Why ICI: Intracavernosal Injection Concerns Worth Dispelling 

While PDE5is like sildenafil, vardenafil, and tadalafil are a central component of the erectile dysfunction (ED) journey for many, progressing medical conditions may prevent or even contraindicate some patients from being candidates for these medications. Up to a third of patients will not achieve success with oral therapy and may need to pivot to local injectable therapy.  

Talk about playing hard to get.  

Intracavernosal injections (ICI) can offer therapeutic benefit without systemic side effects. But there’s a catch: getting patients to actually use them. Discontinuation rates are high for all forms of erectile support and remain an issue regardless of route of administration. As complex as ED can be, here are a handful of concerns to address with your patients that may help uncomplicate matters. 

Concern #1: Injecting a drug into the penis will hurt.  

Fear of the unknown is a powerful thing. Your patients’ perception of pain with a penile injectable is staggering. “You want me to put what, where?” may be a phrase you hear on repeat. An observational study asked a small sample of patients to predict how painful their first ICI would be on a scale from 1-10. On average, the pre-injection predicted pain score was 5.29 +/- 1.90, which suggests a significant concern for comfort.  

So, how did these men feel after their first injection? The perceived average pain score fell over 4 points, to 1.21+/- 0.81, implying minimal discomfort. Risking a pinch seems like a small price to pay for physical connection. 

Concern #2: The sexual experience with a partner will be inadequate. 

Research has shifted to tackle not only ED medication efficacy, but satisfaction domains as well. Sexual satisfaction studies demonstrate that patients using ICI consistently are highly contented with their intimate experiences.  

Using the International Index of Erectile Function (IIEF), the gold standard in assessing erectile function and satisfaction, one study investigated outcomes primarily with injectable Trimix (a combination of Alprostadil, Paperverine HCl, and Phentolamine Mesylate). Erectile function, combined satisfaction, intercourse satisfaction, and overall satisfaction were all evaluated.  

After ICI intervention, all scores rose, highlighting significant satisfaction increases with 86% of patients experiencing an erection hardness score EHS >3 (hard enough for penetration). In addition, consistent ICI use can help patients feel more self-confident, potentially empowering sexual endeavors. 

Concern #3: The side effects are too risky. 

An evaluation of twelve studies revealed that historically, roughly 8% of patients discontinue ICI therapy due to side effects. Of these, fibrosis and priapism are the most concerning. 

Penile fibrosis is a consideration for long-term ICI patients, especially those using multi-drug therapy, as it can be medication-related. Higher incident rates may be seen with papaverine. Favorably, a third to nearly ½ of these potential fibrotic lesions tend to resolve on their own.  

Priapism is a prolonged erection that can require pharmacological intervention to alleviate. Generally, if an erection lasts over 4 hours medical attention is advised. Research suggests that priapism rates can be drug and dose-related, and the earlier a patient receives proper education, the better.  

Concerns may be lessened once patients understand it’s common practice to perform a test injection in the office under supervision. As a safety measure, reviewing administration technique to avoid unexpected events at home may help ICI feel less overwhelming. 

The biggest factor that can make or break patients’ successful intervention with ICI is connecting with a health care professional within the first 3 to 6 months. Patients who receive counseling on the full spectrum of advantages and disadvantages are better informed and less likely to stop therapy. Providers that evaluate individual response and direct dose titration after early injections will likely limit negative outcomes. Remember, what feels like therapy failure to a patient might merely be an opportunity to dose adjust. 

Women’s International Pharmacy has pharmacy staff specialized in erectile dysfunction options. These medical professionals understand the stress and anxiety related to sexual problems like ED and how these feelings can cloud patient judgment. Ups and downs are expected. Clear guidance from you and your pharmacy helps prevent patients from developing therapy beliefs that stand in the way of intimacy. 

References 

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2. Belew D, Klaassen Z, Lewis RW. Intracavernosal Injection for the Diagnosis, Evaluation, and Treatment of Erectile Dysfunction: A Review. Sex Med Rev. 2015 Mar;3(1):11-23. doi: 10.1002/smrj.35. Epub 2015 Oct 19. PMID: 27784568. 

3. Bernie HL, Segal R, Le B, Burnett A, Bivalacqua TJ. An Empirical vs Risk-Based Approach Algorithm to Intracavernosal Injection Therapy: A Prospective Study. Sex Med. 2017 Mar;5(1):e31-e36. doi: 10.1016/j.esxm.2016.08.001. PMID: 28190453; PMCID: PMC5302379. 

4. Chung E. A Review of Current and Emerging Therapeutic Options for Erectile Dysfunction. Med Sci (Basel). 2019 Aug 29;7(9):91. doi: 10.3390/medsci7090091. PMID: 31470689; PMCID: PMC6780857. 

5. Hatzimouratidis K, Salonia A, Adaikan G, Buvat J, Carrier S, El-Meliegy A, McCullough A, Torres LO, Khera M. Pharmacotherapy for Erectile Dysfunction: Recommendations From the Fourth International Consultation for Sexual Medicine (ICSM 2015). J Sex Med. 2016 Apr;13(4):465-88. doi: 10.1016/j.jsxm.2016.01.016. Epub 2016 Mar 25. PMID: 27045254. 

6. Hsiao W, Bennett N, Guhring P, Narus J, Mulhall JP. Satisfaction profiles in men using intracavernosal injection therapy. J Sex Med. 2011 Feb;8(2):512-7. doi: 10.1111/j.1743-6109.2010.02093.x. Epub 2010 Nov 3. PMID: 21054797. 

7. Krzastek SC, Bopp J, Smith RP, Kovac JR. Recent advances in the understanding and management of erectile dysfunction. F1000Res. 2019 Jan 25;8:F1000 Faculty Rev-102. doi: 10.12688/f1000research.16576.1. PMID: 30740217; PMCID: PMC6348436. 

8. Williams P, McBain H, Amirova A, Newman S, Mulligan K. Men’s beliefs about treatment for erectile dysfunction-what influences treatment use? A systematic review. Int J Impot Res. 2021 Jan;33(1):16-42. doi: 10.1038/s41443-020-0249-1. Epub 2020 Mar 31. PMID: 32231275.