The Fourth Pan Arab Congress on Sexual Medicine
Transcription
The Fourth Pan Arab Congress on Sexual Medicine
The Fourth Pan Arab Congress on Sexual Medicine Cairo 26 - 28 February 2009 The Fourth Pan Arab Congress on Sexual Medicine Opening Lecture O1 Current perspectives for the treatment of female sexual disorders O2 Premature Ejaculation: 2009 Update John Dean Clinical Professor of Urology, University of California at San Francisco. Past President, International Society for Sexual Medicine President of the International Society for Sexual Medicine The diagnosis and treatment of female sexual disorders (FSDs) is challenging because of poorly-defined distinctions between normal and abnormal, a limited ability to integrate subjective and objective findings and an inability to incorporate contextual factors that play a significant role in sexual behaviour. The utility of current diagnostic systems, of which DSM-IV-TR is best-known and most widely-used have significant limitations in clinical practice; the very common situation of co-existence and interdependence of more than one DSM-IV-TR FSD diagnosis further complicates the situation for clinicians. Recent regulatory decisions and events affecting the development of FSD interventions have highlighted the lack of consensus with regard to clinically meaningful FSD outcomes, as well as shortcomings in a U.S. Food and Drug Administration draft document that provides the primary guidance for conducting FSD clinical studies. Cognitive-behavioural and couple-based approaches to treatment of specific FSDs, such as anorgasmia and vaginismus, are highly effective, but are of limited benefit to women with hypoactive sexual desire disorder (HSDD), sexual aversion disorder and other sexual pain disorders. Whilst the involvement of a specialist psychotherapist remains the optimum intervention, brief advice from other clinicians and the use of self-help programmes should not be ignored, particularly where social and cultural issues affect treatment planning. There have recently been important developments in pharmacotherapy. There is evidence from randomized controlled trials that androgen therapy improves the quality of the sexual experience for postmenopausal women with low libido, and preliminary data that this may also apply to premenopausal women. A transdermal testosterone preparation has been approved in Europe for the treatment of HSDD in surgically menopausal women. A new centrally-acting serotonin receptor modulator (5-HT1a agonist - 5-HT2a antagonist) for the treatment of HSDD, flibanserin, is currently in phase 3 clinical trial and appears to be a promising development, offering a non-hormonal approach to HSDD. Sexual pain disorders remain challenging to treat, although a systematic approach to diagnosis and an integrated, multi-modal approach to treatment seems to offer the best hope to affected women. A rare, new disorder has recently been described, Persistent Genital Arousal Disorder (PGAD, PSAD); it is debilitating and extremely distressing to affected women, and lack of professional awareness about its nature has resulted in poor outcomes. All physicians working in the field of Sexual Medicine should be aware of this condition, its possible causes, and its management. 16 Cairo 26 - 28 February 2009 Ira Sharlip Premature ejaculation (PE) is one of the most common forms of male sexual dysfunction. It occurs in 20-30% of men of all ages throughout the world. It is the most common sexual dysfunction in young and middle-aged men. There are about 500 million men worldwide who have this condition. Some men with PE are not bothered by it but about 25-50% of men with PE are distressed by the condition. It can produce significant personal and relationship problems. The International Society for Sexual Medicine (ISSM) has recently written an evidence-based contemporary definition of lifelong PE. ISSM defines PE as a male sexual dysfunction characterized by ejaculation which always or nearly always occurs prior to or within about 1 minute of vaginal penetration, and the inability to delay ejaculation on all or nearly all vaginal penetrations, and negative personal consequences such as distress, bother, frustration and/ or the avoidance of sexual intimacy. While there is no evidence base other than for lifelong PE, this definition probably applies also to men with acquired PE and to men whose sexual activities do not include vaginal penetration. While most men with PE have an intravaginal ejaculatory latency time of less about one minute, studies have identified that intravaginal ejaculatory latency time in men who do not have PE is 5-7 minutes or more. In the past, it was thought that the etiology of PE is predominantly psychological but there is mounting evidence that PE, especially lifelong PE, has a neurobiological basis. Current evidence suggests that abnormalities in serotonin metabolism, especially in certain key nuclei of the brainstem and hypothalamus, are involved with the mechanism of ejaculation and PE. There is also good evidence that these abnormalities have a genetic basis. Treatment of PE can based on psychological approaches, topical anesthetics and/or oral drugs. The value of psychotherapy has not been established by outcome studies but many pyschotherapists believe strongly that psychotherapy should be combined with pharmacologic therapy in most men with PE. Topical application of anesthetic agents such as lidocaine and/or prilocaine has been effective in a small number of small studies. A new topical anesthetic preparation which is rapidly absorbed through the skin of the glans penis is being developed and holds promise. Oral therapy with selective serotonin reuptake inhibitors (SSRI’s), originally developed for the treatment of depression, has also been quite effective using either on-demand or daily dosing schedules. The SSRI’s commonly used for PE are paroxetine, sertraline and fluoxetine. Well over 50% of men who use these drugs experience a significant improvement in PE. Side effects of SSRI’s used for the treatment of PE include dry mouth, nervousness, GI upset, headache, drowsiness, cognitive impairment, decreased libido and erectile dysfunction. A new short-acting SSRI called Dapoxetine The Fourth Pan Arab Congress on Sexual Medicine is also being developed specifically for the treatment of PE. Phase 3 studies of Dapoxetine have been completed and approval has been requested from , but not yet granted by, regulatory agencies in the European Union and elsewhere. O3 Sugary of Male Genitalia in Islamic Medicine Adel AL Dayel King Fahad Specialist Hospital, Dammam, KSA Islamic medicine is the Knowledge and practice of Medicine under the auspices of Islamic Culture which extended for more than ten centuries from 650 AD. Surgery was considered one of the healing arts, which was practiced by physicians. Muslim physician described many surgical procedures perform on male genital organs. This is a review of the main compendiums of Islamic medicine for the written details of the surgical procedures, its indications, patient preparations and management of complications. Cairo 26 - 28 February 2009 17 The Fourth Pan Arab Congress on Sexual Medicine Plenary Presentations PL1 Hypogonadism in Aging Men: An Update PL3 Risk Factors of Erectile Dysfunction Ahmed I. El-Sakka Lamin Samida Professor of Urology, Suez Canal University, Ismailia, Egypt and Al-Noor Specialist Hospital, Makkah, KSA Professor of Urology, Centre Tanit Medical .Avenue du Japon Montplaisir 1073- Tunis/ TUNISIA A decline in testicular function with a consequent decline in Testosterone level is recognized as a common occurrence in older men. The mechanisms of this phenomenon have not been fully uncovered, and are probably multi-factorial, involving the hypothalamic-pituitary-testicular axis. Despite the fact that androgen and ED are age-related events; a direct cause and effect relationship is not confirmed. Several studies had shown that the ED rates are higher in hypogonadic men and correction of testosterone level might be a pre-requisite before ED treatment. Recent studies provided convincing evidence that there is powerful effect of testosterone on the anatomical and physiological substrate of penile erection. Furthermore, it has become clear that testosterone is not only one of the so many factors playing a role in erectile (dys) function but is closely related to the manifestations of other etiological factors in ED, such as atherosclerotic disease, diabetes mellitus and metabolic syndrome. In this presentation we will address: • Definition of Hypogonadism • Effects of Hypogonadism • Aging and Hypogonadism: New Concepts • Testosterone and sexual function • Role of Androgens in Penile Tissue Development • Diabetes and Hypogonadism • Guidelines for Diagnosis and Management of Hypogonadism The erectile dysfunction (ED) constitutes a current medical problem that daily challenges the most urologists. In addition to the General Practitioner, the Urologist remain the practitioner the most called upon by patients suffering erectile dysfunction. This dysfunction is often associated to other pathologies and could occur at any age. Co-morbidities are usually LUTS and BPH, Cardio-vascular Diseases and AHT or Diabetes. That is how we undertook within the external Urological consultation a prospective and multicentered epidemiological survey of the masculine ED in TUNISIA. The objective of this Survey is to identify the risk factors by ED in the Tunisian urological environment for better attendance of these patients. PL2 Treatment with testosterone Amr El-Meliegy Professor of Andrology, Cairo University. Head of Andrology Unit, Soliman Fakeeh Hospital, Jeddah, KSA Hypogonadism in men represents a disease which leads to a marked decrease in quality of life and exposes the patient to further health risks. The clinical use of testosterone is substitution therapy of male hypogonadism. Testosterone preparations have been in clinical use for about sixty years. However, only within recent years has the physician been able to choose from a variety of preparations with variable duration of action and modes of delivery. Treatment with testosterone has to be accompanied by standardized surveillance particularly for older men. This talk is aimed at displaying the various testosterone preparations and the ways to monitor the treatment efficacy and safety and in particular the testosterone prostate sensitive issue. 18 Cairo 26 - 28 February 2009 PL4 Penile transplantation Rauf Seyam Professor of Urology, Faculty of Medicine, Suez Canal University, Ismalia, Egypt and Urologist, King Faisal Specialist Hospital & Research Center, Riyadh, KSA Early success of composite tissue allotransplantation is gaining attention from the medical community and the public. Penile allotransplantation might be a viable option for patients who need penile reconstruction. Basic questions need to be answered before contemplating clinical application. It is not known how allotransplantation and immunosuppression affect erectile tissue, urethra and penile growth. The rat is an economic animal in terms of availability, resistance to infection, ease of maintaining and small body weight. A more clinically relevant animal is the baboon. A successful autotransplantation animal model is a first step towards proceeding for allotransplantation. We herein describe autotransplantation following transaction of the penis in the rat and baboon. PL5 The relationship between the LUTS and erectile dysfunction. Ian Erdely Consultant Urologist, Leeds Teaching Hospital Trust. President, European Society of Sexual Medicine There is good epidemiological evidence of an age independent association between lower urinary tract symptoms (LUTS) and erectile dysfunction (ED). With the high prevalence of both sets of symptoms in elderly men, together with the potential use of PDE5 inhibitors for both sets of symptoms, a better understanding of the pathophysiological relationship between LUTS and ED is needed. To date, the relationship, if one exists, appears to be mediated via The Fourth Pan Arab Congress on Sexual Medicine vascular mechanisms. Research studies have suggested possible roles for nitric oxide, autonomic hyperactivity, rho-kinase and atherosclerosis in the pathophysiology of both conditions, although a conclusive relationship has not yet been proven. Further, there are clear psychological mechanisms that might relate to both sets of symptoms. Complicating factors include the multifactorial nature of the causes of both sets of symptoms. While ED might have a vascular cause, it can also be due to neuropathy, endocrinopathy, psychological problems or a number of other causes. Intriguingly, while we commonly think of LUTS as a male, prostate related, set of symptoms, we increasingly understand that many of the symptoms of LUTS actually relate to bladder dysfunction, and again this may be relevant to any possible pathophysiological link. At this time, PDE5 inhibitors are standard therapy for ED, but there are ongoing trials for the treatment of both LUTS and OAB, and as these indications come closer to the marketplace, it seem inevitable that our understanding of the mechanisms involved will increase. PL6 Erectile dysfunction form the female perspective Shereef Ghazy etiologies underwent genital reconstructive surgery, age of surgical reconstruction range from 2 to 28 yrs. The size of the phallus is the most important anatomical single factor that should be considered in sex assignment. Male genital reconstruction was accomplished in 49 patients while female genital reconstruction in 33 patients. The outcome was satisfactory in properly selected cases. Main complications of male genitoplasty were urethral fistulae and disruption, inadequate phallus and persistent penile curvature. Inadequate phenotypic appearance and vaginal stenosis were complications of female genital reconstruction. Early diagnosis and management of the sexual ambiguity is mandatory and it gives the best results. Female Pseudohermaphrodites should be reared up and reconstructed as females. Male Pseudohermaphrodites are better reconstructed as males especially those presenting in late childhood unless they have small phallus less than 5cm which is not uncommon. PL8 Management of penile curvature Hisham Badawy Professor of Urology, Cairo University Men and women have a different views and interest in sex. While men are more likely to focus on coitus and to consider their ability to have sex as synonyms to virility, women tends to focus on emotional aspects and to consider sex as part of their relationship with their partners. In case of erectile dysfunction the reaction of both partners is different and usually result in disruption of the relationship and decrease in both non-nonsexual and sexual intimacy activities. Decrease communication and lack of affection is reported to be the most important ED sequel by females but not males. Female sexual dysfunctions can be the result of and/or the predisposition to erectile dysfunction. Although presence of female partners in the clinic can contribute valuably to treatment of ED, still many factors make this difficult including the clinic’s setting, cultural factors, physician training and more importantly patient attitude. Many men in liberal and conservative societies do not wish to involve their partners in their treatment. Female attitude towards different available treatments varies between different cultures. Any treatment aimed for the treatment of ED should address the female partner needs and respect her perspectives. Normal elasticity and compliance of all tissue layers of the penis are critical for erectile function. Penile curvature arises when there is relative asymmetry of one or more aspect of these layers. Curvatures of the penis may be congenital or acquired. Congenital cases are usually associated with hypospadias and epispadias and constitute the majority of congenital curvatures. Isolated penile curvatures are not frequent with an incidence of 0.6%. These may be lateral, ventral or dorsal and are usually associated with a large penis. Acquired curvatures are theorized to be the result of trauma to the penis during intercourse. The trauma may be repetitive and develop over years as in Peyronie's disease or may be an acute buckling trauma followed by scarring as in overt fracture or subclinical fracture of the penis. Curvatures over 30 degrees are considered clinically significant and those over 60 degrees will definitely interfere with satisfactory sexual intercourse. Congenital curvatures usually respond to plication sutures with satisfactory long-term cosmetic and functional outcome. Grafting is reserved for the severe cases. On the other hand, in acquired fractures that require surgical repair, grafting with autologous or synthetic material is the mainstay of treatment. PL7 Surgical management of ambiguous external genitalia PL9 Impact of the metabolic syndrome on the management of erectile dysfunction. Amr Nouir Tarek Anis Professor of Urology, Ain Shams University. Professor of Andrology, Cairo University External genitalia which cannot be distinguished as male or female is considered to be ambiguous. There is wide range of ambiguity from clitoromegaly to minor degrees of hypospadias. Management of ambiguous genitalia is considered to be a clinical and surgical challenge. The principles of repair of ambiguous genitalia depends on an overall gender appropriate appearance, good sexual function, reproductive potential, stable gender identity, and psychological well being. Eighty two patients with genital ambiguity due to different Metabolic syndrome (MS) refers to the clustering of several cardiometabolic risk factors, including abdominal obesity, hyperglycemia, dyslipidaemia, and elevated blood pressure. The experts of the National Cholesterol Education Program Adult Treatment Panel III created one of the widely accepted definitions of MS in 2001. In this definition, abdominal obesity, high blood pressure, and high fasting blood glucose (FBG), high triglyceride (TG), and low high-density lipoprotein (HDL) cholesterol levels have been suggested as risk factors for MS. The presence of any three of the five factors has been defined as MS. Recent studies support the notion that these Professor of Andrology, Cairo University, Head of Andrology department, Samir Abbas Centers, KSA Cairo 26 - 28 February 2009 19 The Fourth Pan Arab Congress on Sexual Medicine metabolic abnormalities do indeed cluster beyond the effect of chance, and that a single factor may underlie the association. That insulin resistance and abdominal obesity, key components of this cluster, are also associated with perturbations in plasma adipokine levels, altered fatty acid metabolism, endothelial dysfunction, pro-coagulant state and systemic inflammation underscores the breadth and complexity of the patho-physiology of this clustering, which is still poorly understood. In addition to cardiovascular disease and diabetes, insulin resistance is also associated with a wide spectrum of clinical disorders, including polycystic ovary syndrome, non-alcoholic fatty liver disease, sleep-disordered breathing, hypogonadism, chronic kidney disease and certain cancers. The National Health and Nutrition Examination Survey 1999–2002 estimated the age-adjusted prevalence of MS in US adults aged 20 years and over to be 39.1%. Similar to erectile dysfunction, MS is more prevalent with increasing age, affecting half of adults aged 60 years and over. The prevalence of MS is increasing in parallel with population ageing and “epidemic” childhood obesity, which presents a challenging problem for the future. Many recent studies have demonstrated that erectile ED is more frequent in men with MS, and that the prevalence of ED among men with MS increases with the number of MS components. Endothelial dysfunction is considered the initial, inciting process of metabolic risk factor-induced ED and cardiovascular diseases. In a recent study, Suetomi et. al., demonstrated a negative Impact of MS on the responsiveness to Sildenafil in Japanese men. They reported a lower response rate for sildenafil in patients with MS, which was 40%, compared with 70% in general patients. The response rate significantly decreased as the number of MS components increased. Management of MS is aimed primarily at reducing longer-term risk of cardiovascular disease and diabetes. Current guidelines recommend initial focus on intensive therapeutic lifestyle interventions (such as increased physical activity, dietary modification and modest weight reduction) that address many of the metabolic risk factors in MS, including insulin resistance. Chronic use of PDE5 inhibitors to improve endothelial function may be a useful way to improve the response PDE5 inhibitors. PL10 Modern concepts in the pathophysiology and therapy of priapism Arthur Burnett Professor of Urology. Director, Basic Science Laboratory in Neurourology. Director, Male Consultation Clinic, Johns Hopkins Medical Institutions. The basic understanding of the pathophysiology of priapism has steadily evolved with significant progress achieved in recent years. The classic veno-occlusive hypothesis pertaining to ischemic priapism (hypercoagulable vascular state and increased blood viscosity) has given way to modern concepts of dysregulatory molecular mechanisms acting either at central or peripheral regulatory levels accounting for such clinical presentations. The pathophysiology of true nonischemic priapism is believed to have a trauma-induced causation, with formation of an arterio-sinusoidal fistula within the delicate vascular framework of the penis. A body of science has recently burgeoned indicating that aberrant signaling of the nitric oxide/cGMP/phosphodiesterase type 5 signaling pathway, which serves as the main erection mediatory system responsible for penile erection, constitutes a major 20 Cairo 26 - 28 February 2009 mechanism for priapism. According to this concept, tonically deficient nitric oxide (NO) actions in the penis, resulting from penile vasculopathy, produces a downregulated condition of PDE5 expression and activity. This condition refers to “NO imbalance” within the penis, and conceivably develops because of reduced endothelial NO bioactivity, impaired NO circulatory delivery, or oxidative stress effects occurring within the penis. Under this condition, cGMP (the product of NO signaling) is produced in low, steady state amounts, rather than at normative substantial levels, and because of this diminished signaling phosphodiesterase type 5 (PDE5) function is lowered according to cGMP-dependent feedback control mechanisms. Downregulated function of other molecular determinants of the erectile response in the penis may also occur by changes in their set points by feedback control mechanisms. Recurrent ischemic priapism then is a condition of uncontrolled penile erection occurring after sexual stimulation or nocturnal erectile activity in the absence of proper erection control mechanisms. New pathophysiologic insights regarding priapism can be expected to translate into innovative therapies for the condition as well. At an investigational level, PDE5 inhibitors used according to a strict therapeutic regimen have been applied to normatively regulate PDE5 function in the penis, re-establishing the erection regulatory basis of this enzyme. Early success has been shown in men presenting with recurrent ischemic priapism, including men with sickle cell disease-associated recurrent priapism. Randomized, placebo-controlled, blinded clinical trials are under way in this field, which may affirm the usefulness of this therapy. It is acknowledged that current therapies for priapism, in either its recurrent or major form, remain imperfect. Scientific research in this area may produce further insights that may truly lead to correction of the problem. In the meantime, standard therapeutic algorithms are appropriately followed in the attempt to preserve sexual function. PL11 Novel concepts in penile implant surgery John P. Mulhall Associate Professor of Urology. Director of the Sexual Medicine Program, and Director of Sexual Medicine Research Laboratory at Weill Medical College of Cornell University Penile implant surgery represents an excellent treatment strategy for men with erectile dysfunction, especially those who failed medical therapy or find such treatment unsatisfactory. While numerous device modifications have contributed to the longevity and ease of use of implants, there are several other strategies that can be used to maximize patient satisfaction. Assessment of patient satisfaction post-penile implant surgery is hampered by the absence of a validated penile implant specific satisfaction questionnaire. Mulcahy introduced the concept of salvage surgery for the infected penile implant several years ago and the results with this approach have proven to be excellent avoiding the gross penile shortening experienced by explant patients. Henry has shown that devices being removed for malfunction are colonized by bacteria within their biofilm and advocates a revision surgery washout a la Mulcahy to minimize postoperative implant infection. While a randomized controlled trial is awaited, there is a solid rationale for doing this. Sellers has suggested that the sue of a vacuum device for some time prior to penile implant surgery results in improved penile length which of course will translate into improved patient satisfaction. The Fourth Pan Arab Congress on Sexual Medicine Length loss is a significant concern of patients after penile implant surgery, yet there is exists robust data indicating that there is no length loss between immediately preoperatively and the 6-month postoperative time-point. Some patients complain of failure of the glans to engorge and we have used PDE5 inhibitor and the intra-urethral PGE suppository in such patients with improved satisfaction. This lecture will review these and other concepts in the management of the patient undergoing penile implant surgery. PL14 Changing Medico – Social "Norms" About Homosexuality Ashraf Fayez Professor of Andrology, Cairo University This lecture is an overview of the management of genital injuries. Simple injuries such as frenular tears can often be difficult to treat if repetitive and a frenular graft is sometime needed. Circumcision injuries are not uncommon, usually too much skin has been excised and skin grafting is needed. At other time a glans injury is apparent and in advanced cases will need a peudoglans fashioned using skin grafts. The commonest penile injury is a fractured penis, usually from violent sexual intercourse but also from cultural practices. The treatment of this is early debridement and repair of the tunical tear to prevent a penile deformity from occurring. Approximately 30% of patients may also have a urethral injury and so a pre-operative work up is mandatory. Less common penile injuries include suspensory ligament rupture and cavernosal injury, both presenting with delayed sexual dysfunction. For advanced trauma of penile amputation a trial of reattachment should always be attempted but often this is not possible and a delayed phalloplasty will be necessary. Testicular injuries are common, usually a blunt injury as a result of a kick or during sport. The signs are sometime subtle and any testicular rupture and viability will be picked up by an urgent Duplex ultrasound study so that a salvage procedure can be performed. For much of 20th century, homosexuality was considered a personality defect or a symptom of psychiatric illness. Traditional psychological theories and social theories were recently reinforced by many biological theories trying to explain the etio-pathogenesis of the disorder. In 1970s, homosexuality was removed from the American Psychiatric Association's list of mental disorders with the recognition that homosexuality is not pathologic. That point of view continued to the present and has gathered strength over the years. The concept of homophobia was developed in the 1970s to explain societal prejudice against homosexual individuals. Homophobia is also used to describe negative feelings among homosexual people, which hold them back from appropriate assertion of non-discriminatory treatment in society. Discrimination against homosexual individuals remains powerful even in Western society, and homosexual couples are not afforded the rights and protections available to heterosexuals. Recently, many Western communities are adopting antidiscriminatory constitutions, as part of the democratization process. In their opinion, “equality begins when we recognize that all of us have the right to be different”. Their most remarkable feature is the effort to change social norm under what they claim as “respecting differences” One part of their anti-discriminatory battle against homophobia is the change in regular definition of homosexuality and considering it as a normal human sexual variation. Moreover, terms like homosexual, gay, lesbian are being changed into Men who have Sex with Men (MSM) and Women who have Sex with Women (WSW). What is expected from “Changing socio-medical norms about homosexuality”? … To what destination we are heading? PL13 Management of Peyronie's disease PL15 Amelioration of Penile Fibrosis: Myth or Reality? Amr Jad Ahmed El Sakka Consultant Urology, Andrology & Male Infertility. Chairman of The Saudi Andrology Group. Professor of Urology, Suez Canal University, Ismailia, Egypt and Al-Noor Specialist Hospital, Makkah, KSA PL12 Management of genital trauma David J Ralph Consultant Urologist and Senior Lecturer, St Peter's Hospital and The Institute Of Urology, London, UK Peyronie`s disease is characterized by the development of circumscribed, dense, fibrous plaque toward which the erect penis ungulates. This plaque is characterized by an initial inflammatory reaction followed by fibrous scarring of the tunica albuginea and the areolar space between the tunica albuginea and erectile tissue. In some patients the fibrous plaque is extensive and involves the whole circumference of the penis, and the septum results in penile shortening or hour glass rather than angulation during erection. Also oral and intraleasional medication are of limited efficacy especially in well established disease also researches are promising, still surgical treatment should be considered only after failure of conservative measures and after at least one year of established disease. I will discuss different treatment methods available now the techniques, indications, advantages and disadvantages of the most popular operations that have been used for the treatment of Pyronie’s disease as will as the most recent techniques. The aim of this presentation is to address this interesting issue, can or cannot we ameliorate penile fibrosis? We will tackle this issue from its different aspects. Aging-related erectile dysfunction is characterized by a loss of smooth muscle cells (SMCs) and fibrosis in the corpora cavernosa, and functionally characterized by corporal veno-occlusive dysfunction. It has been postulated that these histologic changes in the aged corpora are caused by increased oxidative stress and/or other profibrotic factors that stimulate SMC apoptosis and collagen deposition. Other model of penile tunica albuginea fibrosis is Peyronie's disease, where the fibrosis is characterized by an increased collagen over cellular compartment. It is recently demonstrated that long-term treatment with PDE5A inhibitors could upregulate NOS2A expression via cGMP modulation, and thus contribute to SMC protection and ultimately ameliorate the functional and histological changes. The improvement of the SMC:collagen ratio is assumed to be due to Cairo 26 - 28 February 2009 21 The Fourth Pan Arab Congress on Sexual Medicine the antifibrotic effects of cGMP. It is known that cGMP acts as proproliferative or anti-proliferative agent according to the cell type. In addition, the oxidative stress and TGFB1 levels were not affected by PDE5I. cGMP is not a direct inhibitor of TGFB1 expression but does interfere with TGFB1 signaling both by blocking pSMAD 2 and 3 nuclear translocation or SMAD-induced gene expression and by the conversion of latent TGFB1 to its active form. The inhibition of TGFB1 expression by nitric oxide is not mediated by cGMP. In contrast to nitric oxide, cGMP is not a key modulator of oxidative stress, although it is possible that a PDE5I effect may be detected by markers of this process other than xanthine dehydrogenase. We can conclude that, although it seems challenging to reverse penile fibrosis, however recent researches had demonstrated promising results and probably paved the road to this dream comes true. PL16 Female Anorgasmia Omayma Idrees Professor of Ob Gyne, Cairo University Healthy sexuality is a topic that is coming to the forefront in our society after being closeted for decades. Yet female sexuality is less studied and less understood than male sexuality. Anorgasmia is the commonest female sexual dysfunction and in spite of that it did not receive much attention until relatively few years ago. It affects between 24 % & 37 % of women. Anorgasmia defined as persistent or recurrent inability to attain or maintain sufficient sexual excitement, causing personal stress, which may be expressed as a lack of subjective excitement or genital lubrication or other somatic responses. It can be divided into 1ry, in which a woman has never experienced orgasm through any means of sexual stimulation, 2ry, in which a woman is anorgasmic after a period of time when she was orgasmic, situational (e.g., when a woman can’t reach orgasm in certain situation) or randam anorgasmia. Causes of anorgasmia include; psychological factors, cultural factors, organic causes, stress and fatigue, depression or anxiety disorders & also may result from female physiological changes with her aging. Effective treatment for anorgasmia depends on its cause. Several approaches are available including pharmacological approach (vasoactive drugs & estrogen), treatment of dyspareunia, psychological approach and non specific measures that increase stimulation and minimize inhibition (sensate focus, sex therapy & education). PL17 Sexual Pain Disorders Amany Shaltout Associate Professor of Ob&Gyn ,Cairo University. Sexology Consultant, Dr Samir Abbas medical center ,Jeddah, KSA Sexual pain disorders affect women almost exclusively and include dyspareunia and vaginismus. Dyspareunia is the persistent or recurrent pain with attempted vaginal intercourse. In a general gynecologic practice population, the prevalence of dyspareunia may be as high as 15 percent. There are 3 types of dyspareunia: superficial or entry-pain (vulvodynia), vaginal pain and deep pain. Evaluation of a patient with dyspareunia requires attention to details during the history and physical examination. Often a treatable cause of dyspareunia is identified and resolution or improvement will be obtained following its treatment. 22 Cairo 26 - 28 February 2009 Vaginismus is the persistent or recurrent difficulties of the woman to allow vaginal entry of a penis, a finger and/or any object ,despite the woman’s expressed wish to do so. This is a conditioned response that results from associating sexual activity with pain and fear. It consists of a phobia of penetration of the vagina. Vaginismus may be primary (when a women has never experienced vaginal penetration),or secondary (when a woman has had vaginal penetration without a problem in the past). Why some women develop vaginismus and others do not is uncertain. The initial response may be secondary to any type of vaginal pain, including all causes of dyspareunia. Management includes sex education, self exploration of sexual anatomy, sex therapy and the use of vaginal trainers. The management of sexual pain disorders is not easy, the key point is “no size fits all”, accordingly management should be individualized and have a patient based approach, in which the patient shares in the decision about the modality of treatment. PL18 An Evidence-Based Perspective to Commonly Performed Erectile Dysfunction Investigations. Hussein Ghanem Professor of Andrology, Cairo University. PASSM General Secretary Introduction: Currently there is no universally accepted gold standard diagnostic test to differentiate psychogenic from physical erectile dysfunction (ED). Instead, sexual health specialists rely on a detailed history, a focused physical examination and specialized diagnostic tests to decide if the etiology of the ED is mainly psychogenic or organically caused. Objective: In this review we point out the status of evidence based principles in the area of diagnosis in Sexual Medicine Methods: We review the concepts of evidence-based medicine (EBM) in the area of medical diagnostic tests. We highlight four of the well-known diagnostic tests (penile duplex, pharmacoarteriography, pharmacocavernosometry/cavernosography [PHCAS/PHCAG] and nocturnal penile tumescence [NPT]) monitoring for ED evaluation within an evidence-based perspective. Conclusions: While penile duplex / color Doppler has good evidence of supporting its use in the diagnosis of arteriogenic ED, data supporting its diagnosis of a physical disorder associated with cavernous venous occlusion dysfunction are lacking. PHCAS/PHCAG’s main drawback is an unknown positive predictive value and a possibility of frequent false positive results. NPT has many advantages when differentiating psychogenic from organic ED, however, several questions related to its physiological mechanisms do exist. The Fourth Pan Arab Congress on Sexual Medicine Commonly Performed ED Investigations Test Main Benefits Limitation Questionnaires Easy to administer Do not diagnose the Etiology of ED Color duplex Ultrasonography Tested against a (historic) gold standard Unknown PPV for venogenic ED Diagnose severity of ED Well tested and validated Suggest arteriogenic or ‘venogenic ED Might predict other vascular disease (e.g. CAD) Anxiety/sympathetic overtone might lead to false +ve results Redosing & retesting may be needed Pharmaco-Arteriography Delineates arterial anatomy before arterial Invasive Pharmaco-Cavernosometry / Diagnose ‘venogenic ED Moderately invasive Cavernosography reconstructive surgery in post-traumatic cases Demonstrates site of leak & cavernosal abnormalities Results influenced by methodology and timing Error Margin 20% Unknown PPV Anxiety/sympathetic overtone might lead to false +ve results NPT testing Closest to a gold standard to differentiate organic (physical) from psychogenic ED Sexually stimulated erections might be regulated by different pathways Physical disorders might alter NPT even in Psychogenic ED Axial rigidity might differ from radial rigidity Did not correlate well with IIEF domain scores Neurological Testing Assess somatic Pathways Do not directly assess autonomic nerve function No universally accepted and reproducible criteria Complex, time-consuming, Unknown PPF PL19 NAION and PDE5i an update Said Kattan Professor and Consultant of Urology, King Faisal Specialist Hospital and Research Center, Riyadh, KSA Phosphodiesterase type 5 inhibitors (PDE5i) are important medications that have been widely used with an excellent safety profile in pre-marketing and post-marketing studies. Non-Arteritic Anterior Ischemic Optic Neuropathy (NAION) is rare but an alarming condition that attracts the attention of patients, regulatory agencies, consumer advocates and media. The small number of reported cases does not support strong evidence that PDE5i cause NAION. However, the possibility that PDE5i precipitate NAION cannot be ruled out. Only prospective randomized studies with adequate number of patients can clarify the relation of NAION and PDE5i. For the time being patient education might be warranted. Physician must be vigilant towards history of visual problems and development of hypotension particularly in patients with risk factors for NAION. PL20 Post-radical prostatectomy erectile dysfunction Arthur Burnett Professor of Urology. Director, Basic Science Laboratory in Neurourology. Director, Male Consultation Clinic, Johns Hopkins Medical Institutions. In the modern era of prostate cancer management, the need exists for effective oncologic control while maximally preserving functional outcomes such as sexual function. Historically, interventions for prostate cancer have had a significant impact on the male sexual response including penile erection, ejaculatory function and orgasm, and sexual libido. This dilemma has causes patients to ponder the impact of various treatment approaches for prostate cancer since many place paramount importance on the opportunity for retaining natural erectile function afterwards. Specialists in this field have sought to optimize techniques associated with therapy such as cavernous nerve-sparing radical prostatectomy and conformal pelvic radiation therapy to limit sexual dysfunction complications, but current studies still find that such interventions do not fully overcome their toll in this regard. In addition to optimization techniques, therapeutic strategies are applicable to address these concerns. Current treatment approaches for post-intervention erectile dysfunction include pharmacotherapeutic options such as oral pills, intraurethral suppositories, and intracavernosal injections and nonpharmacotherapeutic options such as mechanical vacuum constriction devices and penile prosthetic surgery. Counseling intervention for prostate cancer survivors and their partners may also offer therapeutic benefit. With particular attention given to erectile dysfunction management, new directions in this field revolve around innovative strategies such as erection rehabilitation and neurobiologic therapies, derived from Cairo 26 - 28 February 2009 23 The Fourth Pan Arab Congress on Sexual Medicine an increasingly scientific understanding of the basis of erection physiology. Such strategies are designed specifically to preserve the integrity of the structures involved in penile erection and restore their biological function. Active investigation is being carried out at both clinical and preclinical levels to develop treatments which will better address sexual dysfunction following prostate cancer treatments and maximally preserve quality of life. PL21 The Small Penis syndrome Ian Erdely Consultant Urologist, Leeds Teaching Hospital Trust. President, European Society of Sexual Medicine The male is often troubled by concerns that his penis is not large enough to satisfy his partner or himself. He is ashamed to have others view his penis, especially in the flaccid state. Such concerns might be unfounded in reality and might be a presentation of social anxiety or some other clinical problem, such as erectile dysfunction. Concern over the size of the penis, when such concern becomes excessive, might present as the ‘small penis syndrome’, an obsessive rumination with compulsive checking rituals, body dysmorphic disorder, or as part of a psychosis. However, it is often a worry that can be described as within the normal experience of many men. Various potential causal factors are considered. It is recommended that the initial approach to a man who has SPS is a thorough urological, psychosexual, psychological and psychiatric assessment that might involve more than one clinician. More research is required on the effects of race and age on penile length. Conservative approaches to therapy, based on education and self-awareness, as well as short-term structured psychotherapy (CBT) are often successful, and should be the initial interventions in all men. Of the physical treatments available, there is poorly documented evidence to support the use of penile extenders. More information is need on the outcomes with these devices. Similarly, there is emerging evidence about the place of surgery and there are now several reports suggesting that dividing the suspensory ligament can increase flaccid penile length. There are only limited data relating to operations designed to enhance penile circumference. While there are emerging data about the effect of surgical treatment on penile dimensions, there is much less information about the patients’ satisfaction with the outcome of surgery. Such assessments have only been reported occasionally, and in a situation where surgery is used cosmetically to treat a psychological condition, such outcomes are vital to assess the place of such surgery. PL22 Management of PDE5 inhibitors non responders Bahgat Metawei Professor of Andrology Cairo University. PASSM Founder Although world wide clinical studies have proved the efficacy of PDE5 inhibitors in the treatment of the majority of ED patients, still non responders constitute a considerable clinical problem. Most of the real PDE5 I non responders proved to have a sever penile arterial or veno-occlusive disorders. Treatment of concomitant disease e.g. diabetes, hypertension, hypercholesterolemia or combination of testosterone in partial androgen deficiency has synergistic effect and can help many of 24 Cairo 26 - 28 February 2009 the non responders. Also re-counseling or shifting from one type of PDE5 I to another may also help some of those non responders. Again the chronic daily use of PDE5I or combination with other drugs e.g. ICI alprostadil and vacuum therapy rescue other patients. PL23 The benefit of testosterone administration to men not responding to PDE-5 inhibitors: State of the art Aksam A. Yassin Professor of Urology & Human Sexuality, Chairman Institute of Urology and Andrology, Segeberger Kliniken, Norderstedt-Hamburg - Germany Introduction: Delivery of the phosphodiesterase type 5 inhibitors (PDE 5-inhibitors) has been a step forward in the treatment of erectile dysfunction. The success of the PDE 5-inhibitors rendered androgens as treatment for erectile problems in the average patient as something of the past. Methods: Over the last 15 years the age-related decline of circulating testosterone in men has received serious attention. Moreover, new research has presented convincing evidence that testosterone has profound effects on tissues of the penis involved in the mechanism of erection and that testosterone deficiency impairs the anatomical and physiological substrate of erectile capacity, at least in part reversible upon androgen replacement. Results: There are androgen receptors in the human corpus cavernosum. The expression of nitric oxide (NO) synthesis is regulated by androgens. Several studies show that androgen plays a critical role in restoring and maintaining the penile trabecular smooth muscle structure and function as well as regulating the cell apoptosis. Testosterone deficiency induces both biological and structural/functional changes in the trabecular cavernosal tissues. Adipocyte accumulation in penile subtunical area of the corpus cavernosum emphasized the potential mechanism for venoocclusive dysfunction in androgen deficiency. Conclusion: So, in androgen-deficient men, testosterone may restore the anatomical/biochemical substrate on which the PDE-5 inhibitors act. The above argues for measurement of testosterone in men with complaints of erectile dysfunction. Several studies, including our own, show that testosterone treatment alone, or in addition to PDE-5 inhibitors, may restore erections in these men. PL 24 Conservative surgery for penile cancer David J Ralph Consultant Urologist and Senior Lecturer, St Peter's Hospital and The Institute Of Urology, London, UK Penile cancer is a rare malignancy which presents in 300 patients per year in the UK. A 2 cm clearance of the primary tumour has previously been recommended, which has usually meant a partial penile amputation with the resultant sexual and urinary difficulties. Newer techniques have now been developed to preserve penile length and function and without compromising local control.The majority of tumours are distally based and depending on the stage and grade penile preservation is usually possible. Carcinoma in situ and Ta lesions are now treated by total glans resurfacing with the use of skin grafts. More invasive lesions that do not involve the tunica can be treated by a glansectomy with peusdoglans formation. Even with tunical invasion local excision with tunical reconstruction with synthetic substitutes and be performed. Although local recurrence rates of approximately 10% can be expected this can be dealt with easily and without a change in life expectancy. The Fourth Pan Arab Congress on Sexual Medicine Podium Presentations P1 Functional outcome of colpoplasty using sigmoid colon Amr Noweir, Ehab A Eltahawy. Cairo, Egypt. Urology Department Ain Shams University, Cairo-Egypt INTRODUCTION AND OBJECTIVE: Different replacement procedures are available for vaginal substitution either as tubularised grafts or from local flaps. The sigmoid colon offers a readily available well vascularised tissue that is functionally appealing as it has a wet surface. METHODS: 38 patients were evaluated during 1988 to 2006. 18 patients were genetic females with congenitally absent vagina (Rokitanski syndrome), or had traumatic or iatrogenic injury that resulted in small vagina. 20 patients were genetic males with ambiguous genitalia, decision was made for genital feminization. Preoperative pelvic CT, and colon preparation was done in all cases. A segment of the sigmoid colon 10-15 cm was harvested, and primary Closure of the colon was done. A plane between the bladder and the colon was developed starting perineally, then continued from the abdomen. The proximal end of the neovagina was closed and fixed to sacrum, in one patient this was anastomosed to the uterus. The distal end was anastomosed to the introitus. A vaginal pack was left for 10 days. RESULTS: Mean age was 22 years (12-42), mean follow up was 14 months (6-38). In all patients an adequate size neovagina was achievable. 12 patients are sexually active. 15 patients developed introital narrowing and use regular dilatation, 8 patients required introital incision. 2 patients had prolonged ileus that resolved spontaneously. One patient presented with acute abdomen due to ruptured neovagina and was explored for repair. CONCLUSIONS: The use of pelvic colon in vaginal reconstruction has several advantages. It is available, wet, and adequate size can be reconstructed. Patient satisfaction was high with this technique, though some patients need frequent introital dilatation. P2 Parylene coating improves mechanical survival of AMS 700 CX penile prosthesis Emad Salem, John Delk, Mario Cleves, Steven Wilson Urology department - Zagazig university Introduction: Parylene coating was added to AMS 700 CX penile prosthesis cylinders beginning January 2001. The coating was placed on non-tissue contacting surfaces to increase lubricity, reduce friction and silicone wear Aim: is to compare mechanical reliability of the original and parylene enhanced AMS 700 CX Methods: This study was conducted on of 775 implant surgeries (596 virgin and 179 revisions). Revision free survival was estimated using the Kaplan-Meier product limit method and compared using the log rank test. Main outcome measures: Mechanical survival from (fluid leakage, cylinder or tubal breakage, pump or reservoir defects) was estimated Results: For the entire series (virgin + revised) the 3 year revision free survival for any cause improved from 78.6 % for non-coated to 87.4 % for the parylene coated implants. Freedom from mechanical breakage showed similar improvement from 89.2 % for the noncoated to 97.5 % for enhanced models. Conclusions: This study documents that mechanical reliability is significantly increased with parylene coated AMS CX cylinders compared to the earlier model with non-coated cylinders P3 Penile Augmentation and Reconstruction Alexander Krakovsky MD, PhD, DrSc, FAAPS American Academy of Phalloplasty Surgeons Objective: Historically, men have considered a larger penis to be a symbol of greater masculinity. In our time, the erect penis has become the most powerful of a man’s symbolic “muscles.” Despite this lack of acceptance by the society, many men undergo surgical penile augmentation and reconstruction (phalloplasty) to enhance the length, girth, and glans of their penises. Materials and Methods: A total of 374 phalloplasty surgeries performed using AlloDerm® were evaluated. Single augmentation includes girth enhancement only; combination augmentation include dual augmentation (lengthening and girth enhancement combine) and triple augmentation (lengthening, girth enhancement and glanular enhancement combine.) AlloDerm is a cadaveric acellular tissue regeneration matrix that is minimally processed to remove epidermal and dermal cells, while preserving the structure of the dermis. Results: 97.2% of patients successfully went through surgery and postoperative period without any complications. 3.24% of patients developed surgical complications that were successfully treated medically and surgically. 4.9% of patients experienced localized swelling 3-7 days after surgery that resolved spontaneously and 7.3% of patients reported temporary post surgical retraction that were successfully treated medically and surgically. Discussion: Today a man can modify the size and shape of his penis using procedures introduced by cosmetic/plastic surgery. With the use of AlloDerm, these changes could be considered almost permanent. Permanent penile enlargement and reconstruction surgeries are the surgeries that do not require maintenance of the desired size or shape after surgery, through additional grafting. The dermal fat graft, or DFG (a graft made from the patient’s own skin) and AlloDerm (a graft created from cadaver skin) are the two types of grafts that offer permanent penile enlargement and reconstruction. Conclusion: The patient’s satisfaction was analyzed using the Penis Image Assessment Scale Questionnaire. The assessment was based upon questions related to the size of the penis, satisfaction of sexual experiences and the psychological perspective of the patient to his penis before and after surgery. The results showed a high satisfaction rate with a new surgical technique for penile augmentation (Penile Triple Augmentation TM) developed and used by the author. All surgical complications were successfully treated medically and surgically. Cairo 26 - 28 February 2009 25 The Fourth Pan Arab Congress on Sexual Medicine P4 Penile Prosthesis Insertion in Cases of Severe Penile Fibrosis Abdel Raheem A, Garaffa G, Spillings A, Christopher AN, Ralph DJ Institute of Urology, London, UK Aim : To present long-term results of the insertion of penile prosthesis in patients with severe penile fibrosis are presented. Materials and Methods : A penile prosthesis was inserted into 50 patients (mean age 43.4 yrs; range 22 -70yrs) who presented with extensive cavernosal fibrosis. The aetiology was post priapism (n=27), explantation of an infected penile prosthesis (n=14), perineal and penile trauma (n=6), extensive urethral reconstruction (n=1), abscess of the corpora (n=1) and Scleroderma (n=1). A 3 pieces inflatable prosthesis was inserted in 28 patients and a malleable prosthesis in 22 patients. The dilatation was often difficult due to advanced fibrosis but was managed with the use of Rossello cavernotomes in 26 patients and an additional subcoronal incision in 22 patients. In one patient the tip of one of the corpora had been destroyed by infection and therefore a Dacron cap was necessary to house the cylinder. Main Outcome Measures : The incidence of intra-operative, postoperative complications and patient satisfaction rate. Results : The majority of patients needed downsized cylinders (80%) due to the fibrotic corpora. The intra-operative complications included urethral perforation in 3 patients, managed by a delayed secondary operation, and cylinder cross over in 4 patients, 3 of which was recognized and immediately corrected. Despite of the intra-operative difficulties all patients had 2 cylinders inserted with a satisfaction rate of 90% after a median follow up of 17 months. Ten patients later had an elective exchange of their malleable to an inflatable penile prosthesis using an upsized cylinder in all patients with a mean increased length of 1.5 cm (range 0-3). The prosthesis was explanted in 5 patients (infection (3), erosion (2)) and revised in a further 4 patients (soft glans 1 and mechanical failure 3). Floppy glans was present in 6 patients; 1 was managed with glanspexy, the remainder conservatively (MUSE 1 and PDE5 inhibitors 4). Conclusions : The presence of dense fibrosis of the corpora is not a contraindication to the insertion of penile prosthesis, however patients must be warned that the complication rate is higher than in virgin patients (16%) and that revision surgery may be required (28%). P5 Total phallic reconstruction using the radial artery forearm free flap Garaffa G, Abdel Raheem A, Spillings A, Christopher AN, Ralph DJ Institute of Urology, London, UK Aim : This is a series of 35 consecutive men that had a total phallic reconstruction using the radial artery forearm free flap. Patients and Methods : The mean age was 39y (22-54). The indications for surgery were micropenis in 12 patients (Exstrophy 3, 5 alpha reductase deficiency 8, Robinow syndrome1) and following penile amputation in 23 patients (trauma=8, cancer=15). The procedure involves formation of the phallus from the non-dominant forearm with an incorporated neourethra and microsurgical vascular and nerve transfer. A primary urethral anastamosis was performed in 32 patients and a penile implant inserted into 12 patients so far. 28 Cairo 26 - 28 February 2009 The surgical outcome, complications and patients’ satisfaction were recorded. Results : After a mean follow up of 23 months (1-69), 100% of the patients are very satisfied with the phallus size and cosmesis. Currently 31 patients void through the urethral meatus, 3 have a Mitroffanoff stoma and 1 patient a suprapubic catheter awaiting revision. Urethral fistulae and strictures requiring surgical correction occurred in 34% of cases. Other complications included an arterial thrombosis requiring re-exploration in 1 patient, partial necrosis of the phallus requiring split skin grafts in 2 patients and penile implant explanation for infection in 2 patients. Conclusion : Forearm free flap phalloplasty yields excellent cosmetic and functional results for phallic construction. Despite multiple stages and revision surgery, the patient satisfaction is excellent. P6 T shunt with intracavernous tunneling for the management of refractory ischemic priapism Tarek Anis and Hussein Ghanem Department of Andrology, Cairo University Introduction: Refractory ischemic priapism is defined as painful penile erection that persists despite appropriate corporal aspiration and/or injection of sympathomimetic agents. It remains a difficult to treat and poorly understood phenomenon. The multitude of surgical shunt procedures that have been reported and used in the management of this condition lack reproducibility and reliable results using any of the established modalities. Clearly, there is a need for an improved procedure that can simply and reproducibly create a large shunt to drain the corpora cavernosa in cases of refractory ischemic priapism. The so called “T shunt” and its’ bilateral form, the “TT shunt” were developed at the University of California, San Francisco for this very purpose. For ischemic priapism of more than 3 days duration, the addition of bilateral intracavernous tunneling, the “TTT shunt,” will help to restore blood circulation to the entire corpora cavernosa despite severe tissue edema and cell death. Material and Methods: In this report we describe the management of a case of idiopathic refractory ischemic priapism of 32 days duration. The procedure is simple and straight forward and can be performed with local anesthesia in the emergency room or the clinic. The tip of the corpus cavernosum is palpated through the glans; typically this is not difficult as the glans remains soft in ischemic priapism and the firm corporal tips are easily felt through this tissue. After appropriate local anesthesia, a 10 blade scalpel is advanced through the glans tissue and into the ipsilateral corporal body. A 10 blade is preferred as a smaller blade will not create a sufficiently large shunt. The knife is then rotated 90 degrees laterally away from urethra and withdrawn. Typically there is a prompt efflux of dark, deoxygenated blood. The penis is then “milked” repeatedly to expel cavernous blood until there is noticeable lightening of blood expressed, suggestive of restoration of arterial blood flow. The wound is closed with a 4-0 chromic or 5-0 absorbable synthetic suture and observed for 10-15 minute. If rigid erection recurs, the procedure is repeated on the contralateral side. In cases of prolonged priapism (often of 3 or more days duration), tissue edema/death may make the fistula created with T shunt alone insufficient to restore circulation within the corporal bodies. In these cases it is necessary to perform corporal tunneling with a The Fourth Pan Arab Congress on Sexual Medicine 20-24 French dilator. For corporal tunneling, the dilator is advanced through the glanular incision and into the ipslilateral corporal body, using gentle pressure, as far as possible. Care is taken to direct the axis of the sound approximately 10 degrees lateral to the midline in order to minimize the chance of the dilator “crossing over” and potentially leading to urethral injury. Corporal tunneling should be performed bi-laterally. Results: The procedure resulted in restoration of arterial circulation and immediate relief of pain and unwanted erection. Conclusion: T shunt procedure alleviates pain in patients who have little to no hope of functional erectile recovery. We believe that the simplicity and efficacy of the T shunt procedure makes it the procedure of choice in the contemporary management of refractory ischemic priapism. P7 Augumentation Phalloplasty: Apical and pericavernousal penile implant Jamal Salhi and M. Del Prete Androclinic - Rome Introduction and objectives : The augmentation surgery of the penis has not yet solved the problem of the type of material to be used for the increase of the penile circumference, besides the persistence of perplexity and disrust toward this type of surgery burdened by complications and failures. The implant is comprised of three parts: the first is inserted at the tip of the cavernous bodies under the glans and for this is called “apical", the other two are specular lateral parts, right and a left, called "pericavernouse". The implant is constituted of a hemicilinder crescent section with flattened distal extremity. The apical portion of the implant is “ bean-shaped” and it is inserted between the distal surface of the cavernous bodies and the glans projecting it forward and laterally adding as well a certain increase to the length of the penis. The structure of this implant is composed from an external wrap ( multi-layer ) in biocompatible material filled by highly cohesive silicon gel . There are different sizes that can accomodate greate anatomical variations for total length, width, and thickness. Technique : The surgery is performed in day-hospital using regional anesthesia, with two small transversal incisions at the base of the glans, bilaterally. A pocket of sub-glandular lodging is prepared proceeding from the sides so as not to injure the dorsal neurovascular bundle and the urethra. After the insertion of the implant the glans is sutured to the corpora by interrupted stiches. For the pericavernous implant, a subfascial tunnel is prepared bilaterally for the whole length of the penis down to its root. The pericavernous prosthesis is fixed to the corpora cavernosa only distally. Results : From January 2002 up to December 2007, 112 patients between the ages of 21 and 54 have undergone augmentation phalloplasty with this new pericavernous implant. Only 7 of these patients received the apical implant in addition to the pericavernousal one, and in 3 cases the surgery was limited to the apical implant to resolve the problem of primary disproportion of glans and the volume of the penis. Infection occurred in two patients and was treated by explantation-reimplantation after six months Conclusions : This pericavernous implant responds to a demand for a simple and rapid procedure that can provide good and lasting aesthetical results without jeopardizing penile function. P8 The impact of the internet on the male/female sexual behavior Marizia Bonifacio CRP from Brazil and SBRASH Introduction. Men and women free of cultural values and religious, to experience sexual pleasure. Instruments: semi-structured interviews and questionnaires. Methods: Sample of 5000 adult, 2.500 men and 2.500 women, 30% single, 32% divorced, 38% marriage. Representativeness North America, Canada, Central America, South America, Europe, Asia and Africa. It was observed several disorders, including: dependence on the Internet 12 hours per day; occurrence of orgasms only when in contact with the computer; men presenting penile impotence; women with vaginal irritation and compulsion, aggression, need for new illusions, sado-masochism often for obtaining pleasure; real difficulties in relationships; sharp exchange partners; disruptions caused by the use of marriage and the internet Match and mismatch. Result: All respondents reported the occurrence of orgasm, via the Internet in specific rooms for sex, and the existence of the feeling of freedom. The Internet allows a world without borders. Everyone can feel sexual pleasure, regardless of cultural and religious values, but there are ethical and moral values, taxes per person and groups depending on the search directly aware inconsciente.Todos and make a dive in the dark's own emotional history, causing surprises, questioning and denial of attitudes. Enter in hole dark. Relacionship fragile, accommodated, old. Breaking of paradigm. If allow living new emotions. If allow feel without responsibility without possession, without possess. The mirror of soul. Perversion and perverted. Without handcuffs, Free to feel. Intolerance for recoveries. Game power and control. To be criate. To be more motivation. Ilusion of LOVE.Making to perform fantasies, NEUS diseases by sleeping little, high anxiety, depression, deviations and sexual dysfunctions were aspects observed. The interaction through the Internet, allows self knowledge, freedom of expression of innermost desires and never before manifests. There is a catharsis without professional monitoring. It may be good in the short term and bad in the long term. The sexual instinct without the limits imposed by the moral and ethical values arising from the culture and religion, the imbalance generate spiritual, emotional and physical, leading the individual to the existential chaos, the madness, disease and various kinds of deviations. The interaction through the Internet, allows self knowledge, freedom of expression of innermost desires and never before manifests. There is a catharsis without professional monitoring. It may be good in the short term and bad in the long term. The sexual instinct without the limits imposed by the moral and ethical values arising from the culture and religion, the imbalance generate spiritual, emotional and physical, leading the individual to the existential chaos, the madness, disease and various kinds of deviations. Cairo 26 - 28 February 2009 29 The Fourth Pan Arab Congress on Sexual Medicine Cultural influence can change the perception of pleasure and social acceptance, but on the Internet, where there is no interest in life to have two, these influences are not significant. The construction of knowledge clearly shows that sex is sex and love is amor.Na Internet, the individual can live the sexual pleasure of genuine independent responsibilities determined by internalized the values of viver.Também soon realizes is pronounced individualism, selfishness, the sexual masturbation is enough, because it is only virtual sex masturbation shared. The lack of control, is generating psychophysical imbalance, causing decline in school performance and bad production on the desktop (job). P9 ENT Problems and Peyronie’s Disease: A New Risk Association Onder Canguven, Sena F. Sezen, Bruce Trock, and Arthur L. Burnett The James Buchanan Brady Urological Institute, Johns Hopkins Hospital, Baltimore, USA Introduction: The etiology and related diseases for Peyronie’s disease (PD) remain largely obscure. Aim: The aim of this study was to investigate the relationship between ENT (Ear, Nose and Throat) problems and PD. Methods: We conducted a retrospective hospital-based casecontrol study in the urology department from January 2007 to March 2008. We analyzed the files of 43 men with PD and 113 localized prostate cancer patients serving as controls. Demographics, complete medical history and domain scores on IIEF and AUA symptom questionnaires were obtained. The association between PD and selected co-morbidities was also evaluated and compared with findings reported in the literature. Results: Median patient ages of PD and control groups were 55 (17-72) and 61 (41-93) years, respectively. Univariate logistic regression analysis demonstrated that ENT problems (e.g. sleep apnea, sinusitis, nasal polyps, adenoid hypertrophy) were significant co-morbidities of PD (OR: 4.58; CI: 1.85-11.33, p<0.01) (30.2% vs. 10.6%, p<0.05). We also noted that PD patients had high AUA symptom scores (14% vs. 7.9%, p<0.01). No significant difference was found between the two patient groups in terms of hypertension (42% and 30.6%, p>0.05) and DM (10% vs. 5.8% respectively, p>0.05). Conclusion: ENT problems may be included among clinical risk factors for PD. The association suggests a common susceptibility to fibrotic disease changes. P10 Management of complaint of a Small Penis in Physically Normal Men Hussein Ghanem Department of Andrology, Sexology and STD, Cairo University Introduction: With the worldwide increase in penile augmentation procedures and claims of devices designed to elongate the penis, it becomes crucial to study the scientific basis of opting to penile augmentation or other forms of treatment. Aim of the work: To evaluate the management options for physically normal men with a complaint of a small penis. Methods: We report on the outcome of using a structured management and counseling and management protocol. We also 30 Cairo 26 - 28 February 2009 review the literature about what the normal penile size is, what patients complaining of a small penis usually suffer from, benefits versus complications of surgery, penile stretching /traction devices, and patient education and counseling versus surgery. Results: Using a structured management and counseling protocol only 2% of physically normal men (5/246) chose surgery. We also propose a practical approach for evaluating and counseling patients complaining of a small sized penis. Conclusion: Based on the current status of science, almost all men can be managed conservatively. Surgery is still considered experimental and should only be limited to special circumstances within research or university institutions with supervising ethics committees. P11 Self Injection of Foreign Materials in the Genitalia: Our Experience Abdel Raheem A, Garaffa G, Christopher AN, Ralph DJ, Minhas S. Institute of Urology, London, UK. Introduction: Patients with penile dysmorphophobia are preoccupied with the size and shape of their penis. In many cases this preoccupation causes a decline in the patient's social, occupational, or educational functioning. Patients with penile dysmorphophobia are convinced that they have a physical abnormality in the penis and are constantly seeking a drug or surgery that will augment the penis. However some patients will take matters in their own hands by injecting foreign material in their penis believing this will make their penis bigger. Aim: To report our experience of managing patients with penile dysmorphophobia who have self injected foreign material in their genitalia. Material and Methods : Over the past year four patients with penile dysmorphophobia presented to our unit after self-injecting foreign material into their penis and scrotum. The materials injected were washing-up liquid, mineral (baby) oil, petroleum jelly and silicone respectively. The injection of washing-up liquid, baby oil and petroleum jelly induced a foreign-body-type granulomatous reaction with overlying skin necrosis. Silicone injection did not cause an immune reaction or infection, but was associated with progressive scrotal lymphoedema. The patient who injected silicone required partial scrotectomy for the lymphoedema.The patient who injected petroleum jelly healed well by secondary intention following debridement. The other 2 patients who injected washingup liquid, mineral (baby) oil required debridement and skin-grafting (1 immediate, 1 delayed). Results: The patient who injected petroleum jelly later developed preputial lymphoedema that was managed by circumcision. The patient who underwent partial scrotectomy following silicone injection got a good cosmetic result, but will require a further scrotectomy. Of the 2 patients who had skin grafts, one had complete recovery with an excellent cosmetic result, while the other developed a ventral contracture due to scarring. Conclusion: Self injection of foreign material into the genitalia is a hazardous process that damages the skin and subcutaneous tissues. Initial management involves drainage, excision of the involved skin, and skin-grafting defects. Where lymphoedema develops, all the involved tissue needs to be excised to achieve resolution. The Fourth Pan Arab Congress on Sexual Medicine P12 Surgical management of circumcision injuries Osama Shaeer Department of Andrology, Faculty of Medicine, Cairo University Circumcision injuries are under rated regarding their incidence. Methods for repair are not standardized. Most cases end up with permanent mutilation and disfigurement. This work presents experience with management of circumcision injuries, and standardization of surgical repair. Methods: Cases with circumcision injuries ranged from urethral fistulation , subtotal or total amputation of the glans penis, loss of the penile skin, to subtotal or total amputation of the penile shaft. The surgical procedure for each case is described, varying from re-anastomosis of the glans, neo-glansplasty, fistula repair, penile skin coverage, and penile elongation. Main outcome measures: Cosmetic appearance, nocturnal erections Results: All patients ended up with a cosmetically adequate penis, with probable functional adequacy. Conclusion: A penis, injured upon circumcision, can be salvaged with standardized techniques. P13 Testosterone Replacement Therapy in Elderly Males: Is It Safe to the Prostate? Mohamed Mostafa Arafa and Khaled Ezz El-Din Department of Andrology - Cairo Univerity Introduction: The widespread use of testosterone replacement therapy (TRT) in treatment of erectile dysfunction (ED) associated with partial androgen deficiency in aging men (PADAM) lead to a world wide concern about its safety. Aim: The aim of the present study is to assess the effect of TRT on the prostate in PADAM patients with erectile dysfunction as regards risk of neoplasia and aggravation of lower urinary tract symptoms (LUTS). Patients and methods: sixty-one patients with PADAM and ED were included in the study. TRT was given for 12 months with follow up at 1, 6 and 12 months. Patients were asked to complete IIEF, PADAM score, International prostate symptom score (IPSS) and were subjected to total testosterone assay measurement, TRUS, PSA testing and uroflowmetry at the beginning of the study and in the follow up visits. Results: Fifty-two patients completed the study. There was significant improvement in IIEF, PADAM score and total testosterone in the follow up visits compared to initial assessment. There was no significant increase in PSA, IPSS score, prostate size or Q max in the follow up visits compared to initial assessment. Patients were then grouped into 2 groups according to presence of diagnosed BPH (Group A = 29 patients) or absence of diagnosed BPH (Group B = 23 patients). Group A showed no significant deterioration in PSA, IPSS score, prostate size or Q max in the follow up visits compared to initial assessment. No focal lesion was detected in the prostate during TRUS in any patient. Conclusions: Testosterone replacement therapy is safe on the prostate and does not promote enlargement of the prostate, deterioration of LUTS or development of prostate cancer. P14 Female Sexuality: An Egyptian Experience Shouikar Tawfiq Faculty of Medicine, Benha University, Benha, Egypt Background: Due to the sensitivity of the matter, female sexuality is not a common subject in Egyptian medical literature. Aim: This study aimed at filling the gap in this respect. Subjects and methods: The subjects interviewed were 313 married women attending or working in Family Planning Centers in 3 cities using a face-to-face questionnaire covering many aspects of female sexuality. Results: The commonest coital frequency was 1-2 and 3-6/weak that decreases during pregnancy,after delivery and with aging. Most women reported no change of libido throughout the menstrual cycle. Reaching orgasm frequently was reported by the majority of women and they commonly faked an orgasm if they did not obtain it. Affirmative replies about premarital masturbation and the use of oral sex were uncommon. Missionary position is the most commonly used position and women are largely satisfied with their sexual life as a whole. Conclusion: Despite economic difficulties and relative male dominance, the women of the sample looked at their sexual life with a positive look. P15 Clinical parameters that predict successful outcome in men with premature ejaculation and inflammatory prostatitis Wael Zohdy Andrology Consultant Samir Abbass Medical Center, Al Khobar, KSA., Ass. Prof. of Andrology, Coiro University - Egypt. Introduction: Premature ejaculation (PE) affects 30–40% of sexually active men. One of the most important organic causes of PE is chronic prostatitis (CP). Aim. The aim of this study is to fined out clinical parameters that predict successful outcome after management of men with PE & chronic prostatitis. Methods. Two hundreds and ten heterosexual men were included in this retrospective study. 155 men were suffering from secondary premature ejaculation (SPE) and 55 had primary premature ejaculation (PPE). Participants were included If 10 or more white blood cells (WBC) per high power field (HPF) were present in the expressed prostatic secretions. All men were asked to complete the National Institutes of Health Chronic Prostatitis Symptom Index (NIH CPSI). Sequential microbiologic specimens were obtained according to the standardized Meares and Stamey protocol. Nonbacterial prostatitis was defined by the evidence of inflammation but negative cultures of urine and prostatic fluids in men with various genitourinary symptoms. One hundred and eighty four men received 4 weeks course of antibiotics and 26 men refused or did not comply with antimicrobial therapy and were taken as control group. All men were reevaluated clinically after 28 days. Results. Men aged between 20–56 years. Two men from the control group experienced delay in their intravaginal ejaculatory latency 2/26 (7.7%) while 107/184 (59.2%) from men who received antimicrobial therapy reported improvement of the PE (P=0.001). There was no significant difference between men who received antibiotics and control cases regarding age, education, intercourse Samy Hanafy, Taymour Mostafa, Ihab Younis, Hanan Sabry, Cairo 26 - 28 February 2009 31 The Fourth Pan Arab Congress on Sexual Medicine frequency, NIH-CPSI domains, total score or the number of pus cells in the EPS analysis. Bacterial prostatitis was diagnosed in 175 men (83.3%). Using ROC curve analysis; antimicrobial therapy is best effective if pus cells in the EPS analysis is ≥ 19 HPF, with sensitivity 85.6% and specificity 70.7% (AUC 0.783, 95% confidence interval 0.716–0.850). Other clinical parameters such as NIH CPSI domains and total score were unhelpful in predicting the outcome of the antimicrobial therapy. Conclusions. Results in this study showed that antimicrobial therapy is useful in premature ejaculators complicated with inflammatory prostatitis. The treatment is most effective when pus cells in EPS analysis is ≥ 19 HPF. P16 Premature ejaculation: new combination therapeutic approach for couple satisfaction 1992). According to the WHO, the central topics of Andrology are : infertility, hypogonadism, male contraception, male sexual dysfunction and male aging. Andrology is established today as a firm discipline of medicine in only very few countries. Our mission is to establish andrology as a separate medical specialty dealing with all aspects of male reproductive and sexual functions. We established a new Master degree of andrology in Cairo University. The duration of the course is three years divided into one and half year for basic science and one and half year for andrology. Also we have Medical Doctorate of andrology P18 Effects of Glans Penis Augmentation Using Hyaluronic Acid Gel for Premature Ejaculation Shedeed Ashour Amr Al-Ahwani, Hamed A. Hamed, Taha Abdelnasser , Hossam Hosni ,Amr Al-Ahwani ,Ahmed Abdel Hady, and Osama Selim Department of Andrology, Cairo University Department of Andrology, Cairo university Introduction: Premature Ejaculation (PE) as one of the most common male sexual dysfunctions (MSD) and its individual and relationship consequences have been recognized in the literature for centuries. A new, evidence-based definition of (PE) developed by ISSM2008. Despite the fact that PE affects 30% of population across all countries it is under treated satisfactorily. Many treatment modalities had been tried for PE treatment with variable success rates. Aim of the study: To evaluate the efficacy of the combination therapeutic technique in treating PE. Also, to assess the effects of this approach on the patient and Partner's satisfaction and relationship. Patients and Methods: 128 Pts of 1ry PE recruited from a privateHospital Andrology clinic in Saudi Arabia. Average age was 30.78 +6.84SD ys. And average IVELT duration 1.07+ 0.443SD min (stopwatch evaluated). Duration of the problem ranged from 1-84 month with an average of 16.23 +13.01SD month. All patients received a treatment of 4 weeks the combines an SSRI (Ecitalopram 10 mg OD) + Combination technique of Counting the thrusts for distraction alternating between shallow and deep thrusts and startstop techniques. 2 weekly evaluations were done for 2 month. Outcome measures: IVELT after treatment and pt & partner satisfaction with the results. Results: the IVELT increased from 1.07+ 0.443SD min to 1.97 + 0.697 and 2.98 + 0.84SD min. after 2 and 4 weeks respectively (p. value: 0.019). Global assessment Question (GAQ) showed patients and partners satisfaction by 97 and 93%.Follow up period extended to 2 month post treatment and showed no recurrence to the base line in 102 pts.(79.68%). Conclusions: The Multimodal contemporary approach in the management of PE is beneficial and showed good evidence of sustained improvements. Further studies of the same technique and longer follow-up is still needed. The main limitation of medical treatment for premature ejaculation is recurrence after withdrawal of medication. We evaluated the effect of glans penis augmentation using injectable hyaluronic acid (HA) gel for the treatment of premature ejaculation via blocking accessibility of tactile stimuli to nerve receptors. This study was carried on fortynine men with PE. Patients have been classified into two groups A & B according to the technique of injection: Group A: In which 30 patients were injected by 2 ml hyaluronic acid gel using the fan technique.Group B: In which 30 patients were injected by 2 ml hyaluronic acid gel using the multiple puncture technique. All patients were interviewed at the beginning of the study , after one and three months to record their recorded IELTs using a stopwatch. In our study , the mean IELT was found to be significantly higher in both groups after injection of 2 ml hyaluronic acid gel.he effects of glans penis augmentation using filler might be the results of reduced sensory of glans penis by formation of barrier for stimuli to access the receptor and increased self-esteem P17 Andrology training at Cairo University Amr Gadalla and Ibrahim Fahmy Department of Andrology, Cairo University Andrology is defined as the branch of science and medicine dealing with reproductive functions of the male under physiological and pathological conditions (European Academy of Andrology 32 Cairo 26 - 28 February 2009 P19 Premature Ejaculation Management Guidelines Khaled Othman Consultant Andrology ,Infertility, and Sexual medicine ,Sexology Department, Alsalma Hospital ,Abu-Dhabi,UAE Introduction. Premature ejaculation is considered the most frequent self reported male sexual dysfunction , affecting nearly one in three men worldwide between the ages of 18 and 59 years . Until very recently , scientific investigation of premature ejaculation has been hampered by lack of standardized management guidelines with the wide range of causes , investigations , treatment options . The numbers of the randomized controlled studies evaluating various treatment options of the premature ejaculation have also added to the challenges facing the clinicians who manage premature ejaculation . Aim. The aim of this work to provides a summary of relevant the peer-reviewed literature pertaining to the management guidelines of the premature ejaculation (definition , pathophysiology of ejaculation , investigations , and medical therapy of premature ejaculation) Objectives • update the knowledge of professionals involved in the management The Fourth Pan Arab Congress on Sexual Medicine of premature ejaculation . • raise awareness of the disorder and Pathways of diagnosis and strategies for management. • Identify the current and future challenges in treating premature ejaculation . Methods. A retrospective review of peer reviewed publications relevant to the filed of premature ejaculation including definitions, related physiology, pathophsiology, investigations, and medical therapies . Main Outcome Measures. Data were obtained by extensive examination of published peer-reviewed literature relevant to the filed of premature ejaculation definitions, etiology, as well as safety and efficacy of various medical therapies for premature ejaculation . Results: The literature contains several definitions of premature ejaculation (PE), In 2007the Ad Hoc Committee for the Definition of Premature Ejaculation of ISSM propose a new evidence-based definition of PE. PE is multidimensional dysfunction composed of biological dysfunctions with psychosocial disorders , it include time (IELT; i.e.,time from vaginal penetration to ejaculation) as an objective parameter and subjective parameters such as “control”, ”satisfaction”, and “ distress” . SSRIs have been promising agent to treat premature ejaculation. Recent experiences with use of Tramadol raises the hope that this might prove to be an agent as effective as SSRIs with less worrisome risk of side-effects. Dapoxetine is the first SSRIs for which a marked authorization request has been submitted for PE. Topical solutions current and novel formulations for PE another therapeutic option. Conclusions. The diagnosis of PE is based upon sexual history ,pathophysiology of PE appears to be both neurobiogenic and psychogenic . The combination therapy integrating sex therapy and pharmaceuticals is frequently the best treatment approach for PE. Clinical researches in this field are hampered by the complexity, variability among different men and cultures, and subjectivity of PE. P20 The Role of PSA doubling time & Gleason score in Prostatic Cancer Bizanti, Sadik Tripoli, Libya Accumulating data from other reports support the view that the PSA doubling time (PSA-DT) provides a surrogate marker for both clinical metastasis-free survival and prostate cancer-specific mortality in men with a rising serum PSA after RP, And It is less well studied after external beam RT, and has not been studied or validated after brachytherapy. In the largest series of 8669 men with clinical localized or locally advanced nonmetastatic prostate cancer (5918 treated surgically, and 2751 irradiated), a PSA-DT of <3 months identified men who were 20-fold more likely to die of prostate cancer than those with a PSA-DT of 3 months. A later analysis suggested that the addition of the Gleason score to PSA-DT provided a better estimate of prostate cancer-specific mortality in men with a rising PSA following RT. When the PSA-DT was <3 months, the estimates of prostate cancer-specific mortality five years after biochemical failure were 75 versus 35 percent for men with a Gleason score of 8 and 7, respectively. In contrast, for men with PSA-DT 3 months, the corresponding five-year rates of prostate cancer-specific mortality for Gleason score 8 and 7 disease were 15 and 4 percent, respectively. In another report of 1136 men undergoing treatment for localized prostate cancer, men who died of their disease within 10 years had a median post treatment PSA doubling time of 0.8 years, while those who did not die of prostate cancer had either no post treatment increase in serum PSA or a PSA doubling time longer than 1 year. Summary: Taken together, these data support the view that men who have a short PSA-DT and Gleason score 8 disease are unlikely to achieve long-term disease control from local-only salvage therapies. Men with a short PSA-DT following local therapy (eg; < 3 to 6 months) also have a reduced time to distant disease recurrence , and this population may be appropriate for early rather than delayed androgen deprivation therapy to in order to forestall the onset of symptomatic bone metastases. P21 Vascular risk factors and flow mediated dilatation of cavernosal and brachial arteries in healthy and erectile dysfunction patients Anis TH, Selim O, Abdelhady A, Abosafe A Department of Andrology, Cairo university Introduction: Erectile dysfunction (ED) commonly coexists with coronary artery disease (CAD) and/or risk factors for atherosclerosis. Study of these risk factors and their effect on endothelial function represented by flow mediated dilatation (FMD) would give a new insight on how to prevent rather to treat ED. Aim: To investigate the correlations between vascular risk factors and flow mediated dilatation of cavernosal and brachial arteries. Methods: FMD of brachial and cavernosal arteries was measured using Doppler US in 120 patients complaining of vasculogenic ED, and in 60 male subjects not complaining of ED, correlations were made between FMD and fasting blood sugar, total cholesterol, triglycerides, blood pressure, smoking Results: Significant negative correlations were demonstrated between FMD of brachial and cavernosal arteries with total cholesterol, TAG, smoking, fasting blood sugar (p=0.000) in cases and controls, significant negative correlation was documented between FMD of cavernosal and brachial arteries in cases but showed insignificant negative correlation with controls. Conclusion: Patients with vasculogenic ED exposed to vascular risk factors have impaired endothelial function as compared to those without risk factors; the results were similar in male subjects without ED except for blood pressure which showed insignificant negative correlation with FMD. P22 Effect of HO-1 cDNA-liposome complex transfer on erectile signaling in aged rats Taymour Mostafa, Abdel Aziz MT, Atta H, Mahfouz S, Wassef MA, Fouad H, Kamel M, Rashed LA, Sabry D , Mouhamed O Department of Andrology & Sexology. Faculty of Medicine, Cairo University. Aim: To assess the efficacy of heme oxygenase-1 (HO-1) cDNAliposome complex transfer as a mediator of erectile signaling in aged rat. Methods: One hundred and fifty aged white albino rats were equally divided into five groups; controls, rats received lipofectamine, rats received intracorporeal HO-1 cDNA-lipsome complex, rats received HO-1 cDNA-liposome complex plus nitric oxide synthase (NOS) inhibitor and rats received HO-1 cDNA-liposome complex plus HO Cairo 26 - 28 February 2009 33 The Fourth Pan Arab Congress on Sexual Medicine inhibitor. Six rats were sacrificed from each group after 12, 24 h, 48 h, 1 wk and 2 wk. Main Outcome Measures: In dissected cavernous tissues the following were assessed: HO-1 gene expression, Western blot for HO-1, HO enzyme activity, cGMP, and histopathology. Results: HO-1 cDNA-liposome complex transfer led to a significant increase in cavernous tissue HO-1 protein, HO-1 gene expression, HO enzyme activity and cGMP up to 1 wk. NOS Inhibition exhibited no effect on HO-1 gene enhancement of cavernous tissue HO enzyme activity or cGMP whereas inhibition of HO significantly decreased these parameters. Histopathology of cavernous tissue demonstrated a significant dilation of helicine arteries in HO-1 cDNA-liposome complex treated group after 48h compared with controls. Conclusion: HO-1 cDNA-liposome complex transfer augments cavernous tissue cGMP with subsequent sinusoidal relaxation. P23 The role of PDE5 inhibitors in heme oxygenasecGMP relationship in rat cavernous tissues. Taymour Mostafa, Aziz MT, Atta H, Rashed L, Marzouk SA, Obaia EM, Sabry D, Hassouna AA, El-Shehaby AM, Aziz AT. Department of Andrology & Sexology. Faculty of Medicine, Cairo University. INTRODUCTION: Heme oxygenase (HO) enzyme catalyzes oxidative degradation of heme to biliverdin and carbon monoxide (CO). CO shares many properties NO including the activation of soluble guanyl cyclase. AIM: To assess cavernous tissue HO activity and cGMP levels in response to oral PDE5 inhibitors. METHODS: Seven hundred twenty male Sprague-Dawley rats, divided into six groups, were investigated. Group 1, controls; group 2 received sildenafil citrate orally; group 3 received vardenafil HCl; and group 4 received tadalafil. Group 5 was subdivided into three equal subgroups, received the same dose of each drug added to an HO inhibitor (Zn protoporphyrin). Group 6 was subdivided into 3 equal subgroups, received the same dose of each drug added to an NO inhibitor (L-nitroarginine methylester). Eight rats from each group/subgroup were sacrificed at 0.5, 1, 2, 3, 4, 6, 18, 24, and 36 hr. MAIN OUTCOME MEASURES: HO enzyme activity assay and cGMP tissue levels in the dissected rat cavernous tissues. RESULTS: Both cavernous tissue HO enzyme activity and cGMP levels were increased significantly in sildenafil-, vardenafil-, and tadalafil-treated rats compared with the controls, with significant decreases after either HO or NO inhibition. Cavernous tissue HO enzyme activity and cGMP showed a positive significant correlation (r = 0.854, P < 0.001). CONCLUSION: The effects of PDE5 inhibitors in cavernous tissue are partly mediated through HO enzyme activity. P24 Possible evidence for alternative pathways in apomorphine-induced erection in rats? Rany Shamloul and Michael Adams Queen's University, Canada Introduction: L-NAME ((N-I]-nitro-L-arginine methyl ester), the well-known nitric oxide synthase (NOS) inhibitor, has been used extensively to delineate the various physiological roles of NO, including its role in cavernous relaxation and erections. In most 34 Cairo 26 - 28 February 2009 studies, in vivo and in vitro, L-NAME, in various doses, has been shown to significantly, but not completely, inhibit NO-dependent penile relaxation. Furthermore, in most studies L-NAME was administered for very short time periods. Aim: To investigate whether a supramaximal dose of NG-nitro-Larginine methyl ester (L-NAME) (a well-known nitric oxide synthase inhibitor) can eradicate apomorphine-induced erections in rats. Methods: Two groups of 12 week-old male Sprague-Dawley rats were included in the study. Group A (n=3) had access to regular drinking water, while group B (n=4) had access to L-NAME (1g/ kg/day) dissolved in drinking water for 5 days. Aspartame (33 mg/kg/day) was added to the drinking water to facilitate L-NAME consumption. Main outcome measures: Measurement of body weight and water consumption was done prior to the study and on daily basis during the study period. Penile erection was assessed prior to the study and on daily basis during the study period using subcutaneouslyinjected apomorphine hydrochloride [apo] (80 μg/kg) prepared in solution with ascorbic acid (100 μg/ml). Results: There was no significant difference between groups A and B regarding mean (SD) baseline body weight, water consumption, apo-induced erectile responses and apo-induced yawns. Five days after L-NAME administration there was no significant difference between both groups regarding the average number of apoinduced yawns, however, the mean apo-induced erectile responses of group B rats was significantly reduced in comparison to their baseline values (0.5 ± 1 vs 2.75 ± 0.3), and also to group A (0.5 ± 1 vs 2.6 ±0.5), but not eradicated. There was also slight significant difference between the mean body weights and water consumption of group B animals after 5 days of L-NAME versus control group, 392.2 ± 10.7g vs 430 ± 33.4g and 28.2 ± 15.6ml vs 57.6 ± 11.6 ml, respectively. Conclusions: A supramaximal dose of L-NAME could not eradicate apo-induced erections in rats. This suggests that other non nitric oxide-dependent pro-erectile mechanisms may be involved in this type of pharmacologically-induced erection. P25 The influence of G protein-3 subunit (GNB3 C825T) gene polymorphism on erectile dysfunction and response to sildenafil in Egyptian patients Ihab A. Osman1 and Olfat G. Shaker2 1. Department of Andrology, Cairo University 2. Medical Biochemistry & Molecular Biology Unit, Biochemistry Department, Faculty of Medicine, Cairo University Objectives: To investigate the influence of G protein-3 subunit GNB3 C825T gene polymorphism on erectile dysfunction (ED), and the response of ED patients to Sildenafil. Setting: Andrology and Sexology clinic, Faculty of Medicine, Cairo University Hospitals, Cairo, Egypt Patients: Sixty ED patients with mean (standard deviation) age 49.67 years (9.68) were enrolled in this study, and they were further classified into 2 sub groups (30 patients each) according to their response to Sildenafil. Interventions: peripheral blood sampling for DNA extraction and GNB3 C825T allele status determination by polymerase chain reaction (PCR) technique performed with the specific primers. Main Outcome Measures: GNB3 C825T allele status for all ED patients. Results: Frequency of the 825T allele was higher in patients with The Fourth Pan Arab Congress on Sexual Medicine versus without cardiovascular co-morbidities (57.1% versus 48%), and interestingly, all TT patients in our study had cardiovascular co-morbidities (p = 0.04). Analysis of the influence of GNB3 C825T polymorphism on the response of ED patients to Sildenafil, a significant association of homozygous 825T allele status with the drug response was observed, as 85.7% of TT genotype carriers showed a statistically significant response to sildenafil, compared to 46.4% of CC genotype and 44% of TC genotype patients (p = 0.04). Conclusion: GNB3 C825T gene polymorphism is significantly associated with the response to Sildenafil in ED patients. P26 Yohimbine enhances the effect of sildenafil on erectile process in rats. Taymour Mostafa and Senbel AM Department of Andrology, Cairo University Background: Combining the centrally acting drug yohimbine with the peripheral conditioner sildenafil might be an approach to erectile dysfunction cases in which sildenafil alone failed. Aim: To investigate the effect of yohimbine on sildenafil-induced facilitation of erectile process. Method: Erectile responses to electrical stimulation of the cavernous nerve in anesthetized male rats were recorded. Intracavernosal pressure/systemic arterial pressure (ICP/SAP) was calculated, 1 and 5 min after intravenous administration of sildenafil, yohimbine or a combination of both. Main outcome Measures: Changes in sexual arousal and copulatory performance indices before and after injections using behavioral mating experiments. It Results: Systemic administration of sildenafil produced a significant increase in ICP/SAP than control at doses >or=10 micromol kg(-1). Yohimbine alone failed to potentiate erectile responses but yohimbine (1 micromol kg(-1)) significantly potentiated the effect of sildenafil 1-10 micromol kg(-1) and 1 mmol kg(-1), 1 and 5 min after injection. Potentiation of ICP/ SAP induced by their combination was greater than the sum of the effects of the corresponding doses of either drug at the same time interval. A nonsignificant additional decrease in SAP than sildenafilinduced was observed if administered with yohimbine. Addition of sildenafil to yohimbine significantly enhanced the effect of the latter on intromission frequency, intercopulatory interval and the number of ejaculations per session. Conclusion: Yohimbine may enhance and prolong the effect of sildenafil on erectile process without additional hypotension. Sildenafil may enhance the central effects of yohimbine on erection; it amplifies the effect of yohimbine on male copulatory performance but not on sexual motivation. The potential effect was more pronounced on the central than on the peripheral component of the erectile process. P27 Endothelial nitric oxide synthase gene polymorphism in Egyptian patients with erectile dysfunction Ihab A. Osman, Ashraf H. Fayez, and Olfat Shaker Departments of Andrology, and Biochemistry and Molecular Biology, Cairo University INTRODUCTION: The nitric oxide (NO) pathway is of critical importance in the physiologic induction and maintenance of erections. The role of endothelial nitric oxide synthase (eNOS) in penile erection is becoming increasingly recognized. The current consensus is that endothelial dysfunction is the common denominator in the pathogenesis of Erectile Dysfunction (ED) and many vascular diseases often coexist, and that, at the cellular level, endothelial dysfunction results in an impaired release of NO. Recently, evidence has accumulated proving that eNOS gene polymorphism may be associated with an increased risk of developing cardiovascular or metabolic disorders and they affect some of those exact same physiological pathways that are known to play a role in the regulation of penile vasomotor tone. AIM OF THE STUDY: To investigate a potential association between endothelial nitric oxide synthetase (eNOS) gene polymorphism and ED. PATIENTS AND METHODS: The study was carried on 60 ED male patients. All patients were subjected to complete medical and sexual history taking including the international index of erectile function (IIEF-5) questionnaire, as well as general and local genital examination. Estimation of serum levels of testosterone and prolactin was done and each patient was subjected ICI test. Patients with a negative response were evaluated through a penile dynamic duplex study to clarify the etiology of ED being arterial, veno – occlusive, or psychogenic. eNOS genotype polymorphism was determined by polymerase chain reaction (PCR) performed with the specific primers, size fractionation on agarose gels, and visualization under ultraviolet illumination. RESULTS: The mean age of patients was 49.67 years (range of 29 – 69 years). The duration of ED ranged between 1 – 14 years (mean of 3.45 years). The prevalence of risk factor like diabetes and hypertension were 51.7% and 16.7% respectively. The main cause of ED in the studied cases was veno – occlusive (43.33%), while the least common was the arteriogenic (20%). The psychogenic etiology was present in the remaining 37.67% of patients. In our series, the most common NOS genotype was GG that represented in 46.67% of patients, followed by GT in 43.33%, then TT in 10% of them. The present study demonstrated a significant correlation between the grade of ED and NOS3 genotype. CONCLUSION: eNOS gene polymorphism might be a factor of genetic susceptibility to ED, most probably related to downregulation of NO levels, and a consequent altering of the cavernosal smooth muscle relaxation mechanism, however, a definitive association between the eNOS gene polymorphism and ED remains to be elucidated, as data available from different studies are limited and controversial. eNOS is only a single component of the multifactorial balance of vasomotor tone in the corpora cavernosa. Further researches with larger subject groups and further molecular basis studies are needed to clarify the role of the eNOS gene polymorphism in the pathogenesis of ED, & to reveal additional polymorphism associations with ED, and these might be added to environmental factors to have a complete predictive scheme specific for each population. P28 The changes in expression of platelet derived growth factor (PDGF) and PDGF receptor in rat corpus cavernosum after exposure to in vivo hypoxia and cigarette smoking. IHAB I. KAMEL1 EMAN F. KHALEEL2, LAILA A. RASHED3 1.Departments of Andrology, sexology and STDs 2. Physiology, and 3. Biochemistry, Cairo University Background: Platelet derived growth factor (PDGF) over activity has Cairo 26 - 28 February 2009 35 The Fourth Pan Arab Congress on Sexual Medicine been implicated in atherosclerosis and several fibrotic conditions including lung and kidney fibrosis, liver cirrhosis and myelofibrosis. Low oxygen tension (hypoxia) and cigarette smoking is a known stimulus for transcriptional induction of (PDGF) ligand and receptor gene that are associated with induction of fibrosis which may lead to erectile dysfunction. Aim: To study the expression of (PDGF-A)and (PDGFR-β)in adult male rat isolated corpus cavernosum under hypoxic and cigarette smoking condition Material and methods: Fifty adult male albino rats were used in this experiment. They were divided into 5 groups. Group I (n=10), served as control group. Group II(n=10) rats exposed to acute hypoxia. Group III (n=10) rats exposed to chronic hypoxia. Group IV(n=10) rats exposed to acute cigarette smoking. Group V(n=10) rats exposed to chronic cigarette smoking. In all groups at the end of each experiment corpora cavernosa of all rats were carefully dissected and free from surrounding tunica albuginia then frozen in -80C◦ for subsequent reverse transcriptase polymerase chain reaction (RT-PCR). In all groups of rats PDGF-A and PDGR-m RNA were measured. Results: There was significant increase in PDGF-A mRNA and PDGF-β receptor in acute hypoxic group, chronic hypoxic group, and chronic cigarette smoking groups of rats compared to control group. Conclusion: It was found that hypoxia, whether, acute or chronic has similar effect of increasing PDGF-A mRNA and PDGF-β receptor as well in chronic cigarette smoking group of rats. This may lead to erectile dysfunction. P29 Opportunity to Rescue Patients Failing PDE5 Inhibitors through the Combination of Vacuum Erection Device and PDE5 Inhibitors Onder Canguven4, James Bailen3, William Fredriksson1, David Bock2 and Arthur L. Burnett4 1.Urologic Institute, Meridian, Idaho 2.Kansas City Urology Care, Overland Park, Kansas 3.Metropolitan urology, Jeffersonville, Indiana 4.The James Buchanan Brady Urological Institute, Johns Hopkins Hospital, Baltimore, MD Introduction: This prospective study evaluated whether a vacuum erection device (VED) and phosphodiesterase type 5 inhibitors (PDE5i) in combination are effective in treating erectile dysfunction (ED) in subjects failing PDE5i alone. Patients and Methods: We evaluated 65 men (aged 36-82 years) with ED of diverse etiologies (excluding post-prostatectomy ED) in whom PDE5i at the highest recommended dose with at least 4-6 intercourse attempts had previously failed. Efficacy was evaluated using the International Index of Erectile Function-5 (IIEF-5) questionnaire, Sexual Encounter Profile (SEP)-2, SEP-3, and Global Patient Assessment Scale (GPAS). Results: After 4 weeks of treatment the mean IIEF-5 score increased significantly over baseline from 9.2 to 17.5 (p<0.001). Of the 31 subjects with a SEP-2 response of ‘No’ at baseline, 24 (77%) responded ‘Yes’ after combination therapy (p<0.001). Of the 46 subjects with a SEP-3 response of ‘No’ at baseline, 31 (67%) responded ‘Yes’ after combined therapy (p<0.001). Furthermore, of the 39 subjects with a GPAS response of ‘not at all’ or ‘slightly’ improved at baseline, 29 (74%) responded ‘moderately’ or ‘greatly’ improved after combination therapy (p<0.001). One subject (2%) 36 Cairo 26 - 28 February 2009 experienced VED-related intermittent penile pain, which resolved after 4 days without any action. Conclusion: Statistically significant improvements over baseline in patient-reported outcomes were seen with combination therapy. These results suggest that combination therapy may be effective for PDE5i failures and may be considered prior to more invasive alternatives. P30 The role of vacuum therapy to mechanically straighten the penis in Peyronie’s disease Abdel Raheem A, Garaffa G, Dixon M, Spillings A, Christopher AN, Ralph DJ Department of Andrology, Cairo University and Institute of Urology, London, UK Introduction & Aim : Several non-surgical therapies have been tried in Peyronie’s disease, yet none of these therapies proved to be effective in treating the penile deformity. At the present time surgery is the most effective method for managing the penile deformity. This study assesses the role of vacuum therapy to mechanically straighten the penile curvature of Peyronie’s disease. Material and methods : The study included 27 patients, aged 27-71 yrs (mean 51 yrs), who had newly diagnosed Peyronie’s disease (mean duration 9.9 months). Over a 3 month period, the patients used the vacuum device without the constriction ring for 10 minutes twice daily to stretch the penis. Assessment at study entry and at completion after 3 months included: an IIEF questionnaire, a visual analogue pain score, the angle of penile deformity assessment by an intracavernosal injection of PGE1 and stretched penile length measurement. There was a statistically significant improvement in penile length, angle of curvature and pain after 3 months of using the vacuum pump. However there was no significant difference in any of the IIEF domains. Of the 27 patients in the study 18(66.7%) had a reduction in the angle of curvature by 5º-25º, 3(11.1%) had worsening of the curvature and in the remaining 6(22.2%) there was no change in curvature. Patients with significant pain had a mean of 10º curvature improvement. Surgical correction of the curvature was performed in 13 patients while the rest of the patients n=14(51%) were satisfied with the outcome and did not want surgery at this stage. Conclusion : Vacuum therapy may improve or stabilize the curvature of Peyronie’s disease and is safe to use in the early active stage of the disease and may reduce the number of patients going on to surgery. The Fourth Pan Arab Congress on Sexual Medicine Results Mean Scores Week 1 Week 12 Max. score P-value 2.37 1.12 10 <0.05 13.27 cm 13.5 cm - <0.05 Penile curvature 48.33° 40.74° - <0.05 *Erectile Function 20.25 18.88 30 NS *Orgasmic Function 8.3 7.74 10 NS *Desire 6.88 7.07 10 NS *Intercourse Satisfaction 6.74 6.59 15 NS *Overall Satisfaction 5.4 5.66 10 NS Pain Penile Length *IIEF domain / Statistical significance (P<0.05)/NS (non significant) P31 Penile prosthesis insertion in Peyronie’s Disease Garaffa G, Abdel Raheem A, Sacca A, Christopher AN, Ralph DJ Institute of Urology, London, UK Introduction and Aim : The long-term results of the insertion of penile prosthesis in patients with Peyronie’s Disease (PD) are presented. Methods : A penile prosthesis was inserted into 98 patients (mean age 53.7yrs; range 32 -74yrs) who presented with PD. The indications for insertion were significant erectile dysfunction (ED) in 92 patients and extensive curvature with penile shortening in 6 patients. A previous unsuccessful straightening procedure had been performed in 13 patients (Nesbit 6, Grafting 7) and 31 patients were diabetic. A 3 pieces inflatable prosthesis was inserted in 67 patients and a malleable prosthesis in 31 patients. Difficult dilatation due to advanced fibrosis was managed with the use of Rosello cavernotomes in 12 patients and a double subcoronal incision in 1 patient. A residual curvature > 20 degrees after implantation was noted in 27 patients and was corrected intraoperatively by the moulding technique (21), plication (2), plaque incision (1) or plaque incision+grafting (3). In 4 patients the residual curvature after the insertion of prosthesis was < 20 degrees and therefore no further treatment was required. The remainder had a straight penis. Results : After a median follow up of 13 months (1-120 mts) a complete straightening of the penis has been achieved in 91 patients (92%) and 4 have a minor curvature that doesn’t impede penetration. However, 4 patients with an inflatable prosthesis required further surgical management of their residual curvature (Nesbit 2, grafting 1, moulding 1). Two patients had an infected malleable prosthesis requiring explantation. Overall, revision of the prosthesis was necessary in 26 patients (elective exchange of a malleable to inflatable prosthesis (2), autoinflation (4), soft glans (5), downsizing of the rods (5), infection (2), repositioning of the pump (4) and correction of residual curvature (4)). Overall the recorded patient satisfaction was 97% with 3 patients partially unhappy about penile shortening (1 had a previous Nesbit). Floppy glans was present in 14 patients; 5 were managed with glanspexy, the remainder conservatively (MUSE 5, PDE5 inhibitors 4). Overall, 96% of patients that have resumed sexual intercourse postoperatively. Conclusions : The insertion of a penile prosthesis in patients with PD achieves good patient satisfaction by correcting both the penile deformity and the associated ED allowing maintenance of penile length and function. P32 Peyronie's disease: relation to coital position Shedeed Ashour1 and Ahmed Nassar2 Department of Andrology, Cairo University Tanta University Introduction: Peyronie's disease (PD) is characterized by fibrotic plaques in the penile tunica albuginea that cause curvature of the erect penis, and is often accompanied by pain and/or erectile dysfunction. This condition affects up to 9% of men. Injury to the erect penis is thought to trigger PD by inducing extravasations of fibrin and subsequent fibrosis. Despite the lack of statistical support for a causal association between trauma and PD, it is possible that undetected microtrauma is involved. Aim: We studied the prevalence of the potential risk of trauma to the penis in the female superior coital position as a causal factor for PD. Patients and methods: Randomly selected Twenty three patients average age 51.2 +7.8 SD Ys with PD (average duration of disease 29.4 + 11.03SD month. All examined for the presence, site and multiplicity of the plaques, Penile measurements and curvature. Sexual history included asking about the use of the female superior position. Associated medical co- morbidities were also asked for. Main outcome measures: Percentage and frequency of users of female superior position and correlation to PD Results: All the 23 pts. selected had PD. The average stretched penile length was 11.5 + 1.78SD cm. & girth of 9.5 + 1.47SD cm. Two pts had ventral curvature and 21 had dorsal one (91.3%). Twenty two were diabetics (20 type II &1 type I); (95.6%), 8 Hypertensives (34.8%), 7 IHD (30.4%), two pt had history of coronary artery bypass (8.7%), 4 pts. Had LOH and Dylipedaemia (17.4%). The use of Female superior position was reported as frequently used by 21 pts (91.3%). Three pts have vitiligo, one pt used to practice tucking the penis, one pt had Deuptryn's contracture and 1 had a Cairo 26 - 28 February 2009 37 The Fourth Pan Arab Congress on Sexual Medicine history of sub-acute penile fracture due to coital trauma. Conclusions: despite the small sample there is evidence that the frequent type of trauma in the female superior position may play a role in the causation of PD. P33 Penile fracture: surgical repair and late effects on erectile function. Ahmed Ateyah, Mostafa T, Nasser TA, Shaeer O, Hadi AA, Al-Gabbar MA. Department of Andrology, Cairo University INTRODUCTION: Penile fracture is described as a traumatic rupture of the tunica albuginea because of blunt injury of an erect penis. AIM: To assess the etiology, treatment maneuvers, and late effects of penile fractures treated by surgical repair. METHODS: Thirty-three patients diagnosed provisionally as having fractured penises. Thirty patients were managed by immediate surgical repair and three by delayed repair. MAIN OUTCOME MEASURES: International Index of Erectile Function-5 for married cases and Single-question Self-report of Erectile Dysfunction questionnaires and recording complications after 2, 3, and 6 months. RESULTS: The most common cause of fracture penis is self-inflicted acute bending (54.5%). The tear was visualized by ultrasound in 20/30 patients (66.7%) mostly on the right proximal third of the penis. All tears were unilateral with mean length 2.0 +/- 0.9 cm (range 0.5-4 cm). All patients who completed their follow-up after 6 months (N = 24) were able to achieve an adequate erection except two married cases who felt mild erectile dysfunction. Penile nodules were the most common postoperative complication (41.7%) after 6 months' follow-up. Patients treated with immediate or delayed repair had comparable complications. CONCLUSIONS: Fracture penis is not uncommon as an emergency that must be repaired either immediately or delayed. Clinical diagnosis is more predictive than ultrasound in diagnosis and determining the site of the tear. Ultrasound may be of value in patients where there is clinical doubt. P34 Delayed Surgical Repair of Penile Fracture under Local Anesthesia Taha Abdel Nasser and Taymour Mostafa Department of Andrology, Cairo University Introduction: Penile fracture is a traumatic rupture of the tunica albuginea because of blunt injury of an erect penis. Aim: To assess the efficacy of a simple delayed surgical repair of penile fracture after a conservative treatment under local anesthesia in patients presented after 24 hours. Methods: Twenty-four patients with penile fracture presented after 24 hours were subjected to history taking, clinical examination, urine analysis, and penile ultrasound. They underwent conservative treatment for 7–12 days, and then a surgical repair under local anesthesia was carried out. Main Outcome Measures: A follow-up for 6 months for sexual activity and any associated complaints in addition to local examination. Results: All cases were presented with unilateral single tear, and the main cause of penile fracture was sexual intercourse. No intraoperative or postoperative complications were encountered. 38 Cairo 26 - 28 February 2009 They regained their sexual activity 4–6 weeks after the repair. One case developed a mild penile deviation that did not interfere with sexual relation after the 6-month follow-up. Conclusion: Surgical repair of penile fracture after a conservative treatment is an effective method for patients with delayed presentation devoid of urethral involvement. P35 Penile Reconstruction for Benign Disease with the Use of Skin Grafting Abdel Raheem A, Garaffa G, Sacca A, Christopher AN, Ralph DJ Institute of Urology, London, UK Aim: The long term results of penile reconstruction for benign disease with the use of skin grafts in 59 patients are reported. Patients and Methods: The patient’s aetiologies included Balanitis Xerotica Obliterans (BXO,n=20), traumatic amputation(n=5), excessive circumcision(n=12), frenular pathology(n=7), end stage lymphoedema(n=6), iatrogenic skin loss(n=4), hypospadias surgery(n=3), buried penis(n=1) and Fournier’s gangrene(n=1). All BXO and Lymphoedma patients had the disease area excised and grafted. The traumatic and circumcision injuries had skin added. Split skin grafts harvested from the inner thigh were used for glans and coronal pathology in 34 patients, whereas full thickness grafts from non-hair-bearing areas were used on the shaft to prevent erectile dysfunction due to graft contraction in 25 patients. Results: After a median follow-up of 21.5 months(1-60), all patients were satisfied with the outcome although partial graft loss and subsequent contracture did occur in 7 patients. These were managed successfully by delayed excision and re-grafting. The happiest were the BXO and trauma groups where effectively extra skin had been added. An improvement in cosmesis and sexual function was reported by 53 patients with an overall satisfaction rate of 93%. Conclusion: Loss of penile skin of various causes can be reliably managed by skin grafting. P36 Prostate Cancer & Testosterone Therapy – Is there an expectation of paradigm shift Aksam A. Yassin Professor of Urology & Human Sexuality, Chairman Institute of Urology and Andrology, Segeberger Kliniken, Norderstedt-Hamburg, Germany. Objectives: Prostate safety is a primary concern when aging men receive testosterone therapy (TT), but little information is available regarding the effects of TT on prostate tissue in men with a major concern: DHT levels. History of prostate cancer has been an absolute contraindication for testosterone therapy. We want to review the historical origins and current evidence for the belief that testosterone (T) causes prostate cancer (PCa) growth. Methods: Review of the historical literature regarding testosterone administration and PCa, as well as more recent studies investigating the relationship of T and PCa. Hypogonadal patients treated with radical retropubic prostatectomy (RRP), or even Radiotherapy for organ confined prostate cancer to determine if testosterone therapy (TT) could be efficacious and administered safely without causing recurrent prostate tumor. Dihydrotestosterone (DHT) levels show no alteration under Testosterone Therapy, also no DHT overexpression in Prostate tissues in placebo controlled studies. The Fourth Pan Arab Congress on Sexual Medicine Results: According to A. Morgenthaler, in 1941 Huggins and Hodges reported that marked reductions in T by castration or oestrogen treatment caused metastatic PCa to regress, and administration of exogenous T caused PCa to grow. Remarkably, this latter conclusion was based on results from only one patient. Multiple subsequent reports revealed no PCa progression with T administration, and some men even experienced subjective improvement, such as resolution of bone pain. More recent data have shown no apparent increase in PCa rates in clinical trials of T supplementation in normal men or men at increased risk for PCa, no relationship of PCa risk with serum T levels in multiple longitudinal studies, and no reduced risk of PCa in men with low T. The apparent paradox in which castration causes PCa to regress yet higher T fails to cause PCa to grow is resolved by a saturation model, in which maximal stimulation of PCa is reached at relatively low levels of T. Dihydrotestosterone (DHT) levels show no alteration under Testosterone Therapy, also no DHT overexpression in Prostate tissuses in placebo controlled studies. Conclusions: This historical perspective reveals that there is not now —nor has there ever been— a scientific basis for the belief that T causes PCa to grow. Discarding this modern myth will allow exploration of alternative hypotheses regarding the relationship of T and PCa that may be clinically and scientifically rewarding. P37 Shaeer's ultrasound-assisted penoscopy for visually guided excavation of penile fibrosis Osama Shaeer Department of Andrology, Cairo University Objectives: Implantation of penile prosthesis in case of corporeal fibrosis poses a greater risk of complications due to the blinded aggression involved. This work describes combination of penoscopy-guided and ultrasound-guided excavation to enhance safety and ease of implantation in such cases. Material and Methods: 18 patients with penile fibrosis were operated upon. A guide wire was inserted under ultrasound monitoring, along which penoscopic corporotomy and resection was performed. Ultrasound was also used to monitor penoscopic excavation towards the tip of the corpus cavernosum and crus. Main outcome measures: Ease, safety and extent of dilatation and prosthesis survival. Results: The procedure was relatively easy. Ten cases were dilated up to size 13.5 Hegar, and 2 up to size 14. Size 13 prosthesis was implanted in all cases and survived throughout one year follow up Conclusion: The relative safety of the procedure, the low incidence of complications, the possibility of restoring length and girth to an extent, and the resultant generous dilatation of the corpora for accommodating a sizable unhindered inflatable penile prosthesis all make ultrasound-guided penoscopic corporotomy and resection a valid option for prosthesis implantation in cases of penile fibrosis. P38 Testosterone and obesity Aksam A. Yassin1, Farid Saad2, 1-Professor of Urology & Human Sexuality, Chairman Institute of Urology and Andrology, Segeberger Kliniken, Norderstedt-Hamburg / Germany 2-Gulf Medical College School of Medicine, Ajman/UAE & Bayer Schering Pharma AG, Berlin, Germany Introduction and objective: Obesity is a worldwide problem. It is often clustered with the so-called metabolic syndrome consisting of (visceral) obesity, hypertension, decreased insulin sensitivity and dyslipidemia, which predisposes to cardiovascular disease and diabetes. Increasingly, a role for testosterone is recognized in the metabolic syndrome. Methods: A large number of studies have documented that visceral obesity and diabetes is associated with low plasma total testosterone levels. A recent study demonstrated a positive correlation between serum testosterone levels and insulin sensitivity in men across the full spectrum of glucose tolerance: Men with prostate cancer, treated with androgen deprivation, develop an increase of body mass, fat mass, hyperinsulinemia, hyperglycemia, and insulin resistance. There is growing insight into the relationship between testosterone and adipose tissue. Testosterone regulates lineage determination in mesenchymal pluripotent cells. Results: Testosterone promotes development of muscle cells of pluripotent cells and inhibits differentiation into the adipogenic cells through an androgen receptor-mediated pathway. The observation that differentiation of pluripotent cells is androgen dependent provides a unifying explanation for the reciprocal effects of androgens on muscle and fat mass in men. From this it would follow that restoration of testosterone levels to normal would lead to an increase of muscle mass and a decrease of fat mass, which is the case. Conclusion: Some studies indicate that raising testosterone levels in viscerally obese men leads to a reduction of visceral fat and an improvement of the cardiovascular and diabetogenic risk factors associated with it, but others do not confirm this result. Treatment of obesity is notoriously difficult. Obesity is often associated with mood disorders and testosterone has mood elevating effects. Obesity is also a risk factor for erectile dysfunction. Increasingly, studies document that restoration of testosterone levels to normal improves erectile dysfunction and can remedy failures of the phosphodiesterase type 5 inhibitors. P39 A Study of the Sexual Function in Patients Undergoing Coronary Artery Bypass Graft Surgery Hamed Abdalla Hamed, Mohamed Mohamed Farid, Tarek Mohamed Helmy, and Ali Mohamed Mahran Department of Andrology, Cairo University BACKGROUND: The published articles discussing the effect of coronary artery bypass graft surgery (CABG) on sexual function are few and based on subjective data (questionnaires) rather than objective data (e.g. penile duplex) in the evaluation of sexual function. Furthermore, there are no studies that have been conducted till now discussing the effect of the new Off Pump Coronary Artery Bypass Graft (OPCABG) surgery on the sexual function. OBJECTIVES: Our work aims at evaluation of the impact of CABG on sexual function, assessment of probable prognostic factors that may predict the future sexual function in patients undergoing CABG, and comparison between the conventional CABG and the new OPCABG as regards the impact of each on the sexual function. METHODS: One hundred CABG patients completed our study. Before surgery, all patients were subjected to full history taking including the IIEF-5 score, general and local examination and cardiac assessment based on the European System for Cardiac Cairo 26 - 28 February 2009 39 The Fourth Pan Arab Congress on Sexual Medicine Operative Risk Evaluation (EuroSCORE). Patients with normal IIEF-5 score (> 21) were not subjected to further investigations. Patients with erectile dysfunction (ED) according to the IIEF-5 score were subjected to pharmaco-penile duplex ultrasound and serum prolactin and testosterone levels when indicated. At the time of surgery patients were classified into two matched groups; Group I: Patients who underwent the conventional CABG (50 patients) and Group II: Patients who underwent the OPCABG (50 patients). Six months after surgery, the patients were subjected again to the same procedures for follow up of the postoperative erectile function outcome. RESULTS: Eighty percent of patients candidate for CABG complained of ED. After surgery, mean IIEF-5 scores of patients showed a slight increase that did not reach a significant value. Penile duplex results showed no significant change after surgery. After surgery, 36%, 30%, and 34% of patients reported improvement, decline, and no change in their IIEF-5 scores respectively. The factors which predict the postoperative erectile function outcome were: 1) Preoperative IIEF-5 score: 70% of patients with normal preoperative IIEF-5 score preserved their sexual function postoperatively, while 68.4% of patients with severe ED preoperatively reported no improvement after surgery. 2) Cardiovascular risk factors (RF): 42% of patients with two or more RF reported postoperative IIEF-5 score decline compared to 7.1% of patients with no RF (p<0.001). 3) Preoperative penile duplex results: 100%, 49.1%, and 11.7% of patients with normal duplex, arteriogenic ED, and venocclusive dysfunction respectively reported improvement of their IIEF-5 scores after surgery (p<0.001). 4)The onset of ED: 58.7% of patients who reported ED after the onset of myocardial infarction (MI) reported postoperative erectile function improvement compared to 34.8% of patients who reported the onset of ED before the occurrence of MI (p<0.05). 5). The EuroSCORE: 46.4% of low risk patients reported postoperative erectile function improvement compared to 21.4% of medium risk patients (p<0.01). 6)Operative factors: OPCABG patients reported significantly higher Mean ± SD IIEF-5 score after surgery compared to conventional CABG patients (15.88 ± 6.67 versus 12.48 ± 7.19, p< 0.05). Moreover, 46% of OPCABG patients reported postoperative improvement of their IIEF-5 score compared to only 26% of the conventional CABG patients (p< 0.05). CONCLUSION: The impact of CABG on the sexual function is variable. It depends on many preoperative and operative factors. These factors might be useful and should be considered to predict the postoperative sexual function outcome. P40 Prostate volume and prostate cancer: safety of long-term oral testosterone-replacement therapy in hypogonadal men Shedeed Ashour, Ibrahim M. Shedid, Abdel-Halim A. AbdelHalim, Zeinab A. Ibrahim, Dalia M Shabaan, and Ahmad H. Nassar Faculty of Medicine, Cairo University Objective: To evaluate the effect of long-term oral testosterone (T)replacement therapy on total serum prostate-specific antigen (PSA) level, prostate volume, lower urinary tract symptoms (LUTS), and the possible development of prostate cancer in hypogonadal men. Patients & Methods: A total of 172 (44 of the 5th, 60 of the 6th, and 68 of the 7th decade) hypogonadal men were prescribed oral T undecanoate from September 2002 to August 2007. All 40 Cairo 26 - 28 February 2009 patients were tested for the Saint Louis Questionnaire to screen for androgen decline in the aging men (SLQ-ADAM) and International Prostatic Symptom Score (IPSS) and underwent routine laboratory investigations, total serum T level, DRE and total serum PSA level at the baseline and every 6 months during treatment. Transrectal ultrasound (TRUS) was performed at baseline, every year, and exceptionally if DRE and/or total serum PSA level was abnormal. TRUS-guided prostatic biopsy was done for patients with a total serum PSA level > 4 ng/ml and/or PSA velocity > 0.75 ng/ml/year during treatment. Comparative statistical analysis of pretreatment and post treatment results was performed. Results: 158 patients completed the study. Their age ranged from 42 to 65 years. The mean age±SD for all patients was 53.0±12.0 year. There was a significant increase of the post treatment total serum T level in comparison to the pretreatment level (P<0.05) for all age groups. Total serum PSA level increased post treatment, but insignificantly in comparison to pretreatment (P >0.05) for all age groups. The mean PSA velocity at the end of the study was 0.57, 0.42, 0.68 ng/mL/year for the 5th, 6th, and 7th decade groups, respectively. The mean change of prostatic volume was statistically significant posttreatment in comparison to pretreatment one (P<0.05) for all groups, but lower urinary tract symptoms (LUTS) were reported in only 4 patients. Prostatic intraepithelial neoplasia (PIN) was detected in only one patient of the 7th decade group who had evident increase of total serum PSA level (4.67 ng/ mL) and PSA velocity of 1.61 ng/mL/year. Conclusions: Oral T undecanoate-replacement therapy in hypogonadal men does not increase the risk of prostate cancer in selected patients, but it could be associated with increased prostatic volume, a minor elevation in total serum PSA level, and occurrence of LUTS. P41 Hypogonadism prevalence among patients presenting with metabolic syndrome: An initial experience with testosterone treatment Abdel Rahman Zahran and Mostafa Sakr Department of Urology, Alexandria University, Egypt. INTRODUCTION & OBJECTIVE: Recently, metabolic syndrome became a very prevalent disease among Egyptians owing to the westernization of the country. This syndrome is characterized by central obesity, insulin resistance, dyslipidemia and hypertension. The aim of this prospective work is to estimate the incidence of hypogonadism among patients presenting with metabolic syndrome & to assess the beneficial effects of testosterone (T) therapy on the hypogonadal state& other parameters of the syndrome. METHODS: In the past two years 88 patients with metabolic syndrome presented to the metabolic and andrology outpatient clinics of the Alexandria school of Medicine, Alexandria, EGYPT. All Patients were subjected to evaluation of the body mass index (BMI), Glycosylated hemoglobin (HbA1c), Lipid profile, Blood pressure measurement (BP), in addition to total & free testosterone assessment Patients proven to be hypogonadal were treated with oral T in the form of testosterone undecanuate( 120 mg daily) for a period of 3 months & then re-evaluated in regards of the prementioned parameters. RESULTS: Patient’s age ranged from 25-55 years. At initial visit all patients had a BMI >30 Kg/m2,90%of them had BP>140/90 mmHg, serum triglycerides(TG)>150mg/dl & low High density lipoproteins(HDL)<35mg/dl.The prevalence of hypogonadism was The Fourth Pan Arab Congress on Sexual Medicine 82% (72 patients)with a mean T level of< 250 ng/dl. After 3 month of treatment with the oral T, there was no significant difference in regards of the BMI, & lipid profile (p>0.05).However there was a significant increase in the total T level (p<0.01). In addition, there was a significant improvement in the control of the glycemic status (HbA1c <6.5;p<0.02). Interestingly, patients who previously failed oral PDE5I treatment responded favorably to the drug after receiving T alone. CONCLUSIONS: Hypogonadism is highly prevalent among patients with metabolic syndrome. Testosterone supplementation will not only improve the hypogonadal status, but other parameters of the syndrome as well. P42 DHEA for treating sexual dysfunction in premenopausal women Amany Shaltout Dr Samir Abbas Medical Center, Jeddah Introduction: An estimated 40% of women experience sexual dysfunction, yet information regarding treatment is still limited. Much more information is available concerning sexual dysfunction in postmenopausal than in premenopausal women. Although studies have shown that women with sexual dysfunction have lower androgen levels compared to age-matched normal control groups, yet the role of androgen treatment in women remains controversial. Aim: to evaluate the effect of DHEA in treating premenopausal women with female sexual dysfunction having normal estrogen but their androgen values were either below or in the lower quartile of the physiologic range Methods: 62 premenopausal women with ages ranging from 35 to 45 years and presenting with female sexual dysfunction were enrolled in the study. All women had healthy marital relationships, with no reported medical or psychological disease and were not on oral contraceptive use. Total testosterone, free androgen index and DHEA-S levels were measured before and after treatment. DHEA in a dose of 50 mg per day was given from 3 to 6 months until androgen values reached the upper half of the physiologic range. The FSFI was used to evaluate the sexual function before and after treatment. Results: 55% of the women had desire disorder,29% had arousal disorder, 5% had dyspareunia and 11 % had combined sexual disorders. Decreased androgen levels correlated with decreased full-scale FSFI score and FSFI-desire, FSFI-arousal, FSFIlubrication and FSFI-orgasm scores, with a statistically significant improvement in all scores after treatment. Side effects included increased facial hair (6%), weight gain (5%), acne (4%), temporary breast tenderness (1%) Conclusion: DHEA treats sexual dysfunction in premenopausal women with decreased androgen level. The rather weak conversion of DHEA into testosterone protects from the risk of overdosing associated with testosterone preparations. P43 Corporal “Snake” Maneuver: Modification of Corporoglanular Shunt Surgery for Ischemic Priapism Arthur L. Burnett, Phillip M. Pierorazio The James Buchanan Brady Urological Institute, Johns Hopkins Hospital, Baltimore, USA Introduction: Penile shunt surgery is frequently applied as part of standard priapism treatment algorithms. We describe the application of a modified distal corporoglanular shunt surgery in three patients with major ischemic priapism episodes who failed prior penile shunt surgical attempts. Patients and Methods: Three patients, ages 40, 43 and 48 years, presented with major priapism episodes of 4, 1, and 2 days duration, respectively. Priapism etiologies were idiopathic in the first patient and secondary to trazodone use in the latter two. All three had undergone initial intracorporal aspiration and irrigation procedures in combination with sympathomimetic administration as well as either Winter or Al-Ghorab corporoglanular shunt surgeries without resolving their conditions. Priapism recurred and continued for 2, 1, and 3 days, respectively, prior to their transfer and further operative management at the Johns Hopkins Hospital. All patients then underwent modified Al-Ghorab procedures: after creation of a tunical window at the surgically exposed distalmost portions of the corpora cavernosa bilaterally, a size 7/8 Hegar dilator was inserted retrogradely and then advanced using gentle boring motions to release congested, viscous blood. Blood evacuation from the corporal bodies was assisted by manual compression of the penis. Results: Penile detumescence was achieved without priapism recurrences in all patients. One patient (no. 2) reported erection recovery satisfactory for sexual intercourse within one month after surgery. Conclusion: The corporal ‘snake’ maneuver applied as a modification of the Al-Ghorab corporoglanular shunt may offer a useful surgical approach for managing major ischemic priapism, particularly that refractory to initial surgical management. P44 Penile prosthesis insertion in acute ischaemic priapism: Long term follow-up Garaffa G, Abdel Raheem A, Spillings A, Christopher AN, Ralph DJ Institute of Urology, London, UK Introduction and Aim: The long term results of the immediate penile prosthesis insertion in patients with ischaemic priapism are presented. Materials and Methods : A penile prosthesis was inserted into 53 patients (mean age 42y; range 26 -73) who presented with ischaemic priapism of a mean duration of 171 hours (24-408). All patients had failed aspiration and instillation of alpha-agonists and 28 patients had had unsuccessful shunt surgery performed prior to referral. The diagnosis was confirmed by cavernosal blood-gasanalysis, colour-Doppler-ultrasonography and cavernosal smooth muscle biopsy in 39 patients. Results: The aetiology of the priapism was related to medications (n=17), haemaglobinopathy (n=10) and idiopathic in 26 patients. A malleable prosthesis was inserted initially in 49 patients, 10 of which were later electively revised to a 3-piece-inflatable device, and 4 patients a 3-piece-inflatable prosthesis placed in the acute setting. After a mean follow-up of 17 months, 5 patients needed revision surgery due to infection (n=4) or curvature (n=1). All patients are currently able to have sexual intercourse and the satisfaction rate is of 98%. Conclusions: The immediate insertion of a penile prosthesis in ischaemic priapism is simple to perform with higher satisfaction and lower complication rates when compared to a delayed insertion. Cairo 26 - 28 February 2009 41 The Fourth Pan Arab Congress on Sexual Medicine P45 Penile Reconstruction Surgeries. The Complications stretched penile length in adults potent Egyptians was 12.9 cm while in ED patients was shorter than normal. Alexander Krakovsky P47 Primary anastomosis of the traumatically amputated penis American Academy of Phalloplasty Surgeons Objective: Today, a man is capable not only of understanding his own nature and anatomy, but also of altering it. Specifically, surgical penile reconstruction and augmentation (phalloplasty) is available to enhance the length, girth, and glans of the penis. This presentation describes surgical complications after phalloplasty surgery. Methods: In 12 patients (3.24%) serious infections developed that required different treatment. Treatment includes medical and surgical approaches and it was successful in all cases. Results: In 7 of these cases, after 2 weeks of continuous treatment with general and local antibiotics, the infection was cured. These patients were successfully signed off from the treatment with subsequent instructions regarding continuity of care. In 5 of these cases, the AlloDerm required removal in order to successfully treat the infections. Twelve patients (4.9%) experienced localized swelling 3 to 7 days after surgery. This swelling resolved spontaneously. Eighteen patients (7.3%) reported post surgical retraction that was successfully treated medically and surgically. Conclusion: All complications after penile reconstruction and augmentation surgeries are treatable and required systemic approach. The surgical procedures for infection treatment consist of several steps. First, the wound has to be cleansed, and a drain has to be inserted. The drain must be flushed regularly with an antibiotic solution for five to seven days. After that, the drain must be removed. Next, the surgeon has to follow up with the patient for two weeks. If infection has not cleared up by that time, the graft must be removed. In this study, using the described technique, the success rate for saving the graft was about 60%. Retraction treatment program also has two steps. First, the patient must contact the office immediately if this condition developed and undergo medical treatment that includes cortisone injections into the suprapubic area, as well as very intensive physiotherapy stretching exercises. If this treatment does not bring enough satisfaction, the patient undergoes surgery that includes reconstruction of suprapubic area and excision of the scar tissue. P46 Penile measurement in adult Egyptians Amr Gadalla, Hussein Ghanem, Ihab Ismail, and Mohamed Mousa Faculty of medicine, Cairo university This study aimed to determine the penile size in adults Egyptians and to clarify the relationship between fully stretched penile measurement in normal males and erectile dysfunction patients. 1027 adults Egyptians were divided into two groups; group 1(n= 949) normal adults and group 2 (n=78) ED patients. Penile length and girth were measured using a tape measure in the fully stretched states in both groups. In group 1, the mean fully stretched length was 12.9 ± 1.9 cm and the mean fully stretched girth was 8.9 ± 0.9 cm. In group 2 the mean fully stretched length was 11.2 ± 1.5 cm and the mean fully stretched girth was 8.8 ± 0.8 cm. Comparing the mean of fully stretched length in both groups revealed significant difference (P<0.001) ,while the fully stretched girth in both groups was nonsignificant (P=0.474). It is concluded that the average fully 42 Cairo 26 - 28 February 2009 Hosni K. Salem and Taymour Mostafa Departments of Urology and Andrology Cairo University. Introduction: Penile amputation is an uncommon condition for which immediate surgical replantation is warranted. Aim: To represent intervention and management for an amputated penis by replantation and reconstruction. Method: A 23 years old male presented with traumatic penile amputation for 2h where the penile proximal part was 1 cm far from the pubis. Replantation included; end to end anastomosis of urethral mucosa over a catheter, approximation of the corpus cavernosum & tunica albuginea, anastomosis of the deep dorsal vein, dorsal nerve, both dorsal arteries, and superficial dorsal vein. Results: At day 5 post-operative, the replanted penis had preserved capillary filling. The catheter was removed at day 11, where the patient urinated smoothly. Preliminary cosmetic appearance was satisfactory with frequent morning erection, reported night emission twice within the first month post-operative. Sensation was preserved in the distal anastomosed stump. Conclusion: Meticulous microsurgical technique decreases the possibility of skin loss and increases the chance of regaining erectile function. P48 Erectile Dysfunction Evaluated by the Use of Erection Hardness Score and Quality of Erection Questionaire in Taiwan Thomas I.S. Hwang, Te-Fu Tsai, Yi-Chia Lin, Han-Sun Chiang Objectives: To provide up-to-date data on the prevalence of erectile dysfunction (ED) in Taiwanese men and to investigate the effects of erection hardness score (EHS) and quality of erection questionnaire (QEQ). Methods: A representative sample of 1,060 men aged 30 years or above completed a telephone interview. ED status was obtained by direct questioning and by the abridged five-item version of the 15-item International Index of Erectile Function (IIEF-5) assessment. Responses regarding the EHS, QEQ, marital and sexual satisfaction, and attitude to treatment were also obtained. The data were analyzed with simple descriptive statistics and linear regression. Results: The prevalence of ED as defined by IIEF-5 was 27% among all respondents and 29% among those aged 40 or above. The prevalence of ED increased with age but men of all ages tended to underestimate their erectile problems. Among the men self-reported not having ED, 25% were found to have mild to moderate ED by IIEF-5 assessment. EHS 3,2,1 are 22%, 5%, and 3% respectively, (30% in total), which is similar to the prevalence of ED (27%) in Taiwan. In addition to ED, chronic diseases including prostate hyperplasia, diabetes, and heart disease also had a negative impact on EHS. EHS is consistent with QEQ, when the EHS is 4, the satisfaction of each domain of QEQ ranges from 85 to 90%. The QEQ score correlated well with the IIEF-5 score in Taiwan, and was found to be a significant variable affecting both sexual and marital satisfaction (p<0.005). Conclusion: ED is common in Taiwan, with a prevalence of 27% The Fourth Pan Arab Congress on Sexual Medicine among men aged 30 or above; however, tend to be neglected the presence. EHS is considered to be a simple, practical tool clinically. QEQ score is suggested to be value in the assessment and monitoring of ED patients. P49 Length-preserving correction of penile curvature by corporal rotation Osama Shaeer and Kamal Shaeer Department of Andrology, Cairo University Aim: Correction of extreme degrees of penile curvature by plication of the convex aspect of the corpora cavernosa can result in significant shortening. This work describes corporal rotation whereby ventral and dorsal curvatures of up to 90 degrees can be corrected with neither shortening nor erectile dysfunction. Material and Methods: Corporeal rotation was performed in 22 patients with various degrees of curvature. Degree of deviation, erect penile length, symmetry, and erectile function were evaluated and compared pre and post operatively. Main outcome measures: Penile straightness, length, girth and erectile function Results: Full correction of curvature was achieved in 20 out of 22 patients, with no shortening, asymmetry or erectile dysfunction. Residual curvature in 2 patients was no more than 10 degrees. Conclusions: Corporal rotation can restore straightness to the penis with no loss in phallic length, asymmetry, or erectile dysfunction. While a variety of surgical techniques are feasible for correction of milder degrees of curvature, we believe that severe degrees should be spared the shortening and corrected by corporeal rotation. P50 Safety and efficacy of escitalopram in the treatment of premature ejaculation Selim O, Ghanem H, Hosny H, Abd-Elhady A, Sultan G Department of Andrology,Sexology and STDs, Cairo university Introduction: Premature ejaculation (PE) is the most common male sexual disorder. Selective serotonin reuptake inhibitors (SSRIs) have been used off-label for PE, with varied results. escitalopram has the highest selectivity for the human serotonin transporter. Aim: To evaluate the efficacy and safety of most selective serotonin reuptake inhibitor drug, escitalopram, in delaying ejaculation in patients with premature ejaculation (PE). Study design: double blind randomized placebo controlled study. Material and Methods: A total of 100 married men (mean age, 36.25 years) with PE were randomly assigned to receive 10 mg of escitalopram (n = 50; GroupA) or placebo (n = 50; Group B) for 4 weeks. Pretreatment evaluation included history and physical examination, intravaginal ejaculatory latency time (IELT), International Index of Erectile Function (IIEF-5), and Arabic Index of Premature Ejaculation (AIPE). The efficacy of 2 treatments was assessed after 2 weeks and at the end of study. Results: At the end of 4-week treatment, the escitalopram group had a 6.03-fold increase of the geometric mean IELT, whereas after placebo, the geometric mean IELT did not increase significantly 1.325-fold (P = 0.001). AIPE score showed marked improvement in group A and IIEF-5 clarified safety of escitalopram on erectile function. Minor insignificant side effects were recorded. Conclusions: Oral escitalopram seems to be an effective treatment for PE. Further studies are required to draw final conclusions on the efficacy of this drug in PE. P51 Erectile Dysfunction among Saudi Patients with Type 2 Diabetes Mellitus, Hypertension and/or Dyslipidemia: Impact of Applying Different Methods of Inquiring Techniques Ahmed I. El-Sakka, Ahmed M. Hegazy, Tarek A. Ismail, and Epidemiology Study group in Saudi Arabia Suez Canal University, Ismailia, Egypt, Al-Noor Specialist Hospital, Makkah, Saudi Arabia, Pfizer Global Pharmaceuticals, Saudi Arabia Purpose: Our objective was to determine the impact of applying different methods of inquiry techniques on the detection of erectile dysfunction (ED) among patients with type 2 diabetes mellitus, hypertension and/or dyslipidemia in Saudi Arabia Material and Methods: A total of 5004 male patients (30-70 years) in Saudi Arabia who had attended 500 selected primary care clinics and who sought treatment for one or more of the following: diabetes mellitus, hypertension and/or dyslipidemia were the candidates of this study. Patients were divided into three groups according to inquiring technique : (1) voluntarily complain of ED, (2) respond to only one direct question about ED in which the answer of the patient is either yes or no, and (3) answer the SHIM (Sexual Health Inventory for Men) Questionnaire respectively. At screening visit, patients were also interviewed for socio-demographic data and medical history. 4817 patients provided complete answers and their data were subjected to statistical analysis. Results: Mean age ±SD for the study sample was 50.2±8.3 years. No significant difference in age among the three investigated diseases. The overall prevalence of ED was 63.8% among the study population. There were significant differences in ED prevalence 41.1%, 68.9% and 83.1% among groups 1, 2 and 3 respectively (p<0.001 for each). After adjustment for disease, the detection of ED was 43.9%, 77.5% and 88.2% in diabetics 38.1%, 64.5% and 79.7% in hypertensives; and 42%, 64.6% and 81.3% in dyslipidemics according to the groups 1, 2 and 3 respectively (p<0.001 for each). Stratification analysis of data according to the method of inquiring technique revealed a significant increase of ED detection in group 3 than groups 1 and 2 and a significant increase of ED detection in group 2 than group 1 irrespective to the age groups. Conclusions: Erectile dysfunction was very prevalent among patients in Saudi Arabia with diabetes, hypertension and/or dyslipidemia. The use of SHIM questionnaire had significantly augmented the detection rate of ED in comparison to voluntary complain or using a direct closed end question techniques among our patients. P52 Repeated intracorporeal self-injection: effect on peak systolic velocity and cavernosal artery diameter Mohamed Abbas, Awad H, El-Karaksy A, Mostafa T, Kamel II, Arafa M, Zeidan A Department of Andrology, Cairo University Aim: To evaluate the effect of repeated intracavernosal injection (ICI) self-injection on the peak systolic velocity (PSV) and the diameter of cavernosal arteries. Methods: Sixty erectile dysfunction (ED) patients who were positive responders for ICI therapy were studied. Pharmacopenile duplex ultrasonography (PPDU) was carried out before starting ICI Cairo 26 - 28 February 2009 43 The Fourth Pan Arab Congress on Sexual Medicine and after 10 doses of home therapy in an open-label uncontrolled study. Results: There was significant increase in the cavernosal artery diameter and their PSV before and after injection. Cavernosal arteries diameter before injection in both right and left sides was 0.64+/-0.13 and 0.63+/-0.12 mm at the start and became 0.81+/0.22 and 0.79+/-0.22 mm respectively at the end with significant differences (P<0.001). Cavernosal arteries diameter after injection in both right and left sides was 1.10+/-0.18 and 1.09+/-0.19 mm at the start and became 1.34+/-0.39 and 1.27+/-0.33 mm respectively at the end with significant differences (P<0.001). PSV at the start was 33.77+/-13.26 and 32.33+/-8.09 cm/s on both right and left sides and became 44.4+/-1.19 and 46.1+/-5.86 cm/s respectively at the end with significant differences (P<0.001). Conclusion: Repeated ICI improves arterial erectile response with associated increase in PSV and cavernosal artery diameters. P53 A pilot study: Is penile length a factor on treatment of erectile dysfunction with PDE-5 inhibitor? Murat Savas, Ercan Yeni, Halil Ciftci, Ufuk Topal, Mazhar Utangac, Ayhan Verit Harran University Medical School, Department Of Urology, Sanliurfa - TURKEY Introduction: Erectile dysfunction (ED) is highly prevalent diseases among men and several factors can be conduce to failure treatment of erectile dysfunction with PDE-5 inhibitors. Aim: The aim of this study was to investigate the impact of penile size on treatment of ED with PDE-5 inhibitor (tadalafil 20 mg). Methods: We prospectively scrutinized and enrolled to the present study 42 consecutive patients with ED. All the measurements of penile length in fully stretched states and IIEF-ED scores were recorded by the same physician (MS). Main outcome and measures: Patients were divided into three groups according to stretched penile length as small (<25th percentiles), normal (25-75 percentiles) and large (>75th percentiles). Before and after treatment period mean IIEF-ED scores were recorded. Patients received tadalafil 20 mg, taken on demand, for at least 6 times. Results: Overall the mean stretched penile length was 13.44±2.4 (range 9.50-18.00) cm. Overall mean IIEF-ED domain scores for before and after treatment period were recorded as 11.90±4.78 and 18.67±6.70, respectively. Althought PDE-5 inhibitor treatment significantly improved all domains of the IIEF-ED scores (p<0.05), no statistically significant difference was found among three groups according to mean IIEF-ED domain scores before and after treatment (p>0.05). Conclusion: We concluded that penile size is not a factor on treatment ED patients with a PDE-5 inhibitor. P54 The evaluation of lifelong erectile dysfunction with nocturnal penile tumescence rigican (NPTR) testing combined with a phosphodiesterase type 5 inhibitor Abdel Raheem A, Garaffa G, Spillings A, Christopher AN, Ralph DJ Institute of Urology, London, UK Aim : Young men with lifelong erectile dysfunction (ED) that have failed phospho-diesterase type 5 inhibitor (PDE5I)medication often 44 Cairo 26 - 28 February 2009 end up with surgery due to the inability to establish a diagnosis. This study assesses the effect that a PDE5I has on nocturnal erections. Material and Methods : Twelve men with lifelong ED and having failed PDE5I medication were evaluated. All patients had a radiological diagnosis of veno-occlusive dysfunction by penile duplex. All patients then had 2 nights of nocturnal penile tumescence and rigidity (NPTR) monitoring with 100mg sildenafil given on the second night. A normal NPTR test was considered when there were 2 erectile episodes of 10 minutes duration with 70% base and tip rigidity. Results : For the first night, 10/12 patients had an abnormal NPTR. On the second night with the addition of sildenafil, 4/12 patients continued to have an abnormal NPTR (true PDE5I failures), those patients were managed surgically. Of the 8 patients (2 psychogenic + 6 organic) that were now shown to respond to PDE5I therapy, 6 were successfully managed conservatively and 2 ended up having surgery. Conclusion : Young men with lifelong ED are notoriously difficult to manage. They are often extremely anxious individuals which results in an abnormal failure to relax their cavernosal smooth muscle, even in response to a PDE5I or PGE1 intracavernosal injections resulting in a false positive diagnosis of veno-occlusive dysfunction. NPTR testing with PDE5I is the investigation of choice in these patients to obtain a diagnosis that is not biased by psychogenic factors and confirm that it is worthwhile re-challenging the patient with further PDE5I therapy. This test will reduce the number of unnecessary operations in these patients. P55 Oral phosphodiesterase-5 inhibitors and sperm functions Taymour Mostafa Department of Andrology, Cairo University Background: cGMP-specific PDE5 is one of the PDEs that have been intensively studied because of its fundamental pharmacological relevance, as oral PDE5 inhibitors are used successfully in treating erectile dysfunction. Specific relevance of the cGMP system in reproductive functions has been recently proposed. Aim: To elucidate the possible effects of phosphodiesterase-5 (PDE5) inhibitors on sperm functions. METHOD: A systematic review of published studies in this affair based on a Pubmed and medical subject heading databases search of all concerned articles. MAIN OUTCOME MEASURES: Demonstrated beneficial as well as applicable uses of oral PDE5 inhibitors. Results: Oral PDE-5 inhibitors were shown to be devoid of effects on semen volume, concentration, sperm membrane integrity or sperm penetration assay. Most available studies demonstrated a significant increase in sperm motility and viability both in vivo and in vitro, which seems to be enhanced at low doses and reduced at high concentrations. In addition, these molecules showed a role in capacitation and a debated one concerning acrosome reaction. Conclusion: Due to the relative short period since the launching of oral PDE5 inhibitors, more investigations should be carried out in wider scales to assess their effect(s)on variant sperm function that could be beneficial as potential therapeutic approaches. The Fourth Pan Arab Congress on Sexual Medicine P56 Couple satisfaction to different therapeutic modalities for organic erectile dysfunction Ashraf Hassan, El-Hadidy M, El-Deeck BS, Mostafa T Department of Dermatology & Andrology, Mansoura University, Egypt INTRODUCTION: Erectile dysfunction (ED) treatment studies do not measure treatment response and treatment satisfaction (both patient and partner satisfaction) where dissatisfaction reflects an aspirations/achievement gap. AIM: To test the subjective implications of satisfaction to various therapeutic modalities for pure or mixed organic ED, and to address changes in the health-oriented quality of life (QoL) and the relation of psychiatric status of these patients to treatment satisfaction. METHODS: A prospective study included of 354 couples classified according to their line of therapy into five treated groups: testosterone, sildenafil citrate, intracavernosal injection, external negative vacuum device, and penile prosthesis. MAIN OUTCOME MEASURES: Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) and the International Index of Erectile Function (IIEF). Satisfied patients were compared to unsatisfied cases using the PCASEE scale for QoL and Middlesex Hospital Questionnaire (MHQ) for psychiatric status. RESULTS: Sildenafil citrate-treated group represented the highest mean value of satisfaction score on EDITS, erectile function, orgasmic function, and overall satisfaction domains of IIEF. Penile implants-treated group was the second for satisfaction score on EDITS. The testosterone-treated group represented the highest mean value for sexual desire domain score of IIEF. Low scores in various domains of QoL were significantly improved among satisfied cases more than unsatisfied subjects after therapy. High association was found between dissatisfaction and scores for anxiety, obsession, and phobia, followed by scores of depression and somatic concomitant of anxiety. CONCLUSION: ED is best conceived as intermingle of somatic, lifestyle, psychological, and partner relationship determinants. This should be taken into account to increase sexual satisfaction with improved QoL, and not only to produce rigid erection. Cairo 26 - 28 February 2009 45 The Fourth Pan Arab Congress on Sexual Medicine Bayer Satellite Symposium Symposium Title : Restore the man Chairpersons : Amr El Meliegy The link between underlying medical conditions & ED " Is there a role for PDE5 inhibitors Ian Eardley (UK) The link between metabolic syndrome , hypogonadism (TDS) and ED. " The benefits of new long acting testosterone therapy. Aksam Yassin Cairo 26 - 28 February 2009 47 The Fourth Pan Arab Congress on Sexual Medicine Pfizer satellite Symposium Restoring Hardness of Erections, Restoring Confidence: Patient’s perspectives. John Dean (UK) President, International Society for Sexual Medicine Restoring Hardness of Erections, Restoring Confidence: Physician’s perspectives. John Mulhall (USA) Associate Professor of Urology, Director of the Sexual Medicine Program, and Director of Sexual Medicine Research Laboratory at Weill Medical College of Cornell University Restoring Hardness of Erections, Restoring Confidence: Pharmacological perspectives. Tarek Anis (Egypt) Professor of Andrology, Cairo University 48 Cairo 26 - 28 February 2009