Cavernosal Artery Research Articles

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.

Color Doppler flow imaging diagnosis and treatment selection for erectile dysfunction.

Targeted therapy for erectile dysfunction (ED) involves fewer screening tests and provides a variety of treatment choices for patients. Although the advantage of targeted therapy in diagnosis and therapy for ED has been recognized, the rational mode for oriented ED therapy has not been established. This study aimed to investigate targeted diagnosis and therapy for ED. A total of 198 patients with ED were included in the study. After intracavernosal vasoactive agent injection was given, color Doppler flow imaging was performed and penile rigidity was classified as Schramek grade 5 (10 minutes duration), grade 4 (10 minutes duration), grade 3 and grade 2, defining four patient groups as group V (143 cases), group IV (23 cases), group III (18 cases), and group II (14 cases). Appropriate and acceptable treatment was recommended to patients according to erection grade. In 198 patients with ED, the peak systolic velocity, end diastolic velocity, and resistance index in the cavernosal artery and dorsal artery and the flow velocity in the deep dorsal vein were not significantly different before injection (P > 0.05). After injection, peak systolic velocity, end diastolic velocity, and resistance index in the cavernosal artery were different among the four groups (P < 0.05). Between each two groups, the difference in resistance index was significant (P < 0.05). The statistical differences in other indexes were not significant (P > 0.05). Selective targeted therapy based on erection grade by color Doppler flow imaging improved the clinical satisfaction rate to 91.91% (182/198). Based on the routine diagnosis of ED, blood flow indexes in the cavernosal artery are measured by color Doppler flow imaging following minimally invasive intercavernosal injection, which is combined with the Schramek grade of erection. The most appropriate and acceptable treatment is recommended according to the different groups, which improves the clinical satisfaction of treatment for ED and is an ideal model of targeted diagnosis and treatment.

Brachial artery flow mediated assessment: A tool to predict the response to chronic PDE5 inhibition with tadalafil in patients with erectile dysfunction

Subjects, n 26 11 15 Age, years 60.9±9.6 59.4±10.7 62.0±8.9 BMI 26,5±3,5 26±3,5 26,9±3,5 HB1c 6,8±1,7 5,6±0,3 7,6±1,9 Smoking history 11/26 2/11 9/15 Comorbidities Diabetes, % 6/26 0/11 6/15 Hypertension, % 3/26 0/11 3/15 Diabetes+hypertension 6/26 0/11 6/15 ⁎ Corresponding author. Andrology, San Paolo Hospital, University of Milano, Via A. di Rudini, 8 20142 Milano, Italy. E-mail address: mancinis178@msn.com (M. Mancini). Impairment of cavernosal arteries responsiveness is the most common cause of erectile dysfunction (ED) whose pathogenesis primarily depends on vascular endothelial dysfunction [1]. Atherosclerotic risk factors increase the rate of ED and most male patients with angiographically documented coronary artery disease (CAD) exhibit ED [2]. Endothelial injury is a basic step in the development of artheriosclerosis and its in-vivo evaluation by brachial artery flow mediated dilatation (BAD) technique provides relevant clinical and prognostic information [3]. Phosphodiesterase 5 inhibition (PDE5i) is an effective strategy for ED improvement which improves BAD response in both ED and non-ED patients [4,5]. It is undefined whether different pretreatment endothelial BAD patterns may predict the ED response to chronic PDE5i therapy. 26 impotent patients with no previous cardiovascular events diagnosed by IIEF questionnaire (questions 1, 2, 3, 4, 5, and 15) were enrolled and grouped according to absence (group A; n=11) or coexistence of hypertension and diabetes comorbidities (group B; n=15, n=6 with diabetes n=3 with hypertension, n=6 with diabetes and hypertension). All underwent brachial artery flowmediated evaluation (high resolution ultrasound Philips 11 MHz linear-array transducer) with measures of BAD and hyperemic (HYP) response [6], penile Duplex Ultrasound (DS) cavernosal peak systolic velocity (PSV) measure [7], and IIEF questionnaire evaluation before and after PDE5i treatment with tadalafil 10 mg on alternate days for 30 days. Differenceswithin group A and between group A and Bwere tested by ANOVA analysis and paired and unpaired Student t-test when appropriate. Linear regression analysis with least square method was used to correlate delta PSV with delta BAD and HYP. Populations were similar in terms of age, BMI, HB1c, and smoking history (Table 1). In all patients, a trend but not statistically significant increase in PSV (p=0.08) after tadalafil was observed while IIEF increased significantly (pb0.01) (Table 2). Significant differences in the BAD response were observed between group A and group B before and after treatment, even though tadalafil did not cause significant BAD improvement in both populations. Conversely, group A exhibited a significantly greater HYP response both at preand post-tadalafil treatment (Table 3). Post-tadalafil HYP response was significantly increased just in group A. After disease distribution a significant correlation between delta PSV and delta HYP was found in group A unless group B (Fig. 1A and B, r=0.677; p=0.022 and r=0.24; p=NS). The major finding of our study is that BAD may be a helpful screening technique in the identification of impotent patients that very likely may or may not get a hemodynamic advantage from midterm PDE5i treatment with tadalafil at current doses. Our observation provides a rationale for systematically using PSV evaluation in combination with BAD in the management of ED patients. In populations with variable degrees of cardiovascular risk, brachial ultrasound assessment has emerged as a strong and independent predictor of cardiovascular morbidity and mortality [3]. In this regard, changes in arterial diameter are considered more reliable than changes in flow. This because variations in flow reflect those in forearm microcirculation and brachial artery occlusion may still induce some degree of responsiveness to post-ischemic reperfusion stimuli even when the lumen of brachial conduit artery does not change significantly. In the present study no correlation was observed between changes in BAD and PSV. Conversely, brachial artery HYP response correlated with changes in PSV, at least in ED patients without hypertension and/ or diabetes. Remarkably, this seems to reflect a behavior similar to that observed at penile microcirculatory level and support the idea that in the initial stages of a penile arterial disease, a reduced PSVmay arise from an impaired microcirculation reactivity rather than from a real atherosclerotic process. Major study limitations are the small number of patients investigated, especially when considering the subset with comorbid conditions such as diabetes or hypertension and the lack of a followup period with PDE5i drug withdrawal. In conclusion, a preserved reactivity at brachial artery level in the absence of comorbid conditions predicts a favorable response at penile microcirculatory level to standard doses of PDE5i treatment. This study was supported by funds provided by the Monzino Foundation, Milano-Italy. The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [8].

Posttraumatic high-flow priapism in children treated with autologous blood clot embolization: long-term results and review of the literature

Usually high-flow priapism is caused by perineal or penile blunt trauma with direct cavernosal artery injury and formation of an arterial-lacunar fistula. Rarely, cavernosal artery injury may result from penetrating trauma. Treatment of high-flow priapism is not considered an emergency because patients are at low risk for permanent complications. For this type of priapism there are several options for treatment including embolization or surgical ligation. To describe the technique of superselective transcatheter embolization with the use of autologous blood clot and to discuss the long-term results. Seven children with a mean age of 10 years suffering from high-flow priapism were treated with superselective transcatheter embolization with autologous blood clot. In all cases, colour Doppler US was performed to demonstrate increased cavernous blood flow with definitive diagnosis established by superselective arteriography. After the angiographic diagnosis, superselective transcatheter embolization of the fistula with autologous blood clot was performed during the same session. The children were followed up on a monthly basis up to 1 year with clinical findings and penile colour Doppler US examinations. After 1 year, they were followed up annually with clinical assessment only. The mean follow-up period was 6.0 years. Following embolization complete detumescence was achieved in all but one child, who was treated with a second embolization 3 d after the initial session. In addition, for one child a second session of embolization was performed due to the recurrence of partial erection during the 1 week period after the initital embolization. In both cases, complete detumescence was achieved after the second embolization, and no recurrence of priapism was observed in the follow-up period. Selective arterial embolization with autologous clot achieved treatment for high-flow priapism in this study with 100% occlusion rate with a maximum of two sessions and no signs of erectile dysfunction were observed in any of the children during long-term follow-up.

Correlation between penile cavernosal artery blood flow and retinal vascular findings in arteriogenic erectile dysfunction

Arteriogenic erectile dysfunction (ED) is a target organ disease of atherosclerosis, and therefore might be a predictor of systemic atherosclerosis. Being systemic, it might be possible to evaluate the extent of atherosclerosis from retinal vascular findings. We investigated the possible correlation between penile cavernosal artery blood flow and retinal vascular findings in patients with arteriogenic ED. Sixty patients with ED were divided according to the peak systolic velocity (PSV) in their penile cavernosal arteries into two groups; Group A included 30 patients with PSV less than 25 cm/sec, and Group B included 30 patients with PSV more than 35 cm/sec. Blood flow in the penile cavernosal artery was measured with color Doppler ultrasonography. All patients were assessed by ocular fundus examination under amydriatic conditions to evaluate retinal vascular atherosclerotic changes using Hyman's classification. Evidence of retinal vascular atherosclerotic changes was found in 19 patients (63.3%) in Group A and in 10 patients (33.3%) in Group B. Our study confirms the possibility of predicting penile arterial vascular status in patients with ED from their retinal vascular findings by using amydriatic simple, practical funduscopy.

ORIGINAL RESEARCH—ERECTILE DYSFUNCTION: Evaluation of Microalbuminuria in Patients with Erectile Dysfunction

ABSTRACTIntroductionThe recent sophisticated diagnostic procedures aimed at identifying the exact cause of erectile dysfunction (ED) are often complicated in clinical application, invasive, or highly expensive. Microalbuminuria, a test easy to perform and of low cost, is a marker of extensive endothelial dysfunction, and it has been suggested to be linked to ED.AimThe aim of this study was to investigate the eventual role of microalbuminuria in differentiating patients with arteriogenic and non arteriogenic ED.MethodsThe diagnosis of ED was based on the International Index of Erectile Function 5-questionnaire, and patients were classified as arteriogenic (N=29) and non-arteriogenic (N=49) in relation to the results of echo-color-doppler examination of cavernosal arteries in basal conditions and after intracavernous injection of 10 µg prostaglandin E1.Main Outcome MeasuresThe microalbuminuria of 78 males without the most common atheriosclerotic risks and with ED was measured.ResultsMicroalbuminuria, defined as urinary albumin/creatinine ratio, was not significantly (P &amp;gt; 0.05) different between patients of the two groups.ConclusionsOur data show that in ED patients the cavernosal arteries damage, as assessed by dynamic echo-color-doppler, may be independent on or precede extensive endothelial dysfunction, and that microalbuminuria cannot be predictive of penile arteriogenic etiology.

Penile Embryology and Anatomy

Knowledge of penile embryology and anatomy is essential to any pediatric urologist in order to fully understand and treat congenital anomalies. Sex differentiation of the external genitalia occurs between the 7and 17 weeks of gestation. The Y chromosome initiates male differentiation through the SRY gene, which triggers testicular development. Under the influence of androgens produced by the testes, external genitalia then develop into the penis and scrotum. Dorsal nerves supply penile skin sensation and lie within Buck's fascia. These nerves are notably absent at the 12 o'clock position. Perineal nerves supply skin sensation to the ventral shaft skin and frenulum. Cavernosal nerves lie within the corpora cavernosa and are responsible for sexual function. Paired cavernosal, dorsal, and bulbourethral arteries have extensive anastomotic connections. During erection, the cavernosal artery causes engorgement of the cavernosa, while the deep dorsal artery leads to glans enlargement. The majority of venous drainage occurs through a single, deep dorsal vein into which multiple emissary veins from the corpora and circumflex veins from the spongiosum drain. The corpora cavernosa and spongiosum are all made of spongy erectile tissue. Buck's fascia circumferentially envelops all three structures, splitting into two leaves ventrally at the spongiosum. The male urethra is composed of six parts: bladder neck, prostatic, membranous, bulbous, penile, and fossa navicularis. The urethra receives its blood supply from both proximal and distal directions.

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.

Comparison of one-side and bilateral intracavernosal papaverine injection on a Doppler study of the penis

Intracavernosal injection of a vasodilating agent, followed by color Doppler ultrasonography of the penis, is used to diagnose vascular impotence. The vasodilating agent is usually injected into one of the corpora cavernosa and the peak systolic velocity (PSV) of the cavernosal arteries is measured on both sides, presuming that the connection between the two cavernosal bodies will distribute the drug uniformly on both sides and will consequently affect the cavernosal arteries and sinusoids equally. According to our experience, the PSV of the injection side is higher than that of the contralateral side. This difference could affect the results of the evaluation. In this study, our objective was to compare the results of both-side injections with those of one-side injection. A total number of 60 patients with a normal Doppler study of the penis were enrolled in the study and were randomly divided into three groups. In the first and second group, 60 mg papaverine was injected into the right and left corpus cavernosa each. In the third group, half of the dose was injected into each side. The mean maximum PSV was measured and compared in each group. The mean maximum PSV in the group with the right-side injection was 47.7+/-10.8 and 40.3+/-9.2 on the right and left side, respectively. The mean maximum PSV in the group with the left side injection was 44.4+/-7.1 and 51.4+/-7.1 on the right and the left side, respectively. The mean maximum PSV in the group with bilateral injection was 47+/-9.9 on the right side and 46.7+/-10.7 on the left side. In the first two groups, there was significant difference between the mean maximum PSV of the right and left cavernosal arteries, but in the third group, there was no significant difference between the mean maximum PSV of both side cavernosal arteries. Injecting papaverine in only one corpus cavernosum, despite a perfect postinjection manipulation of the penis, will affect the sinusoids and cavernosal artery at the same side of the injection more than the contralateral side. This results in a higher increase in the blood flow and PSV on that side and results in an artifactual difference between the velocity of the right and left side, which could ultimately exaggerate or mask the actual difference between the two sides. Dividing the total dose of the vasodilating agent and injecting half of the dose into each corpus cavernosum separately prevents artifactual difference between blood flow and velocity on the right and left side.

ORIGINAL RESEARCH–SURGERY: Treatment of Penile Deep Dorsal Venous Leakage of Erectile Dysfunction by Embedding the Deep Dorsal Vein of the Penis: A Single Center Experience with 17 Patients

The common surgery for venous leakage was not very successful; unsatisfactory long-term results have reduced the indications for venous surgery for erectile dysfunction (ED). To assess the outcomes of embedding the deep dorsal vein of the penis (EDDVP), a new surgical technique used in patients with penile deep dorsal venous leakage of ED. Between December 2001 and November 2007, 17 patients diagnosed with penile deep dorsal venous leakage of ED underwent embedding the deep dorsal vein of the penis. All cases were available for follow up by using the abridged 5-item version of the International Index of Erectile Function (IIEF-5) scoring system and penile color Doppler ultrasound. Dynamic cavernosography were also assessed in three patients at 3 months postoperatively. After surgery, 14 patients were able to achieve satisfactory intercourse and three had sufficient erection after oral sildenafil (50-100 mg). The IIEF-5 scoring changed from a preoperative mean IIEF-5 score of 8.8 +/- 3.9 to 20.8 +/- 4.1 (P < 0.05). Peak systolic velocity (average of right and left cavernosal arteries) changed from 41.9 +/- 7.7 cm/second to 44.2 +/- 9.2 cm/second (P > 0.05), resistance index changed from 0.79 +/- 0.1 to 1.00 +/- 0.0 (P < 0.05), and venous velocity changed from 8.4 +/- 4.0 cm/second to 0.0 +/- 0.0 cm/second (P < 0.05). Dynamic cavernosography demonstrated a smooth flow of the deep dorsal vein during the flaccid phase. During the tumescent phase, the deep dorsal vein of the penis was compressed between the dilated sinusoidal spaces and the tunica albuginea and resulted in venous drainage blockade. And then the hardness of erection was improved and maintained. The new surgical technique of EDDVP is a simple operative procedure, which seems to be efficient in the treatment of penile deep dorsal venous leakage of ED.

Targeting Vascular Structure for the Treatment of Sexual Dysfunction

Erectile dysfunction (ED) and cardiovascular disease often coexist and have many common risk factors. In hypertension, the structure of blood vessels is modified such that there is an increase in medial wall thickness relative to lumen size. Certain antihypertensive agents have been found to induce a regression of vascular structure such that a "hypertensive" vessel appears phenotypically more like that from a normotensive. To provide an update on the findings to date on the impact of vascular remodeling on erectile function. Review of peer reviewed literature related to vascular remodeling induced by antihypertensive agents and the potential impact on sexual function. A literature review was performed on clinical and experimental evidence regarding the association between cardiovascular disease and ED, the impact of vascular remodeling on these conditions, the impact of antihypertensive therapy on ED, and the mechanisms of antihypertensive drug-induced remodeling. There is increasing evidence that ED may be an early marker for progressing cardiovascular disease. Certain antihypertensive agents have beneficial effects on both vascular structure and erectile function. The major site of resistance in the penile vasculature occurs at the level of the pudendal artery. Although structural remodeling has not yet been investigated in this vessel specifically, antihypertensive drugs have been shown to induce remodeling of the pudendal-penile vasculature and cavernosal arteries. Antihypertensive drug-induced vascular remodeling can be characterized by a decrease in the ratio of wall thickness to lumen diameter, and may result from vascular smooth muscle cell apoptosis, rearrangement of cells around a smaller lumen, and/or changes in the extracellular matrix composition depending on the vessel type. Determining the mechanisms involved in antihypertensive drug-induced vascular remodeling in the pudendal vasculature may provide novel targets for the treatment of ED.

Vasculogenic Erectile Dysfunction Is a Predictor of Abnormal Stress Echocardiography

Erectile dysfunction (ED) and atherosclerotic vascular disease have the same risk factors; furthermore, endothelial dysfunction has been shown to be a common link between these conditions. A high prevalence of silent coronary artery disease (CAD) in patients with ED has been observed. The aims of this article were to define the prevalence and identify predictors of occult obstructive CAD in patients with documented vasculogenic ED. Duplex Doppler penile ultrasonography (DUS); exercise stress echocardiography; IIEF; CAD risk factors. Methods. Patients presenting with ED who had penile vascular insufficiency documented by DUS and who had no history of diabetes or symptoms of CAD were prospectively enrolled for noninvasive cardiac stress testing using exercise stress echocardiography. Forty-nine men (mean age 517 years) with an average duration of ED of 2.52 years were evaluated. Penile arterial insufficiency was present in 94%, and venous leak in 20% of patients. Comorbidities included hypertension (51%), hyperlipidemia (41%), and smoking (35%). All patients had at least one vascular risk factor, with 40% having two, 15% three, and 15% four risk factors. Ten patients (20%) had abnormal cardiac stress test. On univariate analysis, age, IIEF-EF domain score, cavernosal artery insufficiency, presence of venous leak, and history of a first-degree relative with CAD were significant predictors. On multivariate analysis, cavernosal artery insufficiency, venous leak, and family history of CAD continued to be predictors of an abnormal stress test. A significant proportion of men with vasculogenic ED have abnormal cardiac stress test. The greatest chance for abnormal cardiac stress test was observed in those with corporo-venocclusive dysfunction or family history of CAD. In some men presenting with ED, even without a CAD history, performing penile DUS or cardiology referral for stress testing should be considered.

Predictive value of cavernosal peak systolic velocity in the flaccid penis

The routine use of intracavernosal injection before Doppler investigation may cause time loss, side effects due to vasoactive agents used and incorrect evaluation in the diagnosis of arterial insufficiency because of psychological inhibition and anxiety. Doppler investigation without intracavernosal injection avoids these pronounced disadvantages. In our study we tried to evaluate whether PSV values prior to intracavernosal injection are predictive in the diagnosis of arterial insufficiency in diabetic and non-diabetic cases. 120 male diabetic (type-2) and non-diabetic patients affected by erectile dysfunction (ED) were enrolled in this study. The Doppler parameters - PSV, end diastolic velocity (EDV) of both cavernosal arteries - were recorded before intracavernosal injection (ICI) (60 mg-2 ml-papaverine hydrochloride (HCl)) and 5, 10 and 30 minutes after ICI into corpus cavernosum. Based on our results we chose 2 cut-off values for the pre-ICI PSV-10 cm/sec and 15 cm/sec. A PSV value less than 25 cm/sec after ICI was used as the diagnostic criteria for arterial insufficiency. We calculated the sensitivity, specificity, positive and negative predictive value of pre-ICI PSV in predicting arteriogenic impotence as diagnosed by post-ICI Doppler sonography. Only type 2 DM patients were included in our study. Statistically significant differences were found in the PSV values before and after ICI, ICI response and EDV values after ICI in both cavernous arteries when diabetic and nondiabetic groups compared. Flow in the cavernosal arteries in the flaccid state could determine nondiabetic patients with vasculogenic impotence with a high accuracy rate.

ORIGINAL RESEARCH—ERECTILE DYSFUNCTION: Penile Doppler Ultrasound in Patients with Erectile Dysfunction (ED): Role of Peak Systolic Velocity Measured in the Flaccid State in Predicting Arteriogenic ED and Silent Coronary Artery Disease

The use of the penile peak systolic velocity (PSV) measured in the flaccid state during penile color Doppler ultrasound (PCDU) examination has been questioned without substantial evidence. To assess the validity of PSV measured in the flaccid state during PCDU, in patients consulting for erectile dysfunction (ED). A consecutive series of 1,346 (mean age 55.0 +/- 12.0 years) male patients was studied. All patients underwent PCDU performed both in the flaccid state and dynamic (after prostaglandin E1 stimulation) conditions. A subset of 20 subjects with uncomplicated type 2 diabetes underwent diagnostic testing for silent coronary heart disease by means of adenosine stress myocardial perfusion scintigraphy (SPECT). In these subjects penile arterial flow was simultaneously assessed by PCDU before and after systemic adenosine administration. Flaccid PSV showed a significant (r = 0.513, P < 0.0001) correlation with dynamic PSV. Receiver operating characteristic (ROC) curve analysis demonstrated that when a threshold of 13 cm/seconds was chosen, flaccid PSV was predictive for dynamic PSV < 25 and <35 cm/seconds with an accuracy of 89% and 82%, respectively. Among the subset of patients who underwent SPECT, an impaired coronary flow reserve (ICFR) occurred in nine cases (45%). When the same threshold of <13 cm/seconds was chosen, PSV before SPECT was predictive of ICFR with an accuracy of 80% (area under the ROC curve = 0.798 +/- 0.10; P < 0.05). After adjustment for confounders, anxiety symptoms were related to dynamic PSV (Adj. r = -0.154, P < 0.05) but not to flaccid PSV. Our results show that flow in the cavernosal arteries can be routinely evaluated by PCDU in the flaccid state. Performing PCDU only in the flaccid state allows identifying subjects with pathological dynamic PSV with accuracy higher than 80%. Furthermore, our preliminary data suggest that the same examination could identify diabetic subjects with ICFR with an accuracy of 80%.

Risk Factors for Erectile Dysfunction in Patients with Urethral Strictures Secondary to Blunt Trauma

Erectile dysfunction (ED) is a well-known consequence of pelvic fracture, particularly in cases involving urethral injury. There are several risk factors that may be related to ED. However, no systemic approach is used to assess erectile function secondary to urethral trauma. To investigate ED associated with urethral injury secondary to pelvic fracture and perineal trauma. Forty patients with traumatic urethral strictures secondary to blunt traumatic impact episode to the pelvis or perineum were included in our study. Pelvic fractures and urethral strictures were categorized according to injury types and radiological findings. All patients underwent nocturnal penile tumescence (NPT) monitoring, dynamic color-duplex Doppler ultrasonography (D-CDDU) before surgery. NPT monitoring was conducted again after surgery. The events of NPT and D-CDDU were recorded. In all patients, 11 had organic ED demonstrated by NPT. Vascular pathology was identified in three of 11 patients (27%). The peak systolic velocity of cavernosal artery was lower in patients with pubic diastasis in comparison to those without diastasis (P < 0.05). Significant changes in penile length and circumference were noted in posterior urethral injury compared with anterior urethral injury during erection (P < 0.05). The erectile duration time has a similar statistical difference in two groups mentioned above. However, no significant difference could be observed in the end-to-end anatomosis procedure before and after surgery (P > 0.05). The pelvic fracture type, especially pubic diastasis, is a risk factor for ED following urethral injury. Location of the stricture is also a risk factor for subsequent erectile dysfunction.

Temporary Cavernosal–Cephalic Vein Shunt in Low-Flow Priapism Treatment

BackgroundSurgical shunting might be considered as the only option in the treatment of extended ischemic priapism that does not respond to aspiration and medication. ObjectiveA modified, simple, minimally invasive, and easily applicable artificial cavernosal–venous shunt technique for treating priapism is described in this report. Design, setting, and participantsA total of 15 patients with extended and nonresponsive low-flow priapism were treated with this technique between January 1998 and February 2007. InterventionWhen the conservative treatment of low-flow priapism does not yield the expected results, then the temporary cavernosal–cephalic vein shunt should be applied. The standard equipment required for this modified technique includes three angiocaths, two shorn blood serum sets, and saline solution with heparin. The blood in the cavernosa and the saline solution infusion are incorporated into the systemic circulation with the aid of serum sets and angiocaths. MeasurementsPriapism duration, history, causes, its relation with sexual stimulation, pain, and any prior management of priapism were assessed in all patients. A complete blood count and blood gases assessment were conducted in corporal aspirates, and duplex penile ultrasonography was performed, which showed attenuated blood flow in the cavernosal artery. Results and limitationsThis technique was applied in 15 patients. Complete detumescence was achieved in 13. In the two cases in whom the technique did not yield the expected results, there was a need for a sapheno–cavernosal shunt. These patients later complained of erectile dysfunction and penile pain that continued for 6 mo. Of the 13 patients in whom detumescence was achieved, 3 reported erectile dysfunction according to International Index of Erectile Function (IIEF) scores at the 12-mo follow-up. ConclusionsArtificial cavernosal–cephalic vein shunt in the treatment of priapism is simple, safe, effective, easily applicable, and warrants primary consideration when the second-line treatment of priapism is initiated.

Why a combined intracavernosal injection with trimix and oral sildenafil is reliable therapy in the ultrasonographic evaluation of erectile dysfunction

To evaluate prospectively and compare the clinical response and the change in nucleotides correlating with haemodynamic changes in the cavernosal arteries after an intracavernosal injection (ICI) with vasoactive agents with or without oral sildenafil in men with erectile dysfunction (ED). In all, 80 patients with ED were prospectively evaluated by clinical assessments, measuring nucleotides in blood plasma and haemodynamics in cavernosal arteries. All patients had colour Doppler ultrasonography (CDU) twice with an interval of 5 h. First, each patient had CDU after ICI with trimix (0.25 mL) or prostaglandin E1 (PGE1, 5 microg), and the second CDU was after ICI trimix given 1 h after oral placebo (group I), sildenafil 25 mg (group II) or 100 mg (group III) and after ICI with PGE1 at 1 h after oral placebo (group IV) or 100 mg sildenafil (group V). Levels of cGMP and cAMP in peripheral venous and penile cavernosal blood plasma were measured at 15 min after ICI. The mean peak systolic velocity (PSV) at 5, 10, 15 min, and resistive index at 10 min in the second CDU after ICI with trimix, were significantly increased in group III. The mean (sem) levels of cavernosal cGMP were significantly increased in group III and V, from 1130.1 (313.5) to 2056.7 (580.4) and 1017.0 (214.2) to 1905.2 (915.0) fmol/mL, respectively. cAMP was significantly increased in group V, from 9533.1 (2068.4) to 12150 (3684.2) fmol/mL. The haemodynamic changes and cGMP and cAMP production in the cavernosum were improved by trimix plus sildenafil more than with than PGE1 plus sildenafil or one ICI with trimix or PGE1. The results suggest that ICI with trimix and sildenafil is the best combination for a pharmacological erection test.

Darstellung von Penisgefäßanastomosen mittels farbkodierter Doppler-Sonographie: Vergleich mit CW-Dopplersonographie und Klinik

In fourteen patients undergoing surgical revascularization (11 with Hauri's, three with Virag's anastomosis) because of erectile dysfunction, the patency of vascular anastomosis was evaluated and visualized by color-coded-Doppler sonography (CCDS). Results were compared with continuous-wave Doppler (CWD) and clinical data. CCDS proved to be superior to CWD with regard to assessment of flow in the penile vessels and to applicability. Strength and direction of flow can be judged visually. Therefore, the nature of the imaged vessel (artery or vein, deep or dorsal artery) can be differentiated. There is a good correlation of CCDS and CWD in their evaluation of the patency of the anastomosis. CCDS showed higher accuracy in detecting deep cavernosal arteries.

Pathogenetic aspects of erectile dysfunction in patients with the metabolic syndrome

Background Although it is well known that the metabolic syndrome is a common cause of erectile dysfunction (ED) the pathogenesis of the latter in this group of patients is poorly understood. The present study aimed to improve our knowledge in this area. Methods The study included 385 men with ED (control group) who underwent a full evaluation, including laboratory and ultrasound assessment of endothelial function. Results The full complex evaluation showed that arteriogenic impairment in the cavernosal circulation was the primary pathogenic factor for ED in patients with the metabolic syndrome. The ultrasound-assisted measurement of postocclusive changes in the diameter of the cavernosal arteries, which reflects the local endothelial function, was the most valuable method in the diagnosis of this form of ED. In addition, a considerable number of patients with the metabolic syndrome demonstrated both hormonal and neurological disorders which also contribute to the pathogenesis of ED in this cohort of men. Conclusion The pathogenesis of ED in patients with the metabolic syndrome is multifactorial in nature: ED is primarily caused by arteriogenic disorders which are combined with neuropathic disorders in almost every second patient and with hormonal factors in every third one. In addition, psychomotor status has an impact on the development of ED in patients with metabolic syndrome.

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.