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antony
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« Reply #278 on: October 04, 2007, 09:20:46 PM »

Hello, thanks for answers.

To Hawk, yes, but lots of men with peyronies can have erection, despite of the fibrosis. It can be painful, disformed, or maybe like you say with reduced hardness, but it doesn't make you impotent organically. And as i told im asking why a fibrosis like this is visible on MRI and why my fibrosis, which is probably really worse, is not visible.

To Liam, thanks for precisions.
About the doctor, or the doctors coz i saw a lot coz most of them are not competent, the last i saw says there was a penile injury at origin, but not a fracture. But something had broken inside my penis and the scar tissue created fibrosis. Fibrosis creates symptoms like impotence, reduced size of penis, hardness of tunica albuginea, curvature, loss of elasticity. Then the rest would be a consequence: the loss of sensitivity coz the penis has changed anatomy, so maybe it compresses a nerve, and the ejaculatory trouble, because the area where it's no more right in penis, makes that the ejaculation is stopped at a moment in urethra, and despite of going out strongly, it drips (drop after drop without any force and with no orgasm and sensation). But he says that without being convinced, and coz the MRI shows nothing , he is lost and says we can do anything. Aparently this type of problem is rare. Doctors left me alone...

So i wanted to know if some of you had passed MRI or dopller and the imagery shows this fibrosis. But the link you gives me proves some of them are not so visible. But they say dificult peyronies to see are visible on MRI so (in this case, plaques in the septum of the penis. The MRI i made say the septum is normal...)   Do you know what is a 'endourethral ultrasound'??

About the question, if i ask you, it's precisely coz the doctor says nothing and doesnt know. I was just 'hoping' somebody had same thing and would have known ... My doctor (who is a 'famous' specialist) doenst know and gave me... cialis...

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Hawk
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« Reply #277 on: October 04, 2007, 02:23:01 PM »

One further point.  MOST men with Peyronies Disease do have reduced hardness with their erections.
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Liam
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« Reply #276 on: October 04, 2007, 04:10:25 AM »

The abstract below just shows some imaging techniques that are used and one unusual finding. 
You said:
Quote
total impotence, lose of sensitivity, small curvature on right side, torsion at basis of penis, hardness of tunica albuginea, big loss of size of penis, loss of elasticity, ejaculatory trouble since the begining of my problem
   
With what you describe, a doctor should be able to pick up on something concrete (no pun intended) instead of some ethereal plaque.  Was your doctor able to see and document all your symptoms?  You may have more than one thing going on.


Try searching Google about regrowing penis tissue.

You said:
Quote
How is it possible that a fibrosis which doesn't create impotence , like in peyronie, is visible on MRI, and one which creates impotence and these numerous symptoms, isn't visible?
Thats a good question for your doctor.


Quote
G. Helweg1   , F. Frauscher1, H. Strasser2, R. Knapp1, W. Judmaier3, D. zur Nedden1 and A. Reissigl2
(1)  Department of Radiology II, University of Innsbruck, Anichstr. 35, A-6020 Innsbruck, Austria
(2)  Department of Urology, University of Innsbruck, Anichstr. 35, A-6020 Innsbruck, Austria
(3)  MRI Institute, University of Innsbruck, Anichstr. 35, A-6020 Innsbruck, Austria

Received: 16 May 1994  Revised: 12 December 1994  Accepted: 10 May 1995 

Abstract   We report the case of a 44-year-old male presenting with deviation of the penis during erection. Upon physical and clinical examination the patient did not have the typical findings of Peyronie's disease, therefore he was admitted for further evaluation by conventional sonography, duplex Doppler ultrasound, endourethral ultrasound and magnetic resonance imaging (MRI). Endourethral ultrasound and MRI provided evidence of Peyronie's disease with atypical involvement of the corpus spongiosum and, in addition, demonstrated nonpalpable plaques in the septum of the penis.
Source: http://www.springerlink.com/content/ukp6614284862302/
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antony
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« Reply #275 on: October 04, 2007, 01:06:34 AM »

Hello all,


i would like to know something, has somebody passed some MRI to diagnose their peyronie, or to confirm it? And is the fibrosis plaque is visible on imagery exams? (MRI, echography?). Because i'm asking myself something, in the peyronie disease, you have a curvature and pain at erection because of fibrosis, but most of cases, it doesn't make you impotent. And i was told in most of cases we can see the fibrosis at exams. And as for me, despite of my terrible and numerous symptoms i had told here ( total impotence, lose of sensitivity, small curvature on right side, torsion at basis of penis, hardness of tunica albuginea, big loss of size of penis, loss of elasticity, ejaculatory trouble since the begining of my problem .... all that following a paintful intercourse some months ago), the MRI's i did (i made 2) show nothing.... and the same for eccho doppler. But the doctor says with these symptoms, there is necessary fibrosis in penile tissues. So are the MRI machines in france crap? How is it possible that a fibrosis which doesn't create impotence , like in peyronie, is visible on MRI, and one which creates impotence and these numerous symptoms, isn't visible?

And i would like to know if you have some information here concerning the genetic cells therapy or something like that, to 'recreate' a 'safe' tunica albuginea , coz i still can't (and will never) imagine to put a penile prothesis.

Thanks
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« Reply #274 on: September 14, 2007, 10:50:47 PM »

George... the stuff looks promising doesn't it? Are you going to take a break from it after the 4 day round? If so, and you do another round, post if you notice in the next round anything like the nocturnal activities that you experienced or anything that suggests it was the Tongkat kicking in. Fascinating.
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« Reply #273 on: September 14, 2007, 08:22:48 PM »

Those of you that know me around here know that I am always trying something new.  My latest little experiment is Tongkat Ali.  I recently purchased a bottle of Herbal Powers Tongkat Ali, which seems to be the brand blessed by the Malay government.  This stuff supposedly elevates Testosterone naturally and without the harmful side effects of replacement approaches.  So I read the label.  It basically says no more than 8 caps per day maximum.  For "general health" 2 to 4 caps per day.  It also says that I "should see the results in about four days".  So I decide to take 4 per day, one every six hours and see what happens.  They recommend taking it for a few days then taking a break, then repeating the pattern.  So yesterday was my fourth day which passed rather uneventfully.  But then last night, something very interesting occurred.  Out of nowhere, I actually had a "wet dream" for the first time in about 25 years.  I was blown away.  Is this some sort of strange coincidence or does this stuff really work as hyped (a real rarity on the supplement front)?  I'll let you all be the ones to critique my experience.  As for me, I think this is one supplement I am going to continue taking.  I am really curious what possible impact it might have on the Peyronies issue.  - George
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MUSICMAN
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« Reply #272 on: September 05, 2007, 11:19:37 AM »

I'm sure this subject has been covered but some information would be
helpfull. I seem to have nocturnal erections at times. I'm not sure if all
the time or just by the chance I wake up at that time. Yes It is bent
like the end of a golf club but it is a firm erection. My question is why
am I not able to have a awake erection? My guess is that it is a mental
issue as the bend and look removes any idea as to what it could be
used for. My disease has been stable for some time now and I do not
have any pain.
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Tim468
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« Reply #271 on: August 30, 2007, 04:43:47 PM »

Like I said in the original post, it is a long post, but well worth reading (IMHO).

http://www.peyroniesforum.net/index.php/topic,23.msg10993.html#msg10993

It is a discussion by a very talented urologist about how he would work up erectile dysfunction. In his discussion (which is about one man), he touches on all of the tests, and their strengths and weaknesses.

Tim
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antony
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« Reply #270 on: August 30, 2007, 01:33:34 PM »

Hello all,

Just a question, do you know (in the usa) ALL the tests /exams, that are done in theses cases of impotence?
(like radiologic test or blood tests, i dont know if there are some in your country that i wasnt told here)?
I did blood test, and RIM (reasonance imagery magnetic, i think it's the word in english).
And eccho doppler.

Thanks.
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« Reply #269 on: August 29, 2007, 08:48:56 PM »

thanks for the reply guys. Viagra I might postpone till after I lose my weight. the reason is because I'm not too sure my doctor will prescribe it for me unless I drop that excess body-fat first. He is centered around the excess BF being the source of all my problems- and I kinda agree with that- and wants to see if my condition improves after I lose my weight. as for stress the only stress is practical work from the chem lab. finding the right solvent system is a bummer and discovering from day-to-day that I'm not very well suited for labwork has kinda blurred my self-confidence. Angry
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« Reply #268 on: August 28, 2007, 10:19:56 PM »

Hitman,,,Low testosterone will affect your ability to have day or nightime erections and so will stress. I've been through it all,,when i get my stress level down i begin to have night time erections again,,not a lot,,but at least i get them..

Liam is right about taking 25 mg of viagra,,i would suggest taking about an hour before bedtime and then eat something light about 20 minutes after taking it, and maybe a Tylenol,,,,this will help avoid getting the headache...

LIAM,,,,I've been using the viagra now for about 10yrs,,100 mg,,,for the first 2 to 3 yrs i had the bad headache's , after that i haven't had any side effects....Now that i am 62 yrs, i am trying to cut back to about 50 mg, I've noticed since my lower intestines was damaged 2 yrs ago by a parasite, lately when i take a 100 mg it just makes my insides hurt some and it's not comfortable afterwards, so i'm making myself cut back,,,otherwise i really don't experience any side effects....

Hope this helps,,,,,,,Kimo
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Hitman
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« Reply #267 on: August 28, 2007, 06:31:12 PM »

Hitman,

The cause of the loss of night-time erections could be for the reasons you mentioned or other physical  issues ranging from impaired arterial flow, venous leakage, and possibly other physical issues not occurring to me at the moment.

I personally think psychological issues can impact night-time erections.  I have never awaken with an erection on a night I was wrestling with a traumatic issue.   

Do you ever get an erection day or night?

I used to at some stage. now I don't get any day erections whatsoever. On occasion i will get semi-spontaneous nightly erections. thats about it. I suspect I have a hormonal problem + probably impaired arterial flow because of my excess bodyweight. however there might be a third problem. I've been experiencing some sensation of heat in my inner thighs and around my anal area as well.
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Liam
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« Reply #266 on: August 28, 2007, 06:21:29 PM »

Try 25 mg Viagra at bedtime every night if you can.  It helps with night itme erections.  It is a very low dosage and easily tolerated.  I have severe headaches with the three major ED drugs.  I can handle this.  I hope you can, too.

Liam
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« Reply #265 on: August 28, 2007, 07:15:51 AM »

I moved several posts by Tim, Ninja, myself, and other from this ED thread to the "Psychological Component" topic since they had much more to do with that aspect.  Moving the posts, making quotes, and the redirect links was not real fun (sorry for the whining) .  Most of them made no direct mention of ED.  You can go to these posts by clicking the link below.

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« Reply #264 on: August 28, 2007, 07:11:22 AM »

Hitman,

The cause of the loss of night-time erections could be for the reasons you mentioned or other physical  issues ranging from impaired arterial flow, venous leakage, and possibly other physical issues not occurring to me at the moment.

I personally think psychological issues can impact night-time erections.  I have never awaken with an erection on a night I was wrestling with a traumatic issue.   

Do you ever get an erection day or night?
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Hitman
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« Reply #263 on: August 28, 2007, 06:08:05 AM »

just out of curiousity would a lack of nocturnal or morning erections indicate a hormonal or neurological problem?
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antony
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« Reply #262 on: August 27, 2007, 08:37:23 PM »

Hello all,


Liam, to answer to your question, no i dont have night time erection, no more than morning ones, i lost all of them. I tried one or 2 times viagra before sleeping, but these medicine have some bad side effects, and are too expensive, so cant take too often.
But i've tried to take cialis several time (anyway it doesn't give me good erections coz of the fibrosis), and i have the feeling after a certain time, the body is 'used to it', and the product makes me less and less effect... :-(

Yes i mentioned the seminal fluid. In fact,before my problem, i had seminal fluid like everybody during exitation, but now, as soon as i take something that tries to make me erect, (viagra, cialis), as soon as the penis becomes a little hard, there is a big quantity of this fluid that goes out from the urethra. I don't know why, but it's not really clean. Anyway, that's not the most important point for sure, but it's not cool.

To finish, depression is good for nobody, and can affect libido and erection. But i am in depression since last month really, since i was told by the doctors they can do nothing. But i had this problem of penis since already five months. It's not depression which created my problem for sure, even if of course depression makes everything going worse. But you're right to attack by this side too, and i do it, i am treated for depression. But it changes nothing to the rest of the probem (physical part).


Ninja, for sure people who have 'small problems' and think it's 'the end of the world' make me laugh... But i think we have to have a big problem to realize it. Sometimes, everybody complain about stupid things, nothing serious. But the day when it happens a serious thing...  Anyway, speak to you in PM.


Tim, it's no problem to say what you think, you gave me medical advice, and that was what i asked for, so it's cool. For the moral thing, nobody who becomes totally impotent so young can realize how hard to live it is. Anyway that's not the matter, i asked if there were medical things for impotence/fibrosis, etc, you told me about pentox, daily viagra, anti depressor, etc, so it's cool if it can help, for the rest just believe it's very very very hard to live, especially in my situation, but it's no way to speak about that, i cant explain all in english, and moreover it's not a psychological forum. Just as i told, i try to do the things, and don't just 'complain'. But i think you would be out of hope and force living my last 6 months...(i dont have a peyronie as for me).
So  thank you for advice and help, and for the rest, nobody can help or judge.

Thanks everybody

Antony

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Liam
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« Reply #261 on: August 27, 2007, 02:40:02 PM »

How are your night time erections?  Have you tried low dose (25mg) Viagra at bedtime?

BTW, I saw a past post you mention seminal fluid leaking after using Viagra.  That part is normal.  It is "lubrication"  Wink 

I think it would be a good idea to use medicines to have frequent erections.  Keep your blood flowing.

Depression can also cause ED (more acurate term).  I think depression is making the physical symptoms worse.  Attack this problem from all sides.  I take Wellbutrin.  There are other drugs.  Also, excersise!
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« Reply #260 on: August 26, 2007, 11:21:32 PM »

ok thanks for the replies guys.

I did want to ask George about what supplements he has found to be useful for ED or Peyronies Disease in general.
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Peyronies Disease/56 yrs. Arrested state w/VED, straight again!!


« Reply #259 on: August 26, 2007, 01:21:07 PM »

Hitman:

Top of the morning to you!

RX = A written prescription for drugs (medicine), medical equipment or anything in the medical field that requires to be prescribed by a board certified and/or licensed physican, etc.

Welcome aboard and keep looking around the threads and topics of the forum. There is a wealth of information about Peyronies Disease, VEDs and other alternative therapies for men's health problems.

Old Man
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Hitman
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« Reply #258 on: August 26, 2007, 08:39:07 AM »

hmm whats an Rx?

(forgot to say that I live in NZ by the way)
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Liam
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« Reply #257 on: August 26, 2007, 08:34:39 AM »

Diet and excersise is great.  George can offer some good advice as far as diet and nutrition.

If your doc will give you a Rx for the VED, your insurance may pay.
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« Reply #256 on: August 26, 2007, 07:01:34 AM »

hey Liam

thanks for the reply. I will read and look into the VED and discuss it with my doctor should my ED continue further after I've gotten rid of the weight.

as for losing weight, no I will not go down the surgery track. I'm very determined to get rid of it through an exercise and diet regime.

regards
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Liam
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« Reply #255 on: August 26, 2007, 05:59:43 AM »

HitMan, 

Have you thought about trying a VED?  You can read about them here:

http://www.peyroniesforum.net/index.php/topic,439.0.html

This section is a good way to "catch up" on some of the posts quickly (Thanks Angus!)

Another thought is to look at different medical treatment options for weight loss.  I have two friends who have had surgery (gastric bypass, I believe) and are totally different people now.  They say many other health problems they had dissapeared with the extra weight.  One told me her breathing problems improved and she has more energy (she's almost "hyper" now).  I am mentioning this because there have been discussions of Peyronies Disease being related to sugar levels in the body.  Also, it is just for your health.

Good luck!
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« Reply #254 on: August 26, 2007, 05:24:09 AM »

Wellbutrin is the name of the drug.   Smiley

Vouloir, c'est pouvoir! 
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antony
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« Reply #253 on: August 25, 2007, 06:01:23 PM »

I know you're right Tim, it's just very very hard to live, at that moment of my life, anyway everybody has his own history, but believe me that was not the good moment to have a problem like that. (it's never the good moment, but especially now).

Anyway i spoke to a doctor specialist about fibrosis in france, i will take apointement on monday, he spoke to me about pentox. Will see with the doc.

Concerning viagra, for reasons of price, i cant take it daily, moreover i have some bad side effects.
I take cialis 2 times a week (it is said to be about a 36hours effect). Doenst help me a lot.

I will see one of the most 'famous' urologists/surgeon in france but can't have apointement before end of november, it's not my fault.

I have been made one injection by the doctor, it induces a 'sort of erection', but smaller, painful, with a curvature, and non sensitive.
So my penis can react to an injection even if it's not pleasant ( like something totally non elastic), but it has totally changed of form, size and sensation.

Thanks for advice, and one again don't think i only complain without trying things. I hope to recover medically but not surgically.

The fact is also all that costs a lot of money, and i have lost a lot in 6 months, for absolutely nothing. So i am far from being rich...

I know that i am not alone, and i don't try to compare, but i say it's not possible to  have worse than i have concerning a sexual problem : total impotence with loss of size, of sensitivity, curvature, pain, ejaculation problem, sorry but its very hard to live, i maintain especially when you are young. Its not a comparison, its (sadly for me) a fact, and it's another that doctors here quickly live you alone if they dont know what to do.

No problem for  you to sound 'blunt',you just say what you think and its not a problem, as for me i have just told what i live, that's all.



Liam, what do you say is good on depression and doesn't interfer with sexual function?  qu'est ce qui est bon? lol

Antony
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« Reply #252 on: August 25, 2007, 05:39:08 PM »

hello everybody

I thought I post my story here coz its more ED-related

I'm 5'9-5'10 240lbs (20% bf, not very healthy at all). I suffer from weak erections at the moment and what seems to be a curve on the left side of my penis. -I suspect this is from too much wanking using my right hand-. The curve is around 15-20 degrees. On occasion I will get weak nocturnal erections but no morning erections. I can however induce a strong manual erection for some strange reason.

My Penile sensitivity is poor. My penis looks small and shrunk in the flaccid state. I've visited my GP who has requested some blood and lipid profiles mainly thyroid, prolactin, DHEA-s and testosterene. My triglycerides are quite high. Cholestrol is normal. I suspect I also have adrenal fatigue- but my doctor doesn't believe in it-

Last year I went to a urologist because of pain I was experiencing at the tip of the penis and he did notice I was quite tender in the urethreal region. They found no trace of infections however.The doctor said its some sort of trauma to the area and its inflammed.

any thoughts or comments would be really appreciated.

Hitman
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« Reply #251 on: August 25, 2007, 04:55:44 PM »

Antony,

You should consider - strongly - taking pentox at a dose of 400 three times a day, L-arginine at a dose of 2000-6000 mg a day, and viagra or similar at a dose of 25-50 a day (again this is not for erection but for antifibrotic activity). You should get going with a VED. Consider a better evaluation with measurement of testosterone levels, and you should definitely get injected to see if your penis can get hard AT ALL (in other words, regardless of your feelings and emotions).

According to the limited  data available for men in similar positions as you, it has taken up to two years to recover - but that is if they do the therapy.

Finally, as I mentioned before, there are surgical reconstructions available for young men whose penis - for whatever reason - has failed. Right now, that may seem impossible or unacceptable. But if all else failed me, I would go for that in a heartbeat. But only after all else had failed.

So, you say that you will "ask about" pentox, but I suggest that you READ about it using the articles that I posted for you over two weeks ago. I am sorry to sound so blunt - for I have great feelings of empathy and sorrow for what you have suffered. But I have also suffered, as have many men here who can no longer have intercourse either. You are not alone. Instead of listing how many ways in which you are different (and therefore "worse") I hope you can start to see how you are not so isolated or alone. You are not the only guy whose life is altered in a way that is depressing and frustrating. Yet you will see, along with the depression, signs of hope and optimism here as well - and that is not because they "don't have it as bad as you". It is due to doing the work of recovery that we must all do to heal our hearts. And if you listen long enough you will also hear the words of the women who love men despite their failure to have a perfect penis any more.

You can heal either medically or surgically - that is a fact - though it may entail spending time and money and feeling sad. But for now, it may be of more help to get going on the "recovery" part of what you are facing.

Tim

Some responses to this post were moved to the "Psychological Component" topic.  Click the link below to go to those posts.
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« Reply #250 on: August 25, 2007, 03:23:11 PM »

It is good for depression and does not intefere with sexual function  Wink

C'est bon!
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« Reply #249 on: August 25, 2007, 02:58:45 PM »

Hello Tim,

the only fact is i dont stay like that without doing anything, i have taken the problem at the beginning, and if i would have been well diagnosed, i wouldn't be there now.
We don't have the same thing because you have a peyronie disease and it's not what i have. My problem is not only a curvature during erection, or a pain , but of being impotent, and probably for definitive.
I think it's understable to be depressive when you learn that at my age. Of course, i have the curvature and the pain TOO, but the main fact is that even with medicine , i cant really have normal erections. Moreover , the penis is always cold, it's horrible sensation,, and i have an ejaculatory problem too. I can go where i want, i have the problem on me, and not only at some moments, its always cold, painful, have changed form, really smaller and so impotent.
If i now complain, it's because doctors i saw clearly told me they could do nothing exept giving cialis or viagra.
I would prefer have a peyronie disease , than total impotence.
Anyway i continue searching, i saw lots of doctors, i take medicine for depression, i spoke about my problem, so i do what i can do. But the fact is that the problem is just getting worse....
Anyway i will ask about pentox, try some vaccuum, and continue treating depression, and i dont see what i can do more...
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« Reply #248 on: August 23, 2007, 07:06:36 PM »

Dear Antony,

At some point you may chose to stop feeling sorry for yourself and take more action. Some of us have offered you advice on methods that have helped us get better. Not all methods work, but by taking steps we learn what does work and what does not.

At this point, it appears that your anger and sadness is preventing you from taking proper care of yourself, or moving forward. And yet, you have taken steps previously. When we hit hurdles in life, we either stop or we take them. I hope that you are able to see that if you help yourself, your depression will improve.

Tim

Oh - and by the way - to be perfectly blunt..  I was sexually active by 13, and had had many more lovers than most men by the age of thirty. I did that with Peyronie's Disease for most of that time. I pleased women and had a great time - in fact, the disease gave me ultimately a disease of the spirit as I tried to prove my sexual prowess. You can be whomever you want to be. If you want to remain in pain emotionally, then do so. If you want to heal, then start that journey. But every man here has the same disease that you have, and we are not all complaining about how down we are - we are working on getting better. It is not easy work, but it is worth it. I hope - very much so - that you can come to see that.
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« Reply #247 on: August 23, 2007, 06:33:29 PM »

Hello man,

thanks for your message. You look more 'courageous' than me on that point... Wait until 30 , leaving the last 5/6 years of 'yougness' with such a destroying problem, just sounds impossible for me.
Anyway, i know you're right on what you say, but i am just honest enough to reconize that i agree 100% with what you tell me, but i can't apply it ...
Anyway i will write to you a PM and explain you how i see the things and why.
Sad that no 'effective treatment' exists for the problem. For the 'moral' part, we'll speak together, even if one again you're right , but, as for me, i can't see things like that.
Speak to you soon.
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« Reply #246 on: August 22, 2007, 06:34:57 PM »

Hi Old man, I hope Antony and the others will keep walking on no matter what happens.
Yes, I'll practice what I said, that means taking 4-5 years (till I'm 30 or so) to see what I can do to improve the situation, hopefully there will be more treatments for that problem in the years to come.

In the meatime, I'll work in order to live a bit "in the fast lane" (that means make money and achieve some dreams like travelling, owing a Mustang (the car, not the horse  Wink ), or any other silly dream that I may want to achieve. Helping others of course is important in my daily life, because it brings some satisfaction. You help others too (as you told me in another post) so you know what I mean...

Sometimes my mom asks me "why do you never relax? You go to your work, then you spend your evenings + weekends in renovating a house (+ the house I live in I should add  Wink ), you haven't taken any holidays  for the past 3 years..."
I just can't tell her why. She already had a tough life like that  (long story, includes her own history + living with my dad, which is really not easy) and I just want to make money in order to make her gifts, and buy her whatever she would need. That + my own dreams to achieve is the reason why I don't stop...

Yes, I probably could do without the Mustang or the trips to Asia / USA, but I guess in our situation we need to "escape" from reality from time to time. That's why I'm working so hard to get the money now... and not in 10 years.
And if I become desperate enough  Smiley I might do a few months stay in a shaolin temple...I know they accept occidentals now... I've got crazy dreams, but it seems I need to achieve them all, just because of this problem... Otherwise I might have done just one or two... It's just that if I deceided to do stg silly in the future (you know... Undecided), even in 5,10,20 years or later, I just would like to think before I do that : "I've done and seen things that most people I know never experienced, so I had a nice life after all...".

You know what I mean? But we're not there yet, don't worry  Wink 
I'll fight. And I'll try to encourage people around me as much as I can.
Bye, thanks for your support!!!
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« Reply #245 on: August 22, 2007, 02:32:01 PM »

Ninja:

Well said my young friend! Your advice and wisdom in this matter is very far beyond your years. Just practice what you are preaching and the rest will come easy. Keep up the good work!!!

Regards, Old Man (Almost 78 now)
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« Reply #244 on: August 22, 2007, 09:07:22 AM »

Hi Antony,

I'll quote you on 2 points:
Quote
When i know some men of 70year old who complain because they lose a little their erection and feel losing their virility, it makes me mad...
I've been witnessing some situations like that, and you just want to knock the guy out... It's usually people who have never been living hard times (like serious diseases) in their life. And it's also unfair for us young guys, but life is not fair.

My best friend told me lately that sometimes, he "comes" prematurely, and that's a problem to him... (man, you're gonna make me cry  Cry!)
Because of a frustrated mood, I only replied: "Mate, If you knew... you would think you're the happiest man on earth". He asked why and I just replied, "never mind."
No need talking to people who don't live the same stuff.
>>>Even if talking doesn't cure the problem, not talking just make it worse.


With all the "sligth" problems I had in the past + this one, now I consider that life is like a poker game in which you have to make the best with the cards you've been given... Even if you have crappy cards...

Sometimes I think about kids with cancer and sick disease like (sorry no translation) mucoviscidose... Why them also?

But there's no need asking why, it's life and if God exists, (sorry for the US guys, I know religion is important to you), He's not here to help people out. He's an observer... But no point talking about religion, sorry.

Just wanted to say that when you say :
Quote
I would be more optimistic if some medicine would directly help on restaure the tissues... (will definitely speak about pentox to the sexologist). How it doesnt exist in 2007??? Knowing the importance that sex has in a mans life and human life in general (according to me)
Sex life is not a priority (not my point of view of course), AIDS and Cancer are...
For us it's a priority cause we're affected by it... Sad

But I do think that they'll come up with drugs and treatment (collagenase maybe?) to help you out.
Take the drugs (cialis or viagra) if it can help restore night erections (it might take some time, but you never know).
A depressed mood will also ruin your erections (I know that!, when I feel down, the rest of me is feeling down too  Wink) so either take anti depressants (check which ones to take 1st, cause some might ruin the erections I think  Undecided) or find activities to bring your mood upwards...

I think you should talk to Hawk, Liam and Old man in order to get more advice cause they are more experienced than me.

I know it's hard to get this stuff out of your mind (I don't know if it's possible, but when I do some things I like doing, it takes my mind away (at least 50% of it  Smiley ) from my problems.
"Keep busy" as they say...

I live bad times psychologically too, but the more you think, the more it hurts, (good old vicious circle) so keep busy.

In any case, any time, you can talk I'm here (private message or not).
And don't give up now, I said take 4-5 years to see if it improves or not. No matter what. You're a man, you have to consider this stuff as a battle, and you're a damn warrior Angry.
A man can take anything.

Ok, over with the "Rocky" stuff...I know it doesn't help much, but you have to take this philosophy for the 4-5 years to come at least. Even if you think it's too hard, grind your teeth and keep fighting. At least a few years. Then you'll see what are your options.

Sorry for the basic imagery, but that's the only thing that works on me. I know it's hard taking the comments of other people who are healthy and lead a normal life and still complain... And some girls won't be nice too, but you have to avoid the bad company for a while. Keep close to the people that cheer you up or make you happy.

Also, regarding girls: as long as you have this problem, stay away from the "Paris Hilton" kind of girls, they won't bring you up. I know that some people (a small %age of the human beings) have absolutely no desire for sex. I think they're called "the angels" or stg like that. Search on the forums or meetic stuff for such a girl. Say you look for a girl with no sex drive. Be direct, no need to explain why.
It can catch the attention of a girl in this situation and she'll bring you more support than a girl who needs sex. It'll cheer you up to be loved for other reasons that your "thing", and you'll take your treatment in the meantime and you'll wait for the erections to come back. There must be a way.

And when it works again, you'll give her a good "slapping" shag to change her opinion about sex  Cheesy Cheesy and you'll think about us who told you to keep fighting, see what I mean?  Smiley

I know it sounds silly, but I think finding such a girl could do some good to your mind and heart.


And to conclude,
I know it's hard to take, but you'll take it. And you'll find a way.

4-5 years, that's all I ask you to take before doing anything silly.

Don't isolate yourself, that's not good either. Just keep the good people around you, say "bye bye" to the bad influence people. That's the only way you can bear this s..t for the next 4-5 years.
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« Reply #243 on: August 20, 2007, 10:48:32 AM »

Hello ninja ,

Thanks for moral help, you know since the begining i try to think about something else, but the problem of a 'illness' like that is that it's 'on you', you can go evrywhere, do what you want, you have it 'inside you', and that's terrible.
I supose that a 45° bent, and sensitivity/hardness problems are already really hard to support, (by the way how it happened to you?), so imagine that at my age i become totally impotent and that medicines like ciallis dont work so much, and the erectile tissues have become totally fibrosed, because of... such a 'little thing', a night when a girl made a f'^+'ing bad move during intercourse at the top of me...(i would have prefered to be amonk pfff). And it was not a typical penile fracture, and not a peyronie, but worse consequences than both of them... The shock i received was hard but not so terrible, and now my man's life is finished, and i am too young for that.And of course i'm scared about future, wife, kids,too, and to have lost all what i liked, and to stay some years like that, like a dependant person because i stopped job.
When i know some men of 70year old who complain because they lose a little their erection and feel losing their virility, it makes me mad...

I was told that maybe in 5-6 years tunica albuginea could be put in 'culture' in order to repair it , and to insert the new one in good form into the penis. But it's not sure, trials are just done on animals, and anyway, 7 months like that were so horrible, i can't imagine 6 years.

I will go to see the doctor to speak about the anti depressor who can help night erection , 'trazadone', if it can make both anti depressor, and help for erection, could be something helpful? Anyway , i am against medicine like anti depressor too, but maybe don't have the choice now you're right.

I believe , like you, that only people who have the same thing can really understand.

The problem is, (according to me), speaking about the problem helps on the moment, but don't heal you (if we could speak to people who would have healed, it would be better), and not speaking is horrible to stay like that alone with your problem and dark ideas.

I would be more optimistic if some medicine would directly help on restaure the tissues... (will definitely speak about pentox to the sexologist). How it doesnt exist in 2007??? Knowing the importance that sex has in a mans life and human life in general (according to me)

Anyway thanks you for recomfort, but i can't be sure of doing nothing 'stupid', coz my life has been too much broken by this crap (i can't enter in detail, but i lost so much in so few time).

Good luck to you too.
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« Reply #242 on: August 20, 2007, 07:54:02 AM »

Antony,

> ninja gaiden was indeed a video game  Wink

You need to find a way to think about something else (ha ha, you must be reaaally having fun reading this advice Undecided) I know it's hard thinking about something else and I can't imagine your situation, having "just" a 45° bent and a couple of other sensitivity / hardness problems that spoil the fun of a normal sex life. And of course, I have the same questions about the future, family, kids, can't imagine a bright future too.

You had hard times, I had my share too, and not small stuff that people usually complain about, but I know that this is the most shattering experience I'm living now. It pretty spoils my activities too.

But we have to wait at least a few years and try some options before thinking about giving up. You can't give up so soon, try for a 4-5 years to see what can be done.

I would not recommend the use of antidepressant in general, but in your case, take it because you're at the bottom at the moment. As time goes by, you'll have more time to think more "clearly" and look for solutions.

Unless you tried all, you can't give up. Don't make anything stupid ok?
Talk here, send messages as much as you want, we'll pay attention to you. But you have to talk about this in order to feel a little better.

Let the pride on a shelf cause in this case, not talking will bring you down.
Theses problems are too serious to be kept to oneself, but talk to people  who are in the same boat, only them can understand (to my point of view).

Take you medication + go to a psychologist in order to get advice to get out of this depression.

Keep us informed about you because we don't want you to think you're alone.


And if music hurts, do something else (sport, anything) that will help you smile. Keep us informed please.
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« Reply #241 on: August 17, 2007, 11:48:56 AM »

Hello guys ,

thanks a lot for your comments, really.

To GEORGES, i think i will defintely ask to my doctor about pentox. A french doctor was making research about fibrosis and i have read she used that for treating fibrosis -but not penis fibrosis, it was in order to treat post-surgery fibrosis, i have mailed her to ask her if it was the same principle for penis.
Maybe the vaccumm can help too efectively. You're right telling that the sexologist probably knows more than the generalist doctor, but i saw so many crap specialists in so few time that now my trust in them is very low.
In fact at flaccid state (99% of time now i am impotent), there is like a torsion at basis of penis, probably the blood can't circul normally and lead to the fibrosis of tissues.
Few months more are maybe 'not a lot' at the point where i am, but each day which goes is harder. As i told, the worst is not to have this problem if there was a common and well known way to heal it, the worst is that it seems there is so few to do, and what can i try like vaccum or pentox, i am totally not sure it will do something, and that i will recover. I've tried some diferents treatments since the begining (antibiotics for a prostatisis i didnt have, medical chinese herbs, cialis, anxiolitics, each time it should 'heal' me , but in fact it did about nothing).
After, when you say 'there is really more to life than sex'... Ah, it's too long to explain. for me it was 'a part of the balance', to stay stable. The 'side' with girls had a very important part in my life, i was also working in music band like 'sexy music' ,that speaks about a lot of parties, sex, relationships between guys and girls, etc, so i had t give up everything in so few time. I lost work, girlfriend, projects, confidence, and these olidays(this one is not the main thing), and probably my... life. And sure, there is not only sex in life, i could stay some time without having sex it was ok, but there is a diference between 'chosing not having sex', and 'dont have the possibility because i've become fisically importent...' Imagine, just later for having a wife and family... I'm just 25...
Anyway, i lost evrything in that problem, i don't want to move you to pity , not my goal, not my behaviour, but just hope i can do something to heal .
Anyway thanks a lot for your encouragement.


To NINJA GAIDEN (it was a video game if i remember well): thanks too for your post, you know the story now, and you know why i have so dark ideas. (lol dark things in my mind are darker than coffee or chocolate...)After, maybe it's a matter of age, way of life, personality, area where you live, etc, etc, the way how you react.
As for me, to become impotent was the worst thing that could happen, even in a nightmare i couldnt think that. I have ever had lots of muddles, quite rough and very speed life, some hard or sad moments, its ok, no problem, I can manage and recover very quickly. Every body has its dificulties. But this one... One night you make love, you feel something serious and bad hapened in your penis, nobody takes you seriously, especially doctors -, and few months later you have lost everything in your life.... (i can't sum up all what i tried, did, consulted, wasted my money for NOTHING in only 6 months, its not believable -you could make a film or book, 'how to go from the top to the hell in so few time'). So, even being proud, i admit without any problem that this thing is too hard for me.

i totally see what you mean speaking about 'comedian doctors'. And yes, the 'wait and see' of french doctors i saw... I was like: 'wait and see what?Huh wait i become definitely impotent??? ' Go to hell these doctors, i prefer one who admits that it's serious but he doesn't really know what to do, than the ones who say 'wait, it will be ok, and give you... nothing'.

Concerning the urologist, i think i continue with the sexologist i see at the moment, but i don't know if i have to find one in 'peyronies disease' coz in fact, it looks like a lot a peyronie disease but not sure that its a typical one (or if it is, i am in the crap becoz i read on all french sites that when you become impotent because of peyronies disease, you will never recover. You can recover from curvature, from erectile pain, but not impotence caused by this illness.) My case looks like a lot, but my fibrosis of erectile tissues doesn't come from a peyronies disease i think (at least no doctor told me that, even if they said so much crap). Sure i have wasted enough time and money in the ones that make you do  urinary analyses when you speak about total impotence, no sensitivity in penis, hardeness of penis , deformation and fibrosis....

Thank you a lot for your recomfort, but for sure, can't continue my activities,especially music, and have stopped smiling. Anyway , about finding a treatment, i'm looking for all what i can, but concerning the 'mind' , it's too hard .

But i thank you , and good luck to find my house for kicking ass lol, haven't you heard in riots of november 2005, that it's dangerous to come in some areas now, it has become like Compton or Harlem here loool. Wink


To LIAM: No, this doctor is about sure about what i have, but said to me he can do nothing. Just adviced me to another 'famous' doctor, i have apointment at the end of november, and this one will probably tell me he can do nothing, so waiting for these apointments that only make me waste few money i have now, are useless. He told me , just like that, 'hope in some years you will have a normal sex life again' (before that crap problem, i had never had even one small problem concerning sex).
I've read the french sites about penis fracture, they all say that you need a surgery very quiclky in order to avoid consequences like impotence precisely, curvature or pain in penis.... But during my intercourse, i had a big pain when the girl did wrong move, but no visible haematoma, so when i visited doctor because i had pain, he said 'it's nothing, it will go better soon'... you know the following of the story.
I can read about american articles on penis fracture, but i think this problem is 'international', they will probably say that, once it has bad scared, in a bad way, you're elasticity in erection is condamned for erver and need a penile protesis....

I saw recently a doctor for my dark thoughts, even if i don't like so much this type of doctors or medicine (its the 1st time i am confronted to that) , i made effort. But no medicine like anti depressor will make me forget what happened, and happens , to me... Maybe i should ask for the tarazadone i read about here?

Thanks for your message and the link.

Antony
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« Reply #240 on: August 17, 2007, 05:14:23 AM »

Quote
The last doctor i saw thinks i had a shock on tunica albuginea during the intercourse in February and sadly, the scar healing went in bad way, and made a scar tissue on erectile tissue, and that condamns erection!!! According to him, i have a fibrosis of erectile tissues!!And he can't do anything apparently. All that for that. Now i don't trust doctors anymore, and have really dark ideas.


Does this doctor think you will heal?  Does this doctor think you will have normal sex in the future?  Here is a site about penile fracture (broken penis) and other trauma to the penis.  Try to Google penis fracture.  I'm sure there are sites in French, too.  Go to a doctor for dark thoughts (depression).  Medicine will help that.  Smiley  My favorite is Wellbutrin, but they have other "flavors", too. Smiley  Good Luck!

http://www.emedicine.com/med/topic3415.htm  - the part about fracture skips around  Sad  You will have to scroll down the page.
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« Reply #239 on: August 17, 2007, 04:00:08 AM »

Hi guys!

 Antony, I do think that before you make a bad move (talking about dark things, I don't think it's about coffee or chocolate), think twice and take time to search for solutions.
You've been to comedian-doctors like there are some many as it seems...
In France (at least north of France), they know close to nothing about Peyronies Disease, just talk about "corrective" surgery, or "just wait and see"... Very frustrating isn't it?

Now, forget about these comedians, take time to find a urologist interested in Peyronies Disease. Ask him directly over the phone if you can, don't waste time and money with guys specialized in urinary leaks...

If you need to just talk in order to feel better, you can send private messages to me or the veterans of this forum, they've been through tough s..t too, (we're babies here, they know more than us) so they can help you raise you head.

In the meantime, don't do anything stupid, talk about this whenever you need (here we keep it private, right guys ? Cheesy) and do activities that you enjoy the most (music if it's what you like). I think some doctors are searching for solutions, stuff that might not help you recover full  use of your penis right now, but some techniques may give you back a part of your sex life, and then in a few years, who knows? They'll find a cure.

So keep your head up and do things that you enjoy, or I'll find your house and will kick your ass!  Angry

Smile my friend Wink  I know it's hard, but you're just too young to give up now.
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« Reply #238 on: August 16, 2007, 07:30:19 PM »

Antony,

Just a couple of comments.  First of all, Pentox has been used to tried different types of fibrosis with some degree of success.  Secondly, I suspect that your Sexologist might well know more about the vacuum therapy than your general doctor.  A gentle application of vacuum would be more likely to be helpful in my opinion (I am not a doctor) than harmful.  So these are two potentially useful approaches.  But, at this point, a few more months is not likely to make a whole lot of difference on the effectiveness of treatment.  BUT, a few more months can make a lot of difference on the impression you can make on the doctor as to your degree of knowledge on the subject.  And that is VERY important.  You need to carefully study the use of the generic drug Pentox and also the use and concept of the VED (Vacuum Erection Device).  You need to know the course of treatment you want to pursue and you need to be able to provide your doctor with convincing evidence that this course of treatment might be effective.  It really sounds to me like the Sexologist is on the right track here, so perhaps you need to give him/her the opportunity to help you further.  But, in any case, you will need to discuss this further with your general doctor and enlist him on your side in this project.  Most doctors DO respond to legitimate research, so the more of that you have in hand when you go to the office, the better.  And the more you learn about fibrosis in general and those strategies that might work against it,  the better equipped you will be to deal with this over the long term.  Both Tim and Hawk are giving you excellent advice.  Take your time and learn, learn, learn.  And don't let yourself be disabled by depression.  There really IS more to life than sex.  But the more attention you pay to building up your general health with a good diet and healthy exercise, the better prepared you will be to potentially get rid of this monster.  I wish you the very best.

God bless you,

George
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« Reply #237 on: August 16, 2007, 06:33:49 PM »

Hello Hawk,

i didnt know where to post exactly, but my problem deals with impotence , fibrosis, so i thought it was in erectile dysfunction. In fact it's a little like a peyronies disease with total impotence.

Yes you're right about the doctor. The problem is, as i explained, that i saw lots of them, at the begining they didn't take it seriously (they said it was a prostatisis, nothing, psy, etc etc). Now they tell me its very serious. So i am no more really patient with them, and don't really trust them anymore. The sexologist who works with me now wants to make me use vaccumm during 3 months, i was nearly to try when my generalist doctor told me it wasn't good, and adressed me to another specialist (i have apointment in... the end of november). So i think they made me lose enough time ; so if a treatment can help and they didn't suggest it , i will speak to them about it. I can't stay like that. The problem is already very very serious in itself , with bad consequences, but the worst is that ... they suggest me absolutely nothing (exept the one with vaccumm).
So if treatments with positive results were seen here for fibrosis of erectile tissues , i have to speak to the doctor about them.

Being relax, you know, i was at the begining. But i've heard that during 6 months ('no panic', 'it will be better', 'cool', etc etc, coz for doctors it's easy to say. I stayed cool some months, and i saw the situation was decreasing. Now i'm told that i will stay impotent , so hard to stay cool. I even post on american forums!!) Don't know who would be relax with all my symptoms and my life break in so few time.

I will read your link , and try to find articles Tim mention on internet. (french ones say there is nothing to do with fibrosis).

Antony
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« Reply #236 on: August 16, 2007, 06:11:22 PM »

Antony,

I just want to let you know that I will be moving these posts to another topic since most of it really is not about erectile dysfunction, but I will leave them here for now because I want to be sure you see the posts.

Pay very close attention to what Tim is saying.  I think it is VERY unlikely that you can just go to your doctor and "ask about pentox".  You must educate yourself thoroughly about its use with Cialis or Viagra to treat Peyronies Disease. You must take documentation.  You must present this in a way the doctor will take you seriously and without offense.  You also must prepare for the fact that even then he may refuse and you will be going to yet another doctor.

You have time, and you have options.  Be calm, relax, think positive.  Life is not over.

The articles Tim ended his post with are on the internet.

Also please start by reading this on the forum http://www.peyroniesforum.net/index.php/topic,440.0.html

Hawk
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« Reply #235 on: August 16, 2007, 05:31:05 PM »

Tim,

yes i will ask to my urologist about pentox or other treatments VS fibrosis.
The fact is in 6 months i have seen a lot of doctors who did a lot of mistakes, and i have seen some of 'famous' ones who can now do nothing (it's their own words, 'just take cialis and see')....

For that reason such a despair :  1 'little' accident, 6months to know what i had, lots of doctors and mistakes, an impotence and retracted penis as a conclusion.

For the implants, you're right but i realy dont want of that.

I will try to read the highlights too .

Pentox and arginine have really healed people who had fibrous tissue after priapism?? here, urologists say that when you have fibrosis of erectile tissue after priapism, there is nothing to do, its for life.

Are the related articles you give me are on the forum or on the net?

Thank you.

Antony
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« Reply #234 on: August 16, 2007, 04:52:17 PM »

Antony,

I have learned to never say never. You should know that implants have a high satisfaction rate, and men can experience orgasm and good sensations, and it is not mechanical etc. Think of it this way. What if you struggled for3 years, or 5 years, or ten years and got no better? Would you then want to get a bigger and straighter penis that worked and pleased a woman and allowed you to have an orgasm with intercourse? I think the answer is yes. But you are not there now. That is OK - just understand that if you fail to improve, that you DO have an option that can restore you to a way to have back your sex life.

Having said that, I want to remind you that I wanted you to simply remember that you have other options to fall back on as you struggle with your feelings of despair.

Now, as for viagra or cialis... althoug it is hard, you really should go back to read some of the "highlights" on the "Newly Diagnosed Highlights " area. There you will see why we are saying that might be good for you.

The Viagra or Cialis is not intended to promote erection for fibrosis, but to promote healing. Getting harder erections is simply a good side effect! Rather, the viagra, and arginine promote what are called "nitric oxide" (also known as 'NO') biochemical pathways in the body. This will promote an anit-inflammatory healing, and allow recovery better than when such drugs are not given.

Pentoxifylline is designed to reduce the formation of transforming growth factor Beta-1 (TGF-Beta), which is a chemical in the body that promotes fibrosis. By blocking it's formation with pentoxifylline, you allow the fibrosis to gradually reverse.

So, using those medicines may allow a reversal of fortune for you over time. I would waste no time in digging up these articles and reading them and then finding a uroolgist who is willing to work with you.

Tim

Related articles:

Valente EG et al. (2003) L-arginine and phosphodiesterase (PDE) inhibitors counteract fibrosis in the Peyronie's fibrotic plaque and related fibroblast cultures. Nitric Oxide 9: 229–244

Schwartz EJ et al. (2004) Sildenafil preserves intracorporeal smooth muscle after radical retropubic prostatectomy. J Urol 171: 771–774

Rajfer J. Gore JL. Kaufman J. Gonzalez-Cadavid N. Case report: Avoidance of palpable corporal fibrosis due to priapism with upregulators of nitric oxide. [Case Reports. Journal Article] Journal of Sexual Medicine. 3(1):173-6, 2006 Jan.

Aslan A. Karaguzel G. Melikoglu M. Severe ischemia of the glans penis following circumcision: a successful treatment via pentoxifylline. [Case Reports. Journal Article. Research Support, Non-U.S. Gov't] International Journal of Urology. 12(7):705-7, 2005 Jul.

Evliyaolu Y. Kayrin L. Kaya B. Effect of pentoxifylline on veno-occlusive priapism-induced corporeal tissue lipid peroxidation in a rat model. [Journal Article] Urological Research. 25(2):143-7, 1997

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...grab some scalpels and settle this like doctors


« Reply #233 on: August 16, 2007, 03:47:55 PM »

Quote
What do you think?
Maybe I should see a sexologist for the low sexual desire, at the same time as a urologist specialised in Peyronies Disease...


Sound like a reasonable approach to me.  As far as supplements, many men swear by "horny goat weed" .  "Red Korean Ginseng" has good reviews, also.
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« Reply #232 on: August 16, 2007, 01:11:04 PM »

Hello Tim, and thanks a lot for answers,

Yes, for sure its a BIG problem, and it's a terrible experience that can give you very, very dark ideas.
I'm 25, last year i was going out with a model and worked in music, some months later my life is destroyed, what happened between that two points? An unusual sexual accident, bad diagnosed by urologists, and now i am just told that i will stay impotent for rest of my life, juste makes me crazy.


'It sounds like you have developed diffuse fibrosis in response to a non-specific injury. It sounds similar to what might happen to the corora cavernosa and tunica when one develops priapism (prolonged painful erection). In priapism, one potential outcome is development of a penis such as you describe (interestingly, that is not always the outcome of priapism - why not?).'

>>>> yes it's exactly what i feel, and what last doctor i saw thinks too. (after....7months!!!!) , and when you say 'non specific injury', its totally that, because what i had doenst look typical, not a typical peyronie, not a priapism, not a very violent penile fracture.

Do you know if some vaccumm exercise can help with such a problem? Or oral medication? (i ask here coz i dont really trust doctors anymore now...one told me to do vaccum, the other told me it wasn't good)... and me, i stay in my condition...


Do you have the name of the french surgeon you speak about?

I tried to take cialis during last month two times a week. In my case, the problem is that the penis has changed of anatomy. I would say the cialis 'works', but the induced erection is now small, with curvature (not a big one, that's not the problem), paintful, with no sensation, and totally hard, with no elasticity in the penis. In fact my penis becomes very very hard and 'sticks itself' to the belly and navel (if you see the image), it doesnt go in 'normal direction' like before, i mean pointing right. There is definitely a big organic problem. It's for that reason i would like treating the fibrous tissue if it's possible, and not only take medicine like cialis or viagra, coz they are not very useful in my case.

What are pentox and arginine ? are they used with 'success' if following impotence due to priapism?(sorry if i haven't read the whole forum, its quite hard for me to understand evrything in english)

For sure i am looking for a very good evaluation, but lots of doctors are not competent here. About sexual problems, they first say its psychologic when you are young  (pffffffffff, i know it was organic), and finally when in my case they admitted it was fisical (just have to see the form of penis!!!, and the unpossibility to stretch it at flaccid state), they said it was too late and now can only give cialis or viagra pfffff i am so disgusted. So i dont know a doctor who could do it.

Do you know if things like fish oil or vitamine E can help?
Has anyone already experienced such a problem as mine?

To finish, i would defintely never accept a penile prothese. First because i cant accept that i went to doctor very soon at the beginning of problem and they let the problem go to total impotence. Secondly because i read some about prothese and it's horrible, it's totally mechanic, you have no more pleasure or what. I am young, not married, i liked enjoying life and go to see different girls, it's not as if i was with my wife and explain her that. And i am too young . And too expensive. Any way that's a solution i can't accept. My goal is to recover from the fibrous tissue. How could i become impotent in so few time? Disgusted.

Anyway thanks a lot for your answers and help. I'm in a such despair, i hope so much find a 'treatement' (to take 1 year to recover, or even more, would make me mad, but i could to that, because it's worth to do it, but if i am clearly said that i just can do nothing, useless to live it).

Thanks Tim,

Antony

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« Reply #231 on: August 16, 2007, 12:08:06 PM »

One can have radical surgery.

RECONFIGURATION OF THE SEVERELY FIBROTIC PENIS WITH A
PENILE IMPLANT
FRANCESCO MONTORSI, ANDREA SALONIA, TOMMASO MAGA, RENZO COLOMBO,
ANDREA CESTARI, GIORGIO GUAZZONI AND PATRIZIO RIGATTI

These surgeons are in Italy from the Department of Urology, University “Vita e Salute-San Raffaele,” Milan, Italy.

No time to post the pictures (i have posted them before - one can search through my old posts). The make the severely shortened and fibrotic penis longer by adding grafts and making relaxing incisions before putting in the prosthesis. It is a last resort, but one should know that those who get this after struggling for a long time with other avenues have a very high satisfaction rate.

Tim
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« Reply #230 on: August 16, 2007, 12:00:07 PM »

JAMA. 2004;291:2994-3003.

INTRODUCTION   

DR BURNS: Mr G is a 66-year-old man with a history of hypertension and sleep apnea. He lives in a suburb of Boston with his wife and has commercial indemnity insurance.

Mr G first developed erectile dysfunction (ED) several years ago. Four months ago when he saw his primary care physician for a routine checkup, he asked about using sildenafil (Viagra). He noted decreased libido and difficulty attaining an erection. He had slight urinary urgency, but no difficulty initiating urination. He had no history of diabetes or cardiovascular disease. In the past, he had used a dental device to treat his sleep apnea but was no longer using one. His other past medical history was a colonic adenoma found on a screening colonoscopy in 2001. His medications were aspirin (81 mg daily), hydrochlorothiazide (12.5 mg daily), and ibuprofen (600 mg 4 times a day as needed). His wife had metastatic breast cancer and was doing well with maintenance therapy. He was working part-time and noted considerable stress due to a home renovation project.

On physical examination his blood pressure was 150/90 mm Hg; his heart rate was 76/min; his lungs were clear to auscultation; and his heart had regular rate and rhythm without murmurs, rubs, or gallops. The abdomen was soft and nontender, without organomegaly. Genitourinary examination revealed small soft testicles and a smooth firm prostate that was minimally enlarged without nodules. His pulses were bilaterally intact.

Laboratory evaluation for secondary causes of ED included the following values: prolactin (4.9 µg/L [reference range, 2-20 µg/L]), thyroid-stimulating hormone (1.7 mIU/mL [reference range, 0.27-4.2 mIU/mL]), total testosterone (505 ng/dL [17.5 nmol/L]; reference range, 270-1100 ng/dL [9.4-38.2 nmol/L]), free testosterone (1.0 ng/dL [0.03 nmol/L]; reference range, 1.5-3.5 ng/dL [0.05-0.12 nmol/L]), and prostate-specific antigen (PSA) (1.4 ng/mL [reference range, 0-4 ng/mL]).

Atenolol (25 mg daily) was added to improve his blood pressure control. He was given a prescription for sildenafil (50 mg to take as directed).

Two months later, Mr G was seen at a follow-up examination. At that visit, his blood pressure was well controlled with hydrochlorothiazide (12.5 mg) and atenolol (25 mg). He noticed no change in his sexual difficulties with the addition of atenolol. Mr G stated that after reading the patient information sheet about potential adverse effects of sildenafil, he decided not to take the medication. His primary care physician suggested that he see an endocrinologist or urologist about beginning testosterone replacement. Mr G is concerned about the potential adverse effects of testosterone therapy. He wonders about the pros and cons of the different treatment options for male sexual dysfunction.


MR G: HIS VIEW   

I'm not quite sure if it started when my wife was getting sick, but that's when it became more noticeable. Not the same desire, and physically it changed. The erection wasn't there. It becomes an embarrassment. That's how I felt about it. So you know, I really didn't say anything. I never investigated it. Maybe I'm from the old school that's very private. But the only thing that I ever knew that they would do is the implants, the Viagra [sildenafil], or the testosterone.

I think Viagra and the testosterone need to be better explained. It seems like they're always putting a mystery to it. The side effects can be a lot worse than what people tell you. They'll say, with Viagra, 10% of the people may have this side effect. But if you're among those 10%, wouldn't you like to know about it first? The only way that I found out about the side effects was I went to the drug store and asked for a printout as to what it does and how it works. Even the pharmacist said, "I don't know all the side effects, because some of them are so minuscule that they're not printed." But if you're affected by it, it makes a big difference.

I'm not very keen on taking medication. So I'd have to do quite a bit of thinking about it, you know. And right now, I'm undecided.


DR K: HIS VIEW 

Mr G actually came to me and asked me for a prescription for sildenafil. He said that he had a normal libido. It wasn't an issue of libido so much as initiating and maintaining erections. One thing that's happened as a result, I think, primarily because of advertising by the drug company that makes sildenafil, is that people come in and actually raise the issue much more easily than they used to.

In someone like this patient, particularly with a borderline low or a low free testosterone value, who probably would respond to either testosterone or sildenafil, what would Dr Morgentaler recommend? I'd like to know whether he thinks that every gentleman who is given a prescription for testosterone should get a prostate biopsy. I'd also like his opinion on whether primary care physicians should be managing much of this by themselves and when the urologist is particularly useful.


AT THE CROSSROADS: QUESTIONS FOR DR MORGENTALER
 

What is the definition of male sexual dysfunction? How prevalent is it? What are the causes and pathophysiology of ED? What evaluation should be undertaken for a man with sexual dysfunction? What are the medical treatment options? When should a patient be referred to a urologist for sexual dysfunction? What are the surgical treatment options and when should they be considered? What are the risks and benefits of each? What do you recommend for Mr G?

DR MORGENTALER: Mr G is a 66-year-old married man who presents with a history of diminished libido and ED of several years' duration. The onset of symptoms began when his wife became ill. The history suggests various possibilities regarding etiology: psychological (temporal relationship to wife's illness), vascular (age and hypertension as risk factors), or hormonal (low serum testosterone level). Although sildenafil was prescribed, Mr G never tried it. Mr G expressed concerns about the risks of treatment for sildenafil as well as for testosterone.

Mr G presents with a set of common, yet vexing problems for the primary care physician. What kind of evaluation is required for a man with sexual dysfunction? In a case such as this, how does the clinician decide whether to treat first for hypogonadism (low serum testosterone level) or ED, and how to balance risks vs benefits for treatment of a quality-of-life issue such as male sexual dysfunction?

Male Sexual Dysfunction

Male sexual dysfunction can be broadly separated into several major categories, as outlined in Box 1. The introduction of sildenafil, the first of the oral phosphodiesterase inhibitors, in 1998 has created widespread recognition of ED as a primary form of sexual dysfunction in men, and there is gathering interest as well in hypogonadism. However, there is far less awareness of ejaculatory disorders and of anatomical abnormalities of the penis such as Peyronie disease, an inflammatory condition of the penis that results in palpable plaque or curvature with erection.


Box 1. Classification of Male Sexual Dysfunction


It is of the utmost importance to distinguish which of these conditions is present when a man complains of sexual dysfunction, recognizing that more than one may be present in a given individual.1 This is particularly true in older men, since both ED and hypogonadism become increasingly prevalent with age. A common error is to assume that any sexual complaint in a man represents ED, which may lead to inappropriate and ineffective treatment.2 For example, sildenafil is generally not helpful for men with a primary complaint of diminished libido.3

Mr G presents with symptoms of both ED and diminished libido. Sildenafil, as a treatment for ED, may be a reasonable first step. However, successful treatment of patients like Mr G requires an approach that addresses both conditions. Participation by the partner is always encouraged and can be extremely useful; however, many men prefer to address their sexual dysfunction as a personal issue without involvement of their partner, and this wish must be respected.

A Second Sexual Revolution

The advent of oral contraceptives, coupled with the women's liberation movement in the 1960s, ushered in major changes in sexuality and sexual attitudes and has often been termed a "sexual revolution." The introduction of sildenafil in 1998 has created a second sexual revolution, not only because it is the first effective and safe oral medication for the treatment of ED, but also because it has widely affected social attitudes and behaviors regarding sexuality.1-2 Men, as well as women, are now much more likely to raise the topic of sexual dysfunction with their physicians, and it has become a common scenario for patients like Mr G to specifically request a prescription for Viagra (sildenafil) by name. Sexual dysfunction can lead to depression and a profoundly altered sense of self-esteem that negatively affects many relationships; increased awareness and treatment are thus to be greatly encouraged, due to the profound benefits in life satisfaction that may result.2

Epidemiology of ED

Erectile dysfunction is one of the most common chronic disorders affecting men and becomes increasingly prevalent with age. Data from the Massachusetts Male Aging study showed that 52% of men aged 40 to 70 years reported some degree of ED.4 A similar prevalence of ED has also been found in numerous countries worldwide, affecting greater than 40% of men older than 60 years of age in Finland,5 Italy,6 Japan,7 the United Kingdom,8 Australia,9 and Iran.10

Risk factors for ED include age, diabetes mellitus, hypertension, hyperlipidemia, coronary and peripheral vascular disease, smoking, obstructive voiding symptoms, obesity, renal failure, and alcoholism.4, 11 It is difficult to estimate the relative prevalence of these various etiologies, particularly since more than one may be a contributing factor for many affected men.

Medications are also a common contributing factor. The most common offenders include antihypertensive medications, digoxin, antidepressants, spironolactone, -adrenergic agents, and testosterone-lowering medications, such as gonadotropin-releasing hormone agonist/antagonists. New-onset ED associated with a new medication, or an increased dosage, suggests medication as the likely cause. However, this may occur on either a physical or psychogenic basis, since sexual function may be compromised by fears associated with beginning any new treatment, particularly related to cardiovascular health. For instance, the -blocker class of antihypertensives has generally been considered one of the most common causes of medication-induced ED.12 However, in a study of 96 men with newly diagnosed cardiovascular disease and without ED, 31% reported ED after beginning treatment with atenolol (50 mg) and being informed of its sexual adverse effects. In contrast, only 3% of men who were similarly treated reported ED when they were blinded as to the study drug.13 Nevertheless, the development of new or worsening sexual dysfunction of any type in temporal association with initiation of a new medication should prompt consideration of discontinuation of the medication. Treatment with a phosphodiesterase type 5 (PDE 5) inhibitor may be indicated depending on individual circumstances and the medical necessity of the new medication.

There is growing evidence that ED itself represents a risk factor for subsequent development of cardiovascular events, since it is often a manifestation of atherosclerotic disease.14-15

Pathophysiology of ED

Erection occurs as a coordinated event involving psychic arousal and increased arterial inflow to the corpora cavernosa of the penis in response to parasympathetic nerve signaling via the S2-4 nerve roots, together with trapping of blood within the corpora cavernosa via a veno-occlusive mechanism mediated by smooth muscle relaxation12 (Figure 1). Psychic arousal and sexual behavior is facilitated by androgen priming of the anterior hypothalamus/preoptic area.16 Flaccidity occurs in response to sympathetic influences. Corporal smooth muscle relaxation is mediated by the conversion of guanosine triphosphate (GTP) to cyclic guanine monophosphate (cGMP), under the influence of nitric oxide.17-18 The medications sildenafil, vardenafil, and tadalafil act by inhibiting the metabolism of cGMP by PDE 5, which is found almost exclusively in the corpora cavernosa.19



Erections may fail due to inadequate psychic arousal (eg, anxiety, depression); inadequate hormonal priming of sexual centers in the brain (eg, low testosterone); inadequate nerve signaling to the penile vessels (eg, spinal cord injury, multiple sclerosis, radical prostatectomy); arterial insufficiency (eg, atherosclerosis, vascular surgery, pelvic/perineal trauma); or impaired veno-occlusive ability within the corpora cavernosa (eg, radiation, Peyronie disease, atherosclerosis).1

Evaluation of the Man With ED

Face-to-face evaluation provides the best opportunity to explore the physical and psychological aspects of male sexual dysfunction and allows for identification of modifiable risk factors that may have an impact on general health, such as low serum testosterone level, diabetes mellitus, hypertension, hyperlipidemia, smoking, alcoholism, and depression. Creation of a therapeutic relationship may be critical for a successful outcome, since initial treatment attempts are often less than completely satisfactory.

The Sexual History. The primary goals of the sexual history are to identify the problem, assess its severity, and determine the degree to which the patient and/or his relationship has been affected. The diagnosis of ED is made by history alone and is defined by the inability to achieve or maintain an adequate erection for satisfactory sexual function.1 If ED is present, it is useful to try to determine whether the problem is likely to be organic (physical) or psychological in etiology, since this may influence treatment. Complicated psychosocial issues should be referred to a mental health professional. In Mr G's case, it is noteworthy that he describes his difficulties as occurring around the time of his wife's illness. This is not an uncommon presentation and suggests a psychological contribution to the sexual dysfunction. Some men may understandably feel hesitant or guilty about initiating sex when their partner has been ill, even when the partner encourages the activity.

I recommend a set of questions that are direct and nonjudgmental (Box 2).20 The use of clear terminology, such as the words "penis," "erection," and "orgasm," is helpful, particularly since this gives the patient the opportunity to use similar language without concern that he is using offensive terms. Two questions that have been particularly valuable in my experience are: "What happens when you try to have sex?" and "Is the penis usually hard enough to go inside your partner?"


The intermittent or sudden inability to have a firm erection suggests a psychogenic etiology. Low sexual desire suggests the diagnosis of hypogonadism, depression, or a medication effect. Inability to maintain an erection is most often due to poor veno-occlusive function of the penis, but it is helpful to ask whether softening of the penis happens before or after orgasm, since men with premature ejaculation may describe their symptoms similarly.1

Physical Examination. A directed physical examination should be performed for the man with sexual dysfunction. Specific items to be evaluated include assessment of general health, vigor, mood, and blood pressure. The presence of gynecomastia should be noted. The penis should be palpated to identify the presence of penile plaque, which is indicative of Peyronie disease. Testicular size and consistency should be noted, since small, soft testicles are associated with low serum testosterone level. Peripheral pulses should be evaluated. Neurological assessment should include a digital rectal examination (DRE), since nerve roots S2-4 mediate both erection and anal tone. The prostate should be assessed for size and for the presence of nodularity or asymmetry.

Diagnostic Tests. The goal of diagnostic testing in the primary care setting is to identify abnormalities that may contribute to sexual dysfunction, such as an endocrinopathy, or treatable medical conditions that may be associated with ED, such as diabetes and hyperlipidemia. For this reason, based on clinical experience, I recommend routinely performing the following blood tests in men who present with ED: hematocrit, glucose, total and free testosterone, prolactin, and a lipid profile. Tests of thyroid function and hemoglobin A1C are optional. The luteinizing hormone level should be measured if the history suggests hypogonadism. Men with penile curvature or premature ejaculation do not require diagnostic testing but should be referred to an appropriate specialist, usually a urologist. Testosterone levels should be considered in men with difficulty achieving orgasm unless their symptoms are clearly related to medications known to have this adverse effect, such as the serotonin reuptake inhibitor class of antidepressants.21

A variety of testosterone assays exist. Total testosterone has been used most frequently; however, since the majority of circulating testosterone is bound tightly to sex hormone–binding globulin and is not biologically functional, exclusive reliance on the total testosterone assay will result in underdiagnosis of hypogonadism. Although there is as yet no consensus regarding what serum level defines hypogonadism, values less than 300 ng/dL (10.4 nmol/L), and in some cases 350 ng/dL (12.1 nmol/L), are often used as an inclusion criterion for clinical trials. Unfortunately, the reference ranges for serum testosterone provided by many laboratories are overly generous at the lower range, resulting in categorization of too many results as normal when in fact they suggest hypogonadism.22 The measurement of bioavailable or free testosterone appears to be more useful. Although there is debate regarding the accuracy of the widely used analog assay for free testosterone,23 my experience is that it aids considerably in the identification of hypogonadal men who might benefit from treatment.24 There is no basis for the use of age-adjusted reference values for testosterone, since men of any age will experience similar symptoms at low testosterone levels.

More sophisticated tests, such as nocturnal penile tumescence and rigidity monitoring25-26 or penile Doppler ultrasound of the cavernosal arteries,27 can provide additional functional information but are not necessary in the initial evaluation.

Oral Phosphodiesterase Inhibitors

Treatment must be tailored to the individual. Some men may not desire treatment at all. Others, perhaps like Mr G, are interested primarily in gathering information about treatment options before initiating therapy.

The oral phosphodiesterase inhibitors—sildenafil, vardenafil, and tadalafil—represent first-line therapy for men with ED. Sildenafil and vardenafil have similar pharmacokinetic properties, with peak serum concentrations at approximately 1 hour and a half-life of 4 to 5 hours.3, 28 Tadalafil has a considerably longer half-life of approximately 18 hours, with evidence that erectile function continues to be enhanced for at least 36 hours.29 Although to date no head-to-head clinical trial results between these drugs have been published, their overall clinical efficacy appears to be fairly similar, with minor differences in results likely due to variations in the patient populations studied.3, 28, 30 For example, in a double-blind randomized study of 532 men, successful intercourse was achieved in 69% of men receiving 100 mg of sildenafil compared with 22% of men receiving placebo.3 In a study of 348 men using tadalafil (20 mg), 59% successfully reported intercourse at 36 hours, compared with 28% in the placebo group.30 And in a multicenter, double-blind, placebo-controlled trial, 69% of men receiving vardenafil (20 mg) successfully reported completing intercourse, compared with 22% receiving placebo.28

Approximately half of men with diabetes mellitus or more advanced coronary and peripheral vascular disease report benefit.31-32 A success rate of roughly 30% has been noted following radical prostatectomy.33 An attempt at treatment with oral agents is warranted only if the nerves have been spared, and even then, success is unlikely unless at least partial return of erections has occurred.

Patient education is critical for optimal response to sildenafil. This includes informing the patient to take the medication on an empty stomach and to time sexual activity so that it occurs within 1 to 6 hours, as well as explaining that sexual activity of some sort is necessary to obtain a positive effect. If an initial starting dose of 50 mg is ineffective, I recommend increasing the dosage immediately to 100 mg: nothing is gained by repeated attempts at a subtherapeutic dose. Similar instructions should be provided for vardenafil. However, instructions regarding the timing of intercourse may be considerably liberalized for tadalafil due to its prolonged duration of effect, although peak concentration occurs somewhat later, at 2 hours.

Limitations. Many men who fill prescriptions for sildenafil never refill them, and many others, like Mr G, receive a prescription but never fill it. Reasons for this include ambivalence about taking a medication for sex, cost, concerns regarding risk, and negative partner attitudes regarding sex or the medication. Many men and their partners believe that sexual activity should be natural and spontaneous, and they object to the planning required for successful use of oral medications. Still others may hope that their own sexual abilities will return with time or with resolution of personal problems.

Risks. The phosphodiesterase inhibitors have undergone extensive clinical study and have a fairly benign safety profile when taken as directed.3, 28, 30 The single important contraindication is the use of any nitrates, either on a chronic or intermittent basis, due to the potential for significant hypotension. Sildenafil also should not be taken within 4 hours of -adrenergic blockers,34 and vardenafil should not be used at all with them.35 The most common adverse effects are headache (15%), flushing (10%), nasal/sinus congestion (8%), dyspepsia (7%), and transient color vision changes (3%).3, 27, 29 Mr G should be reassured that priapism is extremely rare and treatable, and that he may safely take sildenafil in combination with his antihypertensive medications, atenolol and hydrochlorothiazide.36

Cardiovascular Effects. The relationship of PDE 5 inhibitors and cardiovascular health has been extensively studied. Daily administration of tadalafil (20 mg) for 26 weeks in healthy men or patients with mild ED resulted in blood pressure changes similar to those observed after placebo administration.37 Sildenafil studies have revealed a minor reduction in systolic and diastolic pressures of 2 to 8 mm Hg without appreciable change in heart rate.38

The cardiac effects of sildenafil during exercise in men with suspected coronary artery disease was studied in a randomized, double-blind, crossover study of 105 men with ED who underwent supine bicycle echocardiograms 1 hour after taking sildenafil or placebo. No negative effect of sildenafil was seen with regard to symptoms, exercise duration, or ischemia.39 Similar safety was noted in a double-blind single-dose crossover study using vardenafil (10 mg) or placebo in 41 men with stable exertional angina who underwent exercise tolerance testing.40 No differences were noted between vardenafil and placebo with regard to exercise time or time to first awareness of angina, but vardenafil did significantly prolong the time to ischemic threshold.

A persistent concern among men and their partners is that sildenafil or its competitors might cause a myocardial infarction, based on early reports of sudden death reported in the lay press. An unquantified number of these anecdotal cases were clearly related to the contraindicated simultaneous use of nitrates. Nevertheless, the data regarding PDE 5 inhibitors and coronary artery disease have been reassuring. Cardiac catheterization for severe coronary artery disease was performed in 14 men before and 45 minutes following administration of sildenafil (100 mg), resulting in no negative hemodynamic effects.41 Moreover, an investigation of reports of sildenafil-associated deaths showed no difference from expected death rates,42 and the rate of cardiac events in England among users of sildenafil appeared to be no higher than that of the general population.43 Nevertheless, it must be recognized that sexual activity itself is associated with a small risk of myocardial infarction,44 and cardiovascular assessment should be considered prior to treatment of ED in any patient considered at increased risk for a cardiac event.

Since cardiovascular disease often coexists with ED, the Princeton Consensus Panel was convened to review existing data and provide recommendations regarding the treatment of sexual dysfunction in men with heart disease.45 Those recommendations indicate the need for no additional evaluation prior to treatment for men in a low-risk group, including those with controlled hypertension; mild, stable angina; history of uncomplicated myocardial infarction; and mild valvular disease. A high-risk group was identified in whom treatment of sexual dysfunction should be withheld until further safety data could be accumulated. This group included men with unstable or refractory angina, uncontrolled hypertension, high-grade congestive heart failure, myocardial infarction within the previous 2 weeks, high-risk arrhythmias, obstructive cardiomyopathy, and moderate to severe valvular disease. Men with intermediate risk, eg, those with moderate angina or recent myocardial infarction (<6 weeks), should undergo further cardiac evaluation before restratification into one of the other groups.

Other Treatment Options for ED

Treatment options for ED, benefits, and approximate costs are presented in Table 1. Penile injections with vasoactive medications are effective in 70% to 80% of patients, have an onset of action within 10 minutes, and are nearly painless.46-47 They represent the most common treatment for men who take nitrates or have had no success with phosphodiesterase inhibitors and are used by approximately 10% of men with ED. Alprostadil48-49 is most frequently prescribed but can cause an unpleasant burning sensation in about 20% of men. Papaverine and phentolamine can be used to avoid this problem or used in combination with alprostadil for greater efficacy.50 In a study of 615 cases of men using penile injection therapy, penile fibrosis was noted in 3%, and 4% of men experienced a prolonged erection, representing 0.3% of injections.47 Although less than half of men taught to use penile injection therapy continue to use this therapy for more than a few years,51 satisfaction rates among users are comparable to men who use sildenafil as therapy for ED.52



Intraurethral suppositories of alprostadil avoid penile injection but are less effective and require the use of a tourniquet at the base of the penis for optimal results.53 Initial treatment should occur in a health care environment with proper monitoring due to the rare occurrence of syncope.

Vacuum constriction devices offer a noninvasive yet mechanical treatment and is used by approximately 5% of men with ED.54 A plastic cylinder is placed around the penis and negative pressure is created, drawing blood into the penis. A tourniquet is placed at the penile base once adequate rigidity has been achieved, trapping blood within the corpora cavernosa. Some men find this treatment ideal, although many others find it cumbersome or unappealing.

Surgical implants remain a highly successful and satisfying treatment for men whose condition has failed oral therapy and find other treatment options unsatisfactory.55-56 Nevertheless, the number of procedures performed is relatively low compared with the estimated population of men with ED. A review of 372 cases using the AMS 700CX inflatable prosthesis (American Medical Systems Inc, Minnetonka, Minn) revealed 86% device reliability after 5 years, and 79% of men continued to use it for intercourse at least monthly.56 In a study of 434 patients implanted with the Mentor alpha-1 inflatable prosthesis (Mentor, Santa Barbara, Calif), functional results were similar, with patient satisfaction rates of greater than 80%, and partner satisfaction rates slightly lower than this.57 The appearance and sensation of the penis is quite natural, and psychologically, many men say they feel their problem has been "fixed" after placement of a penile prosthesis. The primary risks are device failure (2% at 2 years; 14% at 5 years) and infection in 2% to 3% of cases.55-56,58

Other Oral Therapies. Apomorphine is a centrally acting oral medication that has shown mild clinical efficacy in the treatment of ED,59 but is not available in the United States. Yohimbine is a plant-derived -adrenergic inhibitor with limited efficacy in the treatment of ED.60 Despite aggressive marketing, no data support the assertion that nutritional supplements, herbal therapies, or vitamins have any beneficial effect in the treatment of ED.1

Hypogonadism

When a man like Mr G presents with symptoms such as diminished libido and ED in association with a low serum testosterone level, the condition is termed hypogonadism.21 Other symptoms and signs of hypogonadism include depressed mood; reduced energy, muscle mass, and strength; reduced bone density; anemia; fatigue; and impaired cognition. Less well-recognized sexual symptoms of hypogonadism include difficulty achieving orgasm, diminished intensity of the orgasm, reduced sexual sensation in the penis, and reduced ejaculate volume.21

Hypogonadism is quite common, since testosterone levels decline 1% per year beginning around 40 years of age.61-62 Thus, the male population at risk for both ED and hypogonadism overlaps considerably. A major issue for clinicians caring for patients like Mr G is whether to first treat his ED, his hypogonadism, or both in combination. Treatment of hypogonadism results in reliable improvement in the symptoms of diminished libido and feelings of enhanced sexuality.63-64 However, ED itself may not respond as well, particularly in older men, due to coexisting vascular pathology.

Forms of Testosterone Supplementation. Forms of testosterone treatment include intramuscular injections every 1 to 3 weeks with testosterone esters (cypionate or enanthate) or topical daily treatments with gels or patches. Gels have become the favored mode of treatment for many patients due to their high efficacy in restoring physiological testosterone levels,65 ease of use, and infrequent skin irritation, the last representing a significant limitation in acceptance of the patches.66 Oral agents available in the United States all share a significant risk of hepatotoxicity,67 and their use is therefore discouraged. An informal survey of Boston pharmacies in April 2004 revealed a monthly treatment cost of approximately $220 for gels and $24 for injections.

Risks of Testosterone Treatment. Testosterone supplementation within the physiological range is generally well tolerated. Risks include erythrocytosis in as many as 50% of men receiving injections, but in only 5% of men using gels or patches.21 Gynecomastia, peripheral edema, exacerbation or de novo sleep apnea, acne, and mild weight gain occur in less than 2% of men.64 Testicular atrophy can occur, more prominently in younger men. In addition, men must be advised that fertility will be impaired while receiving exogenous testosterone due to negative feedback on pituitary gonadotrophins.68 Exacerbation of bladder outlet voiding symptoms is uncommon. Transdermal preparations are associated with local skin reactions in 3% to 5% of men using gels and as many as 40% of men using patches.21 There is no evidence that testosterone supplementation represents a risk for cardiovascular disease; on the contrary, some studies suggest that it may even be beneficial.69-71 Although testosterone treatment may reduce high-density lipoprotein cholesterol, total cholesterol is generally reduced as well, resulting in a neutral net effect.72 Liver toxicity does not seem to be associated with transdermal or intramuscular preparations of testosterone.21

One must also consider the risks of failing to treat men with hypogonadism. These may include depression, diminished sense of vitality, sexual dysfunction, anemia, and reduced bone mineral density.21

Testosterone and the Prostate

The greatest concern of clinicians regarding testosterone replacement therapy (TRT) is possible stimulation of an occult prostate cancer. This follows from the work of Huggins et al in the 1940s,73 who showed that prostate cancer was androgen-sensitive by following chemical markers in an uncontrolled study of 8 men with metastatic prostate cancer who underwent bilateral orchiectomy. Nevertheless, the limited clinical trials to date have shown a risk of prostate cancer in men undergoing TRT of approximately 1%, a rate not different from untreated men undergoing screening.74 Moreover, population-based studies have failed to demonstrate that men with higher levels of testosterone are at any increased risk of developing prostate cancer or that men with low testosterone levels are somehow protected against developing prostate cancer.75-78 Furthermore, only 1 of 20 hypogonadal men at high risk for prostate cancer based on a prior history of prostatic intraepithelial neoplasia developed cancer after 1 year of testosterone treatment,24 suggesting that TRT may not adversely affect progression of prostate cancer.

Who Should Be Referred for Prostate Biopsy in Association With TRT?

Men with an elevated PSA level or an abnormal DRE finding should undergo biopsy prior to initiation of TRT. Prostate biopsy should also be performed if the PSA rises above the normal range or the DRE becomes abnormal during treatment. There is ongoing debate whether the historical upper PSA threshold of 4.0 ng/mL should be lowered to 2.6 ng/mL.79-80 A rapid rise of PSA is a further indication for biopsy, since this may be a sign of prostate cancer as well. Bhasin and colleagues recommend biopsy for a rise of 1.0 ng/mL or greater within the first 6 months of treatment, and for any rise of 0.4 ng/mL per year after that time.74 Although most clinicians currently reserve prostate biopsy for the indications above, it has been my own practice to perform prostate biopsy prior to initiation of TRT in all men age 45 years or older, since 14% of hypogonadal men with a normal DRE and PSA less than 4.0 ng/mL have biopsy-detectable prostate cancer.81 There is evidence that high-grade prostate cancer, Gleason 8-10, is particularly associated with low testosterone.82

Once treatment has been initiated, men should be monitored with PSA and DRE, as well as hemoglobin or hematocrit, 2 to 3 times within the first year, and 1 to 2 times per year thereafter.21, 74

Who Should Treat the Man With ED?

Most men with ED can be effectively treated by their primary care physicians. Men with physical abnormalities of the penis, such as Peyronie disease, should be referred to a urologist. If oral medication fails or is contraindicated, then the man should be referred to a specialist in sexual dysfunction, which in most cases will be a urologist. Sexual problems related to hypogonadism may also be treated by the primary care physician or referred to a urologist or endocrinologist. Referral to a psychotherapist is indicated for significant personal or relationship issues that appear to be more complicated than a straightforward complaint of ED or low sexual desire.

The Competing Issues of Hypogonadism and ED

The 2 primary treatment options offered to Mr G, testosterone and sildenafil, have widely different actions. Sildenafil effectively improves blood flow to the penis, thus aiding erection, but has no direct effect on libido. Testosterone supplementation, on the other hand, has a wide variety of potential benefits, including improved erections, libido, mood, strength, and sense of well-being. Men who respond to TRT often report that they "feel normal again."

As a rule, I treat hypogonadal men with TRT first, since this may offer a more complete response than addressing ED alone. If ED does not respond to testosterone treatment, I then prescribe a PDE 5 inhibitor. If the man has experienced benefits from TRT, such as improved libido, he may continue both treatments together. If no symptomatic improvement resulted from TRT itself, it is my practice to discontinue it. However, some clinicians choose to continue treatment to address the metabolic effects of hypogonadism.

Recommendations for Mr G

I would first offer Mr G a trial of TRT in the form of a topical gel, adjusting dosage and mode of therapy as needed to achieve physiological testosterone levels. It is my own practice to perform prostate biopsy before initiating treatment because of the substantial prevalence of biopsy-detectable cancer in this population. However, this approach is impractical for nonurologists, and a reasonable alternative strategy is to monitor with PSA and DRE at 3, 6, and 12 months, reserving biopsy for worrisome changes. If Mr G noted improvement in ED and libido with testosterone supplementation, I would continue this treatment indefinitely. If he notices no benefit at all despite mid- to high-normal testosterone levels, I would discontinue the testosterone trial. I would then offer treatment with one of the oral PDE 5 inhibitors. If libido improves with TRT but ED persists, I would continue TRT and add a PDE 5 inhibitor to the treatment regimen.

Given Mr G's concerns regarding risks, I would reassure him that both testosterone and PDE 5 inhibitors have been widely studied and both appear to have good safety profiles. I would specifically add that sildenafil by itself has not been found to be dangerous for the heart, that it can be taken together with his antihypertensive medications, and that priapism is extremely rare and treatable. I would emphasize that he will require monitoring of his prostate and hematocrit indefinitely while receiving TRT. I would then encourage him to begin treatment if he wishes.

It is my own belief that the mission of physicians must include doing our best to improve the quality of life of our patients. Given the importance of sexuality in human life, I encourage clinicians to become knowledgeable in the area of male sexual dysfunction to ably assist their patients to experience full, satisfying, and loving lives.


QUESTIONS AND DISCUSSION   
 

A PHYSICIAN: You mentioned that sildenafil worked in 80% of psychogenic and 65% of organic cases of ED. What about placebo response in each group?

DR MORGENTALER: The placebo response depends greatly on the study population. Trials that include populations of men with psychogenic ED, as in the first published study of sildenafil, showed 80% efficacy for the highest dose of sildenafil for some measures, with a corresponding placebo response rate as high as 50%.3 Studies of men with more significant medical conditions demonstrate efficacy in 40% to 60%, with a placebo response rate of 10% to 15%.32

A PHYSICIAN: If a man has a nest of prostate cancer cells present on biopsy, would you still offer him testosterone therapy or would you recommend other treatments?

DR MORGENTALER: The single absolute contraindication to testosterone therapy is the presence of prostate cancer,74 and I would not offer testosterone therapy to a man with untreated prostate cancer. Historically, this contraindication has been extended to all men with a history of prostate cancer, with the thought that quiescent cancer cells may be stimulated by testosterone supplementation. But, in my opinion, a blanket contraindication doesn't make sense. We withhold testosterone therapy from hypogonadal men who underwent radical prostatectomy 5 to 10 years ago with an undetectable PSA level even though they are likely cured of their cancer. Why can't we treat them? If their own testosterone level were normal, no one would suggest these men should be castrated.

Another example is that we often give testosterone-lowering treatments to men as an adjunct to radiation therapy for prostate cancer. Afterward, testosterone levels typically return to normal, but not always. Even if those men are highly symptomatic, with hot flashes, low energy, and absent libido, we do not give testosterone because of their history of prostate cancer. But if their testosterone levels spontaneously returned to normal, we say that's fine. This is an artificial distinction. Why should we penalize the man who remains symptomatically hypogonadal?

A PHYSICIAN: Could you comment on the recreational use of sildenafil in men without ED?

DR MORGENTALER: The mythology of Viagra on the street is that it can turn any man into a sexual superstar.2 The ease of obtaining sildenafil via the Internet has essentially demedicalized PDE 5 inhibitors for a substantial number of men without ED who use it for recreational purposes. Some of my own patients without ED have reported that sildenafil provides them with greater rigidity and a shortened refractory interval. However, the effects of the recreational use of PDE 5 inhibitors have not been well studied. My major concern is the psychological impact of taking these medications for younger men who are not yet in a stable relationship. I have seen cases where men who lack for nothing except confidence secretly take sildenafil every time they go on a date, in the hope that it will help them please their partner. However, this can create obstacles for a solid intimate relationship. Apart from issues of authenticity, trust, and honesty, it seems to me that the key psychological cost of using sildenafil recreationally is that, by relying on a pharmacologic enhancement to his sexuality, a man loses an opportunity to achieve what we all look for in relationships—namely, to be loved and accepted for whom we really are.


AUTHOR INFORMATION   
 
 

Corresponding Author: Abraham Morgentaler, MD, Men's Health Boston, One Brookline Place, Suite 624, Brookline, MA 02445 (amorgent@yahoo.com).

This conference took place at the Medicine Grand Rounds of Beth Israel Deaconess Medical Center, Boston, Mass, on May 29, 2003.

Acknowledgment: We thank the patient and his doctor for sharing their stories with us.

Author Affiliation: Dr Morgentaler is Director, Men's Health Boston, and Associate Clinical Professor of Surgery (Urology), Harvard Medical School, Boston, Mass.


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Addendum: Useful Questions in the Sexual History

What actually happens when you try to have sex?
Is the penis ever firm enough to go inside your partner?
Does your penis ever become firm?
   Upon awakening?
   With masturbation?
How long has this been a problem?
Did anything happen, medically or socially, around the time that this problem began?
Any new medications around the time that the problem began?
What do you think is causing the problem?
How has this affected you? Your partner? Your relationship?
Are you interested in treating the problem?
Are you able to have an orgasm?
Is there any new curve when you have an erection?
What treatments, if any, have you tried so far?
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52, Peyronies Disease for 30 years, upward curve and some new lesions.
Tim468
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« Reply #229 on: August 16, 2007, 11:54:46 AM »

Dear Antony,

First off, I am really sorry that you have gone through such a terrible and frustrating experience. It sounds simply awful.

I cannot diagnose you over the internet, but it sounds like you have a BIG problem. My next post will be a reprint of a JAMA article on managing and evaluating erectile dysfunction - you may get some ideas from it. Also, there is an article referenced in the "Surgery" section that I posted that was written by a French surgeon. He MAY be a good person to go see.

It sounds like you have developed diffuse fibrosis in response to a non-specific injury. It sounds similar to what might happen to the corora cavernosa and tunica when one develops priapism (prolonged painful erection). In priapism, one potential outcome is development of a penis such as you describe (interestingly, that is not always the outcome of priapism - why not?).

You really need a very good evaluation. The ultrasound needs to be done with an injection of the penis with PGE2 to induce a firm erection (as firm as you can get). Then, the blood flow can be evaluated better. If there is evidence of fibrosis. I think that you would be a good candidate for going on Pentox, viagra (or vialis) and arginine for a LONG time (ie 2-3 years) to see if you can reverse this process. The diffuse fibrosis after priapism has been successfully treated in this way.

Finally, if you have a bad outcome (meaning erectile dysfunction and a densely fibrotic penis that does not heal), you wuold be a good candidate for a penile implant WITH grafting. See the reference below. Remember that although it is frightening to think of such things, it should remind you that at the end of this process, you should have back your sexuality - one way or another.

Tim
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52, Peyronies Disease for 30 years, upward curve and some new lesions.
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