脊髓损伤与男性不育(英文)

脊髓损伤 (SCI)通常会对育龄男性造成一定的影响。脊髓受损后的男性大多会在以下方面发生问题 :如勃起和射精功能障碍 ,精子发生受损 ,精子存活力、活率及形态异常 ,泌尿生殖系统感染以及内分泌异常。本文将从病理生理、评价和治疗等方面对脊髓损伤引起的男性不育症进行论述。脊髓损伤可对精浆产生影响并加速精液氧化 ,从而使得SCI男性的精液质量下降。本文还将对用于SCI男性的精子复苏技术和辅助生育技术所取得的进展进行讨论。     

Male Infertility Following Spinal Cord Injury

ABSTRACT

Ejaculatory dysfunction and poor semen quality are responsible for male infertility following spinal cord injury (SCI). Techniques which have been used to obtain semen include intrathecal neostigmine, subcutaneous physostigmine, direct aspiration of sperm from the vas deferens, vibratory stimulation and electroejaculation. Vibratory stimulation and electroejaculation are most widely used in the United States and have a 50–90% success rate at obtaining semen. Poor semen quality following SCI has been attributed to stasis of semen, testicular hyperthermia, urinary tract infections, sperm contact with urine, possible changes in the hypothalamic-pituitary axis, chronic use of various medications and possible sperm antibodies. The Outlook for having a child following SCI continues to improve with advancements in obtaining and processing sperm and assisted reproductive technologies.     

Evaluation and Treatment of Erectile Dysfunction Following Spinal Cord Injury: A Review

ABSTRACT

The majority of spinal cord injured (SCI) men with upper motor neuron lesions have reflex erections. However, these erections are often not adequately sustained making it difficult if not impossible to have intercourse. The majority of SCI men with lower motor neuron lesions do not have erections. Penile implants are effective in producing erections following SCI. However, they have the disadvantages of being a surgical procedure and of having the risk of infections and erosion of the implant through the skin. Intracavernous injections of papaverine and phentolamine and vacuum erection devices have recently been added to our armamentarium of ways to treat erectile dysfunction. A major concern particularly in SCI men is that papaverine and phentolamine may cause prolonged erections in SCI men. We presently have little data on the use of vacuum devices in SCI men, but preliminary reports on those who are using FDA-approved devices appear promising. (J Am Paraplegia Soc 1991; 14: 43–51)     

男性性功能障碍与脊髓损伤及其他神经系统疾病

男性性功能是人与环境之间错综复杂的相互作用过程。性刺激的认识整合和生理反应必须依赖于神经系统的功能。因此 ,中枢或外周神经功能紊乱也许会损伤男性性功能。本文对男性性活动的正常的神经解剖学、流行病学、病理生理学 ,及由于脊髓损伤、脑血管疾病、多发性硬化和帕金森病等引起的性功能障碍进行了综述     

睾丸扭转误诊后导致男性不育及勃起功能障碍(英文)

睾丸扭转在25岁以下的男性中其发病率约为1/4 000,其高发人群为新生儿和进入青春期的青少年。睾丸扭转的误诊率为4%,非同期的双侧睾丸扭转被误诊的发病率没有报导。本文报道1例由于双侧睾丸扭转误诊后导致的睾丸功能衰竭、性腺功能低下及勃起功能障碍。患者在睾丸扭转10年后才因不育和勃起功能障碍就诊,精液分析检查为无精症,血清中的睾酮水平降低到去势的水平(0.14 nmol/L)。其不育为永久性,其勃起功能经睾酮替代和使用西地那非后得以恢复。     

Efficacy And Safety Of Oral Sildenafil In Men With Erectile Dysfunction And Spinal Cord Injury

Abstract

Objective: To assess the efficacy of sildenafil in men with spinal cord injury (SCI) and erectile dysfunction (ED).

Methods: Seventeen men with SCI were selected from February to September 1998 for sildenafil treatment of ED. The initial dose of 25-mg was increased by 25-mg increments as needed. Patients underwent baseline physical examination and answered questions from the abridged International Index of Erectile Function before and during therapy.

Results:Sixteen patients tolerated therapy; 1 developed hypotension and dis continued therapy. There was significant improvement in erectile function (P < .05) after 5.3 ± 2.2 months when compared with baseline or previous therapies (P < .05). Of the 17 patients,94% recommended sildenafil to others. Six of these16 patients were available for long-term follow-up. There was further significant improvement in quality of erection (P < .05), but no change in satisfaction.

Conclusion:Sildenafil is effective and well tolerated in men with SCI and ED.     

Patient Preference for ln-Exsufflation for Secretion Management with Spinal Cord Injury

Abstract

An important aspect of respiratory management in patients with acute spinal cord injury (SCI) is the elimination of secretions. Methods utilized for secretion management in patients with SCI includes endotracheal suctioning and mechanical in-exsufflation (MI-E). Surveyed here is a group of patients with SCI who have had experience with both endotracheal suctioning and MI-E via tracheostomy, to determine patient opinions and experiences regarding the 2 techniques. The survey was administered to 18 patients with traumatic SCI, with an average age of 34. 72% were ASIA A, 22% percent were ASIA B, and 6% were ASIA C, with neurological level of injury ranging from C-1-T-3. Results indicate that patients found MI-E significantly less irritating (p < 0.001 ), less painful (p < 0.001 ), less tiring (p = 0.01 ), and less uncomfortable (p < 0.001) than endotracheal suctioning. In a direct comparison, 89% of patients preferred mechanical in-exsufflation to suctioning. In addition, 89% of patients found MI-E faster, 78% found MI-E more convenient, and 72% found MI-E more effective than suctioning. This study demonstrates that all measured aspects of patient experience are more positive for MI-E than for endotracheal suctioning.     

细胞凋亡与男性勃起功能障碍

勃起功能障碍(ED)是男性,尤其是老年男性的常见病和多发病。目前,对于引起ED的机制了解尚不深入。越来越多的研究发现勃起组织的过度凋亡是引起ED的重要机制之一。多数ED的危险因素均可以引起阴茎勃起组织的过度凋亡,从而影响勃起功能。本文就细胞凋亡的机制、凋亡在ED中的作用及凋亡与ED的危险因素糖尿病、高脂血症、海绵体神经损伤和衰老之间的关系作一综述。     

NADPH氧化酶与男性勃起功能障碍

勃起功能障碍是男性的常见病和多发病。目前认为氧化应激是引起阴茎勃起功能障碍的重要机制之一。NADPH氧化酶广泛存在于机体多个系统(包括阴茎组织),发挥重要的生理功能。在多种病理情况下,NADPH氧化酶可以在阴茎组织中催化合成大量活性氧,导致过度氧化应激,从而影响阴茎勃起功能。本文就NADPH氧化酶的组成、同源物、活性调节、生理功能、在勃起功能障碍中的作用以及在勃起功能障碍治疗中的应用作一综述。     

Epidemiology of Current Treatment for Sexual Dysfunction in Spinal Cord Injured Men in the USA Model Spinal Cord Injury Centers

ABSTRACT

This study is a prospective multicenter cooperative survey of the evaluation and treatment of erectile dysfunction in men with spinal cord injury (SCI). Uniform database questionnaires were completed prospectively by patients seeking therapy for erectile dysfunction. Eighty-five SCI men aged 17–68 years (mean age=26±17) were enrolled. Mean duration of traumatic SCI was 3±3.2 years (Range=0.3–18 years). The level of injury was cervical in 20 patients, thoracic in 31, lumbar in 29 and sacral in five. Patients were fully evaluated and then counseled as to their therapeutic options. Twenty-eight chose to use a vacuum erection device (VED), 26 preferred pharmacological penile injection and five used both intracorporeal therapy and VED. The remainder were managed with marriage and sexual counseling in 10 patients, three underwent penile prosthesis placement and two used topical pharmacotherapy. Four patients used other forms of treatment and in nine no therapy was recommended. Of the patients that used pharmacologic injection only, 74 percent used papaverine as a single agent, 20 percent used papaverine with phentolamine, five percent used prostaglandin E (PGE1) alone and one percent used a mixture. Patients using injection therapy report sexual intercourse a mean of 3±3.4 times per month as compared with 5±3.2 times per month in those using VED. Five intracorporeal injection patients developed priapism while two patients using the VED developed subcutaneous bleeding and one developed penile ischemia. We conclude that although a spectrum of erectile dysfunction treatment is present among SCI centers, VED and pharmacological penile injection are by far the two most popular methods of treatment and papaverine is the most common drug. The incidence of complications is small in the model centers. (J Spinal Cord Wed; 19:186–189)     

Testosterone and Erection: Practical Management for the Patient with Erectile Dysfunction

Although erectile dysfunction (ED) and testosterone deficiency syndrome are two independently distributed disorders, there is a degree of overlap between them. Testosterone replacement therapy, either alone or combined with other treatments such as a phosphodiesterase type 5 (PDE5) inhibitor, may therefore be useful in some men with ED. Corrective treatment of ED includes sex therapy, risk factor modification, chronic usage of PDE5 inhibitors, and testosterone replacement. Studies have shown that testosterone replacement in men with hypogonadism improves libido and erectile function in a significant proportion of cases. If corrective treatment fails or is not indicated, symptomatic treatments such as oral PDE5 inhibitors or intraurethral/intracavernous therapy are available. PDE5 inhibitors are an excellent first-line choice, although a significant proportion of men still fail to respond to monotherapy. Testosterone deficiency may be overlooked in some men with ED and, because this may be associated with lower expression of PDE5 in the penis, it could result in failure of PDE5 inhibitor therapy. Recent recommendations, therefore, suggest the need for combination therapy in some patients. In conclusion, all men presenting with ED should have their testosterone levels checked, and testosterone replacement should be considered in those with low levels. Testosterone replacement should also be considered in hypogonadal men with ED not responding to PDE5 inhibitors. If erections remain insufficient after 3 mo, a combination of testosterone and a PDE5 inhibitor may be beneficial.     

急性颈髓损伤围手术期处理探讨

目的 :探讨急性颈髓损伤围手术期处理 ,为降低手术危险性、促进功能康复提供依据。方法 :对我院 1989～ 1999年收治 5 0例手术病人进行回顾性分析。结果 :术前术后并发症发生率为 96.4%。术中 ,院内无死亡病人。按Frenkle标准优良率为 86.95 %。结论 :急性颈髓损伤病人病情复杂。术前对病人并发症、并发病积极处理 ,严格掌握手术时机。     

Early Surgical Management of Acute Spinal Cord Injury

ABSTRACT

Fibrocartilaginous emboli to spinal cord vessels is an apparently rare cause of spinal cord injury. A review of the medical literature reveals only 24 reported cases, none of which were noted prior to 1961. The authors have reviewed an additional, but as yet unpublished, case. The majority of patients presented with the acute onset of pain located around the vertebral column which was followed by progressive paresis/paralysis and respiratory insufficiency. Minor trauma to the vertebrae prior to onset was noted in most cases. The time to maximum neurologic deficit (typically paraplegia or quadriplegia) ranged from minutes to 24 to 48 hours. In all but one case the spinal cord injury resulted in death within 11 months of onset with a median of 2.5 to 4 months. One patient lived six years and seven months with respiratory support. In yet another case, a fibrocartilaginous embolus to a sacral nerve root was found as an incidental finding at autopsy. The incidence of both asymptomatic and clinically significant emboli may be more common and depends on the awareness of the medical community to consider this in the differential diagnosis of spinal cord injury. (J Am Paraplegia Soc 1990; 13: 18–23)     

Surgical Management of Urolithiasis in Spinal Cord Injury Patients

Urolithiasis is a common condition in patients with spinal cord injury (SCI). Surgical management of stones in this population is more challenging and associated with lower clearance rates than the general population. The rate of complications – specifically infectious complications – is also high due to the chronic bacterial colonization. Shock wave lithotripsy (SWL) has a low clearance rate of 44–73 %. Percutaneous nephrolithotripsy is indicated for larger nephrolithiasis, but multiple procedures may be required to clear the stones. Ureteroscopy has been associated with low success rates because of difficulty in obtaining ureteral access. Historically, bladder stones were managed with open surgery or SWL. Recently, good results have been reported with the combination of endoscopic and laparoscopic techniques. Surgical management of urolithiasis in patients with SCI should be performed in high-volume centers in light of the technical challenges and higher rate of perioperative complications.     

Management of Pain in Persons With Spinal Cord Injury

Abstract

Pain is a common complaint following spinal cord injury (SCI). While nociceptive pain can often be effectively managed by traditional therapies, neurogenic pain is more refractory to treatment. Several categories of pain are recognized in persons with SCI and an accurate diagnosis will improve the therapeutic response. Nociceptive pain is usually perceived to be above or at the level of the cord lesion and is most commonly related to musculoskeletal pathology. Neurogenic pain is usually felt by the patient at or below the neurological level and may be classified as radicular, segmental or deafferentation central pain, depending on its hypothetical origin and the clinical presentation. Management requires recognition of all factors that may influence pain perception and knowledge of the entire range of therapeutic options. (J Spinal Cord Med 1997; 20:186-199)     

Urolithiasis Associated With Indinavir in A Patient With Spinal Cord Injury

Abstract

Objective: To report a case of indinavir-induced urolithiasis, and the greater risk of this occurrence in individuals with spinal cordinjury (SCI) who require fluid restriction for an intermittent catheterization program (ICP).

Methods: Case report.

Results: A 38-year-old man with a T4 ASIA A SCI (according to the American Spinal lnjury Association classification scale) and human immunodeficiency virus (HIV) infection wasusing an ICP and taking indinavir (a protease inhibitor) as part of his antiviralregimen.Cystoscopy was performed to rule out recurrent urethral condylomata. He was found to haveabladder stone measuring 0.5cm × 0.5 cm × 0.3 cm, which, on analysis, was composed ofindinavir (100% exterior, 90% interior). The bladder stone wasremoved under direct visualization. The plain abdominal radiograph did not reveal any stones.

Conclusion: lndinavir is a frequently used drug for the treatment of HIV that has the potential to induce urinary Iithiasis. This isparticularly problematic for individuals with SCI who are on fluid restriction and an ICP. Therefore, cystoscopy and monitaring forindinavir-induced urolithiasis should be undertaken in individuals with SCI who are takingindinavir. Considerations include switchingto a different protease inhibitor or choosing an entirely new HIV drug cocktail with less potential for urolithiasis.     

Neurogenic Bowel Management in Adults with Spinal Cord Injury

Abstract

Background: Individuals with spinal cord injury (SCI) have a lifelong increased risk of systemic infection, which may be associated with episodes of life-threatening bacteremia. Information concerning specific organisms causing bacteremia, the sites of primary infection, and clinical predictors for mortality are necessary to provide optimal treatment.

Methods: A retrospective review of positive blood cultures collected over a 3 2-month period in chronic SCI patients treated at the Veterans Affairs Medical Center SCI Unit.

Results: One hundred and twenty-three episodes of bacteremia occurred in 63 patients during 83 hospitalizations; 30 patients had multiple episodes of bacteremia. There were 1 ,644 admissions during this period, yielding an incidence of bacteremia of 7 .5% (5.8% after excluding positive cultures that were believed to be caused by contaminants). The patients (31 with paraplegia and 32 with quadriplegia) had a mean age of 59 ± 2 years, and a mean duration of injury of 23 ± 2 years. Bladder management technique consisted of indwelling bladder catheter (n = 53), ileal conduit (n = 6), intermittent catheterization (n = 2), and spontaneous voiding (n = 2). Episodes of bacteremia were nosocomial in 89 out of 123 episodes. Multiple debilitating factors were present, including pressure ulcers in 3 6 out of 63 patients, chronic ventilator dependency in 5 out of 63 patients, recent surgical procedures in 17 out of 63 patients, unde rlying malignancy in 5 out of 63 patients, and evidence of malnutrition in 2 9 out of 63 patients (serum albumin concentration < 2.5 g/dl). Early mortality rate (death within 30 days of bacteremia) occurred in 8 out of 63 patients (13 %) and late mortality (> 1 month following a bacteremic episode) occurred in 1 0 additional participants, such that total mortality was 1 8 out of 63 (2 9%). The sources of bacteremia were urinary tract infection (n = 3 9), presumed contaminant (n = 28), decubitus ulcers (n = 21 ), intravascular catheter (n = 1 9), pneumonia (n = 5), and other (n = 11 ). Gram-negative rods accounted for 2 6 out of 3 9 episodes of bacteremia from a urinary source. Methicillin-resistant Staphylococcus au reus, methicillin-sensitiveS au reus, and coagulase-negative staphylococci were the predominant organi sms when intravascular catheters or pressure ulce rs were the source of bacteremia.

Conclusion: In this population, bacteremia predominantly was caused by hospital-associated organisms, and occurred mainly in malnourished patients who required hospitalization for major unde rlying debilitating conditions, particularly pressure ulcers. Chronic indwelling bladder cathet e rs and chronic vascular catheter usage also were highly prevalent in patients with bacteremic episodes. Hypoalbuminemia was the strongest independent predictor for mortality.