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Erectile Dysfunction? There's a Prosthetic for That

If you're struggling with erectile dysfunction, you may be able to find relief with prosthetic surgery. In this podcast, we'll discuss this treatment option and how it can help you regain sexual function.

Use of Prosthetics to Treat Erectile Dysfunction | Urology | Podcast

Erectile dysfunction (ED) affects millions of men worldwide and can have a profound impact on quality of life. Although medical and surgical therapies are available, they are not always effective. Penile prostheses are an effective treatment option for many men with ED. This podcast will review the indications, types, and complications of penile prostheses as well as the surgical approach to implantation.

What are the indications for penile prosthesis surgery?

The indications for penile prosthesis surgery are:

  • Patient dissatisfaction with previous medical or surgical therapy for ED
  • Inability to attain or maintain an erection sufficient for satisfactory sexual activity
  • Inability to achieve orgasm
  • Penile deformity
  • Peyronie’s disease

What are the types of penile prostheses?

There are three types of penile prostheses:

  • Non-inflatable
  • Inflatable
  • Semi-rigid

What are the complications of penile prosthesis surgery?

The complications of penile prosthesis surgery include:

  • Infection
  • Erosion
  • Extrusion
  • Malfunction
  • Autoinflation
  • Necrosis
  • Urethral injury
  • Loss of penile length
  • Loss of penile girth

How is the surgical approach to penile prosthesis surgery performed?

The surgical approach to penile prosthesis surgery is via a midline or lateral incision. The penis is then mobilised and the cavernosal bodies are exposed. The corpora are then dissected free of the urethra and the tunica albuginea is incised. The prosthesis is then implanted and the incisions are closed.

Urologist and men’s health specialist, Dr. Richard Natale, joins us this week to discuss the use of prosthetics to treat erectile dysfunction.

Dr. Natale is a urologist with Carolina Urology Partners in the Charlotte, North Carolina region. You can learn more about his practice:

The Erectile Dysfunction Radio Podcast is hosted by certified sex therapist, Mark Goldberg, LCMFT, CST. This podcast aims to educate men about erectile dysfunction, improve confidence, and enhance relationships. New episodes are released every Monday morning.

Learn to think differently about erections to resolve your ED struggles with our “Beyond the Little Blue Pill” eCourse:

More free E.D. education and resources:

Mark helps men resolve erectile dysfunction. He offers individual, one-on-one services to men throughout the world through a secure, telehealth platform. It’s 100% confidential. You can visit the Center for Intimacy, Connection and Change website to schedule a free consultation with Mark:

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Video transcription:

Welcome to another episode of the erectile dysfunction radio podcast today we are joined by dr richard nitelli. Dr natalia is a board certified urologist practicing in north carolina at carolina urology partners. He completed a urology residency in 2009 at the university of florida. Dr natali has specific interest in treating men’s health concerns, including erectile dysfunction, low testosterone and peyronie’s disease, among other urologic conditions. Dr nately, thank you very much for joining us well mark. Thank you for having me appreciate the opportunity. So what we want to explore in today’s episode is the role of prosthetics and sexual health and in urology more broadly. One of the things that we have found is that health issues relating to genitals, even when they do not have a direct physical impact on sexual function, can be psychologically impactful, leading to erectile dysfunction, ejaculatory disorders and whatnot. So prosthetics can be a solution for a number of these conditions, and we hope to learn more about that today. So to get things started, dr natalia, can you tell us a little bit about your practice sure so I’m a general urologist in terms of background in in original training, taking care of all kind of gamut of diseases, urologic diseases, but I’ve focused in on the area of men’s health over the last decade of my practice, so that kind of comprises a catch net of erectile dysfunction issues as we as you’re making mention earlier before peyronie’s disease and as well as things like prostate enlargement, urinary issues that may come with it now in the terms of the specific area of erectile dysfunction, specialists or someone who has the focus and interest that, as I do we’ll walk people through the whole treatment paradigm and try to evaluate them in a very comprehensive, wholesome way, moving from just counseling and discussion, all the way up to and through surgery. So that’s kind of that’s the the the summary of my practice. In a nutshell, I’m assuming that you are in clinical practice full-time. Is that correct full-time? I am I’m also the president of my group, so I do have some administrative responsibilities. A couple of days a month that I take off and work helping guide our practice, but otherwise full-time urologists, being patients yeah, okay. So, dr natalia, can you tell myself and our listeners? What is this word prosthetic prosthesis? What exactly does this mean and we can take it from there to get some of the applications to practical medical concerns? Sure the the bottom line with prosthetic urology or prosthesis and and prosthetics in this arena is a surgical device that is implanted to help achieve an erection and those typically folks who failed other medical therapies beforehand. So we think about the penile prosthesis as the mainstay of this, but their other part of prosthetic urology exists is in the function of urinary, incontinence and issues related to post cancer surgery, side effects. So the prosthetic urologist is someone who engages in the treatment of ed with surgical implants, but also incontinence with surgical implants as well. What what constitutes a prosthetic when it comes to prosthetics, so a prosthetic being the actual physical device that, like different types of prosthetics, that would be implanted include a rod like device for erections there’s a two-piece device which is partially pump pumped and then there’s a three-piece device, which is the most commonly implanted implant that essentially mimics as best as possible. The erectile function that we have normally with a hydraulic pump that draws fluid from a reservoir and puts it into the cylinders of the penis to get your direction got it. Okay. Now, when it comes to the treatment of erectile dysfunction, what exactly is the role of the prosthetic? Does this create an erection? Does it help to assist in erection? What what? What exactly does it do it? It creates the erection so in men, who’ve had whatever the causes are, of which there are many, but men who are refractory to medical treatment, so the standard viagra, cialis and all the rest. Those guys then may move on to this surgical implant to help them actually achieve the erection. Okay. Now, what is the surgery process of getting a prosthetic? I guess from its packaging into the penis. Well, the process itself is is a usually an under one hour, minimally invasive surgical procedure, where we make incisions either just above the penis or right below the penis, depending on patients different parameters, we were able to insert the prosthetic device through those incisions, including the reservoir, that the pocket of fluid that helps get the pump activated. We’re able to do through one single incision, most often as again, the surgery is about an hour. Usually you either go home the same day or you may stay overnight, go home the next day once the device is in. Does it require maintenance? Does this have to like? Do men have to come back in for tune-ups? Does it need replacement parts, or is this like a one-and-done type of type of surgery, yeah? Well, the the maintenance of it and the success reliability of the implant? The mechanical reliability is is excellent, and it really has been so over the last 20 years plus- and it’s just been improved upon over time, so that your likelihood of having a failure of a device is less than one percent. With that being said, the more repetitive use over time will eventually compromise its dysfunction and eventually it may need to be replaced. Unfortunately, there is no way to maintain it in terms of they almost put in grease to to a squeaky part. Can’t do that. So, if there’s anything that does break, it does require surgical revision, but the lifespan of this of the implant can be as long as 15 to 20 years, which I’ve I’ve taken care of a number of patients. Who’ve had implants for that long or longer. Okay, and I assume that at the 15 to 20 year mark the device would have to be replaced at that point just because it’s no longer effective. Honestly, I know as long as the implant’s doing what it’s supposed to do in getting the erection it, it only needs to be replaced if it stops working. So usually I I’ve been surprised. I had a probably the longest implant. I’ve seen in a patient was 20 23 years, he’d had it so that was fantastic. Still, work got it so, in other words, there’s high mechanical integrity to these devices that it could. It could go for quite some time, but I I assume, there’s no warranty for the lifespan. In other words, there is a limited warranty in terms of what medicine or medical devices could guarantee, but but some men have very long runs with a device before it would need to be replaced precisely correct. Yes, okay, now, if a man decides that a prosthetic is a good option, he’s not having reliable erections causing a lot of distress, and he wants to go ahead with this procedure. Can he decide three or four years down the line that he now wants to go ahead and reverse this? That’s the tough part about the procedure. The answer is no, once you’ve made the commitment towards putting an implant in that is going to be the way you’re going to get erections moving forward. There are some exceptions: occasionally men will able to achieve erection with a vacu assist device. The the kind of the penis pumps that you hear about more commonly may work on getting a man erection if they were to have the device removed, but most often this is a commitment of of this is the way we’re going to do it from now on. Okay. So this is a a big life decision from what I have understood about these devices that once they are in there’s a very high rate of satisfaction among people who are using them. Has that been your experience as well? Yes, absolutely I I sort of try to coin a phrase and I’m trying to think of of other r words, but I start off with the three r’s reproducibility, reliability and rigidity. The other ones are spontaneity and durability. What I mean by all that is you get what you need when you need it for as long as you need it as rigid as you need it, and can do so with very little planning. So that’s the advantage of of the penile implants that that you can take to the arena of the love making process afterwards right. So you don’t have to be the guy who runs over to the refrigerator and gets a shot or has to wait for his pill to work. In other words, a couple pumps- and this is done. But to that end, can you describe the listeners? How is a penile prosthesis used for gaining an erection? Okay, so the the prosthesis that the three parts, as we kind of made mention of earlier, those that those the implant implantable parts of the penis, the cylinders? Imagine just kind of condensed flattened for lack of a better description balloons that fill with saline and those are inserted in the erectile bodies of the penis itself, so the pump, which is a manual pump and in the scrotal skin, is you underneath the scrotal skin excuse me is pumped by the patient, drawing fluid into those cylinders until they’ve reached such a maxim rigidity that now you have achieved the erection and it mimics the body’s natural process of getting an erection by filling those erectile chambers. Now, instead, with blood now you’re doing it with a with a saline pump, okay, so so again, a man pumps, this pump, which is located. He said behind the scrot. Actually, it’s right in the front and the lower part of the screen typically lower part of the scrot yeah and that fills the chambers with saline which creates until the desired rigidity engages in a sexual activity and then what so once- and this is the the joke. I kind of tell my patients going back to that durability issue about how long it lasts. So you a man, can climax and will remain erect afterwards until you turn off the device. So I joke, because you’re kind of like the superman right you can, if you do climax to you sooner, not your partner hasn’t reached that point. Yet your penis, your erection, will not go away until you tell it to so with the pump that has an off button to it, so it’ll stay erect throughout the entire intercourse act, and and how does that off button work? So it’s a this is a hydraulic pump. So as soon as you hit the off button, what you’re doing is releasing the fluid back from the cylinders and usually what you’re trying to establish when you hit the off button is you’re opening up the valve that exists in between the pump itself and the in the cylinders allowing the fluid to kind of pulse back into the reservoir. But typically, what we wind up doing is you’ll hold the button for a few seconds, release it and then squeeze the penis to drain the rest of the fluid out. Okay and then I guess the penis returns at that point to being flaccid yes, and is there a refractory period that the device has to then rest or could it be re-pumped without without needing any break in between? You can be re? You can re-pump it without needing the brake okay and because it works as a hydraulic and with a pump is. Is it the number of pumps that are used over the lifespan that generally indicate how long the device is going to last? So I’m sure there’s some men who use it pretty frequently and other men who use it on occasion. Yes, that make a difference that exactly exactly right. So a couple of things in terms of the pumping first of all, the number of pumps that are cycled actually depends on the size of your penis, so the larger, the penis, obviously the more you’re gonna have to pump the device to get enough filled into the chambers to get the erection the more you manipulate the pump and and squeeze it over time, whether it’s the number of pumps itself or just the actual action of pulling in on the tubing eventually will lead to compromise of that tubing, which would would make the device no longer work. Therefore, theoretically speaking the more often you’re using it, the greater the likelihood that it will break sooner than the guys who don’t use it very frequently, okay, which makes a lot of sense. Now. You mentioned something that caught my ear, which is the number of pumps, is going to correlate to the size of the penis. Does that mean that a prosthetic is custom made or custom designed for each for each penis, depending on its size and its girth? Or is there like a one-size-fits-all inflate until there’s no more space yeah? That that’s a great question? So the answer is: it is relatively customized to your penile length and what I mean by that is that the device is made up of two parts, the actual cylinders that are get erect in the penis. There is the cylinder itself that fills and then something called a rear tip and what happens is depending on the particular measurements of the man’s penis. We will change the length of the cylinder and or the length of the rear tip the back side of it to fit the penis in such a manner where you get the best rigidity possible out of the implant. So it is custom to the patient’s overall measurements. We just don’t put a one-size-fits-all, because not one size does fit got it. So dr natalie, who is a candidate for a penile prosthetic, because I think our listeners are well aware that medications like viagra cialis, obviously their generics are well consumed in the general general male population, really ranging in all ages. When it comes to these other treatments, these other interventions, I think it becomes a little bit more confusing as to who really is an appropriate candidate or a right candidate for the prosthesis. So if you could let our listeners know who fits the bill or who could potentially be a good fit for for a prosthetic sure. I I have a tendency- and I might be a little bit long-winded in this particular response, but I I do so because I be, I feel so passionate about about treating erectile dysfunction, in particular with the idea of prosthetic prosthetics as necessary. To me, I usually define the need for this surgical intervention based upon a patient’s sexuality and sexual needs first, so I kind of flip the paradigm to some degree. Yes, I will ask patients to march through some of the of the steps. I certainly don’t want to put a prosthetic in someone who’s. Never tried viagra, but with that being said, the first assessment is well tell me a little bit more about your sexuality. Are you making love or were you making love three times a week two times a day, or was it a once in every six months? I idea that then guides me as to what the patient may need. So, if I go from there to the next thing is well. What have you failed? What’s worked if they haven’t tried anything, always always always it’s medications, but as we get patients who are pushing the envelope they’re not doing well with the medications, maybe they’re, even doubling them up at times, then the next step beyond that is the discussion of okay. Here are the remaining treatment options. Do we need to just consider a prosthetic implant, because you make love often or do you want to try perhaps a less invasive option, because we don’t, you may only make them twice a year, so we I understanding the patient’s needs in the bedroom, for me is then helps me. Walk them through that journey apply whatever therapy is appropriate, and I really really appreciate that answer, because I think in particular, when it comes to sexual function, even that word itself is so much dependent on what what is happening in a person’s life and and what’s happening in their in their relationships or in their sexual relationships and being able to look at erectile dysfunction as a situational as opposed to just a a object, an objective medical diagnosis, because anybody who’s struggling with erections one could make. The argument could be a candidate for an implant right. It really depends on what’s going on in their life as to whether this really is a good option for them, if they’re not overly sexually active and don’t plan on being, maybe this isn’t exactly the treatment that would make the most sense for them, whereas somebody who is very sexually active and is deeply distressed by not having a reliable erection, this could be a really great alternative. They may have the same medical profile, but their lifestyle may send them down different treatment, roads, yeah 100, it’s about! I it’s it’s! If you are, I I hate to to say this in this way, sounds like I’m boasting, but if you’re good at your job, you’re going to look at the patient as a person it in. Maybe this is wrong with me to say, but I sometimes I’ll put myself in their shoes and try to understand from their perspective, because if, if everything is a nail, because I’m a hammer, I’m not doing my job right really truly, I I I don’t want to put everybody into that into that kind of around square peg and around hole, type stuff. I I think you need to really customize to the patient’s needs. First and that’s listening, that’s understanding their journey. What their needs are it’s just key and we talk a lot on on this podcast about the the nuance and the individuality to erectile dysfunction and- and I you always appreciate when, when the medical counterparts to the psychological side of erectile dysfunction also can see the patient in that way. So deep appreciation for for how you approach that now, how many men, who are potentially good candidates go through with this treatment. It does sound a little bit invasive and I know that many men do get a little bit squeamish when it comes to injections and surgery and whatnot around around the penis yeah all right. Well, this global statistics that we hear very frequently quoted is, if you were, if you apply the definition of ed being anything from I’m, not able to get it as hard as I used to all the way up to. I can’t get anything at all: there’s probably 30 million men in the united states who have this trouble, and I put that in perspective out of the 30 million. Obviously, tens of millions are getting prescriptions for their medications, they’re only about 15 to 20 000 implants put in per year, and you got to figure that some of those implants are patients that have had device revisions over the lifetime. So you’re you’re talking about a tiny fraction of people who will make that next step? Now I think a lot of it has to do with something else we sort of discuss, which is this, this kind of idea that sexuality is not something we need to share with our physician in a medical discussion, and so people don’t seek out that care so that we we get a lot of the the old joke about hey. I had my hand on the on the on the door handle about to walk out hey. Can I get a script for viagra? I think, because of that people aren’t getting the exposure to this as they need to be, because then there’s one last piece of data to share, which is the average time it takes a patient who is a candidate for an implant to actually go to implant is about seven years, so these are guys who’ve been sitting there struggling silently they’re miserable waiting and waiting and they’re finally going into this stuff. So I can tell you that while there’s 15 plus thousand implants being put in per year, I can tell you, there’s probably hundreds potentially of thousands of men who probably should get enough yeah. We certainly don’t doubt that, because I, I think it’s something which is across the board when it comes to probably medical care, but certainly when it comes to sexual health- and I see the same thing in my practice with just coming to talk to somebody about this. So I hear rather often that I’ve been sitting with your card for a year and I I look at it every day, but I I just can’t bring. I couldn’t bring myself to call until it got to a point where it’s so challenging. I picked up the phone, so I I certainly hear that. But what I’m gathering for you is that it is really a fraction of the men who probably could benefit from an intervention like this that actually are following through yes with the procedure. We’ve spoken a lot about the use of the prosthetic when it comes to erectile dysfunction, which I understand is its primary use. But could you educate both myself and the listeners about what are some of the other medical uses for a prosthetic? What conditions are they used to treat? Well, I’m gonna start off first with what it’s not, and I tell you that, because there are some men who will come- and this is probably this is actually a very important topic for both of us to talk about. There’s men who come with almost a body dysmorphia of my penis isn’t normal. I need it to be bigger. I need to be wider. I need to be different. The penile prostate prosthesis is not like a breast implant, so it’s not going to give you. I’ve always wanted a 10 inch penis. It can’t do that. So it’s a hundred percent functional there’s, not an aesthetic use for it all at all. Now that being said, the use and application of the device outside of simply erectile dysfunction is the other use for the device is for the correction of a condition called peyronie’s disease. So men who’ve had severe curvature of the penis in which either medical therapies have not worked, or the severity of such would be that any surgical treatment to correct this, the curvature would result in erectile dysfunction. We oftentimes will implant a penile prosthesis, because the devices themselves, because the nature of how they work the rigidity they in the numb of themselves, may correct the curvature or, at the very least, allow for us to do more advanced, surgical techniques to correct the curvature outside of that I’ve had some men who honestly have penile prosthesis, so they can gain access to their penis more easily. There are some men who, between the effects of medical issues, age obesity, will have a such a shortening of their penis that they just can’t get to it. So, by putting something, that’s somewhat rigid in there, or at least has stretches his face, they’re actually able to to kind of grab the penis and just do simple things like go, go pee and if I can yeah, if I could just kind of pause you there for a moment now. I know that we spoke a little bit more about the inflatable prosthesis yeah with in in the situation where there’s a shortening of the penis and it’s hard to reach. Would that would would a more traditional prosthesis, where, like it’s just a like from what I understand like a tube, it could be bent and create more rigidity. Would that be like, like a more common or more appropriate? Yes yeah, particularly if it’s not the rigid implants are difficult for sexual satisfaction just because of the nature of how they bend and move. Now, I’m not saying that they can’t be used for that reason as well, but if we’re looking typically for someone like I just mentioned of yeah, absolutely in fact, ideally that patient would be a candidate for it also because usually they’re heavy set, and what comes with that is other medical conditions such as diabetes and other rest. So if we were to do something simple and a little bit quicker of a surgery and in less risk of infection, that’s an ideal circumstance. Okay are there? Are there any other urological conditions where a penile prosthesis would be used to treat not necessarily the outside of those two things so outside of erectile dysfunction in peyronie’s disease, the penile prosthesis itself for the purpose of erections? That’s it! It was really the other prosthetic implants that I’d mentioned earlier about urinary continence. Okay, and can can you just kind of refresh our lizard’s memory about the other types of sure sure so occasionally, when men, for example, have had prostate removal for cancer, they’ll develop a condition called stress, urinary, incontinence and they’ll leak with cough laughing sneezing, they may even they may even just leak constantly after the surgery. There are two implantable devices. One is called a sling, the advanced male sling, which can re-support reposition the urethra and allow for the better support and therefore more control, typically the more mild to moderate leakage, patients and that you hear the word sling. A lot of people get worried about the the ugly words we heard about in the media a few years ago, but this is not that type of material or at least type of device. The second is something which I find brilliant is an artificial urinary sphincter, which is a cuff that wraps around the urethra channel out of the bladder and mimics our pelvic floor, and it’s a really neat device, because it’s it’s filled with saline. It keeps the urethra closed captioning not available in a cycle in which you’re closed, you press a pump, you open you pee, and it slowly closes back on itself, mimicking our normal function, so there there are obviously other uses of prosthetics in urology outside of erectile, especially when it comes to a penile implant that seems to be really around erectile function and and possibly correcting peyronie’s disease, which there’s a fair amount of overlap between protons disease and and erectile dysfunction. Yes, but these these other. These other prosthetics, though, are not for that purpose. Yeah, that’s correct, yeah! All right doctor is there anything else that you want our listeners to know about prosthetics. Certainly if there are listeners out there who maybe are on the fence or are curious about this, what would you want to message to them so to wrap that part of it up? I think that it’s important to find the people who are going to focus on taking care of the patient first right so having a good interaction with your physician, understanding kind of their philosophy is how they take care of patients. That’s number one number two is making sure that that doctor also does a fair volume, because you can reduce the risk of complication and improve the likelihood of a good outcome with a surgeon who does more than a few a year and that we know that to be the case with through all types of specialties. So having someone who’s more focused on that is very important from there. It’s also just about doing your homework of the device. It’s easy to google search something and find the negative things like we can do for everything in the world, but understanding the positives, understanding how it fits in your life take taking that time is important, and, finally, I really encourage all my patients to come with their partners. Not involving your partner is a mistake because that’s not any other reason, but you want to have a supportive environment which we’re collaborating together on how to fix this problem, obviously with the person you’re making love with. So those are the kind of key things I think are important for my patients that I that I hope that they all think about or any anybody who’s. Listening to the podcast, I would suggest that to them as well. Okay! Well, dr natalie, thank you very much for joining us. This is going to be very informative to our listeners out there, and I can’t wait to get this episode out awesome. Thank you.

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