Erectile Dysfunction

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Erectile Dysfunction
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Penile Anatomy
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Penile Anatomy

• Three columns of spongy tissue
• Corpora cavernosa paired
• Primary tissue of erection
• Lie parallel on dorsal aspect
• Contain multiple sinusoids with walls containing
  smooth muscle
• Surrounded by tunica albuginea
• Dense fibrous sheath providing structure
  support during an erection
• Corpus spongiosum (1)
• Ventral side of penis
• Surrounds the urethra
• Expands to lesser extent during erection

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Penile Perfusion

• Common iliac artery
• Internal iliac artery
• Pudendal artery
• Penile artery
• Cavernosal artery
• Helicine arteries
• Main artery of erection
• Dorsal artery
• Bulbourethral artery
• Corpus spongiosum

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Penile Perfusion

• Cavernosal artery with helicine arterial branches

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Penile Perfusion

• Venous drainage
• Corpora cavernosa
• Small veins perforating the tunica albuginea
• Drain into the deep dorsal vein
• During an erection these are occluded due to
  expansion of the corpora cavernosa and stretching
  of the tunica albuginea
• Base of the penis
• Small veins drain into the pelvic veins into
  the internal pudendal vein

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Flaccid State

• Corporal arterioles are vasoconstricted
• Sinus cavity smooth muscles are contracted
• Precavernosal A-V shunting
• Minimal blood flow into cavernosa

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Erectile Function - Normal

• Increased parasympathetic motor activity
• Relaxation of smooth muscle in walls of
  cavernosal sinusoids
• Decreases resistance to incoming blood flow
• Cavernosal arteries dilate
• Increased blood flow into penis
• Sinusoids fill with blood
• Corporal cavernosa expand and stretch
• Draining veins occlude
• Preventing blood from leaving
• Cavernosal arterial blood flow decreases
• Due to increased resistance within corpora
  cavernosa

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Impotence Etiology

• Physiological factors (organic)
• Neurogenic
• Hormonal imbalance
• Vascular
• Arterial insufficiency
• Venous leak
• Psychological factors
• Psychogenic

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Erectile Function

• Previously normal men
• gt 50 have organic cause
• Majority have arterial insufficiency, venous
  insufficiency or both
• Arteriogenic causes occur most often in patients
  with risk factors for atherosclerosis
• Hypertension
• Diabetes
• Hypercholesterolemia
• Tobacco abuse
• Venous causes
• Failure of occlusion of the draining veins
• May partially attain erection but cannot sustain

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Abnormalities - Other

• Scarring within the corpora cavernosa
• Scarring or fibrosis of sinusoidal tissue
• Calcified plaques within the tunica albuginea
• Peyronies disease

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Peyronies Disease
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Vascular Impotence Testing

• Obtain pertinent history
• Ability to achieve erection
• Frequency, intermittent or persistent
• Maintain, sustain erection
• Nocturnal tumescence
• History of
• Peripheral arterial disease with claudication
• Tobacco abuse
• Diabetes Mellitus
• Hypertension
• Arterial revascularization procedures
• Prostate surgery

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Impotence TestingIndirect Methods

• Obtain ankle/brachial indices
• Obtain penile systolic pressure
• Doppler
• PPG
• Calculate penile/brachial indices (PBI)
• Obtain plethysmographic waveform
• PVR
• PPG

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Impotence EvaluationTraditional Methods

• Nocturnal tumescence testing
• Penile pressure - penile/brachial index
• Doppler or PPG
• Pulse volume recording (PVR)
• PPG waveform recording

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Penile Pressure - Doppler
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Penile/Brachial Index (PBI)
0.7 - 1.0 normal 0.6 - 0.7 borderline
abnormal lt0.6 abnormal
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Penile PVR
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Impotence EvaluationDirect Methods - Flaccid
State

• Long and transverse views to evaluate for
  scarring, fibrosis and plaques
• Measure diameter of cavernosal arteries
• Record spectra from cavernosal arteries
• Measure PSV EDV

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B-mode Imaging

• Short long axis views

Normal nonerect penis symmetric corpora
cavernosa (RCC LCC), corpus spongiosum (CS),
Tunica albuginea (thick arrows)
Cavernosal artery in nonerect penis
echogenic walls
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B-mode Imaging

• Short long axis views

Erect penis dilated cavernosal artery surrounded
by blood filled sinusoids
Erect penis enlarged corpora cavernosa, speckled
appearance due to blood filled sinusoids
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B-mode Imaging
Sinusoidal scarring plaquing within the corpora
cavernosa bilaterally
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B-mode Imaging
Peyronies disease calcified plaques with
acoustic shadowing within between the corpora
cavernosa in A (short axis view)
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Penile Color Duplex Exam Duplex Methods

• Tourniquet band placed at base of penis
  optional
• Left in place until Doppler assessment begins
• Patient or MD injects vasodilatory agent
• Single injection
• Obtain spectra from proximal cavernosal arteries
  beginning 2-3 minutes after injection
  and continuing at 5, 10, 15, 20 minutes
  post-injection

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Vasodilatory AgentsIntracavernosal Injection

• Papavarine
• Prostaglandin E1

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Penile Color Duplex ExamDuplex Methods
Post-Injection

• Normal
• PSV gt35 cm/s
• EDV lt5 cm/s
• 75 increase in artery diameter
• Abnormal
• EDV gt6 cm venous leak
• PSV lt25 cm/sec
• lt75 increase in diameter

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Penile Color Duplex Exam Duplex Methods
Post-Injection

• Initially
• increase in systolic diastolic flow
• When rigid
• decrease in diastolic velocity
• Retro pan-diastolic flow is common

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Pre-Injection Cavernosal Flow Normal
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5 Minutes Post-Papavarine Injection

• Decreasing resistance - Normal

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Duplex Scan - Normal

• Increasing resistance

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Duplex Scan - Normal

• Increasing resistance - Normal

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15 Minutes Post-Papavarine Injection

• Increasing resistance with retrograde
  pandiastolic flow

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Post-Papavarine InjectionAbnormal
Venous leak- persistent diastolic flow
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Duplex Scan - Abnormal

• Persistent low velocity diastolic flow

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Duplex Scan - Abnormal

• Abnormally low peak systolic velocity

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Duplex Scan - Abnormal

• Persistent diastolic flow suggesting venous
  incompetence

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Duplex Scan - Abnormal

• Persistent flow in a dorsal vein

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Other Tests

• Cavernosometry
• Most accurate method
• Performed with vasoactive pharmacologic agents
• Cavernosography
• Utilized when venous incompetence is found