Men’s Health

Oral and injectable ED medications can have a side effect of an erection lasting greater than 4 hours (priapism). Treat prolonged erections lasting greater than 4 hours as a true emergency and seek medical attention.  Visit the NIH website for more information.

Phenylephrine is commonly used to reverse the effects of PGE/Trimix/Quadmix to prevent an erection lasting too long while the patient is learning their correct dosage. It is also used to reverse the effects of the in office test dose.  Phenylephrine should be injected using the same method as PGE/Trimix/Quadmix, but only after about 4 hours of sustained erection to prevent negative outcomes. Dosing with 0.5 ml and repeating every 5-10 minutes until the erection subsides is advised, but frequent use for erection “knock down” is not recommended due to potential risks.

Skippack Pharmacy offers a phenylephrine injection as a reversal agent. We still recommend you seeking medical attention if you experience an erection lasting greater than 4 hours.

Compounded Men’s Health medications are not currently covered by insurance, and are only available at an OUT OF POCKET COST.  You can use your HSA or FSA card if you would like.  The pricing for a month’s supply of compounded medication including supplies and a complimentary consultation with our staff can be found here – MEN’S HEALTH OPTIONS AND PRICING

Please fill out our INTEREST FORM at your earliest convenience, so we can establish a direct line of communication with you. Detailed next steps will be provided once the form is submitted. This allows us to better serve you by having some information on file, so when we get the script it can be processed at lightning speed.

We also provide a PROVIDER PRESCRIPTION ORDER for easier prescribing of our injectable medication options.

Tadalafil (Cialis) and sildenafil (Viagra) are classified as PDE-5 inhibitors. The physiologic mechanism of an erection involves release of nitric oxide (NO). Increased nitric oxide causes an increase in an enzyme called guanylate cyclase (cGMP). This enzyme is responsible for increased smooth muscle relaxation, which leads to an erection. PDE-5 is responsible for degrading cGMP causing nitric oxide to have less of an effect. Sildenafil and tadalafil inhibit PDE-5 leading to nitric oxide having a prolonged effect on cGMP because cGMP is no longer being degraded by PDE-5.

About 30-35% of patients do not respond to on-demand administration of PDE-5 inhibitors like sildenafil and tadalafil. However, patients who do not respond still have options available! Patients can be considered for chronic daily administration of PDE-5 inhibitors or they are also eligible for injectable medications.

Trimix is a compounded injectable medication comprised of papaverine, phentolamine, and PGE that is injected directly into the penis. This combination of medications triggers a vasodilation effect that causes the relaxation and expansion of blood vessels. This allows for increased blood flow that is needed to achieve and sustain an erection. Quadmix has an additional medication named atropine, which also aids in smooth muscle relaxation. 

Clinical trial results indicate patients using Trimix/Quadmix achieved erections 82-90% of the time, while PDE-5 inhibitors achieve an erection 62-72% of the time. Trimix may also work faster compared to the oral medications because it is injected directly into the penis. Because Trimix is injected locally into the penis, there are typically few to no systemic side effects, unlike oral medications that circulate through the bloodstream and can possibly cause headaches, nausea, or vomiting.

Patients may choose to have their medication discreetly shipped to them at an additional fee of $30 or pick up their medication from the pharmacy at no additional cost.

Yes, although brand new scripts directly from the provider are preferred, if your script is at another pharmacy and you would like us to transfer it over for you, please send us an email at clinic@skippackpharmacy.com or text 267-766-0076.

For oral products we will be able to supply you with an equivalent dose for a stress free transition.

PGE/Trimix/Quadmix injectable medications come in many different dosing options and can be heavily customized to each patient’s needs. Starting at the lower doses is recommended. Talk to your provider to see what is best for you!

After completing the payment form, it takes approximately 1-2 business days for the order to be processed.  We strive to process the orders as quickly as possible while still prioritizing accuracy and appreciate your patience.

We understand your concern for the  injectables, but do not worry as we have extensive learning material and it is recommended to have your provider aid you with your first injection. Finding an experienced urologist who can provide optimal dosing and treatment for PGE/Trimix/Quadmix injectables is critical for a timely and good long-term result.

PDE-5 inhibitors are still available for use and we offer varying doses that might be right for you! On demand are the most frequent dosing schedules for PDE-5 inhibitors, but we also offer daily dosing of PDE-5 inhibitors as well.

Sildenafil (Viagra) is PDE5 inhibitor oral tablet that works within 30-60 minutes of administration and can last from 4-6 hours. The most frequent dosing for sildenafil is 25mg, 50mg, or 100mg once daily as needed. Adverse effects include headache, flushing, indigestion, abnormal vision, nasal congestion, back pain, muscle pain, nausea, dizziness and rash. Patients should seek emergency treatment if an erection lasts >4 hours. Discontinue use of sildenafil if there is a sudden loss in vision or hearing. Monitor for low blood pressure.

Tadalafil (Cialis) is an  PDE5 inhibitor oral tablet that works within 30-60 minutes of administration and can last up to 36 hours. The most frequent dosing for on demand dosing is 5mg, 10mg, or 20mg as needed. Tadalafil is also available for once daily dosing at 2.5mg or 5mg without regard to sexual activity. Adverse effects include headache, indigestion, nasal congestion, back pain, muscle pain, flushing, and pain in limb. Patients should seek emergency treatment if an erection lasts >4 hours. Discontinue use of tadalafil if there is a sudden loss in vision or hearing. Monitor for low blood pressure.

PGE/Trimix/Quadmix are intracavernous injections that either contain PGE alone, combination of three medications, papaverine, phentolamine, and PGE, or papaverine, phentolamine, PGE, and atropine. These medications in combination relax muscles and widen blood vessels and enable continuous blood flow to achieve and sustain an erection. Trimix/Quadmix works within 5-10 minutes or less and often lasts for 1-2 hours. You can inject PGE/Trimix/Quadmix up to 3 times per week, as long as there is more than 24 hours between doses. Side effects include mild to moderate penile pain, prolonged erections, penile scarring, bruising or hematoma, low blood pressure, dizziness, allergic reactions. Seek medical care for an erection lasting longer than 4 hours.

Quadmix has an additional medication that Trimix does not have; atropine.  Atropine aims to increase the effectiveness of the combination injectable and to also decrease related side effects through its action on smooth muscle. These medications are all patient-specific and may or may not be more effective. Finding the right dose and formulation is unique and depends on each individuals specific factors.

Finasteride is a 5-alpha-reductase inhibitor, preventing the conversion of testosterone into dihydrotestosterone (DHT) decreasing scalp and serum DHT which leads to the development of male-pattern balding. Finasteride 1mg is taken once daily.

Topical minoxidil‘s mechanism is not fully understood, but the possible mechanisms include increased blood flow as a result of the medications vasodilation effects, resulting in stimulation of resting hair follicles into active growth and stimulation of hair follicle cells. Minoxidil has various dosing regimens.

Male pattern hair loss

• (Liquid) 2 mL of 2% hair oil applied topically once daily to the scalp. Use continuously; results may occur after approximately 1 to 2 months [7]
• (Foam) Half a capful of 5% foam applied topically twice daily to the scalp in the area of hair loss. Use continuously to increase and maintain hair regrowth; results may occur at 2 months, however use for at least 4 months may be required. Consider discontinuation if no hair regrowth occurs in 4 months [11].
• (Solution) 1 mL of 5% solution applied topically twice daily directly onto the scalp in the area of hair loss. Use continuously to increase and maintain hair regrowth; results may occur at 2 months, however use for at least 4 months may be required. Consider discontinuation if no hair regrowth occurs in 4 months

Hair Graft – Male Pattern Hair Loss (Severe)

• 1 mL of 5% solution applied topically twice daily may be administered in combination with hair transplantation (guideline dosage)

ManeTain (Minoxidil 5%/Fluocinolone Acetonide 0.01%/Retinoic Acid 0.01%/Vitamin E Acetate 0.5% solution) 100ml spray bottle. This formulation has the same 5% minoxidil discussed previously, but has added ingredients fluocinolone, tretinoin, and Vitamin E. Fluocinolone is a low-to-medium potency corticosteroid that has anti-inflammatory, anti-itch, and vasoconstrictive properties. Topical tretinoin has current evidence that suggests tretinoin decreases cohesiveness of follicular epithelial cells with decreased clogged hair follicles. Additionally tretinoin stimulates increased cell production and increased turnover of follicular epithelial cells causing more clogged hair follicles to break free. Vitamin E is an antioxidant  that provides protection against oxygen radical  damage. This is important for the development and maintenance of nerve and muscle function.

Sildenafil and tadalafil are available as oral tablets and rapid dissolve tablets (RDTs). The RDTs are available in higher strengths compared to their oral tablet formulations. These medications are taken by allowing the tablet to dissolve in the mouth without water. These medications may work faster compared to the other non-RDT oral tablets.

As with any medication, each person responds differently to any medication they take.  Everyone’s situation is a little bit different, so we always recommend speaking to your health care provider and getting their thoughts. Our products allow for patients to have more options for their Men’s Health needs.

YES, we believe in the products’ quality and safety.  Our team diligently assessed many options for compounding pharmacy partners and have chosen a partner we fully trust. Analytical testing, API, facility, cleanroom, and quality are just some of the measures in place to ensure this. The American Urology Association guidelines also outline appropriate therapy for Erectile Dysfunction. 

Traditional compounding pharmacies are regulated by state boards of pharmacy. Community and hospital compounding pharmacists are allowed exemptions to the Federal Food, Drug, and Cosmetic Act of 1938 if they comply with the regulations outlined in Section 503A. All pharmacists and pharmacies engaged in compounding are subject to oversight by both federal and state authorities.

Pharmacists engaged in compounding are expected to follow applicable standards and regulations for the types of preparations that are compounded. FDA has oversight for the integrity and safety of the drugs (called Active Pharmaceutical Ingredients, or APIs, by FDA) used in compounded preparations. The Drug Enforcement Administration (DEA) has oversight for any controlled substances used in the preparation of compounded medications. Controlled substances include narcotics such as hydrocodone, amphetamines, and similar drugs, and drugs such as those used for anxiety and sleep disorders.

In addition, the United States Pharmacopeial (USP) Convention issues standards that apply to compounding. This private, nonprofit organization defines the chemical purity of drugs and also issues practice standards. USP develops standards for the identity, quality, strength, and purity of medicines, dietary supplements, and food ingredients that may be used in compounding preparations. These standards, in particular, are relevant to compounding pharmacists.

USP General Chapter <797> is a national standard for 503A compounding pharmacies for the process, testing and verification of any compounded sterile preparations. It provides guidance on preventing microbial contamination and other variances in compounded sterile preparations, regardless of setting (e.g., hospitals, community pharmacies) or who is performing the compounding (pharmacists, nurses, pharmacy technicians or others).

The Compounding Quality Act, passed in 2013, defined a new designation of compounding pharmacy, called a 503B FDA Outsourcing Pharmacy. This type of pharmacy, is a compounding pharmacy that is directly regulated by the FDA using cGMP regulations. cGMP are the same regulations followed by pharmaceutical manufacturers. Therefore, a 503B pharmacy is a compounding pharmacy that operates under cGMP guidelines, which are much more stringent than USP 797 guidelines that traditional 503A compounders operate under. There are less than eighty 503B pharmacies in the United States. Olympia is a 503B compounding pharmacy.

USP General Chapter <795> provides similar guidance for non-sterile preparations that are compounded in healthcare settings. It describes categories of compounding (simple, moderate, complex), defines concepts such as beyond-use date and stability, and provides criteria for compounding pharmacists to follow in preparing various drug preparations.

USP General Chapter <800> is a new standard developed by USP that establishes practice and quality standards of hazardous drugs to minimize the exposure to hazardous drugs within healthcare settings. This standard aims to promote worker safety (pharmacists, pharmacy technicians, veterinarians, veterinary technicians, and many others), patient safety, and environmental protection. This standard was published on February 1, 2016, but will not be officially implemented until July 1, 2018. The current list of hazardous drugs is available from the National Institute for Occupational Safety and Health (NIOSH).

Compliance with these and other USP guidelines is considered the minimum standard of practice in pharmacy.

These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease. Compounded products are not approved by the FDA. This means the FDA does not review these drugs for safety, efficacy, or quality before they reach patients. Product Images are for display purposes only and do not reflect actual drug products.

Sildenafil (Viagra) is for men suffering from erectile dysfunction and would prefer an as needed by mouth dosing regimen. 

Tadalafil (Cialis) is also for men suffering from erectile dysfunction and would prefer the choice between an as needed by mouth regimen or once daily by mouth regimen. This is because tadalafil lasts longer in the body compared to sildenafil. Tadalafil is often preferred more compared to sildenafil.

Trimix/Quadmix injections may be suggested for men with erectile dysfunction as an alternative to PDE5 inhibitors if they have proven ineffective or resulted in side effects. Trimix/Quadmix may also be appropriate for patients who’ve had prostate surgery or certain cardiovascular diseases, or patients that also take concurrent nitrate therapy or certain beta blockers that are contraindicated to PDE-5 inhibitors.

For anyone without a provider/doctor, Skippack Pharmacy has worked with Physician 360 Health Clinic, which is a telemedicine service who can evaluate patients and write prescriptions for weight loss injectables (consult is $69.95).

Please visit our clinic page to learn more.

**we are not directly affiliated with Physician 360, and simply provide them as a cost-effective option for our patients to use**

Sildenafil and tadalafil are generally well tolerated. Patients taking sildenafil may experience headaches, nausea, flushing, stuffy nose, and possibly indigestion or dizziness. Potential serious adverse effects of these medications include an erection lasting >4 hours, a blue hue to vision, and loss of hearing. Speak with your provider immediately and seek medical attention. 

Patients that take tadalafil may also experience back pain, cough, and upper respiratory tract infections. Side effects from tadalafil may last longer due to the drug staying in the body longer compared to sildenafil. 

PGE/Trimix/Quadmix is an injectable that has only local effects so it does not have as many systemic side effects like sildenafil and tadalafil. Side effects from PGE/Trimix/Quadmix include mild to moderate penile pain, prolonged erections, penile scarring, bruising or hematoma, low blood pressure or dizziness, and allergic reactions

Sildenafil

• Patients using any form of organic nitrates
• History of known serious hypersensitivity to sildenafil

Tadalafil

• Patients using any form of organic nitrate
• History of known serious hypersensitivity to tadalafil

PGE/Trimix/Quadmix

• Known allergies to PGE/Trimix/Quadmix ingredients
• Sickle cell anemia
• Bleeding disorders
• Conditions increasing prolonged erections
• Leukemia
• Penile abnormalities
• Penile implants
• Explicit medical advice to refrain from sexual activity

Yes, since the medication is a healthcare product/RX – this can be paid for with an HSA or FSA card.  You can use the HSA or FSA card when making a payment on our website: www.SkippackPharmacy.com/payment

Most medications will come in either a multi-dose vial, available in different strengths. Along with the medication, our team will provide the following complimentary items:

• Syringes with needles
• Alcohol swabs as needed for injection site sterilization and vial sterilization
• Educational handouts

Once punctured, multiple-dose vials should not be used for longer than the assigned beyond use date (BUD) of 28 days—to minimize the likelihood of microbial contamination. 

Yes, you can purchase multiple vials of a specific strength at once – when you make the payment online, select the quantity of vials you would like to purchase.  If you are just starting the medication, make sure the strength you purchase isn’t going to change the following month. Purchasing a greater number of vials or a larger month’s supply is recommended for patients who are established on a certain strength.

The question may arise: “If my prescription is for a strength which equates to 2.5mL, can’t I just fill for a 5mL vial and use that vial over a period of 3 months?”  This would be amazing. However, as mentioned above, the beyond use date on the vials is 28 days once punctured.  If you receive a 5mL vial and used 2.5mL total over one month, you would need to discard the other 2.5mL at the end of the month.

All PGE/Trimix/Quadmix vials should be frozen at 0-31°F, except for the vial that is currently in use, which should be refrigerated at 32-39°F. When the active vial starts running low, remove a frozen vial to refrigerate to replace the active vial. Frozen Trimix/Quadmix can be stored for up to 1 year. For travel, use ice packs to maintain temperature.

When you pick your prescription up at Skippack Pharmacy, our team will ensure you feel confident about administering the injection before you leave! However, at home, you will use a syringe to draw up your instructed dose from the medication vial, and administer the medication via an intracavernous injection. After the first puncture of the medication vial, the vial is good for 28 days. Please discard any unused medication after the expiration date.  Vials which are not punctured, if stored in a freezer, are good until the expiration date listed on the outside of the package. Feel free to use the following links to review our personalized educational materials.

Typically, the starting Trimix dosage should be 0.05-0.2 cc. We recommend waiting 48 hours before increasing the dose, then going up by 0.025-0.05 cc until optimal results are achieved. Speak with your prescriber before any changes.

How to administer from a VIAL:

• Instructional Handout 
• Instructional Video

No, unfortunately we are not permitted to perform this type of injection on-site at the pharmacy. However, when you pick your prescription up at Skippack Pharmacy, our team will ensure you feel confident about administering the injection before you leave!  Also, feel free to use the following links to review our personalized educational materials.

How to administer from a VIAL:

• Instructional Handout 
• Instructional Video

Each fill, you will receive 1 vial that includes the medication your provider has ordered for you. The specific amount of mL in the bottle is dependent on your dose. PGE, Trimix, or Quadmix can be taken 3 times per week, with at least >24 hours between doses. 

The best practice for injection is before sexual activity. PGE/Trimix/Quadmix usually takes about 5-10 minutes to begin working and lasts for 1-2 hours after.

 Do not administer an extra dose or increase the dose without speaking with your provider.

It is recommended to rotate the injection site with each dose to minimize irritation, penile scarring, bruising, and penile pain. This also prevents the development of a fatty lump formation under the skin that can occur over time with damaged tissue and over-used injection sites.

Oral Medications – Sildenafil (Viagra) and Tadalafil (Cialis)

These medications should be stored in the original container in a cool dry place at room temperature. 

Injectables – PGE/Trimix/Quadmix  and Phenylephrine (Reversal Agent)

All PGE/Trimix/Quadmix vials should be frozen at 0-31°F, except for the vial that is currently in use, which should be refrigerated at 32-39°F. When the active vial starts running low, remove a frozen vial to refrigerate to replace the active vial. Frozen Trimix/Quadmix can be stored for up to 1 year. For travel, use ice packs to maintain temperature.

Phenylephrine (Reversal Agent) should be stored in the original container in a cool dry place at room temperature. 

The ingredients in each of injectables are as follows:

COMPOUNDED VIALS: 

• PGE
  • Active Ingredient – PGE
  • Inactive Ingredients – 
• Trimix
  • Active Ingredient – papaverine, phentolamine, PGE
  • Inactive Ingredients –
• Quadmix
  • Active Ingredient – papaverine, phentolamine, PGE, atropine
  • Inactive Ingredients –

 Here is the link for reordering: REFILL LINK [need to update this link]

You will have the option to select up to 10 vials and inform our team if you will continue the same dose or take a different strength. We can use existing refills or scripts on hold to fill your next order. If no refills remain, your provider will need to send a new script.

Regardless whether you are or are not using an erectile dysfunction medication, it is important to implement other non-medication strategies such as eating a balanced diet and exercising regularly to promote a healthier lifestyle! Try to avoid or limit foods high in saturated fats, such as red meat and fried foods, full-fat dairy products, refined carbohydrates, packaged foods,  alcohol, and smoking. Implement healthy choices such as vegetables, fruits, legumes, unsaturated fats, and whole-grain foods.

Common disease states and conditions lead to ED include diabetes, chronic kidney disease, obesity, COPD, high blood pressure, low testosterone, thyroid imbalance, nerve damage/disorders, enlarged prostate and penile curvature.

Medications can also cause ED as a side effect, including…

• Antidepressants
• Appetite suppressants
• Antihistamines
• Blood pressure medications
• Chemotherapy
• NSAIDs, codeine, and oxycodone
• Sedatives

Please visit the NIH website for more information on Erectile Dysfunction.