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International Journal of Impotence Research (2004) 16, 175–180
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Satisfaction with the malleable penile prosthesis among couples
from the Middle East: is it different from that reported elsewhere?
N Salama1*
1
Department of Urology, Alexandria Faculty of Medicine, Alexandria, Egypt
No studies from the Middle East have investigated the psychosexual aspects of penile prosthesis.
Therefore, several questions were used herein to address satisfaction with the use of malleable
penile prosthesis among couples from this geographic area, as an option to treat erectile dysfunction
(ED). A total of 50 patients who underwent the insertion of AMS 650 and Acu-form penile
prostheses and their partners were evaluated with a retrospective clinical record review, as well as
patient and partner questionnaires. In all, 70% of the patients and 57% of the partners were
satisfied with the prosthesis. There was an increase in frequency of intercourse, sexual desire, and
ability to achieve orgasm. Dislike for the device was the most common cause for nonsatisfaction of
patients with the device, while sense of unnaturalness was that for partners. Results from this
evaluation highlight the obvious need for proper preoperative counseling for both the patient and
his partner to minimize unrealistic expectations. They also emphasize the importance of careful
screening of both psychosocial and psychosexual aspects of the couple based on cultural ethnic
background, since these are important predictors of the therapeutic outcome of prosthesis insertion.
Efforts to extend information about ED to the public may be useful to reduce patients’ exaggerated
embarrassment about this problem and make their partners actively involved in the treatment.
International Journal of Impotence Research (2004) 16, 175–180. doi:10.1038/sj.ijir.3901150
Published online 12 February 2004
Keywords: impotence; partner; satisfaction; prosthesis tradition
Introduction
Insertion of penile prosthesis for treatment of
irreversible erectile dysfunction (ED) is a common,
well-established treatment in western countries.1
Even in the era of the newly available oral medications, penile prostheses continue to have such a
nonoptional place. These prostheses are either
semirigid or hydraulic types. Implantation of the
semirigid prostheses, whether malleable or mechanical, types is technically uncomplicated, and due to
their simple construction and use, mechanical
problems associated with them are rare. They are
also reliable and inexpensive.2
Despite the widespread use of penile prostheses,
our knowledge of the psychological and interpersonal impacts of these implants remains limited. Most
*Correspondence: N Salama, Department of Urology,
Faculty of Medicine, University of Alexandria, Alexandria, Egypt.
E-mail: [email protected]
Received 24 January 2003; revised 24 July 2003; accepted
6 August 2003
large studies evaluating these issues have taken
place in western countries.3 No long-term study
from the Middle East regarding patient use and
satisfaction with penile prostheses has been reported. Immigrants from the Middle East are living
in all western countries, and many Middle Eastern
patients seek treatment for their ED in these
countries. Therefore, it would be of interest to
investigate satisfaction with malleable penile prostheses among couples from the Middle East for
optional treatment of ED.
Material and methods
The current study included 50 patients, 23–64 y old
(mean age 42 y), who underwent malleable penile
prosthesis insertion, and their partners, 14–62 y old
(mean age 31 y). The surgery was performed between
June 1991 and July 2002 at the Departments of
Urology, Alexandria Faculty of Medicine, Alexandria, Egypt and Al-Mouwasat Hospital, Madina,
Saudi Arabia. Most (28) patients were Egyptian,
while the remaining were Saudi (11), Algerian (1),
Libian (2), Sudanese (3), Syrian (1), and Yemeni (4).
Satisfaction with malleable penile prosthesis
N Salama
176
In all, 29 (58%) patients received the AMS 650
penile prosthesis (AMS, Inc., Minnetonka, MN,
USA), while the Acu-form (Mentor, Goleta, CA,
USA) was inserted in the remaining 21 (42%)
patients. Both types of devices were inserted via
the penoscrotal approach. Institutional review board
approval was obtained, and all participants gave
informed consent.
A retrospective review of clinical records of the
study patients was performed. Data were collected
on patient history, physical examination, hormonal
studies, vascular testing, and psychological evaluation. Any nocturnal penile tumescence testing,
which was performed for a subset of patients,4 was
recorded. Each related medical illness and operation
was also considered, in an attempt to identify the
possible conditions associated with ED. The device’s complications and the method of treatment
used to correct the resulting problem were also
documented.
After the chart reviews, patients were contacted
by phone and asked to return with their partners to
the clinic, so that the prosthesis could be checked
and possible problems addressed. During the clinic
visit, examination of the prosthesis was performed,
and the idea of the current study was discussed with
the couple. A special emphasis was placed on the
usefulness of their assessment of and opinion about
penile prosthesis, and how this would be considered with the new couples in the future. Confidentiality of answers was confirmed. An extraordinary
assurance was given to the partner that her answers
would not be revealed to her husband. The patient
and his partner were then seated in separate private
areas, and received distinct questionnaires concerning satisfaction with sexual life after penile prosthesis implantation. A female nurse, who was not
involved with the present study, occasionally
accompanied the partner to help her complete the
questionnaires. Participants were advised to give
answers only for questions that they completely
understood. Clarification of some unanswered questions was occasionally needed. If the partner did not
accompany the patient to the clinic, a female nurse
completed the questionnaires with her via telephone. Evaluation of satisfaction following prosthesis implantation was performed using a scale of 1
(very dissatisfied), 2 (dissatisfied), 3 (neutral), 4
(satisfied), or 5 (very satisfied).5
The patient questionnaire assessed the possible
physical, sexual, and emotional effects of prosthesis
implantation including penile pain, penile size,
sensation, rigidity, function, concealment, desire
changes, satisfaction after revision and its duration,
frequency of intercourse after implantation, and
orgasm and ejaculation changes. The patient was
also asked to compare the prosthesis with previous
treatment modalities such as the vacuum constriction devices, intracorporal injection therapy, or
others, and to state whether they would be willing
International Journal of Impotence Research
to undergo the procedure again and recommend it to
friends.
Additionally, the patient was asked if he had
received thorough preimplantation counseling, including the concepts that the penile prosthesis does
not create normal erection but only supports the
penis for sexual activity, may decrease penile
sensation and length, and would not improve an
already diminished libido,1,3 as well as whether he
was made aware of the possible postoperative
complications.
The partner questionnaire evaluated the nonsexual relationship before and after prosthesis insertion, penile size following insertion, comparison of
the relative efficacy of penile implants with other
treatment options, any circumcision or gynecological problems, and whether she attended a preoperative counseling meeting with her husband.
Statistics
The raised data were analyzed using SPSS statistical
software. Statistical analysis was performed using w2
and Z-tests. A P-value o0.05 was considered
significant.
Results
A total of 30 (60%) patients returned to the clinic
and completed the questionnaires after the initial
phone call, while the remaining 20 (40%) patients
did so after a second call. Follow-up ranged from 8
months to 10.5 years (mean 7 years). Partners of
seven patients did not accompany their husbands,
where three of these were divorced 0.5–1 years
prior, three were out of town, and one was deceased.
In total, 38 partners completed their questionnaires
in the clinic, and 15 did so via phone. Five partners
refused to complete the evaluation. The total
number of evaluated patient–partner relationships
was 38, including 29 monogamous and nine polygamous. These latter included three with two wives
each and six with three wives each. Therefore, the
total number of evaluated partners was 53, resulting
in a total response rate of 81%.
The majority (96%) of the study patients had an
organic cause of their ED, while in only 4% the ED
was believed to have a psychological basis. The
most common etiology in the study patients was
diabetes mellitus (Table 1). The duration of ED
before surgery was 3–12 years (mean 8 years).
Patients received several types of treatment before
they underwent implant insertion. Traditional treatment entailing herbs, certain foods, penile metal
rings, and spiritual-religious handling was tried by
all (100%) patients before prosthesis implantation,
while sex therapy was attempted by the fewest
number of patients (Table 2).
Satisfaction with malleable penile prosthesis
N Salama
Table 1 Primary etiology of ED
Table 3 Complaints from 15 (30%) patients and 23 (43%)
partners nonsatisfied with the prosthesis
Primary etiology
177
No. of Pts (%)
Diabetes mellitus
Hypertension
Coronary artery disease
Pelvic trauma
Pelvic surgery
Psychiatric illness
18
12
7
6
5
2
(36)
(24)
(14)
(12)
(10)
(4)
Pts: patients
Patient’s complaint
Hating the prosthesis
Pain
Delayed ejaculation
Decreased sensation
or numbness
Decreased orgasm
Appearance of deviation
No of
Pts
5
4
2
2
Partner’s
complaint
Unnaturalness
Dysparunia
Cold glans
Insufficient
penile girth
No of
Prs
11
8
3
1
1
1
Table 2 Previous treatment of ED
Treatment
No. of Pts (%)
Traditional treatment
Yohimbine
Hormonal therapy
Injection therapy
Penile implant
Vacuum device
Venous ligation
Sex therapy
Patient % (total n=50)
a
50
30
10
5
3
2
2
1
(100)
(60)
(20)
(10)
(6)
(4)
(4)
(2)
60
50
40
Very Satisfied
30
Satisfied
Dissatisfied
20
Very Dissatisfied
10
0
n=26
n=9
n=10
n=5
Partner % (total n=53)
b
40
40
Very Satisfied
Satisfied
20
Dissatisfied
10
Very Dissatisfied
0
n=20
n=10
n=10
n=13
Figure 1 Patient (a) and partner (b) satisfaction with the
prostheses.
In all, 35 (70%) patients, 20 with AMS 650 and 15
with Acu-form prosthesis, claimed to be satisfied or
very satisfied with the prosthesis (Figure 1a). The
levels of satisfaction were 69 and 71% for AMS 650
and Acu-form prosthesis, respectively, with no
statistically significant differences (P ¼ 0.85) between both kinds. However, these levels were
significant (Po0.01 for AMS 650, while Po0.02
for Acu-form) for each kind when comparing
between the satisfied and nonsatisfied patients
using it. Satisfied couples claimed that these
prostheses performed well in a sexual setting with
both patients and partners reporting an adequate
rigidity for intercourse, which was performed
regularly with a mean frequency of 13 times per
month. There was increased sexual desire and
improved ability to achieve orgasm noted by 31
(89%) of these satisfied patients and 23 (77%) of
satisfied partners. Most (80%) of these satisfied
couples also reported that the operation had improved the quality of their relationship and that they
would recommend it to friends.
The 15 (30%) patients who were dissatisfied or
very dissatisfied (Figure 1a) gave various reasons
(Table 3). Four patients with the complaint of penile
pain had previous complications with the implant
due to infection, which resulted in subsequent
revision. The average frequency of intercourse in
this nonsatisfied group was three times a month.
These patients reported diminished orgasmic feelings and also claimed that they would not recommend the prosthesis to friends. Conjugal
relationships were reportedly unchanged, and partners of these patients also reported nonsatisfaction.
A total of 30 partners had husbands with AMS 650
prosthesis, and 23 had husbands with the Acu-form.
Altogether, 17 of the AMS 650 partners and 13 of the
Acu-form partners recorded being very satisfied or
satisfied with their husbands’ prostheses, resulting
in the same satisfaction level of 57% in each group
(P ¼ 99). There was no significant difference between the number of satisfied and nonsatisfied
partners in either group (P ¼ 0.10 for AMS 650 and
P ¼ 0.68 for Acu-form). In all, 23 (43%) partners
reported being nonsatisfied (Figure 1b) for a variety
of reasons, as shown in Table 3. Nonsatisfaction due
to dysparunia was reported by eight partners with a
history of circumcision, of whom four had Sudanese
type. These eight circumcised females were partners
in six of the nine polygamies included in this study.
Husbands of 15 nonsatisfied partners also claimed
to be nonsatisfied.
There were 24 partners in the nine polygamies
included in this present study, representing about
International Journal of Impotence Research
Satisfaction with malleable penile prosthesis
N Salama
178
Table 4 Partner and patient satisfaction in nine polygamies
Partner satisfaction
3-Wives polygamy
Very satisfied, satisfied,
satisfied
Very satisfied, very satisfied,
dissatisfied
Very satisfied, very satisfied,
dissatisfied
Satisfied, dissatisfied, very dissatisfied
Very dissatisfied, very dissatisfied,
very dissatisfied
Very satisfied, very satisfied, satisfied
2-Wives polygamy
Very dissatisfied, very dissatisfied
Satisfied, satisfied
Very dissatisfied, very dissatisfied
Patient satisfaction
Very satisfied
Very satisfied
Satisfied
Satisfied
Very dissatisfied
Very satisfied
Very dissatisfied
Satisfied
Very dissatisfied
45% of all the evaluated females. In total, 13 of these
partners reported being satisfied or very satisfied,
with a total satisfaction rate in this group of 54%
(Table 4). There were different responses to the
prosthesis between partners in five of the nine
polygamies (Table 4). Three of the nine polygamous
patients with nonsatisfied partners also claimed
nonsatisfied.
Although all patients received a preoperative
counseling, 13 (25%) denied completely that they
were informed preoperatively about the cold glans
and possibility of diminished penile length and
sensation after implantation. All partners except
three (94%) indicated that they did not meet with or
receive any counseling from the implanting surgeon.
In addition, 34 (64%) partners claimed that they did
not even know that their husbands underwent
penile prosthesis implantation until after the procedure. Eight of these 34 partners were not aware of
the prosthesis, but reportedly felt that the penis got
abnormal during intercourse.
Discussion
The principal objective of this study was to evaluate
the long-term satisfaction of Middle Eastern patients
and female partners with the malleable penile
prosthesis. To the best of our knowledge, no such
investigation has been reported. This study also
touched on the topic of female sexuality, which
remains taboo so far in this geographic area. The
study, therefore, aimed at stimulating further research into this topic.
The study design included a retrospective chart
analysis and concurrent questionnaire completion
during direct or telephone structured interviews.
The questionnaires have been used previously by
several investigators for the evaluation of penile
International Journal of Impotence Research
prostheses.6,7 However, these studies were criticized
for the absence of partner participation, the shortterm follow up, and the high drop-out rate—pitfalls
which were obviated in the current study.
All study patients initially tried one or more
treatments for their ED, such as herbs, certain kinds
of food, penile metal rings, or spiritual and religious
sessions. These types of alternative medicine have
been reported as remedies for ED.8–12 In their move
toward more modern medicine, most patients
initially tried yohimbine, which is a simpler treatment than intracorporal therapy. When this did not
yield satisfactory results, they decided on prosthetic
surgery. This parallels the findings of Jarrow et al,13
who noted that ultimate satisfaction with therapy
for ED was the highest for surgery vs all other
alternatives. Patients did not try the modern oral
medications (viagra), which were not legally
launched in the respective countries until after the
patients had undergone surgery.
The satisfaction levels reported in the present
study were 70% for patients vs 57% for partners,
with no significant differences between the two
kinds of prostheses used. This included couples
who reported being satisfied or very satisfied, and
who indicated an increase in the frequency of
intercourse, sexual desire, and ability to achieve
orgasm. These levels are lower than those reported
in previous studies,14,15 which were 85% for patient
and 70% for partner satisfaction with semirigid
prostheses. Our lower rates may be related to the
four patients of prosthesis revision. These patients
became anxious about the possible recurrence of
postimplantation complications due to overindulgence in the intercourse. This anxiety spreads to the
partners, who also reported nonsatisfaction and
worry about new or ongoing problems with the
implants. Therefore, the relationship between reduced complications with the prosthesis and increased sexual activity was quite clear. This agrees
with the findings of other investigators who showed
similar correlation.5,16 However, the main complaint
of the nonsatisfied patients in the present study was
dislike for the implanted prosthesis in spite of its
good functioning to the point of strong desire to
remove it. This may have resulted, in part, from
hesitancy of the partner to engage in sexual contact,
since many partners reported a feeling of unnatural
intercourse, as it was going on with a cold piece of
plastic material. The partners also reported feeling
that the penis was always erect, thus minimizing
foreplay which participates in fulfilling her satisfaction.17 This feeling of unnatural intercourse was also
reinforced by delayed ejaculation, which is a
possible side effect of prosthesis insertion18 and
was noted by some of the study patients. In the
present study, patient dissatisfaction seemed to
spread to the partner, who then also reported
dissatisfaction. This finding is in agreement with
other similar studies.5–7,14–16
Satisfaction with malleable penile prosthesis
N Salama
An interesting finding in this study was that one
partner, in a polygamy, showed better response to
the implant than other partners of the same patient.
This occurred in five of the nine polygamies
included. This may be attributed to the Sudanese
circumcision, which represents the severest form of
female circumcision, and which was performed on
four partners in these polygamies. This circumcision delays or prevents arousal and subsequent
orgasm to the degree that some women are not even
aware what orgasm is.19 In addition to the remarkable genital anatomical mutilation which may
prevent any comfortable intercourse, circumcised
women may accept the fact that their only sexual
pleasure is received indirectly by giving pleasure to
the husband.20 This circumcision-induced dysparunia may be an important factor underlying the
discrepancy between patient and partner satisfaction in this study, with sexual partners reporting
13% less satisfaction than patients. Both psychosexual and psychosocial factors based on cultural
ethnic background of the couple, therefore, should
be included during preoperative evaluation of the
treated couples, as they were indicated to be
important predictors of the therapeutic outcome of
prosthesis insertion21—a point which was, unfortunately, missed in the present study.
The higher rate of partner nonsatisfaction may be
also related to the fact that, for some partners, the
operation did not completely fulfill preoperative
expectations. These unrealistic expectations most
likely reflect the absence of preoperative counseling
or, in the best situations, incomplete counseling for
the female partner. Low partner satisfaction rates
may also be attributed to the separate interview
process, which prevented the patient from responding for the partner. This might also have allowed the
partner to express her opinion about the prosthesis
more freely and openly. This is in accord with other
investigators who documented lower levels of
partner satisfaction when she was interviewed
separately than if she was interviewed with the
husband,22 and also agrees with other reports which
demonstrated the difference between patient and
partner satisfactions.23,24 However, in these prior
reports, partner nonsatisfaction was attributed
mainly to the absence of participation by a significant number of partners—a problem that we did
not have in the current study, with a partner
response rate of 81%.
In conclusion, the present results emphasize the
need for proper preoperative counseling for both the
patient and his partner, to avoid unrealistic expectations of penile prosthesis. This should be combined
with careful evaluation of both psychosocial and
psychosexual interactions of the couple based on
cultural ethnic background, since couple selection
may be viewed as the key factor for long-term
success of prosthetic implantation. The results also
highlight the importance of careful surgical techni-
que to reduce surgical complications and hence
patient nonsatisfaction. Efforts to extend information about ED to the public through a well-organized
sex education program may reduce a patient’s
exaggerated embarrassment about his difficulty,
and encourage him to involve his partner in the
problem and its treatment.
179
Acknowledgements
Professor Susumu Kagawa, Head of Urology Department, University of Tokushima, Tokushima, Japan,
is gratefully acknowledged for his continuous support during this study. Stacy Kopka and Usama
Khater, Cleveland Clinic Florida, Weston, FL, are
greatly appreciated for the English edition of this
manuscript. Some of the results of this study were
presented at the 15th World Congress of Sexology,
Paris, France, June 24–28, 2001.
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