After nerve-sparing radical prostate cancer surgery, even when the neurovascular bundle responsible for erection is preserved, it may take some time for erectile function to recover. This recovery period can range from a few weeks to 1–2 years. The variability in recovery time can be attributed to several factors, including:

Age
Preoperative erectile function
Risk factors that may affect erection quality (such as smoking, diabetes, hypertension)
Excessive use of cautery near the neurovascular bundle for bleeding control during surgery
Temporary nerve injury caused by excessive traction on the nerve bundle during surgery
Individual variations in nerve anatomy that may result in partial nerve removal

During the recovery phase, when sufficient erection for sexual intercourse is not yet achieved, it is important to maintain penile blood flow and tissue health. If oral medications are ineffective, intracavernosal injections can be used to induce erections.

In addition to penile rehabilitation, in patients who undergo radical prostatectomy without nerve preservation due to the extensive nature of the cancerous tissue, intracavernosal injection therapy is also used to achieve erection and support the maintenance of sexual function.

Since the penis receives adequate nourishment only when erect, it is essential to maintain periodic erections during this period to preserve penile tissue health and facilitate sexual activity. Patients are therefore taught to perform these injections on specific days of the week — a process called Self-Injection Therapy.

In this method, personally demonstrated and taught by Prof. Dr. Tibet Erdogru, M.D., patients learn step-by-step how to prepare the syringe, draw the medication, and correctly inject it into the penis. Detailed written instructions with photos and diagrams are provided to reinforce the procedure.

A specially prepared erectile-inducing medication mixture will be given to you in a sterile, vacuum-sealed tube. You will draw a small amount of this medication into a fine insulin syringe and inject it into the penis.

Figure 1 shows the prepared medication in a sterile vacuum tube and drawn into an insulin syringe ready for injection. This section explains, step-by-step, how to properly draw the medication from the sterile tube into the syringe and the critical points to pay attention to during the process.

All details are provided to ensure that the injection is performed correctly into the erectile tissues and that the medication is handled in a fully sterile manner. It is crucial that the drug be administered under strict sterilization conditions to ensure both safety and effectiveness.

Figure 1: Sterile vacuum-sealed tube containing the medication mixture for inducing erection, and a small amount of the drug drawn into an insulin syringe.

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Figure 2: Removal of the insulin syringe from its sterile package.

A new syringe must be used for each application. Syringes that have already been used, or those whose sterile packaging has been opened and left unused for a long time, must not be used. As shown in Figure 2, the insulin syringe inside the sterile package should be opened by holding the edges of the package.

The syringe to be used for drawing the medication is removed from its package, and the protective cap covering the needle — which keeps it sterile (free from contamination) — must be removed before drawing the medication from the tube. However, this cap should only be removed after the rubber stopper of the sterile vacuum tube has been cleaned with an alcohol swab (or a cotton ball moistened with cologne at home).

While the cap remains on, you may safely place the syringe on a clean surface, ensuring the cap cannot be accidentally opened (Figure 3). As long as the cap is closed, the needle remains uncontaminated.
Once the cap is removed, the needle tip must not touch any surface, and the syringe must never be placed down while the needle is exposed.

Figure 3: The syringe with its cap on can be safely placed on the counter. However, when the cap is removed and the needle is exposed, the syringe must not be set down, and the needle tip must not touch any surface.

After removing the syringe from its sterile package, place it safely on the counter with the cap still on. Take the sterile vacuum-sealed tube containing the prepared medication and place 4–5 drops of alcohol (or household 80° cologne) onto the concave rubber stopper on the cap. Then, using an alcohol swab, thoroughly clean the surface of the stopper (Figure 4).

Figure 4: Cleaning the rubber stopper on the cap of the sterile vacuum-sealed tube with alcohol.

After thoroughly cleaning the rubber stopper of the tube, remove the cap from the syringe and place the cap aside. Hold the syringe and needle in one hand, making sure not to touch any surface with the needle. With your other hand, take the tube whose stopper you have just cleaned. Insert the needle vertically into the rubber stopper of the tube (Figure 5).

Figure 5: Remove the syringe cap and insert the needle vertically into the cleaned rubber stopper without touching it to any other surface.

After inserting the needle vertically into the stopper, turn the tube upside down and slowly pull back the plunger of the syringe to draw the medication into it. Draw the medication up to the level recommended by your doctor. Then, carefully remove the needle from the stopper (Figure 6).

Figure 6: Turning the tube upside down and drawing a portion of the medication

Place the tube back on the counter. While holding the syringe in the air, being careful not to let the needle touch any surface, immediately replace the protective cap to prevent contamination. Once the cap is securely in place, you can safely set the syringe down (Figure 1).

After safely placing the capped syringe nearby, prepare the injection site. Sit down on a chair and lower your underwear. Hold the penis by the glans (tip)—not by the skin, as the penile shaft can rotate within the skin and lead to incorrect needle placement. Stretch the penis slightly and lay it to the right or left side, keeping it steady in that position.

Using an alcohol swab (or a cotton ball moistened with cologne), thoroughly clean the lateral surface of the penis where you will perform the injection, as shown in Figure 7.

Figure 7: The erectile (spongy) tissue responsible for erection is called the corpus cavernosum. The needle must be inserted perpendicularly into this tissue through the right or left lateral wall of the penis. The dorsal (upper) side of the penis contains blood vessels and nerves and should never be injected to avoid injury. The ventral (lower) side contains the urethra (urinary canal) and must also not be injected, as it may cause urethral injury. The injection must be made through the right or left side wall of the penis.

Hold the syringe like a pen, remove the cap, and insert the needle at a right angle (perpendicular) into the erectile (spongy) tissue that produces the erection. Insert the entire needle in a single, quick motion into the penis. Make sure the needle remains stable and does not move or slip into the subcutaneous tissue or any unintended area.

Figure 8: Use lateral side of the penis for injection

Push the plunger to inject the entire medication into the erectile tissue of the penis. After administering the medication, withdraw the needle and press the injection site with the alcohol swab you used earlier for about 2 minutes. It is very important to prevent any bleeding from the puncture site.

The effect of the medication will appear within 5–10 minutes.

Prof. Tibet Erdogru, M.D.

Urology

Uro-Klinik Istanbul