Penile extracorporeal low-intensity shock wave therapy (LIST) to the penis has recently emerged a... more Penile extracorporeal low-intensity shock wave therapy (LIST) to the penis has recently emerged as a novel and promising modality in the treatment of erectile dysfunction (ED). LIST has angiogenic properties and stimulates neovascularization. If applied to the corpora cavernosa, LIST can improve penile blood flow and endothelial function. In a series of clinical trials, including randomized double-blind sham-controlled studies, LIST has been shown to have a substantial effect on penile hemodynamics and erectile function in patients with vasculogenic ED. LIST is effective in patients who are responsive to phosphodiesterase 5 inhibitors (PDE5i) and can also convert PDE5i nonresponders to responders. The response to LIST wanes gradually over time, and after 2 years, about half of the patients maintain their function. Extensive research is needed to understand the effect of LIST on erectile tissue, to modify the treatment protocol to maximize its outcomes, and to identify the patients w...
Growing evidence has linked circumcision with some protection against HIV infection. Should natio... more Growing evidence has linked circumcision with some protection against HIV infection. Should nations with a high HIV infection rate encourage male circumcision? Four people with expertise and/or interest in the area of circumcision and HIV were asked to contribute their opinions. To provide food for thought, discussion, and possible further research in a poorly discussed area of sexual medicine. Three clinical trials in Africa showed the benefit of circumcision in reducing HIV incidence in men. Sadeghi-Nejad cites these, but balances this with the pandemic in India, and the cultural implications of circumcision. Pollack cites these studies as well, but reinforces the World Health Organization and UNAIDS recommendations that male circumcision should not replace safe sex. As a Nigerian, Aisuodionoe-Shadrach discusses the indirect ways in which circumcision can reduce the spread of HIV, and advocates the surgery, although he proposes infant circumcision may be wiser. Ira Sharlip, Presid...
To determine the occurrence of clinically significant decreases in blood pressure (BP) with silde... more To determine the occurrence of clinically significant decreases in blood pressure (BP) with sildenafil use in normotensive and hypertensive men by means of ambulatory BP monitoring. On 2 nights, 49 men (22 hypertensive, 27 normotensive) had their ambulatory systolic BP (SBP), diastolic BP (DBP), and heart rate monitored during the first 3 hours (waking period) and every 30 minutes after midnight for 3 additional hours (sleeping period). No medication was taken on one night; sildenafil 100 mg was taken on the other. Sildenafil decreased SBP (-6.0 mm Hg; P = 0.0003), DBP (-4.5 mm Hg; P = 0.001), and mean arterial pressure (-5.3 mm Hg; P = 0.00008). The BP-lowering effects of sildenafil did not differ significantly in the normotensive and hypertensive men. Age significantly affected the BP reductions; decreases in SBP, DBP, and mean arterial pressure were greater in men 49 years old and older than in those younger than 49 years old. According to readings averaged over the entire contro...
Two cases are reported of fracture of the double-J ureteric stent during its prolonged placement ... more Two cases are reported of fracture of the double-J ureteric stent during its prolonged placement for extracorporeal ultrasound shock wave lithotripsy (ESWL). The causation of such fracturing is discussed and it is recommended that double-J stents employed in long-term ESWL be renewed within 5 months of their initial placement.
A rare case of abscess of the corpus cavernosum is described. Culture of the abscess yielded beta... more A rare case of abscess of the corpus cavernosum is described. Culture of the abscess yielded beta-hemolytic streptococcus. Ultrasound scan and cavernosography confirmed the physical examination findings of involvement of the corpus cavernosum. The patient was treated successfully by percutaneous ultrasound-guided aspiration drainage and systemic antibiotic therapy.
Objectives. To investigate the possible communication of the glans penis and corpus spongiosum wi... more Objectives. To investigate the possible communication of the glans penis and corpus spongiosum with the corpora cavernosa.
Objectives. Neurologic disorders might be responsible for many cases of female sexual dysfunction... more Objectives. Neurologic disorders might be responsible for many cases of female sexual dysfunction. Yet, they are currently undiagnosed because of the lack of measurement tools to assess genital neural function. Therefore, our objective is to provide norms for sensory thresholds in the vagina and clitoris, for a wide range of patient ages. Methods. Vaginal and clitoral warm, cold, and vibratory sensory thresholds were measured in 89 healthy paid volunteers by the method of limits. Normograms were derived from this group of healthy volunteers. An additional 61 patients were also tested, for a total of 150 individuals. Sixty-two individuals (42 healthy volunteers and 20 patients) from the total group were tested twice to provide test-to-test repeatability data across the range of clinical (normal and abnormal) responses. Results. Normograms are presented, providing age-corrected upper and lower normal values, expressed as 95% confidence limits for warm, cold, and vibratory thresholds. Intertest repeatability is also reported. Conclusions. Thermal and vibratory thresholds of both the vaginal and clitoral region are clinically feasible, valid, and repeatable. These can be applied as a valuable diagnostic tool to assess neural dysfunction through sensory assessment of the female genitalia.
Vulvar vestibulitis syndrome (VVS) is a common cause of dyspareunia in pre-menopausal women. Prev... more Vulvar vestibulitis syndrome (VVS) is a common cause of dyspareunia in pre-menopausal women. Previous quantitative sensory test (QST) studies have demonstrated reduced vestibular pain thresholds in these patients. Here we try to find whether QST findings correlate to disease severity. Thirty-five vestibulitis patients, 17 with moderate and 18 with severe disorder, were compared to 22 age matched control women. Tactile and pain thresholds for mechanical pressure and thermal pain were measured at the posterior fourcette. Magnitude estimation of supra-threshold painful stimuli were obtained for mechanical and thermal stimuli, the latter were of tonic and phasic types. Pain thresholds were lower and supra-threshold magnitude estimations were higher in VVS patients, in agreement with disease severity. Cut-off points were defined for results of each test, discriminating between moderate VVS, severe VVS and healthy controls, and allowing calculation of sensitivity and specificity of the various tests. Our findings show that the best discriminative test was mechanical pain threshold obtained by a simple custom made 'spring pressure device'. This test had the highest kappa value (0.82), predicting correctly 88% of all VVS cases and 100% of the severe VVS cases. Supra-threshold pain magnitude estimation for tonic heat stimulation also had a high kappa value (0.73) predicting correctly 82% overall with a 100% correct diagnosis of the control group. QST techniques, both threshold and supra-threshold measurements, seem to be capable of discriminating level of severity of this clinical pain syndrome.
Aims: To describe the temporal relationship between increases in lower urinary tract (LUT) sensat... more Aims: To describe the temporal relationship between increases in lower urinary tract (LUT) sensation and changes in detrusor and/or urethral pressures measured in real time. Methods: We reviewed 33 multichannel urodynamic tracings that included a continuous recording of LUT sensation and that demonstrated detrusor overactivity incontinence (DOI) or detrusor overactivity (DO). Four physicians reviewed each urodynamic tracing and reached agreement about the temporal relationship between LUT sensation and detrusor contraction. Results: Median age was 60 (36-82) years. Fourteen (42%) had urodynamic diagnoses of mixed incontinence, 18 (55%) had DOI, and 1 (3%) had DO without DOI. We reviewed 119 episodes of detrusor overactivity from the 33 recordings. We found no difference in change in sensation level when comparing DO episodes with DOI episodes or between different urodynamic diagnoses (P > 0.5). There was no dominant temporal pattern seen for the whole group (P ¼ 0.84), that is, there was no evidence that the change in sensation level was more likely to occur before, during, or after DO/DOI episodes. When evaluating the changes in the urethral pressure, the most common pattern seen was an increase in sensation level after a fall in urethral pressure, but no dominant pattern was seen. Conclusions: Our findings suggest that increased LUT sensation during DO/DOI is not reliably caused by measurable alterations in bladder or urethral pressure.
Electrical signals recorded from the penis have been suggested as reflecting electromyographic ac... more Electrical signals recorded from the penis have been suggested as reflecting electromyographic activity in the underlying smooth muscles. In order to verify this assertion, we manipulated the signal recorded from rat urethra surface. Stimulation of the pelvic nerve brought about a reduction of activity (965 ± 826 to 166 ± 143 µV, root mean square of the power at range 0.005-1 Hz, P = 0.008), with a significant frequencyresponse relationship (P = 0.0002). This effect was not altered by temporary closure of the aorta (P = 0.89), thus ruling out hemodynamic artifact as a possible cause of signal change during stimulation. Our findings support the assertion that the signal indeed reflects activity in smooth muscle.
Female sexual dysfunction (FSD) is highly prevalent (45-74%) in multiple sclerosis (MS) patients.... more Female sexual dysfunction (FSD) is highly prevalent (45-74%) in multiple sclerosis (MS) patients. Quantitative sensory testing (QST) has recently been used to assess normal neural function of the female genitalia. In this study we used QST for assessment of the genital neural function of female MS patients. We examined 41 female MS patients aged 21-56, with 10 years median disease duration. Each patient had a neurological examination, and evaluation of sexual function (SF) by both questionnaire and a focused interview. QST was performed at the clitoris and vagina for temperature and vibratory stimuli, by method of limits. By questionnaire, 25 patients (61%) had FSD; the most common complaints were decreased libido (61%) and orgasmic disturbances (54%). Sensory deficit was very common--significant correlations were found between high sensory thresholds and FSD parameters; the most significant correlation was between clitoral vibratory sensation and orgasmic dysfunction (r = 0.423, P = 0.006). Another interesting significant association was found between cerebellar deficit and orgasmic dysfunction (P = 0.0012). This study suggests that QST of the genitalia, specifically clitoral vibration, may be a useful test for detecting sexual dysfunction in MS patients, and supports an important role of the cerebellum in SF.
Tadalafil, a new phosphodiesterase type 5 inhibitor, has an extended period of responsiveness com... more Tadalafil, a new phosphodiesterase type 5 inhibitor, has an extended period of responsiveness compared with other agents in this class. The distinct pharmacological profile of tadalafil may allow more flexibility for men to establish individual sexual timing behavior patterns. We determined if patients took advantage of the pharmacological profile of tadalafil by assessing the frequency, timing and success of intercourse attempts in men with erectile dysfunction. Data on Eastern European countries were combined from 2 identically designed, randomized, double-blind, placebo controlled, parallel group studies. Patients self-administered 20 mg tadalafil (406) or placebo (108) as needed for 12 weeks. Of the men 63% made at least a quarter of their attempts and 42% made at least half of their attempts more than 4 hours after dose. At least 1 attempt was made after 8, 12 or 24 hours after dose by 87%, 75% and 52% of the men, respectively. Throughout a 36-hour post-dose period tadalafil was associated with significantly higher intercourse success rates than placebo (p <0.001) with 61% to 69% of tadalafil treated patients reporting success rates of greater than 75% compared with 19% to 30% of those on placebo (p <0.001). Tadalafil was well tolerated. In this study various use patterns of the tadalafil period of effectiveness were apparent, reflecting differences in the sexual timing behavior of patients. Tadalafil may provide men with erectile dysfunction more flexibility in deciding when to attempt intercourse in accordance with their sexual habits and attitudes.
Purpose: We report the dropout rate associated with intracavernosal self-injection for erectile d... more Purpose: We report the dropout rate associated with intracavernosal self-injection for erectile dysfunction at long-term followup, and determine parameters related to dropout.
Penile extracorporeal low-intensity shock wave therapy (LIST) to the penis has recently emerged a... more Penile extracorporeal low-intensity shock wave therapy (LIST) to the penis has recently emerged as a novel and promising modality in the treatment of erectile dysfunction (ED). LIST has angiogenic properties and stimulates neovascularization. If applied to the corpora cavernosa, LIST can improve penile blood flow and endothelial function. In a series of clinical trials, including randomized double-blind sham-controlled studies, LIST has been shown to have a substantial effect on penile hemodynamics and erectile function in patients with vasculogenic ED. LIST is effective in patients who are responsive to phosphodiesterase 5 inhibitors (PDE5i) and can also convert PDE5i nonresponders to responders. The response to LIST wanes gradually over time, and after 2 years, about half of the patients maintain their function. Extensive research is needed to understand the effect of LIST on erectile tissue, to modify the treatment protocol to maximize its outcomes, and to identify the patients w...
Growing evidence has linked circumcision with some protection against HIV infection. Should natio... more Growing evidence has linked circumcision with some protection against HIV infection. Should nations with a high HIV infection rate encourage male circumcision? Four people with expertise and/or interest in the area of circumcision and HIV were asked to contribute their opinions. To provide food for thought, discussion, and possible further research in a poorly discussed area of sexual medicine. Three clinical trials in Africa showed the benefit of circumcision in reducing HIV incidence in men. Sadeghi-Nejad cites these, but balances this with the pandemic in India, and the cultural implications of circumcision. Pollack cites these studies as well, but reinforces the World Health Organization and UNAIDS recommendations that male circumcision should not replace safe sex. As a Nigerian, Aisuodionoe-Shadrach discusses the indirect ways in which circumcision can reduce the spread of HIV, and advocates the surgery, although he proposes infant circumcision may be wiser. Ira Sharlip, Presid...
To determine the occurrence of clinically significant decreases in blood pressure (BP) with silde... more To determine the occurrence of clinically significant decreases in blood pressure (BP) with sildenafil use in normotensive and hypertensive men by means of ambulatory BP monitoring. On 2 nights, 49 men (22 hypertensive, 27 normotensive) had their ambulatory systolic BP (SBP), diastolic BP (DBP), and heart rate monitored during the first 3 hours (waking period) and every 30 minutes after midnight for 3 additional hours (sleeping period). No medication was taken on one night; sildenafil 100 mg was taken on the other. Sildenafil decreased SBP (-6.0 mm Hg; P = 0.0003), DBP (-4.5 mm Hg; P = 0.001), and mean arterial pressure (-5.3 mm Hg; P = 0.00008). The BP-lowering effects of sildenafil did not differ significantly in the normotensive and hypertensive men. Age significantly affected the BP reductions; decreases in SBP, DBP, and mean arterial pressure were greater in men 49 years old and older than in those younger than 49 years old. According to readings averaged over the entire contro...
Two cases are reported of fracture of the double-J ureteric stent during its prolonged placement ... more Two cases are reported of fracture of the double-J ureteric stent during its prolonged placement for extracorporeal ultrasound shock wave lithotripsy (ESWL). The causation of such fracturing is discussed and it is recommended that double-J stents employed in long-term ESWL be renewed within 5 months of their initial placement.
A rare case of abscess of the corpus cavernosum is described. Culture of the abscess yielded beta... more A rare case of abscess of the corpus cavernosum is described. Culture of the abscess yielded beta-hemolytic streptococcus. Ultrasound scan and cavernosography confirmed the physical examination findings of involvement of the corpus cavernosum. The patient was treated successfully by percutaneous ultrasound-guided aspiration drainage and systemic antibiotic therapy.
Objectives. To investigate the possible communication of the glans penis and corpus spongiosum wi... more Objectives. To investigate the possible communication of the glans penis and corpus spongiosum with the corpora cavernosa.
Objectives. Neurologic disorders might be responsible for many cases of female sexual dysfunction... more Objectives. Neurologic disorders might be responsible for many cases of female sexual dysfunction. Yet, they are currently undiagnosed because of the lack of measurement tools to assess genital neural function. Therefore, our objective is to provide norms for sensory thresholds in the vagina and clitoris, for a wide range of patient ages. Methods. Vaginal and clitoral warm, cold, and vibratory sensory thresholds were measured in 89 healthy paid volunteers by the method of limits. Normograms were derived from this group of healthy volunteers. An additional 61 patients were also tested, for a total of 150 individuals. Sixty-two individuals (42 healthy volunteers and 20 patients) from the total group were tested twice to provide test-to-test repeatability data across the range of clinical (normal and abnormal) responses. Results. Normograms are presented, providing age-corrected upper and lower normal values, expressed as 95% confidence limits for warm, cold, and vibratory thresholds. Intertest repeatability is also reported. Conclusions. Thermal and vibratory thresholds of both the vaginal and clitoral region are clinically feasible, valid, and repeatable. These can be applied as a valuable diagnostic tool to assess neural dysfunction through sensory assessment of the female genitalia.
Vulvar vestibulitis syndrome (VVS) is a common cause of dyspareunia in pre-menopausal women. Prev... more Vulvar vestibulitis syndrome (VVS) is a common cause of dyspareunia in pre-menopausal women. Previous quantitative sensory test (QST) studies have demonstrated reduced vestibular pain thresholds in these patients. Here we try to find whether QST findings correlate to disease severity. Thirty-five vestibulitis patients, 17 with moderate and 18 with severe disorder, were compared to 22 age matched control women. Tactile and pain thresholds for mechanical pressure and thermal pain were measured at the posterior fourcette. Magnitude estimation of supra-threshold painful stimuli were obtained for mechanical and thermal stimuli, the latter were of tonic and phasic types. Pain thresholds were lower and supra-threshold magnitude estimations were higher in VVS patients, in agreement with disease severity. Cut-off points were defined for results of each test, discriminating between moderate VVS, severe VVS and healthy controls, and allowing calculation of sensitivity and specificity of the various tests. Our findings show that the best discriminative test was mechanical pain threshold obtained by a simple custom made 'spring pressure device'. This test had the highest kappa value (0.82), predicting correctly 88% of all VVS cases and 100% of the severe VVS cases. Supra-threshold pain magnitude estimation for tonic heat stimulation also had a high kappa value (0.73) predicting correctly 82% overall with a 100% correct diagnosis of the control group. QST techniques, both threshold and supra-threshold measurements, seem to be capable of discriminating level of severity of this clinical pain syndrome.
Aims: To describe the temporal relationship between increases in lower urinary tract (LUT) sensat... more Aims: To describe the temporal relationship between increases in lower urinary tract (LUT) sensation and changes in detrusor and/or urethral pressures measured in real time. Methods: We reviewed 33 multichannel urodynamic tracings that included a continuous recording of LUT sensation and that demonstrated detrusor overactivity incontinence (DOI) or detrusor overactivity (DO). Four physicians reviewed each urodynamic tracing and reached agreement about the temporal relationship between LUT sensation and detrusor contraction. Results: Median age was 60 (36-82) years. Fourteen (42%) had urodynamic diagnoses of mixed incontinence, 18 (55%) had DOI, and 1 (3%) had DO without DOI. We reviewed 119 episodes of detrusor overactivity from the 33 recordings. We found no difference in change in sensation level when comparing DO episodes with DOI episodes or between different urodynamic diagnoses (P > 0.5). There was no dominant temporal pattern seen for the whole group (P ¼ 0.84), that is, there was no evidence that the change in sensation level was more likely to occur before, during, or after DO/DOI episodes. When evaluating the changes in the urethral pressure, the most common pattern seen was an increase in sensation level after a fall in urethral pressure, but no dominant pattern was seen. Conclusions: Our findings suggest that increased LUT sensation during DO/DOI is not reliably caused by measurable alterations in bladder or urethral pressure.
Electrical signals recorded from the penis have been suggested as reflecting electromyographic ac... more Electrical signals recorded from the penis have been suggested as reflecting electromyographic activity in the underlying smooth muscles. In order to verify this assertion, we manipulated the signal recorded from rat urethra surface. Stimulation of the pelvic nerve brought about a reduction of activity (965 ± 826 to 166 ± 143 µV, root mean square of the power at range 0.005-1 Hz, P = 0.008), with a significant frequencyresponse relationship (P = 0.0002). This effect was not altered by temporary closure of the aorta (P = 0.89), thus ruling out hemodynamic artifact as a possible cause of signal change during stimulation. Our findings support the assertion that the signal indeed reflects activity in smooth muscle.
Female sexual dysfunction (FSD) is highly prevalent (45-74%) in multiple sclerosis (MS) patients.... more Female sexual dysfunction (FSD) is highly prevalent (45-74%) in multiple sclerosis (MS) patients. Quantitative sensory testing (QST) has recently been used to assess normal neural function of the female genitalia. In this study we used QST for assessment of the genital neural function of female MS patients. We examined 41 female MS patients aged 21-56, with 10 years median disease duration. Each patient had a neurological examination, and evaluation of sexual function (SF) by both questionnaire and a focused interview. QST was performed at the clitoris and vagina for temperature and vibratory stimuli, by method of limits. By questionnaire, 25 patients (61%) had FSD; the most common complaints were decreased libido (61%) and orgasmic disturbances (54%). Sensory deficit was very common--significant correlations were found between high sensory thresholds and FSD parameters; the most significant correlation was between clitoral vibratory sensation and orgasmic dysfunction (r = 0.423, P = 0.006). Another interesting significant association was found between cerebellar deficit and orgasmic dysfunction (P = 0.0012). This study suggests that QST of the genitalia, specifically clitoral vibration, may be a useful test for detecting sexual dysfunction in MS patients, and supports an important role of the cerebellum in SF.
Tadalafil, a new phosphodiesterase type 5 inhibitor, has an extended period of responsiveness com... more Tadalafil, a new phosphodiesterase type 5 inhibitor, has an extended period of responsiveness compared with other agents in this class. The distinct pharmacological profile of tadalafil may allow more flexibility for men to establish individual sexual timing behavior patterns. We determined if patients took advantage of the pharmacological profile of tadalafil by assessing the frequency, timing and success of intercourse attempts in men with erectile dysfunction. Data on Eastern European countries were combined from 2 identically designed, randomized, double-blind, placebo controlled, parallel group studies. Patients self-administered 20 mg tadalafil (406) or placebo (108) as needed for 12 weeks. Of the men 63% made at least a quarter of their attempts and 42% made at least half of their attempts more than 4 hours after dose. At least 1 attempt was made after 8, 12 or 24 hours after dose by 87%, 75% and 52% of the men, respectively. Throughout a 36-hour post-dose period tadalafil was associated with significantly higher intercourse success rates than placebo (p <0.001) with 61% to 69% of tadalafil treated patients reporting success rates of greater than 75% compared with 19% to 30% of those on placebo (p <0.001). Tadalafil was well tolerated. In this study various use patterns of the tadalafil period of effectiveness were apparent, reflecting differences in the sexual timing behavior of patients. Tadalafil may provide men with erectile dysfunction more flexibility in deciding when to attempt intercourse in accordance with their sexual habits and attitudes.
Purpose: We report the dropout rate associated with intracavernosal self-injection for erectile d... more Purpose: We report the dropout rate associated with intracavernosal self-injection for erectile dysfunction at long-term followup, and determine parameters related to dropout.
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Papers by Yoram Vardi