Current approaches to the diagnosis of vascular erectile dysfunction

Evaluating the feasibility of a new non-invasive technique for improved diagnostics in vascular erectile dysfunction using an ultra-high-resolution ultrasound probe and venous compression: a proof of concept study

INTRODUCTION

Erectile dysfunction (ED) is a clinically relevant condition, particularly among older men, with vascular causes such as venous leakage and arterial insufficiency being primary contributors.

AIM

This study aimed to assess the diagnostic accuracy of a novel, non-invasive approach employing ultrasound-guided venous compression to identify the primary vascular etiology in patients with ED.

METHODS

A proof-of-concept study was conducted involving 40 male patients with confirmed ED. High-resolution Dynamic Duplex Sonography (DSU) was performed following intracavernosal injection of alprostadil to assess penile blood flow dynamics, including peak systolic velocity (PSV) and end-diastolic velocity (EDV). In 17 patients, a compression ring was individually selected using ultrasound and applied to restrict venous outflow while maintaining arterial inflow. PSV and EDV values were compared between standard DSU and venous compression + DSU (VC-DSU) with an individual selected compression ring. In addition, diagnostic accuracy was validated against CT-arteriography and CT-cavernosography in 10 patients.

MAIN OUTCOMES MEASURES

The primary outcome was an improvement in diagnostic accuracy of VC-DSU compared to standard DSU.

RESULTS

VC-DSU significantly improved detection of the primary vascular cause in ED, with an accuracy of 90% versus 20% for DSU. Under venous compression, changes in PSV served as key diagnostic markers: a marked increase indicated a venous origin, while stable or varied PSV values distinguished arterial or mixed causes. The accuracy of VC-DSU was comparable to CT cavernosography (P = 0.096), highlighting its potential as a reliable non-invasive alternative.

CLINICAL IMPLICATIONS

VC-DSU offers a non-invasive method to assess vascular contributions to erectile dysfunction with promising diagnostic potential to more accurately identify the vascular cause.

STRENGTHS AND LIMITATIONS

Key strengths of this study include its innovative, non-invasive approach and its direct comparison to cavernosography. However, the limited sample size restricts the generalizability of findings, highlighting the need for larger-scale trials to validate these results. Additionally, patient allocation to VC-DSU and cavernosography was based on willingness to participate rather than a predefined protocol, introducing a potential selection bias.

CONCLUSION

VC-DSU represents a promising non-invasive and accurate tool that complements traditional diagnostic methods for vascular ED, particularly by enhancing the differentiation of the predominant vascular etiology.

Factors Influencing Continued Usage of Intracavernosal injections for Erectile Dysfunction: A Retrospective Analysis

PURPOSE

Intracavernosal injections are used to treat erectile dysfunction. Patient compliance with intracavernosal injections is required for success, though factors influencing compliance are unknown. This study aimed to identify factors that influence compliance with intracavernosal injections among men with erectile dysfunction.

MATERIALS AND METHODS

A retrospective analysis was conducted using men who were prescribed intracavernosal injections between 2017 and 2022 at an academic medical center in a cosmopolitan area. Custom Python code was used to capture the first and last prescription refill events, and the duration of intracavernosal injection use was calculated. Additional patient-related data, including demographics and comorbidities, were gathered through chart reviews. Cox Proportional Hazards Regression models were used to evaluate the effects of predictor variables on the duration of intracavernosal injection use.

RESULTS

A total of 4,072 patients were included in the analysis. The study revealed that age significantly predicted discontinuation of intracavernosal injection therapy, showing an elevated hazard ratio of 1.007 for each additional year of age (p<0.001). Men who preferred to speak Spanish as their primary language was a significant predictor of discontinuation of injection therapy, showing a hazard ratio of 1.163 compared to those who preferred English (p=0.004). Men with a history of prostate cancer treatment stayed on treatment for 80 days fewer on average than those without (p=0.002).

CONCLUSIONS

Older age, prior history of prostate cancer treatment, and men who preferred to speak Spanish were all identified as factors potentially associated with reduced continuation of intracavernosal injection therapy for erectile dysfunction. Understanding these factors can help healthcare providers in both patient selection and counseling when discussing treatment options for erectile dysfunction.

Identification of Systemic Drug Targets for Anti-cavernous Fibrosis in the Treatment of Erectile Dysfunction, Guided by Genome-Wide Mendelian Randomization

The treatment of erectile dysfunction (ED) remains a significant challenge. Mendelian randomization (MR) is being increasingly utilized to identify novel therapeutic targets. In this study, we carried out a genome-wide MR analysis on druggable targets with the aim of pinpointing latent therapeutic alternatives for ED. We collected data on the druggable genes and filtered out those associated with blood eQTLs, then performed two-sample MR and colocalization analyses using ED genome-wide association data to screen genes significantly linked to the condition. In addition, we carried out phenome-wide studies, enrichment analysis, protein network modeling, drug prediction, and molecular docking. We screened 3,953 druggable genes from the DGIdb and 4,463 from a review. Following data integration, 74 potential druggable genes were found to potentially regulate corpus cavernosum fibrosis. MR analysis of eQTL data uncovered five drug targets (TGFBR2, ABCC6, ABCB4, EGF, and SMAD3) significantly associated with ED risk. Colocalization analysis suggested a shared causal variant between ED susceptibility and TGFBR2, with a posterior probability (PPH4) exceeding 80%. Drug predictions utilizing DSigDB identified nolone phenylpropionate, sorafenib, and NVP-TAE684 as significantly associated with TGFBR2. Finally, molecular docking indicated strong binding affinities between these candidate drugs and the protein encoded by TGFBR2 (Vina score < -50). Through MR and colocalization analyses, the present study identified five potential drug targets for ED, with TGFBR2 showing remarkable relevance in blood. These findings offer valuable insights and potential leads for the development of more effective ED therapies, which may also contribute to cutting down the expenses involved in drug development.

Establishing the role of shear wave elastography in differentiating corporal rigidity between vasculogenic versus non-vasculogenic erectile dysfunction patients

Introduction

Shear wave elastography is a new modality for the evaluation of erectile dysfunction by assessing the stiffness of corpora cavernosal tissue. We evaluated the shear wave elastography values in erectile dysfunction participants and compared shear wave elastography values between vasculogenic and non-vasculogenic erectile dysfunction participants.

Methods

Overall, 40 participants with clinically diagnosed erectile dysfunction filled out an abridged five-item version of the international index of erectile dysfunction-5 questionnaire and underwent shear wave elastography as well as pharmacologically induced penile erection test after intracavernosal papaverine injection. Shear wave elastography values were obtained serially at 5-minute interval at two locations: Central (cavernosal artery centered circular region) and Peripheral (near the tunica albuginea). Shear wave elastography values were compared with the erectile dysfunction subtypes.

Results

Median international index of erectile dysfunction-5 score was 11 (interquartile range: 9-14). Median central shear wave elastography values were significantly lower in the erectile state as compared to flaccid state in both vasculogenic (8.27 kPa (interquartile range: 6.3-12.5) vs 23.27 kPa (interquartile range: 15.9-28.6) p = 0.000) and non-vasculogenic (5.50 kPa (interquartile range: 4.4-6.7) vs 23.85 kPa (interquartile range: 17.8-33.6) p = 0.000) erectile dysfunction participants. Vasculogenic erectile dysfunction participants had significantly higher central shear wave elastography value in erectile state than non-vasculogenic erectile dysfunction participants (8.27 kPa (interquartile range: 6.3-12.5) vs 5.50 kPa (interquartile range: 4.4-6.7) p = 0.001). Receiver operating characteristics curve analysis revealed that the cut-off value for central shear wave elastography was 5.65 kPa in erectile state with the sensitivity, and specificity for predicting vasculogenic erectile dysfunction being 90.9% and 61.1%, respectively (area under the curve -0.816; standard error of 0.071 (p = 0.001)).

Conclusion

Central cavernosal shear wave elastography is a good modality to objectively quantify the penile rigidity and can be used to distinguish the subtype of ED.

Effect of pelvic arterial stenosis on erectile function: determining the severity threshold for erectile dysfunction

BACKGROUND

Pelvic arterial (PLA) stenosis is associated with arterial insufficiency of the penis and erectile dysfunction (ED), but the effect of different severities of PLA stenosis on ED remains unclear.

AIM

To investigate how different severities of PLA stenosis affect erectile function.

METHODS

We included patients who visited our clinic for ED and underwent computed tomography angiography (CTA) and dynamic duplex sonography (DUS). The erectile hardness score (EHS), simplified International Index of Erectile Function (IIEF-5), DUS and CTA results, and flow index (FI) calculated from the peak systolic velocity (PSV) and PLA stenosis percentages were analyzed. EHS < 3 was defined as significant ED. PLA stenosis was analyzed by the mean PLA (average of the right and left PLA) and unilateral or bilateral stenoses. According to severity, stenosis was classified as mild, moderate, or severe.

OUTCOMES

Subjective and objective parameters, including the IIEF-5 score, EHS, PSV, and FI, in relation to different severities of PLA stenosis.

RESULTS

The study included 182 patients. Vascular parameters such as the mean PSV, PLA stenosis, and FI correlated with EHS and IIEF-5 scores. Receiver operating characteristic analyses for predicting EHS ≥ 3 showed that all vascular parameters had acceptable discriminatory ability. During the analysis performed using the mean PSA stenosis, EHS decreased in patients with mild and severe mean PLA stenosis, although a PSV drop was noted only in severe cases. The proportion achieving EHS 3 significantly dropped in patients with at least mild mean PLA stenosis. Using unilateral or bilateral PLA stenosis, the EHS significantly dropped in patients with severe unilateral and bilateral PLA stenosis, with PSV decreasing on the affected side in severe unilateral stenosis. However, the mean PSV did not drop despite different unilateral stenosis severities. The proportion achieving EHS 3 significantly dropped among patients with at least moderate unilateral PLA stenosis and bilateral PLA stenosis but not in mild unilateral cases.

CLINICAL IMPLICATIONS

The severity of PLA stenosis is correlated with the risk of ED.

STRENGTHS & LIMITATIONS

The strength of this study lies in its analysis of the effect of PLA stenosis on erectile function from various perspectives, including unilateral, bilateral, and mean stenosis. However, the absence of validation regarding the outcomes of endovascular therapy is a limitation.

CONCLUSION

Mild mean PLA stenosis and moderate unilateral PLA stenosis are associated with increased risks of ED; however, mild unilateral PLA stenosis does not affect erectile function.

Current and Future Directions of Technology in Assessment of Peyronie's Disease

PURPOSE OF REVIEW

This review assesses the effectiveness of various imaging modalities for diagnosing and managing Peyronie's disease (PD), exploring their clinical utility and limitations.

RECENT FINDINGS

Ultrasonography, currently the only modality endorsed by the American Urological Association, effectively detects calcifications and assesses vascular status but struggles with identifying non-palpable plaques. Computed tomography and magnetic resonance imaging provide detailed anatomical views but are costly along with other deterring factors. Autophotography and 3-dimensional imaging offer convenient home assessments but with variable accuracy. Elastography improves upon traditional ultrasonography, while emerging AI technologies show promise for automating precise curvature assessments, pending further validation. A combined approach tailored to each individual patient based on their needs enhances diagnostic accuracy. Supplementing ultrasonography with elastography and potentially AI could improve diagnostic outcomes and better guide treatment decisions. Continued research is vital to integrate these advancements into standard clinical practice and develop updated standardized protocols.

Sexual dysfunction after open abdominal aortic aneurysm repair: 16 years' experience in a quaternary center and literature review

Background

Open abdominal aortic aneurysm (AAA) repair can lead to sexual dysfunction (SD) in men.

Objectives

To determine the prevalence of SD following open AAA repair, explore whether surgical techniques for aortic reconstruction can have a differential impact on the occurrence of SD, and summarize current knowledge in this field.

Methods

Retrospective review of 100 patients submitted to open AAA repair between 1995 and 2010 in a quaternary center. Sexual dysfunction was assessed according to questions from the modified International Index of Erectile Function (IIEF), considering the condition before surgical repair and 3 months after surgery. The chi-square test, Fisher's exact test, and Student's t test were used for statistical analyses.

Results

100 patients were included (mean age = 66.4 years old). Normal sexual activity, no sexual activity, erectile dysfunction, and retrograde ejaculation with preserved erectile function were found in 36%, 21%, 18%, and 24% of patients, respectively. The group of patients with no sexual activity was older (mean age = 72.3 years old vs 64.5 years old, p < 0.001). Erectile dysfunction prevalence was higher in patients submitted to an aorto-bifemoral bypass (p = 0.032). Retrograde ejaculation was more frequent in patients submitted to an aorto-aortic bypass (p = 0.007).

Conclusions

Sexual function is a frequent condition intimately associated with the aortic reconstruction technique. The literature review found contradictory results regarding whether the endovascular approach is protective compared with open repair, but clearly demonstrated the importance of techniques targeting preservation of the internal iliac artery and the superior hypogastric plexus.

Erectile dysfunction: role of computed tomography cavernosography in the diagnosis and treatment planning of venous leak

BACKGROUND

Venous leak appears to be the most common cause of vasculogenic erectile dysfunction (ED), which can be treated with venous embolization. Traditionally, conventional cavernosography was used for the diagnosis and treatment planning of venous leak. Recently, computed tomography (CT) cavernosography was introduced as a novel cross-sectional imaging method proposed to be advantageous over conventional cavernosography. We created a novel management algorithm for diagnosing venous leak including CT cavernosography as an imaging modality. In order to provide a broader basis for our management algorithm, a systematic literature review was conducted.

MAIN BODY

In this article we systematically review relevant literature on using CT cavernosography for the diagnosis and treatment planning in ED patients with venous leak following the PRISMA selection process. Nine full-text articles were included in the review and assigned a level of evidence grade (all grade II). Two studies (2/9) compared the results of conventional cavernosography with those of CT cavernosography which was superior for site-specific venous leak identification (19.4% vs. 100%, respectively). CT cavernosography is a more detailed imaging method that is faster to perform, exposes the patient to less radiation, and requires less contrast material. In one study (1/9), CT cavernosography was used for diagnostic purposes only. Eight studies (8/9) cover both, diagnostic imaging and treatment planning including embolization (1/9) and sclerotherapy (2/9) of venous leak in patients with venogenic ED. Three studies (3/9) describe anatomical venous leak classifications that were established based on CT cavernosography findings for accurate mapping of superficial and/or deep venous leak and identification of mixed or more complex forms of venous leak present in up to 84% of patients. In addition to treatment planning, one study (1/9) used CT cavernosography also for follow-up imaging post treatment.

CONCLUSION

CT cavernosography is superior to conventional cavernosography for diagnosis and treatment planning in patients with ED caused by venous leak (grade II levels of evidence). Consequently, CT cavernosography should be included in management algorithms for ED patients with suspected venous leak.

Periodontitis as a risk factor for organic erectile dysfunction: A case-control study in a sub-Saharan population

Background

This study investigated the association between periodontitis and organic erectile dysfunction (ED) in a sub-Saharan population.

Methods

This multicenter analytical study lasted from April to September 2021. A total of 114 patients (38 cases and 76 controls) were recruited and matched on age, diabetes, and smoking status. Medical history and ED were recorded, as well as the plaque index, bleeding index, maximum interdental clinical attachment loss (CALmax), maximum probing depth, clinically detectable furcation involv ement, number of teeth in the mouth, number of teeth lost for periodontal reasons, and tooth mobility. The analysis was performed with SPSS 20.0 with a significance threshold set at 5%.

Results

The two study groups were comparable regarding sociodemographic characteristics. Periodontitis was present in 76.31% of cases and 75% of controls without a significant difference (P=0.878). Logistic regression showed a significant association between high blood pressure and ED with an OR=4.78 (95% CI: 1.80‒12.70). Periodontitis was not associated with ED (OR=1.52, 95% CI: 0.55‒4.16); however, severe periodontitis was significantly associated with severe ED (OR=1.44, 95% CI: 1.11‒1.85, and OR=1.68, 95% CI: 1.15‒2.44, respectively for CALmax and tooth loss).

Conclusion

Within the limits of this study, periodontitis was not associated with organic ED. However, the severity of periodontal disease significantly increased in patients with organic ED.

Doppler Ultrasonographic Evaluation of Erectile Dysfunction in a Northern Nigerian Tertiary Hospital

Background

Colour duplex Doppler is a noninvasive tool for the evaluation of the vascular mechanism of erectile dysfunction (ED). It can be used to determine the integrity of the vascular mechanism and to differentiate between arterial and venous insufficiency.

Objectives

To identify the vasculogenic causes of ED and subclassify them into arteriogenic, venogenic, or mixed to assist in predicting the clinical outcome.

Materials and Methods

A retrospective study was conducted at the Department of Radiology, ABUTH Zaria, from records of patients who had presented to the Doppler suite with symptoms of ED available between July 2020 and August 2022.

Results

A total of 23 patients were involved in this study. The age range was 25-66 years. The majority of the patients were seen in age groups 51-60 years and 41-50 years with 48% (11) and 22% (5), respectively. Only 3 (13%) of the patients were found to have normal penile Doppler study, 12 (52%) patients were found to have arteriogenic, and another 4 (17.4%) patients were found to have venogenic cause. In four (17.4%) patients, there was mixed/inconclusive picture. Among the nine (39%) patients with Peyronie's disease, only one showed normal Doppler study. The incidence of vasculogenic cause of ED was found to increase with age.

Conclusions

The colour Doppler study is an important noninvasive nonionizing radiation tool for swift evaluation of penile erectile function and, thus, helps in classifying ED causes into structural, vascular, or possibly psychogenic, hence guiding the clinicians on the therapeutic options.

The atherosclerotic cardiovascular disease risk score is a reliable tool to identify patients with arteriogenic erectile dysfunction

BACKGROUND

The atherosclerotic cardiovascular disease risk score is a validated algorithm predicting an individual's 10-year risk of developing acute cardiovascular events (cardiovascular disease). Patients who suffer from arteriogenic erectile dysfunction are susceptible to developing cardiovascular disease in the future.

OBJECTIVES

To apply the atherosclerotic cardiovascular disease score at a homogenous cohort of men with erectile dysfunction undergoing a dynamic penile colour Doppler duplex ultrasound and explore its predictive ability to identify patients with vasculogenic erectile dysfunction at colour Doppler duplex ultrasound.

MATERIALS AND METHODS

Complete data of 219 patients undergoing colour Doppler duplex ultrasound were analysed. All patients completed the International Index of Erectile Function. The atherosclerotic cardiovascular disease score and Charlson comorbidity index were applied to the entire cohort. Patients were divided into those with normal vs. pathological parameters at colour Doppler duplex ultrasound. Descriptive statistics were used to explore differences between the two groups. Logistic regression models tested the potential role of atherosclerotic cardiovascular disease to predict arteriogenic and/or venogenic erectile dysfunction. Local polynomial smoothing models graphically displayed the probability of pathological colour Doppler duplex ultrasound parameters at different atherosclerotic cardiovascular disease scores.

RESULTS

Overall, arteriogenic erectile dysfunction and venous leakage were diagnosed in 88 (40.2%) and 28 (12.8%) patients respectively. The median (interquartile range) atherosclerotic cardiovascular disease score was 7.7 (3.9-14). Patients with pathologic colour Doppler duplex ultrasound were older (59 vs. 54 years, p < 0.001), had higher Body Mass Index (26.5 vs. 25.6 kg/m2 , p = 0.04), more comorbidities (Charlson comorbidity index ≥ 1) (76.5% vs. 54.4%, p = 0.002) and higher median atherosclerotic cardiovascular disease scores (9.95 vs. 7, p = 0.005), respectively. At logistic regression analysis, a higher atherosclerotic cardiovascular disease risk score was independently associated with arteriogenic erectile dysfunction at colour Doppler duplex ultrasound (odds ratio: 1.03, 95% confidence interval: 1.01-1.08, p = 0.02) after adjusting for Body Mass Index, physical activity, alcohol consumption and severe erectile dysfunction.

DISCUSSION

As vasculogenic erectile dysfunction may precede by some years the onset of acute cardiovascular diseases, the rigorous identification of patients with deficient cavernosal arterial blood flow, would definitely allow the implementation of earlier and more effective cardiovascular prevention strategies in men with erectile dysfunction.

CONCLUSIONS

The atherosclerotic cardiovascular disease risk score represents a reliable tool to identify patients with arteriogenic erectile dysfunction in everyday clinical practice.

A Review on Penile Doppler and Ultrasonography for Erectile Dysfunction

PURPOSE OF REVIEW

Herein, we seek to review the clinical applications of penile duplex Doppler ultrasound (PDDU) in sexual medicine practices and discuss the indications, protocols, advantages, and limitations of this diagnostic modality. Other more outdated diagnostic tests, such as cavernosometry, are briefly discussed to provide the reader a background of understanding on the evolution of diagnostic testing within the realm of sexual medicine.

RECENT FINDINGS

PDDU has become a key diagnostic tool in the clinical evaluation of both erectile dysfunction (ED) and Peyronie's disease (PD). With the assistance of intracavernosal injections such as alprostadil, clinicians can utilize ultrasound technology to produce a detailed description of the hemodynamics of the patient's erection cycle. This information plays a pivotal role in establishing an accurate diagnosis and creating a sensible management plan for the patient. This review aims to provide a better understanding regarding the technique and interpretation of PDDU as it pertains to male sexual function.

Advances in physical diagnosis and treatment of male erectile dysfunction

Erectile dysfunction (ED) is the most common male sexual dysfunction by far and the prevalence is increasing year after year. As technology advances, a wide range of physical diagnosis tools and therapeutic approaches have been developed for ED. At present, typical diagnostic devices include erection basic parameter measuring instrument, erection hardness quantitative analysis system, hemodynamic testing equipment, nocturnal erection measuring instrument, nerve conduction testing equipment, etc. At present, the most commonly used treatment for ED is pharmacological therapy represented by phosphodiesterase five inhibitors (PDE5i). As a first-line drug in clinical, PDE5i has outstanding clinical effects, but there are still some problems that deserve the attention of researchers, such as cost issues and some side effects, like visual disturbances, indigestion, myalgia, and back pain, as well as some non-response rates. Some patients have to consider alternative treatments. Moreover, the efficacy in some angiogenic EDs (diabetes and cardiovascular disease) has not met expectations, so there is still a need to continuously develop new methods that can improve hemodynamics. While drug have now been shown to be effective in treating ED, they only control symptoms and do not restore function in most cases. The increasing prevalence of ED also makes us more motivated to find safer, more effective, and simpler treatments. The exploration of relevant mechanisms can also serve as a springboard for the development of more clinically meaningful physiotherapy approaches. Therefore, people are currently devoted to studying the effects of physical therapy and physical therapy combined with drug therapy on ED. We reviewed the diagnosis of ED and related physical therapy methods, and explored the pathogenesis of ED. In our opinion, these treatment methods could help many ED patients recover fully or partially from ED within the next few decades.

Application of dual-energy CT angiography in diagnosis of arterial erectile dysfunction: new scanning technology, new scanning area

OBJECTIVES

To explore the value of dual-energy computed tomography (DE-CT) angiography in diagnosis of arteriogenic erectile dysfunction (ED) patients and feasibility of new scanning area that excludes the testis.

MATERIALS AND METHODS

Ninety-three patients suspected of suffering arterial ED and 40 health volunteers underwent penile duplex Doppler ultrasound and DE-CT angiography (DE-CTA). The scanning range of DE-CTA covered whole arterial system of pelvis and testis was excluded. Two blinded investigators independently evaluated the arterial system that supplies the penis.

RESULTS

Finally, 1596 segments were evaluated and 470 segments were judged to be abnormal. The distribution was: 2 (0.4%) in common iliac artery, 7 (1.5%) in internal iliac artery, 82 (17.5%) in internal pudendal artery, 89 (18.9%) in penile artery, 120 (25.5%) in dorsal artery, and 170 (36.2%) in cavernosal artery. The specificity, sensitivity, positive predictive value, and negative predictive value of DE-CTA in diagnostic were 86.02%, 87.50%, 94.12%, and 72.92%. Besides, the new scan area allowed for effective evaluation of the arteries while excluding the testis.

CONCLUSION

DE-CTA can provide unbiased, safe evaluation of the vascular status of the penile bed in patients with ED.

Wearable Soft Microtube Sensors for Quantitative Home-Based Erectile Dysfunction Monitoring

Quantifiable erectile dysfunction (ED) diagnosis involves the monitoring of rigidity and tumescence of the penile shaft during nocturnal penile tumescence (NPT). In this work, we introduce Erectile Dysfunction SENsor (EDSEN), a home-based wearable device for quantitative penile health monitoring based on stretchable microtubular sensing technology. Two types of sensors, the T- and R-sensors, are developed to effectively measure penile tumescence and rigidity, respectively. Conical models mimicking penile shaft were fabricated with polydimethylsiloxane (PDMS) material, using different base to curing agent ratios to replicate the different hardness properties of a penile shaft. A theoretical buckling force chart for the different penile models is generated to determine sufficiency criteria for sexual intercourse. An average erect penile length and circumference requires at least a Young's modulus of 179 kPa for optimal buckling force required for satisfactory sexual intercourse. The conical penile models were evaluated using EDSEN. Our results verified that the circumference of a penile shaft can be accurately measured by T-sensor and rigidity using the R-sensor. EDSEN provides a private and quantitative method to detect ED within the comfortable confines of the user's home.

The flow index provides a comprehensive assessment of erectile dysfunction by combining blood flow velocity and vascular diameter

Dynamic duplex sonography (DUS) is not comprehensive in the evaluation of arteriogenic erectile dysfunction (ED). We introduced a new parameter, the flow index (FI), into the assessment of arteriogenic ED. A retrospective review of a prospective database was conducted. Patients undergoing DUS and pelvic computed tomography angiography for the evaluation of ED were included. The FI was calculated from peak systolic velocity (PSV) and the percentages of pelvic arterial (PLA) stenosis. Correlations between PSV, PLA stenosis, the FI, and erectile function were calculated. Eighty-three patients were included. Compared with PSV, the FI had better correlations with the erection hardness score (EHS) (r_s = 0.405, P < 0.001 for FI; r_s = 0.294, P = 0.007 for PSV). For EHS < 3, the areas under the ROC curve of FI and PSV were 0.759 and 0.700, respectively. In patients with normal DUS but EHS < 3, PLA stenosis was more severe (62.5% vs. 10.0%, P = 0.015), and the FI was lower (8.35 vs. 57.78, P = 0.006), while PSV was not different. The FI is better than PSV in the evaluation of arteriogenic ED. On the other hand, assessment of the pelvic arterial system should be included in the evaluation of ED.

Prospective cross-sectional evaluation of penile helicine circulation by power doppler during dynamic ultrasound in veno-occlusive erectile dysfunction

OBJECTIVE

To evaluate the usefulness of Power Doppler to improve the diagnostic work up of veno-occlusive erectile dysfunction patients.

MATERIALS AND METHODS

Patients affected by erectile dysfunction, mean IIEF 5 = 13.5 (12-17) for at least 6 months, were enrolled in a prospective cross-sectional study. All patients underwent Dynamic Power Doppler after intracavernous injection of vasoactive drugs (PGE1 20 mcg and Papaverine 6 mg). Poor responders' patients subsequently underwent to cavernosometry to get a full assessment of the vascular framework.

RESULTS

202 patients (mean age 46 y.o.), were included in the study. 96 subjects (47.5%) who did not adequately respond to the intracavernous injection -test, subsequently underwent to cavernosometry. In 42/96 patients (43.7%) cavernosometry was positive for veno-occlusive dysfunction. In a total of 160 patients who did not have veno-occlusive dysfunction (54 with negative cavernosometry + 106 intracavernous injection-test responders), the Power Doppler was normal in 126 (78.8%) and pathological in 34 (21.3%) in terms of steric conformation of "low flow" vessels corresponding to the Cavernosal Terminal Unit. The diagnostic sensitivity of Power Doppler towards veno-occlusive dysfunction was found to be 52.4% (Positive Predictive Value: 39.3%), the specificity was 78.8% (Negative Predictive Value: 86.3%) and the total diagnostic accuracy was equal to 73.3%.

CONCLUSIONS

Collected data evidenced that patients who reported altered morphological features of the Cavernosal Terminal Unit had an approximately 4-fold greater risk of having veno-occlusive dysfunction compared to patients who had normal Power Doppler features (OR = 4.076; 95% CI: 1.996-8.327).

Long-term high-dose L-arginine supplementation in patients with vasculogenic erectile dysfunction: a multicentre, double-blind, randomized, placebo-controlled clinical trial

PURPOSE

The current randomized, double-blind, placebo-controlled clinical trial addressed the effects on penile erectile function of relatively high daily oral doses (6 g/day) of L-ARG for 3 months (N = 51) compared to placebo (N = 47), in patients with vasculogenic ED, with comparison between mild-moderate and severe vasculogenic ED.

METHODS

The outcome measures included IIEF-6 score and cavernous arteries peak systolic flow velocity (PSV) at dynamic penile duplex ultrasonography (PDU).

RESULTS

L-ARG supplementation for 3 months significantly increased IIEF-6 score in the overall cohort (p < 0.0001) and in subgroups of patients with mild-moderate (p < 0.0001) and severe (p = 0.007) vasculogenic ED; PSV was significantly increased in the overall cohort (p < 0.0001) and in patients with mild-moderate (p < 0.0001), but not severe vasculogenic ED. At study completion, 74% of patients improved ED degree category, although only 24% of patients, mainly belonging to the baseline category of mild ED, reached IIEF-6 scores compatible with absence of ED; moreover, 20% of patients, exclusively belonging to the baseline category of mild-moderate vasculogenic ED, reached PSV values compatible with absence of ED.

CONCLUSION

The results of the current study demonstrated that supplementation with relatively high doses of L-ARG as a single compound for 3 months significantly improved penile erectile function, assessed by both IIEF-6 score and PSV at dynamic PDU in patients with mild-moderate, and improved IIEF-6 score, but not PSV, in patients with severe vasculogenic ED, therefore suggesting that L-ARG might be an alternative treatment in mild-moderate vasculogenic ED patients experiencing adverse effects or with contraindications for chronic treatment with PDE5i compounds.

X-ray micro-computed tomography in the assessment of penile cavernous fibrosis in a rabbit castration model

BACKGROUND

Current assessment methods of penile cavernous fibrosis in animal models have limitations due to the inability to provide complex and volume analysis of fibrotic alterations.

OBJECTIVE

The aim was to evaluate micro-computed tomography (micro-CT) for assessment of cavernous fibrosis and compare it with histological, histochemical, immunohistochemical, and RT-PCR analysis.

MATERIALS AND METHODS

A controlled trial was performed involving 25 New Zealand male rabbits with induced testosterone deficiency by orchidectomy. Penile samples were obtained before and after 7, 14, 21, 84 days from orchidectomy. We consistently performed: a) gray value analysis of corpora cavernosa 3D models reconstructed after micro-CT; b) morphometry of smooth muscles/connective tissue ratio, collagen type I/III ratio, and area of TGF-beta-1 expression in corpora cavernosa; c) RT-PCR of TGF-beta-1 expression.

RESULTS

Micro-CT allowed visualization of penile structures at the resolution comparable to light microscopy. Gray values of corpora cavernosa decreased from 1673 (1512-1773) on the initial day to 1184 (1089-1232) on 21 day (p < 0,005); however, on 84 day, it increased to 1610 (1551-1768). At 21 and 84 days, there were observed a significant decrease in smooth muscle/connective tissue ratio and a significant increase in collagen type I/III ratio (p < 0,05). TGF-beta1 expression increased on 84 day according to immunohistochemistry (p < 0,005). RT-PCR was impossible to conduct due to the absence of RNA in obtained samples after micro-CT.

DISCUSSION AND CONCLUSIONS

Micro-CT provided 3D visualization of entire corpora cavernosa and assessment of radiodensity alterations by gray value analysis in fibrosis progression. We speculate that gray value changes at early and late fibrosis stages could be related to tissue reorganization. RT-PCR is impossible to conduct on tissue samples studied by micro-CT due to RNA destruction. We also suggest that micro-CT could negatively affect the immunohistochemical outcome, as a significant increase of TGF-beta-1 expression occurs later than histological fibrotic signs. This article is protected by copyright. All rights reserved.

Alternative medicine and herbal remedies in the treatment of erectile dysfunction: A systematic review

Objectives: To systematically review and discuss the current evidence from placebo-controlled clinical trials that investigated the use of alternative medicines and herbal remedies in the management of erectile dysfunction (ED). Methods: A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-based systematic review using specific keyword combinations was conducted on the PubMed and Scopus databases. Randomised controlled trials investigating herbal medicine in at least one group and using the International Index of Erectile Function (IIEF) as an outcome in patients primarily diagnosed with ED were included for review. Results: Following the literature search, screening and eligibility analysis, a total of 42 articles were included. The 42 articles were categorised as single herb extractions (n = 14), combination herbal formula (n = 5), combination of herbal formula and non-herbal nutraceuticals (n = 7), non-herbal nutraceuticals (n = 5), acupuncture and moxibustion (n = 2), diet and nutrition (n = 3), exercise (n = 5), and topical treatments (n = 1). Based on the results, Korean ginseng, Pygnogenol and Prelox, Tribulus terrestris, Lepidium meyenii, L-arginine, acupuncture and lifestyle interventions were the more predominantly investigated treatments interventions for ED. Conclusions: Panax ginseng, Pygnogenol, Prelox and Tribulus terrestris have promising evidence as herbal products, alongside L-arginine as a nutritional supplement, for ED based on IIEF outcomes, and warrant further clinical investigation. The mechanisms of action remain unclear, but each of these appears to in part increase nitric oxide synthesis. Importantly, improved diet and exercise should be considered, particularly in patients with obesity or diabetes mellitus.

Effect of Intracavernosal Injection of Prostaglandin E1 on Duration and Rigidity of Erection in Patients With Vasculogenic Erectile Dysfunction: Is It Dose Dependent?

OBJECTIVE

To assess if the effect of intracavernosal injection of prostaglandin E1 (PGE1) on duration and rigidity of erection is dose dependent in patients with different types of vasculogenic erectile dysfunction (ED)?

METHODS

A hundred patients with ED were assigned into 4 groups (n = 25/each); group (A) patients with arteriogenic ED, group (B) patients with veno-occlusive ED, group (C) patients with mixed (arteriogenic and veno-occlusive) ED, and group (D) patients who have only psychogenic ED (control). After intracavernosal injection of PGE1, patients were assessed using penile Doppler ultrasonography and erection hardness score together with calculation of erection duration. The starting dose of PGE1 was 5 μg which was increased to 10 µg and 20 µg as a maximal dose when needed.

RESULTS

The mean PSV of patients in groups A, B, C, and D were 24.38 ± 3.3, 37.74 ± 8.28, 22.24 ± 3.85, and 47.76 ± 6.27, respectively. In group D, 88% have achieved the best response at dose of 5 µg while 5.3%, 21.7%, and 0% have achieved the best response at dose of 5 µg in groups A, B, and C, respectively (P < .05 for each). The rest of patients have required either 10 or 20µg to achieve the best response. Patients in group C have required the highest dose of PGE1 to achieve the best response (P < .05).

CONCLUSION

Intracavernosal injection of PGE1 in escalating doses have improved the rigidity and duration of erection in patients with different types of vasculogenic ED. Patients with mixed arteriogenic and veno-occlusive ED have required the highest dose of PGE1 to achieve the best response.