Venous leakage treatment revisited: pelvic venoablation using aethoxysclerol under air block technique and Valsalva maneuver.

OBJECTIVE: We evaluated the effectiveness of pelvic vein embolization with aethoxysclerol in aero-block technique for the treatment of impotence due to venous leakage in men using sildenafil for intercourse. The aim of the procedure was to reduce the use of sildenafil. METHODS: A total of 96 patients with veno-occlusive dysfunction, severe enough for the need of PDE5 inhibitors for vaginal penetration, underwent pelvic venoablation with aethoxysclerol. The mean patient age was 53.5 years. Venous leaks were identified by Color Doppler Ultrasound after intracavernous alprostadil injection. Under local anesthesia a 20-gauge needle was inserted into the deep dorsal penile vein. The pelvic venogram was obtained through deep dorsal venography. Aethoxysclerol 3% as sclerosing agent was injected after air-block under Valsalva manoeuver. Success was defined as the ability to achieve vaginal insertion without the aid of any drugs, vasoactive injections, penile prosthesis, or vacuum device. Additionally, a pre- and post- therapy IIEF score and a digital overnight spontaneous erections protocol (OSEP) with the NEVA™-system was performed. RESULTS: At 3 month follow-up 77 out of 96 patients (80.21%) reported to have erections sufficient for vaginal insertion without the use of any drug or additional device. Four (4.17%) patients did not report any improvement. Follow up with color Doppler ultrasound revealed a new or persistent venous leakage in 8 (8.33%) of the patients. No serious complications occurred. CONCLUSIONS: Our new pelvic venoablation technique using aethoxysclerol in air-block technique was effective, minimally invasive, and cost-effective. All patients were able to perform sexual intercourse without the previously used dosage of PDE5 inhibitor. This new method may help in patients with contra-indications against PDE5 inhibitors, in patients who cannot afford the frequent usage of expensive oral medication or those who do not fully respond to PDE5-inhibitors.

Standardization of vascular assessment of erectile dysfunction: standard operating procedures for duplex ultrasound.

INTRODUCTION: In-office evaluation of erectile dysfunction by color duplex Doppler ultrasound (CDDU) may benefit the decision-making process in regard to choosing the most appropriate therapy. Unfortunately, there is no uniform standardization in performing CDDU resulting in high variability in data expression and interpretation when comparing results among various centers, especially when conducting multicenter trials. Establishing standard operating procedures (SOPs) is a major step that will help minimize such variability. AIM: This SOP describes CDDU procedure with focus on establishing uniformity and normative parameters. MAIN OUTCOME MEASURE: Measure intra-arterial diameter, peak systolic velocity, end-diastolic velocity, and resistive index for each cavernosal artery. METHODS: After initial discussion with the patient about his history and International Index of Erectile Function evaluation describe procedural steps to the patient. Perform the CDDU in a relaxed state, scanning the entire penis (in B-mode image) using a 7.5- to 12-MHz linear array ultrasound probe. An intracorporal injection of a single or combination of vasoactive agents (e.g., prostaglandin E1, phentolamine, and papaverine) is then administered and CDDU performed at various time points, preferably with audiovisual sexual stimulation (AVSS). RESULTS: Monitor penile erection response (tumescence and rigidity) near peak blood flow. Self-stimulation or AVSS leaving the patient alone in room or redosing may be considered to decrease any anxiety and help achieve a maximum rigid erection. CONCLUSION: Considering the complexity and heterogeneity of CDDU evaluation, this communication will help in standardization and establish uniformity in such data interpretation. When indicated, invasive diagnostic testing involving (i) penile angiography and (ii) cavernosography/cavernosometry to establish veno-occlusive dysfunction may be recommended to facilitate further treatment options.

SOP: corpus cavernosum assessment (cavernosography/cavernosometry).

INTRODUCTION: There is no universal gold standard diagnostic test to differentiate psychogenic from organic erectile dysfunction (ED). Cavernosography/cavernosometry has been used to evaluate veno-occlusive dysfunction (VOD) in men with a proposed organic ED. AIM: To develop evidence-based guidelines for the performance and interpretation of cavernosography/cavernosometry. METHODS: Review the methodology behind cavernosography/cavernosometry and evaluate the evidence that supports its use and interpretation of results. MAIN OUTCOME MEASURE: Expert opinion based on review of the literature, extensive internal committee discussion, public presentation, and debate. RESULTS: The detailed technique of cavernosography/cavernosometry is described. An evidence-based perspective to the use and interpretation of cavernosometry is presented. CONCLUSION: The positive predictive value of cavernosometry still needs further assessment. It is unknown how many potent men would test positive for VOD (false positive).

Correlation between the European System for Cardiac Operative Risk Evaluation and sexual function after coronary artery bypass graft surgery.

INTRODUCTION: The published studies discussing the prognostic factors for expected sexual function after coronary artery bypass graft (CABG) are still limited. AIM: Examining the correlation between the European System for Cardiac Operative Risk Evaluation (EuroSCORE) and the abridged form of International Index of Erectile Function questionnaire (IIEF-5), as a quick and inexpensive tool for the cardiologist to predict the sexual function after CABG. MAIN OUTCOME MEASURES: Validated standardized questionnaire commonly used by cardiologists in identifying appropriate weight to various risk factors related to adult cardiac operations. METHODS: Preoperatively patients were evaluated as regards to the sexual function by (IIEF-5) and pharmaco-penile duplex ultrasound. Moreover all patients were evaluated bu EuroSCORE. Six months after surgery, the erectile function of all patients was revaluated according to the same preoperative procedures. The patients were categorized with EuroSCORE as follows: The low-risk group (EuroSCORE 0­2), the medium-risk group (EuroSCORE 3­5), and the high-risk group (EuroSCORE 6 plus). RESULTS: The EuroSCORE was negatively correlated with the IIEF-5 score (r = -0.224, P = 0.025 or rs = -0.259, P = 0.009). Moreover, low-risk patients had significantly higher IIEF-5 scores compared with medium-risk patients (mean standard deviation = 15.27 6.03 vs. 12.18 6.07, P < 0.05). CONCLUSIONS: There is an inverse correlation between the components of EuroSCORE and the IIEF-5 score. Patients with higher EuroSCORE had lower IIEF-5 scores and vice versa. The EuroSCORE is a useful, quick, and inexpensive tool that allows prediction of ED in those patients with coronary artery disease patients who are undergoing CABG.

Female Assessment of Male Erectile dysfunction detection scale (FAME): development and validation.

INTRODUCTION: Although erectile dysfunction (ED) affects both members of the couple, no tools exist for the detection of ED by the female partner. AIM: The aim of this study was to develop a scale for the detection of ED, as assessed by the female partner. METHODS: Development and validation of the Female Assessment of Male Erectile dysfunction detection scale (FAME) consisted of five stages: (i) two focus group discussions conducted among female partners of ED sufferers; (ii) item construction; (iii) initial content validation to document face validity and reduce number of items; (iv) final selection of items and investigation of concurrent validity and reliability, sensitivity and specificity of the scale in 83 Spanish-speaking couples; and (v) multicenter study conducted in a group of 106 English-speaking couples. Concurrent validity was assessed using Spearman's rho correlation coefficients between FAME and clinical diagnosis, the Sexual Health Inventory for Men (SHIM), and the erectile function domain of the International Index of Erectile Function (IIEF-EF). Reliability was tested using Cronbach's alpha, and sensitivity and specificity was investigated using clinical diagnosis as the gold standard criterion. MAIN OUTCOME MEASURES: Validity, reliability, specificity, and sensitivity of the FAME scale when correlated with SHIM, IIEF-EF, and clinical diagnosis. RESULTS: Qualitative analysis yielded 44 clues; 21 items demonstrated statistical significance as the best discriminating items using a t-test for independent samples. A final scale of six items was tested for validity, reliability, specificity, and sensitivity. FAME correlated significantly with clinical diagnosis (0.791, P < 0.001), the SHIM (0.788, P < 0.001), and the IIEF-EF (0.777, P < 0.001). Additional support for discriminant validity was obtained with receiver operating characteristics analysis. Cronbach's alpha was 0.941. Sensitivity was 96.1% and specificity 86.0%. CONCLUSIONS: Accurate detection of ED in men by the female partner is possible. In this study, FAME demonstrated concurrent validity and very good reliability, as well as excellent sensitivity and specificity.

Gravity cavernosometry and assessment of complete smooth muscle relaxation: helpful in the differential diagnosis of cavernous leakage?

OBJECTIVE: To establish whether the relationship between cavernosal pressures and gravitational pressures of infused liquid during gravity cavernosometry is linear when complete smooth muscle relaxation is achieved and whether the determination of this relationship could be helpful in the differential diagnosis between organic and functional cavernous leakage. METHODS: Gravity cavernosometry was performed in 50 impotent patients. The cavernosal pressure was measured at at least four different gravitational pressures of the infused liquid. RESULTS: A linear relationship was obtained in all patients with normal maximal cavernosal pressure at gravity cavernosometry. A flat or nonlinear relationship was found in those with abnormal maximal pressure, whatever the cause of cavernous leakage. CONCLUSIONS: A linear relationship between cavernosal and gravitational pressures characterizes complete smooth muscle relaxation during gravity cavernosometry. However, the usefulness of the determination of this relationship is not yet established.

Improved minimally-invasive assessment of penile haemodynamics: the combination of colour Doppler sonography and injection-stimulation test.

The aim of this study was to assess the diagnostic value of erotically enhanced penile colour Doppler sonography as a minimally invasive tool to evaluate penile haemodynamics. Colour Doppler sonography was used to study the cavernosal arteries of 135 consecutive impotent patients after intracavernous injection of a vasoactive mixture (injection phase) and after subsequent genital and audiovisual sexual stimulation (stimulation phase). The erectile response was upgraded after the adjunct of genital and audiovisual stimulation in 36% of patients. Colour Doppler assessment performed after the stimulation phase identified 16% of patients as arteriogenic despite normal erections, and 7% of patients falsely diagnosed as venogenic after the injection phase. When colour Doppler sonography and the injection-stimulation test are performed together as a single diagnostic procedure the overall diagnostic accuracy is significantly enhanced.