For the erection mechanism to function normally, the arterial and venous systems of the penis must function normally. Venous insufficiency is one of the conditions that cause erectile dysfunction (erectile dysfunction, ED, erectile dysfunction) of vascular origin. In this article, I will talk about the causes, diagnosis and treatment of venous leakage or venous insufficiency that causes erection problems.

What is venous insufficiency?

Normally, in order for an erection to occur, clean blood must flow to the penis through the penile arteries (arterial vein), and this blood must remain in the penis as a result of the closure of the veins (veins) that drain the blood from the penis. Then, as a result of orgasm (ejaculation, ejaculation), the venous valves open and the erection ends with the blood coming out of the penis. In the case of venous insufficiency, there is a problem in the closure of the penile veins (venoclusive dysfunction) and the clean blood coming to the penis through the arteries cannot stay in the penis and escapes back because the veins are not closed. This condition is called venous leakage, venous insufficiency. Erection problem that develops as a result of venous insufficiency is one of the causes of vascular (vascular) origin.

What are the symptoms of venous leakage?

It is not always possible to diagnose venous leakage based on the symptoms and the patient’s anamnesis alone. If patients who apply to us with erection problems have the complaints summarized below, we should suspect venous leakage and carry out appropriate investigations.

• Inability to maintain or create an erection
• Inability to have a full hard erection for intercourse
• Change of erection depending on the position
• There may be a shortening of the length of the penis (if there is Peyronie’s disease)
• Penis-wide thinning
• Insufficient hardening of the glans penis in case of erection
• The head of the penis is cold

How is venous insufficiency diagnosed?

A good questioning and anamnesis is required in patients with erectile dysfunction due to venous insufficiency. Patients should be investigated for their general health conditions, vascular diseases, diabetes (diabetes, diabetes mellitus), nervous diseases. The incidence of venous insufficiency is high in these diseases. Penile Doppler ultrasonography and cavernosography are important radiological examinations for the diagnosis of venous leakage.

• Penile color doppler USG: Penile Doppler ultrasonography (USG) is a diagnostic method that we use frequently in the evaluation of erectile dysfunction. Here, after the injection that will create an erection to the penis, the arteries and veins of the penis (arteries, dopplar veins) are evaluated. Arterial and vein blood flow at different times after injection gives an idea about penile vessels. Normally, during an erection, arterial blood flow should increase and venous return should be closed. If the patient has venous insufficiency, the penile veins will not close and the blood coming to the penis will pass into the circulation. This condition is called “venous leakage” or “venous insufficiency”.
• Cavernosometry: Contrast material is given to the penis and it is evaluated whether there is leakage in the veins. The contract material in the veins can be shown on the X-ray film.
• Dynamic infusion cavernosometry: Dynamic infusion cavernosometry is the method that gives the best results in the evaluation of venous leakage. Here, after an erection-providing injection is made into the penis, a contrast agent is injected into the cavernous body under certain pressure. At this time, the patient’s pelvis X-ray is taken and it is evaluated whether there is leakage in the penile veins. If there is a leak, it can be easily seen that the given contrast agent has escaped from the veins.

What are the causes of venous leakage?

There are many reasons that cause erection problems by causing venous leakage. Many of these are also conditions that cause erectile dysfunction. Patients who come to the andrology specialist with the complaint of erectile dysfunction should be evaluated in detail. We can summarize the factors that may cause venous leakage as follows.

• Psychological reasons. Stress or anxiety can cause venous leakage.
• Neurological causes
• May develop as a result of side effects of some drugs
• Diabetes (diabetes)
• Testosterone (male hormone) deficiency
• Having lower urinary system complaints
• Those with general vascular disease
• Radiotherapy: It can be seen in patients who receive radiotherapy to the pelvic region due to cancer.

Recommendations for patients in the treatment of venous insufficiency

Lifestyle is very important in patients with erectile dysfunction. We can list our suggestions for lifestyle changes such as nutrition, sports, alcohol-smoking habits in patients who develop erectile dysfunction due to venous insufficiency as follows:

• Nutrition style: Vegetable and fruit-based diet
• Diet rich in protein and fiber
• Vitamin and mineral support
• The habit of eating less and often at meals
• Low-carbohydrate diet
• Regular exercise: To increase testosterone levels by doing weight training, cardio exercises
• Reducing or cutting out those who use too much coffee
• Cessation of smoking and drug habits, if any
• If there is a weight problem, it is important that they reach the ideal weight.
• Cut or reduce alcohol use if any
• Coping with stress

Venous leak treatment (non-surgical, non-surgical treatment methods)

Patients with erectile dysfunction due to venous insufficiency should be evaluated in detail and treated accordingly. Before surgical treatment, especially in patients with mild venous leakage, treatment methods are as follows;

• Psychological treatment: Some of the patients with erection problems may have psychological problems. Patients with psychological problems may experience venous insufficiency and erection problems as a result. In treatment, problems should be resolved with psychological counseling service.
• Drug therapy: PDE5i group drugs taken orally used by patients with erectile dysfunction can be used in the treatment of this disease. However, patients with severe venous leakage usually do not respond well to these treatments.
• Testosterone therapy: Testosterone deficiency can cause venous insufficiency. In patients presenting with erectile dysfunction, serum testosterone level measurement and, if low, treatment is required.
• Penile injection therapy: Various drugs are given to the penis with a fine needle to increase erection. After the necessary training is given to the patients under the control and recommendation of the urologist, the patients inject themselves into the penis. The amount of medication to be administered here may vary from patient to patient. This treatment may not be effective in patients with very severe venous leakage.
• ESWT therapy: ESWT penile shock wave therapy has been used for 10-15 years in the treatment of erectile dysfunction. It is effective by increasing the formation of new vessels in the penis and causing regeneration in the endothelial cells in the inner parts of the corpus cavernosum. There is no study in the literature regarding the efficacy of ESWT in the treatment of erectile dysfunction due to venous insufficiency. ESWT may be beneficial in patients with mild venous leakage and without serious underlying disease. It has been reported in the literature that positive results were obtained when ESWT was applied postoperatively in patients who underwent venous leak surgery.
• Urethral suppositories: In these patients, the drugs in the form of gels that are squeezed into the urethra, which we use in patients with erection problems, can be used.
• Herbal suplement: Such treatments have no scientific place. There are no published studies on this subject in reliable sources.
• PRP treatment: There is no study in the literature regarding the effectiveness of PRP application in the treatment of venous insufficiency. We do not recommend such treatment methods to our patients.
• Stem cell therapy: Stem cell therapy is currently being tried in the treatment of many diseases. There is no study in the medical literature that it is effective in the treatment of venous insufficiency.

What are the surgical/surgical methods for the treatment of venous insufficiency?

If the erection problem is due to leakage in the penile veins and other treatment methods have not been effective, there are some surgical methods we apply to these patients. These venous leak/insufficiency surgeries vary according to the person or the degree of the disease and the underlying cause. There are 3 types of surgical methods that we frequently use for this purpose.

• Venous surgery (deep dorsal vein ligation): In this surgery, the deep veins in the dorsal (back) region of the penis are ligated and cut. Not only is it sufficient to cut these deep veins, we also ligate the small veins (collateral) associated with these large veins during the surgery. During this surgery, care should be taken not to damage the penile nerve and artery. This venous surgery, which was popular in the 1990s, is no longer preferred today. The reason is that although the surgery is effective in the early stages, its effect gradually decreases in the following years. However, it is an operation that can be performed on selected patients. Venous leak surgery (vein ligation, deep dorsal vein ligation, deep dorsal vein ligation) is performed under general or spinal anesthesia. The process takes up to 1 hour. Patients stay in the hospital for 1 day and have intercourse after 4-6 weeks. We perform this surgery, which we have done in the past, only on highly selected patients. There are studies showing that ESWT shock wave therapy is effective in patients undergoing venous surgery. ESWT treatment can be applied to these patients 4-6 weeks after the surgery.
• Venous ligation and crus plication: In this surgical method, deep dorsal vein ligation and crus plication (crural plication) are performed simultaneously. Crus plication is applied bilaterally from the region close to the root of the corpus cavernosum. In eligible patients, this technique has been shown to be more successful than just deep dorsal vein ligation. We have very positive results with this technique, which we do in appropriate cases. These types of surgeries are delicate surgeries that require experience and are delicate.
• Penile prosthesis surgery (penile prosthesis): Penile prosthesis (penile prosthesis) surgery is the last option for patients with erectile dysfunction. Because prosthetic surgery is an irreversible procedure. Especially in young patients, it is necessary to thoroughly research other treatment options before wearing a prosthesis. After the patients are evaluated in detail, if the last option is penile prosthesis, then the prosthesis should be fitted. Before surgery, patients should be given detailed information about the surgery. Appropriate prosthesis type should be preferred according to the patient’s condition. Penile prosthesis surgery is usually the preferred treatment in elderly patients with severe venous leakage due to diabetes or other reasons.

In summary; Venous leakage (venous insufficiency) is a disease characterized by the development of erectile dysfunction as a result of the inability of the veins of the penis to close during erection. Appropriate treatment is planned according to the cause and degree of the disease. Venous surgery is a surgical method with vein ligation. Penile prosthesis is the last option in severe cases.

Prof. Dr. Emin ÖZBEK

Urologist