The first visit consists of the clinician injecting the man’s penis with the selected vasoactive agent. The goal of this visit is to assess the man’s response to a low dose of medication (rigidity and duration) while allowing him to experience a penile injection to alleviate potential needle anxiety. The man’s response to the medication will determine the medication and dose to be ordered for the second visit. If the man experiences penile discomfort (burning or aching) throughout his shaft , especially in men who have undergone radical pelvic surgery in the past 12 months, Bimix should be considered for the second injection session.

The patient is instructed to disrobe below the waist and provided an examination gown or a sheet to be draped across his lap. Inquire if the patient has taken an oral PDE5 inhibitor medication recently as there is a potential risk of prolonged when combined with an intracavernosal agent.

The side effects of ICI reviewed with the patient include :

The clinician grasps the glans and gently stretches the penis away from the patient’s body so it is taut. The area to be injected is then cleansed with an alcohol pad. The prescribed dose is injected into the penile shaft at 2 o’clock or 10 o’clock with the needle injected up to the hub (Fig. 17.2). The plunger is depressed fully and then the needle is swiftly removed. Instruct the patient to hold direct pressure with the alcohol swab at the injection site with his thumb and index finger for 2–3 min (5–6 min if on blood thinner) to minimize the risk of bleeding, ecchymosis or hematoma formation. Explain it is normal to feel a warm sensation throughout his shaft within the first few minutes after the injection. Men are encouraged to gently massage and stimulate their penis after removing the alcohol pad to improve tumescence; however, instruct him to abstain from achieving an orgasm as this will prevent the clinician’s ability to grade the erection hardness. Inform the patient you will return to the room in 10–15 min to assess his response.

The clinician should knock on the door prior to entering the room to allow the man to prepare for your entry. Ask the patient to rate his erectile response on a scale of 0–10, where 0 = no response, 6 = just firm enough for vaginal penetration, 7 = firm enough for anal penetration, 10 = fully rigid response. After he rates his response, the clinician should palpate the penis to confirm his assessment and confirm comprehension of the erection scale. It is important the patient understands how to correctly rate his erection using the scale, because the patient will be instructed to contact the office to report his response after each of the first few home injections.

If his response is <60 % upon reentering the room, have the patient wait an additional 10–15 min as anxiety may have delayed his response. When returning to the room for reevaluation, the patient can be discharged if the response remains <60 %. Explain that although his erection is not completely detumesced, there is limited risk of priapism . Reassure the patient he may have a partial erection until the medication has been completely eliminated; however, should tumescence occur with an erection ≥60 % lasting 60 min, he should contact the office.

The patient will remain on site if his response is ≥60 % until detumescence begins and his response is <50 %. Neo-Synephrine^® (phenylephrine HCl) is administered intracavernosally if the erection is ≥60 % after 1 h (Chap. 18). Men commonly achieve an erection response <60 % at the first visit. Reassure the patient this is not unusual and remind him a low dose was selected to avoid aprolonged erectile response while allowing him to experience a penile injection. Explain the dose will be increased for his second visit. Men may stand and walk around the room for a few minutes to determine if the response improves while in standing position (suggestive of venous leak).

Second injection visit : The supplies for this session include (Fig. 17.1):

The second visit consists of the patient and/or spouse/partner receiving instructions on how to inject at home. The man or his spouse/partner is taught how to draw fluid from a multidose vial using the vial of normal saline and a 29-gauge syringe. The amount he practices drawing into the syringe is the dose he has been prescribed for the second visit. Once the correct dose is drawn into the syringe the man or his spouse/partner is taught how and where to inject using a rubber penis model.

Review penile anatomical landmarks with the man to prevent nerve, artery, or vein injury with self-injection. Instruct the man or his spouse/partner where to inject on the penile shaft. The penis should be divided into two parts: the first is proximal to mid-shaft; the second is mid-shaft to glans . The needle will be injected mid-shaft at the 10 o’clock (left side) or 2 o’clock (right side) position (Fig. 17.2). The injection should occur at 45° mid-shaft.

After the patient has practiced injecting the rubber model and the clinician and patient are comfortable with the technique, the patient will self-inject the prescribed dose (or the spouse/partner will inject the patient if the patient is unable to self-inject due to needle anxiety, dexterity issues, or an obese abdomen where he cannot visualize his penis ). The man’s response (rigidity and duration) at the second visit will determine the dose he will be ordered to inject at his first home self-injection.

When ready to inject, instruct the man or his spouse/partner to grasp the glans of his penis in their non-dominant hand and stretch the penis away from the body. The foreskin should be retracted if uncircumcised to permit a firm grip. Identify the area to be injected as defined above avoiding any visible superficial veins. Hand the man a prefilled syringe with the medication and dose to be injected. Instruct the man or his spouse/partner to touch the needle to the shaft and swiftly slide the needle into the shaft up to the hub (Figs. 17.3, 17.4, and 17.5). The plunger is then depressed to instill the prescribed dose. Remind the man and his spouse/partner to observe that the needle is not being withdrawn as the medication is injected. Direct pressure is applied at the injection site as outlined earlier. The clinician should return within 10–15 min to assess the man’s response.