The Role of Penile Color-Duplex Ultrasound for the Evaluation of Erectile Dysfunction

Vascular hemodynamic effects of penile revascularization surgery and the role of resistive index in follow-up

BACKGROUND

To evaluate the effects of penile revascularization surgery on penile vascular hemodynamics and to assess the utility of the resistive index (RI) as an objective parameter for postoperative patient follow-up.

METHODS

This study included a total of 35 patients who underwent penile revascularization. Penile color Doppler ultrasonography was performed preoperatively and at the third postoperative month to evaluate cavernosal arteries, dorsal arteries, deep dorsal vein, and inferior epigastric artery. During these evaluations, peak systolic velocity, end diastolic velocity, and resistive index were measured. The International Index of Erectile Function questionnaire was administered before surgery and at the third postoperative month. In addition, corpus cavernosum electromyography and cavernosometry tests were performed in all cases preoperatively. Anastomotic patency was assessed using computed tomography angiography at the end of the follow-up period.

RESULTS

The mean preoperative resistive index values were determined to be 0.74 ± 0.07 and 0.73 ± 0.09 cm/s for the right and left cavernosal arteries, respectively, and these values increased to 0.95 ± 0.09 and 0.96 ± 0.06 cm/s, respectively, at the last postoperative control. The mean International Index of Erectile Function-5, 15 scores for the right and left cavernosal arteries were 8.52 ± 4.83 and 19.4 ± 8.54, respectively, preoperatively, and these scores improved to 15.26 ± 4.50 and 35.76 ± 13.65, respectively, at the last postoperative follow-up.

CONCLUSION

The results of this study suggest that the resistive index can be used as an objective parameter in the diagnosis of erectile dysfunction of vascular origin and in the follow-up and management of the disease following penile revascularization.

TRIAL REGISTRATION

NCT06350019/04/03/2024 (retrospectively registered).

A novel strategy to induce penile erection during penile doppler ultrasound: oral sildenafil administration plus alprostadil injection

OBJECTIVES

To evaluate the efficacy of a novel approach to achieve the optimal penile erection during the penile doppler ultrasound (PDU) examination, which was oral sildenafil combined alprostadil injection.

MATERIALS AND METHODS

A total of 60 ED patients were enrolled in our prospective study, and they were randomly assigned to two group with different PDU order. The approaches assisted the PDU included two models, mode A meaning injection of 15 μg alprostadil and model B meaning oral sildenafil 100 mg plus injection of 15 μg alprostadil. The PDU parameters were measured continuously before induced erection, and 5, 10, 15, 20, 25 min.

RESULTS

Each group included 30 ED patients with similar clinical characteristics. After pooling the results together, the PSV, EDV, and RI were all improved significantly, when adding the oral sildenafil administration to assist PDU. Also, the clinical response of oral sildenafil administration plus alprostadil injection was better than that in alprostadil injection alone (p = 0.016). The arterial ED were decreased from 31.67% to 15.00% with the P value 0.031, and the mixed ED was also decreased statistically (23.33% vs 8.33%, p = 0.024).

CONCLUSION

Oral sildenafil administration plus alprostadil injection could improve the diagnostic accuracy of PDU.

A Study of the Relationship Between Objective Tests to Diagnose Erectile Dysfunction and Markers of Cardiovascular Disease

Background: Erectile dysfunction (ED) can stem from various organic and functional causes but is often linked to vascular health and cardiovascular disease. Limited data exist on how cardiovascular disease markers correlate with objective ED tests like the Nocturnal Penile Tumescence and Rigidity (NPTR) test and Penile Color Doppler Ultrasound (PCDU). Methods: A prospective observational study was performed, and 58 men with ED were assessed using the International Index of Erectile Function-15 (IIEF-15), NPTR test, and PCDU. Peripheral vascular health was evaluated through carotid intima-media thickness (cIMT) and brachial flow-mediated dilation (FMD). Results: Out of the participants, 44 had normal NPTR results, while 14 had abnormal results. The group with abnormal NPTR results was significantly older and had higher rates of hypertension and diabetes. Although the IIEF-15 scores were similar between the two groups, those with abnormal NPTR results had a lower peak systolic velocity (PSV) and a higher prevalence of impaired PSV. Correlations between the IIEF, NPTR, PCDU, and peripheral vascular markers lost significance after the age adjustment. Conclusions: This study suggests that abnormal NPTR results, combined with cardiovascular risk factors, may signal vascular ED and generalized vasculopathy, highlighting the need for cardiovascular assessment. An accurate ED diagnosis should integrate clinical evaluation with multiple tests while considering aging as a key risk factor.

Serum folic acid: an effective indicator for arteriogenic erectile dysfunction

Background

The present study is the first to explore the correlation between serum folic acid (FA) level and penile arterial peak systolic velocity (PSV) as measured via penile color Doppler ultrasonography (PDU), which directly reflects endothelial function in the penile artery.

Materials and methods

A total of 244 consecutive erectile dysfunction (ED) patients and 72 healthy controls, recruited from the Andrology department and the Healthy Physical Examination Center of our hospital, respectively, from June 2020 to April 2022, were included in the study. Serum FA was measured in ED patients and healthy controls, and PDU examinations were conducted for all eligible ED patients. The Pearson method was used to evaluate the correlation between FA levels and PDU parameters in ED patients. A receiver operating characteristic (ROC) curve analysis was also performed to calculate the sensitivity and specificity of these parameters for prediction of arteriogenic ED.

Results

After the PDU test, the average serum FA level among patients diagnosed with arteriogenic ED was 8.08 ± 2.64 ng/ml, lower than the average of 10.78 ± 2.87 ng/ml among healthy controls. There were no statistically significant inter-group differences on any basic parameters, including age, body mass index, fasting blood glucose, total cholesterol, and triglyceride. For further analysis, we divided the arteriogenic ED group into three subgroups by PSV range to compare serum FA levels among these subgroups. The mean FA levels in each of these groups were 5.97 ± 1.51ng/ml, and 8.21 ± 2.37ng/ml, and 10.55 ± 2.56ng/ml, while the corresponding PSV values were 15.75 ± 2.39cm/s, 23.53 ± 2.19cm/s, and 32.72 ± 1.64cm/s. Overall, a positive correlation between PSV and FA level was found among patients with arteriogenic ED (r=0.605, P<0.001). Furthermore, when FA level was used, with a cut-off value of 10.045 ng/ml, as a criterion to distinguish patients with arteriogenic ED from healthy controls, the area under the curve (AUC) was 0.772 (95% confidential interval: [0.696, 0.848]), for a sensitivity of 0.611 and specificity of 0.824.

Conclusion

Serum FA level is positively correlated with PSV in ED patients, and has the ability to distinguish patients with arteriogenic ED from healthy controls. Taking these findings together, FA deficiency should be regarded as an independent risk factor for arteriogenic ED.

Low-intensity shockwave treatment (LISWT) improves penile rigidity in eugonadal subjects with erectile dysfunction: a pilot study

BACKGROUND

Since low-intensity shockwave treatment (LISWT) has putative effects on penile hemodynamics remodeling, the aim of this study was to evaluate any improvement of penile vascular flows after LISWT treatment in patients with erectile dysfunction (ED) and poor response to PDE5i.

METHODS

Twenty-one eugonadal patients with different ED severity underwent 6 weekly LISWT sessions (1500-4000 pulses) after 2 weeks withdrawal from PDE5i assumption. Once daily Tadalafil (2.5 mg daily) was reintroduced 4 weeks apart from LISWT termination and patients were evaluated at 1, 2 and 6 months follow-up (T1, T2, T6) by the International Index of Erectile Function-15 items questionnaire (IIEF-15) erectile function (EF) domain, Erection Hardness Score (EHS) and Global Assessment Questionnaires (GAQ). Basal Penile Color-Doppler Ultrasound parameters in the flaccid state (B-PCDU) were evaluated before, during and after interventional protocol.

RESULTS

Mean EHS score improved in 35% of patients at T1, and in up to 50% of patients at T2 and T6 follow-up visits (P<0.05). We found 25% improvement of EF scores at T1 session, 43.75% at T2 and 62.5% at T6, respectively (P<0.05). No statistically significant differences in flow parameters, EF-domain and testosterone levels were found when baseline and last observation carried forward (LOCF) parameters were compared. The GAQ questionnaire scored higher satisfaction rates either at the end of the treatment (100%), or at LOCF (92.5%).

CONCLUSIONS

Despite the study limitations with respect to B-PCDU in this setting, our results confirm a trend toward improvement of erectile questionnaire scores after LISWT with higher overall satisfaction rates among patients with ED. We conclude that LISWT may be an effective option in some difficult-to-treat patients with ED by improving the erectile response to PDE5i.

Cardiovascular/Stroke Risk Assessment in Patients with Erectile Dysfunction-A Role of Carotid Wall Arterial Imaging and Plaque Tissue Characterization Using Artificial Intelligence Paradigm: A Narrative Review

PURPOSE

The role of erectile dysfunction (ED) has recently shown an association with the risk of stroke and coronary heart disease (CHD) via the atherosclerotic pathway. Cardiovascular disease (CVD)/stroke risk has been widely understood with the help of carotid artery disease (CTAD), a surrogate biomarker for CHD. The proposed study emphasizes artificial intelligence-based frameworks such as machine learning (ML) and deep learning (DL) that can accurately predict the severity of CVD/stroke risk using carotid wall arterial imaging in ED patients.

METHODS

Using the PRISMA model, 231 of the best studies were selected. The proposed study mainly consists of two components: (i) the pathophysiology of ED and its link with coronary artery disease (COAD) and CHD in the ED framework and (ii) the ultrasonic-image morphological changes in the carotid arterial walls by quantifying the wall parameters and the characterization of the wall tissue by adapting the ML/DL-based methods, both for the prediction of the severity of CVD risk. The proposed study analyzes the hypothesis that ML/DL can lead to an accurate and early diagnosis of the CVD/stroke risk in ED patients. Our finding suggests that the routine ED patient practice can be amended for ML/DL-based CVD/stroke risk assessment using carotid wall arterial imaging leading to fast, reliable, and accurate CVD/stroke risk stratification.

SUMMARY

We conclude that ML and DL methods are very powerful tools for the characterization of CVD/stroke in patients with varying ED conditions. We anticipate a rapid growth of these tools for early and better CVD/stroke risk management in ED patients.

Long-term high-dose L-arginine supplementation in patients with vasculogenic erectile dysfunction: a multicentre, double-blind, randomized, placebo-controlled clinical trial

PURPOSE

The current randomized, double-blind, placebo-controlled clinical trial addressed the effects on penile erectile function of relatively high daily oral doses (6 g/day) of L-ARG for 3 months (N = 51) compared to placebo (N = 47), in patients with vasculogenic ED, with comparison between mild-moderate and severe vasculogenic ED.

METHODS

The outcome measures included IIEF-6 score and cavernous arteries peak systolic flow velocity (PSV) at dynamic penile duplex ultrasonography (PDU).

RESULTS

L-ARG supplementation for 3 months significantly increased IIEF-6 score in the overall cohort (p < 0.0001) and in subgroups of patients with mild-moderate (p < 0.0001) and severe (p = 0.007) vasculogenic ED; PSV was significantly increased in the overall cohort (p < 0.0001) and in patients with mild-moderate (p < 0.0001), but not severe vasculogenic ED. At study completion, 74% of patients improved ED degree category, although only 24% of patients, mainly belonging to the baseline category of mild ED, reached IIEF-6 scores compatible with absence of ED; moreover, 20% of patients, exclusively belonging to the baseline category of mild-moderate vasculogenic ED, reached PSV values compatible with absence of ED.

CONCLUSION

The results of the current study demonstrated that supplementation with relatively high doses of L-ARG as a single compound for 3 months significantly improved penile erectile function, assessed by both IIEF-6 score and PSV at dynamic PDU in patients with mild-moderate, and improved IIEF-6 score, but not PSV, in patients with severe vasculogenic ED, therefore suggesting that L-ARG might be an alternative treatment in mild-moderate vasculogenic ED patients experiencing adverse effects or with contraindications for chronic treatment with PDE5i compounds.

Homocysteine levels correlate with velocimetric parameters in patients with erectile dysfunction undergoing penile duplex ultrasound

INTRODUCTION

Hyperhomocysteinemia may contribute to the development of endothelial dysfunction and, consequently, atherosclerosis, a systemic disease involving the vessels that may affect the cavernous arteries leading to vasculogenic erectile dysfunction. Our study aims therefore to explore the relationship between homocysteine levels and velocimetric parameters detected by basal penile duplex ultrasound such as peak systolic velocity and flaccid penile acceleration in patients with erectile dysfunction.

METHODS

A cross-sectional study was conducted collecting clinical, metabolic, hormonal, and instrumental (basal penile duplex ultrasound) data in patients affected by vasculogenic erectile dysfunction.

RESULTS

Data of 126 subjects affected by erectile dysfunction were collected. Mean age was 52.1 ± 12.6 years, whereas mean body mass index was 25.6 ± 4.0 kg/m² . Basal penile duplex ultrasound showed peak systolic velocity values of 13.1 ± 2.9 cm/s and mean flaccid penile acceleration of 2.28 ± 0.70 m/s² , with a strong correlation among these two parameters (r = 0.690; p < 0.001). Frankly pathological values of peak systolic velocity and flaccid penile acceleration were detected in 39.7% and 4.8% of the subjects examined, respectively. Mean homocysteine levels were 14.9 ± 9.5 μmol/l. Homocysteine values >15 μmol/l were found in 26% of the subjects with erectile dysfunction. Peak systolic velocity values and homocysteine levels showed an inverse correlation (r = -0.213; p = 0.03). Similarly, flaccid penile acceleration values were inversely correlated to homocysteine levels (r = -0.199; p = 0.05). In addition, an inverse correlation was found between both peak systolic velocity and flaccid penile acceleration and body mass index, atherogenic lipid pattern, and age. Homocysteine and metabolic parameters showed no significant correlations.

CONCLUSION

Hyperhomocysteinemia is highly prevalent in erectile dysfunction patients. The results of our study show that homocysteine levels correlate with velocimetric parameters assessed by basal penile duplex ultrasound, confirming the role of hyperhomocysteinemia in the genesis of erectile dysfunction of arterial origin.

Combination therapy with topical alprostadil and phosphodiesterase-5 inhibitors after failure of oral therapy in patients with erectile dysfunction: a prospective, two-arm, open-label, non-randomized study

Phosphodiesterase type 5 inhibitors (PDE5Is) are the first-line therapeutic option for erectile dysfunction (ED), while second-line therapy includes the alprostadil. Due to the different pharmacodynamic mechanism of PDE5Is and alprostadil, a synergistic action is conceivable when they are administered in combination. The aim of present study was to evaluate the efficacy and safety of combination therapy with PDE5I and topical alprostadil in patients with ED non-responders to PDE5I alone. We designed a prospective, two-arm, open-label, non-randomized study. Patients over 18 years old, with a stable sexual relationship for at least 6 months, and ED non-responders to PDE5I monotherapy were included in the study. At baseline the variables assessed were 5-item version of the International Index of Erectile Function (IIEF-5), and Sexual Encounter Profile Questions 2 and 3 (SEP-2 and SEP-3). In addition, all subjects underwent penile dynamic duplex ultrasonography. All patients were assigned to the monotherapy group (Group A) or combination therapy group (Group B) based on their preference. Topical alprostadil 300 μg/100 mg (Virirec®) was the treatment assigned to Group A, while the combination therapy with the last PDE5I taken (at the maximum recommended dose) plus topical alprostadil 300 μg/100 mg (Virirec®) was assigned to Group B. After 3 months from assignment to groups were evaluated IIEF-5, SEP-2 and SEP-3 regarding the last sexual intercourse, and Global Assessment Questionnaire-Questions 1 and 2 (GAQ-1 and GAQ-2). All adverse events (AEs) that occurred during the study period were recorded. A total of 170 patients were included in the study (72 in Group A and 98 in Group B). Fifty-two patients were previously treated with sildenafil 100 mg (30.6%), 6 with vardenafil 20 mg (3.5%), 56 with tadalafil 20 mg (32.9%), and 56 with avanafil 200 mg (32.9%). No significant differences among the study groups were found at baseline (p > 0.05). The mean IIEF-5 score increased significantly in Group B after treatment compared to baseline (12.4 ± 3.4 vs. 17.1 ± 4.5; p < 0.001), conversely patients in Group A showed no significant increase (12.2 ± 2.5 vs. 12.7 ± 3.1; p = 0.148). The number of affirmative responses to SEP-2 was significantly higher after treatment compared to baseline only in Group B (57 vs. 78; p < 0.001). The number of affirmative responses to SEP-3 was significantly higher after treatment compared to baseline in both groups (p < 0.001). The number of affirmative responses to GAQ-Q1 and GAQ-Q2 was significantly higher in Group B compared to Group A (p < 0.001). A total of 59 (34.7%) patients experienced AEs. They were mild, self-limited, and did not cause discontinuation of treatment. No episode of priapism was recorded. No statistically significant difference was recorded between the AEs of the two groups, except for facial flushing that was reported only in Group B (p = 0.021). The combination therapy with topical alprostadil and PDE5I seems to be more effective than topical alprostadil alone without worsening the safety of the treatment.

Smoking status and the baseline international index of erectile function score can predict satisfactory response to platelet-rich plasma in patients with erectile dysfunction: A prospective pilot study

Erectile dysfunction (ED) is a common condition with a significant impact on the quality of life. Regenerative medicine maladies are intended to repair or replace damaged tissues and organs through different therapeutic mechanisms. Our aim was to study the effect of intra-corporeal injection (ICI) of platelet-rich plasma (PRP) in ED patients. Thirty-four patients' erectile function was evaluated by filling up an abridged form of the international index of erectile function (IIEF-5) before and after PRP therapy. ICI of PRP was done once per week for 2 months. All patients were prescribed PDE5Is for one month after PRP therapy. Penile haemodynamics was assessed using 20 µg of PGE1 before and 3 months after initiating PRP therapy. Interestingly, our study had shown that there was a statistically significant difference in the IIEF-5 score after ICI of PRP (-5.5, ±5.2, p=<0.001). Furthermore, in multiple logistic regression model for PRP responsiveness, smoking and IIEF score before PRP were the only significant independent variables (p = .040, p = .023 respectively). PRP injection for ED patients may be a promising modality as well as baseline IIEF-5, and smoking status can be used as predictors for a satisfactory response to PRP in such patients.

Cavernous artery intima-media thickness predicts the response to sildenafil in erectile dysfunction patients as a morphological parameter

While the intima-media thickness (IMT) of the cavernous artery was used for diagnosis for vascular erectile dysfunction (ED) with more accuracy than the peak systolic velocity, the role of the IMT in predicting treatment responses remained unexamined. A total of 136 patients with ED were enrolled. The baseline clinical and laboratory characteristics were collected. Penile Doppler ultrasonography (PDU) was performed on all patients by a blinded sonographer. Sildenafil was administrated to all patients with an adjusted dose of 50 or 100 mg on demand over a period of 3 months. A follow-up was conducted on all patients using the Erectile Hardness Score (EHS) questionnaire along with the visual and tactile version of the standardised EHS tool. The peak systolic velocity (PSV) and IMT were compared between sildenafil responders and sildenafil nonresponders, while receiver operator characteristic (ROC) curves were used to calculate the cut-off values and compare the test power respectively. There was no statistical difference from the baseline characteristics. The IMT of cavernous artery was more accurate than PSV to predict the sildenafil response (AUC = 0.809, 0.626 respectively). IMT could predict sildenafil responders more accurately than PSV, and the cut-off value of the IMT of the cavernous artery was less than 0.22 mm.

The penile duplex ultrasound: How and when to perform it?

BACKGROUND

Because it is a superficial structure, the penis is ideally suited to ultrasound imaging. A number of disease processes, including Peyronie's disease, penile fractures and tumors, are clearly visualized with ultrasound. Baseline and dynamic assessment of cavernosal arterial changes after pharmaco-stimulation with alprostadil allows standardized diagnosis of arterial and venogenic causes of erectile dysfunction (ED).

OBJECTIVE

To illustrate how to correctly perform flaccid and dynamic penile duplex ultrasound (D-PDU) and in which patients to recommend it.

MATERIALS/METHODS

An extensive search of the literature was carried out on Pubmed with the insertion of the following Medical Subjects Headings (MeSH) terms and keywords "penile color Doppler ultrasound" "peak systolic velocity" "end-diastolic velocity", "acceleration time", "resistance index".

EVIDENCE

In our experience, arterial erectile dysfunction is identified after standardized intracavernous injection (ICI) of alprostadil (10 mcg) when values of peak systolic velocity (PSV) are <35 cm/s and, in the most severe forms, for values <25 cm/s. Arterial insufficiency can also be identified by increased acceleration time (AT) values (>110 ms) and/or by a lack of visualization of helicine arteries at power Doppler mode along with incomplete achievement of penile rigidity. The veno-occlusive incompetence is determined when end-diastolic velocity (EDV) values are >4.5-5 cm/s or in the case of resistance index (RI) values <0.75. The assessment of additional surrogate markers of endothelial dysfunction, that is, intima-media thickness, mean platelet volume (MPV), endothelial progenitor cells (EPC), endothelial cell specific molecule-1(endocan) are also useful in assessing the patient's cardiovascular risk but are still considered investigational in the interpretation of D-PDU results.

CONCLUSION

D-PDU scan after ICI with vasoactive drugs is a safe procedure and represents the gold standard for the diagnostics of penile pathologies and should be performed in men with ED not responding to oral conventional therapies and/or in those requiring accurate stratification of cardiovascular risk.

Differences in Penile Hemodynamic Profiles in Patients with Erectile Dysfunction and Anxiety

Background: Penile echo-color Doppler ultrasound (PCDU) is the gold standard for the diagnosis of arterial erectile dysfunction (ED). Its reliability in patients with anxiety was questioned, due to false-positive results. Aim: To assess the penile hemodynamic response to intracavernous injection (ICI) of alprostadil in patients with anxiety-related ED. Methods: Patients with non-organic ED and a 5-item International Index of Erectile Function (IIEF-5) score ranging between 5 and 7 were enrolled. They were asked to compile the 7-item Generalized Anxiety Disorder (GAD-7) questionnaire to assess the degree of anxiety and were divided according to the GAD-7 score in Group 1 with minimal level of anxiety (n = 20), Group 2 with mild anxiety (n = 20), Group 3 with moderate anxiety (n = 20), and Group 4 with severe anxiety (n = 20). Peak systolic velocity (PSV) and the end-diastolic velocity (EDV) were sampled in all patients, through PCDU in the flaccid state, and 5, 10, 15, and 20 min after ICI of alprostadil at the standard dose of 10 μg. Results: In penile flaccidity, the patients showed a mean PSV of 8.0 ± 4.0 cm/s. The degree of anxiety was found to significantly influence both PSV and EDV at all assessed time-points. Particularly, it was negatively associated with the PSV at time 5 (r = −0.9, p < 0.01), 10 (r = −0.9, p < 0.01), 15 (r = −0.9, p < 0.01), and 20 (r = −0.7, p < 0.01) minutes, and positively with the EDV at time 5 (r = 0.7, p < 0.01), 10 (r = 0.6, p < 0.01), 15 (r = 0.5, p < 0.01), and 20 (r = 0.3, p < 0.01) minutes. Although all patients showed a mean dynamic PSV > 25 cm/s (which excluded an arterial ED according to the current guidelines), a peculiar hemodynamic pattern was found in patients with severe anxiety. In these patients, normal PSV values were reached only after 20 min from ICI, suggesting a “late-responder” profile. Conclusion: If further studies confirm the existence of a distinct hemodynamic profile in patients with severe anxiety, sampling the PSV and the EDV values could be proposed, for detecting patients with severe anxiety-related ED. Dynamic PCDU could be considered an accurate diagnostic test in patients with non-organic ED, since zero false-positive results were found in the present study. PSV in the flaccid state is not able to discriminate between arterial- or non-organic ED.

Standardization of penile hemodynamic evaluation through color duplex-doppler ultrasound

INTRODUCTION

The vascular evaluation of the erectile function through Color Duplex-Doppler Ultrasound (CDDU) of the penis can benefit the therapeutic decision-making process. Unfortunately, there is no standard procedure for CDDU conduction, a fact that results in high result-interpretation variability.

OBJECTIVE

The aims of this review are to promote greater standardization during CDDU of the penis and discuss the fundamental principles for its accurate conduction.

METHODS

CDDU is initially conducted with the penis in the flaccid state; the whole penis must be assessed (images at B mode) with a high-frequency linear transducer (7.5-18 MHz). Intracavernous injection of vasodilating agents (prostaglandin E1, papaverine, phentolamine) is performed to induce a rigid erection. Serial measurements at different times should be taken during the CDDU session and penile rigidity must be assessed in each evaluation.

RESULTS

It is important to monitor the erection response after the vasoactive agent (hardness scale), and scanning during the best-quality erection should be contemplated. Manual self-stimulation, audiovisual sexual stimulation (AVSS), and vasoactive agent re-dosing protocols must be taken into account to reduce the influence of psychogenic factors and to help the patient to get the hardest erection possible. Such measurements contribute to the maximal relaxation of the erectile tissue, so the hemodynamic parameters are not underestimated.

CONCLUSIONS

CDDU is a relevant specialized tool to assess patients with erectile dysfunction; therefore, this guideline will help to standardize and establish uniformity in its conduction and interpretation, taking into consideration the complexity and heterogeneity of CDDU evaluations of the penis.

Effect of Intracavernosal Injection of Prostaglandin E1 on Duration and Rigidity of Erection in Patients With Vasculogenic Erectile Dysfunction: Is It Dose Dependent?

OBJECTIVE

To assess if the effect of intracavernosal injection of prostaglandin E1 (PGE1) on duration and rigidity of erection is dose dependent in patients with different types of vasculogenic erectile dysfunction (ED)?

METHODS

A hundred patients with ED were assigned into 4 groups (n = 25/each); group (A) patients with arteriogenic ED, group (B) patients with veno-occlusive ED, group (C) patients with mixed (arteriogenic and veno-occlusive) ED, and group (D) patients who have only psychogenic ED (control). After intracavernosal injection of PGE1, patients were assessed using penile Doppler ultrasonography and erection hardness score together with calculation of erection duration. The starting dose of PGE1 was 5 μg which was increased to 10 µg and 20 µg as a maximal dose when needed.

RESULTS

The mean PSV of patients in groups A, B, C, and D were 24.38 ± 3.3, 37.74 ± 8.28, 22.24 ± 3.85, and 47.76 ± 6.27, respectively. In group D, 88% have achieved the best response at dose of 5 µg while 5.3%, 21.7%, and 0% have achieved the best response at dose of 5 µg in groups A, B, and C, respectively (P < .05 for each). The rest of patients have required either 10 or 20µg to achieve the best response. Patients in group C have required the highest dose of PGE1 to achieve the best response (P < .05).

CONCLUSION

Intracavernosal injection of PGE1 in escalating doses have improved the rigidity and duration of erection in patients with different types of vasculogenic ED. Patients with mixed arteriogenic and veno-occlusive ED have required the highest dose of PGE1 to achieve the best response.

Sonography of the penis/erectile dysfunction

Erectile dysfunction (ED) is defined as the persistent inability to achieve and/or maintain an erection for a satisfactory sexual activity. It is secondary to several organic, psychogenic, and combined causes, and represents a serious health dilemma affecting both men and their partners. The diagnostic approach to erectile dysfunction has significantly changed in the last years with the advent of phosphodiesterase-5 (PDE5) inhibitors, and with the recognition that surgical treatment of both arterial insufficiency and penile venous leak have poor long-term clinical outcomes. Although imaging modalities have diminished in importance, differentiating among causes of erectile dysfunction remains mandatory in good medical practice, and ultrasound (US) still remains the cornerstone of the diagnostic workup. US provides an objective, minimally invasive evaluation of penile hemodynamics. Moreover, it provides an excellent depiction of the penile anatomy and of its changes in pathological conditions such as in patients with Peyronie's disease, priapism, and posttraumatic erectile dysfunction.

Erectile dysfunction and cardiovascular risk: a review of current findings

Introduction: A large body of evidence has clearly documented that erectile dysfunction (ED) represents not only a complication of cardiovascular (CV) diseases (CVD) but often an early sign of forthcoming CVD.Areas covered: All the available data from meta-analyses evaluating the association between ED and CV risk were collected and discussed. Similarly, all available meta-analyses investigating the significance of ED as a possible early marker for major adverse cardiovascular events (MACE) were analyzed. In addition, data originally obtained in a Florence cohort, dealing with a large series of patients seeking medical care for sexual dysfunction, will be also reported.Expert opinion: Available evidence indicates that ED represents a risk factor of CV mortality and morbidity. Not only conventional CV risk factors but also unconventional ones, derived from a perturbation of the relational and intrapsychic domains of ED, might play a possible role in CV risk stratification of ED subjects. Finally, penile doppler ultrasound can give important information on CV risk, especially in younger and low risk subjects. The presence of ED should become an opportunity - for the patient and for the physician - to screen for the presence of comorbidities improving not only sexual health but, more importantly, men's overall health.

Current approaches to the diagnosis of vascular erectile dysfunction

Vascular erectile dysfunction (ED) is closely related to cardiovascular events, and early diagnosis of vascular ED may be helpful to predict the occurrence of cardiovascular events and improve prognosis. At present, there are many approaches to diagnose ED, but each method has its advantages and limitations. This study retrospectively reviewed all available literature focusing on the diagnosis of vascular ED through a systematic PubMed and EMBASE search. According to the different application scenarios, the main methods for the diagnosis of vascular ED are divided into four categories. Intra-cavernous injection of vasoactive drugs is the earliest method used in the diagnosis of vascular ED and is a basic test. For the diagnosis of arterial ED, color duplex Doppler ultrasound, selective penile angiography, magnetic resonance imaging, and computed tomography are more commonly used. While for the diagnosis of venous ED, shear wave elastography, dynamic infusion cavernosometry and cavernosography are more accurate. Endo-peripheral arterial tonometry (PAT) has also been used to detect vascular endothelial function. Although various existing examinations are widely used for the evaluation of vascular ED, they still have some shortcomings, such as invasiveness, contingency, high false positive (negative) rate. New methods of long-term dynamic detection are needed.

Penile hemodynamics study in erectile dysfunction men: the influence of smoking obesity on the parameters of penile duplex

INTRODUCTION

Erectile dysfunction (ED) was established to be linked to the risk factors of coronary artery disease such as metabolic syndrome, hypertension, diabetes, smoking, obesity and dyslipidemia.

OBJECTIVE

To study the influence of smoking and obesity on penile hemodynamics in patients with erectile dysfunction.

PATIENTS AND METHODS

This prospective study was carried out on 130 patients above 40 years and suffering from ED for more than 6 months. Selected patients were divided into four groups: group 1 (nonsmokers/non-obese) N = 36, group 2 (nonsmokers/obese) N = 30, group 3 (smokers/non-obese) N = 34, group 4 (smokers and obese) N = 30. Other risk factors for ED were excluded except dyslipidemia. All patients were subjected to personal history, sexual history, history of medical disorders or operations, evaluation of erectile function using an abridged IIEF-5. Measuring of BMI, fasting lipid profile, blood sugar, TT, prolactin, and PSA was performed. Penile hemodynamics was evaluated using intracavernosal injection of 1 cc Bimix (papaverin + phentolamine) and penile duplex ultrasound measuring the peak systolic velocity (PSV), end diastolic velocity (EDV), resistive index (RI), and cavernosal artery diameter before and after injection.

RESULTS

The mean ages of group 1, group 2, group 3 and group 4 were 50.92 ± 6.52, 55.20 ± 7.18, 50.88 ± 7.66 and 52.30 ± 7.61, respectively, with no statistically significant (p = 0.341). A statistically significant difference observed between mean value of PSV between group 1 and all other groups on both sides and between group 3 and 4. Also, our results recorded a statistically significant difference between mean value of EDV and RI between group 1 and all other groups on both sides. Concerning the change in the cavernosal artery diameter after ICI, there was a significant difference was seen between the following groups 1 and 4, 3 and 4 on both sides and between groups 1 and 2 at right side only. There was a statistically significant difference between the study groups concerning patient's response to ICI (p value 0.000). A significant negative correlation between BMI and total testosterone was recorded (p = 0.001). Regarding the mean value of testosterone, a significant difference was observed between the different four groups (p = 0.002). And a statistically significant difference was reported between group 1 and group 2 (p = 0.004) and group 2 and group 3 (p = 0.007).

CONCLUSION

Both smoking and BMI are strong risk factors for ED and affect response to ICI and penile duplex parameters (PSV, EDV, RI). Smoking and BMI together cause more deterioration of penile duplex parameters and response to ICI. The effect of smoking on EDV and RI was more than BMI. The effect of BMI on PSV, response to ICI and testosterone levels was more than smoking.

Contemporary and Novel Imaging Studies for the Evaluation of Erectile Dysfunction

Traditionally, it was thought that the pathogenesis of erectile dysfunction (ED) can be divided into psychological and organic factors. However, recent literature supports the development and progression of ED due to multidimensional alterations of a complex interplay of central and peripheral systems, from neural cognitive and efferent networks to loco-regional neuro-hormonal factors which are responsible for impaired penile vascular hemodynamics and ensuing lack of, or suboptimal, blood flow into the penis and/or veno-occlusive dysfunction. It is recognised that ED is strongly correlated with cardiovascular health and published clinical guidelines advocate screening for cardiovascular and metabolic risk factors in men presenting with ED. Over the past few decades, various imaging modalities have been developed and utilised to provide objective evaluation for ED to better characterise the state of penile health and exclude psychogenic components. The following article evaluates current and emerging imaging diagnostic tools for ED.

Variability in penile duplex ultrasound international practice patterns, technique, and interpretation: an anonymous survey of ISSM members

Penile duplex ultrasound (PDU), combined with pharmacologic stimulation of erection, is the gold standard for the evaluation of multiple penile conditions. A 30-question electronic survey was distributed to members of the International Society for Sexual Medicine (ISSM). The survey assessed the variability in current PDU practice patterns, technique, and interpretation. Chi-square test was used to determine the association between categorical variables. Approximately 9.5% of all 1996 current ISSM members completed the survey. Almost 80% of members surveyed reported using PDU, with more North American practitioners utilizing PDU than their European counterparts (94% vs 69%, p < 0.01). Approximately 62% of PDU studies were performed by a urologist and more than 76% were interpreted by a urologist. Although almost 90% of practitioners reported using their own protocol, extreme variation in the technique existed among respondents. Over ten different pharmacologic mixtures were used to generate erections, and 17% of respondents did not repeat dosing for insufficient erection. Urologists personally performing PDU were more likely to assess the cavernosal artery flow using recommended techniques with the probe at the proximal penile shaft (73% vs 40%) and at a 60-degree angle or less (68% vs 36%) compared with non-urologists (p < 0.01). Large differences in PDU diagnostic thresholds were apparent. Only 38% of respondents defined arterial insufficiency with a peak systolic velocity < 25 cm/s, while 53% of respondents defined venous occlusive disease with an end diastolic velocity > 5 cm/s. This is the first study to assess the variability in the PDU protocol and practice patterns, and to pinpoint areas of improvement. As in other surveys, recall bias, generalizability, and response rate (9.5%) are inherent limitations to this study. Although most respondents report utilizing a standardized PDU protocol, widespread variation exists among practitioners in terms of both technique and interpretation, limiting accurate diagnosis and appropriate treatment of penile conditions.

A pilot study of penile hemodynamics in men with penile curvatures

Penile curvature (PC) is bothersome to the patient. PC is either congenital or acquired. In most of the circulatory system, blood flows in a laminar profile with minimal energy expenditure. When a fluid passes in a curved tube, the laminar profile is disturbed and changed into a turbulent flow. It increases the energy expenditure and reduces the flow. Turbulent flow may have a role in the development of an atherosclerotic plaque and in localizing its site. The aim of this research was to study penile hemodynamics before and after correction of PC. This prospective study included 20 participants, with PC more than 30°. For each participant, preoperative color duplex doppler ultrasonography (CDDU), correction of the curvature using 16 dot plication technique and post-operative CDDU were done. Furhtermore, arterial systolic velocity was estimated distal to the site of curvature/correction every 5 min for 25 min. The degree of curvature ranged from 30° to 90° with a mean of 55±18.98. Comparative study between the preoperative and post-operative data proved a significantly higher postoperative peak systolic velocity distal to the site of correction, whereas CDDU data had insignificant differences. We concluded that correction of PC is associated with improvement of penile arterial blood flow distal to the site of correction.

Effects of tadalafil treatment combined with physical activity in patients with low onset hypogonadism: results from a not-randomized single arm phase 2 study

PURPOSE

To investigate a possible relation between penile Doppler ultrasound examination (PDUE) parameters and efficacy of chronic therapy with tadalafil (TAD) combined with a protocol of aerobic physical activity (PA) in patients with late onset hypogonadism (LOH).

METHODS

The study evaluated 30 patients consecutively enrolled with LOH and erectile dysfunction which present contraindication to hormonal replacement therapy for concomitant prostate disease. These patients were subjected to a combined protocol with phosphodiesterase V selective inhibitors (TAD 5 mg daily) and aerobic PA.

RESULTS

After three months, we observed significant improvements in erectile function [IIEF-5, median (IQR) = 13.0 (7.0-18.0) versus 6.0 (5.0-6.75); p < 0.01] and of the main metabolic [homeostatic model assessment index, median (IQR) = 2.5 (1.62-3.37) versus 3.0 (2.0-3.75); p < 0.01; body mass index, median (IQR) = 27.0 (24.0-28.75) versus 27.5 (24.0-29.5)] and vascular parameters [peak systolic velocity, median (IQR) = 29.5 (24.25-31.0) versus 28.0 (23.0-24.25); acceleration time, median (IQR) = 114 (105.25-134.0) versus 115.0 (106.5-134.0)], assessed by PDUE.

CONCLUSION

PA in association with phosphodiesterase V inhibitors could compensate the effects of hypogonadism on erectile function and facilitate the clinical response to these drugs even in the absence of adequate serum concentrations of total testosterone.

Biomarkers, erectile dysfunction, and cardiovascular risk prediction: the latest of an evolving concept

A number of circulating and imaging biomarkers are robustly associated with cardiovascular (CV) risk. The overall expectation from a biomarker in the erectile dysfunction (ED) setting is to enhance the optimal management of a man with this disorder but no clinical atherosclerosis. Evidence demonstrating that these biomarkers enhance risk prediction for individuals with ED is at this stage still limited for most of them. A better identification of the subsets of the ED population that require further risk stratification, as well as the initiation of randomized trials that will formally test the ability of biomarkers to predict CV risk, could make biomarker-guided prevention an attainable goal.

Measurement of endothelial dysfunction via peripheral arterial tonometry predicts vasculogenic erectile dysfunction

Introduction

Endothelial cell dysfunction is associated with cardiovascular disease and vasculogenic erectile dysfunction (ED). Measured via Peripheral Artery Tonometry (PAT), endothelial dysfunction in the penis is an independent predictor of future cardiovascular events.

Aim

Determine whether measurement of endothelial dysfunction differentiates men with vasculogenic ED identified by duplex ultrasound from those without.

Methods

A total of 142 men were retrospectively assessed using patient history, penile duplex ultrasonography (US) and PAT (EndoPAT 2000). ED was self reported and identified on history. Vasculogenic ED was identified in men who exhibited a peak systolic velocity (PSV) of ≤25 cm/s obtained 15 minutes following vasodilator injection. The reactive hyperemia index (RHI), a measurement of endothelial dysfunction in medium/small arteries and the Augmentation Index (AI), a measurement of arterial stiffness, were recorded via PAT.

Results

Penile duplex US separated men into those with ED (n=111) and without (n=31). The cohort with ED had a PSV of 21±1 cm/s (left cavernous artery) and 22±1 cm/s (Right). The control group without ED had values of 39±2 cm/s (Left) and 39±2 (Right). Given the potential for altered endothelial function in diabetes mellitus, we confirmed that hemoglobin A1c, urinary microalbumin, and vibration pulse threshold were not different in men with vasculogenic ED and those without. RHI in patients with ED (1.85±0.06) was significantly decreased compared to controls (2.15±0.2) (p<0.05). The AI was unchanged when examined in isolation, and when standardized to heart rate.

Conclusions

Measurement of endothelial function with EndoPAT differentiates men with vasculogenic ED from those without. RHI could be used as a non-invasive surrogate in the assessment of vasculogenic ED and to identify those patients with higher cardiovascular risk.

The role of interventional radiology in the diagnosis and management of male impotence

Erectile dysfunction (ED) is defined as the persistent inability to reach or maintain penile rigidity enough for sexual satisfaction. Nearly 30% of the men between ages 40 and 70 years are affected by ED. A variety of pathologies, including neurological, psychological, or endocrine disorders and drug side effects, may incite ED. A commonly identified cause of ED is vascular disease. Initial diagnostic workup includes a detailed physical examination and laboratory tests. Whilst duplex ultrasound is considered the first-line diagnostic modality, intra-arterial digital subtraction angiography is still considered the "gold standard" for the diagnosis of arteriogenic impotence. Percutaneous endovascular treatment may be offered in patients with vasculogenic ED that has failed to respond to oral medical therapy as an alternative to penile prosthesis or open surgical repair. In arteriogenic ED balloon angioplasty of the aorto-iliac axis, and in veno-occlusive ED, percutaneous venous ablation using various embolization materials has been reported to be safe and to improve sexual performance. Recently, the ZEN study investigated the safety and feasibility of drug-eluting stents for the treatment of arteriogenic ED attributed to internal pudendal artery stenosis with promising preliminary results. This manuscript highlights the role of interventional radiology in the diagnosis and minimally invasive treatment of male impotence.

Defining the aetiology of erectile dysfunction in men with chronic pelvic pain syndrome

Men presenting with chronic pelvic pain syndrome (CPPS) frequently report concomitant erectile dysfunction (ED), but the underlying cause of ED in this patient population has not been previously studied. This study prospectively investigated the aetiology of ED in men with CPPS. The study population comprised 46 men with penile pain or dysorgasmia, and concomitant ED. All participants completed the NIH-CPSI and international index of erectile function- erectile function domain (IIEF-EFD) questionnaires, and underwent penile duplex Doppler ultrasonography (DUS), following intracavernosal trimix injection, to evaluate erectile hemodynamic parameters. Pearson's correlation between NIH-CPSI and IIEF-EFD scores, and between NIH-CPSI score and the erectile response to trimix injections was investigated. The prevalence of mild, moderate and severe CPPS symptoms was 26, 48 and 26% respectively. The severity of ED was mild, moderate or severe in 15, 61 and 24% of men respectively. NIH-CPSI and IIEF-EFD scores were negatively correlated (r = -0.32, p = 0.002). Peak systolic velocity (PSV) and end-diastolic velocity (EDV) were normal in 96 and 100% of men respectively. The majority of men (78%) required ≥2 trimix injections to attain an adequate erection for DUS. NIH-CPSI scores and the number of trimix injections needed were positively correlated (r = 0.22, p = 0.035). The aetiology of erectile dysfunction in men who present with CPPS and concomitant ED is almost always psychogenic. Penile DUS in this population of men is fraught with the potential for error, and frequently necessitates more than one dose of a vasoactive agent.

Metabolic and cardiovascular outcomes of fatherhood: results from a cohort of study in subjects with sexual dysfunction

INTRODUCTION

Previous cross-sectional and longitudinal studies reported a negative correlation between fatherhood and testosterone (T) levels, likely due to a centrally mediated downregulation of the hypothalamic-pituitary-gonadal axis. Moreover, epidemiological data indicate that fatherhood might affect metabolic and cardiovascular outcomes, although different results have been reported. Up to now, no studies have evaluated these associations in a population of men seeking treatment for sexual dysfunction (SD).

AIM

To explore biological and clinical correlates of number of children (NoC) and its possible associations with forthcoming major cardiovascular events (MACE) in a sample of men with SD.

METHODS

A consecutive series of 4,045 subjects (mean age 52 ± 13.1 years old) attending the Outpatient Clinic for SD was retrospectively studied. A subset of the previous sample (N = 1,687) was enrolled in a longitudinal study.

MAIN OUTCOME MEASURES

Information on MACE was obtained through the City of Florence Registry Office.

RESULTS

Among patients studied, 31.6% had no children, while 26.3% reported having one child, 33.4% two, and 8.8% three or more children. Although fatherhood was negatively related with follicle-stimulating hormone levels and positively with testis volume, we found a NoC-dependent, stepwise decrease in T plasma levels, not compensated by a concomitant increase in luteinizing hormone. NoC was associated with a worse metabolic and cardiovascular profile, as well as worse penile blood flows and a higher prevalence of metabolic syndrome (MetS). In the longitudinal study, after adjusting for confounders, NoC was independently associated with a higher incidence of MACE. However, when the presence of MetS was introduced as a further covariate, the association was no longer significant.

CONCLUSIONS

This study supports the hypothesis that bond maintenance contexts and fatherhood are associated with an adaptive downregulation of the gonadotropin-gonadal axis, even in a sample of men with SD. Moreover, our data suggest that NoC predicts MACE, most likely because of an unfavorable, lifestyle-dependent, parenthood-associated behavior.

Is erectile dysfunction a reliable proxy of general male health status? The case for the International Index of Erectile Function-Erectile Function domain

INTRODUCTION

Erectile dysfunction (ED) has emerged progressively as a sentinel marker of cardiovascular disease (CVD). The correlation between ED and the burden arising from multiple comorbid conditions has been incompletely analyzed.

AIM

Assess whether erectile function, defined with the International Index of Erectile Function-Erectile Function (IIEF-EF) domain score, is associated with health-significant comorbidities scored with the Charlson comorbidity index (CCI).

METHODS

Clinical and hemodynamic variables of the last 140 consecutive patients who underwent penile color Doppler ultrasonography for new-onset ED were considered. Patients were assessed with a thorough medical and sexual history. Health-significant comorbidities were scored with the CCI.

MAIN OUTCOME MEASURE

Descriptive statistics and either linear or logistic regression models tested the association among IIEF-EF, hemodynamic parameters, and CCI, which was included in the model both as continuous and categorized variable (0 vs. ≥1).

RESULTS

Complete data were available for 138 patients (98.6%) (mean age 46.6 years [standard deviation 13.0]; range 21-75 years). CCI was 0, 1, and ≥2 in 94 (68.1%), 23 (16.7%), and 21 (15.25%) patients, respectively. Of all, 35 patients (79.5%) did not have a CVD comorbidity. Mean IIEF-EF was 13.7 (9.3). ED severity was no ED, mild, mild to moderate, moderate, and severe in 12 (9.1%), 28 (20.2%), 12 (9.1%), 23 (16.2%), and 63 (45.5%) patients, respectively. At multivariable linear regression analysis, CCI significantly worsened with increased age (β=0.33; P=0.001) and decreased IIEF-EF values (β=-0.25; P=0.01). At logistic regression analysis, age (odds ratio [OR]: 1.05; P=0.004) and IIEF-EF (OR: 0.95; P=0.04) emerged as significant predictors of categorized CCI.

CONCLUSIONS

Severity of ED, as objectively interpreted with IIEF-EF, accounts for a higher CCI, which may be considered a reliable proxy of a lower general male health status regardless of the etiology of ED.

Abnormal endothelial function in ED patients with normal nocturnal penile tumescence and rigidity: is it the role of psychogenic factors?

Underlying endothelial dysfunction (EnD) may present in the early stage of ED or psychogenic ED. We retrospectively evaluated 191 ED patients with effective nocturnal penile tumescence and rigidity (NPTR) recording, including detailed medical and psychosexual history, International Index of Erectile Function-5 and vascular parameter. All patients were allocated into psychogenic and organic groups according to the NPTR test. Brachial artery flow-mediated dilation (FMD) was used to diagnose EnD, and ED patients were classified into two groups: non-EnD (FMD10) and EnD (FMD<10). General and vascular parameters were compared between psychogenic and organic groups, and non-EnD and EnD groups with ED were compared in terms of NPTR parameters. In all, 48.7% and 51.3% patients were diagnosed as psychogenic and organic ED, respectively. 73.1% of the psychogenic patients had EnD and 39.8% organic patients had normal endothelial function. In all parameters, only the FMD value showed significant difference between psychogenic and organic ED groups (8.26±2.57 vs 9.16±2.76, P=0.020). No statistical difference was founded in NPTR parameters between non-EnD and EnD groups (P>0.05). In conclusion, NPTR cannot effectively identify the underlying vasculogenic ED from psychogenic ED. Psychogenic causes may cause or aggravate EnD in these ED patients with normal NPTR.