Erectile dysfunction (ED) is an inability to achieve and sustain an erection that is rigid enough for the entirety of sexual intercourse. This is a very common problem that most men will experience at some point in their life. Unfortunately, as men age, the incidence of ED increases. The good news is that it’s very treatable. A typical treatment algorithm includes oral therapies (i.e. tadalafil, sildenafil), intraurethral therapies (i.e. two drug gel), intracavernosal injections (i.e. bimix, trimix), and penile prosthesis. Any patient with erectile dysfunction can consider intracavernosal injection therapy as a treatment option for their ED.
Most practitioners will start with oral therapies prior to proceeding with ICI in their treatment algorithm
Intracavernosal injections (ICI) have been around since the early 1980’s and used to be the only non-surgical therapy choice until the introduction of the oral therapies in 1998. ICI still remains an effective and preferred treatment option for most patients that have moderate to severe ED, or those with mild disease that cannot tolerate oral medications. ICI is also used for the diagnosis and evaluation of ED. This therapy is incorporated during the penile Doppler ultrasound, a test utilized for diagnosis of penile vascular abnormalities. Most practitioners will start with oral therapies prior to proceeding with ICI in their treatment algorithm, unless there is a reason a patient cannot tolerate oral therapies, in which case ICI therapy will be recommended.
The injection is self-administered using a small gauge needle and syringe that holds a maximum 1mL of fluid (similar to the syringes used for insulin by diabetic patients). Ten to fifteen minutes prior to intercourse the side of the penis is cleaned by an alcohol swab, then injected with the appropriate volume of bimix/trimix close to the base. The entire length of the needle is inserted into the penis in order to ensure that the medicine is delivered into the corpora cavernosum.
The patient is instructed to start at a low dose, increasing it with each subsequent sexual encounter until an erection rigid enough and sustainable for the entirety of sexual intercourse
Intracavernosal injections (ICI) are usually composed of a combination of two or three vasoactive substances: prostaglandin, phentolamine and papaverine. Many different concentrations are available and a patient can control the dose at home by adjusting the amount injected until the desired effect is achieved. Depending on the severity of the patients ED, a specific concentration is chosen by the practitioner. The patient is instructed to start at a low dose, increasing it with each subsequent sexual encounter until an erection rigid enough and sustainable for the entirety of sexual intercourse is achieved, but lasting less than one hour. With each subsequent office visit, the concentration may be increased or decreased.
The first injection should be completed by a Urologist, in their office, to ensure proper technique and to make sure that no abnormal reactions occur. This often times is done in conjunction with the penile Doppler ultrasound. This allows for the teaching of proper technique and choosing the appropriate concentration. In office teaching helps minimize the learning curve for self-injection first timers. Online resources are also available, including videos, and written guides with illustrations.
The injection is practically painless when done correctly – like a small pinch on your arm
I know the idea of inserting a needle into the side of your penis may sound off putting. Just like a diabetic needing to switch from oral medicine to injectable insulin, patients are not typically thrilled about the notion of an injection. That said, hundreds of thousands of men have used this therapy successfully. It is very common for even the most reluctant injectors to be amazed with the ease of the process and positive results. The injection is practically painless when done correctly – like a small pinch on your arm.
Like most therapies there are certain risk factors and side effects, but overall, injection therapy is extremely well tolerated. Bleeding, infection, and scarring are all possible, but with appropriate teaching of the technique and counseling they are manageable. Priapism (an erection lasting more than four hours) is also a risk factor. By starting at a lower dose and slowly working up on the dosage this is also preventable. If any of these side effects happen, seeking medical attention is always advisable.
Injection therapy has a very high patient satisfaction, efficacy, and safety rate
Intracavernosal injection therapy is a great treatment option for ED and remains a staple in the Urologist’s arsenal for the diagnosis and management of this very difficult disease. It has a very high patient satisfaction, efficacy, and safety rate. For many decades men have relied on this treatment modality to help them carry on a normal sex life. It has survived the test of time and is an excellent option for anyone who is frustrated and wishing to claim victory against erectile dysfunction.
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