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Purpose: In this study, we retrospectively reviewed the penile color Doppler ultrasound (PCDU) scans of the patients who had admitted to our clinic with erectile dysfunction and aimed to evaluate the contribution of penile Doppler scan results to the clinical decisions., Material-Method: The data of patients admitted to our outpatient clinic with complaints of erectile dysfunction (IIEF-5 score<22 or IIEF-EF score<26) between January 2005 and January 2018 were retrospectively evaluated. Patients whose testosterone level is lower than 280ng/ml or who had undergone radical prostatectomy were excluded from the analysis., Results: Three thousand ninety patients were included in the study. The mean age of our patients was 55.05±13.05 years. In total, 2139 (69%) patients had normal PCDU findings, 351 (11%) patients had arterial insufficiency, 531 (17%) patients had venous insufficiency, and 69 (2%) patients had arterial insufficiency with concurrent venous leakage. When the patients were divided into 2 groups ≤40 years (Group 1) old and >40 years (Group 2) old; normal PCDU findings were found in 432 patients (84%) of the Group 1 patients and normal PCDU findings in 1707 (66%) patients of the Group 2 patients (p<0.0001). There were arterial insufficiency findings in 24 (4.7%) and 327 (12.7%) patients of the Group 1 and 2, respectively (p=0.002)., Conclusion: The etiology is psychogenic in the majority of patients who present with ED complaints to the urology clinic. With age, the prevalence of psychogenic ED is decreasing but still more than organic., (Copyright © 2019 Asociación Española de Andrología, Medicina Sexual y Reproductiva. Publicado por Elsevier España, S.L.U. All rights reserved.)

Introduction: This study aimed to explore the time-effect of color duplex Doppler ultrasound (CDDU) in the diagnosis of vascular erectile dysfunction (ED)., Material and Methods: Using a self-control study, we included patients who underwent penile CDDU and cavernosography in our hospital. We compared the arterial peak systolic velocity (PSV) of CDDU among different intervals for the diagnosis of arterial ED. We included 357 patients who were under consideration for vascular ED., Results: We found significant differences in all the pairwise comparison of PSV in the 1st (0-5 min), 2nd (6-10 min), 3rd (11-15 min), and 4th (16-20 min) 4 intervals after the injection of prostaglandin E1 (p<0.001), except the 11-15 min vs. the 16-20 min interval (p=0.387). Using cavernosography, 294 patients were diagnosed with venous ED. Compared with other intervals, the diagnosis of CDDU 11-15 min after the intracavernous injection of 20 ug prostaglandin E1 (PGE1) had the best consistency with cavernosography (Kappa=0.761; p<0.001). Compared with other intervals, CDDU at 11-15 min had the highest specificity (93.65%), the highest Youden index (0.85), positive likelihood ratio of 14.46, positive predictive value of 98.54%, negative predictive value of 71.08% and a coincidence rate of 92.16%., Conclusions: Our findings support the increased utilization of CDDU for the diagnosis of both arterial and venous ED. The diagnosis at 11-15 min after intracavernous injection of PGE1 is accurate and stable, which would help to simplify the process and shorten the time of CDDU.

Background: This prospective study is to evaluate the potential value of sonographic measurements in the flaccid penis for the screening of arteriogenic impotence., Methods: A consecutive series of 260 Chinese males consulting for sexual dysfunction and 54 controls underwent sonographic examination. The sonographic parameters were correlated with the clinical gold standards, including the international index of erectile function (IIEF) and penile erectile hardness grading scale (EHGS). The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and area under the receiver operating characteristic curve (AUROC) of flaccid peak systolic velocity (PSV) in predicting patients with normal function were analyzed., Results: The mean cavernous PSV of both sides in the patients with sexual dysfunction ranged from 7.76 to 11.12 cm/sec with a stepwise increase in IIEF and EHGS grading scale (P < .05). The cutoff value of flaccid PSV for the differential diagnosis of grade 4 of IIEF-5 or EHGS was 8.20-8.90 cm/sec, with an AUROC of 0.657-0.724, specificity of 82.96-86.84% and PPV of 95.20-96.60%, respectively., Conclusions: This simple flaccid PSV measurement is a specific tool for screening arteriogenic impotence.

Objective: A precise characterization of erectile dysfunction (ED) of vascular origin has not yet been achieved, although cavernous peak systolic velocity (PSV) is generally considered a major parameter. Nevertheless the penile dynamic color Doppler is invasive and linked to several complications. The intima-media thicknesses (IMT) of cavernosal artery would add to the predictive value of vasculogenic ED risk and outcomes. We also hypothesized the existence of a correlation between IMT cavernosal artery and IMT carotid arteries. This study seeks to evaluate these hypotheses with our experience, investigating the predictive accuracy of carotid and cavernosal Doppler ultrasound findings for discriminating patients with vasculogenic ED., Material and Methods: A total of 59 subjects (32 vasculogenic ED patients - group A - and 27 no vasculogenic ED patients - group B) were evaluated in our andrological center from September 2012 to June 2013 and enrolled in the study. All subjects underwent medical history, erectile function domain of the International Index of Erectile Function, physical examination, routine and sex hormone blood tests, and high resolution dynamic color Doppler ultrasound evaluation of carotid and penile districts and valuation of IMT in both districts., Results: The values of cavernosal artery IMT in group A were higher than in group B (0,28 ± 0,06 mm vs 0,17 ± 0,07 mm). Even the values of carotid artery IMT in vasculogenic ED group were higher than in no vasculogenic ED group (0,74 ± 0,14 mm vs 0,59 ± 0,11 mm). The cavernosal IMT showed a moderate (r = 0.61) positive linear correlation (p < 0.001) with the carotid artery IMT., Conclusions: An increased cavernous IMT might predict ED of vascular origin with more accuracy than PSV and could be a sensitive predictor also for systemic atherosclerosis at an earlier phase.

Aim: Our aim is to introduce the cavernous artery ondulation index (CA-OI) as a new parameter that could be accepted as an indirect indicator of vascular hemodynamics and also gives us information about the efficiency of erection., Patients and Methods: A total of 27 patients with erectile dysfunction were evaluated with penile Doppler ultrasonography (PDUS). After injection of papaverine intracavernously, arterial diameter and peak-systolic and end-diastolic velocities were measured. For measuring at a standart time, five minutes after injection, bilateral cavernosal arteries were examined and gray scale and color Doppler US images through the long axis were recorded at the mentioned phases. Cavernosal artery ondulation index (CA-OI) showing the amount of ondulation was calculated for each subject using these images., Results: In 9 of total 27 patients, erection could not pass the tumescence phase with 3 flaccid phases, while the remaining 18 had full erection. Mean CA-OI values were measured as 2.51±0.37 mm, 3.15±0.38 mm, and 2.68±0.09 mm in normal, arterial insufficiency and venous insufficiency groups, respectively., Conclusions: It is possible to differentiate the arterial insufficiency by using the cut-off value of CA-OI ≥ 2.5 values as a criteria.

Introduction: The objective of this study was to explore the role of intracavernous injection (ICI) and audiovisual sexual stimulation (AVSS) during real-time pharmacopenile Doppler ultrasonography (PDDU) in vasculogenic subtypes of erectile dysfunction., Materials and Methods: A total of 200 consecutive men with erectile dysfunction (ED) were enrolled. Each patient received 2 sessions of real-time PDDU. Session A was performed under ICI alone. Session B was performed under ICI plus AVSS. The interval between sessions was 7 days. Penile vascular parameters, including peak systolic velocity (PSV), end diastolic velocity (EDV) and resistive index, were monitored 5, 10 and 20 min after the start of the test. Patients were asked to describe the level of sexual arousal generated by choosing one of the pre-set answers., Results: In veno-occlusive ED, during session A, EDV at 10 min was significantly greater than at 5 and 20 min (p < 0.05). During session B, there was a significant difference regarding PSV in arteriogenic ED (p < 0.05). Mixed vasculogenic ED showed significant differences in PSV levels during session B, and EDV at 5 min was greater than at 10 and 20 min (p < 0.05). PDDU under ICI alone diagnosed 34 (17%), 35 (17.5%), 31 (15.5%) and 100 (50%) cases of arteriogenic, veno-occlusive, mixed vasculogenic and nonvasculogenic ED, respectively. The combination of ICI plus AVSS diagnosed 27 (13.5%), 44 (22%), 7 (3.5%) and 122 (60.7%) cases, respectively., Conclusions: Adding AVSS during PDDU improves the recording of physiologic erectile response and may help the physician to accurately evaluate the cause of ED., (Copyright © 2013 S. Karger AG, Basel.)

Background: Asymmetric dimethylarginine (ADMA), a selective endogenous nitric oxide synthase inhibitor, is elevated in many conditions associated with erectile dysfunction (ED), such as hypertension, diabetes, hyperlipidemia, and renal failure; it is also increased in men with coronary artery disease and ED. The dynamic penile colour Doppler ultrasound is considered the gold standard for the evaluation of penile vascular damage., Objective: We investigated whether the extent of ultrasonographically documented penile vascular disease is associated with higher ADMA levels., Design, Setting, and Participants: One hundred four consecutive ED patients (mean age: 56 ± 9 yr) without manifest cardiovascular/atherosclerotic disease and 31 subjects with normal erectile function matched for age and traditional risk factors were studied., Measurements: We evaluated penile dynamic colour Doppler parameters of arterial insufficiency (peak systolic velocity) and veno-occlusive dysfunction (end diastolic velocity) and measured systemic inflammatory markers/mediators., Results and Limitations: Compared to men without ED, ED patients had significantly higher ADMA levels (p<0.001). ADMA was significantly increased in patients with severe arterial insufficiency (PSV<25 cm/s) compared to subjects with borderline insufficiency and men with normal penile arterial function (p<0.001, by analysis of variance). Multivariable analysis adjusting for age, mean pressure, other risk factors, high-sensitivity C-reactive protein, testosterone, and treatment showed independent inverse association between ADMA level and peak systolic velocity (p<0.01). The combination of higher ADMA level with arterial insufficiency showed greater impact on 10-yr risk of a cardiovascular event compared to either parameter alone., Conclusions: ADMA level is independently associated with ultrasonographically documented poor penile arterial inflow. This finding underlines the important role of ADMA as a marker of penile arterial damage and implies a contribution of this compound to the pathophysiology of generalised vascular disease associated with ED., (Copyright © 2011 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Introduction: The use of the penile peak systolic velocity (PSV) measured in the flaccid state during penile color Doppler ultrasound (PCDU) examination has been questioned without substantial evidence., Aim: To assess the validity of PSV measured in the flaccid state during PCDU, in patients consulting for erectile dysfunction (ED)., Methods: A consecutive series of 1,346 (mean age 55.0 +/- 12.0 years) male patients was studied., Main Outcomes Measures: All patients underwent PCDU performed both in the flaccid state and dynamic (after prostaglandin E1 stimulation) conditions. A subset of 20 subjects with uncomplicated type 2 diabetes underwent diagnostic testing for silent coronary heart disease by means of adenosine stress myocardial perfusion scintigraphy (SPECT). In these subjects penile arterial flow was simultaneously assessed by PCDU before and after systemic adenosine administration., Results: Flaccid PSV showed a significant (r = 0.513, P < 0.0001) correlation with dynamic PSV. Receiver operating characteristic (ROC) curve analysis demonstrated that when a threshold of 13 cm/seconds was chosen, flaccid PSV was predictive for dynamic PSV < 25 and <35 cm/seconds with an accuracy of 89% and 82%, respectively. Among the subset of patients who underwent SPECT, an impaired coronary flow reserve (ICFR) occurred in nine cases (45%). When the same threshold of <13 cm/seconds was chosen, PSV before SPECT was predictive of ICFR with an accuracy of 80% (area under the ROC curve = 0.798 +/- 0.10; P < 0.05). After adjustment for confounders, anxiety symptoms were related to dynamic PSV (Adj. r = -0.154, P < 0.05) but not to flaccid PSV., Conclusions: Our results show that flow in the cavernosal arteries can be routinely evaluated by PCDU in the flaccid state. Performing PCDU only in the flaccid state allows identifying subjects with pathological dynamic PSV with accuracy higher than 80%. Furthermore, our preliminary data suggest that the same examination could identify diabetic subjects with ICFR with an accuracy of 80%.

Renal transplant recipients (RTRs) have a high incidence of erectile dysfunction (ED). Differentiation of penile vasculogenic impotence from other causes is important for treatment. Conventional 2-D color Doppler assessment after intracavernosal stimulant injection often fails to produce reliable results because of limited views by the cross-sectional imaging and the painful procedure. In comparison to the findings in three healthy volunteers, we determined cavernosal vascular hemodynamics in eight RTRs with ED before and after oral sildenafil by using live 3-D ultrasound and dynamic 3-D color Doppler. Results showed that, before sildenafil, penile arterial flow signals could only be reliably detected in one patient. After sildenafil, all had reliably detectable flow with grades II to III erection. Our data suggest that 3-D volumetric changes of the penis and its vasculature during erection can be studied by this technique and that this method could be useful for the evaluation of new drugs and therapeutic biofeedback.

Recently, it was reported that phentolamine redosing during penile duplex can abolish a false diagnosis of venous leakage in patients with impotence. The aim of this study is to identify any useful role of phentolamine redosing in diagnosis of venogenic impotence. Sixty-seven consecutive patients complaining of weak erection for at least 6 months were included in this study. Penile color Doppler ultrasound (CDU) was performed using a 7.5 MHz linear array transducer with a color flow mapping capability. Following intracavernous injection of 20 microg prostaglandin E1 (PGE1), all patients with persistent end diastolic velocity (EDV) >5 cm/sec with an erectile response of E3 or lower, 20 min after intracavernosal injection of PGE1, were asked to revisit our clinic for a second CDU, 2 weeks later. During initial CDU examination, all 67 patients experienced poor response to 20 microg PGE1 with their average peak systolic velocity (PSV) and EDV being 42.8 and 6.6 cm/sec, respectively. The second CDU examination had similar results to the first one. Addition of 2 mg phentolamine did not significantly change the PSV and EDV of cavernosal arteries in any of the 67 patients. In conclusion, addition of intracavernous phentolamine during PGE1 CDU examination carries no advantage over the use of PGE1 alone regarding cavernosal artery response in patients with suspected venogenic EDV.

Background: Erectile dysfunction is a common and potentially treatable problem. Other than psychological, anatomical and metabolic factors, vasculogenic causes also play an important role in erectile dysfunction. Among the various diagnostic tools available for the diagnosis of vasculogenic causes, colour Doppler sonography is noninvasive, simple and promising., Methods: This preliminary prospective study was conducted on 40 patients with erectile dysfunction, coming from a rural background to a hospital situated in a semi-urban setting., Results: It was found that a cut-off value of 10 cm/second for peak systolic velocity in flaccid penis had the best accuracy among three chosen cut-off values, i.e. 5, 10, 15 cm/second, for detecting arterial insufficiency with sensitivity of 94.1%, specificity of 93.6%, negative predictive value of 98% and positive predictive value of 80%., Conclusion: Doppler sonography may be used as a good predictor of clinical response to intracavernosal injection of a vasodilating pharmacological agent.

Objective: To evaluate deep penile arterial flow after an intracavernosal injection with prostaglandin E1 in patients with erectile dysfunction (ED)., Methods: 527 patients with ED were evaluated using Color Doppler Ultrasonography. Diagnostic tests were undertaken after an intracavernosal injection with 20 microg prostaglandin El. The peak systolic velocity (PSV), end diastolic velocity (EDV) and resistive index (RI) were analysed., Results: There were 112 patients (26.99%) with nonvasculogenic ED, 207 patients (49.88%) with arteriogenic ED, 144 patients (34.70%)with venogenic ED, 64 patients (15.42%)with mixed ED., Conclusion: The Color Doppler Ultrasonography technique allows accurate location and evaluation of deep penile arteries. Vascular pathology may be differentiated after an intracavernosal injection with a vasomotor agent. Recognising the pathological pattern assists in choosing the best method of treatment.

Objective: To evaluate the possible relationship between the basal and dynamic diameter of the cavernous arteries and altered peak diastolic (PDV) and systolic values (PSV) in patients undergoing penile Doppler ultrasound for differential diagnosis of erectile dysfunction (ED)., Materials and Methods: From December 2003 to December 2004 we examined 132 consecutive patients suffering from erectile dysfunction and 30 controls. All patients underwent penile Doppler ultrasound in basal and dynamic conditions and all the examinations were performed by measurements of the cavernous arteries diameters in basal and dynamic conditions., Results: In the 30 healthy controls the mean cavernous arteries diameter was 0.82 mm (range 0.6-1.3 mm) on the right and 0.8 mm (range 0.5-1.25 mm) in basal conditions vs 1.30 mm (range 0.9-1.6 mm) on the right and 1.25 on the left (range 0.9 -1.60 mm) in dynamic conditions after injection of 10 microg. In the 132 patients with a diagnosis of organic ED, the mean diameter was 0.70 mm (range 0.3-1.3 mm) on the right and 0.76 mm (range 0.3-1.24) on the left in basal conditions vs 1.21 mm (range 0.8-1.93 mm) on the right and 1.24 mm (range 0.9-1.66 mm) on the left in dynamic conditions after injection of 10 microg., Conclusion: In our experience, assessment of the cavernous arteries in basal and dynamic conditions provides important additional data. Altered basal and dynamic values are predictive of anomalous PDV and PSV findings.

The etiology of erectile dysfunction is wide ranging. Penile vascular disorders may result in impaired erection or complete impotence. Almost 30% of erectile dysfunction is due to the presence of systemic disease which affects the blood supply to the penis. The intracavernosal injection test with prostaglandin E1 alone offers limited information on the vascular status. In accordance with the increasing demand for less invasive procedures, penile color-coded duplex sonography (CCDS) combined with the pharmaco-erection test represents a first-line noninvasive approach to investigate arterial and veno-occlusive function. Peak systolic velocity and a change in cavernous artery diameter are indicators of arterial inflow, while the pathological end diastolic velocity and resistance index point out veno-occlusive dysfunction. The combined investigation of power and standard color Doppler ultrasound may yield more details of penile vascular anatomy.

Increased sympathetic tone may cause an equivocal response to a prostaglandin E1 (PGE1) penile Doppler ultrasound (US) examination interpreted as a venous leak. We evaluated the US parameters and erectile response to the addition of phentolamine to a PGE1 penile Doppler US examination to ascertain whether addition of phentolamine would abolish a suboptimal response. 32 patients (median age 29 years, range 17-70 years) with either a previous Doppler US pattern of venous leakage or a clinical suspicion of venogenic impotence, underwent Doppler US after a total dose of 20 microg of PGE1. Peak systolic velocity (PSV), end diastolic velocity (EDV) and grade of erection were documented. If erectile response was suboptimal irrespective of the EDV measurement, 2 mg-intracavernosal phentolamine was administered and measurements repeated. Six patients had a normal erectile response, the remaining 26 received phentolamine. A significant increase in PSV between baseline and 20 microg PGE1 (p<0.001) was observed in all cases. Following phentolamine there was a significant increase in grade of erection (p=0.0001) and a significant reduction in the EDV (p=0.0001). A reduction of the EDV to below 0.0 cm s(-1) was observed in 16 patients. Four patients with EDV <5.0 cm s(-1) but >0.0 cm s(-1) had improved erectile response following phentolamine while six showed persistent EDV elevation >5 cm s(-1). No priapism was documented. It is essential to ensure cavernosal relaxation using phentolamine before a Doppler US diagnosis of venous leak is made. This two-stage assessment will allow this to be done efficiently and with a low risk of priapism.

Objectives: To evaluate the clinic value of doppler ultrasonography in diagnosis of vasculogenic erectile dysfunction (ED)., Methods: The hemodynamic change was obsreved by doppler ultrasonography during the erection of penis and the results between patients with vasculogenic ED and controls were compared. The doppler ultrasonographic characteristics of vascular ED was analyzed., Results: In the patients with arterial ED the peak systolic velocity(PSV) in deep artery was apparently lower than controls(P < 0.01), and in the patients with venous ED, the velocity of deep dorsal vein was higher during complete erection than controls(P < 0.05)., Conclusions: The result of doppler ultrasonography examination effectively helps the diagnosis of vasculogenic.

Objective: Varicocele can be defined as an abnormal tortuosity and dilatation of the veins of the pampiniform plexus. Contradictory results have been obtained from experimental animal models and a few clinical human studies on testicular arterial blood flow in varicocele. The purpose of this study was to determine the changes in testicular arterial blood flow parameters in patients with varicocele., Material and Methods: A total of 62 patients with a clinical diagnosis of left varicocele and a scrotal vein with a diameter of > or = 3 mm on color Doppler ultrasonography were included in the study. A total of 44 fertile normal male volunteers served as controls., Results: Median testicular arterial blood flow and median flow rate in milliliters per minute per 100 g of testicular tissue were found to be significantly decreased in the patient group compared to the control group: blood flow, 1.42 and 2.00 ml/min; flow rate, 9.63 and 12.35 ml/min/100 g, respectively (p < 0.05). Positive correlations were found between sperm concentration and left testicular artery blood flow (p < 0.05) and between left testicular volume and testicular artery blood flow (p < 0.05)., Conclusions: Testicular arterial blood flow was found to be significantly decreased in men with varicocele. This may be a reflection of the impaired microcirculation. Following decreased testicular arterial blood flow, impaired spermatogenesis may result from defective energy metabolism in the microcirculatory bed.

Our objective was to investigate prevalence and Doppler characteristics of penile cavernosal-spongiosal communications (CSC). These vessels are either anastomoses connecting the cavernosal arteries with the urethral arterial network or afferent vessels to the corpus spongiosum. Sixty-one consecutive patients underwent penile color Doppler US. Waveform changes in CSC were evaluated in comparison with changes in the cavernosal artery. Eighteen of 61 patients had normal erection, 17 of 61 had arterial insufficiency, and 26 of 61 had veno-occlusive dysfunction. Resistance index (RI) in CSC was significantly lower than in cavernosal arteries in all patients and increased during phases 1-2 (positive diastolic flow). Peak systolic velocity (PSV) in CSC was significantly higher in the patients with veno-occlusive dysfunction. During cavernosal phase 4 (diastolic flow reversal) CSC of patients with normal erection or with arterial insufficiency disappeared, underwent markedly reduced diastolic flow, or had systolic flow inversion. Conversely, low resistance flow was appreciable in CSC of patients with veno-occlusive dysfunction who reached phase 4. During phase 5 (systolic peak reduction) all CSC disappeared. Color Doppler US allows evaluation of CSC both in patients with normal and impaired erection.

Introduction: Vasculogenic impotence is one of the major causes of erectile dysfunction. Cavernosometry and cavernosography is traditionally the gold standard for evaluation of venogenic impotence. However, it is invasive and there are potentially significant complications. Penile colour flow Doppler imaging (PCDI) is non-invasive and can be used to assess venous incompetence., Materials and Methods: One hundred and sixty-eight patients were referred for PCDI assessment from March 1998 to February 2001. Forty-three of these also had cavernosogram and cavernosometry done and were included in the study., Results: The sensitivity was 93.9%, the specificity was 90.0%, the accuracy was 93.0% with a negative predictive value of 81.8% and a positive predictive value of 96.9%. Kappa value of 0.81 was obtained, indicating excellent agreement between PCDI and cavernosogram and cavernometry., Conclusions: Penile colour flow Doppler imaging is accurate in the assessment of venogenic erectile dysfunction. It can replace cavernometry and cavernosogram as a screening tool. Cavernometry and cavernosogram should only be done in cases when PCDI suggests venogenic impotence, and when surgery is contemplated.

The aim of this paper is to evaluate whether echo-color Doppler diagnostics allows to detect the different evolutionary stages of arteriopathy affecting the cavernous arteries of the penis. 124 patients with erectile deficiency were examined. All of them were evaluated by andrologic and psychologic anamnesis. An echo-color Doppler examination was performed on cavernous arteries before (basal) and after (dynamic) an injection of Prostaglandin E1 (10 micrograms). The penile circulation has been observed for twenty minutes after the injection to detect anomalous collateral vessels of the cavernous arteries. The population was divided into 4 groups according to the basal and dynamic peak systolic velocity (PSV). Cardiovascular risk factor incidence in patients with normal basal and dynamic PSV values (group A) and in patients with pathologic basal and dynamic PSV values (group C) is 10% and 44% respectively (p < 0.002). Psychologic disorder in group A and C is 41% and 26% respectively (p < 0.05). Patients with pathologic basal PSV and normal dynamic PSV (group B) show an intermediate (26%) incidence of cardiovascular disorders as compared to A and C. Anomalous side branches are equally represented in A and B (41% and 38%) and to a lesser extent in C (26%). Based on anamnestic and instrumental data, Group B ranges at an intermediate position between A and C. In this group, the presence of incipient arteriopathy affecting the penile circulation may be suspected. The ability to detect patients with vascular diseases still at a subclinical stage, as it already happens for other organs, would allow a prompt therapeutic action.

Objectives: The poor sensitivity of conventional color-coded Doppler sonography (CCD) for low-flow signals limits its use for investigating patients with erectile dysfunction. Power Doppler sonography (PD) has recently been described for enhanced visualization of the microcirculation. Aim of this study was to determine the value of PD to demonstrate penile vascular pathophysiology as compared with conventional techniques., Methods: 33 consecutive men with erectile dysfunction were investigated using the standard workup with conventional CCD and cavernosography before and after prostaglandin E(1) intracavernosal injection. Patients were subdivided into an arteriogenic, a venogenic, or a psychogenic group according to findings in the standard diagnostic workup. PD was used in addition to the standard protocol to demonstrate microcirculation, arterial blood flow, and venous leakage. The accuracy of the diagnosis obtained by PD and response to intracavernosal injection was compared with the clinical outcome in these groups at 6 months., Results: PD was found to be superior to CCD in visualizing cavernosal microcirculation. In addition, arterial flow at basal peak systolic velocity was demonstrated in all patients with PD, whereas a signal sufficient for evaluation was obtained with CCD in only 69.7% (23/ 33). No significant difference in the maximal peak systolic velocity was noted using either PD or CCD. The positive predictive value of PD for venous leakage was poor (60%) when compared with cavernosography. PD used in conjunction with the response to intracavernosal injection was found to reliably predict the clinical outcome in the arteriogenic (p = 0.0007), the venogenic (p = 0.005), and the psychogenic group (p = 0.0002)., Conclusions: Our data indicate that PD improves the evaluation of penile microcirculation and arterial function, but fails to reliably demonstrate venous leakage alone. Nevertheless, in most patients cavernosography could have been avoided by the aid of PD, since the underlying pathology can be calculated at a high predictive value without the need of further invasive tests. Therefore, with the aid of PD, the morbidity for patients being investigated for erectile dysfunction can be significantly reduced.

Aims: The results of history and physical examination, nocturnal penile tumescence testing (NPT), colour flow duplex Doppler ultrasonography and dynamic infusion cavernosometry and cavernosography (DICC) were retrospectively correlated in 207 patients with erectile dysfunction., Methods and Materials: The predictive value of the patient's own subjective assessment of early morning and nocturnal erections, history of cigarette smoking, the presence of vascular risk factors was correlated to the outcome of investigations. The result of Rigiscan NPT was correlated to the peak systolic velocity (PSV) and the resistance index (RI) determined at colour flow duplex Doppler ultrasonography, and the maintenance flow rate (Qm) determined at DICC., Results: Eighty-five out of two hundred and seven patients (41%) had normal NPT comprising 48 out of 85 patients (56%) who described rigid early morning and nocturnal erections, 15 out of 85 patients (18%) who smoked cigarettes and 9 out of 85 patients (11%) with other positive vascular risk factors. 72 out of 85 patients (85%) had a normal PSV (>30 cm/s), 80 out of 85 patients (94%) had a normal RI (>0.85) and 82 out of 85 patients (96%) had a normal Qm), (<10 ml/min). Vascular investigations in this group identified 71 out of 85 patients (84%) with no penile vascular disease, 11 out of 85 patients (13%) with arteriogenic impotence, 2 out of 85 patients (2%) with mixed vasculogenic impotence and 1 out of 85 patients (1%) with cavernosal venous leakage (CVL). One hundred and twenty-two out of two hundred and seven patients (59%) had an abnormal NPT comprising 18 out of 122 patients (15%) who continued to experience rigid early morning erections, 65 out of 122 patients (53%) who smoked cigarettes, 59 out of 112 patients (48%) with other positive vascular risk factors, 36 out of 112 patients (29%) had an abnormal PSV (<30 cm/s), 49 out of 122 patients (40%) had an abnormal RI (<0.85) and 55 out of 122 patients (45%) had an abnormal Qm (>10 ml/min). Vascular investigations in this group identified five patients with no penile vascular disease, 51 out of 122 patients (41%) with arteriogenic impotence, 31 out of 122 patients (25%) with cavernosal venous leakage (CVL) and 35 out of 122 patients (29%) with mixed vasculogenic impotence., Conclusions: (1) a history of cigarette smoking and positive vascular risk factors are good predictors of organic impotence whereas the patient's subjective assessment of his own early morning erections is unreliable; (2) normal NPT correlates well with normal PSV, RI and Qm but does not exclude organic impotence; (3) abnormal NPT correlates well with abnormal PSV, RI and Qm.

The purpose of this study was to assess the accuracy of multi-parameter measurements with color-coded duplex sonography (CCDS) for the diagnosis of venous leakage in patients with erectile dysfunction. Sixty patients with repeated unsatisfactory reactions after intracavernous injection of vasoactive substances underwent CCDS. Following intracavernous injection of prostaglandin E1, peak systolic velocity (PSV), enddiastolic velocity (EDV), time averaged velocity (TAV), resistance index (RI), and pulsatility index (PI) were measured in the cavernous arteries over 30 min (one measurement per minute). The results were compared with independent measurements based on dynamic pharmaco-cavernosometry/cavernosography (DPCC). Dynamic pharmaco-cavernosometry/cavernosography revealed venous leakage in 33 patients. Of 48 patients with normal PSV ( > 25 cm/s), 25 had veno-occlusive dysfunction and the remainder presented normal venous function. No statistically significant differences between these groups were found in EDV, RI, and PI measurements. In contrast, differences in TAV were significant between patients with (mean 9.4 +/- 4.6 cm/s) and without venous leakage (mean 5.5 +/- 2.2 cm/s; p = 0.001). Analysis of relative frequencies revealed a broad overlap of EDV, TAV, RI, and PI measurements between both groups. Sensitivities and specificities determined from receiver-operating-characteristic curves were > 80 % and > 50% for a TAV threshold of 5 cm/s, and an RI threshold of 1.0. Measurements of EDV, TAV, RI, and PI in patients with repeated unsatisfactory reactions on intracavernous prostaglandin injection are poor predictors of venous leakage and should not replace DPCC in the investigation of vasculogenic impotence.

Objective: To determine the role of colour Doppler imaging (CDI) in the investigation of erectile dysfunction in patients with Peyronie's disease., Patients and Methods: Fifty consecutive patients (age 35-75 years) with Peyronie's disease who were considered suitable for surgical treatment were investigated using CDI to determine the haemodynamic variables of penile vasculature after an intracorporeal injection of 20 microg of alprostadil (with manual self-stimulation). A clinician independently recorded the quality of erection and the deformity., Results: Twenty of 50 patients (40%) considered they had normal erectile function despite their penile deformity and all had normal responses, although they tended to exaggerate the degree of penile deformity. Of the 30 remaining patients, 21 who considered themselves to have erectile dysfunction had normal clinical and CDI haemodynamic responses to alprostadil. The remaining nine patients had a variety of erectile problems and whilst CDI showed altered haemodynamic values, in no case did CDI alter the proposed treatment based on the clinically apparent features of those patients., Conclusion: Colour Doppler imaging of the penis after pharmacologically induced erection gives anatomical and functional information in patients with Peyronie's disease but does not provide useful additional information to aid the selection of surgical treatment for the disease.

Background: Pharmaco-dynamic infusion cavernosometry and cavernosography (pharmaco-DICC) is essential for diagnosis of venogenic impotence, however it is so invasive. On the other hand, color Doppler ultrasonography is non-invasive and has become one of the useful diagnostic methods for arteriogenic impotence. And there are some reports evaluating whether venogenic impotence can be diagnosed using color Doppler ultrasonography. In this study, we investigated whether the resistance index (RI) could be useful for screening for venogenic impotence., Methods: We performed color Doppler ultrasonography in 49 patients who had shown negative responses to an intracavernous injection of 20 mcg of prostaglandin E1 (PGE1). They previously underwent pharmaco-DICC and were diagnosed venogenic impotent when the maintenance flow rate was equal to or more than 20 ml/min. In 49 patients, 17 patients had DICC normality, while 32 patients had corporal leakages. After an intracavernous injection of 20 mcg of PGE1, we performed color Doppler ultrasonography, and measured peak systolic velocity (PSV) and end diastolic velocity (EDV) in the cavernous artery. RI was calculated as follows. RI = (PSV-EDV)/PSV We adopted the RI value near to 1 as the case's RI from two RI values of bilateral cavernous arteries, and compared RI values with the results of pharmaco-DICC., Results: RI range in patients with normal DICC results was 0.895 +/- 0.092 (0.70-1.00), while RI range in patients with corporal leakages was 0.742 +/- 0.095 (0.55-0.97). RI values in patients with corporal leakages were significantly lower than those in patients with normal DICC results although there was some overlap in each group. From receiver-operating-characteristic curve (ROC curve) of the correlation between sensitivity and specificity at various RI values compared with DICC results, the RI cut off values were set up at 0.75 and 0.90, and classified the patients into 3 group according to their RI cut off values. In 10 patients with 0.9 < RI, 9 patients (90%) had DICC normality. In 17 patients with 0.75 < RI < or = 0.9, 7 patients had DICC normality while 10 patients had corporal leakages. In 22 patients with RI < or = 0.75, 21 patients (95.5%) had corporal leakages., Conclusion: We consider without carrying out pharmaco-DICC that patients with 0.9 < RI were not venogenic impotent, while patients with RI < or = 0.75 had corporal leakages. Pharmaco-DICC will remain essential only in patients with 0.75 < RI < or = 0.9.

Erectile dysfunction has taken on increasing importance in urologic practice. Still open is the question of which tests are mandatory for adequate clinical assessment of erectile dysfunction. One accepted standard modality is the intracavernous pharmacotest with vasoactive agents. In contrast, color duplex sonography is not considered mandatory although it reveals detailed information about penile vessels and functional implications. The question remains whether the information gained by color duplex sonography is relevant for therapy, making it an indispensable standard procedure. Patients with erectile dysfunction were evaluated, without preselection, by extensive history, clinical evaluation, laboratory tests, tumescence and rigidity measurements, intracavernous administration of vasoactive drugs and color duplex sonography. Seventy-nine patients were available for final analysis. Color duplex sonography revealed 39 normal tests, 16 arterial impairments. 19 venous leakages and 5 arteriovenous fistulae. Intracavernous vasoactive agents (pharmacotest) revealed 44 reactions sufficient for intercourse and 35 insufficient responses. In 89% of patients, the diagnoses on color duplex sonography and intracavernous pharmaco-testing were similar. The accuracy of the two methods in diagnosing erectile dysfunction was not statistically different (McNemar's test). In contrast to intracavernous pharmaco-testing, color duplex sonography permitted further etiologic subdivision into arterial disease, venous leakage, arteriovenous fistula and normal result. This was made possible by measuring significantly (P < 0.01) different arterial peak flow velocities, end-diastolic velocities and calculated resistance index. These data did not imply direct clinical consequences. Color duplex sonography and intracavernous pharmacotesting reveal comparable results concerning the diagnosis of an erectile dysfunction. In contrast to pharmacotesting, color duplex sonography reveals details of the nature of the erectile dysfunction. Because this information has no profound implications for the choice of therapeutic procedure, color duplex sonography can not be recommended as a standard procedure in the evaluation of erectile dysfunction.

The enormous success of Ultrasound is derived from its good spatial resolution and diagnostic accuracy. The most recent and most important application of Ultrasound is Color Doppler. Color Doppler has introduced the dynamic factor, allowing the superimposition, on the high-resolution image, of flow information. For the first time, detailed and non-invasive information is obtained that is not only morphological, but also functional, through the visualisation of organ flow and perfusion. The clinical applications of Color Doppler are briefly discussed, encompassing areas that have long been studied by Duplex Doppler, such as the carotid-vertebral and the peripheral vessels. The most recent applications are also reviewed, namely: Tissue characterisation; Hemodynamics of portal hypertension and arterial hypertension; The evaluation of renal and hepatic transplants; and erectile dysfunction studies.

Doppler ultrasonographic findings in patients after penile vein ligation surgery are described and compared to the results of cavernosometry and cavernosography. Peak systolic and end diastolic velocities were recorded for both cavernosal arteries at 5 min intervals after papaverine injection for a total of 30 min. Peak end diastolic flow rates were compared with cavernosometric and cavernosographic results at 0-10 min, 11-20 min, and 21-30 min. Cavernosography identified venous leakage in nine patients. The end diastolic velocities were greater than the 5 cm/s threshold level generally considered to be indicative of venous leakage in nine of the nine patients (100%) at 0-10 min, in eight of the nine (89%) at 11-20 min, and in nine of the nine (100%) at 21-30 min. Although peak end diastolic velocities at or near the 5 cm/s threshold could be found in patients both with and without recurrent venous leakage in the initial 10 min of the studies, only patients with recurrent venous leakage had diastolic velocities that exceeded the 5 cm/s level when measured 10 min or more after injection. Measurement of end diastolic velocities between 21 and 30 min after injection seemed to discriminate most effectively the patients with recurrent venous leakage from those without leakage in the postoperative population.

This prospective study involved 27 patients who underwent dynamic infusion cavernosometry/cavernosography and color duplex Doppler ultrasound. Phase III dynamic infusion cavernosometry/cavernosography determination of cavernous artery systolic occlusion pressure and color duplex Doppler measurements of peak velocity flow were performed. Four subpopulations were defined: 1) normal cavernous artery systolic occlusion pressure and peak velocity flow, 2) abnormal systolic occlusion pressure and normal peak velocity flow, 3) normal systolic occlusion pressure and abnormal peak velocity flow, and 4) abnormal systolic occlusion pressure and peak velocity flow. Peak velocity flow significantly correlated with cavernous artery systolic occlusion pressure and, using a normal value of greater than 25 cm. per second, resulted in a sensitivity and specificity of 95%. The positive predictive value of an abnormal peak velocity flow was calculated to be 95%. We conclude that peak velocity flow is an effective, reliable and noninvasive means of evaluating corporeal arterial function in an office setting.

When the pathomechanism of erectile dysfunction is obscure, intraurethral administration of prostaglandin E1 is followed by a marked increase in blood flow velocity in the penile arteries as measured by color-coded Duplex sonography. This increase compares to that following intracavernous administration of half the dose of prostaglandin E1. The difference in the effects after intraurethral and intracavernous administration is the missing rigidity after intraurethral application; there must be a loss of pharmacological efficacy to the smooth penile muscles. Clinical efficacy is to be expected with higher intraurethral dosage.

The gold standard in the diagnosis of venous impotence is cavernosometry. But a less invasive and time-consuming screening test for patients with a high probability of venous impotence is required. Therefore we evaluated 82 men with erectile dysfunction by color Doppler sonography after intracavernosal injection of 60 mg papaverine. 28 of them who had a poor erectile response but sufficient arterial inflow were included in this study. 6 patients who were previously found to have psychogenic impotence formed the control group. After pharmacological stimulation by papaverine, all patients were examined for 20 min by color Doppler sonography in order to detect diastolic flow velocities in the cavernosal arteries and erectile responses. Both groups of patients underwent pharmaco-cavernosometry in a blind fashion afterwards. The diagnosis of venous impotence with color Doppler sonography was confirmed by dynamic pharmaco-cavernosometry in 25 of 28 (89%) and 6 of 6 (100%) subjects of the study and control groups, respectively. Statistically, in the diagnosis of venous dysfunction, color Doppler sonography had a sensitivity of 100%, specificity of 66.6%, accuracy rate of 91% and a positive predictive value of 0.892. The gold standard in the diagnosis of venous impotence is still cavernosometry, but it seems that color Doppler sonography may provide a sensitive assessment of penile venous competence.

Cadaveric dissections have revealed that accessory blood vessels to the penis often arise near or through the apex of the prostate. These accessory vessels may be easily injured during radical prostatectomy. Increasing attention since the 1980s has focused on preserving potency after radical prostatectomy with a nerve sparing technique. However, many patients are impotent even after a nerve sparing procedure. An arterial, venous or psychological mechanism may be involved. A prospective study was designed to assess cavernous artery diameter, peak systolic flow velocity, penile blood flow, end diastolic flow velocity and resistance index preoperatively and postoperatively in patients undergoing radical prostatectomy. Ten patients with a mean age of 60 years were evaluated, of whom 8 underwent a unilateral nerve sparing procedure, 1 bilateral nerve sparing procedure and 1 bilateral nonnerve sparing procedure. Mean penile blood flow as calculated by the formula penile blood flow = peak systolic flow velocity x pi (diameter/2)2 increased 0.33 ml. per second (+26%) on the nerve spared side, while diminishing 0.68 ml. per second (-41%) on the nonspared side. Overall penile blood flow was diminished. End diastolic flow velocity increased on spared and nonspared sides after surgery. The resistance index for all radical prostatectomy patients diminished 7% from 0.83 preoperatively to 0.77 postoperatively (p = 0.16). While these findings were not statistically significant, they suggest that arterial insufficiency and corporeal venous occlusive dysfunction may be involved in sexual dysfunction after nerve sparing radical prostatectomy.

The haemodynamic effects of different dosages of adenosine were studied using colour flow Doppler sonography (CFDS) in 33 men, whose penile vascular bed responded well to papaverine. In six cases, we injected 25, 50, 100, 250 micrograms dosages of adenosine intracavernously at 15 min intervals and no erection occurred. However, 500 and 1000 micrograms doses of adenosine increased the arterial blood velocities for a few seconds in five cases. Later on, in eight cases, we infused 80 and 120 micrograms/kg/min adenosine for 3 min and only with 120 micrograms/kg/min dosage, did we observe clinical response and significant changes in CFDS parameters. Finally, 120 micrograms/kg/min adenosine dosage was infused for 10 min in 14 men and eight showed full erection while six had only tumescence. As adenosine was rapidly metabolized by adenosine deaminase, the erection lasted for only 5 to 13 min. No prolonged erection and no other side-effect was observed. In addition no fibrosis and curvature was detected 6 months after the injections. We found that, in men, 10 min infusion of 120 micrograms/kg/min adenosine increased the arterial flow and to some extent venous resistance, resulting in full erection or tumescence. Therefore, adenosine may be used as an agent for the diagnosis of vasculogenic impotence, but further studies for determining the standard dosage of adenosine are needed.