Association of elevated estradiol with remote testicular trauma in young infertile men.

OBJECTIVE: To determine the incidence of remote testicular trauma and of possible related permanent hormonal and seminal changes in infertile men. DESIGN: Retrospective clinical study of hormonal and seminal parameters in a subpopulation of infertile men. SETTING: Andrology Clinic in an academic research environment. PARTICIPANTS: Infertile men, with and without history of remote testicular trauma, and fertile volunteers. MAIN OUTCOME MEASURES: Percentage of infertile men with history of blunt testicular trauma, concentrations of reproductive hormones, and semen parameters. RESULTS: Significant remote blunt testicular trauma was reported by 16.8% of infertile men. This had occurred 2 to 17 years (mean, 16.4 years) before evaluation, mostly with contact sports at adolescent age. Estradiol concentrations after testicular trauma were 19% and 25% higher than in infertile men without history of testicular injury and in fertile controls. Elevated E2 levels did not correlate with T. Infertile men with and without history of testicular trauma showed changes in seminal parameters. CONCLUSION: The incidence of remote blunt testicular trauma in infertile men is unexpectedly high. After injury, FSH-stimulated aromatization of T may increase testicular E2 production, interfere with spermatogenesis, and cause infertility. Consistent use of protective devices in contact sports is recommended.

Treatment of vasculogenic sexual dysfunction with pentoxifylline.

OBJECTIVE: To evaluate the use of pentoxifylline to treat impotence in men with mild to moderate penile vascular insufficiency. DESIGN: Double-blind randomized clinical trial. SETTING: Sexual Dysfunction Clinic at VA Medical Center, Sepulveda, CA. PARTICIPANTS: Convenience sample of couples. INTERVENTION: Twelve weeks of treatment with placebo or 400 mg tid of pentoxifylline. MEASUREMENTS: (1) Report of patient verified by partner as to number of coital episodes per month; (2) penile-brachial pressure index determinations. RESULTS: Pentoxifylline therapy regularly increased the PBPI in impotent men in comparison with the placebo, frequently into the normal range. Pentoxifylline therapy was particularly useful in restoring the PBPI in men with the pelvic steal syndrome; six of seven such subjects improved into the normal range. During the pentoxifylline treatment period, in contrast with the control period, nine men were able to reestablish coital function and three had no improvement. Six couples did not attempt intercourse despite a professed interest in sexual activity; however five out of the six men experienced erections during episodes of fantasy or attempts at masturbation during treatment. There were no complications of therapy. CONCLUSIONS: These promising preliminary results suggest a well tolerated alternative therapy for erectile dysfunction in patients with mild to moderate penile vascular disease.

Use of a vacuum tumescence device in the management of impotence in men with a history of penile implant or severe pelvic disease.

PURPOSE: To evaluate the use of a vacuum tumescence device in the treatment of impotence in couples wishing to restore coital function, whose male partners had unsatisfactory results from penile implants or in whom the man was impotent following treatment for prostate or colon carcinoma. SUBJECTS: Convenience sample of seventeen couples seeking treatment of male factor sexual dysfunction. METHODS: After completion of a comprehensive diagnostic evaluation of the male partner, couples who expressed a wish to restore coital function were instructed in the use of the vacuum tumescence device. Partners each filled out and initialled a daily diary of sexual activity and returned to clinic for followup at 3 and 6 months. RESULTS: Sixteen patients were able to obtain firm to hard erections lasting an average of 14.9 minutes and had satisfactory coitus with vaginal ejaculation an average of 3.9 times per month. There were no significant complications. CONCLUSION: The vacuum tumescence device can be effective in the treatment of impotence after penile prosthesis explantation, in enhancement of inadequate erections with a prosthesis in place, and after surgical or radiation therapy for prostate or colon carcinoma.

Secondary hypogonadism in older men: its relation to impotence.

The relation of the reproductive endocrine system to impotence in older men was examined by measuring the concentrations of testosterone (T), bioavailable testosterone (BT), LH, and PRL and body mass index (BMI) in 57 young controls (YC), 50 healthy potent older controls attending a health fair (HF), and 267 impotent patients (SD). The SD and HF had markedly reduced mean T and BT values compared to YC. When adjusted for age and BMI there was no difference in BT between potent and impotent older men. The percent BT was much higher in YC than in the older groups. While the percent BT rose significantly with increased T in YC, it was inversely related to T in the older subjects, suggesting that increased sex hormone-binding globulin binding was a primary event leading to a low BT. Forty-eight percent of HF and 39% of SD were hypogonadal, as defined by a mean BT of 2.5 SD or more below the mean of YC (less than or equal to 2.3 nmol/L). Ninety percent of these had LH values in the normal range, suggesting hypothalamic-pituitary dysfunction. Thirty-four SD and six each of YC and older control volunteers (OC) underwent GnRH testing. Older subjects showed impaired responsiveness to GnRH compared to YC. A low basal LH level correlated very highly with hyporesponsiveness to GnRH. Thus, secondary hypogonadism and impotence are two common, independently distributed conditions of older men.

Use of a vacuum tumescence device in the management of impotence.

This study evaluated the use of a vacuum tumescence device in the treatment of impotence in older men. Twenty couples with sexual dysfunction due to erectile impotence and who were interested in restoration of sexual function were treated by providing them with both a vacuum tumescence device to engorge the penis and an obstructing band to impede venous return. Nineteen patients established firm to hard erections lasting an average of 16 minutes and were able to have satisfactory coitus with vaginal ejaculation an average of three times per month. The penile-brachial pressure index, supine and after exercise (a measure of the adequacy of penile arterial flow), exhibited a significant increase following six month's use of the vacuum tumescence device. The only significant complications were mild, self-limited hematomas on three occasions of use. Thus in this limited series the vacuum tumescence device provided a well-accepted, relatively inexpensive therapeutic approach to impotence.

Biweekly intracavernous administration of papaverine for erectile dysfunction.

To determine the efficacy of the intracavernous administration of papaverine hydrochloride every 2 weeks to treat male impotence, we recruited 50 patients from a sexual dysfunction clinic. Of these, 8 did not complete the course of papaverine therapy. A total of 8 had complications, including priapism in 3 and ecchymoses or urethral bleeding in 5. In 30 patients who had substantial vasculogenic disease, there was a notable improvement in the penile blood pressure after papaverine treatment, although only 9 reported successful sexual intercourse. The penile blood pressure in the remaining 12 patients without substantial vascular disease increased modestly after therapy, and 5 persons reported satisfactory sexual activity. We conclude that administering papaverine intracavernosally every 2 weeks improves sexual potency in a subset of sexually impotent patients. Those with severe vasculogenic disease and a penile-brachial pressure index of less than 0.65 are not good candidates for this regimen.

Impotence and aging: clinical and hormonal factors.

A cross-sectional study of 216 impotent men aged 40 to 79 years (mean age 60.9 years) was conducted to determine if there are age-related changes in clinical and hormonal parameters in an impotent population. There was a slight increase in the degree of sexual dysfunction with age, with complete erectile failure occurring in a larger percent of the 60- and 70-year-olds than in the younger patients (41% vs 27% for the 40 year olds, P less than .05). No patient above the age of 70 years reported any full erections, even of short duration. In contrast, reported levels of libido did not vary significantly with age. Abnormal penile Doppler studies diagnostic of vasculogenic impotence were found in 17.8% of the patients tested, and an additional 17.8% were found to have evidence suggestive of a vascular etiology. These abnormal vascular findings were associated with an extremely high prevalence of clinically apparent atherosclerosis in this population. In 22.9% of the subjects, an abnormal vascular response was found only on exercise, ie, a "pelvic steal", which only occurred above the age of 50 years. There was a marked age-related alteration in the concentration of testosterone (T) and bioavailable testosterone (BT), but no statistically significant change in the levels of gonadotropins with age. An increase in the prevalence of eugonadotropic hypogonadism with age was found, which suggested an increasing prevalence of hypothalamic pituitary dysfunction in this patient group. For both vascular and hormonal changes (such as low T and BT), the greatest changes appear to occur after the age of 50.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of free fatty acids on the bioavailability of plasma testosterone and dihydrotestosterone.

Free fatty acids (FFA) are known to interfere with the binding of thyroid hormone and estrogens to circulating proteins, but their effect on androgen binding is unknown. The effect of linoleic, oleic and palmitic acids at physiological concentrations on the binding of testosterone (T) and dihydrotestosterone (DHT) to circulating proteins was evaluated in vitro, using equilibrium dialysis and ammonium sulfate precipitation techniques. The results indicate that FFA can inhibit T binding to albumin and SHBG. They also can inhibit DHT binding to albumin, whereas DHT binding to SHBG is not altered, suggesting that FFA at physiological concentrations may be important regulators of bioavailability of T to tissues.

Relationship of penile brachial pressure index to myocardial infarction and cerebrovascular accidents in older men.

Vascular disease is a major cause of impotence in patients over the age of 40. In a prospective study of 130 impotent patients followed for 24 to 36 months, patients with a penile brachial pressure index (PBPI) of 0.65 or less had a significantly greater risk of a myocardial infarction or a cerebrovascular accident than patients with higher PBPIs. It is concluded that impotence in association with a low PBPI should be considered an indicator of a future major vascular event.

Peripheral nerve conduction studies and bulbocavernosus reflex in the investigation of impotence.

Patients with erectile dysfunction underwent sensory and motor conduction and bulbocavernosus reflex tests to determine the incidence of peripheral nerve involvement. Of a total of 111 patients, abnormal sensory conduction was found in 87 (78%), abnormal motor conduction in 56 (50%), and abnormal bulbocavernosus reflex in 40 (36%). Most of these patients had other medical problems. Objective evidence of peripheral nerve involvement helped in the management of these patients.

Evaluation of impotence in older men.

Careful evaluation was carried out in 93 men older than 50 with erectile dysfunction. Their mean age was 61 years and the disorder had been present for a mean of 4.5 years. While 14 men (15%) had psychosocial factors that may have been pertinent, only 2 scored poorly on an Affect Balance Scale and 3 were receiving psychoactive medications. Results of nocturnal penile tumescence were abnormal in 91%. In 39% penile-brachial pressure indices were suggestive of pelvic vascular disease and in 9% were consistent with a pelvic "steal syndrome." Pelvic or peripheral nerve conduction disorders were also commonly seen in 54%. Endocrinopathy may have contributed to the dysfunction in 35%. Twenty-one men had diabetes mellitus, two new cases of hypothyroidism were discovered and hypogonadism was diagnosed definitely in four and considered likely in five others. Coexisting medical conditions were found in more than 90% of the men, especially hypertension, use of antihypertensive medications and atherosclerotic disease. Previous prostatectomies (19%) and vasectomies (30%) were common in the surgical histories. Given the wide range of disorders uncovered in older men complaining of impotence, diagnostic study of potential causes may lead to a more rational approach for the evaluation and management of these men.

The effect of weight loss on reproductive hormones in obese men.

The effects of weight reduction on reproductive hormones were investigated in 24 moderately obese men, 18-108% above ideal body weight. Serum estrone (E1), estradiol (E2), testosterone (T), percent free T (%FT), sex hormone binding globulin (SHBG) capacity, and, in 9 subjects, androstenedione (A) were measured serially before and during an outpatient supplemented fasting program (320 kcal/day) for 8-20 weeks. In the baseline state mean E1 was elevated to 100 +/- 7 pg/ml (normal, 30-60 pg/ml). The E2 was slightly elevated to 36 +/- 3 pg/ml (normal, 8-35 pg/ml). The mean T of 400 +/- 20 ng/dl was at the lower end of normal (400-1000 ng/dl). The mean %FT was elevated to 4.1 +/- 0.2% (normal 1.6-3%). The calculated free T was normal. The mean SHBG binding capacity was 0.99 +/- 0.05 micrograms dihydrotestosterone bound/dl (normal, 1.0-1.8 micrograms/dl). The mean A of 52 +/- 5.8 ng/dl was normal. These data were in accord with previous findings in much heavier men. Eight weeks of weight loss (mean, 19.5 kg) were associated with normalization of all the measured parameters. The mean E1 decreased to 48 +/- 23 pg/ml, E2 to 28 +/- 2.1 pg/ml. T increased to 536 +/- 35 pg/dl and %FT fell to 3.2 +/- 0.2%. Data on men remaining on the program for 16 or 20 weeks showed a continued fall of estrogens and stabilization of T and %FT. SHBG and A did not change significantly over the entire time period. In conclusion, increased circulating estrogens and reduced androgen binding were found in moderately obese men, which were completely corrected with weight loss.

Mineralocorticoid response to low dose adrenocorticotropin infusion.

The adrenocorticoid responses to low dose ACTH of plasma aldosterone (aldo), corticosterone (B), 11-deoxycorticosterone (DOC), 18-hydroxycorticosterone (18-OHB), 18-hydroxycorticosterone (18-OH-DOC), and cortisol (F) were compared. Alpha ACTH-)1-24) was infused beginning at 0800 h at increasing rates from 12.5-200 mIU/30 min in supine normal subjects under the following conditions: 1) regular Na (120 meq) diet, 2) low Na (10 meq) diet, 3) dexamethasone preadministration (0.5 mg every 6 h for 48 h), and 4) night study (2000 h; 120 meq Na intake). Plasma 18-OH-DOC and B demonstrated quantitatively the greatest responses to ACTH, while DOC and 18-OHB responses were intermediate. Increments in aldo and F were least after ACTH and were maximum at 50 mIU/30 min ACTH, whereas other corticosteroids demonstrated linear responses up to infusion rates of 200 mIU/30 min. All corticosteroids, however, were similar in their threshold responses to ACTH which were at infusion rates of approximately 7-9 mIU/30 min. Na restriction enhanced aldo and 18-OHB responses to ACTH 2- to 3-fold but did not alter the other corticosteroid responses. Dexamethasone pretreatment augmented aldo, 18-OHB, and F responses but did not change the responsitivity of the other corticosteroids to ACTH. Adrenal corticosteroid responses to ACTH were not significantly different between 0800 and 2000 h in subjects on 120-meq Na intake. Thus, corticosteroids show markedly different responses to physiological doses of ACTH, which may have more importance in their regulation than heretofore proposed. Dexamethasone pretreatment enhances aldo, 18-OHB, and F responses to ACTH but does not affect the responses of other corticosteroids. Contrary to reports in experimental animals, corticosteroid responses to ACTH in man do not differ from day to night.