Acute scrotal pain from idiopathic ilioinguinal neuropathy: diagnosis and treatment with EMG-guided nerve block.

Ilioinguinal nerve entrapment presents with a clinical triad of pain in the iliac fossa and inguinal region, sensory abnormalities in the cutaneous distribution of the nerve and tenderness on palpation 2-3 cm medial and below the anterior superior iliac spine. The syndrome poses diagnostic difficulties, as genitofemoral nerve entrapment and non-neurological conditions of the lower abdomen may cause similar pain. We report on a patient with acute groin pain radiating towards the scrotum, caused by ilioinguinal nerve entrapment. The clinical diagnosis was strongly suggested by electromyographic examination, using the monopolar needle as a deep stimulating electrode. Subsequent nerve blockade caused complete relief of symptoms. The technique is described. Future applications for treatment of post-surgical pain are discussed.

Disappearance of a mucosa-associated lymphoid tissue (MALT) lymphoma of the urinary bladder after treatment for Helicobacter pylori.

A59-yr old man presented with macroscopic hematuria. A non-Hodgkin's lymphoma of the MALT type of the urinary bladder, stage I A-E, was diagnosed. Radiotherapy was advised, but the patient refused this kind of treatment. Because of the known relationship of a gastric MALT lymphoma and Helicobacter pylori, the patient was treated with HP eradication therapy. Afterwards the lymphoma disappeared. The patient is 3 yr later in a persistent complete remission. This is the first known case of the disappearance of a MALT lymphoma of the urinary bladder after treatment with HP eradication therapy.

Comparative tolerability and efficacy of treatments for impotence.

Modern pharmacological treatment of impotence is determined by the presenting symptoms. Since this involves symptomatology with a heterogenous aetiology, many different drugs are involved in the treatment of impotence. Drugs used for libido and arousal problems include testosterone, yohimbine, trazodone and apomorphine. Since patient self-assessment is the only parameter that can be used to measure the result of treatment and positive results are seldom affirmed, no positive benefit of these agents can be assumed at present. Oral medications for erectile dysfunction include yohimbine, trazodone, apomorphine, phentolamine, arginine and sildenafil. Of these drugs, sildenafil has been the most systematically studied for effectiveness, but long term safety data await the results of post-marketing surveillance. Of the ejaculation disorder therapies, treatments for premature ejaculation are the best studied. Favourable results have been obtained with clomipramine, paroxetine and fluoxetine. The safety of these medications has been assessed through their long term use in psychiatry. Intracavernous self-injections for erectile disorders are performed using a variety of drugs and drug mixtures. Only alprostadil and the combination of papaverine with phentolamine are widely used. Alprostadil is very well tolerated; however, penile pain is a serious problem in a significant proportion of patients. Papaverine in combination with phentolamine is effective, but penile fibrosis and priapism occur more often than with the use of alprostadil. Several new developments in this area are currently under way. Alternative routes for medication for erectile dysfunction include ointments and patches to the penile skin and the glans. Only transurethral alprostadil, 'MUSE' (medicated urethral system for erection) has been shown to be effective in large trials. Long term safety still has to be demonstrated, but the 1-year safety profile is encouraging. In general, the end points of impotence treatment studies are very diverse so efficacy data can only be assessed in comparative studies. However, long term comparison studies have not been performed. Safety demands must be set very high for this type of treatment since the disorders being treated present no threat to the patient's health.

Trazodone, a double blind trial for treatment of erectile dysfunction.

OBJECTIVE: to assess the effectiveness of oral trazodone 150 mg/d for treatment of erectile dysfunction. PATIENTS AND METHODS: A double-blind, placebo controlled, multicentre trial. A run-in period of two weeks was followed by four weeks of medication. Evaluation was done by patients diary, a questionnaire and Rigiscan nightly penile tumescence and rigidity (NPTR) measurements in the second and sixth week of the trial. RESULTS: 69 patients were randomised, two patients never returned for follow-up, nine patients stopped the medication due to side-effects, so 58 patients are evaluable for effect assessment. Half of the patients suffered psychogenic impotence. There was no significant difference in the subjective results of trazodone compared to placebo. Side effects occurred more often with the use of trazodone, but this was not statistically significant. CONCLUSION: In a group of patients, that was not selected on the basis of the etiology of the erectile dysfunction, nor selected on the duration of the complaint, the efficacy of trazodone 150 mg/d, could not be shown.

Recurrent priapism as a side effect of zuclopenthixol decanoate.

Priapism has been described as a rare side effect of certain phenothiazine antipsychotics with high alpha1-adrenergic blocking potential. We describe a patient who in the course of clinical treatment with the thioxanthene antipsychotic zuclopenthixol (Clopixol) decanoate had several episodes of priapism. Although the alpha-blocking potential of zuclopenthixol is only moderate, it seems that in sufficient dose, or in combination with other antipsychotics, this drug is capable of inducing priapism.

Analysis of continuous nocturnal penile rigidity measurements with the use of the RigiScan summary analysis software program.

The evaluation of the RigiScan nocturnal recordings of 324 patients, 18 to 72 years old (mean age 49 years), according to guidelines based on normal data, were compared with analysis of these recordings by using the RigiScan Summary Analysis Software Program. This enabled us to provide normal values for this program. We conclude that it should be possible to extend this RigiScan software program in such a way that a probability of normality is given to its user. In patients with corporal veno-occlusive dysfunction a significant lower total event duration was found when compared with the results of patients with normal and abnormal findings.

Relation of intracorporal pressure and end-diastolic velocity during duplex Doppler sonography in the evaluation of veno-occlusive dysfunction.

In 37 patients 25 to 69 years old (mean age 49.6 years) with suspected 'vasculogenic erectile dysfunction', diagnosed on the basis of repeated negative reactions to intracavernous pharmacological stimulation, duplex Doppler measurements and pharmacocavernosometry were performed in one session under simultaneous pressure registration. A statistically significant difference between patients with and without veno-occlusive dysfunction was found by combining end-diastolic velocity and pressure in time. We conclude that color Doppler scanning in combination with simultaneous pressure registration can predict veno-occlusive dysfunction in 83-95% of the patients.

The effect of orgasm on prostate-specific antigen.

To identify the effect of orgasm on serum prostate-specific antigen (PSA) levels, a prospective trial before and after orgasm was performed in 14 healthy colleagues aged 32-62 years (mean, 44.4 years) with no evidence of prostatic disease. PSA determinations were performed on serum samples obtained before and after orgasm. Significant changes in PSA levels after orgasm were found (P = 0.002, analysis of variance). We conclude that the impact of orgasm on PSA levels should be taken into account when the latter are used for the detection of prostatic disease.

Comparison of a mixture of papaverine, phentolamine and prostaglandin E1 with other intracavernous injections.

OBJECTIVE: evaluation of a self-injection program with a mixture of papaverine, phentolamine and prostaglandin E1 (PGE1). METHOD: a self-injection program for erectile dysfunction was started by 48 patients, using a 1-ml mixture of 4.5 mg papaverine, 0.2 mg phentolamine and 1.5 micrograms PGE1. Patients completed a questionnaire at 6 weeks and at 3 months and were followed at the Outpatients Department for an average of 1 year. RESULT: of these patients 25 had previous experience with 20 micrograms PGE1 for intracavernous use and 22 patients had previously used 30 mg papaverine with 1 mg phentolamine. None of these 3 self-injection drugs is obviously superior in its ability to induce erections. Priapism occurred twice on a total of 1,290 injections. After 1-year follow-up, 4 patients had developed problems with fibrosis of the corpora, 2 of whom had encountered this problem also in a previous self-injection program. CONCLUSION: this triple mixture has the disadvantage of causing fibrosis and priapism in susceptible patients.

Treatment of corpus cavernosum abscess by aspiration and intravenous antibiotics.

We report the successful treatment of an abscess in the corpus cavernosum of a paraplegic man on intracavernous papaverine injection therapy by means of percutaneous aspiration and intravenous antibiotics. After 3 months of intracavernous pharmacotherapy the patient experienced good erections again and only minimal fibrosis could be found on palpation.

The negative pressure device for erectile disorders: when does it fail?

Of 74 men with erectile dysfunction who used a vacuum device at home only 20 were satisfied with the erections achieved. The device was offered only to men who had not been helped by sexual counseling, self-injection therapy or venous surgery, and to 8 patients who had had problems with a penile implant. Fibrosis reduces the chances of success with the vacuum device, and only 2 of 14 such patients used it successfully. In all 9 patients with psychogenic impotence the device failed. Although 9 men did achieve erections with the device, they disliked it so much that they did not begin regular use. Our disappointing overall result was probably due to negative patient selection.

The value of increased end diastolic velocity during penile duplex sonography in relation to pathological venous leakage in erectile dysfunction.

In 58 patients 23 to 71 years old (mean age 49.5 years) with suspected vasculogenic erectile dysfunction diagnosed on the basis of repeated negative reactions to intracavernous pharmacological stimulation (rigidity less than 60% when measured with the RigiScan* device) pharmacocavernosometry and duplex Doppler measurements were performed. The end diastolic velocity in the 24 patients without venous leakage ranged from 0 to 21 cm. per second (mean 7.5 +/- 6.3, standard deviation). The end diastolic velocity in the 34 patients with venous leakage ranged from 0 to 26 cm. per second (mean 9.0 +/- 6.7). In 23 of the 58 patients a peak systolic velocity of less than 25 cm. per second was found, which is an indication of arterial disease. Of 35 patients with a normal peak systolic velocity 15 were in the group without and 20 were in the group with leakage. In the group with a normal peak systolic velocity no statistically significant difference was found in end diastolic velocity between patients with and without leakage. We conclude that the end diastolic velocity during color Doppler analysis of patients with negative reactions on intracavernous pharmacological stimulation does not provide a good indication of potential pathological venous leakage.

Experiences with the Surgitek Art-1000 penile tumescence and rigidity monitor, and comparison with the RigiScan.

We compared real-time and nocturnal penile tumescence and rigidity monitoring with 2 different ambulatory rigidity and tumescence monitors: the Surgitek Art-1000 and the RigiScan devices. Real-time studies were performed in 5 patients with both devices used simultaneously. The results of the measurements with both monitors were rather identical, indicating that both devices are applicable in a satisfactory manner for real-time investigation. Within a short period 5 patients performed nocturnal monitoring at home with the Surgitek Art-1000 and RigiScan devices during 2 consecutive nights. The Surgitek Art-1000 device provided less reliable and less informative results when compared with the RigiScan monitor during these nocturnal measurements. It appears that problems with sizing and fixing of the passive sensing loops of the Surgitek Art-1000 device by the patient are the main cause of these disappointing results. We believe that when the loops are sized and fixed by the investigator, for example during nocturnal measurements in the hospital, the applicability will be more satisfying. This monitor seems not to be suitable for nocturnal measurements by the patient at home.