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Sexual Dysfunction and Varicocele G 338 II.2 Mechanisms of Dysfunction and Pathology Tessler AN, Catanese A (1987) AIDS and germ cell tumors of cessory gland infection for subsequent fertility with special testis. Urology 30:203–204 focus on prostatitis. Hum Reprod Update 5:431–432 Trum JW, Pannekoek Y, Spanjaard L, Bleker OP, Van Der Veen Weidner W, Diemer T, Huwe P,Rainer H, Ludwig M (2002) The F (2000) Accurate detection of male subclinical genital tract role of Chlamydia trachomatis in prostatitis. Int J Antimic- infection via cervical culture and DNA hybridization assay rob Agents 19:466–470 of the female partner. Int J Androl 23:43–45 Weigel M (2003) [German-Austrian guidelines for diagnosis Uuskula A, Kohl PK (2002) Genital mycoplasmas, including and treatment of HIV-discordant couples who wish to have Mycoplasma genitalium, as sexually transmitted agents. Int children]. Dtsch Med Wochenschr 128 (Suppl 1):S32–S35 J STD AIDS 13:79–85 Westrom LV (1994) Sexually transmitted diseases and infertili- Van Leeuwen E, Cornelissen M, De Vries JW,Lowe SH, Jurriaans ty. Sex Transm Dis 21:S32–S37 S, Repping S, Van der Veen F (2004) Semen parameters of a se- Wilken H, Rosler EM (1985) [Prevention of sterility]. Zentralbl men donor before and after infection with human immunode- Gynakol 107:593–604 ficiency virus. A case report. Hum Reprod 19:2845–2848 Williams CD, Finnerty JJ, Newberry YG, West RW, Thomas TS, Vernazza PL, Troiani L, Flepp MJ, Cone RW, Schock J, Roth F, Pinkerton JV (2003) Reproduction in couples who are af- Boggian K, Cohen MS, Fiscus SA, Eron JJ (2000) Potent anti- fected by human immunodeficiency virus: medical, ethical, retroviral treatment of HIV-infection results in suppression and legal considerations. Am J Obstet Gynecol 189:333–341 of the seminal shedding of HIV. The Swiss HIV Cohort Witkin SS, Kligman I, Bongiovanni AM (1995a) Relationship Study. Aids 14:117–121 between an asymptomatic male genital tract exposure to Vicari E, Mongioi A, Speciale A, Caccamo F, Calogero A, Guli- Chlamydia trachomatis andanautoimmuneresponseto zia S, Pellegrino MB, Macchi M, D’Agata R (1986) Enhancing spermatozoa. Hum Reprod 10:2952–2955 detectionofgonococcusinejaculatesofadultmalesusing Witkin SS, Kligman I, Grifo JA, Rosenwaks Z (1995b) Ureaplas- sperm dilution. Arch Androl 16:19–23 ma urealyticum and Mycoplasma hominis detected by the Vicari E, Di Mauro C, Caruso V, Mongioi A (1991) [Antibiotic polymerase chain reaction in the cervices of women under- therapy in infertile subjects with chronic gonococcal infec- going in vitro fertilization: prevalence and consequences. J tions: measurement of sperm output]. Arch Ital Urol Nefrol Assist Reprod Genet 12:610–614 Androl 63:315–321 WolffH,NeubertU,ZebhauserM,BezoldG,KortingHC,Meu- Vigil P, Morales P, Tapia A, Riquelme R, Salgado AM (2002) rer M (1991) Chlamydia trachomatis induces an inflamma- Chlamydia trachomatis infection in male partners of infer- tory response in the male genital tract and is associated with tile couples: incidence and sperm function. Andrologia altered semen quality. Fertil Steril 55:1017–1019 34:155–161 Workowski KA, Levine WC, Wasserheit JN (2002) U.S. Centers Villette JM, Bourin P, Doimel C, Mansour I, Fiet J, Boudou P, for Disease Control and Prevention guidelines for the treat- Dreux C, Roue R, Debord M, Levi F (1990) Circadian varia- ment of sexually transmitted diseases: an opportunity to tions in plasma levels of hypophyseal, adrenocortical and unify clinical and public health practice. Ann Intern Med testicular hormones in men infected with human immuno- 137:255–262 deficiency virus. J Clin Endocrinol Metab 70:572–577 Wortley PM, Hammett TA, Fleming PL (1998) Donor insemi- Watson EJ, Templeton A, Russell I, Paavonen J, Mardh PA, Sta- nation and human immunodeficiency virus transmission. ry A, Pederson BS (2002) The accuracy and efficacy of Obstet Gynecol 91:515–518 screening tests for Chlamydia trachomatis: a systematic re- Yoshikawa Y, Truong LW, Fraire AE, Kim HS (1989) The spec- view. J Med Microbiol 51:1021–1031 trum of histopathology in the testis in acquired immunode- WeidnerW,KrauseW,LudwigM(1999)Relevanceofmaleac- ficiency syndrome. Mod Pathol 2:233–238 II.2.5 Disorders of Blood Flow: Arterial and Venous/ Sexual Dysfunction and Varicocele G. M. Colpi, M. Mancini, G. Piediferro, F. I. Scroppo Summary ■ Endothelial damage is the key disorder in ■ In cases of testicular torsion there is reduced vasculogenic organic erectile dysfunction (ED). blood flow in the contralateral side due to a ■ Middle-aged men with ED should be screened sympathetic reflex arising from the testicular for vasculogenic risk factors. artery under distress. II.2 ■ Our improved understanding of endothelial ■ Anomalies of testicular circulation are six damage will facilitate the development of a times more frequent in men who have had marker of endothelial damage, which, if devel- orchiopexy for testicular maldescent compared oped, could have a significant impact on the with normal men. Although some of this may diagnosis of men’s vascular disorders. be intrinsic some of this vascular damage is ■ Varicocele alters the dynamics of testicular iatrogenic. circulation and this, in turn, damages spermato- genesis and endocrine function of the testis. II.2.5 Disorders of Blood Flow: Arterial and Venous/Sexual Dysfunction and Varicocele 339 II.2.5.1 searched for in organic ED. Vascular damage may in- Erectile Dysfunction and Vascular Disease volve both large and small vessels. II.2.5.1.1 Summary II.2.5.1.3 Large and Small Vessel Damage Vascular penile dysfunction has been attributed to re- duced arterial inflow and excessive venous leakage but Involvement of large vessels in atherosclerosis is part of the role of venous leakage in the aetiology is now doubt- the extensive structural damage caused to the penile ed. Reduced arterial inflow may be both the cause and shaft. consequence of endothelial damage. Endothelial func- In the past, slowly progressive ED was considered to tion impairment is one of the initiating events in athero- be typical of vascular disease. sclerosis. So far, no reliable marker of early endothelial As early as 1988, Little and coworkers had shown damage has been validated in erectile dysfunction (ED). that obstructive damage of small lower limb arteries At present, risk factors are the most important elements correlated with increased risk of myocardial infarction. for identifying men with early atherosclerosis. Cavernosal arteries, the most important functional vessels in the penis, have a smaller diameter than coro- nary arteries (1–2 mm and 3–4 mm, respectively). In II.2.5.1.2 the presence of systemic atherosclerosis, a critical ob- Pathogenesis of Penile Vascular Damage struction (>50%) of cavernosal arteries can become A multifactorial origin is now generally accepted for symptomatic as ED, at first without any thoracic dis- ED.InmanyEDpatients,themaincauseisvascular comfort. Therefore, ED could be the first marker of ath- disease. Vascular involvement is ultimately due to me- erosclerosis, preceding cardiac or limb symptoms. Six- chanical and biochemical factors. ty-seven per cent of patients with coronary artery dis- Arterial flow in cavernosal arteries is crucial in or- ease experienced some ED more than 3 years before der to obtain a good erection. To support this mecha- their heart disease (Montorsi et al. 2003). Moreover, nism, luminal, endothelial and muscular integrity are even only partially impaired penile arterial circulation essential. Thereafter, trabecular tissue relaxation is reg- is thought to be bound to evolve into severe permanent ulated by paracrine contracting and relaxing factors. ED. Pritzker (1999) presented penile circulation as a Finally, penile pressure should be counterbalanced by window to the hearts of men. the albuginea wall, leading to venous compression. Ar- The wide variability of peak systolic velocities in the terial flow loss results in venous leakage. different segments of the penile arterial tree means that Although smooth muscle loss was found in men thelattermustbestudiedbycarefulechoDopplerul- classified as having venous leakage (Nehra et al. 1996) it trasound investigation, which can also identify any is now thought that venous leakage is a consequence of damage in small vessels. Observation of the latter and vasculogenic ED rather than a causative factor. their variations over time is crucial in order to under- Conversely, atherosclerotic damage of penile large stand the state of health of the penile circulation. Mea- vessels resulting in blood flow loss and pressure decline surement of cavernosal peak systolic velocity in a flac- in corpora cavernosa has been shown as a pathogenetic cid state can still be predictive of vascular damage, to mechanism. Trabecular fibrosis with reduced numbers be confirmed by dynamic echo Doppler (Mancini et al. of elastic fibres and increased collagen compounds hin- 2000a, b). Reduced penile arterial ramification and in- der rigid erection (Persson et al. 1989; Jevtich et al. creased vascular communications between dorsal and 1990; Wespes et al. 1991). The ultrastructural changes cavernosal arteries are reported to be markers of initial occurring within the corpora cavernosa are similar to damage (Mancini et al. 1996; Sarteschi et al. 1998). what is observed in the wall of the thinnest penile arter- Ischaemia and reperfusion phenomena may modify ies (Ferrini et al. 2004). Ischaemic processes increase the circulation, especially in a dynamic structure such reactive oxygen species (ROS), stimulating transform- as the penis. This was also confirmed following chronic q q ing growth factor- 1 (TGF- 1) accumulation and fibro- treatments with vasodilators, which may promote cir- blastic proliferation. culation remodelling (Mancini et al. 2004). II.2 The main factor counterbalancing this phenomenon Vascular damage is a dynamic process, and for diag- is production of inducible nitric oxide synthase (iNOS) nosing early changes markers of endothelial function by smooth muscle cells (SMCs). Nitric oxide (NO) scav- are needed, as these early changes cannot be detected enges ROS, thus inhibiting collagen deposition. The with echo Doppler ultrasound.
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