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the lacunar spaces of the corpora, bypassing the protective, high-resistance helicine arterioles This constant unregulated ow results in the pathognomonic arterial lacunar stula (ALF) of high- ow priapism The clinical characteristics of non-ischemic priapism typically include a pre-morbid history of trauma, delayed onset of priapism following the trauma, incomplete rigidity of the phallus compared to premorbid sexually-stimulated erectile rigidity, and a constant erection that is painless, non-tender, of persistent partial rigidity throughout the day and night, with the potential for increase to full rigidity with sexual stimulation Although spontaneous resolution may occur, with non-ischemic priapism the painless, partial erection will often continue unless active intervention is performed Selective internal pudendal arteriography has been the mainstay of diagnostic and therapeutic maneuvers for arterial priapism The pathognomonic arteriographic nding is of an arterial lacunar stula a characteristic intracavernosal cone-shaped blush of contrast at the site of the cavernosal artery laceration Unfortunately, these therapies have had little success in reversing the high- ow priapism state and are currently not recommended by the AUA guidelines for priapism therapy The current standard of intervention remains selective internal pudendal arteriography with transcatheter autologous clot embolization The goal of this therapy is to induce temporary occlusion of the cavernosal artery in order to allow the injured site to heal The temporary nature of this occlusion allows for the subsequent reestablishment of physiologically-controlled normal cavernosal blood ow, with preservation of erectile tissue viability and normal long-term erectile function This form of minimallyinvasive intervention has a high probability for resolution of the priapism with restoration of erectile potency compared to more invasive techniques, including permanent coil embolization and surgical ligation of the cavernosal artery Studies comparing perineal duplex ultrasound and concomitantly preformed selective internal pudendal arteriography have revealed excellent sensi-

ENDPOINTS TRANSPORT PPP to access server; UDP/IP between access servers Yes (tunnel ID and session ID) Yes (security parameter index) Yes (security parameter index) Yes (label) Yes (key field) No IP IP Any L2 IP IP 1 Host 2 Access server Host Router Router Router Router

Psychosexual issues are more frequently a cause in life-long orgasmic dif culties, while biologic etiology should be considered with gradual or rapid onset of anorgasmia If the history and physical assessment has ruled out any hormonal, neurophysiologic, or pharmacologic-related causes, the treatment of orgasmic disorders should then focus on an assessment of knowledge Teaching women and their partners about appropriate arousal techniques may be all that is needed In addition, sociocultural factors need to be considered; that is, there may be inhibitions about receiving pleasurable sexual stimuli (usually in generalized primary anorgasmia, but not always) Education can be given about how women become aroused, the amount of time needed for arousal, and the types of stimulation commonly needed for orgasm to be experienced Information that most women are not able to experience orgasm from vaginal intercourse, and that extended clitoral or vaginal (G spot) stimulation may be needed, is also important information to disseminate [33,34] Referral of the woman and/or couple to a certi ed sex therapist is helpful here (see wwwaasectorg for a certi ed sex therapist in your geographic area) The treatment of anorgasmia has been based on psychoanalytic, cognitive-behavioral, systems theory, and pharmacologic approaches [35] According to Meston and colleagues, cognitive behavioral therapy for anorgasmia focuses on promoting changes in attitudes and sexually-relevant thoughts,

Don t let the ties that bind blind you to professional practice Make sure you have a formal contract outlining the terms of loans and any other support that family members provide, and the benefit to them of the arrangement Don t take the support of family for granted, unless you wish to invite resentment Honour your agreement as you would that with any other lender

13 Table 133 Signaling Protocols PROTOCOL Q2931 L2TP IPSec/IKE GRE CR-LDP RSVP-TE TUNNEL ATM* MPLS IPSec GRE MPLS MPLS

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VPN mechanisms built directly upon ATM tunneling mechanisms do not qualify as VPNs in the sense that they are not lower layer agnostic * For comparison only; sets up true layer 2 VCs rather than VPNs