New methods in the diagnosis of impotence: RigiScan® penile tumescence and rigidity monitoring and diagnostic papaverine hydrochloride injection

Summary In 26 patients with erectile impotence and 8 healthy volunteers the value of continuous monitoring of penile tumescence and rigidity by means of the RigiScan was tested. Based on history and routine screening tests the patients were divided into 3 groups of preliminary diagnosis: psychogenic (5 patients), organic (10 patients), mixed (11 patients). Real-time measurements of tumescence and rigidity were performed during direct visual stimulation and after intracorporeal injection of 80 mg papaverine hydrochloride according to a specific protocol. A total of 21 patients were monitored during sleep studies for 2 or 3 consecutive nights. The rigidity figures of the volunteers correlated well with their subjective interpretation of the erection. Evaluation of the recordings of the impotent patients enabled reclassification of the mixed group into 3 patients with mainly organic and 8 patients with mainly psychogenic impotence. RigiScan recording of penile tumescence and rigidity appears to be of great value in the diagnosis of impotent patients. Real-time monitoring during direct visual stimulation and after papaverine injection can generally replace nocturnal measurements. If the patient shows a positive response on visual sexual stimulation (VSS) alone, then his impotence is of psychogenic origin. Failing rigidity during VSS after injection indicates vascular impotence. In patients who show negative results during VSS alone, and positive response after injection or during subsequent VSS, nocturnal monitoring will differentiate between psychogenic and neurogenic impotence.     

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.     

Penile response to intracavernosal vasoactive intestinal polypeptide alone and in combination with other vasoactive agents

Intracavernosally injected vasoactive intestinal polypeptide (VIP) (2 micrograms and 4 micrograms) resulted in penile tumescence even in men with predominantly organic impotence. Papaverine and phentolamine were successful in inducing erections in all subjects studied but the addition of VIP to this combination improved the erectile response further. A combination of papaverine and VIP produced penile rigidity similar to that with papaverine and phentolamine. While intracavernosal VIP alone produced disappointing penile responses, its combination with papaverine potentiated the response to this drug, probably by increasing venous outflow resistance.     

Hemodynamics of papaverine- and phentolamine-induced penile erection

We investigated the hemodynamic changes induced in the canine corpora cavernosa by intracorporeal injection of papaverine or phentolamine. In six dogs studied, papaverine profoundly increased the resistance to venous outflow, whereas phentolamine (an alpha-adrenergic blocker) had little or no effect. In four other dogs, flow within the internal pudendal artery was measured with an ultrasonic flow probe placed directly on the artery. Papaverine increased arterial flow by 300 to 700 per cent over baseline levels, whereas the increase with phentolamine was only 50 to 100 per cent. We conclude that papaverine, by virtue of its direct smooth-muscle-relaxing properties, has a dual hemodynamic effect: it decreases the resistance to arterial inflow, thereby allowing large increases in the flow of blood into the penis during tumescence; and increases the resistance to venous outflow. Phentolamine only decreases the resistance to arterial inflow, more modestly than papaverine, and does not increase the resistance to venous outflow.     

Impact of carbon dioxide and helium insufflation on cardiorespiratory function during prolonged pneumoperitoneum in an experimental rat model

BACKGROUND: Experimental studies on laparoscopic surgery are often performed in rats. However, the hemodynamic and respiratory responses related to the pneumoperitoneum have not been studied extensively in rats. Therefore, the aim of this study was to investigate in spontaneously breathing rats the effects of CO2 and helium, insufflation pressure, and duration of pneumoperitoneum on blood pressure, arterial pH, pCO2, pO2, HCO3-, base excess, and respiratory rate. METHODS: Five groups of 9 Brown Norway rats were anesthetized and underwent CO2 insufflation (6 or 12 mmHg), helium insufflation (6 or 12 mmHg), or abdominal wall lifting (gasless control) for 120 min. Blood pressure was monitored by an indwelling carotid artery catheter. Baseline measurements of mean arterial pressure (MAP), respiratory rate, arterial blood pH, pCO2, pO2, HCO3-, and base excess were recorded. Blood gases were analyzed at 5, 30, 60, 90, and 120 min during pneumoperitoneum, and MAP and respiratory rate were recorded at 5 and 15 min and at 15-min intervals thereafter for 2 h. RESULTS: CO2 insufflation (at both 6 and 12 mmHg) caused a significant decrease in blood pH and increase in arterial pCO2. Respiratory compensation was evident since pCO2 returned to preinsufflation levels during CO2 insufflation at 12 mmHg. There was no significant change in blood pH and pCO2 in rats undergoing either helium insufflation or gasless procedures. Neither insufflation pressure nor the type of insufflation gas had a significant effect on MAP over time. CONCLUSION: The cardiorespiratory changes during prolonged pneumoperitoneum in spontaneously breathing rats are similar to those seen in clinical practice. Therefore, studies conducted in this animal model can provide valuable physiological data relevant to the study of laparoscopic surgery.     

The peritoneal environment during infection. The effect of monomicrobial and polymicrobial bacteria on pO2 and pH.

Intraperitoneal (IP) abscesses frequently are composed of aerobes and anaerobes, and, in experimental models, a particulate adjuvant. The environmental changes effected by these components, either singularly or in combination, have not been well defined. The IP pO2, pH, and recoverable bacteria from the peritoneum of rats were quantified over 6 hours during simple aerobic and anaerobic infections and during mixed peritonitis with and without a sterile feces-barium sulfate adjuvant (SFA). Fourteen groups were studied, receiving intraperitoneally, at time of oxygen probe placement, 1 mL normal saline (control), Escherichia coli (EC), Bacteroides fragilis (BF), SFA alone, or a mixture of EC and BF, EC and SFA, BF and SFA, or EC, BF, and SFA. Control animals exhibited a stable IP pO2 and pH during 6 hours. In monomicrobial EC peritonitis, inocula well below the LD50 produced an increased IP pO2 and reduced arterial-peritoneal gradient (APG), with a stable IP pH. By 6 hours lethal doses of EC produced a dramatic decline in IP pO2, with no change in arterial pO2 as well as acidic IP and arterial pHs. Simple BF peritonitis caused no or minor elevations in IP and arterial pO2 with no change in pH. During mixed infections a significant decline in the IP pO2 and pH at 6 hours in those groups infected with both SFA and EC of a moderate, normally sublethal inoculation was observed, while arterial pO2 was unchanged and arterial pH was decreased only slightly. Concomitantly there was a significant increased number of aerobic bacteria in those groups with SFA as adjuvant compared to similar inocula without SFA. This study demonstrates the complex interactions of bacteria, sterile particulate adjuvant (SFA), and the host peritoneum. It suggests that the combination of SFA and aerobic bacteria alter the peritoneal environment to one permitting anaerobic growth and promoting abscess formation.     

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.     

The value of using a facilitating dose of papaverine chlorhydrate during cavernometry

In order to establish diagnostic cavernometric criteria, we selected 63 patients who did not respond positively to visual sexual stimulation. They were subjected to the following protocol including Rigiscan monitoring of 2 or 3 nights erections for, hormonal assays, penile doppler, cavernometry and cavernography. Intracorporeal injection of 8 mg of papaverine was performed during the hemodynamic tests. Our results showed that the erection maintenance blood flow and the maintenance index are statistically reliable diagnostic criteria for venous leaks (the maintenance index is more accurate). The use of 8 mg of papaverine reduces the incidence of false positive results without significant hemodynamic changes. In order to exclude psychogenic false positive patients, it is recommended to select the candidates for cavernometry after papaverine tests and nocturnal penile tumescence and rigidity monitoring.     

Intracavernous injection of prostaglandin E1 in combination with papaverine: enhanced effectiveness in comparison with papaverine plus phentolamine and prostaglandin E1 alone

We compared the erectile response to intracavernous injection of a combination of papaverine and prostaglandin E1 with that of a combination of papaverine and phentolamine (49 patients), and prostaglandin E1 alone (38). The degree of erection achieved was significantly better with papaverine plus prostaglandin E1 than with papaverine plus phentolamine and the duration of erection was less, although the incidence of prolonged erections (greater than 5 hours) was similar with both combinations. Papaverine with prostaglandin E1 likewise resulted in a significantly better degree of erection than prostaglandin E1 alone (prolonged erections occurred only after the drug combination). All erections subsided spontaneously and none required medical intervention throughout the study. Pain was noted only after injection of prostaglandin E1. The incidence was clearly lower (7 of 38 versus 13 of 38) after the injection of only 5 micrograms. prostaglandin E1 in combination with papaverine (although the difference is not statistically significant). Subjectively, the side effects caused by the drug combination were described as much less dramatic by the patients than after prostaglandin E1 alone. The combination of papaverine and prostaglandin E1 shows a clearly synergistic effect and might suitably replace papaverine plus phentolamine or prostaglandin E1 alone in patients who do not respond well or suffer side effects after high single doses.     

Usefulness of power Doppler ultrasonography in evaluating erectile dysfunction

OBJECTIVE: To evaluate deep penile arterial flow after an intracavernosal injection with papaverine in patients with erectile dysfunction (ED). PATIENTS AND METHODS: Twenty patients with ED were evaluated using power Doppler ultrasonography with a linear probe (8 MHz). Diagnostic tests were undertaken after an intracavernosal injection with 40 mg papaverine. The peak systolic velocity (PSV), end-diastolic velocity (EDV) and resistive index (RI) were analysed. RESULTS: After injecting papaverine, seven patients had a normal erection and appropriate waveform patterns; their mean PSV was 30.7 cm/s, the EDV 4.42 cm/s and the RI 0.85. There was tumescence and elongation of the penis with no rigidity in eight patients; their mean PSV was 23.9 cm/s, the EDV 7.34 cm/s and the RI 0.72. There was no erection in five patients. The abnormal flow values showed insufficient arterial vessels in a quarter of the men, venous leakage in 15% and mixed ED in 20%. CONCLUSION: The power Doppler technique allows the accurate location and evaluation of deep penile arteries. Vascular pathology may be differentiated after an intracavernosal injection with a vasomotor agent. Recognising the pathological pattern assists in choosing the best method of treatment.     

Utility of Rigiscan and papaverine in diagnosis of erectile impotence

The Rigiscan machine was used to measure nocturnal penile tumescence and rigidity in 41 men referred for evaluation of erectile impotence. In 6 patients, the Rigiscan was compared with the Tumistore and Snap-Gauge bands. Two patients achieved significant tumescence as measured by Tumistore, and 3 had significant tumescence as indicated by the breaking of two or three of the Snap-Gauge bands. None of these men achieved sufficient rigidity for intercourse as measured by the Rigiscan. Fourteen patients with organic impotence received intracorporeal injections of papaverine and were then monitored by Rigiscan. Six of the 14 were noted to have a Peyronie plaque. Of the remaining 8, 6 of these men achieved lasting erections sufficient for intercourse. The other 2 had erections that lasted ten minutes and were considered to have venous leak impotence. All patients with Peyronie disease had tumescence after papaverine injection, but in 5 the penis became rigid only at the base. Complications of papaverine injection were uncommon and minor. The Rigiscan and papaverine are useful in the diagnosis and management of erectile impotency.     

The influence of body position on pulmonary function in low birthweight babies.

The influence of the prone and supine body positions on the respiratory rate, arterial pH, pO2, pCO2 and serum bicarbonate level; on alveolar pO2 and pCO2; and on alveolar/arterial gradients for carbon dioxide and oxygen, were compared in 10 low birthweight infants. THE ALveolar pCO2 was higher in the prone, while pO2 was higher in the supine position, possibly as a result of ventilation/perfusion imbalance with increased physiological dead space in the supine position. There were no significant differences between the other parameters studied. Since aspiration of feed by the low birthweight infant is a major cause of morbidity and mortality, evidence is presented in favour of the prone nursing position.     

Experimental study on intrahepatic gas tensions measured by mass spectrometry: effect on temporary occlusion of the afferent hepatic circulation

In 24 mongrel dogs, a mass spectrometer was utilized to measure intrahepatic pO2 and pCO2 levels subjected to various degrees of inspired oxygen concentration, or interruption of the afferent hepatic circulation. The mean intrahepatic pO2 and pCO2 levels in dogs breathing 70% O2 were 46.0 +/- 13.3(SD) mmHg and 27.4 +/- 13.0mmHg, respectively. Progressive rise of the intrahepatic pO2 and pCO2 was observed with increase in the arterial pO2 and pCO2 when the hepatic circulation was kept constant. When the hepatic artery was interrupted, mean intrahepatic pO2 fell rapidly to 20% of the control value, and mean intrahepatic pCO2 rose to 200%. Rather wide dispersion of the values among the experimental animals during the hepatic artery interruption was speculated to reflect the variety of collateral hepatic arterial supply and various degrees of congestion of portal blood flow. Transient decrease in the mean intrahepatic pO2 was observed following interruption of the portal vein. Intrahepatic pO2 rapidly fell to zero and pCO2 increased in a lineal fashion when the total hepatic circulation was interrupted. The latter rose to 453% of the control value 30 minutes after interruption, then the rate of rise gradually decreased until a plateau was reached one hour later. This decrease in the rate of rise in intrahepatic pCO2 was regarded to reflect the reduction of energy production through the anerobic pathway due to irreversible hepatic parenchymal degeneration. It is suggested that the measurement of intrahepatic gas tensions under various conditions by a mass spectrometer technique is useful for evaluating changes of intrahepatic microcirculation and dynamic aspects of anerobic metabolism of the liver.     

Objective double-blind evaluation of erectile function with intracorporeal papaverine in combination with phentolamine and/or prostaglandin E1.

We performed a double-blind, crossover study using objective measurements to compare maximum rigidity and duration of erections with papaverine hydrochloride in combination with phentolamine mesylate and/or prostaglandin E1. The rationale for the protocol was to combine a smooth muscle relaxant (papaverine) with either or both vasodilating agents (phentolamine and prostaglandin E1) commonly used for injection therapy. The 7 volunteer patients with organic impotence documented by abnormal nocturnal penile tumescence testing were injected with 0.5 to 1.0 ml. papaverine (30 mg./ml.) in combination with phentolamine (0.5 mg./ml.) and/or prostaglandin E1 (5 micrograms./ml.). Each patient received 2 injections on each of 2 testing dates; injection 2 was given after tumescence resulting from injection 1 had subsided completely. The medications were given in a randomized, counterbalanced order following double-blind procedures. Patients evaluated the erections subjectively. In addition, the RigiScan device was used to measure maximum rigidity and duration of erections. All patients observed increased duration of erections with both combinations containing prostaglandin E1. Analysis of RigiScan measurements showed no statistically significant differences for maximum rigidity (p greater than 0.1) but significantly greater duration of erections with papaverine plus prostaglandin E1, and papaverine plus phentolamine plus prostaglandin E1 compared to papaverine plus phentolamine (p less than 0.001). There was no statistical difference in rigidity or duration of erections between papaverine plus prostaglandin E1 and papaverine plus phentolamine plus prostaglandin E1. No patient reported significant penile pain with any of the injections. We conclude that the combination of papaverine and prostaglandin E1 produces erections of longer duration than papaverine plus phentolamine and that no additional benefit is gained by adding phentolamine to a combination of papaverine and prostaglandin E1. Further studies are in progress to define optimal dose response curves for papaverine and prostaglandin E1 as individual agents and in combination.     

无创性动态阴茎海绵体测压的临床应用

目的　初步评价应用VISER软件行无创性动态阴茎海绵体测压在阳萎 (ED)诊断中的作用。　方法　采用AquariusXLT型尿动力学仪配置的VISER软件 ,辅助眼镜式影像仪听觉视觉性刺激 (AVSS)或阴茎海绵体内血管活性药物注射 (ICI)进行无创性动态海绵体测压 39例 ,其中ED患者 32例 ,正常对照 7例。　结果　正常对照 7例均可通过AVSS诱发勃起 ;32例ED患者中 ,13例单纯AVSS可诱发勃起 ,占 4 0 % ;19例单纯AVSS无效者 ,给予罂粟碱 10mg海绵体内注射 ,其中 13例出现勃起 ,占 6 8%。结果除ED罂粟碱组勃起平均时间延长外 ,勃起数据和峰值数据中的其他多项指标ED各组均低于对照组 ,尤以勃起和峰值总能量降低明显。　结论　VISER具有精确的动态阴茎海绵体测压功能 ;辅助眼镜式影像仪有助于增强AVSS效果和减少阴茎海绵体血管活性药物注射剂量 ;VISER检查具有无创、准确、便捷等优点 ,有望成为ED诊断的首选方法     

Evaluation of erectile dysfunction with continuous monitoring of penile rigidity

Measurement of nocturnal penile tumescence or circumferential expansion is a valuable method for the diagnosis of erectile impotence. However, only a few investigations have been made of penile rigidity during tumescence with a single isolated measurement. A new method of continuous and simultaneous recording of nocturnal penile rigidity and circumferential expansion (tumescence) was used in 105 patients with erectile impotence. The method provided several findings concerning nocturnal penile erection. Circumferential expansion was not always accompanied by penile rigidity. A dissociation of rigidity between the tip and base of the penis was observed in some patients. Shortened episodes and low amplitude of rigidity also were seen. Of 11 patients with psychogenic impotence diagnosed by conventional methods 3 (27.3 per cent) showed abnormal nocturnal rigidity and 8 of 94 (8.5 per cent) with organic impotence diagnosed by conventional methods showed normal nocturnal rigidity. Because of its ambulatory character the continuous measurement of nocturnal penile rigidity is of value in defining features of nocturnal penile erection and differentiating psychogenic from organic impotence.     

Aerobic blood sampling technique using the B 109-syringe (author's transl)]

A syringe (B 109 Radiometer) for arterial blood sampling with modified aerobic technique is described. The blood sampling and subsequent storage during 2 h in ice water induces no clinically significant changes in the pH, pCO2 and pO2 of the blood.     

Comparison of blood gas and electrolyte test results from the Gem-Stat and CDI-300 versus a conventional laboratory analyzer

Continuous blood gas monitoring devices have been an aid to the perfusionist since the introduction of the oxygen saturation meters of the early 1980s. Since that time, the perfusionist has had to decide between continuous versus intermittent sampling, and on-line (an analyzer that can automatically sample either at prescribed intervals and/or on demand) versus in-line devices (monitors that continuously sample and display results). This report compares the continuous, in-line CDI-300 blood gas monitor and the Mallinckrodt Gem-Stat blood gas analyzer using intermittent sampling with the Corning 278 blood gas analyzer and 2500 Co-Oximeter. Thirty samples were taken, one per 30 patients, for comparison. Five samples were disqualified from the study. When comparing the remaining 25, the Gem-Stat results to the Corning 278 blood gas analyzer results, all measured values (arterial pH, pCO 2, pO 2, venous pO 2, Na, K and Hct) correlated greater than 0.5000 with a p value of less than 0.001. The exception was the ionized calcium value which had a correlation of 0.2473 with a p value of less than 0.232. When comparing the CDI-300 results to the Corning 278 blood gas machine results, all measured values (pH, pO 2, pCO 2, and venous pO 2) correlated greater than 0.5000 with a p value of less than 0.003 or better. When comparing the Gem-Stat results to the CDI results, all measured values (pH, pCO 2, pO 2 and venous pO 2) correlated greater than 0.5000 with a p value of less than 0.002 or better.     

Open multicenter study of the differential diagnosis of erectile dysfunction with a papaverine-phentolamine combination (BY023)

We report the results of an open multicenter clinical trial with 115 patients. The results of a pharmacological test using intracavernously applied mixture of papaverine and phentolamine were compared with the results of a multidisciplinary evaluation of erectile dysfunction. Sensitivity and specificity of our test were determined. The injection of our drug solution caused an increase in tumescence and/or rigidity in all patients. The evaluation of the dose dependent erectile response makes it possible to distinguish between the three main pathogenetic principles: non-vascular, arterial and venous etiology of erectile dysfunction. The pharmacological test requires one to four intracavernous injections of 0.5-3.0 ml of the drug solution (7.5-45 mg papaverine hydrochloride, 0.25-1.5 mg phentolamine mesylate).     

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.