Penile Peak Systolic Velocity Research Articles

Arterial stiffness, blood pressure progression and penile vascular disease in males with erectile dysfunction: a closer look at microcirculatory damage

Abstract Background Elevated aortic stiffness may be associated with microvascular remodelling and damage, which may be an important causal contributor to incident cardiovascular disease. Recent evidence supports the independent of age and blood pressure (BP) level predictive value of severe penile arterial insufficiency for adverse cardiovascular events. Purpose Aim of the study is to examine in men with erectile dysfunction the association of increased aortic stiffness with penile vascular damage by taking into account BP level. Methods We measured carotid-femoral pulse wave velocity (PWV) and assessed microvascular (penile vascular damage) changes in four age-matched groups without a history of diabetes and cardiovascular disease; Normal BP (n=137), high-normal BP (n=94), stage I hypertension (n=82) and stage II and III hypertension (n=76). Microvascular damage was examined by measuring penile peak systolic velocity (PSV) with a dynamic penile color Doppler ultrasonography after intracavernous injection of prostaglandin E1. Lower PSV values indicate severe penile vascular disease. Results Carotid-femoral PWV increased and PSV decreased across BP groups (all P<0.001). In regression analysis increased systolic BP (b= -0.185, P<0.01) and PWV (b= -0.170, P<0.05) are significant determinants of low penile PSV after controlling for age, body mass index, cholesterol and smoking. We dichotomized carotid-femoral PWV taking into account the mean value in the whole study population. Figure shows the differences in PSV across the BP groups considering the cut-off PWV value of 8.5m/s (high vs low PWV). Individuals with higher PWV had lower penile PSV in normal BP (P<0.01) and in high normal BP group (P=0.02) after adjusting for age and systolic BP. On the contrary, hypertensive patients already have significant structural damage in the penile arteries and high PWV does not further reduce penile blood flow. Interestingly, figure shows the comparable PSV measurements between individuals with high-normal BP level who had high PWV and patients in stage 1 hypertension group denoting significantly impaired microvascular damage in males with high-normal BP and increased aortic stiffness. The high normal BP group has significantly lower PSV compared to normal BP group independently of PWV value. Conclusion Increased aortic stiffness may promote penile microvascular remodelling and damage in men without increased BP level. Additionally, in men with high-normal BP higher arterial stiffness is associated with comparable penile microvascular damage of men with arterial hypertension. Because aortic stiffening may be preventable, further clinical research on earlier preventive measures that focus on aortic stiffness and microvascular remodelling within individuals with erectile dysfunction who have normal BP is warranted.Aortic stiffness, BP level and PSV

Association between office blood pressure, antihypertensive medication use and male sexual dysfunction: a penile Doppler study

Abstract Background Arterial hypertension is associated with an almost two-fold increase in the likelihood of having an abnormal penile blood flow. Recent evidence supports the independent of age and blood pressure (BP) level predictive value of severe penile arterial insufficiency for adverse cardiovascular events. Purpose Aim of this study is to quantify the association between BP level and severity of penile vascular disease and to examine the potential for differences in effect of BP lowering medication use on the associations between BP level and penile vascular damage. Methods We measured penile peak systolic velocity (PSV) in 356 consecutive men with erectile dysfunction (ED) and without a history of diabetes and cardiovascular disease; The cohort was divided according to office systolic BP (SBP) and diastolic BP in three BP categories: normal (SBP <130 and DBP <85 mmHg, n=117), high normal (130≤SBP<140 or DBP 85≤DBP<90mmHg, n=91), and hypertension (SBP≥140 or DBP≥90mmHg, n=148). 164 (46%) patients of the whole study population were treated with antihypertensive medications. Low PSV values after intracavernous injection of prostanglandin E1 indicate impaired penile blood inflow and severe vasculogenic ED. Results Figure shows PSV measurements of the three office BP categories subdivided according to use of antihypertensive therapy. Treated and untreated hypertensive patients had similar mean PSV. Interestingly, the mean PSV of men with high normal BP not receiving antihypertensive drugs was significantly higher compared to PSV of men with high normal BP under therapy and significantly lower compared to PSV of normotensive males without therapy (all P<0.05). Among males not receiving antihypertensive medications there was a progressive decrease in PSV values from normal BP, to high normal BP and to hypertension (P=0.01, after adjustment for age), while among males under antihypertension therapy, the three BP categories had similar PSV level (P=0.54 after adjustment for age) (figure). Conclusion The inverse associations observed between hypertension status and penile arterial insufficiency in men not taking antihypertensive medication were attenuated or disappeared among men reporting antihypertensive medication use reflecting a medication effect or structural effects of longstanding hypertension on the penile vasculature. BP level, hypertension therapy and PSV Funding Acknowledgement Type of funding source: None

P6136Intense daily cigarette smoking accelerates vascular damage of smokers with a moderate cumulative tobacco smoke exposure

Abstract Purpose Coronary artery disease death has been associated with increased cigarette smoking intensity. Aim of the study is to investigate the impact of cigarette smoking intensity on vascular function and structure changes among male smokers with similar age at starting smoking and moderate cumulative tobacco smoke exposure. Methods Indices of vascular function and structure including carotid-femoral pulse wave velocity (PWV), brachial flow-mediated dilation (bFMD), carotid intima media thickness (cIMT) and microvascular damage (penile vasculature) were measured in 118 smokers consuming up to 1 pack (20 cigarettes)/day and 58 patients smoking >1 pack (20 cigarettes)/day. The two groups had a similar mean cigarette smoking exposure (32 pack/years). Microvascular damage was examined by measuring penile peak systolic velocity (PSV) with a dynamic penile color Doppler ultrasonography after intracavernous injection of prostanglandin E1. Lower PSV values indicate severe penile vascular disease. Results The individuals smoking more than 1 pack/day were 10 years younger than smokers consuming up to 1 pack/day, however systolic, diastolic blood pressure, body-mass index, fasting blood glucose levels, lipid profile, C-reactive protein and total testosterone concentration were similar between the two groups. Figure shows mean bFMD, penile PSV, PWV and cIMT of the two groups. Interestingly, despite the similar cumulative smoking exposure between the two groups, the younger in age individuals with the intense cigarette smoking history had significantly lower mean bFMD and penile PSV (all P<0.05) and similar PWV and cIMT compared to the mean values of older subjects smoking up to 1 pack/day. Smoking intensity and vascular changes Conclusions Intense daily smoking accelerates damage of large arteries and significantly impairs microvascular and systemic endothelial function. Considering the predictive value of vascular biomarkers, the findings of this study imply the possibility that baseline daily smoking intensity could be a better summary measure of smoking-related cardiovascular risk among young heavy smokers, relative to total pack-years of smoking.

P806High normal blood pressure and vascular parameters in patients with erectile dysfunction

Abstract Purpose High blood pressure (BP) is a common risk factor for erectile dysfunction (ED) which is considered as an early clinical manifestation of generalized vascular disease. High–normal BP (130–139/85–89 mmHg) is associated with high rates of progression to hypertension. Aim of the study is to examine vascular and structure parameters of patients with high-normal BP complaining of ED. Methods We assessed macrovascular and microvascular (penile vascular damage) changes in four age-matched groups without a history of diabetes and cardiovascular disease; Normal BP (n=162), high-normal BP (n=87), stage I hypertension (n=49) and stage II and III hypertension (n=44). All hypertensive patients were not receiving antihypertensive therapy. Indices of vascular function and structure including carotid-femoral pulse wave velocity (PWV), augmentation index (AIx), carotid intima media thickness (cIMT) and microvascular damage (penile vasculature) were evaluated in all patients. Microvascular damage was examined by measuring penile peak systolic velocity (PSV) with a dynamic penile color Doppler ultrasonography after intracavernous injection of prostaglandin E1. Lower PSV values indicate severe penile vascular disease. Results Body-mass index (BMI) was significantly higher in patients with hypertension and patients with high- normal BP compared to subjects with normal BP. Smoking prevalence and LDL-C level were not different between the four subgroups. Figure shows a progressive increase in PWV and cIMT from normal BP group, to patients with high- normal BP and to untreated patients with hypertension. Compared to patients with normal BP, patients with high- normal BP had significantly higher PWV (p<0.01), cIMT (p<0.05), AIx (p<0.05) and lower penile PSV (p<0.01). Interestingly, figure shows that the individuals with high- normal BP level and patients with stage I hypertension had similar AIx and penile PSV denoting no difference in central haemodynamics and penile vasculature between the two groups. High-normal BP and vascular parameters Conclusions Middle-aged men with high-normal BP have significant microvascular and macrovascular damage compared to subjects with normal BP. The ultrasonographically documented functional changes in the vascular wall of the smaller in size penile vasculature are similar to that of men with stage I arterial hypertension. These findings bring new insights into the clinical significance of high- normal BP, which might be a premising therapeutic target for men with ED who are considered to be at a higher cardiovascular risk.

P2644Coronary atherosclerotic burden and risk of major adverse cardiac events in hypertensive patients with erectile dysfunction

Abstract Purpose Aim of the study is to assess the prevalence of angiographically coronary artery disease (CAD) and the incidence of future cardiovascular (CV) events among hypertensive males with erectile dysfunction (ED) on the basis of calculated total CV risk at first presentation. Methods A total of 392 hypertensive ED patients without diabetes or known cardiovascular disease underwent a comprehensive evaluation for presence of target organ damage (TOD) and stratified into three total CV risk categories based on blood pressure (BP) category, CV risk factors, TOD and presence of chronic kidney disease. Total testosterone (TT) and peak systolic velocity (PSV) at penile arteries were measured as markers of ED severity and predictors of CV risk. All patients underwent exercise treadmill test and stress echocardiography to reveal myocardial ischemia. Men with positive one or both of the two tests were referred for coronary angiography in order to document CAD. Our primary outcome was a composite measure which included acute myocardial infarction (AMI), stroke, congestive heart failure, revascularization with either percutaneous coronary intervention or coronary artery bypass graft surgery. All patients were followed from cohort entry until major CV event, or end of study period (December 2018), whichever occurred first. Results The whole population was divided into high (n=176), intermediate (n=120) and low (n=96) total CV risk groups. The three groups had similar mean age (57 yrs). The prevalence of angiographically documented CAD was significantly higher among patients in the high risk group (n=32, 18%), compared to intermediate (n=15, 12.5%) and low risk (n=4, 4.1%) (overall P<0.05). Furthermore, there was a progressive decrease in penile PSV and TT levels from low to moderate and high total CV risk (35 vs 31 vs 28 cm/s and 5.1 vs 4.3 vs 3.8 ng/ml, respectively, overall P<0.001), indicating significant microvascular damage and androgen deficiency in men with a higher CV risk category. Interestingly, Kaplan-Meier analysis revealed a comparable incidence of major CV events in patients who were at high and intermediate total CV risk at entry (12.5% vs. 11%, respectively, log-rank =0.57) and a greater incidence of major CV events compared to that of low CV risk patients (3.2%), (log-rank P=0.004, for all comparisons) during a 9-year follow-up period (figure). CV events during a 9-year follow-up Conclusion The incidence of future CV events is considerably high among hypertensive ED patients with a intermediate total CV risk at first evaluation. Such patients may require a comprehensive evaluation to reveal occult CAD and they need an aggressive management of BP and concomitant risk factors to reduce their CV risk and improve their sexual life.

668 Peyronie's Disease is common in poorly controlled diabetics but is not associated with the metabolic syndrome

The root cause of Peyronie's disease (PD) is unknown. Many theories have been advocated for its etiology, but the most widely accepted is trauma to the tunica albuginea. Because prevalence varies widely, the potential for contributory cofactors/comorbidities has been proposed. We hypothesized that metabolic syndrome and other systemic comorbidities may be found at higher rates in the PD population, and endeavored the largest descriptive study ever to test this hypothesis. A retrospective chart review of 1833 patients presenting to a men's health clinic with a variety of complaints: erectile dysfunction (ED), premature ejaculation (PE), premarital checkup, small penis, decreased libido, lower urinary tract symptoms (LUTS) and PD were screened for PD. Variables collected: presence/absence of diabetes mellitus (DM), hypertension (HTN), dyslipidemia (DL), body mass index (BMI), total testosterone (T), penile peak systolic velocity (PSV), end diastolic velocity (EDV) in patients with ED and/or PD, smoking, glycosylated hemoglobin level (HbA1c) in patients with diabetes, and the presence of metabolic syndrome. Patients with PD were compared to patients without PD.

Carotid atherosclerosis, aortic stiffness and penile vascular damage in patients with erectile dysfunction: Relation to low density lipoprotein levels and statin therapy

Purpose/Background/ObjectivesAim of the study is to examine the possible differentiation of aortic stiffness, carotid atherosclerosis and penile vascular function among patients with erectile dysfunction (ED) according to cholesterol level and statin therapy.MethodsWe measured carotid intima-media thickness (IMT), carotid-femoral pulse wave velocity (PWV) and penile peak systolic velocity (PSV) 20 min after intracavernous injection of prostaglandin E1 in 356 consecutive ED patients (mean age 57 ± 9 years). Lipid parameters and total testosterone were measured in all patients.Results95 (26.7%) ED patients are treated with statins. The patients not receiving statin therapy (n = 261) were subsequently divided into three groups according to LDL level (group 1: LDL <100 mg/dl, group 2: LDL: 100–155 mg/dl, group 3: LDL > 155 mg/dl).Patients with statin therapy and subjects in group 2 have similar mean LDL level. Carotid IMT was higher in patients with LDL >155 mg/dl (group 3) compared to patients treated with statins (P = 0.01) and subjects with LDL: 100–155 mg/dl (P = 0.005) and LDL < 100 mg/dl (left plot, P < 0.001). Post hoc analysis showed that patients treated with a statin and subjects in group 3 had comparable penile PSV and lower mean value compared to that of patients in group 1 and group 2 (right plot).Carotid-femoral PWV was similar between the studied groups. Testosterone levels were similar between patients treated with a statin and males not receiving hypolipidemic therapy (groups 2 and 3).ConclusionsAlthough treated hypercholesterolemic patients exhibited lower atherosclerotic burden compared to untreated individuals with high LDL levels, penile blood inflow remains significantly impaired.

PS-07-002 Penile vascular alterations and carotid atherosclerosis in patients with erectile dysfunction: The effect of cholesterol levels and statin therapy

Aim of the study is to examine possible differentiation of microvascular and macrovascular damage among patients with erectile dysfunction (ED) according to cholesterol levels and statin therapy. ... : We measured carotid intima-media thickness (IMT), carotid-femoral pulse wave velocity (PWV) and penile peak systolic velocity (PSV) 20 min after intracavernous injection of prostaglandin E1 in 356 consecutive ED patients (mean age 57±9 years) without manifest cardiovascular/atherosclerotic disease or diabetes. Biochemical parameters and total testosterone were measured in all patients. Low PSV indicates severe penile vascular disease and increased risk of major cardiovascular events. 95 (26.7%) ED patients are treated with statins. The patients not receiving statin therapy (n=261) were subsequently divided into three groups according to LDL level (group 1: LDL<100 mg/dl, group 2: LDL: 100-155, group 3: LDL >155 mg/dl). The four studied groups have similar age and prevalence of hypertension and smoking. Patients under statin therapy and subjects in group 2 have similar mean LDL level. Carotid IMT was significantly higher in patients with LDL >155 mg/dl (group 3) compared to patients treated with statins (P=0.01) and subjects with LDL:100-155 mg/dl (P=0.005) and LDL<100 mg/dl (P<0.001). Post hoc analysis showed that patients treated with a statin and subjects in group 3 had comparable penile PSV and significantly lower values compared to those of patients in group 1 and group 2 (figure). Carotid-femoral PWV was not different between the four groups. Testosterone levels were not different between patients treated with a statin and males not receiving hypolipidemic therapy (groups 2 and 3).

PS-08-004 Effect of antihypertensive drugs in dynamic penile peak systolic velocity

Antihypertertensive drugs, in particular thiazide diuretics and β-blockers may worsen erectile function as a side effect, however no study has yet investigated the effect of each drug class on penile artery haemodynamics. 156 treated hypertensive males with erectile dysfunction were evaluated for cavernous vascular disease severity by dynamic penile Doppler ultrasound. The effect of each drug class on dynamic peak systolic velocity (PSV) between patients taking monotherapy was studied. We also compared the effect of specific 2-drug combination therapies (as a fixed-dose combination pill or separate agents) on PSV. None of these patients was taking a diuretic as a monotherapy. Patients receiving either a β-blocker (BB) or a calcium channel blocker (CCB) as monotherapy had lower mean PSV compared to males receiving an angiotensin-converting enzyme inhibitor (ACEi) or angiotensin II receptor blocker (ARB) (31.2 and 30.5 cm/s vs 34.5 cm/s, respectively), however the differences after adjustment for age and BP level were not significant (P = 0.21 and P = 0.14). Among patients with a 2-drug combination therapy, the group of males who are taking ACEi/ARB plus diuretic had significantly lower age and BP level-adjusted PSV compared to subjects taking either a ACEi/ARB plus CCB or other combinations without a diuretic (27.2 vs 31.9 cm/s or 30.6 cm/s, all P < 0.05). The number of antihypertensive drugs did not affect cavernous vascular disease severity.

Evaluation of penile vascular status in men with epilepsy with erectile dysfunction

PurposeErectile dysfunction (ED) is common in males with epilepsy, likely of multifactorial etiology, including possible systemic vascular comorbidities and medication effects. Here we examined male patients for the possibility of a vasculogenic element of ED. MethodsResearch participants included 47 men with epilepsy (mean age=30.98 years; duration of illness=13.98 years) and 25 healthy matched men (mean age=30.36). Erectile function was assessed using the International Index of Erectile Function Questionnaire (IIEF-5). Penile blood flow was assessed using Duplex Ultrasonography (PDU) after intracavernous alprostadil injection. Penile peak systolic velocity (PSV), end-diastolic velocity (EDV) and resistance index (RI) were the functional parameters analyzed. Carotid artery intima media thickness (CA-IMT) was also measured. ResultsThirteen of the 47 men with epilepsy (23.40% versus 0% for controls) reported ED, and of these patients, 11 (84.62%) had abnormal PDU [PSV=28.23±6.1cm/s, P=0.0001; EDV=2.22±5.71cm/s, P=0.004; RI=0.89±0.22, P=0.071] suggesting vasculogic ED. Penile arterial insufficiency was identified in 5 (45.45%), while 6 (54.54%) had mixed arterial insufficiency and venous leak. Compared to patients with high PSV, patients with low PSV had lower IIED-5 scores, higher EDV, lower RI, higher diastolic blood pressure and higher CA-IMT values. There were no differences in depression, anxiety or concentrations of sex hormones. Significant correlations were evident between PDU variables and duration of illness, depression and anxiety scores and CA-IMT values. In multivariate analysis, the association between PDU parameters and CA-IMT values remained significant even after adjustment for other confounding variables. ConclusionsVasculogenic ED is frequent with epilepsy and its relationship to systemic atherosclerosis cannot be excluded.

High-tone electric muscles stimulation of thigh augments the impaired penile blood flow of diabetic patients without improving symptoms of erectile dysfunction

Erectile dysfunction (ED) is a major complication in diabetes mellitus. A novel method, high-tone external muscle stimulation (HTEMS), has been proven to be useful in the therapy of diabetic and uremic peripheral polyneuropathy. The aim of this study was to test the potential effect of HTEMS on ED in diabetic patients. An open-label, self-controlled interventional prospective study was conducted at the 2nd Department of Internal Medicine and N.C. University of Pécs, Hungary. Six Type 2 diabetic patients (mean age 59 ± 7 years) with severe ED (International Index of Erectile Function (IIEF) score: 7.7 ± 8.5) and impaired renal function (eGFR: 61 ± 16 ml/min) were involved. The thigh muscles of the patients were treated with HTEMS for 1 h 3 times per week for a duration of 4 weeks. Penile peak systolic velocity (PSV) (in the flaccid state and semi-rigid (after 10 mg intracavernous papaverine injection)), IIEF score, quality of life and laboratory parameters. At the beginning also the acute effect of HTEMS on penile PSV was investigated. Under basal conditions penile PSV was rather low. The first HTEMS session of the thighs induced an insignificant increase of PSV in the flaccid state (4.1 ± 1.2 to 6.3 ± 3.3 cm/s) and a significant rise of PSV in the semi-rigid penis (from 6.5 ± 2.5 to 8.9 ± 2.2 cm/s (p = 0.009)). After 4 weeks of HTEMS treatment, under basal conditions no significant change of penile PSV (flaccid and semirigid) was observed. Similarly, IIEF score did not improve over the time period (7.7 ± 8.1 vs. 6.7 ± 8.5, p > 0.05). Also, metabolic parameters and eGFR were not influenced. In a pilot study of diabetic patients with severe ED HTEMS of the thighs induced an acute rise of penile PSV in the semi-rigid state. However, after 4 weeks of HTEMS therapy the basal PSV and symptoms of ED were not improved.

ORIGINAL RESEARCH—ERECTILE DYSFUNCTION: Penile Doppler Ultrasound in Patients with Erectile Dysfunction (ED): Role of Peak Systolic Velocity Measured in the Flaccid State in Predicting Arteriogenic ED and Silent Coronary Artery Disease

The use of the penile peak systolic velocity (PSV) measured in the flaccid state during penile color Doppler ultrasound (PCDU) examination has been questioned without substantial evidence. To assess the validity of PSV measured in the flaccid state during PCDU, in patients consulting for erectile dysfunction (ED). A consecutive series of 1,346 (mean age 55.0 +/- 12.0 years) male patients was studied. All patients underwent PCDU performed both in the flaccid state and dynamic (after prostaglandin E1 stimulation) conditions. A subset of 20 subjects with uncomplicated type 2 diabetes underwent diagnostic testing for silent coronary heart disease by means of adenosine stress myocardial perfusion scintigraphy (SPECT). In these subjects penile arterial flow was simultaneously assessed by PCDU before and after systemic adenosine administration. Flaccid PSV showed a significant (r = 0.513, P < 0.0001) correlation with dynamic PSV. Receiver operating characteristic (ROC) curve analysis demonstrated that when a threshold of 13 cm/seconds was chosen, flaccid PSV was predictive for dynamic PSV < 25 and <35 cm/seconds with an accuracy of 89% and 82%, respectively. Among the subset of patients who underwent SPECT, an impaired coronary flow reserve (ICFR) occurred in nine cases (45%). When the same threshold of <13 cm/seconds was chosen, PSV before SPECT was predictive of ICFR with an accuracy of 80% (area under the ROC curve = 0.798 +/- 0.10; P < 0.05). After adjustment for confounders, anxiety symptoms were related to dynamic PSV (Adj. r = -0.154, P < 0.05) but not to flaccid PSV. Our results show that flow in the cavernosal arteries can be routinely evaluated by PCDU in the flaccid state. Performing PCDU only in the flaccid state allows identifying subjects with pathological dynamic PSV with accuracy higher than 80%. Furthermore, our preliminary data suggest that the same examination could identify diabetic subjects with ICFR with an accuracy of 80%.

Asymmetric development of peripheral atherosclerosis in patients with erectile dysfunction: An ultrasonographic study

Recent literature focused on erectile dysfunction (ED) as a reliable predictive parameter of cardiovascular diseases.ED patients have a higher prevalence of atherosclerotic lesions (increased intima-media thickness and plaques) at carotid site, but data on femoral site are still lacking. Nevertheless, there is accumulating evidence concerning a significant involvement of femoral atherosclerosis in other clinical conditions associated to ED, such as diabetes mellitus and coronary disease.Therefore, we investigated the prevalence of carotid and femoral atherosclerotic lesions and penile peak systolic velocity (PSV) in 238 ED patients by Eco-Colour Doppler ultrasonoghaphy (US).We found – irrespective of the presence of cardiovascular risk factors – a significant increase of atherosclerotic lesions in ED group with respect to 52 controls (66.4% versus 36.5%) and a higher prevalence of atherosclerosis at the femoral site (23.1% versus 5.7%), also with respect to the carotid site (8%). Moreover, PSV was significantly lower in ED patients with atherosclerosis compared to those without atherosclerotic lesions (41.9±15.3cm/s versus 55.2±17.7cm/s), and it was particularly low in those with combined carotid and femoral atherosclerosis (34.8±13.3cm/s) and those with isolated carotid atherosclerosis (37.9±13.0cm/s).These data confirm the strong relation between atherosclerosis and ED, an asymmetric development of atherosclerotic lesions in ED patients and suggest to perform an US study of both femoral and carotid district in these subjects.

Peak systolic velocity in patients with arterial erectile dysfunction and peripheral arterial disease

The aim of this study is to evaluate whether penile peak systolic velocity (PSV) varies in patients with erectile dysfunction (ED) due to artery insufficiency associated with abnormalities in other arterial districts or not. To accomplish this, cavernous artery PSV was determined 10, 20 and 30 min after intracavernously administering alprostadil by means of echo-color Doppler to a total of 65 consecutive patients (age range 52-78 years). In all, 18 patients had ED alone (group A) and served as controls, 15 had ED plus atheroma plaques and/or marked intima-media thickness of the common carotid artery (group B); 17 had ED plus lower limb artery abnormalities; 17 had ED plus carotid and lower limb artery abnormalities (group D). Group B and C patients had a similar PSV, which turned out to be significantly lower than that in group A. Group D patients had the lowest PSV, which proved to be significantly lower than that in groups A, B and C. This study shows that a more generalized peripheral atherosclerotic process is associated with a severer penile artery insufficiency. Therefore, ED patients with a severe arterial insufficiency should undergo an extensive echo-duplex examination.