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A Review on Penile Doppler and Ultrasonography for Erectile Dysfunction - Beyond the Abstract

Penile duplex Doppler Ultrasound (PDDU) has become a key diagnostic tool in the evaluation of erectile dysfunction (ED) and Peyronie’s disease. Among the multiple known etiologies that explain the cause of ED, organic ED due to vasculogenic causes has become a focused area of study, due to the association with cardiovascular disease diagnosis and prevention.1

Diagnostic modalities, such as nocturnal penile tumescence and injection cavernosometry, have been used in the past to aid in the diagnosis of ED, however, were discontinued due to the development of false negatives and inaccurate results, per AUA guidelines.2 Proper diagnosis of ED begins with a detailed past medical history and initial assessment along with validated questionnaires, such as the Sexual Health Inventory for Men (SHIM) and the International Index of Erectile Function (IIEF-5).3,4,5

PDE-5 inhibitors are considered first-line maneuvers for patients experiencing ED.6 Patients who fail to respond to these agents can consider PDDU to evaluate for organic causes and aid in understanding the nature of their erectile dysfunction.7 Color duplex Doppler ultrasound (CDDU) is considered a first-line method for diagnosis of vascular ED.1 The cavernosal arteries are assessed at regular intervals until peak systolic velocity (PSV) and end-diastolic velocity (EDV) are obtained. These parameters measured by CDDU can isolate vascular causes, such as arterial insufficiency and venous leak, from nonvascular causes as well as quantifying the particular type of vascular ED.

Vascular ED is further subdivided into arterial insufficiency, venous leak, and mixed arterial and venous insufficiency (indeterminate). Peak systolic velocity (PSV) is the main parameter used to evaluate arterial insufficiency, a condition that stops the inflow of blood to a particular organ. This condition is most commonly linked to atherosclerosis.8 A PSV of < 25cm/s or difference of > 10 cm/s between both right and left cavernosal arteries is indicative of arteriogenic ED.9 End-diastolic velocity (EDV) and resistive index are the measures used for identifying venous leak, or insufficient penile blood retention.9 An EDV of > 5 cm/s and RI of < 0.8 cm/s is indicative of venous leak and inadequate blood retention in the penis.9 An indeterminate result or a mixed arterial and venous ED is seen when arterial inflow is normal, but there is still a poor erectile response. The use of penile Doppler ultrasound is inefficient in diagnosing indeterminate ED because venous competence cannot be measured in a patient with significant arterial insufficiency.10

Penile ultrasound can also be a useful tool in diagnosing Peyronie’s disease. On gray-scale US, focal hyperechoic thickening of the tunica albuginea can be visualized.10 Increased Doppler signal demonstrating hyperperfusion of the plaques can be useful in identifying inflammation in the condition as well.9

PDDU has some limitations to its use, such as being operator-dependent and requiring complete relaxation of the smooth muscle for accurate results. Additionally, measurement of PSV and EDV at different anatomic locations using Doppler imaging has been shown to cause variability.1 One must be aware of the technique and limitations of penile duplex Doppler ultrasound in order to provide a proper diagnosis of erectile dysfunction and create an individualized management plan for the patient.

Written by: Kareem Elgendi1 & Jonathan Beilan2

  1. Class of 2024 Doctor of Osteopathic Medicine (D.O.) Candidate, Nova Southeastern University Dr. Kiran C. Patel College Of Osteopathic Medicine
  2. Advanced Urology Institute, Largo, FL, US

References:

  1. Ma M, Yu B, Qin F, Yuan J. Current approaches to the diagnosis of vascular erectile dysfunction. Transl Androl Urol. 2020;9(2):709-21
  2. Burnett AL, Nehra A, Breau RH, Culkin DJ, Faraday MM, Hakim LS, et al. Erectile dysfunction: AUA guideline. J Urol. 2018;200(3):633–41.
  3. Rosen RC, Riley A, Wagner G, Osterloh IH, Kirkpatrick J, Mishra A. The international index of erectile function (IIEF): a multidimensional scale for assessment of erectile dysfunction. Urology. 1997;49(6):822–30.
  4. Cappelleri JC, Rosen RC, Smith MD, Mishra A, Osterloh IH. Diagnostic evaluation of the erectile function domain of the International Index of Erectile Function. Urology. 1999;54(2):346–51.Rosen RC, Cappelleri JC, Smith MD, Lipsky J, Pena BM. Development and evaluation of an abridged, 5-item version of the International Index of Erectile Function (IIEF-5) as a diagnostic tool for erectile dysfunction. Int J Impot Res. 1999;11(6):319–26.
  5. Rosen RC, Riley A, Wagner G, Osterloh IH, Kirkpatrick J, Mishra A. The international index of erectile function (IIEF): a multidimensional scale for assessment of erectile dysfunction. Urology. 1997;49(6):822–30.
  6. du Moon G. Evolution of phosphodiesterase-5 inhibitors. World J Mens Health. 2015;33(3):123–4.
  7. Jung DC, Park SY, Lee JY. Penile Doppler ultrasonography revisited. Ultrasonography. 2018;37(1):16–24.
  8. Aversa A, Crafa A, Greco EA, Chiefari E, Brunetti A, La Vignera S. The penile duplex ultrasound: how and when to perform it? Andrology. 2021;9(5):1457–66.
  9. Varela CG, Yeguas LAM, Rodriguez IC, Vila MDD. Penile Doppler ultrasound for erectile dysfunction: technique and interpretation. AJR Am J Roentgenol. 2020;214(5):1112–21.
  10. Mutnuru PC, Ramanjaneyulu HK, Susarla R, Yarlagadda J, Devraj R, Palanisamy P. Pharmaco penile duplex ultrasonography in the evaluation of erectile dysfunction. J Clin Diagn Res. 2017;11(1):TC07–TC10.
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