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Experience with Penile Prosthesis in Spinal Cord Injury Patients
0022-5347/79/1213-0288$02. 00/0 THE JOURNAL OF UROWGY Copyright © 1979 by The Williams & Wilkins Co.
Vol. 121, March Printed in U.S.A.
EXPERIENCE WITH PENILE PROSTHESIS IN SPINAL CORD INJURY PATIENTS HOSSEIN GOLJI From the Spinal Cord Injury Service, Veterans Administration Medical Center, Long Beach and the Department of Surgery, Division of Urology, University of California, Irvine, California
ABSTRACT
During the last 2 years 30 patients in the spinal cord injury service at our hospital received a penile prosthesis implant. The records of 25 patients were reviewed and 20 patients were interviewed 3 to 27 months postoperatively. A detailed evaluation of each patient shows that in properly selected patients the results of this operation can be satisfactory and gratifying. The use of a penile prosthesis to treat erectile impotence in the male subject has been a matter of concern for the last 40 years. The credit for the first attempt to provide a sustained erection with a rigid or semi-rigid, rod-shaped prosthesis belongs to Bogoras, who used cartilage and bone, but the results of his experiments were disappointing. 1' 2 Since then the enthusiasm for treatment of erectile impotence has increased and efforts have been made to find and choose the kind of prosthesis that would 1) give a normal-appearing erection, 2) be non-irritating to the body tissue and 3) have a long life expectancy without deterioration. The table shows the highlights of the search for and improvement in the technique of implantation, and the structure of the prosthesis with the latest advocation of a hydraulic system that provides erection when and where it is needed. 1- 11 The purpose of this study is to present some aspects of erectile impotence in spinal cord injury patients and to illustrate the results and values of the penile prosthesis in this group of individuals. In patients with a spinal cord injury or lesion the occurrence and quality of erection depend upon the extent and location of the damage to the spinal cord. If the spinal cord is damaged above the lumbosacral segments the reflex erection should not be affected. However, the psychogenic erection may be absent or diminished when the lesion is complete or incomplete, respectively. If the lesion or transection is at the lumbosacral segments, conus medullaris and/or cauda equina the presence and quality of psychogenic or reflex penile erection depend on the extent of damage. In patients with a complete lesion both are absent and in patients in whom the lesion is incomplete both may be diminished. In patients with upper and lower motor neuron lesions the quality of penile erection may diminish as the results of shifts in the level of the lesion, trophic changes of neurovascular or muscular tissue and/or genitourinary complications. MATERIALS AND METHODS
During a 2-year interval, ending December 1976, 30 patients from the spinal cord injury service at our hospital received a .Small-Carrion penile prosthesis to remedy erectile impotence or impotence complicated by a small-sized penis for the application of external condom drainage. Of the 30 patients 5 were excluded from this study: 3 because of short followup and 2 because they were transferred elsewhere. The remaining 25 patients who were followed regularly were interviewed just before completion of the study. The youngest of these patients was 25 years old and the oldest was 60 years old but the majority of patients were between 30 and 40 years old. Preoperative evaluation of these patients included history Accepted for publication June 30, 1978. Read at annual meeting of Western Section, American Urological Association, San Francisco, California, March 13-17, 1977. 288
and physical examination, routine laboratory studies, excretory urography, cystourethrography and, in 15 patients, cystometrogram and urethral pressure profile. Fifty per cent of the patients underwent psychosocial evaluation. As a result of the preoperative evaluation urethral sphincterotomy and/or transurethral resection of the bladder neck was necessary in 5 of the 25 patients to alleviate the lower urinary obstruction. Four other patients underwent sphincterotomy and/or transurethral resection of the bladder neck elsewhere as part of the rehabilitation. One patient underwent sphincterotomy 4 months post-implantation at our hospital, without any side effects or difficulty. The erectile impotence was the main reason for the implantation of a penile prosthesis. Additionally, 6 patients had a small penis and difficulty in applying the external condom drainage. In 2 patients the primary interest was only to lengthen the penis for easy application of condom drainage. Forty per cent of the patients were married, 20 per cent were divorced and 40 per cent were single. Two patients were divorced because of the sexual impotence. All of the patients received gentamicin therapy 1 day preoperatively and 3 to 4 days postoperatively. Then, most of the patients underwent another week of other antibiotic or urinary antiseptic therapy. ETIOLOGY OF IMPOTENCE
Erectile impotence can be the product of congenital anomalies, inflammation and/or infection, trauma, endocrine disturbances, cardiovascular abnormalities, neoplasms, neurologic problems and metabolic disorders described in detail by others. s, 12 In this series the sole etiology for impotence was trauma to the spinal cord, causing partial or total interruption of the pathways to the reflex center of erection in the sacral segments. An automobile accident was the cause of injury in 11 patients, war casualty in 7 and other accidents, such as a fall, diving and so forth, in 7. Also, the study showed that 56 per cent (14) of the patients had thoracic injury, 36 per cent (9) had cervical injury, 4 per cent (1) had lumbar injury and 4 per cent (1) had cauda equina injury. In 68 per cent of the patients the lesion was complete and in 32 per cent it was incomplete. TECHNIQUE OF IMPLANTATION
The perineal approach was used in all of the patients except for 2 in whom the dorsal penile approach was used. Of these 2 patients 1 (T. R.) had extruded the prosthesis after the perinea! approach. The operative technique was the same in all cases and as described by Small and associates. 9 However, in the last few cases a slight modification in approach had been adopted. This modification involves the skin incision and, consequently, the exposure of the corpora. The midline perinea! longitudinal incision starts from 1 cm. distal to the
EXPERIENCE WITH PENILE PROSTHESIS IN SPINAL CORD INJURY PATIENTS
Highlights of development of penile prosthesis Prosthesis Used
Comments
Bogoras' Goodwin and Scott2 Loeffler and Sayegh'
Cartilage and bone, 1939 Synthetic (acrylic), 1952 Synthetic (acrylic), 1960
Lash and associates'
Silicone rubber, 1964
Pearman'
Silicone rubber (single), 1967 Silicone rubber (single), 1968 Polyethylene rods (paired), 1966 Polyethylene rods (paired), 1973 Sponge-filled silicone (paired), 1973, 1975
Disappointing results First time used Between the corpora (partial erection necessary) Between the corpora (partial erection necessary) Under tunica albuginea (dorsally) Under tunica albuginea (dorsally) First time used intracorporeally Used intracorporeally
Lash' Beheri' Morales and associates' Small and associates'
J
Kothari and associates10
Inflatable silicone rubber (paired), 1972
Scott and associates"
Inflatable silicone rubber (paired), 1973
Dorsal penile and perinea! approach, intracorporeally Hydraulic fluid transfer system, suprapubic approach, intracorporeally Hydraulic fluid transfer system, suprapubic approach, intracorporeally
perineoscrotal junction and stops about 5 cm. from the anus. This approach has facilitated the exposure of the corpora cavernosa with less dissection of the subcutaneous fat. Also, it avoids the disturbance of bulbocavernous and ischiocavernous muscles. At the newly exposed area the corpora cavernosa are located just lateral to the distal portion of the bulb and are covered only by a few strands of muscle. Also, through this approach, dilation of the corpora and the introduction of the prosthesis are easier. No problem with healing of the incision and no complications owing to the change in approach have been encountered. Furthermore, application of surgical dressings is facilitated and the fear of contamination of the wound is decreased. The 15.8 x 1.1 cm. size prosthesis was the most common choice followed by the 17, 13.3 and 18 cm. size prostheses. Each patient was placed on a 16F catheter before leaving the operating room and the catheter was removed the following day. However, in 1 patient no catheter was used and in 2 others the catheter was left indwelling for 12 to 14 days. COMPLICATIONS
The most serious complication seen in this group of patients was extrusion of the penile prosthesis in 2 patients, caused by infection. These 2 patients had remained on indwelling urethral catheters for 12 to 14 days postoperatively. In 1 of the 2 patients the left side penile prosthesis was eliminated 3 months postoperatively. At a later date a new prosthesis was implanted in this patient but it was extruded again. The patient remained happy and satisfied with the 1-sided implant. In the other patient, a diabetic, it was necessary to remove the infected prosthesis 14 days postoperatively. This patient had a repeat implant through the dorsal penile approach without further complication. The other complication seen was the wound infection in 2 patients, both of whom improved under conservative treatment. EVALUATION OF RESULTS
Each patient and his sexual partner, if any, answered a series of questions that involved their sexual habits preoperatively and their reactions and responses to the penile implant postoperatively. In 68 per cent of the patients oral sex was the only means of satisfaction before operation and, for the rest, no specific pattern in sexual satisfaction was noted. However,
289
the patients and their partners were all dissatisfied with whatever method they were practicing except for 3 partners who enjoyed oral sex. After the operation penovaginal intercourse had increased or improved the sexual pleasure, feeling of manhood or womanhood, and morale or well being of the patients and their partners. However, 1 of the patients still preferred oral sex over penovaginal intercourse. DISCUSSION
The implantation of a penile prosthesis in patients with spinal cord injury has been a controversial procedure and application of it has met some criticism and resistance. This study was undertaken to evaluate the advantages, benefits and/or disadvantages of this procedure. As reflected herein, the study includes a cross-section of patients. The ages ranged from 25 to 60 years old, the injuries resulted from all kinds of mishaps and their hopes were to remedy the sexual impotence, save marriages and/or improve the application of external condom drainage. Do these patients know and understand what they want? Since they are paralyzed do they need erection and sex life? Are the results of a penile implant helpful and beneficial to them and do they have any second thoughts about their operation? Evaluation reveals that all patients, including the 50 per cent who did not have psychosocial evaluation, knew what they wanted. The ones with impotence had tried other means of sexual satisfaction for their partners but all except 1, including the partners, preferred penovaginal relations. Of 20 patients 18 wished that they had had the penile implant sooner and 2 patients indicated that their marriages could have been saved if they had had a penile implant earlier. Are the complications of penile implants in patients with spinal cord injury more damaging or diverse than in the general population? Evaluation and comparison of the number and forms of complications with reported cases in non-paraplegics provide a negative answer. As a whole, the results of this study show the merits of considering a penile prosthesis in selected and well adjusted spinal cord injury patients, unless future reports and studies prove otherwise. REFERENCES
1. Bogoras, N. A.: Uber die volle plastiche Wiederherstellung eines zum Koitus fahigen Penis (Penilplastica totalis). Zentralbl. f. Chir., 63: 1271, 1936. 2. Goodwin, W. E. and Scott, W. W.: Phalloplasty. J. Urol., 68: 903, 1952. 3. Loeffler, R. A. and Sayegh, E. S.: Perforated acrylic implants in management of organic impotence. J. Urol., 84: 559, 1960. 4. Lash, H., Zimmerman, D. C. and Loeffler, R. A.: Silicone implant inlay method. Plast. Reconstr. Surg., 34: 75, 1964. 5. Pearman, R. 0.: Treatment of organic impotence by implantation of a penile prosthesis. J. Urol., 97: 716, 1967. 6. Lash, H.: Silicone implant for impotence. J. Urol., 100: 709, 1968. 7. Beheri, G. E.: Surgical treatment of impotence. Plast. Reconstr. Surg., 38: 92, 1966. 8. Morales, P.A., Suarez, J.B., Delgado, J. and Whitehead, E. D.: Penile implant for erectile impotence. J. Urol., 109: 641, 1973. 9. Small, M. P., Carrion, H. M. and Gordon, J. A.: Small-Carrion penile prosthesis. New implant for management of impotence. Urology, 5: 479, 1975. 10. Kothari, D.R., Timm, G. W., Frohrib, D. A. and Bradley, W. E.: An implantable fluid transfer system for treatment of impotence. J. Biomech., 5: 567, 1972. 11. Scott, F. B., Bradley, W. E. and Timm, G. W.: Management of erectile impotence. Urology, 2: 80, 1973. 12. Pearman, R. 0.: Insertion of a silastic penile prosthesis for the treatment of organic sexual impotence. J. Urol., 107: 802, 1972.
Vol. 121, March Printed in U.S.A.
EXPERIENCE WITH PENILE PROSTHESIS IN SPINAL CORD INJURY PATIENTS HOSSEIN GOLJI From the Spinal Cord Injury Service, Veterans Administration Medical Center, Long Beach and the Department of Surgery, Division of Urology, University of California, Irvine, California
ABSTRACT
During the last 2 years 30 patients in the spinal cord injury service at our hospital received a penile prosthesis implant. The records of 25 patients were reviewed and 20 patients were interviewed 3 to 27 months postoperatively. A detailed evaluation of each patient shows that in properly selected patients the results of this operation can be satisfactory and gratifying. The use of a penile prosthesis to treat erectile impotence in the male subject has been a matter of concern for the last 40 years. The credit for the first attempt to provide a sustained erection with a rigid or semi-rigid, rod-shaped prosthesis belongs to Bogoras, who used cartilage and bone, but the results of his experiments were disappointing. 1' 2 Since then the enthusiasm for treatment of erectile impotence has increased and efforts have been made to find and choose the kind of prosthesis that would 1) give a normal-appearing erection, 2) be non-irritating to the body tissue and 3) have a long life expectancy without deterioration. The table shows the highlights of the search for and improvement in the technique of implantation, and the structure of the prosthesis with the latest advocation of a hydraulic system that provides erection when and where it is needed. 1- 11 The purpose of this study is to present some aspects of erectile impotence in spinal cord injury patients and to illustrate the results and values of the penile prosthesis in this group of individuals. In patients with a spinal cord injury or lesion the occurrence and quality of erection depend upon the extent and location of the damage to the spinal cord. If the spinal cord is damaged above the lumbosacral segments the reflex erection should not be affected. However, the psychogenic erection may be absent or diminished when the lesion is complete or incomplete, respectively. If the lesion or transection is at the lumbosacral segments, conus medullaris and/or cauda equina the presence and quality of psychogenic or reflex penile erection depend on the extent of damage. In patients with a complete lesion both are absent and in patients in whom the lesion is incomplete both may be diminished. In patients with upper and lower motor neuron lesions the quality of penile erection may diminish as the results of shifts in the level of the lesion, trophic changes of neurovascular or muscular tissue and/or genitourinary complications. MATERIALS AND METHODS
During a 2-year interval, ending December 1976, 30 patients from the spinal cord injury service at our hospital received a .Small-Carrion penile prosthesis to remedy erectile impotence or impotence complicated by a small-sized penis for the application of external condom drainage. Of the 30 patients 5 were excluded from this study: 3 because of short followup and 2 because they were transferred elsewhere. The remaining 25 patients who were followed regularly were interviewed just before completion of the study. The youngest of these patients was 25 years old and the oldest was 60 years old but the majority of patients were between 30 and 40 years old. Preoperative evaluation of these patients included history Accepted for publication June 30, 1978. Read at annual meeting of Western Section, American Urological Association, San Francisco, California, March 13-17, 1977. 288
and physical examination, routine laboratory studies, excretory urography, cystourethrography and, in 15 patients, cystometrogram and urethral pressure profile. Fifty per cent of the patients underwent psychosocial evaluation. As a result of the preoperative evaluation urethral sphincterotomy and/or transurethral resection of the bladder neck was necessary in 5 of the 25 patients to alleviate the lower urinary obstruction. Four other patients underwent sphincterotomy and/or transurethral resection of the bladder neck elsewhere as part of the rehabilitation. One patient underwent sphincterotomy 4 months post-implantation at our hospital, without any side effects or difficulty. The erectile impotence was the main reason for the implantation of a penile prosthesis. Additionally, 6 patients had a small penis and difficulty in applying the external condom drainage. In 2 patients the primary interest was only to lengthen the penis for easy application of condom drainage. Forty per cent of the patients were married, 20 per cent were divorced and 40 per cent were single. Two patients were divorced because of the sexual impotence. All of the patients received gentamicin therapy 1 day preoperatively and 3 to 4 days postoperatively. Then, most of the patients underwent another week of other antibiotic or urinary antiseptic therapy. ETIOLOGY OF IMPOTENCE
Erectile impotence can be the product of congenital anomalies, inflammation and/or infection, trauma, endocrine disturbances, cardiovascular abnormalities, neoplasms, neurologic problems and metabolic disorders described in detail by others. s, 12 In this series the sole etiology for impotence was trauma to the spinal cord, causing partial or total interruption of the pathways to the reflex center of erection in the sacral segments. An automobile accident was the cause of injury in 11 patients, war casualty in 7 and other accidents, such as a fall, diving and so forth, in 7. Also, the study showed that 56 per cent (14) of the patients had thoracic injury, 36 per cent (9) had cervical injury, 4 per cent (1) had lumbar injury and 4 per cent (1) had cauda equina injury. In 68 per cent of the patients the lesion was complete and in 32 per cent it was incomplete. TECHNIQUE OF IMPLANTATION
The perineal approach was used in all of the patients except for 2 in whom the dorsal penile approach was used. Of these 2 patients 1 (T. R.) had extruded the prosthesis after the perinea! approach. The operative technique was the same in all cases and as described by Small and associates. 9 However, in the last few cases a slight modification in approach had been adopted. This modification involves the skin incision and, consequently, the exposure of the corpora. The midline perinea! longitudinal incision starts from 1 cm. distal to the
EXPERIENCE WITH PENILE PROSTHESIS IN SPINAL CORD INJURY PATIENTS
Highlights of development of penile prosthesis Prosthesis Used
Comments
Bogoras' Goodwin and Scott2 Loeffler and Sayegh'
Cartilage and bone, 1939 Synthetic (acrylic), 1952 Synthetic (acrylic), 1960
Lash and associates'
Silicone rubber, 1964
Pearman'
Silicone rubber (single), 1967 Silicone rubber (single), 1968 Polyethylene rods (paired), 1966 Polyethylene rods (paired), 1973 Sponge-filled silicone (paired), 1973, 1975
Disappointing results First time used Between the corpora (partial erection necessary) Between the corpora (partial erection necessary) Under tunica albuginea (dorsally) Under tunica albuginea (dorsally) First time used intracorporeally Used intracorporeally
Lash' Beheri' Morales and associates' Small and associates'
J
Kothari and associates10
Inflatable silicone rubber (paired), 1972
Scott and associates"
Inflatable silicone rubber (paired), 1973
Dorsal penile and perinea! approach, intracorporeally Hydraulic fluid transfer system, suprapubic approach, intracorporeally Hydraulic fluid transfer system, suprapubic approach, intracorporeally
perineoscrotal junction and stops about 5 cm. from the anus. This approach has facilitated the exposure of the corpora cavernosa with less dissection of the subcutaneous fat. Also, it avoids the disturbance of bulbocavernous and ischiocavernous muscles. At the newly exposed area the corpora cavernosa are located just lateral to the distal portion of the bulb and are covered only by a few strands of muscle. Also, through this approach, dilation of the corpora and the introduction of the prosthesis are easier. No problem with healing of the incision and no complications owing to the change in approach have been encountered. Furthermore, application of surgical dressings is facilitated and the fear of contamination of the wound is decreased. The 15.8 x 1.1 cm. size prosthesis was the most common choice followed by the 17, 13.3 and 18 cm. size prostheses. Each patient was placed on a 16F catheter before leaving the operating room and the catheter was removed the following day. However, in 1 patient no catheter was used and in 2 others the catheter was left indwelling for 12 to 14 days. COMPLICATIONS
The most serious complication seen in this group of patients was extrusion of the penile prosthesis in 2 patients, caused by infection. These 2 patients had remained on indwelling urethral catheters for 12 to 14 days postoperatively. In 1 of the 2 patients the left side penile prosthesis was eliminated 3 months postoperatively. At a later date a new prosthesis was implanted in this patient but it was extruded again. The patient remained happy and satisfied with the 1-sided implant. In the other patient, a diabetic, it was necessary to remove the infected prosthesis 14 days postoperatively. This patient had a repeat implant through the dorsal penile approach without further complication. The other complication seen was the wound infection in 2 patients, both of whom improved under conservative treatment. EVALUATION OF RESULTS
Each patient and his sexual partner, if any, answered a series of questions that involved their sexual habits preoperatively and their reactions and responses to the penile implant postoperatively. In 68 per cent of the patients oral sex was the only means of satisfaction before operation and, for the rest, no specific pattern in sexual satisfaction was noted. However,
289
the patients and their partners were all dissatisfied with whatever method they were practicing except for 3 partners who enjoyed oral sex. After the operation penovaginal intercourse had increased or improved the sexual pleasure, feeling of manhood or womanhood, and morale or well being of the patients and their partners. However, 1 of the patients still preferred oral sex over penovaginal intercourse. DISCUSSION
The implantation of a penile prosthesis in patients with spinal cord injury has been a controversial procedure and application of it has met some criticism and resistance. This study was undertaken to evaluate the advantages, benefits and/or disadvantages of this procedure. As reflected herein, the study includes a cross-section of patients. The ages ranged from 25 to 60 years old, the injuries resulted from all kinds of mishaps and their hopes were to remedy the sexual impotence, save marriages and/or improve the application of external condom drainage. Do these patients know and understand what they want? Since they are paralyzed do they need erection and sex life? Are the results of a penile implant helpful and beneficial to them and do they have any second thoughts about their operation? Evaluation reveals that all patients, including the 50 per cent who did not have psychosocial evaluation, knew what they wanted. The ones with impotence had tried other means of sexual satisfaction for their partners but all except 1, including the partners, preferred penovaginal relations. Of 20 patients 18 wished that they had had the penile implant sooner and 2 patients indicated that their marriages could have been saved if they had had a penile implant earlier. Are the complications of penile implants in patients with spinal cord injury more damaging or diverse than in the general population? Evaluation and comparison of the number and forms of complications with reported cases in non-paraplegics provide a negative answer. As a whole, the results of this study show the merits of considering a penile prosthesis in selected and well adjusted spinal cord injury patients, unless future reports and studies prove otherwise. REFERENCES
1. Bogoras, N. A.: Uber die volle plastiche Wiederherstellung eines zum Koitus fahigen Penis (Penilplastica totalis). Zentralbl. f. Chir., 63: 1271, 1936. 2. Goodwin, W. E. and Scott, W. W.: Phalloplasty. J. Urol., 68: 903, 1952. 3. Loeffler, R. A. and Sayegh, E. S.: Perforated acrylic implants in management of organic impotence. J. Urol., 84: 559, 1960. 4. Lash, H., Zimmerman, D. C. and Loeffler, R. A.: Silicone implant inlay method. Plast. Reconstr. Surg., 34: 75, 1964. 5. Pearman, R. 0.: Treatment of organic impotence by implantation of a penile prosthesis. J. Urol., 97: 716, 1967. 6. Lash, H.: Silicone implant for impotence. J. Urol., 100: 709, 1968. 7. Beheri, G. E.: Surgical treatment of impotence. Plast. Reconstr. Surg., 38: 92, 1966. 8. Morales, P.A., Suarez, J.B., Delgado, J. and Whitehead, E. D.: Penile implant for erectile impotence. J. Urol., 109: 641, 1973. 9. Small, M. P., Carrion, H. M. and Gordon, J. A.: Small-Carrion penile prosthesis. New implant for management of impotence. Urology, 5: 479, 1975. 10. Kothari, D.R., Timm, G. W., Frohrib, D. A. and Bradley, W. E.: An implantable fluid transfer system for treatment of impotence. J. Biomech., 5: 567, 1972. 11. Scott, F. B., Bradley, W. E. and Timm, G. W.: Management of erectile impotence. Urology, 2: 80, 1973. 12. Pearman, R. 0.: Insertion of a silastic penile prosthesis for the treatment of organic sexual impotence. J. Urol., 107: 802, 1972.