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Penile Ultrasound

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Practical Urological Ultrasound

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Abstract

Penile ultrasound is frequently used in the diagnostic evaluation of a patient with erectile dysfunction (ED). However, it also plays an important role in penile assessment by providing an anatomic and functional vascular assessment in a multitude of other conditions, including Peyronie’s disease, high-flow priapism, penile fracture, penile urethral strictures, urethral stones, urethral diverticula, or masses involving deep tissues of the penis. This imaging modality, which incorporates real-time imaging of the vasculature, vessel wall compliance, and blood flow dynamics in an end-organ small-vessel arterial system, also plays a central role in the early detection and diagnosis of small-vessel disease. Penile ultrasound, thus, provides a readily available, minimally invasive diagnostic modality that evaluates both the structural anatomy and functional hemodynamics at a reasonable cost.

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Notes

  1. 1.

    An initial injection of 0.05 cc of a Trimix solution (10 mcg/ml alprostadil, 30 mg/ml of papaverine, and 1 mg/ml of phentolamine) is given. Then every 10 minutes if the erection is not maximal in tumescence and rigidity, we give an additional amount equal to the sum of the last injections (i.e., at 10 minutes an additional 0.05 cc, at 20 minutes an additional 0.1 cc, and at 30 minutes an additional 0.2 cc). Therefore, the maximum amount we give of the Trimix is 0.4 cc, and the maximum time for the study is 40 minutes.

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Author information

Authors and Affiliations

  1. The Smith Institute for Urology, Zucker School of Medicine of Hofstra/Northwell, New Hyde Park, NY, USA

    Andrew Ng

  2. Zucker School of Medicine of Hofstra/Northwell, The Arthur Smith Institute for Urology, New Hyde Park, NY, USA

    Bruce R. Gilbert

  3. Department of Surgery, Banner Desert Medical Center, Arizona State Urological Institute, Chandler, AZ, USA

    Gideon Richards

Authors
  1. Andrew Ng
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  2. Gideon Richards
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  3. Bruce R. Gilbert
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Corresponding author

Correspondence to Bruce R. Gilbert .

Editor information

Editors and Affiliations

  1. Department of Urology, Texas Health Presbyterian Hospital of Dallas, Dallas, TX, USA

    Pat F. Fulgham

  2. Zucker School of Medicine of Hofstra/Northwell, The Arthur Smith Institute for Urology, New Hyde Park, NY, USA

    Bruce R. Gilbert

Appendices

Appendix 1: Suggested Protocol for Evaluation of Erectile Dysfunction

Dorsal view is primary, ventral view as needed (indicate which view is used on image)

Preinjection (also images for noninjection penile ultrasound studies)

  1. 1.

    Longitudinal and transverse survey scan of the phallus with cine loops

  2. 2.

    Split screen base, mid and distal view of phallus in transverse plane

  3. 3.

    Split screen longitudinal view of left and right corpora cavernosa

  4. 4.

    Flaccid phallus (image taken in mid 2/3 of exposed phallus):

    1. (a)

      AP and width of each corpora

    2. (b)

      Inner diameter measurements of left and right cavernosal artery at mid phallus

    3. (c)

      Spectral Doppler waveform with PSV, EDV, and RI

    4. (d)

      Optional measurements: acceleration time, pulsatility index, and velocity index

PostinjectionFootnote 1

  1. 1.

    5 and 10 minutes

    1. (a)

      Spectral Doppler waveform with PSV, EDV, and RI

    2. (b)

      Inner diameter measurements of left and right cavernosal artery at mid phallus

    3. (c)

      Optional measurements: acceleration time, pulsatility index, and velocity index

    4. (d)

      Subjective evaluation of tumescence and rigidity

  2. 2.

    15 and 20 minutes (second injection if indicated, document total dose)

    1. (a)

      Spectral Doppler waveform with PSV, EDV, and RI.

    2. (b)

      Inner diameter measurements of left and right cavernosal artery at mid phallus

    3. (c)

      Optional measurements: acceleration time, pulsatility index, and velocity index

    4. (d)

      Subjective evaluation of tumescence and rigidity

  3. 3.

    25 and 30 minutes (third injection if indicated, document total dose)

    1. (a)

      Spectral Doppler waveform with PSV, EDV, and RI

    2. (b)

      Inner diameter measurements of left and right cavernosal artery at mid phallus

    3. (c)

      Optional measurements: acceleration time, pulsatility index, and velocity index

    4. (d)

      Subjective evaluation of tumescence and rigidity

  4. 4.

    End of study

    1. (a)

      Inner diameter measurements of left and right cavernosal artery and mid phallus

Subjective evaluation of tumescence and rigidity

Appendix 2: Patient Instructions for Penile Injection Therapy

I. Preparation for Injection

Items You Will Need

  • Alcohol sponges or swaps.

  • 1 mL insulin syringe with #28 or #30 gauge needle. These are disposable and not to be reused for a second injection. Disposal should be performed with the cap on the needle so as not to injure anyone disposing of trash.

  • Papaverine/phentomlamine combination, prostaglandin E1 or papaverine/phentolamine/prostaglandin combination either pre-drawn by the physician or pharmacist into the syringe, or in a vial to be drawn into the syringe by the patient in the appropriate volume as prescribed by the physician. The medication must be refrigerated and away from light exposure.

Filling the syringe:

  1. 1.

    Check the expiration date of medication. Hold the medication bottle so that your fingers do not touch the rub or stopper.

figure a
  1. 2.

    Using a circular motion, wipe off the top of the bottle with alcohol swab.

figure b
  1. 3.

    Remove the needle cover. Do not allow the needle to touch anything before drawing the medication or before injecting the medication.

figure c
  1. 4.

    Draw a small amount of air into the syringe. The amount of air should be equal to the volume of medication that will be next drawn into the syringe. This action is to prevent a vacuum from forming in the vial making drawing medication into the syringe difficult.

figure d
  1. 5.

    Turn the bottle and syringe upside down. Solely draw the medication into the syringe. Tap the syringe gently to remove the bubbles.

figure e
  1. 6.

    Move the plunger in and out several times while gently tapping the syringe, just removing all air bubbles.

figure f
  1. 7.

    Gently remove the needle from the bottle and carefully replace the needle protective cap. Place the filled syringe within easy reach prior to injection.

figure g

II. Self-injection Technique

  • Step 1 Grasp the head of the penis, not the skin, and hold upward toward the trunk. Position the penis along your inner thigh. Choose the injection site on the side of the penis. Avoid injecting into any visible veins. The crossed hatched areas in the figure below represent the ideal locations to inject into.

figure h

  • Step 2 Wipe the skin with an alcohol swab.

figure i

  • Step 3 Pick up the syringe between the thumb and middle finger, like a pen, and push the needle gently but firmly through the skin until the entire need is buried inside the penis.

figure j

  • Step 4 Holding the syringe and use your thumb to slowly (8–10 s) inject the entire amount of medication. Then remove the needle from your penis.

figure k

  • Step 5 Immediately apply pressure on the injection site with another alcohol wipe for at least 2 minutes. Make sure there is no bleeding.

figure l

  • Step 6 Dispose of the syringe unit into the puncture-proof receptacle provided.

  • Step 7 Stand up to allow your erection to develop quickly. You are now ready to start sexual foreplay. You will have a full erection within a few minutes.

  • Normally, the erection will last anywhere from 30 to 120 minutes. If your erection lasts longer than 3 hours, you should seek immediate medical attention.

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Ng, A., Richards, G., Gilbert, B.R. (2021). Penile Ultrasound. In: Fulgham, P.F., Gilbert, B.R. (eds) Practical Urological Ultrasound. Springer, Cham. https://doi.org/10.1007/978-3-030-52309-1_7

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  • Online ISBN: 978-3-030-52309-1

  • eBook Packages: MedicineMedicine (R0)

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