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Doctor's Information

Name : Morteza, Hamidreza
Family : Sanei Taheri, Haghighatkhah
Affiliation :Radiology Department, Shohada Tajrish Hospital, SBMU
Academic Degree : Associate Professor of Radiology
Email : This email address is being protected from spambots. You need JavaScript enabled to view it.
Resident : Mohsen Zakavati

Case Section

Interventional Radiology

Patient's Information

Gender : Male
Age : 30

Clinical Summary

Different cases with prior history of pelvic fracture presented with erection dysfunction.

Imaging Findings

1st image>>Rt. internal pudendal A. angiogram: Abrupt termination of the dorsal penile artery on the right.
2nd image>> Lt. internal pudendal A. angiogram: Normal left dorsal artery of the penis, Abrupt termination of the cavernosal artery on the left is seen. Bulbourethral A. is absent. 3rd image>>Lt. internal pudendal A. angiogram: Proximal cut off in dorsal A. of the penis. Filling of the distal aspect of the left dorsal penile artery via collaterals, Two cavernosal arteries arising from the Left common penile artery, Normal blush of corpus spongiosum, extravasation from the cavernosal artery, normal bulbourethral A. and post. Scrotal A. is noted.
4th image>> Rt. internal pudendal A. angiogram: Normal right dorsal artery of the penis and cavernosal A. is noted. Bulbourethral A. is absent.
5th image>> Lt. internal pudendal A. angiogram: Normal left dorsal artery of the penis and Normal blush of corpus spongiosum is present. Cavernosal A. and bulbourethral A. is absent. Pelvic fixation device is noted.
6th image>> Rt. internal pudendal A. angiogram: all penile arteries are absent.
7th image>> Lt. internal pudendal A. angiogram: all penile arteries are absent.
8th image>>Rt. internal pudendal A. angiogram: all penile arteries are absent. Normal blush of corpus spongiosum and Pelvic fixation device is noted.

Differential Diagnosis

Multiple factors may be responsible for ED including, vascular, endocrine, neurologic, and psychiatric etiologies.

Final Diagnosis

Arterial Erection Dysfunction.

Discussion (Related Text)

Erectile dysfunction (ED) is defined as the inability to achieve and maintain an erection sufficient to allow for satisfactory sexual intercourse. ED is a common condition, impacting up to 30 million men in the United States. Ten percent of these men are between the ages of 18-59. Multiple questionnaires and studies have demonstrated that ED significantly affects patient’s quality of life. The incidence of ED will likely increase in the future as men live longer and develop more risk factors. Multiple factors may be responsible for ED including, vascular, endocrine, neurologic, and psychiatric etiologies. ED caused by vascular insufficiency is responsible for approximately 25% of all medically evaluated cases. Common risk factors associated with vasculogenic ED include hypertension, smoking, diabetes, and pelvic irradiation. Focal stenosis or common penile artery occlusion may also occur in men who have sustained blunt pelvic or perineal trauma. While pharmaceutical treatment for patients with ED has been effective, surgical alternatives such as penile artery reconstruction offer a more permanent and curative solution. This procedure is most often used for younger patients who have had penile trauma and injury to the small vessels of the penis. The procedure involves using the inferior epigastric artery to augment arterial inflow to the dorsal penile artery. Pudendal arteriography is an important step in assessing patients with ED. An understanding of the normal and variant anatomy Is necessary for endovascular intervention and surgical planning. Normal anatomy: It is important to start the arterial assessment of ED in the distal aorta. This is true especially when other symptoms may be present and if there is concern for Leriche syndrome. The common iliac artery divides into an anterior and posterior division. Normally the internal pudendal artery is a branch from the anterior division of the internal iliac artery. The pudendal artery traverses the lower part of the greater sciatic foramen coursing below the piriformis muscle. It passes through the foramen and enters the gluteal region. It then re-enters the pelvis by passing behind the ischial spine accompanied by the pudendal nerve and the nerve to obturator internus. It enters the pudendal canal within the ischiorectal fossa in the obturator fascia and passes medially where it exits just inferiorly to the arcuate pubic ligament. This is where the artery divides into two branches -the dorsal penile and cavernosal (deep) arteries of the penis. Procedure: IV conscious sedation is used per protocol. Prior to start of the procedure a Foley catheter is inserted to prevent obstructed visualization of the pelvic arterial anatomy by a contrast filled bladder. An intracavernosal injection of 30mg of papaverine is administered to achieve erection. The papaverine acts to relax the smooth muscle walls of the cavernosal sinusoids, as the muscles relax they are distended with blood

References

1. NIH Consensus Conference. Impotence. JAMA. 1993 Jul 7;270(1): 83-90.
2. Brosman, Stanley. MD Erectile Dysfunction. July 22, 2009. (http://emedicine.medscape.com/article/444220-overview)
3. Glenn, James Francis. Glenn’s Urologic Surgery6th Edition. 2004: 573-581.
4. Secin, Fernando. Anatomy of Accessory Pudendal Arteries in Laparascopic Radical Prostatectomy, The Journal of Urology, 2005, Vol 174, pp.523-526. 5. Miller, Kenneth. The Radiology of Impotence, Radiographics, 1982, 2 pp. 131-152. 6. Pretorius, E. Scott. MR Imaging of the Penis, Radiographics, 2001, 21 pp.283-298. 7. Schunke, Michael. Thieme Atlas of Anatomy, 2006. p. 498
5. Jeffery G. Brooks, Nii-Kabu Kabutey. Pudendal Arteriography for Erectile Dysfunction. Boston University Medical Centure, Boston ,MA. Radiology.

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