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FIT FOR LIFE -WNHO-CLINIC FranchiseeFranchise Purchase AgreementTHIS AGREEMENT (“the Agreement) is made on ………………………………………………, by the between ………………………………………………………………………………………(“Franchisor’)……………………………………………………………………………. (the Franchiser”) ………………………………………………………………………. On the basis of the following understanding & AgreementAbout WNHO’S PROGRAMJoint the natural way towards good healthSince last 30 years, WNHO has been treating chronic diseases with satisfying rate, Our Program provides excellent results to relieve chronic diseases by using microcellular rejuvenation activated herbal globules. Testimonials of patients as video available on You tube. Our patients have reported great relief from following diseasesProcedure at Centre-1-Acne Cure Micro- Dermabrader Machine2-Warts, corn, skin tag Removal by Radio Surgery3- Skin tightening and hyper pigmentation by HIFU Beauty Machine4-Psychotherapy and Counselling5-Sexual Medicine Consulting (Male and Female, Marriage Counseling)6-Asthma rehabilitation and PFT (Computerized Pulmonary Function Test).7- Allergy Test and Hypo-sensitization Medicine.8-Height Increasing and Weight Gain Program. (Non-surgical)9-Holistic Body Analysis and Acupuncture Point detection.10-laser Acupuncture and laser Auricular Acupuncture.11-Homoeopathic and Herbal LM potency-Natural way to Health.12-Alcohol De-addiction13-Sexual Therapy package with LM Potency medicineWHO CAN BE FRANCHISEE PARTNER?WNHO-CLINIC is selectively expanding its network in India.Arrange 500-700 Sq. Feet in an easily accessible location.Organized panel doctors and yoga teacher.If you area doctor, or manage a polyclinic, you will be at an advantageHow will we Partner?We are tied-up with the world’s leading companies in testing & insights, as well as equipment markers.A full-fledged brand building and complementary medicine Programmed.Center will be equipped with Customized in clinic software, extensive education material, state-of -the-art infrastructure to provide patient support through phone, web, e-mail, video-conferencing. E-access to Medical records.A detailed orientation and training Program is also in Place.BENEFITS10 Times better chance of Success than Independent brand.Experience Not Necessary (Franchisee Trains & Guides)Good Margine, High ROI (Return on Investment) & low RiskGREAT BENEFITS OF WNHO CLINIC FIT FOR LIFE FRANCHISE1-Familiar Name WNHO CLINIC Proven Business SystemWNHO Clinic has been existing since 1999, recorded an average CAGR of 50% per year. We have considerable brand recognition & name familiarity throughout. Franchisee’s risk profile is zero and the statistical of success are very high. Reap the benefits of a “per existing customer base” which would ordinarily take years to establish. Most important you can start at your place without any extra investment.2-WNHO CLINIC-FIT FOR LIFE National marketing efforts.WNHO-CLINIC has three-pronged marketing strategy. National level … at www.lybrate.comState level…… at www.practo.comGlobal level…. at http://wnhohealthcare.com/, http://www.wnhocare.co.in/E-mail-wnhohealthcarepvt.ltd@gmail.comWNHO CLINIC Marketing Team, is composed of experts who meticulously craft an Annual Marketing & groups for each business vertical and also earmarks Cooperative activities with partners.3-COMPLETE ‘BUSINESS BLUEPRINT AND CONSTANT OPERATIONAL SUPPORT UNDER GUIDANCE OF FOUNDER DR. RAMESH MAHESHWARISUPPORT FROM WNHO HEALTH CARE PVT.LTD1- Web Clinic and Net marketing / All Intellectual involvement.2- Holistic Evaluation3- Line of treatment and prescription4- Chatting/ Telephonic/Video Conferencing with Patient5- Instrument and Kits from WNHO HEALTH CARE PVT.LTD6- Complete Patient satisfactionSub-Center going for Franchisees Need Place and staff for PracticeSharing1- 50 %-50% both the side when there is No Direct Involvement from Dr Ramesh Maheshwari face to face with patients. Here 50% to Wnho and 50% to Sub-Center.2- 70%-30% -- 70% to WNHO and 30% to Center on Selling Kits and During Visit of Director.aThe Agreement as of the Date first above set forthFRANCHISORBy…………………………………. Its……………………………FRANCHISORBY…………………………………. ITS………………………………………….………………………………………………………………………………………………………………………………………………….Note- Contact 9822006427/ Email-drrameshm2@gmail.com
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WNHO HEALTH CARE PRIVATE LIMITED PROJECTS.Dear Sir/MadamHere is Great Opportunity to become Partner with Govt. Recognized Startup with HUGE Earnings and 50% Income sharing by mutual Association. WNHO IntroductionJoin the natural way towards good health -Since last 30 years, WNHO has been treating chronic diseases with satisfying rate. Our program provides excellent results to relieve chronic diseases by using microcellular rejuvenation activated herbal globules. Testimonials of patients as video available on you tube.Great Benefits of WNHO Clinic fit for life FranchiseFamiliar Name WNHO Clinic Proven Business System- WNHO Clinic has been existing since 1999, recorded an average CAGR of 50% per year. We have considerable brand recognition and name familiar throughout. Franchisee’s risk profile is zero and the statistical of success are very high. Reap the benefits of a 'per existing customer base' which would ordinarily take years to establish. Most important you can start at your place without any extra investments. WNHO Clinic - Fit for Life Franchisees national marketing efforts.WNHO clinic has three-pronged marketing strategy. National level. at www.lybrate.com state level...at www.practo.com Global level .at www.wnhocare.co.in/ www.wnhohealthcare.com. WNHO Clinic Marketing Team, is composed of experts who meticulously craft an Annual Marketing and group for each business vertical and also earmarks Cooperative activities with partners.Memberships in the World Nature's Health Organization are available at several different levels. From our associate membership, which is open to everyone, to our professional membership which is open for anyone in a health care, counseling, or any other professional field. Lifetime memberships are also available. Contact us WNHO Health Care Private Limited 1 Benefits-Doctor will receive' World Nature's Health Organization' Certificate of Award Affiliation for Rehabilitation and Prolong relief in Chronic Diseases by Complementary Medicine.2 Can attend Monthly club meeting to increased Contacts.
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WNHO'S FRANCHISEWNHO IntroductionJoin the natural way towards good health -Since last 30 years, WNHO has been treating chronic diseases with satisfying rate. Our program provides excellent results to relieve chronic diseases by using microcellular rejuvenation activated herbal globules. Testimonials of patients as video available on you tube.Great Benefits of WNHO Clinic fit for life FranchiseFamiliar Name WNHO Clinic Proven Business System- WNHO Clinic has been existing since 1999, recorded an average CAGR of 50% per year. We have considerable brand recognition and name familiar throughout. Franchisee’s risk profile is zero and the statistical of success are very high. Reap the benefits of a 'per existing customer base' which would ordinarily take years to establish. Most important you can start at your place without any extra investments. WNHO Clinic - Fit for Life Franchisees national marketing efforts.WNHO clinic has three-pronged marketing strategy. National level. at www.lybrate.com state level...at www.practo.com Global level ..at www.wnhocare.co.in WNHO Clinic Marketing Team, is composed of experts who meticulously craft an Annual Marketing and group for each business vertical and also earmarks Cooperative activities with partners.Memberships in the World Nature's Health Organization are available at several different levels. From our associate membership, which is open to everyone, to our professional membership which is open for anyone in a health care, counseling, or any other professional field. Lifetime memberships are also available. Contact us WNHO Health Care Private Limited 1 Benefits-Doctor will receive' World Nature's Health Organization' Certificate of Award Affiliation for Rehabilitation and Prolong relief in Chronic Diseases by Complementary Medicine.2 Can attend Monthly club meeting to increased Contacts.Health and Wealth Forum (WNHO club) Membership Benefits-1 All Members can attend Monthly Morning Meeting with Introduction and Training Meditation, Rekhi , Pranic healing , Hypnotism , Acupressure, Meridian stimulation........etc.2 All Register Member get 20% discount in Holistic Health Scan and Medical Test.3 Members will get Platform for Exchange their Business Card to improve their Contacts.4 Along with Consultant and Specialist will discuss Various Health issues Cure by Natural way.5 Register Member can bring their Family member and friends for Health Programs.
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WNHO'S other Courses Provided :• Yogic Science Complementary medicine• Hypnosis• Therapeutic laser• Natural Therapy• classical Homeopathy• Holistic medicine• Certificate course in Yogic Therapy• Certificate course in Naturopathy• Certificate course in Acupressure Therapy• Certificate course in Prana Healing primary• Diploma in Advanced Prana healing• Certificate course in back-ache & rehabilitation• Certificate course in Allergy detection and therapy• Height increasing course• Weight gain course• Certificate course in immediate laser therapy.• Certificate course in Cosmetic laser therapy• Certificate course in stress management• Certificate course in Counseling of mental, Physical & Social problems• Certificate course in Nutrition & Health• Certificate course in family Counseling and interpersonal relationship• Certificate course in Medico legal Course• WNHO Introduction Join the natural way towards good health -Since last 30 years, WNHO has been treating chronic diseases with satisfying rate. Our program provides excellent results to relieve chronic diseases by using microcellular rejuvenation activated herbal globules. Testimonials of patients as video available on you tube. Great Benefits of WNHO Clinic fit for life Franchise Familiar Name WNHO Clinic Proven Business System- WNHO Clinic has been existing since 1999, recorded an average CAGR of 50% per year. We have considerable brand recognition and name familiar throughout. Franchisee’s risk profile is zero and the statistical of success are very high. Reap the benefits of a 'per existing customer base' which would ordinarily take years to establish. Most important you can start at your place without any extra investments. WNHO Clinic - Fit for Life Franchisees national marketing efforts. WNHO clinic has three-pronged marketing strategy. National level. at www.lybrate.com state level...at www.practo.com Global level ..at www.wnhocare.co.in WNHO Clinic Marketing Team, is composed of experts who meticulously craft an Annual Marketing and group for each business vertical and also earmarks Cooperative activities with partners. Memberships in the World Nature's Health Organization are available at several different levels. From our associate membership, which is open to everyone, to our professional membership which is open for anyone in a health care, counseling, or any other professional field. Lifetime memberships are also available. Contact us WNHO Health Care Private Limited 1 Benefits-Doctor will receive' World Nature's Health Organization' Certificate of Award Affiliation for Rehabilitation and Prolong relief in Chronic Diseases by Complementary Medicine. 2 Can attend Monthly club meeting to increased Contacts. Health and Wealth Forum (WNHO club) Membership Benefits- 1 All Members can attend Monthly Morning Meeting with Introduction and Training Meditation, Rekhi , Pranic healing , Hypnotism , Acupressure, Meridian stimulation........etc. 2 All Register Member get 20% discount in Holistic Health Scan and Medical Test. 3 Members will get Platform for Exchange their Business Card to improve their Contacts. 4 Along with Consultant and Specialist will discuss Various Health issues Cure by Natural way. 5 Register Member can bring their Family member and friends for Health Programs.TimingsMON-SAT10:30 AM - 08:00 PMSUN04:00 PM - 06:00 PMLocationNo.2014, 3, Danwantari Complex, Tilak Road, Sadashiv PethTilak Road Pune, Maharashtra - 411030
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WNHO BUSSINESS OPPORTUNITY.WNHO REHABILITATION PARTNERSHIP PROGRAMME - Your Growth is our Business.About Complementary Therapy in India.Preventive Health programmed is fast growing in selected metros & Tier I cities like Mumbai, Pune, Delhi, Chennai, Hyderabad, Bangalore…etc.Estimated market of Rs. 5, 000 Crore. Any registered Doctor e.g. MBBS, BAMS, BHMS….etc. can associate without much investment, simply visit to www.wnhohealthcare.com send massage with email and contact number. Our executive will in touch with in 24 hours.WNHO HEALTH CARE PRIVATE LIMITED is Government Certified Startup is fastest growing Preventive Health Advisory & Aggregator for WNHO’S Rehabilitation in various Chronic Diseases like Asthma, Diabetes, Obesity, Pain clinic, Male & Female Sexual Disorders & Cosmetology & laser, HIFU, Shockwave therapy.WNHO is managed by highly experienced domain in Sexology- Psychosexual Medicine, Cosmetology & Obesity. WNHO provide better preventive multitherapy approach for Hope for Hopeless Medical Cases. THE BUSINESS PERPOSAL – BE PARTNER WITH WNHO.INVITING BUSINESS PARTNER FOR ALL MAJORE CITIES.WNHO is looking for Business Partner to join hands & profit from service providing to community is the great opportunity that is offered by Government certified STARTUP WNHO HEALTH CARE PRIVATE LIMITED, PUNE .PARTERNERSHIP MODELS-1 Education Skill Empowerment Fellowship in Sexology/Cosmetology/Asthma logy/Obesity, Diabetes/Pain clinic, / Healing Meditation and Acupuncture Meridian stimulation…etc. Course Fee up to Own Center Development registration Rs. 1, 00000/only. 2. WNHO’S Franchisees Fellowship with Fit FOR LIFE WNHO Franchisees. With full support from WNHO Head Office. Fees Rs.1, 00000 + 20% sharing in Gross Income.3. PURE Franchisees – Here All WNHO programmed and Activity conducted just like Sub Head Office or Territorial Office. 4. PURE INVESTMENT PARTNER PIP – Will be Share Equity Partner.Requirements- Basic Franchisees ModelArea/infra structure minimum 300sq feet including reception of 150 sq feet + treatment room of 150 sq. Feet. Investment minimum 1lac to5 lacks. Good location & Air condition needed.Initial Agreement for 36 month & your centers will be branded by WNHO’S Fit For Life.WNHO UPGRADED CENTER WILL PROVIDE SALES LEADS and here revenue sharing 80% to Center owner and 20% to WNHO.Health Software will be provided by centers only. Basic price of the treatment will be prefixed mutually.WNHO’S SUPPORT• Complete Branding & Advertisement• Complete sales/marketing up to lead generation• Operation and counselling.HOW TO MOVE AHEADSTEP 1 – SIMPLY SEND REQUEST AT INQUIARY AT WEBSITE -www.wnhohealthcare.com and fill the formSTEP 2. APPROVAL & REJECTION AFTER CRUTINISING REQUEST FORM.STEP 3 . AGREEMENT SIGNINGSTEP4. HANDS ON TRAINING AND HANDS OVER OF CERTIFICATE AND PROCESS MANNUALS.SEP 5. OPERATIONAL PROCESS START….EARNING START MINIMUM 1LACK TO 3 LACKS PER MONTHS.………………………………………………………………………………………………………………………Director WNHO, Pune.Mobile-09822006427.
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WNHO BUSINESS OPPORTUNITY.WNHO REHABILITATION PARTNERSHIP PROGRAMME - Your Growth is our Business.About Complementary Therapy in India.Preventive Health programmed is fast growing in selected metros & Tier I cities likeMumbai, Pune, Delhi, Chennai, Hyderabad, Bangalore…etc. Estimated Market of Rs. 5, 000 Crore. Any registered Doctor e.g. MBBS, BAMS, BHMS….etc. can associate without much investment, simply visit to www.wnhohealthcare.com send massage with email and contact number. Our executive will in touch with in 24 hours. WNHO HEALTHCARE PRIVATE LIMITED is Government Certified Startup is fastest growing Preventive Health Advisory & Aggregator for WNHO’S Rehabilitation in various Chronic Diseases like Asthma, Diabetes, Obesity, Pain clinic, Male& Female Sexual Disorders & Cosmetology & laser, HIFU, Shockwave Therapy.WNHO is managed by highly experienced domain in Sexology- Psychosexual Medicine, Cosmetology & Obesity. WNHO provide better preventive multi therapy approach for Hope for Hopeless Medical Cases. THE BUSINESS PROPOSAL – BE PARTNER WITH WNHO.INVITING BUSINESS PARTNER FOR ALL MAJOR CITIES.WNHO is looking for Business Partner to join hands & profit from service provided to community is the great opportunity that is offered by Government certified STARTUP WNHO HEALTH CARE PRIVATE LIMITED, PUNE . PARTNERSHIP MODELS-1 Education Skill Empowerment Fellowship in Sexology/Cosmetology/Asthma logy/Obesity, Diabetes/Pain clinic, / Healing Meditation and Acupuncture Meridian Stimulation…etc. Course Fee up to Own Center Development registration Rs.1, 00000/only. 2. WHO’S Franchisees Fellowship with Fit FOR LIFE WNHO Franchisees. With full support from WNHO Head Office. Fees Rs.1, 00000 + 20% sharing in Gross Income.3. PURE Franchisees – Here All WNHO programmed and Activity conducted just like SubHead Office or Territorial Office. 4. PURE INVESTMENT PARTNER PIP – Will be Shared Equity Partner.Requirements-Basic Franchisees ModelArea/infrastructure minimum 300 sq feet including reception of 150 sq feet + treatment room of 150 sq. Feet. Investment minimum 1 lac to 5 lacks. Good location & Air condition needed.Initial Agreement For 36 month & your centers will be branded by WNHO’S Fit For Life.WNHO UPGRADED CENTER WILL PROVIDE SALES LEADS and here revenue sharing 80% to Centerowner and 20% to WNHO.Health Software will be provided by centers only. Basic price of the treatment will be prefixed mutually.WNHO’S SUPPORT· Complete Branding & Advertisement· Complete Sales/marketing up to lead generation· Operation And counselling. HOW TO MOVE AHEAD STEP 1 – SIMPLY SEND REQUEST AT INQUIARY AT WEBSITE-www.wnhohealthcare.com and fill the formSTEP 2. APPROVAL & REJECTION AFTER SCRUTINIZING REQUEST FORM.STEP 3 . AGREEMENT SIGNING STEP 4. HANDS ON TRAINING AND HANDS OVER OF CERTIFICATE AND PROCESSMANNUALS. STEP 5. OPERATIONAL PROCESS START….EARNING START MINIMUM 1LACK TO 3 LACKSPER MONTHS.………………………………………………………………………………………………………………………Director WNHO, Pune. WNHO’S Forum For INNOVATIONS Free Registration for MDA/MEDIJAIN/IMA Members.& All Allied Medical Branches Allopathy/Ayurvedic/Homeopathic.Get Inspired To Innovate – Be with the Change Preventive & Curative Health Care.All Doctors Are inviting with preventive ideas in their respective Branch & associates with Govt. Certified Startup WNHO HEALTH CARE PRIVATE LIMITED.You can send your ideas with Article & Photo to represent at website www.wnhohealthcare.com & email details - wnhohealthcarepvt.ltd@gmail.com cc to Director drrameshm2@gmail.com Call 020-24463540/020-41211108 and mobile 09822006427.
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Evaluation of Male Erectile Dysfunction INTRODUCTION In recent years, the importance of physical factors in the enteropathogenesis of male erectile dysfunction has become incontrovertibly established. It is now know that erectile dysfunction can occur as a result of psychological factors, physical factors or both. HISTORY- TAKING Too often, history taking is performed very cursorily; this can lead to great blunders. Because of the intimate admixture of psychological and physical issues in erectile function, a detailed psychosexual, marital and social history is mandatory. Such a history not only improves the diagnostic yield but also goes a long way in planning proper treatment. Importantly, it can help avert many a post- operative disaster should the candidate require surgery. A detailed sexual history is invaluable. Direct questions should be asked about the rigidity and duration of erection during sleep, masturbation and sexual intercourse. History- Taking should also include a systematic check list for contributory organic factors (Table 1) often; a good history alone can lead the clinician to a working diagnosis of the relative preponderance of psychological or physical factors in any given patient. PHYSICAL EXAMINATION Although physical examination often contributes very little to the eventual diagnosis and treatment plan, the importance of its thoroughness cannot be over- emphasized. A thorough general and local examination must be performed. A complete neurogenic impotence is still made mainly by elimination of other causes coupled with a high index of clinical suspicion. INVESTIGATIONSa) General Systemic investigations contribute little to the diagnosis and management of impotence per se. However, these must be performed in the interest of the general health of the patient and to identify contributory underlying causes. Monitoring of diabetes, for example, does little to alter the continuing impact of the diabetic process on the erectile apparatus. The same is perhaps true for other systemic diseases associated with erectile dysfunction. It must be noted that even endocrine disorders usually affect the libido rather than the erection itself. Hormonal measurements, therefore, do not obviate the need for more specific tests. b) Specific The armamentarium of diagnostic gizmos and devices flooding the impotence market is quite confusing to the newcomer dabbling in impotence. While some of these are indubitably useful, many are mere research tools that contribute little to an objective diagnosis. Besides, the international literature on the subject is very contradictory and clear standards have not been enunciated for many of these tests.It is still possible, however, with the modalities available today to make a fairly accurate diagnosis of the predominant causal factor/s in any patient. It is not necessary to perform all tests on all patients. The work-up should be tailored according to the individual needs of the patient. Apart from the patient’s economic capacities, time is an important consideration especially in case of the patients coming from faraway places. The psychological make-up and the attitude of the patient are also important. An invasive test should be eschewed in favor of non-invasive ones in especially anxious. The ultimate goal of the investigative work-up is to determine whether the cause of the impotence is psychological, arterial, venous, neurological or endocrinological. It is important to remember that often many factors may co-exist in the same patient. 1) The Injection TestIf performed correctly, this test alone can enable a working diagnosis within one day. Drug used are prostaglandin or papaverine hydrochloride. Prostaglandin is preferable when the patient has to travel within a few hours because of the much lesser risk of priapism. Many other vaso-active substances and their combinations (most notably papaverine – phentolamine have been described. However, these are not indispensable and their non –availability should not be a deterrent to an accurate diagnosis. Papaverine hydrochloride alone is adequate for most purposes. It is cheap and freely available throughout India. Prolonged erections and priapism, should they occur, are very easy to treat. The biggest enemy of papaverine is the anxious patient. For these reasons, it is very important that the patient’s anxiety should be allayed. If necessary, the test should be repeated on more than on occasion. If there is no suspicion of neurological disease, it is safe to start with a dose of 45-60mg. A 26-30 gauge needle is used to inject the drug directly into the corpora cavernosa at the mid-shaft level. The patient should always be given the privacy of a quiet, relaxed room. This test should never be performed in a busy out- patient setting with people walking in and out. This is certain to affect the outcome of the test. The patient should be seated upright during the injection. Pressure on the puncture site should be very gentle or it can have a retrograde milking effect on the penis. This can lead to false-negative results even after appropriate dosage and can cause drug-related systemic side effects as well. After injection, the penis should be gently stroked in order to distribute the drug and facilitate the lubricating jelly help. Visual Sexual Stimulation (VSS) using erotic literature, computer software or video films may be used but doesn’t always help. Unlike in the west, erotica does not have the same effect on the Indian male. This is probably because of socio-cultural and attitudinal differences. Lastly, it must be remembered that erotic literature and films are prohibited by law in India. For these reasons, VSS can be safely omitted without notable compromise in diagnostic yield.Likewise, it may or may not be very helpful to keep the patient in his sexual partner’s company during the conduct of this test. Many men are embarrassed in their partner’s presence and this might affect the outcome of the test. The patient remains seated throughout the test, it is best to seat the patient on a large bed with his back propped against a back- rest or a wall. The legs should be stretched out on the bed. These simple precautions will prevent accidental injuries which could arise from the systemic effects of papaverine hydrochloride. If the patient is relaxed and a suitable does has been injected, a good erection will occur within 10 minutes. Erectile dysfunction secondary to arterial disease may take several minutes longer to produce an erection. Patients with neurogenic importance may develop priapism with very low doses of papaverine but this should not be a deterrent to using adequate dosages. If the erection is unequivocally rigid and the penis cannot be buckled, vasculo genic importance can be virtually eliminated and no further investigations are necessary. If the erection is not rigid enough, a second does may be employed at the same setting. This is quite safe and systemic side effects are uncommon. However, it must be emphasized that this should be performed in a hospital setting with full infrastructural back-up rather than in an office environment. Any curvature of the penis can be studied at the same time. If the erection is still not rigid enough, vascular disease must be eliminated using more sophisticated tests. A Doppler study can be easily combined with the injection test. If an objective measurement of the erection is desired either for academic, medico-legal or psychotherapeutic purpose, a real- time Rigiscan monitoring may be performed at the same session. 2) The Rigiscan Test The Rigiscan is the gold standard for NPTR (Nocturnal Penile Tumescence and Rigidity) measurement. It is the test of choice for non-invasive diagnosis.It is especially suitable for anxious patients since it can be performed in the privacy of their own bedrooms. Its ability to objectively quantify erectile rigidity and establish physical normalcy makes it an important, reassurance providing device to the patient with purely functional problems. It is also useful in medico-legal cases. Time and cost are two relative deterrents.A Rigiscan tracing showing a good number of erectile episodes with rigidity levels of 80% or more and a duration of 20 minutes or more in a single episode almost effectively rules out serious vascular disease. Arterial insufficiency and venous leaks can also be suspected on the basis of the Rigiscan graphs. Patients with purely arterial disease generally have low levels of maximum rigidity but of adequate duration. Patients with predominant venous leakage will have varying rigidity levels depending on the severity of the leakage but the duration is almost always shortened. These patients must be evaluated using other means. The erectile response to vaso-active injection can be objectively studied by the concomitant application of the Rigiscan monitor. This is called a Real time study.1 Abnormal NPTRShowing few ill sustained episodes with inadequate rigidity. All in all, the Rigiscan is an extremely useful device. In an era where many doctors as well as patients continue to believe that most impotence is predominantly due to psychological factors, it is important to eliminate psychological causes first even though such a policy grossly violates conventional medical teaching according to which organic disease must always be eliminated first. 2) Penile UltrasoundA Doppler evaluation of the penile arteries is indicated if the erectile response to the injection test is inadequate or if the patient’s Rigiscan study is suggestive of arterial insufficiency. Pure arterial disease or trauma.Ultrasonograpic evaluation of the cavernosal arteries can be performed with varying degrees of sophistication once cavernosal smooth muscle has been effectively relaxed by vaso-active injection. A simple acoustic Doppler probe, which is inexpensive and portable, emits auditory signals which can effectively eliminate gross cavernosal arterial disease. Duplex Doppler and Colour Doppler studies can help visualization of the cavernosal arteries and measurement of flow.They can also hint at the presence of venous disease. But while these are useful for quantifying penile arterial flow and help diagnose abnormalities in the main cavernosal arteries, they cannot altogether eliminate arterial insufficiency because of their inability to image the microvasculature. Thus, a normal arterial study does not eliminate arterial disease. This is important to bear in mind. 3) DICC (Dynamic Infusion Cavernosometry & Canvernosography) The DICC is an useful hemodynamic test for the diagnosis of CVOD (Corporal Veno-Occlusive Dysfunction). In its simplest form, two cannula are inserted into the corpora cavernosa after smooth muscle relaxation has been achieved with a vaso-active injection. One cannula is connected to a pressure transducer; the other conducts saline or radio-opaque contrast solution at controlled flow rates through an adjustable flow pump. Pressures are measured after injection and 30 seconds after a pressure of 150 mm Hg has been induced. Flow rates are measured in order to induce erection and attain 150 mm Hg, to maintain erection at150 mm Hg; the study is then repeated at a pressure setting of 90 mm Hg. The Convernosal Artery Systolic Occlusion Pressure (CASOP) is also measured at the same time using a Doppler device. These are also the only universally accepted standards for DICC evaluation. There are some centers that perform an 8 or 9 track multi- phasic DICC. Radiologic visualization of leaking penile veins (cavernosography) is performed at the same sitting in many centres. Such radiologic studies are useful only if site-specific, selective ligation is planned as a surgical option. 4) Neurologic Evaluation Many tests have been used for the evacuation of neurogenic impotence. These include nerve conduction studies, biothesiometry and corpus cavernous electromyography (CCEMG), among others. None of these is 100% reliable. The diagnosis of neurogenic impotence continues to be based on elimination of vasculogenic causes, a high index of clinical suspicion and a thorough neurological examination. In any case, tests for neurogenic impotence, whatever their results, will not alter treatment options.
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