Management strategy for arterial priapism: therapeutic dilemmas

PURPOSE: We present 7 cases of arterial high flow priapism and propose management algorithms for the condition. MATERIALS AND METHODS: We studied 2 children and 5 adults with posttraumatic arterial priapism. Blood gas analysis and color Doppler ultrasonography of the corpora cavernosa confirmed the diagnosis in 4 adults, while 1 patient had already undergone cavernous artery ligation in elsewhere. In the children perineal compression resulted in detumescence, a sign that is proposed to be indicative of the diagnosis of arterial priapism (piesis sign) complementing physical examination. Mechanical compressive force was applied to the perineum of 1 boy, while the other received a watchful waiting program. All adults participated in an observation regimen except 1, who decided to undergo immediate embolization of the internal pudendal artery. RESULTS: Perineal compression led to the resolution of priapism in 1 child, while spontaneous resolution was noted in the other. An adult noticed spontaneous penile detumescence 3 to 4 months after trauma, which was attributable to site specific venous leakage and decreased, inflow in the contralateral cavernous artery. The patient underwent venous surgery and is on an intracavernous injection regimen. Successful embolization of the internal pudendal artery was performed immediately in 1 man and in the other 4 months after trauma due to social inconvenience. Adult patient 3 is still on the watchful waiting protocol (42 months), while the one who underwent cavernous artery ligation is receiving treatment for erectile dysfunction. CONCLUSIONS: Absent of long-term damaging effects of arterial priapism on erectile tissue combined with the possibility of spontaneous resolution or progressive concomitant hemodynamic abnormalities associated with blunt perineal trauma are suggestive of the introduction of an observation period in the management algorithm of high flow priapism. Such a period may help avoid unnecessary intervention and determine the impact of priapism on patient personal life. Perineal compression may be also added as part of the physical examination as a sign specifically indicative of arterial priapism.     

MANAGEMENT OF INVASIVE PENILE CANCER BY SYNCHRONOUS PENILE LENGTHENING AND RADICAL TUMOUR EXCISION TO AVOID PERINEAL URETHROSTOMY

Background: Adequate excision of invasive penile carcinoma often results in penile stump of inadequate length to control the urinary stream. A simple technique to lengthen the stump and avoid urethrostomy is described here. Methods: Additional corporal length is gained by dividing the dorsal suspensory ligaments through transverse lower abdominal skin incision. Skin length is gained by vertical closure of this incision. Results: Conclusions: In selected cases this technique may avert the need for perineal urethrostomy after adequate excision of penile cancer.     

PREOPERATIVE TREATMENT WITH HUMAN CHORIONIC GONADOTROPIN IN INFANCY DECREASES THE SEVERITY OF PROXIMAL HYPOSPADIAS AND CHORDEE

PURPOSE: We determined whether human chorionic gonadotropin (HCG) pretreatment of severe proximal penoscrotal hypospadias and chordee causes sufficient penile shaft or skin enlargement to enhance surgical repair and improve patient outcome. MATERIALS AND METHODS: A total of 12 boys 6 to 12 months old with proximal hypospadias and severe chordee received a course of HCG for 5 weeks immediately preceding hypospadias repair. RESULTS: Chordee decreased and penile length increased in all cases (mean increase 94%). Penile length gain was disproportional. Most of the increase in length was proximal to the urethral meatus, which moved the meatus distally an average of 11.4 mm. (range 6.0 to 19.0), producing a mean increase of 586% in the distance between the penoscrotal junction and meatus. In contrast, there was no statistically significant increase in penile shaft length distal to the urethral meatus. Surgical treatment was facilitated by HCG pretreatment. Three meatal based repairs were performed, only 1 urethral fistula developed and chordee was corrected by penile degloving only in 8 cases. CONCLUSIONS: HCG pretreatment in infancy produces disproportional penile enlargement, which advances the meatus distally to decrease the severity of hypospadias and chordee. This response pattern simplifies the required surgical procedure and appears to improve surgical results. It may benefit select patients, and provide insights into the endocrinopathy of hypospadias and the embryopathy of the hypospadias-chordee complex.     

PENILE ANATOMY UNDER THE PUBIC ARCH: RECONSTRUCTIVE IMPLICATIONS

PURPOSE: We have previously defined the anatomy of the neurovascular bundle in the normal and hypospadiac penis. These studies were based on analysis of the fetal penis distal to the pubic arch without total inclusion of the crural bodies. To our knowledge the neuroanatomy beneath the pubic arch has not been well described. We defined the nerve distribution under the pubic arch and the relationship of the nerves to the crural bodies, corporeal bodies and urethra of the penis. MATERIALS AND METHODS: Eight normal human fetal penile specimens (at 17.5 to 29 weeks of gestation and 1 hypospadiac specimen at 32 weeks were serially sectioned and stained with Masson's trichrome, and the neuronal markers protein gene product 9.5 and S-100. These specimens were unique in that they contained the whole penis from the glans to the crural bodies beneath the pubic arch. Older specimens were decalcified before fixation. Computer reconstruction with commercially available graphics software allowed 3-dimensional analysis of the nerves and crural bodies in relation to the pubic arch and surrounding structures. RESULTS: The nerves of the penile shaft and glans surrounded the corporeal bodies, extending from the junction of the urethral spongiosum to the classic 11 and 1 o'clock positions with a paucity of nerves at the 12 o'clock position in the dorsal midline. Beneath the pubic arch the nerves to the penis were an extension of the dorsal neurovascular bundle of the prostate. The nerves formed 2 bundles following a path just under the pubic arch in close proximity to the bone, superior to the urethra and medial to the origin of the crural bodies. The nerve bundles joined the corporeal bodies at the proximal origin, where the 2 crural bodies fused together. At this point perforating branches into the corporeal bodies from the cavernous nerves were documented. As the dorsal nerves joined the dorsal aspect of the corporeal bodies, they immediately began to fan out along the surface of the corporeal tissue to the junction of the urethral spongiosum. Three-dimensional reconstruction showed the relationship of the nerves to the pubic arch and urethra in multiple views. CONCLUSIONS: A precise understanding of penile anatomy beneath the pubic arch and at the origin of the crural bodies is important for preserving neuronal structures. This anatomy is especially germane in children undergoing posterior urethral reconstruction secondary to trauma, intersex requiring feminizing genitoplasty and severe hypospadias.     

Ejaculation latency times and their relationship to penile sensitivity in men with normal sexual function

PURPOSE: There is a need for objective and validated measurements of ejaculation latency time and penile sensitivity in men with normal sexual function. We determined 1) the normal range and repeatability of ELT in a laboratory vs at home masturbation and intercourse in normal men, 2) the threshold and repeatability of penile sensitivity on 6 penile surface areas measured by 2 vibrometers and 3) whether penile sensitivity correlates with ejaculation latency time. MATERIALS AND METHODS: A total of 58 healthy volunteers between 20 and 40 years old provided ejaculation latency times during 3 procedures and were evaluated with a biothesiometer and SMV-5 vibrometer (Suzuki-Matsuoka, Teknologue, Tokyo, Japan) on 6 penile surface areas. RESULTS: Ejaculation latency time was highest during intercourse (median 8.25 minutes, range 1.32 to 18.31), lower in the laboratory (median 7.22, range 1.37 to 18.79) and lowest during masturbation (median 4.89, range 1.08 to 14.19). The 3 ELT scores were highly reproducible within subjects (ICC 0.88 to 0.93). There was high variability among subjects. Vibrotactile thresholds on 6 penile surface areas were also similar and highly repeatable for the 2 vibrometers (ICC 0.81 to 0.96). However, there was no correlation between penile sensitivity and ELT (R2 less than 8%). CONCLUSIONS: ELT in the laboratory is lower than during intercourse and higher than during masturbation. Vibrometers produce reliable and repeatable penile vibrotactile threshold results. However, penile sensitivity measurements do not correlate with ELT in men with normal sexual function.     

Glanuloplasty with scrotal flap for partial penectomy

PURPOSE: To our knowledge the physiological mechanisms involved in sexual intercourse have not been completely explored. We hypothesized that vaginal distention induced by penile thrusting may affect the function of the bladder and urethra. To verify this supposition we assessed the effect of vaginal distention on vesical and urethral pressure. No relevant reports in the literature were identified. MATERIALS AND METHODS: The response of vesical and urethral pressure to vaginal distention was recorded in 26 healthy women volunteers with a mean age plus or minus standard deviation of 36.7 +/- 9.8 years. A condom was introduced into the vagina and inflated with carbon dioxide in increments of 10 ml. up to 80 ml. Vesical and urethral pressure was measured by a 2-channel microtip catheter connected to a transducer. The vesicourethral pressure response to vaginal distention was also tested after individual anesthetization of the bladder, urethra and vagina. RESULTS: No vesicourethral pressure response was recorded with 10 and 20 ml. of vaginal distention. At 30 and up to 80 ml. of distention bladder pressure decreased and urethral pressure increased (p <0.05). There was no significant difference when the volume of vaginal distention was increased. Mean duration of the pressure response was 4.2 +/- 0.6 seconds. Pressure returned to normal after a latency period of 5.2 +/- 1.1 seconds, although the vagina was continuously distended. Vaginal distention during anesthetization of the bladder, urethra or vagina did not evoke a pressure response. CONCLUSIONS: The vesicourethral response to the inserted condom, which by inflation adopts the shape of the erect penis, seems to simulate the response of the vagina when it is distended by the erect penis during coitus. The constant vesicourethral pressure response to vaginal distention postulates a reflex relation, which we call the vagino-vesicourethral reflex. This reflex is apparently evoked during coitus, leading to momentary vesical dilatation and increased urethral sphincter activity, which most likely acts to prevent urinary leakage during coitus. Reflex disorders may explain urinary leakage during coitus in some neuropathic conditions.     

Blunt traumatic hematuria in children. Is a simplified algorithm justified?

PURPOSE: We determined whether radiographic evaluation is indicated in all children with traumatic hematuria. MATERIALS AND METHODS: We retrospectively reviewed the records of 110 children from 1992 to 1999 diagnosed with blunt trauma and hematuria. It is routine practice at our emergency department to perform radiographic evaluation in all children with hematuria regardless of the degree. Each chart was evaluated for the mechanism of injury, degree of hematuria, hypotension, imaging studies, renal injury, renal anomalies, associated injuries and outcome. RESULTS: A total of 110 patients 1 to 18 years old (mean age 9) were identified. The most common mechanism of injury was motor vehicle accident in 37 children (34%), followed by a fall in 32 (29%). Grades I to V renal injury was present in 5, 6, 6, 6 and 1 cases, respectively (22%), while 1 (0.9%) involved ureteropelvic junction avulsion. No child had renal pedicle injury. In 9 patients renal anomalies were detected incidentally. Of the 110 patients 101 underwent radiographic evaluation, including computerized tomography in 97 (88%). The 24 patients (22%) with significant renal injury and all with incidentally diagnosed renal anomalies had 50 or greater red blood cells per high power field on urinalysis, while 1 with ureteropelvic junction avulsion presented without hematuria. Hypotension was present in only 3 patients (2.7%), who also had associated injuries, including 2 who presented with renal injury. All 3 with associated injuries. Associated injuries were identified in 11 of 25 patients (44%). The 9 patients (8%) who did not undergo radiographic imaging had negative results on repeat urinalysis with an excellent outcome. CONCLUSIONS: We recommend that radiological evaluation consisting of abdominal and pelvic computerized tomography should be performed only in patients with 50 or greater red blood cells on urinalysis, hypotension at presentation to the emergency room or based on the severity of mechanism of injury, for example high speed motor vehicle accident deceleration injuries. The patient who presented with ureteropelvic junction avulsion without hematuria would have undergone imaging considering the mechanism of injury and number of associated injuries.     

Scrotal dartos flap for the prevention of the urethrocutaneous fistula on hypospadias urethroplasty

BACKGROUND: Urethrocutaneous fistula is a common complication of urethroplasty for severe hypospadias, even when a microsurgical technique is applied. PATIENTS AND METHODS: From June 2001 to July 2003, we applied the scrotal dartos flap wrapping technique to prevent the occurrence of urethrocutaneous fistula in 14 patients with hypospadias. RESULTS: Hypospadias was repaired without fistula formation in all but one patient, who developed a tiny fistula which was later closed successfully by a simple procedure. CONCLUSIONS: We recommend the scrotal dartos wrapping technique for covering the neourethra with a well-vascularized flap because of fewer complications, although the procedure to obtain the vascularized flap may take longer.     

34例创伤性肝破裂的外科治疗体会

目的探讨创伤性肝破裂救治的最佳措施。方法对2003年1月2009年1月间收治的34例外伤性肝破裂病例的诊断、治疗方法及其预后进行回顾性分析。结果4例行非手术治疗,30例手术治疗,治愈30例。术后并发切口感染者2例,胆漏2例,膈下感染1例,死亡4例,死亡率为11．8％,主要死因为失血性休克。结论综合选择手术术式可以明显提高手术成功率及减少并发症和死亡率。     

Ulaanbaatar procedure for tubularization of the glans in severe hypospadias

PURPOSE: We developed a new procedure for the repair of proximal hypospadias in which the distal urethra is constructed as part of the first of 2 stages, and reviewed the results of 34 cases. MATERIALS AND METHODS: We performed stage 1 of the Ulaanbaatar procedure in 35 children 0.6 to 11 years old (average age 2.5), and stage 2 in 20. The meatus was at the posterior third of the shaft in 14 children, at the penoscrotal junction in 16 and in the perineum in 5. Three patients had a previous operation, and none had Byars flaps formed. Followup was less than 2(1/2) years for stage 1 and less than 1(1/2) years for stage 2. In 2 stage 2 procedures a free graft was also used to augment the proximal part of the urethroplasty. RESULTS: Urethral fistula did not develop in any patient, a minor early stricture occurred in 2 patients and 1 urethral diverticulum occurred in 1 patient after stage 2. In all patients the glans and meatus were more normal compared to other 2-stage procedures after the first operation, and the cosmetic result was usually satisfactory. CONCLUSIONS: The Ulaanbaatar technique provides an alternative approach to the formation of the glans urethra in severe hypospadias. It does not have the risks associated with a single stage procedure but has the benefit of enabling tunneling of the urethra through the glans, thus facilitating a favorable cosmetic outcome and an easy stage 2.     

Preservation of the thin distal urethra in hypospadias repair

PURPOSE: We report our experience with preserving the thin distal urethra lacking corpus spongiosum for the treatment of hypospadias. MATERIALS AND METHODS: From January 1997 to October 1999 we treated primary hypospadias in 77 boys with a mean age of 4 years 10 months. After degloving the penile skin a segment of thin distal urethra lacking corpus spongiosum was noted in 18 patients (23.4%) with a mean age of 3 years 5 months. The thin distal urethra was preserved and incorporated as part of urethroplasty (group 1). The procedure was primarily completed by tubularized incised plate urethroplasty. We also performed tubularized incised plate urethroplasty in 31 boys (40.3%) with a mean age of 5 years 2 months who had normal coverage of the corpus spongiosum of a hypospadiac urethra (group 2). We compared the results of treatment in these 2 groups. The remaining 28 patients (36.4%) treated with other methods were excluded from study. RESULTS: In group 1 the distance from the original meatus to the urethra covered by healthy corpus spongiosum was 4 to 20 mm. (mean 8.2). If the thin distal urethra had been excised, the urethral meatus would have been relocated more proximal in these boys. Mean followup in groups 1 and 2 was 9.9 and 7.6 months, respectively. Postoperatively there were 2 (11.1%) urethrocutaneous fistulas in group 1 and 4 (12.9%) in group 2. Tubularized incised plate repair was successful in all 10 cases (100%) of distal hypospadias in group 2, and in 15 of 18 (83.3%) and 17 of 21 (81%) of proximal hypospadias cases in groups 1 and 2, respectively. There was no statistically significant difference in the success rate of hypospadias repair in the groups. CONCLUSIONS: We noted a significantly thin distal urethra in 23.4% of our cases of primary hypospadias. Mean length of the thin distal urethra was 8.2 mm. Preserving the thin distal urethra may simplify the operative procedure without compromising the surgical results of tubularized incised plate urethroplasty.     

A prospective study comparing paroxetine alone versus paroxetine plus sildenafil in patients with premature ejaculation

PURPOSE: We compared the efficacy of paroxetine alone and combined with sildenafil in patients complaining of premature ejaculation. MATERIALS AND METHODS: Enrolled in this study were 80 consecutive potent men 19 to 47 years old (mean age 34) with premature ejaculation but without any obvious organic cause. Pretreatment evaluation included a history, self-administration of the International Index of Erectile Function (IIEF) questionnaire, physical examination and the Meares-Stamey test to exclude genital tract infection. The initial 40 patients received 10 mg. paroxetine daily for 21 days and then 20 mg. as needed, that is 3 to 4 hours before planned sexual activity, for 6 months (group 1). The other group of 40 men received 10 mg. paroxetine daily for 21 days and then 20 mg. as needed plus 50 mg. sildenafil as needed, that is 1 hour before planned sexual activity, for 6 months (group 2). Patients were followed 3 and 6 months after beginning therapy and were evaluated using several general assessment questions, IIEF and ejaculatory latency time. RESULTS: Mean ejaculatory latency time +/- SE in group 1 was 0.33 +/- 0.04, 3.7 +/- 0.10 (p <0.01) and 4.2 +/- 0.03 (p <0.01) minutes at baseline, 3 and 6-month followup, while in group 2 it was 0.35 +/- 0.03, 4.5 +/- 0.07 (p <0.01) and 5.3 +/- 0.02 (p <0.001) minutes, respectively. When improvement in ejaculatory latency time was compared in the 2 groups, group 2 results proved to be significantly greater (p <0.05). Baseline, and 3 and 6-month mean intercourse satisfaction domain values of the IIEF were 9, 11 and 11 (p = 0.09, not significant), and 9, 11 and 14 (p <0.05) in groups 1 and 2, respectively. Group 2 patients reported significantly greater intercourse satisfaction than those in group 1 (p <0.05). At baseline, 3 and 6 months there was a mean of 0.9 +/- 0.1, 1.7 +/- 0.3 (not significant) and 2.5 +/- 0.3 (p <0.01) coitus episodes weekly in group 1, and 1 +/- 0.2, 2.3 +/- 0.3 (p <0.01) and 3.2 +/- 0.1 (p <0.001) in group 2, respectively. Group 2 patients reported a significantly higher number of coitus episodes weekly (p <0.05). Side effects in the 40 group 1 cases included anejaculation in 1 (2.5%), gastrointestinal upset and/or nausea in 5 (12.5%), headache in 4 (10%) and decreased libido in 2 (5%). Side effects in the 40 group 2 cases included anejaculation in 1 (2.5%), headache in 8 (20%), gastrointestinal upset and/or nausea in 6 (15%) and flushing in 6 (15%). Group 2 patients reported significantly more headaches (p <0.01) and flushing episodes (p <0.001) than those in group 1. After 6 months of treatment 33 men (82.5%) in group 1 and 36 (90%) in group 2 were willing to continue therapy (not significant). CONCLUSIONS: Paroxetine combined with sildenafil appears to provide significantly better results in terms of ejaculatory latency time and intercourse satisfaction versus paroxetine alone in potent patients with premature ejaculation. However, combined treatment is associated with a mild increase in drug related side effects.     

Use of ultrasonography for the diagnosis of testicular injuries in blunt scrotal trauma

PURPOSE: We determined the use of scrotal ultrasonography in the initial diagnosis and management of testicular injuries due to blunt scrotal trauma. MATERIALS AND METHODS: We performed a retrospective review of 65 patients presenting to our Emergency Department with blunt scrotal trauma in the last 25 years. In 47 patients an inconclusive clinical examination prompted scrotal ultrasonography. A heterogeneous echo pattern of the testicular parenchyma with loss of contour definition was the basis for diagnosis of testicular rupture. The sensitivity and specificity of scrotal ultrasonography were determined by comparing this radiographic criterion with definitive intraoperative findings and the need for delayed orchiectomy due to undiagnosed testicular rupture. RESULTS: Of the 65 patients sustaining blunt scrotal trauma 44 (68%) underwent scrotal exploration, and 30 (46%) of these injuries involved rupture of the tunica albuginea. Among the 47 scrotal ultrasounds performed to supplement a nondiagnostic clinic examination, there were 32 suspected testicular ruptures. Thus, the 2 false-positives resulted in a specificity of 93.5% in those patients explored. No delayed orchiectomies were performed for missed testicular ruptures, resulting in 100% sensitivity. The majority of testicular ruptures were salvaged (83%), with only 5 of the 30 (17%) requiring orchiectomy (4 of these patients had delayed presentation greater than 48 hours). CONCLUSIONS: Scrotal ultrasonography, with the single radiographic finding of a heterogeneous echo pattern of the testicular parenchyma with loss of contour definition, is highly sensitive and specific in the diagnosis of testicular rupture in an otherwise equivocal scrotal examination. Accurate diagnosis and prompt repair led to a salvage rate for testicular rupture specifically of 83% and overall of 92%, with preservation of the testicular parenchyma and hormonal function, and avoidance of the delayed complications of chronic pain, atrophy and orchiectomy associated with missed testicular rupture.     

Morphological features of external genitalia in hypospadiac rat model: 3-dimensional analysis

PURPOSE: We examined 3-dimensionally the process of external genitalia formation in the experimental hypospadiac rat model. MATERIALS AND METHODS: We administered 7.5 mg flutamide daily, a blocker of androgen receptor, into the abdomen of naturally pregnant female Sprague-Dawley rats from gestational days 14 to 20 to produce a hypospadiac rat model. The control group consisted of male offspring not exposed to flutamide. The fetal phallus was obtained at gestational days 17.5, 19.5 and 21.5. We observed them by scanning electron microscopy. RESULTS: In the 17.5-day-old embryo the projection on the ventral side of the phallus was observed from the base of the phallus to the coronary sulcus in the control rat. This finding demonstrated that the urethra develops from the base of the phallus to the coronary sulcus. On the other hand, this projection was not observed in the hypospadiac rat and the urethra was not seen on the ventral side of the phallus. In the 19.5-day-old embryo the ventral preputial closure appeared in the proximal phallus of the control rat but not of the hypospadiac rat. In the control rat the scrotum was discerned in the perineum and divided by a median fold (the raphe). The raphe reached the base of the phallus, where it was concurrent with the preputial fold that covers the urethra. On the other hand, the hypospadiac rat did not have a raphe and the hollow at the base of the phallus appeared to give rise to the future orifice of the urethra. In the 21.5-day-old embryo the control rat prepuce completely surrounded the distal phallus, whereas that of the hypospadiac rat was dorsally hooded with a ventral cleft and the external appearance resembled the morphology of human penoscrotal hypospadias. CONCLUSIONS: This hypospadiac rat model is considered valuable for further studying penile growth and differentiation, and the molecular mechanisms in external genitalia formation in hypospadias.