Testosterone Helped. So Why Is ED Still Here?

A practical look at tadalafil, sildenafil, Trimix, and the PRP sex shot

By Dr. Steve Tieche

Let us say your testosterone was low, you started appropriate treatment, and you now feel noticeably better. Your energy is up. Your mood is better. Your drive is back.

But your erection apparently did not get the memo.

This is where some men become frustrated and assume testosterone “did not work.” Often, testosterone did exactly what it was supposed to do. It improved the symptoms related to testosterone deficiency. The continuing ED may have a different cause and may need a different—or additional—treatment.

In the first blog of this series, I explained why low testosterone and ED overlap but are not the same condition. If you missed it, start there.

[ Blog 1 - Erectile Dysfunction and Low Testosterone]

And if your wife has been reading Cynthia's women's sexual-wellness series, good. Read it with her. Sexual wellness is not a competition over whose hormones are causing the problem. Both partners benefit when they understand what the other person may be experiencing.

Cynthia Tieche's Women's Sexual Wellness series

• Hormones. PRP. Scream Cream. Vaginal Laser. No whispering required!
• Yes, I Tried the PRP Sex Shot - and Scream Cream Too!
• The Vaginal Laser Her Husband Noticed - and She Never Told Him!

A Patient Who Felt Better—but Needed One More Piece

One patient came to Recharge Clinic after beginning testosterone therapy. The treatment had made a significant difference in how he felt. He had more energy, better motivation, improved mental clarity, and stronger sexual desire.

The problem was that his erections were still inconsistent.

We reviewed the distinction between libido and erectile function. Wanting sex and having reliable blood flow are related, but they are not identical. We discussed his health history, medications, lab results, and the available ED treatments. After determining that tadalafil was an appropriate option for him, he tried it and had excellent results.

He was grateful—and a little surprised—that the answer was not automatically “more testosterone.”

That is a point worth repeating: more hormone is not always more treatment. Sometimes the right answer is a different tool.

Before We Choose a Treatment, We Look for the Cause

ED treatment should not begin with a radio advertisement and end with a syringe arriving in the mail. Before recommending a medication or procedure, I want to know whether we are dealing with hormones, blood flow, diabetes or insulin resistance, a medication effect, nerve injury, pelvic or prostate surgery, sleep apnea, stress, or several factors at once.

ED can also be a clue that the vascular system deserves a closer look. Depending on the patient, we may review blood pressure, glucose or A1C, cholesterol, weight, smoking, family history, and exercise tolerance. Then we can build a reasonable treatment ladder.

Tadalafil and Sildenafil: Often the First Medication Options

Tadalafil and sildenafil are oral phosphodiesterase type 5 inhibitors, commonly called PDE5 inhibitors. They help improve the blood-flow response needed for an erection. They do not create desire, and they do not usually produce an automatic erection without sexual stimulation.

Sildenafil is commonly used as an on-demand medication before sexual activity. Tadalafil may be used on demand or in a lower daily regimen for selected patients, and its longer duration can give couples a broader window rather than making intimacy feel scheduled down to the minute. Tadalafil may also help certain men who have urinary symptoms associated with benign prostate enlargement.

Which one is better? The one that is safe for you, fits your health history and lifestyle, and works reliably with tolerable side effects.

These medications are not appropriate for everyone. In particular, PDE5 inhibitors must not be combined with nitrate medications because the combination can cause a dangerous drop in blood pressure. Other cardiovascular conditions and medication interactions also matter. This is why I want to know what you take—even the medication you only use occasionally and forgot to put on the form.

What If the First Pill Does Not Work?

One unsuccessful attempt does not always mean the medication failed. Timing, dose, food, alcohol, stimulation, anxiety, other medications, and the severity of the condition can affect the result. We may adjust the plan, try another PDE5 medication, treat a confirmed testosterone deficiency at the same time, or discuss additional options when oral medication is not enough.

The PRP Sex Shot: An Emerging Regenerative Option

A PRP sexual-wellness injection uses platelet-rich plasma prepared from a patient's own blood. This is an in office minor procedure where the patients blood is drawn and processed to concentrate platelets, and the PRP is injected into targeted penile tissue. The theory is that platelet signaling may support tissue repair, blood-vessel function, and healing processes.

PRP is not the same thing as Trimix. PRP is not injected to create an immediate medication-driven erection. It is offered as a regenerative approach intended to support tissue function over time. Read more about PRP injections here.

The PRP sex shot may be especially interesting for men whose concern is not only getting or maintaining an erection, but also decreased sensitivity or a sexual response that simply does not feel as strong as it used to. The platelets release growth factors involved in blood-vessel support, tissue repair, and cell signaling. I tell patients to think of PRP less like flipping an erection “on” with medication and more like trying to improve the circulation, tissue health, and responsiveness behind the scenes.

What makes PRP hopeful is that it works with the patient’s own biology and can potentially be combined with other treatments, such as testosterone optimization, tadalafil, or sildenafil, when appropriate. Men often consider it because they are hoping for firmer, more reliable erections, improved sensitivity, and a more natural sexual response over time. However, PRP is not a guaranteed cure. That is why I evaluate the whole patient first. We need to understand what is causing the ED, set realistic expectations, and decide whether PRP belongs in the treatment plan—not simply sell every man the same injection and promise it will fix everything.

Trimix: Effective, but Not Where I Automatically Start

Trimix is an intracavernosal injection, meaning medication is injected directly into the erectile tissue of the penis. It commonly combines three medications—alprostadil, papaverine, and phentolamine—that work together to increase blood flow and produce an erection.

Trimix can be very effective, but it should not automatically be the first treatment offered to every man who reports ED. It is a valuable tool; the concern is using a powerful treatment before evaluating why the problem is happening or whether a simpler option could work.

At Recharge Clinic, Trimix is generally a later-step option after appropriate evaluation and after safer, simpler treatments have been considered or have not provided adequate results. Men who use Trimix need careful teaching and individualized dose titration. Too much medication can cause priapism—an erection lasting longer than four hours—which is a medical emergency. Pain, bruising, and scar tissue are other potential concerns.

This is not the kind of medication for “a little extra, just in case.” The correct dose is the lowest dose that produces the desired result safely.

Why Follow-Up Is Part of the Treatment

Whether a man uses testosterone, tadalafil, sildenafil, PRP, Trimix, or a combination, I want follow-up. I want to know what worked, what did not, what side effects occurred, and whether the underlying health picture has changed.

I have treated thousands of men, and experience teaches that two men with the same complaint may need different plans. Good sexual-health care is not about selling the strongest treatment. It is about choosing the right treatment, in the right order, for the right patient.

Recharge Clinic offers free consultations for men's sexual-health and performance services. You can ask the questions you have been avoiding, learn about the options, and find out whether an evaluation or treatment may be appropriate for you.

Book a FREE consultation and receive a $20 Recharge credit!

In the final blog of this series, we will talk about the part many men skip entirely: routine labs, PSA awareness, and why “I feel fine” is not a medical monitoring plan.

[ Blog 3 - Feeling Fine Is Not a Lab Result]

Frequently Asked Questions

1. What is the difference between tadalafil and sildenafil?

Both are PDE5 inhibitors that improve the blood-flow response involved in an erection. Sildenafil is typically used on demand and has a shorter window. Tadalafil lasts longer and may be prescribed on demand or as a daily option for selected patients. The right choice depends on health history, other medications, side effects, and personal preference.

2. Can I take tadalafil or sildenafil if I use nitroglycerin or another nitrate?

No. PDE5 inhibitors and nitrates can cause a dangerous drop in blood pressure when combined. Tell your provider about every prescription, supplement, and recreational substance you use before taking an ED medication.

3. Are the PRP sex shot and Trimix the same treatment?

No. PRP uses a concentrated portion of the patient's own blood and is an emerging regenerative treatment; it is not intended to produce an immediate medication-driven erection. Trimix is a compounded prescription medication injected into erectile tissue to trigger an erection through increased blood flow.

4. What should I do if an erection lasts longer than four hours?

Seek emergency medical care immediately, even if the erection is not painful. A prolonged erection can permanently damage erectile tissue if treatment is delayed.

5. Where does Recharge Clinic offer men's ED consultations?

Men can schedule free consultations through Recharge Clinic locations serving Ocala, Lady Lake/The Villages, and Clermont. Telehealth is available, although some evaluations, teaching, labs, and procedures require an in-person visit.

External References

National Institute of Diabetes and Digestive and Kidney Diseases: Treatment for Erectile Dysfunction

Open reference

PubMed: Intracavernosal Injection of Autologous Platelet Concentrates for Managing Erectile Dysfunction—A Meta-Analysis of Randomized Placebo-Controlled Trials (2026)

Open reference

Medical note: This article is for education only and does not replace an individualized medical evaluation. Prescription ED medications and injections can have serious contraindications and risks and must be prescribed and monitored by a qualified medical provider.