“Why does prescription medicine come with instructions saying the pills must be “taken by mouth?” How else would one take them? I shudder to think!” My cousin posted that on Facebook and a litany of reasons followed in response.
No sooner than that discussion began to explore the importance of being very specific with prescriptions, that I filled a prescription for diazepam 5mg to be used vaginally! It was not an error, the patient suffers from pelvic floor dysfunction. Sure enough, there is some evidence in the literature to support this off-label use. One small (n=21) study published in Urologic Nursing found that 62% of the participants were moderately or markedly improved. So there does seem to be some rationale for using diazepam to minimize pain during intercourse for women with urogenital pain or pelvic floor dysfunction.
Speaking of vaginas, did you see that University of Wisconsin student who made some homemade yogurt from the bacteria in her vagina? A healthy vagina should have a decent population of lactobacillus so it makes sense that she could get a starter culture from her vag (using a wooden spoon!) to add to milk. Heat, culture, serve. She ate at least a couple bowls of the stuff despite the warnings from FDA that “vaginal secretions are not considered ‘food’, and they may transmit human disease, a food product that contains vaginal secretions or other bodily fluids is considered adulterated.” I assume that she was fully aware of where her genitalia had been and who it had been hanging out or hooking up with, if anyone. One of my techs noted that people will willingly “eat” each other’s genitals, but will cringe and avoid eating a brown spot on a banana. People are fun!
I digress. The FDA recognizes over 100 routes of administration for medications. Many of these involve needles, where the drug is delivered to a precise target in the body (retrobulbar = behind the eyeball), to the more common injections such as into a vein (IV = intravenous), or into a muscle (IM = intramuscular), or under the skin (SQ or SC = subcutaneous).
Of course, any orifice is available for drug delivery and pharmaceutical scientists study the feasibility and pharmacokinetics of our various entrances and exits. The great variety of delivery sites coupled with the huge number of drug dosage forms gives medical science an expanding universe of dosing possibilities.
To be fair, let’s take a look at drugs used for erectile dysfunction (ED) so that we give equal time to the penis. If you’ve been following this blog, you already know that early ED remedies included rubbing a variety of spicy concoctions on the uncooperative member. Science progressed beyond those early and messy attempts at erectile achievement.
Prior to any FDA approved meds for ED, many men opted to have penile implants which involved surgery to insert flexible cylinders into the penis which could be filled with saline using a pump, often within the scrotum, to move saline from the reservoir, elsewhere in the groin, to the cylinders within the penis, mimicking an erection. A release valve on the pump would allow the saline to return to the reservoir. This gave a whole new meaning to the “I am here to pump you up!” skits on SNL.
Other drugs were tried before the advent of Viagra and its cousins, including MUSE, an urethral insert containing alprostadil, a prostaglandin (PGE-1). This drug can be absorbed thru the urethral lining, promoting increased blood flow and a viable erection. Take note that a small plastic delivery device is needed and a small urethral suppository is inserted into the penis. It’s been a while since I dispensed one of these but that applicator goes at least an inch into the penis and the suppository must be retained within the shaft and rolling the penis between a pair of hands will help release the drug. All told there is significant penile manipulation involved.
Another way to deliver alprostadil into the penis is by injection directly into the penis. Obviously not for the faint of heart, Caverject is injected directly into the corpus cavernosum. Fortunately, there is a corpus cavernosum on either side of the penis, allowing for alternating injection sites.
Of course the oral medications are the number one ED therapy and constitute most of the $4 billion US market. The next frontiers in sexual therapies involve female libido and premature ejaculation. More on that in a future blog post, suffice to say, science is tapping the huge market demand for unlimited sex with satisfaction guaranteed! Give me an O!
As we bask in the post-coital afterglow of all this activity, let me reiterate the need for very specific patient instructions to avoid the all too familiar tales of suppositories still wrapped in foil inserted into the rectum, or perhaps unwrapped and allowed to melt away between cheek and gum, or the young lady that thought she was supposed to take an OC pill “every time” and came in for a refill after a week, or the mom who put that pink amoxicillin into her child’s ears. It’s safe to say that a pharmacist should always be sure that the patient will administer the medication properly and the patient have no doubt in their mind regarding storage and use of the medications they are using. Remember that old maxim, never assume, or you could make an ass out of you and me.
I thought you might get a chuckle out of these images from my Safe Sex in the Future presentation at the Sixtieth Annual Pacific Coast College Health Association Conference, in November 1996 in Irvine, CA.
That talk also featured this product prediction: