Infection From Testosterone Injection
This product is the best!The administration of testosterone substitution is injdction if both a deficiency is measured in the blood and the corresponding symptoms are reported by the testosteron gehalte testen. If the testosterone level is borderline low, special laboratory analyses testosterone injection leg cramps after be performed. Testosterone can be administered in various ways. The most natural way is the daily application of a testosterone-containing ointment, because this most closely reflects the aftre variations in testosterone levels in the blood. Alternatively, testosterone can be injected into the gluteal muscle at regular intervals or administered in the form of capsules.
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Erectile dysfunction in young men is an increasingly common chief complaint seen in urology clinics across the world 1. The international urologic community has taken an increased interest in this topic, with experts in the field of andrology and sexual dysfunction publishing multiple review articles 2 , 3 and an AUA Update Series Lesson 4 dedicated to this concerning issue.
These articles skillfully address the epidemiology and diagnostic evaluation of ED and categorize ED Table 1 into psychogenic or organic causes, addressing treatment options with specific interventions for each of the most common diagnoses.
Previous studies have shown that elevated central sympathetic tone may be one cause of impotence 6 , 7. This article focuses on the presentation, work-up, and treatment of young men age: It is important to identify the precise etiology of ED in these men before proceeding with potentially unnecessary evaluation and treatment as the process can be anxiety-provoking, invasive, and costly and may provide an unreliable diagnosis which produces further psychological distress in these psychologically fragile young men.
Sexuality and erection are controlled by multiple areas of the human brain including the hypothalamus, the limbic system, and the cerebral cortex. Stimulatory or inhibitory messages are relayed to the spinal erection centers to facilitate or inhibit erection 5. Two mechanisms have been proposed to explain the inhibition of erection in psychogenic dysfunction: Animal studies demonstrate that the stimulation of sympathetic nerves or systemic infusion of epinephrine causes detumescence of the erect penis 6 , 7.
Clinically, higher levels of serum norepinephrine have been reported in patients with psychogenic ED than in normal controls or patients with vasculogenic ED 9. Multiple authors have demonstrated that anxiety, depression, and stress clearly produce major neurochemical and neuroendocrine changes in the brain 10 , Changes in neurobiology would be expected to contribute to impaired erectile function.
Stress and anxiety lead to increased epinephrine production, and heightened sympathetic tone leads to exaggerated cavernosal smooth muscle contraction, inability of smooth muscle to relax, and subsequent erectile dysfunction 6 , 7.
Failure to achieve a fully rigid erection may aggravate performance anxiety leading to a vicious cycle. These are among the most challenging patients seen in urology practice today: These men often have co-morbid diagnoses, such as anxiety, depression, or mood disorders, which make the issue of ED more complex for both the patient and the urologist The psychological burden of ED in these young men is more pronounced than it might be in older men as this is the phase of life during which many men expect to be highly sexually active 4.
These young men are usually technologically savvy and may have scrutinized much of the readily available information on the internet regarding ED. Often they arrive to clinic armed with an understanding of the diagnostic evaluation that may be offered to further investigate the etiology of their concerns.
This makes the evaluation and treatment of these men more challenging since additional diagnostic testing is often not indicated after a thorough history and physical examination. In many cases, they may have self-diagnosed and self-treated based on the information that they obtained prior to seeing a physician. Many of these men will see multiple urologists on their quest to find a pathophysiology that they can accept, and many have unrealistic expectations of a rapid cure or a surgical cure.
Care for these patients, who in many cases are emotional, demanding, and time consuming, may evoke feelings of frustration and anticipatory anxiety in the time-strapped urologist. It is important to ensure that the doctor-patient interaction is informative and task oriented for greater patient buy-in and compliance with treatment 13 , Affirm to the patient that regardless of the short time allotted for the visit that the doctor-patient relationship will endure even after the visit.
This may be accomplished through a scheduled follow-up telephone call, electronic message, follow-up clinic visit, or a written letter. It may also be beneficial to refer the patient to a sex therapist or counselor though many young men will reject the idea that there is a psychosocial element to their ED and may refuse to consider therapy. It is important early during the visit to engage the patient and provide him reassurance that you will work as a team to evaluate and treat his disorder.
A detailed history is the most important component of the evaluation. A thorough sexual history has many components. It should begin with information regarding onset, duration, severity, patient-suspected etiology of the ED. Ask the patient to define his specific concerns. Ask specific questions regarding erectile hardness and sustainability during self-stimulation versus with a partner global versus situational ED. Determine if the patient has ED in certain positions lying down versus upright or seated.
Inquire about libido and nocturnal erections. It is also important to ask the patient about past treatments and response. Inquire about any concomitant pain issues, irritative or obstructive voiding symptoms, or pelvic floor complaints. A thorough physical examination should be performed on all new patients with emphasis on the cardiovascular, genital, endocrine, and neurologic systems.
On physical examination in a man with hypertonic cavernous smooth muscle, the penis may initially be contracted and tender to palpation. As the exam proceeds and the patient becomes less anxious, the penile tissue will often noticeably relax. After a full history and physical examination, the urologist likely has a perception of the etiology of the problem. Additional laboratory evaluations may be necessary to evaluate for specific types of organic disease. These are not mandatory components of the assessment in a patient with hypertonic cavernous smooth muscle as the source of ED.
Oftentimes, after a thorough history and physical examination, additional diagnostic testing is not necessary to categorize ED Depending on concerns raised from the history and physical examination, directed lab-work or additional studies may be conducted to ensure that the patient does not have medical disease that might be causing ED.
All men with suspected vasculogenic erectile dysfunction deserve a cardiovascular assessment These are tests that can be performed quickly during the office visit and provide useful information about the function of the dorsal nerve of the penis Table 3.
If the patient reports a history of trauma to the genitals that preceded his erectile dysfunction, further evaluation with pharmacologic injection and penile color duplex ultrasound PCDU would be indicated to assess for arterial insufficiency or venous occlusive dysfunction If those medications are effective, you have effectively ruled out significant arterial insufficiency or venous leakage disease as an etiology.
Regardless of outcome of PCDU, no surgical intervention would likely be offered to this man who responds well to oral agents. If the patient reports life-long erectile dysfunction, having never obtained an erection rigid enough for penetration, he should be assessed with an appropriate laboratory evaluation and PCDU. If the patient obtains erections in certain situations self-stimulation without medication, he does not need additional laboratory or ultrasound assessment.
His diagnosis can be made from the history alone. If the patient requires PDE5 inhibitors to obtain and maintain all erections, you might consider laboratory assessment prior to proceeding. If the patient reports intermittent ability to obtain and maintain an erection, evaluation with combined injection and stimulation test CIS will give you additional diagnostic and potentially therapeutic answers. It will determine if he has adequate inflow to obtain erection and if he has adequate venous occlusive function to maintain erection.
It may also provide reassurance to the patient that his anatomy is functional. However, it is well documented that due to increased sympathetic tone these young men will often require additional injection or a separate visit in order to respond appropriately with complete smooth muscle relaxation 7 , 20 , In most young men with ED, additional testing to assess for the origin of ED is unnecessary as the history gives you the information that you need.
With this said, it may be therapeutic for the patient to know his laboratory assessments are normal, in which case additional testing does add significant value to the assessment. From the history alone, we find that most of these men will have situational erectile dysfunction that responds well to low dose oral PDE-5 inhibitors.
If the patient does respond well to these medications, the diagnosis of neurogenic erectile dysfunction, clinically significant arterial insufficiency, or venous-occlusive dysfunction can efficiently be ruled out. If the patient responds inconsistently or does not respond to the oral medications, additional workup should be considered, dependent on the additional history provided.
If the patient reports that PDE 5 inhibitors work poorly or inconsistently, we offer CIS to objectively assess erectile function and to provide diagnostic information. After 5 minutes, instruct the patient to self-stimulate, then assess his response to injection. This often requires reversal of erection using phenylephrine after the study.
In rare patients who failed to achieve and maintain erection with 0. For patients who have ED related to hypertonic cavernous smooth muscle and excessive sympathetic discharge, we recommend a trial of a low-dose alpha adrenergic blocker, such as terazosin 1 mg PO at bedtime nightly. We typically increase the dosage as needed every 2—3 weeks for 3—5 months until the patient experiences improvement of the erection or we determine that treatment is ineffective.
We explain the potential side effects of orthostasis, dizziness, and retrograde ejaculation in detail. This detailed discussion helps to engage the patient in the treatment plan and provides encouragement regarding the potential for response to treatment and recovery. During these encounters, we utilize teaching tools, such as diagrams, drawings, printed handouts, and other visual aids to ensure that the discussion is patient-focused and patient-friendly.
Patient education is critical to exploring treatment options and developing confidence in our ability to treat the ED, and their own ability to overcome and eventually resolve the problem of ED.
If this treatment approach fails, it is useful, however frustrating, to start again from the beginning. Reassess the history to ensure that nothing was missed originally. Obtain labs and perform a PCDU. This will give the objective information that you might need in order to make a diagnosis of a known etiology for ED and to provide the patient reassurance that your evaluation has been thorough.
He also reports decreased penile sensation since the event. He can obtain and maintain an erection with masturbation. He reports inability to obtain or maintain an erection with a partner unless he takes tadalafil 5 mg.
He reports straight phallus, normal libido, orgasm, and ejaculation. The remainder of his history is negative. His physical examination is normal. Structural, neurogenic, arteriogenic, and venous occlusive erectile dysfunction can be ruled out as he has normal self-stimulated erections. He responds well to low dose oral PDE5 inhibitors. Additional assessment with cold and hot perception testing and biothesiometer were performed due to his complaint of decreased sensation; both test results were normal.
He was started on low dose terazosin once daily at bedtime along with Cialis 5 mg as needed. He is responding well to treatment. A year-old male presents with a past medical history of mild traumatic brain injury, remote bilateral orchitis, depression, anxiety, and PTSD from childhood bullying. He presents with his mother. His chief complaint is ED that began at 19 years old. He reports strong, sustainable erections with tadalafil 5 mg and recovery of sensation when he uses marijuana.
He has read extensively on the internet and self-treats with topical vitamin creams, self-administered laser treatment to the penis, pulsed electromagnetic therapy, and hyperbaric oxygen treatment for ED for the past 6 months.
He reports no change with any of these treatments. He reports reduced libido and has recently started treatment with HCG and testosterone gel for testosterone of without any change in his symptoms with T of His free T is normal. He lives at home, is unemployed, and is sedentary. Prior to the visit, his mother called the clinic to inform personnel that her son was very sensitive, potentially suicidal, and emotionally disturbed by this problem.
Treatment - Departement of Urology | University Hospital Tuebingen
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