ERECTILE DYSFUNCTION

The whole point of restoring a man's sexual ability is that it is so vital to his self-esteem and feeling of wholeness. ED is a medical disease with potentially deep psychological effects. Men will often feel that they aren't men if they can't perform sexually. No amount of reassurance or consolation from the partner can suffice to fill the void he feels by not being able to function as he considers men should. Men who don't feel whole make poor partners. Feeling they aren't doing their job, they will emotionally pull back from their relationships. Women define their role as women as being "that which attracts men". Naturally then, a man's being able to be a "man" is equally important in helping a woman feel she is a "woman". Only then will she really feel valued and needed in their relationship. When one person in a relationship has ED, both partners suffer. I often tell patients that treating ED is very gratifying because every time I treat one ED patient, I help two people.
 
Normal Penile Function
 
Normally, under the right mental or mechanical stimulation, penile blood flow dramatically increases, creating an erection. Within the penis are a series of chambers, the corpora, which fill with blood, to provide this rigidity.  The blood filling these chambers must be delivered with a certain forcefulness or speed, as it is the rapid delivery of the blood into these chambers which causes their exits to slam shut, trapping the blood as an erection. If the forcefulness of blood flow is decreased, the exits don't slam shut, blood leaks out rather than being trapped, and a firm erection is never achieved.

The penis is a vascular organ which requires "exercise". There is something to the statement:"Use it or lose it!”  Normally men experience nocturnal or nighttime erections while they are sleeping. They may experience 3 to 5 erections associated with REM (Rapid Eye Movement) sleep per night. These erections may last up to one hour or more in time. They are important for oxygenating the penile erectile tissue.   Research has shown that men who experience these nighttime erections have more smooth muscle in their penises, which is necessary to trap the blood in the penis during the erection process. Men who do not achieve nighttime erections may have had the smooth muscle in their penis replaced with collagen or scar tissue. Collagen is not able to trap the blood in the penis, and thus the men will experience erectile failure.  This implies that delay in treatment of ED decreases the important oxygenation, resulting in increased scarring, which makes successful treatment less likely.
 
Hitting Bottom
 
Not only can delay in treatment worsen the impotence itself, untreated ED can often result in irreparable damage to a relationship. Communication between the partners can come to a standstill. There can be much arguing and fighting. Much anger and resentment can often be expressed toward each other... Both men and women may have affairs to see if things will be better with someone else. Often, one partner blames the other as the cause of the problem. The final result can be separation and even divorce. ED isn't usually the sole cause of divorce, but it’s often a contributing factor. Hopefully, the man and his partner will be directed to proper help early so they don't have to hit bottom.
 
 A recent study asked patients how impotence affected their life and behavior:
 
-65% reported a decline in their self esteem and self confidence.( Personally, I think the number is greater than this. I see it in about 95% of patients I have treated)
 
-71% reported increased levels of frustration
 
-61% reported increased anxiety
 
-there were significant increases in smoking and drinking.
 
-one in four speculated that their impotence was a definite or possible factor in the breakup of a relationship.
 
 A man will seek treatment when he has experienced enough pain and realizes and feels the impact of his problem. Action occurs when his pain and potential loss of his partner or self esteem becomes greater than his fear and embarrassment associated with his problem and expected treatment. 
  

OBSTACLES TO TREATMENT
 
Myths
 
Under this section I would include any fear- based, misinformation messages we get- from strangers, family, friends, or sometimes even from doctors. Sometimes, we can't even remember where we got the misinformation from.  i.e.: "I can't remember where I heard it, or why I think that way, but I just do".

Examples of this misinformation at work include:  You summon up the courage to finally mention to someone that you are considering treatment for your ED and they reply something along the lines of "You're getting too old for that”, " You've had a good sex life. Now its time to quit", "Don't be a fool, at YOUR age?", "I heard those things don't work/are dangerous." “I heard you can't take that pill if you're on a water pill" (name any pill that has never caused a problem. the message is one of fear. Fear that, if heeded, would prevent you from looking into treatment before you ever started.

Anything said along those lines, which tends to discourage you, before you've even begun to look into the problem, would be included in this section. These things are often said to cover some other, more embarrassing truth, such as the person telling you this may really be trying to justify their not addressing similar problems of their own.
 
Not everyone feels the need to restore their erectile function. Its a very "individual thing”, yet, at the same time, it's understandably also a "couple's thing".  Some patients, due to personal feelings, age, medical conditions or medical conditions of their partner, may have come to a decision that, while they enjoyed their sexuality during the time they had , they don't feel the need to restore it. Such is a personal decision, and should be respected.. Equally as valid, though, is when a man's identity, his maleness, is very strongly tied to his being able to function sexually, regardless of age. To such a person, losing his ability to have relations is like losing his reason for living. Since that is his belief, it also should not be invalidated. 
 
Herbal Remedies

This is a variation of the "myth" category.  Myth : "Rumor has it that some special ancient/ modern herb, spanish-fly, rhinocerous horn can help you restore your erections." This is implied, in advertising, to be so successful that the drug companies are secretly trying to suppress it.( while in reality, drug companies passed on the remedy years ago) The buyer is often encouraged to act quickly, while supplies last.  Confidentially, through the mail, you can receive this magic male enhancement elixir. Such scams are very successful for their perpetrators for several reasons. Legally, if someone says their solution is "herbal", they do not have to prove their claims or results to the FDA ( Food and Drug Administration). As far as the government is concerned, if the "product" is herbal, it's a salad, not a medicine( buyer beware). Part of the appeal of such solutions is that you can "fix " yourself  without  having  to tell anyone you ever had the embarrassing problem in the first place ( or so they would have you believe ). You don’t have to go to your local store and risk friends and neighbors seeing you pick up a medication for ED. When the product doesn't work, the company counts on your being so embarrassed you spent your money on it, that you will not be likely to ask for a refund.( Shame of the victim prevents this from ever being reported as a crime.) Trying things like this is a giant step backward.

The bad thing about these scams is that, afterward, the victimized person usually feels worse about their self and their problem, and more hopeless of it ever being successfully treated. These bad experiences can make people give up on trying finding a treatment that does work.
 
Finding the Right Doctor

Finding the right doctor is a very difficult process for most men suffering from ED.  Men generally do not talk about private issues. They especially do not like to talk about erectile problems. It may be difficult for a man to gather the courage to ask for help. Frequently, when he does ask his doctor for help, he is met with a less than satisfying answer. Many physicians are not aware of the different treatment alternatives available, do not have time to discuss an emotional issue, and do not feel comfortable or want to get involved in discussing a sexual problem. Many doctors, pressed for time, feel they don't have the emotional energy to get involved in the treatment of impotence. Patients can also be the cause of the communication problem. A patient often finds it much easier to tell his work associates or a family member that he has been diagnosed with prostate cancer or had a heart attack, than telling them about an erectile problem. Impotence is a taboo subject in our society. So, for many reasons, the people who need help and those who can help often don't talk. However, ED affects every part of a man's life. Impotence is a critical threat to a man's ego and self image. All of this makes finding a doctor one can comfortably talk to about ED even more vitally important. You should look for a qualified Urologist - one, like me, who specializes in impotence. He should offer you all of the different treatment options discussed here. 
 

Causes of erecticle dysfunction

In a process as complex as penile erection, problems can occur for many reasons. Very often an erectile problem will have more than one cause. The causes may be psychological (psychogenic impotence), physical (organic impotence), or a combination of both. Distinguishing between causes is important to successful treatment.

Psychogenic Impotence

Psychological causes of ED include psychiatric illnesses such as depression as well as lesser, but equally debilitating problems , such as stress and anxiety due to marital, financial, or other personal problems. For example, a sexually active man may suddenly find himself unable to have an erection shortly after losing his job. It is possible for the man's stress and anxiety to interfere with nerve impulses from his brain when he attempts sexual intercourse.

In "Performance anxiety", a man's fear about his ability to "perform" creates actual physical conditions that make it so he cannot perform- causing more fear, thus completing a vicious cycle. With fear, our bodies prepare for a fight by secreting adrenalin, which tightens blood vessels to the stomach and penis, shunting flow that would normally go to them toward the brain and arm /leg muscles instead. With less penile blood flow, performance anxiety becomes full-blown ED. This is not "in his head". The patient experiences a real physical response from a psychological event. Moreover, after experiencing erectile failure, the man is almost expecting failure the next time he tries to engage in sexual activity. The man will hope the problem will get better on its own. At times he may become his own worst enemy. By delaying treatment a small problem can become much bigger and more difficult to treat. At some point in time, the man will expect to fail on every attempt at sexual intercourse. At this time his problem becomes much more significant.

Though organic impotence is more common than psychogenic, it is important to recognize that even in patients with purely organic impotence, there is an underlying psychogenic component caused by the performance anxiety their ED creates.

Organic impotence

The most common cause of this inability is poor circulation. Anything that slows or lessens penile blood flow can bring about erectile dysfunction.
Common causes affecting this route include high blood pressure, lipid problems (high cholesterol, triglycerides), diabetes, and smoking. ED, unfortunately, can also be caused by any medication used to lower a high blood pressure. So, if your blood pressure was 180 /100 for years, and a medicine now lowers it to 140 /70, the blood flow to your penis at this lower pressure may not be forceful enough to slam the exits shut and trap itself as an erection.  In other words, both high blood pressure and the medicines to treat it can cause ED.  Diabetes causes ED by affecting both the nerves and blood vessels involved. Diabetics, through blocked small vessels, normally have less blood flow to the penis and also, through damaged small nerves, have less ability to dilate those vessels on demand. They can’t increase the flow to create an erection. ED can also be caused by direct damage to the nerves. This could be seen after a pelvic fracture (trauma), radiation to the pelvis (brachytheraphy, or seeds, and external beam for prostate cancer), and prior pelvic surgery (major prostate, bladder and bowel operations). Direct trauma to the perineum (bicycle injury) can cause vascular problems and lead to ED.
 
Medications can cause ED. (blood pressure pills, cold medications, hormones, antidepressants, tranquilizers, alcohol, heroin and cocaine). 

TREATMENTS

Oral Medications (Viagra, Cialis, Levitra)
 
An enzyme, phosphodiesterase type five, exists in healthy penile tissue and normally serves to turn erections "off" after their use. By blocking this enzyme ( blocking an "off switch"), viagra, cialis, and levitra promote the development and maintenance of erections.  These medications (PDE inhibitors) help men with borderline penile circulation to function more normally. Note: these medications do not create erections by dilating blood vessels directly, but instead block the "off switch" of erections. Since they don't directly dilate blood vessels, they work best in cases where flow is only mildly to moderately impaired. 
 
These medications provide a great solution for ED cases of lesser severity. Not only are they effective, but they are low risk. They do have one potentially serious possible risk. PDE 5 inhibitors should never be used by anyone using any form of nitrate therapy. (Nitroglycerine (NTG) is used to dilate heart blood vessels to treat or prevent chest pain of angina. Some patients take nitroglycerine patches or creams to keep their heart arteries dilated at all times.) Young club-goers who don't have ED and use PDE5 inhibitors recreationally to enhance sexual performance should avoid using "poppers"(an inhaled form of nitroglycerine that gives the user a "rush" by dilating blood vessels). Use of PDE5 inhibitors and any form of NTG at the same time causes severe rapid uncorrectable decreases in blood pressure that could be fatal. Other than this avoidable problem, PDE5 inhibitors are very low risk.

A small number of men reported a sudden decrease or loss of vision in one or both eyes some time after taking PDE5 inhibitors. It is not possible to determine whether these events are directly related to use of ED medications. If you experience a sudden decrease or loss of vision, stop taking PDE5 inhibitors and call a doctor right away. Common side effects of these medications include headache, back and muscle pain, stuffy nose, indigestion, flushing, and having a bluish tinge to your vision. These are common and stop within several hours of discontinuing the medication. Patients should be completely familiar with the package insert safety instructions each company provides with their product before trying any of these medicines.
 
Priapism is an erection sustained without interruption for more than four hours, and is a medical emergency. Patients experiencing this should report to an emergency room. Priapism is best avoided by not taking more than your prescribed dosage of these medications and by not mixing these meds with any other form of ED therapy. Priapism may ruin your future chances of ever having good erections.
 

The exact role testosterone plays in the normal creation of erections is unknown. Testosterone creates sexual desire. Patients who seek treatment for ED seek treatment because of frustrated desire. They are thus likely to have normal testosterone levels. Testosterone replacement therapy can increase the  risk of prostate enlargement and cancer. Other current ED therapies are probably more effective and lower risk, and should be considered before testosterone replacement.
 

Injectable Medications:

Another way to overcome ED is by injecting the penis directly with a substance that causes the penile arteries to dilate. Obviously (since this takes a medicine that does dilate arteries and puts it directly at the site its needed), this would create a better erection than any pill, but requires the patient give himself an injection.

Its difficult to make giving an injection part of foreplay.- so use of  injection therapy brings a lack of spontaneity to one's love-life. However, the needle involved is very skinny and easy to tolerate and the technique of self injection is easy to learn. The possible risks of injection therapy include scarring inside the penis, bleeding from the injection site (hematoma) causing deformity, and the possibility of creating a prolonged painful erection (priapism = an erection sustained, without interruption, for more than four hours) that could permanently worsen your ability to create future erections. These risks can be practically eliminated by simply following the instructions found in the medication's package insert.

Urethral Medications- Urethral Suppositories (MUSE)

 

A slightly less effective, but less invasive, variation of the this, is a tiny pellet (MUSE) of similar medication that, when slipped down the man's urethra (pee channel), liquifies, is absorbed, dilates the arteries and creates an erection - all without the need for an injection.  MUSE will be solid at room temperature, but liquifies at body temperature, which is only slightly higher. The pellets should, therefore, be kept refrigerated and out of direct sunlight until used. The absorption of this medication across the pee channel differs from patient to patient. The medication is a vasodilator (dilates blood vessels), i.e. it is the ideal type of medication to create an erection with. The variability in its absorption makes it difficult to predict exactly which patient will enjoy good results with it.

Other Therapies

Vacuum Devices
Alternately, patients can purchase a vacuum cylinder for treatment of ED. By placing their penis in it and pumping the air out of the cylinder, a vacuum is created, drawing blood into the penis, bringing about an erection.  The patient pre-fits the cylinder with a rubber band around its base before application. Then, once the erection is created, the rubber band is slid off the cylinder just before its removed. The band’s deployed position around the base of the penis helps keep the blood trapped in the erection. Some patients report good results with the vacuum alone, without using the rubber band. Others require both. Some patients report discomfort from the constriction band. Some vacuum devices are battery powered (and more expensive), others use a hand pump. The battery powered ones are far more user friendly, worth the extra cost, and the only ones I would recommend. 

Patient Satisfaction

Two Questions
Luckily for patients, there are many successful treatment options to consider today. Patients naturally choose the least invasive treatment that produces best results.
For a great many patients, the pills now available are a godsend. They are truly a remarkable advance in the treatment of ED, and enable many patients to return to functioning that is very close to how they were in their prime, with minimal inconvenience. There are two questions one should ask when evaluating satisfaction with these therapies.

The first question is:" Does it work?" Does the pill, injection, vacuum device, suppository create an erection satisfactory for successful sexual relations?  This will largely depend on the severity of the patient’s disease. Obviously, the more severe the block in blood flow, the less satisfactory the results of pills. Such patients would switch to injections or vacuum devices, and, as their disease progressed, would find these less able to create erections as well.

The second question is: "Is patient's total experience with the solution pleasurable enough to make him want to use it again and again?"  This question looks at the "cost" of success in terms of the inconveniences that go along with using that particular remedy. What compromises does the patient have to accept in order to get that erection? Ideally, the answer would be "none". The answer to this question is determined to some extent by the severity of the patient's disease but also by the therapies themselves.

For Example:
Treatment with pills does require patients accept a certain loss of spontaneity. One has to predict: "Will their partner be in the mood when they are ready?" and “Will they be ready when their partner is in the mood?"
 
Transportation of these solutions (so they are readily available whenever the opportunity arises) can sometimes pose its own problems. Patients must remember to pack injection kits or vacuum devices whenever they take a vacation. Suppose Customs Agents at the airport search your bag?  Would that be embarrassing? Are these items visible on the X-ray scanners now used for airport security? (I don't know.)
 
At home, how does one conceal injection kits and vacuum devices from family and company, yet also keep them readily available to be easily reached when the opportunity arises?
Muse (the urethral suppository) requires refrigeration. How does one keep it refrigerated while traveling? How do you hide it in the refrigerator so your grandson won't discover it while he's getting a glass of milk?
 
Leaving one's partner to go inject oneself, drop the urethral suppository, or apply the vacuum device does tend to shatter the romantic mood. Patients often get depressed when they get out their "solution", and remember back fondly to the old days when they didn’t need one. That “Now it’s come to this!" feeling is very depressing. Depressed patients don’t feel good about themselves, no matter how well their therapy works.
 
All of these considerations contribute to that "total experience" the patient evaluates in question #2.
 
Its not surprising, then, that patient satisfaction surveys show, even when these remedies do work, patients are often not happy using them. Their frequency of relations decreases, not because they don't work, but, because patients tire of all the compromises these solutions force them to accept. This does not lessen how great all of these therapies are.  Certainly they enable many men to return to active sex lives they otherwise couldn't have had. But, their sex lives on these therapies are very different from what they were like before- or what they'd ideally like them to be. The compromises demanded by these therapies makes them all fall far short of being able to deliver what men( and women) want.
 
What Patients Want

The truth is: what patients really desire is to function like they did when they were younger. They'd like to be able to get a good erection at a moments notice, to be able to take advantage of any opportunity, and to not have to plan ahead. They'd like to be sure their erection would be reliably rigid, and to not have to worry about losing it in the middle of love making.  

Penile Implants (penile prostheses)

As ED worsens over time, results from once successful therapies fall further and further short of this ideal men really desire. They eventually reach a point where their negatives out-weigh the positives.  In contrast, patient and partner surveys after penile implants show extremely high, lasting satisfaction rates. It's no wonder, since penile implants provide maximum rigidity, durability and concealability. For a patient with severe ED, who's  bottomed-out in terms of erectile function, helping him by implanting a penile prosthesis allows him to immediately perform not only better than his peers,  but, in many respects, also even better than he himself ever had in his prime.  Because his implant stays erect until he deflates it, he needn't ever worry about not lasting until his partner is satisfied or climaxing too soon.

Once implanted, men are cured of their ED and can throw away all their worries, medications, considerations and planning.  They, and their partners, no longer suffer from ED.

It is clear that penile implants, because of their spontaneity, rigidity, and reliability offer patients a very high level of satisfaction not found with other forms of ED treatment. Patients appreciate that only a penile implant allows them to be able to do what they want, whenever (and wherever) they want, for as long as they want. The freedom an implant restores to the patient makes the patient satisfaction survey results very easy to understand. Penile implant surgery has undergone significant advances over the three and a half decades since its introduction, making  this a highly safe and effective means of treating men with ED. Advances have led to several models produced today with 90% of those implanted 10 years ago still functioning. Risk of Infection, once quoted at 6-12 % in the 1980’s, has now decreased to less than 3 % due to advances in materials, antibiotics and sterile techniques.  Satisfaction rates, then, are high because implants do cure ED, and because modern implants are now extremely reliable and problem free. 
  
Patient Selection
 
Patients who attempt but dislike or fail to achieve satisfactory results with pills, suppositories, vacuum devices or injections are candidates for a penile implant procedure.
 
Implant Selection.
 
Prostheses can be divided into two main categories, malleable (also known as non-hydraulic or semi-rigid) and inflatable (also referred to as hydraulic). The latter can be divided into 2-piece and 3-piece devices depending upon the locations of the fluid used for inflation. 
 
The malleable devices have an outer shell with a central core of metal or plastic.  These prostheses are paired solid devices implanted in the erectile bodies that produce constant penile rigidity. The primary advantage is their ease of implantation, while their disadvantages include a constantly rigid penis that resembles neither normal erection nor flaccidity, difficulty with device concealment, and an increased risk of device erosion. Malleable proistheses should be avoided in patients at high risk of erectile body or urethral erosion, such as spinal cord injured patients and diabetics, as well as men who have had penile irradiation.

Malleable models are only occasionally placed in this era, given the recent data regarding the excellent low-complication/ high-longevity profile of current inflatable devices.
 
Inflatable Penile Implants

Historically, inflatable penile implants were of three varieties:

• self - contained (which are now out of production)
• 2-piece
• 3-piece devices.

Two-piece Inflatable Implant The AMS 2-piece (Ambicor) implant is the only 2-piece in production at present. It consists of cylinders that are pre-connected to a ball shaped pump, which is seated in the scrotum. Compression of the pump results in transfer of fluid from the back part of the cylinders into the middle portion, resulting in rigidity. The deflation mechanism involves simply bending the penis at mid-shaft, resulting in fluid being returned to the back section. The sensitivity of the deflation mechanism is set so that it wont ever deflate in the course of normal activity, yet will deflate easily when you intend it to.

There are a number of populations in which I consider implanting the AMS Ambicor
2-piece device. This is my personal preference, developed thru experience over time. Other authorities utilize 3-piece devices in some of these populations with excellent safety and satisfaction. These populations include(i) Patients who have had radical  cystoprostatectomy (bladder removal) surgery; (ii) Patients who have had renal transplant surgery or are about to receive such a transplant (iii) Certain patients who have had radical prostatectomy: (iv) Patients who have had  bilateral inguinal hernia surgery( especially with mesh) and ( v) Spinal cord injured patients who desire penile implant surgery for erectile dysfunction as well as permitting the application of a condom catheter.  
 

Three-piece Inflatable Implant The 3-piece concept of a penile implant was designed by Brantley Scott MD in 1973. Constant innovations on this basic design led to the superior, advanced, reliable implants of today. Three-piece inflatable implants have paired cylinders, a small scrotal pump, and a large-volume fluid reservoir (which is placed behind the abdominal wall muscles).

Between the two different companies making implants today, there are several different 3- piece devices available to address most implant situations. Both companies are working conscientiously to develop better and better implants. Recent years have seen such advances as cylinders with anti-microbial protectant coating (reducing infections), easier to use pump designs, and reservoirs that prevent unwanted device inflation. Today's inflatable implants embody man's highest achievements in technology and engineering. 
 
Choosing between a two- and three-piece implant.
 
I like the test of time. Reliable products come about when companies take such pride in their work that they use only good materials and follow only good designs.

Defects in design or materials result in early, and high, failure rates. So, when over 90% of devices implanted 10 years ago are still functional today, it can only mean that the manufacturer made a quality product. I, personally, only implant devices having documented durabilities of 90% at ten years. The average patient is not going to be privy to this data. I see this as my responsibility being your Urologist- to scour the data and find only the best implants for patients. That said, there are both 2- and 3- piece implants available today that fit that requirement ( -that have 10 year reliability rates greater than 90%).

From there, patient's body build, past medical history and personal preferences should be evaluated to see if one model suits him better than another.  For example, 3-piece implants contain more fluid to shift than 2-pieces. For this reason, a 3-piece would provide both better rigidity and flaccidity for patients with "greater than average" builds. Since the 3-piece has one piece more to be placed than the 2-piece, its recovery time afterward is slightly longer. This slightly longer recovery period is reasonable for the larger patient to undergo to get the enhanced rigidity and concealment that third piece provides. For patients with "normal" or smaller-size builds, there honestly would not be any appreciable decrease in the quality of the erection by their choosing the 2-piece. They'd get just as excellent erections with the 2-piece and have a slightly shorter recovery.
 
Patients should be aware of the differences, and their personal preferences contribute greatly to which model they choose. Some patients may have had prior abdominal surgeries that may interfere with the placement of the 3-piece's reservoir. There are ways to safely place a 3-piece, even under these circumstances.  All of these considerations are thoroughly discussed before the patient is allowed to choose an implant model. 
 

Will My Insurance Cover My Treatment?
 
To formally document ED, the patient could be given a penile injection to dilate the arteries and increase the blood flow. After a few minutes, once the medication has had a chance to take effect, the peak penile blood flow could be measured with a duplex doppler ultrasound. His flow could then be compared to normal levels. Unfortunately, this test would only document what the patient already knows -that he can't get good erections. The results of the test would not alter therapy. Regardless of how poor blood flow is, patient satisfaction after penile implant is much much higher than after revascularization procedures.  Though restoring penile blood flow (revascularization) would seem the logical treatment treatment for a disease caused by poor circulation, the truth is that the penile arteries are so tiny that the bypasses have serious problems staying open. Within 2.5 years after revascularization, approximately 50 % of bypasses have a occluded. Compare this to the high patient satisfaction with and reliability rates of penile implants, and you can see why such testing has dropped out of fashion. Some insurers will occasionally insist that a duplex doppler be done prior to penile implantation approval, but for the most part, they don't.

Some insurers will require a letter from a Urologist saying that the patient failed prior medical therapies before authorizing an implant. It largely depends on the insurer. Most insurers recognize impotence as a medical disease, and consider it's treatment a covered service. 

 
First Office Visit
 
Generally, patients come to the office for their first visit, during which a thorough history( medical and sexual) and physical exam is performed. The different treatment options are discussed. Patients interested in implants are shown the 2- and 3- piece models, specifically covering their features that may make one more personally appealing to him than the other. The implant consent is reviewed with the patient and he is given a copy of it along with literature on the various models to review before his next visit. A second visit is scheduled. Before that, the patient's insurance is contacted to make sure his future treatment is pre-approved and covered.  During his second visit any questions about the different implant models, the implant procedure, post-op expectations, and recovery are answered. The implant is then scheduled.

Post-op
The Implant Procedure itself takes one to two hours, during which patients are asleep.  The device is placed through a small one-inch opening at the top of the scrotum. The final sutures are absorbable, and dissolve on their own over time. Patients stay one night in the hospital. I see them early the next morning, give them discharge instructions and supplies, as well as a follow-up appointment. They are discharged, and seen back in the office one week after the implant. During that week, patients can walk steps and take showers. They should not lift more than 10 pounds, strain, or try to have sex. Patients can return to normal activities (except sex) at two weeks.
 
Patients with 2-piece implants can drive after one week, and, after two weeks, can resume normal activities (except sex).
 
Patients with 3-piece implants should not drive for two weeks, and should not lift more than 10 pounds or strain for four weeks. (During this time your body will heal and seal around the reservoir, preventing it from ever herniating. i.e. these instructions are for that purpose)

Most patients will take two weeks off from work after the device placement. Patient's returning for their one week post op visit generally look remarkably well. Their swelling, black-and-blue discoloration, and pain have greatly subsided in just one week. Though post-op discomfort is easily controlled with medication and subsides rather quickly, it usually takes two weeks before a patient will appear to others as if he hasn’t had any procedure done (i.e. His walking is normal and nosey well-wishers are no longer coming up to him asking if he's ok.)
 
Using Your Implant
 
The implant needs to heal for 8 weeks before it can be used. Do not use it before 8 weeks, even if you feel you want to.

The thought of inflating their implant doesn't usually cross a patient's mind for the first four weeks. By the eighth week, patients can't wait to cycle their implants. At this time they are given their second post-op appointment, during which they are shown how to cycle the implant on a demo model, then they cycle the demo themselves, then I cycle them, then they cycle themselves- all in front of me. They are then discharged but are welcome to come in again at anytime if they need any further help perfecting their inflation /deflation techniques. Patients are encouraged to use their implants daily and to not treat them like they are fragile (they aren’t). Since their impotence is now cured, patients can be discharged from my care at this point. Many patients continue to come to me yearly just for their routine annual prostate check. 
  
 

Complications

Post-operative complications of penile implant surgery are not common. They include but are not limited to implant infection, mechanical failure, device erosion, device migration, sizing problems, auto inflation, persistent pain, loss of sensation, and loss of penile length.

There is some truth to the adage " If you don't use it, you'll lose it". Patients have implants because they have not been able to get good erections on their own for varying lengths of time. During this time, their penis has not enjoyed the oxygen-rich blood it needs, and, even on a microscopic level, scarring and shortening have occurred they may not be aware of. During the implant, the corporal bodies inside the penis will be sized, and the largest size implant that fits correctly will be placed. The size of the implant placed will be dictated by the size of the corpora when they are measured during the procedure.  Though everyone would like to be "bigger", its impossible to put in an implant bigger than your size will allow, and, since you haven’t seen your penis erect for some time, your post -op size will be smaller than you previously remember yourself to be. It’s very important that patients realize implants do not increase the size of your penis. An implant only gives your reliable rigidity. An implant allows you to fill out whatever size you have left and to make it maximally rigid at will.

Infection occurs in approximately 2-3 % of primary (first time) implant surgeries. Infection and subsequent device removal may result in penile scarring and loss of penile length, which may lead to the inability to perform any further implant surgery. Following implantation, the time frame for the presentation of infection will vary depending on the bacteria involved. Infections with more virulent and aggressive bacteria will usually present within the first few days to weeks after surgery (fever, pain, and swelling), but low-grade infection may not present for a year after surgery. When infection of the prosthesis is diagnosed, the standard treatment is the removal of the entire prosthesis and re-implantation of another device several months later. In an effort to prevent penile length loss and a difficult re-implantation procedure, prosthesis salvage has been proposed and preliminary results using this approach have been very encouraging, with up to 80% of salvage patients keeping their secondary implant.
 
Re-operation rates for mechanical failure are approximately 10% during the 10 years after the initial placement, thus approximately 90 % of men still have their original, still-functional implant 10 years after it was first placed. 
 

What Patients Say /Satisfaction Surveys.

Patient satisfaction is related to factors as diverse as degree of post-operative discomfort, post-operative complications, concealability, cosmetic outcome, implant function, ease of use and partner acceptance. It is clear that penile implants offer the patient a high level of satisfaction when compared to other forms of ED treatment and do so because of their spontaneity, consistency, and rigidity.  We believe that excellent pre-operative counseling to ensure that the patient has realistic expectations is essential to a satisfactory outcome. We inform our patients that penile prostheses do ONE thing and that is to increase the hardness of the shaft of the penis; that they do not routinely lengthen the penis.
 
According to published reports, penile prosthesis implantation has the highest satisfaction rates (nearly double) of all treatment options for erectile dysfunction. In one study, approximately 90% of implanted men and 80% of their partners were satisfied.
 
In a study comparing penile prosthesis implantation with penile injection therapy, with similar follow-up, 70% of implant recipients reported having sex on a regular basis, whereas only 41% of injection therapy patients were still sexually active. 
 
In one study of patient satisfaction after penile implant, patients filled out satisfaction questionnaires postoperatively and at 3, 6, and 12 months postoperatively. Satisfaction scores increased as time passed. Patients felt more and more comfortable with their implant, were increasingly happy with it, and were more and more certain that getting the implant was the right choice.
 
Many patients have written me the most heartfelt thank you letters after their implants. This is not surprising when you consider that prior to having the implant, their sex life was a source of embarrassment and shame for them.  Take any patient like that and give him all the freedom and control one can only get from an implant, and its not surprising to receive such glowing testimonials. I also have received a number of nice letters from grateful wives, who have thanked me for restoring their man's sense of masculinity with an implant.
 
So, Why Don't More Men Get Implants?
 
Given the large number of men suffering from high blood pressure, diabetes and elevated cholesterol, and how good implants are at curing ED, why don't more men get implants? Who says they don't? You wouldn't be able to tell, not even by looking at them directly in the nude. There are many more men with implants than you might suspect. And, being men, who, as a sex, tend not to talk about their problems, they wouldn't tell you either. Well, actually, some would. Many of my patients, knowing firsthand what you are going thru, have volunteered to share their experience with any man considering an implant.