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Pelvic/Perineal Trauma ASSOCIATED ERECTILE DYSFUNCTION

In cases of perineal trauma associate erectile dysfunction (ED), the patient will recall a distinct change in erectile function following an episode of trauma, assuming he was old enough to be aware of his previous function. The perineal trauma could be from forces in an upward direction, such as a karate kick or hockey stick or piece of lumber in the crotch. Forces could also be body weight falling onto an object, such as from skydiving or a fall onto a fence post or bicycle bar. In rare circumstances the episode of trauma might result in blood in the urine or a laceration requiring medical attention.

The penis is attached deep within the perineum and does not end, as it appears to, at the scrotum but rather near the anus, so it is vulnerable when sandwiched between the blow and the ischiopubic bone. The tubelike structure called Alcock’s canal, which lies along the ischiopubic ramus, is where the nerves and arteries enter the penis. The penile artery gets crushed and the endothelium is injured, initiating the atherosclerotic process in the penile arteries. Perineal trauma may lead to localized atherosclerosis secondary to a focal endothelial injury of the arteries within Alcock's canal and compromised blood supply to the penis over an unknown time period resulting in erectile dysfunction. The subsequent change in erectile function can occur immediately after the blunt trauma, but may be delayed up to one year or more after the episode. There may have been pain associated with the blunt trauma that is usually temporary, but in rare cases the injury leads to pudendal nerve damage and chronic pain. The dilemma in blunt trauma is that the artery gets sandwiched between the force and the bone, resulting in immediate artery blockage and inflammation to the lining, slowly leading to the artery blockage.

Diagnosis of circulation abnormalities is by sophisticated testing including duplex Doppler ultrasonagraphy, dynamic cavernosometry and internal pudendal selective arteriography. Hormonal and endocrine testing are not necessarily needed but can be performed if issues such as decreased penile sensitivity, low interest or concomitant ejaculation or orgasm problems are identified. Psychologic evaluation is important because of the emotional trauma of being young and healthy with erectile dysfunction, the disruption to normal relationships, and the lack of understanding by the general healthcare community that there could be a physical cause to the erectile difficulties. Too often the younger man seeking help is dismissed as someone seeking recreational drugs, rather than a patient with a bona fide organic erectile dysfunction.

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