Comparison of penile duplex ultrasonography with nocturnal penile tumescence monitoring for the evaluation of erectile impotence

A total of 50 patients with erectile dysfunction underwent comprehensive evaluation, including vascular evaluation with penile duplex ultrasonography and papaverine injection, as well as nocturnal penile tumescence monitoring. The latter was performed in a sleep laboratory setting in all patients. The results of penile duplex ultrasonography with papaverine injection were classified as 18 patients with normal vascular findings, 22 with arterial insufficiency, 3 with the pelvic steal syndrome and 7 with isolated venous leakage. Of the patients 15 had normal ultrasonographic and nocturnal penile tumescence findings, 29 had abnormal ultrasonographic vascular and nocturnal penile tumescence findings, 3 had abnormal ultrasonographic vascular findings and normal nocturnal penile tumescence (including 1 with the pelvic steal syndrome as evidenced by penile brachial index) and 3 had normal ultrasonographic vascular findings and abnormal nocturnal penile tumescence (including 2 with neurogenic erectile dysfunction). Penile duplex ultrasonography with papaverine injection appears to be a useful objective method to evaluate vasculogenic impotence and to correlate favorably with nocturnal penile tumescence monitoring. It also may have a higher yield than nocturnal penile tumescence monitoring in patients with the pelvic steal syndrome. While nocturnal penile tumescence is impaired in patients with neurogenic impotence, penile duplex ultrasonography with papaverine injection reveals, as expected, normal findings in patients with neurogenic impotence and normal vascular systems.     

Is intracavernous injection of papaverine a reliable screening test for vascular impotence?

To determine whether intracavernous injection of papaverine can discriminate vascular versus psychogenic impotence 80 mg. papaverine were injected intracorporeally into 27 impotent patients without any hormonal or neurological abnormality. The patients also underwent dynamic cavernosography, the artificial erection test and selective internal iliac arteriography. In addition, 21 of the patients underwent nocturnal penile tumescence monitoring. The response to intracavernous papaverine injection was noted as positive (fully rigid erection), intermediate or negative (soft or absent erection). Among 14 patients with severe arterial lesions and/or severe venous leakage the response was negative in 11 and positive in none. Among the remaining 13 patients (moderate or absent vascular abnormalities) the response was positive in 4 but negative in 4. Of 15 patients with an abnormal nocturnal penile tumescence test the response to intracavernous papaverine injection was negative in 12 and positive in none. However, of 6 patients with a normal nocturnal penile tumescence test the response was positive in only 1. Over-all, the results of the intracavernous papaverine injection test are correlated only fairly with those of the nocturnal penile tumescence test and the vascular investigations. This test could be useful to save some nocturnal penile tumescence tests in cases of suspected vascular impotence. However, the safety of this procedure must be confirmed in larger series. Indeed, 1 of our patients suffered priapism after a second intracavernous papaverine injection performed for a therapeutic purpose.     

Crural ligation for primary erectile dysfunction: a case series

PURPOSE: Some men with primary erectile dysfunction (ED) have maldevelopment of the crura of the penis. We report our experience with crural ligation for primary venous leakage ED in the last 5 years. MATERIALS AND METHODS: Between December 1998 and March 2004, 11 patients with primary ED underwent crural ligation surgery for congenital venous leakage. All patients were evaluated with pertinent history and physical examinations, color duplex ultrasound, nocturnal penile tumescence study with RigiScan, cavernosometry and cavernosography. Localized crural leakage was the pathognomonic feature in these patients. Surgery involved reflection of the dorsal and cavernous arteries and nerves off of the crura, followed by ligation of the 2 crura proximal to the entrance of the cavernous artery with umbilical tapes. Followup was performed by telephone interview or personal interview at the clinic. A retrospective preoperative and postoperative questionnaire, that is the abridged 5-item version of the 15-item International Index of Erectile Function, was given at the time of the interview. Statistical analysis was performed with the paired t test. RESULTS: Median patient age at surgery was 28 years (range 22 to 39) and mean followup after surgery was 34 months (range 6 to 58). Mean International Index of Erectile Function +/- SD preoperatively and postoperatively was 8.9 +/- 4.5 and 17.5 +/- 5.0, respectively. For questions 2, 3 and 5 mean postoperative scores were significantly better than postoperative scores (p <0.05). Marked improvement in erectile function was noted in 9 of our 11 patients. CONCLUSIONS: Penile venous surgery may not have a lasting result in men in whom venous leakage is due to systemic diseases or penile smooth muscle atrophy. However, in patients with a congenital venous leak abnormality of the crura ligation of the proximal crura with umbilical tapes seems to have a satisfactory, durable result.     

Nocturnal penile tumescence in cigarette smokers with erectile dysfunction.

We examined the relationship between cigarette smoking and erectile physiology in 314 men with erectile dysfunction. All of the men studied were currently cigarette smokers. Evaluations included interviews, physical examinations, and polysomnographic assessment of sleep-related erections. Penile rigidity during nocturnal erection inversely correlated with the number of cigarettes smoked per day. Smoking was also associated with indices of impairment on autonomic function tests and some measures of penile blood pressure. The group of men who smoked the most (more than 40 cigarettes per day) had the fewest minutes of nocturnal tumescence and detumesced fastest. These data are discussed with respect to the results of studies performed in dogs that demonstrated smoking-related reduction in arterial flow and venous restriction. Our findings suggest that smoking may further compromise penile physiology in men experiencing difficulty in maintaining erections long enough for satisfactory intercourse.     

Penile venous ligation surgery for the management of cavernosal venous leakage.

Forty-one patients underwent penile venous ligation surgery for pure cavernosal venous leakage diagnosed by infusion cavernosometry and cavernosography. Before surgery, arterial integrity was assessed by pelvic angiography, and all patients were found to have a normal penile arterial system. The patients were divided into two groups on the basis of the type of venous operation performed. The overall complete-potency success rate was 46% (19 of 41 patients). Postoperative complications were minimal. Our experience shows that penile venous surgery remains an acceptable option for treatment of carefully selected patients with documented pure cavernosal venous leakage of a mild degree who have no evidence of arterial insufficiency and who do not prefer, or are not suitable for, other medical or surgical treatment options. Patients who had more severe degrees of cavernosal venous leakage had a poor result from this procedure. For patients with moderate to severe venous leakage, we now perform a combined surgical procedure, deep dorsal vein arterialization and venous ligation.     

Autonomic nerve involvement and venous leakage in diabetic men with impotence

OBJECTIVE: To determine the neurophysiological and vascular factors in diabetic impotence, particularly the role of autonomic neuropathy on venous leakage and erectile impotence. PATIENTS AND METHODS: Thirty-four diabetic men with impotence were investigated using various neurophysiological and radiological methods. The results were compared with those from patients with idiopathic penile venous leakage for autonomic neuropathy, especially for spontaneous cavernosal activity (SCA). RESULTS: Of the neurophysiological tests, the SCA was most frequently abnormal, with the loss of normal periodic oscillations. Penile venous leakage, either alone or with arterial insufficiency, was the most frequent vascular problem (67%) in patients with diabetic impotence, in whom the SCA was absent in most (83%). Conversely, the SCA was normal in all impotent patients with idiopathic venous leakage. CONCLUSION: Venous leakage in diabetic patients is probably produced by autonomic dysfunction of the penile vascular innervation or degeneration of penile smooth muscles, because the SCA was absent more often in these patients.     

Digital angiography of erectile failure

Digital angiography of pudendal and penile arteries was performed in 44 consecutive patients with erectile failure of suspected vascular origin. Intra-arterial injection of contrast medium via selective catheterisation of the hypogastric arteries was used in six cases. In 39 patients, one of whom had already had arterial catheterisation, contrast medium was administered by the intravenous route, using a single, large volume, high speed bolus. In 12/44 cases (27%), digital angiography showed a normal vascular picture at the pudendal and penile level but the remaining 32 patients (73%) had steno-occlusive lesions of different degrees of severity. The pictures obtained after administration of intravenous contrast were diagnostically as good as the studies with selective arterial catheterisation. In addition, the intravenous route allowed the simultaneous representation of the arterial network on both sides and was quicker and less invasive. In 31/44 patients (79%), functional determinations of nocturnal penile tumescence and of penile blood flow with Doppler ultrasonography were performed for comparison. Nocturnal penile tumescence results correlated well with the angiographic picture. Penile blood flow measurements with the Doppler technique were less sensitive than digital angiography.     

Penile calibration for nocturnal penile tumescence studies

Artificial penile erections were created in 23 impotent patients by infusion of heparinized saline solution into the corpora cavernosa. Penile circumference as related to rigidity was accurately assessed. The increase in circumference necessary to produce erection adequate for vaginal penetration varied from 7.5 to 35 mm, whereas for maximum rigidity the penile circumference increase varied between 10 mm and 40 mm. These were then compared with the changes during nocturnal penile tumescence studies. Even though 5 patients in the series had erection greater than 15 mm, 40 per cent of them did not achieve rigidity adequate for vaginal penetration. One patient had nocturnal tumescence of only 12 mm; this, however, was an erection adequate for vaginal penetration. The approach discussed in this article may allow the rational use of portable home tumescence monitoring.     

New concept parameters of RigiScan in differentiation of vascular erectile dysfunction: Is it a useful test?

BACKGROUND: The aim of this study is to investigate the value of new nocturnal penile tumescence recording parameters, such as tumescence activity unit and rigidity activity unit values, total erection number and erection times, in differentiating between psychogenic erectile dysfunction and organic erectile dysfunction. We also aimed to determine the role of these parameters in differentiating arterial erectile dysfunction from veno-occlusive dysfunction. METHODS: Eighty-seven consecutive patients were allocated into three groups as psychogenic, arterial and venous erectile dysfunction after investigations. Nocturnal penile tumescence recording parameters between psychogenic and vascular erectile dysfunction and arterial and veno-occlusive dysfunction were compared. Mann-Whitney U-test, Pearson's chi2 test and correlation coefficient tests were used for statistical analysis. RESULTS: Depending on intracavernous injection, penile Doppler ultrasonography and cavernosometry tests, 37 patients (43%) had psychogenic impotence while 50 (57%) had organic pathologies. Of the 50 patients diagnosed with vascular impotence, 29 (48%) had arterial failure and 21 (42%) had veno-occlusive dysfunction. Nocturnal penile tumescence recording revealed psychogenic erectile dysfunction in 34 patients (39%) and vascular erectile dysfunction in 53 patients (61%). Nocturnal penile tumescence recording has been regarded as the gold standard and, in our series, it showed 90.6% sensitivity and 88.2% specificity in differentiating the cause of erectile dysfunction. Values of rigidity activity unit and tumescence activity unit were significantly higher in patients with psychogenic impotence (P < 0.001), when compared with vascular impotence. In patients with a vascular cause, no difference was found between arterial failure and veno-occlusive dysfunction with regard to tip tumescence activity unit, base tumescence activity unit, tip rigidity activity unit, base rigidity activity unit and erection time (P > 0.001). However, patients with arterial failure had less erection than patients with veno-occlusive dysfunction (P < 0.001). CONCLUSION: New recording parameters of nocturnal penile tumescence can differentiate organic and psychogenic erectile dysfunction more precisely. However, these recording parameters cannot distinguish subgroups with a vascular cause of erectile dysfunction.     

脊柱或骨盆损伤后阴茎勃起功能障碍的病因分析

目的 分析脊柱或骨盆损伤后阴茎勃起功能障碍(ED)的可能病因.方法 回顾性分析2005-2009年收治的67例因脊柱或骨盆损伤后ED患者资料.年龄18 ～64岁,平均32岁.伤后时间3～144个月,平均38个月.其中骨盆骨折56例(84％),脊柱外伤11例(16％).患者自诉受伤前性功能正常.患者在未服用或停用PDE-5抑制剂的情况下进行IIEF-5评分、夜间勃起监测(NPT,Rigiscan系统,连续检测3晚)、阴茎彩色多普勒超声(CDU)检查.NPT检测夜间勃起＜3次,每次阴茎头部勃起硬度＜70％,时间＜ 10 min诊断为器质性ED.阴茎Ⅳ度勃起情况下,CDU检查峰收缩期速率(PSV)＜ 25 cm/s诊断为动脉性ED;PSV＞ 25 cm/s,舒张末期速率(EDV) ＞5 cm/s诊断为静脉性ED;排除其他原因的器质性ED诊断为神经性ED.结果 62例患者在6个月内未尝试性生活,5例患者IIEF-5评分5～8分.NPT检测证实62例患者均为器质性ED,其中骨盆骨折患者中神经性ED 24例(43％),动脉性ED 22例(39％),静脉性ED 10例(18％);脊柱外伤患者均为神经性ED.结论 骨盆骨折或脊柱外伤可导致器质性ED.骨盆骨折导致的ED可能合并血管性因素,而脊柱外伤所致ED为神经性.     

Evaluation of vasculogenic erectile impotence using penile duplex ultrasonography

A total of 140 patients underwent penile vascular evaluation with intracavernous papaverine injection combined with duplex ultrasonography. Of these patients 8 were potent men who were evaluated for reasons other than erectile failure. These potent men were used as controls to obtain normal values. The remaining 132 patients had erectile impotence of various etiologies. Real-time imaging with high resolution, high frequency probes allowed for visualization of the cavernous arteries along the entire length in addition to accurate measurement of the diameter. Simultaneous selectively focused Doppler ultrasonography was used to measure the blood velocity and other vascular parameters in the cavernous and dorsal arteries. Comparison of measurements before and after papaverine injection allowed for objective interpretation of the injection results. The results were analyzed and compared to other data available on the same patients, such as history and physical examination, nocturnal penile tumescence, penile blood pressures, selective arteriography and dynamic cavernosography. In addition to the 8 potent men, there were 35 patients (27% of the impotent patients) whose vascular findings were normal. A total of 78 patients (59% of the impotent patients) had arterial insufficiency; a subgroup of 13 patients had the pelvic arterial steal syndrome. Dynamic cavernosography confirmed venous leak in all 19 patients (14% of the impotent patients) whose penile duplex ultrasonography suggested the possibility of a venous leak. Ten patients (7%) had prolonged erection after papaverine injection and they were managed without consequences. One patient had a small hematoma that resolved uneventfully. Penile duplex ultrasonography was a helpful and objective method to evaluate vasculogenic impotence.     

Penile blood flow and musculovascular events during sleep-related erections of middle-aged men

The relationships among penile segmental pulsatile blood flow, pelvic musculovascular events, phases of nocturnal penile tumescence, and sleep stages were studied by all-night polysomnography in 23 healthy middle-aged men. Penile blood flow peaked during maximal tumescence. Bursts of phasic musculovascular activity were more frequent during ascending and maximal tumescence than during detumescence and baseline. Both penile blood flow and the number of musculovascular events increased during REM sleep. These data describe important local aspects of penile erectile mechanisms in normal men. The findings on musculovascular events support the notion that the bulbocavernosus-ischiocavernosus muscles have a role in human penile erection.     

Reproducibility in monitoring nocturnal penile tumescence and rigidity.

The evaluation of sexual dysfunction has improved with the advent of methods to test nocturnal penile tumescence that also monitor penile rigidity. Earlier techniques may not have recorded abnormal rigidity despite normal tumescence. To test the reproducibility of penile tumescence and rigidity, the results of initial and repeat tracings performed a mean of 39 days apart were compared in 17 patients (median age 62 years). Three nocturnal patterns were identified. 1) Among the 17 patients the initial penile tumescence and rigidity pattern was reproduced on repeat testing in 15. 2) Patterns that were not reproduced in the other 2 patients were explained by the ingestion of alcohol or because of a febrile illness during the period monitored. 3) Nocturnal penile rigidity and tumescence tracings from these patients reproduced previous patterns. Monitoring of nocturnal penile tumescence and rigidity is a useful and reproducible tool in the evaluation of male sexual dysfunction.     

Predictive value of patient history and correlation of nocturnal penile tumescence, colour duplex Doppler ultrasonography and dynamic cavernosometry and cavernosography in the evaluation of erectile dysfunction

AIMS: The results of history and physical examination, nocturnal penile tumescence testing (NPT), colour flow duplex Doppler ultrasonography and dynamic infusion cavernosometry and cavernosography (DICC) were retrospectively correlated in 207 patients with erectile dysfunction. METHODS AND MATERIALS: The predictive value of the patient's own subjective assessment of early morning and nocturnal erections, history of cigarette smoking, the presence of vascular risk factors was correlated to the outcome of investigations. The result of Rigiscan NPT was correlated to the peak systolic velocity (PSV) and the resistance index (RI) determined at colour flow duplex Doppler ultrasonography, and the maintenance flow rate (Qm) determined at DICC. RESULTS: Eighty-five out of two hundred and seven patients (41%) had normal NPT comprising 48 out of 85 patients (56%) who described rigid early morning and nocturnal erections, 15 out of 85 patients (18%) who smoked cigarettes and 9 out of 85 patients (11%) with other positive vascular risk factors. 72 out of 85 patients (85%) had a normal PSV (>30 cm/s), 80 out of 85 patients (94%) had a normal RI (>0.85) and 82 out of 85 patients (96%) had a normal Qm), (<10 ml/min). Vascular investigations in this group identified 71 out of 85 patients (84%) with no penile vascular disease, 11 out of 85 patients (13%) with arteriogenic impotence, 2 out of 85 patients (2%) with mixed vasculogenic impotence and 1 out of 85 patients (1%) with cavernosal venous leakage (CVL). One hundred and twenty-two out of two hundred and seven patients (59%) had an abnormal NPT comprising 18 out of 122 patients (15%) who continued to experience rigid early morning erections, 65 out of 122 patients (53%) who smoked cigarettes, 59 out of 112 patients (48%) with other positive vascular risk factors, 36 out of 112 patients (29%) had an abnormal PSV (<30 cm/s), 49 out of 122 patients (40%) had an abnormal RI (<0.85) and 55 out of 122 patients (45%) had an abnormal Qm (>10 ml/min). Vascular investigations in this group identified five patients with no penile vascular disease, 51 out of 122 patients (41%) with arteriogenic impotence, 31 out of 122 patients (25%) with cavernosal venous leakage (CVL) and 35 out of 122 patients (29%) with mixed vasculogenic impotence. CONCLUSIONS: (1) a history of cigarette smoking and positive vascular risk factors are good predictors of organic impotence whereas the patient's subjective assessment of his own early morning erections is unreliable; (2) normal NPT correlates well with normal PSV, RI and Qm but does not exclude organic impotence; (3) abnormal NPT correlates well with abnormal PSV, RI and Qm.     

Vascular-induced erectile impotence in renal transplant recipients.

The incidence and pathogenesis of sexual dysfunction were studied in 16 male renal allograft recipients. In 9 patients with bilateral renal transplants in whom both internal iliac arteries were occluded nocturnal erections were absent and a penile arterial pulse could not be palpated. Of 7 patients with 1 renal allograft 4 demonstrated penile nocturnal tumescence and the penile pulse could be palpated in 5. Since interruption of pelvic arterial blood supply appears to contribute to impotence in renal transplant recipients consideration should be given to the use of the external iliac artery for arterial anastomosis. Two patients were treated successfully with an inflatable penile prosthesis.     

Erectile impotence associated with transurethral prostatectomy

A prospective study was done on the erectile function of 35 randomly-selected patients undergoing transurethral prostatectomy for benign prostatic hypertrophy. A preoperative sexual history was obtained, and the erectile function of each patient was recorded using a nocturnal penile tumescence monitor. Four to six weeks postoperatively, a repeat sexual history was taken and the erectile function was reassessed. In 12 of the 35 patients we noted a discordance between the erectile potency they reported in their sexual histories and the objective testing. There was no significant difference between the preoperative and postoperative nocturnal penile tumescence recordings for any given patient.     

Controlled trial of infusion cavernosometry in impotent and potent men

Infusion cavernosometry often is performed to diagnose venous leak impotence. However, normal values have seldom been established in proved potent men. We performed a prospective study of infusion cavernosometry on nocturnal penile tumescence confirmed potent male volunteers and impotent men. Of 20 potent male controls 19 had resistance values of greater than 5 (mm. Hg.minute)/ml. Of 38 impotent men 20 (53%) had resistance values of less than 5 (mm.Hg. minute)/ml. There was considerable overlap between resistance values and infusion rates in potent and impotent men. Impotent men with resistances of greater than 5 (mm.Hg.minute)/ml. more often had normal nocturnal penile tumescence results than men with lower resistance values. Venous leakage is a significant cause of impotence.     

Snap-gauge compared to a full nocturnal penile tumescence study for evaluation of patients with erectile impotence

A total of 50 consecutive male patients underwent simultaneous Snap-Gauge and full nocturnal penile tumescence evaluation with objective rigidity measurements to determine the correlation between the 2 studies. Subsequent clinical evaluation was conducted in patients in whom the 2 tests differed regarding diagnoses to determine which test more accurately predicted the clinical outcome. One patient was excluded from the study for technical reasons. Of 14 patients who had a normal Snap-Gauge evaluation, defined by breakage of all 3 bands, 12 (86%) had a normal and 2 (14%) had an abnormal nocturnal penile tumescence evaluation. A total of 28 patients failed to break any of the Snap-Gauge bands and 7 broke only 1 or 2 bands. Of these 35 patients with an abnormal Snap-Gauge study 14 (40%) had a normal and 21 (60%) had an abnormal nocturnal penile tumescence evaluation. In a subsequent clinical evaluation 1 of the 2 patients with a normal Snap-Gauge study and an abnormal nocturnal penile tumescence test reported continued inadequate sexual function and, subsequently, he received a penile prosthesis. Of the 14 patients with an abnormal Snap-Gauge study and a normal nocturnal penile tumescence test 11 were located and 8 were sexually active with adequate erections for intercourse without further medical treatment other than counseling. We conclude that the correlation between Snap-Gauge and nocturnal penile tumescence is not good, and that the nocturnal penile tumescence test is more accurate to determine the clinical diagnosis.     

Problems in the interpretation of nocturnal penile tumescence studies: disruption of sleep by occult sleep disorders

A review of the sleep of 31 patients 45 years old or older undergoing nocturnal penile tumescence studies showed that 19 had a previously undiagnosed sleep disorder. Of the patients 9 had periodic leg movements in sleep, 9 had sleep apnea and 1 had both disorders. In 10 of these patients the sleep disorders affected nocturnal penile tumescence by disrupting sleep and causing brief periods of detumescence, movement artifacts and delays in the tumescing phase of nocturnal penile tumescence. These disruptions resulted in an apparently abnormal nocturnal penile tumescence that appeared as if the patient had difficulty in achieving or maintaining an erection. The nocturnal penile tumescence disruptions may have reflected only a disruption of the necessary conditions for normal nocturnal penile tumescence to occur, namely adequate sleep and rapid eye movement sleep. The results strongly suggest that failure to measure concurrent sleep parameters and screen for occult sleep disorders could result in the incorrect diagnosis of abnormal nocturnal penile tumescence.     

Impotence due to corporeal veno-occlusive dysfunction: long-term follow-up of venous surgery.

Corporeal veno-occlusive dysfunction is an important cause of organic impotence and is characterized by increased flow rates to create and to maintain erection during artificial erection produced by intracavernous saline infusion. Sixty-seven patients with this erectile insufficiency underwent penile ligature-resection of deep dorsal vein between 1982 and 1986, and were evaluated by nocturnal plethysmography, pharmacocavernometry as well as a questionnaire about their sexual life for long-term follow-up. The surgical procedure was controlled in the operating room by reduction of the erectile flow rates. Thirty-one patients were potent postoperatively and were able to have satisfactory intercourse. Results after resection were slightly better than after simple ligation of the deep dorsal vein. Four patients had penile glans insensibility resulting from the surgical dissection. There were 7 relapses several months after the procedure due to leakage through other deeper veins. Eight failures were due to additional psychogenic disorders or to neurologic disease not accurately diagnosed before the treatment because they all developed normal papaverine-induced erection after venous surgery while before it they only developed a slight tumescence. Reduction of the erectile flow rates within normal values was impossible during surgery in 3 patients. Eleven failures were due to concomitant arterial disease. Resection of the deep dorsal vein can restore penile erection in patients with cavernovenous leakage in about 50% of well-selected patients.