Diagnosis
A 47-year-old man was diagnosed with erectile dysfunction due to venous leakage following an urological intervention not further specified 20 years ago. Patient especially complains about insufficient penile rigidity and early penile relaxation during sexual activity. Furthermore, he is a non-responder to PDE-5-inhibitors. Patient was assessed with an International Index of Erectile Function Questionnaire (IIEF-15) score of 43 indicating moderate erectile dysfunction.
Color Doppler Flow Analysis
For patient work-up, venous color Doppler flow analysis was performed using direct pharmacological stimulation with an intra-cavernosal injection of 10 µg prostaglandin E1 resulting in penile tumescence grade E3 (considered not sufficient for sexual intercourse). At 15 minutes post injection (rigid phase), a high systolic flow rate of 50 cm/s (peak systolic velocity; normal <25 cm/s) and a persistent end-diastolic velocity of 11 cm/s (normal <5 cm/s) was found compatible with venous leakage. Arterial color Doppler flow analysis was without pathological findings.
Computed Tomography Cavernosography
For confirmation of diagnosis and anatomical depiction of venous leaks computed tomography cavernosography was performed post intra-cavernosal injection of 10 µg prostaglandin E1 resulting in penile tumescence grade E3. Fifteen minutes post injection a 23-G needle was inserted at the dorso-lateral side of the corpora cavernosum. Graduated injection of normal saline into corpora cavernosum at increasing flow rates up to a flow rate of 0.6 ml/s resulted in penile tumescence grade E4. Subsequently injection of 30 ml 50% saline-diluted non-ionic iodinated contrast medium (300 mg ml-1) with an infusion velocity of 0.6. ml/s was performed. Computed tomography parameters were as follows: 64 × 0.625 mm collimation, gantry rotation time 0.75 s, time resolution 30 ms, pitch factor 0.984. Continuous scanning was performed under real time monitoring of contrast distribution up to the iliohypogastric veins extending from the upper brim of the true pelvis to the most distant level of the penis. The data constructive section thickness was 1 mm with a reconstruction increment of 1 mm for post-processing. For post-processing, multiplanar reformation using maximum intensity projection and volume rendering was applied. This patient demonstrated major venous leakage of paired deep dorsal penile veins via periprostatic veins and internal pudendal veins draining into both iliohypogastric veins (Figure 1). Furthermore, a more peripheral minor venous leak was found with drainage to superficial inferior epigastric veins (Figure 2).
Endovascular Treatment
The treatment strategy for this patient was embolization of major penile venous leakage. The procedure was performed in an angiosuite. The patient was prepared and draped in the supine position. Following local subcutaneous administration of lidocaine 2%, an ultrasound-guide puncture of a penile deep dorsal vein was performed using a stiff 20-G micropuncture set with a 0.018-inch guide wire and 4-French introducer (Cook Inc., Bloomington, Indiana, U.S.A.). The stiff set appears to be advantageous compared to a regular floppier micropuncture set. The introducer was carefully advanced and positioned in close proximity to the radix penis and a diagnostic venogram was acquired confirming venous leakage via periprostatic veins and bilateral internal pudendal veins draining into both iliohypogastric veins (Figure 3). Subsequently, all materials were flushed using 5% glucose solution to preserve catheter patency and prevent its inadvertent adhesion to the vessel wall. Afterwards venous embolization was performed with a slow but steady injection using N-butyl-2-cyanoacrylate (Histoacryl, Braun, Melsungen, Germany) and ethiodized oil (Lipiodol by Guerbet, Zurich, Switzerland) mixed in a 1:3 ratio under Valsalva maneuver and continuous fluoroscopic monitoring (Figure 4). The injection was terminated in time prior to inadvertent distribution of embolization material to the iliohypogastric veins. The total amount of N-butyl cyanoacrylate used in this case was 3 ml. Periinterventional sedation, antiphlogistic and pain medication were administered. The more peripheral minor venous leak draining into superficial inferior epigastric veins was not treated at the time. Whenever necessary, these veins would rather qualify for percutaneous venous sclerotherapy than for embolization since reflux of embolization material into deep dorsal penile veins should be avoided since it may cause phlebitis.
Clinical Outcome
On 4-week follow-up this patient’s erectile dysfunction had resolved and his erectile function was back to normal without additional need for supportive vasoactive medications. Long-term follow-up is pending.