Pudendal artery syndrome with erectile dysfunction: treatment by pudendal canal decompression

Pudendal artery syndrome (PAS) was studied in 10 patients with erectile dysfunction (ED). Ages ranged from 38 to 55 years. All had chronic constipation and straining at stool, absent nocturnal penile tumescence, low penobrachial pressure index (p < .01), low peak flow velocity (p < .001), and a diameter increase (p < .0001) upon duplex ultrasonography screening. Four of the 10 patients had perineal hypoesthesia, prolonged bulbocavernosus reflex (p < .05), and pudendal nerve terminal motor latency (p < .05), and weak anal reflex and EMG activity of the external anal sphincter. The levator EMG activity was reduced in all patients. Intracavernous papaverine injection induced partial erection after a period longer than normal. Selective pudendal arteriography showed narrowing or obstruction of the distal part of the internal pudendal artery (IPA) on both sides with poorly or non-visualized penile arteries. A generalized arterial disease was excluded and pudendal artery compression in the pudendal canal (PC) was suspected as causing ED. The narrow or obstructed part of the IPA corresponds to the part in the PC. Four of the 10 patients had manifestations of pudendal neuropathy in addition to IPA compression. Pudendal canal decompression (PCD) was performed through a perineal approach. ED improved in 8 of the 10 patients 3-6 months postoperatively. Two of the 4 patients who had pudendal arteriopathy combined with neuropathy did not improve. In conclusion, the 10 patients with ED had common clinical and investigative findings that constitute the pudendal artery syndrome. PCD effected improvement in 80% of the cases.