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Urology/Damage to penis?

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Question
Hello doc! I have two questions:

1. I've had a fear that I might have developed a venous leakage in the past, e.g. don't get night erections and don't get aroused (because of post-SSRI?, venous leakage?). Week ago I still woke up from a nap and I had a very rigid erection. Does this mean that there is no way that I might have this condition?

2. I've also been having a hard time of getting and orgasm when masturbating/intercourse. So the day before yesterday I masturbated quite long and maybe a bit aggressively, it didn't still hurt or anything, but I noticed that my penis was rather/quite red after this session. Is it possible that I might have done some damage this way? (above-mentioned venous leakage? etc.)...

Answer
Al, based on the information provided, I think it is very unlikely that you have a venous leak.  The reddening of the penile skin after a "long" and "aggressive" masturbation session was undoubtedly due to excessive friction to the penile skin.  This would not cause a venous leak.  

You did not mention either your age or medications you are taking.  If one is over 40, changes in erection potential are subtle but common.  Most nocturnal erections occur during the REM (rapid eye movement) stage of sleep, average about 3-5 per night and last for up to 30 minutes. They are thought to be triggered by fantasy dreams, but during REM, most of the dream content remain amnestic to us. Therefore, most of these fantasies (and the accompanying erection) are not remembered on awakening.  The presence of normal nocturnal erections can easily be documented by having testing done for this condition (NPT monitoring).  Furthermore, if you are taking SSRI drugs, as a side effect , they often cause difficulty obtaining and maintaining an erection as well as problems with ejaculation.  Lowering the dose or changing to a different medication that is better tolerated typically relieves the symptom.  Stopping the medication, if medically indicated, also reverses the sexual problem.

To follow is a "macro" I have written on erectile dysfunction.  If you are still concerned, make an appointment to see a urologist skilled in the evaluation and treatment of this problem.

There are many causes for erectile dysfunction (ED).  The most common diseases associated with this disorder are vascular conditions (ie atherosclerosis – “hardening of the arteries” and abnormal varicose veins inside the penis - so called "venous leak") and diabetes.  Some others include hormone imbalances, neurologic pathology, local penile diseases (ie Peyronie’s disease), smoking, obesity, alcoholism, prostatitis, prostate surgery, certain medications, "recreational drugs", trauma to pelvic nerves or vasculature and chronic perineal pressure from overly aggressive bike or horse back riding.  A variety of emotional disturbances (most commonly depression or performance anxiety) can also cause or be a significant factor in those suffering from ED.  Very commonly, the etiology is multifactoral.  As a result, consultation with a urologist skilled in the evaluation and treatment of ED is recommended.   

In addition to a history and physical examination, specialized tests may be indicated to find a cause.  Some of the commonly ordered studies include routine blood tests, hormone levels, and penile duplex color ultrasound.  

If a correctable cause is found, specific treatment is instituted.  If the condition is irreversible, most men today can still be restored to normal functionality with the numerous treatments available including oral medications in the class of PDE5 inhibitors  (ie Viagra, Levitra, Cialis & Stendra), vacuum erection devices (VEDs), confidence rings (for those with a pure venous leakage), penile injections (ie Edex, Caverject), urethral suppositories (Muse) and penile prosthetic surgery.   PDE5 inhibitors (in proper dosage which varies with the individual) have shown success in about 80% of patients.  Side effects may include headaches, flushing, heart- burn, nasal congestion, visual disturbances, dizziness, etc.  These drugs are contraindicated in patients with coronary artery disease who take nitrates (ie nitroglycerine) as some deaths have occurred in this group.   There is also the potential for a severe drop in blood pressure if PDE5 inhibitors are used in patients who take alpha- blockers (ie Hytrin, Cardura, etc.) or are hypertensive.  It is now a recommendation that not more than 25 mgm of Viagra be used within 4 hours of taking an alpha blocker  Several other types of medication may alter the blood level of PDE5 inhibitors possibly leading to significant side effects.  Other contraindications include certain types of liver and visual disorders (ie retinitis pigmentosa).  PDE5 inhibitors have been noted to cause abnormal liver function tests in some otherwise normal men.  Because of this, although PDE5 inhibitors are well tolerated by most, they should only be taken with caution and under the supervision of a physician.   All 3 of the PDE5 inhibitors available in the USA have about the same success rate.  If one fails to respond to the initial dose, it should be increased until either tolerance or the desired effect is obtained.  

The way one takes the PDE5 inhibitors may significantly affect their action.  The following should guide you in their administration. One should initially start with the lower dose.  

Cialis is available in 2 forms: daily use and long acting.  The former comes in 2.5 and 5 mgm. doses while the latter is available in doses of 5,10 & 20 mgm.  They  can be taken without regard to meals. The onset of action is 30-60 minutes for the daily dose and 30 minutes to 4 hours for the long acting form. Cialis for daily use lasts 4 hours while the beneficial effect of  the long acting form lasts 18-36 hours.    

Viagra is available in doses of 25, 50 & 100 mgm.  Levitra comes in 2.5, 5, 10 & 20 mgms doses.  Both medications have an  onset of action in 30-60 minutes and last about 4 hours.  They are typically taken 1 hour before planned sexual intercourse.  The absorption of these 2 medications can be adversely affected by diet, especially a diet high in fat.   Therefore, it is best to take these an hour or 2 after meals.

Stendra was approved by the FDA in April of 2012.  It comes in doses of 50, 100 and 200 mgms.  It has a rapid onset in the 15-30 minute range and lasts 3-6 hours.  It is not effected by dietary intake.  Although the potential exists to lower the blood pressure too much in men taking nitrates, the risker is lower than with the other drugs in this class.

About 60% of patients who fail to respond to maximum doses of one of the PDE5 inhibitors, respond favorably to another and, in the absence of side effects, this is worth trying.  Good luck.

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Arthur Goldstein, M.D.

Expertise

Problems or questions related to the field of urology; ie urinary stone disease, urinary cancers (kidney, bladder, prostate, testis, etc.), urinary infections, etc. I no longer answer questions related to erection problems or male sexual dysfunction.

Experience

I am retired from the active practice of urology. My 34 years was totally in the clinical field and involved the entire gamut of genitourinary problems, with special interest in endourology.

Organizations
American Medical Association, American Urological Association, American College of Surgeons

Education/Credentials
College degree - BS Medical degree - MD Master of Science - MS

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