PROVINCETOWN — As summer ramps up, so too does a nightlife scene that draws throngs of gay men to the tip of the Cape. Nightclubs like Purgatory and the Paramount host packed underwear parties, and the thumping music of house parties can persist long after the A-House dance floor goes quiet at 1 a.m.
According to two local urologists, Provincetown in summer is also a hotbed of unsanctioned medical activity. In recent years, according to Dr. Evangelos Geraniotis of the Urology Associates of Cape Cod, there’s been an increase in the number of patients coming to the emergency room with extremely prolonged erections, or priapism.
“We are seeing a lot of men come to Cape Cod Hospital as emergencies with issues from this,” Geraniotis said. The men show up in excruciating pain, erect but not aroused, and require an injection of phenylephrine to counteract the earlier injection that caused their condition.
In most cases, these patients have injected an improperly large dose of the medically effective compound TriMix — which contains three active agents — or the FDA-approved Caverject.
Those injections are “known, accepted medical treatments for erectile dysfunction,” Geraniotis said. They work by triggering blood vessel chambers to open and create an erection. The drugs are safe when administered correctly and at the right dose — but if misused, there is danger of short-term and long-term damage, including lasting impotence.
“Every weekend,” said Dr. Andrew Kramer, also a member of Urology Associates of Cape Cod, he sees patients who say, “ ‘My friend or partner gave me the shot.’ And lo and behold, the man destroys his penis.”
Damage is magnified when men wait too long to seek medical help. Kramer said he’s seen patients come to the hospital after six hours, while others waited three full days.
“It’s a risky business,” said Geraniotis. Constricted blood flow can deprive tissue of oxygen, and the longer that goes on, “the greater the risk of lasting impotence from this catastrophe.”
Kramer said that on typical summer weekends, at least one or two patients come to Cape Cod Hospital with a priapism emergency. Overall, he said, nine out of ten such emergencies involve men coming from Provincetown.
Dr. Marie Andrine Constant, chief population health officer at Outer Cape Health Services, said that since February she had heard of one case of priapism at the clinic. It was linked to TriMix, although she was not sure if the patient had a prescription for the drug or had received the injection socially.
“Because I haven’t seen the patient, I can’t dig into that information, but I know it was associated with the use of that medication,” Constant said. The patient was sent to Cape Cod Hospital, Constant said.
“There is a culture in Provincetown where men are offered injection therapy for erections, many times without any medical background on the part of who is offering this,” said Geraniotis. “It’s almost like an illicit drug use.”
To establish a patient’s correct dose of TriMix, doctors inject tiny amounts of the drug in incrementally larger doses until an effective dose is established. At that point, patients typically are shown how to administer the medication at home, with the goal being an erection that lasts about 20 minutes, Geraniotis said.
When the drug is shared with other men, however, “It’s a very slippery slope from efficacious to way too potent,” Kramer said. Sharing can happen at home and at parties, the doctors said.
On the Saturday night before July Fourth, two Independent reporters asked 13 men on the patio of Club Purgatory about erection injections.
None of them said they had used TriMix, but almost half said they had heard about it. One had seen an injection at a house party, and a second had an out-of-state friend who had suffered complications from TriMix. A third was interested in learning about the drug.
TriMix is not a controlled substance and is readily available from compounding pharmacies, Kramer said. “Because this type of medication is widely available, men offer it to other men without any knowledge of how much to give or how to give it,” he said.
Constant stressed that it’s important not to share medications. “You don’t share your medication for diabetes, you don’t share your medication for ADHD,” Constant said. “That’s just a general precaution.”
Platelet-Rich Plasma
The market for penile enhancement is robust: by “hitting at men’s deepest insecurities,” Kramer said, “you’ve got a captive audience.”
In her July 3, 2023 article on penis enlargement in the New Yorker, Ava Kofman exposed what she called the “clannish, hypermasculine world of American urology.” Some doctors market procedures before they have been fully assessed.
A report last week in the New York Times about solutions to erectile dysfunction referred to “several regenerative therapies currently undergoing extensive research,” some of which have “shown promise” but have not been fully assessed. Among those therapies are platelet-rich plasma (PRP) injections — which are currently being advertised by a newly established local business, Helltown Aesthetics, as “penile PRP” or the “P-shot,” according to founder Brandon Christopher, who is a registered nurse.
Penile PRP injections are entirely different from TriMix; neither of the urologists the Independent consulted had heard of serious medical issues resulting from PRP injections.
“In anecdotes of hundreds of men, I’ve never seen it hurt anybody, and I’ve never seen it help anybody,” said Kramer.
In PRP therapy, the patient’s own blood is drawn from the arm and spun through an FDA-approved centrifuge, and the platelets and plasma are reinjected. PRP is broadly accepted in the world of orthopedics and is used in sports medicine to speed up recovery from joint injuries. It has been shown to accelerate tissue healing after cardiac and plastic surgeries.
Following on those uses, penile PRP involves injecting the patient’s blood components into the penis “to basically bring accelerated healing to that area,” Christopher said.
“It enhances sensation,” Christopher said, adding that penile PRP is effective in treating erectile dysfunction and Peyronie’s disease. “And then, as an added bonus, it can also add some size and girth to the penis as well,” Christopher said.
Christopher’s professional background includes emergency room critical care nursing as well as make-up and aesthetics. He said penile PRP is a way of “serving the LGBT community” by “enhancing someone’s beauty and confidence, while also at the same time not changing them.”
He recommends that clients purchase a treatment package with three injections administered four to six weeks apart. A single injection costs $1,900; a package of three treatments is $5,500.
Helltown Aesthetics began offering penile PRP injections in May of this year; since then, they’ve administered it to four clients in Provincetown, Christopher said. At his previous practice in Boston, he treated an estimated 50 clients.
There’s no insurance coverage for the procedure, Christopher confirmed. That fact is one basis for Kramer’s skepticism about the therapy: “The bona fide treatments are typically things you don’t pay cash for,” he said.
Evidence for the efficacy of PRP as an erectile dysfunction treatment is both limited and encouraging. A study published in 2021 in the Journal of Sexual Medicine involving 60 patients with moderate erectile dysfunction found that 69 percent of those injected with PRP saw medically significant improvement. Though promising, “further high-quality studies are warranted to corroborate our findings,” the researchers wrote.
A 2022 medical review of evidence for PRP as an erectile dysfunction treatment published in Frontiers of Reproductive Health cited the 2021 study. Although it showed “impressive response,” the reviewers wrote, “further longer-term follow-up data is required to understand the longer-term impact of the PRP injections on erectile function.”
When asked about the medical uncertainty surrounding PRP as an erectile dysfunction treatment, Christopher said the procedure doesn’t fit neatly into modern medicine.
“It’s more of a natural product that comes from your own body,” Christopher said. “It kind of doesn’t line up with how doctors are trained. I have never spoken to a urologist on this,” Christopher added, though he has consulted other clinicians and his trainer, Dr. Charles Runels, an emergency room doctor who began practicing hormone therapies and who claims to have invented the “P-shot.”
A complicating factor in the question of efficacy is the strong evidence for placebo benefits, Kramer said. Research published in 2020 involving 12,564 patients found that placebo treatments significantly improved erectile dysfunction.
That has a lot to do with confidence and a relaxed parasympathetic nervous system, Kramer said. “I always tell men, ‘Your biggest sex organ is your brain,’ ” Kramer said.
Staff reporter Aden Choate contributed reporting.
