DOI: 10.1148/rg.253045100
Color Doppler US of the Postoperative Penis: Anatomy and Surgical Complications1
Michele Bertolotto, MD,
Giovanni Serafini, MD,
Gianfranco Savoca, MD,
Giovanni Liguori, MD,
Loretta Calderan, MD,
Cristiana Gasparini, MD and
Roberto Pozzi Mucelli, MD
1 From the Departments of Radiology (M.B., L.C., C.G., R.P.M.) and Urology (G. Savoca, G.L.), University of Trieste, Trieste, Italy, and the Department of Radiology, A.O. Santa Corona, Pietra Ligure, Italy (G. Serafini). Presented as an education exhibit at the 2003 RSNA Scientific Assembly. Received May 5, 2004; revision requested June 14 and received December 8; accepted December 13. All authors have no financial relationships to disclose.
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Figure 1a. Normal penile anatomy. Drawings illustrate a transverse section through the penile shaft (a) and a sagittal view of the penis (b). The tunica albuginea (gray line) is seen enveloping the two corpora cavernosa (CC) and the corpus spongiosum (CS). Two other fascial layers, one deep (Buck fascia [green line]) and one superficial (Colles fascia) [blue line]), surround the tunica albuginea. The deep dorsal vessels (DDV), the superficial dorsal vein (SDV), and the cavernosal arteries (CA) are also seen. The urethra (U) is divided into a prostatic portion, which passes through the prostate gland (Pr); a membranous portion, which passes through the urogenital diaphragm (UD); a bulbar portion, which extends to the suspensory ligament of the penis (S); and a pendulous portion, which extends to the external urethral meatus.
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Figure 1b. Normal penile anatomy. Drawings illustrate a transverse section through the penile shaft (a) and a sagittal view of the penis (b). The tunica albuginea (gray line) is seen enveloping the two corpora cavernosa (CC) and the corpus spongiosum (CS). Two other fascial layers, one deep (Buck fascia [green line]) and one superficial (Colles fascia) [blue line]), surround the tunica albuginea. The deep dorsal vessels (DDV), the superficial dorsal vein (SDV), and the cavernosal arteries (CA) are also seen. The urethra (U) is divided into a prostatic portion, which passes through the prostate gland (Pr); a membranous portion, which passes through the urogenital diaphragm (UD); a bulbar portion, which extends to the suspensory ligament of the penis (S); and a pendulous portion, which extends to the external urethral meatus.
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Figure 2a. Normal penile anatomy. (a) Transverse US image obtained on the ventral aspect of the penis shows the paired corpora cavernosa (CC) and the corpus spongiosum (CS). The tunica albuginea (arrowheads) appears as a thin echogenic line surrounding the penile bodies. The Buck fascia is stuck to the tunica albuginea and cannot be distinguished from it. The cavernosal arteries (white arrows) are appreciable as a pair of dots located slightly medially within the corpora cavernosa. The dorsal vessels (black arrows) are visible in the dorsal aspect of the penis beyond the tunica albuginea. (b) Transverse color Doppler US image shows the cavernosal arteries (solid arrows), the dorsal penile vessels (open arrows), and the helicine arteries branching from the cavernosal arteries.
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Figure 2b. Normal penile anatomy. (a) Transverse US image obtained on the ventral aspect of the penis shows the paired corpora cavernosa (CC) and the corpus spongiosum (CS). The tunica albuginea (arrowheads) appears as a thin echogenic line surrounding the penile bodies. The Buck fascia is stuck to the tunica albuginea and cannot be distinguished from it. The cavernosal arteries (white arrows) are appreciable as a pair of dots located slightly medially within the corpora cavernosa. The dorsal vessels (black arrows) are visible in the dorsal aspect of the penis beyond the tunica albuginea. (b) Transverse color Doppler US image shows the cavernosal arteries (solid arrows), the dorsal penile vessels (open arrows), and the helicine arteries branching from the cavernosal arteries.
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Figure 3a. Normal Doppler waveform changes in the cavernosal arteries during the onset of erection. Images of the Doppler spectrum show the monophasic flow with minimal or no diastolic flow that occurs in the flaccid state (a), increased systolic and diastolic flow (b), absence of end diastolic flow (c), and holodiastolic flow reversal (d).
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Figure 3b. Normal Doppler waveform changes in the cavernosal arteries during the onset of erection. Images of the Doppler spectrum show the monophasic flow with minimal or no diastolic flow that occurs in the flaccid state (a), increased systolic and diastolic flow (b), absence of end diastolic flow (c), and holodiastolic flow reversal (d).
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Figure 3c. Normal Doppler waveform changes in the cavernosal arteries during the onset of erection. Images of the Doppler spectrum show the monophasic flow with minimal or no diastolic flow that occurs in the flaccid state (a), increased systolic and diastolic flow (b), absence of end diastolic flow (c), and holodiastolic flow reversal (d).
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Figure 3d. Normal Doppler waveform changes in the cavernosal arteries during the onset of erection. Images of the Doppler spectrum show the monophasic flow with minimal or no diastolic flow that occurs in the flaccid state (a), increased systolic and diastolic flow (b), absence of end diastolic flow (c), and holodiastolic flow reversal (d).
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Figure 4a. Complications after urethral surgery. US of the urethra was performed through the scrotum following retrograde distention with saline solution. (a) Longitudinal US image obtained after urethral dilation in a 60-year-old man with recurrent postinflammatory stenosis shows the bulb of the corpus spongiosum (*) and a bulbar urethral restricture (arrowheads) with mucosal thickening. (b) Longitudinal US image obtained in a 23-year-old man with a history of bladder exstrophy and urethral duplication, with the ectopic urethra opening onto the anal canal and atresia of the proximal orthotopic urethra, shows a hair-bearing ectatic neourethra. The urethral malformation had been corrected during childhood by closing the ectopic urethral orifice and connecting the ectopic urethra to the bulbar portion of the orthotopic urethra proximal to the atresic portion using a scrotal skin flap.
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Figure 4b. Complications after urethral surgery. US of the urethra was performed through the scrotum following retrograde distention with saline solution. (a) Longitudinal US image obtained after urethral dilation in a 60-year-old man with recurrent postinflammatory stenosis shows the bulb of the corpus spongiosum (*) and a bulbar urethral restricture (arrowheads) with mucosal thickening. (b) Longitudinal US image obtained in a 23-year-old man with a history of bladder exstrophy and urethral duplication, with the ectopic urethra opening onto the anal canal and atresia of the proximal orthotopic urethra, shows a hair-bearing ectatic neourethra. The urethral malformation had been corrected during childhood by closing the ectopic urethral orifice and connecting the ectopic urethra to the bulbar portion of the orthotopic urethra proximal to the atresic portion using a scrotal skin flap.
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Figure 5. Drawings illustrate the Nesbit operation. After dissection of the neurovascular bundle, one or more ellipses of the tunica albuginea are excised on the side opposite the curvature and the edges of the albugineal defects are approximated to correct the curvature and closed with running absorbable sutures.
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Figure 6. Albugineal sutures in a 63-year-old man with Peyronie disease who had undergone a Nesbit operation 15 days earlier. Longitudinal US image obtained on the side opposite the curvature shows that the penis is straight. The albugineal sutures are visible as hyperechogenic dots (arrowheads).
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Figure 7a. Albugineal patches in patients with Peyronie disease who had undergone penis lengthening operations. The grafts are identified as interruptions of the normally appreciable hyperechoic interface of the tunica albuginea. (a) Axial US image shows a dermal graft that appears as a thick, echogenic interface (arrows). (b) Axial US image obtained in a different patient shows a saphenous vein graft (arrows) that appears less echogenic than the adjacent tunica albuginea. Sutures are visible as hyperechogenic dots.
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Figure 7b. Albugineal patches in patients with Peyronie disease who had undergone penis lengthening operations. The grafts are identified as interruptions of the normally appreciable hyperechoic interface of the tunica albuginea. (a) Axial US image shows a dermal graft that appears as a thick, echogenic interface (arrows). (b) Axial US image obtained in a different patient shows a saphenous vein graft (arrows) that appears less echogenic than the adjacent tunica albuginea. Sutures are visible as hyperechogenic dots.
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Figure 8. Penile hematoma in a 24-year-old man who developed penile, scrotal, and perineal ecchymosis following corporeal plication for congenital penile curvature. Axial US image shows a large, organized extraalbugineal hematoma on the dorsal aspect of the penis (*).
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Figure 9. Recurrent penile curvature in a 64-year-old man who had undergone plaque excision with grafting 1 year earlier. Axial US image shows deformation of the left corpus cavernosum (arrowheads) due to contracture of the graft.
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Figure 10. Graft bulking in a 51-year-old man with a dermal graft complicated with veno-occlusive dysfunction. Longitudinal US image shows bulking of the graft (arrowheads) with herniation of the cavernosal tissue (*).
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Figure 11a. Epidermoid cyst in a 61-year-old man with Peyronie disease who had undergone plaque excision with dermal grafting 7 years earlier. (a) Photograph shows an elastic, mobile, painless tumescence that had developed at the site of the graft on the dorsum of the penis. (b) Axial US image shows a well-circumscribed echogenic lesion with acoustic enhancement (*). At histologic analysis, the lesion proved to be an epidermoid cyst arising from the graft, probably originating from accidental inclusion of surface epithelium.
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Figure 11b. Epidermoid cyst in a 61-year-old man with Peyronie disease who had undergone plaque excision with dermal grafting 7 years earlier. (a) Photograph shows an elastic, mobile, painless tumescence that had developed at the site of the graft on the dorsum of the penis. (b) Axial US image shows a well-circumscribed echogenic lesion with acoustic enhancement (*). At histologic analysis, the lesion proved to be an epidermoid cyst arising from the graft, probably originating from accidental inclusion of surface epithelium.
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Figure 12. Iatrogenic high-flow priapism in a 23-year-old man who developed the priapism in the early postoperative period following corporeal plication for congenital penile curvature. Axial color duplex US image of the distal portion of the penile shaft shows an arterial-lacunar fistula of the right cavernosal artery with characteristically high systolic velocity and turbulent flow. It is conceivable that the cavernosal artery tear was produced during surgery by the needle used to create the artificial erection.
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Figure 13a. Corporeal cylinders in a 37-year-old impotent man who had undergone prosthesis implantation. Axial US images of the penile shaft obtained before (a) and after (b) inflation of the corporeal cylinders show the cylinders as anechoic structures replacing the cavernosal tissue.
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Figure 13b. Corporeal cylinders in a 37-year-old impotent man who had undergone prosthesis implantation. Axial US images of the penile shaft obtained before (a) and after (b) inflation of the corporeal cylinders show the cylinders as anechoic structures replacing the cavernosal tissue.
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Figure 14a. Abdominal reservoir in a 60-year-old impotent man who had undergone prosthesis implantation. US images of the pelvis obtained before (a) and after (b) inflation of the corporeal cylinders show the abdominal reservoir of the prosthesis (*) adjacent to the bladder (B). The shape of the reservoir changes and its volume is reduced when the corporeal cylinders are inflated.
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Figure 14b. Abdominal reservoir in a 60-year-old impotent man who had undergone prosthesis implantation. US images of the pelvis obtained before (a) and after (b) inflation of the corporeal cylinders show the abdominal reservoir of the prosthesis (*) adjacent to the bladder (B). The shape of the reservoir changes and its volume is reduced when the corporeal cylinders are inflated.
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Figure 15a. Complications after penile prosthesis implantation. (a) Corporeal fibrosis in a 60-year-old diabetic man with severe penile shortening who had undergone removal of an infected penile prosthesis 2 years earlier. Axial US image shows diffuse fibrosis appearing as echogenic areas within the corpora cavernosa. (b) Penile deformation in a 40-year-old man with an inflatable prosthesis that had suddenly deflated during sexual intercourse. Longitudinal US image shows deformation of a cylinder along with fluid extravasation, findings that helped confirm the clinical diagnosis of tear.
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Figure 15b. Complications after penile prosthesis implantation. (a) Corporeal fibrosis in a 60-year-old diabetic man with severe penile shortening who had undergone removal of an infected penile prosthesis 2 years earlier. Axial US image shows diffuse fibrosis appearing as echogenic areas within the corpora cavernosa. (b) Penile deformation in a 40-year-old man with an inflatable prosthesis that had suddenly deflated during sexual intercourse. Longitudinal US image shows deformation of a cylinder along with fluid extravasation, findings that helped confirm the clinical diagnosis of tear.
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Figure 16a. Drawings illustrate surgical revascularization procedures for patients with erectile dysfunction. (a, b) Penile arterial revascularization is performed with anastomosis of the inferior epigastric artery to the dorsal artery that either retains the normal direction of blood flow (ie, from the epigastric artery to the proximal and distal portions of the dorsal artery) (a) or creates flow in the opposite direction (ie, from the epigastric artery to the proximal portion of the dorsal artery with inverted flow toward the origin of the cavernosal artery) (b). (c) In deep dorsal vein arterialization, the inferior epigastric artery is anastomosed end-to-side to the deep dorsal vein without ligation of the emissary veins. The deep dorsal vein is then ligated proximal to the retrocoronal plexus.
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Figure 16b. Drawings illustrate surgical revascularization procedures for patients with erectile dysfunction. (a, b) Penile arterial revascularization is performed with anastomosis of the inferior epigastric artery to the dorsal artery that either retains the normal direction of blood flow (ie, from the epigastric artery to the proximal and distal portions of the dorsal artery) (a) or creates flow in the opposite direction (ie, from the epigastric artery to the proximal portion of the dorsal artery with inverted flow toward the origin of the cavernosal artery) (b). (c) In deep dorsal vein arterialization, the inferior epigastric artery is anastomosed end-to-side to the deep dorsal vein without ligation of the emissary veins. The deep dorsal vein is then ligated proximal to the retrocoronal plexus.
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Figure 16c. Drawings illustrate surgical revascularization procedures for patients with erectile dysfunction. (a, b) Penile arterial revascularization is performed with anastomosis of the inferior epigastric artery to the dorsal artery that either retains the normal direction of blood flow (ie, from the epigastric artery to the proximal and distal portions of the dorsal artery) (a) or creates flow in the opposite direction (ie, from the epigastric artery to the proximal portion of the dorsal artery with inverted flow toward the origin of the cavernosal artery) (b). (c) In deep dorsal vein arterialization, the inferior epigastric artery is anastomosed end-to-side to the deep dorsal vein without ligation of the emissary veins. The deep dorsal vein is then ligated proximal to the retrocoronal plexus.
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Figure 17a. Epigastric artery–dorsal artery anastomosis in a 32-year-old impotent man who had undergone penile arterial revascularization. (a) Longitudinal color Doppler US image obtained on the dorsal aspect of the base of the penis shows retrograde revascularization of the dorsal artery (arrowhead) with the epigastric artery (arrow). (b) Axial US image of the penile shaft shows abnormal enlargement of the corpus spongiosum (*).
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Figure 17b. Epigastric artery–dorsal artery anastomosis in a 32-year-old impotent man who had undergone penile arterial revascularization. (a) Longitudinal color Doppler US image obtained on the dorsal aspect of the base of the penis shows retrograde revascularization of the dorsal artery (arrowhead) with the epigastric artery (arrow). (b) Axial US image of the penile shaft shows abnormal enlargement of the corpus spongiosum (*).
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Figure 18a. Physiologic changes in a 36-year-old man who had undergone arterialization of the deep dorsal vein 8 years earlier. Postoperative US was performed after intracavernous administration of vasoactive drugs. (a) Axial US image demonstrates engorgement of the corpus spongiosum (*), which appears larger than the corpora cavernosa. (b) Longitudinal US image of the distal portion of the corpora cavernosa demonstrates enlargement of the corpus spongiosum (*) and dilatation of the perispongiosal veins (arrowheads). (c) Axial US image shows the deep dorsal vein with a thick, stratified wall as a consequence of arterialization (arrows).
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Figure 18b. Physiologic changes in a 36-year-old man who had undergone arterialization of the deep dorsal vein 8 years earlier. Postoperative US was performed after intracavernous administration of vasoactive drugs. (a) Axial US image demonstrates engorgement of the corpus spongiosum (*), which appears larger than the corpora cavernosa. (b) Longitudinal US image of the distal portion of the corpora cavernosa demonstrates enlargement of the corpus spongiosum (*) and dilatation of the perispongiosal veins (arrowheads). (c) Axial US image shows the deep dorsal vein with a thick, stratified wall as a consequence of arterialization (arrows).
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Figure 18c. Physiologic changes in a 36-year-old man who had undergone arterialization of the deep dorsal vein 8 years earlier. Postoperative US was performed after intracavernous administration of vasoactive drugs. (a) Axial US image demonstrates engorgement of the corpus spongiosum (*), which appears larger than the corpora cavernosa. (b) Longitudinal US image of the distal portion of the corpora cavernosa demonstrates enlargement of the corpus spongiosum (*) and dilatation of the perispongiosal veins (arrowheads). (c) Axial US image shows the deep dorsal vein with a thick, stratified wall as a consequence of arterialization (arrows).
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Figure 19a. Aneurysmal dilatation of an anastomosis in a 36-year-old man who had undergone arterialization of the deep dorsal vein 8 years earlier and had developed a slowly enlarging lump on the dorsal aspect of the penile base. (a) Photograph shows the clinical appearance of the tumescence. (b) Sagittal color Doppler US image demonstrates an aneurysm originating at the anastomosis between the inferior epigastric artery and the deep penile dorsal vein.
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Figure 19b. Aneurysmal dilatation of an anastomosis in a 36-year-old man who had undergone arterialization of the deep dorsal vein 8 years earlier and had developed a slowly enlarging lump on the dorsal aspect of the penile base. (a) Photograph shows the clinical appearance of the tumescence. (b) Sagittal color Doppler US image demonstrates an aneurysm originating at the anastomosis between the inferior epigastric artery and the deep penile dorsal vein.
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Figure 20a. High-velocity blood flow in a 27-year-old man with nonischemic priapism. The base of the penile shaft had been crushed against the gas tank of the patient’s motorcycle during a road accident. (a) Sagittal color Doppler US image of the left corpus cavernosum shows the cavernosal artery (arrowheads) and a color blush in the area of the cavernosal artery tear (*). (b) Color duplex US image of the fistula shows high-velocity turbulent flows. (c) Angiogram shows extravasation of contrast material from the torn vessel (arrowhead), a finding that indicates arterial laceration. (d) Angiogram obtained after embolization shows occlusion of the fistula.
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Figure 20b. High-velocity blood flow in a 27-year-old man with nonischemic priapism. The base of the penile shaft had been crushed against the gas tank of the patient’s motorcycle during a road accident. (a) Sagittal color Doppler US image of the left corpus cavernosum shows the cavernosal artery (arrowheads) and a color blush in the area of the cavernosal artery tear (*). (b) Color duplex US image of the fistula shows high-velocity turbulent flows. (c) Angiogram shows extravasation of contrast material from the torn vessel (arrowhead), a finding that indicates arterial laceration. (d) Angiogram obtained after embolization shows occlusion of the fistula.
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Figure 20c. High-velocity blood flow in a 27-year-old man with nonischemic priapism. The base of the penile shaft had been crushed against the gas tank of the patient’s motorcycle during a road accident. (a) Sagittal color Doppler US image of the left corpus cavernosum shows the cavernosal artery (arrowheads) and a color blush in the area of the cavernosal artery tear (*). (b) Color duplex US image of the fistula shows high-velocity turbulent flows. (c) Angiogram shows extravasation of contrast material from the torn vessel (arrowhead), a finding that indicates arterial laceration. (d) Angiogram obtained after embolization shows occlusion of the fistula.
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Figure 20d. High-velocity blood flow in a 27-year-old man with nonischemic priapism. The base of the penile shaft had been crushed against the gas tank of the patient’s motorcycle during a road accident. (a) Sagittal color Doppler US image of the left corpus cavernosum shows the cavernosal artery (arrowheads) and a color blush in the area of the cavernosal artery tear (*). (b) Color duplex US image of the fistula shows high-velocity turbulent flows. (c) Angiogram shows extravasation of contrast material from the torn vessel (arrowhead), a finding that indicates arterial laceration. (d) Angiogram obtained after embolization shows occlusion of the fistula.
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Figure 21a. Idiopathic ischemic priapism. (a) Sagittal color Doppler US image of the right corpus cavernosum obtained in a 32-year-old man shows no flow in the cavernosal artery (arrowheads). In addition, no flow was appreciated in the contralateral cavernosal artery. (b) Sagittal color duplex US image of the right corpus cavernosum obtained in a 45-year-old man shows very low-velocity high-resistance flows. Similar findings were appreciated in the left corpus cavernosum.
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Figure 21b. Idiopathic ischemic priapism. (a) Sagittal color Doppler US image of the right corpus cavernosum obtained in a 32-year-old man shows no flow in the cavernosal artery (arrowheads). In addition, no flow was appreciated in the contralateral cavernosal artery. (b) Sagittal color duplex US image of the right corpus cavernosum obtained in a 45-year-old man shows very low-velocity high-resistance flows. Similar findings were appreciated in the left corpus cavernosum.
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Figure 22. Corporeal fibrosis in a 32-year-old man with ischemic priapism who had undergone glans–corpus cavernosum anastomosis performed with the Winter technique 1 month earlier and had subsequently become impotent. On an axial US image of the penile shaft, the echogenicity of the corpora cavernosa is diffusely increased due to fibrosis caused by ischemic damage.
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Figure 23. Drawing illustrates a glans–corpus cavernosum shunt created for the treatment of ischemic priapism using the Winter technique. A large biopsy needle is inserted percutaneously through the glans and deep into the corpora cavernosa.
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Figure 24a. Glans–corpus cavernosum shunts in patients with ischemic priapism. On longitudinal US images of the right corpus cavernosum (CC) obtained in a 32-year-old man who had undergone shunt creation with the Winter technique (a) and in a 45-year-old man who had undergone shunt creation with the El-Ghorab technique (b), the shunt (open arrow in a, arrow in b) appears as an interruption of the tunica albuginea (arrowheads). In a, the wound created by the biopsy needle appears as an anechoic tubular structure (solid arrows) extending from the glans (*) into the corpus cavernosum. In b, only the albugineal interruption is appreciable.
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Figure 24b. Glans–corpus cavernosum shunts in patients with ischemic priapism. On longitudinal US images of the right corpus cavernosum (CC) obtained in a 32-year-old man who had undergone shunt creation with the Winter technique (a) and in a 45-year-old man who had undergone shunt creation with the El-Ghorab technique (b), the shunt (open arrow in a, arrow in b) appears as an interruption of the tunica albuginea (arrowheads). In a, the wound created by the biopsy needle appears as an anechoic tubular structure (solid arrows) extending from the glans (*) into the corpus cavernosum. In b, only the albugineal interruption is appreciable.
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Figure 25. Neourethral hair growth in a 41-year-old transsexual patient who had undergone sex reassignment 5 years earlier. Phalloplasty was complicated by extrusion of the prosthetic cylinders from the neophallus and anastomotic urethral stenosis that required explantation of the prosthesis, closure of the urethral anastomosis, and urinary diversion at the base of the neophallus. The patient presented because of pus discharge from the defunctionalized neourethra. On a longitudinal US image of the neophallus obtained following retrograde distention of the neourethra with saline solution, the terminal portion of the neourethra at the base of the neophallus is filled with hair (arrowheads).
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Figure 26. Neophallic vascular supply in a 24-year-old transsexual patient who had undergone phalloplasty in which the neourethra had not been created (modified Chang technique). On an axial color Doppler US image, the neophallus appears heterogeneous owing to the presence of subcutaneous and muscular tissue. Both arterial (arrow) and venous (arrowheads) vascularization are appreciated.
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Copyright © 2005 by the Radiological Society of North America.
