Apport de l’injection intracaverneuse de Prostaglandine E1 lors de la premiere consultation de l’impuissant: à propos de 414 cas

The authors report their experience of 414 injections of prostaglandin E1 (prostine). The diagnostic orientation between functional or organic impotence was assessed through questionaires and more particularly on the presence or absence of nocturnal or morning erections. The prostine reconditioning and self injection use techniques are precised: 80% of positive responses with better results in the oldest patients, whatever their medical antecedents. No relation between positive response to prostaglandin E1 and normal nocturnal erections could be found. Patients still presenting erections can present good or bad responses. This confirms the results previously given only allow us to put in evidence the good functional and anatomic state of cavernous bodies, without any etiological orientation (not mentioning the cases in which these self-injections reveal the presence of deformation, bend or fibrosis). The acceptance of self injection is low (30%) as well as a regular and prolonged medical observance (only 15%). This work confirms the low rate of local complications after repeated injections and the low rate of prolonged erections or priapism during Test 1. However, these possibilities must incite to prudence as for the generalization of this kind of treatment, out of specialized centers.     

Synthese de la table ronde: “Apport de la Prostaglandine E1 dans l’exploration et le traitement de l’impuissance”

Intracavernosal injections of prostaglandin E1 (PGE1) have induced positive erectile responses in 70% of subjects investigated. Mild pain was reported in 15% of cases, with only 5% describing the pain as annoying. Prolonged erections were uncommon and priapism extremely rare. No systemic or generalised complication has ever been reported in about 1500 subjects. Pharmaco-Döppler, using intracavernosal 10 μg PGE1 injections, and pharmacocavernosometry have been investigated. Self-administered injections are obviously of great interest due to the high prevalence of positive responses and absence of complications. Long-terme tolerance is excellent, far better than with other drugs. PGE1 has also been used, with favourable preliminary findings as a treatment for specific conditions, particularly venous leakage and intractable erectile failure with combined organic and psychogenic lesions. PGE1 is becoming progressively more important in the investigation and management of impotence, principally because of its reliability and innocuous nature.     

Apport de la Prostaglandine E1 dans l’exploration et le traitement de l’impuissance: A propos de 980 cas dont 510 traites par auto-injections

Since 1982, many substances have been injected intracavernosally to produce erections in impotent men. Because the first-generation drugs (phenoxybenzamine, papaverine) were associated with severe side-effects, including priapism and penile fibrosis, it was essential that a safe and effective substance be found for this application. In a series of 980 patient with erectile dysfunction who received prostaglandin E1 intracavernosal injections, 70 % developped an erection lasting more than 30 minutes with minimal side-effects. All the 510 men who entered a self-administration protocol were capable of engaging in intercourse and experienced no major sideeffects. Prostaglandin E1 is effective, safe and preferable to all other drugs currently used for intracavernosal injection.     

Succes des auto-injections intra-caverneuses de Prostaglandine E1 dans des cas d’impuissance par dysfonction veino-occlusive rebelles a la Papaverine

Erectile failure due to veno-occlusive dysfunction (venous incompetence) is generally thought to be resistant to auto-intra-cavernosal injection therapy. Because PGE1 recently emerged as a drug more potent than Papaverine, we tested it in 26 impotent patients presenting this condition. All of them had abnormal Nocturnal Penile Tumescence and Rigidity recording, a non rigid response to intracavernosal injection (ICI) of 80 mg papaverine, and abnormal pharmacocavernosometry (maintenance flow rate exceeding 30 ml/mn after 80 mg of papaverine). When tested with 20 μg of PGE1 and observed for 30 mn in our office, 16 out of 26 developped a rigidity seeming consistent with vaginal intromission, including full rigidity in 2. In several additional patients, partial or full rigidity was achieved after leaving the center. The patients who did not develop rigidity were retested with high dosages. Finally 19/26 developped a rigidity seeming consistent with vaginal intromission within 2 hours of an ICI of 20 to 60 μg of PGE1. Seven of those patients elected to try auto-ICI of 20 to 60 μg of PGE1. The treatment failed in 2. The 5 other ones were able to have intercourse after each ICI, but not without ICI. 2 achieved full rigidity, and 3 only partial rigidity. Papaverine failed in everyone. Until now they have performed about 250 ICI of PGE1, and the maximum follow-up is 18 months. No complications has been observed, including no priapism and no fibrotic nodule. PGE1 widens the possibilities of the auto-ICI therapy. It seems the first medical treatment effective in case of erectile failure due to severe veno-occlusive dysfunction, or at least the most powerful.     

Place de la prostaglandine E1 intra urétrale dans le traitement de l’impuissance érectile

Transurethral alprostadil (Muse) is an effective and safe treatment of erectile dysfunction. Nevertheless, the result after its exit on the US market two years ago were not as good as the investigational studies which claimed aroud 60% of sccess rate. In the litterature success rate were between 35% and 40% all together. The Muse had a better acceptance than the intra-cavernous injection despite a lower success rate (40 % v.s 75 %). Since Sildenafil came on the market, it seems that the place of Muse is reduced because comparative studies give better results for Sildenafil than Muse (70 % v.s 40 %) and of course with a better acceptance. Nevertheless there are absolute and relative counter-indications to the Sildenafil which could benefit to the treatment by Muse. All the comparative studies, IIC, v.s Muse and sildenafil v.s Muse will be studied in this article. In conclusion Muse should be used as an alternative and should remain an effective tool that must be available to all physicians dealing with erectile dysfunction, perhaps using new formula with a combination of alprostadil with an alpha-blocker.     

Facteurs psychologiques et conjugaux de l’impuissance: Toujours d’actualite

Although many cases of impotence are associated with “hidden” organic lesions undetectable by normal clinical assessment, and only detectable by paraclinical examination, it is obvious that interactions between psychological and factors often prevail in such cases. The paper describes the main psychological factors implicated in impotence, as well as recent data wich start to provide an explanation of the mechanisms by which psychological factors perturb sexuality. At the peripheral level, stress-induced sympathetic hyperactivity probably inhibits erection by causing contraction of the cavernosal smooth muscle. At a central level, animal experimentation and results from the pharmacological treatment of human impotence, suggest that psychological factors might inhibit sexual drive, and perhaps erection, through α 2—adrenergic receptors and the hypersecretion of endogenous opioids. These data open some highly stimulating pharmacological pespectives.     

Etat des traitements chirurgicaux de l’impuissance

The current status of the various surgical alternatives in the treatment of impotence is reviewed. Microsurgical techniques for arterial revascularization succeed in 70 to 87% of cases with a mean follow-up of 48 months. In cases of venous incompetence, arterialization of the deep dorsal vein gives the best, most long-lasting results. Penile prostheses have benefitted from continual technological advances with inflatable prostheses providing the best cosmetic appearance. Mechanical failures are now rare, but the cost of prostheses remain high. Vascular surgery continues to be the first option by virtue of its being physiological, and not compromising other procedures such as self-administered injections, vacuum or penile prostheses.     

Resultats preliminaires d’injections intracaverneuses d’un donneur d’oxyde d’azote (NO), la linsidomine,dans le traitement de l’impuissance

Recent experimental studies showed an important role of endothelium derived relaxing factor (EDRF) for cavernous smooth muscle relaxation. Since nitric oxide (NO) seems to account for the biological actions of EDRF, a study was done to examine a possible role of the NO-donor SIN-1 in the treatment of erectile dysfunction. To determine the therapeutic range, 0.1, 0.2, 0.5 and 1 mg SIN-1 were injected intracavernously in 2 patients with erectile dysfunction each. Then, 40 patients were injected 1 mg SIN-1 including 4 patients that had prolonged erections to minimal doses of papaverine-phentolamine and 4 patients that did not respond with a full erection to other pharmacologic agents. Intracavernous injection of SIN-1 induced a dose dependent erectile response by increasing the arterial inflow and relaxing cavernous smooth muscle. To 1 mg SIN-1, 19 patients had a full, 14 an almost full and 7 a moderate erection. There were no systemic or local side effects. In the patients with prolonged erections to papaverine-phentolamine, the mean duration of a full erection to SIN-1 was 68 minutes. Compared to a papaverine (15 mg/ml)-phentolamine (0.5 mg/ml) mixture, the erectile response to SIN-1 was superior in 8, comparable in 29 and inferior in 3 patients. Our preliminary data suggest a possible role of SIN-1 for the treatment of erectile dysfunction. The absence of prolonged erections by its spontaneous intracavernous decomposition, a maximal smooth muscle relaxation by a receptor independant action and its low cost indicate its potential to become a standard drug for intracavernous pharmacotherapy.     

Éléments d’une théorie générale de la croissance d’une population

In this paper, discrete models of reproduction are studied. In part one, definitions are given, particularly on order of the reproduction; part two concerns the growth of the population; part three, the phenomena of delay or acceleration; and part four, the consequences of mortality.      

Méthodologie d’évaluation de l’impact d’une formation sur la qualité de l’utilisation d’une nouvelle technologie

For health care professionals, training is critical to assure the patient safety. This paper is interested in the nurses training when a new technology is introduced in their work environment, and more particularly in the impact of the type of training on the quality of the new device use. This means that both the learned knowledge and their integration in the work environment have to be evaluated. Two types of training were compared through qualitative and quantitative indicators of the device used in the work situation. The results highlight a better satisfaction of learners and more effective results on the practice with one of the two trainings.     

Apports de l’acquisition TDM couplée à la scintigraphie pulmonaire dans l’exploration d’une suspicion d’embolie pulmonaire

Pulmonary embolism is a frequent disease difficult to diagnose because of heterogeneous clinical presentation. Pulmonary embolism diagnosis requires additional examinations, which are guided by clinical probability scores. The ventilation/perfusion scintigraphy is a validated technic in pulmonary embolism diagnosis strategies, which represents one of its most important indications. In the past years, the technique of scintigraphy evolved with the appearance of hybrid cameras, allowing the realization of tomoscintigraphy coupled with computerised tomodensitometry (CT). One of the major interests of this technique is the possibility of considering alternative diagnosis in case of negative result of scintigraphy. The purpose of this article is to offer nuclear medicine physicians a review of the alternative diagnoses that can be found during pulmonary ventilation/perfusion tomoscintigraphy according to the underlying scintigraphic and morphological abnormalities. In this review, we will first on diseases responsible for: a mismatch (pathological perfusion and normal ventilation), an inverted mismatch (normal perfusion and pathological ventilation) and for associated disorders in ventilation and in perfusion patterns (identically abnormal perfusion and ventilation). The final part will address some specific CT features that can be encountered on a low dose CT centered on thorax.     

Apport de l’échographie dans le bilan d’une infécondité masculine

Recent technical progress in ultrasound, particularly with respect to high-frequency linear probes and transrectal probes, now enables a very detailed morphological approach to the scrotal, prostate and surrounding structures, such as the seminal vesicles, the vas deferens and the ejaculatory ducts. For almost 20 years, in close collaboration with Male Sterility Center of Toulouse, we have carried out such examinations as part of infertility testing procedures, and we set out below the results of our experience. After a short anatomical reminder, we shall begin with an echographical study of the scrotum, followed by the prostate and its adjoining structures, pursuant to a transrectal examination. In the course of these two examinations, we shall consider the various pathologies that we have encountered, which have tended to be secretory with respect to the scrotum, and excretory in the prostate area, in order to determine the usefulness and importance of echographical examinations in male infertility.     

Test pharmacologique oral: Son interet dans l’impuissance a propos de 110 cas

A pharmacological oral treatment has been systematically prescribed for one month in 110 unselected impotents patients: Trazodone (75 mg/d) associated with Moxisylite (180 mg/d), + Trazodone (25 mg) and Moxisylite (60 mg) one hour before any sexual activity. While side effects were few, the recovery of a satisfactory sexual activity occured in 28% of cases, and an improvement of spontaneous erections alone in 42% more cases. No improvement occured in 30% of cases. Thus, this pharmacological oral test presents 3 interests: a) it makes easier both diagnosis and treatment of impotence by eliminating some moderate psychogenic impotences, b) it reduces both morbidity and cost of impotence investigation by reducing the number of performed tests, c) it underlines the role of oral treatment in impotence. To sum up, this pharmacological oral test should be used first, owing to its simplicity, its innocuity and its real efficiency.     

Impact diagnostique de la TEMP–TDM dans l’exploration des tumeurs endocrines

Image fusion using single photon emission computed tomography–computed tomography (SPECT–CT) associates functional and morphological images. This study evaluates the added value of SPECT–CT, obtained with a hybrid SPECT–CT gamma camera, on anatomic localization and diagnostic impact in assessment of endocrine tumours and pheochromocytomas.MethodSix months prospective study was undertaken including 33 consecutive exams encompassing 20 Somatostatin Receptor Scintigraphies (SRS) and 13 ¹²³I-meta-iodo-benzyl-guanidine (MIBG) scans. Two experienced nuclear medicine physicians independently analysed independently planar and SPECT images in a first time, then, SPECT–CT fused images in a second time. They evaluated two parameters: SPECT–CT impact on anatomic localization (LA) and its diagnostic impact (ID). Each parameter was scored according three levels of evaluation.ResultsAn added value of SPECT–CT images was evidenced in 55% of cases on the anatomic localization and in 41% of the patients on the diagnostic impact. Therefore, a more important benefit was noted when SPECT was positive (LA: 90%; ID: 70%) than when it was negative (LA: 15%; ID: 8%). Furthermore, the added value proved higher for the SRS compared to MIBG scans.ConclusionSPECT–CT fusion images obtained by a hybrid system is more relevant to determine anatomic localization and more accurate than SPECT alone, particularly in the assessment of endocrine tumours. The added value of SPECT–CT seems to be lower for MIBG scans in the assessment of pheochromocytomas.     

Indications d’une étude méiotique dans l’infertilité masculine

Meiotic investigation is rare in male infertility. Now, some mutations affecting spermatogenesis exhibit characteristic cytogenetic figures, whereas testicular histology does not show specific aspects of this pathology. In male infertility with abnormal somatic caryotype, the aim of meiotic survey is to find the mechanisms inducing spermatogenic failure, and thus to lead to a better understanding of normal spermatogenesis. In addition to cytogenetic techniques, meiosis is also investigated by electron microscopy and molecular biology. Also, we think that a larger place must be grant to meiotic study in male infertility evaluation when the indication of testicular histopathology was settled.