Penile doppler – A practical approach
Dr Ritesh Mahajan
Free lance radiology
Approach towards basic imaging
35 yr male patient with h/o depression And Erectile dysfunction.Grey scale / color doppler assessment was done to assess vasogenic / other etiology of the erectile dysfunction.
PENILE ANATOMY………………………..
Penile vascular anatomy………. Internal pedundle artery
through bulbar artery supplies base of the penis . Penile artery divides into two cavernosal arteries and continues as dorsal artery . There are helicine arteries that run through the substance of the corpora .
Cavernosal arteries are paramedian in location.
Cavernosal and dorsal arteries show more variability than venous drainage of the penis .
Venous drainage is through efferent venules – emisssary veins - dorsal veins . Base of the penis through crural veins drains into the periprostatic venous plexus in to the internal iliac veins .
The glans region has it’s drainage into the external iliac venous system.
Penile venous system is more constant than the arterial anatomy.
Basis of normal erection……….
After neural impulse Vasodilatation Increased blood supply Increased
intracavernosal pressure Efferent venous channel
are obstructed by taut tunica albuginea.
On doppler study predictable spectral waveform corrborates with changes in the intra cavernosal pressure .
Flaccid state : Intracavernosal arterial resistance is high . Cavernosal arterial flow has low systolic, dampened diastolic flow .
After giving vasoactive agent : Increased dilatation of the cavernosal arterial tree is there with increased systolic and diastolic component of the flow and velocities.
There is sinusoidal expansion of the arterial flow with obstructed venous egress
Further rise in cavernosal pressure leads to systolic dampening and loss of diastolic component .
With rigid erection – there is near total loss of diastolic flow and at times reversal .
As far as venous flow is concerned : flaccid state has sluggish flow. With vasoactive agent there is increase in the dorsal venous flow and with rigid erection the venous flow can stop . Retrograde venous flow is also appreciated in normal individuals.
Basis of normal erection……Phases of erection ………….
Flaccid Latent Tumescent Rigid Detumescence
After neural impulse there is rise in the intracavernosal presssure –There is cavernosal arterial dilatation and rise in the systolic and diastolic flow . The dorsal venous flow also rises initially . With rise in the cavernosal pressure – distended sinusoids abut the tunica albuginea and this leads to cessation of the venous egress and leads to rigid erection. With rigid erection ,this diastolic component of the cavernosal arterial flow is lost and at times reverses also .
Penile imaging ………………………..
ERECTILE DYSFUNCTION ETIOLOGY
Psychogenic Endocrine Pharmacological Neurological Vascular
Organic etiology – Vasogenic etiology is important and penile Doppler assessment can be of use to ascertain the same .
Penile imaging …………………………….Diagnostic work up for erectile dysfunction Penile anatomy
Medical / drug history .
Routine / endocrine blood analysis.
Non invasive testing Brachial – penile
indices Nocturnal penile
tumescence.
Three distensible corpora chambers -
1. Corpora spongiosum enveloping the urethera. This does not play significant role in erection.
2. Corpora cavernosa – dorsal in position –paired .
Mid line septum separates the two corpora cavernosa . Thick fascia (tunica albugenia) encircles the corpora cavernosa and bucks fascia covers corpora cavernosa and spongiosa .
Basic methodology of penile doppler
Linear transducer parallel to skin surface is used . Both ventral and dorsal transducer position approaches can be used.
Slow flow detection settings are to be used.
Longitudinal and parasagitttal image acquisition is to be done .
Grey scale assessment involves assessment of echogenic tunica albuginea. Midlevel echoes of the corpora cavernosa . Assess mid line septum .
Cavernosal arteries are assessed by echogenic walls and with paramedian location.
Brief about doppler examination……. Complete discussion of
the examination with the patient is to be done .
Assessment of the privacy is to be done .
Quiet examination setting is necessary .
Pharmacological agents : papaverine, phentolamine, prostaglandin E
Eye technique : visual inspection is important .
Velocity measurements are done along the base of the penis . Angle of assessment <60 degree.
PSV, EDV, RI , PI is done for cavernosal arteries on either side .
Look for cavernosal artery stenosis , occlusion, retrograde arterial flow , dampened spectral flow.
Cavernosal artery dilatation <75% of the base arterial diametre is indirect e/o vasogenic etiology of erectile dysfunction.
Grey scale sonography…..Grey scale
sonography
Good for assessment of Peyronie’s disease. Penile trauma Penile neoplasm
venous insufficiency………
Variations …………………..
Venous insufficiency
Absence of the penile artery : +_ cause of the impotence .
Corpora cavernosa - corpora spongiosum collaterals , dorsal venous and corpora collaterals should also be assessed.
Most common form of impotence
EDV > 5cm/sec suggests venous incompetence .
PSV > 30 cm/sec helps to rule out arterial etiology and search for venous etiology has to be sorted out .
EDV > 2 to 6cm/sec supports venous insufficiency .
Instead of measuring EDV : RI ( <.8) , PI (<4) also support venous insufficiency as etiology of erectile dysfunction.
Grey scale and basic doppler assessment
GREY SCALE
PLAQUE / CALCIFICATION.
MID LEVEL ECHOES OF CORPORA CAVERNOSA
TUNICA ALBUGENIA /BUCKS FASCIA
BASIC COLOR DOPPLER ASSESMENT – DONE AT BASE OF THE PENIS
Imaging especially for doppler is done along the base of the penis .
The sequence of the imaging is as following :
1. Flaccid state
2. Papaverine injection
3. Post injection imaging is done at 5 , 10,15,20,25 minutes .
PARAMETRES TO BE ASSESED IN THE FLACCID STATE
Dorsal vein diameter Cavernosal artery ( both
left and left artery ) 1. Diametre 2. PSV3. EDV4. PI5. Dorsal cavernosal collaterals6. Cavernosal spongiosal
collaterals
PARAMETRES TO BE ASSESED POST PAPAVERINE INJECTION
Post papaverine injection
5minutes 10minutes 15 minutes 20 minutes 25 minutes
Dorsal vein diameter Cavernosal artery ( both
left and left artery ) 1. Diametre 2. PSV3. EDV4. PI
INTERPRETATION
PSV Rt cavernosal artery PSV left cavernosal artery Difference between the PSV on
either side ( should not be more than 10cm/sec).
Diastolic flow loss DIASTOLIC REVERSAL Persistence of the dorsal venous flow
NORMAL VALUES
Corpora cavernosal artery PSV values :1. PSV : 35 cm/sec : Normal2. PSV : 25-35 cm/sec : indeterminate 3. PSV : <25 cm/sec : Abnormal Venoocclusive incompetence 1. No diastolic flow loss2. No diastolic flow reversal3. EDV ( Cavernosal artery): 2 to 6 cm/sec 4. RI ( Cavernosal artery) < .85. PI (cavernosal artery) <4
PRECAUTIONS
Inject papaverine only once Keep region of injection pressed Use insulin syringe Alcohol swab to clean Keep watch for priapism ( urologist
/anesthetist support ) .
Flaccid state
Dorsal vein diametre Flaccid state assessment of the dorsal vein
Flaccid state Flacid state assesment of the corpora / bucks fascia / intercavernosal connection
Sagittal / axial images
Cavernosal artery on either side diametre assesment
Flaccid state – cavernosal artery Rt cavernosal artery flaccid state – appreciate relatively high resistance flow no diastolic component
Left cavernosal artery flaccid state – appreciate relatively high resistance flow no diastolic component
Ancilliary findings
No e/o dorsal cavernosal collaterals . No e/o cavernosal spongiosal collaterals
Injection of the papaverine injection in the left corpora cavernosa
INSULIN SYRINGE USED
INJECTION DONE IN LEFT CORPORA CAVERNOSA
GUIDED INJECTION DONE AVOIDING THE LEFT SIDE CAVERNOSAL ARTERY
ANESTHETIST WAS INVOLVED IN THE INTERVENTION .
ALCOHOL SWAB WAS USED .
PRECAUTIONS WERE TAKEN TO AVOID SPILL.
5 MINUTES AFTER INJECTIONCAVERNOSAL ARTERIES ON EITHER SIDE AFTER PAPAVERINE INJECTION
APPRECIATED THE SURGE IN SYSTOLIC FLOW AND DIASTLOLIC FLOW
5 MINUTES AFTER INJECTIONDORSAL VEIN FLOW AFTER FIVE MINUTES
DORSAL VEIN DIAMETRE AFTER 5 MINUTES
10 MINUTES AFTER INJECTIONCAVERNOSAL ARTERIES ON EITHER SIDE 10 minutes AFTER PAPAVERINE INJECTION
APPRECIATED THE SURGE IN SYSTOLIC FLOW AND DIASTLOLIC FLOW
10 MINUTES AFTER INJECTIONDORSAL VEIN FLOW AFTER TEN MINUTES
DORSAL VEIN DIAMETRE AFTER 10 MINUTES
Helicine branches
15 MINUTES AFTER INJECTIONDORSAL VEIN FLOW AFTER fifteen MINUTES
DORSAL VEIN DIAMETRE AFTER 15 MINUTES
15 MINUTES AFTER INJECTIONCAVERNOSAL ARTERIES ON EITHER SIDE AFTER 15 minutes of PAPAVERINE INJECTION
APPRECIATE THE SURGE IN SYSTOLIC FLOW AND DIASTLOLIC FLOW
20 MINUTES AFTER INJECTIONDORSAL VEIN FLOW AFTER twenty MINUTES
DORSAL VEIN DIAMETRE AFTER 20 MINUTES
20 MINUTES AFTER INJECTIONCAVERNOSAL ARTERIES ON EITHER SIDE 20 minutes AFTER PAPAVERINE INJECTION
APPRECIATED THE SURGE IN SYSTOLIC FLOW AND DIASTLOLIC FLOW
25 MINUTES AFTER INJECTIONDORSAL VEIN FLOW AFTER twenty five MINUTES
DORSAL VEIN DIAMETRE AFTER 25 MINUTES
25 MINUTES AFTER INJECTIONCAVERNOSAL ARTERIES ON EITHER SIDE 5 minutes AFTER PAPAVERINE INJECTION Diastolic loss
30 MINUTES AFTER INJECTIONDORSAL VEIN FLOW AFTER thirty MINUTES
DORSAL VEIN DIAMETRE AFTER 30 MINUTES
30 MINUTES AFTER INJECTIONCAVERNOSAL ARTERIES ON EITHER SIDE thirty minutes AFTER PAPAVERINE INJECTION
Diastolic loss
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