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Adding Audiovisual Component to Penile Doppler Ultrasound is Worthwhile

Audiovisual Sexual Stimulation Improves Diagnostic Accuracy of Penile Doppler Ultrasound in Patients With Erectile Dysfunction


Felipe Carneiro MD, PhD; Bruno Nascimento MD; Eduardo P. Miranda MD, PhD, FECSM; José Cury MD, PhD; Giovanni G. Cerri MD, PhD; Maria Cristina Chammas MD, PhD

FIRST PUBLISHED: December 10, 2019 – The Journal of Sexual Medicine



Penile Doppler ultrasonography (PDU) is the “gold standard” tool for assessing penile hemodynamics in men with erectile dysfunction (ED). However, clinicians need complete smooth muscle relaxation in cavernous arteries and erectile tissue for accurate results. Excessive sympathetic discharge during PDU can impair this process and lead to false diagnoses of arterial insufficiency (AI) or corporal veno-occlusive dysfunction (CVOD).

This study examined the use of audiovisual sexual stimulation (AVSS) during PDU.

Participants and Methods

Forty heterosexual men with an average age of 62 years were enrolled. The men had had ED for at least six months and had unsatisfactory responses to phosphodiesterase type 5 inhibitor therapy. None of the men had received intracavernous injections (ICI) before, nor had they undergone PDU studies.

All patients completed the Portuguese version of the International Index of Erectile Function (IIEF).

Each participant underwent 2 PDU sessions, which were spaced 7 days apart:

  • Session A: patients received ICI (alprostadil) 5 minutes before PDU.
  • Session B: After ICI, patients were allowed to “partially self-stimulate” themselves while watching a 4-minute heterosexual pornographic film.

The following penile vascular parameters were evaluated before ICI and again at 5, 10, 15, and 20 minute time points afterward:

  • Peak systolic velocity (PSV)
  • End-diastolic velocity (EDV)
  • Resistive index (RI)

Twenty-three men had session A first, while the remaining 17 began with session B. A week later, the groups switched: those who had started with session A underwent session B and vice versa.


Overall, 38% of the participants had hypertension, 40% had diabetes mellitus, and 35% had dyslipidemia. None were obese. Seventy percent were sedentary, and 20% smoked every day.

The following findings were reported:

  • EDV and RI assessments were better in AVSS sessions, but PSV was not influenced.
  • Four patients had a change in diagnosis after the AVSS intervention. In a group of 12 patients who were diagnosed with CVOD based on PDU without AVSS, 3 men “were considered normal after PDU with AVSS.” In addition, in a group of 4 men diagnosed with AI based on PDU without AVSS, 1 man was “deemed normal” after PDU with AVSS.
  • Patients with abnormal PDU had lower IIEF scores.
  • Diabetes mellitus and IIEF scores “were the only independent predictors of abnormal PDU studies.”


AVSS increases sexual arousal, and its use during PDU could reduce rates of false diagnoses. The procedure is “closer to a bedroom scenario” and men might feel less stressed in that environment.

“From a biological perspective, it is thought that AVSS leads to an increase in parasympathetic output, resulting in better vasodilation and relaxation of the corpora cavernosa and consequently in a more rigid erection than with ICI alone.”

It was also noted that patients who had their second session without AVSS had higher PSV values. It’s possible that apprehension and anxiety were decreased in these men for their second session.

As noted above, some patients had their diagnoses changed after undergoing PDU with AVSS. “These findings might have positive repercussions on patients’ prognosis, as an abnormal PDU usually lead to more invasive approaches.”

Limitations, including the lack of a rigidity assessment and redosing protocol, were acknowledged.


“The combination of ICI and AVSS is a better erectogenic strategy than ICI alone in the evaluation of ED patients with PDU. This useful tool makes PDU more accurate and can be decisive for accurate diagnosis.”

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