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Aims: To compare patient compliance with treatment and the dosages of vaso-active drugs used, for the management of impotence in diabetic and non-diabetic patients., Methods: Eighteen diabetic and a control group of 22 non-diabetic men were followed up regularly for 7 years after they had begun self-injections for severe erectile dysfunction. Rigiscan was used for the objective determination of the initial dosage and then doses were regulated in order to introduce an erection suitable for penetration and maintenance of erection for 30 min., Results: Sixteen of 18 diabetic men are still using self-injections successfully after 7 years while of the 22 non-diabetic men, only 7 still continue injections. Compliance of diabetic men with treatment is significantly higher compared to the control group (p = 0.001). Doses of prostaglandin E(1) (PGE(1)) or mixtures of PGE(1) and papaverine (PAP) had to be increased over time. Although self-injections were a safe kind of treatment and no major complications were observed in both groups, a decrease in the frequency of injections was observed, particularly in the diabetic group, but this was not statistically significant (p = 0.15)., Conclusions: Diabetic patients with severe erectile dysfunction have much higher compliance with self-injections than the non-diabetic patients. They respond initially to reasonable doses of PGE(1) but over time need increasing doses of PGE(1) or mixtures of PGE(1) and PAP. Frequent follow-up visits and the adjustment of dosage to continue the success of therapy may prevent patient dissatisfaction and drop-out from treatment. Patients treated with self-injections decrease the frequency of injections over time. They are satisfied with less frequent but successful intercourse and have a low risk of side-effects.

Objective: The aim of the present study was to evaluate the therapeutic potency of an electrotherapy of striated ischiocavernous muscles in patients with erectile dysfunction., Patients and Methods: Transcutaneous electrostimulation of striated ischiocavernous muscles by self-adhesive penile or perineal skin electrodes was performed in 48 patients with erectile dysfunction. 6/48 patients (R) responded to intracavernous pharmacotherapy while 42/48 (NR) did not show significant penile rigidity even to intracavernous papaverine/phentolamine/PGE1 triple drug medication., Results: Within the observation time of 3 months, 10/48 patients dropped out. 22/38 patients reported a penile rigidity for sufficient sexual intercourse whereby 3/22 NR required additional intracavernous pharmacotherapy. Penile rigidity could be objectivated by triple drug medicaton in 12/14 NR after ischiocavernous muscle stimulation (EIS) therapy. 5/6 R were treated successfully for premature erection loss. During EIS treatment neither discomfort nor complications could be observed., Conclusion: Transcutaneous electrostimulation of ischiocavernous muscles is a new, noninvasive therapy for the improvement of penile rigidity. The clinical results underline the importance of the striated ischiocavernous muscles for penile rigidity.

Thirty-eight men aged 26-69 years (mean 58) who failed to achieve a full, sustained erection with intracavernosal injections of papaverine and phentolamine (PIPE) and who had evidence of a venous leak on digital subtraction dynamic cavernosography underwent penile vein ligation. Postoperative follow-up ranged from 7 to 44 months (mean 28). Nineteen patients regained spontaneous erections which would allow intercourse (mean follow-up on these men was 23 months). Of these 19 patients, 5 experienced recurrent loss of potency over a 6- to 17-month period (mean 9 months), 4 of these subsequently responding to intracavernosal therapy. Of the 19 without full erections after ligation, 8 obtained erections which would allow intercourse with intracavernosal injections. Two of these patients subsequently lost their response to injections at 2 and 6 months postoperatively. Eleven men had no benefit from surgery (either with or without injections). Of the total of 27 men with erections allowing intercourse, only 19 made an attempted coitus during the follow-up period. Of 9 men with treatment failure who had undergone repeat cavernosography, 8 had evidence of a persistent leak, usually arising from the cavernosal veins. At the time of this study, 4 men had been re-explored, following which 3 obtained erections with the aid of PIPE. Patients who fail to improve following ligation may benefit from re-investigation and repeat ligation using a different surgical approach.

At certain centers, microsurgical penile revascularization, using different surgical techniques, has gained importance throughout the past years. In general, only patients classified as intracavernous injection nonresponders are subjected to this kind of surgery. Since 1988, revascularization surgery has been performed at our clinic on 19 intracavernous injection nonresponders. The Hauri technique was carried out on the first 6 patients. The last 10 patients underwent modified anastomosis surgery. The inferior epigastric artery and the dorsal penile artery are anastomosed, one behind the other, end-to-side, to the dorsal penile vein. This results in a more simple procedure with assurance of flow. The Virag technique was performed on 3 patients. 18 patients achieved erections with or without the aid of intracavernous injections (at a mean follow-up of 13.4 months). 11 patients were capable of spontaneous erections, whereby it was particularly noted that 8 of the 10 patients undergoing the modified technique achieved spontaneous erections. The results demonstrate that intracavernous injection nonresponders benefit from revascularization surgery.

The diagnosis and treatment of male impotence have been radically modified by the introduction of intracavernous injections of papaverine. Papaverine treatment can solve more than 70% of male impotence cases, so that the real clue to the diagnosis of impotence is to discriminate between patients who can be treated by papaverine alone and patients deserving thorough investigation. The association of papaverine injection plus video sexual stimulation for this purpose was adopted in our last 250 unselected patients and represents a valuable tool. 115 of 250 achieved successful treatment for their impotence according the following percentages: intracavernous papaverine injections at the practice or at home 75.8%; prosthesis, 19.1%; venous surgery, 3.4%, and arterial surgery, 1.7%.

156 patients undergoing intracavernosal autoinjection pharmacotherapy for periods of 2-36 months were studied for the effect of treatment on self-esteem, performance anxiety, partnership and acceptance using a semi-structured questionnaire. Replies were received from 86.3% of the patients. 93% gave a very good, good or satisfactory rating of intracavernosal pharmacotherapy. 78.2% indicated that their self-esteem had grown. 79.4% said that performance anxiety diminished in the course of therapy (25.6%) or disappeared entirely (53.8%). 71.8% of the replies confirm the positive effect of treatment on marital relations or partnership. 61.9% of the patients used intracavernosal pharmacotherapy permanently. 28.3% needed therapy intermittently or at large intervals only, and 4.5% (7 patients) were cured of their chronic sexual dysfunction. When preceded by thorough multidisciplinary diagnostics and careful patient selection, intracavernosal pharmacotherapy constitutes an efficient mode of treatment for chronic erectile dysfunction.

A case of loclaised penile corporeal fibrosis is described in a psychogenically impotent diabetic, following a short course of self-injection therapy with papaverine. The possible aetiology and implications of this complication are discussed together with the need to obtain informed written consent from patients undergoing this form of treatment.

Pelvic trauma, especially when complicated by a posterior urethral disruption, may cause impotence in 50% of patients. The treatment of this kind of impotence has always been troublesome for the urologist. In fact penile prostheses or the revascularization procedures have sometimes been failures. We present a series of 6 patients with impotence after pelvic trauma managed by intracavernous injection of papaverine and we describe here the preliminary results obtained.

Intracavernous administration of papaverine and phentolamine has become an essential and indispensible element in the diagnosis and treatment of erectile dysfunction. This paper assesses the frequency and meaning of the main side effects of intracavernous injections (prolonged erections, fibrosis, etc.). It is concluded that the benefit from this new method definitely exceeds the possible risks. However, for the safe implementation of this method, close and intensive cooperation between the physician and his patient is a condition that has to be guaranteed. Each patient carrying out autoinjection therapy has to be examined at reasonable intervals to evaluate the to date unknown effects of long-term therapy.

Six methods for prevention of renal arterial vasospasms, due to extensive surgical trauma are compared in an experimental study in rats. The 'proximal transit time' was chosen as a measure for renal arterial flow 1, 5, 10 and 15 min after a standard surgical trauma. Xylocaine infiltration around the renal pedicle was least effective. Hydration of the rat, preoperative mannitol perfusion, and preoperative phenoxybenzamine treatment gave comparable effects and were significantly better than no treatment. The topical application of papaverine (1 mg/kg) around the renal pedicle did significantly better than the above-mentioned methods. The most effective treatment, however, was the combination of hydration, mannitol perfusion and papaverine application around the renal pedicle.

Thirty-three patients with erectile failure were taught to self-inject papaverine intracavernosally. The dose was from 15 to 80 mg. Phentolamine was added if 80 mg was not sufficient. The patients kept a diary on the effects of the regimen, and also filled out a questionnaire after a follow-up of 4-16 months. The results showed that 55% were satisfied with the method. However, technical difficulties were common. Sexual stimulation turned out to be very important resulting in varying erections on consecutive occasions with the same papaverine dose. Prolonged erection occurred once in 5 patients and was easily handled conservatively in all. Fibrous plaques developed in 2 patients. Twelve patients (36%) stopped the injections for various reasons. When failure occurred the disappointment was usually severe. Thus, the selection of patients for self-injection is important.

From October 1985 to June 1986 we have treated 82 impotent patients. We related their penis-brachial pressure index (PBPI) with the dosage of papaverine necessary to obtain a full erection as measured by tumistore. We describe the technique and the relationship between the PBPI and the dose of papaverine necessary for the erection; in this way PBPI should be used as guide for the dosage of intracavernous papaverine injection.

A new device for the autoinjection of papaverine into the corpus cavernosum for the treatment of impotence is described. Its use is much easier than conventional tuberculine syringes.