Cavernous Blood Flow Research Articles

Assessment of the treatment effectiveness of men with mild and medium degree of erectile dysfunction.

. Aim: To assess the effectiveness of monotherapy and complex treatment of patients with erectile dysfunction depending on its severity. Materials and Methods: Men with moderate and mild erectile dysfunction took part in the study, who, in turn, were divided into groups, depending on the treatment, with the evaluation of the results of the International Index of Erectile Function (MIEF-15), the state of cavernous hemodynamics and the function of the vascular endothelium before and after treatment. Results: In patients with an average degree of severity, who received complex treatment including a course of low-energy shock wave therapy, against the background of taking sildenafil and L-arginine, the best results were obtained in the quality of erection and increased cavernous blood flow, which positively affected satisfaction with sexual intercourse and overall satisfaction. It has also been proven that the function of the endothelium was improved in patients receiving L-arginine, due to which there was a probable decrease in endothelin-1. A probable improvement of erectile function was obtained in the group of patients with a mild degree who received L-arginine, and there was no statistical difference from the indicators in the group who received sildenafil, which was confirmed by the data of dopplerography. Conclusions: Patients with an average degree of erectile dysfunction require comprehensive treatment. The use of L-arginine can be an alternative to phosphodiesterase type 5 inhibitors in the treatment of mild erectile dysfunction.

Penile implants in low flow priapism.

Priapism is a persistent or prolonged erection, in the absence of sexual stimulation, that fails to subside. Prolonged ischaemic or low flow priapism is defined as a full or partial erection persisting for more than 4 h and unrelated to sexual interest or stimulation, characterised by little or no cavernous blood flow. Low flow priapism leads to progressive corporal fibrosis, which could, in turn, lead to long-lasting erectile dysfunction if left untreated. Penile prosthesis implantation is recognised as a management option in refractory and delayed low flow priapism for restoring erectile function with high patient satisfaction rates. However, the ensuing corporal fibrotic scarring poses a surgical challenge to clinicians, given the higher complication rates in this patient subset. Postoperative patient satisfaction has been closely linked to preoperative expectations and perceived loss of penile length. Therefore, thorough patient counselling concerning the risk and benefits of penile implants should be a priority for all clinicians. Moreover, there is a lack of consensus on the ideal prosthesis choice and procedural timing in refractory low flow priapism. In this review, we will examine the existing literature on penile implants in patients with priapism and discuss the options for managing complications associated with penile prosthesis surgery.

Priapism managed with anti-platelets after failed shunting

Priapism is a non-sexual, persistent erection characterized by little or no cavernous blood flow and abnormal cavernous blood gases [1].

A Comprehensive Approach in the Treatment of Erectile Dysfunction in Obesity Patients

As early as in the middle of the twentieth century, obesity became one of the most important medical and social problems in the world, especially among the population of developed countries due to its high prevalence and the enormous cost of overcoming its consequences. One of the complications of obesity is sexual dysfunction in men. The objective: to evaluate the effectiveness of udenafil in the form of 200 mg tablets in the treatment of erectile dysfunction in obese patients. Materials and methods. The clinical efficacy of udenafil PDE-5 inhibitor in 125 patients with ED and obesity was studied. The mean age of the patients was 47.4±6.7 years. When dividing patients into groups in order to objectively assess the results of different types of therapy, the groups were homogeneous in age, severity of obesity and ED, and then randomized patients into groups. Group I included 37 patients with ED and obesity who received therapy to normalize erectile function (healthy lifestyle, modification of individual risk factors, local negative pressure therapy, phosphodiesterase type 5 inhibitor udenafil) and obesity treatment aimed at weight loss; diet therapy, physical therapy, pharmacotherapy according to the indications, adequate level of physical activity). Group II – 56 patients with ED and obesity who received similar therapy to normalize erections. Group III 32 patients with ED and obesity treated with obesity without the use of phosphodiesterase type 5 inhibitors. The follow-up was 12 weeks. Criteria for assessing the clinical effectiveness of treatment: the dynamics of the International Erectile Function Index (ICEF). The diagnosis of ED was established by the total of points in the answers to questions 1–5, 15; which is 26 or less. The severity was assessed as severe – 1–10 points, moderate – 11–16 points, mild – 17–25 points; assessment of changes in cavernous hemodynamics according to Doppler data of cavernous vessels; assessment of body mass index and waist circumference; dynamics of lipid parameters (total cholesterol, triglycerides and atherogenic factor); dynamics of hormonal background indicators (testosterone, estradiol, LH, FSH, prolactin); Characteristics of the rate of onset of the effect of maximum erection and duration of action of udenafil. Statistical data processing was performed using the application package Statistica for Windows v. 6.0. Results. After 3 months, the following results were obtained. In group I, the average total ICEF score (questions 1–5, 15) increased from 17.3±3.8 to 26.7±5.3 points, ie 1.54 times (p<0.05). In group II – increased 1.33 times – from 16.4±3.2 to 21.8±4.6 points (p<0.05). In the third group – increased from 15.8±2.7 to 17.9±3.8 points, ie 1.13 times (p>0.05). BMI decreased in group I from 38.7±4.7 kg/m2 to 35.3±3.8 kg/m2 (p>0.05); in the second group of patients – from 36.4±4.3 kg/m2 to 35.0±3.9 kg/m2 (p>0.05); in group III BMI also did not undergo significant changes. (decrease from 36.4±4.3 kg/m2 to 32.4±3.4 kg/m2) (p>0.05) As a result of treatment, the indicators of total cholesterol, triglycerides, atherogenic coefficient and HDL levels improved, especially in patients of groups I and III, but they did not acquire signs of reliability. The increase in testosterone levels also did not achieve a statistically significant difference. In the study of cavernous blood flow, peak systolic velocity increased from 24.3±2.2 cm/s to 32.3±2.6 cm/s in the penis during erection (1.5-fold increase) in patients of the first group. p<0.05). In patients of the second and third groups, respectively, from 21.7±2.5 cm/s to 28.8±2.8 cm/s (p<0.05) and from 23.2±2.2 cm/s to 24,3±2.1 cm/s (p>0.05). Conclusions. According to the patients from the first and second groups taking udenafil, 74 (79.6%) of 93 patients rated the effectiveness of the drug as «excellent», 12 (12.9%) of 93 patients as «good», 4 (4.3%) as «satisfactory». The final evaluation of the effectiveness of therapy revealed «excellent» and «good» results in 95.7% of patients. Changes of indicators such as BMI, total cholesterol, triglycerides and atherogenic factor, testosterone levels, did not achieve a statistically significant difference because the observation period was too short. Udenafil can be considered a first-line drug in the treatment of erectile dysfunction in obese patients.

Application of laser speckle blood perfusion imaging in the evaluation of erectile function in rats.

Intracavernosal pressure measurement is the gold standard for evaluating erectile function in experimental animals, but it has the shortcoming of being invasive. This study aimed to explore the application of laser speckle perfusion imaging in evaluating erectile function in rats. Sixty Sprague Dawley rats were randomly divided into the sham operation and model groups (n=30 each). A rat model of neuroinjury erectile dysfunction was established by surgically damaging the bilateral cavernous nerves in the model group. Simulated surgery was performed in the sham operation group; the nerves were not damaged. Erectile function was evaluated by comparing the changes in intracavernosal pressure and blood flow fluctuations when the cavernous nerve was stimulated using the same voltage parameters. Intracavernosal pressure in the model group was significantly lower than that in the other group when using 2.5V. No significant difference was found in cavernous blood flow fluctuation between the two groups when using 0.5V. Cavernous blood flow fluctuation in the model group after 2.5V, 5V and 7.5V stimulations was significantly lower than that in the sham operation group. Evaluating erectile function in rats is feasible by measuring the cavernous blood flow using laser speckle perfusion imaging.

Study of the Efficiency of Using Type 5 Phosphodiesterase Inhibitors in the Therapy of Ereсtile Dysfunction in Patients with Metabolic Syndrome

Metabolic syndrome is a symptom complex that combines abdominal obesity, insulin resistance, hyperglycemia, dyslipidemia and arterial hypertension. One of the complications of metabolic syndrome is sexual dysfunction in men. The objective: is to evaluate the efficacy and tolerability of udenafil 200 mg in the treatment of erectile dysfunction in patients with metabolic syndrome. Materials and methods. The clinical efficacy of the IV generation PDE-5 inhibitor medicine udenafil in 76 patients with erectile dysfunction of mixed origin and with metabolic syndrome in dynamics was studied. The average age was 51,6±8,2 years. The observation period was 12 weeks, but the control of metabolic syndrome parameters (anthropometry, review, biochemical blood tests) and the assessment of erectile function were carried out for 6 months. Results. After 12 weeks, patients achieved positive results in weight loss, BMI and waist circumference, although not significantly. It is necessary to note the positive changes in the indicators of the cardiovascular system. The downward trend was demonstrated by such indicators as heart. Diet therapy and taking statins have improved the indicators of fat metabolism. Correction of metabolic disorders in patients was accompanied by an increase in total and free testosterone. However, there was no statistically significant difference in the degree of increase in the concentration of androgens. Correction of metabolic disorders in patients was accompanied by an increase in total and free testosterone. During treatment, almost all integrative indices of IIEF increased. Specifically, the index «erectile function» improved 2,26 times (p<0,01), «satisfaction with intercourse» 2,59 times (p<0,001), «orgasm» 2,0 times (p<0,01), «libido» – 2,9 times (p<0,001), «general satisfaction» 2,3 times (p<0,01). According to various indicators, the sexual function of men with metabolic syndrome and erectile dysfunction improved 2–2,9 times. Changes in cavernous blood flow on Doppler ultrasonography showed an increase in peak systolic blood flow rate by 1,5 times, which is associated with the udenafil half-life. Our data indicate that the use of the medicine udenafil is perspective in men with erectile dysfunction and metabolic syndrome and in those who do not have stable family-sexual relations to ensure spontaneity of sexual relations. Conclusions. Udenafil can be considered as a first-line medecine in the treatment of erectile dysfunction in patients with metabolic syndrome.

Acute Ischemic Priapism: An AUA/SMSNA Guideline.

Priapism is a persistent penile erection that continues hours beyond, or is unrelated to, sexual stimulation and results in a prolonged and uncontrolled erection. Given its time-dependent and progressive nature, priapism is a situation that both urologists and emergency medicine practitioners must be familiar with and comfortable managing. Acute ischemic priapism, characterized by little or no cavernous blood flow and abnormal cavernous blood gases (ie, hypoxic, hypercarbic, acidotic) represents a medical emergency and may lead to cavernosal fibrosis and subsequent erectile dysfunction. A comprehensive search of the literature was performed by Emergency Care Research Institute for articles published between January 1, 1960 and May 1, 2020. Searches identified 2948 potentially relevant articles, and 2516 of these were excluded at the title or abstract level for not meeting inclusion criteria for any key question. Full texts for the remaining 432 articles were reviewed, and ultimately 137 unique articles were included in the report. This Guideline was developed to inform clinicians on the proper diagnosis and surgical and non-surgical treatment of patients with acute ischemic priapism. This Guideline addresses the role of imaging, adjunctive laboratory testing, early involvement of urologists when presenting to the emergency room, discussion of conservative therapies, enhanced data for patient counseling on risks of erectile dysfunction and surgical complications, specific recommendations on intracavernosal phenylephrine with or without irrigation, the inclusion of novel surgical techniques (eg, tunneling), and early penile prosthesis placement. All patients with priapism should be evaluated emergently to identify the sub-type of priapism (acute ischemic versus non-ischemic) and those with an acute ischemic event should be provided early intervention. Treatment of the acute ischemic patient must be based on patient objectives, available resources, and clinician experience. As such, a single pathway for managing the condition is oversimplified and no longer appropriate. Using a diversified approach, some men may be treated with intracavernosal injections of phenylephrine alone, others with aspiration/irrigation or distal shunting, and some may undergo non-emergent placement of a penile prosthesis.

Evaluation of Therapy Effectiveness in Men with Different Erectile Dysfunction Severity

Sexual health is an integral part of everyone’s quality of life. Sexual harmony depends on a man’s sexual desire and erectile function. The most common disorder of male sexual health is erectile dysfunction. Improving the treatment of patients with this pathology helps to improve both physical and mental health and thus improve the quality of life. The objective: the aim of the study was to evaluate the efficacy and safety of combination course therapy and monotherapy in patients with erectile dysfunction. Materials and methods. The observation included 89 men with erectile dysfunction of mixed genesis aged 25 to 50 years with mild to moderate severity. All patients were divided into three groups. The I group of 32 patients with moderate ED, received during the month in the morning Bodrex 1 sachet 60 minutes before meals and in the evening Strondex one spray into the oral cavity (12,5 mg sildenafil), regardless of the presence or absence of sexual activity in this day and an additional 30 minutes before sexual intercourse from 12,5 to 25 mg, followed by a comparative assessment of clinical results immediately after treatment in relation to a group of patients (II group – 32), also with moderate ED who received sildenafil in tablet form dose of 25 mg 1 hour before sexual intercourse, but not more often than once a day. The third group (III group – 25) of patients consisted of men with mild ED, who received during the month only Bodrex in the morning 1 sachet 60 minutes before meals, with comparing clinical data before and after treatment. Bodrex and Strondex preparations are presented on the market by the pharmaceutical company Geolik Pharm Marketing Group. Results. The use of course combination therapy (Strondex + Bodrex) in the treatment of patients with moderate ED was found to be significantly more effective than sildenafil monotherapy at a dose of 50 mg on demand before sexual intercourse, as evidenced by subjective assessment of patients and objective data. Namely, the integrative indicator «erectile function» in this group of patients improved almost twice, while in the second group of patients this indicator improved by 62,9% (p<0,05). Accordingly «оverall satisfaction" in group I patients improved 2,3 times, and in group II patients 1,8 times. Dopplerosonography of the penis in patients with moderate ED showed a probable decrease in hemodynamics in the corpora cavernosa, which indicated the presence of vascular factor with impaired vascular endothelial function (p<0,05). After treatment, a more pronounced increase in cavernous blood flow occurred in group I, namely an increase in peak systolic velocity by 69,5%, while in group II by 38,5% (p1<0,05). It was noted that the concentration of ET-1 in the serum of patients with moderate ED was 3 times higher than the average in the group of almost healthy men, which may indicate severe endothelial dysfunction (p<0,05). Accordingly, after treatment, the level of ET-1 in the blood of patients decreased in group I, who received combination therapy, by 44,2%, while in group II by 28,3% (p1<0,05). Before treatment, the majority of patients with moderate ED, namely 78,1%, could not have sexual intercourse due to insufficient erection. After treatment in 53,1% of group I patients receiving combination therapy (Strondex + Bodrex), erection was completely restored, while in group II erection was completely restored in 28,1% of patients. Also, according to the obtained data, it should be noted a significant positive dynamics of all integrative indicators of IIEF on the background of taking Bodrex in patients with mild ED (p<0,05). An increase in the baseline «erectile function» by 1,4 times, contributed to an increase in sexual satisfaction and sexual satisfaction in general by 2,3 times. The mean peak systolic rate of cavernous blood flow before treatment in this group of patients was lower compared with the control group by 21,2% (p<0,05). This indicator improved after treatment by 21,7%, and became not significantly different from this indicator in the control group of almost healthy men (p1<0,05; p2>0,05), which indicated the normalization of hemodynamics in penis. In patients with mild ED, the concentration of ET-1 in the serum was 1,7 times higher than in the control group (p<0,05). After treatment, this index decreased by 1.5 times, approaching the rate in the group of almost healthy men (p2>0,05). Before treatment in this group, no patient had a complete erection, and less than half of the patients (45,5%) had a pratial erection. After a course of treatment with Bodrex, complete erection was restored in 68,2% of patients, and a total of 86,4% of patients were able to have sexual intercourse. Conclusions. The use of combination course therapy (Strondex + Bodrex) in patients with moderate ED and course monotherapy (Bodrex) in patients with mild ED contributes to a more stable clinical effect, as evidenced by the dynamics of the data.

Algorithm for the Diagnosis and Treatment of Penile Injury

Injuries of the external genital organs in men are most often found in active age with a predominance of closed injuries and require careful implementation of the entire necessary amount of diagnostic and therapeutic measures, active surgical tactics aimed at preventing distant cavernous blood flow disturbances, the development of fibrotic changes in the cavernous tissue, protein membrane and stricture of the penile urethra.

The Case Files

FigureFigureFigureA 41-year-old man with a past medical history of bipolar disorder, PTSD, and alcohol abuse presented to the emergency department for an erection that wouldn't go away. He said his erection had persisted for 28 hours and was starting to be painful. He had taken trazodone the day before but was unable to recall the dosage. He denied any erectile dysfunction in the past when he was on trazodone a year before. Physical examination showed an uncomfortable-appearing man lying supine in bed but in no acute distress. The physical exam was normal except for the genitourinary exam, which revealed an erect penis without any visible discoloration, trauma, or tenderness. Management was started by a urologist. The patient was given local anesthesia, and phenylephrine was injected locally into each corpora. No result was observed. Then corporal aspiration with a 19-gauge needle on either side of the corpora was performed. Prior to starting the procedure, the patient's blood pressure was recorded at 144/93 mm Hg, with a hemoglobin level of 14.0 g/dl. During the procedure, he began to have chills and became tremulous and diaphoretic. His blood pressure dropped to 75/50 mm Hg and his hemoglobin level to 10.3 g/dl. He was given normal saline bolus, transfused one unit of packed red blood cells type O (Rh negative), and started on ciprofloxacin 500 mg BID. After the procedure, he continued to complain of lightheadedness, looked pale, and was shivering. His blood pressure was 80/49 mm Hg. A second 1L bolus of normal saline and a second unit of packed red blood cells were given, and his blood pressure rose to 101/65 mm Hg. After detumescence and cessation of bleeding through the penis, he was admitted to the hospital for continued observation. The patient said he did not experience adverse reactions to trazodone when he took it previously. Trazodone is an antidepressant that works by acting as a serotonin (5-HT2) inhibitor. Trazodone-induced priapism is estimated to occur in one in 1,000 to one in 10,000 patients with doses ranging from 50 to 400 mg. (J Clin Psychiatry 1990;51[10]:430.) Priapism is a persistent erection for more than four hours in the absence of sexual stimulation. A total of 32,462 cases of priapism were reported in the United States between 2006 and 2009. (J Urol 2013;190[4]:1275.) It can occur in any age group, but incidence is most common in children between 5 to 10 and adults between 20 to 50. (Postgrad Med J 2006;82[964]:89.) Low-flow priapism is associated with pain, decreased cavernous blood flow, and corporal rigidity. Risk factors include sickle cell disease or trait, medications, cocaine use, antidepressants, and total parenteral nutrition. (Urol Clin North Am 2007;34[4]:631.) Many antidepressants and antipsychotics are known to cause priapism, such as bupropion, fluoxetine, sertraline, lithium, clozapine, risperidone, olanzapine, chlorpromazine, and thioridazine. Priapism is a known but uncommon side effect of trazodone. Priapism can be divided into low-flow (ischemic) and high-flow (nonischemic) priapism. Trazodone results in low-flow priapism, which causes inadequate drainage of blood from the penis and an erect penis. Treatment of ischemic priapism can involve corporal aspiration, placement of a penile surgical shunt to establish a fistula to allow an outflow channel from corpora cavernosa and implantation of a penile prosthesis. (Blood 2015;125[23]:3551; Korean J Urol 2013;54[12]:816.) Corporal aspiration resulting in blood loss can cause hemorrhagic shock, which requires proper implementation of resuscitative strategy. Low-flow priapism requires rapid detumescence to prevent long-term effects, and it involves aspiration with intracavernous alpha agonist (phenylephrine) injection. The patient's hemoglobin level dropped from 14 mg/dL to 10 mg/dL over the course of an hour. Sudden drop in intravascular volume results in hypovolemic shock with symptoms of hypotension, tachycardia, tachypnea, cool, clammy skin, feelings of lightheadedness, and abnormal mental status. Managing hemorrhagic shock requires fluid resuscitation through crystalloid, blood transfusion, hemorrhage control, and preventing trauma-related coagulopathy. Crystalloid is used to allow for maintenance of preload, while blood transfusion helps improve tissue oxygenation. Transfusion and crystalloid help prevent the mechanisms of traumatic coagulopathy such as loss-dilution, excessive activation of coagulation, hypothermia, metabolic acidosis, and anemia. Without aggressive fluid repletion, the patient remains susceptible to tissue hypoxia, inflammation, and end-organ damage. The patient had presented with priapism, but addressing his primary complaint resulted in shifting his treatment priority to hemorrhagic shock. Hemorrhage is a major cause of preventable death after trauma, or in this case, corporal aspiration. Hemorrhagic shock limits oxygen delivery, resulting in tissues hypoxia, inflammation, and organ dysfunction.

Designed angiopoietin-1 variant, COMP-angiopoietin-1, rescues erectile function through healthy cavernous angiogenesis in a hypercholesterolemic mouse.

Despite the advent of oral phosphodiesterase-5 inhibitors, curative treatment for erectile dysfunction (ED) remains unavailable. Recently, the link between ED and cardiovascular disease was unveiled and the main etiology of ED was found to be vasculogenic. Therefore, neovascularization is a promising strategy for curing ED. Angiopoietin-1 (Ang1) is an angiogenic growth factor that promotes the generation of stable and functional vasculature. Here, we demonstrate that local delivery of the soluble, stable, and potent Ang1 variant, COMP-Ang1 gene or protein, into the penises of hypercholesterolemic mice increases cavernous angiogenesis, eNOS phosphorylation, and cGMP expression, resulting in full recovery of erectile function and cavernous blood flow up to 8 weeks after treatment. COMP-Ang1-induced promotion of cavernous angiogenesis and erectile function was abolished in Nos3-/- mice and in the presence of the NOS inhibitor, L-NAME. COMP-Ang1 also restored the integrity of endothelial cell-cell junction by down-regulating the expression of histone deacetylase 2 in the penis of hypercholesterolemic mice and in primary cultured mouse cavernous endothelial cells. These findings constitute a new paradigm toward curative treatment of both cavernous angiopathy and ED.

Intracavernosal injections in the diagnosis and treatment of PDE-5 resistant erectile dysfunction.

Dupplex Doppler study after intracavernosal injection (ICI) of vasoactive drugs is a valuable tool in the evaluation of vascular status in patients suffering from erectile dysfunction [1]. Normal erection after ICI suggests sufficient venous occlusion. Persistent diastolic cavernous blood flow measured by end–diastolic velocity (EDV) despite adequate arterial inflow measured by peak systolic velocity (PSV) suggests insufficient veno–occlusive mechanism which results in venous leakage [1]. EDV >5 cm/s and resistive index (RI) less than 0.75 have been universally accepted as pathologic reflecting venous outflow, though controversies exist about normal values of PSV. EAU recommends considering PSV of >30 cm/s, EDV 0.8 as normal while some authors consider PSV values between 25 and 35 and EDV between 5 and 7 cm/s as grey zone [1, 2, 3]. Dupplex Doppler studies have some limitations. The tests may be false negative in up to 20% with borderline arterial inflow (25–35 cm/s) [1]. Repeated duplex Doppler examinations revealed normal vascular status in a significant number of patients [4]. Moreover, several studies showed that EDV and RI in patients with repeated unsatisfactory reactions to intracavernous prostaglandin injection are poor predictors of venous leakage and should not replace dynamic pharmacocavernosometry/cavernosography (DPCC) in the investigation of vasculogenic impotence [5]. Cavernosography definitely has its place in diagnosing cavernosal venous leakage and is considered the gold standard by some authors [3, 4]. False positive results of duplex Doppler studies may be due to e.g. anxiety during the examination, which can resolve with repeated administration out of the office. The authors [6] present a concept of repeated ICI in patients with erectile dysfunction resistant to oral and intracavernosal therapy and EDV >5 cm/s on duplex Doppler examination, which suggests that at least part of those men suffered from venous leakage. No pharmacocavernosometry studies were done, which may however reflect common daily practice. Repeated self–administered ICI resulted in symptomatic improvement and reduction in mean EDV and increase in RI, while no significant difference in mean PSV was noted. Those patients who responded to therapy were generally younger and had worse erection quality before start of the study, which may have resulted in bigger potential for improvement and better quality of cavernous tissue. Improvement in EDV was noted in 21 patients and 10 of them reached EDV <5 cm/s which was considered normal. Possible explanation of that finding is discussed in the article. Despite that, only six men with EDV <5 cm/s during duplex Doppler examination after the treatment reported improvement in erectile response after ICI including three who regained spontaneous erections without injections. It would therefore be interesting to look at PSV values in responders and non–responders before and after the treatment, as differences in PSV changes between those groups could reflect existence of mixed vasculogenic pathology and arterial insufficiency component. Despite those considerations, an idea of repeated self–administered ICI in treatment of men with erectile dysfunction and abnormal EDV during dupplex Doppler studies seems to be interesting. Such an approach would be helpful to identify a group of non–responders who should then be referred to angiografic imaging as potential candidates for vascular surgery. Further studies including pharmacocavernosometry/pharmacocavernosography are needed to verify the role of repeated self–administered ICI in the treatment of erectile dysfunction due to cavernosal venous leakage.

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.

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.

T-Shaped Shunt and Intracavernous Tunneling for Prolonged Ischemic Priapism

Conservative management of prolonged ischemic priapism is rarely effective. Interventions include corporal aspiration/irrigation, injection of vasoconstrictive agents or surgical procedures. We describe a technique that fulfills several important criteria in the surgical management of ischemic priapism in that immediate resolution of ischemic pain is achieved, a wide area, reliably patent shunt is created, the procedure is technically simple and it may be performed with the patient under a local anesthetic. We reviewed the records of 13 patients treated with the T-shunt for whom followup, including erectile function, was available. Records were available for review for 13 men who underwent the T-shunt procedure from April 2006 to January 2008. In most cases priapism had lasted for more than 24 hours and previous irrigation/intracorporal administration of sympathomimetics had been unsuccessful. Of these 13 men 6 had undergone unsuccessful distal or proximal shunt procedures before presentation to our service. All procedures were performed using local anesthetic only. Cavernous blood flow was restored in all but 1 patient and another required a second procedure. T-shunts resulted in resolution of penile pain in all patients and all but 2 had recovery of erectile function. The T-shunt technique results in immediate resolution of ischemic penile pain and rigidity. Ultrasonography confirms that blood flow is usually restored to the previously ischemic corpora cavernosa after the procedure. The T-shaped shunt is simple and reliable, and access also allows for proximal trans-shunt dilation. We observed surprisingly excellent recovery of erectile function. This procedure may facilitate recanalization of corporal circulation and could make proximal shunts obsolete.

Surgical Techniques: Distal Cavernosum–Glans Shunts for Ischemic Priapism

Priapism is a pathological condition of a penile erection that persists beyond or is unrelated to sexual stimulation. It is an important medical condition that requires evaluation and may require emergency management. Ischemic priapism is the most common form of priapism; it is usually a painful, rigid erection characterized clinically by absent cavernous blood flow. Ischemic priapism beyond 4 hours is a compartment syndrome requiring emergent medical intervention. Potential consequences are irreversible corporal fibrosis and permanent erectile dysfunction. Initial assessment of priapism involves history and physical (penile) examination, assessment of corporal blood flow status by visual inspection (color, consistency) of corporal aspirate, corporal blood gas (pH, PO2, PCO2), or color duplex ultrasound. After adequate penile anesthesia via penile block, aspiration with or without injection of an adrenergic agonist is used initially to induce detumescence. Monitoring of vital signs is recommended in patients with a history of cardiovascular diseases. As in all ischemic compartment conditions, rapid intervention is a necessity. Aspiration + administration of an adrenergic agonist are highly recommended before any surgical treatment. Treatments initiated beyond 72 hours may have benefits in relieving unwanted erection and associated pain, but have little documented benefit in potency preservation. Three possible outcomes can result from the aspiration + adrenergic agonist combination after a reasonable dosage and duration (e.g., 20 mg of diluted phenylephrine over 1 hour): complete resolution, partial resolution, and no resolution. Complete resolution (completely flaccid penis) often occurs in priapisms of less than 24-hour duration, although occasionally it may occur in those of longer duration. In cases of complete resolution, instructions are provided to the patient for management of possible recurrence and follow-up visits. Partial resolution (of less than 75% rigidity with a compressible penis) should be regarded as a borderline situation. When in doubt, color duplex ultrasound can be used to confirm the flow in the cavernous arteries. In such cases, inpatient observation is recommended and interval physical examination of penis and/or interval assessment of cavernosal arterial blood flow status by color duplex ultrasound. Adrenergic agonists may be administered, by intracavernous injection or orally, on an interval basis to maintain detumescence. No resolution (more than 75% rigidity) or recurrent priapism after a transient detumescence is a common outcome in priapisms of more than 24-hour duration, despite repeated adrenergic agonist administration. Absence of cavernous arterial flow can be confirmed with color duplex ultrasound if necessary. This condition is due to interstitial edema as well as smooth muscle and endothelial cell dysfunction. In such cases, the patient should be managed by a percutaneous cavernosum–glans surgical shunt procedure. Adrenergic agonist irrigation Baseline

Diabetes induced alteration of clitoral hemodynamics and structure in the rabbit.

We investigated the effect of diabetes on clitoral hemodynamics and structures in the rabbit. A total of 25 New Zealand White female rabbits weighing 3 to 3.5 kg. were divided into 2 groups, including 5 in the control and 20 in the experimental group. Experimental animals received intravenous injection of alloxan hydrochloride (Sigma Chemical Co., St. Louis, Missouri) (100 mg./kg.). The development of diabetes was verified by measuring body weight and blood glucose levels. After 12 weeks clitoral cavernous blood flow in ml. per minute per 100 gm. tissue was measured with a laser Doppler flowmeter. Cross sections of the clitoris were used for histochemistry and histomorphometric image analysis. After 12 weeks 5 animals were included in the diabetes group. Mean baseline flaccid and peak clitoral cavernous blood flow plus or minus standard deviation significantly decreased in the diabetic group compared with the control group (3.9 +/- 1.6 and 5.8 +/- 2.2 versus 7.2 +/- 2.5 and 12.9 +/- 5.8 ml. per minute per 100 gm. tissue, respectively, p <0.05). Histology revealed diffuse clitoral fibrosis in the diabetic group. On histomorphometry the mean proportion of clitoral cavernous smooth muscle in the diabetic group was significantly decreased compared with the control group (51.9% +/- 4.9% versus 62.3% +/- 3.1%, p < 0.05). These results show that diabetes mellitus produces significant adverse effects on the hemodynamic mechanism of clitoral engorgement and leads to diffuse clitoral cavernous fibrosis. It implies that decreased sexual arousal in diabetic women may result from structural changes in the clitoris.

Diabetes Induced Alteration of Clitoral Hemodynamics and Structure in The Rabbit

We investigated the effect of diabetes on clitoral hemodynamics and structures in the rabbit. A total of 25 New Zealand White female rabbits weighing 3 to 3.5 kg. were divided into 2 groups, including 5 in the control and 20 in the experimental group. Experimental animals received intravenous injection of alloxan hydrochloride (Sigma Chemical Co., St. Louis, Missouri) (100 mg./kg.). The development of diabetes was verified by measuring body weight and blood glucose levels. After 12 weeks clitoral cavernous blood flow in ml. per minute per 100 gm. tissue was measured with a laser Doppler flowmeter. Cross sections of the clitoris were used for histochemistry and histomorphometric image analysis. After 12 weeks 5 animals were included in the diabetes group. Mean baseline flaccid and peak clitoral cavernous blood flow plus or minus standard deviation significantly decreased in the diabetic group compared with the control group (3.9 +/- 1.6 and 5.8 +/- 2.2 versus 7.2 +/- 2.5 and 12.9 +/- 5.8 ml. per minute per 100 gm. tissue, respectively, p <0.05). Histology revealed diffuse clitoral fibrosis in the diabetic group. On histomorphometry the mean proportion of clitoral cavernous smooth muscle in the diabetic group was significantly decreased compared with the control group (51.9% +/- 4.9% versus 62.3% +/- 3.1%, p < 0.05). These results show that diabetes mellitus produces significant adverse effects on the hemodynamic mechanism of clitoral engorgement and leads to diffuse clitoral cavernous fibrosis. It implies that decreased sexual arousal in diabetic women may result from structural changes in the clitoris.

The Presence of Arterial Anatomical Variations Can Affect the Results of Duplex Sonographic Evaluation of Penile Vessels in Impotent Patients

Purpose Since penile arterial communications are present in a significant percentage of impotent patients, we evaluated whether peak systolic cavernous blood velocity after intracavernous prostaglandin E1 injection might be different in patients with and without arterial variants. Materials and Methods Cavernous blood flow was assessed with echo color Doppler ultrasound before and after intracavernous injection of prostaglandin E1 in 63 impotent patients. The penile shaft was accurately evaluated to detect arterial anatomical variants. Clinical erectile response was assessed by visual inspection and palpation. Results Of 23 patients who obtained a full erection with full rigidity after prostaglandin E1 injection the cavernous peak blood velocities in 11 with penile arterial communications were significantly less than those in 12 without arterial communications. Conclusions The generally accepted limit of normal for cavernous peak blood flow obtained after prostaglandin E1 injection (greater than 25 to 30 cm. per second) must be interpreted carefully because lower peak blood velocities may be found in subjects with a full erectile response if arterial communications are present.

Assessment of Penile Blood Flow by Duplex Ultrasonography in 44 Men with Normal Erectile Potency in different Phases of Erection

Duplex ultrasonography is important in the diagnosis of vasculogenic erectile dysfunction. We measured the ultrasonographic parameters of cavernous blood flow in different phases of penile erection. We examined 44 volunteers with normal erectile potency. Doppler spectra of the cavernous artery were obtained in a time-dependent manner after intracavernous administration of papaverine. Following intracavernous pharmacological stimulation, the Doppler spectrum alters according to a specific pattern indicating the different hemodynamic phases of erection. Peak flow velocity and acceleration time, measured in the early post-injection phase, may be used to grade arterial inflow. The difference between resistance index in the pre-injection and late post-injection phases may be used to estimate veno-occlusive function. References values are defined.