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Pudendal Arteriography for Erectile Dysfunction

Jeffery G. Brooks, Nii-Kabu Kabutey, Neeraj Rastogi, Rajendran Vilvendhan, Ducksoo Kim

Boston University Medical Center, Boston, MA

Introduction

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.

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. Next the common femoral artery is cannulated and digital subtraction angiography is obtained in the RAO and LAO projections. This allows for assessment of inferior epigastric arteries as well as a road map for catheterizing the internal pudendal artery. It is important to assess the length, caliber and origin of the inferior epigastric artery. This artery can be used to establish arterial inflow in patients with ED by mobilizing the vessel and anastamosis to the dorsal artery of the penis. If the obturator artery has a common origin with the inferior epigastric then it may not have enough perfusion pressure to supply the increased intracorporal pressure needed to produce erection. Once the internal pudendal artery is cannulated intra-arterial administration of 5mg of phentolamine over 1 minute is performed to improve arterial perfusion. This has been shown to complement the effect of papaverine by inhibiting alpha adrenergic receptors in arterial muscular walls. A Roberts or C2 catheter is placed into the pudendal artery while in the LAO projection. Magnified DSA images are taken to delineate the penile anatomy. These steps are duplicated for injection of the contralateral side. Both left and right internal iliac and internal pudendal angiograms must be evaluated because there is a significant amount of variability in pudendal arterial inflow. Three patterns of penile arterial supply are seen. Type I- arising exclusively from internal pudendal artery. Type II-arising from both accessory and internal pudendal artery. Type III-arising exclusively from accessory pudendal artery. An accessory internal pudendal artery is present in approximately 10% of patients.

Pathologic States and Variants Continued

Right internal pudendal angiogram Arrows show filling of both left and right dorsal penile arteries from this unilateral injection. This is an example of a hemodynamic dominance of the right internal pudendal artery.

Acute Traumatic injuries

Young male with erectile dysfunction after trauma. CT image shows bilateral healed inferior pubic rami fractures. Image on the right shows abrupt end of internal pudendal artery (B) which in this case is post-traumatic. Image on the left normal left internal pudendal(A) and branches. Left obturator angiogram Filling of dorsal artery of the penis via accessory pudendal artery from obturator artery.

Normal anatomy

Inferior epigastric artery normal and variant 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. Inferior epigastric arteries, multiple projections from different patients. A, B - Normal inferior epigastric arteries without early branching. C - Deep circumflex iliac artery, ascending branch. D, E - Variant where 2 inferior epigastric arteries come from a common trunk. F - Inferior epigastric artery. G - Anomalous origin of the obturator artery. The arrow points to the common trunk. Evaluation of the inferior epigastric arteries is a vital part of this evaluation. If the inferior epigastric artery has an early branching pattern or an anomalous origin of the obturator artery then use of this artery for penile arterial reconstruction could result in a steal phenomenon. Blood flows through the path of least resistance. If this artery was used for reconstruction of the penile artery then blood would preferentially flow into the obturator artery and there would be no increase in penile artery inflow. The goal of arterial transfer is to improve vascular inflow to the penis.

A ­ Large amount of extravasation from an acute traumatic injury to the cavernosal artery. This was treated with pledgets of gelfoam. B ­ No extravasation after gelfoam embolization.

Left and right internal pudendal angiogram A ­ Normal left dorsal artery of the penis. B ­ Absence of cavernosal branches arising from the left. C ­ Normal right dorsal artery of the penis. D ­2 cavernosal arteries arising from the R common penile artery.

LAO - Distal Aortagram A ­ Common iliac artery B ­ Internal iliac artery C ­ Superior gluteal artery D ­ Obturator artery E ­ Internal pudendal artery F ­ Inferior epigastric artery G ­ Common femoral Artery

RAO - Internal iliac Angiogram A ­ Internal iliac artery B ­ Lateral sacral artery C ­ Superior gluteal artery D ­ Obturator artery E ­ Internal pudendal artery F ­ Inferior gluteal artery

Example of post reconstruction angiogram

Right Inferior Epigastric Artery Bypass Arrow points to the right inferior epigastric artery that has been mobilized and used as a bypass vessel to the right dorsal penile artery.

Right Internal Pudendal Artery Angiogram A ­ Internal Pudendal artery B ­ Dorsal artery of the penis C ­ Cavernosal artery D ­ Scrotal arterial branches E ­ Blush of contrast in Corpus spongiosum F ­ Artery to glans penis

Left and right internal pudendal angiogram A ­ Abrupt termination of the dorsal penile artery on the left. B ­ Filling of the distal aspect of the left dorsal penile artery via collaterals. C, D ­ Normal right dorsal penile artery and cavernosal branches.

3 images from right pudendal angiogram, 1 image left pudendal angiogram A ­ Lacunar fistula involving the cavernosal artery on the left following trauma. B ­ Tip of the microcatheter on a roadmap image in position for embolization with gelfoam. C, D ­ Post embolization images show no filling of the AV fistula, and patency of the left dorsal artery of the penis. E­ On injection of the right internal pudendal artery, an accessory right internal pudendal is seen filling the AV fistula. F ­ Right dorsal artery of the penis. The right accessory pudendal was embolized and the AV fistula resolved.

Conclusion Pathologic States and Variants

In conclusion, erectile dysfunction is a very prevalent and increasing disorder. It is important to understand normal and variant anatomy for assessment and treatment. Pelvic angiography remains an important step in the diagnosis and treatment of erectile dysfunction.

Left Internal pudendal angiogram The arrow points to a focal narrowing within the cavernosal branch of the common penile artery. No other cavernosal branches are identified.

References

Left and right internal pudendal angiogram A ­ Tapering and mid occlusion of the right dorsal artery of the penis. B ­ Dominant hemodynamic flow to the left dorsal artery of the penis. C, D ­ Cavernosal branches. E ­ Normal blush of corpus spongiosum.

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 Surgery 6th 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

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