Multiphasic diagnostic evaluation of arteriogenic, venogenic, and sinusoidogenic impotency. Value of noninvasive tests compared with penile duplex ultrasonography

Fifty patients with a mean age of fifty-five years (range 25 to 75 years) in whom vasculogenic impotency was suspected clinically were evaluated to determine the type of vascular lesion involved: arterial insufficiency, venous leak, or sinusoidal dysfunction. All patients underwent first, noninvasive diagnostic tests including penile brachial index, penile brachial subtraction index, and penile plethysmogram, followed by penile duplex ultrasonography with papaverine and phentolamine injection. Patients with abnormal ultrasonography were divided into two groups: One group with suspected sinusoidal dysfunction and those with either arteriogenic or venogenic insufficiency but not considered candidates for surgery; they were not subjected to further studies. Another group with suspected proximal arteriogenic lesions and those with suspected venous leakage considered candidates for surgical correction were subjected to angiography and cavernosometry-cavernosography, respectively. The findings of the noninvasive tests were compared with those provided by the invasive tests. The results indicated that noninvasive tests can predict whether or not impotency is arteriogenic in approximately 90 percent of cases. The noninvasive tests, however, were less accurate in predicting venogenic and sinusoidogenic impotency, for which penile duplex ultrasonography seems to be the choice.     

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.     

The role of colour duplex ultrasonography in the diagnosis of vasculogenic impotence.

Colour duplex ultrasonography was used to obtain peak systolic velocity (PSV) readings from cavernosal arteries at rest and during papaverine-induced tumescence. Results from 31 men with vasculogenic impotence were compared with those from 17 men with non-vasculogenic impotence and a control group of 6 potent men. In the flaccid state no significant differences in PSV readings were found between the vasculogenic and control groups. Following the injection of papaverine, men from the vasculogenic group without venous leakage were alone in having significantly lower PSV readings compared with the potent controls. All 23 men with normal penile haemodynamics had a mean PSV greater than or equal to 20 cm/s during tumescence. This was also the case for 19 (61%) of the vasculogenic group, including 9 (69%) of the 13 patients with venous leakage. The remaining 12 men in the vasculogenic group (39%) had a mean PSV less than 20 cm/s, this being diagnostic of an inadequate arterial inflow. Colour duplex ultrasonography can identify patients who have marked arterial insufficiency as the major cause of their impotence and hence allows more rational selection for angiography and revascularisation. Lesser degrees of arterial deficit are difficult to characterise using mean PSV readings alone.     

Anatomy of penile venous drainage in potent and impotent men during cavernosography

Recent data suggest that approximately 80 per cent of the men with vasculogenic impotence have evidence of failure to store blood (venous leakage) within the corpora cavernosa. To identify the venous channels into which corporeal blood drains in impotent men, we performed cavernosograms after intracorporeal injection of papaverine in 44 consecutive men presenting with erectile dysfunction and these were compared to studies in 10 potent men. The cavernosograms were examined for evidence of venous drainage from the penis and the site of leakage was identified. It was determined that among the impotent population with vasculogenic impotence 37 of 40 evaluable men (92.5 per cent) demonstrated contrast medium in the venous system draining the penis: the deep dorsal vein was visualized in 55 per cent, proximal cavernosal and crural veins in 55 per cent, deep dorsal and proximal veins in 22.5 per cent and corpus spongiosum in 25 per cent. Only 2 of the 10 potent men demonstrated contrast medium in the venous channels draining the penis. From these observations we conclude that in men suspected of having venogenic impotence identification of the drainage vessels by cavernosography appears to be important in planning any surgical approach to occlude these veins. However, the finding of a venous leak by cavernosography must not be considered a sine qua non diagnosis of venogenic impotence, since a certain percentage of potent men will demonstrate this radiographic finding.     

Diagnostic value of the radioisotope erection penogram for vasculogenic impotence

Radioisotope erection penography of 113 consecutive impotent patients (41 with psychogenic and 72 with vasculogenic impotence) and 15 normal potent men were obtained. Twenty minutes after intracavernous injection of 99mtechnetium-pertechnetate 40 mg. papaverine hydrochloride were administered into the corpus cavernosum to induce erection. A gamma camera with a pinhole collimator was used to monitor the radioactivity. Various penogram indexes were calculated from the time activity curve and their usefulness was evaluated. Index A1 was useful to differentiate vasculogenic and psychogenic importance. Indexes V1 and V2 were useful to differentiate arteriogenic and venogenic impotence. The radioisotope erection penogram is a simple, less invasive and valuable screening test in the identification of vasculogenic impotence, and is effective in differentiating arteriogenic and venogenic impotence.     

双功能超声和彩色多普勒显像对血管性阳萎的诊断分析

５９例阳萎患者海绵体内注射罂粟硷前后的双功能超声和彩色多普勒显像，与阴茎血压、灌注性阴茎海绵体造影和部分手术结果进行分析对比，发现１１例血管正常（１９％），１９例动脉功能不全（３２％），２９例静脉漏（４９％）。对阴茎海绵体双功能超声和彩色多普勒显像诊断血管性阳萎的临床价值作了探讨。     

Dual radioisotopic study: a technique for the evaluation of vasculogenic impotence.

Arterial and venous systems are the main points for the evaluation of vasculogenic impotence. To evaluate both of these systems in the same study we propose a dual radioisotopic study in which 99mtechnetium (99mTc) and 133xenon (133Xe) were used. The changes in 99mTc and 133Xe radioactivities administered intravenously and intracavernously, respectively, were monitored before and after intracavernous papaverine injection. These changes were determined as time activity curves, which were generated from the region of interest over the penis. A 99mTc penogram index derived from the 99mTc time activity curve was significantly different in the control and arteriogenic impotence groups (131.67 +/- 74.6 versus 62.94 +/- 51.6, p less than 0.01). A meaningful correlation between 99mTc penogram index results and duplex ultrasonographic findings were observed (r = 0.905). 133Xe penogram index, derived from the 133Xe washout curve was significantly different in the control and venogenic impotence groups (-25.65 +/- 24.9 versus -56.09 +/- 13.4, p less than 0.01). Also, a meaningful correlation was obtained between pharmacocavernosometry and 133Xe penogram index results of venogenic impotent patients (r = 0.86). These findings suggest that the dual radioisotopic study will be a useful technique in the evaluation of the entire vascular system of the penis, since it is a noninvasive method.     

Functional evaluation of penile arteries with duplex ultrasound in vasodilator-induced erection

In 657 impotent patients in whom erection was induced by intracavernous injection of papaverine, we evaluated changes in the pulsation, diameter, and blood flow velocity of the penile arteries by duplex sonography and pulsed Doppler spectrum analysis. An additional 18 patients who were proved to have good erection by nocturnal tumescence testing were used as controls. All patients were studied before achieving full erection after papaverine injection. In the flaccid state, the inner diameter of the deep penile arteries averaged 0.51 mm, and blood flow velocity was rarely measurable. The normal arterial reaction to papaverine was an initial increase in the inner diameter of the scanned segment of the cavernous artery with good concentric pulsations and a mean peak blood flow velocity of 34.8 cm per second and a mean diameter of 0.89 mm. With this technique, we assessed the functional capability of each deep and dorsal artery. Arterial and erectile response allowed indirect evaluation of the venous system. Of the 657 patients, 48 had neurogenic or psychogenic impotence or both. In 97, impotence could be ascribed to venogenic causes, in 210 to arteriogenic causes, and to mixed arteriogenic and venogenic causes in 282 patients. The exact cause of impotence in the remaining 20 patients could not be determined. Statistically, patients who were older or had diabetes mellitus or coronary artery disease tended to have smaller penile arteries and lower peak blood flow velocity after papaverine injection.     

Diagnostic tests for impotence: a comparison of papaverine injection with the penile-brachial index and nocturnal penile tumescence monitoring

The diagnostic usefulness of nocturnal penile tumescence monitoring, penile-brachial index and intracorporeal injection of papaverine (60 mg. in 20 ml. normal saline) was compared in 43 impotent men. Intracorporeal pressure was measured with a pressure transducer. Based on turgidity, and the time of onset and duration of erection, we classified the impotence as psychogenic/neurogenic (normal vascular competence), mild or severe arteriogenic, or venogenic. The intracorporeal injection of papaverine was useful as a functional diagnostic test for impotence. The penile-brachial index, an indirect measurement of the flaccid penis, did not correlate well with the results of the papaverine test. A poor response to papaverine injection documents organic impotence and, under these circumstances, nocturnal penile tumescence monitoring is not necessary. We conclude that the intracorporeal injection of papaverine currently is the best screening technique for the differential diagnosis of vasculogenic impotence.     

静脉性勃起功能障碍中阴茎静脉漏的彩色多普勒超声观察

目的 探讨静脉性勃起功能障碍(ED)患者阴茎静脉的血液动力学变化. 方法 静脉性ED患者32例,年龄26～63岁,平均41岁.病程6个月～10年,平均2.5年.采用前列腺素E1试验后行常规阴茎彩色多普勒超声检查,观察阴茎背深静脉、海绵体静脉、球静脉的超声表现,分析其与海绵体动脉阻力指数(RI)的相关性. 结果 32例患者诱发勃起前静脉内径(0.06±0.15)mm,血流速度(4.30+1.36)cm/s,诱发勃起5 min后阴茎静脉管径(1.23±0.30)mm,血液回流增多,血流速度(11.50+4.02)cm/s.阴茎背深静脉、海绵体静脉、球静脉流量与海绵体动脉RI的相关系数r分别为-0.55,-0.53,-0.24(P＜0.05).考虑存在混合性静脉漏因素的前提下,阴茎静脉流量与海绵体动脉RI的r为-0.88(P＜0.001). 结论 高频超声能清楚显示阴茎静脉漏部位,可初步判断静脉性ED患者的静脉漏部位及其程度.     

IIEF-5在血管性勃起功能障碍诊断中的应用

目的:评价国际勃起功能简化量表(IIEF-5)对血管性勃起功能障碍(ED)病因区分的意义,以指导血管性ED诊断及治疗。方法:将103例ED患者分为4组,非血管性ED组37例(37/103,35.9%)、动脉性ED组18例(18/103,17.5%)、静脉性ED组35例(35/103,34.0%)、混合性ED组13例(13/103,12.6%),其IIEF-5得分与海绵体血管活性药物注射试验结果、多普勒超声检查结果及双核素检测结果进行比较,以非参数检验的多个独立样本检验(Kruskal-WallisTEST)比较各组之间IIEF-5得分差异的显著性。结果:上述4组之间的IIEF-5得分没有统计学差异(P=0.253)。结论:IIEF-5不能作为一种诊断工具用于鉴别血管性ED的病因以及判断血管病变严重程度。     

Internal iliac artery revascularization in the treatment of vasculogenic impotence

Five impotent men underwent internal iliac artery revascularization in conjunction with end-to-side aortobifemoral bypass after preoperative testing suggested a vasculogenic cause for impotence. All patients had abnormal preoperative penile/brachial arterial pressure indices (mean, 0.42 +/- 0.12). Following operation, all patients regained erectile capability and had normal postoperative penile/brachial indices (mean, 0.80 +/- 0.06). One patient developed retrograde ejaculation, emphasizing the need for meticulous nerve-sparing dissection with this operation. Internal iliac artery revascularization in conjunction with end-to-side aortobifemoral bypass is effective in relieving vasculogenic impotence in properly selected patients.     

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.     

Color-coded duplex sonography in impotence: significance of different flow parameters in patients and controls.

The use of color-coded duplex sonography of the cavernous arteries in the assessment of arteriogenic impotence was evaluated in 70 consecutive men referred for erectile dysfunction. Controls were 16 of the men with an unequivocal nocturnal penile tumescence and rigidity. After intracavernous injection of prostaglandin E1, peak flow velocity was 26.8 +/- 12.5 cm/s in patients and 37.2 +/- 13.0 cm/s in controls (p less than 0.05). 50% of the patients, but none of the controls, had peak flow velocities of less than 20 cm/s in at least 1 cavernous artery. However, within the range of 20-40 cm/s, there was marked overlap between groups. The mean flow velocity and resistance index did not improve the discriminative value of peak flow velocity. Peak flow velocity after intracavernous injection of vasoactive drug enables the discrimination between impotent patients and controls. In a single patient, however, particularly one with a flow velocity of 20-40 cm/s, definition of arteriogenic impotence remains difficult.     

Experience in diagnosis and treatment of impotence caused by cavernosal leak syndrome

To delineate neural, arterial, and venous components contributing to impotence, we used a previously described noninvasive screening sequence combined with stimulation of artificial erection with papaverine injection, selective pudendal arteriography (SPA), and dynamic cavernosography (DC). Among 572 men with impotence, age range 17 to 78 years (average age 54.8 years), 26 men with potential cavernosal leaks in absence of other factors were identified; 16 underwent DC; among these five had normal cavernous venous drainage. Eight men with abnormal cavernosal venous drainage required cavernous infusion flow rates higher than 120 ml/min to obtain erection and higher than 40 ml/min to maintain erection. Radiographic studies showed cavernosal leakage in all eight patients. Eight men, ages 39 to 61 years, underwent surgical ablation of abnormal cavernosal venous drainage. Among these, five men have had excellent results for up to 3 years. One failure was related to unrecognized penile arterial disease later shown by SPA. In two men small doses of papaverine now induce erection. We now recommend SPA before DC to rule out an arterial abnormality. Accurate identification of factors contributing to erectile failure is critical for successful treatment; in this experience candidates for correction of cavernosal leak syndrome were uncommon.     

Results of deep dorsal vein ligation for venogenic impotence]

We treated seventy venogenic impotence with ligation of the deep dorsal vein of the penis. Their corporal veno-occlusive function was evaluated by dynamic infusion cavernosometry and cavernosography (DICC). Under local anesthesia, we made a longitudinal skin incision at the base of the penis. The deep dorsal vein was ligated and also a portion of this vein of 1.5 cm long was resected together with branches surrounding the vein. After the operation, the infusion rate determined by DICC was confirmed to be decreased in almost all patients. Thirty nine out of seventy cases had their erectile capability restored and reported that they could achieve sexual intercourse. Sixty one of the seventy cases showed full erection together with an intracavernous papaverine injection. However fifty percent of the sixty one patients who became capable of obtaining erection with the treatment had lost their erectile capability again within one year of the operation, however the other fifty percent were shown to maintain their erectile capability for up to three years. As four years after the treatment only thirty percent of those who had achieved the initial erectile capability still remained potent. This operation is easy to perform without any major complications, and its outcome is as good as that achieved by other more invasive venous ligation in the treatment of patients with venogenic impotence. We therefore conclude that penile deep dorsal vein ligation and partial resection of the vein one of the most useful treatments currently available for venogenic impotence and should be the treatment of choice.     

Non-invasive assessment of arteriogenic impotence: a comparative study

This study was undertaken to determine the relative accuracy of computerised Doppler waveform analysis and colour coded duplex ultrasonography in the diagnosis of arteriogenic impotence. Twenty men with ostensibly normal penile haemodynamics were compared with 50 men whose impotence was considered due to compromised penile haemodynamics. In each patient the penile arterial inflow was assessed by both methods of investigation, which were performed at an interval of 2 weeks. The results demonstrated both techniques to be sensitive in detecting penile artery insufficiency but colour coded duplex ultrasonography was significantly more accurate.     

Significance of phentolamine redosing during prostaglandin E1 penile color Doppler ultrasonography in diagnosis of vascular erectile dysfunction

Recently, it was reported that phentolamine redosing during penile duplex can abolish a false diagnosis of venous leakage in patients with impotence. The aim of this study is to identify any useful role of phentolamine redosing in diagnosis of venogenic impotence. Sixty-seven consecutive patients complaining of weak erection for at least 6 months were included in this study. Penile color Doppler ultrasound (CDU) was performed using a 7.5 MHz linear array transducer with a color flow mapping capability. Following intracavernous injection of 20 microg prostaglandin E1 (PGE1), all patients with persistent end diastolic velocity (EDV) >5 cm/sec with an erectile response of E3 or lower, 20 min after intracavernosal injection of PGE1, were asked to revisit our clinic for a second CDU, 2 weeks later. During initial CDU examination, all 67 patients experienced poor response to 20 microg PGE1 with their average peak systolic velocity (PSV) and EDV being 42.8 and 6.6 cm/sec, respectively. The second CDU examination had similar results to the first one. Addition of 2 mg phentolamine did not significantly change the PSV and EDV of cavernosal arteries in any of the 67 patients. In conclusion, addition of intracavernous phentolamine during PGE1 CDU examination carries no advantage over the use of PGE1 alone regarding cavernosal artery response in patients with suspected venogenic EDV.     

Efficacy of virtual glasses in audio-visual sexual stimulation during penile color duplex Doppler ultrasonography

OBJECTIVE: To examine whether audio-visual sexual stimulation (AVSS) with virtual glasses is effective in improving the recording of penile hemodynamics during penile color duplex Doppler ultrasonography. PATIENTS AND METHODS: A total of 64 consecutive patients with erectile dysfunction underwent penile color duplex Doppler ultrasonography after intracavernosal injection of 10-20 microg prostaglandin El and subsequent genital stimulation. AVSS with virtual glasses and earphones was applied when peak systolic velocities (PSV) were less than 35 cm/s or end diastolic velocities (EDV) were more than 5 cm/s. PSV, EDV and the resistive index of both cavernosal arteries were continuously monitored. Clinical erectile response was assessed with visual inspection and manual palpation. RESULTS: AVSS with virtual glasses was performed on 40 of 64 patients. AVSS improved the clinical erectile response in 26 (65%) of 40 patients. Doppler ultrasonography without AVSS identified 11 (27.5%), 5 (12.5%), and 24 (60%) patients with arteriogenic, veno-occlusive, and mixed-type impotence, respectively. However, after real-time AVSS 15 (37.5%), 7 (17.5%), 8 (20%), and 10 (25%) patients demonstrated non-vasculogenic, arteriogenic, veno-occlusive, and mixed-type impotence, respectively. Real-time AVSS improved the Doppler wave forms in 65% of cases. CONCLUSION: AVSS with virtual glasses improves the recording of physiologic erectile response and may be used as a valuable tool during penile color duplex Doppler ultrasonography.     

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.