If you experience erectile dysfunction, you’re not alone: according to the National Institutes of Health, it impacts 30 million men in the United States. 

While cases occur due to complications from prostate cancer treatments, others can be related to long term effects stemming from medical conditions such as diabetes, heart disease, high blood pressure and aging.  

What’s not common, though?

Patients knowing about a safe solution that can actually fix the problem: a penile implant.

And the even bigger problem?

Most primary care providers, and even some urologists, don’t educate patients about their options either due to a lack of familiarity with available treatments, or because their focus is on other pressing medical problems during the little time doctors get with their patients.

“Some people view erectile dysfunction as a natural progression of life and that nothing can be done. There is a sense of surrender that can come with it,” said Bahaa Malaeb, M.D., a urologist who annually evaluates over 500 patients with erectile dysfunction and performs over 100 penile reconstructive surgeries a year at Michigan Medicine.

“But it doesn’t have to be this way. There are safe and reliable options available.”

What is erectile dysfunction?

Erectile dysfunction is described as having trouble getting or maintaining an erection firm enough for sex. 

Although having problems from time to time is normal, issues with erections occurring more frequently, and interfering with your sex life, need to be discussed with a provider. 

The common condition not only impacts self esteem, but also relationships. 

And it can be difficult to ask for help.

“Newer online companies that offer virtual visits and expedited prescriptions for medications are helping normalize the way we talk about ED,” said Malaeb, who explains it’s making patients more comfortable bringing up the topic with their doctors and seeking treatment.

Addressing the issue

The first line of treatment used for ED is an oral agent, pills such as Viagra and Cialis. 

When pills stop working, other options, such as penile injections, are then sought out. 

But when those don’t work?                        

Penile implants are the next treatment of choice, and contrary to popular belief, they’re not new – they’ve been around since the late 70s.

“The problem is that there is a misconception among most primary providers, general practitioners and a lot of urologists that this is a very aggressive and dangerous treatment option,” explained Malaeb.

But that isn’t the case.

“I present it to patients as a 30-minute outpatient procedure that restores your ability to have an on-demand erection that is as hard as you want it to be and lasts for as long as you want it.”

It’s not surprising that penile implants have the highest patient and partner satisfaction rates of all available options, Malaeb says. Penile implants have around a 95% patient satisfaction rate as compared to pills, which only have around 50%, and injections only 30%. 

What is penile implant surgery? 

“One way to describe it is drawing similarities with putting an inner tube inside of a flat tire,” said Malaeb. 

“Patients often come in thinking that this is some sort of external sex toy or something that is going to be very obvious and noticeable. It’s not.”

The penile implant is a fluid-filled three-piece device, with a part that goes into the penis that gets inflated to give an erection. Everything is placed inside and controlled by a small pump that’s hidden inside the scrotum.

We should do better breaking the ice and connecting the patient with treatments that work, in the hands of doctors that do it best.”Bahaa Malaeb, M.D.

The control mechanism is then placed inside the scrotum, and the procedure is done through a small, less than 4 cm (2 inches), incision. 

"It, very easily, goes unnoticed," said Malaeb.

After the procedure, patients rest at home and return in at two weeks for a wound check and then again at six weeks to get taught how to activate the device and start using it. 

Generally, patients return to their daily activities, unrestricted, at six weeks, too. 

“They can golf, bike, swim and participate virtually in any activity they want to do. And, it gives them their sex life back,” explained Malaeb.

The approach aids in preserving the normal, pleasurable sensation had with sex and provides people the ability to achieve an orgasm. 

“The patient comes in, we discuss treatment options. If pills and injections have failed, we discuss an implant,” Malaeb explained. 

“I take time to clear up a lot of the misconceptions that the patient might have about the procedure, show them the available brands, discuss the differences and determine with the patient which one fits their needs the best. We also discuss potential complications, how the procedure will go, as well as recovery time.” 

Durability and complications

Having an implant doesn’t pose restrictions long term, says Malaeb. 

“Mechanically, these implants last on average around 10-12 years. Sometimes it’s longer, sometimes it’s shorter. It’s very much like a car.” 

It’s important to remember, though, that high volume providers and centers (hospitals) have mature processes in place and are able to perform these procedures quickly, reducing the risk of complications like infections. 

“The unfortunate reality is that the majority of implants done by providers in the community are low volume, usually under 10 implants a year,” cautioned Malaeb, who performs them regularly.

“Less than 5% of urologists are considered high volume.” 

Complication rates and suboptimal outcomes, related to sizing and placement, are higher in lower volume practices. 

Malaeb says that this, unfortunately, adds to the stigma that these procedures are more dangerous than they really need to be and cautions patients, as well as their surgeons, to be more anxious about offering or undergoing it. 

He stresses that patients should be encouraged by their providers to seek out this option, but only with high volume surgeons and centers. 

“In the case of infection, for example, the reported rate of infection in the literature is around 1-3%,” said Malaeb.

In Malaeb’s practice, the rate of infection is as low as 0.5%. 

“This was part of my specialty fellowship training in genitourinary reconstructive surgery. I chose this practice because of its impact on a person’s quality of life. I am not dealing with life and death surgery,” said Malaeb.

“But to me, seeing a patient who worked his entire life planning for a pleasant and active retirement, only to find himself incontinent and impotent after treatment for prostate cancer, for instance, is heartbreaking. They lost their sex life. They lost their social life. They’re worried about urine leakage in public… I am grateful to be able to restore these functions for my patients.”

More on the provider issue

Another layer of complexity? 

After prostate cancer treatment, there’s a wide variability in reported ED rates, which can be as high as 70%; Patient reported outcomes indicate a higher rate of erectile dysfunction than physician-reported outcomes. 

This issue is likely for two reasons: erectile dysfunction is usually managed by the person who handles the prostate cancer treatment, which creates a hurdle with patients feeling uncomfortable bringing up the problem.

“They’re concerned about sounding ungrateful for the cancer treatment they were provided, so they’re less likely to inquire about it,” said Malaeb.

And the second, on the urologist side, the problem with ED reporting is the inherent conflict in acknowledging a complication of the treatment they've given. 

Malaeb stresses how important it is for physicians to ask how their patient’s sexual function is before, and after, the procedure, and to create a comfortable space for the conversation. 

“As physicians, we are constantly squeezed by larger forces, such as hospital systems and insurance companies, forced to spend less and less time with patients due to the increasing documentation and administrative burdens shifted onto the physician,” said Malaeb.

“We tend to focus on the one main issue that is bringing the patient in, often ignoring the importance of asking about sexual function during visits for conditions that are known to be associated with ED."

Whether it’s a diabetes follow up, prostate cancer treatment visit, cardiac condition, or other, Malaeb says many times providers rely on the patient to bring up the concern when they feel it’s critical enough, forgetting that it’s usually very difficult for people to initiate that conversation. 

“We should do better breaking the ice and connecting the patient with treatments that work, in the hands of doctors that do it best.”

U-M is making access easier for patients who want to discuss erectile dysfunction, by offering both in-person and virtual options to discuss the concern. Contact Michigan Medicine’s Urology Call Center and request an appointment at 734-936-7030.

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