Painful Penile Induration: Imaging Findings and Management

Abstract

A number of benign and malignant diseases with different causes, clinical features, management, and outcome can manifest as painful penile induration. The most common such conditions are active Peyronie disease, inflammation, trauma, venous or corporal thrombosis, acute ischemic disorders, and primary or secondary tumors. In patients with painful penile induration, a preliminary differential diagnosis is based on the patient's history and results of laboratory studies, penile inspection, and palpation. Imaging is often required to confirm the clinical diagnosis, assess the extent of disease, and determine patient treatment. A basic clinical investigation comprising penile inspection and palpation should be performed by the radiologist before imaging; such an evaluation is a great help in selecting the best imaging modality and examination technique. Moreover, acquisition of preliminary clinical information eases interpretation of the imaging features and facilitates identification of clinically relevant information that may result in a change in patient treatment. In standard clinical practice, color Doppler ultrasonography is often the first imaging modality used to evaluate patients with painful penile induration. This technique clearly demonstrates normal penile anatomy and its corresponding changes in most of the clinically relevant situations. Magnetic resonance imaging is the optimal imaging modality for tumor staging. Other imaging modalities are required less frequently.

Ultrasound evaluation of the penis

“…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 (1) . At the beginning of erection, the systolic and diastolic flows undergo progressive increases.…”

“…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) .…”

“…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 (1) . Penile trauma, priapism, Peyronie's disease, and erectile dysfunction are some of the conditions in which penile ultrasound finds significant applicability.…”

“…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 (1) . 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 (2) .…”

Ultrasonographic Evaluation of Acute Urinary Tract and Male Genitourinary Pathology

“…Ultrasonography is a noninvasive way to differentiate between ischemic and nonischemic priapism, instead of blood gas sampling that requires needle aspiration. 34 Color and pulsed Doppler imaging are used to evaluate for patency of the cavernosal arteries as well as detailed evaluation of the blood flow including waveforms and peak systolic and end-diastolic velocities. In general, patients with ischemic priapism have minimal or absent blood flow in the cavernosal arteries (Fig.…”