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

Vascular hemodynamic effects of penile revascularization surgery and the role of resistive index in follow-up

BACKGROUND

To evaluate the effects of penile revascularization surgery on penile vascular hemodynamics and to assess the utility of the resistive index (RI) as an objective parameter for postoperative patient follow-up.

METHODS

This study included a total of 35 patients who underwent penile revascularization. Penile color Doppler ultrasonography was performed preoperatively and at the third postoperative month to evaluate cavernosal arteries, dorsal arteries, deep dorsal vein, and inferior epigastric artery. During these evaluations, peak systolic velocity, end diastolic velocity, and resistive index were measured. The International Index of Erectile Function questionnaire was administered before surgery and at the third postoperative month. In addition, corpus cavernosum electromyography and cavernosometry tests were performed in all cases preoperatively. Anastomotic patency was assessed using computed tomography angiography at the end of the follow-up period.

RESULTS

The mean preoperative resistive index values were determined to be 0.74 ± 0.07 and 0.73 ± 0.09 cm/s for the right and left cavernosal arteries, respectively, and these values increased to 0.95 ± 0.09 and 0.96 ± 0.06 cm/s, respectively, at the last postoperative control. The mean International Index of Erectile Function-5, 15 scores for the right and left cavernosal arteries were 8.52 ± 4.83 and 19.4 ± 8.54, respectively, preoperatively, and these scores improved to 15.26 ± 4.50 and 35.76 ± 13.65, respectively, at the last postoperative follow-up.

CONCLUSION

The results of this study suggest that the resistive index can be used as an objective parameter in the diagnosis of erectile dysfunction of vascular origin and in the follow-up and management of the disease following penile revascularization.

TRIAL REGISTRATION

NCT06350019/04/03/2024 (retrospectively registered).

The penile duplex ultrasound: How and when to perform it?

BACKGROUND

Because it is a superficial structure, the penis is ideally suited to ultrasound imaging. A number of disease processes, including Peyronie's disease, penile fractures and tumors, are clearly visualized with ultrasound. Baseline and dynamic assessment of cavernosal arterial changes after pharmaco-stimulation with alprostadil allows standardized diagnosis of arterial and venogenic causes of erectile dysfunction (ED).

OBJECTIVE

To illustrate how to correctly perform flaccid and dynamic penile duplex ultrasound (D-PDU) and in which patients to recommend it.

MATERIALS/METHODS

An extensive search of the literature was carried out on Pubmed with the insertion of the following Medical Subjects Headings (MeSH) terms and keywords "penile color Doppler ultrasound" "peak systolic velocity" "end-diastolic velocity", "acceleration time", "resistance index".

EVIDENCE

In our experience, arterial erectile dysfunction is identified after standardized intracavernous injection (ICI) of alprostadil (10 mcg) when values of peak systolic velocity (PSV) are <35 cm/s and, in the most severe forms, for values <25 cm/s. Arterial insufficiency can also be identified by increased acceleration time (AT) values (>110 ms) and/or by a lack of visualization of helicine arteries at power Doppler mode along with incomplete achievement of penile rigidity. The veno-occlusive incompetence is determined when end-diastolic velocity (EDV) values are >4.5-5 cm/s or in the case of resistance index (RI) values <0.75. The assessment of additional surrogate markers of endothelial dysfunction, that is, intima-media thickness, mean platelet volume (MPV), endothelial progenitor cells (EPC), endothelial cell specific molecule-1(endocan) are also useful in assessing the patient's cardiovascular risk but are still considered investigational in the interpretation of D-PDU results.

CONCLUSION

D-PDU scan after ICI with vasoactive drugs is a safe procedure and represents the gold standard for the diagnostics of penile pathologies and should be performed in men with ED not responding to oral conventional therapies and/or in those requiring accurate stratification of cardiovascular risk.

Erectile dysfunction and cardiovascular risk: a review of current findings

Introduction: A large body of evidence has clearly documented that erectile dysfunction (ED) represents not only a complication of cardiovascular (CV) diseases (CVD) but often an early sign of forthcoming CVD.Areas covered: All the available data from meta-analyses evaluating the association between ED and CV risk were collected and discussed. Similarly, all available meta-analyses investigating the significance of ED as a possible early marker for major adverse cardiovascular events (MACE) were analyzed. In addition, data originally obtained in a Florence cohort, dealing with a large series of patients seeking medical care for sexual dysfunction, will be also reported.Expert opinion: Available evidence indicates that ED represents a risk factor of CV mortality and morbidity. Not only conventional CV risk factors but also unconventional ones, derived from a perturbation of the relational and intrapsychic domains of ED, might play a possible role in CV risk stratification of ED subjects. Finally, penile doppler ultrasound can give important information on CV risk, especially in younger and low risk subjects. The presence of ED should become an opportunity - for the patient and for the physician - to screen for the presence of comorbidities improving not only sexual health but, more importantly, men's overall health.

Impaired masturbation-induced erections: a new cardiovascular risk factor for male subjects with sexual dysfunction

INTRODUCTION

Erectile dysfunction (ED) is considered an early surrogate marker of silent, or even overt, cardiovascular diseases (CVD). However, epidemiological studies take into account only sexual intercourse-related erections. Although autoeroticism is a very common practice, data on masturbation-induced erections as a possible predictor of major adverse cardiovascular events (MACE) are lacking.

AIM

To evaluate the clinical correlates of impaired masturbation-induced erections and to verify the importance of this sexual aspect in predicting MACE.

METHODS

A consecutive series of 4,031 male patients attending the Outpatient Clinic for sexual dysfunction for the first time was retrospectively studied. Among these subjects, 64% reported autoeroticism during the last 3 months, and only this subset was considered in the following analyses. In the longitudinal study, 862 subjects reporting autoeroticism were enrolled.

MAIN OUTCOME MEASURES

Several clinical, biochemical, and instrumental (Prostaglandin E1 [PGE1 ] test and penile color Doppler ultrasound) parameters were studied.

RESULTS

Subjects with an impaired erection during masturbation (46% of those reporting autoeroticism) had more often a positive personal or family history of CVD, a higher risk of reduced intercourse- and sleep-related erections, hypoactive sexual desire and perceived reduced ejaculate volume, and impaired PGE1 test response. Prolactin levels were lower in those having impaired erection during masturbation. In the longitudinal study, unadjusted incidence of MACE was significantly associated with impaired masturbation-induced erections. When dividing the population according to the median age and diagnosis of diabetes, the association between impaired masturbation-induced erections and incidence of MACE was maintained only in the youngest (<55 years old) and in nondiabetic subjects, even after adjusting for confounders (hazard ratio [HR] = 3.348 [1.085-10.335], P = 0.032 and HR = 2.108 [1.002-4.433], P = 0.049; respectively).

CONCLUSION

This study indicates that, in subjects with male sexual dysfunction, evaluating an often neglected sexual parameter, such as masturbation-induced erections, can provide further insights on forthcoming MACE in particular in "low risk" subjects.

Poor response to alprostadil ICI test is associated with arteriogenic erectile dysfunction and higher risk of major adverse cardiovascular events

INTRODUCTION

Intracavernous alprostadil injection (ICI) test has been considered useless in assessing the vascular status of subjects with erectile dysfunction (ED).

AIM

To analyze the clinical correlates of ICI test in patients with ED and to verify the value of this test in predicting major adverse cardiovascular events (MACE).

METHODS

A consecutive series of 2,396 men (mean age 55.9 ± 11.9 years) attending our outpatient clinic for sexual dysfunction was retrospectively studied. A subset of this sample (N = 1,687) was enrolled in a longitudinal study.

MAIN OUTCOME MEASURES

Several clinical, biochemical, and instrumental (penile color Doppler ultrasound; PCDU) factors were evaluated. All patients underwent an ICI test, and responses were recorded on a four-point scale ranging from 1 = no response to 4 = full erection.

RESULTS

Among the patients studied, 16.4%, 41.2%, 40.2% and 2.2% showed grade 4, 3, 2, and 1 ICI test response, respectively. After adjusting for confounders, subjects with grade 1 ICI test response showed reduced perceived sleep-related, masturbation-related, and sexual-related erections when compared with the rest of the sample. In addition, a worse response to ICI test was associated with a higher prevalence of hypogonadism-related symptoms and signs along with lower testosterone levels. The prevalence of both diabetes mellitus and metabolic syndrome was inversely related to ICI test response. Accordingly, dynamic and basal peak systolic velocity (PSV), as well as acceleration at PCDU, decreased as a function of ICI test response. In the longitudinal study, after adjusting for confounders, grade 1 response was independently associated with a higher incidence of MACE (hazard ratio = 2.745 [1.200-6.277]; P < 0.05). These data were confirmed even when only subjects with normal PSV (>25 cm/s) were considered.

CONCLUSIONS

Our results demonstrate that poor ICI test response is associated with several metabolic disturbances and higher incidence of MACE. We strongly recommend performing ICI test with alprostadil in all ED subjects.

Autoeroticism, mental health, and organic disturbances in patients with erectile dysfunction

INTRODUCTION

Masturbation is a common, but often neglected, male sexual behavior.

AIM

To investigate the psychobiological correlates of self-reported masturbation in the last 3 months.

METHODS

A consecutive series of 2,786 heterosexual male patients (mean age 48.4 +/- 13.2) consulting an outpatient clinic for erectile dysfunction (ED) was studied.

MAIN OUTCOME MEASURES

Several hormonal, biochemical and instrumental parameters (penile Doppler ultrasound [PDU]) were investigated. Patients were interviewed, prior to the beginning of any treatment, with Structured Interview on Erectile Dysfunction (SIEDY) and ANDROTEST structured interviews. They also completed the Middlesex Hospital Questionnaire, a brief self-reported questionnaire for the screening of the symptoms of mental disorders in a nonpsychiatric setting.

RESULTS

Among the patients studied, 1,781 (61.9%) reported they had masturbated at least once per month in the preceding 3 months. The frequency of masturbation was inversely related to age (r = -0.329; P < 0.0001) and directly associated with education level (adj r = 0.052, P < 0.05 after adjustment for age). A feeling of guilt during masturbation was reported by 274 (15.4%) patients. After adjusting for age, masturbation was positively associated with testosterone levels, stressful conditions, and both unstable and long-lasting couple relationship. Urogenital problems such as varicocele and prostate abnormalities also increased the chance of masturbation. Reported guiltiness during autoeroticism was associated with psychological disturbances, low prolactin, low testosterone, and increased relational problems. An erection not normal during masturbation was declared by 1,361 (76.4%) patients and associated with a prevalent organic component of ED, because of lower peak systolic velocity PDU and higher SIEDY Scale 1 scores.

CONCLUSIONS

This study indicates that masturbation is a relatively frequent behavior in male subjects with ED. Inquiring about this sexual behavior is an important issue for understanding overall patients' sexual attitudes and behavior.

Cardiovascular risk engines can help in selecting patients to be evaluated by dynamic penile color doppler ultrasound

General dynamic penile color doppler ultrasound (D-PCDU) screening in patients with erectile dysfunction (ED) has been questioned due to an inadequate cost-benefit ratio. The aim of the present study is to evaluate the validity of different risk scores in the identification of patients being screened for arteriogenic ED (AED) at D-PCDU. A consecutive series of 738 patients with ED was studied. AED was defined when peak systolic velocity (PSV) was lower than 25 cm/sec. The assessment of cardiovascular risk was evaluated using different risk engines, derived from the Framingham, the PROCAM and the Progetto Cuore studies. An iterative receiver operator characteristic (ROC) curve analysis was used to determine the most proper threshold for different scales for the screening of AED. Among the patients studied, 52 (7%) had PSV<25 cm/sec. The area under the ROC curves for pathological PSV in relation to cardiovascular risk estimated with different engines was 0.762+/-0.03, 0.716+/-0.03, and 0.667+/-0.03 for Progetto Cuore, Framingham, and PROCAM engines, respectively. Sensitivity and specificity of Progetto Cuore estimated risk were 67%, 71% when a threshold of 15% was chosen. Corresponding figures for Framingham and PROCAM engine were 74%, 57% and 69%, 55%, respectively. If D-PCDU is performed only on patients with cardiovascular risk >15%, who represent about 1/4 of all patients (26.8%), as estimated by Progetto Cuore, about 70% of cases of arteriogenic ED can be identified. Estimated cardiovascular risk, assessed through risk engines, could be used to identify patients who should undergo D-PCDU evaluation for the diagnosis of AED.

Penile doppler ultrasound in patients with erectile dysfunction (ED): role of peak systolic velocity measured in the flaccid state in predicting arteriogenic ED and silent coronary artery disease

INTRODUCTION

The use of the penile peak systolic velocity (PSV) measured in the flaccid state during penile color Doppler ultrasound (PCDU) examination has been questioned without substantial evidence.

AIM

To assess the validity of PSV measured in the flaccid state during PCDU, in patients consulting for erectile dysfunction (ED).

METHODS

A consecutive series of 1,346 (mean age 55.0 +/- 12.0 years) male patients was studied.

MAIN OUTCOMES MEASURES

All patients underwent PCDU performed both in the flaccid state and dynamic (after prostaglandin E1 stimulation) conditions. A subset of 20 subjects with uncomplicated type 2 diabetes underwent diagnostic testing for silent coronary heart disease by means of adenosine stress myocardial perfusion scintigraphy (SPECT). In these subjects penile arterial flow was simultaneously assessed by PCDU before and after systemic adenosine administration.

RESULTS

Flaccid PSV showed a significant (r = 0.513, P < 0.0001) correlation with dynamic PSV. Receiver operating characteristic (ROC) curve analysis demonstrated that when a threshold of 13 cm/seconds was chosen, flaccid PSV was predictive for dynamic PSV < 25 and <35 cm/seconds with an accuracy of 89% and 82%, respectively. Among the subset of patients who underwent SPECT, an impaired coronary flow reserve (ICFR) occurred in nine cases (45%). When the same threshold of <13 cm/seconds was chosen, PSV before SPECT was predictive of ICFR with an accuracy of 80% (area under the ROC curve = 0.798 +/- 0.10; P < 0.05). After adjustment for confounders, anxiety symptoms were related to dynamic PSV (Adj. r = -0.154, P < 0.05) but not to flaccid PSV.

CONCLUSIONS

Our results show that flow in the cavernosal arteries can be routinely evaluated by PCDU in the flaccid state. Performing PCDU only in the flaccid state allows identifying subjects with pathological dynamic PSV with accuracy higher than 80%. Furthermore, our preliminary data suggest that the same examination could identify diabetic subjects with ICFR with an accuracy of 80%.

Duplex ultrasonography detects clinically significant anomalies of penile arterial vasculature affecting surgical approach to penile straightening

OBJECTIVES

To determine the frequency of aberrant penile arterial anatomy in men with Peyronie's disease (PD) and the potential impact on the surgical approach to penile straightening.

METHODS

A retrospective analysis of 63 consecutive men undergoing penile duplex ultrasonography in preparation for penile straightening surgery was performed. They were compared with a group of 61 men with erectile dysfunction (ED) undergoing penile duplex ultrasonography during the same period.

RESULTS

Arterial anomalies distal to the pubic symphysis were noted in 44% of men with PD and 46% of men with ED. The most common anomaly observed was crossing cavernosal arteries seen in 37% of the men with PD and 39% of the men with ED. Distal perforators of the dorsal artery supplying the cavernosal bodies were observed in 10% and 8% of the men with PD and ED, respectively. No difference was found in the overall frequency or type of arterial anomalies between the two groups.

CONCLUSIONS

Men with PD have a high prevalence of arterial anomalies, including distal perforating arteries. Their preoperative evaluation should include duplex ultrasonography with delineation of the penile arterial anatomy. This will aid in surgical planning and potentially prevent maneuvers that may adversely affect the cavernosal blood supply and place the patient at risk of postoperative ED.

Aging and pathogenesis of erectile dysfunction

The prevalence and the severity of erectile dysfunction (ED) increase with advancing age; different pathogenetic factors could contribute to age-related ED. We studied organic, relational and intrapsychic components of ED as a function of patients' age in a consecutive series of 977 patients with ED, using the specifically designed structured interview SIEDY. A complete physical examination and a series of biochemical, hormonal, psychometric and penile vascular tests were also performed. Relational factors seems to be more relevant in patients aged over 60 y, while intrapsychic disturbances play a major role in younger subjects. Organic factors are the most important determinant of ED in all age groups, but their contribution is more important in older patients. In fact, basal and dynamic peak cavernosal velocity at Doppler ultrasound penile examination was reduced in older patients. Among hormonal factors, the body mass index-dependent reduction of testosterone in older patients does not seem to play a crucial role in the pathogenesis of ED. No significant correlation was observed between testosterone level and the severity of ED, although patients reporting hypoactive sexual desire showed significantly lower testosterone levels when compared with the rest of the sample. A better understanding of the relative contribution of age-related pathogenetic factors of ED could be of help in the design of appropriate therapeutic approaches.

Difficulties in achieving vs maintaining erection: organic, psychogenic and relational determinants

Achieving and maintaining a penile erection are two essential components of the male sexual response. It has recently been suggested that distinct molecular mechanism could underlie the two disturbances. The aim of the present study is to verify possible clinical differences on pathogenetic factors underlying difficulties of achieving and maintaining an erection. We studied a consecutive series of 560 patients (aged 51.9+/-12.8 y old) reporting erectile dysfunction (ED), using SIEDY structured interview. Patients were classified into two distinct categories: those with difficulties in maintaining, rather than achieving, an erection (sample A) and those with main problems in achieving an erection (sample B). A complete physical examination and a series of metabolic, biochemical, hormonal, psychometric, penile vascular tests and nocturnal penile tumescence and rigidity evaluations (NPT) were also performed. Sample B patients showed a higher prevalence of organic conditions related to ED, when compared with sample A as confirmed by higher SIEDY scale 1 scores (3[1-5] vs 1[0.1-3] for sample B vs sample A, respectively; P < 0.0001) which explores organic component of ED and higher prevalence of pathological instrumental parameters. No difference among groups was observed for SIEDY scale 2 (relational component) and SIEDY scale 3 (intrapsychic component) of ED. In conclusion, this study shows for the first time that patients with difficulties in maintaining erection are less likely to be affected by organic disturbances interfering with sexual function, when compared with those unable to achieve a valid erection.

Psycho-biological correlates of hypoactive sexual desire in patients with erectile dysfunction

We studied the psychological and biological correlates of hypoactive sexual desire (HSD) in a consecutive series of 428 patients with erectile dysfunction (ED), by using the structured interview SIEDY. A complete physical examination and a series of biochemical, hormonal, psychometric, and penile vascular tests were also performed. Among the patients studied, 22.8% reported a mild, 12.9% a moderate, and 4.6% a complete loss of sexual interest. Patients reporting HSD showed significantly lower testosterone (T) levels than the rest of the sample, although the prevalence of hypogonadism (T<10 nM) was comparable in the two groups. Only a minority (<2%) had severe hyperprolactinemia (>700 mU/l), which, nonetheless, was closely associated with a relevant HSD. Both mental disorders and use of medication interfering with sexual function were significantly associated with HSD, as well as depressive and anxiety symptoms. HSD patients showed significantly higher scores in SIEDY scale 2, which explores the relational component of ED. In particular, perceived partner's libido and climax were crucially associated with an impairment of patients' sexual desire. In conclusion, HSD in ED is associated with several biological, psychological, and relational factors that can be simultaneously identified and quantified using the SIEDY structured interview.

Evaluation of penile perfusion by color-coded duplex sonography in the management of erectile dysfunction

The etiology of erectile dysfunction is wide ranging. Penile vascular disorders may result in impaired erection or complete impotence. Almost 30% of erectile dysfunction is due to the presence of systemic disease which affects the blood supply to the penis. The intracavernosal injection test with prostaglandin E1 alone offers limited information on the vascular status. In accordance with the increasing demand for less invasive procedures, penile color-coded duplex sonography (CCDS) combined with the pharmaco-erection test represents a first-line noninvasive approach to investigate arterial and veno-occlusive function. Peak systolic velocity and a change in cavernous artery diameter are indicators of arterial inflow, while the pathological end diastolic velocity and resistance index point out veno-occlusive dysfunction. The combined investigation of power and standard color Doppler ultrasound may yield more details of penile vascular anatomy.

Anatomic variations of cavernous arteries and their effect on measurement of hemodynamic parameters: a power Doppler study

OBJECTIVES

To assess the cavernous arterial (CA) anatomy with power Doppler imaging and evaluate the effects of any anatomic variations on the measurement of hemodynamic parameters.

METHODS

Thirty-three patients with and 26 without a vascular component to their erectile dysfunction were examined. The CA anatomy was evaluated, and hemodynamic variables were measured at multiple sites, including sites in each artery, if multiple CAs were present.

RESULTS

The frequency of anatomic variation was similar between the two groups. A single CA, considered normal, was observed in 57.7% of 52 corpora in the nonvasculogenic group and in 63.6% of 66 corpora in the vasculogenic group. Seven patients (26.9%) in the nonvasculogenic group and 11 (33.3%) in the vasculogenic group had CA anatomy that was different between the right and left corpora. In both groups, a single CA ordinarily showed at least a 35.0% decrement in the mean peak systolic velocity (PSV) between the crura and the proximal shaft; double, triple, and bifurcated CAs also had distally decreased PSV. However, two corpora with a single CA showed an increased PSV distally; in 1 patient, arterial communication between the corpora was responsible. In 86.7% of corpora with double CAs in the vasculogenic group and in 52.6% in the nonvasculogenic group, the CA distant from the crura showed a greater PSV than that near the crura.

CONCLUSIONS

CA anatomy is variable, and the PSV differs between sites, irrespective of the presence of a vascular component to erectile dysfunction. Thus, anatomic variations should be considered when interpreting Doppler sonography.

Sildenafil citrate vs intracavernous alprostadil for patients with arteriogenic erectile dysfunction: a randomised placebo controlled study

We compared the effectiveness of sildenafil citrate and alprostadil in improving arterial penile inflow (peak systolic velocity (PSV)) and penile rigidity in 55 patients with erectile dysfunction caused by atherosclerosis. A total of 35 patients with pure vasculogenic impotency were randomly assigned to alprostadil (Av group; n=11), sildenafil (Sv group; n=12), or placebo (P group; n=12), and 20 patients with nonvasculogenic impotency were randomly assigned to alprostadil (A group; n=10) or Sildenafil (S group; n=10): Av and A used alprostadil injection (capable of giving a full erection) once a week for 1 month, Sv and S took daily oral sildenafil (25 mg) for 1 month, and P took daily oral placebo for one month. The PSV was measured with Duplex sonography and penile rigidity was assessed using the IIEF-15 questionnaire, both of which were administered before and after treatment. Although both treatments improved penile rigidity, they increased PSV only in the Av and Sv groups. Our results suggest that alprostadil and oral therapy should be the starting therapy in men with vasculogenic impotency, whereas alprostadil should be avoided as the first-line approach in men with nonvasculogenic impotency.

Erectile dysfunction: symptom or disease?

Erectile dysfunction (ED) has been defined by the National Institute of Health (NIH) as the inability to achieve and/or to maintain an erection for a sufficiently long period of time so as to permit satisfactory sexual intercourse. ED affects millions of men throughout the world and could have a negative influence on the individual's well-being as well as on the quality of life of affected subjects. Discordant data have been reported on ED epidemiology with prevalence ranging from 12% to 52%, probably depending on the different criteria utilized in the different studies for patient selection. ED is a symptom, sometimes the first, of different pathological conditions. In 15.7% of 45-yr-old patients with vascular ED a dynamic ergometric test has shown electrocardiographic alterations in the absence of any cardiac symptom. In 15% of the patients with ED, high fasting glucose plasma levels are discovered for the first time and in patients with ED and normal fasting glucose plasma levels the prevalence of undiagnosed diabetes mellitus is 12.1% after an oral glucose tolerance test (OGTT). The different risk factors are often additive in the possible development of systemic vasculopathy, neuropathy and ED. ED, underestimated in clinical practice due to archaic prejudice which hinders the patient in spontaneously revealing the problem and the physicians in investigating it, can mark the point where evaluation and prevention of important diseases (such as diabetes, arterial hypertension, atherosclerosis) hitherto unknown by the patients, can begin. The physicians' cultural baggage must include the ability to identify the pathology that can determine ED and the ability to program a specific diagnostic workup. In this paper the different specialists involved in ED diagnosis agreed that a clinical approach which allows the identification of systemic pathologies contributing to the development of ED constitutes an improvement in disease prognosis and may either induce a spontaneous reduction of ED or facilitate its specific treatment.

Colour Doppler ultrasound of the penis

Because it is a superficial structure, the penis is ideally suited to ultrasound imaging. A number of disease processes, including Peyronie's disease, penile fractures and penile tumours, are clearly visualized with ultrasound. An assessment of priapism can also be made using spectral Doppler waveform technology. Furthermore, dynamic assessment of cavernosal arterial changes after pharmaco-stimulation allows diagnosis of arterial and venogenic causes for impotence. This pictorial review illustrates the range of diseases encountered with ultrasound of the penis.

Structured interview on erectile dysfunction (SIEDY): a new, multidimensional instrument for quantification of pathogenetic issues on erectile dysfunction

The aim of the present study is the definition of a brief structured interview (SI) providing scores useful for identification and quantification of pathogenetic factors of erectile dysfunction (ED). A SI was developed and applied to a consecutive series of 320 ED patients. A 13-item SI, with three-factor analysis-derived scales, was identified and applied for validation to an independent consecutive series of 194 ED patients. PGE(1) (10 microg) intracavernosal injection, penile duplex ultrasound (PDU), blood hormones, PSA, glycemia, and lipids were used for the assessment of an organic component (OC), and Middlesex Hospital Questionnaire (MHQ) modified for psychological disturbances. Scale 1, dealing with OC, showed a positive correlation with age, BMI, blood pressure, glycemia, and inverse correlation, with testosterone, PGE(1) and several parameters derived from PDU. Scale 2, related to partner's relationship, was not correlated with organic parameters. Scale 3, which measures psychopathological traits was correlated with MHQ scales. Scale 1 (>3) had a sensitivity of 67.9% and a specificity of 67.6% for OC. SIEDY((c)) provides information on ED pathogenesis and might assist physicians in diagnostic and therapeutic choices.

Urological manifestations of vascular disease

We have detailed several of the urological manifestations of vascular disease. With the aging of the North American population, urologists will encounter the urological complications of vascular disease with ever-increasing frequency.

Doppler sonography of the penile cavernosal artery: comparison of intraurethral instillation and intracorporeal injection of prostaglandin E1

PURPOSE

We compared the Doppler sonographic findings in the penile cavernosal artery (arteria profunda penis) after intraurethral instillation and intracorporeal injection of prostaglandin E1 (PGE1) to evaluate the hemodynamic changes during drug-induced erection.

METHODS

Twenty healthy male volunteers were enrolled in the study. Ten subjects (intraurethral group) were examined with Doppler sonography of the penile cavernosal artery after intraurethral administration of 1 mg of PGE1. The remaining 10 subjects (intracorporeal group) underwent Doppler sonography of the cavernosal artery after intracorporeal injection of 5 microg of PGE1. The peak systolic velocity, minimal diastolic velocity, and resistance index were determined at 5-minute intervals for 30 minutes following administration of PGE1 in both groups. The results were compared between the 2 groups.

RESULTS

The peak systolic velocity in the intraurethral group increased progressively from a mean of 31.1 cm/second at 5 minutes to 65.6 cm/second at 30 minutes after intraurethral administration of PGE1. In the intracorporeal group, the mean peak systolic velocity ranged from 44.1 to 83.2 cm/second, reached a maximum at 10 minutes, and then decreased continuously through 30 minutes after intracorporeal injection of PGE1. The mean peak systolic velocities were significantly higher in the intracorporeal group at 10 and 15 minutes (p < or = 0.05); the mean minimal diastolic velocities were significantly lower in the intracorporeal group at 15, 20, and 25 minutes (p < or = 0.05); and the mean resistance indices were significantly higher in the intracorporeal group at all time points except 5 minutes (p < or = 0.05).

CONCLUSIONS

The intracorporeal injection of PGE1 produced a greater vasoactive response in the cavernosal artery than did intraurethral instillation.

Duplex ultrasound evaluation of cavernosal peak systolic velocity and waveform acceleration in the penile flaccid state: clinical significance in the assessment of the arterial supply in patients with erectile dysfunction

The aim of this paper was to establish if duplex ultrasound parameters obtained for assessment of the patency of cavernosal arteries in the penile flaccid state can give sufficient clinical information without the use of intracavernosal injection of vasodilatory drugs. We assessed mean cavernosal peak systolic velocity (PSV) in the penile flaccid state (basal PSV), and after PGE1 injection (dynamic PSV) in 339 unselected patients with erectile dysfunction. In 55 of these patients the waveform acceleration in the flaccid state was also assessed. The results of the study can be summarized as follows: (1) a significant relationship was found between basal and dynamic PSV in the 339 patients (r=0.477; p < 0.0001); (2) a basal PSV >12.5 cm/sec was predictive of a dynamic PSV >/=30 cm/sec in 129/139 (92.8%) of the patients, whereas in patients with a basal PSV </=12.5 a dynamic PSV both > or <30 cm/sec could be found; and (3) an acceleration >1 m/sec2 in the flaccid state was coupled to a dynamic PSV >30 cm/sec in 43/46 (93.5%) of the patients independent of the basal PSV. In conclusion, these results suggest that the combined duplex ultrasound assessment of PSV and waveform acceleration in the penile flaccid state can predict arterial dynamic inflow in the majority (51/55; 92.7%) of patients with erectile dysfunction, with less time and expense and less discomfort for the patient.