Penile Color Doppler Sonography in Erectile Dysfunction Dr Ho Siew Hong Consultant Urologist S H Ho Urology & Laparoscopy Centre Gleneagles Hospital

Ultrasound and Color Doppler Sonography B mode ultrasound - linear array of transducers simultaneously scans a plane - two-dimensional image Doppler sonography - enhanced with Doppler effect - power Doppler for calculation of speed - color Doppler for direction

B mode ultrasound - linear array of transducers simultaneously scans a plane - two-dimensional image

Doppler sonography - enhanced with Doppler effect - power Doppler for calculation of speed - color Doppler for direction

Color Doppler Sonography Structure Diameter Direction of flow Velocity of flow (visual / audio)

Structure

Diameter

Direction of flow

Velocity of flow (visual / audio)

Penile Color Doppler Sonography in Erectile Dysfunction Corpora cavernosa, corpus spongiosum, tunica albuginea Hemodynamics of cavernosal arteries – before and after erection

Corpora cavernosa, corpus spongiosum, tunica albuginea

Hemodynamics of cavernosal arteries – before and after erection

Vaculogenic ED Organic ED 50-90% Vasculogenic ED 50-70% Arterial insufficiency Venous incompetence / veno occlusive dysfunction / endothelial disease Majority - mixed

Organic ED 50-90%

Vasculogenic ED 50-70%

Arterial insufficiency

Venous incompetence / veno occlusive dysfunction / endothelial disease

Majority - mixed

Why penile color doppler u/s ? V/S penile arteriography or cavernosography / cavernosometry All investigations require vasodilators Less invasive - avoid cannulation of iliac vessels - avoid contrast exposure - avoid radiation exposure

V/S penile arteriography or cavernosography / cavernosometry

All investigations require vasodilators

Less invasive - avoid cannulation of iliac vessels - avoid contrast exposure - avoid radiation exposure

Indications for Color Doppler Sonography in ED Excluded endocrine and neurological etiology Failed trial of PDE 5 I History suggestive of a. AV fistula b. veno occlusive dysfunction c. Peyronie’s disease

Excluded endocrine and neurological etiology

Failed trial of PDE 5 I

History suggestive of a. AV fistula b. veno occlusive dysfunction c. Peyronie’s disease

Vascular anatomy of Penis

Step 1 Homogenous corpora cavernosa, tunica albuginae Areas of increased echogenicity – fibrosis or Peyronie’s

Homogenous corpora cavernosa, tunica albuginae

Areas of increased echogenicity – fibrosis or Peyronie’s

Step 2 Pre-injection / flaccid state Peak systolic velocity (PSV) > 10 cm/s Measurement of cavernosal artery diameter – controversial and difficult to reproduce (0.3-10mm, increase by 75% or > 0.7mm)

Pre-injection / flaccid state

Peak systolic velocity (PSV) > 10 cm/s

Measurement of cavernosal artery diameter – controversial and difficult to reproduce (0.3-10mm, increase by 75% or > 0.7mm)

Step 3 - Injection of PGE E1 Measurement after 5 mins, mulitple measurements Cavernosal arteries Lower resistance arterial flow Peak systolic velocity PSV < 25-30 cm/s Suggestive of arterial insufficiency

Measurement after 5 mins, mulitple measurements

Cavernosal arteries

Lower resistance arterial flow

Peak systolic velocity

PSV < 25-30 cm/s

Suggestive of arterial insufficiency

Other systolic measurements Mean of both left and right cavernosal artery readings Systolic rise time Intima thickness

Mean of both left and right cavernosal artery readings

Systolic rise time

Intima thickness

Step 4 – Diastolic measurements Diastolic flow decreases with erection End diastolic velocity decreases to zero and reverses Persistent or EDV > 5 cm/s Suggestive of venous leak Absence of dilated veins Most accurate in presence of normal arterial flow

Diastolic flow decreases with erection

End diastolic velocity decreases to zero and reverses

Persistent or EDV > 5 cm/s

Suggestive of venous leak

Absence of dilated veins

Most accurate in presence of normal arterial flow

Step 5 Correlation of vascular abnormalities Plaques with penile vessels Location of AVF

Correlation of vascular abnormalities

Plaques with penile vessels

Location of AVF

Complications Pain – 20% severe, 30% moderate Priapism – 10% Ecchymosis – 5%

Pain – 20% severe, 30% moderate

Priapism – 10%

Ecchymosis – 5%

Take home message Penile Color Doppler U/S is not for every patient with suspected vasculogenic ED ‘ Normal’ values are still not finalized PSV and EDV stood test of time May replace penile cavernosometry / cavernosography and arteriography in some circumstances

Penile Color Doppler U/S is not for every patient with suspected vasculogenic ED

‘ Normal’ values are still not finalized

PSV and EDV stood test of time

May replace penile cavernosometry / cavernosography and arteriography in some circumstances

Thank you