Is my ED physical, psychological or hormonal?

[TestBoosted]

Good morning all,

Hope everyone is well.

I am a 33 year old man, currently weighing 88kgs and height 1.83 cm (6 foot).

I have been battling erectile dysfunction for 10 years or so, starting from when I was 22 or 23 years old. I have posted about my journey in this thread (Help with blood test results and erectile dysfunction - Excel Male Health Forum).

Below is a quick summary of what was said in the other thread:

i) Started experiencing ED at 22 or 23 years old.

ii) At first, doctors blamed anti-depressants I used to take.

iii) Blood test confirmed I had secondary hypogonadism and was put on testosterone.

iv) After being put on Nebido (testosterone undecanoate), erections came back full force after 3 months. I was finally cured and happy but this only lasted 2 years.

v) After I got Covid, erections deteriorated again.
a) Nowadays, I wake up with weak morning wood.
b) Erections are soft, where the shaft is semi-rigid and the head of the penis does not engorge and is soft.
c) I can't maintain erections standing up. I can only maintain soft erections when sitting down e.g. on the toilet.
d) I don't respond to 5mg Cialis, 20mg Cialis, 20mg Viagra, 100mg Viagra. I used to respond in the 2 years when my erections came back.
e) Caverject (penile injection in Europe) and Vitaros only give me a partial erection (still soft)
f) I am only able to get and somewhat maintain a decent erection with an acceptably engorged head if I wear a tight and oversized cock ring.

vi) Started investigating issue again.
a) Cardiologist did 24 hour blood pressure test and echocardiogram. Everything is good.

b) Found that I had some insulin resistance and cholesterol. Went to dietician 4 months ago and lost 7 kg (results attached). Insulin resistance and cholesterol are good now.

c) Have been going to psychiatrist to try and change anti-depressant medication. Have tried fluvoxamine 100mg daily, brintellix daily, anafranil 10 mg daily, anafranil 25 mg daily, adding wellbutrin 150mg to anafranil 25mg daily. All to no avail.

d) Did 2 Doppler tests. For both Doppler tests, I was given 20mcg Caverject injection. Both doppler tests showed good artery inflow but high end diastolic velocity. In fact, the diastolic velocity on both sides of the penis for both tests were greater than 10cm/s (results attached). Caverject only gave me weak erection.

e) Experimented with TRT dose. Changed to testosterone enanthate. Initially, SHBG was 16 nmol/L. Tried with 50mg twice a week, 30mg 3 times a week, 22.5mg EOD. Attached testosterone results at trough, all were good but no change in ED. (Results attached)



----------

Now here is the catch guys. After going through all of this, especially given the Doppler test results, the fact that I no longer respond to PDE5 inhibitors and caverject, as well as the fact that the only thing that helps is a cock ring, I was 100% convinced that it must be a physical issue.

My urologist kindly ordered a Nocturnal penile tumescence test using Rigiscan, where they measure my erections during the night. The test stated that I had 3 erectile episodes lasting 1 hour with 85% rigidity. This was a suprise honestly as I wake up with weak morning wood and my penis was very shrunken before the test, given that I even stopped taking 5mg Cialis before the test. I still take 5mg CIalis till this day even though I don't respond that much to it, but it helps a bit.

Thus, the conclusion from the Nocturnal penile tumescence test was that I have phsycological ED and was recommended to a sex therapist. The thing is I can never get decent erections, neither when waking up, masturbating alone, with a partner, nothing. Sometimes I think the reason I got these erectile episodes during the test was due to the fact that my bladder was full of urine, and sometimes it creates enough pressure to get an erection. I also noticed this way before, that when I wake up to pee, I have better erections.

At this point, I don't know what to do honestly. I am trying to experiment the psychological side more, going to try some more medication under the guidance of my physicatrist.

What do you guys think? Is my ED physical, hormonal or phsycological? Should I try going to a pelvic floor therapist, try PRP or shockwave? What would you do in my situation?


Current medications I take
------------------------------------

i) Vitamin D + K2
ii) 2 capsules Omega 3 (2g each)

iii) 25mg Anafranil (Clomipramine)
iv) 150mg Wellbutrin

v) Cialis 5mg

vi) Atorvastatin 20mg

 

[TestBoosted]

Good morning all,

Hope everyone is well.

I am a 33 year old man, currently weighing 88kgs and height 1.83 cm (6 foot).

I have been battling erectile dysfunction for 10 years or so, starting from when I was 22 or 23 years old. I have posted about my journey in this thread (Help with blood test results and erectile dysfunction - Excel Male Health Forum).

Below is a quick summary of what was said in the other thread:

i) Started experiencing ED at 22 or 23 years old.

ii) At first, doctors blamed anti-depressants I used to take.

iii) Blood test confirmed I had secondary hypogonadism and was put on testosterone.

iv) After being put on Nebido (testosterone undecanoate), erections came back full force after 3 months. I was finally cured and happy but this only lasted 2 years.

v) After I got Covid, erections deteriorated again.
a) Nowadays, I wake up with weak morning wood.
b) Erections are soft, where the shaft is semi-rigid and the head of the penis does not engorge and is soft.
c) I can't maintain erections standing up. I can only maintain soft erections when sitting down e.g. on the toilet.
d) I don't respond to 5mg Cialis, 20mg Cialis, 20mg Viagra, 100mg Viagra. I used to respond in the 2 years when my erections came back.
e) Caverject (penile injection in Europe) and Vitaros only give me a partial erection (still soft)
f) I am only able to get and somewhat maintain a decent erection with an acceptably engorged head if I wear a tight and oversized cock ring.

vi) Started investigating issue again.
a) Cardiologist did 24 hour blood pressure test and echocardiogram. Everything is good.

b) Found that I had some insulin resistance and cholesterol. Went to dietician 4 months ago and lost 7 kg (results attached). Insulin resistance and cholesterol are good now.

c) Have been going to psychiatrist to try and change anti-depressant medication. Have tried fluvoxamine 100mg daily, brintellix daily, anafranil 10 mg daily, anafranil 25 mg daily, adding wellbutrin 150mg to anafranil 25mg daily. All to no avail.

d) Did 2 Doppler tests. For both Doppler tests, I was given 20mcg Caverject injection. Both doppler tests showed good artery inflow but high end diastolic velocity. In fact, the diastolic velocity on both sides of the penis for both tests were greater than 10cm/s (results attached). Caverject only gave me weak erection.

e) Experimented with TRT dose. Changed to testosterone enanthate. Initially, SHBG was 16 nmol/L. Tried with 50mg twice a week, 30mg 3 times a week, 22.5mg EOD. Attached testosterone results at trough, all were good but no change in ED. (Results attached)



----------

Now here is the catch guys. After going through all of this, especially given the Doppler test results, the fact that I no longer respond to PDE5 inhibitors and caverject, as well as the fact that the only thing that helps is a cock ring, I was 100% convinced that it must be a physical issue.

My urologist kindly ordered a Nocturnal penile tumescence test using Rigiscan, where they measure my erections during the night. The test stated that I had 3 erectile episodes lasting 1 hour with 85% rigidity. This was a suprise honestly as I wake up with weak morning wood and my penis was very shrunken before the test, given that I even stopped taking 5mg Cialis before the test. I still take 5mg CIalis till this day even though I don't respond that much to it, but it helps a bit.

Thus, the conclusion from the Nocturnal penile tumescence test was that I have phsycological ED and was recommended to a sex therapist. The thing is I can never get decent erections, neither when waking up, masturbating alone, with a partner, nothing. Sometimes I think the reason I got these erectile episodes during the test was due to the fact that my bladder was full of urine, and sometimes it creates enough pressure to get an erection. I also noticed this way before, that when I wake up to pee, I have better erections.

At this point, I don't know what to do honestly. I am trying to experiment the psychological side more, going to try some more medication under the guidance of my physicatrist.

What do you guys think? Is my ED physical, hormonal or phsycological? Should I try going to a pelvic floor therapist, try PRP or shockwave? What would you do in my situation?


Current medications I take
------------------------------------

i) Vitamin D + K2
ii) 2 capsules Omega 3 (2g each)

iii) 25mg Anafranil (Clomipramine)
iv) 150mg Wellbutrin

v) Cialis 5mg

vi) Atorvastatin 20mg

Here are also the blood test results for:

i) Testosterone enanthate 30mg x3
ii) Testosterone enanthate 22.5mg EOD


I also am attaching my full blood test results taken when I was on testosterone enanthate 22.5 mg EOD.

 

[Gman86]

As far as protocols go, the best erections I’ve ever had, and the best erections that I’ve seen quite a few others have, on HRT, seem to have come from a nandrolone based protocol, with a small amount of test. Like 100-200mg of nandrolone, and around 20-40mg of test. The high amount of androgens the nandrolone introduces to the system, along with the lowish level of estrogen u’ll have, seems like a great combo for optimal erections, again, based on my personal experience, and a lot of anecdotal experiences of others that have tried it. So u could always give a nandrolone based protocol a try

Ur test levels are too low, and ur estrogen levels are too high it seems like. Or at least ur test to estrogen ratio is off. For better erections, I would assume u’d do better with higher test levels, and lower estrogen levels

Based on ur TSH, it seems like u could be be dealing with some hypothyroidism. For better erections, and ur body functioning better in general, u definitely want to get ur thyroid functioning better

1000% get off of that statin. Ur cholesterol levels are way too low. Cholesterol is one of the most important things that the body produces. For optimal health, including avoiding cardiovascular disease, u actually want high cholesterol levels. Total, hdl, and ldl. I know it sounds crazy to people that haven’t done the research on their own, but it’s true. Can send u endless material backing up that high cholesterol levels are what humans actually do best with, in every aspect. So absolutely drop the statin asap

As far as ur depression goes, I do like that ur on a medication that increases dopamine, opposed to serotonin, since increased serotonin levels can hurt erections, while increased dopamine levels can improve erections, due dopamine and prolactin having an inverse relationship. Higher dopamine levels can mean lower prolactin levels, and high prolactin levels can obv be an erection killer. Plus, I just think if u want to improve mood, increasing dopamine levels is always a better option than increasing serotonin. But overall, I think 99% of people can most likely get rid of their depression by improving their diet and optimizing certain lifestyle factors. Like improving sleep and decreasing stress, for a few examples. Haven’t done any personal research into clomipramine, but again, I’m not a fan of anything that purposely increases serotonin, due to serotonin tending to have a negative effect on erections, and either no positive effect on mood, or possibly causing an emotional numbing effect, to where u are kind of apathetic to things. Which does have its place. For example, if someone is suicidal, experiencing a lack of emotions can be better than feeling extremely depressed/ suicidal. But again, for most people, when it comes to mood/ overall well being, I’m absolutely not a fan of increasing serotonin levels. One drug I’m a pretty big fan of is selegiline. I take it myself. Not for depression, but it can help with that. Due to it increasing dopamine levels in the system. It’s also one of the very few medications that seems to have properties that increase longevity. Can send u endless material on selegiline, if ur interested

Speaking of diet, looks like urs is pretty poor. Again, looks like u might have hypothyroidism. Ur triglycerides are also too high, and ur fasting insulin is too high. Which means ur diet most likely includes a lot of processed foods, is high in carbs, includes a good amount of crap process oils, and is lacking in enough fatty ruminant animal meat. For optimal health, u basically want the opposite. A diet very high in fatty ruminant animal meat, low in processed foods and low in crap oils. It can include carbs, but those carbs have to be from sources like fruits (ideally organic) and raw honey, again, if optimal health is the goal. Carbs like white rice and potatoes (without the skin) when cooked enough, are going to be like benign sources of carbs. Not good, but not bad either. Basically only recommend those if u need extra carbs for the gym/ to build muscle, or if u simply just really enjoy them. Again, they are neutral carbs. So only recommend them if u really enjoy them, or if u need them for improved athletic performance. Otherwise would avoid them if optimal health is the goal

 

[Gman86]

How much vitamin D and K2 are u taking? I wouldn’t take vitamin D without magnesium, fyi. So definitely grab urself a magnesium supplement. I recommend magnesium to everyone anyways, as almost everyone is deficient in magnesium

 

[Gman86]

As far as fish oil goes, Im currently not a fan of taking it in supplement form. I’m not 100% against it, but from my research it’s probably not ideal. I still need to do more research to fully figure out where I stand on it tho. Here’s some stuff to checkout and make ur own decision on whether u should continue taking it or not

(Paul SALADINO January 2025 u’ll never take fish oil again after seeing this video)

(Matt Blackburn)
-10 mins in talks about fish oil an PUFAS and how they damage and mess with thyroid and get stored in brain and tissues)
-11:30 PUFAS can cause male pattern baldness and hair follicles to atrophy

(WHY DHA IS POISON, MATT BLACKBURN)

(3 min vid talking about why fish oils bad, Matt Blackburn)

 

[madman]

Good morning all,

Hope everyone is well.

I am a 33 year old man, currently weighing 88kgs and height 1.83 cm (6 foot).

I have been battling erectile dysfunction for 10 years or so, starting from when I was 22 or 23 years old. I have posted about my journey in this thread (Help with blood test results and erectile dysfunction - Excel Male Health Forum).

Below is a quick summary of what was said in the other thread:

i) Started experiencing ED at 22 or 23 years old.

ii) At first, doctors blamed anti-depressants I used to take.

iii) Blood test confirmed I had secondary hypogonadism and was put on testosterone.

iv) After being put on Nebido (testosterone undecanoate), erections came back full force after 3 months. I was finally cured and happy but this only lasted 2 years.

v) After I got Covid, erections deteriorated again.
a) Nowadays, I wake up with weak morning wood.
b) Erections are soft, where the shaft is semi-rigid and the head of the penis does not engorge and is soft.
c) I can't maintain erections standing up. I can only maintain soft erections when sitting down e.g. on the toilet.
d) I don't respond to 5mg Cialis, 20mg Cialis, 20mg Viagra, 100mg Viagra. I used to respond in the 2 years when my erections came back.
e) Caverject (penile injection in Europe) and Vitaros only give me a partial erection (still soft)
f) I am only able to get and somewhat maintain a decent erection with an acceptably engorged head if I wear a tight and oversized cock ring.

vi) Started investigating issue again.
a) Cardiologist did 24 hour blood pressure test and echocardiogram. Everything is good.

b) Found that I had some insulin resistance and cholesterol. Went to dietician 4 months ago and lost 7 kg (results attached). Insulin resistance and cholesterol are good now.

c) Have been going to psychiatrist to try and change anti-depressant medication. Have tried fluvoxamine 100mg daily, brintellix daily, anafranil 10 mg daily, anafranil 25 mg daily, adding wellbutrin 150mg to anafranil 25mg daily. All to no avail.

d) Did 2 Doppler tests. For both Doppler tests, I was given 20mcg Caverject injection. Both doppler tests showed good artery inflow but high end diastolic velocity. In fact, the diastolic velocity on both sides of the penis for both tests were greater than 10cm/s (results attached). Caverject only gave me weak erection.

e) Experimented with TRT dose. Changed to testosterone enanthate. Initially, SHBG was 16 nmol/L. Tried with 50mg twice a week, 30mg 3 times a week, 22.5mg EOD. Attached testosterone results at trough, all were good but no change in ED. (Results attached)



----------

Now here is the catch guys. After going through all of this, especially given the Doppler test results, the fact that I no longer respond to PDE5 inhibitors and caverject, as well as the fact that the only thing that helps is a cock ring, I was 100% convinced that it must be a physical issue.

My urologist kindly ordered a Nocturnal penile tumescence test using Rigiscan, where they measure my erections during the night. The test stated that I had 3 erectile episodes lasting 1 hour with 85% rigidity. This was a suprise honestly as I wake up with weak morning wood and my penis was very shrunken before the test, given that I even stopped taking 5mg Cialis before the test. I still take 5mg CIalis till this day even though I don't respond that much to it, but it helps a bit.

Thus, the conclusion from the Nocturnal penile tumescence test was that I have phsycological ED and was recommended to a sex therapist. The thing is I can never get decent erections, neither when waking up, masturbating alone, with a partner, nothing. Sometimes I think the reason I got these erectile episodes during the test was due to the fact that my bladder was full of urine, and sometimes it creates enough pressure to get an erection. I also noticed this way before, that when I wake up to pee, I have better erections.

At this point, I don't know what to do honestly. I am trying to experiment the psychological side more, going to try some more medication under the guidance of my physicatrist.

What do you guys think? Is my ED physical, hormonal or phsycological? Should I try going to a pelvic floor therapist, try PRP or shockwave? What would you do in my situation?


Current medications I take
------------------------------------

i) Vitamin D + K2
ii) 2 capsules Omega 3 (2g each)

iii) 25mg Anafranil (Clomipramine)
iv) 150mg Wellbutrin

v) Cialis 5mg

vi) Atorvastatin 20mg

v) After I got Covid, erections deteriorated again.
a) Nowadays, I wake up with weak morning wood.
b) Erections are soft, where the shaft is semi-rigid and the head of the penis does not engorge and is soft.
c) I can't maintain erections standing up. I can only maintain soft erections when sitting down e.g. on the toilet.
d) I don't respond to 5mg Cialis, 20mg Cialis, 20mg Viagra, 100mg Viagra. I used to respond in the 2 years when my erections came back.
e) Caverject (penile injection in Europe) and Vitaros only give me a partial erection (still soft)
f) I am only able to get and somewhat maintain a decent erection with an acceptably engorged head if I wear a tight and oversized cock ring.




The good news which is critical is your arteries are working well, and there’s no scarring or calcification in the ED tissue as this would rule out any serious causes of ED.

Dorsal Vein (vein on top of penis) was unremarkable which means looks normal and would not be causing issues.

What is more concerning here is what you stated in your reply in a-f especially c suggests venous leak (veins don’t close properly, letting blood drain out too fast).

The high PSV values (127/152 cm/s) confirm that blood is flowing into the penis very well which would rule out arterial insufficiency (e.g., blocked arteries) as the cause of ED.

The partial erection (60-65%)/high EDV values (11/13 cm/s) would suggest that blood might not be staying in the penis long enough.

Stated in the conclusion of your report "the presence of venous leak cannot be excluded".

This would suggest it's possible that you may have venous leak.

You would need to get a dynamic cavernosography to confirm/rule out venous leak.

Dynamic cavernosography is like a detailed X-ray of the penis’s veins during an erection, using dye to spot leaks that cause ED

It’s more definitive than PDU because it directly visualizes the veins and how blood flows out, whereas the ultrasound relies on indirect measures like EDV and resistive index (RI).


* For young men, diagnosing venous leakage can be challenging. Traditional color Doppler ultrasound may miss it, whereas grayscale ultrasound, which requires high-resolution equipment, is more effective.




Results:

• High EDV (11 and 13 cm/s): These values are above the ideal threshold (≤5 cm/s). High EDV means blood is escaping the erectile tissue too quickly, which can prevent a firm, lasting erection.
• Moderate Tumescence (60-65%): The partial erection despite strong arterial inflow (high PSV) suggests the issue isn’t getting blood in but keeping it there.
• RI (~0.91): While not terrible, it’s lower than the ideal >0.95 for a rock-solid erection, supporting the idea of some venous leakage.

Venous leak is a common cause of ED, especially in younger men without heart disease or diabetes. It’s when the veins in the penis don’t compress enough to trap blood during an erection. About 20-30% of ED cases involve venous leak, and it’s more likely when arterial inflow is good.

​

What Is Dynamic Cavernosography?

Dynamic cavernosography is a test that takes detailed pictures of the veins in the penis to see if they’re leaking blood during an erection. It’s called "dynamic" because it’s done while the penis is in an erect state (usually induced by a medication) to mimic real-world conditions. The test focuses on the corpora cavernosa (the spongy tissues that fill with blood to create an erection) and the veins that should trap blood to maintain the erection.

​

Why Is It Done?

Dynamic cavernosography is used when a doctor suspects a venous leak as the cause of ED, especially after tests like penile Doppler ultrasound suggest (e.g., high end-diastolic velocity [EDV] and partial erection despite good arterial inflow). It’s more invasive than an ultrasound and is typically done to:

• Confirm a venous leak diagnosis.
• Pinpoint exactly which veins are leaking (e.g., deep dorsal vein, cavernosal veins).
• Guide treatment decisions, like whether surgery (venous ligation) might help.

Thread 'Penile Doppler Explained: Normal Study vs Arterial Insufficiency and Venous Leak'

Aug 23, 2025

Penile Doppler ultrasound is a vital tool for evaluating vascular causes of erectile dysfunction. In a normal study, adequate arterial inflow is demonstrated by a peak systolic velocity (PSV) greater than 30–35 cm/s, and proper venous occlusion is confirmed by a low end diastolic velocity (EDV) approaching zero. This pattern supports the achievement and maintenance of a firm erection. In contrast, the abnormal case shows a PSV less than 25 cm/s, indicating arterial insufficiency, and a persistently elevated EDV of 5–9 cm/s with continuous diastolic flow...

• madman
• penile doppler us; ed; vascular; imaging technique
• Replies: 10
• Forum: Health & Wellness

 

[madman]

Thread 'Venous leak in erectile dysfunction'

Sep 2, 2023

Professor Eric Allaire explains what is venous leakage in erectile dysfunction, what are the symptoms and what is the medical exam that can certify the disease. The good news is that there is a solution. Yes, venous leakage can be cured.


Professor Eric Allaire

What are the signs of venous leakage?

There are 4 signs:

*first one is absence or very weak erections in the morning

*the second sign is that during self- stimulation the hardness of the erection is not very high

*the third sign is that erections are not the same whether one is lying...

• madman
• ed; venous leak; causes/treatment
• Replies: 7
• Forum: When TRT Is Not Enough (ED, Libido, & More)

Professor Eric Allaire

What are the signs of venous leakage?

There are 4 signs:

*first one is absence or very weak erections in the morning

*the second sign is that during self- stimulation the hardness of the erection is not very high

*the third sign is that erections are not the same whether one is lying on his back or on his belly or on one side or being seated, if erections vary according to man's position, this is highly evocative of caverno-venous leakage

*the fourth sign is that when man applies fingers at the basis of penis erections are better, fingers press on veins and reduce leakages

 

[madman]

* what we now know is that what we used to call Venous Leak is really just a lack of arterial pressure, a lack of hydraulic pressure because if your pressure doesn't get high enough blood Is going to leak out

Post in thread 'Why ED Pills Stop Working—and What to Do Next | ED Treatment Landscape'

Aug 8, 2025

VENOUS LEAK!


* what we now know is that what we used to call Venous Leak is really just a lack of arterial pressure, a lack of hydraulic pressure because if your pressure doesn't get high enough blood Is going to leak out




What do you recommend for a diagnosis of a Venous Leak?

• madman

 

[madman]

This is something overlooked by many men suffering from ED!

Many young men can suffer from this.

*ED due to caverno-venous leakage (CVL), whether isolated or accompanying other causes of erectile dysfunction, is frequent specially among young adults

Thread 'Cavernoscanner: Technique and modelling in ED due to caverno-venous leakage'

Sep 2, 2023

This is something overlooked by many men suffering from ED!

Many young men can suffer from this.

*ED due to caverno-venous leakage (CVL), whether isolated or accompanying other causes of erectile dysfunction, is frequent specially among young adults

• madman
• ed; ct scan; venous leak; penile ultrasonography
• Replies: 16
• Forum: When TRT Is Not Enough (ED, Libido, & More)

•