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 an inability to have adequate erections.  This can be a problem with rigidity, sustainability of the erection, or both.  The most common causes of erectile dysfunction are diabetes, hypertension (high blood pressure), atherosclerosis (hardening of the arteries), cigarette smoking, obesity, deficiency of male hormones (testosterone), and high cholesterol.

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 because of failure to work.  Other reasons for discontinuation are side effects, cost, and complaints such as “lacking spontaneity.”

The treatment options most often utilized include:

• Medications: Viagra, Levitra, Cialis, and Stendra.  
• Injection Therapy
• Vacuum Devices
• Intraurethral suppositories

When all other options have been exhausted, a urologist may suggest insertion of a penile prosthesis.  We always emphasize that this is utilized as the last treatment option because once inserted, a patient can never go back to a different treatment option.  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 2 main categories: Semi- rigid or. 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 can be in the flaccid state and then be inflated using a small squeeze pump that is implanted into the scrotum (testicular sac).  Regardless of the type, they both serve to stiffen the corporal cavernosal bodies.  These are the two 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	Inflatable
Advantages	Shorter Surgery; fewer complications; lower incidence of mechanical failure, easier to use	More natural in appearance and feel, can be deflated
Disadvantages	Less natural in appearance, always erect	Longer Surgery, higher complication rate, higher incidence of mechanical failure, more difficult to use

Preparation

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 do not swallow the water.  If you are on medications that must be taken, you will have discussed this with us and/or the anesthesiologist. Instructions will have been given to you. The procedure will not be performed if you are currently taken or have recently taken any medications that may interfere with your ability to clot your blood (blood thinners, aspirin, plavix, Coumadin, anti-inflammatory medications, 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 the the medications within the last 7 days.  We will have reviewed all of your current medications with you during the pre operative consultation.  You are obligated to inform us if anything has changed since your previous visit.

Procedure

The duration of the operation varies for every patient, reflecting the type of prosthesis implanted and differences in each patient’s anatomy.  In general the procedure takes around 1-2 hours.  

Your position on the table will be supine (flat on your back).  The type of anesthesia utilized will reflect the suggestion of the anesthesiologist as well as contributions from your preferences and the preferences of the surgeon.  General anesthesia is used most commonly.

The first part of the procedure 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 the surgery.  In addition, it is easier for you overnight if you do not have to get up to urinate.  You will go home with a catheter and it will be removed the next morning.

If an inflatable device is being placed, the incision may be on over the scrotum.  The corporal bodies will be opened and the inflatable cylinders will be placed within these two chambers (one on each side of the penis).  The reservoir, which holds the fluid, is placed directly in front of the urinary bladder.  The pump will be placed in the most dependent portion of the scrotum.  All of the component pieces will be completely concealed within the body and are placed through the small incision over the scrotum.  

The surgery for the semi-rigid device is very similar, however, there is no pump and no fluid reservoir.

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 the procedure is usually small.  Your surgeon may choose to leave a drain which will exit either the left or right groin.  If a drain is left in place, it will be removed the next morning.

Post Procedure

After the procedure, you will be in the recovery room until you are discharged to home.  Most often you go home the same day as the procedure.  Occasionally, in certain circumstances, your doctor will keep you in the hospital overnight.  As mentioned, you will have a catheter draining your urine.  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 significant discomfort after the procedure, but this can usually be controlled with pain medication.

The following morning your urethral catheter will be removed.  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 to go home with.  We also recommend a stool softener, such as miralax, while taking pain medications. This helps to avoid constipation.  If a drain was left in place, it will be removed on the first day after your surgery.

At home, it is important that you take it easy for at least 2 weeks.  We strongly encourage at least 1 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 to apply ice compresses to the penis for at least 48 hours.  You may notice a significant amount of bruising after the procedure.  

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 in the first 1 week after the surgery.  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 VERY 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 cleared by your physician.  This is often 6 weeks from your surgery date.

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.

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 the 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 discharge, or persistent pain.  Those at greatest risk are patients with diabetes.  If antibiotics and warm soaks do not work, the entire device will need to be removed.  In this instance, we may wait several weeks or longer before implanting a new prosthesis.  In some cases, it can be impossible to place a second device.  Infection can present with any combination of the following: fevers, shaking chills, weakness, dizziness, nausea, vomiting, or persistent pain of the implant. A septic patient may need a short hospital stay for intravenous antibiotics, fluids, and observation.  If you have symptoms suggesting any of the above, 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 prosthesis can usually be removed and replaced in the same operation.
• Urethral Injury:  The urethra is the tube through which you urinate.  While dilating the corpora cavernosa, it is possible for the dilators to perforate the wall of the corpora cavernosa and puncture the urethra.  This injury usually ends the procedure.  In most instances, the catheter would remain in for at least 7-10 days to allow healing.  The surgery could be rescheduled at a future date.  Injuries to the urethra can result in stricture formation.  Strictures are scar tissue which narrows the urethra.  Strictures can make urinating difficult and may need to be surgically corrected.
• 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 infection that presents with symptoms of burning with urination, urinary frequency, and a strong urge to urinate.  This will usually resolve within a few days after beginning antibiotics.  If the infection enters the blood stream, you could become more ill.
• Chronic Pain: While unusual, any patient can develop chronic pain in an area that was subject to surgery.  Sometimes, the 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 of time, it can slowly erode through the tissue even in the absence of infection. The device would require removal.
• Deep Vein Thrombosis/Pulmonary Embolism: In any operation, you can develop a clot in a vein of your leg (DVT).  Typically, this presents 2-7 days after the procedure as pain, swelling, and tenderness to the touch in the lower leg (calf).  Your ankle or foot can become swollen. If you notice these signs, you should go directly to an emergency room and call our office.  Although less likely, this blood clot can move through the veins and block 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 information for the 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, and the points on this page have been covered in face-to-face consultation.

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We recommend that you read this carefully in order to prepare yourself or family members for the proposed procedure.  If you still have any questions or concerns, we strongly encourage you to contact our office prior to your procedure.  We may clarify any pertinent issues.  “An educated patient is the best patient.”