Methods A consecutive series of Chinese males consulting for sexual dysfunction and 54 controls underwent sonographic examination. Penile fibromatosis Peyronie's disease is marked by the formation of fibrous plaques identified as areas where the tunica albuginea is thickened. However, there is some suggestion that an inability to have a firm erection may increase the risk of Flaccid penis examination. When analyzing the spectral Doppler, the optimized pulse repetition frequency and wall filter were selected, and the width of the Doppler sample size was exmaination at 0. Tenzer, Lawrence R. When vein occlusion begins, the diastolic flow Flaccid penis examination pens, and once stiffness is established, it becomes negative 1. However, 17 additional lesions were found by ultrasound imaging.
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Closeup of shaved erect penis and scrotum. Sign in. Penis ohne Vorhaut hat eine Erektion. Smegma on an erect penis. Media in category "Close-up photographs of human penises" The following 82 files are in this category, out of 82 total. Well, you are right, the grower. Penis Files are Flaccid penis examination under licenses specified on their description page. In addition, the same factor also helps you enjoy a more flaccid penis. Erection development, male age Penile ulltrasonography is medical ultrasonography of the penis. Penis double. Human penis flaccid and erect. Namespaces Category Discussion. From Wikipedia, the free encyclopedia.
The penis spends most of its time flaccid, or soft and hanging loosely.
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Ultrasound is an excellent method for the study of penis. In this article, using a critical review of the literature and teaching files, we present examples of the major findings in the ultrasound routine, focusing on trauma, priapism, Peyronie's disease, and erectile dysfunction. Ultrasound is an imaging modality that, in addition to being well tolerated and widely available, is considered an excellent method for the evaluation of many penile diseases 1. Penile trauma, priapism, Peyronie's disease, and erectile dysfunction are some of the conditions in which penile ultrasound finds significant applicability.
Currently, linear transducers have a maximum frequency of MHz, which increases the definition on ultrasound images. Although penile evaluation is usually performed when the penis is flaccid, in some situations, such as in cases of erectile dysfunction, the examination should be performed during erection, by injection of vasoactive drugs into the corpora cavernosa 1.
The penis should be positioned in the anatomical position over the abdomen and evaluated in the transverse and longitudinal directions, from the glans toward the base of the penis 2. The corpora cavernosa are homogeneous and relatively hypoechoic cylindrical structures 2 lined with tunica albuginea, a thin membrane that has a thickness of approximately 2 mm when the penis is flaccid and 0. The corpus spongiosum, a ventral, medial body that is more echoic than the corpora cavernosa, is also covered by the tunica albuginea and contains the urethra.
As can be seen in Figures 1 and 2 , it is more dilated and prominent in its proximal segment, known as the bulb, and in its distal segment, constituting the glans 2. Buck's fascia is superficial to the tunica albuginea and covers all of the structures described. Note the corpus spongiosum asterisk adjacent to the corpora cavernosa. Note the cylindrical structure, corresponding to the corpus cavernosum thick arrow , in the superior portion and the corpus spongiosum thin arrow , adjacent to the corpus cavernosum, in the inferior portion.
Venous drainage is performed by the deep and superficial dorsal veins of the penis. The dorsal arteries of the penis are located adjacent to the deep dorsal vein and a cavernous artery is located in the center of each corpus cavernosum. On color Doppler, the cavernous arteries present single phase flow. At the beginning of erection, the systolic and diastolic flows undergo progressive increases.
When vein occlusion begins, the diastolic flow decreases progressively, and once stiffness is established, it becomes negative 1. Normal flow pattern of the cavernous artery in a flaccid penis. Penile trauma can result from a blunt or penetrating injury, the latter being rarely investigated by imaging methods, almost always requiring immediate surgical exploration 2. In the erect penis, trauma results from stretching and narrowing of the tunica albuginea, which can undergo segmental rupture of one or both of the corpora cavernosa, constituting a penile fracture.
In the ultrasound examination, a lesion of the tunica albuginea presents as an interruption in loss of continuity of the echoic line representing it Figure 4.
Small, moderate, or broad hematomas demonstrate the extent of that discontinuity 4. Intracavernous hematomas, sometimes without the presence of a tunica albuginea fracture, can be observed when there is a lesion of the smooth muscle of the trabeculae surrounding the sinusoid spaces or the subtunical venular plexus 3.
Longitudinal section showing rupture of the tunica albuginea with an adjacent 1. B: Axial T2-weighted turbo spin-echo magnetic resonance imaging scan showing left-sided discontinuity of the tunica albuginea arrow , secondary to fracture. When blood is observed in the urethral meatus, contrast-enhanced evaluation of the urethra is necessary. In cases in which the ultrasound findings are inconclusive, the use of magnetic resonance imaging can facilitate the diagnosis 4 and is recommended by various authors 3 , 4.
Priapism is defined as a painful and prolonged penile erection, with or without sexual stimulation 4. Color Doppler ultrasound is the imaging method of choice for the investigation of priapism, because it is noninvasive, widely available, and highly sensitive 4.
By means of this method, it is possible to diagnose priapism and differentiate between its low- and high-flow forms. Low-flow ischemic priapism is a urologic emergency in which there is inadequate venous drainage, resulting in hypoxia, ischemia, and tissue acidosis, which can in turn result in fibrosis and erectile dysfunction. A number of causes have been described, including sickle cell anemia most common in children , leukemia, and other blood dyscrasias such as thalassemia and multiple myeloma , and the use of various licit or illicit drugs, as well as neoplasms.
On Doppler, the flow in the cavernous arteries is reduced or absent 4. As the condition progresses, there is an increase in echogenicity of the corpora cavernosa, attributed to tissue edema. Eventually, changes in the echotexture of the corpora cavernosa can be observed due to the fibrotic transformation generated by tissue anoxia 1.
High-flow priapism is not considered an emergency, because patients are at lower risk of permanent sequelae 4. It is associated with blunt trauma to the perineum or penis, with laceration of the cavernous artery, which can generate an arterial-lacunar fistula.
In the Doppler study, one can observe normal or increased, turbulent blood flow in the cavernous arteries. The area surrounding the fistula presents a hypoechoic, irregular lesion in the cavernous tissue 4 , as depicted in Figure 5.
Peyronie's disease is characterized by fibrotic thickening of the tunica albuginea, which can lead to curvature of the penis and difficulty in achieving an erection 5. Penile fibromatosis Peyronie's disease is marked by the formation of fibrous plaques identified as areas where the tunica albuginea is thickened 1.
Although plaques are more common on the dorsum of the penis, they can also be seen on the ventral face, lateral face, or septum. The typical finding on ultrasound is hyperechoic focal thickening of the tunica albuginea. Due to associated calcifications, the imaging of patients with Peyronie's disease shows acoustic shadowing 5 , as illustrated in Figures 6 and 7.
Less common findings, attributed to earlier stages of the disease still mild fibrosis , are hypoechoic lesions with focal thickening of the paracavernous tissues, echoic focal thickening of the tunica without posterior acoustic shadowing, retractile isoechoic lesions with posterior attenuation of the beam, and focal loss of the continuity of the tunica albuginea.
In the Doppler study, increased flow around the plaques can suggest inflammatory activity and the absence of flow can suggest disease stability 6. Ultrasound is useful not only for the identification of lesions but also to determine their relationship with the neurovascular bundle 1.
Individuals with Peyronie's disease can present with erectile dysfunction, often related to venous leakage, due to insufficient drainage at the site of the plaque 5. Note the echoic image with posterior acoustic shadowing, corresponding to calcification arrow , in the left corpus cavernosum. Most cases of erectile dysfunction of organic causes are related to changes in blood flow in the corpora cavernosa, represented by occlusive artery disease, most often of atherosclerotic origin, or due to failure of the veno-occlusive mechanism 7.
Preceding the ultrasound examination with Doppler, the penis must be examined in B mode, in order to identify possible tumors, fibrotic plaques, calcifications, or hematomas, as well as to evaluate the appearance of the cavernous arteries, which can be tortuous or atheromatous. The use of prostaglandin E1 is contraindicated in patients with a predisposition to priapism e. Phentolamine 2 mg is often added. Visual and tactile stimulation produces better results 8.
Some authors recommend the use of oral medication sildenafil citrate, 50 mg to replace the injectable drug s in cases of contraindications, although the efficacy of such medication is controversial in the literature 9 , Image obtained after induction of an erection, 15 min after injection of prostaglandin E1, showing dilated sinusoids arrows. Prior to the injection of the chosen drug, the flow pattern is monophasic, with low systolic velocities and an absence of diastolic flow. After injection, it is expected that systolic and diastolic peak velocities will increase, decreasing progressively with vein occlusion and becoming negative when the penis becomes rigid Figure 9.
The data obtained should be correlated with the degree of erection observed. A: Single-phase flow with minimal or absent diastole when the penis is flaccid. B: Increased systolic and diastolic flow 10 min after vasoactive drug injection. C: Increased systolic flow and reverse diastole 25 min after injection of prostaglandin. Flow of the cavernous arteries at 5, 15, and 25 min after prostaglandin injection A , B , and C , respectively.
Ultrasound is a quite useful method, both for its availability and efficacy in penile evaluation: in terms of diagnosis, as in the case of penile fracture and Peyronie's disease; and in the identification of etiological factors, as in cases of priapism and erectile dysfunction. The knowledge of how to differentiate between normal and pathological aspects of the penis, as well as of how to manage Doppler techniques for this purpose, is extremely important for diagnosis and patient management.
Painful penile induration: imaging findings and management. Imaging of penile and scrotal emergencies. Sonographic evaluation of penile trauma. J Ultrasound Med. Color Doppler imaging of posttraumatic priapism before and after selective embolization. New sonographic aspects of Peyronie disease. US imaging in Peyronie's disease.
J Clin Imaging Sci. Penile duplex sonography in the diagnosis of venogenic impotence. J Vasc Surg. Ultrasound evaluation of the penis for assessment of impotence. J Clin Ultrasound.
A classification based in peak systolic velocity and diastolic velocity predict sindenafil citrate success. Scan J Urol Nephrol. Sildenafil citrate for penile hemodynamic determination: an alternative to intracavernosal agents in Doppler ultrasound evaluation of erectile dysfunction.
Colour Doppler ultrasound of the penis. Clin Radiol. Mailing address: Dr. Luis Ronan Marquez Ferreira de Souza.
Uberaba, MG, Brazil, E-mail: luisronan gmail. This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Services on Demand Journal. Pictorial Essay Ultrasound evaluation of the penis. Abstract Ultrasound is an excellent method for the study of penis. Received: August 21, ; Accepted: November 25, How to cite this article.
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The datasets used and analyzed during the current study are available from the corresponding author on reasonable request. Email: wangw73 mail. This prospective study is to evaluate the potential value of sonographic measurements in the flaccid penis for the screening of arteriogenic impotence.
A consecutive series of Chinese males consulting for sexual dysfunction and 54 controls underwent sonographic examination. The sonographic parameters were correlated with the clinical gold standards, including the international index of erectile function IIEF and penile erectile hardness grading scale EHGS.
The sensitivity, specificity, positive predictive value PPV , negative predictive value NPV and area under the receiver operating characteristic curve AUROC of flaccid peak systolic velocity PSV in predicting patients with normal function were analyzed. The mean cavernous PSV of both sides in the patients with sexual dysfunction ranged from 7. This simple flaccid PSV measurement is a specific tool for screening arteriogenic impotence.
In addition to psychological and metabolic factors and relational problems, arteriogenic causes play important roles in erectile dysfunction [ 2 — 4 ]. Changes in any one of these factors may result in ED. For diagnosis of arteriogenic causes, color Doppler ultrasound is one of the most noninvasive, simple and promising tools [ 1 — 3 , 5 — 8 ].
The peak systolic velocity PSV of the cavernous artery measured after the intra-cavernous injection ICI of vasoactive agents is a widely accepted criterion for evaluating penile circulation [ 2 , 6 ]. However, the clinical adaptability of this method is relatively limited because of the time consuming, lack of standardization, and side effects due to vasoactive agents [ 2 ].
Currently, a growing number of male are anxious about their sexual lives. A simple parameter for evaluating penile arteriogenic health, with limited costs in terms of time and money and without the inconvenience of priapism, is an ideal goal. Doppler investigation in the flaccid state would avoid these disadvantages.
It has been reported that PSV values that were measured in the flaccid state show a significant correlation with post-ICI PSV and might be predictive in the determination of arterial insufficiency [ 2 , 7 , 9 ]. However, these studies all used the PSV measured in the flaccid state as an additional tool to evaluate penile circulation.
In our opinion, the evaluation of PSV in the flaccid penis alone for screening arteriogenic impotence remains underestimated. In this prospective study, we tried to evaluate the potential value of ultrasound US parameters measured in the flaccid state for the diagnosis of arteriogenic impotence, correlated with the international index of erectile function IIEF and penile erectile hardness grading scale EHGS [ 10 — 12 ].
This prospective study was approved by the research ethics board of our institution, and informed consent was obtained. From October to October , a consecutive series of Chinese male patients consulting for sexual dysfunction were referred. Among them, 6 patients declined the US examination. The remaining eligible patients underwent color Doppler sonographic examination.
Fifty-four healthy adult volunteers who did not have a history of sexual dysfunction were examined by US and served as a control group for which the same US parameters were obtained. No volunteers had taken any medication or drugs at the time of the US examination.
The mean ages of the two groups were To ensure patient privacy, all exams were performed in a quiet, comfortable room. Excessive compression with the transducer was avoided. First, in grayscale US, the penis was evaluated in both the longitudinal and transverse planes in the flaccid state. Then, color Doppler sonography was optimized to obtain the best longitudinal plane of the cavernosal arteries. In this longitudinal plane, spectral analysis of the cavernosal arteries was performed in the proximal part of the penis.
The optimal site for spectral analysis was the proximal part of the cavernosal arteries where the vessels curved. When analyzing the spectral Doppler, the optimized pulse repetition frequency and wall filter were selected, and the width of the Doppler sample size was set at 0. Three consecutive similar waveforms were considered to constitute a satisfactory test.
The IIEF-5, a 5-item questionnaire, is used for clinical diagnosis of the severity of ED, including scores on the 5-item form that is, Erection confidence, Penetration ability, Maintenance frequency, Maintenance ability, Intercourse satisfaction [ 12 ]. These items focus on erectile function and intercourse satisfaction. It is a convenient, four-grade scale for ED that provides a reliable measure of the degree and duration of penile rigidity, according to data reported at the European Association of Urology.
The sensitivity, specificity, accuracy, positive predictive value PPV and negative predictive value NPV were calculated. Figures were drawn using the Origin 8. The mean PSVs of both sides in the patients consulting for sexual dysfunction ranged from 7. Box plots show the range between the 25 th and 75th percentiles box , mean small square in the box , median horizontal line in the box , and outliers whiskers of flaccid cavernous PSV.
Box plots show the range between the 25th and 75th percentiles box , mean small square in the box , median horizontal line in the box , and outliers whiskers of flaccid cavernous PSV.
This study was performed to determine the potential value of sonographic measurements in the flaccid penis for diagnosing arteriogenic impotence. The optimal cutoff for PSV is 8. The incidence of ED in adults is rapidly increasing [ 13 ]. Although there are complicating factors, arteriogenic impotence is among the most important cause of erectile dysfunction [ 14 — 16 ]. Color Doppler sonographic examination is a noteworthy diagnostic tool for detecting failure of the penile arterial supply [ 2 , 5 ].
For patients consulting for sexual dysfunction, the most commonly used evaluation is Doppler investigation in conjunction with ICI of vasoactive substances. Meanwhile, Doppler investigation after ICI is a time-consuming technique.
Psychological inhibition and anxiety during ICI may disturb the assessment of arterial supply [ 1 ]. Kahvecioglu et al. Furthermore, Corona et al. Furthermore, the utility of flaccid PSV alone had not been sufficiently studied.
Considering the patients consulting for sexual dysfunction and the controls as a whole, the ROC curve indicated that a threshold of 8. The findings of the current study indicated that when the PSV cutoff was set at 8. We believe that this finding is of interest because a PSV of 8. In this study, our data showed that the flaccid penile US evaluation has the potential to become a specific tool to diagnose arteriogenic impotence. Nonetheless, many other factors regulate sexual function in ED patients, which may explain the low sensitivity and NPV in this study.
One limitation of our study is that we did not include post-ICI PSV as a reference standard because of the complexity and invasiveness. We intended to explore the clinical importance of flaccid PSV for screening for arteriogenic impotence. Second, the mean age of the patients in our study was lower than the general mean age of patients with ED, which might be due to selection bias.
We infer that those men are in an active stage of their sexual life with higher expectations. Thus, they were more likely to seek help from doctors when they were included in our study. The best flaccid PSV cutoff value was 8. This easily performed method has the potential to become a specific tool in screening for arteriogenic impotence. All authors read and approved the final manuscript. All participants signed written informed consent.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Li-Da Chen, Phone: , Email: nc. Wei Wang, Phone: , Email: nc. National Center for Biotechnology Information , U. BMC Med Imaging. Published online Nov 6. Author information Article notes Copyright and License information Disclaimer. Corresponding author. Received Mar 2; Accepted Oct Associated Data Data Availability Statement The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.
Abstract Background This prospective study is to evaluate the potential value of sonographic measurements in the flaccid penis for the screening of arteriogenic impotence. Methods A consecutive series of Chinese males consulting for sexual dysfunction and 54 controls underwent sonographic examination. Results The mean cavernous PSV of both sides in the patients with sexual dysfunction ranged from 7.
Conclusions This simple flaccid PSV measurement is a specific tool for screening arteriogenic impotence. Keywords: Erectile dysfunction, Ultrasound, Peak systolic velocity, Receiver operating characteristic, International index of erectile function, Erectile hardness grading scale. Methods Patients population This prospective study was approved by the research ethics board of our institution, and informed consent was obtained. Parameters No. Open in a separate window. Discussion This study was performed to determine the potential value of sonographic measurements in the flaccid penis for diagnosing arteriogenic impotence.
Acknowledgements Not applicable. Availability of data and materials The datasets used and analyzed during the current study are available from the corresponding author on reasonable request. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. References 1. Non-invasive detection of endothelial dysfunction in children and adults at risk of atherosclerosis.
Penile doppler ultrasound in patients with erectile dysfunction ED : role of peak systolic velocity measured in the flaccid state in predicting arteriogenic ED and silent coronary artery disease. J Sex Med. Cavernous artery intima-media thickness: a new parameter in the diagnosis of vascular erectile dysfunction.
Assessment of the relational factor in male patients consulting for sexual dysfunction: the concept of couple sexual dysfunction. J Androl. Duplex Doppler sonography of the flaccid penis: potential role in the evaluation of impotence.