POINT OF VIEW

Standardization of penile hemodynamic

evaluation through color duplex-doppler
ultrasound

Felipe Carneiro1
Osmar Cassio Saito1
Eduardo P. Miranda2

1. Departamento de Radiologia, Universidade de São Paulo, São Paulo, SP, Brasil.

2. Departamento de Urologia, Universidade Federal do Ceará, Fortaleza, CE, Brasil.

http://dx.doi.org/10.1590/1806-9282.66.9.1180

SUMMARY
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, phen-
tolamine) 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 proto-
cols 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.
KEYWORDS: Erectile dysfunction. Erectile dysfunction/diagnosis. Ultrasonography. Ultrasonography, Doppler.

INTRODUCTION
Color Duplex-Doppler Ultrasound (CDDU) of the diagnostic method, but it requires specific training.
penis was first described by Lue et al.1 and remains An objective hemodynamic evaluation through CDDU
one of the most important tools available to assess has prognostic importance and helps to choose the
patients with ED2,3. CDDU of the penis is an objective best treatment strategy4,5. Possible indications for

DATE OF SUBMISSION: 14-Feb-2020

DATE OF ACCEPTANCE: 22-Mar-2020
CORRESPONDING AUTHOR: Felipe Carneiro
Rua Tucuna, 481 – São Paulo, SP, Brasil – 05021-010
E-mail: [email protected]

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 CARNEIRO, F. ET AL

FIGURE 1. DOPPLER TRACING BEHAVIOR PRESENTING

CDDU include: young patients with primary ED, pelvic PROGRESSIVE INTRACAVERNOUS PRESSURE (ICP)
trauma history, drug abuse, pre-operative evaluation DURING ERECTION. ICP = INTRACAVERNOUS
PRESSURE; DBP = DIASTOLIC BLOOD PRESSURE; SBP =
for Peyronie’s disease, psychogenic ED documenta- SYSTOLIC BLOOD PRESSURE.
tion, and medicolegal situations6.
The lack of standardized hemodynamic evaluation
through CDDU is one of the main limitations of this
method7. It explains the great variability in performing
and interpreting penile hemodynamic studies in both
clinical practice and scientific studies. These factors
have contributed to the fact that CDDU is often con-
sidered unreliable, as it may lead to mistaken treat-
ment protocols8.
The aim of the present article is to establish stan-
dard operational procedures to minimize confounders
in order to help predict with reasonable accuracy the
etiology of ED. It is also our goal to discuss the basic B. Pharmacology
principles of drug-induced erection. Oral drugs act through nitric oxide pathways and
increase Cyclic GMP concentration inside the mus-
Basic Principles in Sexual Medicine cle cell because they inhibit the enzyme responsible
for Cyclic GMP degradation, known as type 5 phos-
Erection anatomy and physiology phodiesterase (PDE5)11. Intracavernous vasoactive
A. Blood flow and veno-occlusive mechanism agents act through direct muscle relaxation. The
The erectile tissue is mainly composed of smooth most common agents are papaverine, phentolamine,
muscle, elastic fibers, and endothelium, which and prostaglandin.
together form the sinusoids of the corpora cavernosa. On the other hand, sympathomimetic agents
Arterial supply is achieved through the internal puden- contract the intracavernous smooth muscle and
dal artery, which branches out and gives origin to the antagonize the veno-occlusive mechanism of erec-
cavernous artery. The venous drainage of the cavern- tion. Etilefrine is the medication available in Brasil
ous tissue is performed by a surface and deep vein sys- presenting the greatest selectivity to alpha-receptors,
tem; however, the subtunical venules promote blood which should be preferred to minimize beta-adrener-
exit from the intracavernous space during erection. gic activity.
Blood flow increases during sexual stimulus with-
out changes in systemic blood pressure. The smooth C. Clinical evaluation
muscle relaxes and expands, as the sinusoids get full Having a basic evaluation is fundamental to exam
of blood. This expansion generates relative venous conduction. Medical history, including comorbidities,
drainage reduction, mainly because of the passive medication use, and previous pelvic or retroperito-
venoconstriction of the subtunical veins, which trig- neal surgery must be questioned. The patient must
gers the veno-occlusive mechanism. Axial rigidity be asked about his hardest erection, which would
increases exponentially when the compression of the be the minimal erection hardness to be obtained
subtunical venules is complete9. There is blood flow in during the exam. Information about ED chronology
systole, but not in diastole (diastole zero), when ICP and the permanence of nocturnal erections can be
becomes equal to the diastolic blood pressure (DBP). In quickly obtained.
a progressive way, the reverse diastole phenomenon,
which is featured by blood inflow in the systole and D. Erection Hardness Scales
blood efflux in diastole, happens when ICP is higher The examiner must get used to constantly reassess-
than DBP. ICP can eventually be higher than the sys- ing erection quality during CDDU sessions through
tolic peak pressure, and this process makes blood visual evaluation and penis palpation. In order to facil-
inflow in systole minimal or even absent10. The cor- itate this evaluation, there are validated erection qual-
relation between CDDU findings and Doppler velocity ity scales, among them is the EHS (Erection Hardness
is shown in Figure 1. Score), which is the most common and broadly used.

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Standardization of penile hemodynamic evaluation through color duplex-doppler ultrasound

It is possible to use a 0-10 erection scale, whose score at the beginning of the exam. Although there are some
6 (or 60%) corresponds to the minimal hardness for studies presenting good predictive PSV values at flac-
penetration. This decimal scale is easily comprehen- cid state, the universal consensus lies in conducting
sible and can be converted into the EHS scale. CDDU with drug-induced erection14-16. In order to do
so, it is important to administer vasoactive agents1,5,17.
Exam Preparation There is no consensus about the dose to be admin-
CDDU can be performed in clinics and/or hospi- istered for erection induction; however, the dose is
tals, as long as these facilities are well equipped. The expected to be the least necessary to generate a hard
vascular ultrasonography assessment of the penis is erection (EHS 4). If such an erection is not possible,
dynamic and requires an intracavernous injection at least a bedroom quality erection (BQE) should be
(ICI) of vasodilating agents in order to help the patient obtained, which may require re-dosing of ICI. There-
achieve the hardest erection possible7,12,13. Thus, the fore, there is no standard dosage to be universally
examiners must be familiar with the physiology of used, because each patient has a different response to
erection and recognize common confounding factors intracavernous pharmacotherapy. A re-dosing protocol
and artifacts in order to perform an adequate inter- based on frequent reassessments is able to minimize
pretation. Moreover, the examiner must be able to the adrenergic effect and allows satisfactory relax-
identify and/or treat prolonged erections and priapism ation of the smooth muscle. Yet, there is no consensus
caused by ICI. about the proper medication, dose, and the number of
injections at re-dosing18.
Technical preparation The transducer position during cavernous artery
A. About the location evaluation can change from the crura to the base of
i. CDDU must be performed in a quiet location, the penis - on its ventral or dorsal aspect. Conceptu-
due to the influence of psychological and envi- ally, there would be no problem in assessing the cav-
ronmental effects on the erectile response; ernous arteries at any point of their extension, since
ii. Equipment to provide audio-visual sexual cavernous bodies are tridimensional structures that
stimuli is an interesting tool, because it helps work as a single cavity. However, some studies have
patients to get a harder erection with smaller already assessed the influence of transducer position
doses of vasoactive agents; and they have shown that more proximal evaluations
iii. Medication vials properly stored are required, overestimate the PSV values, whereas the most distal
these include vasoactive agents and sympath- evaluations underestimate EDVs19. Overall, we suggest
omimetics for the eventual need of reversion. the readings should be made on the ventral face, close
to the penoscrotal junction, in order to avoid artifacts
B. About the equipment resulting from too proximal or too distal positions.
i. Ultrasound device with Doppler;
ii. High-Frequency Linear Transducer (7.5 – 18 Step-by-step guide for CDDU examination
MHz); A. Turn the ultrasound device on to start the
iii. Device to store the images and a printer. exam; select the transducer and the appropri-
ate configurations.
Exam conduction B. Explain all the steps of the evaluation to the
The CDDU exam starts with the penis in a flac- patient and ask his consent to proceed.
cid state. The whole penis must be scanned through C. Instruct the patient to lie on a horizontal dor-
longitudinal and cross-sectional images at mode B sal decubitus position and to relax as much
by using a high-frequency linear transducer (7.5 – as possible.
18 MHz). This assessment aims at seeking changes D. Place the transducer with transmitter gel on
in the eco-texture of both the erectile tissue and the the base of the penis to start scanning.
tunica albuginea. E. Assess the anatomy of the corpus cavernou-
Measurements of the internal diameter of the sum and spongiosum, and record any abnor-
cavernous arteries (right and left) and, optionally, malities in the eco-texture.
of the peak systolic velocity (PSV) in the cavernous F. Take cross-sectional and longitudinal images
arteries at spectral Doppler mode can be performed of both cavernous arteries (at proximal aspect/

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 CARNEIRO, F. ET AL

third of the penile shaft) and report possible a fact that considerably reduces patient’s
anatomic variations. Measure the intraluminal response to sympathomimetic agents and
diameter of the left and right cavernous arter- increases the need of aspiration. The adminis-
ies and record the appropriate nomenclature. tration of an alpha-adrenergic selective agonist
G. Use a syringe (0.5-3mL) with insulin needle (e.g., 1-2 mg etilefrine) in the cavernous body
(27-30 gauge, 0.5-in) and hold the penis tight; every 5-10 minutes - until completing one full
inject the vasodilating agent in the dorsolateral hour - can be adopted for detumescence. Symp-
aspect of the proximal or middle third of the toms such as acute hypertension, headache,
penile shaft, and take it away from the dor- reflex bradycardia, tachycardia, palpitations,
sal neural bundle. Press the injection site for or cardiac arrhythmias must be monitored
10 seconds in order to avoid agent reflux to through a cardiac monitor and serial blood
surface planes. Register the drug-administra- pressure must be taken. In some cases, the
tion time. patient must be subjected to cavernous body
H. AVSS use is recommended, mainly in anxious aspiration in order to help detumescence and,
patients. In order to do so, the patient must consequently, to reduce the amount of admin-
stay alone in the examination room during the istered alpha-adrenergic, as well as to reduce
time to stimulate smooth muscle relaxation7,20. adverse reaction time.
I. Take images of left and right cavernous arter- O. The examination report must be detailed
ies at mode B. Turn the Doppler mode on, reg- and express all calculated and collected data
ulate the sample and the angle (<60 degrees) throughout the assessment (mode of report in
in order to measure the PSV21. appendix). Clinical impressions also have to be
J. Repeat the same procedure to both cavern- informed in the report (for example, patient
ous arteries and distinguish the laterality in anxiety during the study, among others).
the records. P. Send the patient home and give him overall
K. It is essential to assess PSV and EDV at the orientations and warnings (for example, pria-
erection peak because these measurements pism signs) and, whenever necessary, schedule
are the most important clinical evaluations. a follow-up visit.
The evaluation is based on the time after the Q. File all images and the report in the patient’s
injection, it can also be taken at 5, 10, 15, medical records.
and 20 minutes, as long as the hardness is
assessed - at each new assessment time - for Interpretation of hemodynamic parameters
proper interpretation. The following parameters are often used in the
L. Take cross-sectional and longitudinal images hemodynamic evaluation of systemic vessels and
of the cavernous arteries (similar to step G) at they are also useful for ED evaluation7,14-16,20: Peak
hardness peak or maximum hardness (EHS Systolic Velocity (PSV); End Diastolic Velocity (EDV);
4) and measure the intraluminal diameter at Resistivity Index (RI); Pre and post diameter of cav-
both sides. Register the acquired data and the ernous arteries. The cavernous artery diameter has
respective laterality. limited value and has also been questioned due to its
M. After the exam, ask the patient to wait from incapacity to predict the proper hardness, mainly in
30 minutes to 1 hour to evaluate possible col- patients presenting suspicion of atherosclerosis and
lateral effects caused by the pharmacological increased cardiovascular risk22. Changes in intracav-
induction agent (prolonged painful erection, ernous diameter (sagittal and transverse), as well as
priapism, discomfort in the area where the in PSV, EDV, and RI can be evaluated in each cavern-
drug was injected). ous artery at different moments. There can be differ-
N. If the patient presents a prolonged painful erec- ences in the basal features to find PSV between fast
tion, it is worth reversing it in order to avoid and slow responders.
priapism. We do not recommend waiting for An objective rigidity evaluation must be routinely
more than 4 hours to perform the reversion, performed before each reading of hemodynamic
since prolonged erections for longer than 1 parameters. This approach minimizes false diagnosis
hour can cause edema in the cavernous bodies, of cavernous veno-occlusive dysfunction since similar

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Standardization of penile hemodynamic evaluation through color duplex-doppler ultrasound

findings are obtained in cases of adrenalin-mediated FIGURE 2. DOPPLER ULTRASOUND WAVEFORM IN

DIFFERENT HEMODYNAMIC DIAGNOSES.
failure to obtain optimal rigidity10,23.
The PSV measurement to assess arterial compe-
tence enables researchers to accept values between
25-30 cm/s as the lower normality limit3,10. A PSV
higher than 30 cm/s highlights normal arterial flow
after proper pharmacological stimulus; on the other
hand, a PSV < 25cm/s is a diagnostic of arterial insuf-
ficiency. Confirmatory studies based on angiography
have shown that a velocity limit higher than 25 cm/s
leads to 92% accuracy in arterial integrity diagnostic2,10.
EDV and RI measurements bring information about
the mechanism of penile veno-occlusion. A EDV > 5
cm/s and RI < 0.75 show veno-occlusion associated
with normal arterial function10,15. Lack of specific-
ity for venous leak caused by arterial insufficiency
is the main limitation of this exam. Proper arterial
inflow with short-duration semi-rigid erection and as well as to make a precise description of the follow-
persistent diastolic flow > 5 cm/s (attention to the ing parameters:
angle) - at all moments of the study - suggests venous
leak10,15. However, it is important to be while reporting 1. It is important to record the patient’s relevant infor-
this condition since it is irreversible and has a great mation such as age, dose, and type of drug used. The
influence on the patient’s treatment, mainly because following assessed parameters must be recorded,
rigidity loss during the exam or suboptimal ICI dosage ideally:
generates similar traces and can cause pseudo-diag- i. Longitudinal and cross-sectional diameters of
nostics. The literature has demonstrated that up to the left and right cavernous arteries before and
50% of veno-occlusive dysfunction reports are equiv- after pharmacological induction;
ocal24. Table 1 demonstrates possible CDDU diagno- ii. PSV, EDV, and RI during different examination
ses according to hemodynamic parameters. Figure times of the two cavernous arteries;
2 shows Doppler ultrasound waveform in different iii. final drug-dose administered during the exam.
hemodynamic diagnoses.
2. Data evaluation and interpretation:
Recording relevant findings i. Hardness data must also be documented
Proper data recording evidences high-quality care during the hemodynamic evaluation of the
of patients; this has to be a priority. Images must con- penis through CDDU.
tain the exam date and patient identification; more- ii. Structural abnormalities in the penis related
over, anatomical structures must be properly named. to tunica albuginea, corpus cavernous, and
It is fundamental to keep permanent files of all exams spongy (heterogeneity, hyperechoic areas,
and medical reports for clinical and legal purposes, and plaques), as well as in the arteries, must
be reported.
TABLE 1. HEMODYNAMIC CLASSIFICATION BASED ON iii. It is necessary to recognize Doppler artifacts
CAVERNOUS ARTERY VELOCITIES. such as aliasing, acoustic shadow, mirror
Doppler parameters PSV EDV (cm/s) RI image, among others23.
Hemodynamics (cm/s)
iv. Sometimes, it is difficult to properly interpret
Normal ≥ 30 <5 >0.9
hemodynamics With preferential blood flow direction in some regions of the
0 (zero) or negative vascular tree, mainly in bifurcations, ramifica-
Arterial insufficiency < 25 <5 -
tions, stenoses, and in areas distal to plaques.
Veno-occlusive ≥ 30 ≥6 < 0.75
cavernous dysfunction Variations in blood flow direction depend on
Mixed dysfunctions Different combinations transducer positioning and on the appropri-
PSV = Peak systolic velocity; EDV = Ending diastolic velocity; RI = Resistant index ate use of the angle, among others. Thus, the

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 CARNEIRO, F. ET AL

examiner must be an expert in the method to skills in drug-induced erection and hardness scores
avoid wrong evaluations and interpretations25. in order to provide more sophisticated evaluations.

Author’s Contribution
CONCLUSIONS
FC, OCS, and EPM were responsible for the initial
The hemodynamic evaluation of the penis by color concept and design. FC and EPM drafted the manu-
Doppler is a very useful tool for a specialized evalua- script. OCS revised it critically for important intel-
tion of ED. Evaluation of hemodynamic velocities with- lectual content. FC, OCS, and EPM performed the
out a deep understanding of the erectile mechanism literature review. FC, OCS, and EPM helped revise and
may lead to wrong interpretations and negative conse- edit the final version of the manuscript. All authors
quences to the patient. Examiners must improve their read and approved the final manuscript.

RESUMO
INTRODUÇÃO: A avaliação vascular da função erétil por meio da ultrassonografia com Doppler colorido do pênis (UDCP) pode trazer
benefícios na tomada de decisão. Infelizmente, a falta de padronização na condução de UDCP resulta em alta variabilidade do exame,
além de poder comprometer a interpretação dos resultados.
OBJETIVO: Os objetivos desta revisão são promover uma maior padronização durante o UDCP e discutir os princípios fundamentais
para sua correta condução e interpretação.
MÉTODOS: O UDCP é conduzido inicialmente com o pênis no estado flácido; todo o pênis deve ser avaliado (imagens no modo B)
com um transdutor linear de alta frequência (7,5 -18 MHz). A injeção intracavernosa de agentes vasodilatadores (prostaglandina E1,
papaverina, fentolamina) é realizada para induzir uma ereção rígida. Medições seriais em momentos diferentes podem ser realizadas
durante a sessão da UDCP e a rigidez peniana deve ser estimada em cada avaliação.
RESULTADOS: É importante monitorar a resposta da ereção após o agente vasoativo (escala de rigidez), bem como realizar avaliação
hemodinâmica durante a ereção de melhor qualidade. Os protocolos de estimulação sexual manual e audiovisual (AVSS) e redosagem
de agente vasoativo devem ser levados em consideração para reduzir a influência de fatores psicogênicos e ajudar o paciente a obter
a ereção mais rígida possível. Tais medidas contribuem para o relaxamento máximo do tecido erétil, de modo que os parâmetros
hemodinâmicos não são subestimados.
CONCLUSÕES: O UDCP é uma ferramenta especializada relevante para avaliar pacientes com disfunção erétil; portanto, esta diretriz
ajudará a padronizar e estabelecer uniformidade em sua condução e interpretação, se considerarmos a complexidade e a heterogene-
idade das avaliações do pênis por UDCP.
PALAVRAS-CHAVE: Disfunção erétil. Disfunção erétil/diagnóstico. Ultrassonografia. Ultrassonografia Doppler.

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