Novel Evidence-Based Classification of Cavernous Venous Occlusive Disease.

PURPOSE: The primary aim of our study was to determine whether an evidence-based rationale could categorize cavernous venous occlusive disease into mild, moderate and severe erectile dysfunction. MATERIALS AND METHODS: A total of 863 patients underwent color duplex Doppler ultrasound from January 2010 to June 2013 performed by a single urologist. We identified a cohort of 75 patients (8.7%) with a diagnosis of cavernous venous occlusive disease based on a unilateral resistive index less than 0.9, and right and left peak systolic velocity 35 cm per second or less after visual sexual stimulation. At a median followup of 13 months patients were evaluated for treatment efficacy. RESULTS: A total of 75 patients with a median age of 60 years (range 19 to 83) and a mean body mass index of 26.3 kg/m(2) (range 19.0 to 39.3) satisfied the criteria of cavernous venous occlusive disease. When substratified into tertiles, resistive index cutoffs were obtained, including mild cavernous venous occlusive disease-81.6 to 94.0, moderate disease-72.6 to 81.5 and severe disease-59.5 to 72.5. Using these 3 groups the phosphodiesterase type 5-inhibitor failure rate (p = 0.017) and SHIM (Sexual Health Inventory for Men) score categories (1 to 10 vs 11 to 20, p = 0.030) were statistically significantly different for mild, moderate and severe cavernous venous occlusive disease. Treatment satisfaction was also statistically significantly different. Penile prosthetic placement was a more common outcome among patients with erectile dysfunction and more severe cavernous venous occlusive disease. CONCLUSIONS: Our retrospective analysis supports a correlation between the phosphodiesterase type 5 inhibitor failure rate, SHIM score and the rate of surgical intervention using resistive index values. Our data further suggest that an evidence-based classification of cavernous venous occlusive disease by color Doppler ultrasound is possible and can triage patients to penile prosthetic placement.

[Dynamic infusion cavernosometry and cavernosography for the diagnosis and classification of venous erectile dysfunction].

OBJECTIVE: To explore the procedures of dynamic infusion cavernosometry and cavernosography (DICC) and their application in the diagnosis and classification of venous erectile dysfunction (VED). METHODS: This study included 103 ED patients, aged 20 to 43 years, highly suspected of VED, with disease courses of 4 months to 6 years. DICC was performed and analyses were made on the results, especially the parameters of flow-to-maintain (FTM) and pressure decay (PD) in the corpus cavernosum. RESULTS: Based on the parameters of FTM and PD, 21 of the patients were normal, 5 were suspected of VED, 39 had mild VED, 25 had moderate VED, and 13 had severe VED. Penile subcutaneous hematoma was found in 4 of the patients, all recovered after 3 to 5 days, with no other complications. CONCLUSION: DICC is a reliable, safe and minimally invasive method for the diagnosis and classification of VED.

Radiologic anatomy of arteriogenic erectile dysfunction: a systematized approach.

INTRODUCTION: Erectile Dysfunction is a highly prevalent disease and there is growing interest in its endovascular treatment. Due to the complexity of the male pelvic arterial system, thorough anatomical knowledge is paramount. We evaluated the applicability of the Yamaki classification with Computerized Tomography Angiography and Digital Subtraction Angiography in the evaluation of patients with arteriogenic Erectile Dysfunction, illustrating the arterial lesions that can cause Erectile Dysfunction. METHODS: Single-center retrospective analysis of the Computerized Tomography Angiography and Digital Subtraction Angiography imaging findings in 21 male patients with suspected arteriogenic Erectile Dysfunction that underwent selective pelvic arterial embolization. Assessment of erectile function was achieved using the IIEF-5. The branching patterns of the Internal Iliac Artery were classified according to the Yamaki classification. The diagnosis of arteriogenic Erectile Dysfunction was based on the presence of atherosclerotic lesions (stenoses and/or occlusions) of the Internal Iliac Artery or the Internal Pudendal Arteries. RESULTS: The mean patient age was 67.2 years; with a mean IIEF of 10.6 points. Computerized Tomography Angiography and Digital Subtraction Angiography findings allowed classification of all the 42 pelvic sides according to the Yamaki classification. Twenty-four pelvic sides were classified as Group A (57%), 9 as Group B (21.5%) and 9 as Group C (21.5%). The Digital Subtraction Angiography detected 19 abnormal Internal Pudendal Arteries (with atherosclerotic lesions) (45%). The Computerized Tomography Angiography detected 24 abnormal Internal Pudendal Arteries (57%). CONCLUSION: Computerized Tomography Angiography and Digital Subtraction Angiography findings of arteriogenic Erectile Dysfunction include stenotic and occlusive lesions of the Internal Iliac Artery and Internal Pudendal Artery. The Yamaki classification is radiologically reproducible and allows easy recognition of the Internal Pudendal Artery in patients with arteriogenic Erectile Dysfunction.

Introdução: A disfunção erétil é uma doença com elevada prevalência existindo crescente interesse na sua terapêutica endovascular. Devido à complexidade do sistema arterial pélvico masculino, o conhecimento anatómico é fundamental. Avaliou-se a aplicabilidade da classificação de Yamaki na avaliação de doentes com disfunção erétil arteriogénica usando a Angiografia Tomográfica Computorizada e a Angiografia Digital de Subtração.Métodos: Análise retrospetiva dos achados imagiológicos de Angiografia Tomográfica Computorizada e Angiografia Digital de Subtração em 21 doentes do sexo masculino, com suspeita de disfunção erétil arteriogénica, que foram submetidos a embolização pélvica seletiva numa única instituição. A função erétil foi avaliada através do IIEF-5. O padrão de bifurcação da Artéria Ilíaca Interna foi caracterizado de acordo com a classificação de Yamaki. O diagnóstico da disfunção erétil arteriogénica foi feita baseado na presença de lesões ateroscleróticas da Artéria Ilíaca Interna e da Artéria Pudenda Interna.Resultados: A idade média foi de 67,2 anos; a média do IIEF foi 10,6 pontos. A Angiografia Tomográfica Computorizada e a Angiografia Digital de Subtração permitiram a classificação de todos os 42 lados pélvicos de acordo com a classificação de Yamaki. Vinte e quatro lados pélvicos foram classificados como Grupo A (57%), nove como Grupo B (21,5%) e nove como Grupo C (21,5%). A Angiografia Digital de Subtração detectou 19 Artérias Pudendas Internas anormais (lesões ateroscleróticas) (45%). A Angiografia Tomográfica Computorizada detectou 24 Artérias Pudendas Internas anormais (57%).Conclusão: Os achados por Angiografia Tomográfica Computorizada e Angiografia Digital de Subtração incluem estenoses e oclusões da Artéria Ilíaca Interna e da Artéria Pudenda Interna. A classificação de Yamaki tem reprodutibilidade radiológica e permite o reconhecimento da Artéria Pudenda Interna em doentes com disfunção erétil arteriogénica.

New classification of anomalous venous drainage using caverno-computed tomography in men with erectile dysfunction.

INTRODUCTION: Venous leak evaluation remains a challenge in many ED patients. Adequate anatomical evaluation may help with optimizing therapeutic strategies. AIM: Propose a new classification of venous leakage using multidetector computed tomography (MDCT) cavernography, after contrast media intracavernous injection (ICI), under pharmacological stimulation. METHODS: Thirty-eight patients gave informed consent for the study: 34 complained of ED, unsatisfied with treatment and suspected to have cavernovenous leak; four having morphological anomalies and needing surgery. Patient's clinical history, including age, vascular risk factors, penile nitric oxide release test, Doppler ultrasound and previous treatments were evaluated. MDCT consisted in: 1-ICI of 1 mL of vasoactive medications containing papaverine, chlorydrate (20 mg), urapidil chlorydrate (2.75 mg) and alprostadil (10 mcg); 2-ICI of 20-60 cc of diluted contrast media (1/3) using 20 cc of Ioprimide (300 mg/mL); 3-Spiral MDCT acquisition and three-dimensional volume rendering. MAIN OUTCOMES MEASURES: Erection degree was assessed using the erection hardness score (EHS); venous drainage was analyzed and deep, superficial veins (SVs), and caverno-spongious communications identified. MDCT findings were compared with clinical data. RESULTS: The deep dorsal vein (DDV) was opacified in 58% of patients and the SV in 50%. Cavernospongious communications were visible in 18.4%. Sixteen percent presented no visible drainage. A new classification of venous drainage anomalies is proposed: A-No visible drainage (N = 8); B-DDV and preprostatic plexus opacification (N = 11); C-Exclusive SV opacification (N = 10); D-Opacification of both SV and DDV (N = 9). All patients (with one exception) in group A quoted 4 at the EHS vs. none in the others groups (P < 0.0001, exact Fisher test). One patient in group A needed venous drainage due to prolonged erection. CONCLUSIONS: MDCT after ICI contrast media was able to differentiate between various venous pathways in men with venous origin ED, leading to a new anatomical classification. Absence of leakage was associated with normal erection under pharmacological stimulation.

Considerations for diagnostic criteria for erectile dysfunction in DSM V.

INTRODUCTION: The Diagnostic and Statistical Manual of Mental Disorders, 4th Ed., text revision (DSM-IV-TR) criteria for erectile disorder have been criticized as multiple grounds including that the criteria lack precision, that the requirement of marked distress is inappropriate, and that the specification of etiological subtypes should be deleted. AIM: The goal of this manuscript is to review evidence relevant to diagnostic criteria for erectile disorder published since 1990. METHOD: Medline searches from 1990 forward were conducted using the terms erectile disorder and impotence. Early drafts of proposed alterations in diagnostic criteria were submitted to advisors. MAIN OUTCOME MEASURE: Evidence regarding modification of criteria for DSM V diagnostic criteria for erectile dysfunction was judged by whether existing data justified the adoption of precise criteria which would lead to homogenous groups for research. Another outcome measure was whether data exist to reliably differentiate fluctuations in normal function from pathological states. RESULTS: The literature review revealed a large literature concerning erectile disorder but minimal evidence concerning an operational definition for this disorder. CONCLUSIONS: It is recommended that erectile disorder be precisely defined in order to clearly differentiate alterations in normal function from a condition requiring medial intervention and to facilitate clinical research. It is specifically proposed that erectile dysfunction be defined as failure to obtain and maintain an erection sufficient for sexual activity or decreased erectile turgidity on 75% of sexual occasions and lasting for at least 6 months. It is also recommended that erectile disorder be defined independently of distress.

Dynamic infusion cavernosometry and cavernosography in diagnosing and classifying venoocclusive dysfunction.

Dynamic infusion cavernosometry and cavernosography (DICC) were performed in 22 patients who were referred with symptoms of partial erection and transient erection and who were diagnosed as deep dorsal venous leakage by means of colour Doppler ultrasonography. We reached the diagnostic values for corporovenous leakage (CVL), also classified them and showed the veins that need to be ligated. With these advantages, DICC is a very cost-effective and safe technique that can be performed routinely in the diagnosis of corporovenous leakage.