Penile Duplex Doppler Ultrasonography Research Articles

546 Assessment of predictors of abnormal peak systolic velocity and end diastolic velocity in penile doppler ultrasound

Penile duplex Doppler ultrasound (PDDU) is used to assess the etiology of erectile dysfunction(ED). Peak systolic velocity (PSV), and end-diastolic velocity (EDV), are the main PDDU parameters. To evaluate the impact of different cardiovascular risk factors, Peyroni disease(PD), and penile size on PSV and EDV. A retrospective review of all men presenting with erectile dysfunction (ED) who did PDDU between January 2011 and January 2012 has been carried out, including patients diagnosed as psychogenic ED. A total of 362 patients with complete data were included in this analysis. Collected data included patient demographics, vascular, and anatomic parameters. The patients’ data included known cardiovascular risk factors (age, tobacco consumption, body mass index (BMI), testosterone levels(T), diabetes mellitus(DM), hypertension(HTN), dyslipidemia and PD. Penile size was measured at the time of full erection on the dorsal aspect of the penis, from the pubic bone to tip of the glans(BTT),from skin to tip(STT) and circumference of base of penis. PDDU was done for all patients after intracavernosal injection(ICI) with Trimix. PSV and EDV were measured after 15 minutes.

Relationship between Response to PDE5 Inhibitors and Penile Duplex Doppler Ultrasound in Erectile Dysfunction.

The relationship between the results of penile duplex Doppler ultrasound (PDDU) and response to vardenafil was investigated in patients diagnosed with erectile dysfunction (ED). Data from 148 patients with ED were analyzed retrospectively. Patients who did not respond to therapy were classified in to Group I (n = 32), those who responded partially were classified into Group II (n = 40), and complete responders were classified into Group III (n = 76). Age, comorbidities, and vascular and penile pathologies were compared among the three groups. While diabetes mellitus (DM) and dyslipidemia positivity adversely affected the response to treatment, the presence of hypertension (HT), Peyronie’s disease and priapism increased the therapeutic response to the treatment (p < 0.05). Arterial insufficiency was present in 20 (30.3%), 25 (37.9%) and 21 (31.8%) of the patients in Group I, Group II and Group III, respectively (p = 0.001). Venous insufficiency was observed in three (14.3%) patients in Group I and in eight (85.7%) patients in Group III (p = 0.001). Arterial/venous insufficiency was seen in 9 (30%), 14 (46.7%) and 7 (23.3%) of the patients in Group I, Group II and Group III, respectively (p = 0.001). The response rate to treatment was highest in normal patients according to PDDU, followed by patients with venous insufficiency. In addition, it was found that DM decreased the response to treatment, whereas the response increased in cases with HT, priapism and Peyronie’s disease.

Effect of collagenase Clostridium histolyticum on penile vascular and morphological parameters in patients with Peyronie's disease.

BackgroundTo examine the changes in penile vascular parameters after the administration of collagenase Clostridium histolyticum (CCH) in patients with Peyronie’s disease (PD).MethodsWe retrospectively reviewed the records for all patients treated with CCH for PD between 04/2014 and 05/2017 who underwent penile duplex Doppler ultrasound (PDDU) after pharmacologically induced erection both before and after four cycles of CCH treatment. The primary outcomes measured were changes in peak systolic velocity (PSV), end diastolic velocity (EDV), and resistive index (RI) after CCH treatment. Paired t-tests, chi-squared tests, and correlation coefficients were performed between functional and vascular parameters before and after four rounds of CCH to determine statistical significance (P<0.05).ResultsA total of 51 patients were included in the study. After four cycles of CCH therapy, there was no statistically significant change in PSV, EDV, RI, or International Index of Erectile Function score when compared to baseline. Similarly, there was no correlation between vascular parameters and change in curvature. There was a statistically significant change in penile curvature (60˚±16.9˚ to 40.8˚±14.9˚, P<0.001) and erect penile circumference (11.6±1.0 to 11.9±1.0 cm, P<0.05) after treatment.ConclusionsIn spite of a significant change in penile curvature, this change did not correlate with changing penile vascular or morphological parameters. Overall, CCH therapy seems to have a negligible impact on penile vasculature, furthering evidence of its favorable safety profile.

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

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

161 Beyond Curvature: Prevalence and Characteristics of Volume Loss Deformities in Men with Peyronie's Disease

We sought to describe the prevalence and functional impact of non-curvature, penile volume-loss deformities in our cohort of men with Peyronie’s disease (PD). We retrospectively examined medical records of patients with PD who consecutively underwent penile duplex doppler ultrasound (PDDU) with physical examination of the erect penis after intracavernosal injection by a specialized urologist from December 2012- July 2015. Curvature was measured with goniometer. Volume loss deformities were characterized as hourglass deformities, unilateral indentations, and distal tapering based on physical examination. Axial instability was determined subjectively as present when application of axial force resulted in penile buckling. Each patient completed the Male Sexual Health Questionnaire (MSHQ) and was asked if they experienced anxiety about sexual performance. Clinical data of patients with and without volume-loss deformities were compared using chi-squared tests and two-sided t-tests. 54% of the cohort (62/114) had volume-loss deformities. Hourglass deformities, distal tapering and unilateral indentations were present in 27 (24%), 17 (15%), and 18 (16%) patients, respectively. Curvature was present in 109 patients (96%). The patients with volume-loss deformities had significantly higher rates of axial instability (40% vs. 22%, p=0.04) and anxiety about sexual function (18% vs. 6%, p=0.05) compared to patients without volume-loss deformities. We did not observe differences in PDDU parameters or any of the 5 MSHQ sexual function domain scores between patients with and without volume-loss deformities, although men with volume-loss deformities had more instances of perceived delayed ejaculation (4.1 vs. 3.5, p=0.04).

Penile vascular diagnostic categorization using penile duplex Doppler ultrasound: Differences in vascular hemodynamics parameters by differences in anatomic sampling location.

In 2013 the International Society for Sexual Medicine(ISSM) published the guidelines regarding the standard operating procedure (SOP) for penile duplex Doppler ultrasound (PDDU). Although ISSM-SOP have given important strides in reducing interobserver variability in PDDU by procedural protocol and parameters these guidelines do not address the anatomic location along the penis at which hemodynamic measurements have to be done. In our opinion a "double sampling" may be interesting to detect the arteriogenic or venogenic nature of the erectile dysfunction (ED). In particular sampling measurements at the "crus" (at the level of the peno-scrotal junction) may be significative for detection of veno-occlusive dysfunction (VOD),whereas an evaluation at "mid penis" (1/2 distance between peno-scrotal junction and coronal sulcus), may be useful to diagnose an arterial insufficiency (AI). We evalued 90 men, mean age 56.3, affected with ED of medium degree, responder to PDE5-I that urdergone to PDDU and also responder after pharmacologic intracavernosal injection (PII)of prostaglandin E1 20 mcg, with rigid erection and normal maintenance. We moreover evalued 90 men in youthful age (mean 35.2), in absence of vascular risk factors, no responder to PDE5-I that undergone to PDDU by PII at high dosage (bimix: prostaglandin E1 20 mcg, papaverine 20 mg). In the first pool the sampling at "mid penis" resulted significative for arterial insuffciency (AI) in 81% (73), in presence of normal or borderline end diastolic velocity (EDV). Sampling at the "crus" resulted negative for VOD in 90% (81). In the second pool, 66.6% (60) resulted responder with rigid erection and normal maintenance in presence of normal hemodynamic parameters: peak systolic velocity (PSV) and end diastolic velocity (EDV) both at the "crus" and at "mid penis" sampling. 33.4% (30) responded with a semirigid erection and manifested a constant deficit of maintenance; at the "crus"and at "mid penis" the hemodynamic arterial parameters resulted normal. At the "crus" the EDV resulted significantly augmented (VOD index) in 96.6% (29); at "mid penis" augmented EDV was founded in 50% (15). These observational data would be able to confirm the utility of a routinary "double sampling" procedure, at the "crus" and at "md penis", during PDDU in order to better distinguish between VOD or AI or in any case to be useful to stimulate a future more precise standardization in execution of PDDU examination.

Failure to attain stretched penile length after intracavernosal injection of a vasodilator agent is predictive of veno-occlusive dysfunction on penile duplex Doppler ultrasonography.

Penile duplex Doppler ultrasound (PDDU) assesses the etiology of erectile dysfunction. Peak systolic velocity (PSV), end-diastolic velocity (EDV), and resistive index (RI) are common PDDU parameters. We assessed whether stretched penile length (SPL) in the flaccid state and measured penile length at peak erection after intracavernosal injection (ICI) of a vasodilator during PDDU correlated with the etiology of erectile dysfunction. We performed a retrospective review of 93 patients who underwent PDDU for erectile dysfunction. Normal and stretched penile length were measured, both at a flaccid state prior to ICI and at peak erection during PDDU. Collected data included patient demographics, vascular, and anatomic parameters. The mean age was 52years. SPL was equivalent to peak penile length after ICI in 60 patients (65%, group 1) and did not match in 33 (35%, group 2). There were no significant differences between the two groups in terms of flaccid, stretched, and post-ICI erect penile lengths, IIEF score, PSV, percent rigidity or tumescence, and vasodilator dose used. Patients in group 2 had less of a change in penile length from flaccid to erect state (36% vs. 44%, p=0.02), higher EDV (12.0 vs. 8.5, p=0.041), lower RI (0.6 vs. 1.0, p=0.046), and more veno-occlusive dysfunction (82% vs. 53%, p=0.001). On multivariate analysis, failure to reach maximum SPL at peak ICI erection (OR 2.255, CI 1.191-4.271, p=0.0126), EDV (OR 1.281, CI 1.115-1.471, p<0.001) and RI (OR 0.694, CI 0.573-0.723, p=0.009) predicted veno-occlusive dysfunction. Failure to reach maximal SPL during PDDU using ICI with a vasodilator agent predicted veno-occlusive dysfunction, which is independent of both penile rigidity and tumescence. This measurement could serve as another diagnostic tool for predicting veno-occlusive dysfunction when PDDU is not readily available. Limitations include the subjective nature of penile measurements and different PGE1 doses used.

MP43-18 ASSESSING THE IMPACT OF AUDIO-VISUAL SEXUAL STIMULATION (AVSS) ON THE NEED FOR REPEAT VASOACTIVE AGENT INJECTION DURING PENILE DUPLEX DOPPLER ULTRASONOGRAPHY

INTRODUCTION AND OBJECTIVES: The accuracy of penile duplex Doppler ultrasonography (DDUS) is optimized using a repeat vasoactive agent-redosing schedule. AVSS has been proposed as a means to achieve complete smooth muscle relaxation during DDUS thus minimizing the need for repeat intracavernosal injections (ICI). Clinical experience has taught us that while some patients are comfortable utilizing adult movies for AVSS, some are not. Our goal was to identify if AVSS decreased the number of ICI needed to achieve optimal penile rigidity. METHODS: Prior to DDUS patients were counseled regarding the potential utility of AVSS during the study. A variety of adult movies were available to the patients. No mandate was made to use AVSS, rather patients were encouraged to view the material only if they felt comfortable doing so. Penile rigidity was recorded on a 10-point scale (0 no tumescence, 10 maximal rigidity) by a single examiner. Patients received repeated ICI up to a total of 3 injections until they achieved rigidity equivalent to their best rigidity at home or until their end-diastolic velocities (EDV) were negative. The number of ICI required to achieve this was compared between those men who opted to use AVSS vs those who opted not to do so. RESULTS: Mean age of 168 men 1⁄4 54 14 years. 87 men used AVSS 81 men did not. Median number of vascular risk factors (VRF) 1⁄4 0 (IQR1⁄41), mean VRF 1⁄4 0.77 1.0, with no difference between the two groups. 27% had an abnormal DUS (8% arteriogenic ED, 18% venous leak, 2% mixed vasculogenic ED), evenly distributed across the two groups. Mean number of ICI used was not significantly different between groups (AVSSþ 1⁄41.9; AVSS1⁄4 1.8 1, p1⁄40.71). Median ICI number 1⁄4 2 for each group. There was a trend toward a higher percentage of men in the AVSS group needing phenylephrine reversal compared to the no AVSS group (43% vs. 30%, p1⁄40.08, RR 1⁄4 1.43, 95% CI: 0.95-2.17). CONCLUSIONS: One should expect an equivalent need for repeat ICI during DDUS in patients who opt to utilize AVSS compared to those who do not. It is possible that patients using AVSS may be more likely to need erection reversal after DDUS completion.

The direction and severity of penile curvature does not have an impact on concomitant vasculogenic erectile dysfunction in patients with Peyronie's disease.

Although the association between Peyronie's disease (PD) and erectile dysfunction (ED) is well established, limited data are available correlating penile curvature and penile hemodynamic parameters. We sought to examine this association in a cohort of PD men undergoing penile duplex Doppler ultrasound (PDDU). PD patients were retrospectively evaluated to correlate the extent and direction of penile curvature with measured vascular parameters. Demographic variables, disease characteristics and PDDU parameters were tabulated and statistically compared based on extent (≤ 45° and >45°) and direction (dorsal, ventral, lateral, ventrolateral, dorsolateral) of curvature. A total of 220 PD patients (mean age of 55.0 ± 9.2 years) underwent PDDU at one institution from January 2008 to December 2010. Overall, 69.5% of patients were found to have vasculogenic ED (arterial insufficiency (AI): 10%; veno-occlusive dysfunction (VOD): 43.2%; AI + VOD: 16.4%). Mean curvature was similar among all PDDU groups (AI: 41.7 ± 5.2°; VOD: 41.3 ± 2.5°; AI+VOD: 37 ± 4.1°; no-ED: 37.3 ± 3°; P > 0.85). No significant differences were noted in the presence or type of ED among various directions of curvature (P = 0.34) or when curvatures were stratified by ≤ 45° and >45°. The direction and extent of penile curvature are not associated with altered rates of vasculogenic ED on PDDU in PD patients.

Erectile dysfunction in men treated for testicular cancer

To study the unique characteristics of erectile dysfunction (ED) in a population of men who developed ED after testicular cancer (TC) diagnosis and treatment. All men treated for TC who presented for sexual function evaluation were included in an institutional database. All men underwent standard evaluation including a history/physical examination, completion of the International Index of Erectile Function (IIEF) questionnaire, testosterone/gonadotropin measurement and penile duplex Doppler ultrasonography (DUS). The study population comprised 76 men whose mean (SD) age was 29 (8) years and of whom 25% were married/had a partner. In all, 39% of the patients had seminoma and 61% had non-seminomatous germ-cell tumour (NSGCT). A total of 66% of patients with seminoma underwent radiation therapy. Of the patients with NSGCT, 79% received chemotherapy, 18% underwent primary retroperitoneal lymph node dissection (RPLND) and 20% underwent post-chemotherapy RPLND. The mean (SD) time before seeking sexual medicine consultation was 12 (7) months after treatment completion, the median (range) number of vascular risk factors was 0 (0-2) and the mean (SD) remaining testis volume was 16 (8) mL. Mean (SD) total testosterone, luteinizing hormone, follicle-stimulating hormone levels were 312 (186) ng/dL, 9 (7) IU/mL, 17 (12) IU/mL. A total of 26% of patients had total testosterone levels <300 ng/dL. In all, 84% of patients complained primarily of loss of erection-sustaining capability and 24% had episodes of transient ED before TC diagnosis. The mean (SD) IIEF erectile function domain score was 16 (7). All the patients (100%) had a normal DUS. Mean (SD) peak systolic and end-diastolic velocities were 48 (16) and 1.2 (2.2) cm/s, respectively. A total of 88% of patients responded to phosphodiesterase type 5 inhibitor (PDE5i) use with erections sufficient for penetration, but 12% did not (mean [SD] erectile function domain score 27 [5] vs 17 [6]). There were no differences in haemodynamics between those men with and without hypogonadism. Men with TC presenting with ED after treatment appear uniformly to have normal erectile haemodynamics, suggesting adrenaline-mediated ED. While the majority of TC survivors with ED respond successfully to PDE5i, a significant minority do not.

PD22-06 EFFICACY OF PENILE TRACTION THERAPY AMONG PATIENTS UNDERGOING INTRALESIONAL INTERFERON TREATMENT FOR PEYRONIE’S DISEASE

You have accessJournal of UrologySexual Function/Dysfunction/Andrology: Peyronie's Disease1 Apr 2014PD22-06 EFFICACY OF PENILE TRACTION THERAPY AMONG PATIENTS UNDERGOING INTRALESIONAL INTERFERON TREATMENT FOR PEYRONIE’S DISEASE Landon Trost, Taylor Peak, Ronny Tan, Suresh Sikka, and Wayne JG. Hellstrom Landon TrostLandon Trost More articles by this author , Taylor PeakTaylor Peak More articles by this author , Ronny TanRonny Tan More articles by this author , Suresh SikkaSuresh Sikka More articles by this author , and Wayne JG. HellstromWayne JG. Hellstrom More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.1857AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Peyronie’s disease (PD) is a fibrosing condition, characterized by penile curvature and is managed with oral, topical, intralesional, and surgical therapies. Currently, controversy exists regarding the role and efficacy of penile traction therapy (PTT) concomitant with intralesional injection (ILI) therapy for PD. We sought to evaluate the efficacy of PTT on PD variables among patients undergoing ILI with interferon alpha-2b (IFN). METHODS A retrospective chart review of all patients undergoing IFN therapy during 2001-2012 was performed. Charts were reviewed for demographic information, objective measures of penile curvature, and vascular status (via penile duplex Doppler ultrasonography). Statistical analyses were performed to compare outcomes of patients using routine PTT versus patients not using PTT. All patients underwent IFN therapy for PD. RESULTS One-hundred, twenty-four patients underwent a median of 12 IFN injections (range 6-24). Mean age was 54 years (range 25-76), and mean pre-treatment curvature was 42.4° (SD 18.6°). Forty-two patients (34%) reported regular use of PTT during the study period. PTT did not impact change in curvature (PTT 7.6° [SD 16.2°] vs. no PTT 9.6° [SD 12.0°], p=0.48) or penile length (PTT +0.04cm [SD 1.2] vs. no PTT +0.13cm [SD 0.8], p=0.67) and was associated with minimal worsening of end-diastolic velocity (PTT 2.0cm/sec [SD 5.9] vs no PTT -1.7cm/sec [SD 4.9], p=0.01). PTT use did not correlate with patient age (p=0.88), pre-treatment erectile function (p=0.53), BMI (p=0.31), years with PD (p=0.65), pre-treatment curvature (p=0.96), changes in peak systolic velocity (p=0.18), or resistive index (0.38). CONCLUSIONS From this data, routine use of PTT during IFN therapy for PD does not affect outcome of therapy related to improvements in penile curvature, length, or vascular status. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e674 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Landon Trost More articles by this author Taylor Peak More articles by this author Ronny Tan More articles by this author Suresh Sikka More articles by this author Wayne JG. Hellstrom More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

Prophylactic phenylephrine for iatrogenic priapism: a pilot study with Peyronie's patients.

PurposeAlthough penile duplex Doppler ultrasonography (PDDU) is a common and integral procedure in a Peyronie's disease workup, the intracavernosal injection of vasoactive agents can carry a serious risk of priapism. Risk factors include young age, good baseline erectile function, and no coronary artery disease. In addition, patients with Peyronie's disease undergoing PDDU in an outpatient setting are at increased risk given the inability to predict optimal dosing. The present study was conducted to provide support for a standard protocol of early administration of phenylephrine in patients with a sustained erection after diagnostic intracavernosal injection of vasoactive agents to prevent the deleterious effects of iatrogenic priapism.Materials and MethodsThis was a retrospective review of Peyronie's disease patients who received phenylephrine reversal after intracavernosal alprostadil (prostaglandin E1) administration to look at the priapism rate. Safety was determined on the basis of adverse events reported by subjects and efficacy was determined on the basis of the rate of priapism following intervention.ResultsPatients with Peyronie's disease only had better hemodynamic values on PDDU than did patients with Peyronie's disease and erectile dysfunction. All of the patients receiving prophylactic phenylephrine had complete detumescence of erections without adverse events, including no priapism cases.ConclusionsThe reversal of erections with phenylephrine after intracavernosal injections of alprostadil to prevent iatrogenic priapism can be effective without increased adverse effects.

The influence of different metabolic syndrome definitions in predicting vasculogenic erectile dysfunction: is there a role for the index of central obesity?

Aims: Analyze the capacity of ICO, the ratio of waist circumference (WC) and height, in predicting hemodynamic impairment in Erectile Dysfunction (ED) patients, independently and integrated in Metabolic Syndrome (MetS) definitions.Methods: Four hundred and eighty-five ED patients followed in Urology consult from January 2008 until March 2012 were evaluated by a standardized protocol: health questionnaire, anthropometric measurements (AM), blood pressure and analysis, and Penile Duplex Doppler Ultrasound (PDDU) exam. Associations between AM and MetS definitions, including ATPIII, IDF and a new definition replacing WC by ICO in ATPIII MetS definition (ModATPIII), and PDDU were calculated.Results: ICO was the measure of obesity more strongly correlated with diminished mean Peak Systolic Velocity (mPSV) (r = −0.189, p < 0.001). A positive association remained when replacing WC by ICO ≥ 0.60 (a nationally obtained ratio) in ATPIII MetS definition (ModATPIII). Patients with ModATPIII had lower mPSV when compared to non-MetS patients (30.8 versus 37.1, p < 0.001). Only the IDF definition had a significant association with AD (OR = 1853; 95%CI, 1.202–2.857).Conclusions: ICO revealed potential value to predict PDDU changes in a MetS context. However, IDF definition presented a stronger correlation with arteriogenic ED. Although longitudinal studies are necessary to confirm this hypothesis, our study highlights the importance of different MetS definitions for ED assessment.

Endothelial function in patients with metabolic syndrome and erectile dysfunction: a question of Angiopoietin imbalance?

Erectile dysfunction (ED) is a highly prevalent disease whose aetiology is mostly vasculogenic. It is nowadays considered a marker of future cardiovascular events reflecting the underlying endothelial dysfunction, the common link with the metabolic syndrome (MetS). The recent association between MetS, endothelial dysfunction and peripheral artery disease, but not with coronary artery disease (CAD), suggests that the pathophysiologies of CAD and peripheral artery disease may be distinct. Moreover, several recent studies support an emerging role for an imbalance of angiogenic growth factor levels like Angiopoietin 1 and 2 in cardiovascular disease, considering its intimate association with chronic low-grade inflammation. We aim to find a correlation between Angiopoietins levels and systemic and local endothelial function in MetS and ED patients. Forty-five MetS patients with ED were enrolled. ED severity was assessed by International Index of Erectile Function questionnaire (IIEF5) and penile duplex Doppler ultrasound (PDDU). Endothelial function was assessed by Peripheral arterial tonometry (PAT), and serum asymmetric dimethylarginine (ADMA), Ang1 and Ang2 levels. Obesity and hypertension were the most frequent MetS parameters (91.1 and 88.9% respectively). Severe ED was present in 35.6% of patients. Penile haemodynamic was impaired in 77.5%. Endothelial dysfunction (PAT criteria) was present in 40.9% of patients. Ang2 levels were significantly higher in men with abdominal obesity. We observed an inverse correlation between Ang1 and peak systolic velocity, and in patients with penile arterial dysfunction, Ang1 levels were significantly higher and Ang2/Ang1 ratio significantly lower, than patients with normal arterial function. Neither ADMA nor PAT parameters were correlated with ED severity evaluated by IIEF5 or PDDU exam. In conclusion, there is an imbalance of angiopoietins in MetS and ED patients. The absence of correlation with PAT or ADMA levels suggests that angiopoietins may be early markers of endothelial dysfunction in this population of higher cardiovascular risk.

Defining the aetiology of erectile dysfunction in men with chronic pelvic pain syndrome

Men presenting with chronic pelvic pain syndrome (CPPS) frequently report concomitant erectile dysfunction (ED), but the underlying cause of ED in this patient population has not been previously studied. This study prospectively investigated the aetiology of ED in men with CPPS. The study population comprised 46 men with penile pain or dysorgasmia, and concomitant ED. All participants completed the NIH-CPSI and international index of erectile function- erectile function domain (IIEF-EFD) questionnaires, and underwent penile duplex Doppler ultrasonography (DUS), following intracavernosal trimix injection, to evaluate erectile hemodynamic parameters. Pearson's correlation between NIH-CPSI and IIEF-EFD scores, and between NIH-CPSI score and the erectile response to trimix injections was investigated. The prevalence of mild, moderate and severe CPPS symptoms was 26, 48 and 26% respectively. The severity of ED was mild, moderate or severe in 15, 61 and 24% of men respectively. NIH-CPSI and IIEF-EFD scores were negatively correlated (r=-0.32, p=0.002). Peak systolic velocity (PSV) and end-diastolic velocity (EDV) were normal in 96 and 100% of men respectively. The majority of men (78%) required ≥2 trimix injections to attain an adequate erection for DUS. NIH-CPSI scores and the number of trimix injections needed were positively correlated (r=0.22, p=0.035). The aetiology of erectile dysfunction in men who present with CPPS and concomitant ED is almost always psychogenic. Penile DUS in this population of men is fraught with the potential for error, and frequently necessitates more than one dose of a vasoactive agent.

Penile vascular indices in surgically treated and conservatively treated penile fracture: does conventional immediate repair matter?

To investigate the impact of immediate surgical repair and conservative treatment of penile fracture (PF) on penile vascular indices. The study includes 146 surgically treated (group 1), and 56 conservatively treated patients (group 2). All of the participants underwent penile duplex Doppler ultrasonography (PDDU), and Doppler parameters including the peak systolic velocity (PSV), end diastolic velocity (EDV), and resistive index (RI) were measured in both corpora at baseline and after intracavernosal injection of 20 μg prostaglandin E1. Univariable and multivariable Cox regression analysis addressed study variables. An increased number of men in group 2 (25.0%) compared with men in group 1 (19.2%) reported ED, but the difference did not reach statistical significance (P=0.06). In patients with ED the mean PSV did not differ significantly between the group 1 (30.1±4.02 cm/s) and group 2 (30.1±4.02 cm/s) (P=0.32). Also, in patients without ED, the mean PSV for group 1 (82.4±24.1 cm/s) subjects did not differ significantly from the means for the group 2 patients (79.4±27.2 cm/s) (P=0.21). Vascular hemodynamics in fractured corpus cavernosum did not differ significantly between two groups (P=0.08). Current method of surgical treatment does not provide better outcome in terms of erectile function and penile vascular hemodynamics.

Are All Metabolic Syndrome Components Responsible for Penile Hemodynamics Impairment in Patients with Erectile Dysfunction? The Role of Body Fat Mass Assessment

Erectile dysfunction (ED) is a common disease that is mostly vasculogenic in nature. ED correlates with cardiovascular risk factors, with endothelial dysfunction being the common link. Hypertension (HTA) and insulin resistance are the most important determinants of arteriogenic ED, and are also components of the metabolic syndrome (MetS), which supports a strong association between MetS and ED. However, MetS and, specifically, obesity interference on penile hemodynamics is still controversial. To evaluate the impact of independent MetS criteria and obesity on penile duplex Doppler ultrasound (PDDU) parameters in men with ED. Consecutive patients (n = 212) referred to a unit of PDDU were evaluated for cardiovascular risk factors and MetS (ATP III criteria). Body mass index and body fat percentage (BF%) were calculated. Each patient underwent a PDDU by the same investigator. Data are expressed as mean ± standard deviation, and statistical significance was considered at P level < 0.05. Statistical analysis of clinical, laboratory, and PDDU parameters was performed with SPSS® software. To evaluate the individual power of MetS clusters and obesity as predictive factors for penile hemodynamic changes namely mean peak systolic velocity (mPSV). MetS was present in 24.8% of men, and 80.8% of them presented penile hemodynamics alterations, with mPSV significantly lower comparatively to no MetS patients (29.0 vs. 35.4 cm/s, P = 0.004). Multivariate analysis demonstrated that, considering all MetS parameters, only HTA was significantly associated with diminished mPSV. However, after further adjustment for all cardiovascular risk factors, BF% remained the sole independent clinical factor for penile hemodynamics impairment. There is a strong association between MetS and ED, but within MetS criteria, only HTA was independently associated with the deterioration of penile hemodynamics parameters. Although the classical methods of evaluating obesity in MetS were not individually associated with PDDU impairment, BF% represented by itself an excellent predictor of vascular ED.

Feasability of a Novel Audio-Video Sexual Stimulation System: An Adjunct to the Use of Penile Duplex Doppler Ultrasonography for the Investigation of Erectile Dysfunction

Penile color Doppler ultrasonography (CDUS) with pharmacotesting has become an important tool for evaluating vascular erectile dysfunction (ED), and audio-visual sexual stimulation (AVSS) has been suggested to be helpful in assisting the performance of CDUS during the examination. To investigate the feasibility of using a novel, remotely controllable AVSS system to assist CDUS. This prospective randomized cross-over study recruited 60 consecutive ED patients. Each patient received three randomized sessions of CDUS under different conditions-AVSS, intracavernous injection (ICI) of alprostadil 20 microgram, or AVSS plus ICI. Clinical responses (rigidity) and penile vascular parameters including peak systolic velocity (PSV), end diastolic velocity (EDV), and resistive index (RI) were measured. At the end of the study, patients were asked about how they perceived the AVSS system in generating sexual arousal. PSV, EDV, RI, and rigidity. Fifty-eight ED patients (aged 21-79) underwent 174 sessions of CDUS. The mean PSV and maximal rigidity of patients under ICI alone were significantly greater than those of patients under AVSS alone (48.25 ± 22.78 vs. 36.54 ± 23.25 cm/second and 65.00 ± 23.93% vs. 43.28 ± 31.79%, respectively; both P < 0.05). The mean PSV of patients under AVSS plus ICI (55.38 ± 28.81 cm/second) was significantly greater than that of patients under ICI alone (P < 0.05), while the mean maximal rigidity (72.50 ± 22.03%) was only marginally greater (P = 0.082). EDV or RI was of no significant difference among the different conditions. Ultrasonographic diagnoses of ED under different conditions varied substantially. Fifty-four (93%) patients considered the AVSS system "very satisfactory" or "satisfactory" in evoking sexual arousal. The novel, remotely controllable AVSS system is well accepted by patients and, in conjunction with ICI, helps to produce higher PSV for patients undergoing CDUS.

Association of the T‐786C, G894T and 4a/4b polymorphisms of the endothelial nitric oxide synthase gene with vasculogenic erectile dysfunction in Iranian subjects

• To investigate the association of the T-786C, G894T and variable number of tandem repeats (VNTRs) in intron 4 (a/b) polymorphisms of the eNOS gene in Iranian subjects with vasculogenic erectile dysfunction (ED). • A total of 322 consecutive patients with vasculogenic ED were recruited. Patients with concomitant risk factors for ED were excluded. • Patients with ED were identified based on history-taking, detailed physical examination, serum biochemistry, sex hormone measurements, application of the International Index of Erectile Function (IIEF) questionnaire, and penile duplex Doppler ultrasonography after intracavernosal injection of 20 µg prostaglandin E(1) . The control group comprised 318 age-matched healthy male volunteers. • Genotyping was performed by polymerase chain reaction-restriction fragment length polymorphism and the T-786C, G894T and VNTR intron 4 polymorphisms of the eNOS gene were determined. • After multivariate regression analysis, significant differences were seen in the frequencies of genotypes and alleles of the two T-786C and G894T polymorphisms when patients with ED and normal controls were compared. • In a multiple logistic regression analysis, the odds ratio (OR) of increased ED was strongly associated with the -786C allele [adjusted OR = 3.12, 95% confidence interval (CI) = 2.28-4.25; P= 0.001] and the 894T allele (adjusted OR = 3.87, 95% CI = 2.53-4.87; P= 0.001). • The data showed a higher prevalence of the T-786C CC genotype (adjusted OR = 2.72, 95% CI = 1.88-3.65; P= 0.006), and the G894T GT (adjusted OR = 1.72, 95% CI 1.24-2.83; P= 0.037) and G894T TT genotypes (adjusted OR = 3.42, 95% CI 2.42-4.26; P= 0.001) in patients with ED than in the controls. • The findings of the present study suggest that the eNOS T-786C and G894T polymorphisms are strong predictors of the predisposition to ED in addition to traditional risk factors, signifying a genetic influence for this multifactorial disease. • Further studies in different ethnic populations are needed to better elucidate the role of eNOS gene polymorphism in the pathogenesis of ED.

Can the International Index of Erectile Function distinguish between organic and psychogenic erectile function?

To define the ability of the International Index of Erectile Function (IIEF) to differentiate between organic and psychogenic erectile dysfunction (ED). Patients presenting for the evaluation and treatment of ED who had penile duplex Doppler ultrasonography (DUS) completed the IIEF questionnaire. Accepted ranges of the IIEF EF domain were used to grade baseline severity (severe, moderate and mild < or =11, 11-17, 18-25, respectively). Accepted criteria were used to define normality on DUS (peak systolic velocity >30 cm/s and end-diastolic velocity <5 cm/s). Patients with documented Peyronie's disease, hypogonadism and a history of radical prostatectomy were excluded. In all, 112 patients were enrolled, with a mean (sd) age and duration of ED of 56 (16) and 2 (0.6) years, respectively. The vascular risk-factor profile included diabetes in 15%, hypertension in 26% and hyperlipidaemia in 20%. The baseline severity of ED was mild, moderate and severe in 28%, 41% and 32% men, respectively. All patients had normal testosterone levels. Patients also with a normal DUS were diagnosed with psychogenic ED, in 50%, 13% and 17% of men with mild, moderate and severe ED by the IIEF, respectively. No patient with venous leak had mild ED, and 62% of men with venous leak had severe ED. These results indicate that the IIEF is not completely accurate in differentiating between organic and psychogenic ED, and that almost a fifth of men in this study population with severe ED by the IIEF had normal erectile haemodynamics. These data have potential ramifications for evaluating the baseline severity of ED in trials of erectogenic agents.