No, verapamil injections can certainly begin without an ultrasound, but an ultrasound does provide information as to whether there is extensive calcification in the plaque. A large sheet of bone will make intralesional injection of any drug result in little benefit as the needle cannot penetrate the calcification. Before initiating any form of treatment in my patients, I perform a penile duplex ultrasound using intracavernosal injection. This test provides significant information regarding penile blood flow, presence of calcification, erect deformity which can be measured with a protractor as well as girth assessment. All of this information can be useful in terms of offering subsequent treatment.