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Urology/Venous Leak


Dear Dr. Leslie,
I have ED that is psychogenic. Sometimes I wake up with great morning erections. Sometimes I can masturbate to full erection and maintain till orgasm, sometimes I cant. Sometimes I can receive oral sex with no problems, sometimes I cant. Sometimes I can have vaginal sex using only l-arginine or DHEA or some herbs, etc. and sometimes when anxious I cant.

My question is as follows: I have had two penile ultrasounds both with alprostadil. Inflow totally normal. But I still couldn't maintain an erection due to my EXTREME anxiety disorder for which I have to take high doses of anti-depressants.

I am not going to have another ultrasound, as those tests are extremely unreliable in young patients suffering from anxiety disorders, and I do not feel comfortable getting my penis injected with high doses of trimix or quad-mix. The fact that I can get and maintain an erection on my own sometimes, or other times with something as weak as l-arginine (which only causes a momentary n.o. spike) and have had my own morning erections shows exactly how unreliable these ultrasounds can be!

What I do know is that when I have a full erection, the outflow is 0 (this was actually showed by the ultrasound). But, as an extremely anxious heterosexual young man, getting the erection to stay up while you are sitting in an exam room with an overweight man holding an ultrasound wand to your penis is no small feat. Surely, this is not the way god intended erections to present themselves!

SO the question is as follows: how long on average does one need to maintain an erection without use of a PDE5 inhibitor to effectively rule out venous leak?



There is no set time limit, but in general patients with a significant venous leak cannot maintain the erection at all without inevitable and rapid loss of rigidity; usually just seconds before it starts to become flaccid.

Since you have intermittent problems and lots of anxiety, your issue is clearly an anxiety one so why worry about venous leak which you haven't got?  Another way to look at it is that it doesn't matter what the US says.  What's important is that clinically you have an intermittent problem which cannot be due to a purely physical cause; only a psychological one.


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Stephen W. Leslie, MD


Questions concerning erectile dysfunction, kidney stones and prostate disorders including prostate cancer. I have a special interest in kidney stone disease prevention.


Full time practicing urologist with 30 years experience. Associate Professor of Surgery and Chief of Urology at Creighton University Medical Center. Editor in Chief of eMedicine Urology internet textbook. Author of only NIH approved book written for patients by a urologist on the subject of kidney stones "The Kidney Stones Handbook". Inventor of the "Parachute" and "Escape" kidney stone baskets and the "Calculus" stone prevention analysis computer program.

American Urological Association, Ohio State Medical Association, Sexual Medicine Society

Men's Health, Journal of Urology, Urology, Healthwatch Magazine, Emergency Medicine Monthly, eMedicine, "The Kidney Stones Handbook", and numerous articles in various newspapers. He is also the editor of the Urology Board Review by McGraw-Hill used by urologists to study for their Board Certification Examinations.

Graduate of New York Medical College with residencies completed at Metropolitan Hospital New York, Albany Medical Center and University of Wisconsin-Madison.

Awards and Honors
Thirlby Award of the American Urological Association. Rated as one the country's Best Urologists by the Independent Consumer's Research Institute

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