Sexual impotence caused by vascular disease: diagnosis with duplex sonography

We used duplex Doppler sonography to assess the hemodynamic function of the penis in patients with impotence to determine if there is arterial disease or if the veins are incompetent. The penis was scanned in the flaccid state, then again after erection was induced by intracorporal injection of papaverine. The diameter of each cavernosal artery was measured before and after injection and, by using Doppler sonography, the maximal systolic velocity in each cavernosal artery was measured. The Doppler gate was placed over the dorsal vein to detect any flow in that vein signifying venous leakage. The Doppler gate then was placed over the cavernosal veins in an attempt to detect cavernosal venous incompetence. Forty-five men with impotence were included in the study. In 39 patients, the cause of impotence was confirmed by other studies. The diameter of the cavernosal arteries and the increase in diameter of these arteries after induction of an erection were similar in all diagnostic groups. The peak systolic velocity, however, was decreased in patients with arterial insufficiency as compared with the velocity in normal subjects. In normal subjects, the mean peak velocity was 47 +/- 9 cm/sec; in patients with mild to moderate arterial insufficiency it was 35 +/- 16 cm/sec; in patients with severe arterial insufficiency it was 7 +/- 8 cm/sec. The difference in peak velocities between the right and left cavernosal arteries after papaverine injection (asymmetric arterial response) was significantly larger in patients with mild to moderate arterial insufficiency than in other diagnostic groups. Four patients with venous incompetence had detectable flow in the dorsal vein, but no flow could be detected with Doppler sonography in the cavernosal veins in any patients, including those who were proved to have significant cavernosal venous leaks. Our findings suggest that Doppler measurement of maximal systolic velocity in the cavernosal arteries after papaverine injection is an accurate indicator of arterial function. Asymmetric flow in the cavernosal arteries also suggests some degree of arterial insufficiency. Diameters of the cavernosal arteries and their increase after injection are not predictive of arterial patency. Doppler sonography cannot show cavernosal venous leakage, but in some cases it can show dorsal venous incompetence.     

Color Doppler sonography in the evaluation of erectile dysfunction: patterns of temporal response to papaverine.

Most studies of duplex Doppler sonography for the assessment of erectile dysfunction involve determination of peak systolic velocities 5 min after intracavernosal injection of papaverine. The purpose of this study was to determine the effect of the timing of Doppler measurements of flow after papaverine injection for establishing the presence of arterial and venous abnormalities. Color Doppler sonography was performed in 75 patients for evaluation of vasculogenic impotence. After intracavernosal injection of 60 mg of papaverine, measurements of peak systolic and end-diastolic velocities were obtained in each cavernosal artery at 5-min intervals for a total of 30 min. A peak systolic velocity of less than 25 cm/sec was used as the threshold for arterial insufficiency. An end-diastolic velocity of greater than 5 cm/sec was used to predict venous incompetence. Scanning was performed for direct assessment of dorsal venous flow. Thirty patients were subsequently evaluated by cavernosometry and cavernosography. In most patients (76%), maximum response to papaverine was achieved within the first 5 min. In eight patients, significant increases in systolic velocity were seen only after 5 min. In 10 patients, significant changes in end-diastolic velocity between 5 and 30 min resulted in diagnostic reclassification. Data acquisition for 30 min significantly improved the sensitivity (95%) and specificity (83%) for the prediction of venous incompetence in patients with correlative cavernosography. Transient, early dorsal vein flow was noted in normal subjects. Persistent dorsal vein flow had an 80% sensitivity and 100% specificity for venous incompetence. Our results suggest that, when using color Doppler sonography, gathering data for 30 min may improve the prediction of vasculogenic impotence.     

Evaluation of normal erectile function with color flow Doppler sonography

To understand better the vascular events that occur during normal erection, we used color flow Doppler sonography to examine the erectile process in seven normal subjects. The relationship of systolic/diastolic velocities and spectral waveform changes in the penile arteries was studied in response to increasing pressure within the corpora cavernosa (tumescence) before and after the intracorporal administration of drugs to induce erection. A characteristic spectral waveform pattern was identified throughout the erectile cycle, and the pattern was correlated with increasing pressure. Both systolic and diastolic velocities were elevated during the initiation of erection, at which time the pressure within the corpora cavernosa was low (11-25 mm Hg). Systolic velocities remained elevated until the last phase of erection (83-106 mm Hg). Diastolic velocity decreased as the intracorporal pressure increased from 25 to 40 mm Hg. Between 40 and 63 mm Hg, diastolic velocity approximated zero. With increasing pressure (63-83 mm Hg), diastolic flow reversed. As the corpora cavernosa approached full erection (83-105 mm Hg), both the forward systolic and reverse diastolic flow components diminished. At approximately 106 mm Hg (systolic occlusion pressure), flow ceased. Systolic/diastolic velocity and waveform phase relationships could be used to define the integrity of both the cavernosal artery inflow and the venous sinusoidal outflow occlusion mechanisms. Color flow Doppler sonography enhanced our ability to observe and quantify dynamic erectile events and provided new insights into understanding normal erectile function.     

Duplex and color Doppler sonographic evaluation of vasculogenic impotence

One hundred eighty patients with suspected vasculogenic impotence were evaluated with conventional penile duplex sonography with spectral analysis and color Doppler imaging. Measurements of mean peak systolic and end-diastolic velocities were obtained from the cavernosal arteries before and after intracavernosal injections of papaverine. Sixty-one patients were examined with dynamic cavernosography and cavernosometry, and 12 patients were studied with selective internal pudendal and penile arteriography. All five patients with abnormal arteriography had mean peak systolic velocities in the cavernosal arteries of less than or equal to 25 cm/sec (sensitivity, 100%; 95% confidence interval, 48-100%) after the injection of papaverine. Six of the seven patients with normal arteriography had mean peak systolic velocities of greater than 25 cm/sec (specificity, 85.7%; 95% confidence interval, 42-100%) after injection of papaverine. By using data from a receiver-operating-characteristic curve, we determined that end-diastolic velocities in the cavernosal arteries of greater than or equal to 5 cm/sec after the injection of papaverine correctly identified patients with excessive venous leakage on cavernosometry; the sensitivity was 90% (95% confidence interval, 77-97%) and the specificity was 56% (95% confidence interval, 30-80%). The addition of color Doppler sonography made the detection of vessels easier and the correction of the Doppler angle more accurate, resulting in more rapid and accurate acquisition of data. Penile duplex sonography with spectral analysis and color Doppler imaging are sensitive and noninvasive means of examining patients with potential vasculogenic impotence.     

Color Doppler appearance of penile cavernosal-spongiosal communications in patients with normal and impaired erection

Our objective was to investigate prevalence and Doppler characteristics of penile cavernosal-spongiosal communications (CSC). These vessels are either anastomoses connecting the cavernosal arteries with the urethral arterial network or afferent vessels to the corpus spongiosum. Sixty-one consecutive patients underwent penile color Doppler US. Waveform changes in CSC were evaluated in comparison with changes in the cavernosal artery. Eighteen of 61 patients had normal erection, 17 of 61 had arterial insufficiency, and 26 of 61 had veno-occlusive dysfunction. Resistance index (RI) in CSC was significantly lower than in cavernosal arteries in all patients and increased during phases 1-2 (positive diastolic flow). Peak systolic velocity (PSV) in CSC was significantly higher in the patients with veno-occlusive dysfunction. During cavernosal phase 4 (diastolic flow reversal) CSC of patients with normal erection or with arterial insufficiency disappeared, underwent markedly reduced diastolic flow, or had systolic flow inversion. Conversely, low resistance flow was appreciable in CSC of patients with veno-occlusive dysfunction who reached phase 4. During phase 5 (systolic peak reduction) all CSC disappeared. Color Doppler US allows evaluation of CSC both in patients with normal and impaired erection.     

Pulsed and color Doppler sonographic findings of penile Mondor's disease.

This report describes the color and pulsed Doppler US findings of penile Mondor's disease. The pulsed Doppler US findings of penile Mondor's disease have not been previously published, so we report here for the first time on the cavernosal arterial flow signal pattern of penile Mondor's disease. Penile Mondor's disease is rare disease that's characterized by thrombosis in the dorsal vein of the penis. The previous reports on penile Mondor's disease are concerned with the color Doppler US finding without the flow signals in this area, but these findings are insufficient to understand the hemodynamics in penile Mondor's disease. We report for the first time on a cavernosal artery flow signal pattern of low peak systolic velocity and high-resistance.     

Assessment of normal and abnormal erectile function: color Doppler flow sonography versus conventional techniques

The penile arteries were studied with color Doppler flow sonography in 10 subjects with normal and 39 patients with abnormal erectile function. The relationships of systolic and diastolic velocities to spectral waveform changes in the penile arteries in response to tumescence were studied before and after intracorporal injection of vasoactive medications that induce erection. In normal subjects, a characteristic spectral waveform pattern corresponded to increasing intracorporal pressure. Patients with abnormal arterial inflow and/or abnormal venous sinusoidal leakage demonstrated deviation from the patterns noted in normal subjects. Patients with abnormal arterial inflow had lower mean peak systolic velocities than normal subjects. Patients with severe venous sinusoidal incompetence had an arrest of waveform progression with evolution to but not beyond phases 1 or 2 (diastolic flow remained positive). Patients with abnormal arterial inflow and abnormal venous sinusoidal outflow had waveform changes that reflected both processes. Systolic/diastolic velocity and waveform relationships can be used to define the integrity of both the cavernosal artery inflow and venous sinusoidal outflow occlusion mechanisms.     

Postbiopsy renal transplant arteriovenous fistulas: color Doppler US characteristics

Color Doppler ultrasound (US) with point-spectral analysis was performed on eight patients with postbiopsy renal transplant arteriovenous fistulas. Waveform analysis of the supplying artery documented decreased resistive indices in all cases and increased flow velocities in seven. The peak-systolic flow velocity in the arteries supplying the fistulas ranged from 55 to 180 cm/sec (mean, 92 cm/sec), while the range in normal arteries was 20-52 cm/sec (mean, 32 cm/sec). The resistive indices of the arteries supplying the fistulas ranged from 0.31 to 0.50 (mean, 0.45), while the resistive indices of the normal arteries ranged from 0.60 to 0.92 (mean, 0.74). Arterialization of the venous waveform from the draining vein was also documented in all cases. In six cases, the increased flow velocities resulted in increased color saturation toward white in the supplying artery (n = 2) or in both the artery and the draining vein (n = 4), which was detectable on the realtime image. In six cases, flow turbulence resulted in localized tissue vibration, which appeared as random color assignment in extravascular renal parenchyma adjacent to the fistula. Knowledge of these imaging and Doppler characteristics should aid in the identification of renal transplant arteriovenous fistulas with color Doppler US.     

Identification of feeding arteries to establish the intra- or extraparotid location of jugulodigastric nodules: value of color Doppler sonography

OBJECTIVE: The objective of our study was to determine the value of color Doppler imaging as an adjunct to gray-scale sonography to reveal the intra- or extraparotid origin of jugulodigastric nodules of uncertain location. SUBJECTS AND METHODS: Forty nodules in the jugulodigastric area from 38 patients were imaged with gray-scale, color, and power Doppler sonography. Nodules receiving vessels from salivary glands were assumed to be intraglandular; those accepting vessels from paraparotid spaces were considered to arise from outside the gland. Imaging results were correlated with biopsy and surgical findings. RESULTS: In 38 of 40 cases, color and power Doppler sonography displayed discrete feeding arteries leading to the nodules: 25 nodules had one supplying artery, nine received two arteries, and four had three or more arteries. Intraparotid nodules received vessels from the gland in 20 cases. In two cases, the source of vessels was indeterminate. In two malignant tumors, multiple arteries derived from both the parotid and the neck spaces. All 14 extraparotid nodules received the arterial supply from paraparotid spaces. Color Doppler sonography enabled prediction of the intraglandular location of the nodules in 91% of cases and the extraglandular location in 87.5% of cases. The correct diagnosis was achieved in 34 of 40 nodules, with a global accuracy of 85%. CONCLUSION: Color Doppler sonography can help to assess the intra- or extraparotid location of jugulodigastric nodules. In practice, this technique can support the diagnosis when gray-scale sonography raises doubts about the origin of a jugulodigastric nodule.     

Doppler examination of the kidney in infants and children

Doppler sonography has become a reliable indicator of renal vascularization. Color Doppler permits mapping of regional intrarenal blood flow, as well as flow in the main renal artery and vein. The spectral display of the Doppler signal arising from the renal arteries yields valuable information about the state of the peripheral vascular bed. Our understanding of intrarenal Doppler curves has evolved from a simplistic model of pulsatility index number equals diagnosis to the more sophisticated concept that changes in these curves imply a change in the physiology of the kidney. This is a summary of current clinical applications of the Doppler technology to diseases of the kidney in the child.     

Doppler examination of the kidney in infants and children

Doppler sonography has become a reliable indicator of renal vascularization. Color Doppler permits mapping of regional intrarenal blood flow, as well as flow in the main renal artery and vein. The spectral display of the Doppler signal arising from the renal arteries yields valuable information about the state of the peripheral vascular bed. Our understanding of intrarenal Doppler curves has evolved from a simplistic model of pulsatility index number equals diagnosis to the more sophisticated concept that changes in these curves imply a change in the physiology of the kidney. This is a summary of current clinical applications of the Doppler technology to diseases of the kidney in the child.     

Transorbital color Doppler flow imaging of the carotid siphon and major arteries at the base of the brain.

PURPOSETo describe and evaluate an application of sonography, transorbital color Doppler flow imaging of the carotid siphon and major intracranial arteries, and to compare it with transtemporal color Doppler flow imaging.METHODSThe carotid siphon and major arteries at the base of the brain of 50 healthy volunteers were screened using the transorbital color Doppler flow sonography. These arteries were also studied by a transtemporal approach for comparison. In 5 volunteers, MR images in special inclination planes were obtained and compared with the transorbital color-coded Doppler flow images.RESULTSThe B-mode image of the orbit and intracranial anatomic structures, in addition to the color-coded flow images, provided an unambiguous identification of the carotid siphon and major intracranial arteries. The failure rate was lower when using the transorbital approach than when using the transtemporal approach in identifying the anterior cerebral artery (17% versus 32%). Color Doppler flow imaging using the transtemporal approach was better for the middle cerebral artery, whereas color Doppler flow imaging using the transorbital approach was better for the anterior cerebral artery (contralateral). The Doppler incident angles using the transorbital approach were better for the carotid siphon and anterior cerebral artery (contralateral).CONCLUSIONTransorbital color Doppler flow imaging, when used in conjunction with the transtemporal examination, can add information concerning the major arteries at the base of the brain.     

Carotid artery disease assessed by color Doppler flow imaging: correlation with standard Doppler sonography and angiography

Carotid artery disease was assessed in 180 patients by means of color Doppler flow imaging. Color Doppler findings in 360 carotid arteries were compared with the results of standard Doppler sonography, and color Doppler findings in 60 bifurcations were compared with the results of intraarterial angiography. The sensitivity of color Doppler for the detection of carotid disease was 100% when compared with angiography. The accuracy of color Doppler in classifying minor (40-60%), moderate (61-80%), and severe (81-90%) stenosis ranged from 91.3% to 97.8% vs standard Doppler sonography, and from 91.7% to 95.8% vs angiography. Whereas all occlusions were identified correctly by both color Doppler and angiography, four pseudoocclusions of the carotid artery were misdiagnosed as occluded. Characteristic features providing reliable criteria of the degree of stenosis are (1) intensity, extent, and duration of color fading; (2) postprocessed systolic peak frequency; (3) plaque extent on serial sonograms; and (4) poststenotic flow patterns. Display of hemodynamic disturbances induced by less pronounced plaques showed highly variable patterns that could not be anticipated from the plaque morphology alone. Thus, color Doppler preserves the advantages of standard Doppler and duplex sonography but provides additional information about otherwise anechoic necrotic and thrombotic material that often causes cerebral embolisms. With atherogenesis, repair mechanisms may be sustained or progression be stopped by reducing the risk factors and instituting medical treatment; thus, the application of this noninvasive technique is important.     

Carotid artery disease assessed by color Doppler flow imaging: correlation with standard Doppler sonography and angiography

Carotid artery disease was assessed in 180 patients by means of color Doppler flow imaging. Color Doppler findings in 360 carotid arteries were compared with the results of standard Doppler sonography, and color Doppler findings in 60 bifurcations were compared with the results of intraarterial angiography. The sensitivity of color Doppler for the detection of carotid disease was 100% when compared with angiography. The accuracy of color Doppler in classifying minor (40-60%), moderate (61-80%), and severe (81-90%) stenosis ranged from 91.3% to 97.8% vs standard Doppler sonography, and from 91.7% to 95.8% vs angiography. Whereas all occlusions were identified correctly by both color Doppler and angiography, four pseudoocclusions of the carotid artery were misdiagnosed as occluded. Characteristic features providing reliable criteria of the degree of stenosis are (1) intensity, extent, and duration of color fading; (2) postprocessed systolic peak frequency; (3) plaque extent on serial sonograms; and (4) poststenotic flow patterns. Display of hemodynamic disturbances induced by less pronounced plaques showed highly variable patterns that could not be anticipated from the plaque morphology alone. Thus, color Doppler preserves the advantages of standard Doppler and duplex sonography but provides additional information about otherwise anechoic necrotic and thrombotic material that often causes cerebral embolisms. With atherogenesis, repair mechanisms may be sustained or progression be stopped by reducing the risk factors and instituting medical treatment; thus, the application of this noninvasive technique is important.     

Duplex and color Doppler flow sonography of occlusion and near occlusion of the carotid artery.

PURPOSETo determine whether color Doppler flow imaging with the use of slow-flow sensitivity improves sensitivity and specificity in the differentiation of occlusion and near occlusion of the internal carotid artery.METHODSColor Doppler and duplex sonography were performed in symptomatic patients who had angiographically confirmed occlusion and/or near occlusion of the internal carotid artery. The study consisted of two phases: in the first, we assessed the usefulness of color Doppler flow imaging by retrospectively reviewing the records of 35 patients with 36 angiographically confirmed occlusions or near occlusions of the internal carotid artery who were examined with color Doppler flow imaging at our institution during a period of 4 years; in the second phase, we incorporated color Doppler sonography into the routine scanning protocols of 39 patients with 41 occluded or nearly occluded internal carotid arteries seen over a period of 2 1/2 years.RESULTSOverall, color Doppler imaging correctly showed all 34 of the near occlusions (sensitivity, 100%) and 36 of the 43 occlusions (specificity, 84%). Seven patients with angiographically confirmed occlusion had sonographic findings that suggested near occlusion. In the first phase, eight near occlusions were misinterpreted as occlusions with conventional duplex sonography, but were correctly shown with color Doppler flow imaging. In the second phase, sensitivity increased from 50% to 100% (18 or 18) because of better detection of the nearly occluded lumen. This was at the expense of a decrease in specificity (from 100% to 78%). owing to identification of apparent flow in the internal carotid artery on color Doppler flow images in five of 23 occlusions.CONCLUSIONBecause of its ability to depict slow flow, color Doppler imaging with slow-flow sensitivity is superior to conventional duplex sonography for the noninvasive discrimination of occlusion from near occlusion of the internal carotid artery.     

The role of power Doppler sonography in the prenatal evaluation of fetal renal vasculature.

This study was performed to determine whether power Doppler sonography is superior to color Doppler sonography in the depiction of the normal fetal intrarenal vasculature during pregnancy. Twenty-five fetal kidneys in 22 healthy fetuses between 22 and 40 weeks of gestation (mean 32.6 weeks) were studied with color and power Doppler sonography with a 3.75 MHz transducer. The efficacy of power and color Doppler sonography were compared in assessing fetal renal vasculature. Power Doppler sonography demonstrated diffuse "blush" in almost the entire cortex in 21 of 25 fetal kidneys, whereas it was demonstrated in half of the cortex in the other four kidneys. Color Doppler sonography failed to demonstrate a cortical blush in fetal kidneys. Power Doppler sonography has been shown to be superior to color Doppler sonography in the depiction of normal fetal intrarenal vasculature during pregnancy by demonstrating vascular blood flow better than color Doppler sonography.     

Cranial arteriovenous malformations in neonates: color Doppler imaging with angiographic correlation

Five neonates with cranial arteriovenous malformations were studied with color Doppler sonography. Excellent correlation was found between sonography and subsequent angiography. In three patients with vein of Galen aneurysms, sonography showed a cystic structure with rapid or swirling flow. Careful adjustment of the color Doppler system was required to demonstrate flow in another patient with a dural arteriovenous malformation. An arteriovenous fistula in a fifth patient appeared as an area of increased flow. Arterial feeders and major draining veins were visualized in all five patients. Color Doppler imaging also was used to assess the effect of embolic or operative therapy in three of the patients. We conclude that color Doppler sonography is able reliably to characterize flow patterns in neonatal cranial arteriovenous malformations. Color Doppler imaging also is helpful in assessing flow after embolic or surgical therapy.     

Optic neuritis: evaluation with orbital Doppler sonography

PURPOSE: To evaluate orbital blood flow velocities with Doppler sonography in patients with acute unilateral optic neuritis. MATERIALS AND METHODS: Orbital Doppler sonography was performed in 20 patients with acute unilateral optic neuritis. Optic neuritis was diagnosed by a neurologist on the basis of clinical presentation, presence of decreased visual acuity, and assessment of visual evoked potentials. The peak systolic and end diastolic velocities and the resistive index were measured in the ophthalmic and central retinal arteries of both orbits. The values obtained from affected and unaffected orbits were compared by using the paired t test. RESULTS: The peak systolic and end diastolic velocities in the ophthalmic artery were significantly increased in the affected orbits (for peak systolic velocity P <.001, for end diastolic velocity P <.05). Resistive indexes in the ophthalmic arteries did not differ (P >.05). The difference between the peak systolic and end diastolic velocities and resistive indexes in the central retinal arteries of affected and normal eyes was not statistically significant (P >.05). CONCLUSION: Peak systolic and end diastolic velocities in the ophthalmic artery are increased in patients with acute optic neuritis.     

Therapeutic embolization of high-flow priapism 1 year follow up with color Doppler sonography

Objective

The aim of this study was to evaluate the use of color Doppler sonography (CDS) for the diagnosis of high-flow priapism and the treatment of cavernosal arterial fistula via super-selective arterial embolization.

Methods and materials

We reviewed eight cases of high-flow priapism with cavernosal arterial fistula, from 2005 to 2011. All of the patients were diagnosed with a high-flow priapism and unilateral artery fistula via CDS. Conventional treatments for the eight cases were unsuccessful, and the patients were then treated through super-selective embolization. Diagnostic angiograms of the internal iliac artery showed a fistula on one side of the cavernosal artery, thus confirming the CDS images. We compared hemodynamic parameters including the peak systolic velocity, end diastolic velocity the resistance index of the pathological cavernosal artery and intracavernosal pressure in all patients before and after treatment using t-test. The efficacy of super-selective embolization and the erectile function of all patients were evaluated at a follow-up time of 12 months.

Results

All patients were successfully treated and angiography showed that the fistulas disappeared after treatment. Additionally significant differences were found in the peak systolic velocity, the end diastolic velocity, the resistance index and intracavernosal pressure between pre-treatment and post-treatment (P < 0.05). At 5 days post-treatment, only one case relapses had occurred. Seven cases displayed restored erectile function and only one case exhibited erectile dysfunction.

Conclusion

Color Doppler sonography is a highly sensitive method for the examination of high-flow priapism, and super-selective embolization is a safe and effective treatment for cavernosal arterial fistula.     

Vasculogenic impotence evaluated by high-resolution ultrasonography and pulsed Doppler spectrum analysis

Vasculogenic impotence was evaluated by high-resolution sonography and quantitative Doppler spectrum analysis in 21 patients and two normal volunteers. Erection was induced by intracorporeal injection of papaverine, and B-scan imaging and Doppler analysis were performed with the penis flaccid and erect. The corpora cavernosa and its deep arteries, median septum, and corpus spongiosum were clearly displayed in every subject, with the dorsal vein and dorsal artery seen ventral to the corpora cavernosa. In the flaccid state, in all subjects, Doppler analysis demonstrated flow in the dorsal arteries but not in the deep arteries. During erection, the B-mode image showed varying degrees of enlargement of the corpora cavernosa, with increased tissue echogenicity, as well as a hypoechoic area in the peri-arterial region. The diameter of the penile arteries and flow within them also increased by varying degrees. Quantification of blood flow through all deep and dorsal arteries is feasible with this technique.