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Sympathetic fibers to the clitoris are derived from the hypogastric nerve erectile dysfunction levitra viagra plus 400 mg low price, which is in turn derived from the paravertebral sympathetic chain ganglia (Giuliano et al erectile dysfunction diabetes qof buy viagra plus 400 mg online, 2002). The dorsal nerve of the clitoris is the principal somatic sensory innervation of the clitoris and surrounding tissues. These fibers are positive for cholinergic and nitrergic neurons (Yucel and Baskin, 2004). It is implied that the vasoactive neuronal innervations from cholinergic and nitrergic fibers are relevant primarily to the erectile portions of the clitoris, whereas sensory neurons are of primary importance in the clitoral glans. Clitoral stimulation is typically pleasurable for women and may lead to orgasm; the nature of desirable stimulation however varies from woman to woman and may vary for a woman in different circumstances (Leff and Israel, 1983). Internal Genitalia Like the labia minora, the vulvar vestibule is derived from embryonic endoderm (Woodruff and Friedrich, 1985). The hymen is a circumferential skin structure located immediately proximal to the vaginal introitus. There is variability in hymen appearance but in most cases it has fenestrations to permit passage of menstrual blood. The urethra, although not technically a sexual organ, is in close approximation to the vagina and clitoris, and periurethral tissue may engorge during sexual arousal. The distal urethra also contains glandular elements known as Skene glands, which may produce some fluid during sexual arousal (Goldberg et al, 1983). Conservativestrategies failed to resolve the clitoral pain; both women underwent a dorsal slit procedure that resolvedtheglansbalanitis. Vagina the vagina is a tubular structure with a mucosal surface that connects to the endodermal tissue of the vulvar vestibule. There are four layers to the vagina; from superficial to deep, these include the mucosa, lamina propria, muscularis, and areolar connective tissue rich in collagen and elastin. There is a rich network of vascular tissue in the lamina propria, which permits engorgement of the vagina with blood during sexual arousal (Musicki et al, 2009). The muscularis layer is composed of outer longitudinal fibers and inner circular fibers (Munarriz et al, 2002a). In premenopausal women, the vagina has a baseline level of moisture that may allow for sexual intercourse even without additional production of vaginal transudate fluid (van Lunsen and Laan, 2004). The acidity of the vagina is maintained in part by the metabolism of glycogen from the vaginal mucosa into lactic acid (Goldstein and Alexander, 2005). More recent evidence has suggested that vaginal epithelial cells may also contribute to vaginal acidity by direct secretion of hydrogen ions by an estrogen sensitive mechanism (Gorodeski, 2005). Perturbations of vaginal pH may be cause or effect of bacterial overgrowth, infection, and vaginal discomfort (Bachmann et al, 1999). Changes in pH and the absence of Lactobacilli have been associated with a loss of estradiol (E) effect after menopause; this may predispose women to bladder or vaginal infection with enteric organisms (Bachmann, 1995). There appears to be ethnic variability between women with respect to vaginal microbiome (Zhou et al, 2004). These variations are not necessarily pathologic and there may be a cultural/dietary component to some of the variability (Ravel et al, 2011). These differences may also explain (or be explained by) ethnic variations in vaginal pH that have been reported (Ravel et al, 2011). The vagus is purported to serve as a "bypass mechanism," by which women who have had spinal cord injury may still experience vaginal and cervical sensation (Komisaruk et al, 2004). Sympathetic fibers to the vagina are derived from the hypogastric nerve, which is in turn is derived from the paravertebral sympathetic chain ganglia (Giuliano et al, 2002). In rodent studies the sympathetic fibers to the vagina are localized to the lower thoracic and upper lumbar spinal roots (Nadelhaft and Booth, 1984). The density of nerve receptors is greatest in the distal portion of the vagina (Pauls and Berman, 2002) and on the anterior vaginal wall (Hilliges et al, 1995). Vaginal blood supply is derived from the vaginal branches of the uterine and hypogastric arteries proximally and from the middle hemorrhoidal and clitoral arteries distally (Salonia et al, 2010). More recently, some authors have reported the presence of distinct periurethral tissues that are more developed in women who report pleasure from G-spot stimulation and/or female ejaculation (Wimpissinger et al, 2007). Female ejaculation is itself a controversial topic in that glandular elements capable of producing significant volumes of fluid are difficult to locate radiographically or anatomically in women. This suggests a glandular source potentially analogous to the male prostate and argues against female ejaculate as urine (Goldberg et al, 1983; Davidson et al, 1989).

At 3 months erectile dysfunction due to drug use purchase generic viagra plus on line, the capsule that forms around the reservoir typically protects it from any pressure increase and decreases the incidence of autoinflation (Wilson and Mulcahy impotence pills discount viagra plus 400 mg online, 2006). It is important for the patient to understand that capsule formation should occur when the reservoir is full, and the reservoir should not be left in a partially filled state for extended periods. If the capsule forms around a partially filled reservoir, the capsule will restrict future expansion of the reservoir, prohibit complete cylinder emptying, and potentially cause autoinflation, resulting in a need for surgical revision. Abbosh and colleagues (2012) described the use of outpatient laparoscopic capsulotomy to treat this problem. The extent to which a patient experiences postoperative pain varies depending on his tolerance and any preexisting conditions. An empty reservoir is placed through the nasal speculum next to the bladder, the speculum is removed, and the reservoir is filled with the appropriate amount of saline. A back-pressure test performed by applying gentle pressure on the lower abdominal wall. A palpable reservoir or back-pressure of saline noted into the syringe is an indication that it has not been properly positioned. A surrogate test should then be performed, using a syringe as the reservoir, to confirm proper reservoir placement and check for backpressure. It is important that the prosthesis is completely deflated before tubing from the pump is trimmed and connected to tubing from the filled reservoir. Every effort must be made to maintain the reservoir full during the immediate postoperative period to prevent autoinflation of the device later on. Allowing healing to occur over a partially filled reservoir limits its ability to store an adequate volume of saline. If hematuria if present at this point, it could potentially indicate injury to the bladder wall, which must be ruled out before closing. Closure At this point, the surgical site should be irrigated and reexamined for hemostasis. When hemostasis is confirmed, Buck fascia and the dartos muscle are closed, followed by closure of the skin. A benefit of using nonabsorbable sutures are the warm baths (lying flat, not sitting) started on postoperative day 3, which help relieve pain, decrease any swelling or edema, and keep the scrotum clean. The catheter can be removed the morning after the surgery by the patient at home, and the stitches are removed after 14 days. The use of a closed-suction drain to reduce the risk of hematoma after inflatable penile implant surgery is controversial. Two retrospective studies investigating the use of drains did not produce conclusive results, and there have been no randomized controlled clinical trials evaluating the efficacy of using a drain after implant surgery (Wilson et al 1996; Sadeghi-Nejad et al, 2005; Kramer et al, 2011). Proponents posit that draining the scrotum can decrease edema, increase comfort, and decrease the time to initiation of device cycling. Opponents argue that draining increases the risk of infection, drain fracture, bleeding during placement, and damaging the device and inconveniences the patient, who then has to return to the clinic the following day to have the drain removed (SadeghiNejad et al, 2005; Kramer et al, 2011). An oral narcotic is often required the first week, followed by nonsteroidal anti-inflammatory medication as needed. The first postoperative visit typically occurs at 2 weeks to assess wound healing and manage any signs of autoinflation. During this visit, it is critical to identify early signs or symptoms of local infection. The patient again returns to the clinic at approximately 4 weeks after surgery for an appointment focusing on how to operate the device. Initial inflation of the prosthesis may be difficult, and the patient should be instructed to cycle the device. The patient can then attempt sexual intercourse as soon as he feels comfortable using the device. Subsequent follow-up at 3 months, 6 months, and then annually should be scheduled to assess healing, particularly cylinder tip position in the glans; device functioning; and patient satisfaction.

PostoperativeManagement Sterile fluff gauze dressings are held in place with a snug-fitting scrotal supporter erectile dysfunction drugs market viagra plus 400 mg visa. They wear a scrotal supporter at all times (except in the shower) impotence while trying to conceive discount viagra plus 400 mg, even when sleeping, for 6 weeks postoperatively. Thereafter, a scrotal supporter is worn during athletic activity until pregnancy is achieved. Semen analyses are obtained at 1, 3, and 6 months postoperatively and every 6 months thereafter. If azoospermia persists at 6 months, a redo vasovasostomy or vasoepididymostomy will be necessary. Vasoepididymostomy Before the development of microsurgical techniques, accurate approximation of the vasal lumen to that of a specific epididymal tubule was not possible. Vasoepididymostomy was performed by aligning the vas deferens adjacent to a slash made in multiple epididymal tubules and hoping a fistula would form. Microsurgical approaches allow accurate approximation of the vasal mucosa to that of a single epididymal tubule (Silber, 1978), resulting in marked improvement in the patency and pregnancy rates (Schlegel and Goldstein, 1993; Chan et al, 2005). Microsurgical vasoepididymostomy, however, is the most technically demanding procedure in all of microsurgery. Microsurgical vasoepididymostomy should be attempted only by microsurgeons who perform the procedure frequently. Indications the indications for vasoepididymostomy at the time of vasectomy reversal are reviewed in the earlier section on vasovasostomy. For obstructive azoospermia not caused by vasectomy, vasoepididymostomy is indicated when the testis biopsy reveals complete spermatogenesis and scrotal exploration reveals the absence of sperm in the vasal lumen with no vasal or ejaculatory duct obstruction. The preoperative evaluation is identical to that described earlier for vasovasostomy. Microsurgical End-to-Side Vasoepididymostomy End-to-side techniques of vasoepididymostomy have the advantage of being minimally traumatic to the epididymis and relatively bloodless (Table 25-2) (Wagenknecht et al, 1980; Krylov and Borovikov, 1984; Fogdestam et al, 1986; Thomas, 1987; Chan et al, 2005; Schiff et al, 2005). When the level of epididymal obstruction is clearly demarcated by the presence of markedly dilated tubules proximally and collapsed tubules distally, the site at which the anastomosis should be performed is readily apparent. The endto-side approach has the advantage of allowing accurate approximation of the muscularis and adventitia of the vas deferens to a precisely tailored opening in the tunica of the epididymis. This is the preferred technique when vasoepididymostomy is performed simultaneously with inguinal vasovasostomy because it is possible to preserve the vasal blood supply deriving from epididymal branches of the testicular artery. This provides blood supply to the segment of vas intervening between the two anastomoses. The vas deferens is identified, isolated with a Babcock clamp, and then surrounded with a Penrose drain at the junction of the straight and convoluted portions of the vas deferens. If microscopic examination of this fluid reveals the absence of sperm, the diagnosis of epididymal obstruction is confirmed. When sperm are found, the puncture sites are sealed with microbipolar forceps, a new buttonhole is made in the epididymal tunic just proximal, and the tubule is prepared as described previously. The vas deferens is drawn through an opening in the tunica vaginalis and secured in proximity to the anastomotic site with two to four interrupted sutures of 6-0 polypropylene placed through the vasal adventitia and the tunica vaginalis. The vasal lumen should reach the opening in the epididymal tunica easily, with length to spare. The posterior edge of the epididymal tunica is then approximated to the posterior edge of the vas muscularis and adventitia with two to three interrupted sutures of double-armed 9-0 nylon. This is done in such a way as to bring the vasal lumen in close approximation to the epididymal tubule selected for anastomosis. Further confirmation of patency may be obtained by injecting indigo carmine, catheterizing the bladder, and observing blue-tinged urine. After the tunica vaginalis has been opened, the epididymis is inspected under the operating microscope. An anastomotic site is selected above the area of suspected obstruction, proximal to any visible sperm granulomas, where dilated epididymal tubules are clearly seen beneath the epididymal tunica.

The superficial nodes drain to the deep inguinal nodes (those deep to the fascia lata) erectile dysfunction cream viagra plus 400mg visa. From there jack3d impotence cheap viagra plus generic, drainage is to the pelvic nodes (external iliac, internal iliac, and obturator). Penile lymphangiographic studies demonstrate a consistent pattern of drainage that proceeds from superficial inguinal to deep inguinal to pelvic node sites without evidence of ipsilateral drainage (Cabanas, 1977, 1992). Multiple cross-connections exist at all levels of drainage, so that penile lymphatic drainage is bilateral to both inguinal areas. Metastatic enlargement of the regional nodes eventually leads to skin necrosis, chronic infection, and death from inanition, sepsis, or hemorrhage secondary to erosion into the femoral vessels. Clinically detectable distant metastatic lesions to the lung, liver, bone, or brain are uncommon and are reported to occur in 1% to 10% of patients in most large series (Staubitz et al, 1955; Riveros and Gorostiaga, 1962; Beggs and Spratt, 1964; Derrick et al, 1973; Johnson et al, 1973; Kossow et al, 1973; Puras et al, 1978, reviewed in Pettaway et al, 2010). Such metastases usually occur late in the course of the disease after the local lesion has been treated. Carcinoma of the penis is characterized by a relentless progressive course, causing death for the majority of untreated patients within 2 years (Beggs and Spratt, 1964; Skinner et al, 1972; Derrick et al, 1973). Rarely, long-term survival occurs, even with advanced local disease and regional node metastases (Furlong and Uhle, 1953; Beggs and Spratt, 1964). Five percent to 15% of patients have been reported to develop a second primary neoplasm (Buddington et al, 1963; Beggs and Spratt, 1964; Gursel et al, 1973), and one series reported secondary carcinoma in 17% of patients (Hubbell et al, 1988). ModesofPresentation Signs It is the penile lesion itself that usually alerts the patient to the presence of penile cancer. The presentation ranges from a relatively subtle induration or small excrescence to a small papule, pustule, warty growth, or more luxuriant exophytic lesion. It may appear as a shallow erosion or as a deeply excavated ulcer with elevated or rolled-in edges. Eventually, erosion through the prepuce, foul preputial odor, and discharge with or without bleeding call attention to the disease. Penile tumors may arise anywhere on the penis but occur most commonly on the glans (48%) and prepuce (21%). Other tumors involve the glans and prepuce (9%), the coronal sulcus (6%), or the shaft (<2%) (Sufrin and Huben, 1991). This distribution of lesions may be the result of constant exposure of the glans, coronal sulcus, and interior prepuce to irritants. Rarely, a mass, ulceration, suppuration, or hemorrhage in the inguinal area may be caused by nodal metastases from a lesion concealed within a phimotic foreskin. Urinary retention or urethral fistula from local corporeal involvement is a rare presenting sign. NaturalHistory Carcinoma of the penis usually begins with a small lesion that gradually extends to involve the entire glans, shaft, and corpora. The lesion may be papillary and exophytic or flat and ulcerative; if it is untreated, penile autoamputation may occur as a late result. The rates of growth of the papillary and ulcerative lesions are similar, but the flat, ulcerative tumor has a tendency toward earlier nodal metastasis and is associated with poorer 5-year survival rates (Dean, 1935; Marcial et al, 1962; Ornellas et al, 1994). Lesions larger than 5 cm (Beggs and Spratt, 1964) and those extending over 75% of the shaft (Staubitz et al, 1955) are also associated with an increased incidence of metastases and a decreased survival rate. However, others have not found a consistent relationship among lesion sizes, presence of metastases, and decreased survival (Ekstrom and Edsmyr, 1958; Puras et al, 1978). Buck fascia acts as a temporary natural barrier to local extension of the tumor, protecting the corporeal bodies from invasion. Penetration of Buck fascia and the tunica albuginea permits invasion of the vascular corpora and establishes the potential for vascular dissemination. Urethral or bladder involvement is rare (Riveros and Gorostiaga, 1962; Thomas and Small, 1968). The earliest route of dissemination from penile carcinoma is metastasis to the regional femoral and iliac nodes. A detailed description of lymphatic drainage of the penis is found elsewhere in this text and is well documented in the literature (Dewire and Lepor, 1992).