Establishing an intracavernosal injection (ICI) program in clinical practice requires more than just ordering medications and hoping for the best. Success depends on systematic protocols, proper safety measures, and evidence-based clinical decision-making frameworks.
Dr. Martin Gross, an experienced urologist from Dartmouth, recently shared his comprehensive approach to ICI test dose protocols alongside clinical pharmacist Lianne Snyder of PharmaLabs. Their discussion provided practical implementation strategies developed through years of clinical experience with thousands of patients.
Here are the key protocols and insights that can help you establish a successful ICI program in your practice.

Standardizing your test dose selection and initial protocols

The foundation of any successful ICI program starts with consistent test dose protocols. Dr. Gross emphasizes the importance of standardization in initial dosing decisions.

“This is pretty much the consensus across the board that 10 microgram alprostadil trimix is the standard you start guys at and you work your way up or down from there,” he explained. “Looking at the literature on this, it really is the conventional wisdom for everybody who’s doing a lot of intracavernosal injection in the office.”

Dr. Gross’s standard protocol begins with 20 units (0.2 mL) of Trimix #5, providing enough medication for initial testing with flexibility for dose adjustments during the visit.

“The good thing about Trimix number five is it gives you a lot of options above and below that strength to work with, and you can kind of over time create an algorithm in your head of which way you want to steer a guy.”

Essential office setup and safety protocols

Proper safety protocols are non-negotiable when implementing ICI testing. Dr. Gross emphasizes systematic pre-injection screening to prevent complications.

“If I have to give them phenylephrine to counteract this erection, I have to make sure that their blood pressure is within safe parameters before we get started,” he explained.

His safety thresholds are specific: “If the guy’s got a diastolic blood pressure of 120 and a systolic of 160, I’m probably gonna cancel for that day and have him go see his PCP.”

Essential office supplies include:

• Phenylephrine (4-5 vials in stock, monitored for expiration)
• BD Safety Glide 27-gauge half-inch needles for office use
• Cardiac monitoring equipment
• Emergency protocols following AUA priapism guidelines

Dr. Gross maintains a systematic approach to emergency preparedness: “I tend to have my staff keep about four or five vials of phenylephrine in stock in the office, and this stuff expires once every six months or so.”

Clinical evaluation and documentation systems

Objective assessment techniques are crucial for optimizing therapy and ensuring patient safety. Dr. Gross employs a systematic evaluation approach combining clinical assessment with patient feedback.

“I will evaluate the erection myself manually. Just put some gloves on and say, you know, this looks like it’s about a five or a six out of 10,” he describes. “I’ll also ask the patient what he feels the erection is, which is important because you really want to gauge what their perception of this is.”

Using a structured tracking system provides the documentation you need to track results. This includes:

• Rigidity scale (0-10 rating system)
• Progress log for home use
• Volume injected tracking
• Duration and effectiveness metrics

For practices with ultrasound capability, Dr. Gross noted additional advantages: “What you can do from there, depending on the results you get in the office with the ultrasound, you have the advantage of seeing exactly why it is or is not working, and you get a sense of the parameters you can use to upgrade the strength.”

Dose escalation algorithms and clinical decision-making

Systematic dose escalation prevents both treatment failures and complications. Dr. Gross has developed a specific algorithm based on clinical response patterns.
His standard escalation pathway: Trimix #5 → #8 → #9 → #13 → #16, with specific decision points at each level.

“If number five is not effective in the office, generally my pathway is to go to number eight, which is 20 micrograms. Then potentially go to number nine, which is 40 micrograms, and then number 13, which is 60 micrograms.”

At higher failure rates, Dr. Gross employs what he calls “gambler assessment”:

“If a guy fails number nine, I try to assess what kind of gambler he is. Some guys want to gamble and push all their chips on the table and go with number 16, and they often get a really good response.”

The conservative option (Trimix #13) represents a 50% strength increase, while the aggressive option (Trimix #16) more than doubles the alprostadil concentration. Clinical judgment based on patient psychology and risk tolerance guides this decision.

Managing challenging cases and complications

Certain patient populations require modified approaches and adjusted expectations. Dr. Gross provides particularly valuable insights regarding post-prostatectomy patients.

“I often find that injections do not work particularly well for patients who’ve had prostate cancer treatment, whether it’s radiation or surgery,” he stated. “Those guys tend to develop venous leakage erectile dysfunction, and venous leak ED does not respond great to intracavernosal injection because venous leak does not keep the blood in the penis. You can pump as much blood in as you want, but you’re never gonna get to that pristine 10 to one ratio of blood in to blood out.”

For priapism management, Dr. Gross advocates for immediate intervention: “If there’s evidence that this priapism is not going anywhere, I’m busting out the phenylephrine and getting to work.”

His protocol includes:

• Cardiac monitoring during phenylephrine administration
• Bilateral injection sites (alternating sides)
• Documentation of vital signs throughout treatment
• Clear discharge criteria before patient release

Patient education and technique instruction protocols

Success with ICI therapy depends heavily on proper injection technique instruction. Dr. Gross emphasizes the importance of hands-on demonstration and partner involvement.

“I expect guys to fail about 50% of the time for their first 10 injections because they’re not used to this,” he explained. “This is not a thing one normally does, right? This is a very foreign concept.”

His injection technique protocol specifies:

• 10 o’clock or 2 o’clock positioning within first inch of penis
• Alternating sides with each injection
• Alcohol swab preparation and pressure application
• Partner involvement for patients with visualization difficulties

“It really helps to involve partners for these visits, particularly for the primary injection teaching,” Dr. Gross notes. “Many of my patients can’t see their penis particularly well, and the partner’s very capable of learning how to inject them.”

Follow-up protocols and long-term management

Systematic follow-up ensures optimization and safety monitoring. Dr. Gross typically schedules follow-up at 4-6 weeks, preferring the longer interval for practical reasons.

“I tend to err towards the six-week option because it gives guys time to get the medication, the shipping process and stuff like that, and get familiar with the process.”

His prescription protocol also includes specific safety language: “Inject 20 units, increase or decrease as needed in two to five unit increments, maximum dose 40 units, seek emergency attention for rigid erection lasting longer than four hours.”

Long-term management expectations are crucial for patient counseling: “When I counsel a guy about intracavernosal injection, what I’m usually telling him is that you will experience, on average, a four to five year response with this medication. And in that timeframe, we’ll have to increase strength as time goes by.”

Implementation considerations for clinical practice

Successful ICI programs require systematic implementation with attention to logistics, safety, and patient selection. Dr. Gross’s experience demonstrates that consistent protocols, proper safety measures, and realistic expectations lead to better outcomes.

Some important implementation factors include:

• Dedicated staff training for safety protocols
• Proper medication storage and inventory management
• Clear documentation systems for tracking outcomes
• Emergency preparedness with phenylephrine protocols
• Patient selection criteria and counseling frameworks

The clinical insights from Dr. Gross and Lianne Snyder provide a roadmap for establishing evidence-based ICI protocols that prioritize both efficacy and safety.

Looking to implement more comprehensive ICI test dose protocols in your practice?

The complete webinar provides detailed clinical protocols, medication formulations, emergency management procedures, and implementation strategies developed through extensive clinical experience.

Access the full clinical presentation here to review complete test dose protocols, ordering procedures through menMD, and comprehensive clinical management strategies for successful ICI program implementation.