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

Abstract

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 PGE₁ 5 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.

Keywords

Duplex color doppler ultrasonography - end diastolic velocity - erectile dysfunction - erection hardness score - International index of erectile function questionnaire - peak systolic velocity - phentolamine - prostaglandin – E1 - time to erection

Publication History

Received: 13 October 2019

Accepted: 03 May 2020

Article published online:
19 July 2021

• References

• 1 Huang ST, Hsieh ML. Different hemodynamic responses by color Doppler ultrasonography studies between sildenafil non-responders and responders. Asian J Androl 2007; 9: 129-33
• 2 Araujo AB, Travison TG, Ganz P, Chiu GR, Kupelian V, Rosen RC. et al. Erectile dysfunction and mortality. J Sex Med 2009; 6: 2445-54
• 3 Dick B, Reddy A, Gabrielson AT, Hellstrom WJ. Organic and psychogenic causes of sexual dysfunction in young men. Int J Med Rev 2017; 4: 102-11
• 4 Foresta C, Caretta N, Palego P, Selice R, Garolla A, Ferlin A. Diagnosing erectile dysfunction: Flow-chart. Int J Androl 2005; 28: 64-8
• 5 Aiyekomogbon JO, Igashi JB, Lawan RO, Bioku MJ, Ameadaji M. Colour doppler sonography of the penis in the evaluation of erectile dysfunction: Our experience in Abuja, Nigeria. Niger Postgrad Med J 2017; 24: 210
• 6 Khanzada U, Khan SA, Hussain M, Adel H, Masood K, Adil SO. et al. Evaluation of the causes of erectile dysfunction in patients undergoing penile Doppler ultrasonography in Pakistan. World JMens Health 2017; 35: 22-7
• 7 Jung DC, Park SY, Lee JY. Penile Doppler ultrasonography revisited. Ultrasonography 2018; 37: 16-24
• 8 Altinbas NK, Hamidi N. Penile Doppler ultrasonography and elastography evaluation in patients with erectile dysfunction. PolJRadiol 2018; 83: e491
• 9 Yafi FA, Libby RP, McCaslin IR, Sangkum P, Sikka SC, Hellstrom WJ. Failure to attain stretched penile length after intracavernosal injection of a vasodilator agent is predictive of veno-occlusive dysfunction on penile duplex Doppler ultrasonography. Andrology 2015; 3: 919-23
• 10 Pezzoni F, Scroppo FI. Penile vascular diagnostic categorization using penile duplex Doppler ultrasound: Differences in vascular hemodynamics parameters by differences in anatomic sampling location. Arch ItalUrolAndrol 2016; 88: 183-5
• 11 Gandaglia G, Briganti A, Jackson G, Kloner RA, Montorsi F, Montorsi P. et al. A systematic review of the association between erectile dysfunction and cardiovascular disease. Eur Urol 2014; 65: 968-78
• 12 Bella AJ, Brant WO, Lue TF. Penile anatomy. In: Bertolotto M. editor Color Doppler US of the Penis. Berlin: Springer; 2012: 11-4
• 13 Belgrano E, Bucci S, Liguori G, Trombetta C. Clinical evaluation of erectile dysfunction in the era of PDE-5 inhibitors: The residual role of penile color Doppler US. In: Bertolotto M. editor Color Doppler US of the penis. Berlin: Springer; 2008: 21-3
• 14 Sen J, Godara R, Singh R, Airon RK. Colour Doppler sonography of flaccid penis in evaluation of erectile dysfunction. Asian J Surg 2007; 30: 122-5
• 15 Golijanin D, Singer E, Davis R, Bhatt S, Seftel A, Dogra V. Doppler evaluation of erectile dysfunction: Part 1. Int J Impot Res 2007; 19: 37-42
• 16 Pastuszak AW. Current diagnosis and management of erectile dysfunction. Curr Sex Health Rep 2014; 6: 164-76
• 17 Gao QQ, Chen JH, Chen Y, Song T, Dai YT. Dynamic infusion cavernosometry and cavernosography for classifying venous erectile dysfunction and its significance for individual treatment. Chin Med J (Engl) 2019; 132: 405-10
• 18 Gontero P, Sriprasad S, Wilkins CJ, Donaldson N, Muir GH, Sidhu PS. Phentolamine re-dosing during penile dynamic colour Doppler ultrasound: A practical method to abolish a false diagnosis of venous leakage in patients with erectile dysfunction. Br J Radiol 2004; 77: 922-6
• 19 Bernie HL, Segal R, Le B, Burnett A, Bivalacqua TJ. An empirical vs risk-based approach algorithm to intracavernosal injection therapy: A prospective study. Sex Med 2017; 5: e31-6
• 20 Cavallini G, Maretti C. Unreliability of the duplex scan in diagnosing corporeal venous occlusive disease in young healthy men with erectile deficiency. Urology 2018; 113: 91-8
• 21 Patel DV, Halls J, Patel U. Investigation of erectile dysfunction. Br J Radiol 2012; 85: S69-78