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ORIGINAL ARTICLE
Year : 2017  |  Volume : 20  |  Issue : 6  |  Page : 729-733

Dynamic and morphologic evaluation of erectile dysfunction on penile doppler sonography and contrast cavernosography


1 Department of Radiology, College of Health Sciences, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria
2 Department of Surgery, College of Health Sciences, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria
3 Abubakar Imam Urology Center, Kano, Nigeria

Date of Acceptance10-Jan-2017
Date of Web Publication27-Jun-2017

Correspondence Address:
A Ismail
Department of Radiology, Bayero University/Aminu Kano Teaching Hospital, Kano
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_158_16

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   Abstract 

Background: Penile erection is a complex phenomenon that involves coordinated interaction of the psychologic, hormonal, nervous, arterial, venous, and sinusoidal systems. Erectile dysfunction (ED) is the persistent inability to attain or maintain penile erection sufficient for sexual intercourse. This study aims to determine the real-time morphologic vascular abnormalities in men with ED using penile Doppler sonography in Kano, Nigeria. Materials and Methods: Twenty-one patients who were referred from urology clinics on account of suspected vasculogenic ED were reviewed. The cavernorsal arteries were examined with 7.5 MHz linear transducer in gray scale and duplex Doppler modes before and after intracavernosal injection of 60 mg papevarine. Serial peak systolic velocity (PSV), end diastolic velocity (EDV), and diameter measurements were performed at 5-min intervals for 30 min. Results: The mean age of the patients was 43.14 ± 9.84 years. Out of the 21 patients examined, 5 showed normal findings while 10 had evidence of venous leakage. Five patients had arterial insufficiency; out of which 3 patients showed calcifications of the tunica albuginea, suggesting Peyronie's disease. Interestingly, 1 patient showed combining features of arterial insufficiency and of venous leakage. Those with arterial insufficiency were relatively older than other patients. They also had compounding medical conditions of diabetes and hypertension. Conclusion: Vascular etiologies are important contributors of ED in our setting. Papavarine-induced Doppler sonography and cavernosography shows promise in accurate assessment and overall care of these patients.

Keywords: Cavernosography, Doppler scan, erectile dysfunction, papevarine, vasculogenic impotence


How to cite this article:
Ismail A, Tabari A M, Alhasan S U, Abdullahi A. Dynamic and morphologic evaluation of erectile dysfunction on penile doppler sonography and contrast cavernosography. Niger J Clin Pract 2017;20:729-33

How to cite this URL:
Ismail A, Tabari A M, Alhasan S U, Abdullahi A. Dynamic and morphologic evaluation of erectile dysfunction on penile doppler sonography and contrast cavernosography. Niger J Clin Pract [serial online] 2017 [cited 2022 Jan 21];20:729-33. Available from: https://www.njcponline.com/text.asp?2017/20/6/729/208949


   Introduction Top


Penile erection is complex process which results from coordinated interaction of the psychologic, hormonal, nervous, arterial, venous, and sinusoidal systems. Erectile dysfunction (ED) is the persistent inability to attain or maintain penile erection sufficient for sexual intercourse.[1] The majority of cases have an organic etiology, most commonly vascular disease that decreases blood flow into or allow early venous leakage from the penis.[1] Regardless of the primary cause, erectile dysfunction can have a negative impact on self-esteem, quality of life, and interpersonal relationships.[1],[2] The estimated global prevalence has projected that the number of men with ED will rise to 322 million by the year 2025.[2]

Erectile dysfunction is usually underestimated in Nigeria because it is not a life threatening condition, and due to associated stigma men with the problem rarely seek help.[2] The reported prevalence of ED in Nigeria varies 26.4–46.9% taking the multifactorial etiologic factors into consideration.[2],[3] However, the frequency of vascular abnormalities in ED patients in unknown in our setting. Therefore, it would be of benefit to routinely evaluate the penis vasculature in all patients who at least do not present with an obvious nonvascular cause of ED.[4]

The approach to the investigation of vasculogenic impotence includes the use of one or a combination of dynamic infusion cavernosometry and cavernosography (DICC), Doppler sonography, internal pudendal angiography, penile venography, and scintigraphy. The infusion component of DICC and arteriography are too invasive, whereas scintigraphy is not widely available. Hence, for hemodynamic and morphologic assessment, this study combines the use of penile Doppler sonography and cavernosography (PDSC) to determine the pattern of vasculogenic ED in Kano, Nigeria.


   Materials and Methods Top


Twenty-one patients who were referred from urology clinics on account of suspected vasculogenic erectile dysfunction within an 18-month period (from October 2013 to March 2015) were reviewed. The cavernorsal arteries were examined with 7.5 MHz linear transducer in gray scale and duplex Doppler modes before and after intracavernosal injection of vasodilator (60 mg papevarine). Serial peak systolic velocity (PSV), end diastolic velocity (EDV), and diameter measurements at 2, 5, 10, 15, 20, 25, and 30 min were obtained. A PSV of less than 25 cm/s was considered to be the threshold for arterial insufficiency [Figure 1].[5] An EDV of ≥5 cm/s 15 min post injection was used to predict venous incompetence [Figure 2].[5] Contrast cavernosography was obtained following the preliminary film and intracavernosal injection of contrast medium and papevarine [Figure 3].
Figure 1: Doppler sonogram of the right cavenorsal artery 16 min post injection of papevarine, showing a PSV of 20.92 cm/s

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Figure 2: Doppler sonogram of the left cavenorsal artery 21-min post injection of papevarine, showing a persistently elevated EDV (14.32 cm/s)

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Figure 3: Contrast cavenorsography showing a fairly uniform opacification of the cavenorsal tissues

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   Results Top


The age of the patients ranged from 25 to 60 years with a mean of 43.14 ± 9.84 years. Almost all patients showed significant increase in cavernosal artery diameter within the first 5 min post injection of papevarine. As shown in [Table 1], 10 patients had venous leakage, constituting 47.6% of the study population. These patients never sustained rigid erection, which rapidly collapsed to the flaccid state until the disappearance of the effects of papevarine. On Doppler analysis, they showed high EDV (≥5 cm/s) 15 minutes post injection, and majority (75%) showed evidence of opacification of the penile and pelvic veins on contrast cavernosograms [Figure 4]. Furthermore, one of the patients showed alternating wave form of the cavernosal arteries due to cardiac arrhythmia.
Table 1: Showed the distribution of the findings on the cavernosograms. ART + VENOUS DZ

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Figure 4: Contrast cavenorsogram, in a patient with ED secondary to venous leakage. It shows opacification of the dorsal and left cavenorsal veins

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Five patients had arterial insufficiency (23.8%). These patients never achieved rigid erection during the course of the examination and remained in a flaccid state until the resolution of the effects of papevarine. On sonography, these patients showed minimal increase in diameter of the cavernosal artery compared to those with venous leakage. In addition, the PSV of their cavernosal arteries never reached 25 cm/s throughout the period of the examination. Out of these 5 patients with arterial insufficiency, 3 patients showed calcifications of the tunica albuginea on gray-scale ultrasound, which suggest a likelihood of Peyronie's disease [Figure 5].
Figure 5: A transverse sonogram at the root of the penis showing calcifications of the tunica albuginea in a patient, suggesting a likelihood of Peyronie's disease

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On the other hand, 5 patients showed normal findings, constituting 23.8% of the study population. Interestingly, one of the patients showed combining features of arterial insufficiency and that of venous leakage. This index case showed a maximum PSV of 22 cm/s in the cavernosal arteries and EDV of 5.2 cm/s at approximately 16 min of the examination. Thus, suggesting a mixed pattern of vasculogenic impotence.

[Table 2] shows the age summarizing the indices of the different diagnostic groups of the study population. Those with arterial insufficiency were relatively older than those with venous leakage and those with normal cavernosograms. Although these differences were not statistically significant, approximately 4 patients with arterial insufficiency also had compounding medical conditions of diabetes and hypertension, whereas only 1 patient with venous leakage had hypertension.
Table 2: Age-descriptive statistics of the findings at cavernosography

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   Discussion Top


Doppler evaluation in erectile dysfunction (ED) has a significant role in determining the cause of ED.[4],[5],[6] The advantages of penile Doppler and pharmacologic duplex ultrasonography include being objective and minimally invasive evaluation of penile hemodynamics at a relatively low cost. According to Quam et al.,[7] DICC is comparable to other invasive techniques such as cavernosometry and pelvic arteriography. They found 6 of the 7 patients with normal arteriography had mean peak systolic velocities of greater than 25 cm/s (specificity = 85.7%; 95% confidence interval = 42–100%) after injection of papaverine. They also found that the EDV in the cavernosal arteries of greater than or equal to 5 cm/s after the injection of papaverine correctly identified patients with excessive venous leakage on cavernosometry; the sensitivity was 90% (95% confidence interval = 77–97%) and the specificity was 56% (95% confidence interval = 30–80%).[7]

In general, Doppler ultrasound has been successfully used to document veno-occlusive dysfunction in some patients. It has shown good correlation between EDV of the cavernosal arteries and the presence of venous leakage. In the normal erectile response, there should be little (<5 cm/s) if any detectable flow within the cavernosal arteries during the diastolic phase 15–20 min after intracavernous injection and self-stimulation.[5],[6],[7],[8]

This review of 21 patients with ED showed a mean age of 43.14 ± 9.84 years. This is in agreement with the review of Clifford and Toppo [9] that included 50 patients with ED; they found a mean age of 40.83 years. Bari et al.[10] also recorded a similar mean age (of 41 ± 12.25 years) from Pakistan. However, a slightly older age (of 51.7 years) was documented by Mulhall et al.[11] among 49 patients when they attempted to define the prevalence and identify predictors of occult coronary artery disease in patients with vasculogenic ED. Similarly, in their review of 220 patients with ED, Serefoglu et al.[12] reported a mean age of 55.0 ± 9.2 years. On the other hand, McMahon [13] recorded a much older mean age (63.1 years) in his attempt to standardize the pharmacological diagnostic screening of vasculogenic impotence with prostaglandin E-1 among 283 men. Nevertheless, these differences could be from variations in life expectancies and in sample sizes of the studies.

Majority of our participants (76.2%) showed variety of abnormalities on cavernosograms whereas 23.8% had normal cavernosograms. Clifford and Toppo [9] also showed a high prevalence of vasculogenic ED (54%) whereas 46% had normal findings. In the same vein, a review of 220 patients by Serefoglu et al.[11] showed that 69.5% of their participants had abnormal cavernosograms whereas 30.5% were normal. However, this is at variance with the findings of a Greek study conducted among 67 patients with moderate-to-severe ED by Vakalopoulos et al.[4] Only 33.3% of their patients showed abnormalities of either arterial insufficiency or venous leakage whereas 66.7% had normal findings. Similar to the Greek study, Bari et al.[10] also found the prevalence of vasculogenic impotence at 33% on 70 cavernosograms in Pakistan.

Among patients with abnormalities on cavernosograms, there was predominance of venous disease (constituting 47.6%). Arterial insufficiency constituted 23.8% whereas 4.8% presented with a combined arterial and venous disease. Though there are differences in the relative frequencies of the arterial and combined abnormalities (arterial and venous disease), our findings in respect of venous disease corroborate those of Serefoglu et al.[12] from their study in an American population; they found a prevalence of arterial insufficiency at 10%, venous disease of 43.2%, while combined disease of 16.4%. On the contrary, Bari et al.[10] reported near-equal prevalence of arterial insufficiency (12/70) and (11/70) venous leak among the 70 cases reviewed. On the other hand, a Turkish study involving 32 patients with ED by Yavas et al.[14] showed high preponderance of arterial insufficiency (50%) compared to those with venous incompetence (25%).

In this study, the mean age of those with venous leakage was 41.10 years. This is lower than 30.6 years recorded by Tang et al.[15] (in their study on 358 patients with ED) but lower than the mean of 56 years documented by Vale et al.,[16] in their review of long-term results of patients after surgery for the management of ED caused by venous leakage. A closer look at those with arterial insufficiency showed a relatively older mean age (45.75 years). This may be attributable to the high frequency of medical conditions and risk factors for cardiovascular diseases. As shown in these patients, almost all cases of hypertension and diabetes were found in this group of patients with ED in our series.

Vasculogenic causes are important causes of erectile dysfunction, and papavarine-induced Doppler sonography and cavernosography are promising and accurate tools for assessing these patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

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Vakalopoulos I, Thanos P, Gkotsos G, Radopoulos D. Are vascular disorders a common cause of erectile dysfunction in non hypogonadal, non neuropsychiatric patients. Hippokratia 2011;15:244-6.  Back to cited text no. 4
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Quam JP, King BF, James EM, Lewis RW, Brakke DM, Ilstrup DM, et al. Duplex and colour Doppler sonographic evaluation of vasculogenic impotence. Am J Roentgenol 1989;153:1141-7.  Back to cited text no. 7
    
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Clifford A, Toppo JN. Role of penile color Doppler in the evaluation of erectile dysfunction. Indian J Radiol Imaging 2006;16:891-6.  Back to cited text no. 9
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Bari V, Ahmed NM, Rafique ZM, Ashraf K, Memon WA, Usman MU. Evaluation of Erectile Dysfunction with Color Doppler Sonography. J Pak Med Assoc 2006;56:258-61.  Back to cited text no. 10
    
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Mulhall J, Teloken P, Barnas J. Vasculogenic erectile dysfunction is a predictor of abnormal stress echocardiography. J Sex Med 2009;6:820-5.  Back to cited text no. 11
    
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Serefoglu EC, Trost L, Sikka SC, Hellstrom WJG. The direction and severity of penile curvature does not have an impact on concomitant vasculogenic erectile dysfunction in patients with Peyronie's disease. Int J Impot Res 2015;27:6-8.  Back to cited text no. 12
    
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McMahon CG. An attempt to standardize the pharmacological diagnostic screening of vasculogenic impotence with prostaglandin E1. Int J Impot Res 1995;7:83-90.  Back to cited text no. 13
    
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Yavas US, Calisir C, Kaya T, Degirmenci NA. A Sign of Arteriogenic Insufficiency on Penile Doppler Sonography Retrograde Flow in Penile Cavernosal-Spongiosal Communications. JUM 2007;26:1643-48.  Back to cited text no. 14
    
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Tang Y, Guo X, Jiang X, He L, Wen J. Dynamic observation of penile hemodynamic change in patients with vasculogenic erectile dysfunction after prostaglandin E 1 treatment. Sci Res Essays 2011;6:3770-5.  Back to cited text no. 15
    
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Vale JA, Feneley MR, Lees WR, Kirby RS. Venous leak surgery: Long-term follow-up of patients undergoing excision and ligation of the deep dorsal vein of the penis. Br J Urol 1995;76:192-5.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2]


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