SS-Penogram: a New Diagnostic Test for Erectile Dysfunction

The clinical reports on Sildenafil sulfate (Viagra) are mainly based on individual observations. However, there is a paucity of objective studies in the literature. In order to objectively examine the effect of Sildenafil, a SS (Sexual Stimulation)- Penogram that is a non-invasive, simple and physiologic method was developed using a radioisotope (RI). One hundred and four SS-penograms were performed on patients who had a documented erectile dysfunction (ED) lasting for more than 6 months. After an intravenous injection of 99mTc-RBC (15 mCi), the first penogram was taken immediately after sexual stimulation, which was done by 30 minutes of erotic videotape viewing. Forty minutes after administering 25 to 100 mg of Sildenafil, a second penogram was taken. The characteristics of each penogram were analyzed according to a previously reported method. The results were graded as follows; Type I(normal function; 5 min or more of peak erectile response with an induction period of 1 to 6 min), Type II-A (impossible function type; i.e., showing less than 2 times the basal radioactivity level), Type II-B (the unstable type; showing less than 5 min of peak erectile response), and Type II-C (the delayed type; which showed a delay of more than 15 min after the start of sexual stimulation). The patients were grouped according to their response after Sildenafil administration, and the effect of Sildenafil was assessed by comparing the radioactivity from between 7 to 22 minutes and the changes in the characteristics of the penogram. The mean age of the patients was 44.9 +/- 10.2 (23 - 68) years. In the first penogram, Type I was found in 12 patients, and Type II-A in 14, Type II-B in73, Type II-C in 1 and a mixed (II-B + C) type was found in 4 patients. A second penogram after Sildenafil administration, showed Type I in 46 patients, and Type II-A in 10, Type II-B in 46 and a mixed type was found in 2 patients. The responses after Sildenafil were categorized as follows: 1) An excellent response group (consisting of 56 patients-53.9%); Those who showed greater than 50% increase in the RI area after Sildenafil treatment. 2) A good response group consisting of (23 patients-22.1%); i.e., those who showed a less than 50% but greater than a 20% increase in the RI area after Sildenafil administration. 3) A borderline group (consisting of 15 patients-14.4%); showing less than a 20% change in the RI area after Sildenafil treatment. 4) non-response group (consisting of 10 patients-9.6%). The therapeutic efficacy of Sildenafil, as determined by the SS-penograms, revealed that there was an augmentation in the erectile capabilities in 76% of men (79/104) but a non-response was observed in 9.6% (10/104). The efficacy of Sildenafil on the SS-penogram did not correlate with the patient's age (p=0.198). It is believed that the SS-penogram can be used to accurately evaluate the natural erectile status in sexual and pharmacological stimulation, and provides the most objective erectile response in any therapeutic trial. Consequently, the primary challenge for any erectile dysfunction remedy is to be able to demonstrate its efficacy. A further evaluation is warranted in the non-response group, which was not based on any severe organic dysfunction.

Analysis of AVS- penogram in 3000 Impotent Patients / 대한비뇨기과학회지

Audio visual stimulation penogram(AVS-penogram) is used as a screening method for evaluation of erectile dysfunction. In this study, 3000 patients were evaluated from Dec. 1986 to Dec. 1992 and finally diagnosed by comprehensive diagnostic methods. The patients were classified according to AVS-penogram curves into 4 types and correlated with the patient's final diagnosis. For 800 patients who were evaluated with combined AVS penogram and NPT monitoring, compatibility ratios between psychogenic and organic group were compared. After correlating each of the curve type with the patients and comparing erotic and nocturnal erection, following results were obtained. 1. The mean age of the patients was 41.25 years. 2. The overall rate of final diagnosis were 57.5%, 14.3%, 8.9% in psychogenic, arteriogenic and venogenic impotence 3. Type I group was proved as psychogenic impotence in 87% of the patients. 4. Type II A group was proved as organic impotence in 79% of the patients and most of them had neurogenic and arteriogenic impotence. 5. Type II B group was proved as psychogenic impotence in 51%, organic impotence in 49% of the patients. Among the organic impotence group, most of them had arteriogenic, venogenic and neurogenic impotence. The difference of both group was statistically insignificant. 6. Type II C group was proved as psychogenic impotence in 39%, organic impotence in 61% of the patients. Further studies are needed for subclassification of both groups. 7. The compatibility ratio of the AVS-penogram and NPTM was 85.9% in psychogenic group with normal finding in both tests and 44.7% in organic group with abnormal finding in both tests. In conclusion, AVS-penogram is a primary diagnostic method in screening impotent patients and type I is regarded as psychogenic impotence. In Type IIB and IIC, subclassification of curve type is needed for differential diagnosis between psychogenic and organic impotence. Further studies are needed in more cases to obtain the objective analysis with compatibility ratio in combined AVS-penogram and nocturnal penile tumescence monitoring.

Response to audiovisual stimulation in patients with premature ejaculation / 대한비뇨기과학회지

Twenty-nine premature ejaculation patients entered this study using audiovisual stimulation penogram(AVS-Penogram) to evaluate their dynamic blood flows in the penis. The patients, ages twenty seven through fifty-two(average 34 years), complained of short time-to-coital ejaculation less than 90 seconds. We performed Bulbocavernous Reflex Latency(BCRL) and Pudendal Nerve Somatosensory Evoked Potential (DNSEP) test in nineteen of them. According to the results of audiovisual stimulation penogram the patients were classified into two group: fifteen patients had type I (normal) finding and fourteen patients had type X a(unstable erection due to severe fluctuation in blood flow) Finding. Five patients(33%) of fifteen patients with type I (normal) penogram and eleven patients(78%) of fourteen patients with unstable type II n penogram complained of concomitant erectile failure(p<0.06). The age, time-to-coital ejaculation and the results of expressed prostatic secretion(EPS) were not statistically different between above two groups. Furthermore, all cases in whom BCRL and DNSEP was performed had normal results in both tests. This study indicates that premature ejaculation can occur combined with organic erectile failure seeing that the patients show an unstable hemodynamics, and that in such case premature ejaculation has to be treated with underlying organic causes of impotence.

A study on subclassification of AVS-penogram / 대한비뇨기과학회지

We have effectively used AVS-Penogram as the primary diagnostic method for impotence. In this study, we classified the types of curve on AVS-Penogram in detail and evaluated the origin of each of the classified types for 308 patients who were finally diagnosed by comprehensive diagnostic methods. Also we divided the unstable type into the multi-peak type and the one-peak type based on the number of peaks in the curve. and the delay type into the simple-delay type and the unstable-delay type based on whether there were fluctuations or not. After evaluating and considering the clinical significance of each of the curve type. we have reached the following conclusion. I. Type I group which is similar to normal control group was proved as psychogenic impotence in 86% of the patients. 2. The impossible type II A group was proved as organic impotence in 97% of the patients and most or them had neurogenic and arteriogenic impotence. 3. The unstable type II B group was proved as psychogenic impotence in 52% of the patients ;61% in the case of the multi-peak type, and 15% in the case of the one-peak type. The difference between both types were statistically significant. We think the one-peak type is more strongly related to organic cause, and in the case of the multi-peak type. further studies are needed for differential diagnosis between psychogenic and vasculogenic impotence, which were the most frequent types. 4. The delay type II C group was proved as psychogenic impotence in 4l% of the patients; 44% in the case of the simple-delay type, and 39% in the case of the unstable-delay type. There was no significant difference between these two types. In the case of the delay type, further studies are needed for differential diagnosis between psychogenic and arteriogenic impotence, which were the most frequent types. In conclusion, AVS-Penogram is a useful method in measurement of natural erotic erection and a primary diagnostic method in impotence, and it is an important differential diagnostic parameter to divide the unstable type into the multi-peak type and the one-peak type. Also in the case of the patient classified as multi-peak type, if more studies about neurotransmitter can be done, diagnostic methods from these studies can be developed. and the objective analysis of nocturnal penile enlargement can be achieved. new organic factor will be found in the patients proved to be psychogenic impotence.

A comparison of radioisotope erection penogram, penile angle and nocturnal penile tumescence test / 대한비뇨기과학회지

Intracavernous papaverine injection may be the first step in the assessment of the impotent patient Since measurement of the rigidity requires a sophisticated procedures that may not be available to the majority of the practitioners, we attempted to find an objective method to evaluate the results or this common test. We tested 44 patients complaining of impotence and 2 normal potent men with intracavernous injection of 30mg. papaverine and measured the angle between the penis and the legs with the patient in the standing position and obtained radioisotope erection penogram. Various penogram indexes were calculated from the time activity curve and their usefulness was evaluated and was compared with the findings of nocturnal penile tumescence. The papaverine test can distinguish between the vasculogenic and psychogenic impotent patients. Measurement of the erectile angle after intracavernous injection of papaverine is a simple, objective and reliable method to evaluate patients with vascular impotence. The penogram indexes were significantly correlated with the penile arterial inflow and venous outflow during erection. but not significantly correlated with nocturnal penile tumescence test.

The Comparison of Nocturnal Erection Using Rigiscan with Erotic Erection Using Audiovisual Stimulating Penogram / 대한비뇨기과학회지

Penile erection is either sexual stimulating erection or nocturnal erection. The difference of precise mechanism between the two types is not clarified yet. In order to evaluate nocturnal erection, we used the Rigiscan which could simultaneously record nocturnal penile tumescence and rigidity. And sexual stimulating erection was evaluated by Audiovisual Stimulating Penogram which was introduced by Choi and Kim in 1987. The following results were obtained. The compatibility ratio of 16 normal sexual stimulating erection to nocturnal erection test was 56%, while that of 35 cases of abnormal sexual stimulating erection was 51% . The compatibility ratios of the group IIA and group IIC were 80% and 78%, respectively, revealing high percentage of concordance between the two types of erection. On the other hand, the compatibility ratio of group IIB was low(33%). From the results presented here, it can be concluded that the AVS-Penogram is useful for the screening test and to obtain more useful information, evaluation of the nocturnal erection using Rigiscan is necessary.

Impotence in Single Males / 대한비뇨기과학회지

Due to the increased awareness of impotence, including primary impotence, in single males, we studied its characteristics and a comparative study was performed with other impotence groups. From March 1986 to February 1989, 53 impotent single males without previous trauma history (Group A) were evaluated and diagnosed by implementing diagnostic procedures when available. During the same period. Rigi Scans were performed in 66 patients with erectile failure (excluding impotent single males, Group B) and AVS penograms were also done in 647 patients belonging to the same group. Of the 53 evaluated patients, twenty were found to have primary impotence which was composed of 9 with organic and 11 with psychogenic impotence. The comparison of 9 Patients with primary organic impotence and 11 patients with primary psychogenic impotence showed significant differences in the results of diagnostic studies, but the data size was insufficient to obtain significance. Comparison of the ratio of organic and psychogenic impotence in primary impotence patients and nonprimary impotence patients among 53 single males revealed these to be almost the same, as 0.82 (45%/55%,9/20 / 11/20) and 0.83 (45.5 %/54.6 %, 15/33 / 18/33) respectively. According to these results, single males with erectile failure including primary impotence can be classified as one of the disease entities. The Rigi Scan classification used in this study was revealed to be significant in comparison of Groups A and B (p=0.02). The type distribution of the AVS penogram was statistically significant in comparing Group A to B (p=0. 004). The difference in Rigi Scan and AVS penogram results between Group A and B signifies psychologic and organic dissimilarity between these groups. The unstable erection seen in Rigi Scan was considered to be due to some organic, especially some form of hemodynamic problem that needs further investigation.

The Comparison of Nocturnal Erection and Audiovisual Stimulating Erection / 대한비뇨기과학회지

This study is to compare the diagnostic usefulness and relationships between AVS penogram. Snap gauge test, and NPT monitoring in impotent patients confirmed using multidisciplinary diagnostic approach at the Department of Urology, Yonsei University College of Medicine from December 1986 to June 1987. Following results were obtained. 1. Among 24 cases of Group I(AVS penogram) 20 cases(83.3%) were psychogenic impotence, where 15 cases(75%) revealed sufficient penile rigidity on the Snap gauge test. 4 cases(16.7%) of group I were organic impotence, which revealed incomplete penile rigidity on the Snap gauge test. Among 45 cases of Group II-B(AVS Penogram) 34 cases(75.6%) were psychogenic impotence, where 28 cases(82.4%) showed sufficient penile rigidity on the Snap gauge test. 10 cases(24.4%) of Group II-B were organic impotence, which showed incomplete penile rigidity on the Snap gauge test. Among 17 cases of Group II-A and II-C 5 cases were psychogenic impotence, all of which revealed sufficient penile rigidity on the Snap gauge test. >From above results, the AVS Penogram is not a confirmative method, but using AVS Penogram and the Snap gauge test simultaneously will give useful information differentiating organic impotence and psychogenic impotence. 2. In comparison of AVS penogram and NPT monitoring, among 20 cases 7 cases of erectile curve showed similar shape, but the precise mechanism of each penile erection is not yet certain, more study is needed in the near future.

AVS(Audiovisual Stimulation)-Penogram / 대한비뇨기과학회지

In an effort to find more comprehensive and general diagnosis of erectile failure, we already have analysed 90 cases and reported the results. After that we added 199 more cases and performed a computer based analysis of total 289 cases in the dynamic changes of penile blood flow during natural physiologic erection after exposure to the audiovisual stimulation. The following results were obtained. 1. In normal volunteers, we were able to achieve uniform penogram findings in all cases with T.T.(Transit Time) ranging 1 to 3 minutes(mean 2.17 minutes), the EPT(Erection Persistent Time) over 30 minutes and no fluctuation phenomena after AVS. 2. Erectile failure group.(2.83 cases) (1) Group I.(108 cases; 38.2%). They demonstrated similar penogram features with the normal volunteers but EPT more than 5 minuets(mean 18.26 minutes) at least. most common causes were psychogenic origin(57 cases). (2) Group II.(175 cases ; 61.8%). Patients were showing abnormal penogram findings, and were divided into following 3 types. a) A type-Impossible type(10 cases ; 3.5%). They failed to show more than 2 fold increase in the maximal radioactivity after AVS when compared to the pre-stimuli level(mean 1.83 times). The underlying causes were identified to be arteriogenic and neurogenic. b) B type-Unstable type(124 cases ; 43.8%). They were unable to sustain erection due to fluctuation(mean 1.83 times). The underlying causes were psychogenic, vasculogenic and neurogenic origins. c) C type-Delayed type(41 cases ; 14.5%). They were showing T.T. more than 15 minutes(mean ; 23.71 minutes), and the underlying causes were arteriogenic, psychogenic and neurogenic origins. Based on these results, we have concluded that AVS-Penogram seems to the most appropriate diagnostic method for screening test and follow-up evaluation after vascular surgery. Through more clinical experience and investigation, and more comparison and analysis with other diagnostic methods, it will be a standard diagnostic approach in the future.

Radioisotope Penogram in Diagnosis of the Impotence / 대한비뇨기과학회지

Forty two patients including 1O cases of the normal control were studied with the radioisotope penogram. The causes of the impotence were arteriogenic in 1O cases, venogenic in 6, diabetes mellitus in 8, neurogenic in 2, endocrinogenic in 1 and psychogenic in 15, ranging from 19 to 70 years of age. Ten normal volunteers for the control group were ranged from 21 to 38 years of age. All were subjected to Snap-Gauge test and measurement of the penile blood pressure with estimation of the penile brachial index (P.B.I.). We calculated the Penogram Index in time-activity curve of the radioisotope penogram and studied the inter-relationship between the Penogram Index and the etiologic diseases, Snap-Gauge test, PBI. The results were obtained as follows; 1. Inter-relationship between the diseases and the penogram index, arterial index (Index A) and venous index (Index V1, V2); 1) Index A was 1.44 in normal control group, 0.55 in arteriogenic. 0.62 in venogenic, 0.64 in diabetes mellitus, 0.95 in neurogenic, l.29 in endocrinogenic and 1.03 in psychogenic impotence. This suggested that Index A was significantly correlative with state of the penile arterial inflow. 2) Index V1, V2 were 0.09, 90 in normal control group, 0.09, 51 in arteriogenic, 0.40, 29 in venogenic, O.8l, 38 in diabetes mellitus, 0.84, 90 in neurogenic, O.92, 34 in endocrinogenic, and 0.91, 64 in psychogenic impotence. This suggested that Index V1 and V2, particularly V1 was representative of maintenance of the penile blood flow and the penile venous outflow or leak. 2. Relation between Snap-Gauge test and Index A; Correlated in 77.8% of the patients and the normal controls, respectively. 3. Relation between P.B.I. and Index A; Correlative. 4. Relation between P.B.I and Index V1, V2; Not correlative Therefore, the radioisotope penogram was a very useful method in diagnosis of the organic impotence, particularly vasculogenic impotence to different late arteriogenic and venogenic.