Biomedical subjects
Publications and source records attributed to W J Hellstrom.
Flow cytometry can be performed on testicular aspirates of vasovasostomy candidates preoperatively. On the basis of ploidy ratios and debris components, DNA histograms can be classified as normal or abnormal. Using this method, the likelihood of the presence of sperm may be predicted.
For the neurologically impaired patient electroejaculation with a rectal probe can furnish sperm for artificial insemination. However, documentation of pregnancies in this patient group has been limited. Deoxyribonucleic acid flow cytometry has been shown to be a reproducible quantitative method with which to evaluate spermatogenesis. We assessed the ability of deoxyribonucleic acid flow cytometry on testicular aspirates to predict the quality of sperm production in 13 men undergoing electroejaculation. Semen analysis was performed on antegrade and retrograde specimens. Deoxyribonucleic acid histograms from testicular aspirates were evaluated for the relative proportions of haploid, diploid and tetraploid cells. These ratios were compared to the means reported for our own series of 25 patients who at vasovasostomy had sperm intraoperatively and to the similar figures from a group of 10 accident victims. Five patients had normal testicular ploidy compartments defined as within 2 standard deviations from control means. Of the 5 patients 4 had normal sperm counts and motilities (30 per cent or greater). Two patients have contributed sperm for artificial insemination; 1 has resulted in pregnancy. Three patients had moderately abnormal (2 to 4 standard deviations) testicular ploidy classes. These patients had adequate sperm counts but low motilities (5 per cent or less). Of the 5 patients with markedly abnormal (greater than 4 standard deviations) histograms 4 remained azoospermic despite repeated attempts at electroejaculation. Our data support the use of deoxyribonucleic acid flow cytometry on testicular aspirates as a predictor of which patients might succeed and those who are unlikely to succeed in an electroejaculation program.
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The correlation between the amount and location of antisperm antibody binding to the sperm surface and the level measured in the serum has not been previously reported. Hence, the value and limitations of screening blood sera from men with suspected immunologic infertility are not currently known. In this study 70 paired sera and semen samples were assayed by the immunobead test (IBT). A screening protocol for blood sera was constructed to be 100% sensitive for detecting semen specimens with 20% or more of sperm binding IgG or IgA immunobeads. The specificity of this screening protocol was determined to be 79%. Serum IgA was not a good predictor of IgA on the sperm surface. The true positive predictive rate for antisperm antibodies on the sperm surface using circulating antisperm antibodies as a screening assay was estimated to be as low as 35%. There was little correlation between the site of immunobead binding following passive antibody transfer from patients' sera to donor sperm and the site of naturally occurring antibodies on the patients' sperm surface. Although direct assessment of antibodies on the sperm surface is preferred, these data suggest that serum IgG alone can be used as a sensitive screening assay for antisperm antibodies in men. A positive screen dictates that a direct assay on semen should be performed.
Although chronic nonbacterial prostatitis is common, the condition remains poorly understood and refractory to treatment. Another approach, i.e., a urodynamic explanation, seems warranted. The underlying cause of the symptoms may be an inappropriate spasm of of the distal urethra/external sphincteric unit, leading to increased pressure in the prostatic urethra with a resultant reflux of urine into the prostatic ducts. The presence of urine (sterile or infected) could induce ductal and periductal inflammation, which could further aggravate spasm of the involved pelvic musculature, exacerbating the voiding dysfunction. We present 3 patients in whom this sequence of events was documented radiographically and urodynamically. Consequently, treatment involved modulation of the dysfunction of the distal urethra/external sphincteric unit: (1) reeducation by reassurance and biofeedback was the initial line of therapy; (2) pharmacologic manipulation using alpha-blockers (to affect smooth and striated muscle irritability) and striated muscle relaxants was next tried; (3) finally, in unremitting symptoms, we used selective sacral-root electro-stimulation, successfully fatiguing the involved muscles and relieving the voiding dysfunction.
We believe that, without evidence of inflammation (greater than 5 WBC on VB1), there is no indication for routine culture or antibiotic treatment of infertile men. In the presence of active inflammation and positive cultures for chlamydia, treatment with antibiotics is appropriate. However, active inflammation and positive chlamydial cultures were rare findings in our population (2 of 52 and 1 of 52, respectively). Thus, we find no evidence for a role of current asymptomatic mycoplasma or chlamydial infection in male infertility.
Immunologic infertility is an important area of current clinical research. The immunobead test is a laboratory method that identifies the classes of antisperm antibodies and their binding sites on the sperm surface. In this study we have investigated the variability in the pattern of antibody binding to spermatozoa after passive transfer from blood serum. Serum from a single donor containing antisperm antibodies of the IgG class was used in all experiments. The spermatozoa from 27 semen donors were found to differ significantly in the degree and location of immunobead binding after exposure to this serum. There was substantial day-to-day variability in the results for individual semen donors and the overall variability in test results was significantly greater when a number of semen donors was used rather than a single donor. These data suggest that details of antisperm antibody binding after passive transfer from body fluids may depend on the sperm donor. The design of research studies involving antibody transfer must take this source of variability into account.
The recent introduction of intracorporeal injections of papaverine and phentolamine for the diagnosis and treatment of impotence has resulted in an increased incidence of iatrogenic priapism. Based on our research into penile hemodynamics we propose a refined approach to all types of priapism. Intracorporeal blood gas and pressure monitoring should be used to differentiate ischemic (low flow) from nonischemic (high flow) types. Most cases of papaverine-induced or phentolamine-induced priapism will respond to aspiration alone or in combination with intracorporeal instillation of a diluted alpha-adrenergic agent. In spontaneous priapism alpha-adrenergic agents can be tried first if patients have only mild or no ischemia. In patients with severe ischemia stagnant blood should be evacuated and a shunt procedure should be performed to allow metabolic replenishment of tissue. Intracorporeal pressure monitoring will help to determine the size and number of shunts needed to re-establish corporeal circulation.
We performed urological evaluations in 18 patients with the tethered spinal cord syndrome. Of the patients 4 had low grade vesicoureteral reflux but none had significant upper tract anomalies. Urodynamic studies documented a flaccid bladder in 9 patients (5 with supersensitivity to bethanechol), an uninhibited bladder in 5, mixed bladder dysfunction in 2 and normal function in 2. Repeat urodynamic studies were performed in 15 patients at least 6 months after release of the tethering. Of 8 patients with flaccid bladders studied postoperatively 6 had significant changes: 2 became normal, 2 had limited contractions and 2 had evidence of upper motor neuron abnormalities. Supersensitivity to bethanechol was of no predictive value. All 4 patients with uninhibited bladders who were evaluated preoperatively and postoperatively had improved and 3 currently are entirely normal. Careful urological evaluation of patients with the tethered spinal cord syndrome is helpful not only for diagnosis but also for appropriate management preoperatively and postoperatively. The fact that lower urinary tract function improves in some patients should encourage early and aggressive neurosurgical management of patients with this syndrome.
To elucidate the hemodynamic changes during erection, we measured corporeal blood gases in 6 monkeys before, during, and after erection induced by either papaverine or phentolamine or a combination of the two. Papaverine alone caused a strong erection (maximal tumescence and rigidity) by means of a rapid, large increase in pO2 and pCO2 with a pH drop to the acidic range. Phentolamine alone caused 'delayed' tumescence with less rigidity; the intracorporeal pO2 level increased, but pCO2 and pH values did not change significantly. The combination of both drugs offered no advantage over papaverine alone. We conclude that papaverine is a potent erection-inducing drug that acts in a bimodal manner, namely, it increases the arterial inflow and, at the same time, decreases the venous outflow. Phentolamine affects the arterial component of erectile function only.
Thirteen cases of fetal hydronephrosis associated initially with normal volumes of amniotic fluid were diagnosed by maternal sonography. No invasive procedures were done in utero. Postnatal evaluation demonstrated 8 neonates with urinary tract obstruction and 5 normal neonates. Long-term followup of these 13 patients revealed that 12 are healthy and have normal renal function. The exception is a child whose amniotic fluid decreased during pregnancy. Our data suggest that fetuses with normal volumes of amniotic fluid do well. Treatment should be limited to frequent prenatal sonography and subsequent early postnatal evaluation. Caution should be exercised with the diagnosis of hydronephrosis, since 5 of our patients had false positive findings. In the rare instances when oligohydramnios develops during pregnancy fetal intervention may be warranted.
The generation of reactive oxygen species (ROS) and sperm damage was evaluated in (a) samples obtained during electroejaculation (EE) of men with spinal cord injury and (b) in electrolyzed HAM's F-10 medium subjected to electric current in vitro. Chemiluminescence data showed a significant increase in ROS in the ejaculates (6 x 10(7) photons/ml) collected immediately after EE and in the electrolyzed medium (3 to 7 x 10(6) photons/ml) when compared to the control (4 to 7 x 10(4) photons/ml). Incubation of normal human sperm with the electrolyzed medium resulted in a significant threefold decrease in percent motility and a twofold decrease in percent viability. Sperm subjected to direct electric stimulation in vitro exhibited a significant twofold decrease in percent motility and percent viability. Superoxide dismutase (SOD) activity decreased significantly in sperm subjected to direct electric current in comparison to the control or the sample incubated with electrolyzed medium. These studies indicate that in vitro and in vivo electrical stimulation generate reactive oxygen species and affect SOD activity, which in part are responsible for decreased sperm motion and viability.
Intralesional therapy is a less invasive method for the treatment of Peyronie's disease. The objective of this study was to evaluate intralesional injections of interferon alpha 2B (IFN-alpha-2B) as an effective alternative to the surgical treatment of Peyronie's disease. Twenty-one patients with Peyronie's disease were evaluated by use of penile duplex Doppler ultrasonography for cavernosal blood flows, degree of penile curvature, and plaque size. A questionnaire was given to all patients to assess sexual function. Each patient then received biweekly intralesional injections of 1 x 10(6) units of IFN-alpha-2B in 10 ml of normal saline over a period of 6 months. There was no placebo control group in this study. At the conclusion of the study, penile duplex Doppler imaging was repeated. A questionnaire was completed by all patients to assess changes in sexual function after treatment. Twenty patients completed the study, with all men reporting subjective softening of their plaques. Nine of 10 patients initially reporting penile pain with erection (90%) had resolution of their phallalgia while on study protocol. Thirteen patients (65%) had significant improvement in curvature, ranging from 20 to 90%. Seventeen patients (85%) demonstrated an objective 10 to 80% decrease in plaque size. Biweekly intralesional injections of Peyronie's plaques with IFN-alpha-2B resulted in a significant improvement in penile curvature, diminished pain, and reduced plaque size, and resulted in a subjective improvement in sexual function.
Peyronie's disease remains an enigma. With the recent introduction of an animal model for Peyronie's disease, the entry of a number of double-blind placebo-controlled clinical trials, and the application of new molecular diagnostic methods, the investigation of this wound-healing disorder of the penile tunica albuginea should illuminate many of the unknowns. Investigators need to be open to innovations in other fields of medicine involving idiopathic fibrosing conditions in other organ systems, eg, Dupuytren's contracture, keloids, hypertrophic scarring, etc. Applications from these other disciplines will undoubtedly widen our scope about Peyronie's disease. While a minority of patients respond with observation alone, most authorities recommend at least a trial of medical therapy with a safe, inexpensive, and well-tolerated agent, as early-stage disease is reputedly more likely to respond better than patients with established, longstanding Peyronie's plaques. The reintroduction of intralesional therapies (verapamil and interferon alpha-2b) provides the clinician with an alternative minimally invasive intervention that has promising possibilities. In severe fibrotic or calcified plaques or with major structural abnormalities, the judicious use of surgery with or without grafting materials and a penile prosthesis can restore many men back to their previous level of high esteem and provide both partners an excellent quality of life.
Nitric oxide (NO) is a product of nitric oxide synthase (NOS) activity and is recognized as the main mediator of penile erection by induction of cavernosal smooth muscle relaxation. Although excessive NO can be generated via inducible NOS activation under certain inflammatory and noninflammatory conditions, for example, in response to TGF-beta and gamma-IFN (the proinflammatory cytokines), the effect of excessive NO produced as reactive nitrogen radical (NO.-) in the corpora cavernosa is not known. The present study was designed to evaluate whether the effect of NO.- on human cavernosal cells in primary culture is via oxidative stress. Cell growth was monitored by DNA synthesis, and mitochondrial function was evaluated by adenosine triphosphate (ATP) production. Primary culture was initiated with explants from human corpora cavernosa, and the monolayer cavernosal cells (passage 2-3) were plated on 12-well tissue culture plates. At 70%-80% confluency, the cells were incubated with varying concentrations of sodium nitroprusside (SNP) for 16 hours. The cell growth (DNA synthesis) was monitored by measuring [3H] thymidine incorporation, ATP levels (nanomoles per 10(4) cells) were measured by chemiluminescence assay using a luminometer, the total oxidative stress was monitored by measuring the levels of 8-iso PGF2alpha (picograms per milliliter) by using an enzyme-linked immunosorbent assay kit, and NO production was monitored by accumulation of nitrite levels (micrometer per 10(4) cells). Human cavernosal smooth muscle cells (HCSMC) exposed to SNP (0 to 0.8 mM) exhibited a dose-dependent (two- to fivefold) decrease in DNA and ATP synthesis, accompanied by a two- to threefold increase in the levels of 8-iso PGF2alpha and about an eightfold increase in nitrite accumulation. These findings suggest that the NO released by SNP (>0.8 mM) exhibited a significant cytotoxicity to HCSMC, mediated by increased oxidative stress to these cells.
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Peyronie's disease is an idiopathic, localized connective tissue disorder of the penis, involving the tunica albuginea of the corpus cavernosum and adjacent areolar space. Current proposals as to the origin of Peyronie's disease suggest that fibrosis and collagen changes of the tunica are the result of an inflammatory process following vascular trauma. Our laboratory and other investigators have recently proposed an animal model for the study of Peyronie's disease. When transforming growth factor-beta1 (TGF-beta1) was injected into the rat tunica albuginea, tissue fibrosis was observed at 6 weeks. Therefore, our aim was to assess arginase II, endothelial and inducible nitric oxide synthase isoforms, and nitrotyrosine levels--all factors involved in inflammatory reactions--in the cavernosal tissue of saline-injected and TGF-beta1-injected rats after 6 weeks in order to evaluate the roles these enzymes may play in the induction of a Peyronie's-like condition in the rat. To examine the expression of endothelial nitric oxide synthase (eNOS), iNOS, and arginase II protein, and mRNA in the corpus cavernosum, immunoblot analysis, and reverse transcriptase-polymerase chain reaction were performed. We also determined immunohistochemically the expression of nitrotyrosine, a marker of peroxynitrite formation, in the rat penis. After 6 weeks, iNOS protein and gene expression was up-regulated and eNOS protein and gene expression was down-regulated in the corpora cavernosa of the TGF-beta1-injected penises. Furthermore, arginase II protein expression as well as immunohistochemical localization of nitrotyrosine was significantly higher in the TGF-beta1-injected corpora cavernosa. These results suggest that iNOS is the key control element for peroxynitrite formation, arginase II expression, and eNOS down-regulation in the induction of a Peyronie's-like condition in the rat.
The ability of pentoxifylline to stimulate the motion characteristics of antegrade and retrograde sperm collected at the time of electroejaculation with a rectal probe was assessed in six neurologically impaired men. Before electroejaculation, the bladder was rinsed and instilled with 20 to 30 ml Ham's F-10 medium. Washed sperm were incubated with various doses (0, 0.1, 1, and 3 mmol/L) of pentoxifylline. Video sequences were recorded at intervals from 0 to 4.5 hours and analyzed for sperm motion parameters using manual and computer-assisted semen analysis. The results were compared with equimolar concentrations of caffeine. Both pentoxifylline and caffeine demonstrated a dose-dependent stimulation of percent motility and other motion parameters. A maximal stimulation of two-fold to three-fold for both percent motility and curvilinear velocity, and 30% to 60% for straight line velocity was observed after incubation under these conditions. A significant increase in mean linearity was observed in samples incubated with 0.1 mmol/L pentoxifylline at 1.5 hours. Significant lateral head displacement was not observed at any time point. Two couples underwent gamete intrafallopian transfer (GIFT) in conjunction with this electroejaculation sperm stimulation procedure, and one has since delivered a normal child. These studies show that pentoxifylline stimulation can improve the movement characteristics of asthenospermic sperm from neurologically impaired men. Such sperm stimulation techniques do not affect the fertilization process and may improve the chances for conception in some cases of male-factor infertility.