Venous leak and ED explained; symptoms, causes, treatments

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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.

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Understanding venous leak

How does a normal erection work?

For an erection to happen requires two fundamental things; blood must flow into the penis, and blood must be blocked from flowing out faster than it flows in.

Blood flows into the penis through the cavernosal arteries deep within the penile shaft. These arteries dilate (expand) when a man is sexually aroused, increasing blood flow to the penis to start the erection. Normally blood to the penis flows back out through the penile veins and deep dorsal vein. However when an erection starts, the corporal tissue (the three main spongy parts of the penis shaft) fills with blood and starts to get hard. As it does it squeezes (compresses) the veins, slowing the flow of blood out of the penis. As long as the flow in (arteries) is faster than the flow out (veins) the erection is maintained.

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"Please explain venous leak to me"

Venous leak is when excess blood flows out of the erection because the valve in the dorsal veins, that should hold the blood in, doesn't work properly.

Think of an erection as like pumping up a tire. You need to get air in, but you also need the valve to hold the air in. If the valve is rusty or doesn't work, the air can leak out, causing a soft tire, or a flat.

Similarly, with an erection, you need blood to flow in and you need the outflow valve to work properly to prevent the blood from flowing out. If the outflow valve doesn't work properly, blood escapes and the erection goes soft or is lost.

The condition of the blood escaping to cause loss of the erection is called venous leak.

The following diagrams illustrate the mechanism and cause of venous leak.

For an animated video illustrating venous leak, click here.

This is the cross section of a penis
(what it would look like if you cut it in half
and looked at the cut end)
Blood flows into the penis through arteries.
Blood flows out of the penis through veins.
During a normal erection, the penis expands, and the pressure of the erection causes the veins to compress, which slows the blood outflow. When the blood outflow is slowed, this maintains the erection.
If the pressure of the erection is too low, the veins have hardened with normal aging, or for reasons related to disease or injury, the veins may not compress properly.
If the veins don't compress, blood is able to escape. The blood outflow is called venous leak, and causes loss of the erection.

What is venogenic erectile dysfunction?

Venogenic erectile dysfunction is the medical term for ED caused by venous leak.

On the other hand, arteriogenic erectile dysfunction is the medical term for ED caused by insufficient blood inflow. Remember, blood flows in through arteries and out thorough veins.

To summarize;

Arteriogenic ED = too little blood inflow through arteries.

Venogenic ED (venous leak) = too much blood outflow through veins.

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What is veno-occlusive dysfunction?

Veno-occlusive dysfunction is another medical term for venous leak. Occlusive means blocking, so veno-occlusive dysfunction means the vein-blocking system (the valve) is not functioning properly (dysfunction). When the valve doesn't function properly, it causes too much blood outflow, or venous leak.

What is CVOD?

CVOD is corporoveno-occlusive dysfunction. This is yet another medical term for venous leak. The term is similar to veno-occlusive dysfunction, and simply adds the "corporo" prefix to indicate that the dysfunction relates to the corporal vessels of the penis. The corporal vessels are the three spongy parts of the penis that fill with blood during an erection.

How common is venous leak?

Venous leak occurs in about 12% of men under the age of 45. As age increases over 45 years, the frequency of venous leak also increases. For all men with ED, venous leak is a factor about 55% (over half) of the time.

One study found that the average age of patients with venogenic erectile dysfunction (venous leak) was found to be significantly lower (51 years) than that of patients with arteriogenic erectile dysfunction (insufficient blood inflow) (59 years)

Is the blood actually leaking out?

Venous leak means the blood is actually leaking out. In all parts of the body, blood flows in through arteries and out through veins. In an erection, there's a special valve in the veins to slow the blood outflow. When this valve starts to fail, blood leaks out just as air leaks out of a bad tire valve, and the erection goes soft.

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Why does the valve stop working?

There are several reasons the valve can stop working, but the most common reason is aging. The valve 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.

Why don’t drugs or injections work? 

Drugs and injections activate blood inflow. Think of drugs and injections as pumping more air into the tire. If there's only a slow leak, then more pumping will keep the tire inflated. However as the leak gets worse, the tire goes soft or flat, even with a lot of pumping.

Similarly with the erection, if there's venous leak, the drugs and injections that activate blood inflow may not be sufficient to maintain the erection. The erection goes soft.

Why don’t pumps work? 

Pumps draw blood into the penis with vacuum. By creating a vacuum around the penis, the normal blood pressure in the body becomes greater than the blood pressure in the penis, so blood flows into the region of less pressure. As long as the vacuum pump remains in place, the erection is maintained due to the pressure differential.

However, when the pump is removed, there is no longer a vacuum around the penis. The blood pressure in the penis is the same as the blood pressure in the body. There's no longer a pressure differential encouraging blood flow into the penis. So if there's venous leak, the blood will flow out again.

If the pump is used with a ring, then the ring attempts to maintain the erection. It does so by physically compressing the dorsal veins to "shut off" the blood outflow. This can sometimes be effective, and some men have good results with regular rings.

However, many men find the rings that come with pumps don't work as effectively as hoped. They find that after the pump is removed, the erection starts to go soft. Other men find the erection stays until they attempt intercourse, then it goes soft.

The reason rings that come with pumps often aren't effective is because they tend to move around. They slide over the penile skin due to lubrication and body fluids in the area, or they slide along the penile shaft due to the penile skin itself moving along the shaft. During intercourse the normal thrusting action accentuates the movement of the ring back and forth along the penile shaft.

This continuous small movement causes blood to leak from the erection under the ring, which causes the erection to go soft or to be lost.

Drugs or injections used to work but they don’t any more. How come?

Let's go back to the tire example. If the pump used to work but now it doesn't, what's happening? Either the pump isn't getting air in, or there's a leaky valve (or a leak in the tire).

In the case of an erection, if drugs or injections used to work but now they don't, it may be that the drugs or injections are not as effective at creating blood inflow. Or it may be that venous leak is starting to occur or getting worse, causing excess blood outflow.

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Diagnosing venous leak

How do I know if I have venous leak?

If you're wondering whether you have venous leak, you can get a test done by a qualified urologist. The urologist injects the penis with a drug to cause an erection, then uses a doppler ultrasound machine to measure the blood flow. The ultrasound is painless. It's similar to the ultrasound used to check the health of a foetus during pregnancy.

If you'd rather not see a urologist for the test, you can self-diagnose. There are some common symptoms that can give you clues that you may have venous leak:

  • You can get an erection but you have difficulty maintaining it.
  • Drugs or injections used to work but now they don't work as well.
  • You can get an erection in some positions, but when you change position it goes away.
  • You erection is soft.

Can you feel venous leak?

You can't feel venous leak. Venous leak is simply the flow of blood in veins. Like the flow of blood in all your veins, it's not something you can feel.

My erection goes away too early

If your erection goes away too early, it may be a sign that you have venous leak. However, it may also be a sign that there's very little blood inflow. Even after the erection is hard, some blood inflow is required to maintain it. So although early loss of erection is a good clue to venous leak, it's not a conclusive sign of venous leak.

My erection is soft

Similar to your erection going away too early, having a soft erection may be a sign that you have venous leak. However, it may also be a sign that there's very little blood inflow. Even after the erection is hard, some blood inflow is required to maintain it. So although a soft erection is a good clue to venous leak, it's not a conclusive sign of venous leak.

My erection depends on position

If you notice that certain body positions make it difficult either to get or maintain an erection, then it could be due to venous leak.

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My erection depends on the time of day

The parasympathetic nervous system is the system that's active while your body rests and repairs itself. It’s responsible for things like digestion, getting rid of waste, and sexual arousal.

The parasympathetic nervous system is active when you’re asleep, so erections sometimes happen in your sleep. Penises can become erect and then flaccid again several times in the course of one night. You’re more likely to notice it when you wake up, so you may find that you have morning erections.

It's common in the early stages of ED to have strong morning erections, but to have trouble getting erections later in the day. This could indicate that you have venous leak, or it could indicate insufficient blood inflow.

If you find the quality of morning erections diminishing, it is often a sign of venous leak.

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

The injections are a very powerful erection stimulant, so if you had no venous leak, you would very likely get at least a partial erection from injections. If you can't get an erection at all, even with drugs or injections, then it's likely that you have venous leak.

My doctor says I have venous leak.

If your doctor has evaluated you carefully and possibly done a doppler ultrasound and concluded that you have venous leak, then it's likely they're correct.

Be aware, however, that the ultrasound is not 100% accurate, and sometimes indicates venous leak when there is none present. One study involving 292 patients has reported that there’s a significantly high chance of younger adults to be wrongly diagnosed with venous leak when checked through a penile ultrasound.

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Causes of venous leak

What causes venous leak?

There are many potential causes of venous leak including;

  • Psychological stress
  • Neuro deficiencies
  • Hypertension (high blood pressure)
  • Adverse effect of certain drugs
  • Chronic diseases like diabetes
  • Lower urinary tract issues
  • Testosterone deficiency
  • Damaged vein walls
  • Hereditary factors
  • Lifestyle factors
  • Diseases
  • High stress
  • Physical trauma
  • Psychological or sexual trauma
  • Normal aging

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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.

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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.

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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.

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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.

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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.

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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
nigel@xialla.com

Please note that the information provided in this article is for general informational purposes only. Any information provided here is not intended or implied to be a substitute for professional medical advice, diagnosis or treatment. Before beginning any type of treatment regimen you should always seek the advice of your licensed healthcare professional. Xialla Inc. are not liable for any direct or indirect claim, loss or damage resulting from use of the information in this message. Any application of the information provided in this message is at the reader's sole discretion and responsibility.
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