- Email: [email protected]
Forensic Identification for Erectile Dysfunction: Experience of a Single Center
Male Sexual Dysfunction Forensic Identification for Erectile Dysfunction: Experience of a Single Center Liuhong Cai, Manbo Jiang, Yanfei Wen, Cheng Peng, and Bin Zhang OBJECTIVE METHODS
RESULTS
CONCLUSION
To analyze the characteristics of forensic identification cases and evaluate the importance of integrating penile erection length, angle, and rigidity in diagnosing erectile dysfunction (ED). Retrospective analysis of the forensic identification cases between Jan 2009 and May 2013. Correlation between ED diagnosis and nocturnal penile tumescence (NPT) test result or the site of injury was analyzed. In total, 148 patients came for forensic identification of sexual function because of rape charges, divorce, medical accidents, or injury: 126 of 148 (85.1%) because of injury, of which 95 (75.4%) resulted from traffic accidents. There was a significant correlation between the site of injury and ED diagnosis; pelvic fracture with urethral or perineum injury was the most common. Our data showed that ED diagnosis was in general significantly associated with NPT results. However, we also identified three cases of diagnosed organic ED with normal NPT reactions. Our analyses showed that abnormal length and/or angle of the erectile penis were contributing factors to the diagnoses in these cases. In addition to NPT test, which measures the rigidity of the erectile penis, the length and angle of the erectile penis should also be considered in diagnosing ED, particularly in the case of forensic identification of sexual function. UROLOGY 86: 68e71, 2015. 2015 Elsevier Inc.
E
rectile dysfunction (ED) is highly prevalent, with 5%-20% of men estimated to suffer from moderate to severe ED.1 ED is defined as the persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance.2 Most patients with ED can be diagnosed based on medical and sexual history, penile deformities, complex psychiatric or psychosexual disorders, and complex endocrine disorders. Additional tests such as the nocturnal penile tumescence (NPT) test can be performed to further determine the cause of erection problem. Penile rigidity is considered to be one of the most important indicators; hence, male erectile function (EF) has often been evaluated with the maximum changes of penile circumference and rigidity during NPT measurement. The NPT test has also been widely used in forensic identification of sexual function (SF) for legal purposes. In China’s “guidelines for male sexual dysfunction forensic identification (SF/ZJD
Liuhong Cai and Manbo Jiang contributed equally to this work. Financial Disclosure: The authors declare that they have no relevant financial interests. Funding Support: This work was partly supported by funding from Guangdong Province Science and Technology Project (number 2013B021800091). From the Center for Reproductive Medicine, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; and the Department of Infertility and Sexual Medicine, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China Address correspondence to: Bin Zhang, M.D., Ph.D., Department of Infertility and Sexual Medicine, The Third Affiliated Hospital, Sun Yat-sen University, 600 Tianhe Road, Guangzhou 510630, China. E-mail: [email protected] Submitted: November 14, 2014, accepted (with revisions): April 2, 2015
68
ª 2015 Elsevier Inc. All Rights Reserved
0103002-2010),” it is required that NPT results are obtained to evaluate and diagnose ED for every patient. The European Association of Urology guidelines also recommend specific diagnostic tests including the NPT test using RigiScan for young patients with a history of pelvic or perineal trauma.3 Although NPT is widely used and its general objectivity and reliability have been reported,4 it is important to determine whether additional measurements such as erectile angle and/or length, which are not evaluated in NPT tests, should be considered for forensic identification purposes. Because forensic conclusion usually can be made only once, and it may affect the legal outcome, it is crucial for the forensic evidence to be objective and comprehensive. In this retrospective study, we demonstrated 3 special cases in which patients with normal NPT results had difficulty in sexual activities due to abnormal erection angle or length. These results will provide important references for future improvement in objective forensic identification.
METHODS Patients This was a single-center retrospective study. Data from 148 male patients commissioned to the Department of Infertility and Sexual Medicine, the Third Affiliated Hospital, Sun Yat-sen University, between January 2009 and May 2013, for forensic identification of EF were included. http://dx.doi.org/10.1016/j.urology.2015.04.001 0090-4295/15
Table 1. The legal purposes for forensic identification Purpose Rape charges Divorce Medical accidents Injury Total
Cases 7 6 9 126 148
Age (y) 32.4 40.8 36.0 34.2
15.0 8.1 6.2 9.9
Identification and Diagnostic Workup Patients were interviewed and underwent a complete physical examination, especially for testis volume, penis, and scrotum. The stretched flaccid length of penis was measured from the pubopenile skin junction to the urethra. The fat pad depth was measured by pushing the tape into the pubic bone, under maximal extension of the phallus. The stretched flaccid length was not measured during a nocturnal erection as part of the NPT. The erection angle of the penis from the body was measured when patient was in standing position. Blood samples were drawn in the morning and after an overnight fast for levels of glucose, lipids, thyroid function, and sexual hormones. Penile Doppler ultrasonography (PDU) examination was performed before and 20 minutes after PGE1 (10 mg) intracavernous injection (ICI). Penile brachial pressure index (PBI) was applied to every patient. According to the guidelines, NPT was applied to every patient. Blood test and PDU examination were adopted based on the possible etiology. PDU was not administered in case 1 and case 2 described in this study because of concerns that ICI might cause priapism.
NPT Measurement NPT tests were performed using RigiScan. The results of the RigiScan were considered normal if at least 1 episode of penile tip rigidity >60% with >10 minutes in duration was recorded during 2 consecutive nights of recording.5
Ethics Signed informed consent forms were obtained from all patients before identification enrollment. This study was conducted in accordance with the Declaration of Helsinki and was approved by the Reproductive Ethics Committee of the Third Affiliated Hospital of Sun Yat-sen University.
Statistical Analysis Statistical analysis was performed using Microsoft Excel and SPSS17.0 (SPSS Inc., Chicago, IL).
RESULTS In total, 148 cases of forensic identification were included in this study; 85% of these patients were aged 30-40 years. Both the youngest one (19-year) and the oldest one (59 years) were in the rape-charged group. The legal purposes for all the forensic identification cases are summarized in Table 1. Among these patients, 126 of 148 (85.1%) were admitted after physical injuries caused by traffic accidents, which account for majority of the cases (95 of 126), street fighting, or work-related accidents (Table 1). Sites of injury and ED diagnosis are summarized in Table 2. Almost half of patients in the injury group and UROLOGY 86 (1), 2015
Table 2. Sites of injury and ED diagnosis (cases) Organic Psychological ED ED Normal Total
Site of Injury Pelvic fracture with urethral or perineal injury Perineal injury Vertebral injury Brain injury Total
52
1
7
60
2 15 6 75
2 2 1 6
23 12 3 45
27 29 10 126
ED, erectile dysfunction. Pearson chi-square ¼ 51.070, likelihood ratio ¼ 56.062, linearby-linear association ¼ 9.639; P <.01.
Table 3. The NPT and ED diagnosis results NPT Normal NPT Abnormal NPT
Psychological ED Organic ED Normal Total 4 2
3 79
60 0
67 81
NPT, nocturnal penile tumescence; other abbreviations as in Table 2. Pearson chi-square ¼ 130.953, likelihood ratio ¼ 170.470, linear-by-linear association ¼ 86.213; P <.01.
60 of 148 total forensic identification cases suffered from pelvic fracture with urethral or perineal injury. Among these 60 cases with urethral or perineal injury, only 7 were diagnosed with normal EF, indicating a significant correlation between the site of injury and ED diagnosis (Table 2). The NPT and ED diagnosis results of the 148 cases are summarized in Table 3. Overall, the ED diagnoses were significantly associated with NPT results. All 81 patients with abnormal NPT results were diagnosed with either psychological ED (2 of 81) or organic ED (79 of 81), indicating the effectiveness of NPT test in positively detecting EDs. However, 7 patients (of 67) with normal NPT results were also diagnosed with EDs, suggesting the ineffectiveness of NPT test in excluding EDs (Table 3). There were 3 cases in which the patients with normal NPT reaction were diagnosed with organic ED (Fig. 1). In the first case (Fig. 1A), the patient came for forensic identification after a traffic accident that caused injuries to his penis and scrotum. Three injury-related operations had been performed before he was admitted for the forensic identification. Scarred vulva and penis, deformed scrotum, and shortened penis length of 4 cm (stretched flaccid length) were recorded. Major functional deficiency includes erection without penis length change, stiff penis, and the downward-pointing angle of the erected penis. As a consequence, it became extremely difficult for the patient to succeed in vaginal insertion although his test results of NPT and PBI were both normal. The second case in these special cases also experienced a traffic accident (Fig. 1B). The injury resulted in incomplete fracture of penis, urethral rupture, and testicular shift. The deformed penis had a flaccid length of 5.1 cm and a stretch length of 6.4 cm. Subcutaneous fibrosis occurred at the base, and the penis had an 69
Figure 1. Three patients with normal nocturnal penile tumescence reaction were diagnosed with organic erectile dysfunction. (A) A 23-year-old man, with a “short and stiff penis.” The scarred vulva and penis as well as deformed scrotum can be seen. The penis had a shortened stretched flaccid length of 4 cm, without change of length in erection. The penis was stiff and always pointing downward. (B) A 31-year-old man, with an “atrophied and triangle penis.” The deformed penis had a flaccid length of 5.1 cm and a stretch length of 6.4 cm and could partially penetrate into the vagina. Subcutaneous fibrosis occurred at the base and the penis had a shape of triangle. (C) A 26-year-old man, with “unstable penis.” The patient’s penis could attain an erection with enough hardness and penetrate the vagina with hand assistance. The penis is unusually slender with an obviously small base and could not point upward in erection and was unstable at the base. (Color version available online.)
irregular triangle shape. His NPT result test was normal; however, the patient described that it was hard to adapt to a sexual intercourse position though sometimes the penis could partially penetrate. The third case was admitted to forensic identification as a part of the legal process of divorce (Fig. 1C). In this case, the patient’s penis was able to attain an erection with sufficient hardness for penetration of the vagina with the help of hands. Physical examination revealed that the penis was slender with an obviously small base. The patient’s NPT, PBI, and PDU test results were all normal. After ICI of vasoactive drugs, the penis reached hardness of level 3-4, but it was not able to point upward and was unstable at the base. Unlike many other cases of organic ED in which a vacuum constriction device can facilitate an “erection like state” of the penis, penetration with the help of hand and achievement of sexual satisfaction, such a device did not improve the sexual function of this patient. Owing to this abnormality, the patient was unable to perform successful sexual intercourse to the satisfaction of his partner.
COMMENT With the steady improvement of life quality in recent years, the general public in China is becoming increasingly more aware of the importance of sexual satisfaction. As a consequence, the first forensic center for sexual function identification in Guangdong province, China, was founded in 2009 in our department. We present a retrospective analysis of 148 forensic identification cases between 2009 and 2013. In addition to identifying some unique aspects of forensic sexual function analysis, this study also had a particular emphasis on the reliability and sensitivity of the NPT test in this legal process. 70
First, our study revealed that no females came for sexual function identification. This is in agreement with our general clinical observation that sexual dysfunction is predominantly male related. However, there were 6 cases in which the patients were admitted for the legal purpose of divorce. In these cases, sexual dissatisfaction of the couples was one of the main causes for divorce. This indicates that although we did not yet have a female patient, females are also concerned about their sexual satisfaction. Our study also revealed that injury was the main reason for forensic identification of sexual function. With the increasing popularity of motor vehicles, more traffic accidents have occurred in recent years. It was not surprising that in 95 of 148 patients (64.2%) the injury resulted from traffic accidents. Pelvic fracture with urethral or perineal injury, vertebral injury, and brain injury were the common injury causes related to ED. The pelvic fracture type, especially pubic diastasis, is a risk factor for ED.6 The damage to the neurovascular bundle or to the internal pudendal or common penile artery at the time of injury to pelvic fractures with ruptured posterior urethra is predominantly responsible for most of the ED seen after these injuries.7 In terms of the age composition, all groups of patients had an average age of 30-40 years. The rape-charged group has the largest age range among all groups. Close examination of these cases revealed that patients in this group, age ranging from 19 years to 59 years, tend to be either younger or older than most patients in other groups who are predominantly middle aged. This may reflect the unique psychological characteristics of the group. Forensic identification of sexual function is based on the general principle and practice of clinical diagnosis but has more stringent requirements. Because the diagnosis UROLOGY 86 (1), 2015
can significantly affect legal outcomes, objective evidence is extremely important. Currently, both the clinical and forensic workups focus on the hardness of the penis. As a consequence, the results of the NPT test, which has been widely used to record the rigidity of erectile penis with the aim to distinguish psychogenic ED from organic etiology, are required in China to grade and diagnose ED in forensic identification, as specified in the “guidelines for male sexual dysfunction forensic identification (SF/ ZJD0103002-2010).” However, some experts have questioned NPT’s accuracy, reliability, and usefulness in differential diagnosis.8,9 In this study, our data have shown that the ED diagnosis was significantly associated with NPT results, validating the guideline in general. However, our study also identified 3 special cases in which the patients had normal NPT responses but still were diagnosed with organic ED. The main reason is that the NPT test itself does not take into consideration the length and angle of the erecting penis. These 2 factors, in addition to penile rigidity measured by the NPT test, are both important factors in evaluating sexual functionality, no matter for forensic or general clinical diagnosis purpose. Data obtained from 5196 healthy Chinese males showed that mean value of penile length was a flaccid length of 6.50.7 cm and a stretched length of 12.91.2 cm and a mean erectile length of 12.9 1.3 cm.10 As for Western men, it should be a little longer.11 The angle of the erectile penis from the body is measured when the man is in standing position. The mean angle, in degrees down from vertical, was 60 -85 identified by the Kinsey team.11 In our study, both the first case and the second case were diagnosed with organic ED due to injury-related penile deformities. Injury-related surgical scars or skin grafting often result in deformed or atrophied penis with decreased stretching length and increased stiffness, which contribute to the difficulty in maintaining sexual intercourse position. The third case had an unstable penis. The erectile penis could not keep an upward angle for vaginal penetration. The patient had to help the penis for penetration with hands. Although the patient was able to achieve vaginal penetration and ejaculation with
UROLOGY 86 (1), 2015
constant hand assistance, his wife filed for divorce because of this sexual abnormality.
CONCLUSION Our study found that ED diagnosis was in general significantly associated with NPT results. However, our data also caution against the exclusion of EDs solely based on NPT results, particularly in the practice of forensic identification of sexual function. We recommend that the rigidity, length, and angle of the erect penis all be considered in diagnosing ED. References 1. Feldman HA, Goldstein I, Hatzichristou DG, et al. Impotence and its medical and psychosocial correlates: results of the Massachusetts Male Aging Study. J Urol. 1994;151:54-61. 2. Montorsi F, Adaikan G, Becher E, et al. Summary of the recommendations on sexual dysfunctions in men. J Sex Med. 2010;7:3572-3588. 3. Hatzimouratidis K, Amar E, Eardley I, et al; European Association of Urology. Guidelines on male sexual dysfunction: erectile dysfunction and premature ejaculation. Eur Urol. 2010;57:804-814. 4. Jiang X, Xu Z. Applicable value of nocturnal penile tumescence test in judgement of erectile dysfunction after trauma. Chin J Forensic Med. 2006;21:45-47. 5. Hatzichristou DG, Hatzimouratidis K, Ioannides E, et al. Nocturnal penile tumescence and rigidity monitoring in young potent volunteers: reproducibility, evaluation criteria and the effect of sexual intercourse. J Urol. 1998;159:1921-1926. 6. Feng C, Xu YM, Yu JJ, et al. Risk factors for erectile dysfunction in patients with urethral strictures secondary to blunt trauma. J Sex Med. 2008;5:2656-2661. 7. Persu C, Cauni V, Gutue S, et al. Diagnosis and treatment of erectile dysfunction—a practical update. J Med Life. 2009;2: 394-400. 8. Mizuno I, Komiya A, Watanabe A, Fuse H. Importance of axial penile rigidity in objective evaluation of erection quality in patients with erectile dysfunction—comparison with radial rigidity. Urol Int. 2010;84:194-197. 9. Jannini EA, Granata AM, Hatzimouratidis K, Goldstein I. Use and abuse of RigiScan in the diagnosis of erectile dysfunction. J Sex Med. 2009;6:1820-1829. 10. Chen XB, Li RX, Yang HN, Dai JC. A comprehensive, prospective study of penile dimensions in Chinese men of multiple ethnicities. Int J Impot Res. 2014;26:172-176. 11. Sparling J. Penile erections: shape, angle, and length. J Sex Marital Ther. 1997;23:195-207.
71
RESULTS
CONCLUSION
To analyze the characteristics of forensic identification cases and evaluate the importance of integrating penile erection length, angle, and rigidity in diagnosing erectile dysfunction (ED). Retrospective analysis of the forensic identification cases between Jan 2009 and May 2013. Correlation between ED diagnosis and nocturnal penile tumescence (NPT) test result or the site of injury was analyzed. In total, 148 patients came for forensic identification of sexual function because of rape charges, divorce, medical accidents, or injury: 126 of 148 (85.1%) because of injury, of which 95 (75.4%) resulted from traffic accidents. There was a significant correlation between the site of injury and ED diagnosis; pelvic fracture with urethral or perineum injury was the most common. Our data showed that ED diagnosis was in general significantly associated with NPT results. However, we also identified three cases of diagnosed organic ED with normal NPT reactions. Our analyses showed that abnormal length and/or angle of the erectile penis were contributing factors to the diagnoses in these cases. In addition to NPT test, which measures the rigidity of the erectile penis, the length and angle of the erectile penis should also be considered in diagnosing ED, particularly in the case of forensic identification of sexual function. UROLOGY 86: 68e71, 2015. 2015 Elsevier Inc.
E
rectile dysfunction (ED) is highly prevalent, with 5%-20% of men estimated to suffer from moderate to severe ED.1 ED is defined as the persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance.2 Most patients with ED can be diagnosed based on medical and sexual history, penile deformities, complex psychiatric or psychosexual disorders, and complex endocrine disorders. Additional tests such as the nocturnal penile tumescence (NPT) test can be performed to further determine the cause of erection problem. Penile rigidity is considered to be one of the most important indicators; hence, male erectile function (EF) has often been evaluated with the maximum changes of penile circumference and rigidity during NPT measurement. The NPT test has also been widely used in forensic identification of sexual function (SF) for legal purposes. In China’s “guidelines for male sexual dysfunction forensic identification (SF/ZJD
Liuhong Cai and Manbo Jiang contributed equally to this work. Financial Disclosure: The authors declare that they have no relevant financial interests. Funding Support: This work was partly supported by funding from Guangdong Province Science and Technology Project (number 2013B021800091). From the Center for Reproductive Medicine, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; and the Department of Infertility and Sexual Medicine, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China Address correspondence to: Bin Zhang, M.D., Ph.D., Department of Infertility and Sexual Medicine, The Third Affiliated Hospital, Sun Yat-sen University, 600 Tianhe Road, Guangzhou 510630, China. E-mail: [email protected] Submitted: November 14, 2014, accepted (with revisions): April 2, 2015
68
ª 2015 Elsevier Inc. All Rights Reserved
0103002-2010),” it is required that NPT results are obtained to evaluate and diagnose ED for every patient. The European Association of Urology guidelines also recommend specific diagnostic tests including the NPT test using RigiScan for young patients with a history of pelvic or perineal trauma.3 Although NPT is widely used and its general objectivity and reliability have been reported,4 it is important to determine whether additional measurements such as erectile angle and/or length, which are not evaluated in NPT tests, should be considered for forensic identification purposes. Because forensic conclusion usually can be made only once, and it may affect the legal outcome, it is crucial for the forensic evidence to be objective and comprehensive. In this retrospective study, we demonstrated 3 special cases in which patients with normal NPT results had difficulty in sexual activities due to abnormal erection angle or length. These results will provide important references for future improvement in objective forensic identification.
METHODS Patients This was a single-center retrospective study. Data from 148 male patients commissioned to the Department of Infertility and Sexual Medicine, the Third Affiliated Hospital, Sun Yat-sen University, between January 2009 and May 2013, for forensic identification of EF were included. http://dx.doi.org/10.1016/j.urology.2015.04.001 0090-4295/15
Table 1. The legal purposes for forensic identification Purpose Rape charges Divorce Medical accidents Injury Total
Cases 7 6 9 126 148
Age (y) 32.4 40.8 36.0 34.2
15.0 8.1 6.2 9.9
Identification and Diagnostic Workup Patients were interviewed and underwent a complete physical examination, especially for testis volume, penis, and scrotum. The stretched flaccid length of penis was measured from the pubopenile skin junction to the urethra. The fat pad depth was measured by pushing the tape into the pubic bone, under maximal extension of the phallus. The stretched flaccid length was not measured during a nocturnal erection as part of the NPT. The erection angle of the penis from the body was measured when patient was in standing position. Blood samples were drawn in the morning and after an overnight fast for levels of glucose, lipids, thyroid function, and sexual hormones. Penile Doppler ultrasonography (PDU) examination was performed before and 20 minutes after PGE1 (10 mg) intracavernous injection (ICI). Penile brachial pressure index (PBI) was applied to every patient. According to the guidelines, NPT was applied to every patient. Blood test and PDU examination were adopted based on the possible etiology. PDU was not administered in case 1 and case 2 described in this study because of concerns that ICI might cause priapism.
NPT Measurement NPT tests were performed using RigiScan. The results of the RigiScan were considered normal if at least 1 episode of penile tip rigidity >60% with >10 minutes in duration was recorded during 2 consecutive nights of recording.5
Ethics Signed informed consent forms were obtained from all patients before identification enrollment. This study was conducted in accordance with the Declaration of Helsinki and was approved by the Reproductive Ethics Committee of the Third Affiliated Hospital of Sun Yat-sen University.
Statistical Analysis Statistical analysis was performed using Microsoft Excel and SPSS17.0 (SPSS Inc., Chicago, IL).
RESULTS In total, 148 cases of forensic identification were included in this study; 85% of these patients were aged 30-40 years. Both the youngest one (19-year) and the oldest one (59 years) were in the rape-charged group. The legal purposes for all the forensic identification cases are summarized in Table 1. Among these patients, 126 of 148 (85.1%) were admitted after physical injuries caused by traffic accidents, which account for majority of the cases (95 of 126), street fighting, or work-related accidents (Table 1). Sites of injury and ED diagnosis are summarized in Table 2. Almost half of patients in the injury group and UROLOGY 86 (1), 2015
Table 2. Sites of injury and ED diagnosis (cases) Organic Psychological ED ED Normal Total
Site of Injury Pelvic fracture with urethral or perineal injury Perineal injury Vertebral injury Brain injury Total
52
1
7
60
2 15 6 75
2 2 1 6
23 12 3 45
27 29 10 126
ED, erectile dysfunction. Pearson chi-square ¼ 51.070, likelihood ratio ¼ 56.062, linearby-linear association ¼ 9.639; P <.01.
Table 3. The NPT and ED diagnosis results NPT Normal NPT Abnormal NPT
Psychological ED Organic ED Normal Total 4 2
3 79
60 0
67 81
NPT, nocturnal penile tumescence; other abbreviations as in Table 2. Pearson chi-square ¼ 130.953, likelihood ratio ¼ 170.470, linear-by-linear association ¼ 86.213; P <.01.
60 of 148 total forensic identification cases suffered from pelvic fracture with urethral or perineal injury. Among these 60 cases with urethral or perineal injury, only 7 were diagnosed with normal EF, indicating a significant correlation between the site of injury and ED diagnosis (Table 2). The NPT and ED diagnosis results of the 148 cases are summarized in Table 3. Overall, the ED diagnoses were significantly associated with NPT results. All 81 patients with abnormal NPT results were diagnosed with either psychological ED (2 of 81) or organic ED (79 of 81), indicating the effectiveness of NPT test in positively detecting EDs. However, 7 patients (of 67) with normal NPT results were also diagnosed with EDs, suggesting the ineffectiveness of NPT test in excluding EDs (Table 3). There were 3 cases in which the patients with normal NPT reaction were diagnosed with organic ED (Fig. 1). In the first case (Fig. 1A), the patient came for forensic identification after a traffic accident that caused injuries to his penis and scrotum. Three injury-related operations had been performed before he was admitted for the forensic identification. Scarred vulva and penis, deformed scrotum, and shortened penis length of 4 cm (stretched flaccid length) were recorded. Major functional deficiency includes erection without penis length change, stiff penis, and the downward-pointing angle of the erected penis. As a consequence, it became extremely difficult for the patient to succeed in vaginal insertion although his test results of NPT and PBI were both normal. The second case in these special cases also experienced a traffic accident (Fig. 1B). The injury resulted in incomplete fracture of penis, urethral rupture, and testicular shift. The deformed penis had a flaccid length of 5.1 cm and a stretch length of 6.4 cm. Subcutaneous fibrosis occurred at the base, and the penis had an 69
Figure 1. Three patients with normal nocturnal penile tumescence reaction were diagnosed with organic erectile dysfunction. (A) A 23-year-old man, with a “short and stiff penis.” The scarred vulva and penis as well as deformed scrotum can be seen. The penis had a shortened stretched flaccid length of 4 cm, without change of length in erection. The penis was stiff and always pointing downward. (B) A 31-year-old man, with an “atrophied and triangle penis.” The deformed penis had a flaccid length of 5.1 cm and a stretch length of 6.4 cm and could partially penetrate into the vagina. Subcutaneous fibrosis occurred at the base and the penis had a shape of triangle. (C) A 26-year-old man, with “unstable penis.” The patient’s penis could attain an erection with enough hardness and penetrate the vagina with hand assistance. The penis is unusually slender with an obviously small base and could not point upward in erection and was unstable at the base. (Color version available online.)
irregular triangle shape. His NPT result test was normal; however, the patient described that it was hard to adapt to a sexual intercourse position though sometimes the penis could partially penetrate. The third case was admitted to forensic identification as a part of the legal process of divorce (Fig. 1C). In this case, the patient’s penis was able to attain an erection with sufficient hardness for penetration of the vagina with the help of hands. Physical examination revealed that the penis was slender with an obviously small base. The patient’s NPT, PBI, and PDU test results were all normal. After ICI of vasoactive drugs, the penis reached hardness of level 3-4, but it was not able to point upward and was unstable at the base. Unlike many other cases of organic ED in which a vacuum constriction device can facilitate an “erection like state” of the penis, penetration with the help of hand and achievement of sexual satisfaction, such a device did not improve the sexual function of this patient. Owing to this abnormality, the patient was unable to perform successful sexual intercourse to the satisfaction of his partner.
COMMENT With the steady improvement of life quality in recent years, the general public in China is becoming increasingly more aware of the importance of sexual satisfaction. As a consequence, the first forensic center for sexual function identification in Guangdong province, China, was founded in 2009 in our department. We present a retrospective analysis of 148 forensic identification cases between 2009 and 2013. In addition to identifying some unique aspects of forensic sexual function analysis, this study also had a particular emphasis on the reliability and sensitivity of the NPT test in this legal process. 70
First, our study revealed that no females came for sexual function identification. This is in agreement with our general clinical observation that sexual dysfunction is predominantly male related. However, there were 6 cases in which the patients were admitted for the legal purpose of divorce. In these cases, sexual dissatisfaction of the couples was one of the main causes for divorce. This indicates that although we did not yet have a female patient, females are also concerned about their sexual satisfaction. Our study also revealed that injury was the main reason for forensic identification of sexual function. With the increasing popularity of motor vehicles, more traffic accidents have occurred in recent years. It was not surprising that in 95 of 148 patients (64.2%) the injury resulted from traffic accidents. Pelvic fracture with urethral or perineal injury, vertebral injury, and brain injury were the common injury causes related to ED. The pelvic fracture type, especially pubic diastasis, is a risk factor for ED.6 The damage to the neurovascular bundle or to the internal pudendal or common penile artery at the time of injury to pelvic fractures with ruptured posterior urethra is predominantly responsible for most of the ED seen after these injuries.7 In terms of the age composition, all groups of patients had an average age of 30-40 years. The rape-charged group has the largest age range among all groups. Close examination of these cases revealed that patients in this group, age ranging from 19 years to 59 years, tend to be either younger or older than most patients in other groups who are predominantly middle aged. This may reflect the unique psychological characteristics of the group. Forensic identification of sexual function is based on the general principle and practice of clinical diagnosis but has more stringent requirements. Because the diagnosis UROLOGY 86 (1), 2015
can significantly affect legal outcomes, objective evidence is extremely important. Currently, both the clinical and forensic workups focus on the hardness of the penis. As a consequence, the results of the NPT test, which has been widely used to record the rigidity of erectile penis with the aim to distinguish psychogenic ED from organic etiology, are required in China to grade and diagnose ED in forensic identification, as specified in the “guidelines for male sexual dysfunction forensic identification (SF/ ZJD0103002-2010).” However, some experts have questioned NPT’s accuracy, reliability, and usefulness in differential diagnosis.8,9 In this study, our data have shown that the ED diagnosis was significantly associated with NPT results, validating the guideline in general. However, our study also identified 3 special cases in which the patients had normal NPT responses but still were diagnosed with organic ED. The main reason is that the NPT test itself does not take into consideration the length and angle of the erecting penis. These 2 factors, in addition to penile rigidity measured by the NPT test, are both important factors in evaluating sexual functionality, no matter for forensic or general clinical diagnosis purpose. Data obtained from 5196 healthy Chinese males showed that mean value of penile length was a flaccid length of 6.50.7 cm and a stretched length of 12.91.2 cm and a mean erectile length of 12.9 1.3 cm.10 As for Western men, it should be a little longer.11 The angle of the erectile penis from the body is measured when the man is in standing position. The mean angle, in degrees down from vertical, was 60 -85 identified by the Kinsey team.11 In our study, both the first case and the second case were diagnosed with organic ED due to injury-related penile deformities. Injury-related surgical scars or skin grafting often result in deformed or atrophied penis with decreased stretching length and increased stiffness, which contribute to the difficulty in maintaining sexual intercourse position. The third case had an unstable penis. The erectile penis could not keep an upward angle for vaginal penetration. The patient had to help the penis for penetration with hands. Although the patient was able to achieve vaginal penetration and ejaculation with
UROLOGY 86 (1), 2015
constant hand assistance, his wife filed for divorce because of this sexual abnormality.
CONCLUSION Our study found that ED diagnosis was in general significantly associated with NPT results. However, our data also caution against the exclusion of EDs solely based on NPT results, particularly in the practice of forensic identification of sexual function. We recommend that the rigidity, length, and angle of the erect penis all be considered in diagnosing ED. References 1. Feldman HA, Goldstein I, Hatzichristou DG, et al. Impotence and its medical and psychosocial correlates: results of the Massachusetts Male Aging Study. J Urol. 1994;151:54-61. 2. Montorsi F, Adaikan G, Becher E, et al. Summary of the recommendations on sexual dysfunctions in men. J Sex Med. 2010;7:3572-3588. 3. Hatzimouratidis K, Amar E, Eardley I, et al; European Association of Urology. Guidelines on male sexual dysfunction: erectile dysfunction and premature ejaculation. Eur Urol. 2010;57:804-814. 4. Jiang X, Xu Z. Applicable value of nocturnal penile tumescence test in judgement of erectile dysfunction after trauma. Chin J Forensic Med. 2006;21:45-47. 5. Hatzichristou DG, Hatzimouratidis K, Ioannides E, et al. Nocturnal penile tumescence and rigidity monitoring in young potent volunteers: reproducibility, evaluation criteria and the effect of sexual intercourse. J Urol. 1998;159:1921-1926. 6. Feng C, Xu YM, Yu JJ, et al. Risk factors for erectile dysfunction in patients with urethral strictures secondary to blunt trauma. J Sex Med. 2008;5:2656-2661. 7. Persu C, Cauni V, Gutue S, et al. Diagnosis and treatment of erectile dysfunction—a practical update. J Med Life. 2009;2: 394-400. 8. Mizuno I, Komiya A, Watanabe A, Fuse H. Importance of axial penile rigidity in objective evaluation of erection quality in patients with erectile dysfunction—comparison with radial rigidity. Urol Int. 2010;84:194-197. 9. Jannini EA, Granata AM, Hatzimouratidis K, Goldstein I. Use and abuse of RigiScan in the diagnosis of erectile dysfunction. J Sex Med. 2009;6:1820-1829. 10. Chen XB, Li RX, Yang HN, Dai JC. A comprehensive, prospective study of penile dimensions in Chinese men of multiple ethnicities. Int J Impot Res. 2014;26:172-176. 11. Sparling J. Penile erections: shape, angle, and length. J Sex Marital Ther. 1997;23:195-207.
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