Effective Treatments for Erectile Dysfunction

Mental Impotence Healer Program

Mike Millers Mental Impotence Healer is an eBook that utilizes guided imagery to help you to cure your psychological impotence. In guided imagery, you will be guided into imagining a scenario which will help you overcome psychological and physical issues. It commonly uses descriptive language and instructions that have direct affects on the brain. Because the mind greatly influences your body, this system will help you have rock-hard erections whenever you need them most. Simply listen to The Mental Impotence Healer Program for 60 days and completely annihilate your sexual fears and in next to little time you will definitely make yourself a brand new You! Recharged with sexual energy, bursting with self-confidence, rock solid on command, and conditioned to believe that your times of Psychological Impotence have dissapeared, permanently! The Mental Impotence Healer Program provides you with your confidence back and will maximize your self-esteem to amazing new heights. Listen to the beautiful, calm and relaxing Guided Imagery session and it definitely will totally transform your sex life. You will obtain control over your erections without taking any harmful medication or dangerous pills. Grab a set of headphones and the recordings will go to work while you relax. The carefully mastered binaural beats and subliminal messages will reprogram your subconscious mind to a radically altered state of heightened sexual awareness and desire! Read more...

Mental Impotence Healer Program Overview

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Can Impotence Be Due To The Drugs Patients Are Taking

Almost any drug, or just knowing that you have a heart condition that necessitates taking a drug, may cause or contribute to impotence. Some groups of drugs given to either prevent or treat patients with coronary heart disease are particularly likely to cause impotence. These are

Are These The Viagra Tablets

The new group of drugs, called phosphodiesterase type-5 inhibitors (PDE-5-drugs ending in tadalafil), of which sildenafil (or Viagra) was the first, may help. Others (tadalfil, vardenafil) are available. They are safe and useful in most men with impotence. Depending on what other conditions the man has, for example, diabetes, his internist or cardiologist may be able to

The Human Sexual Response

Vaginal Vasocongestion

The sexual response, similar in both sexes, is often divided into four phases excitation, plateau, orgasm, and resolution. The excitation phase, also known as arousal, is characterized by myo-tonia (increased muscle tone) and vasocongestion (the engorgement of a sexual organ with blood). This results in erection of the nipples in both sexes, although the effect is more intense and evident in females than in males. The clitoris swells (analogous to erection of the penis), and the labia minora swell to more than twice their previous size. Vasocongestion of the vagina leads to secretion of fluid, producing vaginal lubrication. Vasocongestion also causes considerable enlargement of the uterus, and in women who have not breast-fed a baby the breasts may enlarge as well. (pigmented areas surrounding the nipples). Pronounced engorgement of the outer third of the vagina produces what Masters and Johnson, two scientists who performed pioneering studies of the human sexual response, called the...

Central Mechanisms Of Penile Erection And Flaccidity

And genital sensations but does not lead to penile erection. Conversely, stimulation of cortical-subcortical areas linked to the limbic system elicit penile erections in response to stimulation, as demonstrated in monkeys (5,171-173). Direct study of the human brain is limited to observations made during neurosurgical procedures. Conversely, stimulation of the amygdala (a limbic structure) can induce erotic emotions similar to those experienced during intercourse. Analogous observations have been made by comparing the experiences of patients suffering from epilepsy with parietal lobe foci to those with mediobasal temporal foci. Animal experiments have shown that damage to the fornix and prefornical area also injures the paraventricular nucleus (PVN) outflow to the MFB, possibly accounting for the impotence associated with these operations. The current hypothesis of the inhibitory role of the cortex is supported by the findings of hypersexuality and penile erection in the Kluver-Bucy...

Modes Of Penile Erection

Penile erections are elicited by local sensory stimulation ofthe frenulum, glans penis, and perigenital skin (reflexic erections) as well as by central stimuli received by, or generated within, the brain (psychogenic erections). Both types of erectile mechanisms likely act in a synergistic manner and are controlled by the autonomic nervous system (see Fig. 6 Table 7).

The Sexual Response

The sexual response depends on a complicated series of reflexes that involve the neuromuscular transmissions stimulated by a wide variety of visual, tactile (touch), olfactory (smell), and emotional sensations. Sexual excitement and response begin in the brain. Electrical signals are transmitted from the brain areas involved via the spinal cord to the sexual organs or genitals, through nerves that exit near the base of the spinal cord. The pathways between the brain and the genitals are long and complex, and demyelination may short-circuit them. Impulses leave the CNS from the sacral spinal cord via the auto-nomic nervous system, which controls bodily functions that are considered automatic. For example, this system controls the arousal that men and women experience without external stimulation, such as that which occurs during sleep. There are two divisions to the autonomic nervous system, the parasympathetic and the sympathetic. The parasympathetic section controls the erectile...

Erectile Dysfunction

Open prostatectomy can have an adverse impact on sexual performance. The review conducted by McConnell and associates revealed postoperative erectile dysfunction in 32 , 16 , and 18 in patients undergoing perineal, retropubic, and suprapubic prostatectomy, respectively (21). In theory, leaving an intact and nonviolated prostatic capsule should mitigate against the development of either incontinence or erectile dysfunction. It has been assumed that preexisting erectile dysfunction may be more pervasive than previously suggested. However, the study conducted by Ertekin et al. documented postoperative erectile dysfunction in more than half of patients who claimed preoperative potency and subsequently underwent suprapubic prostatectomy (25). In that study, however, there was no clear connection between surgical technique and development of erectile dysfunction. As anticipated, the incidence of retrograde ejaculation is very high, occurring in about 77 of all cases, a rate similar to that...

Other Important Publications

Impotence treatment by autoinjection of vasoactive drugs. Br Med J (Clin Res Ed) 5 295(6598) 596-596, 1987. Armstrong D, Convery A, and Dinsmore W. Intracavernosal papaverine and phentolamine for the medical management of erectile dysfunction in a genitourinary clinic. Int J STD AIDS 4(4) 214-216, 1993. Dinsmore W, Alderdice D. Vasoactive intestinal polypeptide and phento-lamine mesylate administered by autoinjection in the treatment of patients with erectile dysfunction resistant to other intracavernosal agents. Br J Urol 81(3) 437-440, 1998.

Conclusions From Original Reports

This study shows the effectiveness of intracavemosal injections of vasoactive agents (phentolamine and papaverine) in treating impotence of various etiologies (psychogenic, neuropathic, and arteriogenic). These results also suggest that any placebo effect is minimal in this group of patients, in which there is a considerable psy-chogenic overlay to their impotence.

Inclusion Criteria

Men with erectile dysfunction of > 6 months duration and of organic (70 ), psychogenic (11 ), or mixed (18 ) origins. Men with ED n 532- Men with ED n 329- Sildenafil 25mg Sildenafil 50mg Sildenafil 100mg Sildenafil (open-label) Figure 12.1. Phase III pivotal study of sildenafil. Double-blind placebo controlled escalating dose study design SILDENAFIL UTILITY CONFIRMED 47

Functional Neuroanatomy Of Penile Function

Ischiocavernosus Erection

Penile Erection PENILE ERECTION AND FLACCIDITY PHYSIOLOGICAL MECHANISMS Penile erection is a neurovascular event controlled by corporal smooth muscle tone. In the flaccid state, the corporal smooth muscle of cavernous arteries, helicine arteries, and trabeculae are tonically contracted. This limits the blood flow to the penis at 5 mL min, which is sufficient for nutritional purposes (39). There are four physiological components necessary to achieve a penile erection Fig. 5. Schematic representation of neural innervation of the pelvic structures and penile erection. Fig. 5. Schematic representation of neural innervation of the pelvic structures and penile erection. Vascular pulsation of the fully erect penis becomes visible when a steady state has been achieved. Pressure in the lacunar space during an erection results from the equilibrium between the perfusion pressure in the cavernosal artery and the resistance to blood outflow through the compressed subtunical vessels. Therefore, the...

Spinal Mechanisms And Pathways

Additionally, bilateral anterolateral cordotomies in humans result in the complete loss of erectile function and block orgasm-associated sensations. Because touch and two-point discrimination are not altered by this procedure, it appears likely that the erotic quality of genital stimulation depends on the ascending fibers running with the spinothalamic pathways for pain and temperature. In monkeys, electrical stimulation along the course of the spinothalamic pathways at the level of the brain stem elicits erection and ejaculation (219). The relevant fibers could be traced to the caudal thalamic intralaminar nuclei, which may be the receiving area for erotic genital sensation. Stimulation of these nuclei in humans has been reported to cause erotic feelings and orgasm. Under normal conditions, it seems likely that psychogenic and reflexic stimuli act in a synergistic manner to produce erections. Psychogenic erections in paraplegic men are usually short-lived, only partial, and lack the...

Relevance

Although phenoxybenzamine has largely been replaced by prostaglandin E1 (PGE1) and mixes of vasorelaxant agents, until the arrival of sildenafil intracavernosal administration was the mainstay of therapy. Even after the arrival of sildenafil, there is still relatively widespread use of injectables, and indeed some patients prefer the quality of the erection achieved.

Outcome Measures

Penile response was assessed by an Erection Assessment Scale 1 no response, 2 some enlargement, 3 full enlargement (but insufficient rigidity), 4 erection sufficient for intercourse, and 5 full rigidity. The duration of response and overall level of comfort were recorded before and 15, 30, 45, and 60 minutes after administration.

Erectile Tissue

Penile Artery

The tunica albuginea of the corpus spongiosum is much thinner than that of the corpora cavernosa and contains more elastic fibers. Cadaveric studies have demonstrated that the thinnest portion of the tunica is at the 6 o'clock position over the urethra, which explains the epidemiology of perforation during penile prosthesis implantation. Emissary veins run between the inner and outer bundles obliquely and, therefore, can be occluded easily by the shearing action of the tunical layers during erection. The outer layer appears to play an additional role in compression of the veins during erection. However, dorsal artery branches take a more direct perpendicular route and are protected by compression during erection by a peri-arterial fibrous sheath. The tunica albuginea provides tough uniform backing for engorged sinusoidal spaces. injury to these structures during deep pelvic surgery can lead to vasculogenic erectile dysfunction. Collateral vessels may open in the setting of...

Pharmacologic Therapy

Because neither the anatomic nor the chemical source of dyspepsia was determined until the late 19th century, therapy before that time was empiric and often quite imaginative. Recommendations included sedum (stonecrop), chewing green tea, and magnesia. For centuries, relief from dyspepsia was provided by chalk, charcoal, and slop diets.94 At the turn of the 20th century, proprietary medicines were popular, and were offered not only as cures for heartburn but also for impotence and alopecia.94 Therapy at that time centered on avoidance of acidic foods, otherwise bland diets free of cap-saicin, milk, antacids, and elevation of the head of the bed. In addition to their acid-neutralizing effects, antacids were subsequently demonstrated to increase lower esophageal sphincter pressure and decrease gastroe-sophageal reflux.95,96 Alginic acid, which reacts with saliva to form a viscous coating that protects the esophagus (and stomach) was shown to have effects on reflux symptoms similar to...

The Spinal Cord Coordinates Many Autonomic Reflexes

Reflexes coordinated by centers in the lumbar and sacral spinal cord include micturition (emptying the urinary bladder), defecation (emptying the rectum), and sexual response (engorgement of erectile tissue, vaginal lubrication, and ejaculation of semen). Sensory action potentials from receptors in the wall of the bladder or bowel report about degrees of distenion. Sympathetic, parasympathetic, and somatic efferent actions require coordination to produce many of these responses.

Symptoms of Normal Pituitary Hormone Loss

The next hormones to become deficient are usually the gonadotropins. Prepubertal children have no effects from gonadotropin deficiency, but adults develop oligoamenorrhea, impotence, and or infertility. Deficiencies of TSH, which leads to hypothyroidism, and ACTH, which leads to hypoadrenalism, are less common, even with large tumors. Deficiency of prolactin (PRL) is also uncommon and only presents in the postpartum period as a failure to lactate. Diabetes insipi-

Development Of 5aReductase Inhibitors

As discussed, although other approaches to androgen ablation and androgen inhibition (antiandrogens) have been evaluated in the past, these methods produced only a moderate desired impact and had many side effects, thus limiting their use (14). Typical antiandrogen (e.g., flutamide) side effects include onset of erectile dysfunction, impairment in libido and ejaculation, gastrointestinal distress, nausea, flatulence, gynecomastia, breast pain, diminished energy levels, impairment in spermatogenesis, and decreased muscle mass. In contrast, because mature (postpubertal) patients with 5 a-reductase deficiency did not appear to have impaired sexual function or diminished external mascu-linization, the 5 a-reductase enzyme was a logical target for treating men with clinically significant BPH. The potential blockade of 5a-reductase seemed to provide hope for decreasing prostate growth and minimizing side effects. blocking 5a-reductase without affecting the binding of T to the androgen...

Nitric oxide is a gas that can act as a second messenger

The spectacular discovery of NO as a second messenger explained the action of nitroglycerin, a drug that has been used for over a century to treat angina, the chest pain caused by insufficient blood flow to the heart. Nitroglycerin releases NO, which results in relaxation of the blood vessels and increased blood flow. Penile erection is also caused by the dilation of blood vessels in that organ, and the new drugs that promote erection are NO synthesis activators.

Indirect Outcome Measures

Given the similarity of improvement in indirect parameters, the lower risk profile associated with TUIP has become a major criterion for promotion of TUIP. These factors include the cost related to operative and hospitalization time, patient comfort related to catheterization time, risk of blood transfusion, stricture or bladder neck contracture, impotence, and retrograde ejaculation. The mean intervention time required for TUIP was 14-18 min compared with 32-44 min for the transurethral resection group (30,32,37,39,58).

Win Races and Lose Racing The Example of Physical Enhancements

What is a human performance and what is an excellent one And what makes it excellent as a human performance For it seems that some performance-enhancing agents, from stimulants to blood doping to genetic engineering of muscles, call into question the dignity of the performance of those who use them. The performance seems less real, less one's own, less worthy of our admiration. Not only do such enhancing agents distort or damage other dimensions of human life - for example, by causing early death or sexual impotence - they also seem to distort the athletic activity itself. What is at stake here is the very meaning of human agency, the meaning of being at-work in the world, being at-work as myself, and being at-work in a humanly excellent way. (President's Council on Bioethics 2003 140-141)

Other Potential Causes of Androgen Deficiency

Men with pre-existing testicular dysfunction (including renal failure) may be more susceptible to further impairment of steroidogenesis caused by medications or illnesses. HMG-CoA reductase inhibitors inhibit cholesterol synthesis and may, therefore, impair steroidogenesis, particularly because adverse events consistent with androgen deficiency (gynecomastia and impotence) have been reported. A prospective, open-label study of 25 nephrotic, hyperlipidemic men with moderate chronic renal failure treated for 12 mo with lovastatin (40 mg d) showed no change in baseline and GnRH-stimulated LH, FSH, and testosterone levels (38). A more discerning test of testicular steroidogenesis, such as testosterone response to submaximal hCG stimulation, was not reported. Adrenal steroidogenesis (plasma cortisol before and after adrenocor-ticotropic hormone ACTH stimulation) was comparable with age-matched healthy controls at entry and remained unchanged by lovastatin treatment. Not surprisingly,...

Hypnotic Interventions in the Treatment of Sexual Dysfunctions

Clinical difficulties in sexual functioning can arise at any phase of the normal sexual response and can come about from a wide variety of causes. The phases represented in normal sexual response are respectively sexual interest sexual arousal sexual penetration sexual orgasm, post-sexual resolution and post-sexual feelings. At each phase of the emotional and physical response, male sexual functioning may be hindered. Factors involved in the likely aetiology of the respective disorders are dealt with later. All disorders are classified by type, that is the phase of the sexual response involved, and along three other dimensions (a) whether lifelong or acquired (b) whether generalized or situation specific and (c) whether due to psychological or combined psychological and medical causes general medical condition-related or substance use-related (prescribed or non-prescribed). The lack of good epidemiological studies on normal sexual functioning, in particular contemporary studies, means...

Metaphorical Therapies

Other metaphors including warmth, sweating, and so on, may also be used to enhance the sexual response. Cartoon or dramatic representations of the most erotic involvement have also been used (Araoz, 1982) to rehearse, give permission for and enhance involvement in sexual activity. Symbolic transformation of the parts of the anatomy which may be perceived negatively has also been used to remove anxiety-based inhibitory responses (Araoz, 1982) (e.g. the labia are perceived as the petals of a lovely flower or the penis may be represented as a beautiful ivory or marble column, and so on).

Relating Acute Vasoconstriction and Vasoactive Mediators to Hypoxic Remodeling

Although a variety ofvasoactive blockers will lower pressure, endothelin (ET) receptor blockade appears to be most promising as a selective strategy in reversing acute hypoxic pulmonary vasoconstriction (HPV) as well as the remodeling associated with chronic hypoxia. For example, an ET-A receptor blocker has proven most effective in reducing the structural abnormalities associated with hypoxia-induced pulmonary hypertension in piglets (2). These studies have provided convincing evidence that the high ET levels are causally related to HPV. In addition, hypoxia inhibits ET-B receptor-mediated NO synthesis (NOS) (42). Impaired NOS and vasodilatation in chronic hypoxia is also associated with impaired cGMP-dependent mechanisms (6). To this end protection against the structural changes associated with chronic hypoxia has been achieved with sildenafil, related in part to the induction of natiuretic peptides (57). Agents also shown to be effective in the treatment of chronic hypoxic...

Assessment Of Response To Gamma Knife Treatment

Because GH production is influenced by age and gender (GH secretion declines with increasing age), it is necessary to have the IGF-1 level measured in a laboratory that provides normal values in relation to age and gender. In patients with CD, the 24-h UFC concentration is the best measure of integrated cortisol production. A normal 24-h UFC is an excellent measure of excessive cortisol production but is not helpful to assess adrenal insufficiency. A single serum PRL measurement in a patient with a prolactinoma is sufficient to assess the response to Gamma Knife therapy. Gonadal function is assessed by a history of normal libido and erectile function and a normal serum testosterone in men. In premenopausal women, regular menses indicate normal ovarian function. Men should have serum testosterone measured regularly, and menstrual history and serum estradiol levels should be measured in premenopausal women. In patients with Nelson's syndrome (increased serum ACTH...

Muscleinvasive bladder cancer MIBl

The typical morbidities after radical cystectomy are erectile dysfunction and disturbed sexual life on the one hand, and urinary leakage and stoma problems on the other.3-6 Change of body image and disturbed sexuality may be followed by decreased self-esteem. High-dose radiotherapy is another therapeutic option which in non-randomized series seems to result in similar survival rates comparable to patients with small tumours (T2).7 An important condition for a favourable outcome of such an approach is the feasibility of qualified follow-up combined with salvage cystectomy if necessary. Typical radiotherapy related side-effects are diarrhoea due to the irradiated bowel, irritative symptoms from the bladder, dryness of the vagina and erectile dysfunction. Dependent on age and co-morbidity, 64 of the patients with MIBC recorded erectile dysfunction present before any treatment was given, and 51 recorded decreased libido.8 Urinary symptoms were present in 2661 of the patients with...

Sexual Problems in Multiple Sclerosis

Given the complexity of the sexual response in terms of the neuro-muscular transmissions involved, it is no surprise that sexual difficulties often are encountered in MS. Such difficulties frequently are clearly physical, although a psychological component may be involved in many or most instances of difficulty. More than 90 of all men with MS and more than 70 of all women with MS report some change in their sexual life after the onset of the disease. Men most often report impaired genital sensation, decreased sexual drive, inability or difficulty in achieving and maintaining an erection, and delayed ejaculation or decreased force of ejaculation. Women report impaired genital sensation, diminished orgasmic response, and loss of sexual interest they also may be bothered by intense itching, diminished vaginal lubrication, weak vaginal muscles, and a reflex pulling together of the legs (adductor spasms).

Clinical Focus Box 351

Diabetic neuropathy typically involves symmetric sensory loss in the distal lower extremities or autonomic neuropathy, leading to impotence, GI dysfunction, or anhidrosis (lack of sweating) in the lower extremities. The diabetic foot is an example of several complicating factors exacerbating one another. About 50 to 70 of non Diabetic peripheral neuropathy is also a common complication of long-standing diabetes. This disorder usually involves sensory nerves and those of the autonomic nervous system. Many persons with diabetes experience diminished sensation in the extremities, especially in the feet and legs, which compounds the problem of diminished blood flow to these areas (see Clinical Focus Box 35.1). Often, impaired sensory nerve function results in lack of awareness of severe ulcerations of the feet caused by reduced blood flow. Men may develop impotence, and both men and women may have impaired bladder and bowel function.

Are All Drugs In The Group The Same With The Same Side Effects

There are several drugs (made by different companies) within each group or family of drugs. They tend to be very similar, with only slight differences, because they have a similar chemical structure. Usually, if one of the group causes impotence, another will do the same. Sometimes, it's worth switching to another drug in the same group to find out. If a drug causes impotence, stopping it should cure the problem. If it doesn't, it is unlikely that the drug is responsible. Patients with impotence should discuss this with their internist or cardiologist.

Erection Emission and Ejaculation

Bulbourethral Gland Inflammation

Erection is achieved by parasympathetic nerve-induced vasodilation of arterioles that allows blood to flow into the corpora cavernosa of the penis. The neurotransmitter that mediates this increased blood flow is now believed to be nitric oxide (fig. 20.23). Nitric oxide released by parasympathetic axons and produced by the endothelial cells of penile blood vessels activates guanylate cyclase in the vascular smooth muscle cells. Guanylate cyclase catalyzes the production of cyclic GMP (cGMP), which closes Ca2+ channels in the plasma membrane (fig. 20.23). This decreases the cytoplasmic Ca2+ concentration, causing smooth muscle relaxation (chapter 12). The penile blood vessels thereby dilate to increase the blood flow into the erectile tissue, producing an erection. Erection is controlled by two portions of the central nervous system the hypothalamus in the brain and the sacral portion of the spinal cord. Conscious sexual thoughts originating in the cerebral cortex act via the...

Total Proctocolectomy with Brooke End Ileostomy

As a general rule, such an extensive operation should be avoided. However, current candidates for total proctocolectomy with Brooke end ileostomy include elderly patients in good condition with poor anal sphincter function, patients with massive rectal bleeding or distal rectal cancer invading the anal sphincter and patients who have a personal preference for this surgical option. Complications, such as impotence and perineal wound breakdown, can be reduced if an intersphincteric proctectomy is performed. Continent ileostomy as functioning Kock pouches 44-46 , the Barnett pouch or the T-pouch 34, 47 have achieved some level of acceptance. However, these procedures are associated with numerous complications and are performed largely in referral centres where the need for reoperations is lower than 10 .

Occlusive Disease of the Aorta and Branches

Aorta Collaterals

The vast majority of stenotic (Fig. 19) and occlusive diseases of the aorta in the western world result from atherosclerosis. Occlusion of the abdominal aorta can be acute or chronic. Abrupt occlusion of the aortic bifurcation is rare. It is characterized by the sudden onset of pain, pallor, paralysis, and coldness in the legs. Usually a filling defect-meniscus on MIP projections indicates embo-lus. Urgent embolectomy is indicated and can usually be performed transfemorally. Chronic occlusion of the aortic bifurcation (Leriche's syndrome) is usually due to arteriosclerosis, is most frequently seen in the elderly, especially males with a history of smoking and manifests as intermittent claudication in the legs and buttocks and erectile impotence (Fig. 20). Leriche syndrome typically re-

Nitric Oxide and Carbon Monoxide as Neurotransmitters

In the PNS, nitric oxide is released by some neurons that innervate the gastrointestinal tract, penis, respiratory passages, and cerebral blood vessels. These are autonomic neurons that cause smooth muscle relaxation in their target organs. This can produce, for example, the engorgement of the spongy tissue of the penis with blood. In fact, scientists now believe that erection of the penis results from the action of nitric oxide, and indeed the drug Viagra works by increasing this action of nitric oxide (as described in chapter 20 see fig. 20.23). Nitric oxide is also released as a neurotransmitter in the brain, and has been implicated in the processes of learning and memory. This will be discussed in more detail later in this chapter.

Indications For Open Prostatectomy

There are a number of factors that should prompt the serious consideration of suprapubic transvesical prostatectomy. These include the following (1) adenomas > 75 g (2) transition zone hyperplasia associated with a large, prominent subtrigonal component (3) presence of a physiologically relevant diverticulum (4) multiple large bladder calculi (5) confounding orthopedic problems such as severe spinal stenosis and fusion ankylosis of the hip joints (6) large scrotal hernia or massive hydrocele (7) rigid or semirigid penile prosthesis (8) multiple urethral strictures (9) trigonal distortion resulting from trauma or previous surgery that places the ureteral orifices in close proximity to the bladder neck (10) expectations prejudices of the patient and (11) skill experience of the surgeon (1). There are two major reasons for the infrequent use of simple perineal prostatectomy for the management of BPH. First, there is a general attrition of perineal surgical skills. Second, this approach...

Clinical Aspects of the Male Reproductive System

Transurethral Incision The Prostate

ERECTILE DYSFUNCTION Erectile dysfunction, also called impotence, is the male lack of ability to perform intercourse because of failure to initiate or maintain an erection until ejaculation. The disorder may be broadly characterized as psy-chogenic, in which case it is caused by emotional factors, or organic, caused by some physical problem such as an anatomic defect or circulatory problem. More specifically, neurogenic impotence results from a disorder of the nervous system, such as a central nervous system lesion, paralysis, or neurologic damage complicating diabetes. Erectile dysfunction may also be a side effect of drug treatment. Drugs that are used to treat erectile dysfunction work by dilating arteries in the penis to increase blood flow to that organ. One highly prescribed drug of this sort is sildenafil (trade name, Viagra). Penile vacuum pumps and penile prostheses are nondrug approaches to therapy for erectile dysfunction. A lack of ability to perform intercourse in the man...

Reproductive Disorders Are Associated With Hypogonadotropic or Hypergonadotropic States

Lactinemia, whether from hypothalamic disturbance or pituitary adenoma, often results in decreased GnRH production, hypogonadotropic state, impotence, and decreased libido. It can be treated with dopaminergic agonists (e.g., bromocryptine), which suppress PRL release (see Chapter 38). Excess androgens can also result in suppression of the hypothalamic-pituitary axis, resulting in lower LH levels and impaired testicular function. This condition often results from congenital adrenal hyperpla-sia and increased adrenal androgen production from 21-hydroxylase (CYP21A2) deficiency (see Chapter 34).

Protocol For Treatment And Followup

New hormone deficiency or deficiencies are identified by obtaining a thorough clinical history and physical examination and measurement of appropriate hormone concentrations. Fatigue, weight gain, decreased mental alertness, and constipation suggest hypothyroidism. Fatigue, orthostatic symptoms, diminished appetite, and weight loss suggest adrenal insufficiency. A decrease in libido or erectile dysfunction suggests hypogonadism in men and a change in menses (irregular menses, amenorrhea), diminished libido, or hot flashes suggest gonadal failure in women. The symptoms of GH deficiency overlap with other hormone deficiencies and include fatigue, decreased exercise tolerance, increase in abdominal adiposity, and diminished sense of well-being. Appropriate hormone studies include measurement of serum thyroxine (or free thyrox-ine, free T4), early morning cortisol, testosterone (men), and estradiol (women). Measurement of serum thyroid-stimulating hormone (TSH) is not helpful and may be...

Finasteride Phase Iii Clinical Trials

In both phase III trials, adverse side effects associated with finasteride were evaluated. On the basis of these studies, finasteride was shown to be clinically safe. The incidence of adverse side effects for finasteride patients in both studies was limited and was generally quite similar to the incidence in placebo patients. Exceptions to this included a higher incidence of decreased libido, erectile dysfunction, and diminished ejaculate volume in patients receiving finasteride.

Proscar Longterm Efficacy And Safety Study

No difference in the incidence of serious adverse events between the two groups was observed. In fact, the only adverse effects that were drug-related and for which the incidence was greater than or equal to 1 and greater than placebo were symptoms of sexual dysfunction (impotence, decreased libido, decreased ejaculate volume, ejaculation disorder), breast enlargement tenderness, and rash. Interestingly, two cases of breast cancer were diagnosed in the placebo group neither man had an antecedent history of gynecomastia. No cases of breast cancer were detected in the finasteride group during the study.

An Electroencephalogram Records Electrical Activity of the Brains Surface

Sleep Cycle Hypertension

REM sleep is also known as paradoxical sleep, because of the seeming contradictions in its characteristics. First, the EEG exhibits unsynchronized, high-frequency, low-amplitude waves (i.e., a beta rhythm), which is more typical of the awake state than sleep, yet the subject is as difficult to arouse as when in stage 4 slow-wave sleep. Second, the autonomic nervous system is in a state of excitation blood pressure and heart rate are increased and breathing is irregular. In males, autonomic excitation in REM sleep includes penile erection. This reflex is used in diagnosing impotence, to determine whether erectile failure is based on a neurological or a vascular defect (in which case, erection does not accompany REM sleep).

Sexual Dysfunction Secondary to Surgical Treatment

There are no randomised controlled trials on this aspect and the only study that has compared results after mesorectal (111 patients) or close rectal (45 patients) dissection for IBD, did not show significant differences between the two techniques in terms of permanent impotence (4.5 vs. 2.2 ) or minor erectile difficulties (13.5 vs. 13.3 ) 128 . In the event of postoperative impotence, a period of observation is always indicated, because dysfunction is transitory in the majority of cases. In the mean time, other possible causes such as psychological or vascular causes should be excluded. Problems that persist beyond 3-6 months are likely to be permanent. In these cases, the therapeutic options are injection of the cavernous corpora with vasodilatory drugs (papaverine, prostaglandin) or surgical implant of either a malleable or inflatable prosthesis 155 . The last are preferred because they give a more natural appearance to the penis 156 and a higher grade of satisfaction 155 . New...

Lambert Eaton Myasthenic Syndrome Clinical features

Active Zone Freeze Fracture Endplate

Lambert-Eaton myasthenic syndrome (LEMS) is a presynaptic disorder of neuromuscular transmission which is caused by the production of antibodies to voltage-gated Ca2+ channels at the motor nerve terminals. This results in a marked reduction in acetylcholine release, the failure of neuromuscular transmission and muscle weakness. Muscle weakness is most common in the limbs, so that patients complain that their legs feel stiff or weak and they find difficulty in walking indeed, in some individuals the symptoms of the disease may be sufficiently severe to render them bedbound. Tendon reflexes are also weak or absent. Unlike myasthenia gravis, in LEMS muscle weakness does not increase with exercise in fact, muscle strength and tendon reflexes are briefly enhanced during the first few seconds of maximal effort. LEMS is also associated with symptoms indicative of disturbance of the autonomic nervous system, including decreased salivation and sweating, constipation and impotence. In most, but...

Long Term Complications

Long-term complications following TURP primarily include urinary tract infection, obstruction, incontinence, and erectile dysfunction, although there is debate about whether the latter is truly associated with the procedure. Interestingly, despite the use of prophylactic and perioperative antibiotics, delayed genitourinary infection is still a significant problem after TURP, accounting for nearly half of long-term complications (4 ) (21). This is probably not a result of persistent bacteriuria from the procedure but is more likely the result of some of the complications discussed below, including obstruction and incontinence. be at greater risk for perforation of the capsule and thus may be more susceptible to problems with erection (28). Rates of new-onset erectile dysfunction are debatable, ranging from 5 to 33 depending on the study and risk factors of the patient (28,29). Wasson et al. found no differences in the incidence between men with BPH managed with either watchful waiting...

Hypogonadism Can Result From Defects at Several Levels

To establish the cause(s) of reproductive dysfunction, physical examination and medical history, semen analysis, hormone determinations, hormone stimulation tests, and genetic analysis are performed. Physical examination should establish whether eunuchoidal features (i.e., infantile appearance of external genitalia and poor or absent development of secondary sex characteristics) are present. In men with adult-onset reproductive dysfunction, physical examination can uncover problems such as cryptorchidism (nondescendent testes), testicular injury, varicocele (an abnormality of the spermatic vasculature), testicular tumors, prostatic inflammation, or gynecomastia. Medical and family history help determine delayed puberty, anosmia (an inability to smell, often associated with GnRH dysfunction), previous fertility, changes in sexual performance, ejacula-tory disturbances, or impotence (an inability to achieve or maintain erection).

Physiopathology of Hypogonadism

Prolactinomas are the most common functional adenomas of the anterior pituitary (representing 60 of hormone-secreting pituitary tumors). Men with prolactinomas usually present with macroadenomas (tumors > 10 mm in diameter) and with high prolactin (PRL) levels, erectile dysfunction, loss of libido and or infertility. These symptoms are related to the hypogonadism that occurs secondary to hyperprolactine-mia (3). Infertility Decreased libido Impotence Gynecomastia Galactorrhea Loss of pubic hair Osteoporosis Apathy

Introduction Acquired and Genetic Disorders of Iron Metabolism

Iron related disorders leading either to exhausted or to overloaded iron stores, are extremely common in all parts of the world. Iron deficiency as a cause for anaemia has been recognized for centuries. Probably the first report on the beneficial effects of iron in anaemia comes from Greece in 1500 BC. It was told that prince Iphyclus of Thesaly suffered from sexual impotence (Fairbanks etal, 1971). He was treated by the physician Melampus who scraped the rust from the blade of an old knife into some wine, which was given to Iphyclus to drink. The result was spectacular the impotence of Iphyclus was cured and the dynasty of Thesaly was saved. The cause of the discomfort of the prince may have been blood loss from playing with another, hopefully not rusty, knife. Interestingly, impotence may also be caused by severe iron overload. Although the pathophys-iology is rather different, many symptoms of iron deficiency are identical with those observed in haemochromatosis. In both conditions...

The Brain Is a Target Site for Androgen Action

In normal men, no correlation is found between circulating testosterone levels and sexual drive, frequency of intercourse, or sexual fantasies. Similarly, there is no correlation between testosterone levels and impotence or homosexuality. Castration of adult men results in a slow decline in, but not a complete elimination of, sexual interest and activity. See Clinical Focus Box 37.2 for a discussion of the effects of testosterone administration.

Male Erectile Disorder

Crasilneck (1979, 1982) reported an extensive follow-up study of the application of hypnosis to individual patients with erectile dysfunction. Direct suggestions of firm, hard erections can be of assistance, or metaphorical associations of erectile firmness may be suggested in indirect approaches. Suggestions of arm or finger catalepsy may be transferred to erectile functioning (Crasilneck & Hall, 1975 Araoz, 1982 Hammond, 1990). Post-hypnotic suggestions of erectile firmness have proved successful (Crasilneck & Hall, 1975). Hypnotically assisted age regression to a time of successful sexual functioning may be used (Kroger & Fezler, 1976) Hypnotically based desensitization and rehearsal of sexual success may aid in reestablishing confidence and the expectation of successful functioning. Hypnosis may also be used to explore and accentuate past or present sexual fantasies which may then be incorporated into contemporary sexual activity, either in reality with the current...

Clinical Experience in BPH

Who did not have thermometry required catheterization. There were minor and transient effects such as hematuria and hematospermia, but minimal irritative symptoms were noted. No erectile dysfunction, transfusions, incontinence, or changes in sexual function were noted. Injury to the rectum or periprostatic tissue did not occur with the exception of insignificant subtrigonal extension in one patient seen on cystoscopy. Transient urinary retention was noted in 92 (46 50) of patients. Erectile function was not altered, but one patient had retrograde ejaculation. Other side effects were minor, except for one patient who had a

Ureteral Injury

Male impotence and infertility is another possible side effect of medical therapy, especially during treatment with sulphasalazine 138-140 . This fact has also been noticed in a survey that compared the quality of life between patients with ulcerative colitis treated medically and patients who had received a restorative proctocolectomy utilising specific questionnaires, it emerged that 26 of patients under medical therapy suffered from impotence and another 16 reported regular failure of ejaculation, while these problems were present in only 8 of those who underwent surgery 141 . However, in most cases discontinuation or changing of the drug is sufficient to return to normality 138,139 .

Estrus

External estrus signals vary greatly by species. In every case, they are largely produced by hormonal influences, and are keyed to evoke specific sexual response from the male of the species. Such signals may be visual, behavioral, auditory, or scent-based, or may possibly draw on senses imperceptible to human observers.

Beta Blockers

The common side effects are cold hands and feet (and so are generally avoided in people with peripheral vascular disease), depression, bad dreams, sluggishness of thought and ability to do things (this is why they are sometimes used to calm people down), impotence and dizzy spells.

Contraindications

Contraindications specific to TUMT are evolving as the technology changes and outcomes are studied further. Patients with a history of TURP or pelvic trauma should not undergo TUMT because of potential alterations in pelvic anatomy. Patients with glands < 25 gm or with a prostatic urethral length < 2.0 cm respond poorly to TUMT, as do patients with glands > 100 gm or patients with a prominent median bar or middle lobe. Other contraindications include the presence of a penile prosthesis, severe urethral stricture disease, Leriche syndrome severe peripheral vascular disease, or an artificial urinary sphincter. Patients with pacemakers should consult their cardiologist concerning pacemaker management during therapy. Hip replacement is no longer a contraindication. Acute urinary retention was previously thought to be a contraindication to TUMT however, high-energy TUMT has shown promise in this population, although efficacy has yet to be determined.

HCV Treatment

Of serious psychiatric symptoms during interferon-alpha treatment may not be high, and that psychiatric illness or the possibility of psychiatric complications should not be used as a reason to refuse this treatment to patients with hepatitis C (Mulder et al. 2000). Nevertheless, psychiatric disorders may influence the course of treatment of HCV infection, and clinicians as well as internists should be aware of the substantial psychiatric comorbidity in these patients. Although neuropsychiatric complications of HCV itself are not a significant problem, some of the symptoms of liver failure, such as fatigue, loss of appetite, loss of sexual drive, and impotence, can overlap with the complications of interferon treatment, the symptoms of psychiatric disorders, and the side effects of psychotropic drugs.

Laser TUIP

The use of lasers for TUIP represented efforts to further decrease the risk of transfusion, catheterization time, and establish TUIP as an outpatient procedure (42-44). Investigators have described the use of both the neodymium yttrium-aluminum-garnet and Holmium lasers. In one series of 100 men, a single transmural incision out to the fat was made from the ureteral orifice to the verumontanum using holmium yttrium-aluminum-garnet laser energy (transmitted through a 400-nm fiber sheathed in a ureteral catheter). The patients reported rapid improvements in symptom scores (International Prostate Symptom Score decreased from 19.2 to 3.7 at 6 wk), urine flow rates (peak urinary flow rate decreased from 9.79 to 19.23), and postvoid residuals (decreased from 133.6 mL preoperatively to 27 mL after the procedure). All of these values were unchanged after 2-yr follow-up. Finally, laser TUIP was performed without the need for postoperative catheterization, and erectile dysfunction did not...

The sexual history

Sexual dysfunction and sexually transmitted diseases are common they are not confined to young adults, or to promiscuous individuals. Although such topics are often avoided by patients because of embarrassment, it is particularly important to ask patients about sexual function and activity and if they have any of the disorders known to predispose to sexual dysfunction. These include diabetes mellitus, alcohol abuse, chronic renal failure, marital difficulty or psychological disorder. Similarly, when sexually transmitted diseases are suspected, e.g. IIIV. hepatitis or pelvic inflammatory disease, a careful sexual history should be undertaken. In females, dyspareunia (pain related to sexual intercourse) or failure to achieve an orgasm are common and are frequently caused by. or lead to. psychological difficulties. In males, loss of libido, premature ejaculation and inability to maintain an erection may also be primarily psychological. Questions should be asked objectively with tact and...

Discussion

Roehrborn reported the following order of magnitude of symptomatic improvement attributed to therapies for LUTS transurethral resection, open prostatectomy, transurethral incision, balloon dilation, a-blocker therapy, placebo, and finasteride (68). Long-term outcome data from randomized trials revealed no statistically significant difference in total, irritative, or obstructive symptom improvement at all follow-up intervals for either the TURP or TUIP group (59). Operating time, estimated blood loss, time to catheter removal postoperatively, and duration of postoperative hospital stay were all significantly better with TUIP (59). The cost associated with TUIP may be reduced because of decreased operative time, decreased hospital stay, and the ability to perform the surgery using local anesthesia (69). Further, sexual function, including erectile function and ejaculation, are better preserved after TUIP. Finally, long-term success rates are probably less than with TURP or open...

Androgen Deficiency

Men with chronic renal failure exhibit features consistent with classical androgen deficiency reproductive manifestations, including gynecomastia, impotence, testicular atrophy, impaired spermatogenesis, and infertility, as well as somatic disorders of bone, muscle, and other androgen responsive tissues (1,2). However, only a single well-controlled study has examined androgen replacement therapy in men with uremia (34). Nineteen men who were receiving regular hemodialysis were randomized to receive either oral testosterone undecanoate (240 mg d) or placebo for 12 wk. Libido and sexual activity were increased, but hemoglobin was unchanged. There were no adverse clinical effects or hepatotoxicity. Effects on bone, muscle, cognition, and well-being were not reported. Further studies examining physiological androgen replacement therapy in men with chronic renal failure, notably using nonparenteral therapies in view of the increased bleeding risks in men with chronic renal failure, would...

Safety and Morbidity

The safety of any device is of obvious importance. Mebust et al. reviewed the immediate and postoperative complications of TURP, which serves as a benchmark for comparison (13). Immediate complications occurred in 18 of patients, with the most common being failure to void (6.5 ), bleeding requiring transfusion (3.9 ), clot retention (3.3 ), and infection (2.3 ). Intraoperative complications occurred in 6.9 of patients, with the most common complication being bleeding requiring transfusion (2.5 ). Dilutional hyponatremia caused by TUR syndrome occurred in 2 of patients. Late complications after TURP included bladder neck contracture (2.7 ), urethral stricture (2.5 ), mild stress incontinence (1.2 ), and significant incontinence (0.5 ). The reported incidence of impotence was variable and ranged from 4 to 13 . These complication rates were reported from a national survey of American urologists conducted by the AUA in 1987.

Endocrine disease

The most important endocrine disorder encountered in surgical patients is diabetes mellitus. Diabetics appear to be at slightly greater risk for postoperative death, likely because of the greater prevalence of ischemic heart disease in these patients. Several reports also suggest that diabetics with autonomic insufficiency (manifested by postural hypotension, impotence, nocturnal diarrhea) may be at risk for sudden cardiopulmonary arrest postoperatively. Numerous regimens for the management of diabetics in the perioperative setting have been reported. A common method is to give one-half of the patient's usual morning dose of NPH (neutral protamine Hagedorn) on the morning of surgery together with 5 dextrose.

Corticosteroids

Cutaneous side effects include acne, hirsutism, striae, purpura, and impaired wound healing. Osteoporosis, myopathy, and aseptic necrosis of bone may occur. Gastrointestinal side effects include peptic ulceration with bleeding or perforation and pancreatitis. Hypertension and edema secondary to fluid retention occur. Steroid psychosis and benign intracranial hypertension are the central nervous system adverse reactions. Ocular effects include cataracts and glaucoma. Patients may suffer growth arrest, secondary amenorrhea, impotence, and suppression of the hypothalamic-pituitary-adrenal axis. Glucose intolerance, hyperosmolar nonketotic coma, and centripetal obesity occur. The risk for infection is increased. Intraarticular corticosteroids may cause a crystal-induced transient synovitis. Immobilization and ice compress will facilitate resolution persistence of the synovitis beyond 24 hours raises the possibility of an arthrocentesis-related infectious arthritis. Topical steroids,...

Sexual Function

The regulation of sexual function involves multiple brain regions, neurotransmitters, and hormones, and thus is complex (Meston and Frohlich 2000). Sexual interest or sexual function may be impaired directly because of schizophrenia (e.g., negative symptoms may include decreased interest generally, including interest in sex, and severe positive symptoms or social dysfunction may interfere with the ability to develop sexual relationships). Sexual interest or function may thus improve with antipsychotic treatment, or may be impaired as a side effect of antipsychotic treatment. For example, in a study of men with schizophrenia who were in stable relationships (51 taking antipsychotics, 20 drug free, and 51 healthy control subjects), untreated men reported the lowest levels of sexual desire or interest, with antipsychotic-treated men reporting greater interest than untreated men (but less than healthy controls) but decreased ability to maintain an erection and impaired orgasm, and...

Hypogonadism

Male hypogonadism is characterized by low testosterone levels in serum, accompanied by androgen deficiency symptoms, which depend on the time of manifestation. When hypogonadism begins before adolescence, it results in a failure to undergo puberty, whereas postpubertal hypogonadism causes a regression of reproductive function, with impaired libido and impotence, diminished body hair, soft skin, weakness and muscle atrophy, anemia, and osteoporosis. Low testosterone levels, in combination with high gonadotropin levels, indicate a testicular origin (hypergonadotropic or primary hypogonadism), whereas in combination with low gonadotropin levels, the cause is central (hypogonadotropic or secondary hypogonadism) (3). In both primary and secondary hypogonadism, androgen deficiency symptoms can be treated by testosterone substitution (see Chapter 18). In most causes of primary testicular failure, improvement of fertility is not possible, whereas in secondary hypogonadism, fertility may be...

Treatment

It is unclear whether asymptomatic hyperprolactinemia is of any clinical consequence, especially if the prolactin level is not extraordinarily elevated. In symptomatic patients with high prolactin levels, anti-psychotic dose reduction should always be considered as a first option, because hyperprolactinemia is usually dose related. In addition, there are now several prolactin-sparing antipsychotics available, including quetia-pine, olanzapine, and ziprasidone. Switching to one of these antipsychotics is thus a potential treatment option when dose reduction is not effective or feasible. Direct treatment of symptomatic hyperprolactinemia with a dopamine agonist (e.g., cabergoline, bromocriptine, amantadine) may be considered for patients who have had a good response to the current prolactin-elevating antipsychotic, who require depot antipsychotics, or who do not wish to switch medications (American Psychiatric Association 1997). There are numerous case reports of reduction...

Ginseng

Tertiary Structure Ginsenoside

And Canada, and P. notoginseng (Sanchi-ginseng) from China, have been widely used in China and Russia for the treatment of a number of diseases including anaemia, diabetes, gastritis, insomnia, sexual impotence, and as a general restorative. Interest in the drug has increased considerably in recent years and ginseng is widely available as a health food in the form of powders, extracts, and teas. The dried and usually peeled root provides white ginseng, whereas red ginseng is obtained by steaming the root, this process generating a reddish-brown caramel-like colour, and reputedly enhancing biological activity. Ginseng is classified as an 'adaptogen', helping the body to adapt to stress, improving stamina and concentration, and providing a normalizing and restorative effect. It is also widely promoted as an aphrodisiac. The Korean root is highly prized and the most expensive. Long term use of ginseng can lead to symptoms similar to those of corticosteroid poisoning, including...

Prostaglandins

Metabolite Pgi2

Delivered by continuous intravenous infusion. Alprostadil is also of value in male impotence, self-injectable preparations being used to achieve erection of the penis. An interesting modification to the structure of PGE1 is found in the analogue misoprostol. This compound has had the oxygenation removed from position 15, transferred to position 16, plus alkylation at position 16 to reduce metabolism (compare 15-methyl PGF2a above). These modifications result in an orally active drug which inhibits gastric secretion effectively and can be used to promote healing of gastric and duodenal ulcers. In combination with non-specific NSAIDs, it can significantly lower the incidence of gastrointestinal side-effects such as ulceration and bleeding.

Seahorses

Seahorse Species

Overfishing is a serious threat to the future of seahorses. The demand for them is large in traditional Asian medicine, where they are touted as cures for everything from asthma and heart disease to incontinence and impotence. An estimated twenty million seahorses are so used annually. Live animals are also sold for aquariums, where maintaining them is difficult because of their nutritional preference for live crustaceans and their

Sexual Dysfunction

There is increasing experience applying the recent advances in the management of erectile dysfunction, notably pharmacotherapy and mechanical devices, to men with chronic renal failure. For men with chronic renal failure complaining of erectile dysfunction, the management involves initially optimizing conventional medical treatment for uremia, including intensive dialysis or transplantation, nutritional support (including raising hemoglobin), and medication review (70). The first line of specific therapy is oral sildenafil (71), which appears significantly better than placebo in a preliminary report of a randomized, placebo-controlled study (72), which extends similar positive experience from uncontrolled studies of men on dialysis (73,74). However, particular vigilance with sildenafil usage is required for men with chronic renal failure in view of their accelerated rates of atherogenesis. Sildenafil is absolutely contraindicated in men using nitrates for coronary artery disease...

Complications

Erectile dysfunction after TURP or TUMT is rare if a patient is previously normal but is commonly observed in patients with prior erectile difficulties. Although the cause has not been fully elucidated, psychogenic factors, bladder neck trauma, and neurogenic voiding dysfunction probably play a role. Lower-energy TUMT protocols have a lower incidence of erectile dysfunction (28) reported an incidence of erectile dysfunction in 18.2 of patients undergoing high-energy TUMT, compared with 26.5 for TURP.

Hodgkins Disease

Several studies have shown reduced fertility in men with Hodgkin's disease. Padron et al. (7a) found oligospermia (sperm count < 20 x 106 mL) in 18 of 49 (37 ) patients with Hodgkin's disease who produced semen for cryopreservation before treatment. Similar rates of oligospermia were also demonstrated by Vigersky et al. (8) (total sperm count < 40 x 106 in 40 ) and Chapman et al. (9) (total sperm count < 50 x 106 in 36 ). In addition to reductions in sperm number, there is also evidence of abnormalities of sperm motility. When this is considered, up to 70 of men with Hodgkin's disease have abnormal semen analysis before treatment (8,10-12). Because of severe debilitation or impotence, not all men can provide semen for cryopreservation before treatment. Because these reports examined only men who were able to do so, they may have selected out a slightly healthier cohort and may, thus, underestimate the extent of gonadal dysfunction before treatment.

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