Embolization for Erectile Dysfunction

Context and indications

Venous erectile dysfunction — known as veno-occlusive dysfunction or "venous leak" — occurs when blood does not remain sufficiently in the penile corpora cavernosa to maintain a rigid erection. This mechanism represents a common and frequently underdiagnosed cause of erectile dysfunction.

Penile venous embolization is offered when first-line medical treatments (phosphodiesterase type 5 inhibitors such as sildenafil, tadalafil) prove insufficient and a venous leak has been documented by complementary investigations. In some cases, embolization can be combined with penile arterial revascularization when an arterial component coexists (mixed erectile dysfunction).

Pre-procedural workup

Diagnosis relies on a specialized workup including:

• Penile Doppler ultrasound with intracavernosal injection of prostaglandin E1, assessing arterial inflow and venous outflow.
• Dynamic cavernosometry (pharmacological stimulation followed by intracorporal pressure measurement), the gold standard examination for confirming venous leak.
• CT cavernosography to precisely map leak sites and plan the approach. This examination distinguishes superficial leaks (dorsal vein), deep leaks (cavernosal veins, periprostatic plexus, pudendal veins), or mixed patterns.

Access routes

Venous leak embolization can be performed through different vascular access routes, selected based on venous anatomy and leak location:

• Anterograde access via the deep dorsal penile vein: ultrasound-guided percutaneous puncture of the deep dorsal vein at the base of the penis under local anesthesia. This route provides direct, preferential access to the cavernous drainage network. In a landmark prospective study of 50 patients (Diehm et al., CVIR 2023), procedural success reached 98% via this route, with no major adverse events.
• Retrograde access via the femoral vein: puncture of the femoral vein at the groin, followed by catheterization of the internal iliac and pudendal veins to the periprostatic plexus. This classic approach is particularly used for deep leaks.
• Retrograde access via the brachial vein (arm): puncture of the brachial vein at the elbow, with navigation to the target pelvic veins. This upper limb alternative may be preferred based on anatomical criteria and patient comfort.

The access route is determined by the interventional radiologist on a case-by-case basis, guided by CT cavernosography findings and the patient's venous anatomy.

Procedure

The intervention is performed in an angiography suite under local anesthesia and light sedation. After puncture of the chosen access site and introducer placement, a microcatheter is guided under fluoroscopic control to the veins responsible for the leak.

Embolization is carried out using appropriate embolic agents:

• Biological glue (N-butyl-2-cyanoacrylate, such as Glubran or Histoacryl) mixed with Lipiodol (ethiodized oil) in a 1:1 to 1:3 ratio, providing rapid and durable occlusion of the incompetent veins.
• Fibered microcoils, used as adjuncts in high-flow veins to prevent glue migration.
• Sclerosing agents, used in selected cases for superficial leaks.

A completion venogram is performed at the end of the procedure to confirm occlusion of the targeted leaks. The procedure takes approximately 1 to 2 hours.

Results

Recent evidence from the literature is encouraging:

• Technical success: 86 to 99.5% across published series (Doppalapudi et al. meta-analysis, 2019; Diehm et al. multicenter registry, 2025: 193/194 patients).
• Clinical improvement: approximately 60 to 68% of patients experience significant improvement in erectile function, measured by the IIEF-15 score (improvement ≥ 4 points at 6 weeks in 68% of cases; Diehm et al., CVIR 2023).
• Patient satisfaction: in the Diehm et al. study, 78% of patients reported willingness to undergo the procedure again, and 82% reported overall improvement.

In cases of mixed erectile dysfunction (arterial and venous), venous embolization combined with pudendal artery angioplasty can provide additional benefit (American Hospital Paris, series of 661 patients, improvement in 65.4%).

Risks and complications

The overall complication rate is low (approximately 5% in published series). The main risks include:

• Mild to moderate penile pain in the days following the procedure (common, transient).
• Puncture site hematoma.
• Asymptomatic pulmonary microembolization of embolic material (rare, < 4%, managed with short-term anticoagulation).
• Embolic material migration (exceptional).
• Recurrence of venous leak over time.

No major adverse events were reported in the prospective series of 50 patients by Diehm et al. (2023).

Recovery and follow-up

Patients are discharged on the same day (outpatient procedure). A relative rest period of 3 to 5 days is recommended before resuming sexual activity, and 7 days for strenuous physical exercise. Improvement in erectile function is progressive, typically over 4 to 8 weeks.

Clinical follow-up is scheduled at 6 weeks and 3-6 months, with IIEF questionnaire assessment and follow-up Doppler ultrasound if needed.

Practical information

The procedure is performed under local anesthesia and light sedation, on an outpatient basis. A prior consultation with the interventional radiologist allows assessment of the case and definition of the optimal treatment strategy.