[Tadalafil versus sildenafil citrate in the treatment of ED:Italian patients' preferences and explanatory notes].

This is an open, multicentre, randomized, crossover study having the aim to evaluate the preference for sildenafil citrate or tadalafil in a population of Italian patients affected by ED, and to compare the efficacy and safety of these two drugs. MATERIAL AND METHODS. From October 2003 to November 2004, thirteen Italian centers enrolled ED patients (age >18) being in steady and naïve relation to ED treatment, both through PDE5 inhibitors and any other treatment option. These patients were randomized to sildenafil or tadalafil for 12 weeks, after which they were switched to the alternative treatment for a further 12 weeks. The preference was evaluated through the Treatment Preference Question (TPQ): "During this clinical trial you have taken tadalafil and sildenafil for the treatment of erectile dysfunction. Which medication do you prefer to take for the next 8 weeks of treatment?". Moreover, patients were asked to express their preference as "strong" or "moderate" and to answer some questions to clarify the reasons behind their preference. SEP and IIEF-EF questionnaires were used for a comparison of efficacy. RESULTS. 167 patients were enrolled, 144 of whom completed both treatment periods. On being asked the TPQ, 75% of patients (n=108) decided to continue treatment with tadalafil, in particular because it made it possible to have an erection many hours after taking the medication (first or second preference reason for 64.8% of patients), while 25% (n=36) preferred sildenafil (p=0.001). Both drugs improved the IIEF-EF and SEP scores compared to baseline, with a slightly but significantly greater improvement with tadalafil for both parameters. CONCLUSIONS. Tadalafil and sildenafil are both effective and well tolerated. Most of the patients prefer tadalafil thanks to the possibility of having sexual intercourse many hours after taking the medication.

Functional anatomy of cavernous helicine arterioles in potent subjects.

PURPOSE: We investigated the morphological and functional features of cavernous helicine arterioles in male potent subjects. MATERIALS AND METHODS: Ten young men reporting normal rigid erections which were confirmed by polysomnographic recording underwent power Doppler sonography of the cavernous helicine arterioles during flaccidity, after intracavernous injection of alprostadil, and after subsequent genital and audiovisual sexual stimulation. RESULTS: During flaccidity the helicine arterioles were never detected by power Doppler imaging while they became evident in all cases after alprostadil injection. They usually originated from the cavernous artery forming an acute angle and showed 3 orders of ramifications. Systolic and diastolic flow was present. After genital and audiovisual sexual stimulation, and achievement of maximum rigidity, the helicine arterioles were still evident but with only 1 or 2 orders of distal ramifications. Only systolic flow was present. During penile tumescence the helicine arterioles disappeared in all cases. CONCLUSIONS: Using power Doppler sonography it is possible to investigate the functional anatomy of the cavernous helicine arterioles during the various phases of the erectile cycle. Our preliminary study suggests that the helicine arterioles are functionally inactive during penile flaccidity while they are activated during penile tumescence and continue to supply blood to the corpora also during maximum penile rigidity.

[Prostatic-vesical inflammation and sexual problems]. / Flogosi prostatovesciocolari e problematiche sessuali.

With the purpose of investigating the relationship between prostatico-vesical inflammation and sexual disturbances, two groups of 15 patients with uncomplicated BPH were treated with mepartricin 150,000 U/die for 60 days. The two groups differed from each other for the presence of sexual disturbances only present in group A. The relationship between BPH and sexual picture was studied on the grounds of both the symptomatic and instrumental variables habitually adopted in the presence of the pathology in question and of a specific method for the quantitative evaluation of dynamic erection. The examination of the results obtained confirmed BPH clinical implications on sexuality as well as mepartricin excellent manageability, confirmed by the fact that never were sexual disturbances brought about by the drug. On the other hand the erectile activity index measured in the two groups, underwent a qualitative improvement even in the absence of changes in the quantitative datum.

[L-arginine and male infertility]. / L-arginina e infertilità maschile.

The clinical efficacy and acceptance of L-arginina HCL was tested in 40 infertile men. All of these men had a normal number of spermatozoa (> 20 million/ml), but a decreased motility; this decreased motility was not due to infection or to immunological disorders. The treatment consisted of 80 ml of 10% L-arginine HCL administered daily per os for 6 months. L-arginine HCL showed to be able to improve the motility of spermatozoa without any side-effects.

[Echographic aspects of gynecomastia]. / Aspetti ecografici della ginecomastia.

Gynecomastia is a size increase of man's breast, due to non neoplastic ductal and glandular stroma proliferation. Prevalent ductal proliferation defines the "florid" type, while prevalent stroma increase defines the "quiescent" type. Pseudo-gynecomastia is a non glandular volume increase. Sonography is able to recognize the different parts of normal male breast and to diagnose gynecomastia. Moreover by sonography we can distinguish three echo-patterns linked to the anatomopathologic pattern which can lead therapy.

Use of a novel non-steroidal anti-inflammatory drug, nimesulide, in the treatment of abacterial prostatovesiculitis.

Nimesulide, a novel non-steroidal anti-inflammatory drug, was used in cases of abacterial prostato-vesiculitis. Thirty patients with a mean age of 33.7 years (range 18-58) were studied. Nimesulide was administered orally 100 mg b.i.d. for three cycles of 10 d each. Dysuric symptoms, semen analysis, and transrectal ultrasound were examined during the study. The concentration-time curves of nimesulide (NIM) and its metabolite, hydroxynimesulide (OH-NIM) in seminal fluid were also evaluated after single oral administration (100 mg) using an HPLC technique. Following administration of the drug, the Cmax was reached in seminal fluid at the second hour for NIM (with a mean value +/- SD of 0.58 +/- 0.13 micrograms ml-1) and at the fourth hour for OH-NIM (2.98 +/- 0.38 micrograms ml-1). Maximal seminal fluid concentrations compared to blood plasma levels were observed at the fourth hour for both substances (31.73 +/- 2.34% for NIM; 31.87 +/- 8.66% for OH-NIM. Dysuric symptoms were relieved in 20 (66%) patients. A clear amelioration of inflammatory signs were observed at transrectal ultrasound evaluation in 16 (54%) patients. No statistically significant changes of sperm count and motility in the whole sample were observed, while a significant reduction in the number of abnormal forms occurred. From these results, nimesulide appears to be an effective anti-inflammatory drug with a good diffusion into the genital apparatus and low side-effects.

Treatment of abacterial prostato-vesiculitis with nimesulide.

The efficacy and tolerability of nimesulide were assessed in the treatment of patients with prostato-vesiculitis. In a noncomparative investigation, 30 patients received oral nimesulide 100mg twice daily for three 10-day cycles. Micturition-related symptoms were resolved in 20 patients and clear amelioration of inflammatory signs was observed with transrectal ultrasound in 16 patients. Abnormal sperm forms decreased from 57 to 49% (p < 0.001). In a comparative investigation, 40 patients received nimesulide 200mg twice daily or ketoprofen 100mg twice daily via the rectal route. Patients and physicians expressed an overall opinion on efficacy in favour of nimesulide. In a pharmacokinetic study of healthy volunteers who received oral nimesulide 100mg as a single dose, the mean maximum nimesulide concentration (0.58 +/- 0.13 mg/L) in seminal fluid was achieved after 2 hours while the maximum seminal fluid: blood plasma ratio 0.32 +/- 0.02 was observed after 4 hours. These data suggest that nimesulide is an effective NSAID in the treatment of abacterial prostato-vesiculitis and also demonstrate that this drug has a favourable disposition within the genital tract.

[Recent diagnostic and therapeutic aspects in male sexual impotence]. / Recenti aspetti diagnostici e terapeutici dell'impotenza sessuale maschile.

Male sexual impotence is the symptom of an alteration of central and peripheral mechanism neuropsychoendocrine, vascular and neurological. Nowadays it affects 8-10% of sexually active population. In some diseases, like diabetes and uremia, it can reach very high percentages of incidence. At our Andrology Center 35% of referrals are represented by sexual complaints. In the last years the diagnostic accuracy has increased, narrowing the percentage of unknown causes. Vasculopathy represents the most relevant pathological condition associated with impotence: it can affect both arterial and venous vessels. The new medical technologies and procedures permit an increase of the life span but often affecting the quality of life. Therefore, the iatrogenic causes of impotence, both pharmacological and surgical, are growing. A modern diagnostic approach starts with an accurate clinical history and physical examination, followed by an NPT (nocturnal penile tumescence) test and/or ICI (intracavernosal injection) with a standard dose of PGE1 and Doppler flowmetry of penile arteries. An endocrine evaluation (LH, testosterone and prolactin) is also performed. Further investigation of a vascular dysfunction is represented by more invasive procedures, like arteriography, cavernosography and cavernosometry. A suspect of neurological disease is confirmed by sacral evoked potentials. According to the findings of these examinations, a correct therapeutical approach can be applied in 100% of cases. An endocrine treatment is adequate only when a clear reduction of T plasma level or hyperprolactinemia are present. The treatment of other central disorders causing psychoneuroendocrine impotence is promising, but still under investigation. The intracavernosal injection of vasoactive drugs, apart from having revolutionized the diagnostic approach to the impotent patient, represents a clear standpoint in medical management of impotence, particularly in vascular and neurological diseases. The great advancement in the technology of penile prostheses has allowed the development of valuable and reliable tools to be used in selected cases.

[Endocrine therapy of sexual impotence in men]. / La terapia endocrina dell'impotenza sessuale maschile.

Male sexual activity is in all mammalian species, included man, androgen-dependent. The role of testosterone (T) starts already during intrauterine life. It continues thereafter, inducing the development of sexual secondary characteristics and libido. Therefore T has represented the "classical" treatment of male sexual dysfunctions. In the therapeutic routinary use T is employed ad ester, like cipionate, enanthate and other i.m., undecanoate per os. When a pituitary defect is present and the testicular receptors are functioning a treatment with HCG can be employed.

[Transdermal therapy of erectile insufficiency]. / La terapia transdermica dell'insufficienza erettile.

The introduction of intracavernosal (i.c.) administration of vasoactive drugs has revolutionized diagnosis and treatment of sexual impotence. This procedure, though, carries some risks and undesired side-effects, such as fibrosis, priapism, hematomas, etc. Thus, at our Centre has been evaluated the possibility of a transdermal (TS), either active or passive, treatment of impotence. In a first trial, double blind crossover, 62 patients have been treated with yohimbine (YOH) as ointment. About 5 mg of the drug were applied at the balanopreputial sulcus, twice daily. In 10 patients YOH was also assayed by HPLC in the blood drawn from the corpora cavernosa after the application of the drug: a rapid adsorption of the drug was demonstrated and a peak value of 58 ng/ml at 25 min. Treatment with YOH was particularly satisfactory in patients with impotence of recent onset and mild degree, that is without major vascular alterations. The active TD drug administration was tested with papaverine delivered with cavernous bodies by a C.T.D.A.S. (Controlled Transdermal Drugs Administration System). Thin layer chromatography has shown the passage of about 10% of patients a relevant amelioration of erectile function was observed.

[Defects in canalization of seminal pathways]. / I difetti di canalizzazione delle vie seminali.

We assessed the value of ultra sonography in diagnosis and grading the alterations in canalization of seminal pathways. After clinical examination and semen analysis, we studied 4100 patients by scrotal US with sector mechanical (7.5 MHz) probe with water bag and by transrectal US for prostatic vesicular region evaluation with 5-6.5 MHz linear probe (lately we used biplanar probe). In three cases, we performed us guided aspiration and contrast media injection of prostatic cavity. In 63 cases (1.53%) we found developmental malformations of seminal vesicles. The abnormality was bilaterally in 33% and it was associated with malformations of urinary tract in 17.46%. Other malformations were found in 0.12% cases. Ultrasonography was always able to establish obstruction level and type, and the possible associated abnormalities. US permitted to avoid or to restrict testis biopsy or vasoseminal vesiculogram. Ultrasonography is eventually able to guide second level diagnostic examination (aspiration biopsy and contrast media injection of prostatic cysts) and endourethral approach to drainage.

[The Rigiscan system in the diagnosis of male sexual impotence]. / Il Rigiscan system nella diagnostica dell'impotenza sessuale maschile.

The article reviews historical basis of Nocturnal Penile Tumescence (NPT) test and the evolution of techniques to perform it. From complex and time-consuming instruments, modern technology has brought us to the use of the Rigiscan system. This is a transportable (home or office usable), computerized method to detect change of penile rigidity and circumference during sleep-related spontaneous-or daytime induced-erections. While the instrument was mainly developed to perform NPT tests, it is nowadays used to record penile rigidity in realtime after the intracavernous injection of vasoactive drugs. In our experience, normal parameters to refer for a NPT evaluation are: number of erectile episodes: 4-5 per night; mean duration od episodes: > 30 minutes; increase of penile circumference: > 3 cm (base loop) and > 2 cm (tip loop); maximal rigidity: > 70% (both base and tip). Reference parameters for realtime monitoring after intracavernous injection of PGEI are: latency of response: < 12 minutes; duration (with a stable plateau): > 30 minutes; constant plateau: > 70%; increase of penile circumference: > 3 cm (base) and > 2 cm (tip). The use of these reference parameters, together with the data coming from other procedures (e.g. penile arterial flow with the Doppler), allows a better diagnostic accuracy in the approach to sexual impotence.

Effects of progesterone administration on follicle-stimulating hormone and prolactin release in estrogen treated eugonadal adult men.

In order to investigate the modulatory effect of steroids on FSH secretion in vivo, we studied 16 human males, aged 51-81 years, affected by prostatic carcinoma. They were given estradiol or E2 plus progesterone (P), added at different times during E2 treatment. Daily blood samples were collected in order to determine LH, FSH, and PRL levels; moreover, blood samples were collected at 2 h intervals for 12 h on the day of P administration. We observed the expected biphasic effect on LH secretion, whereas daily basal FSH levels, during E2 treatment, decreased gradually and progressively from the first day until the end of the study. FSH levels exhibited, after P administration, wide fluctuations, with peak levels observed from 2 to 6 h after P in 4 of 6 patients studied (at 72 h during E2 treatment). A clear trend toward FSH increase was also observed in 3 out of 5 patients in whom P was administrated 96 h after starting E2 administration. In this case, FSH increases were delayed, becoming evident between 8th and 10th h after P injection. Finally, during E2 administration basal PRL levels showed a progressive increase, which was significant in all three groups. In conclusion, these data confirm the biphasic effects of estrogen administration on LH secretion in eugonadal adult human males; while estrogens alone showed an inhibitory effect on FSH secretion, the addition of P induced also a positive action, resulting in a clear FSH peak in some patients tested. The time course of E2 and P administration seems to be critical for the hormone response pattern.(ABSTRACT TRUNCATED AT 250 WORDS)

Ultrasound monitoring of testis and prostate maturation in hypogonadotropic hypogonadic males during gonadotropin-releasing hormone treatment.

The effects of the administration of gonadotropin-releasing hormone (GnRH) on the increase of testis and prostate volume was monitored by ultrasound in six patients affected by idiopathic hypogonadotropic hypogonadism. A significant increase of testis volume was observed after 90 and 180 days (6.65 versus 3.32 mL, 99.1% net increase and 8.47 mL, 176.8% increase, respectively) of pulsatile GnRH treatment. A similar increase of prostate volume was observed at day 90 (12.67 versus 7.78 mL, 70.3% net increase) and day 180 (14.70 mL, 97.7% increase). The ultrasound monitoring of the modifications of testis and prostate volume may represent a biological assay of the effects of GnRH treatment and offer additional data on the response of target organs to the hormonal treatment.

[Possibility of using the piezoelectric lithotriptor in the treatment of severe cavernous fibrosis]. / Possibilità di impiego del litotritore piezoelettrico nel trattamento delle fibrosi cavernose gravi.

The treatment of serious cavernous corpora fibrosis due to priapism, a prosthesis explantation, iatrogenic causes, or Peyronie's disease, is by now still uncertain. Therefore we tried, when medical and physical therapy failed, to find out the possibility of extracorporeal lithotripter to treat such a complicated cases. From February 88 until now 16 patients underwent extracorporal shock waves treatment, out of 16, 9 had a serious Peronie's disease (a), in 3 fibrosis was a consequence of priapism (b), in 3 of prosthesis explantation (c), 1 patient of cavernosography (d). The treatment was performed by Wolf piezoelectric lithotripter (Piezolith 2300), the patients were treated once a week for 6 weeks. (800 SW; power ranged between 40 and 100 Mpa, frequency between 1 and 2.5 Hertz). In all the patients an orally steroid drugs was administered and a ionophoresis therapy associated. After one year of follow up a penile ultrasound scan, artificial erection tests, rigidometry. None side effects was noted but local ecchimosis. The were done results obtained might support our effort and suggest further studies.