Venous leak and ED explained; symptoms, causes, treatments

Guys have many questions

Venous leak is a common cause of erectile dysfunction. Yet venous leak is not well understood. Guys I talk to have many questions about venous leak related to understanding, diagnosis, causes and treatments.

Purpose of this article

In this article, I'll do my best to answer all these questions. My hope is that you come away with a better understanding of venous leak, its causes, diagnosis and treatment, and what specific steps you can take to fix your venous leak.

Understanding venous leak

Understanding a normal erection

The key to an erection lies in the harmony of two fundamental processes: the influx of blood into the penis, and the impedance of blood from flowing out faster than it pours in.

Deep within the penile shaft lie the cavernosal arteries, the conduits for blood flow into the penis. When a man experiences sexual arousal, these arteries dilate, or expand, promoting an increased blood supply to the penis and initiating the erection. Ordinarily, the blood destined for the penis is returned through the penile veins and the deep dorsal vein.

However, the onset of an erection alters this flow. The corporal tissue, comprising the three main spongy components of the penile shaft, fills with blood and begins to harden. This engorgement compresses the veins, slowing the blood's exit from the penis. The erection is sustained as long as the inflow of blood, facilitated by the arteries, surpasses the outflow coursing through the veins.

Understanding venous leak

Venous leak refers to a condition where the erection is compromised due to excessive blood flow out of the penis, as the valve in the dorsal veins, which is supposed to retain the blood, fails to function adequately.

Consider an analogy of inflating a tire. To maintain the tire's firmness, air needs to be pumped in while the valve ensures the air is retained. If the valve is faulty or corroded, the air can leak out, leading to a deflated or soft tire.

The same principle applies to an erection. For an erection to occur and be maintained, blood needs to flow into the penis, and the outflow valve needs to function correctly to prevent the blood from escaping. If the outflow valve malfunctions, blood leaks out, causing the erection to soften or dissipate entirely.

This phenomenon of blood escaping, leading to the loss of an erection, is termed venous leak.

Detailed diagrams below illustrate the mechanism and causative factors of a venous leak.

For a comprehensive understanding of venous leak, watch this animated video click here.

 

Exploring venogenic Erectile Dysfunction

Venogenic erectile dysfunction denotes a type of erectile dysfunction (ED) that arises due to a venous leak.

Conversely, arteriogenic erectile dysfunction is a term used to describe ED resulting from inadequate blood inflow. To recall, arteries are responsible for blood inflow, while veins manage blood outflow.

To put it succinctly:

Arteriogenic ED corresponds to insufficient blood inflow via arteries.

Venogenic ED, also known as venous leak, is characterized by excessive blood outflow through veins.

What is veno-occlusive dysfunction?

Veno-occlusive dysfunction is another term used in medical parlance to describe a venous leak. The term 'occlusive' refers to blockage, thus 'veno-occlusive dysfunction' denotes a malfunction in the vein-blocking mechanism, specifically the valve. When the valve fails to operate correctly, it results in excessive blood outflow, giving rise to what is known as a venous leak.

What is CVOD?

CVOD stands for corporoveno-occlusive dysfunction, an additional medical term synonymous with venous leak. This term closely mirrors veno-occlusive dysfunction, with the prefix "corporo" added to specify that the dysfunction pertains to the corporal vessels of the penis. These corporal vessels, consisting of three spongy segments of the penile shaft, are the regions that engorge with blood during an erection.

How common is venous leak?

Venous leak is a condition that affects approximately 12% of men under the age of 45. As age ascends beyond 45 years, the incidence of venous leak correspondingly escalates. When considering all men with erectile dysfunction (ED), venous leak is a contributing factor in about 55% of cases, representing more than half.

In one significant study, it was discerned that the average age of patients with venogenic erectile dysfunction (venous leak) was considerably lower, at 51 years, in contrast to patients with arteriogenic erectile dysfunction (insufficient blood inflow), who averaged at 59 years. 

Is the blood actually leaking out?

Indeed, the term 'venous leak' refers to the actual leakage of blood. In every part of our body, arteries facilitate the inflow of blood, while veins manage its outflow. Unique to an erection, there's a special valve in the veins designed to decelerate the outflow of blood. When this valve begins to malfunction, similar to air escaping from a faulty tire valve, blood leaks out causing the erection to soften. This scenario precisely characterizes venous leak.

Understanding the deterioration of the valve

There could be several reasons why the valve may cease to function efficiently, but aging is typically the most prevalent cause. The functioning of the valve is pressure-activated; the pressure exerted by the erection forces the valve to close. As we age, two factors impact this mechanism detrimentally.

Firstly, with advancing years, erections may not be as firm as before, resulting in less pressure being applied to close the valve. Secondly, veins tend to harden with age, requiring more pressure to close the valve effectively, much like the valve stiffening over time.

So essentially, an erection in the older age is trying to close a stiffer valve with less available pressure. Consequently, the valve doesn't seal as effectively as it did during youth, leading to venous leak.

Why don’t drugs or injections always maintain the erection?

Drugs and injections primarily work by stimulating blood inflow. Think of these therapies as the equivalent of pumping more air into a tire. If there's just a slow leak, the additional pumping may suffice to keep the tire inflated. However, as the leak intensifies, the tire may still deflate, regardless of the consistent pumping.

Analogously, in the context of an erection, if a venous leak is present, the drugs and injections designed to amplify blood inflow may fall short in maintaining the erection. Despite their use, the erection could still soften due to the excessive outflow of blood.

Addressing the effectiveness of pumps

Addressing the Effectiveness of Pumps:

Pumps function by creating a vacuum around the penis, which draws blood into it. The vacuum causes the blood pressure in the body to be greater than that inside the penis, thereby driving blood towards the area of lower pressure. As long as the vacuum pump remains engaged, the erection is sustained due to this pressure differential.

However, the moment the pump is disengaged, the vacuum around the penis is lost. The blood pressure within the penis equalizes with the systemic blood pressure. Without a driving pressure differential, blood will escape from the penis if a venous leak exists.

While some men have had success using rings in combination with pumps, others find the effectiveness less than ideal. These rings work by physically compressing the dorsal veins to inhibit blood outflow. But they often shift position due to lubrication and body fluids in the area, or because the penile skin itself moves along the shaft during the thrusting motion of intercourse.

This continual repositioning of the ring allows some blood to escape from underneath it, potentially causing the erection to soften or dissipate completely. Hence, although pumps can be beneficial in certain cases, they may not provide a satisfactory solution for all men, particularly those experiencing venous leak.

Understanding decrease in efficacy of drugs and injections over time

Think of it akin to the analogy of a tire. If a pump that used to fill your tire effectively no longer does so, it indicates one of two possible issues - either the pump isn't efficiently delivering air into the tire, or there's a leak in the tire or its valve that's letting air escape faster than it's being filled.

Similarly, in the context of an erection, if drugs or injections that once worked to maintain an erection are no longer doing so, it could imply that the effectiveness of these medications in encouraging blood inflow has decreased. Alternatively, it could suggest the onset or worsening of a venous leak, which is allowing more blood to escape from the penis than the amount being supplied by the arteries.

Either situation leads to an imbalance between the inflow and outflow of blood, undermining the effectiveness of the drugs or injections that were once able to maintain an erection.

Diagnosing venous leak

How do I know if I have venous leak - diagnostic tests and self-diagnosis

If you suspect you might have venous leak, there are a couple of ways to investigate. One way is to visit a qualified urologist who can perform a diagnostic test. This typically involves the administration of a drug to induce an erection, followed by the use of a Doppler ultrasound machine to measure blood flow in the penis. This ultrasound process is entirely painless, akin to the procedure used to monitor the health of a fetus during pregnancy.

However, if you're hesitant about visiting a urologist for a diagnostic test, there are certain symptoms that might hint towards venous leak and allow for self-diagnosis:

1. You are able to achieve an erection but find it challenging to maintain it.
2. Prescription drugs or injections that previously were effective no longer seem to work as efficiently.
3. Your ability to maintain an erection is position-dependent - you lose it when changing positions.
4. Despite achieving an erection, it feels softer than normal.

These signs could indicate a potential venous leak, prompting a need for further professional evaluation and treatment.

Can you feel venous leak?

Venous leak is a subtle condition that can't be felt physically. It refers to the abnormal flow of blood in the veins, particularly in the context of an erection where the blood exits the penis too quickly. Much like the circulation of blood throughout your body's network of veins, this process is silent and imperceptible. Hence, venous leak isn't something you can physically feel, but its effects, such as difficulties in maintaining an erection, can be experienced.

My erection goes away too early

Experiencing an erection that dissipates prematurely could potentially indicate venous leak. However, it may also signal insufficient blood inflow. Even after achieving a full erection, a certain level of blood inflow is necessary to sustain it. Hence, while early loss of an erection might suggest the presence of venous leak, it shouldn't be viewed as a definitive sign. Other factors may be involved, necessitating a more comprehensive assessment to accurately determine the cause.

My erection is soft

If you're experiencing a soft erection, it could potentially indicate the presence of venous leak. However, it's important to consider that a soft erection may also arise from insufficient blood inflow. Even after achieving initial hardness, an ongoing blood inflow is necessary to maintain the erection. Therefore, while a soft erection can be suggestive of venous leak, it should not be considered as a definitive confirmation. Other factors may contribute to this condition, necessitating further evaluation to determine the underlying cause accurately.

My erection depends on position

If you find that specific body positions make it challenging to either achieve or sustain an erection, it may be indicative of venous leak. Venous leak can disrupt the balance between blood inflow and outflow during an erection, leading to difficulties in maintaining optimal penile rigidity in certain positions. If you observe such position-dependent erection difficulties, it could be a strong clue suggesting the presence of venous leak. Consulting with a healthcare professional can help determine the underlying cause and provide appropriate guidance for management.

My erection depends on the time of day

The timing of your erections can provide valuable insights into the underlying causes of erectile difficulties. Morning erections, also known as nocturnal penile tumescence, are often attributed to the activation of the parasympathetic nervous system during sleep. The parasympathetic system plays a role in sexual arousal, among other functions, and is particularly active during periods of rest and repair.

During sleep, it's normal for the penis to undergo cycles of erection and flaccidity, with multiple occurrences throughout the night. You may notice these erections upon awakening, commonly referred to as morning erections.

In the early stages of erectile dysfunction (ED), it's not uncommon for individuals to experience robust morning erections while encountering difficulties in achieving erections later in the day. This pattern could suggest the presence of venous leak or insufficient blood inflow.

I can't get an erection at all, even with drugs and injections

Injections are a potent method for inducing an erection, and if there were no underlying venous leak, it is highly probable that you would experience at least a partial erection from such injections. However, if you find that you are unable to achieve an erection at all, even with the use of drugs or injections, it is likely that venous leak is contributing to your condition.

Venous leak can hinder the effectiveness of medications and injections by allowing excessive blood outflow from the penis. As a result, the expected response to these interventions may be compromised, leading to the inability to achieve an erection. It is advisable to consult with a healthcare professional to discuss your symptoms and explore further diagnostic tests to confirm the presence of venous leak and explore appropriate treatment options.

My doctor says I have venous leak.

If your doctor has conducted a thorough evaluation, including a doppler ultrasound, and diagnosed you with venous leak, it is reasonable to trust their professional assessment. They have likely considered various factors, symptoms, and diagnostic tests to arrive at this conclusion.

It is important to note, however, that diagnostic tools, including ultrasounds, are not infallible and may have some margin of error. Studies have indicated that there is a possibility of misdiagnosis, particularly among younger adults, when relying solely on penile ultrasound for identifying venous leak. Therefore, it's essential to have open communication with your doctor, discuss any concerns you may have, and consider seeking a second opinion if necessary.

Remember, your doctor's expertise and knowledge of your specific case are crucial in determining the most appropriate course of action and treatment for your condition.

Causes of venous leak

What causes venous leak?

Venous leak can arise from various factors and conditions, including:

1. Psychological stress
2. Neurological deficiencies
3. Hypertension (high blood pressure)
4. Adverse effects of certain drugs
5. Chronic diseases, such as diabetes
6. Lower urinary tract issues
7. Testosterone deficiency
8. Damaged vein walls
9. Hereditary factors
10. Lifestyle factors
11. Diseases
12. High stress levels
13. Physical trauma
14. Psychological or sexual trauma
15. Normal aging process

These factors can contribute to the development or exacerbation of venous leak, leading to the inefficient retention of blood in the penis during an erection. Identifying and addressing the underlying cause, in conjunction with appropriate treatment strategies, can help manage venous leak and restore erectile function.

Diseases and disorders that cause venous leak

Vascular diseases

The most common diseases linked to venous leak are diseases of the vascular system. These include: arteriosclerosis (hardening of the arteries), peripheral artery disease, carotid artery disease, pulmonary embolism, collagen vascular disease, and cerebrovascular disease.

Because vascular diseases are by definition diseases of the vessel system, especially those that carry blood, they are often linked to problems with the penile vessel system, and therefore can either directly cause venous leak or be predictors of venous leak.

Diabetes

The prevalence of ED is three times higher in diabetic men, occurs at an early stage of diabetes and increases with disease duration.

Boston University School of Medicine reports in one study that "In comparison to control erectile tissue from potent men, erectile tissue specimens from diabetic men showed impaired ability to relax smooth muscle. This abnormality leads to loss of blood from the erection chambers, causing poor ability to maintain the erection. This is called venous leak."

Peyronie's disease

Peyronie's disease is a buildup of scar tissue in the penis that leads to curved, sometimes painful erections.

John Hopkins Medicine notes that "Erectile function may be adversely affected by Peyronie’s disease. It is unclear whether erectile dysfunction causes Peyronie’s disease or vice versa. It is probably a little bit of both."

While most patients with Peyronie’s disease report normal penile rigidity during erections, some have trouble maintaining erections due to leaky veins (venous leak) in the penis.

Obesity

PubMed reports in one study that "It is clearly apparent that the development of the obese condition can have profound, and frequently difficult to predict, impacts on integrated vascular function." Because of the impact on vascular function (including function of the blood vessel system), obesity can often trigger venous leak.

Hypertension

An article in the National Library of Medicine makes the case that since smooth muscle of the penile corporal tissues (where the blood is stored during an erection) is the same as smooth muscle of the venous system (blood vessels), it follows that age-related deterioration of the blood vessels also occurs in the penis. Therefore, they argue, symptoms of hypertension (high blood pressure) will often correlate with ED caused by venous leak.

Lifestyle factors for venous leak

Lifestyle and nutrition have been recognized as central factors influencing both vascular health and corresponding erectile function. Lifestyle habits that decrease low-grade clinical inflammation may have a significant role in reducing erectile dysfunction. Both basic and clinical studies have shown that targeting several lifestyle factors commonly associated with ED, such as smoking, alcohol consumption, obesity, and limited physical activity can have significant effects on improvement of erectile function, as well as improving testosterone levels.

Genetics

I was unaware that venous leak could be genetically inherited until a Xialla customer read this article and wrote to me to say that he has genetic venous leak from a young age, and that his urologist informed him that it may be passed on to his children. He suggested that I mention it in this article. Thank you for your contribution.

Aging and venous leak

Perhaps the most common cause of venous leak is normal aging. As mentioned previously , the valve that controls blood outflow is pressure-activated, meaning that the pressure of the erection closes the value. Two factors of old age make this mechanism less effective. The first factor is that the erection is not as hard as it used to be, so there's not as much pressure closing the valve. The second factor is that the veins harden with age, so it takes more pressure to close the valve. It's like the valve stiffens with age.

So the erection is trying to close a stiffer valve, with less pressure. The valve doesn't close off as well as it did when we were younger, resulting in venous leak.

Does a prostatectomy cause venous leak?

Prostatectomy surgery usually results in temporary or permanent reduction of erectile function.Pubmed reports that nerve-related tissue damage resulting from the surgery may cause venous leak. The prevalence of venous leak has been found to correlate to whether the surgery was nerve-sparing, with bilateral nerve-sparing having the lowest incidence of venous leak, unilateral nerve-sparing having the next lowest incidence, and non nerve-sparing having the highest incidence of venous leak.

Does enlarged prostate cause venous leak?

Men who have benign prostatic hyperplasia (BPH), a noncancerous enlargement of the prostate, may experience erectile dysfunction and ejaculatory problems.

Although BPH does not itself cause these problems, some of the treatments used for BPH can do so. For example, finasteride (Proscar), an anti-testosterone drug prescribed for BPH, has been linked to erectile dysfunction in 3.7% of men who use it and to diminished libido in 3.3%.

On the other hand, alpha blockers such as  tamsulosin, alfuzosin, and silodosin can improve the symptoms of BPH with a lower risk of sexual side effects.

Transurethral resection of the prostate, a surgical technique often used when medication fails, also causes erectile dysfunction in a small percentage of men.

Treatment of venous leak

Is venous leak curable?

The current definitive cures for venous leak are ligation surgery, deep-penile-vein arterialization surgery, and surgery involving a combination of the two techniques. Ligation surgery involves ligature (closing off) of selected blood veins to slow the venous leak. Arterialization surgery splices blood vessels between the arteries and veins so that blood can cross from arteries to veins and vice versa and so that pressure can be partially equalized between arteries and veins.

How successful is venous leak surgery?

Venous leak surgery is not very successful.

A PubMed article reports 49% success rate treating venous leak with ligation surgery. It also reports a growing preference for combination arterialization/ligation surgery over regular ligation surgery. However, another PubMed article reports a low success rate (25%) for arterialization surgery.

Frontiers in Cardiovascular Medicine reports in one article that "Not very encouraging, long-term success rates of surgical ligation of the deep dorsal vein and its collaterals are reported to be approximately 25%".

How do you fix venous leak?

New York Urology Specialists reports that "Veno-occlusive dysfunction is one of the most challenging problems to treat.  For some patients with mild venous leak, ED medications might work. Using a penile constrictive ring might allow men to maintain erections for a prolonged period of time.  Some men are successful in using vacuum erection devices or penile injections in combination with a penile constrictive ring.

Pelvic floor exercises

A PubMed article reports that significant improvement of venous leak can be achieved through pelvic floor exercises. Thank you to our customer who sent me the article link.

Treating venous leak with Xialla

Xialla is a new medical device designed to treat venous leak simply, effectively, and without drugs, injections or surgery.

Xialla works on the principle of direct compression of the dorsal veins by means of a penile constrictive ring. Unlike other rings, however, Xialla is secured in place against the scrotum by means of a patented mechanism, thus preventing it from sliding back and forth longitudinally along the penile shaft during intercourse. The anchoring mechanism makes Xialla three times as effective as regular rings at blocking venous outflow.

How does Xialla work for venous leak?

Xialla works by compressing the penile veins and deep dorsal vein, slowing blood outflow. Think of it as fixing a leaky valve on a tire.

Why is Xialla better than other rings?

Xialla is better than other rings because it's anchored in place to prevent it from moving back and forth along the penile shaft during intercourse. Other rings are not anchored in place, and therefore they tend to slide forward and backward along the penis shaft. The back and forth movement allows blood to escape from the erection.

Is Xialla better than a pump?

Xialla is not better than a pump. Rather, it works well when it's used as a replacement for the rings that come with the pump. The pump can be used to draw blood into the penis to start the erection. Once the pump is removed, Xialla will hold the blood in better than a regular pump ring.

Many of our customers find their erection goes away after pumping, even with the pump ring in place. They report that Xialla holds the erection better.

For more information on using Xialla with ED pumps, we have an article here.

For a step-by-step guide to using Xialla with ED pumps, we have an article here.

Why will Xialla work if drugs and injections don’t?

Drugs and injections increase blood inflow. However they don't fix excess blood outflow (venous leak). Xialla fixes excess blood outflow.

I read that Xialla can be used in combination with drugs or injections. Please explain. 

Erectile dysfunction can be caused by too little blood inflow, too much blood outflow, or a combination of the two. In cases where the ED is caused by a combination of causes, it may require a combination of therapies to achieve successful results.

Using a combination of therapies, drugs or injections are used to increase blood inflow while Xialla slows the blood outflow. The combination is proven to achieve excellent results in many cases.

For more information on using Xialla with medications or injections, see this article.

I read that Xialla can be used in combination with pumps. Please explain.

While both the manual and battery-powered pumps are high-quality products that are proven to effectively enhance blood inflow, the rings may not be as effective at preventing blood outflow. This is because the standard ring-style constriction device tends to move during sex, sliding up and down the shaft of the penis during intercourse. With each motion, blood can escape from the penis, which in turn reduces the firmness of the erection. To reduce the amount of blood outflow, the constriction device ideally needs to be anchored in place so that it can provide a more effective barrier against blood outflow. 

Xialla is anchored in place using a patented mechanism. It provides an excellent substitute for the rings that come with pumps.

For information on using Xialla with pumps, see this article. For a step by step guid to using Xialla with pumps, see this article.

Conclusion

Venous leak is a common cause of erectile dysfunction. Yet venous leak is not well understood. Venous leak is difficult to treat, and it's important to have a good understanding of venous leak in order to be able to make an informed treatment decision.

In this article, I've tried to answer all the questions that I hear from guys about venous leak. I welcome your ongoing comments and feedback to continue to improve the article.

Email me at:

Nigel Shaw
hello@xialla.com