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The management of vasospasm associated with traumatic subarachnoid haemorrhage presents many challenges. We present a 20-year-old male admitted after sustaining a closed head injury complicated by a Fisher grade III traumatic subarachnoid haemorrhage. Despite treatment with intravenous nimodipine he developed a delayed ischaemic neurological deficit due to cerebral arterial vasospasm. The vasospasm was successfully managed with serial papaverine angioplasty.

In 24 patients there was studied up the preparation Nospa-forte efficacy in renal colic occurrence due to presence of calculus in ureter, basing on analysis of the pain syndrome dynamic, the heart rhythm changes, the central and systemic hemodynamics indexes, renal function and urinanalysis. There was established efficacy of the preparation in the pain syndrome removal, the blood circulation hyperdynamics reduction, the vegetative nervous system state optimization and the heart rhythm stabilization. It is expedient to use Nospa-forte in the treatment of various visceral pain.

Objective: To compare the effect of papaverine (PPV) by different routes of administration for the treatment of experimental acute cerebral vasospasm., Methods: A rabbit model of acute cerebral vasospasm induced by autologous blood injected into the basilar and prepontine cistern was used. The PPV (2mg/kg) was injected either by an intravenous (IV), intra-arterial (IA), intra-cisternal (IC), or combination of intra-arterial and intra-cisternal (IA+IC) routes. Basilar artery diameters were measured before and after vasospasm was induced and after PPV treatment., Results: Induction of vasospasm reduced basilar artery diameters by more than 50% in all animals. Compared to artery diameters before vasospasm, diameters after PPV treatment via the IV route were only reduced by 0.5+/-4.7%. Other reductions in the diameter included 29.1+/-10.4%, about 1.8+/-3.1%, and about 26.7+/-8.4% in the IA, IC, and IA+IC groups, respectively. However, IA administration of PPV caused obvious side effects., Conclusion: Intra-arterial application of the PPV was the most effective way to treat vasospasm in this study. The efficacy of IC route in our study did not confirm the results of prior study. The possibility of side effects of PPV via the IA route should be considered before clinical application.

Successful treatment of superior mesenteric artery embolism depends on an aggressive approach in patients at risk for mesenteric ischemia. This approach favors an early diagnosis and permits the reestablishment of arterial flow within an appropriate time, with prevention of vasospasm and control of organic insufficiencies. We report here a case of superior mesenteric artery embolism in which arterial flow was reestablished by selective intra-arterial infusion of streptokinase. The literature has reported 18 similar cases thus far. This procedure could be an alternative to embolectomy in selected patients, i.e., patients with an early diagnosis, no evidence of intestinal necrosis and with partial occlusion and/or occlusion of secondary branches of the superior mesenteric artery. Frequent arteriographies and intensive care are necessary in this approach. The patient should be continuously monitored because of the possibility of treatment failure and the need for embolectomy.

Erectile dysfunction (ED) is a common problem with a prevalence of approximately 50% in men aged 40 to 70. There are several etiologies for ED including vasculogenic, neurogenic, hormonal and/or psychogenic factors; one-fourth of ED cases can be drug-related. Penile erection involves a complex interaction between the CNS and local factors. It is a neurovascular event modulated by psychological and hormonal factors. Pharmacologically, neural modulation and endocrine status are very important to attaining penile erection. There have been several significant advances for the pharmacologic treatment of ED. Treatments include agents that are not only orally effective, but possess either local or central acting mechanisms of action. Apomorphine, a centrally-acting agent, is effective in the treatment of ED. Sildenafil, another orally effective agent, acts by inhibiting cyclic GMP-specific phosphodiesterase Type V. Testosterone can be effective transdermally. Non-orally active agents include alprostadil and papaverine. Phentolamine and trazodone are effective in selected cases. Some agents can interact with other medications. Several pharmacological agents, some with central-acting mechanisms and some with Iocally-acting vascular effects, are therapeutically useful in the treatment of ED.

Unlabelled: Despite recent advances in the management of aneurysmal subarachnoid haemorrhage delayed ischaemic deficits from cerebral vasospasm remains a major cause of morbidity and mortality. As magnesium is a potent cerebral vasodilator we have introduced routine supplementation in patients presented with subarachnoid haemorrhage to determine whether there has been a reduction in the incidence of cerebral vasospasm., Method: All patients presented with aneurysmal subarachnoid haemorrhage from February 1997 were included except those who presented after day 5 following bleed. Identical management protocol was used except intravenous magnesium supplementation which was introduced to all patients from May 1999. Incidence of cerebral vasospasm on angiograms among the two groups was analysed., Results: Seven out of 10 patients who did not receive magnesium supplement developed vasospasm requiring intra-arterial papaverine compared with 2 of 13 patients among the treated group (P<0.008)., Conclusions: From our pilot study it appears that magnesium supplement has a beneficial role in the prevention of cerebral vasospasm following aneurysmal subarachnoid haemorrhage. Further studies would seem justified., (Copyright 2002 Elsevier Science Ltd. All rights reserved.)

Gastrointestinal complications after extracorporeal circulation are rare but well known complications. We describe and illustrate 2 patients with occlusive intestinal ischemia of different origin presenting after cardiopulmonary bypass (CPB) and present the different therapeutic algorithm.

Oral therapy has become first line treatment for patients with mild to moderate erectile dysfunction (ED). Studies have shown that sildenafil may not be effective in all patients, and has been associated with a variety of adverse effects and an adverse interaction with nitrates and inhibitors of cytochrome P450 enzymes. The objective was to compare the efficacy and safety of three different oral combinations with the highest dose of sildenafil in men with moderate to severe ED. Randomized, double blind, unblinded active-controlled, Phase II study was carried out at three sites in Mexico. After a 4-week placebo run-in period, patients received all four of the following treatments using a 4-way cross-over design: 40 mg phentolamine (PM) +6 mg apomorphine (Apo); 40 mg PM +150 mg papaverine (Pap); 40 mg PM +6 mg Apo +150 mg Pap (Tricombo); 100 mg sildenafil (SC). With the exception of sildenafil tablets, all study medication was blinded. Moderate to severe ED was defined as a less than 50% vaginal penetration success rate during the placebo run-in period. A total of 44 patients were enrolled, of whom 36 completed all four treatment periods. All treatments produced a significant effect in primary efficacy variable (Sexual Encounter Profile) compared to baseline, however, no statistically significant differences were found between treatments. A significant period effect was observed. Also, the four treatments were found not to differ significantly in five out of six secondary efficacy variables. The lowest incidence of treatment-related adverse events (AE) occurred in the 40 mg PM +6 mg Apo group (9.8%), followed by 100 mg SC (15%), and the other two combinations (16.7 and 17.5%, respectively). Nasocongestion and headache were the most frequently reported AE. An oral combination of vasoactive agents may provide an alternative approach to sildenafil. Based on these results a combination of phentolamine and apomorphine warrants further clinical investigation.

The aim of this study was to evaluate the effectiveness of a progressive program for the treatment of erectile dysfunction in patients with cardiovascular disease in whom sildenafil citrate (Viagra) was not an option. The study population included 106 patients selected from 267 with cardiovascular disease. The intracavernous injection program consisted of three protocols of increasingly complex combinations of vasoactive drugs, papaverine, phentolamine, prostaglandin E1 and atropine sulfate. Patients who failed the first protocol were switched to the second, and those who failed the second were switched to the third. A positive response was defined as an erection sufficient for vaginal penetration. A positive response was achieved on protocol I in 61 of the 106 patients (57.5%); protocol II in 32 of the remaining 45 patients (71.1%); and protocol III in seven of the remaining 13 patients (53.8%); the total success rate was 94.3%. These 100 patients were included in the 1-year follow-up, and 90 reported successful coitus at the end of that period: 79 patients (87.8%) with intracavernous injection and 11 (12.2%) without injection. The remaining 10 patients (10%) dropped out of the program, seven (7.0%) for health or marital reasons and three (3.0%) because of treatment failure. We conclude that a progressive program of intracavernous injections of vasoactive drugs may be a good alternative for the treatment of erectile dysfunction in patients with cardiovascular disease.

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.

Background: Microcatheter-guided intra-arterial (IA) papaverine infusion in conjunction with balloon angioplasty is an available therapy for patients with symptomatic vasospasm after subarachnoid hemorrhage (SAH) that is refractory to hypertensive, hypervolemic therapy. However, side effects and complications have been reported in association with its use., Case Description: We report on a patient who developed symptomatic vasospasm after subarachnoid hemorrhage due to rupture of a left terminal internal carotid artery (ICA) saccular aneurysm. Seven days after the hemorrhage and 4 days after surgical clipping, the patient developed aphasia and right hemiparesis due to vasospasm, which was refractory to maximal medical treatment with volume and blood pressure elevation. Cerebral angiography identified severe narrowing of distal ICA and proximal middle cerebral artery segments bilaterally. These findings partially resolved after balloon angioplasty. However, after 300 mg of IA papaverine, the patient developed generalized convulsions. This occurred despite therapeutic serum levels of phenytoin. Twenty-four hours later, after brief neurologic improvement, recurrent neurologic deficits prompted repeat papaverine administration. Seizures again occurred after the administration of 240 mg of IA papaverine and prevented administration of the full dose. The patient did not develop further seizures and her neurologic deficits continue to resolve., Conclusions: IA papaverine-induced seizures are infrequently reported. This potential complication should be considered when papaverine administration is entertained in the treatment of anterior circulation refractory symptomatic vasospasm after SAH.

In 43 cases with symptomatic cerebral vasospasm after aneurysmal subarachnoid hemorrhage treated by intraarterial infusion of papaverine (IAP), we studied cerebral hemodynamics by measuring cerebral circulation time (CCT) using digital subtraction angiogram. CCT on the middle cerebral artery site was defined as CCT-LAV and on the anterior cerebral artery side as CCT-MAV. In the CCT-LAV, two phases were further defined; the arterial phase (CCT-A) and the capillary phase (CCT-CAP). Mean CCT-LAV before and after IAP was 6.35+/-1.69 sec, 4.91+/-1.56 sec, and mean CCT-MAV was 6.15+/-1.68 sec, 4.80+/-1.58 sec, each showing a significant shortening. Mean CCT-A before and after IAP was 0.274+/-0.105 sec, 0.226+/-0.066 sec and mean CCT-CAP was 6.00+/-1.62 sec and 4.60+/-1.55 sec. The shortening rate of CCT-A and CCT-CAP were 11.2+/-25.7% and 22.7+/-14.6% respectively. Our study confirmed that IAP shortened CCT and improved cerebral hemodynamics. Compared with CCT-A, CCT-CAP was shortened significantly, suggesting that IAP is working not only in the proximal vessels but also in the distal vessels, that is, effective for resolution of vasospasm in the view of cerebral microcirculation. Clinical outcome was not improved statistically, however, it is the fact that there are not a few cases improved neurologically and IAP is still useful for vasospasm as a means to directly dilate intracranial peripheral arteries.

The grouping together of erectile dysfunction and erectile disorder (i.e. dysfunction with distress) has led to the presentation of incredibly high prevalences (up to 52%). When limited to erectile disorder, two Dutch open population studies, among men aged 40-79 years, show remarkably similar and more realistic prevalences, namely 3 to 10%. Although the 'Leiden Impotence Screening Test' appears to reliably exclude somatic aetiological factors, it would be preferable if the general physician posed such diagnostic questions. It is hoped that the availability of pharmacotherapeutic treatments (notably sildenafil) will not tempt the general physician to join the patient in his inclination to 'somatise' his erectile disorder. Both intracavernosal self-injection therapy and the implantation of an erectile prosthesis give rise to a large proportion of dissatisfied men. In the Netherlands to date, the number of continuation prescriptions for sildenafil equals the number of first prescriptions, which suggests that many men also stop with this therapy. In the Netherlands, health insurance companies only reimburse self-injections and prosthesis implantations. It can be argued that all cost-effective treatments for erectile disorder, including psychosexual therapy, should be reimbursed, or none at all.

The routine use of arterial grafts in coronary surgery is facilitated by peroperative adjunction of antispasmodic drug to reduce the event of spasm. Diltiazem has been favoured in most clinical studies devoted to the radial artery graft. The aim of this study was to assess the efficacy of a spasm preventing protocol associating hydrostatic dilation of the graft with a diluted solution of papaverine and nicardipine infusion, starting preoperatively and continued postoperatively in i.v. and per os forms. Between September 1996 and March 1997, a consecutive series of 50 patients underwent myocardial revascularization using the radial artery. The radial artery was prepared by hydrostatic dilation with papaverine (1%) and nicardipine was administrated at 0.25 microgram/kg/min and titrated according to the arterial systemic pressure. Operative mortality was 4% (sepsis). There was no evidence of perioperative MI nor hypoperfusion syndrome. Mean CKMB level at 18 hours was 36 micrograms/l. No ischaemic anomalies of the ECG were detected. Angiography performed in the last 20 patients showed a 98% (51/52) permeability rate for all graft; 19/20 radial grafts (95%) were patent. One radial graft presented a 50% stenosis at the proximal anastomosis, and another a moderate spasm (40%) in the middle part of the conduit. This study confirms that the radial artery conduit can be used with satisfactory results for routine coronary artery bypass. The use of nicardipine allows the control the vasoreactivity of the radial graft without totally obviating at least angiographic spasm. This drug is easy to titrate, and well tolerated in association to beta-blockers in the routine perioperative management of the coronary patients.

The objective of this work was to determine the effectiveness of intracavernous injections (ICI) of vasoactive drugs in elderly men with erectile dysfunction and to compare the results obtained with the injection of two different drug combinations. It was a case control study. The sample consisted of 300 men, 63-85 y of age (mean 67.1) with erectile dysfunction of organic origin. Among the patients 180 underwent first trial with injection of prostaglandin E1 (PE). Further on these 180 patients and another 120 (in total 300 patients) were treated with a triple combination of papaverine hydrochlorate, phentolamine messylate and prostaglandin E1 (PPR). The number of responders to the injection of either PE alone or the drug combination was recorded. The quality of the erections was evaluated in the outpatient clinic by the medical staff and through patient's report after home trial. The average volume of either PE or PPR necessary to obtain a functional erection was measured. We observed a statistically significant association between the results obtained after the injection of PPR as compared to PE (chi2 with 2 d.f.: 34.666; P= < 0.001). A functional erection was obtained in 224/300 (74.7%) after the injection of PPR as compared to 87/180 men (48.3%) treated with PE. The average volume of PPR necessary to obtain a functional erection was 0.35+/-0.14 ml whereas that of PE was 1.3+/-0.3 ml. intracavernous injection of vasoactive drugs is still one of the most successful therapies for patients suffering from organic impotence. It is less effective in the older age group as compared to younger. However, if this form of therapy is chosen for aged men the triple combination therapy (PPR) yields a higher response rate than that obtained with prostaglandin alone.

Although the search for newer and more effective oral therapies is continually expanding, intracavernosal and intraurethral treatments continue to keep pace and are expected to remain in the clinician's armamentarium in the years to come. Unless there are contraindications, oral therapies are effective, have minimal side effects, and are first-line treatment. Some patients who have failed intraurethral and intracavernosal injection therapies previously have been shown to have successful outcomes with oral sildenafil in 56% to 57% of cases. If oral therapies are ineffective or have undesirable side effects, the intraurethral or intracavernosal routes are the next approach that should be prescribed.

Objectives: There is an increasing use of arterial conduits for coronary artery bypass grafting, and the radial artery is commonly used as the third graft. The major drawback of the radial artery is its proclivity to spasm. Both papaverine and phenoxybenzamine have been recommended as topical vasodilators in clinical practice. We compared the efficacy of both drugs to prevent radial artery spasm and their ability to preserve endothelial function., Methods: The ability of both drugs to prevent alpha-adrenoreceptor mediated constriction was tested in vitro in an organ bath in radial artery segments obtained from 20 patients. Vessel viability was determined by potassium (K(+)) constriction, and endothelial function was assessed by observing endothelium-dependent relaxation by a synthetic analogue of acetylcholine, carbachol., Results: Papaverine consistently abolished and prevented spasm for up to a maximum of 30 min in all segments. In contrast, phenoxybenzamine consistently abolished and prevented radial artery spasm in all segments for at least 6 h. Whereas papaverine damaged the endothelium of 70% of vessels, there was no evidence of endothelial damage in any arterial segments after exposure to phenoxybenzamine., Conclusions: Phenoxybenzamine more effectively prevents alpha-adrenoreceptor mediated spasm of the human radial artery than papaverine. It is also less harmful to the endothelium.

Objective: To evaluate the incidence of pharmacologically induced priapism in the diagnostic and therapeutic management of erectile dysfunction., Patients and Methods: Over a period of 7 years, 685 men were investigated for erectile failure. They underwent a simple test with vaso-active drugs, and the nonresponders were further investigated. Eventually, 83 men began autoinjections and 45 still continue., Results: Eight (1.2%) cases of priapism presented during the simple test with vaso-active drugs in these patients, while none occurred during self-injection treatment. Three were prolonged erections induced by prostaglandin E1 (PGE1) and 5 by papaverine (Pap). Six were treated safely with intracavernosal injection of etilephrine without blood aspiration., Conclusion: Priapism is always a potential phenomenon where no individual, no particular drug and no specific dose are completely safe. It may be caused even with 5 microg of PGE1 or 7.5 mg of Pap. Auto-injection therapy however is a safe kind of treatment in well-experienced patients. Careful regulation of the doses and practice in the use of vaso-active drugs may reduce the priapism rate.

Acute bowel ischemia is a rare but often catastrophic event after coronary bypass surgery. We report three cases in our department and highlight the difficulty in making the diagnosis thus delaying timely intervention. We discuss why an aggressive approach in both investigating and managing this condition is warranted. We believe that early mesenteric angiogram and directed exploratory laparotomy are the preferred methods in managing this difficult condition.

The functional state of the penis, flaccid or erect is governed by smooth muscle tone. Sympathetic contractile factors maintain flaccidity whilst parasympathetic factors induce smooth muscle relaxation and erection. It is generally accepted that nitric oxide (NO) is the principal agent responsible for relaxation of penile smooth muscle. NO is derived from two principal sources: directly from non-adrenergic non-cholinergic parasympathetic nerves and indirectly from the endothelium lining cavernosal sinusoids and blood vessels in response to cholinergic stimulation. The generation of NO from L-arginine is catalysed by nitric oxide synthase (NOS). There has been controversy over the relative prevalence of endothelial or neuronal NOS within the penis of different animal species. This review examines the role of NO in the penis in detail. Established and new treatments for erectile dysfunction whose effects are mediated via manipulation of the NO pathway are also described.

Objective: To determine the long-term efficacy of nonsurgical sterilization with quinacrine., Design: Observational cohort study., Setting: Rural provinces in northern Vietnam., Patient(s): Two thousand seven hundred and nine women who had quinacrine insertions between 1989 and 1993., Intervention(s): Interviews in 1994, 1995, and 1996 and review of available medical records. Pregnancy rates were corrected for problems in detecting and confirming pregnancies., Main Outcome Measure(s): Pregnancy rates., Result(s): Over 90% of women were interviewed at least once. Uncorrected cumulative pregnancy rates were 12.9% at 5 y after two insertions and 27.3% after one insertion. Effectiveness varied by age group: the partially corrected pregnancy rates after two insertions were 6.8% in women 35 or older at the time of insertion and 13.0% in women under 35. A subgroup of women who received oral papaverine at the time of quinacrine insertion had lower pregnancy rates, with a cumulative uncorrected rate of 5.3% at 4 years among women of all ages., Conclusion(s): Efficacy of quinacrine appears reasonable for two insertions of quinacrine in women 35 and older. It may be possible to improve efficacy by the use of papaverine or the Hieu insertion technique.

We describe two patients with subarachnoid haemorrhage due to a ruptured intracranial aneurysm and severe symptomatic vasospasm. The aneurysm was occluded with detachable coils followed by intra-arterial infusion of papaverine to treat vasospasm as an one-stage procedure. There was significant resolution of the vasospasm. The long-term clinical outcome in one patient was excellent, the other still has minor deficits. Combined endovascular aneurysm therapy followed by intra-arterial spasmolysis with papaverine is a technically feasible therapeutic alternative in patients with symptomatic vasospasm.

Erectile dysfunction (ED) is a common condition and can usually be managed pharmacologically, with drugs delivered by intracavernosal injection (ICI), transurethrally or orally. The cardiovascular status of the patient and his overall fitness for renewed sexual activity must be assessed before treatment for ED is initiated. The efficacy of sildenafil is related to the extent and severity of ED, and is significantly reduced in patients with severe vasculogenic ED, ED associated with diabetes and after radical prostatectomy. Alprostadil (prostaglandin E1) is the drug of first choice in patients treated with ICI; it is effective in 72.6% of men with ED and is associated with a low risk of priapism and cavernosal fibrosis. Transurethral alprostadil is significantly less effective than alprostadil ICI, producing improved erections in 30%-40%, but rigid erections in only 10%, of men with ED. There is Level II evidence that: alprostadil ICI is an effective treatment for ED papaverine ICI is associated with a high risk of cavernosal fibrosis and priapism papaverine ICI should be restricted to informed patients refractory to treatment with alprostadil ICI transurethral alprostadil is less effective than alprostadil ICI sildenafil is an effective treatment for ED.

Restoration of flow-dependent coronary artery dilation by angiotensin-converting enzyme inhibition (ACEI) has been demonstrated in patients with hypertension. The aim of the present study was to evaluate whether dilation of conductance coronary arteries may alter maximal coronary blood flow (CBFmax) and minimal coronary resistance (CRmin) in hypertensive patients with reversible impairment of flow-dependent coronary artery dilation. Thirteen hypertensive patients with angiographically normal coronary arteries and no other risk factors were studied. Cross-sectional areas (CSAs) of proximal and distal left anterior descending (LAD) coronary arteries were determined by quantitative angiography. Coronary flow velocity was recorded in the distal LAD with an intracoronary Doppler catheter. Estimates of coronary blood flow and resistance were calculated at rest and during maximal increase in blood flow induced by papaverine injected in the midportion of the LAD, both before and after ACEI. Flow-dependent dilation of the proximal LAD, abolished before ACEI, was restored after (26.7 +/- 11.2%; p < 0.001). The increase in CSA of the distal LAD exposed to papaverine was significantly higher after ACEI than before (from 33.4 +/- 20.5% to 51.5 +/- 23.4%; p < 0.001). After restoration of proximal LAD flow-dependent dilation, CBFmax was increased by +21.0 +/- 10.3% (p < 0.001), and CRmin was reduced by 19.3 +/- 9.5% (p < 0.001). Thus, dilation of epicardial coronary arteries participates substantially in the coronary resistance in hypertensive patients. Restoration of flow-dependent coronary artery dilation by ACEI may improve the ability of coronary circulation to deliver its maximal myocardial blood flow in hypertensive patients.

Objective: To assess the levels of adrenomedullin (a vasodilatory peptide) in penile blood before and after injection with papaverine in impotent men, and in the internal spermatic vein in infertile patients with varicocele, comparing the results with levels in the brachial vein in the same patients., Patients and Methods: Intracavernosal levels of adrenomedullin were determined in 14 impotent men (with no vascular pathology, as assessed by colour Doppler ultrasonography) before and after papaverine-induced penile erection. The effect of needle puncture alone was assessed in eight control patients. The level of adrenomedullin was also measured in the internal spermatic vein and brachial vein in 14 infertile men with varicocele., Results: The mean (SD) intracavernosal adrenomedullin levels in the 14 impotent men were significantly different between the flaccid and papaverine-induced erectile state, at 93.5 (33.0) and 135.8 (34.9) pmol/mL, respectively, (P < 0.05). Needle puncture alone had no effect on adrenomedullin levels. In men with varicocele, the adrenomedullin level of 139.0 (34.3) pmol/mL within the internal spermatic vein was significantly higher than that in the brachial vein, at 103.9 (37.6) pmol/mL (P < 0.05)., Conclusion: Injection with papaverine increases adrenomedullin release into penile blood; this release may be responsible for the increase in penile blood flow and penile erection. Higher levels of adrenomedullin within the internal spermatic vein of patients with varicocele may result from the retrograde flow of venous blood from the left adrenal gland and kidney. Further studies are needed to determine the role of adrenomedullin in male infertility and impotence.

Aim: To investigate the correlation between angiographic cerebral circulation time (CCT) and cerebral blood flow (CBF) evaluated by single photon emission computed tomography (SPECT) before and after endovascular treatment for symptomatic vasospasm., Materials and Methods: Seven patients with unilateral vasospasm as demonstrated by catheter angiography who underwent pre- and post-treatment SPECT were selected. All patients had angiographic vasospasm of unilateral middle cerebral artery (MCA). Eight vessels in seven patients underwent intra-arterial papaverine infusion and three vessels underwent percutaneous transluminal angioplasty. Angiographic CCT was defined as the interval from the first image in which contrast medium was visible at the origin of MCA to its disappearance from the cortical arteries in the MCA territory. In SPECT studies, the ischaemic degree in MCA territory was analysed by side to side comparison with calculating the asymmetry index (AI)., Results: The pre-treatment mean CCT was 4.1 +/- 0.8 s. The mean CCT immediately after treatment was 2.7 +/- 0.5 s. In the control subjects (n = 15) with unruptured aneurysm, mean CCT was 3.5 +/- 0.2 s. The pre-treatment mean CCT was significantly prolonged compared with that in the control subjects (P = 0.02). The post-treatment mean CCT was significantly shortened compared with that in the control subjects (P = 0.001). The pre-treatment mean AI was 71.2 +/- 7.4%, and that immediately after treatment was 90.5 +/- 3.6%. AI increased in all territories treated with endovascular treatment; the mean change was 19.3%. Angiographic CCT was closely correlated with AI in both pre- (r = - 0.95) and post-treatment (r = - 0.79)., Conclusion: Measurement of CCT is useful in evaluating cerebral haemodynamics of endovascular treatments in patients with cerebral vasospasm.

We present a case of limb ischemia in a young man. For acute alcohol withdrawal, this patient was given chlordiazepoxide (Librium) through an angiocatheter inadvertently placed into a brachial arterial line. This caused severe spasm of the brachial artery and its branches. These findings were confirmed by angiography. Successful treatment occurred with intra-arterial papaverin.

Objective: To review current pharmacologic treatment options for erectile dysfunction., Methods: Relevant literatures from the past two decades regarding the following treatments were reviewed: intracavemous injection, topical therapy, transurethral therapy and oral drugs., Study Selection: More than 125 originally identified articles were reviewed, and 45 were selected that especially addressed the stated purpose., Results: Among the pharmacologic treatment options available, intracavemous injection therapy remains the most effective although the drop-out rate is high. Topical creams and gels have not been very successful. Transurethral alprostadil can be more effective if a constriction device is applied at the base of the penis. Oral sildenafil has the highest patient acceptance rate although systemic side effects can be a major drawback., Conclusions: Effective pharmacotherapies for ED of various etiologies are now available. However, proper evaluation of every patient should be performed before giving treatment so that a number of potentially life-threatening causes of erectile dysfunction would not be missed.

The early detection of prostate cancer through the use of prostate-specific antigen screening has resulted in the performance of many more radical prostatectomy procedures as a curative treatment for this disease. Many patients who are candidates for this procedure already suffer from erectile dysfunction, and the incidence of inadequate erections following radical prostatectomy is certainly high. Nerve-sparing procedures during performance of this operation are encouraged as the incidence of erectile dysfunction is lower if one or both nerves are spared. If the patient is already impotent before the procedure, medical treatments with oral agents, intraurethral compounds, or intracorporally injected medications may be more effective with the nerves intact. Early institution of medical therapy, specifically intracorporal injections, after 2 months postoperatively has resulted in a higher incidence of spontaneous return of erections at 1 year. Vacuum erection devices may be successful in restoring erections but extensive practice in their use is necessary, and they may be unappealing to many patients. A penile prosthesis will restore erections if the patient is so motivated for implantation of such a device. These are expensive and require invasive surgery, but satisfaction rates among patients and partners who have used them have been in the range of 85%, the highest satisfaction rate among all of the treatments of erectile dysfunction.

Background: The radial artery (RA) is used increasingly for myocardial revascularization. Having an ultrasonic dissector available in our unit, we began to use it for RA harvest with the impression that harvest spasm might be less for the new technique., Methods: We compared RA harvest using standard techniques (21 RA) with ultrasonic dissection (41 RA) in which all branches were divided between clips with scissors in the former and bleeding branches were clipped in the latter., Results: Harvest times were not different. Conventional technique used 74+/-18 (mean +/- standard deviation) clips versus 3.2+/-4.3 clips (p<0.001). In situ free flow was 17.2+/-20.7 mL/min for conventional technique versus 52.5+/-48.1 for ultrasonic (p<0.001). Free flow after the proximal anastomosis to the left internal thoracic artery was 38.5+/-60.4 mL/min for conventional technique and 50.7+/-29.6 for ultrasonic (p = 0.008). Free flow 10 minutes after intraluminal papaverine was 78.5+/-45.9 mL/min for usual technique versus 102.8+/-51.7 for ultrasonic (p = 0.016). No patient required reoperation for bleeding., Conclusions: Ultrasonic dissection of the RA is associated with decreased RA spasm, good hemostasis, no additional harvest time, and has become our standard technique.

There is growing evidence that the field of pharmacotherapy, particularly oral drugs, will be dominant in the future management of sexual dysfunction. Basic research has led to the understanding of the intracellular mechanisms that control penile smooth muscle contractility and therefore erection, opening a vast area for pharmacological intervention. Moreover, the importance of central neurohormonal mechanisms has made these pathways the target for new centrally acting drugs. Given these trends most patients suffering from erectile dysfunction will respond to pharmacological agents in the not so distant future.

The pathogenesis and clinical course of traumatic cerebral vasospasm (TCV) are not yet fully understood. We report a case of delayed symptomatic TCV exaggerated by hyponatremia in spite of minor subarachnoid hemorrhage. A 77-year-old woman was admitted to our hospital with multiple injury caused by a traffic accident. Glasgow coma scale on admission was 8, and CT scan revealed right temporal lobe contusion, thin sub-arachnoid hemorrhage in the right sylvian cistern and right temporal bone fracture. The patient's consciousness level and CT findings improved gradually, but on the 11th day, she suddenly fell into a comatose state. No apparent change was observed on the CT scan, but her serum sodium level was markedly low (113 mEq/L). Under the suspicion of hyponatremia induced consciousness disturbance, sodium replacement therapy was commenced. She showed transient neurological recovery, but on day 13, worsening of left hemiparesis and a new low density area on CT were observed. Vasospasms of the right M2 proximal portion were confirmed by cerebral angiogram, so we performed intraarterial papaverine infusion leading to good extension of spastic vessels, but regrettably, there was no neurological recovery. In general, subarachnoid blood plays an important role in the delayed development of cerebral vasospasm, following not only aneurysmal rupture but also head injury. TCV tends to pass subclinically, but secondary water and electrolyte imbalance may unexpectedly cause TCV to manifest itself clinically. We can confirm that with this patient management of electrolyte balance following head injury was the most important strategy to avoid symptomatic TCV.

Objectives: To examine the impact of intracavernosal therapy on libido, ejaculatory control, quality of life and treatment dependency in men with erectile failure. Furthermore to assess the drop-out rate and reasons for dissatisfaction with the technique., Subjects and Methods: Questionnaires were sent to 1116 subjects with erectile failure who had previously elected to use intracavernosal therapy in the period 1995-1997., Results: The response rate was 72.5%. The majority of erections lasted 30-60 min, 10-20% of the erections were considered unsatisfactory for intercourse and 15% of subjects reported erections lasting longer than 5 h on at least 10% of the occasions. Bleeding at the injection site occurred in 60% on at least 10% of the occasions and various degrees of deformation of the penis shaft were reported by 10%. The latter was related to the age of the subject and not the type of medication employed. Forty percent experienced at least partially improved control over ejaculation and almost 50% experienced some degree of increase in libido. One quarter retained penile rigidity after ejaculation but this was age-dependent. In those satisfied with intracavernosal treatment, 80% admitted that it had improved the quality of their lives. Sixty percent did not feel that their dependency on intracavernosal treatment had lessened during the treatment period. Approximately 40% of subjects admitted to dropping out of the programme, the majority within the first six months. The age of the subject did not influence the decision and the type of medication or the mode of injection had only a minor impact on drop-out rate. Of those currently using IC therapy, 87% were either fully or partly satisfied with this form of treatment. The corresponding figure for those discontinuing treatment was 58%. Dissatisfaction was higher in the younger age groups and could not be clearly related to the mode of injection. The major reasons for drop out or dissatisfaction were inadequate penile rigidity, the expense of the treatment, penile discomfort and the lack of spontaneity it necessitated. Penile discomfort was more associated with younger age groups, whilst an inadequate response to medication was more often experienced by men over 60 y. Deformation of the penile shaft was observed in 5% of those dissatisfied with IC therapy and was four times more often reported by those over 70 compared to subjects younger than 40 y. In 6% of cases, a return of spontaneous erections was given as reason for drop-out. This was more often associated with younger subjects. In 16% of the subjects, the partner had expressed dissatisfaction with the technique primarily because of inadequate rigidity, lack of spontaneity or the complicated nature of the treatment., Conclusions: Intracavernosal treatment for erection failure is associated with side-effects such as penile fibrosis and bleeding at the injection site but has advantages including increased libido, an increase in the quality of life and ejaculatory control. Only a small proportion of men reduce their dependency on the technique with time. The therapy has a relatively high attrition rate. In many cases, the reasons for subject and partner dissatisfaction are potentially correctable e.g. by altering the medication used, by the use of injector devices or by obtaining financial support for IC medication from medical welfare.

Endovascular treatment of cerebral vasospasm induced by subarachnoid hemorrhage has become a useful therapy. The two main treatments that have been used are balloon angioplasty and intra-arterial papaverine infusion. Both treatments have been shown to reverse subarachnoid hemorrhage-induced vascular spasm, increase cerebral blood flow and improve delayed ischemic neurologic deficits induced by vasospasm. Balloon angioplasty is superior to papaverine for treatment of proximal vessel vasospasm by virtue of a more sustained effect on the vessels. Papaverine can be useful as an adjunct to balloon angioplasty and also for the treatment of distal vessels that are not accessible for balloon angioplasty.

This report emphasizes the fact that the patients operated show a bigger motivation in facing the problem of erectile deficit; this motivation lacks in patients treated with chemotherapy, radiotherapy and hormonotherapy. The results are anyway very interesting because the pharmacology prosthesis is generally well accepted and tolerated; very rare are the complications.

Background: During the past few years, after much research, progress has been made in reducing the risk of spinal cord injury after descending or thoracoabdominal aortic repairs., Methods: Based on that research I describe a method to reduce the risk of spinal cord injury., Results: Our data show that with this technique, less than 5% of our patients had a permanent injury whereby they are unable to walk., Conclusion: The use of intrathecal papaverine, cerebrospinal fluid drainage, hypothermia, and reimplantation of intercostal arteries from below T6 to and including L1 are recommended.