Review of Impotence Literature

Home , Castration, Emasculation, Penectomy

Sexual function in patients with penile carcinoma: a References prospective study 1 Stadler WM, Elwell CM, Jones WG. Penile cancer. In: Vogelzang NJ, Scardino PT, Shipley WV, Coffey DS (eds). ACL Pompeo, GF Carvalhal, A Sarkis, W Alfer Jr, Comprehensive Textbook of Genitourinary Oncology. Wil- WP Toledo and S Arap, liams & Wilkins: Baltimore, 1996, 1097±1102. Hospital das Clinicas, SaÃo Paulo, Brazil 2 Tulli RE, Di Iorio JM, Vaccari R, Tre®letti S, Degni. J Bras Urol 1997; 23: 10±14. Adrenal control of erectile function and nitric oxide Abstract: Sexual function is a major concern in the synthase in the rat penis treatment of penile cancer patients. Although sexual dysfunctions may be present initially, they tend to DF Penson, C Ng, J Rajfer and NF Gonzalez-Cadavid develop after the treatment of penile lesion, sig- Department of Urology, University of California ni®cantly in¯uencing patient's quality of life. From School of Medicine, Harbor-UCLA Medical Center, 1981 to 1993 we conducted a prospective study Torrance, California. focusing on the normal function of 50 patients (average age of 52 y) with surgically managed penile Endocrinology 1997; 138: 3925±3932. carcinoma. Preoperative anamnesis showed that 11 patients (22%) had normal impairment previously Editorial comment: The androgen dependence for the to the development of the tumour. The treatment of nitric oxide (NO)-mediated process of penile erection penile lesion consisted of 41 partial penectomy, 8 in the rat may not refer only to androgens of testicular total penectomy and 1 emasculation; all of them origin since castration reduces the neurostimulated were submitted to bilateral inguinal lymphadenect- rat erectile response by only 40±50%. These investi- omy. Among the 39 preoperatively potent patients, gators proposed that androgens or other substances 21 (53%) complained of erectile dysfunction when derived from the adrenal gland may contribute to evaluated one year after surgery. All of 18 patients regulating the NO synthase (NOS) pathway involved who remained potent had a penile stump larger than in the response. In rats treated with adrenalectomy 4 cm and none of those with a stump less than 4 cm and castration, separately or in combination, with and preserved potency. Preservation of erectile function without hormone replacement, neurostimulated pe- was negatively associated with tumor stage. Three nile erections were most signi®cantly reduced in patients complained of premature ejaculation pre- combined adrenalectomized and castrated animals operatively and remained with the same symptom although this reduction was prevented in similarly after partial penile amputation. treated animals which were replaced with mineralo- corticoids and glucocorticoids. Adrenalectomy did not further reduce penile NOS activity measurements Comments: Penile cancer is responsible for almost from that observed in castrated only animals, although 20% of male neoplasia in undeveloped countries.1 this manipulation in combination with castration was Sexual function after partial or total penectomy is apparently suf®cient to cause a decrease in penile always a major concern for patients and doctors. neuronal NOS protein content from baseline levels This study shows the importance of a focused that were maintained with castration alone. In addi- anamnesis about sexual function in the preoperative tion to showing that factors of adrenal origin partici- period since 22% of the patients had been impotent pate in the erectile mechanism, the investigators have even before the development of the tumor. It seems established a role for corticoids and possibly other that the minimum size of a sexually functional adrenal substances in this mechanism. The adrenal penile stump is 4 cm and this should be the contribution to effects on the NOS pathway mediating surgeon's goal without compromising the radicality penile erection in the rat may pertain to neuronal NOS of the procedure. It is interesting that premature expression. However, the absence of an effect on ejaculation remained unchanged after partial pe- penile NOS activity following adrenal manipulation nectomy showing that penile nerves section does suggests that the role of adrenal substances in the not correlate with an enlargement of ejaculatory erectile function of the rat involves mechanisms time as had been proposed in the past.2 distinct from NO synthesis and release. S Glina, MD AL Burnett, MD Review of Impotence Literature

200 Spinal Fos labeling and penile erection elicited by intracavernosal injection of vasoactive intestinal stimulation of dorsal nerve of the rat penis polypeptide (VIP), adrenomedullin (ADM), the novel nitric oxide donor diethylamine-nitric oxide O Rampin, S Gougis, F Giuliano and JP Rousseau complex sodium (DEA=NO), and the control triple- Laboratoire de Neurobiologie des functions Vegeta- drug combination consisting of papaverine, phentol- tives, INRA, F-78352 Jouy-en-Josas Cedex, France. amine, and prostaglandin E1. These results suggest that this novel peptide may have usefulness as an Am J Physiol 1997; 272: R1425±R1431. erectogenic agent. Further investigations may con®rm its role in erectile physiology and establish Editorial comment: While it is known that the spinal its mechanism of action in the penis. re¯ex pathway which carries out re¯exive penile AL Burnett, MD erections consists of an afferent limb represented by the dorsal nerve of the penis and an efferent limb represented by the pelvic nerve, the intraspinal Vasoactive intestinal polypeptide and phentolamine circuitry responsible for re¯exive erections has not mesylate administered by autoinjector in the treat- been fully established. Following dissection and ment of patients with erectile dysfunction resistant electrical stimulation of the dorsal nerve of the penis to other intracavernosal agents. in anesthetized rats, these investigators immuno- histochemically con®rmed the expression of c-fos, a Dinsmore WW and Alderdice DK marker of somatic and visceral afferent spinal Department of Genito-Urinary Medicine, Royal neuron pathways, in the dorsal horn, the dorsal Victoria Hospital, Belfast, Northern Ireland, UK. gray commissure, and the sacral parasympathetic nucleus. These localizations provide morphological Br J Urol 1998; 81: 437±440. support for neuronal interconnections at the spinal cord level. However, since the Fos immunohisto- This study evaluated the effect of a new combinat- chemical technique is not suf®cient to specify ion of vasoactive agents. 25 mg vasoactive intestinal which Fos-positive spinal neurons represent inter- polypeptide (VIP) with 1 (VIP1) or 2 (VIP2) mg neurons or preganglionic neurons, further investiga- phentolamine mesylate in 70 patients who failed to tion employing functional techniques is required to respond to intracavernosal prostaglandin-E1 (20mg), identify the precise roles of these neurons in papaverine (30 mg) and 1 mg phentolamine mesy- segmental re¯ex and supraspinal modulatory path- late. The causes of erectile dysfunction in this group ways that in¯uence penile erection. of patients included spinal cord lesion, diabetes, AL Burnett, MD ischaemic heart disease, hypertension or idiopathic causes. Forty seven percent of the patients re- sponded to VIP1 and 20% to VIP2. In total 67% of Nociceptin, a novel endogenous ligand for the ORL1 patients achieved erections suf®cient for sexual receptor, has potent erectile activity in the cat intercourse. The most common side-effect was HC Champion, R Wang, WJG Hellstrom and PJ transient facial ¯ushing, as it was reported by 53% Kadowitz of the patients. Other side effects were truncal ¯ushing in 9%, bruising in 20% and pain from the Departments of Pharmacology and Urology, Tulane injection needle in 11%. It should be noticed that University School of Medicine, New Orleans, Louisi- none of the patients experienced priapism. ana, USA. Am J Physiol 1997; 273: E214±E219. Editorial Comment: In the era of the new developments in the ®eld of erectile dysfunction, with the Editorial comment: One may theorize that redun- oral agent and intraurethral alprostadil already dant erectile mechanisms exist to ensure a means for available in the market, little attention has been procreation and species survival. Nociceptin has paid to the group of patients who do not respond to been recently identi®ed as an endogenous ligand the even most ef®cacious intracavernosal combina- which binds to and activates the orphan opioid tions. Available data from an impressive number of receptor (ORL1) and shown to produce decreased clinical trials have shown that the new drugs have muscular tone in several peripheral organs in the rat limited ef®cacy to the so called `severe cases'. and mouse. With this knowledge, these investigators Future oral or intraurethral developments seem hypothesized that the ORL1 receptor is present in extremely dif®cult to cover this group of patients, the corpora cavernosum of the cat and offers an due to the systemic effects of the drugs. It is also alternative pathway that mediates cavernosal well known that a certain percentage of patients smooth muscle relaxation responses. Intracaver- who do not respond to any injectable drug combina- nosal injections of nociceptin in anesthetized cats tion, do not favor a penile prosthesis implantation. resulted in potent, long-lasting erectile responses, Such observations make clear the necessity for the comparable with erectile responses elicited by development of new, more potent injectables. The Review of Impotence Literature paper shows that VIP1 & 2 may be useful in such postoperative erections, 67% of patients reporting 201 cases, as it is effective, with minor side-effects. The potency had severely reduced rigidity, and only lack of priapism is not surprising, as patients who 12% were able to achieve full erections. The authors do not respond to high doses of drug combinations concluded that the incidence of incontinence and have severe cavernosal veno-occlusive dysfunction. impotence following radical prostatectomy is high, In such patients we are mainly aware of major but the impact of these complications appears to be systemic effects due to systemic absorption of the surprisingly low. vasoactive agents. The minor side-effects noticed in the present study make the new combination an attractive alternative to the existing injectable solu- tions. Crossover studies are necessary to further Editorial comment: During the last ®fteen years, early diagnosis of prostate cancer has led to an determine the ef®cacy and safety pro®le of this increasing number of patients with post-prostatect- promising new combination. omy erectile dysfunction. The introduction of the D Hatzichristou, MD nerve-sparing technique on the other hand, made this type of surgery more appealing, as it helped not Prevalence and impact of incontinence and only to preserve potency but also continence. There impotence following total prostatectomy assessed is certainly a great deal of discussion about the anonymously by the ICS-Male Questionnaire. ef®cacy of the technique in preserving potency, as other factors (for example damage of vascular Bates TS, Wright MP and Gillatt DA structures) may cause or contribute to postoperative Bristol Urological Institute, Southmead Hospital, impotence. Other critical issues however, such as UK. patients expectations, have been dismissed. The authors found that most of their patients did not Eur Urol 1998; 33: 165±169. report impotence as a signi®cant complication. In addition, 41% reported potency postoperatively, This study, using the ICS-male questionnaire, although only 12% had full erections. Such data assessed the incidence of incontinence and impo- demonstrate that many patients considered them- tence in patients following radical prostatectomy selves potent, although their erections were not ®rm and the impact of these two conditions on patients enough for vaginal penetration. This observation quality of life. A total of 87 patients (mean age 65 y) clearly shows that preoperative potency status and were included, who had undergone radical retro- patients desire to preserve potency are critical issues pubic prostatectomy by the same surgeon, during 8 y in preoperative counseling. In addition, a more period. Eighty-three (95%) of the patients completed extensive surgery that ultimately will be more the questionnaire. The mean interval between effective in removing the tumor should be always surgery and the completion of the questionnaire considered, while nerve-sparing technique should was 22 months. Postoperatively, 69% (57 out of the be performed only in cases where it is equally 83) of the patients reported some degree of leakage effective in eradicating the tumor. Today, with of urine, but only 34% of them considered incon- several treatment options available for impotence, tinence as a problem. Of the 74 patients, who were the ®rst goal in performing radical prostatectomy potent prior to surgery, only 30 remained potent should be to remove all of the cancer, second to postoperatively (potency rate 41%). However, 10% preserve continence (as treatment options are lim- of all patients considered postoperative impotence ited) and third to preserve potency to be a serious problem, while 47% stated that it was not a problem at all. Regarding the quality of their D Hatzichristou, MD