Special Features

• Clinical Trials - Universities in California
• Successful Self Penile Injection Hints, Questions and Answers

Clinical Trials - Universities in California

We are currently in the process of obtaining the websites for Clinical Trials of the Universities in California. We currently have the websites for:

      University of California at Davis -       <http://www.ucdmc.ucdavis.edu/cancer/clinical_trials/>

      University of California at San Francisco -       <http://cc.ucsf.edu/trials/adult_index_gu.html>

      University of California at Los Angeles -
       <www.cancer.mednet.ucla.edu> click on research

      University of California San Diego -                <http://cancer.ucsd.edu/PatientCare/ClinicalTrials/study_list.asp> Type in        Prostate 

University of Southern California, Norris Cancer Center -
       <http:/ccnt.hsc.usc.edu/CLTrials/Site.aspx>  Click on Gentiurinary, then click
       on Prostate

University of California - Irvine -
       <http:/www.ucihealth.com/clinicaltrials/default.htm> Click on    Prevention/Treatment

Stanford University -       <http:/www.cancer.standordhospital.com/healthinfo/cancerTypes/prostate/clinic  alTrials/Index.html>
 

POST-RADIATION

• Q4. Are there different recommendations for treating erectile dysfunction with injections for erectile dysfunction resulting from radiation therapy?
  A4. There is no difference

INJECTION MEDICATIONS AND MECHANISM

• Q5. It seems that there are several different medications suitable for injections. What are they and what are the trade offs?
  A5. Each of these medications will work to help you achieve an erection. You should always consult your physician to discuss which is best for you. Some of the medicines currently in use include the following Papaverine--low cost and stable at room temperature but is less effective and may have a higher tendency to cause scarring (fibrosis). Papaverine plus phentolamine--more potent than papaverine alone but with the same potential side effects. Alprostadil--priapism is rare but pain is more common. (Alprostadil is also known prostaglandin or PGE-1, in powdered for it may be called Caverject or Edex.) Papaverine plus phentolamine plus Alprostadil--this is the most potent but requires refrigeration and has the same side effects as papaverine or phentolamine alone.
• Q6. How do these medications work to produce an erection?
  A6. These drugs create an erection by relaxing the smooth muscles and widening the blood vessels in the penis. They are not dependant on nerve stimulation. (For a more complete discussion of how the penis functions see Lue, Thomas F.: A patient's Guide to Male Sexual Dysfunction.)
• Q7. Are there long term side effects to the use of injections? What are they?
  A7. One possible side effect is development of curvature in the erect penis, which can be painful and interfere with intercourse. This is called Peyronie's Disease. It is caused by a buildup of plaque or scar tissue inside the penis in the lining of the corpora cavernosum. These are the two sponge-like cylinders running the length of the penis into which the medication is injected. It is relatively rare (about 3%) and can be treated. (You can minimize the risk by learning to inject correctly…this is not difficult.)
• Q8. Are there medical conditions that preclude the use of injections?
  A8. Yes.
  1. Severe scarring of the penis.
  2. Allergic to any of the 3 medications.
  3. Active infection or sore on the penis.

ERECTIONS FROM INJECTIONS

• Q9. What percentage of men will get a useful erection from an injection? Do they work for everyone?
  A9. If the medication is properly dosed (this is done by your physician) and properly injected, a useful erection should result in at least 80%? of the men.
• Q10. Does the medication continue to work indefinitely or is a tolerance created requiring increasing dosage?
  A10. Both have been seen.
• Q11. How long will the erections last?
  A11. This depends on a number of factors including one's general health, current physical status, whether the proper dosage was properly injected, other stimulation, etc. Erections generally appear in 5 to 10 minutes and on average last 30 minutes or so.
• Q12. Can injections be used with vacuum erection devices?
  A12. DO NOT use a vacuum erection device after injecting! Severe bleeding can result. There are exceptions. Please consult your doctor.
• Q13. My medication requires refrigeration. How long can it be left un-refrigerated?
  A13. Three hours.
• Q14. If I am traveling, are there medications that don't require refrigeration that I can use in place of my regular medication.
  A14. If your standard medication is Alprostadil (Prostaglandin), then Caverject or Edex can be used. They are mixed from a powder at the time of use. Papaverine + phentolamine doesn’t need refrigeration, but should not get exposed to a lot of heat.
• Q15. What is the definition of priapism?
  A15. It is a prolonged erection. This is an easily managed but potentially serious complication. If ignored, it may result in severe pain and may require a small operation. In addition, it may also make you completely impotent necessitating placement of a penile prosthesis. Therefore, it is very important that if you develop a full erection lasting for more than 4 hours, YOU SHOULD CALL YOUR DOCTOR AT ONCE OR GO TO THE EMERGENCY ROOM!
• Q16. I’ve heard that Sudafed and Benadryl as well as Terbutaline can reduce a prolonged erection. WHEN should these be used?
  A16 If the erection lasts more than 2 hours.
• Q17. Can I use an ice pack to reduce the erection? Where & how should it be applied?
  A17. Yes, on the penis or inner part of thighs. (A cold shower also works.)

INJECTION MECHANICS

• Q18. When filling the syringe, I have heard that the plunger should be pulled down to the 1.0 cc mark before pushing the needle through the rubber stopper and then pressing on the plunger, pushing the air into the ampoule before withdrawing the medication. Is there an advantage to this procedure?
  A18. It makes withdrawing easier.
• Q19. Where in the penis do I want the medication to go? What structures am I aiming for and which do I want to avoid?
  A19. Alternate between injecting at the 3 and 9 o’clock positions. You will be injecting into the corpus cavernosum (erectile bodies). When choosing an injection site, avoid any area were a vein is clearly visible.
• Q20. Besides the 3 and 9 o'clock positions, I've also been told that I can inject at 2, 4, 8 and 10 o'clock positions. Does it matter?
  A20. 2, 4, 8, and 10 are all OK, but 3 and 9 the best.
• Q21. Are there any cues you can give me to tell when I'm in the right place? What should I feel when I inject? Will it hurt? Should I feel resistance? Can I feel if the needle is in too deep or too shallow?
  A21. As there are few nerve endings for pain in this area, there will probably be just slight momentary discomfort. Once through the skin (some resistance may be felt), push firmly until the needle is in the penis right up to the hub.
• Q22. Sometimes I feel more resistance to the plunger than others; when that happens, the injection usually fails. How come? What should I do?
  A22. The needle may be in too far or not far enough. Pull the needle back a little or push it in further. If that does not work, the needle is probably in the wrong place.Do not inject if the resistance is strong. Withdraw the needle and reinsert in another suggested place. The plunger should press quite easily. Your doctor can demonstrate.
• Q23. If I don't get any response to an injection can I follow up with another injection maybe to a different side of the penis and perhaps using a smaller dose?
  A23. Yes.
• Q24. I'm bothered by the pain of the injection, are there topical anesthetics that I can use?
  A24. Yes, EMLA is the best.
• Q25. Are there thinner needles available that could be used to reduce discomfit?
  A25. This is not recommended. Needle breakage has been reported with 30 gauge needles. But see following question on auto injectors.
• Q26. What's an autoinjector and how might it help me?
  A26. An autoinjector is a spring-loaded device, which inserts the needle into the penis very quickly, minimizing any discomfort. You still push the plunger. Many men are happy using the autoinjector. Check with your local drug store to obtain one. Some of us have personal experience with the Becton Dickinson “Inject-Ease” automatic injector, but there are other brands out there as well. They are not very expensive.
• Q27. Can I use 'needle-less' injections systems like are being used
  for diabetics?
  A27. No they only get into the skin. These will not work.
• Q28. At what angle should the needle enter the penis? Should it be 90 degrees or a shallower angle to stay away from the urethra?
  A28. Angle of injection can be defined in two different mutually independent ways. One way is as seen from above and the other way is as seen in a “front view”. Ninety degrees should be used in every view.
• Q29. Sometimes I see a tiny amount of blood from the injection site just when the needle is withdrawn and sometimes I don't. Why? Is it a problem either way?
  A29. It depends on whether or not you hit a small blood vessel. It is not a problem.
• Q30. What's the best way to hold the penis for the injections? Should the penis be pulled to maximum extension for example? Should I pull just the outer layer or the whole penis?
  A30. You should pull the whole penis. Some men find it best for them to lay the penis along one leg while injecting, without pulling.
• Q31. Is it important to apply pressure to the injection site for a full 5 minutes after injections? Aren’t a few minutes enough?
  A31. Five minutes is best. On the needle site, using the alcohol pledget, immediately apply pressure to the penis with the thumb and index finger for 5 minutes, or longer if there is still bleeding.
• Q32. Should I vary the injection site? What is the best way to do that?
  A32. The places for injection are limited by the anatomy of the penis and you must adhere to these. Changing injection sites from left to right and back again is O.K. and actually recommended.
• Q33. Is it important to get all the bubbles, even the littlest, out of the syringe before injection?
  A33. The littlest are not necessary.
  DOSAGE, etc.
• Q34. How is the correct dosage determined? How do I know when I have the right dose?
  A34. With the appropriate amount of drug as determined by their physician (usually less than 1cc), erections usually occur in 5 to 10 minutes, last for 30 minutes or so, and become more rigid if sexual stimulation occurs.
• Q35. Is sexual stimulation required for an erection ? Can I use less medication if I have more stimulation?
  A35. Stimulation is not required but may speed things up a bit. You may be able to use less medication with stimulation.
• Q36. Sometimes a dose that has worked fine before, produces no erection. I'm sure I was in the right place. What happened?
  A36. You were probably in the wrong place or too deep or too shallow, or the medication was expired.
• Q37. My instructions say not to inject more than twice a week. What's the reason for not injecting every day, for example?
  A37. May cause scarring.
• Q38. Does the medication lose potency over time even if stored
  correctly?
  A38. Yes, after about six months.
• Q39. Will I develop a tolerance over time requiring an increasing dose?
  A39. This sometimes occurs

PROBLEMS

• Q40. What, if any lasting damage can be done to the penis by the wrong injection technique? Can just one injection if done incorrectly cause permanent damage?
  A40. Yes, scarring, Peyronie’s disease. If a patient injects too much medication it could cause priapism and damage to the erectile tissue. Not compressing of the injection site after injection may cause internal bleeding and scar tissue.
• Q41. After an injection I've seen blood coming from the urethra. What happened? What should I do immediately if this happens?
  A41. You have punctured the urethra. Just grab the whole penis and squeeze for 7 minutes.
• Q42. What happens if I accidentally hit a large blood vessel? What should I do?
  A42. If bleeding continues after applying pressure, abstain from intercourse. Continue to apply firm pressure until bleeding stops.
• Q43. Do infections ever develop from injections? How commonly?
  A43. This happens very rarely.
• Q44. Does the injection site make me more susceptible for contracting a sexually transmitted disease?
  A44. Possibly. If in doubt, put on a condom.
• Q45. Can injections be used with Viagra? If so, can a lower dose be
  used?
  A45. Not a good idea because of the increased possibility of priapism.
• Q46. After using the injections for a while my erections have developed a curvature. What's happening?
  A46. The injections may have caused some scar tissue to have formed. This condition is called Peyronie's disease. Talk to your doctor about causes and treatment.
• Q47. Does this curvature develop for all men using injections?
  A47. No, only 3-8 percent of men.
• Q48. Can this problem be the result of improper injection technique?
  A48. Yes. The patient must make sure that he maintains pressure on the injection site for 5 minutes to stop bleeding, including possible internal bleeding that will not be seen. Also attention must be paid to the doctors instructions on WHERE to inject, the alternation of injection sites, and the frequency of injections.
• Q49. Based on 100 injections a year is it crucial to inject both sides?
  A49. It is better if you can inject both sides.
• Q50. Can just one injection cause Peyronie's?
  A50. Possible, if too much medication injected or injected incorrectly.
• Q51. Can men that develop curvature continue to safely use injections?
  A51. If it is a mild curvature.
• Q52. Are there medications that can be helpful? If so, which ones and what are
  the “track records”?
  A52. Colchicine is helpful in the early phase.
• Q53. Can surgery be useful?
  A53. Yes, but only when the condition has stabilized, and after non-surgical treatments have failed.

IN THE FUTURE

• Q54. What kinds of medications or procedures are on the horizon to help us with ED, especially those of us who have had surgery or radiation for Pca?
  A54. Vardenafil and Tadalafil…Viagra-like pills. And Alprox-TD - (topical Prostaglandin applied to tip of penis).

Men’s Experiences
Patient 1
I am 62 and was 60 at the time of my cancer treatment (seeds). I first tried Viagra but erections were not always firm and were easily lost. I now alternate between injections and Viagra and have sex about 10-15 times per month.

About 15 months after treatment and struggling with Viagra, I went to an ED specialist for injection therapy. My doctor started me on bi-mix, a mixture of 30 mg papaverine and 1 mg phentolamine. In the office, he injected a dose of 0.2 ml, but the erection was too strong and he had to give me two shots of an antidote to bring it down. I went back the following week to demonstrate that I could inject myself. This time the dose was 0.1 ml and this was not enough for an erection. He then gave me a prescription for 10 ml and told me to increase the dose in small increments until I found the right mix. The right dose for me is 0.12 ml and I get an erection of about 45 minutes to two hours with that mix. Occasionally, the erections persist and I have to take Sudafed and/or do some stair climbing to lose the erection. My doctor was adamant in not taking a dose that would cause an erection that would last for more than two hours. I am allowed to inject everyday as long as I wait 24 hours between injections.

I find injections to be much better than Viagra, although the feel is not quite as natural. About 10-20% of the time, I fail to get an erection with injections and have to take a dose of Viagra to supplement. I use 0.3 ml diabetic syringes with either a ¼ or ½ needle. There is no pain to speak of either with the needle or the erection. I understand auto injectors are available, but I have never felt the need. The injection itself takes about 5 minutes, about 1 minute to clean with an alcohol swab and inject and another 3-4 minutes of holding pressure on the injection site after removing the needle. I usually have a full erection within 5-15 minutes of injecting.

As I recall, my doctor said that bi-mix is effective about 80% of the time. He added that about 50% of the users show an improvement in potency after using injections and find that they do not have to always inject. About 5% of users are able to get off of the injections entirely. In my case, after about 6 weeks of injecting, I found that I am now able to use Viagra successfully. I generally inject about twice per month and use Viagra the rest of the time.

If bi-mix is not successful, my doctor prescribes tri-mix with the third ingredient being prostaglandin (Caverject). Prostaglandin causes pain, sometimes severe, in about 20% of the users. The cost of a bi-mix injection (at my dose rate of 0.12 ml) is about $1 plus 25 cents for the syringe. My insurance pays 80% of this cost. Caverject, I understand, is quite a bit more expensive.

Editor’s Note: The decrease in the requirement for injections depends on the condition of the nerves. If the nerves have been removed or severely damaged in a prostatectomy, for instance, an erection will never start occurring naturally.

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(another patient responds to the above message)
This is an usual frequency that you are permitted. Most uros hold to the old dictum that 3x a week or 10 x a month is the max for injectibles. However, a friend of mine - a veteran of injecting for many years - began ignoring these rules long ago, with no negative effects. He keeps his regular appointments to check for scar tissue and has none.

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Patient 2
I am an eight-year survivor. I had a radical prostatectomy with bilateral nerve sparing at age 55. However, I am as impotent as I can be. I was also very, very angry. I tried everything, vacuum devices, Caverject and tri-mix injections, Viagra, the pellet, and nothing seemed to work. I had Doppler studies done to determine if I had a venous leak, but it seemed normal.

In my Houston support group, one member urged me to try the tri-mix again. It has not failed ever since, not even once! It seems to me that I was terrified of Self-injecting, and that had a mental impact on me. I then discovered an autoinjector, and all the fear and apprehension of injections went away. With the autoinjector, I don’t even feel the needle go in. As an added bonus, I am now able to inject on both sides of my penis, in order to minimize scarring, which I was not able to do before.

I would strongly emphasize to your support group the use of an autoinjector.

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Patient 3
Prostate-ease and related supplements off again, on again over past 5 or more years, with questionable results. Viagra gave limited results briefly then seemed to stop working altogether.. There appears to be a Quality Control problem in supply of Tri-Mix, however, this batch is up to standard.

Have been using Tri-Mix for two years now. Don’t really mind the needles. It really does what it was developed for. I recommend it highly. Occasionally I miss or possibly hit something other than the corpora cavernosum and it does not work. This last batch may have been weak or something, as had to use triple amount to effect the same response

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Patient 4
By the time I was 8 months post op, (at 50 years old) I had already been through Viagra, Muse, the pump and all combinations. I thought I was doomed until I tried Caverject. While no one in their right mind would look forward to inserting a needle into their penis, it is rather painless and is something you can do in the bathroom alone before you retire to the bedroom. It needs not be an integral part of the night, as opposed to using the pump at bedside - what a turn off. An erection of several hours is not uncommon, and you must carefully regulate the dosage (it’s not difficult) in order for your erection not to exceed 2 hours. After a number of very satisfying events, I am now 18 months post op and able to get an erection w/o the aid of any of the above. Use it or lose it! Good Luck!

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Patient 5
I had my RRP 4 years ago. The first year I tried all the options - without any guidance or direction from my surgeon. I used the pump, tried MUSE &, when Viagra hit the market, tried it. After close to a year the subject of injecting surfaced. I started with a Tri-mix combo & Caverject - both caused me severe pain (the common aching side effect associated with the use of Prostaglandin E). At that point I learned of other injecting options, found PCAI & got an Rx for a Bi-mix combo of Regitine & Papaverine. It worked like a champ. I also started using straight Papaverine (because it doesn’t require refrigeration & could be used when I’m traveling). Both options do the job. After 2 years I realized that this was a more than acceptable way of retaining the ability to have erections. The only regret I have is not starting with injections immediately because the only change/impact on my current situation is that my penis is somewhat smaller - probably the result of not getting back into the routine within a few months.

My wife & I now have a “normal” love life & I actually am a little thankful - e.g., I never have to worry about losing an erection! When I use the bi-mix my erection stays around for 2 hours & with straight Papaverine I can control the duration with the dosage from 30 minutes to an hour. Injecting, as such, is NOT a problem for me &, after 2+ years of a couple of injections a week, I see no evidence of damage to tissue. Lesson Learned - all urologists/surgeon need to understand the impotence side of an RRP & start those that want an active sex life, on injections within the first 6 to 8 weeks. EVERYONE should start with straight papaverine - minimal side effects, minimal erection duration & cheapest option. If that doesn’t work then move to a bi-mix. Patients should not use tri-mix or Caverject (Prostaglandin E products) initially because if they get the aching side effect it tends to immediately discourages you on injections - in general. Stay with the simplest & minimal hit option & move up if you need more.

For me, Regitine does not apparently cause any side effects. When you’re using the bi-mix you’re usually injecting less than a third of the liquid (I use 0.17 cc of Pap & only 0.06 of bi-mix), so it’s possible that less is better???? I honestly do NOT notice any difference in my erection when using either. The only difference is (1) the length of time I’m erect (significantly shorter when using just Pap) and (2) it takes a few minutes less to become erect when using Pap. My “routine” is mostly based upon being convenient. If we decide quickly it’s time to make love, I grab the Pap out of the bathroom draw & inject. If we’re thinking about it earlier in the evening or there’s a conscious decision that the event should last for an hour or so that the obvious option is to head for the Frig & grab the bi-mix.

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Patient 6
My first experience with the needle, in the doctor’s office was pure joy! The excitement of getting an erection clearly outweighed the slight discomfiture of the pinprick. Incidentally, this was before Viagra. Subsequently, I tried Viagra experiencing mild success with hot flashes being the only and easily survivable side effects. I use the needle almost exclusively. Do I have a problem? You’re damned right! Why? After almost four years? The pure psychological effect of poking a needle anywhere in my body, let alone that poor, innocent, defenseless penis. Yes, to this day, I fear the needle. I work on the reward theory. I know that the reward to my wife and, thus, to me is worth the puncture. I also suffer from a mild loss of desire, which doesn't help. Further, orgasms are difficult. Thus, we go through this routine of psyching up, remembering the joy of a very happy wife, and puncture the little sucker and make him big and bold, just like she likes.

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Patient 7
As to my experience with “injecting” Caverject. Age 65, RP 4/99, doing fine. I’ve used Caverject injections for the last 2 years and they work well for me, giving me a good erection of from 1 -3+ hours depending on how much I inject (I’m currently using between .2 and .3 cc) and my mood etc. I use the B-D ULTRA-FINE 1cc 29 gauge ½” needles, as well as the B-D ULTRA-FINE II 1/2cc 30 gauge SHORT 5/16 needles. It does not seem to make any difference as I’m injecting .2 to .3cc. I would say that my success rate is about 90 per cent, and I get a nice hard erection. I did try an automatic injector, but I’ve found it’s easier for me to inject without it.

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Patient 8
I underwent an RP in December of 1998-a month short of my 59th birthday. I started trying to get erections about three months later and my urologist started my on Viagra that did not do the job; then he put me on Muse with similar non-results. So it was time to try injections. He first injected me with 10 mcg of Caverject. It did something but not nearly enough. I tried the full 20 mcg dose while my wife was waiting. The results were disastrous. It hardly worked at all, so I waited another three months and tried 40 mcg of Edex in combination with Viagra. It worked very well but I had aching pain afterwards. So I gradually stepped down the dosage until I was down to 2.5 mcg. That worked well under the best of conditions, but five mcg was more dependable and 10 mcg was totally dependable without pain. I kept this up for about 15 months when I discovered that Viagra would work well without injections. This was about at my two year anniversary of surgery. Since then I have not injected. When I did inject, I preferred to use the size 30 diabetic needles that you can buy in packages of 10. They were smaller and easier to handle. When learning to inject, it seems to be important to have a successful injection when you are not expecting intercourse so that you can take your time and become comfortable with the process. It does not hurt to inject yourself-it just stings a little. I think the injections started me on the road to recovery of my sexual function, and I encourage everyone for whom other methods have failed to give them a try. Don’t just sit there and wait for erections to occur, you have to help then along or they may never come. The injections worked for me and I’m glad I tried them.

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Patient 9
Diagnosed in October 1998 at age 49. Had RRP in December 1998. PSA at time of diagnosis 4.7 Gleason score = 7.
I have used tri mix injections for almost three years and I suppose I would have to classify my experience semi-bad or semi-good. Depending on how you perceive things i.e. is the glass half full or half empty. Anyway for the first ten months or so the injections worked wonderfully. Then about 10 months post op I began developing Peyronie’s or scar tissue. Still not sure it was caused by the injections. Following treatment for the Peyronie’s, the curvature has subsided significantly and the pain has gone entirely. I continue to use the tri mix injections. My erections while sufficient for intercourse are not as rigid or as full when compared to immediate post op much less pre op. However I am thankful that they still work.

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Patient 10
I’m 52 years old and had a nerve sparing prostatectomy in July 01. At present, 8 months post-op, I’m still having no natural erections and no useful response to Viagra. I’ve been using the injections for about 5 months (about 25 injections) with mixed results. Here’s a short chronology: After about 3 months after my operation, with no return of natural erections (it was still early), I made an appointment to learn about injections. I was told that the injections may help bring my natural erection back faster but was not a cure. I was then given a scary waver to sign followed by an injection so that they could do an ultrasound study to test my circulation. The injection didn’t produce much of an erection and if they learned anything from the ultrasound they didn’t share it. The shot hurt a little going in then burned like crazy. They seemed surprised by the amount of pain and attributed perhaps to the alcohol prep (which I didn’t believe).

I was sent home with an instruction sheet and a prescription for bi-mix. I tried escalating doses of the bi-mix (up to .6ml) but it didn’t do very much. It certainly didn’t produce a useful erections. Doing the injections myself, I never experienced the burning pain of the first injection but then I wasn’t sure I was doing it exactly right either. After further consultation I was given a prescription for tri-mix and, being wary, I injected only half the recommended dose resulting in an erection that lasted over two hours, going on 3, with no stimulation required. I was nervous because the instruction sheet was very specific about calling an emergency number for any erection that lasted longer than 3 hours warning that a prolonged erection could cause irreversible tissue damage.

Based on the first experience, I injected a smaller dose the next time during a vacation. This time the erection showed no sign of going away after 3 hours and, after calling the emergency number, I headed for the local emergency room. After about 4 hours, just before I was examined, the erection went down on it’s own and I headed home.

After these experiences, I tried much lower doses. Sometimes they worked, sometimes they didn’t. I gradually started increasing the dose and had some successful, and pleasant results. But the dose response didn’t seem very repeatable.

Lately a curvature in my penis has started to develop that also makes intercourse somewhat painful. I was told this happens to about 5% of men that use the injections. The curvature occurs as a result of scar tissue that forms in the penis and I was told if I stopped the injections immediately there was a 50% chance the scar tissue would heal. I was also given a prescription for Colchicine that would help prevent further scaring and perhaps eliminate the scaring that I have (Colchicine isn’t given unless needed because of the risk of side effects). My examination with ultra sound confirmed a ‘small’ area of scaring that my physician had felt earlier. I was advised to stop the injections and continue medication for 2 more months (for a total of 3 months). I was also advised to use a combination of VED and Viagra for intercourse in the meantime.

So, the story continues. I’m 8 months post-RP and at this rate, like many of us, I’ll have tried all the ED remedies by the time I’m 12 months post-op. Of the treatments I’ve tried, the injections seem to be the easiest to live with for me so I hope to be able to keep using them.

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Patient 11
I was 58 years old when I underwent bilateral nerve sparing RP on June 11, 2001. In August, I tried 100 mg of Viagra and I got a 30-50% erection. Shortly thereafter I went to an ED specialist. He asked me to excite myself so he could evaluate the extent of my erection. He felt my penis and prescribed Bi Mix which is a compound mixture of Phentolamine .5mg/cc and papaverine 30/cc. I understand that this compound does not need to be refrigerated. The insulin syringe is 1cc with 28 ½ needle. I don’t know what it means but I assume there are different size needles. The recommended dosage was .3cc/injection. My first erection lasted almost 4 hours and this concerned me. He told me to drop dosage to .25cc. Out of the 20 times I have injected myself, it did not work on about the 4th attempt so I increased dosage to .28 and have been at that level since. The erections are good and sometimes the penis is cold. There is the swivel effect where the erection is not necessarily connected to the base of the penis. It is not too noticeable and has no effect on the general love making process. My wife feels that my erections are harder than before the operation. I am not sure. The orgasms are good and are generally the same, however there is some difference which is harder to explain. I do plan to use the injection more frequently. Hopefully in the future I will be able to use Viagra to get full erection and eventually nothing at all. The main advice I would give to everyone is start early with treatment and do it frequently.

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Patient 12
I had a year of triple hormone blockade, then a non-nerve sparing RP and then (due to a “micro focus” of Prostate Cancer) 7 weeks of radiation. Total hormone ablation was 18 months. Tried many doses of Viagra to no effect. Tried the pump and got my first erection in many months. Fairly happy with using the pump, but had trouble maintaining the erection for very long.

Then tried straight prostaglandin. Worked from day one like a charm. Never tried any other of the possible injectibles. Why should I since no pain from (several hour long) erections.

At some point I wondered if Muse would work since it too was prostaglandin. But even the maximum dose Muse barely got me hard.

Back to the injection. I wanted to try an autoinjector because although the pain at the actual time of injection is very short, who needs it? So I got the Becton Dickinson auto injector.

The actual injection was miraculously painless. I loved it! Then it stopped working! I had noticed when injecting manually that if I went in too deep, not deep enough, at the wrong angle or in the wrong place that I had a similar experience of the injection not working. So I assumed that the autoinjector was injecting too far in and gave up using it.

A year later, someone reminded me that the autoinjector came with some spacer rings that would reduce the depth of the injection. So I went and tried the autoinjector again just a few months ago. This time it worked, and continues to work flawlessly.

Thanks to:
Tom F. Lue, MD
Chris Timossi
Jim Watson
James Wilcox
Harry Scheer

Feedback
Please send any corrections or suggestions for this document to Stan Rosenfeld at "mailto:vegstan2@ix.netcom.com"