| SExUAL DySFUNCTioN | opinion
provide a permanent, although manageable, erection; and inflatable implants that, as their name suggests, can be inflated to produce an erection when required. There are two types of inflatable implant, two-piece and three-piece. All vacuum constriction devices work
on the same principle. A cylinder, usually made from clear plastic, is placed over the penis and a seal created between the end of the cylinder and the patient’s body. Air is then pumped out of the cylinder, generating a partial vacuum that encourages blood to flow into the penis. once an erection has been achieved, a constriction band is placed around the base of the penis to prevent blood leaving the organ, and the cylinder can then be removed. in the US, most insurance policies, including Medicare, cover at least part of the costs of a vacuum constriction device, especially if a medical cause for the ED has been established. in patients where PDE5 inhibitors are
contraindicated, and in whom vacuum constriction devices give less than satisfactory results, a penile implant may be considered. The penile implant market is dominated by two companies, American Medical Systems of the US and Coloplast of Denmark. As the insertion of an implant is an
invasive, surgical procedure, it is normally the approach of last resort. There are two main concerns about penile implants — the risk of postoperative infection, and the risk of mechanical failure. infection after implantation occurs in only 3% of patients, but is considered to be a serious event that usually necessitates removal of the device. Such infections are not usually susceptible to systemic antibiotics. Mechanical failure also normally demands that the device be removed, or at least repaired by a further surgical procedure. in addition, penile implants have a finite useful life. on the other hand, implants can offer a
more or less permanent solution to the problem of ED, and one that does not interfere, or interferes only minimally, with intercourse. The devices are designed to feel natural before, during and after sex, and to not affect orgasm. As with vacuum devices, implants are generally covered by insurance. There are two types of penile implant, and
non-inflatable inflatable. Non-inflatable implants account for some
8–10% of the overall number of procedures carried out. They consist of two bendable, semi-rigid plastic rods that are surgically placed in the corpora cavernosa. This results in the penis being permanently erect. The patient bends the device into the upright position when he wants to have intercourse, and bends it down to conceal it in the clothing at other times. The benefits of non-inflatable implants
include their simplicity of use, although there may be an issue in elderly patients with conditions such as arthritis. Compared with inflatable implants they allow greater spontaneity during sex, and are more straightforward and less expensive to implant. one of their disadvantages is that they take longer to get used to on account of the permanently erect state of the penis; this may cause embarrassment in men’s changing rooms, or when the patient is wearing tight clothing or swimming attire, for example. The best known implants of this type
are American Medical Systems’ Spectra Concealable Penile Prosthesis and Coloplast’s Genesis implant.
implants can offer a more or less
permanent solution to the problem of erectile dysfunction, and one that does not interfere, or interferes only minimally, with intercourse.
inflatable penile implants are of two
types, two-piece and three-piece. The two-piece implant comprises two hollow cylinders that are implanted into the corpora cavernosa, connected to a small pump that is inserted into the scrotum. The entire system is filled with sterile saline solution. The three-piece implant has, in addition to these components, a small reservoir of fluid that is placed inside the lower abdomen. When a patient with a two-piece
implant requires an erection, he gently squeezes the scrotum a number of times, which forces the fluid from the pump into the cylinders. To release the erection, the penis is held downwards for a few seconds, which allows the fluid to drain back into the pump. The three-piece implants are slightly more sophisticated in that squeezing the pump transfers fluid from the reservoir into the cylinders, and the erection is released by operating a valve that allows the fluid to flow back into the reservoir.
Practically, there are few differences
between the two types of implant. Both are claimed to give a more natural-looking erection than other methods, and both are simple to use, and thus do not interfere with the spontaneity of the sexual act. While three-piece systems are more complicated to implant and tend to be more expensive, they are said to create the most realistic-looking erection. American Medical Systems’ main
offerings in this segment are the Ambicor 2-Piece inflatable Penile implant and the AMS 700 Series 3-Piece inflatable Penile implant, while the Coloplast Titan is the Danish company’s offering in this area.
Conclusions Despite the general success of these types of treatment for ED, new ways of treating the condition continue to be explored. For example, israeli scientists have developed a device that consists of one or more electrodes applied to a blood vessel that carries blood into or out of the penis, and an associated control unit. The system facilitates erections by peristaltically pumping blood in the blood vessel, by stimulating nitric oxide production in the vicinity. And a recent patent application by Medtronic described a method for treating ED caused at least in part by atherosclerosis in a pelvic artery by inserting a stent to restore blood flow and administering an appropriate drug, such as a PDE5 inhibitor. Whether approaches such as these will
ultimately have a significant impact on the size of the ED treatment market is yet to be seen. What is clear, however, is that the number of treatment options available is growing, which can only be good news for patients.
References
1. Cherry DK, Burt CW, Woodwell DA. National Ambulatory Medical Care Survey: 1999 Summary. Adv Data. 2001; 322: 1–36
2. Diabetes and Erectile Dysfunction. The Global Diabetes Community. Coventry, UK: 2011. http://
tinyurl.com/6gkjadq (accessed 3 June 2011)
3. Khan AS, Sheikh Z, Khan S, Dwivedi R, Benjamin E. Viagra deafness—Sensorineural hearing loss and phosphodiesterase-5 inhibitors. Laryngoscope. 2011; 121(5): 1049–54
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