A Perfect Penile Prosthesis Result May Require More than Surgery

This blog post is inspired by a recent tweet from Rachel S. Rubin, MD, a urologist and sexual medicine specialist who practices in Washington, DC: 

“I see a couple for their sexual dysfunction. He has a perfect penile implant … but he can’t penetrate because his partner’s vulva and vagina are too narrow due to a lack of hormones. How can I get my #sexmed colleagues to care about this?” 

I often like Dr. Rubin’s tweets, but this one particularly caught my eye, because I have been advocating since the 1980’s that preparation for surgery to implant a penile prosthesis should always include a session with a mental health professional trained in sex therapy (and ideally a follow-up session after initial healing). If the patient is in a committed relationship, his partner (male or female) should definitely be included. This has not been a very popular idea with urologists or with male patients, who tend to see putting in a penile prosthesis as a great way to restore a man’s ability to have firm erections on demand. Indeed, patient satisfaction and likelihood of having an active sex life are far higher after having an inflatable penile prosthesis than with any other medical treatment for erectile dysfunction (ED). 

Indignant patients may say, “Why do I need to see a shrink! I’m not crazy!” In fact, a man’s mental health per se is rarely the issue. However, learning to enjoy sex again after prosthesis surgery takes some practice and communication. Would you have a hip or knee replacement and skip the post-surgical physical therapy? Well, having a great result from a penile prosthesis is not quite that labor-intensive, but some coaching definitely can help—especially since in most situations, two people are trying to create the best experience together! 

Here are some of the common barriers to a good sex life after penile prosthesis surgery that can be avoided with some strategic education and counseling:

Dr. Rubin mentioned one of the top ones—nobody talked to the man’s female partner and since she is likely to have had a period of sexual inactivity and to be past menopause, she may have major, unexpected vaginal dryness and pain with penetration. With a good GYN exam and some brief counseling on optimal use of vaginal moisturizers plus lubricants, or if that doesn’t do the trick, low-dose vaginal hormone replacement, this complication can be avoided or remedied.

Another common situation is that the man thinks if his penis is hard because of the prosthesis, he does not need any extra mental or physical sexual stimulation. So he goes for some wham-bam-thank-you-ma’am sex with less than climactic results for either partner. Some men do not reach an orgasm at all, even though the surgery does not disrupt penile erotic sensation. Remember that most men who have this surgery are past age 50. With aging, both mental and physical sexual arousal take longer for men and women. Instead of having regrets, take it as a challenge to be more creative and open about what pleases each partner.

Some partners are afraid to caress the man’s penis out of fear of causing pain, or sometimes out of anxiety about what exactly has been done during surgery. Showing the partner a diagram of how the prosthesis works and explaining the healing process can help get the partner on board.

Some men do fine with foreplay and penetration, but once they have had an orgasm, think it is a great idea to keep going and give the partner more thrusting, since a penile prosthesis does not deflate on its own (unless there was a far less-than-perfect surgical result!). If the man persists too long, he may end up with a sore penis and a feeling that sex is just a performance—or even a chore!

A few times I have had a female partner say that the erection with the prosthesis is too small to give her pleasure. It is true that most men lose some length of the erect penis, at least compared to their youthful nostalgia, but the rigidity and thickness of the shaft is usually quite good. My experience is that the “too small” complaint is a sign of couple anger and conflict. What better way to deflate your partner’s self-esteem? It also may reflect poor sexual communication and lack of time spent on getting aroused before or after penetration. 

Having that session of counseling before surgery also has a few other potential benefits:

Men are given a schedule of when and how often to inflate and deflate the prosthesis. This involves some discomfort and persistence. During counseling, the importance of this process in healing can be emphasized, and any barriers to following the schedule can be identified, with suggestions on how to cope.

A few men have mental health issues, such as unidentified drug or alcohol abuse, relationship conflict, body image distortions, or unrealistic expectations about the surgical result. It may be better for the patient to postpone or cancel surgery. In fact, in answer to Dr. Rubin’s question about how to get colleagues to care, we started requiring a mental health/sex therapy evaluation before penile prosthesis surgery at one of my past jobs after a couple of malpractice suits. 

Finally, what about cost? Some insurance will not cover surgery to implant a penile prosthesis. The total out-of-pocket costs may be about $25,000. Even men with good insurance may have some co-pays and deductibles. Some insurance also does not cover seeing an expert mental health professional who may be out of network. In most cities, the out-of-pocket cost of that initial evaluation session would be $150-$300. I think that is a pretty good value!

This educational material is intended for informational purposes only and is not intended to replace, or substitute for, professional advice, counseling, diagnosis, or treatment. Always seek the advice of a qualified health provider with any questions you may have regarding a condition. Never disregard professional advice or delay in seeking treatment because of something you have read in this educational material.

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