Venous leak occurs when veins are unable to keep enough blood in the penis for a suitable erection.  As noted above, a firm erection results when blood flows into the penis.  Veins normally constrict to keep the blood inside until the man ejaculates.  A venous leak prevents blood from staying in the penis.  Instead, blood leaks back into the body and the erection fails to stay rigid.
Neelima V. Chu, MD, is an endocrinology fellow in the Division of Endocrinology and Metabolism at the University of California, San Diego. Steven V. Edelman, MD, is an associate professor of medicine in the Division of Endocrinology and Metabolism at the University of California, San Diego, and the Division of Endocrinology and Metabolism at the San Diego VA Health Care Systems in San Diego. He is founder and director of Taking Control of Your Diabetes, a nonprofit organization, and an associate editor of Clinical Diabetes.

So here’s something that’s really fascinating. Healthy eating is a way to reduce anxiety and stress. Now how, you may be asking, right? Well, think about it. We live in a world where there are so many variables and where we don’t have control over our lives. But now, with healthy eating, we have control over what goes into our body. And now having that control empowers us to be even healthier, to be more directive in what we do. And certainly, that begins then to reduce the anxiety and the stress. So all in one, you have a healthier body, but certainly a healthier mind.
Before taking any medication for erectile dysfunction, including over-the-counter supplements and herbal remedies, get your doctor's OK. Medications for erectile dysfunction do not work in all men and might be less effective in certain conditions, such as after prostate surgery or if you have diabetes. Some medications might also be dangerous if you:
The various PDE5 inhibitors for the treatment of ED share several common side effects, including headache, flushing, nasal congestion, nausea, dyspepsia (stomach discomfort), and diarrhea. Differences exist in side effects of the different PDE5 inhibitors, and thus it is important to be familiar with the prescribing information of the PDE5 inhibitor you are prescribed.
Medications: Many common medicines produce erectile dysfunction as a side effect. Medicines that can cause erectile dysfunction include many used to treat high blood pressure, antihistamines, antidepressants, tranquilizers, and appetite suppressants. Examples of common medicines that can cause erectile dysfunction include propranolol (Inderal) or other beta-blockers, hydrochlorothiazide, digoxin (Lanoxin), amitriptyline (Elavil), famotidine (Pepcid), cimetidine (Tagamet), metoclopramide (Reglan), naproxen, indomethacin (Indocin), lithium (Eskalith, Lithobid), verapamil (Calan, Verelan, Isoptin), phenytoin (Dilantin), gemfibrozil (Lopid), amphetamine/dextroamphetamine (Adderall), and phentermine. Prostate cancer medications that lower testosterone levels such as leuprolide (Lupron) may affect erectile function. Some chemotherapies such as cyclophosphamide (Cytoxan) may affect erectile function.
Men with a rare heart condition known as long QT syndrome should not take vardenafil since this may lead to abnormal heart rhythms. The QT interval is the time it takes for the heart's muscle to recover after it has contracted. An electrocardiogram (EKG) measures the QT interval. Some people have longer than normal QT intervals, and they may develop potentially life-threatening abnormal heart rhythms, especially when given certain medications. Men with a family history of long QT syndrome should not take vardenafil, as it is possible to inherit long QT syndrome. Furthermore, vardenafil is not recommended for men who are taking medications that can affect the QT interval such as quinidine (Quinaglute, Quinidex), procainamide (Pronestyl, Procan-SR, Procanbid), amiodarone (Cordarone), and sotalol (Betapace).
Chronic and persistent alcohol use is known to induce sexual dysfunction, which leads to marked distress and interpersonal difficulty. This, in turn, is known to worsen the alcohol abuse. Sexual dysfunction in the alcoholic may be due to the depressant effect of alcohol itself, alcohol-related disease or due to a multitude of psychological forces related to the alcohol use.[1] The spectrum of sexual dysfunction encompasses:

Erectile dysfunction, also known as ED or impotence, is the inability to attain or maintain an erection of the penis adequate for the sexual satisfaction of both partners. It can be devastating to the self-esteem of a man and of his partner. As many as 30 million American men are afflicted on a continuing basis, and transient episodes affect nearly all adult males. But nearly all men who seek treatment find some measure of relief.
If not properly controlled, both type 1 and type 2 diabetes can cause complications due to high blood sugar levels. Over time, these high levels can cause irreversible nerve damage and narrow your blood vessels. While nerve damage may affect the sensitivity of your penis, blood vessel damage can affect the blood flow to your penis and make it more difficult for you to get an erection.
Urinary infections are more common in people with poorly controlled diabetes and can cause discomfort for women during intercourse and for men during urination and ejaculation. These generally are temporary complications, but they can recur. Sexual activity should be stopped during treatment of urinary tract and yeast infections, which also are relatively common in people with diabetes.

Although ED can become a permanent condition, this typically isn’t the case for men who experience occasional erectile difficulties. If you have diabetes, you may still be able to overcome ED through a lifestyle that includes sufficient sleep, no smoking, and stress reduction. ED medications are usually well-tolerated, and can be used for many years to help overcome any ED problems.


While erectile dysfunction can occur at any age, the risk of developing erectile dysfunction increases with age. According to the Massachusetts Male Aging Study, the prevalence of erectile dysfunction was 52% in men 40-70 years of age. The prevalence of complete erectile dysfunction increases from 5% at 40 years of age to 15% among men 70 years of age and older.

This is a 17-year-old male with a past medical history of insomnia, anxiety and depression who presents with complaints of gradual onset (2 years ago) of decreased ability to obtain and maintain erections adequate for intercourse. He reports normal nocturnal erections “most days of the week”. He does not masturbate because he feels that masturbation may have desensitized his brain and caused ED; however, he can masturbate and have an erection with normal orgasm/ejaculation. He has had a successful erection and intercourse with a partner, last time 2 weeks ago. He feels that his ED might have been associated with SSRI treatment but noted no improvement after stopping his SSRI. Cialis 5 mg is effective. He reports normal libido “but not where it was”. His testosterone (T) and free T are normal. He is in the care of a sexual therapist and has read extensively on the internet. He takes trazodone nightly for sleep.


Tobacco use though, was not found to be a significant determinant of sexual dysfunction. This is contrary to all reported evidence.[19] This finding is most likely to be due to our treatment of tobacco use as a categorical (present / absent) variable in a situation where almost 90% of the sample was using tobacco. Future studies need to use indices of severity to avoid this error.
This initial release of NO causes rapid and short-term increases in penile blood flow and short-term relaxation of the penile smooth muscle, initiating an erection.  The resulting expansion of penile blood vessels and smooth-muscle relaxation allows more blood to flow into the penis. This increased blood flow (shear stress) activates the eNOS in penile blood vessels causing sustained NO release, continued relaxation and full erection.
In most healthy men, some of the drug will remain in the body for more than two days after a single dose of tadalafil. Metabolism (clearing of the drug from the body) of tadalafil can be slowed by liver disease, kidney disease, and concurrent use of certain medications (such as erythromycin, ketoconazole, and protease inhibitors). Slowed breakdown allows tadalafil to stay in the body longer and potentially increase the risk for side effects. Therefore, doctors have to lower the dose and frequency of tadalafil in the following examples:
While self-esteem can be affected by the perceptions of others, it is largely how you feel about yourself. If you have a negative view of yourself and your abilities, it is going to color your experience and actions on a daily basis. Many people with low self-esteem get so caught up in their own perception of themselves, that they begin to project it onto others. For example, a man with low self-esteem might believe that he is not capable of satisfying a woman and, as a result, he becomes unable to perform in the bedroom. Low self-esteem can also be a sign of other psychological issues such as depression.  
If the patient reports a history of trauma to the genitals that preceded his erectile dysfunction, further evaluation with pharmacologic injection and penile color duplex ultrasound (PCDU) would be indicated to assess for arterial insufficiency or venous occlusive dysfunction (19). Prior to PCDU, however, you might give him a trial of oral PDE5 inhibitors. If those medications are effective, you have effectively ruled out significant arterial insufficiency or venous leakage disease as an etiology. Regardless of outcome of PCDU, no surgical intervention would likely be offered to this man who responds well to oral agents.
Getting blood glucose under control is a good anti-ED tactic. Men with diabetes and poor blood glucose control are two to five times as likely to have ED as those with good control. One study in a group of men who had had type 1 diabetes for up to 15 years with minor complications found that intensive blood glucose control lowered the risk of ED compared with conventional treatment. A study in men with type 2 diabetes found that lowering A1C (average blood glucose in the past two to three months) below 7 percent and reducing blood pressure through a combination of medication, diet, and exercise improved sexual functioning.

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If the patient reports that PDE 5 inhibitors work poorly or inconsistently, we offer CIS to objectively assess erectile function and to provide diagnostic information. For the CIS, inject bimix (such as papaverine 30 mg/phentolamine 0.5 mg/mL—0.2–0.3 cc) and have the patient compress the injection site for 5 minutes. After 5 minutes, instruct the patient to self-stimulate, then assess his response to injection. One could also combine penile color duplex ultrasound (PCDU) with the CIS. However, PCDU is expensive, may not be covered by the patient’s insurance, and may require increased dosages of pharmacologic agents, such as trimix (papaverine 30 mg/phentolamine 0.5 mg/alprostadil 10 mg–0.5 cc) to obtain complete smooth muscle relaxation. This often requires reversal of erection using phenylephrine after the study. In rare patients who failed to achieve and maintain erection with 0.5 mL of trimix, we may proceed with pharmacologic cavernosography or pharmacologic arteriography depending on the results of PCDU.
ICI Alprostadil may be used as a mixture with two other drugs to treat ED. This combination therapy called "bimix or trimix" is stronger than alprostadil alone and has become standard treatment for ED. Only the Alprostadil ingredient is FDA approved for ED. The amount of each drug used can be changed based on the severity of your ED, by an experienced health professional. You will be trained by your health professional on how to inject, how much to inject and how to safely raise the drug's dosage if necessary.
Erectile dysfunction (ED) generally affects men older than 65, but younger men can get it too. If it happens at a younger age, ED may be a warning sign of another health issue. If you have no obvious risk factors and no other health problems, like diabetes, your doctor will run laboratory tests and may order heart tests. The same process that affects the arteries in the penis affects the ones in your heart, too. If something is wrong and it is not diagnosed and treated, you have a fairly high risk over the next four to five years of having some type of cardiac event.

For oral erectile dysfunction medicines to work as desired, they must be used properly in the first place. This means taking the medicine 30–45 minutes before engaging in sexual intimacy; taking the drug on an empty stomach or at least avoiding a heavy or high-fat meal before taking the drug (this is especially important when using sildenafil); and engaging in adequate genital stimulation before attempting intercourse. Drinking small amounts of alcohol (one to two drinks) should not compromise the effectiveness of erectile dysfunction medicines, but larger amounts of alcohol can diminish a man’s ability to have an erection.
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