penile doppler a review

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


10 MINUTES AFTER INJECTIONDORSAL VEIN FLOW AFTER TEN MINUTES


Helicine branches

15 MINUTES AFTER INJECTIONDORSAL VEIN FLOW AFTER fifteen 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


20 MINUTES AFTER INJECTIONCAVERNOSAL ARTERIES ON EITHER SIDE 20 minutes AFTER PAPAVERINE INJECTION


25 MINUTES AFTER INJECTIONDORSAL VEIN FLOW AFTER twenty five 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


30 MINUTES AFTER INJECTIONCAVERNOSAL ARTERIES ON EITHER SIDE thirty minutes AFTER PAPAVERINE INJECTION

Diastolic loss

penile doppler a review

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