Oral and lozenge medication overview

Oral medications, otherwise known as PDE5i (phosphodiesterase type 5 inhibitors), are the mainstay of erectile dysfunction treatment and management. They are relatively effective, convenient, side effects are not common and they are accessible on a Doctor’s prescription. They are however still relatively expensive however are coming down in price as they come off patent protection. There are 3 prioratory PDE5i available in Australia; these include brands such as Cialis (tadalafil), Viagra (sildenafil) and Levitra (vardenafil). Lozenges containing PDE5i are used sub buccally, meaning that they are placed between the teeth and the cheek and gentle sucked on until they dissolve. These are less commonly seen in Australia as most Doctors are unfamiliar with them despite their advantages to the prioratory oral tablets listed above. The lozenges are custom made for each individual patient according to the Doctor’s prescription and this is generally done to get patients the best possible outcome; further it allows a more custom or tailored approach to be utilised. There are a number of benefits to using PDE5i in the sub buccal form and these will be explored below. As a note, recipes or suggested combinations and dosages have been complied by Men’s Health Downunder over many years and are available to Doctors through the Doctor login part of this website.

The main benefit of the sub buccal lozenges include:

• They allow the Doctor to prescribe a custom option; that being multiple PDE5i; multiple types of ED medications in one lozenge
• Use of the sub buccal route of administration avoids hepatic metabolism and all PDE5i are extensively broken down by the liver reducing their effectiveness when taken orally. This is avoided with the lozenge giving greater results
• The onset of action is faster meaning greater ability to have a spontaneous sexual relationship
• They tend to be more cost effective than the prioratory products listed above

How do they work?

Generally speaking PDE5 inhibitors help the body's natural response to sexual stimulation. Basically they block an enzyme that breaks down the chemical messenger responsible for creating an erection; cyclic GMP (cyclic GMP is created from GMP when nitric oxide in the blood enters the smooth muscle of the penis and this is what causes an erection) - hence the cyclic GMP stays in the smooth muscle for longer, which means more erection. So really, these PDE5i do not cause erections, but they help the body's normal response to sexual stimulation assisting in the formation of an erection.

As a rule this group of medications is generally used ‘on demand’ and work quite well; for patients post prostate surgery they tend to be quite ineffective as their blood flow and nerve connections have been interrupted. This is why we generally use the injectable PDE5i contained in medications like Caverject and Trimix to give an erection as they do not rely on blood flow alone to elicit their effect.

PDE5i in prostatectomy patients

In patients post prostatectomy we use oral PDE5 inhibitors at low dose to increase blood flow to the penis. This will not likely result in an erection as the doses used tend to be lower than that of the ‘on demand’ doses used to aid sexual function. The other benefit inferred by low dose PDE5i is that they will assist in keeping the blood vessel lining (the endothelial lining) healthy which is vital in getting oxygen from the blood into the penis tissue keeping it alive and functional. Generally a small dose of Viagra (sildenafil) or Cialis (tadalafil) might be used - 25mg Viagra or 5mg Cialis. The main benefit of tadalafil in this situation over sildenafil (or Levitra - vardenafil) is that it remains in the blood having an effect for more than 24 hours, where the others are only effective for 4-8 hours or so and this is important want to infer the aforementioned benefits for the penis 24 hours a day to get the maximum benefit. The drawback of tadalafil is its cost compared to sildenafil and this may need to be taken into consideration.

Side effects

Common side effects include facial flushing and a blocked or runny nose. They can also cause headaches, muscle aches and pains, and indigestion. Most side-effects are not troublesome and only last an hour or so. In the case of taking the low dose tadalafil every day post prostatectomy muscular ache (back, neck or thight most commonly) is the most commonly seen side effect and it is seen in approximately 1% of the population. There are many ways to work around these side effects so please don’t hesitate to contact us if you need assistance in this regard.

When not to take PDE5i

PDE5i are not to be used with ‘nitrate' drugs; these ‘nitrate’ drugs treat certain forms of heart disease - if you are not sure check with your Doctor or Pharmacist. Further, PDE5i should not be used when suffering from unstable heart disease, which should again be checked and discussed with your Doctor or Cardiologist.

Intracavernosal (penile) injections overview

Sometimes your Urologist or Doctor will prescribe ‘erection’ drugs which are to be injected into the penis (known as an intracavernosal injection). These medications are often used to bypass the oral route of administration. This can be for a number of reasons such as side effects of oral equivalents, poor outcome of oral equivalents, drug interactions, impaired blood flow and so on. Despite the fact that injections can be uncomfortable (and certainly unnatural for most patients) they are very effective and with the correct dose and technique will be reliable.

The 2 most commonly used medications for penile injection are Caverject (alprostadil) and Trimix; a mixture of 3 ingredients: alprostadil (PDE5i), phentolamine (alpha blocker), and papaverine (vasodilator)). These ingredients work by relaxing the smooth muscle and opening the blood vessels in your penis, thus leading to an erection.

Caverject is a propitiatory made injection (made by Pfizer) which is available at most pharmacies (some may need to order in for you);

Trixmix (comes in a range of strengths) is specially compounded by a sterile compounding Pharmacy and it needs to be specially ordered each time you need it. Men’s Health Downunder Pharmacists can arrange this for you - please get in touch and we will be happy to supply it to you and ensure that you know how to use it safely and effectively.

Your Urologist/Doctor will decide which medication and dose is most appropriate for you and provide you with a prescription.

Storing your medication

The alprostadil in Trimix can weaken over time, so Trimix should be stored in the refrigerator or freezer and away from light. This can keep the medication good for a few additional months. If you’re using Caverject the unused syringes can simply be kept at room temperature.

In the case where you have been prescribed Bimix or papaverine alone, you can keep these medication vials at room temperature also as they do not contain the light and temperature sensitive alprostadil.

Intracavernosal injections are generally reserved for patients who do not get the desired result with an oral or sub buccal PDE5i (eg Viagra or Cialis). They are injected into the cavernosal tissue of the penis and work quickly and reliably to give a good firm erection within 10-15 minutes. The main concern expressed by patients prescribed the injections is not surprisingly around the concept of injecting into their penis. The information below may help to demystify the concept of intracavernosal injection. Certainly Men’s Health Downunder is here to assist all men with any questions or support that they may need so don’t hesitate to contact us if you need support.

In summary, there are 2 main intracavernosal injections we use; that being Caverject which is available on a prescription from most pharmacies (ie a proprietary product) and Trimix (which we have specially compounded in accordance with your Doctor’s prescription) - there are many formulations/strengths of Trimix and again, as with the sub buccal lozenges, these recipes can be accessed by your Doctor in the practitioner section of our website; generally intracavernosal injections contain a PDE5i - most commonly alprostadil. It is worth noting that you may use the medication for intracavernosal injection up to twice a week (you should not use 2 injections within 3 days - and not more than 8 times in a month)

The goal is to induce an erection lasting 30-60 minutes – this can require some dose adjustment; the Pharmacist or Doctor can advise on this dose adjustment to ensure that you are able to find the best dose for you, noting that everyone will be different.

The erection will hopefully not last more than two hours, however if it does this is ok, just not desirable from a patient point of view. However when it lasts more than 3-4 hours it is called priapism and you should seek help as detailed in the ‘Priapism fact sheet’ below. Priapism can damage the penis and must be dealt with as soon as possible.

It is also worth noting that if the penis starts to bend/change shape it may be a side effect of the injections. If this does happen stop using the intracavernosal injections and seek advice from your Urologist/Doctor/Pharmacist. This is known as Peyronie’s disease and again is not desirable and needs to be managed by a healthcare professional. Similarly, if you have Peyronie’s disease you should not use intracavernosal injections.

Incorrect technique may result in a partial erection or no erection. It does not cause any harm. You can try again on a different day if this occurs and if you are unsure if your technique is correct check with your Pharmacist or Doctor. Inappropriate technique is the greatest cause of a failed injection and should be easily corrected with a little bit of education by the Pharmacist. Men’s Health Downunder pharmacists are all specially trained to assist you with your technique. Contact us should you need any assistance.

When using intracavernosal injections it is always wise to avoid alcohol as alcohol may counteract their effect resulting with no, or only a limited, unsatisfactory response. Alcohol may have this effect with any medication used for erectile dysfunction (tablets or injections) and as a general rule should be avoided.

To achieve the best response, you should be relaxed, sexually aroused (either from contact with a partner or from self-stimulation) and not overly tired; this is easier said than done so try your best

The erection can be uncomfortable and should this occur simple analgesic is appropriate - eg Panadol – for more information see the ‘Priapism factsheet’

If you find the injection painful local application of an anaesthetic cream may be appropriate; we would typically use Emla or Numbit 5% which should be applied an hour before and covered with a little spot bandaid - ask us for further advice

Finally some patients prefer to use a device called Inject Ease or Autoject to assist them with injection of Trimix; this is not appropriate for use with Caverject but may make the process of injecting with the insulin style syringe more comfortable. Your Men’s Health Downunder Pharmacist should be able to supply you with and explain how to use the Inject Ease or Autoject device

The below instructions are to assist patients or their carers to administer an intracavernosal injection.

Do not use the medication if it has particles or is cloudy. Equally do not use if the rubber stopper comes off of the vial

Preparing the injection

1. Prepare a clean surface for your supplies.
2. Gather your supplies including: medication vial; syringe (one-time use only); alcohol wipes; sharps container
3. In the case of Caverject Impusle follow the instructions or video given to you
4. Wash your hands well with soap and water

Drawing up the medication from the vial

1. Open an alcohol wipe and wipe the rubber stopper on the top of the vial. You must always wipe the rubber stopper with alcohol before you insert the needle. This will kill any bacteria on the rubber stopper
2. Take out the syringe, remove the cap from the needle. Be very careful not to let anything touch the needle. If anything touches the needle, you must throw the entire syringe away in the sharps container and use a new one as it will no longer be sterile
3. First, holding the syringe upright so the needle faces the sky, pull the plunger of the syringe back past the dose you were told to inject. Next, push the plunger back up until the top of the plunger (the thin black line closest to the needle) is at the dose you were told to inject
4. Turn the syringe downward so the needle is facing the floor. Hold the syringe in your hand like you hold a pen or dart. Hold the syringe close to the needle with your thumb, index (first) and middle (second) fingers. This will keep the needle from bending as you insert it into the rubber stopper. Support the medication vial with your other hand
5. Holding the vial upright and the syringe downward, insert the needle through the circle in the center of the rubber stopper. Push the plunger down to inject the air into the vial (see Figure 1). You do this because the vial is pressurized. You must replace the amount of medication you remove from the vial with air
6. Turn the vial and syringe upside down (see Figure 2). Hold the syringe with the hand you use to write with and the vial with your other hand. Don’t let go of the vial, or the needle will bend. Make sure the tip of the needle is in the medication. Rotate the syringe so you’re looking at the numbers and lines on the syringe

7. Pull the plunger down past your prescribed dose. This will help remove any air bubbles. Slowly push the plunger back up to your prescribed dose. Check the amount of medication in the syringe to make sure it’s the correct dose
8. Check for air bubbles in the syringe. If you see any air bubbles, pull more medication into the syringe. They will go to the top, towards the needle. Slowly push the air bubbles and the extra medication back into the vial. Look at the syringe again to make sure that you have the right amount of medication
9. When you have the correct amount, pull the needle out of the vial. Place the cap back on the syringe without touching or bending the needle. If you touch or bend the needle, you will need to throw away the syringe and start at step 2. When you place the cap back on the syringe, make sure you don’t push the plunger by accident. This will push the medication into the cap and result in the wrong amount when it’s time to inject yourself
10. If you’re using Trimix, put the medication vial back into the refrigerator. If you’re using Bimix or Papaverine, you don’t need to keep your medication in the refrigerator

Choosing an injection site

You must inject the medication into a specific area of your penis. This is so you don’t inject into a nerve or blood vessel

Imagine that your penis is divided in 3 parts. You will give the injection in the middle third of your penis at the 10 o’clock (left side) or the 2 o’clock (right side) position (see Figure 3)

To prevent trauma to your penile tissue, always change sides of your penis each time you inject the medication (right side, then left side). Keep a record each time so you don’t forget. Don’t inject into any vein you can see or feel because it could cause a large bruise on your penis. Don’t inject straight down on the top or the bottom of your penis.

Injecting the medication

1. Grasp the head of your penis, not the skin. This will allow your penis to be more fully stretched. It’s easiest to inject if your penis is pulled straight out in front of you. If you aren’t circumcised, pull your foreskin back before grasping the head of your penis. This will prevent the needle from going between the skin and cavernosal tissue. For your injection to work, the medication needs to go into the cavernosal tissue
2. Locate the area to be injected (the middle third of your penis). Wipe it with an alcohol wipe. Let go of the head of your penis and pick up the syringe with 2 hands
3. Remove the cap covering the needle. Look at the syringe to make sure the dose is correct and you haven’t pushed any medication out by accident
4. Hold the syringe between your thumb, index and middle fingers like a pen or a dart. The needle should be facing the floor. Don’t place your index finger or thumb on the plunger
5. Once again, grasp the head of your penis and pull it straight out. Keep pulling on your penis from the time the needle goes into your penis until it comes out. Don’t twist your penis as this could lead to injecting the wrong area
6. Touch the needle to your skin then allow it to slide into the shaft of your penis. Remember to avoid any veins. Make sure to insert the needle at a slight angle (either the 10 o’clock or 2 o’clock position, as shown in Figure 3)
7. Move your finger so that your index finger or thumb can push in the plunger
8. Push down on the plunger to inject the medication into the shaft of your penis. Be careful not to pull the syringe out as you’re injecting the medication
9. Once you have injected all of the medication, quickly pull the needle straight out of your penis. Pull it straight out. Don’t use a twisting or jerking motion because this may cause bruising. Apply pressure at the injection for 30 seconds (slightly longer if you are on a blood thinner as this will help to decrease any bleeding or bruising) then massage the penis from the base to the tip approximately 5-10 times; The penis should become erect (with the assistance of foreplay) in 5-20 minutes
10. Place the syringe in the sharps container. You don’t need to recap it

Research shows that vacuum therapy is highly beneficial as a method of rehabilitation therapy after radical prostatectomy.

The goal of penile rehabilitation therapy after radical prostatectomy is to get good regular blood flow into the penis; this aids in preventing atrophy (death of the cells/tissue of the penis). Beyond this you tend to find that regular use of the pump will also increase the length of the penis (noting a shortened penis post surgery) and to maximize erectile function so that a spontaneous erection can be produced.

The vacuum therapy device does this by creating negative pressure around the penis, thereby increasing blood flow to the penis. When used as a treatment, the penile tube is placed over the penis, and the vacuum suction is applied and the erection induced. Once the erection is achieved, the silicone constriction band is placed around the base of the penis and this will hold the erection in place.

When using vacuum therapy for rehabilitation therapy it works in much the same way, except without the constriction ring. The negative pressure is applied to increase blood flow to the penis. However, the ring is not used because it prevents venous outflow. Using vacuum therapy without the ring helps stimulate oxygenated blood flow, which can reduce the fibrotic changes that can occur after a radical prostatectomy.

We feel that it is important that patients invest in a quality, medical-grade pump designed for therapeutic use. It’s important at this juncture not to buy a “toy” or “novelty” pump, but to look for a quality instrument, backed by a solid reputation.

Sample routine

When using vacuum therapy as penile rehabilitation, the goal is to get blood to the penis and improve blood flow; this in turn helps to repair and maintain the penile tissue. In a typical session this involves the following steps:

1. Apply the vacuum suction and draw blood into the penis (you may need to lightly shave around the base of the penis and further may wish to use a little water based lubricant)
2. Leave the penis fully engorged in the pump for 5 minutes
3. Remove the pump and let the penis return to flaccid for 1 to 2 minutes
4. Repeat the vacuum suction and hold the erection for another 5 minutes. This should be done 2-3 times in a row. Alternatively you may wish to simply leave the pump over the penis for 10-15 minutes

Doing this repeatedly can increase blood flow, decrease swelling, and increase lactate and oxygen exchange.

Rehabilitation tips

• Wait two full weeks after your catheter is removed before beginning rehabilitation
• Be patient, be patient and be persistent. It is common to not get full engorgement for some days or weeks so don’t be dismayed and try not to become frustrated; this is normal and will improve with time
• Give yourself time to get familiar again with the sensation of being engorged. To do this, some men prefer to activate the pump for 30 seconds, and then rest for 30 seconds before activating the pump again; initially when starting your rehabilitation this ‘on/off’ process may be a gentle way to become acquainted with the process

There are a number of what we call ‘other’ ejaculatuion issues that men can encounter. These may include:

• Retrograde ejaculation
• Delayed ejaculation
• Painful ejaculation

These are described briefly as below:

• Retrograde ejaculation - occurs when the muscle at the opening of the bladder does not close normally. When the muscle does not close properly semen flows back into the bladder meaning, little or no semen is discharged from the penis during ejaculation, and the first urination after sex looks cloudy as the semen has mixed with the urine. Retrograde ejaculation is uncommon and usually harmless and can be a side effect of a number of medications; particularly those used to treat benign prostatic hyperplasia (aka BPH) and those for high blood pressure; and health conditions such as diabetes, multiple sclerosis, and spinal cord injury
• Delayed ejactulation - sometimes referred to as anorgasmia (the complete inability to ejaculate) are the terms used describe the inability to ejaculate at will. Interestingly “orgasm” and “ejaculation” are often thought to be the same, but some men can experience orgasm even though they don’t ejaculate and this is common after prostate surgery. Other causes can include spinal cord injury, major lymph node surgery, diabetes, multiple sclerosis and traumatic injury to the pelvic region where the nerve supply is affected. Medications can also be implicated and the most common of these are the SSRI antidepressants (also of note is that for premature ejaculation one of the Doctor may prescribe could be a SSRI’s at low dose)
• Painful ejaculation - occurs when painful, burning sensations are felt during or following ejaculation. During ejaculation, pain can be felt in the perineum (the area between the anus and the genitals) and the urethra (a tube that runs from the bladder to the end of the penis). The condition can cause discomfort in the testes and interfere with sexual pleasure. Basically any condition that causes inflammation or an infection of the organs involved in ejaculation or the surrounding structures, such as prostatitis, may cause painful ejaculation. A referral the the urologist may be sort in the case of painful ejaculation

Shortened penis, also known as buried penis, is where the penis itself does not extend outside the body even though there is an opening where the penis would normally hang. In buried penis the and the glans, or head of the penis, is usually flush with skin or can even be retracted beyond the pelvic tissue. Generally it happens gradually and can be a side effect of large weight loss or surgery which see the penis retract.

The complications of a buried penis generally present as difficulty urinating both sitting and standing, inability to have intercourse and infection.

Where desired by the patient and with the a referral from the general practitioner a Urologist may be seen to have a surgical fix.

The main complication of buried penis beyond urination generally relates to hygiene and the possibility of infection developing. As the skin around the penis may be often be damp and warm it is an ideal site for a fungal infection and/or lichen sclerosus.

• Fungal infections may cause the skin to breakdown, become itchy, red, inflamed, flakey and sore. Fungal infections are well managed generally with topical antifungals such as Canesten (see General Care Downunder below). It will require regular review and possibly semi-regular application of the antifungal cream/powder. Certainly it is important to keep the area as dry as possible.
• Lichen sclerosus is is the development of patchy, white skin that is thinner than normal; it can also make the skin look crinkly. This appears on the glans (head) of the penis and may lead to urethral stricture which further impacts on the patient's ability to urinate. Treatment of lichen sclerosus generally involves the use of a steroid cream (see General Care Downunder below).

Lichen sclerosus

• Lichen sclerosus, of which the cause is unknown, is is the development of patchy, white skin that is thinner than normal; it can also make the skin look crinkly. This appears on the glans (head) of the penis and may lead to urethral stricture which further impacts on the patient's ability to urinate. Certainly it is likely to increase the risk of the skin breaking and this would make it painful and his may affect your ability to have and/or enjoy sex.
• Lichen sclerosus is not contagious or sexually transmitted and its diagnosis generally made by sending a biopsy for pathology. It can also occur on the female genitalia and around the breasts and anus.
• Because it can appear white and itchy it can be misdiagnosed as thrush so it is important to speak with the Doctor if it is not improving.
• The mainstay of treatment involves the use of topical steroids and they work relatively well. Topical steroids can be prescribed by the Doctor or purchased without script from the Pharmacy. As a last resort, surgery can be performed however this is not without its risks

Candida/thrush

• Thrush is an overgrowth of a fungus and may also be known as a yeast infection. The causative fungus, called Candida, normally does not cause any problems because it is kept under control by the immune system and by other bacteria and viruses in the body. However, some factors such as skin irritation, taking antibiotics or poorly controlled diabetes or an area which gets warm and moist (such as the genital area) can allow the fungi to grow and multiply, which can lead to an overgrowth which we notice as symptoms
• The most common symptoms are itchy, red, and sore head of the penis (glans), small red spots on the head of the penis (glans), discharge from the penis, pain when passing urine, difficulty pulling back the foreskin and a 'cheese-like' substance that smells yeasty and sometimes collects under your foreskin. Cracking and inflammation of the foreskin can also occur
• Medical treatment generally includes management with antifungal creams such as Canesten; powders such as Daktarin (useful because they tend to keep the skin dry) and even use of the oral antifungals. Your Pharmacist can assist with these preparations
• Non medical treatments include keeping the area dry, allowing airflow, and good hygiene

Chafing

• Chafing of the groin generally occurs if you are an exercise enthusiast, or if you are overweight. Chafing is the annoying and often painful result of skin rubbing against skin or clothing. It can occur anywhere on your body, but the thighs, groin, underarms, and nipples are particularly vulnerable. There are a number of ways to prevent skin chafing and prevention is better than treatment.
• Preventative measures are based around reducing friction and include:
  • Staying dry with the use of powders such as talcum or alum powder
  • Lubricating with petroleum jelly to high risk areas
  • Dressing appropriately where possible with moisture-wicking synthetic fibres. Compression shorts are useful also. Avoiding clothes with seams is also a good idea
• Treatments include cleaning then application of petroleum jelly or similar. In the case where the skin is very painful, swollen, bleeding, or crusted seek further advice from your Doctor or Pharmacist

Psoriasis

• Psoriasis is a long-term skin condition that can also affect joints. Although the cause of psoriasis is unknown, it is thought that psoriasis occurs in people who have a genetic tendency for their immune system in their skin to react to certain triggers
• The most common symptoms are dry, raised, red patches of skin (plaques) covered with silvery scales. The patches usually appear on the knees, elbow and scalp, but they can appear anywhere on the body including the groin. Psoriasis can also cause dents and discolouration of the nails
• There is no cure for psoriasis but there are many treatments that can help to keep it under control. Mild psoriasis is usually treated with products applied to the skin. These include: moisturisers, tar preparations, dithranol, corticosteroid creams or ointments and vitamin D preparations. Ultraviolet light therapy is another option that the Doctor may consider. If the psoriasis needs stronger treatment the Doctor may prescribe oral medications (tablets or pills) or injected medications

Pubic Lice

• Pubic lice, or crab lice, infest pubic hair. They can also sometimes affect the hair of the armpit, eyebrows, eyelashes, beard and torso. The infection is also called pediculosis pubis and the lice are called Phthirus pubis. Pubic lice are small, flat, light-brown parasites that cling to pubic hair and suck blood for nourishment. Blood sucking from pubic lice can cause small red areas or sores and itching. Pubic lice are usually transmitted through direct skin-to-skin contact during sexual activity. However, they can also be spread by contact with towels, undergarments and bedding of an infected person. Lice infestation causes no serious harm, but can be irritating
• Applying topical creams or lotions containing permethrin such as Lyclear or Quellada to the whole body from neck to toes is the most commonly recommended treatment. For advice on appropriate use of these treatments speak with the Pharmacist

Sexually transmitted infections

• Sexually transmissible infections (STIs) are common all around the world. They may be caused by bacteria, viruses or parasites. You may think that only other people get STIs and that you are not at risk of catching one, but anybody who is sexually active can get an STI if they do not practice safe sex. You can’t tell just by looking at a person that they have an STI. If you have unprotected sex with a person who has an STI, you are at high risk of catching that infection.
• Sexually transmissible infections include, among others, chlamydia, herpes, gonorrhoea, syphilis, Mycoplasma genitalium, genital herpes, scabies, pubic lice (crabs), hepatitis and HIV.
• If you think you have been exposed to an STI, it’s a good idea to talk to your GP or sexual health service about having a check-up, even if you do not have any signs or symptoms of an STI. Don’t try to diagnose your symptoms yourself, and remember that not all genital signs and symptoms are caused by an STI.
• For more information see https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/sexually-transmissible-infections-stis