Ejaculatory disorders: epidemiology and current approaches to definition, classification and subtyping

Ejaculatory disorders (disorders of emission, ejaculation and orgasm) are the most frequent sexual complaint. Conventional algorithms on ejaculatory disorders are based on an organic or psychogenic dichotomy, with the latter being traditionally considered the main etiological cause. The scope of this review is to propose a new classification of ejaculatory disorders, with special emphasis on epidemiology and subtyping of the most frequent: premature ejaculation (PE). There is growing agreement on definition, diagnosis, and treatment options. In many cases, ejaculatory disorders can be classified by psycho-neuro-uro-endocrine symptoms. Epidemiological data, new classifications and subtyping, together with new diagnostic procedures and the availability of pharmacological aids, place this topic in the mainframe of sexual medicine. This will soon demolish the barriers to seeking help perceived by patients suffering ejaculatory disorders.     

神经功能性不射精症诊断和电磁刺激振动按摩治疗的临床研究

目的　探讨功能性不射精症的诊断及有效治疗方法。　方法　在临床实验的基础上 ,用神经电生理技术测定了 2 50例功能性不射精症 (不射精组 )和 40例射精正常者 (对照组 )的阴部神经传导时间及速度 ;对 2 50例诊断为神经功能性不射精症用电磁刺激阴部神经并振动按摩阴茎治疗的同时 ,用神经电生理技术测定其阴部神经传导时间及速度。　结果　不射精组与对照组比较 ,阴部神经传导时间明显延长、传导速度明显减慢( P<0 .0 5)。经电磁刺激并振动按摩治疗 ,2 50例不射精组临床治愈 1 3 6例 ( 54 .4% ) ,显效3 9例 ( 1 5.6 % ) ,好转 2 3例 ( 9.2 % ) ,总有效率为 79.2 %。电磁刺激治疗前后相比 ,阴部神经传导时间及速度均有显著性差异 ( P<0 .0 5) ;治疗后与对照组相比 ,相应指标均无显著性差异 ( P>0 .0 5)。　结论　由于功能性不射精症的阴部神经传导性减退 ,难以达到射精阈值和触发射精反射 ,因此可定义或诊断为神经功能性不射精症。经过反复阴部神经电磁刺激并阴茎振动按摩治疗后 ,阴部神经传导性提高 ,易达射精阈值而触发射精反射     

Management of chronic scapholunate ligament injury

Scapholunate ligament is the most commonly injured ligament in the wrist and requires accurate diagnosis and treatment. It presents with pain, stiffness and can lead to carpal instability as well as degenerative arthritis if left untreated, with subsequent loss of function and disability. There are several management options currently available but there is no consensus on how best to manage a wrist with chronic sequelae of scapholunate ligament injury. This review explores available evidence in the literature on optimal treatment options including non-operative and operative procedures, relevant surgical techniques and their associated outcomes. A summary of the current concepts in the management of Chronic Scapholunate ligament injury is presented.     

Treatment of advanced carpometacarpal joint disease: trapeziectomy and hematoma arthroplasty

Some surgical treatment options of painful basal joint arthritis do not require complex arthroplasty or suspensionplasty techniques. Simple trapeziectomy with temporary pinning of a slightly overdistracted thumb metacarpal can provide reliable pain relief, good motion, and functional stability. Recent literature supports alternative options when compared with formal ligament reconstruction or suspensionplasty procedures. Simple trapeziectomy is associated with less morbidity due to shorter operative times and the lack of need for graft harvest and ligament reconstruction.     

Pudendal neuralgia after pelvic surgery using mesh: Case reports and laparoscopic pudendal nerve decompression

Persistent pain after vaginal mesh surgery is a rare and agonizing entity that has devastating consequences for the patient's quality of life. Many etiologies have been blamed including nerve injuries and entrapments. Pudendal neuralgia is a rare chronic neuropathic pain syndrome in the anatomical territory of the pudendal nerve. Various treatment options, such as medication management, physiotherapy, nerve blocks, decompression surgery and neuromodulation, have been used, but the most appropriate treatment for pudendal neuralgia has not yet been determined. In this article, we present two cases of postoperative pelvic pain thought to be secondary to injury or mechanical distortion of the pudendal nerve after rectocele repair using mesh and tension‐free vaginal tape sling. In cases of failed conservative treatment and of mesh removal surgery, laparoscopic pudendal nerve decompression and omental flap wrapping operation can be a treatment option for pudendal neuralgia.     

Subtraction hemiarthoplasty in basal joint arthritis: A case report

BACKGROUND Basal joint arthritis is a common disease which is especially present in postmenopausal women. A variety of procedures have been described once conservative treatment has failed. The purpose of our study is to present a novel surgical technique based on a clinical case with three-year follow-up which is highly effective, even after failure of previous procedures.CASE SUMMARY We present a case of a 39 year-old-woman who suffered from recurring,persistent, sharp left thumb pain for several years After two operative procedures, she presented again with intolerable, sharp pain over the trapeziometacarpal joint, and wished to proceed with a pain relieving procedure or arthroplasty. Intraoperatively, the articular surfaces appeared well, without any bare areas of bone or eburnation, resulting in the decision to perform a"subtraction hemiarthroplasty". A shortening osteotomy of the os trapezium was performed by removing a slice of 8-9 mm bone, without damaging the joint cartilages. The osteotomy was stabilized using two screws, the ligament and capsular tissue was suture imbricated, and a cut down on the translation and a dorsal radial ligament reconstruction were performed. Three years after the final procedure, a long-term follow-up demonstrates excellent results, pain free with full range-of-motion.CONCLUSION Subtraction hemiarthroplasty with ligament tightening imbrication and reconstruction of the radial ligament led to excellent results in motion and pain.     

Pelvic pain in urogynecology. Part II: treatment options in patients with lower urinary tract symptoms

Therapeutic options for chronic pelvic pain in women offer only a limited symptom relief. Especially in the patient with lower urinary tract symptoms (LUTS), where overlap of pain, storage and voiding symptoms is common, data on the efficacy of treatment of pain are limited. We conducted a literature review to detect articles which pertained to female patients with LUTS and pelvic pain and we included articles which evaluated the efficacy of the treatment of pelvic pain. Forty-one articles were detected, which included nerve stimulation (sacral and pudendal), intravesical instillations and injections, oral pharmacological treatments, periurethral injections as well as physical and manual therapy as treatment options. Only five controlled trials were found, which did not show superiority of the active treatment versus placebo. Although some treatment options show promising results in the treatment of pelvic pain in patients with LUTS, more randomised controlled trials are needed to confirm these results.     

Recalling superior mesenteric artery syndrome

BACKGROUND: Superior mesenteric artery syndrome is uncommon and characterized by postprandial epigastric pain, nausea, vomiting, anorexia and weight loss. The syndrome is caused by compression of the third part of the duodenum in the angle between the aorta and the superior mesenteric artery. This review updates etiology, epidemiology, diagnosis, treatment and outcome of the superior mesenteric artery syndrome. METHODS: Review of the literature. RESULTS: Frequently, predisposing medical conditions associated with catabolic states or rapid weight loss result in a decrease of the aortomesenteric angle and subsequent duodenal obstruction. External cast compression, anatomic variants and surgical alteration of the anatomy following spine surgery or ileoanal pouch anastomosis can also precipitate the syndrome. Once radiologic studies have established diagnosis, first-line treatment is usually conservative with jejunal or parenteral nutrition for restoration of the aortomesenteric fatty tissue. If conservative management fails, surgical options include open or laparoscopic duodenojejunostomy or duodenal mobilization and division of the ligament of Treitz. CONCLUSION: Superior mesenteric artery syndrome is clearly defined and frequently associated with a wide range of predisposing conditions and surgical procedures; clinicians have to consider this syndrome in such a setting. Larger studies are needed to better define the optimal treatment for this disease.     

Ejaculatory disorders may affect screening for prostate cancer

PURPOSE: Ejaculatory disorders will be experienced in most men who are treated for localized prostate cancer. Baseline rates of ejaculatory disorders are unknown in men at risk for prostate cancer. Therefore, we explored the prevalence of those disorders and associated bother in men without evidence of prostate cancer who participated in an annual prostate cancer screening event. MATERIALS AND METHODS: A cohort of 1,273 men without clinical evidence of prostate cancer completed the self-administered Danish Prostate Symptom Score for sexual dysfunction. This questionnaire quantifies the rate of reduced ejaculatory volume, ejaculatory pain and the rate of coexistent erectile dysfunction. RESULTS: Mean age was 57.6 years (range 40 to 89). Of all men 46% (563) had reduced ejaculatory volume and 66% (356) of affected men were bothered by this condition. Ejaculatory pain was reported in 11% (134) and 89% (118) of these men reported associated bother. Finally, 45% (554) reported erectile dysfunction and 73% (403) reported associated bother. Reduced ejaculatory volume was associated with erectile dysfunction (p<0.001) and advanced age (p<0.001). Ejaculatory pain was not associated with one of these variables. CONCLUSIONS: Virtually all men will be affected by ejaculatory disorders after definitive treatment for localized prostate cancer. Therefore, it is important to observe that half of these individuals already have underlying reduced ejaculatory volume before treatment. Moreover, 1 of 10 men will be affected by ejaculatory pain. Both disorders are a significant source of bother and should be considered when treatment related quality of life is assessed.     

Role of sacral ligament clamp in the pudendal neuropathy (pudendal canal syndrome): results of clamp release

Pudendal canal syndrome (PCS) is treated by pudendal canal (PC) decompression. We studied the hypothesis that failure of PCD to relieve anal and perianal pain could result from compression of the pudendal nerve (PN) not only in the PC but also in the sacral ligament clamp (SLC), i.e., in the space between sacrotuberous and sacrospinous ligaments. SLC release was performed in 21 patients with proctalgia who had not improved after PCD. PN terminal motor latency was higher than normal. The SLC release operation comprised entering the ischiorectal fossa through a para-anal incision, identifying the PN, and division of sacrospinous ligament. Treatment was successful in 17 patients and failed in 4. The former showed pain disappearance and improvement in fecal incontinence, perianal sensation, and anal reflex. Clinical manifestations and investigative results improved after SLC release in 80.9% of the cases. We assume that these results denote traumatization of the PN not only in the PC but also in the SLC.     

Nervus-pudendus-Neuralgie infolge Gewalttrauma

Pudendal neuralgia is a neuropathic disease which is predominantly caused by pelvic trauma with pressure or stretching strain of the pudendal nerve. The Nantes criteria are used for the differential diagnostics of this disease and therapy includes pressure-relieving and analgesic measures using laparoscopic or open decompression procedures. This article reports the case of a female patient who developed pudendal neuralgia following violent trauma to the pelvic and urogenital regions. Due to the complexity of the symptoms combined sacral and pudendal neuromodulation (PNM) was carried out. A direct comparison of neuromodulative techniques revealed that PNM was superior resulting in almost complete freedom from pain. The PNM procedure could represent a therapeutic option for treatment of pudendal neuralgia.     

Thumb carpal metacarpal arthritis

The thumb carpometacarpal (CMC) joint is the most common site of surgical reconstruction for osteoarthritis in the upper extremity. In patients older than age 75 years, thumb CMC osteoarthritis has a radiographic prevalence of 25% in men and 40% in women. The thumb CMC joint obtains its stability primarily through ligamentous support. A diagnosis of thumb CMC arthritis is based on symptoms of localized pain, tenderness and instability on physical examination, and radiographic evaluation. A reproducible radiographic classification for disease severity is based on the four-stage system described by Eaton. Nonsurgical treatment options include hand therapy, splinting, and injection. Surgical treatment is tailored to the extent of arthritic involvement and may include ligament reconstruction, metacarpal extension osteotomy, arthroscopic partial trapeziectomy, implant arthroplasty, and trapeziectomy with or without ligament reconstruction and tendon interposition.     

Pudendal nerve neuromodulation with neurophysiology guidance: a potential treatment option for refractory chronic pelvi-perineal pain

Refractory chronic pelvi-perineal pain (RCPPP) is a challenging entity that has devastating consequences for patient’s quality of life. Many etiologies have been proposed including pudendal neuralgia. Multiple treatment options are used but the reported results are sub-optimal and temporary. In this article, we present the technique of pudendal nerve neuromodulation with neurophysiology guidance as a treatment option for RCPPP. This technique is a two-step procedure that includes electrode implantation under neurophysiology guidance followed by the implantation of a permanent generator after a successful trial period. We report the cases of three women who underwent this procedure as a last-resort treatment option. After 2 years of follow-up, their symptoms are still significantly improved. No major complication occurred.     

Ejaculatory pain: a specific postherniotomy pain syndrome?

BACKGROUND: Sexual dysfunction due to ejaculatory and genital pain after groin hernia surgery may occur in approximately 2.5% of patients. However, the specific psychosexological and neurophysiologic characteristics have not been described, thereby precluding assessment of pathogenic mechanisms and treatment strategies. METHODS: Ten patients with severe pain-related sexual dysfunction and ejaculatory pain were assessed in detail by quantitative sensory testing and interviewed by a psychologist specialized in evaluating sexual functional disorders and were compared with a control group of 20 patients with chronic pain after groin hernia repair but without sexual dysfunction, to identify sensory changes associated with ejaculatory pain. RESULTS: Quantitative sensory testing showed significantly higher thermal and mechanical detection thresholds and lowered mechanical pain detection thresholds in both groups compared with the nonpainful side. Pressure pain detection threshold and tolerance were significantly lower in the ejaculatory pain group compared with the control group. 'The maximum pain was specifically located at the external inguinal annulus in all ejaculatory pain patients, but not in controls. The psychosexual interview revealed no major psychosexual disturbances and concluded that the pain was of somatic origin. All patients with ejaculatory pain had experienced major negative life changes and deterioration in their overall quality of life and sexual function as a result of the hernia operation. CONCLUSIONS: Postherniotomy ejaculatory pain and pain-related sexual dysfunction is a specific chronic pain state that may be caused by pathology involving the vas deferens and/or nerve damage. Therapeutic strategies should therefore include neuropathic pain treatment and/or surgical exploration.     

Benign prostatic hyperplasia (BPH) and prostatitis: prevalence of painful ejaculation in men with clinical BPH

OBJECTIVES: To determine the prevalence and importance of pain/discomfort on ejaculation (prostatitis-like symptom) in men with lower urinary tract symptoms (LUTS) diagnosed with clinical benign prostatic hyperplasia (BPH). PATIENTS AND METHODS: Baseline data from 5096 men reporting LUTS suggestive of BPH, and enrolled in the ALF-ONE study by general practitioners and urologists in Europe, Asia, Latin America, the Middle East and Canada, were analysed to determine the prevalence and significance of pain/discomfort on ejaculation. All the men were asked to complete the International Prostate Symptom Score (IPSS) questionnaire, the bother score (IPSS question 8), and the Danish Prostate Symptom Score sexual-function questionnaire (DAN-PSSsex) which assesses three symptoms (rigidity of erection, amount of ejaculate and pain/discomfort on ejaculation) and their bothersomeness. RESULTS: There were 3700 sexually active men who had an evaluable answer to the DAN-PSSsex question related to pain/discomfort on ejaculation. Of these, 688 (18.6%) reported pain/discomfort on ejaculation and 609 (88%) considered it was a problem. Patients with painful ejaculation had more severe LUTS and reported greater bother (P < 0.001). Of men with painful ejaculation, 72% reported erectile dysfunction, of whom 91% considered it a problem, and 75% reported reduced ejaculation, of whom 81% considered it a problem. By contrast, of men with no ejaculatory discomfort, 57% reported erectile dysfunction, of whom 79% considered it a problem, and 56% reported reduced ejaculation, of whom 57% considered it a problem. A history of urinary tract infection was reported by 12% of men in the ejaculatory pain group, compared with 7% in the LUTS-only group, while 5% of men in the ejaculatory pain group reported macroscopic haematuria, compared to 3% in the LUTS-only group. Men with ejaculatory pain were slightly younger, but there were no significant differences in duration of LUTS, history of acute urinary retention, prostate-specific antigen concentrations or maximum urinary flow rate compared to the LUTS-only group. CONCLUSIONS: Of sexually active men with LUTS suggestive of BPH, approximately 20% complain of specific prostatitis-like symptoms of pain/discomfort on ejaculation, and these men clearly differ from those who present with LUTS only. For most the symptom is a significant bother. Men with BPH and painful ejaculation have more severe LUTS and reported greater bother, and had a higher prevalence of erectile dysfunction and reduced ejaculation, than men with LUTS only. Evaluation and treatment strategies should address this population of men with symptoms suggestive of both prostatitis and BPH.     

Intra-abdominal laparoscopic pudendal canal decompression – A feasibility study

BACKGROUND: Pudendal canal syndrome (PCS) is induced by the compression or the stretching of the pudendal nerve within Alcock's canal. METHODS: Considering the difficulty and possible complications involved in exposing the pudendal canal and nerve by either transperineal, transgluteal or transischiorectal approaches, an intra-abdominal laparoscopic pudendal canal decompression (ILPCD) was employed. For this technique, 30 male adult human cadavers were examined. RESULTS: Measurements revealed an adequate working space in 16 (80%) of the 20 cadavers, while in four specimens the ischiococcygeus muscle was too large to be mobilized sufficiently. The mean working space was 24 mm with a range of 18 to 31 mm. It was considered that a working space of less than 20 mm would not be sufficient for manipulation of the instruments. With regards to pudendal nerve compression, it was observed that 7 (35%) of the 20 cadavers exhibited anatomic signs of PCS. In five (25%) specimens, the compression was observed between the sacrospinous and sacrotuberous ligaments, while the other two (10%) exhibited a broader compression, by the falciform portion of the sacrotuberous ligament. Under the guidance of a laparoscope, the peritoneum was cut laterally to the bladder, and fascia pelvis was identified. The latter was split and the internal iliac vein was traced to the opening of the pudendal canal allowing clear visualization of its contents. Subsequently, either the sacrospinous or sacrotuberous ligament was cut. CONCLUSIONS: Considering that none of the surgical procedures currently used are known to completely improve all the symptoms of PCS, ILPCD could theoretically reduce stretching of the pudendal nerve.     

Die mediale OSG Instabilität

The deltoid ligament is the primary stabilizer of the ankle joint. Injuries of the deltoid ligament are more frequent than assumed but still are often missed. Inadequate treatment can lead to chronic pain, instability and ankle arthritis. The deltoid ligament is strongly connected to the spring ligament. Patient history and clinical assessment as well as magnetic resonance imaging help identify the injured structures. Treatment options range from immobilization in a cast to ligament reconstruction using a free tendon.     

Laparoscopic decompression as treatment for median arcuate ligament syndrome

Median arcuate ligament syndrome (MALS) is a rare disorder due to coeliac trunk compression by the median arcuate ligament, resulting in coeliac artery stenosis characterised by chronic, recurrent abdominal pain. Patients with MALS are often middle-aged females presenting with a triad of postprandial epigastric pain, weight loss and abdominal bruit. It is a diagnosis of exclusion and confirmed by computed tomography or magnetic resonance imaging. Laparoscopic or open surgical decompression are the only treatment options in MALS. We present two cases of MALS treated by laparoscopic decompression as well as a literature review on this treatment.     

Therapie der patellaren Instabilit?t bei Kindern und Jugendlichen

To address recurrent patellar instability in children and young adolescents a variety of therapeutic options exist either as non-operative or operative treatment. Recent options, such as reconstruction of the medial patellofemoral ligament have evoked a new focus of attention on this topic. The intention of this article is to present diverse therapeutic options and to evaluate them by reference to the current literature.     

Post-operative pain management in orthopaedic surgery and traumatology

Provision of sufficient post-operative pain therapy is an obligation in the clinical management of patients. A wide range of medical, technical and organizational options is used to improve post-operative pain management in orthopaedic surgery. Measurement of pain is as important as the correct use of analgesics and application techniques. Standardized pain therapy algorithms should facilitate autonomous treatment of patients. Additional procedures like patient-controlled analgesia or local catheter for pain are necessary for individualized or operation-specific pain therapy. The balanced combination in postoperative pain therapy could reduce side effects and complication rates, increase mobility and enhance patient satisfaction.