My Experience with Dr. Kably and a Warning on Venous Leak Diagnoses

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Hey guys,

There has been some talk on this forum before about Dr. Kably from the University of Miami Health System, Interventional Radiology (IR - his specialty) and its approach towards diagnosing and treating ED. IR diagnostics include things like the traditional penile doppler ultrasound as well as more advanced diagnostic procedures like CT Cavernosographies and Arteriograms. IR treatments for ED include sclerotherapy and embolization.

At the end of May of this year, I paid Dr. Kably a visit in Miami. What follows is a review of my experience there.

I went to see Dr. Kably to confirm my Venous Leak diagnosis with a CT Cavernosography, to be very sure of the physiological origin of my ED before going for an implant. I was pretty sure I had a VL. I had been diagnosed with it 3 times before my top urologists in the US. The last 2 times, Dr. Eid was the one who diagnosed me. You can see my readings in my signature. That being said, I wanted to triple-check before pulling the trigger on an implant, since I'm still young.

Penile Doppler

I met Dr. Kably on 3 separate days. On the first day, I had a penile doppler scheduled. It was conducted by Lorely, Dr. Kably's head nurse. I must say that Dr. Kably's whole team is very personable. The nurses in the radiology department are extremely personable. Lorely is very sweet and Dr. Kably nice too. He is a pretty busy doctor but he was able to step in for a moment to administer the first shot of trimix for the doppler. (Note: if you go see him for a doppler, you need to order and take the trimix there yourself. They don't have any. They give you a prescription for this).

The penile doppler Lorely ran on my was the most thorough one I have ever done. It lasted over an hour and was done in 3 different positions (semi-sitting, lying down, standing), with readings at the 10, 15 and 20 minute marks. The different positions were done because of my specific issues. I told them my greatest issue is lying down, and they took measurement standing up and lying down flat to be able to compare and simulate the sexual positions closely. They also did a baseline reading, and even suggested I watch some 'happy videos' on my phone with headphones on while they ran the doppler to keep me erect.

During the doppler, I had my regular series of erections that go away with no stimulation. The nurse could tell these were not normal erections, to the point where it was hard for her to get the readings she needed of my erect at times. Core findings of the doppler:

- Cavernosal artery insufficiency (right artery only) shown throughout the examination in different positions.
- Congestion of the collateral cavernosal bodies sinusoidal space seen at baseline that could reflect venous stagnation.
- No evidence of venoocclusive disease in the examination.
- Bilateral sublinical varicocele in my testicles (apparently correlated with
VL, but I don't have VL by the looks of it)

All of this was news to me. I was shocked to hear I did not have a VL after 3 VL diagnoses. Dr. Kably later said that other doctors are generally not very thorough and meticulous when running doppler scans, and are too gung-ho about dishing out VL diagnoses. My EDV was below 5 except for one datapoint it was 5.5 - borderline. My PSV indicated “lazy arteries” as Dr. Kably put it - below 25 sometimes, sometimes slightly above that.

Based on these results, Kably said we needed a CT Angiography, not a CT Cavernosography. The problem was inflow more than outflow, so he wanted to look at arteries, not veins. In theory, it was possible that I had arterial insufficiency because of an arterial blockage. Perhaps unlikely at my age, but a closer look was warranted in any case. It's also more important to be hard for a CT Cavernosography, and he said I may not be able to get hard enough for it anyway even with trimix. I had the CT Angiography two days later.

CT Angiography

It was a very long and exhausting day. I went into the radiology department at 7 am and left at 7 pm. There were interesting findings however. During the scan, I was injected with trimix once again, and pumped with contrast will images were take of my genital area. They are then able to create a 3D digital reconstruction of your arterial flow into the penis. I saw the images, very cool.

Through the CT Angiography, Dr. Kably discovered that my right pudendal artery was apparently barely pumping blood into my penis. In any case, the contrast wasn't reaching my penis on the right side. He also discovered I had an anatomical variation: a third pudendal artery going towards the penis, where most people only have two. That third artery didn't seem to be pumping blood into the penis either.

Dr. Kably discussed the results with me, and said he wanted to find out why contrast wasn't reaching the penis through the right and third arteries as it should. To do so, he would need enter my artery in a third procedure called an IR Arteriographic Pelvic Arteriogram. After discussing the findings and procedure with him, I decided to go forward with it. It was held two days later. The rest days in between were very appreciated, lol.

IR Arteriographic Pelvic Arteriogram

This is a somewhat more invasive procedure. Dr. Kably inserts a catheter in my femoral artery and threads a camera through there to my pudendal arteries, injects contrast and takes a bunch of x-rays. Findings:

- Extremely sluggish flow of contrast of the penile arteries without underlying organic arterial lesion. Could be explained by the baseline vascular congestion of the sinusoidal spaces that was observed during the baseline ultrasound imaging (penile doppler). This could be related to a venous congestion phenomena causing baseline elevated pressures in a context of a relatively low systemic arterial blood pressure of the patient.

In other words, he discovered that the pudendal arteries sending blood to the penis are unobstructed and healthy, but that the amount of pressure required for blood to reach my penis is extremely high. Based on this as well as on the congestion he saw in my penis at baseline during the penile doppler, he came to the conclusion that my penile veins are likely deficient at draining blood away from my penis and back to the body (to the lungs presumably). This blood is oxygen-poor and full of contaminants that need to be cleaned by other organs. Abnormally high pressure is required to 'displace' this blood - pressure that I do not generate. Over time, this stagnated, oxygen-poor blood apparently damages the veins and cells in the area even more, making them even worse at draining blood in a vicious cycle. This poor drainage also happens in my testicles where it has developed into subclinical varicocele.

Takeaways and recommendations from Dr. Kably

He said this problem has barely been studied. It's even less common than a venous leak. He says that this could have developed from environmental and/or lifestyle factors (poor diet, disease, lead exposure, accidents, etc.). He didn't believe it could be congenital apparently. As such, he thought it could be reversed.

Given we are in uncharted medical territory here with such an uncommon condition, he pulled from various disciplines to give his recommendations. He thinks my ED could potentially be reversed by improving environmental and lifestyle factors, meaning:
1) Penile rehab (VED therapy, daily 5mg cialis, nitric oxide supplementation, etc.)
2) Seeing a functional medicine doctor and having him run advanced diagnostics tests for things like for environmental contaminants in my blood (lead, arsenic, mercury, etc.). Correcting imbalances as needed.
3) Improving the typical things like diet, exercises etc. The functional medicine doctor would support with this.
4) He also says my blood pressure is a bit weak anyway and says it wouldn’t hurt to see a cardiologist.

Personal reaction to the recommendations and final thoughts

Outside of the contaminant screening, I am frankly skeptical of how much this will actually help me since I was already doing some of these things, even if I was doing them inconsistently. Couldn’t you argue that any venous leaks or health issues could be fixed if you correct these kinds of lifestyle factors “to perfection” and restore your body’s harmony? In theory, perhaps any dysfunction could be corrected with the regimen of an olympic athlete/buddhist monk with a perfect mind-body connection, but how realistic is it to achieve that when you’re leading a regular life with regular stressors and demands on your time, like 9-5 jobs, friend groups, etc.?

Anyway, beggars can't be choosers. I have not been cynical about it and am actually giving it a shot. I am giving myself until the end of the year to see an improvement and if nothing changes, I will get an implant. I'm also taking the chance to try alternative therapies like shockwave therapy, all for peace of mind if I do end up getting an implant.

I'm glad I saw Dr. Kably, because it has given me more insight on my condition. Mentally, it is hard to adjust my expectations from “I’m getting an implant in the next 3 months” to “I need to try a bunch of other things for at least 6 months”. But I'll do it for peace of mind. Also, as a note, Dr. Kably is not a fan of implants, at least not for young guys. He stressed the fact that I would lose 'one to two inches' of length with them and mentioned other complications as though they are much more common than I understand them to be. Take that for what you will.

I share this so FrankTalkers can get more info on Dr. Kably's practice and to emphasize that you should take your venous leak diagnosis from penile dopplers with a grain of salt, even if it's done by a top doctor!. I can recommend the ones done by Dr. Kably's practice, as they clearly seemed to be the most reliable. That being said, I can't really recommend the embolization procedures he might offer to VL patients, since embolizations seem to have mixed and sometimes disastrous outcomes. Penile dopplers are clearly not infallible. Get second, third and fourth opinions from different doctors.

My apologies if this post seems disjointed at times. I scraped it together from the messages I was sending at the time on the ED discord server. I hope this is helpful to others.

[s7utty]

amazing post brother.
thanks for sharing and especially in such detailed way.
i have my fingers crossed for your future path in resolving this shit.

[Pumpingvictum]

I had weaker erection after cavernosography.
Do you think it cause damage?

[passerarf]

Hey man, any updates on your case? Did you take any further action with Dr. Kably?