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GENITOURINARY Year : 2006 | Volume : 16 | Issue : 4 | Page : 891-896 Role of penile color doppler in the evaluation of erectile dysfunction AClifford,JNToppo Department of Radio-diagnosis, Christian Medical College. Ludhiana, India Date of Submission Date of Acceptance 28-Jun-2005 10-Nov2006

Abstract Objective : The aim of this study is to find out hoe effective high frequency ultrasonographic Color Doppler can be to detect the cause of erectile dysfunction. Material and Methods : The hemodynamic function of the penis can be evaluated non-invasively by performing or power Doppler US with spectral analysis following injection of a vasoactive pharmacological agent Papavarine, to induce an erection. Results : The sensitivity of PBI in the diagnosis of erectile dysfunction was 61% and the specificity was 74%. After the addition of Duplex Doppler, sonography the sensitivity increased to 89% with a specificity of 95%. On further evaluation with post- papavarine, injection the sensitivity increased to 97% and the specificity increased to 99%. The increase was significant (p<0.001). Conclusion : Papavarine induced Color Duplex Doppler Sonography is an excellent and highly accurate means of assessing patients with erectile dysfunction. Keywords: Doppler Ultrasonography, Erectile Dysfunction How to cite this article: Clifford A, Toppo JN. Role of penile color doppler in the evaluation of erectile dysfunction. Indian J Radiol Imaging 2006;16:891-6 How to cite this URL:

Clifford A, Toppo JN. Role of penile color doppler in the evaluation of erectile dysfunction. Indian J Radiol Imaging [serial online] 2006 [cited 2012 Apr 9];16:8916. Available from: http://www.ijri.org/text.asp?2006/16/4/891/32377 Introduction

Penile erection is a complex phenomenon, which includes coordinated interaction of the nervous, arterial, venous and sinusoidal systems. A defect in any of these systems may result in erectile dysfunction. Erectile Dysfunction is defined as the consistent inability to generate or maintain an erection of sufficient rigidity for sexual intercourse. Around 10% of men aged 40-70 years have complete, 17.1% have mild and 25.2% have moderate amount of erectile dysfunction.[1],[2] The normal chain of events leading to penile erection begins with psychological factors that cause transmission of parasympathetic impulses to the penis. The walls of the arterioles and sinusoids of the corpora cavernosa relax, leading to an increased inflow of blood through the cavernosal artery. With filling of the sinusoidal spaces, corporal veno-occlusive mechanism works. The emissary veins leaving the corpora are compressed passively against the fibrous tunica albuginea and rigid penile erection is achieved and maintained. Detumescence occurs after neurological stimulated contraction of trabecular smooth muscle in the corpora cavernosa.[1],[2],[3] Erectile dysfunction is caused by the interruption in the above chain of events including psychogenic, neurogenic, arteriogenic and venogenic causes. Often more than one cause is combined. Establishing a specific cause is important particularly in young men because of frequency of correctable vascular abnormalities. Organic causes of erectile dysfunction are found in 50-90%, and organic impotence in the presence of normal endocrine balance and intact nervous system is vascular in origin in about 50-70%, either arterial insufficiency or venous incompetence. Pure arteriogenic impotence accounts for about 30% of cases and isolated venogenic impotence is found in about 15%. Often erectile dysfunction is caused by combined arteriogenic and venogenic causes. Occasionally, organic impotence is caused by morphological abnormalities of the penis such as Peyronies disease.[1] The cavernosal arteries are the primary source of blood flow to the corpora cavernosa while dorsal arteries supply blood to the skin and glans of the penis. multiple anastomotic channels connect the cavernosal arteries with dorsal arteries. Arteriography with selective internal iliac angiography is considered the gold standard in evaluation of arteriogenic impotence. However, this technique is invasive and therefore not suitable as a screening examination.[1] Recently many patients have been screened for Vasculogenic impotence by measuring their clinical response to an intra cavernosal injection of a vasodilating pharmacological agent.[4],[5] Lue et al showed that precise Doppler sampling and blood velocity measurements of the deep cavernosal arteries could be performed before and after intracavernosal injection of vasodilating agents and 75% increase in vessel diameter is good

indication of normal arterial flow into the cavernosal artery. Commonly many investigators use 60 mg of Papavarine in a 2 ml solution injected into either the right or left corpus cavernosum.[3],[4],[5] Few have used a triple agent consisting of Papavarine 4.4 mg, phentolamine 0.15 mg and PG-E1 1.5 in a 0.25 ml to minimize the possibility of drug induced priapism, which may occur in 2%-3% of the patients. Benson et al have grouped impotent patients into A. Normal, with an average PSV of 47 cm/sec. B. Mild to moderate with average peak systolic velocity (PSV) of 35 cm/sec. And C. Severe arterial insufficiency with an average PSV of 7 cm/sec. The investigators concluded that a peak systolic velocity of 40cm/sec was normal. The parameters that indicate the presence of arterial disease are a subnormal clinical response to vasoactive agents, a less than 60% increase in the diameter of the cavernosal artery, and a peak systolic velocity of the cavernosal arteries less than 25cm/sec. In the presence of normal arterial function, Doppler findings suggestive of an abnormal venous leak are persistent end diastolic velocity of the cavernosal artery greater than 5 cm/sec and demonstration of flow in the deep dorsal vein. The development of Diastolic flow reversal after an injection has been found to be a reliable indicator of venous competence.[4],[5],[6] Material and Methods

The hemodynamic function of the penis can be evaluated non-invasively by performing or power Doppler US with spectral analysis following injection of a vasoactive pharmacological agent Papavarine, to induce an erection. The present study design was a one-year prospective study or a minimum of 50 patients, to be conducted in the Department of Radio diagnosis, Christian Medical College, Ludhiana from July 2003 to June 2004. The study comprised of all patients with erectile dysfunction referred for a Penile Artery Doppler. All patients were evaluated with real time Ultrasonographic Color Doppler using a high frequency transducer (7.5 to 9.0 MHz, MHz transducer, logic 500 MD, GE Medical Systems. Doppler US is performed with the patient supine and the penis in the anatomical position, lying on the anterior abdominal wall. High-resolution linear probes with frequencies of 7.5-9.0 MHz will be used. The following is our protocol for Penile Doppler US.[3],[4],[5],[6]. Pre injection measurement 1.In the flaccid state, the inner diameter of the cavernosal artery is measured. 2.Baseline Peak Systolic velocity.

Post injection measurement The patient is left alone for some time for him to achieve a full erection or the maximum, which he can attain. After an intracavernosal injection of 60 mg of papavarine, the inner diameter of the cavernosal artery is measured again at intervals of 5, 10, 15 & 20 minutes and the Doppler spectra are obtained from the proximal cavernosal arteries at the base of the penis.[4],[5],[6],[7] The study included the International Index of Erectile Function (IIEF)(10) which is a multi-dimensional scale for the assessment of Erectile Dysfunction. Penile Brachial Index (PBI)[11],[2] will be calculated to assess the relative flow in the penile artery by using the formula PBI= Penile artery pressure/Brachial artery pressure. Discussion

The present study has been carried out on 51 patients who presented to the department of Radiology, in the Christian Medical College & Hospital, Ludhiana. The Statistical analysis was done using Epi-Info version 6 software from CDC, Atlanta. In this study, the range varied from 22 to 59 years. The mean age was 40.83 years. The maximum numbers of patients were in the age group of 21-30 years. Out of the 18 patients in this age group, 4 (22.22%) patients had erectile dysfunction. In the next age group of 51-60 years, there were 13 patients, out of which 10 (76.92%) patients had erectile dysfunction. The third largest group was 41-50 years, and there were 11 patients in this group, out of which 6 (54.55%) patients had erectile dysfunction. The last group was of the age group of 31-40 years, which comprised of nine patients out of which 4 (44.44%) patients had erectile dysfunction. Out of the 51 patients in the study, 46 patients (90.19%) were married and 5 patients (09.80%) were unmarried. All the unmarried patients were from urban population and 43 of the married patients were from urban areas (93.48%). Out of the total population, examined 3 (5.88%) out of 51 patients were from rural areas. All the unmarried patients had a normal response to the test. All the rural patients were suffering from erectile dysfunction. Out of the 43 married patients living in urban areas 24 (55.81%) patients were suffering from erectile dysfunction. Out of the total 51 patients examined, 8 (15.65%) patients were known cases of some medical illness. Out of these 7 (13.73%) patients were found to be suffering from controlled hypertension. 1 (01.96%) patient was suffering from both diabetes mellitus and hypertension; and 1 (01.96%) patient was undergoing treatment for epilepsy. Out of these patients 3 (05.88%) patients belonged to the 41-50 age group, and, 5

(09.80%) patients belonged to the 51-60 age group. Out of the 7 hypertensives 5 (09.80%) of the patients were suffering from erectile dysfunction. Both the diabetic and epileptic were found to be suffering from erectile dysfunction. Of the 51 patients presenting to the department 31 (60.78%) patients had some form addiction.17 (33.33%) patients were smokers and 15 (29.41%) were alcoholics. Only one patient out of these was both a smoker and alcoholic. Out of the smokers, 8 (15.69%) patients' were suffering from erectile dysfunction and 10 (19.60%) patients who were pure alcoholics were suffering from erectile dysfunction. It was observed that maximum number of patients were in the mild to moderate group. There were no patients with severe loss of erectile function and only 4 patients had normal erectile function. It was seen on duplex doppler sonography that only 27 patients had abnormal erectile function. Out of the total patients, presenting most of them had mild orgasmic dysfunction only. Out of the total of 51 patients who presented to the department, 50 of the patients were having mild to moderate or moderate level of dis-satisfaction while having intercourse. There were no patients who were fully satisfied with their sexual intercourses, or had only mild dissatisfaction. Maximum number of patients had only a mild or mild to moderate loss of sexual desire. Moreover, the urge to lead an active sexual life was intense. Out of the total of 51 patients which were evaluated, 37 patients showed a PBI of more than or equal to 0.7 indicating normal vascular function. However out of these 37(72.55%) patients, 16 (31.37%) were found to have a poor response on papavarine testing and 21(41.18%) had a moderate or firm erection on papavarine injection analysis. 14 (27.45%)patients showed a poor response in the penile brachial test, out of which 8 (15.69%) patients showed a poor response on papavarine injection also but 6 (11.76%) patients showed a moderate to firm erection. Results

All patients with a pressure response of more than 60 m Hg had a good erectile response, however patients who had a pressure response of less than 40 mm Hg had a poor response. It may be noted that a peak systolic velocity of 25 mmHg or more was considered normal. Therefore, in the study a gray Zone of 25-40 mm Hg was seen in which, though the patient was normal on reports, yet he could not achieve a very satisfactory erection. Most patients a best response in 2-5 minutes. The intracorporeal pressure ranged between 29-120 mmHg.

Most erections lasted for 30-60 minutes. One patient developed priapism following the intracavernous injection of papavarine and had an erection, which lasted for almost 48 hours. The help of the urologists was sought and the patient was returned to normalcy following a local injection of an anti-adrenergic agent. Ten patients had an erection, which lasted for less than 10 minutes. In all these patients, a venogenic cause was established for their erectile dysfunction, as these patients had high levels of end diastolic velocities. The complications encountered in this study were very few and easily manageable i.e. Two patients sustained hematoma at the injection site. Positive pressure was applied at the hematoma and it was seen to readily subside after approximately 15-30 minutes. Nearly half the patients had ecchymosis, which developed within a period of approximately 7 days, but needed no corrective measurement as it spontaneously subsides in 15-20 days. Only the patient needs to be re-assured. One patient complained of penile pain till one day after the injection. Constraining Factors

The penile brachial index can be measured only in the flaccid state of the penis. Penile Brachial Index is recorded by measuring the blood pressure in the dorsal arteries. These dorsal arteries do not supply the corpora cavernosa and hence there is a discrepancy in the results of the penile brachial index and post papavarine duplex doppler sonography. Patients with diabetes mellitus, diseases of the arterioles or a venous leak may have a normal penile brachial index but poor response on papavarine injection. Absolute values of 0.6 have been indicative of a vasculogenic cause of impotence; however careful review of literature reveals that no clear relationship has been established between any absolute value of the Penile Brachial Index and any specific etiology.Although low values on repeated measurements suggest arterial insufficiency, a higher value does not exclude it. Hence, the value obtained by the clinician cannot be used to confirm or refute a vasculogenic etiology for erectile dysfunction. The values obtained are dependant on the expertise of the examiner and may be examiner variable.Penile Brachial Index can only measure the dorsal arteries and not the deep arteries. The velocity in the dorsal arteries is close to the deep arteries in the flaccid state but is completely different in the erect state after an intracavernous injection of a vasoactive agent. It is difficult to measure penile brachial index in the deep arteries because they are situated deep and it is difficult to obtain signal from them. In addition, the cuff obscures the base of the penis and the doppler probe has to

be placed distally to the cuff where the deep arteries may have already branched. Penile Brachial Index is difficult to assess in patients with a small sized penis.Unilateral blood supply of the dorsal vessels is a normal variation. The sensitivity of PBI in the diagnosis of erectile dysfunction was 61% and the specificity was 74%. After the addition of Duplex Doppler, sonography the sensitivity increased to 89% with a specificity of 95%. On further evaluation with postpapavarine, injection the sensitivity increased to 97% and the specificity increased to 99%. The increase was significant (p<0.001). (Zonderland JU 1999) The sensitivity of International Index of Erectile Function (IIEF) was 60%, the specificity was 94% and the negative predictive value was 97%. Sensitivity of post papavarine duplex Doppler sonography alone was 100%, specificity was 97% and negative predictive value was 100%. (Kaiser JU 2002). Sensitivity, specificity, negative predictive values and positive predictive values and accuracy of PBI in the detection of Erectile Dysfunction were 67.6%, 78.8%, 54.8,72.6 and 78.6 respectively; those of IIEF were 27.6%, 79.4%, 79.4%, 28.9% and 78.8% respectively; and those of papavarine induced color duplex Doppler sonography were 95.3%, 96.8%, 08.5% and 96.6% respectively. Duplex doppler sonography also allows the evaluation of the structure of the corpora cavernosa and the presence of any fibrous plaques and thus can help in further evaluating the structural causes of erectile dysfunction also in addition to the vasculogenic causes. Out of the total of 51 patients, doppler sonography diagnosed 27 patients who were suffering from erectile dysfunction out of which eight were suffering from psychogenic impotence, one was suffering from neurogenic impotence, three were suffering from arteriogenic impotence, ten were suffering from venogenic impotence and only one was suffering from structural deformity. In this study, the range varied from 22 to 59 years. The mean age was 40.83 years. Sensitivity, specificity, negative predictive values and positive predictive values and accuracy of papavarine induced duplex Doppler sonography were 95.3%, 96.8%, 08.5%, 95.8% and 96.6% respectively. Out of the total of 51 patients which were evaluated, thirty-seven patients showed a PBI of more than or equal to 0.7 indicating normal vascular function. However, out of these thirty-seven patients, sixteen were found to have a poor response on papavarine testing and twenty-one had a moderate or firm erection on papavarine injection analysis. Fourteen patients showed a poor response in the penile brachial test, out of which eight patients showed a poor response on papavarine injection also but six patients showed a moderate to firm erect. The sensitivity of PBI in the diagnosis of erectile dysfunction was 61% and the specificity was 74%. Conclusions

We conclude that calculation of penile Brachial Index is not sufficient to evaluate patients with Erectile dysfunction because accurate measurement of blood pressure in the cavernosal arteries is impossible even in combination with a vasoactive agent. Evaluation of patients based on the International Index of Erectile Function (IIEF) is a useful tool to screen a patient with erectile Dysfunction for the etiology and level of dysfunction. However, it is also limited in its usefulness because of the inaccurate and reserved history provided by the patients. Medical illnesses and use of certain drugs does predispose patients towards erectile dysfunction. Almost fifty percent of patients who were suffering from erectile dysfunction had a vasculogenic cause for their Impotence. Papavarine induced Color Duplex Doppler Sonography is an excellent and highly accurate means of assessing patients with erectile dysfunction. In the absence of it being an invasive test, we propose that it should replace Angiography and Cavernosometry as the Gold Standard Technique for evaluating patients of Erectile Dysfunction.[12] References 1. NIH consensus conference on Impotence. JAMA JULY 7, 1993- vol 270, NO.1. 2. Schwartz AN, Wang KY, Mack LA, Lowe M, Berger RE, Cyr DR, Feldman M evaluation of normal erectile function with color flow Doppler sonography. AJR 1989; 153:1155-1160. 3. Bookstein JJ, Valji K, Parsons L, Kessler W.Pharmacoarteriography in the evaluation of impotence, J Urol. 1987; 137: 333-337. [PUBMED] 4. Quam JP,King BF, James EM, et al. Duplex and color Doppler sonographic evaluation of vasculogenic impotence. AJR 1989; 153:1141-1147. [PUBMED] 5. Rajfer J, Canan V, Dorey FJ, et al. Correlation between penile angiography and Duplex scanning of cavernous arteries in impotent men. J Urol 1990; 143:11281130. [PUBMED] 6. Virag R Frydman Dlegman M et al. Intracavernous injection of papavarine as a diagnostic and therapeutic method in erectile dysfunction. Angiology journal Vasc. Diseases 1984; 35:79-87. 7. Buvat J,Bervat-Hertaut M, Dehaene JL et al. Is injection of papavarine a reliable screening test for Vasculogenic impotence? J. Urology 1986; 135:476-78. 8. Jeffery P Quam, Bernard F. King Ronald Lewis. Duplex and color Doppler sonographic evaluation of vasculogenic impotence. AJR December 1989 153:1141-1147. 9. Carol B Benson, Martyn A Vickers. Sexual impotence caused by vascular disease: Diagnosis with duplex sonography. AJR December 1989 153:11491153. 10. R C Rosen, J C cppaleri, M D Smith et al. Development and evaluation of an abridged, 5 item version of the International Index of Erectile Function as a diagnostic tool for erectile dysfunction. International Journal of Impotent research 1999; 11:319-326.

11. Jason C Abber, Tom F Lue, Bradley R Orvis et al. A comparison of papavarine injection with the penile brachial index. J Urol.,May 1986;135: 1355-1362. 12. Stephan C Mueller, Hubertus V Wallengerg, Gunther E et al. Comparison of selective internal iliac pharmaco-angiography, penile brachial index and duplex sonography with pulsed Doppler analysis for the evaluation of vasculogenic impotence. J Urol; May 1990: 1435-1443.

Correspondence Address: A Clifford Department of Radio-diagnosis, Christian Medical College. Ludhiana India

DOI: 10.4103/0971-3026.32377

Figures [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]

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