For these men the use of prescription phosphodiesterase type 5 inhibitor (PD-5) medications like Viagra, Cialis, and Levitra—may be needed in combination with testosterone replacement. However, some men do not respond well to these oral agents or have side effects such as headaches, nasal congestion, flushing, gut problems, and, in the case of Cialis, back pain. Cialis may last longer than the others (36 hours compared to 4 hours for Viagra or Levitra), but so may its side effects. Some men take Claritin and ibuprofen with these drugs to per-treat nasal congestion and headaches, respectively. Cialis is also approved for daily use at 5 or 10 mg/day dose (regular dose is 20 mg/day).
If erectile dysfunction is not improved while on testosterone, ask your doctor about adjusting your dose of testosterone. Ensure that your total testosterone level is between 500 and 1000ng/dL. Also, have your doctor check your blood levels of estradiol; if too much testosterone is converted into this female hormone as it may cause sexual dysfunction. Low levels of thyroid hormone, infections, lack of sleep, alcohol, smoking, medications and depression also can cause erectile dysfunction in the presence of normal testosterone levels. Last but not least, lack of attraction for our sexual partner can get in the way of achieving a strong erection.
Other options for men who need an extra erectile boost while using testosterone replacement:
Yohimbine—available over-the-counter or by prescription (Yocon); increases sex organ sensitivity. It can raise blood pressure and cause insomnia and anxiety, so talk to your doctor. A small study showed that men who used Yohimbine with the amino acid arginine had better erections (read section on supplements in this book). Muse (alprostadil)—this is a prescription pellet that inserts into the penis to produce an erection. Not very popular.
Trimix or Quadmix—available by prescription from compounding pharmacies. These are mixtures of prostaglandins and papaverine that increase blood flow and retention into the penis. Prostaglandins are mediators and have a variety of strong physiological effects, such as regulating the contraction and relaxation of smooth muscle tissue.Prostaglandins are not hormones and they are not produced at one discrete site, but rather in many places throughout the human body.
Trimix is a mixture of two prostaglandins (phentolamine and alprostadil) plus papaverine (a vasodilator medication) that increase blood flow to the penis and cause strong and lasting erections, with or without sexual stimulation. These compounds appear to act together to increase arterial inflow, dilate smooth muscles, and restrict venous outflow promoting erectile rigidity with greater success and in smaller doses than if these compounds were used as single therapies. An example of a dosage combination for tri-mix is 10 micrograms of alprostadil, 500 micrograms of phentolamine and 15 mg of papaverine. Dosing of tri-mix preparations has not been standardized. Trimix is injected directly into the side of the penis through a fine-gauge “insulin-style” needle in very small amounts (0.1-0.33 cc) that increase blood flow to the penis. It results in strong and lasting erections. The main potential side effect are hematomas (bruising), fibrosis if used too frequently and on the same injection site, pain, and dangerously long-lasting erections (priaprism). Priaprism may sound great but this can literally kill your penis by causing gangrene of the tissue after stagnant blood coagulates inside it. There are a men who had to go to an emergency rooms 8 hours after having used too much Trimix and have the blood drained from their penis. To ensure perfect injection technique and dosing, it is imperative to be trained on how to dose this with the help of an urologist. Compounding pharmacies sell two types of Trimix formulations: Freeze dried (powder to be mixed later with water) or pre-mixed vials. Some men find the freeze dried form not to be as effective.
It is extremely important to remember never to use Viagra, Cialis, or Levitra before or at the same time as you use Trimix. This is a dangerous combination that can increase the risk of priaprism. Be particularly careful with Cialis since it can stay in your blood stream for a longer time.
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