Standardization of penile blood flow parameters in normal men using intracavernous prostaglandin E1 and visual sexual stimulation

Venous Leak Embolization Results in Clinical Improvement of Patients with Mixed Arterio-Venous Erectile Dysfunction Not Responding to Arterial Revascularization Alone

PURPOSE

To analyze the safety and efficacy of additional venous leak embolization after an initial arterial revascularization to treat patients with combined arteriogenic and venogenic erectile dysfunction (ED).

MATERIALS AND METHODS

Single-center observational study from October 1, 2019, to September 30, 2022, including 26 patients with ED resistant to phosphodiesterase-5-inhibitors (PDE5i) and without significant clinical benefit after arterial revascularization of erection-related arteries. Additional treatment with venous leak embolization was performed 458 ± 424 days after arterial revascularization. Arterial obstruction and venous leak were verified based on color Doppler flow analysis, computed tomography angiography, and computed tomography cavernosography. The primary safety endpoint was any major adverse event 6 weeks after the procedure. The primary feasibility endpoint was defined as an IIEF-6 (International Index of Erectile Function-6) score improvement of ≥ 4 points at 6-week follow-up post intervention.

RESULTS

Procedural success was achieved in all patients with no major adverse events on follow-up. The primary feasibility endpoint at 6-week follow-up was reached with 3/26 (11.5%) of patients following arterial revascularization only. Six weeks after additional venous embolization, the primary feasibility endpoint was reached in 17/26 (65.4%) of patients.

CONCLUSION

Venous leak embolization yields additional clinical improvement and treatment potential in patients with vasculogenic ED not responding to PDE5i due to mixed arterio-venous disease and insufficient clinical improvement after arterial revascularization alone.

Early-onset and uncontrolled diabetes mellitus factors correlate with complications of Peyronie's disease

BACKGROUND

Peyronie's disease (PD) is a connective tissue disorder that affects the penis and is characterized by abnormal collagen structure in the penile tunica albuginea, resulting in plaque formation and penile deformity. PD's overall prevalence is estimated at 3.2% to 8.9%, with rates as high as 20.3% among men with type 2 diabetes mellitus (DM). However, the characteristics of DM associated with PD complications remain unclear.

AIM

To explore clinical associations between DM characteristics and PD complications.

METHODS

We conducted a retrospective analysis of patients with DM and PD who presented at our institution between 2007 and 2022. We examined patients' clinical histories, DM- and PD-related clinical parameters, and complications. Penile deformities were assessed through physical examination, photographs, and penile Doppler ultrasound. Patients were categorized into subgroups based on age of DM onset: early (<45 years), average (45-65 years), and late (>65 years).

OUTCOMES

Outcomes included effects of DM characteristics on PD development, progression, and severity.

RESULTS

In total, 197 patients were included in the evaluation. Early-onset diabetes and elevated hemoglobin A1c (HbA1c) levels exhibited significant correlations with the early development of PD (ρ = 0.66, P < .001, and ρ = -0.24, P < .001, respectively). Furthermore, having DM at an early age was associated with the occurrence of penile plaque (ρ = -0.18, P = .03), and there were no significant differences in plaque dimensions (ρ = -0.29, P = .053). A rise in HbA1c levels after the initial PD diagnosis displayed positive correlations with the formation of penile plaque (ρ = 0.22, P < .006).

CLINICAL IMPLICATIONS

These findings emphasize the need for comprehensive assessments and personalized treatment strategies for individuals with DM and PD. Enhanced management approaches can improve outcomes for those facing both challenges.

STRENGTHS AND LIMITATIONS

Limitations include the single-site retrospective design with potential selection bias, inaccuracies in medical record data, and challenges in controlling confounding variables.

CONCLUSIONS

This study highlights that early-onset diabetes and poor diabetes control, as indicated by a subsequent rise in HbA1c levels following PD diagnosis, are significantly correlated with the onset and severity of PD. Revealing the mechanisms behind these findings will help us develop better management strategies for individuals with DM and PD.

Accurate and time‐saving, two‐step intracavernosal injection procedure to diagnose psychological erectile dysfunction

Background

The recognition of the erectile dysfunction pathogenesis is essential to identify the appropriate erectile dysfunction management. As vascular erectile dysfunction could be a manifestation of a systemic arterial damage, the watershed in the erectile dysfunction diagnostic framework is the discrimination between psychological erectile dysfunction and vascular erectile dysfunction. However, reliable tools to directly diagnose psychological erectile dysfunction are currently lacking.

Objective

To identify which parameters could predict psychological erectile dysfunction. Moreover, we suggest a new intracavernosal injection procedure to optimize the erectile dysfunction diagnostic workup.

Materials and methods

A retrospective, real‐world analysis was carried out including all men who underwent intracavernosal injection procedure at the Modena Andrology Unit from 2018 to 2021. A first intracavernosal injection procedure with 5 µg of prostaglandin E‐1 (PGE‐1) was performed. In the absence of a full drug‐induced erection (immediate or delayed), an echo‐color Doppler penile evaluation after administration of PGE‐1 10 µg was conducted, measuring intracavernosal blood flows, to document a possible vascular etiology. Hormonal evaluations were performed.

Results

Out of 179 enrolled patients, 70.4% showed psychological erectile dysfunction, 21.7% vascular erectile dysfunction, and 7.8% hormonal genesis. Multinomial logistic regression analysis identified absence of cardiovascular disease (p = 0.017), presence of spontaneous morning erections (p = 0.018), and normal penile erections with masturbation (p = 0.035) as predictors of psychological erectile dysfunction. Clinically, normal intracavernosal injection test response was detected in 86 patients and abnormal response in 93 subjects. Among the latter, 54 patients experienced a delayed response. The combination of intracavernosal injection test with late penile erections evaluation was able to diagnose psychological erectile dysfunction (sensitivity 97%, specificity 100%), avoiding unnecessary retesting.

Discussion

We propose a two‐step intracavernosal injection procedure that allows to recognize psychological erectile dysfunction with a high sensitivity/specificity, saving costs and time, and limiting adverse events. Moreover, the presence of spontaneous morning erections and valid penile erections after masturbation could guide the diagnostic workup, indirectly identifying those patients deserving of a deeper evaluation of vascular health.

Standardization of penile hemodynamic evaluation through color duplex-doppler ultrasound

INTRODUCTION

The vascular evaluation of the erectile function through Color Duplex-Doppler Ultrasound (CDDU) of the penis can benefit the therapeutic decision-making process. Unfortunately, there is no standard procedure for CDDU conduction, a fact that results in high result-interpretation variability.

OBJECTIVE

The aims of this review are to promote greater standardization during CDDU of the penis and discuss the fundamental principles for its accurate conduction.

METHODS

CDDU is initially conducted with the penis in the flaccid state; the whole penis must be assessed (images at B mode) with a high-frequency linear transducer (7.5-18 MHz). Intracavernous injection of vasodilating agents (prostaglandin E1, papaverine, phentolamine) is performed to induce a rigid erection. Serial measurements at different times should be taken during the CDDU session and penile rigidity must be assessed in each evaluation.

RESULTS

It is important to monitor the erection response after the vasoactive agent (hardness scale), and scanning during the best-quality erection should be contemplated. Manual self-stimulation, audiovisual sexual stimulation (AVSS), and vasoactive agent re-dosing protocols must be taken into account to reduce the influence of psychogenic factors and to help the patient to get the hardest erection possible. Such measurements contribute to the maximal relaxation of the erectile tissue, so the hemodynamic parameters are not underestimated.

CONCLUSIONS

CDDU is a relevant specialized tool to assess patients with erectile dysfunction; therefore, this guideline will help to standardize and establish uniformity in its conduction and interpretation, taking into consideration the complexity and heterogeneity of CDDU evaluations of the penis.

A novel method for hemodynamic analysis of penile erection

Measurement of blood flow velocity through the cavernosal arteries via penile color Doppler ultrasound (PDUS) is the most common objective method for the assessment of erectile function. However, in some clinical cases, this method needs to be augmented via the invasive intracavernosal pressure (ICP) measurement, which is arguably a more direct index for erectile function. The aim of this study is to develop a lumped parameter model (LPM) of the penile circulation mechanism integrated to a pulsatile, patient-specific, bi-ventricular circulation system to estimate ICP values non-invasively. PDUS data obtained from four random patients with erectile dysfunction are used to develop patient-specific LPMs. Cardiac output is estimated from the body surface area. Systemic pressure is obtained by a sphygmomanometer. Through the appropriate parameter set determined by optimization, patient-specific ICP values are predicted with only using PDUS data and validated by pre- and post-papaverine injection cavernosometry measurements. The developed model predicts the ICP with an average error value of 3 mmHg for both phases. Penile size change during erection is predicted with a ~15% error, according to the clinical size measurements. The developed mathematical model has the potential to be used as an effective non-invasive tool in erectile function evaluation, expanding the existing clinical decision parameters significantly.

Surgical niche for the treatment of erectile dysfunction

Penile erection implicates arterial inflow, sinusoidal relaxation and corporoveno-occlusive function. By far the most widely recognized vascular etiologies responsible for organic erectile dysfunction can be divided into arterial insufficiency, corporoveno-occlusive dysfunction or mixed type, with corporoveno-occlusive dysfunction representing the most common finding. In arteriogenic erectile dysfunction, corpora cavernosa show lower oxygen tension, leading to a diminished volume of cavernosal smooth muscle and consequential corporoveno-occlusive dysfunction. Current studies support the contention that corporoveno-occlusive dysfunction is an effect rather than the cause of erectile dysfunction. Surgical interventions have consisted primarily of penile revascularization surgery for arterial insufficiency and penile venous surgery for corporoveno-occlusive dysfunction, whatever the mechanism. However, the surgical effectiveness remained debatable and unproven, mostly owing to the lack of consistent hemodynamic assessment, standardized select patient and validated outcome measures, as well as various surgical procedures. Penile vascular surgery has been disclaimed to be the treatment of choice based on the currently available guidelines. However, reports on penile revascularization surgery support its utility in treating arterial insufficiency in otherwise healthy patients aged <55 years with erectile dysfunction of late attributable to arterial occlusive disease. Furthermore, it is noteworthy that penile venous surgery might be beneficial for selected patients with corporoveno-occlusive dysfunction, especially with a better understanding of the innovated venous anatomy of the penis. Penile vascular surgery might remain a viable alternative for the treatment of erectile dysfunction, and could have found its niche in the possibility of obtaining spontaneous, unaided and natural erection.

Complete Human Penile Scaffold for Composite Tissue Engineering: Organ Decellularization and Characterization

Reconstruction for total penile defects presents unique challenges due to its anatomical and functional complexity. Standard methods suffer from high complication rates and poor functional outcomes. In this work we have developed the first protocol for decellularizing whole-organ human penile specimens for total penile tissue engineering. The use of a hybrid decellularization scheme combining micro-arterial perfusion, urethral catheter perfusion and external diffusion enabled the creation of a full-size scaffold with removal of immunogenic components. Decellularization was complete as assessed by H&E and immunohistochemistry, while quantification of residual DNA showed acceptably low levels (<50 ng/mg). An intact ECM was maintained with histologic architecture preservation on H&E and SEM as well as preservation of key proteins such as collagen-1, laminin and fibronectin and retention of growth factors VEGF (45%), EGF (57%) and TGF-beta1 (42%) on ELISA. Post-decellularization patency of the cavernosal arteries for future use in reseeding was demonstrated. Scaffold biocompatibility was evaluated using human adipose-derived stromal vascular cells. Live/Dead stains showed the scaffold successfully supported cell survival and expansion. Influence on cellular behavior was seen with significantly higher expression of VWF, COL1, SM22 and Desmin as compared to cell monolayer. Preliminary evidence for regional tropism was also seen, with formation of microtubules and increased endothelial marker expression in the cavernosa. This report of successful decellularization of the complete human phallus is an initial step towards developing a tissue engineered human penile scaffold with potential for more successfully restoring cosmetic, urinary and sexual function after complete penile loss.

Endovascular Therapy for Erectile Dysfunction-Who Benefits Most? Insights From a Single-Center Experience

PURPOSE

To report the 1-year outcomes of a single-center, all-comers registry aimed to assess effectiveness and safety of endovascular revascularization for atherosclerotic erectile dysfunction (ED) in an unselected patient cohort.

MATERIALS AND METHODS

Between April 2016 and October 2017, 50 consecutive patients (mean age 59.6±10.3 years) underwent endovascular revascularization for ED owing to >50% stenosis in 82 erection-related arteries. Patients were treated by means of standard balloon angioplasty (16%), drug-coated balloon angioplasty (27%), or drug-eluting stent (55%) implantation. The primary feasibility outcome measure was the incidence of a minimum clinically relevant improvement of ≥4 in the 6-question International Index of Erectile Function Questionnaire (IIEF-6) score at 12 months. Clinical effectiveness was improvement in erectile function as quantified in the mean difference (MD) of the IIEF-15 score at 3 and 12 months as well as the mean changes in IIEF-15 questions 3 and 4.

RESULTS

Procedure success was achieved in 49 (98%) of 50 patients. At 12 months, 30 (65%) of 46 patients achieved a minimum clinically relevant improvement in the IIEF-6 score. The overall IIEF-15 score, as well as scores for questions 3 and 4, improved in 32 (65%) of 49 patients, 28 (57%) of 49 patients, and 29 (60%) of 48 patients, respectively. Change in the overall IIEF-15 score at 12 months was consistent among subgroups, except for elderly patients [MD -5.0 (95% CI -9.7 to -0.2), p=0.041] and those with hypertension [MD -11.0 (95% CI -20.5 to -1.5), p=0.025], who showed less improvement.

CONCLUSION

Endovascular revascularization was safe and efficacious in the majority of ED patients through 1 year.

Erectile dysfunction and alcohol intake

The objective of this work is to evaluate in a selection of patients with erectile dysfunction the influence of alcohol consumption and the response to alcohol abstinence with and without sildenafil association.

Materials and Methods.

In a population of 150 consecutive patients with erectile dysfunction we studied 50 patients aged between 22 and 77 years (mean 56±14 SD). These 50 patients were divided into three different treatment groups and were screened for three different levels of alcohol risk with two questionnaires. All patients were evaluated with an International Index Erectile Dysfunction (IIEF) questionnaire before and after one month of treatment.

Results.

The 50 patients included 14 patients with high alcohol risk, 34 patients with low alcohol risk and only 2 patients with no alcohol risk. After one month, 29 patients responded to the therapy, and 21 did not respond. The IIEF questionnaire presented a statistically significant difference between the different risk groups before and after treatment (p≤0.05). All the patients were examined with a penile Doppler Ultrasound. Only 10 of them had an abnormal diastolic peak velocity (PDV) and only 1 presented both pathologic systolic peak velocity (PSV) and PDV. These 11 patients did not respond to therapies and 10 of them were at high alcohol risk. The alcohol consumption risk was directly correlated with PDV (p=0.00001; R=0.4).

Conclusions.

The results of this study demonstrated a significant relationship between alcohol consumption and erectile dysfunction. This underlines the important therapeutic issue of alcohol abstinence in treating patients with erectile dysfunction.

Lesion Pattern in Patients With Erectile Dysfunction of Suspected Arterial Origin

Purpose: To determine the specific lesion pattern of supplying arteries in patients with cardiovascular risk factors suffering from treatment-refractory erectile dysfunction (ED). Methods: From May 2012 to August 2013, 26 men (median age 55 years) poorly responsive to phosphodiesterase-5 inhibitor therapy were evaluated for a possible vascular cause for their ED. The men were examined with penile duplex sonography and digital subtraction angiography (DSA). Arterial lesions in the common and internal iliac arteries and the internal pudendal arteries considered amenable to endovascular therapy were treated with angioplasty ± stents. Retrospectively, 2 blinded investigators independently evaluated the DSA images and categorized the vascular patterns of the erection-related arteries as normal, macroangiopathy (occlusive lesions of the internal pudendal arteries), or microangiopathy (smaller caliber arteries distal to the internal pudendal circulation with no distal arterial reconstitution). Results: Seventeen macroangiopathic lesions were successfully treated by angioplasty in 11 patients. The treated arterial lesions were mainly located in the internal (n=10) and common iliac arteries (n=2), whereas the internal pudendal artery were involved in 5 cases. Microangiopathic lesions lacking distal reconstitution were present in 7 patients, and the remaining 8 patients had normal vessels supplying the penis. Patients with macroangiopathy undergoing angioplasty had a higher prevalence of peripheral artery disease (63.6% vs 6.7%, p=0.003). Conclusion: In this preliminary series of ED patients with cardiovascular risk factors and pathologic duplex sonographic flow parameters, roughly 40% exhibited arterial lesions amenable to endovascular revascularization. In the patients with macroangiopathy, vessels upstream of the internal pudendal artery were most commonly affected. More studies are warranted to define the role of endovascular procedures in this ED subpopulation.

Erectile Dysfunction

Erectile dysfunction has been defined by the National Institutes of Health as the inability to achieve and/or to maintain an erection for satisfactory sexual intercourse. It may result from psychological or organic causes. With the advent of oral pharmacotherapy, the diagnostic approach has significantly changed over the past decade. The number of patients examined at the radiology clinics has also been decreased. However, evaluation by imaging modalities, such as color Doppler ultrasound, cavernosography, and angiography, still remains the cornerstone of the diagnostic workup of the patients with erectile dysfunction. The aim of this review was to focus briefly on the penile anatomy, the pathophysiology of erection, and radiological techniques for investigating vascular causes of erectile dysfunction and findings on different radiological methods.

Colour Doppler sonography of flaccid penis in evaluation of erectile dysfunction

BACKGROUND

Erectile dysfunction is a common and potentially treatable problem. Other than psychological, anatomical and metabolic factors, vasculogenic causes also play an important role in erectile dysfunction. Among the various diagnostic tools available for the diagnosis of vasculogenic causes, colour Doppler sonography is noninvasive, simple and promising.

METHODS

This preliminary prospective study was conducted on 40 patients with erectile dysfunction, coming from a rural background to a hospital situated in a semi-urban setting.

RESULTS

It was found that a cut-off value of 10 cm/second for peak systolic velocity in flaccid penis had the best accuracy among three chosen cut-off values, i.e. 5, 10, 15 cm/second, for detecting arterial insufficiency with sensitivity of 94.1%, specificity of 93.6%, negative predictive value of 98% and positive predictive value of 80%.

CONCLUSION

Doppler sonography may be used as a good predictor of clinical response to intracavernosal injection of a vasodilating pharmacological agent.

Surgical outcomes and patient satisfaction after dermal, pericardial, and small intestinal submucosal grafting for Peyronie's disease

INTRODUCTION

Peyronie's disease, a localized fibrosis of the tunica albuginea surrounding the penile corpora, results in penile curvature and sexual dysfunction. Surgical management involving grafting to straighten the penis is the treatment of choice in conditions unresponsive to conservative therapy where penile length preservation is important.

AIM

To determine surgical outcomes and patient satisfaction after dermal, pericardial, and small intestinal submucosal grafting for Peyronie's disease.

MAIN OUTCOME MEASURES

The International Index of Erectile Function (IIEF), postoperative self-reports, patient satisfaction, and clinical characteristics were used to measure outcomes.

METHODS

We retrospectively reviewed charts of 36 patients who underwent surgery for Peyronie's disease requiring grafting from 1999 to 2005. Follow-up to subjectively assess outcomes was conducted.

RESULTS

Average patient age at surgery was 55 +/- 1 years. Body mass indexes were similar among all groups. Erectile dysfunction risk factors were comparable with 36% reporting hypertension and 22% hypercholesterolemia. Overall patient follow-up time was 673 +/- 98 days. Self-reported resolution of penile curvature was noted in 60% of dermal, 100% of Tutoplast, and 76.9% of Stratasis graft recipients. Stratasis patients maintained presurgery length (54%) and rigidity (77%) more so than dermal (30%, 60%) and Tutoplast (23%, 39%) patients. Assessment of erectile dysfunction using the IIEF-5 captured significant improvements in patients receiving Stratasis grafts (preoperative: 10.1 +/- 1.1 vs. postoperative: 17 +/- 1.6). Overall, 89% of patients reported satisfaction following surgical intervention.

CONCLUSIONS

Surgical management of Peyronie's disease results in correction of penile curvatures and high rates of patient satisfaction. Loss of penile length and decreased rigidity occurred to a lesser degree with Stratasis grafts. While detailed informed consent is essential in this patient population, novel materials such as Tutoplast and Stratasis grafts improve outcomes following surgical correction of Peyronie's disease.

Diabetes mellitus is associated with severe Peyronie's disease

OBJECTIVES

To evaluate the severity of penile deformity and penile blood flow variables in men with Peyronie's disease (PD) and diabetes mellitus (DM), and those with no risk factors.

PATIENTS AND METHODS

Men with PD and DM (59 men, group 1) and those with no risk factors (109, group 2) were compared for penile blood flow variables, severity of penile deformity, patient's age, duration of PD, the presence of pain on erection, and the degree of erectile dysfunction (ED). The men were evaluated with penile duplex Doppler ultrasonography and were categorized into specific vascular groups, using established criteria. Penile curvature was objectively measured and stratified according to the Kelâmi classification. Results were compared using Student's t-test.

RESULTS

Men with PD and DM (group 1) were significantly older than those in group 2. The duration of disease was significantly longer in group 1 than in group 2 (median 24 vs 12 months). The mean degree of penile deformity in group 1 was significantly higher than in group 2 (45.2 degrees vs 30.2 degrees). The rate of severe penile curvature (>60 degrees ) was more frequent in group 1 (27.1% vs 5.5%). Pain on erection was significantly higher in group 2 (39.7% vs 25.5%), whereas the rate of ED was more common in group 1 (81% vs 47%). Group 1 had poorer peak-systolic velocity values and significantly higher rates of arterial insufficiency and mixed vascular disease. Nonvascular causes were twice as common in group 2 than in group 1.

CONCLUSIONS

This comparative clinical study suggests that the presence of DM as the only risk factor significantly increases the severity of PD. Furthermore, DM as a risk factor is associated with significantly worse vascular status, as shown by penile duplex Doppler ultrasonography, in men with PD.

Doppler evaluation of erectile dysfunction – Part 1

Erectile dysfunction (ED) is the consistent inability to achieve and maintain an erection sufficient for satisfactory sexual activity. Erectile dysfunction affects as many as 30 million men in America, with an increasing prevalence with age. Erectile dysfunction is secondary to organic, psychogenic and combined causes. The first part of this review article describes the guidelines for evaluation and treatment plans for men with ED. It also describes the normal sonographic anatomy of the penis, sonographic technique for evaluation of ED and the normal phases of erection.

Only the nose knows: penile hemodynamic study of the perineum-saddle interface in men with erectile dysfunction utilizing bicycle saddles and seats with and without nose extensions

PURPOSE

To investigate the differential impact of straddles (A(ns) and B(ns)) and noseless two-cheek seats (A(ntcs) and B(ntcs)) on penile hemodynamics and perineal compressive forces in subjects who cycle in a stationary bicycle.

MATERIALS AND METHODS

Subjects underwent cavernosal artery peak systolic velocity (CAPSV) measurements after intracavernosal injection of vasoactive agents while supine, sitting upright on an examination table, straddling a saddle, sitting on a seat, and again supine. Mean perineal compression pressures recorded while straddling the saddles were compared with those while sitting upright.

RESULTS

No differences were found in right and left CAPSV values while supine, sitting upright on an examination table, sitting on a seat, and supine again. Right/left CAPSV (cm/second) values straddling A(ns) and saddle B(ns) (0.7 +/- 2.9/1.5 +/- 6.2 and 0/0, respectively) were significantly lower than values obtained while sitting on A(ntcs) and B(ntcs) (25.6 +/- 13.4/23.8 +/- 12.0 and 17.3 +/- 6.4/18.3 +/- 6.5, respectively) (P < 0.001). Mean perineal compression pressures (mm Hg) on A(ns) and saddle B(ns) (315.2 +/- 39 and 387.9 +/- 64.3, respectively) were significantly higher than values obtained while sitting upright on an examination table (47.6 +/- 5.2 and 46.0 +/- 8.1, respectively) (P < 0.001).

CONCLUSIONS

We have identified an objective test to assess if an individual bicycle rider, sitting on a certain shape of bicycle saddle or seat generates sufficient compressive forces at the perineal-saddle interface to obstruct cavernosal arterial inflow. This study also demonstrated that straddling bicycle saddles with nose extensions is associated with perineum-saddle interface compressive pressures that exceed systolic perfusion pressures, significantly diminishing penile hemodynamics.

The Impact of Intralesional Interferon α‐2b Injection Therapy on Penile Hemodynamics in Men with Peyronie's Disease

INTRODUCTION

Penile duplex Doppler ultrasound (PDDU) is currently the preferred method for the functional evaluation of penile hemodynamics. PDDU may be used to monitor objectively changes in penile vascular parameters in men who undergo treatment for Peyronie's disease (PD), including intralesional interferon alpha-2b (IFN alpha-2b).

AIM

To investigate the impact of intralesional IFN alpha-2b therapy for PD on penile hemodynamics by using PDDU and to assess the objective role of PDDU in monitoring treatment outcomes.

MATERIALS AND METHODS

Thirty-nine patients (20 in the placebo and 19 in the IFN alpha-2b treatment arm) were enrolled in this prospective, placebo-controlled, parallel study. Patients received either 10 mL saline or 5 x 10(6) units of IFN alpha-2b intralesional injections every other week for a total of six injections. Patients in each group were evaluated at baseline and after completion of treatment regarding changes in penile hemodynamic parameters, penile curvature, plaque size and density, pain on erection, and erectile function. Specific published criteria were used for PDDU measurements. Outcomes were statistically compared between each group by using Mann-Whitney U and chi-square tests.

RESULTS

The mean age of the patients and the duration of PD were similar in both groups. The improvement in penile blood flow was significantly greater in IFN alpha-2b-treated patients than those in the placebo group. The number with the nonvascular classification increased significantly in the IFN alpha-2b arm from 31.5% to 57.8%. Additionally, improvements in penile curvature, plaque size and density, and pain on erection were better in the IFN alpha-2b group compared with the control. No significant improvement was observed in the erectile function domain in either group.

CONCLUSION

This study reveals that intralesional IFN alpha-2b injections have a significant benefit on penile hemodynamic parameters. Moreover, intralesional IFN alpha-2b is an effective, minimally invasive treatment for PD, and PDDU is a useful adjunct to monitor objectively changes in penile vascular parameters. interferon alpha-2b injection therapy on penile hemodynamics in men with Peyronie's disease.

Prevalence of asymptomatic coronary artery disease in men with vasculogenic erectile dysfunction: a prospective angiographic study

OBJECTIVES

Erectile dysfunction (ED) shares common risk factors with coronary artery disease (CAD). It has been suggested that ED may be considered a clinical manifestation of a generalized vascular disease affecting also the penile arteries. The aim of this prospective study was to evaluate angiographically the incidence of asymptomatic CAD in men with ED of vascular origin.

METHODS

Fifty consecutive asymptomatic men, aged 41-74 years, with non-psychogenic and non-hormonal ED were comprehensively evaluated using medical history and examination, exercise treadmill test and stress echocardiography. Patients who had positive one or both of the two non-invasive procedures were referred for coronary arteriography in order to document CAD and evaluate the severity of the disease.

RESULTS

The mean time interval between the onset of ED and cardiological assessment was 25 months (range 1-66). Smoking (32 patients/64%), hypertension (31 patients/62%) and hyperlipidemia (26 patients/52%) were the most common risk factors. Moreover, 35 men (70%) had two or more risk factors. Twelve patients (24%) with ED had positive one or both of the two non-invasive procedures and one patient presented with acute myocardial infarction before he completed the non-invasive investigation. Coronary arteriography performed in ten patients (in nine with positive one or both of the two non-invasive procedures [while the other three refused], and in the patient with acute myocardial infarction) demonstrated that one patient had three-vessel disease, two patients had two-vessel disease and six patients had single-vessel disease.

CONCLUSIONS

A considerable proportion (9/47 or 19%) of patients with ED of vascular origin has angiographically documented silent CAD. These findings support the strategy that patients with ED should undergo further cardiovascular evaluation.

THE RELATIONSHIP BETWEEN THE TYPE OF PENILE ABNORMALITY AND PENILE VASCULAR STATUS IN PATIENTS WITH PEYRONIE'S DISEASE

PURPOSE

We evaluated penile vascular status using penile duplex Doppler ultrasound (PDDU) according to the type of abnormality in men with Peyronie's disease (PD).

MATERIALS AND METHODS

A total of 523 patients with PD were evaluated retrospectively. Each patient underwent PDDU following injections of 10 to 15 mug prostaglandin E1 intracavernously with accompanying visual sexual stimulation to evaluate penile blood flow. Abnormalities were divided into 7 groups. Objective evaluation of penile curvature was done with a protractor during maximum erection. Specific criteria were used to categorize patients into varying definitions of vascular status. The results were compared statistically among groups.

RESULTS

Mean patient age +/- SEM was 54.2 +/- 1.5 years. The most frequently noted type of curvature was dorsal (43.5% of cases), followed by lateral (24.8%). Mean peak systolic velocity in the ventrolateral group was the highest, while the lowest peak systolic velocity was noted in the hourglass abnormality group. The hourglass group had the highest rate of pure arterial insufficiency, while veno-occlusive dysfunction was seen most commonly in the ventral curvature group. The ventrolateral group showed the most normal vascular status parameters.

CONCLUSIONS

This study demonstrates there is a relationship between the type of curvature and penile hemodynamics. Although patients with PD in the hourglass abnormality group were the youngest, this abnormality was associated with the poorest penile vascular status. Patients with ventrolateral curvature had the best penile hemodynamics in our series. PDDU findings may direct the treating physician to different treatment options.

Histomorphometry of penile smooth muscle fiber in severe erectile dysfunction

CONTEXT AND OBJECTIVE

Smooth muscle fiber has fundamental importance in erection. Alterations in its function or quantity may be associated with erectile dysfunction. The study objective was to assess the proportion of penile smooth muscle fiber in patients with severe erectile dysfunction.

DESIGN AND SETTING

Clinical study, in the Sexual Dysfunction Group, Universidade Federal de São Paulo (Unifesp), and in the Anatomy Laboratory, Universidade Estadual do Rio de Janeiro (UERJ).

METHODS

Twenty patients with severe erectile dysfunction were selected to form two groups of ten patients: one with normal arterial flow (age range: 44 to 78 years) and the other with altered arterial flow (age range: 38 to 67 years). These groups were compared with a group formed by ten cadavers aged 18 to 25 years that were presumed to have been potent. Quantification of the smooth muscle fibers was done by means of an immunohistochemical study.

RESULTS

The proportion of smooth muscle fiber found was 41.15% for the control group. The patients with erectile dysfunction and normal arterial flow presented 27.24% and those with altered arterial flow presented 25.74%; 19 patients presented at least one chronic disease or risk factor for erectile dysfunction, with prominence for diabetes mellitus, systemic arterial hypertension and smoking.

CONCLUSION

Among patients with severe erectile dysfunction, the arterial flow on its own does not present interference in the proportion of smooth muscle fiber. The diminution of the proportion of smooth muscle fiber may result from chronic diseases and vascular risk factors.

A NEW CLINICAL METHOD FOR THE ASSESSMENT OF PENILE ENDOTHELIAL FUNCTION USING THE FLOW MEDIATED DILATION WITH PLETHYSMOGRAPHY TECHNIQUE

PURPOSE

Penile endothelial function (EnF) is 1 of the major factors involved in the pathophysiology of erectile dysfunction. EnF assessment could offer crucial information on the etiology and degree of severity of cavernosal vascular pathology. In the present study we propose a new technique for the evaluation of penile EnF and test its applicability using strain gauge plethysmography.

MATERIALS AND METHODS

A total of 23 healthy subjects (13 younger and 10 older than 40 years) with no history of erectile dysfunction were studied. The flow mediated dilation technique was applied to the arm and penis in both age groups for the assessment of EnF. Baseline blood flow and the sequential flow recordings after rapid cessation of 5 minutes of ischemia were obtained in both organs.

RESULTS

Baseline flow in the penis was significantly higher (approximately 3-fold) than that in the forearm and was not affected by age in either organ. Both measures of penile EnF, ie area under the flow-time curve (AUC) and maximal flow obtained after ischemia were significantly lower in the older group compared to the younger group (p <0.01 and p <0.02, respectively). Individual penile AUC and maximal flow were significantly correlated with age (r = 0.55, p <0.01 and r = 0.50, p <0.02, respectively). Finally a positive, significant correlation existed between penile and forearm AUC (p <0.05, r = 0.48).

CONCLUSIONS

The implementation of the flow mediated dilation technique using mercury strain gauge plethysmography is simple and applicable for the assessment of penile EnF. Endothelial function parameters in the penis were found to correlate with those in the forearm, thus support for the validity of the technique is given. Further strength for the validity of this procedure in the penis comes from the comparison between the forearm and penis, and the relation to subject age.

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.

Intralesional Interferon-α-2B Injections for the Treatment of Peyronie’s Disease

BACKGROUND

Intralesional therapies provide an alternative to surgical treatment of Peyronie's disease (PD). This study examines the efficacy of intraplaque injections of interferon-alpha-2B (IFN-alpha-2B) in the treatment of PD.

METHODS

Twenty-five patients were enrolled in the study with 21 completing the study. The average age of the study participants was 55.8 years, with 10 of the 21 having diabetes, hypertension, or both. Seven patients received placebo injections using 10 ml saline biweekly for 6 weeks before interferon therapy, and all 21 patients received biweekly injections of 2 x 10(6) U IFN-alpha-2B for 6 weeks before reevaluation. Patients were evaluated with duplex Doppler ultrasonography to assess penile curvature and blood flow.

RESULTS

The International Index of Erectile Function questionnaire was completed by 14 of 21 men to assess severity of erectile dysfunction (ED) before and after treatment. Improvements of 20% or more in penile curvature occurred in 14 (67%) of 21 men. Penile pain decreased in eight (80%) of 10, and plaque size decreased subjectively in 15 (71%) of 21 participants. The International Index of Erectile Function questionnaire showed significant improvement of ED in five (71%) of seven men with baseline moderate to severe ED. Peak systolic blood flow improved in three (43%) of seven men with baseline hemodynamic impairment, and veno-occlusive disease resolved in three (18%) of 17 individuals. IFN-alpha-2B injections led to significant improvements in penile pain and curvature caused by PD.

CONCLUSION

Results of intralesional IFN-alpha-2B injections in improving ED are encouraging. The study findings warrant further investigation of the effectiveness of IFN-alpha-2B injections for treatment of PD.

Measurement of intracavernosal catecholamine during a prostaglandin E1 test

Background : Erectile dysfunction (ED) can be a cause of male infertility among young men. The prostaglandin E₁ (PGE₁) intracavernous injection test, an erectile function test, is known as an objective method of examining the penile vasculature system. However, some ED patients fail to sufficiently maintain an erection because of the stress load upon them during the test. Thus, we measured changes in catecholamine levels by stress loading when we performed dynamic infusion cavernosometry (DIC). Methods : Among the 221 ED patients undergoing a PGE₁ test, 10 were selected as the subjects for the present study. These 10 patients were 25-56 years of age, with a mean of 32.8 years, whose maximal penile rigidity was normal, but in whom penile erection could not be maintained sufficiently in the PGE₁ test. Stress loading via vibratory sensory measurement during the PGE₁ test suppressed penile rigidity strongly. Catecholamine levels were measured by using blood samples obtained from the corpus cavernosum and the cubital vein when erection was suppressed by stress loading, pain caused by needle insertion, and also when erection recovered from the suppression. Dynamic infusion cavernosometry was performed after each blood sampling time, to check corporeal veno-occlusive function and cavernosal arterial flow. Results : Penile norepinephrine levels were 0.20 ± 0.06 ng/mL during a suppressed erection and 0.15 ± 0.03 ng/mL during an erection, showing a significantly higher level (Student's t-test, P = 0.0309) during suppressed erection. The results of the DIC measurement indicated a normal corporeal veno-occlusive function and cavernosal artery in all cases. Conclusion : The results of the present study revealed that corporeal veno-occlusive function and cavernosal arterial flow are normal in men who have normal maximum penile rigidity, but cannot sufficiently maintain the erection in the PGE₁ test, suggesting the involvement of stress-induced penile norepinephrine in the suppression of erection maintenance. (Reprod Med Biol 2002; 1: 11-15).

Peyronie's disease: surgical correction of 40 patients with relaxing incision and duramater graft

OBJECTIVE

Assessment of a long-term follow-up of a previously described technique to correct the curvature of the penis in Peyronie's disease.

MATERIAL AND METHODS

Forty patients (43-69 years old) were operated between 1989 and 1999. The eligibility criteria for surgery were: lesion stabilised during, at least, one year; angulation of 40 degrees or more; and difficult or impossible sexual intercourse. Moreover, the patients had to have good libido, maintained erections and interested sexual partners. The operative technique consisted in making an I-shaped relaxing incision in the zone of higher angulation of the tunica albuginea and the defect created in the tunica was covered with a human duramater graft.

RESULTS

The follow-up varied from 1 to 6 years (70%, > or =2 years). Cosmetic results: 95% good, 5% satisfactory (not needing further correction). Functional results: 85% good, 15% erectile dysfunction (10% moderate and 5% severe).

COMPLICATIONS

one recurrence, one partial necrosis of the foreskin, nine decreases in the sensibility of the glans (eight recovered after 4-12 months post-operatively).

CONCLUSIONS

The I-shaped relaxing incision and duramater graft procedure had a satisfactory success rate in the correction of severe Peyronie's disease. The utilisation of ready to use material (homo or hetero graft) avoids additional surgery, reduces the operative time and possible complications. Like in other procedures, the major problem of this surgery is the erectile dysfunction rate.

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.

Variable response to intracavernous prostaglandin E1 testing for erectile dysfunction

OBJECTIVES

Anxiety and apprehension may negatively influence the erectile response to the first intracavernous injection with vasoactive agents. This may result in too many false-positive diagnoses of vascular insufficiency if the first injection ever made in a patient is used for color Doppler duplex sonography (CDS) evaluation.

METHODS

One hundred sixty-eight consecutive patients (aged 18 to 75 years) with erectile dysfunction underwent a standardized evaluation, including the intracavernous injection test (ICIT) stimulated with 10 microg prostaglandin E1. Responses were recorded on a four-point scale: no response = 0, tumescence = 1, rigidity sufficient for intercourse = 2, full erection = 3. ICIT was repeated after 10 days and combined with CDS. The clinically assessed response to ICIT was correlated with end-diastolic flow velocity.

RESULTS

Of 168 patients, 114 (68%) responded equally to the first and second ICIT, but 45 (27%) had an improved response, from tumescence to full erection in the second test (P <0.0001); in 9 (5%), the response deteriorated. The overall mean response was 1.6 (95% confidence interval 1.5 to 1.7) and 1.9 (95% confidence interval 1.7 to 2.0) (P <0.0001) for the first and second test, respectively. Of 168 patients, 89 (53%) responded with erections sufficient for intercourse when tested the first time and 104 (62%) did so after the second injection.

CONCLUSIONS

Erectile response to diagnostic intracavernous injection of prostaglandin E1 significantly improved in the second compared with the first test. Therefore, cautious interpretation of CDS is advised when patients are injected for the first time because too many false-positive tests may result.

Electrical activity of the corpus cavernosum in denervated rats

BACKGROUND

We evaluated the electrical activity of the corpus cavernosum after intracavernous papaverine injection in rats that had been denervated experimentally.

METHODS

Twenty-four male adult Sprague Dawley rats were divided into three groups: (i) controls (n=8) (ii) unilateral cavernous nerve resection on the right side (n=8); and (iii) bilateral cavernous nerve resection (n=8). Through a suprapubic incision, the urinary bladder was retracted laterally to locate the major pelvic plexus on the lateral surface of the prostate. The major branch of the cavernous nerve, running caudally from the pelvic plexus, was isolated and excised using an operating microscope. Three weeks later, recording of the electrical activity of the corpus cavernosum (EACC) was performed by using a Neuropack-2 EMG unit (Nihon Kohden, Tokyo, Japan) and coencentric needle electrode. Changes in amplitude were evaluated before and after intracavernosal papaverine injection. The results in the flaccid state and after papaverine injection were compared by using the Mann Whitney U-test in all three groups and paired t-test between groups.

RESULTS

In the flaccid penis, the mean (+/- SD) amplitude of electrical activity of the corpus cavernosum was 17.42+/-2.05, 12.42+/-1.88, 9.71+/-1.59 and 5.85+/-0.96 microV in control rats, in unilaterally denervated rats (in which the cavernous nerve was intact on the left side), in unilaterally denervated rats in which the cavernous nerve was resected on the right side and in bilaterally denervated rats, respectively. In the flaccid state, EACC is lower in the bilaterally denervated group than in the control and unilaterally nerve-resected groups (P < or = 0.05). The recording of electrical activity of the corpus cavernosum was continued for 20 min after papaverine injection. In the control group and in both groups of unilaterally denervated rats, we observed a significant decrease in the electrical activity of the corpus cavernosum in the first 5 min after papaverine injection (P < or = 0.05). However, no difference was observed in bilaterally denervated rats after injection (P > or = 0.05).

CONCLUSIONS

We conclude that electrical activity of the corpus cavernosum continues after unilateral nerve injury in rats. Cross-innervation may play a role in penile innervation and corpus cavernosum electromyography shows electrical activity in denervated rats.

Evaluation and nonsurgical management of erectile dysfunction

The addition of oral drugs to the armamentarium of therapies for erectile dysfunction promises to dramatically increase the number of men seeking treatment for this condition. It is important to have a rational approach to the diagnostic evaluation of erectile dysfunction and to tailor the evaluation to each patient's goals for his sexual function. It is important also to offer each patient the full array of therapeutic options for erectile dysfunction. This article reviews the outpatient diagnostic work-up and current treatment possibilities for erectile dysfunction. The article also discusses clinical research experience with new forms or oral and topical therapies now being developed for future treatment of erectile dysfunction.

Electron microscopic findings of penile tissues in veno-occlusive dysfunction: is penile biopsy necessary?

In this study, we examined the biopsy patterns of penile tissues taken during operation from patients subjected to surgical treatment for veno-occlusive dysfunction, and evaluated the importance of penile biopsy. We evaluated the findings from 17 patients with venous impotence. Fourteen of them underwent total vein ligation and the rest penile prosthesis implantation. Tissue specimens taken from superficial and deep dorsal veins, tunica albuginea and corpus cavernosum during operation were examined under electron microscope. Tissue specimens taken from 3 cadavers were used as the control group. Although the deep and superficial vein specimens of all patients did not show significant differences, oedema and increase of fibroblasts in collagen fibres of the corpus cavernosum and tunica albuginea were demonstrated. We concluded that penile biopsy as an invasive method does not give enough information about the choice of treatment for erectile dysfunction.

The resistance index represents the corporeal pressure and not the cavernous wall resistance

PURPOSE

We compare the results of the resistance index generated by duplex scanning and the corporeal pressure generated by the intracavernous injection test followed by gravity cavernosometry.

MATERIALS AND METHODS

We examined 40 impotent subjects with duplex scanning and gravity cavernosometry.

RESULTS

For the entire group a significant correlation (r = 0.77, p < 0.001) was found between the resistance index and intracavernous injection test, and between the resistance index and the gravity cavernosometry (r = 0.62, p < 0.01). Excluding the results of patients who had a full erection during scanning, the correlation between the resistance index and intracavernous injection test remained but the correlation between the resistance index and gravity cavernosometry disappeared (r = -0.02, p > 0.05).

CONCLUSIONS

There was no relationship between the value of the resistance index and the cavernous wall resistance, except in patients capable of developing a full erection after vasodilator injection.

Ultrasound evaluation of the penis for assessment of impotence

Image directed Doppler ultrasonography of the cavernous arteries provides functional, quantifiable assessment of penile arterial flow during a pharmacological erection. In this respect, this modality is superior to arteriography as a means of evaluating arteriogenic impotence. Peak flow velocity, arterial dilatation, and vessel pulsation are the most reliable ultrasonic indicators of arterial health. Aberrant arterial anatomy should be noted as this may contribute significantly to total penile blood flow. A thorough understanding of erectile physiology and anatomy is necessary to properly perform and interpret Doppler ultrasound results.