What is the use of intraurethral alprostadil (Prostaglandin E1)?

From the Guidelines

Intraurethral alprostadil is a viable treatment option for erectile dysfunction, particularly for men who are contraindicated for PDE5 inhibitors or prefer not to use oral medication, and should be considered after an in-office test dose and proper counseling. The treatment involves inserting a small medication pellet into the urethra, with dosages ranging from 125 to 1000 mcg, and most patients starting at 250 mcg and adjusting based on response 1. To use it, patients should urinate first to moisten the urethra, then insert the applicator about 2-3 cm into the penis and press the button to release the medication. After insertion, rolling the penis between the hands for 10 seconds and standing or walking for 10 minutes can enhance absorption. The medication works by dilating blood vessels in the penis, increasing blood flow and facilitating erection, typically within 5-10 minutes and lasting 30-60 minutes.

Key Considerations

• Side effects may include penile pain, burning sensation in the urethra, dizziness, and rarely prolonged erection 1.
• It should not be used more than twice in 24 hours or with other erectile dysfunction treatments simultaneously.
• Patients with cardiovascular disease should consult their doctor before use, and the medication should be avoided by those with penile implants, priapism history, or conditions that might predispose to priapism 1.
• The initial trial dose of alprostadil intra-urethral suppositories should be administered under healthcare provider supervision due to the risk of syncope 1.

Treatment Approach

• Intraurethral alprostadil is a less invasive treatment option than penile injection and may be considered for select patients such as men who are either not candidates for or have failed therapy with oral PDE5 inhibitors 1.
• The combination of intra-urethral alprostadil suppositories with other pharmacotherapies or a penile constriction device holds some promise, but additional studies are needed to assess dosing, efficacy, and safety 1.
• Patients who have failed a trial with phosphodiesterase type 5 (PDE5) inhibitor therapy should be informed of the benefits and risks of other therapies, including the use of a different PDE5 inhibitor, alprostadil intra-urethral suppositories, intracavernous drug injection, vacuum constriction devices, and penile prostheses 1.

From the Research

Intraurethral Alprostadil Overview

• Intraurethral alprostadil is a synthetic vasodilator used to treat erectile dysfunction (ED) 2.
• It is delivered using the Medicated System for Erection (MUSE), a single-use pellet containing alprostadil suspended in polyethylene glycol 2.
• The recommended initial dose is 500 μg, which has a higher efficacy than the 250 μg dose with minimal differences in adverse events 2.

Efficacy and Safety

• Intraurethral alprostadil has a fast onset of effect and a good safety profile, with no occurrences of priapism, fibrosis, or typical systemic effects 2.
• The overall success rate of intraurethral alprostadil is approximately 56% 3.
• Common adverse events include penile pain and urethral bleeding [(3,4)].
• Intraurethral alprostadil has been associated with high patient preference, acceptance rates, and quality of life compared to intracavernosal injection 2.

Patient Selection and Administration

• Intraurethral alprostadil can be administered to all patients with ED, regardless of the origin of their condition 2.
• It is recommended as a first-line option for patients who have failed or are contraindicated for therapy with phosphodiesterase type 5 (PDE5) inhibitors 2.
• Patient and partner education is important for successful treatment, and in-office initial titration is an integral part of this success 3.

Comparison with Other Treatments

• Intraurethral alprostadil is an alternative treatment option for patients who do not respond to PDE5 inhibitors [(5,6)].
• Combination treatment with sildenafil may be a possible efficient alternative when single oral or local treatment has failed 2.
• Topical alprostadil has also shown promise as a treatment option for ED, with significant improvements in symptoms compared to placebo 4.