Heart & Vascular Institute Physician eNewsletter - Spring 2011
Diagnose This: Making the Diagnosis of PAD in Patient with Erectile Dysfunction
Dan* is 48 and happily married. Until two years ago, he was sexually active without any limitations. Then, he presented with left leg claudication symptoms and erectile dysfunction, despite treatments with Sildenafil (Viagra) up to 100 mg. Dan has a history of smoking, hypertension, hyperlipidemia, coronary artery and peripheral arterial disease. What could be the cause of Dan’s erectile dysfunction?
Examination and Diagnosis
Dan had a physical examination and ankle-brachial test. The physical examination revealed weak pulses in the popliteal, posterior tibial, and dorsalis pedis arteries on the left side. The ankle-brachial index was abnormal for significant peripheral arterial disease (PAD) in Dan’s left leg. Based on these findings and his claudication symptoms, Dan was brought in for angiography (Figure 1). This revealed totally occluded internal iliac arteries on both sides (Arrows).
Dan underwent percutaneous endovascular treatment of the left internal iliac artery via the right groin using standard coronary wires. Four drug-coated stents were placed (Figure 2). A repeat CTA revealed patent internal iliac and pudendal artery on the left two weeks after the procedure.
After two to three weeks, Dan was able to engage in sexual activity without Viagra. His quality of life was significantly improved and he inquired about treatment of the contralateral side (which is not necessary at this point).
Adequate arterial flow is important for the penis to initiate and maintain an erection. Proximal arterial inflow deficiency was first described in 1923 by the French surgeon René Lerihe, who observed that bi-aortoiliac occlusion in patients like Dan with PAD caused impotence due to a failure of perfusion of the corporal bodies. Lack of blood flow results in buttock claudication, gluteal muscle atrophy and impotence. Surgical revascularization of arterial inflow can be performed successfully, but it is limited by the surgical morbidity and the availability of an arterial conduit.
The internal pudendal artery courses as a straight line continuation of the internal iliac artery and can be accessed percutaneously from the contralateral femoral artery. There have been a few reports of percutaneous revascularization of the internal pudendal artery in the pre-stent era. Initial success rates have been limited because of restenosis (recurrent narrowing blood vessels), which cause a return of erectile dysfunction. However, treatment with stents may alter the restenosis rate and provide a more lasting solution for erectile dysfunction. Endovascular treatment of erectile dysfunction worked for Dan. However, it's important to note that improving penile arterial inflow does not treat all cases of erectile dysfunction because of the many causes of this disorder.
*Not his real name