TRAUMA, AND GENITAL AND URETHRAL RECONSTRUCTION
250
Re: Women’s Expectations and Experiences of Hormone Treatment for Sexual Dysfunction E. Fooladi, R. J. Bell, A. M. Whittaker and S. R. Davis Women’s Health Research Program, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia Climacteric 2014; Epub ahead of print.
Abstract available at http://jurology.com/ Editorial Comment: There is a paucity of information regarding the expectations of women regarding medical treatment for female sexual dysfunction (FSD) and their self-appraisal of treatment outcomes. First time attendees to an endocrinologist with the complaint of sexual difficulties were identified and invited to participate in an in-depth interview on the same day as (but before) the medical consultation. Followup telephone interviews took place 3 to 4 months later. A total of 17 women 26 to 70 years old participated in the face-to-face interview. Of these women 10 participated in the followup interview. Major themes that emerged from the patient narrative stories were 1) the personal psychological distress associated with FSD, 2) concern about the adverse effect of FSD on the relationship with the sexual partner, 3) a belief in a relationship between FSD and “hormone deficiency,” and 4) an expectation of treatment that included positive physical and sexual changes. These data provide guidance to the clinician treating women with FSD. Allen D. Seftel, MD
Trauma, and Genital and Urethral Reconstruction Re: A Guide for Inflatable Penile Prosthesis Reservoir Placement: Pertinent Anatomical Measurements of the Retropubic Space G. Henry, W. Hsiao, E. Karpman, A. J. Bella, R. Carrion, L. Jones, B. Christine, E. Eisenhart, M. A. Cleves and A. Kramer Regional Urology, Shreveport, Louisiana J Sex Med 2014; 11: 273e278.
Abstract available at http://jurology.com/ Editorial Comment: Not surprisingly, patients with altered pelvic anatomy from prior surgery often present challenges during reservoir placement or removal. This study is a clever review of the important anatomical male pelvic relationships at play during inflatable penile prosthesis “blind” reservoir placement from a penoscrotal approach, which was based on dissections on several dozen cadavers. Such anatomical data are rare in the published literature. The authors indicate that the external inguinal ring (the gateway for reservoir placement) is only 2.5 to 4 cm away from the external iliac vein, and a similar distance from the filled bladder. These short distances are important for all implanters to remember. The authors suggest that Trendelenburg positioning may increase these distances slightly and is thus recommended during reservoir placement. Allen F. Morey, MD
TRAUMA, AND GENITAL AND URETHRAL RECONSTRUCTION
251
Re: Outcomes of Abdominal Wall Reservoir Placement in Inflatable Penile Prosthesis Implantation: A Safe and Efficacious Alternative to the Space of Retzius D. S. Stember, B. B. Garber and P. E. Perito Department of Urology, Beth Israel Medical Center of Mount Sinai Health System, New York, New York J Sex Med 2014; 11: 605e612.
Abstract available at http://jurology.com/ Editorial Comment: The experience of Perito with inflatable penile prosthesis reservoir placement in nearly 3,000 patients represents a significant contribution to the literature. Included is his favorable experience with reservoir placement above the transveralis fascia in more than 400 cases. He has noted a slightly higher revision rate due to palpability/bother/herniation in the submuscular reservoir cases but the technique has been proved to be safe otherwise compared to space of Retzius procedures, especially in cases having hostile pelvic anatomy. The introduction of flat reservoirs to the market by AMSÔ and Coloplast beginning in 2011 makes alternative locations and techniques a viable option. Our own experience with submuscular reservoir placement in more than 200 cases has been similarly favorable. This report offers important additional evidence that reservoir placement anterior to the transversalis fascia should no longer be considered “off label.” Allen F. Morey, MD
Re: Prevention of Recurrent Ischemic Priapism with Ketoconazole: Evolution of a Treatment Protocol and Patient Outcomes M. P. Hoeh and L. A. Levine Department of Urology, Rush University Medical Center, Chicago, Illinois J Sex Med 2014; 11: 197e204.
Abstract available at http://jurology.com/ Editorial Comment: Recurrent ischemic priapism is a troublesome clinical problem with no clear standardized treatment algorithm. Many cases occur in conjunction with sickle cell disease. This report is an important contribution to the literature that suggests a potential means of effective oral medical management. Patients with recurrent ischemic priapism often experience prolonged sleep related erections, a process that appears to be substantially influenced by androgens, more so than ordinary erections arising due to tactile and/or visual erotic stimuli during waking hours, which are relatively androgen independent. Ketoconazole (KTZ) is an antifungal drug known to inhibit androgen production in the testicle and adrenal gland. High dose KTZ (400 mg 3 times daily) is a standard treatment option for advanced prostate cancer and is typically given with 5 mg prednisone to prevent adrenal insufficiency. Low dose KTZ (200 mg daily) has been shown to decrease total and free plasma testosterone levels to 60% below baseline within 4 to 8 hours, followed by a return to basal values within 24 hours. In this study more than 90% of patients had complete resolution of priapism while on treatment. Effects were noted immediately after therapy was started, and no sexual side effects were attributable to KTZ. A majority of patients remained priapism-free when the medication was stopped after 6 months. Costs of an emergency visit due to priapism have been estimated at roughly $2,000 and more than $40,000 if hospitalization is required. Conversely a 1-month regimen of generic KTZ costs roughly $20. The take home message is that KTZ appears to be a cost-effective means of managing this difficult problem. Allen F. Morey, MD
250
Re: Women’s Expectations and Experiences of Hormone Treatment for Sexual Dysfunction E. Fooladi, R. J. Bell, A. M. Whittaker and S. R. Davis Women’s Health Research Program, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia Climacteric 2014; Epub ahead of print.
Abstract available at http://jurology.com/ Editorial Comment: There is a paucity of information regarding the expectations of women regarding medical treatment for female sexual dysfunction (FSD) and their self-appraisal of treatment outcomes. First time attendees to an endocrinologist with the complaint of sexual difficulties were identified and invited to participate in an in-depth interview on the same day as (but before) the medical consultation. Followup telephone interviews took place 3 to 4 months later. A total of 17 women 26 to 70 years old participated in the face-to-face interview. Of these women 10 participated in the followup interview. Major themes that emerged from the patient narrative stories were 1) the personal psychological distress associated with FSD, 2) concern about the adverse effect of FSD on the relationship with the sexual partner, 3) a belief in a relationship between FSD and “hormone deficiency,” and 4) an expectation of treatment that included positive physical and sexual changes. These data provide guidance to the clinician treating women with FSD. Allen D. Seftel, MD
Trauma, and Genital and Urethral Reconstruction Re: A Guide for Inflatable Penile Prosthesis Reservoir Placement: Pertinent Anatomical Measurements of the Retropubic Space G. Henry, W. Hsiao, E. Karpman, A. J. Bella, R. Carrion, L. Jones, B. Christine, E. Eisenhart, M. A. Cleves and A. Kramer Regional Urology, Shreveport, Louisiana J Sex Med 2014; 11: 273e278.
Abstract available at http://jurology.com/ Editorial Comment: Not surprisingly, patients with altered pelvic anatomy from prior surgery often present challenges during reservoir placement or removal. This study is a clever review of the important anatomical male pelvic relationships at play during inflatable penile prosthesis “blind” reservoir placement from a penoscrotal approach, which was based on dissections on several dozen cadavers. Such anatomical data are rare in the published literature. The authors indicate that the external inguinal ring (the gateway for reservoir placement) is only 2.5 to 4 cm away from the external iliac vein, and a similar distance from the filled bladder. These short distances are important for all implanters to remember. The authors suggest that Trendelenburg positioning may increase these distances slightly and is thus recommended during reservoir placement. Allen F. Morey, MD
TRAUMA, AND GENITAL AND URETHRAL RECONSTRUCTION
251
Re: Outcomes of Abdominal Wall Reservoir Placement in Inflatable Penile Prosthesis Implantation: A Safe and Efficacious Alternative to the Space of Retzius D. S. Stember, B. B. Garber and P. E. Perito Department of Urology, Beth Israel Medical Center of Mount Sinai Health System, New York, New York J Sex Med 2014; 11: 605e612.
Abstract available at http://jurology.com/ Editorial Comment: The experience of Perito with inflatable penile prosthesis reservoir placement in nearly 3,000 patients represents a significant contribution to the literature. Included is his favorable experience with reservoir placement above the transveralis fascia in more than 400 cases. He has noted a slightly higher revision rate due to palpability/bother/herniation in the submuscular reservoir cases but the technique has been proved to be safe otherwise compared to space of Retzius procedures, especially in cases having hostile pelvic anatomy. The introduction of flat reservoirs to the market by AMSÔ and Coloplast beginning in 2011 makes alternative locations and techniques a viable option. Our own experience with submuscular reservoir placement in more than 200 cases has been similarly favorable. This report offers important additional evidence that reservoir placement anterior to the transversalis fascia should no longer be considered “off label.” Allen F. Morey, MD
Re: Prevention of Recurrent Ischemic Priapism with Ketoconazole: Evolution of a Treatment Protocol and Patient Outcomes M. P. Hoeh and L. A. Levine Department of Urology, Rush University Medical Center, Chicago, Illinois J Sex Med 2014; 11: 197e204.
Abstract available at http://jurology.com/ Editorial Comment: Recurrent ischemic priapism is a troublesome clinical problem with no clear standardized treatment algorithm. Many cases occur in conjunction with sickle cell disease. This report is an important contribution to the literature that suggests a potential means of effective oral medical management. Patients with recurrent ischemic priapism often experience prolonged sleep related erections, a process that appears to be substantially influenced by androgens, more so than ordinary erections arising due to tactile and/or visual erotic stimuli during waking hours, which are relatively androgen independent. Ketoconazole (KTZ) is an antifungal drug known to inhibit androgen production in the testicle and adrenal gland. High dose KTZ (400 mg 3 times daily) is a standard treatment option for advanced prostate cancer and is typically given with 5 mg prednisone to prevent adrenal insufficiency. Low dose KTZ (200 mg daily) has been shown to decrease total and free plasma testosterone levels to 60% below baseline within 4 to 8 hours, followed by a return to basal values within 24 hours. In this study more than 90% of patients had complete resolution of priapism while on treatment. Effects were noted immediately after therapy was started, and no sexual side effects were attributable to KTZ. A majority of patients remained priapism-free when the medication was stopped after 6 months. Costs of an emergency visit due to priapism have been estimated at roughly $2,000 and more than $40,000 if hospitalization is required. Conversely a 1-month regimen of generic KTZ costs roughly $20. The take home message is that KTZ appears to be a cost-effective means of managing this difficult problem. Allen F. Morey, MD
