Penile revascularization may benefit middle-aged men

Las Vegas-Middle-aged men with erectile dysfunction may benefit from penile microvascular arterial bypass surgery as much as young men do, Boston University researchers reported at the Sexual Medicine Society of North America fall meeting here.

The investigators drew their conclusions from a study of 84 otherwise healthy men whose erectile dysfunction was attributed to vascular damage caused by perineal trauma. The older half of the group (age 32 to 54 years) enjoyed the same benefits from the surgery as the younger half (age 18 to 31) did.

"It was a little bit surprising," said co-author Ricardo Munarriz, MD, associate professor of urology at Boston University. "I always thought that people in their 40s and 50s would not do as well."

Before offering the surgery, Dr. Munarriz and his group took detailed medical and psychological histories of their patients to identify any trauma to the perineum, vascular risk factors, hormonal abnormalities, or other causes of erectile dysfunction. Based on this screening, if patients were determined to be good candidates, the team then used penile Doppler, dynamic infusion cavernosometry, and internal pudendal arteriograms to see if they were anatomically fit for the procedure.

Improvement in scores

To determine whether patients benefited from the procedure, they were asked to complete the International Index of Erectile Function (IIEF), Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS), Center for Epidemiological Survey-Depression (CES-D), and Sexual Distress Scale (SDS) questionnaires before and after the procedure, and the two groups showed an equally high rate of improvement on all of the questionnaires.

In general, the outcomes were good. On the total IEFF scale, younger men's scores jumped 21.3 points, while older men's scores increased 22 points. On the IEFF erectile domain, younger men improved 10.7 points and older men improved 11.1 points.

On the SDS, the improvements were 20.9 points for younger men and 17.0 points for older men, and on the CES-D, younger men improved by 7.2 points and older men, by 6.8 points.

Dr. Munarriz said he still doesn't recommend the surgery for men age 55 and over, even with such screening. The research hasn't been done in this population because the risk factors are even greater and because the surgery isn't as likely to make a difference in these patients' lives, he explained.

"Erectile dysfunction has an amazing impact on younger people in their ability to form relationships," he said.

Older men, who are more likely to be in stable relationships in which erectile dysfunction is not as troubling, can more comfortably take advantage of other treatments, added Jayant Uberoi, MD, a resident at Boston University and the study's lead author.

The surgery is difficult to perform because it requires taking the inferior epigastric artery, which measures only 5 mm, and anastomosing it to the dorsal penile artery using sutures that are one-third the diameter of a human hair.

On the other hand, Dr. Munarriz pointed out, younger men are sometimes denied the surgery because of false assumptions.

"Classically, young men are labeled with psychogenic erectile dysfunction, and that's not fair," he said.

Many types of injury, such as bicycle riding, a fall on a beam or fence, or a kick in the groin, can cause vascular damage that constricts blood flow, and these types of injury are amenable to surgery.