Clinical presentations of Peyronie's disease.

Patients with Peyronie's disease usually present soon after the onset of the disease with penile pain and deformity when they develop an erection. They are middle-aged men and a palpable plaque is usually present. A good clinical history and examination are all that are necessary to manage most patients with Peyronie's disease. Further investigation is only required in those men with erectile dysfunction or where surgery is indicated.

The Lue procedure: an analysis of the outcome in Peyronie's disease.

OBJECTIVE: To assess the Lue procedure (plaque incision and venous grafting) for correcting the penile deformity of Peyronie's disease (which can cause penile shortening and erectile dysfunction) as an alternative to the Nesbit procedure (which can worsen the shortening). PATIENTS AND METHODS: Fifty-one patients (mean age 51 years, range 27-68) with Peyronie's disease had their penile deformity corrected by plaque incision and saphenous vein grafting. All patients had stable Peyronie's disease and a mean (range) penile deformity of 57 (20-90). The vein graft was taken from the long saphenous vein at the ankle or groin and several sites grafted in 14 patients. The mean follow-up was 16 months. RESULTS: An excellent or satisfactory result was obtained in 47 patients (92%); the penis was completely straightened in 42 (82%). Four patients (8%) developed postoperative erectile dysfunction. Eighteen men (35%) had some degree of penile shortening (> 1 cm in eight), among whom intercourse was affected to a variable extent in six (12%). CONCLUSION: The Lue procedure is an effective option in the surgical management of Peyronie's disease, but penile shortening after surgery remains a risk.

Sildenafil: efficacy and safety in daily clinical experience.

OBJECTIVES: Sildenafil citrate (Viagra) is a potent selective inhibitor of phosphodiesterase type 5 proposed for the oral treatment of erectile dysfunction (ED). The aim of this study was to evaluate its efficacy and safety when used in daily practice in patients with ED of various aetiology. PATIENTS AND METHODS: From September 1998 to April 1999, 380 patients chose sildenafil as treatment for their ED. One hundred and forty-five (38%) of them suffered from psychogenic ED, 125 (33%) organic and 110 (29%) of mixed aetiology. The grade of erection achieved and the occurrence of satisfactory sexual intercourse assessed the efficacy. Safety and tolerance were evaluated recording any side effect or adverse event. RESULTS: The overall efficacy of Viagra was 77%, with a response of 100% among the group of hormonal patients, 88% for psychogenic, 72% for mixed, 69% for diabetes, 65% for vascular and 60% for neurological symptoms. A few and mild to moderate side effects were recorded. CONCLUSION: These results indicate that the use of sildenafil citrate is an effective and well-tolerated therapy for men with ED of various aetiology with an overall success rate of 77%.

Severe blunt hepatic trauma in children.

BACKGROUND: Severe blunt hepatic injury in children is associated with a high mortality rate. Although nonoperative management has become the treatment of choice for mild to moderate liver trauma, there is no consensus as to the optimal treatment for the most severe hepatic injuries in children. METHODS: A statewide trauma registry was reviewed to identify children (age 18 years or less) treated for a severe blunt liver injury for the period 1993 to 1998. Only children with an American Association for the Surgery of Trauma grade V (AIS code 541828.5) liver injury were included. Database records were reviewed for demographic information, associated injuries, survival rate, length of stay (LOS), intensive care days (ICUD), and treatment rendered after resuscitation in the emergency department. RESULTS: Thirty children with a grade V liver injury were identified. The mean age was 11.2 years (range, 1 to 18), and the overall survival rate was 56%. Data for 5 patients were excluded (4 patients died in the emergency department, and 1 patient was transferred to another institution after arrival). Survivors had a trend toward a lower injury severity score (ISS) (36.1 v 44.6; P <.1) and a significantly higher Glasgow Coma Scale (GCS), 12.5 v 6.6; P <.007). Patients with a decreased GCS had a lower overall survival rate (GCS < 8, 30% v GCS > 8, 76%). In the subset of 14 patients taken directly to the operating room, there was no difference between survivors (n = 6, 43%) and nonsurvivors (n = 8, 57%) in ISS (43 v 43; P value, not significant) or GCS (8.6 v 8.0; P value, not significant). Of the 11 patients treated nonoperatively, 10 (91%) survived with an average ISS of 33 and GCS of 13.8. Nonsurvivors more often had identified associated injuries to other abdominal and retroperitoneal organs. CONCLUSIONS: Severe hepatic injury is associated with a very high overall mortality rate in children. A low GCS is associated with a significant decrease in survival rate and may be the most important factor in outcome. Patients taken directly to the operating room have a slightly greater injury severity and a decreased survival rate compared with those treated nonoperatively. Thresholds and indications for laparotomy in these patients are not clear, and the need for operative management should be guided by the child's physiologic response to resuscitation. For those patients whose physiologic response to resuscitation permitted nonoperative management, a good outcome was achieved.

The Nesbit operation for Peyronie's disease: an analysis of the failures.

OBJECTIVE: To analyse critically the reasons for a poor outcome of the Nesbit operation for Peyronie's disease in 51 patients over a 20-year period. PATIENTS AND METHODS: Fifty-one patients who were classified as having a poor result from the Nesbit operation were reviewed (mean age 53 years, mean follow-up 21 months). The factors responsible for a poor result were analysed and classified into three groups: (i) deformity > 30 degrees; (ii) penile shortening > 2 cm; and (iii) impaired erection. Patients with a recurrent deformity were further classified according to the interval from surgery to the presentation of the recurrence. RESULTS: Thirty-one patients had a deformity of > 30 degrees; this occurred immediately in three patients through surgical error, soon after surgery in eight patients because of suture failure and after 11 months in the remaining 20 patients because their Peyronie's disease progressed. Penile shortening of > 2 cm was present in 19 patients but this only affected coital function in four. Erection was impaired in 10 patients but this was present before surgery in most. CONCLUSION The results of the Nesbit operation for Peyronie's disease can be improved by a preoperative assessment of erectile function and the use of sutures of high tensile strength. Patients should be warned that the disease may progress and that some penile shortening should be expected, although this does not affect coital function.

Early diagnosis of retroperitoneal necrotizing fasciitis.

OBJECTIVE: To report survival of retroperitoneal necrotizing fasciitis in an inmunocompromised patient and to demonstrate early clinical signs that may help in the prompt diagnosis and treatment of this severe infection. DESIGN: Case report and literature review. SETTING: An adult, 18-bed intensive care unit within a university hospital. PATIENT: A 38-yr-old man who had undergone an uncomplicated closed hemorrhoidectomy was readmitted to the hospital on postoperative day 5 for erythema around the hemorrhoidectomy and a dirty brown discharge from the wound. INTERVENTIONS: Early diagnosis of retroperitoneal necrotizing fasciitis, wide and repeated debridement, broad-spectrum antibiotics, and eventual abdominal wall reconstruction. MEASUREMENTS AND MAIN RESULTS: This patient manifested periumbilical and bilateral flank erythema, reminiscent of the pattern of ecchymosis seen in cases of retroperitoneal hemorrhage. The findings demonstrate a variation of Cullen's and Grey Turner's sign, most often found in patients with hemorrhagic pancreatitis. An abdominal radiograph revealed a ground glass appearance with radiolucency outlining the bladder, consistent with retroperitoneal air. The chest radiograph showed mediastinal air extending into the neck. Sharp debridement of the retroperitoneal fat, the right anterior rectus sheath, and the right anterior thigh fascia was required to gain control of the infection. Operative cultures grew a mixed flora with Eschericha coli, beta-hemolytic streptococcus, and Bacteroides fragilis predominating. The hospital course was complicated by hemodynamic instability, renal failure, pneumonia, and a pelvic abscess. The patient ultimately survived and underwent abdominal wall reconstruction with mesh. CONCLUSION: Retroperitoneal necrotizing fasciitis is an uncommon soft tissue infection that is often fatal. Early diagnosis in this case was facilitated by the unique clinical findings of a modified Cullen's and Grey Turner's sign. A review of the limited available literature suggests that survival of retroperitoneal fasciitis is possible with prompt debridement and antibiotic therapy.

Anaphylactic shock from a latex allergy in a patient with spinal trauma.

Allergy to latex is a condition that affects patients as well as health care workers. It is a spectrum of immunologic disorders that ranges from mild hypersensitivity to life-threatening anaphylaxis. Beginning in the early 1970s, the health care community has become more aware of this entity, leading to many improvements in the understanding, diagnosis and treatment of patients with latex allergy. Many hospitals have developed protocols and procedures for patients with latex sensitivity. However, some physicians remain unaware of the logistics of taking care of patients with this disorder. We present a case of a severe anaphylactic reaction to latex in a trauma patient with a spinal cord injury. The difficulty of treating the acutely injured patient with this disorder is illustrated. A list of equipment that may be included in a latex-free emergency kit is provided.

Surgical airway management in the intensive care unit.

Despite having been a known surgical procedure for over 5000 years, the specifics of how, when, and why to perform a surgical airway are still debated. With new procedures, equipment, and techniques, operative airway management is becoming more complex. New methods of surgical airway management have to be evaluated against the gold standard, which will always be the open tracheostomy performed in the operating room. Unlike Dr. Jackson in 1909, surgeons today have to evaluate these new procedures not only by their efficacy but also by their cost effectiveness.

Safety of sildenafil.

Sildenafil has an excellent safety record in its clinical trials but there have been reports of deaths associated with its usage now that it is in widespread clinical use. Many of these deaths are clearly unrelated to the drug and some may be related to usage where there are clear contradictions to its use. Some deaths may occur because the patients are at risk from cardiac problems but there remains an occasional unexplained death. There is no evidence at present to suggest that sildenafil is a specific causative factor and the research so far has failed to support it as such.

The Nesbit operation for congenital curvature of the penis.

OBJECTIVE: To assess the results of the correction of congenital penile curvature using the Nesbit operation. PATIENTS AND METHODS: The records of 106 patients who had a Nesbit operation to correct a congenital penile curvature between 1977 and 1992 were reviewed. RESULTS: An excellent (78.3%) or satisfactory (17.9%) result was achieved representing an overall success rate of 96.2%. The reasons for a poor or satisfactory result were either an impaired erection--7 (6.6%) [all psychogenic] or a residual deformity of 10 degrees--16 (15.1%). There were no major complications although five patients (5.3%) needed a further Nesbit operation. CONCLUSION: The Nesbit operation is a simple and effective technique for the correction of a congenital penile curvature.

Clinical aspects associated with Sertoli-cell-only histology.

OBJECTIVE: To assess the clinical features found in infertile men in whom the histological diagnosis of Sertoli-cell-only (SCO) was made on testicular biopsy. PATIENTS AND METHODS: A retrospective review was carried out of the seminal fluid analysis, testis size and follicle-stimulating hormone (FSH) levels of 72 men who had bilateral testicular biopsies due to infertility when one (30) or both (42) of bilateral testicular biopsies showed tubules containing only Sertoli cells. In a subgroup of 15 men, the biopsies were re-examined to correlate the morphological features with the plasma FSH level. RESULTS: When both biopsies showed bilateral SCO the patient had azoospermia (86%) or oligozoospermia (14%); the testicular size was normal in 36% and the FSH level was normal (43%), raised (21%) or grossly elevated (more than twice normal, 36%). When one biopsy showed SCO, the opposite testis showed appearances which varied from grossly impaired spermatogenesis to almost normal spermatogenesis. The clinical findings were also very variable. CONCLUSIONS: The clinical features associated with the histological diagnosis of SCO are extremely variable. Biopsy evidence of bilateral SCO cannot be relied upon to indicate a total absence of spermatogenesis in the testes.