ED TREATMENT EXPERTS

There are four oral medications for the treatment of ED: Viagra (sildenafil), Levitra (vardenafil), Cialis (tadalafil), and Stendra (avanafil).  They are all members of the class known as phosphodiesterase 5 inhibitors.

How do they work?

All four of these medications have the same mechanism of action. When a man is sexually aroused, a messenger chemical (nitric oxide) is released. This causes a cascade of biochemical reactions: the blood vessels and tissues of the penis relax and dilate, allowing blood to rush in and an erection to occur. But there is another enzyme in the body, called PDE5, which reverses what this messenger chemical (nitric oxide) does. All four oral medications work by blocking the enzyme PDE5.

It is important to note that these medications don’t make you aroused. They just give you a better erection when you are aroused by blocking this enzyme. This is nice for your partner to know that it s/he that is giving you the excitement that gets you the erection, not the pill.

They are so expensive that they get in the way of my wanting to use them!  Can I get them cheaper?

Yes!!!

Viagra (sildenafil) and Cialis (tadalafil) are now off of patent, and available in generic form, which are already cheaper than the branded, but should continue to come down in price.

All four compounds are available from compounding pharmacies.  The medication is the same, but for those medications still under patent the mode of delivery and/or the dosage needs to be changed, in order for compounding pharmacy to make them legally.  Thus for example, avanafil is available as a 200mg troche (which goes under the tongue), vardenafil is available as a 20mg troche, and tadalafil is available as a 27mg capsule (rather than tablet.)

You should be able to purchase a full maximum dosage of these medications, directly from a regular or compounding pharmacy (with a doctor’s prescription) for $4.00-$7.00.  Experts are hopeful that the prices will continue to come down even further.

Who cannot take them?

Please note that all of these drugs are contraindicated for a man who is:

• Currently using nitrates or has retinitis pigmentosis (which is an eye disease)

These oral medications also should be not be taken by men with a predisposition to potentially hazardous cardiovascular events. These conditions include:

• Unstable angina
• Congestive heart failure
• Taking multiple antihypertensive drugs
• MI, heart attack, CVA (stroke), or life threatening arrhythmia within the last six months.
• Hypotension, decreased blood pressure (BP <90/50) or hypertension, increased blood pressure (BP>170/110)
• Patients on alpha blocks for high blood pressure or prostate problems should not take Levitra or Cialis

The general rule of thumb is that if your health makes sexual activity dangerous, you should not take these medications.

What if you can’t take one of the available oral medications or if the medications aren’t working the way you’d like? One of the options available for the treatment of ED is the self-injection of medication into the penis. This often sounds scary to the patient but most men will tell you that the injection doesn’t hurt at all. Some describe it as completely painless. Others report that if feels as if they have been flicked with a rubber band. The injection is extremely quick and uses a very fine needle (usually a 29 or 30 gauge). And since the side of the penis doesn’t have many pain receptors, there is little sensation.

It works like this. The medication goes into the penis with a device that’s similar to the ones used by diabetics. A disposable syringe, with a very fine needle, is placed on the injector. The device is placed against the side of the penis, and you press a button. A spring pushes a very thin needle into the penis and, at the same time, pushes the medication into the penis. Watch our video: How to use the Autoinjector for Penile Injections 

• Medications
  • The three most common medications used for injections are prostaglandin E1, papaverine, and phentolamine. All three act by relaxing the smooth muscles and causing the arteries to dilate, making it possible for blood to get into and be kept in the penis. Prostaglandin E1 received FDA approval in 1996 for ED treatment. It is currently marketed and available in prescription plans under two brand names, Caverject Impulse and Edex. However, all three are available in different combinations and strengths.
  • Each medication has different characteristics:
    • Prostaglandin E1 or Alprostadil
      • Prostaglandin E1 is a powder that is mixed with a fluid prior to use. This is due to the fact that it is stable as a powder at room temperature, but not as a liquid. Prostaglandin E1 can cause some temporary short-lived aching in the penis. Although it is not medically concerning, it can be uncomfortable. Discomfort is experienced by approximately 20% of patients and is most common in patients who have neurological erectile dysfunction (resulting from, for example, diabetes or post-radical prostatectomy).
    • Papaverine and Phentolamine
      • Papaverine is a smooth muscle relaxant. It acts directly on the blood vessel walls to relax and thus dilate, as well as activate, the trapping mechanism. It is usually mixed with phentolamine which is an alpha-blocker which causes smooth muscle relaxation through a different mechanism.
      • The papaverine and phentolamine come in a liquid, do not need to be refrigerated, and do not cause aching. 
  • Usually, one of three formulations is used:
    1. Prostalandin E1 (stable as a powder, but needs to be refrigerated as a liquid.)
    2. Bimix: is a combination of Papaverine and Phentolamine. It comes as a liquid only, but does not need to be refrigerated. This makes it very convenient for men who travel, or those who don’t want to store their medication in a shared refrigerator. It also never causes any aching.
    3. Trimix: is a combination of Papaverine, Phentolamine, and ProstaglandinE1. Because it contains PGE1 it needs to be refrigerated and can cause aching in some patients. However, it is often stronger than an equivalent dosage of Bimix (papaverine and phentolamine alone), and thus is often used.
• How do I learn to do the injections?
  • Learning how to use the injections, though intimidating, is actually quite straight-forward. It is important that your practitioner schedules you for several visits, both to teach you how to do the injections comfortably, and to figure out the right dosage.
  • At Maze, this usually takes three visits. At the first visit you receive your first injection, to introduce you to them, and to see how you respond. Based on your experience, you can decide whether or not you would like to continue with them.
  • At your second visit, you will receive a second injection (the dosage of which is based on your response to your first injection). You will also be supplied with the auto injector, and taught how to use it. You will be strongly encouraged to practice it (empty-no syringe) at home.
  • On your third visit, you will give yourself an injection, under our observation. By then, we will have figured out the right dosage and medication, based on your responses to the previous two injections. You are then usually sent home with five preloaded syringes, sometimes of increasing dosages to use at home.
  • Some men need more practice and coaching than other. Rest assured that we will work with you for as long as it takes to get you comfortable with the technique.
• How good will my erection be?
  • Our goal is for you to achieve a great erection that can last as long as you want (up to two hours).  If you have a problem with your trapping mechanism, this may not be possible, but it is what most of our patients achieve. We are successful in getting about 90% of our patients, many of whom have failed with pills and injections at other centers, great erections.
• If I have already failed injections somewhere else, can you help me?
  • It is extraordinarily frustrating for us how poorly penile self-injections are managed by “shot clinics” and non-specialists. We estimate that 80% of men who have failed injections at other practices, are successful at ours.This is because we have the expertise and take the time to insure that each patient has the right equipment, training and dosages he needs to succeed.
• What are the possible complications of penile self-injections?
  • There are two potential complications, but they are rare if patients are taught how to inject properly and follow the dosages prescribed. 
  • The first is a prolonged erection, or “priapism.”  When you have a rigid erection, you are trapping the blood in your penis.  This causes pressure, which makes your penis hard but also acts like a tourniquet around your penile arteries, shutting off the flow.  This prevents fresh blood from coming into the penis.  When your erection goes down, the arteries then can bring fresh blood into your penis.  If the erection remains rigid for too long, you are not getting fresh blood into your penis. This is why we ask patients to call us if their erections last more than four hours.  If left untreated for too long, a priapism can cause permanent damage. However, this is extremely rare, especially if the dosage is right and you don’t abuse it.  If it happens, a priapism can almost always be taken care of in the office.
  • The second potential complication is developing scar tissue of the lining of the penis.  This is also uncommon, particularly if you are taught the right technique.  It is important that you vary the site in the penis and that you compress the site for five minutes after the injection. This prevents bleeding on the inside which can cause scar tissue.  This is, of course, part of what we teach you.
• How long have penile injections been around?
  • Penile injections were developed in 1983 and were the second method developed for the treatment of erectile dysfunction.  They thus predated the pills by more than a decade.  Viagra was the first pill and was approved March 29, 1998.
• How do I maintain spontaneity while using the injections?
  •  In some ways, the injection is a more spontaneous solution for treating ED than oral medications since it can be used right before a sexual encounter.
  • Also, in our experience people vastly prefer excellent sex to spontaneous sex.  There are very few periods in a person’s life where sex can be regularly spontaneous.  Working around parents and siblings, roommates, and then children  means that people generally put far more planning into having sex than they think.
• Will my body get used to the injections to the point where they stop working?
  • There are certain drugs that the body routinely builds up a tolerance to, requiring more and more to achieve the same effects.  This is called “tachyphylaxis.”  Fortunately, this does not happen with these injections.  In fact we often see that when men start using the injections their own erections (when not using an injection) improve.  This is probably a combination of physical changes to the penis ( which is both stretched and getting more oxygen) and more confidence.  However, some men need somewhat higher doses as they age, just due to the natural aging process. The vast majority of men are able to use the injections for the duration of their whole sexual life

LI-ESWT (Low Intensity- Extracorporeal Shock Wave Therapy) is a relatively new, painless method for treatment of ED. It has been proven, in the past 10 years, to be extremely effective, in improving ED in most men.

The extraordinary feature of LI-ESWT is that it is the first potential non-surgical curative treatment for ED.  Current treatment of ED, using pills or injections, is extremely successful, but they have always relied on ongoing management of the condition. That is, anyone using pills or other treatments must plan to use them before each sexual activity. LI-ESWT treatment potentially improves a man’s sexual functioning whenever he is sexually active.  This may allow him to get and maintain a good erection without requiring an immediate intervention, or improve his function so that he can use a less powerful method to be successful (i.e. function with using pills as opposed to injections.)

Read more about this extremely effective treatment option or contact us.

Who is this for?  Men with mild to moderate ED are the best candidates for Regenerative Cell Therapy. Regenerative Cell Therapy is a relatively new treatment option for erectile dysfunction (ED). It is one of the few options that is potentially curative, improving your base line erectile function, rather than managing it. You may be able to get and maintain a good erection without advanced planning, or with a less invasive method (e.g. only pills, without injections).

Excellent new research published by The Journal of Sexual Medicine in 2021, shows that Regenerative Cell Therapy improves erectile dysfunction in men with mild to moderate ED. We’ve waited to offer this treatment for ED to our patients until we felt the evidence for a specific protocol, with specific equipment, was found to be convincingly effective from a science-based perspective.

Learn more about Regenerative Cell Therapy for ED.

The earliest treatment for ED, and one still frequently used, is placement of a penile implant. The technique involves placing cylinders in the two erection chambers of the penis.  When they are inflated or bent upwards, they allow a man to have a rigid penis.  Originally, they consisted of bendable rods put into the erection chambers.  However, they have developed significantly since that time.

Today most prosthesis are inflatable.  They consist of a closed system filled with saline. There is a reservoir that holds most of the fluid when you don’t want to be erect.  It is hidden under your abdominal muscles or, occasionally, in your scrotum.  There is a pump placed  in your scrotum which you can feel and manipulate through the scrotal skin painlessly.  When you want an erection, you literally pump the fluid from the hidden reservoir to the cylinders in the erection chambers, giving yourself an erection.  Your orgasm and sensation will be the same.  When you no longer need/desire the erection, you press a valve on the pump and then gently squeeze the penis. This transfers the fluid out of the penile cylinders and back into the reservoir.

The surgery, when done by an expert with a lot of experience, is quite short.  It is done in the hospital. Most physicians keep their patients in the hospital overnight, though some discharge them home the day of the surgery.  All of the pieces can be placed through one small incision, which is either in the scrotum, or right above the pubic bone, in the middle.  None of the pieces are visible.