Wolfgang Bähren

Arterial anatomy and arteriographic diagnosis of arteriogenic impotence

One hundred twenty-six bilateral selective arteriographic examinations of the iliopudendal vascular tree were performed after comprehensive multidisciplinary evaluation in patients with chronic erectile dysfunction. Best imaging results were obtained by performing the arteriography under epidural anesthesia after intracavernous injection of a vasoactive drug combination. The arteriography is mandatory prior to revascularization procedures. It is further indicated in primary erectile dysfunction and posttraumatic erectile failure. The importance of cavernosography and selective arteriography in primary erectile dysfunction is stressed. Increasing knowledge about the influence of vasoactive drugs on penile hemodynamics has led to its application in diagnosis and therapy of erectile dysfunction. Pharmacocovernosography, Doppler-ultrasound of penile arteries after intracavernous injection of a vasoactive drug combination, and pharmacoarteriography are refined techniques to prove a vascular etiology of erectile dysfunction. The results of the morphologic studies of the vascular system are correlated with functional testing of erectile capacity by intracavernous application of a papaverinephentolamine drug combination.

Functional Evaluation of Penile Hemodynamics

A multidisciplinary study was performed on 200 consecutive patients with erectile dysfunction more than 1 year in duration, which included a standardized intracavernous injection of a vasoactive substance mixture (15 mg. per ml. papaverine plus 0.5 mg. per ml. phentolamine). The multidisciplinary findings correlated well with the intracavernous dose needed for full erection. The group without pathological hemodynamic findings (36 patients) needed an average of 0.67 ml. and the group with pathological inflow (107) needed an average of 1.07 ml. In the venous insufficiency group (57 patients) only 18 achieved full erections with an average of 2.1 ml. (39 achieved tumescence only to 3 ml.). The results show that standardized intracavernous injection of a vasoactive substance mixture is a useful method to evaluate penile hemodynamics. This pharmacological test appears to be effective in the differential diagnosis of nonvascular and vascular erectile dysfunction.

Primary Erectile Dysfunction

We evaluated 67 patients 18 to 60 years old (mean age 28.5 years) with primary erectile dysfunction (absence of full sustained erections since early childhood or puberty) using a multidisciplinary approach. Organic causes of the erectile dysfunction were found in 57 of the 67 patients (85 per cent): 12 (18 per cent) had neurological, 35 (52 per cent) arteriogenic and 35 (52 per cent) venogenic abnormalities. Psychogenic factors were diagnosed in 11 patients (16 per cent), while in 4 (6 per cent) a classification was not possible. Concomitant psychogenic abnormalities were found in 39 of the 57 patients (68 per cent) with organic primary erectile dysfunction. Our results suggest that primary erectile dysfunction is caused mainly by organic factors. However, for successful therapy the frequent secondary psychogenic abnormalities must be considered.

Diagnostic accuracy of Doppler ultrasound technique of the penile arteries in correlation to selective arteriography

In 63% of 265 patients with erectile dysfunction a relevant arterial inflow disturbance was found by Doppler ultrasound examination. Correlation between Doppler and arteriography in 58 patients showed an accuracy of 95% in detecting penile arteries and an accuracy of 91% in discovering a pathological arterial pattern (arterial anomaly or arteriosclerotic obstruction). In 15 patients the arterial inflow was measured additionally by Doppler ultrasound technique after intracavernosal injection of vasoactive drugs (IIVD) (7.5 mg papaverine and 0.25 mg phentolamine). This technique proved to be more reliable than in the flaccid state and markedly facilitated localization and assessment of pathological changes of the cavernosal arteries.

Percutaneous sclerotherapy of idiopathic varicocele in childhood: a preliminary report.

Of 31 boys 10 to 16 years old referred for treatment of a left grade II or III varicocele 28 underwent percutaneous sclerotherapy. Due to anatomical and technical obstacles sclerotherapy was not possible in 3 boys. At follow-up 1 of 16 boys (6.2 per cent) had a mild recurrence detected by Doppler sonography of the spermatic cord. Percutaneous sclerotherapy had no serious side effects, and proved to be an efficient and convenient treatment of left varicocele in childhood.

Mid-term results of autoinjection therapy for erectile dysfunction

Of over 300 patients with erectile dysfunction, 186 were selected for intracavernosal autoinjection therapy with a standardized papaverine-phentolamine mixture. A total of 156 patients performed 4,813 protocol autoinjections with a minimum of 10 and a maximum of 230 per patient. The dose that induced a full erection at the hospital could be reduced under home conditions by a mean of 35 per cent. Systemic side effects were not observed. The most inconvenient local side effects were prolonged erections in 24 patients in diagnostic use and in 3 patients in therapeutic use. There were treated easily without further consequences.

Erectile dysfunction due to ectopic penile vein.

A total of 86/260 patients with erectile dysfunction had venous leakage as (joint) etiology. In 5 of 86 patients cavernosography showed pathologic cavernosal drainage only via an ectopic penile vein into the femoral vein. After ligation of this pathologic draining vessel, 4 of 5 patients regained spontaneous erectability. One patient with pathologic bulbocavernosus reflex latencies needed intracavernosal injection of vasoactive drugs for full rigidity.

Erectile response to intracavernousinjection of vasoactive drugs after penile prosthesis removal

Two patients with a history of penile prosthesis removal presented for non-prosthetic treatment of their erectile dysfunction. The first patient had a penile implant for two years before it was removed and showed extensive cavernosal fibrosis. He did not respond to intracavernosal injection of vasoactive drugs. The second patient had the prosthesis for four weeks. He showed no evidence of cavernosal fibrosis and responded well to the intracavernous injection. He has been in an intracavernous autoinjection program for more than one year without complications.

Incidence, pathophysiology and treatment of prolonged erections

SummaryProlonged erections (pharmacologically induced erections over 6 hours) are the most inconvenient side effects encountered in the diagnosis and therapy of erectile dysfunction with intracavernous injection of vasoactive drugs. Out of a total of 29 prolonged erections, 26 were seen after diagnostic use in 300 patients and 3 after therapeutic application in more than 4800 protocolled autoinjection of a standardized vasoactive solution (papaverine hydrochloride 15 mg/ml and phentolamine mesylate 0.5 mg/ml). In 25 of these 29 prolonged erections intracavernous injections of the alpha-receptor stimulant metaraminol was done and led to flaccidity in all cases. Another patient with a papaverine-induced erection lasting 26 h did not respond to intracavernous metaraminol and required puncture and aspiration; he lost spontaneous erectability and cavernosal response to vasoactive drugs. Metaraminol was also injected intracavernosally in a further 32 patients with pharmacologically induced full erections: flaccidity was obtained in all patients.