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Pharmaco-Induced Erections for Penile Color-Duplex Ultrasound: Oral PDE5 Inhibitors Or Intracavernosal Injection?

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Pharmaco-Induced Erections for Penile Color-Duplex Ultrasound: Oral PDE5 Inhibitors Or Intracavernosal Injection? International Journal of Impotence Research (2012) 24, 191 -- 195 & 2012 Macmillan Publishers Limited All rights reserved 0955-9930/12 www.nature.com/ijir ORIGINAL ARTICLE Pharmaco-induced erections for penile color-duplex ultrasound: oral PDE5 inhibitors or intracavernosal injection? Y Yang1,2, J-l Hu1,2,4,YMa1,2, H-x Wang1,2, Z Chen3, J-g Xia3, Y-x Wang1,2, Y-r Huang1,2 and B Chen1,2 To prospectively compare the clinical responses and penile color-duplex ultrasound (PCDU) results of oral PDE5 inhibitors (PDE5-Is) with papaverine intracavernosal injection (ICI) and to evaluate whether PDE5-Is could be used as alternatives to vasoactive agent injections, 25 ED patients underwent PCDU three times with an interval of at least 1 week, using different pharmacological induction: ICI mode (30--60 mg papaverine), sildenafil mode (100 mg sildenafil) and tadalafil mode (20 mg tadalafil). The preference of the patients was collected when all tests were completed. No significant differences were found in peak systolic velocity and acceleration time among all three modes. However for the ICI mode, end diastolic velocity of the right cavernosal artery was significantly higher than those of the sildenafil and tadalafil modes 5 min after erection induction, and at 15 min it became lower than those of two PDE5-I modes. Consequently, resistance index of the right cavernosal artery in ICI mode was reversed at 5 and 15 min. In all, 60.0 and 56.0% patients managed to reach full erection in PDE5-Is modes, which was significantly lower than in ICI mode (80.0%). Therefore, although PDE5-Is and papaverine ICI showed similar effects on PCDU parameters in detecting arterial ED, more patients had better clinical responses to ICI, and oral PDE5-Is administration still showed some pitfalls in practical use. International Journal of Impotence Research (2012) 24, 191--195; doi:10.1038/ijir.2012.15; published online 17 May 2012 Keywords: erectile dysfunction; penile color-duplex ultrasound; sildenafil; tadalafil; intracavernosal injection INTRODUCTION Therefore, the purpose of our study was to prospectively ED has been defined as the persistent inability to attain and evaluate and compare the clinical responses and PCDU results of maintain an erection sufficient to permit satisfactory sexual oral administration of sildenafil (100 mg) and tadalafil (20 mg) with performance.1 It has been suggested that ED may be considered papaverine ICI and to evaluate whether these PDE5-Is could be as a clinical manifestation of a generalized vascular disease used as alternatives to vasoactive agent injections. Also, the also affecting the penile arteries.2 Among all the etiological differences between these two PDE5-Is were elaborated. factors, it was reported that around 30--50% of ED cases are vasculogenic in origin.3,4 Intracavernosal injection (ICI) of vasoac- tive agents plus penile color-duplex ultrasound (PCDU) have been regarded as the most reliable and least invasive evidence-based PATIENTS AND METHODS assessment of ED5 since Lue introduced this method in 1985.6 Patients Although ICI is an important method for assessing penile A total of 25 consecutive patients (age range from 27 to 61 years old, mean hemodynamics, patients’ fear of injection often produces a 37.3±10.1) were randomly selected from our andrological outpatient heightened sympathetic response, which inhibits the response department. All the patients enrolled were naive about both the PDE5-I and of the cavernous smooth muscle to intracavernous agents. This the ICI approach. All the patients had at least a 3-month history of ED and may produce a false-positive result.7 In addition, erection were excluded from the study if their International Index of Erectile induction with vasoactive agents results in several complications, Function-5 (IIEF-5) scores were 421 or if they had any ICI and PDE5-I from the common (pain, ecchymosis and penile hematoma) to the contraindications such as poor cardiac performance, severe ischemia, most serious (priapism) in up to 7% of cases.5 On the other hand, coagulation defects, recent myocardial infarction and nitrates or nitric oxide PDE5 inhibitors (PDE5-Is), including sildenafil, tadalafil and donors taken in any form either regularly or intermittently. The patients vardenafil, have become the first-line drug therapies for the underwent complete diagnostic evaluations, including detailed medical treatment of ED.8 As PDE5-Is are safe, noninvasive and effective in and sexual history, physical examination, biochemical (fasting glucose, 70--80% cases of ED from various causes, there have been studies serum cholesterol, triglycerides, low- and high-density lipoprotein) and concerning the application of PDE-Is in PCDU tests, more hormonal testings (prolactin and total testosterone). Psychological tests specifically, using PDE5-Is as alternatives to vasoactive agent (self-rating anxiety scale (SAS) and self-rating depression scale (SDS)) injections. However, the results remain controversial.9,10 Moreover, and nocturnal penile tumescence assessment were also performed to studies have focused on sildenafil11 and vardenafil.12 determine the psychological status of patients and etiology of ED. The 1Department of Urology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China, 2Shanghai Institute of Andrology, Shanghai Jiaotong University School of Medicine, Shanghai, China and 3Department of Ultrasonography, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China. Correspondence: Professor B Chen, Department of Urology, Renji Hospital, Shanghai Jiaotong University School of Medicine. 7th Floor, No. 1 building, No. 145, Middle Shandong Road, Shanghai 200001, China. E-mail: [email protected] 4Current address: Department of Anaesthesiology, Shanghai First People’s Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China. Received 27 May 2011; revised 24 February 2012; accepted 10 April 2012; published online 17 May 2012 For penile color-duplex ultrasound: oral PDE5 inhibitor or ICI? Y Yang et al 192 Institutional Review Board of Renji hospital approved the study, and written Table 1. Characteristics of participants informed consents were obtained from all the study patients. Age (years) 37.3±10.1 Under 30 24% (6/25) Erection induction and ultrasonography 30--50 60% (15/25) Above 50 16% (4/25) A MyLab 90 Doppler ultrasound diagnostic apparatus (Esaote, Genoa, Italy) and a 10-MHz linear array transducer were used for obtaining real-time Morbidities (%) images of the corpora cavernosa and for visualization and Doppler Hypertension 12% (3/25) calculations of the blood flow in the cavernous arteries. Patients were Diabetes mellitus 16% (4/25) examined in a quiet, dim room in supine position, with the penis slightly Current smokers 32% (8/25) stretched to the abdomen. The transducer was placed on the ventral Cardiovascular diseases 0% (0/25) penile surface and the cavernous arteries were examined at the Genital malformation 0% (0/25) penoscrotal junction. The Doppler angle was maintained at 601.Peak Low testicular volume 0% (0/25) systolic velocity (PSV), end diastolic velocity (EDV), resistance index (RI) IIEF-5 score 10.0±4.1 and acceleration time (AT) of bilateral cavernous arteries were recorded. SAS-scaled score 40.8±10.2 Clinical responses of pharmaco-induced erections were also assessed Anxiety 24.0% (6/25) and recorded. SDS-scaled score 0.45±0.12 All the patients underwent clinical response and PCDU tests before and Depression 28.0% (7/25) after three modes of pharmacologic stimulus, which are described in detail Total testosterone (ng mlÀ1) 4.81±1.72 as follows: Hypogonadism 8.0% (2/25) À1 ICI mode: Patients underwent an ICI treatment with papaverine Fasting glucose (mmol l ) 5.86±1.71 30--60 mg. An audiovisual sexual stimulus (AVSS) was given to promote Glycemia 28.0% (7/25) À1 ± penile erection as soon as the injection was given. Total cholesterol (mmol l ) 4.79 0.88 Triglycerides (mmol lÀ1) 1.41±0.72 Sildenafil mode: Patients were asked to take sildenafil 100 mg 1 h before 1 HDL (mmol lÀ ) 1.42±0.30 PCDU. An AVSS was given 15 min before the test, accompanied by self- LDL (mmol lÀ1) 2.97±0.71 genital stimulation. Hyperlipoidemia 44.0% (11/25) Tadalafil mode: Patients were asked to take tadalafil 20 mg 2 h before PCDU. Also, an AVSS and self-genital stimulation were performed 15 min Abbreviations: HDL, high-density lipoprotein; LDL, low-density lipoprotein; before the test. SAS, self-rating anxiety scale; SDS, self-rating depression scale. Data are expressed as mean±s.d. Hyperlipoidemia refers to total PCDU tests were performed at 5 and 15 min after the injection (ICI cholesterol, triglycerides or LDL higher than normal value. Hypogonadism mode) or AVSS (sildenafil and tadalafil modes). refers to serum total testosterone lower than normal value. Anxiety refers to Every patient underwent these three different modes with a washout SAS-scaled score over 50 and depression refers to SDS-scaled score over 0.5. period of at least 1 week between each mode. The sequence of the modes was determined by a random number table generated by a Visual Basic program (version 8.0, Microsoft, Redmond, WA, USA). Upon completion, patients were asked to fill in a self-made questionnaire about their Table 2. PCDU parameters measured 5 min after erection induction preferences of these modes. The questionnaire contained the following with three modes single-choice questions and options: (1) Which mode do you like the best before the ultrasound test? (a) Blue pills only; (b) Injection only; (c) Yellow ICI mode Sildenafil mode Tadalafil mode pills only. (2) The reasons why you choose this mode are: (a) Adequate hardness; (b) Painless; (c) Quick response; (d) Naturalness; (e) Others PSV (cm sÀ1) specify here. Right side 48.5±16.0 50.5±14.2 47.0±18.0 All the PCDU tests were done by the same experienced sonographer, Left side 43.8±12.4 48.3±14.3 44.1±13.9 and the same experienced urologist performed all ICIs and clinical EDV (cm sÀ1) assessments.
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