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Artificial erection in diagnosis and treatment of impotence
ARTIFICIAL
ERECTION
TREATMENT
AND
OF IMPOTENCE
R. VIRAG, M.D. I? PERRY SPENCER, D. FRYDMAN,
IN DIAGNOSIS
M.D.
M.D.
From the Centre Paris, France
d’Etudes
et de Recherches
de l’Impuissance,
ABSTRACT-The use of artificial erection (AE) for the diagnosis and treatment of erectile failure was studied in 180 impotent males selected from a group of 440 men who underwent a complete multidisciplinary approach including nocturnal penile tumescence (NPT), arterial, neurologic, hormonal, and psychologic studies. Five groups were identified: (1) nonorganic (15.3 %) impotence considered as a control group for AE normal values; (2) arterial (26.6 X); (3) neurologic (12.2 %); (4) arterial and neurologic (19.4 %); and (5) a group of 47 remaining patients (26.1%) with abnormal NPT and normal arterial and neurologic studies who had the highest flow to obtain and maintain erection and were classified as “venous incompetence.” Results of AE flows of patients of groups 2, 3, 4, and 5 are presented and discussed in the focus of erectile physiology, pathophysiology of erectile failure, and surgery. Patients of groups 2 and 4 with normal flows had a 26.6 per cent rate of improvement due to AE. Results and comments indicate that AE ranks as a major procedure in the diagnosis and treatment of impotence.
Impotence is a common complaint, 1,2which requires thorough evaluation to establish causation and appropriate therapy. The need for examination of the erect penis has been emphasized by various authors.1%2 Among the techniques available are: nocturnal penile tumescence (NPT) monitoring,3 Xenon washout measurements under visual sexual stimulation (VSS),4 and artificial erection (AE) .5 We have chosen NPT and AE as routine tests in a multidisciplinary evaluation program to study impotent. patients. The diagnostic and therapeutic results of artificial erection in a series of 180 impotent men are presented. Material
Clinical study Noninvasive arterial study Doppler Postocclusive reactive hyperemia Artificial erection with cavernosography Phalloarteriography and aortography Neuromuscular studies Bulbocavernous reflex Evoked potential NPT monitoring Hormonal evaluation MMPI Papaverine test Artificial
/
AUGUST
1984
/
VOLUME
XXIV,
NUMBER
(AE)
Artificial erection was performed under local anesthesia (1% lidocaine subcutaneously on each side of the balano preputial sulcus). One corpus was punctured with 19-F Intracath to inject either a 1 per cent heparinized saline solution at 37” C and/or a 30 per cent iodine contrast solution.
and Methods
In the 180 patients selected for this study data were recorded at the time of examination without knowledge of any other results, and each patient was subjected to the following multidisciplinary approach:
UROLOGY
erection
2
157
Injection was made with a specially designed pump, * allowing a flow of 0 to 500 mllmin. An electronic device allowed triggering of the flow by the intracavernous pressure (ICP). Permanent monitoring of the ICP was achieved with a separate 21-F Intracath inserted in the opposite cavernous body. Change of the penis circumference was measured by a mercury-filled strain gauge. Velocimetric changes were evaluated by means of a continuous wave ultrasonic Doppler. Electrocardiogram (EKG) and arterial pressure were monitored continuously. The pump was started at 50 ml/min. Flow rate and examination of the cavernous bodies were made by fluoroscopy. An x-ray film was taken every fifteen seconds. If no (or little) change in the ICP and the penis size was observed after three minutes, the flow was slowly increased until tumescence or full erection was obtained. The lowest flow rate necessary to obtain a full erection is described as the output to obtain erection (OOE). The flow rate was automatically triggered by the ICP to the lowest value necessary to maintain a fully rigid erection. This value is described as the output to maintain a full erection (OME) . Radiographs were taken while full erection was maintained. Left and right lateral views were necessary to see the whole penis and the crura, as well as the pelvic veins. The pumping was discontinued while ICP and penis size were monitored until complete detumescence. Doppler studies were performed after the pump had been stopped for one minute. Velocity of the dorsal and deep arteries on both sides was recorded. Finally, an x-ray film was taken at the fifteenth minute of the examination. From the OOE and the OME, we calculated the maintenance index (MI), which represents the ratio between the OME and the OOE. The minimum circumference increase (MCI), which gives full rigidity, must be compared with the circumference increase obtained during NPT studies. Etiology
of Impotence
The cause of impotence was considered to be organic when the penile circumference on NPT was less than that of the MCI. The degree of severity was greater when the penile circumference on NPT was 50 per cent or less than that ‘Cavernopump, 75018.
158
Sofimec,
103 bis rue
Lamark,
Paris,
France
of the MCI. When the NPT circumferenc& are 75 per cent or more than those of the MCI, the duration of each nocturnal tumescence event must then be compared with the duration of the REM period. The quotient between the length of NPT event and REM event determines an erectile capacity index (ECI).e When the NPT, MCI, and EC1 are each above 0.75, organic etiology is excluded and the impotence considered nonorganic. Organic impotence Arterial. When penile blood pressure index (PBI) in the flaccid state was lower than 0.9 and arterial lesions were demonstrated on phallo-arteriogram, an arterial etiology was certain. The PBI allows differentiation between severe (0.65), mild (0.65-O.SO), and minimal (0.80-O. 90) arterial insufficiency. A neuroZogic etiology was considered when the bulbocavernous latency exceeded 40 msec and/or the conductivity of the sural nerve below 40 msec. ATterial and neurologic etiology may occur simultaneously. Endocrine abnormalities were considered if testosterone, luteinizing hormone, follicle-stimulating hormone, prolactin, or estradiol were abnormal. Classification
of 180 patients
According to the previous parameters, five clinical groups were isolated: (1) a nonorganic group of 28 patients (15 % ) where NPT related to MCI and the entire etiologic examination was normal; (2) an arterial group of 48 patients (26%); (3) a neurologic group of 22 patients (12%); (4) a mixed arteriahneurologic group of 35 patients (19%), and (5) a group of 47 patients (26%) with abnormal NPT related to MCI and normal arterial, neurologic, and endocrine studies classified as the venous group. There was no endocrine group. Age, OOE, OME, MI, and MCI were compared in all five groups to evaluate the results of AE, cavernosography, and the ability of these to discriminate the hemodynamic changes by the examinations and/or by pathology. Results of Artificial
Erection
Results of AE in the five groups are shown in Figure 1. The nonorganic impotent group (normal NPT related to MCI) has been considered as having normal erectile capacity. The mean values of OOE, OME, and MI were 133 mllmin ( f 42.1), 41 mllmin ( f 31), and 0.3 (* O.lS),
UROLOGY
/
AUGUST
1984
i
VOLUME
XXIV,
NUMBER
2
Y
FIGURE 2. Lack of correlation of measurements of penile circumference increase and output to obtain erection, in control group N = 28.
divided into three different categories with severe MI (m 0.84), mild MI (m 0.67), and minimal MI (m 0.52) venous incompetence according to cavernosography and the rapid washout from the cavernous bodies. and neurologic groups According to these results the three other groups were reassessed and classified by the following criteria: FO (no incompetence), Fl (minimal), F2 (mild), and F3 (severe). (1) Arterial group (n = 48): 27 patients were of the FO type, 11 of the Fl, 8 of the F2, and 2 of the F3. (2) Neurologic group (n = 22): 12 were of the FO type, 3 of the Fl, and 7 of the F2 and F3 types. (3) Arterialheurologic group (n = 35): 13 patients were of the FO type, 5 of the Fl, 6 of the F2, and 11 of the F3.
Arterial
FIGURE 1. Mean values and repartition of output to obtain and maintain erection. In cartridge, values of maintaining index for 5 clinical groups of impotent: NO: nonorganic, ART: arterial, ART + N: arterial and neurologic, N: neurologic, V: venous.
respectively, There was no significant correlation between the size of the penile changes and the OOE in the control group (Fig. 2).
by artificial erection Fifteen patients (8.33 % ) reported improvement of their erection in the days immediately following the examination. This improvement lasted from a few days to two months. The patients claimed that their erections lasted longer and were better. The mean values of the 15 patients, the OOE, the OME, and the MI were 133 mllmin ( k 40 ml), 35 ml/min ( + 18), and 0.26 ml/min ( 5 0.11)) respectively. All patients belonged to the arterial or arteriahneurologic groups.
Improvement
OOE There is no statistical difference* between the nonorganic group and the group with arterial insufficiency. An increasing statistical difference was found between the three other groups (arterial, neurologic, and the neurologickenous group). OME and MI The four organic groups show a statistical difference from the nonorganic group. The venous group has the greatest difference with the highest flows to obtain erection (m 217 ml/min +- 87) as well as to maintain erection (m 153.6 ml/min f 98)) giving a high mean MI of (0.7 mllmin f 0.16). This group has been sub*Student’s
UROLOGY
t test using
/
AUGUST
the Fisher
1984
and Yaks
/
VOLUME
statistical
XXIV,
Comment Artificial erection, by intracavernous infusion of saline, was first used by Newman, Northup, and Devlin7 to study the mechanism of erection in cadavers.
tables.
NUMBER
2
159
TABLE 1.
Indications
for treatment I
ETIOLUGY
UF ERECIILE
FAILURE
1
according to value of maintaining F3: severe venous incompetence) I
-AE RESULIS (Maintaining Index)
I
InDIcAlIon
If
Fails
--
Surgery
I I
iliac
High
Normal
or
lntra cavernous Perfusions
Lou If
Fails
Deep Dorsal Pericavcrnous vein
Vein Arterialization lie and comunication to cavernous bodies
with
i 1
Deep Dorsal
Vein ktcrialization Epigastric Artery
with
--Surgery
AND NEUROLOGIC Young -High
surgery
I -r FI
VENOUS
f2
r3
Intracavernous access for blood transfusion was used during World War II. Michal and Pospicha18 reported the use of AE during phalloarteriography with the purpose of better visualization of the penile arterial vessels. In 1979, we reported the use of AE in the diagnosis of impotence.5 According to these previous works, it was already known that an erection could be obtained by infusion of saline at a certain rate in the cavernous bodies and maintained at a lower rate. In in vivo studies AE has proved to be a dynamic study, inducing arterial changes, as demonstrated by phallo-arteriography and velocimetric Doppler studies.e According to these findings in normal patients, the OOE is the combined ‘result of delivery from the pump and from the pudendal arterial bed. Permanent monitoring of the ICP has been useful in understanding the physiology of erection. No change in penis size occurs until ICP reaches 25 mm Hg. Below 50 mm Hg, no rigidity will be achieved. There is a critical point for the ICP, between the diastolic and the mean arterial pressure, allowing full rigidity to occur presum-
160
Vein Arterialization Epigastric ktery
1 I I 1 1 I I
Surgery
I
ARTERIAL
Deep Dorsal with the
I (
Aorto
SURGICAL 1ECHlIOUE
1ntra cavernous Perfusions
or Lou
I
(Excluding obstruction)
F2: mild,
/
Normal
ARTERIAL
index (Fl: minimal,
onservative
or Surgery
! I
surgery
I
I
I
Vein
with
Pcricavcrnous
Over
60 --
Arterialization Tie
Prosthesis --
Deep Dorsal Vein Resection and Pericavernous Tic
Ireatment
I"
Deep Dorsal
Rrterialilation with Epigastric and Pericavernous lie
Artery
Surgery
ably when the occlusion point is reached. This full rigidity is usually achieved when the ICP is suprasystolic. To maintain full erection during artificial erection there is a critical level of flow which is 25 to 35 per cent of the flow needed to achieve erection. This OME is the result of arterial blood delivery and venous occlusion during full erection. The normal values for obtaining and maintaining erection were achieved on patients with proved nonorganic impotence. Factors which might influence flow rates are pathology of arterial delivery, abnormal closure mechanism, and pathology of the cavernous tissue, such as Peyronie disease. There is no problem in understanding the hemodynamic patterns of impaired arterial inflow or abnormal drainage through pathologic pathways (i.e., abnormal cavernous to glans shunts),10 or ectopic veins draining permanently the cavernous bodies.” These conditions are also recognized by the 133Xenon-washout studies under VSS.4 Clinically, we have classified as drainage failure cases with demonstrated evidence of
UROLOGY
/ AUGUST1984
/ VOLUMEXXIV,NUMBERZ
Used as a diagnostic or therapeutic tool, AE is painless and harmless. No complications were observed except for superficial hematomas resulting from the punctured points. To obviate this it is useful to wait until detumescence has occurred before withdrawing the needles. In addition, artificial erection has helped in the comprehension of erection9 It is now recognized that a fully rigid erection needs a complete venous blockage.2,Q The comparative studies of circumference increase and intracavernous pressure have confirmed the lack of relationships between volume changes and penile rigidity. In conclusion artificial erection has demonstrated its validity in the differential diagnosis of impotence. A new clinical entity, the unstable erection syndrome due to abnormally high venous drainage, is acknowledged, thus leading to different surgical approaches.
erection with short duration, if such cases are “short duration erections” showing similar during NPT. Artificial erection and dynamic cavernosography both will provide the final evidence for such incompetent regulation of drainage from the corpora cavernosa. If neither arterial nor neurologic lesions can be demonstrated, they are classified as “venous” on the basis of our previous studies.” In the arterial and/or neurologic groups artificial erection discriminates those with a normal MI and those with a high MI. This suggests different behavior toward the closure mechanisms either because of a decreased arterial delivery or secondary to the failure of the autonomic nervous system to regulate the penile blood flow. Since evidence of VIP release12 during the human erection has been brought to light, the question of the leakage of this neurotransmitter during such abnormalities is in question. This study confirms early findings on the therapeutic effects of artificial erection. The 15 patients reporting an improvement after they had experienced AE are all in the arterial and arterial/neurologic groups, and all have normal or low OME. If considering only these patients, the rate of improvement is 27.7 per cent (15154 patients), The question of a placebo effect has been rejected because none of the nonorganic group claimed improvement while the study was performed. Due to these findings and the favorable effect of intracavernous papaverine, a pilot therapeutic study of 30 impotent patients with arterial and arterial/neurologic lesions was performed with intracavernous injection of papaverine associated with artificial erection. Initial results were recently r3 An encouraging rate of improvepublished. ment of 66 per cent was obtained after a oneyear survey. This could be a routine semiconservative therapy for many impotent patients with distal arterial lesions (PBI between 0.70 and 0.80) especially the diabetic group (with normal AE results). The MI helps to choose between the different procedures as shown in Table I. When arterial lesions are present with normal MI (especially if OOE and OME are in a normal range), we are careful in the size of the graft used to perform the revascularization. For venous incompetence the MI distinguish between minimal (Fl), mild (F2), and severe incompetence leading to a different therapeutic approach for each group.
UROLOGY
/
AUGUST
1984
/
VOLUME
XXIV,
NUMBER
Paris, France (DR. VIRAG) ACKNOWLEDGMENT. To Dr. Gorm Wagner, Panum Institute, University of Copenhagen, Denmark, for critical discussion. References 1. Wagner G, and Green R: Impotence-Physiological, Psychological, Surgical Diagnosis and Treatment. New York. Plenum Publiihing Corporation,-1981. 2. Bennett AH: Management of Male Impotence, Baltimore, Williams & Wilkins, vol. 5, 1982. 3. Karacan I: Clinical value of nocturnal erection in the prognosis and the diagnosis of impotence, Med Aspects Hum Sex 4: 31 (1970). 4. Wagner G, and Uhrenholdt A: Blood flow measurement by the clearance method in the human corpus cavernosum in the flaccid and erect states. Presented at the First International Conference on Vasculogenic Impotence, New York, 1978. 5. Virag R, Legman M, Zwang G, and Dermange H: L’utilisaton de l’erection passive dans l’exploration de l’impuissance d’origine vasculaire, Contraception, Fertiliti, Sexualitk 7: 707 (1978). 6. Frydman D, and Virag R: Use of sleep related nocturnal penile tumescence and artificial erection. Presented at the 6th European Congress of Sleep Research, Zurich, March, 1982. 7. Newman H, Northup JD, and Devlin J: Mechanism of human penile erection, Invest Urol 1: 350 (1964). 8. Michal V, and Pospichal: Phalloarteriography in the diagnosis of erectile impotence, World J Surg 2: 239 (1977). 9. Virag R: Arterial and venous haemodynamics in male impotence, in Bennett AH: Management of Male Impotence, Baltimore, Williams & Wilkins, 1982, vol 5, p 108. 10. Ebbehdj J, and Wagner G: Insufficient penile erection due to abdominal drainage from the cavernous bodies, Urology 5: 507 (1979). 11. Virag R, Zwang G, Dermange H, and Legman M: Vasculogenic impotence: a review of 92 cases with 54 surgical operations, Vast Surg 15: 9 (1981). 12. Virag R, et al: VIP release during penile erection in man, Lancet 2: 1166 (1982). 13. Virag R: Intracavernous injection of papaverine for erectile failure. Lancet 2: 938 (1982).
2
161
ERECTION
TREATMENT
AND
OF IMPOTENCE
R. VIRAG, M.D. I? PERRY SPENCER, D. FRYDMAN,
IN DIAGNOSIS
M.D.
M.D.
From the Centre Paris, France
d’Etudes
et de Recherches
de l’Impuissance,
ABSTRACT-The use of artificial erection (AE) for the diagnosis and treatment of erectile failure was studied in 180 impotent males selected from a group of 440 men who underwent a complete multidisciplinary approach including nocturnal penile tumescence (NPT), arterial, neurologic, hormonal, and psychologic studies. Five groups were identified: (1) nonorganic (15.3 %) impotence considered as a control group for AE normal values; (2) arterial (26.6 X); (3) neurologic (12.2 %); (4) arterial and neurologic (19.4 %); and (5) a group of 47 remaining patients (26.1%) with abnormal NPT and normal arterial and neurologic studies who had the highest flow to obtain and maintain erection and were classified as “venous incompetence.” Results of AE flows of patients of groups 2, 3, 4, and 5 are presented and discussed in the focus of erectile physiology, pathophysiology of erectile failure, and surgery. Patients of groups 2 and 4 with normal flows had a 26.6 per cent rate of improvement due to AE. Results and comments indicate that AE ranks as a major procedure in the diagnosis and treatment of impotence.
Impotence is a common complaint, 1,2which requires thorough evaluation to establish causation and appropriate therapy. The need for examination of the erect penis has been emphasized by various authors.1%2 Among the techniques available are: nocturnal penile tumescence (NPT) monitoring,3 Xenon washout measurements under visual sexual stimulation (VSS),4 and artificial erection (AE) .5 We have chosen NPT and AE as routine tests in a multidisciplinary evaluation program to study impotent. patients. The diagnostic and therapeutic results of artificial erection in a series of 180 impotent men are presented. Material
Clinical study Noninvasive arterial study Doppler Postocclusive reactive hyperemia Artificial erection with cavernosography Phalloarteriography and aortography Neuromuscular studies Bulbocavernous reflex Evoked potential NPT monitoring Hormonal evaluation MMPI Papaverine test Artificial
/
AUGUST
1984
/
VOLUME
XXIV,
NUMBER
(AE)
Artificial erection was performed under local anesthesia (1% lidocaine subcutaneously on each side of the balano preputial sulcus). One corpus was punctured with 19-F Intracath to inject either a 1 per cent heparinized saline solution at 37” C and/or a 30 per cent iodine contrast solution.
and Methods
In the 180 patients selected for this study data were recorded at the time of examination without knowledge of any other results, and each patient was subjected to the following multidisciplinary approach:
UROLOGY
erection
2
157
Injection was made with a specially designed pump, * allowing a flow of 0 to 500 mllmin. An electronic device allowed triggering of the flow by the intracavernous pressure (ICP). Permanent monitoring of the ICP was achieved with a separate 21-F Intracath inserted in the opposite cavernous body. Change of the penis circumference was measured by a mercury-filled strain gauge. Velocimetric changes were evaluated by means of a continuous wave ultrasonic Doppler. Electrocardiogram (EKG) and arterial pressure were monitored continuously. The pump was started at 50 ml/min. Flow rate and examination of the cavernous bodies were made by fluoroscopy. An x-ray film was taken every fifteen seconds. If no (or little) change in the ICP and the penis size was observed after three minutes, the flow was slowly increased until tumescence or full erection was obtained. The lowest flow rate necessary to obtain a full erection is described as the output to obtain erection (OOE). The flow rate was automatically triggered by the ICP to the lowest value necessary to maintain a fully rigid erection. This value is described as the output to maintain a full erection (OME) . Radiographs were taken while full erection was maintained. Left and right lateral views were necessary to see the whole penis and the crura, as well as the pelvic veins. The pumping was discontinued while ICP and penis size were monitored until complete detumescence. Doppler studies were performed after the pump had been stopped for one minute. Velocity of the dorsal and deep arteries on both sides was recorded. Finally, an x-ray film was taken at the fifteenth minute of the examination. From the OOE and the OME, we calculated the maintenance index (MI), which represents the ratio between the OME and the OOE. The minimum circumference increase (MCI), which gives full rigidity, must be compared with the circumference increase obtained during NPT studies. Etiology
of Impotence
The cause of impotence was considered to be organic when the penile circumference on NPT was less than that of the MCI. The degree of severity was greater when the penile circumference on NPT was 50 per cent or less than that ‘Cavernopump, 75018.
158
Sofimec,
103 bis rue
Lamark,
Paris,
France
of the MCI. When the NPT circumferenc& are 75 per cent or more than those of the MCI, the duration of each nocturnal tumescence event must then be compared with the duration of the REM period. The quotient between the length of NPT event and REM event determines an erectile capacity index (ECI).e When the NPT, MCI, and EC1 are each above 0.75, organic etiology is excluded and the impotence considered nonorganic. Organic impotence Arterial. When penile blood pressure index (PBI) in the flaccid state was lower than 0.9 and arterial lesions were demonstrated on phallo-arteriogram, an arterial etiology was certain. The PBI allows differentiation between severe (0.65), mild (0.65-O.SO), and minimal (0.80-O. 90) arterial insufficiency. A neuroZogic etiology was considered when the bulbocavernous latency exceeded 40 msec and/or the conductivity of the sural nerve below 40 msec. ATterial and neurologic etiology may occur simultaneously. Endocrine abnormalities were considered if testosterone, luteinizing hormone, follicle-stimulating hormone, prolactin, or estradiol were abnormal. Classification
of 180 patients
According to the previous parameters, five clinical groups were isolated: (1) a nonorganic group of 28 patients (15 % ) where NPT related to MCI and the entire etiologic examination was normal; (2) an arterial group of 48 patients (26%); (3) a neurologic group of 22 patients (12%); (4) a mixed arteriahneurologic group of 35 patients (19%), and (5) a group of 47 patients (26%) with abnormal NPT related to MCI and normal arterial, neurologic, and endocrine studies classified as the venous group. There was no endocrine group. Age, OOE, OME, MI, and MCI were compared in all five groups to evaluate the results of AE, cavernosography, and the ability of these to discriminate the hemodynamic changes by the examinations and/or by pathology. Results of Artificial
Erection
Results of AE in the five groups are shown in Figure 1. The nonorganic impotent group (normal NPT related to MCI) has been considered as having normal erectile capacity. The mean values of OOE, OME, and MI were 133 mllmin ( f 42.1), 41 mllmin ( f 31), and 0.3 (* O.lS),
UROLOGY
/
AUGUST
1984
i
VOLUME
XXIV,
NUMBER
2
Y
FIGURE 2. Lack of correlation of measurements of penile circumference increase and output to obtain erection, in control group N = 28.
divided into three different categories with severe MI (m 0.84), mild MI (m 0.67), and minimal MI (m 0.52) venous incompetence according to cavernosography and the rapid washout from the cavernous bodies. and neurologic groups According to these results the three other groups were reassessed and classified by the following criteria: FO (no incompetence), Fl (minimal), F2 (mild), and F3 (severe). (1) Arterial group (n = 48): 27 patients were of the FO type, 11 of the Fl, 8 of the F2, and 2 of the F3. (2) Neurologic group (n = 22): 12 were of the FO type, 3 of the Fl, and 7 of the F2 and F3 types. (3) Arterialheurologic group (n = 35): 13 patients were of the FO type, 5 of the Fl, 6 of the F2, and 11 of the F3.
Arterial
FIGURE 1. Mean values and repartition of output to obtain and maintain erection. In cartridge, values of maintaining index for 5 clinical groups of impotent: NO: nonorganic, ART: arterial, ART + N: arterial and neurologic, N: neurologic, V: venous.
respectively, There was no significant correlation between the size of the penile changes and the OOE in the control group (Fig. 2).
by artificial erection Fifteen patients (8.33 % ) reported improvement of their erection in the days immediately following the examination. This improvement lasted from a few days to two months. The patients claimed that their erections lasted longer and were better. The mean values of the 15 patients, the OOE, the OME, and the MI were 133 mllmin ( k 40 ml), 35 ml/min ( + 18), and 0.26 ml/min ( 5 0.11)) respectively. All patients belonged to the arterial or arteriahneurologic groups.
Improvement
OOE There is no statistical difference* between the nonorganic group and the group with arterial insufficiency. An increasing statistical difference was found between the three other groups (arterial, neurologic, and the neurologickenous group). OME and MI The four organic groups show a statistical difference from the nonorganic group. The venous group has the greatest difference with the highest flows to obtain erection (m 217 ml/min +- 87) as well as to maintain erection (m 153.6 ml/min f 98)) giving a high mean MI of (0.7 mllmin f 0.16). This group has been sub*Student’s
UROLOGY
t test using
/
AUGUST
the Fisher
1984
and Yaks
/
VOLUME
statistical
XXIV,
Comment Artificial erection, by intracavernous infusion of saline, was first used by Newman, Northup, and Devlin7 to study the mechanism of erection in cadavers.
tables.
NUMBER
2
159
TABLE 1.
Indications
for treatment I
ETIOLUGY
UF ERECIILE
FAILURE
1
according to value of maintaining F3: severe venous incompetence) I
-AE RESULIS (Maintaining Index)
I
InDIcAlIon
If
Fails
--
Surgery
I I
iliac
High
Normal
or
lntra cavernous Perfusions
Lou If
Fails
Deep Dorsal Pericavcrnous vein
Vein Arterialization lie and comunication to cavernous bodies
with
i 1
Deep Dorsal
Vein ktcrialization Epigastric Artery
with
--Surgery
AND NEUROLOGIC Young -High
surgery
I -r FI
VENOUS
f2
r3
Intracavernous access for blood transfusion was used during World War II. Michal and Pospicha18 reported the use of AE during phalloarteriography with the purpose of better visualization of the penile arterial vessels. In 1979, we reported the use of AE in the diagnosis of impotence.5 According to these previous works, it was already known that an erection could be obtained by infusion of saline at a certain rate in the cavernous bodies and maintained at a lower rate. In in vivo studies AE has proved to be a dynamic study, inducing arterial changes, as demonstrated by phallo-arteriography and velocimetric Doppler studies.e According to these findings in normal patients, the OOE is the combined ‘result of delivery from the pump and from the pudendal arterial bed. Permanent monitoring of the ICP has been useful in understanding the physiology of erection. No change in penis size occurs until ICP reaches 25 mm Hg. Below 50 mm Hg, no rigidity will be achieved. There is a critical point for the ICP, between the diastolic and the mean arterial pressure, allowing full rigidity to occur presum-
160
Vein Arterialization Epigastric ktery
1 I I 1 1 I I
Surgery
I
ARTERIAL
Deep Dorsal with the
I (
Aorto
SURGICAL 1ECHlIOUE
1ntra cavernous Perfusions
or Lou
I
(Excluding obstruction)
F2: mild,
/
Normal
ARTERIAL
index (Fl: minimal,
onservative
or Surgery
! I
surgery
I
I
I
Vein
with
Pcricavcrnous
Over
60 --
Arterialization Tie
Prosthesis --
Deep Dorsal Vein Resection and Pericavernous Tic
Ireatment
I"
Deep Dorsal
Rrterialilation with Epigastric and Pericavernous lie
Artery
Surgery
ably when the occlusion point is reached. This full rigidity is usually achieved when the ICP is suprasystolic. To maintain full erection during artificial erection there is a critical level of flow which is 25 to 35 per cent of the flow needed to achieve erection. This OME is the result of arterial blood delivery and venous occlusion during full erection. The normal values for obtaining and maintaining erection were achieved on patients with proved nonorganic impotence. Factors which might influence flow rates are pathology of arterial delivery, abnormal closure mechanism, and pathology of the cavernous tissue, such as Peyronie disease. There is no problem in understanding the hemodynamic patterns of impaired arterial inflow or abnormal drainage through pathologic pathways (i.e., abnormal cavernous to glans shunts),10 or ectopic veins draining permanently the cavernous bodies.” These conditions are also recognized by the 133Xenon-washout studies under VSS.4 Clinically, we have classified as drainage failure cases with demonstrated evidence of
UROLOGY
/ AUGUST1984
/ VOLUMEXXIV,NUMBERZ
Used as a diagnostic or therapeutic tool, AE is painless and harmless. No complications were observed except for superficial hematomas resulting from the punctured points. To obviate this it is useful to wait until detumescence has occurred before withdrawing the needles. In addition, artificial erection has helped in the comprehension of erection9 It is now recognized that a fully rigid erection needs a complete venous blockage.2,Q The comparative studies of circumference increase and intracavernous pressure have confirmed the lack of relationships between volume changes and penile rigidity. In conclusion artificial erection has demonstrated its validity in the differential diagnosis of impotence. A new clinical entity, the unstable erection syndrome due to abnormally high venous drainage, is acknowledged, thus leading to different surgical approaches.
erection with short duration, if such cases are “short duration erections” showing similar during NPT. Artificial erection and dynamic cavernosography both will provide the final evidence for such incompetent regulation of drainage from the corpora cavernosa. If neither arterial nor neurologic lesions can be demonstrated, they are classified as “venous” on the basis of our previous studies.” In the arterial and/or neurologic groups artificial erection discriminates those with a normal MI and those with a high MI. This suggests different behavior toward the closure mechanisms either because of a decreased arterial delivery or secondary to the failure of the autonomic nervous system to regulate the penile blood flow. Since evidence of VIP release12 during the human erection has been brought to light, the question of the leakage of this neurotransmitter during such abnormalities is in question. This study confirms early findings on the therapeutic effects of artificial erection. The 15 patients reporting an improvement after they had experienced AE are all in the arterial and arterial/neurologic groups, and all have normal or low OME. If considering only these patients, the rate of improvement is 27.7 per cent (15154 patients), The question of a placebo effect has been rejected because none of the nonorganic group claimed improvement while the study was performed. Due to these findings and the favorable effect of intracavernous papaverine, a pilot therapeutic study of 30 impotent patients with arterial and arterial/neurologic lesions was performed with intracavernous injection of papaverine associated with artificial erection. Initial results were recently r3 An encouraging rate of improvepublished. ment of 66 per cent was obtained after a oneyear survey. This could be a routine semiconservative therapy for many impotent patients with distal arterial lesions (PBI between 0.70 and 0.80) especially the diabetic group (with normal AE results). The MI helps to choose between the different procedures as shown in Table I. When arterial lesions are present with normal MI (especially if OOE and OME are in a normal range), we are careful in the size of the graft used to perform the revascularization. For venous incompetence the MI distinguish between minimal (Fl), mild (F2), and severe incompetence leading to a different therapeutic approach for each group.
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Paris, France (DR. VIRAG) ACKNOWLEDGMENT. To Dr. Gorm Wagner, Panum Institute, University of Copenhagen, Denmark, for critical discussion. References 1. Wagner G, and Green R: Impotence-Physiological, Psychological, Surgical Diagnosis and Treatment. New York. Plenum Publiihing Corporation,-1981. 2. Bennett AH: Management of Male Impotence, Baltimore, Williams & Wilkins, vol. 5, 1982. 3. Karacan I: Clinical value of nocturnal erection in the prognosis and the diagnosis of impotence, Med Aspects Hum Sex 4: 31 (1970). 4. Wagner G, and Uhrenholdt A: Blood flow measurement by the clearance method in the human corpus cavernosum in the flaccid and erect states. Presented at the First International Conference on Vasculogenic Impotence, New York, 1978. 5. Virag R, Legman M, Zwang G, and Dermange H: L’utilisaton de l’erection passive dans l’exploration de l’impuissance d’origine vasculaire, Contraception, Fertiliti, Sexualitk 7: 707 (1978). 6. Frydman D, and Virag R: Use of sleep related nocturnal penile tumescence and artificial erection. Presented at the 6th European Congress of Sleep Research, Zurich, March, 1982. 7. Newman H, Northup JD, and Devlin J: Mechanism of human penile erection, Invest Urol 1: 350 (1964). 8. Michal V, and Pospichal: Phalloarteriography in the diagnosis of erectile impotence, World J Surg 2: 239 (1977). 9. Virag R: Arterial and venous haemodynamics in male impotence, in Bennett AH: Management of Male Impotence, Baltimore, Williams & Wilkins, 1982, vol 5, p 108. 10. Ebbehdj J, and Wagner G: Insufficient penile erection due to abdominal drainage from the cavernous bodies, Urology 5: 507 (1979). 11. Virag R, Zwang G, Dermange H, and Legman M: Vasculogenic impotence: a review of 92 cases with 54 surgical operations, Vast Surg 15: 9 (1981). 12. Virag R, et al: VIP release during penile erection in man, Lancet 2: 1166 (1982). 13. Virag R: Intracavernous injection of papaverine for erectile failure. Lancet 2: 938 (1982).
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