Endovascular therapy for vasculogenic erectile dysfunction.

OPINION STATEMENT: Erectile dysfunction (ED) is an important clinical condition that affects a significant proportion of men. Although there are many etiologies for ED, many cases have a vascular basis that is related to inadequate arterial inflow, veno-occlusive dysfunction, or abnormalities in smooth muscle (cavernosal tissue) relaxation. These vascular abnormalities can exist in isolation or combination. Since the advent of phosphodiesterase-5 inhibitor (PDE5i) therapy, the initial management of ED in most cases consists of a brief medical evaluation followed by a trial of PDE5i therapy. However, up to 50% of men have an inadequate response to PDE5i therapy and discontinue therapy. Subsequent therapies for ED are increasingly invasive, including penile injection of vasodilators, vacuum pumps, and penile implants. With increased awareness of ED among clinicians and the growing mechanistic link between ED and atherosclerotic vascular disease, there has been renewed interest in the diagnosis and management of arteriogenic ED. Prior reports in the 1980s described the existence of arterial inflow lesions in patients with ED, and there are a modest number of reports describing the feasibility of revascularization with balloon angioplasty. Despite initial clinical success, enthusiasm for this technique waned, presumably because ED frequently recurred due to restenosis and lack of small vessel endovascular therapies. Recent investigation and the availability of newer tools such as drug-eluting stents have renewed interest in this field. Although conceptually attractive, endovascular therapy for ED presents significant challenges related to unanswered questions such as the prevalence and appropriate diagnostic evaluation of arteriogenic ED, and the safety and feasibility of stent-based therapies in this population. In addition, the evaluation, management, and follow-up of patients with vascular ED require a multi-disciplinary team with specialists in urology, sexual medicine, and vascular medicine. Despite these challenges, the potential for endovascular treatment of these patients remains one of the most exciting areas of investigation in vascular medicine.