Penile US and Doppler US

Min Hoan Moon, M.D., Il Sung Hwang, M.D., Jung Suk Sim , M.D., Seung-Hyup Kim, M.D.
Department of Radiology
Seoul National University College of Medicine, Seoul, Korea

Introduction
US and Doppler US are being used as primary imaging modalities in the
evaluation of the patient with erectile dysfunction and various other penile
disease. This exhibit will illustrate (1) the technique and normal findings of
penile US and Doppler US (2) color / power / spectral Doppler US in the
normal variation, arteriogenic and venogenic impotences, diabetic arteriopathy, arteriovenous fistula and Peyronies disease. This exhibit will also
include the Doppler findings of priapism. The findings in other imaging
modalities such as penile arteriography and corpus cavernosography will be
compared.

cavernosal artery is measured. Two or three minutes after an intracavernosal injection of 10 -15 g of prostaglandin -E1, the inner diameter of the
cavernosal artery is measured again and Doppler spectra are obta ined from
the proximal cavernosal arteries at the base of the penis. The d orsal penile
arteries and deep dorsal vein are also evaluated. Doppler angle is kept
between 30 -60 degrees. The sample volume and wall filter are fixed at
minimum. Color or power Doppler US improves the localization of the penile
vessels and thus permits more rapid acquisition of Doppler waveforms.

Normal Penile US & Doppler US

Penile anatomy

Diagram of the penile anatomy

( Reprinted from reference 4 )
A. Cross-sectional diagram of the
penile shaft near the base
illustrates compartments of the
penis.
B. Diagram of typical penile arterial
anatomy.
C. Diagram of typical penile venous
anatomy

The penis is made up of three corporal bodies: Two corpora cavernosa and
a single corpus spongiosum. Corpora cavernosa are main erectile bodies
and corpus spongiosum contains the urethra. A septum divides two corpora
cavernosa but contains fenestrations that provide communications between
both corpora.The blood supply of the penis is primarily from the internal
pudendal arteries that originate from the anterior division of t he internal iliac
arteries. Each internal pudendal artery gives off the penile art ery proper
which branches into a cavernosal artery and a dorsal artery at the base of
the penis. The cavernosal arteries are the primary source of blo od flow to
the corpora cavernosa while dorsal arteries supply blood to the skin and
glans of the penis. Venous drainage from the corpora cavernosa is through
small emissary veins, which drain into the dorsal, crural, and cavernosal
veins.

Normally the corpora cavernosa are symmetric and

have homogeneous medium-level echoes. The
tunica albuginea appears as a thin echogenic line
surrounding the corpora. The cavernosal arteries
(asterisk) are located slightly medially in the
corpora.

B
C
A
The normal progression of cavernosal arterial flow during penile erection(A) is
well known. In the flaccid state, monophasic flow is present with minimal diastolic
flow. With the onset of erection, there is an increase in both systolic and diastolic
flow(B). As intracavernosal pressure increases, a dicrotic notch appears and a
decrease in diastolic flow occurs. With continuously increasing pressures, enddiastolic flow declines to zero and then undergoes diastolic flo w reversal(C). Then
the systolic envelop is narrowed and diastolic flow disappears completely with firm
erection.

Erectile Dysfunction
Erectile dysfunction can result from psychogenic, neurogenic, arteriogenic,
and venogenic causes. Often more than one causes are combined.
Establishing a specific cause is important particularly in young men because
of the frequency of correctable vascular abnormalities. Organic causes of
erectile dysfunction are found in 50-90%, and organic impotence in the
presence of normal endocrine balance and intact nervous system is
vascular in origin in about 50-70%, either arterial insufficiency or venous
incompetence. Pure arteriogenic impotence accounts for about 30% of
cases and isolated venogenic impotence is found in about 15%.

Arteriogenic Impotence

Penile Doppler: Technique

A
dorsal artery

cavernosal artery

deep dorsal vein

superficial dorsal vein

Illustration showing penile Doppler technique ( reprinted from reference 5)

Doppler US is performed with the patient supine and the penis in the
anatomic position, lying on the anterior abdominal wall. High-resolution US
scanners with frequencies of 5-10MHz are used. The followings are our
protocol of penile Doppler US. In the flaccid state, the inner diameter of the

A 32 year-old man with posttraumatic arteriogenic impotence

A.Iliac angiogram shows near total occlusion of left
internal iliac artery.
B.On selective internal pudendal angiogram (right ),
left cavernosal artery is also seen (arrow).
C.Transverse color Doppler flow image shows collateral
supply(arrow) from right cavernosal artery.
D.On spectral waveform obtained after prostagladin-E1
injection, the peak systolic velocity is less than 25
Cm/sec, indicating arterial insufficiency.

The parameters that indicate the presence of arterial disease are a subnormal clinical response to vasoactive agents, a less than 60% increase in the
diameter of the cavernosal artery, and a peak systolic velocity of the cavernosal arteries less than 30cm/sec.

Venogenic Impotence

A 47 year-old man with

venogenic impotence.
Spectral waveform(A)
obtained after PG-E1
injection shows persistent
diastolic flow of cavernosal
artery. Cavernosogram(B)
confirms veno-occlusive
failure

Another patient with

venogenic impotence.
Spectral waveform(C)
obtained from cavernosal
artery after PG-E1 injection
shows continuous diastolic
flow. Doppler of dorsal vein
(D) demonstrates steady
C
flow in the dorsal vein.
In the presence of normal arterial function, Doppler findings suggestive of
an abnormal venous leak are persistent end -diastolic velocity of the
cavernosal artery greater than 5cm/sec and demonstration of flow in the
deep dorsal vein. The development of diastolic flow reversal after an
injection has been found to be a reliable indicator of venous co mpetence.

Diabetic Arteriopathy
A 52 year-old man with
diabetes mellitus.
Color Doppler image (A)
shows calcification of
cavernosal arterial wall.
On spectral waveform
(B), obtained from
cavernosal artery after
PG-E1 injection, the
peak systolic velocity is
less than 30 Cm/sec.
Diabetes mellitus in particular is thought to be responsible for a significant
number of cases of erectile failure. The detrimental effects of diabetes on
male sexual function appear to be manifestations of generalized damage to
both blood vessels and peripheral nerves. Peripheral sensory and autonomic neuropathy has been well documented in the diabetic patient pop ulation.
Evidence also suggests that this disease leads to development of profound
arterial small vessel disease involving penile arteries and their tributaries.
Although controversy exists concerning the primary pathophysiolo gic mechanism by which diabetes influences erectile function, studies showing the
presence of arteriogenic impotence in the absence of significant neuropathy
indicate that arterial occlusive disease may be more detrimental to male
sexual function in the diabetic patient population.

Priapism

Priapism is a prolonged penile erection not associated with sexual stimulation. Two forms of priapism are known to occur. The more common type,
the veno-occlusive form, is manifested by a painful erection and is chara cterized by ischemia, venous stasis, and pooling of blood within the corpora
cavernosa. The pathophysiologic mechanism of venous priapism is blood
clot in the corpora impeding venous drainage. It is usually idiopathic,
though it is more common in patients with sickle cell traits. An uncommon
type, arterial (high flow) form is associated with painless erection and
usually is of traumatic origin. The pathophysiologic mechanism of high flow
priapism is thought to be unregulated arterial inflow.

Peyronies Disease
*

*
*

Peyronies disease.Plain radiograph (A) demonstrates linear radioopacity (arrow).

Transverse sonogram (B) & longitudinal sonogram (C) shows echogenic line with
posterior shadowing (asterisks), regarded as calcified plaque.
Peyronie's disease is fibrosis of the tunica albuginea covering the corpora
cavernosa. The cause is unknown, but it is thought to represent an
inflammatory response or a vasculitis. The disease usually involves the
dorsum of the penis, but it can involve any portion of the tunica albuginea
including intercavernosal septum. During erection the penis bend s toward
the side of the fibrosis, since the involved portion of the corp ora can not
lengthen normally. The condition can be painful, and it can be a cause of
impotences. The sonographic findings include a thick echogenic plaque with
echogenecity similar to or higher than the tunica albuginea; a calcified
plaque in thickened tunica albuginea; and are occasionally associated with
calcification in the corpora cavernosa.

Penile Fracture

A 34 year-old man with penile trauma. Transverse sonogram(A) shows fluid

collection(arrows) on the ventral aspect of the penile shaft. This fluid collection has
partial septation(arrow in B). In this patient, interruption of the tunica albuginea is
not demonstrated.
A penile fracture is a tear in the tunica albuginea. Penile fractures results
from acute bending of the erect penis. Fractures can be diagnosed sonographically by visualizing interruption of the thin echogenic line of the tunica
albuginea. Heterogeneous echoes caused by blood and disrupted corporal
tissue usually are seen in the lesion of tear.

Reference

A 27 year-old man
with drug induced
priapism.

Color Doppler image shows no demonstrable blood flow within cavernosal artery
(A). After needle aspiration, blood flow through cavernosal artery is restored (B).

A 34 year-old man with posttraumatic high flowpriapism.

Sagittal color Doppler image (C)
shows abnormal ,asymmetric
blush of color flow (asterisk), adja cent to the artery. In the flaccid
state, there is an increase in both
systolic and diastolic flow (D).

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