- Email: [email protected]
The Evaluation of Impotence. What is Necessary?
Impotence 832
833
THE EVALUATION OF IMPOTENCE. WHAT IS NECESSARY? *Charles 0. Turk, Leon Lome, and *Daniel Houlihan, Chicago, IL (Presentation to be made by Dr. Lome) Three hundred males were evaluated for erectile dysfunction. Patients were evaluated with psychiatric interview, physical examination and hormonal studies. Snap-gauge, NPT, and vascular penile blood flow studies were employed on an individual basis. 'rhe role of these diagnostic modalities is carefully scrutinized. Data indicate that routine hormonal screening and blood flow studies have not been helpful in identifying a treatable cause of impotence.
SPONGIOSOLYSIS: A NEW SURGICAL TREATMENT OF IMPOTENCE CAUSED BY DISTAL VENOUS LEAKAGE
834
Until quite recently, ligation of the dorsal veins of the penis had been the only effective surgical treatment in cases of erectile dysfunction caused by venous insufficiency of the corpora cavernosa. Failures of this operation can be due to persistent distal venous leakage, consisting of venous shunts between the corpora cavernosa and the corpus spongiosum in their distal portion, which can be demonstrated by cavernosography. These shunts can be closed successfully by spongiosolysis, i.e. by dissecting the distal half of the corpus spongiosum and by isolating the tips of the corpora cavernosa. Out of five patients who underwent spongiosolysis, four regained the ability of erection with the help of intracavernous injection of vasoactive drugs, which was necessary because of concomitant arterial lesions. The only failure proved to be the consequence of persisting venous insufficiency of the deep dorsal vein of the penis. Since none of the patients developed any serious complication, spongiosolysis seems to be a safe procedure in the treatment of distal venous leakage.
835
URODYNAMICS AND THE IMPOTENT PATIENT.
Richard A. Schmidt,
San Francisco, CA. Based on the responses obtained with neurostimulation, the S2 and S3 nerves would appear to have the most impor-
tant neurophysiologic roles in the initiation and maintenance of an erection.
P. Gilbert
These are also the principal con-
trolling nerves for continence and voiding. Given the similarity in innervation, all patients presenting with a principal complaint of impotence should be carefully screened for complaints of voiding dysfunction. Subtle deficiencies in the performance of the pelvic musculature or voiding mechanism may provide significant insight as to the neurologic basis for a patient's impotence, These thoughts are based on the deficiencies noted in patients
studied urodynamically for a voiding problem who had additional significant complaints regarding potency. Urodynamic studies in impotent patients with associated urinary tract symptomatology should be considered.
LJMITATIONS OF NON-INVASIVE STUDIES FDR EVALUATION OF VASCULOGENIC IMPOTENCE. *Stephen L. Brewer and Arnold M. Belker, Louisville, KY (Presentation to be made by Dr.
Brewer) A universally acceptable method for evaluating vasculogenic impotence does not exist. }lany diagnostic tests attempt to correlate direct and derived information with the presence or absence of suspected lesions in the penile arteries. Many operator dependent factors can render ultrasound data useless. Ultraso1.DJ.d techniques may be unreliable due to difficulty locating individual penile arteries. Values derived from ultrasmmd measurements are prone to magnify small into large errors. The recently described pulsed Doppler technique for direct measurement of penile artery blood flow may be unreliable because the small size of the deep arteries requires utilizing the device at or near the limits of its capability. Plethysmography is a crude estimator of total penile blood flow and cannot provide useful data about individual arteries. Likewise, radionucleotide scans, or Xenon washout to assess venous outflow, cannot define flow in the individual arteries. Understanding the concepts of human erection helps interpret the potential sources of error for each test. Maximal penile blood flow occurs during tumescence. Flow in the flaccid and erect states is considerably less than during turescence. It is possible that the constantly changing physical characteristics of the penis during tumescence may make meaningful measurerrent of penile blood flow impossible. We conclude that a minimum evaluation of vasculogenic impotence for now must include a direct assessment of deep artery blood flow with correlation by arteriography to confirm abnonnalities. Selective arteriography remains the gold standard. The technique of pulsed Doppler rreasurement of deep arterial blood flow, with further refinement of equipment and interpretation, potentially could replace arteriography.
312A
833
THE EVALUATION OF IMPOTENCE. WHAT IS NECESSARY? *Charles 0. Turk, Leon Lome, and *Daniel Houlihan, Chicago, IL (Presentation to be made by Dr. Lome) Three hundred males were evaluated for erectile dysfunction. Patients were evaluated with psychiatric interview, physical examination and hormonal studies. Snap-gauge, NPT, and vascular penile blood flow studies were employed on an individual basis. 'rhe role of these diagnostic modalities is carefully scrutinized. Data indicate that routine hormonal screening and blood flow studies have not been helpful in identifying a treatable cause of impotence.
SPONGIOSOLYSIS: A NEW SURGICAL TREATMENT OF IMPOTENCE CAUSED BY DISTAL VENOUS LEAKAGE
834
Until quite recently, ligation of the dorsal veins of the penis had been the only effective surgical treatment in cases of erectile dysfunction caused by venous insufficiency of the corpora cavernosa. Failures of this operation can be due to persistent distal venous leakage, consisting of venous shunts between the corpora cavernosa and the corpus spongiosum in their distal portion, which can be demonstrated by cavernosography. These shunts can be closed successfully by spongiosolysis, i.e. by dissecting the distal half of the corpus spongiosum and by isolating the tips of the corpora cavernosa. Out of five patients who underwent spongiosolysis, four regained the ability of erection with the help of intracavernous injection of vasoactive drugs, which was necessary because of concomitant arterial lesions. The only failure proved to be the consequence of persisting venous insufficiency of the deep dorsal vein of the penis. Since none of the patients developed any serious complication, spongiosolysis seems to be a safe procedure in the treatment of distal venous leakage.
835
URODYNAMICS AND THE IMPOTENT PATIENT.
Richard A. Schmidt,
San Francisco, CA. Based on the responses obtained with neurostimulation, the S2 and S3 nerves would appear to have the most impor-
tant neurophysiologic roles in the initiation and maintenance of an erection.
P. Gilbert
These are also the principal con-
trolling nerves for continence and voiding. Given the similarity in innervation, all patients presenting with a principal complaint of impotence should be carefully screened for complaints of voiding dysfunction. Subtle deficiencies in the performance of the pelvic musculature or voiding mechanism may provide significant insight as to the neurologic basis for a patient's impotence, These thoughts are based on the deficiencies noted in patients
studied urodynamically for a voiding problem who had additional significant complaints regarding potency. Urodynamic studies in impotent patients with associated urinary tract symptomatology should be considered.
LJMITATIONS OF NON-INVASIVE STUDIES FDR EVALUATION OF VASCULOGENIC IMPOTENCE. *Stephen L. Brewer and Arnold M. Belker, Louisville, KY (Presentation to be made by Dr.
Brewer) A universally acceptable method for evaluating vasculogenic impotence does not exist. }lany diagnostic tests attempt to correlate direct and derived information with the presence or absence of suspected lesions in the penile arteries. Many operator dependent factors can render ultrasound data useless. Ultraso1.DJ.d techniques may be unreliable due to difficulty locating individual penile arteries. Values derived from ultrasmmd measurements are prone to magnify small into large errors. The recently described pulsed Doppler technique for direct measurement of penile artery blood flow may be unreliable because the small size of the deep arteries requires utilizing the device at or near the limits of its capability. Plethysmography is a crude estimator of total penile blood flow and cannot provide useful data about individual arteries. Likewise, radionucleotide scans, or Xenon washout to assess venous outflow, cannot define flow in the individual arteries. Understanding the concepts of human erection helps interpret the potential sources of error for each test. Maximal penile blood flow occurs during tumescence. Flow in the flaccid and erect states is considerably less than during turescence. It is possible that the constantly changing physical characteristics of the penis during tumescence may make meaningful measurerrent of penile blood flow impossible. We conclude that a minimum evaluation of vasculogenic impotence for now must include a direct assessment of deep artery blood flow with correlation by arteriography to confirm abnonnalities. Selective arteriography remains the gold standard. The technique of pulsed Doppler rreasurement of deep arterial blood flow, with further refinement of equipment and interpretation, potentially could replace arteriography.
312A