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Penile Prosthesis Implant Surgery

Research and Publication

Erectile Dysfunction

Erectile dysfunction (ED) is one of the most common sexual problems reported world over. It is also known as Male Erectile Disorder, Male Erectile Dysfunction, Impotence, Psychogenic Impotence etc. Erectile dysfunction is an inability to achieve or maintain an erection sufficient enough to have a successful or satisfactory sexual intercourse. 10% of all men suffer from ED.

Normal erections require a complex and delicate balance of psychological, hormonal, neurological, vascular and general health factors and all must work together with a fine tuning. Any disruption or imbalance of one or more of these factors can compromise erection quality and leads to an ED.

Seventy percent of men suffer episodes of ED at some time during their life, 30% of men experience one episode of ED in a given month. Prevalence of ED noted in literature reviews vary from 5 to 71%. ED increase with age.

From 31st January 2006 to 31st January 2013 we have seen 12718 patients at Dr. Promodu's Institute of Sexual & Marital Health Pvt. Ltd, Kochi, Kerala, India. Out of this 10977 patients comprising of 9605 males and 1372 females visited the hospital exclusively for seeking treatment for their sexual problems. Among the male sexual problems erectile dysfunction was found to be the most common, accounting for 6235 cases that is 62 percent.

Causes erectile dysfunction

The etiology of ED is often multifactorial and can broadly be categorized into  organic and psychogenic causes. In a few cases a combination of both factors can be present.

Organic causes

The most common organic causes are problem with the blood flow to the penis such as arterial dysfunction and venous leak (veno-occlusive dysfunction), poor filling of the corpus cavernosa, smooth muscle dysfunction, hormonal imbalances, various systemic illnesses such as diabetes mellitus, hypertension, neurological diseases etc, side effects of medicines, alcohol abuse, smoking and other substance abuse. 

Artereogenic ED

Sufficient blood supply to the penis is necessary for erections. The small arteries that bring blood to the penis are often damaged or narrowed down by years of high blood pressure, high cholesterol, diabetes or chronic smoking. This leads to inadequate blood supply to the penis leading to poor filling of corpus cavernosum causing an ED. Arterogenic ED worsens gradually and reaches to a stage with complete loss of erection. Patients with artereogenic ED will always experience a difficulty to achieve an erection. They cannot get the full hardness or rigidity. However tactile stimulation or erectogenic medication can temporarily increase the rigidity by improving the blood flow.

Venous leak

It is known as venous occlusive dysfunction. The mental component of sexual excitement signals the heart to pump more blood into the peripheral organs of the body as a result more blood flows in to the penis causing an erection. The blood flown into the corpus cavernosa must stay there till the ejaculation followed by detumscence. Venogenic ED occurs when the blood flows out from the penis during erection instead of trapping in the cavernous sinuses. In short instead of trapping in the penis the blood flows back to the heart leading to loss of erection. Patient with VOD can achieve an erection but it doesn’t sustain for more than a few seconds, the rigidity or the hardness loses immediately. Artereogenic and venogenic ED can only be identified by a proper colour duplex ultrasound scanning by an expert team of andrologist, radiologist and a clinical psychologist well versed in sexual medicine.

ED and heart attack

Sexual problems might mean you have a broken heart. ED can be a warning sign that a heart attack or a stroke may follow, often in the next 3 to 5 years. Often the onset of ED is a warning sign of potentially dangerous blockage of the coronary arteries that can lead to heart attacks. Unfortunately, many of the medications that treat high blood pressure can also cause erectile dysfunction as well. Artereogenic ED is considered as forerunner of an emerging cardiac problem. Because the pathology of artereogenic ED and heart attack are the same. So at Dr. Promodu’s Institute we evaluate each and every cases of ED from this perspective so as to avoid or prevent a potential danger of an emerging heart attack. 

Diabetes Mellitus and erectile dysfunction

Diabetes mellitus is one of the most common causes of erectile dysfunction in middle aged and elderly men. Diabetes can disrupt function of the microvasculature of the penis and lead to endothelial cell dysfunction. The condition also causes neuropathy in many other organ systems and it stands to reason that the penile innervation is similarly affected. Prevalence of ED is 20% to 71% in diabetic patients. Our data shows that out of the 6235 ED cases 1667 (26.73%) had diabetes mellitus. Endothelial dysfunction due to chronic or uncontrolled diabetes mellitus leads to poor filling of the corpus cavernosum during erections and causes ED. Erectile dysfunction in diabetic patients worsens gradually and reaches to end stage ED or complete loss of erection which doesn’t respond to conventional medical treatment.

Erectile dysfunction & Hypertension

Hypertension is another cause of ED. Seventy percent of men with Hypertension experience one episode of ED in a given month. Eighty percent of men who complain of ED are later found to have high Blood Pressure. Forty percent of men with Hypertension are already suffering from ED when they make their first visit for the treatment of Hypertension. High BP causes tear in the arterial / arteriolar wall which is leading to ED.At Dr. Promodu’s Institute of Sexual & Marital Health pvt. Ltd we found that 26.73% of our Ed cases have been suffering from hypertension.

Erectile dysfunction & Dyslipidemia

Cholesterol can affect your love life. Dyslipidemia is a condition marked by abnormal concentrations of lipids or lipoproteins in the blood. Hyperlipidemia, meaning high lipid levels or fat in the blood. Dyslipidemia may lead to atherosclerosis, sometimes called hardening of the arteries. It is the build up of plaques in the arterial walls. The smaller arteries in the body, such as in the penis, are the first to get plugged up or bloked. The plaque reduces blood flow in the penis, making an erection difficult. Erectile dysfunction is an alert to look for atherosclerosis in larger arteries supplying your heart and other organs too and to take steps to treat it. Atherosclerosis also increases your risk of other problems, including aneurysm, stroke and peripheral artery disease in addition to ED. The statins used in the treatment of dyslipidemia can improve erection. Analysis of all 11 studies combined found a statistically significant effect of statins on erectile function in men who had both high cholesterol and erectile dysfunction. American researchers have found that the commonly used drugs for dyslipidemia such as statins may benefit men with erectile dysfunction. 

Psychogenic causes

Out of the 6235 cases about 45% had psychogenic ED. Causes vary from patient to patient. It includes intra psychic as well as interpersonal conflicts. Most common psychogenic factors we found in our study are performance anxiety, trauma of past failures in sexual encounters, guilt feelings, anxious personality pattern, marital conflict, dislike towards the partner, lack of erotic feelings or attraction towards the partner, occupational stress, other stressors in life etc.

Investigations for erectile dysfunction

After the careful evaluation of history, at Dr. Promodu’s Institute, we do an ED profile assay as a screening test to exclude the common disease conditions and hormonal imbalances that can cause ED. This is followed by the andrological examination. Based on the evaluation further investigations may be planned if there is an indication. Second level evaluation of ED includes a colour duplex ultrasound study of penile erection (CDDU). To differentiate between the artereogenic, venogenic and psychogenice ED a proper CDDU by an expert team comprising of andrologist, radiologist and a clinical psychologist well versed in sexual medicine is essential. So we perform this scanning procedure as a team work. 

Treatment of erectile dysfunction

The number of people seeking treatment for sexual problem in general and erectile dysfunction or impotence in particular is increasing day by day. Since the etiology of ED is multifactorial, treatment also must focus on all the aspects. So Dr Promodu’s Institute of Sexual & Marital Health offers a multidisciplinary treatment for all kinds of erectile problems.   

Our treatment for erectile disorder or erectile problem includes sex therapy, medication, venous ligation surgery, penile prosthesis implant operation etc, depending upon the causes. Sometimes a combination of different treatment modalities may be more effective for erectile problems. There is scientific and effective treatment in modern medicine for erectile dysfunction. Most of the erectile problems can be either cured or controlled with appropriate treatment.

Medicines

There is a giant leap in the treatment of ED with advent of magic pill the Viagra. On 27th March1998 FDA gave approval for Viagra to be used as an oral medication for impotence. Later on various other PDE 5 inhibitors came to the market such as cialis, levitra etc. A few such as Avenafil, Lodenafil, Mirodenafil etc are waiting for approval. At Dr. Promodu’s Institute of Sexual & Marital Health we treat all patients very judiciously. For organic erectile dysfunction we treat with a combination of different medications so as to suit the need of each patient. Now there is effective treatment for ED. But the treating physician has to be very cautious, careful, appropriate and accurate in choosing medication, deciding its dosage and course when treating ED cases. Long term use of Viagra (sildenafil citrate) may cause chronic hypoxaemia and lead to permanent erectile dysfunction. Our penile biopsy reports showed some evidence for permanent damage to corpus cavernosum in chronic sidenafil users. So Viagra is not panacea for ED, there is so many things beyond Viagra. Many patients buy erectogenic medicines from the medical shops on their own and use. This may be harmful as many of these medicines can have adverse effects. This is the reason why the government has implimented very strict control and monitoring on the sale of such medicines.

Sex Therapy

Human sexual function is a bio-psycho-social phenomenon. For sexual dysfunction with psychogenic etiology, sex therapy is the treatment of choice. Psychogenic erectile dysfunction can be successfully treated within 3 weeks with the newly developed short term intensive sex therapy programme.  Sex therapy is a form of treatment for sexual problems by modifying and incorporating sexual experiences to alleviate or cure the symptoms or disorders with the help of psychological methods (K. Promodu, 2013 Indian Journal of Clinical  Psychology 40 (1) 8-12).

In the traditional manner it takes about six months to one year or more to successfully treat a sexual problem. But at Dr. Promodu’s Institute we have newly designed short term intensive inpatient sex therapy programme for patients with sexual problems of psychogenic nature. With this method we treat the psychogenic ED within 3 weeks period. This short term intensive sex therapy was experimented with 78 couples and the results showed an overall success rate of 97.4%. This research was presented at the International conference of the European Society of Sexual Medicine and Asian Federation of Sexology held at Istanbul in October 2013.

Operation
Venous ligation and penile prosthesis implant operation are the common surgeries done for erectile dysfuction.

Venous ligation surgery

Venous ligation surgery is an operation perfomed  for the venous leak causing ED. It helps the patient to achieve a normal erection as well as detumscence withou fitting any artifcial devices. We have done two venous ligation operations during the last 3 years and it is found to be highly successful. It is the best choice in certain patients with venous leak, but doesn't suit all patients. Accurate identification and selection of patient is very important otherwise the operation can be failure.

Penile prosthesis implant surgery.

Penile implant surgery is an option for men who suffer from erectile dysfunction and doesn’t respond to other types of treatments. It is the last resort in Ed patients. Implant is the best choice for chronic diabetic patients. It is a surgical procedure where we implant a pair of prosthesis inside the penis to help the patient to achieve an erection. Implant is or the device is placed either through the incision in the scrotum or through an incision in the lower abdomen or right above the penis.

Types of Implants: There are inflatable and non inflatable devices.

Malleable implant.jpg
Malleable implant
AMS 650 Malleable implnt.JPG
Malleable implant AMS 650
Two piece implant.jpg
Two piece implant
Three piece implant.jpg
Three piece implant

 
The inflatable device can be subdivided into 2-piece and 3-piece devices depending upon the location of the fluid used for inflation.  

The two piece implant: It is an inflatable device. There is a set of cylinders to be placed inside the penis and a pump which can be hidden inside the scrotum. Erection can be attained by gently pressing the pump hidden inside the scrotum and can be deflated by bending the erected penis with a little force.

Two piece implant illustration.jpg
Two piece penile implant
Three piece penile-implant illustration.jpg
Three piece penile implant

 

The three piece implant: is a device with two cylinders, a reservoir and a pump. Both cylinders are placed in the erection chambers of the penis, reservoir in the lower abdomen and the pump into the scrotum. Patient can achieve an erection by gently pressing the pump in the scrotum allowing the fluid from the reservoir to travels to the tubes fitted inside the penis. By pressing the pump again erected penis can be deflated. Today, many men choose inflatable prosthesis, which allows them to have an erection whenever he desires and much easier to conceal which appears more natural.

The Non inflatable prosthesis: got a pair of rigid or malleable or bendable tubes which is implanted inside the cavernosal structures of the penis. When required, the malleable implants can be lifted with the hand and kept to the desired position for intercourse. This is the simplest type of implant and one need not worry about the mechanical failure of the device.

Advantages of Implant:- There are so many advantages for implant operation compared to medication. Medicines got some side effects and some patients cannot tolerate these side effects, medicine cannot be given to patients taking nitrates. All the patients with vascular (artereogenic and venogenic) ED reach to a stage with complete loss of erection and none of the medicines are effective; in such cases implant is the best choice. The best advantage of implant is that a man can engage in sexual act as and when he feels the need and need not rush to a medical store to buy a tablet or wait to get the effect. He can continue intercourse even after the ejaculation as the penis continues to stay erected even after ejaculation. He may stop only after his partner achieves full satisfaction or when he wishes to stop.

Implant operations done at Dr. Promodu's Institute  

Dr Promodus Institute is the pioneer institution in Kerala, India to perform so many penile prosthesis implant surgeries during a short period. During the last 3 years we have successfully done 74 implant operations to treat ED. Out of this 46 shah prosthesis, 5 AMS 650, 22 AMS spectra and 1 inflatable prosthesis were used. We allow the patient to stay in the hospital for 7 – 10 days so as to avoid the post surgical complications. We take maximum precautions to avoid complications. Usually we post the patient for operation only after through physical, medical and cardiological evaluations. Though world over many complications are reported for implant operations so far we never had any such problems. Our study shows that patient’s as well as partner’s satisfaction in sexual life has significantly increased after the implant. The choice of implant, choice of size, fitting of implant and the techniques of surgery are the most important ones. Only a veteran surgeon in the field can do it properly.

Penile prosthesis implant operation done at Dr. Promodu's Institute - Fitted with Shah implant

 

Implanted penis fitted with Shah prosthesis 1.JPG
Implanted penis fitted with Shah prosthesis 2.JPG
Implanted penis fitted with Shah prosthesis 3.JPG
Implanted penis fitted with Shah prosthesis 4.JPG

Penile prosthesis implant operation done at Dr. Promodu's Institute - Fitted with AMS Spectra

Implanted penis fitted with AMS Spectra-Penis kept in flaccid position - Front view.JPG
Implanted penis fitted with AMS Spectra 1.JPG
Implanted penis fitted with AMS Spectra 2.JPG
AMS Spectra -Penis kept in flaccid position - Side view.JPG
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