// October 30th, 2010 // No Comments » // Impotence

The initial brouhaha attending the introduction and early years of penile prosthesis surgery has subsided. It is now possible to reflect and cast a sober eye on the role of penile prostheses in the treatment of impotent men. It is clear now that surgical skills alone are not enough to solve the problem of impotence.The penile prosthesis industry is highly lucrative and competitive. The five penile-prosthesis manufacturers collectively accounted for $60 million in worldwide sales up to 1998.It is too early to know whether the availability of Viagra will dampen enthusiasm for penile prosthesis implantation. Still, the most optimistic estimates indicate that Viagra is effective in restoring erectile function in about 65 percent of impotent men. Among those 35 percent of impotent men who have a suboptimal response to Viagra are men who have become impotent as a result of:

• Radical prostatectomy
• Neurogenic impotence
• Diabetes mellitus

Thus, the remaining 35 percent of men with erectile dysfunction who do not respond satisfactorily to Viagra are precisely those men who have, in the past, been considered to be ideal candidates for penile prosthesis surgery. However, these are the same men who may also respond to penile injection therapy or intra-urethral alprostadil (medicated urethral suppository, or MUSE) therapy. With so many treatment options now available to correct erectile dysfunction, significant adjustments in strategy will be needed to decide exactly what treatments are best for the 30 percent of men who do not benefit from Viagra.


// October 30th, 2010 // No Comments » // Impotence

Prostheses have been implanted in men with virtually every known type of impotence, but some men are more appropriate candidates for surgery than others. Urologic surgeons prefer to implant devices in men whose impotence is a result of a physical cause, either neurogenic or vasculogenic. Included in the category of neurogenic impotence are men with diabetes mellitus, spinal-cord injuries, and multiple sclerosis, along with paraplegics and men whose pelvic nerves have been damaged or severed during prostate or lower abdominal surgery. Vasculogenic impotence applies to men with either decreased penile arterial inflow or increased venous outflow; vascular surgery is the preferred form of treatment for these men. But they are not always willing to go through the somewhat more complex surgical procedures and may elect prosthetic implantation instead.

As noted, patients with Peyronie’s disease have no difficulty achieving an erection. The problem is that the erection bends, so the penis deviates, often creating a J-shaped erection unsuitable for intercourse. Peyronie’s disease occurs when fibrous bands grow in the outer lining of the penis and tug at the penile shaft. The bands can be removed surgically, but this is only a temporary solution because these strictures tend to recur at the same or different locations in the penis. Implanting a prosthesis is often the only way to circumvent the problem.Men with endocrine disorders, whose potency can be restored with appropriate hormonal therapy, and men with overt psychologic problems, who require psychotherapy, psychiatric medications, or both, are the only groups to whom physicians do not routinely offer penile prosthetic implants.


// October 30th, 2010 // 4 Comments » // Impotence

Although surgical success rates for some devices now approach 90 to 95 percent, patient satisfaction does not parallel this impressive figure. A major problem is disappointment with postoperative penile length and width. Some men never attempt intercourse after the prosthesis is implanted; others have intercourse for only a brief time and then abandon sexual activities. Additional areas of disaffection with prostheses have surfaced in response to specific questions.

The majority of urologists are men, and in the beginning, the male perspective distinctly colored the reported results of prosthesis surgery. Female health-care professionals saw things differently. They approached the issue of satisfaction after implantation by interviewing both partners. Some couples were not having intercourse at all. Of those who were having intercourse, 25 percent reported restriction in positions because of the decreased penis size. Fifteen percent of the men experienced diminution of orgasmic intensity. Still, 79 percent of men said that they would, if given the opportunity, undergo the operation again. Only 59 percent of their partners had no hesitation.

Some urologists claim that satisfaction depends on the type of prosthesis, with IPP recipients being generally more satisfied than those who receive other prostheses. Because they are easily concealed and readily activated, one would have anticipated that the multicomponent IPP would have emerged by now as the dominant, if not the only, penile prosthetic device implanted.

This has not turned out to be the case, for two reasons. Significant problems with the internal hydraulics of IPPs remain, and mechanical failures are common. Perhaps more troublesome is the fact that a certain amount of manual dexterity is required to inflate the IPP.Originally, in an effort to mimic the genital caressing that is a natural component of sexual foreplay, the man’s sexual partner was encouraged to play an active role in pumping the scrotal bulb so that fluid could be transferred from the abdominal reservoir to the prosthesis, a maneuver intended to mimic a stimulated erection. This has not been as warmly embraced as expected.Sexual partners are often unwilling to participate in the pumping procedure. Some are simply not deft at manipulating the scrotal bulb. As a result, inadequate amounts of fluid are transferred from the reservoir to the prosthesis shaft, and a suboptimal erection ensues. In such cases, failure of the device has been ascribed not to mechanical problems of the unit itself but to the inadequate level of participation of sexual partners. Those who have been unwilling to become involved as vigorous squeezers of the scrotal bulb have been decried as “timid pumpers.” Other factors may also have a significant impact on postoperative sexual satisfaction. Any of the following put the couple’s satisfaction at risk:

• Extreme obesity
• Psychogenic impotence
• Impotence not the only sexual problem
• Sexual dysfunction in woman
• Severe marital conflict
• Unreasonable expectations
• Partner opposed to surgery
• Woman pressuring man to have surgery
• Couple ceased all sexual touching

Obese patients are often displeased following penile prosthesis surgery because the length of the unit protruding beneath their lower abdominal fat pad is limited. Most prostheses are approximately eight inches in length. If there is an extensive overhanging fat pad, then perhaps only an additional four inches of rigid penile tissue will protrude for purposes of sexual intercourse. If the patient’s partner is also obese, it will be very difficult for the couple to find a position in which penile-vaginal penetration and adequate vaginal containment is possible. For obese couples, postoperative sexual gratification may be limited.

Inappropriate expectations are high on the list of reasons for postoperative patient-partner dissatisfaction. The prosthesis provides only the penile rigidity necessary to achieve vaginal penetration. Patients who anticipate

that the equipment will allow them to recapture the real, or imagined, sexual prowess of their youth are likely to be displeased.

Patients whose impotence is attributed to psychogenic factors do not derive as much long-term benefit from prosthetic surgery as those whose impotence is caused by either neurogenic or vasculogenic factors.

On occasion, impotent men have sexual problems other than erectile dysfunction. Lack of spontaneous arousal, limited libido, and ejaculatory disorders are not corrected by penile prosthesis implantation.

The level of preoperative patient-partner interaction is a critical determinant in evaluating postoperative satisfaction. If, for example, the female partner has her own sexual dysfunction, such as pain during intercourse, then she may be fearful of experiencing vaginal penetration again. A man may choose to have a penile prosthetic implant without notifying his partner. Such a decision is commonly interpreted as a rejection of the partner. In addition, some women are fearful that their previously impotent partners, now outfitted with penile prostheses, will seek other lovers. Limited studies exploring this question have indicated that penile prosthesis recipients are no more susceptible to seduction than other comparably aged potent men, nor do they routinely seek out new sexual opportunities more often than their potent peers.

On the other hand, some female partners of impotent men, frustrated after long periods of sexual abstinence, may pressure the men into surgery. Any discordance in patient-partner desires for penile prosthesis surgery is considered a major risk factor for postoperative dissatisfaction.

Couples who have distanced themselves sexually from each other and have ceased hugging, touching, and all sensual and erotic contact may not be able to retrieve all aspects of normal sexual function merely by placing a prosthetic rod in the penis. Clearly, satisfaction is maximal only when both partners are involved in all discussions and decisions from the beginning.


// October 30th, 2010 // No Comments » // Impotence

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.