My trimix sucks, what strength should I have?

[Melody68]

Hey guys, I'm 69, take TRT, and have been using the Trimix prescribed by a urologist, with a formula of 20mg/1mg/25mcg, for a few months now. It works, but not that well.

After injection, I'll kinda sorta get a 6/10 erection which can then be manipulated by me to an 8/10, which isn't bad, but then softens quickly if stimulation stops. If it's me by myself, then I control the tempo and it works fine. But if I'm with my wife and things slow, or I change positions, then I begin to go soft. It's very much like Viagra behaved, that's why I wanted to try the Trimix.

I found that 10 units works the best; I've tried up to 20 units and it's no different in the critical first 30 minutes than the smaller dose, except that it hangs on longer in the post sex phase. I don't care about afterwards - all that I care about is how hard I am for the first 1/2 hour.

I'm in Canada and will have to wait months to see the urologist again. I spoke to the pharmacist - he seems to be a favourite of the urologist - and the pharm said the only stronger dose they typically carry would be 20mg/1mg/33mcg; only the last figure, the alprostadil, is different at 33mcg instead of 25mcg. Is that a big enough difference to be effective? Any suggestions as to a formula that I should try?

I'm thinking I might try Defy or one of the other online pharms - hopefully I wouldn't have to wait as long, and maybe they'll give me a stronger prescription. Thoughts? Many thanks . . .

 

[madman]

Hey guys, I'm 69, take TRT, and have been using the Trimix prescribed by a urologist, with a formula of 20mg/1mg/25mcg, for a few months now. It works, but not that well.

After injection, I'll kinda sorta get a 6/10 erection which can then be manipulated by me to an 8/10, which isn't bad, but then softens quickly if stimulation stops. If it's me by myself, then I control the tempo and it works fine. But if I'm with my wife and things slow, or I change positions, then I begin to go soft. It's very much like Viagra behaved, that's why I wanted to try the Trimix.

I found that 10 units works the best; I've tried up to 20 units and it's no different in the critical first 30 minutes than the smaller dose, except that it hangs on longer in the post sex phase. I don't care about afterwards - all that I care about is how hard I am for the first 1/2 hour.

I'm in Canada and will have to wait months to see the urologist again. I spoke to the pharmacist - he seems to be a favourite of the urologist - and the pharm said the only stronger dose they typically carry would be 20mg/1mg/33mcg; only the last figure, the alprostadil, is different at 33mcg instead of 25mcg. Is that a big enough difference to be effective? Any suggestions as to a formula that I should try?

I'm thinking I might try Defy or one of the other online pharms - hopefully I wouldn't have to wait as long, and maybe they'll give me a stronger prescription. Thoughts? Many thanks . . .

After injection, I'll kinda sorta get a 6/10 erection which can then be manipulated by me to an 8/10, which isn't bad, but then softens quickly if stimulation stops. If it's me by myself, then I control the tempo and it works fine. But if I'm with my wife and things slow, or I change positions, then I begin to go soft. It's very much like Viagra behaved, that's why I wanted to try the Trimix.


When you had your penile duplex doppler ultrasound done what was your PSV/EDV?

If you are losing your erection when changing positions this could be due to venous leak.

Some men even with the use of intracavernosal injections need to use a cock ring due to venous leak depending on the severity.




What are the signs of venous leakage?

There are 4 signs:

* first one is absence or very weak erections in the morning

* the second sign is that during self- stimulation the hardness of the erection is not very high

* the third sign is that erections are not the same whether one is lying on his back or on his belly or on one side or being seated, if erections vary according to man's position, this is highly evocative of caverno-venous leakage

* the fourth sign is that when man applies fingers at the basis of penis erections are better, fingers press on veins and reduce leakages




Penile duplex Doppler ultrasound is a key test for evaluating erectile dysfunction, particularly in the context of intracavernosal therapy. It assesses both blood flow into (arterial) and out of (venous) the penis by measuring two main parameters:

• Peak systolic velocity (PSV): Represents the maximum speed of blood entering the penis during systole.
• End-diastolic velocity (EDV): Represents the blood flow remaining during diastole (linked to venous outflow).

• Arterial inflow (PSV):
  
  • Normal: PSV > 30 cm/sec (some sources use > 25 cm/sec)
  • Borderline: PSV 25–30 cm/sec
  • Abnormal/arterial dysfunction: PSV < 25 cm/sec
  • Normal: EDV < 5 cm/sec
  • Abnormal/venous dysfunction: EDV > 5 cm/sec (suggests venous leak if arterial function is normal)

• After intracavernosal injection (such as papaverine or prostaglandin E1), a PSV ≥ 30 cm/sec and an EDV < 5 cm/sec typically indicate normal vascular response.
• Venous leak (outflow abnormality): If EDV stays > 5 cm/sec even when PSV is normal, there is insufficient veno-occlusive function and blood flows out too quickly, making erections unsustainable.
• Arterial insufficiency: If PSV fails to reach 25–30 cm/sec regardless of EDV, arterial supply is insufficient.
• Both abnormalities: Low PSV and high EDV suggest combined arterial and venous insufficiency.

Peak Systolic Velocity	> 30 cm/sec	Good arterial inflow
End-Diastolic Velocity	< 5 cm/sec	Good venous occlusion
Resistive Index	> 0.9	Normal resistance

I'm thinking I might try Defy or one of the other online pharms - hopefully I wouldn't have to wait as long, and maybe they'll give me a stronger prescription.

Defy or any US based pharmacy cannot write a prescription for someone living in Canada.

Canadian law requires prescriptions to be written by Canadian-licensed healthcare providers.

 

[Melody68]

After injection, I'll kinda sorta get a 6/10 erection which can then be manipulated by me to an 8/10, which isn't bad, but then softens quickly if stimulation stops. If it's me by myself, then I control the tempo and it works fine. But if I'm with my wife and things slow, or I change positions, then I begin to go soft. It's very much like Viagra behaved, that's why I wanted to try the Trimix.


When you had your penile duplex doppler ultrasound done what was your PSV/EDV

If you are losing your erection when changing positions this could be due to venous leak.

Some men even with the use of intracavernosal injections need to use a cock ring due to venous leak depending on the severity.




What are the signs of venous leakage?

There are 4 signs:

* first one is absence or very weak erections in the morning

* the second sign is that during self- stimulation the hardness of the erection is not very high

* the third sign is that erections are not the same whether one is lying on his back or on his belly or on one side or being seated, if erections vary according to man's position, this is highly evocative of caverno-venous leakage

* the fourth sign is that when man applies fingers at the basis of penis erections are better, fingers press on veins and reduce leakages



Penile duplex Doppler ultrasound is a key test for evaluating erectile dysfunction, particularly in the context of intracavernosal therapy. It assesses both blood flow into (arterial) and out of (venous) the penis by measuring two main parameters:

• Peak systolic velocity (PSV): Represents the maximum speed of blood entering the penis during systole.
• End-diastolic velocity (EDV): Represents the blood flow remaining during diastole (linked to venous outflow).

• Arterial inflow (PSV):
  
  • Normal: PSV > 30 cm/sec (some sources use > 25 cm/sec)
  • Borderline: PSV 25–30 cm/sec
  • Abnormal/arterial dysfunction: PSV < 25 cm/sec
  • Normal: EDV < 5 cm/sec
  • Abnormal/venous dysfunction: EDV > 5 cm/sec (suggests venous leak if arterial function is normal)

• After intracavernosal injection (such as papaverine or prostaglandin E1), a PSV ≥ 30 cm/sec and an EDV < 5 cm/sec typically indicate normal vascular response.
• Venous leak (outflow abnormality): If EDV stays > 5 cm/sec even when PSV is normal, there is insufficient veno-occlusive function and blood flows out too quickly, making erections unsustainable.
• Arterial insufficiency: If PSV fails to reach 25–30 cm/sec regardless of EDV, arterial supply is insufficient.
• Both abnormalities: Low PSV and high EDV suggest combined arterial and venous insufficiency.

Peak Systolic Velocity	> 30 cm/sec	Good arterial inflow
End-Diastolic Velocity	< 5 cm/sec	Good venous occlusion
Resistive Index	> 0.9	Normal resistance

I'm thinking I might try Defy or one of the other online pharms - hopefully I wouldn't have to wait as long, and maybe they'll give me a stronger prescription.

Defy or any US based pharmacy would not be able to write a prescription for someone living in Canada.

Canadian law requires prescriptions to be written by Canadian-licensed healthcare providers.

Hey Madman, your memory that I got a penile ultrasound is impressive.

That experience was a little disheartening. There was a significant fee payable for the test. The doctor came in, injected me, and said he'd be back in 10 minutes to do the scan. But, he was back in no more than one or two minutes, I wasn't erect yet. He put on some lubricant, moved the ultrasound wand around, and declared that everything's fine, I just needed the Trimix for a little jolt. And that was that. I was happy enough to get the script.

I had read about a venous leak; I understand that it's not a leak in the conventional interpretation of the word, whereby there is a hole of sorts where a fluid leaks out. It's more an issue of the erection (not) building up enough pressure to close the veins that allow blood to exit the penis. This layperson explanation of how it works is confusing to me . . . it seems that you need a hard erection to close the veins, but you can't get that hard erection unless you close the veins first. Hmmmm . . .

I have tied the penis base off with a thicker shoelace for 5 minutes or so - I didn't notice any difference in hardness; maybe that's not the same effect as a proper constrictive device?

I do get very hard morning erections; not every day, but a few times a week. I always wish I could get that hard when it counts!

Regardless, even if one has a venous leak, isn't the treatment the same? Ignoring hydraulics, don't you just take stronger Trimix?

 

[madman]

Hey Madman, your memory that I got a penile ultrasound is impressive.

That experience was a little disheartening. There was a significant fee payable for the test. The doctor came in, injected me, and said he'd be back in 10 minutes to do the scan. But, he was back in no more than one or two minutes, I wasn't erect yet. He put on some lubricant, moved the ultrasound wand around, and declared that everything's fine, I just needed the Trimix for a little jolt. And that was that. I was happy enough to get the script.

I had read about a venous leak; I understand that it's not a leak in the conventional interpretation of the word, whereby there is a hole of sorts where a fluid leaks out. It's more an issue of the erection (not) building up enough pressure to close the veins that allow blood to exit the penis. This layperson explanation of how it works is confusing to me . . . it seems that you need a hard erection to close the veins, but you can't get that hard erection unless you close the veins first. Hmmmm . . .

I have tied the penis base off with a thicker shoelace for 5 minutes or so - I didn't notice any difference in hardness; maybe that's not the same effect as a proper constrictive device?

I do get very hard morning erections; not every day, but a few times a week. I always wish I could get that hard when it counts!

Regardless, even if one has a venous leak, isn't the treatment the same? Ignoring hydraulics, don't you just take stronger Trimix?

When it comes to testing for venous leak traditional color duplex doppler is not the most effective method as it can miss it.

You would need greyscale ultrasound which uses high resolution equipment.

PDE5i tend to work in mild cases of venous leak whereas intracavernosal injections especially Trimix or Quadmix are way more potent and much more effective in mild-moderate cases.

In severe cases or when someone suffers from severe ED due to vascular damage the last resort would be a penile implant.

​

How an Erection Normally works

An erection happens when blood flows into the penis faster than it flows out, causing it to become firm.


Here's the process:

1. Sexual stimulation: Signals from the brain or physical stimulation trigger the release of chemicals (like nitric oxide) that relax the smooth muscles in the penis.
2. Blood inflow: This relaxation allows arteries to widen, letting blood rush into two sponge-like chambers called the corpora cavernosa.
3. Pressure buildup: As these chambers fill with blood, they expand and press against the veins that normally drain blood out of the penis.
4. Vein compression: The expanding chambers squeeze the veins against a tough outer layer of the penis (the tunica albuginea), partially closing them off. This traps blood in the penis, increasing pressure and creating a firm erection.
5. Maintenance: The trapped blood keeps the penis hard until stimulation ends or ejaculation occurs, after which the veins reopen, and blood flows out, ending the erection.

So, in a normal erection, the veins don’t need to be fully "closed" to start the process. The inflow of blood creates enough pressure to expand the chambers, which then compresses the veins enough to slow blood outflow, allowing the erection to build and sustain.

​

What's a Venous Leak?

A venous leak, or veno-occlusive dysfunction, happens when the veins don’t compress properly, allowing too much blood to flow out of the penis during an erection. This prevents the penis from building or maintaining enough pressure to stay firm. It’s not a physical "hole" leaking blood; it’s a failure of the mechanism that traps blood in the penis.

• You don’t need a fully hard erection to start compressing the veins. The process is gradual: as blood flows in, the chambers expand, and vein compression begins. This creates a feedback loop where more blood stays in, leading to more expansion and better vein compression.
• In a venous leak, the veins are too open (due to structural or functional issues) or the tissue doesn’t compress them effectively. Even if blood flows in, it flows out too quickly, so the pressure never builds enough to create or maintain a firm erection.
• The erection process doesn’t require the veins to be fully closed at the start. It’s a dynamic balance between inflow and outflow.
• With a venous leak, the problem is that the outflow is too high, so the penis can’t trap enough blood to reach the pressure needed for firmness, even if inflow is norma