Ultrasonography after pharmacological stimulation of erection for the diagnosis and therapeutic follow-up of erectile dysfunction due to cavernovenous leakage

The goal of this work was to demonstrate that Doppler ultrasound (DUS) after pharmacological stimulation of erection (PSE) can be used to evaluate the presence and intensity of a cavernovenous leak (CVL) suspected in erectile dysfunction (ED) patients. The study was built around 50 DUS-PSE exams of penile arteries and veins, which were carried out 3, 5, 10 and 20minutes after pharmacological stimulation. Measured parameters were end diastolic velocity of the cavernous arteries and mean velocity of the deep penile vein and/or penile superficial veins. A score from 0 to 3 was attributed to each according to the recorded velocities. A final score from 0 to 9 was established by adding the three values: patients quoting 0 and 1 were classified as "no leak" (n=8); from 2 to 9 (n=42) as "leaking". Penile computed tomography (CT-scan) under identical pharmacological stimulation identified the cavernovenous leak to be compared with the DUS-PSE results, which were valid in 47 cases (94%), with 97.6% sensitivity and 77.7% specificity. The kappa correlation coefficient for CT-scan diagnosis of suspected CVL was 0.7875 (P<0.001). In addition, we found that end diastolic velocity in the cavernous artery, considered up until now as the gold standard in cases of suspected CVL was insufficient (negative predictive value=47%). In addition to its well-known diagnostic value regarding ED of arterial origin, DUS-PSE is an excellent screening test for CVL, especially in young patients without vascular risk factors who are resistant to medical treatments. For those with well-established CVL, confirmation by CT-scan to discuss possible surgery should be the next step. Moreover, DUS-PSE is useful in postoperative monitoring.

[Inflatable penile prostheses: results, complications and prognostic factors]

OBJECTIVE

To identify the main prognostic factors influencing the immediate and long-term results of inflatable penile prosthesis implantation.

PATIENTS AND METHODS

Between February 1999 and December 2007, 118 inflatable penile prostheses were implanted, by the same operator, on 96 patients with a mean age of 54.4 years. One third of the implanted patients had had previous penile surgery. Three different penile implants were used: TITAN alpha1 (N = 32), EXCEL (N = 6), and TITAN RESIST (N = 80).

RESULTS

Median follow-up was 25 months [6-114]. One patient with sickle-cell disease died from a massive pulmonary embolism. Seven patients (7.3%) had a postoperative scrotal haematoma. Eleven patients (11.5%) had a postoperative infection. Fourteen patients (14.6%) had a material migration. Sixteen patients (16.7%) had a surgical revision for mechanical dysfunctions after a mean period of 21 months. The rate of postoperative complications was significantly increased in case of prior penile surgery (p = 0.049) or in case of associated surgical procedure (p = 0.0095). The rate of migration was significantly more important in case of postpriapism erectile dysfunction (p = 0.00035). The risk of mechanical dysfunctions was significantly increased in case of Peyronie's disease. In the end of the follow-up, 85% of patients (and 91% of first-time implantations) had a functional prosthesis.

CONCLUSION

The long-term functional results of inflatable penile prosthesis are suitable but the postoperative complications are frequent in case of prior penile surgery, associated surgical procedure, Peyronie's disease, or postpriapism implantation.

Impairment of shear-stress-mediated vasodilation of cavernous arteries in erectile dysfunction

Penile NO release test (PNORT) has been designed to try to evaluate clinically the penile endothelial function (PEF). The shear-stress flow-mediated vasodilation (FMD) of the cavernous arteries is evaluated in two groups of patients with neurogenic (n=23) and vasculogenic (n=23) erectile dysfunction (ED) by measuring their percent of increase after a 5 min occlusion of the flow. Both groups show an important FMD decrease (17.78+/-11.78 and 17.82+/-13%) as compared to the age-matched control group (n=12) (65.14+/-30.5%, P<0.001). In the vasculogenic and control groups, mean FMD is lower in patients with one or more arterial risk factors(41 vs 67%, P=0.025), and show a positive correlation with the plasmatic levels of bioavailable testosterone (r=0.37, P=0.03) and of DHEA-S (r=0.46, P=0.014). Patients achieving full erection at pharmacological test with visual sexual stimulation have a higher FMD (43.8+/-38%) than those who did not (18.52+/-14.37%, P=0.008). We confirm clinically that PEF is strongly impaired in organic ED linked to neurological, vascular and endocrine factors.

[Flow-dependent dilatation of the cavernous artery. A potential test of penile NO content]

BACKGROUND

Nitric oxide (NO) is now considered as the main contributor to elicit and maintain erection. It is also established that flow-dependent dilatation of conduit arteries is mediated by NO. The present study was designed to verify the possibility of assessing the penile NO content when measuring the post occlusive vasodilatation of the cavernous arteries.

PATIENTS AND METHODS

Ninety five subjects, 22 with normal erections (control group) and 73 with various degrees of erectile dysfunction (ED), measured with the international index of erectile function (IIEF) and erectile activity index (IAE). Multidisciplinary evaluation helped to separate two subgroups: mainly organic (n=47) and mainly psychologic (n=26). The diameter of one of the two cavernous arteries was measured by duplex-scan before and after a five-minute complete occlusion of penile vascular flow. The criterion retained was the maximum percentage of dilatation achieved within 45 to 90 sec after the release of the occlusion. Means were compared in the clinical groups. Influences of IIEF, IAE, age, arterial risk factors, preocclusive diameter of the artery, testosterone and DHEA levels were evaluated.

RESULTS

The mean percentage of increase in the control group was 65.2 +/- 26.3% vs 34.9 +/- 34.9% for the ED group (p=0.0003). The psychologic subgroup with 68.2 +/- 40% was similar to the control group as opposed to the organic group which showed a highly-significant difference (16.4 +/- 8.4; p=0.0001). In the control group and the psychological sub-group, subjects with arterial risk factors exhibited a less pronounced response (53.7 +/- 22) as compared to those free of any risk factors (80.3 +/- 30%) p=0.007. Age (r=0.29), preocclusion arterial diameter (r=0.3) and DHEA-S (r=0.56) as well as IIEF and IAE were correlated with the magnitude of the reaction. Sensitivity (100%) and specificity (92%) have been achieved in discriminating organic from psychologic DE.

CONCLUSION

Flow-dependent vasodilatation of the cavernous artery is extremely strong. It is much stronger in control subjects and in patients with predominantly psychological ED. An increase of 30% seems to be a critical level since only patients in the organic group were below that level. Thus, organic ED seems to be linked to the decrease of NO production by the cavernous bodies. If these results were confirmed post occlusive vasodilatation of the cavernous artery might be proposed as a fully non-invasive diagnostic and prognostic test in the study of ED. We propose to call it PNORT (penile NO release test).

Indications and early results of sildenafil (Viagra) in erectile dysfunction

OBJECTIVES

To assess the acceptability, feasibility, and early results of sildenafil (Viagra) in a nonselected cohort of 316 patients (median age 58 years) who sought treatment for male sexual dysfunction during a 10-week period.

METHODS

Erectile status and activity were evaluated by questionnaire; erectile function was assessed by pharmacologic testing and visual sexual stimulation. Cardiovascular contraindications were assessed. Patients selected for the trial received treatment for 2 months. Results based on the possibility of penetration and individual satisfaction (scale from 0 to 10) were classified as good, fair, or bad. Multifactorial analysis was performed to define factors influencing the response to sildenafil.

RESULTS

Twenty-five percent of the patients from the initial cohort refused or did not meet the criteria for oral treatment; 25% of the remaining had a cardiovascular contraindication. At the end of the trial, 157 patients (88.7%) had completed the study; the efficacy of and satisfaction with sildenafil were considered good for 50 (31.84%), fair for 46 (29.29%), and bad for 61 (38.85%). Spontaneous nocturnal erections, organic etiologies, especially cavernovenous impotence, and previous treatment with self-intracavernous injections were significant factors influencing responses to oral treatment. Finally, 32% of the patients after completing the trial (17.2% of the initial cohort) were using sildenafil as their sole treatment, 34% chose self-intracavernous injections, and 25% decided to alternate between oral and local therapy.

CONCLUSIONS

In the present study, sildenafil had a 60% efficacy rate and was chosen as the sole treatment by only 30% of the patients tested. We propose pretreatment tests to help to predict the response to this medication.

[Exploration of the deep dorsal vein of the penis using pulsed Doppler ultrasonography. Preliminary study]

OBJECTIVES AND METHODS

This was an open preliminary study of 36 unselected men suffering from erectile dysfunction (DE) for the evaluation of the deep dorsal vein of the penis (VDP) by duplex scan (EDP). All men had an intravenous injection (IIC) with a vaso active agent: alprostadil (Edex) (n = 24), a mixture of papaverine ifenprodyl tartrate (Vadilex) (n = 4) or papaverine, ifenprodyl tartrate and alprostadil (n = 7). The deep dorsal vein was evaluated, with a 13 mHz mechanical probe 5 and 10 minutes after the injection, during visual sexual stimulation (SSV) carried on for 10 mn, and 3 mn after having stopped SSV. The influence of deep breathing and contraction of the ischio and bulbo-cavernous muscles was recorded at each of the periods.

RESULTS

The deep dorsal vein was identified in all cases. After pharmacological stimulation flow was present in 61% of the cases, with a statistically significant difference between alprostadil (80%) and both mixtures (20%). The addition of sexual stimulation caused flow to disappear in 64% of the cases (91% for the mixture and 44% for alprostadil). There was a range of variation under breathing and muscular contraction which deserves further evaluation.

CONCLUSIONS

1) The deep dorsal vein is easily studied under duplex scan and should be part of the routine examination of the vascular component of erection during erectile dysfunction. 2) The vein is subjected to modification of flow after intracavernous injection and sexual stimulation which varies with the agent injected and the clinical condition of the patients. 3) Absent flow early after injection seems to be predictive of the possibility of a prolonged erection.

[Vascular and functional evaluation of erectile dysfunctions using erection provocation tests]

The provoked erection test (TEP) consists in exploring successively, the sexual arteries, the penile volume and rigidity charges after pharmacological and sexual visual stimulation. Quantified arteria were proposed to evaluate the arterial flow and the caverno venous component obtained though a global appraisal of the erectile function. From these, TEP allows a quick approach to the diagnosis of erectile dysfunction for an early therapeutic decision.

[Prevention and treatment of erectile disorders in sickle cell disease]

Priapism is a frequent and serious cause of morbidity in males with sickle cell disease. Acute priapism (AP) is preceeded in two-thirds of the cases by repeated minor events called stuttering priapism (SP). Since 1994, we have used a specific approach to prevent the commonly devastating effects of AP, using the alpha adrenergic agent etilefrine. Treatment of AP has been simplified (drainage without aspiration followed by one or two intracavernous injections (ICI) of 10 mg of etilefrine, until detumescence). For SP lasting more than one hour or causing pain, we use oral etilefrine and/or self ICI. This strategy was effective in five patients seen having AP, 21 patients with SP; it is simple, cheap, and avoids surgical procedure and transfusion. Moreover, erectile dysfunction, present in three patients, has been treated safely by ICI of protaglandins.

[Nosology, epidemiology, clinical quantification of erectile dysfunctions]

After a review of the literature and of our own data base this article specifies: the nosology of erectile dysfunction (ED) defined as an inability to achieve enough rigidity for a satisfactory intercourse. This lack of firmness is frequently associated with a loss of libido (37%), performance anxiety (37%), and premature ejaculation (40%). The prevalence of ED in the overall French population, age 18 to 70 years is 39% (11% presenting permanent ED defined as a rate of failure to perform of 50%). This rate increases with age to 52 and 25% respectively. A quantification of the symptomatology is proposed scoring three different aspects of sexual activity during intercourse, erectile activity in absence of intercourse, patient's satisfaction, and partner satisfaction. Figures of normal subjects and patients with ED are presented.

[Clinical models and decisional algorithm in the management of erectile disorders]

The diagnosis of erectile dysfunction (ED) needs an appropriate evaluation of global function and specific component of the erection. We have used a quantified methodology to grade each of the specific factors: arterial, venous, neurologic, endocrine, psychological and anxiety, in four groups of increasing severity. With this information each patient is them classified organic, psychological or mixed. The prevalence of "mixed" aetiology appears in the statistical objective offered by two different retrospective studies with a 76% rate of psychological prevalence and a 85% of organic prevalence. In two out of three of the patients both factors are present.

[Intracavernous injections and new medical treatments of impotence]

Intracavernous injections (IIC) of vasoactives drugs is the most frequent treatment of erectile dysfunction (ED). Indications, technique and immediate as well as long term results are presented here. A retrospective quantified study of the follow up at 5 years of use shows that 94% of the patients who still use the treatment are satisfied, comparing with 48% who have stopped, and 21% who have never taken it. The overall rate of patients cured (i.e.; having a normal sexual life, without using the treatment) is 26.6%. The drop out rate linked to the treatment itself is 25%. Complications are seldom and benign: 7% of prolonged erection episodes, all solved by a medical regimen, mostly administered by the patient itself; nodules are present in 3% of the patients or do not interfere with the efficacy of the treatment; they are 1.6% Peyronie's like plaques. Perspectives opened by new treatments such as the Muse system and oral therapy by sildenafil or apomorphine are discussed.

[Ambulatory treatment and prevention of priapism using alpha-agonists. Apropos of 172 cases]

From 1985 to 1995, 172 patients (149 on self intracavernous injection of vasoactive drugs, 16 with Sickle cell disease, 6 surgical patients under heparin therapy, and 1 after oral administration of trazodone), having experienced one or several episodes of priapism, lasting from 3 h to 8 days have been treated or submitted to self medication with alpha-agonist agents (eprephrine, phenylephrine or etilefrine) with an eventual drainage of the corporae. All episodes have disappeared and sexual function was preserved. A conservative treatment of priapism has been designed using corporal drainage and intracavernous etilefrine for acute priapism; as well as preventive treatment for those of the patients exposed to Sickle cell disease to avoid surgery and its frequent fribrotic sequelae, leading to impotence in 50% of the cases.

Preventive treatment of priapism in sickle cell disease with oral and self-administered intracavernous injection of etilefrine

OBJECTIVES

Priapism is a common and currently unsatisfactorily managed complication of sickle cell disease (SCD). In June 1994, 6 SCD patients received a new therapeutic regimen to prevent the occurrence and recurrence of priapism.

METHODS

The patients (5 with SS and 1 with SC) were adults and had frequent episodes of stuttering priapism (SP), and two of them had had acute episodes (AP) lasting more than 3 hours. The treatment consists of preventive oral administration of the alpha-adrenergic agent etilefrine, and self-administered intracavernous injection (SICI) of the same agent to reverse episodes lasting more than 1 hour.

RESULTS

Since the beginning of treatment, all patients were protected against AP, 4 patients had no recurrence with the oral treatment alone, 2 had to use SICI, 1 occasionally and 1 constantly. There was no modification of sexual activity and no complications. Blood pressure was unaffected.

CONCLUSIONS

This treatment is simple, cheap, and self-administered. It should be proposed to all patients with SCD in all geographic areas as part of an educational program for active prevention of this severe complication.

Dynamic echography of the penis in the follow-up of impotent patients treated with intracavernous injections

Dynamic echography of the penis (DEP) after pharmacological stimulation of erection has been designed to evaluate the albugineal wall thickness (AWT), the cavernosal appearance in the normal penis and corporeal changes in patients treated with intracavernous injections presenting with haematomata, hyperechoic images, prolonged erection and Peyronie's disease. DEP was performed in 973 patients who had had an average number of 89 (+/- 16) intracavernous injections for 16.7 +/- 11.7 months. A total of 1424 DEP examinations were performed. Transducer positioning, erectile condition, clinical recording and computer retrieval methods were adapted to gather ultrasonography data. The standard average AWTs recorded in patients free from Peyronie's disease and who were untreated were 0.11 cm at the septum, 0.17 and 0.15 cm at the dorsal root and the tip of the albuginea respectively, 0.14 cm ventrally and the diameter of the corpus cavernosum averaged 1.61 cm. Intracavernous therapy brought an increase in AWT of 15.38% to the septum, 11.76% and 10.53% to the dorsal tip and root respectively and 12.5% ventrally. Frequent haematomata induced greater increase, while prolonged erections did not. Patients with untreated Peyronie's disease were found to have greater AWT which decreased after treatment with intracavernosal injections. Before treatment abnormal penile hyperechoic images were found in 3.18% (intracavernous images) and 3.31% (albugineal nodules) of DEP, and in 7.09% and 7.54% respectively post-treatment.

Arterial and venous surgery for vasculogenic impotence: a combined French and American experience

A multidisciplinary approach with emphasis on hemodynamic tests was used to diagnose 421 patients with arteriogenic, venogenic or mixed arteriogenic/venogenic impotence who underwent a vascular surgical procedure. With an average follow-up of nearly five years, approximately 50% of patients were cured and an additional 20% were improved.

Intracavernous self-injection of vasoactive drugs in the treatment of impotence: 8-year experience with 615 cases

Of 615 patients with impotence of varying etiologies who were followed from 12 to 96 months after the institution of intracavernous self-injection therapy with vasoactive drugs (papaverine alone, papaverine and alpha-blockers, and Ceritine, a new multilevel acting drug) 87% (533 patients) returned for followup visits or were regularly contacted. Of these patients sexual activity was restored in 91%. The dropout rate was 11.25%. The 114 episodes of prolonged erections among 51 patients (4.57%) represented less than 3 per 1,000 of the 34,875 recorded injections. All patients were treated without complications. The percentage of patients suffering from nodules or permanent deformations was 2.8%. There were no cases of intracavernous fibrosis. The percentage of satisfied patients (satisfaction index 7 or greater) was 84.8%. Improvement in spontaneous erections during sexual intercourse was obtained in 65% of the cases: 15% no longer needed self-injections and 50% only used them occasionally while 35% remained entirely dependent.

Self intra-cavernous injections as a successful treatment in pure neurogenic impotence

The aim of our research is to investigate the success of the vasoactive intracavernous therapy in subjects suffering impotence only on a neurological basis. We have submitted 50 subjects to a multisciplinary study including P.B.P.I., intracavernous minitest plus V.S.S., M.M.P.I., B.C.R. latency, duration, aspect and an hormonal screening (SH, LH, PRL, F. TEST, 17 BE2). The patients, or their partners, were instructed in the technique of self intracavernous injection (S.I.C.I.) of vasoactive drugs. Papaverine alone was given to 37 patients in a mean dose of 20.8 +/- 11.7 mg. Other 13 patients were treated with papaverine plus phentolamine in order to obtain a full erection. Comprehensive results of the treatment were judged at 80% effective: only 10 patients discontinued self injection treatment, unable to perform this technique properly.

Human penile erection and organic impotence: normal histology and histopathology

A very large amount of human material (7 embryos, 12 stillborns, 12 penes of males aged between 2 and 86 years, as well as bioptical material from 80 subjects affected by impotence problems) has been examined so as to study the penis arterial and venous walls, the blood flow regulation mechanisms and the intracavernal trabecular morphology. The amount of muscle tissue and of collagenous connective tissue has been numerically quantified by computer-assisted methods. This study enables the authors to underline three fundamental facts: (a) it confirms the normal penile erection mechanism, and the consequent theory, (b) it confirms that vascular sclerosis is a systemic phenomenon correlated to age, and that the penis is not exempt, and (c) in the case of impotence problems, the same sclerosis phenomenon may appear at an earlier age, and therefore induce pathological impotence.

The morphological basis for the Polster theory of penile vascular regulation

The discovery of the papaverine erection test by Virag in 1982 stimulated the interest of research workers in the physiology of the penis. Since then, the scheme of functioning proposed by Conti [Acta anat. 14:217-262, 1952] in 1952 has been frequently cited in the literature, although its finalism is evident. It is based upon the presence of regulatory mechanisms along penile arteries, veins and arteriovenous anastomoses. In spite of the fact that these anastomoses were unanimously admitted, recently the presence of arterial and venous cushions has been controverted or even denied. Before attempting any functional explanation using nerves and chemical mediators, we made sure first of the concrete material reality of these anatomical structures. Thirty-five years after the main study, the present observations confirm the morphologic descriptions made in 1952. The contrary would have been astonishing. In fact, arterial and venous cushions were demonstrated by the School of Anatomy of Padova, the most ancient and venerable of all (Fallope, 1550), then by other institutes of morphology that dealt with these cushions in practically all the organs of the human body. It remains to establish their role in erection - whether it is null, complementary or primordial: that is the question.

Is impotence an arterial disorder? A study of arterial risk factors in 440 impotent men

The distribution of four main arterial risk factors (ARF) (diabetes, smoking, hyperlipidaemia (HLP), and hypertension) was investigated in 440 impotent men (mean age 46.8) in whom the penile blood-pressure index (PBPI) (ie, the ratio of the lowest systolic pressure in one of the four main arteries of the penis to the systolic pressure in the arm) was measured. In 222 the cause (organic or functional) of impotence was sought by further investigations, such as cavernosonography. 80% of this subgroup had organic impairment of erection. In 53% of these there was evidence of an arterial lesion. Smoking (64%), diabetes (30%), and HLP (34%) were all significantly more common in the 440 impotent men than in the general male population of a similar age. Whenever two or more ARFs were present mean PBPI was significantly lower. The frequency of organic impotence increased from 49% in the absence of any ARF to 100% in patients with 3 or 4 ARFs. It is concluded that increase in the frequency of impotence with age is mainly related to arteriosclerotic changes for the arteries of the penis and that the ARF and PBPI should be evaluated first in any patient complaining of impotence.

Artificial erection in diagnosis and treatment of impotence

The use of artificial erection (AE) for the diagnosis and treatment of erectile failure was studied in 180 impotent males selected from a group of 440 men who underwent a complete multidisciplinary approach including nocturnal penile tumescence (NPT), arterial, neurologic, hormonal, and psychologic studies. Five groups were identified: (1) nonorganic (15.3%) impotence considered as a control group for AE normal values; (2) arterial (26.6%); (3) neurologic (12.2%); (4) arterial and neurologic (19.4%); and (5) a group of 47 remaining patients (26.1%) with abnormal NPT and normal arterial and neurologic studies who had the highest flow to obtain and maintain erection and were classified as "venous incompetence." Results of AE flows of patients of groups 2, 3, 4, and 5 are presented and discussed in the focus of erectile physiology, pathophysiology of erectile failure, and surgery. Patients of groups 2 and 4 with normal flows had a 26.6 per cent rate of improvement due to AE. Results and comments indicate that AE ranks as a major procedure in the diagnosis and treatment of impotence.

[Peyronie's disease. Hemodynamic and morphological conditions and treatment. Apropos of 14 cases]

A study of fourteen cases of Peyronie's disease with an evaluation of the hemodynamics of the erectile function shows that erectile dysfunction, as a complication, is mainly due to abnormal venous drainage from the corpora cavernosa. This article discusses the therapeutical conclusions to be drawn, in the light of the results of seven operations.

Intracavernous injection of papaverine as a diagnostic and therapeutic method in erectile failure

The effect of intracavernous injection of papaverine (ICIP) has been investigated in 45 men: 6 normally potent volunteers, 10 psychogenic, and 29 organic impotent males. The first two groups obtained erections within 10 minutes, lasting from 1 to 4 hours, after injection of 80 mg of papaverine. Those belonging to the organic group experienced delayed, weaker and shorter erections, related to various degrees of arterial and/or venous and neurologic lesions. Haemodynamic and radiologic studies done concomitantly, showed a strong vasodilation in the penile arteries (even when pathologic) and a diminished outflow from the cavernous bodies. Subsequently, a pilot study was performed in a series of 63 patients suffering from various degrees of angiogenic impotence, in order to study the therapeutic effect of repeated intracavernous injections of papaverine completed by intracavernous infusion of heparinized saline. Erections improved significantly in 66% of the patients with a mean follow up of one year.

Penile erection: possible role for vasoactive intestinal polypeptide as a neurotransmitter

Concentrations of vasoactive intestinal polypeptide were measured in blood drawn from the cavernous spaces of corpus cavernosum of the human penis during tumescence and erection, and the effect of injecting the polypeptide into the cavernous spaces was studied. A significant release of the polypeptide was shown during tumescence and erection. Injection of exogenous vasoactive intestinal polypeptide induced erection. These findings support the concept of vasoactive intestinal polypeptide as a neurotransmitter in penile erection and suggest that it might have a clinical use in patients suffering from erectile dysfunction.