External Mechanical Devices and Vascular Surgery for Erectile Dysfunction

Abstract

Introduction The field of sexual medicine is continuously advancing, with novel outcomes reported on a regular basis. Given the rapid evolution, updated guidelines are essential to inform practicing clinicians on best practices. Aim To summarize the current literature and provide clinical guidelines on penile traction therapy, vacuum erection devices, and penile revascularization. Methods A consensus panel was held with leading sexual medicine experts during the 2015 International Consultation on Sexual Medicine (ICSM). Relevant literature was reviewed and graded based on Oxford criteria to develop evidence-based guideline and consensus statements. Main Outcome Measures The development of clinically relevant guidelines. Results Penile traction therapy is a viable therapy to modestly improve penile length as a primary therapy, before penile prosthesis placement in men with decreased penile length or after surgery for Peyronie's disease. It also might have a role in the acute phase of Peyronie's disease but has inconsistent outcomes in the long-term phase. Vacuum erection devices are effective in creating an erection satisfactory for intercourse, even in difficult-to-treat populations. They also might be used in the post-prostatectomy setting to maintain penile length but have insufficient evidence as a penile rehabilitation therapy. For vasculogenic erectile dysfunction, men with suspected arterial insufficiency can be evaluated with penile Duplex Doppler ultrasonography and confirmatory angiography. Penile revascularization procedures have consistently demonstrated benefits in very select patient populations; however, inadequate data exists to suggest the superiority of one technique. Men with vascular risk factors are likely poor candidates for penile revascularization, although veno-occlusive dysfunction and age are less significant. Therapies for treating primary veno-occlusive dysfunction are not recommended and should be reserved for clinical trials. Conclusions Since the prior ICSM meeting, multiple developments have occurred in external mechanical devices and penile revascularization for the treatment of erectile and sexual dysfunction. Sexual medicine clinicians are encouraged to review and incorporate recommendations as applicable to their scope of practice.

Current diagnosis and management of erectile dysfunction

“…Colour duplex Doppler imaging after an intracorporal injection of a vasoactive drug (eg, alprostadil) provides information about penile haemodynamics and can distinguish arterial insufficiency and veno‐occlusive dysfunction from other causes of ED . All guidelines agree that pharmacoangiography should be reserved for young men with arterial trauma and abnormal duplex haemodynamics or for embolisation of high flow priapism due to an arterio‐lacunar fistula following penile or perineal trauma . DICC involves the perfusion of the corpora cavernosa with saline and a radio‐opaque dye after an intracavernosal injection of a vasodilator drug to determine the efficacy of the veno‐occlusive mechanism and the site of corporal venous leakage.…”

Surgical niche for the treatment of erectile dysfunction

“…A conclusion has been drawn that the effectiveness of penile revascularization surgery remained to be determined due to the disadvantage of a small sample size of 50 patients. A summary of studies evaluating revascularization surgery for the management of ED is adapted in Table …”

“…Current research cannot prove that one procedure surpasses another (LOE = 3; strength of recommendation = C; option). For vascular repair of aortoiliac occlusive disease, the internal iliac artery should be spared to diminish the risk of associated ED (LOE = 3; strength of recommendation = B; recommended) …”

“…proposed a remedy for CVOD through the synergistic effects exerted by venous surgery and medication with oral sildenafil . For the treatment of ED, a summary of evaluations appraising penile venous surgery is adapted in Table …”

“…In 2015, the panel in the fourth Paris International Consultation on Sexual Medicine concluded that venous surgery or embolization is not recommended for the treatment of CVOD; regardless, the procedures can be carried out under the circumstances of clinical research with informed consent, standardized methods of diagnosis and surgical treatment. Standardized questionnaires (IIEF) and long‐term (a minimum of 24 months) follow up are also required (LOE = 4; strength of recommendation = C; option) …”