Evaluation of the Causes of Erectile Dysfunction in Patients Undergoing Penile Doppler Ultrasonography in Pakistan

Doppler Ultrasonographic Evaluation of Erectile Dysfunction in a Northern Nigerian Tertiary Hospital

Background

Colour duplex Doppler is a noninvasive tool for the evaluation of the vascular mechanism of erectile dysfunction (ED). It can be used to determine the integrity of the vascular mechanism and to differentiate between arterial and venous insufficiency.

Objectives

To identify the vasculogenic causes of ED and subclassify them into arteriogenic, venogenic, or mixed to assist in predicting the clinical outcome.

Materials and Methods

A retrospective study was conducted at the Department of Radiology, ABUTH Zaria, from records of patients who had presented to the Doppler suite with symptoms of ED available between July 2020 and August 2022.

Results

A total of 23 patients were involved in this study. The age range was 25-66 years. The majority of the patients were seen in age groups 51-60 years and 41-50 years with 48% (11) and 22% (5), respectively. Only 3 (13%) of the patients were found to have normal penile Doppler study, 12 (52%) patients were found to have arteriogenic, and another 4 (17.4%) patients were found to have venogenic cause. In four (17.4%) patients, there was mixed/inconclusive picture. Among the nine (39%) patients with Peyronie's disease, only one showed normal Doppler study. The incidence of vasculogenic cause of ED was found to increase with age.

Conclusions

The colour Doppler study is an important noninvasive nonionizing radiation tool for swift evaluation of penile erectile function and, thus, helps in classifying ED causes into structural, vascular, or possibly psychogenic, hence guiding the clinicians on the therapeutic options.

Is Penile Doppler Ultrasonography Overdiagnosed?

AIM

The objective of this study was to determine whether penile Doppler ultrasonography (USG) examinations, combined with the administration of intracavernosal vasoactive agents, were correctly performed as a second-line diagnostic method with the proper indications in a select patient group.

METHODS

A total of 200 patients who underwent penile Doppler ultrasounds in our clinic were included in the study. Patients' demographic data were collected, information about their medical-sexual history was taken, physical examinations were performed, and laboratory analyses were conducted. Patients were informed in detail about the process, and their consent was given prior to the study. Procedure outcomes and complications were also recorded. The relationship of vasculogenic pathologies was analysed, and the rate of abnormal results and complications was compared with the existing literature.

RESULTS

Following the investigations, abnormal results were found in 24.5% of patients, while this rate was 6.8% in patients under the age of 40. Arterial insufficiency was found in 31 patients and venous insufficiency in 18 patients. Five patients had both pathologic conditions. No statistically significant correlation was found between arterial insufficiency and age, while venous insufficiency was significantly correlated with age (p=0.006).

CONCLUSION

Penile Doppler ultrasounds should only be ordered for a carefully selected patient group. Ordering ultrasounds without a proper indication can result in unnecessary labour and financial loss, as well as an increase in invasive procedures.

Randomized Placebo Controlled Trial of Sildenafil Citrate, Cognitive Behavior Sex Therapy and Integrated Treatment in Men Diagnosed With Non Organic Erectile Dysfunction

Introduction

The integrated treatment combining phosphodiesterase-type 5 inhibitors (PDE5i) and Cognitive Behavior Sex Therapy (CBST) has been shown to yield promising results in the treatment of Non Organic Erectile Dysfunction (NOED) in young men.

Aim

The current study aimed to establish the efficacy of integrated treatment combining Sildenafil Citrate (SC) 50mg and CBST as a treatment of choice in young Pakistani men with NOED.

Methods

One hundred thirty-seven young men were recruited to participate in the study out of 164 men referred from sexual health clinics in Pakistan. They were randomized sequentially into 4 treatment groups namely SC = 35, CBST = 34, integrated treatment = 35, and placebo = 33. 7, 4, 6, and 4 men were dropped out of each treatment group respectively. The data of 116 men were analyzed. The on demand SC 50 mg, twice weekly 50 minutes sessions and home assignments, a combination of SC and 50 minutes sessions, and placebo were administered to firsst, second, third, and fourth group respectively for a period of 12 weeks. The follow-up assessment was done after 12 weeks of post-treatment for all groups.

Main Outcome Measures

The Urdu standardized versions of International Index of Erectile Functoning-5 (IIEF-5) and Depression Anxiety Stress Scale-21 (DASS-21) were the main outcome measures.

Results

The mixed repeated measures analysis of co-variance yielded significant impact of both CBST and integrated treatment groups in improving IIEF-5 scores at post treatment as compared to placebo. The CBST group experienced reduction in depression scores at post treatment as compared to both SC and integrated treatment. Only the integrated treatment brought reduction in anxiety scores at post treatment as compared to SC. The covariates age and NOED duration did not significantly impact the treatment outcome for all treatment groups.

Clinical Implications

The efficacy of integrated treatment approach for improving symptoms of NOED and associated depression and anxiety is strong clinical implication of the study.

Strengths & Limitations

The effectiveness of integrated treatment approach in the improvement of NOED symptoms and associated depression and anxiety scores is the main strength of the study. The improvement in depression scores is the added strength of CBST component of integrated treatment approach. The study should have included other PDE5i to compare their effects with the CBST or placebo groups.

Conclusion

The study concludes that the CBST and integrated treatments are treatment of choice for NOED and associated depression and anxiety in young men.

Bilal A, Abbasi NH. Randomized Placebo Controlled Trial of Sildenafil Citrate, Cognitive Behavior Sex Therapy and Integrated Treatment in Men Diagnosed With Non Organic Erectile Dysfunction. Sex Med 2022;10:100464.

Li-Eswt improves hemodynamic parameters thus suggesting neoangiogenesis in patients with vascular erectile dysfunction

Extracorporeal treatment with low intensity shock-wave therapy (LI-ESWT) is a recently introduced non-invasive method which purposes the restoration of the pathophysiological alterations at the base of vasculogenic ED in male patients. The evidence in favour of the neoangiogenic potential of this treatment derived from in vitro studies and on animal models. The purpose of this study, in which the Power Doppler method was applied, is to demonstrate 'objectively' the real efficacy of LI-ESWT at the level of the microcirculation of the corpora cavernosa (neoangiogenesis) in patients affected by vasculogenic ED. Data from this study show, for the first time, that LI-ESWT treatment promotes neovascularisation of the functional arteries in patients affected by vasculogenic ED.

Diagnostic categorization of erectile dysfunction using duplex color doppler ultrasonography and significance of phentolamine redosing in abolishing false diagnosis of venous leak impotence: A single center experience

Background and Aims:

Erectile dysfunction (ED) is an inability to achieve and maintain erectile rigidity sufficient for satisfactory sexual performance. It is either organic or psychogenic in origin. This study was aimed at establishing vasculogenic causes among patients being evaluated for ED using Penile Doppler Ultrasound.

Methods:

Fifty-two consecutive patients with the clinical diagnosis of ED were evaluated with color Doppler ultrasound scan using a 7.5 MHz high-frequency linear transducer between July 2016 and June 2019. The examination was commenced 3 min after an intracavernosal injection with 10-20 μg of PGE₁ and continued for 30 min. The measurements were obtained alternately from both deep penile arteries. The variables analyzed were the peak systolic velocity (PSV), end-diastolic velocity (EDV) and resistive index (RI), calculated as (PSV-EDV)/PSV. Erection Hardness was evaluated subjectively using the EH Score (EHS), a 5-point response score denoting how the patient would rate his erection. ED was subjectively assessed using the International Index of Erectile Function (IIEF-5) questionnaire. In patients with a diagnosis of vasculogenic ED, intracavernosal PGE₁ injection was started with a 5 μg dose and then increased in 5 μg increments until the final dose of 20 μg was reached.

Results:

PSV of cavernosal arteries (CA) varied between 19.2 and 106.2 cm/s (mean: 43.8 ± 18.2) among the entire patients and between 19.7 and 80.2 cm/s (mean: 42.6 ± 11.3) among patients with arteriogenic ED. Arteriogenic ED was found in 8 patients (15.3%), while venogenic ED was observed in 12 patients, which constituted 23% of the entire study population and mixed arteriogenic-venogenic ED was found in 6 patients (11.5%) of the study population. DICC performed on patients diagnosed with venogenic ED on color Doppler ultrasonography revealed venous leakage and no statistically significant differences between results of DICC and color Doppler ultrasonography were found in EDV, RI, and PI measurements (P< 0.005). Among patients with venogenic ED and mixed arteriogenic-venogenic ED,2 patients had a normal erectile response and the remaining 16 received 2 mg phentolamine. A significant increase in PSV between baseline and 20 mg 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 was observed in 12 patients. In patients with arteriogenic erectile dysfunction, mean (±standard deviation) duration of erection for consecutive doses of PGE₁5 μg, 10 μg, 15 μg, and 20 μg were 42.2±18.4, 55.4±24.1, 66.1 ± 31.1, and 83.3±36.7 minutes, respectively, with significant increase for each dose. In patients with veno-occlusive dysfunction, mean durations of erection significantly increased from 9.1±8.0 minutes at 10 μg to 19.2±9.8 minutes at 20 μg.

Conclusion:

In the current study, 50% of patients had vasculogenic ED and “false-positive’’ diagnosis of venous leakage was unmasked by phentolamine re-dosing. It is therefore imperative that patients with ED benefit from duplex color Doppler ultrasonography which is safe, cheap and non-ionizing diagnostic modality before initiating therapy as ED treatment is cause specific.

Cognitive Behavioral Sex Therapy: An Emerging Treatment Option for Nonorganic Erectile Dysfunction in Young Men: A Feasibility Pilot Study

Introduction

An increasing number of young men have been found to develop nonorganic erectile dysfunction (NOED) in recent years. The NOED has been shown to respond better to cognitive behavior sex therapy (CBST) in a few past studies.

Aim

The present research aims to establish the efficacy of CBST as a promising treatment option in young men suffering from NOED by administering a feasibility pilot trial.

Methods

28 young men (M = 31 years) out of a total of 39 men (7 excluded, 4 quit treatment) diagnosed with NOED from sexual health clinics in Pakistan were recruited to receive CBST treatment (n = 13) on average twice a week for a period of 50 minutes per session for a period of 4, 6, 8, and 12 weeks for the mild, mild to moderate, moderate, and severe forms of NOED, respectively, and sildenafil citrate group (n = 15) receiving sildenafil citrate 50 mg on demand. The trial design was sequential random assignment clinical trial.

Main Outcome Measures

International Index of Erectile Functoning-5 and Depression Anxiety Stress Scale-21 were used before treatment, after treatment, and in follow-up as the main outcome measures.

Results

The repeated measures analysis of covariance established a nonsignificant difference between CBST and sildenafil citrate 50 mg in NOED scores improvement, NOED severity reduction, and reduction in depression scores at posttreatment assessment. There were significant differences among different CBST modalities in improving NOED scores, reduction in NOED severity, and depression scores. There was significant difference in CBST and sildenafil citrate 50 mg in anxiety reduction at posttreatment assessment. The covariates age, age groups, and NOED duration did not significantly impact the treatment outcome for both treatment groups except age which impacted the interaction of treatment and anxiety scores.

Conclusion

The CBST is an emerging and promising treatment choice in younger men suffering from NOED.

Bilal A, Abbasi NuH. Cognitive Behavioral Sex Therapy: An Emerging Treatment Option for Nonorganic Erectile Dysfunction in Young Men: A Feasibility Pilot Study. J Sex Med 2020;8:396–407.

Vitamin D and Male Erectile Function: An Updated Review

Literature support that vitamin-D is important for different systems of the human body including, but not limited to endocrine and immune systems, vasculature and endothelial function of the body. Male erectile function depends on many factors and can be perceived as a health indicator of the body. Epidemiological data have shown that vitamin-D deficiency is also associated with erectile dysfunction. In this review, our aim is to interpret the mechanisms by which vitamin-D might regulate anatomy and physiology of penis. Evidence showed that vitamin-D is needed for an adequate erectile function. Briefly, vitamin-D is crucial for a better healthy body and sexual activity.

Penile Doppler Ultrasound for Erectile Dysfunction: Technique and Interpretation

OBJECTIVE. Erectile dysfunction (ED) is a common medical condition that has a high prevalence and incidence worldwide and may have a significant impact on both physical and psychosocial health. The purpose of this article is to review the role of penile Doppler sonography in the assessment of ED. CONCLUSION. Penile Doppler sonography is an essential tool for differentiating between vascular and nonvascular causes of ED; therefore, radiologists must be familiar with the imaging protocol, the limitations of the technique, and interpretation of its findings, to warrant an accurate diagnosis and appropriate patient management.

Diagnostic Accuracy of Different Criteria of Pharmaco-penile Duplex Sonography for Venous Erectile Dysfunction

OBJECTIVES

The aim of this study was to analyze the diagnostic accuracy of different criteria of pharmaco-penile duplex sonography in venous erectile dysfunction (ED).

METHODS

The following parameters were measured after an intracavernous injection test in patients with ED from May 2016 to February 2017 at our hospital: diameter, peak systolic velocity, end-diastolic velocity, and resistance index of the cavernous artery; diameter and peak velocity (if leak occurred) of the deep dorsal vein. Three ultrasonographic diagnostic criteria of venous ED were applied. Criterion A: continuous blood flow signals in the deep dorsal vein, peak velocity greater than 3 cm/s, peak systolic velocity greater than 30 cm/s, end-diastolic velocity greater than 5 cm/s; Criterion B: resistance index less than 0.89 and other parameters corresponding with Criterion A; Criterion C: resistance index less than 0.80 and other parameters corresponding with Criterion A. The diagnostic results of each criterion were compared with the cavernosographic results.

RESULTS

Thirty-six patients were diagnosed as venous ED by cavernosography in 54 ED cases. The diagnostic specificity, sensitivity, and accuracy of Criterion A were 70.6%, 91.7%, and 84.9%, respectively. Those of Criterion B were 82.4%, 69.4%, and 73.6%, while the results for Criterion C were 94.1%, 33.3%, and 52.8%, respectively. Criterion A had the highest diagnostic accuracy, the largest area under the receiver operating characteristic curve (area = 0.811), and the highest consistency (kappa = 0.642) with the cavernosographic results in the 3 criteria. The difference was statistically significant (P < .05).

CONCLUSIONS

Among the 3 commonly used ultrasonographic criteria, Criterion A is most appropriate in the diagnosis of venous ED.

Distribution of psychogenic and vascular impotence in a tertiary health-care center's cohort: A retrospective study using penile Doppler imaging

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.

Finasteride and Erectile Dysfunction in Patients with Benign Prostatic Hyperplasia or Male Androgenetic Alopecia

Finasteride is primarily used to treat benign prostatic hyperplasia (BPH) and male androgenetic alopecia (MAA). Five-alpha reductase inhibitors (5α-RIs) could induce male sexual dysfunction due to their effects on testosterone and dihydrotestosterone. There is evidence suggesting that 5α-RIs may independently increase the risk of erectile dysfunction (ED). However, many investigators believe that side effects of 5α-RIs will disappear with continuous treatment. Considerable controversy exists regarding the severity and persistence of side effects of finasteride on ED. The aim of this review was to summarize current research studies on finasteride associated with ED. The search strategy used each term of finasteride and ED against PubMed database to identify related studies. ED data reported from available trials for finasteride were summarized and reviewed. Although there is not enough evidence to prove the relationship between finasteride and ED, most studies in this review found that finasteride for BPH was correlated with ED. However, most studies included in this review revealed that finasteride for MAA was not correlated with ED. On the other hand, some studies reported side effects of finasteride associated with sexual dysfunction, including ED, male infertility, ejaculation problem, and loss of libido, even in MAA patients. Well-designed randomized controlled trials are needed to further determine the mechanism and effects of finasteride on ED. However, physicians should discuss with their patients possible long-term effects of finasteride on sexual function, although we do not have evidence showing that adverse events of sexual dysfunction are absolutely associated with 5α-RIs.

Parenchymal neuro-Behçet disease with erectile dysfunction and micturition disturbances: case report and literature review

Parenchymal neuro-Behçet disease (NBD) is a serious clinic condition with a sub-acute or chronic disease course that results in incapability through pyramidal tract involvement. Though well-known consequences can deter a patient's life, both urinary symptoms and sexual dysfunction are underestimated complications of NBD and closely related in timing. Here, we report the case of a young male patient with parenchymal NBD who developed urinary incontinence and erectile dysfunction in addition to widespread pyramidal tract signs and symptoms. We discuss clinical features, prognosis and treatment of the case. A review of English literature was conducted for cases of concurrent urinary or sexual dysfunction complicating parenchymal-NBD.