Causes of erectile dysfunction Erectile dysfunction (ED) is the inability to get or keep an erection. It can be caused by physical or psychological problems. Physical causes include: heart disease...Read More
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I’m, dr. Flanagan I’m, a urologist at Vancouver, General, Hospital associated with University of British Columbia, also, the clinical lead for the prostate cancer, supportive care program, sexual rehabilitation clinic in this video. We want to go over penile injection therapy for erectile dysfunction, penal injections, otherwise termed intra cavernosa injections, I, see I is a treatment for erectile dysfunction that involves subjecting a small amount of medication into the erectile tube in the penis. Common medications include: try mix by mix and prostaglandin after the injection of the medication. An erection is typically created within 5 to 10 minutes and once we find the appropriate dose, this lasts between 30 and 60 minutes. The great thing about this treatment for patients with following prostate cancer treatment is that it does not rely on intact nerve function. The medication acts locally within the muscle of the penis, so it does not require a signal for erection by the nerves. We typically provide teaching for the injection therapy in the clinic by one of our sexual health clinicians and really just go through the steps required to perform the injection safely and some of the education that’s required to know around changing the dose, as well as the potential risks and complications once you’re, confident and comfortable with this. Then we get you to perform the injections at home by yourself or with the partner. So how is a medication work? Well, medication is delivered into the muscle within the penis by the needle and it simulates increased oxygenated arterial, penile blood flow, and it also works to relax the muscle within the penis. This relaxing of the muscle expands and it traps that increased blood flow and as it traps it, it decreases the amount of blood that can leave as a result. What happens is the penis will expand both length and width and become more rigid, effectively creating interaction. The effect is localized to the penis, so it will not cause effects on the rest of the body. In most circumstances, indications for penile injections include individuals that have tried other forms of erectile dysfunction, therapies and either cannot achieve a desired direction or the erections are not firm enough for desired and intended purposes. Also, if you’re engaging in penile rehabilitation, then the injections can be very effective in helping to increase blood flow to the penile tissue and increase oxygenation, as well as smooth muscle, relaxation and exercise some of the contraindications or those scenarios that we think injections may not be the best fitted for our individuals that either have limited hand dexterity that you cannot safely put the needle into the penis or if the eyesight is limited, that you cannot visualize the correct dose to draw the medication. Similarly, if you have a history of significant bleeding disorder, where you get severe bleeding or bruising with needle injections, then we’d recommend that you speak with your prescribing physician regarding the use of intercostal injections for you. Now, if we look at how to perform the injection first thing that I’d recommend is ensuring that you have all of the supplies with you before you begin. This includes the medication that you’re going to inject, which is typically stored in the fridge. The needles that you’re going to use to inject alcohol, swabs the yellow sharps disposal container that the pharmacy will give you injection information package, including the dosing chart that our clinic will provide sudafed pills in case of a prolonged erection and also of note, is helpful to use a flat surface to place all of these supplies on whether that’s a night table in your bedroom or countertop in your vacu or nearby. So when we go to perform the injections I like breaking this down into three steps, one prepare the medication to prepare the penis to receive the medication and three deliver the injection okay. So we have all of our supplies that we need here. We have our medication that was recently refrigerated and was just taken out. We have our alcohol swabs here we have our injection needle here and we’re going to be using this penal model to do the injection on here today. So we’ll first start off with the needle. This is a typical needle that is used for penile injection therapy. Here is a safety cap that you can pull off and discard of appropriately. This is the plunger the syringe and then under this orange cap is the needle. The needle is pretty small and it’s quite sharp. Now the important thing to know is: if the needle touches anything outside the inside of this cap, then it’s contaminated and should be thrown away. So if it touches to the table, the outside is capped or skin. That has not been prepared. We’d recommend throwing it away. Now, if you go to recap, there’s a few different ways to do it. You can just try to do it. Freehand like this. However, it can be somewhat challenging, especially if you have a small amount of tremor. Sometimes a strategy might be to touch your hands together, which will stabilize the right and left hand and make it easier. Another option to make it easier is to put your hands on the table, and recap it like this, and the final way is there’s a flat surface on this cap that you can place on to the table. Using your dominant hand, you can guide it in and press down like that. This is probably the safest way, so you don’t poke yourself with the needle now. If we look specifically at the syringe to understand the dosing, there’s numbers that go up by 10, 10, 20, 30 40, all the way to 100 now 100 units is the equivalent of one milliliter, the dose that we will typically start most individuals on is about five units. Now, if we look at the small scale here, we see that each big line is approximately ten units and each small hash is two units we measure to the top of this black plunger. So if we want to measure five units, we approximately be there okay. So it’s a very small amount of medication that you’re going to be using for the first injection. So now that we understand how this works, we can then go at preparing the medication, so we have our flat surface here. We have our bottle of medication. It usually comes with a plastic cap that you can just pop off like this. Now, in the middle, there is a rubber target in the middle, and this is we’re going to be placing the nail through. You always confirm that the medication that you think you’re injecting is actually what’s written on the bottle. Next I’d recommend taking an alcohol swab. You can tear this open and take it out anytime. The needle is going to pass through rubber or pass through skin. There should be an alcohol swab, that’s applied, so I’d recommend swabbing this and, of course, before we’ve started. All of this we’ve washed our hands. Okay, so that will call swab is down. Now we remove the cap again, we can place it down in preparation once we have the medication in the syringe, because most of the vials are glass, you have to introduce the same amount of air into the vial as the amount of medication you’re planning and taking out. Otherwise it will create a vacu. So here we have approximately five units of air that I’m going to place into the vial. So, using my dominant hand, I puncture, the rubber all the way in and I inject the air in now, because the air comes to the top and the fluids at the bottom. We need to turn this entire system upside down. Now the air is at the top and the water is at the bottom near the syringe. So we’re going to draw back I, usually like drawing a little bit more than the dose I’m interested in and I push it all back in again. Trying to get a small air bubble out again will draw back just past five units, so I’m at approximately six to seven units now I’m going to push it in just to the dose of requiring five units. There’s a very tiny air bubble there that won’t be significant for the injection. But if there is a larger air bubble, then we would absolutely want to get rid of this. First now that I have my medication dose I’m, going to pull this out and I’m gonna put the vial now I’m going to recap this carefully again making sure pay attention not to touch anything else on the outside of the lid okay. So now it is recapped. Our medication is ready now for Phase, two is preparing the skin site for injection I’d use a new alcohol swab pad, and we want to perform the injection on either the ten o’clock or two o’clock position of the PNL shaft now essentially anywhere between the base and the outer part of the shaft is okay to inject I would not recommend injecting it to the glands when it won’t work and -. It will be uncomfortable. These structures that we’re trying to avoid are the nerves and the vessels that run on the top of the penis, typically between 11:00 and 1:00 o’clock, and the urethra or the p-channel, which is on the bottom of the penis so anywhere in between between the 2 o’clock and 3 o’clock or 9 o’clock and 10 o’clock is the best location to put it in. So, if your right hand, dominant, I’d, recommend cleaning the right side of the penile shaft you’re, going to use your left hand to secure and grasp the penis and you’re going to use the right hand to do the injection. Alternatively, if I was left-handed, I would clean the left side of the penile shaft and I’d use my right hand to grab the penis and stabilize it okay. So now that we’ve cleaned the skin in a broad area on the penile shaft, it is now ready to receive the injection. So we’ll now move to the third phase of the injection and that’s actually performing the injection here. What I’d recommend is removing the cap from the needle and holding the needle there’s various ways that you can hold it to be effective. The key parts are pulled in near the end, so you have good control and keeping your finger off of the plunger when you go to poke through the skin. By doing this, this will hopefully prevent any accidental or unintended injection of the medication prior to having it all the way into the cavern dorsal body I like holding it with. My third and fourth digit here, because it frees up my index finger to do the injection okay now, with respect to holding the penile shaft I’d recommend grabbing the head of the penis and pulling it straight out or slightly over to the side which exposes this area for you to see to perform the injection. Now, if you do not have a circumcised, penis I’d recommend pulling the skin back cleaning the area with the alcohol after you pull the skin back to perform the injection. So exactly where the head of the penis is another way that you can do it is you can squeeze the shaft, which causes this portion to bubble out and present itself and make it easy to target with a needle. Whatever you find is more comfortable. Those are two different strategies that can be very effective. So if I grab the head of penis and I, pull it out away from the body and a little bit to the left, my right hand is ready to inject again. This is almost. This is going to be coming in perpendicular and nearly horizontal. This would be horizontal and and at the nine o’clock position- and this would be more at the ten o’clock position anywhere in that range- is adequate. It can be used towards the base, the middle we’re near the end, and those are all also adequate to do. The injection, through the skin I’d recommend a quick poke all the way in. So you see that the plastic is directly against the skin. Now draw your attention to the plunger oftentimes, as you do that you may drift out with the needle. So as you put your finger on the plunger I’d look back at the needle and the skin of the penis, so you ensure that it’s all the way in once you identify that. It’s all the way in now. You can inject all the medication into the penis. You can see the plunger move to the end. Next, you take this out, put it down on a safe surface and put pressure at the site that you injected hold this for approximately 30 seconds to prevent any bleeding or bruising. Once this is done, he can massage the medication into the penis, although it’s not absolutely necessary. This is going to take five to ten minutes to take effect. In the meantime, you can clean up your supplies, you’re going to recap your needle and dispose of this in the yellow sharps container that the pharmacy provided for you once this container is approximately two-thirds or three-quarters full. You can bring it back to the pharmacy and they’ll dispose of it properly. For you, with respect to dosing, the goal of penile injection therapy is seeking an erection, that’s adequate for sexual activity that you wish to engage in. We recommend limiting rigid erections to 60 minutes or less dose. Adjustments in our program are guided by a dosing chart provided with your prescription and information package. If you have questions or concerns, please consult your sexual health clinician and do not aggressively increase dose beyond our parameters as a main place at risk for prolonged erection, called priapism. Priapism is an erection that lasts too long. There is a smaller risk of having priapism with these injections, which is the erection that lasts for 4 hours or more following the therapy to prevent priapism we’d recommend not taking more medication than the dose prescribed do not combine with any other erectile dysfunction. Medications such as b5 inhibitors, like Viagra, Cialis or levitra, and limiting to one injection for 24 hours. If you do develop priapism after one hour, we recommend attempt to have a climax gentle physical activity or a cold shower. Tell the erection goes away if it’s still there at two hours, we’d recommend taking four 30-minute milligram tablets of sudafed or 120 milligram dose, which will often help make the erection go away. But if, by three hours, you still have a rigid erection, that’s not going away we’d recommend that you proceed to the local emergency department and notify them that your the injection protocol and that you’re presenting with priapism an erection lasting longer in four hours, is a medical emergency and could result in penile muscle damage and future risk of further decline of erectile function. Just want to take this opportunity to thank all of our supporters for the prostate cancer supportive care program. The speCialist Services Committee provided funding to help us initiate this program in January of 2013 and more recently, the Ministry of Health has provided funding in 2017 that allowed for the provincial expansion of our program to reach more British Columbians with sexual dysfunction and survivorship is useful and prostate cancer. I would also like to acknowledge all of the other agencies that have supported our program throughout the years, as well as the individuals and families that have provided generous philanthropic support if you’d like to look more into our program or connect with us here, our contact details, including our email, web site, Twitter and Facebook programs. Thank you.
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