Figure 1 Safe zones for injecting the penis
Sometimes the only thing more demoralizing than having erectile dysfunction is seeking and then failing treatment for erectile dysfunction. It used to be that no one talked about ED, and now it seems that no one will shut up about it. You can’t watch TV, especially if it’s a sporting event, without being reminded of how good your sex life could be if you just popped a pill. Unfortunately, you will be sitting in that Cialis bathtub a long, lonely time, long after the sun has set, if you are one of the 35 percent of men for whom the pills won’t work.1
The previous chapter reviewed strategies to make the pills work better, but for many men the underlying problem is too big for the medication to overcome. The blood vessels may be too narrowed, the penis may be too fibrotic, the nerves may be too damaged, or the anxiety may be too great. In some cases the side effects are too much, or the pills may be dangerous because the guy has to take nitroglycerine for his heart. Fortunately, in all of these scenarios, it’s not game over, it’s just time to step up the game. There are other options that usually work even when the pills cannot. Most have been around longer than the pills, but the pills really allowed men to come out from hiding, so now these other treatments have seen a big revival. These “second-line” treatments include the vacuum erection device, an injection into the penis that stimulates bloodflow, or a suppository or gel for the urethra that stimulates bloodflow. If none of these methods is successful, there is still the highly effective “third-line” treatment of penis implant surgery. So there is no need to give up if the samples don’t work. Keep your big head up, because one way or another you can get your little head up.
One of the situations where pills do not work is when there has been a significant amount of nerve damage. The pills all work by blocking the breakdown of nitric oxide (NO) in the penis, as NO stimulates more bloodflow. NO mainly comes from nerve endings in the penis. If the signal never reaches the nerve endings, NO will not be released. Without NO, there really isn’t any way that the pills can help the erection. The pills are like Hamburger Helper, but in this case, there’s no hamburger.
When there is damage to the spine, the signal from the brain can’t make it to the penis to release NO. Nerves in the lower spine still can send a signal to release NO in the penis as a reflex to stimulation coming into those nerves from the penis. This signal is weak, but it’s enough for the pills to work. On the other hand, if the damage to the spine is below the level of these reflex nerves, then they are cut off from the penis and the pills won’t work. If a man has an injury to the pelvis that damages the nerves that end in the penis, then the NO won’t get released. These nerves run right between the prostate and the rectum, so surgery or radiation on these parts can cause erection problems that may not be improved with pills.
Before there was Viagra, when there were no pills that really worked very well, an eccentric English scientist named Professor Giles Brindley was puttering around, experimenting on various drugs that could be injected right into the penis to wake it up. His test subject was Mr. Johnson, as in his own johnson. In the great tradition of mad scientists before him, he thought outside the box (so that others could get back into the box). After trial and error, some bruising, and most likely an exhausted spouse, he presented his findings at the national meeting of the American Urological Association (my homies) in none other than Las Vegas in 1983. This would prove to be the most exciting presentation of the meeting, and some would say the most exciting presentation ever. He had actually injected his own penis in his hotel room prior to his allotted lecture time and arrived at the podium in some loose-fitting clothes—Ron Jeremy casual—in front of an audience of mainly suits and a few skirts. Midway through his presentation, he stepped out from behind the podium, dropped trou, and revealed his discovery. To really ram home the point, he then circulated amongst the crowd to allow the attendees the opportunity to evaluate “firsthand” how solid his research really was. What happened in Vegas didn’t stay in Vegas. From this seminal presentation arose the development and widespread use of injections to treat erectile dysfunction. This became the only reliable medical therapy available until Viagra was developed. Ultimately about seven injectable drugs were identified that have some effect on a penis (mainly Dr. Brindley’s penis). Of these, one has been FDA approved for clinical use.
The only FDA-approved penis injection is called alprostadil, aka prostaglandin E1 (PGE1). It works by directly stimulating the blood vessels to open up and increase bloodflow into the penis. The nerves don’t have to be involved. In fact, the brain doesn’t have to be involved. An injection of alprostadil right into the penis can cause an erection even if you have no sexual desire whatsoever. You can be doing your taxes or paying bills and it will still work.
Sometimes the nerves are okay but the blood vessels of the penis are in such poor condition that the increased NO the penis pills allow isn’t enough to do the job. The blood vessel lining makes less and less NO just from aging alone. The pills may have worked at one point, but as time passes and blood vessels age and disease progresses, they can stop working. Diabetes causes nerve damage as well as blood vessel disease, and the nerves of the penis in a man with diabetes may simply not release enough NO for the pills to work with, plus the blood vessels may not be able to respond well enough to the increased NO the pills can allow. Diabetics are one of the largest groups of men for whom pills may not work, and in the vast majority, the injections will. Alprostadil can work when pills fail because not only can it cause an increase in NO with or without the nerve endings, but it also triggers other reactions that make the blood vessels open up.
Other injectable medications work in ways very similar to but not exactly the same as alprostadil, and when combined, the effects are even more powerful. One goes by the name of papaverine, which is what Dr. Brindley was rocking that fateful day in Vegas. Another is phentolamine, which works by blocking adrenaline-like molecules from squeezing off the bloodflow to the penis. Atropine is less commonly used; its effect is basically a double reverse. It decreases a reaction that decreases a reaction that stimulates a reaction that stimulates the blood vessels to open up and allow an erection.2 (Whew! Try keeping your erection while sorting that one out!) Although it’s often prescribed in combination with all three other agents, it has not been proven to add much to the erection. Atropine is more commonly used during cardiac arrest to stimulate the heart.
Alprostadil works in about 70 percent of patients in general and about 90 percent of those who have failed to improve with pills.3, 4 As the only injectable agent that is FDA approved, alprostadil comes as two brands: Caverject and Edex. These medications are by prescription only. The difference between the two is the injection syringe, but the ingredient is the same. Both are packaged as prefilled syringes with powder and liquid that mix automatically in the syringe just before injection. Generic alprostadil comes as a powder in its own vial with a separate vial of liquid that you must combine yourself before using. The other injectables are not FDA approved but are considered to meet the proper standard of care and therefore widely prescribed by doctors and prepared by compounding pharmacies that have to meet regulatory standards to keep patients safe. They come in combinations of ingredients, such as papaverine and phentolamine, which is called “bimix,” or they come premixed along with alprostadil (aka PGE1) or along with alprostadil and atropine in combinations known as “trimix” and “quadmix.” These formulas must be kept in the refrigerator between uses and gradually degrade over time. They don’t go bad quickly like milk, but 2 months later they will be about 30 percent less potent.5
Alprostadil is the most effective of the medications, but it can cause a burn or ache in the shaft of the penis in a small percentage of men. For these men, the alternative bimix doesn’t burn as much. Trimix, which includes alprostadil, burns less than alprostadil alone but is more powerful. Because of the papaverine in the trimix, there is a small risk—6 percent—of developing fibrosis in the penis.6 If a guy develops fibrosis, it is often permanent. If he stops injections for a few months, it may go away.7 For guys who can’t get a satisfactory erection with pills or vacuum devices, the trade-off of risking fibrosis in order to have erections is usually acceptable.
Regardless of the brand or the combination, the medication is injected in very small amounts—just a fraction of 1 milliliter—through a very small needle into the side of the penis. The needle is about a half inch long and the diameter is about 30 gauge, which is one-fourth of 1 millimeter in thickness. It’s hard to even see the needle. The needle is inserted in the side of the penis. And the truth is it really doesn’t hurt very much. Trust me, I’m a doctor. Most of the sensitive nerves are in the head of the penis, not the sides of the shaft. You should avoid injecting into the top surface of the penis (side facing upward), where you might pierce one of the larger veins or a surface artery and cause a lot of bleeding and swelling. Also, you could stab the nerve bundles (ouch!) that run along the top side of the shaft toward the head of the penis.
The shaft of the penis is made of two cylindrical chambers, kind of like two pontoons situated side by side. The lining is tough but the inside of the chamber is a soft, spongy matrix of blood vessels. The key is to get the needle tip well inside the chamber so the medication can be circulated throughout the spongy spaces. Fortunately, this is very easy to do. You don’t need a professional medical degree to be able to inject your penis, but a doctor or another person with a professional medical degree should teach you how to do it. There is no special vein or artery you have to thread. You simply have to get the needle squarely into your shaft, usually up to the hub. There is even an autoinjector that can make the whole process fairly easy. You only have to inject one side because the blood flows from one chamber to another. The urethra runs along the underside of the shaft of the penis in its own compartment. You should avoid injecting the urethra, otherwise you will cause bleeding and burning with urination—but no erection.
The dose you use will be determined by your prescribing doctor. Typically, your first injection or two will be performed in the doctor’s office as a test to help determine what dose you need. When it comes to injecting penises, one size does not fit all. Some men have excellent blood vessels but no nerve signal. They won’t need very much of the injection to get an excellent erection. In fact, a very low dose is all that they likely will need. As with any injection, it is important to use sterile technique and fresh needles and syringes each time.
After the injection, hold pressure on your penis for a couple of minutes, and you should expect an erection within 10 to 20 minutes. Depending on how you respond, the erection will last a varying length of time. The goal is to achieve an erection that can last 30 minutes to an hour. This is much longer than most couples ever last, but it allows time for getting back into bed. There’s even time to put on the Barry White, light a few candles, and break out the can of whipped cream—or the whips, depending on the mood.
If the dose isn’t strong enough, you can inject more the next time, but wait another day because if you inject more on the same day, the response becomes less predictable and you may develop an erection that lasts too long. This is a dangerous condition because the longer an erection lasts, the less oxygen there is for the penis, to the point where there can be permanent damage. The injections have a much greater range of potencies than pills. They can be made stronger not only by injecting more volume but also by making the solution itself more concentrated. As a rule of thumb, younger men will not require as strong a formula as older men, and men with longstanding diabetes will tend to require higher concentrations. Because the dosing is definitely not one size fits all, try to get the dose worked out on your own or with a partner with whom you are very comfortable before you put yourself on the spot in a high-stakes situation such as a special occasion, long-awaited vacation, or tryst with a new love.
Figure 1 Safe zones for injecting the penis
Figure 2 Needle placement for injecting the penis
If the dose is too strong, the erection will last too long, which is a condition known as priapism. You may have heard the warning in the commercials for penis pills to “contact your doctor if an erection lasts more than 4 hours.” And you may have even thought that was just subliminal marketing to make you want to try them. In reality, I almost never see that happen with the pills. On the other hand, the injections are so much more powerful than the pills that I do see that happen with the injections much more often. So what do you do if an erection lasts more than 4 hours? One of my patients told me he would call all his friends! But honestly, by the 4th hour, it’s not so fun anymore. A 4-hour erection is not a healthy situation for your penis because the blood is trapped in the erection and, over time, the penis becomes starved for oxygen. Ever try to hold your breath too long? It hurts, and so does your penis as the hours go by. As if that weren’t bad enough, the tissues of the penis will start to die and eventually get replaced with fibrotic tissue, which cannot become erect normally.
If you get an erection that lasts longer than a couple hours, you need to start taking evasive maneuvers. The first maneuver is to try to climax. When you climax, you release a lot of adrenaline-type molecules into your bloodstream (so intense!) and the adrenaline shunts your blood away from your smaller parts, like your fingers, toes, and penis, diverting it to the essential organs of the lungs, heart, and brain. This is why you lose your erection after you ejaculate. It’s normal. But an injection of medication in the penis is more than “normal,” so the adrenaline release from ejaculation may not be sufficient.
Another way to pump up the adrenaline is with exercise. Hit the treadmill or climb some stairs, but try not to put anyone’s eye out with that thing!
If the clock is running and you are still hard, you can take medication that mimics adrenaline to try to squeeze closed the blood vessels to the penis. If you find yourself hard up after ejaculating, or you just can’t get there, drive over to the drugstore and pick up some Sudafed (psuedo-ephedrine—not Sudafed PE) over the counter. It has adrenaline-like properties. Get the immediate-release 60-milligram version and take two. Another over-the-counter countermeasure is Neo-Synephrine nasal spray. A couple of squirts up the nose gets phenylephrine, a very potent adrenaline-like molecule, into your bloodstream and on its way to your penis. Terbutaline is a prescription medication that works in many cases as an alternative to Sudafed. You take 5 milligrams and give it 15 minutes; if you are still running around more than half-cocked, you take another 5 milligrams. If one or another of these medications doesn’t work, call your doctor and head on in to the emergency room or to the office for an antidote injection. The injection actually contains the same ingredient as Neo-Synephrine (generic name: phenylephrine), but it is injected right into the penis, where it’s much more concentrated than the dilute stuff arriving from way up in your nose. Normally, injected phenylephrine is used to increase blood pressure in a severely ill person in an emergency situation, so when it’s injected into a healthy person with a hard-on, it has to be done with great care, often with blood pressure monitoring and slow, gradual doses. If you are very sensitive to a penis injection, and you develop priapism, the doctor will instruct you to give it a rest and then try again with a lower dose. If you still have a recurring problem despite trying to use very low doses, your doctor may actually prescribe some prefilled syringes of dilute Neo-Synephrine to use at home. If so, follow the instructions carefully.
An important advantage the injections have over the pills, besides being more powerful, is that they present fewer risks to the body as a whole. The pills have very little risk as it is, but they cannot be taken with nitroglycerine or nitroglycerine-containing medications. The injections only affect the penis—the site where they are injected—and their effects are diluted in the rest of the body, so men who take nitroglycerine can use the injections to restore their love life without risking their whole life. Of course, if you have a serious heart condition, check with your cardiologist that the exertion of sex alone does not overstrain your heart.
There are a few instances in which the injections should not be used, as for patients who are at high risk of getting priapism—a prolonged erection—due to an underlying medical condition. Patients with sickle cell anemia, leukemia, and multiple myeloma are at risk because their blood is sludgy with abnormal cells due to their condition, and the sludgy blood may not flow out of the erect penis as easily, causing it to be trapped and leading to a prolonged, painful erection that can be harder to treat than just your run-of-the-mill priapism. Also, men with Peyronie’s disease (a condition where there is already fibrosis in the penis) should consider avoiding these injections due to the added risk of more fibrosis. If a man is on blood thinners, he can still use the injections because the needle is so small. Nonetheless, he should hold pressure after the injection for about 5 minutes.
Remember when you were a kid and you had to go to the doctor to get a shot and you would get a lollipop or a sticker? Well, your reward for a shot in the penis is a whole lot better, but even so, not everyone can handle the idea of a needle in the dick. There is an alternative called MUSE and it is an FDA-approved medication. MUSE is alprostadil, the same master ingredient in the injections, but it is formulated to be put into the pee hole and be absorbed by the lining of the urethra. That’s not to say that sticking something up your urethra is a pleasant thought, but for many men it’s more acceptable than the needle. The medication comes as a pellet that’s smaller than a rice grain and it’s preloaded in a little plunger that fits easily up the urethra for a short distance. Once you push it in you squish your penis a bit to smash the pellet up so it can be absorbed (I favor the fire-starter maneuver where you roll the penis back and forth between your hands like you’re trying to spark a campfire with a stick). MUSE is typically stronger than pills but not as strong as injections. Because it has to be absorbed in the urethra, it makes it into the critical chambers of the penis less directly and so it’s not as potent. Higher doses must be used to get the same or lesser effect. Whereas the maximum dose of Caverject is 40 micrograms of alprostadil, the maximum dose of MUSE is 1,000 micrograms. About 40 to 50 percent of men will get a good response with MUSE. Also, MUSE can be combined with pills to get an extra oomph out of both. Because the alprostadil gets absorbed into the bloodstream at higher doses, there is up to a 6 percent risk of a drop in blood pressure, dizziness, or even passing out.8
Okay, no needles sounds good, but can we please just not stick anything in there? Topical formulas with alprostadil and some other agents have been tried, but so far they are not very effective. It’s really hit or miss with these products, and it’s more often miss.
Figure 3 Suppository for the urethra
There is an alternative treatment to pills and injections and urethral suppositories, and it sucks—literally. It’s the vacuum erection device (VED), commonly referred to as the “penis pump.” Featured prominently in the Austin Powers comedies (“That’s my bag, baby!”), it’s no joke. It actually is a very safe and effective alternative and has been around longer than any of the other remedies.
It’s a simple device. A transparent plastic cylinder is placed over the penis. The tube has a device at the far end to pump air out, creating a vacuum in the cylinder. This causes the blood to rush into your penis as your penis expands, trying to fill the vacuum. Voilà! An erection. It doesn’t matter if the proper nerves are sending signals or if the arteries are stimulated—this is a complete override. If pills don’t work, and even if shots don’t work, the vacuum erection device can still work. Once the penis is maximally erect, an elastic constriction band is slipped off the near end of the cylinder onto the base of the penis in order to prevent the drainage of blood out of the erection. The constriction band, which is essentially a silicone cock ring, can stay in place safely only for up to 30 minutes—so don’t waste time checking your email or watching TV. After 30 minutes, the tissues need some oxygen. One of the advantages of the penis pump is that it’s a reusable device so there are no recurring costs. You only have to pay to play one time, and after that it’s free. (Well, let’s face it, is it ever really free?) You just rinse and repeat.
Vacuum devices have evolved over the years. The first use of a vacuum cylinder was in the late 1800s but there was no constriction band, so your erection was fun to look at but not very useful.9 Kind of like a snow globe, but with a penis in it. Hollywood came to the rescue and a silent film star, Otto Lederer, patented the use of added constriction bands.10 The system wasn’t really perfected until the early 1980s, when the FDA approved the Osbon ErecAid.11 The current models have safety valves to prevent the suction from getting too strong and overstretching you. Until recently, FDA-approved penis pumps could be prescribed and be paid for by Medicare and some insurances; however, Medicare no longer covers these devices. There are many brands at a wide range of prices, from under $100 to over $400. They can be found on pornographic Web sites or in pharmacies, but they no longer require a prescription. It is best to keep with an FDA-approved model because of the pressure pop-off safety mechanism. Depending on how much you want to spend (it’s your penis, don’t cheap out), you can obtain a model with a battery-powered vacuum pump or just a hand-squeezed pump. The electric models are good for men with arthritis as well.
These pumps are very effective for many men, but not all. The reported success rates range widely, from 30 percent to 90 percent.12 Although many men are put off by the mechanical nature of the device, it’s only required for a few minutes and then it’s out of sight. Of course, an understanding and cooperative partner makes all the difference. The device is mechanical in nature so it may require some adjustments when you are first starting to use it. It may not be as simple as plug and play. The most important tweak is ensuring a good seal for the vacuum to form. Lubricant and firm pressure help make the seal. Some pumps come with a rubber dam that fits around the base to help with the seal. Shaving the hair at the base of the penis may help too. Constriction bands are not one size fits all, and some men may require a tighter band than others not just due to size but also due to the amount of compression their tissue requires to hold the blood in the penis.
The main medical reason for failure is an inability to effectively keep the blood trapped in the erection by the constriction band. In some cases the tissues of the penis just won’t compress effectively enough. In other cases the band is too painful at the tightness required for it to work. The nature of the erection is different than a natural erection because the constriction band makes the penis harder from that point on, but the root of the penis is less hard and so there may be a “hinge” effect at that point. This may cause the penis to pivot or angulate. For some it may make insertion more awkward. Again, a willing and understanding partner is key. Because the device is purely mechanical, there are no drug side effects nor interactions with other medications. Still, as with the injections, use caution with conditions like sickle cell anemia or leukemia where the blood can be sludgy and an erection more difficult to reverse. The side effects that can occur due to the vacuum suction include bruising or petechia (small reddish spots on the skin, like microbruises) or edema (swelling of the skin). The constriction band can cause temporary symptoms of less sensation in the penis, a bluish appearance of the skin due to congestion of blood in the veins, or some discomfort with ejaculation due to compression of the urethra. Some bands are designed to compress the urethra less.
Even if it’s not effective as a “stand-alone” treatment, the penis pump can be used in combination with pills, shots, and urethral suppositories. Think of it as a kick-starter. Ultimately, it may not be effective or satisfactory for sex, even in combination, but it is still potentially useful for “penis rehab.” The penis can be a use-it-or-lose-it organ. Just as your muscles stay toned with regular athletic activity, your penis stays expandable with regular filling and stretching. If your erectile dysfunction has left you going for long periods of time without erections, the spongy tissue of your penis that expands with blood will lose its flexibility, smooth muscle cells that line the blood vessels will die off and be replaced by stiffer collagen, and the penis will contract and shorten, leaving you higher and drier. This damage occurs even more quickly when ED is due to a loss of nerve stimulation such as can happen with prostate cancer surgery or radiation. Under normal circumstances, Mr. Happy gets hard and happier several times over the course of a day and night. Even if you don’t recall getting an erection today, and even if you are a celibate monk living in a cave in the mountains, you still have erections several times a night while you are asleep. Your body does this automatically, whether or not you are dreaming and whether or not you are dreaming about your penis. If you have significant erectile dysfunction due to an underlying medical condition, as opposed to a behavioral or psychological cause, your body will not be able to cause the erections properly, and then the tissues will wither on the vine. The vacuum device can be used to give your penis a “flush.” Using the penis pump for 5 or 10 minutes a day, without the constriction band, expands the penis tissues, circulating more blood through them. It’s like a personal trainer for the penis. It’s also possible that this boost in circulation helps boost natural production of NO and other molecules within the tissues, which helps prevent cell death and fibrosis and rejuvenates the tissues at a molecular level.13 Men who have lost length can regain some or all of it over weeks to months of daily use.14 Size enhancement does not occur to any meaningful degree for men with healthy, normal erections.15 (For more about size enhancement, see Chapter 5.)
Figure 4 Vacuum erection device
A lot of attention has been given to treatment of erectile dysfunction caused by prostate surgery. Prostate cancer is the most common cancer in men, and it’s the number two cause of cancer death in men after lung cancer. Fortunately, it can be detected early and cured in most cases, but the cure, which is surgical removal of the prostate or radiation of the prostate, often damages the nerves that switch on the bloodflow into the penis during an erection. This is because these nerves run right next to the prostate so they get injured a little or a lot during surgery and often during radiation. Even if the surgeon is performing an operation specifically designed to “spare the nerve,” the nerves still have to be moved out of the way, which will usually affect them, even if only temporarily. When the nerve signals are stopped, the flow of blood for erections stops, even at night when the man is asleep, so there can be a fairly rapid deterioration in the penis tissues and an accelerated case of use it or lose it. The nerves may recover quickly, or they may take up to a year or even two. In the meantime, it has been shown that “penile rehab” can help reduce shrinkage and speed the return of erections.
Penile rehab has been attempted with pills, injections of alprostadil alone or in combination with other agents, or the vacuum constriction device. These treatments have been tried alone and in various combinations. Penis pills are prescribed to be taken every day following surgery for up to a year. The pills can allow for sex if there is enough of the nerve functioning to allow enough NO to be released for the pills to work on. Even if the effect of the pills is not good enough for sex, there may still be some increased circulation—a stuffie—and therefore some benefit to the tissues in the penis. This will be true at night as well, when the guy is sleeping and the body is trying to stimulate erections. The longer the pill is active in the system, the better, and so daily Cialis has become the most popular choice because its effect lasts for more than 24 hours, whereas the other penis pills last for about 4 to 8 hours. These shorter-acting pills would typically be used in the evening to maximize nocturnal erections.
Prescription penis injections such as alprostadil or the various combinations like bimix or trimix are used for rehab as well, and are often more successful for full erections and sexual function while also serving the purpose of preventive maintenance. In fact, the return to erections without medication is better when injections are used versus pills.16 With this approach, the guy gives himself an injection in the penis 3 to 4 days a week on alternating days whether or not he is having sex. The dose he uses at home is prescribed by the doctor after a test dose in the office. Studies show the injections to be about twice as effective as pills alone, but of course, they’re not as easy as just taking pills.17 Penis shots aren’t for everyone, and the urethral suppository can be used for rehab, but it’s not as potent as the injections; however, as with all the treatments it can be combined with the pills for added effect.18 The vacuum device can also be used daily for rehab. It’s applied at home for about 10 minutes a day or more with the goal of pumping up and expanding the penis whether or not the guy has sex, so the constriction band is not used when you are just getting “pumped up.” The penis pump always improves the results of penis rehab when used in combination with pills or injections, and it is the most effective way to prevent shrinkage. In fact, the earlier it’s used, the better the chance to prevent or reverse shrinkage.19
Erectile dysfunction doesn’t have to ruin your sex life, and one way or another it can be treated. The injections usually work when the pills don’t, and they tend to be less expensive per dose. The vacuum device can work even when the pills and the injections don’t, but even so, it doesn’t always work for all men. Fortunately, there is still more that can be offered, and for some men, the very best option is surgery. We will explore this option further in the next chapter.