British Journa/ofUro/ogy(1988),61, 151-155 0 19x8 British Journalof Urology Diagnosis and Treatment of Venous Leakage: a Curable Cause of Impotence GORDON WILLIAMS, M. J. MULCAHY, G. HARTNELL and E. KIELY Departments of Surgery and Radiology, Hammersmith Hospital and Ro yal PostgraduateMedical School, London Summary-Sixteen of 149 patients complaining of impotence of a non-neurogenic or endocrine aetiology and with a penile brachial index of >0.7 failed to achieve an erection following intracavernosal injection of 30 mg papaverine and 1 mg phentolamine. All 16 were shown to have a significant venous leak using digital subtraction cavernosography. Nine of the 13 so far operated upon have had a full return of potency. Repeat cavernosography in three failures showed persistent leakage into crural veins in two and non-ligated superficial veins in one. Impotent men with a normal penile brachial index who fail to respond to papaverine and phentolamine have a venous leak, a curable cause of impotence. Surgical access should allow ligation of all identified leaking veins. A penile erection is dependent on an increase in arterial flow, an increase in intracorporeal pressure and venous outflow restriction (Juenemann et al., 1986). A venous contribution to the aetiology of impotence was first recognised by Lowsley and Bray (1936). Venous leakage presenting either as a fistula or abnormal shunting between the corpora cavernosa and the glans can be a cause of impotence (Wagner, 1979). Potency has been restored by reversal of these shunts in some cases by ligation of the deep dorsal veins (Wespes and Schulman, 1985). Although patients with venous leakage often give a history of poorly sustained erections or variation of the erection with position during intercourse, the best method of assessment of functional erectile capacity is the observation of the response to a pharmacologically induced penile erection (PIPE) (Kiely et al., 1987). Many tests have been advocated for the investi- gation of a patient with impotence (Van Arsdalen and Wein, 1983). The adequacy of the arterial inflow can be assessed with 95% accuracy using Read at the 43rd Annual Meeting of the British Association of Urological Surgeons in Edinburgh, July 1987 Doppler studies to determine the penile brachial index (PBI), an index of <0.6 being indicative of impaired arterial perfusion (Jevtich, 1980). The failure to develop a pharmacologically induced erection in the presence of a normal penile brachial index would therefore suggest a diagnosis of venous leakage. To test this hypothesis all men attending a Male Sexual Dysfunction Clinic who fulfilled these criteria were further investigated by intracaver- nosal saline infusion and pressure studies and dynamic digital subtraction cavernosography. The results in these patients were compared with those in a group of impotent mcn with no obvious organic abnormality. Patients and Methods One hundred and eighty-one men referred to our Male Sexual Dysfunction Clinic underwent a full clinical history and examination and measurement of serum testosterone and prolactin. Systolic pres- sure in at least two penile arteries was determined using a paediatric cuff and a 10mHz Doppler probe, and the penile brachial systolic index was calculated. Thirty-two patients with evidence of either a peripheral or autonomic neuropathy were excluded from this protocol because of their 151
Transcript
British Journa/ofUro/ogy(1988),61, 151-155 0 19x8 British Journalof Urology
Diagnosis and Treatment of Venous Leakage: a Curable Cause of Impotence
GORDON WILLIAMS, M. J. MULCAHY, G. HARTNELL and E. KIELY
Departments of Surgery and Radiology, Hammersmith Hospital and Ro yal Postgraduate Medical School, London
Summary-Sixteen of 149 patients complaining of impotence of a non-neurogenic or endocrine aetiology and with a penile brachial index of >0.7 failed to achieve an erection following intracavernosal injection of 30 mg papaverine and 1 mg phentolamine. All 16 were shown to have a significant venous leak using digital subtraction cavernosography. Nine of the 13 so far operated upon have had a full return of potency. Repeat cavernosography in three failures showed persistent leakage into crural veins in two and non-ligated superficial veins in one.
Impotent men with a normal penile brachial index who fail to respond to papaverine and phentolamine have a venous leak, a curable cause of impotence. Surgical access should allow ligation of all identified leaking veins.
A penile erection is dependent on an increase in arterial flow, an increase in intracorporeal pressure and venous outflow restriction (Juenemann et al., 1986). A venous contribution to the aetiology of impotence was first recognised by Lowsley and Bray (1936). Venous leakage presenting either as a fistula or abnormal shunting between the corpora cavernosa and the glans can be a cause of impotence (Wagner, 1979). Potency has been restored by reversal of these shunts in some cases by ligation of the deep dorsal veins (Wespes and Schulman, 1985).
Although patients with venous leakage often give a history of poorly sustained erections or variation of the erection with position during intercourse, the best method of assessment of functional erectile capacity is the observation of the response to a pharmacologically induced penile erection (PIPE) (Kiely et al., 1987).
Many tests have been advocated for the investi- gation of a patient with impotence (Van Arsdalen and Wein, 1983). The adequacy of the arterial inflow can be assessed with 95% accuracy using
Read at the 43rd Annual Meeting of the British Association of Urological Surgeons in Edinburgh, July 1987
Doppler studies to determine the penile brachial index (PBI), an index of <0.6 being indicative of impaired arterial perfusion (Jevtich, 1980). The failure to develop a pharmacologically induced erection in the presence of a normal penile brachial index would therefore suggest a diagnosis of venous leakage. To test this hypothesis all men attending a Male Sexual Dysfunction Clinic who fulfilled these criteria were further investigated by intracaver- nosal saline infusion and pressure studies and dynamic digital subtraction cavernosography. The results in these patients were compared with those in a group of impotent mcn with no obvious organic abnormality.
Patients and Methods
One hundred and eighty-one men referred to our Male Sexual Dysfunction Clinic underwent a full clinical history and examination and measurement of serum testosterone and prolactin. Systolic pres- sure in at least two penile arteries was determined using a paediatric cuff and a 10mHz Doppler probe, and the penile brachial systolic index was calculated. Thirty-two patients with evidence of either a peripheral or autonomic neuropathy were excluded from this protocol because of their
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assumed sensitivity to a penile injection of papav- erine and phentolamine (Kiely et a f . , 1987). The remaining 149 patients received, while lying supine, an intracavernosal injection of papaverine 30 mg and phentolamine 1 mg. Patients were asked to report any facial flushing following the injection. After 3 min they were asked to stand and the penile response observed over 20 min. Sixteen patients (mean age 48.6 years, range 37-63) with a normal PBI (> 0.7) either had no response or developed tumescence only as a result of the injection. A further 10 patients (mean age 46.8 years, range 35- 58) in whom no organic abnormality could be determined, with a normal response to PIPE and normal Doppler studies, were also studied as controls. All 26 patients underwent a passive erection test with saline, and in 14 of these patients simultaneous intracavernosal pressure measure- ment was recorded during the infusion.
For the erection test the lateral aspect of one corpus cavernosum was punctured obliquely with a 21 gauge butterfly needle without anaesthesia. Saline infusion commenced at a rate of 80 ml/min and was increased gradually until an erection had occurred or until the flow rate had reached 300 ml/ min for more than 60 s. If no erection was obtained, the test was repeated twice with massage of the penis by the patient. In those in whom an erection was induced, the flow rate was reduced to the minimum necessary to maintain an erection. The intracavernosal pressure was measured by punctur- ing the contralateralcorpus with a 21 gauge butterfly needle which was connected to a pressure trans- ducer for continuous monitoring.
Digital subtraction dynamic cavernosography was carried out on all patients using a dedicated digital angiography machine (Philips DVI 2). Ioxaglate 320 contrast medium was diluted to half strength and was injected into the corpora using the butterfly needle inserted for the passive erection test. The venous anatomy was demonstrated in the flaccid state initially (Fig. 1) and then during an infusion of saline which either produced a passive erection (Fig. 2) or during the maximum infusion rate of 300 ml/min (Figs 3-5). Images were recorded at 2-s intervals both in the AP and 30 to 40" oblique positions.
Operative Technique Surgery was performed under general anaesthesia and the infrapubic approach was used in all patients. All superficial veins were ligated and divided as far as the superficial inguinal ring on both sides. The deep dorsal vein (or more usually
Fig. 1 Digital subtraction (DS) cavernosogram of a normal patient in the flaccid state showing penile drainage into Santorini's plexus (D) and via superficial veins (C).
Fig. 2 DS cavernosogram during a slow infusion in a normal patient showing an erect penis with filling of the deep dorsal vein (A) and the pelvic veins (B).
the deep dorsal veins) was divided, removing at least 2.5 cm of the vein, taking care to avoid the penile arteries and nerves. All circumflex veins and their tributaries exiting through the tunica were ligated, and the incision deepened into the peri- neum when all veins draining laterally to the cremasteric systems were also divided and ligated. At the end of the procedure a saline infusion test was repeated in 12 of the 16 cases. The suspensory
DIAGNOSIS AND TREATMENT OF VENOUS LEAKAGE 153
Fig. 3 Right anterior oblique projection of DS cavernosogram during control injection without infusion showing multiple deep dorsal vein (G) drainage into Santorini’s plexus (D) and into superficial veins (C).
ligament, which was frequently divided during this procedure, was reconstituted and the wound closed with drainage.
Results
All 16 patients with a normal PBI who failed to respond to the intracavernosal injection of papav- erine and phentolamine were shown to have a significant venous leak using digital subtraction cavernosography (Figs 3-5). Seven of these patients reported variation of their erection with position and five had facial flushing following the intracor- poreal injection of papaverine and phentolamine. No venous leak was observed in the 10 patients with a normal PBI and a normal response to papaverine and phentolamine (Figs 1 and 2). The flow required to induce and maintain an erection in the control group is shown in Table 1. Three of
the patients in this group did not obtain an erection during the first infusion test but did when the infusion was repeated after massaging the penile corpora. Three patients subsequently shown to have a venous leak achieved an erection during the infusion but with a much higher flow rate (Table 1). Thirteen patients did not achieve an erection despite a flow rate of > 300 ml/min. There was no rise in intracorporeal pressure in this group, whereas in the control group the pressure rose to a mean 120 mm mercury during the erection phase. Dynamic cavernosography using AP and oblique views showed the venous anatomy (Fig. 1). During the erection (Fig. 2) the deep dorsal vein could be clearly seen but with minimal flow into the pelvic veins. During infusion in the 16 patients with venous leakage, contrast filled either the deep dorsal vein, the superficial veins or crural veins, or a combination of two or three of these (Table 2). An example of filling of the superficial, crural and deep dorsal veins is shown in Figures 3 ,4 and 5.
Results of Surgery
Thirteen patients have been treated by penile vein ligation with a mean follow-up of 20 weeks (range 1045). Two patients are awaiting surgery and one has refused further treatment. Nine of those operated on are having regular erections permitting intercourse (this was confirmed by an excellent response to PIPE). All claimed to have regained nocturnal erections. One patient had temporary improvement of his potency for the first month after the operation, but has a poor response to PIPE. Three patients had no improvement. Three of the four patients who failed to become potent have been re-studied with digital subtraction dynamic cavernosography. Two show persistent opacification of the crural veins at high flow rates. In one the crural veins were seen to be a site of leakage pre-operatively and in the other the crural veins were not adequately visualised. The third still shows opacification of previously unseen superficial
Table 1 Results of Pressure Infusion Test in Control Patients and in Patients with Venous Leaks ~~
Flow to produce an Flow to maintain an Mean intracaoernosal erection (ml/min) erection (ml/min) pressure (mm Hg)
Table 2 Site of Venous Leakage during Infusion of Contrast Medium
No. q/’ patients Deep dorsal Superficial Crural
3 + + + 4 + + 3 + 4 + 1 + + Not adequately
1 + - Not adequately
- - -
+ -
visualised
visualised
veins and of veins draining into the plexus of Santorini.
Four patients developed oedema of the penile shaft and glans following operation ; this resolved satisfactorily. Three patients had temporary numb- ness and tingling along the penile shaft which lasted up to 5 weeks. No other significant side effects were seen.
Discussion
Until recently the only satisfactory treatment for erectile impotence was the insertion of a penile prosthesis and even in large series significant complications occurred in 8 to 40% of patients, depending on the complexity of the prosthesis (Kaufman et al., 1982). Alternative, less invasive therapies are now available using vacuum devices (Perry et al., 1986) or the intracavernosal injection
Fig. 5 Infusion DS cavernosogram showing leakage into deep dorsal vein (A), crural veins (F), superficial veins (C) and Santorini’s plexus (D).
of vasoactive compounds (Zorgniotti and Lefleur, 1985; Kiely et al., 1987). With the increasing availability of such therapies it is essential that an accurate diagnosis is made. Many tests of erectile function have been advocated (Van Arsdalen and Wein, 1983). In this study the adequacy of penile arterial perfusion has been simply assessed using Doppler studies to determine the adequacy of arterial inflow by calculation of the penile brachial systolic index (PBSI). The ability of the penis to become erect was assessed in patients without neurological abnormalities by determining their response to the intracorporeal injection of papav- erine and phentolamine. It has been shown in previous studies that the erectile response to papaverine and phentolamine is greater than papaverine alone irrespective of the diagnosis and penile brachial systolic index (Kiely et al., 1987). On this basis we assumed that patients with a normal PBSI > 0.7 who failed to develop an erection with papaverine and phentolamine had significant venous leakage; this has proved correct. All 16 patients who fulfilled these criteria were shown to have significant leakage using digital subtraction cavernosography. Only seven of these patients reported, after direct questioning, variations in erectile strength with position and five developed facial flushing as a result of direct leakage of papaverine and phentolamine into the systemic circulation following injection into their corpora.
in whom no organic cause for their impotence could
Fig. 4 DS cavernosogram during an infusion showing leakage into superficial veins (C), internal ydendal veins (E) and Santorini’s plexus (D). (AP projection).
No such history was obtained from the 10 patients
DIAGNOSIS AND TREATMENT OF VENOUS LEAKAGE 155
be determined. Thirty-two patients were excluded from this study because of proven neurological abnormalities. All of these patients underwent a pharmacologically induced penile erection with a reduced dose of papaverine to avoid problems of prolonged erections. All developed a satisfactory erection and we concluded that there were no leaks in these patients. However, two of the 16 patients in this series who proved to have a leak were also diabetic and this was the original diagnosis as a cause of their impotence.
Although saline infusion studies were performed on all patients and cavernosal pressure studies in the majority, the results provided little extra diagnostic information and could have been mis- leading in the three control patients who failed to achieve an erection after the first infusion of up to 300 ml/min. These three patients achieved an erection only after penile massage. The flow required to achieve an erection in the control group was a mean of 125 ml/min and was similar to that reported by Buvat et al. (1986), as was the flow required to maintain the erection. Three patients with leaks required a significantly higher flow (mean 265 ml/min) to achieve an erection and the remaining 13 did not achieve an erection despite flows exceeding 300 ml/min.
Digital subtraction dynamic cavernosography has considerable advantages over other techniques used to investigate structural abnormalities or abnormal venous leakage. Far less contrast media and infusion fluid are required and with subtraction of the pelvic bones the abnormal veins are easily seen. The ability to review the image rapidly ensures that there has been adequate demonstration of abnormal draining veins. By combining this with AP and oblique views, the normal venous anatomy and the sites of leakage were easily identified. In the normal flaccid state, blood was seen to drain from the penis via the deep dorsal vein to Santorini’s plexus, superficial veins into the external iliac system and the crural veins into the internal pudendal and internal iliac system. Although venous outflow constriction is necessary for an erection, this is not complete, and filling of the deep dorsal vein and pelvic vein occurs despite the erect penis. Of the 16 patients with a leak, only three leaked solely into the deep dorsal vein, the remaining 13 into combinations of the three major draining systems. This undoubtedly accounts for the failure in both this series and that of Wespes and Schulman (1985) to obtain 100% success with surgical ligation. The contribution of each system to the venous leak is probably variable. Although
the majority of leaking veins could be reached using the surgical approach described, it is unlikely that all leaking crural veins were ligated, though potency was still restored in some. In some patients ligation of the crus of each corpus cavernosum may be required (Bar-Moshe and Vandendris, 1987). This study shows the value of simple diagnostic tests, i.e. Doppler studies, to assess arterial inflow and the response to pharmacologically induced penile erec- tions as a measure of venous outflow constriction in the diagnosis of this treatable cause of impotence.
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The Authors Gordon Williams, MS, FRCS, Consultant Urologist. M. J. Mulcahy, FRCSI, Registrar in Urology. G. Hartnell, MRCP, FRCR, formerly Senior Registrar, Depart-
ment of Urology. Now Consultant Radiologist, Royal Infir- mary, Bristol.
E. Kiely, FRCSI, Registrar in Urology, Meath Hospital, Dublin.
Requests for reprints to: Gordon Williams, Department of Surgery, Hammersmith Hospital, Du Cane Road, London W12 OHS.
