Penile prosthesis surgery (penile prosthesis, happiness stick surgery) is widely used in patients with erection problems today. Penile prosthesis surgery is the last method to be used in patients with erection problems (erectile dysfunction, erectile dysfunction, ED). It is performed as the last treatment method in ED patients who do not respond to existing treatments.

There are different shapes of penile prostheses. The prosthesis is selected according to the socioeconomic and intellectual structures of the patients. There is a 95-98% satisfaction rate among people and their couples who receive prosthesis. We generally do not encounter serious problems in long-term follow-up in conscious patients. In this article, considering my own experiences since 1992, I will talk about the long-term follow-up and controls of patients who underwent penile prosthesis surgery and the problems that may be encountered.

Early follow-up in patients with penile prosthesis

• Pain control: Pain may occur in the first 2-3 weeks after prosthesis surgery. It’s normal. Over time, the pain decreases. The pain disappears after 3-4 weeks. In the early stages, patients are given relaxing painkillers. Cold application is effective in reducing pain and edema. Rarely, very strong painkillers are needed. Broad-spectrum preventive antibiotic treatment against infection is given for a period of 1-2 weeks.
• Swelling (edema) at the surgery site: Edema (swelling) and bruising may occur in the penis, scrotum and lower abdomen in the early postoperative periods. These are normal in the early period and will improve over time.
• Wound care: For prosthesis surgery, we make a small incision of about 2-3 cm. There is no serious problem with the incision. Care should be taken to keep this area clean and dry. We start protective antibiotic treatment against infection.
• Daily life: You can shower 48 hours after the surgery. We generally do not recommend bathing in the early stages. Excessive pressure should not be applied to the wound site in the early stages. In penile prosthesis surgery, we usually close the skin with self-dissolving stitches. These are absorbed spontaneously in 3-4 weeks.
• Regarding the prosthesis and the pump: After 2-3 weeks, the pump is pulled down and released 3 times a day without too much trauma. In this way, the pump is prevented from escaping backwards. The penis is inflated and deflated several times a day. Thus, the expansion of tissues is ensured. However, intercourse is not possible during this period.
• Early control: We keep our patients in the hospital for one day after surgery. 5-6 hours after the surgery, patients start taking it orally, stand up and walk. We recommend that patients do not stand for long periods of time during the first 2-3 weeks. In this way, it is ensured that excessive edema does not occur in the penis. One week after the surgery, patients start their daily activities. Normal sexual intercourse begins after 4-6 weeks. After 4-6 weeks, you can do sports and lift weights. Patients were 3, 6 and 12 months postoperatively. He/she is called for a check-up once a month, and later once a year.

After penis prosthesis surgery, a doctor should be called in the following cases

Patients who have penis prosthesis surgery should be more careful in the early stages. Patients should definitely call their doctor in the following cases:

• If there is severe edema (swelling) in the penis, scrotum and lower abdomen
• If there is discharge from the surgery site
• If there is severe pain despite painkillers
• Redness and extreme pain on the operation forehead
• If there is a high fever, chills, or shivering.
• If there is inability to urinate

What are the possible problems with long-term penile prosthesis?

Penile prosthesis surgery is a delicate surgery. No serious problems are encountered in surgeries performed by experienced surgeons. Some problems may occur in later periods. Patients need to be informed about these issues. We can list the problems that may be related to penile prosthesis in the late stages as follows:

• Mechanical problems and malfunctions related to prostheses
• Penile and scrotum erosions due to prostheses
• Penile erosions due to prosthesis
• Urethral erosions due to prostheses
• Penile prosthesis infections
• Prosthetic replacement

Mechanical problems and malfunctions related to prostheses

Penile prostheses are foreign objects placed in the body. As with other prostheses used in the treatment of various diseases, mechanical failures may occur in these prostheses over time. Mechanical failures commonly occur with three-piece, inflatable prostheses.

Three-piece prostheses are a more complex system than one-piece ones. Therefore, it is natural for malfunctions to occur. 3-piece penile prostheses consist of a pump placed in the scrotum, a reserve placed in the lower abdomen and two cylinders placed in the penis (corpus cavernosum). When people want to have intercourse, they activate the prosthesis with the pump in the scrotum and have intercourse whenever they want. Finally, it deflates the penis again with the mechanism in the scrotum.

There is a possibility of malfunction at any stage in the pump, reservoir and cylinders placed on the penis. Usually malfunctions occur during activation and lowering of the prosthesis. In such cases, the malfunction must be corrected with surgery again. Since prostheses have been used for more than 40 years, a significant amount of experience and knowledge has accumulated in this field. The materials used in making prosthesis are advanced materials. For these reasons, we encounter such problems extremely rarely.

Penis and scrotum erosions due to prostheses

During long-term use of penile prostheses, erosion may develop in the contact tissues over time. These erosions are usually seen at the tip of the penis and the scrotum. Sometimes it is seen as urethral erosions. Scrotal erosions: In those who use prosthesis for a long time, erosions and irritations on the scrotum skin may occur in the pump part. To prevent this, patients need to be careful. Overly traumatic manipulations of the scrotum should be avoided during prosthesis activation and deactivation. Scrotal erosions occur with three-piece dentures.

Penile erosions due to prosthesis

In long-term penile prosthesis patients, erosions on the head of the penis (glans penis) may occur in the late stages. Glans erosions are more common in two-piece (malleable, non-inflatable) penile prostheses. Erosion is less common with three-piece, inflatable penile prostheses. Usage is also important in causing erosion. We encounter this problem less in patients who use it more consciously. Penile erosion is more common in diabetics. For these reasons, we prefer inflatable prostheses in young patients because they will be used for a longer period of time.

Urethral erosions due to prostheses

One of the problems we encounter in those who use prosthesis for a long time is that the tip of the prosthesis opens into the urethra (urinary canal in the inner part of the penis). Over time, it is seen that the prosthetic tip opens into the urethra. This situation is noticed by patients. In such cases, the prosthesis must be removed. Sometimes, the prosthetic tip does not open completely into the urethra, but the urethra can be felt just under the urethra mucosa. It is possible for prostheses in this situation to pierce the mucosa and open into the urethra over time. In patients with this situation, the prosthesis must be removed. Urethral erosions are more common in one-piece prostheses because they are constantly upright.

Penile prosthesis infections

One of the important problems in patients with penile prosthesis is prosthesis infections. Prosthetic infections are not very common today. This is because:

• Giving importance to sterilization during surgery,
• Use of protective broad spectrum antibiotics,
• Improvements in surgical techniques and surgical materials
• Coating of prostheses with antibiotics

Penile prosthesis infection is a serious problem. Although it is rare, if it occurs and there is a serious infection, the penis must be removed. The most common cases of penile prosthesis infection are:

• Those receiving immunosuppressive therapy (patients who have undergone organ transplants such as kidney transplants)
• Diabetics
• Patients with spinal cord paralysis and continuous use of urethral catheters
• Irregularly controlled diabetics
• Patients with renal failure

Prosthesis replacement

Our patients who previously had a malleable, that is, one-piece prosthesis, sometimes want to replace it with a three-piece prosthesis. These patients are evaluated and replaced with a three-piece if appropriate. The risk of infection is high in such cases. Maximum care should be taken against infection during surgery. Apart from this, pre-existing dentures may need to be removed. If it is appropriate to insert a new prosthesis in the same session, it can be inserted; if not, a new prosthesis can be inserted at a convenient time.

Recommendations for patients with penile prosthesis

Penile prosthesis surgery is a delicate surgery. It is important for our patients to be careful about possible complications and to come for regular check-ups. We recommend our patients to pay attention to the following:

• Medications given after surgery should be used regularly
• The wound site should be taken care of and kept dry and clean.
• Avoid standing for long periods of time within 1-2 weeks after the surgery.
• Weight should not be lifted and excessive sports should not be done before 4-6 weeks.
• Sexual intercourse should be started after 4-6 weeks
• Care should be taken when using the prosthesis, it should not be used traumaticly.
• Trauma to the scrotal and penile areas should be avoided.
• Regular follow-up and treatment of those with chronic diseases such as diabetes
• In case of a problem, patients should definitely contact their doctor.

In summary: Penile prosthesis surgery is the last preferred method for erectile dysfunction patients who do not respond to known treatments. There are two types of prostheses: inflatable and fixed (flat). Both patient and partner satisfaction in prosthesis patients is 95-98%. It is decided which prosthesis will be suitable according to the patient’s condition. It is important to follow up prosthesis patients. Some problems may arise in the early and late periods. Most of these heal simply and without problems. There may be some problems with the prostheses during long-term follow-up. These are generally mechanical problems. It is very important for patients to follow the doctor’s recommendations when using a prosthesis. In this way, problems that may arise due to use are prevented. During our 15-20 years of follow-up, we did not encounter any serious problems in patients who used it consciously. Our recommendations to our patients; It is possible to use prostheses for a long time if they use them carefully and follow the doctor’s recommendations.

Prof. Dr. Emin ÖZBEK

Urology Specialist

Istanbul- TURKEY