Insertion of Penile Prosthesis
Sexual dysfunction is the inability to participate in sexual activity. It can be secondary to anxiety or emotional disorders, or the loss of libido (sex drive). The most common reason for sexual dysfunction is erectile dysfunction (ED). ED is inability to have adequate erections. In this country, the most common cause of ED is long-term smoking. A close second is the presence of diabetes. Long-standing hypertension (high blood pressure), history of atherosclerosis ("hardening of the arteries"), uncontrolled high-cholesterol, history of penile or perineal (area between the scrotum an the anus) trauma, and deficiency in male hormones(testosterone), may all be causes in and of themselves. Very often, patients have a combination of reasons.
After a thorough evaluation, the options for treatments will be presented based on the contributing factors. Often, a patient may try many treatment options before he has success. The most common reason a treatment is discontinued is simply because it did not work. Other reasons include side-effects, cost of the treatment, and complaints that it is inconvenient, cumbersome or lacks spontaneity.
*When all other options have been exhausted, a urologist may suggest insertion of a penile prosthesis. We always emphasize that this is a last resort because once inserted, a patient can never go back to other treatment options. In other words, the surgery changes the anatomy of the penis in such a way that the prior treatment options are usually no longer effective.
There are several types of prosthesis manufactured by different companies. We basically separate them into two main categories: semi-rigid vs. inflatable (commonly referred to as "the pump"). A semi-rigid prosthesis is one that consists only of two malleable rods that are inserted into the penis. They are always rigid and thus the penis always appears to be erect. An inflatable device is more complicated. The penis can be in a flaccid (non-erect) state and can then be inflated using a small squeeze pump that is implanted in the scrotum (skin sac that covers the testicles). Regardless of the type, they both serve to stiffen the corporal cavernosal bodies (corpora cavernosum). These are the two (one left and one right) cylinder-like portions of the inner penis that accept and subsequently entrap blood and become stiff during an erection. They have a lumen (center cavity) much like a pipe, and these are the spaces into which the cylinders of the prosthesis are placed.
SEMI-RIGID Advantages: Shorter surgery; fewer complications;
lower incidence of mechanical
failure; easier to use. Disadvantages: Less natural in appearance and feel; always erect
It is necessary, as with any procedure or operation requiring anesthesia, that you have not eaten for at least eight hours prior to the scheduled time.
It is probably to your advantage not to strain to have a bowel movement in the week after the procedure. It may be uncomfortable while you are healing. We therefore recommend that for the entire week before the procedure, you avoid constipating foods such as rice, bananas and red meat. You should be eating lots of fruits and vegetables as well as oatmeal and cereals. If you have a known problem of constipation, you should administer an enema before bed the night before your procedure.
As with any procedure in which anesthesia is administered, you will be asked not to eat or drink anything after midnight on the evening prior to your surgery. You may brush your teeth in the morning but not swallow the water. If you are on medications that must be taken, you will have discussed this with us and/or the anesthesiologist and instructions will have been given to you. The procedure will not be performed if you are currently taking, or have recently taken any medication that may interfere with your ability to clot your blood ("blood thinners, aspirin, anti-inflammatory medicines, etc."). The most common of these medications are aspirin and all related pain relievers or anti-inflammatory compounds (whether prescription or over-the-counter). Please refer to the attached list and tell us if you took any of these within the past 10 days. If your new medication is not on the list, alert us immediately so that we may ensure optimal procedure safety. We will have reviewed all of your current medications with you during the pre-operative/pre-procedure consultation. You are obligated to inform us if anything has changed (medication or otherwise) since your previous visit.
The duration of the operation varies for every patient, reflecting the type of prosthesis implanted and differences in each patient's anatomy. In general, a semi-rigid takes 1-2 hours, while an inflatable can take 2-3 hours.
Your position on the table will be supine (flat on your back) or in the lithotomy position (on your back with your legs elevated in holsters called stirrups). The type of anesthesia used will reflect the suggestion of the anesthesiologist as well as contributions from your preferences as well as that of your surgeon. General anesthesia (complete sleep) or a spine are acceptable.
The first part of the operation involves placing a catheter down the urethra (tube through which you urinate) and into the bladder. This allows us to easily palpate the urethra during surgery. In addition, it is easier for you overnight to not have to urinate.
If an inflatable device is being placed, the incision may be on the very lower aspect of the abdomen called the suprapubic region. It will extend down toward the penis. The pump device will be placed in the scrotum, and the inflatable cylinders will be placed within the center cavity of the corpora cavernosa. In order to do so, we gently enlarge the lumen of the cavernosum with dilators (spreading instruments).
In most instances, there is a reservoir cylinder that stores the fluid that will be placed behind the pubic bone of the pelvis. All of the parts are connected by air-tight tubing.
Less commonly, a two-piece device has no separate fluid reservoir, and so all of the fluid is stored in the pump in the scrotum. When there is no reservoir, an incision on the lower abdomen is not always used.
When a semi-rigid device is being implanted, there is no pump and no reservoir. There are only the cylinders. The approach to the cavernosum (i.e. the skin incision) can be similar to that of the inflatable device (just a bit lower and called "infrapubic"). It can be anywhere on the penis itself, or even where the penis and scrotal sac meet (penoscrotal). Your anatomy combined with the preference of the surgeon will determine the location of the incision.
Throughout the procedure, the operative field is irrigated with antibiotic solutions. After the device is implanted, the areas are irrigated once again and the incisions are closed. Sterile dressings are then applied. Blood loss during this procedure is usually small.
After the procedure, you will be in the recovery room until you are ready to be moved to a regular room. In some instances, this may be done as an ambulatory surgery. As mentioned, you will have a urethral catheter draining your urine, and this catheter may give you a constant sensation that you need to urinate. Depending on the choice of prosthesis, you may have sterile dressings on your suprapubic area or loosely wrapped around the penis. There may be ice compresses on the penis itself. You may feel pain and pain medication will be prescribed as needed.
The following morning, the catheter may be removed, and you will be discharged with instructions for follow-up in our office. If done on an ambulatory basis, you may be asked to come to the office the following day for catheter removal. It may slightly burn or sting the first few times that you urinate on your own. Other than your regular medications it is customary for us to give you an antibiotic and a pain medication. Other medications are rarely necessary but depend on your particular needs.
At home, it is important that you take it easy for a few days. We strongly encourage you to take one week off from work and perhaps more if your occupation requires strenuous activity or heavy lifting. In the first 48 hours, it is to your advantage to minimize activity and to often rest in a sitting reclined or lying down position. Try to keep the penis pointing up on your abdomen while lying down. You should not lay face down on your abdomen. Periodic walking is encouraged. You should continue applying ice compresses to the penis as directed. You may notice that while the swelling diminishes over the first week, the bruising (black and blue) may increase.
Depending on the location of your bandage, it may have been removed in the hospital or we will have given you instructions otherwise. Your surgeon will have discussed bathing with you. Some physicians ask that you only shower (no baths) in the first few days while others may request that you take warm baths by the second or third day. If your wound has no bandage, we may instruct you to apply an antibiotic ointment to the area a few times per day.
Expectations of Outcome
Most patients are quite satisfied with the results of the procedure. It is important to realize that the swelling will not fully resolve for up to six weeks. You cannot engage in any form of sexual activity until we tell you that you may. This is often for six weeks or until you are fully healed.
With the inflatable device, it may take a little practice before you are adept at locating the pump in the scrotum or properly inflating and deflating the cylinders. We may ask you to inflate and deflate the cylinders once or a few times per day when at home. You will be instructed on how to do this. The erection produced by a prosthesis should be rigid enough for sexual activity, but may not have the same girth or even length as your natural erection. In addition, the glans penis (head) may remain soft or floppy at the tip of the erection.
Possible Complications of the Procedure
ALL surgical procedures, regardless of complexity or time, can be associated with unforeseen problems. They may be immediate or even quite delayed in presentation. While we have discussed these and possibly others in your consultation, we would like you to have a list so that you may ask questions if you are still concerned. Aside from anesthesia complications, it is important that every patient be made aware of all possible outcomes which may include, but are not limited to:
- Infection: Infection is the most worrisome complication of any surgery in which an artificial device has been implanted. Despite all precautions, infection can arise. It could present with redness, swelling, fevers, chills, whitish to yellowish drainage, or persistent pain. Those at greatest risk are patients with diabetes. If antibiotics and warm soaks do not work, to clear the infection part of (as with inflatable prosthesis) or the entire device will need to be removed. In this instance, we may wait several weeks or longer before re-implanting a new one. Sometimes the infection may result in scarring or inflammation making placement of a new prosthesis difficult. If the infection enters the bloodstream, you may feel very ill. This is termed "sepsis." This type of infection often presents with any combination of the following: fevers, shaking chills, weakness or dizziness, nausea and vomiting. A septic patient may need a short hospitalization for intravenous antibiotics, fluids and observation. This scenario is more common in diabetics, patients on long-term steroids, or patients with any disorder of the immune system.
*If you have symptoms suggesting any of the above after your discharge from the hospital, you must contact us immediately or go to the nearest emergency room.
- Mechanical Failure: Like any other device, it is possible for the parts to malfunction. It can be early, or years later. In this instance, the malfunctioning prosthesis can usually be removed and a new one replaced in the same operation.
- Urethral Injury: The urethra is the tube through which you urinate. While dilating the corpora cavernosum, it is possible for the dilators to perforate through the wall of the corpora cavernosum and puncture the urethra. This injury usually ends the procedure. In most instances, the catheter would remain in for a week to ten days to allow healing. The prosthesis placement would have to be rescheduled. Injuries to the urethra can result in stricture formation (scar tissue that narrows the urethra). Strictures can interfere with urination, and may require surgical correction.
- Urinary Tract Infection: We usually administer intravenous antibiotics once you enter the operating room. Nevertheless, any operation can lead to infections, especially when a catheter has been inserted. It may be a simple urinary tract infection that presents with symptoms of burning urination, urinary frequency and a strong urge to urinate.
- This will usually resolve with a few days of antibiotics. If the infection enters the bloodstream, you could become more ill (see above).
- Chronic Pain: While unusual, any patient can develop chronic pain in an area that was subject to surgery. Sometimes, a prosthesis may just feel uncomfortable. While this usually resolves with time, persistent pain may warrant removal of the prosthesis.
- Erosion: If the cylinder is forcibly pressing up against tissue over an extended period, it can slowly erode through the tissue even in the absence of infection. The device would require removal.
- Deep Vein Thrombosis (DVT)/Pulmonary Embolus (PE): In any operation(especially longer operations), you can develop a clot in a vein of your leg (DVT).Typically, this presents 2-7 days (or longer) after the procedure as pain, swelling, and tenderness to touch in the lower leg (calf). Your ankle and foot can become swollen. If you notice these signs, you should go directly to an emergency room and also call our office. Although less likely, this blood clot can move through the veins and block off part of the lung (PE). This would present as shortness of breath and possibly chest pain. We may sometimes ask the medical doctors to be involved with the management of either of these problems.
We provide this literature for patients and family members. It is intended to be an educational supplement that highlights some of the important points of what we have previously discussed in the office. Alternative treatments, the purpose of the procedure/surgery, and the points in this handout have been covered in our face-to-face consultation(s).
The information contained in this document is intended solely to inform and educate and should not be used as a substitute for medical evaluation, advice, diagnosis or treatment by a physician or other healthcare professional. While Delta Medix endeavors to ensure the reliability of information, such information is subject to change as new health information becomes available. Delta Medix cannot and does not guaranty the accuracy or completeness of the information contained in this document, and assumes no liability for its content or for any errors or omissions. Please call your doctor if you have any questions.
Delta Medix, P.C.