Question:
I am new here, and will appreciate any help I can get to revealing an
embarrassing problem-- impotence-- which I guess everybody here is dealing
with. So I will start with my question / concern and then present some
background should it be helpful or useful in answering:
Should I see a urologist, and is that generally more productive than a
general physician and howso? Suggestions / ideas to treat anxiety related
impotence? What are my options on the market as far as medication (I
thought I heard there was some new fast-acting sublingual viagra coming
out)?
I am a 44 year old male. ~9 yrs ago I had my testosterone levels checked by
my Primary Care Physician/cClinic and the testosterone was in the LOW range
of normal. That concerned me, as I have had problems with impotence in
sexual situations (certainly anxiety is part of the problem, but since I am
no longer 20 years old how to cure the viscious cycle without some help for
getting erections during the all too infrequent opportunities). I also went
to counseling to discuss the anxiety issues and impotence. I got a
prescription for the equivalent of caverject, which worked great a couple of
times, but it always seemed to be tricky to use-- sometimes it worked,
sometimes it just caused a hell of a sting in my penis and no erection.
I have tried Viagra, though without having a partner, and it seems to work,
though the timing seems tricky, and I worry if it will come through for me
when I do have a willing sexual partner, or if the anxiety will overpower
the Viagra effects-- so should I combine it with something else like
caverject?
I can have erections during masturbation (unless I overdo it, or am really
tired) and the early morning rise, so I know is not so much physiological,
though it is harder of course being 44; the spontaneous arousal with a woman
is just not so easy.
I have only slept with four women, and I was a virgin until age ~35. I have
only had sex with two women, one using caverject type injection, the other
(and last one) did happen naturally; but since then I have had a couple of
opportunities, like a few months ago when I had a babe (28 yo) in my car and
she said to pull over into a side road at night, and she proceeded to take
down her pants-- then wanted me to 'fuck her' -- I did not have an erection,
not that I did not want to. I just had the anxiety, and the situation was
not what I wanted (I wanted to be in bed with her and have slower arousal,
and I am also 6'4" and the small car just created logistical problems with
bodies getting together). A couple of othe times years ago I had
opportunities but was so bombed on alcohol I know that the alcohol was
contributing greatly to the impotence.
I am so frustrated at not 'getting any' I am ready to use some viagra and
caverject and hire an Escort or two to get some anxiety release and
experience. SOme might say this is unholy and sinful and I would agree, but
I do not know any other way to work at getting rid of the anxiety related
impotence other than combine meds with a sex professional (escort) who will
work with me.
Answer:
That would be great if you can get an Rx for several Caverjects and pay only
one copay.
That's how I do with AndroGel. My Rx is for 10 G/dy....that's two boxes and
my copay is $25....the same as I my Rx was for 5 G/dy.
This is probably more than you want to know about Trimix...but I like giving
comprehensive information...you can skip over what's of uninterested to you.
Trimix = mixture of Papaverine, Regitine and Prostaglandin E in varying
proportions, my Trimix Rx is Pap 150/phen 5/PG 50 in 7.5 ml
= Pap 20 mg/ml Phen 0.67 mg/ml PG 6.67 mcg/ml
I went thru the Powerpack site below and fished out recommended beginning
doses for Pap, Phen and PG and compare them with my Rx...recommended dosage
ranges given in ( ).
Pap 20 mg/ml (18 - 60 mg/ml)
Phen 0.67 mg/ml (0.5 - 20)
PGE1 6.67 mcg/ml* - initial dose of 2.5 mcg
* always in mcg amts instead of mg amts.
Good sites on components of trimix and approximate effective dosage levels
http://www.wmfurology.com/med_inj_rx.htm
The below is from this site
http://www.powerpak.com/CE/Pfizer-ED/lesson.cfm
"Papaverine-Papaverine (Cerespan®) is a smooth muscle relaxant that is an
alkaloid obtained synthetically or from opium. It acts on the smooth muscle
to cause inhibition of phosphodiesterase, leading to an accumulation of
cyclic adenosine monophosphate and smooth muscle cell relaxation. It
facilitates erection by relaxation of smooth muscles in the sinusoids and by
dilatation of the helicine arteries.53 The plasma half-life of papaverine is
1 to 2 hours and it is extensively metabolized in the liver. Papaverine
reaches a maximum concentration in the circulation within half an hour after
intracavernosal injection.35,53
The intracavernosal dose may vary with age and etiology of erectile
dysfunction, from 10 mg initially to a maximum of 60 mg for older patients
with vasculogenic erectile dysfunction.3 When given in combination with
phentolamine, the dose is reduced.35 The number of responders to papaverine
monotherapy is reported to be low, about 35%, compared to 65% when combined
with phentolamine.54
Patients should be monitored for prolonged erections. Prolonged erection
when papaverine is used alone is seen in up to 10% of patients.53 Local
complications such as subcutaneous hematomas and pain occur. Longer-term use
of intracavernous injections of papaverine may induce corporeal fibrosis,
corporal nodules, and plaques or fibrosis. This may be due to the acidity of
papaverine solutions (pH 3 to 4) which cannot be corrected by the use of a
buffer due to precipitation at a pH greater than 5.50.
Systemic effects include vasovagal reaction, bradycardia, hypotension,
dizziness, and facial flushing. Papaverine is potentially hepatotoxic.50 The
incidence of drug-induced hepatitis is less than 1 in 1000 in patients with
normal liver function, but may be seen in 1 of 100 patients with existing
elevated transaminase levels.
Phentolamine-Phentolamine mesylate (Regitine®) is an alpha-adrenergic
receptor blocker. By blocking sympathetic activity on smooth muscle,
phentolamine causes dilation of penile arterial vessels. Phentolamine is not
very effective for the treatment of erectile dysfunction when used as
intracavernosal injection monotherapy. It is usually given in combination
with other agents such as papaverine and alprostadil. After intracavernosal
injection, phentolamine reaches a maximum serum concentration within 30
minutes, and declines rapidly to undetectable levels.53 Phentolamine has a
short plasma half-life of 30 minutes and is extensively metabolized by the
liver. The amount of phentolamine used for intracavernosal injection
mixtures commonly varies from 0.5 to 20 mg, with a usual dose around 1 to 2
mg. Systemic adverse effects may include orthostatic hypotension and
tachycardia. These effects are reduced when used in lower-dose combinations
with other vasoactive agents.
Prostaglandin E1 or Alprostadil-Alprostadil, or PGE1, is an analogue of
arachidonic acid. Alprostadil has alpha-blocking properties in the penile
tissue which causes relaxation of the cavernous and arteriolar smooth muscle
while causing restriction of venous outflow. Alprostadil is the only
injectable medication formally approved for the treatment of erectile
dysfunction. The two products available are Caverject® (Pharmacia-Upjohn)
and Edex® (Schwarz Pharma). It can be used either as monotherapy or in lower
doses in combination with other vasoactive agents. Alprostadil that enters
systemic circulation is quickly metabolized, primarily by the lungs.35 The
plasma half-life of alprostadil is less than one minute.
The initial dose is usually 2.5 mcg. The dose is increased, if necessary, on
subsequent office visits until a satisfactory response is obtained. The goal
is to produce an erection that is satisfactory for sexual activity and is
maintained for no longer than one hour.35,50 The maximum recommended dose is
40 mcg for Edex® 55 and 60 mcg for Caverject®.56 The average therapeutic
dose is higher in older compared to younger men (21 mcg versus 12.5 mcg,
respectively).3 This is likely because of the higher prevalence of arterial
occlusive disease in older people. In a study by Garceau et al,57 the
average effective dose of alprostadil differed depending on the cause of
erectile dysfunction; in men with vascular causes, the dose averaged 19.1
mcg; psychogenic causes, 11.5 mcg; and neurogenic causes, 15.3 mcg. The
efficacy of alprostadil has been documented to be about 75% in doses between
10 to 20 mcg intracavernously, with doses as low as 2.5 to 5mcg occasionally
being effective.53 Patient and partner satisfaction after injection was
reported in up to 87% of partners.58
Using appropriate injection technique, alprostadil should produce an
erection in five to twenty minutes. It is recommended not to inject more
than three times per week and to separate each use by at least 24 hours. The
patient should been examined by a physician every 3 months during
self-injection therapy to assess treatment and to adjust the dose if
needed."
