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Early Manifestations of Erectile Dysfunction Following Hypospadias Repair: Etiology, Treatment and Concerns
Douglas Husmann, MD.
Mayo Clinic, Rochester, MN, USA.

Purpose: To review our findings and concerns regarding the onset of erectile dysfunction (ED) following hypospadias repair in a transitional urologic practice.
Materials and Methods: Patients with a history of ED and a prior hypospadias repair were screened by obtaining an IIEF-5 score and serum testosterone (T). Patients with abnormal T levels (x2) were treated with T and reassessed. In pts with normal T levels, PDE5 inhibitors were prescribed for IIEF5 scores ≤ 16. Patient failing two different PDE5 inhibitors underwent a Doppler penile ultrasound with injection to assess for vasculogenic impotence. Individuals not responding to injection therapy were offered a trial of a vacuum erection device, and if unsatisfied were offered placement of an inflatable penile prosthesis (IPP). Due to a large number of pts with ED having hypospadias repairs complicated by concurrent recalcitrant urethral strictures , we compared this group to similar pt population without ED.
Results: 33 patients fit our study criteria, median age, 25 yrs range 18-30, median IIEF5 score of 13, range 5-16. Patients with ED were divided into two groups those without and those with concomitant recalcitrant urethral strictures. 30% (10/33) were not associated with urethral strictures; 50% (5/10)had a history of imperforate anus with partial or complete sacral agenesis, one of these patients had a ventral SIS graft placed for profound chordee, 20% (2/10) had spina bifida, 20% (2/10) had juvenile type 1 diabetes mellitus, 10% (1/10) had low T values. 90% (9/10) responded to PDE5 inhibitors (1required PDE5 and T). One pt with an SIS graft failed all therapies and received an IPP.
70% (23/33) had recalcitrant urethral strictures and ED. 57% (13/23) responded to PDE5 inhibitors, 9%(2/23) required PDE5 and T , 4% (1/23) T alone, 4% (1/23) penile injection Rx , 9% (2/23) a vacuum erection device and 17% (4/23) an IPP . Median follow up of 5 yrs, range 2-11.
Doppler studies in the 8 pts failing to respond to PDE5 inhibitors, revealed venous leak in 5, poor arterial inflow in 2 and no vasculogenic ED in 1. Noteworthy, 75% ( 6/8 )of the pts not responding to PDE5 inhibitors had ventral penile grafts in situ( 3-SIS, 2-Dermal, 1-Tunica vaginalis). 40% (2/5) of the pts with IPP’s had significant technical problems occur during placement due to corporal fibrosis. Comparison of our two pt populations reveled major operative differences in pt with recalcitrant strictures with and without ED, specifically, the incidence of ventral corporal grafting to repair chordee, p < 0.001 (35%; 8/23 pts vs 0%;0/41 pts, respectively) and the performance of ≥3 internal urethrotomies for treatment of stricture disease, p < 0.0046 (43%:10/23 pts vs 12%; 5/36 pts respectively) were significantly associated with the risk of ED.
Conclusion: ED following hypospadias repair, may be related to concurrent birth defects and/or possibly induced by our surgical intervention. Noteworthy in this study is the association of ED with the placement of ventral grafts for the management of chordee and multiple urethrotomies ≥3 for the management of urethral stricture disease .

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