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Erectile Dysfunction in 25yr old confirmed by University based Urologist- please help

Hi Doctor,

Thank you so much for taking the time to read this. I am very scared and confused with what to do. I apologize for the length, but these are direct reports of my situation from my urologist Dr. Ricardo Munarriz from Boston University:

Appointment 1:
"….His past medical history is only remarkable for removal of a varicose vein in June of 2008. He takes propecia for hair loss, and he takes multi-vitamins and some herbal supplements. On physical examination he is alert, awake, and oriented x3. His neuro exam is grossly intact (Not sure how he came to this conclusion?). His abdomen is benign. He has male external genitalia, with bilaterally descended testicles. I did not feel any penile plaques at this point.

His total testosterone is 935, with free testosterone of 26.8. His Hemogoblin A1c, cholesterol, and triglycerides are normal.

At this point, the patient underwent a penile duplex Doppler ultrasound, after intracavernosal injection of 15 units of mix#5. This resulted in a priapismic erection that rules out the possibility of a venous leak. Gray scale scanning of the penis reveals some areas of tunical thickening, which may be suspicious for Peyronie's disease. However, there are no calcifications. His peak systolic velocities were 13.8 and 32.6cm/sec, which is consistent with mild right-sided cavernosal artery insufficiency. I have scheduled him for a dynamic infusion cavernosometry to cavernosonography to gain a better understanding of his vasculogenic erectile dysfunction. "

Appointment 2:

"…..The patient was placed in the supine position. Cardiopulmonary monitoring devices were applied. At this point, a penile block was performed with 6 cc of lidocaine 1%. Two intracavernosal lines were placed in the right and left cavernosal bodies. His openings intracavernosal pressure was 8mmHg, and he achieved an equilibrium pressure of 58 mmHg after 20 units of Trimix #5 were administered intracavernosally. At the point, a repeat ultrasound was performed, which showed peak systolic velocities of 13.8 and 11.7 cm/sec, which is consistent with cavernosal artery insufficiency. His flows to maintain were 4-5 ml/min, which rules out the possibility of a venous leak.

This was further documented by a normal pressure decay, with 46mmHg. However, investigation of arterial gradients revealed gradients of 56 and 67 mmHg for the right and left cavernosal arteries.

In summary, this hemodynamic evaluation is consistent with pure cavernosal artery insufficiency. In consequence, he is an excellent candidate for microarterial bypass surgery. The patient will contact my office to schedule a selective internal prudenal arteriogram to define his vascular anatomy prior to his surgery. "

Again, I apologize because I have so many questions to ask. I will try to keep it as brief as possible, but honestly, your input is immensely needed:

1. What exactly is cavernosal artery insufficiency? I left my appointment confused on what exactly I had wrong with my body.  From my understanding it is that blood from my body is not coming into my penis at a fast enough rate to keep an erection because there is damage to the arteries somewhere in my body.  I asked my urologist if this problem is due to my penis itself and if the arteries in my penis are damaged.  I thought that may be the case because sometimes in a flaccid state, my penis takes on a bit of an hourglass shape, this restriction is causing blood flow not to get in sufficiently. I do recall one night a couple years ago when my partner was grabbing onto my penis as it was losing its erection and squeezing it hard and tugging upwards in an attempt to trap the blood. It was done hard enough for me to say ouch and make him stop. However, there was no bruising or anything of that sort.  I cannot say for sure if the occasional flaccid hour glass shape penis was caused by that one night. Do you think that could be the case? I have to re-iterate that my penis was semi-erect at the time of the incident. From what I understand, the penis is pretty resilient if it’s not completely erect. Do you think injury could have been from this? Is it safe to say that if my penis is completely erect, with no signs of bending, etc. then the structure of my penis is okay?
2. The urologist said there was no problem with the actual penis arteries but that my situation was most likely caused by a physical injury and that the bad arteries were somewhere along my inner thigh. Does this sound right to you? I guess I am confused as Cavernosal Arteries are in the penis, correct?
3. Furthermore, if Dr. Munarriz is correct, wouldn’t that mean that I would have faulty arteries on both sides of my legs, as I am assuming that the velocity is bad on both cavernosal arteries?
4. Lastly, if it is indeed somewhere in the thigh or within a region that does NOT deal with my penis itself, would this be a less risky version of the surgery? After reading Dr. Munarriz’s published paper, the surgery seems incredibly scary, as several patients report losing sensation in their penis, and several more report losing length of their penis.
5. It was stated that “Gray scale scanning of the penis reveals some areas of tunical thickening, which may be suspicious for Peyronie’s disease. However, there are no calcifications”
Can you please put into your own word what this means? Is this common? Could this have been caused by the experience I described above with my partner grabbing rough and tugging up? Could this tunical thickening repair itself?
6. My urologist mentioned that a selective internal pudendal arteriogram can be done to define my vascular anatomy prior to surgery.  What exactly is this? I cannot find any literature on it. My urologist mentioned that he will not perform this test unless I commit to the surgery. Do you think this is correct? I would like to have one done to see exactly what is causing my issue. Do you think I should go to another urologist to see if they can help me?
7. Any thoughts on Propecia playing a role in this? I have heard horror stories all over the net, and most recently some Swedish study saying that permanent sexual problems have occurred. (can be seen on Wikipedia search for “finasteride”)
8. Does the straining of your body have any effect on this part of your body? I specifically remember an instance in which I tried some opium tea. This made me so incredibly constipated such that I was on the toilet for about an hour trying to move my bowel. It was soon after that instance when I witnessed the varicose vein appear on my leg.  Could this huge amount of strain cause any rupture of sort in the male sexual area? Does fact that I did not cause a hernia mean that it had no impact?
9. Is there ANY potential for this to be something different than a cavernosal artery insufficiency? I don’t feel too comfortable coming to this conclusion so quickly and after two tests. Could there be something perhaps blocking the blood flow (i.e. tumor, cyst), rather than having damaged arteries? Could there be something neurological going on here? For years now I feel like I lost feeling in my penis. I cannot orgasm during sex and it does not feel pleasurable. When I orgasm, it does not feel how it used to. Do you think there is any other test that can be done or that you recommend that can aide me in my fight to figure out what is going on with my body. Please, anything, even thinking outside the box, is so greatly appreciated.

Thank you and God bless you.
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