative treatment and follow-up for one out of the five patients. CONCLUSIONS: Although the use of HAL cystoscopy identified at least one cancer lesion more than WL cystoscopy on one out of the three patients, the recurrence-free period was not significantly different.

Phosphodiesterase type 5 inhibitors: unmet needs.

Erectile dysfunction (ED) has been revolutionized during the last two decades, as several treatment options are available today. Phosphodiesterase type 5 (PDE5) inhibitors (sildenafil, tadalafil, vardenafil) are currently the first choice treatment option for ED by most physicians and patients due to their high efficacy rates and favourable safety profiles. Despite the fact that more than 50 million ED patients have been treated successfully worldwide with PDE5i several issues remain to be addressed. Patients with severe neurologic damage, diabetes mellitus, or severe vascular disease may be resistant to PDE5i. Inappropriate instructions, lack of follow-up and lack of patient-centered care models have been identified as main reasons for "nonresponse", leading to drop-out rates of even > 50%. Preservation of corporal smooth muscle with chronic administration of PDE5i has been reported and there is a substantial body of evidence for beneficial effects of these drugs on endothelium and cardiovascular function. Finally, improvement of lower urinary symptoms after PDE5i administration has been reported and a possible role on treatment of premature ejaculation has been proposed. Many new PDE5i are candidates to enter the market in the forthcoming years. However, pharmacokinetic differences should be obvious to consider a truly better option for patients. Patients must be aware of all treatment options since no ideal treatment exists and physicians must offer personalized medicine to their patients in the future. The development and adaptation of a patient-centered care model in sexual medicine will increase efficacy and safety of current and future treatments.

Reproductive health and midwives: does occupational status differentiate their attitudes on assisted reproduction technologies from those of the general population?

BACKGROUND: Advancements within assisted reproduction technologies (ART) raise ethical questions; however, research on health care professionals' attitudes towards their application is limited. This study aimed at assessing certified (CMs) and Student (SMs) midwives' attitudes towards various aspects of ART as well as comparing them with public opinion. METHODS: The final sample included 567 female CMs and 605 women from the general population (age range: 25-62 years), 221 SMs and 209 female non-SMs (age range: 18-24 years). The questionnaire administered included socio-demographic information, items addressing knowledge issues and attitude statements. Data were analysed using principal components analysis, one-way analysis of variance and Friedman's test, as well as multiple linear regression. RESULTS: Four attitudinal factors emerged: 'genetic counselling' (GC), 'application of ART', 'moral dilemmas' and 'socio-ethical aspects'; occupational status did not affect attitudes towards GC, however SMs expressed more positive attitudes regarding the latter three factors (P<0.001: 17.49, 14.14 and 11.55). Student groups expressed more negative attitudes for multifetal pregnancy reduction (SMs: 1.88+/-0.83; non-SMs: 2.17+/-0.77) whereas the other two groups were least favourable towards embryo donation (2.30+/-0.80, CM; 2.32+/-0.83, general population). Sex selection and the use of ART by menopausal or homosexual women were the least acceptable practices for all groups (P<0.001). A high level of relevant knowledge was positively associated with 'application of ART' and acceptability of its use by specific population groups (b=0.469, b=0.19). Findings on factors influencing attitudinal patterns are further discussed. CONCLUSIONS: In this first attempt, it was revealed that CMs express the same conservative attitudes as the general population.

Protective role of the glans penis during coitus.

To examine the hypothesis that the glans penis acts protectively, absorbing forces, during coitus. Five potent patients (mean age 46.8+/-9.7 y), who had indication for surgical excision of the glans for penile carcinoma were included in the present study. Intraoperatively, intracavernosal pressure (ICP) was adjusted by saline infusion and maintained by a pressure feedback infusion pump to a pressure value of 70 mmHg. Using a dynamometer, an external compressive force of 0.5 kg was applied at the glans penis and the changes in ICP were monitored. Measurements were repeated after surgical excision of the glans. Significant ICP changes were noticed in all patients after excision of the glans. Mean preoperative ICP was 161+/-11.5 mmHg, while after glansectomy it reached 206.6+/-13 mmHg. DeltaICP was 45.8+/-10.57 mmHg. Two of the patients' partners reported pain during intercourse postoperatively, possibly due to the impact of the force applied by the rigid corpora cavernosa on the anterior vaginal wall without any absorption by the glans. The glans penis restricts the increase in ICP during sexual intercourse, playing a protective role for both the corpora cavernosa and the female genitalia.

Normal hemodynamic parameters do not always predict the presence of a rigid erection: a quantitative assessment of functional erectile impairment.

The purpose was to assess objectively and quantitatively the hemodynamic status and the degree of functional erectile impairment in a group of impotent patients. A clinical study was designed, incorporating pharmacocavernosometry (to evaluate arterial and veno-occlusive function) with axial buckling forces and penile geometry measurements in a group of impotent patients. The pressure gradient between the intracavernosal pressure associated with the presence of penile axial rigidity and the equilibrium intracavernosal pressure was calculated (axial rigidity gradient, ARG); such methodology allowed a quantitative characterization of functional impairment, as ARG expresses the intracavernosal pressure increase necessary to achieve axial rigidity and therefore potency. Penile geometry characteristics were also expressed by calculating the penile aspect ratio (diameter/length, D/L). In 83 consecutive patients tested (mean age 42.89+/-9.96), rigidity occurred at intracavernosal pressures between 50 and 100 mm Hg. A conversely proportional relation was noticed between penile aspect ratio values and the intracavernosal pressure associated with rigidity values, clearly demonstrating the important functional role of penile geometry. ARG demonstrated a wide range of values (3-69 mm Hg), reflective of the severity of the erectile dysfunction on each patient. Half (50.6%) of the patients had ARG values < or =20 mm Hg, indicative of minimal and minimal-to-moderate erectile impairment, while 20.48% had ARG between 21-30 and 28.92% >30 mm Hg, indicative of moderate and severe erectile dysfunction (ED) respectively. In all, 6% of the study group, all of them with primary ED, ARG <20 mm Hg had normal hemodynamics, but low penile aspect ratio values indicating that penile geometry may be the cause of insufficient rigidity. Hemodynamic integrity is the most critical, but not the only determinant of penile rigidity, as erectile impairment may be noticed in patients with normal arterial inflow and corporal veno-occlusive function. In such cases, unfavorable penile geometry should be considered as the possible etiological factor of impotence.

Glansectomy: an alternative surgical treatment for Buschke-Löwenstein tumors of the penis.

OBJECTIVES: To present the surgical excision of the glans penis (glansectomy) as an alternative surgical treatment to penectomy. Buschke-Löwenstein tumors of the penis include the entities described in published reports as verrucous carcinoma and giant condyloma acuminatum of the penis. Both types are well-differentiated tumors, typically confined to the glans penis, with distinctly rare metastatic activity. METHODS: The study included 7 patients, 40 to 63 years of age, with exophytic, papillary lesions involving the glans penis. Biopsy led to the diagnosis of verrucous carcinoma in 4 patients and giant condyloma acuminatum in 3 patients. All patients reported normal erectile function. Because of the low malignant potential of the tumor and its confinement to the glans penis, a simple glansectomy was performed in all patients to preserve the maximal penile length and functional integrity of the corpora cavernosa. RESULTS: The postoperative course was uncomplicated. With 18 to 65 months of follow-up, all patients were disease free. One patient required more aggressive treatment because of local recurrence of the tumor. All patients returned to normal sexual activity 1 month postoperatively. The only change during sexual activity, noted by two of the patients' partners, was vaginal pain, possibly due to the absence of the glans. CONCLUSIONS: Glansectomy may be considered the treatment of choice in patients with Buschke-Löwenstein tumors of the penis, with more radical techniques reserved for second-line treatment.

Effects of oral phentolamine, taken before sleep, on nocturnal erectile activity: a double-blind, placebo-controlled, crossover study.

The objective of this study was to determine the effects of oral phentolamine, administered before sleep, on nocturnal penile erectile activity of men with mild to moderate erectile dysfunction (ED). We studied five patients with mild to moderate ED (mean age 34.8 +/- 8.13 and mean duration of ED 31.8 +/- 23.5 months), in a double-blind, placebo-controlled, crossover study. All patients received oral phentolamine (Vasomax) at a dose of 40 mg and placebo for three consecutive nights respectively and were submitted to nocturnal penile tumescence and rigidity monitoring (NPTR) with the Rigiscan device. NPTR parameters of the two 3-night recordings were evaluated and compared. Administration of oral phentolamine before sleep was associated with a statistically significant increase in the number of erectile events with rigidity > or = 60% lasting > or = 10 min (P = 0.02), as well as the rigidity activity units (RAU) value per hour sleep, both at the base (P = 0.023) and the tip of the penis (P = 0.019). The number of events as measured by Rigiscan software (20% change in circumference), as well as tumescence activity units (TAU)/h values did not show any statistical difference. No adverse effects were recorded. It is concluded that oral phentolamine administered before sleep enhanced NPTR parameters associated with the quality of the erectile events. Such results provide a pathway for the development of a prevention strategy for ED. Future studies will elucidate whether vasoactive agents taken on a regular basis before sleep, can prevent ED in men at risk, protecting also minimally and moderately impotent patients to become moderately and severely impotent respectively.

Hemodynamic characterization of a functional erection. Arterial and corporeal veno-occlusive function in patients with a positive intracavernosal injection test.

OBJECTIVES: To characterize hemodynamically a functional/rigid erection and study the hypothesis that a positive intracavernosal injection test indicates normal arterial and corporeal veno-occlusive function. METHODS: 33 patients (mean age 39.5 +/- 9 years), who developed rigid erection during pharmacocavernosometry, included in the present study. The presence of axial rigidity was determined at steady state equilibrium intracavernosal pressure, by absence of buckling to axial force of 1 kg, applied to the erect penis and sustained for >/=15 min. Arterial and veno-occlusive hemodynamic parameters were analyzed. RESULTS: Flow-to-maintain at intracavernosal pressure 150 mm Hg and mean pressure decay values ranged between 0.5-13 ml/min and 5-85 mm Hg, respectively. Flow-to-maintain values >5 ml/min were noticed in 8 patients (24. 24%), while pressure decay values >45 mm Hg in 13 patients (39.39%). Pharmacocavernosography revealed moderate opacification of venous structures in 7 cases (21.21%). Abnormal systemic-cavernosal systolic arterial pressure gradients in both cavernosal arteries were noticed in 9 patients (27.27%). All patients with flow-to-maintain values >5 ml/min had normal arterial function. CONCLUSIONS: A functional/rigid erectile response may coexist with arterial insufficiency or corporeal veno-occlusive dysfunction. Presence of normal or borderline arterial inflow may compensate minimal or moderate veno-occlusive dysfunction, resulting in a functional - but not normal - erection. Such information is critical when the intracavernosal injection test is used for diagnostic purposes.

Nocturnal penile tumescence and rigidity monitoring in young potent volunteers: reproducibility, evaluation criteria and the effect of sexual intercourse.

PURPOSE: We studied the reproducibility of nocturnal penile tumescence, rigidity evaluation criteria and the possible effects of sexual intercourse in young, healthy, potent male volunteers. MATERIALS AND METHODS: We recruited 12 male medical students 21 to 24 years old into the study. A disorder-free medical history, availability of a sexual partner and normal erectile function were the inclusion criteria. All subjects completed 3 sessions of 3 nights of recording using the RigiScan* device with at least a 3-day interval between recordings. During the last 3-night recording subjects were asked to have sexual intercourse at least once. Analysis of the recordings was focused on the best erectile event as well as on rigidity and tumescence activity units normalized per hour. RESULTS: The subjects completed 36, 3-night recordings. Of the total of 108 sessions 18 occurred after sexual intercourse. We analyzed 562 erectile episodes. All 3-night recordings included at least 1 episode of rigidity at the penile tip greater than 60% and more than 10 minutes in duration. Sexual intercourse did not significantly affect nocturnal penile tumescence and rigidity. When rigidity and tumescence activity unit values were normalized by the hour and expressed as mean values of the 3-night sessions, documented values became reproducible. CONCLUSIONS: At least 2 consecutive nights of recording are necessary to evaluate nocturnal penile tumescence and rigidity recordings. Nocturnal penile tumescence and rigidity with at least 1 erectile episode of tip penile rigidity greater than 60% and 10 minutes in duration may be associated with potency. Mean rigidity and tumescence activity unit values per hour of a recording may be used as objective parameters to measure overall erectile activity. In addition, sexual intercourse seems to decrease nocturnal penile tumescence and rigidity measurements, although not statistically significant. We anticipate that application of these criteria for nocturnal penile tumescence and rigidity evaluation will improve the diagnostic validity of the test. Future research will determine whether these criteria are too strict for the evaluation of aging men.