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Impotence/Erectile Dysfunction (cont.)

Surgical Treatment

Patient Comments

Penile Prosthesis

In the event that all above options have been tried and the resultant outcome is not optimal for the patient, the option of a surgical implant can be considered. Penile prosthetics can include the use of a semi-rigid device or an inflatable three-piece device. The main difference between the two is that for the semi-rigid, the implanted two tubes within the corpora cavernosa will always remain the same stiffness. As such, the patient will permanently have a semi-erect penis and the inflatable devices are malleable. The main drawback is the lack of hardness one may have in order for intercourse. Moreover, the inflatable device is more dynamic. This involves a slightly more extensive surgery with the implantation of two inflatable tubes into the corpora cavernosa (which will fill and empty with sterile water), a water reservoir (small spherical chamber which is placed under the inguinal muscle), and finally the scrotal device activator. This last piece is the button the patient will pinch and squeeze in order to transfer the water from the reservoir into the corpora cavernosa to create the erection. All three compartments are connected with sterile tubing and all remain under the skin. The main advantage of this type of prosthesis is the more natural look of the implant, the ability of the patient to control the erection and the more rigid state of firmness (turgor) once erect. Both of these implants are performed via a circumcision-like incision in the main operating theater under a general anesthesia. Complications and side effects include wound infection, hematoma, bleeding, transfusion, prosthetic infection or erosion, urethral injury, pain and penile prosthetic device failure. This is more unique to the inflatable three-piece device where there are more dynamic parts, water, valves, and tubes.

  • Penile implants: In the past, the placement of prosthetic devices within the penis was the only effective therapy for men with organic ED. Now, this has become one of the last options considered. Nevertheless, this remains a reliable form of therapy. Before selecting this form of management, a doctor will discuss the benefits and risks of this procedure with you and your partner. Nearly 100% of the men with implants express satisfaction. Part of this enthusiasm is related to the failure of other therapies and a highly motivated user.
  • Two types of devices are available:
    • A semirigid device implant
    • A multicomponent inflatable system.
  • With the semirigid device, two matching cylinders are implanted into the penis. These devices provide enough rigidity for penetration and rarely break. The major drawbacks are the cosmetic appearance of the penis, the need for a surgery, and the destruction of the natural erectile mechanism when the device is implanted.
  • The inflatable devices consist of two cylinders inserted into the penis, a pump placed in the scrotum to inflate the cylinders, and a reservoir that is contained or in a separate reservoir placed beneath the tissue of the lower abdomen. The inflatable prosthesis generally remains functional for seven to 10 years before a replacement may be necessary.
  • Complications of all penile implants include infections in 2% of users, device malfunction in 4%, erosion of the device through the urethra or skin in 2%, painful erections in 1%, infection, and hematoma formation.

Alternative Surgical Procedures

Similar to heart-disease-related to atherosclerosis (plaque formation within the blood vessels), the concept of bypassing or angiographically dilating and stenting penile arteries has been entertained recently with improvements in microvascular surgery and interventional radiology. However, the main drawback with most erectile dysfunction is the failure of vascular relaxation within the corpora cavernosa rather than the one feeding penile artery. Stenting or surgical grafting to bypass a blockage would be ideal for a single obstruction site along a penile artery. Because most erectile dysfunction pathology resides within the sponge-like vascular plexus of the penis, the ability of diffusely dilating and expanding the many vascular chambers of the penis is difficult to impossible. As such, unless the situation is that the penile artery was injured during a pelvic trauma, and the potential to bypass another vessel into the single penile artery, the concept of vascular reconstruction or angio-radiology stenting has very low yield.

Hormonal Therapy

Testosterone replacement: Men with low sex drive (libido) and ED may be found to have low testosterone levels. Hormone replacement may be of benefit by itself or as a complementary therapy used with other treatments. Libido and an overall sense of well-being are likely to improve when serum testosterone levels are restored. The constitution of symptoms of low libido, fatigue, decreased muscle mass and force, and increased body fat may be related to andropause. As mentioned previously, in the patient workup section, serum total testosterone and bioavailable testosterone blood tests can be performed to evaluate for low serum levels. If determined to be below normal, replacement of testosterone may be suggested as a treatment option. The primary objective of testosterone replacement is to improve libido, energy levels, and symptoms of andropause. Only secondarily would correction of low testosterone levels potentially have impact on erectile function.

  • Replacement testosterone is available as oral pills, intramuscular injections, skin patches, and a gel that is rubbed into the skin. Men with low sexual desire and ED may have low testosterone (male hormone) levels. This is referred to as andropause. Hormone replacement may occasionally be of some benefit, especially when used in combination with other therapies. Testosterone supplementation alone is not particularly effective in treating erectile dysfunction. Sexual desire and an overall sense of well-being are likely to improve when serum testosterone levels (the levels in the blood) are restored. This can take several months after starting testosterone replacement.
  • The normal range of testosterone levels in healthy adult males is between 280-1,100 nanograms per deciliter (ng/dL). Less is considered low, but this varies depending on the laboratory that does the testing.
  • Oral therapy (pills) is the least effective and the most likely to be associated with liver problems, even though this is a small risk. This is related to the first-pass effect of all medications ingested via the digestive system. Once absorbed from the intesting, all food materials must pass through the hepatic (liver) system and be metabolized. As such, the actual delivery to the systemic blood system is low due to the liver metabolism of the testosterone. For this reason, the oral doses are quite high in order to get serum levels higher.
  • Injections are most likely to restore testosterone levels, but this therapy requires periodic injections, usually every two to four weeks, to sustain an effective level. As such, it is less ideal for patients to depend on frequent medical visits for long-duration therapy. Coupled with injection-related pain, hematoma formation, and inconvenience, the serum blood levels of testosterone are also variable.
  • More recently developed skin patches and daily applied skin gels deliver a more stable, sustained dose and generally are well accepted by patients. The latter involves AndroGel, Testim, and Axiron.
  • Proper informed consent with your physician should be performed to understand all risks and benefits of hormonal replacement therapy. Follow-up testosterone (hormone) levels and periodic blood counts and prostate checks are necessary for all men on long-term testosterone replacement therapy.
  • Additional lifestyle modifications of cardiovascular conditioning, improved sleep, stress reduction, and increased smooth muscle mass can be beneficial to improving testosterone levels without an exogenous chance.
Review of Surgical Therapies for Erectile Dysfunction
Semi-Rigid or Malleable Rod ImplantsSimple surgery
Relatively few complications
No moving parts
Least expensive implant
70%-80% success rate
Highly effective
Constant erection at all times
May be difficult to conceal
Does not increase width of penis
Risk of infection
Permanently alters or may injure erection bodies
Most likely implant to cause pain or erode through skin
If unsuccessful, interferes with other treatments
Fully Inflatable ImplantsMimics natural process of rigidity-flaccidity
User controls state of erection
Natural appearance
No concealment problems
Increases width of penis when activated
70%-80% success rate
Highly effective
Relatively high rate of mechanical failure
Risk of infection
Most expensive implant
Permanently alters or may injure erection bodies
If unsuccessful, interferes with other treatments
Self-Contained Inflatable Unitary ImplantsMimics natural process of rigidity-flaccidity
User controls state of erection
Natural appearance
No concealment problems
Simpler surgery than fully inflatable prosthesis
70%-80% success rate
Highly effective
Sometimes difficult to activate the inflatable device
Does not increase width of penis
Mechanical breakdowns possible
Long-term results not available
Risk of infection
Relatively expensive
Permanently alters or may injure erection bodies
If unsuccessful, interferes with other treatment
Vascular Reconstructive SurgeryRestores natural erections when successful
Natural appearance
No implant required
If unsuccessful, does not interfere with other treatments
40%-50% overall success rate
Moderately effective
Most technically difficult surgery
Only 50% of men are potential candidates
Extensive testing required
Risk of infection, scar tissue formation with distortion of the penis, and painful erections
May cause shortening or numbness of the penis
Long-term results not available
Relatively high relapse rate
Very expensive
Medically Reviewed by a Doctor on 7/29/2015

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