Urologist treats ED caused by blood flow blockages

DEAR DR. ROACH: Some months ago, you wrote that the blood flow to the penis could be reduced by blockages in the arteries. What kind of doctor should a guy go to, and what tests should be asked for?

— J.

ANSWER: Low blood flow to the penis is one common cause of erectile dysfunction. Without adequate blood to the arteries supplying the penis, an adequate erection may not be possible.

It is unusual that those arteries are the only ones blocked. This symptom occurs most commonly in people with multiple blockages, although ED is occasionally the first indication of atherosclerotic arterial disease. Hence, men with ED should be have an evaluation for other arterial blockages, such as to the legs, heart or brain. An imaging study or stress test may be appropriate in men with risk factors.

Although family doctors, internists and cardiologists all do evaluation for arterial disease, a urologist who specializes in erectile dysfunction may have additional tools available, such as an arterial duplex ultrasound of the penis to look for blockages.

DEAR DR. ROACH: I was discharged from the Army with an epigastric hernia, which I was told was the size of a football and was considered disabling. Recently I was examined and told that my hernia could be fixed by surgery. I’m concerned because I had a heart attack a few years ago and had four blocked arteries. I feel that at age 82, surgery is too dangerous. My cardiologist recommended against surgery. Should I get surgery?

— A.H. ANSWER: A hernia is a defect in the abdominal wall, with the possibility that the abdominal contents, such as bowel, could come through the opening. An epigastric hernia occurs in the midline between the navel and the bottom of the breastbone.

Extensive physical conditioning, such as you probably received during Army training, is a known risk factor for epigastric hernia.

There’s one critical piece of information you haven’t told me, and that is whether the hernia is causing symptoms, usually pain. If there is pain, you would have to decide by weighing the risk of surgery against the benefit of pain relief. Most people with epigastric hernias have only mild discomfort. Although surgery is typically lower risk, any surgery has risks, and because of your history of heart attack and known blockages, your risk is higher than an average 82-year-old’s. The fact that your cardiologist is recommending against this should be taken very seriously.

In absence of symptoms, or with very mild symptoms, I would not recommend surgery for a person in your situation. The risk of complications from an epigastric hernia is small. The most dangerous complication is a loop of bowel coming through the hernia opening and getting stuck (called incarceration) or worse yet, losing its blood supply (called strangulation). These are surgical emergencies, and happen in 2%-3% of people every year. That’s the overall number; epigastric has a lower risk. Obviously, repair at a younger age makes more sense due to a longer lifetime of risk as well as (usually) lower risk from surgery.