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Carcinoma in situ of testicular tissue adjacent to malignant germ-cell tumors: a study of 105 cases. Self-reported premature ejaculation and aspects of sexual functioning and satisfaction. Berridge (2008) proposed that the rhythmic contractions of corpus cavernosum smooth muscle depend on an endogenous pacemaker driven by a cytosolic Ca2+ oscillator that releases Ca2+ from the sarcoplasmic reticulum periodically. Lymphatic fluid from the head, neck, right thorax, right arm, and right heart drains into the right innominate vein. The tunica is thinner in the spongiosum (with only a circular layer [see earlier]) and is absent in the glans (Table 26-2). The ureter is placed behind a retractor to keep it out of the field of dissection. In addition, good initial success has been reported with polidocanol as a sclerosing agent for extensive urethral hemangiomas. Nonischemic priapism is much rarer than ischemic priapism, and the cause is largely attributed to trauma. The spinous process projects posteroinferiorly, and the transverse processes project posterolaterally. Full bilateral dissections to include bilateral suprahilar dissections were performed on every patient. They suggested that their findings may differ from findings of other investigators because of their use of a preoperative, adjuvant, alcohol-based skin preparation. The specimen is placed in an endobag and dropped on the contralateral side of the abdomen. In other cases, monopolar cautery can be used in the superficial structures, but bipolar cautery is better during dissection around the corpus spongiosum, elevation of penile and scrotal flaps, division of the perineal intracorporeal space, and dissection of the dorsal neurovascular structures. Oversized cylinders can result in erosion and an S-shaped penile deformity, which can cause increased wear at the flexion point of the curve and lead to mechanical failure (Wilson et al, 1996; Montague, 2011). A compared two cohorts of patients undergoing penile implant for refractory ischemic priapism. There are no comparative trials of sympathomimetics in the management of priapism, nor are there studies of dosage tolerance to report. Although not immediately germane to sexual response, the ovaries are obviously essential in reproduction and may lead to sexual problems in disease states. Orgasmic dysfunction is common in patients who receive carbamazepine therapy, and loss of sexual desire is common in men treated with valproate (Kuba et al, 2006). Thus, either superficial or complete modified inguinal dissection should adequately identify microscopic metastases in patients with clinically normal inguinal examination findings, without the need for a pelvic dissection if the inguinal nodes are negative. Patients should also be reassured that this is not a disorder that will degenerate into a cancer and is therefore not life-threatening. A trans-scrotal orchiectomy or biopsy is contraindicated because it leaves the inguinal portion of the spermatic cord intact and may alter the lymphatic drainage of the testis, increasing the risk of local recurrence and pelvic or inguinal lymph node metastasis. Thus, six series reveal an improvement in survival for patients undergoing early therapeutic versus delayed therapeutic dissection. At the level of the scrotum, however, the pampiniform plexus of veins are intimately entwined with the coiled testicular artery. If the partner of the patient is present during the history, she may relate valuable information. For the 60 to 69 age group, most of the world showed a high rate (20% to 40%), with some showing increases after age 65 except for the Scandinavian reports, in which the 70s and older were the time of major rate change. Objective sensory nerve testing may be performed using a biothesiometer to determine vibratory perception thresholds (expressed in volts) as displayed (left). Its origin is at L5 and the iliac fossa, and it attaches to the inferior border of the 12th rib and the transverse processes of L1-L4. Teratoma following cisplatin-based combination chemotherapy for nonseminomatous germ cell tumors: a clinicopathological correlation.

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The periprostatic plexus anastomoses with the deep dorsal vein of the penis and the internal iliac (hypogastric) veins. Comparison of the immunogenicity and reactivity of a prophylactic human papillomavirus (types 6,11,16,18) L1 878. PostoperativeManagement Sterile fluff gauze dressings are held in place with a snug-fitting scrotal supporter. Magnetic Resonance Imaging Scans Cases of central (hypogonadotropic) hypogonadism as well as unexplained hyperprolactinemia prompt central imaging of the pituitary. Similarly, it is prudent to be concerned about the potential victimization of women and their partners for financial gain (Bancroft, 2002). Intraoperative risk factors for infection may include inadequate skin preparation with alcohol/chlorhexidine; prolonged surgical time. Given this finding and the chemoresistance of teratoma, adjuvant chemotherapy is not recommended in these patients. Transdermal testosterone treatment in women with impaired sexual function after oophorectomy. When handling testis biopsy material for permanent fixation, avoid crushing tissue in any way (including with forceps) because this may traumatize and distort the testicular architecture. Leiomyomas also may be discovered incidentally during routine pelvic examination or an unrelated surgical proce dure (Cornella et al, 1997). In summary, radiation therapy to the inguinal area is not recommended as prophylaxis for patients at high risk for inguinal node metastases. Recording techniques have been standardized, and normative values have been defined to include maximum peak-to-peak amplitudes between 120 and 500 mV and mean potential durations of 12 seconds (Stief et al, 1994). Sacral parasympathetic neurons are important in the preservation of reflexogenic erection, although the thoracolumbar pathway may compensate for sacral loss through synaptic connections. Functional relationship between obesity and male reproduction: from humans to animal models. We marsupialize the bladder epithelium as described by Eggleston and Walsh (1985), place anastomotic sutures in the urethral stump, and pass a stenting catheter. This information allows us to proceed to pudendal angiography only in patients with abnormal arterial parameters on duplex ultrasonography; patients with normal findings on ultrasonography predictably do well with reconstruction. Should unilateral obstruction be present with adequate spermatogenesis present in the ipsilateral testis and the existence of spermatogenic pathology in the contralateral testis, impaired bulk seminal parameters may result and microductal reconstruction may be indicated. Evidence to support these concepts is confined to observation studies with varying numbers of cases. We have proposed that, in many cases, the sparing of the proximal anterior urethra demonstrates the distribution of the glands of Littre for a given patient. To complicate matters, semen analysis parameters are highly variable, and investigators typically recommend a minimum of two analyses separated by 2 to 3 weeks for assessment (Centola, 2011). Dubey and colleagues (2005) showed the extent of luminal narrowing to be a predictor of success with internal urethrotomy: the narrower the percent of narrowing, the worse the outcome, with a cutoff of 74% narrowing. Surgi cal consolidation was then performed in 21 patients, and their mean overall survival was 25. The anterior urethra begins at the perineal membrane and continues distally to the urethral meatus. In humans, sperm aging as a result of extended epididymal transit time and prolonged storage may contribute to reduced fertility (Johnson and Varner, 1988). Over 50% of the tumors were actually heterogeneous with respect to grade, and among these tumors any proportion of grade 3 cancer was associated with lymph node metastasis. L-Carnitine is hypothesized to act by increasing mitochondrial respiration and decreasing free radical formation (Bremer,1983). Treatment has trended toward a multimodality approach in recent years based on previously reported outcomes. Evaluate the patient every 3 to 6 months after treatment initia tion and then annually to assess symptom response and assess adverse effects. The posterior lamina of Gerota fascia is thicker and more frequently visualized radiographically than the anterior lamina. Sexual dysfunction in middle-aged women: a multicenter Latin American study using the Female Sexual Function Index.

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In general, empirical treatment falls within two categories: either endocrine or nutraceutical based. It is important for the patient to understand that capsule formation should occur when the reservoir is full, and the reservoir should not be left in a partially filled state for extended periods. The sheath of the convoluted vas may be carefully dissected free of its attachments to the epididymal tunica. The dorsal artery generally travels along the dorsum of the penis between the deep dorsal vein medially and the dorsal nerves laterally, with a coiled rather than a straight configuration. Collaborative efforts with a mental health clinician who has expertise in psychosexual therapy may be necessary to implement intensive therapy techniques. The outcome of studies using other interferons has been less clear (Zouboulis et al, 1991). Findings of obesity, elevated blood pressure, or abnormal femoral or pedal pulses, all signs representative of cardiovascular disease, convey a potential vascular causation. Hence, testis biopsy simultaneously with other procedures such as testis sperm extraction may yield pathologic information that can explain procedural outcomes as well as provide information about other related future diseases. This can proceed to the formation of an abscess, or the fistula may open to the skin or the rectum. For accurate mucosal approximation, only a small amount of mucosa is included, but one third to one half the muscle wall thickness. Long acting testosterone undecanoate therapy in men with hypogonadism: results of a pharmacokinetic clinical study. Iliacus Quadratus lumborum Spine the spine consists of 7 cervical vertebrae, 12 thoracic vertebrae, 5 lumbar vertebrae, the sacrum, and the coccyx. A high level of distress was reported by 94% of these young men, with 34% seeking treatment for an anxiety or mood disorder (Tal et al, 2012). Precipitating events reported from greatest to least were sexual arousal or intercourse, fever, sleep, cold weather, and dehydration. The prostatovesicular artery can also arise from the superior vesicular artery or from the pudendal artery. Patency rates with the intussusception technique can exceed 80% (Berger, 1998; Brandell and Goldstein, 1999; Marmar, 2000). Clinical presentation includes local discomfort, pruritus, and occasionally a serosanguineous discharge involving the penis, the scrotum, or even the perianal area. AnastomosisintheConvolutedVas Vasovasostomy performed in the convoluted portion of the deferens is technically more demanding than anastomoses in straight portion. Testosterone is negatively associated with the severity of coronary atherosclerosis in men. Such evaluation may confirm or define etiologic medical conditions associated with the sexual dysfunction. Radiation-based strategies are discussed later in the section on radiation therapy for the primary lesion. Erectile dysfunction precedes other systemic vascular diseases due to incompetent cavernous endothelial cell-cell junctions. A series from Horenblas and colleagues (1991) also found that the sensitivity of fine-needle aspiration cytology was approximately 71% in 18 patients with clinically negative lymph nodes. Careful bilateral palpation of the inguinal area for adenopathy is extremely important. Increased quantities of blood products should be considered for patients requiring more complex resections. The investigators reported that patients receiving an implant without the use of dilation experienced less postoperative pain and increased penile length compared with patients in whom dilators were used to facilitate cylinder insertion (Moncada et al, 2010). Ficarra and colleagues (2006) developed the first penile cancer nomogram using data from 175 patients. Care should be taken to avoid energy sources such as electrocautery when dissecting nerve fibers (Peschel et al, 2002; Bhayani et al, 2003; Abdel-Aziz et al, 2006; Steiner et al, 2008). The importance of bleomycin in combination chemotherapy for good-prognosis germ cell carcinoma. Radiotherapy with 16 Gy may fail to eradicate testicular intraepithelial neoplasia: preliminary communication of a dose-reduction trial of the German Testicular Cancer Study Group. Lymphedema of the penis involves the tissues of the dartos fascia and the dermal layer of the skin. The majority of long-term observation studies have not suggested a significant increase in cancer risk for women taking exogenous T for as long as 2 years (Braunstein, 2007; Davis et al, 2009; Jick et al, 2009).

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The inferior skin flap is mobilized by sharply dividing the intervening subcutaneous tissue and rectourethral muscle. The peripheral zone makes up the posterior and lateral aspects of the prostate gland. In a clinical trial with larger sample size and longer duration, treatment with bicalutamide alone resulted in a smaller decrease in sexual desire than did castration (Iversen et al, 2000). All that remains of the mem branous urethra proximally is an illdefined fibrotic band, and it should be completely excised. The most significant feature related to the prognosis of cryptorchidism is whether the condition is unilateral or bilateral (Lee et al, 2001; Miller et al, 2001; Lee, 2005). Priapism: a three-phase concept of management according to etiology and prognosis. Gap junctions, intercellular communication channels, are responsible for synchronization and coordination of the erectile response (Christ et al, 1991). Stimulation of the medial preoptic area of the hypothalamus in the rat elicits increases in intracavernous pressure. Sealing devices such as ultrasonic shears and bipolar devices should be used with caution and can be unreliable in sealing large lymphatic channels. In many instances, however, accessory arteries exist, arising from the external iliac, obturator, and vesical and femoral arteries, and they may constitute the dominant or only arterial supply to the corpus cavernosum in some men (Breza et al, 1989). Each packet should be placed in a separate sac during dissection to help increase yield of nodal evaluation and count. Both patches have been associated with itching, chronic skin irritation, and allergic contact dermatitis. Serum testosterone levels are maintained when application site is washed 4 to 6 hours after application. Once a patent lumen has been established on the testicular end, the vas is milked and a clean glass slide is touched to its surface. Thus, although the mechanical barrier contributes to the isolation of the testis, other "functional" components must also exist to suppress the normal immune response. Bernal and Henry (2012) reviewed all relevant research published over the past two decades and identified nine studies meeting their inclusion criteria. Radical orchiectomy is the most definitive treatment, although low-dose radiotherapy (20 Gy) is associated with similar rates of local control with the prospect of preserving testicular endocrine function owing to the relative radioresistance of Leydig cells compared with germinal epithelium (Heidenreich et al, 2001; Montironi, 2002; Dieckmann et al, 2003). Surgical therapy in infertile men with ejaculatory duct obstruction: technique and outcome of a standardized surgical approach. The depth and density of the scar in the spongy tissue can be deduced from the physical examination, the appearance of the urethra in contrast-enhanced studies, and the amount of elasticity noted on urethroscopy. Pregnancies after intracytoplasmic injection of single spermatozoon into an oocyte. Anterior extraperitoneal approach to laparoscopic retroperitoneal lymph node dissection: a novel technique. When circumstances demand a large area of inguinal soft tissue sacrifice, primary closure may be obtained by scrotal skin rotation flaps (Skinner, 1974), an abdominal wall advancement flap (Tabatabaei and McDougal, 2003), or a myocutaneous flap based on the rectus abdominis or tensor fasciae latae (Airhart et al, 1982) for more extensive defects. If the fistula is small and closure of the hole does not decrease the lumen of the urethra, a button of skin is removed from around the fistula, and its edges are cut flush with the urethral wall. The thinned graft diminishes the total graft mass, while preserving the physical characteristics and not adversely affecting the vascular characteristics. Before ejaculation, semen is a liquid, and after all components mix with the seminal vesicle secretions, it coagulates. On seeing the device, patients are often concerned about the size of the incision required to implant it, and they should be reassured that only a 1-inch incision is necessary. Hence, there is indirect evidence of a role for the adrenergic neurotransmitter norepinephrine in opposing genital vasodilatory responses in humans as well.

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There is a difference between genital full-thickness skin (penile and preputial skin grafts) and extragenital full-thickness skin. Simultaneous retroperitoneal, thoracic, and cervical resection of postchemotherapy residual masses in patients with metastatic nonseminomatous germ cell tumors of the testis. Application of nocturnal electrobioimpedance volumetric assessment: a feasibility study in men without erectile dysfunction. Diagnosis and treatment of erectile dysfunction for reduction of cardiovascular risk. In this study, a semiquantitative system that estimated the amount of high-grade cancer. First, because the management of MetS-related conditions primarily rests with cardiologists, endocrinologists, and primary care physicians, how urologists should approach urologic diseases in the context of MetS is currently unclear. Testosterone levels can reach castration levels (reduced by >85% when compared to controls) within 24 hours after administration of a single opioid (Aloisi et al, 2005). McRoberts and Sadove (2002) proposed the use of the fibular osteocutaneous flap for phallic construction. Long-term results of a combination of paclitaxel, cisplatin and gemcitabine for salvage therapy in male germ-cell tumours. Clitoral stimulation is typically pleasurable for women and may lead to orgasm; the nature of desirable stimulation however varies from woman to woman and may vary for a woman in different circumstances (Leff and Israel, 1983). The glands of Littre are rich in goblet cells and enter the spongy tissue between the vascular spaces and the trabeculae. The design of these islands must take into consideration the location of hair on the shaft of the penis and the mechanics of flap transfer. Diagnostic Delay Diagnostic delay is a well-recognized phenomenon of this disease, with patients and physicians contributing to this delay. The epithelium in the ductuli efferentes consists of ciliated and nonciliated cells (Holstein, 1969). In some men these testes remain in the abdomen virtually all the time, except when in a warm shower or under anesthesia. Although there is evidence supporting this effect in cervical and anal neoplasia, definitive proof for penile cancer awaits further study (Northfelt, 1994). The premise is that the vein survives by endothelial direct perfusion and reestablishment of vein wall blood flow by perfusion of the vasa vasorum. For patients who need vascularized tissue only to cover the shaft of the penis, we have used the upper lateral arm flap. In this position, a sudden "faux pas de coit" or missed thrust may lead to high intracorporeal pressures (Bitker et al, 1988). Impact of premature ejaculation: the psychological, quality of life, and sexual relationship consequences. Prospective association of serum androgens and sex hormone-binding globulin with 555. Sperm Granuloma Leaky closure of a vasography site may lead to the development of a sperm granuloma, which can result in stricture or obstruction of the vas. Determining if and when to proceed with resection of thoracic disease in the setting of retroperitoneal necrosis is a decision that needs to be based on the expertise of a multidisciplinary testicular cancer team that has extensive experience in dealing with this disease. Obstructive urinary symptoms occur less frequently (Fry et al, 1988; Leidinger and Das, 1995). Occupational exposures obtained by questionnaire in clinical practice and their association with semen quality. One will be able to spare the saphenous vein in most patients, and the small branches of the femoral artery and vein may be clipped and divided. Methods used in cross-cultural comparisons of sexual symptoms and their determinants. Once sperm have been identified, they are aspirated into glass capillary tubes and flushed into media for cryopreservation.

Syndromes

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When administered into the muscle, testosterone is absorbed directly into the bloodstream. Other topical anesthetics are associated with significant penile hypoanesthesia and possible transvaginal absorption, resulting in vaginal numbness and resultant female anorgasmia unless a condom is used (Busato and Galindo, 2004). After the sleeve of preputial skin has been removed, hemostasis is obtained, and the skin edges are reapproximated. This maneuver has eliminated the occurrence of false passages with use of a sound such as the Haygrove staff through the suprapubic site and has eliminated the occurrence of misanastomosis of the anterior urethra to sites other than the apical proximal urethra. Involvement of the prostate with tumor (either superficial or invasive) and the form of urinary diversion were independent risk factors. The global prevalence and incidence of MetS have increased substantially since the mid-2000s, particularly in the developed world. As a result, men are often told by their physicians that nothing can be done during the acute phase and they should wait 6 months to a year, because there is a "good chance" that the disease process will resolve. The term island flap is not synonymous with the terms skin island and skin paddle. Differential expression of extracellular matrix molecules and the alpha 6-integrins in the normal and neoplastic prostate. Congenital abnormality of corpora cavernosa and erectile dysfunction: a case report. Within- and between-subject variation in semen parameters in infertile men and normal semen donors. Symmetrical hypoplasia of the phallus, micropenis, is often related to urethral developmental abnormalities such as hypospadias and epispadias (Reilly and Woodhouse, 1989) or endocrine deficiency. The mixing of seminal vesicle with prostatic secretions results in human semen having a mildly alkaline pH. Squamous cell carcinoma of the penis: multivariate analysis of prognostic factors and natural history in a monocentric study with a conservative policy. For example, testosterone passively diffuses from veins to the artery in a concentration-limited manner (Bayard et al, 1975). In globozoospermia, the majority of the sperm lack acrosomal caps, rendering the heads spheric rather than ovoid. The concept of sentinel lymph node biopsy as described by Cabanas (1977) is predicated on detailed penile lymphangiographic studies that have demonstrated consistent drainage of the penile lymphatics into a sentinel node or group of nodes located superomedial to the junction of the saphenous and femoral veins in the area of the superficial epigastric vein. Lymphatic and vascular embolizations are independent predictive variables of inguinal lymph node involvement in patients with squamous cell carcinoma of the penis. Involvement of superoxide radical in the impaired endothelium-dependent relaxation of cavernous smooth muscle in hypercholesterolemic rabbits. Although there will be extremely rare exceptions to this bold statement, if those exceptions are encountered, their existence should still be questioned. Laparoscopic retroperitoneal lymph node dissection for clinical stage I nonseminomatous testicular carcinoma: long-term outcome. Sexual function after highly selective embolisation of cavernous artery in patients with high-flow priapism: long-term follow-up. Specifically, some men ejaculate very rapidly after, or sometimes even before, penetration and do so with minimal stimulation. When it is harvested, the graft exposes the intradermal plexus and the deep dermal plexus. Epididymal proteins mimic the androgenic effect of zona pellucida recognition by immature hamster spermatozoa. Patients and physicians must carefully consider the unique acute and long-term side effects of radiation therapy. Lactate dehydrogenase as a biomarker of hemolysis associated nitric oxide resistance, priapism, leg ulceration, pulmonary hypertension and death in patients with sickle cell disease. The traction suture from the distal tip of each cylinder is secured to a Keith needle and passed into the distal aspect of the penile shaft and through the glans penis with the Furlow introducer. Deep to the raphe, the scrotum is divided by a septum into two compartments, each containing a testis.

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In an attempt to standardize and improve reproducibility of assessment of sperm interaction with cervical mucus, investigators devised model systems in which sperm and mucus could be observed ex vivo (Niederberger et al, 1993). This suggests that immediately before emission, with sympathetic stimulation, sperm is rapidly transported from the distal epididymis through the vas deferens to the ejaculatory duct. This prevents posterior pump migration, which renders it less accessible to the patient. The objective response rate was 50% (15 of 30 patients), and the pathologic complete response rate was 10% (3 patients). Free testosterone plasma levels are negatively associated with the intima-media thickness of the common carotid artery in overweight and obese glucose-tolerant young adult men. It would seem intuitive that once the scarring process has begun, there would be a progressive increase in deformity; but we have found that up to 20% of patients will experience a sudden onset of deformity that can be as great as 90 degrees. The most common cause of vulvovaginal atrophy is estrogen deficiency related to menopause (surgical or natural) (North American Menopause Society, 2013). Longterm diseasefree survival has been reported in this setting (Mandler and Pool, 1966; Konnak, 1980; Gheiler et al, 1998; Hakenberg et al, 2001; Karnes et al, 2010). In these patients, the correction of the curvature is similar to that described for patients with ventral curvature, with incision through the circumcision scar with the skin reflected. They found at the beginning of treatment that the mean number of episodes of stuttering priapism per patient was 22. Modified corporoplasty for penile curvature: long-term results and patient satisfaction. In these patients, the placement of an aligning catheter may allow the urethra to heal virtually unscarred or with an easily managed stenosis. In an effort to aid epithelialization, nature invokes the forces of wound contraction, not to be confused with scar contraction. Chlamydia trachomatis infection among women reporting sexual activity with women screened in family planning clinics in the Pacific Northwest, 1997 to 2005. However, a highly select group of patients with rising serum tumor markers who are deemed to have resectable disease limited to a single site (usually the retroperitoneum) may be candidates for salvage surgery, commonly referred to as desperation surgery. While applying upward traction to the penis, the base of the crus is palpated, and Scarpa fascia is bluntly divided. If drains were placed, the patients are given detailed instructions (with explicit drawings) on how to remove the drains the next morning. A Gigli saw passed through the obturator foramina, or an osteotome is used to incise the sym physis transversely, joining the foramina. Simvastatin and niacin, antioxidant vitamins, or the combination for the prevention of coronary disease. However, we and others have extensive experience with these flaps and, in select cases, have had very good results. On the other hand, a -adrenergic agonist, which would relax cavernous smooth muscle and dilate the cavernous artery and arterioles, could promote oxygenated arteriolar blood to enter the cavernous spaces and wash out deoxygenated blood. Larger-scale studies indicate that the most critical criterion for any grafting procedure is the quality of preoperative erections (Flores et al, 2011; Taylor et al, 2012). The layers from innermost to outermost are the intima, internal elastic lamina, media, external elastic lamina, and adventitia. The perirenal fat is finer and lighter yellow in color compared with the coarser yellow-orange pararenal fat. Well-documented histologic changes occur within the corporal smooth muscle as a consequence of prolonged ischemia. The fundiform ligament arises from Colles fascia and is lateral, superficial, and not adherent to the tunica albuginea of the corpora cavernosa. Over a 30-year span involving more than 1200 patients, approximately 1% required this procedure. Gerbaulet and Lambin (1992), using percutaneously placed interstitial iridium-192 implants, reported successful local control in 82% of 109 patients, with long-term survival rates of 75% to 80% in patients with tumorfree regional lymph nodes. The structure of the corpus spongiosum and glans is similar to that of the corpora cavernosa except that the sinusoids are larger. Normal and variant appearances of the adult epididymis and vas deferens on high-resolution sonography.

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One of these dopaminergic systems, the tuberoinfundibular system, secretes dopamine into the portal hypophysial vessels to inhibit prolactin secretion (Ganong, 1999a). Another fundamental issue is whether the testing appropriately evaluates wakeful, sexually relevant erections. Matin and colleagues performed a thorough evaluation of the adequacy of a robotic inguinal lymph node dissection by subsequently opening the incision and having a second surgical oncologist look for unretrieved residual nodal tissue in 10 patients. Surgical evaluation of high-risk, clinically node-negative patients is recommended so that additional treatment can be tailored to the actual pathology, rather than just offering "prophylactic" radiation to the inguinal nodes. Basic parameters studied included the concentration of sperm, their movement, and their shape (MacLeod, 1951). Early surgical intervention may be preferable in patients with malignant or poorly controlled hypertension or for men who are using monoamine oxidase inhibitor medications contraindicating -adrenergic therapies. Because of the association of a penile metastatic lesion with advanced disease, survival after its presentation is limited, and the majority of patients die within 1 year (Robey and Schellhammer, 1984; Mukamel et al, 1987; Fischer and Patrick, 1999). The microsurgical approach with delivery of the testis lowers the incidence of varicocele recurrence to less than 1% compared with 9% with use of conventional inguinal techniques (Goldstein et al, 1992; Marmar and Kim, 1994). Ravi (1993b) performed early prophylactic dissection in 113 patients with invasive penile cancer and compared the 5-year survival with that of 258 similarly staged patients who were initially observed. One alternative to immediate lymphadenectomy for all patients has been to observe patients with normal findings on inguinal examination. The association between testosterone and cerebral vascular disease appeared to be gender specific. Long-term outcome of postorchiectomy surveillance for stage I testicular seminoma. Awareness of cultural paradigms is useful; however, individual women may not conform to stereotypes of their culture. Platelets increase the tone of quiescent rat aortic rings by release of serotonin and potentiate the subsequent contractile response to norepinephrine. Thus, in addition to describing the number of positive lymph nodes, it also includes a potential quality variable in incorporating the total lymph node yield. The thickness of the total muscle layer gradually decreases along the length of the vas deferens. Lifelong monitoring of these patients for the secondary effects of inflammation is necessary. Sequential resection of residual abdominal and thoracic masses after chemotherapy for metastatic nonseminomatous germ cell tumours. The cavernous nerves are believed to supply autonomic innervation to the intrinsic smooth muscle of the membranous urethra (Steiner et al, 1991). Further investigation is needed to establish the relationship of volumetric changes and the rigidity of the penis. However, according to a study by Kava and colleagues (2011), less than 10% of devices removed because of malfunction or rerouted because of extrusion were colonized with pathogenic bacteria. Other associated fibrotic conditions are contracture of the plantar fascia (Ledderhose disease) and tympanosclerosis, both of which are uncommon disorders (Box 31-2). These complications are rare today because of the less frequent use of aggressive internal urethrotomy as a treatment modality for urethral strictures. Most patients with progressive disease despite first-line and second-line chemotherapy have a dismal prognosis. There is increasing evidence that for many women absence of sexual desire may be typical and not associated with distress. The 5-year relapse rates for patients with zero, one, and two risk factors were 12%, 16%, and 32%. Examining the Spermatic Cord Palpation of the spermatic cord yields two features of reproductive significance: whether the vas deferens is palpable, and whether a varicocele is present. In many cases of genital lymphedema, the posterior scrotum and the lateral scrotal wall are spared from the edematous process; in these cases, the bulk of the scrotum is excised, and closure is accomplished with use of the posterior and lateral scrotum. Testicular sperm are incapable of fertilizing eggs unless injected into them with micromanipulation (Orgebin-Crist, 1969; Bedford, 1974; Yanagimachi, 2005).

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Nevertheless, D4 receptors seem to play only a modest role in the pro-erectile effect (Melis and Argiolas, 2011). Testes that change in position after descent and those that are nearly but not fully descended present special challenges in assessing potential alterations in reproductive potential. NerveSupply Branches of the ilioinguinal and genitofemoral nerves innervate the anterior scrotal wall. Response of the human testicular capsule to electrical stimulation and to autonomic drugs. Women with sexual dysfunction may compensate for it in some fashion and thus preserve a sense of sexual satisfaction or at least contentment. Anecdotally, the fusion of the ventral-meatal skin that causes meatal stenosis can be avoided. The assistant grasps the cord with a Babcock clamp and delivers it through the wound. If the orchiectomy was performed properly, the distal cut end of the gonadal vein and suture ligature should be easily retrievable. It does not involve any impairment of fertility, when intravaginal ejaculation occurs. Individual women may have intense arousal response to stimulation of parts of their body that are not generally deemed erogenous. The differential effects of -adrenoceptor antagonists on erectile function may be explained by whether they are general antagonists, are selective antagonists, or possess vasodilatory properties. Additionally, in some cases in which multiple attempts at fistula closure have been attempted and failed, the tissues adjacent to the fistula are so scarred that staged reconstruction is needed to import "better tissue. Right-SidedDissection the ascending colon is mobilized by incising the white line of Toldt from the pelvis and around the hepatic flexure. The ascending colon and hepatic flexure overlie the right-sided retroperitoneal structures, and the splenic flexure and descending colon cover the left-sided retroperitoneal structures. If the patient is not in steep lateral oblique position for retrograde urethrography, the length of the stricture will be underestimated. Obstruction or aplasia of the inguinal vas or ejaculatory duct on one side and epididymal obstruction on the contralateral side. The metabolic syndrome and disturbances in hormone levels in long-term survivors of disseminated testicular cancer. Other, less common complications include hematoma in up to 9% of patients, urethral injury in less than 2%, and phimosis in up to 5% (Tornehl and Carson, 2004; Kadioglu et al, 2011b; Larsen and Levine, 2013). Testis cancer cells have a genetic determination for a high sensitivity to apoptosis inducing stimuli. The scope can be passed to the stricture, and it often is unnecessary to pass it beyond that level. A new power Doppler ultrasound guiding technique for improved testicular sperm extraction. The blood supply to the seminal vesicle arises from the internal iliac artery and inferior vesicular artery through the prostatovesicular branch (Clegg, 1955). The intertubular capillaries are located within the columns of interstitial tissue, whereas the ladderlike capillaries running near the seminiferous tubule are called peritubular capillaries. An upper limit of sperm density has not been established above which endocrine dysfunction is unlikely to be discovered; clinicians may reasonably use the 50th percentile value Examining the Phallus In the typical setting of intercourse, semen must be deposited proximal to the cervical os for optimal chance of reproduction. The duodenum may be mobilized medially using a Kocher maneuver to expose these right-sided retroperitoneal structures. Varicocele the diagnosis of varicocele was discussed in the section detailing the physical examination of the infertile man: why imaging such as ultrasound is most rationally not recommended for the screening evaluation of a varicocele is discussed in the section describing imaging. Similar conclusions were reported in other studies (Montorsi et al, 2006; Inman et al, 2009). The best results are achieved when the following technical points are observed: the area of fibrosis is totally excised; the urethral anastomosis is widely spatulated, creating a large ovoid anastomosis; and the anastomosis is tension free. InflatableProstheses Inflatable prostheses are designed to approximate normal function more closely by permitting girth and length expansion during erection and penile flaccidity when not in use.

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Gonadal function after 12-Gy testicular irradiation in childhood acute lymphoblastic leukaemia. Standard-dose, second-line chemotherapy is the preferred approach for patients who relapse more than 6 months after first-line chemotherapy. Are men with erectile dysfunction more likely to have hypertension than men without erectile dysfunction Effects of first-line antihypertensive agents on sexual function and sex hormones. Cavernous arterial and arteriolar circulation in patients with erectile dysfunction: a power Doppler study. The 5-year disease-free survival was 57% for early lymphadenectomy compared with 13% for delayed node dissection. Visual inspection of the color and consistency of an initial penile aspirate will reveal dark deoxygenated blood with a "crankcase oil" appearance in ischemic priapism. The median duration of response was 16 weeks with an overall survival of 28 weeks (Haas et al, 1999). The sexual response cycle comprises the four interactive stages of desire, arousal, orgasm, and resolution. Vergleichende untersuchungen uber das Lymphgefasssytem des Nebenhodens und Hodesn von Mensch, hund unk Kaninchwen. Alpha and beta sympathetic responses to isoproterenol by the isolated rat vas deferens. The primary and frequently noted side effect was varying degree of ecchymosis and local penile bruising. The 3-year survival for patients detected during close surveillance was only 35% compared with 84% (P =. Chapter22 MaleReproductivePhysiology 523 Seminiferous Tubules the seminiferous tubules consist of germ cells and supporting cells and are a unique environment for gamete production. The politics of sexual identity: sexual attraction and behavior among lesbians and bisexual women. The only adverse event reported by patients was temporary mild erythema at the treatment site (Greenfield et al, 2007). Neurological disturbances of sexcual function with special reference to 529 patients with spional cord injury. Although Schreiter and Noll (1989), who first described the procedure of mesh split-thickness skin graft, often proceeded to the second stage within 3 to 4 months, we wait 12 months between the first-stage and second-stage surgeries if a splitthickness skin graft is used. Endoluminal vascular stents have also been reported to have transient success in preventing vascular erosion by tumor (Link et al, 2004). The importance of mental, cognitive, and partner-related factors cannot be overlooked in any pain disorder. Of 1200 melanomas treated at Memorial Sloan Kettering Cancer Center, only 2 were of penile origin (Das Gupta and Grabstald, 1965). The best-elucidated function of human semen appears to be its ability to provide antioxidative protection to sperm. Plication or tunical incision/ excision with or without grafting may rarely be necessary (Hudak et al, 2013; Segal and Burnett, 2013). In assessing success rates for any therapy directed toward reproduction, outcomes must be carefully identified. The use of a vacuum constrictor device to augment a partial erection following an intracavernous injection. We have used a combination of 3-0 Monocryl and 3-0 polydioxanone sutures for this purpose. Reappraisal of the role of radiotherapy and surgery in the management of carcinoma of the penis. The surveillance schedule employed in published series is highly variable, and no schedule has been demonstrated to be superior to another in terms of survival. For initial dilation, we favor the use of balloons placed over wires that have been passed through the stricture under endoscopic control. Ultimately, most peptide hormones induce phosphorylation of proteins that alter cell function. If the patient presents acutely with the amputated distal part of his penis, microvascular replantation is the favored approach. Instruments developed more recently were implemented primarily in clinical trials associated with new drug development, and they particularly captured efficacy end points including sexual interest, performance, and satisfaction. However, many women mistake bodily sensations as ovulation, and symptoms alone cannot reliably be used to assess optimal timing for intercourse.