Vacuum Erection Device

A 34 year old man already married came to us with erectile dysfunction.After basic evaluation he was started on PDE-5 inhibitors but the result was sub-optimal.
He was then given option of Intra-cavernosal Injection therapy with Bimix but he was repulsive for any injection over the penis.
His basic cause for erection was psychological so we though the medications along with Vacuum Erection Device would be good as he is bound to recover with thecourse of the time.
He opted for battery opted device and is happy with the usage.His wife has also accepted the method whole heartedly.
Vacuum erection devices, also known as vacuum constriction devices have been utilized for improving erectile rigidity for ovrigidity of the penile erection.

The vacuum device consists of a clear plastic cylinder with an aperture at one end that is placed over the penile shaft ; extending till the base of the penis. At the other end of the cylinder is a pump mechanism that is used to generate negative pressure within the cylinder. The pump mechanism can be in the form of either a manually operated(Figure 1 ) or a battery-operated system(Figure 2).


The former requires two hands to operate the device, one on the pump handle and the other to steady the cylinder on the penis itself. So this device is better to be given for people relatively yound and having dexterity over the movements.
The battery-operated device can be used with one hand. This is a better device in relatively infirm patients with neurological weaknesses.
Technique
Once a decision has been made to pursue sexual relations, water-soluble jelly is applied to the base of the penis (As shown in Figure). This maneuver helps in creating a water-tight seal, thus maintaining the negative pressure within the cylinder.
The patient can shave of the pubic hair for better fitting of the instrument. Once the cylinder has been placed over the penile shaft and held firmly against the pubic bone, the pump mechanism can be activated (either by hand held or battery). The negative pressure (vacuum generation) will cause blood to be drawn in the corpora cavernosa. The negative pressure build up is gradual and slow to prevent bruises and hematoma and resultant pain.
Once the erection is achieved the pressure can be let off and again rebuilt to maximize the erection . Once the erection has been achieved, a constriction ring (band) is applied to the base of the penis to act as an artificial valve, thus maintaining the blood within the corporal bodies. The rings come in a variety of shapes, sizes, and most importantly tension (tightness). The choice of the ring depends upon the patients penile size,turgidity and the patients preference.
Indications:
The vacuum device is indicated for men with ED. Especially in older patient and with cardiac comorbidities who are not suitable for medications.The patients who donot improve with the medications also can respond to the Vacuum Erection Device.
It is best suited for the patients with co-operative partner who accepts the usage of the Vacuum Erection Device.
Contra-indications:
(i) using antiplatelet agents/or presence bleeding disorders
(ii) history of priapism
(iii) congenital penile curvature/peyronies disease
(iv) psychiatric disorders/neurological disorders
There are instances in older people mistakenly the Vacuum Erection Device has been applied over the testis also along with the penis and resultant gangrene of the testis.It may so happen that in an inebriated patient may forget to remove the ring after the sexual act.The patient having neurological deficit and no sensations over the penis may neglect ongoing hematoma or even may forget to remove the ring causing grave implications.
It is generally advised to keep ring for not more than 30 minutes.It is essential in old couple to involve both the partners so that such problems can be avoided.
Important Facts to remember:

It has been estimated that the surface temperature of the penis during use of the VED is lower than the temperature prior to application of the device. The patient and his partner should be counseled regarding this fact prior to the initial use of the device as some couple might find cool penis repulsive for the sexual act. The device can take around 15 minutes to obtain erection.This may sometimes kill the already awakened sexual excitement /arousal .
Side Effects
1)cool penis sensations
2)Penile hematomas/bruising
3)The penile numbness might develop in some patients
4)The penis may loosely hand beyond the ring.


Satisfaction:
Despite the apparent drawbacks to the use of vacuum devices, there is a population of patients who find its use easy and it has allowed many couples to successfully resume penetrative sexual relations. The satisfaction rate varies from 35-80% but there are drop outs because of the side effects or some couple opting for better alternatives like penile implants which tries to imitate the natural erection.This device is not good for young people who may feel embarrassed to do whole action-applying the Vacuum Erection Device ;creating the pressure and carrying it everywhere as cumbersome.

BOTOX: UTILITY IN UROLOGY

Botox, which has been smoothing wrinkles for years, now it will also help in relief of the bothersome urinary symptoms associated with an enlarged prostate or bladder conditions.



Botulinum toxin (BTX), a neurotoxin produced by the gram-positive, rod-shaped anaerobic bacterium Clostridium botulinum, was isolated in 1897 by Belgian scientist Professor Pierre Emile van Ermengem. BTX acts by blocking the release of acetylcholine at the neuromuscular junction. As a result of this chemodenervation, a temporary flaccid paralysis ensues. Different medical disciplines have taken advantage of this temporary paralysis to treat muscular hypercontraction. BTX was first approved by the US Food and Drug Administration in 1989 for use in patients with strabismus and blepharospasm. Since then, BTX has been used to treat a number of different neuromuscular disorders. BTX has been used successfully in urology to treat neurogenic and non-neurogenic detrusor overactivity, detrusor-sphincter dyssynergia, motor and sensory urge, and chronic pain syndromes.
The BOTOX toxin is of various types:A to F.The BOTOX A is the more potent with greater duration of action.It has wide urological applications.The BOTOX will bind irreversibly to presynaptic membrane and cause skeletal muscle atrophy but the axons will regenerate after 3-6 months.
BOTOX has been used in many urological consitions such as intractable overactive bladder,neurogenic bladder causing upper tract damage(kidney damage),Detrusor-External Sphicter Dyssenrgia( causing intermittent flow,obstructed stream in Neurological illnesses),chronic prostatic pain,non fibrotic bladder outflow obstruction(prostatic enlargement).
But the most common usage of BOTOX is in irritative bladder symptoms (frequency,nocturia,urgency,urge incontinence not yielding to medicines).The overactive bladder symptoms if doesnot abate with usual anti-cholinergic medications makes the life of the patient miserable. It will have physical problems-leakage causing personal inhygiene, psychological problems-embarrassment and loss of dignity, social problems-social isolation, sexual problems- because of genital skin rashes and foul smell( partner will have repulsion) etc.
The overactive bladder is widely prevalent affecting 50-100 millions of people all around the globe and some of them don’t respond to conventional treatments.These are the people who suffer silently and eventually end up in depression and self esteem.The BOTOX provides a ray of hope in such patients.
Typically 100-300 Units of BOTOX –A toxin is used. Briefly, the BoNT/A dose (200 or 300 units) is reconstituted with saline 0.9% at a total volume of 30 mL. The actual procedure of giving bladder Botox injections is fairly simple. It will take less than 20 minutes, and is minimally invasive. The procedure can be performed under local or general anaesthetic, and will not require an overnight stay in hospital.
A cystoscope – a small tube containing a camera – is passed into the bladder through the urethra so that the surgeon can inspect the inside of the bladder before performing the operation. A very thin needle is then passed through the cystoscope, and Botox is injected into between 20 and 30 different areas of the bladder muscle walls




BOTOX BEING INJECTED IN BLADDER FOR NEUROGENIC BLADDER
The BOTOX helps in alleviation of urological symptoms in 80% of the cases and the effect of BOTOX instillation lasts for 6-14 months.The injection can be repeated at those intervals.The BOTOX injection rarely causes systemic toxicity and rarely causes bladder paralysis needing long term catheterization.
One other area where BOTOX helps is neurogenic voiding dysfunction-either Detrusor Hyperreflexia or Detrusor External Sphincteric Dyssenergia in children with spina bifida/meningocele/myelomeningocele. These voiding dysfunction can gradually destroy the kidneys because of high bladder pressures.This can be brought down with BOTOX and kidney function thus preserved.
Certain novel areas like intractable chronic prostatitis and benign prostatic enlargement especially with detrusor overactivity ; many urologists have started using it with promising results.
The main implication of the BOTOX is that many patients having lower urinary tract symptoms with incontinence,urgency are elderly population with lot of other associated comorbidities like heart ailments.This makes them unsuitable for the conventional surgery if the medical line of treatment fails.In these group of patients BOTOX comes as a boon relieving them of the incontinence as it can be performed under local anaesthesia.
BOTOX although many people have reservations about its usage in urology is here to stay and its acceptance is going to increase because of its simplicity of performance and promising results.

Buccal Mucosal Graft Urethroplasty : A recent case

A -27- old gentleman came with history of weak stream, straining at micturition.There was no history of obvious trauma or prior urological intervention( like catheterization).He did not have the history of exposure also.There was no evidence of Balanitis Xerotica Obliternas on genital skin and mucosa.
He was evaluated and found to be short segment stricture in the proximal bulbar urethra.
He underwent multiple endoscopic interventions and urethral dilatations.
He needed recurrent dilatations. He was advised option of definitive urethroplasty.

He was taken up for ventral onlay urethroplasty.

Under spinal anesthesia through a midline perineal incision the bulbar urethra is exposed without mobilisation. Methylene Blue dye was injected through the meatus. A bougie was passed through the meatus upto the level of the stricture. Ventral urethrotomy is performed through the strictured urethra into normal proximal bulbar urethra upto 1.5cm. Methylene Blue stained urethral mucosa helps to identify the narrowed lumen of the urethra. A 2 cm wide and 6cm long buccal mucosal graft harvested from the cheek and it was defatted.




The BMG is sutured to the urethral mucosa with continuous sutures of 4/0 vicryl to the ventral urethrotomy throughout. A 14 F silastic Foley catheter was inserted to the bladder. The corpora spongiosa was over closed with continuous sutures of 4/0 vicryl and taking anchoring stitches through the buccal mucosa graft. The wound is closed in layers. The catheter is planned to be removed after 4 weeks.

Angioembolisation in Haemorrhagic cystitis

a 65 year old man presented to us with frank hematuria of 1 day duration. he was known case of small capacity bladder with hemorrhagic cystitis with no apparent reason.He was operated in 2002 for clam cystoplasty. He was apparently alright for 8 years just to land up in emergency department with gross total hematuria.



He is known case coronary artery disease and hypertension on medication.He was on ecosprin when he came for hematuria.
Immediately ecosprin was stopped.He was supported with irrigation,tranexa and cystoscopy and evacuation followed by alum irrigation.
After this surgery he was fine for 2 days then suddenly he had bout of frank hemturia causing fall of Hb from 13 TO 10 GM% and BP to fall from 130/80 mm Hg to 70/30 mmHg.

He was immediate taken up for cystoscopy and clot evacuation again with institution of proper blood support and plasma expander support.The bladder base region had angry looking globular mass? Rest of the bladder mucosa and the intestinal mucosa was normal.

The clots were removed with resectoscope and cautery and ellicke evacuator.A three way Foleys catheter was introduced wnd alum irrigation was started..The urine effluent was clear.

aFTER THE CLOT EVACUATION WAS DONE BILATERAL ANGIOEMBOLISATION WAS CARRIED OUT SELECTIVELY ON ANTERIOR DIVISION OF INTERNAL ILIAC ARTER USING SELDINGERS TECHNIQUE.The both iliac arteries anterior divison was blocked with gel foam mixture viscous with the contrast,




The process of Angioembolisation of the internal iliac artery --the end result of the embolisation is seen as the disapperance of the terminal branches of the vesical arteries.
The next plan was if the patient bleeds again then re-ileal conduit and extirpation of the diseased bladder at a later point of time.




The urological hemorrhage is an important problem in contemporary urological practice with significant associated morbidity and mortality. furthermore, these emergencies present a number of challenges to clinicians as current practice has evolved due to the increased availability of new imaging techniques and transarterial embolisation (tae). in this review we have explored the epidemiology, etiology and management of both renal and bladder hemorrhage. renal bleeding secondary to accidental or iatrogenic trauma and neoplastic disease requires careful but expeditious assessment and treatment. we have described current conservative, surgical and radiological approaches to the management of this challenging problem. moreover, bladder hemorrhage due to hemorrhagic cystitis, boadder cancer and infection represents a significant problem in current practice. advances in technology have changed the management options and again we have explored the literature in order to determine the optimum treatment approaches.

Post-Papavarine Injection Priapism:Management

A 35 year old gentleman presented with painful persistent penile erection after the injection of papavarine for penile doppler evaluation .The penile doppler and the intra-corporal injection were given 12 hours before.He had erection lasting for almost 12 hours before he presented to us.

The examination revealed tender turgid erecion with glans also rigid.

He was taken up for immediate intra-corporal aspiration with 21 G scalp vein.About 200 ml dark blood was evacuated followed which red blood started coming.

Then Phenyl Epinephrine (1 ml in 20 ml----500 mcg) was injected and kept for 5 moin.Then the rigidity was seen to subside.

But the tumuscence was still there.

One more dose was given and then the scalp vein was again clamped.Now this time the penis has become totally flaccid





PRIAPISM:

Priapism is erection that persists beyond or unrelated to sexual activity. It is of two types
Low flow-This is because of priapism due to lack of outflow leading to congestion of blood in corpora and subsequent decrease in arterial flow leading to ischemia. In this there is anoxia of smooth muscle component of corpora.
PRIAPISM IS AN EMERGENCY. Any delay in the treatement will result in corporal ischemia and fibrosis. This will lead to permanent erectile dysfunction and penile deformity.
High Flow: This is due to trauma to perineum causing arteriovenous fistula and increased flow. This is not an emergency.
History-Detailed history regarding Intracavernosal Injection of Vasoactive agents, Hematological diseases, substance abuse, perineal trauma should be taken. The duration and any accompanying pain should be inquired. Any past history of priapism should be inquired.
Clinical examination-

Very Important to feel for any Malignant induration (metastases causing priapism), Bruit in perineum (trauma related high flow priapism). These obviously pinpoint to aetiology and help in treatment.
Invstigations:
1) Duplex Doppler Ultrasound-to differentiate between low and high flow priapism. Duplex ultrasound will reveal low flow and constricted cavernosal artery while in high flow the flow will be turbulent indicative of arteriovenous fistula.
2) Cavernosal Blood gas Analysis (Important) Ph< 7.25, pCO2>60,pO2>30 (Low Flow).The arterial blood gas picture is reverse in High Flow variant. This is an important necessary tool because it definitively pinpoints the type of priapism. It involves aspiration of blood from the corpora and sending it to ABG analyser(usually present in ICU)
Management

Low flow variety
1) Hematological disorders-Always hydrate the patient first
2) If Priapism less than 4 hours-Intracavernosal Injection of Phenylephrine bolus 500mcg repeated after 5 minutes. Importantly patient’s vitals should be kept on monitoring.
3) If priapism more than 4 hours-Drain one corpora with 21 G scalp vein with aspiration to remove old anoxic blood and inject a bolus of Phenylephrine ( 1 ml of Phenylephrine with 19 ml Normal saline mixture).The scalp vein should be clamped for 5 minutes. Repeat the procedure if there is no response.
4) Alternatively drain the corpora with 20 G scalp vein passively and let the blood drain out on its own. Initially the drained blood is dark anoxic slowly once the smooth muscle component of the corpora recovers red blood oozes out and that is the end-point of the drainage.

5) No response-------Send to Andrologist for Performance of corpora-glanular shunt (AL GHORAB SHUNT) .This procedure is simple .It can be done under penile block anaesthesia. It involves peroration of the corpora cavernosa through spongiosum (glans).This is followed by dilatation of the fenestration by Hegar´s dilator. The aim is to allow drainage of anoxic cavernosal blood into relatively supple spongiosum. The glans wound is then closed .This procedure is safe and quick.

High flow variety:
Initially conservative treatment like application of pressure packing, ice packing, use of adrenergic agents as written above. If these measures fail then Internal pudental angiography and angioembolisation is the treatment.
Stuttering Priapism:
Many patients, especially children, have a pattern of multiple short episodes over a period of days or several weeks. The priapism is often normal flow and prognosis is generally good and therapy is conservative. If the episode lasts longer and turns painful; then it should be like low flow variety. The long term prevention can be done with Baclofen 40 mg at the bed time.