The effect of combination treatment with low-intensity shockwave therapy and daily tadalafil on severe erectile dysfunction: a double-blind, randomized, sham-controlled clinical trial.

BACKGROUND: Patients with severe erectile dysfunction (ED) remain the most challenging group in terms of available noninvasive treatment modalities. AIM: The study sought to assess the role of combination therapy with low-intensity shockwave therapy (LiST) and daily tadalafil 5 mg in a highly select group of patients with severe vasculogenic ED through a double-blind, randomized trial. METHODS: Forty-eight sexually active men were randomly assigned to 12 sessions of LiST 3 times weekly and tadalafil 5 mg once daily (n = 34) or sham therapy and tadalafil (n = 17) for 4 weeks. Patients were assessed at 1 and 3 months after completion of treatment. OUTCOMES: Improvement of erectile function was evaluated through the International Index of Erectile Function-Erectile Function domain (IIEF-EF) or 6-item IIEF and the Sexual Encounter Profile (SEP) diary. The primary outcome was the difference between the groups in the IIEF-EF at 3 months after completion of treatment. Secondary outcomes comprised (1) the difference between the groups in the IIEF-EF at 1 month after completion of treatment, (2) the difference between the groups in the "yes" responses to question 3 of the SEP diary at 1 and 3 months, and (3) the treatment-related adverse events. The number of patients attaining a minimal clinically important difference in the IIEF-EF (improvement of at least 7 points) was also assessed. RESULTS: After treatment, the absolute scores in the IIEF-EF were higher in patients receiving LiST and tadalafil vs sham therapy and tadalafil both at the 1-month (12.1 ± 2.4 vs 10.2 ± 1.7; P = .002) and at the 3-month (12.9 ± 2.1 vs 10.8 ± 1.8; P < .001) evaluation. Between the 2 groups, the proportion of "yes" responses to question 3 of the SEP diary was not statistically significant, whereas the number of patients attaining a minimal clinically important difference in the IIEF-EF was statistically significant only at the 3-month evaluation. No adverse events occurred. CLINICAL IMPLICATIONS: Application of LiST in patients with severe vasculogenic ED receiving daily dose tadalafil may further improve erectile function compared with tadalafil as a stand-alone treatment on the short term. STRENGTHS AND LIMITATIONS: Although we provided the first study in the field, severe vasculogenic ED was defined based on medical history and clinical examination and not based on penile ultrasound measures. CONCLUSION: The combination of 12 sessions LiST 3 times weekly and daily tadalafil for 4 weeks led to a 2-point difference in the IIEF-EF compared with sham therapy and daily tadalafil among patients with severe vasculogenic ED after 1 and 3 months from completion of treatment.

Impact of low-intensity extracorporeal shockwave therapy on vascular parameters and sexual function in patients with arteriogenic erectile dysfunction.

Previous published studies have shown an improvement of penile hemodynamic parameters after low-intensity extracorporeal shockwave therapy (Li-ESWT). However, the clinical significance of these findings remains unclear, and definitive selection criteria for Li-ESWT based on preexisting comorbidities have yet to be established. This was an observational study of 113 patients with ED, evaluated between January 2019 and December 2021 in Andrology Unit at the Department of Urology and Renal Transplantation, University of Foggia (Foggia, Italy). Penile dynamic Doppler was performed to evaluate vascular parameters and 5-item version of the International Index of Erectile Dysfunction (IIEF-5) questionnaire was administered to assess the severity of ED. This was repeated 1 month after treatment. Patients with a peak systolic velocity (PSV) <30 cm s -1 were considered eligible for Li-ESWT. Our protocol consisted of 8 weekly sessions with 1500 strokes distributed in 5 different locations along the penis. After treatment, a significant mean (±standard deviation [s.d.]) PSV increase of 5.0 (±3.4) cm s -1 was recorded and 52/113 (46.0%) patients reached a PSV >30 cm s -1 at posttherapeutic penile dynamic Doppler. A clinically significant IIEF-5 score improvement was observed in 7 patients, 21 patients, and 2 patients with mild-to-moderate, moderate, and severe pretreatment ED, respectively. No different outcomes were assessed based on smoking habits, previous pelvic surgery, or use of oral phosphodiesterase-5 inhibitor (PDE5i). On the other side, only 1 (6.7%) in 15 patients with diabetes mellitus showed an IIEF-5 score improvement after Li-ESWT. Shockwave treatment determined a significant increase in PSV and correlated IIEF-5 improvement in ED patients. This advantage seemed particularly evident for moderate ED and was not affected by smoking habits, previous pelvic surgery, and use of PDE5i. Conversely, diabetic patients did not benefit from the treatment.

Role of Lp(a) in patients with erectile dysfunction undergoing angioplasty for symptomatic pelvic artery disease.

Background: Atherosclerotic disease of erection-related arteries is a major reason for erectile dysfunction (ED). Lp(a) has been implied in the pathophysiology of atherosclerosis in the coronary and lower limb arteries. Here, we investigated if Lp(a) plays a specific role in ED due with symptomatic pelvic artery atherosclerosis. Patients and methods: Out of 276 consecutive patients treated for ED with angioplasties on proximal (69%) and distal (31%, distal to Alcock channel) erection-related arteries, 236 patients (age: 62±10 years) of which Lp(a) values were available were retrospectively analyzed. Results: The baseline International Index of Erectile Function-15 (IIEF-15) score was 29±15 and significantly increased to 43±20 (increase: 14±21) after treatment at average follow up of 286±201 days. In 25%, Lp(a) values were elevated to more than 30 mg/dL. Hypercholesterolemia, coronary, lower extremity peripheral, and polyvascular disease were more common in patients with Lp(a) ≥60 mg/dl. Anatomic arterial lesion distribution (proximal/distal), improvement in IIEF-15 and clinically driven re-intervention rate (overall 7%) did not differ between patients with <30, 30-59, and ≥60 mg/dL Lp(a). Conclusions: While angioplasty is an effective therapy for ED of arterial origin in patients with obstruction of erection-related arteries, Lp(a) does not seem to play a major role for clinical outcomes in these patients.

The atherosclerotic cardiovascular disease risk score is a reliable tool to identify patients with arteriogenic erectile dysfunction.

BACKGROUND: The atherosclerotic cardiovascular disease risk score is a validated algorithm predicting an individual's 10-year risk of developing acute cardiovascular events (cardiovascular disease). Patients who suffer from arteriogenic erectile dysfunction are susceptible to developing cardiovascular disease in the future. OBJECTIVES: To apply the atherosclerotic cardiovascular disease score at a homogenous cohort of men with erectile dysfunction undergoing a dynamic penile colour Doppler duplex ultrasound and explore its predictive ability to identify patients with vasculogenic erectile dysfunction at colour Doppler duplex ultrasound. MATERIALS AND METHODS: Complete data of 219 patients undergoing colour Doppler duplex ultrasound were analysed. All patients completed the International Index of Erectile Function. The atherosclerotic cardiovascular disease score and Charlson comorbidity index were applied to the entire cohort. Patients were divided into those with normal vs. pathological parameters at colour Doppler duplex ultrasound. Descriptive statistics were used to explore differences between the two groups. Logistic regression models tested the potential role of atherosclerotic cardiovascular disease to predict arteriogenic and/or venogenic erectile dysfunction. Local polynomial smoothing models graphically displayed the probability of pathological colour Doppler duplex ultrasound parameters at different atherosclerotic cardiovascular disease scores. RESULTS: Overall, arteriogenic erectile dysfunction and venous leakage were diagnosed in 88 (40.2%) and 28 (12.8%) patients respectively. The median (interquartile range) atherosclerotic cardiovascular disease score was 7.7 (3.9-14). Patients with pathologic colour Doppler duplex ultrasound were older (59 vs. 54 years, p < 0.001), had higher Body Mass Index (26.5 vs. 25.6 kg/m2 , p = 0.04), more comorbidities (Charlson comorbidity index ≥ 1) (76.5% vs. 54.4%, p = 0.002) and higher median atherosclerotic cardiovascular disease scores (9.95 vs. 7, p = 0.005), respectively. At logistic regression analysis, a higher atherosclerotic cardiovascular disease risk score was independently associated with arteriogenic erectile dysfunction at colour Doppler duplex ultrasound (odds ratio: 1.03, 95% confidence interval: 1.01-1.08, p = 0.02) after adjusting for Body Mass Index, physical activity, alcohol consumption and severe erectile dysfunction. DISCUSSION: As vasculogenic erectile dysfunction may precede by some years the onset of acute cardiovascular diseases, the rigorous identification of patients with deficient cavernosal arterial blood flow, would definitely allow the implementation of earlier and more effective cardiovascular prevention strategies in men with erectile dysfunction. CONCLUSIONS: The atherosclerotic cardiovascular disease risk score represents a reliable tool to identify patients with arteriogenic erectile dysfunction in everyday clinical practice.

Venous Leak Embolization in Patients with Venogenic Erectile Dysfunction via Deep Dorsal Penile Vein Access: Safety and Early Efficacy.

PURPOSE: This all-comers registry aimed to assess safety and early efficacy of venous embolization in patients with venogenic erectile dysfunction due to venous leak in an unselected cohort. METHODS: Between October 2019 and September 2022, patients with venogenic erectile dysfunction resistant to phosphodiesterase-5-inhibitors were treated with venous embolization using ultrasound-guided anterograde access via a deep dorsal penile vein in a single center. A mix of ethiodized oil and modified cyanoacrylate-based glue n-butyl 2 cyanoacrylate (NBCA) monomer plus methacryloxy-sulpholane monomer (Glubran-2, GEM, Italy) was used as liquid embolic agent. Prior to embolization, venous leak had been verified based on penile duplex sonography and computed tomography cavernosography. Procedural success was defined as technically successful and complete target vein embolization. The primary safety outcome measure was any major adverse event 6 weeks after the procedure. The primary feasibility outcome measure was IIEF-15 (International Index of Erectile Function-15) score improvement ≥ 4 points in ≥ 50% of subjects on 6 weeks follow-up post intervention. RESULTS: Fifty consecutive patients (mean age 61.8 ± 10.0 years) with severe erectile dysfunction due to venous leak underwent venous embolization. Procedural success was achieved in 49/50 (98%) of patients with no major adverse events on follow-up. The primary feasibility outcome measure at 6 weeks was reached by 34/50 (68%) of patients. CONCLUSION: Venous leak embolization via deep dorsal penile vein access using a liquid embolic agent was safe for all and efficacious in the majority of patients with severe venogenic erectile dysfunction on 6 weeks follow-up.

Application of dual-energy CT angiography in diagnosis of arterial erectile dysfunction: new scanning technology, new scanning area.

OBJECTIVES: To explore the value of dual-energy computed tomography (DE-CT) angiography in diagnosis of arteriogenic erectile dysfunction (ED) patients and feasibility of new scanning area that excludes the testis. MATERIALS AND METHODS: Ninety-three patients suspected of suffering arterial ED and 40 health volunteers underwent penile duplex Doppler ultrasound and DE-CT angiography (DE-CTA). The scanning range of DE-CTA covered whole arterial system of pelvis and testis was excluded. Two blinded investigators independently evaluated the arterial system that supplies the penis. RESULTS: Finally, 1596 segments were evaluated and 470 segments were judged to be abnormal. The distribution was: 2 (0.4%) in common iliac artery, 7 (1.5%) in internal iliac artery, 82 (17.5%) in internal pudendal artery, 89 (18.9%) in penile artery, 120 (25.5%) in dorsal artery, and 170 (36.2%) in cavernosal artery. The specificity, sensitivity, positive predictive value, and negative predictive value of DE-CTA in diagnostic were 86.02%, 87.50%, 94.12%, and 72.92%. Besides, the new scan area allowed for effective evaluation of the arteries while excluding the testis. CONCLUSION: DE-CTA can provide unbiased, safe evaluation of the vascular status of the penile bed in patients with ED.

The relationship between serum 25-hydroxy vitamin D and arteriogenic erectile dysfunction.

This study aimed to assess the relationship between 25(OH) levels and erectile dysfunction (ED), particularly arteriogenic ED (A-ED). From September 2020 to January 2022, 150 patients diagnosed with ED by the International Index of Erectile Function-5 (IIEF-5) questionnaire were included. All patients were classified as organic ED and psychological ED by nocturnal penile tumescence and rigidity (NPTR) examination. Organic ED patients were divided into A-ED and NA-ED by penile doppler ultrasound (PDU) examination. Finally, 150 patients complaining of ED were enrolled in our study. 25(OH)D levels were significantly lower in patients with organic ED (18.24 ± 6.04 ng/ml) than in patients with psychogenic ED (20.90 ± 8.79 ng/ml) (p = 0.032). In A-ED and NA-ED, the mean of peak systolic flow velocity (PSV) values was 18.94 ± 5.28 cm/s and 51.57 ± 15.42 cm/s (p < 0.001), and the mean of 25(OH)D was 15.66 ± 5.86 ng/ml and 20.48 ± 5.90 ng/ml, respectively (p < 0.001). The results showed that 25(OH)D levels were positively correlated with IIEF-5 scores and the PSV values in A-ED patients. The 25(OH)D cut-off value differentiating between A-ED and NA-ED was 15.05 ng/ml. Low 25(OH)D levels may be an independent risk factor for ED, especially A-ED. ED patients should routinely undergo serum 25(OH)D level measurement, and 25(OH)D replacement therapy is necessary for patients with low vitamin D levels.

Significance of detailed hematological parameters as markers of arteriogenic erectile dysfunction.

BACKGROUND: Several hematologic parameters have been shown to be strongly associated with cardiovascular disease, yet few studies were conducted to assess their relationship with atherogenic erectile dysfunction. OBJECTIVES: To find out the differences in hematological parameters between patients with atherogenic erectile dysfunction and healthy controls through as comprehensive a hematological examination as possible and try to assess and predict atherogenic erectile dysfunction using possible indicators. MATERIALS AND METHODS: We collected hematological parameters in detail from 105 healthy controls and 183 patients with erectile dysfunction (119 patients with atherogenic erectile dysfunction patients and 64 patients with venous erectile dysfunction) who were selected by nocturnal penile tumescence and rigidity and color duplex doppler ultrasound. RESULTS: Statistically significant differences were found between the atherogenic erectile dysfunction and venous erectile dysfunction groups in platelet to lymphocyte ratio, neutrophil to lymphocyte ratio, and mean platelet volume (all p < 0.01). When comparing atherogenic erectile dysfunction with the healthy population, we found statistically significant differences between the two groups in white blood cell, neutrophil to lymphocyte ratio, platelet to lymphocyte ratio, mean platelet volume, triglycerides, high-density lipoprotein cholesterol, and non-high-density lipoprotein cholesterol (neutrophil to lymphocyte ratio, platelet to lymphocyte ratio, mean platelet volume, triglycerides, and high-density lipoprotein cholesterol, p < 0.01; white blood cell, p = 0.024; non-high-density lipoprotein cholesterol, p = 0.036). Receiver operator characteristic curve analysis showed that neutrophil to lymphocyte ratio and platelet to lymphocyte ratio had the highest diagnostic value (neutrophil to lymphocyte ratio: area under the curve = 0.810, p < 0.001, cut-off = 1.995; platelet to lymphocyte ratio: area under the curve = 0.782, p < 0.001, cut-off = 126.3). CONCLUSION: Several hematological parameters (white blood cell, platelet to lymphocyte ratio, neutrophil to lymphocyte ratio, mean platelet volume, triglycerides, high-density lipoprotein cholesterol, and non-high-density lipoprotein cholesterol) can be considered markers of atherogenic erectile dysfunction, while these parameters were not significantly different in venous erectile dysfunction compared to healthy subjects. This suggests that hematological examinations may be a convenient and effective method to help evaluate and diagnose atherogenic erectile dysfunction.

Is There a Role for Vascular Surgery in the Contemporary Management of Erectile Dysfunction?

Erectile dysfunction management is intended to restore capacity for penile erection. Although effective, none of the currently available treatments approved by the US Food and Drug Administration reverse erectile dysfunction pathophysiology. Penile arterial bypass surgery is intended to restore erectile function without the need for the chronic use of vasoactive medications or penile prosthesis placement. In select cases, venous ligation surgery may be beneficial, but this approach is not supported by the most recent guidelines on erectile dysfunction management. The lack of high-quality research surrounding penile vascular surgery has limited its use.

Diagnostic value of penile color doppler ultrasonography in patients with veno-occlusive erectile dysfunction.

BACKGROUND: The method used in the first assessment of patients with veno-occlusive erectile dysfunction (ED) is penile color doppler ultrasonography (PCDU). However, cavernosography performed following intracavernosal pharmacostimulation is accepted as a more precise method for showing venous leakage. AIMS: The objectives of this study were to compare results obtained from patients undergoing PCDU, and those undergoing cavernosography, and to investigate the diagnostic value of PCDU in the diagnosis. METHODS: A total of 133 patients who presented at the urology clinic due to ED have veno-occlusive dysfunction (VOD) detected as a result of PCDU and underwent cavernosography for further assessment when scheduled for penile embolization. The results obtained were retrospectively evaluated. RESULTS: The mean age of 133 patients with VOD identified as a result of PCDU was 48.7 ± 11.2 years. In cavernosography performed after PCDU, venous leakage was detected in 127 patients (95.49%), while no leakage was found in six patients (4.51%). Bilateral venous leakage was found in 91.34% (n:116), right venous leakage in 5.51% (n:7), and left venous leakage in 3.15% (n:4) of the patients with venous leakage. CONCLUSION: Evaluating the cavernosography results, PCDU alone is often sufficient to diagnose veno-occlusive ED. Cavernosography is a more invasive diagnostic method compared to PCDU that is adequate in cases where venous surgery or embolization is not considered, and cavernosography is not recommended in these patients.

Role of shear wave elastography measured in the flaccid state in predicting arteriogenic erectile dysfunction.

The gold-standard method for diagnosing arteriogenic erectile dysfunction (AED) is the penile Doppler ultrasonography. We proposed a novel method for predicting AED using ultrasonic shear wave elastography (SWE) considering that the former was invasive and variable. A total of 98 male patients were enrolled in our study, referred for ED between December 2018 and October 2020. For comparison, we also included 42 volunteers from the Healthy Physical Examination Center of our hospital. The Penile Doppler Ultrasonography (PDU) and SWE were performed for all patients with the intracavernosal injection (ICI). We named three groups as AED group, nonvascular ED group and healthy controls group. No statistically significant differences were found among the three groups in terms of demographic and clinical characteristics. There were no significant differences in IIEF-5 between AED and nonvascular ED. A significant (r = 0.642, p < 0.0001) positive correlation between flaccid and erectile SWE was observed. With a cut-off value of 13.45 KPa, the area under curve, specificity, and sensitivity of the SWE values under the flaccid state in distinguishing AED from healthy subjects were 0.867, 0.786 and 0.896 respectively. The SWE value in the flaccid state can distinguish the AED from healthy subjects.

Prognostic Indicators for Successful Low-intensity Extracorporeal Shock Wave Therapy Treatment of Erectile Dysfunction.

OBJECTIVE: To assess prognostic factors affecting successful low-intensity extracorporeal shockwave therapy (Li-ESWT) treatment of erectile dysfunction (ED) in patients with vasculogenic ED and to report 30-month follow-up. METHODS: This study was conducted upon 425 patients with vasculogenic ED. Assessment of ED was done using Sexual Health Inventory for Men (SHIM) score. Patients were treated by Li-ESWT using PiezoWave2 (Richard Wolf) device. Successful Li-ESWT was defined as 6-month SHIM score of 22-25. Patients with successful treatment were followed for 30 months. RESULTS: Mean Baseline SHIM scores for the total population studied was 11.8 with a range from 5 to 20. After 6 months from treatment, 220 (51.8%) patients reported satisfactory sexual intercourse. Age, diabetes, hypertension, smoking, obesity, hyperlipidemia, pretreatment SHIM score, and the duration of ED were all found to be significant factors affecting the success of Li-ESWT. At 30-month follow-up, 168 (76.3%) patients from those who responded to Li-ESWT still reported satisfactory sexual intercourse with a SHIM score of 22-25 without using PDE5i. CONCLUSION: Li-ESWT is safe and effective treatment of ED with 30 months success in 39.5% of patients treated. Li-ESWT should be offered to patients with mild-to-moderate ED and not to those with severe ED.

Vasculogenic Erectile Dysfunction: The Impact of Diet and Lifestyle.

Vasculogenic erectile dysfunction has been aptly called the "canary in the coal mine" for cardiovascular disease because it almost always precedes other manifestations of atherosclerotic cardiovascular disease, including myocardial infarction and stroke. It is common, associated with the presence of modifiable cardiovascular risk factors, and impacted by diet and lifestyle choices. This concise review provides an update on the use of dietary and other lifestyle interventions to improve vasculogenic erectile dysfunction and atherosclerotic cardiovascular disease.

Effect of Intracavernosal Injection of Prostaglandin E1 on Duration and Rigidity of Erection in Patients With Vasculogenic Erectile Dysfunction: Is It Dose Dependent?

OBJECTIVE: To assess if the effect of intracavernosal injection of prostaglandin E1 (PGE1) on duration and rigidity of erection is dose dependent in patients with different types of vasculogenic erectile dysfunction (ED)? METHODS: A hundred patients with ED were assigned into 4 groups (n = 25/each); group (A) patients with arteriogenic ED, group (B) patients with veno-occlusive ED, group (C) patients with mixed (arteriogenic and veno-occlusive) ED, and group (D) patients who have only psychogenic ED (control). After intracavernosal injection of PGE1, patients were assessed using penile Doppler ultrasonography and erection hardness score together with calculation of erection duration. The starting dose of PGE1 was 5 µg which was increased to 10 µg and 20 µg as a maximal dose when needed. RESULTS: The mean PSV of patients in groups A, B, C, and D were 24.38 ± 3.3, 37.74 ± 8.28, 22.24 ± 3.85, and 47.76 ± 6.27, respectively. In group D, 88% have achieved the best response at dose of 5 µg while 5.3%, 21.7%, and 0% have achieved the best response at dose of 5 µg in groups A, B, and C, respectively (P < .05 for each). The rest of patients have required either 10 or 20µg to achieve the best response. Patients in group C have required the highest dose of PGE1 to achieve the best response (P < .05). CONCLUSION: Intracavernosal injection of PGE1 in escalating doses have improved the rigidity and duration of erection in patients with different types of vasculogenic ED. Patients with mixed arteriogenic and veno-occlusive ED have required the highest dose of PGE1 to achieve the best response.

Rectification of cavernosal fibrosis and veno-occlusive dysfunction by administration of suberoylanilide hydroxamic acid in a rat model of cavernosal nerve injury: Comparison with a PDE5 inhibitor.

BACKGROUND: Cavernosal fibrosis, which is induced by cavernosal nerve (CN) injury and progresses with time, is the main cause of cavernosal veno-occlusive dysfunction (CVOD) after radical prostatectomy. OBJECTIVES: To determine whether daily oral administration of suberoylanilide hydroxamic acid (SAHA; vorinostat) for 5-weeks from the immediate post-injury period after CN injury would rectify CVOD by suppressing cavernosal fibrosis and normalizing HDAC pathway in a rat model of CN crush injury (CNCI) and to compare the results with those obtained using chronic administration of PDE5-inhibitors (a positive control). METHODS: Fifty-six 12-week-old rats were randomized into the four groups: sham surgery (S), CNCI (I), and CNCI treated with daily administration of 25.0 mg/kg SAHA (V) or 20.0 mg/kg udenafil (P). Group-V and Group-P received the respective treatment for 5-weeks from the following day after CNCI. At 5 weeks after surgery, dynamic infusion cavernosometry (DIC), histological staining, and Western blot analysis were performed. RESULTS: Group-I had a significantly decreased papaverine response, higher maintenance rate or drop rate, lower smooth muscle (SM)/collagen ratio, decreased SM content, and increased protein expression of HDAC2, HDAC3, TGF-ß1, and collagen-1, compared with Group-S. The three DIC parameters in Group-V and Group-P significantly improved compared to those in Group-I. Except for the maintenance rate, the improvement in papaverine response and drop rate in Group-V was not significantly different from that in Group-P. Group-V and Group-P showed the rectification of SM/collagen ratio and protein expression of TGF-ß1 or collagen-1. SM content was improved in Group-P, but not in Group-V. Group-V showed the normalization of protein expression of both HDAC2 and HDAC3, whereas protein expression of only HDAC2 was partially restored in Group-P. DISCUSSION: Treatment strategies targeting the HDAC pathway might be helpful to alleviate CVOD induced by CN injury. CONCLUSIONS: According to our data, chronic administration of SAHA improves post-injury CVOD by suppressing cavernosal fibrosis via rectifying the HDAC/TGF-ß1 pathway in nerve-injured rats, comparable to that with PDE5 inhibitors.

Erectile Dysfunction Resistant to Medical Treatment Caused by Cavernovenous Leakage: An Innovative Surgical Approach Combining Pre-operative Work Up, Embolisation, and Open Surgery.

OBJECTIVE: Thirty per cent of cases of erectile dysfunction (ED)/male impotence are resistant to oral treatment. Half of these cases are due to blood drainage from the corpora cavernosa occurring too soon, due to cavernovenous leakage (CVL). The aim of this study was to report on an innovative treatment scheme combining pre- and post-operative haemodynamic assessment, venous embolisation, and open surgery for drug resistant ED caused by CVL. METHODS: An analysis of prospectively collected data, with clinical and haemodynamic pre- and post-operative assessment, was carried out. Forty-five consecutive patients operated on for drug resistant ED caused by CVL were evaluated pre-operatively and three months post-operatively by pharmacologically challenged penile duplex sonography (PC-PDS), pharmacologically challenged Erection Hardness Score (PC-EHS), and pharmacologically challenged computed caverno tomography (PC-CCT). Follow up consisted of patient interview, PC-PDS, PC-EHS and if needed PC-CCT. RESULTS: Mean patient age was 43.9 ± 12.0 years (range 20-67). Forty-nine per cent of patients had primary ED. Patients with diabetes, a smoking habit, hypercholesterolaemia, and hypertension were 18%, 11%, 9%, and 4%, respectively. Three months post-operatively, PC-EHS increased from 2.0 ± 0.7 to 3.1 ± 0.74 (p < .001), with an EHS of 3 being the threshold allowing for penetration. Deep dorsal vein velocity, a haemodynamic marker of CVL, decreased from 14.2 ± 13.0 to 0.9 ± 3.5 cm/s (p < .001). After a 14.0 ± 10.7 month follow up, the primary success rate (clinical EHS ≥ 3, possible sexual intercourse with penetration, no vascular re-operation, no penile prosthesis implant) was 73.3%. Four patients (9%) underwent successful re-operation for persistent ED and CVL. Accordingly, compared with a possible penetration rate of 8.9% before surgery, 37 patients (secondary success rate: 82.2%) were able to achieve sexual intercourse with penetration. Type of ED (primary vs. secondary) and diabetes had no influence on the results. Thirty-two per cent of patients with secondary success achieved penetration with no medication. CONCLUSIONS: After a 14 month follow up, pre-operative work up, embolisation, and open surgery during the same procedure allowed patients with ED resistant to oral medical to achieve intercourse with penetration.

MODERN ENDOVASCULAR TREATMENT METHODS FOR ERECTILE DYSFUNCTION: A CRITICAL ANALYSIS.

OBJECTIVE: 75% of men with coronary artery disease confirmed by coronarography have erectile dysfunction in history, while 75% of patients with a vascular etiology of ED have significant stenoses in penile arterial vascularization. Patients with coronary artery disease have shown a relationship between the range of the lesions in the coronary vessels and erectile dysfunction intensity. This paper aims at attempting to systematize the knowledge of the benefits and drawbacks of nonsurgical endovascular treatment methods for erectile dysfunction with confirmed vascular causes. It analyzes seven studies which assess the results of erectile dysfunction treatment with percutaneous angioplasty. It also mentions the limitations of the cited works and formulates relevant conclusions. CONCLUSION: Conclusions: The analysis shows that endovascular procedures in erection-related arteries are safe in a specially selected group of men. It is necessary to conduct further studies to define an appropriate group of patients who have a chance of benefiting optimally from the endovascular treatment of erectile dysfunction in a long-term follow-up.

Erectile Dysfunction in Peripheral Vascular Disease: Endovascular Revascularization as a Potential Therapeutic Target.

INTRODUCTION: Erectile dysfunction (ED) affects more than 150 million men worldwide, with deleterious effects on quality of life. ED is known to be associated with ischemic heart disease but the impact of ED in patients with peripheral arterial disease (PAD) is unknown. We assessed the prevalence and severity of ED in patients with PVD. METHODS: Following ethical approval, sequential male patients diagnosed with PAD over a 1-year period following diagnosis of intermittent claudication. The patient demographics and comorbidities were recorded, with the International Index of Erectile Function (IIEF-5) questionnaire used to grade severity of ED. Computed tomographic angiography and severity of stenosis in the proximal vessels and internal pudendal arteries were correlated using a modified Bollinger Matrix scoring system. RESULTS: 60 patients were recruited, most (77.2%) reported erectile dysfunction (52.5% severe, 22.5% moderate). Patients with severe ED were more likely to have 2 or more comorbidities (P = .009). 86.7% with severe ED had bilateral internal pudendal artery stenosis with a mean modified Bollinger score of 17.6. 35.5% of moderate ED patients had bilateral internal pudendal stenosis with a mean Bollinger score of 11.75. There was significant difference in overall scores between moderate and severe erectile dysfunction (p< 0.05), thus indicating a potential link between ED severity and extent of vessel stenosis. CONCLUSION: There is a substantial burden of clinically significant ED among patients with PAD. This study suggests ED should be discussed with all PAD patients and ED may precede a PAD diagnosis. There is scope for endovascular revascularization as a treatment option for ED secondary to arterial insufficiency.

Erectile dysfunction is associated with defective L-cysteine/hydrogen sulfide pathway in human corpus cavernosum and penile arteries.

H2S signaling was proposed to participate in erectile physiology. L-cysteine (CYS)/H2S pathway stimulation causes cGMP-dependent relaxation of human corpus cavernosum (HCC) and penile arteries (HPRA). The aim was to evaluate the impact of ED on CYS/H2S pathway at functional and molecular level in human penile vascular tissues. NaHS- and CYS-induced responses were evaluated in HCC and HPRA from organ donors without ED (NoED, n = 29) and from ED patients undergoing penile prosthesis insertion (n = 45). cGMP accumulation and cystathionine ß-synthase and cystathionine γ-lyase expression were also determined. NaHS-induced relaxations were slightly but significantly impaired in HCC but not in HPRA from ED patients. In contrast, CYS-induced relaxations were markedly impaired in HCC (Emax 67.6 ± 4.9% vs 46.2 ± 4.6%, P < 0.01) and HPRA (Emax 80.8 ± 4.0% vs 48.1 ± 8.6%, P < 0.05) from men with ED. Impairment of CYS-induced responses was observed even after separating diabetic ED patients. In HPRA from ED patients, CYS- but not NaHS-induced vasodilation was significantly associated to endothelial function measured as vasodilatory capacity of acetylcholine (ACh) in these preparations (r2 = 0.481, P < 0.01). Impairment of CYS-induced relaxations was related to significant reduction in CYS-induced accumulation of cGMP in cavernosal tissue. Furthermore, the expression of H2S synthesizing enzymes was significantly reduced in HCC from ED patients with respect to NoED. This was confirmed by immunofluorescence in HCC and HPRA sections. ED involves impairment of CYS/H2S pathway in penile vascular tissues associated with decreased expression of H2S generating enzymes, CBS and CSE. These evidences support a therapeutic potential for modulation of CYS/H2S signaling in the management of ED.