Ogni antibiotico è efficace in relazione a un determinato gruppo di microrganismi comprare doxycycline senza ricettain caso di infezioni oculari vengono scelte gocce ed unguenti.
Microsoft word - 001-10702 post arm_final-ch
Management of Sexual Disorders in Spinal Cord Injured Patients
Vafa Rahimi-Movaghar1 and Alexander R Vaccaro2
1 Department of Neurosurgery, Research Deputy, Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
2 Department of Orthopaedics and Neurosurgery, Thomas Jefferson University and the Rothman Institute, Philadelphia, Pa 19107, USA
Received: 20 Jul. 2011; Received in revised form: 27 Oct. 2011 ; Accepted: 22 Feb. 2012
Spinal cord injured (SCI) patients have sexual disorders including erectile dysfunction (ED),
impotence, priapism, ejaculatory dysfunction and infertility. Treatments for erectile dysfunction include four
steps. Step 1 involves smoking cessation, weight loss, and increasing physical activity. Step 2 is
phosphodiesterase type 5 inhibitors (PDE5I) such as Sildenafil (Viagra), intracavernous injections of
Papaverine or prostaglandins, and vacuum constriction devices. Step 3 is a penile prosthesis, and Step 4 is
sacral neuromodulation (SNM). Priapism can be resolved spontaneously if there is no ischemia found on
blood gas measurement or by Phenylephrine. For anejaculatory dysfunction, massage, vibrator, electrical
stimulation and direct surgical biopsy can be used to obtain sperm which can then be used for intra-uterine or
in-vitro fertilization. Infertility treatment in male SCI patients involves a combination of the above treatments
for erectile and anejaculatory dysfunctions. The basic approach to and management of sexual dysfunction in
female SCI patients are similar as for men but do not require treatment for erectile or ejaculatory problems.
2012 Tehran University of Medical Sciences. All rights reserved.
Acta Medica Iranica
, 2012; 50(5): 295-299.
Spinal cord injury; Management; Sexual disorders; Erectile dysfunction
dysfunction" in PubMed from 1966 to 20th July 2011.
The reference lists of the identified articles were also
Spinal trauma complicated by spinal cord injury (SCI) is
a devastating event on a personal and family level, as
well as a great financial burden to society because of its
attendant morbidity, expense, and prolonged treatment
requirements (1, 2).
There is less known about SCI-related sexual
The prevalence of SCI has been evaluated in two
dysfunction in females than in males. However, these
papers reporting ranges from 110 to 1120 and 223 to
studies have shown that when vaginal stimulation is
755 per million people (3,4). In a population based
done in SCI females and a normal control group, orgasm
study, the point prevalence of SCI in Tehran was
will happen in 100% of normal controls but in less than
440/million (95% CI: 120-1140) (5). In Tehran, the
50% of T12-L1 SCI patients. In females with S2-S5
incidence was 98/million in males and 47/million in
lesions, only 17% achieved orgasm (8).
females (6). SCI complications were evaluated in 5995
In female SCI patients, fertility is possible. However,
complete motor SCI (ASIA A and B) patients supported
pregnancy needs careful observation for autonomic
by the Welfare Organization in Iran (7). The prevalence
dysreflexia. For delivery, Oxytocin induction is
of sexual dysfunction in males was 32.4% and in
contra-indicated but epidural anesthesia is recommended
females was 13.9%. Prevalence of infertility was 12.1%
to decrease the risk of autonomic dysreflexia.
and 7.0% in males and females, respectively.
Careful observation for bed sores, urinary tract
infections (UTI), leg edema, thrombophlebitis, transient
Materials and Methods
ischemic attack (TIA) and anemia is important.
Meanwhile, sequential breast examination is necessary.
A literature review was performed using the terms
In patients with cervical lesions, lactation typically
"spinal cord", "injury", "patient", "treatment",
continues for 3 months and then stops because of lack of
"management", "sex", "sexual", and "erectile
Department of Neurosurgery, Research Deputy, Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
Tel: +98 216 6757010, 915 3422682, Fax: +98 216 6757009, E-mail: email@example.com
Management of sexual disorders in spinal cord injured patients
Most men with SCI are infertile. Erectile dysfunction
not successful, laboratory assessment is recommended to
(ED), ejaculatory dysfunction and semen abnormalities
include a fasting blood glucose level and lipid panel,
contribute to the problem. Although sperm count is
thyroid-stimulating hormone, and testosterone level
normal in SCI men, sperm motility is low. There is
abnormal sperm viability and morphology, too.
Genitourinary infection and endocrine abnormalities can
also be present (9-11).
First-line therapy for ED consists of lifestyle
changes, modifying drug therapy that may cause ED,
Erectile dysfunction (ED)
and pharmacotherapy with phosphodiesterase type 5
ED is defined by the National Institutes of Health
inhibitors (PDE5I). Obesity, inactive lifestyle, and
(NIH) as the inability to achieve or maintain an erection
smoking greatly increase the risk of ED. Grade A
sufficient for satisfactory sexual performance. ED is the
treatment recommendations, based on high-quality
most common sexual problem in men (10). The
patient-oriented studies, suggest that PDE5I are the most
incidence increases with age and affects up to one third
effective oral drugs for the treatment of ED in SCI
of men throughout their lives. It causes a considerable
patients (15,16). Retail sales of the three most popular
negative impact on close relationships, quality of life,
PDE5Is Sildenafil (Viagra), Tadalafil (Cialis), and
and confidence (12).
Vardenafil (Levitra) approached $1.48 billion in 2007
Compared with placebo, Sildenafil has been shown
ED may result from variety of psychological and/or
to improve erections (74% versus 21%) (18) and results
organic causes including vascular, neurogenic,
in more frequent intercourse attempts (57% versus 21%)
hormonal, anatomic and drug-induced conditions. A
normal sexual erectile response results from the
Approximately one third of men with ED do not
interaction between neurotransmitters and vascular
respond to therapy with PDE5 inhibitors. In addition,
smooth muscle initiated by parasympathetic and
these agents are not effective for improving libido (20).
sympathetic neuronal triggers that combine physical
The three PDE5I are considered to be somewhat
stimulation of the penis with sexual perception and
similar in effectiveness, but there are differences in
desire. Nitric oxide produced from endothelial cells after
dosing, onset of action, and duration of therapeutic
parasympathetic stimuli triggers a molecular cascade
that results in smooth muscle relaxation and arterial
The standard dose for Sildenafil is 50 to 100 mg
influx of blood into the corpus cavernosum. Then,
daily. Recommended time between onset of dosing and
compression of venous return occurs, and an erection
intercourse is one hour. Drug action starts in 14 to 60
minutes and drug duration extends for up to four hours.
Tadalafil and Vardenafil dose is 10 to 20 mg daily.
History taking and physical examination
Although the duration of action in Vardenafil and
In a patient with SCI, history and physical
Sildenafil are similar, the duration of action for Tadalfil
examination are adequate in making an accurate
is up to 36 hours.
diagnosis of ED in most cases. Sexual history should
There are no conclusive data to suggest that one
focus on erection adequacy, altered libido, quality and
PDE5I is better than others. An open-label trial
timing of orgasm, volume and form of ejaculate,
established that patients preferred Tadalafil and
presence of sexually-induced genital pain or penile
Vardenafil over Sildenafil (22). However, nearly all
curve and partner sexual function.
evidence supports equal efficacy between Sildenafil and
The physical examination should evaluate blood
pressure and heart rate; body habitus, for central obesity;
Headache is the most frequently reported side effect
and cardiovascular, neurologic, and genitourinary
of PDE5Is, occurring in roughly 10% of patients.
systems, including penile, testicular, and digital rectal
PDE5Is should not be taken simultaneously with nitrates
because this may lead to a synergistic effect, resulting in
a potentially severe, even lethal, decrease in blood
Laboratory workup is not initially necessary in SCI
The most frequent predictor of success for PDE5I is
patients. However, if the first line of treatment for ED is
upper motor neuron (UMN) lesion. Most patients
296 Acta Medica Iranica, Vol. 50, No. 5 (2012)
V. Rahimi-Movaghar and A. R Vaccaro
tolerate these medications well, and in a meta-analysis,
those taking anticoagulants. The worst complication of
only 1% of patients discontinued their PDE5I. However,
constriction devices in SCI patients with loss of penile
PDE5Is had no positive effect on ejaculation except in
sensation would be ischemic gangrene of penis.
Third line: Surgically implanted penile prostheses
When first and second line therapies have failed,
There is a limited indication for testosterone in SCI
surgical implantation of an inflatable penile prosthesis
patients. Testosterone supplementation in men with
can be considered in consultation with an urologist
hypogonadism improves ED and libido but requires
(31,32). There is a 16.7% complication rate associated
interval monitoring of hemoglobin, serum transaminase,
with penile prostheses, which include wound infections,
and prostate-specific antigen levels because of an
penile pain due to excessive prosthesis length, and
increased risk of prostate adenocarcinoma (25,26).
displeasure due to the partner's abnormal sensation (33).
Intracavernosal pressure and PDE5 activity are
androgen-dependent. The prevalence of hypogonadism
Fourth line: Sacral neuromodulation (SNM)
in men with ED is estimated to be 5 to 10 percent (27).
The fourth line of treatment can be SNM, which can
In men with hypogonadism, testosterone is superior
be performed in patients with complete SCI in detrusor
to placebo in improving erections and sexual function.
atonic phase 2-3 months after SCI (34). This minimally
Response rates are higher in primary versus secondary
invasive surgical operation can be performed under local
testicular failure. Testosterone is also associated with
anesthesia. It involves insertion of an electrode in each
improved satisfaction with erectile function and sexual
S3 root, using anal sphincter contraction following
stimulation to determine correct placement. Sievert et
performed the procedure in 10 patients and 6
Second line treatment
controls and showed the procedure prevented detrusor
Intracavernous and intraurethral injection of
overactivity and urinary incontinence, ensured normal
Papaverine, intraurethral prostaglandins (29), and
bladder capacity, reduced urinary tract infection rates,
vacuum constriction devices are alternative therapeutic
and improved bowel and erectile functionality without
options when PDE5Is fail. Much lower doses of
nerve damage (34).
intracavernous injection is prescribed in SCI patients
than those who have vasculopathies (29). Intra-
Cognitive behavioral therapy
cavernosal Papaverine is more effective, better tolerated,
Cognitive behavioral therapy aimed at improving
and preferred by men over the intraurethral form. There
relationships may help to improve ED (35). Education
is a danger for prolonged erection (priapism), which is a
about medical and psychosocial etiologies of ED in
medical emergency. Priapism is most frequently treated
combination with physician assurance may help patients
with aspiration of blood from the corpus cavernosum. If
return to normal male sexual function.
this treatment is inadequate, then intra-cavernosal
Screening for cardiovascular risk factors should be
injections of Phenylephrine should be performed with
considered in men with ED because symptoms of ED
hemodynamic monitoring. There is similar efficacy for
present on average three years earlier than symptoms of
intracavernosal Papaverine and oral PDE5I Sildenafil
coronary artery disease. Men with ED are at increased
risk of vascular diseases (36).
Vacuum constriction devices
Management of anejaculation
Some patients refuse vacuum constriction devices
Semen retrieval is necessary in the management of
treatment due to negative cultural perceptions, minor
anejaculatory patients hoping to conceive and can be
complications such as ecchymoses or petechiae, and
performed by penile vibratory stimulation,
lack of motivation. However, vacuum constriction is a
electroejaculation, prostate massage, and surgical sperm
reasonable, safe, and noninvasive alternative, and
retrieval, Intravaginal insemination, intrauterine
possibly a better initial treatment for the management of
insemination (pregnancy rate 28.6% per couple), and in
impotence secondary to SCI.
fertilization (pregnancy rate of 68.75% per couple)
Vacuum constriction is a noninvasive second-line
can all be used (37). Intracytoplasmic sperm injection
option and has minor side effects. It is contraindicated in
can be required if there is a low total motile sperm
men with sickle cell anemia or blood dyscrasias and in
Acta Medica Iranica, Vol. 50, No. 5 (2012) 297
Management of sexual disorders in spinal cord injured patients
Priapism might be seen in SCI males. Corporal blood
11. Brackett NL, Ibrahim E, Iremashvili V, Aballa TC, Lynne
gas measurement is recommended to confirm non-
CM. Treatment for ejaculatory dysfunction in men with
ischemic priapism. Intracorporeal phenylephrine is used
spinal cord injury: an 18-year single center experience. J
for priapism treatment. Spontaneous resolution might
happen within 5 hours (38).
12. Bacon CG, Mittleman MA, Kawachi I, Giovannucci E,
Detrusor-external sphincter dyssynergia (DSD) is
Glasser DB, Rimm EB. Sexual function in men older than
seen in SCI patients. DSD is a debilitating problem and
50 years of age: results from the health professionals
even life expectancy can be affected. This can be
follow-up study. Ann Intern Med 2003;139(3):161-8.
managed with urethral stents and botulinum toxin
13. McVary KT, Kaufman J, Young JM, Tseng LJ. Sildenafil
injection. First line treatment is the use of antimuscarinic
citrate improves erectile function: a randomised double-
medication and catheterization. External sphincterotomy
blind trial with open-label extension. Int J Clin Pract
is the surgical option in refractory cases. However, it can
lead to ED (39).
14. Montague DK. Penile prosthesis implantation for end-
stage erectile dysfunction after radical prostatectomy. Rev
Urol 2005;7 Suppl 2:S51-7.
15. Esposito K, Giugliano F, Di Palo C, Giugliano G, Marfella
1. Rahimi-Movaghar V. Efficacy of surgical decompression
R, D'Andrea F, D'Armiento M, Giugliano D.
in the setting of complete thoracic spinal cord injury. J
lifestyle changes on erectile dysfunction in obese men: a
Spinal Cord Med 2005;28(5):415-20.
randomized controlled trial. JAMA 2004;291(24):2978-84.
2. Rahimi-Movaghar V, Vaccaro AR, Mohammadi M.
16. Vardi M, Nini A. Phosphodiesterase inhibitors for erectile
Efficacy of surgical decompression in regard to motor
dysfunction in patients with diabetes mellitus. Cochrane
recovery in the setting of conus medullaris injury. J Spinal
Database Syst Rev 2007;(1):CD002187.
Cord Med 2006;29(1):32-8.
17. Modern Medicine Network. Drug Topics. Top 200 brand
3. Blumer CE, Quine S. Prevalence of spinal cord injury: an
drugs by retail dollars in 2007. [Internet] 2008 Mar 10
international comparison. Neuroepidemiology
[cited 2012 Mar 15]; Available from:
4. Wyndaele M, Wyndaele JJ. Incidence, prevalence and
epidemiology of spinal cord injury: what learns a
worldwide literature survey? Spinal Cord 2006;44(9):523-
18. Burls A, Gold L, Clark W. Systematic review of
randomised controlled trials of Sildenafil (Viagra) in the
5. Rahimi-Movaghar V, Saadat S, Rasouli MR, Ganji S,
treatment of male erectile dysfunction. Br J Gen Pract
Ghahramani M, Zarei MR, Vaccaro AR. Prevalence of
spinal cord injury in Tehran, Iran. J Spinal Cord Med
19. Stuckey BG, Jadzinsky MN, Murphy LJ, Montorsi F,
Kadioglu A, Fraige F, Manzano P, Deerochanawong C.
6. Rahimi-Movaghar V, Moradi-Lakeh M, Rasouli MR,
Sildenafil citrate for treatment of erectile dysfunction in
Vaccaro AR. Burden of spinal cord injury in Tehran, Iran.
men with type 1 diabetes: results of a randomized
Spinal Cord 2010;48(6):492-7.
controlled trial. Diabetes Care 2003;26(2):279-84.
7. Taghipoor KD, Arejan RH, Rasouli MR, Saadat S,
20. Goldstein I, Lue TF, Padma-Nathan H, Rosen RC, Steers
Moghadam M, Vaccaro AR, Rahimi-Movaghar V. Factors
WD, Wicker PA. Oral sildenafil in the treatment of erectile
associated with pressure ulcers in patients with complete or
dysfunction. Sildenafil Study Group. N Engl J Med
sensory-only preserved spinal cord injury: is there any
1998;338(20):1397-404. Erratum in: N Engl J Med
difference between traumatic and nontraumatic causes? J
Neurosurg Spine 2009;11(4):438-44.
21. Brant WO, Bella AJ, Lue TF. Treatment options for
8. Sipski ML. The impact of spinal cord injury on female
erectile dysfunction. Endocrinol Metab Clin North Am
sexuality, menstruation and pregnancy: a review of the
literature. J Am Paraplegia Soc 1991;14(3):122-6.
22. Tolrà JR, Campaña JM, Ciutat LF, Miranda EF.
9. Patki P, Woodhouse J, Hamid R, Craggs M, Shah J.
Prospective, randomized, open-label, fixed-dose, crossover
Effects of spinal cord injury on semen parameters. J Spinal
study to establish preference of patients with erectile
Cord Med 2008;31(1):27-32.
dysfunction after taking the three PDE-5 inhibitors. J Sex
10. Heidelbaugh JJ. Management of Erectile Dysfunction. Am
Fam Physician 2010;81(3):305-12.
298 Acta Medica Iranica, Vol. 50, No. 5 (2012)
V. Rahimi-Movaghar and A. R Vaccaro
23. Rubio-Aurioles E, Porst H, Eardley I, Goldstein I;
incontinence and sexual disability of patients with spinal
Vardenafil-Sildenafil Comparator Study Group.
cord injury. Paraplegia 1986;24(5):307-10.
Comparing vardenafil and sildenafil in the treatment of
32. Kimoto Y, Iwatsubo E. Penile prostheses for the
men with erectile dysfunction and risk factors for
management of the neuropathic bladder and sexual
cardiovascular disease: a randomized, double-blind, pooled
dysfunction in spinal cord injury patients: long term follow
crossover study. J Sex Med 2006;3(6):1037-49.
up. Paraplegia 1994;32(5):336-9.
24. Lombardi G, Macchiarella A, Cecconi F, Del Popolo G.
33. Kim YD, Yang SO, Lee JK, Jung TY, Shim HB.
Ten years of phosphodiesterase type 5 inhibitors in spinal
Usefulness of a malleable penile prosthesis in patients with
cord injured patients. J Sex Med 2009;6(5):1248-58.
a spinal cord injury. Int J Urol 2008;15(10):919-23.
25. Jain P, Rademaker AW, McVary KT. Testosterone
34. Sievert KD, Amend B, Gakis G, Toomey P, Badke A,
supplementation for erectile dysfunction: results of a meta-
Kaps HP, Stenzl A. Early sacral neuromodulation prevents
analysis. J Urol 2000;164(2):371-5.
urinary incontinence after complete spinal cord injury. Ann
26. Rhoden EL, Morgentaler A. Risks of testosterone-
replacement therapy and recommendations for monitoring.
35. Melnik T, Soares BG, Nasselo AG. Psychosocial
N Engl J Med 2004;350(5):482-92.
interventions for erectile dysfunction. Cochrane Database
27. Earle CM, Stuckey BG. Biochemical screening in the
Syst Rev 2007;(3):CD004825.
assessment of erectile dysfunction: what tests decide future
36. Thompson IM, Tangen CM, Goodman PJ, Probstfield JL,
therapy? Urology 2003;62(4):727-31.
Moinpour CM, Coltman CA. Erectile dysfunction and
28. Boloña ER, Uraga MV, Haddad RM, Tracz MJ, Sideras K,
subsequent cardiovascular disease. JAMA
Kennedy CC, Caples SM, Erwin PJ, Montori VM.
Testosterone use in men with sexual dysfunction: a
37. Heruti RJ, Katz H, Menashe Y, Weissenberg R, Raviv G,
systematic review and meta-analysis of randomized
Madjar I, Ohry A. Treatment of male infertility due to
placebo-controlled trials. Mayo Clin Proc 2007;82(1):20-8.
spinal cord injury using rectal probe electroejaculation: the
29. Linsenmeyer TA. Treatment of erectile dysfunction
Israeli experience. Spinal Cord 2001;39(3):168-75.
following spinal cord injury. Curr Urol Rep
38. Gordon SA, Stage KH, Tansey KE, Lotan Y. Conservative
management of priapism in acute spinal cord injury.
30. Yildiz N, Gokkaya NK, Koseoglu F, Gokkaya S, Comert
D. Efficacies of papaverine and sildenafil in the treatment
39. Ahmed HU, Shergill IS, Arya M, Shah PJ. Management of
of erectile dysfunction in early-stage paraplegic men. Int J
detrusor-external sphincter dyssynergia. Nat Clin Pract
Rehabil Res 2011;34(1):44-52.
31. Iwatsubo E, Tanaka M, Takahashi K, Akatsu T. Non-
inflatable penile prosthesis for the management of urinary
Acta Medica Iranica, Vol. 50, No. 5 (2012) 299
O'Shaughnessy's • Winter 2015/16 —7— Cannabis in the Treatment of Pediatric Epilepsy By Bonni Goldstein, MD The author documents the progress of more than 100 patients using CBD-rich cannabis oil to treat seizure disorders. I have been a medical cannabis physician seeing adult tion they are going to give their child. They cannot give oil, the added expense of testing every bottle becomes pro-
IFS FOOD VERSION 5 IFS COMPENDIUM OF DOCTRINE ENGLISH VERSION CORRESPONDING TO THE ENGLISH VERSION OF THE IFS FOOD VERSION 5 © IFS, July 2008 Doctrine IFS version 5, July 2008 I. DOCTRINE The Doctrine Concept .4 1) Doctrine - definition:. 4 2) Goals of the IFS doctrine:. 4 3) Date of applicability: . 4