Can Severe Ostial Stenosis of the Left Internal Iliac Artery Cause Erectile Dysfunction?
Yes, severe ostial stenosis of the left internal iliac artery can definitively cause erectile dysfunction, particularly when bilateral internal iliac artery disease is present or when the stenosis is hemodynamically significant enough to reduce penile arterial perfusion pressure. 1
Pathophysiological Mechanism
The internal iliac (hypogastric) arteries are the primary vascular supply to the erectile apparatus through the internal pudendal arteries, which ultimately perfuse the cavernous bodies of the penis. 1, 2 When stenotic lesions occur at the ostium of the internal iliac artery, they create a hemodynamic bottleneck that reduces downstream arterial pressure in the penile circulation, preventing adequate blood accumulation in the cavernous spaces required for rigid erection. 3
Bilateral internal iliac artery stenosis proximal to the vessel origins produces the most severe erectile dysfunction, as documented in ACC/AHA guidelines, because it eliminates collateral compensation from the contralateral side. 1 However, even unilateral severe stenosis can contribute to erectile dysfunction, particularly in patients with pre-existing endothelial dysfunction or when the contralateral internal iliac artery has subclinical disease. 4
Clinical Evidence Supporting Causation
Pelvic arterial insufficiency is the predominant cause of erectile dysfunction in men over 50 years of age, with stenosis anywhere along the iliac-pudendal-penile arterial axis capable of producing symptoms. 2
A 2023 case-control study of 33 men with common iliac artery stenosis >80% demonstrated significantly worse erectile function compared to healthy controls (P=0.002), with improvements in erectile function (P=0.008), orgasm (P=0.021), and desire (P=0.014) observed 6 months after endovascular revascularization. 4
The PERFECT registry from Taiwan showed clinical improvement in over 60% of patients at one year following pelvic angioplasty for arterial insufficiency-related erectile dysfunction. 2
Historical angioplasty series from the 1980s-1990s demonstrated that 65-67% of patients with internal iliac or internal pudendal artery stenosis experienced resolution of erectile dysfunction following percutaneous transluminal angioplasty. 5, 6
Diagnostic Approach
When evaluating a patient with erectile dysfunction and known left internal iliac artery ostial stenosis, the key diagnostic steps are:
Assess for bilateral disease using CT angiography of the pelvis, as unilateral findings on one imaging study may miss contralateral stenosis that compounds the hemodynamic impact. 2
Perform penile duplex ultrasound to measure dorsalis penis artery pressure and flow velocities, which directly quantify the downstream hemodynamic consequences of the proximal stenosis. 2
Document response to phosphodiesterase-5 inhibitors (PDE5i), as poor response suggests fixed arterial insufficiency rather than functional endothelial dysfunction. 2
Evaluate for associated lower extremity claudication symptoms (buttock, thigh, or hip), which indicate more extensive aortoiliac disease and strengthen the case for vascular causation. 1
Treatment Considerations
Endovascular revascularization should be considered for patients with anatomically suitable vessels and functionally significant stenoses who have failed medical therapy. 2, 6
Balloon angioplasty with or without stenting of internal iliac artery ostial lesions has demonstrated safety and efficacy, with 60-65% of patients achieving sustained improvement in erectile function. 2, 5, 6
The procedure is repeatable with low complication rates and represents a less invasive alternative to surgical revascularization. 6
A 30-40% restenosis rate in distal internal pudendal and penile arteries remains a limitation, though proximal iliac interventions have better durability. 2
Critical Caveats
Bilateral internal iliac artery exclusion during aortoiliac interventions causes buttock claudication in 36% of patients and can worsen or precipitate erectile dysfunction. 1, 7 When treating aortoiliac aneurysmal or occlusive disease, preservation of at least one hypogastric artery is crucial to maintain pelvic perfusion. 1, 7
The presence of ostial stenosis alone does not guarantee causation—correlation with hemodynamic significance (reduced penile arterial pressure on duplex ultrasound) and failure of PDE5i therapy strengthens the causal relationship. 2 Psychogenic factors, neurogenic dysfunction, and hormonal abnormalities must be excluded as competing or contributing causes. 3