Volume 3 Issue 7 July, 2013
Consultation Liaison Psychiatry Focus: Urology
Erectile dysfunction (ED) is a sexual dysfunction characterized by the inability to develop or maintain an erection of the penis. Treatment consists of education, therapies, medications, penile pump and surgery. Surgical interventions are indicated in cases of penile injuries, Peyronie’s disease, ischaemic priapism or infection. They are also considered when medical treatment for erectile dysfunction is contraindicated, unsuccessful or when such treatment cause undesirable effects. Liaison of psychiatry & Urology is necessary in this scenario. Before surgical intervention it is may be beneficial to refer patient for opinion from psychiatrist. Surgical interventions are in the form of penile prosthesis surgery or penile revascularization therapy (arterial revascularization or venous reconstruction).
Penile prosthesis surgery:
Penile prosthesis surgery is a mechanism for creating penile rigidity that differs from a physiologic or pharmacologically induced erection. Many malleable (semi-rigid) and inflatable (hydraulic) devices are currently available for this purpose.
There are two different types of inflatable prostheses i.e. 3 piece and 2 piece. The non inflatable prosthesis is a semi-rigid device that is bendable. Penile prosthesis are available from American Medical Systems (AMS) and from Coloplast. The AMS 700 series is a 3 piece inflatable penile implant which allows expansion in both length and girth (LGX). The AMS 700 series is also available with inhibizone, an antibiotic impregnation of rifampicin and minocycline.
Patients must be extensively counseled regarding the risks and benefits of prosthesis placement and they must be informed that alternative therapies may not be successful following removal of prosthesis in ED. Some may notice a loss of penile length in the erect state because most prostheses do not provide expansion of length. The decision regarding the type of prosthesis to be placed depends on the patient’s wants and needs, surgeon’s preference and the patient’s anatomy and history. For example patient with ED and history of Peyronie’s disease are best treated with AMS 700 CX whereas patient with extensive intracorporeal fibrosis, a narrow cylinder (AMS 700 CXR) may be best. 3 piece prosthesis achieves better results than 2 piece prosthesis in men with larger phallus. Precautions may be taken up to help minimize the risk of infection like administering pre and post-op antibiotics, ensuring that the urine is sterile, scrubbing and shaving at the time of surgery and providing copious intra-op irrigation with the antibiotic solution. Patients should be counseled regarding long term complications including infection, malfunction, erosion, corporal perforation, pump migration and cylinder cross-over. They should be instructed to follow-up if pain, swelling, redness, discharge, visible tip through glans and malfunction of pump or tubing.
Penile revascularization:
Arterial revascularization: It is designed to create arterial inflow to the corpora cavernosa. The following inclusion criteria should be met to select patient for arterial surgery: age younger than 55 years, non smoker, non diabetic, absence of venous leakage and radiographic confirmation of stenosis of internal pudendal artery. Complications of this procedure are glans hyperemia, shunt thrombosis and inguinal hernia.
Venous reconstruction: It was proposed to prevent blood egress from the penis. Success with these surgeries has not been affirmed owing primarily to inaccurate or deficient methods for diagnosing or correcting the relevant anatomic defect.
Comprehensive care for erectile dysfunction in some cases may require close liaison of many specialities for the benefit of patients and specialities should come together to know from each other’s expertise.
Dr Prasad Mylarappa MBBS MS DNB MCh Urology, MRCS (Edinburgh) Associate professor of Urology, M. S. Ramaiah Medical College & Hospital, Banglore
