My venous leak investigation

Hi,

I think I have a venous leak and I am currently investigating all available information related to treatment and surgery. I will be continuously dumping all information and questions here and I appreciate any inputs from the community.

So first of all I’d like to quote some recent papers on this topic.

Paper: “Venous leak and erectile dysfunction – an important differential”
Released: March 2019
Abstract: Congenital venous leak or veno-occlusive dysfunction is an important cause of vasculogenic erectile dysfunction, posing a significant challenge to urologists. To date no medical therapy exists for the treatment of this condition, whilst surgical management options are based on resection or ligation of the offending venous drainage with a significant decline in efficacy with follow-up exceeding 12 months, perhaps as a consequence of collateral drainage. This review article highlights the importance of veno-occlusive dysfunction. We discuss the pathophysiology, investigations and the required treatment.

Interesting quotes from this paper:

— In men with veno-occlusive dysfunction, cavernosal smooth muscle damage results in insufficient sinusoidal relaxation and expansion during tumescence, leading to improper closure of emissary veins as the albuginea layers are inadequately compressed. Thus, venous leak ensues, leading to detumescence and ED. On a cellular level the intracorporal pressure is significantly lower than controls with resultant atrophy to the tunica albuginea resulting in failure of compression both of the subtunical venular plexus and the emissary veins, leading to venous leak. 8 Current data suggest many patients’ veno-occlusive dysfunction results from endothelial dysfunction and damage to the trabecular smooth muscle content because of multifactorial degenerative processes. 9 Known possible causes of venous leak are congenital vascular anomalies, arterial insufficiency, trauma and post-priapism, diabetes and Peyronie disease. 9 Notwithstanding this, there are a plethora of other causes and the exact epidemiology is not fully understood.

— An attempt to standardise the vascular assessment of patients with ED resulted in a recent standard operating procedure (SOP) recommending the use of colour digital Doppler ultrasound (CDDU) with a 7.5–12 MHz probe to determine various vascular parameters (Table 3) for each of the two cavernous arteries at specified timed intervals both in the erect and flaccid penis. 13 In the presence of normal arterial inflow, as defined by a peak systolic volume (PSV) greater than 30 cm/sec, veno-occlusive dysfunction is present if the end diastolic volume (EDV) is greater than 6 cm/sec with a corresponding resistive index (RI) of less than 0.6. Arterial insufficiency is present when the PSV is below 25 cm/sec, 1 and in this circumstance the diagnosis of veno-occlusive dysfunction is hindered

— Furthermore, recent trials have shown that multi-detector computed tomography (CT) scan with intracavernosal injections were able to differentiate among various venous pathways in men with primary venous origin ED. 27 In addition, 3D CT and magnetic resonance imaging has been shown to be helpful in the diagnosis of veno-occlusive dysfunction. 28,29

— There have been only limited low-volume studies assessing the potential role of embolisation of venous leak sites, each utilising a different approach and with varying follow-up end points between 12 and 22 months.

— A recent study addressing embolisation of the peri-prostatic venous plexus via the deep dorsal vein of the penis yielded a three-month success rate of 81% as defined by an EDV of less than 5 cm/sec but this declined by almost 50% by 13 months. 33 In an earlier study, fluoroscopy-aided embolisation of the deep dorsal vein with visually confirmed occlusion was successful in enabling 69% of 32 men to achieve unaided penetrative sexual activity at 25 months. 34 Both studies relied on CDDU for diagnosis and utilised N-butyl cyanoacrylate with or without supplementary endovascular coils for embolisation.

— Vein ligation surgery remains both the most popular and most researched method of intervention for veno-occlusive dysfunction, but the literature base remains hindered by a lack of standardisation and variable-quality observational studies.

— Early work focussed on targeted single-vein ligation with studies universally reporting fewer than 50 cases. Ligation of the deep dorsal vein of the penis offered an early three-month success rate between 66% and 70% 35–37 with only marginal decline at 12 months, 33 failures being thought to arise from persistent leakage, perhaps previously undetected, from the crural, cavernous or bulbourethral veins. 35

— Ligation of the penile vein immediately following its formation by the merger of the bulbo-urethral and cavernous veins results in a range of reported success rates from 24% to 63% at 12 months, 38,39 to 38% to 71% at two years. 40,41 The only study to assess both 12- and 24-month success rates revealed a significant decline in success of almost 40% during the second 12 months. 38 Again, failures were thought to be secondary to remaining leakage from the crural and deep dorsal vein as well as the peri-prostatic venous plexus.

Paper: Erectile dysfunction and caverno-venous leak disease
Release: March 2018
Abstract:
Erectile dysfunction is an increasing issue, especially in young man. Whereas the current treatment strategies are mostly focused on older men, young patients are seeking more for a longer lasting or defi nitive solution, rather than a life-long medical treatment. Possibly, this is a reason why currently 70% of men with erectile dysfunction are not under treatment. This aspect becomes also a socioeconomic relevance, as this generation of patients can also be called the backbone of most societies. As a logical consequence the treatment strategies in diff erent stages of life should be reviewed. Whereas various chronic disorders have been reported to be associated with elevated rates of ED including depression, diabetes, cardiovascular and neurological diseases in older men, the young generation is more suff ering from vascular problems which aff ects the storage capacity of the penis. Th e aim of this work is to review the effi ciency of newly developed minimal invasive treatment strategies for this blood storage problem, causing erectile dysfunction which is mostly described as caverno-venous leakage. Th e systematic review of the literature reveals a signifi can’t number of recent studies dealing with new minimal invasive methods to provide a potential solution of caverno-venous leakage. Even long-term results reported demonstrate considerable improvement of erectile dysfunction caused by this condition. Furthermore, 3D-Computed tomography cavernosography (CT-cavernosography) is a new technology, which can provide high-resolution images of venous drainage from any angle and shows to be very helpful for both the diagnosis of corporal veno-occlusive dysfunction and the anatomical study of the human penile venous system. Th e application of this technology may also lead to better strategies in venous leak treatment. In summary, over 30 published studies could be found in the literature with constantly good results after caverno-venous leak treatment. Altogether, 13 comparable studies including 538 patients could be found, in which a mean short-term success rate of almost 80% and a mean long term success rate of 74% was achieved. None of the studies described major complications. These encouraging results should lead to reconsider or current strategy in treatment of erectile dysfunction in young men.

Interesting quotes:

— Interestingly, venous leak disease as cause for erectile dysfunction is, in no case, only a condition found in human. Several reports demonstrate an erectile dysfunction due to corporo-venous insuffi ciency in various animal species, including bulls and boars [7-10].
It can be found that clinically bulls can also be unable to achieve erection when stimulated with an electroejaculator and in natural breeding trials. Vascular shunts can be located as cause of erectile dysfunction by serial contrast radiography of the corpus cavernosum penis. If surgical correction of the shunts is attempted by wedge resection of the tunica albuginea, this surgical correction is successful in 50% of the treated animals and the bulls can be returned to service [10].

— Simple isolated ligation of the deep dorsal vein in humans for the permanent cure of erectile dysfunction due to venous leak is up to now not recommended, due to some reported low long-term success rates [3, 11, 12].

— In this context, a compilation of outcome data of simple ligation techniques published until 2005 was discussed [14]. In the here revised literature a wide variety of success rates was found. For the authors, no single operative technique seemed to be superior to others, and a steep decline of success has to be noted with length of follow-up in single ligation procedures. But, the authors stated, that young patients with site-specific congenital, posttraumatic or post-infl ammatory leaks may be considered for vein ligation with informed consent. The choice of operation offered should be decided on available wisdom and infrastructure, the experience and preference of the operating surgeon, and the basis of the site, nature, and size of the leak [14].In contrast to these ancient findings, various modified and improved technologies with much better short- and long-term outcome have been recently described.

— Due to the fact that more recent literature dealing with new concepts of minimal invasive technologies and modern diagnostic tools our aim was to present an overview over the results from this more recent studies. A structured review of English-language articles on PubMed published till 2017 coupled with examination of tables of contents of high-impact journals to identify articles related to venous leak treatment was performed. These articles were appraised for their importance to medicine.

— Current publications explored, that 3D-CT cavernosography can provide high-resolution images of venous drainage from any angle. Th erefore, the authors conclude that the images obtained by 3D-CT cavernosography are very helpful for both the diagnosis of corporal veno-occlusive dysfunction and the anatomical study of the human penile venous system and may lead to better strategies in venous leak treatment [17–21].

— Interrestingly, penile venous surgery with ligation of the crura for venous leakage has revealed good long term results and high patient satisfaction. Th e unanimously stated conclusion from these studies is, that this technique should be off ered in young men with primary cavernosal erectile dysfunction. Young patients with normal penile arterial system and no risk factors such as diabetes had the best chance to improve erection and have a good postoperative success [22–27].

— Another reasons responsible for the good long-term outcome of the procedure might be the application of a Computed tomography cavernosography with 3D-reconstruction. The superior visualization of the complex venous draining system in a 3D-CT cavernosography before (Figure 1) and aft er sclerotherapy (Figure 2) was fi rst described by Virag [7] and could be verified by Uhl [20] and Xu [48]. Th e picture in fi gure 1 describes the complex situation in venous leakage disease and the need for a more complex renovation of the situation. It might also explain the fact, that neither simple ligation of penile veins, nor ligation of crural veins could sustainly solve the problem of venous leak disease. Furthermore, these pictures might reveal the up to now unexplained relation between erectile dysfunction and hemorrhoids [49] and possible erectile dysfunction after hemorrhoid sclerotherapy [50], due to the fact that the related veins are connected via the deep pelvic vein system. Th ese results also demonstrate the urgent need to re-explore the veinous drainage system with new higher sophisticated techniques. Th erefore, this in many cases underlying combination of cavernosal and crural insuffi ciency should be addressed in one procedure to prevent early relapse [18]. In a very recent study of Herwig and Sansalone these aspects are respected in a newly described technique, which reaches the deep dorsal vein system, as well as the crural venous system [17, 46, 47].

— When preparing the deep dorsal vein at the proximal penis shaft , the ligation of the vein distally closes the primary leak from the deep dorsal vein. In addition, the afore localized major leakage point revealed by 3D-CT cavernosography can be closed by several distal and proximal ligations. Afterwards, a 5F-Angiokatheter is placed in the proximal part of the vein. Under Valsalva-Maneuver, which has to be performed by the patients, the blood flow is reduced in the lower pelvis equal to the compression described in general surgery guidelines. When injecting polidocanol as a sclerosing agent during this time, the agent can stay longer at the venous wall and the effect of the sclerosing therapy is maximized. No residual crural or deep dorsal vein leakage could be detected after integrate combined ligation of the deep dorsal vein and antergrade sclerotherapy procedure (Figure 2). Therefore, this method is providing a therapy for deep dorsal vein and crural venous leakage in a minimal invasive setting at the same time [17, 46, 47]. With this newly described technique, at 3 month follow-up 77 out of 96 patients (80.21%) reported to have erections sufficient for vaginal insertion without the use of any drug or additional device Four (4.17%) patients did not report any improvement. Follow up with color Doppler ultrasound and CT Cavernosography revealed a new or persistent venous leakage in 8 (8.33%) of the patients. After a follow up of 12 months (n = 22) 16 (72.73%) patients still reported to have a strong enough erection for sexual intercourse. Four (18.18%) patients used PDE5 inhibitors and 2 (9.09%) patients did not report any change to their preoperative state. As before, the authors denied serious complications. These new and encouraging results in almost 540 patients show a short-term success rate of about 80% and long-term success in 73,7%. Depending on the method applied there is a slight advantage towards a combination of ligation and antegrade sclerotherapy with 80% short- term and 81,66% long-term success rate in 267 patients.

— These recent good results with this technique lead Rebonato et al. [51-53] to the statement, that even so, embolization techniques should be considered in all the cases of confirmed ED due to VOD especially in young patients. Although the technique is not always successful restoring completely the erectile function, in most cases, the patients have a satisfactory erectile function just resorting to oral pharmacotherapy (PDE5 inhibitors), delaying the time to penile prosthesis. Although further exploration in randomized controlled studies is needed, these results should lead to re-consider venous leakage treatment with these minimal invasive methods in therapy of erectile dysfunction. The described methods are minimally invasive, are carried out in local anesthesia and do not contain major risks or complications.

It seems that nowadays the venous leak surgery becomes more recognized as I am able to see this in a portfolio of some clinics:

https://erectio nvascular.com/e … venous-leakage/
https://mhdclin ic.com/venous-l … atment-surgery/
http://dr-herwigclinic.com/

By any chance anybody has any experience with these? Or maybe some other clinics/doctors ?

By the way, how do you know you have it? Did you see a urologist and diagnosed with having this?

Could you show your doppler?

No, not yet, my visit was canceled due to coronavirus :/

So my main problem is soft glans. I’ve read through all available threads here on thundersplace and it seems that my symptoms match the symptoms described in the many soft glans/venous leak threads around here.

That said, I am continuing my investigation. I know about Tweaking user - he ended up with a conclusion that it is a pelvic floor muscle problem. Unfortunately, there is no follow-up information from him whether he was successful solving his soft glans problem just by working on his pelvic floor inbalance. I purchased his recommended book and really it is all about calming yourself down, fixing your diet&lifestyle and stretching pelvic floor.

I will be now working on my plevic floor too but my current opinion is that this soft glans type erection just should not be so heavily dependent on one being in “super zen” state. I just think it should be more “automatic”, more “effortless”.

I will keep updating this thread about my further findings.

Here is a quotation from book “HF Unraleveled”:

Another common issue experienced by men with HF is what is sometimes referred to
As “Soft Glans Syndrome.” This is when the head of the penis fails to engorge during
Erection, resulting in an otherwise normal erection, but with the head of the penis re-
Maining deflated and soft. This can be troubling for men, as the engorgement of the
Head of the penis acts a protective cushion during sexual intercourse — They also
Aren’t very happy about the way it looks.
Soft Glans Syndrome goes hand-in-hand with another condition known as “Ve-
Nous Leak” which, in my opinion, is a dangerously misleading name with equally dan-
Gerous “treatments” being offered for it. Were a major vein actually “leaking” blood,
The tissue surrounding it would quickly take on the appearance of a horrifying purple
Hematoma, and would likely have some very serious consequences. This so-called Ve-
Nous Leak represents, in my opinion, nothing more than an inability of the dorsal vein
Of the penis to properly seal.
I have done extensive research on this, as well as experienced it firsthand. Dur-
Ing the erection process, the smooth muscles of the penis expand, putting outward
Pressure on the dorsal vein and causing it to “seal.” This mechanism of sealing the dor-
Sal vein is what enables engorgement of the glans. Any man with soft glans has proba-
Bly noticed that if they apply pressure to the dorsal vein, the glans engorges normally,
And if they release that pressure, it deflates again. This usually leads them to conclude
That the problem must be with their dorsal vein, but that is an incorrect assumption.
What is actually likely happening is that the hypertonic state of the smooth mus-
Cle of their penis is preventing it from expanding enough to properly seal off the dorsal
Vein. Additionally, this extra tension is making for a much less pliable surface to suffi-
Ciently hold the seal. Here’s an analogy you can try to help visualize what I mean:

The erection process is a precise mechanism, and your body’s own erection proc-
Ess has been fine-tuned over the course of your entire life to precisely fit with the exact
Dimensions of your own penis. HF is throwing off those measurements, as well as
Changing the texture of the playing field. It may be by a very small amount, but it’s
Enough to disrupt this delicate process.
Another Soft Glans/Venous Leak misconception comes by way of the fact that a
Man will report being able to temporarily engorge the glans by performing a clench of
The pelvic muscles, or “kegel” motion. They are assuming that the contraction of the
Muscles is somehow forcing blood into the penis. This is not only incorrect, but impos-
Sible. The clenching of muscles in your pelvic floor can only serve to interfere with
Blood flow to the penis, not improve it.
What is occurring, is that in the brief moment before them clenching, those mus-
Cles relax. You cannot flex a muscle which is not relaxed, and the act of flexing a mus-
Cle first involves an automatic reflex of it relaxing itself before your conscious com-
Mand of flexing of it takes place. So, when they do this, the muscles which could be
Hindering blood flow are relaxing just long enough to allow a bit more blood into the
Penis, while also removing some of the excess pressure which was causing the escape
Of trapped blood to begin with. If they could only maintain that automatic relaxed
State of those muscles, they would be experiencing perfect erections.
At any rate, the good news is that soft glans should resolve right alongside the
Rest of your pelvic floor issues, so don’t get too worried about it. To date, we are yet to
See any man with HF be diagnosed with any genuine vascular anomaly. If you suspect
It’s something else, like a vascular pr

I think there can be 3 possible culprits to soft glans syndrome:

1) Venous leak (genetics, injury, etc.)
2) Pelvic floor problem (mental, bodily tension, bad “life” habbits)
3) Incorrect muscle-mind connection (learned and hardened by bad sex and masturbation habbits)