Proximal claudication remains a difficult diagnosis. The ankle to brachial index may be insensitive in the case of isolated hypogastric lesions. Penile pressure represents an alternative method for proximal arteries. Surprisingly, the accuracy of penile pressure measurement in detecting lesions on the arteries supplying pelvic circulation in patients suffering claudication has rarely been studied. We aimed to evaluate the diagnostic accuracy of the penile brachial index < 0.60 (penile over brachial systolic pressure ratio) to non-invasively investigate arteriographic lesions on arteries supplying the hypogastric circulation in 88 male patients referred for Fontaine stage II. The receiver operating characteristic (ROC) curve was used to define the diagnostic performance of the penile brachial index and search for a specific cut-off point in this population. Accuracy was 69.3% (95% confidence interval: 58.6-78.7) for the detection of an arterial stenosis or occlusion on at least one side. The penile brachial index </= 0.45 was 74% sensitive and 68% specific to discriminate the 19 patients with bilateral arterial occlusion from the other 66 patients. In conclusion, the penile brachial index is relatively insensitive for the detection of proximal abnormal blood flow impairment except in the case of bilateral occlusion of arteries supplying the hypogastric circulation in patients with claudication. A normal penile pressure is probably not efficient enough to rule out the presence of lesions on the arteries towards the hypogastric circulation in patients with arterial claudication.