Penile Revascularization Restores Blood Flow After an Arterial Injury
In 1997, when Stewart Sullivan was 19 years old, he was horsing around on a playground and slipped and fell on a metal bar. Sullivan landed on the bar right between his legs.
As any man who's been struck in the groin can imagine, he was in severe pain and curled up in a ball on the ground.
Days later, he tried to have sex with his girlfriend. He couldn't get an erection.
"Before [the injury], I was ready to go in two seconds," Sullivan, now 45, said. "I kept having more and more pain. I finally went to the doctor."
Sullivan went to a general practitioner and multiple urologists. None of them knew what was causing the erectile dysfunction (ED). Sullivan had never had any erectile difficulties prior to the injury.
"I had my son when I was 17," Sullivan said. "He was 2 at that point. I remember thinking, 'I just want to be able to have sex.'"
Getting a diagnosis
Eventually, Sullivan, a Boston native, was referred to Irwin Goldstein, M.D., a urologist who was at Boston University School of Medicine at the time.
"He checked everything," Sullivan said. "He said, 'Yep, you got a blockage.' He pinpointed it right away."
The injury had crushed an artery that feeds blood to the penis during an erection, causing poor erectile function. Goldstein determined Sullivan was a candidate for a highly specialized and rare surgery known as penile revascularization surgery, or penile artery bypass surgery.
Goldstein successfully performed the procedure on Sullivan, who has been having erections with no problem for more than 25 years.
"I feel like he saved my life," Sullivan said. "We've stayed in contact, and I go see him every few years to check to make sure I'm OK."
What does a penile revascularization entail?
The prime candidates for penile revascularization are males in their teens or 20s who have suffered perineal trauma—injury in the area between the scrotum and anus—and crushed or blocked a penile artery. Motorcycle accidents, bicycle accidents and pelvic fractures are among the potential causes of this rare injury that's frustrating because everything works except the arterial blood flow to the penis.
The solution in this case is to borrow an artery to replace the damaged one.
"There's an artery that is in the abdominal wall called the inferior epigastric artery," Goldstein explained. "It's kind of a spare part."
This artery can be removed without any major health consequences. It is then transferred to the base of the penis using a microscope and very small nylon sutures.
"You can connect this new artery to the penis, bypassing the blockage in the crotch area of the perineum, and thereby reestablish sexual function," Goldstein said. "It's not typically complicated other than there's a very, very rare population that needs it."
The procedure usually takes about five hours, as it's a series of surgeries.
The first operation is to identify the recipient artery of the penis. If a recipient artery can't be found, the procedure can't go forward.
"Theoretically, you have that information with preoperative selective arteriography," Goldstein said.
Arteriography involves using X-rays and a special dye to see inside the arteries.
The next step is harvesting the artery.
"You have to free it up from its current attachment and then bring it into the base of the penis," Goldstein said.
The third and final step is bringing in a microscope and connecting the arteries.
The patient is typically held overnight for pain management. Goldstein advises patients to abstain from sexual activity until they are fully healed in four to six weeks.
As for outcomes, Goldstein said 2 out of 3 patients do extremely well.
Only a handful of urologists with special skills in microsurgery perform penile revascularization in the United States because the procedure is so rare.
"It's a very specific injury causing a very specific pathology," said Goldstein, who has been performing these procedures since the 1970s.
Goldstein learned the surgery from the doctor who developed penile revascularization, Vaclav Michal, M.D., a microvascular surgeon from Prague.
"If the injury also hurts the tissue of the penis, where difficulty maintaining the erection is another problem, then the surgery can't be done," Goldstein said. "If the injury not only causes artery injury but also nerve injury, because the nerves are there, then the surgery can't be done."
Another potential option: penile implants
Jesse Mills, M.D., does not perform penile revascularization, but young men ask him about it because he's a urologist and penile surgeon. Mills, the director of the Men's Clinic at UCLA in Los Angeles, said he's "not a huge fan" of penile vascularization, adding that it was done more in the 1980s before penile implants went mainstream.
Mills pointed to the length of the surgery and what the guy has to go through during and afterward as reasons he doesn't perform it. Plus, he says it's not as effective as a penile implant.
What is a penile implant? It involves surgically implanting a device into the penis that allows the man to get an erection. Mills said it is only a 30-minute outpatient surgery and it has high success and patient satisfaction rates.
"The only issue with penile implants is that very young men would need more than one because they do have a mechanical life expectancy of 10 to 15 years," Mills said. "If there's a 22-year-old professional snowboarder who severs his penile arteries and is not getting good erections, I would certainly think that a penile revascularization would be a reasonable thing to approach."
Penile vascularization is also expensive and not covered by insurance. Patients can expect to pay at least $10,000 out of pocket, Goldstein said.
Still, Goldstein finds that many young men prefer a physiological erection over one that is medication-based or from a penile implant, which is why they choose to go through with penile vascularization.
While most medical facilities prefer to perform penile implants over the riskier and rare penile revascularization, the artery bypass procedure is another viable option in specific cases.
Sullivan, who now lives in Tucson, Arizona, and works as a crystal and stone wholesaler, is still glad he had the procedure done.
"I remember being scared for my penis," he said. "And then I remember waking up with my first erection a few days later and was like, 'Oh, my God!' I had no issues."