THE MULTIDISCIPLINARY APPROACH TO VASCULOGENIC IMPOTENCE

Abstract

The vascular surgeon requires the ability to participate in a multidisciplinary approach to diagnosis of human erectile dysfunction and needs an understanding of pelvic hemodynamics to design aortoiliac reconstructions that optimize pelvic blood flow. A history and physical examination carefully designed to evaluate erectile ability and detail vascular involvement is performed. Outpatient serum samples are obtained for hormonal analysis. In the noninvasive vascular laboratory, the penile blood pressure is measured using a 2.5 cm cuff and a 10 MHz Doppler probe. Measuring the right and left cavernosal artery pressures directly and determining the penile/brachial index (PBI) most accurately reflects penile flow. A PBI less than 0.6 is diagnostic of vasculogenic impotence and a PBI greater than 0.75 is normal. The pelvic steal test is performed exercising the thigh and buttock muscle groups, and comparing the PBI before and after exercise. A decrease of 0.1 or more represents a positive steal test. Measurement of nocturnal penile tumescence is valuable in cases where history, physical examination and noninvasive vascular laboratory evaluations do not correspond. A neurologic evaluation may include cystometrography or sacral latency testing when indicated. Psychological screening is performed in all patients; 54 vascular clinic patients were screened and 81% were symptomatic of erectile dysfunction. In this group, 79% had a PBI less than 0.75 and 38% had a positive pelvic steal test. Illustrative cases are presented and the implications in aortoiliac surgery are discussed.