Penile Color Duplex-Doppler Ultrasound in Erectile Dysfunction Diagnosis and Management: A Complete Guide to Best Practices

Preface
Contents
Chapter 1: History of Functional Assessment of Penile Erection
	1.1 Introduction
	1.2 Noninvasive Methods to Penile Erection Assessment
		1.2.1 Nocturnal Penile Tumescence and Rigidity Tests
		1.2.2 Visual Sexual Stimulation Plethysmography (VSS)
		1.2.3 Questionnaires
		1.2.4 Hormonal Tests
	1.3 Invasive Methods for Penile Erection Assessment
		1.3.1 Angiography and Dynamic Infusion Cavernosography/Cavernosometry
		1.3.2 Intracavernous Injection Test (IIT)
		1.3.3 Penile Doppler Ultrasound with Intracavernous Injection (PDU)
	1.4 Conclusion
	References
Chapter 2: Principles of Doppler Ultrasound
	2.1 Introduction
	2.2 Ultrasound Physics
	2.3 Creation of Ultrasound Images
		2.3.1 Sound Attenuation and Compensation
	2.4 Image Resolution
	2.5 Ultrasound Imaging Artifacts
	2.6 Doppler Effect
	2.7 The Doppler Effect Applied to Diagnostic Ultrasound
		2.7.1 Relationship Between Doppler Shifted Signal (Fd) and Blood Flow Velocity (V)
		2.7.2 Significance of the Doppler Angle (θ)
	2.8 Doppler Modes
	2.9 Doppler Parameters
		2.9.1 Focusing
		2.9.2 Doppler Frequency
		2.9.3 Pulse Repetition Frequency (PRF)
		2.9.4 Doppler Gain
		2.9.5 Doppler Angle
		2.9.6 Wall Filter
		2.9.7 Doppler Box
		2.9.8 Sample Volume
		2.9.9 Color Priority
	2.10 Most Common Doppler Artifacts
		2.10.1 Aliasing
		2.10.2 Blooming Artifact
		2.10.3 Directional Ambiguity
		2.10.4 Artifact of Partial Volume
		2.10.5 Pseudoflow
		2.10.6 Flashing
		2.10.7 Mirror Artifact
		2.10.8 Edging
		2.10.9 Twinkling
	2.11 Tips and Tricks for Better Clinical Practice Using Doppler Methodology
	2.12 Conclusions
	References
Chapter 3: Minimum Requirements for an Ultrasound Machine, Basic Setup, and Adjustments for Penile Hemodynamic Studies
	3.1 Introduction
	3.2 Ultrasound Machine and Transducer
	3.3 Spectral or Pulse Wave (PW) Doppler Ultrasound
		3.3.1 PWD Parameter Adjustment
			3.3.1.1 Transmission Frequency
			3.3.1.2 Pulse Repetition Frequency (PRF)/Scale
			3.3.1.3 Baseline
			3.3.1.4 Wall Filter
			3.3.1.5 Sweep Speed
			3.3.1.6 Gate/Sample Volume
			3.3.1.7 Angle of Doppler
			3.3.1.8 Inversion
			3.3.1.9 Post-processing
		3.3.2 Automatically Optimizing Images
	3.4 Color Doppler and Power Doppler Ultrasound
		3.4.1 Parameters Settings in CD
			3.4.1.1 Transmission Frequency
			3.4.1.2 Pulse Repetition Frequency/Scale
			3.4.1.3 Baseline
			3.4.1.4 Color Doppler Box
			3.4.1.5 Doppler Steering and Angle
			3.4.1.6 Inversion
			3.4.1.7 Gain
	3.5 Duplex and Triplex Modes
	3.6 Conclusion
	References
Chapter 4: Penile Anatomy and Physiology of Erection
	4.1 Introduction
	4.2 Anatomy
		4.2.1 Penile Anatomical Structures
		4.2.2 Tunica Albuginea
		4.2.3 Arterial Supply
		4.2.4 Venous Outflow
		4.2.5 Nerve Supply
	4.3 Physiology of Erection
		4.3.1 Autonomic Central Nervous System and Peripheric Control
		4.3.2 Blood Flow and Veno-Occlusive Mechanism
	4.4 Conclusions
	References
Chapter 5: Clinical Aspects of Erectile Dysfunction
	5.1 Introduction
	5.2 Definition
	5.3 Epidemiology
	5.4 Etiology (Psychogenic vs. Organic)
	5.5 Clinical Evaluation
		5.5.1 Medical History
		5.5.2 Physical Examination
	5.6 Complementary Testing
	5.7 Treatment Algorithms for ED
	5.8 Conclusions
	References
Chapter 6: The Role of Penile Doppler Ultrasound in the Diagnosis and Management of Erectile Dysfunction
	6.1 Introduction
	6.2 Indications of Penile Doppler Ultrasound
		6.2.1 Psychogenic vs. Organic ED
		6.2.2 ED Evaluation in Peyronie’s Disease
		6.2.3 Non-responders to PDE5i
		6.2.4 Assessment of Cardiovascular Risk
	6.3 Secondary Indication of PDU Studies
		6.3.1 Post-radical Pelvic Surgery
		6.3.2 Medicolegal Cases
	6.4 Prognosis
	6.5 Translation from PDE5i to More Invasive Therapies
	6.6 Conclusions
	References
Chapter 7: Pharmacotherapy for Inducing an Erection
	7.1 Introduction
	7.2 Historical Background
	7.3 Vasoactive Agents
		7.3.1 Prostaglandin E1
		7.3.2 Papaverine
		7.3.3 Phentolamine
		7.3.4 Combination Therapy
			7.3.4.1 Bimix
			7.3.4.2 Trimix
			7.3.4.3 Quadrimix
			7.3.4.4 High Concentration Preparations
	7.4 How to Choose the Ideal Agent?
	7.5 Redosing Protocol
	7.6 Application Technique
	7.7 Principles of Long-Term Intracavernosal Therapy
	7.8 Contraindications and Complications
		7.8.1 Priapism
		7.8.2 Penile Fibrosis
	7.9 Conclusions
	References
Chapter 8: Penile Rigidity Assessment
	8.1 Introduction
	8.2 Erection Biomechanics
	8.3 Measures of Erectile Function
		8.3.1 Validated Questionnaires
	8.4 Erection Hardness Score (EHS)
		8.4.1 Decimal Scale
	8.5 Other Measures of Erection Rigidity That Might Be Complementary to PDU
		8.5.1 Digital Rigidometer
		8.5.2 Elastography
	8.6 Rigidity-Based vs. Timed-Based Protocols for PDU Hemodynamic Scanning
	8.7 How to Assess Penile Rigidity During PDU?
	8.8 Conclusions
	References
Chapter 9: Audiovisual Sexual Stimulation During Hemodynamic Evaluation of the Penis
	9.1 Introduction
	9.2 Audiovisual Sexual Stimulation and Penile Doppler Ultrasound
	9.3 Lessons from a Prospective Study
	9.4 Recommendations of AVSS
	9.5 Conclusion
	References
Chapter 10: Erection Reversal Protocols and Management of Prolonged Erections
	10.1 Introduction
	10.2 Physiology of the Flaccid Penis
	10.3 Definitions of Prolonged Erection and Priapism
	10.4 Physiopathology of Ischemic Priapism
	10.5 Epidemiology
	10.6 Detumescence Strategies
		10.6.1 Non-pharmacological Interventions and Oral Medications
		10.6.2 Intracavernous Sympathomimetic Agents
			10.6.2.1 Phenylephrine
			10.6.2.2 Etilefrine
			10.6.2.3 Epinephrine
			10.6.2.4 Other Amines
			10.6.2.5 In-Office Aspiration Procedures
			10.6.2.6 Detumescence Protocols
	10.7 Conclusions
	References
Chapter 11: Evaluation of Penile Deformities in the Erect State of the Penis
	11.1 Introduction
	11.2 Is It Worth Performing Ultrasound of the Flaccid Penis in Peyronie’s Disease?
	11.3 Plaque and Calcifications Measurements
	11.4 Evaluation of Erectile Function in the Curved Penis
	11.5 Principles of Curvature Assessment
		11.5.1 Location, Direction, and Magnitude
		11.5.2 Assessment of Volume Loss
		11.5.3 Assessment of Penile Instability
	11.6 Conclusions
	References
Chapter 12: Interpretation and Clinical Implications of Penile Hemodynamic Parameters
	12.1 Introduction
	12.2 Normative Parameters
		12.2.1 Suggested Cutoffs
		12.2.2 Hemodynamic Parameters in the Flaccid State of the Penis
	12.3 Normal PDU Indicates No Erectile Dysfunction?
	12.4 Implications of Normal PDU Studies
	12.5 Implications of Abnormal PDU Studies
	12.6 Further Interpretation of Penile Hemodynamic Studies
	12.7 Prognostic Value of PDU
	12.8 PDU Results and Clinical Decision-Making in Erectile Dysfunction
	12.9 Conclusions
	References
Chapter 13: Step-by-Step Guide for Penile Doppler Ultrasound Examinations: Practical Tips
	13.1 Introduction
	13.2 Exam Preparation
	13.3 Technical Prep Work
	13.4 Exam Conduction
	13.5 Step-by-Step Guide for PDU Examination
	13.6 Recording Relevant Findings
	13.7 Conclusion
	References
Chapter 14: Limitations of Penile Hemodynamic Studies with Doppler Ultrasound
	14.1 Introduction
	14.2 The Paradox of Normal Versus Abnormal in PDU Studies
	14.3 Mixed Vascular Dysfunction of the Penis
	14.4 Normal Parameters in a Non-responsive Penis
	14.5 Abnormal Parameters in a Hard Penis
	14.6 Severe Atherosclerosis in Cavernosal Arteries
	14.7 Geometric Erectile Dysfunction
	14.8 Using Clinical Parameters to Solve Potential Limitations
	14.9 Conclusions
	References
Chapter 15: Applicability of Additional Penile Investigation Modalities Using Ultrasound Devices
	15.1 Introduction
	15.2 Elastography
	15.3 Contrast-Enhanced Ultrasound Imaging (CEUS)
	15.4 Microvascular Imaging
	15.5 Conclusion
	References
Chapter 16: Optimizing Written Medical Reports
	16.1 Introduction
	16.2 Structured Report Template for Penile Hemodynamic Evaluation
		16.2.1 Methodology
		16.2.2 Clinical Findings
		16.2.3 B-Mode Sonographic Findings
		16.2.4 Pharmacological Induction and Reversion Schedule
		16.2.5 Audiovisual Sexual Stimulation
		16.2.6 Hemodynamic Parameters
		16.2.7 Rigidity Assessment
		16.2.8 Diagnostic Conclusions and Examiners’ Impression
	16.3 Structured Report Template for Penile Deformity Assessment
		16.3.1 B-Mode Sonographic Findings
		16.3.2 Clinical Findings
		16.3.3 Diagnostic Conclusions and Examiners’ Impression
	16.4 Conclusions
	References
Chapter 17: Sample of Case Studies
	17.1 Introduction
	17.2 Case 1
	17.3 Case 2
	17.4 Case 3
	17.5 Case 4
	17.6 Conclusions
	References
Index