What should be done for an elderly man with hard surface penile veins after using a Vacuum Erection Device (VED)?

Management of Hard Surface Penile Veins After VED Use

Reassure the patient that hard surface penile veins after VED use typically represent benign vascular changes that resolve spontaneously with device discontinuation, though evaluation for potential complications is warranted if symptoms persist or worsen. 1

Immediate Assessment

Determine the severity and associated symptoms:

• Assess for pain, discomfort, or functional impairment during sexual activity 1
• Examine for penile ecchymoses, petechiae, or bruising—the most common minor adverse effects that resolve without intervention 1
• Evaluate for signs of more serious complications including skin necrosis, urethral bleeding, or development of penile plaques 2
• Review anticoagulation status, as patients on anticoagulant therapy (heparin, warfarin) face higher risk of subcutaneous penile hemorrhage and should use VEDs with extreme caution 1, 3

Initial Management Strategy

For isolated hard veins without other complications:

• Temporarily discontinue VED use to allow vascular changes to resolve 2
• Most minor adverse effects including transient vascular changes resolve spontaneously without intervention 1
• Reassess after 2-4 weeks of device cessation to determine if vascular prominence has normalized 2

If the patient wishes to continue VED therapy:

• Ensure proper technique: verify use of only VEDs containing a vacuum limiter 1
• Confirm constriction ring is not left in place for excessive duration (maximum 30 minutes) to prevent ischemic complications 2
• Consider switching to a properly sized constriction ring, as incorrect sizing can cause vascular trauma and lead to penile ecchymoses and plaque formation 2

Evaluation for Serious Complications

Monitor for warning signs requiring urologic referral:

• Development of penile plaques or curvature suggestive of Peyronie's disease, which has been reported after prolonged VED use 2
• Urethral bleeding, which may indicate development of urethral varicosities from chronic VED use 2
• Persistent pain or progressive vascular changes despite device discontinuation 2
• Any signs of skin necrosis or ischemic changes 2, 3

Alternative Treatment Options

If VED complications necessitate discontinuation:

• First-line alternative: PDE5 inhibitors (sildenafil, tadalafil, vardenafil) for erectile dysfunction management 1
• Second-line options include intraurethral alprostadil or intracavernosal injection therapy after appropriate in-office testing and instruction 1
• Surgical penile prosthesis implantation for patients not responding to or experiencing adverse effects with conventional medical therapy 1

Key Clinical Pitfalls

Common errors to avoid:

• Failing to assess anticoagulation status before VED use—bleeding disorders represent a critical contraindication requiring extreme caution 1, 3
• Dismissing vascular changes as always benign without proper follow-up, as rare but serious complications including Peyronie's disease and urethral varicosities can develop 2
• Not educating patients on proper technique and duration limits for constriction ring application 2
• Overlooking that elderly patients may have reduced sensation and fail to recognize excessive constriction duration, increasing complication risk 2