Erectile dysfunction (ED) is a big issue in various populations worldwide. Erectile dysfunction is defined as a situation or inability to achieve and/or maintain penile erection that is sufficient for satisfactory sexual performance. It’s been observed that around 52% of the male population is affected with ED amongst which over 30% of young males are suffering from this condition. Scientific investigations have observed that the prevalence of ED is strongly associated with increasing age, making it a major health problem since with the increase of the aging population, the worldwide prevalence of ED has been predicted to reach 322 million by 2025.
Blood vessels play a prime role to keep erections firm. Under normal physiological circumstances, during sexual arousal nerves release chemicals that increase blood flow into the corpus cavernosum (erection chambers in the penis), the arteries in the penis expand to allow the inflow of blood which makes the erection firm. However, to keep the erection rigid, blood needs to stay in the penis until the man ejaculates. For this, penile veins constrict to trap the blood inside, which is known as veno-occlusion. At the end of sexual stimulation, the veins widen and blood flows back into the body. If the veins do not constrict enough, blood leaks back into the body, which results in softening of the erection, this phenomenon is known as a venous leak in which the erection gradually loses its firmness. Therefore, venous leak is a defect where a male is unable to have strong erections even with sufficient blood into the penis as a result of abnormal venous drainage in the penis corpora cavernosa, thus retarding the typical erectile capability of men. Venous leak is often listed under erectile dysfunction causes in younger men. Surveys have found that about 70% of the affected population by ED does not get treated therefore, men suffering from this condition experience shame and choose to be secluded in sexual relations. If you have concerns regarding being affected by this condition, contact your urologist, and get an early treatment since venous leakage is treatable. Although there are quite a few causes of erectile dysfunction, nonetheless, many non-invasive remedial options are available for such patients that will improve fertility and its progression.
Erectile Dysfunction Causes
There are many different underlying factors that can qualify as erectile dysfunction causes. Based on etiology, erectile dysfunction is divided into three major types: psychological (such as depression, stress, and anxiety), organic (related to vascular system, nervous system and endocrine system) and mixed.
When we talk about organic causes, defects in the physiology of vascular system are a common occurrence, in patients with venogenic erectile dysfunction, veno-occlusive dysfunction is recognized as underlying cause in most cases which can be due to either aging or injury related changes to the tunica albuginea, cavernosal smooth muscle dysfunction or excessive adrenergic input or shunts created during priapism episodes. There are several potential risk factors such as age, diabetes, obesity, cardiovascular disorders, hypertension, atherosclerosis, prostatectomy, pelvic radiation, Peyronie’s disease (development of scar tissue inside the penis), and androgen deprivation therapy that appear to be associated with organic ED.
Diagnosis and Treatment
In order to diagnose venous leak erectile dysfunction, your doctor will take your personal history, would likely do a physical examination, and recommend some tests such as Penile doppler ultrasound,certain male hormone and routine blood tests along with urine tests to rule out any doubts.
It is advisable for patients with venous leak erectile dysfunction to make lifestyle modifications and prevent physiological stresses to overrule these conditions and take adjunct medications. Furthermore, for patients suspected with ED are commonly prescribed phosphodiesterase type 5 inhibitors (PDE5Is) therapy which is not a curative treatment but rather symptom-relieving treatment and loses its effect in in a few months. There are surgical interventions also available in the market such as penile implant(recommended only in elderly and patients who had radical prostate surgery) and venous ligation surgery, which aims to repair the leaking veins(discouraged by surgical fraternity for recurrence and high failure rates).
Moreover, an interventional radiological approach that is endovascular treatment is a promising approach to treat patients with erectile dysfunction or venous leakage. Endovascular therapy with 3D precision-guided embolization of venous leak is a minimally invasive procedure and a safer alternative to surgical methods. For endovascular embolization, administration of local anesthesia followed by real-time fluoroscopic monitored puncture of a venous access is performed to reach the leaking veins and periprostatic venous plexus under sonographic and 3-D precision guided fluoroscopic guidance.
The non-invasive endovascular treatment can be performed by two different approaches, such as antegrade approach via deep dorsal penile vein and retrograde transfemoral venous approach via internal iliac veins. Although both approaches aim to embolize the periprostatic venous plexus along with other unusually shaped or abnormally functioning veins due to valvular incompetence, antegrade endovascular treatment is preferred since it provides a more direct route for catheterization of the periprostatic venous leaks.3D Precision guided fluoroscopic guidance helps the catheter reach the specific veins, following a diagnostic venogram embolization is performed using N-butyl-2-cyanoacrylate and ethiodized oil mixed in specific ratios depending on proximity, size and extent of venous leaks under continuous fluoroscopic control in neutral projection with optional oblique projection for precison guided embolization of incompetent pelvic veins.
This non-surgical treatment- 3D precision-guided embolization of venous leak is a complex and challenging procedure which requires high expertise in the said field. Its treatment in Pakistan was introduced by Dr. Imtiaz Ahmed in 2019, making him a pioneer. Dr Imtiaz Ahmad is an endovascular surgical specialist and an interventional radiologist who treats men suffering from venous leakage, erectile dysfunction and infertility issues that may have little hope left otherwise. His expertise in the field speaks volume for itself, which can be inferred by the accolades of his treated patients.
Penile venous insufficiency or corporal veno-occlusive dysfunction, commonly known as venous leak is often a consequence of a vascular disease since the vascular network is well connected throughout the body. Vascular diseases comprise faults in vessels, veins or arteries but may also influence the blood flow to different tissues. To understand venous leak, the mechanism of tumescence, or erection must first be understood. Under normal physiology during tumescence, the blood inflow to the penis is faster than the outflow due to arterial dilation and venous occlusion, helping sustain the state of erection. One of the causes of not being able to do so is venous leak, wherein the blood that must be stored in the sinusoids from a few minutes up to half an hour, leaves too quickly, much like a bottle of water with a hole in it. This happens due to inefficient sinusoidal relaxation and expansion which results in a poor attempt to close the emissary veins that drain the sinusoids. The process of constricting blood outflow under normal physiology is known as veno occlusion but the failure of it may be due to venous leak. Venous leak has been attributed to being the most common cause of venogenic impotence or erectile dysfunction (ED) in men but cannot always be concluded as the sole reason for impotence, owing to a multiplex of factors involved. Statistically, one in five men suffer from ED and seek venous leak easy treatment after they notice venous leak symptoms. Such men may complain about abnormality in tumescence but experience a normal libido, otherwise.
What Causes Venous leak?
Venous leak may occur in men eventually over the course of life but can also be congenital, meaning, faults in the venous drainage system around the penis may be persisting since birth. The pathophysiology of a venous leak is rather ambiguous, to date, however, studies have found venous leak to be of a more common incidence in elderly men, men with diabetes mellitus, or those who have undergone prostatectomy, hormone therapy and radiation therapy. Causes of a venous leak may also include accidents and physical injury. Interestingly, many men seeking treatment for erectile dysfunction end up finding diseases they are at a risk of developing and would have, otherwise, found out once the symptoms had worsened. It is, therefore, crucial for the overall well-being of a man to reach out to a specialist rather than shying away from the symptoms of venous leak erectile dysfunction.
Venous Leak Symptoms and Diagnosis
The most obvious symptom of a venous leak is facing difficulty in maintaining tumescence. This may include a short span of erection, not being able to get one at all, difficulty sustaining it unless manual stimulation is provided, penis shrinkage (Peyronie’s disease), or cold glans syndrome wherein the vascular structure forming at the tip of the penis called glans, does not fully swell during tumescence.
Psychogenic factors leading to erectile dysfunction are first ruled out and history taking is streamlined to include only organic causes. If the specialist suspects a venous leak in the patient, a penile doppler ultrasound is performed. The procedure first requires the administration of a Vasodilator that causes an erection as the blood flows and fills the sinusoids in the penis. An ultrasound probe is then kept in a longitudinal arrangement (from tip to the belly) and is used to record the velocities of inward and outward blood flow at regular intervals. Ideally, the inward blood flow velocity(systolic) should be 25 to 35 cm/s and outward flow velocity(diastolic) of less than 3-5 cm/s is regarded as normal. In case of lesser values of systolic velocity, an arterial disease may be diagnosed while diastolic diseases like venous leak can be concluded if velocity is greater than 5cm/s. Venous leak cure foundations on finding the location of the leak and is a complex process. Additionally, certain blood tests are also performed to have a clear idea about the hormone levels and other comorbidities. Once venous leak is suspected over the doppler ultrasound, cavernosometry and cavernosography may be performed to locate specific sites of venous leak.
Venous Leak Treatment Options
Treatment approach largely depends on a lot of factors such as age and comorbidities. The first choice of treatment is the administration of PDE-5 inhibitors like Cialis, Viagra and Stendra, to help alleviate the symptoms, however, they have a lower success rate, regardless. Additionally, sclerosing agents may also be administered to achieve tumescence. Being the most common approach towards venous leak treatment, surgical treatment options available are not only invasive but also criticized for having a very low success rate (approximately 25%). The ligation of veins results in a painful state of erection post-surgery along with high recurrence and is therefore, frowned upon as an approach towards venous leak treatment.
Non-Surgical Treatment for Venous Leak
Venous Leak treatment in Pakistan is being conducted by Dr Imtiaz Ahmed and is a non-surgical, minimally invasive procedure to treat venous leak erectile dysfunction. Men who are young and respond, certainly not very well, but to some extent to PDE5 inhibitors are strongly advised to undergo venous leak non-surgical treatment. The non-surgical endovascular treatment takes on two main approaches: antegrade and retrograde. Both approaches aim to embolize the peri-prostatic venous plexus along with other veins that may seem irregular in shape or function. Antegrade endovascular treatment is performed via the deep dorsal penile vein while retrograde treatment involves transfemoral path via the internal iliac vein. Fluoroscopic guidance helps the catheter reach the selective veins after which glue therapy is performed using specialized FDA approved drugs. Out of the two approaches, specialists prefer using the antegrade approach, which provides a much straighter route to the periprostatic veins. The non-surgical treatment for venous leak is a complex and challenging procedure which requires expertise in the field.
