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Urology/Venous Leak


QUESTION: Dear Dr. Suppe,

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?


First of all the penile duplex study performed and interpreted in the trained hands is extremely accurate , weather a doctor can read between the lines of a patient with a history of psychogenic symptoms and a true venous leak is to be determined by his-her training. If you can have a morning or nocturnal erection rules out venous leak. Detumescing (losing erection) during intercourse or a duplex study does not mean a patient has valvular incompetence. Venous leak is defined by an injection of vaso dilator that is unable to surpass 60% erection sufficient for penetration and a venous outflow of greater than 5cm/s. When we have a zero outflow that states that the valves are capable to hold flow back. Psychogenic ED is caused by the release of adrenaline which is a more potent vaso-active hormone thany any injectable medication. Adrenaline surges when we are nervous, anxious and scared, this constricts blood vessels that are supposed to stay dilated in order to allow smooth muscle relaxation and subsequent veno-occlusion. Therefore one who can have a full erection can never be diagnosed with a true venous leak, the term gets thrown around too much and misinterpreted. The best way to treat psychogenic ED is with sexual psychotherapy in tandem to traditional psychotherapy and PDE5 inhibitors like daily Cialis. The other factors may also be testosterone level and the type of anti depressant. Many SSRI (selective serotonin reuptake inhibitors) effect libido grealy and subsequent ED is the result. There are other drugs like Dopamine reuptake inhibitors like Bupropian HCI (Wellbutrin) that have little to no libido/ED problems. I believe you may benefit by speaking to the prescribing physician of the drugs to re-evaluate the benefit vs the down fall. A man with no erections will hardly make progress in treating depression if sex is absent so that makes therapy counterintuitive. To wrap this up you do not have a plumbing problem you have a psychological problem and possibly a pharmacological problem effecting your erections. I wont rule out testoserone as a factor until blood levels are confirmed normal.

---------- FOLLOW-UP ----------

QUESTION: Dear Dr. Suppe, a follow up question. There have been numerous, numerous reports of venous leak false positives, especially in young anxious patients during ultrasound. A simple google search with the words "venous leak false positive" yields a multitude of reports in which patients, after being injected with the vasoactive drug, had inflow above 40 cm/s but outflow above 5 cm/s. granted, most of these ultrasounds were performed using only Alprostadil, but even occurred at doses of 20. Last night, while masturbating, I got and maintained an erection for 13 minutes. I have had numerous solid morning erections. I have had sex while using dhea or arginine only and sometimes have received oral sex successfully taking nothing at all. I obviously do not have venous leak. However, I am one of the many many patients who have had ultrasounds with Alprostadil who, although inflow was normal, could not get or maintain the erection, and it ended up being a complete scare. How, then, can we rely on these ultrasounds to accurately diagnose venous leak?

As a patient your job is to research your physician thoroughly and hopefully they will be using accurate trained specialists of the field that they perform diagnostics. I can tell you that I read outside PDX reports and 70% are misdiagnosed due to a general technologist and a general radiologist being the professional opinion for uro-radiology. They do not teach penile ultrasound in US schools or even most medical school urology residencies due to the private nature of the scan, so if they are not fellowship trained then its likely to get a not so accurate diagnosis. I spent 2 years in my fellowship training in uro-radiology and this is why I now teach this to urology residents so they can do the duplex themselves and interpret the the findings. Picture your general doctor doing cardiology they would not dare but since monetary gain is involved diagnostic centers and un-trained urologists will perform duplexes and as long as no one can say they did it wrong bc no one knows then they continue misdiagnosing patients and leaving them completely confused. I will take a blood pressure and spend time reviewing history to feel out for nervousness or psychogenic red flags.

---------- FOLLOW-UP ----------

QUESTION: Dear Dr. Suppe,
Thanks so much for your answer. Two final follow up questions, if you don't mind:

1. I am still having trouble understanding the following: lets say a patient gets an ultrasound with Alprostadil injection. Inflow is normal and outflow is above 5. A diagnosis of venous leak is given. Some time later, the patient is functioning perfectly fine and the diagnosis turns out to be a false positive. As I mentioned earlier, this happens all the time. So is it correct to assume that while the vasoactive drug induced enough smooth muscle relaxation to get a normal inflow, the anxiety/adrenaline prevented the erection from taking place? I am living proof that this can and does happen when the patient is extremely anxious, as I was (I have numerous major psychiatric disorders)?

2. You mentioned earlier that venous leak is when a patient gets less than 60% erection with vasoactive injection with outflow of over 5 cm/s. you also stated that one who can have a full erection cannot be diagnosed with venous leak. So if a patient can take Viagra and get a 100% rock hard erection, then why do we even ultrasound patients like that and test for venous leak. The injection is way stronger than Viagra. I can understand a patient who does not respond to a pde5 inhibitor being tested for venous leak. But I cannot understand the logic behind telling a patient who gets and maontains rock hard erections with low dose Viagra that he needs to be tested for venous leak by injecting a stronger agent into him. Obviously if the patient is getting fully rigid erections with Viagra there is no blood leaking out. So then why would we administer a yet stronger agent and test to see if blood is leaking then?

Jeff, (last response)

If a patient has capability for oral PDE5 drugs to work intermittently but most of the time perform enough for penetration then a duplex is not necessary. Now if this is a younger person we duplex them as they should have no organic reason for ED. There is a difference between adrenaline mediated venous leak from psychogenic factors and venous leak from valvular incompetence. The vaso dilating drug is decided based on age, medical history and testosterone levels. A male suspect of psychogenic ED is best to have alprostadil (I only endorse EDEX use due to best PH and no stinging upon injection)for the test because bi or trimix is too potent and will induce a potential priapism that must be reversed with phenylephrine or irrigation. A man in his 60s with a history of diabetes or cardiovascular disease is a better candidate for trimix. A man at any age who responds normal to sildenafil in any dose should not be tested at all as there is no suspect of arterial or venous abnormalities.  


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Thomas A Suppe RDMS CLT


Invervential urologic radiology , urologic laser surgery, cryotherapy of the prostate and kidney, extracorporal shockwave lithotripsy, holmium laser lithotripsy, urodynamics (video-non video),male infertility, erectile dysfunction, Peyronies disease, hypogonadism ,kidney stones, prostate cancer detection, BPH, voiding dysfunction, bladder cancer and continent diversions.


For the past 20 years performing intervential and diagnostic uro-radiology for a multitude of urologic surgeons from New York, New Jersey, Lousianna and Texas. Founder of DMS medical LLC introducing the Texas Medical Center to the first high power Green Light laser for the treatment of BPH just after its release by the FDA from Laserscope and its sucessful trials at the Mayo Clinc.

American Registery of Diagnostic Medical Sonographers (ARDMS), American Urologic Assocoation (AUA), American Medical Systems (AMS) Laserscope,Oncura, Allergan and Auxilliam pharmaceuticals.

Comprehention of Urologic Ultrasonography for the Resident Physician (Journal of Urology 2012), Author of the syllabus for the uro-radiology residency course at The Scott Dept of Urology at Baylor College of Medicine Houston Texas (2010 to present). Past Clinical Studies: Principal radiology investigator Allergan Inc for "The treatment of BPH with intra-prostatic injections of Botox" with Larry I Lipshultz MD 2011-2012, principal radiology investigator for Allergan Inc for "The treatment of Peyronies disease by intra-lesional penile injections of Botox" with Mohit Khera MD MBA MPH (2011-2012). Current studies: Principal investigator of "Blood pressure risk factors of intra cavernosal injections of Trimix and PGE1 during Penile Duplex's.

BS from Ramapo College of NJ, Registered diagnostic medical sonographer with the ARDMS, 2 year fellowship of Uro-Radiology and intervential sonography at Baylor College of Medicine Houston TX, laser safty officer in state of Texas and certified in KTP, Holmium and Lithium Tri-boride laser systems from Laserscope San Jose, California and American Medical Systems Minnatonka Minnasota, trained and certified by Oncura Inc Isreal in ultrasound guided argon cryotherapy of the prostate and kidney.

Awards and Honors
Honorary instructor of GU ultrasound course 2012 international meeting of the American Urologic Association. Author of the the AUA course for "Ultrasonography of the Testes and Scrotum" 2012.

Past/Present Clients
Baylor College of Medicine (BCM) Lousianna State University (LSU), LSU Medical Center Shreeveport LA, The Methodist Hospital Houston Texas, St Lukes Episcopal Hospital Houston Texas, Memorial Herman Health Systems Houston Texas, Palestine RMC Texas, Doctors Regional Hospital Corpus Christi Texas, Valverde Regional Medical Center DelRio Texas, Current instructor/technologist for two internationally recognized urologists : Larry I Lipshultz MD and Mohit Khera MD, MBA, MPH at Baylor College of Medicine. I served as intervential sonography consultant for Oncura Inc cryotherapy systems. Former lead trainer for Urosource mobile medical services , training new surgeons in PVP or photo-selective vaporization of the prostate for BPH, BNCs and urethral stricture vaporization.

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