Clinical Consult

Faculty


Culley C. Carson III
Culley C. Carson III, MD
Rhodes Distinguished Professor and Chief of Urology
University of North Carolina at Chapel Hill
Chapel Hill, North Carolina
J. Francois Eid

 J. Francois Eid, MD
Clinical Associate Professor of Urology
Weill-Cornell Medical College of Cornell University
Director, Advanced Urological Care
New York, New York
J. Francois Eid Susanne A. Quallich, ANP-BC, NP-C, CUNP
Andrology Nurse Practitioner
University of Michigan Medical Center
Ann Arbor, Michigan


Question

Given the very high rate of patient satisfaction with penile prostheses, what are some of the barriers to implantation that still exist for patients and providers? What can be done to remove some of these barriers to further increase patient, partner, and provider satisfaction?

Response by Culley C. Carson III, MD
Penile prosthesis implantation is an excellent treatment choice for patients experiencing erectile dysfunction (ED) who cannot be treated successfully with phosphodiesterase type 5 (PDE5) inhibitor therapy because of ED severity, for instance, or ED secondary to severe cardiovascular disease or caused by diabetes or penile fibrosis.1,2 It is also an excellent option when PDE5 inhibitor therapy is effective but the patient would like to discontinue medical therapy because they find it impractical, cannot tolerate the side effects, or would prefer not to need to take a pill.

Reported patient satisfaction with prostheses is very high. A recent study evaluating satisfaction rates, as assessed by the Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) questionnaire, demonstrated that 97% of patients using a 3-piece inflatable prosthesis were satisfied with treatment; additionally, patients reported that 91% of their partners were satisfied with treatment.3 Despite such overwhelmingly positive statistics, barriers to implantation persist; penile prosthesis is an option often left unmentioned by clinicians and met by patients with apprehension.

Appropriate education and careful patient selection are critical to overcoming barriers to implantation. Clinicians should fully apprise patients of the array of ED treatment options, including the types of implants and their advantages and caveats. It is equally crucial that clinicians screen candidates for implantation to ensure they are highly motivated and interested in resuming an active sex life.1,2

When counseling patients who are considering penile prosthesis surgery, particularly those who have undergone radical prostatectomy or have Peyronie disease, it is important to address the issue of penile shortening. A study by Deveci and colleagues demonstrated that, though penile prostheses do not affect measured stretched flaccid penile length, experienced subjective penile length loss was commonly reported, at a rate of 32% for patients who had undergone radical prostatectomy before implantation.4 Early daily intervention with a vacuum erection device after radical prostatectomy has been shown to significantly lower the risk of loss of penile length (P<.0001), as defined by stretched penile length.5 Also, various procedures have been proposed to salvage implants in cases of penile infection, because removal of the prosthesis can cause fibrosis and measurable penile shortening.6


Response by J. Francois Eid, MD
Although penile implants garner extremely high satisfaction rates, many patients do not explore this as a viable ED treatment option, often because of a lack of awareness. Misconceptions concerning the success of penile prosthesis surgery can be coupled with fear of complications, such as infection or prolonged pain.7

Infection rates have been reduced by standard sterile surgical techniques; antibiotic-coated devices, such as InhibiZone™ and Titan™; and improved surgical procedures, including the “no-touch technique,” which eliminates direct and indirect contact between the prosthesis and the patient’s skin, which can harbor bacteria.8-12 The importance of avoiding sexual activity for 6 weeks after surgery, to ensure proper healing, avoid damaging the incision, and reduce opportunity for infection, also should be explained to patients.13 To concerns about prolonged pain, patients may feel encouraged that implant recipients report that pain diminishes each day, subsiding almost completely by 3 to 4 weeks.1

Without appropriate education, patients may be apprehensive that a prosthesis would appear unnatural or interfere with everyday activities, including physical intimacy. Patients may erroneously believe that the pump would be located externally or that penile stimulation, ejaculation, or urination would be altered. These fears and misconceptions can be dispelled by providing adequate information and showing images or videos to illustrate how the implant functions and is concealed within the penile shaft and scrotum.14 It should also be reinforced to the patient that implants do not negatively affect penile sensation or the ability to climax or ejaculate.1,13

The prosthesis itself may provoke anxiety, particularly for patients unfamiliar with this therapeutic option. Patients may lack confidence in operating the device and worry about damaging it through improper use.15 Such concerns may be alleviated by describing advances in the design of penile prostheses,16 originally manufactured in 1973, and stressing the high level of treatment success. Manufacturers of the current multicomponent devices have focused on improving reliability, increasing the lifespan to up to 10 years when used once per week, 2 or 3 times per month.

To help alleviate patients’ concerns, it may be beneficial to enlist the support of men who have undergone implant surgery and are willing to be contacted about their experiences. Though the etiology of their ED may vary (eg, radical prostatectomy, radiation therapy, treatment for bladder cancer, diabetes, or severe vasculogenic disease), these patients can offer firsthand experience about how the implant feels and is used. This can be very reassuring to a patient considering implantation. A patient support system helps foster realistic expectations and assuage misgivings about the procedure and postoperative pain and discomfort. Also, patients may consider such referrals an indicator of their physician’s comfort level with their other patients’ surgical experiences.


Response by Susanne A. Quallich, ANP-BC, NP-C, CUNP
Simple measures can help optimize penile implantation treatment success, satisfaction, and outcomes. During the preoperative evaluation, penile prosthesis options should be discussed with both the patient and partner, including the benefits and risks. Fostering a supportive environment for shared decision-making, as well as understanding patient’s and partner’s needs and expectations, is paramount to ED treatment success.12,13,17 Treatment satisfaction rates rise with counseling and education of both patient and partner when possible, particularly when they are coached to set realistic expectations and allowed to discuss preferences and concerns.7,13

With the help of proper education, patient comfort and satisfaction rates can be optimized.14 Though patients may find penile prosthesis options equally suitable, selection of prosthesis type should be individualized to improve satisfaction outcomes. Both clinician and patient may find that novel prosthesis devices confer superior results when compared with traditional penile implant devices. For example, a patient with mild dexterity difficulty who wishes to experience the “natural” feeling of a multicomponent inflatable prosthesis may benefit from the Momentary-Squeeze button design of the AMS 700™ or the One-Touch Release pump design of the Titan® OTR™.15,18,19 In a study to evaluate the impressions of those who teach patients to use these devices and determine whether pump designs afforded appreciable differences in satisfaction rates, all devices were found to be efficacious and garnered the highest overall preference ratings among clinicians. However, the Titan® OTR™ consistently attained significant clinician preference for anticipated time to train patients postoperatively.15 Both large and small practices, as well as their patients, could benefit from this device’s ease of operation and instruction.

When instructing patients in how to use a penile prosthesis, a systematic approach is recommended, applying principles of adult learning, which include motivation, experience, engagement, and application of knowledge.14 Acknowledging the range of adult learning styles (ie, visual, auditory, and kinesthetic) may be helpful to clinicians when educating patients to successfully operate penile prostheses.15 Perhaps the most important aspect of the process, application of knowledge, can be achieved through a hands-on learning opportunity, during which the manual dexterity of the patient may be assessed, as well as the patient’s and/or partner’s comfort with inflating and deflating the device.14

Patient care within the context of a multidisciplinary team approach is key to treating ED. Because penile prosthesis implantation is a procedure performed only by select urologic surgeons, many urologists and primary care clinicians particularly would benefit from a referral network of penile implant surgeons. Appropriate referral to a specialist fosters mutual trust and respect between patient and clinician, ultimately enhancing ED management and treatment outcomes.


References

  1. Mulcahy JJ, Austoni E, Barada JH, et al. The penile implant for erectile dysfunction. J Sex Med. 2004;1(1):98-109.

  2. Montorsi F, Dehò F, Salonia A, et al. Penile implants in the era of oral drug treatment for erectile dysfunction. BJU Int. 2004;94(5):745-751.

  3. Natali A, Olianas R, Fisch M. Penile implantation in Europe: successes and complications with 253 implants in Italy and Germany. J Sex Med. 2008;5(6):1503-1512.

  4. Deveci S, Martin D, Parker M, Mulhall JP. Penile length alterations following penile prosthesis surgery [abstract]. Eur Urol. 2007;51(4):1128-1131.

  5. Dalkin BL, Christopher BA. Preservation of penile length after radical prostatectomy: early intervention with a vacuum erection device. Int J Impot Res. 2007;19(5):501-504.

  6. Wilson SK, Delk JR II. Inflatable penile implant infection: predisposing factors and treatment suggestions. J Urol. 1995;153(3 pt 1):659-661.

  7. Lewis JH, Rosen R, Goldstein I. Erectile dysfunction in primary care. Nurse Pract. 2004;29(12):42-46, 48-50, 55.

  8. Carson CC. Diagnosis, treatment and prevention of penile prosthesis infection. Int J Impot Res. 2003;15(suppl 5):S139-S146.

  9. Abouassaly R, Angermeier KW, Montague DK. Risk of infection with an antibiotic coated penile prosthesis at device replacement for mechanical failure. J Urol. 2006;176(6 pt 1):2471-2473.

  10. Wolter CE, Hellstrom WJG. The hydrophilic-coated inflatable penile prosthesis: 1-year experience. J Sex Med. 2004;1(2):221-224.

  11. Eid JF. Penile prosthesis proximal cross-over case using “no-touch technique” drape and exposure [abstract]. J Urol. 2008;179(4 suppl):363. Abstract V1054.

  12. Hatzimouratidis K, Hatzichristou DG. A comparative review of the options for treatment of erectile dysfunction: which treatment for which patient [review]? Drugs. 2005;65(12):1621-1650.

  13. Quallich SA, Ohl DA. Penile prosthesis: patient teaching and perioperative care. Urol Nurs. 2002;22(2):81-90, 92.

  14. Liechty A, Quallich SA. Teaching a patient to successfully operate a penile prosthesis. Urol Nurs. 2008;28(2):106-108.

  15. Quallich SA, Ohl DA, Dunn RL. Evaluation of three penile prosthesis pump designs in a blinded survey of practitioners. Urol Nurs. 2008;28(2):101-105, 108.

  16. Moncada I, Jara J, Cabello R, Monzo JI, Hernández C. Radiological assessment of penile prosthesis: the role of magnetic resonance imaging. World J Urol. 2004;22(5):371-377.

  17. Burnett AL. Erectile dysfunction. J Urol. 2006;175(3 pt 2):S25-S31.

  18. Bella AJ, Lue TF, Phonsombat S, Brant WO, Nehra A. Initial experience with 50 patients using the new AMS 700 with MS pump series inflatable penile prosthesis [abstract]. Presented at: Annual Meeting of the Sexual Medicine Society; December 7, 2007; Chicago, IL. Poster 44.

  19. Knoll LD, Culkin D, Henry G, et al. Physician and patient satisfaction with the new AMS 700™ MS™ inflatable penile prosthesis [abstract]. Presented at: Annual Meeting of the Sexual Medicine Society; December 7, 2007; Chicago, IL. Poster 45.


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