The multidisciplinary approach to vasculogenic impotence

The proper assessment of erectile dysfunction can be objectively accomplished only by examining the vascular, hormonal, neurologic, and psychologic components. The vascular surgeon today requires the ability to participate in multidisciplinary approach to diagnosis and needs an understanding of pelvic hemodynamics to design aortoiliac reconstructions that optimize pelvic blood flow. We perform a history and physical examination carefully designed to evaluate erectile ability and detail vascular involvement. Outpatient serum samples are obtained for hormonal analysis. In the noninvasive vascular laboratory, we measure the penile blood pressure using a 2.5 cm cuff and a 10 MHz Doppler probe. We feel strongly that 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. We perform our pelvic steal test by 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. We screened 54 vascular clinic patients and found 81% to be 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 herein and the implications in aortoiliac surgery are discussed.