Urology/priapism

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Question
i have had a few priapisms lasting about 4 hours, I now have no sensation in my penis and don't get any spontaneous erections, I sometimes wake up with a small soft erection but I never feel the urge to have sex, my ultrasound came back normal with no scarring or plaques or fibrosis? what can be causing my symtoms is it nerve damage? what can be done to get the nerves back? my urologist says I have venous leak can a venous leak make your penis shrivel up in the flaccid state because it shrivels up really bad at times it feels like I don't have a penis what is going on I am suicidal over this it has been a year with no improvement. I got a erection after caverjet after masturbating but it wasn't fully ridged you could still squish it? should I try taking Cialis I am worried about the length of time I am going with out hard erections is there any hope it mite get back normal again???

Answer
James, if you write to me in the future, please state your age, medications being taken and any significant medical problems you have.  As far as the priapism is concerned, lasting less than 4 hours and with no evidence of scarring on ultrasound, I doubt this is a related factor to your erectile dysfunction.  There are many conditions that you might have, venous leak being only one of them.   However, in my experience, it does not cause your penis to "shrivel up".  It merely makes it difficult to get a full erection as blood coming into the penis to cause erection is leaving too soon by the dilated veins.  As far as your loss of libido is concerned, it probably is due to the psychological effects of your ED.  Once you begin to get good erections again,I think your libido will return to normal.  ED is a problem that I have written about extensively on this web site.  To follow is some information I have posted previously that will explain the possible causes and options for treatment.

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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