John J. Bauer, M.D. www.flinturology.com Urology Services, Inc. G-1121 West Hill Rd. Flint, Michigan 48507 Tel: 810.232.8888 Fax: 810.232.9190 Email: jbauer@flinturology.com [map]

Page contents:
Penile Doppler Ultrasound Information Sheet
Penile Injection Instructions

Penile Doppler Ultrasound is a procedure that is used to predict the response of your erectile dysfunction to vasodilator medications. It also allows the urologist to determine and document if you have an inflow or outflow type of erectile dysfunction. Erectile dysfunction has many etiologies, some respond well to the vasodilator drugs initially or for the rest of your life. Some diseases such as arteriosclerosis (associated with heart disease), high blood pressure, and diabetes exert their effects on blood vessels throughout the body, the penis included.

If your disease causes an inflow erectile dysfunction, over time or when you present to our office for the first evaluation, the vasodilator drugs may not be able to dilate the arteries feeding the erectile bodies. It would be wasteful and an inconvenience to you to try all these therapies if this study could predict their failure up front.

If you have a severe outflow erectile dysfunction, then any therapy that causes an increased inflow during erection may not be adequate for maintaining erections hard enough and/or long enough for satisfactory intercourse. Depending on the severity these outflow problems may only be adequate treated with penile prosthetics.

Equipment used:

1- 25 gauge needle and Tuberculin syringe
1- injectable papaverine (1 vial) 30-60mg or Caverject penile injection set
2- alcohol prep pads
3- three non-sterile gloves
1- Ultrasound probe-3 mhz

Procedure:

Supplies are available on the working surface of the US machine, your name, SSN# will be put into the device. In the mean time you will be laying on you back on the examining room table. A penile injection will be performed to provide the penis with a medicine that causes increased inflow by vasodilating the penile arteries. Once this is accomplished and after 5 minutes, we will do Penile Doppler US of the cavernosal arteries on both sides of the penis. We then allow you to have privacy and view a pornographic video to assist with arousal. Fifteen (15) minutes after the injection, we will do the same penile doppler study of the cavernosal arteries. To do the penile doppler study we simply lubricate the end of the probe and place it on the penis. There is no pain involved during this portion of the procedure. You will experience a very short, mild discomfort initially during the penile inject. Please find the explanation and description of the penile injection procedure below.

Evaluation:

The information obtained will help the urologist determine if you have an inflow or outflow problem.

If you have an out flow leak, the end diastolic velocity will be noted to greater than zero. Average end-diastolic velocity usually increases by 6-7 cm/second. During normal erections when inflow is increased, there should be no significant outflow of blood from the penis. If this portion of the test is normal and your end-diastolic flow is zero or less, you do not have an outflow problem and there is a better chance that vasoactive agents will work in your case.

If the arterial flow is normal, it should be greater than 25 cm/sec during erection, anything less will indicate an arterial inflow problem.

Patients may have a combination of inflow and outflow problems, unfortunately even though the inflow problem is potentially correctable with vasoactive agents, the outflow problem may be so severe that the overall erectile function will be inadequate. Patients with any significant out flow problem are better treated with prosthetics.

Penile injection therapy is a simple procedure that may seem to the first time user to be offensive. Many patients thought they could not do the self-injection and later, after an educational session with the doctor or erectile dysfunction nurse, they are able to perform this simple procedure without difficulty. We ask you to have an open mind and only reject this therapy if after a few instructional sessions you are unable to tolerate or perform the procedure.

General

The penis has three structures that must be avoided. Fortunately, these are very easily avoided areas. The topside (12 o'clock position) of the penile shaft where the nerves and large blood vessels run and the bottom/under side (6 o'clock position) of the penile shaft where the urethra or urinating tube runs. You should also avoid the head of the penis. Injection should be at the mid shaft level on either lateral side (3 or 9 o'clock positions). If you notice a large vein just under the skin (bluish structure), please adjust the entry point to avoid it. You should enter at a 90-degree angle until you get a blood flush in the syringe. This indicates that you are in the correct area, the spongy erectile tissue of the corpora cavernosum.

Step-wise Directions

Steps 1-5 are if you have a reusable vial.

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1. Wash your hands with soap and water.
2. Wash the top of the vial with an alcohol pad.
3. Remove the cap off the syringe, draw up some air equal to the volume you intend to inject and place the needle into the vial.
4. Inject the air in the plunger and withdraw the medication to the volume recommend by your physician. Take care to make sure the tip is in the medication solution; do not draw up air from the vial. It may help to tip over the vial during removal of the desired amount of medication.
5. Replace the cap on top of the syringe and prepare the injection site.
   

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6. Wash your hands with soap and water. Only if you have not done steps 1-5.
7. Clean the injection site with an alcohol pad, allow it to dry.
8. Grasp the head of the penis (not just the skin) with your index finger and the thumb, pulling firmly outward and to the side against your leg. This tenses the penis. It is important that the tension is maintained and that the penis is not twisted or improper injection to the topside or underside of the penis may result.
9. Hold the syringe between your thumb and index finger with the opposite hand. Aim the syringe at the injection site (between 1 and 3 o'clock or between 9 and 11 o'clock position). Do not inject the topside or underside of the penile shaft and avoid the head. Avoid obvious veins in order to reduce the possibility of bleeding or hematoma formation (swelling of a bleeding blood vessel). If this does occurs finish the injection and apply direct pressure to the site for 5 minutes.
10. With a steady, continuous motion, penetrate the skin, advancing the entire needle into the injection site. Once through the skin, a resistance will be felt initially, but continue until the syringe is hubbed. You are now in the spongy tissue of the corpus cavernosa.
11. Shift the injecting hand so that the thumb can depress the syringe plunger. Inject the entire contents of the syringe in a slow, steady motion (in about 4-8 seconds). Withdraw the needle and syringe from the penis.
12. Immediately apply pressure with an alcohol pad or a sterile gauze pad to the injection site to avoid bleeding. If bleeding is present after stopping pressure, maintain the pressure longer until the bleeding stops.
13. Dispose of the needle and the syringe using a safe disposal procedure.

I have read the above instructions and understand the technique, the physician or the erectile dysfunction nurse has adequately instructed me multiple times in the office under direct supervision.

Physician's Signature: ________________________________ Date: __________________

Patient Signature: __________________________________ Date: __________________

Witness: __________________________________ Date: __________________