Marys Medicine

Successful Self Penile Injection Hints, Questions and Answers Greetings!
This document was prepared to make the process as easy and painless as possible for men
who have decided to use injection therapy for erectile dysfunction. This document
should also be useful to those considering the use of injection therapy.
At the end of the document you will find a list of contributors, a request for feedback, andan index.
It should also be noted that it is not necessary to have an erection to have an orgasm. Avibrator and/or a creative partner can be helpful.
You may want to refer to Tom F. Lue, MD's excellent book A Patient's Guide to MaleSexual Dysfunction for more detail. This book is available online at, or ordered through your local bookstore. ISBN: 1884065821,keywords: Male Sexual Dysfunction.
Q1. After a nerve sparing Prostatectomy, will injections help recovery of my naturalerections? A1. Yes, if your nerves were spared, the use of injections, which stimulate the flow ofblood to the penis, may help the recovery of your natural erections.
Q2. What is the optimal time after surgery to begin injection therapy? A2. As soon as the patient recovers from surgery and feels OK to start a sexualrelationship again, usually 4 to 12 weeks after surgery.
Q3. Will injections work on men with non-nerve sparing prostatectomies? A3. Yes. Injections work independently of the nerves.
Q4. Are there different recommendations for treating erectile dysfunction with injectionsfor erectile dysfunction resulting from radiation therapy? A4. There is no difference INJECTION MEDICATIONS AND MECHANISM
Q5. It seems that there are several different medications suitable for injections. What arethey and what are the trade offs? A5. Each of these medications will work to help you achieve an erection. You shouldalways consult your physician to discuss which is best for you. Some of the medicinescurrently in use include the following: 1. Papaverine is available at a low cost and is stable at room temperature but isless effective than the other medications and may have a higher tendency to causescarring (fibrosis).
2. Papaverine plus phentolamine is more potent than papaverine alone but withthe same potential side effects such as priapism and scar tissue formation.
3. Alprostadil rarely causes priapism but with its use pain is more common.
(Alprostadil is also known as prostaglandinE-1 or PGE-1, in powdered form itmay be called Caverject or Edex.) 4. Papaverine plus phentolamine plus Alprostadil (Trimix) is the most potent butrequires refrigeration and has the same side effects as Papaverine and Alprostadil.
Q6. How do these medications work to produce an erection? A6. These drugs create an erection by relaxing the smooth muscles and widening theblood vessels in the penis. They are not dependent on nerve stimulation. For a morecomplete discussion of how the penis functions see our Your Health Matters documententitled, Managing Impotence - A Patient Guide. Available at: the UCSF Urology Clinicat Parnassus, the UCSF Urologic Oncology Clinic or, the UCSF Cancer Resource Centerat Mt. Zion or from the UCSF Urology Website at Q7. Are there long-term side effects to the use of injections? What are they? A7. One possible side effect is the development of curvature in the erect penis, which canbe painful and interfere with intercourse. This is called "Peyronie's Disease." It is causedby a buildup of plaque or scar tissue inside the penis in the lining of the corporacavernosa. These are the two sponge-like cylinders running the length of the penis intowhich the medication is injected. It is relatively rare and can be treated. You canminimize the risk of getting Peyronie's by learning to inject correctly. This is notdifficult.
Q8. Are there medical conditions that preclude the use of injections? A8. Yes. 1. Severe scarring of the penis.
2. Allergy to any of the 3 medications.
3. Active infection or sores on the penis.
Note: Blood thinners such as aspirin and Coumadin can increase bleeding. Men may useinjection therapy when taking these medications IF they compress the injection site for atleast 7 minutes.
Q9. What percentage of men will get a useful erection from an injection? Do injectionswork for everyone? A9. If the medication is properly dosed (this is done by your physician) and properlyinjected, a useful erection should occur in at least 80% of men.
Q10. Does the medication continue to work indefinitely or is a tolerance created requiringincreasing dosage? A10. Both have been seen.
Q11. How long will the erections last? A11. This depends on a number of factors including: one's general health, currentphysical status, whether the proper dosage was properly injected and the presence ofother stimulation. Erections generally appear in 5 to 10 minutes and on average lastapproximately 30 minutes.
Q12. Can injections be used with vacuum erection devices? A12. DO NOT use a vacuum erection device after injecting! Serious bleeding can result.
There may be exceptions. Please consult your doctor.
Q13. My medication requires refrigeration. How long can it be left un-refrigerated? Q14. If I am traveling, are there medications that don't require refrigeration that I can usein place of my regular medication? A14. If your standard medication is Alprostadil (Prostaglandin), then Caverject or Edexcan be used. These are mixed from a powder at the time of use. Papaverine +phentolamine doesn't need refrigeration.
Q15. What is the definition of priapism? A15. It is a prolonged erection. This is an easily managed but is a potentially serious
complication. If ignored, it may result in severe pain and complete impotence
necessitating placement of a penile prosthesis. Therefore, it is very important that if you
develop a full erection lasting for more than 4 hours, you should call your doctor at
once or go to the emergency room.

Q16. I've heard that Sudafed and Benadryl as well as Terbutaline can reduce a prolongederection. When should these be used? A16. If the erection lasts more than 2 hours. If it is still a problem after 4 hours call yourdoctor or go to the emergency room.
Q17. Can I use an ice pack to reduce an erection? Where and how should it be applied? A17. Yes, on the penis or inner part of thighs. (A cold shower also works.) Again, if it isstill a problem after 4 hours call your doctor or go to the emergency room.
Q18. When filling the syringe, I have heard that that the plunger should be pulled downto the 1.0 cc mark before pushing the needle through the rubber stopper. Once the needleis pushed through the rubber stopper, the plunger should be pressed on, pushing the air into the ampoule before withdrawing the medication. Is there an advantage to thisprocedure? A18. It makes withdrawing the medication easier.
Q 19. Where in the penis do I want the medication to go? What structures am I aimingfor and which do I want to avoid? Intra-cavernous injection therapy.
After cleaning with alcohol swab,insert needle into side of penisand inject medication.
Correct Place to Inject
A19. Alternate between injecting at the 3 and 9 o'clock positions. You will be injectinginto the corpus cavernosum (erectile bodies). When choosing an injection site, avoid anyarea were a blood vessel is clearly visible.
Q20. Besides the 3 and 9 o'clock positions, I've also been told that I can inject at 2, 4, 8and 10 o'clock positions. Does it matter? A20. 2, 4, 8, and 10 are all OK, but 3 and 9 are the best.
Q21. What should I feel when I inject? Will it hurt? Should I feel resistance? Can I feelif the needle is in too deep or too shallow? A21. As there are few nerve endings for pain in this area, there will probably be just aslight momentary discomfort. The needle should be pushed firmly until it is fully in thepenis, slight resistance may be felt.
An autoinjector may reduce even further this momentary pain.
Q22. Are there any cues you can give me to tell when I'm in the right place? Sometimes Ifeel more resistance to the plunger than other times; when that happens, the injectionusually fails. Why? What should I do? A22. The amount of resistance to pushing the plunger is one of the best indicators ofgood needle placement. If a lot of resistance is felt then the needle may be in too far ornot far enough. Pull the needle back a little or push it in further. If that does not workwithdraw the needle and reinsert it in another suggested place. The plunger shoulddepress quite easily. Your doctor can demonstrate. Do not inject if the resistance isstrong.
Q23. If I don't get any response to an injection can I follow up with another injectionmaybe to a different side of the penis and perhaps using a smaller dose? A23. No, the first injection may have punctured the urethra or other tissue. A secondinjection may cause more bleeding in the wrong area. The next time you inject (onanother day) do it on the other side of the penis.
Q24. I'm bothered by the pain of the injection, are there topical anesthetics that I can use? A24. Yes, any local anesthetic such as xylocaine jelly or cream will help. EMLA, acombination of 2.5% lidocaine and 2.5% prilocaine, is available with a prescription.
ELA-Max, 4% or 5% lidocaine is available over the counter, without a prescription.
Q25. Are there thinner needles available that could be used to reduce discomfit? A25. This is not recommended. Needle breakage has been reported with 30 gaugeneedles and smaller. (See following question on auto injectors.) Q26. What's an autoinjector and how might it help me? A26. An auto-injector is a spring-loaded device, which inserts the needle into the penisvery quickly, minimizing the discomfort and psychological "hesitancy." It comes in twoforms, a simple non-prescription device designed to insert the needle for you and aprescription-required device that also depresses the plunger for you. You can check withyour local drug store to obtain the simple auto-injector (no prescription required).
Moreover, many men prefer the autoinjector that does not inject the medications for thembecause they maintain the necessary feel to know that they have injected in the rightplace and to the right depth (The patient still pushes the plunger, there is no painassociated with this.) If the plunger does not push easily, as happens on occasion,withdraw the needle a little and try the plunger again. If it is still difficult to push theplunger then use the autoinjector in a different location in the penis.
Many men are happy using the autoinjector. Check with your local drug store to obtainone. Some men have personal experience with the Becton Dickinson "Inject-Ease"automatic injector, but there are other brands available. They are not very expensive.
Auto-Injection Technique. Themedication is drawn into the auto-injector. The side of the penis iscleaned with an alcohol swab andthe injector placed against thepenis. Pressing a button thenactivates the injector and the needleis automatically inserted.
Q27. Can I use 'needle-less' injections systems like are being used by diabetics? A27. No, they only place medications into the skin. The medication needs to go in to thedeeper tissue (corpora cavernosa).
Q28. At what angle should the needle enter the penis? Should it be 90 degrees or ashallower angle to stay away from the urethra? A28. The angle of injection can be defined in two different mutually independent ways.
One way is as seen from above and the other way is as seen in a "front view." Ninetydegrees should be used in every view.
Injecting the needle at 90 degrees will ensure that you will not puncture the urethra. Ashallow injection should not be used because the medication will not get into the corporacavernosa, and not be effective.
Q29. Sometimes I see a tiny amount of blood from the injection site just when the needleis withdrawn and sometimes I don't. Why? Is it a problem either way? A29. It depends on whether or not you hit a small blood vessel. It is not a problem.
Q30. What's the best way to hold the penis for the injections? Should the penis be pulledto maximum extension? Should I pull just the outer layer or the whole penis? A30. If you need to, you should pull the whole penis. But some men find it best to laythe penis along one leg while injecting, without pulling.
Q31. Is it important to apply pressure to the injection site for a full 5 minutes afterinjections? Aren't a few minutes enough? A31. Five minutes is best. On the needle site, using an alcohol swab. Immediately applypressure to the penis with the thumb and index finger for 5 minutes, or longer if there isstill bleeding.
Q32. Should I vary the injection site? What is the best way to do that? A32. The places for injection are limited by the anatomy of the penis and you mustadhere to these. Changing injection sites from left to right and back again isrecommended.
Q33. Is it important to get all the bubbles, even the littlest, out of the syringe beforeinjection? A33. Removing those as small as poppy seeds is not necessary.
DOSAGE, etc.
Q34. How is the correct dosage determined? How do I know when I have the right dose? A34. Dose consists of both the strength of the medication and the amount used. With theappropriate strength and amount of drug as determined by a physician (usually less than1cc), erections usually occur in 5 to 10 minutes, last for approximately 30 minutes to anhour, and become more rigid if sexual stimulation occurs.
Q35. Is sexual stimulation required for an erection? Can I use less medication if I havemore stimulation? A35. Stimulation is not required but may speed things up a bit. You may be able to useless medication with stimulation.
Q36. Sometimes a dose that has worked fine before, produces no erection. I'm sure Iinjected in the right place. What happened? A36. You were probably in the wrong place or too deep or too shallow, or the medicationhad expired (lost its effectiveness).
Q37. My instructions say not to inject more than twice a week. What's the reason for notinjecting every day, for example? A37. Injecting into the penis frequently may cause scarring.
Q38. Does the medication lose potency over time even if stored correctly? A38. Yes, after about six months the medication will be less effective.
Q39. Will I develop a tolerance over time requiring an increasing dose? A39. This occurs infrequently but if it does, your physician may have to readjust thedosage of medication.
Q40. What, if any lasting damage can be done to the penis by the wrong injectiontechnique? Can just one injection if done incorrectly cause permanent damage? A40. Yes, although it is rare, scarring can occur (Peyronie's disease). If a patient injectstoo much medication it could cause priapism and damage to the erectile tissue. Notcompressing the injection site after injection may cause internal bleeding and scar tissue.
Q41. After an injection I've seen blood coming from the urethra. What happened? Whatshould I do immediately if this happens? A41. You have punctured the urethra. Grab the whole penis and squeeze for 5-7 minutes.
Q42. What happens if I accidentally hit a large blood vessel? What should I do? A42. If bleeding continues after applying pressure, abstain from intercourse untilbleeding stops. Continue to apply firm pressure until bleeding stops.
Q43. Do infections ever develop from injections? How common is this? A43. This happens very rarely.
Q44. Does the injection site make me more susceptible for contracting a sexuallytransmitted disease? A44. Possibly, but not likely. If in doubt, put on a condom.
Q45. Can injections be used while taking Viagra orally? If so, can a lower dose be used? A45. You should not inject and take Viagra at the same time. Using both treatmentstogether causes an increased possibility of priapism. (Consider alternating using Viagraand injections.) Q46. After using injections for a while my erections have developed a curvature. What'shappening? A46. The injections may have caused some scar tissue to have formed. This condition iscalled Peyronie's disease. Talk to your doctor about causes and treatment.
Q47. Does this curvature develop for all men using injections? A47. No, only 3-8 percent of men.
Q48. Can this problem be the result of improper injection technique? A48. Yes. The patient must make sure that he maintains pressure on the injection site for5 minutes to stop bleeding; including possible internal bleeding that will not be seen.
Also, attention must be paid to the doctor's instructions on where to inject, the alternationof injection sites, and the frequency of injections.
Q49. It is difficult for me to inject on both sides, because I am right handed I havedifficulty injecting on one side. I inject less than 100 times a year. Is it crucial to injectboth sides? A49. It is better if you can inject both sides. You can't go wrong with alternating sideseven if you only use injections monthly. However, you do not need to change sides ifinjections are used less than twice a week.
Q50. Can just one injection cause Peyronie's disease? A50. If too much medication is injected or if the medication is injected incorrectly it ispossible but not likely.
Q51. Can men that develop curvature continue to safely use injections? A51. If it is a mild curvature.
Q52. Are there medications that can be helpful? (to treat curvature of the penis?) A52. Colchicine may be helpful in the early phases of Peyronie's disease.
Q53. Can surgery be useful? A53. Yes, but only when the condition has stabilized, and after non-surgical treatmentshave failed.
Q54. What kinds of medications or procedures are on the horizon to help men witherectile dysfunction? A54. Prostaglandin, which is currently injected and used as a urethral suppository, isbeing tested in a clinical trial for a new use. This trial is to put prostaglandin gel to theurethral opening at the tip of penis. New pills and nasal sprays are being tested in thelaboratory and in clinical trials including medications that would be given at the time ofprostate surgery to protect the cavernous nerve.
Alprostadil, 2, 4
apply pressure, 7 Peyronie's, 2, 9, 10 blood, 1, 2, 7, 9 priapism, 2, 4, 9 questions and answers, 1 radiation therapy, 2 reduce the erection, 4 corpora cavernosum, 2 refrigeration, 2, 3, 4 curvature, 2, 9, 10 damage to penis, 9 scar tissue, 2, 9, 10 sexually transmitted disease, 9 stimulation, 2, 3, 8 Dr. Tom F. Lue, 1 storing medication, 8 effectiveness of injections, 3 filling the syringe, 4 how do these medications work, 2 vacuum erection devices, 3 medications, 2, 3, 4, 10, 11 when to begin injection therapy, 1 natural erections, 1 where in the penis do I want the needle is in too deep or too shallow, 5 medication to go, 4 QUESTIONNAIRE
Please take a few minutes to answer the following questions. Your answers will help
improve future editions of this guide.

Please check the appropriate box: AGREE NOR
Overall, the guide was helpful The information was presented clearly andin a way that was easy to understand Too Little
The amount of information presented was: 1. What was most helpful about the Guidelines? 2. What was least useful about the Guidelines? Why? 3. Should anything have been made more understandable? 4. Should anything be added, or discussed in more detail? 5. Was anything in conflict with what you already know about erectile dysfunction? Please detach the questionnaire and either bring it in to the reception desk in the Uro-Oncology Department at the UCSF Comprehensive Cancer Center or mail it to: Successful Self Injection – Patient Information DocumentDepartment of Urology, Box 1695University of California, San FranciscoSan Francisco, CA 94143-1695 QUESTIONS?
If you would like to talk about the Successful Self Penile Injection booklet with a
member of the group that prepared it, please contact Stan Rosenfeld, UCSF volunteer and
prostate cancer advocate. Stan can be reached by telephone at 415-459-4668 or by email
at [email protected]


Making sense of low oxygen sensing

TRPLSC-927; No. of Pages 10 Making sense of low oxygen sensing Julia , Takeshi FukaoDaniel J. GibbsMichael J. , Seung Cho , Francesco ,, Pierdomenico , Laurentius A.C.J. ,and Joost T. van 1 Center for Plant Cell Biology, Department of Botany and Plant Sciences, University of California, Riverside, CA 92521-0124, USA 2 Division of Plant and Crop Sciences, School of Biosciences, University of Nottingham, Loughborough LE12 5RD, UK

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