The role of nocturnal penile tumescence monitoring in the diagnosis of impotence: a review

The value of shear wave elastography combined with red blood cell distribution width in evaluating arterial erectile dysfunction

PURPOSE

A retrospective study was conducted to determine the value of shear wave elastography (SWE) and red blood cell distribution width (RDW) in the diagnosis of various forms of erectile dysfunction (ED).

METHODS

With the method of Nocturnal Penile Tumescence and Rigidity (NPTR) and the screening method of Color Duplex Doppler Ultrasound (CDDU), hematological data were collected from 131 individuals, among whom 24 are with psychogenic ED, 48 are with non-arterial ED(NAED) and 59 are with arterial ED(AED) with erectile dysfunction. SWE value of penile corpus cavernosum(CCP) and cavernous arterial flow velocity were measured before (flaccid state) and after (erect state) intracavernous injection (ICI) in all patients.

RESULTS

Among the AED patients and other types of ED patients, there were statistically significant differences in the abridged five-item International Index of Erectile Function (IIEF-5), red blood cell distribution width-coefficient of variation (RDW-CV), red blood cell distribution width-standard deviation (RDW-SD), and SWE values (all P < 0.01). In the AED patients, the IIEF-5 scores had a significant negative relationship with RDW-CV, RDW-SD, and SWE values, with SWE values having the strongest correlation. (p < 0.001, r=-0.638).

CONCLUSION

The combination of RDW level and SWE value demonstrated the greatest performance in diagnosing AED, according to the receiver-operator characteristic(ROC) curve analysis (AUC = 0.870, p < 0.0001, cut-off value of 0.75, sensitivity of 74.6%, specificity of 91.7%).RDW and SWE value may develop into an incredibly simple, practical tool for predicting and diagnosing AED.

TRIAL REGISTRATION

retrospectively registered.

Approach to the male patient with sexual dysfunction

The management of the male patient with sexual dysfunction (SD) requires special knowledge and abilities. Generally, SD is best approached from the physiologic perspective, keeping in mind that sexual functioning has important psychosocial dimensions. The history obtained from the patient and, if possible, from his partner should seek information not only on the SD, but also on coexisting neurologic or medical disorders. A list of drugs should be obtained, as many prescription drugs, even in low doses, can influence sexual function. The clinical examination, including sensory, motor, and reflex testing of the lumbosacral segments, may reveal pertinent somatic abnormalities, which in the case of a suspected peripheral nervous system lesion may be supported by clinical neurophysiologic testing. The first-line diagnostic approach includes defining the type of sexual dysfunction to allow the most appropriate therapy. Metabolic and other systemic diseases need to be ruled out. Patients suspected of having psychologic, structural, urologic, endocrinologic, or vascular etiology of SD should be referred to the appropriate specialist.

Sleep apnea is an independent correlate of erectile and sexual dysfunction

INTRODUCTION

Obstructive sleep apnea (OSA) has been linked with erectile dysfunction (ED), but it is unknown whether this association is maintained in the presence of other risk factors for ED.

AIM

The aim of this study was to evaluate the relationship between ED/sexual dysfunction and polysomnographic measures of sleep apnea in patients with known risk factors for ED.

METHODS

Prospective cross-sectional analysis of 401 male patients undergoing in-lab polysomnography for suspected OSA. Erectile (EF) and sexual function were assessed by the 15-item International Index of Erectile Function (IIEF-15) questionnaire.

MAIN OUTCOME MEASURES

Severity of OSA via apnea-hypopnea index (AHI) and mean/lowest nocturnal oxygen saturation (SaO(2)). The IIEF-15 including the sexual domains: EF, intercourse satisfaction, orgasmic function, sexual desire, and overall satisfaction.

RESULTS

OSA (AHI > 5/h) was diagnosed in 92% of patients. ED (EF subdomain < or = 25) was present in 69% of patients with, and 34% of patients without OSA (P < 0.001). Multivariate stepwise regression analyses including known risk factors for ED, such as age, obesity, coronary heart disease, peripheral occlusive disease, hypertension, diabetes, prostate surgery, and beta-blocker treatment, and measures of sleep apnea identified mean nocturnal SaO(2) as independently associated with ED (P = 0.002; mean [95% CI] normalized slope 0.126 [0.047; 0.205]). Age (P < 0.001), peripheral occlusive disease (P = 0.001), prostate surgery (P = 0.018), and hypertension (P = 0.021) were confirmed as risk factors for ED, but did not abolish the sleep apnea-associated risk. Similar results were obtained for sexual dysfunction. Logistic regression analysis using the diagnosis of ED (EF subdomain < or = 25) as binary dependent variable confirmed that mean nocturnal SaO(2) (P = 0.012), as well as age (P < 0.001) were independently associated with ED.

CONCLUSIONS

ED and overall sexual dysfunction were highly prevalent in patients with suspected OSA. Irrespective of known risk factors, mean nocturnal SaO(2) was an additional, independent correlate of these dysfunctions, suggesting that OSA-related intermittent nocturnal hypoxemia specifically contributes to their development.

Erectile Dysfunction after PlasmaKinetic Vaporization of the Prostate: Incidence and Risk factors

PURPOSE

To determine the incidence of erectile dysfunction (ED) after PlasmaKinetic vaporization of the prostate (PKVP) using objective and subjective parameters and risk factors.

PATIENTS AND METHODS

A total of 153 men completed a questionnaire detailing perceived sexual dysfunction and underwent nocturnal penile-tumescence testing using the RigiScan for three consecutive nights 3 or 4 days preoperatively and 3 months postoperatively. The International Index of Erectile Function (IIEF)-5 scores were obtained preoperatively and postoperatively. Full details of each operation were recorded, including grams of tissue resected, operative time, any short-term complications, especially emphasizing capsular perforation, and concomitant diseases such as diabetes and hypertension. The association of risk factors with the development of ED after PKVP was assessed. Complete data were available for 103 men (67.3%). Their mean age was 62.1 years (range 48-83 years).

RESULTS

Postoperatively, 11 patients (10.6%) were found to have ED. Patients who developed ED postoperatively had a lower IIEF-5 score and penile-tumescence parameters preoperatively (for all parameters, P < 0.0001). As risk factors, diabetes, capsular perforation, and an IIEF-5 score <21 were found to be significant.

CONCLUSIONS

The incidence of ED after PKVP measured objectively was 10.6%. In the absence of the risk factors, PKVP is a safe therapeutic strategy with regard to sexual function.

Nocturnal penile tumescence and rigidity (NPTR) findings in spinal cord injured men with erectile dysfunction

This prospective study aimed at determining whether nocturnal penile tumescence and rigidity (NPTR) findings correlate to the neurologic disorders in spinal cord injured (SCI) patients suffering from erectile dysfunction (ED). A total of 25 acute SCI male patients with post-traumatic ED underwent neurological, electrophysiological and urodynamic examinations, respectively, as well as NPTR recordings. The mean value for rigidity (R), tumescence (T) and duration (D) during NTPR tests were 83.3%, 3.3 cm, 6.4 min in patients with a complete lesion above the sacral (S2-S4) spinal cord (n=10), 46.1%, 1.6 cm, 5.5 min in patients with a complete lesion involving the sacral metameres (n=5) and 89.8%, 3.8 cm, 29 min in patients with an incomplete suprasacral lesion (n=7). The differences among these groups were statistically significant (P<0.05). Patients with lesions involving both sacral and thoracolumbar spinal cord showed no erections (n=3). We found four NTPR patterns: (1) normal R and T, short D; (2) weak R and T, short D; (3) normal R, T and D; and (4) no erections, which can be assigned to different levels and completeness of spinal cord lesions. Nocturnal erections of normal quality need preservation of thoracolumbar and sacral neuronal control as well as partially intact connections of the spinal erection centres with brain areas responsible for sexual arousal.

Sleep-related erections: Neural mechanisms and clinical significance

Penile erections during rapid eye movement (REM) sleep are a robust physiologic phenomenon in all normal healthy males, irrespective of age. Given the involuntary nature of erections in sleep, sleep-related erection (SRE) testing has been used to differentiate psychogenic from organic impotence. The historical background of nocturnal penile tumescence, its current use, and common misconceptions of SRE testing are discussed. An animal model has been developed to study SRE mechanisms and has provided a new neural model regarding REM-related erectile control. The implications of these recent data on clinical SRE evaluation are presented. Finally, guidelines regarding SRE testing with polysomnography have not been available, contributing to a decline in formal SRE testing even though erections in sleep are commonly evaluated by urologists using home screening devices that do not record sleep. We propose a set of clinical indications when formal SRE evaluation in a sleep laboratory should be considered.

Clinical value of combined electrophysiological and urodynamic recordings to assess sexual disorders in spinal cord injured men

AIMS

To assess the significance of combined neurophysiological and neurourological examinations for diagnosis of neurogenic male sexual dysfunction.

METHODS

This is a prospective study of 32 spinal cord injured men. Each underwent clinical and neurophysiological examinations (sympathetic skin responses (SSR), pudendal somato-sensory evoked potentials (P-SSEP), bulbocavernosus reflex (BCR)) and neuro-urological measurements (urodynamic examination (UE), reflex erections (RE), psychogenic erections (PE) and nocturnal penile tumescence recordings (NPTR)).

RESULTS

Erectile dysfunction due to impairment of RE was associated with loss of BCR and detrusor areflexia (P > 0.001), whereas that due to impairment of PE was associated with loss of perineal SSR (P < 0.001). P-SSEP corresponded in 94% with impairment of penile sensibility and duration of erections in NPTR. The NPTRs were less related to functional sexual impairment. NPTRs in complete and incomplete suprasacral (level > T10) spinal lesion showed sufficient erections despite strongly disturbed PE. NPTRs in lumbosacral lesion revealed significant reduction in or absent erections and underestimated the presence of well excitable PE.

CONCLUSIONS

Combined neurophysiologic and neurourologic testing provides highly relevant diagnostic informations about sexual dysfunction in men with spinal cord injury. Loss of the BCR and detrusor areflexia imply loss of somatic and parasympathetic reflex activity and correlate with loss of RE. Loss of PE correlates with loss of perineal SSR (sympathetic denervation).

Nocturnal penile tumescence and effects of complete spinal cord injury: possible physiologic mechanisms

OBJECTIVES

To determine the role of the spinal cord in the initiation and/or modulation of nocturnal erectile activity, we measured nocturnal penile tumescence (NPT) in men with complete spinal cord injuries at known locations.

METHODS

Eighteen men between the ages of 27 and 57 years (mean 45) with known complete spinal cord lesions and no history of other medical problems adversely affecting erectile function completed International Index of Erectile Function questionnaires and underwent RigiScan testing for two consecutive nights. RigiScan tracings were evaluated for the presence and quality of NPT activity. Erectile episodes lasting longer than 10 minutes with base and tip rigidity greater than 70% were designated "good"; the remainder were designated "borderline," "poor," or "absent."

RESULTS

Of 9 men with cervical injuries and 9 with thoracic injuries, 8 and 3, respectively, had evidence of NPT. Of the 9 men with cervical injuries, 3 had one or more "good" nocturnal erections, and 1 of 9 men with thoracic injuries had one or more "good" nocturnal erections. The mean duration of the single longest erectile event was 26 minutes in men with cervical spinal injuries and 12 minutes in men with thoracic spinal injuries. Men with cervical and thoracic injuries had a mean overall International Index of Erectile Function score of 10 and 16 and a mean erectile domain score of 2 and 3, respectively.

CONCLUSIONS

Spinal regulation is critical for nocturnal erectile activity, and the isolated thoracic cord is less effective than the isolated cervical cord in maintaining NPT. Despite the presence of nocturnal erectile activity, volitional erectile function in spinal cord-injured men is significantly impaired.

New concept parameters of RigiScan in differentiation of vascular erectile dysfunction: is it a useful test?

BACKGROUND

The aim of this study is to investigate the value of new nocturnal penile tumescence recording parameters, such as tumescence activity unit and rigidity activity unit values, total erection number and erection times, in differentiating between psychogenic erectile dysfunction and organic erectile dysfunction. We also aimed to determine the role of these parameters in differentiating arterial erectile dysfunction from veno-occlusive dysfunction.

METHODS

Eighty-seven consecutive patients were allocated into three groups as psychogenic, arterial and venous erectile dysfunction after investigations. Nocturnal penile tumescence recording parameters between psychogenic and vascular erectile dysfunction and arterial and veno-occlusive dysfunction were compared. Mann-Whitney U-test, Pearson's chi2 test and correlation coefficient tests were used for statistical analysis.

RESULTS

Depending on intracavernous injection, penile Doppler ultrasonography and cavernosometry tests, 37 patients (43%) had psychogenic impotence while 50 (57%) had organic pathologies. Of the 50 patients diagnosed with vascular impotence, 29 (48%) had arterial failure and 21 (42%) had veno-occlusive dysfunction. Nocturnal penile tumescence recording revealed psychogenic erectile dysfunction in 34 patients (39%) and vascular erectile dysfunction in 53 patients (61%). Nocturnal penile tumescence recording has been regarded as the gold standard and, in our series, it showed 90.6% sensitivity and 88.2% specificity in differentiating the cause of erectile dysfunction. Values of rigidity activity unit and tumescence activity unit were significantly higher in patients with psychogenic impotence (P < 0.001), when compared with vascular impotence. In patients with a vascular cause, no difference was found between arterial failure and veno-occlusive dysfunction with regard to tip tumescence activity unit, base tumescence activity unit, tip rigidity activity unit, base rigidity activity unit and erection time (P > 0.001). However, patients with arterial failure had less erection than patients with veno-occlusive dysfunction (P < 0.001).

CONCLUSION

New recording parameters of nocturnal penile tumescence can differentiate organic and psychogenic erectile dysfunction more precisely. However, these recording parameters cannot distinguish subgroups with a vascular cause of erectile dysfunction.

The correlation between penile tumescence measured by the erectometer and penile rigidity by the RigiScan

BACKGROUND

The goal of this study was to evaluate the correlation between increments of penile tumescence and penile rigidity measured by the erectometer and the RigiScan, respectively.

METHODS

Nocturnal penile tumescence (NPT) was measured in 25 volunteers (mean age, 49.5 years). The erectometer and the RigiScan were used simultaneously for a total of 47 nights. We studied the correlation between maximum penile circumferential changes determined by the erectometer and penile rigidity patterns measured by the RigiScan.

RESULTS

Maximum circumferential changes during NPT measured by the erectometer were well correlated to those determined by the RigiScan (correlation coefficient, 0.719). In addition, penile circumferential changes measured by the erectometer corresponded well to the penile rigidity pattern determined by the RigiScan (P=0.0001). Specifically, maximum penile circumferential changes of more than 30 mm and less than 10 mm had 70% positive predictive value and 100% negative predictive value for predicting the normal rigidity pattern, respectively.

CONCLUSIONS

Penile circumferential changes measured by the erectometer were well correlated to penile rigidity measured by the RigiScan, particularly when the increments were larger than 30 mm or less than 10 mm. These results suggested that the erectometer was a useful tool to estimate the penile rigidity patterns of the RigiScan.

Bacille Calmette-Guérin in superficial transitional cell carcinoma

The mechanisms by which BCG exerts its antitumour activity remain unclear. Attachment of BCG to the bladder via FN has been shown to be an important step in initiating its antitumorigenic activity. The mechanism(s) by which BCG operates requires LAK cells, BCG-activated killer cells, T lymphocytes (CD4) helper cells and CD8 suppressor/cytotoxic cells) and monocytes. The optimal route of administration is intravesical. The efficacy of a BCG vaccine depends on the viability, dose and strain. Differences in efficacy and side-effects have not been shown between different strains. Low-dose regimens successfully protect from recurrences, with fewer side-effects. The initial schedule of BCG is a course of six instillations in 6 weeks; when the patient fails this course, two possibilities arise. The first is maintenance therapy; response rates improve but there is more local and systemic toxicity. The second is a further 6-week course, and this seems most useful in those with a sustained response to the initial treatment. The clinical response to BCG therapy can be monitored using cytokine measurements or p53 determinations. Toxicity remains a major problem in BCG treatment and triple antituberculosis combination therapy should be given for 3 months in those with severe systemic side-effects. The use of prophylactic isoniazid is not recommend to decrease side-effects. The clinical results of BCG have been good, with success rates of 58-100%, with a minimal follow-up of one year in prophylaxis. BCG seems superior to intravesical therapy, but at the cost of inducing more adverse effects. BCG is not indicated for low- and intermediate-risk patients, in whom chemotherapy is the first choice. BCG can also be used to eliminate tumour after an incomplete TUR, or in patients who are unfit for surgery, with a 60-70% success rate. The primary and best treatment for CIS is intravesical BCG; encouraging results have been reported, with success rate of 42-83% after a minimal follow-up of one year. Although currently BCG seems to be the choice for high-risk superficial TCC, many questions remain unanswered, especially about the mechanism(s) of action, the optimal dose and clinical schedule.

Nocturnal penile tumescence and rigidity monitoring in young potent volunteers: reproducibility, evaluation criteria and the effect of sexual intercourse

PURPOSE

We studied the reproducibility of nocturnal penile tumescence, rigidity evaluation criteria and the possible effects of sexual intercourse in young, healthy, potent male volunteers.

MATERIALS AND METHODS

We recruited 12 male medical students 21 to 24 years old into the study. A disorder-free medical history, availability of a sexual partner and normal erectile function were the inclusion criteria. All subjects completed 3 sessions of 3 nights of recording using the RigiScan* device with at least a 3-day interval between recordings. During the last 3-night recording subjects were asked to have sexual intercourse at least once. Analysis of the recordings was focused on the best erectile event as well as on rigidity and tumescence activity units normalized per hour.

RESULTS

The subjects completed 36, 3-night recordings. Of the total of 108 sessions 18 occurred after sexual intercourse. We analyzed 562 erectile episodes. All 3-night recordings included at least 1 episode of rigidity at the penile tip greater than 60% and more than 10 minutes in duration. Sexual intercourse did not significantly affect nocturnal penile tumescence and rigidity. When rigidity and tumescence activity unit values were normalized by the hour and expressed as mean values of the 3-night sessions, documented values became reproducible.

CONCLUSIONS

At least 2 consecutive nights of recording are necessary to evaluate nocturnal penile tumescence and rigidity recordings. Nocturnal penile tumescence and rigidity with at least 1 erectile episode of tip penile rigidity greater than 60% and 10 minutes in duration may be associated with potency. Mean rigidity and tumescence activity unit values per hour of a recording may be used as objective parameters to measure overall erectile activity. In addition, sexual intercourse seems to decrease nocturnal penile tumescence and rigidity measurements, although not statistically significant. We anticipate that application of these criteria for nocturnal penile tumescence and rigidity evaluation will improve the diagnostic validity of the test. Future research will determine whether these criteria are too strict for the evaluation of aging men.

Comparison of results of nocturnal penile tumescence and rigidity in a sleep laboratory versus a portable home monitor

OBJECTIVES

To validate the results of the home penile tumescence monitor versus the sleep laboratory studies of erectile function.

METHODS

We used both methods to study 18 episodes of rigidity and 19 episodes of tumescence in 10 subjects with erectile dysfunction before and after the use of an experimental vasodilating medication.

RESULTS

The tumescence measurement in the sleep laboratory compared favorably with the changes in tumescence with the RigiScan portable home monitor: at the base (r = 0.70; P < 0.001), and at the tip (r = 0.84; P < 0.001). In measuring rigidity, the buckling pressure in the sleep laboratory compared favorably with the RigiScan measurements of percent average rigidity at the base (r = 0.56; P = 0.017), at the tip (r = 0.62; P = 0.006), and mean rigidity of the base and tip (r = 0.64; P = 0.004). In a comparison of the buckling pressure with the new RigiScan Plus quantitative program, there was good correlation with the rigidity activity units at the base (r = 0.70; P = 0.001) and at the tip (r = 0.72; P < 0.001). A clinical estimate of penetrable rigidity correlates with the RigiScan base rigidity of 55% to 60% and tip rigidity of about 50%.

CONCLUSIONS

The portable home monitor is a viable and cost-effective clinical tool to measure nocturnal penile activity.

Psychogenic impotence in spinal cord injury patients

OBJECTIVE

To compare subjective assessments of erectile function with results obtained from nocturnal penile tumescence and rigidity (NPTR) monitoring in patients with spinal cord injury (SCI).

DESIGN

A prospective study.

SETTING

Erectile function questionnaires were completed by each patient. NPTR monitoring was performed at the patient's home with the Rigiscan system.

PATIENTS

Thirty SCI patients (8 cervical, 16 thoracic, 5 lumbar, 1 sacral) were between 22 and 75 (mean 48) years old. Twenty patients (67%) had complete SCI and 10 patients (33%) had incomplete SCI with mean duration since injury of 14 years.

MAIN OUTCOME MEASURES

The results from two consecutive nights of NPTR monitoring were compared with each patient's own response to our erectile function questionnaire.

RESULTS

Twenty-three patients (77%) reported normal erectile function: 16 had normal NPTR studies and the remaining 7 had abnormal NPTR studies. Seven patients (23%) reported poor-to-absent erectile function: 3 had normal NPTR studies and 4 had abnormal NPTR studies. All 10 patients (100%) with incomplete SCI had NPTR studies that corroborated their own assessment of erectile function, compared to 11 of 20 patients (55%) with complete SCI. NPTR studies in the remaining 9 patients (45%) with complete SCI were inconsistent with their own assessment of erectile function.

CONCLUSION

A direct correlation (p<.05) existed between incomplete SCI patients' NPTR studies and their own assessment of erectile function. Complete SCI patients demonstrated significant discrepancy between their own assessments of erectile function and results from NPTR studies. Incomplete SCI patients tended to maintain normal erectile function, as opposed to complete SCI patients. Ten percent of SCI patients who reported erectile dysfunction may actually be suffering from psychogenic impotence.

Assessment and treatment of impotence

Impotence is a common problem. History is primarily relied on to diagnose psychogenic impotence. Sex therapy is an effective treatment. Antihypertensive and psychiatric medicines often cause impotence, but most medicines should be considered a cause if this is supported by the history. Hormonal causes should be suspected in a patient with decreased libido or decreased testicular size, and testosterone should be measured in these cases. Hormone replacement may restore sexual function in hypogonadal men. Doppler sonogram or arteriography should be used to diagnose vascular impotence for men who would be good surgical candidates. Only young men without other illness are considered. There is little need to test neurologic function because there is no specific treatment for neurogenic impotence. These patients and patients who do not respond to the aforementioned treatments should be offered the vacuum erection device, penile self-injection therapy, or penile prosthesis. Choice depends on comorbid illness as well as patient preference. A basic algorithm for the evaluation and treatment of impotence is given in Figure 2.

Erectile impotence in multiple sclerosis: a neurophysiological study

Pudendal evoked potentials, motor evoked potentials of the bulbocavernosus muscle to magnetic stimulation and bulbocavernosus reflex were recorded in 34 patients with multiple sclerosis (MS). Responses were delayed in 26, 20 and 3 cases respectively. No relationship was found between neurophysiological abnormalities and the presence or severity of erectile dysfunction, showing that these tests have little diagnostic usefulness in MS patients with impotence. Nocturnal penile tumescence was assessed in 14 cases: the test result was normal in 10 patients, including 3 severely paraplegic subjects.

Oral androgens in the treatment of hypogonadal impotent men

A study was designed to assess the effect of supplemental oral methyltestosterone in the treatment of impotence associated with low total serum androgen levels. A total of 22 hypogonadal impotent men underwent a comprehensive investigation of erectile dysfunction, including an evaluation of the pituitary-gonadal axis. The patients then received a 1-month course of 2 different commercial preparations of oral methyltestosterone. Hormonal changes induced by the medication were assessed on days 15 and 30 of treatment. The patients kept daily records of sexual activity, and completed visual analogue scales to assess energy levels, mood and sensation of well being on a weekly basis. Supra-physiological levels of total serum testosterone were achieved in every patient but the free fraction of the hormone did not increase proportionally and in many cases a marked decrease was recorded. In all but 1 subject there was a decrease in circulating sex hormone binding globulin. Pituitary gonadotropin levels showed a marked decrease at the end of treatment. The clinical response was disappointing. Only 9% of the patients reported a complete recovery of sexual function. Visual analogue scales did not reveal noticeable changes for any individual in the levels of energy, mood or feeling of well being between pretreatment and posttreatment assessments. Oral methyltestosterone is of limited effectiveness in men with hypogonadal impotence. The positive responses in this study were recorded in men with the most profound deficiency. Exogenous administration of androgens to impotent men should be limited to those with profound hypogonadism as documented by at least 2 abnormal serum free testosterone determinations.

Diurnal penile tumescence recording in the etiological diagnosis of erectile dysfunction

Rapid eye movement sleep occurs during napping. We investigated the appearance of penile tumescence during periods of day napping in a population of 18 impotent men who, in addition, underwent a comprehensive sleep investigation for impotence, including polysomnographic recording and nocturnal penile tumescence monitoring. Of the subjects 16 (88%) had rapid eye movement sleep during the night. Four patients who did not have erections on 2 separate sessions of nocturnal sleep recording also did not experience penile tumescence during the day. Of the 12 patients with documented erections at night 9 (75%) also exhibited erectile episodes during napping. Diurnal penile tumescence recording is less cumbersome, less expensive and more convenient to perform than its nocturnal counterpart. Diurnal penile tumescence appears to be a summary reflection of nocturnal penile tumescence episodes. The consistency between nocturnal and diurnal penile tumescence suggests that further study of this new technique is worthwhile. Validation of diurnal penile tumescence may offer a viable alternative to the comprehensive assessment of impotent men.

Prospective comparison of topical minoxidil to vacuum constriction device and intracorporeal papaverine injection in treatment of erectile dysfunction due to spinal cord injury

OBJECTIVE

To compare the effectiveness of topically applied 2% minoxidil to that of intracorporeal injection therapy and vacuum constriction devices for the treatment of erectile dysfunction in the spinal cord injured (SCI) male.

METHODS

Eighteen SCI men, aged nineteen to sixty-five years (median age, 29), and level of injury C7 to L3 (15 thoracic level) were prospectively evaluated. All patients were able to achieve only a poorly sustained reflex erection that was inadequate for satisfactory intercourse. No patient had suffered erectile dysfunction prior to his SCI. In each patient, 1 mL of a 2% minoxidil solution was applied as an aerosol spray to the glans penis. The erectile response was compared to that obtained with a vacuum constriction device (VCD) and intracorporeal papaverine injection. In each case, the subjective assessment by both the patient and the physician, as well as objective results of penile base rigidity as measured by the RigiScan DT Monitor Device, were recorded.

RESULTS

Papaverine increased rigidity at the base of the penis by a median 77 percent (range, 30-100%). The VCD increased rigidity by a median 57 percent (range, 30-80%). Minoxidil induced no change in rigidity (range, 0-15%). No complications were observed for any method of inducing tumescence.

CONCLUSIONS

Papaverine and VCD proved to be effective means of establishing penile erection in male SCI patients. Both subjective and objective erectile responses to minoxidil were poor. Nevertheless, the principle of topical therapy is an attractive alternative to existing modalities. Further investigation is warranted.

Patient-reported erectile dysfunction: a cross-validation study

Previous work highlighting a significant correspondence between patient-reported sex history information and physiological indices of erectile functioning was cross-validated. The matched sample comprised of 46 older male veterans presenting with erectile dysfunction, with many experiencing chronic physical illnesses. All subjects underwent a comprehensive medical and psychological evaluation, followed by 2 consecutive nights of in-hospital Rigiscan diagnostic monitoring, to evaluate penile rigidity, tumescence, and duration of erectile episodes. Stringent criteria were employed to control for confounding of Rigiscan results, with elimination from the study for affective, thought, or sleep disorders. Results from the multiple regression analyses showed that patient reports of AM erections and erectile quality accounted for significant proportions of the variance in the Rigiscan criterion measures, with 3 of the 4 R2 values falling within the Herzberg criterion for cross-validation. Results confirm the diagnostic significance of patient self-report for the population of older, chronically ill men who present with impaired erectile functioning.

Evaluation of erectile dysfunction by dynamic infusion cavernosometry and cavernosography (DICC). Multi-institutional study

In a cooperative, private practice, multi-institutional impotence study, dynamic infusion cavernosometry and cavernosography (DICC) was performed on 743 patients to make an accurate diagnosis and/or identify candidates for penile revascularization. Maximum equilibrium intracorporeal pressure achieved following papaverine and phentolamine injection (Phase I) averaged 29.42 +/- 0.76 mm Hg, approximately one third of normal erection pressure. Corporeal pressure fall from 150 mm Hg over thirty seconds (cavernosometry) averaged 82.38 +/- 1.33 mm Hg (Phase II). The gradient between systolic and cavernosal artery pressure averaged 42.84 +/- 1.12 mm Hg on the right and 43.33 +/- 1.13 mm Hg on the left (Phase III). Cavernosography at 90 mm Hg erection pressure was performed in Phase IV. Of the 124 patients from one center who were reviewed in greater detail, pure cavernosal artery insufficiency (CAI) was found in 25 (20.2%), corporeal veno-occlusive dysfunction (CVOD) in 26 (21.0%), and 73 patients (58.9%) demonstrated combined CAI and CVOD. Diabetics (n = 69) achieved lower equilibrium intracorporeal pressures than nondiabetics, had similar CVOD, and worse CAI. Smokers (n = 365) and patients with Peyronie's disease (n = 32) had erectile dysfunction similar to those without these conditions. Patients impotent after trauma (n = 124) were younger, achieved higher intracorporeal pressures, and showed better corporeal veno-occlusive function than those without trauma. Complications of DICC were minimal and infrequent. After DICC, 169 patients underwent internal pudendal arteriography, 105 had arterial bypass surgery with or without penile venous ligation procedures, and 45 had venous surgery alone. Dynamic infusion cavernosometry and cavernosography is a useful erectile function study to evaluate impotence and can be performed easily in a private practice setting.

Standardization of penile blood flow parameters in normal men using intracavernous prostaglandin E1 and visual sexual stimulation

The evaluation of vasculogenic impotence by color flow Doppler ultrasound after injection of intracavernous vasoactive agents allows for simultaneous visualization in real time of arterial and venous blood flow. Normal arterial blood flow parameters after prostaglandin E1 injection have yet to be standardized. Our study was initiated to evaluate blood flow parameters in a normal control population after prostaglandin E1 and visual stimulation. A total of 20 healthy male volunteers 45 to 60 years old with histories of normal sexual function was selected. All volunteers were given intracavernous injections of 10 micrograms prostaglandin E1 and received concurrent visual stimulation by means of an erotic video. All patients developed rigid erections with no complications. Using color flow Doppler ultrasound measurements were done before and after prostaglandin E1 injection of right and left superficial and deep cavernous artery diameters, peak blood flow velocities and blood flow volumes. Results (mean plus or minus standard error) showed a significant increase in diameters after prostaglandin E1 in the superficial (20% increase) and deep (70% increase) penile arteries. Blood flow volume increased 3-fold for the superficial penile arteries (from 7.3 +/- 1.4 to 20 +/- 3.5 cc per minute) and 4-fold for the deep cavernous arteries (from 3.8 +/- 1 to 12.5 +/- 1.8 cc per minute). Peak blood flow velocity increased 2-fold (from 22 +/- 3 to 46 +/- 7 cm. per second) for the superficial arteries and 3-fold (from 12.5 +/- 2 to 37 +/- 5 cm. per second) for the deep cavernous arteries. These data suggest control values for normal erectile function in middle-aged men as a 70% increase in deep cavernous artery diameter, a systolic peak blood flow velocity greater than 30 cm. per second and more than 10 cc per minute of blood flow volume. With these standards the clinician may assess, design and follow treatment strategies for vasculogenic impotence.

Reproducibility in monitoring nocturnal penile tumescence and rigidity

The evaluation of sexual dysfunction has improved with the advent of methods to test nocturnal penile tumescence that also monitor penile rigidity. Earlier techniques may not have recorded abnormal rigidity despite normal tumescence. To test the reproducibility of penile tumescence and rigidity, the results of initial and repeat tracings performed a mean of 39 days apart were compared in 17 patients (median age 62 years). Three nocturnal patterns were identified. 1) Among the 17 patients the initial penile tumescence and rigidity pattern was reproduced on repeat testing in 15. 2) Patterns that were not reproduced in the other 2 patients were explained by the ingestion of alcohol or because of a febrile illness during the period monitored. 3) Nocturnal penile rigidity and tumescence tracings from these patients reproduced previous patterns. Monitoring of nocturnal penile tumescence and rigidity is a useful and reproducible tool in the evaluation of male sexual dysfunction.

Proposal of a ruler for studying parameters of the nocturnal penile tumescence test by Rigiscan

The evaluation of nocturnal erection, represents an essential test in uninvasive diagnostics of erection insufficiency. Most authors agree in considering the Nocturnal Penile Tumescence Test as the “first step” in evaluating impotence, especially if it is performed at the patient's domicile. The Authors have developed a ruler, enabling suitable information to be obtained as to the best erection event, which is selected and enlarged after 1 hour.

Preoperative and postoperative dynamic cavernosography and cavernosometry: objective assessment of venous ligation for impotence

A total of 11 men (mean age 51.4 years, 1-year followup) with venous leakage impotence underwent surgical venous ligation. Of the men 8 had erections twice per week immediately after the procedure but at 3 months only 2 remained potent. Dynamic pharmacological cavernosography and cavernosometry were repeated 3 months postoperatively and 6 of the 11 men had venous leakage. These men with venous leakage underwent percutaneous embolization with platinum coils and 4 had successful results. Three additional men became potent after embolization. Of the 11 men 9 are documented to have normal dynamic cavernosography and cavernosometry findings after the combination of an operation and embolization, and 5 are potent. The postoperative and post-embolization dynamic cavernosometry data show that all 11 men have a marked decrease in the flow to maintain erection. Eight men have erections with papaverine or prostaglandin E1 intracorporeal injections. Postoperative dynamic cavernosography and cavernosometry can be diagnostic as well as therapeutic with embolization.

The predictive significance of patient-reported sexual functioning in RigiScan sleep evaluations

We evaluated the relevance of patient reported sex history information in predicting erectile functioning as measured by the RigiScan monitor. A total of 46 male veterans who presented with erectile dysfunction completed an extensive medical and psychological evaluation including a sexual history, and then underwent 2 consecutive nights of inhospital RigiScan sleep evaluation performed under supervision. Multivariate analyses indicated a significant relationship among patient reported sex history information, and RigiScan measurements of tip and base duration, and rigidity. The sex history item with the greatest predictive power was the question regarding early morning erections. The results of this study highlight the importance of patient reported information, and the significance of obtaining a detailed sex history in the evaluation of older, primarily chronically ill patients who present with erectile dysfunction.

Patient-reported sexual symptomatology in predicting functional and insufficient erectile capacity

We evaluated the clinical utility of patient-reported erectile functioning information in discriminating Rigiscan-determined functional (greater than or equal to 70% penile tip and base rigidity and greater than or equal to 10 minutes' duration) from insufficient (less than 40% penile tip and base rigidity and less than or equal to 6 minutes' duration) erectile capacity, in a population of chronically ill men presenting with erectile dysfunction. Forty-three male veterans completed an extensive medical and psychologic evaluation, including a detailed assessment of sexual functioning, and then underwent two consecutive nights of supervised in-hospital Rigiscan sleep evaluations. Results of discriminant function analysis indicated that patient reports of morning erections and ejaculatory ability accurately predicted group membership for functional (96.7%) and insufficient (100%) categories. Careful attention to patient self-report is suggested for the urologist's initial appraisal of erectile dysfunction in populations of older, chronically ill men.