October 3, 2012

October 3, 2012
When Testosterone Replacement Doesn’t
Lead to Better Erections - Part 2


Welcome to another day in my life. Today is Wednesday and we have almost made it through the middle of another work week. I hope you are having a safe and great week so far.

Yesterday, I started a blog on testosterone levels and erectile dysfunction which I will continue today:

If you are older than age 65, or have serious liver or kidney problems, your doctor may start you at the lowest dose (25 mg) of Viagra or any of the other two drugs.

Tell your doctor about all the medicines you take. ED drugs and other medicines may affect each other. Especially tell your doctor if you take any of these:

• Medicines called alpha-blockers. These include Hytrin® (terazosin HCl), Flomax® (tamsulosin HCl), Cardura® (doxazosin mesylate), Minipress® (prazosin HCl), Uroxatral® (alfuzosin HCl), or Rapaflo® (silodosin). Alpha-blockers are sometimes prescribed for prostate problems or high blood pressure. In some patients the use of PDE5 inhibitor drugs with alpha-blockers can lower blood pressure significantly, leading to fainting. You should contact the prescribing physician if alpha-blockers or other drugs that lower blood pressure are prescribed by another healthcare provider

• HIV protease inhibitors including Ritonavir (Norvir®) or indinavir sulfate (Crixivan®), saquinavir (Fortavase® or Invirase®) or atazanavir (Reyataz®) • Antifungals like ketoconazole or itraconazole (such as Nizoral® or Sporanox®)

• Antibiotics like erythromycin or clarithromycin

• Tell your doctor if you take medicines that treat abnormal heartbeat. These include quinidine, procainamide, amiodarone, and sotalol. Patients taking these drugs should not use ED drugs.

If you are taking HIV protease inhibitors your doctor may recommend the lowest dose of each ED drug to start with and work your way up if the starting dose does not provide the desire benefits. Norvir, part of HIV protease inhibitor regimens, can boost blood levels of Ed drugs by slowing down the liver’s clearance of those drugs, so lower doses are needed to achieve the desired effect with the fewest side effects.

In rare instances, men taking PDE5 inhibitors have reported a sudden decrease or loss of vision. It is not possible to determine whether these events are related directly to these medicines or to other factors. If you experience sudden decrease or loss of vision, stop taking PDE5 inhibitors and call a doctor right away.

Sudden decrease or loss of hearing has been rarely reported in people taking PDE5 inhibitors. It is not possible to determine whether these events are related directly to the PDE5 inhibitors or to other factors. If you experience sudden decrease or loss of hearing, stop taking the oral ED drug and contact a doctor right away.

If you have prostate problems or high blood pressure for which you take medicines called alpha blockers, your doctor may start you on a lower dose of ED drugs. People who use recreational drugs called “poppers” like amyl nitrite and butyl nitrite should be careful while using ED drugs since a sudden decrease in blood pressure can occur.

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 urethra to produce an erection. Not very popular since some men do not respond well or are afraid to hurt themselves if they do not stick the pellet applicator carefully through the external urethral orifice of the penis head. You can ask your urologist for a sample with a training video that comes with it to see if this option is for you.

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 (0.1-0.5 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. I know men who had to go to an emergency room 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.

Tomorrow I will conclude this three day series of blogs on this subject matter.

I hope you have a beary safe and great Wednesday!

Until we meet again; here's wishing you health, hope, happiness and just enough.

big bear hug,



Daddy Dab