1. health and fitness
2. disease

The Fourth Pan Arab Congress on Sexual Medicine
Cairo 26 - 28 February 2009
The Fourth Pan Arab Congress on Sexual Medicine
Opening Lecture
O1
Current perspectives for the treatment of female
sexual disorders
O2
Premature Ejaculation: 2009 Update
John Dean
Clinical Professor of Urology, University of California at San Francisco. Past President, International Society for Sexual Medicine
President of the International Society for Sexual Medicine
The diagnosis and treatment of female sexual disorders (FSDs) is
challenging because of poorly-defined distinctions between normal
and abnormal, a limited ability to integrate subjective and objective
findings and an inability to incorporate contextual factors that play a
significant role in sexual behaviour. The utility of current diagnostic
systems, of which DSM-IV-TR is best-known and most widely-used
have significant limitations in clinical practice; the very common
situation of co-existence and interdependence of more than one
DSM-IV-TR FSD diagnosis further complicates the situation for
clinicians. Recent regulatory decisions and events affecting the
development of FSD interventions have highlighted the lack of
consensus with regard to clinically meaningful FSD outcomes, as
well as shortcomings in a U.S. Food and Drug Administration draft
document that provides the primary guidance for conducting FSD
clinical studies.
Cognitive-behavioural and couple-based approaches to treatment
of specific FSDs, such as anorgasmia and vaginismus, are highly
effective, but are of limited benefit to women with hypoactive
sexual desire disorder (HSDD), sexual aversion disorder and
other sexual pain disorders. Whilst the involvement of a specialist
psychotherapist remains the optimum intervention, brief advice
from other clinicians and the use of self-help programmes should
not be ignored, particularly where social and cultural issues affect
treatment planning.
There have recently been important developments in
pharmacotherapy. There is evidence from randomized controlled
trials that androgen therapy improves the quality of the sexual
experience for postmenopausal women with low libido, and
preliminary data that this may also apply to premenopausal women.
A transdermal testosterone preparation has been approved in
Europe for the treatment of HSDD in surgically menopausal
women. A new centrally-acting serotonin receptor modulator
(5-HT1a agonist - 5-HT2a antagonist) for the treatment of HSDD,
flibanserin, is currently in phase 3 clinical trial and appears to be
a promising development, offering a non-hormonal approach to
HSDD.
Sexual pain disorders remain challenging to treat, although a
systematic approach to diagnosis and an integrated, multi-modal
approach to treatment seems to offer the best hope to affected
women. A rare, new disorder has recently been described, Persistent
Genital Arousal Disorder (PGAD, PSAD); it is debilitating and
extremely distressing to affected women, and lack of professional
awareness about its nature has resulted in poor outcomes. All
physicians working in the field of Sexual Medicine should be aware
of this condition, its possible causes, and its management.
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Cairo 26 - 28 February 2009
Ira Sharlip
Premature ejaculation (PE) is one of the most common forms of
male sexual dysfunction. It occurs in 20-30% of men of all ages
throughout the world. It is the most common sexual dysfunction
in young and middle-aged men. There are about 500 million men
worldwide who have this condition. Some men with PE are not
bothered by it but about 25-50% of men with PE are distressed by
the condition. It can produce significant personal and relationship
problems.
The International Society for Sexual Medicine (ISSM) has recently
written an evidence-based contemporary definition of lifelong PE.
ISSM defines PE as a male sexual dysfunction characterized by
ejaculation which always or nearly always occurs prior to or within
about 1 minute of vaginal penetration, and the inability to delay
ejaculation on all or nearly all vaginal penetrations, and negative
personal consequences such as distress, bother, frustration and/
or the avoidance of sexual intimacy. While there is no evidence
base other than for lifelong PE, this definition probably applies
also to men with acquired PE and to men whose sexual activities
do not include vaginal penetration. While most men with PE have
an intravaginal ejaculatory latency time of less about one minute,
studies have identified that intravaginal ejaculatory latency time in
men who do not have PE is 5-7 minutes or more.
In the past, it was thought that the etiology of PE is predominantly
psychological but there is mounting evidence that PE, especially
lifelong PE, has a neurobiological basis. Current evidence suggests
that abnormalities in serotonin metabolism, especially in certain
key nuclei of the brainstem and hypothalamus, are involved with
the mechanism of ejaculation and PE. There is also good evidence
that these abnormalities have a genetic basis.
Treatment of PE can based on psychological approaches, topical
anesthetics and/or oral drugs. The value of psychotherapy has not
been established by outcome studies but many pyschotherapists
believe strongly that psychotherapy should be combined with
pharmacologic therapy in most men with PE.
Topical application of anesthetic agents such as lidocaine and/or
prilocaine has been effective in a small number of small studies.
A new topical anesthetic preparation which is rapidly absorbed
through the skin of the glans penis is being developed and holds
promise.
Oral therapy with selective serotonin reuptake inhibitors (SSRI’s),
originally developed for the treatment of depression, has also been
quite effective using either on-demand or daily dosing schedules.
The SSRI’s commonly used for PE are paroxetine, sertraline and
fluoxetine. Well over 50% of men who use these drugs experience
a significant improvement in PE. Side effects of SSRI’s used for
the treatment of PE include dry mouth, nervousness, GI upset,
headache, drowsiness, cognitive impairment, decreased libido and
erectile dysfunction. A new short-acting SSRI called Dapoxetine
The Fourth Pan Arab Congress on Sexual Medicine
is also being developed specifically for the treatment of PE. Phase
3 studies of Dapoxetine have been completed and approval has
been requested from , but not yet granted by, regulatory agencies
in the European Union and elsewhere.
O3
Sugary of Male Genitalia in Islamic Medicine
Adel AL Dayel
King Fahad Specialist Hospital, Dammam, KSA
Islamic medicine is the Knowledge and practice of Medicine under
the auspices of Islamic Culture which extended for more than ten
centuries from 650 AD. Surgery was considered one of the healing
arts, which was practiced by physicians.
Muslim physician described many surgical procedures perform on
male genital organs. This is a review of the main compendiums of
Islamic medicine for the written details of the surgical procedures,
its indications, patient preparations and management of
complications.
Cairo 26 - 28 February 2009
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The Fourth Pan Arab Congress on Sexual Medicine
Plenary Presentations
PL1
Hypogonadism in Aging Men: An Update
PL3
Risk Factors of Erectile Dysfunction
Ahmed I. El-Sakka
Lamin Samida
Professor of Urology, Suez Canal University, Ismailia, Egypt and Al-Noor Specialist Hospital, Makkah, KSA
Professor of Urology, Centre Tanit Medical .Avenue du Japon Montplaisir 1073- Tunis/ TUNISIA
A decline in testicular function with a consequent decline in
Testosterone level is recognized as a common occurrence in
older men. The mechanisms of this phenomenon have not
been fully uncovered, and are probably multi-factorial, involving
the hypothalamic-pituitary-testicular axis. Despite the fact that
androgen and ED are age-related events; a direct cause and effect
relationship is not confirmed. Several studies had shown that the ED
rates are higher in hypogonadic men and correction of testosterone
level might be a pre-requisite before ED treatment.
Recent studies provided convincing evidence that there is
powerful effect of testosterone on the anatomical and physiological
substrate of penile erection. Furthermore, it has become clear that
testosterone is not only one of the so many factors playing a role
in erectile (dys) function but is closely related to the manifestations
of other etiological factors in ED, such as atherosclerotic disease,
diabetes mellitus and metabolic syndrome.
In this presentation we will address:
• Definition of Hypogonadism
• Effects of Hypogonadism
• Aging and Hypogonadism: New Concepts
• Testosterone and sexual function
• Role of Androgens in Penile Tissue Development
• Diabetes and Hypogonadism
• Guidelines for Diagnosis and Management of Hypogonadism
The erectile dysfunction (ED) constitutes a current medical problem
that daily challenges the most urologists.
In addition to the General Practitioner, the Urologist remain the
practitioner the most called upon by patients suffering erectile
dysfunction. This dysfunction is often associated to other
pathologies and could occur at any age. Co-morbidities are usually
LUTS and BPH, Cardio-vascular Diseases and AHT or Diabetes.
That is how we undertook within the external Urological consultation
a prospective and multicentered epidemiological survey of the
masculine ED in TUNISIA.
The objective of this Survey is to identify the risk factors by ED in
the Tunisian urological environment for better attendance of these
patients.
PL2
Treatment with testosterone
Amr El-Meliegy
Professor of Andrology, Cairo University. Head of Andrology Unit, Soliman Fakeeh Hospital,
Jeddah, KSA
Hypogonadism in men represents a disease which leads to a
marked decrease in quality of life and exposes the patient to further
health risks. The clinical use of testosterone is substitution therapy
of male hypogonadism.
Testosterone preparations have been in clinical use for about sixty
years. However, only within recent years has the physician been
able to choose from a variety of preparations with variable duration
of action and modes of delivery. Treatment with testosterone has to
be accompanied by standardized surveillance particularly for older
men.
This talk is aimed at displaying the various testosterone preparations
and the ways to monitor the treatment efficacy and safety and in
particular the testosterone prostate sensitive issue.
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Cairo 26 - 28 February 2009
PL4
Penile transplantation
Rauf Seyam
Professor of Urology, Faculty of Medicine, Suez Canal University, Ismalia, Egypt and Urologist, King Faisal Specialist Hospital & Research Center, Riyadh, KSA
Early success of composite tissue allotransplantation is gaining
attention from the medical community and the public. Penile
allotransplantation might be a viable option for patients who need
penile reconstruction. Basic questions need to be answered
before contemplating clinical application. It is not known how
allotransplantation and immunosuppression affect erectile tissue,
urethra and penile growth. The rat is an economic animal in terms
of availability, resistance to infection, ease of maintaining and
small body weight. A more clinically relevant animal is the baboon.
A successful autotransplantation animal model is a first step
towards proceeding for allotransplantation. We herein describe
autotransplantation following transaction of the penis in the rat and
baboon.
PL5
The relationship between the LUTS and erectile
dysfunction.
Ian Erdely
Consultant Urologist, Leeds Teaching Hospital Trust. President, European Society of Sexual Medicine
There is good epidemiological evidence of an age independent
association between lower urinary tract symptoms (LUTS) and
erectile dysfunction (ED). With the high prevalence of both sets of
symptoms in elderly men, together with the potential use of PDE5
inhibitors for both sets of symptoms, a better understanding of the
pathophysiological relationship between LUTS and ED is needed.
To date, the relationship, if one exists, appears to be mediated via
The Fourth Pan Arab Congress on Sexual Medicine
vascular mechanisms. Research studies have suggested possible
roles for nitric oxide, autonomic hyperactivity, rho-kinase and
atherosclerosis in the pathophysiology of both conditions, although
a conclusive relationship has not yet been proven. Further, there
are clear psychological mechanisms that might relate to both sets
of symptoms.
Complicating factors include the multifactorial nature of the causes
of both sets of symptoms. While ED might have a vascular cause,
it can also be due to neuropathy, endocrinopathy, psychological
problems or a number of other causes. Intriguingly, while we
commonly think of LUTS as a male, prostate related, set of
symptoms, we increasingly understand that many of the symptoms
of LUTS actually relate to bladder dysfunction, and again this may
be relevant to any possible pathophysiological link.
At this time, PDE5 inhibitors are standard therapy for ED, but there
are ongoing trials for the treatment of both LUTS and OAB, and as
these indications come closer to the marketplace, it seem inevitable
that our understanding of the mechanisms involved will increase.
PL6
Erectile dysfunction form the female perspective
Shereef Ghazy
etiologies underwent genital reconstructive surgery, age of surgical
reconstruction range from 2 to 28 yrs. The size of the phallus is the
most important anatomical single factor that should be considered
in sex assignment. Male genital reconstruction was accomplished
in 49 patients while female genital reconstruction in 33 patients.
The outcome was satisfactory in properly selected cases. Main
complications of male genitoplasty were urethral fistulae and
disruption, inadequate phallus and persistent penile curvature.
Inadequate phenotypic appearance and vaginal stenosis were
complications of female genital reconstruction.
Early diagnosis and management of the sexual ambiguity
is mandatory and it gives the best results.
Female
Pseudohermaphrodites should be reared up and reconstructed as
females. Male Pseudohermaphrodites are better reconstructed
as males especially those presenting in late childhood unless they
have small phallus less than 5cm which is not uncommon.
PL8
Management of penile curvature
Hisham Badawy
Professor of Urology, Cairo University
Men and women have a different views and interest in sex. While
men are more likely to focus on coitus and to consider their ability
to have sex as synonyms to virility, women tends to focus on
emotional aspects and to consider sex as part of their relationship
with their partners. In case of erectile dysfunction the reaction of
both partners is different and usually result in disruption of the
relationship and decrease in both non-nonsexual and sexual
intimacy activities. Decrease communication and lack of affection
is reported to be the most important ED sequel by females but not
males. Female sexual dysfunctions can be the result of and/or the
predisposition to erectile dysfunction. Although presence of female
partners in the clinic can contribute valuably to treatment of ED,
still many factors make this difficult including the clinic’s setting,
cultural factors, physician training and more importantly patient
attitude. Many men in liberal and conservative societies do not wish
to involve their partners in their treatment. Female attitude towards
different available treatments varies between different cultures. Any
treatment aimed for the treatment of ED should address the female
partner needs and respect her perspectives.
Normal elasticity and compliance of all tissue layers of the penis
are critical for erectile function. Penile curvature arises when
there is relative asymmetry of one or more aspect of these layers.
Curvatures of the penis may be congenital or acquired. Congenital
cases are usually associated with hypospadias and epispadias
and constitute the majority of congenital curvatures. Isolated penile
curvatures are not frequent with an incidence of 0.6%. These may
be lateral, ventral or dorsal and are usually associated with a large
penis.
Acquired curvatures are theorized to be the result of trauma to the
penis during intercourse. The trauma may be repetitive and develop
over years as in Peyronie's disease or may be an acute buckling
trauma followed by scarring as in overt fracture or subclinical
fracture of the penis.
Curvatures over 30 degrees are considered clinically significant
and those over 60 degrees will definitely interfere with satisfactory
sexual intercourse.
Congenital curvatures usually respond to plication sutures with
satisfactory long-term cosmetic and functional outcome. Grafting
is reserved for the severe cases. On the other hand, in acquired
fractures that require surgical repair, grafting with autologous or
synthetic material is the mainstay of treatment.
PL7
Surgical management of ambiguous external
genitalia
PL9
Impact of the metabolic syndrome on the
management of erectile dysfunction.
Amr Nouir
Tarek Anis
Professor of Urology, Ain Shams University.
Professor of Andrology, Cairo University
External genitalia which cannot be distinguished as male or female
is considered to be ambiguous. There is wide range of ambiguity
from clitoromegaly to minor degrees of hypospadias. Management
of ambiguous genitalia is considered to be a clinical and surgical
challenge.
The principles of repair of ambiguous genitalia depends on an
overall gender appropriate appearance, good sexual function,
reproductive potential, stable gender identity, and psychological
well being.
Eighty two patients with genital ambiguity due to different
Metabolic syndrome (MS) refers to the clustering of several cardiometabolic risk factors, including abdominal obesity, hyperglycemia,
dyslipidaemia, and elevated blood pressure. The experts of the
National Cholesterol Education Program Adult Treatment Panel III
created one of the widely accepted definitions of MS in 2001. In this
definition, abdominal obesity, high blood pressure, and high fasting
blood glucose (FBG), high triglyceride (TG), and low high-density
lipoprotein (HDL) cholesterol levels have been suggested as risk
factors for MS. The presence of any three of the five factors has
been defined as MS. Recent studies support the notion that these
Professor of Andrology, Cairo University, Head of Andrology department, Samir Abbas
Centers, KSA
Cairo 26 - 28 February 2009
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The Fourth Pan Arab Congress on Sexual Medicine
metabolic abnormalities do indeed cluster beyond the effect of
chance, and that a single factor may underlie the association. That
insulin resistance and abdominal obesity, key components of this
cluster, are also associated with perturbations in plasma adipokine
levels, altered fatty acid metabolism, endothelial dysfunction,
pro-coagulant state and systemic inflammation underscores the
breadth and complexity of the patho-physiology of this clustering,
which is still poorly understood. In addition to cardiovascular
disease and diabetes, insulin resistance is also associated with
a wide spectrum of clinical disorders, including polycystic ovary
syndrome, non-alcoholic fatty liver disease, sleep-disordered
breathing, hypogonadism, chronic kidney disease and certain
cancers.
The National Health and Nutrition Examination Survey 1999–2002
estimated the age-adjusted prevalence of MS in US adults aged
20 years and over to be 39.1%. Similar to erectile dysfunction, MS
is more prevalent with increasing age, affecting half of adults aged
60 years and over. The prevalence of MS is increasing in parallel
with population ageing and “epidemic” childhood obesity, which
presents a challenging problem for the future.
Many recent studies have demonstrated that erectile ED is more
frequent in men with MS, and that the prevalence of ED among men
with MS increases with the number of MS components. Endothelial
dysfunction is considered the initial, inciting process of metabolic
risk factor-induced ED and cardiovascular diseases.
In a recent study, Suetomi et. al., demonstrated a negative Impact
of MS on the responsiveness to Sildenafil in Japanese men.
They reported a lower response rate for sildenafil in patients with
MS, which was 40%, compared with 70% in general patients.
The response rate significantly decreased as the number of MS
components increased.
Management of MS is aimed primarily at reducing longer-term risk of
cardiovascular disease and diabetes. Current guidelines recommend
initial focus on intensive therapeutic lifestyle interventions (such as
increased physical activity, dietary modification and modest weight
reduction) that address many of the metabolic risk factors in MS,
including insulin resistance. Chronic use of PDE5 inhibitors to
improve endothelial function may be a useful way to improve the
response PDE5 inhibitors.
PL10
Modern concepts in the pathophysiology and
therapy of priapism
Arthur Burnett
Professor of Urology. Director, Basic Science Laboratory in Neurourology. Director, Male
Consultation Clinic, Johns Hopkins Medical Institutions.
The basic understanding of the pathophysiology of priapism has
steadily evolved with significant progress achieved in recent years.
The classic veno-occlusive hypothesis pertaining to ischemic
priapism (hypercoagulable vascular state and increased blood
viscosity) has given way to modern concepts of dysregulatory
molecular mechanisms acting either at central or peripheral
regulatory levels accounting for such clinical presentations. The
pathophysiology of true nonischemic priapism is believed to have
a trauma-induced causation, with formation of an arterio-sinusoidal
fistula within the delicate vascular framework of the penis.
A body of science has recently burgeoned indicating that aberrant
signaling of the nitric oxide/cGMP/phosphodiesterase type 5
signaling pathway, which serves as the main erection mediatory
system responsible for penile erection, constitutes a major
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Cairo 26 - 28 February 2009
mechanism for priapism. According to this concept, tonically
deficient nitric oxide (NO) actions in the penis, resulting from
penile vasculopathy, produces a downregulated condition of PDE5
expression and activity. This condition refers to “NO imbalance”
within the penis, and conceivably develops because of reduced
endothelial NO bioactivity, impaired NO circulatory delivery, or
oxidative stress effects occurring within the penis. Under this
condition, cGMP (the product of NO signaling) is produced in low,
steady state amounts, rather than at normative substantial levels,
and because of this diminished signaling phosphodiesterase
type 5 (PDE5) function is lowered according to cGMP-dependent
feedback control mechanisms. Downregulated function of other
molecular determinants of the erectile response in the penis may
also occur by changes in their set points by feedback control
mechanisms. Recurrent ischemic priapism then is a condition of
uncontrolled penile erection occurring after sexual stimulation or
nocturnal erectile activity in the absence of proper erection control
mechanisms.
New pathophysiologic insights regarding priapism can be expected
to translate into innovative therapies for the condition as well. At
an investigational level, PDE5 inhibitors used according to a strict
therapeutic regimen have been applied to normatively regulate
PDE5 function in the penis, re-establishing the erection regulatory
basis of this enzyme. Early success has been shown in men
presenting with recurrent ischemic priapism, including men with
sickle cell disease-associated recurrent priapism. Randomized,
placebo-controlled, blinded clinical trials are under way in this field,
which may affirm the usefulness of this therapy.
It is acknowledged that current therapies for priapism, in either
its recurrent or major form, remain imperfect. Scientific research
in this area may produce further insights that may truly lead to
correction of the problem. In the meantime, standard therapeutic
algorithms are appropriately followed in the attempt to preserve
sexual function.
PL11
Novel concepts in penile implant surgery
John P. Mulhall
Associate Professor of Urology. Director of the Sexual Medicine Program, and Director of
Sexual Medicine Research Laboratory at Weill Medical College of Cornell University
Penile implant surgery represents an excellent treatment strategy
for men with erectile dysfunction, especially those who failed
medical therapy or find such treatment unsatisfactory. While
numerous device modifications have contributed to the longevity
and ease of use of implants, there are several other strategies that
can be used to maximize patient satisfaction.
Assessment of patient satisfaction post-penile implant surgery is
hampered by the absence of a validated penile implant specific
satisfaction questionnaire.
Mulcahy introduced the concept of salvage surgery for the infected
penile implant several years ago and the results with this approach
have proven to be excellent avoiding the gross penile shortening
experienced by explant patients. Henry has shown that devices
being removed for malfunction are colonized by bacteria within
their biofilm and advocates a revision surgery washout a la Mulcahy
to minimize postoperative implant infection. While a randomized
controlled trial is awaited, there is a solid rationale for doing this.
Sellers has suggested that the sue of a vacuum device for some
time prior to penile implant surgery results in improved penile length
which of course will translate into improved patient satisfaction.
The Fourth Pan Arab Congress on Sexual Medicine
Length loss is a significant concern of patients after penile implant
surgery, yet there is exists robust data indicating that there is no
length loss between immediately preoperatively and the 6-month
postoperative time-point. Some patients complain of failure of
the glans to engorge and we have used PDE5 inhibitor and the
intra-urethral PGE suppository in such patients with improved
satisfaction.
This lecture will review these and other concepts in the management
of the patient undergoing penile implant surgery.
PL14
Changing Medico – Social "Norms" About
Homosexuality
Ashraf Fayez
Professor of Andrology, Cairo University
This lecture is an overview of the management of genital injuries.
Simple injuries such as frenular tears can often be difficult to treat
if repetitive and a frenular graft is sometime needed. Circumcision
injuries are not uncommon, usually too much skin has been
excised and skin grafting is needed. At other time a glans injury is
apparent and in advanced cases will need a peudoglans fashioned
using skin grafts. The commonest penile injury is a fractured penis,
usually from violent sexual intercourse but also from cultural
practices. The treatment of this is early debridement and repair
of the tunical tear to prevent a penile deformity from occurring.
Approximately 30% of patients may also have a urethral injury and
so a pre-operative work up is mandatory. Less common penile
injuries include suspensory ligament rupture and cavernosal injury,
both presenting with delayed sexual dysfunction.
For advanced trauma of penile amputation a trial of reattachment
should always be attempted but often this is not possible and a
delayed phalloplasty will be necessary.
Testicular injuries are common, usually a blunt injury as a result
of a kick or during sport. The signs are sometime subtle and any
testicular rupture and viability will be picked up by an urgent Duplex
ultrasound study so that a salvage procedure can be performed.
For much of 20th century, homosexuality was considered a
personality defect or a symptom of psychiatric illness. Traditional
psychological theories and social theories were recently reinforced
by many biological theories trying to explain the etio-pathogenesis
of the disorder.
In 1970s, homosexuality was removed from the American
Psychiatric Association's list of mental disorders with the recognition
that homosexuality is not pathologic. That point of view continued
to the present and has gathered strength over the years.
The concept of homophobia was developed in the 1970s to explain
societal prejudice against homosexual individuals. Homophobia
is also used to describe negative feelings among homosexual
people, which hold them back from appropriate assertion of
non-discriminatory treatment in society. Discrimination against
homosexual individuals remains powerful even in Western society,
and homosexual couples are not afforded the rights and protections
available to heterosexuals.
Recently, many Western communities are adopting antidiscriminatory constitutions, as part of the democratization process.
In their opinion, “equality begins when we recognize that all of us
have the right to be different”. Their most remarkable feature is the
effort to change social norm under what they claim as “respecting
differences”
One part of their anti-discriminatory battle against homophobia is
the change in regular definition of homosexuality and considering
it as a normal human sexual variation. Moreover, terms like
homosexual, gay, lesbian are being changed into Men who have
Sex with Men (MSM) and Women who have Sex with Women
(WSW).
What is expected from “Changing socio-medical norms about
homosexuality”? … To what destination we are heading?
PL13
Management of Peyronie's disease
PL15
Amelioration of Penile Fibrosis: Myth or Reality?
Amr Jad
Ahmed El Sakka
Consultant Urology, Andrology & Male Infertility. Chairman of The Saudi Andrology Group.
Professor of Urology, Suez Canal University, Ismailia, Egypt and Al-Noor Specialist Hospital, Makkah, KSA
PL12
Management of genital trauma
David J Ralph
Consultant Urologist and Senior Lecturer, St Peter's Hospital and The Institute Of Urology,
London, UK
Peyronie`s disease is characterized by the development of
circumscribed, dense, fibrous plaque toward which the erect penis
ungulates. This plaque is characterized by an initial inflammatory
reaction followed by fibrous scarring of the tunica albuginea and
the areolar space between the tunica albuginea and erectile tissue.
In some patients the fibrous plaque is extensive and involves the
whole circumference of the penis, and the septum results in penile
shortening or hour glass rather than angulation during erection.
Also oral and intraleasional medication are of limited efficacy
especially in well established disease also researches are
promising, still surgical treatment should be considered only after
failure of conservative measures and after at least one year of
established disease.
I will discuss different treatment methods available now the
techniques, indications, advantages and disadvantages of the
most popular operations that have been used for the treatment of
Pyronie’s disease as will as the most recent techniques.
The aim of this presentation is to address this interesting issue, can
or cannot we ameliorate penile fibrosis? We will tackle this issue
from its different aspects.
Aging-related erectile dysfunction is characterized by a loss of
smooth muscle cells (SMCs) and fibrosis in the corpora cavernosa,
and functionally characterized by corporal veno-occlusive
dysfunction. It has been postulated that these histologic changes
in the aged corpora are caused by increased oxidative stress
and/or other profibrotic factors that stimulate SMC apoptosis and
collagen deposition. Other model of penile tunica albuginea fibrosis
is Peyronie's disease, where the fibrosis is characterized by an
increased collagen over cellular compartment.
It is recently demonstrated that long-term treatment with PDE5A
inhibitors could upregulate NOS2A expression via cGMP modulation,
and thus contribute to SMC protection and ultimately ameliorate
the functional and histological changes. The improvement of the
SMC:collagen ratio is assumed to be due to
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the antifibrotic effects of cGMP. It is known that cGMP acts as proproliferative or anti-proliferative agent according to the cell type. In
addition, the oxidative stress and TGFB1 levels were not affected
by PDE5I. cGMP is not a direct inhibitor of TGFB1 expression but
does interfere with TGFB1 signaling both by blocking pSMAD 2 and
3 nuclear translocation or SMAD-induced gene expression and by
the conversion of latent TGFB1 to its active form. The inhibition
of TGFB1 expression by nitric oxide is not mediated by cGMP. In
contrast to nitric oxide, cGMP is not a key modulator of oxidative
stress, although it is possible that a PDE5I effect may be detected
by markers of this process other than xanthine dehydrogenase. We
can conclude that, although it seems challenging to reverse penile
fibrosis, however recent researches had demonstrated promising
results and probably paved the road to this dream comes true.
PL16
Female Anorgasmia
Omayma Idrees
Professor of Ob Gyne, Cairo University
Healthy sexuality is a topic that is coming to the forefront in our
society after being closeted for decades. Yet female sexuality is
less studied and less understood than male sexuality. Anorgasmia
is the commonest female sexual dysfunction and in spite of that
it did not receive much attention until relatively few years ago. It
affects between 24 % & 37 % of women. Anorgasmia defined as
persistent or recurrent inability to attain or maintain sufficient sexual
excitement, causing personal stress, which may be expressed
as a lack of subjective excitement or genital lubrication or other
somatic responses. It can be divided into 1ry, in which a woman
has never experienced orgasm through any means of sexual
stimulation, 2ry, in which a woman is anorgasmic after a period
of time when she was orgasmic, situational (e.g., when a woman
can’t reach orgasm in certain situation) or randam anorgasmia.
Causes of anorgasmia include; psychological factors, cultural
factors, organic causes, stress and fatigue, depression or anxiety
disorders & also may result from female physiological changes
with her aging. Effective treatment for anorgasmia depends on its
cause. Several approaches are available including pharmacological
approach (vasoactive drugs & estrogen), treatment of dyspareunia,
psychological approach and non specific measures that increase
stimulation and minimize inhibition (sensate focus, sex therapy &
education).
PL17
Sexual Pain Disorders
Amany Shaltout
Associate Professor of Ob&Gyn ,Cairo University. Sexology Consultant, Dr Samir Abbas
medical center ,Jeddah, KSA
Sexual pain disorders affect women almost exclusively and include
dyspareunia and vaginismus.
Dyspareunia is the persistent or recurrent pain with attempted
vaginal intercourse. In a general gynecologic practice population,
the prevalence of dyspareunia may be as high as 15 percent.
There are 3 types of dyspareunia: superficial or entry-pain
(vulvodynia), vaginal pain and deep pain. Evaluation of a patient
with dyspareunia requires attention to details during the history and
physical examination. Often a treatable cause of dyspareunia is
identified and resolution or improvement will be obtained following
its treatment.
22
Cairo 26 - 28 February 2009
Vaginismus is the persistent or recurrent difficulties of the
woman to allow vaginal entry of a penis, a finger and/or any
object ,despite the woman’s expressed wish to do so. This is a
conditioned response that results from associating sexual activity
with pain and fear. It consists of a phobia of penetration of the
vagina. Vaginismus may be primary (when a women has never
experienced vaginal penetration),or secondary (when a woman
has had vaginal penetration without a problem in the past). Why
some women develop vaginismus and others do not is uncertain.
The initial response may be secondary to any type of vaginal pain,
including all causes of dyspareunia. Management includes sex
education, self exploration of sexual anatomy, sex therapy and the
use of vaginal trainers.
The management of sexual pain disorders is not easy, the key
point is “no size fits all”, accordingly management should be
individualized and have a patient based approach, in which the
patient shares in the decision about the modality of treatment.
PL18
An Evidence-Based Perspective to Commonly
Performed Erectile Dysfunction Investigations.
Hussein Ghanem
Professor of Andrology, Cairo University. PASSM General Secretary
Introduction: Currently there is no universally accepted gold
standard diagnostic test to differentiate psychogenic from physical
erectile dysfunction (ED). Instead, sexual health specialists rely on
a detailed history, a focused physical examination and specialized
diagnostic tests to decide if the etiology of the ED is mainly
psychogenic or organically caused.
Objective: In this review we point out the status of evidence based
principles in the area of diagnosis in Sexual Medicine
Methods: We review the concepts of evidence-based medicine
(EBM) in the area of medical diagnostic tests. We highlight four of the
well-known diagnostic tests (penile duplex, pharmacoarteriography,
pharmacocavernosometry/cavernosography [PHCAS/PHCAG] and
nocturnal penile tumescence [NPT]) monitoring for ED evaluation
within an evidence-based perspective. Conclusions: While penile
duplex / color Doppler has good evidence of supporting its use in
the diagnosis of arteriogenic ED, data supporting its diagnosis of
a physical disorder associated with cavernous venous occlusion
dysfunction are lacking. PHCAS/PHCAG’s main drawback is an
unknown positive predictive value and a possibility of frequent false
positive results. NPT has many advantages when differentiating
psychogenic from organic ED, however, several questions related
to its physiological mechanisms do exist.
The Fourth Pan Arab Congress on Sexual Medicine
Commonly Performed ED Investigations
Test
Main Benefits
Limitation
Questionnaires
Easy to administer
Do not diagnose the Etiology of ED
Color duplex Ultrasonography
Tested against a (historic) gold standard
Unknown PPV for venogenic ED
Diagnose severity of ED
Well tested and validated
Suggest arteriogenic or ‘venogenic ED
Might predict other vascular disease (e.g. CAD)
Anxiety/sympathetic overtone might lead to false
+ve results
Redosing & retesting may be needed
Pharmaco-Arteriography
Delineates arterial anatomy before arterial
Invasive
Pharmaco-Cavernosometry /
Diagnose ‘venogenic ED
Moderately invasive
Cavernosography
reconstructive surgery in post-traumatic cases
Demonstrates site of leak & cavernosal
abnormalities
Results influenced by methodology and timing
Error Margin 20%
Unknown PPV
Anxiety/sympathetic overtone might lead to false
+ve results
NPT testing
Closest to a gold standard to differentiate organic
(physical) from psychogenic ED
Sexually stimulated erections might be regulated by
different pathways
Physical disorders might alter NPT even in
Psychogenic ED
Axial rigidity might differ from radial rigidity
Did not correlate well with IIEF domain scores
Neurological Testing
Assess somatic Pathways
Do not directly assess autonomic nerve function
No universally accepted and reproducible criteria
Complex, time-consuming,
Unknown PPF
PL19
NAION and PDE5i an update
Said Kattan
Professor and Consultant of Urology, King Faisal Specialist Hospital and Research Center,
Riyadh, KSA
Phosphodiesterase type 5 inhibitors (PDE5i) are important
medications that have been widely used with an excellent safety
profile in pre-marketing and post-marketing studies. Non-Arteritic
Anterior Ischemic Optic Neuropathy (NAION) is rare but an
alarming condition that attracts the attention of patients, regulatory
agencies, consumer advocates and media. The small number of
reported cases does not support strong evidence that PDE5i cause
NAION. However, the possibility that PDE5i precipitate NAION
cannot be ruled out. Only prospective randomized studies with
adequate number of patients can clarify the relation of NAION and
PDE5i. For the time being patient education might be warranted.
Physician must be vigilant towards history of visual problems and
development of hypotension particularly in patients with risk factors
for NAION.
PL20
Post-radical prostatectomy erectile dysfunction
Arthur Burnett
Professor of Urology. Director, Basic Science Laboratory in Neurourology. Director, Male
Consultation Clinic, Johns Hopkins Medical Institutions.
In the modern era of prostate cancer management, the need exists
for effective oncologic control while maximally preserving functional
outcomes such as sexual function. Historically, interventions for
prostate cancer have had a significant impact on the male sexual
response including penile erection, ejaculatory function and
orgasm, and sexual libido. This dilemma has causes patients to
ponder the impact of various treatment approaches for prostate
cancer since many place paramount importance on the opportunity
for retaining natural erectile function afterwards. Specialists
in this field have sought to optimize techniques associated with
therapy such as cavernous nerve-sparing radical prostatectomy
and conformal pelvic radiation therapy to limit sexual dysfunction
complications, but current studies still find that such interventions
do not fully overcome their toll in this regard.
In addition to optimization techniques, therapeutic strategies
are applicable to address these concerns. Current treatment
approaches for post-intervention erectile dysfunction include
pharmacotherapeutic options such as oral pills, intraurethral
suppositories, and intracavernosal injections and nonpharmacotherapeutic options such as mechanical vacuum
constriction devices and penile prosthetic surgery. Counseling
intervention for prostate cancer survivors and their partners may
also offer therapeutic benefit.
With particular attention given to erectile dysfunction management,
new directions in this field revolve around innovative strategies such
as erection rehabilitation and neurobiologic therapies, derived from
Cairo 26 - 28 February 2009
23
The Fourth Pan Arab Congress on Sexual Medicine
an increasingly scientific understanding of the basis of erection
physiology. Such strategies are designed specifically to preserve
the integrity of the structures involved in penile erection and restore
their biological function. Active investigation is being carried out
at both clinical and preclinical levels to develop treatments which
will better address sexual dysfunction following prostate cancer
treatments and maximally preserve quality of life.
PL21
The Small Penis syndrome
Ian Erdely
Consultant Urologist, Leeds Teaching Hospital Trust. President, European Society of Sexual Medicine
The male is often troubled by concerns that his penis is not large
enough to satisfy his partner or himself. He is ashamed to have
others view his penis, especially in the flaccid state. Such concerns
might be unfounded in reality and might be a presentation of
social anxiety or some other clinical problem, such as erectile
dysfunction. Concern over the size of the penis, when such concern
becomes excessive, might present as the ‘small penis syndrome’,
an obsessive rumination with compulsive checking rituals, body
dysmorphic disorder, or as part of a psychosis. However, it is often
a worry that can be described as within the normal experience of
many men. Various potential causal factors are considered.
It is recommended that the initial approach to a man who has
SPS is a thorough urological, psychosexual, psychological and
psychiatric assessment that might involve more than one clinician.
More research is required on the effects of race and age on penile
length. Conservative approaches to therapy, based on education
and self-awareness, as well as short-term structured psychotherapy
(CBT) are often successful, and should be the initial interventions
in all men.
Of the physical treatments available, there is poorly documented
evidence to support the use of penile extenders. More information
is need on the outcomes with these devices. Similarly, there is
emerging evidence about the place of surgery and there are now
several reports suggesting that dividing the suspensory ligament
can increase flaccid penile length.
There are only limited data relating to operations designed to
enhance penile circumference. While there are emerging data
about the effect of surgical treatment on penile dimensions, there
is much less information about the patients’ satisfaction with the
outcome of surgery. Such assessments have only been reported
occasionally, and in a situation where surgery is used cosmetically
to treat a psychological condition, such outcomes are vital to assess
the place of such surgery.
PL22
Management of PDE5 inhibitors non responders
Bahgat Metawei
Professor of Andrology Cairo University. PASSM Founder
Although world wide clinical studies have proved the efficacy of
PDE5 inhibitors in the treatment of the majority of ED patients, still
non responders constitute a considerable clinical problem.
Most of the real PDE5 I non responders proved to have a sever
penile arterial or veno-occlusive disorders.
Treatment of concomitant disease e.g. diabetes, hypertension,
hypercholesterolemia or combination of testosterone in partial
androgen deficiency has synergistic effect and can help many of
24
Cairo 26 - 28 February 2009
the non responders. Also re-counseling or shifting from one type of
PDE5 I to another may also help some of those non responders.
Again the chronic daily use of PDE5I or combination with other drugs
e.g. ICI alprostadil and vacuum therapy rescue other patients.
PL23
The benefit of testosterone administration to men
not responding to PDE-5 inhibitors: State of the art
Aksam A. Yassin
Professor of Urology & Human Sexuality, Chairman Institute of Urology and Andrology,
Segeberger Kliniken, Norderstedt-Hamburg - Germany
Introduction: Delivery of the phosphodiesterase type 5 inhibitors
(PDE 5-inhibitors) has been a step forward in the treatment of
erectile dysfunction. The success of the PDE 5-inhibitors rendered
androgens as treatment for erectile problems in the average patient
as something of the past.
Methods: Over the last 15 years the age-related decline of circulating
testosterone in men has received serious attention. Moreover, new
research has presented convincing evidence that testosterone has
profound effects on tissues of the penis involved in the mechanism
of erection and that testosterone deficiency impairs the anatomical
and physiological substrate of erectile capacity, at least in part
reversible upon androgen replacement.
Results: There are androgen receptors in the human corpus
cavernosum. The expression of nitric oxide (NO) synthesis is
regulated by androgens. Several studies show that androgen plays
a critical role in restoring and maintaining the penile trabecular
smooth muscle structure and function as well as regulating the
cell apoptosis. Testosterone deficiency induces both biological and
structural/functional changes in the trabecular cavernosal tissues.
Adipocyte accumulation in penile subtunical area of the corpus
cavernosum emphasized the potential mechanism for venoocclusive dysfunction in androgen deficiency.
Conclusion: So, in androgen-deficient men, testosterone may
restore the anatomical/biochemical substrate on which the PDE-5
inhibitors act. The above argues for measurement of testosterone
in men with complaints of erectile dysfunction. Several studies,
including our own, show that testosterone treatment alone, or in
addition to PDE-5 inhibitors, may restore erections in these men.
PL 24
Conservative surgery for penile cancer
David J Ralph
Consultant Urologist and Senior Lecturer, St Peter's Hospital and The Institute Of Urology,
London, UK
Penile cancer is a rare malignancy which presents in 300 patients
per year in the UK. A 2 cm clearance of the primary tumour has
previously been recommended, which has usually meant a partial
penile amputation with the resultant sexual and urinary difficulties.
Newer techniques have now been developed to preserve penile
length and function and without compromising local control.The
majority of tumours are distally based and depending on the stage
and grade penile preservation is usually possible.
Carcinoma in situ and Ta lesions are now treated by total glans
resurfacing with the use of skin grafts. More invasive lesions that
do not involve the tunica can be treated by a glansectomy with
peusdoglans formation. Even with tunical invasion local excision
with tunical reconstruction with synthetic substitutes and be
performed. Although local recurrence rates of approximately 10%
can be expected this can be dealt with easily and without a change
in life expectancy.
The Fourth Pan Arab Congress on Sexual Medicine
Podium Presentations
P1
Functional outcome of colpoplasty using sigmoid
colon
Amr Noweir, Ehab A Eltahawy. Cairo, Egypt.
Urology Department Ain Shams University, Cairo-Egypt
INTRODUCTION AND OBJECTIVE: Different replacement
procedures are available for vaginal substitution either as
tubularised grafts or from local flaps. The sigmoid colon offers
a readily available well vascularised tissue that is functionally
appealing as it has a wet surface.
METHODS: 38 patients were evaluated during 1988 to 2006. 18
patients were genetic females with congenitally absent vagina
(Rokitanski syndrome), or had traumatic or iatrogenic injury that
resulted in small vagina. 20 patients were genetic males with
ambiguous genitalia, decision was made for genital feminization.
Preoperative pelvic CT, and colon preparation was done in all
cases. A segment of the sigmoid colon 10-15 cm was harvested,
and primary Closure of the colon was done.
A plane between the bladder and the colon was developed starting
perineally, then continued from the abdomen. The proximal end of
the neovagina was closed and fixed to sacrum, in one patient this
was anastomosed to the uterus. The distal end was anastomosed
to the introitus. A vaginal pack was left for 10 days.
RESULTS: Mean age was 22 years (12-42), mean follow up was
14 months (6-38). In all patients an adequate size neovagina was
achievable. 12 patients are sexually active. 15 patients developed
introital narrowing and use regular dilatation, 8 patients required
introital incision. 2 patients had prolonged ileus that resolved
spontaneously.
One patient presented with acute abdomen due to ruptured
neovagina and was explored for repair.
CONCLUSIONS: The use of pelvic colon in vaginal reconstruction
has several advantages. It is available, wet, and adequate size can
be reconstructed. Patient satisfaction was high with this technique,
though some patients need frequent introital dilatation.
P2
Parylene coating improves mechanical survival of
AMS 700 CX penile prosthesis
Emad Salem, John Delk, Mario Cleves, Steven Wilson
Urology department - Zagazig university
Introduction: Parylene coating was added to AMS 700 CX penile
prosthesis cylinders beginning January 2001. The coating was
placed on non-tissue contacting surfaces to increase lubricity,
reduce friction and silicone wear
Aim: is to compare mechanical reliability of the original and parylene
enhanced AMS 700 CX
Methods: This study was conducted on of 775 implant surgeries
(596 virgin and 179 revisions). Revision free survival was estimated
using the Kaplan-Meier product limit method and compared using
the log rank test.
Main outcome measures: Mechanical survival from (fluid leakage,
cylinder or tubal breakage, pump or reservoir defects) was
estimated
Results: For the entire series (virgin + revised) the 3 year revision
free survival for any cause improved from 78.6 % for non-coated to
87.4 % for the parylene coated implants. Freedom from mechanical
breakage showed similar improvement from 89.2 % for the noncoated to 97.5 % for enhanced models.
Conclusions: This study documents that mechanical reliability is
significantly increased with parylene coated AMS CX cylinders
compared to the earlier model with non-coated cylinders
P3
Penile Augmentation and Reconstruction
Alexander Krakovsky MD, PhD, DrSc, FAAPS
American Academy of Phalloplasty Surgeons
Objective: Historically, men have considered a larger penis to be
a symbol of greater masculinity. In our time, the erect penis has
become the most powerful of a man’s symbolic “muscles.” Despite
this lack of acceptance by the society, many men undergo surgical
penile augmentation and reconstruction (phalloplasty) to enhance
the length, girth, and glans of their penises.
Materials and Methods: A total of 374 phalloplasty surgeries
performed using AlloDerm® were evaluated. Single augmentation
includes girth enhancement only; combination augmentation
include dual augmentation (lengthening and girth enhancement
combine) and triple augmentation (lengthening, girth enhancement
and glanular enhancement combine.) AlloDerm is a cadaveric
acellular tissue regeneration matrix that is minimally processed to
remove epidermal and dermal cells, while preserving the structure
of the dermis.
Results: 97.2% of patients successfully went through surgery and
postoperative period without any complications. 3.24% of patients
developed surgical complications that were successfully treated
medically and surgically. 4.9% of patients experienced localized
swelling 3-7 days after surgery that resolved spontaneously and
7.3% of patients reported temporary post surgical retraction that
were successfully treated medically and surgically.
Discussion: Today a man can modify the size and shape of his penis
using procedures introduced by cosmetic/plastic surgery. With
the use of AlloDerm, these changes could be considered almost
permanent. Permanent penile enlargement and reconstruction
surgeries are the surgeries that do not require maintenance of the
desired size or shape after surgery, through additional grafting.
The dermal fat graft, or DFG (a graft made from the patient’s own
skin) and AlloDerm (a graft created from cadaver skin) are the
two types of grafts that offer permanent penile enlargement and
reconstruction.
Conclusion: The patient’s satisfaction was analyzed using the Penis
Image Assessment Scale Questionnaire. The assessment was
based upon questions related to the size of the penis, satisfaction
of sexual experiences and the psychological perspective of the
patient to his penis before and after surgery. The results showed
a high satisfaction rate with a new surgical technique for penile
augmentation (Penile Triple Augmentation TM) developed and
used by the author. All surgical complications were successfully
treated medically and surgically.
Cairo 26 - 28 February 2009
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The Fourth Pan Arab Congress on Sexual Medicine
P4
Penile Prosthesis Insertion in Cases of Severe
Penile Fibrosis
Abdel Raheem A, Garaffa G, Spillings A, Christopher AN,
Ralph DJ
Institute of Urology, London, UK
Aim : To present long-term results of the insertion of penile
prosthesis in patients with severe penile fibrosis are presented.
Materials and Methods : A penile prosthesis was inserted into 50
patients (mean age 43.4 yrs; range 22 -70yrs) who presented with
extensive cavernosal fibrosis. The aetiology was post priapism
(n=27), explantation of an infected penile prosthesis (n=14),
perineal and penile trauma (n=6), extensive urethral reconstruction
(n=1), abscess of the corpora (n=1) and Scleroderma (n=1). A
3 pieces inflatable prosthesis was inserted in 28 patients and a
malleable prosthesis in 22 patients. The dilatation was often difficult
due to advanced fibrosis but was managed with the use of Rossello
cavernotomes in 26 patients and an additional subcoronal incision
in 22 patients. In one patient the tip of one of the corpora had been
destroyed by infection and therefore a Dacron cap was necessary
to house the cylinder.
Main Outcome Measures : The incidence of intra-operative,
postoperative complications and patient satisfaction rate.
Results : The majority of patients needed downsized cylinders
(80%) due to the fibrotic corpora. The intra-operative complications
included urethral perforation in 3 patients, managed by a delayed
secondary operation, and cylinder cross over in 4 patients, 3 of
which was recognized and immediately corrected. Despite of the
intra-operative difficulties all patients had 2 cylinders inserted with
a satisfaction rate of 90% after a median follow up of 17 months.
Ten patients later had an elective exchange of their malleable to an
inflatable penile prosthesis using an upsized cylinder in all patients
with a mean increased length of 1.5 cm (range 0-3). The prosthesis
was explanted in 5 patients (infection (3), erosion (2)) and revised
in a further 4 patients (soft glans 1 and mechanical failure 3). Floppy
glans was present in 6 patients; 1 was managed with glanspexy,
the remainder conservatively (MUSE 1 and PDE5 inhibitors 4).
Conclusions : The presence of dense fibrosis of the corpora is not
a contraindication to the insertion of penile prosthesis, however
patients must be warned that the complication rate is higher than
in virgin patients (16%) and that revision surgery may be required
(28%).
P5
Total phallic reconstruction using the radial artery
forearm free flap
Garaffa G, Abdel Raheem A, Spillings A, Christopher AN,
Ralph DJ
Institute of Urology, London, UK
Aim : This is a series of 35 consecutive men that had a total phallic
reconstruction using the radial artery forearm free flap.
Patients and Methods : The mean age was 39y (22-54). The
indications for surgery were micropenis in 12 patients (Exstrophy 3,
5 alpha reductase deficiency 8, Robinow syndrome1) and following
penile amputation in 23 patients (trauma=8, cancer=15). The
procedure involves formation of the phallus from the non-dominant
forearm with an incorporated neourethra and microsurgical vascular
and nerve transfer. A primary urethral anastamosis was performed
in 32 patients and a penile implant inserted into 12 patients so far.
28
Cairo 26 - 28 February 2009
The surgical outcome, complications and patients’ satisfaction
were recorded.
Results : After a mean follow up of 23 months (1-69), 100% of
the patients are very satisfied with the phallus size and cosmesis.
Currently 31 patients void through the urethral meatus, 3 have a
Mitroffanoff stoma and 1 patient a suprapubic catheter awaiting
revision. Urethral fistulae and strictures requiring surgical correction
occurred in 34% of cases. Other complications included an arterial
thrombosis requiring re-exploration in 1 patient, partial necrosis
of the phallus requiring split skin grafts in 2 patients and penile
implant explanation for infection in 2 patients.
Conclusion : Forearm free flap phalloplasty yields excellent
cosmetic and functional results for phallic construction. Despite
multiple stages and revision surgery, the patient satisfaction is
excellent.
P6
T shunt with intracavernous tunneling for the
management of refractory ischemic priapism
Tarek Anis and Hussein Ghanem
Department of Andrology, Cairo University
Introduction: Refractory ischemic priapism is defined as painful
penile erection that persists despite appropriate corporal aspiration
and/or injection of sympathomimetic agents. It remains a difficult
to treat and poorly understood phenomenon. The multitude of
surgical shunt procedures that have been reported and used in
the management of this condition lack reproducibility and reliable
results using any of the established modalities.
Clearly, there is a need for an improved procedure that can
simply and reproducibly create a large shunt to drain the corpora
cavernosa in cases of refractory ischemic priapism. The so called
“T shunt” and its’ bilateral form, the “TT shunt” were developed at
the University of California, San Francisco for this very purpose.
For ischemic priapism of more than 3 days duration, the addition
of bilateral intracavernous tunneling, the “TTT shunt,” will help to
restore blood circulation to the entire corpora cavernosa despite
severe tissue edema and cell death.
Material and Methods: In this report we describe the management
of a case of idiopathic refractory ischemic priapism of 32 days
duration.
The procedure is simple and straight forward and can be performed
with local anesthesia in the emergency room or the clinic. The tip
of the corpus cavernosum is palpated through the glans; typically
this is not difficult as the glans remains soft in ischemic priapism
and the firm corporal tips are easily felt through this tissue. After
appropriate local anesthesia, a 10 blade scalpel is advanced
through the glans tissue and into the ipsilateral corporal body. A 10
blade is preferred as a smaller blade will not create a sufficiently
large shunt. The knife is then rotated 90 degrees laterally away
from urethra and withdrawn. Typically there is a prompt efflux of
dark, deoxygenated blood. The penis is then “milked” repeatedly to
expel cavernous blood until there is noticeable lightening of blood
expressed, suggestive of restoration of arterial blood flow. The
wound is closed with a 4-0 chromic or 5-0 absorbable synthetic
suture and observed for 10-15 minute. If rigid erection recurs, the
procedure is repeated on the contralateral side.
In cases of prolonged priapism (often of 3 or more days duration),
tissue edema/death may make the fistula created with T shunt
alone insufficient to restore circulation within the corporal bodies.
In these cases it is necessary to perform corporal tunneling with a
The Fourth Pan Arab Congress on Sexual Medicine
20-24 French dilator. For corporal tunneling, the dilator is advanced
through the glanular incision and into the ipslilateral corporal body,
using gentle pressure, as far as possible. Care is taken to direct the
axis of the sound approximately 10 degrees lateral to the midline
in order to minimize the chance of the dilator “crossing over” and
potentially leading to urethral injury. Corporal tunneling should be
performed bi-laterally.
Results: The procedure resulted in restoration of arterial circulation
and immediate relief of pain and unwanted erection.
Conclusion: T shunt procedure alleviates pain in patients who have
little to no hope of functional erectile recovery. We believe that
the simplicity and efficacy of the T shunt procedure makes it the
procedure of choice in the contemporary management of refractory
ischemic priapism.
P7
Augumentation Phalloplasty: Apical and
pericavernousal penile implant
Jamal Salhi and M. Del Prete
Androclinic - Rome
Introduction and objectives : The augmentation surgery of the penis
has not yet solved the problem of the type of material to be used for
the increase of the penile circumference, besides the persistence
of perplexity and disrust toward this type of surgery burdened by
complications and failures.
The implant is comprised of three parts: the first is inserted at
the tip of the cavernous bodies under the glans and for this is
called “apical", the other two are specular lateral parts, right and
a left, called "pericavernouse". The implant is constituted of a
hemicilinder crescent section with flattened distal extremity.
The apical portion of the implant is “ bean-shaped” and it is inserted
between the distal surface of the cavernous bodies and the glans
projecting it forward and laterally adding as well a certain increase
to the length of the penis.
The structure of this implant is composed from an external wrap
( multi-layer ) in biocompatible material filled by highly cohesive
silicon gel .
There are different sizes that can accomodate greate anatomical
variations for total length, width, and thickness.
Technique : The surgery is performed in day-hospital using
regional anesthesia, with two small transversal incisions at the
base of the glans, bilaterally. A pocket of sub-glandular lodging is
prepared proceeding from the sides so as not to injure the dorsal
neurovascular bundle and the urethra.
After the insertion of the implant the glans is sutured to the corpora
by interrupted stiches.
For the pericavernous implant, a subfascial tunnel is prepared
bilaterally for the whole length of the penis down to its root. The
pericavernous prosthesis is fixed to the corpora cavernosa only
distally.
Results : From January 2002 up to December 2007, 112 patients
between the ages of 21 and 54 have undergone augmentation
phalloplasty with this new pericavernous implant.
Only 7 of these patients received the apical implant in addition to
the pericavernousal one, and in 3 cases the surgery was limited to
the apical implant to resolve the problem of primary disproportion
of glans and the volume of the penis. Infection occurred in two
patients and was treated by explantation-reimplantation after six
months
Conclusions : This pericavernous implant responds to a demand
for a simple and rapid procedure that can provide good and lasting
aesthetical results without jeopardizing penile function.
P8
The impact of the internet on the male/female sexual
behavior
Marizia Bonifacio
CRP from Brazil and SBRASH
Introduction. Men and women free of cultural values and religious,
to experience sexual pleasure.
Instruments: semi-structured interviews and questionnaires.
Methods: Sample of 5000 adult, 2.500 men and 2.500 women,
30% single, 32% divorced, 38% marriage.
Representativeness North America, Canada, Central America,
South America, Europe, Asia and Africa.
It was observed several disorders, including: dependence on the
Internet 12 hours per day; occurrence of orgasms only when in
contact with the computer; men presenting penile impotence;
women with vaginal irritation and compulsion, aggression, need for
new illusions, sado-masochism often for obtaining pleasure; real
difficulties in relationships; sharp exchange partners; disruptions
caused by the use of marriage and the internet Match and
mismatch.
Result: All respondents reported the occurrence of orgasm, via the
Internet in specific rooms for sex, and the existence of the feeling
of freedom.
The Internet allows a world without borders. Everyone can feel
sexual pleasure, regardless of cultural and religious values, but
there are ethical and moral values, taxes per person and groups
depending on the search directly aware inconsciente.Todos and
make a dive in the dark's own emotional history, causing surprises,
questioning and denial of attitudes.
Enter in hole dark. Relacionship fragile, accommodated, old.
Breaking of paradigm. If allow living new emotions. If allow feel
without responsibility without possession, without possess. The
mirror of soul. Perversion and perverted. Without handcuffs, Free
to feel. Intolerance for recoveries. Game power and control. To
be criate. To be more motivation. Ilusion of LOVE.Making to
perform fantasies, NEUS diseases by sleeping little, high anxiety,
depression, deviations and sexual dysfunctions were aspects
observed.
The interaction through the Internet, allows self knowledge, freedom
of expression of innermost desires and never before manifests.
There is a catharsis without professional monitoring. It may be
good in the short term and bad in the long term.
The sexual instinct without the limits imposed by the moral and
ethical values arising from the culture and religion, the imbalance
generate spiritual, emotional and physical, leading the individual to
the existential chaos, the madness, disease and various kinds of
deviations.
The interaction through the Internet, allows self knowledge, freedom
of expression of innermost desires and never before manifests.
There is a catharsis without professional monitoring. It may be
good in the short term and bad in the long term.
The sexual instinct without the limits imposed by the moral and
ethical values arising from the culture and religion, the imbalance
generate spiritual, emotional and physical, leading the individual to
the existential chaos, the madness, disease and various kinds of
deviations.
Cairo 26 - 28 February 2009
29
The Fourth Pan Arab Congress on Sexual Medicine
Cultural influence can change the perception of pleasure and social
acceptance, but on the Internet, where there is no interest in life
to have two, these influences are not significant. The construction
of knowledge clearly shows that sex is sex and love is amor.Na
Internet, the individual can live the sexual pleasure of genuine
independent responsibilities determined by internalized the values
of viver.Também soon realizes is pronounced individualism,
selfishness, the sexual masturbation is enough, because it is only
virtual sex masturbation shared.
The lack of control, is generating psychophysical imbalance,
causing decline in school performance and bad production on the
desktop (job).
P9
ENT Problems and Peyronie’s Disease: A New Risk
Association
Onder Canguven, Sena F. Sezen, Bruce Trock, and Arthur L.
Burnett
The James Buchanan Brady Urological Institute, Johns Hopkins Hospital, Baltimore, USA
Introduction: The etiology and related diseases for Peyronie’s
disease (PD) remain largely obscure.
Aim: The aim of this study was to investigate the relationship
between ENT (Ear, Nose and Throat) problems and PD.
Methods: We conducted a retrospective hospital-based casecontrol study in the urology department from January 2007 to March
2008. We analyzed the files of 43 men with PD and 113 localized
prostate cancer patients serving as controls. Demographics,
complete medical history and domain scores on IIEF and AUA
symptom questionnaires were obtained. The association between
PD and selected co-morbidities was also evaluated and compared
with findings reported in the literature.
Results: Median patient ages of PD and control groups were 55
(17-72) and 61 (41-93) years, respectively. Univariate logistic
regression analysis demonstrated that ENT problems (e.g.
sleep apnea, sinusitis, nasal polyps, adenoid hypertrophy) were
significant co-morbidities of PD (OR: 4.58; CI: 1.85-11.33, p<0.01)
(30.2% vs. 10.6%, p<0.05). We also noted that PD patients had
high AUA symptom scores (14% vs. 7.9%, p<0.01). No significant
difference was found between the two patient groups in terms of
hypertension (42% and 30.6%, p>0.05) and DM (10% vs. 5.8%
respectively, p>0.05).
Conclusion: ENT problems may be included among clinical risk
factors for PD. The association suggests a common susceptibility
to fibrotic disease changes.
P10
Management of complaint of a Small Penis in
Physically Normal Men
Hussein Ghanem
Department of Andrology, Sexology and STD, Cairo University
Introduction: With the worldwide increase in penile augmentation
procedures and claims of devices designed to elongate the penis,
it becomes crucial to study the scientific basis of opting to penile
augmentation or other forms of treatment.
Aim of the work: To evaluate the management options for physically
normal men with a complaint of a small penis.
Methods: We report on the outcome of using a structured
management and counseling and management protocol. We also
30
Cairo 26 - 28 February 2009
review the literature about what the normal penile size is, what
patients complaining of a small penis usually suffer from, benefits
versus complications of surgery, penile stretching /traction devices,
and patient education and counseling versus surgery.
Results: Using a structured management and counseling protocol
only 2% of physically normal men (5/246) chose surgery. We
also propose a practical approach for evaluating and counseling
patients complaining of a small sized penis.
Conclusion: Based on the current status of science, almost all
men can be managed conservatively. Surgery is still considered
experimental and should only be limited to special circumstances
within research or university institutions with supervising ethics
committees.
P11
Self Injection of Foreign Materials in the Genitalia:
Our Experience
Abdel Raheem A, Garaffa G, Christopher AN, Ralph DJ, Minhas S.
Institute of Urology, London, UK.
Introduction: Patients with penile dysmorphophobia are preoccupied
with the size and shape of their penis. In many cases this
preoccupation causes a decline in the patient's social, occupational,
or educational functioning. Patients with penile dysmorphophobia
are convinced that they have a physical abnormality in the penis
and are constantly seeking a drug or surgery that will augment the
penis. However some patients will take matters in their own hands
by injecting foreign material in their penis believing this will make
their penis bigger.
Aim: To report our experience of managing patients with penile
dysmorphophobia who have self injected foreign material in their
genitalia.
Material and Methods : Over the past year four patients with penile
dysmorphophobia presented to our unit after self-injecting foreign
material into their penis and scrotum. The materials injected
were washing-up liquid, mineral (baby) oil, petroleum jelly and
silicone respectively. The injection of washing-up liquid, baby oil
and petroleum jelly induced a foreign-body-type granulomatous
reaction with overlying skin necrosis. Silicone injection did not
cause an immune reaction or infection, but was associated with
progressive scrotal lymphoedema. The patient who injected silicone
required partial scrotectomy for the lymphoedema.The patient
who injected petroleum jelly healed well by secondary intention
following debridement. The other 2 patients who injected washingup liquid, mineral (baby) oil required debridement and skin-grafting
(1 immediate, 1 delayed).
Results: The patient who injected petroleum jelly later developed
preputial lymphoedema that was managed by circumcision. The
patient who underwent partial scrotectomy following silicone
injection got a good cosmetic result, but will require a further
scrotectomy. Of the 2 patients who had skin grafts, one had
complete recovery with an excellent cosmetic result, while the
other developed a ventral contracture due to scarring.
Conclusion: Self injection of foreign material into the genitalia is
a hazardous process that damages the skin and subcutaneous
tissues. Initial management involves drainage, excision of the
involved skin, and skin-grafting defects. Where lymphoedema
develops, all the involved tissue needs to be excised to achieve
resolution.
The Fourth Pan Arab Congress on Sexual Medicine
P12
Surgical management of circumcision injuries
Osama Shaeer
Department of Andrology, Faculty of Medicine, Cairo University
Circumcision injuries are under rated regarding their incidence.
Methods for repair are not standardized. Most cases end
up with permanent mutilation and disfigurement. This work
presents experience with management of circumcision injuries,
and standardization of surgical repair. Methods: Cases with
circumcision injuries ranged from urethral fistulation , subtotal
or total amputation of the glans penis, loss of the penile skin,
to subtotal or total amputation of the penile shaft. The surgical
procedure for each case is described, varying from re-anastomosis
of the glans, neo-glansplasty, fistula repair, penile skin coverage,
and penile elongation. Main outcome measures: Cosmetic
appearance, nocturnal erections Results: All patients ended up with
a cosmetically adequate penis, with probable functional adequacy.
Conclusion: A penis, injured upon circumcision, can be salvaged
with standardized techniques.
P13
Testosterone Replacement Therapy in Elderly Males:
Is It Safe to the Prostate?
Mohamed Mostafa Arafa and Khaled Ezz El-Din
Department of Andrology - Cairo Univerity
Introduction: The widespread use of testosterone replacement
therapy (TRT) in treatment of erectile dysfunction (ED) associated
with partial androgen deficiency in aging men (PADAM) lead to a
world wide concern about its safety.
Aim: The aim of the present study is to assess the effect of TRT on
the prostate in PADAM patients with erectile dysfunction as regards
risk of neoplasia and aggravation of lower urinary tract symptoms
(LUTS).
Patients and methods: sixty-one patients with PADAM and ED were
included in the study. TRT was given for 12 months with follow
up at 1, 6 and 12 months. Patients were asked to complete IIEF,
PADAM score, International prostate symptom score (IPSS) and
were subjected to total testosterone assay measurement, TRUS,
PSA testing and uroflowmetry at the beginning of the study and in
the follow up visits.
Results: Fifty-two patients completed the study. There was
significant improvement in IIEF, PADAM score and total testosterone
in the follow up visits compared to initial assessment. There was no
significant increase in PSA, IPSS score, prostate size or Q max in
the follow up visits compared to initial assessment. Patients were
then grouped into 2 groups according to presence of diagnosed
BPH (Group A = 29 patients) or absence of diagnosed BPH (Group
B = 23 patients). Group A showed no significant deterioration in
PSA, IPSS score, prostate size or Q max in the follow up visits
compared to initial assessment. No focal lesion was detected in the
prostate during TRUS in any patient.
Conclusions: Testosterone replacement therapy is safe on the
prostate and does not promote enlargement of the prostate,
deterioration of LUTS or development of prostate cancer.
P14
Female Sexuality: An Egyptian Experience
Shouikar Tawfiq
Faculty of Medicine, Benha University, Benha, Egypt
Background: Due to the sensitivity of the matter, female sexuality is
not a common subject in Egyptian medical literature.
Aim: This study aimed at filling the gap in this respect.
Subjects and methods: The subjects interviewed were 313 married
women attending or working in Family Planning Centers in 3 cities
using a face-to-face questionnaire covering many aspects of
female sexuality.
Results: The commonest coital frequency was 1-2 and 3-6/weak
that decreases during pregnancy,after delivery and with aging.
Most women reported no change of libido throughout the menstrual
cycle. Reaching orgasm frequently was reported by the majority
of women and they commonly faked an orgasm if they did not
obtain it. Affirmative replies about premarital masturbation and the
use of oral sex were uncommon. Missionary position is the most
commonly used position and women are largely satisfied with their
sexual life as a whole.
Conclusion: Despite economic difficulties and relative male
dominance, the women of the sample looked at their sexual life
with a positive look.
P15
Clinical parameters that predict successful outcome
in men with premature ejaculation and inflammatory
prostatitis
Wael Zohdy
Andrology Consultant Samir Abbass Medical Center, Al Khobar, KSA., Ass. Prof. of Andrology, Coiro University - Egypt.
Introduction: Premature ejaculation (PE) affects 30–40% of sexually
active men. One of the most important organic causes of PE is
chronic prostatitis (CP).
Aim. The aim of this study is to fined out clinical parameters that
predict successful outcome after management of men with PE &
chronic prostatitis.
Methods. Two hundreds and ten heterosexual men were included
in this retrospective study. 155 men were suffering from secondary
premature ejaculation (SPE) and 55 had primary premature
ejaculation (PPE). Participants were included If 10 or more white
blood cells (WBC) per high power field (HPF) were present in the
expressed prostatic secretions. All men were asked to complete
the National Institutes of Health Chronic Prostatitis Symptom Index
(NIH CPSI). Sequential microbiologic specimens were obtained
according to the standardized Meares and Stamey protocol.
Nonbacterial prostatitis was defined by the evidence of inflammation
but negative cultures of urine and prostatic fluids in men with
various genitourinary symptoms. One hundred and eighty four men
received 4 weeks course of antibiotics and 26 men refused or did
not comply with antimicrobial therapy and were taken as control
group. All men were reevaluated clinically after 28 days.
Results. Men aged between 20–56 years. Two men from the control
group experienced delay in their intravaginal ejaculatory latency 2/26
(7.7%) while 107/184 (59.2%) from men who received antimicrobial
therapy reported improvement of the PE (P=0.001). There was no
significant difference between men who received antibiotics and
control cases regarding age, education, intercourse
Samy Hanafy, Taymour Mostafa, Ihab Younis, Hanan Sabry,
Cairo 26 - 28 February 2009
31
The Fourth Pan Arab Congress on Sexual Medicine
frequency, NIH-CPSI domains, total score or the number of pus
cells in the EPS analysis. Bacterial prostatitis was diagnosed
in 175 men (83.3%). Using ROC curve analysis; antimicrobial
therapy is best effective if pus cells in the EPS analysis is ≥ 19
HPF, with sensitivity 85.6% and specificity 70.7% (AUC 0.783, 95%
confidence interval 0.716–0.850). Other clinical parameters such
as NIH CPSI domains and total score were unhelpful in predicting
the outcome of the antimicrobial therapy.
Conclusions. Results in this study showed that antimicrobial therapy
is useful in premature ejaculators complicated with inflammatory
prostatitis. The treatment is most effective when pus cells in EPS
analysis is ≥ 19 HPF.
P16
Premature ejaculation: new combination therapeutic
approach for couple satisfaction
1992). According to the WHO, the central topics of Andrology
are : infertility, hypogonadism, male contraception, male sexual
dysfunction and male aging. Andrology is established today as a
firm discipline of medicine in only very few countries. Our mission
is to establish andrology as a separate medical specialty dealing
with all aspects of male reproductive and sexual functions. We
established a new Master degree of andrology in Cairo University.
The duration of the course is three years divided into one and half
year for basic science and one and half year for andrology. Also
we have Medical Doctorate of andrology
P18
Effects of Glans Penis Augmentation Using
Hyaluronic Acid Gel for Premature Ejaculation
Shedeed Ashour
Amr Al-Ahwani, Hamed A. Hamed, Taha Abdelnasser , Hossam Hosni ,Amr Al-Ahwani ,Ahmed Abdel Hady, and Osama
Selim
Department of Andrology, Cairo University
Department of Andrology, Cairo university
Introduction: Premature Ejaculation (PE) as one of the most
common male sexual dysfunctions (MSD) and its individual and
relationship consequences have been recognized in the literature
for centuries. A new, evidence-based definition of (PE) developed
by ISSM2008. Despite the fact that PE affects 30% of population
across all countries it is under treated satisfactorily. Many treatment
modalities had been tried for PE treatment with variable success
rates.
Aim of the study: To evaluate the efficacy of the combination
therapeutic technique in treating PE. Also, to assess the effects
of this approach on the patient and Partner's satisfaction and
relationship.
Patients and Methods: 128 Pts of 1ry PE recruited from a privateHospital Andrology clinic in Saudi Arabia. Average age was 30.78
+6.84SD ys. And average IVELT duration 1.07+ 0.443SD min (stopwatch evaluated). Duration of the problem ranged from 1-84 month
with an average of 16.23 +13.01SD month. All patients received
a treatment of 4 weeks the combines an SSRI (Ecitalopram 10
mg OD) + Combination technique of Counting the thrusts for
distraction alternating between shallow and deep thrusts and startstop techniques. 2 weekly evaluations were done for 2 month.
Outcome measures: IVELT after treatment and pt & partner
satisfaction with the results.
Results: the IVELT increased from 1.07+ 0.443SD min to 1.97 +
0.697 and 2.98 + 0.84SD min. after 2 and 4 weeks respectively
(p. value: 0.019). Global assessment Question (GAQ) showed
patients and partners satisfaction by 97 and 93%.Follow up period
extended to 2 month post treatment and showed no recurrence to
the base line in 102 pts.(79.68%).
Conclusions: The Multimodal contemporary approach in the
management of PE is beneficial and showed good evidence of
sustained improvements. Further studies of the same technique
and longer follow-up is still needed.
The main limitation of medical treatment for premature ejaculation
is recurrence after withdrawal of medication. We evaluated the
effect of glans penis augmentation using injectable hyaluronic acid
(HA) gel for the treatment of premature ejaculation via blocking
accessibility of tactile stimuli to nerve receptors.
This study was carried on fortynine men with PE. Patients have
been classified into two groups A & B according to the technique
of injection:
Group A: In which 30 patients were injected by 2 ml hyaluronic acid
gel using the fan technique.Group B: In which 30 patients were
injected by 2 ml hyaluronic acid gel using the multiple puncture
technique. All patients were interviewed at the beginning of the
study , after one and three months to record their recorded IELTs
using a stopwatch. In our study , the mean IELT was found to be
significantly higher in both groups after injection of 2 ml hyaluronic
acid gel.he effects of glans penis augmentation using filler might be
the results of reduced sensory of glans penis by formation of barrier
for stimuli to access the receptor and increased self-esteem
P17
Andrology training at Cairo University
Amr Gadalla and Ibrahim Fahmy
Department of Andrology, Cairo University
Andrology is defined as the branch of science and medicine
dealing with reproductive functions of the male under physiological
and pathological conditions (European Academy of Andrology
32
Cairo 26 - 28 February 2009
P19
Premature Ejaculation Management Guidelines
Khaled Othman
Consultant Andrology ,Infertility, and Sexual medicine ,Sexology Department, Alsalma Hospital ,Abu-Dhabi,UAE
Introduction. Premature ejaculation is considered the most frequent
self reported male sexual dysfunction , affecting nearly one in three
men worldwide between the ages of 18 and 59 years . Until very
recently , scientific investigation of premature ejaculation has been
hampered by lack of standardized management guidelines with
the wide range of causes , investigations , treatment options . The
numbers of the randomized controlled studies evaluating various
treatment options of the premature ejaculation have also added
to the challenges facing the clinicians who manage premature
ejaculation .
Aim. The aim of this work to provides a summary of relevant the
peer-reviewed literature pertaining to the management guidelines
of the premature ejaculation (definition , pathophysiology of
ejaculation , investigations , and medical therapy of premature
ejaculation)
Objectives
• update the knowledge of professionals involved in the management
The Fourth Pan Arab Congress on Sexual Medicine
of premature ejaculation .
• raise awareness of the disorder and Pathways of diagnosis and
strategies for management.
• Identify the current and future challenges in treating premature
ejaculation .
Methods. A retrospective review of peer reviewed publications
relevant to the filed of premature ejaculation including definitions,
related physiology, pathophsiology, investigations, and medical
therapies .
Main Outcome Measures. Data were obtained by extensive
examination of published peer-reviewed literature relevant to the
filed of premature ejaculation definitions, etiology, as well as safety
and efficacy of various medical therapies for premature ejaculation
.
Results: The literature contains several definitions of premature
ejaculation (PE), In 2007the Ad Hoc Committee for the Definition
of Premature Ejaculation of ISSM propose a new evidence-based
definition of PE. PE is multidimensional dysfunction composed
of biological dysfunctions with psychosocial disorders , it include
time (IELT; i.e.,time from vaginal penetration to ejaculation) as an
objective parameter and subjective parameters such as “control”,
”satisfaction”, and “ distress” . SSRIs have been promising agent
to treat premature ejaculation. Recent experiences with use of
Tramadol raises the hope that this might prove to be an agent
as effective as SSRIs with less worrisome risk of side-effects.
Dapoxetine is the first SSRIs for which a marked authorization
request has been submitted for PE. Topical solutions current and
novel formulations for PE another therapeutic option.
Conclusions. The diagnosis of PE is based upon sexual history
,pathophysiology of PE appears to be both neurobiogenic and
psychogenic . The combination therapy integrating sex therapy and
pharmaceuticals is frequently the best treatment approach for PE.
Clinical researches in this field are hampered by the complexity,
variability among different men and cultures, and subjectivity of
PE.
P20
The Role of PSA doubling time & Gleason score in
Prostatic Cancer
Bizanti, Sadik
Tripoli, Libya
Accumulating data from other reports support the view that the
PSA doubling time (PSA-DT) provides a surrogate marker for
both clinical metastasis-free survival and prostate cancer-specific
mortality in men with a rising serum PSA after RP, And It is less
well studied after external beam RT, and has not been studied or
validated after brachytherapy.
In the largest series of 8669 men with clinical localized or locally
advanced nonmetastatic prostate cancer (5918 treated surgically,
and 2751 irradiated), a PSA-DT of <3 months identified men who
were 20-fold more likely to die of prostate cancer than those with a
PSA-DT of 3 months.
A later analysis suggested that the addition of the Gleason score
to PSA-DT provided a better estimate of prostate cancer-specific
mortality in men with a rising PSA following RT. When the PSA-DT
was <3 months, the estimates of prostate cancer-specific mortality
five years after biochemical failure were 75 versus 35 percent for
men with a Gleason score of 8 and 7, respectively. In contrast, for
men with PSA-DT 3 months, the corresponding five-year rates of
prostate cancer-specific mortality for Gleason score 8 and 7 disease
were 15 and 4 percent, respectively. In another report of 1136 men
undergoing treatment for localized prostate cancer, men who died
of their disease within 10 years had a median post treatment PSA
doubling time of 0.8 years, while those who did not die of prostate
cancer had either no post treatment increase in serum PSA or a
PSA doubling time longer than 1 year.
Summary: Taken together, these data support the view that
men who have a short PSA-DT and Gleason score 8 disease
are unlikely to achieve long-term disease control from local-only
salvage therapies. Men with a short PSA-DT following local therapy
(eg; < 3 to 6 months) also have a reduced time to distant disease
recurrence , and this population may be appropriate for early rather
than delayed androgen deprivation therapy to in order to forestall
the onset of symptomatic bone metastases.
P21
Vascular risk factors and flow mediated dilatation
of cavernosal and brachial arteries in healthy and
erectile dysfunction patients
Anis TH, Selim O, Abdelhady A, Abosafe A
Department of Andrology, Cairo university
Introduction: Erectile dysfunction (ED) commonly coexists with
coronary artery disease (CAD) and/or risk factors for atherosclerosis.
Study of these risk factors and their effect on endothelial function
represented by flow mediated dilatation (FMD) would give a new
insight on how to prevent rather to treat ED.
Aim: To investigate the correlations between vascular risk factors
and flow mediated dilatation of cavernosal and brachial arteries.
Methods: FMD of brachial and cavernosal arteries was measured
using Doppler US in 120 patients complaining of vasculogenic ED,
and in 60 male subjects not complaining of ED, correlations were
made between FMD and fasting blood sugar, total cholesterol,
triglycerides, blood pressure, smoking
Results: Significant negative correlations were demonstrated
between FMD of brachial and cavernosal arteries with total
cholesterol, TAG, smoking, fasting blood sugar (p=0.000) in cases
and controls, significant negative correlation was documented
between FMD of cavernosal and brachial arteries in cases but
showed insignificant negative correlation with controls.
Conclusion: Patients with vasculogenic ED exposed to vascular
risk factors have impaired endothelial function as compared to
those without risk factors; the results were similar in male subjects
without ED except for blood pressure which showed insignificant
negative correlation with FMD.
P22
Effect of HO-1 cDNA-liposome complex transfer on
erectile signaling in aged rats
Taymour Mostafa, Abdel Aziz MT, Atta H, Mahfouz S, Wassef
MA, Fouad H, Kamel M, Rashed LA, Sabry D , Mouhamed O
Department of Andrology & Sexology. Faculty of Medicine, Cairo University.
Aim: To assess the efficacy of heme oxygenase-1 (HO-1) cDNAliposome complex transfer as a mediator of erectile signaling in
aged rat.
Methods: One hundred and fifty aged white albino rats were equally
divided into five groups; controls, rats received lipofectamine, rats
received intracorporeal HO-1 cDNA-lipsome complex, rats received
HO-1 cDNA-liposome complex plus nitric oxide synthase (NOS)
inhibitor and rats received HO-1 cDNA-liposome complex plus HO
Cairo 26 - 28 February 2009
33
The Fourth Pan Arab Congress on Sexual Medicine
inhibitor. Six rats were sacrificed from each group after 12, 24 h, 48
h, 1 wk and 2 wk.
Main Outcome Measures: In dissected cavernous tissues the
following were assessed: HO-1 gene expression, Western blot for
HO-1, HO enzyme activity, cGMP, and histopathology.
Results: HO-1 cDNA-liposome complex transfer led to a significant
increase in cavernous tissue HO-1 protein, HO-1 gene expression,
HO enzyme activity and cGMP up to 1 wk. NOS Inhibition exhibited
no effect on HO-1 gene enhancement of cavernous tissue HO
enzyme activity or cGMP whereas inhibition of HO significantly
decreased these parameters. Histopathology of cavernous tissue
demonstrated a significant dilation of helicine arteries in HO-1
cDNA-liposome complex treated group after 48h compared with
controls.
Conclusion: HO-1 cDNA-liposome complex transfer augments
cavernous tissue cGMP with subsequent sinusoidal relaxation.
P23
The role of PDE5 inhibitors in heme oxygenasecGMP relationship in rat cavernous tissues.
Taymour Mostafa, Aziz MT, Atta H, Rashed L, Marzouk SA,
Obaia EM, Sabry D, Hassouna AA, El-Shehaby AM, Aziz AT.
Department of Andrology & Sexology. Faculty of Medicine, Cairo University.
INTRODUCTION: Heme oxygenase (HO) enzyme catalyzes
oxidative degradation of heme to biliverdin and carbon monoxide
(CO). CO shares many properties NO including the activation of
soluble guanyl cyclase.
AIM: To assess cavernous tissue HO activity and cGMP levels in
response to oral PDE5 inhibitors.
METHODS: Seven hundred twenty male Sprague-Dawley rats,
divided into six groups, were investigated. Group 1, controls; group
2 received sildenafil citrate orally; group 3 received vardenafil HCl;
and group 4 received tadalafil. Group 5 was subdivided into three
equal subgroups, received the same dose of each drug added to
an HO inhibitor (Zn protoporphyrin). Group 6 was subdivided into
3 equal subgroups, received the same dose of each drug added to
an NO inhibitor (L-nitroarginine methylester). Eight rats from each
group/subgroup were sacrificed at 0.5, 1, 2, 3, 4, 6, 18, 24, and 36
hr.
MAIN OUTCOME MEASURES: HO enzyme activity assay and
cGMP tissue levels in the dissected rat cavernous tissues.
RESULTS: Both cavernous tissue HO enzyme activity and cGMP
levels were increased significantly in sildenafil-, vardenafil-, and
tadalafil-treated rats compared with the controls, with significant
decreases after either HO or NO inhibition. Cavernous tissue HO
enzyme activity and cGMP showed a positive significant correlation
(r = 0.854, P < 0.001).
CONCLUSION: The effects of PDE5 inhibitors in cavernous tissue
are partly mediated through HO enzyme activity.
P24
Possible evidence for alternative pathways in
apomorphine-induced erection in rats?
Rany Shamloul and Michael Adams
Queen's University, Canada
Introduction: L-NAME ((N-I]-nitro-L-arginine methyl ester), the
well-known nitric oxide synthase (NOS) inhibitor, has been used
extensively to delineate the various physiological roles of NO,
including its role in cavernous relaxation and erections. In most
34
Cairo 26 - 28 February 2009
studies, in vivo and in vitro, L-NAME, in various doses, has been
shown to significantly, but not completely, inhibit NO-dependent
penile relaxation. Furthermore, in most studies L-NAME was
administered for very short time periods.
Aim: To investigate whether a supramaximal dose of NG-nitro-Larginine methyl ester (L-NAME) (a well-known nitric oxide synthase
inhibitor) can eradicate apomorphine-induced erections in rats.
Methods: Two groups of 12 week-old male Sprague-Dawley rats
were included in the study. Group A (n=3) had access to regular
drinking water, while group B (n=4) had access to L-NAME (1g/
kg/day) dissolved in drinking water for 5 days. Aspartame (33
mg/kg/day) was added to the drinking water to facilitate L-NAME
consumption.
Main outcome measures: Measurement of body weight and water
consumption was done prior to the study and on daily basis during
the study period. Penile erection was assessed prior to the study
and on daily basis during the study period using subcutaneouslyinjected apomorphine hydrochloride [apo] (80 μg/kg) prepared in
solution with ascorbic acid (100 μg/ml).
Results: There was no significant difference between groups A and
B regarding mean (SD) baseline body weight, water consumption,
apo-induced erectile responses and apo-induced yawns. Five days
after L-NAME administration there was no significant difference
between both groups regarding the average number of apoinduced yawns, however, the mean apo-induced erectile responses
of group B rats was significantly reduced in comparison to their
baseline values (0.5 ± 1 vs 2.75 ± 0.3), and also to group A (0.5 ±
1 vs 2.6 ±0.5), but not eradicated. There was also slight significant
difference between the mean body weights and water consumption
of group B animals after 5 days of L-NAME versus control group,
392.2 ± 10.7g vs 430 ± 33.4g and 28.2 ± 15.6ml vs 57.6 ± 11.6 ml,
respectively.
Conclusions: A supramaximal dose of L-NAME could not eradicate
apo-induced erections in rats. This suggests that other non nitric
oxide-dependent pro-erectile mechanisms may be involved in this
type of pharmacologically-induced erection.
P25
The influence of G protein-3 subunit (GNB3 C825T)
gene polymorphism on erectile dysfunction and
response to sildenafil in Egyptian patients
Ihab A. Osman1 and Olfat G. Shaker2
1. Department of Andrology, Cairo University
2. Medical Biochemistry & Molecular Biology Unit, Biochemistry Department, Faculty of
Medicine, Cairo University
Objectives: To investigate the influence of G protein-3 subunit
GNB3 C825T gene polymorphism on erectile dysfunction (ED),
and the response of ED patients to Sildenafil.
Setting: Andrology and Sexology clinic, Faculty of Medicine, Cairo
University Hospitals, Cairo, Egypt
Patients: Sixty ED patients with mean (standard deviation) age
49.67 years (9.68) were enrolled in this study, and they were further
classified into 2 sub groups (30 patients each) according to their
response to Sildenafil.
Interventions: peripheral blood sampling for DNA extraction and
GNB3 C825T allele status determination by polymerase chain
reaction (PCR) technique performed with the specific primers.
Main Outcome Measures: GNB3 C825T allele status for all ED
patients.
Results: Frequency of the 825T allele was higher in patients with
The Fourth Pan Arab Congress on Sexual Medicine
versus without cardiovascular co-morbidities (57.1% versus 48%),
and interestingly, all TT patients in our study had cardiovascular
co-morbidities (p = 0.04). Analysis of the influence of GNB3 C825T
polymorphism on the response of ED patients to Sildenafil, a
significant association of homozygous 825T allele status with the
drug response was observed, as 85.7% of TT genotype carriers
showed a statistically significant response to sildenafil, compared
to 46.4% of CC genotype and 44% of TC genotype patients (p =
0.04).
Conclusion: GNB3 C825T gene polymorphism is significantly
associated with the response to Sildenafil in ED patients.
P26
Yohimbine enhances the effect of sildenafil on
erectile process in rats.
Taymour Mostafa and Senbel AM
Department of Andrology, Cairo University
Background: Combining the centrally acting drug yohimbine with
the peripheral conditioner sildenafil might be an approach to erectile
dysfunction cases in which sildenafil alone failed.
Aim: To investigate the effect of yohimbine on sildenafil-induced
facilitation of erectile process.
Method: Erectile responses to electrical stimulation of the cavernous
nerve in anesthetized male rats were recorded. Intracavernosal
pressure/systemic arterial pressure (ICP/SAP) was calculated, 1
and 5 min after intravenous administration of sildenafil, yohimbine
or a combination of both.
Main outcome Measures: Changes in sexual arousal and
copulatory performance indices before and after injections using
behavioral mating experiments. It Results: Systemic administration
of sildenafil produced a significant increase in ICP/SAP than
control at doses >or=10 micromol kg(-1). Yohimbine alone failed
to potentiate erectile responses but yohimbine (1 micromol kg(-1))
significantly potentiated the effect of sildenafil 1-10 micromol kg(-1)
and 1 mmol kg(-1), 1 and 5 min after injection. Potentiation of ICP/
SAP induced by their combination was greater than the sum of the
effects of the corresponding doses of either drug at the same time
interval. A nonsignificant additional decrease in SAP than sildenafilinduced was observed if administered with yohimbine. Addition of
sildenafil to yohimbine significantly enhanced the effect of the latter
on intromission frequency, intercopulatory interval and the number
of ejaculations per session.
Conclusion: Yohimbine may enhance and prolong the effect of
sildenafil on erectile process without additional hypotension.
Sildenafil may enhance the central effects of yohimbine on
erection; it amplifies the effect of yohimbine on male copulatory
performance but not on sexual motivation. The potential effect was
more pronounced on the central than on the peripheral component
of the erectile process.
P27
Endothelial nitric oxide synthase gene
polymorphism in Egyptian patients with erectile
dysfunction
Ihab A. Osman, Ashraf H. Fayez, and Olfat Shaker
Departments of Andrology, and Biochemistry and Molecular Biology, Cairo University
INTRODUCTION: The nitric oxide (NO) pathway is of critical
importance in the physiologic induction and maintenance of
erections. The role of endothelial nitric oxide synthase (eNOS)
in penile erection is becoming increasingly recognized. The
current consensus is that endothelial dysfunction is the common
denominator in the pathogenesis of Erectile Dysfunction (ED) and
many vascular diseases often coexist, and that, at the cellular
level, endothelial dysfunction results in an impaired release of
NO. Recently, evidence has accumulated proving that eNOS
gene polymorphism may be associated with an increased risk of
developing cardiovascular or metabolic disorders and they affect
some of those exact same physiological pathways that are known
to play a role in the regulation of penile vasomotor tone.
AIM OF THE STUDY: To investigate a potential association between
endothelial nitric oxide synthetase (eNOS) gene polymorphism and
ED.
PATIENTS AND METHODS: The study was carried on 60 ED
male patients. All patients were subjected to complete medical and
sexual history taking including the international index of erectile
function (IIEF-5) questionnaire, as well as general and local
genital examination. Estimation of serum levels of testosterone
and prolactin was done and each patient was subjected ICI test.
Patients with a negative response were evaluated through a penile
dynamic duplex study to clarify the etiology of ED being arterial,
veno – occlusive, or psychogenic. eNOS genotype polymorphism
was determined by polymerase chain reaction (PCR) performed
with the specific primers, size fractionation on agarose gels, and
visualization under ultraviolet illumination.
RESULTS: The mean age of patients was 49.67 years (range of
29 – 69 years). The duration of ED ranged between 1 – 14 years
(mean of 3.45 years). The prevalence of risk factor like diabetes and
hypertension were 51.7% and 16.7% respectively. The main cause
of ED in the studied cases was veno – occlusive (43.33%), while
the least common was the arteriogenic (20%). The psychogenic
etiology was present in the remaining 37.67% of patients. In our
series, the most common NOS genotype was GG that represented
in 46.67% of patients, followed by GT in 43.33%, then TT in 10%
of them. The present study demonstrated a significant correlation
between the grade of ED and NOS3 genotype.
CONCLUSION: eNOS gene polymorphism might be a factor
of genetic susceptibility to ED, most probably related to downregulation of NO levels, and a consequent altering of the cavernosal
smooth muscle relaxation mechanism, however, a definitive
association between the eNOS gene polymorphism and ED
remains to be elucidated, as data available from different studies
are limited and controversial. eNOS is only a single component
of the multifactorial balance of vasomotor tone in the corpora
cavernosa. Further researches with larger subject groups and
further molecular basis studies are needed to clarify the role of the
eNOS gene polymorphism in the pathogenesis of ED, & to reveal
additional polymorphism associations with ED, and these might
be added to environmental factors to have a complete predictive
scheme specific for each population.
P28
The changes in expression of platelet derived
growth factor (PDGF) and PDGF receptor in rat
corpus cavernosum after exposure to in vivo
hypoxia and cigarette smoking.
IHAB I. KAMEL1 EMAN F. KHALEEL2, LAILA A. RASHED3
1.Departments of Andrology, sexology and STDs 2. Physiology, and 3. Biochemistry, Cairo
University
Background: Platelet derived growth factor (PDGF) over activity has
Cairo 26 - 28 February 2009
35
The Fourth Pan Arab Congress on Sexual Medicine
been implicated in atherosclerosis and several fibrotic conditions
including lung and kidney fibrosis, liver cirrhosis and myelofibrosis.
Low oxygen tension (hypoxia) and cigarette smoking is a known
stimulus for transcriptional induction of (PDGF) ligand and receptor
gene that are associated with induction of fibrosis which may lead
to erectile dysfunction.
Aim: To study the expression of (PDGF-A)and (PDGFR-β)in adult
male rat isolated corpus cavernosum under hypoxic and cigarette
smoking condition
Material and methods: Fifty adult male albino rats were used in
this experiment. They were divided into 5 groups. Group I (n=10),
served as control group. Group II(n=10) rats exposed to acute
hypoxia. Group III (n=10) rats exposed to chronic hypoxia. Group
IV(n=10) rats exposed to acute cigarette smoking. Group V(n=10)
rats exposed to chronic cigarette smoking. In all groups at the end
of each experiment corpora cavernosa of all rats were carefully
dissected and free from surrounding tunica albuginia then frozen
in -80C◦ for subsequent reverse transcriptase polymerase chain
reaction (RT-PCR). In all groups of rats PDGF-A and PDGR-m
RNA were measured.
Results: There was significant increase in PDGF-A mRNA and
PDGF-β receptor in acute hypoxic group, chronic hypoxic group,
and chronic cigarette smoking groups of rats compared to control
group.
Conclusion: It was found that hypoxia, whether, acute or chronic
has similar effect of increasing PDGF-A mRNA and PDGF-β
receptor as well in chronic cigarette smoking group of rats. This
may lead to erectile dysfunction.
P29
Opportunity to Rescue Patients Failing PDE5
Inhibitors through the Combination of Vacuum
Erection Device and PDE5 Inhibitors
Onder Canguven4, James Bailen3, William Fredriksson1, David Bock2 and Arthur L. Burnett4
1.Urologic Institute, Meridian, Idaho
2.Kansas City Urology Care, Overland Park, Kansas
3.Metropolitan urology, Jeffersonville, Indiana
4.The James Buchanan Brady Urological Institute, Johns Hopkins Hospital, Baltimore, MD
Introduction: This prospective study evaluated whether a vacuum
erection device (VED) and phosphodiesterase type 5 inhibitors
(PDE5i) in combination are effective in treating erectile dysfunction
(ED) in subjects failing PDE5i alone.
Patients and Methods: We evaluated 65 men (aged 36-82 years)
with ED of diverse etiologies (excluding post-prostatectomy ED)
in whom PDE5i at the highest recommended dose with at least
4-6 intercourse attempts had previously failed. Efficacy was
evaluated using the International Index of Erectile Function-5
(IIEF-5) questionnaire, Sexual Encounter Profile (SEP)-2, SEP-3,
and Global Patient Assessment Scale (GPAS).
Results: After 4 weeks of treatment the mean IIEF-5 score
increased significantly over baseline from 9.2 to 17.5 (p<0.001).
Of the 31 subjects with a SEP-2 response of ‘No’ at baseline, 24
(77%) responded ‘Yes’ after combination therapy (p<0.001). Of the
46 subjects with a SEP-3 response of ‘No’ at baseline, 31 (67%)
responded ‘Yes’ after combined therapy (p<0.001). Furthermore,
of the 39 subjects with a GPAS response of ‘not at all’ or ‘slightly’
improved at baseline, 29 (74%) responded ‘moderately’ or ‘greatly’
improved after combination therapy (p<0.001). One subject (2%)
36
Cairo 26 - 28 February 2009
experienced VED-related intermittent penile pain, which resolved
after 4 days without any action.
Conclusion: Statistically significant improvements over baseline in
patient-reported outcomes were seen with combination therapy.
These results suggest that combination therapy may be effective
for PDE5i failures and may be considered prior to more invasive
alternatives.
P30
The role of vacuum therapy to mechanically
straighten the penis in Peyronie’s disease
Abdel Raheem A, Garaffa G, Dixon M, Spillings A, Christopher AN, Ralph DJ
Department of Andrology, Cairo University and Institute of Urology, London, UK
Introduction & Aim : Several non-surgical therapies have been tried
in Peyronie’s disease, yet none of these therapies proved to be
effective in treating the penile deformity. At the present time surgery
is the most effective method for managing the penile deformity.
This study assesses the role of vacuum therapy to mechanically
straighten the penile curvature of Peyronie’s disease.
Material and methods : The study included 27 patients, aged 27-71
yrs (mean 51 yrs), who had newly diagnosed Peyronie’s disease
(mean duration 9.9 months). Over a 3 month period, the patients
used the vacuum device without the constriction ring for 10 minutes
twice daily to stretch the penis. Assessment at study entry and at
completion after 3 months included: an IIEF questionnaire, a visual
analogue pain score, the angle of penile deformity assessment by
an intracavernosal injection of PGE1 and stretched penile length
measurement.
There was a statistically significant improvement in penile length,
angle of curvature and pain after 3 months of using the vacuum
pump. However there was no significant difference in any of the
IIEF domains.
Of the 27 patients in the study 18(66.7%) had a reduction in the
angle of curvature by 5º-25º, 3(11.1%) had worsening of the
curvature and in the remaining 6(22.2%) there was no change in
curvature. Patients with significant pain had a mean of 10º curvature
improvement. Surgical correction of the curvature was performed in
13 patients while the rest of the patients n=14(51%) were satisfied
with the outcome and did not want surgery at this stage.
Conclusion : Vacuum therapy may improve or stabilize the curvature
of Peyronie’s disease and is safe to use in the early active stage
of the disease and may reduce the number of patients going on to
surgery.
The Fourth Pan Arab Congress on Sexual Medicine
Results
Mean Scores
Week 1
Week 12
Max. score
P-value
2.37
1.12
10
<0.05
13.27 cm
13.5 cm
-
<0.05
Penile curvature
48.33°
40.74°
-
<0.05
*Erectile Function
20.25
18.88
30
NS
*Orgasmic Function
8.3
7.74
10
NS
*Desire
6.88
7.07
10
NS
*Intercourse Satisfaction
6.74
6.59
15
NS
*Overall Satisfaction
5.4
5.66
10
NS
Pain
Penile Length
*IIEF domain / Statistical significance (P<0.05)/NS (non significant)
P31
Penile prosthesis insertion in Peyronie’s Disease
Garaffa G, Abdel Raheem A, Sacca A, Christopher AN, Ralph
DJ
Institute of Urology, London, UK
Introduction and Aim : The long-term results of the insertion of
penile prosthesis in patients with Peyronie’s Disease (PD) are
presented.
Methods : A penile prosthesis was inserted into 98 patients
(mean age 53.7yrs; range 32 -74yrs) who presented with PD. The
indications for insertion were significant erectile dysfunction (ED)
in 92 patients and extensive curvature with penile shortening in
6 patients. A previous unsuccessful straightening procedure had
been performed in 13 patients (Nesbit 6, Grafting 7) and 31 patients
were diabetic.
A 3 pieces inflatable prosthesis was inserted in 67 patients
and a malleable prosthesis in 31 patients. Difficult dilatation
due to advanced fibrosis was managed with the use of Rosello
cavernotomes in 12 patients and a double subcoronal incision in
1 patient. A residual curvature > 20 degrees after implantation
was noted in 27 patients and was corrected intraoperatively by the
moulding technique (21), plication (2), plaque incision (1) or plaque
incision+grafting (3). In 4 patients the residual curvature after the
insertion of prosthesis was < 20 degrees and therefore no further
treatment was required. The remainder had a straight penis.
Results : After a median follow up of 13 months (1-120 mts) a
complete straightening of the penis has been achieved in 91
patients (92%) and 4 have a minor curvature that doesn’t impede
penetration. However, 4 patients with an inflatable prosthesis
required further surgical management of their residual curvature
(Nesbit 2, grafting 1, moulding 1).
Two patients had an infected malleable prosthesis requiring
explantation.
Overall, revision of the prosthesis was necessary in 26 patients
(elective exchange of a malleable to inflatable prosthesis (2), autoinflation (4), soft glans (5), downsizing of the rods (5), infection (2),
repositioning of the pump (4) and correction of residual curvature
(4)).
Overall the recorded patient satisfaction was 97% with 3 patients
partially unhappy about penile shortening (1 had a previous Nesbit).
Floppy glans was present in 14 patients; 5 were managed with
glanspexy, the remainder conservatively (MUSE 5, PDE5 inhibitors
4). Overall, 96% of patients that have resumed sexual intercourse
postoperatively.
Conclusions : The insertion of a penile prosthesis in patients with
PD achieves good patient satisfaction by correcting both the penile
deformity and the associated ED allowing maintenance of penile
length and function.
P32
Peyronie's disease: relation to coital position
Shedeed Ashour1 and Ahmed Nassar2
Department of Andrology, Cairo University
Tanta University
Introduction: Peyronie's disease (PD) is characterized by fibrotic
plaques in the penile tunica albuginea that cause curvature of
the erect penis, and is often accompanied by pain and/or erectile
dysfunction. This condition affects up to 9% of men. Injury to the
erect penis is thought to trigger PD by inducing extravasations of
fibrin and subsequent fibrosis. Despite the lack of statistical support
for a causal association between trauma and PD, it is possible that
undetected microtrauma is involved.
Aim: We studied the prevalence of the potential risk of trauma to
the penis in the female superior coital position as a causal factor
for PD.
Patients and methods: Randomly selected Twenty three patients
average age 51.2 +7.8 SD Ys with PD (average duration of disease
29.4 + 11.03SD month. All examined for the presence, site and
multiplicity of the plaques, Penile measurements and curvature.
Sexual history included asking about the use of the female superior
position. Associated medical co- morbidities were also asked for.
Main outcome measures: Percentage and frequency of users of
female superior position and correlation to PD
Results: All the 23 pts. selected had PD. The average stretched
penile length was 11.5 + 1.78SD cm. & girth of 9.5 + 1.47SD cm. Two
pts had ventral curvature and 21 had dorsal one (91.3%). Twenty
two were diabetics (20 type II &1 type I); (95.6%), 8 Hypertensives
(34.8%), 7 IHD (30.4%), two pt had history of coronary artery
bypass (8.7%), 4 pts. Had LOH and Dylipedaemia (17.4%). The
use of Female superior position was reported as frequently used
by 21 pts (91.3%). Three pts have vitiligo, one pt used to practice
tucking the penis, one pt had Deuptryn's contracture and 1 had a
Cairo 26 - 28 February 2009
37
The Fourth Pan Arab Congress on Sexual Medicine
history of sub-acute penile fracture due to coital trauma.
Conclusions: despite the small sample there is evidence that the
frequent type of trauma in the female superior position may play a
role in the causation of PD.
P33
Penile fracture: surgical repair and late effects on
erectile function.
Ahmed Ateyah, Mostafa T, Nasser TA, Shaeer O, Hadi AA,
Al-Gabbar MA.
Department of Andrology, Cairo University
INTRODUCTION: Penile fracture is described as a traumatic
rupture of the tunica albuginea because of blunt injury of an erect
penis.
AIM: To assess the etiology, treatment maneuvers, and late effects
of penile fractures treated by surgical repair.
METHODS: Thirty-three patients diagnosed provisionally as having
fractured penises. Thirty patients were managed by immediate
surgical repair and three by delayed repair.
MAIN OUTCOME MEASURES: International Index of Erectile
Function-5 for married cases and Single-question Self-report of
Erectile Dysfunction questionnaires and recording complications
after 2, 3, and 6 months.
RESULTS: The most common cause of fracture penis is self-inflicted
acute bending (54.5%). The tear was visualized by ultrasound in
20/30 patients (66.7%) mostly on the right proximal third of the
penis. All tears were unilateral with mean length 2.0 +/- 0.9 cm
(range 0.5-4 cm). All patients who completed their follow-up after 6
months (N = 24) were able to achieve an adequate erection except
two married cases who felt mild erectile dysfunction. Penile nodules
were the most common postoperative complication (41.7%) after
6 months' follow-up. Patients treated with immediate or delayed
repair had comparable complications.
CONCLUSIONS: Fracture penis is not uncommon as an
emergency that must be repaired either immediately or delayed.
Clinical diagnosis is more predictive than ultrasound in diagnosis
and determining the site of the tear. Ultrasound may be of value in
patients where there is clinical doubt.
P34
Delayed Surgical Repair of Penile Fracture under
Local Anesthesia
Taha Abdel Nasser and Taymour Mostafa
Department of Andrology, Cairo University
Introduction: Penile fracture is a traumatic rupture of the tunica
albuginea because of blunt injury of an erect penis.
Aim: To assess the efficacy of a simple delayed surgical repair of
penile fracture after a conservative treatment under local anesthesia
in patients presented after 24 hours.
Methods: Twenty-four patients with penile fracture presented after
24 hours were subjected to history taking, clinical examination,
urine analysis, and penile ultrasound. They underwent conservative
treatment for 7–12 days, and then a surgical repair under local
anesthesia was carried out.
Main Outcome Measures: A follow-up for 6 months for sexual activity
and any associated complaints in addition to local examination.
Results: All cases were presented with unilateral single tear,
and the main cause of penile fracture was sexual intercourse. No
intraoperative or postoperative complications were encountered.
38
Cairo 26 - 28 February 2009
They regained their sexual activity 4–6 weeks after the repair. One
case developed a mild penile deviation that did not interfere with
sexual relation after the 6-month follow-up.
Conclusion: Surgical repair of penile fracture after a conservative
treatment is an effective method for patients with delayed
presentation devoid of urethral involvement.
P35
Penile Reconstruction for Benign Disease with the
Use of Skin Grafting
Abdel Raheem A, Garaffa G, Sacca A, Christopher AN, Ralph
DJ
Institute of Urology, London, UK
Aim: The long term results of penile reconstruction for benign
disease with the use of skin grafts in 59 patients are reported.
Patients and Methods: The patient’s aetiologies included Balanitis
Xerotica Obliterans (BXO,n=20), traumatic amputation(n=5),
excessive circumcision(n=12), frenular pathology(n=7), end
stage lymphoedema(n=6), iatrogenic skin loss(n=4), hypospadias
surgery(n=3), buried penis(n=1) and Fournier’s gangrene(n=1). All
BXO and Lymphoedma patients had the disease area excised and
grafted. The traumatic and circumcision injuries had skin added.
Split skin grafts harvested from the inner thigh were used for glans
and coronal pathology in 34 patients, whereas full thickness grafts
from non-hair-bearing areas were used on the shaft to prevent
erectile dysfunction due to graft contraction in 25 patients.
Results: After a median follow-up of 21.5 months(1-60), all patients
were satisfied with the outcome although partial graft loss and
subsequent contracture did occur in 7 patients. These were
managed successfully by delayed excision and re-grafting. The
happiest were the BXO and trauma groups where effectively extra
skin had been added. An improvement in cosmesis and sexual
function was reported by 53 patients with an overall satisfaction
rate of 93%.
Conclusion: Loss of penile skin of various causes can be reliably
managed by skin grafting.
P36
Prostate Cancer & Testosterone Therapy – Is there
an expectation of paradigm shift
Aksam A. Yassin
Professor of Urology & Human Sexuality, Chairman Institute of Urology and Andrology,
Segeberger Kliniken, Norderstedt-Hamburg, Germany.
Objectives: Prostate safety is a primary concern when aging men
receive testosterone therapy (TT), but little information is available
regarding the effects of TT on prostate tissue in men with a major
concern: DHT levels. History of prostate cancer has been an
absolute contraindication for testosterone therapy. We want to
review the historical origins and current evidence for the belief that
testosterone (T) causes prostate cancer (PCa) growth.
Methods: Review of the historical literature regarding testosterone
administration and PCa, as well as more recent studies investigating
the relationship of T and PCa. Hypogonadal patients treated with
radical retropubic prostatectomy (RRP), or even Radiotherapy
for organ confined prostate cancer to determine if testosterone
therapy (TT) could be efficacious and administered safely without
causing recurrent prostate tumor. Dihydrotestosterone (DHT)
levels show no alteration under Testosterone Therapy, also no DHT
overexpression in Prostate tissues in placebo controlled studies.
The Fourth Pan Arab Congress on Sexual Medicine
Results: According to A. Morgenthaler, in 1941 Huggins and
Hodges reported that marked reductions in T by castration or
oestrogen treatment caused metastatic PCa to regress, and
administration of exogenous T caused PCa to grow. Remarkably,
this latter conclusion was based on results from only one patient.
Multiple subsequent reports revealed no PCa progression with
T administration, and some men even experienced subjective
improvement, such as resolution of bone pain. More recent data
have shown no apparent increase in PCa rates in clinical trials
of T supplementation in normal men or men at increased risk for
PCa, no relationship of PCa risk with serum T levels in multiple
longitudinal studies, and no reduced risk of PCa in men with low T.
The apparent paradox in which castration causes PCa to regress
yet higher T fails to cause PCa to grow is resolved by a saturation
model, in which maximal stimulation of PCa is reached at relatively
low levels of T. Dihydrotestosterone (DHT) levels show no alteration
under Testosterone Therapy, also no DHT overexpression in
Prostate tissuses in placebo controlled studies.
Conclusions: This historical perspective reveals that there is not
now —nor has there ever been— a scientific basis for the belief
that T causes PCa to grow. Discarding this modern myth will allow
exploration of alternative hypotheses regarding the relationship of
T and PCa that may be clinically and scientifically rewarding.
P37
Shaeer's ultrasound-assisted penoscopy for visually
guided excavation of penile fibrosis
Osama Shaeer
Department of Andrology, Cairo University
Objectives: Implantation of penile prosthesis in case of corporeal
fibrosis poses a greater risk of complications due to the blinded
aggression involved. This work describes combination of
penoscopy-guided and ultrasound-guided excavation to enhance
safety and ease of implantation in such cases.
Material and Methods: 18 patients with penile fibrosis were
operated upon. A guide wire was inserted under ultrasound
monitoring, along which penoscopic corporotomy and resection
was performed. Ultrasound was also used to monitor penoscopic
excavation towards the tip of the corpus cavernosum and crus.
Main outcome measures: Ease, safety and extent of dilatation and
prosthesis survival.
Results: The procedure was relatively easy. Ten cases were dilated
up to size 13.5 Hegar, and 2 up to size 14. Size 13 prosthesis was
implanted in all cases and survived throughout one year follow up
Conclusion: The relative safety of the procedure, the low incidence
of complications, the possibility of restoring length and girth to an
extent, and the resultant generous dilatation of the corpora for
accommodating a sizable unhindered inflatable penile prosthesis all
make ultrasound-guided penoscopic corporotomy and resection a
valid option for prosthesis implantation in cases of penile fibrosis.
P38
Testosterone and obesity
Aksam A. Yassin1, Farid Saad2,
1-Professor of Urology & Human Sexuality, Chairman Institute of Urology and Andrology,
Segeberger Kliniken, Norderstedt-Hamburg / Germany
2-Gulf Medical College School of Medicine, Ajman/UAE & Bayer Schering Pharma AG,
Berlin, Germany
Introduction and objective: Obesity is a worldwide problem. It is
often clustered with the so-called metabolic syndrome consisting of
(visceral) obesity, hypertension, decreased insulin sensitivity and
dyslipidemia, which predisposes to cardiovascular disease and
diabetes. Increasingly, a role for testosterone is recognized in the
metabolic syndrome.
Methods: A large number of studies have documented that visceral
obesity and diabetes is associated with low plasma total testosterone
levels. A recent study demonstrated a positive correlation between
serum testosterone levels and insulin sensitivity in men across
the full spectrum of glucose tolerance: Men with prostate cancer,
treated with androgen deprivation, develop an increase of body
mass, fat mass, hyperinsulinemia, hyperglycemia, and insulin
resistance. There is growing insight into the relationship between
testosterone and adipose tissue. Testosterone regulates lineage
determination in mesenchymal pluripotent cells.
Results: Testosterone promotes development of muscle cells of
pluripotent cells and inhibits differentiation into the adipogenic
cells through an androgen receptor-mediated pathway. The
observation that differentiation of pluripotent cells is androgen
dependent provides a unifying explanation for the reciprocal effects
of androgens on muscle and fat mass in men. From this it would
follow that restoration of testosterone levels to normal would lead
to an increase of muscle mass and a decrease of fat mass, which
is the case.
Conclusion: Some studies indicate that raising testosterone levels
in viscerally obese men leads to a reduction of visceral fat and an
improvement of the cardiovascular and diabetogenic risk factors
associated with it, but others do not confirm this result. Treatment
of obesity is notoriously difficult. Obesity is often associated with
mood disorders and testosterone has mood elevating effects.
Obesity is also a risk factor for erectile dysfunction. Increasingly,
studies document that restoration of testosterone levels to normal
improves erectile dysfunction and can remedy failures of the
phosphodiesterase type 5 inhibitors.
P39
A Study of the Sexual Function in Patients
Undergoing Coronary Artery Bypass Graft Surgery
Hamed Abdalla Hamed, Mohamed Mohamed Farid, Tarek
Mohamed Helmy, and Ali Mohamed Mahran
Department of Andrology, Cairo University
BACKGROUND: The published articles discussing the effect of
coronary artery bypass graft surgery (CABG) on sexual function
are few and based on subjective data (questionnaires) rather than
objective data (e.g. penile duplex) in the evaluation of sexual function.
Furthermore, there are no studies that have been conducted till
now discussing the effect of the new Off Pump Coronary Artery
Bypass Graft (OPCABG) surgery on the sexual function.
OBJECTIVES: Our work aims at evaluation of the impact of CABG
on sexual function, assessment of probable prognostic factors
that may predict the future sexual function in patients undergoing
CABG, and comparison between the conventional CABG and
the new OPCABG as regards the impact of each on the sexual
function.
METHODS: One hundred CABG patients completed our study.
Before surgery, all patients were subjected to full history taking
including the IIEF-5 score, general and local examination and
cardiac assessment based on the European System for Cardiac
Cairo 26 - 28 February 2009
39
The Fourth Pan Arab Congress on Sexual Medicine
Operative Risk Evaluation (EuroSCORE). Patients with normal
IIEF-5 score (> 21) were not subjected to further investigations.
Patients with erectile dysfunction (ED) according to the IIEF-5
score were subjected to pharmaco-penile duplex ultrasound and
serum prolactin and testosterone levels when indicated. At the time
of surgery patients were classified into two matched groups; Group
I: Patients who underwent the conventional CABG (50 patients)
and Group II: Patients who underwent the OPCABG (50 patients).
Six months after surgery, the patients were subjected again to the
same procedures for follow up of the postoperative erectile function
outcome.
RESULTS: Eighty percent of patients candidate for CABG
complained of ED. After surgery, mean IIEF-5 scores of patients
showed a slight increase that did not reach a significant value. Penile
duplex results showed no significant change after surgery. After
surgery, 36%, 30%, and 34% of patients reported improvement,
decline, and no change in their IIEF-5 scores respectively. The
factors which predict the postoperative erectile function outcome
were: 1) Preoperative IIEF-5 score: 70% of patients with normal
preoperative IIEF-5 score preserved their sexual function postoperatively, while 68.4% of patients with severe ED preoperatively
reported no improvement after surgery. 2) Cardiovascular risk
factors (RF): 42% of patients with two or more RF reported
postoperative IIEF-5 score decline compared to 7.1% of patients
with no RF (p<0.001). 3) Preoperative penile duplex results: 100%,
49.1%, and 11.7% of patients with normal duplex, arteriogenic ED,
and venocclusive dysfunction respectively reported improvement
of their IIEF-5 scores after surgery (p<0.001). 4)The onset of ED:
58.7% of patients who reported ED after the onset of myocardial
infarction (MI) reported postoperative erectile function improvement
compared to 34.8% of patients who reported the onset of ED before
the occurrence of MI (p<0.05). 5). The EuroSCORE: 46.4% of low
risk patients reported postoperative erectile function improvement
compared to 21.4% of medium risk patients (p<0.01). 6)Operative
factors: OPCABG patients reported significantly higher Mean ±
SD IIEF-5 score after surgery compared to conventional CABG
patients (15.88 ± 6.67 versus 12.48 ± 7.19, p< 0.05). Moreover,
46% of OPCABG patients reported postoperative improvement of
their IIEF-5 score compared to only 26% of the conventional CABG
patients (p< 0.05).
CONCLUSION: The impact of CABG on the sexual function is
variable. It depends on many preoperative and operative factors.
These factors might be useful and should be considered to predict
the postoperative sexual function outcome.
P40
Prostate volume and prostate cancer: safety of
long-term oral testosterone-replacement therapy in
hypogonadal men
Shedeed Ashour, Ibrahim M. Shedid, Abdel-Halim A. AbdelHalim, Zeinab A. Ibrahim, Dalia M Shabaan, and Ahmad H.
Nassar
Faculty of Medicine, Cairo University
Objective: To evaluate the effect of long-term oral testosterone (T)replacement therapy on total serum prostate-specific antigen (PSA)
level, prostate volume, lower urinary tract symptoms (LUTS), and
the possible development of prostate cancer in hypogonadal men.
Patients & Methods: A total of 172 (44 of the 5th, 60 of the 6th,
and 68 of the 7th decade) hypogonadal men were prescribed
oral T undecanoate from September 2002 to August 2007. All
40
Cairo 26 - 28 February 2009
patients were tested for the Saint Louis Questionnaire to screen for
androgen decline in the aging men (SLQ-ADAM) and International
Prostatic Symptom Score (IPSS) and underwent routine laboratory
investigations, total serum T level, DRE and total serum PSA level
at the baseline and every 6 months during treatment. Transrectal
ultrasound (TRUS) was performed at baseline, every year, and
exceptionally if DRE and/or total serum PSA level was abnormal.
TRUS-guided prostatic biopsy was done for patients with a total
serum PSA level > 4 ng/ml and/or PSA velocity > 0.75 ng/ml/year
during treatment. Comparative statistical analysis of pretreatment
and post treatment results was performed.
Results: 158 patients completed the study. Their age ranged from
42 to 65 years. The mean age±SD for all patients was 53.0±12.0
year. There was a significant increase of the post treatment total
serum T level in comparison to the pretreatment level (P<0.05) for
all age groups. Total serum PSA level increased post treatment,
but insignificantly in comparison to pretreatment (P >0.05) for
all age groups. The mean PSA velocity at the end of the study
was 0.57, 0.42, 0.68 ng/mL/year for the 5th, 6th, and 7th decade
groups, respectively. The mean change of prostatic volume was
statistically significant posttreatment in comparison to pretreatment
one (P<0.05) for all groups, but lower urinary tract symptoms
(LUTS) were reported in only 4 patients. Prostatic intraepithelial
neoplasia (PIN) was detected in only one patient of the 7th decade
group who had evident increase of total serum PSA level (4.67 ng/
mL) and PSA velocity of 1.61 ng/mL/year.
Conclusions: Oral T undecanoate-replacement therapy in
hypogonadal men does not increase the risk of prostate cancer
in selected patients, but it could be associated with increased
prostatic volume, a minor elevation in total serum PSA level, and
occurrence of LUTS.
P41
Hypogonadism prevalence among patients
presenting with metabolic syndrome: An initial
experience with testosterone treatment
Abdel Rahman Zahran and Mostafa Sakr
Department of Urology, Alexandria University, Egypt.
INTRODUCTION & OBJECTIVE: Recently, metabolic syndrome
became a very prevalent disease among Egyptians owing to the
westernization of the country. This syndrome is characterized by
central obesity, insulin resistance, dyslipidemia and hypertension.
The aim of this prospective work is to estimate the incidence of
hypogonadism among patients presenting with metabolic syndrome
& to assess the beneficial effects of testosterone (T) therapy on the
hypogonadal state& other parameters of the syndrome.
METHODS: In the past two years 88 patients with metabolic
syndrome presented to the metabolic and andrology outpatient
clinics of the Alexandria school of Medicine, Alexandria, EGYPT.
All Patients were subjected to evaluation of the body mass index
(BMI), Glycosylated hemoglobin (HbA1c), Lipid profile, Blood
pressure measurement (BP), in addition to total & free testosterone
assessment Patients proven to be hypogonadal were treated with
oral T in the form of testosterone undecanuate( 120 mg daily) for
a period of 3 months & then re-evaluated in regards of the prementioned parameters.
RESULTS: Patient’s age ranged from 25-55 years. At initial visit
all patients had a BMI >30 Kg/m2,90%of them had BP>140/90
mmHg, serum triglycerides(TG)>150mg/dl & low High density
lipoproteins(HDL)<35mg/dl.The prevalence of hypogonadism was
The Fourth Pan Arab Congress on Sexual Medicine
82% (72 patients)with a mean T level of< 250 ng/dl. After 3 month
of treatment with the oral T, there was no significant difference in
regards of the BMI, & lipid profile (p>0.05).However there was
a significant increase in the total T level (p<0.01). In addition,
there was a significant improvement in the control of the glycemic
status (HbA1c <6.5;p<0.02). Interestingly, patients who previously
failed oral PDE5I treatment responded favorably to the drug after
receiving T alone.
CONCLUSIONS: Hypogonadism is highly prevalent among
patients with metabolic syndrome. Testosterone supplementation
will not only improve the hypogonadal status, but other parameters
of the syndrome as well.
P42
DHEA for treating sexual dysfunction in
premenopausal women
Amany Shaltout
Dr Samir Abbas Medical Center, Jeddah
Introduction: An estimated 40% of women experience sexual
dysfunction, yet information regarding treatment is still limited.
Much more information is available concerning sexual dysfunction
in postmenopausal than in premenopausal women. Although
studies have shown that women with sexual dysfunction have
lower androgen levels compared to age-matched normal control
groups, yet the role of androgen treatment in women remains
controversial.
Aim: to evaluate the effect of DHEA in treating premenopausal
women with female sexual dysfunction having normal estrogen
but their androgen values were either below or in the lower quartile
of the physiologic range
Methods: 62 premenopausal women with ages ranging from 35
to 45 years and presenting with female sexual dysfunction were
enrolled in the study. All women had healthy marital relationships,
with no reported medical or psychological disease and were not on
oral contraceptive use. Total testosterone, free androgen index and
DHEA-S levels were measured before and after treatment. DHEA
in a dose of 50 mg per day was given from 3 to 6 months until
androgen values reached the upper half of the physiologic range.
The FSFI was used to evaluate the sexual function before and after
treatment.
Results: 55% of the women had desire disorder,29% had arousal
disorder, 5% had dyspareunia and 11 % had combined sexual
disorders. Decreased androgen levels correlated with decreased
full-scale FSFI score and FSFI-desire, FSFI-arousal, FSFIlubrication and FSFI-orgasm scores, with a statistically significant
improvement in all scores after treatment. Side effects included
increased facial hair (6%), weight gain (5%), acne (4%), temporary
breast tenderness (1%)
Conclusion: DHEA treats sexual dysfunction in premenopausal
women with decreased androgen level. The rather weak conversion
of DHEA into testosterone protects from the risk of overdosing
associated with testosterone preparations.
P43
Corporal “Snake” Maneuver: Modification of
Corporoglanular Shunt Surgery for Ischemic
Priapism
Arthur L. Burnett, Phillip M. Pierorazio
The James Buchanan Brady Urological Institute, Johns Hopkins Hospital, Baltimore, USA
Introduction: Penile shunt surgery is frequently applied as part
of standard priapism treatment algorithms. We describe the
application of a modified distal corporoglanular shunt surgery in
three patients with major ischemic priapism episodes who failed
prior penile shunt surgical attempts.
Patients and Methods: Three patients, ages 40, 43 and 48 years,
presented with major priapism episodes of 4, 1, and 2 days
duration, respectively. Priapism etiologies were idiopathic in the
first patient and secondary to trazodone use in the latter two. All
three had undergone initial intracorporal aspiration and irrigation
procedures in combination with sympathomimetic administration as
well as either Winter or Al-Ghorab corporoglanular shunt surgeries
without resolving their conditions. Priapism recurred and continued
for 2, 1, and 3 days, respectively, prior to their transfer and further
operative management at the Johns Hopkins Hospital. All patients
then underwent modified Al-Ghorab procedures: after creation
of a tunical window at the surgically exposed distalmost portions
of the corpora cavernosa bilaterally, a size 7/8 Hegar dilator was
inserted retrogradely and then advanced using gentle boring
motions to release congested, viscous blood. Blood evacuation
from the corporal bodies was assisted by manual compression of
the penis.
Results: Penile detumescence was achieved without priapism
recurrences in all patients. One patient (no. 2) reported erection
recovery satisfactory for sexual intercourse within one month after
surgery.
Conclusion: The corporal ‘snake’ maneuver applied as a
modification of the Al-Ghorab corporoglanular shunt may offer a
useful surgical approach for managing major ischemic priapism,
particularly that refractory to initial surgical management.
P44
Penile prosthesis insertion in acute ischaemic
priapism: Long term follow-up
Garaffa G, Abdel Raheem A, Spillings A, Christopher AN,
Ralph DJ
Institute of Urology, London, UK
Introduction and Aim: The long term results of the immediate
penile prosthesis insertion in patients with ischaemic priapism are
presented.
Materials and Methods : A penile prosthesis was inserted into
53 patients (mean age 42y; range 26 -73) who presented with
ischaemic priapism of a mean duration of 171 hours (24-408). All
patients had failed aspiration and instillation of alpha-agonists and
28 patients had had unsuccessful shunt surgery performed prior
to referral. The diagnosis was confirmed by cavernosal blood-gasanalysis, colour-Doppler-ultrasonography and cavernosal smooth
muscle biopsy in 39 patients.
Results: The aetiology of the priapism was related to medications
(n=17), haemaglobinopathy (n=10) and idiopathic in 26 patients. A
malleable prosthesis was inserted initially in 49 patients, 10 of which
were later electively revised to a 3-piece-inflatable device, and 4
patients a 3-piece-inflatable prosthesis placed in the acute setting.
After a mean follow-up of 17 months, 5 patients needed revision
surgery due to infection (n=4) or curvature (n=1). All patients are
currently able to have sexual intercourse and the satisfaction rate
is of 98%.
Conclusions: The immediate insertion of a penile prosthesis in
ischaemic priapism is simple to perform with higher satisfaction and
lower complication rates when compared to a delayed insertion.
Cairo 26 - 28 February 2009
41
The Fourth Pan Arab Congress on Sexual Medicine
P45
Penile Reconstruction Surgeries. The Complications
stretched penile length in adults potent Egyptians was 12.9 cm
while in ED patients was shorter than normal.
Alexander Krakovsky
P47
Primary anastomosis of the traumatically amputated
penis
American Academy of Phalloplasty Surgeons
Objective: Today, a man is capable not only of understanding
his own nature and anatomy, but also of altering it. Specifically,
surgical penile reconstruction and augmentation (phalloplasty) is
available to enhance the length, girth, and glans of the penis. This
presentation describes surgical complications after phalloplasty
surgery.
Methods: In 12 patients (3.24%) serious infections developed
that required different treatment. Treatment includes medical and
surgical approaches and it was successful in all cases.
Results: In 7 of these cases, after 2 weeks of continuous treatment
with general and local antibiotics, the infection was cured. These
patients were successfully signed off from the treatment with
subsequent instructions regarding continuity of care. In 5 of these
cases, the AlloDerm required removal in order to successfully treat
the infections. Twelve patients (4.9%) experienced localized swelling
3 to 7 days after surgery. This swelling resolved spontaneously.
Eighteen patients (7.3%) reported post surgical retraction that was
successfully treated medically and surgically.
Conclusion: All complications after penile reconstruction and
augmentation surgeries are treatable and required systemic
approach. The surgical procedures for infection treatment consist
of several steps. First, the wound has to be cleansed, and a drain
has to be inserted. The drain must be flushed regularly with an
antibiotic solution for five to seven days. After that, the drain must be
removed. Next, the surgeon has to follow up with the patient for two
weeks. If infection has not cleared up by that time, the graft must be
removed. In this study, using the described technique, the success
rate for saving the graft was about 60%. Retraction treatment
program also has two steps. First, the patient must contact the
office immediately if this condition developed and undergo medical
treatment that includes cortisone injections into the suprapubic
area, as well as very intensive physiotherapy stretching exercises.
If this treatment does not bring enough satisfaction, the patient
undergoes surgery that includes reconstruction of suprapubic area
and excision of the scar tissue.
P46
Penile measurement in adult Egyptians
Amr Gadalla, Hussein Ghanem, Ihab Ismail, and Mohamed
Mousa
Faculty of medicine, Cairo university
This study aimed to determine the penile size in adults Egyptians
and to clarify the relationship between fully stretched penile
measurement in normal males and erectile dysfunction patients.
1027 adults Egyptians were divided into two groups; group 1(n=
949) normal adults and group 2 (n=78) ED patients. Penile length
and girth were measured using a tape measure in the fully stretched
states in both groups. In group 1, the mean fully stretched length
was 12.9 ± 1.9 cm and the mean fully stretched girth was 8.9 ± 0.9
cm. In group 2 the mean fully stretched length was 11.2 ± 1.5 cm
and the mean fully stretched girth was 8.8 ± 0.8 cm. Comparing the
mean of fully stretched length in both groups revealed significant
difference (P<0.001) ,while the fully stretched girth in both groups
was nonsignificant (P=0.474). It is concluded that the average fully
42
Cairo 26 - 28 February 2009
Hosni K. Salem and Taymour Mostafa
Departments of Urology and Andrology Cairo University.
Introduction: Penile amputation is an uncommon condition for
which immediate surgical replantation is warranted.
Aim: To represent intervention and management for an amputated
penis by replantation and reconstruction.
Method: A 23 years old male presented with traumatic penile
amputation for 2h where the penile proximal part was 1 cm far from
the pubis. Replantation included; end to end anastomosis of urethral
mucosa over a catheter, approximation of the corpus cavernosum
& tunica albuginea, anastomosis of the deep dorsal vein, dorsal
nerve, both dorsal arteries, and superficial dorsal vein.
Results: At day 5 post-operative, the replanted penis had preserved
capillary filling. The catheter was removed at day 11, where the
patient urinated smoothly. Preliminary cosmetic appearance
was satisfactory with frequent morning erection, reported night
emission twice within the first month post-operative. Sensation was
preserved in the distal anastomosed stump.
Conclusion: Meticulous microsurgical technique decreases the
possibility of skin loss and increases the chance of regaining
erectile function.
P48
Erectile Dysfunction Evaluated by the Use of
Erection Hardness Score and Quality of Erection
Questionaire in Taiwan
Thomas I.S. Hwang, Te-Fu Tsai, Yi-Chia Lin, Han-Sun Chiang
Objectives: To provide up-to-date data on the prevalence of erectile dysfunction (ED) in
Taiwanese men and to investigate the effects of erection hardness score (EHS) and quality
of erection questionnaire (QEQ).
Methods: A representative sample of 1,060 men aged 30 years or
above completed a telephone interview. ED status was obtained
by direct questioning and by the abridged five-item version of
the 15-item International Index of Erectile Function (IIEF-5)
assessment. Responses regarding the EHS, QEQ, marital and
sexual satisfaction, and attitude to treatment were also obtained.
The data were analyzed with simple descriptive statistics and linear
regression.
Results: The prevalence of ED as defined by IIEF-5 was 27%
among all respondents and 29% among those aged 40 or above.
The prevalence of ED increased with age but men of all ages
tended to underestimate their erectile problems. Among the men
self-reported not having ED, 25% were found to have mild to
moderate ED by IIEF-5 assessment. EHS 3,2,1 are 22%, 5%, and
3% respectively, (30% in total), which is similar to the prevalence of
ED (27%) in Taiwan. In addition to ED, chronic diseases including
prostate hyperplasia, diabetes, and heart disease also had a
negative impact on EHS. EHS is consistent with QEQ, when the
EHS is 4, the satisfaction of each domain of QEQ ranges from 85
to 90%. The QEQ score correlated well with the IIEF-5 score in
Taiwan, and was found to be a significant variable affecting both
sexual and marital satisfaction (p<0.005).
Conclusion: ED is common in Taiwan, with a prevalence of 27%
The Fourth Pan Arab Congress on Sexual Medicine
among men aged 30 or above; however, tend to be neglected
the presence. EHS is considered to be a simple, practical tool
clinically. QEQ score is suggested to be value in the assessment
and monitoring of ED patients.
P49
Length-preserving correction of penile curvature by
corporal rotation
Osama Shaeer and Kamal Shaeer
Department of Andrology, Cairo University
Aim: Correction of extreme degrees of penile curvature by
plication of the convex aspect of the corpora cavernosa can result
in significant shortening. This work describes corporal rotation
whereby ventral and dorsal curvatures of up to 90 degrees can be
corrected with neither shortening nor erectile dysfunction.
Material and Methods: Corporeal rotation was performed in 22
patients with various degrees of curvature. Degree of deviation,
erect penile length, symmetry, and erectile function were evaluated
and compared pre and post operatively. Main outcome measures:
Penile straightness, length, girth and erectile function
Results: Full correction of curvature was achieved in 20 out of 22
patients, with no shortening, asymmetry or erectile dysfunction.
Residual curvature in 2 patients was no more than 10 degrees.
Conclusions: Corporal rotation can restore straightness to the penis
with no loss in phallic length, asymmetry, or erectile dysfunction.
While a variety of surgical techniques are feasible for correction of
milder degrees of curvature, we believe that severe degrees should
be spared the shortening and corrected by corporeal rotation.
P50
Safety and efficacy of escitalopram in the treatment
of premature ejaculation
Selim O, Ghanem H, Hosny H, Abd-Elhady A, Sultan G
Department of Andrology,Sexology and STDs, Cairo university
Introduction: Premature ejaculation (PE) is the most common male
sexual disorder. Selective serotonin reuptake inhibitors (SSRIs)
have been used off-label for PE, with varied results. escitalopram
has the highest selectivity for the human serotonin transporter.
Aim: To evaluate the efficacy and safety of most selective serotonin
reuptake inhibitor drug, escitalopram, in delaying ejaculation in
patients with premature ejaculation (PE).
Study design: double blind randomized placebo controlled study.
Material and Methods: A total of 100 married men (mean age,
36.25 years) with PE were randomly assigned to receive 10
mg of escitalopram (n = 50; GroupA) or placebo (n = 50; Group
B) for 4 weeks. Pretreatment evaluation included history and
physical examination, intravaginal ejaculatory latency time (IELT),
International Index of Erectile Function (IIEF-5), and Arabic Index
of Premature Ejaculation (AIPE). The efficacy of 2 treatments was
assessed after 2 weeks and at the end of study.
Results: At the end of 4-week treatment, the escitalopram group
had a 6.03-fold increase of the geometric mean IELT, whereas after
placebo, the geometric mean IELT did not increase significantly
1.325-fold (P = 0.001). AIPE score showed marked improvement
in group A and IIEF-5 clarified safety of escitalopram on erectile
function. Minor insignificant side effects were recorded.
Conclusions: Oral escitalopram seems to be an effective treatment
for PE. Further studies are required to draw final conclusions on
the efficacy of this drug in PE.
P51
Erectile Dysfunction among Saudi Patients with
Type 2 Diabetes Mellitus, Hypertension and/or
Dyslipidemia: Impact of Applying Different Methods
of Inquiring Techniques
Ahmed I. El-Sakka, Ahmed M. Hegazy, Tarek A. Ismail, and
Epidemiology Study group in Saudi Arabia
Suez Canal University, Ismailia, Egypt, Al-Noor Specialist Hospital, Makkah, Saudi Arabia,
Pfizer Global Pharmaceuticals, Saudi Arabia
Purpose: Our objective was to determine the impact of applying
different methods of inquiry techniques on the detection of erectile
dysfunction (ED) among patients with type 2 diabetes mellitus,
hypertension and/or dyslipidemia in Saudi Arabia
Material and Methods: A total of 5004 male patients (30-70 years)
in Saudi Arabia who had attended 500 selected primary care clinics
and who sought treatment for one or more of the following: diabetes
mellitus, hypertension and/or dyslipidemia were the candidates of
this study. Patients were divided into three groups according to
inquiring technique : (1) voluntarily complain of ED, (2) respond
to only one direct question about ED in which the answer of the
patient is either yes or no, and (3) answer the SHIM (Sexual Health
Inventory for Men) Questionnaire respectively. At screening visit,
patients were also interviewed for socio-demographic data and
medical history. 4817 patients provided complete answers and
their data were subjected to statistical analysis.
Results: Mean age ±SD for the study sample was 50.2±8.3 years.
No significant difference in age among the three investigated
diseases. The overall prevalence of ED was 63.8% among
the study population. There were significant differences in ED
prevalence 41.1%, 68.9% and 83.1% among groups 1, 2 and 3
respectively (p<0.001 for each). After adjustment for disease, the
detection of ED was 43.9%, 77.5% and 88.2% in diabetics 38.1%,
64.5% and 79.7% in hypertensives; and 42%, 64.6% and 81.3%
in dyslipidemics according to the groups 1, 2 and 3 respectively
(p<0.001 for each). Stratification analysis of data according to the
method of inquiring technique revealed a significant increase of ED
detection in group 3 than groups 1 and 2 and a significant increase
of ED detection in group 2 than group 1 irrespective to the age
groups.
Conclusions: Erectile dysfunction was very prevalent among patients
in Saudi Arabia with diabetes, hypertension and/or dyslipidemia.
The use of SHIM questionnaire had significantly augmented the
detection rate of ED in comparison to voluntary complain or using
a direct closed end question techniques among our patients.
P52
Repeated intracorporeal self-injection: effect
on peak systolic velocity and cavernosal artery
diameter
Mohamed Abbas, Awad H, El-Karaksy A, Mostafa T, Kamel II,
Arafa M, Zeidan A
Department of Andrology, Cairo University
Aim: To evaluate the effect of repeated intracavernosal injection
(ICI) self-injection on the peak systolic velocity (PSV) and the
diameter of cavernosal arteries.
Methods: Sixty erectile dysfunction (ED) patients who were positive
responders for ICI therapy were studied. Pharmacopenile duplex
ultrasonography (PPDU) was carried out before starting ICI
Cairo 26 - 28 February 2009
43
The Fourth Pan Arab Congress on Sexual Medicine
and after 10 doses of home therapy in an open-label uncontrolled
study.
Results: There was significant increase in the cavernosal artery
diameter and their PSV before and after injection. Cavernosal
arteries diameter before injection in both right and left sides was
0.64+/-0.13 and 0.63+/-0.12 mm at the start and became 0.81+/0.22 and 0.79+/-0.22 mm respectively at the end with significant
differences (P<0.001). Cavernosal arteries diameter after injection
in both right and left sides was 1.10+/-0.18 and 1.09+/-0.19 mm at
the start and became 1.34+/-0.39 and 1.27+/-0.33 mm respectively
at the end with significant differences (P<0.001). PSV at the start
was 33.77+/-13.26 and 32.33+/-8.09 cm/s on both right and left
sides and became 44.4+/-1.19 and 46.1+/-5.86 cm/s respectively
at the end with significant differences (P<0.001).
Conclusion: Repeated ICI improves arterial erectile response with
associated increase in PSV and cavernosal artery diameters.
P53
A pilot study: Is penile length a factor on treatment
of erectile dysfunction with PDE-5 inhibitor?
Murat Savas, Ercan Yeni, Halil Ciftci, Ufuk Topal, Mazhar
Utangac, Ayhan Verit
Harran University Medical School, Department Of Urology, Sanliurfa - TURKEY
Introduction: Erectile dysfunction (ED) is highly prevalent diseases
among men and several factors can be conduce to failure treatment
of erectile dysfunction with PDE-5 inhibitors.
Aim: The aim of this study was to investigate the impact of penile
size on treatment of ED with PDE-5 inhibitor (tadalafil 20 mg).
Methods: We prospectively scrutinized and enrolled to the present
study 42 consecutive patients with ED. All the measurements of
penile length in fully stretched states and IIEF-ED scores were
recorded by the same physician (MS).
Main outcome and measures: Patients were divided into three groups
according to stretched penile length as small (<25th percentiles),
normal (25-75 percentiles) and large (>75th percentiles). Before
and after treatment period mean IIEF-ED scores were recorded.
Patients received tadalafil 20 mg, taken on demand, for at least 6
times.
Results: Overall the mean stretched penile length was 13.44±2.4
(range 9.50-18.00) cm. Overall mean IIEF-ED domain scores for
before and after treatment period were recorded as 11.90±4.78
and 18.67±6.70, respectively. Althought PDE-5 inhibitor treatment
significantly improved all domains of the IIEF-ED scores (p<0.05),
no statistically significant difference was found among three
groups according to mean IIEF-ED domain scores before and after
treatment (p>0.05).
Conclusion: We concluded that penile size is not a factor on
treatment ED patients with a PDE-5 inhibitor.
P54
The evaluation of lifelong erectile dysfunction with
nocturnal penile tumescence rigican (NPTR) testing
combined with a phosphodiesterase type 5 inhibitor
Abdel Raheem A, Garaffa G, Spillings A, Christopher AN,
Ralph DJ
Institute of Urology, London, UK
Aim : Young men with lifelong erectile dysfunction (ED) that have
failed phospho-diesterase type 5 inhibitor (PDE5I)medication often
44
Cairo 26 - 28 February 2009
end up with surgery due to the inability to establish a diagnosis.
This study assesses the effect that a PDE5I has on nocturnal
erections.
Material and Methods : Twelve men with lifelong ED and
having failed PDE5I medication were evaluated. All patients
had a radiological diagnosis of veno-occlusive dysfunction by
penile duplex. All patients then had 2 nights of nocturnal penile
tumescence and rigidity (NPTR) monitoring with 100mg sildenafil
given on the second night. A normal NPTR test was considered
when there were 2 erectile episodes of 10 minutes duration with
70% base and tip rigidity.
Results : For the first night, 10/12 patients had an abnormal NPTR.
On the second night with the addition of sildenafil, 4/12 patients
continued to have an abnormal NPTR (true PDE5I failures), those
patients were managed surgically. Of the 8 patients (2 psychogenic
+ 6 organic) that were now shown to respond to PDE5I therapy, 6
were successfully managed conservatively and 2 ended up having
surgery.
Conclusion : Young men with lifelong ED are notoriously difficult to
manage. They are often extremely anxious individuals which results
in an abnormal failure to relax their cavernosal smooth muscle, even
in response to a PDE5I or PGE1 intracavernosal injections resulting
in a false positive diagnosis of veno-occlusive dysfunction. NPTR
testing with PDE5I is the investigation of choice in these patients
to obtain a diagnosis that is not biased by psychogenic factors and
confirm that it is worthwhile re-challenging the patient with further
PDE5I therapy. This test will reduce the number of unnecessary
operations in these patients.
P55
Oral phosphodiesterase-5 inhibitors and sperm
functions
Taymour Mostafa
Department of Andrology, Cairo University
Background: cGMP-specific PDE5 is one of the PDEs that have been
intensively studied because of its fundamental pharmacological
relevance, as oral PDE5 inhibitors are used successfully in treating
erectile dysfunction. Specific relevance of the cGMP system in
reproductive functions has been recently proposed.
Aim: To elucidate the possible effects of phosphodiesterase-5
(PDE5) inhibitors on sperm functions.
METHOD: A systematic review of published studies in this affair
based on a Pubmed and medical subject heading databases
search of all concerned articles.
MAIN OUTCOME MEASURES: Demonstrated beneficial as well
as applicable uses of oral PDE5 inhibitors.
Results: Oral PDE-5 inhibitors were shown to be devoid of effects
on semen volume, concentration, sperm membrane integrity or
sperm penetration assay. Most available studies demonstrated a
significant increase in sperm motility and viability both in vivo and
in vitro, which seems to be enhanced at low doses and reduced at
high concentrations. In addition, these molecules showed a role in
capacitation and a debated one concerning acrosome reaction.
Conclusion: Due to the relative short period since the launching of
oral PDE5 inhibitors, more investigations should be carried out in
wider scales to assess their effect(s)on variant sperm function that
could be beneficial as potential therapeutic approaches.
The Fourth Pan Arab Congress on Sexual Medicine
P56
Couple satisfaction to different therapeutic
modalities for organic erectile dysfunction
Ashraf Hassan, El-Hadidy M, El-Deeck BS, Mostafa T
Department of Dermatology & Andrology, Mansoura University, Egypt
INTRODUCTION: Erectile dysfunction (ED) treatment studies do
not measure treatment response and treatment satisfaction (both
patient and partner satisfaction) where dissatisfaction reflects an
aspirations/achievement gap.
AIM: To test the subjective implications of satisfaction to various
therapeutic modalities for pure or mixed organic ED, and to address
changes in the health-oriented quality of life (QoL) and the relation
of psychiatric status of these patients to treatment satisfaction.
METHODS: A prospective study included of 354 couples classified
according to their line of therapy into five treated groups:
testosterone, sildenafil citrate, intracavernosal injection, external
negative vacuum device, and penile prosthesis.
MAIN OUTCOME MEASURES: Erectile Dysfunction Inventory
of Treatment Satisfaction (EDITS) and the International Index
of Erectile Function (IIEF). Satisfied patients were compared to
unsatisfied cases using the PCASEE scale for QoL and Middlesex
Hospital Questionnaire (MHQ) for psychiatric status.
RESULTS: Sildenafil citrate-treated group represented the highest
mean value of satisfaction score on EDITS, erectile function,
orgasmic function, and overall satisfaction domains of IIEF. Penile
implants-treated group was the second for satisfaction score on
EDITS. The testosterone-treated group represented the highest
mean value for sexual desire domain score of IIEF. Low scores
in various domains of QoL were significantly improved among
satisfied cases more than unsatisfied subjects after therapy. High
association was found between dissatisfaction and scores for
anxiety, obsession, and phobia, followed by scores of depression
and somatic concomitant of anxiety.
CONCLUSION: ED is best conceived as intermingle of somatic,
lifestyle, psychological, and partner relationship determinants. This
should be taken into account to increase sexual satisfaction with
improved QoL, and not only to produce rigid erection.
Cairo 26 - 28 February 2009
45
The Fourth Pan Arab Congress on Sexual Medicine
Bayer Satellite Symposium
Symposium Title : Restore the man
Chairpersons : Amr El Meliegy
The link between underlying medical conditions & ED " Is there a role for PDE5 inhibitors
Ian Eardley (UK)
The link between metabolic syndrome , hypogonadism (TDS) and ED. " The benefits of new long acting
testosterone therapy.
Aksam Yassin
Cairo 26 - 28 February 2009
47
The Fourth Pan Arab Congress on Sexual Medicine
Pfizer satellite Symposium
Restoring Hardness of Erections, Restoring Confidence: Patient’s perspectives.
John Dean (UK)
President, International Society for Sexual Medicine
Restoring Hardness of Erections, Restoring Confidence: Physician’s perspectives.
John Mulhall (USA)
Associate Professor of Urology, Director of the Sexual Medicine Program, and Director of Sexual Medicine Research Laboratory at Weill
Medical College of Cornell University
Restoring Hardness of Erections, Restoring Confidence: Pharmacological perspectives.
Tarek Anis (Egypt)
Professor of Andrology, Cairo University
48
Cairo 26 - 28 February 2009