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ABSTRACT
Year : 2015  |  Volume : 7  |  Issue : 6  |  Page : 62-88  

Erectile Dysfunction


Date of Web Publication10-Jul-2015

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How to cite this article:
. Erectile Dysfunction. Urol Ann 2015;7, Suppl S2:62-88

How to cite this URL:
. Erectile Dysfunction. Urol Ann [serial online] 2015 [cited 2020 Jan 23];7, Suppl S2:62-88. Available from: http://www.urologyannals.com/text.asp?2015/7/6/62/160672

Impotence and penile prosthesis

Dr. Faris M. Ayyat


Aramco Surgical Services Division, Dhahran, Saudi Arabia

Thirty male patients were treated at Dhahran Health Center between 1988 and 1990 for organic impotence by surgical exploration and penile prosthesis implantation. The average patient age was 55 years with a range of 32-67 years. An average follow up of 18 months. The symptoms of sexual dysfunction were of more than one year's duration. Preoperative evaluation included history and physical examination, hematological work-up, urine analysis, culture and sensitivity, hormonal assay, nocturnal penile tumescence and occasional psychiatric evaluation. The main etiology of impotence in this group was diabetes in 60%. Other causes will be discussed. The average hospital stay was 5 days. Penile implants were 66% of the inflatable type and 34% of the malleable type, both manufactured by A.M.S. Company. Complication rate of 13%. Two patients had oversized prosthesis and one pair had to be removed in each patient but both had satisfactory intercourse with one pair only. One patient had mechanical failure and one patient had infection of the skin and the glans penis.

In conclusion, all patients were essentially satisfied with the results and we conclude that penile implant surgery is the ideal treatment for organic impotence in the properly selected patients and surgeons should avoid over dilation of the corpora cavernosa and should use a size smaller than the measured corpora and penile implant should not be the first choice of treatment for organic impotence. Other procedures and manoeuvres should be attempted initially.

Presented at the: 6 th Saudi Urological Conference

National Guard King Khalid Hospital - Jeddah

27-28 November 1991

Prostaglandin E1 in erectile dysfunction in Saudi Arabia

Dr. Abdulmalik Tayeb


Al Hada Military Hospital, Al Hada, Saudi Arabia, Pierre Calcat, M.D., Lyon University, France

A total of 44 patients with different types of erectile dysfunction, 61% of which were diabetic, were treated with Prostaglandin E1 in different doses over an 18 month period. There were no significant reported complications and there were encouraging results.

The study included:

1. Teaching the patients how to inject themselves.

2. The stability of the drug.

3. The mode of action of the drug.

4. Complications and satisfaction of the patient.

Presented at the: 6 th Saudi Urological Conference

National Guard King Khalid Hospital - Jeddah

27-28 November 1991

Double-blind randomised crossover study comparing intracorporeal prostaglandin E1 with combination of prostaglandin E1 and lidocaine in the treatment of organic impotence

S. Kattan


Department of Urology, King Saud University and King Khalid University Hospital, Riyadh, Saudi Arabia

In patients with organic impotence, intracorporeal Prostaglandin E1 pharmacotherapy is often accompanied by pain at the site of injection and through the subsequent induced erection. Twelve such patients who had previously experienced pain with intracorporeal Prostaglandin E1 injections were submitted to a double blind randomised cross-over study in order to comparatively evaluate the effects of intracorporeal Prostaglandin E1 alone and in combination of Lidocaine.

With Prostaglandin E1 monotherapy (20 ug) 91.6% of patients experienced pain and 33% had an adequate erection. With combination therapy (Prostaglandin E1 20 ug plus Lidocaine 1% 1 cc) 58.3% of patients experienced pain and the adequate erectile response rate was 67%. In addition, 30% noted enhancement in the duration of erection. We conclude that Lidocaine can be usefully combined with intracorporeal Prostaglandin E1 pharmacotherapy with alleviation of pain and enhancement of erectile effect.

Presented at the: 7 th Saudi Urological Conference

Riyadh Armed Forces Hospital

11-12 November 1992

Impotence in Saudi males: aetiology and risk factors

Said Kattan


King Khalid University Hospital, Riyadh, Saudi Arabia

A retrospective study was designed to study the aetiology of impotence and the prevalence of the associated risk factors in Saudi males. The study included 178 Saudi male patients presenting with impotence in the period between 1989 to 1994. Their age ranged between 22 and 81 years, mean 52.6 years with the majority of patients above the age of 50 years. The aetiology of impotence was related mainly to organic causes in 82% of cases. Arterial insufficiency and low serum testosterone were the most frequent diagnosis elicited in 57.3% and 18.9% of cases respectively. Old age, diabetes, smoking and cardiovascular disease were the most frequent encountered risk factors. There was no statistical difference in the mean age of onset of impotence between diabetic and non-diabetic and also between smokes and non smokers. Control of diabetes, anti-smoking campaign and correction of hypogonadism may reduce the prevalence of impotence among Saudi males.

Presented at the: 9 th Saudi Urological Conference

King Fahad Hospital - Jeddah

14-16 November 1995

Penile prosthesis long term follow-up

Mostafa K. Mansi


King Fahad National Guard Hospital, Riyadh, Saudi Arabia

Eighty-two patients with erectile dysfunction refractory to other treatment modalities were managed by surgical implantation of malleable penile prosthesis (69 patients) and inflatable penile prosthesis (31 patients). Their age ranged between 23 and 71 years with a mean age of 49.7 years. Sixty-three patients were followed between 6 and 91 months with a mean of 32.7 + 19.4 months. Among these patients 51 received malleable and 12 received inflatable prosthesis was significantly higher than among patients with malleable prosthesis. Peri-prosthetic infection occurred in 2 patients with inflatable prosthesis while no infection was reported among patients with malleable rods. Satisfaction with length and girth of the penis was much better among patients with malleable prosthesis. Concealment was not of much concern as the Thobe helps hiding in the permanently erect penis.

Conclusion: Penile prosthesis implantation is an acceptable treatment modality among Saudi patient suffering from refractory impotence.

Presented at the: 9 th Saudi Urological Conference

King Fahad Hospital - Jeddah

14-16 November 1995

Saudi patients acceptance and satisfaction with nonmedical treatment of impotence

S. Kattan


Urology Section, King Khalid University Hospital, Riyadh, Saudi Arabia

Objective:
To evaluate the acceptance and satisfaction of Saudi patients with nonmedical treatment modalities of impotence including vasoactive intracavernous pharmacotherapy, external negative pressure device and penile prosthesis.

Set-up: Erectile Dysfunction Unit, Urology Section, Department of Surgery, King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia.

Methods: The medical records of 100 consecutive Saudi patients treated for impotence with nonmedical treatment modalities in the period between 1990-1995, were reviewed in a retrospective study.

Results: Eighty-one male patients were enrolled in vasoactive intracavernous pharmacotherapy program. 92.8% proceeded with home treatment after dose determination and injection technique teaching phase, however, the drop rate was 32% and 50% at six and twelve months of follow up respectively. The main causes of dissatisfaction and drop out was lack of spontaneousity 16.5%, inconvenience 14%, unsatisfactory erection 13%, gradual decrease in erectile response 13%, and erection associated pain in 6.5%.

Out of thirty patients who were offered external negative pressure device, 65% of patients agreed to use the device at home after teaching phase. The drop rate was 39% and 62% at 6 months and 1 year of follow up respectively. The main cause of dissatisfaction was poor erection 53.5%, loss of ejaculation 21.4% and lack of spontaneousity 18%.

Thirty-two patients had insertion of Penile Prosthesis (13.3% Malleable, 76.7% inflatable). 30.5% of patients selected surgery for penile prosthesis insertion as first line of treatment while 69.5% of patients refused prosthesis except after trial of less invasive treatment modalities. Minor surgical and postoperative complications occurred in 19% while serious complications leading to loss of prosthesis were encountered in only 2 patients (6%). The satisfaction rate after 6 months and 1 year postoperatively was 93.5% and 87.5% respectively. The main cause of dissatisfaction was loss of prosthesis due to infection or extrusion in 2 patients (6.25%) SST deformity in 1 patient (3%) and difficulty with prosthesis activation in 4 patients (12.5%).

Conclusion: Vasoactive intracavernous therapy had the highest acceptance rate among Saudi impotent patients while penile prosthesis had the lowest. However, the highest patient satisfaction rate is achieved with penile prosthesis followed by vasoactive intracavernous pharmacotherapy. External negative pressure devises had poor acceptance and satisfaction among Saudi males. These results should be considered during counselling of impotent patients regarding their treatment options.

Presented at the: 10 th Saudi Urology Conference

King Fahad National Guard Hospital

26-28 November 1996

Erectile function assessment after kidney transplantation

Waleed Al Khudair, Mostafa Mansi, Sameer Huraib


King Fahad National Guard Hospital, Riyadh, Saudi Arabia

Erectile dysfunction is a common problem in male patients with end stage renal disease which is multifactorial. Twenty-three married kidney transplant male patients were studied regarding the change in their sexual activity after transplantation. Their ages ranged between 23 and 66 years. All patients underwent hemodialysis before transplantation for periods ranging from 2 months to 8 years. They all had stable kidney function 7 to 85 months after transplantation. Twelve patients have received cadaveric, 5 living related and 6 living unrelated kidneys.

After transplantation, 3 (13%) patients noticed increase libido, 14 (61%) reported no change and 6 (26%) suffered decreased libido. Frequency of sexual intercourse per month has increased significantly after transplantation in 4 (17.4%), unchanged in 7 (30.4%) and significantly decreased in 12 (50.2%) patients. The overall satisfaction with the quality of erection and sexual performance has decreased from 82.6% before transplantation to 39% after transplantation.

Intracavernosal injection of 20 microgram Prostaglandin E1 (PGE1) gave satisfactory in-office erection in 13 (56.5%) patients and 40 microgram PGE1 gave good erection in another 6 patients. Two patients had good erection with intracavernosal injection at home. Seventeen patients were enrolled in intracavernosal self-injection program for 3 to 15 months with complete satisfaction in all of them and no compromise of their kidney function. There were no local or systemic complications reported.

Conclusion: This study shows that erectile dysfunction is a common problem among chronic renal failure patients and does not seem to improve significantly after transplantation. It needs more attention from the treating physicians, especially in relatively young kidney transplant patients. Intracavernosal self-injection of PGE1 alone or in combination with Papaverine is a valid treatment option, it gives satisfactory and safe results.

Presented at the: 10 th Saudi Urology Conference

King Fahad National Guard Hospital

26-28 November 1996

Penile implants in the treatment of organic impotence

Moheb Milad


Surgical Services Division, Saudi Aramco Dhahran Health Center, Dhahran, Saudi Arabia

Objectives: To evaluate the reliability and safety of penile implants in the treatment of organic impotence at the Saudi Aramco Dhahran Health Center.

Patients and Methods: A series of 108 cases of organic impotence underwent 125 penile implantation procedures between 1988 and 1997 was reviewed. The follow up period ranged between 6 months and 10 years. The mean age was 57.9 years (range 26-76). The prostheses used were AMS (American Medical System). Inflatable (92 cases) and malleable (16 cases).

Results: There was no complication in 86 patients (79.6%) who had functioning prosthesis all through the follow up period. Revision of the implants was required in 13 patients (14%). The causes of revision were severe infection (1), intolerable pain from an oversized malleable prosthesis (1), and dysfunction of the inflatable prosthesis (11). Removal of the implant was necessary in severe infection (6), intolerable pain (2) and extrusion of the prosthesis (1). All the 9 patients (8.3%) had inflatable prosthesis and refused a second implant. There was no single mortality among our series. The overall procedure complications involved 26 out of 125 procedures (20.8%). It was shown that malleable penile prosthesis have significantly lower procedure complications than the inflatable ones (P<0.05).

Conclusion: Penile implants are reliable and safe modality of treatment for organic impotence with acceptable morbidity.

Presented at the: 13 th Saudi Urological Conference



14-17 February 2000

(09-12 Dhu Al Qa'dah 1420)

Riyadh Armed Forces Hospital

Erectile dysfunction comparison of sildenafil with alprostadil

Faris M. Ayyat


Surgical Services Division, Saudi Aramco Dhahran Health Center, Dhahran, Saudi Arabia

Materials and Methods: In 1997, 100 patients used Alprostadil (Muse) intraurethrally. 17 patients had cardiac disease. A physician did the test and patients were placed under observation. Pre and post-insertion vital signs were recorded. Immediately erection occurred between 5-10 minutes after insertion.

Results: Of the 100 patients, 50% had a satisfactory erection for penetration and 15% had an incomplete erection and 35% failed and no serious complications happened. 17 patients who failed Muse, who did not have cardiac problems, were placed on Sildenafil Citrate 50mg. Of these 15 patients had a good response as reported by patients. 2 had no response.

Conclusions: Although Muse is a safe medication in cardiac patients the success rate is only 50%. A patient who fails Muse can benefit from Sildenafil Citrate unless there is a major contraindication. We recommended both drugs to be used as indicated.

Presented at the: 13 th Saudi Urological Conference



14-17 February 2000

(09-12 Dhu Al Qa'dah 1420)

Riyadh Armed Forces Hospital

Alprostadil therapy: preliminary clinical observations

Egail SA, El-Sayed EA, Ezzibdeh MY, Al-Oraifi I, Al-Dayel A.


King Fahd Military Medical Complex, Dhahran, Saudi Arabia

Objectives: Alprostadil is widely used for the treatment of impotence. We evaluated the efficacy and tolerance of alprostadil administered intrauretherally for the treatment of erectile dysfunction (ED).

Methods: Prospectively we studied 54 consecutive patients with ED (mean age 52 years, range 26-79). All patients completed a baseline International Index of Erectile Function questionnaire (question 2, 3, 5 and 12), underwent a physical examination, a hormone profile and a cause of ED was then assigned. A transuretheral delivery system (MUSE) for alprostadil was used to give 500 to 1000 ΅g of the drug and penile responses were evaluated with erection assessment scale. Patients who had successful results were reviewed after one week and at 3-months interval.

Results: The mean duration of ED was 47 (range 4-120) months. The causes of Ed were psychological (28%), diabetes (28%), mixed diabetes and hypertension (17%) and hypertension (9%). Of these 54 patients, 3 (5%) had rigid erection while 17 (31%) achieved an erection judge by the patient to be sufficient for intercourse and 20 (37%) were dissatisfied with the response. Penile pain occurred in 385 of patients, 2% experienced urethral bleeding. Of the 20 patients achieving satisfactory erections at home, 5 (25%) chose not to continue the therapy because of urethral discomfort or penile pain.

Conclusions: Unlike the clinical trails, our initial results with MUSE therapy are poor, only 28% of our unselected patients found MUSE an effective and acceptable therapy to achieve an erection suitable for penetration.

Presented at the: 13 th Saudi Urological Conference



14-17 February 2000

(09-12 Dhu Al Qa'dah 1420)

Riyadh Armed Forces Hospital

The role of penile duplex ultrasonography in predicting the response to sildenafil (viagra) in diabetic patient

Kattan S, Lindstedt E, Hanash K, Kardar AH, Al Zahrani H, Merdad T, Peracha A, Aslam M


Department of Urology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

Objective: To assess the role of penile duplex ultrasonography in predicting the response of diabetic patients to Sildenafil.

Materials and Methods: 25 diabetic patients complaining of impotence were included. All patients underwent penile duplex ultrasonography and were treated with Sildenafil. The clinical response was correlated to the findings of penile duplex ultrasonography.

Findings: 75% of patients had normal dilatation of the cavernosal artery while 40% and 32% had moderate or severe abnormalities respectively. There was statistical significant difference between patients in the normal and moderate abnormalities group and the patients with severe abnormality group. 40% of patients had normal MSV while 36% and 24% of patients had moderate to severe impairment. Favorable and clinical response to Sildenafil was achieved in 80%, 88% and 33% of these groups respectively. There was statistically significant difference in clinical response between the group of patients with normal and moderate decrease in MSV and the group with severe decrease in MSV. 44% of patients had normal EDV while 32% and 24% of patients had moderate to severe increase in EDV. Favorable clinical response was achieved in 73%, 62% and 83% of these groups respectively. There was no statistically significant di8fference in response between any of these groups.

Conclusions: Determination of cavernosal artery diameter and MSV by penile duplex ultrasonography can be helpful in predicting the response of diabetic patients to Sildenafil. Determination of EDV was not a useful parameter. Patients with severe reduction in MSV and/or with very poor cavernosal artery dilatation during ultrasonography are unlikely to respond to Sildenafil and should be considered for alternative treatment.

Presented at the: 13 th Saudi Urological Conference



14-17 February 2000

(09-12 Dhu Al Qa'dah 1420)

Riyadh Armed Forces Hospital

Cardiovascular safety of sexual activity

R. Shabsigh


Department of Urology, College of Physicians and Surgeons of Columbia University, New York, USA

Introduction: Sexual activity has often been compared to other normal physical activities like walking or running, or to emotional states of anger or fear. The effect of sexual activity on the heart, blood pressure, and oxygen consumed is only a little greater than the effects during sexual arousal. There can be some differences due to individual circumstances surrounding the sexual activity: type of sexual stimulation, familiarity with partner, intercourse position, consumption of alcohol, food, etc. But, in general, sexual activity is similar to mild to moderate exercise for most individuals with or without coronary artery disease. Heart rate during sex rarely increases to 130 beats per minute and blood pressure rarely exceeds 170.

A standard way of measuring physician exertion is MET (metabolic equivalent of energy expenditure at the resting state). MET values have been assigned to a variety of daily activities. For example, walking at 2 miles per hour is assigned an energy expenditure of 2 METs. Sexual activity is given 2 to 3 METs prior to orgasm and 3 to 4 METs during orgasm. Some young people have reached 5-6 METs, but the lower range is the norm for older individuals or those in long-established relationships.

Fewer than 1% of heart attacks occur during sex. A 50-year old man in the United States has a baseline yearly risk of heart attack of about 1%. This risk increases only slightly to 1.01% during sexual activity. Even a high-risk man who's had a previous heart attack has only a 1.10% risk of heart attack during sex.

Treatment of Heart Disease and ED: The chance of ED occurring in men with cardiovascular disease is higher than that in the general population. ED occurring in a male who was previously fine might indicate coronary artery disease. Patients with the onset of ED are frequently curious whether they should have complete cardiac evaluation. At this time there is no adequate evidence to support such a far reaching recommendation. Until evidence and guidelines are established, perhaps a compromise would be to recommend cardiac evaluation to high heart risk patients presenting with ED. ED and cardiovascular disease share many of the same risk factors and frequently occur together. Risk factors for heart disease include: age, male, high blood pressure, diabetes, obesity, cigarette smoking, high cholesterol, sedentary lifestyle.

Patient to be at risk for heart disease are classified into high, low and intermediated categories. The large majority of patients are in the low-risk category. This includes those with:

1. controlled hypertension.

2. mild, stable (being treated angina)

3. successful by-pass surgery (revascularization)

4. a history of uncomplicated myocardial infarction

5. mild disease of heart valves

6. no symptoms of heart disease and less than 3 cardiovascular risk factors.

7. mild congestive heart failure (class 1).

A patient in the low risk category can initiate and resume sexual activity and seek treatment for ED if needed. It is important to continue with routine follow up and monitoring of the risks for heart disease every 6 to 12 months.

The patients in the intermediated-risk category include those with:

1. moderate stable angina

2. a recent MI (less than 6 weeks prior)

3. left ventricle dysfunction and/or class 2 congestive heart failure

4. nonsustained low-risk irregular arrhythmia

5. three or more risk factors for coronary artery disease

A patient in this category should undergo additional evaluation and specialized cardiac testing to determine if the patient will progress to the high-risk category or return to the low-risk category. Men in the high-risk category included those with:

1. unstable or resistant to treatment angina

2. uncontrolled hypertension

3. congestive heart failure (class 3or 4) or

4. very recent MI (less than 2 weeks) or stroke

5. high risk arrhythmias

6. moderate to severe heart valve disease

A patient in this high-risk group should have his cardiac condition stabilized with specialized treatment. The heart condition needs to be completely evaluated, treated and stabilized before resuming any sexual activity or get treated for ED. When that is accomplished the patient will then be able to resume sexual activity or begin treatment for ED.

Resuming sex after heart attack: Although it is common for men who have had an MI or coronary artery by-pass surgery to experience ED after surgery, they and their partners should not come to the notion that they can never resume their normal sex life. Decrease in sexual desire and ED caused by various heart medications can be addressed.

Usually, the couple has a greater concern: the fear that the exertion from engaging in sexual intercourse will cause another heart attack. Sadly, because of this fear, over 50% of all post-MI and post-coronary artery bypass patients never resume a satisfactory sexual life. That need not happen. The fear of inducing another MI while having sex may be real, but there are no facts to back it up. In fact, various research studies show that having sex or reaching an orgasm is no more strenuous than any other moderate exercise. There is no reason not to be able to resume sexual activity 6 to 8 weeks after an MI. Some patients who have successfully completed a stress test may be allowed to resume sex after only 3 to 4 weeks.

The heart medication, Digoxin, has the highest occurrence of causing ED. Digoxin causes the blood vessels to contract, and contraction is the opposite of what is needed to attain an erection. An erection required relaxation of tissues and dilation of the blood vessels.

Here are the facts from one study completed in 1996 by J.E. Muller and reported in the Journal of the American Medical Association.

· The risk of MI in a healthy 50-year-old man in the US is 1% per year, or 1 per million men per hour.

· The absolute risk of a MI occurring during sex or within two hours after sex is 2.5 men per million per hour.

· The relative risk of a MI occurring during sex or within two hours after sex is 2.5.

· In men who have had an MI, the relative risk of a recurrent MI during or after sex is 2.9.

There are however, other risk factors that can trigger another MI. Extreme anger doubles the risk and extreme exercise (like shoveling snow) increases the risk of another MI 15-times! The risk of having an MI during or after sex is very low. And besides that, it is medically proven that sex with your spouse is even less risky than extramarital sex.

Presented at the: 14 th Saudi Urological Conference



13-15 February 2001

(19-21 Dhu Al Qa'dah 1421)



King Fahd Military Medical

Complex - Dhahran

Treatment of erectile dysfunction with sildenafil (viagra)

Al Zahrani A, Egail S, Al Dayel A, Ezzibdeh M, Al Oraifi I, El Sayed E.


Urology/Nephrology Department, King Fahd Military Medical Complex, Dhahran, Saudi Arabia

Objective: To evaluate the effectiveness of Sildenafil (Viagra) in the treatment of male erectile dysfunction in a clinical setting at King Fahd Military Medical Complex.

Methods: In a prospective open-label study, 97 patients with mean age 50 years (range 25-76) a mean duration of ED 3.5 years (range 1.0-10), received 50-100mg Sildenafil one hour prior to sexual activity. Patients completed the Sexual Health Inventory for Men (SHIM) [a brief version of International Index of Erectile Function IIEF-5] questionnaire at baseline and after 6-8 weeks period of treatment. Responses to questions were graded using 5-point scale, with higher scores indicative of favorable outcomes.

Results: The etiology of ED in these patients was 70.3% organic, 24.1% psychogenic and 5.6% mixed. The prevalence of other medical conditions is as follows: diabetes 42.6%, hypertension 24.1%, hyperlipidemia 9.4% and other diseases 11.0%.

There was statistically significant improvement in total SHIM scores (11.4 + 4.8 to 20.7 + 6.5; P<0.001), ability to achieve erection (2.6 + 1.1 to 4.2 + 1.3; P<0.001) and sexual intercourse satisfaction (1.9 + 0.9 to 3.9 + 1.4; P<0.001) with the use of Sildenafil. 86% of patients reported that the treatment had improved their erection and 77% desired to continue the treatment.

Conclusion: Sildenafil is an effective treatment for men with erectile dysfunction of broad spectrum etiology.

Presented at the: 14 th Saudi Urological Conference



13-15 February 2001

(19-21 Dhu Al Qa'dah 1421)



King Fahd Military Medical

Complex - Dhahran

Renal failure and male sexual dysfunction: prones and cones

Fallatah AB, Shehab AB, Abu Zaid MM, Said IMA, Tantawy W, El Sheik TF, Shaheen FAM


King Fahd Hospital - Jeddah, Al Salama Hospital - Jeddah, Bashrahel Hospital - Makkah, Eist Arfan Hospital - Jeddah, Saudi Arabia

The incidence and pathogenesis of male sexual dysfunction were studied among 70 uremic patients on hemodialysis. Fifty seven patients were found to have erectile dysfunction. They were thoroughly evaluated using history physical examination, measurement of Follicle stimulating hormone (FSH), leutinizing hormones (LH), prolactin, testosterone, snap gauge band test, Minnesota Multiphasic Personality Inventory and penile cutaneous perception threshold. Extensive penile hemodynamic studies including penile prostaglandin E1 (PGE1) injection, pharmaco-penile Doppler ultrasound, pharmaco-cavernosometry and caversonography. Snap gauge band test was normal in 12 cases. Twenty one impotent patients had peripheral neuropathy.

Cutaneous perception threshold was high among 16 cases (28%). Fifty four out of 57 studied patients (94%) had abnormal response to penile injection. Venous leak was diagnosed in 94.4% of patients, however abnormal cavernosal arteries by penile Doppler were detected in 12 patients (22.2%).

Hyperprolactinaemia was detected in 43 patients (75.4%). Testicular failure with low testosterone was diagnosed in 17 cases (29.8%). Endocrinal, vascular and neuropsychiatric defects were the major factors responsible for this pathologic disorder.

Such study might help in the management of this disability in an organized pathology directed manner.

Presented at the: 14 th Saudi Urological Conference



13-15 February 2001

(19-21 Dhu Al Qa'dah 1421)



King Fahd Military Medical

Complex - Dhahran

The impact of viagra on urologic practice

R. Shabsigh


Department of Urology, College of Physicians and Surgeons of Columbia University, New York, USA

Sildenafil is indicated for the treatment of male erectile dysfunction. It is not at this time approved for use by women. The Sildenafil clinical trial inclusion criteria have mimicked the clinical practice characteristics including men (18 years of age or older) with a documented clinical diagnosis of erectile dysfunction of at least 6 months duration. Thus patients with a broad age range, etiology and degree of baseline severity were included in the clinical trials. Special population studies have included patients with diabetes mellitus, spinal cord injury and more recently the post-radical prostatectomy population.

The post-radical prostatectomy patients make up a special population for a number of reasons. Many of the patients have no ED prior to surgery. The onset of ED is sudden. The majority are otherwise healthy with long life expectancy. Since the mechanism of action of sildenafil involves the nitric oxide pathway thus depending for its activation on sexual stimulation transmitted through the nerves, it is expected that nerve injury during radical prostatectomy will result in non-response to sildenafil. This expectation has been confirmed in the studies of Zippe et al. demonstrating that the success of sildenafil in the treatment of ED after radical prostatectomy was highest in patients undergoing bilateral nerve-sparing technique, lower in patients undergoing unilateral nerve-sparing and lowest in patients undergoing bilateral nerve resection. Such data should serve as an incentive for attempting nerve-sparing as much as possible. Another important observation was that of Hong et al. A retrospective analysis of the efficacy of sildenafil in treating ED following nerve-sparing radical prostatectomy showed increasing efficacy over time after surgery. The practical implication of this study is that an initial failure of sildenafil in the early post operative period does not rule our later success.

The nerve-sparing approach to radical prostatectomy has significantly improved post-operative erectile function. In a subgroup analysis of patients post-radical prostatectomy (n=142) who had participated in the pivotal American clinical trials, 42.5% of those patients receiving sildenafil demonstrated improved erections as compared to 14.6% of patients receiving placebo. The intercourse success rate in the sildenafil group was nearly 30% as compared to less than 5% for the placebo group. However, the study population was a heterogenous group of nerve-sparing and more so non-nerve sparing patients. In a study performed by Montorsi et al., there is clear demonstration of the value of early institution of intracavernosal pharmacologic therapy in improving the return of spontaneous erections in this population of patients from a dismal 20% to 50-70%. Will early intervention with sildenafil have the same 'prevention' benefit? This question no doubt would soon be answered. The literature also has shown significant efficacy for Viagra in patients post external radiation therapy and brachytherapy for prostate cancer.

Patients with clinically significant penile anatomical deformities (Peyronie's disease, congenital chordee and corporeal fibrosis) were excluded from clinical trials due to the potential difficulty in assessing the end-point of successful sexual intercourse. As such, in the labeling, cautioned is indicated in the use of sildenafil for these patients. However, following FDA approval, the field experience of sildenafil in such patients indicates that it is safe and effective.

With the introduction of successful oral therapy with sildenafil (Viagra), the socioeconomics of ED have been changed forever. The ED patient base has expanded significantly and rapidly with more patients presenting for treatment. Although the majority of prescriptions for ED come from primary care physicians, urology is still a very important specialty for the care of patients with ED. New research is promising to bring new oral medications into ED oral therapy, thus predicting further expansion of the patient base. With such expansion, urology as a specialty is at a crossroads probably with the need to redefine its role and strategic positioning.

Presented at the: 14 th Saudi Urological Conference



13-15 February 2001

(19-21 Dhu Al Qa'dah 1421)



King Fahd Military Medical

Complex - Dhahran

Female sexual dysfunction: Current status and future directions

R. Shabsigh


Department of Urology, College of Physicians and Surgeons of Columbia University, New York, USA

Key words: Female sexual dysfunction.

Definitions and Classification: Female sexual dysfunction (FSD) includes a group of disorders whose definition has been evolving. The lack of a standard classification system has hindered both epidemiologic and clinic outcomes research. For example, variable definitions make prevalence estimates of specific dysfunctions from various populations difficult to compare and without clear definitions, drug studies may fail to find import effects due to inclusion of heterogeneous populations.

Previously, FSD has been classified using the WHO International Classification of Diseases [1] and the Diagnostic and Statistical Manual of Mental Disorders. [2] Both of these systems include disorders of low desire, sexual aversion, arousal disorder, orgasmic dysfunction, dyspareunia and vaginismus but differ in the attribution of these problems to physical versus psychological causes and the degree of associated distress. In 1998, an international, multi-disciplinary consensus panel was convened to "develop a classification system that would include psychogenic and organically based disorders" and the following definitions were proposed. [3] Each disorder is sub-typed as lifelong versus acquired, generalized versus situational and by etiologic origin (organic, psychogenic, mixed, unknown). An important criterion for diagnosis of the non-pain disorders is the presence of personal distress. Thus, a woman who has never experienced orgasm, but is not distressed by this, would not be diagnosed with orgasmic disorder.

Sexual desire disorders:

1. Hypoactive sexual desire disorder: the persistent or recurrent deficiency (or absence) of sexual thoughts/fantasies, and/or desire for or receptivity to sexual activity which causes personal distress.

2. Sexual aversion disorder: the persistent or recurrent phobic aversion to and avoidance of sexual contact with a sexual partner, which causes personal distress.

Sexual arousal disorder: The persistent or recurrent inability to attain or maintain sufficient sexual excitement, causing personal distress, which may be expressed as a lack of subjective excitement, or genital (lubrication/swelling) or other somatic responses.

Orgasmic disorder: The persistent or recurrent difficulty, delay in or absence of attaining orgasm following sufficient sexual stimulation and arousal, which causes personal distress.

Sexual pain disorder:

1. Dyspareunia: the recurrent or persistent genital pain associated with sexual intercourse.

2. Vaginismus: the recurrent or persistent involuntary spasm of the outer third of the vagina that interferes with vaginal penetration, which causes personal distress.

3. Non-coital sexual pain disorder: the recurrent or persistent genital pain induced by non-coital sexual stimulation.

Epidemiology: The National Health and Social Life Survey (NHSLS), conducted in the early 1990's, was a large-scale, population-based study of the sexual behaviour of a representative sample of 1749 US women aged 18 to 59 years. [4] As a small part of this large study, respondents were asked if they had experienced problems with seven aspects of sexual functioning during at least a few months of the preceding year. These data indicate that these sexual problems were highly prevalent. A multi-variate analysis identified several independent factors associated with the presence of FSD which eventually may prove to have a causal role. [5] Non-married women were somewhat more likely to experience difficulty with orgasm and sexual anxiety than married women. Highly educated women were half as likely to report low sexual desire, problems achieving orgasm, sexual pain and sexual anxiety as women who did not graduate from high school. The presence of emotional or stress-related problems, or low happiness and low physical satisfaction were associated with all categories of sexual dysfunction. Negative experience such as forced sex or adult-child sexual contact was highly associated with arousal disorder. These results highlight the importance of the social and psychological relational aspects of female sexuality which must be considered in addition to purely physiologic processes. [6]

Age-related changes in sexual functioning, including menopause, could affect an increasingly large number of women. By the year 2010, it is estimated that 39% of US women will be 45 or more years old. [7] Menopausal and peri-menopausal declines in sex steroids are often cited as causative factors in FSD. However, the incidence of FSD during and after menopause, and its relationship to hormonal changes, has yet to be determined by a well-conducted prospective study. In some women, menopause is associated with urogenital atrophy which can lead to dryness and narrowing of the vagina, and irritation, itching burning of perineal tissues. The NHSLS data indicate that lubrication difficulties become somewhat more prevalent with aging. Women aged 50 to 59 years were 1.4 (95% CI 0.91-2.15) times more likely to complain of difficulty with lubrication than women aged 18 to 29 years. The benefit of systemic and topical estrogen replacement for symptoms of urogenital atrophy is well-established, but effects of estrogen replacement therapy on sexual function remain speculative.

Difficulties of sexual functioning in women are widely prevalent, but the impact of these problems is unknown. Data from the NHSLS did not include a personal distress component. Thus, while many respondents reported low libido and lack of pleasure from sex, the importance of these complaints would depend on the degree of associated distress. Such distinctions are importance since many of those reporting sexual difficulties still describe their sexual relationships satisfying. Among 1,857 men and women either married or cohabiting, more than 80% were extremely or very physically pleased or emotionally satisfied by their sexual relationship despite the fact that only 29% of women always had an orgasm with their partner. [4]

Research recommendations

Until recently, insufficient research has been conducted in female sexual dysfunction (FSD). The recently-convened international multi-disciplinary consensus panel on FSD cited the lack of adequate experimental or clinical trial data and recognized the broad need for basic and applied research in the area. It is highly worthwhile to mention the panel's research recommendations in their entirely:

1. Epidemiological research on the prevalence, predictors and outcomes of sexual dysfunction in women is urgently needed.

2. Anatomic studies are needed to more precisely delineate the vital nerves, arteries and veins of the organs involved in normal female sexual function. This knowledge may lead to innovative nerve-sparing operative approaches during pelvic surgery.

3. Biological mechanisms of sexual arousal and orgasm in women are poorly understood at present, including the role of neurotransmitters and local vasoactive substances. Likewise, the role of steroid hormones in the modulation of sexual desire and arousal in women is not well understood.

4. The effects of aging and menopause, including among other things the role of hormones, psychosocial and interpersonal factors, medication use, and concomitant illnesses, on female sexual functioning are important areas for further research.

5. Many studies have noted a lack of association between physiologic and subjective concomitants of arousal in women. This phenomenon is only minimally understood at present. The determinants of sexual desire in women also remain to be investigated.

6. Urgent investigation is needed concerning the development of reproducible measurement devices and instruments for evaluating physiologic parameters of the female sexual response in the clinical setting. Parameters should include, but are not limited to, measurements of genital blood flow, genital engorgement, genital sensation, vaginal lubrication and vaginal elasticity.

7. Clinical trials of vasoactive agents, steroidal therapies and other medical treatment approaches are encouraged. It is uncertain whether vasoactive drugs, in widespread use for treatment of male erectile dysfunction, will have clinical utility in the treatment of sexual problems in women. Likewise, controlled outcome studies of psychosexual counseling for various sexual problems in women are strongly indicated. The safety and effectiveness of specific treatments in defined patient populations (e.g. post-menopausal, post-hysterectomy or other pelvic surgery, spinal cord injury, post-cancer therapy) remains to be evaluated.

8. Finally, most physicians and other health care providers receive little or no formal training in this area. Studies of physician awareness and competency in female sexual dysfunction are urgently needed.

Ethical considerations: The view of women's sexual problems evolves amid variable and continuous controversies. Evidence-based research is much needed in order to increase the level of objectivity in this field and avoid unsubstantiated dogmas and practices. An emphasis on comprehensive women's sexual health is indispensable. In addition close collaboration of all disciplines involved in female health will form the scientific foundation of ethics of FSD.

Summary: Female sexual dysfunction (FSD) is currently a very unique field of medicine. Its uniqueness is generated by several facts: it is highly prevalent; it is truly multi-disciplinary field with no single specialty capable of researching and servicing it alone; it is in a stage of early development with more questions than answers; research and development are progressing in various directions and the interest in this field is rising sharply. The latter is to the most part driven by the introduction of successful oral medications for the treatment of male erectile dysfunction. Pressure is building up rapidly in the society at large and in the academic arena, the pharmaceutical industry, the regulatory agencies, and the media to answer many questions about all aspects of female sexuality ranging from anatomy to physiology all the way through epidemiology, diagnosis and treatment. The newly established definitions of the various female sexual dysfunctions serve a very important role in this unique situation, forming the basis for progress. At the present, the top priority in FSD is strategic planning for research and development. A well-focused, step-wise and properly priotized plan for research in FSD will help academic centers organize their efforts. It will guide the pharmaceutical industry to employ its resources fruitfully. It will support regulatory agencies in the approval process of new treatments. Most importantly, strategic planning of research and development in ED will ultimately help the many women with FSD who have not found answers or help for many years.

References:

1. World Health Organization: ICD-10: International Statistical Classification of Diseases and Related Health Problems. World Health Organization: Geneva, 1992.

2. American Psychiatric Association: DSM-IV: Diagnostic and Statistical Manual of Mental Disorders, 4th Ed. Wash DC: American Psychiatric Press, 1994.

3. Basson R, Berman J, Burnett A, Derogatis L, Ferguson D, Fourcroy J, et al. Report of the International Consensus Development Conference on Female Sexual Dysfunction: Definitions and Classifications. Urology: 2000,163:888-893.

4. Laumann EO, Gagnon JH, Michael RT, Michaels S. The Social Organization of Sexuality. Sexual Practices in the United States. University of Chicago press, Chicago II, 1994.

5. Laumann EO, Paik A, Rosen R. Sexual Dysfunction in the United States: Prevalence and Predictors. JAMA: 1999,281:537-544.

6. Leiblum S. What every Urologist should know about female sexual dysfunction. Int J Impotence Res: 1999, 11 Suppl 1:539-40.

7. U.S. Bureau of the Census, Statistical Abstract of the United States: 1996 (116th Edition). Washington, DC, 1996.

Presented at the: 14 th Saudi Urological Conference



13-15 February 2001

(19-21 Dhu Al Qa'dah 1421)



King Fahd Military Medical

Complex - Dhahran

Intraurethral prostaglandin for erectile dysfunction

Faris M. Ayyat


Dhahran Health Centre, Aramco, Saudi Arabia

This is an attempt to evaluate the efficacy of intraurethral prostaglandin (MUSE) in the evaluation and management of erectile dysfunction of various etiologies. In this prospective study, 72 patients age 32-76 years were given a trial of Alprostadil intraurethrally during November and December 1997, in the outpatient urology clinic, for evaluation of its efficacy as a diagnostic and therapeutic modality. Of those patients, 61 responded immediately after administration of Alprostadil, (i.e. 85%) and 11 patients had no response, (i.e. 15%).

The response was classified as mild, moderate and satisfactory. Of the 41 patients, (i.e. 68%) had a satisfactory erection for penetration, 16% had a moderate erection and so they needed mild assistance, whilst 16% had a mild erection, i.e. not satisfactory for penetration. In general, 56% of the total group had a satisfactory response to medication.

No patient had any vital sign changes which were recorded pre and post administration of the drug. A few patients had dysuria and burning in the urethra, and one patient had mild hematuria. No priapism was reported. We were able to diagnose cases of venous leak. All 4 psychotic patients and all 4 post-radical prostatectomy patients had excellent response to therapy.

In summary, this prospective study has proven that more than 70% of the patients had satisfactory results with MUSE and the rest of the patients were diagnosed efficiently. Adverse reaction was very minimal. We recommend that intraurethral Alprostadil should be used as a diagnostic and therapeutic modality before surgical treatment is offered. It has no adverse reaction on cardiac patients.

Presented at the: 11 th Saudi Urological Conference

24-26 February 1998 (27-29 Shawwal 1418)



King Fahd Military Medical

Complex - Dhahran

Penile implants in the treatment of organic impotence

Soliman HET, Milad M, Zein T, Hussein EA


Saudi Aramco, Dhahran Health Center, Saudi Arabia

Objectives: To evaluate the reliability and safety of penile prostheses in the treatment of organic impotence at the Saudi Aramco Dhahran Medical Center.

Patients and Methods: A series of 108 cases of organic impotence, who underwent 125 procedures for penile implantation in the period 1988 and 1997, was reviewed and followed for a period between 9 months and 5 years. The mean age was 57.9 years (range 26-76). The prostheses used were AMS (American Medical System), inflatable (92 cases) and malleable (16 cases).

Results: There were no complications in 86 patients (79.6%) who had functioning prostheses all through the follow up period. Revision of implants (17 procedures) was required in 13 patients because of late dysfunction of the inflatable prostheses, severe infection and intolerable pain. One patient among this group had a malleable prosthesis, which needed revision because of severe pain due to oversize. With the 17 revision procedures a successful outcome could be achieved in 12 cases (92%). In 10 patients (9.2%) removal of the implant was necessary because of severe post-operative infection, intolerable pain or late extrusion of the prosthesis. All these cases had inflatable prostheses and refused to have replacement of a second implant. The overall procedure complications involved 27 out of 125 procedures (21.6%). It was shown that malleable penile prostheses had a significantly lower procedure complication rate than the inflatable one (P<0.05).

Conclusion: Appropriate selection of patients is mandatory prior to surgery. Malleable implants have less post-operative complications and revision rates. Penile implants are a reliable and safe modality of treatment for organic impotence, with acceptable morbidity.

Presented at the: 11 th Saudi Urological Conference



24-26 February 1998

(27-29 Shawwal 1418)



King Fahd Military Medical

Complex - Dhahran

The role of sildenafil (viagra) in impotent males treated with chronic intracorporeal vasoactive agents

Kattan S, Al Zahrani H, Kardar AH, Merdad T, Peracha A, Aslam M, Hanash K, Lindstedt Eric


Department of Urology, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia

Introduction: Sildenafil "Viagra" is a phosphoesterase (Type 5) inhibitor that had been proven effective in the treatment of the impotent males of organic and psychogenic etiology. Chronic administration of intracorporeal vasoactive agents is a common successful method of treatment for erectile dysfunction. The role of Viagra in the treatment of these patients who are on intracorporeal therapy is not known. A prospective study was thus designed to study the role of Viagra in patients who were successfully treated with chronic administration of intracorporeal agents.

Material and Methods: 44 male patients who had been receiving chronic intracorporeal therapy for their impotence were included in the study. All of them received Viagra 25-100 mg tablet starting with 50 mg and adjusting the dose according to their response. The quality of erection, side effects and patient satisfaction with intracorporeal therapy and Viagra were recorded. Erection was graded I (unsatisfactory), grade II (satisfactory) and grade III (very satisfactory).

Results: The etiology of impotence was arterial insufficiency in 75% of patients, neurogenic in 9% of patients, veno-occlusive disease in 7% of patients and psychogenic in 9% of patients. Their mean age was 53 years (21-71 years). The quality of erection was grade II and grade III in 31.9% and 68.1% of patients receiving intracorporeal therapy, while it was grade I, II and III in 22.7%, and 55.6% of patients who received Viagra. Of the patients who had grade III erection with IC therapy, favorable response with Viagra occurred in more than 86.6% of patients, while patients who had grade II erections with IC therapy, a favorable response with Viagra was 50.7%. No significant side effects were elicited with both treatment modalities.

Conclusion: Sildenafil is an effective drug in patient who receives chronic intracorporeal treatment for their impotence with a favorable rate of 78%. Patients who had an excellent response to IC treatment were expected to have a better response rate compared to patients with an average response. No significant side effects were encountered with treatment with Viagra in these patients.

Presented at the: 12 th Saudi Urology Conference



23-25 February 1999

(7-9 Dhu Al Qa'dah 1419)



Al Hada and Taif Armed Forces

Hospitals Program

Comparative studies of goal oriented therapy for erectile dysfunction in american and saudi arabian patients

Hanash KA, Kattan S, Lindstedt E, Al Zahrani H, Merdad T, Kardar A, Peracha A, Aslam M.


Department of Urology, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia

Goal oriented therapy for erectile dysfunction was offered to 460 American and 600 Saudi patients suffering from erectile dysfunction. The first choice of treatment was oral pharmacotherapy for about 72% of American and 82% of Saudi patients respectively. Comparison of Viagra and Yohimbine revealed an 80% success rate for the former and 26% for the latter. Intrapenile injection of Trimix was successful in about 75% of the patients for both Saudi and American patients. The Saudi patients rarely selected vacuum therapy. Penile prostheses yielded a high success rate (over 90%) in a selected group of patients who failed other therapies.

Presented at the:

12 th Saudi Urology Conference



23-25 February 1999

(7-9 Dhu Al Qa'dah 1419)



Al Hada and Taif Armed Forces

Hospitals Program

Oral sildenafil (viagra) - a two-stage, double blind, placebo-controlled study in men with erectile dysfunction (ED) caused by traumatic spinal cord injury (SCI)

Derry F 1 , Glass C 2 , Dinsmore W 3 , Fraser M 2 , Gardner B 1 , Muirhead G 4 , Maymtom M 4 , Orr M 4 , Osterloh I 4 , Smith M 4


1
The National Spinal Injuries Centre, Stoke Mandeville Hospital, 2 The Regional SCI Centre, Southport, 3 The Royal Victoria Hospital, Belfast, 4 Pfizer Central Research, Sandwich, Kent, UK

Introduction: The efficacy and safety of oral Sildenafil (a selective inhibitor of Phospho-Diesterase type 5, PDE5) were evaluated in patients with ED caused by SCI.

Materials and Methods: Twenty-seven male patients (mean age 32.9 years, range 21-49) with ED solely attributable to a SCI (cord level T6-L4/5) were studied. Patients with at least a grade 2 reflexogenic erectile response to a vibrator were entered in Stage 1 (single-dose, placebo-controlled, two-way crossover design) in which reflexogenic erections were stimulated by applying a vibrator to the shaft and glans of the penis at set times between T=0 and 1.5 hours after dosing with placebo or 50mg Sildenafil. Efficacy was evaluated by Rigiscan TM recordings. In Stage II (parallel-group design), patients were randomized to receive Sildenafil 50mg or placebo, taken as required (not more than once daily) for 28 days. Efficacy was assessed using a patient diary and a questionnaire.

Results: Regiscan TM assessments (penile base rigidity > 60%; Stage I) and global efficacy question (GEQ: Has the treatment improved your erections?) answered at the end of 28 days of treatment (Stage II) for the 26 available patients are shown below:

Stage I : >60% penile rigidity

Stage II: GEQ



*P<0.01 versus placebo

Conclusion: Sildenafil is an effective, well tolerated oral treatment of ED in patients with SCI who have reflexogenic erectile capacity.

Presented at the: 11 th Saudi Urological Conference

24-26 February 1998 (27-29 Shawwal 1418)



King Fahd Military Medical

Complex - Dhahran

Effectiveness and safety of apomorphine hydrochloride in the treatment of erectile dysfunction

Abuanz S, Al Dayel A, Al Oraifi I, Egail S, Al Zahrani S, Al Sayed E, Al Zahrani A


King Fahd Military Medical Complex, Dhahran, Saudi Arabia

This is a prospective non-randomized open label study to assess the effectiveness and safety of apomorphine hydrochloride in the treatment of patients with Erectile Dysfunction (ED).

Materials and Methods: A total of 78 patients, age between 23-89 (55) years, treated between May '02 and Dec '03. The indication was no erection in 18 (23%) patients, rapid detumescence in 7 (9%) patients, and weak erection in 53 (68%) patients. Associated with chronic renal failure in 2 patients, diabetes in 31 patients, ischemic heart disease in 1 patient, hyperlipidemia in 2 patients and hypertension in 14 patients.

The patients were assessed according to the IIEF score before the treatment and reassessed after 8 weeks, and on changing doses or exit from the study. All patients started on Uprima 3mg sublingual tablet and continued on the same doses if patient had good response.

Results: The mean pre IIEF score was (12.68) and post score was (14.10) with mean improvement of the score of (1.42). Most improvement was in Q5 (0.72) from (2.29) to (3.01). Due to the marginal improvement, 70 (89.7%) patients dropped out of the study and asked for another treatment. The side effect was only nausea in 3 patients (2.34).

Conclusion: This study showed that Uprima has only marginal effect in patients with erectile dysfunction included in this study.

Presented at the: 16 th Saudi Urological Conference

2-4 March 2004 (11-13 Muharram 1425)



King Faisal Specialist Hospital &

Research Centre

A prospective randomized study to optimize the dosage of trimix ingredients compared to prostaglandin E1 alone with respect to efficacy and safety

Raouf Seyam, Khaled Mohamed, Atef Al Akhras and Hashem Rashwan


Division of Urology, Department of Special Surgery, Faculty of Medicine, Suez Canal University, Ismailia, Egypt

Introduction and Objective: Intracavernous injection (ICI) has attained a central role in the management of erectile dysfunction (ED). Different drug combinations have been arbitrarily chosen. We determine the optimal effective dose combination and short term safety of Trimix (Tx) as compared to Prostaglandin E1 (P) 20g.

Methods: We prospectively randomized 180 consecutive ED patients (Pts) into 9 equal groups, according to the dose of Tx. Each dose contained phontolamine (1mg), one dose of P (2.5, 5 or 10΅g) and one dose of papaverine (5, 10 or 20mg). In each group, 10 Pts were injected with 20΅g P in the first visit and one dose of Tx in the 2 nd visit, 1 week later. In the other 10 Pts the order of injection was reversed. Pts were blinded for the drugs injected. Pts underwent a focused history and physical examination and blood chemistry. Following ICI and 5 minutes self stimulation, duplex US of cavernous arteries and axial rigidometry were carried out. Pts ranked the quality of erection, estimated overall satisfaction and reported time to detumescence and side effects. For statistics we pooled data of all Tx doses versus those of all P. Then we compared data within each group regardless of order of administration.

Results: Pts had a mean age of 50.5 SD xx.7y, ED for 40.2 SD 42.6 months, IIEF score of 7.6 SD 5.8 and underlying organic disease in 53.7%. There were no significant differences between the 9 groups. Pooled data showed no significant differences between P and Tx as regards cavernous artery flow (It, 0.27 SD 0.12, 0.29 SD 0.12 m/sec) time to erection (10.3 SD 5.5, 10.6 SD 5.5 min, P=0.29), Pts satisfaction (64.3 SD 26.2, 63.4 SD 28%, P=0.437), BP, average axial rigidity (915 SD 476, 927 SD 510 gm, P=0.574) and pain (32, 26 Pts, P=0.81). P produced higher end diastolic velocity (It, 0.044 SD 0.04, 0.033 SD 0.029 m/sec, P<0.0001), shorter duration of erection (91.9 SD 66.7, 121 SD 90.9 min, P<0.0001) and less priapism (1, 9 Pts, P=0.022). Comparison of P and the smallest dose of Tx showed that P produced shorter onset of erection (8.15 SD 4.29, 10.12 SD 4.31 min, P=0.004) and shorter duration of action (83.40 SD 68.71, 115.5 SD 111.5 min, P=0.03). Tx was associated with 2 cases of priapism. All other responses within that group were comparable.

Conclusions: Low dose Tx produces longer duration of erection and more priapism than P with no significant difference in homodynamic effects, rigidity, pain and self-satisfaction between both drugs.

Presented at the: 16 th Saudi Urological Conference

2 - 4 March 2004 (11-13 Muharram 1425)



King Faisal Specialist Hospital &

Research Centre

The role of free radical scavengers in the prevention of diabetic induced erectile dysfunction

Raouf Seyam, Abdallah Taqi and Hashem Rashwan


Division of Urology, Department of Special Surgery, Faculty of Medicine, Suez Canal University, Ismailia, Egypt

Despite insulin treatment diabetes mellitus remains a significant risk factor for the development of ED. Oxidative stress is part of the deleterious process. Free radical scavengers were shown to decrease diabetic retinopathy and lower limb neuropathy in experimental animals. We set out to test the hypothesis that the addition of scavenger to treatment with insulin could ameliorate the development of ED.

We divided 25 adult male Sprague Dawley rats into five equal groups. In 4 groups streptozotocin induced diabetes was confirmed by determination of blood glucose level after 1 week of induction. Each diabetic rat group was treated either with insulin alone (DI), insulin plus scavenger (DIS), scavenger alone (DS) or not treated al all (D). After 12 weeks the rats were anesthetized and intracorporeal pressure (ICP) and carotid artery pressure were recorded in response to electric stimulation of the cavernous nerves. Tissues from the penis and the major pelvic ganglia were harvest for histological examination.

The initial body weigh was 277.9 + 6.4 grams and not different among groups. Blood glucose level increased significantly from 105.4 + 5.8 mg/dl in the control group to 419.6 + 13.2, P=0.01 in DS group and 333.8 + 57, P=0.02 in D group. ICP rise in the control group was 76.8 cm (+10.3) water. It decreased significantly in D group (23.8 + 16.8, P=0.01) and in DS group 25 SE 3.8, p=0.04). No statistical difference was observed in ICP rise between control, DI and DIS groups.

We conclude that in 12 week diabetic rats we could not demonstrate a beneficial effect of free radical scavenger addition to treatment with insulin as regards the prevention of the development of ED.

Presented at the: 16 th Saudi Urological Conference

2 - 4 March 2004 (11-13 Muharram 1425)



King Faisal Specialist Hospital and

Research Centre

The role of pde / type 5 inhibitor intracorporeal vaso active agents in the treatment of unconsummated marriage

Said Abdulgani Kattan, Hassan Al Zahrani, Khalid Al Othman, Ali Bin Mahfooz, Muhammad Aslam, Alaa Mokhtar,

Raouf Seyam, Kamal A. Hanash


Departments of Urology, King Faisal Specialist Hospital and Research Centre and King Khalid University Hospital, Riyadh, Saudi Arabia

Objective: To assess the rational and effects of PDE/type 5 inhibitors and intracorporeal vaso active agents in the management of couples with unconsummated marriage.

Methods: A prospective study was designed in which male patients presenting with inability to perforate the hymen and penetrate the vagina after marriage were treated with PDE type 5 inhibitor. Non responders were further treated with intracorporeal vaso active agents. Outcome, short and long term success rate and complications were recorded.

Results: Between the period of 1999 and 2003 thirty four male patients who failed to achieve vaginal penetration after marriage were included in this study. The etiology of failure was inability to achieve rigid erection, failure to sustain an erection, premature ejaculation and lack of sexual education. Seven patients had pre-marital poor erections. Twenty one patients were able to achieve normal sustained erection with PDE type 5 inhibitor, only fourteen of them were able to achieve vaginal penetration. Thirteen patients who failed to respond to PDE type 5 inhibitor and four of the patients who responded but failed to penetrate the vagina received intracorporeal vaso active agent (total 17). Fifteen patients achieved sustained rigid erections. Only ten of them were able to achieve vaginal penetration. Of the 24 patients who achieved vaginal penetration, nine and three patients required short and long maintenance therapy respectively. Five cases developed priapism otherwise no serious side effects were noted.

Conclusion: PDE type 5 inhibitor is able to produce a favorable response in 64.7% of these patients while intracorporeal vaso active agents salvaged 84.6% of non responders. Achievement of normal erection doesn't mean successful treatment as 33% of responders failed to achieve vaginal penetration and other factors such as vaginismus and lack of sexual education have to be addressed. Long term maintenance therapy is frequently necessary to prevent relapse.

Presented at the: 16 th Saudi Urological Conference

2 - 4 March 2004 (11-13 Muharram 1425)



King Faisal Specialist Hospital &

Research Centre

Single drug therapy in the treatment of male sexual/erectile dysfunction in islamic medicine

Adel Al Dayel, Naheda Al Zuhair


King Fahd Military Medical Complex, Dhahran, Saudi Arabia

The treatment of Sexual (SD) / Erectile Dysfunction (ED was considered seriously in the early medical writings of the Islamic Physicians and Pharmacists. The Compendiums of Medicine from the Islamic Scholars in between 9 th and 16 th century; from Damascus, Persia, Kairawan (Tunisia), Cordoba (Spain), Cairo, and Yemen; contain variety of drugs and methods of management of sexual dysfunctions emphasizing on erectile issue. The therapy varied from a single drug method to a combination method either a drug or food. We reviewed only the use of single drug therapy for sexual and erectile dysfunction in Islamic medicine. The review based on thirteen distinguished textbooks reflecting different places, cultures, and periods of Islamic civilization, and those are:

All the books were reviewed in there original Arabic language, either as manuscript, or printed. The item will not be considered if it is not mentioned in more than three books. There were (97) items identified from those references in relation to improvement of male sexuality or penile erection. (56) out of (97) were used to improve sexual desire or to treat sexual dysfunction, (23) out of (97) used in the treatment of erectile dysfunction, and (18) out of (97) were used for both conditions, i.e. SD and ED. The routes of administration were mainly oral, with few used as topical or transurethral.

This review indicated that there are materials much more than what we know now a day could be used in the management of sexual or erectile dysfunction, further laboratory and clinical evaluation of the promising ones could introduce new and effective drugs. The differences in the terminologists used to describe the problems, and the effect of the drugs, represent a real challenge for the researches in this field.

Presented at the: 17 th Saudi Urological Conference

8 - 10 March 2005

King Fahd Military Medical Complex

The role of combination therapy in the treatment of impotent patients with inadequate response to sildenafil and intracorporal injection montherapy

Mohamed Ashraf Koraitim


Department of Urology, King Fahd University Hospital, Al Khobar, Saudi Arabia

Objective: We studied the efficacy of combination therapy in impotent patients with inadequate response to Sildenafil and intracorporal injection monotherapy.

Patients and Methods: Enrolled in this study were 23 impotent patients 28-55 years old (mean 46.7) with inadequate response to both Sildenafil and intracorporal injection monotherapy. All patients underwent detailed history and physical examination, FBS determination, penile duplex Doppler ultrasound and pharmaco-cavernosometry. A trial of combination therapy using oral Sildenafil (50-100 mg) and intracorporal injection of trimixture (28 mg/ml Papaverine, 0.58 mg/ml Phentolamine and 10 ug Alprostadil). The response was evaluated and side effects recorded.

Results: The etiology of erectile dysfunction in the studied group was venogenic in 56.25%, arteriogenic in 21.73% and combined arteriogenic and venogenic in 21.73%. Seven out of these 23 patients (30.43%) responded to combination therapy either by complete erection in 4 patients or by moderate rigidity enough for intromission in 3. Non responders showed a higher FME and EDV than those responding to combination therapy. These differences in FME and EDV were statistically highly significant between both groups.

Conclusion: All patients not responding to both oral Sildenafil and intracorporal injection monotherapy had vasculogenic etiology for impotence. Combination treatment may potentially salvage one third of cases refractory to single modality treatment.

Presented at the: 17 th Saudi Urological Conference

8 - 10 March 2005

King Fahd Military Medical Complex

Effectiveness of sildenafil and apomorphine hydrochloride in the treatment of erectile dysfunction in diabetic patient

Saeed Al Zahrani, A. Al Dayel, S. Egail, I. Al Oraifi,

S. Abu Anz, A. Al Zahrani, H. Al Qahtani, E. El Sayed


Department of Urology and Nephrology, King Fahd Military Medical Complex, Dhahran, Saudi Arabia

Objective: This is a prospective non-randomized open label study to assess the effectiveness of sildenafil and apomorphine hydrochloride in treatment of erectile dysfunction (ED) in diabetic patient.

Patients and Methods: A total of 111 diabetic patients, group A 80 patients treated with sildenafil, 21 patients with insulin dependent diabetes mellitus (IDDM) and 59 non-insulin dependent diabetes mellitus (NIDDM). Group B 31 patients treated with apomorphine hydrochloride, 15 patients with (IDDM) and 16 with (NIDDM). Group A treated in period between August 1999 and December 2003. Group B treated in between May 2002 and December 2003. Indication of treatment in group A, no erection in 17 (21%), weak erection in 55 (68.5%), rapid detumescence in 4 (4.8%) and ED associated with hyperlipidemia in 2 (2.6%) and ischemic heart disease in 2 (2.6%).

In group B, indication of treatment, no erection in 11 (35.5%), rapid detumescence in 1 (3.2%), weak erection in 19 (61.3%). Both assessed according to IIEF 5 scores before and after treatment and re-assessed after 8 weeks. Group A treated by Viagra 50mg tablet with a total of 8 doses for two months period. Group B started on Uprima 3mg sublingual tablet and continued the same doses if patients have good response.

Results: In group A, the mean pre-treatment score was (10.36) and post-treatment score was (18.40) with mean improvement of IIEF score of (8.36), most improvement in Q5 (2.17) from (1.75) to (3.88). In group B, mean pre score was (10.58) and post score was (12.61) with mean improvement of score of (2.03), most improvement in Q5 (0.52) from (1.81) to (2.32). Due to marginal improvement 27 patients (89%) dropped out of the study and asked for another treatment. Side effects in group A was headache in 3 (3.9%), dyspepsia in 1 (1.3%), nasal congestion in 1 (1.3%), visual disorder in 1 (1.3%), dizziness in 2 (2.6%). In group B, a side effect was only nausea.

Conclusion: This study showed good response and tolerance to Sildenafil 50mg in treatment of erectile dysfunction in diabetic patients while headache was the main side effect in contrast a marginal effect of Uprima in treatment of erectile dysfunction in diabetic patient.

Presented at the: 17 th Saudi Urological Conference

8 - 10 March 2005

King Fahd Military Medical Complex

New insights into the relationship of erectile dysfunction, hypogonadism and the metabolic syndrome

Ridwan Shabsigh


Professor of Urology, Columbia University, Director, New York Center for Human Sexuality, New York, USA

The metabolic syndrome, characterized by central obesity, insulin resistance, dyslipidemia, and hypertension is highly prevalent. Left untreated, it significantly increases the risk of developing diabetes mellitus and cardiovascular disease and subsequently leading to cardiovascular morbidity and mortality. It has been suggested that hypogonadism may be an additional component of the metabolic syndrome. This has potential implications for the treatment of the metabolic syndrome. A comprehensive review of the world literature on hypogonadism, testosterone, and the metabolic syndrome was performed. Observational data suggest that the metabolic syndrome is strongly associated with hypogonadism in men. Multiple interventional studies have shown that exogenous testosterone has a favorable impact on body mass, insulin secretion and sensitivity, lipid profile and blood pressure-the parameters most often disturbed in the metabolic syndrome. Analysis of longitudinal data from the Massachusetts Male Aging Study showed that erectile dysfunction (ED) was a predictor of the development of the metabolic syndrome. Hypogonadism is very likely a fundamental component of the metabolic syndrome. Testosterone therapy may not only treat the hypogonadism, but via beneficial effects on insulin regulation, lipid profile and blood pressure has tremendous potential to slow or halt the progression from the metabolic syndrome to overt diabetes or cardiovascular disease. Furthermore, the use of testosterone to treat the metabolic syndrome may also lead to the prevention of urologic complications such as neurogenic bladder and ED commonly associated with these chronic disease states. Physicians should be mindful to screen for ED and check for hypogonadism in all men diagnosed with the metabolic syndrome as well as to check for the metabolic syndrome in all men diagnosed with ED and/or hypogonadism. Future research, in the form of randomized clinical trials, should focus in further defining the role of testosterone in the treatment of the metabolic syndrome.

Presented at the: 18 th Saudi Urological Conference

20 - 23 February 2006 (21-24 Muharram 1427)

King Abdulaziz University Hospital

The efficacy of prilocaine-lidocaine local cream in the treatment of premature ejaculation: A prospective clinical study

Ahmed Al Kandari


Department of Andrology, Sexology and STDs, Faculty of Medicine, Cairo University, Pan Arab Society of Sexual Medicine, Cairo, Egypt

Introduction: Premature ejaculation is the most common sexual dysfunction in men. Oral therapy has been used with variable effects but with side effects. A trial with prilocain-lidocaine cream locally was done to treat this condition.

Materials and Methods: Twenty four males with this condition but without erectile dysfunction were treated. Age ranged (24-50 years) mean 37 years. They used prilocaine-lidocaine cream 5% with small amount (1-2 gm) and rub the penis with this cream 10 minutes before intercourse and then either remove it or wear condom to avoid numbness side effects to the wives. Time from intromission to ejaculation with patient satisfaction and wife satisfaction with records of any side effects were recorded. Results were obtained after 1 month of the treatment.

Results: 22 patients out of 24 (91%) reported excellent result which involved ejaculation after 20 minutes with excellent satisfaction. Penile numbness was the most common side effect which was none bothering to most patients. 2 patients had minor effect in which less than 5 minutes was time to ejaculation but were still moderately satisfied. 21/24 wives reported excellent satisfaction (87%), 3 wives reported moderate difference. None of the wives complained of significant numbness.

Conclusion: The use of prilocain-lidocain cream locally is associated with excellent patient and wife satisfaction. A larger and randomized clinical trial to confirm these results is organized.

Presented at the: 18 th Saudi Urological Conference

20 - 23 February 2006 (21-24 Muharram 1427)

King Abdulaziz University Hospital

The pan arab society of sexual medicine

Mohamed Tarek Anis


Department of Andrology, Sexology and STDs, Faculty of Medicine, Cairo University, Pan Arab Society of Sexual Medicine, Cairo, Egypt

The Pan Arab Society of Sexual Medicine (PASSM) was established in 1998 to serve more than 250 million citizens of the Arab region distributed among 22 Arabic speaking nations. PASSM has four objectives: 1) To establish a scientific society to benefit the public by encouraging the highest standards of practice, education, and research in the field of human sexuality in the Arab world, 2) To develop and assist in developing scientific methods for diagnosis, prevention and treatment of conditions affecting human sexual function, 3) To promote the publication and encourage contributions to the medical and scientific literature in the field of sexual function, and 4) To deliver proper sexuality education to the Arabic societies thus helping in the prevention of sexual dysfunctions. PASSM membership is open to all professionals working in the field of sexual function/dysfunction or related areas and who have appropriate qualifications in their discipline. Currently, PASSM has 6 committees namely: Medical Education Committee, Public Awareness Committee, Scientific Committee, Members Communication Committee, Development and Financial Support Committee, Meetings Committee. In this presentation various activities of the society as well as future projects will be discussed.

Presented at the: 18 th Saudi Urological Conference

20 - 23 February 2006 (21-24 Muharram 1427)

King Abdulaziz University Hospital

Sexual health is the portal to men's health

Ridwan Shabsigh


Department of Urology, Columbia University, New York Center for Human Sexuality, New York, USA

This report focuses on a number of specific conditions that are known to be highly prevalent throughout the aging male population worldwide. There are numerous non-cancer, co-morbid disease states have been shown to adversely affect males over the age of 50. Included are problems such as diabetes diabetes mellitus (DM), metabolic syndrome, cardiovascular disease (CVD), erectile dysfunction (ED) hypogonadism, depression and benign prostatic hyperplasia (BPH). These conditions are discussed with special attention aimed at highlighting any associated links that might exist between them in the setting of male aging.

A literature search was conducted on MedLine and PubMed using the key words aging male, DM, metabolic syndrome, CVD, ED, hypogonadism, depression, BPH, quality of life (QoL) and other related key words. The National Institutes of Health (NIH), Centers for Disease Control (CDC) and World Health Organization (WHO) conference proceedings and other pertinent reports were reviewed.

Much of the research to date has done very little to establish whether a cause and effect phenomenon exists between the above conditions. However, many have shown that a strong association exists. It is known that the pathogenesis of several of these problems, for example CVD and ED, is similar. This calls attention to the fact that more detailed investigation is needed in this area of male aging in order to better delineate when and where intervention may be necessary.

Several studies have shown that symptoms of sexual dysfunction and hypogonadism may be early warning markers of important men's health issues, such as cardiovascular disease, diabetes, metabolic syndrome, depression and benign prostatic hyperplasia. The new and evolving concept of endothelial dysfunction in the setting of these conditions further highlights the need for a comprehensive assessment rather than a singular approach when caring for the growing male population. Symptoms of sexual dysfunction may be the manifestation that presents an opportunity to detect the other disorders and hopefully modify patients' behavior to improve men's health.

Presented at the: 18 th Saudi Urological Conference

20 - 23 February 2006 (21-24 Muharram 1427)

King Abdulaziz University Hospital

Management of sexual dysfunction: The 2006 status

Mostafa M Elhilali


Department of Surgery, McGill University Health Center, International Societe d'Urologie, Montreal, Canada

The last few years have witnessed a major shift in the management of erectile dysfunction. The results of each trial were widely presented with claims of superiority on either side. The incidence of complications and side effects are frequently exaggerated and publicized. This ranged from heart problems, blindness as well as potential synergistic side effects profile when combining PDE5 inhibitors and alpha blockers.

The presently available data will be presented and the clinical significance of the outcome and the side effects profile will be highlighted.

Presented at the: 18 th Saudi Urological Conference

20 - 23 February 2006 (21-24 Muharram 1427)

King Abdulaziz University Hospital

The insertion of penile prosthesis in patients with severe corporeal fibrosis. Outcome and complications

Said Abdulgani Kattan, Hassan Al Zahrani, Khalid Al Othman, Ali Bin Mahfooz, Muhammad Aslam, Alaa Mokhtar,

Raouf Seyam, Kamal A. Hanash


Departments of Urology, King Faisal Specialist Hospital & Research Centre and King Khalid University Hospital, Riyadh, Saudi Arabia

Objective: To study the outcome and complications of insertion of penile prosthesis in patients who had severe corporeal fibrosis.

Methods: A retrospective study in which the medical records of all patients with severe corporeal fibrosis who underwent the insertion of penile prosthesis between the period of 1995 to 2003 were reviewed.

Results: 28 patients were included in the study. The etiology of corporeal fibrosis was post explantation secondary to prosthesis infection (16), post priapism (9), intracorporeal injection (3). 17 patients had rigid penile prosthesis (AMS 600), in three of these patients prosthesis insertion was possible. On one side only, 10 patients had inflatable prosthesis (AMS 700 or Ambicor). Failure to insert a prosthesis was experienced in one patient. Intraoperative complications occurred in 5 patients (18%), 3 cases of distal perforation and 2 cases of proximal corporeal perforation. Post operative complications occurred in 6 patients (21.4%), 2 cases of prosthesis migration requiring revision, 2 cases of prosthesis extrusion via the meatus and 2 cases of prosthesis infection requiring exploration and salvage replacement. All cases of post operative extrusion and migration occurred in patients with semi rigid penile prosthesis.

Conclusion: Insertion of penile prosthesis in patients with severe corporeal fibrosis is technically difficult and associated with more intra operative and post operative complications, compared to cases with no corporeal fibrosis. Inflatable penile prosthesis is less likely to be complicated with post operative extrusion or migration.

Presented at the: 16 th Saudi Urological Conference

2 - 4 March 2004 (11-13 Muharram 1425)



King Faisal Specialist Hospital &

Research Centre

Insertion of penile prosthesis for erectile dysfunction: A long term review from a single institution

Muhammad Aslam, Irfan Ahmed, Hasan Al Zahrani, Said Kattan, Ali Bin Mahfouz, Khalid Al Othman, Kamal Hanash


Department of Urology, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia

Objective: To review and evaluate patient selection criteria, indications, complications and patient satisfaction following insertion of different types of penile prosthesis.

Methods: Charts of 51 patients were reviewed retrospectively who underwent penile prosthesis insertion. Parameters studied included preoperative evaluation, indications, type of anesthesia, incision and prosthesis inserted, complications and follow up.

Results: 51 patients underwent penile implant insertion. Mean age was 56 years, mean follow up of 21 months. Indications: diabetes (36), pelvic surgery (6), TURP (2), post priapism (3), Peyronie's disease (2), spinal cord trauma (2). All were selected after evaluation and detailed counseling. Different types of prosthesis inserted were: 6 (AMS 650), 27 (Ambicor), 1 (AMS 700), 5 (AMS 700 cx), 6 (AMS 700 ultrex plus), 5 (AMS ultrex) and 1 (Dynaflex). 98% underwent insertion through penoscrotal incision, 42 (82%) under general anesthesia and 9 (18%) under spinal. All had pre and post operative antibiotics. Complications: 6 got infected and explanted. The hematoma developed in two, resolved spontaneously. Urethral erosion occurred in one and glans penis erosion in two. Wound infection developed in two. Mechanical failure developed in 6 (12%), 5 replaced one waiting replacement. Septal perforation occurred in one. Malpositioned pumps found in two, which were revised, one following revision got infected and explanted. Overall reoperation rate was 25.5% (13). Patient satisfaction documentation found in only 32 (64%), out of these, 26 (52%) were fully satisfied and 6 (12%) were unsatisfied.

Conclusion: Penile prosthesis insertion is a major surgical procedure. Our study concludes that it is not a procedure without complications and we suggest very careful patient selection, detailed pre operative counseling and a meticulous surgical technique by an experienced urologist.

Presented at the: 17 th Saudi Urological Conference

8 - 10 March 2005

King Fahd Military Medical Complex

Where is the female sexual dysfunction destined in 2006?

Ridwan Shabsigh


Department of Urology, Columbia University, New York Center for Human Sexuality, New York, USA

Female sexual disorders are highly prevalent and often undertreated. Beside psychotherapeutic approaches, a number of modalities to treating FSD are evolving, including vasoactive substances, hormonal therapy, and mechanical devices.

Ideally, medications for genital arousal disorder would enhance the action of endogenous neurotransmitters of arousal, including Nitric Oxide (NO) and Vasoactive Intestinal Polypeptide (VIP). A double-blind, placebo-controlled study was evaluated sildenafil in women with arousal disorder. Women were either postmenopausal or post hysterectomy. Significantly more women reported improved sensation and increased satisfaction with sildenafil compared with placebo in this report. These improvements were more pronounced in the subgroup of women without hypoactive desire disorder. Topical vasodilators, such as prostaglandin E 1 , may have a role in genital arousal disorder where there is total disruption of the autonomic nerves involved in the vulvar congestive mechanism. Controlled trials are also conducted on non-prescription drugs showing encouraging preliminary results in the product Zestra.

Estrogen can be administered locally or systemically in the case of vaginal dryness. Although sexuality and desire are determined by multiple factors, androgens play a major role in sexual desire, and low testosterone levels have been associated with low desire. Since androgens decrease steadily with age unrelated to menopause, decreasing levels may contribute to low desire in pre- and postmenopausal women. In younger women, bilateral cophorectomy causes a decrease in androgen levels and sexual desire. Several controlled trials in postmenopausal women on testosterone therapy documented a significant improvement in sexual desire, general health and sexual satisfaction.

Two categories of mechanical devices currently exist: mechanical vibrators and a clitorial vacuum engorgement device. Both devices rely on the finding that vascular engorgement of the clitoris is important and may be used to treat arousal and orgasmic disorders.

Beside psychotherapeutic approaches, which continue to be of major importance, a number of modalities to treating FSD are evolving, including vasoactive substances, hormonal therapy, and mechanical devices. The definitive role of each respective treatment has yet to be resolved in future studies. Interdisciplinary cooperation and team approach as well as education of both, the health care provider and the patient, are paramount importance in improving quality of care in women with FSD.

Presented at the: 18 th Saudi Urological Conference

20 - 23 February 2006 (21-24 Muharram 1427)

King Abdulaziz University Hospital

Honeymoon impotence in saudi arabia

Said Kattan


Department of Urology, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia

Background: Honeymoon impotence is not a common complaint in conservative countries and especially in Saudi Arabia. It occasionally has severe consequences and should be regarded as one of the andrological emergencies. The scope of the presentation is to give an overview evaluation of the problem in Saudi Arabia through prospective study of more than 180 Saudi patients.

Methods: 150 Saudi patients presenting with honeymoon impotence were prospectively studied regarding their risk factors and were treated in a comparative study by short acting and long acting phospodisterase type 5 inhibitors. Their short term and long term response as well as side effects were evaluated monthly for three months. The chi square statistical analysis was used for comparison between both groups.

Results: Patients with premarital history of sexual failure at previous attempt and history of weak erection are at high risk for honeymoon impotence. There was no statistical difference between short acting and long acting phospodisterase type 5 inhibitors after one month. However, there was statistical significance difference in favor of long acting phospodisterase type 5 inhibitors versus short acting in the second and third months.

Conclusions: Prophylaxis is recommended in certain high risk group to prevent honeymoon impotence. Long acting phospodisterase type 5 inhibitors are more effective in the treatment and resolutions of the conditions compared to short acting phospodisterase type 5 inhibitors.

Presented at the: 19 th Saudi Urological Conference

King Khalid University Hospital - Riyadh

26 February - 01 March 2007

Efficacy of sildenafil in treatment of post-radical cysto-prostatectomy patients with prior intracavernous PGE1 therapy

Magdy S. ElBahnasawy 1 , Taha Ismail, Elhouseiny I, Elzalouey and Mahmoud A. Bazeed


Urology-Nephrology Center, Mansoura, Egypt, 1 Al Moosa General Hospital, Al Hasa, Saudi Arabia

Objective: To assess the efficacy and safety of sildenafil citrate in management of erectile dysfunction (ED) following radical cystoprostatectomy in a group of patients on successful ici (intracavernous) PGE1.

Materials and Methods: One hundred patients with ED following (RC) participated in an open labeled non-randomized prospective dose-escalation study. The median age was 53 years and mean period after (RC) was 80.7 + 54.8 months. All patients were on ici PGE1 successfully. The study duration was 12 weeks, 4 weeks washout period followed by two active treatment periods of 50mg and 100mg sildenafil, 4 weeks each. Patients were assessed by the international index of erectile function (IIEF) questionnaire at basal evaluation and after each treatment period. At the end of the study the Global Assessment Question (GAQ) was used to evaluate treatment satisfaction. Factors affecting the patient's response to sildenafil were assessed by univariate and multivariate analysis.

Results: The entire study group was suffering severe ED at basal evaluation with mean erectile function (EF) domain score of (6.5 + 0.93). EF scores improved to (12.2 + 7.76) and (18 + 10.3) with 50mg and 100 mg sildenafil respectively. Sildenafil therapy improved the ability of many patients to achieve and maintain erection significantly. The mean + SD of question 3 were (1 + 0.14, 2.1 + 1.4, and 3 + 1.8), while of question 4 were (1 + 0.10, 1.9 + 1.35 and 3 + 1.85) at basal, 50 mg and 100mg respectively. Satisfaction rate was 54%. All the responders preferred to continue on sildenafil. The response was done dependent but adverse effects increased from (6%) with 50 mg to (34%) with 10 mg.

Conclusions: Sildenafil was safe and satisfactory alternative treatment for post radical cystectomy ED. In absence of spared nerves, long term prior use of ici PGE1 ensured healthy state of cavernous tissue predicting better subsequent sildenafil efficacy. Patients with spontaneous postoperative partial tumescence were the best response.

Presented at the: 19 th Saudi Urological Conference

King Khalid University Hospital - Riyadh

26 February - 01 March 2007

Assessment of female sexual dysfunction following radical cystectomy and urinary diversion

Magdy S. ElBahnasawy 1 , Yasser Osman,

Ahmed El Hefnawy


Urology-Nephrology Centre, Mansoura University, Egypt and Al Moosa General Hospital, Al Hasa, Saudi Arabia*

Purpose: The aim of this work is to investigate the impact of radical cystectomy and different forms of urinary diversion on the female sexuality.

Materials and Methods: Seventy three female patients (mean age 52.3 + 6.5) were subjected to radical cystectomy and urinary diversion for invasive bladder cancer. Inclusion criteria included sexually active patients with stable marital status prior to the surgery, age < 60 years, no local recurrence or distant metastases (1 year post-operative), stable renal function as well as absence of any associated co-morbidities impairing sexual activity. Forty one patients (56.2%) received orthotopic substitutes, 20 (27.4%) ileal conduit, 8 (10.9%) rectal diversion, and 4 (5.5%) simple rectal bladder. General relation to husbands has been addressed as well as sexual questionnaire including full assessment of libido, lubrication, orgasm, satisfaction and pain.

Results: General relation to husbands were described to be the same or even improved with 38 patients (52%), worsened in 29 (39.8%) while divorce was inflected in 6 couple (8.2%). Sexual relation was maintained in 54 patients (74%) with mean frequency of 2.3 + 2.3/month while it was lost in 19 (26%). Among the post-operatively sexually active females, most of the patients (88.9%) described absence of libido, 34 patients (63%) described difficulty in introduction up to utilization oflubricants in 12 patients (63%) described difficulty in introduction up to utilization of lubricants in 12 patients. Dyspareunia was described in 26 patients (48.1%) while orgasm was achieved in only 20 (37%). Overall satisfaction in sexual life was the same as preoperative in 14 patients (26%), worsened in 32 (59.2%). No sexual satisfaction was described in 8 patients (14.8%). Generally, the total mean Index of Female Sexual Function (IFSF) decreased from 18.3 + 5.1 pre-operatively to 11.3 + 7.4 post radical cystectomy (P 0< 0.001). Patients with orthotopic substitutes showed significantly higher post-operative IFSF compared with stoma patients (13.8 + 6.9 vs. 7 + 6.4; P < 0.01). Urinary complaints were described in 34 patients (63%) during or after sexual intercourse including urine leak, hematuria, dysuria, difficulty as well as lower abdominal pain.

Conclusions: Radical cystectomy adversely impact female sexual function in a significant way. Orthotopic bladder substitution offers a better sexual satisfaction compared with non-continent forms of urinary diversion.

Presented at the: 19 th Saudi Urological Conference

King Khalid University Hospital - Riyadh

26 February - 01 March 2007

Post-turp erectile dysfunction: Are there other risk factors?

M. El-Bahnasawy, M. Abol-Ghar, A. Dawood


Urology and Nephrology Center, Mansoura, Egypt

Aim of the Work: Patients who complain of post-TURP ED have multiple co-morbidity factors not only the TURP procedure itself. Aging with its possible associated endocrinal changes (andropause), the presence of comorbid medical, neurological or psychogenic factors may have important role for post-TURP erectile dysfunction. The aim of this study was to evaluate the hemodynamic and endocrinal abnormalities which may be responsible for ED in our patients.

Patients and Methods: This study included 50 mal patients who were subjected to TURP and reported either new onset of ED or significant deterioration of their pre-TURP erectile degree. All patients were evaluated by history taking regarding their erectile, ejaculatory and voiding function. The erectile function was rated as no erection (NE), unsatisfactory erection (UE), adequate erection (AE) or excellent erection (EE). Total testosterone and prolactin serum levels were assessed. ICI test using 20 ΅gm PGE1 was performed for all patients followed by penile duplex ultrasonography.

Results: Mean age of our patients was 59.8 ΁ 6.7 years with mean post -TURP follow up of 3.96 ΁ 4.1 years. Thirty eight patients (76%) had retrograde ejaculation, 6 (12%) had scanty ejaculate volume while 6 other patients had painful ejaculation. Two (4%) patients had stress incontinence while other 3 (6%) had urge incontinence. Four patients had significant hyperprolactinemia (8%) while 9 (18%) had low testosterone level. Penile duplex findings showed that 4 cases (6%) had arteriogenic ED while 23 (46%) were venogenic. On the other hand 23 (46%) showed excellent rigidity suggesting neurogenic insult during TURP. When patients were subdivided according to the presence or absence of associated medical risk factors (DM, hypertension, ischemic heart disease, smoking, etc.), there was no statistical significant correlation between both subgroups and any of the penile duplex indices. However, patients with associated risk factors had significantly lower testosterone level (P=0.005). There was no statistical difference between patients with single versus those with multiple associated risk factors.

Conclusions: Significant percentage of post-TURP patients with ED had associated low testosterone particularly in the presence of comorbid medical risk factors. Arteriogenic ED is very low among post-TUP ED. The high incidence of ejaculatory dysfunction might be a contributing factor and should be considered with care on evaluating ED in this category of patients.

Presented at the: 20 th Saudi Urological Conference

King Fahad Hospital of the University - Tabuk

18 - 20 March 2008

The impact of "sildenafil citrate" on the pharmacokinetics of the anti-seizure drug "phenytoin": An animal study

M. Mostaf, H. Mosli, A. Bahy-El-Deen, A. Khedr


Department of Pharmaceutical Chemistry and Urology, Faculties of Pharmacy and Medicine, King Abdulaziz University, Jeddadh,

Saudi Arabia

Aim of the Work: To investigate the potential effect of Sildenafil Citrate, one of PhosphoDiesterase Enzyme type 5 Inhibitors (PDE5I) on the pharmacokinetic behavior of Phenytoin, the main anti-seizure treatment medication for epileptic disorders.

Method: The para-hydroxy metabolite of phenytoin was successfully synthesized with high purity. A novel analytical technique for determining phenytoin in the presence of sildenafil in plasma was established using high performance liquid chromatographic procedure. Phenytoin plasma levels were estimated with and without Sildenafil administration.

Results: Statistical analysis of the results obtained showed an observable interaction of phenytoin and sildenafil under the planned experimental conditions. Administration of sildenafil citrate resulted in significant alterations of phenytoin pharmacokinetic parameters as evidenced by an increase in the area under the first moment of the plasma concentration-time curve (AUMC) as well as decreases in the elimination rate constant ( Ke) and half life (t1/2). In line with these data, clearance (CI) was significantly decreased by b co-administration of sildenafil. These alterations could be attributed to possible competition for metabolic pathways.

Conclusions: Our data suggest that the administration of Sildenafil citrate has the potential to modulate the pharmacokinetic pattern of co-administered phenytoin. This finding was not reported before and clinical studies are strongly recommended in order to consider dose titration of Sildenafil prescribed to treat ED in patients with disorders of the central nervous system under anti-seizure therapy, in particular those receiving phenytoin.

Presented at the: 20 th Saudi Urological Conference

King Fahad Hospital of the University - Tabuk

18 - 20 March 2008

The effect of proper control of blood pressure on erectile function in non-responders to PDE5 inhibitors

M. Arafa, W. Zohdy, S. Ghazy


Dr. Fakhry Hospital, Saudi Arabia

Aim of the Work: In this retrospective study we sought to evaluate the effect of proper control of hypertension in men with ED who did not respond properly to PDE5 inhibitors.

Patients and Methods: Our participants (N=59) were evaluated for erectile function using an abridged, five-item version of the International Index of Erectile Function-5 before, 1 and 3 months after controlling blood pressure. Penile hemodynamics was assessed using intracavernosal injection and penile duplex study. We compared erectile function status before and after blood pressure control.

Results: The mean age of the patients was 56.8 ΁ 8.3 years. The means of systolic and diastolic pressure before control were 157.3 ΁ 10.6 and 98.8 ΁ 8.9 mmHg. When PDE5 inhibitors were used after 3 months of proper control of blood pressure, all IIEF 5 domains improved significantly as compared to the scores taken before blood pressure control. After one month only one man had a Total IIEF 5 score ≥ 21 1/59 (1.7%) and 3 more cases had a score ≥ 21 after 3 months of proper control of blood pressure and on demand treatment with PDE 5 inhibitors. However, the difference was not statistically significant (P > 0.05).

Conclusion: Proper control of the blood pressure and correction of hyperlipoproteinemia are very important in managing men with ED and poor response to PDE 5 inhibitors.

Presented at the: 20 th Saudi Urological Conference

King Fahad Hospital of the University - Tabuk

18 - 20 March 2008

The use of prilocaine-lidocaine cream in the treatment of premature ejaculation: An excellent outcome in 120 patients

A. Al-Kandari, H. Shaaban, H. Al-Enezi, H. Ibrahim


Urology Division, Al-Adan Hospital, Kuwait

Aim of the Work: Premature ejaculation is the most common male sexual dysfunction. So far no single totally effective agent is widely used. We prospectively evaluated the outcome of Prilocaine-Lidocaine local cream in treating this condition.

Patients and Methods: 120 males suffering from premature ejaculation with age ranging from 20-62 years with mean of 32 years were included. All patients were married and suffered from that condition for minimum of 6 months. They received an amount of up to 1 gm of 5% Prilocaine-Lidocain cream locally 15 minutes before intercourse. Time to ejaculation was estimated by stop watch. Patients and their wives answered questionnaires at the follow up which began after 4 weeks and up to 12 weeks.

Results: Most patients (90 cases) or 75% reported excellent outcome with intra-vaginal latency time (IELT) more than 10 minutes, while 15 cases (12.5%) had IELT (7-10 minutes) which was rated good. Six cases rated the effect fair with IELT (5-7 minutes), and 9 cases rated the effect as poor in which IELT was less than 5 minutes. Most patients complained of some penile numbness which did not lead to discontinuation or significant bother. None of the wives complained of side effects from the medication.

Conclusion: The results of this prospective clinical trial are impressive, in regards to the efficacy of Prilocaine-Lidocaine cream for the treatment of premature ejaculation. A larger randomized clinical trial will be undertaken by us shortly.

Presented at the: 20 th Saudi Urological Conference

King Fahad Hospital of the University - Tabuk

18 - 20 March 2008

Highly selective reversible embolisation of penile arteries with autologous blood clot in refractory high flow priapism

T. Tassadaq, M. Tahir, O. Siddiki, F. Darwiche


Saad Specialist Hospital, Khobar, Saudi Arabia

Aim of Work: To treat refractory high flow priapism with reversible occlusion of penile arteries with autologous blood clot in a young man with sickle cell disease and recurrent priapism.

Patient and Method: A 37-year-old Saudi male who was a known case of sickle cell disease presented to our institution with a refractory priapism of 10 days duration. He had received treatment including aspiration, corporal washouts and alpha agonists. On admission, his Hb was 8.92 gms and Hb5 was 94.7%. A colored Doppler study revealed increased flow velocity in both cavernosal arteries. There was no evidence of arteriovenous fistula.

Initially the patient underwent rehydration and exchange transfusion. A highly selective angiography was performed and cavernosal arteries were embolised with autologous blood clots. Follow up imaging confirmed satisfactory occlusion.

Results: The patient recovered well and regained satisfactory erections.

Conclusions: Highly selective embolisation with autologous blood clot is a feasible option in patients with high flow refractory priapism. This avoids permanent occlusion which is highly desirable in sexually active men.

Presented at the: 20 th Saudi Urological Conference

King Fahad Hospital of the University - Tabuk

18 - 20 March 2008

Surgical management of cases with urethrocutaneous fistulae and corporeal mutilation secondary to hair tourniquet (TIE) syndrome

A. Al-Kandari, A. El-Kassaby


Urology Division, Al-Adan Hospital, Kuwait

Aim of Work: We present our experience in the surgical management of cases with urethrocutaneous fistulae and corporeal mutilation secondary to hair tourniquet (TIE) syndrome.

Patients and Methods: In the period from 1990 to 2000, thirty four patients were referred to us for the management of constrictive penile tie with urethrocutaneous and corporeal mutilation. Patients were divided into 2 groups: Group A (the pediatric group) included 30 patients 1 to 13 year old. Group B (the adult group) included 4 patients 20 to 45 year old. All patients underwent a single surgical procedure to correct their penile deformity. Patients were assessed regularly in the postoperative period to evaluate the cosmetic and functional outcome.

Results: With an average follow-up period of 25.5 months, 88% of patients had an excellent outcome both cosmetically and functionally. Two patients developed urethral stricture at the repair site and were managed successfully by visual urethrotomy. One patient developed fistula which was repaired and another patient had a minor ventral chordee requiring no intervention.

Conclusion: The meticulous surgical management of this unusual urethra-penile injury due to hair tourniquet (TIE) syndrome resulted in an impressive cosmetic and functional outcome.

Presented at the: 20 th Saudi Urological Conference

King Fahad Hospital of the University - Tabuk

18 - 20 March 2008

Medical treatment of retrograde ejaculation in diabetic patients

Arafa M, Tabie O


Dr. Fakhry Hospital, Saudi Arabia

Aim of the Work: To evaluate different drug regimens for the medical treatment of retrograde ejaculation in diabetic patients.

Patients and Methods: Thirty-three diabetic patients with retrograde ejaculation (23 complete and 10 partial) were included in the study. Patients were given 3 sequential courses of medical treatment: Imipramine 25mg twice/day, Pseudo-ephidrine 120 mg twice/day or combination of the 2 drugs. Main outcome measures: Establishment of antegrade ejaculates in cases with complete RE and improvement of semen quality in case of partial RE.

Results: In cases with complete RE Imipramine was successful in producing antegrade ejaculate in 10 patients (38.5%) while pseudo-ephedrine was successful in 11 patients (47/8%) and both drugs given together was successful in 16 patients (61.5%). In cases with partial retrograde ejaculation there was significant increase in the ante-grade semen sample as regards semen volume, sperm count, total and progressive motility with Imipramine alone, pseudo-ephidrine alone and both drugs.

Conclusion: From the present study we can conclude that medical treatment for retrograde ejaculation in diabetic patients is a promising method and should be the first line of treatment in these cases.

Presented at the: 20 th Saudi Urological Conference

King Fahad Hospital of the University - Tabuk

18 - 20 March 2008

The epidemiology of erectile dysfunction and its correlation with men on chronic hemodialysis

M. Abo El-Enen, O. El-Ashry


Tanta University, Egypt

Aim of the Work: To determine the prevalence, etiologic and risk factors of erectile dysfunction (ED) in patients with chronic renal failure under intermittent hemodialysis.

Patients and Methods: Eighty four married, sexually active male patients undergoing regular hemodialysis underwent detailed medical history, clinical examination and laboratory investigations with hormonal profile including serum total testosterone, FSH, LH, PTH and prolactin were measured. The international index of erectile dysfunction "IIEF", Beck depression index score "BDI" and duplex Doppler ultrasonography were used to evaluate organic and psychological status of patients.

Results: ED was found in 72 out of 84 patients (85.7%). According to IIEF, 12 patients had no erectile problem, 48 patients suffering from moderate to severe ED and 24 patients complaining from slight ED. According to BDI scale, 36 patients had mild to moderate depression and 48 patients suffered from moderate to severe depression. There was a significant difference between the mean depression score between patients with and without ED. Most of patients with ED had moderate to severe depression. There is a significant relation between distribution of degree of depression in both groups of patients with ED. Age, depression, diabetes mellitus, hypertension and use of antihypertensive and peptic ulcer drugs are risk factors with the presence of ED. Vascular risk factors "VRF" as smoking, hypertension and hypercholesterolemia were found in 50 patients. There were significant decrease in PSV in patients with VRF and increase of EDV in patients without VRF. The predominant cause of ED in moderate and severe ED was veno-occlusive dysfunction (87.5%).

Conclusion: Age, smoking, depression, DM, dyslipidemia, hypertension and prolonged used of antihypertensive drugs and histamine-H2 antagonist are potent risk factors in development and aggravation of ED in uremic patients. VRF have significant impact on penile hemodynamic changes in impotent uremic men mainly.

Presented at the: 20 th Saudi Urological Conference

King Fahad Hospital of the University - Tabuk

18 - 20 March 2008

The effect of age on penile arterial flow

M. Al Numi 1, 2, 3 , L. De Young 2,3 , G. Brock 1, 2, 3


1
Department of Surgery, The University of Western Ontario, 2 St. Joseph's Health Care, Division of Urology, 3 Lawson Health Research Institute, London, Ontario, Canada

Objective: The most common cause of erectile dysfunction (ED) in men remains arterial insufficiency. The impact of advancing age on arterial cavernous flow across a wide age range still remains poorly described. We measured cavernous arterial flow and associated co-morbid factors among a convenience sample of 589 men seen in our tertiary care ED clinic, ranging in age from 19 to greater than 70 years.

Patients and Methods: Adult men age 19 to >70 years assessed for ED underwent a high resolution duplex penile ultrasound. Cavernous arterial flow was measured following intracavernous injection of 5 - 10 ΅g of PGE-1 and self-stilumation to assure complete cavernous smooth muscle relaxation. Co-morbidity was determined through use of validated questionnaires.

Results: A clear age related diminution in arterial low was measured with advancing age. 19-29 yrs = 29.4 cm/sec, 30-39 yrs = 27.2 cm/sec, 40-49 yrs = 27, 50-50 yrs = 23.8 cm/sec, 60-69 yrs = 22.4 cm/sec, >70 yrs = 18.9 cm/sec. Increasing rates of hypertension, diabetes and dyslipidemia were reported among the older men. The SHIM score before treatment was 19-29 yrs = 8.9, 30-39 yrs = 9.7, 40-49 yrs = 9.5, 0-59 yrs = 8.9, 60-69 yrs = 7.3 and >70 yrs = 5. The improvement of SHIM score with therapy was 5.1, 5.5, 2.2, 2, 1.8, and 3.7 respectively.

Conclusion: Senescence induced an age related decrease in erectile function and arterial flow. Therapy was shown to be effective across all age strata, with the men over age 70 years having a fairly robust treatment response from severe erectile dysfunction at the start of therapy. Understanding the impact of arterial dysfunction in men can optimize therapeutic strategies in cases of ED.

Presented at the: 21 st Saudi Urological Conference

North West Armed Forces Hospital - Tabuk

14 - 16 April 2009

Penile prosthesis implantation, complications and results

Khalid Al Rumaihi, Abdullah Rashid Al Naimi, Ahmad Shamsodini, Riadh Taleb, Haidar Mohsen, Tawiz Gul


Hamad Medical Corporation, Qatar

Introduction: Penile prosthesis implantation has a high patient satisfactory rate among the treatment choices of erectile dysfunction.

Aim: To review the result of indications and the outcome and the patient satisfaction in two pieces and three pieces inflatable penile prosthesis.

Methods: Risk factors of the disease that led to need of the penile prosthesis were analyzed, preoperative measures, approach of the surgery and type of prosthesis was reviewed. Postoperative care and days of stay in the hospital were considered. Effect of blood sugar level at the morning of the operation and insertion of the drain at the surgical site was analyzed.

Results: The morning sugar level was not correlated with the complication of the procedure. Insertion of the drain and draining of the bladder after the operation did not increase the post operative complication. Prosthesis size was directly proportional with the patient satisfactions.

Summary and Conclusion: The penile prosthesis has high patient satisfactions. DM has higher risk for complications. FBS has no direct effect on complications. Patient satisfaction is related to prosthesis size.

Presented at the: 22 nd Saudi Urological Conference



King Faisal Specialist Hospital &

Research Centre

15 - 18 March 2010

Comparative study of erectile dysfunction in patients with diabetes mellitus and non-diabetic patients

Mamdouh M. Abol-Nasr, Alayman F. Hussein,

Adel Samy, Ashraf El-Sherif


El-Minia University Hospital

Objectives: Diabetes is a well-established risk factor for erectile dysfunction (ED). Little is known regarding how diabetic men with ED differ from non-diabetec men with ED. The objective of this study is to investigate if diabetic men with ED have worse symptoms and penile haemodynamic changes and require more invasive treatment than non-diabetic men with erectile dysfunction.

Patients and Methods: Two (2) groups of patients were studied: the first group comprised 42 diabetic patients presented with ED and the second one comprised 126 non-diabetic individuals with ED. The clinical history, physical examination, and blood sugar were reviewed in both groups. The International Index of Erectile Function (IIEF) was used to compare the severity of erectile dysfunction in both groups. Color Doppler ultrasound was used in evaluation of penile hemodynamics. The pre-injection and post-injection cavernosal artery diameter (CAD), peak systolic velocity (PSV), end diastolic velocity (EDV) and resistive index (RI) were measured and evaluated. The effective lines of treatment in the diabetic and non-diabetic patients were evaluated.

Results: There is a significant difference in the IIEF between diabetic and non-diabetic patients (P<0.001). Diabetic paptients presented with more severe degree of ED than non-diabetic patients. Penile color Doppler ultrasound showed worse penile hemodynamics in diabetic patients. We found significant differences in pre-injection CAD, post-injection CAD and PSV between diabetic and non-diabetic patients (p=0.049, P<0.001 respectively). Response of the diabetic patients to Sildenafil was (42.9%) while in the non-diabetic men it was (65.9%). Intracavernosal injection (ICI) was required in 40.5% of diabetic patients compared to 25.4% in non-diabetic men. Penile prosthesis was indicated in 16.6% of diabetic patients compared to 8.7% in non-diabetic men.

Summary and Conclusion: Men with diabetes mellitus present with worse symptoms of erectile dysfunction than non-diabetic men. Those diabetic men have more severe penile hemodynamic changes and hence they are in need for a more invasive treatment than non-diabetic men.

Presented at the: 22 nd Saudi Urological Conference



King Faisal Specialist Hospital &

Research Centre

15 - 18 March 2010

Sexual function of adult women with congenital adrenal hyperplasia

Raouf Seyam, Nabil Bissada, Mohamed AbdElally, Nadia Sakati, Waleed Al Khudair


King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

Background: Classical congenital adrenal hyperplasia (CAH) presents in early childhood with salt loosing crisis and ambiguous genitalia. Earlier detection and improvements in medical and surgical management have resulted in an increasing number of patients reaching adulthood. There is apaucity of data on the long term outcome in women born with congenital adrenal hyperplasia. We set out to review the progress and sexuality of adult women treated at King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia for congenital adrenal hyperplasia.

We reviewed the medical reports of women 20 years or older with the diagnosis of CAH. We identified the clinical history, laboratory date, medical management, surgical reconstruction, marital status, evidence of virilization, fertility and condition at last follow-up.

Results: We identified 28 women with mean age 24.4 years (SE 0.5) with the diagnosis of CAH. Mean follow up was 23.6 years (SE 0.6). Patients presented in infancy and childhood with salt loosing crisis mainly ambiguous genitalia only or both. Few patients presented late with severe virilization. Clitroplasty, valvoplasty and vaginoplasty were performed in 26 girls at the age of 34.7 months (SE 6.7). A deferred vaginoplasty was carried out in four (4) patients at the age of 9.7 years (SE 1.8). Menarche occurred at 13.6 years (SE 0.5). Women had an average weight of 63.7 kg. (SE 3.8) and height of 146.7 cm. (SE 2.6). Only two (2) women were married and both fathered one normal child. Both women had normal sexual performance. Cosmetic genital appearance was good to excellent in 15 patients. Severe vaginal stenosis was found in 2. Seven (7) women had virilization in the form of harsh voice and or hirsutism. Two (2) patients are treated for depression with one attempted suicide.

Conclusion: CAH has a significant impact on the sexuality of women in their adult life. Most patients in early adulthood remain single with variable virilization effect. Some women are able to lead normal sexual life and gave birth to normal children.

Presented at the: 22 nd Saudi Urological Conference



King Faisal Specialist Hospital &

Research Centre

15 - 18 March 2010

Assessment of using antimicrobial irrigation in reducing rate of postoperative infection in penile prosthesis

Hamza Al Sisi, Hussain H. Ashqar,

Abdelrhman Al Qahtani, Khaled Mokri,

Mohamad Al Halawany


King Fahad Hospital - Al Madinah Al Monawarah, Saudi Arabia

Introduction: Intracavernosal inflatable penile prostheses have been used for treatment of erectile dysfunction for >35 yr with reported rated of patient satisfaction exceeding 90%. With the exception of mechanical malfunction, infection associated with these urologic implants constitutes the most problematic and serious complication. Although penile prostheses are generally less likely than other urologic devices, including catheters, to become infected, infection of penile implants results in serious morbidity and can be lethal, particularly in patients with diabetes mellitus and those who receive repeated implants. It has been reported that patients with a glycosylated hemoglobin of 14% have about 40% chance of having postoperative penile prosthesis infection. Other studies have indicated that revision surgeries on genitourinary prostheses are associated with a high (up to 19%) risk of infection. The standard approach for managing infected penile implants involves removal of the entire device, prolonged antibiotic treatment, and subsequent reimplantation of a new prosthesis. The pathogenesis of device-associated infection involves bacterial colonization of the surface of the implanted device and formation of a biofilm. Since bacterial colonization of penile implants is a prelude to both clinical infection and mechanical dysfunction of the implant, antimicrobial irrigation of the implant has the potential clinical benefit in reducing clinical infection.

Materials and Methods: A total of 945 penile implantations have been done in King Fahad Hospital, Al Madinah al Monawarah, Saudi Arabia. These operations were done in the last 15 years. Several types used mentor Alpha-1, AMS 700, AMS Aquaform, Spectra, AMS 3 pieces, Mentor Aquaform. In a retrospective study of using various antibiotics irrigation and soaking the device in antibiotics before insertion. Studying the effect of this method in reducing postoperative infection. Various combinations have been used, Gentamycin plus, Cephalexin, Ciprofloxacin plus Gentamycin, Cefotaxime plus Gentamycin. Also studying the effect of using half strength povidone iodine irrigation. The mean follow up period was 36 months.

Results: Best results have been gained by irrigation with Ciprofloxacin plus Gentamycin 409 of 413 (99.03%) then Cefotaxime plus Gentamycin 221 of 227 (97.35%) then Cephalexin 208 of 215 (96.7%) then using povidone iodine alone 86 of 90 (95.55%) most of them controlled by conservative treatment and in three cases the device have been removed.

Conclusion: Using antimicrobial agents is effective in reducing postoperative infection and can be added as prophylactic measure in penile prosthesis insertion, Ciprofloxacin plus Gentamycin show most successful results, irrigation with povidone iodine alone show lowest results.

Presented at the: 23 rd Saudi Urological Conference

King Fahd Specialist Hospital - Dammam

21 - 24 February 2011

Male infertility - military hospital experience

A. Jamal, S.D. Chowdhury, M.S. Abomelhat


Department of Urology, Riyadh Military Hospital, Riyadh, Saudi Arabia

Introduction: Male infertility is a major problem in Saudi Arabia. Approximately 75 new patients are seen annually at the Male Infertility Clinic, Riyadh Military Hospital. In the 2 year period, 1981-1983, 155 male patients were seen and investigated at our clinic. The majority of these patients were young, healthy males presenting with only primary infertility.

This paper outlines the examination and assessment of these patients. The various investigations, including hormonal status, semen analyses, and testicular biopsy, in elucidating the cause of the infertility, are discussed and their value in the management of such patients is presented.

The management of azoospermia and the problems of oligospermia are discussed, especially in relation to the histological picture found on testicular biopsy. The role and limitations of radiographic studies is also outlined.

The full management of our patients, both medical and surgical, is reported and the results of such treatment fully discussed. The role of surgery in the treatment of associated varicocele is defined. The place of micro or macro by-pass or reconstructive surgery on the vas is also described.

Suggestions for the improvement in diagnosis and treatment of the infertile male are presented.

Presented at the: 3 rd Saudi Urological Conference



King Fahd Hospital of the University - Al Khobar

18 April 1985

Diagnostic value of vasoseminalvesiculography

Harb Al Omari


King Faisal University King Fahd Hospital of the University,

Al Khobar, Saudi Arabia

The site of obstruction was evaluated by seminal vesiculography in 24 cases of azoospermia with normal testicular biopsies. In 21 case, obstruction was located at the level of the tail of the epididymis, in 2 cases ejaculatory duct was obstructed, in one case the injected dye was arrested at the level of Internal Inguinal ring at the site of previous hernia operation. Vesiculogram in the 24 obstructed cases and 4 cases of chronic seminal vesiculitis without obstruction showed, one normal picture, 4 with catarrhal inflammation and the rest with chronic interstitial vesiculitis. Radiological study of a patient complaining of aspermia showed multiple congenital anomalies. The high incidence of chronic vesiculitis and post inflammatory obstruction is attributed to underlying bilharziasis, since 21 of the cases had history of bilharziasis. The x-rays and shadowgraphs of the bilharzial cases will be projected.

Presented at the: 4 th Saudi Urological Conference

Riyadh Central Hospital

18 September 1986






 

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