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The study showed that EHS has predictive value similar to or even greater than Doppler in identifying patients with refractory ED, defined as failure to respond to non-invasive treatments such as sildenafil or alprostadil therapy. These findings are consistent with a previous analysis (21-24), which compared EHS with penile Doppler in a study of patients treated with non-surgical therapy for ED. All data regarding IIEF-5 parameters, penile hemodynamic findings (PSV, EDF, and RI), and V-EHS pre-treatment at 1, 3, and 6 months are described in Table-1. The initial selection of patients was according to the baseline clinical complaint of erectile dysfunction and the presence of moderate erectile dysfunction based on the validated International Index of Erectile Function questionnaire (IIEF to 21) in use of tadalafil 5 mg daily. And no trusted medical organization endorses penis surgery for purely cosmetic reasons. 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