Erectile Function- When Testosterone is Not Enough
From book: Testosterone: A Man's Guide (available on amazon)
Most men find that their sexual desire increases after they
start testosterone replacement. Sexual dreams and nighttime/morning erections
may be more easily achievable, but in some cases testosterone alone does not
make erections strong or lasting enough for successful intercourse. So, some men need some extra help to make
sure that their improved sex drive matches an improved and hard erection.
Before we start covering other options for improving
erections, let’s talk about steps you should take before you start combination
therapy of testosterone plus other options.
If erectile dysfunction or sex drive is not improved while on
testosterone, ask your doctor about adjusting your dose of testosterone. Ensure
that your total testosterone level is between 500 and 1000 ng/dL. Also, have your doctor check your blood
levels of estradiol. High estradiol blood levels caused by conversion of
testosterone into this female hormone by the aromatase enzyme may cause sexual
dysfunction (this can be treated with low dose anastrazole). Low levels of thyroid hormone, infections,
lack of sleep, alcohol, smoking, medications and depression also can cause
erectile dysfunction in the presence of normal testosterone levels. Blood
pressure medications are known to be one of the main causes of erectile
dysfunction, so discuss the different type of medications to keep your blood
pressure in normal ranges (high blood pressure is also a risk factor for
erectile dysfunction). Last but not least, lack of attraction for our sexual partner
can get in the way of achieving a strong erection.
HCG- As mentioned before, human chorionic gonadotropin (HCG)
mimics LH and stimulates the Leydig cells of the testicles to produce
testosterone. HCG has been successfully used alone or in combination with
testosterone replacement to normalize testicular size after long term anabolic
steroid or testosterone use. It has also
anecdotally helped men whose sexual drive does not improve on testosterone
replacement alone. No published studies
have been done on this benefit, however.
Doses of 250-500 IU twice a week while on testosterone replacement are
being prescribed by several physicians who report that their patients perceive
improvements in sexual desire and erectile function on this regimen. We do not
know if this effect lasts after long term HCG use or if it is better to cycle
it on and off.
PD-5 Inhibitors- For many older men the use of prescription
phosphodiesterase type 5 inhibitor (PD-5) medications like Viagra, Cialis, and
Levitra—may be needed in combination with testosterone replacement. However, some men do not respond well to
these oral agents or have side effects such as headaches, nasal congestion,
flushing, gut problems, and, in the case of Cialis, back pain. Cialis may last
longer than the others (36 hours compared to 4 hours for Viagra or Levitra),
but so may its side effects. Some men take Claritin and ibuprofen with these
drugs to pre-treat nasal congestion and headaches, respectively.
Sildenafil (Viagra) was the first PDE5 inhibitor to enter on
the market in 1998. The usual dose of sildenafil is 50 mg (25 to 100 mg) taken
one hour before sex. The effects of sildenafil last for approximately four
hours, and patients should be instructed to use no more than one dose within 24
hours. Fatty meals reduce the absorption of sildenafil; therefore, the drug
should be taken on an empty stomach. This may be an inconvenient factor that
needs careful planning of which some patients are not aware.
Vardenafil (Levitra), the first second-generation PDE5
inhibitor to be developed, is given at a usual dose of 10 mg (2.5 to 20 mg) one
hour before sex. Older men and those with moderate liver dysfunction should
receive a lower initial dose of 5 mg. Vardenafil begins working within 30 to 45
minutes after administration and lasts for about four hours. As with
sildenafil, patients taking vardenafil should not use more than one dose within
a 24-hour period. Patients should not take vardenafil within three hours of
fatty meals, due to a reduction in absorption.
The newest PDE5 inhibitor is tadalafil (Cialis), which has a
longer duration of action--approximately 36 hours--than sildenafil or
vardenafil. In addition, the usual dose of 10 mg (5 to 20 mg) should be taken
about 30 minutes before sexual activity.
This shorter onset time can possibly allow patients more opportunity for
spontaneity. Food intake does not appear to affect the absorption of tadalafil;
this makes it very practical for men who do not plan ahead when they have sex.
Cialis is approved for low dose daily use, but most insurance companies will
not pay for it. If you want to try a 5 or 10 mg dose daily, you can get a free
30 day supply after getting a doctor’s prescription and taking the following
voucher to your pharmacy after downloading it and printing it (you have to
answer some questions online first). You are better off asking your doctor for
a prescription for 10 mg per day and cut the pills in half for the first week
to see if 5 mg per day works well enough for you. If not, you can go up in dose.
Here is the web site address to download the voucher:
Though considered generally safe for most patients,
including those taking multiple antihypertensives, PDE5 inhibitors are not a
viable treatment option for every man with ED.
They need to be used with careful monitoring in patients with a
cardiovascular history that includes heart attacks or stroke (within the past
two weeks) and hypotension (blood pressure <90/50 mmHg),
Because PDE5 is inhibited in penile tissue as well as extra
genital tissue, patients treated with PDE5 inhibitors may experience headache,
facial flushing, nasal congestion, dyspepsia, and dizziness. Sildenafil also
inhibits PDE type 6 in the retina. Therefore, patients treated with sildenafil
may experience sensitivity to light, blurred vision, and loss of blue-green
color discrimination, all of which are generally considered reversible.
Tadalafil also inhibits PDE type 11 in skeletal tissue, possibly leading to
back and muscle pain.
ED drugs are available by prescription but I have heard that
some men are ordering them without a prescription from overseas websites to
save money (overseas sources can be ten times cheaper than products in the
United States). This book does not
endorse the use of these drugs without a prescription, but it is my duty to
mention facts about what is happening out in the real world. For a review of
online sites that sell erectile dysfunction drugs, visit:
The following table shows how long each commercially
available PD-5 drug starts working and how long they stay in your body. This
numbers vary depending on the amount of food or alcohol you ingest before
taking them, your body weight, and your liver metabolism.
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:
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
protease inhibitors including Ritonavir (Norvir® or indinavir sulfate
(Crixivan®, (Fortavase® or
Invirase® or (Reyataz®
like ketoconazole or itraconazole (such as Nizoral® or Sporanox®
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.
PERSONAL COMMENT: I
have a lot of side effects on these drugs.
Flushing of my face is common. Red eyes make me look like I smoked
pot. Sinus congestion happens as soon as
the drug enters my blood stream. And
heart burn happens a few hours later. I
have had a lot of lower back issues and Cialis definitely makes them worse,
even at a lower daily dose. Taking over-the-counter loratadine (brand name:
Claritin), ibuprofen and Propose helps me prevent the side effects, but that
means that I have to take 3 extra pills with these drugs. Talk about a pill burden to get a stronger
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
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.
It is extremely important to remember never to use Viagra,
Cialis, or Levitra before or at the same time as you use Trimix. This is a
dangerous combination that can increase the risk of priaprism. Be particularly careful with Cialis since it
can stay in your blood stream for a longer time. I know someone who had priaprism since he had
forgotten he had taken Cialis two days before using Trimix.
Most men who use Trimix love it, even if they have had to
learn the hard way about priaprism during one instance. Most of these men did not respond well nor
had too many side effects to oral agents like Viagra or Cialis.
For instructions on how to inject Trimix, read:
For instructions for physicians on how to treat priaprism in
the unfortunate case that it happens:
A 10 cc bottle of Trimix can cost from $70 to $100 in
compounding pharmacies. If a dose of
0.15 cc is needed per erection, this bottle can be good for 67 erections. In comparison with Cialis and Viagra ($16 a
pill), this option seems economical.
Caverject— This is an injectable form of alprostadil.
Injections of alprostadil have been reported to cause pain, bleeding, hematomas
and scar tissue leading to Peyronie's Disease (excessive curvature of the
penis) in some patients. Caverjet is
available by prescription and it is not a compounded product, so some doctors
who are not comfortable prescribing compounded products feel more at ease
prescribing it. However, it is not as effective as Trimix, it requires a large
injection volume, and it comes preloaded in syringes with thick needles. It is also 10 times more expensive than
Trimix but several insurance companies pay for it (Trimix is rarely covered by
insurance). This injection into the penis that produces an erection that can
last 1 to 2 hours. Follow instructions
from your urologist since overdosing can also cause priaprism.
For the best treatment algorithm for physicians who want to
learn more about how to prescribe, dose and manage injectable ED drugs like
Trimix, Caverjet and other formulations, this article is probably the most
comprehensive. It was written by Jeffrey A. Albaugh, who is an Advanced
Practice Urology Clinical Nurse Specialist at Northwestern Memorial Wellness
Institute in Chicago:
Penile restriction rings—these rubber or leather restricting
bands (commonly known as “cock rings” can be very effective at maintaining
erections after the penis fills up with blood. Be careful not to use it too
tight. Neoprene and leather rings are the most common. They can be found online.
Other options are penile vacuum devices and penile implants.
Due to the scope of this book, these two options will not be reviewed. Plenty
of information can be found by Googling those terms.