Pharmaco-penile Duplex Ultrasonography Research Articles

065 Perspectives of Non-contrast MRI for Penile Veins Visualization

Pharmaco-Penile Duplex Ultrasonography (PPDU) and Dynamic infusion cavernosometry and cavernosography (DICC) currently are the conventional methods for penile veins examination and veno-occlusive erectile dysfunction (VOD) diagnosis. CT cavernosography is a useful technique that is gaining popularity. The possibilities of MRI for penile veins anatomy study and assessment of the vein leakage were studied less.

Folic acid levels in erectile dysfunction patients

Introduction Erectile dysfunction (ED) is the persistent inability to achieve and maintain an erection to permit satisfactory sexual activity. This study aimed to evaluate the association between serum folic acid (FA) level and ED evaluated by International Index of Erection Function 5 score (IIEF-5 score) and penile duplex ultrasonography. Patients and methods The study included 30 ED patients and 30 persons as controls within the age group of 20–50 years. FA levels were measured using enzyme-linked immunosorbent assay for all patients and controls. All patients and controls were asked to complete the IIEF-5. ED patients underwent pharmacopenile duplex ultrasonography. Results There was statistically significant lower serum FA level in the patient group than control group. There was statistically significant positive correlation between serum FA levels and IIEF-5 scores. There was also statistically significant lower serum FA level among ED patients with arterial insufficiency, venous leakage, and mixed vascular affection than those with normal penile duplex; Also, there were lower serum FA level in patients with arterial insufficiency and mixed vascular affection than those with venous leakage patients. Conclusion A significant lower FA levels was detected in ED patients; FA level correlated positively with IIEF-5 score. FA levels were significantly lower in ED patients with vasculogenic affection detected by penile duplex ultrasound compared with ED patients without vasculogenic affection. FA supplementation is recommended in the treatment of ED.

Relation of pharmacopenile duplex ultrasonography parameters and glycated hemoglobin (HbA1c) in diabetic patients with erectile dysfunction

Introduction and objectivesErectile dysfunction (ED) is one of the main threats in diabetic patients. This research aimed to assess the relationship between glycated hemoglobin (HbA1c) level and pharmacopenile duplex ultrasonography (PPDU) indices in diabetic patients with ED. Materials and methodsA total of 130 males with ED were recruited (100 had diabetes mellitus (DM) and 30 did not as control). The International Index of Erectile Function (IIEF) was used to evaluate patients for ED. Measurement of HbA1c, lipid profile and assessment of erectile function using PPDU were performed. All participants were assessed to take the medical history. ResultsThe mean age±SD was 53.8±8.9 and 53.6±2.8 years for patients and controls, respectively. Patients had variable grades of ED: mild in 20%, mild to moderate in 32.3%, moderate in 35.3%, and severe in 12.3%. A significant association was found between the existence of DM and a deprived response to intracorporeal injection (ICI), rising end-diastolic velocity (EDV), and reducing resistance index (RI) values. Comparing all diabetic groups according to HbA1c with controls, a significant relationship was found in; severity of IIEF-5 score, poor response to ICI, decreased peak systolic velocity (PSV) at 10min, increased EDV at 10, 20min and decreased RI at 10, 20min. A significant relationship was found between smoking, dyslipidaemia, and decreased PSV at 10, 20min and decreased increment ratio. However, a non-significant relationship was observed between age, type of DM and PPDU parameters. ConclusionPoor glycaemic control of DM is associated with an increase in EDV and decrease in RI, and PSV of PPDU.

732 - Determination of cutoff values for resistive index during pharmaco penile duplex ultrasonography in patients with vasculogenic veno-occlusive erectile dysfunction

732 - Determination of cutoff values for resistive index during pharmaco penile duplex ultrasonography in patients with vasculogenic veno-occlusive erectile dysfunction

UP82 - Pharmaco penile duplex ultrasonography in the evaluation of patients with veno-occlusive erectile dysfunction

UP82 - Pharmaco penile duplex ultrasonography in the evaluation of patients with veno-occlusive erectile dysfunction

Daily Oral l-Arginine Plus Tadalafil in Diabetic Patients with Erectile Dysfunction: A Double-Blinded, Randomized, Controlled Clinical Trial

IntroductionErectile dysfunction is a common condition among diabetic men. Many treatments are now available with variable responses. AimThis study aimed to evaluate the effect of daily oral l-arginine plus tadalafil in diabetic patients with mild to moderate erectile dysfunction. MethodsA double-blinded, randomized, controlled clinical trial was conducted with 108 diabetic male patients. Each patient was assessed by medical and sexual histories, International Index of Erectile Function 5-item questionnaires, pharmaco-penile duplex ultrasonography, and serum testosterone level. Main Outcome MeasureImprovement in International Index of Erectile Function 5-item, serum testosterone level and pharmaco-penile duplex ultrasonography. ResultsErectile functions were significantly improved in all patients after treatment as compared with baseline and placebo (P < .001). Patients who received both drugs showed significant improvement compared to those treated with single drugs, as assessed by International Index of Erectile Function scores and total testosterone (P < .001). Pharmaco-penile ultrasound duplex results showed non-significant differences among patients treated with both drugs and those with each drug alone. ConclusionDaily use of l-arginine with tadalafil significantly increased the International Index of Erectile Function scores and total testosterone levels as compared to each drug alone in diabetic patients with erectile dysfunction. No differences were found based on pharmaco-penile duplex findings.El Taieb M, Hegazy E, Ibrahim A. Daily Orall-Arginine Plus Tadalafil in Diabetic Patients with Erectile Dysfunction: A Double-Blinded, Randomized, Controlled Clinical Trial. J Sex Med 2019; 19:1390–1397.

Platelet Indices as a marker for early prediction of erectile dysfunction in diabetic patients.

Erectile dysfunction is one of the major concerns in diabetic patients. Platelet Indices including mean platelet volume, platelet count and platelet distribution width are important biomarkers for platelet activation and pathophysiology of atherothrombosis. Measurement of Platelet Indices may early predict erectile dysfunction in diabetic men. This study aimed to measure Platelet Indices in diabetic patients with erectile dysfunction and to correlate between them and erectile dysfunction especially of vasculogenic type. The study included 30 diabetic patients with diagnosed erectile dysfunction and 20 normal males as a control. Each patient was evaluated by history, International Index of Erectile Function-5, general and local examination, HbA1c, pharmaco-penile duplex ultrasonography and blood sample to measure Platelet Indices. Platelet distribution width and mean platelet volume were significantly higher in patients than controls (p<0.001). Their levels were significantly higher in vasculogenic erectile dysfunction than other types (p<0.001). No statistically significant association regards the platelet count (p>0.05). We concluded that Platelet Indices are high in diabetic patients with erectile dysfunction especially those with vasculogenic aetiology. They can predict erectile dysfunction in diabetic men early, and so they may be considered as cheap, available and useful biomarker for early diagnosis of vasculogenic erectile dysfunction in diabetic patients.

How to avoid the false diagnosis of venous leakage by pharmaco-penile duplex ultrasonography?

Objectives The aim of the present study to carefully reassess the erectile hemodynamic status in men previously diagnosed with venous leak on penile duplex ultrasonography (DUS) under the guidelines of the Australasian Society for Ultrasound in Medicine (ASUM). Background Erectile dysfunction (ED) is a widespread problem affecting men across all age groups (about 50% in 40–70-year age group) and disturbing the quality of life of sexually active men. Vascular insufficiency is one of the major causes of ED. DUS is a useful, minimally invasive method for evaluating penile hemodynamics in patients with ED, but has a propensity to inaccurately assign a diagnosis of venous leak. Patients and methods Fifty patients from 18 to 50 years olds selected from the Andrology Unit, Dermatology and Andrology Department, Faculty of Medicine, Menoufia University, Egypt were included in the study. All cases were subjected to the following: detailed history, thorough clinical examination, routine and hormonal investigations, and imaging studies including re-evaluation through DUS under the guidelines of ASUM. Results Overall, 50% of the patients previously diagnosed with venous leak were shown to be normal when re-evaluated under the guidelines of ASUM. The other 50% demonstrated a significant improvement in the value of end diastolic velocity (EDV). The study demonstrated a significant increase in the value of peak systolic velocity in repeated DUS with a mean difference of 10.29, and a significant decrease in the value of EDV with a mean difference of 4.19 compared with the original DUS. Our results indicated a significant negative correlation between age and value of peak systolic velocity, and an insignificant positive correlation between age and value of EDV for all participants, in both original and repeated DUS. Conclusion Careful assessment should be carried out when performing DUS, especially in younger men without a significant vascular risk factor in history for ED, to avoid misdiagnosis of venous leak.

Pharmaco Penile Duplex Ultrasonography in the Evaluation of Erectile Dysfunction.

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

Clinical predictive factors of sildenafil response: a penile hemodynamic study.

Phosphodiestrase-5 inhibitors are an important line of treatment for erectile dysfunction (ED). To detect the clinical and hemodynamic predictors of sildenafil response, we conducted this study on 124 Egyptian men with ED. All patients were evaluated by thorough history and clinical assessment with measurement of the abridged international index of erectile function-5 (IIEF-5) score. All patients were then subjected to intracavernosal injection (ICI) of trimix and pharmaco-penile duplex ultrasonography (PPDU). Patients were then classified into sildenafil responders and non-responders after six consecutive doses of 100 mg sildenafil. On doing the binary logistic stepwise regression analysis, only ED duration, IIEF-5 score, and response to ICI were the significant independent predictors of sildenafil response. These three parameters together correctly predicted the sildenafil response by 81.5% (p value <0.001). With the receiver operator characteristic curve analysis, the cut-off value of ED duration was 2.5 years and it was 14 for the IIEF-5 score. These findings indicate that ED duration, the IIEF-5 score and response to ICI are more significant predictors of sildenafil response than the more expensive and time-consuming PPDU testing.

A study of the possible effects of repeated intracorporeal self-injection of vasoactive drugs in patients with elevated end diastolic velocity during pharmacopenile duplex ultrasonography.

IntroductionThe aim of the work is to evaluate the effect of repeated intracavernosal self-injection of vasoactive drugs in patients with elevated End Diastolic Velocity (>5 cm/sec) during pharmacopenile duplex ultrasonography (PPDU).MethodsDuplex evaluation was performed to the patients on self-injection therapy for comparison of end diastolic velocity and resistive index before and after completing the eight doses of IC self-injection.ResultsAfter the 8 trials of home therapy, 21 (52.5%) patients showed improvement in the duplex parameters regarding the end diastolic velocity, ten of them showed improvement in the EDV to the level of <5 cm/sec. The effect of different factors that may contribute to the improvement in EDV to <5 cm/sec are shown in the table 2. Age was the only predictive factor for successful response to home therapy intracavernous injection (ICI). Improvement in erectile response was assessed before and after the course of the therapy. Erection response to ICI during penile duplex improved in only six patients (E4 & E4-5)) to the point that it was sufficient for satisfactory sexual performance, 3 of them (7.5%) regained spontaneous erection and stopped using ICI (table 3). The IIEF score was 10.6 ±2.8 before the home therapy and it became 14 ±3.9 one month after completing the treatment course (P value <0.001).ConclusionsEarly rehabilitation of the patients with venous leakage ED using ICI may help to regain normal erection and avoid unnecessary penile prosthesis surgeries.

An Assessment of the Efficacy and Safety of Sildenafil Administered to Patients with Erectile Dysfunction Referred for Posterior Urethroplasty: A Single‐Center Experience

Urethral trauma is often associated with erectile dysfunction (ED). Reconstructive surgery is complex and may impact negatively on sexual function. The aim of this article is to investigate ED in patients with pelvic fracture urethral distraction defects (PFUDD) who underwent urethroplasty, and efficacy of treatment with sildenafil citrate. A total of 41 patients with urethral stricture who suffered from PFUDD were assessed to exclude systemic diseases that may cause ED, such as hypertension, diabetes mellitus, heart disease, and chronic liver disease. The International Index of Erectile Function-5 was used as an evaluation tool. Assessments were made at three time points: the time of admission, two weeks after urethroplasty, and 3 months post-treatment with sildenafil. Pharmacopenile duplex ultrasonography was used to examine blood flow of the cavernosum in order to distinguish arterial ED, venous ED, and nonvascular ED. All patients were treated with oral sildenafil, 100 mg once daily, three times a week, for 3 months. The incidence of ED following injury was 95.12%. There were no significant changes in scores following surgery. However, sildenafil had a success rate of approximately 81%, which appeared to be independent of age. Drug treatment seemed most effective for those with less severe ED at the outset. There was no significant difference in scores post-treatment between those who had vascular and nonvascular ED. Overall, the incidence of side effects due to sildenafil was 19.5%. Urethral trauma is frequently associated with ED. Sildenafil citrate is useful in the drug treatment of ED in these patients and appears to be well-tolerated.

Statistical Evaluation of Hemodynamic Effects of Regular Use of Sildenafil on the Human Corpora Cavernosa

Introduction: Sildenafil citrate is currently used on demand in the treatment of erectile failure, regardless of etiology. Nevertheless, recent data suggest a significant improvement in nocturnal penile erections in potent and impotent men taking a single dose at bedtime. The present study analyzes whether continuous use of sildenafil positively correlates with improvement of penile blood flow and treatment satisfaction referred by patients with erectile dysfunction (ED) of vascular origin. Patients and Methods: A total of 32 patients, mean age 54, with ED of vascular etiology, were evaluated at the beginning and at the end of our study using the International Index of Erectile Function (IIEF-5) and pharmaco-penile duplex ultrasonography during basic and dynamic phases. These patients were treated with sildenafil (50 mg) twice a week for 4 months. During pharmaco-penile duplex ultrasonography, we measured basal peak flow velocity, basal acceleration of peak flow in both cavernous arteries before intracavernous (i.c.) pharmaco-stimulation, maximum peak flow velocities and end-diastolic flow velocities after i.c. stimulation. The data observed were compared with those of 10 patients with ED who voluntarily decided not to take any treatment. Results and Conclusions: In this study, basal peak flow velocity, basal acceleration, maximum peak flow velocity and IIEF-5 scores were found to significantly increase after treatment. All differences were statistically significant (p < 0.05). Only few mild adverse effects were observed. Our data suggest that the regular use of sildenafil (50 mg) improves the blood flow in cavernous arteries increasing sexual performance in patients with ED of vascular origin.

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

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

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

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

Erectile dysfunction in smokers: a penile dynamic and vascular study.

In this study, we aimed to determine the hemodynamic mechanisms through which cigarette smoking, as an independent risk factor, induces erectile dysfunction (ED). We performed a standard ED evaluation that included history; a physical exam; and serum glucose, testosterone, and prolactin levels. We then excluded ED patients with abnormal androgen profiles and patients with ED risk factors other than smoking. A total of 109 ED patients entered the study, including 71 current smokers and 38 nonsmokers. All patients then underwent extensive evaluation, including nocturnal penile tumescence and rigidity (NPTR) monitoring with Rigiscan, followed by pharmacopenile duplex ultrasonography (PPDU) and redosing pharmacocavernosometry (RPC). Results of the above tests were compared in the smoker and nonsmoker groups. We also performed receiver operating characteristic (ROC) curve analysis to determine which diagnostic parameter is most affected by cigarette smoking. The 4 most significant variates served as input features for a logistic regression model, designed to predict smoking. The average age for smokers and nonsmokers was 44.3 and 51.2 years, respectively (P = .02). Eighty-six percent of smokers had abnormal NPTR testing compared with 55% of nonsmokers (P = .02). The average peak systolic velocity (PSV) was 26.8 and 31.2 cm/s for smokers and nonsmokers, respectively, and this difference was not found to be statistically significant (P = .19) in this study. On performing RPC, an abnormal maintenance flow (MF) of >5 mL/min was detected in 89% of smokers and in 47% of nonsmokers, and the difference was significant (P < .01). With the use of smoking as the outcome, the ROC area of different diagnostic parameters was as follows: 0.79 for penile base rigidity, 0.58 for PSV, and 0.77 for MF. A logistic regression model that used the 4 most significant variates as input features yielded a ROC of 0.857. The results of NPTR testing in our smoker and nonsmoker groups indicated that ED in smokers is mainly of organic etiology. On the basis of the PPDU findings and the higher incidence of abnormal MF in the smoker group and its relatively high ROC value, we concluded that dysfunction of penile veno-occlusive mechanisms plays a substantial role in the development of ED in smokers.

Caverno-Occlusive and Autonomic Dysfunction: A New Concept in Young Patients

We attempted to identify the etiology of erectile dysfunction in 50 male patients with a mean age of 31.4 (25–42) years. The physical and neurological examinations, history, biochemistry and serum testosterone and prolactin levels were within normal limits. Pharmacopenile duplex ultrasonography, corpus cavernosum electromyography (CC-EMG) and cavernosometry were performed. Smooth muscle tone and the relaxation response after intracavernous papaverine and sodium nitroprusside injections were evaluated by CC-EMG. Autonomic dysfunction has been defined as increased electrical activities after visual sexual stimulation and lowered amplitudes despite normal smooth muscle content. Our definition is similar to this: paradoxically increased electrical activities after intracavernous injection. Caverno-occlusive dysfunction (COD) and accompanying pathologies were found in 38 patients (76%) with pure COD in 26 (52%), COD and arterial pathology in 2 (4%) and COD + autonomic dysfunction in 10 patients (20%). Amplitudes of cavernous electrical activity were low in 32 of 38 patients with COD. These high COD and autonomic dysfunction rates led us to examine these pathologies on molecular and electrophysiological bases.