Left Cavernosal Arteries Research Articles

Prevalence of Erectile Dysfunction among Patients with Coronary Artery Disease

Both coronary artery disease (CAD) and erectile dysfunction (ED) are widespread illnesses that frequently coexist. Numerous triggering risk factors and pathophysiological mechanisms contribute to both diseases. Penile color Doppler ultrasound can serve as a crucial tool to evaluate penile arterial blood flow. Therefore, this study aims to assess the ED prevalence in CAD patients, to determine the socioeconomic and clinical profiles of the population, and to define risk factors of their development. The cross-sectional study included 100 male patients who were admitted to the coronary angiography (CAG) unit. Patients were asked if they had ED, and if present, it was graded using the International Index of Erectile Function 5. Right and left cavernosal arteries were examined using color Doppler and erection hardness to assess the peak systolic velocity (PSV) and end-diastolic velocity. Among the 52 cases that suffered from ED, most of the cases had mild grades (38.5%). All cases without ED (100%) had penile artery Doppler PSV findings ≥30 (cm/s) with an average Doppler PSV of 48.02 ± 7.49 cm/s for the right cavernosal arteries and 47.4 ± 7.17 cm/s for the left cavernosal arteries. Yet, 71.2% of cases with ED had penile artery Doppler PSV findings <30 (cm/s) with an average Doppler PSV of 29.1 ± 7.57 cm/s for the right cavernosal arteries and 28.69 ± 7.11 cm/s for the left cavernosal arteries. Furthermore, by CAG, 50% of cases without ED had blockage not necessitating a coronary intervention (no significant disease) compared to 25% of cases with ED. There was positive correlation between advanced grade of ED and age (r = 0.327, P <0.001), hypertension (r = 0.213, P = 0.033), DM (r = 0.253, P = 0.011), smoking (r = 0.202, P = 0.044), and severity of CAD (r = 0.332, P <0.001). Patients with multivessel CAD have a significantly higher incidence and more severity of ED. Moreover, pathological penile vessels PSV (<25 or <30 cm/s) via Doppler ultrasound is mostly valuable as a noninvasive tool to define ED attributable to vascular impairment that may be antecedent to atherosclerosis in the coronary vessels.

PD26-12 FLACCID PENILE ULTRASOUND: A NEW POTENTIAL TOOL TO PREDICT THE INDIVIDUAL 10-YEAR RISK OF CARDIOVASCULAR DISEASE

You have accessJournal of UrologyCME1 Apr 2023PD26-12 FLACCID PENILE ULTRASOUND: A NEW POTENTIAL TOOL TO PREDICT THE INDIVIDUAL 10-YEAR RISK OF CARDIOVASCULAR DISEASE Giovanni Cochetti, Giuseppe Maiolino, Michele Del Zingaro, Alessio Paladini, Graziano Felici, Giulia Manfredini, Angelica Tancredi, and Ettore Mearini Giovanni CochettiGiovanni Cochetti More articles by this author , Giuseppe MaiolinoGiuseppe Maiolino More articles by this author , Michele Del ZingaroMichele Del Zingaro More articles by this author , Alessio PaladiniAlessio Paladini More articles by this author , Graziano FeliciGraziano Felici More articles by this author , Giulia ManfrediniGiulia Manfredini More articles by this author , Angelica TancrediAngelica Tancredi More articles by this author , and Ettore MeariniEttore Mearini More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003304.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Cardiovascular risk has become a hot topic in evaluation of patients with vasculogenic erectile dysfunction (ED). Recently, European Society of Cardiology (ESC) designed a cardiovascular disease (CVD) Risk Calculation App to calculate individual 10-year risk of CVD for healthcare professionals based on specific population-target scores. Aim of our study is to evaluate the association between mean basal peak systolic velocity of cavernosal arteries and the 10-year risk in men with vasculogenic ED. METHODS: We prospectively evaluated all patients with vasculogenic ED who underwent penile ultrasound between September 2021 and July 2022. All patients were examined in the same setting: quiet and warm room, one expert operator, sampling of basal PSV in the first third of cavernosal artery with an angle of doppler between 40-50° and calculation of mean basal PSV (mbPSV) between right and left cavernosal artery. Exclusion criteria were: neurological disease or spinal injury, psychogenic (clinical suspicious and/or Beck Inventory Scale ≥14) erectile disfunction. For each patient we calculated 10-year risk of CVD disease using SCORE2 for patients between 40 and 69 years without history of cardiovascular disease and diabetes mellitus, SMART score for patients with a history of cardiovascular disease and ADVANCE score for patients with diabetes mellitus. All risk scores were calculated by CVD Risk Calculation App of ESC. Ethical Committee approval has been obtained. RESULTS: We enrolled 80 consecutive patients. Mean age and BMI were 57,9 years and 26,8 Kg/m2, respectively. Median IIF-5 was 13,7. Average mbPSV and 10-year risk of CVD disease resulted 13,6 cm/sec (range: 5,3 -32,4 cm/sec) and 10,8% (range: 1,9-34%), respectively. We found an inverse and significant correlation between mbPSV and 10-year risk of CVD disease (r: -0.29; p: 0,02). The correlation resulted significant in patients with a history of cardiovascular disease which were evaluated by SCORE2 (r: -0.34; p: 0,017) and a stronger significant inverse correlation was found between mbPSV and 10-year risk of CVD in patients with diabetes mellitus in which the cardiovascular risk was calculated by ADVANCE score (r: -0.61; p: 0,021). mbPSV resulted significantly correlated also with age (r: -0.28; p: 0,021). CONCLUSIONS: MbPSV is a useful screening tool in patients with vasculogenic ED to evaluate 10-year risk of cardiovascular (CVD) disease. A lower mbPSV is correlated with a higher cardiovascular risk, especially in patients with diabetes mellitus where risk is calculated by ADVANCE score. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e739 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Giovanni Cochetti More articles by this author Giuseppe Maiolino More articles by this author Michele Del Zingaro More articles by this author Alessio Paladini More articles by this author Graziano Felici More articles by this author Giulia Manfredini More articles by this author Angelica Tancredi More articles by this author Ettore Mearini More articles by this author Expand All Advertisement PDF downloadLoading ...

Super Selective Angioembolization for Posttraumatic ArterioCavernosal Fistula Presenting with Nonischemic Priapism

Arteriocavernosal fistula generally occurs from penetrating injury and is rarely secondary to blunt trauma. Patients typically present with a painless partial erection following some type of genitoperineal trauma; the resultant arterial damage leads to an arterial-lacunar fistula and occasionally, to an associated pseudoaneurysm. The case reported in this article is unique in a way that the patient presented after 4 months yet super selective angioembolization of the feeder artery yielded promising results. A 24-year-old man was reported to the outpatient department of our center with a history of road traffic accidents and subsequent perineal injury 4 months back. The patient had complaint of inability to get full rigid erection and persistent partial erection of penis for 4 months since the trauma. On clinical examination, the patient had a partial detumescent penis and normal testes. Doppler ultrasonography revealed extravasation of blood from the lacerated cavernosal artery as a characteristic color blush that extended into the erectile tissue. Magnetic resonance imaging of the perineum suggested the possibility of left-sided posttraumatic arteriocavernous fistula. Diagnostic angiogram of left iliac artery demonstrated arteriocavernous fistula, and selective arterial embolization of feeding artery left cavernosal artery was performed with metallic coils. Procedure was uneventful. Complete detumescence was achieved in the immediate postoperative period. Super selective angioembolization of the feeder’s vessel remains the treatment of choice even in patients with long-standing fistula and priapism secondary to it.

Baseline Penile Ultrasound and Color Doppler Parameters – A Comparison Between Psychogenic and Vasculogenic Erectile Dysfunction Patients

Background and Objectives: There are many causes of erectile dysfunction (ED) like congenital anomalies, neurological, endocrinal, pharmacological, psychological, pathological or hemodynamic. Penile doppler ultrasound provides real-time evaluation of cavernosal vascular flow dynamics. Purpose of our study was to evaluate and compare the baseline penile ultrasound and color doppler vascular parameters in patients of ED to see if there was any significant difference between patients of psychogenic and vasculogenic ED (diagnosed on post Papaverine injection color doppler) without the use of intracavernosal Papaverine injection. To best of our knowledge such detailed comparison of baseline penile ultrasound and doppler parameters have not been published in literature. Methods: We have prospectively studied 32 patients of ED who underwent ultrasound, and color doppler pre-and post-papaverine intracavernosal injection. Baseline pre papaverine diameters of right and left cavernosal arteries were measured on grey scale ultrasound. Peak systolic velocity (PSV), end diastolic velocity (EDV) and resistive index (RI) of right and left cavernosal arteries were measured on color doppler before and after injecting intracavernosal papaverine injection. Patients were divided into normal study group (psychogenic ED), arterial insufficiency and venous leakage groups (vasculogenic ED) on the basis of post papaverine color doppler findings. Results: Eighteen patients showed normal study, 11 showed arterial insufficiency and 3 patients had venous leakage on post Papaverine injection color doppler. When base line prepapaverine vascular diameters and color doppler parameters were compared statistically, no significant difference was detected between and within these study groups. We have also compared Ed duration and IIEF scores among various study groups and found statistically significant difference between and within the groups. Conclusion: Use of a vasoactive agent like Papaverine with color Doppler is must to diagnose the vasculogenic ED.

Cavernosal artery peak systolic velocity among normal adults in Abuja, Nigeria: A Baseline parameter for sonographic diagnosis of vasculogenic erectile dysfunction

Background: Erectile dysfunction is consistent inability to achieve and maintain erection of sufficient rigidity for satisfactory sexual performance. It is well known that the hemodynamic function of the penis correlates well with the peak systolic velocity (PSV) of the cavernosal artery (CA) which is the most reliable, sensitive, and objective parameter used in evaluating the state of the erectile tissues of the penis. This study was aimed at establishing the normal CA PSV in this environment, as it may differ from the values among Americans, Caucasians, and Asians. Materials and Methods: The study was conducted between July 2015 and January 2017, at the Department of Radiology, Federal Medical Centre, Abuja. Twenty-nine consecutive patients referred by the urologist to the radiology department of the aforementioned institution for penile ultrasound were evaluated using triplex Doppler sonography with high-frequency linear array transducer. The penile scan was done before and after intracavernosal injection of 10–20 μg prostaglandin E1. The waveforms of CAs were obtained alternately using the angle of inclination ≤60°, and the PSV of the CA was documented at 5-min interval, from 5 to 40 min. Results: PSV of CA varied between 26 and 104.4 cm/s (mean: 46.72 ± 16.21) among the entire research participants. No significant discrepancy was noted between PSV of the right and left cavernosal arteries. The PSV had a strong positive relationship with age (P = 0.002), with the highest values found among those ≤30 years. Conclusion: The mean PSV of cavernosal arteries established in this study is not significantly different from the values obtained among Americans, Caucasians, and Asians, indicating that racial difference has no effect on this important sonographic variable.

Трансплантат слизистой щеки – концепция «идеального графта» в хирурги-ческом лечении болезни Пейрони

Surgical techniques in managing Peyronies disease include plication corporoplasty, plaque incision, grafting and penile prosthesis implantation. The question of an ideal transplant for corporoplasty remains open. To evaluate the effectiveness of the substitution corporoplasty using buccal mucosa transplant (BMT) in treating Peyronies disease. From January 2011 to February 2016, 28 patients with stable stage Peyronies disease underwent substitution coroproplasty using BMT (incision and grafting). The mean age of patients was 54.8+/-6.2 years. All patients completed an IIEF-5 questionnaire and underwent a standard preoperative examination: anamnesis, physical examination, penile duplex pharmaco-ultrasonography and penile fixation photography to assess the type and angle of curvature. The average angle of penile curvature was 82.8 (45-120). All patients underwent incision and grafting using BMT; in 5 patients additionally the plication of the penile tunica albuginea was performed. Follow-up examinations were concluded at 3, 6 and 12 months and more after surgery. Median follow-up was 30 months. Postoperative penile straightening was achieved in 93% of patients. The duplex peak systolic velocity of the right and left cavernosal arteries improved from 42.59 to 45.64 cm/s and from 34.55 to 43.48 cm/s, respectively (p less or equal 0.05). Penile corproroplasty using BMT is a safe and effective method of treating patients with Peyronies disease. Follow-up clinical and instrumental examination showed no impairment of the erectile function or penile hemodynamics.

053 Evaluation of Doppler Parameters in Patients without Organic Erectile Dysfunction

Erectile Dysfunction (ED) can be non-invasively diagnosed by Color Duplex Doppler Ultrasound (CDDU) coupled with intravavenrous injection (ICI) of a penile vasoactive agent. The primary aim of the study was to characterize CDDU parameters for patients without organic erectile dysfunction. A retrospective review was conducted to identify patients without organic ED who underwent office testing with intracavernous pharmacologic erection augmented by visual sexual stimulation and CDDU from January 2009 to January 2010. Patients were further characterized by age, BMI, sexual activity, degree of penile curvature, cardiovascular risk factors (smoking hypertension, hyperlipidemia), co-morbid diagnosis of Dupuytren’s contracture or hypogonadism, tunica plaque characteristics, Sexual Health Inventory for Men score, and prior prostate surgical history. CDDU characteristics including pre and post-visual stimulation ICI peak systolic velocity (PSV) and resistive index (RI) were also identified. 120 patients, with a mean age of 56, were found to have normal Doppler parameters (PSV>35, RI>.90) Average (Right and Left cavernosal artery) pre-visual stimulation PSV was 45.96, while average post-visual stimulation PSV was 57.21. Average (Right and Left) RI was 0.97. For patients under 50 years of age, average pre-visual stimulation PSV was 49.74 and post-visual stimulation PSV was 56.41, with average RI of .95; for patients over 50 years of age, average pre-visual stimulation PSV was 44.64 and post-visual stimulation PSV was 57.48 with an average RI of .97. Mean Doppler parameters were identified for ages 40-49, 50-59, 60-69, and above 70 with the following distribution (pre-visual stimulation PSV/post-visual stimulation PSV/RI): 49.24/53.15/.97, 46.01/56.77/.97, 45.45/59.99/.97, and 31.06/50.38/.98, respectively.

Recurrent idiopathic high-flow priapism treated with selective arterial embolization after repeated initial treatments for low-flow priapism

High-flow priapism is most often seen following perineal and penile trauma. We report the case of a 32-year-old man who presented with recurrent idiopathic priapism initially treated as low-flow priapism on 8 previous emergency department visits. Pelvic angiography revealed an abnormal communication between the left cavernosal artery and the left corpus cavernosum and led to the diagnosis of high-flow priapism. Treatment involved embolization of the left common penile artery, which resulted in successful resolution of the recurrent priapism. Our patient's case highlights the importance of an appropriate work-up, including imaging, to distinguish high- and low-flow priapism and to provide appropriate care.

Penile Duplex Ultrasonography in Men with Peyronie's Disease: Is it Veno‐Occlusive Dysfunction or Poor Cavernosal Arterial Inflow that Contributes to Erectile Dysfunction?

At least 20% of men with Peyronie's disease (PD) suffer from erectile dysfunction (ED). The fundamental mechanism is thought to arise from the progression of penile fibrosis, which was initially limited to the PD plaque within the tunica albuginea. However, recent studies have highlighted the possibility of fibrosis of the cavernosal vessel media wall leading to impairment of arterial inflow. To evaluate the penile duplex ultrasonographic findings in PD of impotent men and to determine whether early features of PD might predict clinical progression. Patient demographic, comorbidities, International Index of Erectile Function-5 scores, surgical intervention, and physical findings were documented. Penile curvature, plaque size, and peak systolic velocity (PSV) and end-diastolic velocity (EDV) on color duplex ultrasonography (CDU) were recorded. We performed a retrospective review of all men presenting with penile curvature and length loss who underwent penile CDU between January 2001 and January 2010. A total of 1,120 men underwent penile CDU during the 10-year period. Complete information was obtained in 810 men; 250 men complained of decreased penile rigidity, while 150 men were unable to sustain erection. Comorbidities were similar between men with PD with and without ED. Tunical thickening (65%) was the most common CDU feature, and mean cumulative calcifications was 24.2 mm(2) (1-360 mm(2) , standard deviation 76). The PSV and EDV on the right cavernosal artery were 14.2 cm/second and 3.5 cm/second, while the left cavernosal artery measurements were 15.1 cm/second and 3.2 cm/second. Multivariate logistic regression model showed strong correlation between plaque size and development of ED. Both veno-occlusive dysfunction and impaired cavernosal arterial inflow were associated with ED. Veno-occlusive dysfunction and impaired cavernosal arterial inflow contributed to the development of ED, and larger plaque size is a strong predictor of surgical intervention.

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.

The Use of Transcatheter Superselective Embolization to Treat High Flow Priapism (Arteriocavernosal Fistula) Caused by Straddle Injury

A28-year-old white male presented with persistent partial erections after an industrial straddle injury 5 months earlier. Immediately following the injury the patient experienced moderate perineal and penile pain with extensive bruising and a small laceration on the perineum. There was no evidence of urethral bleeding at the time of injury. The pain eventually subsided but the patient experienced chronic unwanted erections that were approximately 30% to 40% of full rigidity. The patient was unable to achieve an erection adequate for sexual penetration despite a normal libido. He reported no nocturnal erectile activity or urinary complaints. The patient had a supportive spouse. Otherwise all medical history was noncontributory. The patient was a well developed male with a moderate degree of anxiety. Genitourinary examination revealed moderate rigidity and slight tenderness along the left corporal body with a soft glans. The remaining physical examination was unremarkable. Results from the penile color duplex Doppler ultrasound study revealed 60 cm per second inflow in the left cavernosal artery with a corresponding 24 cm per second venous outflow. There was approximately 80% tumescence with 40% rigidity of the penis during the study. Based on history and Doppler study, diagnosis was left high flow priapism with a venous leakage component, and a pudendal arteriogram with possible embolization was scheduled. Superselective injection of the deep penile artery showed a deep penile arteriocavernosal fistula (part A of figure, arrow) causing massive opacification of the corporum cavernosum (part A of figure, arrowhead). To protect the glans penis against inadvertent embolization which could cause loss of sensitivity, a 0.014 platinum guide wire was temporarily placed into the dorsal penile artery (part B of figure, arrow) through a double lumen catheter while embolizing the fistula through the microcatheter advanced through the second lumen. Following superselective embolization of the fistula with AMICAR® enforced autologous blood clot, salutary occlusion of the fistula with no further opacification of the corpora was observed (part C of figure). Upon successful occlusion the penis became soft and rapidly collapsed. High flow priapism is a rare form that occurs with unregulated inflow of arterial blood into the corpora through an arteriocavernosal fistula, and is usually preceded by some form of perineal or penile trauma. Because there is perfusion of well oxygenated blood, high flow priapism (arterial priapism) is nonpainful, nonischemic and not an acute urological emergency. Thus, there is time for initial pharmacological therapeutic modalities. For high flow priapism refractory to this conservative management, radiological transcatheter superselective embolization has become the treatment of choice. 1 Selective embolization can be conducted using a variety of agents including autologous blood clot, metallic microcoils, gel foam and N-butyl cyanoacrylate. 2 Although there is a paucity of data, current theory suggests that embolization should be done with temporary occlusive agents to prevent irreversible changes in erectile function. Thus, autologous blood clots have become the mainstay of treatment for high flow priapism, with long-term followup rates of resolution at 100% and restoration of erectile function at 86%. 3

Alcock's canal releasing for pudendal artery syndrome resulting from gunshot injury

A 21-y-old man applied to hospital with a complaint of erectile dysfunction, which started soon after a gunshot injury. The entry of the bullet was at the middle right gluteal region without any exit hole. A pelvic X-ray revealed the bullet and the scattered particles. On penile Doppler ultrasonography, the peak systolic velocities (PCV) of the right and the left cavernosal arteries were 19 and 29 cm/s, respectively. Pudendal angiography revealed poor visualization of the right pudendal artery below the level of the bullet. The patient underwent a right-sided Alcock's canal releasing surgery. After the operation, on control penile Doppler ultrasonography, PCV on the right and the left cavernosal arteries were 53 and 35 cm/s, respectively. The control angiography revealed a normal right pudendal artery. The patient was fully potent 2 y after the operation. Not only the entrapment of pudendal nerve but also the pudendal artery may cause Pudendal canal syndrome. A gunshot injury may cause such a condition due to the reaction caused by the bullet. Pudendal canal decompression is a simple and effective treatment for pudendal canal syndrome.

High-flow priapism due to cavernosal artery fistula with pseudoaneurysm treated by N-butyl-cyanoacrylate embolization

Objective: Our purpose is to determine the diagnosis of high-flow priapism due to cavernosal artery fistula with pseudoaneurysm and treatment with N-butyl-cyanoacrylate (NBCA) embolization in a case. Methods and material: A 32-year-old man presented with a 2-month history of painless priapism after perineal blunt trauma. On colour Doppler sonography and clinical examination high-flow priapism due to the left cavernosal artery fistula with pseudoaneurysm was diagnosed in the patient. Right cavernosal artery was normal. The diagnosis was confirmed with angiography. It was treated by transcatheter embolization using NBCA. Results: After treatment, immediate complete detumescence and normal potency was achieved after 2 days follow-up. Conclusion: Perineal colour Doppler ultrasonography is a reliable and noninvasive examination to demonstrate cavernosal artery fistula and pseudoaneurysm. Super selective transcatheter embolization with NBCA is a method of choice in the treatment of the cavernosal artery fistula and pseudoaneurysm.

RECANALIZATION OF EMBOLIZED CAVERNOSAL ARTERY: RESTORING POTENCY IN THE PATIENT WITH HIGH FLOW PRIAPISM

High flow priapism is an uncommon disease. Most cases are secondary to trauma. An arteriocavernous fistula caused by laceration of the cavernosal artery or one of its branches is the most common cause of this hemodynamic alteration. Immediate treatment with reduction of abnormal arterial flow is better possibly than other treatments. In addition, angiographic embolization is safe, selective and affords return to premorbid function and, therefore, it has been the most widely used. In our patient we evaluated the cavernosal blood gas analysis, and performed color Doppler ultrasonography and angiography for diagnosis, and superselective embolization of the internal pudendal artery with the autologous blood clots. The patient was followed with color Doppler ultrasonography and magnetic resonance imaging (MRI) 2 months after embolization. CASE REPORT A 17-year-old man presented with a 7-day history of sustained, painless and incomplete erection that occurred 3 days after blunt penile injury when he fell down on a bicycle. The erection did not subside and drainage of the corpora cavernosa with needle aspiration and several irrigations with 10 mg./ml. phenylephrine, which produced transient flaccidity, had been performed elsewhere. When referred to us, the penis was engorged with no tenderness, except bruising. A color Doppler scan showed abnormal arterial and venous flow in the corpora, and turbulent flow in the pseudoaneurysm. Peak systolic velocity was 30 cm. per second (end diastolic velocity of 3 cm. per second) in the right cavernosal artery and 52 cm. per second (end diastolic velocity of 6 cm. per second) in the left cavernosal artery before embolization. Blood gas analysis of the corpora cavernosa revealed a high oxygen partial pressure tension (93.8%) and oxygen saturation (97.1%). Superselective pudendal angiography performed with the patient under local anesthesia clearly demonstrated extravasation consistent with the presence of a pseudoaneurysm from a branch of the left cavernosal artery (fig. 1, A). Superselective embolization of the left internal pudendal artery with 3 ml. of autologous blood was performed. Repeat contrast injections confirmed a dramatic reduction in blood flow to the penis (fig. 1, B). The penis became gradually flaccid in the following 48 hours. During followup 2 months later, the patient stated that sexual arousal was associated with the return of erections, which were not complete. Physical examination revealed a ring-like fibrotic mass in the penile base but the lesion could not be differentiated as to whether it was in the tunica albuginea or intracavernosum. Color Doppler ultrasonography after injection with intracavernosal vasoactive agents revealed a well circumscribed hypoechoic mass that was no longer connected with the cavernosal artery, and there was no turbulent flow in the hypoechoic cystic mass (fig. 2, A).

Topographical anatomy of the penile arteries.

To determine the relationship of the penile arteries to anatomical landmarks and thus ease their identification, so avoiding injury during surgery. The penile arteries in 12 formalin-preserved adult male cadavers were dissected and the distances measured between the cavernosal arteries and both the endopelvic fascia and distal attachment of the crura to the ischial bones. The distance between the origins of both bulbar and cavernosal arteries, their length and the length of the cavernosal bodies and crural attachments were also measured. Several anatomical variations, e.g. accessory pudendal arteries, multiple cavernosal and bulbar arteries, irrigation of cavernosal bodies by contralateral branches, anastomosis of cavernosal arteries with accessory pudendal branches, dorsal artery or bulbar artery as main branches of accessory pudendal arteries, were observed in 13 of the 24 specimens. The mean distances between the anterior attachment of the crura to the ischial rami and the site on the tunica albuginea where the cavernosal arteries penetrated the cavernosal bodies were 1.26 cm on the right and 0.69 cm on the left. The corresponding measurements between the cavernosal arteries and the endopelvic fascia were 5.68 cm (right) and 4.85 cm (left). The mean extracavernosal lengths of the right and left cavernosal arteries were 2.47 and 2.2 cm, respectively. Multiple anatomical variations of the arterial penile anatomy occur frequently. Surgery at the penile hilum may easily damage the cavernosal arteries, which lie medially to the dorsal nerves and arteries of the penis, have an extracavernosal length of about 2.3 cm and perforate the tunica albuginea about 1 cm distally to the anterior attachment of the crura to the ischial ramus.

Correlation of duplex sonography with arteriography in patients with erectile dysfunction.

Our objective was to assess the accuracy of using measurements of peak systolic velocity in the cavernosal artery for the diagnosis of arteriogenic impotence. Twenty consecutive men with erectile dysfunction had duplex sonography after intracavernosal injection of papaverine to induce an erection. Peak systolic velocities in the right and left cavernosal arteries were measured by using Doppler sonography. Right and left selective penile arteriography was performed with low-osmolality contrast media after intracavernosal injection of papverine and intraarterial tolazoline. On the basis of the angiographic findings, penile arterial function was classified as normal, moderately insufficient, or severely insufficient. Doppler measurements of peak systolic velocity were correlated with arteriographic results. All 11 cavernosal arteries with peak velocities less than 25 cm/sec were associated with arterial disease, nine severe and two moderate. Thirteen of 17 carvernosal arteries with peak systolic velocities 25-34 cm/sec were associated with arterial disease, five severe and eight moderate. Only one of the 12 cavernosal arteries with peak velocity at or greater than 35 cm/sec was associated with arterial disease. We conclude that peak systolic velocity in the cavernosal artery as measured on duplex sonography is an accurate predictor of arterial disease in patients with erectile dysfunction. A peak systolic velocity of at least 35 cm/sec indicates normal arterial supply. At peak systolic velocities less than 35 cm/sec, the likelihood and severity of arterial disease increase as the peak systolic velocity decreases, with a peak velocity less than 25 cm/sec indicating a high likelihood of severe arterial disease.

The Multidisciplinary Approach to Vasculogenic Impotence

The proper assessment of erectile dysfunction can be objectively accomplished only by examining the vascular, hormonal, neurologic, and psychologic components. The vascular surgeon today requires the ability to participate in multidisciplinary approach to diagnosis and needs an understanding of pelvic hemodynamics to design aortoiliac reconstructions that optimize pelvic blood flow. We perform a history and physical examination carefully designed to evaluate erectile ability and detail vascular involvement. Outpatient serum samples are obtained for hormonal analysis. In the noninvasive vascular laboratory, we measure the penile blood pressure using a 2.5 cm cuff and a 10 MHz Doppler probe. We feel strongly that measuring the right and left cavernosal artery pressures directly and determining the penile/brachial index (PBI) most accurately reflects penile flow. A PBI less than 0.6 is diagnostic of vasculogenic impotence, and a PBI greater than 0.75 is normal. We perform our pelvic steal test by exercising the thigh and buttock muscle groups, and comparing the PBI before and after exercise. A decrease of 0.1 or more represents a positive steal test. Measurement of nocturnal penile tumescence is valuable in cases where history, physical examination, and noninvasive vascular laboratory evaluations do not correspond. A neurologic evaluation may include cystometrography or sacral latency testing when indicated. Psychological screening is performed in all patients. We screened 54 vascular clinic patients and found 81% to be symptomatic of erectile dysfunction. In this group, 79% had a PBI less than 0.75, and 38% had a positive pelvic steal test. Illustrative cases are presented herein and the implications in aortoiliac surgery are discussed.