What is penile injection therapy?

• Penile injection therapy, or intracavernosal injection (ICI), is a treatment used to achieve an erection. A man injects medication directly into the side of his penis using a small needle.

• This treatment is often used by men who have erectile dysfunction post prostatectomy or other prostate cancer treatments.

Do penile injections aid in the recovery of the nerves required for natural erections?

• Studies show mixed results. One research paper suggests that using ICI does improve function down the line and make rehabilitation quicker, but many papers that do not show that.

• In essence, injection therapy is another way of ‘exercising’ the penis. This is how to keep the penis healthy when nocturnal erections are not being produced. So, injection therapy is a way of intervening in the penile tissue health, but not necessarily the erection nerves.

Does the penis get cold/blue with injections (like it does with a pump)?

• It is much more like a natural erection so it should be warm and pink. When you're using a pump, it's pumping in more venous blood and when you use an injection it's pumping in more arterial blood.

• The injection is also vasodilating the tissues in the penis, so you will have a constant blood flow (so the penis stays pink and warm to the touch).

• When you use an injection the whole shaft, even the internal part gets engorged with blood. On the other hand, when you're using a pump and putting a ring on it for intercourse you're only getting the engorgement past the ring. This is why it then goes a dusty blue colour and it's cooler to touch.

• It’s important to note it's perfectly fine for the penis to not have a lot of blood flow for 30 minutes when you are using a pump and ring, as long as you release the ring after 30 minutes.

Is it better to use injections or a pump for optimum rehab/blood flow?

• It’s a matter of personal preference, both will deliver the type of exercise and stretch necessary when being used for rehabilitation.

• If your main form of rehabilitation is creating an erection to use for sex, then you will get an added bonus by using injections rather than a pump and ring (due to the continued blood flow you get from injections).

• When you're using a pump for rehabilitation you're pumping it up and letting it down repeatedly, so you are dragging the blood through the internal part of the penis like the injection does.

How often is it safe to use injections?

• It is recommended you use the injections 48 hours apart and definitely not more than once every 24 hours. It is really important to have that gap of time otherwise you risk developing a Priapism (an erection that lasts too long). This can be dangerous for your penis because it's not getting enough blood flow which is not good for the penis.

• Extra notes from Melissa: While you may have read that it is unsafe to inject more than two or three times a week maximum, the drug actually wears out after around 6 hours in the body.

• It’s important to note that if you are injecting into the same spot this can cause scar tissue buildup, so in this case, it is better to only inject intermittently.

• You can inject more regularly as long as you are keeping the penis tissue healthy by ensuring you change the site where you are injecting and using a pump between injecting (using an auto-injector can be a game changer here because it goes in quicker and causes less tissue damage).

How long should the erection stay up after injecting?

• This will vary for each person, however, thirty minutes to one hour is the gold standard.

• You can safely have a solid erection for two hours. You may also have a semi-erection for much longer than that (up to four to seven hours).

• Note that it may take a few iterations to get the right dosage that works best for you.

What happens in a penile injection consultation?

• In a face-to-face consult with Melissa, she would give you the first injection and teach you how to perform the injections on yourself.

• Then you wait ten minutes and give the erection a score out of ten (ten being hard enough for intercourse). Then Melissa gives you samples/mixes of other drugs to take home and test out depending on how they respond. She then checks in a week later to see how you have reacted to each drug.

• Melissa always starts patients on papaverine and phentolamine (which never cause pain). Then if the patient requires the extra hardness she may add a bit of alprostadil, and if the patient isn’t too sensitive to it, she may then add a bit of lignocaine.

• Everyone will end up with a different ‘injection recipe’

Why do men often give up on injections?

• Some men may be injecting in the wrong place or perhaps be using the wrong mixture of drugs for them, then they feel like it is not working and give up.

• A 1:1, in-person consult can be very helpful because patients’ bodies will react differently to the drugs in the injection. Patients have undergone slightly different procedures, are of varying ages, and may have had different pre-op erections or pre-radiation erections. It’s important to then tailor guidance around injections for each individual for optimal results.

• For in-depth guidance with injection therapy (and other rehabilitation options), check out Melissa’s Penile Rehabilitation Course (includes consultation).

Is there a risk of fibrosis, Peyronie's, or scar tissue?

• Melissa has not seen patients develop Peyronie’s because of injections, but she has seen a lot of patients develop Peyronie’s post-prostate cancer treatment (and some have been using injections).

• To avoid scar tissue, it’s important to change the spot you are injecting into each time.

• Using an auto-injector can also aid in reducing damage to the tissue.

• Aftercare for your penis is extremely important. This includes:

  • Regular pump usage.

  • Massaging Vitamin E oil/cream into the penis.

  • Taking any required medications.

Can you buy an auto-injector or do you need a script/consult?

• You can buy an Auto-injector off Melissa’s website.

• Follow this guide for using the Auto-injector with a partner (it is best if you have your correct dose first).

What is Peyronie's Disease?

• Peyronie’s Disease is where you get a bent penis. It can bend in all different directions/angles.

• What happens is you get scar tissue built up in the shaft of the penis. When your penis tries to get an erection, you only see that you've got the scar tissue when it's erect. What often occurs is you will have uneven blood flow to the penis.

• For example - if there's scar tissue on the left side of the shaft, that bit won't stretch as much as the right and the penis will curve to the left.

• People can also be genetically predisposed to Peyronie’s.

Peyronie's Treatment: it doesn't have to be surgery

• To treat Peyronie’s - ideally, you need to have both a prescriber and a physiotherapist.

• Taking a daily dose of Tadalafil and using a pump (like the Vacurect) is also essential in treating it.

• It’s important to begin this conservative style treatment when you notice the first signs of Peyronie’s.

What are the first signs of Peyronie's?

• A bent or curved erection, or an indent in the penis.

• Pain with erection.

• For men post-prostate cancer treatment who are not getting regular erections - it may not be as obvious. So it’s important to use a pump and be doing rehabilitation post-surgery so you can examine any changes in your erection.

Can you take injections on top of daily low-dose Viagra/Cialis?

• Yes. It is safe to take injections alongside low-dose Viagra/Cialis.

• It is not safe however if you're just going to take a one-off dose of Viagra and then use an injection.

• If you are taking your background daily dose and using the correct dosage with your injections too, it is perfectly safe.

• Think of your low daily dose of Viagra/Cialis as like a vitamin pill for your penis.

• Your dose of injection will be different and you won't need as much of it because you've got a background dose of vasodilation.

Can you use a pump with injections?

• First of all, let’s touch on Showers and Growers. Showers are men whose penis is always out in front and looks very impressive all the time and when they get an erection it usually just gets hard rather than larger. A Grower is a guy whose penis is more retracted and then gets longer and harder at the same time.

• If you're a Shower, using injections is easier because there's more of a shaft and therefore a larger target area. For the Growers, it’s recommended to use your pump first because it makes the target area bigger.

• After you've finished using the pump and your rehab, you may stay a bit engorged for a while so it definitely makes the process of injecting easier.

• Some of Melissa’s patients use the pump after injecting, however, there is a risk of causing a tiny trauma to the shaft of the penis and you've also got more chance of getting a bruise (while not harmful it may not look pleasant).

• For many patients, if they are using the correct dose for their injections, they don’t need to use a pump after.

Is there anyone who should not do injections?

• Injections are very localized to the penis tissue and there won’t be an interaction with anywhere else in the body so they are safe for everybody.

• Injections work for most people, and also for people with non-nerve-sparing surgery, they are your best option post-surgery.

• In Melissa’s experience, there are very few people that injections haven't worked for, once they’ve found the right ‘recipe’ and dosage for them.

Do you find that men who have been told they have had non-nerve-sparing surgery, will have no erectile function?

• If the surgeon says he was unable to save any nerves, Melissa advises it is unlikely for men to have spontaneous erections again. However, she has seen men that can still achieve a semi-erection. This is because the cavernous nerves are not easy to see, so what happens is the surgeon may think they have taken them all but there may be some nerves left (check out our interview with urologist, Professor Declan Murphy, for more on erections post non-nerve sparing surgery)

• Injections can be very helpful for men facing this scenario. It’s also key to keep the penis tissue healthy by keeping up with exercise and rehabilitation using a pump. And also find other ways to enjoy pleasure whether that be our course, using injections or, with a pump and a ring.

• If you choose to go down the penile implant route, you will have better outcomes if you have been using a pump and medications prior to this, such as low-dose Cialis to keep the penis tissues healthy.

What if injections don't create erections, why is that happening?

• This can occur due to a vascular leak. The arteries are taking blood into the shaft of the penis and the veins are taking the blood out. When you get an erection the blood goes in and all of the vessels fill up with blood and then the veins are not able to let the blood out until you're ready for the erection to go down. Then everything starts to settle and the blood can drain out.

• Think of the vascular leak like this scenario: if you had a leaky bucket with a small hole at the bottom, you can get the bucket three-quarters full but it's never going to get really full because it's slowly dripping out the bottom.

• We don't know why men develop this but we have found that men will often develop a vascular leak between 6 and 12 months post-op. Everything could have been going along fantastic, they could have been using injections it's all working great, and then for a few months they can't get a proper erection.

• Unfortunately, there is no cure for a vascular leak. In most cases, it fixes itself, yet we still don't know exactly why these occur.

How can you involve a partner in injection therapy?

• Having a partner that is with you at the initial appointment can be very beneficial as they are able to pay close attention and take note of how to perform the injections (whereas the patient may be a little distracted by their concern over how the injection will feel).

• Melissa does encourage men to learn how to inject themselves autonomously. This can help keep the spontaneity alive in the sexual relationship (hear how post-surgery couple, Alan and Fiona, spice up injections!)

• Melissa has a great resource where you can see a demonstration of a couple doing the injection together.

Does stress/arousal affect injection therapy?

• It is quicker to get an erection if you are aroused, but you will get an erection regardless of using injections.

• With tablets like Cialis or Viagra - if you are not aroused you won’t get an erection but with injections, you will.

• Stress or alcohol doesn’t affect the injections.

Advice for men who've tried injections but didn't like them?

• It’s important to have tried more than one mixture before giving up because it often takes three or four different mixes before you find the sweet spot.

• The person prescribing is likely to start off with a very small dose so it’s rare for that first injection to work perfectly.

• It’s important to have realistic expectations and understand this is not a quick fix. Oftentimes it is a trial and error process until you get the right mix/methods for you. Practice makes perfect and you need to be persistent.

Characteristics of men who have the most success?

• The men that realise everyone stuffs it up at some point but keep going. You might get it in the wrong spot or leave the injection out of the fridge for too long. These mistakes can happen.

• It’s important to keep a positive attitude that even if it didn’t work out the first, or even second, or third time, don’t stop trying. Keep tweaking and making changes to make the process more effective.

• Knowledge is power, and expert tailoring too, we recommend Melissa’s online program if you’ve not had luck with injections and want to try again.

Can injections change penis sensation?

• For most men, they don’t have any changes to sensation however, a few of Melissa’s patients each year have noticed that their penis has felt more “wooden” when they have used injections.

• It may be that this is a psycho-social effect due to the injections not feeling “natural”.

• It’s important to note that prostate cancer treatment can also change the sensation of your penis for a period of time. It may be that it’s not until you use the injections and regain your erections, that you begin to notice the sensation is different.

How to inject without pain?

• 1 in 20 men are affected by a common injection ingredient, Alprostadil. Some men have a lot of pain while others people will just have an ache and they describe it as “just not feeling like my penis”. This can be overcome by changing the mix and taking the Alprostadil out.

• The penile tissue itself doesn’t have pain receptors.

• If you feel a stinging sensation, it is a reaction to either the alprostadil or you've put the injector in too shallow. In other cases, men have put the auto-injector on the wrong angle so it will just kind of go down the side of the penis and not into the middle.

• To inject correctly, the whole circle needs to sit flat on the shaft of the penis and always on the right angle. See this video for more information: How to use inject ease.

How much does it cost to do penile injections?

• The cost of an auto-injector is around $90AUD and these last for some time.

• For the mixture, in Western Australia the cost is $145 dollars for 5mls (which is 500 units). With patients, Melissa will adjust the mixture so you get about 15 to 20 injections out of that bottle.

• If someone uses their first bottle and they've only got 10 injections, Melissa would then double the strength so next time you would use half the amount and get 20 shots.

•  It works out to around $8AUD an injection. However, there are a lot of different pharmacies such as compounding pharmacies that have different prices. If you get the mix right it can be very cost-effective, it's about ensuring the dose is right.

• In the US the cost works out around the same.

How is Melissa innovating the consultation process?

• Melissa currently has an online program available which includes the equivalent of 8 consultations worth of education, and you also receive a free 30-minute online Zoom consult.

• Currently, there is a 3-month wait to see Melissa in person (and a 4-6 week wait to see one of her team). So you get to skip the queue by buying her program. Find out more: Melissa's Penile Rehab Program

How to have better sex after prostate surgery (the Rehab mindset)

• It’s important to remember it’s not all about the penis. Experimenting or trying out new ways to pleasure each other. You may just find a new way to achieve orgasm.

• Instead of trying to replicate what you may have done in the past, instead use this situation as an opportunity to explore, mix up the script and do new things!