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PENILE PROSTHESIS SURGERY

With continued experience, physicians have learned much more about who is and is not a good candidate for penile prosthesis surgery. For example, impotence is common in diabetic men who can usually resume sexual intercourse after a penile prosthesis is implanted. However, diabetics are prone to develop infections, particularly when their diabetes is not well controlled. One test commonly performed to assess the adequacy of diabetic control is a test called a glycohemoglobin, which should be no higher than 6.9 percent. Diabetic men strive for but do not consistently achieve this goal. If they are far off the ideal mark and have a glycohemoglobin over 11.5 percent, the chance of infection is so high that some urologists will refuse to install a penile prosthesis. Only when diabetic control is more satisfactory, as judged by a closer-to-normal glycohemoglobin, will surgery be contemplated.

In the early days of penile prosthesis surgery, problems inherent in prosthesis design resulted in mechanical failures, and this structural breakdown

was the primary reason some men who had penile prosthesis surgery had to have the defective implant removed and a new one installed in a second operation. With technical advances in prosthesis design, mechanical failures now occur less frequently and infection is now the major reason for repeat penile prosthesis surgery.

The data in the tables are as reported by Dr. Ronald Lewis from the experience of the Department of Urology at Mayo Clinic. Men who are having their first penile implant should anticipate a reoperation rate of 10-15 percent between five and ten years after the original surgery, whereas those who have already had one penile prosthesis revision should be advised that fully 25 percent of them can anticipate a need for reoperation in less than five years. The majority of men who have penile prostheses implanted do not require any more surgery, making patient and partner satisfaction the primary determinants of the success of the surgery.

LONG-TERM COMPLICATIONS OF PENILE PROSTHESIS SURGERY

All penile prosthetic devices are made of silicone. Now, silicone has proven to be remarkably versatile, and this same material, in liquid form, has been used by plastic surgeons for breast implants, to reconstruct the breast after breast cancer surgery and also to augment the appearance of the breast in other women. When used for purposes of breast reconstruction or augmentation, liquid silicone must be encased in a plastic bag. The silicone-containing plastic bag is then inserted under the skin to reshape the breast. On rare occasions, silicone has leaked out of the bag and drifted into other parts of the body. Women who have had silicone breast implants have subsequently developed serious medical problems such as immunologic diseases and second cancers that they have attributed to the silicone used in breast implants. For the silicone to be responsible for such problems, it must first leak out of its bag and then enter the body’s veins, arteries, or lymph nodes and activate abnormal immunologic responses in the body’s lymphatic system. Such leakages do occur, and it is possible that this is what has caused the serious systemic disease in women who feel they have been injured by silicone breast implants. Although confined to a relatively few women, this is nonetheless a serious problem. Today, the FDA has approved silicone for use in women undergoing breast reconstruction surgery but discourages its use in women who desire augmentation breast surgery.It is reasonable to inquire: Is the silicone used in penile implants in men as hazardous as the silicone used in breast implants in women? For silicone to wreak havoc in the man as it does in some women, the penile prosthesis silicone must shed some particles. These individual silicone particles must migrate, invade, and set off an inflammatory response, first in the fibrous capsule surrounding the prosthesis, then moving on and insinuating themselves into local lymphatic tissue (lymph nodes) to trigger immunologic reactions. Surprisingly, this problem has not been as extensively evaluated in men as it has been in women. Only 25 penile prosthesis recipients have been evaluated to date.

While it is reassuring to learn that no man in this small series developed any immunologic disease or adverse systemic reaction to silicone penile prosthesis implantation, the discovery that particles from the prosthesis can migrate to the capsule and to locations as remote as a lymph node near the aorta was unexpected. The implications of this observation are that physicians caring for penile prosthesis recipients must recognize that silicone particles can separate from the penile prosthesis. Most will remain harmlessly encased in local granulomas, but a few are capable of drifting beyond the confines of the penile shaft and into local or remote lymph nodes. Adverse immunologic reactions, when they occur, begin in lymph nodes, but immunologic disease has not to date been noted in men who have had penile implants.

HOW PROSTHESES ARE IMPLANTED

Normal erections occur as increased blood flows into and is trapped in the two corpora cavernosae and the corpus spongiosum. Penile prosthetic devices, whatever kind, all attempt to duplicate this process by outfitting the penis with silicone surrogates for the two corpora cavernosae. (The corpus spongiosum is not replaced during implant surgery.) Prior to implantation, the tissue in the penile cavernosa must be stretched to accommodate the rods.

Patients receiving either the Scott or Mentor inflatable prosthesis require one additional surgical procedure. The bulb for activation or transfer of fluid from a reservoir to the prosthetic shaft is surgically implanted in the scrotum.

Most prostheses are inserted by making a surgical incision either in the lower abdomen or at the junction of the penis and the scrotum and then advancing the rod forward toward the tip of the penis. Some of the newer self-contained penile prostheses, on the other hand, may be inserted by making an incision around the tip of the penis and pushing the prosthetic rods backward toward the bony joint at the end of the torso. The patient usually requires general anesthesia and stays in the hospital three to five days. Some surgeons give patients a spinal block (or spinal epidural anesthesia) and send them home on the same day, but this practice is not widespread. Inflammation, a reaction to the insertion of a foreign body in the penis, causes some postoperative pain, which is controlled by medication. The pain subsides as the inflammation wanes. Following surgery, the patient must allow four to six weeks for healing. During this interval, the silicone rods become firmly embedded and anchored in the penile shaft. Then the prosthesis is ready for use.

SUCCESS RATE

Recipients of penile prostheses are generally pleased with the results. All acquire a rigidity of the penile shaft adequate for penetration. Initial reports from urologic surgeons were glowing, with success rates reported at 90 to 95 percent. Long-term follow-up has tempered this enthusiasm to some degree. Today, patient and partner satisfaction is closer to 60 to 75 percent.

COMPLICATIONS OF PENILE PROSTHESIS SURGERY

A surprisingly large number of men will require repeat surgery. The most common complications are mechanical failure of the prosthesis, postoperative infection, and penile pain.

Mechanical complications occur most often in multicomponent inflatable prostheses and reflect malfunction in the workings of the rods, cylinders, or hydraulic system or kinks in the tubing. The prosthesis must be

removed and replaced with either a new, identical unit or an alternative type of prosthesis; the choice is up to the urologist and patient.

Postoperative wound infection is less common today than in the past. Now implant recipients receive antibiotic treatment during and immediately after surgery.

Postoperative pain does occur in some patients. It is usually localized in the tip of the penis (the glans); however, discomfort in the penile shaft, scrotum, base of the penis, or abdomen is not uncommon. In one series of 179 penile prosthesis implants performed at the Mayo Clinic, 61 patients reported complications with the prostheses’ mechanisms. Another 42 patients experienced pain, most commonly at the tip of the penis but occasionally in the penile shaft, scrotum, base of the penis, or abdomen. Of these men, 32 rated their pain moderate or severe.

Pain can herald a more serious problem. It may imply that the position of the prosthesis compromises the function of other vital structures. Pressure on the urethra will cause pain and is a warning of some underlying problem. Paraplegic patients, however, do not perceive pain. As many as onethird of impotent paraplegic men with penile prostheses experience damage to their urethra within six months after surgery.

Research indicates that complications as well as the need for reoperation seem to depend on the type of device implanted, the duration of the followup, and the group of patients studied. For example, patients implanted with the older, rigid Small-Carrion prosthesis rarely require reoperation. The reoperation rate is much higher with inflatable penile prostheses (IPP). The malleable and self-contained penile prostheses (SCPP) are the least prone to mechanical breakdown. However, even when these devices were relatively new and most urologists had little more than two to three years of experience with them, reoperation rates were 14 to 22 percent.

TYPES OF PENILE PROSTHESES

The Small-Carrion and Scott penile prostheses are still used but are not the only options. There are a number of different devices on the market today. Four discrete categories of prostheses — semirigid, malleable, inflatable, and hinged — are currently available. All the units listed below have been judged safe and effective by an expert group of urologic surgeons recruited by the American Medical Association to participate in the recent Diagnostic and Therapeutic Technology Assessment panel.
The original Small-Carrion prosthesis consists simply of two rigid rods.
• Penile prostheses with abdominal fluid reservoirs include the ScottAMS 700 and a similar device manufactured by the Mentor Corporation.
• The Jonas prosthesis is a sernimalleable device that depends on a network of internal silver wires to allow for some degree of flexibility.
• The OmniPhase and DuraPhase prostheses have internal cables that allow the device to bend to a flaccid state when not in use. These units are activated by adjusting the cable to produce penile rigidity. Other malleable devices like the AMS 600 and Mentor have similar designs.
• The Finney prosthesis is hinged and converts from flaccid to rigid state merely by locking the hinge in place.
• Newer inflatable prostheses like the Hydroflex and FlexiFlate have internal fluid systems and are designated as self-contained penile prostheses (SCPP). The SCPP transforms the penis from a flaccid to an erect state by manipulation of a valve implanted in the tip of the penis.

Individual urologic surgeons may at one time or another favor one prosthesis over another. However, no single device has yet emerged as the dominant unit of choice. Each device has its own intrinsic advantages and disadvantages.  The rigid, malleable, hinged, and controlled expansion cylinder devices do not increase penis length or girth. These devices come in a variety of lengths; the urologist chooses from an inventory of prosthetic units a rod customized for each individual patient. The Scott and the comparable Mentor multicomponent inflatable penile prostheses (IPPs) both allow some increase in penile girth and rigidity without changing penis length.

Most urologists take pains to discuss this issue in detail. It is important for potential recipients to understand this preoperatively lest they harbor any illusions of acquiring significant augmentation of penile anatomy and sexual prowess. Such fantasies can never be fulfilled by any of the currently available prosthetic devices.

Penile Implants

For years, men suffering from impotence or erectile dysfunction would turn to urologists, surgeons specializing in what were considered to be men’s problems, including urinary difficulties brought on by a large prostate gland, prostate and testicular cancer, and impotence. Focusing on ways to alleviate the mechanical problems of acquiring and maintaining an erection, urologists devised ingenious methods to allow impotent men to enjoy sex once again. They developed silicone penile prostheses and vacuum devices and were at the forefront in the implementation of penile injection therapy.

Surgical implantation of penile prosthetic devices has been and is still an accepted means of restoring erectile capability in impotent men. In 1989, U.S. surgeons implanted an estimated 27,500 penile prostheses. That number has declined only somewhat since the advent of penile injection and MUSE therapy. The fate of penile prosthesis surgery after Viagra remains to be determined. However, since about 30 to 35 percent of impotent men who try Viagra do not respond well enough to resume sexual intercourse, there will always be a sizable number of impotent men who will want to have penile prosthesis surgery or some other erection assistance to help them enjoy sex again.

Dr. William Scott of the Johns Hopkins Medical School and Dr. Michael Small, professor of urology at the University of Miami Medical School, and his associate Dr. H. M. Carrion are recognized as the patron saints of modern penile prosthesis implant surgery. Dr. Scott fashioned a silicone inflatable penile prosthesis (IPP), which he first implanted in early 1973. Drs. Small and Carrion developed their unit shortly thereafter. The Scott and Small-Carrion devices are the prototype for most of today’s penile prostheses.

The original Scott prosthesis, a multicomponent device, had a fluid reservoir implanted in the lower abdomen. A tube from this reservoir was connected to a bulb in the scrotum. The penis remained in a normal flaccid state until intercourse was desired. Then an erection was created by pumping the scrotal bulb to transfer the fluid from the reservoir to the penile implant.
The Small-Carrion prosthesis did not rely on hydraulics to convert the penis from a flaccid to an erect state. Once inserted in the penile corporal bodies, the device provided a perpetual erection. Although highly desirable during moments of sexual intimacy, this proved to be something of a burden at other times. The first recipients of Small-Carrion penile implants found it necessary to gird themselves in tight-fitting underwear or wear baggy pants to camouflage their protruding penis. Concealment was the watchword for these men.Since its inception, penile implant surgery has become so popular that in less than fifteen years, the procedure has generated its own legacy of legends, mythology, and misconceptions. Since penile prosthetic implants are still an integral component of the current spectrum of therapeutic options offered to impotent men, it is important for the potential penile-implant recipient to ask the following questions:
• What aspects of sexual function are improved or unchanged following prosthesis implantation?
• What types of prostheses are currently available?
• How are prostheses implanted?
• Are there any complications of prosthesis surgery? Am I an appropriate candidate for prosthesis surgery? What factors determine patient-partner satisfaction or dissatisfaction following surgery?
• Is the silicone used in penile implants in men as hazardous as the silicone used in breast implants in women?
Penile prostheses serve only one function: They provide the penile shaft with sufficient rigidity to allow for vaginal penetration. They do not increase penis size, nor do they enhance any other aspect of the male sexual response cycle. One of the common misconceptions about penile prosthetic surgery is that men who receive prostheses will be endowed with a penis of prodigious length and girth. This is not the case. Prostheses cannot lengthen the penis since the rods are inserted in the corpora cavernosae of the nonerect penis; they must be confined to this limited anatomic space.In this way, the erectile capability created by a penile prosthesis differs from spontaneous erections. The naturally occurring spontaneous erection causes a discernible increase in penile length and girth. The discrepancy between a man’s recollection of the size of his prior erections and the erection afforded by the penile prosthesis may cause some disappointment. The prosthetic erection provides only the rigidity needed for penetration, nothing more.Men with penile prostheses do not experience enhanced arousal, nor do they have any sense of amplified ejaculation or orgasm. Indeed, most recipients indicate that those aspects of sex may be somewhat less satisfactory than before. This disappointment, however, is usually overshadowed by the sheer relief of once again being able to have erections.

DEPRESSION

Depression is different from sadness. We all get periodically despondent, unhappy, and disheartened over life’s disappointments. After a period of brooding and feeling sorry for ourselves, we usually resume normal function.

Depression, however, disables a person. People who are depressed frequently feel worthless, helpless, and guilt ridden. They cannot mobilize the energy, enthusiasm, and concentration needed for most activities, including sex. Impotence, predictably, reinforces the depression.

Depressed people have abnormal sleeping patterns. On the one hand, many depressed people develop insomnia; either they are unable to drop off to sleep or they tend to wake in the middle of the night and cannot fall asleep again. On the other hand, a significant number of depressed people sleep far too long and too much, yet still feel fatigued. They never feel refreshed after a good night’s sleep. Depressed individuals may be plagued by a variety of other physical symptoms, including headaches, persistent dry mouth, stomach aches, excessive belching, passing wind, occasional palpitations, frequent constipation, and inexplicable weight loss. Symptoms such as these should not be ignored, for they may be harbingers of serious physical problems. However, when medical investigation fails to disclose any physical cause, a diagnosis of depression must be considered.

Health professionals rely on information from patient interviews to establish the diagnosis of depression and then turn to standardized formats like the Hamilton Depression Scale (HAM-D) to gauge the severity of depressive symptoms. The HAM-D explores and grades different aspects of depression, including mood, sleeping problems, feelings of guilt, suicidal thoughts, and sexual dysfunction, and then assigns a numerical score to reflect the intensity of each symptom. The greater the depression, the higher the score. As treatment alleviates depression, HAM-D scores return to normal.
The severity of the depression determines the therapeutic approach. Some depressed men may be incapacitated or suicidal. They may well require hospitalization. Less-severely impaired men who are troubled primarily by their depression-induced impotence and inability to function at work and in relationships can be treated as outpatients. Generally, treatment involves a combined approach utilizing psychotherapy and antidepressant medication.Wide ranges of drugs capable of stabilizing mood and relieving depression are available. The combination of antidepressant medications and psychotherapy is usually effective, and sexual potency frequently returns as treatment lifts the depression.However, antidepressant medication can create another sexual problem. About 25 to 50 percent of men treated with antidepressants experience some difficulty in ejaculating. This is sometimes overcome by switching to another medication.

INSIGHT THERAPY

Impotent men with more deeply rooted emotional problems do not benefit from sensate focus therapy. They must come to terms with the seeds of their discontent through short-term or in-depth therapy. Insight therapy involves an exploration of the factors responsible for original and current erectile failure. The man is obliged to reexamine all aspects of his sexual life.
Andrew’s sexual problems began after his forced retirement. He was unable to make love to his wife the night he received the news. His retirement plan provided a comfortable income but no solace. In his preretirement days, he went to bed confident that he would be at work the following morning. Sexual intercourse was never a problem. Now he went to bed worrying not only about the next day but about the rest of his life. His morning and nighttime erections were as firm as ever, but he could not muster an erection when he attempted to have sex. He felt like a failure.

The sense of worthlessness engendered by his obligatory retirement was overwhelming, and Andrew plunged himself into a frenzy of activity to reaffirm his value as a man. Unfortunately, the intensity of his activity consumed all of his intellectual and sexual energy, leaving no room for his wife. A realignment of priorities was in order. Andrew was encouraged to restructure his daily activity and carve out a specific time of day to focus some of his considerable energy on his sexual feelings for his wife.

Crises have a way of galvanizing a relationship between caring couples, and Andrew was able to reaffirm his love for his wife and rechannel his energies appropriately so that his erectile function and their sexual happiness became “better than they had ever been before retirement.”

All the circumstances surrounding Andrew’s sexual problems were of recent onset and readily recalled so that his therapist had little difficulty piecing together the psychodynamics of his impotence and formulating a treatment plan. This is not always the case.

On occasion, the psychologic root cause of impotence is buried deep within a man’s subconscious and is revealed through the more elaborate psychiatric probing available only with psychoanalysis.

In 1985, Robert was forty-four, single, and impotent. Married briefly, then divorced, he was something of an enigma. He was healthy, worked full-time, and had no difficulty meeting and dating women. Morning erections were normal and he could masturbate, but he was unable to have an erection during sex. When a relationship became serious, Robert became emotionally aroused but could not translate this sense of sexual excitement into an erection. Eventually, he became embarrassed and stopped dating altogether.

No clues regarding the origin of his sexual problems were forthcoming from the standard psychiatric interviews. Eventually, the psychiatrist suggested psychoanalysis to see if the process of free association would divulge the source of his repressed anxiety about sex.

Psychoanalytic sessions are, by nature, rambling and not immediately productive. However, after several sessions, as Robert was recalling events of his childhood, he blurted out, “Don’t pull your pants down. Don’t let them see you with your pants down. If you have to pee, make sure no one is looking.”

EXERCISES TO DELAY EJACULATION

Psychologists and sex therapists cite an 80 to 85 percent success rate in helping men overcome their tendency to ejaculate before maximal sexual excitement has been achieved. Two maneuvers — the squeeze technique and the start-stop technique — help men acquire a sense of confidence and control about timing of ejaculation. Both exercises utilize partner-initiated masturbation to stimulate arousal and are often performed in conjunction with a sensate focus program.

The squeeze technique encourages penile stroking and genital caressing up to the point of orgasm. When the man senses that he is about to ejaculate, he signals his partner, who lightly circles the fingers of her free hand around the glans, the bulbous tip of the penis. When the man senses he has achieved some control of his impulse to ejaculate, stimulation resumes until he reaches a sense of containment of semen.

The start-stop technique also begins with partner-initiated penile stroking to activate an erection. When the man is near ejaculation, he instructs his partner to stop. After a few moments (or minutes), he gives the signal to start, and the process is repeated. As the exercises progress, the interval between the start and stop signals lengthens until finally the man acquires the ability to determine the moment of ejaculation.

The couple may repeat the squeeze or start-stop exercises as often as they like during a session; ultimately, the man will ejaculate. Gradually, as the man becomes used to experiencing prolonged pleasure from sexual stimulation, he will gain confidence and control over the timing of his ejaculation.

VIAGRA FOR MEN WITH PSYCHOGENIC IMPOTENCE

The man who has lost confidence in his ability to engage in sexual intercourse because of his preoccupation with his ability to acquire and then sustain an erection and has lapsed into the ritual of “spectatoring” whenever he attempts to make love is an ideal candidate for Viagra. His concerns regarding the durability of his erection can be put to rest if he is willing to wait for the Viagra to take effect. Then, with the caressing and genital stimulation of normal foreplay, his penis will become erect and will remain so until he has completed intercourse and ejaculated. If, however, he is impatient or brings to the bedroom the anxieties of past sexual failures, he will continue to have problems. In that case, coupling a dose of Viagra with the sensate focus exercises described should allow him to regain his lost self-assurance and enjoy sex once again.

PERFORMANCE ANXIETY

Performance anxiety is one of the most common sexual problems. A man, fully potent for most of his life, suddenly experiences a sexual failure. He is surprised to find that while having sex he can neither achieve nor sustain an erection satisfactory to complete the sexual act.

Men respond to this problem in different ways. Some assume that the failure was a temporary nuisance that will resolve itself spontaneously. They do not dwell on one isolated incident and indeed have no difficulty having an erection the next time they attempt sexual intercourse.

Other men become preoccupied with their ability to achieve an erection. The sexual act shifts from a sensual, erotic experience to a worrisome encounter. The man becomes obsessed with the transition of his penis from a limp to an erect state. Each time he attempts intercourse, he wonders whether he will be able to have an erection, and if so, for how long. These concerns are difficult to extinguish. The man becomes so consumed with them that all other components of the sexual act lose importance. He is, in a sense, staring at his penis like a spectator waiting to see if the erection will occur and praying that once it does occur, it will not fade.
The term spectatoring has been coined to describe this phenomenon. The focus on the penis consumes the man to the exclusion of all other sexual thoughts. The “willingness to make love” has been replaced by an “anxiety over the ability to make love.” The cycle is vicious. The more he concentrates on his penis to see if it will become erect, the more he is destined to fail. A series of failures begets more anxiety, which in turn guarantees further failure.What commonly follows is a cascade of events that makes things worse. First he withdraws, avoiding routine intimate and even conventional physical contact, such as hugging and kissing. His anxiety about his inability to perform becomes intense. Soon he ceases all sensual contact and feels broken and diminished by his impotence.One pragmatic treatment approach accepts a man’s sexual dysfunction and impotence as a fact and does not inquire into the source of the problem. Treatments are designed to help him restore his willingness to make love, his capacity to relax, and his ability to concentrate on sensation. These are the sensate focus exercises popularized by Masters and Johnson.