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Management of psychogenic anejaculation: primary therapy with penile vibratory stimulation (PVS)
MALE REPRODUCTION AND UROLOGY - CLINICAL O-133 Tuesday, October 21, 2014 04:15 PM SEXUAL HEALTH IN COMPLETE MALE EPISPADIAS (CME) PATIENTS. B. M. Inouye, B. Le, U. A. Anele, M. Abdelwahab, S. Reddy, J. P. Gearhart, P. K. Rao. Johns Hopkins School of Medicine, Baltimore, MD. OBJECTIVE: We provide the first long-term followup on sexual function in post-reconstruction CME patients. DESIGN: We administered a sexual-health telephone survey to CME patients who underwent reconstructive surgery at our institution. MATERIALS AND METHODS: We screened a prospective institutional database of 1216 exstrophy-epispadias patients for CME patients currently R18 years of age who underwent reconstruction since 1969. Patients who could be contacted were asked to complete a phone survey regarding sexual function. Reconstructive history and clinical details were obtained by chart/ database review. Patient-perceived importance of fertility was assessed using a five-point Likert-like scale (1 ¼ least important, 5 ¼ most important). Descriptive data is presented as median (range). RESULTS: Of 132 CME patients, 74 met inclusion criteria, and 14 (19%) completed the telephone questionnaire (Table 1). Of the 14 patients, 50% reported currently being in a relationship. Although 86% reported satisfactory sexual intercourse, 71% of patients admitted to problems with sexual function including unsatisfactory/difficulty ejaculating (50%), diminished sensation (21%), and difficulty maintaining an erection (21%). When questioned regarding the importance of fertility, 71% of patients responded with R4. Five patients reported having impregnated a sexual partner. Although four patients described suspicions of fertility problems, only two had confirmed abnormal semen analysis findings.
Patient Demographics and Results Age at First Repair Current Age 1 Epispadias Repair Type: Young/Cantwell-Ransley Pts Requiring Second Epispadias Repair Pts Requiring Bladder Neck Reconstruction Continent via Urethra/Continent via Stoma/Incontinent Length of Follow-Up Relationship Status: Single Partner/Engaged Married
1.5 years (1–14) 30.5 years (20–58) 8 (57%) /6 (43%) 3 (21%) 13 (93%) 10 (71%) /2 (14%) /2 (14%) 19 years (7–41) 7 (50%) 2 (14%) 5 (36%)
Engage in Regular Sexual Intercourse Satisfactory Sexual Intercourse Issues Regarding Sexual Intercourse
11 (79%) 12 (86%) 10 (71%)
Fertility Importance: R4 %3 Impregnated Partner (Natural/ART) Suspected Fertility Issue Abnormal Semen Test
10 (71%) 4 (29%) 5 (3/2) 4 (29%) 2/4 (50%)
CONCLUSION: To the best of the authors’ knowledge, this is the first report on sexual health in post-reconstruction CME. Patients are able to engage in relationships, enjoy sexual intercourse, and sometimes impregnate their partners. Still, these results highlight sexual concerns and issues that can aid in counseling CME patients. O-134 Tuesday, October 21, 2014 04:30 PM MANAGEMENT OF PSYCHOGENIC ANEJACULATION: PRIMARY THERAPY WITH PENILE VIBRATORY STIMULATION (PVS). G. Weitzman, D. Popper. Puah Institute, Jerusalem, Israel. OBJECTIVE: Penile vibratory stimulation can induce ejaculation for men with spinal cord injuries. To-date, only anecdotal evidence of effectiveness
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has been reported in men with psychogenic anejaculation. Our objective was to determine the effectiveness of penile vibrator stimulation (PVS) as primary therapy for psychogenic anejaculation, as an intervention to allow ejaculation independent of the device. DESIGN: Retrospective chart review of thirty four married Orthodox Jewish men with psychogenic anejaculation who were treated at a counseling center in Jerusalem with instruction and application of penile vibratory therapy. All participants had nocturnal emissions. MATERIALS AND METHODS: All men were counseled regarding the treatment of PVS and agreed to use the device in their home setting. None refused the use of the PVS. All couples were provided a PVS device with instructions and agreed to follow up. RESULTS: All thirty four men (mean age ¼ 25.6 years) were married, and the mean duration of marriage was 3.8 years. Of the thirty four men, 58.8% (20/34) were able to ejaculate using the device. Of the men who were able to achieve ejaculation after using the vibrator 55% (11/20) were able to subsequently achieve ejaculation with sexual intercourse. Mean length of follow up was 4 months. Ten pregnancies were achieved among eight men, eight through intercourse and two through fertility treatment. For men who did not succeed with PVS, three were able to produce sperm through electroejaculation, two collected semen from nocturnal emission using a condom for insemination. One man only used the device once and after failure discontinued use. Two men were not compliant with the treatment and follow up was discontinued. CONCLUSION: Penile vibrator stimulation is an effective way of initiating ejaculation and can be used to overcome the psychological block associated with psychogenic anejaculation enabling such patients to learn to achieve ejaculation without using the device. Optimization of the approach and technique for PVS in this population of patients has yet to be done. Once ejaculation has been achieved, men appear to be able to ejaculate vaginally without reliance on the device and their response appears to be durable. We discovered that a learning curve for application of techniques appears to exist, and communication of a counselor with the patient appears to affect the successful treatment. Follow up is also essential to ensure success. O-135 Tuesday, October 21, 2014 04:45 PM CLOMIPHENE CITRATE IS SUPERIOR TO ANASTRAZOLE IN RAISING TESTOSTERONE IN HYPOGONADAL INFERTILE MEN: A PROSPECTIVE RANDOMIZED DOUBLE BLIND COMPARISON TRIAL. S. Helo,a C. Mechlin,a A. Alkaram,a P. Feustel,b E. Ditkoff,c M. Grossman,c A. McCullough.a aUrology, Albany Medical Center, Albany, NY; bCenter for Neuropharmacology & Neuroscience, Albany Medical College, Albany, NY; cCNY Fertility Center, Latham, NY. OBJECTIVE: In this prospective double-blinded randomized trial we set out to show non inferiority of anastrazole (AZ) to clomiphene citrate (CC) with the objectives of raising testosterone (T) and improving testosterone to estradiol (T/E2) ratio in hypogonadal infertile men (HIM). DESIGN: In this randomized double blind study patients were randomized to either CC or AZ. The effects on several hormone levels were then measured. Patient reported measure were also recorded. MATERIALS AND METHODS: Our cohort consisted of 23 men presenting with infertility and hypogonadotropic hypogonadism defined as serum T less than 300 ng/dL and normal gonadotropins. Patients were randomized to either AZ (1 mg/day) or CC (25 mg/day) for 12 weeks. Hormones assayed were total and free T, E2, luteinizing hormone (LH), follicle stimulating hormone (FSH), and sex hormone binding globulin (SHBG). Safety labs included complete blood count and hepatic profile. Patient reported measures were quantified using the International Index of Erectile Function, Erection Hardness Scale, and the Androgen Deficiency in the Aging Male questionnaires. Blood tests and questionnaires were recorded at baseline, 6 and 12 weeks. Semen analyses were performed at baseline and 12 weeks. RESULTS: The mean age was 34 years. The baseline T increased significantly from baseline (AZ 249 ng/dL, CC 250 ng/dL) to 12 weeks (AZ 419 ng/dL, CC 577 ng/dL) in both groups (p<0.007). Mean increase from baseline total T at 12 weeks was less in the AZ group (71%) than the CC group (130%) (p< 0.003). The T/E2 ratio increased from baseline (AZ 10.2, CC 9.3) to 12 weeks (AZ 17.2, CC 12) (p<0.003). LH and FSH levels also increased in both groups. Neither group demonstrated a significant change in safety measures, seminal parameters or patient reported measures. CONCLUSION: While mean T levels increased in both groups at 6 and 12 weeks, CC demonstrated clear superiority. Although both drugs resulted in a
Vol. 102, No. 3, Supplement, September 2014
Patient Demographics and Results Age at First Repair Current Age 1 Epispadias Repair Type: Young/Cantwell-Ransley Pts Requiring Second Epispadias Repair Pts Requiring Bladder Neck Reconstruction Continent via Urethra/Continent via Stoma/Incontinent Length of Follow-Up Relationship Status: Single Partner/Engaged Married
1.5 years (1–14) 30.5 years (20–58) 8 (57%) /6 (43%) 3 (21%) 13 (93%) 10 (71%) /2 (14%) /2 (14%) 19 years (7–41) 7 (50%) 2 (14%) 5 (36%)
Engage in Regular Sexual Intercourse Satisfactory Sexual Intercourse Issues Regarding Sexual Intercourse
11 (79%) 12 (86%) 10 (71%)
Fertility Importance: R4 %3 Impregnated Partner (Natural/ART) Suspected Fertility Issue Abnormal Semen Test
10 (71%) 4 (29%) 5 (3/2) 4 (29%) 2/4 (50%)
CONCLUSION: To the best of the authors’ knowledge, this is the first report on sexual health in post-reconstruction CME. Patients are able to engage in relationships, enjoy sexual intercourse, and sometimes impregnate their partners. Still, these results highlight sexual concerns and issues that can aid in counseling CME patients. O-134 Tuesday, October 21, 2014 04:30 PM MANAGEMENT OF PSYCHOGENIC ANEJACULATION: PRIMARY THERAPY WITH PENILE VIBRATORY STIMULATION (PVS). G. Weitzman, D. Popper. Puah Institute, Jerusalem, Israel. OBJECTIVE: Penile vibratory stimulation can induce ejaculation for men with spinal cord injuries. To-date, only anecdotal evidence of effectiveness
e46
ASRM Abstracts
has been reported in men with psychogenic anejaculation. Our objective was to determine the effectiveness of penile vibrator stimulation (PVS) as primary therapy for psychogenic anejaculation, as an intervention to allow ejaculation independent of the device. DESIGN: Retrospective chart review of thirty four married Orthodox Jewish men with psychogenic anejaculation who were treated at a counseling center in Jerusalem with instruction and application of penile vibratory therapy. All participants had nocturnal emissions. MATERIALS AND METHODS: All men were counseled regarding the treatment of PVS and agreed to use the device in their home setting. None refused the use of the PVS. All couples were provided a PVS device with instructions and agreed to follow up. RESULTS: All thirty four men (mean age ¼ 25.6 years) were married, and the mean duration of marriage was 3.8 years. Of the thirty four men, 58.8% (20/34) were able to ejaculate using the device. Of the men who were able to achieve ejaculation after using the vibrator 55% (11/20) were able to subsequently achieve ejaculation with sexual intercourse. Mean length of follow up was 4 months. Ten pregnancies were achieved among eight men, eight through intercourse and two through fertility treatment. For men who did not succeed with PVS, three were able to produce sperm through electroejaculation, two collected semen from nocturnal emission using a condom for insemination. One man only used the device once and after failure discontinued use. Two men were not compliant with the treatment and follow up was discontinued. CONCLUSION: Penile vibrator stimulation is an effective way of initiating ejaculation and can be used to overcome the psychological block associated with psychogenic anejaculation enabling such patients to learn to achieve ejaculation without using the device. Optimization of the approach and technique for PVS in this population of patients has yet to be done. Once ejaculation has been achieved, men appear to be able to ejaculate vaginally without reliance on the device and their response appears to be durable. We discovered that a learning curve for application of techniques appears to exist, and communication of a counselor with the patient appears to affect the successful treatment. Follow up is also essential to ensure success. O-135 Tuesday, October 21, 2014 04:45 PM CLOMIPHENE CITRATE IS SUPERIOR TO ANASTRAZOLE IN RAISING TESTOSTERONE IN HYPOGONADAL INFERTILE MEN: A PROSPECTIVE RANDOMIZED DOUBLE BLIND COMPARISON TRIAL. S. Helo,a C. Mechlin,a A. Alkaram,a P. Feustel,b E. Ditkoff,c M. Grossman,c A. McCullough.a aUrology, Albany Medical Center, Albany, NY; bCenter for Neuropharmacology & Neuroscience, Albany Medical College, Albany, NY; cCNY Fertility Center, Latham, NY. OBJECTIVE: In this prospective double-blinded randomized trial we set out to show non inferiority of anastrazole (AZ) to clomiphene citrate (CC) with the objectives of raising testosterone (T) and improving testosterone to estradiol (T/E2) ratio in hypogonadal infertile men (HIM). DESIGN: In this randomized double blind study patients were randomized to either CC or AZ. The effects on several hormone levels were then measured. Patient reported measure were also recorded. MATERIALS AND METHODS: Our cohort consisted of 23 men presenting with infertility and hypogonadotropic hypogonadism defined as serum T less than 300 ng/dL and normal gonadotropins. Patients were randomized to either AZ (1 mg/day) or CC (25 mg/day) for 12 weeks. Hormones assayed were total and free T, E2, luteinizing hormone (LH), follicle stimulating hormone (FSH), and sex hormone binding globulin (SHBG). Safety labs included complete blood count and hepatic profile. Patient reported measures were quantified using the International Index of Erectile Function, Erection Hardness Scale, and the Androgen Deficiency in the Aging Male questionnaires. Blood tests and questionnaires were recorded at baseline, 6 and 12 weeks. Semen analyses were performed at baseline and 12 weeks. RESULTS: The mean age was 34 years. The baseline T increased significantly from baseline (AZ 249 ng/dL, CC 250 ng/dL) to 12 weeks (AZ 419 ng/dL, CC 577 ng/dL) in both groups (p<0.007). Mean increase from baseline total T at 12 weeks was less in the AZ group (71%) than the CC group (130%) (p< 0.003). The T/E2 ratio increased from baseline (AZ 10.2, CC 9.3) to 12 weeks (AZ 17.2, CC 12) (p<0.003). LH and FSH levels also increased in both groups. Neither group demonstrated a significant change in safety measures, seminal parameters or patient reported measures. CONCLUSION: While mean T levels increased in both groups at 6 and 12 weeks, CC demonstrated clear superiority. Although both drugs resulted in a
Vol. 102, No. 3, Supplement, September 2014