Vasculogenic Erectile Dysfunction Research Articles

Эректильная дисфункция: современное состояние проблемы, методы диагностики и рентгенэндохирургического лечения

According to the Russian Society of Urologists, almost half of men aged 27 to 77 suffer from erectile dysfunction. ED should be considered not only as a medical nosology, but also as a socio-psychological problem with a demographic aspect. There are many methodsfor improving erectile function, including psychological consultations, drug therapy and penile prosthetics. Given the accumulated international experience,the key pointis an accurate diagnosis ofthe cause of erectile dysfunction to determine the correct approach to treatment. Among the many causes of erectile dysfunction, vascular causes are quite common. Given the rapid development of endovascular and low-traumatic approachesto vascular pathology,the technique of improving inflow and outflow obstruction in vasculogenic erectile dysfunction is becoming increasingly obvious and effective. The presented article discussesthe currentstate ofthe issue and possible prospectsfor endovascularsurgery for vascular erectile dysfunction, including significant venous leakage.

Imaging techniques for diagnosing and managing Peyronie disease.

Erectile dysfunction (ED) affects up to 50% of men to some degree and has a variety of physiologic and psychologic causes, but many patients do not seek specialist treatment. One cause of ED is Peyronie disease (PD) defined by the presence of fibrotic plaques in the tunica albuginea which cause painful penile contractures. While diagnosing PD relies on clinical history and a focused history and physical exam, adding imaging studies can identify nonpalpable plaques and any underlying vasculogenic ED to tailor the extent of surgical treatment and determine when implantable penile prostheses are beneficial. After briefly reviewing penile anatomy, erectile function, and the clinical features of PD, this paper describes the imaging findings of vasculogenic ED on Doppler ultrasound (US), followed by the imaging appearance of PD on US, computed tomography (CT), and magnetic resonance imaging (MRI) to increase recognition of this disease and show how imaging can be used as a problem-solving tool for treatment planning and evaluating post-surgical complications, especially malfunctioning implanted devices. By increasing the understanding of how imaging can be used for patients with PD with or without vasculogenic ED before and after treatment, radiologists and urologists can collaborate on patient management.

Modern methods of diagnosis and treatment of vasculogenic erectile dysfunction

A review of modern methods of diagnosis and treatment of vasculogenic erectile dysfunction is presented. Data regarding the diagnostic value of noninvasive and invasive diagnostic techniques are displayed: stamp test, Snap-Gauge test, use of the RigiScan and Androscan-MIT systems, intracavernous injections of vasoactive drugs, Doppler ultrasound of penile vessels, penile angiography, and magnetic resonance arteriography. The advantages and disadvantages of each of these tests are shown. The main directions of conservative and surgical treatment of vasculogenic erectile dysfunction are presented. Notably, early detection of erectile dysfunction with the prescription of appropriate treatment can improve the quality of life of patients and prevent life-threatening complications of cardiovascular conditions.

Efficient use of penile Doppler ultrasound for investigating men with erectile dysfunction.

Vasculogenic erectile dysfunction is the most common type of erectile dysfunction, and penile Doppler ultrasound (PDUS) is a useful tool to assess erectile hemodynamics in the clinician's effort to discuss prognosis and management strategies with the patient. We herein describe the PDUS protocol used at our center, including indications, technique, and data interpretation. We describe our institutional experience with PDUS and discuss it in the context of a contemporary review of the literature for this investigation. Our institutional PDUS protocol. To perform PDUS properly, adequate training, equipment, setting, technique, and interpretation are critical. The accuracy of PDUS is entirely predicated on achieving complete cavernosal smooth muscle relaxation. A redosing protocol optimizes the reliability and reproducibility of the hemodynamic data acquired during PDUS. A rigidity-based assessment is performed, and patients are scanned according to the erection rigidity achieved (full hardness) or by administration of maximum dose of the vasoactive agent. Peak systolic velocity is considered a measure of arterial inflow (normal, >30cm/s), while end diastolic velocity evaluates the veno-occlusive mechanism (normal, <5cm/s). After the procedure, the patient is evaluated to confirm detumescence. If the patient has a persistent penetration rigidity erection, intracavernosal phenylephrine is administered; however, if detumescence is not achieved with intracavernosal phenylephrine injections alone, corporal aspiration is potentially performed. PDUS is a valuable minimally invasive tool for erectile hemodynamics assessment and an accurate assessment of such, provided that complete cavernosal smooth muscle relaxation is achieved.

US of the Penis: Beyond Erectile Dysfunction.

High-frequency US, with a linear transducer and gray-scale, color, and spectral Doppler US techniques, is the primary imaging modality for evaluation of the penis. It can allow delineation of anatomy and assessment of dynamic blood flow; it is easily available and noninvasive or minimally invasive; it is cost effective; and it is well tolerated by patients. US assessment after pharmacologic induction of erection is an additional tool in assessing patients with suspected vasculogenic impotence, and also in selected patients with penile trauma and suspected Peyronie disease. Penile injuries, life-threatening infections, and vascular conditions such as priapism warrant rapid diagnosis to prevent long-term morbidities due to clinical misdiagnosis or delayed treatment. US can facilitate a timely diagnosis in these emergency conditions, even at the point of care such as the emergency department, which can facilitate timely treatment. In addition, color and spectral Doppler US are valuable applications in the follow-up of patients treated with endovascular revascularization procedures for vasculogenic erectile dysfunction. Image optimization and attention to meticulous techniques including Doppler US is vital to improve diagnostic accuracy. Radiologists should be familiar with the detailed US anatomy, pathophysiologic characteristics, scanning techniques, potential pitfalls, and US manifestations of a wide spectrum of vascular and nonvascular penile conditions to suggest an accurate diagnosis and direct further management. The authors review a range of common and uncommon abnormalities of the penis, highlight their key US features, discuss differential diagnosis considerations, and briefly review management. ©RSNA, 2024 Supplemental material is available for this article.

LRRC8A-VRAC modulates the contractile response by managing the superoxide anion influx in diabetic vasculogenic erectile dysfunction

Introduction: Erectile dysfunction (ED) may be an early marker for cardiovascular diseases, and it is often associated with an hypercontractility of the corpus cavernosum (CC) and pudendal artery (PA) because of increased reactive oxygen species (ROS). Leucine Rich Repeat Containing 8 (LRRC8) Volume Regulated Anion Channels (VRACs) regulates Nox1 and modulates the influx of extracellular superoxide anion (O2•-), contributing to the creation of an oxidized domain, enhancing calcium sensitivity of the smooth muscle which promotes contraction. Objective: We hypothesize that downregulation of NOX1 or LRRC8A would decrease the contractile responses to phenylephrine (PE) and electrical field stimulation (EFS) in the CC, PA and mesenteric resistance artery (MRA) of diabetic mice (dbdb−/−). Methods: The CC and PA of diabetic (dbdb−/−) mice were mounted in myographs. The contraction elicited by PE or EFS was performed in the presence of apocynin (non-selective NOX inhibitor) and GKT137831 (NOX1/4 inhibitor). In LRRC8A KO dbdb−/− mice, contractions to PE and EFS were obtained in the absence or in the presence of GKT137831.Results: In the CC, the maximal contraction to PE was increased in dbdb−/− animals, and in the presence of 3 mM of apocynin, the contractile response was markedly diminished in both control and dbdb−/−. Incubation with GKT137831 reduced the contraction elicited by PE only in the dbdb−/− group (68 ± 9% of the maximal contraction), whereas in the control group this reduction was not significant (82 ± 14% of the PE-maximal contraction). In the PA, the potency of PE was increased in the dbdb−/− group, and apocynin 1mM restored the contraction to normal levels. In the LRRC8A KO dbdb−/− mice, the contraction to PE in the MRA and PA was reduced by 30% compared to dbdb−/−. The response to EFS in CC was similar to dbdb−/−, however, GKT137831 reduced the contraction to EFS with lesser magnitude of inhibition in the LRRC8A KO dbdb−/− mice (35% of inhibition) compared to dbdb−/− mice (50% of inhibition), suggesting that the participation of O2•- in the contractile response was reduced by the lack of functional LRRC8A. Conclusion: LRRC8A modulates the contractile response by managing the influx of reactive oxygen species (ROS) in smooth muscle cells. Inhibition of LRRC8A may be a therapeutic target to prevent hypercontractility of arteries and CC in conditions where there are marked increases in ROS production, such as diabetes. NIH – R01 132948; Institute on Cardiovascular Disease Research, University of South Carolina. This is the full abstract presented at the American Physiology Summit 2024 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

The effect of combination treatment with low-intensity shockwave therapy and daily tadalafil on severe erectile dysfunction: a double-blind, randomized, sham-controlled clinical trial.

Patients with severe erectile dysfunction (ED) remain the most challenging group in terms of available noninvasive treatment modalities. The study sought to assess the role of combination therapy with low-intensity shockwave therapy (LiST) and daily tadalafil 5mg in a highly select group of patients with severe vasculogenic ED through a double-blind, randomized trial. Forty-eight sexually active men were randomly assigned to 12 sessions of LiST 3 times weekly and tadalafil 5mg once daily (n = 34) or sham therapy and tadalafil (n = 17) for 4 weeks. Patients were assessed at 1 and 3 months after completion of treatment. Improvement of erectile function was evaluated through the International Index of Erectile Function-Erectile Function domain (IIEF-EF) or 6-item IIEF and the Sexual Encounter Profile (SEP) diary. The primary outcome was the difference between the groups in the IIEF-EF at 3 months after completion of treatment. Secondary outcomes comprised (1) the difference between the groups in the IIEF-EF at 1 month after completion of treatment, (2) the difference between the groups in the "yes" responses to question 3 of the SEP diary at 1 and 3 months, and (3) the treatment-related adverse events. The number of patients attaining a minimal clinically important difference in the IIEF-EF (improvement of at least 7 points) was also assessed. After treatment, the absolute scores in the IIEF-EF were higher in patients receiving LiST and tadalafil vs sham therapy and tadalafil both at the 1-month (12.1 ± 2.4 vs 10.2 ± 1.7; P = .002) and at the 3-month (12.9 ± 2.1 vs 10.8 ± 1.8; P < .001) evaluation. Between the 2 groups, the proportion of "yes" responses to question 3 of the SEP diary was not statistically significant, whereas the number of patients attaining a minimal clinically important difference in the IIEF-EF was statistically significant only at the 3-month evaluation. No adverse events occurred. Application of LiST in patients with severe vasculogenic ED receiving daily dose tadalafil may further improve erectile function compared with tadalafil as a stand-alone treatment on the short term. Although we provided the first study in the field, severe vasculogenic ED was defined based on medical history and clinical examination and not based on penile ultrasound measures. The combination of 12 sessions LiST 3 times weekly and daily tadalafil for 4 weeks led to a 2-point difference in the IIEF-EF compared with sham therapy and daily tadalafil among patients with severe vasculogenic ED after 1 and 3 months from completion of treatment.

Recovery of the hibernating cavernosum by penile revascularization

ABSTRACT Objective Chronic ischemia-related cavernous dysfunction is considered irreversible. However, in certain patients, cavernous function appears to recover with penile revascularization. In this study, we investigated a potential cavernous dysfunction reversibility from a clinical perspective. Patients and Methods We involved 93 young patients in the study with arterial erectile dysfunction (ED) (median age: 30 years). Erectile function tests were performed according to the standard operating procedures of the International Society of Sexual Medicine. Among the participants, 63 and 30 displayed pure arteriogenic and mixed vasculogenic (due to both arterial insufficiency and cavernous dysfunction) ED, respectively. Penile revascularization was performed by anastomosing the inferior epigastric artery to the dorsal artery. The ED treatment success was considered from a score of at least 24 on the International Index of Erectile Function-6. Results Our results proved that penile revascularization cured 92.1% and 73.8% of the patients with pure arteriogenic and mixed vasculogenic ED, respectively (Kaplan-Meier method, log-rank test: no significant difference). The required time for curing 50% of the patients was 10.5 and 10.0 months for pure arteriogenic and mixed vasculogenic ED, respectively, indicating no recovery delay in patients with mixed vascular ED. Furthermore, the cavernous dysfunction degree did not influence cavernous function recovery. Conclusion Penile revascularization cured ED in 73.8% of the patients with mixed vasculogenic ED. Cavernous dysfunction appears to be reversible in certain cases. Furthermore, we observed no delay in functional recovery compared to participants with healthy cavernous function. These two discoveries suggest that cavernous function recovery after penile revascularization is similar to the concept of hibernating myocardium in ischemic myocardium. Although cavernous dysfunction is considered irreversible, it could be reversed in multiple cases with blood flow restoration to the cavernous tissue.

(193) Low Intensity Shockwave Therapy in Combination with Phosphodiesterase-5 Inhibitors is an Effective and Safe Treatment Option in Patients with Vasculogenic ED who are PDE5i Nonresponders: A Multicenter Single-Arm Clinical Trial

Abstract Introduction Low-intensity shockwave therapy (Li-ESWT) has been shown to be an effective and safe treatment for vasculogenic erectiledysfunction (ED) Objective We aim to evaluate the effectiveness and safety of LiESWT in treating patients affected from vasculogenic ED who did not respond to oral treatment with Phosphodiesterase 5 inhibitors (PDE5-i) Methods It is a multicentric open-label prospective study, in a cohort of patients non-responders to PDE-5i. Li-ESWT was performed in an outpatient setting by using the following schedule: 3000 shockwaves with an energy of 0.25 mJ/mm2 and a frequency of 4–6 Hz, twice a week for 3 weeks. International Index of Erectile Function, Erection Hardness Score and Sexual Quality of Life-Male questionnaires, and penile doppler ultrasound (PDU) are the outcome measurements. Results The Student t-test or Wilcoxon signed-rank test were applied to compare variables, with results considered statistically significant at p &amp;lt; 0.05. 106 (97.2%) completed treatment and performed follow-up visit after 4 weeks. At follow up visit, the mean IIEF-EF increased by 8.6 points (13.47 ± 4.61 vs 22.07 ± 5.27; p &amp;lt; 0.0001). A clinically significant improvement of IIEF-EF was achieved in 75 patients (70.7%). An EHS score ≥ 3, sufficient for a full intercourse, was reported by 72 patients (67.9%) at follow-up visit. 37 (34.9%) patients reported a full rigid penis (EHS = 4) after treatment. Li-ESWT treatment was also able to improve quality of life (SQOL-M: 45.56 ± 8.00 vs 55.31 ± 9.56; p &amp;lt; 0.0001). Li-ESWT significantly increased mean PSV (27.79 ± 5.50 vs 41.66 ± 8.59; p &amp;lt; 0.0001) and decreased mean EDV (5.66 ± 2.03 vs 1.93 ± 2.11; p &amp;lt; 0.0001) in PDU. Conclusions Combination of Li-ESWT and PDE5-i represents an effective and safe treatment for patients affected from ED who do not respond to first line oral therapy Disclosure No.

(023) Mechanical Therapy After Inflatable Penile Prosthesis: A Scoping Review

Abstract Introduction While inflatable penile prosthesis (IPP) allows reliable axial rigidity, common complaints perceived are shorter penis and reduced glans engorgement. Pre-operative factors, such as vasculogenic erectile dysfunction (ED) or corporoglandular morphology, provide a convenient explanation. However, post-operative factors are more recently being interrogated. Post-IPP mechanical therapy protocols, like vacuum erection devices (VED), are being instituted to ameliorate these complaints. The physiological rationale is to improve perfusion of residual erectile tissues and limit cavernous fibrosis/pseudo-capsule formation. This has been hypothetically explained by upregulating endothelial nitrous oxide synthase release, decreasing hypoxia inducible factor and tissue growth factor 1. Post-IPP maximal inflation protocols similarly resulted in a more capacious and compliant tunica albuginea and capsule. Objective To assess the utility of post-IPP mechanical therapy in addressing common post-operative complaints and enhance prosthetic erection. Methods Intervention: Post-op mechanical therapy Population: Men with IPP for ED, with/without Peyronie’s disease (PD) Inclusion Criteria: Articles published in English with full-text available Search Strategy: Literature search was performed in June 2023 using Medline, PubMed, Embase and Scopus. PubMed search included “Mesh” protocols and “free text” to correctly capture study population. Articles relating to the intervention were identified with free text search searches (“VED,” “vacuum erection device,” “vacuum constriction device,” “penis pump,” “mechanical therapy,” or “rehabilitation”). Review Type &amp; Analysis: While a systematic model was initially adopted, a scoping model was ultimately chosen given the limited available literature &amp; variable outcome measures. In this way, we sought to identify knowledge gaps and scope of current literature to guide further studies in this field. Higher-powered analyses were not possible due to inter-study outcome measure variability. Results Initial search strategy retrieved 81 non-duplicate studies with 30 selected for initial screening after search limitations. Ultimately, 5 satisfied inclusion criteria after full-text review and were divided into 3 categories according to post-IPP protocol employed: Early activation (1), Maximal inflation (2,3) and VED (4,5) (Table 1). A common theme encountered was that mechanical therapy improved post-IPP penile length and girth, compared to immediate post-operative measurements. Only one study used a control group who had their device activated for the first time after 4 weeks. The intervention employed in this study was device activation immediately after surgery, left 80% inflated and deflated at 3 weeks, then full erection at night for 3 further weeks. Compared to the control, at maximum inflation, penile length mean was 3.28cm longer and circumference was 1cm greater. In each of these studies, the differences reported were statistically significant. This was also associated with an increased number of pumps required to achieve full inflation over time, irrespective of mechanical protocol used. Articles that reported IIEF-5 and EDITS scores demonstrated a statistically significant improvement over time with post-op intervention. Conclusions Within limits of the included studies, post-implantation mechanical therapy appears to be useful in improving penile dimensions and patient satisfaction over time. The correlation with increasing number of pumps implies that compliance of the tunica albuginea and residual cavernous tissue may play a role in the pathogenesis of shorter penis post-IPP. Further high-powered studies in this area are warranted. Disclosure No.

(159) Factors and Management Strategies for Addressing Reduced Glans Engorgement Following Inflatable Penile Prosthesis: A Scoping Review

Abstract Introduction Inflatable penile prosthesis (IPP) provides a reliable stiffness along the length of the penile shaft, yet patients may express dissatisfaction as it may still differ from their recollection of their previously normal erections. A common complaint is reduced engorgement of the glans penis, which can manifest as subjective reduction in penile length or the feeling of a cold insensitive glans. Patient factors often ensure a sound justification for this complaint, namely vasculogenic erectile dysfunction (ED) or their corporo-glandular morphology despite a well-sized and well-positioned implant. Objective In this study, we sought to identify factors that may contribute to reduced glans engorgement and possible management strategies. Methods Intervention: Any method of treating or avoiding reduced glans engorgement post-IPP. Population: Men undergoing IPP insertion or men with glans complaints post-operatively Inclusion Criteria: Articles published in English with full text available and objective outcome measures Search Strategy: Literature search was performed in June 2023 using Medline, PubMed, Embase and Scopus. PubMed search included both “Mesh” protocols and “free text” to capture the correct study population and intervention utilized. Review Type &amp; Analysis: Although an initial systematic model was considered, a scoping model was ultimately selected due to the limited literature and inconsistent outcome measures. This approach aimed to identify gaps in knowledge and provide an overview of the existing literature, thus informing future studies in this area. The variability in outcome measures across studies prevented higher-powered analyses from being conducted. Results Initial search strategy retrieved 98 non-duplicate studies with 40 being selected for initial screening after applying inclusion criteria. Ultimately, a total of 7 articles were included and categorized by theme: Cavernous-sparing technique (1–3); Pharmacotherapy for post-IPP glans complaints (4–7) (Table 1 &amp; 2). The cavernous-sparing technique described aims to limit disruption of cavernous tissue around the implanted cylinder. This was achieved by omitting dilatation and using Furlow directly for measurements, or by intraoperative intracavernosal (IC) prostaglandin followed by dilatation only with size 7 or 8 Hegar alone. In all studies that compared penile dimensions, girth was significantly greater in the cavernous-sparing group. A higher proportion of men in this group also had detectable cavernous arteries, thicker residual corporal tissue, better residual tumescence post-IPP and demonstrated significant increases in both PSV and EDV post-PDE5i, compared to no PDE5i. Men who had standard dilatation also responded to post-IPP PDE5i but fewer had identifiable cavernous artery and had significant increase in only PSV, compared to no PDE5i. Other articles relating to post-IPP pharmacotherapy unanimously demonstrated that post-IPP glans engorgement was improved. This equated to reported statistically improved satisfaction when compared to the IPP alone groups, as measured by IIEF and EDITS questionnaires. Post-IPP PDE5i were better tolerated than intraurethral alprostadil, which was associated with discomfort. Conclusions Post-IPP pharmacotherapy appears to enhance residual erectile tissue engorgement. It can be used as an adjunctive after-care measure. Cavernous-sparing techniques show the importance of viable residual tissue for improved prosthetic erections. More comprehensive studies are needed to enhance patient experience and explore the microanatomical and hemodynamic role of residual tissue post-IPP. Disclosure No.

(202) Comparative Study of the Efficacy of Avanafil and Atorvastatin Daily Dose in Management of Vasculogenic Erectile Dysfunction

Abstract Introduction Erectile dysfunction (ED) is defined as the “consistent inability to attain or maintain a penile erection, or both, sufficient for adequate sexual relations”. ED is not only a medical problem but affects the marital relations and patient's self-esteem and causes the quality of life to decrease. which in turn causes the patient to go into depression or develop anxiety. In the past, erectile dysfunction was considered, in most cases, to be a purely psychogenic disorder, but current evidence suggests that more than 80% of cases have an organic aetiology. Causes of organic erectile dysfunction can now be broadly divided into nonendocrine and endocrine. Of the nonendocrine aetiologies, vasculogenic (affecting blood supply) is the most common and can involve arterial inflow disorders and abnormalities of venous outflow (corporeal veno-occlusion). Avanafil is a second-generation phosphodiesterase type 5 inhibitor approved for erectile dysfunction by the FDA on 2012 and by EMA in 2013. With a high selectivity for phosphodiesterase type 5 isoform AND faster onset of action compared with other PDE5 inhibitors, it offers more tolerability and less adverse events. Atorvastatin is 3-hydroxy-methylglutaryl (HMG)-CoA reductase inhibitor act on the rate-limiting step in cholesterol biosynthesis (the conversion of HMG-CoA to mevalonate) and are effective in treating dyslipidemia. statins reverse endothelial dysfunction by decreasing the action of oxidized low-density lipoprotein (LDL) on endothelial cells, resulting in an increase of NO activity. Objective is to evaluate and compare the efficacy of avanafil and atorvastatin daily dose in management of patients with vasculogenic erectile dysfunction. Methods A 60 adult heterosexual males complaining of vasculogenic erectile dysfunction proven by penile duplex were collected from outpatient andrology clinics of Al-Azhar University Hospitals. The patients were divided into two treatment groups: (Group A): 30 patients received daily dose of 100 mg avanafil. (Group B): 30 patients received daily dose of 40 mg atorvastatin, The main outcome measures and the difference in penile duplex ultrasound results and IIEF-EF scores between the two groups are evaluated and compared at the end of the study, Age of patients between 20 and 50 years, established diagnoses of Vasculogenic erectile dysfunction, Normal lipid profile, Normal Total and Free testosterone levels and No contraindications to the study medications were included criteria. However patients who failed to fulfill any of the inclusion criteria, psychogenic or neurogenic erectile dysfunction, dyslipidemia Patients with Renal or Hepatic insufficiency and Patients with advanced cardiovascular diseases such as heart failure and coronary artery disease on antianginal drugs especially nitrates were excluded. Results Our study revealed statistically significant improvement in Penile Doppler ultrasonography parameters (PSV, EDV&amp; RI) and IIEF-EF scores in avanafil group compared to atorvastatin group. Conclusions avanafil 100 mg daily dose leads to significant improvement in men with vasculogenic erectile, while atorvastatin 40 mg caused no significant differences, neither positively nor adversely. In summary, avanafil at dose of 100 mg can be a therapeutic appropriate choice in cases of vasculogenic ED. Disclosure No.

(141) Can a Nocturnal Penile Tumescence and Rigidity Test Detect Organic Aetiology of Erectile Dysfunction? A Peripheral and Penile Vascular Study

Abstract Introduction In the diagnostic workup of erectile dysfunction (ED) the Nocturnal Penile Tumescence and Rigidity test (NPTR) is being used less and less because of its inconvenience but also in part because of the intrinsic limits of this test. In particular, the NPTR has been considered very useful to diagnose psychogenic ED when it is positive (normal) but less informative when it is negative (pathological) because of the high incidence of false negatives. Other tests have been suggested to better diagnose an organic ED, especially the dynamic Penile Colour-Doppler Ultrasound (PCDU) to study the penile vascular response and detect a vasculogenic ED. Objective The purpose of the study was to explore the value of a pathological NPTR by investigating relationship between the NPTR result and the peripheral vascular health at the carotid, brachial and cavernous arteries. Methods We conducted an observational study involving patients with ED who had undergone a NPTR as part of their ED diagnostic workup. We assessed their peripheral vascular health through (1) the measurement of the intima-media thickness at the carotid arteries (cIMT), (2) the measurement of the flow-mediated dilation at the brachial artery (FMD), and (3) performing a PCDU. Results Globally, our patients presented with a normal cIMT, FMD and Peak Systolic Value (PSV) in the PCDU. The group with pathological NPTR were significantly older than patients with normal NPTR (55.6 vs 44.1 years, p=0.002), had a higher prevalence of hypertension (50.0 vs 6.8%, p=0.001), longer hypertension duration (8.0 vs 1.3 years, p=0.035), a higher prevalence of diabetes mellitus (42.9 vs 6.8%, p= 0.004), higher blood glucose (111 vs 92 mg/dl, p=0.004) and higher blood triglycerides levels (188 vs 96 mg/dl, p=0.002). Furthermore, they showed lower PSV (46.2 vs 71.0 cm/s, p=0.002) while we did not find significant differences as regards cIMT and FMD between the two groups. Interestingly, the prevalence of patients with pathological PSV (&amp;lt;35 cm/s) was higher among patients with a pathological NPTR but without reaching the statistical significance. However, when adopted an age-dependant cut-off described in the literature (PSV &amp;lt; age x 0.7 + 6.73) the difference between the two groups became significant (50.0 vs 11.4%, p=0.005). Finally, the correlation analysis showed a significant correlation between PSV and the cIMT (-0.352, ρ=0.009), the maximum number of events in the RPTR record (+0.344, ρ=0.012), and the mean tip tumescence (+0.303, ρ=0.036). When corrected for age, these associations lost their statistical significance. Conclusions This study demonstrates the diagnostic value of a pathological NPTR which suggests an organic aetiology of the ED and associates with pathological findings in the PCDU. Age appears to be one of the most important risk factors for ED, even when other risk factors are present. Finally, when using a PCDU to diagnose vasculogenic ED, a cut-off of 35 cm/s might be less sensitive than an age-dependent cut-off to detect early impairments of penile endothelial function. Disclosure No.

(268) Intracavernous Prostaglandin Injection as a Predictor and Effectiveness Measure for LISWT Sessions in ED Patients: A Single Urologist's Experience

Abstract Introduction In recent years, therapeutic approaches for treating vasculogenic Erectile Dysfunction (ED) have evolved, with Low Intensity Shock Wave Therapy (LISWT) emerging as a promising modality. Objective To objectively evaluate the efficacy of LISWT for ED patients and to predict the required number of sessions, we examined the effects of administering up to 10 mcg of intracavernous alprostadil injections both before and after treatment Methods 85 vasculogenic ED patients (Average age: 57); 33 with mild to moderate ED and 52 with moderate or severe ED. Intracavernous injection (ICI) of ≤10 mcg of alprostadil was given before LISWT and one month post-treatment. Depending on ICI response, patients underwent either six (Erection Hardness Score (EHS) ≤3) or four (EHS=4) weekly LISWT sessions using PiezoWave2 from Richard WOLF. LISWT Parameters: 0.16mj/mm2 energy flux density, 8 Hz frequency, 10mm wave focus penetration depth, and 6000 shocks per session distributed among the two crura of the penis (2000 shocks), dorsum penis (2000 shocks), and lateral penis (2000 shocks). Results 33 patients showed a robust response to the 10mcg ICI and were treated with four LISWT sessions. 52 patients exhibited a partial response to the 10mcg ICI, necessitating six LISWT sessions. 78.6% (26 out of 33) of the patients who initially responded well to 10 mcg ICI had a consistent response to 8 mcg ICI; 63.6% (33 out of 52) of those with a partial initial response to 10 mcg ICI demonstrated an improved reaction to the same dosage post-treatment (table 1) (fig. 1). No complications were reported from the ICI. Conclusions Intracavernous prostaglandin injection can serve as a predictor for the required number of LISWT sessions and can objectively gauge the treatment's effectiveness in ED patients. Further randomized studies, incorporating parameters such as EHS, IIEF, and the ICI dosage, are recommended to validate this method's feasibility Disclosure No.

(281) Low-Intensity Shockwave Therapy Combined with Tadalafil 5mg Daily has Better Efficacy for Mild and Moderate Erectile Dysfunction: The Preliminary Results of a Multicenter Clinical Study in China

Abstract Introduction Most clinical studies have demonstrated that low-intensity extracorporeal shockwave therapy (Li-ESWT) can improved erectile function in patients with erectile dysfunction (ED). The EAU guideline recommended to use Li-ESWT for mild vasculogenic ED patients. However, the therapeutic advantages of Li-ESWT combined with phosphodiesterase type 5 inhibitors (PDE5i) have not been explored clearly in clinical practice for mild and moderate ED patients. Objective To compare the therapeutic effects of Li-ESWT and Li-ESWT combined with PDE5i in mild and moderate ED patients with 8≤IIEF-5≤16 from a multicenter clinical study in China. Methods Patients with ED which IIEF-5 score is less than 22 and aged 18–60 years old were enrolled from three clinical centers from Jun. 2019 to Mar. 2023. The demographic data, International Index of Erectile Function-5 (IIEF-5), erectile hardness score (EHS) and self-reported symptom questions were collected. Patients were treated by a linear low-energy shock waves generator (Renova). Low-intensity shock wave (energy density of 0.09mJ/mm2) treatments were applied (once a week, 4 weeks in total, 5000 shocks each time). Patients in Li-ESWT combined with PDE5i group took 5mg of tadalafil once a day for one continuous month during ESWT. Comparative analyses of pre- and post-treatment and intergroup were used for statistics. Results In total, 42 ED cases (37.43±11.86 years) in Li-ESWT group and 116 cases (37.41±10.14 years) in combined group were enrolled for analysis. The IIEF-5 score and EHS in both groups were significantly improved after 1 month treatment (p&amp;lt;0.01). Compared with Li-ESWT group, patients in combined group significantly had higher self-reported efficiency (61.2% vs. 47.6%, p=0.013), IIEF-5 scores (15.34±7.15 vs. 13.96±7.71, p=0.039) and EHS (2.85±0.82 vs. 2.69±0.89, p=0.050). In the mild and moderate ED (with 8≤IIEF-5≤16) sub-group, 30 ED cases (36.81±10.99 years) in Li-ESWT group and 96 cases (36.80±10.69 years) in combined group were enrolled for analysis. The combined regimen showed better therapeutic advantages, including effective parameters IIEF-5(14.50±6.74 vs. 12.87±8.54, p=0.040), EHS (2.85±0.75 vs. 2.81±0.67, p=0.046) and self-reported efficiency (64.2% vs. 54.1%, p=0.001). Conclusions Li-ESWT can effectively improve erectile function in this multicenter clinical study in China, and the combination of Li-ESWT with daily use PDE5i had a better therapeutic effect on Chinese ED patients, especially on mild and moderate ED. Long-term follow-up with large sample study need to be developed for exploring the optimal therapeutic regimen. Disclosure No.

The role of Doppler ultrasound in the evaluation of penile haemodynamics—A sonographer's guide to the documentation of vasculogenic erectile dysfunction

AbstractVasculogenic erectile dysfunction (ED) is the most common form of ED affecting the male population. Once the first line investigation for erectile dysfunction, penile Doppler ultrasound examinations have reduced in number following the introduction of oral phosphodiesterase inhibitors as a treatment method. As such, skilled professionals versed in the performance of these examinations are dwindling. This skill deficit is compounded by the lack of standardisation that exists in the performance and interpretation of penile haemodynamics relative to impotence of vascular origin. Despite the success of pharmacological agents in the treatment of vasculogenic dysfunction, penile Doppler examinations are still relevant in the assessment of ED in non‐responders, and those patients in which pelvic surgery or trauma has altered the normal erectile mechanism. Growing evidence in the literature also suggests that vasculogenic ED may be an early indicator of systemic vascular disease and therefore prognostic of future cardiovascular events. Considering this, the relevance of Doppler assessment of penile haemodynamics with ultrasound should not be underestimated. This article will introduce the sonographer to advanced vascular anatomy of the penis, pathophysiology of erectile function and the principles of normal and pathological penile haemodynamic patterns. It also aims to suggest a standardised protocol for the performance of penile Doppler ultrasound relative to primary vasculogenic ED and reduce the amount of variability that exits between operators. As such the sonographer can make a significant contribution to patient management pathways.

(311) Reduced Glans Engorgement After Inflatable Penile Prosthesis – A Scoping Review of Factors Involved and Management Strategies

Abstract Introduction Inflatable penile prosthesis (IPP) provides a reliable stiffness along the length of the penile shaft, yet patients may express dissatisfaction as it may still differ from their recollection of their previously normal erections. A common complaint is reduced engorgement of the glans penis, which can manifest as subjective reduction in penile length or the feeling of a cold insensitive glans. Patient factors often ensure a sound justification for this complaint, namely vasculogenic erectile dysfunction (ED) or their corporo-glandular morphology despite a well-sized and well-positioned implant. Objective To identify factors that may contribute to reduced glans engorgement and possible management strategies. Methods Intervention: Any method of treating or avoiding reduced glans engorgement post-IPP. Population: Men undergoing IPP insertion or men with glans complaints post-operatively Inclusion Criteria: Articles published in English with full text available and objective outcome measures Search Strategy: Literature search was performed in June 2023 using Medline, PubMed, Embase and Scopus. PubMed search included both “Mesh” protocols and “free text” to capture the correct study population and intervention utilized. Review Type &amp; Analysis: Although an initial systematic model was considered, a scoping model was ultimately selected due to the limited literature and inconsistent outcome measures. This approach aimed to identify gaps in knowledge and provide an overview of the existing literature, thus informing future studies in this area. The variability in outcome measures across studies prevented higher-powered analyses from being conducted. Results Initial search strategy retrieved 98 non-duplicate studies with 40 being selected for initial screening after applying inclusion criteria. Ultimately, a total of 7 articles were included and categorized by theme: Cavernous-sparing technique (1-3); Pharmacotherapy for post-IPP glans complaints (4-7) (Table 1 &amp; 2). The cavernous-sparing technique described aims to limit disruption of cavernous tissue around the implanted cylinder. This was achieved by omitting dilatation and using Furlow directly for measurements, or by intraoperative intracavernosal (IC) prostaglandin followed by dilatation only with size 7 or 8 Hegar alone. In all studies that compared penile dimensions, girth was significantly greater in the cavernous-sparing group. A higher proportion of men in this group also had detectable cavernous arteries, thicker residual corporal tissue, better residual tumescence post-IPP and demonstrated significant increases in both PSV and EDV post-PDE5i, compared to no PDE5i. Men who had standard dilatation also responded to post-IPP PDE5i but fewer had identifiable cavernous artery and had significant increase in only PSV, compared to no PDE5i. Other articles relating to post-IPP pharmacotherapy unanimously demonstrated that post-IPP glans engorgement was improved. This equated to reported statistically improved satisfaction when compared to the IPP alone groups, as measured by IIEF and EDITS questionnaires. Post-IPP PDE5i were better tolerated than intraurethral alprostadil, which was associated with discomfort. Conclusions Post-IPP pharmacotherapy appears to enhance residual erectile tissue engorgement. It can be used as an adjunctive after-care measure. Cavernous-sparing techniques show the importance of viable residual tissue for improved prosthetic erections. More comprehensive studies are needed to enhance patient experience and explore the microanatomical and hemodynamic role of residual tissue post-IPP. Disclosure No.

(312) Manhandling: Post-IPP Mechanical Therapy – A Scoping Review

Abstract Introduction While inflatable penile prosthesis (IPP) allows reliable axial rigidity, common complaints are perceived shorter penis and reduced glans engorgement. Pre-operative factors, such as vasculogenic erectile dysfunction (ED) or corporoglandular morphology, provide a convenient explanation. However, post-operative factors are more recently being interrogated. Post-IPP mechanical therapy protocols, like vacuum erection devices (VED), are being instituted to ameliorate these complaints. The physiological rationale is to improve perfusion of the residual erectile tissues and limit cavernous fibrosis or pseudo-capsule formation. This has been hypothetically explained by upregulating release of endothelial nitrous oxide synthase, decreasing hypoxia inducible factor  and tissue growth factor □1. Post-IPP maximal inflation protocols may similarly result in a more capacious and compliant tunica albuginea and capsule. Objective To assess the utility of post-IPP mechanical therapy in addressing common post-operative complaints and enhance prosthetic erection. Methods Intervention: Post-op mechanical therapy Population: Men with IPP for ED, with/without Peyronie’s disease (PD) Inclusion Criteria: Articles published in English with full-text available Search Strategy: Literature search was performed in June 2023 using Medline, PubMed, Embase and Scopus. PubMed search included both “Mesh” protocols and “free text” to capture the correct study population. Articles relating to the intervention were identified with free text search searches (“VED,” “vacuum erection device,” “vacuum constriction device,” “vacuum,” “penis pump,” “mechanical therapy,” or “rehabilitation”). Review Type &amp; Analysis: While a systematic model was initially adopted, a scoping model was ultimately chosen given the limited available literature and variable outcome measures. In this way, we sought to identify knowledge gaps and the scope of current literature to guide further studies in this field. Higher-powered analyses were not possible due to inter-study outcome measure variability. Results Initial search strategy retrieved 81 non-duplicate studies with 30 selected for initial screening after search limitations. Ultimately, 5 satisfied inclusion criteria after full-text review and were divided into 3 categories relating to the post-IPP protocol employed: Early activation (1), Maximal inflation (2,3) and VED (4,5) (Table 1). A common theme encountered was that mechanical therapy improved post-IPP penile length and girth, compared to immediate post-operative measurements. Only one study used a control group who had their device activated for the first time after 4 weeks. The intervention employed in this study was device activation immediately after surgery, left 80% inflated and deflated at 2-3 weeks, then full erection at night for 3-4 further weeks. Compared to the control, at maximum inflation, penile length mean was 3.28 cm longer and circumference was 1 cm greater. In each of these studies, the differences reported were statistically significant. This was also associated with an increased number of pumps required to achieve full inflation over time, irrespective of mechanical protocol used. Articles that reported IIEF-5 and EDITS scores also demonstrated a statistically significant improvement over time with post-op intervention. Conclusions Within limits of the included studies, post-implantation mechanical therapy appears to be useful in improving penile dimensions and patient satisfaction over time. The correlation with increasing number of pumps implies that compliance of the tunica albuginea and residual cavernous tissue may play a role in the pathogenesis of shorter penis post-IPP. Further high-powered studies in this area are warranted. Disclosure No.

(153) Hyperbaric Oxygen Therapy as a Treatment for Erectile Dysfunction: A Meta-analysis

Abstract Introduction Hyperbaric oxygen therapy (HBOT) is a medical treatment in which the patient is exposed to 100% oxygen at a higher than atmospheric pressure. Over the past few decades, HBOT has been used to treat a variety of medical conditions, including radiation cystitis, decompression sickness and carbon monoxide poisoning. In recent times, there has been a rising curiosity regarding the potential therapeutic benefits of hyperbaric oxygen therapy in the treatment of erectile dysfunction (ED), a prevalent condition that affects a vast number of men globally. Objective The aim of this study was to review and meta-analyze available data regarding the use of HBOT for erectile dysfunction, including its potential mechanisms of action and effectiveness. Methods Two investigators (GS and TN) screened 54 articles and included only those that evaluated the impact of HBOT on ED symptoms using the IIEF score. Prospective non-randomized studies or randomized controlled clinical trials were included, while non-original studies, conference abstracts, and case reports were excluded. Data extraction was performed in duplicate. Data analysis was conducted using Review Manager 5.41, and the presence of heterogeneity between studies was evaluated. The results were presented as the Mean Difference (MD) with 95% confidence intervals (CI). The significance level was set at P = 0.05. Results A total of five studies that reported outcomes using the IIEF scores were included in this analysis, which comprised a total of 175 patients who received HBOT and 178 control patients. The IIEF scores were analyzed by stratifying the studies according to the indication for HBOT or the cause of ED. In patients with post-robotic assisted laparoscopic prostatectomy (RALP)-induced ED, the analysis showed a significant Mean Difference (MD) of -4.13[-6.08, -2.18] p&amp;lt;0.0001 in favor of the control group. Conversely, patients who received HBOT for reasons other than ED exhibited a MD of 4.58[2.63,6.52] p&amp;lt;0.00001. In the group that received HBOT for pure vasculogenic ED, the MD was 10.50[9.92,11.08] in favor of HBOT. Patients with urethral strictures exhibited a MD of 4.25[2.29-6.21] favoring the HBOT intervention. Meta-analysis of these data revealed a nonsignificant difference in erectile function scores, with an MD of 3.86[-2.13, 9.86] p&amp;lt;0.00001. Conclusions The use of HBOT in the treatment of ED appears to be a promising approach. While further research is needed to establish the efficacy and long-term effects of this treatment, preliminary studies have shown encouraging results in terms of improving erectile function in men with vasculogenic ED. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Consultant for AbbVie, Marius, Tolmar, Endo, Petros, Boston Scientific, Coloplast Investor: Sprout.

(055) LRRC8A-VRAC Controls Superoxide Anion Flux in Diabetic Vasculogenic Erectile Dysfunction

Abstract Introduction Erectile dysfunction (ED) may be an early marker for cardiovascular diseases, and it is often associated with an hypercontractility of the corpus cavernosum (CC) as a consequence of increased reactive oxygen species (ROS), which favors the flaccid state of the penis. Leucine Rich Repeat Containing 8 (LRRC8A) Volume Regulated Anion Channels (VRACs) regulates Nox1 and modulates the extracellular production of superoxide anion (O2•-). Downregulation of LRRC8A is associated with decreased production of O2•- and we have demonstrated improved relaxation and reduced contraction of the pudendal artery in LRRC8A knockout mice. Objective We hypothesized that the role of LRRC8A in contractile responses to phenylephrine (PE) and electrical field stimulation (EFS) in the CC of diabetic mice would be exaggerated compared to that in normal mice. Methods To test this hypothesis, the CC of diabetic (dbdb-/-) mice was mounted in a myograph, and contraction elicited by PE or EFS was performed in the presence of apocynin (non-selective NOX inhibitor), GKT137831 (NOX1/4 inhibitor) and montelukast (LRRC8A inhibitor). In LRRC8A KO dbdb-/- mice, contractions to PE and EFS were obtained in the absence or in the presence of GKT137831. Results In the CC, the maximal contraction to PE was increased in diabetic animals, and in the presence of 3 mM of apocynin, the contractile response was markedly diminished in both control and diabetic mice. The LRRC8A inhibitor, montelukast, significantly reduced PE-induced contraction of the CC reaching maximal contraction of 69 + 7% and 65 + 10% in the control and diabetic group, respectively, compared to the contraction in the absence of the inhibitor. In the presence of the Nox1/Nox4 inhibitor, GKT137831, the contraction elicited by PE was reduced only in the diabetic group (68 + 9% of the maximal contraction), whereas in the control group this reduction was not significant (82 + 14% of the PE-maximal contraction). In the LRRC8A KO dbdb-/- mice, the contraction to EFS was similar to dbdb-/-, however, GKT137831 reduced the contraction to EFS with lesser magnitude of inhibition in the LRRC8A KO dbdb-/- mice (35% of inhibition) compared to dbdb-/- mice (50% of inhibition), suggesting that the participation of O2•- in the contractile response was reduced by the lack of functional LRRC8A. Conclusions LRRC8A modulates the contractile response of the CC induced by α-adrenergic stimulation and in diabetes, this may be associated with O2•- production, which plays a role in the development of ED. Inhibition of LRRC8A may be a therapeutic target to prevent hypercontractility of arteries and CC in vasculogenic ED. Disclosure No.