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Hello, I'm Dr. Peter Bajic,
Director of the Center for Men's Health at Cleveland Clinic.
Erectile dysfunction, or ED, is a common condition
that affects many men at some point in their life.
Your healthcare provider will work with you
to identify what is causing your symptoms
and the best treatment to address them.
The most common treatments for ED include pills,
injections, a vacuum device,
and the penile implant procedure.
Penile injections are one of several options
if other treatments fail,
or for men who are unable to take ED oral medication.
Injectable medication is generally not covered by insurance
and is specially formulated by a compounding pharmacy
for maximum efficacy.
It is commonly referred to as Trimix or Bimix.
This video will show you the technique
for safe use of penile injections.
First, you'll assemble the medication and supplies
on a clean surface.
The medication comes in a glass vile
and should be stored in the refrigerator.
Lay out the syringe, two alcohol wipes, the medication vial,
and a sharps container, to dispose of syringes after use.
Wash your hands well with soap and water.
Remove the seal from the medication vial.
Open an alcohol pad
and clean the rubber stopper on top of the vial.
Don't use the vial if the fluid inside is cloudy,
has particles floating in it,
or if the rubber stopper comes off the vial.
Remove the cap from the syringe
without letting the needle touch anything.
If anything does touch it,
put it in your sharps container and use a new one.
Pull back the plunger on the empty syringe
to the dose that was instructed by your provider.
This will draw air into the syringe.
Now, inject this drawn-up air through the rubber stopper
into the vial.
Turn the vial upside down with the needle still inserted,
and pull back the plunger to the dose that was prescribed.
Keep the tip of the needle under the fluid level in the vial
to draw up the medication.
If you see air bubbles in the syringe,
you can draw up extra medication,
allowing the air bubbles to float to the top of the syringe,
and then slowly push out the air.
Look at the numbers on the side of the syringe
and be sure that you have the correct dose in the syringe
and that you see minimal or no air bubbles.
Your urology provider will instruct you which dose to use.
Remove the needle from the rubber stopper
and loosely replace the cap to keep it clean.
Set the syringe down on a clean surface.
Penile injections are most successful
when delivered while standing, if you are able to stand.
The injection should be given at a 90 degree angle
in the middle-third of the penis, not the head of the penis.
The injection site should be at either
the 10 o'clock position on the left side,
or the two o'clock position on the right side
of the penis shaft.
Each time you give yourself an injection,
alternate from left side to right side.
Do not inject straight down on the top side of the shaft
where the nerves are, or directly at the bottom of the shaft
where the urethra is.
Avoid injecting right into a large vein
because you may cause a bruise or bleeding.
Locate the correct area of the penis for the injection
and clean it with an alcohol wipe.
Let it dry before injecting.
Pick up the syringe and take the cap off.
Make sure the medication dose is right.
If you pushed out any medication,
draw up more from the vial using the same steps as before.
Hold the syringe between your thumb, index,
and middle fingers, like you would hold a pencil.
Have the needle pointing down.
If you aren't circumcised, pull your foreskin back
before grasping the head of your penis.
Stretch out your penis by grasping the head
straight out in front of you,
or to the side opposite where you plan to inject.
You can hold it with two fingers
with your hand positioned against the scrotum.
You can also extend the penis against your thigh
for greater stability.
Keep pulling on your penis
from the time the needle goes into the shaft
until it comes out.
Do not twist or rotate your penis
to avoid accidentally injecting the top or bottom surfaces.
Quickly slide the needle into the shaft of your penis.
Move your thumb to the plunger and push down
to inject the medication.
Be sure to keep the needle in place.
After injecting all the medication,
quickly pull the needle straight out.
With an alcohol pad, apply pressure on the injection site
for 2-3 minutes.
If you take a blood thinner, apply pressure for five minutes
to decrease bleeding or bruising.
Drop the syringe into your sharps container.
You don't need to recap it.
For 5-10 minutes after the injection,
you may sit, stand, walk around, or start foreplay
to keep blood flowing downward.
Don't lie on your back.
The medication typically takes 10 minutes
for benefit to occur.
The goal is to get an erection hard enough
for penetrative sex lasting no longer than one hour.
You can inject the medication up to three times a week,
but no more than once in 24 hours.
Keep a journal to help your providers
adjust the dosage as needed.
Entries should include dose injected,
hardness and duration of erection,
and any symptoms associated with the current dose,
such as burning, pain, or bruising.
Be aware of these warnings related to penile injections.
24 hours before or after the penile injection therapy,
do not take any of these medications,
Sildenafil, known as brand name Viagra,
Vardenafil, known as Levitra,
Avanafil, known as Stendra,
or Tadalafil, known as Cialis.
If the medication doesn't work,
don't give yourself another injection for at least 24 hours.
Do not go to sleep until your erection is bendable.
If your erections are lasting longer than one hour,
consider reducing your dose by 2-5 units.
If you experience an erection that is hard and not bendable,
lasting longer than two hours, take two 30 milligram tablets
of an over-the-counter pseudoephedrine HCL,
also known as Sudafed, immediate release.
Don't take extended release or long-acting tablets,
such as Sudafed 12 hour.
If your erection remains hard and not bendable
after another 30 minutes,
take two more 30 milligram tablets.
And if your erection remains rigid
for more than three total hours,
go immediately to the nearest emergency department.
Erections remaining hard for more than four hours
may result in permanent and irreversible damage to the penis
and worsened erectile dysfunction.
And if you're currently receiving chemotherapy for cancer,
ask your oncologist
when you can safely use penile injections.
If the medication is not giving you a rigid enough erection
for penetrative sex,
first be sure that you're using the correct technique
to inject the medication.
If you are, then try increasing your dose
by five units more the next time.
For example, if you started with 10 units,
wait at least 24 hours, then try 15 units.
Continue to increase the dose by five units each attempt,
until you achieve desired firmness.
Do not exceed 50 units.
Your medication concentration can also be adjusted
if you are not getting good response.
Injection therapy is not for everyone.
Some men may be unsatisfied with this treatment
due to pain or ineffectiveness,
or they might not like needles.
Several other options exist,
including the penile implant procedure,
which is an alternative to injection therapy
and is covered by most insurance plans.
If you are not satisfied with your injection treatment
and wanna discuss other options,
or if you're not yet started on a treatment for ED
and you wanna learn more, make an appointment
with our Cleveland Clinic Men's Health team.
We're here to help.
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