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Dear Dr. Roach: Do Trimix injections work for erectile dysfunction, and are they safe?

M.B.

Dear M.B.: Erectile dysfunction is a common problem in men, especially as they get older. It may be a clue to serious disease of blood vessels, but also can represent low testosterone or other abnormal hormone levels, neurological issues or problems with relationships or mental health. Men who are overweight with ED often improve with weight loss. If no particular cause is identified, most men are treated with medications like sildenafil (Viagra), which work by improving the blood flow to the penis.

However, these drugs are effective in only about 60 percent of men who use them. For men who do not get a satisfactory result (and it is imperative to take the drugs correctly — for example, Viagra should be taken on an empty stomach one or two hours before planned sexual activity), then it is time to consider second-line treatments, such as vacuum pumps and medicines that men self-inject directly into the penis. Alprostadil is the only Food and Drug Administration-approved injection drug for ED, and it is successful 90 percent of the time.

Trimix is a compounded mixture of alprostadil along with phentolamine and papaverine. I do not prescribe it because of the increased risk of infection with a compounded product, and because it is not clear to me that it is more effective than alprostadil alone.

Some experts in male sexual problems do recommend it, although only in men who have not responded to alprostadil by itself. Any injection into the penis has the risk of causing a scar (plaque) in the penile tissue.

Dear Dr. Roach: I suffer from what seems to be vasovagal syncope. My family doctor is suggesting that I have a tilt table test. Could you elaborate on this kind of test? I have had stress tests and echocardiograms. I also have seen an electrophysiologist (in 2015) who was not inclined to recommend this test.

R.M.A.

Dear R.M.A.: Vasovagal syncope is the precise name for a common faint. It is a neurological reflex. That’s what “vasovagal” means — the vagus nerve controls heart rate, to a large extent, as well as the blood vessels themselves. The vagus nerve can slow down the heart and dilate blood vessels inappropriately due to neurological signals, causing blood pressure to go down, in response to many conditions, such as emotional stress, pain, fear, prolonged standing and heat exposure.

An experienced clinician usually can make the diagnosis of vasovagal syncope by a careful history and physical exam. Occasionally, there are times when the diagnosis is not clear, and the tilt table test is designed to evaluate that possibility.

A tilt table test is usually performed in an electrophysiology laboratory, so the fact that the electrophysiologist doesn’t recommend it carries weight with me. Your family doctor and cardiologist should make a combined decision about whether you need it.

Dear Dr. Roach: There is a recall of eggs near me due to salmonella. I always notify a friend online about recalls. But she says that as long as she washes her hands and her eggs, she doesn’t care about the recall. Why would they recall eggs if this was all a person had to do? What can I say to change her mind?

D.D.

Dear D.D.: Tell her that you can’t tell whether an egg has salmonella by looking at it, and that washing eggs can bring salmonella from the outside of the egg to the inside. Also, salmonella requires either high heat or low heat for a long time to be killed, which would make the egg unpalatable or inedible. Recalled eggs should NOT be eaten. It’s not worth the risk.

Email questions to ToYourGoodHealth@med.cornell.edu.

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