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Tri what? … The gold standard? Never heard of it. Well, me neither until last November. Trimix has been around since the 1980s, but there is no pharmaceutical company with a multi-million dollar advertising budget marketing Trimix. Its contents are generic meds: papaverine, phentolamine, and alprostadil. These agents act together to dilate smooth muscle, increase arterial inflow, and restrict venous outflow. With an aging male population, erectile dysfunction (ED) is becoming more common, with an estimated 30 million cases occurring in men aged 40–70. Trimix works regardless of age or the cause of ED.

Trimix is administered by injection into the corpora cavernosa at the base of the penis using an insulin syringe and an auto-injector similar to that used by diabetics. The skin at the base is about the same sensitivity as the arm. Many patients are amazed that the injection is painless. Patients are instructed as to landmarks for proper injection. Often the partner of the patient also undergoes injection instruction. Trimix begins working generally five minutes after injection with full effect in about 10 minutes. Increasing circulation further increases results of the injection.

In comparison to the five phosphodiesterase inhibitors, Trimix is a direct acting agent causing vasodilation in the penis. It does not have the side effects of the PDE5i agents – no blood pressure changes, blurred vision, headaches, back aches, flushing, nausea, etc. Trimix can, however, cause priapism, which is typically reversed by oral administration of pseudoephedrine or injection of phenylephrine.

Trimix is safe for patients with heart disease, whether they are on nitrates or not, lung patients, and kidney patients. Contraindications to Trimix include obese abdomen, vaso-vagal response, dexterity problems, uncontrolled hypertension, concurrent use of MAO inhibitors, predisposition to priapism due to hematologic disorders such as multiple myeloma and leukemia, Peyronie’s disease, marijuana, and penile prosthesis.

At the Louisville Men’s Clinic, the majority of the patients we see are diabetic and/or hypertensive cardiac patients and those who have undergone prostatectomy. Virtually all of them have tried the PDE5i’s and treatment has failed or the side effects are too extreme. This is very common as studies have shown failure rate as high as one-third compared to five percent failure rate for Trimix. Trimix has also been found effective in treating ED from depression, performance anxiety, widower syndrome, and as a side effect of prescription drugs – antihypertensives, oral hypoglycemics, beta blockers, etc. Office evaluation includes a test dose of Trimix to measure patient response. Each patient’s dose must be customized for their desired duration and firmness. We carry 12 formulations of Trimix and three formulations of Quadmix (Trimix with atropine) to accomplish this task.

Dr. Bart Goldman is a staff physician with Louisville Men’s Clinic. Neal Berryhill is Clinic Director.