A screening sequence for vasculogenic impotence

Abstract

Delineation of neural, arterial, and venous components contributing to penile erectile failure is critical to proper patient selection for surgical interventions, particularly for a subset of men with impotence as the sole manifestation of pelvic arterial disease. In addition to obtaining a history and physical examination specific for disordered erectile function and vascular risk factors, we developed a sequence of testing to include noninvasive estimates of penile perfusion, pulse volume recording (PVR), and penile/brachial blood pressure indices (PBPI); somatosensory evoked potentials from dorsal penile (PEP) and posterior tibial nerve stimulation (SEP) and bulbocavernosus reflex time (BCR); stimulation of artificial erection with injection of papaverine (AE); and selective hypogastric-pudendal arteriography with patients under epidural anesthesia, and corpus cavernosography with AE. Three hundred fifty-three men complaining of impotence were screened by PVR and PBPI; among these 42 impotent men and 20 additional concurrent potent control subjects had evoked potentials and BCR measurements, and 55 men received one or more AE injections. On the basis of these results, angiographic investigation was recommended. Age and risk factors were similar in the two groups. Abnormal penile blood perfusion was associated significantly only with cigarette smoking (p less than 0.0001) or overt large vessel disease. Impotent men with (138) or without perfusion abnormalities (215) averaged 54 and 56 years of age, respectively; impotent men with normal flow patterns most commonly had treated hypertension or diabetes (79 of 215 men). Covert neurologic abnormalities were detected in 28 of 42 impotent men. Abnormal penile perfusion plus failure of AE predicted isolated ischiopudendal trunk or pudendal artery disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Vasculogenic impotence and cavernosal oxygen tension

“…Arteriography may help answer some of our questions. 24 Regarding cavernosal oxygen tension, patients with mildamoderate venous leak are probably different physiologically from those with severe venous leak. Further investigation is necessary to understand this phenomenon.…”

Vascular surgery for impotence: a review

“…This is also true of deep dorsal vein arterialization. Here the direction of¯ow observed by us 74 and by Sohn et al 75 appears to be mainly into the spongiosum. While the physiology of deep dorsal vein arterialization is not clear, the procedure can be clinically effective in cases of diffuse penile artery obliteration.…”

“…These complications can be averted with prompt distal venous ligation. One of the largest series of deep dorsal vein arterialization, that of Furlow et al, 34 156 patients published in 1992, reported 68% functioning normally with followups of six months to seven and one-half years. Undoubtedly due to the inaccuracies of diagnosis in this developing ®eld and the application of a variety of techniques, 61±64 past results of arterial vascular interventions are dif®cult to assess.…”

“…For example when both dynamic infusion cavernosometry and cavernosography (DICC) and pudendal arteriography were used, 23% of men (average age 48.8 y) with normal non-invasive arterial studies suspected mainly of venous leakage, were found to have segmental arterial obstructive lesions. 21 Without selective arteriography, the mistaken application of a proximal reconstruction or the use of venous interruption would have guaranteed failure in many patients. In contrast, older, even arteriosclerotic men, with proximal lesions and functional smooth muscle can respond adequately to ICI, although erections will be slower to develop.…”

“…Using non-invasive and invasive testing 17,18 it is possible to de®ne subsets of anatomic patterns of vascular disease. 19 Hatzicharistou and Goldstein 20 have recently emphasized angiographic patterns in procedure selection, focusing on planning of microvascular procedures for penile revascularization based on localized distal disease.…”