This article was downloaded by: [McMaster University] On: 09 January 2015, At: 07:53 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Journal of Sex & Marital Therapy Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/usmt20
Noninvasive treatment for erectile dysfunction in the neurogenically disabled population a
a
b
c
Ronit Aloni , Leon Heller , Ofer Keren , Eliezer Mendelson & Gary Davidoff
c
a
Department of Rehabilitation Medicine , Sackler School of Medicine, Tel-Aviv University , Ramat Aviv, Israel b
Rehabilitation Medicine Service , Veterans Affairs Medical Center , Ann Arbor, Michigan, USA c
Department of Physical Medicine and Rehabilitation , University of Michigan , Ann Arbor, Michigan, USA Published online: 14 Jan 2008.
To cite this article: Ronit Aloni , Leon Heller , Ofer Keren , Eliezer Mendelson & Gary Davidoff (1992) Noninvasive treatment for erectile dysfunction in the neurogenically disabled population, Journal of Sex & Marital Therapy, 18:3, 243-249, DOI: 10.1080/00926239208403410 To link to this article: http://dx.doi.org/10.1080/00926239208403410
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &
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Noninvasive Treatment for Erectile Dysfunction in the Neurogenically Disabled Population
Downloaded by [McMaster University] at 07:53 09 January 2015
RONIT ALONI, LEON HELLER, OFER KEREN, ELIEZER MENDELSON, and GARY DAVIDOFF
Erectile dysfunction is the most prevalent sexual dysfunction in wurogenically disabled men. Studies of rehabilitation patients indicate that the restoration of sexual functioning is considered an important pn'ority. This article reports on a pilot study of vacuum tumescence constriction therapy as a noninvasive method for use by a population with traumatic or nontraumatic neurologic disorders such as spinal cord injuty, stroke, multiple sclerosis, and diabetes mellitus. Of the 30 patients who participated in the study, 17 purchased the device and over 50% of them reported wing the device on a long-term basis. Frequency of coitus increased from O.3lwk to 1.5Iwk. Included in the study arp methods used by patients to integrate the devue into their sex lqe, the role of the patient's partner in the deckion to purchase the device, and the rate of partner satisfaction. There were no reports of substantial morbidity. Thus, this method shows promise as a noninvasive treatment for men who are moderately to severely neurogenually disabled. A common comorbidity of traumatic and nontraumatic neurologic disorders, which include spinal cord injury, stroke, and autonomic neuropathy seen in patients with diabetes, is sexual dysfunction. Studies of rehabilitation patients indicate that the restoration of sexual functioning is considered very important, especially the ability for men to achieve penetration and to maintain an erection. Human sexual response is based on the ~~
~
~
This study was supported by a research training grant by the National Institute on Disability and Rehabilitation Research, US Department of Education. Washington, DC (H 133-P80037), and the US-Israel Education Foundation. Tel-Aviv. Israel. T h e first four authors work in the I.owenstein Rehabilitation Centre, Ra'anana. Israel. l.eon Heller, M.D., is also at the Department of Rehabilitation Medicine, Sackler School of Medicine, TelAviv University, Ramat Aviv. Israel. Ofer Keren, M.D.. is at the Rehabilitation Medicine Service. Veterans Affairs Medical Center, Ann Arbor, Michigan. USA. Eliezer Mendelson. M.D.. is at the Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, Michigan, USA. Gary Davidoff, M.D.. is deceased. Address correspondence to: Ronit Aloni, M.A.. Lowenstein Hospital Rehabilitation Centre, 278 Ahuza Street, PO Box 3. Ra'anana, Israel.
Journal of Sex & Marital Therapy, Vol. 18, No. 3, Fall 1992 8 BrunnerlMazel, Inc. 243
244
Joumnl .f Sex t-3 Marital Therapy. Vol. 18, No. 3 , Fall I992
principle of a series of sequentially occurring events. If for any reason, one of the events fails, the dynamics of the whole series can be affected. For example, an erectile dysfunction can affect desire as can anorgasmia.’s2 Thus, people with disabilities that affect their sexual functioning experience a decrease in desire which results in a decrease in frequency of sexual relations.3 This vicious circle is common among men with erectile d y s f u n ~ t i o n . ~ - ~ Commonly used methods for the treatment of neurogenic impotence include either a rigid or inflatable surgically implanted penile prosthesis’-’” or intracavernous injection of vasoactive substances such as pa av erine, either alone or in conjunction with alpha adrenergic blockage. 13 However, these methods a r e associated with substantial treatment morbidity, including infection, dislocation of’ the prosthesis, priapism, and hypotension.”14 Experience using vacuum tumescence constriction therapy (VTCT) for the treatment of neurogenic impotence is very limited, but initial reports o f the use of V‘I’CT indicate that it shows promise as a treatment method for this disorder.15-” I f V T C T could be shown to not have a higher incidence of morbidity than either injections or surgical implants, it would become another option for the management of neurogenic impotence. T h e following is a description o f a pilot study carried out at the Loewenstein Hospital Rehabilitation Center, where 30 patients were evaluated for the use of this device and concurrently received sexual counseling .
Downloaded by [McMaster University] at 07:53 09 January 2015
R-
METHODS All patients were referred for an initial evaluation by the rehabilitation sexuality clinic. Patients completed a maximum of three interviews in open and closed question format, both individually a n d with their sexual partner. Questions surveyed both the patient’s a n d the partner’s sexual histories both prior to and following the onset of the disability a n d included information about desire, quality of the patient’s erection, ability to achieve orgasm, ability to achieve and maintain penetration for a substantial length of time, and ability to ejaculate. Options presented to the patients for the management of impotence included VTCT, pharmacology, and surgical implantation of a prosthesis. T h e couples who chose V T C T received ongoing counseling with the sexual therapist, who advised them how t o integrate the device into their sex life. Concurrently, the couple was referred to a physiatrist, who saw the partners for a minimum of three visits during which the patient and his partner were trained to use the device. T h e goal was to ensure that the couple was completely able to put on and remove the device safely without medical assistance. During the training period the couple was offered individual and partner therapy by a staff sexuality counselor. Following the training period, patients were given the opportunity to purchase the device for regular use at home. T h e patients who purchased the device w e r e followed at six-month intervals by the physiatrist a n d the
Noninvariue Treatment for fhc Neurogenically DisablPd
245
TABLE 1 Patient Demographics (N = 30) Disability
N
Single
Age
Married
Purchased Long-term
(mean) Quadriplegia
2
27
1
1
0
0
10
37
4
6
7
3
Paraparesis Hemiplegia (due to stroke)
7 7
43
3
4
4
3
57
-
7
2
1
Multple Sclerosis
2
30
1
1
1
0
49
-
2
2
2
Paraplegia
Downloaded by [McMaster University] at 07:53 09 January 2015
Use
Polyneuritis (due to diabetes Melitus)
2
sexuality counselor. T h e couple then completed a questionnaire concerning the effect of the VTCT on their sexual relationship. Comparisons in the rates of coitus before and after the V T C T program were made using paired t-tests. RESULTS Thirty patients and their partners chose V T C T as the initial treatment modality for erectile dysfunction as a result of neurogenic disorder. Patient diagnoses included paraplegia ( lo), paraparesis (7), hemiplegia (7), quadriplegia (2), multiple sclerosis (2), and autonomic neuropathy (2). Twenty-one of the patients were married, and all of the patients were sexually active. Seventy-four percent ( 1 7 of 23) of all the patients who were sexually active had been engaged in a monogamous relationship during the year prior to the evaluation for V T C T (see Table 1). Following clinical training, 17 (57%) of the original 30 patients purchased the VTCT device. Only 8 patients of the 13 who did not purchase the device gave us their reasons for not doing so. O f these 8, 5 patients said that their wives disapproved of the method, and 3 patients had improved function or stated that it was t o o expensive. (Most of our patients were reimbursed by their insurance company.) T h e only patient group that refused outright to purchase the device were those patients who were complete quadriplegics (n = 2). T h e mean time from purchase to most recent clinic follow-up was 21 ( - + ) 1 1.7 months (range, 3-36 months). At last clinic follow-up, of the original 17 who had purchased the device, 9 (53%)were continuing to use the device on a regular basis. T h e recorded frequency of coitus among those patients who purchased the device was 0.3 per week prior to V T C T training, and 1.5 per week at follow-up (t = - 5.7, p < 0.0001). Following VTCT training, all of the patients were independent in the use of the
Journal oJ Sex k3 Manta1 Therapy, Vol. 18, No. 3 , Fall I992
246
TABLE 2 How Patients Use the VlC‘I‘ ( N = 17) Patients
Methods of Using the V T C T N
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~
(%)
~~~~
Use the VTC’I‘ with partner aid Use the V’TCT independently
4 13
Put the V T C I ’ o n before engaging in sex Put the V T C f on during sex
15 I
(88) (6)
Put the V’I’CT on in the bathroom Put the V T C I ‘ on in the bedroom
6 11
(35) (65)
device with the assistance of their partner, and 90% (27 of 30) of the patients were totally independent in putting on and removing the device (see Table 2). At follow-up, all 17 couples were asked about their satisfaction with their sexual relationship and about any problems that they may be having with the V‘I’CT. Eighty-three percent (14 patients) of the patients who were still using the VTCT and 100% of the sexual partners reported that they were very satisfied with their present sexual relationship. T h e enhancement in satisfaction was attributed to the fact that patients felt that they now had a greater ability to give pleasure to their sexual partner, and as a result they had an increased desire to engage in sexual activity. Partners, however, felt that this enhancement was secondary to engaging in a more “natural” sexual relationship. T h e r e was no change in the prevalence of ejaculation before or after VTCT training. One-third of the patients had never been able to achieve ejaculation after onset of the disability, one-half reported occasional ejaculation, and 16% reported ejaculation always associated with orgasm. ( I t should be noted that no change in ejaculation was observed after using VTCT. Patients did not ejaculate or had partial ejaculation prior to the use of the VTCT because of their spinal cord in-juries.) T h e incidence of morbidity connected with the use of VTCT was minimal. There were no reports of any associated upper or lower urinary tract infections caused by the use of the device. Seventeen percent (3 of 17) o f the patients complained of suction around the testicles due to VTCT use, and 33% stated that it happened infrequently. Suction around the testicles results from improper use of the device. Instructors in the use o f VTCT should be aware that this can occur, as most of the patients are seated while putting on the device. T h e scrotum is easily sucked in in this position and that causes the resulting erection to be inadequate. Seventeen percent (3 of 17) reported occasional swelling of the testicles, and 33% reported petechial hemorrhage. T h e r e were no reports of technical problems with the device. All of the above mentioned problems
Noninvahe Treatment for the Neurogenically Disabkd
24 7
were temporary and resolved within a few hours after the use of the VTCT device.
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DISCUSSION T h e rehabilitation team encounters difficult physical and psychological problems when treating patients who suffer from erectile dysfunction. Intracavernous injections of vasoactive substances are popular with some patients because they can be performed by the patient or by his sexual partner.” - l3 However, side effects include pain, paresthesia, bruising, and fibrotic changes at the injection site.’’-13 Priapism is a rare but serious side effect.” We have not observed a higher rate of significant side effects than is observed with the other methods that are used. Studies have reported the use of a semirigid or inflatable penile pros~ effects may thesis for the treatment of neurogenic i m p ~ t e n c e . ~Side include infection with subsequent removal of the prosthetic implant, erosion and, extrusion. Several third party payers refuse to reimburse patients for the d e ~ i c e . ~ - ” * ’ ~ In this study, 30 patients underwent a trial of VTCT therapy for erectile dysfunction. Following the counseling and training program, 17 of the 30 chose to purchase the VTCT device, although all 30 patients had satisfactory erections by using the VTCT. At follow-up, 53% of the patients were still actively using the VTCT and reported no complications such as urinary tract infection. Swollen testicles and petechial hemorrhage-if they appeared-were a temporary problem. Side effects were never cited as a reason for not buying the VTCT. Evaluation of the demographic data shows that the cerebral vasular accident patients were the oldest patients; this may partially explain their low motivation to buy and use the VTCT. All of the patients who purchased the VTCT were married or single and involved in a monogamous relationship. Single men involved in a monogamous relationship who were first beginning the adjustment process quit the trial when their relationship foundered. Patients who reported engaging in sexual activity prior to using the VTCT engaged in oral or manual sex. With the VTCT, they engaged in sex with penetration. Sexual response was affected prior to the use of the VTCT because these patients could not have intercourse and thus function “normally.” Sexual desire increased with VTCT use as a result of regaining the ability to achieve and maintain an erection. Patients’ motivation to initiate sexual encounters increased, as did their sexual activity. Increased satisfaction was reported by their partners, which resulted in increased frequency of intercourse. The difference between partner and patient satisfaction may have been due to the fact that, for the partner, once the patient was able to have an erection, coitus appeared normal. Some of our patients have no sensation in their genitals due to their disability, and the VTCT cannot change that. Thus for them, although they may have felt better psychologically, physically, coitus was still less satisfactory than it was for their partner.
’”
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248
.]ournal of SQX& Marital Therupy, Vol. 18. No. 3 , Fall 1992
Independence in putting on and removing the VTCT played an important role in patients' decisions t o purchase and use the device. T h e data indicate that patients with good bilateral upper extremity functioning, such as those with diabetes melitus paraplegia and paraparesis, had a higher rate of purchasing the device than those in the other diagnostic categories. T h e hemiplegic patient who uses the VTCT has good use of both upper extremities. Although the patients had been taught to use the V'I'CT as a part of foreplay, only one patient reported doing so. Other patients chose to use the VTC'I' independently in the bathroom or in the bedroom prior to initiating sexual activity (see Table 2). I t seems that most patients wanted to minimize their partner's involvement and awareness of the VTCT as an aid so that they appeared to be functioning normally. T h e partners cooperated with this attitude, none of them insisted in getting involved at that stage of use of the device. Those patients that needed their partner's assistance in putting on or removing the device did not use the VTCT on a long-term basis. Thus, for these patients, neither injection therapy nor the inflatable prosthesis would be considered suitable. The patient's mate played an important role in deciding whether to purchase the device. Thus, the importance of counseling both the mate and the patient must be emphasized. Resistance by the patients to having their mates involved in counseling has been reported. Therapists should also be aware that spouses may regard erectile dysfunction as their mate's problem and may resist counseling. We suggest that VTCT should be considered as another option in the management of patients with chronic neurogenic impotence, in conjunction with an intensive sexual counseling program including both the patient and his partner. Although some patients may prefer and benefit from the other methods, which are invasive, VTCT is recommended as another option, which can be more advantageous because it is noninvasive and totally reversible. REFERENCES 1. Kaplan HS: The Pvafuufionof stxual disordns. New York, Brunner/Mazel. 1983.
2 . Masters W . Johnson V: Human sexual i d q u u c y . Boston, Little, Brown, 1970. 3 . Schover I-, Jensen B: Sexualily a d chronic illness. New York, Guilford. 1988. 4. Jensen SB: Sexual dysfunction in insulin treated diabetics: A six-year follow-up study of 101 patients. Arch of Sex Bth 15(4). 1986.
5. Monga T, lawson J , Inglis J : Sexual dysfunction in stroke patients. Arch Phy.c Med Rehab 6 7 : 19-22, 1986. 6. IJrey J . Henggeler S: Marital adjustment followirig s.c.i. Arch Phys Med R c h b 68167-74. 1987. 7 . Iwatsubo E. Tanaka M , Takahashi K, Akatsu '1': Non-inflatable penile prosthesis !or the management of urinary incontinence and sexual disability of patient5 with spinal cord injury. P a r a p l e p 24:307-310, 1986. 8. Scott FB. Bradley WE, Timm GW: Management of erectile impotence: Use of implantable inflatable prosthesis. Urology 2:80-82, 1973. 9. Small MY: Small-Carrion penile prostheses: A report o r 1 160 cases and review of the literature. J Urol I I Y:36!i-368, 1978.
Noninvasive Treatment for fhe Neurogenically Disabled
249
10. Van Arsdalen K N , Klein FA, Hackler RH. Brady SM: Penile implants in spinal cord in.jury patients for maintaining external appliances. J Urol 126:33 1-33'2, 1981. 1 I . Lloyd LK, Richards JS: Intracavernous pharmacotherapy for management of erectile dysfunction in spinal cord injury. Paraplegia 27:457464, 1989. 12. Sidi AA, Cameron JS, Dykstra DD, Reinberg Y, l a n g e P H : Vasoactive intracavernous 13.
14.
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15.
16. 17. 18.
19. 20.
pharmacotherapy for the treatment of erectile impotence in men with spinal cord injury. J Urol 138:539-542, 1987. Wyndaele JJ, de Mayer JM, d e Sy WA, Claessens H: lntracavernous injection of vasoactive drugs, an alternative for treating impotence in spinal cord injury patients. Paraplegia 24:27 1-275, 1986. Kabalin JN, Kessler R: Infectious complications of penile prosthesis surgery. J Urol 139:95%955, 1988. Chancellor MB, Hills E, Schwarts M, Hirsch IH: 'rreatment of erectile dysfunction in males with spinal cord injury using the vacuum constriction device (VCD).J Amer Paraplegia SOC14:73, 1991. Lloyd EE, '1'0th LL, Perkash I: Vacuum tumescence: An option for spinal cord injured males with erectile dysfunction. SCI Nursing 7:25-28, 1989. Nadig PW, Ware JC, Blumoff R: Noninvasive device to produce and maintain an erection-like state. Urology 27:126--131, 1986. Zasler ND, Katz PG: Synergist erection system in the management of impotence secondary to spinal cord injury. Arch Phys Med Rehab 70:7 12-716, 1989. Cole T M : Sexuality and physical disabilities. Arch Sex Behau 4:389403, 1975. Hanson RW, Franklin MR: Sexual loss in relation to other functional losses for spinal cord injured males: Arch Phys Med Rehab 57:291-293, 1976.
Journal of Sex & Marital Therapy Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/usmt20
Noninvasive treatment for erectile dysfunction in the neurogenically disabled population a
a
b
c
Ronit Aloni , Leon Heller , Ofer Keren , Eliezer Mendelson & Gary Davidoff
c
a
Department of Rehabilitation Medicine , Sackler School of Medicine, Tel-Aviv University , Ramat Aviv, Israel b
Rehabilitation Medicine Service , Veterans Affairs Medical Center , Ann Arbor, Michigan, USA c
Department of Physical Medicine and Rehabilitation , University of Michigan , Ann Arbor, Michigan, USA Published online: 14 Jan 2008.
To cite this article: Ronit Aloni , Leon Heller , Ofer Keren , Eliezer Mendelson & Gary Davidoff (1992) Noninvasive treatment for erectile dysfunction in the neurogenically disabled population, Journal of Sex & Marital Therapy, 18:3, 243-249, DOI: 10.1080/00926239208403410 To link to this article: http://dx.doi.org/10.1080/00926239208403410
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &
Downloaded by [McMaster University] at 07:53 09 January 2015
Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Noninvasive Treatment for Erectile Dysfunction in the Neurogenically Disabled Population
Downloaded by [McMaster University] at 07:53 09 January 2015
RONIT ALONI, LEON HELLER, OFER KEREN, ELIEZER MENDELSON, and GARY DAVIDOFF
Erectile dysfunction is the most prevalent sexual dysfunction in wurogenically disabled men. Studies of rehabilitation patients indicate that the restoration of sexual functioning is considered an important pn'ority. This article reports on a pilot study of vacuum tumescence constriction therapy as a noninvasive method for use by a population with traumatic or nontraumatic neurologic disorders such as spinal cord injuty, stroke, multiple sclerosis, and diabetes mellitus. Of the 30 patients who participated in the study, 17 purchased the device and over 50% of them reported wing the device on a long-term basis. Frequency of coitus increased from O.3lwk to 1.5Iwk. Included in the study arp methods used by patients to integrate the devue into their sex lqe, the role of the patient's partner in the deckion to purchase the device, and the rate of partner satisfaction. There were no reports of substantial morbidity. Thus, this method shows promise as a noninvasive treatment for men who are moderately to severely neurogenually disabled. A common comorbidity of traumatic and nontraumatic neurologic disorders, which include spinal cord injury, stroke, and autonomic neuropathy seen in patients with diabetes, is sexual dysfunction. Studies of rehabilitation patients indicate that the restoration of sexual functioning is considered very important, especially the ability for men to achieve penetration and to maintain an erection. Human sexual response is based on the ~~
~
~
This study was supported by a research training grant by the National Institute on Disability and Rehabilitation Research, US Department of Education. Washington, DC (H 133-P80037), and the US-Israel Education Foundation. Tel-Aviv. Israel. T h e first four authors work in the I.owenstein Rehabilitation Centre, Ra'anana. Israel. l.eon Heller, M.D., is also at the Department of Rehabilitation Medicine, Sackler School of Medicine, TelAviv University, Ramat Aviv. Israel. Ofer Keren, M.D.. is at the Rehabilitation Medicine Service. Veterans Affairs Medical Center, Ann Arbor, Michigan. USA. Eliezer Mendelson. M.D.. is at the Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, Michigan, USA. Gary Davidoff, M.D.. is deceased. Address correspondence to: Ronit Aloni, M.A.. Lowenstein Hospital Rehabilitation Centre, 278 Ahuza Street, PO Box 3. Ra'anana, Israel.
Journal of Sex & Marital Therapy, Vol. 18, No. 3, Fall 1992 8 BrunnerlMazel, Inc. 243
244
Joumnl .f Sex t-3 Marital Therapy. Vol. 18, No. 3 , Fall I992
principle of a series of sequentially occurring events. If for any reason, one of the events fails, the dynamics of the whole series can be affected. For example, an erectile dysfunction can affect desire as can anorgasmia.’s2 Thus, people with disabilities that affect their sexual functioning experience a decrease in desire which results in a decrease in frequency of sexual relations.3 This vicious circle is common among men with erectile d y s f u n ~ t i o n . ~ - ~ Commonly used methods for the treatment of neurogenic impotence include either a rigid or inflatable surgically implanted penile prosthesis’-’” or intracavernous injection of vasoactive substances such as pa av erine, either alone or in conjunction with alpha adrenergic blockage. 13 However, these methods a r e associated with substantial treatment morbidity, including infection, dislocation of’ the prosthesis, priapism, and hypotension.”14 Experience using vacuum tumescence constriction therapy (VTCT) for the treatment of neurogenic impotence is very limited, but initial reports o f the use of V‘I’CT indicate that it shows promise as a treatment method for this disorder.15-” I f V T C T could be shown to not have a higher incidence of morbidity than either injections or surgical implants, it would become another option for the management of neurogenic impotence. T h e following is a description o f a pilot study carried out at the Loewenstein Hospital Rehabilitation Center, where 30 patients were evaluated for the use of this device and concurrently received sexual counseling .
Downloaded by [McMaster University] at 07:53 09 January 2015
R-
METHODS All patients were referred for an initial evaluation by the rehabilitation sexuality clinic. Patients completed a maximum of three interviews in open and closed question format, both individually a n d with their sexual partner. Questions surveyed both the patient’s a n d the partner’s sexual histories both prior to and following the onset of the disability a n d included information about desire, quality of the patient’s erection, ability to achieve orgasm, ability to achieve and maintain penetration for a substantial length of time, and ability to ejaculate. Options presented to the patients for the management of impotence included VTCT, pharmacology, and surgical implantation of a prosthesis. T h e couples who chose V T C T received ongoing counseling with the sexual therapist, who advised them how t o integrate the device into their sex life. Concurrently, the couple was referred to a physiatrist, who saw the partners for a minimum of three visits during which the patient and his partner were trained to use the device. T h e goal was to ensure that the couple was completely able to put on and remove the device safely without medical assistance. During the training period the couple was offered individual and partner therapy by a staff sexuality counselor. Following the training period, patients were given the opportunity to purchase the device for regular use at home. T h e patients who purchased the device w e r e followed at six-month intervals by the physiatrist a n d the
Noninvariue Treatment for fhc Neurogenically DisablPd
245
TABLE 1 Patient Demographics (N = 30) Disability
N
Single
Age
Married
Purchased Long-term
(mean) Quadriplegia
2
27
1
1
0
0
10
37
4
6
7
3
Paraparesis Hemiplegia (due to stroke)
7 7
43
3
4
4
3
57
-
7
2
1
Multple Sclerosis
2
30
1
1
1
0
49
-
2
2
2
Paraplegia
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Use
Polyneuritis (due to diabetes Melitus)
2
sexuality counselor. T h e couple then completed a questionnaire concerning the effect of the VTCT on their sexual relationship. Comparisons in the rates of coitus before and after the V T C T program were made using paired t-tests. RESULTS Thirty patients and their partners chose V T C T as the initial treatment modality for erectile dysfunction as a result of neurogenic disorder. Patient diagnoses included paraplegia ( lo), paraparesis (7), hemiplegia (7), quadriplegia (2), multiple sclerosis (2), and autonomic neuropathy (2). Twenty-one of the patients were married, and all of the patients were sexually active. Seventy-four percent ( 1 7 of 23) of all the patients who were sexually active had been engaged in a monogamous relationship during the year prior to the evaluation for V T C T (see Table 1). Following clinical training, 17 (57%) of the original 30 patients purchased the VTCT device. Only 8 patients of the 13 who did not purchase the device gave us their reasons for not doing so. O f these 8, 5 patients said that their wives disapproved of the method, and 3 patients had improved function or stated that it was t o o expensive. (Most of our patients were reimbursed by their insurance company.) T h e only patient group that refused outright to purchase the device were those patients who were complete quadriplegics (n = 2). T h e mean time from purchase to most recent clinic follow-up was 21 ( - + ) 1 1.7 months (range, 3-36 months). At last clinic follow-up, of the original 17 who had purchased the device, 9 (53%)were continuing to use the device on a regular basis. T h e recorded frequency of coitus among those patients who purchased the device was 0.3 per week prior to V T C T training, and 1.5 per week at follow-up (t = - 5.7, p < 0.0001). Following VTCT training, all of the patients were independent in the use of the
Journal oJ Sex k3 Manta1 Therapy, Vol. 18, No. 3 , Fall I992
246
TABLE 2 How Patients Use the VlC‘I‘ ( N = 17) Patients
Methods of Using the V T C T N
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~
(%)
~~~~
Use the VTC’I‘ with partner aid Use the V’TCT independently
4 13
Put the V T C I ’ o n before engaging in sex Put the V T C f on during sex
15 I
(88) (6)
Put the V’I’CT on in the bathroom Put the V T C I ‘ on in the bedroom
6 11
(35) (65)
device with the assistance of their partner, and 90% (27 of 30) of the patients were totally independent in putting on and removing the device (see Table 2). At follow-up, all 17 couples were asked about their satisfaction with their sexual relationship and about any problems that they may be having with the V‘I’CT. Eighty-three percent (14 patients) of the patients who were still using the VTCT and 100% of the sexual partners reported that they were very satisfied with their present sexual relationship. T h e enhancement in satisfaction was attributed to the fact that patients felt that they now had a greater ability to give pleasure to their sexual partner, and as a result they had an increased desire to engage in sexual activity. Partners, however, felt that this enhancement was secondary to engaging in a more “natural” sexual relationship. T h e r e was no change in the prevalence of ejaculation before or after VTCT training. One-third of the patients had never been able to achieve ejaculation after onset of the disability, one-half reported occasional ejaculation, and 16% reported ejaculation always associated with orgasm. ( I t should be noted that no change in ejaculation was observed after using VTCT. Patients did not ejaculate or had partial ejaculation prior to the use of the VTCT because of their spinal cord in-juries.) T h e incidence of morbidity connected with the use of VTCT was minimal. There were no reports of any associated upper or lower urinary tract infections caused by the use of the device. Seventeen percent (3 of 17) o f the patients complained of suction around the testicles due to VTCT use, and 33% stated that it happened infrequently. Suction around the testicles results from improper use of the device. Instructors in the use o f VTCT should be aware that this can occur, as most of the patients are seated while putting on the device. T h e scrotum is easily sucked in in this position and that causes the resulting erection to be inadequate. Seventeen percent (3 of 17) reported occasional swelling of the testicles, and 33% reported petechial hemorrhage. T h e r e were no reports of technical problems with the device. All of the above mentioned problems
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were temporary and resolved within a few hours after the use of the VTCT device.
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DISCUSSION T h e rehabilitation team encounters difficult physical and psychological problems when treating patients who suffer from erectile dysfunction. Intracavernous injections of vasoactive substances are popular with some patients because they can be performed by the patient or by his sexual partner.” - l3 However, side effects include pain, paresthesia, bruising, and fibrotic changes at the injection site.’’-13 Priapism is a rare but serious side effect.” We have not observed a higher rate of significant side effects than is observed with the other methods that are used. Studies have reported the use of a semirigid or inflatable penile pros~ effects may thesis for the treatment of neurogenic i m p ~ t e n c e . ~Side include infection with subsequent removal of the prosthetic implant, erosion and, extrusion. Several third party payers refuse to reimburse patients for the d e ~ i c e . ~ - ” * ’ ~ In this study, 30 patients underwent a trial of VTCT therapy for erectile dysfunction. Following the counseling and training program, 17 of the 30 chose to purchase the VTCT device, although all 30 patients had satisfactory erections by using the VTCT. At follow-up, 53% of the patients were still actively using the VTCT and reported no complications such as urinary tract infection. Swollen testicles and petechial hemorrhage-if they appeared-were a temporary problem. Side effects were never cited as a reason for not buying the VTCT. Evaluation of the demographic data shows that the cerebral vasular accident patients were the oldest patients; this may partially explain their low motivation to buy and use the VTCT. All of the patients who purchased the VTCT were married or single and involved in a monogamous relationship. Single men involved in a monogamous relationship who were first beginning the adjustment process quit the trial when their relationship foundered. Patients who reported engaging in sexual activity prior to using the VTCT engaged in oral or manual sex. With the VTCT, they engaged in sex with penetration. Sexual response was affected prior to the use of the VTCT because these patients could not have intercourse and thus function “normally.” Sexual desire increased with VTCT use as a result of regaining the ability to achieve and maintain an erection. Patients’ motivation to initiate sexual encounters increased, as did their sexual activity. Increased satisfaction was reported by their partners, which resulted in increased frequency of intercourse. The difference between partner and patient satisfaction may have been due to the fact that, for the partner, once the patient was able to have an erection, coitus appeared normal. Some of our patients have no sensation in their genitals due to their disability, and the VTCT cannot change that. Thus for them, although they may have felt better psychologically, physically, coitus was still less satisfactory than it was for their partner.
’”
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.]ournal of SQX& Marital Therupy, Vol. 18. No. 3 , Fall 1992
Independence in putting on and removing the VTCT played an important role in patients' decisions t o purchase and use the device. T h e data indicate that patients with good bilateral upper extremity functioning, such as those with diabetes melitus paraplegia and paraparesis, had a higher rate of purchasing the device than those in the other diagnostic categories. T h e hemiplegic patient who uses the VTCT has good use of both upper extremities. Although the patients had been taught to use the V'I'CT as a part of foreplay, only one patient reported doing so. Other patients chose to use the VTC'I' independently in the bathroom or in the bedroom prior to initiating sexual activity (see Table 2). I t seems that most patients wanted to minimize their partner's involvement and awareness of the VTCT as an aid so that they appeared to be functioning normally. T h e partners cooperated with this attitude, none of them insisted in getting involved at that stage of use of the device. Those patients that needed their partner's assistance in putting on or removing the device did not use the VTCT on a long-term basis. Thus, for these patients, neither injection therapy nor the inflatable prosthesis would be considered suitable. The patient's mate played an important role in deciding whether to purchase the device. Thus, the importance of counseling both the mate and the patient must be emphasized. Resistance by the patients to having their mates involved in counseling has been reported. Therapists should also be aware that spouses may regard erectile dysfunction as their mate's problem and may resist counseling. We suggest that VTCT should be considered as another option in the management of patients with chronic neurogenic impotence, in conjunction with an intensive sexual counseling program including both the patient and his partner. Although some patients may prefer and benefit from the other methods, which are invasive, VTCT is recommended as another option, which can be more advantageous because it is noninvasive and totally reversible. REFERENCES 1. Kaplan HS: The Pvafuufionof stxual disordns. New York, Brunner/Mazel. 1983.
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