One of the most common problems in men with diabetes mellitus is erectile dysfunction (erectile dysfunction, impotence, ED). This is a serious problem, especially in long-term and poorly controlled diabetes patients. In long-term and poorly controlled diabetes patients, erectile dysfunction occurs as a result of neuropathy (nerve damage), vascular damage and hormonal changes. In this article, we will provide general information about penile prosthesis surgery in diabetic patients.

How are diabetics prepared before prosthetic surgery?

Since prosthetic surgery is a very sensitive practice, extreme caution should be exercised against infection and this should be taken into account when choosing a hospital.

• Patients who will undergo surgery should be well informed about the importance of sugar control against infection. Ideally, patients should have hemoglobin A1c (HbA1c) levels below 7.5 before surgery. Above this value, the infection rate increases. Patients with very high sugar levels and high HbA1c should definitely be examined by an Endocrinology specialist.
• A regular diet and exercise program is very important in sugar control and reducing the risk of infection.
• Before the operation, blood tests are requested for general surgery, chest X-ray and EKG are taken.
• If patients are using blood thinners, they should be discontinued 1 week in advance.
• If there are any medications that he has taken before, such as blood pressure and diabetes, he should continue to use them, and consultation from the relevant specialist should be requested if necessary.
• The patient should not eat or drink anything at least 5-6 hours before the operation.
• Preventive antibiotics are started before the operation against infection.
• The patient is hospitalized and an informed consent form is signed.

How long is the type of anesthesia, operation time and hospital stay?

Prosthetic surgery is performed with general anesthesia or spinal anesthesia (numbing from the waist down). Penile prosthesis surgeries are performed under operating room conditions, the operation lasts for 1-2 hours, the patients are discharged from the hospital 6-7 hours or 1-2 days after the operation on the same day.

What should be considered after penile prosthesis surgery?

Follow-up after prosthesis surgery is very important in diabetic patients.

The points to be considered in the early and late periods after leaving the hospital are as follows;

• After the operation, patients are taken to their rooms.
• Do not eat or drink anything by mouth for 4-5 hours.
• Antibiotics and painkillers are given intravenously.
• After the effect of anesthesia wears off, patients take liquid and watery food, stand up and walk slowly.
• The urethral catheter is removed the next day, the patient is discharged with antibiotics and painkillers.
• For 4-6 weeks, patients are advised not to lift too much weight and not to do heavy sports. The prosthesis starts to be used after 4-6 weeks.
• Must use diabetes medications regularly
• Much attention should be paid to diet

When should a doctor be called?

Patients should be in contact with their doctor after surgery. In the following cases, the doctor who performed the surgery should be sought;

• If there is severe pain, swelling and bruising in the penis and scrotum
• If there is a high fever
• If there is bleeding from the surgery site
• If there is an inability to urinate

When are diabetic patients fitted with a penile prosthesis?

Not all diabetics are candidates for penile prosthesis. Creating an erection with a vacuum device can be tried as it is a method without side effects. If erections occur with oral pills, it is recommended to continue this treatment. As the vascular and nerve damage increases over time, these pills are not effective and injection treatment into the penis may be required. In the future, if the patients do not respond to injection (penis injection) treatment, or if they do not want to inject and want a definitive solution, the only option in such cases is penile prosthesis (penis prosthesis, happiness stick) surgery.

Does the length of the penis increase or the thickness increases with prosthesis insertion?

Penile prostheses do not lengthen the penis of patients, in case of erection, the longer the penis, the longer the prosthesis. However, if the ligaments that suspend the penis to the pelvis are loosened during the surgery as a different procedure, some (about 1-2 cm) elongation can be achieved. Some researchers reported that 75% of the patients had lengthening of the penis and thickening in diameter. According to our observations, this is related to the satisfaction of the patients with the prosthesis. There is no significant increase.

Penile implant does not cause any enlargement in the head of the penis.

How often can patients use the prosthesis?

This completely depends on the patient and his partner. There are no restrictions on the use of prosthesis. Patients can use it whenever they want.

Which type of prosthesis should be chosen in diabetic patients?

There is no single criterion in the selection of prosthesis. Each patient should be evaluated individually. Many factors such as the age of the patients and their socioeconomic status should be considered.

Inflatable prostheses should be preferred in young patients who do not have anatomical or functional problems in using their hands. Since these prostheses are in a deflated state during intercourse, they give a natural appearance, likewise, a natural appearance is provided during erection. Permanently standing prostheses cause erosion in the head of the penis, as there will be loss of sensation or reduction in diabetic patients. These prostheses should be considered as the last option.

Since patients will activate the pumps of the inflatable prostheses with their hands to have intercourse, if there is a problem in the hands of the patients, there may be problems in the use of the three-piece inflatable prosthesis. In this respect, it should be preferred to use one-piece (malleable), permanently upright prostheses in patients who cannot actively use their hands due to various diseases (such as paralysis, joint rheumatism, loss of fingers or hand due to accident or surgery).

Will sexual desire, semen not coming, premature ejaculation improve with prosthesis?

Penile prosthesis does not increase sexual desire (libido) and interest, does not correct nerve damage due to diabetes (diabetic neuropathy), does not correct loss of sensation. If patients have retrograde ejaculation (retraction of semen, mixing with urine), anejaculation (absence of semen) and premature ejaculation (premature ejaculation), the penile prosthesis does not correct them.

What is the effectiveness and patient satisfaction of penile prosthesis in diabetic patients?

Studies have reported very high patient satisfaction rates of 80-90% with penile prosthesis in diabetics. The same satisfaction was observed on the women’s side as well. Our observations in our own patients are similar. For this reason, penile prosthesis surgery is recommended for patients who have erection problems due to diabetes, if all treatments are insufficient.

With the penile prosthesis, an image similar to a normal erection is obtained, but due to the long-term erection problem, there may be some shortening and thinning of the penis compared to the previous periods. In scientific studies, it has been shown that if penile prostheses that can expand transversely and longitudinally are inserted, the shortening of the penis and the thinning in diameter will improve over time. For this reason, we recommend this type of prosthesis to our patients more. These transverse and longitudinal extensible prostheses are economically a little more expensive than others.

What are the risks of prostheses?

Penile prostheses have 3 important risks;

• Infection
• Prosthesis-related mechanical failures: There may be problems in the pump and reserve, especially in hydraulic prostheses, and repair may be required.
• Internal erosion and adhesions

What are the prosthesis prices?

Since penile prostheses are imported products, their fees are related to the exchange rate. In addition, the total fee, excluding the price of the prosthesis, varies according to the doctor and the hospital where the surgery is performed. Three-piece and longitudinally expanding prostheses are more expensive than fixed ones.

Prosthesis infection in diabetics

A prosthesis is a foreign body that is attached to the body from the outside. One of the most important risk factors for prostheses is “prosthesis infection”.

Infection is higher in diabetics for two reasons:

• Wound healing is not good in diabetic patients
• The immune system (the body’s defense system against infections) is impaired in diabetics.

Prosthetic infection is extremely rare today, with an average rate of 1.6% for all prosthesis patients in general. The risk of denture infection is higher in patients with poorly controlled diabetes than in normal people. In a study, the infection rate in diabetic patients was 1.8%, while this rate was 1.5% in non-diabetic patients.

Reasons for the rare occurrence of prosthetic infection today:

• Advances in surgical techniques
• Improvements in sterilization of operating theaters
• Use of preventive antibiotics
• Advances in prosthetic technology and use of antibiotic prostheses
• Raising awareness of patients

What should diabetics pay attention to to reduce prosthesis infection?

In order to reduce the risk of prosthesis in diabetic patients, the doctor has a lot of responsibility besides the issues that the doctor should pay attention to. The points that patients should pay attention to in order to reduce or eliminate prosthesis infection:

• A proper diet: The risk of infection is highly correlated with diabetes. In this regard, it is very important for patients to keep their sugar levels in balance by paying maximum attention to the recommendations of their doctors. The best indicator of sugar level is HbA1c level, as these values ​​increase, the risk of infection increases accordingly.
• A regular exercise: In this way, sugar control becomes easier.
• Weight control

Does penile prosthesis correct diabetes?

When diabetic prosthetic patients are followed up, it can be seen that their blood sugar and HbA1c levels are lower than before the prosthesis. In a study, the average HbA1c level was found to be 2.5% lower in type-2 diabetics with prosthesis. This does not mean that the prosthesis reduces blood sugar or improves diabetes. The reasons for this situation;

• Patients should be more conscious about prosthetic infection and give more importance to their nutrition and sports activities,
• More strict compliance with the recommendations of doctors and dietitians
• Sex life (sexual life) is regulated and the associated stress disappears,

How long can penile prostheses stay in diabetic patients?

One of the questions frequently asked by patients is “how long and how many years the implants will remain in the body without any problems”.

This question can be answered in two ways:

• Mechanical problems: Mechanically, the duration of the prosthesis is not different in diabetics and other patients. More than 75% of the patients do not need a revision for mechanical reasons in the future, and patients can use the prosthesis for up to 15 years without any problems. It has been reported that prostheses can remain for up to 20 years without any problems.
• Prosthesis infection: Diabetic patients have a higher risk of early or late prosthetic infection, especially in poorly controlled cases than in normal people. To prevent this, we pay great attention to sterilization during surgery and use strong and broad-spectrum preventive antibiotics. In addition to these, we always subject the prostheses to antibiotic solutions before attaching them to the patient during the surgery. In this way, the infection rate is extremely low. In diabetic patients, the risk of prosthesis infection increases even more if there is kidney failure or if these patients are on dialysis.

In summary; Erectile dysfunction is the most important problem in men with long-lasting and poorly controlled diabetes. Penile prosthesis is the last option in erectile dysfunction patients who do not respond to current treatments. Inflatable penile prosthesis should be preferred in diabetics, especially in young people. We recommend the three-piece inflatable prosthesis to our patients. The prosthesis can be used for a long time without any problems. Patient and partner satisfaction is very high, 90% and above. The most serious risk for prosthetic surgery in diabetics is prosthesis infection. If careful attention is paid to sterilization and sugar control is good, the risk of infection is extremely low. Thanks to our 30 years of experience in our patients, our success is very high and our complications are almost non-existent.

Prof. Dr. Emin OZBEK

Urology Specialist

Istanbul – TURKIYE