Penile artery shunt syndrome (PASS) is an

iatrogenic Iatrogenesis is the causation of a disease, a harmful complication, or other ill effect by any medical activity, including diagnosis, intervention, error, or negligence." Iatrogenic", ''Merriam-Webster.com'', Merriam-Webster, Inc., accessed 27 ...

clinical phenomenon first described by Tariq Hakky, Christopher Yang, Jonathan Pavlinec, Kamal Massis, and Rafael Carrion within the Sexual Medicine Program in the Department of Urology, at the

University of South Florida The University of South Florida (USF) is a Public university, public research university with its main campus located in Tampa, Florida, Tampa, Florida, United States, and other campuses in St. Petersburg, Florida, St. Petersburg and Sarasota, ...

, and Ricardo Munarriz, of

Boston University School of Medicine The Boston University School of Medicine (formally the Chobanian and Avedisian School of Medicine) is the medical school of Boston University, a private university, private research university in Boston, Boston, Massachusetts. It was founded in ...

Department of Urology in 2013. It may be a cause of refractory

erectile dysfunction Erectile dysfunction (ED), also referred to as impotence, is a form of sexual dysfunction in males characterized by the persistent or recurring inability to achieve or maintain a Human penis, penile erection with sufficient rigidity and durat ...

in patients who have undergone penile revascularization surgery. PASS Post-Embolization

Diagnosis

Treatment

Percutaneous coil

embolization Embolization refers to the passage and lodging of an embolus within the bloodstream. It may be of natural origin ( pathological), in which sense it is also called embolism, for example a pulmonary embolism; or it may be artificially induced ...

of the aberrant

obturator artery The obturator artery is a branch of the internal iliac artery that passes antero-inferiorly (forwards and downwards) on the lateral wall of the pelvis, to the upper part of the obturator foramen, and, escaping from the pelvic cavity through the o ...

was performed. Arterial flow rapidly improved through the left dorsal penile artery, and brisk opacification was seen through to the

glans penis In male human anatomy, the glans penis or penile glans, commonly referred to as the glans, (; from Latin ''glans'' meaning "acorn") is the bulbous structure at the Anatomical terms of location#Proximal and distal, distal end of the human penis ...

. Post-procedure, the patient experienced an immediate improvement in erectile function.

Considerations

Penile revascularization is a specialized vascular-surgical treatment option for erectile dysfunction. The 2009 International Consultation on Sexual Dysfunctions recommended that revascularization be limited to

nonsmoker Smoking is a practice in which a substance is combusted, and the resulting smoke is typically inhaled to be tasted and absorbed into the bloodstream of a person. Most commonly, the substance used is the dried leaves of the tobacco plant, whi ...

, nondiabetic men younger than 55 years of age with isolated stenosis of the

internal pudendal artery The internal pudendal artery is one of the three pudendal arteries. It branches off the internal iliac artery, and provides blood to the external genitalia. Structure The internal pudendal artery is the terminal branch of the anterior trunk ...

with absence of venous leak. Patients with persistent erectile dysfunction after revascularization may benefit from repeat penile

duplex ultrasound Doppler ultrasonography is medical ultrasonography that employs the Doppler effect to perform imaging of the movement of tissues and body fluids (usually blood), and their relative velocity to the probe. By calculating the frequency shift of a ...

and pelvic angiography to evaluate the status of the

bypass graft Grafting refers to a surgical procedure to move tissue from one site to another on the body, or from another creature, without bringing its own blood supply with it. Instead, a new blood supply grows in after it is placed. A similar technique ...

and to exclude the presence of a PASS as the cause. The prevalence of an aberrant obturator artery arising from the inferior epigastric artery is approximately 10.5%. If an aberrant obturator artery is visualized arising from the inferior epigastric artery prior to surgical penile revascularization, consideration should be given toward using an alternative source artery or to embolization to avoid the creation of a penile artery shunt syndrome encountered in this described case.

History

Penile artery shunt syndrome (PASS) was initially described in a patient who underwent penile revascularization surgery for isolated left cavernosal artery stenosis in the absence of systemic vascular risk factors. An end-to-end anastomosis of the left inferior epigastric artery to the left dorsal penile artery was created using a previously described technique.{{cite journal, last=Munarriz, first=Ricardo , author2=Uberoi, Fantini , author3=Martinez, Lee, journal=Journal of Urology, volume=182, issue=2, pages=634–648, pmid=19539333, doi=10.1016/j.juro.2009.04.031, title=Microvascular arterial bypass surgery: long-term outcomes using validated instruments, date=August 2009 After technically successful revascularization surgery, the patient continued to have post-operative erectile dysfunction despite documented patency of the surgical graft by penile duplex ultrasonography. Pelvic angiography was performed on the patient, revealing an aberrant

originating from the

inferior epigastric artery In human anatomy, the inferior epigastric artery is an artery that arises from the external iliac artery. It is accompanied by the inferior epigastric vein; inferiorly, these two inferior epigastric vessels together travel within the lateral um ...

. The study revealed markedly sluggish forward flow visualized through the anastomosis to the left dorsal penile artery, with dominant flow in the left inferior epigastric artery to the obturator artery and its branches. This culminated in reduced blood flow to the penis.

References

Penile erection Penis disorders Syndromes

Diagnosis

Treatment

Considerations

History

See also

References