Centers of Excellence in Interventional Cardiology and Radiology

Gentleman

Endovascular Treatment for Erectile Dysfunction (ED)

PROCEDURE WITHOUT SURGERY , 24 HOURS AFTER DISCHARGE!

So far he has treated more than 10.000 cases of benign prostatic hyperplasia!

The most modern equipped angiography room , an exceptional medical team

The simplest method of treating the recetile dysfunction!

Only 24 hours hospitalization

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Generalities

Erectile dysfunction (ED) is defined as a permanent inability to obtain or maintain an erection for sexual intercourse. Difficulties with achieving an erection concern men of all age groups, and very often coexist with common diseases – such as atherosclerosis, hypertension, or diabetes.

More than 300 million men worldwide suffer from ED. The majority of cases stem from vascular problems, including insufficient blood flow from the arteries, and is why researchers have suggested stenting pelvic arteries such as the internal pudendal arteries (IPA) can improve ED and sexual function.

Causes of erectile dysfunction

Erectile dysfunction may have different aetiologies and certain causes are age-related. In the group of teenagers and young men, the problems are usually psychologically-related, mostly connected with insecurities, lack of experience or fear of unwanted pregnancy. In middle-aged men, the main factors of erectile dysfunction are stress, the fact of being overworked, as well as problems in personal relationships. Organic causes, including atherosclerosis or diabetes, are of increasing importance. The organic background in sexual dysfunction starts to dominate with age and is present in most of the patients in their mature years. The largest group includes dysfunction connected with the cardiovascular system and with conditions causing changes in vessels supplying blood to the penis.

1. Psychogenic ED

Factors of erectile dysfunction may be related both to the mental condition of the man, as well as to his relationships. It has been long known that nerves, lack of sexual arousal, as well as decisive stressful situations or depression may lead to the deterioration of erectile function. There are specific situations and emotional states that predispose to this kind of dysfunction. They include:

Fear of sexual intercourse

Depression, stress in everyday life

Fear of unwanted pregnancy and sexually transmitted diseases

Problems with relationship

Previous bad experiences connected with sex

The psychological background of the dysfunction may be suspected in men with so called morning erections or those able to achieve an erection through masturbation. However, it shall be underscored that the term ‘psychogenic erectile dysfunction’ should not be used in case of unknown or uncertain etiology of the disease. The diagnosis is based mostly on a conversation with the patient or on psychological tests and it is usually a diagnosis of exclusion – the patient should not be subjected to psychotherapy before elimination of other possible causes of ED.

2. Organic ED

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Neurogenic: the transmission of impulses to nerve endings in cavernous bodies is disturbed and thus the cascade which leads to the release of relaxants of vascular smooth muscles increasing blood inflow to the penis is not activated. This may be in case of: multiple sclerosis, diabetic neuropathy or in case of injuries ( e.g. of the spinal cord). Neurogenic erectile dysfunction is relatively hard to treat because the nervous system has a limited capability of regeneration, and its diseases are not easy to reverse.

Hormonal: hormonal disorders lead to an impaired production of sex hormones – their blood level is decreased, which results in e.g. loss of sex drive or ability to maintain erection and also, may have a significant influence on the quality of erection. Due to a relatively high prevalence of such disorders, accurate laboratory diagnostics including tests of blood or urine level of sex hormones is important.

Vascular: Vascular causes of erection are detected in the majority of cases. Although vascular ED may follow from an injury or congenital malformation, atherosclerosis still remains the most common cause. Systemic deposition of cholesterol in arteries also concerns the arteries of cavernous bodies. This leads to occlusion of their lumen up to a diameter which inhibits blood inflow necessary for an erection. Moreover, cholesterol deposits in the vessels tend to calcify, which significantly reduces the dilatory potential of the arterial smooth muscles.

Vascular mechanism of erectile dysfunction is very similar to the one seen in coronary disease, infarctions, or brain strokes. Damaged vessels cannot efficiently supply organs with blood, which leads to their ischaemia or loss of function. Taking into account that the diameter of the arteries supplying the penis is lower than the one of coronary arteries, it is common that the problem with sexual function significantly precedes the appearance of changes in the heart or other organs. Therefore, it is so important to conduct a wider range of diagnostic procedures in patients with erectile dysfunction. It has also been shown that diabetes and increased levels of blood glucose are connected with erectile dysfunction.

Medication-induced: psychiatric treatment, hormonal treatment or chemotherapy. However, medicines used in the therapy of hypertension and coronary diseases are of the highest influence. Due to that, a proper selection of drugs, taking into account the patient’s comorbidities, is extremely important.

Other: Sexual dysfunction in men may also be caused by many other factors and conditions, with the most frequent ones being:

– Injuries of sex organs due to trauma or surgery

– Prostate hyperplasia

– Smoking habit

– Alcohol

– Drugs.

Symptoms

One of the first symptoms that might indicate ED is a significant extension of the time needed to obtain an erection, despite the excitement and adequate circumstances.

Other distressing symptoms that should prompt a visit to a specialist may include problems with delayed ejaculation, small amount of semen ejected during an ejaculation or a weaker response to sexual stimulation. Decrease in libido and sexual satisfaction are also characteristic features of erectile dysfunction.

The presence of other diseases such as diabetes, hypertension or arteriosclerosis may suggest organic cause of the problem, whereas some circumstances (i.e. ability to get and maintain an erection during masturbation or morning erections) indicate rather psychological background of ED.

Note that although the underlying cause of dysfunction may be suspected basing on specific symptoms, their presence requires further investigation and careful examination. Without proper diagnosis it is not possible to know the true cause of sexual dysfunction, and thus implement appropriate treatment.

Diagnostics

The most important part of ED diagnostics is surely the anamnesis including detailed information on comorbidities or medicines taken by the patient. Moreover, it is necessary to run blood tests, including the hormonal profile. Apart from a general physical examination, it is also important to carry out a neurological evaluation. An important part, especially in older patients, is the examination of the prostate gland.

These basic examinations should be followed by imaging studies, allowing for a differentiation between psychogenic and organic causes of ED.

The main method still remains the Doppler ultrasound examination, which allows the evaluation of the condition of the vessels carrying blood to and from the penis, and measuring blood velocity in those vessels. The administration of a vasodilator to cavernous bodies of the penis improves the visualisation of the lesions. Measurements of blood velocity after drug administration allow for an indirect assessment of blood flow disturbances in the vessels, for detection of potential malformations.

In case of suspected vascular aetiology, it is recommended to perform computed tomography of abdominal and pelvic blood vessels (so called angio-CT). This specialist examination uses a modern technology and intravenous contrast, for a very detailed image of the status of vessels which deliver blood to sex organs. This is one of the most precise methods of assessment of erectile dysfunction of arterial origin.

There are also tests such as erectometry and nocturnal penile tumescence. They are based on a simple rule – every man should have at least 3 erections in the night, and his penis should increase its volume by at least 11.5 mm. This is where erectiometer is used, which measures the circumference of the penis.

Indications

There are many currently applied methods of ED treatment. They include conservative treatment, surgeries, and psychotherapy. The choice of the most appropriate course of management depends on the aetiology of the dysfunction, its clinical picture, and a joint decision of the specialist and the patient. In some cases, it is possible to combine pharmacology with surgery.

1. Psychotherapy – if the sexual dysfunction has a psychological background, psychotherapy may bring about the desired results.

2. Conservative treatment:

Pharmacological treatment: – phosphodiesterase inhibitors(PDE5 inhibitors: Sildenafil, Vardenafil, Tadalafil).

Testosterone – In patients with erectile dysfunction and decreased level of androgens (i.a. testosterone), oral, intramuscular, or transdermal (patches) supplements of testosterone may be administered.

Other medicines used in the therapy of erectile dysfunction include: pentoxifylline improving blood flow, yohimbine (natural, herbal substance influencing the contractility of the vessels), as well as apomorphine.

Injections to cavernous bodies

3. Mechanical methods: vacuum penis pump: does not cure the cause and is only a symptomatic and supportive measure

4. Surgery

Penile prostheses

Hydraulic penile prostheses

5. Reconstructive surgeries: In case of injured sex organs or their vessels and nerves, it is possible to carry out reconstructive procedures. These are mostly very complicated and technically difficult to conduct procedures, and their effect may be unsatisfactory. However, for many patients, they may be the only therapeutic option of restoring normal erectile function.

6. Intravascular procedures:

Arteriography can aid in the diagnosis of macrovascular causes of ED by demonstrating significant atherosclerotic lesions proximal to the dorsal penile arteries. A reduction of luminal diameter by more than 50% in these vessels is thought to be significant.

While long occlusions and intrapenile lesions are unlikely to benefit from angioplasty, short smooth stenoses (2–3 mm) in the internal pudendal and proximal common penile arteries, where approximately 70% of lesions are found, are amenable to percutaneous transluminal angioplasty (PTA).

Procedure

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One of the recently presented therapeutic methods in the treatment of ED of vascular origin is the endovascular procedure consisting of balloon angioplasty of the iliac and pudental arteries, restoration of their patency and implantation of vascular drug-eluting stents (DES).

The procedure of percutaneous arterial angioplasty in patients with erectile dysfunction is very similar to other intravascular procedures on peripheral arteries if it comes to the course of the intervention, indications, and adverse effects.

Tehnique:

The procedure is performed in catheterism lab and it is done under local or general anesthesia. Thus, after local asepsy and proper anticoagulation, a small inguinal incision made. Through this incision, the physician will introduce a small narrow tube into the femoral artery, then through this tube a catheter will be introduced which will reach the affected artery, under fluoroscopic control (X ray control).

The interventionist will perform an angiogram to define the anatomic features of all erectile-related arteries and the catheter position is checked. Using this catheter, an uninflated balloon is placed at the level of the narrowed artery. Your doctor then inflates the balloon, opening up the narrowed arterial segment and increasing the area available for blood flow. The balloon is then removed. This tehnique is called balloon angioplasty.

Sometimes, instead of balloon angioplasty, your doctor may use some small devices, called stents. Pre-dilatation with a balloon catheter less than or equal to the reference diameter of the artery may be performed, in main to provide adequate lesion assessment and preparation before stent placement. Then, your doctor will release the stent in the narrowed segment of the affected artery.

Is it painful?

No, usually, the intervention is performed under local or general anesthesia.

How long does it take?

The duration of the procedure is about 1-2 hours.

Risks

The complications are reduced by the proper preparation and the continuous surveillance of the patient. Potential complications:

• allergic reactions to administered substances, including renal disfunction

• reactions to anesthetic compounds

• arteriovenous fistulas at the vascular puncture site

• minor bleeding at the vascular puncture site

• fever

• headache, migraine

• infection

• gaseous embolism

Before procedure

The preoperative assessment will establish if the interventional treatment is the best option for yout. Physical examination and imagistic tests are key elements which help making a decision.

Prior to the intervention, the your doctor must be prevented about any history of allergic reactions. Blood tests are taken including hemoglobin level, coagulation, renal function, and other specific tests.

The patient is admitted the day before the intervention, and he should not eat before the procedure.

Your doctor will tell you if you should not use some drugs before the prcedure (e.g. PDE5i).

After procedure

You will be given pain medication for incisional pain or you may have had an epidural during surgery which will help with postoperative pain.

Since the procedure is minimally invasive, the postprocedural recovery is usually very fast. The majority of patients can leave the hospital the following day. Indications about recovery and postprocedural treatment will be clearly specified to all patients.

Physical activity should be normal.

Also, antiagregants drugs (such as Aspirin 100mg and Palvix 75mg ) are required for 6 months after procedure. In some cases (if you are know with conditions like diabetes or cardiovascular diseases) treatment duration may be longer.

Important!

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Erectile dysfunction has an adverse influence not only on sexual performance but also on the patient’s general health state. Very often, it constitutes a specific alarm signal, as it may suggest the presence of other diseases. If you feel that erectile dysfunction may concern you, do not hesitate – have a check-up. Comprehensive diagnostics necessary for planning of an appropriate treatment course, are a key issue in the therapy of erectile dysfunction.

Remember that medicine has made a considerable advance in this field. Men with problems to obtain or maintain erection may receive effective help from specialists who are in possession of successful treatment methods.

Stenting a pelvic artery is safe and appears to be a promising treatment option for erectile dysfunction (ED) in men who do not respond to drug therapy.

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Sună Mesaj