Clinical and sonographic assessment of the side effects of intracavernous injection of vasoactive substances

Pathophysiology and Grayscale Ultrasonography of Penile Corporal Fibrosis

INTRODUCTION

Penile corporal fibrosis may occur secondary to explantation of an infected penile prosthesis, severe penile trauma, refractory low-flow priapism, Peyronie's disease, or chronic intra-cavernous injection of vasoactive drugs. Other etiologies of corporal fibrosis, presenting primarily with erectile dysfunction, can develop in chronic smokers, hypertensive patients, alcoholics, diabetics, and after radical prostatectomy. Corporal erectile tissue fibrosis is a significant pathophysiologic component of erectile dysfunction; however, current ultrasound-based penile imaging protocols do not directly assess it.

OBJECTIVE

To determine if grayscale ultrasonography (US) is a suitable imaging modality to identify and assess penile corporal erectile tissue fibrosis.

METHODS

A PubMed literature review was performed for studies that detailed ultrasonographic methods and findings of pathologies causing penile corporal fibrosis. Our main outcome measure was the ultrasonographic findings of pathologies causing penile corporal fibrosis.

RESULTS

Grayscale US demonstrates the capability to detect and localize the fibrotic changes of the corpora cavernosa. Ultrasonographic findings capture penile corporal tissue heterogeneity including diffuse, circumscribed, or localized patterns.

CONCLUSION

Overall, grayscale US may be a useful and convenient imaging modality to assess penile corporal fibrosis secondary to explantation of an infected penile prosthesis, priapism, penile trauma, chronic intra-cavernous injection of vasoactive drugs, diabetes, Peyronie's disease, and vascular disease. While limited by the skill and knowledge of the US operator, the combined knowledge of pathophysiology and US may help clinicians identify and manage the underlying etiology of penile corporal fibrosis. Kim J, Drury R, Morenas R et al. Pathophysiology and Grayscale Ultrasonography of Penile Corporal Fibrosis. Sex Med Rev 2022;10:99-107.

Shear wave elastography as a new, non-invasive diagnostic modality for the diagnosis of penile elasticity: a prospective multicenter study

Objective:

Shear wave elastosonography (SWE) could be used to evaluate the elasticity of penile tissue. Few studies in the literature, however, have investigated its use in patients with erectile dysfunction (ED) or have attempted to correlate findings with International Index of Erectile Function (IIEF-5) scores. The primary aim of this study was to evaluate the characteristics of erectile tissue using SWE and to determine possible relationships with IIEF-5 and Erection Hardness Scale (EHS) scores. The secondary aim was to establish a cut-off SWE examination value over which cavernous tissue stiffness could contribute to a subsequent organic alteration.

Methods:

This prospective study included male patients 18−80 years of age who attended two general andrology clinics and underwent SWE. Subjects were divided into groups according to IIEF-5 score, and correlations between SWE and IIEF-5 and EHS questionnaire scores were explored.

Results:

A total of 270 subjects (mean age 46.7 ± 16.9 years) were included. ED was reflected by low IIEF-5 and EHS scores and a decrease in the mean elasticity of the corpora cavernosa according to SWE, although the difference between the left and right corpora cavernosa was not statistically significant. No statistically significant correlation was found between measurements of the corpora cavernosa (in kPa) and age. The optimal cut-off identified was 24.75 kPa.

Conclusion:

Results demonstrated that the mean elasticity of the corpora cavernosa according to SWE was correlated with IIEF-5 score and EHS score.

The Role of Phosphodiesterase Inhibitors in the Management of Cavernositis With Multifocal Abscesses: A Report of Case Series

Introduction

Cavernositis is a rare acute infection of the corporal bodies of the penis. It might result in corporal cavernosal abscesses, fibrosis, and subsequently erectile dysfunction if the treatment is inadequate. Previous reports advocate penile aspiration when cavernosal abscesses were significantly present.

Aim

We report 2 cases of cavernositis treated by the standard antimicrobial therapy in addition to the daily use of phosphodiesterase type 5 inhibitors (iPDE-5).

Methods

We include 2 patients who fulfill the criteria for the diagnosis of cavernositis. They were diagnosed clinically based on history and physical examination. Patient 1 had multifocal abscesses on initial penile contrast-enhanced magnetic resonance imaging (MRI). This patient showed rapid clinical improvement with the addition of phosphodiesterase inhibitor (PDEi) to the antimicrobial therapy without the need for surgical drainage of the abscesses. Patient 2 had persistent infection despite 3 weeks of oral second-generation cephalosporin (Cefuroxime). But he showed significant clinical improvement after being started on PDEi in conjunction with the current antimicrobial therapy. Follow-up after 3 months by clinical examination and penile magnetic resonance imaging in both patients showed normal erectile function with no scarring.

Conclusion

PDEi have promising results on disease progression and outcomes. It synergizes the effect of antimicrobial therapy and can potentially reduce the residual corporal fibrosis and erectile dysfunction. However, large studies are required to validate and generalize this treatment approach.

Bakhsh A, Daqqaq T, Alhasan A, et al. The Role of Phosphodiesterase Inhibitors in the Management of Cavernositis With Multifocal Abscesses: A Report of Case Series. Sex Med 2020;8:318–322.

Erectile Dysfunction: A Primer for in Office Management

Introduction: Optimizing erectile dysfunction (ED) remains a clinically significant endeavor as insufficient outcomes from oral, injectable and even surgical approaches to treatment remain less than ideal. In this report, we integrate evolving knowledge and provide an algorithmic approach for the clinician to fine-tune management. Methods: We performed a PubMed and Medline search of Erectile Dysfunction treatment optimization, enhanced patient efficacy for ED, and why men fail ED treatment. All relevant papers for the past two decades were reviewed. Results: Establishing the goals and objectives of the patient and partner while providing detailed instructions for treatment can minimize failures and create an environment that allows treatment optimization. A thorough work-up may identify reversible or contributing causes. We identified several areas where treatment of ED could be optimized. These include; management of associated medical conditions, lifestyle improvements, PDE5 inhibitor prescription strategies, management of hypogonadism and the initiation of intracavernosal injection therapy (ICI). Conclusions: In our view, once a man presents for help to the clinician, use of the simple strategies identified in this review to optimize the tolerability, safety and effectiveness of the selected treatment should result in enhanced patient and partner satisfaction, with improved outcomes.

Low-intensity shock wave therapy ameliorates erectile dysfunction in men with pelvic fractures associated with urethral injury

Erectile dysfunction (ED) is common in patients with pelvic fractures associated with urethral injury (PFUI). We aim to assess the efficacy and safety of low-intensity shock wave therapy (LiSWT) in ED treatment related to PFUI. Forty-three consecutive patients with PFUI who underwent surgical repair between January 2014 and March 2017 were sampled in Kaohsiung Medical University Hospital, Kaohsiung, Taiwan. ED onset following surgical repair was initially treated with oral phosphodiesterase type 5 inhibitors (PDE5i) for six months. PDE5i non-responders were referred for LiSWT of six weekly sessions. Erectile function was evaluated by the International Index of Erectile Function-5 (IIEF-5) and Erection Hardness Score (EHS). Forty-three consecutive patients were enrolled in our study. ED was observed in 79.1% (34/43) patients following surgical repair. These 34 patients were given oral PDE5i (Tadalafil^® 5 mg) daily treatment, 64.7% (22/34) patients restored erectile function to normal range (EHS: 3.4 ± 1.3, IIEF-5: 21.7 ± 1.0). The other twelve PDE5i non-responders were referred for LiSWT. Seven patients (58.3%, 7/12) remained unable to maintain the rigidity for full sexual intercourse. The other five patients reported allowing full sexual intercourse. Based on our results, LiSWT may ameliorate the ED in men with PFUI and shift PDE5i non-responders to responders.

Phosphodiesterase type 5 inhibitors as a treatment for erectile dysfunction: Current information and new horizons

INTRODUCTION

Over the past 15 years, the discovery and development of oral medications that selectively inhibit the enzyme phosphodiesterase type 5 (PDE5) have revolutionised the treatment of erectile dysfunction (ED). Currently, three PDE5 inhibitors are widely available clinically, i.e., sildenafil, vardenafil and tadalafil. New PDE5 inhibitors, including avanafil and udenafil, are now in clinical use in a few countries, and other compounds are under development.

METHODS

We describe the current use and future direction of PDE5 inhibitors in the treatment of ED.

RESULTS AND CONCLUSION

Each PDE5 inhibitor has an excellent and comparable efficacy and tolerability. These drugs are highly effective for ED of various causes, and are effective in preventing ED after radical prostatectomy. However, whilst being at least 60% effective, PDE5 inhibitors are still ineffective in at least 30% of patients, prompting current research into other pharmacological targets for ED.

Future prospects in the treatment of erectile dysfunction: focus on avanafil

The treatment of erectile dysfunction (ED) has been revolutionized in the last 15 years with the introduction of type 5 phosphodiesterase (PDE5) inhibitors. Their efficacy, safety, and ease of administration have made them first-line treatment for ED. This article reviews the current therapies available for ED, and the new PDE5 inhibitors that are being investigated. Furthermore, it examines all the current ED treatment options that are in different phases of development (including oral and topical pharmacotherapy, gene therapy, and tissue engineering). A special emphasis is on avanafil, a new PDE5 inhibitor that has been studied extensively in Phase I and II clinical trials and has undergone several Phase III trials. Avanafil is a promising medication for ED due to its favorable pharmacokinetics, safety, and efficacy.

Diabetes-induced erectile dysfunction: epidemiology, pathophysiology and management

Erectile dysfunction (ED) is defined as the inability of the male to attain and maintain erection of penis sufficient to permit satisfactory sexual intercourse. Prevalence of impotence in diabetic men is ≥50%. The pathophysiology of diabetes-induced erectile dysfunction (DIED) is multifactorial and no single etiology is at the forefront. The proposed mechanisms of erectile dysfunction in diabetic patients includes elevated advanced glycation end-products, increased levels of oxygen free radicals, impaired nitric oxide synthesis, increased endothelin B receptor binding sites and up-regulated RhoA/Rho-kinase pathway, neuropathic damage and impaired cyclic guanosine monophosphate (cGMP)-dependent protein kinase-1. The treatment of DIED is multimodal. Treatment of the underlying hyperglycemia and comorbidities is of utmost importance to prevent or halt the progression of disease. Oral medications are considered as the first line therapy for management of DIED. If oral agents cannot be used or have insufficient efficacy despite appropriate dosing and education, second-line treatments should be addressed. When there is lack of efficacy or when there is dissatisfaction with other modalities, penile prostheses are often the best alternative for ED and are considered as the third line therapy for DIED. Future strategies in the evolution of the treatment of DIED are aimed at correcting or treating the underlying mechanisms of DIED.

MR imaging of nonmalignant penile lesions

Magnetic resonance (MR) imaging is potentially useful in the assessment of many benign penile diseases. When T1- and T2-weighted sequences are used, MR imaging can clearly delineate the tunica albuginea and can be used to diagnose penile fracture and Peyronie disease; in both conditions, MR imaging may help refine the surgical approach. It is also useful in cases of priapism; in these cases, intravenously administered contrast material can help assess the viability of the corpora cavernosa and the presence of penile fibrosis. In the assessment of a penile prosthesis, MR imaging provides excellent anatomic information and is the investigation of choice. In the evaluation of erectile dysfunction, MR imaging has limited value, and for urethral stricture, it has not yet proved adequately superior to other modalities to justify its routine use.

Erectile dysfunction and coronary slow flow: distinct presentations of endothelial disease

The aim of the present study was to investigate degree of erectile dysfunction (ED) in males with slow coronary flow (SCF). Endothelial dysfunction was proposed to be the underlying mechanism in both diseases. A total of 29 male patients with slow coronary flow (mean age 45+/-7 years) and 23 male patients with normal coronary arteries (mean age 48+/-12 years) were included in the study. The severity of ED was determined according to the International Index of Erectile Function (IIEF) questionnaire. Mean IIEF scores in patients with SCF and control group were determined as 20.97+/-7.26 and 25.26+/-5.17, P=0.016. ED was detected in 45% (n=13) of SCF patients and 35% (n=8) of the control group (P=0.035). There was a negative correlation between the mean TIMI frame count and IIEF score between patients with SCF and controls (r=-0.31, P=0.029). These data suggest that ED is observed more frequently in patients with SCF phenomenon compared to patients with otherwise normal coronary angiograms.

Pathophysiology and treatment of diabetic erectile dysfunction

The pathophysiology of diabetes is multifactorial and no single etiology is at the forefront. The proposed mechanisms of erectile dysfunction (ED) in diabetic patients includes elevated advanced glycation end-products (AGEs) and increased levels of oxygen free radicals, impaired nitric oxide (NO) synthesis, increased endothelin B receptor binding sites and ultrastructural changes, upregulated RhoA/Rho-kinase pathway, NO-dependent selective nitrergic nerve degeneration and impaired cyclic guanosine monophosphate (cGMP)-dependent kinase-1 (PKG-1). The treatment of diabetic ED is multimodal. Treatment of the underlying hyperglycemia and comorbidities is of utmost importance to prevent or halt the progression of the disease. The peripherally acting oral phosphodiesterase type 5 (PDE5) inhibitors are the mainstay of oral medical treatment of ED in diabetics. Vacuum erection devices are an additional treatment as a non-invasive treatment option. Local administration of vasoactive medication via urethral suppository or intracorporal injection can be effective with minimal side-effects. Patients with irreversible damage of the erectile mechanism are candidates for penile implantation. Future strategies in the evolution of the treatment of ED are aimed at correcting or treating the underlying mechanisms of ED. With an appropriate vector, researchers have been able to transfect diabetic animals with agents such as neurotrophic factors and nitric oxide synthase (NOS). Further studies in gene therapy are needed to fully ascertain its safety and utility in humans.

Early treatment of cavernositis resulted in erectile function preservation

INTRODUCTION

Some of the more common complications of intracavernous injection (ICI) therapy include pain and prolonged erections. Rare reported complications include intracorporeal needle breakage and postinjection cavernositis.

AIM

We report a case of early management of postinjection cavernositis resulting in preservation of erectile function with no angulation.

METHODS

A 53-year-old male with no history of diabetes mellitus presented to our department with a small painful penile swelling 36 hours after ICI of 15 microg prostaglandin E1. Clinical, laboratory, and ultrasound assessments suggested the occurrence of cavernositis. Surgical debridement, abscess drainage, and antibiotics resulted in marked improvement. Follow-up showed normal erectile function with minimal scarring.

CONCLUSIONS

Timely management of cavernositis can help prevent loss of erectile function. Stringent supervision of patients, after adequate ICI training, together with drug prescription, is essential.

Imaging of penile traumas—therapeutic implications

Injury to the penis may result from penetrating or nonpenetrating trauma. Nonpenetrating injury to the erect penis can produce albugineal tear, intracavernous hematoma or extraalbugineal hematoma from rupture of the dorsal vessels. Nonpenetrating injury to the flaccid penis usually follows blunt perineal traumas producing extratunical or cavernosal haematomas, or cavernosal artery tear followed by high flow priapism. Differential diagnosis between albugineal tear and other penile injuries must be obtained as soon as possible, since early surgical repair of albugineal tear reduces significantly the rate of postraumatic curvature and fibrosis. Ultrasonography (US) is able to detect the exact site of the tear in most patients as an interruption of the thin echogenic line of the tunica albuginea. Other imaging techniques are rarely required in the clinical practice. Color Doppler US is the imaging modality of choice to evaluate patients with high flow priapism. Focal or diffuse cavernosal fibrosis can be identified with US as echogenic areas in the cavernosal bodies. Postraumatic erectile dysfunction can result from fibrotic changes, nerve and vascular impairment or both. Doppler evaluation of penile vasculature is required in young patients with postraumatic impotence before surgical revascularization procedures.