ALGORITHMIC IMAGING APPROACH TO IMPOTENCE

Impotence is a common problem that has great impact on the quality of life. Clinical evaluation usually can exclude endocrinologic imbalance, neurogenic dysfunction, and psychological problems as the etiology. A patient who fails to get an erection after vasoactive medications which are injected probably, has hemodynamic impotence. Dynamic studies that include imaging techniques are now available to discriminate between arterial and venous pathology.Doppler ultrasound with color flow and spectral analysis,dynamic infusion corpus cavernosometry and cavernosography, and selective internal pudendal arteriography are outpatient diagnostic procedures that will differentiate, image and quantify the abnormalities in patients with hemodynamic impotence. Not all tests are needed in every patient. Each of these examinations is preceded with the intracavernosal injection of vasoactive medication. Papaverine hydrochloride, phentolamine mesylate, or prostaglandin El will overcome normal sympathetic tone and produce an erection by smooth muscle relaxation and arterial dilatation in a normal patient. Color-flow Doppler and spectral analysis will showthe cavernosal arteries and can identify the hemodynamic effects of stricture or occlusion. Peak systolic velocity is measured. Normal ranges are well established. Spectral analysis also is used to predict the presence of venous disease. Sizable venous leaks in the dorsal penile vein are readily imaged.While the technique may not adequately identify low-grade venous pathology, it will identify the size and location of fibrous plaque formation associated with Peyronie's disease. Cavernosography or cavernosometry is a separate procedure that will quantitate the severity of venousincompetence as well as specifically identify the various avenues of systemic venous return that must be localized if venous occlusive therapy is chosen. In this study, the peak arterial systolic occlusion pressure is quantified during erection,and the presence of arterial pathology can be confirmed.The arterial data are not as reliable as the ultrasound-obtained data because they rely on audible Doppler, which can be obscured in the underlying "noise" heard with erection. The arterial data obtained with both of these examinations are quantitative and replace the qualitative audible Doppler used previously. Specialized equipment allows dynamic data acquisition, ensuring that the needed information is obtained at peak stimulation.Arteriography is done only if reconstructive surgery is contemplated. The examination includes subselective catheterization