Intracavernous pharmacotherapy in psychogenic impotence.

Twenty-five men with psychogenic impotence but without serious psychopathology were considered for intracavernosal therapy with papaverine hydrochloride and phentolamine mesylate. A total of 20 proved suitable and began self-injection in conjunction with sex therapy; 8 patients had return of spontaneous erections without pharmacotherapy, although one of them needs to keep the medication in his refrigerator. The other 12 patients are continuing self-injection therapy. Psychotherapy with self-injection may be helpful in the management of psychogenic erectile impotence.     

Intracavernous self-injection with phentolamine and papaverine for the treatment of impotence

To evaluate the efficacy and safety of intracavernous self-injection of phentolamine and papaverine for the treatment of impotence, 30 patients were enrolled in a prospective, randomized, double-blind, placebo-controlled cross-over study of papaverine and phentolamine versus normal saline. A total of 29 patients completed the study. The phentolamine plus papaverine combination resulted in erection in 24 patients (82.8 per cent) and no erection occurred after injection of saline. Of the patients 12 (41.4 per cent) experienced technical difficulties with the injection. Ecchymosis of the penis at the site of injection was common and 1 patient experienced priapism that resolved spontaneously. No other side effects occurred. Intracavernous self-injection with phentolamine and papaverine appears to be a safe and effective treatment of impotence but long-term effects must be determined.     

Intracavernous injection of papaverine hydrochloride for impotence in patients with spinal cord injury

Twenty-one intracavernous injections of 40 or 60 mg papaverine hydrochloride were given to ten male paraplegics. Erection sufficient for coitus was achieved within a few minutes after 15 of the injections (71.4%). Tumescence of the penis lasted from 18 minutes to 48 hours and the penile tumescence of the patients who had reflective erection usually lasted longer than that of the patients who did not. The trial that lasted for 48 hours resulted in the fracture of the penis that was presumed to have occurred during coitus and it was treated operatively. Intracavernous injection of papaverine hydrochloride is available for the impotence of male paralegics, but both doctor and patient must be careful about the sensory disturbance of the penis to avoid penile injury during erection. Further studies are needed to establish safety and long-term efficacy, as well as to determine if histological change of cavernous body occurs by repeated injection.     

Norepinephrine involvement in response to intracorporeal injection of papaverine in psychogenic impotence.

The levels of catecholamines in penile blood during a papaverine test were measured to investigate whether the secretion of endogenous catecholamines is involved in response to intracorporeal papaverine injection. The level of norepinephrine was higher in patients with psychogenic impotence than in the normal controls and patients with vasculogenic impotence (p less than 0.01), and it was significantly higher in negative responders than in positive responders in the psychogenic impotence group (p less than 0.001). There was no significant difference in the level of epinephrine among the groups. The false negative response to the papaverine test in psychogenically impotent men is believed to be derived from secretion of cavernous norepinephrine, which overwhelms the action of cavernous smooth muscle relaxation by papaverine.     

Intracorporal injection of papaverine and phentolamine in the management of impotence

Intracorporal injection of 0.5 ml papaverine (30 mg/ml) and phentolamine (2.5 mg/ml) was given to 144 patients presenting with various types of impotence. The high response rate (97%) precluded the use of this test to differentiate between types of impotence but provided patients with the choice of embarking on a self-injection programme. Of the 101 patients entering the programme 78 are continuing self-injection therapy with a mean follow-up of 6.5 months. The incidence of complications is low and patients are generally very satisfied with the treatment.     

Intracavernous injection of papaverine (ICIP)

Summary A total of 310 intracavernous injections of papaverine (ICIP) were performed in 100 impotent patients. The results were compared to those of multidisciplinary etiologic investigations, including nocturnal penile tumescence monitoring, the artificial erection test and arteriography. The response to ICIP was fairly reproducible. It differed slightly according to the position of the patient (supine or upright). We observed prolonged erections in 14% and priapism in 4% of the patients that resulted in 2 definitive iatrogenic impotences. The response to 80 mg ICIP was positive (fully rigid erection) in 17% of the organic patients, most of whom were neurogenic and endocrine patients. It was negative (no response or soft erection) in most cases with severe venous incompetence or severe arterial occlusion, but also in 44% of the patients without important vascular abnormality, and 33% of the well-documented psychogenic cases. Apart from self-injections, 27% of the patients (mainly psychogenic cases) were improved by repeating the injections. We observed a high rate of complications among 6 patients who performed self-ICIP, including 2 cases of fibrosis of the cavernous bodies. In conclusion, ICIP is of real, but limited, value in the assessment of the vascular component in impotence. It can also improve certain patients, but involves a significant risk of priapism. Today, less dangerous drugs must be selected for the therapeutic application of ICI.     

Intracavernous injection of vasoactive drugs for treating erectile impotence

Intracavernous injection of various vasoactive drugs was performed in six erectile failure patients. The effects of each drug were evaluated in four grades: complete functional erection, incomplete functional erection, nonfunctional expansion and no effect. When papaverine hydrochloride (40 mg/ml) was administered, 4 of the 6 patients had nonfunctional expansion. By administering a mixture of 80 mg/ml papaverine hydrochloride with 1.0 mg/ml phentolamine mesylate, nonfunctional expansion was seen in four patients and incomplete functional erection in two patients. As for the effects of prostaglandin E1, incomplete functional erections were seen in all patients, while complete functional erection was seen in two patients. These findings indicated that the patients reacted differently to the same vasoactive drug, and that the papaverine and phentolamine mixture had a stronger effect than papaverine alone, while prostaglandin E1 had the strongest effect on erection. Intracavernous injection of the these drugs is useful for the treatment and differential diagnosis of impotence.     

Intracavernous therapy in impotence after pelvic trauma. A preliminary study

Pelvic trauma, especially when complicated by a posterior urethral disruption, may cause impotence in 50% of patients. The treatment of this kind of impotence has always been troublesome for the urologist. In fact penile prostheses or the revascularization procedures have sometimes been failures. We present a series of 6 patients with impotence after pelvic trauma managed by intracavernous injection of papaverine and we describe here the preliminary results obtained.     

Diagnosis of male impotence after intracavernous papaverine test

The diagnosis and treatment of male impotence have been radically modified by the introduction of intracavernous injections of papaverine. Papaverine treatment can solve more than 70% of male impotence cases, so that the real clue to the diagnosis of impotence is to discriminate between patients who can be treated by papaverine alone and patients deserving thorough investigation. The association of papaverine injection plus video sexual stimulation for this purpose was adopted in our last 250 unselected patients and represents a valuable tool. 115 of 250 achieved successful treatment for their impotence according the following percentages: intracavernous papaverine injections at the practice or at home 75.8%; prosthesis, 19.1%; venous surgery, 3.4%, and arterial surgery, 1.7%.     

Intracavernous injection of prostaglandin E1 for the treatment of erectile impotence

We administered intracavernous injections of 20 micrograms. prostaglandin E1 to 135 patients with impotence, and evaluated the effects and side effects. Among 135 patients who underwent intracavernous injection of prostaglandin E1 complete erection was observed in 83 (62 per cent), while incomplete erection was noted in 33 (24 per cent). In both groups the erection was sufficient for sexual intercourse. Tumescence without rigidity was noted in 12 patients and no response was obtained in 7. Poor response was seen frequently in patients with disorders of the vascular system and/or damage to the cavernous body of the penis. Priapism after the injection was not observed. Moreover, we never observed any other severe side effects. Intracavernous injection of prostaglandin E1 could be applicable to the therapy of impotence, especially that due to neurogenic disturbance. Since prostaglandin E1 acts quickly and loses its validity rapidly it is considered to be a more suitable agent than other vasoactive drugs.     

Clinical experience of bromazepam for psychogenic impotence patients

A clinical trial was performed with the tranquilizer Bromazepam on 39 patients undergoing diagnosis of psychogenic impotence, and the drug effect was evaluated according to the criteria based on our protocol. The protocol specifies 8 tests (1 for libido, 4 for erection, 2 for ejaculation, 1 for orgasm) which are scored according to an arbitrary logarithmic scoring system. At the end of the study the points made in the 8 tests were added to obtain the total score as the basis for evaluation of the overall drug effect. After treatment all tests showed an improvement, and the improvement in erection during masturbation, reflective erection, and condition of ejaculation was statistically significant. The total score also improved from 16.77 +/- 2.62 (mean +/- S.D.) before treatment to 11.42 +/- 1.96 after treatment, and the change was again statistically significant (P less than 0.05). The rate of satisfaction as a subjective symptom of improvement also increased from 25.38 +/- 4.40% to 39.10 +/- 4.53%. The results of the present study provide evidence to indicate that Bromazepam is beneficial for psychogenic impotence.     

Utility of Rigiscan and papaverine in diagnosis of erectile impotence

The Rigiscan machine was used to measure nocturnal penile tumescence and rigidity in 41 men referred for evaluation of erectile impotence. In 6 patients, the Rigiscan was compared with the Tumistore and Snap-Gauge bands. Two patients achieved significant tumescence as measured by Tumistore, and 3 had significant tumescence as indicated by the breaking of two or three of the Snap-Gauge bands. None of these men achieved sufficient rigidity for intercourse as measured by the Rigiscan. Fourteen patients with organic impotence received intracorporeal injections of papaverine and were then monitored by Rigiscan. Six of the 14 were noted to have a Peyronie plaque. Of the remaining 8, 6 of these men achieved lasting erections sufficient for intercourse. The other 2 had erections that lasted ten minutes and were considered to have venous leak impotence. All patients with Peyronie disease had tumescence after papaverine injection, but in 5 the penis became rigid only at the base. Complications of papaverine injection were uncommon and minor. The Rigiscan and papaverine are useful in the diagnosis and management of erectile impotency.     

Investigation of intracavernous injection of papaverine for erectile impotence

Forty milligrams papaverine HCl was intracavernously injected to 28 patients with erectile dysfunction for diagnosis and treatment in 14 cases in which it was injected a few times. We designed a brief manual method for measurement of penile hardness by artificial erection. Twenty of the patients corresponding to 71.4%, reacted, but only 16 (57.1%) had efficient erection for possibility of coitus. It was useful for the diagnosis of vascular dysfunction with dorsal penile arterial pulse sound examination in impotence. It was useful for the cases of small vascular impediment with preservation of nerve supply after the operation of intrapelvic malignancies, and self injection might be possible, but on the other hand, it had no effect for the patients of advanced age with vascular impediment and diabetes mellitus neuropathy, and with arteriosclerosis.     

Semi-flexible penile prosthesis for organic and psychogenic impotence

Summary Since the 1970s, penile prostheses, both semi-flexible and inflatable, have been used for surgical treatment of impotence. The semi-flexible implants are highly successful and the rate of complications is low (8%). Indications for penile implants include organic and psychogenic cases, operation in the latter group often being done after unsuccessful psychotherapy. The contraindications are very few. Preoperative, intraoperative and postoperative antibiotic coverage of patient, implants, sizers, dilators and wound is essential and has reduced the incidence of infection from an original 15% (first 20 patients) to 0.5%. Recently, trimming of the implant tails has enabled the surgeon to require fewer prosthesis sizes in the operating room, thus reducing their cost to patients. An additional benefit of the surgical treatment of impotence by penile implantation of a semi-flexible prosthesis is indirect treatment of infertility when infertility is caused by impotence.