Erectile dysfunction, arterial insufficiency

Vascular pathology may involve lesions of the inflow or outflow mechanisms of penile erection. Erectile dysfunction may be a manifestation of generalized atherosclerosis and may even be its initial presentation. Common risk factors associated with generalized penile arterial insufficiency include hypertension, hyperlipidemia, cigarette smoking, diabetes mellitus, and pelvic irradiation (Rosen et al. 1991). Less commonly, local stenosis of the conunon penile artery may occur in men who have sustained blunt pelvic or perineal trauma (Levine et al. 1990). 

Chronic renal failure is also frequently associated with diminished erectile function, impaired libido, and infertility. The mechanism is probably multifactorial low serum testosterone concentrations, diabetes mellitus, vascular insufficiency, multiple medications, autonomic and somatic neuropathy, and psychological stress. Men with angina, myocardial infarction, or heart failure may have erectile dysfunction from anxiety, depression, or concomitant penile arterial insufficiency. 

In the field of erectile dysfunction, penile vascular imaging modalities have diminished in importance over the past 10 years with the introduction of new effective oral medications and recognition that surgical treatment of both penile venous leak and arterial insufficiency has poor long-term clinical outcomes. 

Some authors have studied the possibility to deliver prostaglandin El using transdermal liposomal formulations through the foreskin in men with erectile dysfunction secondary to spinal cord injury or with mild arterial insufficiency (Foldvari et al. 1998). 

Although alteration of the venous occlusive mechanism has been claimed to be present in a high percent of Peyronie s patients with erectile dysfunction (Weidner et al. 1997), the role of arterial inflow must be investigated. In fact, color Doppler ultrasonography shows associated arterial insufficiency in 30%-50% of these patients (Kadioglu et... 

During the follow-up of patients with high-llow priapism, we recommend color Doppler ultrasound 1-2 months after embolization to confirm the absence of recurrent fistula. Recanalization of the em-bolized cavernosal artery can be observed also when non-reabsorbable embolization material has been used (Savoca et al. 2004). In patients with erectile dysfunction, the study should be performed after in-tracavernosal prostaglandin injection to determine whether the functional impairment is caused by insufficient penile blood flow or not. 

Fig. 12.11a-c. Postraumatic erectile dysfunction. A 32-year-old patient who received pelvic bone fractures during a traffic accident, a Doppler interrogation of the cavernosal arteries shows low velocity flows of 12 cm/s, consistent with postraumatic arterial insufficiency, b Left internal pudendal arteriogram shows interruption of the vascular supply to the penis with no opacification of the cavernosal artery, c MDCT angiography demonstrates the same vascular features non-invasively... 

Moreland 1998). Systemic connective tissue disorders, such as systemic sclerosis, are associated to erectile dysfunction in as much as 80% of patients due to combined arterial insufficiency and collage-nization of corporeal smooth muscle (Lotfi et al. 1995). 

---