Vascular Dsyfunction Management

Vascular Dsyfunction Management

Although, vascular blocks are fairly common in a person with diabetes, blocks to the arteries supplying the penis are rarely the cause of the erectile dysfunction.

It is only appropriate in young patients with proven arteriogenic impotence due to congenital vascular anomalies or traumatic injuries to the pudendal or penile arteries.

In fact, even if one considers the full spectrum of erectile dysfunction, irrespective of the somatic cause, only 2% to 3% of all patients meet these criteria for penile arterial bypass.

Most centers have rigid inclusion criteria before undertaking such procedures. Although, these may differ from place to place, the general consensus seems to be that Penile arterial revascularization is indicated for only highly selected patients, young men (less than 45 years old) who have penile, perineal, or pelvic trauma and are either not at risk for atherosclerosis or have modifiable risk factors.

  • Presence of significant corporal veno-occlusive dysfunction (particularly early drainage into the glans penis or corpus spongiosum, which reflects corporal smooth muscle myopathy and/or collagen deposition)
  • Age over 45 to 50 years
  • Generalized atherosclerosis
  • High serum lipids
  • Lack of specific focal lesions affecting internal pudendal arteries or internal branches
  • Insulin-dependent diabetes mellitus
  • Inability to stop using tobacco in any form.

Selective arteriography is recommended only for men who are candidates for arterial revasculization. These are usually young, healthy men who have suffered trauma to the penis or to the area under the scrotum known as the perineum. Prior to proceeding with an arteriogram, which is a very invasive procedure, a Duplex Doppler examination showing the presence of poor blood flow and indicating a probable arterial lesion should be performed. If an obstruction is visualized, it is important to document whether there is flow back through the blockage to the point of obstruction so that the patient will be sure to benefit from the procedure.

The objective of the surgery is to increase the blood flow to the corporal body and therefore improve the erections. The best candidates for surgery are men who have poor erections with spontaneous erections absent and in whom all studies indicate a pure arterial component. Patients with other diseases such as diabetes or heavy smokers are poor candidates for this type of operation.

Ideally, arterial surgery should be the way to treat erectile dysfunction since it seems logical that a damaged or blocked artery could easily be bypassed to provide the necessary blood needed to maintain an erection. Unfortunately, this is not the case because the patients who have this distinct arterial lesion are very limited.

Patients who undergo arteriography should be highly motivated and have a complete workup to rule out all other causes of erectile dysfunction, including hormonal problems or venous leaks. Patients should not proceed with arteriography unless they are good candidates for revascularization.

Candidates should have a percentage of smooth muscle tissue of at least 29%. In studies of selected patients there was improvement in erectile dysfunction in 50% to 75% of men after five years.

In the era of highly effective oral and injectable drug therapy, penile venous surgery must be considered historical. With very few exceptions (cases of ectopic veins in young men), there is no justification for pursuing this kind of treatment in ED patients, especially because most of these procedures end in failure.

A large number of men suffer from erectile dysfunction as a result of venous leak - a condition that prevents the storage of blood in the penis. Without the storage of blood, an erection cannot be maintained. In men with venous leak, blood flows out of the penis as quickly as it flows in. The penis does not become fully erect or loses its erection quickly.

The trapping of blood within the corpora cavernosa by decreasing venous return is a necessary step toward achieving and maintaining erection. Veno-occlusive incompetence or dysfunction is defined as the inability to trap blood within the corpora cavernosa to achieve and maintain erection.

For most practical purposes, venous dysfunction can be inferred from the finding of a normal arterial response to intracavernosal injection in the presence of a poor erectile response.

Venous leakage is a relatively common cause of erectile dysfunction. An inability to achieve and maintain the full erection occurs because blood leaks out in the presence of an adequate arterial inflow due to a damaged veno-corporo-occlusive mechanism.

Patients with pure erectile dysfunction on the basis of a venous leak are rare, but many men have venous leakage as a component of their erectile dysfunction.

The first choice for patients who have venous leakage is a vacuum erection device or treatment with intercavernosal injections. The only patients who are candidates for a venous leakage operation are patients who have failed simple, noninvasive treatments.