Is sildenafil failure in men after radical retropubic prostatectomy (RRP) due to arterial disease? Penile duplex Doppler findings in 174 men after RRP

Sildenafil is frequently the first-line treatment for post-radical retropubic prostatectomy (RRP) erectile dysfunction (ED) with maximum treatment satisfaction rates of 43%-80%. The etiology of erectile dysfunction after RRP has been attributed to psychogenic, vascular, veno- occlusive or nerve injury causes. The purpose of this study was to gain insight into the penile duplex Doppler arterial parameters in men with ED after RRP who failed sildenafil. The purpose was to assess whether sildenafil failure after RRP is associated with underlying corporal arterial disease. A total of 174 consecutive men presenting with sildenafil refractory ED after nerve-sparing RRP underwent color duplex penile Doppler evaluation with vasoactive injection. Mean age was 59.6 y and mean time from surgery was 11.6 months. Some 81% (141/174) of the men had no pre-operative ED (PED). Significant differences in penile duplex Doppler parameters for arterial disease were seen between men with and without PED. In men without PED, 19% (27/141) manifested arterial insufficiency. However, in men with PED, 50% (16/33) demonstrated arterial disease. Nerve sparing status did not affect the presence of arterial disease. Sildenafil refractory erectile dysfunction after RRP in men without PED is not predominantly associated with penile Doppler parameters consistent with arterial insufficiency.     

Relation of C-reactive protein and other cardiovascular risk factors to penile vascular disease in men with erectile dysfunction

Erectile dysfunction (ED) may be an early sign or symptom of cardiovascular disease (CVD). We examined the relation of traditional and emerging risk factors for CVD to the severity of penile vascular disease in men with ED and without clinical coronary artery disease (CAD). In total, 137 men with ED were evaluated for penile vascular disease severity by penile Doppler ultrasound. These men were divided into the following groups based on ultrasound results: normal, cavernous venous occlusive disease, mild arterial insufficiency, and severe arterial insufficiency. Traditional (fasting lipid panel, fasting glucose, age, BMI, smoking, Framingham coronary artery disease risk score) and emerging (C-reactive protein, Lp(a), homocysteine) risk factors for CVD were correlated to severity of penile vascular disease in men with ED and without clinical CAD. Using univariate analysis, penile Doppler groups showed significant positive correlation to CRP (r=0.21; < or = 0.05) and age (r=0.30; < or = 0.01). For CRP, this correlation remained significant even when adjusted for age (< or = 0.05). Men displaying evidence of penile arterial disease (mild and severe arterial insufficiency) were characterized by elevated CRP levels (0.17 mg/dl) compared to men with no evidence of arterial abnormalities in the penis (0.04 mg/dl). CRP levels correlate significantly with increasing severity of penile vascular disease as measured by penile Doppler.     

Relationship of asymmetric dimethylarginine with penile Doppler ultrasound parameters in men with vasculogenic erectile dysfunction

Background

Asymmetric dimethylarginine (ADMA), a selective endogenous nitric oxide synthase inhibitor, is elevated in many conditions associated with erectile dysfunction (ED), such as hypertension, diabetes, hyperlipidemia, and renal failure; it is also increased in men with coronary artery disease and ED. The dynamic penile colour Doppler ultrasound is considered the gold standard for the evaluation of penile vascular damage.

Objective

We investigated whether the extent of ultrasonographically documented penile vascular disease is associated with higher ADMA levels.

Design, setting, and participants

One hundred four consecutive ED patients (mean age: 56 ± 9 yr) without manifest cardiovascular/atherosclerotic disease and 31 subjects with normal erectile function matched for age and traditional risk factors were studied.

Measurements

We evaluated penile dynamic colour Doppler parameters of arterial insufficiency (peak systolic velocity) and veno-occlusive dysfunction (end diastolic velocity) and measured systemic inflammatory markers/mediators.

Results and limitations

Compared to men without ED, ED patients had significantly higher ADMA levels (p < 0.001). ADMA was significantly increased in patients with severe arterial insufficiency (PSV < 25 cm/s) compared to subjects with borderline insufficiency and men with normal penile arterial function (p < 0.001, by analysis of variance). Multivariable analysis adjusting for age, mean pressure, other risk factors, high-sensitivity C-reactive protein, testosterone, and treatment showed independent inverse association between ADMA level and peak systolic velocity (p < 0.01). The combination of higher ADMA level with arterial insufficiency showed greater impact on 10-yr risk of a cardiovascular event compared to either parameter alone.

Conclusions

ADMA level is independently associated with ultrasonographically documented poor penile arterial inflow. This finding underlines the important role of ADMA as a marker of penile arterial damage and implies a contribution of this compound to the pathophysiology of generalised vascular disease associated with ED.     

Diabetes and vascular impotence: does insulin dependence increase the relative severity?

AIM OF THE STUDY: Diabetes is a well documented risk factor for vascular erectile dysfunction (ED). We evaluated the relative roles of insulin dependence (IDDM) vs oral agent controlled diabetes (NIDDM) in predicting the etiologies and severity of ED: arterial insufficiency (AI), venous leakage (CVOD), and mixed vascular disease. The impact of additional risk factors were also analyzed: hypertension (HTN), coronary artery disease (CAD), and smoking (SM). METHODS: Retrospective data on 105 patients complaining of impotence who underwent pharmacotesting with PGE1 (Caverject) and color duplex Doppler was reviewed. Penile blood flow study (PBFS) data following a period of privacy and self-stimulation was compared. PBFS diagnostic criteria were: AI for peak systolic velocity (PSV) < 25 cm/s; CVOD for PSV > or = 35 cm/s and resistive index (RI) < 0.9; mixed vascular disease for PSV > or = 25 cm/s, PSV < 35 cm/s and RI > 0.9. Consistent dosing of PGE1 was used; 6 mcg for age < 60 y and 10 mcg for age > or = 60 y. Patients were NIDDM (79 out of 105) and IDDM (26 out of 105). Mean ages for NIDDM and IDDM were respectively 60, and 55 y. The relative significance of insulin dependence was assessed by Student's t-test. RESULTS: The most common etiology of ED was arterial insufficiency: mean PSV's did not significantly vary and were: 23.5 cm/s for NIDDM, and 21.6 cm/s for IDDM. PBFS parameters did not vary significantly for the risk factors of SM or HTN and diabetes. Mean peak systolic velocities were significantly different among diabetics with coronary artery disease: NIDDM/CAD, 22.9 cm/s compared to IDDM/CAD, 14.8 cm/s (P = 0.006). CONCLUSIONS: We found among the 105 diabetics the most common etiology of vascular ED based on Doppler criteria was arterial insufficiency, 64%. Statistical analysis of additional risk factors (SM, HTN, CAD) suggested that patients with IDDM and CAD have more severe cavernosal arterial insufficiency than patients with NIDDM and CAD. This data tends to support the theory that microangiopathy is the predominant factor in diabetic impotence, and that insulin dependent diabetes with 'large vessel' coronary heart disease have a similar pathology in the 'small vessels' regulating penile inflow which is unfortunately worse than their non-insulin dependent counterparts.     

Doppler evaluation of erectile dysfunction - part 2

Doppler evaluation in erectile dysfunction (ED) has a significant role in determining the cause of ED. The advantages of penile Doppler and pharmacologic duplex ultrasonography include objective, minimally invasive evaluation of penile hemodynamics at a relatively low cost. Arteriogenic ED may be secondary to peripheral vascular disease and diabetes, or may be seen in association with coronary artery disease. Various parameters, such as diameter of the cavernosal artery, peak systolic flow velocity, degree of arterial dilatation and acceleration time, have been suggested for the diagnosis of arteriogenic ED, but peak systolic flow velocity is the most accurate indicator of arterial disease. This second part of the review article describes the various causes of ED and the interpretation and evaluation of color flow Doppler examination in ED.     

The risk of coronary heart disease in men with erectile dysfunction

OBJECTIVES: Erectile dysfunction (ED) is a common disorder of aging male and about 50% of the ED sufferers consult a physician in the Netherlands. As ED is strongly correlated with cardiovascular diseases, we explored how many patients with ED aged 40 to 69 years will develop cardiovascular disease in the Netherlands and, philosophize if and which preventive measures are available to reduce cardiovascular risks in this specific population. METHODS: 158 patients were included and were comprehensively evaluated. All patients underwent a penile-pharmaco duplex ultrasonography to evaluate the penile vascular status and a cut-off value for acceleration time of 100 ms was used to distinguish between patients with and without cavernous arterial insufficiency. Framingham risk functions were used to determine the 4 to 12 year coronary heart disease risk. The results were extrapolated to the Dutch ageing male population. RESULTS: In the age group 40 to 49 years and 60 to 69 years no significant difference was detected in coronary heart disease risk between patients with and without cavernous arterial insufficiency. In the age group 50 to 59 years patients with cavernous arterial insufficiency showed a significantly increased risk to develop coronary heart disease. It is estimated that in total, more than 25,000 ageing men with ED will develop coronary heart disease within 4 years and increases to almost 75,000 men within 12 years in the Netherlands. CONCLUSIONS: Screening on cardiovascular risk factors and taking preventive measures is recommended in men with ED. Men with cavernous arterial insufficiency aged 50 to 59 years are especially prone to develop coronary artery disease.     

Peak systolic velocity in patients with arterial erectile dysfunction and peripheral arterial disease

The aim of this study is to evaluate whether penile peak systolic velocity (PSV) varies in patients with erectile dysfunction (ED) due to artery insufficiency associated with abnormalities in other arterial districts or not. To accomplish this, cavernous artery PSV was determined 10, 20 and 30 min after intracavernously administering alprostadil by means of echo-color Doppler to a total of 65 consecutive patients (age range 52-78 years). In all, 18 patients had ED alone (group A) and served as controls, 15 had ED plus atheroma plaques and/or marked intima-media thickness of the common carotid artery (group B); 17 had ED plus lower limb artery abnormalities; 17 had ED plus carotid and lower limb artery abnormalities (group D). Group B and C patients had a similar PSV, which turned out to be significantly lower than that in group A. Group D patients had the lowest PSV, which proved to be significantly lower than that in groups A, B and C. This study shows that a more generalized peripheral atherosclerotic process is associated with a severer penile artery insufficiency. Therefore, ED patients with a severe arterial insufficiency should undergo an extensive echo-duplex examination.     

Effect of systemic arterial pressure on erectile dysfunction in the initial stages of chronic arterial insufficiency

Study Type – Prognosis (case series)
Level of Evidence 4

OBJECTIVE

To report the effect of systemic arterial pressure on erectile dysfunction (ED) in patients in the initial stages of peripheral arterial disease.

PATIENTS AND METHODS

All patients with a diagnosis of ED in the urology outpatient clinic of the Medicine School in São José do Rio Preto, Brazil were evaluated in a cross‐sectional, quantitative study. The patients were assessed using the International Index of Erectile Function, the ankle‐brachial index, and measurement of arterial blood pressure. Binary logistic regression, log‐likelihood, Pearson chi‐square and likelihood ratio chi‐square and Kruskal–Wallis Test were used for statistical analysis with P < 0.05 being considered acceptable. Fifty‐two patients (mean age 56.63 years) were enrolled in the study.

RESULTS

Differences were detected between the median grades of ED of patients with differing degrees of chronic arterial insufficiency. Hypertensive patients in the initial stages of peripheral arterial disease had less severe grades of ED than normotensive patients.

CONCLUSIONS

The progression of ED parallels the development of chronic arterial insufficiency. Systemic arterial hypertension in the initial stages of peripheral arterial disease might protect against ED, but peripheral arterial disease constitutes an aggravating factor for ED, and thus hypertension might exert a paradoxical effect in this stage of the disease.     

Usefulness of electromyography of the cavernous corpora (CC EMG) in the diagnosis of arterial erectile dysfunction

Electromyography (EMG) of the corpora cavernosa (CC-EMG) is able to record the activity of the erectile tissue during erection, and thus has been used as a diagnostic technique in patients with erectile dysfunction (ED). The present study examines the usefulness of the technique in the diagnosis of arterial ED. A cross-sectional study was made of 35 males with a mean age of 48.5 years (s.d. 11.34), referred to our center with ED for >1 year. The patients were subjected to CC-EMG and a penile Doppler ultrasound study following the injection of 20 μg of prostaglandin E1 (PGE1). The patients were divided into three groups according to their response to the intracavernous injection of PGE1: Group 1 (adequate erection and reduction/suppression of EMG activity); Group 2 (insufficient erection and persistence of EMG activity); and Group 3 (insufficient erection and reduction/suppression of EMG activity). Patient classification according to response to the intracavernous injection of PGE1 was as follows: Group 1: six patients (17%), Group 2: 18 patients (51%), and Group 3: 11 patients (31%). Patients diagnosed with arterial insufficiency according to Doppler ultrasound (systolic arterial peak velocity <30 mm s(-1) in both arteries) were significantly older than those without such damage (54.5 versus 41.8 years, respectively; s.d. 11.12). The patients in Group 3 showed a significantly lower maximum systolic velocity in both arteries than the subjects belonging to Group 2. Likewise, a statistically significant relationship was observed between the diagnosis of arterial insufficiency and patient classification in Group 3. The confirmation of insufficient erection associated with reduction/suppression of EMG activity showed a sensitivity of 66.7% (confidence interval between 50 and 84%) and a specificity of 92.9% (confidence interval between 84 and 100%) in the diagnosis of arterial ED. Owing to the high specificity of CC-EMG response to the injection of PGE1, this test is considered useful as a screening technique in the diagnosis of arterial ED.     

Erectile dysfunction: anatomical parameters, etiology, diagnosis, and therapy

Functional anatomy of the human penis involves various parameters: cavernous tissue, covering integument, prepuce foreskin, corpora cavernosa, corpus spongiosum, glans, facia, arterial supply, venous drainage, lymph drainage, musculature, and nerve supply. Several factors affect the expression/degree of erectile dysfunction (ED) endocrine profile, aging/senescence, demyelinating diseases, and surgery. Risk factors of ED are: age, vascular factors, metabolic diseases (diabetes mellitus), neurologic diseases, and HIV/AIDS. Several drugs are associated with ED: antiandrogenic, anticholinergic, antidepressants, antihypertensive, major tranquilizers, anxiolytics, and certain medicines/metabolites. The International Index of Erectile Function (IIEF) is a multidimensional scale for assessment of erectile dysfunction. The main structures mediating erection are the corpora cavernosa or "erectile bodies," which are fused distally for approximately three-quarters of their length. They separate proximally to fuse with each ischial tuberosity of the pelvis. On their ventral surface lies the corpus spongiosum, which surrounds the urethra. Coital dysfunction is classified into "erectile dysfunction" (psychosexual and endocrine/neuro-endocrine) and "ejaculatory dysfunction" (psychosexual, and genitourinary surgery). Vasculogenic impotence was evaluated by high-resolution ultrasonography and pulsed Doppler spectrum analysis. Cavernosal, alpha-blockade is a technique used to evaluate and treat ED. Another diagnostic procedure for ED involves color floro and spectural Doppler imaging after papaverine-induced erection in impotent men. Color Doppler and duplex ultrasonography are used to evaluate Peyronie's disease. Sildenafil cilrate (Viagra) is an effective therapy of ED in men. Vardenavil is a highly selective phosphodiesterase 5 (PDE5) inhibitor which improved ED. Prostagland E1, vasoactive intestinal polypeptide (VIP), and phentolamine mesylate (administered by autoinjectors) have been applied to treat ED in patients resistant to other intracavernosal agents. Clinical trials were conducted on self-injection of vasoactive drugs, apomorphine SL, and tadalafil in diabetic men. Medical therapy of ED includes: medicated urethral system for erection (MUSE), intravenous pharmacotherapy, arterial revascularization, vacuum devices, two- and three-component inflatable penile prosthesis, semi-rigid penile prosthesis in situ, and inflatable one-piece penile prosthesis. Surgical therapy include procedures to correct Peyronie's penile deformity and penile deformity, procedures to avoid inevitable shortening accompanying Nesbit's disease, and for penile lengthening.     

Risk factors of erectile dysfunction and penile vascular changes after surgical repair of penile fracture

This study was conducted to determine the preoperative and intraoperative risk factors of ED and the underlying penile vascular abnormalities among patients with penile fracture treated surgically. In all, 180 patients with penile fracture were treated surgically and followed up in one center. None of our patients had ED before the penile trauma and only two of them had risk factors for systemic vascular diseases, such as diabetes mellitus (one patient) and hypertension (one patient). After a mean follow-up of 106 months, 11 patients (6.6%) developed ED, 7 had mild ED and 4 had moderate ED. The main risk factors for subsequent ED were aging, >50 years, and bilateral corporal involvement. Among the 11 patients with ED, color Doppler ultrasonography (CDU) showed normal Doppler indices in 4 (36.4%), veno-occlusive dysfunction in 4 (36.4%) and arterial insufficiency in the remaining 3 (27.2%) patients. CDU assessments from the injured and intact sides were comparable. ED of either a psychological or vascular origin can be encountered as a long-term sequel of surgical treatment of penile fracture. Aging, >50 years, at presentation and bilateral corporal involvement is the main risk factors for subsequent development of ED.     

Original evaluation of endothelial dysfunction in men with erectile dysfunction and metabolic syndrome

We have recently demonstrated the diagnostic value of a new immunophenotype of blood endothelial progenitor cells (EPCs=CD45neg/CD34pos/CD144pos) and endothelial microparticles (EMPs=CD45neg/CD144pos/AnnexinVpos) in patients with arterial erectile dysfunction (ED) according to severity of cavernous arterial insufficiency evaluated through penile Doppler. The aim of this study was to evaluate both EPCs and EMPs in patients with arterial ED and metabolic syndrome (MetS), comparing these patients with another group of patients without MetS and ED and a third group with MetS but without ED. For this study 50 patients with arterial ED and MetS were selected (age: 55.0±3.0 years; range: 47-60). A group of age-matched (age: 54.0±2.0 years; range: 44-60) patients without arterial ED and MetS (n=30), and another group of age-matched (age: 57.0±4.0 years; range: 40-62) patients with MetS but without ED (n=20) represented the control groups. EPCs and EMPs were significantly higher in patients compared with other groups (P<0.01). Both EPCs and EMPs correlated positively with the age, body mass index, and score of international index of ED (version five items) and with the following cavernous artery indices: peak systolic velocity, acceleration time and intima-media thickness. Among control groups patients with MetS but without ED showed serum concentrations of EPCs and EMPs significantly higher (P<0.05) compared with patients without MetS and ED. Patients with arterial ED and MetS have higher EPCs and EMPs compared with patients with MetS but without ED and patients without MetS and ED.     

A comparison of the International Index of Erectile Function and erectile dysfunction studies

OBJECTIVE: To evaluate the ability of the five-item version of the International Index of Erectile Function (IIEF-5) to diagnose the vascular aetiology and severity of erectile dysfunction (ED), and to compare it with pharmacological testing and duplex Doppler ultrasonography, as such questionnaires are widely used by the pharmaceutical industry to categorize the severity of ED and to assess the efficacy of drug therapy. PATIENTS AND METHODS: In all, 80 patients (mean age 45.2 years, sd 14.0; mean duration of ED 3.5 years) were reviewed by an examiner unaware of their IIEF scores during testing. Penile blood flow was assessed in each patient after an intracavernosal injection with prostaglandin-E1 (10 micro g), with self-stimulation in privacy. The peak systolic velocity, end diastolic velocity and resistive index were measured for the vascular diagnosis. Visual ratings of erectile responses were also used for analysis. RESULTS: Of the 80 patients, 30 had a normal vascular response, 38 arterial insufficiency and 12 were diagnosed with venous leakage. There was no significant difference in the IIEF scores among patients with a normal vascular response, arterial insufficiency or venous leakage. Analysis of visual ratings of erections showed no difference in IIEF scores among the different groups of patients. CONCLUSION: The IIEF was designed and developed specifically for assessing and evaluating sexual function in clinical trials. However, as shown here, the IIEF cannot and should not be used as a tool to diagnose or compare specific vascular causes of ED.     

Incidence of extragenital vascular disease in patients with erectile dysfunction of arterial origin

This research was carried out to evaluate the prevalence of carotid and/or lower limb artery abnormalities in patients with arterial erectile dysfunction (ED). To this end, patients with ED (Andrology Unit) or suspected peripheral atherosclerosis (Angiology Unit) underwent an independent and parallel echo-Duplex examination. The Andrology Unit examined 167 patients with ED of different etiologies: 52 of them had penile artery insufficiency and consequently their carotids and lower limb arteries had to be evaluated by means of echo-Doppler. In all, 36 out of the 46 patients with nonarterial organic ED and 22 out of the 69 patients with nonorganic ED underwent the same evaluation and served as controls. The Angiology Unit enrolled 457 ED patients who initially underwent echo-Doppler for suspected carotid and/or arterial leg atherosclerosis and subsequently dynamic echo-Doppler. Isolated penile artery insufficiency was found in 23.1 and 25% of the patients evaluated in the Angiology and Andrology Units, respectively. The remaining patients were shown to have ED associated with an atheroma or marked intima-media thickness of the carotid vessels and/or of leg arteries. The frequency of penile arterial insufficiency and of carotid and/or lower limb artery abnormalities was significantly higher (P < 0.01) compared to that found in patients with ED of nonarterial organic or psychogenic origin. Both Units found that the frequency of penile artery insufficiency and carotid or lower limb artery abnormalities was significantly higher than that of penile artery insufficiency alone or plus both carotid and lower limb artery abnormalities. This study showed that penile artery insufficiency is associated with carotid and/or lower limb artery ultrasound abnormalities in about 75% of the cases. Therefore, arterial ED may be regarded as a sign of a more generalized atherosclerosis.     

Penile vascular abnormalities observed long-term after surgical repair of penile fractures.

AIM: To assess the penile vascular system in men long-term after surgical treatment of penile fractures. PATIENTS AND METHODS: During a 15-year period, 36 cases of penile fracture underwent immediate surgical repair at the University of Istanbul, Turkey. At least 1 year after operation, all patients were invited for penile vascular evaluation. 15 patients accepted our call and were enrolled in our study. They were evaluated with detailed medical and sexual history, a serial of serum analyses, and penile color Doppler ultrasonography. RESULTS: By history, 6 of the 36 (16.6%) patients who had undergone surgical repair had erectile dysfunction (ED). The mean interval between surgical intervention for penile fracture and penile vascular evaluation was 3.6 +/- 1.9 (range 1.5-8) years. Evaluation of the penile vascular system of 15 men (mean age 35.7 +/- 17.3, range 21-63 years) revealed normal vascular system in seven (46.7%), while cavernosal insufficiency was observed in four (26.7%) and arterial insufficiency in three (20%) men. The remaining case (6.7%) was diagnosed to have mixed arterial and cavernous insufficiency. Erectile dysfunction in two cases was considered to be in psychogenic origin and vascular in the remaining four. CONCLUSION: Although immediate repair is reported to be the treatment of choice in penile fractures, ED of either a physiological or vascular origin can be encountered as a long-term sequel and deserves to be evaluated in detail.     

The combined use of brachial artery flow-mediated dilatation and carotid artery intima-media thickness measurements may be a method to determine vasculogenic erectile dysfunction

The aim of this study was to investigate the relationship between penile color Doppler sonography (CDS) findings and sonographic endothelial parameters in patients with erectile dysfunction (ED), including intima-media thickness (IMT) of common carotid arteries (CCA) and flow-mediated dilatation (FMD) of brachial artery. Fifty-six ED patients were included in the study. Penile CDS, IMT of CCA and FMD of brachial artery were performed in all patients. According to penile CDS findings, 27 (48%) patients had non-vasculogenic and 29 (52%) patients had vasculogenic ED. Among 29 patients, 17 (30%) patients had cavernous veno-occlusive disease (CVOD) and 12 (22%) patients had arterial/combined insufficiency (AI). Median (interquartile range) FMD values of non-vasculogenic ED, CVOD and AI were 12.50 (6.54)%, 12.82 (7.41)% and 6.25 (7.17)%, respectively. FMD was found to be impaired significantly in AI group when compared to the other groups. FMD values of CVOD group were lower when compared to non-vasculogenic group, but the difference was not statistically significant. IMT values of vasculogenic ED patients were higher than non-vasculogenic ED patients (P<0.05). Although IMT values were higher in AI group when compared to CVOD, the difference was not statistically significant. The combined use of IMT and FMD established the diagnosis of vasculogenic ED with 100% sensitivity and 59.2% specificity. The positive predictive value was 72%, negative predictive value 100% and accuracy 80%. The combined use of brachial artery FMD and carotid arteries IMT measurements may be suggested as an alternative method to evaluate vasculogenic ED.     

Leg ulcer etiology--a cross sectional population study

Three hundred eighty-two patients with active leg ulcers were clinically examined after random selection out of a population of 827 patients identified within a previous cross-sectional population survey. Bidirectional Doppler ultrasonography was used for objective assessment of arterial and venous circulation. The purpose was to register causative factors and the etiologic spectrum. Venous insufficiency was present in 332 (72%) of 463 legs with active ulceration; deep insufficiency occurred in 176 (38%), and purely superficial insufficiency was present in 156 (34%). Ankle/brachial index was 0.9 or less in 185 (40%) of ulcerated legs. Venous insufficiency was the dominating causative factor in 250 legs (54%), of which 60% was the result of deep venous insufficiency. Arterial insufficiency was judged to be the possible dominating factor in 12%, and 6% showed clearly ischemic ulcers. Mixed ulcers with combined arterial and venous insufficiency were found to be common as were patients with diabetes and arterial impairment. In 10% of the legs a multifactorial origin was present, and in 10% no venous or arterial impairment was detectable. Thus after classification of causes 40% of all ulcerated legs showed potentially surgically curable circulatory disturbances. It is necessary to objectively assess all patients with chronic leg ulcers to be able to detect patients with potentially surgically curable disease.     

Stratification of penile vascular pathologies in patients with Peyronie's disease and in men with erectile dysfunction according to age: a comparative study

PURPOSE: Erectile dysfunction (ED) occurs in 20% to 54% of men with Peyronie's disease (PD). We investigated the role of vascular status in the pathophysiology of ED in patients with PD. MATERIALS AND METHODS: A total of 509 consecutive men with PD (group 1--impotent 259, 1a, and potent 250, 1b, mean age +/- SD 54.6 +/- 4.4 years) and 507 consecutive men with ED only (group 2--mean age 49.4 +/- 12.4 years) underwent penile duplex ultrasonography (PDU). Detailed sexual and medical history, and focused physical examination were performed in all patients. Patients in the 2, groups were stratified according to age (18 to 80 years) and classified according to PDU results (normal vascular status, arterial insufficiency, veno-occlusive dysfunction [VOD] and mixed vascular pathology). RESULTS: VOD was observed in 23.1% and 42.8% of patients in groups 1 and 2, respectively (p <0.05). Although VOD was significantly more common in group 2 (ED alone) than in group 1a (PD plus ED) in the third decade (p <0.05), overall PDU results showed no statistical difference for VOD between these 2 groups (p >0.05). Of note, mixed vascular pathologies were significantly higher in group 1a than in group 2 in the third through fifth decades (p <0.05), while arterial insufficiency was more common in the seventh decade (p <0.05). CONCLUSIONS: While many groups have investigated the vascular causes of ED, the exact etiology of ED in men with PD remains controversial. A possible relationship between ED and VOD in patients with PD has been previously reported. The current PDU study demonstrates that for all ages except 30 to 39 years the prevalence of VOD in patients with PD plus ED is similar to that of patients with ED alone.     

多普勒超声技术动态观察血管性勃起功能障碍患者阴茎血流动力学的变化

目的动态观察多普勒超声技术配合阴茎海绵体注射在血管性勃起功能障碍患者诊断中的价值。方法120例疑血管性ED患者在阴茎注射PGE1后5min、10min和20min应用多普勒超声技术测量阴茎血流动力学变化,指标包括:收缩期峰值流速(PSV)、舒张末期峰值流速(EDV)、血流阻力指数(RI)。另100例心因性ED设为对照组。第一次注射后勃起不佳的患者3d后增加PGE1剂量重新检测。结果120例患者可以观察到明显的血流动力学变化,其中有动脉性ED者34例,静脉性ED 55例,混合血管性31例。ICI后不同时间的多普勒测量其血流动力学变化有一定差异。结论多普勒超声技术诊断血管性勃起功能障碍有一定意义。阴茎海绵体注射药物后须动态观察阴茎血流动力学的变化。     

A review of microvascular measurements in wound healing

The microcirculatory evaluation in patients affected by arteriopathic or venous ulcers is usually carried out using laser Doppler flowmetry, transcutaneous oxygen (transcutaneous pressure of oxygen, TcPO(2)), and carbon dioxide (transcutaneous pressure of carbon dioxide, TcPCO(2)) measurements and capillaroscopy. These techniques provide significant pathophysiologic and prognostic information. TcPO(2) and TcPCO(2) diagnose and classify the extent of arterial disease in the leg ulcers caused by arterial disease; the prognostic value is recognized, though doubts about its prognostic potential exist in the case of leg ulcer. Laser Doppler flowmetry is able to identify the first functional impairment in the early stages of the arterial disease and in the complicated venous insufficiency. Capillaroscopy gives us morphological and quantitative parameters of the capillary bed that is damaged in arteriopathic and venous ulcers; nevertheless, it does not provide us with definite prognostic indexes. Combining the 3 methods may contribute to yield objective measures in the clinical management of lower extremity ulcers.