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Tag: Erectile Dysfunction

The Shortest Distance Between two Points in a Straight Line

Posted on by Dr. Ali Thwaini

Peyronie’s disease is a rather common and potentially debilitating condition for sexually Active men.

What is Peyronie’s disease?

It must be quite unnerving in to wake up on a random morning to see one’s erect penis has “taken a turn”.

While the mainly this condition is idiopathic, some are attributed to various other clinical conditions such as Dupuytren’s contracture.

Painful erections with penile deviation to start with, however, with time, the pain settles leaving behind the penile deviation while erect, which sometimes interferes with sexual activity causing dissatisfaction for the patient and the partner

Treatment

There have been several attempts to treat this condition conservatively and most of these conservative treatments were, at best, equal to placebo.

These have ranged from a variety of supplements like vitamin E, Paraamino Benzoic Acid (Potaba) calcium channel blockers, and even local injection of steroids, with no beneficial effects

Surgical interventions on the other hand provide a definite alternative, however, they come with their inherent side effects.

These are generally divided into penile shortening and penile lengthening procedures;

While the former concentrates on shortening the healthy side of the penis to make it as short as this affected side, this inevitably results in losing some of the erect penis’s length, which all men find unsatisfactory..

Penile lengthening procedures, although seemingly appealing, they have the potential side effect of causing erectile dysfunction as it involves cutting the affected segment that’s responsible for the disease, thus causing the potentially venous leak, which will hinder the erectile process

Recently, there has been some treatment which was initially effective. Collagenase clostridium histolyticum (Xiapex) has been tried with initially promising results, however, due to its significantly high price and the potential side effects of corporal rupture, its use has faded, as with other treatments

Other physical treatments such as external shockwave treatment on Penile remodeling have been attempted with modest results

Regenerative medicine has become a viable alternative in a variety of clinical conditions, and Peyronie’s disease is no different.

Several researchers have attempted the injection of platelet-rich plasma cells (PRP) (with or without hyaluronic acid) into the area of the plaque, in addition to exposing the affected area to shockwave treatment and the results are thus far, promising

It takes one or more sessions depending on the severity of the condition and it is carried out as an outpatient procedure with minimal side effects

The immediate results are encouraging, however, we are still waiting for the intermediate long-term results

Watch the space!

References

Li-ESWT with Regenerative Medicine in ED

Posted on by Dr. Ali Thwaini

English


Erectile dysfunction (ED) is a very common health problem that affects a large proportion of men. The word “40 over 40” stands true. Various causes leading to various treatments for ED have been highlighted and adopted respectively. Most, if not all, are situational and not permanent ( apart from modifying lifestyle and care about Men’s health). 

Regenerative therapies for ED


Therefore, additional treatments are being investigated, including regenerative therapies. Regenerative therapies aim to restore function via replacement or regeneration of human cells, tissues, or organs. Regenerative therapies for the treatment of ED include low-intensity extracorporeal shockwave therapy (Li-ESWT).

Benefits of Li-ESWT


Li-ESWT began to be explored as an alternative means of treating ED,33 with the first randomized controlled trial (RCT) published in 2012. The benefits of Li-ESWT stems from its ability to induce microtrauma. A shockwave is a type of longitudinal acoustic wave that is composed of three sequential parts: a short pulse, a rapid increase to max positive acoustic pressure (the “shock”), and a prolonged period of negative pressure.

Stem Cell Therapies (SCT)


On the other hand, stem cell therapies (SCT) seek to harness the regenerative potential of stem cells for the repair of injured or damaged tissues. The utilization of adult stem cells has allowed for easier access to stem cells, leading to a higher likelihood of utility in regenerative medicine.


Since the causes of ED are numerous and include damage to the neurovascular bundle or neuropraxia during radical prostatectomy nerve damage, endothelial dysfunction, and oxidative stress in the setting of diabetes mellitus, SCT has gained a lot of interest in this field.


As opposed to PRP, several studies have evaluated the efficacy of SCT for the treatment of ED in humans, with promising results.


The combination of Li-ESWT and SCT in ED is an emerging concept. For stem cells to reach the affected tissues, and to accept their actions via paracellular and intercellular signals, they have to be “led” to the affected tissues. One method is to induce an acute micro-trauma to the targeted tissues allowing them to release their attractive signals for the relating cells, of more importantly here, the stem cells, to accumulate in that particular area and exceed their restorative tasks. Animal studies have already proven this concept. Human trials are awaited. Food for thought..

Reference : journals.sagepub


Arabic

Li-ESWT مع الطب التجديدي في الضعف الجنسي

ضعف الانتصاب (ED) هو مشكلة صحية شائعة جدًا تؤثر على نسبة كبيرة من الرجال. كلمة “40 فوق 40” صحيحة. تم تسليط الضوء على الأسباب المختلفة التي أدت إلى علاجات مختلفة للضعف الجنسي واعتمادها على الاسباب. معظمها ، إن لم يكن كلها ، ظرفية وليست دائمة (بصرف النظر عن تعديل نمط الحياة والاهتمام بصحة الرجل).

لذلك ، يتم التحقيق في علاجات إضافية ومستديمة ، بما في ذلك العلاجات التجديدية. تهدف العلاجات التجديدية إلى استعادة الوظيفة عن طريق استبدال أو تجديد الخلايا أو الأنسجة أو الأعضاء البشرية. تشمل العلاجات التجديدية لعلاج الضعف الجنسي علاجًا منخفض الكثافة بالموجات الصدمية خارج الجسم (Li-ESWT).

بدأ استكشاف Li-ESWT كوسيلة بديلة لعلاج الضعف الجنسي ، مع أول تجربة ذات ادله (RCT) نُشرت في عام 2012. تنبع فوائد Li-ESWT من قدرته على إحداث الصدمات الدقيقة. موجة الصدمة هي نوع من الموجات الصوتية الطولية التي تتكون من ثلاثة أجزاء متتالية: نبضة قصيرة ، وزيادة سريعة إلى أقصى ضغط صوتي إيجابي (“الصدمة”) ، وفترة طويلة من الضغط السلبي.

من ناحية أخرى ، تسعى علاجات الخلايا الجذعية (SCT) إلى تسخير الإمكانات المتجددة للخلايا الجذعية لإصلاح الأنسجة المصابة أو التالفة. توجيه استخدام الخلايا الجذعية البالغة بالوصول السهل إلى الخلايا الجذعية ، يؤدي إلى زيادة احتمالية الاستفادة منها في الطب التجديدي.

نظرًا لأن أسباب الضعف الجنسي عديدة وتشمل تلف الحزمة الوعائية العصبية أو الأعصاب أثناء تلف الأعصاب الجذري للبروستاتا ، والخلل البطاني ، والإجهاد التأكسدي في حالة مرض السكري ، اكتسبت SCT الكثير من الاهتمام في هذا المجال.

على عكس PRP ، قيمت العديد من الدراسات لفعالية SCT في علاج الضعف الجنسي لدى البشر ، مع نتائج واعدة.

يعتبر الجمع بين Li-ESWT و SCT في ED مفهومًا ناشئًا. لكي تصل الخلايا الجذعية إلى الأنسجة المصابة ، وباستثناء أفعالها عبر الإشارات بين الخلايا والداخلية ، يجب “توجيهها” إلى الأنسجة المصابة. تتمثل إحدى الطرق في إحداث صدمة صغيرة حادة للأنسجة المستهدفة مما يسمح لها بإطلاق إشاراتها الجذابة للخلايا ذات الصلة ، والأهم من ذلك ، الخلايا الجذعية ، لتتراكم في تلك المنطقة بالذات وتتجاوز مهامها التصالحية. لقد أثبتت الدراسات التي أجريت على الحيوانات بالفعل هذا المفهوم.

Testosterone Treatment; pros and cons

Posted on by Dr. Ali Thwaini

Testosterone, a steroid hormone, helps maintain muscle, bone, and libido. Men in their 4th decade (mid-30s), begin to have less testosterone in their bodies, at an average of just under 2% per year. If that drop continues, it could lead to hypogonadism or low testosterone. This happens to 20% of men in their 60s.

Also, Metabolic syndrome; an increasingly common condition, and testosterone deficiency in men, are closely Linked. Studies have shown that Low Testosterone Levels are associated with obesity, insulin resistance, and an adverse Lipid profile in men.

Metabolic syndrome and Low testosterone are associated with increased all-cause and cardiovascular events.

Replacement of testosterone to its physiological levels produces improvement in insulin resistance, obesity, lipid derangement, and eventually sexual dysfunction along with the improved quality of Life. However, there is little evidence on the effect of testosterone replacement on mortality in men with Low Testosterone Levels.

Testosterone Replacement Therapy (TRT) aims to boost those low levels in men with T deficiency. But TRT has had its advantages and disadvantages.

Testosterone and hypertension:

Derangements in lipid metabolism play a pivotal role in the formation of atherosclerotic plaque. High total cholesterol and LDL-C are proatherogenic whereas high HDL seems to be protective against atherosclerosis. The same pathogenic process is also implicated in the development of metabolic syndrome and type 2 diabetes although elevated total cholesterol and LDL-C are not part of the definition of metabolic syndrome. Declining levels of testosterone with age is associated with a relative increase in oestrogen levels through the increased aromatase activity. The increased oestrogen levels are associated with increased circulating cholesterol and more atherogenic lipoprotein particles.


A number of studies have shown a negative correlation between testosterone levels and total cholesterol and LDL-C. A meta-analysis of 19 clinical trials in hypogonadal men reports that significant reductions in total cholesterol and LDL-C is associated with intramuscular TRT.

Studies have shown that low testosterone levels are associated with known hypertension. Conversely, men with anabolic steroid abuse are known to have an increased risk of developing hypertension.

Testosterone and Atherosclerosis:

Low testosterone level is associated with the presence of atherosclerosis. A 4-year follow-up study demonstrated that low testosterone led to increased deterioration of the atherosclerosis. This provides evidence to support the hypothesis that testosterone deficiency promotes the pathogenesis of atherosclerosis.

Testosterone Replacement Therapy (TRT) – FAQ

Are there other than low testosterone that explains sexual dysfunction?


 Yes. Low libido and erectile dysfunction, for example, have many contributing factors to rule out, including heart disease and psychological issues.

When would I know my Testosterone Replacement Therapy is helping?

Your doctor should confirm within 6 months or so whether TRT has improved your symptoms. If it hasn’t, discuss ending treatment.

Will TRT affect my ability to father children?

Yes. TRT decreases sperm production potentially affecting Men’s fertility. Upon stopping TRT, fertility will likely return. In a small number of men, infertility is permanent.

Are there other “natural” measures to elevate my testosterone?


Reducing weight ( in overweight men) and resistance exercises may help boost your levels without medication.

Extra Caporal Shockwave Treatment plus Regenerative Medicine and Treating a Male Sexual Dysfunction: An update

Posted on by Dr. Ali Thwaini

Male sexual dysfunction is an increasing modern life condition with more than 40% of men being affected as age of 40. This is further complicated by the increasing prevalence of metabolic syndrome and the sedentary lifestyle. This has led to ever increasing incidence of atherosclerosis hyperlipidemia and type two diabetes.

Natural Cures for Erectile Dysfunction

In addition to the importance of the emphasis on improving the lifestyle measures and treating a male sexual dysfunction(Mainly in the form of exercise stopping smoking minimizing the alcohol intake and adopting healthy diet), Other medications seem to help Though on a temporary basis.

Recently there has been increasing interest and more permanent and as close to natural as possible solutions for male sexual dysfunction. Below are some of them:

Low-Intensity Extracorporeal Shock Wave Therapy

LiESWT:Shockwave therapy was introduced since the early 80s with the first experience being targeted towards kidney stones. However, recently, studies have shown that microtrauma and used by shockwaves would lead to an acute inflammatory reaction of the effect of tissues with the resultant stimulation of the healing process towards normality.

This would theoretically stimulate the growth and development of small blood vessels with the resultant increase blood flow to the affected area. This has been adopted and treatment of cardiovascular diseases and other several musculoskeletal conditions.

Urology, being at the forefront of other specialties, has adopted this method and treating various mail conditions including Peyronie’s disease and Erectile dysfunction.

Although shockwave treatment as monotherapy has now been adopted at the Urology guidelines its results are marginally encouraging With an estimated success rate of around 70%. The treatment is fairly simple considering 2 to 3 weekly attendances is at the clinic with a 15-minute session per visit for up to six weeks and the results are expected between three and six months

Platelet-rich plasma cells

Another recently adopted treatment for a variety of medical conditions mainly cosmetic with the principle of using the patients’ own fluids after being purified, keeping the platelets and other essential growth factors and nutrients and possibly Stem Cells, to help regenerating and repairing the damage tissues.

While this method is widely adopted in various clinical conditions, its effectiveness in treating erectile dysfunction is yet to be determined

Whilst there are several animal studies a demonstrating the improvements of the erectile tissue following PRP treatment there are no human trials supporting the above.

Stem cell therapy:

Stem cells are “toti-potential” and their nature with the ability to grow and regenerate and eventually specialize into functional sells according to the organ they are being introduced to

There are few but reliable human studies mainly in treating men with erectile dysfunction following radical prostatectomy with the stem cell therapy and the results are very encouraging with more than 80% success in terms of improving erections and penetration until orgasm. However, the number of participants in these trials as very limited.

Stem Cells and LiESWT combined:

The aim of injecting the Stem Cells is to direct them into the targeted area with the aim of repairing and regenerating cells and resultant improvement of the function of that organ.

Stem Cells, however, need guidance to go to the affected area. There are several animal studies demonstrating and using microtrauma to the target in the organs followed by injection of Stem Cells with the resultant of higher concentration of those cells to go to the affected tissue.

Hence, logically, by combining low intensity ESWT and stem cell therapy at the same time might improve the delivery of the stem cells and the two methods would yield more encouraging results in treating erectile dysfunction.

Ongoing studies regarding the above are being carried out and the results are anxiously awaited

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Stem Cell Therapy in Male Sexual Dysfunction:

Posted on by Dr. Ali Thwaini

Erectile dysfunction is becoming a common urological problem affecting men worldwide, with almost 40% of men at and above the age of 40 years being affected by the disease, at various levels.

Whilst there are several conservative and interventional treatments for erectile dysfunction, they would treat but not cure the disease.

What is Stem cells

Stem cells exist as undifferentiated cells. They are present in the embryonic and adult stages of life and are considered as a source for differentiated cells that make up the building blocks of tissue and organs.

Due to their abundant source and high differentiation potential, stem cells are considered as potential new therapeutic agents for various medical conditions.

Recently, there has been a vested interest to investigate their use in male sexual dysfunction.

Stem Cell Therapy for Erectile Dysfunction

According to the European Association of Urology’s latest press release, new clinical trial results demonstrated the ability of stem cells to restore sufficient erectile function to allow previously impotent men to have spontaneous intercourse. This is the first time stem cell therapy has produced patients who have recovered sufficient erectile function to enable intercourse.

In recent years several groups have worked to develop stem cell therapy as a cure for erectile dysfunction. None of the male participants reported significant side effects over the trial period, or in the following year. Within 6 months of the treatment, 8 out of the 21 patients reported that they had recovered sufficient erectile function to achieve penetrative) sexual activity. This improvement has been maintained for a year, indicating that this treatment may confer long-term benefits.

Stem Cell Therapy Results

Results presented at the European Association of Urology conference in London show that 8 out of 21 have successfully regained sexual function.

We use stem cells taken from abdominal fat cells via liposuction (under local anesthetic as an office-based procedure). After isolating the stem cells, they were injected into the corpus cavernosum area of the penis. The patients are able to be discharged the same day.

Is stem cell therapy for ED Safe

This treatment is suitable for men seeking to improve their sexual performance without taking medication and/or any other external treatment, also the patient with Diabetes, Hypertension, and other diseases can benefit from this safe treatment.

Some patients might feel the benefit immediately after the treatment, but the majority will feel gradual improvement over the next 2 to 3 months, with the maximum effects achieved at 6 months.

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Erectile Dysfunction

Posted on by Dr. Ali Thwaini

Erectile dysfunction (ED in men) impotence is defined as an inability to obtain or maintain an erection sufficient for penetration and for the satisfaction of both sexual partners.

ED in men can be caused by many factors and may have a gradual or sudden onset. It can be very upsetting and result in a lot of stress and worry. It can feel embarassing to discuss this with your doctor but it is important that you do, so that you can receive the appropriate help. Erectile dysfunction can also be a sign of other illnesses such as heart disease or diabetes, so it is important that you seek medical advice. 

  • ED in men becomes commoner with increasing age and is seen in 50 – 55% of men between 40 and 70 years old;
  • It is often associated with obesity, high blood pressure, high cholesterol & diabetes which are all significant risks to health;
  • Investigation is only indicated if both partners wish to pursue treatment;
  • Most treatable causes can be identified by a clinical history, physical examination and routine blood tests;
  • If there is no treatable cause, treatment with tablets is the first option for most men;
  • Other methods of treatment are only indicated if medication proves ineffective, causes side-effects or cannot be used because of specific medical conditions.

A psychological component, often called “performance anxiety”, is common in men with impotence. However, a purely psychological problem is seen in only 10%.

Of the 90% of men who have an underlying physical cause, the main abnormalities found are:

  • Cardiovascular disease in 40%;
  • Diabetes in 33%;
  • Hormone problems (e.g. high prolactin or low testosterone levels) & drugs (e.g. antihypertensives, antipsychotics, antidepressants, antihistamines, heroin, cocaine, methadone) in 11%;
  • Neurological disorders in 10%;
  • Pelvic surgery or trauma in 3-5%; and
  • Anatomical abnormalities in 1-3% (e.g. tight foreskin, short penile frenulum, Peyronie’s disease, inflammation, penile curvature).

TREATMENT:

Improvements in your lifestyle, such as a eating healthy diet, reducing alcohol intake, losing weight and increasing your exercise can dramatically improve erectile dysfunction. More specific treatment usually involves:

  • weight loss and increased exercise (this may reduced the risk of erectile dysfunction by up to 70%)
  • treatment of any hormone abnormality (testosterone treatment is only indicated if your testosterone levels are low and may be harmful if your the levels are normal);
  • lifestyle modification (e.g. reduce stress, stop smoking, reduce alcohol consumption & stop illicit drugs);
  • treatment of any anatomical abnormality if present (e.g. circumcision, frenuloplasty, penile straightening);
  • psychological support if necessary.

First line treatment will be medication with a phosphodiesterase inhibitor such as sildenafil (Viagra), tadalafil (Cialis), vardenafil (Levitra) or avanafil (Spedra). These drugs only work when used together with sexual stimulation and will have no effect on your sex drive. There is no evidence that these drugs are dangerous if you have underlying heart disease. However, they should not be used if you are taking nitrates (e.g. GTN, isosorbide) for angina

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ED in men


Phosphodiesterase inhibitors

  • The commonly used PDE-5 inhibitors are sildenafil (generic or ViagraTM), tadalafil (CialisTM), vardenafil (LevitraTM) and avanafil (SpedraTM)
  • They increase blood flow into the penis by blocking the naturally- occurring enzyme (PDE-5) which turns off an erection
  • You should only obtain PDE-5 inhibitors by prescription
  • Side-effects occur in approximately 1 in 9 patients (11%) but only3% stop treatment because of them
  • You should not use PDE-5 inhibitors of you are taking nitratemedications for angina or heart disease

These drugs boost the body’s natural mechanism for getting an erection. This allows erections to be achieved and maintained more easily but they do require sexual stimulation to be effective.

They may not work in severe ED in men or where the natural erectile mechanism has been irreversibly damaged. The drugs work by dilating (opening) the blood vessels supplying the penis; this causes a greater blood flow into the penis and improves your erection.

How should they be taken?

Depending on the medication you are prescribed, a tablet should be taken between 30 minutes and 1 hour before anticipated sexual intercourse. Some of the drugs are affected by eating a heavy or fatty meal before taking the drug. We normally advise you to take them on an empty stomach, or two to three hours after a meal.

You should read the manufacturer’s instruction leaflet carefully because this gives you full instructions. You are advised not to take more than one dose per day. Treatment is usually long-term.

Because of its long half-life, Tadafil (CialisTM) may be taken at a lower, daily dose so that the drug is always in your system to provide a background boost to erections. This can help with night-time and morning erections.

We normally advise you to try treatment for four to six weeks to see whether it works. Your urologist, GP or specialist will suggest a starting dose for you and you will be followed up to see if an increased dosage is needed.

When should they not be taken?

You must not use PDE-5 inhibitors if you take nitrate medications (GTN spray, isosorbide or amyl nitrate) for angina, heart disease or other reasons. If you are not sure whether you are taking these medications, please check with your doctor. PDE-5 inhibitors interact with nitrates and can cause a dangerous drop in blood pressure. This may result in cardiac arrest, or even death.

You should probably avoid taking these drugs with alcohol. If you are unsure as to whether PDE-5 inhibitors are safe for you, consult your GP, specialist or cardiologist who will be able to advise you.

PDE-5 inhibitors are not appropriate if you have been told that sexual activity is inadvisable (e.g. if you suffer from unstable angina or severe heart failure). They should not be used at the same time as other treatments for ED in men, unless you have been advised to do so by a specialist.

What are the side-effects?

The most common side-effects include headache (12%), flushing (10%) and indigestion (7%). Some patients develop altered (blue-tinged) vision and dizziness (3%). If dizziness does occur, you should not to drive or operate heavy machinery. It is important that you report any severe side-effect to your doctor, and consider stopping the drug until you discuss it with your doctor.
PENILE INJECTION THERAPY
Self-administered injections of prostaglandin E1 (Caverject® or Invicorp®) provide a simple means of obtaining a natural erection. You will be taught how to administer the injections (pictured) and told what to do in the event of problems such as an erection which will not go down.

Medicated Urethral System for Erection (MUSE):MUSE offers an alternative route for administration of prostaglandin using a small pellet inserted using an applicator into the tip of the urethra (water pipe opening). Once massaged the prostaglandin is released and helps the blood to flow into the penis to gain an erection. Some men experience a mild burning sensation afterwards in the water pipe but this is a good alternative option for men who do not like the idea of using injection therapy.

Vacuum Erection Assistent Devices (WEDs)
VEDs provide a simple way of obtaining an erection for 30-45 minutes by sucking blood into the penis and holding it in place with a constriction (pictured). Ejaculation may be restricted by the ring but this technique is simple, safe and has no known side-effects. Unfortunately, most patients have to purchase VEDs themselves.

PENILE PROSTHESIS
Insertion of a penile prosthesis (implant) (pictured) is an end stage solution when all other treatment options have failed. It involves a surgical procedure through a small incision in the junction between the penis and scrotum. Patients go home the following day if the procedure is uncomplicated, and the prosthesis can be used for sexual intercourse at 6 weeks following the operation. Complication rates are low in centres that conduct the surgery in large numbers. The risk of infection is <2% and over 85% of the devices are still functioning at 10 years. 

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