Penile neuropathy in insulin-dependent diabetes mellitus

Assessment of changes in penile sensation by electrophysiological study after radical prostatectomy: A pilot study

Background:

To evaluate the changes in penile sensation by electrophysiological tests in patients who underwent radical prostatectomy (RP) and to demonstrate the role of dorsal penile nerve injury in postoperative erectile dysfunction.

Materials and methods:

Twenty-six volunteer patients who were eligible for RP were included in the study. Preoperative penile sensory electromyography and the International Index of Erectile Function-5 (IIEF-5) questionnaire were done for each patient. Erectile function assessment and electrophysiological evaluation of penile sensation were repeated at postoperative 3rd and 6th months.

Results:

Postoperative IIEF-5 scores and electromyography values were significantly lower than preoperative findings (p < 0.05). The IIEF-5 scores in the nerve sparing-RP (NS-RP) group were significantly higher than the non-nerve sparing-RP (NNS-RP) group in the postoperative period. Nerve conduction velocity values in the NS-RP group were also higher than the NNS-RP group at the postoperative 3rd and 6th months. However, these changes were not statistically significant (p > 0.05).

Conclusions:

Patients who underwent RP have decreased penile sensation due to cavernous nerve damage and a possible dorsal penile nerve injury. The decrease of penile sensation may be associated with postoperative erectile dysfunction.

Measurement of electrochemical conductance of penile skin using Sudoscan®: A new tool to assess neurogenic impotence

OBJECTIVES

To investigate the value of electrochemical skin conductance (ESC) measurement at penile level using Sudoscan^® for the diagnosis of neurogenic impotence in diabetics.

METHODS

The following neurophysiological parameters were assessed in 25 male diabetics who complained of impotence and 25 age-matched normal male subjects without erectile dysfunction (age range: 29-70 years): ESC, sympathetic skin responses (SSR), warm detection thresholds (WDT), and cold detection thresholds (CDT) for the penis and the feet, vibration detection thresholds (VDT) for the penis, and sensory nerve conduction study of the dorsal nerve of the penis (DNP) with sensory nerve action potential (SNAP) recording.

RESULTS

Diabetic patients with impotence differed from controls with regard to most neurophysiological results at both penile and foot levels. Among penile innervation variables in the group of impotent diabetics, penile ESC was found to be the most frequently abnormal (80% of patients), followed by penile WDT, CDT, and DNP-SNAP amplitude (52% of patients), and then penile SSR amplitude and VDT (44% of patients). Various combinations of abnormalities were observed: penile ESC was the only abnormal test in 2 patients, while all tests were abnormal in 2 patients and remained normal in only one patient.

CONCLUSION

Erectile dysfunction is common in diabetic men, but the diagnosis of a neurogenic origin is challenging. This study showed that ESC measurement using Sudoscan^® is feasible and more sensitive than SSR recordings to show penile sympathetic innervation impairment. This new test should be further studied to better define its diagnostic accuracy and clinical correlates.

RETRACTED: The effect of the mode of delivery on the quality of life, sexual function, and sexual satisfaction in primiparous women and their husbands

This article has been retracted: please see Elsevier Policy on Article Withdrawal (https://www.elsevier.com/about/our-business/policies/article-withdrawal). This article has been retracted at the request of the Editor-in-Chief. Following the retraction of Dr. Safarinej ad's work by other journals, The Journal of Sexual Medicine has undertaken an extensive re-review of all papers Dr. Safarinejad published with the journal. Following an intensive re-evaluation and close scrutiny of the manuscripts, our expert reviewers raised multiple concerning questions about the methodology, results, and statistical interpretation as presented in this article. Dr. Safarinejad was contacted to provide his original data and offer explanations to address the concerns expressed by the reviewers. Dr Safarinejad chose not to respond. The co-authors of the article have also been contacted and did not respond either. Consequently, we can no longer verify the results or methods as presented and therefore retract the article.

Ultrastructural changes of penile cavernous tissue in multiple sclerotic rats

INTRODUCTION

Multiple sclerosis (MS) is one of the important risk factors resulting in erectile dysfunction (ED). The ultrastructure of corpus cavernous of the penis have an important role in the mechanism of erection.

AIM

It is suggested that different medical conditions produce similar degenerative tissue responses. We investigated the ultrastructural changes of penile cavernous tissue and its association with ED in multiple sclerotic rats.

METHODS

After induction of multiple sclerosis in rat, maximum intracavernosal pressure/mean arterial pressure (ICP(max)/MAP) in the severity multiple sclerotic rats (group A),moderate multiple sclerotic rats (group C), and age-matched control rat (group B) were observed and compared. The ultrastructure of the penile cavernous tissue was studied by transmission electron microscope. Expression of neuronal nitric oxide synthase (nNOS) in penile tissue were examined immunohistochemically.

MAIN OUTCOME MEASURES

Severity MS (score 3) not only significantly decrease the ICPmax/MAP x 100 and the expression of nNOS, but also might affect the ultrastructure of the penis.

RESULTS

The ICP(max)/MAP x 100 in group A was significantly less than in group B and group C at 3 V (5.65 +/- 1.78, 20.49 +/- 5.84, and 12.78 +/- 5.76, respectively) and at 5 V (6.70 +/- 1.39, 23.66 +/- 5.19, and 16.95 +/- 3.31, respectively) stimulation voltage, respectively (P < 0.05). Significant ultrastructral pathological changes characterized by degeneration and demyelination singularly in Schwann cells without significant ultrastructural change of smooth muscle cells and endothelium cells were observed in penile cavernous tissue of group A rats.

CONCLUSIONS

The function of penile erection is affected by MS, and the ultrastructural pathological changes of the penile cavernous tissue may be one of the important mechanisms of ED caused by severity MS.

Anatomy of pudendal nerve at urogenital diaphragm--new critical site for nerve entrapment

OBJECTIVES

To investigate the relations of the pudendal nerve in this complex anatomic region and determine possible entrapment sites that are accessible for surgical decompression. Entrapment neuropathies of the pudendal nerve are an uncommon and, therefore, often overlooked or misdiagnosed clinical entity. The detailed relations of this nerve as it exits the pelvis through the urogenital diaphragm and enters the mobile part of the penis have not yet been studied.

METHODS

Detailed anatomic dissections were performed in 10 formalin preserved hemipelves under 3.5x loupe magnification. The pudendal nerve was dissected from the entrance into the Alcock canal to the dorsum of the penis. The branching pattern of the nerve and its topographic relationship were recorded and photographs taken.

RESULTS

The anatomic dissections revealed that the pudendal nerve passes through a tight osteofibrotic canal just distal to the urogenital diaphragm at the entrance to the base of the penis. This canal is, in part, formed by the inferior ramus of the pubic bone, the suspensory ligament of the penis, and the ischiocavernous body. In two specimens, a fusiform pseudoneuromatous thickening was found.

CONCLUSIONS

The pudendal nerve is susceptible to compression at the passage from the Alcock canal to the dorsum of the penis. Individuals exposed to repetitive mechanical irritation in this region are especially endangered. Diabetic patients with peripheral neuropathy can have additional compression neuropathy with decreased penile sensibility and will benefit from decompression of the pudendal nerve.

Sexual dysfunction in women with diabetes mellitus

Sexual problems in men with diabetes mellitus are common and often result from diabetic complications. However, although diabetic complications are similar in both sexes, little attention has been given to the effects of diabetes on female sexuality and sexual function. It is reasonable to suggest that women with diabetes will experience sexual problems due to neuropathy, endocrine changes and vascular complications. However there is little research into the physical effects of diabetes on female sexual function. Reduced vaginal lubrication in women with diabetes has been reported yet this is rarely documented as a sexual problem. Previous studies in women with diabetes may also neglect the importance of the subjective qualities associated with female sexuality and sexual expression.

Erectile dysfunction: symptom or disease?

Erectile dysfunction (ED) has been defined by the National Institute of Health (NIH) as the inability to achieve and/or to maintain an erection for a sufficiently long period of time so as to permit satisfactory sexual intercourse. ED affects millions of men throughout the world and could have a negative influence on the individual's well-being as well as on the quality of life of affected subjects. Discordant data have been reported on ED epidemiology with prevalence ranging from 12% to 52%, probably depending on the different criteria utilized in the different studies for patient selection. ED is a symptom, sometimes the first, of different pathological conditions. In 15.7% of 45-yr-old patients with vascular ED a dynamic ergometric test has shown electrocardiographic alterations in the absence of any cardiac symptom. In 15% of the patients with ED, high fasting glucose plasma levels are discovered for the first time and in patients with ED and normal fasting glucose plasma levels the prevalence of undiagnosed diabetes mellitus is 12.1% after an oral glucose tolerance test (OGTT). The different risk factors are often additive in the possible development of systemic vasculopathy, neuropathy and ED. ED, underestimated in clinical practice due to archaic prejudice which hinders the patient in spontaneously revealing the problem and the physicians in investigating it, can mark the point where evaluation and prevention of important diseases (such as diabetes, arterial hypertension, atherosclerosis) hitherto unknown by the patients, can begin. The physicians' cultural baggage must include the ability to identify the pathology that can determine ED and the ability to program a specific diagnostic workup. In this paper the different specialists involved in ED diagnosis agreed that a clinical approach which allows the identification of systemic pathologies contributing to the development of ED constitutes an improvement in disease prognosis and may either induce a spontaneous reduction of ED or facilitate its specific treatment.

Prevalence of and risk factors for erectile dysfunction in Hong Kong diabetic patients

AIM

To estimate the prevalence of erectile dysfunction (ED) in Chinese diabetic men and to identify its risk factors, we carried out a cross-sectional survey of 500 Chinese diabetic men attending a community hospital diabetic clinic in Hong Kong.

METHODS

Patients were interviewed and asked to report on their experience of ED as defined in the National Institutes of Health Consensus Conference 1993. Diabetic complications and patient clinical data were obtained from patients' medical records.

RESULTS

Of the 486 patients studied, the prevalence of ED was 63.6% (95% confidence interval 59.3-67.9%). The prevalence of ED increased with age, from 33.3% to 73.8% for diabetic men aged between 21 and 80 years (P = 0.001). Severity of ED also increased with age. Among diabetic men with ED, there was no report of complete ED for diabetic men aged 40 years and below, whereas the proportion of patients with complete ED increased from 7.4% to 71.1% between the ages of 41 and 80 years. ED occurred early in the course of the disease, with a prevalence increasing from 56.0% in men with diabetes mellitus (DM) for < 5 years to 72.0% in those with DM for > 20 years (P = 0.038). Duration of DM was also associated with severity; the proportion of patients with complete ED increased from 30.8% for those with DM for < 5 years to 72.2% for those with DM for > or = 20 years (P < 0.001). Using logistic regression analysis, DM duration, diabetic complications including retinopathy, abnormal albuminuria and sensory neuropathy, and higher level of education were associated with a higher risk of ED. By polychotomous logistic regression, age was the only factor found to be associated with the severity of ED, after adjusting for other variables.

CONCLUSIONS

Chinese diabetic patients have a prevalence of self-reported ED that appears to be higher than that of Western populations. This may be due to cultural differences and the association of abnormal albuminuria and hypertension.

Male sexual function and its disorders: physiology, pathophysiology, clinical investigation, and treatment

This review is designed to help the reproductive endocrinologist integrate his or her professional activity with those of other disciplines including urology, radiology, neurology, and psychology in order to successfully manage all of the inseparable aspects of male sexual and reproductive functioning. Significant advances in the field of male sexual physiology and pathophysiology and new methods of investigation and treatment of male sexual disorders are outlined. The review synthesizes available data on the following: norms of sexual organs, aging and sexuality, role of central and peripheral neurochemicals in each stage of the sexual cycle, role of corporeal smooth muscles in the hemodynamic control of erection and detumescence, influence of psychological factors, drugs, and disease on all aspects of sexual functioning, and use of nocturnal penile tumescence monitoring, imaging investigations, and neurophysiologic studies in the diagnostic workup of males with sexual dysfunction. Clinical algorithms are presented where appropriate. Extensive discussions on newly developed strategies in psychological and behavioral counseling, drug therapy, tissue engineering, nonsurgical devices, and surgical treatments for all forms of sexual disorders are also provided. Lastly, the effect of sexual dysfunction and its treatment on quality of life in affected men is addressed, along with recommendations for future research endeavors.

Perineurium inflammation and altered connexin isoform expression in a rat model of diabetes related peripheral neuropathy

Diabetes related peripheral neuropathy involves both somatic and autonomic nerves and leads to an array of debilitating abnormalities. Mechanisms may include decreased neuronal conductance, reactive oxygen species, and decreased performance of the perineurium blood-nerve barrier. Here we studied the perineurium characteristics of the dorsal penile nerve in a rat model of diabetes related peripheral neuropathy. Immunohistochemistry showed extensive and perineurial cell-specific nitric oxide synthase2 staining in diabetic animals as compared to age matched controls (P<0.05); however no apparent difference in immunostaining pattern was observed for 3-nitrotyrosine (a stable biomarker of peroxynitrite formation). Significant reductions in connexins 32 and 26 were seen in the diabetic perineurium with no detectable levels of connexin 43 in either control or diabetic dorsal nerve. These data provide new evidence of perineurial cell inflammatory responses and altered gap junction protein expression during diabetes related neuropathies and suggests that strategies to protect this cell type may have therapeutic value.

Relationship between penile thermal sensory threshold measurement and electrophysiologic tests to assess neurogenic impotence

OBJECTIVES

Erectile function is usually assessed by neurophysiologic tests such as the bulbocavernosus reflex or pudendal nerve somatosensory evoked potentials. These tests investigate only large nerve fibers, although erection depends on autonomic nerve fibers, which are of small diameter. Warm and cold sensory fibers have similar calibers as the autonomic nerve fibers, and their integrity can be reliably evaluated by the measurement of thermal sensory thresholds. We studied penile thermal sensory testing in parallel with standard electrophysiologic tests to assess their sensitivity in the diagnosis of penile neuropathy.

METHODS

Twenty-five normal male subjects without erectile dysfunction or evidence of diffuse neuropathy (group 1) and 35 diabetic patients who complained of impotence (group 2) were studied. Erectile function was quantitated using the erectile dysfunction symptom score. Warm, cold, and vibratory sensory thresholds were assessed on the dorsal aspect of the penis. In addition, penile sympathetic skin responses and pudendal nerve somatosensory evoked potentials were recorded.

RESULTS

We found a significant difference between the two groups in the erectile dysfunction symptom score (P <0.0001), cold threshold (P = 0.0007), and warm threshold (P = 0.0025), but not for the other parameters. The erectile dysfunction symptom score correlated with the penile warm and cold thresholds (P = 0.0006 and 0.002, respectively).

CONCLUSIONS

Thermal thresholds assess small nerve fiber damage, which can indirectly reflect autonomic disturbances, particularly in the context of a diffuse neuropathy such as diabetic polyneuropathy. Penile thermal sensory testing correlated strongly with the clinical evaluation of erectile function and is a new and promising tool for the diagnosis of neurogenic impotence.

Sexual dysfunction in patients with benign prostatic hyperplasia

Two of the most common problems presenting to urologists are benign prostatic hyperplasia and sexual dysfunction, with an increasing number of patients presenting for treatment as a result of the proliferation of less invasive therapies. How such therapies for lower urinary tract symptoms affect sexual function in men is important to both urologists and their patients, and is the focus of this review.

Peripheral distribution of the human dorsal nerve of the penis

PURPOSE

The integrity of the dorsal nerve of the penis is crucial for normal erectile and ejaculatory function. To our knowledge a description of this nerve along the phallus has not been formally described. We illustrate the distribution of the dorsal nerve of the penis to the penile shaft, anterior urethra and glans.

MATERIALS AND METHODS

Neuroanatomical dissections were performed on 28 cadaver penis specimens. Electrodiagnostic testing was conducted on 10 healthy male subjects to confirm the anatomical findings.

RESULTS

The dorsal nerve of the penis consists of 2 populations of axons, one to innervate the penile shaft and urethra, and the other to innervate the glans. Stimulation of the urethra resulted in responses recorded in the main trunk of the dorsal nerve of the penis and stimulation of the nerve evoked responses within the urethra. Bulbocavernosus muscle contraction was elicited following urethral stimulation.

CONCLUSIONS

Urethral innervation by the dorsal nerve of the penis supports the view that urethral afferent impulses are a component of reflex ejaculatory activity. The pattern of glanular innervation by the dorsal nerve of the penis identifies the glans as a sensory end organ for sexual reflexes. The undulating character of the dorsal nerve of the penis is a mechanism by which the nerve can accommodate to significant changes in penile length with erection. Electrodiagnostic studies of the dorsal nerve of the penis should be modified to consider the anatomical findings.

Bulbocavernosus reflex studies and autonomic testing in the diagnosis of erectile dysfunction

The electrophysiologic evaluation of patients with erectile dysfunction presents an important diagnostic challenge. The bulbocavernosus reflex (BCR) latency has been commonly used to evaluate these disorders. However, it is a measure of somatic penile innervation, whereas erection is primarily dependent on autonomic function. We evaluated 195 men with erectile dysfunction over a 3 year period. Each had electrophysiologic studies, nerve conduction studies and a BCR. BCR studies were abnormal in only 7%, of which most had diabetes or pelvic trauma. The BCR was the sole electrophysiologic abnormality in only 2%. Autonomic testing (AT) was additionally performed in 19 diabetic and 23 non-diabetic patients. This included sympathetic skin responses and measurement of the Valsalva ratio and heart rate variability with 6/min breathing. In the diabetic group, AT was positive in 63%, and most often was the sole abnormality. The bulbocavernosus reflex is relatively insensitive in the diagnosis of erectile dysfunction. Brief autonomic testing may provide valuable additional data, particularly in diabetics.

The effect of pharmacologic erection on the dorsal nerve of the penis

The dorsal nerve of the penis (DNP) is the primary source of afferent somatic input from the penis and is critical in the male sexual functions of erection and ejaculation. Using genitourinary electrodiagnostic techniques, this study was conducted to investigate the effect of pharmacologic erection on the DNP. Three tests were administered, and the changes in the DNP between flaccid, stretched, and erect states were examined. Calculated nerve conduction velocity (cNCV) measurements of the DNP increased with pharmacologic erection because mechanical straightening of the nerve allowed for a more precise measurement of nerve length. The latencies of the cortical evoked response and the bulbocavernosus reflex were not significantly changed with stretch or pharmacologic erection. In the evaluation of impotence, cNCV DNP measurements should be performed on the erect penis.

[Penile neuropathy: clinical and electrophysiologic study. Report of 186 cases]

Penile neuropathy is a common disease due to lesion of the sensory branch of the pudendal nerve, ie, the dorsal nerve of the penis. Sexual disorders (deterioration of erection) and sensory signs (hypoesthesia or paresthesia of the penis) are noted in patients with penile neuropathy. Electrophysiological recordings help guide the diagnosis (reduction of the sensory velocity of the dorsal nerve of the penis). Many etiologies can be found (traumatic, toxic, compressive), but the most common lesion is neuropathy related to diabetes.

Sexuality in the elderly

Sexuality and aging are not incompatible terms. However, sexual issues are often ignored in older adults. Impacts of altered physiology and pathologic changes, such as cardiovascular disease are discussed in this article. What is clear is that many older adults are interested in remaining sexually active throughout the years.

Cerebral responses elicited by stimulation of the vesico-urethral junction (VUJ) in diabetics

To investigate the involvement of the visceral afferent nerves in diabetes mellitus, we enrolled 46 male patients in a study, examining the cerebral potentials evoked by stimulation of the vesico-urethral junction (VUJ CEP) and the pudendal (penile CEP) and posterior tibial nerves (tibial CEP). The age range was 23-67 (mean 45.8) years. The epithelial surface of the vesico-urethral junction was stimulated bipolarly with an electrode attached to a specially produced Foley catheter. Cerebral responses were recorded bipolarly at vertex. VUJ CEPs were absent (27 patients) or protracted and/or of low amplitude (4 patients) (total 31 patients; 67.8%). Penile CEP and/or tibial CEP could be obtained in all cases; however, protracted P1 peak latencies were detected in 15 (32.8%). The abnormalities of VUJ CEP did not correlate with the presence of peripheral neuropathy, while the abnormalities of penile CEP and/or tibial CEP invariably coincided with the presence of peripheral neuropathy. Although neither age nor the duration of diabetes correlated with abnormal CEPs as determined by any of the tests, insulin dependence correlated with abnormal penile CEP and to a lesser extent with VUJ CEP. We conclude that VUJ CEP is informative in evaluating the physiological condition of visceral afferents, and can be used in diagnosis of the early involvement of visceral afferents in diabetes mellitus.

Erectile and copulatory dysfunction in chronically diabetic BB/WOR rats

The pituitary-testicular axis, penile reflexes, and copulatory behavior were studied in male BB diabetic rats from 10 to 40 wk of diabetes. Serum testosterone was diminished from 18 to 28 wk of diabetes, and the responses to human chorionic gonadotropin stimulation were blunted. Serum luteinizing hormone (LH) in diabetic rats did not differ from that of the control rats before or after LH-releasing hormone stimulation. Serum follicle-stimulating hormone and prolactin levels were also similar to controls. After 26 wk of diabetes, androgen-sensitive reproductive accessory organs were significantly reduced in size. This also was true for the androgen-sensitive bulbocavernosus and ischiocavernosus muscles. Penile reflexes in these animals from 20 to 32 wk of diabetes were consistently reduced in number and demonstrated prolonged latency. Copulatory behavior was evaluated in these animals at 25 and 28 wk of diabetes and revealed a reduced number of BB diabetic rats showing normal behavior at 25 wk of diabetes. At 28 wk of diabetes, mount latency, intromission latency, ejaculatory latency, and the postejaculatory interval were all prolonged compared with controls. In addition, the number of diabetic animals showing normal behavior was reduced compared with controls. These studies demonstrate that chronically BB diabetic rats develop diminished testosterone and erectile dysfunction that precedes ejaculatory dysfunction in a similar fashion as impotence in diabetic men. We suggest that further studies in this animal model may be critical to the better understanding and treatment of impotence in diabetic men.

Penile sensory disorders in erectile dysfunction: results of a comprehensive neuro-urophysiological diagnostic evaluation in 123 patients

A total of 123 patients with complaints of erectile dysfunction and no clinically overt neurological disease underwent a comprehensive neuro-urophysiological diagnostic evaluation. The results were compared with those obtained in 50 healthy volunteers. Data gathered consisted of somatosensory evoked potentials from the posterior tibial nerve (tibial evoked potential) and from the dorsal penile nerve (pudendal evoked potential). Also, 2 sacral reflex latencies were measured (bulbocavernosus reflex and urethro-anal reflex). A total of 58 patients (47%) had at least 1 abnormal neuro-urophysiological measurement. Neuro-urophysiological abnormalities were found more frequently in older patients. The tibial evoked potential was abnormal in 30 patients (24%), pudendal evoked potential in 21 (17%), bulbocavernosus reflex in 26 (21%) and urethro-anal reflex in 32 (26%). It was concluded that somatosensory disturbances constitute an important part of neuro-urophysiological abnormalities. Our results suggest a relationship between erectile dysfunction and subclinical, age-related (penile) sensory disorders. Our study corroborates the importance of penile sensibility for erectile (patho)physiology as suggested by others and supports the concept of sensory deficit impotence as an important cause of erectile dysfunction.

Dorsal nerve of the penis nerve conduction velocity: a new technique

In the evaluation of a possible peripheral neuropathic process as the etiology of erectile dysfunction, studies of the dorsal nerve of the penis may be unique in that they allow examination of the most distal segment of pudendal nerve in isolation. This study describes a new technique using a simple traction device for elongation of the penis to determine the orthodromic nerve conduction of the dorsal nerve of the penis. With stimulation at the glans, and recording at the base of the penis, the value obtained in 20 normal subjects was 36.2 +/- 3.2 m/s with an amplitude of 2.29 +/- 1.08 mV.

Bladder cancer. Advances in laboratory innovations and clinical management, with emphasis on innovations allowing bladder-sparing approaches for patients with invasive tumors

In the present decade important progress has been made in the understanding of the biology and management of bladder cancer. Experimental laboratory models and new investigative tools have revealed potentially important prognostic markers and have led to an improved understanding of the histogenesis of the disease. Advances in the management of superficial bladder cancer (intravesical chemotherapy or immunotherapy, improved urinary cytology, laser technology, flexible fiberoptic cystoscopy, and photodynamic therapy) have, in some subgroups, improved tumor control while decreasing patient complications. For invasive bladder cancer (invasive of bladder muscle or beyond) improved techniques of cystectomy and radiotherapy have reduced the complications of treatment and may have contributed small but important improvements in cure. A major improvement in the last decade has occurred in objective remission rates with chemotherapy for patients with metastatic bladder cancer. From 20% to 40% of patients achieve a complete remission, and 10% to 20% may survive for more than 3 years. Randomized Phase III trials are currently in progress and must be completed to define the true role of multidrug chemotherapy in patients with metastatic disease and to validate data from the regimens of cyclophosphamide, methotrexate, and vincristine (CMV) and methotrexate, vinblastine, doxorubicin, and cisplatin (M-VAC) before any of these approaches to treatment can be considered of proven benefit. Preliminary data from the Massachusetts General Hospital are presented of a potentially effective approach to select patients with invasive tumor for successful bladder preservation. In this approach transurethral debulking surgery is combined with upfront CMV chemotherapy plus cisplatin and 4000 cGy. If tumor is found on cystoscopic reevaluation with biopsy and cytology immediately following cisplatin and 4000 cGy, cystectomy is performed; if not, consolidation by a radiation boost to 6480 cGy plus cisplatin is given. The approach is fairly well tolerated, allows cystectomy without undue complications, has yielded a 88% complete response rate in patients selected for bladder preservation, and resulted in 90% of patients free of distant metastases with follow-up ranging from 6 to 30 months. A randomized Phase III trial with and without neoadjuvant MCV chemotherapy for selective bladder preservation is now under way and accruing well.

Impotence in diabetic men

Studies relating to pathogenetic mechanisms resulting in impotence in diabetic subjects have been reviewed. Erectile dysfunction was reported to occur in 50 to 75 percent of diabetic patients and the prevalence appeared to increase with age. Contributions of vascular, endocrine, and neurologic system alterations result in this disturbing condition, but a detailed analysis of all the parameters was not found in any individual study. In our review of 301 veterans presenting to a sexual dysfunction clinic, the clinical and hormonal alterations in the diabetic patients closely resemble those seen in nondiabetic impotent subjects. Atherosclerotic vascular changes play an important predisposing role in the development of impotence. A difference exists between the prevalences of associated medical conditions in diabetic patients taking insulin, compared with those receiving oral agents or receiving dietary management. The high prevalence of impotence in diabetic patients seems to be due to the high prevalence of its vascular complications. Considering the availability of useful therapeutic approaches, it is mandatory to evaluate all diabetic men for the presence of impotence.

Bulbocavernosus reflex latencies and somatosensory evoked potentials after pudendal nerve stimulation in the diagnosis of impotence

The bulbocavernosus reflex (BCR) was examined in 39 normal potent men and in 252 patients with impaired potency of varying aetiology. For BCR evaluation minimum, maximum and mean latencies, the temporal dispersion in ten successive responses, together with minimum and maximum side differences from simultaneous recordings of the left and right bulbocavernosus muscles were determined. Pathological findings were detected in 125 patients. Somatosensory evoked potentials (SSEPs) recorded from the scalp after stimulation of the penile dorsal nerves and the terminal branches of the pudendal nerve were investigated in 30 controls and in 246 patients. An abnormal SSEP was found in 63 patients.

Bulbocavernosus reflex latency in the investigation of diabetic impotence

Impotence in males is a well recognised complication of diabetes mellitus, commonly held to be due to an autonomic neuropathy. The aim of this study was to determine the incidence of periphero-conus neuropathy in diabetic impotence. Nineteen diabetic males seeking treatment for loss of potency had bulbocavernosus reflex latency (BCRL) and sacral reflex latencies (SRLs) performed. The conduction studies indicated that impotence in these cases was associated with peripheral neuropathy in 21% of patients and that BCRL and SRLs are sensitive and useful diagnostic tests.

Selecting initial therapy for bladder cancer

Progress has been made at both ends of the spectrum of bladder cancer. The introduction and increasing use of effective intravesical agents for both treatment and prophylaxis of tumors limited to the mucosa or lamina propria has reduced the incidence and frequency of subsequent tumors. At the other end of the spectrum--patients with locally extensive bladder cancer--neoadjuvant or initial chemotherapy is producing complete and partial responses. Hopefully this will translate into an improvement in the cure rate. In arriving at a decision regarding treatment for a patient with bladder cancer the urologist integrates information derived from a thorough endoscopic examination of the lower urinary tract (bladder and urethra), complete grading and staging of resected tumor including results of mucosal biopsies from suspicious and normal appearing urothelium, and cytology obtained by bladder irrigation. Treatment also may be influenced by such factors as prior history and treatment of bladder cancer and the patient's age and medical status. Assuming no prior bladder tumor history, endoscopic resection/fulguration followed by intravesical therapy will be used for tumors confined to the mucosa (Ta or Tcis) or lamina propria (TI). Optimally the urologist should resect all evident tumor and incorporate the intravesical agent as prophylaxis. Cytology and endoscopy will monitor the success of this approach. If the patient develops another superficial tumor while receiving prophylaxis another intravesical agent can be delivered, possibly using an intensive treatment schedule. Several agents have demonstrated effectiveness both for treatment and prophylaxis. They include mitomycin C, thiotepa, Adriamycin (doxorubicin), and bacillus Calmette-Guerin. The indications for radical cystectomy are invasion into the bladder muscle, tumor extension into the prostatic ducts or prostatic substance, or persistent tumor after an adequate trial of one or more intravesical agents used in conjunction with endoscopic resection. The escalating complete and partial response rates associated with combination chemotherapy of metastatic bladder cancer has led to the use of these regimens before considering cystectomy for patients with locally extensive bladder cancer, e.g., T3, T4, and N1-2. Downstaging with chemotherapy in this group of poor-risk patients may be preferable to the traditional approach of proceeding with exenterative surgery or full-dose radiation and considering chemotherapy later when metastases are evident.

Changes in the VIPergic, cholinergic and adrenergic innervation of human penile tissue in diabetic and non-diabetic impotent males

Penile tissue (consisting of corpus cavernosum and tunica albuginea) was obtained from 19 patients undergoing surgery for the implantation of penile prostheses. The tissue was examined for vasoactive intestinal polypeptide-like immunoreactivity in nerves, acetylcholinesterase-positive staining in nerves and noradrenaline content. Impotence was due to a variety of causes; 11 patients were classified as a 'non-neuropathic' group on the basis of their clinical history which included Peyronie's disease, vascular disease, hypertension and psychogenic impotence. Vasoactive intestinal polypeptide-like immunoreactive and acetylcholinesterase-positive nerves were present and the pattern and distribution were similar in each patient in this group. The noradrenaline content of the tunica albuginea was significantly lower than the corpus cavernosum (p less than 0.02), although there was a linear relationship between the noradrenaline contents of the two regions (r = 0.95, p less than 0.01). By comparison, a complete absence of vasoactive intestinal polypeptide-like immunoreactivity in nerves was observed in a patient with a cauda equina lesion. Five out of six diabetic patients studied revealed a marked reduction in vasoactive intestinal polypeptide-like immunoreactivity in nerves associated with the cavernous smooth muscle, while acetylcholinesterase-positive staining was reduced in three out of five diabetic patients studied. The noradrenaline content of the corpus cavernosum from diabetic patients was significantly lower (p less than 0.02) than that of the 'non-neuropathic' group. The noradrenaline content of the tunica albuginea, however, was similar in both groups. The results provide evidence that VIPergic, cholinergic and adrenergic nerves in the penis are affected in diabetes mellitus and thus may contribute to the development of impotence in diabetic patients.

The value of basic investigations in the diagnosis of impotence

172 patients with impotence symptoms were investigated by SBBBV-test, orthostatic blood pressure, Doppler examination of the superficial and deep penile arteries, penile-brachial index, visual sexual stimulation, papaverin test, and measurement of bulbocavernous reflex latency time. Visual sexual stimulation and papaverin test correlated well with each other, and so did papaverin test and PBI in cases of arterial insufficiency. SBBBV was simple to perform and useful in detecting autonomic neuropathy. There were characteristic differences in the pattern of erectile failure between young and old patients. The differentiation to organic or psychogenic erectile failure was easier in the young age groups, whereas the old patients more often had a combination of vascular and psychogenic aetiology.