Erectile dysfunction holds an important place among male sexual function disorders. Vascular-origin problems often negatively affect the ability to achieve an erection. In recent years, non‑surgical options have attracted attention among treatment methods.
Among these, transcatheter embolization procedures for prominent venous leak problems stand out. This method is considered part of endovascular therapy and is preferred in patients of all ages. Venous insufficiency can begin as early as adolescence. These procedures have the potential to significantly improve the patient’s quality of life.
| Treatment Method | Penile Venous Leak Treatment |
| Indication | Treatment of erectile dysfunction due to penile venous leak |
| Endications | Penile venous leak (on Doppler), erection difficulties, inability to maintain erection, insufficient rigidity during intercourse |
| Procedure Description | Under the guidance of interventional radiologists, angiographic techniques are used to perform embolization or sclerotherapy of the penile veins. |
| Advantages | Minimally invasive, does not require general anesthesia, rapid recovery, discharge within 2 hours. |
| Complications | Infection, bleeding, post‑procedure pain, recurrence of leak after embolization. |
| Success Rate | Around 70%; reduction in dosage of erection‑facilitating drugs, possible completely drug‑free intercourse. Repeat procedure success is very low (unless performed by an inexperienced practitioner). |
| Recovery Process | Rest for several days post‑procedure, abstain from sexual activity for several weeks, clinical follow‑up, possible tenderness in penis and perianal area for days to weeks. |
| Alternative Treatments | Drug therapy (PDE5 inhibitors), vacuum erection devices, intracavernosal injection therapy, penile prosthesis implantation, psychotherapy. |
| Preparation and Precautions | Detailed pre‑procedure imaging (penile Doppler ultrasound), discontinuation of anticoagulants, post‑procedure care and follow‑up. |
| Epidemiology | More common in young and middle‑aged men; hemorrhoids, varicocele, varicose veins are more frequently observed in these patients. |
Prof. Dr. Özgür KILIÇKESMEZ
Interventional Radiology / Interventional Neuroradiology
Arterial Insufficiency
This is observed mostly in older patients with heavy nicotine use, diabetes, or elevated blood lipids. If there is no widespread involvement and the smallest peripheral vessels are intact, balloon angioplasty and stents can achieve success.
Endovascular Approaches in Non‑surgical Penile Venous Leak Treatment
Erectile dysfunction is a common male health issue characterized by impaired sexual function. It can develop due to various factors, with venous leak being a frequent cause. The venogenic form of erectile dysfunction particularly arises from abnormalities in vascular structures.
Disruption of the veno‑occlusive mechanism leads to inadequate trapping of blood in the penile tissue, leakage into the veins, and failure to generate the pressure needed to maintain an erection. This condition can severely affect quality of life.
Among modern treatments, endovascular approaches are prominent. These therapies are applied via minimally invasive methods and accelerate patient recovery. The procedure is usually performed under local anesthesia, and patients can return to daily life shortly afterward. Endovascular treatments are particularly effective in correcting veno‑occlusive dysfunction.
The success of these treatments varies depending on the patient’s specific condition and underlying health issues. Post‑treatment follow‑up is crucial for evaluating effectiveness and planning additional interventions if necessary. Educating patients about treatment options and expected outcomes is essential. This information exchange builds trust between patient and physician and enhances treatment success.
Diagnostic Process for Penile Venous Leaks
Identifying the causes of erectile dysfunction improves treatment success. The International Index of Erectile Function (IIEF‑6) is an important measure in diagnosing venogenic erectile dysfunction. A comprehensive clinical evaluation is conducted to exclude psychogenic factors before treatment.
If veno‑occlusive dysfunction is suspected, an initial evaluation is performed with Doppler ultrasound. This assessment forms the basis for detailed analysis when penile rigidity is insufficient. A rigidity‑promoting drug is administered during this exam to evaluate arterial and venous function. These methods ensure accurate diagnosis and selection of suitable patients for endovascular treatment. Treatment planning is shaped by this diagnostic process.
Penile Venous Leak Diagnosis with Doppler Ultrasonography
For patients diagnosed with organic erectile dysfunction, duplex ultrasonography is applied. This procedure is supported by color Doppler flow analysis and plays a critical role in identifying veno‑occlusive dysfunction. Prostaglandin E1 is injected intracavernosally, allowing detailed observation of penile vascular structure. Systolic flow velocity must exceed 25 cm/s.
Additionally, diagnostic criteria include a resistance index of less than 0.75 within 15 minutes post‑injection and a continuous end‑diastolic velocity exceeding 5 cm/s. These criteria assist in determining appropriate treatment methods. Normally, post‑injection arterial flow velocities increase, venous flow slows, and flow velocity may drop to zero or become negative.
*We recommend filling out all fields so we can respond in the best possible way.
Venous Leak Detection with Dynamic Cavernosometry and Cavernosography
The dynamic cavernosometry and cavernosography methods used in diagnosing erectile dysfunction play a significant role in evaluating veno‑occlusive dysfunction. First, in the dynamic cavernosometry procedure, prostaglandin E1 is injected intracavernosally, pharmacologically inducing an erection. However, these are quite invasive methods.
Next, a predetermined volume of fluid is injected into the corpus cavernosum to monitor intracavernous pressure changes during erection. During cavernosography, contrast agent is administered via venogram while erect, providing effective visualization for identifying venous leaks. Both diagnostic methods allow accurate localization of venous leaks.
Cavernosography for Venous Leak Detection
The cavernosography method used to diagnose veno‑occlusive disease involves a detailed imaging process. Prostaglandin E1 is first injected intracavernosally to induce erection, followed by insertion of a 21‑G needle into the corpora.
Approximately half an hour after injection, a non‑ionic contrast agent is delivered at a flow rate of 2 ml/s. During the procedure, cavernosography helps identify potential venous leak regions, including the deep dorsal vein, cavernosal veins, and external pudendal veins, as well as the internal pudendal veins and periprostatic plexus.
Diagnosis is confirmed by observing leaks in these regions and the failure to achieve expected penile rigidity. This method is a non‑surgical diagnostic option with proven clinical efficacy.
CT Cavernosography for Identifying Penile Venous Leaks
CT cavernosography is an important imaging method for diagnosing veno‑occlusive disease. The examination begins after intracavernosal injection of prostaglandin E1, which induces an erection and enhances vessel visualization. Through a needle placed in the dorsal corporal area, non‑ionic iodinated contrast agent is injected. Various CT techniques are used to obtain high‑resolution images:
- Multiplanar Reconstruction (MPR)
- Maximum Intensity Projection (MIP)
- Volume Rendering (VR)
These techniques enable detailed examination of penile veins and associated vascular structures. The images determine the location and morphology of venous leaks, aiding in selecting appropriate treatment options. Additionally, a detailed map of penile venous drainage is created, categorizing veins into three main groups:
- Superficial veins
- Intermediate veins
- Deep veins
This information is critical for planning surgical or endovascular treatments. CT cavernosography thus stands out as a comprehensive and effective diagnostic tool.
Non‑surgical Penile Venous Leak Treatment Options: Endovascular Approach
Considering the risks and lower success rates of surgical methods for treating veno‑occlusive dysfunction, endovascular techniques take precedence. Endovascular methods for venous leak treatment are notable for their minimally invasive nature.
Transcatheter embolization procedures, in particular, are recognized as an effective alternative. These methods can be performed under local anesthesia without general anesthesia, accelerating patient recovery and reducing hospital stay.
Materials used in endovascular treatment include:
- Histoacryl and Lipiodol or Onyx: This mixture is among the most commonly used materials for occluding leaks within the vessel.
- Fibrous coils: These coils prevent migration of adhesive material in high‑flow vessels.
These treatment methods can effectively resolve venous leak problems and pose fewer risks compared to surgery.
Antegrade Approach via Deep Dorsal Vein (Penile Root Vein) for Penile Venous Leak Treatment
In endovascular treatment of erectile dysfunction, the antegrade approach is considered a safe and effective method. The procedure is carefully performed in an angiography suite. The patient is positioned supine and properly draped. Lidocaine is used for local anesthesia. The main steps of the procedure are:
- Identify the deep dorsal vein using ultrasound.
- Puncture the vein with a micro‑puncture set.
- Under fluoroscopy, use a diagnostic catheter and glidewire for catheterization.
A diagnostic venogram follows, and specialized materials are selected for embolization. Materials used during embolization include:
- N‑butyl‑2‑cyanoacrylate and ethiodized oil mixture,
- Valsalva maneuver and continuous fluoroscopic guidance,
- Oblique projections to prevent non‑target embolization,
- Catheter flushing with 5% dextrose solution,
- Fibrous coils for high‑flow veins.
Sedation and analgesia may be required perioperatively. This process is critical for patient comfort and procedural success.
Retrograde Transfemoral Venous Approach with Transcatheter Embolization
One of the new and effective methods in erectile dysfunction treatment is the retrograde transfemoral venous approach with transcatheter embolization. This technique is performed via the internal iliac veins and targets embolization of the internal pudendal veins and periprostatic venous plexus. It is a minimally invasive option for patients and does not require general anesthesia. Materials used during the procedure include:
- Histoacryl
- Lipiodol
This mixture effectively occludes venous leaks. Because the antegrade approach can be technically challenging, this method offers a smoother access route. Especially in procedures via the deep dorsal penile vein, surgical exposure of the vein may be necessary. This is particularly relevant for patients with deep dorsal vein hypoplasia. This approach accelerates recovery and shortens hospital stay.
Findings from Non‑surgical Penile Venous Leak Treatments
Recent studies have applied various treatment methods to patients with veno‑occlusive disorders. In this study of 212 patients:
- 71 underwent surgical intervention followed by endovascular treatment.
- 126 received direct percutaneous intervention without any surgery.
- Treatment details for the remaining 13 patients were not specified.
Different embolic materials were chosen as treatment options. Embolic materials used included:
- 109 patients treated with N‑butyl‑2‑cyanoacrylate.
- 94 patients benefited from combinations of ethanol, sclerosing agents, coils, and gelfoam.
- Seven patients were treated with ethanol alone.
In most patients, the deep dorsal vein and periprostatic veins were successfully embolized; other deep dorsal vein collaterals were embolized in about 35% of patients. These results demonstrate the effectiveness of the treatment methods.
Outcomes of Non‑surgical Penile Venous Leak Treatments
- image of penile venous leak closure
Endovascular treatment methods for venogenic erectile dysfunction are evaluated in terms of technical and clinical success. Technical success rates are high. However, clinical success rates vary and are generally recorded at 59.5%, ranging from 21.9% to 100%.
- Technical success: 86% – 97%
- Overall clinical success: 59.5% (range 21.9% – 100%)
Finally, complication rates are low, mostly around 5.2%. Major complications, such as pulmonary embolism, are extremely rare (<1%). Therefore, this treatment method stands out with high success rates and low complication risk.
Side Effects of Non‑surgical Penile Venous Leak Treatment
The overall complication rate for endovascular penile venous leak treatment is low. A meta‑analysis reported this rate as 5.2%. Complications during treatment are classified as major and minor. Both major complications were symptomatic pulmonary embolism. Minor complications included:
- Mild penile curvature observed in two patients post‑treatment.
- Mild perineal pain lasting several weeks in one‑third of patients.
- Asymptomatic pulmonary embolism detected in one patient.
- Painful subcutaneous reflux from N‑butyl‑2‑cyanoacrylate use in one patient.
- Small subvesical hematoma in one patient.
- Allergic reaction to disinfectant causing epithelial loss on the glans in one patient.
- Cough lasting two weeks post‑embolization in one patient.
Although these complications affect the overall safety profile, most side effects are non‑serious.
Endovascular Management of Erectile Dysfunction and Venous Leaks
Endovascular treatment methods for venogenic erectile dysfunction offer promising results. Today, this approach emerges as a minimally invasive solution compared to surgical alternatives. Treatment is primarily performed via transcatheter embolization procedures. The embolic materials and techniques used during the procedure are listed below:
- Low‑viscosity embolic materials: N‑butyl‑2‑cyanoacrylate and ethiodized oil.
- Fibrous coils for physical support, effective in preventing venous backflow.
This treatment is a method with high technical success rates; studies have shown success between 86% and 97%. Complication rates are generally low, and serious complications are rarely reported.
The safety of the application is confirmed by low complication rates post‑treatment. In conclusion, endovascular treatment for venous leaks is considered an effective and safe method. This treatment modality should continue to be supported by broader clinical studies.
Frequently Asked Questions
After receiving necessary treatments, individuals with erectile dysfunction should make significant lifestyle changes. First, they should adopt a diet rich in fruits and vegetables. A diet high in protein and fiber is also recommended. They should take necessary vitamin and mineral supplements. They should transition to eating small, frequent meals. Reducing carbohydrate intake by following a low‑carb diet is advisable. Regular exercise to boost testosterone levels is beneficial. Excessive coffee consumption should be reduced or eliminated. If they smoke or use drugs, they must quit. Those with weight issues should reach their ideal weight. Alcohol consumption should be stopped or reduced. Additionally, developing stress‑management techniques will positively affect their health.
Herbal treatments for penile venous leak are not generally accepted by medical professionals. Herbs such as horse chestnut, ginkgo biloba, and ginseng may improve circulation, but there is insufficient scientific evidence that they affect penile venous leakage. Therefore, consulting healthcare professionals is recommended to achieve effective and reliable results for these conditions. It is essential to seek a doctor’s advice before starting any treatment.
Penile venous leak surgery is defined as a surgical procedure performed under general or spinal anesthesia. During this operation, the dorsal vein is ligated, and some patients experience temporary improvement in erection problems. However, recurrence is quite common. Patients typically stay in the hospital for one day and can resume sexual activity four to six weeks later. On the other hand, transcatheter embolization is a minimally invasive intervention targeting venous leak veins. This procedure offers an effective alternative for patients unresponsive to other treatments and reduces erection problems. The success rate is around 70%. However, there is only one chance for a single-session treatment, and it must be performed by professionals who can document interventional radiology training; otherwise, this opportunity is lost.
Additional Resources and Documents
https://ozgurkilickesmez.com/wp-content/uploads/2024/07/venous-1.pdf
Prof. Dr. Özgür Kılıçkesmez graduated from Cerrahpaşa Medical Faculty in 1997. He completed his specialization at Istanbul Education and Research Hospital. He received training in interventional radiology and oncology in London. He founded the interventional radiology department at Istanbul Çam and Sakura City Hospital and became a professor in 2020. He holds many international awards and certificates, has over 150 scientific publications, and has been cited more than 1500 times. He is currently working at Medicana Ataköy Hospital.
Vaka Örnekleri