Impotence and Penile Vascular Testing: Who Are These Men and How Do We Evaluate the Etiology and Severity of Their Complaints?

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Abstract
In 1982, during a routine vascular operation, Ronald Virag noted that infusing papaverine into a pelvic artery produced erection in the anesthetized patient. In 1983 a dramatic demonstration of the efficacy of penile self-injection was offered by Giles Brindley, who injected himself in front of an audience at a national meeting. This demonstration that vasoactive injections could produce penile erection without benefit of psychologic or tactile stimulation revolutionized the diagnosis and treatment of erectile dysfunction (ED) by providing the first direct test of penile health and the first specific therapy for impotence. Pharmacotesting consists of intracavemous injection and visual grading of the subsequent erection; pharmacotesting is the most commonly used diagnostic procedure for ED. It is simple, minimally invasive, and performed without monitoring equipment. A positive response (normal rigidity of sustained duration) in a neurologically normal male implies psychogenic impotence, presumably excluding significant vascular pathology. When diagnostic testing is indicated, a penile blood flow study (PBFS) should be performed. The PBFS consists of an injection of vasoactive medicine (usually prostaglandin El) and examination with duplex Doppler ultrasound. Color duplex Doppler ultrasound (CDDU) is the same technology used to search the carotid neck arteries for atheromatous blockages. The PBFS provides an objective, non-invasive evaluation of an erection. The accuracy of PBFS has been proven through comparison to more invasive X-ray testing (cavernosometry-ography and penile arteriography). Introduced in San Francisco in 1985, over a decade of worldwide experience with the PBFS has yielded a set of hemodynamic parameters which permit the physician to distinguish among the various causes of erectile failure: arterial insufficiency, venous leakage, and mixed vascular disease. CDDU is the least invasive and most informative medical technology for diagnosing ED. In this new era of effective oral pharmacotherapy the quick solution to sexual rehabilitation is to swallow a pill. Very often, though, it is the patient's primary goal to know why he is experiencing erectile failure. When oral pharmacotherapy fails, it becomes the specialist's obligation to establish a diagnosis (end organ vascular failure vs. neurologic dysfunction vs. psychosexual dysfunction), classify the severity of that dysfunction, and find a therapy that is not only acceptable to the patient but also addresses his pathology.