Surgical treatment of erectile dysfunction, types of penile prostheses, and intracavernosal injection therapy

234.

Surgery can treat erectile dysfunction

All types of erectile dysfunction can be treated surgically.

With the advent of new drugs for treating erectile dysfunction and various physical therapy devices, the need for surgical treatment has decreased significantly.

Although non-invasive treatments are generally considered or used, a small percentage of patients still require surgical treatment.

The surgery mainly includes the insertion of a penile prosthesis and correction of vascular malformations.

Before deciding on elective surgery, a detailed examination must be conducted, and then the appropriate surgical treatment will be considered.

In recent years, data has shown that organic erectile dysfunction accounts for more than 50% of all cases, and vascular erectile dysfunction accounts for 40% of all cases of organic erectile dysfunction.

The purpose of various penile vascular reconstruction surgeries is to increase the reduced baseline arterial blood flow to a higher level and reduce excessive venous return, so as to increase the necessary blood flow under appropriate stimulation to ensure full penile erection.

However, penile vascular reconstruction surgery for vascular erectile dysfunction can only improve erectile dysfunction in the short term, and the long-term efficacy is unsatisfactory in most cases.

Therefore, a cautious approach should be taken when performing vascular surgery.

However, modern prosthetic technology can enable almost all patients with erectile dysfunction who have successfully undergone surgery to achieve satisfactory sexual intercourse.

235.

Types of penile prostheses

In order to create a human "penile bone," people use various artificial materials called penile prostheses to support the weak penis and make it erect, so as to achieve satisfactory sexual life and thus achieve the treatment purpose. This is called penile prosthesis implantation surgery.

The main indication for penile prosthesis implantation is erectile dysfunction caused by organic lesions of the corpora cavernosa that are unresponsive to other treatments.

Based on their materials and construction, implants can be classified as: ① rigid implants; ② semi-rigid implants; ③ expandable implants.

Choosing the right prosthesis for a patient depends on many factors, the most important being the patient's requirement for a realistic feel, and the patient's spouse should also be informed about the relevant issues.

236.

Indications and complications of penile prosthesis implantation

Penile prosthesis implantation is suitable for organic erectile dysfunction caused by various reasons, but in patients with normal libido, penile sensation, ejaculation, and orgasm, such as those caused by trauma, pelvic surgery, vascular or endocrine factors.

Whether or not patients with psychogenic erectile dysfunction should undergo prosthesis implantation remains controversial. Some data indicate that patients with psychogenic erectile dysfunction have a higher incidence of complications and a lower satisfaction rate when undergoing prosthesis implantation compared to patients with organic erectile dysfunction.

In a small number of patients who refuse other treatments, implant placement is the only option.

Common complications after penile prosthesis implantation include:

(1) Infection: Infection is a common complication. In recent years, with the development of new technologies and the application of antibiotics, the chance of infection has greatly decreased, with an incidence of about 1% to 10%. The most common cause is infection with Staphylococcus epidermidis transmitted through the air.

The initial symptom of the infection is pain, followed by local redness and swelling.

Antibiotics specifically targeting Staphylococcus should be used for treatment.

If infection occurs, the prosthesis should be removed immediately.

Preoperative prophylactic antibiotics should be administered and strict aseptic techniques should be followed.

(2) Perforation: Penile cavernous body dilation is required during prosthesis insertion. The most common surgical problem is difficulty in cavernous body dilation, which may lead to perforation and damage to the urethra, tunica albuginea, and perineum. If this occurs, it should be treated promptly.

(3) Erosion: often caused by infection, and erosion can lead to prosthesis displacement. Erosion of the glans penis can be caused by an excessively large prosthesis. Once it occurs, remove the prosthesis immediately, rinse with antibiotics, and reinsert it.

(4) Penile curvature deformity: If the prosthesis is not tough or a variable position prosthesis is used, a fibrous capsule is likely to form in the penis, resulting in penile curvature deformity. Therefore, the penis should be fixed upward in the lower abdomen for 4 to 6 weeks after surgery.

(5) Mechanical failure: This is a quality problem of the prosthesis itself, such as liquid leakage.

In addition, due to the trauma of surgery, the insertion of foreign objects and their compression on tissues, patients may still experience postoperative pain, fever, foreskin edema, difficulty urinating and urinary retention after surgery.

237.

Chemical penile prosthesis

It is an effective diagnostic and treatment method that was developed in the 1980s.

Intracavernosal injection (ICI) involves injecting various vasoactive chemicals into the corpora cavernosa of the penis to induce an erection. This is commonly referred to as intracavernosal injection (ICI) therapy. Some call it a chemical prosthesis, but in reality, no prosthesis exists.

238.

Indications for intracavernosal injection of vasoactive substances

The penile cavernous body vasoactive substance injection test can be used as a means of diagnosing erectile dysfunction and can be used to differentiate between psychogenic and vascular erectile dysfunction.

Currently, it is not considered a first-line treatment, but it remains an effective treatment option when non-invasive treatments fail.

It is mainly applicable to neurogenic erectile dysfunction caused by various reasons, and is also used for psychogenic erectile dysfunction, endocrine erectile dysfunction and drug-induced erectile dysfunction that are difficult to cure. It can also be used in combination with other methods to treat vascular and mixed erectile dysfunction.

However, intracavernosal injection only solves the problem temporarily and cannot eradicate the cause. It needs to be injected once before each sexual encounter, but it is fast-acting and effective, and is still accepted by most patients.

However, it should be avoided or used with caution by those who are allergic to vasoactive substances, have other diseases (such as leukemia) that may induce abnormal erections, have penile cavernous fibrosis, have penile prostheses, have cardiovascular diseases, or are elderly and frail.

239.

Drugs for intracavernosal injection

There are six categories of drugs that can induce or enhance erections:

(1) Smooth muscle relaxants, including nitroglycerin, papaverine, etc.

(2) α-receptor blockers, such as phenoxybenzamine and phentolamine.

(3) Calcium channel blocker Isoprena.

(4) Anti-inhibitors - chlorpromazine, chlorperazine.

(5) Peptides, including vasoactive intestinal peptide (VIP).

(6) Prostaglandins - Prostaglandin E₁ (PGE₁).

Commonly used drugs include papaverine, phentolamine, and prostaglandin E₁ (PGE₁).

Papaverine is a nonspecific phosphodiesterase inhibitor that can relax smooth muscle.

The starting dose varies depending on the cause of the disease.

Its efficacy is not as good as PGE₁, and its side effects, such as prolonged erection time and fibrosis of the corpus cavernosum, are more common than other drugs. It is no longer used alone.

Phentolamine is an alpha-receptor blocker that blocks the activity of tonic sympathetic axons, thereby relaxing smooth muscle.

However, it rarely works when used alone.

PGE₁ is a powerful smooth muscle relaxant that reduces corpus cavernosum resistance and increases blood flow to the penis, thus promoting erection.

The starting dose of PGE₁ is 5 micrograms for psychogenic, 10 micrograms for vascular, and 2.5 micrograms for neurogenic.

240.

Correct procedure for intracavernosal injection

Since intracavernosal injections need to be performed before each sexual intercourse, and sometimes patients live far from hospitals or clinics, they can be instructed once or twice to self-inject at home.

The method is as follows: Generally, a skin test syringe and a No. 4 or No. 5 skin test needle are selected. The medication is drawn up, the skin is disinfected, and the penis is pulled to make it tense. The injection site is the area on both sides of the penile shaft where there are no subcutaneous veins. The needle is inserted vertically into the corpus cavernosum. When the tunica albuginea is pierced, there will be a feeling of emptiness. When the needle is confirmed to have not entered a major blood vessel by a back aspiration test, the medication is slowly injected.

Remove the needle and apply pressure to the injection site for 3 minutes, while occasionally massaging the penis to ensure the medication is evenly distributed in the corpora cavernosa on the opposite side. After the injection, have the patient stand up to reduce blood reflux in the corpora cavernosa, which is beneficial for penile erection.

Some advocate wrapping a rubber band tightly around the base of the penis before injection to prevent the medication from draining too quickly through the veins during penile massage.

Penis enlargement is usually visible 3 minutes after injection, and full erection is achieved in 5-10 minutes, at which point sexual intercourse can be completed.

However, the following issues still require serious attention:

(1) Perform aseptic procedures to avoid contamination and infection;

(2) The dosage must be determined by the doctor and cannot be changed or determined by the patient on their own.

(3) Strictly follow the correct procedures as instructed by the doctor to avoid various complications;

(4) Inform the patient that if any complications are found, they should come to the hospital emergency room for treatment immediately;

(5) Note that a single dose of the medication should not be used more than 10 times, and repeated sexual intercourse is not recommended after a single injection.

(6) You should return to the hospital for a follow-up visit every month to check the condition of your penis and other general health conditions.