Clinical value of spontaneous cavernous activity evaluation in identifying misdiagnosed corporal venous occlusive dysfunction in psychogenic erectile dysfunction

Abstract

Background: Previous studies have indicated that corporal venous occlusive dysfunction (CVOD) may be misdiagnosed in some patients with psychogenic erectile dysfunction (ED), as the observed venous leakage could actually reflect cavernous smooth muscle (CSM) relaxation failure due to sympathetic overactivity. Misdiagnosed CVOD can lead to inappropriate treatment decisions, such as unnecessary penile venous surgery or reliance solely on phosphodiesterase type 5 inhibitors (PDE5i), overlooking the need for psychogenic interventions. Therefore, it is important to identify the misdiagnosis of CVOD. Corpus cavernosum electromyography (CC-EMG) offers unique insights into the autonomic and myogenic integrity of CSM. This retrospective analysis aimed to evaluate the clinical value of spontaneous cavernous activity (SCA) assessment in identifying misdiagnosed CVOD in psychogenic ED.

Methods: The study enrolled 168 ED patients who underwent comprehensive evaluation using color duplex Doppler ultrasound (CDDU) and CC-EMG-based SCA assessment (amplitude and duration). Psychogenic ED was confirmed through nocturnal penile tumescence and rigidity (NPTR) monitoring. CVOD patients identified by CDDU were stratified into two subgroups based on NPTR results: psychogenic ED group (misdiagnosed CVOD) and organic ED group (actual CVOD).

Results: The cohort comprised 69 cases (41.1%) of non-vascular ED (NVED), 67 cases (39.9%) of CVOD, 15 cases (8.9%) of arterial ED (AED), and 17 cases (10.1%) of mixed ED (MED). Among CVOD patients, 30 cases were classified as misdiagnosed CVOD and 37 as actual CVOD. Comparative analysis demonstrated that the SCA parameters were significantly higher in the misdiagnosed CVOD group compared to those of the actual CVOD group, with notable differences in amplitude (305.65±196.79 vs. 172.07±86.36 µV, P=0.002) and duration (3.31±1.94 vs. 2.36±1.26 s, P=0.046). Receiver operating characteristic (ROC) curve analysis demonstrated an area under the curve (AUC) of 0.666 [P=0.02, 95% confidence interval (CI): 0.503-0.830] for SCA amplitude, with an optimal cutoff of 357.50 µV yielding 94.7% specificity and 55.0% sensitivity, indicating its potential predictive value for identifying misdiagnosed CVOD in psychogenic ED.

Conclusions: The findings suggested that elevated SCA may contribute to CVOD development in psychogenic ED through impaired CSM relaxation due to sympathetic overactivity. SCA assessment might be a useful diagnostic tool for identifying misdiagnosed CVOD in psychogenic ED. However, given the modest AUC, along with high specificity but low sensitivity of SCA parameters for diagnosing misdiagnosed CVOD, further research is needed to identify additional clinical parameters with better predictive performance.

Keywords: Erectile dysfunction (ED); cavernous smooth muscle (CSM); corporal venous occlusive dysfunction (CVOD); electromyography.

Figure 1

The parameters of spontaneous cavernous activity (amplitude and duration) by CC-EMG. Amplitude was defined as the voltage difference between the highest negative peak and the higher one of the two adjacent positive peaks. Duration is the time window in seconds between the beginning and the end of a CC-potential automatically decided by the program. CC, corpus cavernosum; CC-EMG, corpus cavernosum electromyography.

Figure 2

ROC curve analysis. Non-parametric ROC curve analysis demonstrated AUC of 0.666 (P=0.02, 95% CI: 0.503–0.830) for amplitude, and AUC of 0.615 (P=0.11, 95% CI: 0.445–0.786) for duration. The Youden index, indicating the optimal point along the ROC curve for positive prediction, was calculated at an amplitude level of 357.50 µV, with specificity of 94.7% and sensitivity of 55.0%. AUC, area under the curve; CI, confidence interval; ROC, receiver operating characteristic.