Not sure what is causing ED & How to fix it (29 yo)

[Simbarn]

Three things stood out for me in your post:

Your erectile issue is consistent at all times
Your nocturnal erections are not what they used to be, every time you are able to notice them now.
You do not have a good response from PDE5 inhibitors.

The above suggests to me an organic cause. Psychogenic erectile difficulties normally waver in different situations. Most men with psychogenic ED wake on some mornings with reasonably good nocturnal erections, I would think especially so for guys at your age.
The locus coeruleus is almost shut down during REM sleep (when nocturnal erections occur), removing the inhibition from possible psychogenic input and adrenergic tone.

It appears in your case that something is either consistently inhibiting erections from occurring as effectively or the ability of the corpus cavernosum to trap blood sufficiently at area of the tunica albuginea has become compromised, such as a venous shunt causing more blood to escape than usual.
A congenital issue with the vascular network leaving the penis is a possibility. This may not surface until a particular age. This is a less likely scenario, but still worth mentioning.

When you first wake in the morning, are you able to get an erection more easily and are they any better?

The diminishing quality of nocturnal erections could suggest a decline in testosterone, as these are heavily dependent on sufficient testosterone. The test results you provided do not appear low. However, if you have not had it tested in your early twenties you do not know what your genetic optimal level was.
If your nocturnal erections have been failing for a number of years, this can lead to hypoxia in the penile tissues. This lack of oxygen may accelerate the aging process in the penis, causing smooth muscle loss and collagen deposition (fibrosis) in the trabeculae. It will also affect NO synthase within the
endothelium. It is imperative that nocturnal erections be restored for penile health. Daily Tadalafil can help this if used for 6 to 12 months. Viagra taken nightly can also be used and has shown good results in studies with aging males.

As your issue seems to be reasonably recent in nature, it would also be good to have a prolactin test, to make sure your pituitary is not secreting a constant excess of this hormone as this could also cause a form of inhibition.
Thyroid hormones would also be good to check.
Your free testosterone is on the low end so I would do that again and SHBG, LH and FSH.
As mentioned by the previous poster, check for any signs of diabetes, as this can affect NO synthase and therefore a general drop in erectile performance would be indicative.
What is your good and bad cholesterol levels?
As you have stated you take no medications, no supplements, and no use of anabolic steroids now or in the past; these influences can be ruled out. Be warned that that some bodybuilding supplements are not as innocuous as their manufactures claim.

You also mentioned that you now masturbate once per week, compared to your usual previous higher frequency. Is this because the desire to do it has waned or you are doing this purposely in an effort to reinstate erectile performance?

As you are experiencing such a constant issue with erections, It may have been a good idea to do a complete hormone assay immediately (including all that I mentioned above), with all the other tests for general health. Perhaps your specialist has already done this?
If not, I would be questioning their experience in sexual issues as a previous poster suggested.
Had you had experience with PDE5 inhibitors before your visit with the urologist?
If so, did you mention to him or her, that you had little effect from them?

I mentioned going to see a urologist to my own GP not long ago regarding my own ED. His response was: ‘They are not much use when it comes to erectile dysfunction, in the end all they will suggest is what I am going to suggest to you right now”. He has quite a lot of experience in sexual medicine for a GP.
Therefore I suggest you find a specialist in sexual medicine. Urologists do not spend much time on studying this (unless they have a keen interest in it) nor do most of them keep up to date with current research on ED.

Some males can also have a greater sensitivity to adrenergic tone in the penis. If for some reason this becomes amplified due to other conditions in the body, such as diabetes or even asthma, erectile function may suffer. If you are not aware of how norepinephrine affects the penis, I have posted much on this recently. However, I would think if this was affecting you, in some situations your ED would be worse, such as heightened performance anxiety.
Overtraining in the gym with heavy resistance work can also over time affect levels of oxidative stress in the body. If the body cannot recuperate and is always in a stressed state, erections may suffer. It did not sound like you overtrain, but it is worth mentioning. Do you take a week off training periodically?

[codyj109]

I would start by finding a sex med doctor. Where do you live? urologists have NO TRAINING in sexual medicine. They are surgeons. Everything he has done sounds like he is not at all trained. He sounds like a rank and file urologist. PLEASE run like hell. I am not diagnosing you long distance, but if erections for masturbation are bad as well, it is almost certainly physiological. Of course there is a mental component when things don't work right, but that is corollary, not causal. Big difference.

First off, you need 3 blood tests to determine T levels. The "Normal" thing is bullshit. There is no normal. It is what is optimal for YOU. Please download Nelson Vergel's book - "Beyond Testosterone" it is free. You have to become an expert on your body. As Antelope pointed out, 477 is not winning any awards. That is where most doctors would start - exploring that. Don't let them put you on testosterone if you ever want kids. There are other ways to boost it at your age.
Keep us posted
Paul

Thanks for the info! I will look more into finding a sex med doctor (I'm in the Raleigh, NC area by the way)

[codyj109]

Agreed... I am on the high end of "normal" and I still take 2.5 ml of Delatestryl every three weeks. It's awesome stuff.

What benefits does the Delatestryl provide you? And what are your testosterone levels if you don't mind me asking? I'm just curious. I never heard of Delatestryl before.

[codyj109]

It appears in your case that something is either consistently inhibiting erections from occurring as effectively or the ability of the corpus cavernosum to trap blood sufficiently at area of the tunica albuginea has become compromised, such as a venous shunt causing more blood to escape than usual. A congenital issue with the vascular network leaving the penis is a possibility. This may not surface until a particular age. This is a less likely scenario, but still worth mentioning.

When you first wake in the morning, are you able to get an erection more easily and are they any better?

Thanks for your detailed response! This is very helpful! I'll try to provide answers to your questions as best as possible (as well as add a few of my own)...

Do you know what tests might indicate one of the issues above as you have described?

As far as erections in the morning, I would say they are about the same, maybe just slightly easier to get/better in quality but not by any huge difference.

As your issue seems to be reasonably recent in nature, it would also be good to have a prolactin test, to make sure your pituitary is not secreting a constant excess of this hormone as this could also cause a form of inhibition.
Thyroid hormones would also be good to check. Your free testosterone is on the low end so I would do that again and SHBG, LH and FSH. As mentioned by the previous poster, check for any signs of diabetes, as this can affect NO synthase and therefore a general drop in erectile performance would be indicative.
What is your good and bad cholesterol levels?

You also mentioned that you now masturbate once per week, compared to your usual previous higher frequency. Is this because the desire to do it has waned or you are doing this purposely in an effort to reinstate erectile performance?

As you are experiencing such a constant issue with erections, It may have been a good idea to do a complete hormone assay immediately (including all that I mentioned above), with all the other tests for general health. Perhaps your specialist has already done this? If not, I would be questioning their experience in sexual issues as a previous poster suggested. Had you had experience with PDE5 inhibitors before your visit with the urologist?
If so, did you mention to him or her, that you had little effect from them?

I have had some other bloodwork done too, with thyroid function being one. My TSH was 0.70 ulU/ml (with the standard range being 0.25 - 5.00 ulU/ml). I don't believe I had my cholesterol levels checked, however. I am a healthy eater though, and do exercise regularly, but this is something I can look into.

As far as my masturbation frequency, it's a little hard to tell at this point. I feel like physically my desire has gone down a bit but mentally I'm still with it (want to). Mainly, cutting down stemmed from trying to see if that would help my erections, and trying to see if the longer I go without masturbating, if they become significantly better, as well as cutting out porn more. So far, I haven't noticed a big difference. If I weren't trying to cut back, though, I'd probably still masturbate at least a few times per week.

As far as other bloodwork, here are my results from the other tests done:

Sodium 139 mmol/L
Potassium 4.9 mmol/L
Chloride 100 mmol/L
CO2 30.0 mmol/L
Glucose 93.576 mg/dl
BUN 17.08 mg/dl
Creatinine 1.05 mg/dl
Calcium 9.9 mg/dl
Alkaline Phosphatase 50 IU/L
ALT 17 IU/L
AST 13.9 IU/L
Total Bilirubin 0.8 mg/dl
Albumin 4.6 g/dL
Total Protein 6.5 g/dl
eGFR 88 mL/min/1.73 m2
eGFR If Africn Am 107 mL/min/1.73 m2

Everything in this test was in a standard/normal range. Is there something else I should have tested that isn't here?

As far as PDE5 inhibitors, I did have experience with them before visiting my Urologist. I had taken as-needed Generic Cialis/Tadalafil (as much as 20 mg) and Generic Viagara/Sildenafil (as much as 80 mg). I stated that helped to some degree but weren't really close to what my erections used to be/didn't really fix the problem. They suggested I take daily Cialis instead, for a few months then followup, since I had not taken that routinely before and because they felt it could be mental (it seemed mainly because of my age).

Also for your final question, I don't believe I am overtraining. I weightlift about 3 times per week and it's not super vigorous, it's enough to maintain and stay healthy in that regard and I do occasionally take some extended time off from working out.

[oldbeek]

No body mentioned venous leakage. Where the blood flows out of the penis as fast as it flows in. This is another young person problem. Need a sexual health doc to analyze it. Again where are you located? Someone may no a good clinic close by.

[Charlie2019]

Agreed... I am on the high end of "normal" and I still take 2.5 ml of Delatestryl every three weeks. It's awesome stuff.

What benefits does the Delatestryl provide you? And what are your testosterone levels if you don't mind me asking? I'm just curious. I never heard of Delatestryl before.

I too use 2.5 ml of Delatestryl every three weeks and I agree, it's da bomb

[Simbarn]

No body mentioned venous leakage. Where the blood flows out of the penis as fast as it flows in. This is another young person problem. Need a sexual health doc to analyze it. Again where are you located? Someone may no a good clinic close by.

I did mention venous leakage, I didn’t use the term, which I probably should have:
“or the ability of the corpus cavernosum to trap blood sufficiently at area of the tunica albuginea has become compromised, such as a venous shunt causing more blood to escape than usual”
Venous leakage, can most probably be in two forms: a congenital abnormality as I described in my post, or a form of CVOD. Current research points to the loss of smooth muscle and an increase in fibrotic tissue (collagen deposition) in the corpus cavernosum. This creates a syndrome whereby the corpus cavernosum does not fill with blood as effectively as it once did and the tissues in this area are not as compliant. Therefore the ability of these two cylinders to create a seal at the tunica albuginea is attenuated. They will not perform as well as when greater amounts of smooth muscle were present such as in a young healthy penis. The tunica albuginea can suffer from its own alterations in collagen composition as well, further amplifying the problem. It is an unfortunate part of aging that smooth muscle loss occurs in the penis. Lifestyle and genetics play a big part in this. Oxidative stress and hypoxia can accelerate the process, I have read many studies related to the subject. It appears that the penis may suffer from the above earlier than the rest of the peripheral vascular system due to ischemia (decreased blood flow).

This is where we are up to now in current understanding of CVOD (corporal veno-occlusive dysfunction).

Adrenergic receptors in the penis also become more sensitive as we age. This adds to CVOD, as the inhibition for smooth muscles to be able relax becomes greater, which adds to the inability to trap blood in the penis.
It is the combination of a number of factors that create the conditions to facilitate “venous leakage”.

[oldbeek]

T level. as seen on google. Average T in 350 men 25 to29 is 627. T average 29-44 is 597. There is a study that suggest the reason young guys don't get prostate cancer is because their T is higher when young. This study was looking at guys with prostate cancer in their late 30s that also had low T. Getting prostate cancer will really dampen your sex life. I would be taking a T supplement. I am not a doctor, just an old guy that wishes he could have his prostate back.

[codyj109]

No body mentioned venous leakage. Where the blood flows out of the penis as fast as it flows in. This is another young person problem. Need a sexual health doc to analyze it. Again where are you located? Someone may no a good clinic close by.

I'm located in Raleigh, NC. If anyone is in that area and can recommend a good sexual health doc, that would be great!

[Simbarn]

Thanks for your detailed response! This is very helpful! I'll try to provide answers to your questions as best as possible (as well as add a few of my own)...

I’m happy that you found some useful information in my post.
The tests outlined in this excellent article are some of what can be performed by a specialist who knows what they are looking for in relation to CVOD or a venous leak.
Read this a number of times if you need to. I found its hypothesis very plausible.
https://www.nature.com/articles/ijir201317

I also found this article by the same researcher to be equally interesting and relevant to current thinking into ED:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4713217/

It is important to understand the terminology in these articles/studies. If you don’t know something, look it up, otherwise you will get lost!

Another guy on the forum posted a link to this video on a new technique with regard to imaging venous abnormalities in the penis. This is worth looking at also:
https://doctorpaduch.com/venous-leak-mra/

Not having much of a difference in erectile function when you wake in the morning, also possibly suggests that your condition is not predominantly psychogenic.
Your physician should have checked your cholesterol levels as a matter of general health. This is basic stuff. Telling your doctor that you eat well and exercise is not a reason for them to ignore this one.
Prolactin is also a basic test if you are experiencing ED at a young age.

As the above articles outline, smooth muscle loss can start occurring, much earlier for some males than others, this could be genetic.

For the effects of chronic (everyday) dosing of Cialis to have a physiological effect other than PDE5 inhibition takes 6-12 months from all the studies I have read, in regard to possible restoration of smooth muscle and endothelial health.
I thought it odd to recommend taking Cialis constantly at a low dose as I could not see it working any better for an immediate effect in the short term, when you had already explained to your doctor that you had little effect from a high dose.
It sounds like a cookie cutter approach to me and somewhat dismissive.

How long have you been taking the daily Cialis? I would assume there has been no change as you would have already mentioned that.
I would consider a second, possibly more adept opinion.

Your training schedule sounds as I thought, quite ok. I only mentioned it as it can be a problem.
I think your low normal free T level is suspect of something occurring in your body. As I mentioned earlier, nocturnal erections are very dependent on testosterone. It is concerning that you feel these erections have diminished in quality and frequency. This is when ischemia can begin. Loss of smooth muscle in the penis then follows with changes in tissue structure within the erectile bodies. This process does take time to eventuate, but can start in the 3rd decade of life. I think it is possible that it can be reversed if nocturnal erections are restored in a young person. The older someone gets, as with most degenerative disease, the less likely the body is capable of repair.

I would not get too caught up in what I term the pseudo-science regarding abstinence from masturbation. Masturbation is a very healthy exercise for all males to do regularly. The only time it is an issue is if it becomes obsessive and occurs many times a day. It may then get in the way of a balanced life, I consider this “overtraining of the penis”, it doesn’t have time to recover from the last workout! As we get older we need more recovery time.
3 times a week is very normal and actually good for you. I’m 56 and I still do it 3-4 times a week. It’s even more important to keep doing this at my age. Enjoy your young body now while you can, as believe me when you get older it doesn’t perform in the same way and you will miss this. Various religions have tried their best in the past to make us feel guilty about our bodies and sexual function, these ideas keep popping up under different guise with no real merit to them and causing more grief than good.
We don’t advocate a long break from physical fitness generally unless we are ill. A week off here and there to help the body recover is a good idea. We all know taking a month or two off from exercise and our fitness levels begin to decline.
Why is the penis any different? It isn’t!