MUSE, Vitaros & Caverject: ED Treatments When Tablets Don't Work

By Mr Sarp Keskin, Consultant Urological Surgeon

Tablets such as sildenafil (Viagra) and tadalafil (Cialis) help many men, but around one in three do not get a good enough result – especially men with diabetes, after prostate cancer surgery, or with more severe blood vessel disease. Others cannot take tablets because of heart medicines, or simply dislike the side effects.

If this sounds like you, it is important to know that tablets failing does not mean you have run out of options. The treatments below work in a different way and are often very successful – and all of them can be started in clinic, without any operation.

How these treatments work

Tablets work by helping your body's own signals relax the muscle in the penis. If the nerves or blood vessels are damaged, those signals may be too weak for tablets to help.

The treatments below use a medicine called alprostadil (a natural substance also known as prostaglandin E1) or similar medicines that act directly on the muscle of the penis. This means they can work even when nerve signals are weak.

1. MUSE – the urethral pellet

What is it?

MUSE (Medicated Urethral System for Erection) is a tiny soft pellet of alprostadil, about the size of a grain of rice, which is placed into the opening at the tip of the penis using a slim plastic applicator.

How do you use it?

• Pass urine first – the moisture helps the pellet dissolve

• Gently insert the applicator about 3 cm into the tip of the penis and press the button to release the pellet

• Remove the applicator and roll the penis firmly between your hands for 10–15 seconds to help the medicine absorb

• Stand or walk around for about 10 minutes, which helps blood flow

• An erection usually develops within 5–10 minutes and can last 30–60 minutes

Who suits it?

• Men who would rather avoid needles

• Men with mild to moderate ED, or who get a partial response to tablets (MUSE and tablets can sometimes be used together, on medical advice)

Things to know

• Success rates are lower than with injections – around 4 to 6 men in 10 get a usable erection

• Mild aching or burning in the penis or urethra is common, and a small spot of blood can occur

• Use a condom if your partner is pregnant, as the medicine can pass into the vagina

• Usually no more than 2 doses in 24 hours

2. Vitaros – the cream

What is it?

Vitaros is alprostadil in a cream, supplied in a single-use plunger.

How do you use it?

• Hold the tip of the penis upright and gently open the opening at the tip

• Apply the cream to the opening (not along the shaft)

• An erection usually develops within 5–30 minutes and the effect can last 1–2 hours

Who suits it?

• Men who want the simplest, needle-free option

• Mild to moderate ED

Things to know

• Burning or warmth at the tip of the penis is common and usually short-lived

• The partner may notice some mild vaginal burning or itching; using a condom avoids this and is essential if the partner is pregnant or could become pregnant

• Usually no more than once in 24 hours, and no more than 2–3 times per week

• The cream should be kept in the fridge

3. Penile injections – Caverject and Invicorp

What are they?

Injection treatment (sometimes called intracavernosal injection) means using a very fine needle – similar to an insulin needle – to inject a small amount of medicine into the side of the penis.

• Caverject contains alprostadil

• Invicorp contains two medicines (aviptadil and phentolamine), and causes less aching in some men

Many men are understandably worried about the idea of injecting the penis. In practice, most say the needle is far less uncomfortable than they expected – usually just a brief scratch – and many describe injections as the treatment that "gave them their sex life back".

How well do they work?

• Injections are the most effective non-surgical ED treatment – around 7 to 8 out of 10 men get an erection firm enough for sex

• They often work well when tablets have failed, including in many men with diabetes and after prostate surgery

• The erection looks and feels natural, and orgasm and ejaculation are not affected

How do you start?

Injections are always started under supervision:

• At your first treatment appointment, Mr Keskin will give a small test dose in clinic to see how you respond and find the right dose

• You will be taught, step by step, how to prepare and give the injection yourself – or your partner can learn too

• You will go home with written instructions and a clear plan for adjusting the dose if needed

How do you use them at home?

• Inject into the side of the penis (avoiding the top and underside, where blood vessels and the urethra run), alternating sides each time

• An erection develops within 5–15 minutes, with or without stimulation

• The erection usually lasts 30–60 minutes and may continue after orgasm

• No more than once in 24 hours and usually no more than 3 times a week

Possible side-effects

• A small bruise at the injection site

• An aching sensation in the penis (more common with alprostadil)

• Over a long time, small areas of scar tissue can form inside the penis – changing sides each time and attending follow-up reduces this risk

IMPORTANT – prolonged erection (priapism)

Rarely, an erection can last much longer than intended. If an erection lasts more than 4 hours, go to your nearest A&E department straight away and take your medicine packaging with you. Prolonged erections can permanently damage the penis if not treated promptly. This is uncommon when the dose has been carefully adjusted in clinic, and you will be given detailed advice before you start.

4. Vacuum erection devices

What is it?

A clear plastic cylinder is placed over the penis, and a hand or battery pump removes the air. The vacuum draws blood into the penis, creating an erection. A soft constriction ring is then slipped from the cylinder onto the base of the penis to hold the blood in.

Advantages

• No medicines, needles or tablets

• Safe for men who cannot take ED medicines, including those on nitrates

• Reusable – a one-off cost

• Can be used after prostate surgery to help keep the penis healthy

Things to know

• The ring must not be left on for more than 30 minutes

• The erection is firm beyond the ring but can feel cooler and "hinge" at the base

• Some men find it awkward at first – it gets easier with practice

• Ejaculation can be blocked by the ring, which is harmless

Which one is right for you?

	MUSE	Vitaros	Injections	Vacuum device
Needles	No	No	Yes (very fine)	No
How quickly it works	5–10 min	5–30 min	5–15 min	2–3 min
Effectiveness	Moderate	Mild–moderate	High	Moderate–high
Main drawback	Urethral ache	Burning at tip	Needle, aching	Feels mechanical

The choice depends on how severe your ED is, how you feel about needles, your other health conditions and what suits your relationship. Many men try more than one before settling on a favourite – and some combine treatments.

Before you start

Second-line treatments should always be started after a proper medical assessment, to check for underlying causes such as diabetes, heart disease or low testosterone, and to choose the right medicine and dose safely. Mr Keskin will talk you through each option, demonstrate it, and stay with you through follow-up until you are happy with the result.