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Young patients with impotence and cavernous arterial insufficiency resulting from trauma-induced arterial occlusive disease are ideal candidates for microvascular arterial bypass surgery. To avoid the long abdominal incision required to harvest the inferior epigastric artery, a laparoscopic approach was used. We report a case of laparoscopically assisted penile revascularization for vasculogenic impotence.
PURPOSE: Use of a nonmedical, catalogue type vacuum erection device resulted in a case of vacuum induced vasculogenic impotence and Peyronie's disease. MATERIALS AND METHODS: A 66-year-old potent man used a nonmedical vacuum erection device (cylinder plus a hand pump without a pressure-release valve and a doughnut-shaped ring at the base without tension bands) after having achieved a spontaneous rigid erection. The resultant excessive overinflation of the penis was followed by dorsal curvature, diminished rigidity and decreased erectile maintenance. RESULTS: Physical examination revealed a dorsal mid shaft Peyronie's plaque. Nocturnal penile tumescence testing and office injection testing were abnormal and demonstrated partial, short-lived, dorsally curved erections. Dynamic pharmaco-cavernosometry and pharmaco-cavernosography established vasculogenic impotence with site-specific crural (unrelated to the Peyronie's plaque) veno-occlusive dysfunction and dorsal penile curvature. CONCLUSIONS: Vacuum erection devices create pulling forces on the penis. We estimate that the pulling forces in this case were prohibitively high (approximately 29 pounds) due to absence of a pressure-release valve and to the preexistent erection at vacuum application. These intense pulling forces are hypothesized to have damaged the tunica in the mid shaft (Peyronie's disease) and the crus (veno-occlusive dysfunction), the latter being the site of attachment of the corpora to the ischiopubic ramus and a most likely location for high magnitude pulling forces to exert an abnormal injury effect. The patient underwent a Nesbit plication procedure and presently performs self-injection for satisfactory sexual activity.
We report our experience with the surgical treatment of 30 patients with venous leak impotence seen at the Division of Urology, Toa Payoh Hospital, over a period from April 1991 to August 1993. The patients were assessed by history, clinical examination, hormonal evaluation and intracavernosal injection of papaverine. Confirmation of venous leak impotence was obtained by pharmaco-cavernosography in all patients; dynamic cavernosometry was performed in the later part of the series. Surgical treatment consisted of ligation and stripping of the deep dorsal vein, ligation of all its emissary and circumflex tributaries for all patients, with crural plication and suspensory ligament re-approximation in selected patients. Peroperative intracavernosal injection of papaverine was used to identify veins and to assess the adequacy of the extent of venous ligation. The mean age of the patients was 40 years. The average operative time was 2 hours. The usual period of hospitalisation was 3 days. Patients were followed up for an average period of 15.6 months. Success was defined as having adequate erections for normal coitus; the success rates at 1, 3, 6, 9 and 12 months were 76.2%, 61.9%, 52.4%, 42.9% and 38.1%, respectively.
PURPOSE: Since penile arterial communications are present in a significant percentage of impotent patients, we evaluated whether peak systolic cavernous blood velocity after intracavernous prostaglandin E1 injection might be different in patients with and without arterial variants. MATERIALS AND METHODS: Cavernous blood flow was assessed with echo color Doppler ultrasound before and after intracavernous injection of prostaglandin E1 in 63 impotent patients. The penile shaft was accurately evaluated to detect arterial anatomical variants. Clinical erectile response was assessed by visual inspection and palpation. RESULTS: Of 23 patients who obtained a full erection with full rigidity after prostaglandin E1 injection the cavernous peak blood velocities in 11 with penile arterial communications were significantly less than those in 12 without arterial communications. CONCLUSIONS: The generally accepted limit of normal for cavernous peak blood flow obtained after prostaglandin E1 injection (greater than 25 to 30 cm. per second) must be interpreted carefully because lower peak blood velocities may be found in subjects with a full erectile response if arterial communications are present.
After having reviewed the methods and significance of a new topical administration route for vasoactive drugs, the "Trans-Epidermal Barrier" (T.E.B.), based on the physiological capacity of phosphoric ester molecules (Phosphatidylcholine) to penetrate actively through the epidermal barrier, this paper reports the results obtained in the medical treatment of (micro) vasculogenic impotence with a preparation in the form of a 5% Lipogel, containing, as active principle, a Troxerutine/Phosphatidylcholine Complex. A total of 154 patients were subjected to "short term" treatment in order to quantitatively assess (computer assisted laser-Doppler: LDF) the response of the small arteries and arterioles in the dorsal penile region to pharmacological stimulation (microvasculokinesis test). This test enables separation of the patients into two groups: "responders" and "non-responders", according to which it is possible to instrumentally assess the severity of the anatomo-functional alteration of the small arteries and arterioles in penile microangiopathies originating from diabetes, arteriolosclerosis, hypertension and stasis. Microvascular damage was assessed objectively with the Optic Probe Video-Capillaroscopy, taking into consideration the number of microaneurysms and extension of the subischemic or ischemic areas. 75 "responder" patients undertook long term treatment for a minimum period of three months with the same preparation used for the microvasculokinesis test, at the dose of 2-3 topical administrations per day. The clinical parameters for the evaluation of efficacy were): a) number of spontaneous daily erections; b) duration of the erections; and c) penile rigidity; in addition to subjective elements such as recovery of satisfactory sexual activity consistent with the anatomo-functional damage. The response to the treatment was positive in 54 patients (72% of the cases). The clinical improvement was confirmed by the instrumental LDF results, that show a statistically significant increase (P < 0.0001) in the sphygmicity ("pumping function": inotropic potency of the arterio-arteriolar systole) of the small penile arteries, i.e.:92.63 +/- 26.1 at baseline to 177.6 +/- 74.5 after treatment. Follow-up continued in 15 patients for 6 months and in 11 patients for 12 months. Maintenance of the results was achieved by continuing treatment involving gradual reduction of the number of applications. The new route of application proposed by the authors and the investigation methods adopted for objective instrumental assessment of penile microcirculatory damage in (micro) vasculogenic impotence provides new perspectives from the diagnostic as well as the prognostic and therapeutical viewpoints.
Erectile dysfunction has an incidence of 2-9% and it is seen often in general practice. But the more recent treatment methods such as intracavernous drug injections and vacuum constriction devices are not known by general practitioners and normally used drug treatment has no efficacy. The management of impotence of the general practitioner should concentrate upon internistic conditions like diabetes, hypertension, hypercholesteremia and different drugs causing impotence. The symptomatic treatment of erectile dysfunction has to be done by a specialist, who is able to offer all therapeutic options.
OBJECTIVE: To test the effects of intracavernous injection of Linsidomine, an NO donor, and to compare the results to those obtained after injection of PGE1. MATERIAL AND METHODS: 38 subjects with erectile insufficiency received an intracavernous injection of 10 micrograms of PGE1, followed by an intracavernous injection of 1 mg of linsidomine at least 3 days later. The erectile response after linsidomine was compared to that obtained after PGE1. 21 patients were investigated by Duplex ultrasound after each injection. RESULTS: Linsidomine induced complete rigidity in 4 subjects considered to suffer from psychogenic impotence (versus 11 subjects with PGE1) and 1 subject considered to suffer from arterial disease (versus 8 subjects with PGE1). The maximal systolic velocities recorded after linsidomine were significantly correlated with those measured in the same subject after PGE1. The resistance index was not modified after linsidomine injection. CONCLUSION: Our study confirms the impact of linsidomine on the local mechanisms of erection. It shows that linsidomine is much less effective than PGE1, but nevertheless has a place in the therapeutic armamentarium of impotence.
Nocturnal penile tumescence (NPT) was assessed in 30 impotent patients for the purpose of differential diagnosis. In 11 psychogenic cases, with several exceptions, NPT was found to be normal, with a marked discrepancy between the NPT findings and the patients' estimates of their daytime erectile capacity. In 19 organic patients, maximal NPT corresponded closely to and mirrored the patient's subjective estimate of his impaired waking performance. Statistically, the figures for frequency, degree, duration, and amount of NPT were found to be significantly and markedly greater in the psychogenic group. Statistical significance was maintained when the 11 psychogenic patients were closely age-matched with 11 of the 19 organic cases. The method is not 100% accurate; some 15% of impotent patients without organic findings have reduced NPT, several of whom were shown to be psychogenic, but others in this group may have undetected organic pathology. The NPT method is very promising, but beset by a number of methodological problems.
Eleven impotent men underwent deep-penile-vein arterialization after preoperative assessment by a multidisciplinary team. Penile Doppler pressures, testosterone levels, and nocturnal penile tumescence were used to establish a vasculogenic etiology. Cavernosography, artificial erection by saline infusion, and selective hypogastric arteriography were obtained to delineate whether arterial, venous, or mixed (arterial/venous) factors predominated. Penile revascularization consisted of femoral artery to deep-penile-vein saphenous bypass, with ligation of superficial veins at the base of the penis in patients with venous leakage. Cumulative graft patency was 91% up to 20 months. There were no deaths. The average preoperative flow requirement of values greater than 250 mL/min was reduced to 59 mL/min postoperatively. Follow-up results of nocturnal penile tumescence were excellent in four of four patients with venous (venous leakage), two of three patients with arterial, and one of four patients with mixed factors. Deep-penile-vein arterialization appears to be beneficial for impotence secondary to venous leakage, with inconsistent results for arterial and mixed factors.
This review considers diagnosis and treatment of vasculogenic impotence. It describes current information related to normal mechanisms of penile erection and pathophysiology of organic impotence, methods of preoperative diagnosis, quantitative evaluation of penile blood flow and operative techniques to be employed in aneurysmal or occlusive aorto-iliac disease. The importance of preserving internal iliac flow and neural fibres enervating the genitalia is stressed. Large vessel reconstructions have proved practical in maintaining or restoring normal erectile function, but at present reconstructions of isolated pudendal or penile artery occlusions are experimental. Medical therapy can be effective in certain marginal cases of small vessel occlusion.
Five patients with vasculogenic impotence underwent balloon angioplasty of internal iliac and/or internal pudendal artery obstructions in an attempt to increase the blood pressure in the dorsalis penis artery and thus improve erectile function. Four patients had bilateral obstructions, and one patient had unilateral iliopudendal arterial disease. Balloon angioplasty was used to dilate bilateral lesions in three patients and unilateral lesions in two patients. Four of the five patients had improvement in erectile function for 2 to 18 months (mean, 12 months) after angioplasty. We conclude that balloon angioplasty is an adequate, expeditious, and relatively inexpensive method for treating subtotal obstruction of the internal iliac and/or internal pudendal arteries in patients with vasculogenic impotence.
Impotence in patients is most probably age-related in the untreated case. The therapy of prostate cancer presents many hazards to the retention of sexual function which should be obvious to most urologists. What is now apparent is that surgical treatment of the disease does not necessarily cause impotence in all who were potent before the start of treatment. Documentation during history taking is essential. Increased awareness of the increased chances of retaining potency by physicians and patients will lead to improved results.
Quantitative measurements of the collagen types (I, II, and IV) in the corpora cavernosa of potent and impotent men were carried out to investigate whether quantitative immunohistochemistry might contribute additional information as to the cause of erectile dysfunction. The study group consisted of 22 men with various etiologies of impotence and 4 normal, potent men. The quantitative immunohistochemistry measurements were performed by means of a cell-image processor. Three variables for each of the three types of collagen were studied, namely, the mean optical density (MOD), which relates to histochemical staining intensity; the labeling index (LI), which is positively related to the percentage of immunostaining; and the quick score (QS) index, which takes into account both LI and MOD values. None of the quantitative parameters taken individually (monovariate statistical analyses) made it possible to obtain any statistically significant difference between the types of collagen of the group under study. The mean QS value recorded for collagen type IV was significantly lower than that noted for collagen type I in the psychogenic (P = 0.019), arteriogenic (P = 0.012), and venogenic (P = 0.001) groups, whereas the MOD value was significantly lower in the normal (P = 0.043), arteriogenic (P = 0.013), and venogenic (P = 0.001) groups but not in the psycogenic group. The mean MOD of collagen type III was intermediate between that of the other types. In contrast, the mean LI value recorded for collagen type IV was significantly lower only in the venogenic (P = 0.032) and psychogenic (P = 0.049) groups as compared with the other groups. No objective qualitative change in the collagen types was observed that could be correlated to the etiology of erectile dysfunction. The significant difference seen in the quantitative parameters with regard to collagen type IV and the observed increase in the type I/III collagen ratio might attest to the notion that the response of the erectile tissue to ischemia is similar to that of other organs. The net effect of these changes is a restricted capacity for corporal expansion and alteration of the veno-occlusive mechanism.
A double-blind comparison was made of the effects of testosterone undecanoate (TU) and placebo on sexual potency of 29 impotent men ages 45--75. The main criteria for inclusion in the study were a reduced or nonexistent capacity to have an erection during intercourse and no clinical signs of endocrinological pathology. All patients received placebo for 2 weeks. Then TU was given at a daily dose of 120 mg to 13 patients selected at random while the other patients continued to receive placebo. After 8 weeks all patients received placebo again for 2 weeks. An improvement in sexual potency was reported by five patients given TU and eight patients given placebo, with no significant differences between the groups. Treatment with TU influenced neither the hypothalamic-pituitary-gonadal axis, as judged by levels of prolactin, LH, FSH, and the LHRH-induced LH/FSH response, nor depression, anxiety, and somatic scores or performance tests. The only specific effect of TU treatment was to decrease the total plasma testosterone level. The present findings show pharmacotherapy with androgens to be no more effective than placebo in restoring sexual potency to sexually impotent men without androgen deficiency. Further studies may be needed to elucidate fully the effects of androgen administration on psychological and endocrinological variables in such patients.
Results of a study conducted to assess the therapeutic effectiveness of systematic desensitization of erectile impotence are described. Three groups of eight patients each were formed. They were treated with systematic desensitization or conventional medication and general advice, or put on a waiting list. Therapeutic effects were investigated on the behavioral, subjective, and physiological levels. There were no significant differences among the three groups except on the subjective level. On this level, after therapy the systematic desensitization group rated feelings in sexually arousing situations as associated with significantly less anxiety than the other two groups. Systematic desensitization used alone as a treatment for erectile impotence shows only limited therapeutic effect. The unimproved patients were later treated using a modification of the Masters and Johnson technique. Early results suggest that this technique may be superior to systematic desensitization alone.
Fifty impotent patients have been evaluated with intracorporeal injection of papaverine and colour Doppler ultrasound. The papaverine tests were negative in 34 of 50 patients. Nineteen of 34 patients with negative papaverine results showed normal colour Doppler findings. In 14 of 16 patients with positive papaverine results the colour Doppler analysis revealed normal structure and functions. Correlation between intracorporeal papaverine injection and colour Doppler ultrasound results was found in 59% (p < 0.01). We concluded that intracorporeal papaverine injection is an effective, simple diagnostic test for beginning evaluation of impotent men. However, this screening test should be supported by colour Doppler ultrasound.
The pathophysiologic basis for impotence, as related to possible vascular surgical procedures, is briefly discussed. In order to better classify criteria for selection and results of surgery, various relevant terms are defined. In the authors experience, conventional procedures for venous ligation have restored potency in only about 20% of cases. An additional 60% respond when given supplemental papaverine therapy. A new surgical procedure for venous ligation, which allows access to the cavernosal veins, has produced very promising results in a small pilot series. Arterial reconstruction has been effective in about 80% of a highly selected group of patients with arteriogenic impotence.
Forty-four patients with impotence were evaluated by intracavernous papaverine injection, penile brachial index (PBI) determination and dynamic cavernosography. The correlation between these diagnostic procedures and their diagnostic value were investigated. It was concluded that the papaverine test is an efficient diagnostic procedure and can be used as the first step for the routine work-up of impotent patients.