Surgical Management of Erectile Dysfunction

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Vascular surgery: Although options are varied, not everything is for everyone. In fact, two vascular approaches developed over past decades to restore penile blood flow disrupted by disease or trauma are viable for only a select few:

Penile arterial revascularization: This procedure is designed to keep blood flowing by rerouting it around a blocked or injured vessel. Indicated only for young men (under 45) with no known risk factors for atherosclerosis, this procedure is aimed at correcting any vessel injury at the base of the penis caused by adverse events such as blunt trauma or pelvic facture. When such an event leaves a penile vessel too injured or blocked to transfer blood, the surgeon may microscopically connect a nearby artery to get around the site, clearing the pathway so enough blood can be supplied to the penis to enable an erection.

Venous ligation surgery: This procedure focuses on binding leaky penile vessels that are causing penile rigidity to diminish during erection. Because venal occlusion, necessary for sufficient firmness, depends on arterial blood flow and relaxation of the spongy tissue in the penis, this approach is designed to intentionally block off problematic veins so that there is enough blood trapped in the penis to create an appropriate erection. Since long-term success rates are less than 50 percent, this technique is rarely a choice for correcting ED.

In fact, you are not a candidate for either penile vascular surgeries if you have insulin-dependent diabetes or widespread atherosclerosis. You are also not suited if you still use tobacco or experience consistently high blood serum cholesterol levels. Neither of these surgeries will work if you have injured nerves or diseased and/or generalized damaged blood vessels. Also, if you are a candidate, be aware that vascular surgeries are still considered experimental by some urologists and may also not be covered by your insurance.

What can be expected after surgical treatment for erectile dysfunction (ED)?

Most of the best known treatments for ED have excellent track records for being both effective and safe. But in making your choice, make sure to discuss the potential complications of each option with your doctor.

For instance, the good news about a penile prosthesis is that it does not usually affect urination, sex drive, orgasm or ejaculation. But on rare occasions, these semi-rigid, silicone-covered metal rods or hydraulic devices can cause pain or reduced sensation. While injections can initiate erections within 15 minutes to several hours, be aware that they also can produce prolonged or painful ones, not to mention a hardening of connective penile tissue (fibrosis).

At the same time, a vacuum constriction device should take only one to three minutes to do the job, usually with no serious side effects if used properly and limited to 30 minutes.

Sildenafil citrate has a 75 percent success rate, primarily because it is a subtle solution that works within the hour. But on rare occasions it can cause headaches, flushing and indigestion. Also, if you have heart disease or low blood pressure, the Food and Drug Administration (FDA) cautions a thorough examination before getting a prescription.

Penile arterial revascularization can restore function in men, although only a small percentage of them undergo the procedure. While few patients experience postoperative complications, side effects can include penile scarring, numbness and shortening all of which can cause further impotence.

Venous ligation surgery, although rare, is also known to cause penile shortening, along with other problems. Also, improvements with venous ligation surgery may be temporary.

Frequently asked questions:

When is venous surgery for erectile dysfunction successful?

It has been most successful in young men with abnormally draining veins since birth who have never had a full erection. It has also been used in some patients with an injury to the covering tunica albuginea or the corpora cavernosa.

I am interested in vascular surgery, what should I be aware of?

Realize this is not a surgery for everyone. If you meet the criteria mentioned previously, you will want to find a specialist with a track record of having done these microsurgical techniques. Be aware, however, that penile vascular solutions are still experimental; few specialized urologists or vascular surgeons are trained to do either procedure. If your doctor is not one of them, you will need to ask for a referral. You will also want to get a second opinion if this treatment option is recommended, given that there are few patients who are good candidates.

If I choose vascular surgery, what should I ask my surgeon?

Once you have found a surgeon, ask about his or her experience and outcome record with penile arterial revascularization. Make sure that you understand the potential outcomes and possible complications. Also, ask how the particular approach stacks up against other treatment choices for you. For instance, vacuum devices and oral or injection therapies still work for some people. Penile prostheses, the most widely used surgical technique for ED, usually have a more favorable outcome than vascular techniques.

Is age a factor in impotence?

Yes. Data suggest that while not an inevitable part of aging, the risk of impotence increases as we grow older. About 5 percent of men at age 40 complain of the problem, while between 15 and 25 percent at age 65 experience it. Some experts suggest the numbers may be underreported since men are still embarrassed by this physical and psychological issue. However, the reassuring news is that it is treatable in all age groups.

What should I remember about erectile dysfunction?

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Impotence, or the consistent inability to sustain and maintain an erection, is a widespread problem. It may affect as many as 50 percent of men between ages 40 and 70. Luckily, doctors can identify physical causes involving blood flow, nerves or other mechanical issues involving the penis, which can also be addressed with modern technology. In fact, oral drugs, vacuum devices, injectable medications, psychotherapy and even surgery have made impotence very treatable. The promising news is that new drugs are sure to join existing non-invasive treatments while other experimental options, such as gene therapy, are on the horizon. In addition, ongoing modifications of today's standard treatments will eventually improve the picture for impotent men.

Next: Penile Implants

Last updated: 10/05

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