Cavernosal Artery Diameter Research Articles

(352) Erection Hardness Score (EHS) Correlates With Resistive Index but Not Cavernosal Artery Dilation During Penile Doppler for Erectile Dysfunction and Peyronie's Disease

Abstract Introduction Penile Doppler Ultrasound (PDU) is a non-invasive diagnostic test used to assess organic erectile dysfunction (ED) and Peyronie’s disease and characterize functional changes in penile blood flow. Quantitative measurements taken during penile Doppler testing include changes in cavernosal artery diameter, the velocity of blood flow in the cavernosal artery in systolic and diastolic phases, and a calculated resistive index. It remains poorly understood which of these parameters best predict response to intracavernosal injection therapy and how they are influenced by comorbidities such as age, diabetes, smoking, hypertension, and obesity. Objective The objective of this study is to assess which parameters best predict response to intracavernosal trimix injection and determine the utility of measuring cavernosal artery diameter during penile Doppler testing. Methods This study is a single institutional retrospective cross-sectional review of men undergoing workup for organic ED and/or Peyronie's disease who elected to undergo penile Doppler testing. Only patients who received a standardized 30-1-10 trimix injection were included. Dosing was determined based on age and risk factors using a nomogram, and redosing was performed if the erection quality was below subjective optimal erection quality at home. Baseline cavernosal artery and plaque imaging were performed, and repeat measurements were obtained at 10 minutes following trimix injection. Results 93 men were included in the study with a median age of 59 (IQR 51-67). 47% carried a diagnosis of Peyronie's, 41% had hypertension, 29% were obese, and 30% were smokers. 40% met the criteria for venous leak (RI <0.8). Erectile hardness scale (EHS) scores of 1-4 were documented in 5, 21, 61, and 5 patients, respectively. Linear regression demonstrated no significant relationship between the change in cavernosal artery diameter and trimix dose, resistive index, comorbidities or other Doppler parameters measured. There was no direct relationship between the EHS scores and cavernosal artery dilation. However, there was a statistically significant relationship between EHS and age (p=0.004), trimix dose (p=0.008), and resistive index (p=0.001) on univariate regression. A multivariable model containing age, comorbidities, and these parameters correctly explained 31% of the variance demonstrated (p=0.001). Conclusions Provider-determined EHS scores were directly proportional to patient age, trimix dose, and resistive indices but not to changes in cavernosal artery diameter. Our findings suggest that this measurement may be safely omitted during the evaluation of organic ED and Peyronie’s Disease without changes in diagnostic or management pathways. Disclosure No

Penile hemodynamics study in erectile dysfunction men: the influence of smoking obesity on the parameters of penile duplex.

Erectile dysfunction (ED) was established to be linked to the risk factors of coronary artery disease such as metabolic syndrome, hypertension, diabetes, smoking, obesity and dyslipidemia. To study the influence of smoking and obesity on penile hemodynamics in patients with erectile dysfunction. This prospective study was carried out on 130 patients above 40years and suffering from ED for more than 6months. Selected patients were divided into four groups: group 1 (nonsmokers/non-obese) N = 36, group 2 (nonsmokers/obese) N = 30, group 3 (smokers/non-obese) N = 34, group 4 (smokers and obese) N = 30. Other risk factors for ED were excluded except dyslipidemia. All patients were subjected to personal history, sexual history, history of medical disorders or operations, evaluation of erectile function using an abridged IIEF-5. Measuring of BMI, fasting lipid profile, blood sugar, TT, prolactin, and PSA was performed. Penile hemodynamics was evaluated using intracavernosal injection of 1cc Bimix (papaverin + phentolamine) and penile duplex ultrasound measuring the peak systolic velocity (PSV), end diastolic velocity (EDV), resistive index (RI), and cavernosal artery diameter before and after injection. The mean ages of group 1, group 2, group 3 and group 4 were 50.92 ± 6.52, 55.20 ± 7.18, 50.88 ± 7.66 and 52.30 ± 7.61, respectively, with no statistically significant (p = 0.341). A statistically significant difference observed between mean value of PSV between group 1 and all other groups on both sides and between group 3 and 4. Also, our results recorded a statistically significant difference between mean value of EDV and RI between group 1 and all other groups on both sides. Concerning the change in the cavernosal artery diameter after ICI, there was a significant difference was seen between the following groups 1 and 4, 3 and 4 on both sides and between groups 1 and 2 at right side only. There was a statistically significant difference between the study groups concerning patient's response to ICI (p value 0.000). A significant negative correlation between BMI and total testosterone was recorded (p = 0.001). Regarding the mean value of testosterone, a significant difference was observed between the different four groups (p = 0.002). And a statistically significant difference was reported between group 1 and group 2 (p = 0.004) and group 2 and group 3 (p = 0.007). Both smoking and BMI are strong risk factors for ED and affect response to ICI and penile duplex parameters (PSV, EDV, RI). Smoking and BMI together cause more deterioration of penile duplex parameters and response to ICI. The effect of smoking on EDV and RI was more than BMI. The effect of BMI on PSV, response to ICI and testosterone levels was more than smoking.

Correlation between peak systolic velocity and diameter of cavernosal arteries in flaccid versus dynamic state for the evaluation of erectile dysfunction

Previous studies have suggested that parameters measured in the flaccid state (FS) by penile duplex Doppler ultrasound (PDDU) may predict the outcome after intracavernosal injection (ICI). The aim of this study was to evaluate the association between peak systolic velocity (PSV) and cavernosal artery diameter (CAD) in the FS with PSV and clinical assessment of erection hardness (CAEH) after ICI. Fifty patients who underwent PDDU for erectile dysfunction were prospectively enrolled. PSV and CAD were measured in FS and then correlated with PSV and CAEH after ICI of 20 μg of e1 prostaglandin (PGe1). Even though PSV in FS demonstrated a significant correlation with PSV after ICI (P=0.04, r=0.21), none of the cutoff values tested (10, 13 and 15 cm s-1 in FS) had a combined sensitivity and specificity >80% to predict a PSV after ICI ⩾30 cm s-1. No correlation was observed between CAD in FS and PSV after ICI. Also, no association was observed between PSV in FS and development of a complete full rigid erection after ICI. Although PSV in FS statistically correlates with PSV after ICI, predictive values are low, making it non-reliable to predict accurately the response to ICI of 20 μg PGe1.

133 Grey-Scale Penile Ultrasound Findings in Young Men with Erectile Dysfunction (ED) Who Used Finasteride for Androgenic Alopecia: A Retrospective Review

ED has been reported following use of finasteride in young men with androgenic alopecia. Animal studies reveal erectile tissue fibrosis after exposure to 5 alpha reductase inhibitors. 8 men (mean age 32) met inclusion/exclusion criteria: potent prior to and developed ED since use of finasteride for androgenic alopecia; less than 40 years old without obvious cardiovascular risk factor exposure; underwent Grey-scale and color duplex Doppler ultrasound (Aixplorer 15.4 MHz transducer) during maximal pharmacologic erection, performed using axial B-mode imaging at multiple gains/multiple locations. Presence/absence of erectile tissue homogeneity or observation of hyperechoic/hypoechoic regions, presence/absence of cavernosal artery atherosclerosis, cavernosal artery diameter, and tunical thickness values were noted. Most patients completed: International Index of Erectile Function (IIEF), Sexual Distress Scale- Revised (SDS-R), Patient Heath Questionnaire (PHQ-9), Perceived Stress Scale (PSS) questionnaires. Patients used finasteride for mean 7.4 years. Other complaints were low libido (63%), orgasm dysfunction (50%), cognitive changes (50%), mood changes (50%). Dihydrotestosterone (DHT) blood test values were low/in lower tertile in 63%. On IIEF, EF domain scores were < 26/30, mean 15; mean scores for desire, orgasm, intercourse satisfaction, overall sexual satisfaction were 5/10, 7.7/10, 6.6/15, 3.2/10 respectively, with mean total IIEF score 37.3/75. SDS-R scores were abnormal with depression and stress noted in 71% and 86%. All 8 patients had lack of homogeneity with obvious hyperechoic/hypoechoic regions in erectile tissue consistent with mild to mild-moderate corporal erectile tissue fibrosis. Other Grey-scale measurements included: absent atherosclerosis in right/left cavernosal arteries, mean dorsal/ventral tunical thickness 1.3/1.2 mm; mean right/left cavernosal artery diameter 1.1/1.0 mm. Color duplex Doppler studies revealed mean right/left peak systolic velocity values 23.2/25.2 cm/sec, and mean right/left end diastolic velocity values 1.5/1.4 cm/sec.

Pharmaco Penile Duplex Ultrasonography in the Evaluation of Erectile Dysfunction.

The National Institute of Health defined 'erectile dysfunction' as the persistent inability to achieve and/or to maintain an erection for a satisfactory sexual performance. In last few years, the concept of erectile dysfunction has evolved from that of a disorder referred to as 'impotence' which used to be considered predominantly psychogenic to that of 'Erectile Dysfunction' (ED), a well understood physiologic result of multiple risk factors, both psychological and organic. The most common cause of organic erectile dysfunction is vasculogenic causes. Doppler evaluation of cavernosal arteries after intracavernosal injection of Papaverine is particularly useful in the evaluation of vasculogenic causes. To define the role of intracavernosal injection of Papaverine in the evaluation of vasculogenic causes of erectile dysfunction that includes arterial insufficiency and veno occlusive nature. Pharmaco Penile Duplex Ultrasonography (PPDU) was done using a linear broadband phased array transducer (7-12 MHz) on a E-Saote MyLab 60 ultrasound colour Doppler system on 73 patients over a period of three years. Informed consent was taken from all patients. Visual grading score for erection, Cavernosal Artery Diameter (CAD), PSV (Peak Systolic Velocity), EDV (End Diastolic Velocity), RI (Resistive Index), AT (Acceleration Time) and dorsal vein changes were obtained in all patients following intracavernosal injection of Papaverine. Visual grading for erectile response was E0 in one patient, E1 in 11 patients, E2 in 9 patients, E3 in 7 patients, E4 in 4 patients and E5 in 41 patients. Eighteen patients were diagnosed as having arterial insufficiency, three patients were diagnosed as having venous insufficiency and two patients showed indeterminate results. In our study, Papaverine induced PPDU proved to be highly accurate and excellent method for assessing patients with erectile dysfunction.

Rehabilitation of the cavernous smooth muscle in patients with organic erectile dysfunction

This study aimed at assessing the effect of regular use of intracorporeal injection (ICI), sildenafil citrate and vacuum constriction device (VCD) on cavernous smooth muscle and erectile activity. One hundred and sixty-five patients with organic erectile dysfunction were investigated for 3 months. The patient and his partner were classified prospectively after proper counselling: group I (n = 56) received ICI twice per week; group II (n = 55) received sildenafil 100 mg twice per week; and group III (n = 54) used VCD twice per week. Duplex ultrasound was carried out before and after treatment, and then, the patients were followed up for a month to assess the resumption of unaided erection. The results showed that there was significant improvement in mean peak systolic velocity (PSV) and mean cavernosal artery diameter (CAD) at the end of the treatment in all groups, being higher in the ICI group than in the other two groups. Also, the percentage of patients who resumed unaided intercourse were higher in the ICI group compared with the other two groups (17.9%, 9.1% and 3.7% respectively). It is concluded that repeated regular use of ICI, sildenafil or VCD by patients with organic erectile dysfunction has a positive impact on their cavernous blood flow and erectile activity.

Longer Time to Peak Flow Predicts Better Arterial Flow Parameters on Penile Doppler Ultrasound

To review the associations between measured variables in Penile Doppler ultrasound procedures. Penile Doppler ultrasound is useful in the evaluation of erectile dysfunction, but there is no uniform standard of performing the procedure. It is generally believed that a peak systolic velocity > 30 cm/s, minimal venous leak, and resistive index > 0.8 are essential for adequate erection. While the arterial parameters are well studied, data on the predictive value of time to peak flow are lacking. Penile duplex Doppler ultrasounds performed for either erectile dysfunction or Peyronie's disease evaluation were reviewed. Clinical records, International Index of Erectile Function scores, and ultrasound variables were examined. "Fast" responders reached maximal peak systolic velocity (PSV) < or = 10 minutes, whereas "slow" responders reached maximal PSV between 15 and 25 minutes. Of 146 total patients, 36 (25%) were fast responders and 110 (75%), slow responders. No preprocedural characteristics, including the Erectile Function domain score of the International Index of Erectile Function, predicted time to peak flow. Compared with the fast responders, slow responders had higher mean PSV (left: 33.9 +/- 19.5 vs 25.0 +/- 11.7 cm/s, P = .01; and right: 36.4 +/- 21.3 vs 25.0 +/- 13.3 cm/s, P = .002). There was also a higher percentage of patients with average PSV > 30 cm/s in slow responders (58% vs 36%, P = .02). There were no significant differences in baseline characteristics between slow and fast responders. However, slow responders did seem to have significantly better arterial flow parameters, although penile dimensions, cavernosal artery diameter, Erectile Function domain scores, and subjective rigidity were similar.

Repeated intracorporeal self-injection: effect on peak systolic velocity and cavernosal artery diameter

This work is aimed at evaluating the effect of repeated intracavernosal injection (ICI) self-injection on the peak systolic velocity (PSV) and the diameter of cavernosal arteries. Sixty erectile dysfunction (ED) patients who were positive responders for ICI therapy were studied. Pharmacopenile duplex ultrasonography (PPDU) was carried out before starting ICI and after 10 doses of home therapy in an open-label uncontrolled study. There was significant increase in the cavernosal artery diameter and their PSV before and after injection. Cavernosal arteries diameter before injection in both right and left sides was 0.64+/-0.13 and 0.63+/-0.12 mm at the start and became 0.81+/-0.22 and 0.79+/-0.22 mm respectively at the end with significant differences (P<0.001). Cavernosal arteries diameter after injection in both right and left sides was 1.10+/-0.18 and 1.09+/-0.19 mm at the start and became 1.34+/-0.39 and 1.27+/-0.33 mm respectively at the end with significant differences (P<0.001). PSV at the start was 33.77+/-13.26 and 32.33+/-8.09 cm/s on both right and left sides and became 44.4+/-1.19 and 46.1+/-5.86 cm/s respectively at the end with significant differences (P<0.001). It is concluded that repeated ICI improves arterial erectile response with associated increase in PSV and cavernosal artery diameters.

Does the clinical efficacy of vardenafil correlate with its effect on the endothelial function of cavernosal arteries? A pilot study

To investigate whether the results of the ultrasonographic (US) measurement of post-occlusive changes in the diameters of cavernosal arteries after administering phosphodiesterase type 5 (PDE-5) inhibitor vardenafil could be associated with the response to vardenafil in patients with erectile dysfunction (ED), as currently there are no reliable methods for predicting the success rate of oral PDE-5 inhibitors. The study included 122 men with ED; after a complex evaluation, the endothelial function of the cavernosal arteries was assessed in all patients before and 1 h after oral ingestion of vardenafil (20 mg), using our modification of the US assessment of post-occlusive changes in the diameter of cavernosal arteries. After the evaluation, all patients received vardenafil 20 mg on demand for 4 weeks. A successful response was defined using two endpoints, i.e. the normalization of the International Index of Erectile Function Erectile Function domain score (> or = 26) and positive answers to both Sexual Encounter Profile questions 2 and 3 on > or = 75% of occasions, based on the diary data collected. In all patients the mean (sd) initial percentage increase in the cavernosal artery diameter (PICAD) in responders and nonresponders was not statistically different, at 49 (24) and 43 (26), respectively (P = 0.168), but PICAD values after vardenafil were significantly greater in responders, at 73 (16) vs 55 (23) (P < 0.001). Analysis of data from patients with different causes of ED showed statistically significant differences in PICAD between responders and nonresponders only in those with arteriogenic ED. The sensitivity and specificity of a PICAD of > or = 50% after taking vardenafil 20 mg for predicting a positive response to the same dose of the drug in patients with arteriogenic ED were 94.9% and 91.3%, respectively. The results of the US assessment of post-occlusive changes in the diameter of cavernosal arteries after vardenafil administration are significantly associated with the clinical efficacy of the drug in patients with arteriogenic ED.

Diagnostic value of nitric oxide, lipoprotein(a), and malondialdehyde levels in the peripheral venous and cavernous blood of diabetics with erectile dysfunction

Diabetes mellitus (DM) is the single most common cause of erectile dysfunction (ED) seen in clinical practice. Evaluation of penile arterial insufficiency in diabetic patients currently entails expensive and invasive testing. We assessed the diagnostic value of certain peripheral and cavernous blood markers as predictors of penile arterial insufficiency in diabetic men with ED. This study was conducted on a total of 51 subjects in three groups: 26 impotent diabetics, 15 psychogenic impotent men and 10 normal age matched control males. All subjects underwent standard ED evaluation including estimation of postprandial blood sugar and serum lipid profile. Peripheral venous levels of nitric oxide (NO), lipoprotein(a) (LP(a)), malondialdehyde (MDA) and glycosylated hemoglobin (HbA1c) were obtained in all subjects. Patients in the two impotent groups underwent additional measurement of NO, LP(a) and MDA levels in cavernous blood. They also underwent intracavernosal injection (ICI) of a trimix (papaverine, prostaglandin E1 and phentolamine mixture) and pharmaco-penile duplex ultrasonography (PPDU). Compared to patients in the psychogenic group, diabetic men had significantly lower erectile response to ICI (P<0.001), lower peak systolic velocity (PSV) (P<0.001), and smaller increase in cavernosal artery diameter (CAD) (P<0.001). Peripheral and cavernous levels of both LP(a) and MDA were higher in the diabetic group as compared to the psychogenic ED group (P<0.001), while the values of peripheral venous and cavernous NO were lower (P<0.001) in the diabetic men. Comparison of biochemical marker assays with the PPDU results showed a significant negative correlation between both venous and cavernous LP(a) and MDA levels on the one hand, and PSV, and the percentage of CAD increase on the other. At the same time, peripheral and cavernous NO levels had a significant positive correlation with the same parameters. Lipoprotein(a), MDA and NO levels were better predictors of low PSV than HbA1c, cholesterol or triglyceride levels. The finding of high levels of LP(a) and MDA with low levels of NO in the peripheral and cavernous venous blood of diabetic men with ED correlates strongly with severity of ED as measured by PPDU. This provides a rationale for further studies of biochemical markers as a surrogate for traditional invasive testing in the diagnosis of penile arterial insufficiency.

Testing Endothelial Function of Brachial and Cavernous Arteries in Patients with Erectile Dysfunction

There is considerable clinical and scientific evidence that endothelial dysfunction may be an important clinical link connecting erectile dysfunction (ED) with cardiovascular diseases. To modify the method of assessment of endothelial function of cavernosal arteries, to develop a new algorithm for evaluating its results, and to investigate the relationship between postocclusive changes in the diameter of brachial and cavernous arteries. The study participants were 212 patients presenting to our department complaining of ED and 40 healthy volunteers without sexual problems, which formed the control group. All patients with ED underwent complex evaluation and ultrasound assessment of postocclusive changes in the diameter of cavernosal arteries modified by us and standard ultrasound assessment of endothelium-dependent flow-mediated dilation of the brachial artery. As the main outcome measure, the percent of increase of the cavernosal arteries diameter (PICAD) was recorded. In the patients with arteriogenic ED, PICAD values were significantly less than in other groups (P < 0.001 for pairs of comparison). At the same time there were no differences between the control group and groups of patients with psychogenic and organic nonarterial ED. The sensitivity and specificity of a PICAD value of 50% in diagnosis of arteriogenic ED were 100% and 98.2%, respectively. In all groups and in the entire sample of patients studied we did not find a correlation between PICAD and postocclusive changes in the diameter of brachial arteries. The method of ultrasound assessment of postocclusive changes in the diameter of cavernosal arteries is reliable and a highly informative tool for diagnosis of arteriogenic ED. It cannot be substituted by technically simpler method of ultrasound examination of brachial arteries, while results of the latter could help to define the necessity of performing an examination of cavernous arteries.

The effect of vardenafil on endothelial function of brachial and cavernous arteries

The aim of the present study was to examine the effect of new phosphodiesterase type 5 inhibitor vardenafil on endothelial function of cavernous and brachial arteries in healthy men and in patients with different forms of erectile dysfunction (ED). This prospective, double-blind, placebo-controlled study was performed on 135 men with ED and 30 healthy controls. Complex evaluation was performed in all patients with ED. All participants also underwent our modification of ultrasound (US) assessment of postocclusive changes in the diameter of cavernosal arteries and endothelium-dependent flow-mediated dilation (FMD) of the brachial artery before and 1 h after administration of 20 mg of vardenafil or placebo. After study drug administration, PICAD and FMD significantly increased in patients receiving vardenafil (P < 0.001) but not in patients receiving placebo. Increase in PICAD values was significantly greater in patients with arteriogenic ED compared with patients with organic nonarterial ED (P = 0.007), psychogenic ED (P < 0.001) and controls (P = 0.001). The most prominent increase in brachial artery FMD values were found in patients with arteriogenic ED, although statistically significant differences were present only between patients with arteriogenic ED and control group (P = 0.035). We have found a moderate negative correlation between initial PICAD and its increase after vardenafil and between pretreatment flow-mediated vasodilation of brachial arteries and its increase after vardenafil administration (r = -0.57 and -0.55, respectively). These findings suggest that the use of vardenafil restores impaired endothelial function of cavernous and brachial arteries.

Role of penile vascular insufficiency in erectile dysfunction in renal transplant recipients.

The objectives of this study were to define the role and haemodynamic features of penile vascular insufficiency in impotent renal transplant recipients (RTR) as well as to establish the possible vascular risk factors for impotence in these patients. A total of 54 RTR (35 impotent and 19 potent) and 21 potent healthy subjects were included in this study. All patients were assessed clinically and by measurement of serum creatinine, serum bilirubin, cyclosporine blood levels, haemoglobin and total serum cholesterol. All subjects were subjected to intracavernous injection of 20 microg prostaglandin E1 followed by colour Duplex sonographic examination. Our results showed that impotent RTR were significantly more likely than potent RTR to have hypertension, diabetes and hypercholesterolaemia (P<0.05). Arterial occlusive disease was identified in 42.9% of impotent RTR. Findings suggestive of veno-occlusive dysfunction were found in 68.6% and 26.3% of impotent and potent RTR, respectively (P=0.003). Unilateral ligation of the internal iliac artery has a negative role on haemodynamic parameters compared to unilateral end-to-side anastomosis to external iliac artery in impotent RTR (P<0.05). Impotent RTR receiving more than one antihypertensive drug showed significant decrease in basal peak systolic velocity (PSV), dynamic PSV, erectile angle and cavernosal artery diameter compared to those receiving one drug (P<0.05). In conclusion, penile vascular insufficiency appears to play a substantial role in the pathogenesis of impotence in transplant patients. Anastomosis of the graft to external iliac artery could preserve the potency to some degree. Antihypertensives should be reduced as much as possible to avoid their negative effects on erectile function.

Velocity and Flow Volume Gradients along the Cavernosal Artery: A Duplex and Color Doppler Sonography Study

Duplex and color Doppler sonography were used to assess 130 impotent patients and 8 potent controls. Cavernosal artery diameter, peak flow velocity and volume flow rate were evaluated at the level of the crura of the corpora cavernosa and 1 cm proximal to the corona penis. Potent controls and nonarteriogenic impotent patients showed a 20% reduction in hemodynamic parameters at the periphery of the cavernosal arterial tree. In patients with occlusive disease, involving either the upper arterial tree or the entire course of the cavernosal artery, the gradient was maintained. In patients with selective occlusive disease of the distal segment of the cavernosal artery the hemodynamic gradient almost doubled. Hemodynamic gradients can be identified along the cavernosal artery and provide additional information to arteriographic data for the selection of candidates for penile vascular reconstructive surgery.