Penile Evaluation: An Illustrated Review.

ABSTRACT: High-frequency ultrasound is the imaging modality of choice for evaluating penile pathology because of its easy access, low cost, and patient tolerance ( The Penis, Diagnostic Ultrasound, second edtion . Boca Raton: CRC Press; 2007:957-978). This pictorial review will illustrate the sonographic features of emergent and nonemergent penile conditions such as penile fracture, spongial tear, urethral injury, various types of priapism, erectile dysfunction, penile abscess, and Mondor disease.

Severe penile torsion of 180 degrees in an adult patient: a uro-radiological case report.

Penile torsion is the abnormal three-dimensional twisting of penile corporal bodies. It can be classified as mild, moderate, or severe, depending on the degree of torsion. Severe penile torsion (>90°) is a very rare condition, with an estimated incidence of 0.4%-1% among all penile torsion cases. Our patient was a 37-year-old man complaining of a 2-year history of lower urinary tract symptoms. These symptoms appeared after the patient sustained an iatrogenic injury during Foley catheter insertion. Physical examination incidentally revealed an obvious counterclockwise penile rotation of 180°. Several theories have been proposed to explain the etiology of penile torsion, including theories based on genetic factors, abnormal urethral development, and abnormal attachment of the dartos fascia to the skin. Penile torsion may be associated with other penile anomalies, including chordee, hypospadias, and epispadias; however, it is often detected as an isolated finding. Clinical examination is sufficient to confirm its diagnosis without the need for further imaging. While no standardized procedure has been indicated for all penile torsion cases, the severity of torsion and the presence of other anomalies determine the most suitable procedure. No reports on the imaging features of penile torsion (irrespective of the degree of torsion) are available. We present the first such report on the imaging features, including advanced magnetic resonance imaging findings, of a 180° penile torsion in an adult patient.

Partial Thrombosis of Corpus Cavernosum

Thrombosis of the corpus cavernosum is a rare disease of unknown cause that usually affects young men. We present the case of a 25-year-old man with an unilateral, painful perineal mass and ultrasound scan compatible with this entity. The magnetic resonance and tomography computarised scan images corroborate the diagnosis. Anticoagulants were prescribed which solved the clinical picture (AU)

The penile duplex ultrasound: How and when to perform it?

BACKGROUND: Because it is a superficial structure, the penis is ideally suited to ultrasound imaging. A number of disease processes, including Peyronie's disease, penile fractures and tumors, are clearly visualized with ultrasound. Baseline and dynamic assessment of cavernosal arterial changes after pharmaco-stimulation with alprostadil allows standardized diagnosis of arterial and venogenic causes of erectile dysfunction (ED). OBJECTIVE: To illustrate how to correctly perform flaccid and dynamic penile duplex ultrasound (D-PDU) and in which patients to recommend it. MATERIALS/METHODS: An extensive search of the literature was carried out on Pubmed with the insertion of the following Medical Subjects Headings (MeSH) terms and keywords "penile color Doppler ultrasound" "peak systolic velocity" "end-diastolic velocity", "acceleration time", "resistance index". EVIDENCE: In our experience, arterial erectile dysfunction is identified after standardized intracavernous injection (ICI) of alprostadil (10 mcg) when values of peak systolic velocity (PSV) are <35 cm/s and, in the most severe forms, for values <25 cm/s. Arterial insufficiency can also be identified by increased acceleration time (AT) values (>110 ms) and/or by a lack of visualization of helicine arteries at power Doppler mode along with incomplete achievement of penile rigidity. The veno-occlusive incompetence is determined when end-diastolic velocity (EDV) values are >4.5-5 cm/s or in the case of resistance index (RI) values <0.75. The assessment of additional surrogate markers of endothelial dysfunction, that is, intima-media thickness, mean platelet volume (MPV), endothelial progenitor cells (EPC), endothelial cell specific molecule-1(endocan) are also useful in assessing the patient's cardiovascular risk but are still considered investigational in the interpretation of D-PDU results. CONCLUSION: D-PDU scan after ICI with vasoactive drugs is a safe procedure and represents the gold standard for the diagnostics of penile pathologies and should be performed in men with ED not responding to oral conventional therapies and/or in those requiring accurate stratification of cardiovascular risk.

A rare case of a spontaneous abscess of the corpus cavernosum: the role of contrast-enhanced ultrasound in diagnosis and post-therapeutic follow-up.

In this paper, we describe the pattern of an idiopathic corpus cavernosum (CC) abscess using contrast-enhanced ultrasound (CEUS) and compare this to the lesion characterization achieved using preliminary baseline ultrasound/color doppler (ECD). In a 43-year-old man, who arrived at our emergency department for a penile swelling and hematopyuria, ECD examination showed equivocal mucosal and subcutaneous tissue swelling, an inhomogeneous hypoechoic area in the left CC, and a suspected millimetric interruption of the albuginea. CEUS showed multiple avascular areas wrapped in a hyperperfused rim representing abscesses and a not-perfused balanopreputial-oriented fistula. A CEUS control documented clinical remission after surgery. CEUS is a noninvasive and bedside executable method that allows a more precise evaluation of the entity, localization, and possible complications of CC abscesses and, therefore, permits prescribing the most adequate therapy to the patient, as well as the evaluation of eventual postsurgical sequelae.

Corpus cavernosum thrombosis: the membrane may play its role / Trombosis del cuerpo cavernoso: la membrana desempeña su papel

Partial thrombosis of corpus cavernosum is an uncommon condition that needs a high level of suspicious to be diagnosed. Imaging techniques may be very useful, and MR is the state-of-the-art technique. We present a case of a young male who presented to the emergency department with perineal and painful mass. MR imaging clearly depicted a thrombosed corpus cavernosum and a bilateral membrane that is possibly the underlying predisposing condition. With only conservative treatment the patient had an excellent outcome

La trombosis parcial del cuerpo cavernoso es una rara entidad que necesita de un alto grado de sospecha para su diagnóstico. Las técnicas de diagnóstico por la imagen pueden ser de gran utilidad y la resonancia magnética (RM) es la mejor modalidad disponible. Presentamos el caso de un joven varón que acude al servicio de urgencias con una masa perineal dolorosa. La RM diagnostica trombosis del cuerpo cavernoso y la existencia de una membrana bilateral, un posible factor predisponente. Con apenas tratamiento conservador, el paciente tuvo una excelente evolución clínica

Prenatal ultrasound diagnosis of chordee without hypospadias.

Chordee without hypospadias (CWH) is an extremely rare condition. Here, we describe a case of CWH diagnosed accurately on prenatal ultrasound at 25 weeks' gestation. Physical examination of the newborn confirmed the sonographic findings. To the best of our knowledge, prenatal ultrasound diagnosis of CWH has not been reported in the literature. We emphasize the importance of observing fetal micturition to rule out the possibility of CWH before the diagnosis of hypospadias is made on prenatal ultrasound.

MRI of the Penis: Indications, Anatomy, and Pathology.

The purpose of this review is to discuss the role of magnetic resonance imaging (MRI) in the evaluation of penile pathology. Normal penile anatomy as well as the appearance of neoplastic and non-neoplastic entities on MRI will be reviewed. While ultrasound remains the first line imaging modality in evaluating most penile pathology, MR imaging has specific advantages owing to improved soft tissue resolution, ability to evaluate less accessible or complex anatomy (such as at the base of the penis), and the ability to detect subtle enhancement. Therefore, MRI is useful for when ultrasound and/or clinical findings are equivocal or incongruent. In addition, MR imaging is essential for preoperative surgical planning and is the imaging modality of choice in evaluating penile prostheses. The added value of MRI in these settings makes it an integral component to the management of many pathological entities affecting the penis.

Penile Mondor's disease: Imaging in two cases.

Penile Mondor's disease is a rare and under-recognized benign genital condition consisting of an isolated thrombosis of the dorsal superficial vein of the penis. Symptoms do not show distinctive features and there are asymptomatic cases. The patients usually present with a cord-like induration at dorsum of the penis. Diagnosis is usually made based on history and physical examination. The role of imaging in Mondor's disease is to identify the intravascular thrombus. In case of diagnostic uncertainty, Grey scale and Doppler ultrasound can be useful to detect the extent of thrombosis demonstrating echogenic material within venous lumen, vessel incompressibility and absence of flow, as well as painful selective pressure. The use of Magnetic Resonance imaging is controversial and not used routinely. Usually treatment is conservative: sexual rest, local anesthetics, anti-inflammatories, antibiotics in case of infection and anticoagulants. Sclerosing lymphangitis and Peyronie's disease have been described as possible differential diagnosis.

Corpus Cavernosum Abscess Diagnosed on FDG PET/CT.

The utility of PET in septicemia for showing its source and possible metastatic infection has been demonstrated. We describe the diagnosis on PET/CT of a spontaneous corpus cavernosum abscess in a 64-year-old man presenting with Streptococcus constellatus septicemia, in whom the clinical diagnosis had been elusive for 10 days.

Magnetic Resonance Imaging Findings of Penile Abscess.

A 72-year-old man presented with pain and swelling in the penis, indicating penile infection or abscess. An ultrasound was performed but unable to lead to a diagnosis of abscess. Magnetic resonance imaging with diffusion-weighted imaging was strongly suggestive of penile abscess. The puncture of the abscess was unsuccessful. However, pus was drained spontaneously via the urethra, and the symptoms disappeared eventually. Although ultrasound can be useful, sometimes it might be difficult to distinguish between inflammatory tissue and abscess containing necrotic tissue. Magnetic resonance imaging, especially diffusion-weighted imaging, can be a powerful tool for diagnosing abscess in the penis.

The application of spontaneous corpus cavernosum EMG to assess the status of cavernous smooth muscles, a preliminary study / La aplicación de cuerpo cavernoso EMG espontáneo para evaluar el estado de los músculos lisos cavernosos. Un estudio preliminar

Introduction: Diagnostic tests for vascular erectile dysfunction (ED) depend on cavernous smooth muscles (CSM) relaxation following an intracorporal injection (ICI). Enhanced sympathetic tone, which is not uncommon during performance of these tests, can bias its results. Also, CSM diseases can cause veno-occlusive diseases (VOD) ED. Corpus cavernosum electromyography (CC-EMG) potentials’ amplitudes represent the integrated sympathetic activity of healthy CSM. Stem-cells and gene-therapy are potential therapeutic options for impaired CSM. Objective: To utilize CC-EMG, as a new diagnostic technique that can confirm the integrity of CSM, and to identify patients with impaired CSM activity, among those diagnosed as vascular ED per Color Duplex Doppler Ultrasonography (CDDU). Patient and methods: Group 1 included 24 patients with ED and negative response to ICI. Group 2 included 10 men without ED. Patients included in group 1 had penile CDDU examination and all participants had spontaneous CC-EMG recordings. Results: According to CDDU parameters, group 1 was sub-grouped as nine arterial, ten VOD and five mixed type. CC-EMG potentials' amplitudes ranged 223-320, 179-237, 103-250 and 83-200μV for group 2 and arterial, mixed and VOD subgroups respectively. The widest ranges of potentials’ amplitudes were recorded in the subgroups of patients with an element of VOD. Four patients with ED, within these subgroups, had CC-EMG potentials’ amplitudes ranged 200-250μV that exceeded/approached the lowest value recorded from men in group 2. Conclusion: CC-EMG recordings elicited marked differences of CSM activity among patients diagnosed with an element of VOD ED per CDDU. This finding highlighted the need to utilize CC-EMG to assess the integrity of CSM. Identifying patients with impaired CSM activity may modify the chosen methods for therapeutic interventions

Introducción: Las pruebas diagnósticas para la disfunción eréctil (DE) vascular dependen de la relajación de los músculos cavernosos lisos (MCL) después de una inyección intracorporal (IIC). El tono simpático mejorado, que es frecuente durante la realización de estas pruebas, puede sesgar los resultados. Además, las enfermedades de los MCL pueden provocar DE con enfermedades venooclusivas (EVO). Las amplitudes de los potenciales de la electromiografía de los cuerpos cavernosos (CC-EMG) representan la actividad simpática integrada de los MCL sanos. Las células madre y la terapia génica son opciones terapéuticas potenciales para los MCL con discapacidad. Objetivo: Utilizar CC-EMG como una nueva técnica de diagnóstico que pueda confirmar la integridad de los MCL e identificar a los pacientes con actividad de MCL deteriorada entre los diagnosticados con DE vascular por ecografía Doppler color dúplex (CDDU, por sus siglas en inglés). Paciente y métodos: El grupo 1 incluyó a 24 pacientes con DE con una respuesta negativa a la IIC. El grupo 2 incluía a 10 varones sin DE. En los pacientes incluidos en el grupo 1 se realizó CDDU en el pene y todos los participantes presentaron grabaciones de la CC-EMG espontáneas. Resultados: De acuerdo con los parámetros CDDU, el grupo 1 se dividió en subgrupos, como 9 arteriales, 10 VOD y 5 tipos mixtos. Las amplitudes de los potenciales de la CC-EMG variaron entre 223-320, 179-237, 103-250 y 83-200μV para el grupo 2 y los subgrupos arteriales, mixtos y VOD, respectivamente. Los amplios rangos de amplitudes de los potenciales se registraron en los subgrupos de pacientes con un elemento de VOD. Cuatro pacientes dentro de estos subgrupos tenían amplitudes de potencial de la CC-EMG de 200-250μV que excedían/acercaban el valor más bajo para varones en el grupo 2. Conclusión: Las grabaciones de la CC-EMG provocaron marcadas diferencias de actividad de los MCL entre los pacientes diagnosticados con un elemento de VOD DE por CDDU. Este hallazgo destacó la necesidad de utilizar CC-EMG para evaluar la integridad de los MCL. La identificación de pacientes con actividad de CSM afectada puede modificar los métodos elegidos para las intervenciones terapéuticas

CT-guided minimally-invasive penile fracture repair

ABSTRACT We present the case of a 28 year old patient with an incomplete tear of the tunica albuginea occurred after having sexual intercourse in the female superior position. The diagnostic assessment was performed first clinically, then with CT, owing to its high resolution, allowed to exactly detect the tear location leading to precise preoperative planning. After adequate diagnosis through imaging and proper planning, the patient was performed a selective minimally invasive surgical approach to repair the lesion. The patient had good erection with no angular deformity or plaque formation after a 3-month follow-up.

CT-guided minimally-invasive penile fracture repair.

We present the case of a 28 year old patient with an incomplete tear of the tunica albuginea occurred after having sexual intercourse in the female superior position. The diagnostic assessment was performed first clinically, then with CT, owing to its high resolution, allowed to exactly detect the tear location leading to precise preoperative planning. After adequate diagnosis through imaging and proper planning, the patient was performed a selective minimally invasive surgical approach to repair the lesion. The patient had good erection with no angular deformity or plaque formation after a 3-month follow-up.

MR Imaging of the Penis and Urethra.

MR imaging has been increasingly used as a problem-solving adjunct after an initial ultrasound examination for a variety of penile disorders, and is the best cross-sectional imaging modality for the assessment of urethra and periurethral disease. Critical advantages of MR imaging for penile and urethra imaging include high soft tissue contrast resolution providing detailed anatomic evaluation, which is important for the demonstration and assessment of critical structures such as tunica albuginea or walls of the urethra, larger field of view for better evaluation of extent of disease, and demonstration of proteinaceous material and varying ages of the blood products.

Variability in penile duplex ultrasound international practice patterns, technique, and interpretation: an anonymous survey of ISSM members.

Penile duplex ultrasound (PDU), combined with pharmacologic stimulation of erection, is the gold standard for the evaluation of multiple penile conditions. A 30-question electronic survey was distributed to members of the International Society for Sexual Medicine (ISSM). The survey assessed the variability in current PDU practice patterns, technique, and interpretation. Chi-square test was used to determine the association between categorical variables. Approximately 9.5% of all 1996 current ISSM members completed the survey. Almost 80% of members surveyed reported using PDU, with more North American practitioners utilizing PDU than their European counterparts (94% vs 69%, p < 0.01). Approximately 62% of PDU studies were performed by a urologist and more than 76% were interpreted by a urologist. Although almost 90% of practitioners reported using their own protocol, extreme variation in the technique existed among respondents. Over ten different pharmacologic mixtures were used to generate erections, and 17% of respondents did not repeat dosing for insufficient erection. Urologists personally performing PDU were more likely to assess the cavernosal artery flow using recommended techniques with the probe at the proximal penile shaft (73% vs 40%) and at a 60-degree angle or less (68% vs 36%) compared with non-urologists (p < 0.01). Large differences in PDU diagnostic thresholds were apparent. Only 38% of respondents defined arterial insufficiency with a peak systolic velocity < 25 cm/s, while 53% of respondents defined venous occlusive disease with an end diastolic velocity > 5 cm/s. This is the first study to assess the variability in the PDU protocol and practice patterns, and to pinpoint areas of improvement. As in other surveys, recall bias, generalizability, and response rate (9.5%) are inherent limitations to this study. Although most respondents report utilizing a standardized PDU protocol, widespread variation exists among practitioners in terms of both technique and interpretation, limiting accurate diagnosis and appropriate treatment of penile conditions.