John J Bauer, MD, FACS John J. Bauer, M.D.
www.flinturology.com

Urology Services, Inc.
G-1121 West Hill Rd.
Flint, Michigan 48507
Tel: 810.232.8888
Fax: 810.232.9190
Email: jbauer@flinturology.com
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Penile Injection Consent and Instructions

Page contents:
Counseling and Pre-Op Note
Penile Injection Instructions

Counseling and Pre-Op Note

Patient Name:

Age:

Date:

Procedure: Penile injections

Indications:

Erectile dysfunction or Impotence

Alternatives:

Options for erectile dysfunction include observation; oral agents such as sildenafil, trazadone, and yohimbine; pharmacological injection programs (alprostadil, papaverine, phentolamine and combinations); vacuum tumescence devices; intra-urethral therapy (alprostadil); and behavioral/sexual therapy. Several types of penile implants are available: malleable, semi-rigid; self contained inflatable; and multi-piece inflatable with connectors.

Risks/Complications:

The risks and complications of the procedure were extensively discussed with the patient. The general risks of this procedure include, but are not limited to bleeding, infection, pain, scaring of tissues, failure of the procedure, potential injury to other surrounding structures,

The specific risks of this procedure include, but are not limited to: no long term knowledge concerning this treatment and possible untoward effects resulting from repeated injections to the penis or from such substances to be provided for injection. Although as of this date no patient has had any serious complication, the following must be considered as possibly happening: eventual loss of effect, prolonged infection (priapism), scarring or deformity of the penis, loss of sensation in the penis, loss of penile substance from severe infectious process, side effects from the injected medicines. Patients have noted: transitory pain in the head of the penis, temporary swelling of the skin on the penis due to improper placement of the needle, black and blue coloration of the penile skin, difficulty attaining ejaculation and transitory sensations (parethesias) of the penis.

You understand the procedure, general and specific risks as discussed and agree to proceed with the procedure. You also understand that not every possible complication can be listed in this counseling note and additional risks are possible, although unlikely. You were given the opportunity to ask clarifying questions and are aware that there are alternative methods of treatment, which have been explained. This document is to be kept on file and a copy was given to the patient.

I give consent to Dr. John J. Bauer, MD and/or any Urological physician, PA, or nurse to instruct me in self-injection of the penis for the purpose of alleviating erectile dysfunction. I have been suffering from sexual dysfunction sufficient to prevent me from having normal penetration of the penis with intercourse.

I have read this consent before signing below!

Physician's Signature: ________________________________ Date: __________________

Patient Signature: __________________________________ Date: __________________

Witness: __________________________________

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Penile Injection Instructions

Penile injection therapy is a simple procedure that may seem to the first time user to be offensive. Many patients thought they could not do the self-injection and later, after an educational session with the doctor or erectile dysfunction nurse, they are able to perform this simple procedure without difficulty. We ask you to have an open mind and only reject this therapy if after a few instructional sessions you are unable to tolerate or perform the procedure.

General

The penis has three structures that must be avoided. Fortunately, these are very easily avoided areas. The topside (12 o'clock position) of the penile shaft where the nerves and large blood vessels run and the bottom/under side (6 o'clock position) of the penile shaft where the urethra or urinating tube runs. You should also avoid the head of the penis. Injection should be at the mid shaft level on either lateral side (3 or 9 o'clock positions). If you notice a large vein just under the skin (bluish structure), please adjust the entry point to avoid it. You should enter at a 90-degree angle until you get a blood flush in the syringe. This indicates that you are in the correct area, the spongy erectile tissue of the corpora cavernosum.

Step-wise Directions

Steps 1-5 are if you have a reusable vial.

  1. Wash your hands with soap and water.
  2. Wash the top of the vial with an alcohol pad.
  3. Remove the cap off the syringe, draw up some air equal to the volume you intend to inject and place the needle into the vial.
  4. Inject the air in the plunger and withdraw the medication to the volume recommend by your physician. Take care to make sure the tip is in the medication solution; do not draw up air from the vial. It may help to tip over the vial during removal of the desired amount of medication.
  5. Replace the cap on top of the syringe and prepare the injection site.
  6. Wash your hands with soap and water. Only if you have not done steps 1-5.
  7. Clean the injection site with an alcohol pad, allow it to dry.
  8. Grasp the head of the penis (not just the skin) with your index finger and the thumb, pulling firmly outward and to the side against your leg. This tenses the penis. It is important that the tension is maintained and that the penis is not twisted or improper injection to the topside or underside of the penis may result.
  9. Hold the syringe between your thumb and index finger with the opposite hand. Aim the syringe at the injection site (between 1 and 3 o'clock or between 9 and 11 o'clock position). Do not inject the topside or underside of the penile shaft and avoid the head. Avoid obvious veins in order to reduce the possibility of bleeding or hematoma formation (swelling of a bleeding blood vessel). If this does occurs finish the injection and apply direct pressure to the site for 5 minutes.
  10. With a steady, continuous motion, penetrate the skin, advancing the entire needle into the injection site. Once through the skin, a resistance will be felt initially, but continue until the syringe is hubbed. You are now in the spongy tissue of the corpus cavernosa.
  11. Shift the injecting hand so that the thumb can depress the syringe plunger. Inject the entire contents of the syringe in a slow, steady motion (in about 4-8 seconds). Withdraw the needle and syringe from the penis.
  12. Immediately apply pressure with an alcohol pad or a sterile gauze pad to the injection site to avoid bleeding. If bleeding is present after stopping pressure, maintain the pressure longer until the bleeding stops.
  13. Dispose of the needle and the syringe using a safe disposal procedure.

I have read the above instructions and understand the technique, the physician or the erectile dysfunction nurse has adequately instructed me multiple times in the office under direct supervision.

Physician's Signature: ________________________________ Date: __________________

Patient Signature: __________________________________ Date: __________________

Witness: __________________________________ Date: __________________

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