Penile Doppler Ultrasound: when it's useful and when it's not

You need the Penile Doppler ultrasound. Stop right there. The truth is that most men with erectile dysfunction don't need one. I'm Giangiacomo Ollandini, a consultant urologist and andrologist in London. And today I'll tell you exactly who needs it. What really happens when you step in the clinic and why your anxiety might be one of the biggest factor at all? What is a Penile Doppler?

It's second line and quite niche specialist investigation that allows to see the appearance of the tissues inside the penis and how they are working. It utilizes the ultrasound technique. It is the jelly scan. The same one that is used for many other organs and thinking about thyroid and thinking about liver and thinking about kidneys but also babies before they are born. In this case, it is used for checking inside the penis and to check the structure, how it looks like, if there are abnormalities but much more. Using specific technologies, it allows to check the direction and the quantity of the blood flow. So it allows to check how much blood goes in, how much blood goes out when done appropriately. It is done before and after administering an injection in the penis that creates an erection that will allow to ask the blood vessels how much blood is transiting through at every second of the test. So I have a dynamic understanding of the flow going in, going out and the potential reasons why something might not be perfectly aligned with the expectations.

Does it matter if I am nervous? Anxiety during the test is certainly a component and is a common finding. Why that is pretty obvious? Because nobody will find natural and spontaneous to have an erection in a clinical setting and an erection that lasts for many minutes and having a doctor that is exploring the blood vessels inside the penis while this is happening. So will this affect the quality of the test? It may and the reason is very simple to obtain the erection. We normally use a medication in the syringe that will create the conditions for an erection without the need of being aroused but there is a downside. Non-need for arousal doesn't mean refractory and resistant to anxiety. And if you are too tense, if you are too agitated, if you are feeling too much uncomfortable in the setting, your body will transmit signals to the penis. To tell the penis it's not time for sex that will translate into certain appearances at the ultrasound that resemble the ones that are found commonly in a condition called venous leak. When you suspect a venous leak may not be real.

If I think so, it's not only because of what I see in the Doppler but also the way you speak throughout the investigation, the feature of your heart rate. I already know you, we have already had some discussion, I know your story and I know if this could really be the case. In certain occasions, when this is crucial to know, I may offer you to have the test repeated on a second occasion utilizing a different medication for obtaining the erection. What's the difference? The difference is the addition to the mix of injectables of a component called phentolamine that has the ability of literally blocking the conduction of the adrenaline and noradrenaline messages that are the ones that anxiety uses to tell your penis it's not time for an erection. Which questions are answered with a penile Doppler?

The penile Doppler will not answer if there is not a specific question. And if the question is am I able to have an erection, you might not need the penile Doppler at all. You might just need tests with the intracavernosal injections, that could be sufficient. But if your question is what is the reason why I can't have an erection, then you can have some answer primarily from the lack of inflow. So the arteries are not able to bring enough blood to have a rigid erection or problems with the outflow, that means the blood is coming in sufficiently well. But the system that is in charge of keeping the penis watertight is actually not working very well. And there is some spillage of blood out of the system and that is called the venous leak or a variety of conditions in between. Penile Doppler Test, step by step.

So let's talk about what happens on the day you have booked your penile Doppler. Let's say it's booked for 5 p.m, on a Thursday evening. It's best if you arrive a little bit earlier but as soon as you step into the room, I will welcome you, we will go very quickly through the details of the test because I will have already sent you everything via email with the reminder and with the booking, including the risks and consequences, etc. So you should already be perfectly aware of what's going on. Then I let you lay down on the bed and I will start doing a scan in basal condition. After this is completed, I will inject at those of the medication. The test is a bit long but it's not painful and don't worry about the injection in the penis. I know that it's not appealing but the needle is tiny and the experience is nearly pain free. And depending on which medication we are using, you might experience some dull ache during the erection time and that's also entirely normal and expected. I will have to do certain measurement and certain scans at a set amount of time and in between these times I will look into other characteristics that I can explore with ultrasound. For example, I can have an understanding of how the microcirculation is looking like in your penis quite precisely. When I finish doing all the measurements and I'm satisfied, normally I have the time of showing you directly to lies in my iPad. What am I seeing? So that you understand what I have been doing until that very moment. Keep in mind that during the entire time of the ultrasound I will be talking, explaining so if there are questions, if there are things that you would like me to check, I will be able to respond on that. Is Penile Doppler a safe test?

Regarding complications and risks, they are associated to the injection only because the ultrasound scan is completely risk-free. When you arrive to the clinic for the Penile Doppler, I expect you to be already fully aware because I must have already communicated all the risks to you. It shouldn't be a surprise but I will eventually break it once more that there is a consistent risk and the risk is that in one case out of 200-250 you might have a prolonged reaction that doesn't go away spontaneously. Now why is this important? This is important because the penis is not meant to stay erected for too many hours. We are talking about time frame of 4 hours that I consider before you need to seek for some help. And don't be scared. If instead of 4 hours is 5 hours or 6 hours, there is still not enough time to create any permanent damage to the penis. So that if you find yourself with a rigid direction that doesn't go away — and it's normally painful. 4 hours after the injection has been delivered, you need to immediately go to the first hospital explaining that you have such an injection and they will simply deliver a different type of injection that will resolve the meta promptly. Do I really need a Penile Doppler?

It is important to know that Penile Doppler is a second level of investigation and as I said earlier it is a very good investigation for very few people that really need it. There are some men that want to have it done because they feel reassured by knowing that everything is working even if in clinic I can understand that they have a problem that does not need a resolution with a Penile Doppler. I'm ready to perform a Doppler if the patient desires but I make it clear when this is recommended by me or not. The case is where it is really an important milestone as cases where for example a young man with a history of never being able to achieve and maintain a fully-rigid erection and that is the typical history of the venous leak, the properly said venous leak. Or a patient that can't understand if the anxiety is the only drive for the erectile dysfunction but given the fact there are not only anxiety but also a lot of cardiovascular risk factors. He might already have developed some vascular damage and so I can pinpoint a vascular damage and that can be tremendously helpful for preventing many more serious complications and life-threatening conditions because we know that erectile dysfunction can anticipate by up to 10 years a major cardiovascular event. Admittedly it is important to consider a Penile Doppler before lending to treatments that can help in the long term the erection like the shockwave therapies. These are treatments that are expensive and they work when there is a certain type of vascular damage, a certain type of erectile dysfunction to treat. Lastly, having a Penile Doppler in cases of severe Peyronie's disease, a condition where the cure of the penis can progressively become worse and worse and can be accompanied by a erectile dysfunction. Having a Penile Doppler in those patients is important and having a Penile Doppler before deciding to consider a Penile implant simply because that is a point of non-return and it should be carefully considered if the vascular supply is still good enough for having spontaneous erection without the need of surgery. Take home message.

So, three things to take with you. One, a Penile Doppler is a second-line investigation. It is not for everyone with erection difficulty and most of the time it is not what you need. True, when it is the right test it answers a specific question. Is the problem inflow, outflow or both? Without a question the test is going to be less meaningful. Three, anxiety can make a difference on the scan. Knowing your story, not just your numbers is what tells the two apart. If you are unsure whether you need this test the right starting point is a consultation not a scan. If this is your situation, book a consultation through the link below. If you figure out what you actually need, I am Giangiacomo Ollandini. Thank you for watching.