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Penile prosthesis: Psycholocic factors
PENILE
PROSTHESIS:
THOMAS
D. STEWART,
M.D.
STEPHEN
N. GERSON,
M.D.
From the Veterans Administration West Roxbury, Massachusetts
PSYCHOLOGIC
FACTORS
Hospital,
- A thirty-one-year-old paraplegic male requested a penile prosthesis. Psychiatric evaluations were done of both the patient and his wife. Within seventy-two hours of his arriving home with the prosthesis installed, his wife left their house to seek a divorce. The implications of this event for selecting patients fm such devices are explored. Reservations are expressed about a prosthesis being inserted fm Datients married after the onset of imvotence.
ABSTRACT
Impotence is a common complaint of patients with diabetes mellitus, peripheral vascular disease, spinal cord injury, and in patients who have had intrapelvic operations. There is little mention in the literature with regard to the psychiatric implications of a penile prothesis for the management ofpatients with impotence of any variety. In the only study where psychologic case material is detailed, Gee et al. ’ conclude that preoperative psychiatric evaluation of 16 patients indicated that the “careful screening of the motives and attitudes of the patient is most important.” He states, “routine psychiatric evaluation does not appear to be necessary, if the urologist is aware of careful questioning. However, psychiatric consultations should be sought if there is doubt about motivation or psychosis. ” Our experiences suggest that couples who marry subsequent to the patient’s spinal cord injury should have careful psychiatric evaluation before such a prosthesis is installed. In most cases in which impotence develops after the couple has been married and there has been some type of stable sexual relationship prior to loss of potency, the prosthesis can be seen as a welcome reacquisition of the lost ability. The implications of the procedure are much more complex for those individuals who have married subsequent to the development of impotence. It is well known that spinal cord injuries often have as one of their sequelae an inability to maintain a functional erection.2 It is our impression that, like marriages in the general population, those of men with spinal
400
cord injury vary from being fulfilling to being states of chronic discord. It should be appreciated that many of the postinjury marriages do well with an incidence of divorce possibly less than that of the general population. 3 As it may be expected that more spinal cordinjured patients in the future will be expressing an interest in a penile prosthesis, the following case is reported describing the introduction of a prosthesis into one relationship. It raises compelling questions for factors to consider in the careful psychologic assessment for these couples requesting this procedure. Case Report The patient, a thirty-one-year-old white male, was injured during 1969 in an automobile accident. He has a flaccid paraplegia (T-10 neurologic level) complete for both sensory and motor functions and is unable to have erections of any type. A Scott prosthesis was installed on October 8, 1974. This prosthesis is constructed of Dacron reinforced silicone rubber and is inflatable by means of a subcutaneous pump in the scrotum.4 The patient became aware of the procedure during the course of an interview with his physician (T. D. S.) while in the hospital for a routine annual checkup. The patient was interested in this procedure, and it was explained to him in detail. He and his wife subsequently were interviewed independently by two psychiatrists, male and female, with extensive consultative psychiatric experience. The patient and his wife discussed
UROLOGY
/
APRIL 1976
/
VOLUME
VII,
NUMBER
4
the procedure, its possible complications, and their feelings about it for several weeks before finally agreeing to implantation. Two years ago, which was three years postinjury, he married his wife one month after they had met. She was attracted to him because she found him attractive and strong in appearance. Since that time, the two have lived in a remote area of New England extremely isolated from other towns. He did some repair work around the house and had enrolled in an electrician’s course which he was about to complete and which he felt would enable him to return to work. The patient described satisfactory sexual relations before his injury along with satisfactory sexual experiences in the postinjury but premarried phase of his life. His wife in addition described satisfactory sexual relationships occurring before her marriage. The report of the male psychiatrist included the following: “The patient has been unable to have erections of any kind since his injury. Although he was able to work and earn a living before his injury, he has been unable to hold a job since the accident. He feels this is due to his depression and poor self-esteem. His self-image is that of a small man in spite of his very large physique.” The psychiatrist noted that the patient conceived of himself as small before his injury as well. He stated that one of the most stressing things in his life was his incapacity to have an erection. As he put it, “I look down at myself and see this little shriveled up thing.” The male psychiatrist’s opinion was that their marriage had considerable strengths and weaknesses. It was clear that they had affection for one another even though the thought of divorce had crossed both of their minds. She explained that it was because of their personalities “that we are so different.” He would like her to be more outgoing and have more friends come into the house, whereas she prefers to be alone. He was angry at her because he would like her to find a job to help with their financial difficulties. Although she has a college degree, she refused to do so. They supported themselves on social security disability benefits and his Veterans Administration pension. They described their sexual life as “so-so.” The occurrence of sexual closeness and the satisfaction which it brought had been declining steadily. She believed this was because he was afraid to take the initiative since she occasionally had turned him down. She was aware that this undermined self-confidence, while he on the other hand felt she was bored with the sexual options available to
UROLOGY
/
APRIL 1976
/
VOLUME
VII,
NUMBER
4
them which were manual and oral sex both of which they had employed. He felt that she did not respond to him sufficiently, yet she made it clear that she was satisfied with their sexual closeness. Both agreed that sex fell short of their expectations. They also agreed that they spent too much time together in a small isolated house. Both were questioned about their expectations concerning the procedure. He felt it would do two things: (1) it would increase his “ego,” and (2) it would make it easier for him to apply his condom drainage device which was difficult to do. The psychiatrist asked whether or not there might be hidden expectations that his prosthesis would add a dramatic new dimension to their sexual relationship. He cautioned the two of them that, while the prosthesis might be of help, it would not make either of them different individuals, and it would not “make her respond in a different way. ” The patient felt that simply being able to look at an erect penis would be extremely gratifying. He suspected that this increase in self-esteem would make it easier for him to resume a more aggressive life style. The male psychiatrist was concerned that she might find her husband having an erection a frightening experience and that this would add an element of anxiety to their marriage. She was questioned carefully and explicitly about this and claimed that it was important to her as well as to her husband that he receive this prosthesis. With seeming comfort she denied any fears that the prosthesis might harm her or stir up sexual fears. They were cautioned that the prosthesis might offer help in their marriage but that it alone was not a solution to their difficulties. They were reminded that a significant amount of work would need to be done between them whether or not the prosthesis was implanted. It was the opinion of the male psychiatrist that there was sufficient strength and affection in their marriage for the prosthesis to be helpful in establishing a more rewarding relationship. The female psychiatrist elicited a similar history. Her general impression was similar to that of the male psychiatrist except that she did express a greater note of concern about the wife’s tendency to keep herself isolated, viewing this as being schizoid in character. She felt that the capacity to have erections would be a major boost to the patient’s feelings of self-esteem. Her concern about the wife’s need to be alone will be an important element as will become apparent later on. Subsequent to the procedure the patient returned to their home to join his wife. Three days after his arrival she decided to leave him and end
401
the marriage. Follow-up interviews with both patient and wife indicated that he was upset about this and urged his wife to come back, but she had made up her mind firmly and refused to reconsider. It was clear during the subsequent interview that in the initial discussions with the psychiatrists she had minimized her misgivings about the marriage. In the postoperative interview she stated, “I realized that for me a big part of sex was in exciting and satisfying my partner in the mysterious physiologic process that occurs in a man and in the effect I have on him - not what mechanical change he makes with any device. I achieve some satisfaction by masturbation but that is a lonely way of having sex. I would like to share sex a lot more than that.” Thus an unforeseen factor produced by this prosthesis was a reduction in the wife’s feeling of psychosexual importance to her husband. It made her feel less involved and less important to him than she had before. The wife denied that fear of sex had anything to do with her decision to separate. In retrospect, however, it does seem clearer that this schizoid woman was likely fearful of sexual penetration in the setting of genuine intimacy. She further stated in the follow-up interview, “maybe I was looking to rationalize my desire to leave, wanting to go, when I felt things in his life were otherwise going well.” In other words the wife now felt that the husband’s self-esteem was more stable, and thus she rationalized her departure on this basis. Prior to the operation the psychiatrists did not realize that she would utilize the improvement in his self-esteem as a justification for leaving him. Subsequent to this separation, the couple has sought a divorce. After his wife left at the end of January a mechanical difficulty developed with the prosthesis. It was repaired during late March and was followed three weeks later by mechanical failure and an infection resulting in epididymitis. Because of these complications, the prosthesis was removed on April 28, 1975. These difflculties created considerable frustration within the patient but did not appear to harm his over-all emotional adjustment, as reflected in his recent successes in national wheelchair athletic competition. Following these successes the patient said in June, 1975, that he had never felt so alive since his injury. Comment One cannot with assurance deduce a direct cause and effect relationship in the breakup of such an unstable marriage because of the intro-
402
duction of this prosthesis. It may have added another stress on an already compromised and conflicted couple’s system of relating which led to their decision to leave one another and discontinue any effort toward dialogue and compromise. In retrospect a clearer understanding of the wife’s fear of intimacy would have been helpful. This course of events raises a caveat for those physicians and patients who are thinking of carrying out this procedure within the context of a stable postinjury marital relationship. Many of these couples proceed on the unexamined assumption that traditional sexual intercourse will be a fulfilling addition to their lives. It is our thesis, however, that there are pitfalls in such an assumption. For example, some women who are attracted to and do marry men with spinal cord injury may do so because of fears of direct sexual penetration which they are dimly or not at all aware of. This type of unconscious fear exists in some women and is a well-recognized psychologic phenomenon.5 It is important to recognize that such women and their husbands may already be reasonably fulfilled in their relationship without direct sexual penetration. For some of these people their request for the prosthesis may reflect a cultural value system which places an inappropriate emphasis on traditional sexual performance rather than an insightful pursuit of a realistic improvement in the communication within their marriage. The introduction of sexual intercourse with the aid of the prosthesis into a previously stable relationship could cause disruption. It is our opinion that in the postinjury marriage careful psychologic assessment, counseling, and followup are mandatory when such couples consider this major step in their lives. West Roxbury, Massachusetts 02132 (DR. STEWART) ACKNOWLEDGMENT. To Dr. Miriam Tasini for allowing us to use her evaluation. References 1. GEE, W. F., MCROBERTS, J. W., RANEY, J. O., and ANSELL, J. S.: The impotent patient, J. Urol. 111: 41 (1974). 2. COMARR,A. E.: Sexual function among patients with spinal cord injury, Urol. Int. 25: 134 (1970). 3. IDEM: Marriage and divorce among patients with spinal cord injury, Proceedings of Eleventh Annual Clinical Spinal Cord Injury Conference, 1962, pp. 163-169. 4. SCOTT, F. B., BRADLEY, W. E., and TIMM, I. W.: Management of erectile impotence, Urology 2: 80 (1973). 5. FRIEDMAN, L. J.: Virgin Wives: A Study of Unconsummated Marriages, Springfield, Ill., Charles C Thomas Co., 1962.
UROLOGY /
APRIL 1976 /
VOLUME VII, NUMBER 4
PROSTHESIS:
THOMAS
D. STEWART,
M.D.
STEPHEN
N. GERSON,
M.D.
From the Veterans Administration West Roxbury, Massachusetts
PSYCHOLOGIC
FACTORS
Hospital,
- A thirty-one-year-old paraplegic male requested a penile prosthesis. Psychiatric evaluations were done of both the patient and his wife. Within seventy-two hours of his arriving home with the prosthesis installed, his wife left their house to seek a divorce. The implications of this event for selecting patients fm such devices are explored. Reservations are expressed about a prosthesis being inserted fm Datients married after the onset of imvotence.
ABSTRACT
Impotence is a common complaint of patients with diabetes mellitus, peripheral vascular disease, spinal cord injury, and in patients who have had intrapelvic operations. There is little mention in the literature with regard to the psychiatric implications of a penile prothesis for the management ofpatients with impotence of any variety. In the only study where psychologic case material is detailed, Gee et al. ’ conclude that preoperative psychiatric evaluation of 16 patients indicated that the “careful screening of the motives and attitudes of the patient is most important.” He states, “routine psychiatric evaluation does not appear to be necessary, if the urologist is aware of careful questioning. However, psychiatric consultations should be sought if there is doubt about motivation or psychosis. ” Our experiences suggest that couples who marry subsequent to the patient’s spinal cord injury should have careful psychiatric evaluation before such a prosthesis is installed. In most cases in which impotence develops after the couple has been married and there has been some type of stable sexual relationship prior to loss of potency, the prosthesis can be seen as a welcome reacquisition of the lost ability. The implications of the procedure are much more complex for those individuals who have married subsequent to the development of impotence. It is well known that spinal cord injuries often have as one of their sequelae an inability to maintain a functional erection.2 It is our impression that, like marriages in the general population, those of men with spinal
400
cord injury vary from being fulfilling to being states of chronic discord. It should be appreciated that many of the postinjury marriages do well with an incidence of divorce possibly less than that of the general population. 3 As it may be expected that more spinal cordinjured patients in the future will be expressing an interest in a penile prosthesis, the following case is reported describing the introduction of a prosthesis into one relationship. It raises compelling questions for factors to consider in the careful psychologic assessment for these couples requesting this procedure. Case Report The patient, a thirty-one-year-old white male, was injured during 1969 in an automobile accident. He has a flaccid paraplegia (T-10 neurologic level) complete for both sensory and motor functions and is unable to have erections of any type. A Scott prosthesis was installed on October 8, 1974. This prosthesis is constructed of Dacron reinforced silicone rubber and is inflatable by means of a subcutaneous pump in the scrotum.4 The patient became aware of the procedure during the course of an interview with his physician (T. D. S.) while in the hospital for a routine annual checkup. The patient was interested in this procedure, and it was explained to him in detail. He and his wife subsequently were interviewed independently by two psychiatrists, male and female, with extensive consultative psychiatric experience. The patient and his wife discussed
UROLOGY
/
APRIL 1976
/
VOLUME
VII,
NUMBER
4
the procedure, its possible complications, and their feelings about it for several weeks before finally agreeing to implantation. Two years ago, which was three years postinjury, he married his wife one month after they had met. She was attracted to him because she found him attractive and strong in appearance. Since that time, the two have lived in a remote area of New England extremely isolated from other towns. He did some repair work around the house and had enrolled in an electrician’s course which he was about to complete and which he felt would enable him to return to work. The patient described satisfactory sexual relations before his injury along with satisfactory sexual experiences in the postinjury but premarried phase of his life. His wife in addition described satisfactory sexual relationships occurring before her marriage. The report of the male psychiatrist included the following: “The patient has been unable to have erections of any kind since his injury. Although he was able to work and earn a living before his injury, he has been unable to hold a job since the accident. He feels this is due to his depression and poor self-esteem. His self-image is that of a small man in spite of his very large physique.” The psychiatrist noted that the patient conceived of himself as small before his injury as well. He stated that one of the most stressing things in his life was his incapacity to have an erection. As he put it, “I look down at myself and see this little shriveled up thing.” The male psychiatrist’s opinion was that their marriage had considerable strengths and weaknesses. It was clear that they had affection for one another even though the thought of divorce had crossed both of their minds. She explained that it was because of their personalities “that we are so different.” He would like her to be more outgoing and have more friends come into the house, whereas she prefers to be alone. He was angry at her because he would like her to find a job to help with their financial difficulties. Although she has a college degree, she refused to do so. They supported themselves on social security disability benefits and his Veterans Administration pension. They described their sexual life as “so-so.” The occurrence of sexual closeness and the satisfaction which it brought had been declining steadily. She believed this was because he was afraid to take the initiative since she occasionally had turned him down. She was aware that this undermined self-confidence, while he on the other hand felt she was bored with the sexual options available to
UROLOGY
/
APRIL 1976
/
VOLUME
VII,
NUMBER
4
them which were manual and oral sex both of which they had employed. He felt that she did not respond to him sufficiently, yet she made it clear that she was satisfied with their sexual closeness. Both agreed that sex fell short of their expectations. They also agreed that they spent too much time together in a small isolated house. Both were questioned about their expectations concerning the procedure. He felt it would do two things: (1) it would increase his “ego,” and (2) it would make it easier for him to apply his condom drainage device which was difficult to do. The psychiatrist asked whether or not there might be hidden expectations that his prosthesis would add a dramatic new dimension to their sexual relationship. He cautioned the two of them that, while the prosthesis might be of help, it would not make either of them different individuals, and it would not “make her respond in a different way. ” The patient felt that simply being able to look at an erect penis would be extremely gratifying. He suspected that this increase in self-esteem would make it easier for him to resume a more aggressive life style. The male psychiatrist was concerned that she might find her husband having an erection a frightening experience and that this would add an element of anxiety to their marriage. She was questioned carefully and explicitly about this and claimed that it was important to her as well as to her husband that he receive this prosthesis. With seeming comfort she denied any fears that the prosthesis might harm her or stir up sexual fears. They were cautioned that the prosthesis might offer help in their marriage but that it alone was not a solution to their difficulties. They were reminded that a significant amount of work would need to be done between them whether or not the prosthesis was implanted. It was the opinion of the male psychiatrist that there was sufficient strength and affection in their marriage for the prosthesis to be helpful in establishing a more rewarding relationship. The female psychiatrist elicited a similar history. Her general impression was similar to that of the male psychiatrist except that she did express a greater note of concern about the wife’s tendency to keep herself isolated, viewing this as being schizoid in character. She felt that the capacity to have erections would be a major boost to the patient’s feelings of self-esteem. Her concern about the wife’s need to be alone will be an important element as will become apparent later on. Subsequent to the procedure the patient returned to their home to join his wife. Three days after his arrival she decided to leave him and end
401
the marriage. Follow-up interviews with both patient and wife indicated that he was upset about this and urged his wife to come back, but she had made up her mind firmly and refused to reconsider. It was clear during the subsequent interview that in the initial discussions with the psychiatrists she had minimized her misgivings about the marriage. In the postoperative interview she stated, “I realized that for me a big part of sex was in exciting and satisfying my partner in the mysterious physiologic process that occurs in a man and in the effect I have on him - not what mechanical change he makes with any device. I achieve some satisfaction by masturbation but that is a lonely way of having sex. I would like to share sex a lot more than that.” Thus an unforeseen factor produced by this prosthesis was a reduction in the wife’s feeling of psychosexual importance to her husband. It made her feel less involved and less important to him than she had before. The wife denied that fear of sex had anything to do with her decision to separate. In retrospect, however, it does seem clearer that this schizoid woman was likely fearful of sexual penetration in the setting of genuine intimacy. She further stated in the follow-up interview, “maybe I was looking to rationalize my desire to leave, wanting to go, when I felt things in his life were otherwise going well.” In other words the wife now felt that the husband’s self-esteem was more stable, and thus she rationalized her departure on this basis. Prior to the operation the psychiatrists did not realize that she would utilize the improvement in his self-esteem as a justification for leaving him. Subsequent to this separation, the couple has sought a divorce. After his wife left at the end of January a mechanical difficulty developed with the prosthesis. It was repaired during late March and was followed three weeks later by mechanical failure and an infection resulting in epididymitis. Because of these complications, the prosthesis was removed on April 28, 1975. These difflculties created considerable frustration within the patient but did not appear to harm his over-all emotional adjustment, as reflected in his recent successes in national wheelchair athletic competition. Following these successes the patient said in June, 1975, that he had never felt so alive since his injury. Comment One cannot with assurance deduce a direct cause and effect relationship in the breakup of such an unstable marriage because of the intro-
402
duction of this prosthesis. It may have added another stress on an already compromised and conflicted couple’s system of relating which led to their decision to leave one another and discontinue any effort toward dialogue and compromise. In retrospect a clearer understanding of the wife’s fear of intimacy would have been helpful. This course of events raises a caveat for those physicians and patients who are thinking of carrying out this procedure within the context of a stable postinjury marital relationship. Many of these couples proceed on the unexamined assumption that traditional sexual intercourse will be a fulfilling addition to their lives. It is our thesis, however, that there are pitfalls in such an assumption. For example, some women who are attracted to and do marry men with spinal cord injury may do so because of fears of direct sexual penetration which they are dimly or not at all aware of. This type of unconscious fear exists in some women and is a well-recognized psychologic phenomenon.5 It is important to recognize that such women and their husbands may already be reasonably fulfilled in their relationship without direct sexual penetration. For some of these people their request for the prosthesis may reflect a cultural value system which places an inappropriate emphasis on traditional sexual performance rather than an insightful pursuit of a realistic improvement in the communication within their marriage. The introduction of sexual intercourse with the aid of the prosthesis into a previously stable relationship could cause disruption. It is our opinion that in the postinjury marriage careful psychologic assessment, counseling, and followup are mandatory when such couples consider this major step in their lives. West Roxbury, Massachusetts 02132 (DR. STEWART) ACKNOWLEDGMENT. To Dr. Miriam Tasini for allowing us to use her evaluation. References 1. GEE, W. F., MCROBERTS, J. W., RANEY, J. O., and ANSELL, J. S.: The impotent patient, J. Urol. 111: 41 (1974). 2. COMARR,A. E.: Sexual function among patients with spinal cord injury, Urol. Int. 25: 134 (1970). 3. IDEM: Marriage and divorce among patients with spinal cord injury, Proceedings of Eleventh Annual Clinical Spinal Cord Injury Conference, 1962, pp. 163-169. 4. SCOTT, F. B., BRADLEY, W. E., and TIMM, I. W.: Management of erectile impotence, Urology 2: 80 (1973). 5. FRIEDMAN, L. J.: Virgin Wives: A Study of Unconsummated Marriages, Springfield, Ill., Charles C Thomas Co., 1962.
UROLOGY /
APRIL 1976 /
VOLUME VII, NUMBER 4