Serum testosterone levels in diabetic men with and without erectile dysfunction.

Diabetes mellitus is a common chronic disease, affecting 0.5-2% worldwide. The Massachusetts Male Aging Study reported that up to 75% of men with diabetes have a lifetime risk of developing ED. Type 2 diabetes is associated with low total serum testosterone (TT) identified in several cross-sectional studies and systemic analyses. There is a lack of consensus regarding what constitutes the lowest level of testosterone within the boundaries of normality. In this retrospective study, we sought to evaluate the effect of associated co-morbidities on serum total testosterone (TT) level in men with type 2 diabetes DM, either with or without erectile dysfunction (ED). Three hundred and ninety-one patients were evaluated for erectile function using an abridged, five-item version of the International Index of Erectile Function-5. Measurements of TT, fasting lipid profile, blood sugar and glycated haemoglobin (HbA1c) were conducted. Penile hemodynamics was assessed using intracavernosal injection and penile duplex study. Hypogonadism was found in 126 cases (33.2%), and normal TT was observed in 254 (66.8%). ED was detected in 119 cases in the hypogonadal group (94.4%) as compared to 155/254 (61.0%) in eugonadal group, P = 0.0001. TT was lower in diabetic men with ED as compared to those with normal erectile function (EF), 392.4 ± 314.9 versus 524.3 ± 140.2 ng dl(-1) , respectively, P < 0.0001. After exclusion of patients with hypertension and dyslipidaemia, 185 men were evaluated, and there was no difference in the mean TT level among men with ED 490.6 ± 498.2 ng dl(-1) versus normal EF 540.6 ± 133.4 ng dl(-1) although, HbA1c remained lower in men with normal erectile function. Receiver operating characteristic (ROC) curve of TT in men without associated co-morbidities showed that EF was compromised at TT = 403.5 ng dl(-1) or less. Sensitivity of 63.3% and a specificity of 94.0% were detected. At this level, ED was found in 33/38 (86.8%) men with TT 403.5 ng dl(-1) , whereas ED was observed in 57/147 (38.8%) men with TT ≥ 403.5 ng dl(-1) (P < 0.0001). We propose a cut-off value of 403.5 ng dl(-1) of TT blood levels as an indicator for initiation of testosterone replacement therapy in diabetic men with ED. Further prospective controlled trials are recommended.

Prevalence of late-onset hypogonadism in men with type 2 diabetes mellitus.

Late-onset hypogonadism (LOH) or age-associated testosterone deficiency syndrome is defined as a clinical and biochemical syndrome associated with advancing age and characterised by symptoms and a deficiency in serum testosterone levels. This condition may result in significant detriment in the quality of life and adversely affect the function of multiple organ systems. It has been suggested that sex steroid hormones may play a causal role in the development of insulin resistance and type II diabetes. This comparative study was aimed at determining the prevalence of LOH in diabetic men with erectile dysfunction and investigating the effect of testosterone replacement therapy on erectile function and on glycaemic control.

Treatment of premature ejaculation by glans penis augmentation using hyaluronic acid gel: a pilot study.

Premature ejaculation (PE) is by far the most common male sexual complaint, with millions of men affected all over the world. It is estimated that up to 20-30% of all men may be suffering from various forms of PE. A variety of filler materials are widely used nowadays for soft tissue augmentation. The appropriate filler can restore symmetry, volume and create a smooth skin surface The aim of this pilot study was to evaluate the therapeutic effect of hyaluronic acid gel injection in patients with PE. Sixty men with self-reported PE who were referred to our outpatient andrology clinic (between January 2007 and January 2008) were included in this study. Participants were randomly assigned using random sampling numbers into two distinct groups. Group A (n = 30) received a single injection of 2 ml of hyaluronic acid gel (Hyalift 3.5% micronised hyaluronic acid) using the previously described fan technique. Group B (n = 30) received a single injection of 2 ml of hyaluronic acid gel using the multiple puncture technique. Twenty-three patients (46.9%) received injection by the fan technique, while 26 patients (53.1%) received it through the multiple-point technique. The mean intravaginal ejaculation latency time (IELT) increased significantly from 2.12 ± 1.16 to 7.71 ± 7.86 min, after 1 month of injection and then dropped to 5.32 ± 3.52 min, but still remaining significantly higher than the baseline values. Results from our present pilot study demonstrated the usefulness of the application of hyaluronic acid dermal fillers in the treatment of PE; however, further investigations in large cohorts with longer follow-up are definitely needed to obtain more consistent results.

Impact of cell phone use on men's semen parameters.

The objective of the present retrospective study was to report our experience concerning the effects of cell phone usage on semen parameters. We examined 2110 men attending our infertility clinic from 1993 to October 2007. Semen analysis was performed in all patients. Serum free testosterone (T), follicle stimulating hormone (FSH), luteinising hormone (LH) and prolactin (PRL) were collected from all patients. The information on cell phone use of the patients was recorded and the subjects were divided into two groups according to their cell phone use: group A: cell phone use (n = 991); group B: no use (n = 1119). Significant difference was observed in sperm morphology between the two groups. In the patients of group A, 68.0% of the spermatozoa featured a pathological morphology compared to only 58.1% in the subjects of group B. Patients with cell phone usage showed significantly higher T and lower LH levels than those who did not use cell phone. No significant difference between the two groups was observed regarding FSH and PRL values. Our results showed that cell phone use negatively affects sperm quality in men. Further studies with a careful design are needed to determine the effect of cell phone use on male fertility.

Incisional corporoplasty for the correction of congenital penile curvature: a review of two suturing techniques.

This retrospective study was designed to evaluate the surgical outcome of correction of congenital penile curvature, via multiple vertical incisions in the tunica albuginea using two different types of suture material, simple inverted 2-0 PDS sutures versus Proline 2-0 suture followed by closure with 3-0 vicryl. The study included 45 men with congenital penile curvature and surgeries were performed in four general hospitals. Patients were divided into two groups; Group A (n=24) included patients undergoing penile curvature correction using 2-0 PDS sutures; and Group B (n=21) patients undergoing the same procedure by placing an inverted Proline 2-0 suture in the middle of the suture line and completing the closure of the incision line with 3-0 vicryl. The procedures straightened the penile shaft in all cases but a degree of curvature recurred in three cases (all Group A). No operative or postoperative complications occurred and no reoperations were needed. Four patients complained of penile shortening (all Group A). No recurrence was observed in the proline group (difference not statistically significant). Horizontal plication after vertical corporal incisions is safe and effective in the treatment for congenital penile curvature without hypospadias. We advise avoiding overcorrection to prevent penile shortening.

The prevalence of Peyronie's disease in diabetic patients with erectile dysfunction.

We attempted in this study to investigate the prevalence of Peyronie's disease (PD) among diabetic patients with erectile dysfunction (ED). Two-hundred and six diabetic patients were further evaluated in this study. Forty-two (20.3%) patients had PD. There were significant associations between PD and risk factors of age, obesity and smoking. All patients with PD had also ED. Penile curvature was present in 82.1% of all patients with PD. Of the patients with PD, 25.4% had pain with or without erection. Significant associations between PD and ED and ED duration were detected. This study confirmed the high prevalence of PD among diabetic patients with ED. Further work is needed probing the mechanisms through which diabetes affects the pathogenesis of ED and PD.

Efficacy of sertraline hydrochloride in treatment of premature ejaculation: a placebo-controlled study using a validated questionnaire.

Selective serotonin reuptake inhibitors (SSRIs) are increasingly used to treat premature ejaculation. We report a large prospective placebo-controlled crossover study of sertraline in premature ejaculation (PE) using Arabic Index of Premature Ejaculation (AIPE). One hundred and forty-seven men suffering from PE were enrolled in a randomized single-blinded crossover study of sertraline hydrochloride and placebo. Patients were randomized into group 1 (n=77) and group 2 (n=70). Both groups received sertraline and placebo interchangeably for 4 weeks. Overall, 127 (81%) of 157 subjects experienced a significant increase in their AIPE total score after sertraline treatment. Sixty-six (66%) of 100 patients available for follow-up experienced relapse of PE within 6 months after sertraline withdrawal. The active drug was generally well tolerated. Our relatively large study, using a validated questionnaire (AIPE), confirmed the useful effect of sertraline on PE.

Monitoring circulatory heme level in hemin therapy for lowering blood pressure in rats.

Hemin and other heme derivatives, e.g. heme-L-lysinate (HLL) and heme-L-arginate, have been used extensively to upregulate expression of heme oxygenase and production of endogenous carbon monoxide. Hemin administration has been shown to markedly decrease high blood pressure in spontaneously hypertensive rats (SHR), but not in normotensive Wistar-Kyoto or Sprague Dawley (SD) rats. While methodology to measure serum heme levels has been established long ago, metabolism of the injected hemin or heme derivatives when used to lower blood pressure has not been investigated. In this study, metabolism of hemin or HLL after injected into the rat was monitored by measuring changes in circulatory heme levels. SHR (12-20 weeks old) had significantly higher blood pressure than age-matched SD rats. In both strains, serum heme level was negligible. Hemin or HLL injection (15 mg/kg/day, i.p.) for 5-13 days significantly lowered blood pressure of 12-weeks SHR. High blood pressure was not lowered in SHR older than 20 weeks until hemin or HLL injection period was beyond 5 days. This anti-hypertensive effect of hemin and HLL was synchronized with an increase in serum heme level, from undetectable to 4.3 micromol/l. On the other hand, hemin or HLL had no effect on blood pressure of age-matched SD rats, despite serum heme level rose to the same extent as in the treated SHR. There was no significant difference between hemin and HLL injections in terms of changes in blood pressure and serum heme level in all rats. Our study for the first time correlated changes in serum heme levels with blood pressure levels after injection of hemin or HLL in SHR and SD rats. Hemin and HLL had similar effects on blood pressure change and serum heme level. By determining serum heme levels following the administration of hemin or HLL, we can better understand mechanisms for the blood pressure lowering effect of hemin therapy. Application of this heme monitoring technology will also pave the way for clinical application of hemin therapy in treatment of different types of hypertension pathologies.

Subinguinal microvaricocelectomy versus retroperitoneal varicocelectomy: comparative study of complications and surgical outcome.

OBJECTIVES: To compare and assess objectively the postoperative outcome parameters of both microsurgical subinguinal artery sparing and retroperitoneal high ligation techniques for varicocele in infertile men. METHODS: We performed a prospective study that included 413 consecutive patients who presented with varicocele. Of the 413 patients, 304 underwent subinguinal varicocelectomy (group 1) and 109 patients underwent high ligation varicocelectomy (group 2). Subinguinal varicocelectomies were performed under local anesthesia, with intravenous propofol sedation administered as needed. The operating microscope (x10 to x16) was used to spare the arteries and lymphatics. High ligation was performed through a retroperitoneal approach. RESULTS: All patients went home on the evening after surgery with minimal discomfort. No intraoperative complications occurred. The internal spermatic artery was identified in all microvaricocelectomy cases. No testicular atrophy occurred in either group. Five (1.6%) and seven (6.4%) hydroceles were identified at the 3-month postoperative visit in groups 1 and 2, respectively. CONCLUSIONS: Microvaricocelectomy is safe and effective and associated with a rapid recovery and minimal morbidity. However, it requires microsurgical training.

Correlation between penile duplex findings and stress electrocardiography in men with erectile dysfunction.

The aim of this work is to assess the association between vasculogenic erectile dysfunction (ED) and coronary artery disease in men above the age of 40 y. The study included 40 patients above 40 y of age with vasculogenic ED of more than 3 months duration. A dynamic duplex study after intracavernosal injection of a bimix solution (60 mg papaverine + 2 mg phentolamine mesylate) was carried out using a color ultrasound machine. The patients underwent a stress ECG test, carried out on a motor-driven treadmill according to the 'Bruce Protocol'. A total of 12 patients were diagnosed with positive ischemic heart disease (IHD). Their mean peak systolic velocity (PSV) was PSV = 19.58 cm/s. In all, patients were diagnosed with negative IHD; their mean PSV was 36.21 cm/s. A statistically significant difference was observed between patients with positive IHD and patients with negative IHD regarding PSV (P = 0.003). The sensitivity of a PSV of less than 35 cm/s in predicting IHD was 50% with a specificity of 100%. Positive predictive value for abnormal stress ECG to predict a PSV of less than 35 cm/s was 100%. In conclusion, the PSV of cavernosal arteries is a reliable measure for predicting IHD in patients with vasculogenic ED. Patients with a PSV of less than 35 cm/s should be referred for cardiologic assessment as they carry a real risk of having silent IHD.

Validity of the Arabic version of the sexual health inventory for men among Egyptians.

The objective of this study is to assess the validity of Arabic version of the abridged International Index of Erectile Function among a sample from the Egyptian populace. Two groups were included in this study. Group A included 68 patients complaining of erectile dysfunction (ED) >1 y, who failed oral treatment and accepted intracavernous self-injection. All patients of group A were previously clinically diagnosed as having ED. Group B included 68 men not complaining of ED and not suffering from any major chronic or acute illness. The mean (s.d.) age of all 136 patients was 52+/-5.7 y. Candidates of both groups were requested to complete the Sexual Health Inventory for Men (SHIM) questionnaire. Cronbach's alpha coefficient was used to assess the internal consistency of the SHIM. The items of maintenance ability, erection confidence, maintenance frequency, erection firmness and intercourse satisfaction showed an overall ICC of 0.92. Internal consistency for the whole scale was 0.91. In conclusion, the Arabic version of the SHIM administered to 136 Egyptian men proved to be reliable and valid. It also showed a high degree of specificity and sensitivity among the Egyptian population.

ICSI using testicular sperm in male hypogonadotrophic hypogonadism unresponsive to gonadotrophin therapy.

BACKGROUND: The aim of this study was to assess the use of testicular sperm for ICSI in azoospermic men with hypogonadotrophic hypogonadism unresponsive to gonadotrophin therapy. METHODS: Fifteen patients with hypogonadotrophic hypogonadism who remained azoospermic after hormonal treatment underwent testicular sperm extraction (TESE) and ICSI. These men were recruited from the Egyptian IVF centre over a period of 4 years. All patients were given 75 IU hMG thrice weekly and 5000 IU hCG once or twice weekly for >/=6 months prior to attempting ICSI/TESE. RESULTS: In 11 out of 15 patients (73%), sperm could be retrieved from testicular tissue and were used for ICSI. Two chemical pregnancies resulted but no clinical pregnancies. Nine patients continued gonadotrophin therapy for another 6 months. Sperm appeared in the ejaculate of three of them. The remaining six patients underwent another ICSI cycle, one using cryopreserved sperm and five underwent a second TESE. One chemical pregnancy and three clinical pregnancies were established. One ongoing, one singleton and one twin pregnancies resulted in the delivery of three healthy babies. In total, of 17 ICSI cycles performed using testicular sperm retrieval, the fertilization rate was 41.7% and the cumulative pregnancy rate was 20%. CONCLUSIONS: The use of testicular sperm for ICSI is a treatment option that can be offered to azoospermic males with hypogonadotrophic hypogonadism either not responding or reluctant to continue hormonal treatment. However, prolonged hormonal treatment may improve TESE/ICSI results.

Clinical and sonographic assessment of the side effects of intracavernous injection of vasoactive substances.

The objective of this study is to evaluate the side effects of intracavernous vasoactive agents on clinical and sonographic basis. Two groups of patients were included, group I included 168 ED patients trained on self-injection therapy using one of the three protocols. Protocol A: papaverine; protocol B: PGE1; and protocol C: trimix (papaverine, phentolamine and PGE1). Patients were followed up clinically, sonographically and by laboratory investigations for 6 months to evaluate the occurrence of side effects. Group II included 21 patients presenting to our department for the first time with a complication of intracavernous injection pharmacotherapy (ICI) initiated elsewhere. In all, 168 patients of group I completed the study. Patients on papaverine had the highest incidence of complications concerning prolonged erection, subcutaneous hematoma and penile fibrosis. Postinjection penile pain was observed more with groups B and C than group A. No systemic side effects were reported. Duplex ultrasound was beneficial in detecting mild clinically impalpable fibrosis. In total, 10 patients of group II presented with prolonged erection, seven with penile fibrosis, three with cavernositis and one with intracavernous needle breakage. We conclude that although ICI therapy is an effective second-line treatment option, patients on a self-injection program should be followed up both clinically and sonographically both at the initiation phase and on regular follow-up visits.

The value of penile duplex in the prediction of intracavernous drug-induced priapism.

The aim of this work is to assess the value of penile duplex in the prediction of intracavernous drug-induced ischemic priapism. A total of 400 patients with erectile dysfunction were evaluated before and after diagnostic intracavernous injection of a trimix solution (papaverine+phentolamine+PGE1) using color Doppler sonography. In all, 29 patients experienced sustained rigid erections for more than an hour. Patients were further divided into two groups. Group A included patients with spontaneous resolution of their rigid erection within 3 h (10/29) and group B included patients with priapism (19/29) that did not resolve within 3 h. In group A, patients had minimal cavernous artery blood flow within the first hour postinjection, that increased with relief of their erection. Group B patients had no blood flow in their cavernous artery an hour after intracavernous injection and for 6 h later. The disappearance of blood flow in the cavernous artery after an hour of sustained rigid erection predicted priapism with 100% specificity and sensitivity. The persistent absence of cavernous artery blood flow for more than an hour, as detected by color Doppler ultrasound, is an objective predictor of priapism. This may guide early intervention to resolve the prolonged erection.