Misdiagnosed and inadequately treated vasculogenic sexual dysfunction affects millions of females worldwide, highlighting the importance of a mostly overlooked pathology. Organic female sexual dysfunction, such as vaginal engorgement and clitoral erectile insufficiency, may be associated with hypogastric atherosclerosis. In the author’s vascular medicine setting, they encountered a case of a post-menopausal female patient with symptomatic common iliac and hypogastric artery occlusion. This case highlights the diagnostic management of atherosclerosis and its secondary clinical manifestations, the differentiation between physiological post-menopausal hormonal changes and pathological vasculogenic dysfunction, as well as currently available endovascular treatment options. The 57-year-old patient presented with symptoms indicative of bilateral peripheral artery disease, Fontaine Stage IIb, along with vaginal dryness and dyspareunia. Upon finding occlusions of the common iliac and hypogastric artery, bare metal stenting of the left distal common iliac artery and percutaneous transluminal angioplasty of the internal iliac artery was performed. At 6-week follow-up, an unlimited pain-free walking distance as well as greatly improved vaginal and clitoral erectile function was reported. Local oestrogen application for a year showed no clinical improvement, whereas a significant difference in vaginal and clitoral erectile function was reported shortly after endovascular revascularisation. Vaginal engorgement and clitoral erection depend on increased blood inflow and pulsatile, non-calcified arterial walls. In females with cardiovascular risk factors, arterial insufficiency of the hypogastric-cavernous bed is an underestimated atherosclerotic manifestation for sexual impairment. In these patients with arteriogenic sexual dysfunction, endovascular therapy using drug-eluting stents may be considered as an effective treatment option.

To analyze the safety and efficacy of additional venous leak embolization after an initial arterial revascularization to treat patients with combined arteriogenic and venogenic erectile dysfunction (ED). Single-center observational study from October 1, 2019, to September 30, 2022, including 26 patients with ED resistant to phosphodiesterase-5-inhibitors (PDE5i) and without significant clinical benefit after arterial revascularization of erection-related arteries. Additional treatment with venous leak embolization was performed 458 ± 424 days after arterial revascularization. Arterial obstruction and venous leak were verified based on color Doppler flow analysis, computed tomography angiography, and computed tomography cavernosography. The primary safety endpoint was any major adverse event 6 weeks after the procedure. The primary feasibility endpoint was defined as an IIEF-6 (International Index of Erectile Function-6) score improvement of ≥ 4 points at 6-week follow-up post intervention. Procedural success was achieved in all patients with no major adverse events on follow-up. The primary feasibility endpoint at 6-week follow-up was reached with 3/26 (11.5

BACKGROUND:Venous leak appears to be the most common cause of vasculogenic erectile dysfunction (ED), which can be treated with venous embolization. Traditionally, conventional cavernosography was used for the diagnosis and treatment planning of venous leak. Recently, computed tomography (CT) cavernosography was introduced as a novel cross-sectional imaging method proposed to be advantageous over conventional cavernosography. We created a novel management algorithm for diagnosing venous leak including CT cavernosography as an imaging modality. In order to provide a broader basis for our management algorithm, a systematic literature review was conducted.MAIN BODY:In this article we systematically review relevant literature on using CT cavernosography for the diagnosis and treatment planning in ED patients with venous leak following the PRISMA selection process. Nine full-text articles were included in the review and assigned a level of evidence grade (all grade II). Two studies (2/9) compared the results of conventional cavernosography with those of CT cavernosography which was superior for site-specific venous leak identification (19.4% vs. 100%, respectively). CT cavernosography is a more detailed imaging method that is faster to perform, exposes the patient to less radiation, and requires less contrast material. In one study (1/9), CT cavernosography was used for diagnostic purposes only. Eight studies (8/9) cover both, diagnostic imaging and treatment planning including embolization (1/9) and sclerotherapy (2/9) of venous leak in patients with venogenic ED. Three studies (3/9) describe anatomical venous leak classifications that were established based on CT cavernosography findings for accurate mapping of superficial and/or deep venous leak and identification of mixed or more complex forms of venous leak present in up to 84% of patients. In addition to treatment planning, one study (1/9) used CT cavernosography also for follow-up imaging post treatment.CONCLUSION:CT cavernosography is superior to conventional cavernosography for diagnosis and treatment planning in patients with ED caused by venous leak (grade II levels of evidence). Consequently, CT cavernosography should be included in management algorithms for ED patients with suspected venous leak.

Purpose: Endovascular therapy of erection-related arteries was shown to be a promising treatment option for patients with severe erectile dysfunction. Purpose of this study was to assess the longer-term safety and clinical success rate of endovascular revascularization of erection-related arteries with the Angiolite BTK stent in patients with arteriogenic erectile dysfunction. Materials and Methods: A total of 147 consecutive men (63.5±9.3 years) with erectile dysfunction due to 345 atherosclerotic lesions underwent endovascular revascularization. Patients received an International Index of Erectile Function (IIEF)-15 questionnaire at 30.3±7.2 months (follow-up [FU] period no less than 18 months) after stenting. An improvement by 4 points in the erectile function domain consisting of 6 questions (IIEF-6) was defined as minimal clinically important difference (MCID). Results: Technical success was achieved in 99% of lesions. One major adverse event occurred after endovascular revascularization. Sixty-eight (46%) patients completed their latest FU at least 18 months following the last intervention. Minimal clinically important difference was achieved in 54% (37/68) of patients. Conclusions: In patients with arteriogenic erectile dysfunction not responding to phosphodiesterase-5-inhibitors (PDE-5-Is), endovascular therapy with a novel thin-strut sirolimus-eluting stent is a safe and effective treatment option during short- and longer-term FU. Clinical Impact Patients with severe erectile dysfunction profit greatly from endovascular therapy of erection-related arteries. Stable clinical outcomes are seen beyond a 1-year timeframe. It is proven that, the drug-eluting stent therapy for atherosclerotic ED in patients who have not responded to PDE-5-I therapy is safe and effective during longer-term follow-up.

Background: The extent of arterial disease in patients with erectile dysfunction (ED) non-responsive to intracavernosal injection of Alprostadil is of importance for therapeutic options. However, published evidence, in particular angiographically validated is scarce. Here we investigated arterial lesion patterns in this specific patient cohort by selective angiography. Patients and methods: A cohort of 239 patients received a clinical and duplex-sonographic workup for ED of suspected vascular origin. Duplex ultrasound of the cavernosal arteries was performed after intracavernosal injection of 10 μg Alprostadil. Consequently, standardized workup included grading of the erectile and determination of peak systolic velocity (PSV) and end-diastolic velocity (EDV) in both cavernosal arteries. PSV-values below 30 cm/sec indicated reduced arterial flow, whereas EDV-values above 15 cm/sec indicated a venous leak of the pudendal veins. All patients with suspected arterial ED based on duplex sonography underwent contrast-enhanced computed tomography. Endovascular therapy was carried out in ED patients not responsive or with significant side effects to PDE-5-inhibitors or Alprostadil by selective angiographic depiction of erection-related arteries. Results: 54 patients with a mean age of 61.2 (±9.8) years underwent angioplasty of erectionr elated arteries. Out of these 48/54 (89%) patients presented with an erection considered insufficient for penetration (E0-E3) subsequent to intracavernous application of 10 μg Alprostadil. 14/48 (29%) patients had bilateral arterial obstructions and 34/48 (71%) had unilateral disease. Commonly affected was the internal pudendal artery (n = 31, 65%), followed closely by the common penile artery (n = 30, 64%). The least affected arteries were the dorsal penile (n = 6, 13%), hypogastric (n = 4, 8%), common iliac (n = 4, 8%), cavernosal (n = 4, 8%), and inferior gluteal (n = 1, 2%) arteries. Conclusions: Arterial obstructions amenable to endovascular revascularization are frequent in patients non-responsive to intracavernosal prostaglandin administration. Therapeutic strategies in ED patients non-responsive to conservative measures should therefore consider endovascular treatment opportunities.

Erektionsstörungen sind eine medizinische Erkrankung mit weitreichender Bedeutung für die betroffenen Männer und ihre Partnerinnen/Partner. Das immer bessere Verständnis der zugrunde liegenden pathophysiologischen Veränderungen ermöglicht heute eine differenzierte, individuelle und in den meisten Fällen erfolgreiche Therapie. Jede/r Urologin/e und speziell jede/r Andrologin/e bzw. Sexualmediziner/in sollte detaillierte Kenntnisse in diesem Gebiet besitzen.

A 27-year-old male patient presented in the emergency department (ED) with right acute abdominal pain, tenderness of the abdominal wall, and abdominal guarding. With suspicion of acute appendicitis, we performed bedside sonography. A blind-ending tubular structure, originating from the base of cecum with the presence of an intraluminal calcified “stone,” with the presence of clear peristalsis was seen. Whether this structure represented the appendix or the small bowel, it was not distinguishable sonographically. A consequent surgical consultation indicated a computer tomography scan, and the finding showed acute appendicitis with appendicolith. An inflamed appendix of 15 cm in length was seen laparoscopically and consequently an appendectomy was performed. The histology confirmed a putrid, ulcero-phlegmonous, and hemorrhagic appendicitis with appendicolith. Postoperatively, the patient made a good recovery without complications. The absence of peristalsis is a well-known criterion for diagnosing acute appendicitis. However, we have shown here, that this should be taken into account with caution, as in rare cases such as this appendicitis can be present with peristalsis.

AIM To analyse the incidental findings during computed tomographic angiography (CTA) diagnostic work-up in patients with arteriogenic erectile dysfunction (ED). PATIENTS AND METHODS The medical records of all patients with suspected arteriogenic ED were entered into a database. Risk factors and underlying comorbidities were also collected. Pathological CTA findings were extracted from the CT readings and entered into the database. Incidental findings on CTA were classified as those requiring immediate medical treatment, requiring deferred medical treatment or of no clinical importance. RESULTS A total of 200 patients underwent CTA for suspected arteriogenic ED. Mean patient age was 59.6 ± 11.7 years. Of these, 181 patients (90.5%) had obstructions of erection-related arteries. In 168 patients (84.0%), CTA showed multiple incidental pathological findings. Eighty-five of 200 patients (42.5%) exhibited incidental findings requiring immediate further medical workup and/or treatment: coronary artery calcification was diagnosed in 75/200 (37.5%), aorto-iliac aneurysms in 8/200 (4%) of patients and incidentally detected embolism in 1/200 patient. Pancreatic and liver tumours were less frequent (incidence 1.5% and 1%, respectively). Incidental findings requiring deferred medical workup and/or treatment were detected in 175/200 patients (87.5%). The findings with the highest prevalence were liver steatosis followed by colon diverticulosis and prostate hyperplasia. Findings of little to no clinical importance were reported in 117 (58.5%) patients. These included uncomplicated renal cysts, spinal degeneration and renal vascular anomalies. Almost every second patient presenting with ED had an incidental finding which required immediate treatment. CONCLUSIONS Incidental findings not directly related to ED were common among patients undergoing CTA scans for suspected arterial obstructions. Coronary artery calcification was the leading finding requiring further medical workup and/or treatment. Thus, the benefit of CTA investigations extends beyond the anatomic description of arterial obstructions of erection-related arteries.

Die erektile Dysfunktion kommt zunehmend häufiger in der Praxis vor und gewinnt an sozioökonomischer Bedeutung. Da sie häufig auch ein Indiz für weitere schwerwiegendere Erkrankungen des Herzkreislaufsystems ist — ein Markersymptom für Arteriosklerose —, sollte die Ursache unbedingt genau abgeklärt werden.