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Stiffness of the Central Corpus Cavernosum on Shear-Wave Elastography Is Inversely Correlated with the Penile Rigidity Score in Patients with Erectile Dysfunction

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Stiffness of the Central Corpus Cavernosum on Shear-Wave Elastography Is Inversely Correlated with the Penile Rigidity Score in Patients with Erectile Dysfunction Original Article Male sexual health and dysfunction pISSN: 2287-4208 / eISSN: 2287-4690 World J Mens Health 2021 Jan 39(1): 123-130 https://doi.org/10.5534/wjmh.190094 Stiffness of the Central Corpus Cavernosum on Shear-Wave Elastography Is Inversely Correlated with the Penile Rigidity Score in Patients with Erectile Dysfunction Joo Yong Lee1 , Dae Chul Jung2 , Seungsoo Lee2 , Nam Gyu Kang2,3 , Young Taik Oh2 , Kyunghwa Han2 1Department of Urology, Yonsei Severance Hospital, Urological Science Institute, Yonsei University College of Medicine, 2Department of Radiology, Yonsei Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, 3Korea & Armed Forces Capital Hospital, Seongnam, Korea Purpose: To perform real-time quantitative measurements of penile rigidity for patients with erectile dysfunction (ED) using shear-wave elastography (SWE). Materials and Methods: A total of 92 patients with clinically diagnosed ED filled out an abridged five-item version of the In- ternational Index of Erectile Function (IIEF-5) questionnaire and underwent SWE as well as penile color Doppler ultrasound (CDUS) after intracavernosal injection for penile erection. Elasticity measurements were repeated on two sites of the corpus cavernosum (central and peripheral elasticity of corpus cavernosum [ECC]) and the glans penis during the erection phase. Correlations between penile elasticity and rigidity scores or IIEF-5 were evaluated statistically. Penile elasticity was also com- pared with the ED types based on CDUS. Results: The mean age of all patients was 53.5±13.4 years, and the mean IIEF-5 score was 9.78±5.01. The rigidity score and central ECC value demonstrated a significant correlation (r=-0.272; 95% confidence interval: -0.464 to -0.056; p=0.015). The IIEF-5 score was not significantly correlated with penile elasticity. Vascular ED patients showed significantly higher cen- tral ECC values than nonvascular ED patients (p<0.001). At a cut-off value of 8.05 kPa, the central ECC had a specificity of 41.5%, a sensitivity of 84.6%, and an area under the ROC curve of 0.720 with a standard error of 0.059 (p=0.019) for pre- dicting vascular ED. Conclusions: Quantitatively measuring Young’s modulus of the corpus cavernosum using SWE could be an objective tech- nique for assessing penile erectile rigidity and the vascular subtype in patients with ED. Keywords: Elastography; Erectile dysfunction; Penis; Ultrasonography This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. INTRODUCTION problems among men worldwide. The global prevalence of ED is predicted to increase rapidly due to population Erectile dysfunction (ED) is one of the most common aging [1-3]. ED is frequently associated with cardio- Received: Jul 5, 2019 Revised: Nov 1, 2019 Accepted: Dec 10, 2019 Published online Jan 9, 2020 Correspondence to: Dae Chul Jung https://orcid.org/0000-0001-5769-5083 Department of Radiology, Yonsei Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea. Tel: +82-2-2228-7400, Fax: +82-2-2227-8337, E-mail: [email protected] Copyright © 2021 Korean Society for Sexual Medicine and Andrology https://doi.org/10.5534/wjmh.190094 vascular diseases [4]. The epidemiological correlation SWE has been used to examine several organs and between vasculogenic ED and cardiovascular risk has pathologies, yielding effective outcomes for breast, thy- already been confirmed in previous studies [5-8]. Penile roid, prostate, and liver diseases [16,17]. SWE is thought erection rigidity is an important index in the diagnosis to be a promising candidate for the noninvasive evalu- and treatment monitoring of ED patients because a ation of the stiffness of cavernosal tissues, including penile erection needs to reach and maintain sufficient penile rigidity. To the best of our knowledge, no study rigidity for completing sexual intercourse. Special has reported the effectiveness of SWE compared with equipment for measuring penile erection rigidity in CDUS for predicting penile rigidity in patients with clinical setting is limited due to disadvantages associ- ED or for assessing ED. Thus, the objective of this ated with availability, cost, and discomfort for both study was to perform real-time quantitative measure- the patient and operator [9-12]. Therefore, patients are ments of penile rigidity for ED patients using penile stratified initially and then monitored after treatment SWE. according to self-reported scores from the visual ana- logue scale (VAS) of penile rigidity as well as from an MATERIALS AND METHODS abridged five-item version of the International Index of Erectile Function (IIEF-5) questionnaire, which is 1. Ethics statement considered a valid diagnostic tool. However, since these The present study protocol was reviewed and ap- scoring systems have limitations in that they are based proved by the Institutional Review Board (IRB) of on subjectively self-reported data from patients in Yonsei University Health System, Yonsei Severance questionnaires, a more easily performed and objective Hospital (Reg. No. 4-2018-1048). The IRB waived the re- diagnostic process for evaluating penile rigidity in ED quirement of informed consent. patients that can supplement physical examinations and the patient’s history is needed [13]. 2. Patient selection Penile ultrasonography (USG) is a high-performing Between January 2014 and March 2018, we reviewed noninvasive imaging modality. USG reveals the inter- the clinical data of consecutive patients with ED as nal anatomy and gross pathological changes in real their primary complaint at a Severance Hospital of the time. Additionally, temporal changes in penile blood urology department. These subjects met the following flow, as observed in vasculogenic ED, can be analyzed inclusion criteria: (a) patients with ED were at least with color Doppler ultrasound (CDUS) [14]. A recently 18 years old; (b) patients were invited to complete the developed technique, namely, shear-wave elastography IIEF-5 at the time of their first assessment of ED [18]; (SWE), has been widely used for measuring the stiff- and (c) patients underwent penile CDUS and SWE ness of target soft tissues and organs [15]. Such elastog- after intracavernosal injection to induce penile erec- raphy can be used to calculate Young’s modulus of the tion (Fig. 1). The severity of ED was interpreted using living tissue, which is directly related to its stiffness. published criteria [19]. Based on the Korean version of 113 Consecutive patients with ED as chief complaints Exclusion (n): total6patients No IIEF-5:6patients 107 Patients: IIEF-5 Exclusion (n): total 15 patients No CDUS:0patient No SWE: 15 patients 92 Patients: CDUS with Fig. 1. Flow diagram showing patient ECC measurement selection. ED: erectile dysfunction, IIEF- 5: abridged five-item version of the Inter national Index of Erectile Function, CDUS: color Doppler ultrasound, SWE: Vasculogenic ED: 56 Non-vascular ED: 36 shear-wave elastography, ECC: elasticity of corpus cavernosum. 124 www.wjmh.org Joo Yong Lee, et al: Stiffness of the Corpus Cavernosum vs. Penile Rigidity the IIEF-5 [20], we stratified patients into the following from the cavernosal artery-centered circular region four groups: normal, more than 18 points; mild, 14 to 17 of interest (ROI) with a 4.0-mm diameter, which was points; moderate, 10 to 13 points; and severe, less than 9 placed less than 2 cm in depth on each side of the cor- points. pus cavernosum (CC), namely, the central elasticity of corpus cavernosum (ECC) (Fig. 2). In addition, repeated 3. Ultrasonography technique measurements were performed with the same sized Penile USG was performed by a radiologist with 15 ROI at the peripheral portion of the CC near the tu- years of experience with a high-frequency linear trans- nica albuginea, namely, the peripheral ECC. Finally, ducer (12–15 MHz) of an Aixplorer ultrasound system we measured Young’s modulus by SWE at the glans (SuperSonic Imagine SA, Aix-en-Provence, France) for penis (elasticity of glans penis on SWE, EG). At least all patients. Penile scans were performed on the ven- three valid measurements were obtained for each ROI tral surface using longitudinal and transverse views position on both sides of the cavernosum and glans. for patients in the supine position. Grayscale sonogra- All measurements were performed repeatedly at 10 phy and CDUS were performed for evaluating anatom- to 20 minutes after intracavernosal injection. These ical structure of the penis and penile vessels in flaccid measurements were recorded in kilopascals (kPa). The state. A mixture of agents such as papaverine, phentol- mean value of these measurements was used for sta- amine, and prostaglandin E1 (STANDRO®; Shinpoong tistical analysis. Minimal compression was given to Pharm. Co., Seoul, Korea) was injected into the lateral obtain the grayscale. SWE images were obtained with aspect of the mid-shaft of the penis after evaluating the goal of achieving identical images for all patients. the flaccid state. After grayscale sonographic evalua- In addition, CDUS was simultaneously conducted. Af- tions with a similar method to that described for the ter intracavernosal injection, spectral sampling of the flaccid state, we switched to SWE mode. cavernosal artery was performed at the penile root Elasticity measurements were repeated in the trans- under guidance of a colored Doppler signal. The peak verse plane from the mid-shaft and glans of penis systolic velocity and end diastolic velocity of the cav- every 5 minutes from 5 minutes beginning at 5 min- ernosal artery were measured with angle correction. utes after injection. The first measurement was made Previously published CDUS criteria for diagnosing >50 kPa 0.0 40 30 1.0 20 10 2.0 Q-Box Mean 2.3 kPa Min 0.3 kPa 3.0 Max 3.8 kPa SD 0.7 kPa Mean 0.9 m/s Min 0.3 m/s Max 1.1 m/s SD 0.2 m/s Depth 1.1 cm 1.0 Diam 4.00 mm Fig.
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