Penile Prosthesis Insertion is a surgical procedure designed to create the ability for an erection in individuals who have undergone phalloplasty or metoidioplasty as part of their gender transition. This procedure is also applicable to cisgender men with erectile dysfunction who have not found relief from other treatments. The goal of penile prosthesis insertion is to enable penetrative sexual activity and enhance sexual satisfaction by providing a functional erection.

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Purpose and Importance

For transgender men who have undergone phalloplasty or metoidioplasty, the insertion of a penile prosthesis addresses the lack of natural erectile capability in the neophallus (newly constructed penis). While phalloplasty creates a penis with a more natural appearance, it does not inherently provide the ability to become erect. A penile prosthesis offers a solution by allowing for controlled and functional erections, which is important for many individuals seeking to fully align their physical characteristics with their gender identity.

Penile prostheses can also be a valuable option for cisgender men with erectile dysfunction (ED) who have not responded to medication, vacuum devices, or other less invasive treatments. This procedure offers a permanent solution to ED, improving quality of life and sexual function.

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Types of Penile Prostheses

There are two main types of penile prostheses used, each with its advantages and considerations:

1. Inflatable Prosthesis:

   • Description: This prosthesis consists of two cylinders implanted in the neophallus, a pump placed in the scrotum (or abdomen in some cases), and a fluid reservoir located in the lower abdomen.

   • Function: To achieve an erection, the individual pumps fluid from the reservoir into the cylinders, causing them to expand and produce an erection. The erection can be controlled by the pump, and the prosthesis can be deflated by releasing the fluid back into the reservoir.

   • Advantages: Provides a more natural feel and appearance, both flaccid and erect. Offers control over the firmness of the erection.

   • Considerations: More complex surgery with a risk of mechanical failure, which might require revision surgery.

2. Semi-Rigid (Malleable) Prosthesis:

   • Description: This prosthesis includes two flexible rods inserted into the neophallus. The rods allow the individual to manually adjust the position of the penis.

   • Function: The penis can be bent upward for intercourse and downward when not in use. This type does not become erect on its own but is always in a semi-rigid state.

   • Advantages: Simpler design with fewer components, less risk of mechanical failure.

   • Considerations: May not provide as natural an appearance or feel as the inflatable prosthesis. The penis remains semi-rigid, which can be less discreet and may impact comfort.

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Procedure

Penile prosthesis insertion is typically performed as a secondary procedure after initial phalloplasty or metoidioplasty. The surgery is usually done under general anesthesia and takes about 1–2 hours. Key steps include:

• Incision and Placement: The surgeon makes incisions in the neophallus and, if applicable, the scrotum or lower abdomen. The prosthetic components (cylinders, pump, and reservoir) are carefully inserted and positioned.

• Testing: The prosthesis is tested to ensure proper function before closing the incisions. This step is crucial to confirm that the device operates correctly and is positioned appropriately.

• Closure: The incisions are closed with sutures, and the area is dressed with sterile bandages.

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Recovery

Recovery from penile prosthesis insertion involves several aspects:

• Hospital Stay: Most individuals can go home the same day or after an overnight stay, depending on their overall health and the complexity of the procedure.

• Pain and Discomfort: Pain and swelling are common after surgery, but they are usually manageable with prescribed medications. A catheter may be placed temporarily to assist with urination.

• Activity Restrictions: Individuals should avoid strenuous activities, heavy lifting, and sexual activity for several weeks to ensure proper healing. Full recovery typically takes 6–8 weeks, though recovery time may vary based on individual circumstances and the type of prosthesis.

• Follow-Up Care: Regular follow-up appointments with the surgeon are essential to monitor healing and address any potential issues or complications with the prosthesis.

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Risks and Complications

Like any surgical procedure, penile prosthesis insertion carries risks and potential complications:

• Infection: There is a risk of infection at the incision sites or within the prosthesis. Infections are typically treatable with antibiotics.

• Mechanical Failure: Inflatable prostheses may experience mechanical issues, such as pump malfunction or cylinder leakage, which may require revision surgery.

• Erosion or Displacement: In rare cases, the prosthesis may erode through the skin or become dislodged, requiring additional surgery.

• Sexual Function: While the prosthesis allows for erections, it may not fully replicate the natural sensation and spontaneity of erections. Sensitivity may be reduced, and adjustments might be needed for optimal function.

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Mental Health and Emotional Impact

The insertion of a penile prosthesis can have a significant positive impact on the mental and emotional well-being of transgender men. Achieving functional erections and the ability to engage in penetrative sex can improve sexual satisfaction and self-confidence. It can also reduce dysphoria associated with having a non-functional neophallus.

However, some individuals may experience emotional challenges if the prosthesis does not meet their expectations or if there are complications. Support from mental health professionals, counseling, and support groups can be helpful in navigating these feelings and adjusting to the changes.

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Conclusion

Penile prosthesis insertion is a transformative procedure for transgender men who have undergone phalloplasty or metoidioplasty, as well as for cisgender men with erectile dysfunction. The procedure provides the ability to achieve erections and engage in penetrative sex, enhancing sexual function and satisfaction. While it involves some risks and requires careful consideration, it offers significant benefits for many individuals seeking to align their physical characteristics with their gender identity or manage erectile dysfunction.