a

Penile and Perineal Doppler Ultrasound Demonstration

in this short video we will detail the

techniques we would like you to acquire

during the hands-on portion of the

course there are three primary goals of

the hands-on portion of the course the

first will be for you to become familiar

with the Penal scan this will include

the standard transducer orientation and

scanning technique

the second goal will be to have you

measure the peak systolic velocity and

end diastolic velocity of both the

flaccid phallus as well as the radial

artery the third goal will be to have

you perform a perineal scan and identify

both the urethra and cavernosa bodies

progressing proximally to distally we

would then like you to measure the right

and left Bobo cavernosum muscle in the

transverse projection this will include

both the width measurement at 3 points

and the area of the Bobo cavernosa

smuzzle

the transverse penal anatomy

demonstrates paired kevin hustle bodies

adjacent to each other with the urethra

ventral to the cavernosa bodies there

are three sets of arteries the dorsal

penile arteries the cavernosa Lottery's

and the bow-bow urethral arteries note

that the cavernosa bodies are closest to

the transducer when a ventral approach

is used while the urethra is the first

structure to be interrogated when

viewing from the ventral approach more

compression of the urethra is seen in

the ventral as compared to the dorsal

approach the internal pudendal artery

give rise to three branches the first

are the bobal urethral arteries which

enter the corpus spongiosum structures

the second are the paired dorsal penal

arteries and the third are the paired

cavernosa Lottery's please note again

that in the longitudinal as in the

transverse view that the cavernosa

bodies are closest to the transducer

when a dorsal approach is used while the

urethra is the first structure to be

interrogated when viewing from the

ventral approach more compression of the

urethra is again seen in the ventral as

compared to the dorsal approach

Asian is first draped to allow adequate

access to the fallacy at preserve the

patient's privacy the initial component

of any ultrasound study is a survey scan

with P knowledge or sound studies the

patient is supine and either the phallus

is allowed to drape over the scrotum

where as held by the patient up as shown

in the upper images the ultrasonographer

uses his or her dominant hand to hold

the transducer and the other hand to

manipulate the controls on the

ultrasound machine the standard

orientation on the ultrasound screen

should be as shown in the lower figure

with the right side of the phallus on

the left and the left side of the

phallus on the right

the most common movements used for

scanning the phallus is either a

translational movement called painting

or a non translational movement termed

Fanning we're demonstrating on this

model the translational movement

painting from the base to distal on the

dorsal surface of the phallus

again from a slightly different

perspective we show the translational

movement of the ultrasound transducer

along the dorsum of the phallus here we

demonstrate transverse scanning from the

ventral aspect of the phallus by

convention the orientation on the screen

is similar to that of a CT scan in which

the right side of the phallus is on the

left side of the screen and the left

side of the phallus is on the right side

of the screen the right left orientation

of the screen is maintained regardless

of whether they phallus his image from

the dorsal or ventral aspect the

longitudinal survey scan is a

combination of both translational

movement called painting as well as the

non translational movement called

Fanning in this model the survey scan is

being performed on the dorsal aspect of

the phallus in this video clip the

survey scan is performed on the ventral

aspect of the phallus

the longitudinal survey scan provides an

opportunity to visualize the cavernosa

lotteries as well as any abnormalities

present in the corpora cavernosa please

note the micro calcifications

demonstrated in the scan

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for the purpose of today's hands-on

exercise we will be performing the

spectral Doppler examination at baseline

that is before any pharmacologic

injection is given this video highlights

the difficulty that is often found when

trying to interrogate the cavernosa l--

artery in the flaccid phallus the peak

systolic velocity is less than five to

nine centimeters per second and the

diastolic velocity is zero in the

flaccid phallus

after pharmacologic stimulation both the

cavernosa lottery and spectral doppler

waveform are much easier to see

the resistive index is calculated from

the equation peak systolic velocity

minus end diastolic velocity over peak

systolic velocity the resistive index is

one in the flaccid phallus and then

decreases as the cavernosa lottery

dilates and eventually with a fully

erect phallus returns to one or greater

although we will not be performing a

penal injection today I thought it

important to describe the technique that

we use this technique is used when the

physician is performing the injection

and as effective in minimizing

discomfort for the patient if the

physicians dominant end is of the right

then we would choose to inject into the

left side of the phallus we locate an

area in the middle third of the exposed

portion of the phallus we try at all

times to keep the syringe which has a 28

or smaller gauge needle and is no longer

than half an inch pointed from the left

towards the right cavernosa body we

first point to the area we would like to

inject into then quickly touch the skin

and push the needle in with one quick

movement and then inject the medication

the skin of the phallus is the primary

site of pain for the patient therefore

we minimize the time the needle is in

contact with the skin

gained practice with measurement of the

spectral Doppler waveform of an artery

we will be using the radial artery we

would like to make sure that each

participant is comfortable in being able

to align the transducer with the artery

to visualize the artery and make sure

that the angle of Correction is less

than 60 degrees you should then measure

the peak systolic velocity and end

diastolic velocity as well as the

acceleration time

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the models arm should be outstretched on

the table you should then palpate the

radial artery apply ultrasound gel to

the skin over the radial artery and then

position the transducer parallel to the

artery and aligned with the direction of

blood flow

[Music]

when viewing the ultrasound image on the

screen align the cursor with the

arterial blood flow please make sure

that the angle of incidence is no

greater than 60 degrees ideally the

width of the caliber should be no

greater than 75% of the width of the

artery the next sequence of videos

demonstrate the measurement of the peak

systolic velocity the end diastolic

velocity and the acceleration time the

resistive index in this case is one

point two three and was calculated by

the ultrasound machine

another technique to learn is that of

perineal ultrasound please note that

although we use the term bobo cavernosa

smuzzle in this presentation it is also

known as the bobo spongy osseous muscle

we'll first have you perform a survey

scan of the urethra and cavernosa bodies

from distal to proximal in the

transverse plane the area in red in the

top figure is the Bobo cavernosa smuzzle

draped over the urethra imaging of this

muscle we'll use both translational

motion and non translational techniques

term painting and fanning respectively

at all times you should be aware of the

orientation of the ultrasound transducer

and be able to identify the structures

you are visualizing we will ask that you

that in the transverse plane you measure

the width of the right and left aspects

of the Bobo cavernosa smuzzle as well as

along the tendinous Rafi in the same

projection you will then be asked to

measure the area of the Bobo cavernosa

smuzzle you will then turn the

transducer and perform a survey scan in

the longitudinal direction to

interrogate the urethra to begin the

examination the patient should be

supplied with the legs in a frog-leg

position to enable the sonographer to

gain access to the perineum the area of

interest is the aina genital line as

indicated in the left illustration

the transverse survey scan utilizes a

translational movement called painting

to move the transducer along the

perineum while maintaining the

horizontal orientation

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an additional transducer movement called

Fanning is also used this is especially

useful when examining the Bulbul

cavernosa smuzzle to assure that a

transverse and not an oblique view is

obtained

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here we used the translational movement

of painting to scan the urethra and Bobo

cavernosa smuzzle in this video clip we

are using the non translational movement

of Fanning to assure the best view of

the Bobo cavernosa smuzzle for

measurements to be taken we also ask

that you turn on color Doppler and

follow the cavernosa land urethral

arteries throughout their course in the

perineum as shown in this video you

should obtain the best transverse image

of the Bobo cavernosa smuzzle this

should be where the urethra is seen is

round this orientation will prevent

obtaining an oblique view which might

overestimate the dimensions of the Bobo

cavernosa smuzzle you will then measure

the right and left Bobo cavernosa

smuzzle the Bobo cavernosa area as shown

in the next several images is most often

obtained by freehand drawing using the

trackball on the ultrasound unit

demonstrated in these images our Bobo

cavernosum muscle areas in three

different patients ranging from 1.06

centimeter squared to 0.61 centimeter

squared

to conclude the perineal scan we would

like you to perform a longitudinal

survey scan of the urethra identifying

the area of the bulbar urethra as well

as the location of the paired urethral

arteries with color Doppler try also to

follow the cavernosa bodies to their

proximal tip and identify the cavernosa

lottery from its origin and follow it

distally

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