Injections and urethral suppositories

Alprostadil (sold as Caverject or Edex) is the single-drug version and the only one formally FDA-approved for this use. It is a synthetic prostaglandin that relaxes the arteries directly.

Bimix and Trimix are compounded mixtures — typically papaverine and phentolamine, with alprostadil added in Trimix. They are prepared by a compounding pharmacy rather than a manufacturer, cost less per dose, and often cause less of the aching that alprostadil alone can produce. Because they are compounded, they are not FDA-approved as products, which is normal for this category but worth knowing.

The correct dose varies enormously between men — by more than tenfold. Too little does nothing. Too much causes an erection that will not go down, which is a genuine emergency.

So the first injection is given under supervision, starting low, and stepped up over one or more visits until you reach a dose that produces a usable erection lasting roughly 30 to 60 minutes. You will also be taught the injection technique properly: which side of the shaft, what angle, how to rotate sites so you do not build scar tissue in one spot.

Any clinic willing to post you injectable ED medication without ever titrating a dose in person is cutting a corner that matters.

MUSE is alprostadil in a small pellet inserted into the urethra with an applicator, rather than injected. No needle, which is the entire appeal.

It is also noticeably less effective — roughly a third to a half of men get a usable result, against 70 to 90 percent for injection — and urethral burning is common. It is a reasonable thing to try if the needle is an absolute dealbreaker, but most men who want reliability end up on injections.

If an erection lasts longer than four hours, go to an emergency room. Do not wait to see if it settles overnight, and do not feel embarrassed — emergency departments treat this routinely.

After roughly four to six hours the trapped blood loses its oxygen and starts to damage the erectile tissue. Treated promptly, this resolves with no lasting harm. Left overnight, it can cause permanent, irreversible ED. This is the one risk on this page worth memorising.