Penile Ultrasound

Abstract

Penile ultrasound is used commonly in the diagnostic workup of a patient with erectile dysfunction (ED), but also plays an important role by providing an anatomic and functional vascular assessment in a multitude of other conditions including Peyronie’s disease, high-flow priapism, penile fracture, penile urethral strictures, urethral stones, urethral diverticulae, or masses involving deep tissues of the penis. As a component of the evaluation for ED, penile Doppler ultrasound (PDU) is performed to assess the quality of arterial blood flow and sufficiency of veno-occlusive mechanisms, both necessary for an adequate erection. This imaging modality, which incorporates real-time imaging of the vasculature, vessel wall compliance, and blood flow dynamics in an end organ small vessel arterial system, is playing a central role in the early detection and diagnosis of otherwise silent coronary artery disease (CAD). This is an important clinical finding in men who often present with ED as their initial symptom of underlying cardiovascular disease. PDU is also an essential component of the assessment of external genitalia in trauma situations where high-flow priapism or penile fracture is suspected. Penile ultrasound provides a readily available, minimally invasive diagnostic modality that evaluates both the structural anatomy and functional hemodynamics at a reasonable cost.

Appendices

Appendix 1: A Sample Report Template for a Penile Doppler Ultrasound Performed as a Diagnostic Element in a Case of Erectile Dysfunction

Suggested protocol for evaluation of erectile dysfunction:

DORSAL view is primary, VENTRAL view as needed (indicate which view is used on image)

Pre-injection (also Images for non-injection penile ultrasound studies)

1. Longitudinal and transverse survey scan of the phallus with cine loops

2. Split screen base, mid, and distal view of phallus in transverse plane

3. Split screen longitudinal view of left and right corpora cavernosa

4. Flaccid phallus (image taken in mid 2/3 of exposed phallus):

(a) AP and width of each corpora

(b) Inner diameter measurements of left and right cavernosal artery at mid phallus

(c) Spectral Doppler waveform with PSV, EDV, and Ri

(d) Optional measurements: acceleration time, pulsatility index, velocity index

Post-injection

1. 5 and 10 min

(a) Spectral Doppler waveform with PSV, EDV, and Ri

(b) Inner diameter measurements of left and right cavernosal artery at mid phallus

(c) Optional measurements: acceleration time, pulsatility index, velocity index

(d) Subjective evaluation of tumescence and rigidity

2. 15 and 20 min (second injection if indicated, document total dose)

(a) Spectral Doppler waveform with PSV, EDV, and Ri

(b) Inner diameter measurements of left and right cavernosal artery at mid phallus

(c) Optional measurements: acceleration time, pulsatility index, velocity index

(d) Subjective evaluation of tumescence and rigidity

3. 25 and 30 min (third injection if indicated, document total dose)

(a) Spectral Doppler waveform with PSV, EDV, and Ri

(b) Inner diameter measurements of left and right cavernosal artery at mid phallus

(c) Optional measurements: acceleration time, pulsatility index, velocity index

(d) Subjective evaluation of tumescence and rigidity

4. End of study

(a) Inner diameter measurements of left and right cavernosal artery and mid phallus

Appendix 2: Patient Instructions for Penile Injection Therapy

Preparation for Injection

Items You Will Need

• Alcohol sponges or swaps.

• One milliliter insulin syringe with #28 or #30 gauge needle. These are disposable and not to be reused for a second injection. Disposal should be performed with the cap on the needle so as not to injure anyone disposing of trash.

• Papaverine/Phentolamine combination, Prostaglandin E1 or Papaverine/Phentolamine/Prostaglandin combination either pre-drawn by the physician a pharmacist in the syringe, or in a vial to be drawn into the syringe by the patient in the appropriate volume as prescribed by the physician. The medication must be refrigerated and away from light exposure.

Filling the Syringe

• 1. Check the expiration date of medication. Hold the medication bottle so that your fingers do not touch the rub or stopper (Fig. 7.22).

  

  Fig. 7.22

• 2. Using a circular motion, wipe off the top of the bottle with alcohol swab (Fig. 7.23).

  

  Fig. 7.23

• 3. Remove the needle cover. Do not allow the needle to touch anything before drawing the medication or before injecting the medication (Fig. 7.24).

  

  Fig. 7.24

• 4. Draw a small amount of the air into the syringe to be injected into the medication vial. The syringe needle should be inserted into the center of the rubber stopper of the medication vial. Push the air into the bottle (Fig. 7.25).

  

  Fig. 7.25

• 5. Turn the bottle and syringe upside down. Solely draw the medication into the syringe. Tap the syringe gently to remove the bubbles (Fig. 7.26).

  

  Fig. 7.26

• 6. Move the plunger in and out several times while gently tapping the syringe, just removing all air bubbles (Fig. 7.27).

  

  Fig. 7.27

• 7. Gently remove the syringe from the medication vial and replace the needle cap over the needle. Keep the protected needle on the filled syringe within easy reach prior to injection (Fig. 7.28).

  

  Fig. 7.28

Self-Injection Technique

• Step 1: Grasp the head of the penis, not the skin, and hold upwards toward the trunk. Position the penis along your inner thigh. Choose the injection site on the side of the penis. Avoid injecting into any visible veins. The crossed hatched areas in the figure below represent the ideal locations to inject into (Fig. 7.29).

  

  Fig. 7.29

• Step 2: Wipe the skin with an alcohol swab (Fig. 7.30).

  

  Fig. 7.30

• Step 3: Pick up the syringe between the thumb and middle finger, like a pen, and push the needle gently but firmly through the skin until the entire needle is buried inside the penis (Fig. 7.31).

  

  Fig. 7.31

• Step 4: Holding the syringe, use your thumb to slowly (8–10 s) inject the entire amount of medication. Then remove the needle from your penis (Fig. 7.32).

  

  Fig. 7.32

• Step 5: Immediately apply pressure on the injection site with another alcohol wipe for at least 2 min. Make sure there is no bleeding (Fig. 7.33).

  

  Fig. 7.33

• Step 6: Dispose of the syringe unit into the puncture-proof receptacle provided.

• Step 7: Stand up to allow your erection to develop quickly. You are now ready to start sexual foreplay. You will have a full or action within a few minutes.

Normally, the erection will last anywhere from 30 to 120 min. If your erection lasts longer than 3 h, you should seek immediate medical attention.