Angiodynography (color-coded duplex sonography) in the evaluation of vasculogenic impotence.

The penile arteries of 18 men with erectile dysfunction were examined by angiodynography (color-coded duplex sonography). Blood flow velocity was measured before and after intracavernous injection of papaverine/phentolamine. The angiodynographic findings were compared to arteriography. Normal values of peak flow velocity (after injection) were obtained from 6 men with normal arteriographic findings (deep artery greater than 25 cm/s, superficial artery greater than 30 cm/s). Angiodynography enables good imaging of the four penile arteries superior to duplex sonography. A strong correlation with the arteriographic findings could be found. Thus noninvasive angiodynography may replace penile arteriography for the routine evaluation of impotence.     

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.     

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.     

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.     

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.     

CAVERNOUS ARTERIAL AND ARTERIOLAR CIRCULATION IN PATIENTS WITH ERECTILE DYSFUNCTION: A POWER DOPPLER STUDY

Purpose

We assessed the morphodynamic features of cavernous arteries and helicine arterioles by power Doppler sonography in vasculogenic and nonvasculogenic impotent men.

Materials and Methods

A total of 40 impotent patients with and without definite vascular risk factors were studied by penile power Doppler sonography. The test was performed during penile flaccidity, after intracavernous injection of 20 mcg. alprostadil and after subsequent genital and audiovisual sexual stimulation. A second injection and stimulation were given if the erectile response observed after the initial injection was less than the maximum erection seen during sexual activity. Morphodynamic parameters evaluated by power Doppler imaging included vessel course, shape, wall thickness and pulsatility, peak systolic velocity, end diastolic velocity, acceleration time and resistance index.

Results

In the nonvasculogenic group all patients who achieved rigid erection showed normal cavernosal artery and helicine arteriole inflow. In these cases the arteriolar picture was characterized by the presence of 3 orders of distal ramifications originating from the cavernous arteries with an acute angle, systolic diastolic flow during penile tumescence and systolic flow alone at full rigidity. In the vasculogenic group patients with normal cavernous artery inflow showed an arteriolar tree that was pathological in 50% and was characterized by a reduced number of ramifications originating perpendicularly from the cavernous arteries and irregular caliber (arteriolar impotence). In the same group patients with reduced cavernous artery inflow also showed normal or pathological arteriolar components (pre-penile arterial impotence and diffused penile arterial impotence).

Conclusions

Power Doppler sonography allows a precise study of the morphodynamics of the cavernous arteries and helicine arterioles. Our preliminary data suggest that the intracavernous arteriolar component may have a significant role in the genesis of some forms of 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.     

Duplex scanning in suspected vasculogenic impotence: a worthwhile exercise?

The value of duplex scanning in the assessment of impotence was evaluated in 146 impotent men. Scanning was by means of a Diasonics DRF 400 and penile artery measurements were taken before and after the intracorporeal injection of papaverine hydrochloride. The penile/brachial index was measured in 82 patients and its predictive value compared with the results of duplex scanning and papaverine-induced erection. On scanning evidence of good arterial inflow but poor erections, indirect evidence of venous leakage was assumed. The results showed that the deep artery responses best characterised the erectile response, with the dorsal artery being less helpful. All 37 patients with full erections following papaverine exhibited bilateral deep artery peak velocities of greater than or equal to 25 cm/s. Of the remaining 109 sub-optimal responders, 17 also has this finding; all had undergone dynamic cavernosography, with 16 exhibiting venous leakage. The penile/brachial index was found to classify 13 patients incorrectly. A critical value of deep artery response to attain erection is postulated, enabling more logical use of cavernosography. The penile/brachial index was shown to be suspect and it was concluded that duplex scanning is a useful, non-invasive method in the assessment of impotence.     

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.     

Norepinephrine involvement in response to intracorporeal injection of papaverine in psychogenic impotence.

The levels of catecholamines in penile blood during a papaverine test were measured to investigate whether the secretion of endogenous catecholamines is involved in response to intracorporeal papaverine injection. The level of norepinephrine was higher in patients with psychogenic impotence than in the normal controls and patients with vasculogenic impotence (p less than 0.01), and it was significantly higher in negative responders than in positive responders in the psychogenic impotence group (p less than 0.001). There was no significant difference in the level of epinephrine among the groups. The false negative response to the papaverine test in psychogenically impotent men is believed to be derived from secretion of cavernous norepinephrine, which overwhelms the action of cavernous smooth muscle relaxation by papaverine.     

Evaluation of Penile Arteries with Color-Coded Duplex Sonography: Prevalence and Possible Therapeutic Implications of Connections Between Dorsal and Cavernous Arteries in Impotent Men

Penile revascularization for cases of arteriogenic impotence is based on the assumption of hemodynamically relevant connections between the dorsal penile and cavernous arteries. In 325 clinically impotent patients color-coded duplex sonography was performed with the penis flaccid and tumescent after intracavernous injection of 10 microgram prostaglandin E1. We measured peak flow velocity, end diastolic flow velocity and resistance in the dorsal arteries, deep cavernous arteries and connections perforating the tunica albuginea between the 2 systems. Of our patients 14 percent had at least 1 such anastomosis with a peak flow velocity exceeding 25 cm. per second after stimulation. Peak flow velocities less than 20 cm. per second were noted only in arteriogenically impotent patients, while those exceeding 25 cm. per second without later rigid erection occurred only in patients with venous occlusive dysfunction and end diastolic flow velocity exceeded 5 cm. per second. We conclude that penile revascularization should be contemplated only if hemodynamically relevant connections are detected, peak flow velocity in the cavernous arteries is less than 20 cm. per second and end diastolic flow velocity is less than 5 cm. per second.     

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。     

Experience with intracorporeal injection of papaverine and duplex ultrasound scanning for assessment of arteriogenic impotence

We present our experience with the intracorporeal injection of papaverine and duplex sonography in the assessment of 47 patients with suspected vasculogenic impotence. Sonography and Doppler analysis were performed before and after the papaverine injection. The anatomy of the penis was easily seen. Flow in the deep arteries was obtained in most patients in both the flaccid and erect state. Patients with a good erectile response to papaverine injection had a larger increase in the inner diameter of the deep cavernosal artery than did those with a poor response. However, the percentage change in the diameter did not correlate with the degree of clinical response. Following injection, the systolic peak flow rates and diastolic minimum flow rates were higher in patients with some clinical response but only the increase in diastolic flow rates correlated in a stepwise fashion with the degree of clinical response. This technique provides a method for the objective assessment of response to intracorporeal papaverine injection. Its potential as a diagnostic test will only be determined after normal values are established. At present it appears most useful in patients responding poorly to papaverine injection by indicating the possible area of vascular impairment and the direction for further evaluation.     

Interpretation and quantification of penile blood flow studies using duplex ultrasonography

Duplex ultrasound scanning of the penis combined with intracorporeal pharmacological stimulation of an erection provides an accurate, relatively noninvasive functional assessment of cavernous artery blood flow. Various criteria described for normal have been based on either blood flow velocity alone or the combination of blood flow velocity and arterial dilatation of each cavernous artery. Unfortunately, less than 20% of impotent men have classical arterial anatomy and the aforementioned normal criteria do not take into account the various possible anatomical and acquired anomalies that can exist. In addition, the multiplicity of parameters used to describe normal are cumbersome to use for patient comparison and statistical analysis. In this study, 4 indexes were developed to express the results of a duplex ultrasound penile blood flow study and they were tested in an impotent population comprised of 75 men with arterial disease and 33 men with impotence due to neurogenic or psychogenic causes. A significant difference was observed between these 2 groups using all 4 indexes (p less than 0.001). However, the penile blood flow index, which incorporated velocity and dilatation, performed best as determined by sensitivity, specificity and receiver operating characteristics. Based on the results of this study, the penile blood flow index, which represents the summation of the percentage of dilatation and peak blood flow velocity of each cavernous artery, provides an accurate reflection of total penile blood flow as measured by duplex ultrasound.     

Objective penile vascular response to intraurethral prostaglandin E2 (dinoprostone)

PURPOSE: Intraurethral prostaglandin E2 (PGE2) administration is a noninvasive treatment modality for erectile dysfunction. The purpose of this study was to evaluate the objective effects of this agent by measuring peak systolic velocities of cavernosal arteries after intraurethral PGE2 administration and comparing with the results obtained with an intraurethral placebo gel and intracavernous papaverine injection. MATERIALS AND METHODS: The study group consisted of 22 consecutive impotent volunteers with a mean age of 46 years who had normal penile arterial responses as determined by penile arterial responses on papaverine-stimulated penile duplex ultrasonography. The peak systolic velocity in cavernosal arteries was recorded after intracavernous injection of 60 mg of papaverine. All patients received 1 mg of intraurethral PGE2 gel and placebo at 15-day intervals. The peak systolic velocities were recorded after each treatment. RESULTS: Mean peak systolic velocity achieved by intraurethral administration of PGE2 gel (25 +/- 8 cm/s) was less than that achieved by intracavernous papaverine (40 +/- 6 cm/s) but higher than that obtained by placebo (15 +/- 4 cm/s). Twelve patients had erections, while 9 had partial and 1 had no erection with intraurethral PGE2. Placebo did not cause any erections. No serious side effects were observed. CONCLUSION: Intraurethral administration of PGE2 appears to be an effective and simple method for increasing penile arterial flow and can be used during penile Doppler ultrasonography to stimulate the penile arterial system.     

Colour duplex sonography in the assessment of impotence

We present our experience with colour duplex sonography (Acuson 128) in the assessment of 83 impotent men. Cavernosal artery measurements were taken before and after the intracorporeal injection of papaverine. The peak velocities following papaverine injection correlated well with the degree of clinical response. Percentage diameter change corresponded with some groups of clinical erection grade, although it was not as good a discriminator as peak velocity. Twelve patients with 24 cavernosal arteries were also examined using pharmacological selective arteriography. Correlation between duplex sonography and arteriography showed an accuracy of 87.5%, specificity of 100.0% and sensitivity of 82.4%. All patients with a clinically good response following papaverine injection had peak bilateral cavernosal artery velocities greater than or equal to 25 cm/s. Amongst the remaining suboptimal responders, 18 also had this finding. Fifteen of these underwent pharmacological cavernosography and 14 exhibited venous leakage. Duplex sonography is a valuable and non-invasive tool in the assessment of impotence and can provide valuable information in deciding the course of further evaluation and treatment. The procedure was always completed more quickly with the guidance of colour Doppler.     

Papaverine-induced penile blood flow acceleration in impotent men measured by duplex scanning

We assessed the value of penile blood flow acceleration as a parameter in the evaluation of the penile arteries. Duplex sonography and pulsed Doppler analysis with papaverine were performed in 50 impotent men. Measured parameters included cavernous artery diameters before and after papaverine, post-papaverine peak blood flow velocity and blood flow acceleration. Erections were graded subjectively on a scale of 1 to 4, with 4 being a full erection. Penile blood flow acceleration appeared to correlate with vessel dilatability and poor erectile response, and was subjectively more discriminating than peak blood flow velocity. This parameter provides additional measurable data about arterial function and should be obtained in addition to the other 2 parameters.     

Penile pharmacological duplex ultrasonography: a dose-effect study comparing papaverine, papaverine/phentolamine and prostaglandin E1.

Alternations of penile blood flow are believed to be the most frequent organic cause of erectile dysfunction. Penile duplex ultrasonography following intracavernous injection of a vasoactive agent is an accepted method for diagnosis of penile vascular dysfunction. To determine the diagnostic efficacy of commonly used vasoactive drugs we studied the hemodynamic effects of different dosages of papaverine, the combination of papaverine and phentolamine, and prostaglandin E1 in men with erectile dysfunction and men with normal erectile potency using color duplex ultrasonography. We concluded that 12.5 mg. papaverine and 10 micrograms. prostaglandin E1 are the drugs of choice to be used in conjunction with penile duplex ultrasonography because of optimal effects on cavernous arterial dilatation and low risk of prolonged erection. However, low dose papaverine or prostaglandin E1 has a limited value in evaluating veno-occlusive function.     

Impact of aging on penile hemodynamics in men responding normally to prostaglandin injection: A power Doppler study

AIM: Hemodynamic changes with aging in the penile arterial circulation, including the helicine arteries, were evaluated with power Doppler imaging in erectile dysfunction patients with a normal response to prostaglandin injection. METHODS: In 36 patients with erectile dysfunction and no definite vascular risk factors, 72 corpora were examined using power Doppler imaging. Patients were classified by age: younger than 40 years, from 40 to 49, or 50 and older. Hemodynamic variables in the cavernous arteries, helicine arteries and dorsal arteries were measured after intracavernous injection of prostaglandin E1 (20 microg). RESULTS: All cavernous arteries had a maximum peak systolic velocity of greater than 35 cm/s and a minimum end-diastolic velocity of less than 0 cm/s. Mean peak systolic velocity in the cavernous artery differed between groups (P = 0.016), especially between the younger than 40 age group and the 40-49 age group. Peak systolic velocity correlated negatively with age (P = 0.0048). In the helicine arteries and dorsal arteries, peak systolic velocity did not differ between groups and showed no correlation with age. End-diastolic velocity, resistance index and acceleration time did not differ between groups, or correlate with age for any artery. CONCLUSIONS: Hemodynamic change with aging occurs predominantly in the cavernous arteries, where peak systolic velocity decreases. The arterial circulation beyond the cavernous arteries, including the helicine arteries, as well as veno-occlusive mechanisms, may have an important role in maintaining erectile function in aging.     

Assessment of the functional role of accessory pudendal arteries in erection by transrectal color Doppler ultrasound

PURPOSE: Anatomical studies have demonstrated accessory pudendal arteries originating from supralevator vessels in about two-thirds of men. Injury to accessory pudendal arteries derived from inferior vesical and obturator arteries has been reported to be responsible for vasculogenic impotence after nerve sparing radical prostatectomy. We performed transrectal and perineal color Doppler ultrasound in patients before radical pelvic surgery to identify accessory pudendal arteries and assess their functional role during erection. MATERIALS AND METHODS: A total of 12 patients with a mean age of 60 years were examined before radical prostatectomy (10) or cystoprostatectomy (2). Transrectal and perineal color Doppler flow imaging and spectral waveform analysis were performed. Peak systolic velocity, end diastolic velocity, resistive index and arterial diameter were measured before and during pharmacologically induced erection. Transrectal color Doppler ultrasound data were compared with intraoperative findings. RESULTS: Transrectal color Doppler ultrasound visualized accessory pudendal arteries derived from supralevator arteries in 9, and prostatic and seminal vesicle arteries in all patients. Perineal color Doppler ultrasound visualized internal pudendal arteries in all patients. After intracavernosal injection of papaverine accessory and internal pudendal arteries displayed similar significant hemodynamic changes. Diameter as well as peak systolic and end diastolic velocities increased, and resistive index decreased. Prostatic and seminal vesicle arteries showed no significant change. Presence and location of accessory pudendal arteries demonstrated by transrectal color Doppler ultrasound were confirmed by intraoperative findings. CONCLUSIONS: During pharmacologically induced erection hemodynamic changes in accessory and internal pudendal arteries are similar to those described in cavernous arteries, thus demonstrating the functional role of accessory pudendal arteries in penile erection. Color Doppler ultrasound appears to be reliable to examine internal and accessory pudendal arteries based on morphological and functional criteria.