Within the past few years, veno-occlusion of the corpora cavernosa has become generally recognized as an essential prerequisite for adequate penile erection. Veno-occlusive incompetence is suspected to be a frequent cause of impotence. Our recent experience with cavernosography in two normal volunteers and 36 impotent patients indicates that angiography is reliable in evaluating the competence of the veno-occlusive mechanism only if both pharmacocavernosography (PCG) and pharmacocavernosometry (PCM) are applied. Twenty minutes after intracavernosal (IC) injection of a mixture of 60 mg. papaverine and one mg. phentolamine (regitine), 100 ml. of diluted radiographic contrast medium are infused at the rate of one or two ml./sec. while pressure is recorded, and radiographic films are exposed at the rate of one every eight to 15 seconds. PCM and PCG of the corpora cavernosa indicated the overall degree of competence of the cavernosal veno-occlusive mechanisms, and the sites of veno-occlusive incompetence; non-pharmacologic studies were unreliable in these regards. During non-pharmacologic infusion in normals, pressures rose to 40 to 45 mm. Hg, and free efflux could be visualized from multiple venous systems. After pharmacologic injection in normals, all venous channels closed, and pressures rapidly rose toward or above 200 mm. Hg, at which time the infusion was stopped. Veno-occlusive incompetence was defined angiographically when more than minimal efflux occurred during pharmacocavernosography from any venous system. The incompetence could involve the deep penile system, the deep dorsal system, or the spongiosal system, alone or in combination. Severe veno-occlusive incompetence was considered diagnostic of venogenic impotence, and was defined manometrically when IC pressures failed to exceed 100 mm. Hg during infusion of 100 ml. of fluid at 2 mm./second after IC papaverine and phentolamine injection. We believe these angiographic methods will improve the criteria against which other diagnostic and therapeutic methods can be assessed.
Progress in diagnosis and therapy of impotence is handicapped by the absence of a validated and objective method for evaluating the vascular system; a gold-standard for vasculogenic impotence is needed. Prior experience has indicated that conventional arteriography in unanesthetized patients is unreliable in evaluation of the penile arterial supply. We have improved our arteriographic methods by the routine application of selective pudendal injections, vasodilation pharmacoangiography with nitroglycerin and papaverine, and direct magnification. Experience in 37 impotent patients demonstrates marked improvement in the quality of visualization of distal vessels, and the frequent presence of functional vasoconstriction of medium and small arteries that can be distinguished from organic disease only with vasodilators. We believe these angiographic methods will improve the criteria against which other diagnostic and therapeutic methods can be objectively assessed.
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