Daniel Martinez

When the Pill is Just Not Enough

September 30, 2019 | Category: Physician Articles

Have you ever almost reached your goal? Got to a point where you can see the finish line, but ran out of gas right before crossing? Unfortunately, this can happen during sexual intercourse to men with ED on oral medications, even if the medication works well most of the time.

Oral medications for ED, like sildenafil (Viagra®) or tadalafil (Cialis®), may not be enough. Some men have a rigid erection, but not quite sustainable for the entirety of sex. Others have an “off” day, when their pill isn’t working as well as it usually does. If they only had a little extra ‘boost’ to help them achieve their goal of a rigid erection lasting for the entirety of sexual intercourse…

Combination Treatment Therapies

Prescribed ED treatment plans combining two or more therapies are not new. PDE5i oral medications, plus the use of a vacuum erection device (VED), intraurethral gel, intracavernosal injection (ICI), or hormone supplements have proven effective in some cases where the pills alone don’t produce a satisfactory erection.

Intracavernosal trimix or bimix injections have been used for years to treat erectile dysfunction. Injection therapy is highly effective for the vast majority of men with ED. However, ICI therapy is usually prescribed after a man fails other, less invasive treatments for ED, like oral medications, intraurethral gels, and VEDs.

Unfortunately, oral medications may not work well enough for men with moderate, severe, or complex cases of ED. In addition, stress, fatigue, food and alcohol consumption, or other factors may negatively impact the effectiveness of a man’s usually reliable oral therapy. In these situations, guys may be looking for a little boost to help them get over the hump, so to speak. Something extra that doesn’t require inserting a needle into their penis. Something with a low risk of developing a prolonged erection and an emergency room visit. Something effective and easy to use…

Oral medications with a low dose intraurethral gel may be the answer

A combination of PDE5i oral medications with a low dose, needle-free, intraurethral gel may be the answer. This option is typically more attractive for most men than injection therapy, and includes the same active ingredients found in trimix (phentolamine and prostaglandin). It is also safer than attempting to take high doses of oral medication, which can carry the risks of lowering your blood pressure, causing a heart attack or stroke, and worsening some of the other side effects associated with oral medications for ED. Intraurethral gel can be used alone, or in combination with PDE5i oral medication, as a ‘break glass in case of emergency’ kit.

Study indicates the combination produces an increase in the quality of a man’s erection

One way we measure the quality of a man’s erection is a questionnaire called the Sexual Health Inventory for Men, or ‘SHIM’ score. Please see the SHIM questionnaire below. In one study, presented at the Sexual Medicine Society of North American conference, a significant increase in SHIM score was noted. Men who participated in the study and used the oral medication / intraurethral gel combination therapy experienced an average increase in SHIM score from 5.3 to 15.8. This study indicates the combination of these two types of medications produce an increase in the quality of a man’s erection. Furthermore, no adverse events were reported in the study.

They enjoyed the ease of using intraurethral gel and the performance ‘boost’ realized by the combination therapy

Patients responded favorably to the effectiveness of this combination. They enjoyed the relative ease of using the prefilled, needleless intraurethral gel just prior to sexual activity and the performance ‘boost’ realized by the therapy. Due to the nature of this therapy, and for this study, participants were prescribed a low dose gel, minimizing the burning sensation sometimes felt during drug administration. Click here to learn more about intraurethral gel therapy.

When given the option of injection therapy or taking a pill plus a low dose intraurethral gel, most patients would pick the latter. Moderate to severe ED may not be adequately treated with oral medications alone, and high doses of oral meds are dangerous and should not be taken without direct supervision of your urologist. The combination of oral medication with low dose gel seems to be more tolerable than high dose gel alone. The combination therapy also seems to be adequate enough to treat more advanced cases of ED, and a great option when a patient is not experiencing their usual response to oral medication. Talk with your healthcare provider about this combo treatment if the pills aren’t consistently effective for the treatment of your ED.

Author:

Daniel R. Martinez, M.D.

Daniel R. Martinez, M.D.

Urologist, fellowship trained in Sexual Medicine at Urology Specialty Care

7600 SW 87 Ave., Suite 206
Miami, FL 33173
Phone: (305) 275-5525

SHIM Scorecard

How do you rate your confidence that you could get and keep an erection?

Very Low

1

Low

2

Moderate

3

High

4

Very High

5

When stimulated sexually, how often are your erections hard enough for penetration?

No Sexual Activity

0

Almost Never

1

A Few Times

2

Sometimes

3

Most Times

4

Always

5

During sexual intercourse, how often are you able to maintain your erection after penetration?

No Sexual Activity

0

Almost Never

1

A Few Times

2

Sometimes

3

Most Times

4

Always

5

During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?

No Sexual Activity

0

Extremely Difficult

1

Very Difficult

2

Difficult

3

Slightly Difficult

4

Not Difficult

5

How often is sexual intercourse satisfactory for you?

No Sexual Activity

0

Almost Never

1

A Few Times

2

Sometimes

3

Most Times

4

Always

5

How do you rate your confidence that you could get and keep an erection?
  • Very Low – 1 point
  • Low – 2 points
  • Moderate – 3 points
  • High – 4 points
  • Very High – 5 points
When stimulated sexually, how often are your erections hard enough for penetration?
  • No Sexual Activity – 0 points
  • Almost Never – 1 point
  • A Few Times – 2 points
  • Sometimes – 3 points
  • Most Times – 4 points
  • Always – 5 points
During sexual intercourse, how often are you able to maintain your erection after penetration?
  • No Sexual Activity – 0 points
  • Almost Never – 1 point
  • A Few Times – 2 points
  • Sometimes – 3 points
  • Most Times – 4 points
  • Always – 5 points
During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?
  • No Sexual Activity – 0 points
  • Extremely Difficult – 1 point
  • Very Difficult – 2 points
  • Difficult – 3 points
  • Slightly Difficult – 4 points
  • Not Difficult – 5 points
How often is sexual intercourse satisfactory for you?
  • No Sexual Activity – 0 points
  • Almost Never – 1 point
  • A Few Times – 2 points
  • Sometimes – 3 points
  • Most Times – 4 points
  • Always – 5 points

Scoring Comparisons

22-25
Normal erectile function.
17-21
Mild ED.
12-16
Mild to moderate ED.
8-11
Moderate ED.
≤ 7
Severe ED.

b

b