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Hello everyone,

I’m new here and splitting my time between Rome and London. After reading through many posts, I’m really impressed by the wealth of knowledge shared and the genuine support among members.

I’m 52 and have dealt with some form of ED since I was 27. In the past, PDE5 inhibitors worked well for me, so I never really investigated the root cause. Performance anxiety has always played a role—I’ve typically needed direct physical stimulation to get an erection while with a woman.

However, two years ago, I had a NAION event in my left eye (a mini-stroke affecting the optic nerve), which means I can no longer take PDE5 inhibitors. This led to a period of reclusion, with a significant drop in libido and morning erections. Even during masturbation, erections have become less consistent, although I still experience occasional strong ones.

Recently, I had a dynamic color Doppler ultrasound. After the alprostadil injection, the doctor monitored blood inflow and outflow while I was still quite soft and diagnosed venous leakage. But here’s where it gets interesting: 10 minutes later, I had a 75% erection for 45 minutes while walking home.

This makes me wonder:
. Don’t you need a full erection to properly compress the veins and prevent blood from escaping?
. Could the initial lack of response be psychological or neurological rather than purely vascular?

I’ve consulted three different urologists, and I couldn’t shake the feeling that each of them was pushing me toward an implant. I’m feeling quite confused and would really appreciate insights from those who have been in similar situations.

Has anyone had a similar experience? What are your thoughts on the diagnosis and possible alternatives?

Thanks so much—I truly appreciate any advice you can share!

Yes, anxiety can make alprostadil ineffective.

The simplest treatment for a venous leak, of that is all that's going on, is to use a cockring. You may need to experiment with different types and sizes to find one that works for you.

If available to you, you can also try alprostadil self-injections at higher doses, possibly combined with a cockring if necessary.

I wouldn't put too much stock in stuff like the Doppler test. Be healthy, do lab work, try all the pills, injections and treatments available. If none work, implant

I’m 56 and first noticed ED creeping in when I turned 40.

I’ve seen several urologists over the years and none of them were particularly interesting in a doppler study. The answers each gave were similar. Its essence was this: the treatment options for ED are exactly the same regardless of the cause. It doesn’t matter if it is arterial insufficiency (not enough blood in), venous leak (too much flow out), or psychogenic (however you want to define that). The treatment options are pills, a VED & constriction rings, shots, and implant.

Try all of the options you are interested in. Stop when you find what works for you.

It seems like the alprostadil mostly worked, maybe you need to experiment some more with it before you get it to work reliably. As you say the venous leak test tells you nothing since it’s an inevitable consequence of not being erect.
Did the NAION event happen in connection with having taken a PDE5 inhibitor? If so what dose?

TwoStep wrote:It seems like the alprostadil mostly worked, maybe you need to experiment some more with it before you get it to work reliably. As you say the venous leak test tells you nothing since it’s an inevitable consequence of not being erect.
Did the NAION event happen in connection with having taken a PDE5 inhibitor? If so what dose?

Hi!
Not at all… When I experienced NAION, I hadn’t taken any PDE5 inhibitors for over eight months.
However, every ophthalmologist I consulted advised me to stop using them due to the risk of NAION recurring.

GoodWood wrote:I’m 56 and first noticed ED creeping in when I turned 40.

I’ve seen several urologists over the years and none of them were particularly interesting in a doppler study. The answers each gave were similar. Its essence was this: the treatment options for ED are exactly the same regardless of the cause. It doesn’t matter if it is arterial insufficiency (not enough blood in), venous leak (too much flow out), or psychogenic (however you want to define that). The treatment options are pills, a VED & constriction rings, shots, and implant.

Try all of the options you are interested in. Stop when you find what works for you.

Hello GoodWood, and thank you for your reply.
I agree with your point that urologists tend to take a pragmatic approach, focusing more on treatment than on understanding the underlying causes.
I wonder if consulting a different type of specialist (e.g., a neurologist) or exploring non-Western medicine (e.g., Chinese medicine) could offer a different perspective—one that prioritizes identifying the root causes and, consequently, a different approach to treatment.
Has anyone explored this route?

ObiWan72 wrote:

GoodWood wrote:I’m 56 and first noticed ED creeping in when I turned 40.

I’ve seen several urologists over the years and none of them were particularly interesting in a doppler study. The answers each gave were similar. Its essence was this: the treatment options for ED are exactly the same regardless of the cause. It doesn’t matter if it is arterial insufficiency (not enough blood in), venous leak (too much flow out), or psychogenic (however you want to define that). The treatment options are pills, a VED & constriction rings, shots, and implant.

Try all of the options you are interested in. Stop when you find what works for you.

Hello GoodWood, and thank you for your reply.
I agree with your point that urologists tend to take a pragmatic approach, focusing more on treatment than on understanding the underlying causes.
I wonder if consulting a different type of specialist (e.g., a neurologist) or exploring non-Western medicine (e.g., Chinese medicine) could offer a different perspective—one that prioritizes identifying the root causes and, consequently, a different approach to treatment.
Has anyone explored this route?

You should absolutely explore the potential root causes to the greatest extent possible. Ensure you're sleeping enough, not too stressed, have your various blood levels in check, physically active, don't smoke etc etc

wolfpacker wrote:

ObiWan72 wrote:

GoodWood wrote:I’m 56 and first noticed ED creeping in when I turned 40.

I’ve seen several urologists over the years and none of them were particularly interesting in a doppler study. The answers each gave were similar. Its essence was this: the treatment options for ED are exactly the same regardless of the cause. It doesn’t matter if it is arterial insufficiency (not enough blood in), venous leak (too much flow out), or psychogenic (however you want to define that). The treatment options are pills, a VED & constriction rings, shots, and implant.

Try all of the options you are interested in. Stop when you find what works for you.

Hello GoodWood, and thank you for your reply.
I agree with your point that urologists tend to take a pragmatic approach, focusing more on treatment than on understanding the underlying causes.
I wonder if consulting a different type of specialist (e.g., a neurologist) or exploring non-Western medicine (e.g., Chinese medicine) could offer a different perspective—one that prioritizes identifying the root causes and, consequently, a different approach to treatment.
Has anyone explored this route?

You should absolutely explore the potential root causes to the greatest extent possible. Ensure you're sleeping enough, not too stressed, have your various blood levels in check, physically active, don't smoke etc etc

I certainly explored all the lifestyle issues. Sleep, stress, exercise, smoking.

When ED is severe enough that we are talking about injections and implants, getting an extra couple hours of sleep, managing stress, or Chinese medicine is not going to solve the problem.

Before anyone gets offended, they are all important and have value.

By that point it’s pills, VED, shots, implants.

My main point is that it doesn’t matter what the doppler study shows, the treatment is the same.

GoodWood wrote:

wolfpacker wrote:

ObiWan72 wrote:
Hello GoodWood, and thank you for your reply.
I agree with your point that urologists tend to take a pragmatic approach, focusing more on treatment than on understanding the underlying causes.
I wonder if consulting a different type of specialist (e.g., a neurologist) or exploring non-Western medicine (e.g., Chinese medicine) could offer a different perspective—one that prioritizes identifying the root causes and, consequently, a different approach to treatment.
Has anyone explored this route?

You should absolutely explore the potential root causes to the greatest extent possible. Ensure you're sleeping enough, not too stressed, have your various blood levels in check, physically active, don't smoke etc etc

I certainly explored all the lifestyle issues. Sleep, stress, exercise, smoking.

When ED is severe enough that we are talking about injections and implants, getting an extra couple hours of sleep, managing stress, or Chinese medicine is not going to solve the problem.

Before anyone gets offended, they are all important and have value.

By that point it’s pills, VED, shots, implants.

My main point is that it doesn’t matter what the doppler study shows, the treatment is the same.

Yes I definitely agree. My reply was directed at ObiWan who was suggesting trying Chinese medicine etc