ESG Virtual Wellness Series
- Venous Leak & Erectile Dysfunction

Dr. Benjamin Chua: My name is Dr. Benjamin Chua, a vascular surgeon. And today I’m going to talk about a topic that’s close to the hearts of many men. It may be embarrassing for them sometimes to talk about it. It is like a dirty little secret, and they don’t want to talk about it, but they live with this problem and are embarrassed and they try and find different issues and answers and sometimes to no avail.

And the topic is of course, a venous leak and how it relates to erectile dysfunction. The title of my talk is venous leak and erectile dysfunction, hard to get a grip on some issues? Now really, what is venous leak and how does it lead to erectile dysfunction. Now, traditionally, we know that for men to attain erection for intercourse, sexual intercourse, there are a few factors, but basically it’s related to the way blood flows into the penis and how blood is retaining opinions before it’s released. So venous is first to the ability to maintain an erection in the presence of sufficient arterial blood inflow to the cavernosal tissue of the penis and arteries of the penis and the cause of venous leak is often due to the excessive outflow of blood. In other words, uncontrolled outflow of blood from the same cavernosal arteries and the drain quickly out of the penis as a result of man is unable to sustain an erection for a period of time, at least sufficient enough to have sexual intercourse.

Now, venous leak is responsible for about 80% of causes of cases of erectile dysfunction. How do we diagnose venous leak? Essentially it is using a Doppler ultrasound that is an ultrasound scan. And we use that to check the blood flow in and out of the penis. That is usually the basic investigation we do. And it’s non-invasive, it is not painful at all. It can be done on an outpatient basis and quite quickly, we get the diagnosis really. when the ultrasound does not give us a very clear picture, then we go to something called Cavernosography. Cavernosography is usually a test where we make an injection with some contrast into the penile tissue. And we look at how it flows and how it drains. That is slightly more invasive, but it is not extremely painful and it can be done under local anesthesia.

Now, in such cases, after we diagnose a venous leak, then we think about ways to treat it. And usually the way we look at it is we want to avoid invasive surgery. The traditional surgery to treat venous leak is actually very invasive in removing all the main venous drainage of the penis through open surgery. It can be quite painful. It’s slow recovery. Nowadays. We do a procedure where we call it endovascular embolization and patients who are eligible for this are usually patients who have a proven venous leak and they want to avoid invasive surgery. Now in the endovascular embolization or non-surgical treatment of venous leak, erectile dysfunction. What we do is we make a pinhole puncture into the veins, either in the groin, or sometimes we use the neck, but more often we give a patient a light anesthesia, and we puncture the deep dorsal vein of the penis.

Although it sounds like it’s painful, actually It’s not. patients don’t feel anything at all when we do the procedure and that’s the local anesthetic and a little bit of sedation, we numb the skin around there. We make tiny puncture into the deep dorsal vein, so Penile vein. And then we do something called an angiogram. An angiogram is where we inject a little bit of contrast. Look at the flow patterns in the vein, especially how fast the vein drains blood. In other words, we inject contrast and we see how fast that contrast is drained from the penis. We also look at the size of the drainage veins that are affected and usually the larger it is, it tells us that it’s not working too well. Now, once we diagnose this and we see that the veins are very enlarged and they are draining very fast, we then block off these veins and the idea of blocking off this vein is so that the fast drainage or the loss of blood from the penis after erection is obtained.

That process is now slowed down by blocking off these key drainage, which means as a result, the erection is then sustained. And how do we block these veins? We usually use tiny titanium coils. These are biocompatible coils. They can be left in the body for a long time and they won’t trigger any (inaudible) or anything. We just insert some of these coils to block out the flow. And sometimes we use a little bit of tissue glue. They’re compatible again with the tissues in the human body. And sometimes we use an embolic agent, which is basically some sort of chemical that basically blocks the artery. And this is all localized, the idea is we do this under x-ray guidance so that we permanently seal off these veins. So that only the small site drainage veins are working. And these big defective veins are blocked off.

As a result, blood is able to flow in quickly into the penis, but it’s slow to drain out. And this helps sustain an erection. Now, this procedure, as I mentioned, can be performed under light sedation, which means we give you a little bit of medication to make you feel sleepy. And then we give a local anesthesia around the area that we are going to put in these catheters and coils. And they’re usually numb and painless. And the procedure takes us about an hour, hour and a half. There’s minimal pain and discomfort. More importantly, no open surgical scars and patients essentially, once the procedure is over, they’re awake alert and they can get up and walk immediately after, usually about half an hour to one hour, they can actually be discharged home. Normally we keep patients for two hours just as a precaution and they can return to their daily activities in the patients that we have done. They’ve also reported a quick return to sexual activities and as much as the next morning or next day, they are having an erection already. That is sustained. So this shows you that it’s quite quick. Many of the patients who used to take oral medication for erectile dysfunction after this procedure, they don’t require any more medication and they function quite normally and happily, thank you very much.

Today. I’m going to share with you about venous leak and erectile dysfunction and how venous leak leads to erectile dysfunction in men.Venous leak is a condition where your varicose veins or the pelvis and these veins become very big and what they do is they drain blood excessively from the penis during an erection. As a result, the man is unable to sustain his erection due to this leak and is unable to have intercourse. This results in, then what we call erectile dysfunction, psychologically it affects many men. It affects them mentally. It affects their relationships with their partners, and it’s very distressing. Many men don’t like to talk about it, especially so since it affects young men, more than all men. In fact, in all the cases of erectile dysfunction, venous leak is responsible for up to 80% of these cases. So how do we diagnose the condition of venous leak?

One is a very good history taken from the patient. Although we may ask very intimate questions during the consultation, at least we know from the patient’s history, what the problem is. And sometimes that gives us an indication that there’s a problem with the venous leak, but the real diagnostic test actually comes from doing two things, an ultrasound scan and a CT scan. So we can do the ultrasound scan in the clinic. And in this ultrasound scan, what we do is we examine the patient’s blood flow in his pelvis and also in the penile gland or penis. And sometimes we compliment that with extra imaging then that’s a CT scan. With these two images, which are both non-invasive. We can diagnose the problem of being asleep. So frequently, men who have had venous leak where I’ve tried seeing many doctors, some people have taken some medication like Viagra or Cialis to help them attain an erection, but they still find that they are unable to have intercourse because they cannot sustain that erection.

So after we diagnose the venous leak with an ultrasound or a CT scan, what we then do is then consider treatment. Right now, the latest way of this is actually minimally invasive. In fact, it is almost nonsurgical. If you know the problem of venous leak is actually these big dilated veins. As you can see there on the screen, what we then do is reduce the leak of these veins. And we sometimes use small metallic inert biocompatible coils, or we inject some glue. That’s also biocompatible. As a result, the leak is reduced significantly. And so blood is now retained inside the penis for longer periods. As a result, the man is able to sustain his erection and continue to have intercourse like he did before this problem developed. This is a very good procedure because it is done first, minimally invasive, almost nonsurgical with local anesthesia and a little bit of sedation.

And it’s done like a day surgery. More importantly, the men have undergone this procedure, tell us that by the next morning, they are already feeling a lot better. And they see an improvement in the erectile dysfunction and many men then subsequently also go off all their medication to treat erectile dysfunction and are happy. In terms of how long this is sustainable, this has been shown to be long-term. So many men up to two to five years are still having very good results and are very, very happy. So this is a way of doing this procedure. We call it embolization and coiling for treatment of venous leak resulting in Erectile dysfunction.

No, I will move on to the next topic that I’m going to share with you. And that is a topic of varicose veins in men. You may wonder why I’m talking about varicose veins in men, especially because many of us think that varicose veins are a problem related to women and in their legs, but really varicose veins can affect men. And particularly it is a condition known as a Varicocele. And today I will share with you about how these two things are related to varicose veins and Varicocele. Now, what is Varicocele? Varicocele is a condition that affects men and it is caused by varicose veins within the scrotum of men. Basically there is the loose bag of skin that holds our testicles and varicose veins occur in these veins, in the scrotum when the valves are weakened and do not close properly. Now the condition of Varicocele actually is quite common and affects about 20% of men, about one in every five men.

Now, as a result, the blood flows back down towards the scrotum and the veins above the testicles in the scrotum get dilated and engorged. As a result, the temperature in that region is higher. So one of the side effects of having a Varicocele is low sperm count or low quality of sperm. This is because of the higher temperature in the region due to the backflow of blood. And it’s pulling back the testes. As result, men, a Varicocele may find that they’re infertile also because of the pressure and the back filling of these veins, many men experienced persistent scrotum pain, and this is especially so when they are standing for long periods of time or even sitting for long periods of time, and sometimes so when they are actively involved in sports as a result of the blood pooling there there’s pressure on the testes

and many men feel a persistent, constant ache in the scrotum. In rare cases because of the Varicocele being present above the testes the testes feel a little bit of pressure and heat. They failto develop properly and normally, and may even shrink in size. If you look at this diagram, this is what a varicose seal looks on the outside. Usually people dilated veins in the scrotum, much like a bag of worms. And actually when the man examines himself, he feels these rubbery dilated veins around the region, and sometimes it is tender to touch or they feel a bit swollen and they will know this especially so if they’re standing up for example, in the shower, and this is when they start diagnosing themselves with this. Now again I’m going to talk about the symptoms of Varicocele.

Often they may have some mild symptoms or no signs, but for those with very dilated and large Varicocele patients will experience pain and they range from a dull discomfort and constant ache to sharp pain and swelling in the scrotum. Some people may actually experience severe testicular pain, and this is worse over long periods of time, but particularly they find that this pain will get worse in a day. They find some relief when they’re lying down, especially when they’re going to sleep. Physically, people may feel a lump, like a bag of worms and becomes more noticeable as the veins enlarge. How do we diagnose a Varicocele? In the clinic, we do a physical examination. Usually I’ll palpate or feel the region around the testicle and above the testicle. And usually I will feel a bag of worms or a dilated bunch of veins.

And we do an ultrasound of that region and it shows us very dilated veins. And this confirms the diagnosis. Once diagnosed, how do we treat it? We treat it for a variety of reasons. We treat Varicocelectomy mainly for the pain and patients are very bothered by it. And some men, we treat for the eradication of infertility. They had been trying to have children, and they find that this is a problem, and this is a cause of low sperm count. Now, traditionally, the surgery has been something called Vacocelectomy to me that is open surgery. And what we do is we approach the veins through the groin or an incision above the bag of worms in the scrotal sac. And we look for these veins and we dissect and tie them off. This is so that the veins don’t backflow down to the region and get dilated again.

And sometimes we use laparoscopy to do that surgery. And the advantage of that is open surgery is you can see quite a bit of the veins and you can ligate it there. But the problem is sometimes the recovery is a bit slow and may take a few weeks to recover. Patients frequently feel sore at the surgical site for a few weeks and interim patients also advise against having sex so that the new sperms can develop, if especially if they’re trying, especially if their indication is for infertility. Nowadays, we have a much more minimally invasive non-surgical option. And that is usually a procedure called embolization. It does not require any cuts in the scrotum or any cuts in the groin or any insertion of instruments in the abdominal cavity. Vis-a-vis laparoscopy. This is a new procedure that we have been doing, and it is done through a tiny puncture in the vein.

Usually the femoral vein in the groin or the vein in the neck and you, and what happens is true that tiny puncture, we will put a small tube, caught catheter all the way down to the main vein that leads to the Varicoceles. And once we are there, we usually, again, block off these veins with tiny titanium coils or glue, and this will prevent the back floor down to the scrotum. So we block off these veins to prevent them from swelling up again. Now the advantage of this method is that it is minimally invasive, it’s fast recovery. And usually we block off the veins very extensively so that there is a very little chance of it recurring. Now this is in contrast to surgical ligation, where there is still a risk, these veins redeveloping again in the future. Obviously with this minimally invasive procedure, the recovery is very fast.

Patients are up and about and walking usually about one to two hours after the procedure. And they can resume back to normal activities, including running and jogging after a matter of one to two days. And they can resume having sexual intercourse as soon as one to two days, instead of waiting for a while. So this advantage is definitely less invasive, faster recovery, and certainly minimal pain with no scars. So this procedure is usually performed again under light sedation and a little bit of local anesthetic in our clinic. And we send patients home on the same day. So who is eligible for this procedure? The embolization of Varicocele. Yeah, essentially all patients diagnosed with varicose you with the symptoms of testicular pain or infertility, and mainly patients who want to avoid invasive surgery and want to return back to their daily activities quickly with minimal pain and scarring. Thank you.