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PATIENT'S GUIDE FOR SELF INJECTIONPURPOSE AND BACKGROUND:For many years, doctors have been using various medications to improve circulation through blood vessels. These medications include papaverine, phentolamine and alprostadil. It has been found that these drugs can induce penile erection when injected directly into the penis. This treatment has gained worldwide acceptance since 1983. Alprostadil was approved for penile injection by the FDA in 1995.PROCEDURE AND DETAILED INSTRUCTIONS:(1) There are different forms of Trimix medication for injection: compounded liquid formulation and a powder form that is mixed to liquid formulation.If you are using the powder form, a.k.a. Lyophilized Tri-Mix, you may store it at room temperature for up to 6 months. Once reconstituted to liquid formulation with sterile normal saline, it should be used immediately. You may store any left-over reconstituted medication up to 45 days in the refrigerator. If you are using the compounded liquid form, keep the medication in the refrigerator between uses, especially if it has alprostadil (Caverject, Edex, Trimix). If you are travelling, keep the medication on ice in an ice chest.(2) Tear open an alcohol swab and wipe the rubber top of the bottle to clean it.(3) Peel open the syringe carefully. Remove the protective cover from the needle. It is important that the needle not be contaminated by touching anything but the rubber bottle cap. Push the needle through the rubber stopper, then reverse the vial so that it is upside down and pull on the plunger until it is at the 100 unit mark on the syringe. Still holding the vial upside down, inject back into the vial until the correct number of units, your dose, of the medication is in the syringe (the bottom of the plunger will be at the corresponding number of units). Pull the needle out of the vial and lay the syringe on the edge of a flat surface with the needle projecting beyond the edge so that it touches nothing.(4) Dosage: Your starting dose is: units. Never increase the dose by more than 5 units (0.05cc) or else you run the risk of persistent, painful erection that may require a trip to the Emergency Room.(5) Frequency of injection: not more than three times a week. Never more than once a day.(6) The places for injection are limited by the anatomy of the penis and it is important you inject the medicine as instructed during your clinic visit. Alternating injection sites from left to right as well as up and down shaft and back again is recommended to avoid scarring of the erectile tissue. (7) Grasp the head of the penis between the index finger and thumb. Gently pull the penis away from the body until the skin is taut. When choosing an injection site, avoid any area where a vein is clearly visible. Wipe the skin with the alcohol swab. Pick up the syringe with the other hand pretty much as if throwing a dart and touch the point of the needle to the place chosen for the injection with light pressure.(8) Be sure you are not twisting the penis and hold the syringe at a right angle (90 degrees) to the skin. Holding the syringe like a dart, move quickly to penetrate the skin and erectile tissue. The whole length of the needle should be in the penis. Penetrating the skin quickly helps minimize discomfort. As there are few nerve endings for pain in this area, there will probably be minimal or no discomfort.(9) Now, hold the syringe between the index and middle fingers and place a thumb on the plunger. Inject the entire contents of the syringe slowly. Then withdraw the needle from the penis. Immediately apply pressure to the penis at the injection site with the thumb and index finger for 2 minutes (5 minutes if you are on blood thinners) using the alcohol swab until there is no bleeding.(10) Place the needle in the disposal box.(11) If you contaminate the needle by touching it to any object other than the alcohol-wiped vial top or penile skin, you must discard the syringe and start over. DO NOT insert a dirty needle into the vial or into your penis.(12) Tumescence (enlargement) of the penis and sometimes erection will occur within 5-15 minutes. Many patients will not achieve an erection until sexual foreplay is started. Some patients have noted decrease of penile sensation and difficulty ejaculating. This is usually part of the impotence condition for which the injection is given, although it may be due to inadequate foreplay and excitement.PROBLEMS WHICH CAN ARISE:(I)Bleeding from the injection site:This usually results in a black and blue patch on the skin and usually disappears in a few days. This is due to insufficient post injection pressure to the injection site or from puncturing one of the skin veins. This can usually be prevented by applying pressure at the injection site for 1-2 minutes. It is very important that the injection be carried out without undue haste and in good light. You should wear glasses if needed. If you have failed to penetrate the erectile tissues after injection, you will feel a burning sensation which will go away in about an hour and no erection will result. In order to know that you are in the correct location, you should insert at a right-angle to the skin, feel the “give”, and the needle should be in the shaft of the penis nearly up to the hub. Remember to avoid injecting into the septum of the penis. The way you will know you are in the correct spot is that the medication should go in VERY easily.(2) Prolonged erection (Priapism):This is an easily managed but potentially serious complication. If ignored, it may result in severe pain and may require a small operation. In addition, it may make you completely impotent (i.e. cannot respond to even injections). Therefore, only make SMALL adjustments in your dose, if needed. IF you develop a full erection that lasts more than 3 hours, CALL US AT ONCE at 801-965-2767. Treatment of the condition is fairly simple: we put a small needle in the penis, drain the blood and inject a small amount of adrenaline. If this is done early, usually there is minimal or no damage.(3) Transitory pain:About 10% of patients develop pain or discomfort in the head of the penis shortly after injection. This usually subsides spontaneously after a few minutes. It is more commonly seen in patients with impotence secondary to nerve problems.(4) Temporary swelling of the skin of the penis.This is due to improper placement of the needle.(5) No response: This may result from:-Wrong technique. -Expired medication. -Inadequate dose.(6) Scarring or deformity (curvature) of the penis.(7) Infection of the penis.IMPORTANT POINTS TO REMEMBER:1-Keep medication in the refrigerator.2-Use clean injection technique. 3-Inject only those sites designated.4-Limit the frequency and dose of injections as ordered. 5-Do not inject any substance other than that provided. 6-Do not share needles or medications with other people. 7-Call immediately if erection lasts more than 3 hours. 8-Examination every 3 months after starting the medication, then yearlyUniversity Pharmacy1320 East 200 SouthSalt Lake City, UT 84102Tel: 801-582-7624Fax: 801-582-7633HoursOpen Weekdays 9-8 & Saturday 9-5 ................
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