1 Penile US and Doppler US. Min Hoan Moon, , Il Sung Hwang, , Jung Suk Sim , , Seung-Hyup Kim, Department of Radiology Seoul National University College of Medicine, Seoul, Korea cavernosal artery is measured. Two or three minutes after an intracavernos- Introduction al injection of 10 -15 g of prostaglandin -E1, the inner diameter of the US and Doppler US are being used as primary imaging modalities in the cavernosal artery is measured again and Doppler spectra are obta ined from evaluation of the patient with erectile dysfunction and various other Penile the proximal cavernosal arteries at the base of the penis. The d orsal Penile disease. This exhibit will illustrate (1) the technique and normal findings of arteries and deep dorsal vein are also evaluated.
2 Doppler angle is kept Penile US and Doppler US (2) color / power / spectral Doppler US in the between 30 -60 degrees. The sample volume and wall filter are fixed at normal variation, arteriogenic and venogenic impotences, diabetic arterio- minimum. Color or power Doppler US improves the localization of the Penile pathy, arteriovenous fistula and Peyronie's disease. This exhibit will also vessels and thus permits more rapid acquisition of Doppler waveforms. include the Doppler findings of priapism. The findings in other imaging modalities such as Penile arteriography and corpus cavernosography will be Normal Penile US & Doppler US. compared. Normally the corpora cavernosa are symmetric and have homogeneous medium-level echoes.
3 The Penile anatomy * tunica albuginea appears as a thin echogenic line surrounding the corpora. The cavernosal arteries (asterisk) are located slightly medially in the corpora. A B. Diagram of the Penile anatomy ( Reprinted from reference 4 ) B C. A. A. Cross-sectional diagram of the Penile shaft near the base The normal progression of cavernosal arterial flow during Penile erection(A) is illustrates compartments of the well known. In the flaccid state, monophasic flow is present with minimal diastolic penis. flow. With the onset of erection, there is an increase in both systolic and diastolic B. Diagram of typical Penile arterial flow(B). As intracavernosal pressure increases, a dicrotic notch appears and a anatomy. decrease in diastolic flow occurs.
4 With continuously increasing pressures, end- C. Diagram of typical Penile venous diastolic flow declines to zero and then undergoes diastolic flo w reversal(C). Then C anatomy the systolic envelop is narrowed and diastolic flow disappears completely with firm erection. The penis is made up of three corporal bodies: Two corpora cavernosa and a single corpus spongiosum. Corpora cavernosa are main erectile bodies Erectile Dysfunction and corpus spongiosum contains the urethra. A septum divides two corpora Erectile dysfunction can result from psychogenic, neurogenic, arteriogenic, cavernosa but contains fenestrations that provide communications between and venogenic causes. Often more than one causes are combined. both blood supply of the penis is primarily from the internal Establishing a specific cause is important particularly in young men because pudendal arteries that originate from the anterior division of t he internal iliac of the frequency of correctable vascular abnormalities.
5 Organic causes of arteries. Each internal pudendal artery gives off the Penile art ery proper erectile dysfunction are found in 50-90%, and organic impotence in the which branches into a cavernosal artery and a dorsal artery at the base of presence of normal endocrine balance and intact nervous system is the penis. The cavernosal arteries are the primary source of blo od flow to vascular in origin in about 50-70%, either arterial insufficiency or venous the corpora cavernosa while dorsal arteries supply blood to the skin and incompetence. Pure arteriogenic impotence accounts for about 30% of glans of the penis. Venous drainage from the corpora cavernosa is through cases and isolated venogenic impotence is found in about 15%.
6 Small emissary veins, which drain into the dorsal, crural, and cavernosal veins. Arteriogenic Impotence Penile Doppler : Technique A B C. dorsal artery cavernosal artery A 32 year-old man with posttraumatic arteriogenic impotence deep dorsal vein angiogram shows near total occlusion of left superficial dorsal vein internal iliac artery. selective internal pudendal angiogram (right ), Illustration showing Penile Doppler technique ( reprinted from reference 5) left cavernosal artery is also seen (arrow). Doppler US is performed with the patient supine and the penis in the color Doppler flow image shows collateral anatomic position, lying on the anterior abdominal wall. High-resolution US supply(arrow) from right cavernosal artery.
7 Scanners with frequencies of 5-10 MHz are used. The followings are our spectral waveform obtained after prostagladin-E1. D injection, the peak systolic velocity is less than 25. protocol of Penile Doppler US. In the flaccid state, the inner diameter of the Cm/sec, indicating arterial insufficiency. The parameters that indicate the presence of arterial disease are a subno- Priapism is a prolonged Penile erection not associated with sexual stim- rmal clinical response to vasoactive agents, a less than 60% increase in the ulation. Two forms of priapism are known to occur. The more common type, diameter of the cavernosal artery, and a peak systolic velocity of the cavern- the veno-occlusive form, is manifested by a painful erection and is chara ct- osal arteries less than 30cm/sec.
8 Erized by ischemia, venous stasis, and pooling of blood within the corpora cavernosa. The pathophysiologic mechanism of venous priapism is blood Venogenic Impotence clot in the corpora impeding venous drainage. It is usually idiopathic, though it is more common in patients with sickle cell traits. An uncommon A 47 year-old man with type, arterial (high flow) form is associated with painless erection and venogenic impotence. usually is of traumatic origin. The pathophysiologic mechanism of high flow Spectral waveform(A) priapism is thought to be unregulated arterial inflow. obtained after PG-E1. injection shows persistent diastolic flow of cavernosal Peyronie's Disease artery. Cavernosogram(B). confirms veno-occlusive * * *.
9 A B failure Another patient with *. venogenic impotence. Spectral waveform(C) A B C. obtained from cavernosal artery after PG-E1 injection Peyronie's radiograph (A) demonstrates linear radioopacity (arrow). shows continuous diastolic Transverse sonogram (B) & longitudinal sonogram (C) shows echogenic line with flow. Doppler of dorsal vein posterior shadowing (asterisks), regarded as calcified plaque. (D) demonstrates steady Peyronie's disease is fibrosis of the tunica albuginea covering the corpora C flow in the dorsal vein. cavernosa. The cause is unknown, but it is thought to represent an In the presence of normal arterial function, Doppler findings suggestive of inflammatory response or a vasculitis. The disease usually involves the an abnormal venous leak are persistent end -diastolic velocity of the dorsum of the penis, but it can involve any portion of the tunica albuginea cavernosal artery greater than 5cm/sec and demonstration of flow in the including intercavernosal septum.
10 During erection the penis bend s toward deep dorsal vein. The development of diastolic flow reversal after an the side of the fibrosis, since the involved portion of the corp ora can not injection has been found to be a reliable indicator of venous co mpetence. lengthen normally. The condition can be painful, and it can be a cause of impotences. The sonographic findings include a thick echogenic plaque with Diabetic Arteriopathy echogenecity similar to or higher than the tunica albuginea; a calcified plaque in thickened tunica albuginea; and are occasionally associated with A 52 year-old man with calcification in the corpora cavernosa. diabetes mellitus. Color Doppler image (A). shows calcification of Penile Fracture cavernosal arterial wall.