Penile ultrasonography

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Penile ultrasonography is medical ultrasonography of the penis. Ultrasound is an excellent method for the study of the penis, such as indicated in trauma, priapism, erectile dysfunction or suspected Peyronie's disease. [1]

Contents

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. Penile trauma, priapism, Peyronie's disease, and erectile dysfunction are some of the conditions in which penile ultrasound finds significant applicability. [1]

Currently, linear transducers have a maximum frequency of 12-15 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. 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. In specific situations, such as in the evaluation of Peyronie's disease, the penis should also be positioned on a towel/sheet or on the testicular sac, with a lateral approach. [1]

Anatomy and physiology

Figure 1: Normal penile anatomy, dorsal and cross-sectional view showing two hypoechoic images corresponding to the corpora cavernosa, with an echoic line that surrounds them and corresponds to the tunica albuginea. Normal penis ultrasound.jpg
Figure 1: Normal penile anatomy, dorsal and cross-sectional view showing two hypoechoic images corresponding to the corpora cavernosa, with an echoic line that surrounds them and corresponds to the tunica albuginea.
Figure 2: Longitudinal section of the penis under right lateral access. 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. Longitudinal ultrasonography of the penis.jpg
Figure 2: Longitudinal section of the penis under right lateral access. 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.

The corpora cavernosa are homogeneous and relatively hypoechoic cylindrical structures lined with tunica albuginea, a thin membrane that has a thickness of approximately 2 mm when the penis is flaccid and 0.25 mm when it is erect. 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. Buck's fascia is superficial to the tunica albuginea and covers all of the structures described. [1]

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. In the flaccid penis (Figure 3), the normal cavernous arteries show a systolic peak between 11 and 20 cm/s. 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]

Figure 3: Longitudinal, ventral ultrasound of the penis, with pulsed mode and color Doppler. Normal flow pattern of the cavernous artery in a flaccid penis. Longitudinal doppler ultrasonography of the penis.jpg
Figure 3: Longitudinal, ventral ultrasound of the penis, with pulsed mode and color Doppler. Normal flow pattern of the cavernous artery in a flaccid penis.

Penile trauma

Penile trauma can result from a blunt or penetrating injury, the latter being rarely investigated by imaging methods, almost always requiring immediate surgical exploration. 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. [1]

Priapism

Priapism is defined as a painful and prolonged penile erection, with or without sexual stimulation. Color Doppler ultrasound is the imaging method of choice for the investigation of priapism, because it is noninvasive, widely available, and highly sensitive. By means of this method, it is possible to diagnose priapism and differentiate between its low- and high-flow forms. [1]

Figure 5: Color Doppler ultrasound demonstrating a hypoechoic collection that corresponds to hematoma with arteriovenous fistula secondary to traumatic injury of the penis due to impact with bicycle handlebars, resulting in high-flow priapism. Ultrasonography of traumatic arteriovenous fistula of the penis.jpg
Figure 5: Color Doppler ultrasound demonstrating a hypoechoic collection that corresponds to hematoma with arteriovenous fistula secondary to traumatic injury of the penis due to impact with bicycle handlebars, resulting in high-flow priapism.

Peyronie's disease

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. Penile fibromatosis (Peyronie's disease) is marked by the formation of fibrous plaques identified as areas where the tunica albuginea is thickened. Although plaques are more common on the dorsum of the penis, they can also be seen on the ventral face, lateral face, or septum. [1]

Erectile dysfunction

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. 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. [1]

Figure 8 Transverse ultrasound image, ventral view of the penis. Image obtained after induction of an erection, 15 min after injection of prostaglandin E1, showing dilated sinusoids (arrows). Ultrasonography of dilated penile sinusoids during erection.jpg
Figure 8 Transverse ultrasound image, ventral view of the penis. Image obtained after induction of an erection, 15 min after injection of prostaglandin E1, showing dilated sinusoids (arrows).

Related Research Articles

Erectile dysfunction (ED), also referred to as impotence, is a form of sexual dysfunction in males characterized by the persistent or recurring inability to achieve or maintain a penile erection with sufficient rigidity and duration for satisfactory sexual activity. It is the most common sexual problem in males and can cause psychological distress due to its impact on self-image and sexual relationships.

<span class="mw-page-title-main">Priapism</span> Medical condition where an erection lasts excessively long

Priapism is a condition in which a penis remains erect for hours in the absence of stimulation or after stimulation has ended. There are three types: ischemic (low-flow), nonischemic (high-flow), and recurrent ischemic (intermittent). Most cases are ischemic. Ischemic priapism is generally painful while nonischemic priapism is not. In ischemic priapism, most of the penis is hard; however, the glans penis is not. In nonischemic priapism, the entire penis is only somewhat hard. Very rarely, clitoral priapism occurs in women.

<span class="mw-page-title-main">Peyronie's disease</span> Abnormal growth of scar tissue within the penis

Peyronie's disease is a connective tissue disorder involving the growth of fibrous plaques in the soft tissue of the penis. Specifically, scar tissue forms in the tunica albuginea, the thick sheath of tissue surrounding the corpora cavernosa, causing pain, abnormal curvature, erectile dysfunction, indentation, loss of girth and shortening.

<span class="mw-page-title-main">Chordee</span> Downward or upward curving of the penis head from the shaft

Chordee is a condition in which the head of the penis curves downward or upward, at the junction of the head and shaft of the penis. The curvature is usually most obvious during erection, but resistance to straightening is often apparent in the flaccid state as well. In many cases but not all, chordee is associated with hypospadias. This is not the same condition as Peyronie's disease, which involves curvature of the shaft of the penis most commonly due to injury during adult life.

<span class="mw-page-title-main">Penile fracture</span> Rupture of the fibrous coverings that envelop the peniss erectile tissue

Penile fracture is rupture of one or both of the tunica albuginea, the fibrous coverings that envelop the penis's corpora cavernosa. It is caused by rapid blunt force to an erect penis, usually during vaginal intercourse, or aggressive masturbation. It sometimes also involves partial or complete rupture of the urethra or injury to the dorsal nerves, veins and arteries.

<span class="mw-page-title-main">Corpus spongiosum (penis)</span> Spongy tissue within the human penis

The corpus spongiosum is the mass of spongy tissue surrounding the male urethra within the penis. It is also called the corpus cavernosum urethrae in older texts.

<span class="mw-page-title-main">Corpus cavernosum penis</span> Sponge-like region of erectile tissue

A corpus cavernosum penis (singular) is one of a pair of sponge-like regions of erectile tissue, which contain most of the blood in the penis during an erection.

<span class="mw-page-title-main">Corpus cavernosum of clitoris</span> One of a pair of regions in the clitoris that contain the blood during erection

The corpus cavernosum of the clitoris is one of a pair of sponge-like regions of erectile tissue that engorge with blood during an erection. This is homologous to the corpus cavernosum of the penis. The term corpora cavernosa literally means "cave-like bodies".

<span class="mw-page-title-main">Prostatic plexus (nervous)</span>

The prostatic plexus is continued from the lower part of the pelvic plexus. It lies within the fascial shell of the prostate.

Nocturnal penile tumescence (NPT) is a spontaneous erection of the penis during sleep or when waking up. Along with nocturnal clitoral tumescence, it is also known as sleep-related erection. Colloquially, the term morning wood, or less commonly, morning glory is also used, although this is more commonly used to refer specifically to an erection beginning during sleep and persisting into the period just after waking. Men without physiological erectile dysfunction or severe depression experience nocturnal penile tumescence, usually three to five times during a period of sleep, typically during rapid eye movement sleep. Nocturnal penile tumescence is believed to contribute to penile health.

Venous leak, also called venogenic erectile dysfunction and penile venous insufficiency, is one category of vasculogenic impotence — a cause of erectile dysfunction in males. It affects all ages, being particularly awkward in young men. Much about venous leaks has not reached a consensus among the medical community, and many aspects of the condition, particularly its treatment strategies, are controversial. The prevalence of the condition is still unknown, although some sources claim it to be a common cause of erectile dysfunction.

<span class="mw-page-title-main">Tunica albuginea (penis)</span> Anatomical structure of the penis

The tunica albuginea is the fibrous envelope that extends the length of the corpus cavernosum penis and corpus spongiosum penis. It is a bi-layered structure that includes an outer longitudinal layer and an inner circular layer.

<span class="mw-page-title-main">Helicine arteries of penis</span> Arteries of the penis

The helicine arteries of penis are arteries in the penis. They are found in the corpora cavernosa penis.

<span class="mw-page-title-main">Penile implant</span> Medical device

A penile implant is an implanted device intended for the treatment of erectile dysfunction, Peyronie's disease, ischemic priapism, deformity and any traumatic injury of the penis, and for phalloplasty or metoidioplasty, including in gender-affirming surgery. Men also opt for penile implants for aesthetic purposes. Men's satisfaction and sexual function is influenced by discomfort over genital size which leads to seek surgical and non-surgical solutions for penis alteration. Although there are many distinct types of implants, most fall into one of two categories: malleable and inflatable transplants.

<span class="mw-page-title-main">Human penis</span> Human male external reproductive organ

In human anatomy, the penis is an external male sex organ that serves as a passage for excretion of urine and ejaculation of semen. The main parts are the root, body, the epithelium of the penis including the shaft skin, and the foreskin covering the glans. The body of the penis is made up of three columns of tissue: two corpora cavernosa on the dorsal side and corpus spongiosum between them on the ventral side. The urethra passes through the prostate gland, where it is joined by the ejaculatory ducts, and then through the penis. The urethra goes across the corpus spongiosum and ends at the tip of the glans as the opening, the urinary meatus.

<span class="mw-page-title-main">Erection</span> Physiological phenomenon involving the hardening and enlargement of the penis

An erection is a physiological phenomenon in which the penis becomes firm, engorged, and enlarged. Penile erection is the result of a complex interaction of psychological, neural, vascular, and endocrine factors, and is often associated with sexual arousal, sexual attraction or libido, although erections can also be spontaneous. The shape, angle, and direction of an erection vary considerably between humans.

<span class="mw-page-title-main">Clitoral erection</span> Physiological phenomenon involving the engorgement of the clitoris

Clitoral erection is a physiological phenomenon where the clitoris becomes enlarged and firm.

A penile injury is a medical emergency that afflicts the penis. Common injuries include fracture, avulsion injury, strangulation, entrapment, and amputation.

<span class="mw-page-title-main">Hard flaccid syndrome</span> Medical condition

Hard flaccid syndrome (HFS), also known as hard flaccid (HF), is a chronic painful condition characterized by a semi-rigid penis at the flaccid state, a soft glans at the erect state (cold glans syndrome), pelvic pain, low libido, erectile dysfunction, erectile pain, pain on ejaculation, penile sensory changes (numbness or coldness), lower urinary tract symptoms, contraction of the pelvic floor muscles, and psychological distress. Other complaints include rectal and perineal discomfort, cold hands and feet, and a hollow or detached feeling inside the penile shaft. The majority of HFS patients are in their 20s–30s and symptoms significantly affect one's quality of life.

<span class="mw-page-title-main">Glans insufficiency syndrome</span> Medical condition

Glans insufficiency syndrome, also known as the soft glans, cold glans, or glans insufficiency, is a medical condition that affects male individuals. This condition is characterized by the persistent inability of the glans penis to achieve and maintain an erect or turgid state during sexual arousal, remaining soft and cold. This condition can have an impact on a person's sexual function, including decreased sensitivity, difficulty in maintaining an erection, and overall quality of life.

References

  1. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Originally copied from:
    Fernandes, Maitê Aline Vieira; Souza, Luis Ronan Marquez Ferreira de; Cartafina, Luciano Pousa (2018). "Ultrasound evaluation of the penis". Radiologia Brasileira. 51 (4): 257–261. doi:10.1590/0100-3984.2016.0152. ISSN   1678-7099. PMC   6124582 . PMID   30202130.
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