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Endothelin synthesis is also modulated by oxygen: A low oxygen concentration promotes production gastritis diet buy 20 mg nexium otc, whereas a high concentration inhibits it. During erection and detumescence, communication should exist among cavernous smooth muscles to mediate synchronized relaxation and contraction (Christ et al, 1991). Several studies have demonstrated the presence of gap junctions in the membrane of adjacent muscle cells. These intercellular channels allow exchange of ions such as calcium and second-messenger molecules (Christ et al, 1993a). The major component of gap junctions is connexin-43, a membrane-sparing protein of less than 0. Cell-to-cell communication through these gap junctions most likely explains the synchronized erectile response, although their pathophysiologic impact is still unclear. In general, there are four major types of ion channels: (1) external ligand-gated, which open to a specific extracellular molecule. Smooth muscle has neither a T-tubule system nor a welldeveloped sarcoplasmic reticulum. Extracellular calcium plays an important role, and calcium must enter the cytoplasm through the plasma membrane during an action potential. The presence of voltage-dependent L-type calcium channels (long-duration current, slow calcium channel) in isolated cavernous smooth muscle and cultured muscle cells has been documented. Christ and colleagues (1993a) reported that both calcium influx through calcium channels and mobilization of intracellular calcium stores are involved during phenylephrineinduced and endothelin-induced contraction. Studies have shown at least four types of potassium channel subtypes in the cavernous smooth muscle: (1) calcium-sensitive potassium channel. Decreased intracytosolic potassium and altered potassium conductance have been shown to occur in corpus cavernosum smooth muscle treated with acetylcholine and sodium nitroprusside (Seftel et al, 1996). The movement of positively charged K+ out of the cell causes hyperpolarization and relaxation of smooth muscle (Andersson, 2001). Calcium-activated chloride channels on the smooth muscle cells of corpus cavernosum are thought to be involved in the maintenance of spontaneous tone and the contractile response to adrenaline and other agonists (Fan et al, 1999; Chu and Adaikan, 2008). Intracavernous Tissue Architecture the trabeculae of the corpora cavernosa provide the structural support and regulatory mechanism for the endothelial-lined sinusoidal spaces as well as the conduit for blood vessels and nerves. Relaxation of the trabeculae allows the expansion and filling of the sinusoids by the incoming blood, whereas "recoil" of the trabeculae expels blood to the emissary veins and returns the penis to a flaccid state. In seven men undergoing penile prosthesis implantation, the three components were composed of collagen fibers (41.
Vaginocervical stimulation suppresses the expression of c-fos induced by mating in thoracic gastritis green stool cheap nexium 20 mg otc, lumbar and sacral segments of the female rat. Clitoral and vulvar vestibular sensation in women taking 20 mcg ethinyl estradiol combined oral contraceptives: a preliminary study. The relationship between mode of female masturbation and achievement of orgasm in coitus. Persistent genital arousal disorder in women: case reports of association with anti-depressant usage and withdrawal. Persistent sexual arousal syndrome: a newly discovered pattern of female sexuality. Sexual arousal and orgasm in subjects who experience forced or non-consensual sexual stimulation-a review. Efficacy and safety of alprostadil cream for the treatment of female sexual arousal disorder: a double-blind, placebocontrolled study in Chinese population. Neuropeptide Y in the human female genital tract: localization and biological action. Effect of oophorectomy on circulating testosterone and androstenedione levels in patients with endometrial cancer. Legal and psychological implications in the assessment of sexual consent in the cognitively impaired population. Flibanserin: initial evidence of efficacy on sexual dysfunction, in patients with major depressive disorder. A comparison of lesbian, bisexual, and heterosexual female college undergraduate students on selected reproductive health screenings and sexual behaviors. Effect of estrogen deprivation on the expression of aquaporins and nitric oxide synthases in rat vagina. The sexual health benefits of oral low-dose estrogen plus progestogen and vaginal estrogen for postmenopausal women. Sexual risk factors among self-identified lesbians, bisexual women, and heterosexual women accessing primary care settings. Levonorgestrel effects on serum androgens, sex hormone-binding globulin levels, hair shaft diameter, and sexual function. Effects of estrogen treatment on the size of receptive field and response threshold of pudendal nerve in the female rat. Relaxant and contractile effects of some amines and prostanoids in myometrial and vascular smooth muscle within the human uteroplacental unit. Magnetic resonance imaging and the female sexual response: overview of techniques, results, and future directions. Sexual practices, risk perception and knowledge of sexually transmitted disease risk among lesbian and bisexual women.
Correlation between insula activation and self-reported quality of orgasm in women gastritis diet 40 mg nexium purchase with mastercard. Education in sexual medicine: proceedings from the international consultation in sexual medicine, 2009. Sildenafil inhibits phosphodiesterase type 5 in human clitoral corpus cavernosum smooth muscle. Atherosclerosis-induced chronic arterial insufficiency causes clitoral cavernosal fibrosis in the rabbit. Impact of pelvic floor disorders and prolapse on female sexual function and response. Effects of pregnancy on female sexual function and body image: a prospective study. Somatosensory determinants of lordosis in female rats: behavioral definition of the estrogen effect. Selective facilitation of sexual solicitation in the female rat by a melanocortin receptor agonist. Psychological correlates of sexual dysfunction in female rectal and anal cancer survivors: analysis of baseline intervention data. Female sexual dysfunction in a healthy Austrian cohort: prevalence and risk factors. Ospemifene, a novel selective estrogen receptor modulator for treating dyspareunia associated with postmenopausal vulvar and vaginal atrophy. Anatomy and physiology of the clitoris, vestibular bulbs, and labia minora with a review of the female orgasm and the prevention of female sexual dysfunction. Reproductive hormones in the early menopausal transition: relationship to ethnicity, body size, and menopausal status. The suspensory ligament of the clitoris: connective tissue supports of the erectile tissues of the female urogenital region. Sexual problems among a specific population of minority women aged 40-80 years attending a primary care practice. Effects of hormone replacement therapy on sexual psychophysiology and behavior in postmenopause. Differential expression of estrogen receptor-alpha and -beta and androgen receptor in the ovaries of marmosets and humans. Smelling of odorous sex hormone-like compounds causes sex-differentiated hypothalamic activations in humans. Sexual behaviour and risk reduction strategies among a multinational sample of women who have sex with women. The Global Online Sexuality Survey: public perception of female genital cutting among internet users in the Middle East. The role of the levator ani muscle in evacuation, sexual performance and pelvic floor disorders.
Microvascular and microneurosurgical techniques have made it possible to construct a phallus that allows a patient to void while standing and to enjoy erotic sensibility gastritis nerviosa nexium 20 mg visa. Because the phallus has erotic sensibility and protective sensation, the patient can eventually have a prosthetic implantation that allows an acceptable sexual life. This chapter discusses the general principles of male genital reconstructive surgery; specifics include male urethral surgery, surgery for congenital and traumatic penile lesions, and complex fistula and obliterative issues associated with the posterior urethra. Skin is one of those tissues, and its properties vary from individual to individual and from place to place on the same individual. Variable characteristics such as color, texture, thickness, extensibility, innate skin tension, and blood supply can be useful in various situations. The term tissue transfer implies the movement of tissue for purposes of reconstruction. In contrast to extirpative surgery, the transfer of tissue for reconstruction requires an intimate knowledge of the anatomy of the donor and the recipient sites as well as of the principles that allow the tissue to survive after it is transferred. The dermis has two layers: a superficial layer, the adventitial dermis (also called the papillary or periadnexal dermis, depending on the anatomy), and a deep layer, the reticular dermis. For genitourinary reconstruction, skin without adnexal structures is often used; the papillary dermis is synonymous with the adventitial dermis. Other tissues commonly transferred for genitourinary reconstruction include bladder and oral mucosa. The bladder epithelium is the superficial layer of the bladder; the deep layer of the bladder is termed the lamina propria, with superficial and deep layers. The oral mucosa is the superficial layer of much of the oral cavity, which also has a deeper layer termed the lamina propria, again with superficial and deep layers. All tissue has physical characteristics: extensibility, inherent tension, and the viscoelastic properties of stress relaxation and creep. The physical characteristics of a transferred unit are primarily a function of the helical arrangement of collagen along with the elastin cross-linkages. The collagen-elastin structure is suspended in a mucopolysaccharide matrix that influences the viscoelastic properties. The term graft implies that tissue has been excised and transferred to a graft host bed, where a new blood supply develops by a process termed take. During that phase, the graft survives by "drinking" nutrients from the adjacent graft host bed, and the temperature of the graft is less than the core body temperature. The second phase, inosculation, also requires about 48 hours and is the phase in which true microcirculation is reestablished in the graft. During that phase, the temperature of the graft increases to core body temperature.
The penile urethra receives arterial supply from a branch of the internal pudendal artery gastritis symptoms deutsch cheap nexium 20 mg buy on line, which enters at the level of the penile bulb, and is known as the bulbourethral artery. Venous drainage of the bulbar urethra is by bulbar veins that drain into the prostatic plexus, which is the internal pudendal vein. The penile urethral lymphatics drain through a lymphatic network that is associated with the mucous membrane. These lymphatic channels course longitudinally but anastomose transversely and obliquely. The lymphatic channels drain proximally into trunks at the bulbomembranous urethra. Some lymphatic drainage travels along the urethral artery or artery of the bulb, whereas others drain to the medial retrofemoral node after traveling behind the symphysis pubis. The penile urethral sensory innervation runs through submucosal axons that pass centrally through the dorsal nerve of the penis. FossaNavicularis the glanular portion of the urethra is known as the fossa navicularis, where its caliber dilates when compared to the urethra proximal to the fossa navicularis. The epithelium is separated from the smooth muscle of the spongy tissue by loose connective tissue, and a muscularis mucosa is absent. There are multiple pockets on the dorsal and lateral surfaces of the fossa navicularis. The lacuna magna (Morgagni) is a large pocket opening on the roof of the fossa navicularis. Thearrowheadsindicate the direction of urine flow during voiding in a normal urethra withoutstricture. The paired corpora cavernosa, which are the erectile bodies, prolongate proximally as the crus and attach to the pubic arch. The urethra travels through the corpus spongiosum, with its proximal segment known as the bulb. The fundiform ligament of the penis is composed of collagenous and elastic fibers from the rectus sheath blending with and surrounding Buck fascia. Deep to the muscles of the corpora cavernosa, the tunica albuginea and the Buck fascia fuse (Uhlenhuth et al, 1949). The penile shaft skin is very elastic and its only glandular elements are the smegma-producing glands, located at the base of the corona. The penile skin is very mobile as its dartos fascia backing is very loosely attached to Buck fascia.
They noted that the dorsal nerve of the penis is composed of two to six branches diet gastritis adalah purchase nexium 40 mg online, and in 16 of 22 adult cadaveric specimens, branches perforating the tunica albuginea to the corpus cavernosum were noted. Giuliano and coworkers (1993) have also shown that stimulation of the sympathetic chain at the L4-L5 level elicits an evoked discharge on the dorsal nerve and that stimulation of the dorsal nerve evokes a reflex discharge in the lumbosacral sympathetic chain of rats. These findings demonstrate that the dorsal nerve has somatic and autonomic components that enable it to regulate erectile and ejaculatory functions. The Onuf nucleus in the second to fourth sacral spinal segments is the center of somatomotor penile innervation. These nerves travel in the sacral nerves to the pudendal nerve to innervate the ischiocavernosus and bulbocavernosus muscles. Rhythmic contraction and compression of the bulbocavernosus muscle on the proximal corpus spongiosum helps semen expulsion, provided that the external sphincter is relaxed and the urethral lumen is compressed by the engorged spongiosum. In animal studies, direct innervation of the sacral spinal motoneurons by brainstem sympathetic centers (A5-catecholaminergic cell group and locus ceruleus) has been identified (Marson and McKenna, 1996). This adrenergic innervation of pudendal motoneurons may be involved in rhythmic contractions of perineal muscles during ejaculation. Oxytocinergic and serotoninergic innervation of lumbosacral nuclei controlling penile erection and perineal muscles in male rats has also been demonstrated (Tang et al, 1998). Depending on the intensity and nature of genital stimulation, several spinal reflexes can be elicited (Table 26-4). The best known is the bulbocavernosus reflex, which is the basis of genital neurologic examination and electrophysiologic latency testing. Although impairment of bulbocavernosus and ischiocavernosus muscles may impair erection, the significance of obtaining a bulbocavernosus reflex in overall sexual dysfunction assessment is controversial. Anatomy of cavernous nerves distal to prostate: microdissection studyinadultmalecadavers. Stimulation of the pelvic plexus and the cavernous nerves induces erection, whereas stimulation of the sympathetic trunk causes detumescence. This clearly implies that the sacral parasympathetic input is responsible for tumescence, and the thoracolumbar sympathetic pathway is responsible for detumescence. Paick and Lee (1994) also reported that apomorphine-induced erection is similar to psychogenic erection in the rat and can be induced via the thoracolumbar sympathetic pathway in case of injury to the sacral parasympathetic centers. Many men with sacral spinal cord injury retain psychogenic erectile ability even though reflexogenic erection is abolished. These cerebrally elicited erections are found more frequently in patients with lower motoneuron lesions below T12 (Courtois et al, 1999); no psychogenic erection occurs in patients with lesions above T9. The efferent sympathetic outflow is suggested to be at the levels T11 and T12 (Chapelle et al, 1980). These authors also reported that in patients with psychogenic erections, lengthening and swelling of the penis are observed, but rigidity is insufficient.
In contrast gastritis patient handout nexium 20 mg order with visa, if left unresected, residual viable malignancy is destined to relapse, and only 25% to 35% of patients achieve durable remissions to second-line chemotherapy. Unresected teratoma has the potential to exhibit rapid growth (growing teratoma syndrome), undergo malignant transformation, or cause late relapse, all of which may have lethal consequences. Partial responses were observed in 11 of 24 patients, 6 of whom are alive (Donadio et al, 2003; El Mesbahi et al, 2007). In contrast, seven of nine patients (78%) with teratoma in the primary tumor experiencing a similar reduction in the size of the metastasis with chemotherapy had evidence of viable malignancy and/or teratoma. However, despite statistical modeling using these and other factors, a consistent false-negative rate for necrosis of 20% has been reported (Steyerberg et al, 1995, 1998; Vergouwe et al, 2001). An important concept is that the absence of teratoma in the primary tumor does not reliably exclude its presence in the retroperitoneum (Toner et al, 1990; Beck et al, 2002). Approximately 26% to 62% of patients experience a serologic and radiographic complete response to first-line chemotherapy (Einhorn et al, 1989; Dearnaley et al, 1991; Mead et al, 1992; Debono et al, 1997; Stenning et al, 1998; Ehrlich et al, 2010; Kollmannsberger et al, 2010a). Numerous studies have demonstrated that, on average, patients with residual masses 20 mm or smaller have a 30% and 6% incidence of teratoma and viable malignancy, respectively (Table 34-7) (Fossa et al, 1989b; Toner et al, 1990; Stomper et al, 1991; Fossa et al, 1992; Steyerberg et al, 1995; Beck et al, 2002; Oldenburg et al, 2003; Stephenson et al, 2007). However, patients with complete serologic and radiographic response after induction chemotherapy represent a small minority of the overall population, indicating that observation is a reasonable option for only a select group of patients. Approximately one third of patients have residual masses at multiple anatomic sites (retroperitoneum, chest, and left supraclavicular fossa are the most common), and these patients should undergo resection of all sites of measurable residual disease (Toner et al, 1990; Gerl et al, 1994; Hartmann et al, 1997a; McGuire et al, 2003). Discordant histology between anatomic sites is reported in 22% to 46% of cases (Toner et al, 1990). Patients with zero, one, and two to three risk factors had a 5-year overall survival of 100%, 83%, and 51%. Overall, a significant improvement in 5-year relapse-free survival was observed with postoperative chemotherapy (73% vs. In a subset analysis, patients with one risk factor had an improved 5-year survival with postoperative chemotherapy (88% vs. In a confirmatory study, this prognostic index was validated for relapse-free and overall survival, and no significant difference in these end points was observed among the patients who did and did not receive postoperative chemotherapy (Fizazi et al, 2008). There is no consensus on the appropriate chemotherapy regimen and the number of cycles that should be used in this setting. Patients who have never received chemotherapy have a much more favorable prognosis than patients who have already been treated with chemotherapy for disseminated disease. Although the time to relapse is an important determinant of outcome in relapsing patients who have received prior chemotherapy, chemotherapy-naive patients who relapse more than 2 years after initial treatment have a prognosis similar to patients who relapse earlier. Men who relapse after previously receiving first-line chemotherapy are treated with second-line (salvage) chemotherapy. Most relapses occur within 2 years of completing initial treatment, and these are classified as early relapse (de Wit et al, 1998; Nichols et al, 1998; Michael et al, 2000; Culine et al, 2007; Motzer et al, 2007). Relapses occurring more than 2 years after completion of initial therapy are classified as late relapse and differ substantially in terms of prognosis and therapy (discussed later).
Thelargervenulesaresandwiched and flattened between the distended sinusoids and the tunica albuginea gastritis upper back pain buy 40 mg nexium free shipping. CandD,Scanningelectronmicrographsof casts of a canine subtunical venous plexus in the flaccid (C) and erect (D) states. The second phase shows a slow pressure decrease, suggesting a slow reopening of the venous channels with resumption of the basal level of arterial flow. The third phase shows a fast pressure decrease with fully restored venous outflow capacity. Erection involves sinusoidal relaxation, arterial dilation, and venous compression (Lue et al, 1983). The importance of smooth muscle relaxation has been demonstrated in animal and human studies (Saenz de Tejada et al, 1989a; Ignarro et al, 1990). To summarize the hemodynamic events of erection and detumescence, seven phases have been observed in animal experiments that reflect the changes in and the relationship between penile arterial flow and intracavernous pressure. Corpus Spongiosum and Glans Penis the hemodynamics of the corpus spongiosum and glans penis differ from those of the corpora cavernosa. During erection, the arterial flow increases in a similar manner; however, the pressure in the corpus spongiosum and glans is only one third to one half that in the corpora cavernosa because the tunical covering, which is thin over the corpus spongiosum and virtually absent over the glans, ensures minimal venous occlusion. During the full-erection phase, partial compression of the deep dorsal and circumflex veins between Buck fascia and the engorged corpora cavernosa contributes to glanular tumescence, although the spongiosum and glans essentially function as a large arteriovenous shunt during this phase. In the rigid-erection phase, the ischiocavernosus and bulbocavernosus muscles forcefully compress the spongiosum and penile veins, resulting in further engorgement and increased pressure in the glans and spongiosum (Table 26-3). The sympathetic pathway originates from the 11th thoracic to the 2nd lumbar spinal segments and passes through the white rami to the sympathetic chain ganglia. Some fibers travel through the lumbar splanchnic nerves to the inferior mesenteric and superior hypogastric plexuses, from which fibers travel in the hypogastric nerves to the pelvic plexus. In humans, the T10 to T12 segments are most often the origin of the sympathetic fibers, and the chain ganglia cells projecting to the penis are located in the sacral and caudal ganglia (de Groat and Booth, 1993). The parasympathetic pathway arises from neurons in the intermediolateral cell columns of the second, third, and fourth sacral spinal cord segments. The preganglionic fibers pass in the pelvic nerves to the pelvic plexus, where they are joined by the sympathetic nerves from the superior hypogastric plexus. The cavernous nerves are easily damaged during radical excision of the rectum, bladder, and prostate. Human cadaveric dissection has revealed medial and lateral branches of the cavernous nerves (the former accompanying the urethra and the latter piercing the urogenital diaphragm 4 to 7 mm lateral to the sphincter) and multiple communications between the cavernous and dorsal nerves (Paick et al, 1993). In addition to the cavernous nerve proper, pelvic ganglion cells exist in and along the nerve components and pelvic viscera. These are seen at the bladder/ prostate junction, the dorsal aspect of the seminal vesicles, and along the prostate. From the neurons in the spinal cord and peripheral ganglia, the sympathetic and parasympathetic nerves merge to form the cavernous nerves, which enter the corpora cavernosa and corpus spongiosum to modulate the neurovascular events during erection and detumescence. Because the number of these synapses is less than in men with an intact sacral spinal cord, the resulting erection will not be as strong.
Dimitar, 55 years: The stressors of parenting a newborn and recovery from delivery are short-term barriers to sexual activity, which in some cases may lead to long-term sexuality issues (Pauleta et al, 2010).
Will, 64 years: 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.
Jaffar, 26 years: The effect of testosterone replacement on endogenous inflammatory cytokines and lipid profiles in hypogonadal men.
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