Position Dependent Erectile Dysfunction: All You Need To Know

Erectile Dysfunction is a common condition experienced by 18% of men over age 20 in the United States.¹ Many factors can contribute to the development of erectile dysfunction, including age, disease, and performance anxiety.

However, some men find it harder to maintain an erection in certain positions. This is known as position-dependent erectile dysfunction. 

This article discusses position-dependent erectile dysfunction, its relationship with venous leakage, and how it can be managed through various treatments.

What is position-dependent erectile dysfunction?

Erectile dysfunction is common and affects many men at some point in their lives. Erectile dysfunction can be caused by physical, hormonal, and psychological complications, becoming more common with age. 

For some men, certain positions make it difficult to maintain an erection long enough to achieve satisfying sexual intercourse. This is termed ‘position-dependent erectile dysfunction,’ and it can occur due to venous leakage.

What is venous leakage, and how does it cause erectile dysfunction?

Venous leakage² is used to describe blood leaking back into general circulation from the penis. To fully understand this term, let's look at how an erection occurs and how venous leaks can prevent them from sticking around. 

• The flaccid penis - Within the penis is a sponge-like tissue called the corpora cavernosa. This is filled with many smooth muscle blood vessels that contain little blood when a man is not aroused.

• The tumescent penis - When sexually aroused, the nervous system relaxes the muscles and dilates the blood vessels inside the corpora cavernosa. This lets more blood into the penis, causing it to swell.

• The erect penis - As blood flows into the corpora cavernosa, the blood vessels are compressed by smooth muscles, trapping the blood in the penis. The pressure of the trapped blood causes the penis to become firm. 

Venous leakage occurs due to an improper venous occlusion mechanism. This leads to excessive draining of the veins in the cavernosal penile tissue, preventing blood from being trapped in the penis to allow a firm erection long enough for satisfying intercourse.

What are the causes of venous leakage?

Multiple risk factors are associated with venous leakage, including:

• Vascular disease - Multiple forms of vascular disease, such as peripheral vascular disease, cause loss of smooth muscle and thus can cause venous leakage.

• Diabetes - This disease can cause damage to the vascular and nervous tissue of the penis leading to inadequate blood retention and a lack of sensory information from the penis.

• Peyronie’s disease - A build-up of scar tissue in the penis can obstruct blood vessels, cause pain, and in some men, shorten the penis.

• Nerve disorders - There are over 100 kinds of nerve disorders that can affect one or more nerves.

• Anxiety - This condition can cause changes in blood flow and affect the penis.

• Radiation therapy - This can cause vasculopathy or narrowing of blood vessels.

• Traumatic injury - Damage to the venous architecture of the penis can prevent blood flow and storage.

Venous leakage can also be congenital. 

Symptoms of venous leaks

Symptoms of a venous leak are similar to other forms of erectile dysfunction. However, a few specific signs can indicate that the cause of erectile dysfunction may be a venous leak:

• Patients with congenital venous leaks typically have a lifelong inability to achieve a fully erect penis when engaging in sexual acts on their own and with their partner(s).

• Any spontaneous erection gained is commonly inadequate for penetrative intercourse or is of short duration, quickly becoming flaccid before ejaculation can occur.

• Individuals with venous leaks may experience absent or weak “morning wood” (early morning erections), but, in general, libido is unaffected.

• Patients may find traditional treatments used for erectile dysfunction, e.g., Viagra, ineffective.

• Venous leaks may also occur from a traumatic episode where penile tissue has become damaged.

• Congenital venous leaks present more commonly in younger males.

How are venous leaks diagnosed?

Venous leaks are typically diagnosed by specialized testing after a comprehensive history and examination by a urologist. A penile Doppler Ultrasound will be performed, which uses sound waves to map the vascular architecture of the penis. This can then be used to diagnose a vascular leak. 

The Doppler ultrasound is often performed twice, once before erection and once afterward, to see how the vascular architecture is functioning.

An injection of either prostaglandin E1 or Trimix is administered to the corpus cavernosum to increase penile blood flow and achieve an erection.

A urologist will measure the diameter of the arteries, which should increase after the injection is delivered. They will also measure peak systolic velocity (PSV) and end-diastolic velocity (EDV), i.e., the speed at which blood enters the arteries during and between heartbeats. 

How are venous leaks treated?

Multiple options are available to treat a venous leak. The right method depends on the severity of the issue and the comfort of the patient. 

The first line of oral treatment typical for patients with erectile dysfunction is often insufficient for treating venous leaks. However, numerous other treatment methods may provide better, longer-lasting results.

Penile injections

Many men find penile injections an effective method to maintain erections. These injections are self-administered at home at the base of the penis. 

The medication (alprostadil) increases blood flow to the penis, creating an erection within 5 to 20 minutes after the injection. The dose can be tailored to each patient and has a high efficacy rate. It’s an alternative to oral medications such as Viagra.

However, it may be unsuitable for men who are needle-averse. 

There are some side effects of penile injections that individuals should be aware of:

• risk of prolonged erections (priapism)

• risk of penile scarring

• pain at the injection site

• bruising or bleeding at the injection site

• poor long-term satisfaction

Urethral suppositories

These medications are made of the same ingredient as erectile dysfunction injections, alprostadil, but they’re in the form of a pallet inserted into the urethra, where it dissolves. 

Typically, the first tablet is given under a doctor's supervision to ensure that no complications arise and that patients are comfortable performing the procedure themselves at home. Urethral suppositories are less effective than injections, but they’re less invasive and more accessible. 

There are some side effects of urethral suppositories, such as:

• Pain in the penis

• Bleeding from the urethra

Some men find it difficult to administer urethral suppositories if they suffer from tremors, are morbidly obese, or have a limited range of motion. 

Penile implants

Penile implants are also an option for men suffering from position-dependent erectile dysfunction. Implantation does require minor surgery, but it’s a long-term option that doesn’t interfere with ejaculation/orgasm. 

Penile implants are completely concealed within the body — they look and feel natural — and sexual partners are unlikely to notice any difference. Multiple types of penile implants are available, including malleable rods and inflatable implants, that may be prescribed by a doctor.

As penile implants require surgery, there can be complications:

•  Natural or spontaneous erections can no longer occur.

•  The penis may become shorter, curved, or scarred.

•  Infection can occur, requiring that the implant be removed.

Due to the potential loss of spontaneous erections, surgery is often thought of as a last resort for erectile dysfunction. 

However, men who choose to go ahead with penile implant surgery generally report higher rates of sexual satisfaction for longer than men who opt for other treatments.

Psychosexual therapy

If the cause of venous leakage is not physiological, psychosexual therapy may be beneficial. Psychosexual therapy is a form of counseling that focuses on problems with sexual function and expression. This may be conducted in an individual setting or as couples counseling to help clients overcome difficulties in their sex life, such as erectile dysfunction.

Erectile dysfunction can often be linked to general anxiety, performance anxiety, stress, and feelings of shame or guilt in relation to sex. 

There is new evidence³ that psychosexual therapy is a promising treatment option for men with erectile dysfunction, especially if they are young.

How are venous leaks prevented?

It is difficult to prevent venous leaks as they’re a symptom of other underlying conditions and, in some cases, can be congenital.  Adopting a healthy lifestyle can help reduce the risk of diabetes and vascular diseases, and this can be achieved by:

• getting regular exercise

• eating a balanced diet

• maintaining a healthy weight

• limiting alcohol consumption

• avoiding smoking or using illegal drugs

For men suffering from any underlying condition, keeping on top of regular prescribed medication for the condition is important to prevent further progression of erectile dysfunction. 

Where to get treatment for venous leaks

The first line of contact should be a doctor. However, the doctor may recommend seeing a urologist as diagnosing a venous leak can require specialist testing, such as a doppler ultrasound, to evaluate penile blood flow. 

Treating a venous leak often requires more than the typical oral medications commonly prescribed by general practitioners. A urologist will be able to suggest alternative treatments.

When to visit a doctor

Erectile dysfunction is a common issue among men, but that doesn’t mean they have to live with it. A doctor should be consulted if there are any persistent changes in one’s ability to get and maintain an erection, especially if it affects their sex life and mental health. 

Anyone who has recently started taking a new medication and noticed a change in their sexual performance should bring this to a doctor's attention.

An alternative medication that does not produce the same side effects could be available. Also, an additional medicine may be prescribed to help.

The lowdown

Erectile dysfunction is common in men and can be caused by various factors Position-dependent erectile dysfunction may make maintaining an erection difficult in certain positions. A primary cause of this type of erectile dysfunction is venous leakage, which prevents blood from collecting in the penis.

Venous leakage can be resistant to typical oral medications. However, a number of other therapies that provide more satisfactory and longer-lasting results are available.