Original Article
Evaluation of Erectile Dysfunction with Color Doppler Sonography
Vaqar Bari, M. Nadeem Ahmed, M. Zafar Rafique, Kashif Ashraf, Waseem Ahmad Memon, M. Uzair Usman Radiology Department, Aga Khan University Hospital, Karachi Abstract
Objective: To assess the role of Color Doppler Sonography in the evaluation of erectile dysfunction.
Methods: A cross-sectional study was conducted at the Radiology Department, Aga Khan University Hospital
Karachi from 5-6-2002 to 2-9-2003. All consecutive patients presenting with erectile dysfunction and undergoing
penile color Doppler evaluation with injection PGE1 20 mcg were included in this study.
Results: A total of 70 patients with an age range of 24-70 years {mean 41+ 12.25 years} were included in the
study. A normal response was noted in 45 (psychogenic) cases. Vasculogenic causes were observed in 23
patients, 12 with arterial insufficiency and 11 with venous leak. Peyronie's disease was diagnosed in 2 patients.
Conclusion: Color Doppler evaluation of erectile dysfunction is an effective method for differentiating psy-
chogenic and vasculogenic causes of erectile dysfunction (JPMA 56:258;2006).
Department, Aga Khan University Hospital Karachi from5-6-2002 to 2-9-2003. A total of 70 consecutive patients Color Doppler sonography can be useful in the eval- uation of erectile dysfunction, which can result from psy- presenting with erectile dysfunction and undergoing penile chogenic, endocrinologic, neurogenic, pharmacologic, and color Doppler evaluation with injection Prostaglandin E1 vasogenic causes. It is used to determine the integrity of the A grey scale ultrasound was performed in both lon- The National Institutes of Health (NIH) Consensus gitudinal as well as transverse sections to see any plaque or Development Conference1 advocated that "erectile dysfunc- abnormality. This was followed by a baseline study of the tion" be used instead of "impotence" to describe disorders of cavernosal arteries and pre-injection velocities were record- male sexual function and defined the new terminology as ed. A brief history was taken and adequate privacy and quiet the "inability to achieve an erect penis as part of the overall surrounding was provided to allay patient anxiety as much multifaceted process of male sexual function." However, as possible. The study was performed by one of three expe- use of the term "erectile dysfunction" to refer to all aspects rienced radiologists. All studies were performed on GE of male sexual dysfunction would be inappropriate.
Logiq 500 and Aloka Prosound SSD 4000 Doppler Although the exact prevalence of erectile dysfunc- machines with high frequency transducer and duplex and tion in the United States male population is not known, esti- color Doppler facility. Sampling factors, accurate gate mates have ranged from 12% of males above age 18 in the placement and angle correction was optimized for consis- report of Furlow2 to 25-30% of men between ages 60 and 70 tent and reproducible results. Spectral waveforms from the in the surveys of Kinsey and colleagues2, Schiavi and col- cavernosal artery were measured at the base of penis as leagues3 and Diokno and colleagues4 and 52% in the velocities are highest here and angle correction is optimal.
Massachusetts Male Aging Study.5 Disorders of sexual Intracavernosal injection of 20 microgram of function are common among men of all ages, ethnicities and prostaglandin E1 with a 28 G needle close to the base of cultural backgrounds. It has been estimated that more than penis was given and massaged in. Measurements of peak 152 million men worldwide experienced erectile dysfunc- systolic and end-diastolic velocities were obtained in each tion in 1995, and that this number will rise by 170 million, cavernosal artery at 5-min intervals for a total of 30 minutes.
to approximately 322 million by the year 2025.6 A peak systolic velocity of less than 25 cm/sec was used as The objective of this study was to assess the role of the threshold for arterial insufficiency. An end-diastolic color Doppler sonography in the evaluation of erectile dys- velocity of greater than 5 cm/sec was used to predict venous incompetence. The images were recorded and printed onpaper. Erection was graded at 10 minutes as follows: 1- no Patients and Methods
erection; 2- slight tumescence; 3- full volume without rigid- ity; 4- incomplete rigidity but sufficient for sexual intercourse; 5- full erection with unbending rigidity.
E1 for self injection.9 Prostaglandin E1 because of its effica- cy and safety (low priapism rates) is the drug of choice forfirst penile injection. The demonstration that vasoactive Seventy patients with an age range of 24-70 years injections could produce penile erection without benefit of (mean 41 + 12.25 years) were included in the study. A vast psychic or tactile stimuli revolutionized the diagnosis and majority was in the 30-40 years age group (42%). Two treatment of erectile dysfunction by providing a direct test patients had primary erectile dysfunction and sixty eight of end organ integrity and offering an etiology specific ther- had developed this problem after a period of normal sexual activity. Both patients with primary erectile dysfunction had In contrast to pudendal arteriography, duplex sonog- arterial insufficiency on Doppler study. The duration of raphy is not invasive and can be performed in the office set- symptoms varied from 2 months to 3 years in cases of ting. The high resolution ultrasound probe allows the sono- acquired erectile dysfunction. Four patients had diabetes grapher to image the individual cavernous arteries selective- mellitus and all of them had arterial insufficiency.
ly and perform Doppler blood flow analysis simultaneously.
A normal response was noted in 45 subjects (64%) A fall of resistance within the corporeal vascular bed and and their problem was considered to be psychogenic. Most the subsequent increase in arterial inflow are the major vas- of them achieved a peak systolic velocity of 50 cms/ sec and cular events leading to erection of the penis.10 A dramatic had either reversal of flow in diastole or an end diastolic increase in penile arterial blood flow to about 25 to 60 times velocity less than 5cms/sec. The highest peak systolic that of the flaccid state occurs during the rapid period of velocity achieved was 105 cms/sec. Detumescence was tumescence. Pulse Doppler analysis studies with intracav- noted in all these cases in about 20-35 minutes. No priapism ernous vasoactive drug injections have established that a peak cavernosal artery systolic flow greater than 25 ml/sec Vasculogenic causes were noted in 23 patients is required for erection to occur.11 At full rigidity, an (33%), 12 with arterial insufficiency and 11 with venous increase in penile length of 7.5 cm usually requires the leak. The lowest peak systolic velocity in arterial insuffi- entrapment of 80-115 ml of blood. As the penile volume ciency patients was 10-13 cms/sec and highest velocity increases to near maximum (from <10 ml in the flaccid state achieved was 22cms/sec. In patients with venous leak, the to 60 ml in the erect state), the arterial influx declines and end diastolic velocity was above 6cms/sec and highest plateaus at a level that is sufficient to keep the penis in the velocity recorded was 16-17 cms/sec. No patient in the vas- rigid (full erection) state. Dynamic infusion cavernosometry culogenic group achieved a satisfactory erection. and cavernosography (DICC) studies have shown that a Peyronie's disease was diagnosed in 2 patients (3%) fluid flow rate between 5 and 40 ml/min is required to main- with plaques in tunica albuginea and one of them had a tain a normal penis in the erect state.12 A peak systolic characteristic development of curvature with discomfort velocity of at least 35 cm/sec indicates normal arterial sup- during the Doppler evaluation. The other patient did not ply. At peak systolic velocities less than 35 cm/sec, the like- develop curvature during the study. These two patients had lihood and severity of arterial disease increase as the peak some delayed response to the injection but did not reveal systolic velocity decreases, with a peak velocity less than 25 arterial insufficiency or venous leak.
cm/sec indicating a high likelihood of severe arterial dis-ease.13 Discussion
Vascular insufficiency is probably the most common The normal male sexual response cycle can be func- cause of organic male sexual dysfunction.14 Erectile dys- tionally divided into five interrelated events that occur in a function(ED) secondary to excessive venous leakage is defined sequence: libido, erection, ejaculation, orgasm, and being reported with significant frequency in clinical stud- detumescence. The functional classification of the male sex- ies.15 Penile diseases, such as congenital malformation, ual cycle is the most physically quantifiable one.
Peyronie's disease, priapism and phimosis may interfere In 1982 during a vascular reconstructive procedure, with erectile function. Vasculogenic ED patients have more Ronald Virag noted that infusion of papaverine into the markedly impaired endothelial and smooth muscle func- hypogastric artery produced erection. In 1983 a dramatic tions compared with patients having similar risk factors but demonstration of the efficacy of penile self injection was no ED.16 The prevalence of co morbidities, such as vascularconditions, increased with ED severity, which may indicate Vol. offered by Charles Brindley, who injected himself.7 In 1985 Lue et al introduced the technique of high resolution sonog- that ED is a prognostic marker of overall health and an raphy and quantitative Doppler spectrum analysis.8 In 1986 Ishii published the first clinical series on prostaglandin PGE-1 (alprostadil) is a metabolite of arachidonic acid and is a potent smooth muscle relaxant and acute phase (<12 months) of the disease when the plaque is vasodilator in man. It also has an α-2 adrenergic blocking unstable. Oral therapeutic agents include vitamin E, effect and hence has the potential of reducing sympathetic p-aminobenzoate. Other forms of medical therapy may overtone in patients with psychogenic erectile dysfunction.
include local or systemic glucocorticoids and the intrale- The overall erectile response to prostaglandin intracorpore- sional injection of a collagenase or a calcium channel block- al injections is about 70%.18 Pain is the most common side er (e.g., Verapamil). Medical therapy may help patients with effect, occurring in 13-80% of patients and is dose-related.
moderate disease, whereas surgical correction is the treat- Other side effects associated with PGE-1 injections include ment of choice for those with severe penile deformity.
local corporeal haematoma or ecchymosis (8%), prolonged Color Doppler evaluation of erectile dysfunction is erection to between 4 and 6 hours (5%), priapism of greater an effective method for differentiating psychogenic and vas- than 6 h (1%), penile oedema (2%), and fibrosis (2.3%).19 culogenic causes of erectile dysfunction. As the choices for About 40% of patients with impotence have evi- therapy increase and become more etiology specific clini- dence of abnormal arterial flow. Generally, these conditions cians may look to testing like color Doppler ultrasound to are amenable to surgical correction, and about 60% of these develop vascular profiles to help predict treatment success patients recover spontaneous erectile function postopera- with one or a combination of several agents.
tively. The NIH Consensus Development Conference on References
Impotence, held in 1992, recommended that surgical revas-cularization of the penis be considered experimental and be National Institutes of Health 1993 NIH Consensus Conference: Impotence.
[ NIH Consensus Statement 1992;10:1-31] JAMA. 1993:83-90.
performed only by expert surgeons and as part of clinical Kinsey AC, Pomeroy WB, Martin CE. Early sexual growth and activity. In: Sexual Behavior in the Human Male. WB Saunders Co., Philadelphia, PA,1948, pp. 157-92. Venous ligation results in initial recovery of erectile Schiavi RC, Schreiner-Engel P, Mandeli J, Schanzer H, Cohen E Healthy function within the first 6 months of the surgery as reported aging and male sexual function. Am J Psychiatry 1990;147:766-71. in 60% to 70% of patients.20 However, the long-term suc- Diokno AC, Brown MB, Herzog AR. Sexual function in the elderly. ArchIntern Med 1990; 150:197-200.
cess rate of penile vein ligation is poor, with only about 20% Feldman HA, Goldstein I, Hatzichristou DG, Krane RJ, McKinlay JB.
of patients able to have normal intercourse more than 1 year Impotence and its medical and psychosocial correlates: results of the Massachusetts Male Aging Study. J Urol 1994;151:54-61.
Ayta IA, McKinlay JB, Krane RJ. The likely worldwide increase in erectile Erectile function is an important question in lawsuits dysfunction between 1995 and 2025 and some possible policy consequences.
for divorce, rape, and damages. Lawyers may abuse the assertion of ED in lawsuits for divorce and rape. Doppler Brindley GS. Cavernosal alpha-blockade: a new technique for investigatingand treating erectile impotence. Br J Psych 1983;143:332-37.
evaluation is of considerable help in such cases. The inves- Lue TF, Hricack H, Marich KW, Tanago EA. Vasculogenic impotence evalu- tigation, interpretation, and characteristics of medicolegal ated by high resolution ultrasonography and pulsed Doppler spectrum analy- cases may differ in countries with different cultures. The Ishii N, Watanabe H, Irasawa C. Kikuchi Y, Kobata Y, Kawamura S, et. al.
availability of effective and well-tolerated oral medications Intracavernous injection of prostaglandin E1 for the treatment of erectile has dramatically changed the clinical approach to erectile dysfunction. Pharmacotherapy is the preferred cost-effec- Christ GJ .The penis as a vascular organ. The importance of corporal smoothmuscle tone in the control of erection. Urol Clin North Am 1995;22:727- 45.
tive first-line therapy in the vast majority of patients.22 Fitzgerald SW, Erickson SJ, Foley WD, Lipchik EO, Lawson TL. Color A new noninvasive method for penile Doppler ultra- Doppler sonography in the evaluation of erectile dysfunction. Radiographics1992 ;12:3-17.
sound (PDU) evaluation of erectile dysfunction using oral Padma-Nathan H. Dynamic infusion cavernosometry and cavernosography sildenafil citrate (Viagra) as an erection induction agent has (DICC) and the cavernosal artery systolic occlusion pressure gradient: a com- been used. The results of PDU with oral sildenafil citrate plete evaluation of the hemodynamic events of a penile erection. In: Lue TF(ed) World Book of Impotence. Smith-Gordon, London: 1992, pp. 101-3.
were not statistically different from prostaglandin E1.
CB Benson, JE Aruny, MA Vickers Jr. Correlation of duplex sonography with Patients commented that although PGE 1 was the strongest arteriography in patients with erectile dysfunction. Am J Roen erectogenic agent, sildenafil citrate was the most conven- Goldstein I, Siroky MB, Nath RL, McMillian TN, Menzoian JO, Krane RJ 23 Vardenafil is another safer alternative compared to Vasculogenic impotence: role of the pelvic steal test. J Urol 1982;128:300-06. more invasive intracavernous injection and is also an alter- Wespes E, Schulman C .Venous impotence: pathophysiology, diagnosis and native for patients who fear injections.24 Yavuzgil O, Altay B, Zoghi M, Gurgun C, Kayikcioglu M, Kultursay H.
Treatment of structural penile diseases depends upon Endothelial function in patients with vasculogenic erectile dysfunction. Int J the nature of the underlying disease. Peyronie's disease can be self-limiting in many cases and may not require thera- Shabsigh R, Perelman MA, Lockhart DC, Lue TF, Broderick GA . Health issues of men: prevalence and correlates of erectile dysfunction. J Urol peutic intervention. Medical treatment is suitable in the Porst H. The rationale for prostaglandin E1 in erectile failure: a survey of Singh JC, Devasia A, Gnanaraj L, Chacko KN. Erectile dysfunction.
worldwide experience. J Urol 1996;155:802-15.
Linet OI, Ogrinc FG. Efficacy and safety of intracavernosal alprostadil in men Bacar MM, Batislam E, Altinok D, Yilmaz E, Bacar H. Sildenafil citrate for with erectile dysfunction. The Alprostadil Study Group. N Engl J Med1996;334:873-7.
penile hemodynamic determination: an alternative to intracavernosal agents in Sasso F, Gulino G, Weir J, Viggiano AM, Alcini E. Patient selection criteria Doppler ultrasound evaluation of erectile dysfunction. Urology in the surgical treatment of veno-occlusive dysfunction. J Urol Ardicoglu A, Kocakoc E, Tuygun UO, Bozgeyik Z, Orhan I. Effectiveness Wespes E, Moreira de Goes P, Sattar AA, Schulman C. Objective criteria in of vardenafil versus papaverine in penile Doppler ultrasonography. Urol Int the long-term evaluation of penile venous surgery. J Urol 1994;152:888-90.

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