In this webinar, Dr. Roger Khouri, Urologist, reviews dosing, proper injection technique, and safety, and answers all of your questions about Injection Therapy for erectile dysfunction.
In this webinar, Dr. Khouri discusses:
- Injection Medication
- Syringe and Dosing
- Injection Techniques
- Injection Demo- Q&A
ABOUT THE PRESENTER
Roger Khouri, MD is a urologist with Northwell currently seeing patients in our Hauppauge and Bay Shore offices. Dr. Khouri graduated from medical school at the University of Michigan and urology residency at the University of Texas Southwestern. He completed a Genitourinary Reconstructive Surgeons fellowship at the Cleveland Clinic.
Dr. Khouri’s area of expertise include: Buried Penis, Ejaculatory Dysfunction, Erectile Dysfunction, Genitourinary Fistulas, Low Testosterone, Neurogenic Bladder, Penile Curvature, Male Urinary Incontinence, Urinary Tract Strictures, and Urologic Trauma.
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Penile Injection Therapy: Your Complete Guide to Treating Erectile Dysfunction
If you're dealing with erectile dysfunction (ED) and pills aren't cutting it anymore, you've probably heard about penile injections. The idea might sound scary at first—injecting medication directly into your penis isn't exactly what most guys dream about. But here's the thing: injection therapy works incredibly well for many men, and it's often way less intimidating than you might think.
This guide walks you through everything you need to know about penile injection therapy, also called intracavernosal injection (ICI). We'll cover how it works, what to expect, common concerns, and practical tips to make the process easier.
What Is Penile Injection Therapy?
Penile injection therapy involves injecting medication directly into the shaft of your penis to create an erection. The medication works by opening up blood vessels in your penis, allowing blood to flow in and create a firm erection that lasts long enough for sexual activity.
The most common medications used are combinations called tri-mix or quad-mix. These contain drugs that specifically target the smooth muscle and blood vessels in your penis. The medication starts working within just a couple of minutes—no waiting around like with Viagra or Cialis.
How Effective Is Injection Therapy?
Injection therapy is extremely effective, even for men who haven't had success with oral medications like sildenafil (Viagra) or tadalafil (Cialis). Many urologists consider it one of the best non-surgical options for treating ED.
The injections work regardless of what's causing your erectile dysfunction—whether it's poor blood flow, nerve damage, psychological factors, or a combination of issues. That's why doctors often recommend trying injections before considering more invasive options like penile implants.
Understanding Erectile Dysfunction and Treatment Options
Before we dive deeper into injection therapy, it's helpful to understand where this treatment fits in the bigger picture of ED care.
Who Develops Erectile Dysfunction?
ED becomes more common as men get older. By age 50, roughly half of all men experience some degree of erectile dysfunction. However, if you're a healthy guy in your late 30s who doesn't smoke or drink heavily and you're already having severe ED that doesn't respond to pills, that's pretty uncommon. It's definitely worth seeing a urologist to figure out what's going on.
Treatment Options Beyond Pills
When oral medications stop working or aren't effective enough, you have several options:
- Penile injection therapy (what we're discussing here)
- Intraurethral suppositories (medication inserted into the urethra)
- Vacuum erection devices (mechanical pumps with constriction rings)
- Penile implants (surgical devices placed inside the penis)
Most doctors recommend trying injections before moving to surgery because injections are reversible, effective, and relatively simple once you get the hang of them.
Overcoming the Fear of Self-Injection
Let's address the elephant in the room: sticking a needle in your penis sounds terrifying. Many men refuse to even consider this option when their doctor first mentions it. That's completely normal and understandable.
The Psychological Barrier
The hardest part is psychological—the idea of injecting yourself every time you want to have sex. The actual pain from the injection? Most men report it's minimal or even painless. The needles used are incredibly small, much thinner than what you'd see at a typical doctor's visit.
Trying It for the First Time
If you're nervous, ask your doctor to do a test injection in the office. This lets you experience exactly what it feels like in a controlled environment. If it's truly unbearable, you never have to do it again. But most guys who try it are surprised by how manageable it actually is.
Think of it this way: if this doesn't work, your next option is likely a penile implant surgery. Trying a simple injection first makes a lot of sense.
How the Injection Process Works
Understanding exactly what happens during an injection can help reduce anxiety and improve your technique.
The Anatomy Involved
Your penis contains two cylindrical chambers called the corpora cavernosa. These chambers run along the length of your shaft and fill with blood during an erection. When you inject medication into one side of your penis, it quickly spreads to both chambers because they share a wall with small openings called fenestrations.
This means you only need to inject on one side—the medication automatically reaches both chambers within seconds.
The Injection Site
You'll inject into the shaft of your penis, roughly in the middle portion. Think of your penis like a clock face when looking down at it. The safe injection zones are at the 10 o'clock and 2 o'clock positions. Never inject at the top (12 o'clock) or bottom (6 o'clock) where major blood vessels and nerves run.
If you're uncircumcised, you don't need to pull back your foreskin. The foreskin only covers the head of your penis, and you're injecting into the shaft, so it doesn't interfere.
Timing and Technique
The injection takes effect within a couple of minutes. Unlike oral medications where you need to wait 30-60 minutes and still need sexual stimulation, these injections work automatically. You'll get an erection whether you're thinking about sex or talking about the weather.
You can inject while sitting, standing, or lying down—whatever feels most comfortable and allows you to see what you're doing. There's no medical reason one position works better than another.
Understanding Tri-Mix and Quad-Mix Medications
The medications used in injection therapy are specially compounded formulations designed to maximize blood flow to your penis while minimizing side effects.
What's in the Mix?
Tri-mix typically contains three medications:
- Alprostadil (also called prostaglandin E1)
- Papaverine
- Phentolamine
Quad-mix includes a fourth medication:
- Atropine (added to help men who need extra help beyond tri-mix)
All of these medications work by relaxing the smooth muscle in your penis and opening up blood vessels. They each work through slightly different mechanisms, which is why the combination is more effective than any single drug alone.
Adjusting Your Dose
Finding the right dose is crucial. Your doctor will start you on a low dose and gradually increase it until you find the amount that gives you a reliable erection that lasts long enough for sexual activity but not so long that it becomes a problem.
When adjusting doses, you can either increase the concentration of medication or increase the volume you inject. Generally, increasing the volume is safer because it's easier to measure precisely. Even at the highest volume (1 milliliter), you won't feel any discomfort from the liquid itself.
Managing Side Effects and Complications
Like any medical treatment, penile injections come with potential side effects. Knowing what to watch for helps you use them safely.
Injection Site Pain
Some men experience pain at the injection site, though most report minimal discomfort. If you do have pain, try these approaches:
- Apply ice to the area before and after injection
- Take ibuprofen about 30 minutes before you plan to inject
- Use topical numbing cream (like lidocaine cream) on the injection site
Remember, you only want to numb the injection site, not your entire penis. You still need to feel sensation during sex.
Bleeding and Bruising
A small amount of bleeding after injection is normal. Here's how to handle it:
- Apply firm, direct pressure to the injection site for at least 30 seconds
- If bleeding continues, hold pressure for a full 5 minutes without checking
- If you're on blood thinners, you'll need to apply pressure longer and firmer
- Bruising can happen but usually resolves on its own within a week
Being on blood thinners isn't a reason to avoid injection therapy, but it does mean you need to be more careful about applying adequate pressure after each injection.
Priapism: The Emergency You Need to Know About
Priapism is an erection that won't go down. In the context of injection therapy, we're concerned about erections lasting longer than 4 hours. This is serious but preventable and treatable.
Important facts about priapism:
- It's extremely rare when you use the proper dose
- Exercise can help bring down a prolonged erection by redirecting blood flow to your muscles
- Ice packs applied to the penis can help
- If your erection lasts 4 hours, go to the emergency room immediately
- Doctors have an "antidote" medication that quickly reverses the erection
- Waiting longer than 4 hours can cause permanent damage
Don't be embarrassed about seeking help. Emergency room doctors deal with this regularly, and treating it early prevents long-term problems. The men who end up with permanent damage are the ones who wait a day or two out of embarrassment.
Penis Shrinkage Concerns
Most men don't experience penis shrinkage from injection therapy. However, if you have Peyronie's disease (a condition causing penis curvature from scar tissue), injections could potentially worsen it. That's why doctors typically don't recommend injection therapy for men with active Peyronie's disease.
For healthy men without Peyronie's disease, the risk of developing curvature or shrinkage from injections is extremely low—less than 1% of users.
Practical Tips for Better Results
Getting the most out of injection therapy involves more than just the technical aspects of giving yourself a shot.
Why Results Vary
You might notice that the same dose doesn't always give you the same results. Several factors can affect this:
Your nervous system matters. Erections are controlled by your automatic nervous system—specifically the "rest and digest" part, not the "fight or flight" part. When you're stressed, anxious, or worried about performance, your body literally works against getting an erection. This is true whether you're using injections or not.
Your mental state affects physical performance. Just like you can't lift the same weight at the gym every single day, your body's response to the medication can vary slightly. Fatigue, stress, relationship issues, work pressure—all of these can influence how well the injection works.
Solutions to consider:
- If inconsistency is a problem, you may need to slightly increase your dose
- Consider using a penile ring at the base to help maintain the erection
- Address sources of stress or anxiety in your life
- Talk openly with your partner about any performance worries
The Role of Alcohol
Having a drink or two before sex isn't a problem and won't interfere with the injections. In fact, some men find that moderate alcohol consumption (one or two drinks) helps them relax and reduces performance anxiety.
However, heavy drinking can prevent you from getting an erection even with the injection. If you're intoxicated enough to have trouble handling a needle safely, you've had too much to drink for the injection to work effectively anyway.
Frequency Guidelines
- Wait at least 24 hours between injections
- Don't use injections more than 3-4 times per week
- Never inject twice in the same day
These guidelines help prevent scar tissue buildup and reduce the risk of complications.
Injection Therapy with Other Health Conditions
Many men have other health issues that raise questions about whether injection therapy is safe or effective for them.
High Blood Pressure
Having high blood pressure doesn't prevent you from using injection therapy. The medications used in penile injections do have a blood pressure-lowering effect, but it's mostly localized to your penis. They don't significantly affect your overall blood pressure.
Continue taking your blood pressure medications as prescribed. The two treatments work fine together.
Benign Prostatic Hyperplasia (BPH)
BPH and erectile dysfunction are separate conditions, so treating one doesn't directly affect the other. However, some BPH medications can impact sexual function:
Tamsulosin (Flomax): This common BPH medication won't affect your erections, but it typically causes retrograde ejaculation. This means when you orgasm, the semen goes backward into your bladder instead of coming out. It feels the same, but nothing comes out. This isn't dangerous unless you're trying to conceive.
Finasteride (Proscar): This medication shrinks the prostate but can decrease libido and erectile function in some men. If you notice these side effects, talk to your doctor about alternatives.
Tadalafil (Cialis): The daily low-dose version (5mg) treats both ED and BPH symptoms. Many men find this medication helps with both problems.
You can safely use injection therapy while taking BPH medications.
Blood Thinners
Being on blood thinners like warfarin, apixaban, or aspirin doesn't prevent you from using penile injections. You just need to take extra care:
- Apply firm pressure to the injection site for longer (5 minutes instead of 30 seconds)
- Expect slightly more bruising than someone not on blood thinners
- Report excessive bleeding to your doctor
Blood thinners aren't a contraindication—millions of men safely use both.
Venous Leak
A venous leak means blood flows out of your penis too quickly, preventing you from maintaining an erection. Injection therapy might help because the medications increase blood flow into the penis, which can sometimes compensate for the faster outflow.
However, if injections don't work even at maximum doses, they won't suddenly start working just because you've been diagnosed with a venous leak. At that point, a penile implant becomes the most reliable solution.
Penile rings worn at the base of the penis can help trap blood inside and may improve results for men with venous leak, though they're not highly effective on their own.
Special Situations and Questions
Can You Use Injections After a Failed Penile Implant?
Unfortunately, no. Penile implants are placed inside the corpora cavernosa and compress the natural erectile tissue. Once an implant is removed, that tissue is damaged and can't function on its own anymore.
This is exactly why doctors encourage men to try injections before moving to an implant. You can always go from injections to an implant, but you can't go backward.
If you've had implant failures, you'll likely need another implant. Seek out a reconstructive urologist or a high-volume implant surgeon for these complex revision cases, not just any general urologist.
Intraurethral Suppositories vs. Injections
Some men ask about intraurethral suppositories (medication inserted into the opening of the penis) as an alternative to injections. The honest truth: most doctors don't recommend them because:
- They're generally less effective than injections
- They cause significant burning and pain in many men
- The side effects often outweigh the benefits
If the idea of injections is absolutely impossible for you, you could try intraurethral suppositories, but keep your expectations modest.
Using Injections After Stopping
If you took a break from injection therapy and want to restart, you'll likely need to see your doctor again, especially if you're seeing a new urologist. They'll want to evaluate you at least once before prescribing medication, both to confirm the appropriate dose and to ensure there haven't been any changes to your health.
If you're returning to the same doctor who originally prescribed your injections, a quick phone call might be enough to get you restarted, though many doctors still prefer a brief office visit.
Practical Injection Technique Questions
Dealing with Needle Bending
Needle bending is extremely unusual. The needles used for penile injections are very short and sturdy. If you're experiencing bent needles, consider:
- Make sure you're inserting the needle perpendicular (at a 90-degree angle) to your skin
- Don't twist or angle the needle during insertion
- Check the needle before insertion to ensure it's straight
- Use a device like the "Auto-Injector" which helps guide the needle straight in
If you're bending needles when drawing medication from the vial, slow down and insert the needle straight into the rubber stopper. Once a needle is bent, throw it away and use a fresh one. Never try to straighten a bent needle.
Visibility Issues
If your belly makes it hard to see your penis when injecting, try these approaches:
- Use a wall mirror positioned to give you a clear view
- Lie down so gravity pulls your belly away from your injection site
- Use touch and feeling to locate the correct spot (pinch the injection site with your free hand, then guide the needle to that spot)
- Ask your partner to help with the injection
Many men successfully inject by feel alone once they're familiar with the process.
Better Results on One Side
While it's possible to have better results injecting one side of your penis versus the other, it's uncommon. This might happen if you have scar tissue or Peyronie's disease affecting one side.
Since the medication spreads to both corpora cavernosa within seconds, there's no anatomical reason one side should work dramatically better than the other. But if you find one spot that consistently works well, stick with that spot.
Working with Your Doctor
Injection therapy requires ongoing medical supervision, though the level of involvement decreases once you've established a routine.
Initial Visits and Training
Your first appointment will include:
- Discussion of your ED history and what treatments you've tried
- Physical examination
- Test injection in the office so you can experience it firsthand
- Training on proper technique
- Prescription for home use
Most of this can happen in a single 20-30 minute appointment.
Follow-Up Care
After you start using injections at home, your doctor will want to check in periodically:
- Initial follow-up within a few weeks to ensure the dose is right
- Periodic check-ins to refill prescriptions (often via phone)
- Annual or semi-annual in-person visits
Once you've found a dose that works well and you're comfortable with the process, you might only need brief phone consultations before refills. However, your doctor won't just prescribe indefinitely without any contact—they need to know the treatment is working safely.
When to Contact Your Doctor
Reach out if you experience:
- An erection lasting longer than 4 hours (this is an emergency)
- Excessive pain during or after injection
- Significant bruising that doesn't resolve
- The medication stops working at your current dose
- Any concerning changes in your penis appearance
The Psychological Side of Erections
Understanding the mental component of erections helps you get better results from injection therapy.
Fight or Flight vs. Rest and Digest
Your erection system is wired into your automatic nervous system—the same system that controls breathing, digestion, and heart rate without you thinking about it. Specifically, erections are part of the "rest and digest" mode, not the "fight or flight" mode.
Think about it from an evolutionary perspective: if your ancestor encountered a dangerous animal, getting an erection would be a terrible survival strategy. Your brain evolved to shut down erections during any stressful or threatening situation.
Modern Performance Anxiety
Today, you're not running from bears, but your brain still responds to stress the same way. Performance anxiety, relationship stress, work pressure, and worry about erectile function all trigger that same "shut it down" response.
Even with injection therapy, stress and anxiety can interfere with getting optimal results. The medication helps by bypassing some of these signals, but you'll get better results when you:
- Communicate openly with your partner
- Address relationship issues that create bedroom stress
- Manage work-related anxiety
- Focus on pleasure rather than performance
Erectile Dysfunction in Younger Men
If you're in your late 30s or early 40s with severe ED that doesn't respond to pills, and you don't have obvious health problems, there's often a significant psychological component. This doesn't mean it's "all in your head"—psychological factors create real physical changes in blood flow and nerve signals.
A urologist can help determine if there are physical causes, but addressing stress, anxiety, and relationship dynamics often improves outcomes alongside physical treatments.
The Next Steps in Your ED Journey
If Injections Don't Work
If you've tried injection therapy at maximum safe doses and it's not effective, your remaining options include:
Vacuum erection devices: These mechanical pumps create erections by drawing blood into the penis. A constriction ring at the base traps the blood. Some men find these effective, though they can be awkward to use during intimate moments.
Penile implants: These surgically implanted devices are the most reliable treatment for ED. The most common type is the inflatable penile implant, which includes cylinders placed in the penis and a small pump placed in the scrotum. When you want an erection, you squeeze the pump to transfer fluid into the cylinders.
Penile implants have very high satisfaction rates—over 90% of men and their partners report satisfaction. However, they're permanent and irreversible, which is why doctors recommend exhausting other options first.
If Injections Do Work
For many men, injection therapy provides reliable, satisfying erections for years. Keys to long-term success:
- Follow dosing and frequency guidelines to prevent complications
- Keep regular appointments with your urologist
- Store medication properly according to instructions
- Maintain good injection technique
- Address any issues promptly rather than waiting
Final Thoughts
Penile injection therapy isn't the first choice for treating ED, but for many men whose oral medications have stopped working, it's a game-changer. Yes, the idea of injecting your penis sounds intimidating, but the reality is much less scary than most men imagine.
The needles are tiny, the pain is minimal for most guys, and the results are reliable. Within minutes, you have an erection that lasts long enough for satisfying sexual activity. You're not dependent on perfect timing or ongoing sexual stimulation like with pills.
If you're dealing with ED and pills aren't cutting it anymore, talk to your urologist about injection therapy. Many offices will do a test injection during your visit so you can experience exactly what it's like. You might be surprised by how manageable—and effective—this treatment really is.
Take Action: Talk to Your Doctor
Don't let erectile dysfunction control your sex life and your confidence. If oral medications aren't working for you, penile injection therapy might be exactly what you need to get back to enjoying intimacy with your partner.
Your next steps:
- Schedule an appointment with a urologist if you haven't already. They can evaluate your specific situation and determine if injection therapy is appropriate for you.
- Be honest about your concerns. If the idea of injecting yourself worries you, tell your doctor. They can address your specific fears and might offer a test injection in the office.
- Bring your partner to appointments if possible. Injection therapy works better when your partner understands the process and can offer support.
- Give it a fair try. Even if the first injection isn't perfect, work with your doctor to adjust the dose and technique. Most men find their stride within the first few attempts.
- Ask questions. Your urologist has heard every concern and question before. There's nothing too embarrassing or unusual to ask about.
Remember, you have options. Erectile dysfunction doesn't mean the end of your sex life—it just means finding the right treatment approach for you.
Scientific References
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Medical Disclaimer: This article is for informational purposes only and does not constitute medical advice. Penile injection therapy should only be used under the supervision of a qualified healthcare provider. Always consult with your urologist before starting, stopping, or changing any treatment for erectile dysfunction. If you experience an erection lasting longer than 4 hours, seek emergency medical attention immediately.
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