Background: Primary erectile dysfunction (PED), characterized by its early-onset often results from cavernovenous leakage (CVL) in which blood prematurely returns from cavernosa to general circulation, impeding penile rigidity. Previous notions suggested CVL’s incurability. Objectives: To describe symptoms and profile of PED patients with CVL, their penile hemodynamic profile and response to a new surgical treatment. A comparison is made with secondary ED (SED) patients. Patients and methods: Prospective data from PED and SED patients were analyzed. Penile duplex sonography, computed caverno-tomography were performed. The treatment combined vein ligation and embolization during the same procedure. Results: Ninety-one patients out of 171 (53.2%) had PED, with an average age of onset at 20.1 years vs. 47.4 in SED. PED patients exhibited severe ED symptoms and had waited 14.2 years before surgery. 14.3% PED patients had a mild neurological impairment, hormonal abnormalities were rare, exposure to cardiovascular risk factors was low, in contrast to SED patients, except for smoking. Combined surgery showed an 80.2% success rate, with improvements in hemodynamic parameters at three-month control duplex sonography. The proportion of PED patients with a pharmacologic EHS<3 with no possible penetration dropped from 63.7 to 13.2% after surgery (Chi-2: p<001). After a mean 25.4 months follow-up, IIEF5 score increased from 10.73 to 14.9 in PED patients (p<0001). The success rates of the combined surgery were comparable between the two groups, except that 45.2% PED patients did not use any ED medical treatment after successful surgery, vs. 20.9% in SED (p=024). Conclusions: This study challenges the notion of PED due to CVL as incurable and highlights the efficacy of a novel treatment approach combining open surgery and embolization. Patients with successful treatment showed improved erectile function and reduced reliance on medication. The findings suggest the importance of early detection of CVL in PED.