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With prevalence rates of 20%-25% premature ejaculation (PE) represents the most frequent sexual dysfunction in men. Whereas genetically determined changes in the serotonin receptor-/transporter mechanism seem to be responsible for lifelong PE, acquired PE is often associated with other conditioning diseases such as erectile dysfunction, prostatitis or thyroid dysfunctions. Typical features of PE are a short intravaginal ejaculatory latency time (IELT) <1-2 min, lack of control over ejaculation, personal distress and partner problems. Treatment of PE subdivides into sexual therapy as well as drug therapy. Among the medications considered for PE, oral therapy with selective serotonin re-uptake inhibitors (SSRI), Dapoxetine (the first officially approved medication for PE) and topical therapy with lidocaine/prilocaine-containing medications are given priority.

Leptin and adiponectin are proteins produced and secreted from white adipose tissue and are important regulators of energy balance and insulin sensitivity. Seasonal changes in leptin and adiponectin have not been investigated in mammalian hibernators in relationship to changes in fat cell and fat mass. We sought to determine the relationship between serum leptin and adiponectin levels with seasonal changes in lipid mass. We collected serum and tissue samples from marmots (Marmota flaviventris) in different seasons while measuring changes in fat mass, including fat-cell size. We found that leptin is positively associated with increasing fat mass and fat-cell size, while adiponectin is negatively associated with increasing lipid mass. These findings are consistent with the putative roles of these adipokines: leptin increases with fat mass and is involved in enhancing lipid oxidation while adiponectin appears to be higher in summer when hepatic insulin sensitivity should be maintained since the animals are eating. Our data suggest that during autumn/winter animals have switched from a lipogenic condition to a lipolytic state, which may include leptin resistance.

In the period between December 1989 and December 1991, penile duplex sonography was performed, mostly after intracavernous injection of prostaglandin E1 in more than 1000 patients with erectile dysfunction or other penile disorders (Peyronie's disease, penile deviations, priapism). The most reliable evaluation criterion was the assessment of the peak flow velocity. Values of more than 25-30 cm/s with reference to the deep penile artery and more than 35-40 cm/s with reference to the dorsal artery indicated the integrity of the penile arteries. The assessment of the resistancy index has not proved to be a useful criterion because of its dependence on diastolic blood flow and therefore on the erection state, especially in cases of so-called cavernous insufficiency. Similar observations were made concerning the assessment of the increase in diameter of the deep penile arteries after intracavernous application of vasoactive drugs. Based on the fact that the increase in diameter is more dependent on the relaxation capacity of the cavernous smooth musculature and not on the actual blood flow, the measured values may be equal both in normal and in clearly disturbed blood circulation. In conclusion, duplex sonography is at present, together with color Doppler imaging, the most reliable vascular diagnostic tool and has clearly proved its superiority both to conventional penile Doppler imaging and penile angiography.

Single potential analysis of cavernous electric activity (SPACE) is said to give information on the integrity of the central and peripheral parts of the autonomic nervous system insofar as it is involved in erectile function. A total of 30 patients who underwent radical prostatectomy with simultaneous severance of the cavernous nerves as treatment for locally advanced cancer were investigated by SPACE before and after the operation. The findings were compared to the those recorded on two different dates in 20 age-matched men who had not undergone surgery and in whom there was no evidence of any lesion of the autonomic nervous system. Even in this control group, few reproducible results were found. Nevertheless, with reference to the items "number of wedges" (i.e. monophasic elements with amplitudes of 25-100 microV) and "maximum amplitudes" of SPACE potentials there was a more than change correlation of the values on the two test dates, which was not found in the prostatectomy group. Although this difference between the two groups investigated was statistically significant, these findings cannot be interpreted as an effect of autonomic denervation of the cavernous bodies. This is attributed to the fact that the postoperative results in the prostatectomy group were more similar to the findings in the control group than to the preoperative measurements taken while the autonomic innervation was still intact. Therefore, our investigations lead us to conclude that routine application of SPACE as a direct check on the integrity of the autonomic nerve fibres involved in erectile dysfunction is not justified at present.

In 80 patients suffering from eretile dysfunction both pharmaco-angiography and pharmaco-Dopplerultrasonography of the penis were performed. The two methods showed a correlation of 96% with regard to the dorsal arteries and 92% with regard to the deep penile arteries. In a further 21 patients with erectile dysfunction pharmaco-angiodynography with the new QUANTUM device from Philips has been performed in recent weeks. The excellent illustration of vasculogenic details, even in the penile periphery, the exact measurement of the relevant hemodynamic parameters, e.g. peak flow velocity or pulsatility index, the short time needed for investigation and its non-invasive character give convincing evidence for the superiority of this new method over conventional angiographic procedures. This is also true when procedures for revascularization of the penis are planned. The only remaining indication for conventional pharmaco-angiography of the penis is now clarification of the connections in posttraumatic impotence of arterial etiology.

Between 1985 and 1988, a total of 62 patients with penile deviations underwent corporoplasty; 26 (average age 22.2 years) of the patients had congenital, mainly ventrally directed deviations and 36 (average age 51.7 years), acquired, mainly dorsally directed deviations most of which were due to Peyronie's disease. With a follow-up of at least 6 months (range 6 months to 3 1/2 years), 92.3% of the patients with congenital deviations and 72% of those with acquired curvatures expressed unqualified satisfaction with the results of surgery and said they would agree to the operation again. There were few complications: one patient experienced hematoma requiring reoperation and one patient, a skin necrosis resulting from incorrect wound dressing; three patients complained of recurrence of the angulation, which resulted from plication of the tunica albuginea alone without excision in all three. These results justify the statement that the original Nesbit procedure is the method of choice in both congenital and acquired penile deviations and yields a high success rate. Only in patients with relevant impairment of erectile capacity does the primary insertion of an penile prosthesis seems to be justified.

Nephrotoxic effect of ionic and non-ionic contrast media was examined in a doubleblind study by evaluation of serum creatinine, blood urea nitrogen, urine volume, urinary protein excretion and erythrocyturia before and after selective renovasography. In 19 of 22 patients reliable results were obtained. With optimal hydration before and after renovasography no significant differences between both administered contrast media (Rayvist 300 and Omnipaque 300) could be found by evaluation of the aforementioned parameters. In 3 patients with preexistent proteinuria (greater than 200 mg/l) urine protein excretion remained at the same or a lower level after application of the non-ionic contrast medium Omnipaque 300. Three patients with proteinuria tended to increase the proteinuria after administration of the ionic contrast medium (Rayvist 300) up to 48 h after angiography indicating a higher nephrotoxic potential of ionic contrast media in patients with preexistent renal disease. The constant values of urine volume and serum creatinine indicate an absence of clinically relevant nephrotoxicity of both contrast media in this study when administered in well-hydrated patients. This emphasizes the importance of sufficient hydration in prophylaxis of nephrotoxic effects, especially in patients with risk factors.

In 61 patients with erectile dysfunction a comparative study with intracavernous injection of prostaglandin E1 (PGE1), papaverine and a mixture of papaverine and phentolamine was performed. All patients underwent comprehensive multidisciplinary examinations, including bulbocavernosus reflex (BCR) latencies and somatosensory evoked potentials, penile Doppler sonography, dynamic or pharmaco-cavernosonography, and for 11 patients nocturnal penile tumescence (NPT) was also recorded with the Rigiscan. This diagnostic approach suggested that in 24 (39.3%) of the 61 pts the etiology was psychogenic and in the remaining 37 (60.7%) it was organogenic. PGE1 had a much higher erectile potency than papaverine and a somewhat higher potency than the mixture of papaverine and phentolamine. Complete erection was achieved in 41 of the 61 patients (67.2%) with PGE1, as against 20 of the 61 patients (32.8%) with papaverine alone and 20 of the 61 (32.8%) with papaverine/phentolamine. Whereas 7 of 61 patients (11.5%) had priapism of more than 6 h duration and requiring therapy after injection of papaverine or papaverine/phentolamine, no priapism occurred after PGE1. Thus, compared with papaverine and phentolamine, PGE1 offers important advantages in the diagnosis and perhaps also in the therapy of erectile dysfunction.

The application of objective diagnostic methods to patients complaining of erectile dysfunctions has proved that 30 to 40% are based on pathologic changes of the penile vascular system. The most important diagnostic procedures (NPT, Doppler, BCR-latency time, dynamic cavernosography with simultaneous passive erection, penile angiography) are emphasized and possible pitfalls with reference to misinterpretation of the diagnostic findings are discussed. Technique and results of current revascularization procedures (epigastricopenile anastomosis, revascularization of cavernous and dorsal arteries using vein grafts, deep dorsal vein arterialization) are discussed and first own experiences with aforementioned techniques presented.

Of 447 presenting with erectile dysfunction, 322 (72%) responded to intracavernous injection of PGE1 with erections that were adequate for sexual intercourse. A multidisciplinary comparative study of PGE1 and other vasoactive drugs, e.g., papaverine or the combination of papaverine and phentolamine, was performed in 249 patients. Whereas 180 of the 249 patients (72.3%) showed adequate erections after 10 or 20 micrograms PGE1, only 79 of them (31.3%) did so after papaverine. A further 72 of the 249 patients (29%) had adequate erections after papaverine/phentolamine; thus, a total of 151 of 249 patients (60.3%) developed good erections after papaverine/phentolamine. Whereas after PGE1 no patients at all suffered from priapism lasting more than 6 h, this occurred in 13 of 249 patients (5.2%) after papaverine or papaverine/phentolamine. After intracavernous injection of PGE1, 9.4% of the patients complained of uncomfortable penile sensations during erection interfering with sexual intercourse. Since the initial study, 60 patients have been instructed in self-injection therapy and a further 45 patients obtain intracavernous PGE1 injections periodically, with very promising results. In vitro studies of cavernosal tissue samples obtained from potent men with penile deviations showed both the excellent relaxation of the smooth muscles of cavernous bodies by PGE1 and the antiadrenergic effect of the drug.

The presented case report describes the not-yet-published existence of an epispadia equivalent, which consists of the complete separation of both cavernous bodies associated with both an atypical location of the urethral orifice on the dorsal site of the glans and a considerable ventral deviation of the penis. This separation was simultaneously associated with a unilateral arterialization of the whole penis via the right internal pudendal artery. The patient complained about an inadequate sexual performance, which was due to a marked ventral penile curvature requiring surgical correction. The operative approach included not only a corporoplasty, but also a complicated fusion of the cavernous bodies, accomplished by a fenestration and subsequent anastomosis. The result was cosmetically and functionally optimal.

Within a period of 3 1/2 years, 101 patients with drug-induced priapism lasting more than 6 h were observed. In 73 of the 101 patients (average age 47.4 years) with an average duration of priapism of 11.9 h priapism was interrupted by means including cavernosal puncture, evacuation, and injection of metaraminol. In 28 patients priapism subsided after an average duration of 8.8 h without medical intervention. Intracavernous blood gas analyses revealed unphysiological acid values with clearly negative excess base values. Nevertheless, in the present series only 3 patients had irreversible damage of cavernosal function as a sequela of priapism of more than 24 h duration. Intracavernosal injection of meta-ramininol was followed by severe hypertensive crisis in 2 patients. These results show convincingly that the demand for early interruption of drug-induced priapism within a time limit of 6 h is not based on objective necessity. Interruption of drug-induced priapism within 6-8 h seems to be adequate. Prostaglandin E1 has proved a reliable means of preventing priapism in the initial test period.

In 9 of 152 patients treated between 1975 and 1985 for stage I germ cell tumours of the testis we saw inguinal metastases. They appeared 2 to 26 months (median = 9.3 months) after orchiectomy and unilateral lymphadenectomy, including peri-iliac lymphadenectomy. In 3 cases predisposing factors such as surgical interference or local tumour extent explained the unusual metastasis; in 6 patients it was obviously due to atypical lymphatic drainage. The therapy of choice in these cases is (adjuvant) chemotherapy and salvage lymphadenectomy in the case of residual tumour.

In the course of the evaluation of 500 patients with erectile dysfunction the results of penile Doppler-sonography and penile angiography could be compared in 65 patients, in whom both investigations were carried out under standardized conditions. Criteria for the evaluation of penile Doppler-sonography were the wave form analysis and especially the increase of blood-flow in the investigated arteries after intracavernous injection of papaverine. Criteria for the evaluation of the angiograms were the depiction of the penile arteries as well as the evidence of obstruction and collaterals of the internal iliac and pudendal arteries. In regard to the dorsal penile artery an all over correlation of 96.1% and in regard to the deep penile artery of 92.3% could be found. Based on these findings the conclusion can be drawn that papaverine-induced Doppler-sonography is able to replace penile angiography, thus no longer serving as the golden standard in the diagnosis of arterial insufficiency.

Renal oncocytomas are a well-defined tumor entity and can be differentiated from renal cell carcinomas both from the histological point of view and the clinical course. An illustration of three case reports and a review of the literature underline the diagnostic and therapeutic dilemma in the management of this tumor-type. At present no pre- or intraoperative diagnostic means are available for definite differentiation of pure renal oncocytomas from renal cell carcinomas. Because of this lack of reliable diagnostic means therapeutic management of oncocytomas will continue to be in nephrectomy. In a minority of the reported cases oncocytomas were found in a bilateral or multicentric manifestation thus requiring a more conservative surgical management as recommended for bilateral hypernephromas.

From 38 patients, who had undergone retroperitoneal lymphadenectomy in the period between April 1980 and October 1983, reliable statements were obtained referring to pre- and postoperative erectile and ejaculatory abilities. The thoracolumbar outflow (Th12-L3) of the centers for emission and psychogenic erection is usually damaged in this procedure. About 12% of the radically lymph node dissected patients complained of permanent erectile disturbances; 85% of the radically lymph node dissected patients revealed ejaculatory disorders, 58% of them with a total loss of ejaculation. About 50% of them showed a considerable psychic involvement. In 12 patients a modified lymph node dissection procedure was performed with the intention to preserve ejaculatory capability. Nevertheless 6 (50%) of them revealed postoperative ejaculatory failure, 3 of them with a total loss of ejaculation. Thus our own experiences and a review of the literature indicate that this modified lymph node dissection often fails in its purpose and can not always be considered a valuable procedure for preservation of ejaculation. The administration of sympathomimetic drugs and/or imipramine is a promising approach in the treatment of ejaculatory failure.

For the therapy of pediatric renal trauma there is always the question of the appropriate diagnostic measures. The various procedures such as ultrasound, urography, scintigraphy, computed tomography, conventional angiography, arterial and venous digitalized subtraction angiography are discussed. By these new methods it is possible to judge the severity of renal trauma more accurately and to limit the indications for an operation. With stable circulation an operation should only be performed in the presence of a large, expanding retroperitoneal hematoma, extensive extravasation (urinoma), persistent massive hematuria or if large areas of devitalized renal tissue are found.

Based on 216 dynamic cavernosographies, performed in 25 patients with normal erectile capacity and in 191 patients with erectile dysfunction, an evaluation of this method in regard to its diagnostic validity in erectile dysfunction was possible. An additional comparison of the results of intracavernous application of vasoactive drugs with the outcome of dynamic cavernosography in 141 patients showed that a negative or clearly positive test-outcome indicated in over 90 per cent of the evaluated patients the presence or lack of venous insufficiency during dynamic cavernosography.