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penile duplex ultrasound
penile duplex ultrasou  
QUESTION: Hello,

I'm 29 years old male from Egypt. I have never had sex (I'm a virgin). I suffer from severe erectile dysfunction.

I used to masturbate since I was 14. Two years later (i.e. when I was 16), I started suffering ED. The ED has developed just a few weeks after I started changing the technique I was using to masturbate.

3 years later, when I was 19, I had my blood pressure taken for the first time in my life and, unfortunately, I was diagnosed of hypertension. My BP was 150/100 at that time. I was put on Atenolol for at least 3 years.

In 2006, I suffered a severe depression and since then I'm on antidepressants most of the time. The antidepressants I was on included Venlafaxine (Effexor), Fluoxetine, Paroxetine and sometimes a tricyclic antidepressant. Sometimes I was put on low doses of antipsychotics as well; e.g. Sulpiride and Risperidone.

In 2007, I was diagnosed by a cardiologist that my hypertension is due to the "white coat effect" and I discontinued the BP medications.

Recently, the ED became worse and I had a penile duplex ultrasound. The report is in the attached image.

Currently I'm overweight (probably due to the antidepressant medications) and my LDL-cholesterol level is probably risky but I remained at least 6 years suffering erectile dysfunction without being overweight and with healthy cholesterol levels.

Erections during sleep & early-morning erections are abesnt.

Spontaneous erections: absent.

Erections during visual and/or mental stimulation: absent.

Currently when I try to masturbate, I struggle to achieve a 50% erection (partial tumescence with partial regidity) by using my hand and it lasts only a few seconds.

I tried Sildenafil 50 mg but was of almost no benefit.

Blood tests:

Testosterone (total) 282.73 ng/dL
Testosterone (Free) 6.0 ng/dL
Prolactin 8 ng/mL

Lipid profile:

Triglycerides 109 mg/dL
Cholesterol (Total) 193 mg/dL
HDL-Cholesterol 37.0 mg/dL
LDL-Cholesterol 134.2 mg/dL

I need to know what is wrong with me please?

Thanks in advance.

ANSWER: Ali:

This site is not intended as a diagnostic medium and we do not diagnose or treat patients; just answer general questions.

So, in general, if a patient has ED and has lost nocturnal and morning erections, we usually recommend starting with a trial of sildenafil 50 mg.  It should be taken on an empty stomach and will take at least 20-40 minutes to work.  5 or even 6 tries may be needed for it to kick in.  If that doesn't work, increase to 100 mg.

If that fails, we usually try at least one other similar medication because about 50% of the time, the alternate med will work.

The testosterone level seems a little low and this can be supplemented and then you can try again with the sildenafil.

Other treatments include urethral suppositories, penile injections and external vacuum devices.

You should talk to your urologist.

---------- FOLLOW-UP ----------

QUESTION: Thank you very much, doctor.

I have a few more questions please:

1- Depending on the the values of "peak systolic velocity" and "end diastolic velocity" revealed by the penile duplex ultrasound, what is my main problem? is it venous leakage or arterial insufficiency or BOTH? what is the degree of each? i.e. mild, severe,...etc

2- Some doctor told me that 0.5 cc PGE1 as ICI is an "under dose" (he said it should be 1 cc) and therefore the ultrasound I had could be not so accurate. Do you think this is true?

3- Is it probable that the problem is due to a blood clot (thrombus) in the penile artery?

4- Is it probable that I caused an injury to the penile artery during masturbation?

Thanks in advance.

Answer
Ali:

Interpreting the duplex ultrasound numbers and tracings is the responsibility of the treating physician.  However, in general, we look at the before and after arterial diameters as well as the peak systolic velocity.  The diameter should roughly double after the injection and the Peak Systolic Velocity is usually considered normal if it is above 25-30 cm/sec.

End diastolic velocity is an indication of the venous control.  In general, values more tha 5 cm/sec suggest a venous control issue.

It's impossible to judge the dose of 0.5 cc of PGE1 without knowing the concentration.  0.5cc is just a volume and may or may not be sufficient depending on how concentrated the solution is.

A blood clot in the penile artery is possible, but unlikely and would be considered an unlikely cause of ED.

It is highly unlikely that you caused any injury through masturbation.

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Stephen W. Leslie, MD

Expertise

Questions concerning erectile dysfunction, kidney stones and prostate disorders including prostate cancer. I have a special interest in kidney stone disease prevention.

Experience

Full time practicing urologist with 30 years experience. Associate Professor of Surgery and Chief of Urology at Creighton University Medical Center. Editor in Chief of eMedicine Urology internet textbook. Author of only NIH approved book written for patients by a urologist on the subject of kidney stones "The Kidney Stones Handbook". Inventor of the "Parachute" and "Escape" kidney stone baskets and the "Calculus" stone prevention analysis computer program.

Organizations
American Urological Association, Ohio State Medical Association, Sexual Medicine Society

Publications
Men's Health, Journal of Urology, Urology, Healthwatch Magazine, Emergency Medicine Monthly, eMedicine, "The Kidney Stones Handbook", and numerous articles in various newspapers. He is also the editor of the Urology Board Review by McGraw-Hill used by urologists to study for their Board Certification Examinations.

Education/Credentials
Graduate of New York Medical College with residencies completed at Metropolitan Hospital New York, Albany Medical Center and University of Wisconsin-Madison.

Awards and Honors
Thirlby Award of the American Urological Association. Rated as one the country's Best Urologists by the Independent Consumer's Research Institute

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