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A standard pattern of Doppler waveforms occurs with hemodynamic changes in corporeal pressure during progression to normal full erection impotence emedicine purchase 20 mg apcalis sx fast delivery. In the filling phase when sinusoidal resistance is low (within 5 minutes after vasodilator injection), the waveform increases in size consistent with high forward flow during both systole and diastole. With full erection, the systolic waveforms sharply peak and may be slightly less than during full tumescence. At maximal rigidity, when intracavernous pressure exceeds systemic diastolic blood pressure, diastolic flow may be zero. The sonographic color pattern of the cavernous artery may demonstrate an impressive shift from red to blue in association with the reversal of diastolic flow. A cut point at 25 cm/s included a sensitivity of 100% and a specificity of 95% in patients with abnormal pudendal arteriography (Quam et al, 1989). Diameter changes of the cavernous artery after vasodilator injection were found to increase less than 75% and rarely to exceed 0. Vascular arterial anatomic variants may confound the interpretation of duplex ultrasonography (Breza et al, 1989; Jarow et al, 1993). Early cavernous arterial branching or the presence of multiple such branches may affect blood-flow velocity determinations of the main cavernous artery. The presence of distal arterial perforators extending from the dorsal or spongiosal arteries also may alter the measurement of cavernous arterial blood-flow velocity. On the other hand, asymmetrical blood flow of the cavernous arteries may have diagnostic significance. The findings of dissimilar cavernous artery velocity measurements, which are greater than 10 cm/s between sides, or reversal of flow across a collateral may suggest a significant atherosclerotic lesion (Benson et al, 1993). Cavernous veno-occlusive dysfunction, which refers to failure of erection maintenance despite adequate cavernous arterial inflow, is suggested by assorted sonographic parameters. Generally meaningful at 15 to 20 minutes after stimulatory onset, these parameters include persistent high systolic flow velocities. Several technical modifications of sonographic evaluation of the penis have been described. A portable Midus-pulsed Doppler unit connected to a laptop computer for in-office testing reliably records the Doppler waveform of the cavernous arteries despite the lack of a real-time ultrasound image (Metro and Broderick, 1999). Power Doppler offers an even more specialized technique to visualize distal ramifications of the main cavernous artery down to the level of arterioles (Sarteschi et al, 1998; Golubinski and Sikorski, 2002). Dynamic Infusion Cavernosometry and Cavernosography Cavernosometry and cavernosography, precisely referring to functional hemodynamic and radiographic assessments of the corpora cavernosa, represents third-line evaluation of the vascular integrity of the penis. When used, it generally precedes consideration for corrective penile vascular surgery. The technique involves two needles inserted into the penis for simultaneous saline infusion and intracavernous pressure monitoring following intracavernosal pharmacologic injection (Glina and Ghanem, 2013). The testing requires complete trabecular smooth muscle relaxation to avoid erroneous results, and repeated and maximal pharmacologic dosing protocols are recommended (Hatzichristou et al, 1995). Dynamic infusion cavernosometry and cavernosography evaluates the penile venous outflow system. The existence of venoocclusive dysfunction is indicated by the failure to increase intracavernous pressure to the level of the mean systolic blood pressure with saline infusion or the demonstration of a rapid drop of intracavernous pressure after cessation of saline infusion (Puyau and Lewis, 1983; Rudnick et al, 1991; Shabsigh et al, 1991; Motiwala, 1993). The flow rate required to maintain erection at an intracavernous pressure of more than 100 mm Hg is normally less than 3 to 5 mL/min, and the pressure decrease in 30 seconds from 150 mm Hg is normally less than 45 mm Hg. Cavernosography follows cavernosometric evaluation and is intended to show the site of venous leakage. With normal veno-occlusive function, there should be opacification of the corpora cavernosa with minimal or no visualization of venous structures or corpus spongiosum. With impaired veno-occlusive function, leakage may be identified into such sites as the glans, corpus spongiosum, superficial dorsal veins, and cavernous and crural veins. Penile Angiography Penile angiography essentially refers to an anatomic study of the arterial vasculature of the penis and also represents third-line evaluation of the penile vascular system. The procedure involves selective cannulation of the internal pudendal artery and injection of radiographic contrast. The intracavernosal injection of a vasodilating agent is optimally used to induce maximal vasodilation of the penile arterial supply. The anatomy and radiographic appearance of the iliac, internal pudendal, and penile arteries are then evaluated and documented. The inferior epigastric arteries are frequently studied as well to determine their suitability for use in surgical revascularization. It should be recognized that significant variation of the intrapenile arterial anatomy exists, challenging the angiographer to differentiate congenital variations from acquired abnormalities and to establish their clinicopathologic relevance (Bähren et al, 1988; Benson et al, 1993). The technique involves applying a small pediatric blood pressure cuff to the base of the flaccid penis and measuring the systolic blood pressure with a continuous-wave Doppler probe. The technique has not been found valid because it does not assess the hemodynamic properties of a functionally relevant, induced erection, and thus it is not recommended for use (Aitchison et al, 1990; Mueller et al, 1990). Top to bottom: Cavernosal artery flow recorded by using a continuous-wave Doppler ultrasound probe; systemic brachial systolic and diastolic arterial blood pressure (150/87mmHg); intracavernosal pressure, which varied from 70 to 160mmHg in this tracing; and intracavernosal heparinized saline inflow. Radioisotopic Penography this test quantifies changes in penile blood volume after intracavernosal injection of a vasoactive agent using 99mTc-labeled red blood cells (Shirai et al, 1976). An evaluation comparing color duplex ultrasonography and radionuclide penography showed poor correlation (Glass et al, 1996). In part because of its invasiveness, the test is controversial and thus it remains investigational at present. In general, the documentation of a full erection indicates functional integrity of the neurovascular axis regulating penile erection and thereby raises suspicion of a psychogenic etiology.

Due to ambiguity in terminology impotence pills for men buy 20 mg apcalis sx amex, Raina et al (2007) have suggested a tripartite classification system: 1. Women with sexual complaints are likely to have issues related to their partner and/or their personal experience of sexuality. Education on the anatomy and physiology of sexual response as well as communication and interpersonal skills may be sufficient to resolve many sexual complaints 2. Sexual dysfunction is a disturbance in one more or more phases of the sexual response cycle and/or pain during sexual activity. Women with sexual dysfunction may compensate for it in some fashion and thus preserve a sense of sexual satisfaction or at least contentment. Sexual disorder is the combination of sexual dysfunction and personal distress relating to the sexual dysfunction. These women merit complete evaluation to assess for etiology and treatment options. Whether one adheres to this classification scheme or not, it is always important when evaluating research or seeing a patient to gauge personal distress as this is a very important determinant of which treatments are indicated/desired. Sexual dysfunction is more frequent in older women; sexual complaints may be more frequent in younger women (Roos et al, 2012). Similarly, distress related to sexual issues appears to be higher in premenopausal versus menopausal women (Berra et al, 2010); this may be due in part to adaptation on the part of some older women. The highest prevalence of sexual concerns with attendant distress is in women aged 45-64 (Shifren et al, 2008). It is reasonable to hypothesize that this is an age group in whom sexual activity remains a priority despite physical changes of menopause and advancing age, which may compromise sexual response. Distress is GynecologicSurgeryPatients the effects of hysterectomy on sexual function are mediated in large part by the indication for the procedure (Roovers et al, 2003); women who experience sexual dysfunction from gynecologic conditions. CancerPatients Sexual issues are common in women after pelvic cancer surgeries such as cystectomy/urethrectomy, vulvectomy, colectomy, abdominoperineal resection, and proctectomy (Raina et al, 2007; Donovan et al, 2010; Philip et al, 2013). Sexual dysfunction is also a risk of pelvic radiotherapy as a primary or adjuvant treatment (Incrocci and Jensen, 2013). Disruption of pelvic neurovasculature, side effects of treatment, and body image issues may predispose to impairment of sexual responses and pain (Raina et al, 2007). In cystectomy and/or urethrectomy the anterior vaginal wall may be partially resected or otherwise compromised, leading to difficulty with vaginal penetration (Yang et al, 2006). Disruption of the nerve innervation to the external genitalia, vagina and clitoris is a common risk during cystectomy/urethrectomy (Stenzl et al, 1995). A 2004 study indicated that difficulty with orgasm, desire, and arousal are very common in women after radical cystectomy. Slightly less than half of female cystectomy patients engage in coital intercourse after cystectomy and slightly over half report a decline in sexual life satisfaction (Zippe et al, 2004). Issues in cancer survivorship are discussed in more detail on the Expert Consult website. In recent years concern for quality of life and cancer survivorship have increased interest in promoting sexual wellness for cancer survivors (Raina et al, 2007; Perez et al, 2009). Cancers of nongenital sites may influence sexual function due to alteration in body image, genital and systemic side effects of chemotherapy and radiation, and/or psychological distress (Perez et al, 2009). Particular interest has been dedicated to sexuality and breast cancer survivorship; breast cancer survivors may be treated with estrogen-blocking drugs that may cause genital atrophy and premature symptoms of menopause. Psychosocial issues are also of great importance in breast cancer patients due to the sexual context 755. Bancroft and colleagues (2003) demonstrated that the best overall predictors of sexual distress in women were emotional relationship with partner and general well-being. Physical issues also played a role but these effects were relatively minor (Bancroft et al, 2003). It is legitimate to challenge current concepts in human sexuality with novel ideas. Similarly, it is prudent to be concerned about the potential victimization of women and their partners for financial gain (Bancroft, 2002). As physicians are in the best position to understand the physical (and in some cases mental) processes of sexual response, involvement of the medical community in optimization of sexual wellness is of critical importance for many women. Individual providers will best serve their patients by integrating medical assessment and therapies (when appropriate) with psychosocial intervention in a holistic approach that recognizes the rich complexity of human sexual response (Althof, 2011). The term vaginismus is no longer preferred, as it includes significant semantic baggage as a psychological disorder. Estrogen replacement has been linked to both better (Chedraui et al, 2009) and worse (Blumel et al, 2009) sexual function in postmenopausal women. Some studies have reported lower rates of sexual activity and sexual desire (Smith et al, 2012) in obese women and in women with metabolic syndrome (Martelli et al, 2012); however other studies (Christensen et al, 2011) have suggested that among women who are sexually active, obesity (Christensen et al, 2011) and metabolic syndrome (Kim et al, 2011) are not linked to sexual dysfunction. Although data are ambiguous, concern for general health dictates that practitioners should encourage patients to maintain healthy body weight (Goldstein and Alexander, 2005). While the linear model may not perfectly reflect sexual response in every woman it does represent a convenient means to organize diagnostic criteria. A summary of specific female sexual issues and their estimated prevalence is presented in Table 32-2. There is substantial comorbidity between sexual issues in women (Giles and McCabe, 2009). Duration of at least 6 months is required to apply a diagnosis except in the case of medication-induced sexual dysfunction. There has been scant research using these new diagnoses; in the interest of simplicity we will outline this chapter according to previous diagnostic categories (Basson et al, 2004). It is important to clarify that many early studies characterized sexual desire in terms of spontaneous sexual interest and desire.

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It is advisable for the surgeon to use loupe magnification to reduce the likelihood of injury to neurovascular structures erectile dysfunction yoga youtube apcalis sx 20 mg order on-line. With the shaft exposed, the erection can again be re-created, demonstrating the area of maximum deformity. In the circumstance of a dorsal or dorsal-lateral curvature, the Buck fascia, with the enclosed neurovascular bundle, is elevated by making a pair of parallel incisions just lateral to the urethral ridge, through the Buck fascia to the tunica albuginea. Typically this can be done with delicate, sharp dissection, but occasionally, if there is significant adhesion between the Buck fascia and the tunic, bipolar cautery can be used to elevate this with minimal risk of permanent nerve injury. Once the Buck fascia is elevated off the area of maximum deformity, a full erection is re-created. It should be noted that even with a pure lateral curvature, the tunic to be excised must traverse through the dorsal septum, because this is the anchor point of the scar and if it is not taken, substantial residual curvature will likely remain (Jordan, 2007). When extensive calcification extends beyond the area of partial plaque excision, the calcified component can be removed, leaving the outer lamina intact because the calcification involves the inner circular fibers. Once the rectangular defect is established, the corners are darted in a radial fashion so as to help to recover normal shaft caliber in the area of indentation. We have simplified the geometric principle technique by ensuring that the lateral sides of the defect are of equal length (Egydio et al, 2004; Levine, 2011). In doing this, we create a uniform-sized square or rectangle, which virtually always allows satisfactory correction of lateral and dorsal curvature. Often the proximal transverse length will be longer than the distal transverse length because of distal tapering of the shaft. The penis can now be measured on stretch again; typically there will be increased dorsal length from 0. With these stay sutures on stretch, the defect can be measured longitudinally and transversely. The graft should be sized no more than 10% larger than the measured defect on stretch. An artificial erection is again reestablished; if there is significant residual curvature, this can be addressed with tunica plication. We find it useful to liken the importance of postoperative rehabilitation after penile surgery to the importance of the rehabilitation needed for successful orthopedic joint replacement. Typically a patient is seen 2 weeks after surgery, at which point massage and stretch therapy are initiated (Horton et al, 1987). The patient is instructed to grasp the penis by the glans and gently stretch it away from the body and then with his other hand to massage the shaft of the penis for 5 minutes twice per day for 2 to 4 weeks. This will reinitiate the sexual experience for the couple and hopefully diminish the fear of reinjuring the penis, for which the partner may feel responsible. Finally, external penile traction devices have been encouraged and have been recently shown to reduce length loss postoperatively and can even enhance length gain after both grafting and plication procedures (Levine et al, 2013). There was no patient reported with postoperative length loss among those who used postoperative traction therapy, and although not statistically significant, there was a trend of higher satisfaction for erect length in the groups in which postoperative traction was used. Traction is recommended to be used for 3 or more hours per day, beginning 3 to 4 weeks after surgery, once the wound can tolerate the pressures of the stretching device for 3 months (Rybak et al, 2012). Diminished sensation after grafting has been reported in a few series with a follow-up of less than 5 years (Taylor and Levine, 2008). Additional straightening maneuvers may be necessary, including manual modeling and incising of the tunica albuginea with or without grafting. Recently, transcorporeal approaches have been used before modeling or relaxing incisions; the plaque is incised or stretched from within the corporeal body (Shaeer, 2011; Perito and Wilson, 2013). Manual modeling via the penoscrotal approach is recommended with a high-pressure inflatable cylinder, but all available three-piece and two-piece devices have been used successfully to correct deformity (Wilson and Delk, 1994; Montague et al, 1996; Montorsi et al, 1996; Levine et al, 2001; Chung et al, 2012c). Our approach is to place the prosthesis cylinders first, followed by closing of the corporotomies. With use of a surrogate reservoir attached to the pump tubing, the prosthesis can be filled to full rigidity, which will allow visualization of the deformity. To protect the pump from the high pressures that may occur during manual modeling, shodded hemostat clamps are applied to the tubing between the pump and the cylinders. It is recommended to try to hold the penis in this position for 60 to 90 seconds, but experience has suggested that around 30 seconds may be all that is possible. Once the modeling has been performed, the penis can be reassessed by instilling more fluid, reapplying the hemostats, and then performing the modeling procedure repeatedly until satisfactory curvature correction has been attained. The modeling technique should be a gradual bending rather than a violent maneuver, because this will reduce the likelihood of inadvertent tearing of the tunic or injury to the overlying neurovascular bundle. Urethral injuries during performance of this technique as a result of distal extrusion of the prosthetic cylinders at the fossa navicularis have been reported (Wilson and Delk, 1994; Wilson et al, 2001). To reduce the likelihood of this occurring, the bending hand should be placed on the shaft of the penis rather than on the glans, to avoid downward pressure on the tips of the cylinders. The other hand should be grasping the base of the penis with pressure over the corporotomies, which will provide support to this area and reduce the likelihood of disruption of the suture line. Published reports on the use of modeling have indicated that successful straightening can be expected in 86% to 100% with no higher incidence of device revision; sensory deficit after manual modeling is rare but remains a potential complication that should be discussed with the patient preoperatively (Wilson and Delk, 1994; Montague et al, 1996; Wilson et al, 2001; Levine et al, 2010; Chung et al, 2012c). Although it would appear that for more severe curvature more advanced techniques are necessary, published experience has suggested that manual modeling may be used as first-line therapy for correction of curvature after prosthesis implantation (Levine et al, 2010; Chung et al, 2012c). An alternative to this would be to perform a tunic plication contralateral to the curvature before placement of the prosthesis to correct the curvature (Rahman et al, 2004; Dugi and Morey, 2010). When there is residual curvature of greater than 30 degrees or residual indentation causing the inflated cylinder to buckle, tunical incision is recommended after elevation of the Buck fascia in that area (Levine and Dimitriou, 2000). The transverse penoscrotal skin incision will allow access to virtually the entire shaft, except when the curvature is distal and dorsal on the shaft, so degloving the penis is not always necessary.