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For men who do not achieve satisfactory results with first-line treatments for erectile dysfunction (ED), second-line treatments may be considered which include:

• Intraurethral alprostadil
• Intracavernosal penile injections
• Penile vacuum pumps

Intraurethral Alprostadil

Intraurethral delivery of alprostadil (MUSE) has been found to be effective for achieving and maintaining erections in about 40% of men with erectile dysfunction (ED). Alprostadil (pellet dosage form) is inserted into the urethra (the tube that carries urine from the bladder to the outside of the body) with an applicator device that is placed at the tip of the penis and then pressing a button on the applicator to deliver the drug pellet into the urethra. Because this is a self-administered treatment, patients must be carefully educated and instructed regarding the proper intraurethral administration technique.

Side-effects of intraurethral alprostadil may include:

• Penile pain - most common side effect
• Hypotension - low blood pressure
• Priapism - a persistent, painful erection of the penis not associated with sexual arousal

Intracavernosal Penile Injections

Alprostadil can also be administered by intracavernosal penile injection (injection into the corpus cavernosum of the penis) to stimulate an erection. Intracavernosal penile injections of alprostadil has been found to be effective in about 70% of men with erectile dysfunction (ED). In some cases, alprostadil may be injected in combination with papaverine and phentolamine in a treatment called "triple therapy" in order to promote blood flow to the penis and induce an erection. Although intracavernosal penile injection is usually not associated with major discomfort, men must be carefully instructed about proper injection technique.

Side effects of intracavernosal penile injections may include:

• Scarring at the site of injection
• Pain at the site of injection
• Priapism - a persistent, painful erection of the penis not associated with sexual arousal

Penile Vacuum Pumps

A penile vacuum pump is a vacuum constriction device that is placed on the penis prior to sexual intercourse. The device creates a vacuum around the penis and increases the blood flow to enable the man to achieve an erection. An elastic ring is then placed over the base of the penis to keep the penis engorged with blood and the penile vacuum pump is removed. This device is highly effective in men with ED.

Adverse effects that may be associated with use of these devices include:

• Bruising of the penis
• Petechiae - tiny, pinpoint red spots under the skin of the penis caused by bleeding from small blood vessels
• Numbness of the penis
• Incomplete ejaculation where a portion of the ejaculate (the semen released from the penis during orgasm) remains in the penis.