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Erectile Dysfunction Radio Podcast

Andrew Cohen, MD, joins the Erectile Dysfunction Radio Podcast this week to discuss managing erectile dysfunction with an Inflatable Penile Prosthesis (IPP), also known as an implant. With Johns Hopkins Medicine in Baltimore, Dr. Cohen serves as Assistant Professor of Urology and Director of Trauma and Reconstructive Urologic Surgery.

The Erectile Dysfunction Radio Podcast is dedicated to educating and empowering men to address erectile dysfunction, improve confidence, and enhance the satisfaction in their relationships. This podcast is hosted by certified sex therapist, Mark Goldberg, LCMFT, CST.

Transcript of Episode 42 – Inflatable Penile Prosthesis (IPP) and Erectile Dysfunction with Dr. Andrew Cohen

Mark Goldberg: Today we are joined by Dr. Andrew Cohen. Dr. Cohen is an assistant professor of urology at Johns Hopkins. He serves as Director of Trauma and Reconstructive Urologic Surgery. Dr. Cohen focuses on the management of erectile dysfunction, urinary incontinence, Peyronie’s disease, general skin conditions, and specializes in complex genital urinary reconstruction.

So what we want to discuss on this episode is the inflatable penile prosthesis, also referred to as an IPP or an implant. So before we get into that, Dr. Cohen, can you tell us a bit about your practice?

Dr. Cohen: Yeah, so as you described, I have a wide-reaching practice. I see a lot of men who have a lot of intimate type problems, and pertinent to this podcast, erectile issues.

A good percentage of men that I see are dealing with cancer survivorship type problems, and so cancer survivorship is sort of a whole discipline that is focused on helping people who have  beaten their cancer, who are still fighting their cancer, who are dealing with the consequences of that cancer treatment, many people require chemotherapy, hormone therapy, or radiation when they’re fighting a cancer.

And in particular, men, when they have a cancer in the pelvis, whether it’s prostate cancer or colorectal cancer, a lot of the treatments can impact their sexual health among many other side effects. And so I have a large number of men who seek me out, who come to me in the midst of their cancer care or after their cancer has been treated, and they still want to have healthy active sex lives, that’s still important to them.

And so I find it very rewarding to help them in that situation, and so that’s a very large percentage of the type of men that I see with ED.

Mark Goldberg: I would gather that cancer survivorship really helps to lead into this conversation about the IPP implant, and I would assume that many of those men would potentially be candidates for an IPP implant, so can you tell us what exactly is an IPP implant?

Dr. Cohen: Before we get into that, let me just take a step backwards, because what you said about that group of men would be good candidates for this implant is true, but in general, there’s more than one treatment for ED, and I think that you probably have discussed many of the other treatments on your podcast previously, but for the sake of completeness, a lot of men can get good responses from the oral medications that are available.

There are also injectable medicines that can be very effective some men find good responsiveness to the vacuum assist devices that are out there. So there are a lot of options for ED an a penal implant is one among them.

In this particular patient population of cancer survivors, they often can have pretty severe multifactorial causes for their ED, and what we often find is that those other treatments simply are not effective, and so by and large, if you were to look at all the men across the United States that had an IPP.

Probably, I can’t say definitively because I don’t have the data, but probably the majority of them are cancer survivors, and because these other medicines just or other options just are not suitable or effective.

Getting back to your question of what is an IPP, it’s an excellent question. This is a device that gets implanted underneath the skin and some deeper tissues within the penis that enables a man to have a spontaneous rigid erection suitable for intercourse.

The erection is painless. It does not impact the sexual excitement, your sensation, but it can be sort of activated and deactivated very spontaneously, there’s many different varieties of these types of devices. Sort of by and large, the Cadillac device is a three-piece inflatable penile prosthesis, and that’s where the IPP acronym comes from.

Mark Goldberg: Dr. Cohen, how is this installed? What is the procedure like? And I’m sure men who may be potential candidates also are going to want to know about the recovery from the procedure.

Dr. Cohen: So that’s a great question. There’s essentially two primary means in which an IPP can be placed in terms of the incision location, one of those places is what we call the penis-scrotal junction.

If you think about the anatomy of the penis, it’s where the penis is sort of flopping over on the scrotum. So it’s hidden sort of under that curve. The second place where we can put the incision is a so-called infor pubic, and if you feel around your lower abdomen ultimately below your belly button, but above your penis, you’ll feel your pubic bone and just kind of a finger breath or so below the pubic bone, you can make a small incision and put the device through there.

Everybody has their personal bias as to why what inclusion is better than another, there’re certainly cosmetic concerns.

There may be theoretical differences in how easy it is to place certain parts of the three-piece implant, because from the top side, it’s easier to put in the reservoir, which I’m sure we’ll talk about in detail in a moment, from the bottom side, it’s easier to put in the pump, but ultimately, if you’re considering this, it’s really just the expertise of the surgeon. Most people know how to put it in both ways, so for certain situations, one way is better than the other, but in general, you can go wrong with neither way.

Mark Goldberg: So the device is installed from, again, two potential, two points and that really depends on the surgeon, now, the device is going in, does anything come out to allow that device to be placed or to inflate as it’s supposed to?

Dr. Cohen: Nothing of the penis has to be removed in order for these devices to be put in. Now, the normal tissue that’s inside the penis that’s supposed to fill with blood and give someone a normal physiologic erection, that tissue is sort of pushed out of the way as one of these inflatable prosthesis go in, the normal ability to get an erection is no longer possible fundamentally, once one of these devices goes inside the body.

But again, if you are able to have normal physiologic erections, you wouldn’t be getting implantable prosthesis in the first place. This is a one-way street. And so if one of these goes in and ultimately there’s a problem or what not, and it has to come out, someone who’s had an ex-planted IPP is not going to be able to obtain an erection on their own or with any of those other medicines that we talked about the pills, the injections, those simply are not going to be effective.

Because the natural sort of tissue that fills with blood, it has been altered by the placement of this device.

Mark Goldberg: What is the actual procedure like?

Dr. Cohen: Yeah, so generally, the procedure is done with the patient very comfortable, so whether the patient is very much asleep, if they’re formally sort of intubated where the anesthesiologist is doing the breathing for them, that’s a possibility.

You also can do this procedure with someone wide awake under a spinal so that there’s complete numbness from the waist down, those sort of decisions are discussed between the patient, the anesthesiologist, who’s involved in the case, and the surgeon.

And ultimately in my practice, the vast majority of patients decide to just want to be asleep, they don’t want to hear anything, they don’t want to see anything, and we’re very able to do that and get people comfortable.

In terms of how long does the operation take, typically, a median time would be about 90 minutes. During that time, I’ll just very generally speak to the fact that I’ve alluded to this being a three-piece implantable device, and so the three basic pieces, if you do go for a three-piece device is there are two cylinders that actually go inside the penis that do provide that rigidity.

There is one pump which goes under the skin in the scrotum, which is actually what you manipulate in order to get an erection and to remove the erection, and then there’s a reservoir which is filled with normal saline solution, and normal saline is the same stuff that if you ever need an intravenous fluid run, that’s that same material.

So in the unlikely event that it were to leak, it is completely harmless to your body, and that reservoir is that third component, and we tuck that into a location fairly deep within your pelvis or underneath your muscle, so it’s not typically felt, or it’s not something that’s really under the skin, it’s much deeper than that, so those are the basic components of a three-piece prothesis.

Now, there are other forms of prostheses, there’s a two-piece prosthesis which stores the water within the system, so there isn’t a reservoir, and there’s also so-called malleable devices and these devices are just a single piece, those are just cylinders that go inside the penis, and they can be sort of activated, if you will, by pulling up on the penis so that you have a rigid erection, deactivated by pushing down on the penis.

So that the penis sort of bends down in a more natural position, but those malleable devices, the one drawback is you never really get rid of the sense of a hardness in the penis, it’s always a little bit hard because it is more of a rod-like object, it doesn’t inflate and deflate.

Mark Goldberg: So it doesn’t quite mimic as well, a natural process that a man may be used to?

Dr. Cohen: That is correct, that is correct. However, it is a very good device, if someone has some issues with manual dexterity and they might have difficulty activating the pump of the three-piece device, it also has a role from a financial standpoint, certain insurance companies are more likely to cover a malleable device because it is simply cheaper to manufacture.

Some men like the simplicity, it’s less likely to have a mechanical failure because there’s no fancy moving parts or valves or fluid, it’s just sort of more of the metallic implant, so there are some positives to it, I personally don’t do this, but some people even put in these malleable devices just under local anesthetic in the office, because it is so much simpler than the three-piece device, again, I think patients should be a little more comfortable than that, it’s kind of, as you know, it’s a sensitive organ, but because it’s a simpler device, there are people who do do that.

Mark Goldberg: Coming back to the three-piece device, can you let our listeners know a little more about how this is actually operated?

Dr. Cohen: Well, I can tell you that it’s very easy once a man gets sort of, just like learning any new skill, there’s a learning curve, but one thing that I am very much a proponent of is a rehabilitation plan, so once the surgery takes place in one of my patients, as soon as they feel comfortable in terms of swelling and discomfort in the operative incision area, I want them to actually activate the device early… And I do that for two reasons.

The first one is, so they can get over that learning curve, so that when I tell them, “Hey, you’re all healed up, you can have sex now.” They’re not sort of… “I don’t know how to use it.”

They’re already an expert at activating and deactivating the device. And the second reason is because on the first or a few months after having this in, there’s a lot of positive stretching that can happen in terms of making sure that you’re getting the utmost in length and girth that a man would want during the erection. And so by using the device daily, that encourages that.

But the way that a man actually would activate this, and sometimes it’s not the man, it’s their partner that does the activation either way, it’s very straight forward is there’s this pump that I have been speaking of, is a round object that goes under the skin in the scrotum.

And this object is sort of think of it like an old-fashioned Nike pump-up shoe from the 1980s and early 90s, it has something that you can depress and usually men with their thumb and their index or their middle finger are able to get their hand around device and give it several good squeezes. When they squeeze the pump that cycles fluid from that reservoir that we’ve hidden deep inside the pelvis into the cylinders and the penis, so with each pump, more and more fluid get into the cylinder, when the cylinders filled the fluid, the penis gets hard.

It depends on your hand strength, it depends on how, various factors of the fluid resistance, but ultimately, after a number of pumps, the penis will get a nice, hard erection. This is a painless process once the post-surgical pain has resolved as long as the man is squeezing this pump and not accidentally getting their testicle, which we all know what that feels like.

So people learn that lesson really fast in the post-operative period, and they learn how to find the right thing, but it’s about the size of a testicle, maybe a small testicle is the size of this pump, and it’s right under the skin in the scrotum. So it’s very easy to identify with your hand, but it’s not so obvious that if you’re walking around in a locker room or you’re wearing a Speedo, no one’s really going to notice that you’ve had anything put down there.

And there’s a separate button, if you will, that’s above the pump portion that feels different because it’s a rectangular shape, and so in particularly on the… there’s a few companies that make these devices.

But there is one company, the Boston Scientific company, and on their pump, there’s this rectangular section, and then there’s a little sort of circle that you can feel pretty well with your thumb even through the skin, and that’s the location that you give it one quick press and then you can feel under your thumb, you feel a little fluid rush, and if you listen very carefully, you can even hear a little fluid move under the skin there.

And that’s the fluid starting to exit the penis, going back into the reservoir, it can take as little as 30 seconds to activate this thing, in 30 seconds to deactivate this thing, it’s very spontaneous, especially when you compare it to some of the other methods that we use to treat erections, the vacuum device can be quite cumbersome.

It’s a little bit hard to work that into the foreplay, the injection itself is very quick, but it can take about 10 to 15 minutes for it to start working, you have to sort of be juggling around these needles in the bedroom, it can be a little bit challenging. So one of the best things about the IPP is it gives you that spontaneity back that you used to have whenever you’re ready for the erection, you can have it.

Mark Goldberg: 30 seconds is a fantastic time, because as we cover a lot on this podcast, erections are oftentimes not instantaneous, and it takes some engagement, desire, touch to get things going, even when a man is not necessarily struggling with erections.

Given that the other treatments do take a lot of time, one of the benefits here is that once a man is proficient in operating this the 30 seconds and in 30 seconds out makes this really something that can flow in the natural process happening between a man and his partner.

Dr. Cohen: That’s correct, but there is another side to that story, and I tell men this all the time, which is, when you have one of these in, you have made the erections like flipping a switch, but that has not changed how your sexual drive is.

It doesn’t change how long it takes for you to reach climax, it doesn’t change the fact that you’re going to need to have foreplay so that mentally you are going to be able to enjoy the experience. That piece of it can’t be forgotten if you still want to be able to enjoy and experience the same type of sexual sort of cycle that you did beforehand.

Because, yeah, you certainly could at the flip of the switch have your erection, but if you were just sort of working on your car and changing the oil, you may not be ready, you may not be in the mood, and so those bits are still important to focus on during any sort of sexual encounter, and they need to be incorporated into the experience

Mark Goldberg: With an implant, it sounds like you can produce an erection without necessarily feeling sexual desire, but without that desire present if you’re not in the mood, that can erode the overall experience of the sex act.

Dr. Cohen: That’s correct. And so sometimes if men have one of these in and then they come back and they say, “Oh well, I’m not able to reach orgasm, I’m not having the same level of enjoyment.”

And when I ask a little history and try to figure it out, most of the time what I find is that because you can have an erection at will… that is sort of how the experience pans out for you with an IPP, and you’re forgetting all of those important things that actually mentally got you to a point where you could have orgasm and enjoy those good sensations.

Mark Goldberg: Are there any drawbacks or things that men should be aware of that can go wrong with an implant?

Dr. Cohen: Yeah we have to be realistic. An implant is surgery, and any time anyone undergoes surgery, there are risks associated with it. So some of the main things that we worry about are infection, this is an implant, and so typically, if there’s an infection of the implant, it’s unlikely that antibiotics alone are going to be able to solve that problem.

And oftentimes, what we have to do is we have to go back in and do a surgery where we actually wash out the tissues with antibiotics, and at that setting, we often can just exchange for a new implant, there is a slightly higher risk of infection because you may have left some bacteria there that may go right on the new implant, but by and large, we’ve been pretty good at what’s called salvaging these devices, where we immediately put in a new one.

If someone is really, really ill, they haven’t noticed they had an infection, maybe they didn’t see a doctor for a while, sometimes people are just not healthy enough for us to immediately put one in right away, and ultimately we have to leave them without one, and they’d have to come back at a later time if they want one replaced. But infection is a pretty catastrophic problem because of the need for another surgery.

Luckily, it’s not very common, it depends on what literature you look at, but certainly 3% or less of individuals who are getting these for ED have a serious infection that could require a surgery like that.

Something that is very common is mechanical failure.  As good as these things are, as fantastic as they work, they can break just like any car, you could get a lemon… Just like any car, going back to the mechanic analogy, you may need an oil change.

Everything is under the skin, so there’s no way to fix a valve or a reservoir without doing another sort of surgery, it’s just because everything’s sort of hidden under the skin.

Mark Goldberg: When it comes to the mechanical failure, is this the type of thing that again, has to be replaced or is there a concept of a tune-up where a part could be replaced or the valve has to be changed out?

Dr. Cohen: In these cases,  ultimately it requires a surgery, we need to make an incision, and then depending on what you find in there, if you are very confident that you’ve identified sort of one part that is sort of faulty, you can certainly replace that part, some surgeons are on the idea of any time you make an incision, we’re worrying about infection risk.

And so in those settings, they just replace everything to help reduce that risk, and so it’s a little bit of a case by case basis, but ultimately from a patient perspective, you’re still going to have an incision, there’s still a period of time where you’re not going to want to use the implant while you’re healing. So I don’t know that it makes that huge of a difference from a patient-centric model, whether the whole thing’s replaced or a few parts are replaced, but you can… it is possible to replace a few parts.

Mark Goldberg: But for the most part, from a patient’s perspective, if certainly they’re going under when they wake up, the device hopefully is fixed, whether that’s a full replacement or a couple parts…

Dr. Cohen: Correct, correct. So another potential thing that can happen is called erosion. We’re putting this device that becomes rigid under the skin, and sex is inherently a forceful activity, and so that can ride up against the skin and cause a little bit of damage to the skin.

And if that happens repeatedly, sometimes you can see a little bit of the device coming through the skin, it can break through the skin, and we call that an erosion. We have to fix that it is obviously, it’s not aesthetically pleasing, it can be very alarming to see parts of the device coming out of the skin, so that has to be closed, sometimes that’s also… we worry about that being associated with an infection.

So sometimes we do replace the device or take one out and put one back in in a delayed fashion, it’s a little more likely for that to happen if people have sensation issues, they don’t have good sensation to their skin, so they don’t notice for a while that they’re sort of break down there, so that can be more likely, for instance, in someone who’s diabetic. But erosion is another one of those things that we worry about, it’s very unlikely to happen but it is something that we do watch out for.

Mark Goldberg: Can a man still ejaculate? Is that part of the penis still intact?

Dr. Cohen: Yeah, so that’s a great question, and it really depends on what else is going on in their medical history. So for example, there are a lot of patients who I see who had prostate cancer, they cannot ejaculate because of the treatment for prostate cancer. Even if we fix the erections and their erections are 100%, they’re still not going to be able to ejaculate, but they can orgasm fine, in terms of getting that sensation, the climax, the enjoyment, they can still reach that without producing an ejaculation.

It really depends on one’s medical history, but this device should not impede the ability to reach climax if you are able to ejaculate prior to having the device placed, presumably, you’d be able to ejaculate after the device has been placed, it doesn’t impede that or alter that in any way.

Mark Goldberg: Are erections as firm with an implant as they may have experienced with a natural erection?

Dr. Cohen: The erection that you get from an IPP is not the same as the erection that you remember. Everybody in her mind has this sort of picture of the erection that they think that they get, and the honest truth is that most of the time that’s a picture of the erection they had when they were 21 years old, and they haven’t had that erection in 30 years, but nonetheless, that’s the picture that we all have in our mind of our erection.

This device is not going to give you the erection that you have when you were 21 years old, it is going to give you a very good erection, that’s very suitable for any sort of intercourse that you’d like to have, but memory is a fickle thing.

And a lot of men who have one of these placed, they haven’t had a good erection in many, many years, it’s a touchy subject, but it’s a good erection, it’s not going to meet everybody’s expectation, because I think people’s expectations maybe are not realistic. I will tell you that the main difference that I can describe here, is that the shaft of the penis is where this device goes, and so the shaft is very, very rigid, you can hang a tie off that no problem, put some weights there, it will not be an issue.

But the head of the penis or the glands of the penis during a physiologic erection, there is also some engorgement of the glands, and this device does not go into the glands. And so one thing that is different between an IPP erection and a physiologic erection is the head of the penis is still a little bit soft, but by and large, it does not prevent anyone from enjoying or engaging in intercourse.

Mark Goldberg: Dr. Cohen, aside from cancer survivors, which you mentioned earlier in this recording, is there a common patient profile who tends to be an appropriate candidate for an IPP?

Dr. Cohen: The AUA guidelines, when they describe… that’s my professional society’s guidelines, and when they describe who is a candidate for the various treatments for erectile dysfunction, all the treatments are all on a level playing field. So what that means is that if a man comes to me with this preconceived idea that they want an IPP, they have ED, there’s no mandate that says that I have to try them on all the other treatments before we talk seriously about an IPP.

So any man with ED is theoretically a candidate for an IPP, most men want to try some more minimally invasive things before jumping to that conclusion, but other men for various reasons, whether in their medical history or for other factors, they really want to talk about it more up-front, more seriously, and I don’t have a problem with that.

As long as they understand the risk as long as they understand what they’re getting into, it can be an initial treatment for some men. Other types of guys that I see in my practice are those who’ve had some trauma to the penis, either occupational trauma, penal fracture, serious or very challenging Peyronie’s disease, those men are more likely to be talking about an IPP earlier in their visits with me.

Then sort of men who were toying with the idea of, do they have psychogenic ED, do they have a touch of vascular disease, can we get by with some more minimally invasive treatments… usually those men are not going to go right to an IPP-type discussion.

Mark Goldberg: What are some of the barriers to men choosing an implant that you’ve encountered?

Dr. Cohen: There certainly are patient-driven barriers, patients who are otherwise great candidates who honestly, it really is what they… if they want to have a good sexual experience, it’s what they really need, very severe Peyronie’s disease, for instance, or patients, again, cancer patients who’ve had a number of reasons why none of the other treatments are going to work for them, sometimes those men, despite the council, they’re still reluctant to undergo a surgery, and you have to respect that.

But other barriers that aren’t put up by the patients themselves would be financial. For certain diagnoses, these are covered by certain insurance plans for other diagnoses, sometimes we have a challenge, sometimes the insurance companies try to limit the type of device that we put in, for instance, that malleable device, I think it’s cheaper.

So some insurance companies preferentially say, “Okay, well, if you want this penal surgery, you can have it, but we’re only reimbursing you for this malleable device.”

And so sometimes those are challenges that we have to work around, overall, for a man who’s an appropriate candidate, who is motivated, usually, we try to do everything we can to get them into a better state of sexual health.

Mark Goldberg: Can you tell us a little bit about patient satisfaction? Once the procedure is complete, what are your patients reporting back to you?

Dr. Cohen: Patient satisfaction is really high after these types of procedures… yeah, and probably more importantly… well, I guess it depends on who you ask, but partner satisfaction is also very high.

I think that one thing we didn’t talk about is the post-operative period, it can be a little rough, it’s a sensitive area of your body that is undergoing an operation, and it’s what I tell people, it feels like I kicked you in the nuts for three weeks, because that is how it feels, it’s uncomfortable.

A sensitive area when you sit, when you walk, you’re going to sort of feel it down there, there’s going to be black and blue, it is going to look ugly for a while. Yes, men during that time period, they are not very happy, but long-term, and the studies back this up, long-term men are very, very satisfied with the functionality of the device. Usually, they recommend it to a friend.

They don’t have any regrets. Asking them, “Would you do it again?” The answer is always yes. Very, very high satisfaction with these types of things.

Mark Goldberg: Thank you very much, Dr. Cohen, is there anything that you would want to add as we’re wrapping up?

Dr. Cohen: Yeah, so once again, thank you so much for the invitation. I would sum up and say that for men that are suffering from erectile dysfunction, IPP is one of many different options that can be discussed in terms of how to help them attain their goals in terms of their sexual health.

And certainly, it’s not for everybody, but for those patients that are appropriate candidates who are motivated, you understand the limitations of it and the risk of it, it can be a very effective treatment for men with severe erectile dysfunction.

Mark Goldberg: Once again, thank you for your time and we look forward to potentially hosting you again on the erectile dysfunction radio podcast.

Dr. Cohen: It was my pleasure.

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