Physiopathologie des troubles de l’érection chez l’homme paraplégique

Peripheral mechanisms responsible for penile erection are dependant upon a complex control by the nervous system, including peripheral nervous pathways, spinally mediated reflex loops and supraspinal nervous structures. Spinal cord injury is accompanied by a partial or a complete modification of these controls. In relation to the reflexogenic or psychogenic origin of penile erection, spinal cord injury does not cause the same effects. Reflexogenic erections sitll occur after spinal cord injury at a suprasacral level. After lesions at a level lower than the thoracolumbar spinal cord, tumescence following psychogenic stimulation has been observed. The hypotheses resulting from clinical and experimental observations and explaining the differences at the origin of these response are detailed. The recent developments in the neurophysiology of penile erection and the role of neurotransmitters allow a more analytical approach of the phenomenous and also bring new insights into possible compensatory pathways following spinal cord injury.     

Dosage de la testostérone plasmatique chez l’homme

The measurement of testosterone in plasma is the main tool to investigate the endocrine function of the testis. Radioimmunoassay of total testosterone using³H-testosterone as tracer, after steroid extraction and chromatography avoids the interactions of steroids and plasma proteins in the assay. It can be considered as a method of reference. Direct methods, without extraction and chromatography, and using non-radioactive tracers have been developped. They are easier and faster to perform but less accurate because of the aforementioned interactions. In the plasma, testosterone is mainly bound with a high affinity to SBP and with a low affinity to albumin. Non-SBP-bound testosterone is considered to represent the fraction of the testosterone available for target cells. Non-SBP-bound testosterone can be measured after precipitation of SBP by ammonium sulfate. This procedure is usefull to investigate androgenicity when plasma SBP concentrations are altered such as in hyperthyroidism, aging and severe exocrine testicular failure. Plasma free testosterone can be mesured by equilibrium dialysis, a procedure not suitable for routine assay or more easily but less accuratly by direct measurement in the plasma with methods using tracer analogs. The interpretation of testosterone measurement must take into account moment-to-moment and nycthemeral variations. The inter-subject variations of plasma testosterone concentrations are large, the decrease with aging is very progressive. Testosterone has a permisive effect on male sexual function with a threshold level above which no relationship between plasma testosterone concentration and sexual “performances” could be demonstrated. Because of the multifactorial control of human sexual function, the threshold value is difficult to determine for a given patient.     

Les théories de l’économie animale et l’émergence de la psychiatrie de l’Encyclopédie à l’aliénisme

The author analysesEncyclopédie’s articles devoted to nervous and mental functioning and disorders, showing that a new approach to lunacy as a mental illness, which is defined in some articles as a “general trouble of the animal economy”, progressively emerged. The term,animal economy, unified physical and moral aspects of the study of man. It was elaborated by XVIIIth century physiologists and was widely accepted by French physicians. This idea is based on the vitalistic thought of the Montpellier school, which equated life with sensibility, and on English medical conceptions of a nervous-centred organism. Later on Philippe Pinel’s work displayed the legacy of these conceptions. On one hand, the comprehensive view of physical and moral dimensions in theanimal economy neutralized the question of an organic or psychogenetic origin of madness. This enabled him to consider it as a determinate field of sensibility interactions and as a medical matter, and to legitimize the group of therapeutic practices that he namedtraitement moral. On the other hand, Pinel departed from the classical conception ofanimal economy by developing his concept of aprinciple of mania, which underlies the manifold symptoms and forms of madness, and which are only perceptible to a trained specialist (aliéniste). The historical development analysed in this article show how alienists were enabled to claim both the wholly medical nature of insanity as disease, and their specific competence as apart from the other medical disciplines. To this extent, Esquirol achieved Pinel’s scientific work.     

Le traitement actuel de l’impuissance chez le paraplégique

The author is summing up his 25 years experience in the treatment of paraplegics impotency to account for the present and almost continuous resulting use of self injections of vasoactive drugs. The sexual reeducation, based on the neurological level, that is to say on the physiopathology, has disappeared for 10 years, as the urinary reeducation has been replaced by self catheterism. Nevertheless, there are some education rules left for the paraplegics and the couple in the relationship as well as in the technique. Trying to obtain orgasm for the paraplegics has become a priority, since the erection is obtained easily through drugs. A reference is made to the vasoactive drugs that have been used and their effects. The behaviour is precise somewhat different in the case of the traumatic and total paraplegics as compared to the partial medical paraplegics (cauda equina, spina bifida, multiple sclerosis…) for whom psychology is different. The sensitivity deficiencies which are the same for all of them mustn’t make us forget that there are still reflex erogeneous spots that must be searched for.     

Prevention de l’infertilite d’origine infectieuse chez l’adolescent

Some causes of infertility can be prevented, as is the case for infertility of infectious origin. Genital infections represent a major source of infertility. Prostato-epididymitis consecutive to an urinary infection can be prevented by identifying and treating prostatic localizations at an early stage of urinary infection. The prevention of sexually transmitted diseases (STD), which cause male and female infertility, is, at the moment, accomplished by the prevention of the sexual transmission of the HIV. Teenagers represent a target of choice for the educational campaigns promoting condom use. The role of physicians, especially when teenagers are asking for a contraception, must be complementary to the public health campaign to decrease the spread of HIV and other STDs.     

Prevention de l’infertilite d’origine infectieuse chez l’adolescent

Some causes of infertility can be prevented, as is the case for infertility of infectious origin. Genital infections represent a major source of infertility. Prostato-epididymitis consecutive to an urinary infection can be prevented by identifying and treating prostatic localizations at an early stage of urinary infection. The prevention of sexually transmitted diseases (STD), which cause male and female infertility, is, at the moment, accomplished by the prevention of the sexual transmission of the HIV. Teenagers represent a target of choice for the educational campaigns promoting condom use. The role of physicians, especially when teenagers are asking for a contraception, must be complementary to the public health campaign to decrease the spread of HIV and other STDs.     

La part de l’analyse phénoménologique dans l’étude de cas singulier

We argue that clinical psychiatry oscillates between two epistemological poles: inference and perception. The inferential approach categorises illnesses bottom up, from visible symptoms to the pathological category supposedly causing them. In doing so, psychiatry moves away from the possible instantaneous perception of a patient, as well as from illness as a changing, evolving, phenomenon. From a phenomenological point of view, the perceptive approach enables the therapist, within an encounter, to experience the emergence of an impression of a patient’s overall bearing, or attitude. Thanks to épochè, a sense of form, Gestalt will emerge. The clinical case, nevertheless, is always a construction, an intersubjective narrative about illness, recounted by the patient. Creating a library of clinical cases leads to the development of case types, each becoming a reference to which future clinical cases can be compared and categorised as belonging to a clinical family; it is the participant with respect to Plato’s eidos. Phenomenology contributes to clinical experience in that it makes possible the link between perception and inference, between subjective experience and intersubjective narrative, and between person and case type.     

Stratégies biologiques à l’heure de l’Assistance Médicale à la Procréation chez le blessé médullaire

Most men with spinal cord injury (SCI) men have fertility problems caused by anejaculation and decreased fertility of the ejaculate. There are two main causes for the impaired reproductive potential in SCI men: ejaculatory dysfunction and poor quality semen. However, current treatment techniques allow a large number of SCI males to achieve ejaculation (rectal electro-stimulation, penile vibrator stimulation). Firstly, masturbation and/or penile vibrator are used at home allowing the couple to perform insemination themselves. The semen of men with spinal cord injuries has commonly been characterised by small volume, abnormal count (low or high), decreased sperm mobility, increased formation of reactive oxygen species, sperm autoimmunity, necrospermia. This impairment is thought to be due to insufficient drainage, genitourinary infections and raised scrotal temperature. Testicular biopsy reveals varying degrees of tubule degeneration and decreased spermatogenetic activity. Semen could be used for various assisted reproductive technologies such as intrauterine insemination,in vitro fertilisation (IVF) and microinsemination (ICSI). The literature reports pregnancy rates by intrauterine insemination of about 15 to 20% per couple. Clinical pregnancy rates after IVF and ICSI techniques are 30% per cycle and these results are comparable to the clinical pregnancy rates when these techniques are performed for female infertility. However, semen must be frozen as soon as possible after the injury and the patient must be informed about the various available assisted reproductive technologies.     

Métabolisme de l’Acide 2-Aminoéthylphosphonique (Ciliatine) chez le Poulet

For Podospora anserina, several studies of cellulolytic enzymes have been established, but characteristics of amylolytic enzymes are not well understood. When P. anserina grew in starch as carbon source, it accumulated glucose, nigerose, and maltose in the culture supernatant. At the same time, the fungus secreted α-glucosidase (PAG). PAG was purified from the culture supernatant, and was found to convert soluble starch to nigerose and maltose. The recombinant enzyme with C-terminal His-tag (rPAG) was produced with Pichia pastoris. Most rPAG produced under standard conditions lost its affinity for nickel-chelating resin, but the affinity was improved by the use of a buffered medium (pH 8.0) supplemented with casamino acid and a reduction of the cultivation time. rPAG suffered limited proteolysis at the same site as the original PAG. A site-directed mutagenesis study indicated that proteolysis had no effect on enzyme characteristics. A kinetic study indicated that the PAG possessed significant transglycosylation activity.     

Application de la technique de PCR en temps réel à l’étude de l’ADN ancien

Real-time Polymerase Chain Reaction (PCR) for the study of ancient DNA. The properties of ancient DNA (aDNA) make difficult the retrieval of DNA sequence. The advantage of Real-Time PCR was exploited, for the first time, in the study of aDNA. We determined the optimal condition to amplify, in one round of PCR, aDNA, which should be directly sequenced. Beside the verification of aDNA authenticity, we compared two cleaning bone methods: scalpel and ethanol. The ethanol specimens showed the best DNA yield. The aDNA was extracted and amplified (mitochondrial hypervariable region I) from five skeletons exhumed from the archaeological site of Notre-Dame-du-Bourg (France), dated from 3rd to 17th century. To cite this article: R. Kefi et al., C. R. Palevol 2 (2003) 125–132.     

Intérêt de l’abaissement du testicule non descendu chez l’adulte. Etude à propos de 259 patients

Introduction

Undescended testis is a frequent congenital disease, more often diagnosed and treated during childhood. However, due to ignorance or negligence, this disease can be seen even after puberty, when it raises a therapeutic problem: is orchidopexy still useful? This study was designed to evaluate the outcome of orchidopexy at adulthood in terms of improvement of fertility and prevention of malignant degeneration.

Material and methods

Retrospective study performed over a 23-year period (1983–2005). We have found 259 patients with undescended testis diagnosed and treated after the age of 18 years.

Results

The mean age of patients was 24 years (range: 18–63). In the majority of cases, undescended testis was diagnosed at a systemic medical examination in 199 patients (77% of cases), and in a context of infertility in 33 patients, testicular malignancy in 8 patients, testicular torsion in 2 patients and, in 17 cases, undescended testis had been known since birth but was neglected by the parents. Undescended testis was unilateral in 209 cases and bilateral in 50 cases. Out of 37 couples, only 4 gave birth to children (10.8% paternity rate). Sperm analysis was abnormal in all infertile patients. All patients were treated by orchidopexy, except for 36 patients in whom orchidectomy was performed due to testicular atrophy (27 cases), malignancy (8 cases) or necrosis (1 case). Biopsy of the intrascrotal testis was performed in 3 patients with unilateral cryptorchidism. Histological examination was normal in two cases and abnormal in one case. The long-term outcome was characterized by:

1. Testicular atrophy in 6 patients (2.7% of cases).
2. Progression to malignancy in 3 patients (1.3% of cases).
3. Improvement of sperm parameters in 16 of 33 infertile patients (48.5%); 4 patients fathered children after treatment.

Conclusion

Orchidopexy at adulthood can lead to improvement of infertility. It can also decrease the incidence of malignancy and facilitate clinical examination looking for possible malignancy. However, the best treatment remains preventive, based on early diagnosis and orchidopexy.     

Place de l’embolisation percutanée de la varicocèle dans le traitement de l’infertilité

Objectives

To describe percutaneous embolization of varicocele and to evaluate the effect on fertility disorders.

Materials and methods

One hundred nineteen patients, aged 11 to 48 years, underwent percutaneous embolization for varicocele indicated by a fertility disorder in 23% of cases. Correction of the varicocele and resolution of associated pain, improvement of testicular trophicity and the effect on fertility were studied and a review of the literature was performed.

Results

Percutaneous embolization was performed using neuroleptanalgesia on an outpatient basis. The technique combined venous sclerotherapy and placement of coils in the gonadal vein. The technique was successful in 95% of cases and one complication was observed. At 3 months, the varicocele and related pain had resolved in 98% of treated patients. According to previous reports in the literature, the relations between varicocele and fertility disorders are still unclear, but improvement of fertility (semen quality and conception rates) after varicocele repair has been established.

Conclusion

Although the consequences of varicocele on fertility have not been fully elucidated, treatment of varicocele appears to be beneficial. Percutaneous embolization of varicocele is a safe and effective alternative to surgery. This technique, based on a urological and radiological consensus, is the first-line treatment for varicocele in our institution.     

Reactivite thermique de la peau scrotale chez l’homme

Although the existence of heat exchange between the testicular artery and the adjacent veins is well known, it may be insufficient to maintain the lower temperature of the testis. In order to investigate the role of the scrotum in testicular thermoregulation, the dynamics of scrotal and other skin temperatures was studied in relation to thermal stress. The results of this study revealed that the scrotal skin exhibited a greater thermal inertia than did other skin areas. This finding may be due to modifications in scrotal blood flow patterns as temperature increased, as well as changes in the scrotal surface area. Other possible thermoregulatory factors may include the evaporation of sweat from the scrotum. In conclusion, there seems to be a complex collection of mechanisms, rather than a single specific mechanism, regulating testicular temperature.     

Aspects cliniques et biologiques de l’azoospermie chez l’homme infertile en Tunisie

Objective

It is now very important to investigate azoospermia because the introduction of the intracytoplasmic sperm injection technique during the last decade has allowed many infertile men to achieve their dreams of fatherhood. The purpose of this study was to define the characteristics of infertile men with azoospermia, and to analyse the clinical and laboratory features and the causes of infertility in Tunisia. The authors also discuss various aspects that they consider to be very important in the diagnosis of male fertility.

Material and Methods

This retrospective study analysed the parameters of physical examination, laboratory tests, semen analysis, radiographic examinations, testicular biopsy, karyotype and AZF microdeletions.

Results

Based on the results of endocrinological and cytogenetic examinations, the aetiology of azoospermia was considered to be secretory in 43 cases of azoospermia. Physical examination revealed a high percentage of hypotrophic/atrophic testes (43.9%). Serum follicle stimulating hormone levels were high in 58.5% of cases. The overall incidence of chromosomal abnormalities was 31.4%. The most frequent anomaly was Klinefelter syndrome (9 cases). Seven out of 28 patients (25%) with nonobstructive azoospermia had AZF deletions. None of the patients with excretory azoospermia and severe oligospermia had an abnormal karyotype or AZF microdeletions. 48.8% of patients presented a varicocele, 13.9% had cryptorchidism and 13.0% had a history of genital tract infection.

Conclusion

In line with the literature, genetic abmormalities are the main causes of severe forms of impaired spermatogenesis in the Tunisian population.     

Le principe de l’anonymat du donneur de gamètes à l’épreuve de son contexte. Analyse des conceptions juridiques de l’identité

This study clarifies the lively debate surrounding the anonymity of gamete donors. This principle, which has not been challenged since 1994, is currently criticized by a number of people, who were conceived through medically assisted procreation technologies with donor and who now have reached adulthood. Their testimony has a very significant impact on French public opinion. Several official reports have already suggested that the anonymity of gamete donors may well be removed under certain circumstances. To understand why public opinion has evolved so dramatically, we must revisit the legal position of gamete donors in the specific context of less visible changes in the law. Indeed, the legal concepts of parenthood and identity have been reshuffled over time, and such changes have deeply affected the legal issues relating to the anonymity of gamete donors. Formerly, the law governing the identification of individuals was shaped by political and social objectives. Now it is more concerned with the sense of identity and personal fulfilment of people. This change, based on modern western notions of egalitarianism and individuality, has dramatically affected the outcome of parenthood trials. Moreover, biological tests have made the truth available like never before. The possibility of finding out the truth has shocked the practice of many areas of family law and has created a new set of challenges, especially when the secrecy of the genetic parents has been legally established. In France, women have traditionally been able to deliver their children anonymously. A deadlock has resulted, which may now be overcome by introducing a new concept of personal origins. Now the law is evolving to permit the children to demand their biological mothers’ identity under certain circumstances, but without affecting anyone’s rights. The concept of personal origins has been quite successful on the European scene and has also charged the debate. It is now recognized under French and European laws that individuals must have privileged access to their personal origins. Can the principle of anonymity of gamete donors remain immune from such a (r)evolution ?     

Nouveaux sites paléolithiques de l’oasis de Djizak

The present paper is devoted to the study of Paleolithic settlements recently discovered in the territory of the Djizak Oasis. Some Paleolithic settlements such as Yangikichlak, Azimboulak, Gourdara 1, 2 and Shachmai-Doston were discovered at the roof of the Nourata mountain range in the Farich district. Their cultural layers are not conserved but the single discoveries testify to the presence of prehistoric human camps in the Upper Paleolithic period. The lithic assemblage from the sites of the Djizak Oasis has some similarities with the material coming from the Tachkent site complex and from the Samarkand drainage basin. The discovery of the settlements and their later studies fill gaps on the Paleolithic map of the region.