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SCANNING ELECTRON MICROSCOPIC STUDY ON PENILE VASCULAR CASTS IN DOG AND MONKEY : AN INQUIRY INTO THE POSSIBLE MECHANISM OF ERECTION BASED ON THE FINDINGS Ken-ichi Kano, Shugo Hanyu, Toshiko Iwanaga and Shotaro Sato Depts. Of Urology and anatomy, Niigata Univ. School of Medicine, Niigata, Japan
The vascular constructions of the corpus cavernosum penis in the dog and the monkey were investigated mainly by scanning electron microscopic observation of corrosion casts. The corpus cavernosm penis of the dog was supplied by the deep artery of the penis except the distal portion. The helicine arteries were provided with polsters which protruded into the lumen so prominently that they might conspicuously reduce the luminal space during the flaccid state. The polsters were restricted to the helicine arteries, and could not be found in the penile artery or in the veins of the penis. Postcavernous venules in the corpus cavernosum penis occurred only on the medio-dorsal surface of its crura and they ran for a distance beneath the tunica albuginea. This finding indicates that the venules are effectively compressed between the tunica albuginea and the peripheral sinuses during erection. The vascular construction of the corpus cavernosum penis in the monkey was basically identical with that in the dog.
MICROVASCULAR ARCHITECTURE OF THE HUMAN PENIS : A SCANNING ELECTRON MICROSCOPE STUDY OF CORROSION CASTS Yoshiaki
Banya, Tatsuo Ushiki, Hikaru Aoki, Hiroshi Takagane Department
of Urology and Anatomy School of Medicine,
The penile circulatory system is known to play an important role in each phase of the penile erectile cycle: the flaccid, tumescence, erection, and detumescence phases. However, there remains many unknown anatomical questions concerning the vascular system in the human penis. In order to answer them, it is needed to clarify the fine three-dimensional architecture of the penile vascular system In the present study, vascular corrosion casts were prepared by infusing methylmethacrylate (Merocx, Dainippon Ink Co, ) into the human penis Procured from cadavers, and observed in the scanning electron microscope. The following findings were obtained.
QUANTITATIVE ANALYSIS OF OUTFLOW PATHWAY OF CANINE CORPORA CAVERNOSA USING LUE'S PRESSURE FLOW MODEL Hikaru Aoki, Hiroshi Takagane, Junichi Matsuzawa, Yoshiaki Banya, Tomoaki Fuj ioka, Takashi Kubo and Tsutomu Ohhori Department of Urology, Iwate Medical University, School of Medicine, Morioka, Japan
Using Lue's pressure flow model, in which a constant rate of saline perfusion was performed instead of blood inflow to the corpus cavernosum, with and without pelvic nerve plexus electrostimulation, quantitative analysis of the physiological characteristics of the outflow pathway was performed in 19 male dogs weighing 7.5 to 23.0 Kg. Pressure flow studies were performed repeatedly, varying the saline perfusion rate from small to large (these pressure flow studies were named the antegrade pressure flow studies). Once erection was achieved, the saline perfusion rate was returned to small step by step as producing the plateau phases of the intracorporeal pressure (these pressure flow studies were named the retrograde pressure flow studies). Pressure flow curves of the corpus cavernosum, with and without pelvic nerve plexus electrostimulation, were produced from the intracorporeal pressure at the plateau phase of each pressure flow study. Electroerection was achieved in 14 dogs (erection group) by pelvic nerve plexus electrostimulation, but erection could not be induced in 5 other dogs (non-erection group) In both groups, restriction of the outflow pathway of the corpus cavernosum occurred as a -result of pelvic nerve plexus electrostimulation. The critical saline perfusion rate for artificial erection and the saline perfusion rates needed for electrostimulation (intracorporeal pressure = 150 mmHg) of the erection group and the non-erection group were 9.1 ± 0.9 ml/min., 7.7 ± 3..3 ml/min. and 2.3 ± 1.4 ml/min. , 2 0 : ± 1 1 ml/min., respectively. The rate of decrease of the outflow pathway in both groups was 68.3 @ 16,1% (mean ± S.D. ) and 73.2m 8.6% (mean ± S.D.), respectively. From analysis of the pressure flow curves, it was found that large hysteresis existed between the antegrade and the retrograde pressure flow curves without pelvic nerve plexus electrostimulation. However, the degree of hysteresis found in the relation between the two pressure flow curves with pelvic nerve plexus electrostimulation was small. In addition, the retrograde pressure flow curve without pelvic nerve electrostimulation piled on the pressure flow curves with pelvic nerve plexus electrostimulation. In consideration of the physiological characteristics of the outflow pathway of the corpora cavernosa, it is feasible that restriction can be induced by distension of the corpora cavernosa in addition to the action of pelvic nerve pelexus electrostimulation. The mechansim of restriction of the outflow pathway by distension of its fluid content was identified with the mechanism of restriction by pelvic nerve plexus electrostimulation.
THE MECHANISM OF BLOOD OUTFLOW FROM THE HUMAN CARVENOUS TISSUE Masaharu
Takanami, Teiga Tanaka, Kanaini Kuroda Department of Urology, Toho University School of Medicine Tokyo, Japan
We speculate that the drainage system plays some role in the maintenance of erection. In order to corroborate the speculation, we prepared serial sections of penis specimens obtained at autopsy and observed these sections by light microscopy and computer graphics. Efferent vessels flows from the cavernous spaces to the tunica albuginea, is running obliquely through inner veins toward the outside of the tunica albuginea in the direction of the long axis of the penis, then these veins flow into the veins on the tunica albuginea. These veins seem to aggregate, then most likely run into the vena profunda dorsalis Penis. From the above-mentioned structures we can infer the following mechanism of penile erection. When the volume of the corpus cavernosum penis increases, the tunica albuginea extends, and the veins running inside the tunica albuginea are compressed causing a disturbance in blood outflow and resulting in penile erection. The blood outflow, however, is not completely blocked, and inflow of arterial blood at the same rate as that of the outflow is necessary for maintaining the erection.
INACTIVATION OF NORADRENERGIC ACTIVITY IN THE PENIS IS ESSENTIAL FOR ERECTILE PROCESS P Ganesan Adaikan and Shan S Ratnam. Department of Obstetrics & Gynaecology, National University Hospital, Lower Kent Ridge Road, Singapore 0511.
The excitatory motor neurotransmission to the erectile tissue in the human penis is adrenergic acting on alpha-I adrenoceptors. Suppression of this effect by suitable drugs in vitro results in an inhibitory effect equivalent of enlargement of the penile muscle. It has been hypothetized that continuous burst of adrenergic transmission is responsible for maintaining the flaccid and contracted state of the penis - the state in which it is most of the time. Suppression of the sympathetic supply to the penis with alpha-adrenoceptor blocking drugs produce enlargement of the penis and erection. In addition, it was also found that papaverine and other compounds such as VIP which produce penile enlargement invariably inhibit the noradrenergic activity in the corpus cavernosum. Prostaglandin El which produces erection in impotent man is an inhibitory modulator of the adrenergic transmission in the penis. Inhibition of adrenergic transmission in the penis appears to be the initial step in the erectile process. This activity may well be the change needed for erection to commence.
A PHARMACOLOGICAL STUDY OF ISOLATED CANINE CORPUS CAVERNOSUM TISSUE. REPORT 1. : RELAXING EFFECT OF PAPAVERINE HYDROCHLORIDE, VASOACTIVE INTESTINAL POLYPEPTIDE AND PROSTAGLANDIN E1 ON NOREPINEPHRINE INDUCED CONTRACTION Masato Tamura, Susumu Kagawa, Kazunorl Kimura, Yasuo Kawanishl, Akio Imagawa and Kazuo Kurokawa* Department
of Urology, Takamatsu Red Cross Hospital, Kagawa, Japan.
We made a pharmacological study on isolated preparations of canine corpus cavernosum tissue, observing the contractive action of potassium ions and norepinephrine. The norepinephrine induced contraction was reduced by pretreatment with phentolamine, and recovered by treatment with papaverine hydrochloride and vasoactive intestinal polypeptide. However, prostaglandin F2- alpha failed to produce any contraction and prostaglandin El and Cyclic AMP had no relaxing effect on norepinephrine induced contraction.
A PHARMACOLOGICAL STUDY OF ISOLATED CANINE CORPUS CAVERNOSUM TISSUE REPORT 2: ASSESMENT OF THE ROLE OF THE ALPHA ADRENERGIC SYSTEM Kazunori Kimura, Susumu Kagawa*, Yasuo Kawanishi, Masato Tamura, Akio lmagawa and Kazuo Kurokawa*. Department
of Urology, Takamatsu Red Cross Hospital, Kagawa, Japan
We made a pharmacological assessment of the role of the alpha adrenergic system in erection and flaccidity using canine corpus cavernosum tissue. Phenylephrine (Alpha I agonist) produced a strong contraction in isolated canine corpus cavernosum tissue, while prazosin (Alpha I antagonist) relaxed the precontracted tissue. Clonidine (Alpha 2 agonist) also produced a week 40 % contraction about as compared with a potassium ion produced contraction, while yohimbine(Alpha 2 antagonist) relaxed the contraction. Pharmacologically it is suggested that the density of the alpha I receptors is nearly 7 times that of the alpha 2 receptors. The shift of the EC50 value on a norepinephrine contraction curve with and without prazosin is similar to that with and without Phentolamine. Therefore, alpha-I antagonist could be used intracavernously to produce erection instead of phentolamine which acts not only upon alpha I receptors but also on alpha 2 receptors. The shift of the EC50 value for norepinephrine contraction with and without yohimbine is lower than that with and without phentolamine or prazosin. If some impotents had relatively high densities of postsynaptic alpha-2 receptors, yohimbine may act beneficially to achieve satisfactory erection.
PHARMACOLOGY OF ISOLATED HUMAN CORPUS CAVERNOSUM TISSUE Yasuo Kawanishi,
Susumu Kagawa* Kazunori Kimura, Masato Tamura, Department
of Urology, Takamatsu Red Cross HospitaL Kagawa, Japan.
We made a pharmacological study on isolated human corpus cavernosum tissue to find its role in erection and flaccidity. Phenylephrine (alpha 1 agonist) produced a 50% contraction in isolated human corpus cavernosum tissue as compared with that produced by norepinephrine, and clonidine (alpha 2 agonist) also produced a week 40% contraction as compared with potassium ions. Pretreatment with phentolamine (non-specific alpha antagonist), prazosin (alpha 1 antagonist) and yohimbine (alpha 2 antagonist) reduced the degree of contraction by norepinephrine. The results confirm that there are not only alpha I receptors but also postsynaptic alpha 2 receptors in human corpus eavernosum tissue. However, the pharmacological density of alpha 2 receptors is one in eleven compared with that of alpha I receptors. Carbachol and isoproterenol relaxed the norepinephrine contracted tissue. However vasoactive intestinal polypeptide had the most forceful relaxing effect on precontracted tissue. Vasoactive intestinal polypeptide is expected to be the most likely neurotransmitter for regulating erection.
AGE-RELATED ERECTILE RESPONSE TO SHORT EROTIC STIMULATION IN NORMAL ADULTS Eun Gil Kim and Jun Kyu Suh, Daegu, Korea
Simultaneous monitoring of penile plethysmography, penile tumescence, penile rigidity, BC-IC EMG and EKG was performed on 50 healthy adults (divided into 5 groups, from 20s to 60s) to investigate the age-related erectile response to short Period erotic stimulation and to elucidate the range of its characteristics for the differential diagnosis of impotence. Variability was observed in temporal relationship between penile pulse amplitude and penile erection. Of the 45 subjects who showed erection and/or increase in penile pulse amplitude, Type I was observed in 13 subjects (29%) - erection and increased penile pulse occurring in parallel; Type 11, in 26 subjects (58%) - erection with increased penile pulse during the development or decline of erection but not during maximum erection; Type III, in 4 subjects (9%) - erection with no change in penile pulse; and Type IV, in 2 subjects (4%) - increased penile pulse amplitude without any erection. These reflect that penile erection does not exclusively depend on increase of penile arterial blood flow but on the cooperative mechanism with other action, such as, of venous blockade which corresponds flexibly to the degree of arterial blood flow. There was a tendency to delay in latency time to erection with aging. However, no difference among age groups was observed in penile expansion and rigidity. These indicate that psychic response to erotic stimulation tends to delay with aging, but that maximum erection ensues regardless of aging if a man is affected by libido under the strong erotic stimulation with film. These results with our clinical experience suggest that characteristics of erectile response to erotic stimulation is worthy of further investigation, and that noninvasive erotic stimulation test is a useful method of discriminating among various types of organic and psychogenic impotence.
AUDIOVISUAL STIMULATION (AVS) PENOGRAM Hyung ki, Choi, Cheol Soo, Kim From the Department of Urology, Yonsei University College of Medicinal, Seoul, Korea
In an effort to estimate the penile blood flow changes during spontaneous psychologic erection with the audiovisual sexual stimulation, we injected technethium via antecubital vein and calculated the radioisotope activity of the Penis using computerized Gamma camera in impotent patients and got the following results.
COMPARISON OF VASOACTIVE DRUGS FOR PATIENTS WITH ERECTILE DYSFUNCTION Ryoji Yasumoto, Masazumi Asakawa, Akinori Horii, Takahisa Terada, Rikio Yoshimura, Arata Sawamura, Masato Kamizuru, Hidenori Kawashima, Shoichi Nishio and Masanobu Maekawa. Department of Urology, Osaka City University Medical School, Osaka, Japan.
Six erectile failure patients were intracavernously injected with various vasoactive drugs. The effects of each drug were evaluated in four grades: complete functional erection, incomplete functional erection, nonfunctional expansion and no effect. As a result, when papaverine hydrochloride (40 mg/ml) was administered, 4 out of the 6 patients indicated nonfunctional expansion. By administering a mixture of 80 mg/ml of papaverine hydrochloride with 1.0 mg/ml of phentolmine mesylate, nonfunctional expansion was seen in 4 patients and incomplete functional erection was observed in 2 patients. As for the effects of prostaglandin El, incomplete functional erection was seen in all patients, while complete functional erection was indicated in 2 patients. These results indicated that the patients reacted differently to the same vasoactive drug, and that the papaverine and phentolamine mixture had a stronger effect than papaverine alone, while prostaglandin El had the strongest effect on erection. The intracavernous injection of these drugs is useful for the treatment and diagnosis of impotence.
PAPAVERINE INJECTION AS A DIAGNOSTIC TOOL FOR IMPOTENCE Feng Yi-ping, Guangzhou, China.
Papaverine hydrochloride is a nonspecific smooth muscle relaxant that produces vasodilation. The therapeutic use as an intracorporeal injection for impotence has significant clinical implications. In the study by Virag and associates an intracorporeal injection produced an erection within 10 minutes and lasted 1 to 4 hours. The simplicity of its intracorporeal injection and its unique ability to assess vascular competence of the vessels supplying the corpora cavernosa make it a potentially important screening tool for vasculogenic impotence. There were 40 mem referred to the clinic during a 6-month period for investigation. To perform this test 30-60 mg. Papaverine hydrochloride were mixed in a syringe with 10 c.c. saline and was injected into the lateral corpus cavernosum. 20 patients had a good response, while 10 had a moderate and 10 had poor.
DIAGNOSTIC VALUE OF INTRACAVERNOUS PAPAVERINE-INDUCED ARTIFICIAL ERECTION (IPAE) Sae Chul Kim & Chung Whan oh, Department of Urology Chung-Ang University Hospital, Seoul, Korea
Papaverine Hcl of 40 mg was injected intracorporally into 164 impotent patients to determine whether it can discriminate vascular versus psychogenic impotence. Its diagnostic usefulness was compared with Snap Gauge test, penile brachial index(PBI). The results obtained were as follows.
SYMPATHETIC SKIN RESPONSE: A NEW TEST FOR DIAGNOSING EJACULATORY DYSFUNCTION TAKAHIDE SUGIYAMA, HIRO KIWAMOTO, ATUNOBU ESA, YOUNG-CHOL PARK and TAKASHI KURITA. Department of Urology, Kinki University School of Medicine
Sympathetic skin responses were elicited from the palm and the sole with electrical stimulation on the dorsal nerve of the penis in 42 individuals. In 7 normal subjects and 19 patients with normal ejaculatory function, plantar sympathetic skin responses were obtained. On the other hand, all 13 patients who lacked plantar sympathetic skin response had ejaculatory dysfunction. Since the plantar sympathetic skin response is correlated closely to the mechanism of ejaculation, this test is expected to be helpful to diagnose sexual dysfunction and monitor the effects of treatment.
INTRACAVERNOUS SELF-INJECTION WITH VASOACTIVE DRUGS FOR ERECTILE IMPOTENCE Hee Yong Lee, Choung Soo Kim and Jae Seung Paick. Dept. of Urology, College of Medicine, Seoul National University, Seoul, Korea
The intracavernous self-injection with vasoactive drugs combination is a new and exciting approach to the management of impotence and to the differential diagnosis of erectile impotence. A total of 88 patients with impotence were subjected to this trial for the past 3 years. An age of the patients averaged 56 (range:24-78). The drugs used for this study were a mixture of 30mg/ml papaverine HCl, direct smooth-muscle relaxant, with 0.5mg/ml phentolamine mesylate, alpha-adrenergic blocker. The initial trial injection was performed with a Mantoux syringe with 27 gauge needle unilaterally into the base of the cavernous body by a physician and the patients were sent home to have sexual coitus. Following the initial injections, full erection started in 6 minutes, maximum rigidity attained in 20 minutes and erectile status sustained for 138 minutes. Over-all, coital penetration was possible in 78 patients of the 88 who were submitted to the trial injections. Fifty-six patients of the 78 who experienced successful results were practicing self-injection method of vasoactive drug with satisfied sexual relations from 10 self-injections for 1-3 months to 200 self-injections for 24 months without any untoward side effects. After trial injections, ecchymoses on the injection sites occurred in 11 patients but subsided spontaneously in a few days. Prolonged erections occurred in 3 patients after the trial injection and also in 3 patients during self-injection programme. They were cured by aspirations and intracorporeal irrigation with a dilute solution of epinephrine or dopamine (0.001mg/ml) in 4 cases and subsided spontaneously in the remaining 2 cases.
THE TREATMENT OF IMPOTENCE USING CHINESE TRADITIONAL MEDICINE Feng Yi-ping, Guangzhou, China.
It has a long history in China that impotence had been treated by using many Chinese traditional drugs. There was a record in The Internal Medicine in Wan-Di ( THE KING ). Through a very long period and many centuries we gained glorious experiences in the treatment of impotence. We introduce a compound of drugs of Lou-bi ( testis of the deer ) , Gou-zhen ( the testis of the dog ) Lou-zhun ( deer's horn ), XiOng-dan ( biliary juice of the bear ) and others. The aim of this drug is to increase the strength of the penis. The action may be vasodilation of the pudendal artery. It also has the same effect as papaverine injection. Further investigation is needed to make clear about the action.
GROUP SEX THERAPY FOR SINGLE MALES WITH ERECTILE DYSFUNCTION HONG SHICK
LEE M.D.,DONG HO SONG M.D.,HYUNG KI CHOI M.D.,
This study utilized a control group design to evaluate the effectiveness of group treatment of psychogenic erectile dysfunction without regular sexual partners. After the completion of physical and psychiatric assessments of erectile dysfunction, a group of ten men with psychogenic erectile dysfunction were treated with 10 sessions, a structured, psychoeducational group therapy and another group of 10 men with the same disorder were assigned to waiting list control condition. The evaluations were done in the three divided periods; pretreatment, post treatment(not for the waiting list controls) and 8 weeks period follow-up. The results showed that the treated subjects improved significantly more than those in the waiting list controls on a variety of measures concerning sexual attitudes and knowledge, sexual behaviors related to erectile function. The findings suggest that this particular preliminary approach is quite adequate, cost-effective for psychogenic erectile dysfunction in single patients.
THE CORPOREAL SIZE OF THE PENIS IN CHINESE Johnny Shinn-Nan Lin, M.D. Division of Urology, Department of Surgery, Veterans General Hospital and National Yang-Ming Medical College, Taipei, Republic of China
From October, 1985 through March, 1987, 46 fresh cases were implanted penile prosthesis. Sizing of the corpus cavernosum was measured via a corporotomy. The diameter of the corpora cavernosa were measured with a special measurement tool (n=25) and with a Hegar dilator (n=46). The length of the corpora cavernosa were all measured with a Furlow cylinder inserter. The average size of the corpus cavernosum in Chinese was 11.96±0.47mm in diameter (ranged from 10 to 15mm) and 17.22 ± O.85cm in length (ranged from 15 to 21cm). In most of the patients, the length of the corpus cavernosum ranged from 16 to 18cm (74%) and the maximal diameter was 12mm (67.4%).
CLINICAL EXPERIENCE WITH 25 CASES OF PENILE PROSTHESIS IMPLANTATION HAN-SUN CHIANG M.D. Department of Urology, Taipei Medical College, Taipei, Taiwan, Republic of China
3 different types of penile prosthesis (1). Malleable (AMS 600) (2). Inflatable(AMS 700). Self-Contained(Hydroflex) were implanted into 20 male patients with the problem of organic dysfunction. The most prevalent diagnoses of the candidates were diabetic and vasculogenic impotence. Only one case had postoperative complication of infection, one had rupture of the septum, the others were successfully operated with good mechanical function of the prosthesis thereafter. Satisfaction of the patients and partners was more than 60% based on the work of a follow-up questionnaire. However, some modification of the prosthesis may be needed in the future for the Chinese patient.
100 CASES OF INFLATABLE PENILE PROSTHESIS IMPLANTATION R.A. Cartmill (Australia) * not available *
COMPLICATIONS OF PENILE PROSTHETIC SURGERY Sae Chul Kim & Chung Whan oh, Department of Urology Chung-Ang University Hospital, Seoul, Korea
We have followed up 63 patients, who have underwent penile prosthetic surgeries (Jonas; 12, AMS 600; 17, AMS 700; 11, Mentor IPP; 1, Hydroflex; 22) for erectile dysfunction with a mean follow up Period of 22.6 months. Eight cases of surgical complications in 5 patients and 3 cases of mechanical in 2 patients develop -ed. Of 2 cases of corporal septal perforations, the visible one was repaired and Hydroflex was implanted. The other not visible one was not repaired and AMS 700 was implanted, when the implanted cylinder in a corpus cavernosum was punctured during implanting the other side. In a case of crural perforation, rear reservoir of the implanted Hydroflex was punctured during repairing the crus. So AMS 600 was implanted after the rear tip extender was sutured and fixed to tunica albuginea. The rod implanted into the opposite intact corpus cavernosum was nearly protruded against the glans 14 months after implantation. The protruded rod was removed and not changed. A case of wound disruption was sutured without any further problems. As mechanical complications a crevice of the Hydroflex with fluid leak happened in one side 2 months after implantation and in the opposite side 11 months after implantation. The Hydroflex of the both sides were changed. Fluid leak of unknown source was encountered 20 months after implantation of AMS 700.
THE SEXUAL BEHAVIOR OF PEOPLE WITH SPINAL CORD-INJURIES Byoung Hoon Oh, Hong Shick Lee, Kae Joon Yo Ho Young Lee, Jae Ho Moon, M.D.'s
A clinical study was conducted on the sexual behavior manifested by 200 people with spinal cord-injuries through a survey with a questionnaire during the period from Jan. 1C to Aug. 31, 1986. The purpose of this study is to evaluate the role of the sexual function in general life of these people. 69 people replied and the following results were observed:
Evaluating the above results, we can say that the sexual behavior of people with spinal cord-injuries is a very important part of their lives and we suggest that further investigation of the matter and especially of the proper treatment of the problem is to be earnestly sought after.
ARTIFICIAL EJACULATION AFTER INTRATHECAL INJECTION OF NEOSTIGMINE IN SPINAL CORD INJURY PATIENTS FOLLOWED BY PREGNANCY Tetsuo Ishidoh,M.D., Yasuyuki Suzuki,M.D. and Kazuoki Miyazaki,M.D. Department of Urology The Kanagawa Rehabilitaion Center (Japan)
In general there is no completely therapeutic treatment for ejaculatory disturbance; medication does not restore function. Thus it has been said to be imposible for spinal man to have a baby. But there are three methods for inducing artificial ejaculation in spinal man. In the past ten years we have applied chemical stimulation to 67 patients with ejaculatory disturbance due to spinal cord injury, and with this technique 15 couples have achieved artificial insemination with the hasband's semen. Three cases of this A.I.H. have proven successful.
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