DIAGNOSIS OF ERECTILE DYSFUNCTION AND SURGICAL TREATMENT OF ITS ARTERIAL FORM

The dissertation is devoted to the diagnosis of erectile dysfunction and the surgical treatment of its arterial form. The work examines the epidemiology and etiology of vasculogenic erectile disorders, as well as contemporary approaches to the examination and therapy of patients. The author clarifies the anatomical variants of arterial blood supply of the penis according to pharmaco-dopplerography data, proposes a classification of the variants of blood supply, and develops a method for Dopplerographic determination of the minute volume of blood flow through the cavernous bodies. Based on the assessment of hemodynamic parameters and the degree of impairment of arterial blood flow, indications for various types of surgical treatment have been formulated. The practical implementation of the method made it possible to expand the indications for surgical treatment and achieve sexual rehabilitation in a significant proportion of patients.

Relevance of the Problem

One of the tasks of contemporary medicine is the improvement of the quality of life of patients. Sexual health throughout life is an integral component of human harmony and well-being. The increase in life expectancy over the last ten years has led to a rise in the number of men with sexual function disorders who seek medical help [64]. Patients who experience certain disorders related to erection suffer not only from sexual dissatisfaction but also from difficulties in their relationships with partners, family, and in the social sphere [112, 134, 102]. According to the Massachusetts Male Aging Study (MMAS) (1994), out of 1,290 men who fully completed the questionnaires, 17% of respondents noted erectile dysfunction as minimal, 25% as moderate, and 10% as complete impotence [108]. The prevalence and severity of erectile dysfunction strictly correlate with age, while at the same time not being an exclusive sign of old age [75, 87, 88, 126]. According to calculations by I. B. McKinley (2000), erectile dysfunction is observed in 150 million men worldwide, and it is assumed that within the next 25 years this figure may double [139]. M. I. Kogan et al. (2005), having examined 660 persons aged 18 to 78 living in the Rostov Region, identified ED before the age of 30 in 13.8% of cases, incomplete ED in 11.9%, among men aged 30–39 ED was detected in 20.9% of cases (of which incomplete ED accounted for 15.7%), among men aged 40–49 ED was noted in 31.5% of men (with incomplete ED at 18.8%), at the age of 50–59 ED was recorded in 39.8% of men (complete and incomplete ED were noted in equal proportions), among men older than 60 ED occurred in more than half of cases, amounting to 61.7% (complete ED accounted for 40.2%) [19]. Among married men the prevalence of ED amounts to 28% overall, while among divorced men this figure reaches 50% [42]. Today, boys with serious health disorders are entering the reproductive period. By the age of majority, deviations in general somatic health are detected in 85%. In fact, a generation is entering life with considerably lower reproductive capabilities, even in comparison with the previous generation [36, 9, 60]. G. L. Bilich (2006) believes that the main causes of impotence in men are: hypodynamia and hypokinesia, improper nutrition, constant sleep deficit, chronic psychoemotional stress, reduction in communication, smoking, alcohol abuse (especially dangerous is beer, which contains phytoestrogens), and xenoestrogens (among which pesticides and plastic decomposition products are particularly dangerous) [4]. O. B. Loran et al. (2000) note that before 1970 erectile dysfunction was regarded as a general symptom of psychogenic disorders or of testosterone metabolism [47]. Subsequently it was proved that the psychogenic factor can cause the development of ED, but organic changes play the leading role in the development of erectile disorders [47]. G. D. Avanesov et al. (2006) state that among the causes leading to ED the organic factor accounts for 67.9%, the psychogenic factor for 32.1%, and the mixed organic-psychogenic factor for 79.2% [49]. According to the Massachusetts study, up to 70% of all erectile disorders are caused by vasculogenic factors [108].

At present, the most valuable diagnostic method for examining patients suspected of having erectile dysfunction of vasculogenic origin is dynamic ultrasound Dopplerography of the penis, which evaluates the hemodynamic parameters of penile erectile function at rest and in various phases of erection after pharmacointracavernous injection of vasoactive drugs [27, 13, 14, 31, 19, 181, 133, 134, 142]. E. B. Mazo et al. (2003), when performing Dopplerography of penile arteries, revealed developmental anomalies in 15.6% of cases, introducing the term "Dopplerographic anomaly of the vascular bed of the penis" [31]. The data obtained by pharmaco-dopplerography of the penis characterize blood flow through a single artery; however, the blood filling of the cavernous bodies may be provided by a larger number of arteries than the two cavernous arteries.

The anastomoses and collateral blood supply of the cavernous bodies according to pharmaco-dopplerography data are insufficiently described in the literature; there are no methods for Dopplerographic measurement of the level of total blood flow through the cavernous bodies of the penis that take into account various anastomoses between arteries.

In the absence of indications for specific treatment of ED, the European Association of Urology recommends adhering to a stepwise approach to the treatment of ED [97]. The "third-line" means of treatment is surgical treatment — penile prosthetics [97]. In the period from 1998 to 2000, in connection with the appearance of phosphodiesterase inhibitors, the rate of implantation of phalloprostheses decreased somewhat, but by 2001 it had already recovered to the level of 1996 and continues to grow [140, 179].

The effectiveness of conservative therapy ranges from 25% to 85% [10, 40, 30, 45, 133, 70, 91, 142, 87, 147].

Despite the fact that the main cause of ED is vasculogenic, opinions on surgical, pathogenetic treatment (revascularization, venous surgery) are divergent, and the authors classify this type of treatment as experimental medicine with effectiveness ranging from 29% to 95% [37, 38, 137, 166, 187, 97].

The prevalence of the disease among the male population, the absence of reliable methods for assessing arterial blood supply of the cavernous bodies of the penis taking into account Dopplerographic anomalies of the vascular bed, the low effectiveness of treatment, and the unjustified refusal of revascularizing operations in patients with erectile dysfunction determined the aim and objectives of the present work.

Aim of the Study

Improvement of the results of treatment of patients with erectile dysfunction of arterial genesis.

Objectives of the Study

1. To develop a method for determining the level of arterial blood flow through the cavernous bodies of the penis, taking into account anatomical variants of vascular bed development;

2. To clarify the anatomical variants of penile blood supply in normal conditions and in various forms of ED according to pharmaco-dopplerography data;

3. To determine the hemodynamic parameters in the penis in normal conditions and in ED of various degrees of severity;

4. Having studied the degree of impairment of arterial blood supply of the penis with regard to the variants of arterial blood flow, to develop indications for various types of surgical treatment.

Scientific Novelty of the Work

A classification of arterial blood supply of the penis is given. For the first time, the relationship between certain variants of penile arterial blood supply and erectile dysfunction has been demonstrated.

For the first time, in order to improve the accuracy of arterial blood flow diagnostics with regard to the variants of blood supply, a method for Dopplerographic determination of the minute volume of blood flow through the cavernous bodies of the penis has been proposed (priority invention application No. 2007114190(015407) of 16 April 2007).

Practical Significance of the Work

Dopplerographic study of arterial blood flow with regard to the volume of blood flow through the cavernous bodies of the penis made it possible to diagnose various types of ED, expand the indications for various types of surgical treatment of patients with erectile dysfunction, and achieve sexual rehabilitation in 90%.

Implementation of the Results of the Study into Practice

The method developed in the dissertation work has been implemented in the Regional Uro-Nephrological Center of the Municipal Healthcare Institution "City Clinical Hospital No. 11".

The main provisions of the dissertation were reported and discussed at a meeting of the Department of Surgical Diseases with a Course in Urology of the Ryazan State Medical University named after I. P. Pavlov, and were presented at the First International Symposium on Plastic Surgery of the Urogenital Region on 13 May 2008 in Moscow.

Publications

Twenty-two scientific works have been published on the topic of the dissertation.

Structure of the Dissertation

The dissertation consists of an introduction, a literature review, materials and methods of research, results of Dopplerographic investigation by the conventional technique, variants of arterial blood supply of the cavernous bodies according to Dopplerography data, assessment of the minute volume of blood flow according to pharmaco-dopplerography data, results of surgical treatment of patients with erectile dysfunction, conclusion, conclusions, and practical recommendations.