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QUESTION: Hello,

Recently I've posted a question here but I lost the follow-up question once the other doctor is now on his vacations... I'll briefly summarize my history here.

I am a 26 yo healthy male from northern Europe. A few months ago I started having some difficulties achieving and maintaining an erection which me and my urologist attributed to stress, once it happened all of a sudden. He gave some Levitra 20mg samples which worked very well... my confidence was restored and I was fine.. Recently the problem returned but in a different way, my erections lose strenght (6 out of 10) if I'm flat on my back, other positions are usually fine (8 to 10 out of 10).... Again I was prescribed PDE5i, now daily Cialis, but this does not seem to solve the problem.. I can feel a quicker blood flow but still have some trouble keeping it when lying down...

When I google these symptoms it come back as being "venous leakage", mainly from Dr. Mulhall (NY, US) articles.. But I also saw (from his articles) that high adrenaline levels can mimic venogenic ED once it prevents full muscle relaxation thus veins compression... Please check the link below

http://www.audio-digest.org/pages/htmlos/summary.html?sub1=UR3607


Now, my doctor will be out of city for 3 months and I am not sure of what is the best way to go?

Can you tell me if you seen something similar before? I need to now which direction to go now... Find another doc? Doppler ultrassound?

Best regards,
G

ANSWER: G:

Venous leakage is possible, but you need to think more about treatment options since there are no cures for most types of ED.  These options include MUSE, intracavernosal injections, external vacuum systems, or combination therapy (2 of the previous treatments).  While it is true that high adrenaline levels can cause ED problems mimicking venous leak, that does not necessarily lead to a successful therapy.  Since you've now failed 2 different oral agents, you are left with the options that are available.

If your physician is unavailable for 3 months, chances are that another physician of a similar speciality is covering the practice and you can talk to him or consult a urologist.

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

QUESTION: Hi Leslie, I appreciate your quick reply!

Actually the Levitra 20 worked very well but it's is very expensive if compared to Viagra which I didn't try or daily Cialis. If adrenaline is identified as the troublemaker can a alpha blocker combined with PDE5i improve the response of erectile function?
Another thing, is it reliable to acquire generic Vardenafil from the web?
What about cock rings?

Maybe a DUS would be good just to decide if I should be more or less aggressive in the treatment.

Thanks again,
G

Answer
G:

In theory, an alpha blocker would tend to minimize some of the effects of an adrenaline surge, but there is no evidence that alpha blocker medications are of any clinical use in ED in such situations.  The adrenaline effect tends to overshadow the alpha blocker benefit.

Since you didn't try viagra, that may be worth doing.  You've identified that levitra works well for you so the real issue isn't treatment; it's cost of the medication.

Getting vardenafil from the Internet is like getting anything else obtained from the Web: it depends on the source.  If you are ordering it from a real pharmacy that is regulated and certified, then the risk is minimal.  If it's from a nameless source that is unsupervised or licensed, then you may or may not get the real thing.

A diagnostic duplex ultrasound can be helpful in trying to identify the underlying problem.  However, since it doesn't change the available remedies or outcomes, it may not help much in your case because at the end of the day we still have the same issues about which treatments work and cost of those therapies.

If your current situation is unacceptable, then you don't need a DUS to determine if you need more treatment; it's obvious.  And treatments like MUSE or injections are generally at least double the price of oral drugs.

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Stephen W. Leslie, MD

Expertise

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

Experience

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.

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

Publications
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.

Education/Credentials
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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