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99 Cards in this Set
- Front
- Back
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Explain the difference btw the corpus cavernosum, and the corpus spongiosum?
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Corpora cavernosa
Dorsal surface Sinusoidal spaces (lined with smooth muscle) Corpora spongiosum On ventral surface Surrounds urethra |
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how is the penis profused by the pelvis?
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Common Iliac Artery
Internal Iliac Artery Internal Pudendal Artery |
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how is the penis profused in the penis?
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Cavernosal Artery
Bulbourethral Artery Dorsal Artery |
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explain variations of the cavernosal artery?
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Are common
Cavernosal artery may arise from dorsal artery More than one cavernosal artery may be present |
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explain venous drainage of the penis?
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Small veins from corpora cavernosa:
Perforate tunica albuginea Drain into deep dorsal vein Cruralveins: Base of penis Drain into deep pelvic veins to internal pudendal vein |
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explain the physiology of the penis in a flaccid state?
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Corporal arterioles are vasoconstricted
Sinus cavity smooth muscles are contracted Pre cavernosalA-V shunting Minimal blood flow into cavernosa |
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explain the physiology of the penis in erectile function?
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Physiologic process
Begins with increased parasympathetic nervous activity to penis Cavernosal arteries dilate Sinusoids fill with blood –corpora cavernosa expand and stretch Occludes the draining veins Continued parasympathetic activity maintains erection Smooth muscle in cavernosal sinusoids relaxes Sinusoids expand |
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what factors affect normal erectile function?
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Normal psychological health
Normal endocrine balance Intact innervation to the penis Normal cavernosal sinusoids Adequate arterial blood supply Normal venous occlusion with erection |
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basically differentiate btw organic and psychologic impotnece?
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Organic
Physiologic abnormality is present Found in 50 -90 % of cases Psychogenic Psychological factors |
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what is organic vasculogenic impotence usually due to?
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-hormonal imbalence
-arterial insufficiency -venous leaks |
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how is arteriogenic impotence treated?
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Mild to moderate arterial insufficiency:
Prostaglandin E1 Oral therapy (sildenafil citrate or Viagra Severe Arterial insufficiency: Penile implant |
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venous incompotence?
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Failure of occlusion of draining veins despite adequate filling of the cavernosal sinusoids17DMS
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what are some other causes of impotence?
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Scarring within corpora cavernosa or tunica albuginea
Peyronie’s disease(Calcification of severe scarring in tunica albuginea =plaques) |
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what ultrasound parameters are used to assess vasculogenic impotence?
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2-D Imaging
Doppler Evaluation Penile Pressure Measurements Waveform Assessments |
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what patient history should be obtained, and what trasducer should be used for testing of vasculogenic impotence?
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-r/o aorto-illiac occlusive disease
-ask if patient is diabetic 7-12mHz linear transducer |
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what doppler measurements should be taken of a flaccid penis?
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-Obtain both sagittaland transverse 2-D images
Measure diameter of cavernosalarteries Record color and spectral Doppler tracings from cavernosalarteries Measure PSV & EDV |
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What is the normal 2D appearance of the corpa cavernoa in a flaccid penis
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Corpora Cavernosa:
Homogenous echotexture Symmetric in size Cavernosal arteries = bright walls |
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what is the normal 2D appearance of a tunica albugenia in a flaccid penis?
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Tunica albuginea:
thin echogenic line encasing the corpora |
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what is the normal 2D appearance of a corpus spongiosum in a flaccid penis?
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Smaller than corpora cavernosa
Similar echogenicity |
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Explain the difference btw the corpus cavernosum, and the corpus spongiosum?
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Corpora cavernosa
Dorsal surface Sinusoidal spaces (lined with smooth muscle) Corpora spongiosum On ventral surface Surrounds urethra |
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how is the penis profused by the pelvis?
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Common Iliac Artery
Internal Iliac Artery Internal Pudendal Artery |
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how is the penis profused in the penis?
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Cavernosal Artery
Bulbourethral Artery Dorsal Artery |
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explain variations of the cavernosal artery?
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Are common
Cavernosal artery may arise from dorsal artery More than one cavernosal artery may be present |
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explain venous drainage of the penis?
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Small veins from corpora cavernosa:
Perforate tunica albuginea Drain into deep dorsal vein Cruralveins: Base of penis Drain into deep pelvic veins to internal pudendal vein |
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explain the physiology of the penis in a flaccid state?
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Corporal arterioles are vasoconstricted
Sinus cavity smooth muscles are contracted Pre cavernosalA-V shunting Minimal blood flow into cavernosa |
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explain the physiology of the penis in erectile function?
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Physiologic process
Begins with increased parasympathetic nervous activity to penis Cavernosal arteries dilate Sinusoids fill with blood –corpora cavernosa expand and stretch Occludes the draining veins Continued parasympathetic activity maintains erection Smooth muscle in cavernosal sinusoids relaxes Sinusoids expand |
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what factors affect normal erectile function?
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Normal psychological health
Normal endocrine balance Intact innervation to the penis Normal cavernosal sinusoids Adequate arterial blood supply Normal venous occlusion with erection |
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basically differentiate btw organic and psychologic impotnece?
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Organic
Physiologic abnormality is present Found in 50 -90 % of cases Psychogenic Psychological factors |
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Explain arteriogenic impotence
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Stenoses or occlusions
limit blood flow to the penis even in presence of parasympathetic stimulation |
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who is at risk for arteriogenic impotence?
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Occurs in men with risk factors for atherosclerosis
Diabetes mellitus Hypertension Hypercholesterolemia Smoking |
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what images/measurements should be taken of a penis in a flaccid state?
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-Obtain both sagittaland transverse 2-D images
Measure diameter of cavernosalarteries Record color and spectral Doppler tracings from cavernosalarteries Measure PSV & EDV |
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what is the normal grayscale appearance of the corpus cavernosa of a flaccid penis?
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Homogenous echotexture
Symmetric in size Cavernosal arteries = bright walls |
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what is the normal grayscale appearance of the tunica albugenia of a flaccid penis?
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thin echogenic line encasing the corpora
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what is the normal grayscale appearance of the corpus spongiosum of a flaccid penis?
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Smaller than corpora cavernosa
Similar echogenicity |
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What is the normal grayscale appearance of an erect penis?
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-Corpora cavernosa are larger
Spongiosal tissue: Speckled appearance Small anechoic areas separated by the brightly echogenic sinusoidal septa Corpora cavernosal arteries: Dilated Walls -brightly echogenic |
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What does grayscale look like w/ penis scarring/
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Irregular echogenic areas within corpora
Increased prominence with erection Tunical plaques-focal areas of thickening of tunica albuginea Calcified plaque Brightly echogenic Acoustic shadowing |
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why is a touniquet band placed on the base of the penis?
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to prolong the effects of the prostaglandin 1, or other erectile drugs
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what medications are given to aid in erection during an exam?
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-papavarine-30-60mg
-prostaglandin E1=10 micrograms |
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Explain doppler assessment post injection??
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Measure PSV in each artery
Obtain arterial waveforms at 2-3 minute intervals until peak systolic velocity is above 35 cm/s or has plateaued Measure EDV once peak systolic velocity has plateaued Assess flow in deep dorsal vein |
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Explain what the cavernous artery dopplers should demonstrate in a flaccid state?
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Cavernosal arteries:
High resistance pattern Low systolic peaks Absent or reverse diastolic flow -no dorsal vein flow(w/ color) |
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What should flow be like in the dorsal vein when the penis is flaccid?
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no flow
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What happens physiologically 2-3 minutes post injection, and what should the doppler waveforms be like?
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Smooth muscles in cavernosal sinusoids relax
Increased arterial flow Low resistance arterial waveform High diastolic flow |
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How do the doppler waveforms change during the mid timing evaluation post injection?
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Higher resistance pattern
Sharp systolic waveforms Diminished or absent diastolic flow PSV increases to maximum |
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what is normal doppler evaluation full tumescence?
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PSV decline
Absent or reverse end-diastolic flow No flow in deep dorsal vein (with color) |
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how is arterial insufficiency in the penis best diagnosed?
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Best diagnosed using maximum cavernosal PSV
Lower the PSV, greater the degree of arterial disease |
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What is the doppler criteria for normal when looking for arterial insufficiency? Abnormal
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NORMAL:
PSV > 30 cm/s EDV < 5 cm/s 75 % increase in artery diameter ABNORMAL: EDV > 6 cm/s = venous leak PSV < 25 cm/s < 75 % increase in artery diameter |
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Explain the degrees of penile arterial insufficeincy based on the diagnostic criteria?
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Mild to moderate Insufficiency:
PSV 25 –30 cm/s Severe Arterial Insufficiency: PSV < 25 cm/s Discrepancy in PSV > 10 cm/s between sides = some degree of arterial insufficiency |
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What are the limitations when doing penile spectral doppler?
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Patient anxiety
Psychogenic impotence Patients with variants of cavernosal arterial anatomy Duplicated arteries ** If more than one artery seen, conclusions regarding arterial function cannot be drawn if PSV < 30 cm/sec. |
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what is venous incompetance? When can it be assessed?
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Suspected when failure to generate an adequate erection despite normal cavernosal arterial Doppler waveforms
Can only be assessed if arterial function is normal Arterial insufficiency = cannot determine venous competence |
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what is the ultrasound criteria for venous incompetance?
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Flow in the dorsal vein
Cavernosal arterial flow > 5 cm/s Venous leakage –crural veins: Persistently high diastolic flow No evidence of dorsal venous flow |
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what are the exams of choice for determining penile venous incompetance?
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Exams of choice:
Cavernosometry Cavernosography |
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what is the purpose of doing penile pressures and waveforms?
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-Determine cause of erectile dysfunction
vascular insufficiency other causes May indicate: pelvic steal arterial vasospasm arterial occlusive disease when combined with exercise. |
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what are the contraindications for pressure and waveform testing?
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Patient anxiety
Patient incapable of the exercise testing unable to tolerate injection |
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what is the root of the penis?
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posterior and contains the bulb and crus which is attached to the perineum and is enveloped in muscle.
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what is the shaft of the penis composed of?
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composed of three cylindrical columns of erectile tissue.
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median septum of the penis?
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The fibrous tissue separating the corpora
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corpus spongiosum penis?
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The ventral erectile mass
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what is the glans penis formed by?
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by expanded corpus spongiosum.
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what(overall) needs to be obtained to do a non-duplex test for impotence?
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-obtain ankle/brachial indices(to see if there is diffuse atherosclerotic disease)
-obtain penile systolic pressures using doppler, PPG -calculate penile/brachial indices -obtain PVR and PPG waveforms |
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how is a penile systolic pressure test done?
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-cuff applied to base of penis and connected to a manometer
-locate dorsal artery w/ handheld CW probe -infate cuff to obliterate signal from artery -slowly deflate cuff until doppler signal returns -note penile systolic pressure -repeat test to assure reproducability |
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What are the values for normal, and abnormal penile/brachial indices?
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normal=0.7-1.0
borderline=0.6-.0.7 abnormal=<0.6 |
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What does the segmental gradient compare? What are the normal and abnormal values for this?
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compares diff. btw penile and brachial pressures
<or equal to 20mmHg=normal >or equal to 60mmHg=suspicous for vasculogenic impotence |
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explain the technique for PVR of the penis?
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-connect penile cuff to PVR
-inflate cuff to 60mmHg -record several PVR waveforms |
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Explain the interpretation of a PVR waveform?
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NORMAL:
-sharp waveform -prominent dicrotic notch MILDLY ABNORMAL: -sharp peak -absent dicrotic notch -bowed away from baseline MODERATELY ABNORMAL: -flattened systolic peak -similar upstroke and downstroke, and decreased -absent dicrotic notch SEVERELY ABNORMAL: -low amplitude -equal upslope and downslope times -absent waveform |
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what is the technique for penile plesmography?
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-sensor placed on glans of penis
-record several waveforms(appropriate gain settings) -evaluated similar to PVR waveform |
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Explain the test for reactive hyperemia of the penis?
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-record PVR w/ 60mmHg pressure
-inflate cuff to 20mmHg above penile systolic pressure for 5 minutes -re-inflate to 60mmHg and record several PVR's |
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what should the amplitude of the PVR's be like for reactive hyperemia testing?
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-amplitude should increase by 15% over baseline amplitude.
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what does the bulbourethral artery supply?
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The bulbourethral artery supplies the corpus spongiosum.
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where is blood shunted during an erection?
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blood is shunted from ventral to dorsum causing the corpus cavernosa to fill with blood.
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what are the reflex triggers for an erection?
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Mechanical stimulation of the pressure receptors
Pleasurable sights, sounds, and smells Emotions Thoughts * Emotions or thoughts can also cause the penis to become flaccid. |
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explain the parasympathetic control during an erection?
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The CNS responds by discharging efferent impulses to the second to forth-sacral segments of the spinal cord.
The parasympathetic neurons are activated by the efferent impulses. The parasympathetic nervous activity innervates the internal pudendal arteries causing them to dilate. The bulbourethral glands are also stimulated by parasympathetic nervous activity and provide lubrication to the glans penis. |
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What is The mean pressure in the corpora cavernos in full erection phase
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90-100mmHg
The intracavernous pressure is well above systolic pressure in the rigid erection phase. |
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what infusion rate may cause erection failure?
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<20-50ml/min into the cavernosa
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what patients have the highest likelihood of being impotenet?
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70-80% of patients with aortoiliac arterial occlusive disease are impotent. 50% of diabetics under the age of 40 are impotent.
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how may physical movements cause a penis to become flaccid?
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Blood demands during the physical movements of coitus may shunt the blood away from the penis causing it to become flaccid.
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what is the purpose of penile pressures and waveforms?
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For determination of whether the patient’s erectile dysfunction is related to vascular insufficiency or other.
This test may indicate pelvic steal, arterial vasospasm, or arterial occlusive disease when combined with exercise. |
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if an erection is maintained for 3 hours post pavavarin, what should be suspecte? What should be done about it?
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If the patient’s erection is maintained for 3 hours post injection, priapism is suspected and urologist should be consulted to reverse it.
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explain neurologic testing for vasculogenic impotence>
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No direct methods of testing the neural pathways involved in erection.
Cystometrography is used in testing of the bladder capacity and residual urine but tests the same neural pathways as erectile function. Sacral latency testing tests the bulbocavernosus reflex but must be tested under general anesthetic due to the amount of pain involved. |
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intracavus papavarine
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-used to Differentiates between vasculogenic and psychogenic erectile dysfunction.
-60mg of diluted papaverine is injected into the corpus cavernosum. -A tourniquet is applied at the base of the penis prior to injection - After two minutes, the patient is asked to stand and the tourniquet is removed. -If the patient develops full erection after 10 min, and if it lasts for more than 30 minutes, the arterial, venous and sinusiodal mechanisms are normal. |
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what are the pitfalls of intracavus papavarine>
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Pitfall: a nervous patient may not achieve a full erection. The injection may have to be repeated twice more.
If after three injections, there is failure of erection, an angiogram is required. |
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what is the purpose of angio in assessment of vasculogenic impotence?
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Determines the patency of the large vessels of the pelvis including the internal iliac artery.
-does not assess the smaller vessels of the penis or the collateral systems providing blood flow |
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what is the normal penile doppler velocities?
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-PSV>30cmsec
-EDV<5cm/s -75% increase in artery diameter |
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what is abnormal penile doppler velocities?
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-PSV<25cm/s
-EDV>6cm/sec-venous leak <75% increase in art. diameter |
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w/arterial insufficiency, what is mild, mod, and severe psv?
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Mild-mod=25-30cm/sec
Severe=< or equal to 25 cm/sec PSV>10cm/sec diff btw sides=some art.insufficiency |
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explain the arterial blood supply to the penis?
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-internal iliac arteries give rise to the internal pudendal arteries
-internal pudendal artery gives off the urethral artery, the bulbar artery and a perineal branch before it becomes the penile artery -Each penile artery divides into the right and left cavernosal arteries and the right and left dorsal arteries. |
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what is the latent period following erection?
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Following the expulsion of semen, the muscles of the penis relax and the arterioles constrict and the penis becomes flaccid again.
There is a subsequent latent period where the penis cannot become erect again for about 10-30 minutes. |
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what do the dorsal arteries supply?
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supply the skin of the penis and glands.
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what does the urethral artery supply?
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supplies the corpus spongiosum and urethral tissuesupplies the corpus spongiosum and urethral tissue
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what do cavernosal arteries supply?
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supply the corpora cavernosa and communicate directly with the sinusoidal spaces (small spaces that occupy the corpora cavernosa and the corpus spongiosum that fill with blood during an erection).
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what does the bulbar artery supply?
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supplies the urethral bulb and the bulbourethral gland
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explain the venous drainage of the penis?
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-emissary veins drain into the circumflex veins (both drain the corpus cavernosum)
-they empty into the deep dorsal vein -deep dorsal vein empties into the internal pudendal vien. -crural veins also drain the corpus cavernosum -urethral veins drain the corpus spongiosum, and empty into the internal pudendal vein. -superficial dorsal vein drains the skin and subcutaneous tissue |
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Peyronie disease
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-focal “plaque” or scar develops on the tunica albuginea of the corpora cavernosa.
- During an erection, this causes the penis to have a curvature or bend in that area. |
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how does an AV malformation cause erectile dysfunction
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An arteriovenous malformation allows blood to leave the corpus cavernosum before a sufficient blood pressure is achieved.
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varicocele
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This is another vascular problem in which the veins of the pampiniform plexus or cremasteric plexus become grossly enlarged.
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where do most varicocele's occur? why?
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This occurs more often on the left side due to the high pressures from the left hemiscrotum draining into the left renal vein. The presence of a varicocele on the right may indicate a mass pressing somewhere on the venous pathway.
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how may a varcicocele be removed?
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The varicocele may be removed by ligating the large draining vein, thus allowing the dilated venous tissue to die and become absorbed by the body.
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how are erections graded 10 minutes post injection?
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1 = no erection
2 = slight erection 3 = full erection without rigidity 4 = sufficient for intercourse but still not complete rigidity 5 = full erection with rigidity. |
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why is the PBI not a reliable indicater of vasculogenic impotenct?
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-continuous-wave probe is blind and may not pick up the dorsal arteries instead of the cavernosal arteries
-The measurements taken while the penis is in a flaccid state differ from the measurements taken while the penis is in an erect state. -If the cuff does not fit the penis properly, errors may occur. |
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if there is a dialated vein post injection, what may this indicate?
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raises the suspicion for a venous leak or an arteriovenous malformation
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