Using Penile Injections to Treat Erectile Dysfunction

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In this episode we discuss penile injections for erectile dysfunction, For most guys, treating erectile dysfunction means taking a pill. But what do they do if the pills do not work or if they are not able to take the pills because of certain medical conditions or other medications they are taking? For many such guys, a reasonable next step has been to try penile injections. But how do these injections work? What exactly is involved with administering them? Do they hurt? What kind of risks and side effects are involved? And, of course, do they actually work? To answer these questions and many more, we turned to a true expert.

This Episode's Guest:
Dr. Arthur Burnett

Dr. Arthur Burnett is a professor of urology at the Johns Hopkins School of Medicine. Dr. Burnett is the director of the Male Consultation Clinic at Johns Hopkins Hospital, a clinician-scientist at the James Buchanan Brady Urological Institute, and director of the Basic Science Laboratory in Neurourology at the Johns Hopkins School of Medicine. Dr. Burnett received his undergraduate degree in biology from Princeton University and his medical degree at the Johns Hopkins University School of Medicine. He completed his internship and residency in surgery, and subsequently residency and fellowship in urology at The Johns Hopkins Hospital. Upon completion of his urology residency, he received an American Foundation of Urologic Disease New Investigator Award to continue research work into the regulatory mechanisms of penile erection. He has maintained an active laboratory in neurourology since that time. Dr. Burnett is recognized for being a world-authority in the science and medicine of erectile dysfunction. He contributed original discoveries of the nitric oxide biochemical mechanisms in erectile tissue, which paved the way for the clinical development of oral medications to treat erectile dysfunction such as Viagra. Dr. Burnett has written more than 150 original peer-reviewed articles, along with numerous additional articles, editorials, and book chapters, relating to his biomedical research and clinical activities. He is also the author of a brand new book entitled The Manhood Rx: Every Man’s Guide to Improving Sexual Health and Overall Wellness.

Using Penile Injections to Treat Erectile Dysfunction Transcript:

Better Man Clinics

How do penile injections actually work?  How does the medicine injected into the penis actually cause an erection?

Arthur Burnett, MD

Well, I might even preface by telling you how injections even got started. You may recall that perhaps in the early 1980s, at one of the American Urological Association meetings, this idea of intracavernosal pharmacotherapy or penile injections was introduced by a British pharmacologist by the name of Giles Brindley, who actually gave a lecture to an audience of several hundred people. He had injected himself in the penis at the beginning of his lecture with agents that he had learned while studying this field of medicine that had what we call vasoactive properties, that is, blood flow effects. He actually self-injected, and what could make a more significant impact at a lecture than actually doing a demonstration? Show and tell, if you will. He actually had self-injected and beneath his more or less stretchy pants or sweat pants, he actually walked off the stage, walked through the aisles, pulling his pants down, and the audience got a real view of what an erection looked like. If you have to give a lecture, you know that’s probably one of the most tense moments ever for anybody in front of an audience. So,with all that adrenaline rushing, you would think nobody would need an erection there. Well, he had one. And it was a great demonstration of how this would work. This introduced or almost inaugurated the field of pharmacology and sexual medicine. And we learned how drugs could work by an injection with a needle into the side of the penis, where you’re delivering a medication that has effects on erections.   Through this, we have come to better understand the science of erections and how drugs work, and what the mechanisms of penile erection are.

Better Man Clinics

Yeah, I’m not sure that demonstration would have gone as well today as it did back then. But you know, there’s a time and a place for everything, I guess. Right? But that sounds pretty amazing. Now, you mentioned that these medications allow blood flow to enter the penis. How does that actually work? Do the injected medications cause the blood vessels in the penis to open up? What would cause a penis that otherwise can’t get an erection to now get one with this medicine?

Arthur Burnett, MD

Absolutely. Well, you know that was the amazing thing. Back in the 80s or so, in the world of Sexual Medicine, we were still debating what really made erections work. And I think we only really came to understand the science of erections around that timeline. At that time, there were debates as to whether there was something that was making the blood vessels in the penis to tighten up, which sounds intuitive, because to get erections you’ve got to get hard. But really, the story of the erection process that we learned was that blood vessels that feed into the penis are relatively tightened when we’re in a flaccid state, and the blood vessels have to open up or vasodilate to cause an erection.  There is a mechanism for how that works, with chemicals released from nerve endings, and some other chemicals that can get into the penis, now replicated by drugs that make the blood vessels open up, feed the penis blood, create a kind of an engorgement effect, and cause the penis to swell and that’s what erection is to a certain finite extent. And when it really swells to that maximum extent, that creates the hardness of erection. The cause of that swelling is blood vessels in the penis opening up.

Better Man Clinics

We had mentioned that some men for whom Viagra doesn’t work can try the penile injections. Is the mechanism pretty similar for pills like Viagra as for the injections? Are the injections just stronger because they’re injected directly in the penis versus the pills that have to go through your whole system after being ingested?

Arthur Burnett, MD

Terrific thought. You know, the evolution of therapy along the line of drugs, as you can tell, went with the oral therapy that came after injections. And the idea about the oral therapy was how can you take something by mouth that can then somehow find its way to the penis. Well, there’s a real science behind the so-called phosphodiesterase type 5 inhibitors. And there’s a mechanism there that takes advantage of what we understand about some of the chemicals that seem to be very uniquely active in the penile area. But injections give us a greater range of drugs that can exploit various mechanisms that can bring about the vasodilation of the blood vessels even more effectively than oral therapies may afford. Oral therapies work, but as you mentioned, not for everybody, and the injections may actually bring forward a couple of different options that take advantage of other mechanisms that oral therapies can’t offer.

Better Man Clinics

What are the different types of injectable medications that can be used as part of penile injections and how are they different?

Arthur Burnett, MD

There are several ways that the blood vessels can vasodilate. Therefore, we can take advantage of that understanding that a drug may target one mechanism and another drug may target another mechanism and another drug may target another mechanism. Injections can include a single form or mechanism of therapy (we call that monotherapy) or we can combine various mechanisms to even have a more potent effect. For monotherapy, there is one drug we commonly use called alprostadil or prostaglandin E1 that typically is our first-line injectable drug. But if a combination is used (two drugs together) that’s called Bimix, three drugs together it’s called Trimix. So, there are these backup agents that work through other mechanisms: the other drugs are phentolamine, which works by a mechanism of also making the blood vessel open up, and papaverine, which is another one. And again, for the audience, I’m not going to have  you memorize all these drugs, but just understand that from a high-level view, there are different drugs we use that work in different biological mechanisms that can bring about the effect that we can elect to start with, depending on the desired effect.

Better Man Clinics

If we’re talking about efficacy, the monotherapy, which is usually PGE1 prostaglandin, is kind of like the entry-level medication, and then you go up one level with Bimix.  Trimix is even more effective or stronger, kind of as you work your way up the ladder there, right?

Arthur Burnett, MD

Yes, as needed. And that’s an important message I give, because as we implement therapy, what I commonly hear from my patients is whether there is just one drug dose. And I say, no, it’s a matter of really understanding the extent of the dysfunction that may vary between individuals. Some men may just need just a whiff of medication, some may need the full, maximal strength.  We establish what drug works to achieve an erection response that is usable, but is not going to be excessive. And that’s key. So it’s a matter of really evaluating each man’s need, and then determining the right dosage.

Better Man Clinics

A lot of guys will say, “Ah, I’ll maybe borrow my buddy’s injection. He’ll teach me how to do it and I’ll just give it a try. Give it a test drive before I go to my doctors to make sure it works.” But as you’re explaining here, it’s not one size fits all.  On one dimension, you have to figure out what medication or combination of medications you’re using, and on another dimension, you have to figure out what dosage of that combination you’re using. So, it can be a little complicated. So, it definitely sounds like you should be under a physician’s guidance when you’re doing this type of titration of penile injections, or working on the right combination and dosage. Is that correct?

Arthur Burnett, MD

Absolutely. Our strategy is to really use the initial lower dose, maybe just the monotherapy, maybe with a test injection even in the office, maybe just to make sure that the patient can be safe about it, understand the technique, then also evaluate the patient’s response. Those are three things I check for. And then, if necessary, titrate upwards – go to Bimix or Trimix if we know that the monotherapy injection just produces a weaker erection response. And we know that patient needs to have something firmer to be able to be active in the bedroom. But then we can adjust them to the other higher combinations if needed.

Better Man Clinics

Are penile injections (and the medications used for these injections) considered FDA approved or are they still considered experimental?

Arthur Burnett, MD

Well, good point. That’s a loaded question. In medicine, there are situations where there are drugs that are not necessarily FDA approved, but they’re used for other indications. So, we know they’re safe drugs. For the indication of treating erectile dysfunction, the only real agent that’s been approved to my knowledge is prostaglandin E1 or alprostadil. So using the other ones are what we call off-label, but under supervision and proper dosing, the guidelines have allowed us Urologists to use these other medications within our specialty, either as Bimix or Trimix, understanding that they just have not been brought forward, maybe by a manufacturer, to just go through their ideal approval processes to be FDA approved. But nonetheless, that does not mean that they’re experimental. These drugs have been in use now as you may gather for 30-plus years. And we have very good literature support for their use. They have been reported on in clinical studies, and I think we have good wisdom about how to go about using them.

Better Man Clinics

Can penile injections be used as a first-line therapy to treat erectile dysfunction or do oral medications need to be tried first?

Arthur Burnett, MD

The  American Urological Association(AUA) had commissioned a guideline panel about this for which I was the chairman, and we published a report about four or five years ago now. And we kind of reframed the thinking about this because there was thinking in prior years that each man had to kind of start with the least invasive, perhaps the simplest thing to use, and then work his way up the scale to more invasive, perhaps more intensive, or challenging interventions. We came to realize that we can individualize care better, and not just be so simplistic. Rather, if a man presents with a more significant form of erectile dysfunction, such as a diabetic, or a man who may have had a prior pelvic surgery like a radical prostatectomy for prostate cancer treatment, or radiation, where we know that his erections are really almost non-existent, rather than have that man be frustrated perhaps with the oral medications that have been demonstrated to have limited efficacy there, maybe we can kind of move forward and say, “Okay, Mr. Jones, we may be more effective for you to find a therapy that really addresses your degree of erectile dysfunction.” And if that’s so, maybe injections offer that opportunity. So yes, I think we’re modifying our process of how we go about the administration of treatments, understanding the man’s understanding of the risks and benefits of the different treatments, understanding his preferences, understanding his disease presentation, and helping counsel that man to find the most effective therapy given his condition. That’s kind of the new approach to managing erectile dysfunction with these therapies.

Better Man Clinics

Are there any reasons why men may not be able to use penile injections to treat erectile dysfunction?

Arthur Burnett, MD

We had formerly thought that any man on blood thinners should not be doing injections. That was a big no-no. Patients who may have had a risk to get prolonged erections, or priapism, this may also be a relative contraindication. MAO inhibitors have been listed there- some of these agents that are used in various ways for other psychosocial effects. But I think simply said, with these medications, we’ve kind of almost reconditioned our thinking over time. I think under supervision, all of these may not necessarily be true contraindications. In my practice, realizing what we have for therapies if a man’s not responding to oral therapy, so therefore, that less invasive option is not going to work, he’s not interested in doing surgery, which, as you mentioned before, is much more invasive and irreversible, you can’t go back. So, within their limited options, I think just under careful supervision, maybe in-office testing, very careful description of dosing, and monitoring patients, these other considerations that were thought to be complete contraindications are no longer necessarily contraindications.

Better Man Clinics

How is a penile injection performed to treat erectile dysfunction?  First of all, is this something that a guy can do on his own or does he need to have a partner do it? Or, is it something that’s done in the office and then it works for them once a month? Like what are the actual logistics of penile injections for guys?

Arthur Burnett, MD

Absolutely. The concept here is that this is a treatment for erectile dysfunction, not really a cure. Our understanding to date is that it’s not really rejuvenating or curing the diseased penis. It’s really an on-demand treatment that is applied to create an erection effect, meaning you have to do the treatment in anticipation of getting an erection and then being able to use that erection for sexual activity. With that concept in mind, it stands to reason that a patient needs to learn how to do this, either himself or with his partner. Once taught, they can apply this at home, knowing that the injection response occurs within minutes. It’s not an injection we do in the office expecting you to go home 45 minutes or an hour later with the erection still there. We only want the erection to last for about an hour. So you really want to do it in a timely way. Therefore, patient training along with basic education surrounding it and training to actually carry out the injection process is required. It can be done by the patient or a partner. But in any case, they need to know that it’s momentary, or at least for that episode. If you want another erection, it’s going to be another time you have to inject.

Better Man Clinics

Where are penile injections actually injected in terms of the penis?  Is the medicine injected through the head of the penis? Is it injected on the side? Just to give people context, where is that injection actually applied?

Arthur Burnett, MD

The injection is done toward the base of the penis, off to the side. Not at the head of the penis, which may be a much more sensitive area. It’s an injection with really a diabetic needle, which is only about a third of an inch long, a very slender needle. It’s done very smoothly and safely. We inject the medication, withdraw the needle, hold that area just momentarily for a second or two, and then the erection should come about within a few minutes. So really, it’s a fairly straightforward process. It’s done in an area that can be handled.

Better Man Clinics

Approximately – I know it varies from person to person – but approximately how much actual medication are you injecting? Is this a large volume that you have to inject into the penis? What are we talking about in terms of amount?

Arthur Burnett, MD

Really, it’s a very minimal amount. It’s like a couple of medicine dropper amounts of fluid, if you can picture that. It’s really just a small amount of medication. Then you withdraw the needle, and that’s about it. The medication takes effect.

Better Man Clinics

After a penile injection, does the erection feel like a natural erection? Or does it feel artificial because of this medicine working inside the penis?

Arthur Burnett, MD

The observation I’ve had and patient responses that have been communicated really resemble a natural erection. In point of fact, that’s just what the injectable does. It’s a pharmacological effect, a drug effect that really resembles the chemicals our bodies are making. Now that we’ve understood the science of erections, it creates an erection effect that really resembles the natural erection altogether. So that’s the beauty of it – it doesn’t seem too artificial in how it’s produced. Yes, it’s a challenging thing to deliver in terms of the therapy, but the actual responses are very natural-looking erections.

Better Man Clinics

What potential side effects or risks can we anticipate in guys using penile injections to treat erectile dysfunction?

Arthur Burnett, MD

There are potential risks. Again, this gets back to understanding the balance of risk and benefit. The risks of the actual treatment can be side effects of penile injury. Principally, that can take the form of causing a bruising effect or some scarring in the penis with injections that are done over time in a repeated fashion over some months and years. A person having sexual activity may have to reinject, and in some cases, it can cause welts and scarring. The other risk that we certainly think is one to be very much aware of is having an excessive effect, where the erection is prolonged. We use this word priapism.  Now, how often do these things occur? The bruising effect, I think, is likely to be uncommon if the technique is done well. If it occurs gently, it’s a bruise. You’ll see kind of a purplish discoloration almost beneath the skin, maybe a little swelling. Generally, that’ll just heal and be fine. But again, I think it’s a function of how well the technique of doing injections is done. If that’s done well, those are very uncommon events. As far as scarring in the penis, that is also relatively uncommon. It may relate to how frequently a man injects. It may also relate to just different men having a tendency to develop scarring, but it may still be in the order of less than 5% at most, maybe even in the 1 to 2% range of developing a kind of thickening effect or some scarring effects in the penis.  The other big risk that I think we’ll just refer back to is priapism. I think this is also largely preventable with counseling, demonstrations in the office, and proper dosing. Patients need to be educated well that if an erection does last excessively long – and we see the ads out there with oral therapy that if you have an erection longer than four hours, go to the emergency room – the same sort of thing applies here. In-office testing may help guide a man to have an erection that’s firm but goes up and down within an hour. If we have an erection as long as four hours or even longer, we have conventionally thought that there may be an issue of lack of circulation within the penile tissue with this more prolonged erection time. This can cause not only pain in the penile area but tissue damage from lack of circulation due to that excessive erection. All those kinds of events, priapism events, we do want to avoid. But again, I think that comes down to early demonstration on how to do this properly, proper dosing, not using excessive dosing, and so forth. So I think these are the main issues that we want patients to hear about and avoid.

Better Man Clinics

What happens when men do have go to the emergency room for an erection that last more than four hours after a penile injection? How do they get treated for that?

Arthur Burnett, MD

If that did occur, then we have within our arsenal options to reverse the drug effect. Ideally, that’s what we try to do. There may be some agents that we can locally deliver again with a tiny diabetic needle injection that can almost be an antidote for the drug effect that causes vasodilation. We want to reverse that and cause vasoconstriction or make the blood vessels go back to their flaccid state or just tighten back up. So we have drugs that can do that. But again, that may require injectables that we’d have to do with careful monitoring because some of these drugs have to be done with monitoring. They can have potential risks if they circulate within the body, so we have to be very careful with that. If we have to go one step further, sometimes we do have to do some form of drainage of the penis. I don’t want to be too graphic for the audience here, but there are ways that we actually go about drawing blood out of the penis with a penile block to numb the penis so it’s really safe and hopefully the least traumatic to the patient to get the penis back to the flaccid state. So those are our initial treatments that we try to do if we have to go that far.

Better Man Clinics

What happens if men get scarring from penile injections?

Arthur Burnett, MD

Scarring can have a whole range of effects. It could be just a minor kind of thickening effect, where the penis is otherwise largely physically intact and not really significantly deformed. Otherwise, there can actually be scarring whereby it does create a deformity effect, where the penis, with subsequent erection inductions, can show an angulation or lack of proper lengthening and expansion on a normal-looking erect penis. It can create some sort of deformity if it’s very severe scarring.  At five years with injections, I always inform patients about this risk. If they start to see or feel some scarring and thickening of the penis, we may have a thorough conversation that maybe this is a therapy that we need to pull back on or do less frequently, or even just discontinue for fear of causing more scarring. So, we have to have a conversation about that and understand whether continuing on with the therapy, as much as that may be desired, may be really inadvisable in that particular patient.

Better Man Clinics

How effective are penile injections as a treatment option for erectile dysfunction?

Arthur Burnett, MD

I think overall, the literature would bear out that more than 90% of men – maybe not 100% of them have a complete response – but really, for almost all men, we can find a good effective formula. Maybe that’s monotherapy for some men, and for other men, we have to go to Bimix or Trimix.  There may be occasional men where their erectile tissue just does not respond well to the pharmacologic drugs. Maybe there’s damage within their penile tissue from the underlying disease state that they’re dealing with, be it diabetes, cardiovascular disease, or whatever it is, such that the drugs just aren’t working.  Sometimes we may even do a combination, or we may get to where we do an injection with a constrictive ring at the base of the penis. Therefore, we can do all these other strategies to try and at least have something that a man can use to remain sexually active, rather than have to commit to a penile prosthesis. But by and large, we can say that almost all men have a likelihood of having some benefit from injection therapy.

Better Man Clinics

Something that’s often circulated around internet circles is the combination of using injections like Bimix or Trimix with pills like Viagra or Cialis. Have you heard about that? And what are your thoughts on that combination?

Arthur Burnett, MD

I’ve certainly heard that, and that almost kind of projects as, you know, why not throw everything at the penis short of surgery? The concern here is that the oral medications, so-called PDE5 inhibitors (Viagra, Cialis, Levitra), all these oral medications are really very similar to one of the injectable drugs called Caverject. If you’re using Trimix, you’re more or less already maxing out the mechanism by which these oral therapies would work.  It’s almost like if you’ve got a cup of coffee and you put a heaping spoon of sugar in there – if you put two or three more heaping spoonfuls in there, it’s not going to be a whole lot sweeter. So either you can taste it, or with that amount of sugar, you’re not going to taste it at all because maybe your taste buds are just not tasting. So really, it’s almost like a redundant treatment that’s already been maxed out with the high-level injections.  As such, oral therapies will unlikely offer anything additional to that treatment regimen.

Better Man Clinics

Does the addition of oral medications to penile injections add additional risk, like of priapism or other types of risks? Or is it just basically not doing much?

Arthur Burnett, MD

It’s more the latter – it’s just not likely to have any real true pharmacologic benefit. Which falls in line with that patient really having a poorly functioning erection mechanism – his natural tissues just aren’t responding. And if they’re not responding well to maximal injection therapy like trimix – and we’ve also even used this word “pentamix” with other strategies and drugs that may or may not coordinate much with literature offerings – then adding oral therapy, you’ve just almost maxed out what the drug effect can offer with that man’s erection composition.

Better Man Clinics

If a guy uses a penile injection and he either doesn’t get an erection or the erection is just not up to snuff, can he reinject right afterwards to try to increase the efficacy?

Arthur Burnett, MD

There’s always that consideration that you’re in the middle of a sexual situation, you want to respond well, and you’re not responding there. Why not just reinject? In my practice, I have conventionally told patients that would be something to avoid. There may be a delayed effect from the initial injection. Injecting more medication may be the equivalent of excessive dosing where you could get a prolonged erection effect. So it’s potentially risky. I have conventionally said, if it doesn’t work that day, maybe on another day, proceed with an injection and see what might happen. If there’s too much frustration, we need to have a conversation about how we make a dosage adjustment, or maybe even go from monotherapy to Bimix, try Trimix, or escalate the treatment regimen, but do it under some guidance. Just repeating the injection right away could potentially result in a prolonged erection that might be induced.

Better Man Clinics

How often could or should men be using penile injections for erectile dysfunction? Is it something they could be using a few times a day, every day, every other day? Is there a magic number?

Arthur Burnett, MD

I don’t think there is really a safe magic number. Many of us in our specialty have said injections should not occur more than once daily. Perhaps this is just a safe thing to do. Whether somebody can get away with an injection in the morning, and then maybe do something in the evening, call it another day later, if you will, could be considered because you’re on your vacation and you’re having a honeymoon and really want to get busy. Well, I can understand all that. But again, it’s just a matter of trying to be safe, trying to take precautions that you don’t possibly cause a priapism effect. So, anything within hours, I think, may still be at risk. That’s the main message to here, I think.

Better Man Clinics

Are penile injections something the body can get used to, meaning like, become almost immune to them where they need higher and higher and higher doses? And then they just stop working? Is that something that you see a lot in your practice? And if so, what would that be caused by?

Arthur Burnett, MD

Well, this concept about taking drugs repeatedly having a lack of effect, it’s almost equivalent to somebody drinking a beer every day and getting drunk, but then needing to take a six-pack. We have this term we use, tachyphylaxis, that refers to how some drugs lose effect. But I think the likely concept is really something different. I think the likely effect is just that over time, maybe over a couple of years, a man’s bodily functions and cardiovascular system may actually be changing and becoming less strong, less potent, less functional. Therefore, the erectile tissue, which is part of the cardiovascular system, which is the blood vessel system localized to the penis, may actually just be evolving, be it from an underlying disease state or what have you. And therefore, the responsiveness to the therapy is becoming diminished. So more than likely, that’s the explanation that’s in play.

Better Man Clinics

Somebody goes to the doctor, they are prescribed Viagra, they go to the pharmacy, they have it on the shelf, they put a few pills in a bottle and you’re off to the races. Is it as simple with penile injections? Or is there more to it in terms of these injections? Are these injections sitting on the shelf? Or do they require a little bit more preparation? Is there anything special about how they’re stored because they’re in liquid form versus just pills in a bottle?

Arthur Burnett, MD

Certainly, our pharmacologic colleagues, the individuals who run the drugs, the pharmacists, and the drug shops have helped us out here. With the scientists and the pharmacists, we have tried to strategically bring forward options for our patients. The reason this becomes a topic is if it’s made up as a drug in a vial that we aspirate some fluid from and inject into the patient, there is a concern that the medication could lose its efficacy over time. It may not be quite as effective, may lose its potency, like spoiled milk in the refrigerator. So that is a concern.  There have been formulas made up of reconstituting these medications. That is, they can be kept in such a way that they’re in powder form, and you can reconstitute them almost like concentrated milk. Therefore, a patient doesn’t have to worry about the pre-made or pre-prepared solutions that can expire. These are all options. I think it does come down to really what the manufacturers can produce and what different pharmacies may have access to. I think we all have seen that this field is constantly changing with regard to manufacturers producing some of these drugs. So, it may come down to just what’s available for patients in different locations.  Historically, in the past few decades, we’ve had all these different options with the knowledge that yes, medication can expire if it’s just sitting on a shelf for a prolonged period of time. Some can have some greater duration of benefit if refrigerated. So that’s what I mentioned, I added in pharmacy recommendations. If you can’t do that, understandably some patients don’t want to keep it in a refrigerator if other family members may see what’s going on. For discreetness, the patient may elect to want to use something that they can reconstitute when needed. But that can be a little more tedious.  Along the lines of treating erectile dysfunction, many men may find that they want something more spontaneous and just not too tedious to do. But there are trade-offs in all of this. For discreetness’ sake, if it can be reconstituted, just kept in a drawer and used when needed, that would be an ideal option for some patients.

Better Man Clinics

What happens if, despite all our best efforts, the penile injections just don’t work? In your practice, what’s your next tool or your next arrow in your quiver, if you will, for men who’ve tried pills, they’ve tried injections, both haven’t worked? Is there anything else we can do outside of surgery at that point?

Arthur Burnett, MD

Well, certainly, we touched on this a little bit. Some men can do injections maybe with a constriction band. Again, this is within the range of intermediate therapy without having to go to surgery. These are strategies that can be used here. I know that there are some other therapies out there that maybe your audience has heard about, from shockwave to platelet-rich plasma and all these sorts of things. These things remain investigative, to be frank, and whether they truly can be beneficial in many more severe forms of erectile dysfunction is really in question.  I think just what we have with our more conventional therapies, maybe combining injections with vacuum therapy or with constriction band, may be some additional strategies to consider.