A 67-year-old male presents to his primary health care physician complaining about erectile dysfunction for the last 3 months. He states that he has normal sex drive, but he cannot remember the last time he had a nocturnal erection. His medical history includes dyslipidemia, hypertension, and stable angina. He takes aspirin, irbesartan-hydrochlorothiazide and atorvastatin. He is a current smoker with a 45 pack-year smoking history. Physical examination reveals weak groin and ankle pulses bilaterally. After further questioning, the patient admits having bilateral leg pain after walking barely approximately 100 feet. The pain is relieved upon rest. Urological examination is normal and cremasteric reflex is elicited.
The correct answer is: C. Ankle-Brachial Index (ABI)
This 67-year-old male patient presents with complaints of erectile dysfunction. The gradual onset of his condition and the absence of nocturnal erections indicate an organic cause of his symptoms. Physical examination reveals weak popliteal and pedal pulses. These findings in combination with intermittent claudication highlight the vascular origin of patient's erectile dysfunction and suggest that an ABI is the best next step in the evaluation process.1–3
Leriche syndrome (i.e. aortoiliac occlusive disease) is the thrombotic occlusion of infrarenal aorta that extends to common iliac, femoral, and distal arteries of lower limb. The primary cause is the formation of atherosclerotic plaques that narrow the lumen and distort normal blood supply to lower limb. Potential risk factors include smoking, diabetes, hypertension and hyperlipidemia.1
Leriche syndrome is divided into three classes according to anatomic location of lesions:
- Class I: Infrarenal abdominal aorta and common iliac arteries
- Class II: Infrarenal abdominal aorta, common iliac arteries, external iliac arteries, and femoral bifurcation
- Class III: Infrarenal abdominal aorta, common iliac arteries, external iliac arteries, and femoral bifurcation, popliteal or tibial arteries
The most common presentation of Leriche syndrome is bilateral leg pain relieved upon rest (i.e. bilateral intermittent claudication). Leriche syndrome can also present with impotence, secondary to reduced blood flow to internal iliac artery and subsequently to sinusoidal spaces of the penis. The hallmark of physical examination is weak groin-femoral and pedal pulses bilaterally.1,3
ABI is often the first screening test performed, because it is non-invasive, inexpensive, and reliable. ABI <0.9 is considred abnormal and indicates significant level of peripheral artery occlusion. High resolution computed tomography angiography (CTA) is the "gold standard" in diagnostic evaluation of Leriche syndrome and it can be performed with minimal amount of intravenous contrast. Depending on the specific anatomy, these lesions can be treated with endovascular or surgical approaches.1,2
Psychological counseling (Answer A) is recommended for patients with a psychogenic cause of erectile dysfunction, which usually appears abruptly in a young patient without atherosclerotic risk factors. Gradual onset of impotence in this patient accompanied by intermittent claudication point toward a vascular origin of the condition.
Echocardiogram (Answer B) offers a non-invasive imaging of heart abnormalities and evaluates for a potential cardiac source of peripheral embolus. Because aorta and common iliac arteries have a wide lumen, they are not a common location for a cardiac embolus. Furthermore, peripheral embolism usually occurs unilaterally, affecting the distal vessels of the lower limb.
Duplex ultrasound (Answer D) of penile vasculature contributes to the evaluation of erectile dysfunction of vascular origin, especially in penile arterial insufficiency or venous leak. However, intermittent claudication and absent groin pulses indicate an occlusive lesion in iliac arteries or aorta.
Prostate-specific antigen (PSA) screen (Answer E) is used as a screening tool for determining the extent of prostate cancer and assessing the response to prostate cancer treatment.
Educational Objective
Aortoiliac occlusive disease (Leriche syndrome) involves atheromatous lesions that occludes infrarenal abdominal aorta, common iliac arteries, and popliteal or tibial arteries of legs. Intermittent claudication and erectile dysfunction are common manifestations of the disease. ABI evaluation is a non-invasive and inexpensive first step in assessing the degree of occlusion of aortoiliac vasculature.1–3
References
- Kretschmann T, Usai MV, Taneva GT, Pitoulias GA, Torsello G, Donas KP. The role of open and endovascular treatment of patients with chronic aortoiliac Leriche syndrome. Vascular 2020;28:68-73.
- Meric M, Oztas DM, Ugurlucan M. Internal thoracic artery: a major collateral supply in case of Leriche syndrome. J Thorac Cardiovasc Surg 2019;S0022-5223:31417-5.
- Bhatia MS, Gautam P, Saha R. Leriche syndrome presenting as depression with erectile dysfunction. J Clin Diagn Res 2016;10:VD01-2.
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