Lack of erection capacity

Management of Erectile Dysfunction

Surgical treatment

In patients with significant vascular abnormalities, surgical treatment may be required. Arterial revascularization can be effective in selected patients who are less than 40 years of age, non-smokers and with documented traumatic abnormality.

In these patients, Doppler ultrasound and arteriography must demonstrate a normal vascular tree with localized obstructive arterial lesions. Revascularization is performed using the inferior epigastric artery that is dissected free from the underside from one or both rectus muscles and transferred to the base of the penis.

Microvascular surgical anastomosis is carried out between the inferior epigastric artery and the deep dorsal artery of the penis in an end-to-end or end-to-side fashion. This technique redirects blood from the inferior epigastric artery to the central cavernosal artery and may be effective in as many as 65% of carefully selected patients. Long term data are not currently available to establish the ultimate effectiveness of this treatment modality and it should be limited to centers with significant experience in the diagnosis and treatment of these patients.

Patients with vascular disease, hypercholesterolemia, hypertension or smoking are not candidates for arterial revascularization.

Venoocclusive incompetence is more difficult to treat. In past years venous ligation was carried out for patients with venoocclusive abnormalities. The outcome of these surgical procedures, however, has been poor.

Sustained surgical success has been identified in less than 40% of patients with an additional 40% of patients responding to a combination of surgery and injectable agent.

Postoperative complications including penile shortening, decreased penile sensation, recurrent veno-occlusive incompetence and wound infection and inadequate success rates have limited this surgical option for most patients. Preferred treatments for veno-occlusive abnormalities include oral agents such as sildenafil, intracavernosal injection therapy, vacuum constriction device or penile prosthesis implantation.

Surgically implantable penile prostheses have been successfully used for restoration of erectile function for almost 30 years.

Patient partner satisfaction is usually quite high and is higher than many other forms of treatment for ED.

Many types of penile prosthesis are available classified as either semi-rigid or inflatable. These implants provide satisfactory penile rigidity, normal sensation, erectile size and excellent patient partner satisfaction. Patients should be offered penile prothesis if simpler, less invasive alternatives are inadequate, not well tolerated or contraindicated. Prior to surgery, a careful discussion about the implantation procedure, outcomes, complications and caveats should be held with the patient and partner.

Semi-rigid rod prosthesis

The semi-rigid rod penile prosthesis was the first to be implanted widely for the treatment of ED. A variety of designs continue to be available all of which consist of two flexible rods or cylinders that can be varied in length by trimming or adding measured extensions at the proximal portion to fit the individual patient's measurements. These permanent devices are quite satisfactory for sexual activity although they provide a consistently erect penis when patients are not sexually active and concealment can be difficult. Mechanical malfunction can occur but the principal complication of this design is prosthesis infection.

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