Millions of men are affected by erectile dysfunction to some degree and the vast majority of those men are actively searching for the best therapy available. From the good old "Viva Viagra" TV commercials to today's mass marketing machines of Hims, Roman, and others, men have been conditioned to believe the oral ED tablets (PDE5 Inhibitors) like sildenafil and tadalafil are the only option they have available. If I may quote the immortal Lee Corso, "Not so fast!" Men have many other options available and many offer significant benefits over the little blue pill.
To be clear, PDE5 tablets have been and will be important therapeutic options for men with ED, but many men cannot use them for any number of reasons. For some men, they simply don't work. For others, there are medical conditions or medicine interactions that make them poor options. I am routinely asked about other remedies based on what men see advertised like creams, supplements, and devices that promise results.
One of the most common requests is for a noninvasive topical answer — a cream or gel — that will deliver erectile response. Most topical products function through the use of counterirritants to create sensation and temperature change intended to increase blood flow to the penis. The latest entry into this arena is an OTC product called Eroxon Gel that was approved by the FDA for sale as an OTC treatment for ED. The manufacturer is a European company (Futura Medical/MD3000) that touts clinical trial results very similar to Viagra (65% effectiveness). As is the case with other topical ED remedies, real world data shows a less impressive response rate of 0-25% in mild ED.(1)
Prescription topical preps haven't faired much better. The European drug Vitaros is a topical alprostadil cream for ED. The manufacturer claims 60-90 minute long, rigid erections within 10-12 minutes of application.(2) Double blind studies resulted in a modest 38% response rate compared to manufacturer claims of double that percent effectiveness.(3) Development of new vehicles that enhance skin permeation and drug migration to the vascular bed as well as potentially game-changing nanotechnology that has the capacity to reduce drug particle size may offer solutions and enable topical ED preps to become viable treatment options in the future.
Since the topical options are more novelty than cure, some men look to prescription ED options using intraurethral/transurethral medications that are inserted in the urethra prior to sex. The commercial product MUSE (Medeicated Urethral Suppository for Erection) is the only such drug approved by the FDA. MUSE suppositories, which are inserted into the urethra 5-10 minutes prior to sexual activity, contain high dose alprostadil which is a potent vasodilator. Muse is available in alprostadil doses of 125mcg, 250mcg, 500mcg, and 1000mcg.
More on men's health
Revelation Pharma's blog has more articles on men's health — and how compounding pharmacies can help. From testosterone replacement to hormones for the heart, check it out!Compounding pharmacies can provide very similar options even adding the extra benefits of additional vasodilators in a TriMix form (PFE/PAP/PHEN) and a much lower price point. Unfortunately, the overall response rate based on SHIM scores of urethral products hovers in the same disappointing 35% range due to poor absorption via the urethra.(4) In addition, the urethral products cause discomfort and irritation of the urethra and necessitate the use of condoms in most cases.
To date, the most successful option is the penile injection. Unlike intraurethral products where high dose alprostadil (PGE1) is inserted into the urethra, penile injections employ much lower dose (1/100th) of PGE1 which is injected into the corpus cavernosal chambers within the penis. Commercially available products like Edex and Caverject employ various doses of PGE1 while compounding pharmacies offer single ingredient and multi-ingredient formulas ranging from PGE1 and BiMix (Pap/Phen) to TriMix (Pge/Pap/Phen) and QuadMix which adds atropine on top of Pge/Pap/Phen. Better than ¾ of men with ED (77%+) enjoy satisfactory sexual activity and erectile function using penile injections.
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This demonstrates that penile injections are safe and effective therapy for men who have either failed or cannot take PDE5 inhibitors.(5,6) The availability of compounded penile injections is important because the variation in formulas and ingredients allows us to address issues with comfort, duration, and firmness that the commercially available products cannot and provides those solutions at considerable cost savings.(7,8)
In some instances, patients seek non-medication options due to preference or out of necessity. Fortunately, we have answers for these men as well. Vacuum erection devices (VEDs), or penis pumps, are mechanical pumps that enable men to achieve erections adequate for sexual activity. They are commonly paired with retention rings to help maintain the erection for acceptable duration to allow satisfactory sexual experience for both partners. Other patients may opt for penile sleeves or penile supports which are prosthetic devices that allow adequate firmness for penetrative sex.(9)
As new technology emerges and our applications improve , we will certainly introduce new options for patients with ED. It is important to offer insight and education to patients as they wade through the advertising and marketing storms promising "bigger and better" responses than they've ever had. Not unlike other therapeutic categories, there is no one singularly perfect solution that will fit all patients. That makes our role as educators and advocates so important and impactful in the pursuit of better quality of life for our patients. Having the knowledge and understanding of these therapeutic approaches can improve our relationships with patients and providers alike and establish us as a resource for our community.
References
1. Efficacy and Safety of MED3000, A Novel Topical Therapy for Treatment of Erectile Dysfunction. The Journal of Urology AUA, Sexual Function/Dysfunction, Hormonal and Nonsurgical Therapy II (PD52), 1 May 2024, WJG Hellstrom, G Brock, AL Burnett, K James
2. Becher E., Topical alprostadil cream for the treatment of ED. Expert Opin Pharmacther 5:623-632. 2004
3. Mulhall J., Porst H., Goldstein I., (2013b) comparison of Vitaros efficacy and safety with short term and long term use. J Sex Med 10:264-265
4. Costabile RA, Spevak M, Fishman IJ, Govier FE, Hellstrom WJ, Shabsigh R, Nemo KJ, Rapport JL, Tam PY, Welson KL, et al. Efficacy and Safety of Transurethral Alprstadil in Patients with Erectile Dysfunction Following Radical Prostatectomy. J Urol. 1998; 160:1325-1328. Doi: 10.106/S0022-5347(01)62527-8.
5. Perimenis P, Konstantinopoulos A, Gyftopoulos K, Kartsanis G, Liarsikos E, Athanasopoulos A. Lomg-term Treatment with Intracavernosal Injection in Diabetic Men with Erectile Dysfunction. Asian J Androl. 2006; 8:219-224. Doi: 10.1111/j.1745-7262.2006.00095
6. Raina R, Laskin MM, Thukrat M, Andarwal A, Ausmundson S, Montague DK, Klein E, Zippe CD, Long-term Efficacy and Compliance of Intracorporeal Injection for Erectile Dysfunction Following Radical Prostatectomy: SHIM(HEF-5) Analysis, Int J Impot Res 2003;15:318-322. Doi: 10.1038/sj.ijir.3901025
7. Bechara A, Casabe A, Cheliz G, Romano S, Rey H, Fredotovich N. Comparative Study of Papaverine Plus Phentolamine Versus PGE1 in Erectile Dysfunction. Journal of Urology/Clinical Urology. Doi: Jun 1, 1977
8. Bivalacqua TJ, Kadowitz PJ. Pharmacotherapy for Erectile Dysfunction; Trends in Pharmacological Sciences, 2000
9. Boskey E, PhD, Brahmbhatt J, MD. External Penile Prosthesis for Erctile Dysfunction; VeryWell Health/Urological Health. April 9, 2024
