In Your Pants with Dr. Susie G - Penis implant surgery for erectile dysfunction

Starting point is 00:00:00 you're listening to the in your pants podcast i'm your host dr suzy gronski your penis friendly pelvic health physical therapist sex counselor and educator helping you get in the know down below Hi friends, Dr. Susie G here, and welcome to another In Your Pants podcast. On today's show, we're talking penis implants. Yep, penis implants. What exactly is a penis implant? What does the procedure entail? What kind of penis implants are there as an option? what are some of the pros and cons of getting a penis implant who would be the best candidate for a penis implant and what are some of the complications that might arise getting a penis implant we also dive into the topic of can you use a sex toy for penis implants is it easy to

Starting point is 00:01:17 damage of penile implant. We go into that and a lot more with our expert guest, Dr. Jonathan Clavell. Dr. Jonathan Clavell is a board-certified urologist and men's sexual health specialist in Houston, Texas. His practice focuses on the treatment of erectile dysfunction, low testosterone, BPH, and Peyronie's disease. He is one of the highest volume of surgeons in implant surgery and currently trains doctors both nationally and internationally when it comes to this type of surgery. I learned so much from Dr. Clavel about penis implants and even challenged some of my misconceptions and beliefs around penis implants. So I know that you will get so much from this episode and more. So without further ado, I welcome Dr. Jonathan Clavel.

Starting point is 00:02:23 Dr. Clavel, thank you so much for being on the show today. Well, thank you, Susie, for the invitation. I'm honored. I'm honored to be a part of your podcast. Thank you. Thank you. And we're talking about a very interesting, a special niche really of penile implants. Can you talk to us about what a penile implant is and what that whole procedure entails? Yeah. And then just like we were just talking a few minutes ago off air, this is a topic that I'm extremely passionate about and every listener will probably sense that from me. But anyways, yeah, let's go deep into it. So, I mean, to your first question, yeah, I mean, what is a penile implant? It's simply a device that is placed

Starting point is 00:03:05 inside a man's penis to help him achieve a strong erection for penetrative intercourse it's there's different types though i mean there's a malleable implant and there's also an inflatable implant the malleable implant involves just two rods that a man can just like mold they go straight into the penis and the man can kind of like mold um to make it straight whenever he wants to have sex and then he can just kind of like put it towards his side whenever he's wearing pants um it's the most common implant that's used worldwide um just because it tends to be it's just because of cost it's a little bit cheaper than the inflatable one uh however the inflatable pnl implant is the most commonly used here in the united states it's the one that we call like the surgeons we call it the

Starting point is 00:03:53 cadillac uh why because this one allows the man to have the probably the most uh you know the strongest erection that he can possibly get um and also gives him the natural appearance while it's flaccid so again it allows a man to have the closest thing to a natural erection i mean just think about it in order for a man to have an erection um he needs to get blood you know he needs blood to get inside the penis and stay trapped inside um so when there's ed he's either not able to get blood inside the penis or the blood is not able to stay trapped inside so this implant goes inside and inside those faulty chambers that are not filling up with blood and instead of filling up with blood we're just filling it up with saline it's just saline water

Starting point is 00:04:42 that we're using instead of blood it contains three parts it has two cylinders that are inside the penile shaft and that's what gives the man the erection there's a pump that's inside the scrotum that the man can squeeze. And I usually joke, it's like those Reeboks that we used to wear in the 90s. So they just have to pump that up. And it usually takes them about 30 seconds to a minute to get an erection. Again, everything's inside concealed inside the body. So nobody will be able to tell that they have something there. And the last part of that inflatable implant is a reservoir. And we usually place that deep inside the man's pelvis or underneath the abdominal know muscles uh and that's what holds the fluid and it's basically hydraulic system that's

Starting point is 00:05:29 transferring fluid back and you know back and forth um and again everything is concealed inside the body therefore it is very likely that almost no one will be able to tell that a man has an implant oh that's fascinating where technology has has come to no pun intended there how far we have come for technology and to be able to, you know, do such wonderful surgical procedures to help improve the quality of life for people. And speaking of quality of life, I can't imagine that, you know, the surgery is, it seems very involved. And also who would, because it's so involved in, I can imagine you can't go back. Is there a possibility to go back once you have the implant and and yeah i think i'm getting at complications who would benefit when do you make

Starting point is 00:06:21 that decision to get a penile implant what's that conversation like in your world i mean it's very it's very simple um because again just first of all like just let's let's say like who's a canada for a penile implant you know canada for a penile implant somebody who has erectile dysfunction and has at least failed oral medications um so as opposed to what many people think or they used to think that the pnl implant is the last resort because yes there is no going back in a sense but we know that it's actually the best resort and according to the american urology association guidelines which state that basically once a man fails oral medications like you know the phosphodiesterase 5 inhibitors only known as viagra cialis tendra levitra all these medications

Starting point is 00:07:09 once the man fails those all options are open and that's the conversation that i usually have with my with my male patients like hey have you tried pills no well i'm gonna i'm not gonna offer them the penile implant first um but if they have already failed the the penile implant all other options like all doors are available for them and they choose whatever they think is best for them again the penile implant is not considered the last resort anymore because beyond the pill if we know for a fact that is actually the best resort and then when we say the best resource the one that yields the highest satisfaction for both men and their partners however when you say uh you know to your comments like oh well there's no going back and usually my conversation with

Starting point is 00:07:52 the guy is like okay if you're really considering the implant it's because you're not happy with your sexual life you're not happy with the way that you're able to maintain an erection i mean You might be happy with your sexual life because again, we all know there's multiple things that we can do for sex, right? So sex is not only penetration. But if a guy is not happy or satisfied with his ability to gain or maintain an erection, those are the guys who are considering a penile implant. So when we say there's no going back, think about it. I mean, let's be honest. What are you going back to? Failure, right? When you're considering a penile implant, it's because you feel like your erections are failing you know for you so usually my

Starting point is 00:08:34 conversation is like hey man you have everything you might have everything to gain and not much to lose uh whenever you're considering the penile implant that's very interesting i'd like to unpack that a little bit more because that and i hear what you're saying as far as yes like there's these advantages of you know you're struggling sexually with you know rectal dysfunction And you had mentioned that if the pills aren't working, then this would be a viable option. Now, where does other factors that might contribute to erectile dysfunction come into this conversation? So, for example, what about psychogenic ED or, you know, social cultural factors, you know, more of the biological, I'm hearing that, but also the psychosocial factors that contribute to someone's erectile difficulties and things. Like, where does that come in into the conversation if it does at all? No, it definitely comes in at all. I mean, if I have a guy who's 25 years old and he's coming in, it's like, I want a penile

Starting point is 00:09:35 implant. I mean, I'm not going to tell them straight up the bias. I go, yeah, let's do it. I mean, we need to have a conversation with a guy because we know that usually for younger men and also for older men, it can happen. Psychogenic ED is a real thing. Like, right. Like stress.

Starting point is 00:09:49 I mean, you need to be completely relaxed for your pelvis to relax and blood flow to get to your penis. If you're stressed out, if you're thinking about something else, if you're thinking about your penis and not your partner, you might be psyched out, right? Like, you know, a very good friend of both of ours, you know, Dr. Rachel Rubin, I mean, she usually says like, hey, you can have, you can be in a five-star hotel with, you know, with your ideal partner, your sexual fantasy. And if you have a tiger in the room, all you're going to be thinking about is that tiger is going to eat me, right? You're not going to be thinking about being relaxed and having sex. So, and that usually, again, that's what psychogenic AD usually entails. With a man who has psychogenic AD, I would be very, very cautious of offering a penile

Starting point is 00:10:38 implant because, again, that's a guy who might benefit from other specialists like, you know, psychotherapy. Hey, let's see, you know, let's try to debunk all the myths that you might have about sex, about an erection. uh we have to dig into their religious beliefs or their cultural beliefs just to make sure that we're doing what's right for them uh that being said i remember i once had one patient right like he was married and he was having problems with you know with erectile dysfunction and uh he had tried two you know clinical sexologists who he they were trying to help

Starting point is 00:11:13 him out he went to physical therapy they were trying to help him out and he was still not able to keep an erection. He's like, doc, this might be in my head, but I cannot keep sex in my marriage at this point. And my wife is about to leave me. And if I have a guy who's in that type of situation, I'll be like, who am I? I mean, he already knows all the options. He knows all the risks. And my train of thought was like, who am I to hold back something that might be the solution for this guy again this was an exception this is not the norm um but the guy again we put we place a penile implant and the guy's like doc you helped me restore my marriage and and the guy's super happy with it and he's not and he's barely 30 years old so again this is something that has

Starting point is 00:12:00 you know the penile implant yes it is not the first resort for any type of of erectile dysfunction be it psychogenic hormonal neurological it could be uh you know vasculogenic again even for those who have vascular diseases or vascular genetic reason to have erectile dysfunction, that is not the first resort, but it is, it should not be the last resort either. They don't have to go through vacuum erection device therapy. They do not have to try injection therapy if they really do not want to. They don't have to do, you know, shockwave therapy, all these other treatment options. Like once pills fail for vascular genetic erectile dysfunction, the PLM plan is, it could be an option okay so do you as far as that conversation goes are i'm assuming that those options are put

Starting point is 00:12:47 on the table or at least given to the individual so that they can make the best decision that is for them we ask surgeons again as you know urological surgeons and and sexual health specialists like i will never push a patient to get a penile implant unless it's a guy who's already tried everything and i'm like dude i mean you just have to make the choice and i'm not here to push you to make a choice today but you're at that point i mean if you if you have a guy who has again vasculogenic erectile dysfunction uh he might have already a penile doppler duplex ultrasound that reveals that he has a problem either gaining you know getting blood flow inside the penis or keeping the blood trapped inside and he's already tried injection therapy and the

Starting point is 00:13:36 injection therapy is not able to give him a good enough erection for penetrative intercourse that's a guy who i tell them like hey man you have nothing to lose worst case scenario you're just going to be just where you are right now but if you have a guy who's tried the pills and he hasn't tried anything else i most definitely tell them like hey these are all the options that have been approved uh are recommended by our societies um you know the american urology association or and also the sexual uh medicine society of north america uh so all these societies what they do is i tell them hey you have five options you have pills you have the vacuum erection device you have injection you have intraurethral suppositories and you have the penile implant

Starting point is 00:14:16 shockwave therapy uh the p-shot uh people are injecting botox for this for these things now And again, right now, those are still considered experimental. If you have the money, you can do it. I mean, I don't recommend it unless we have better research studies proving these treatments. But again, all those options are available for you. You decide what's best for you. Okay. So is there a person who maybe a penile implant would never be an option?

Starting point is 00:14:49 like for who would who would those people be where that isn't an option or if that's even a thing i'll i'll answer that i'll this is usually why i tell my patients as long as you have a penis that's attached to your body we can do we can we can place an implant um again a pl implant is a viable solution for any you know male who wants to have an erection a strong erection it can work okay okay unless your penis is damaged and you don't have an implant penis but as long as you have a penis that's attached to your body we should be able and i say that because i once had a guy who he had like multiple surgeries in his urethra that throughout his lifetime and when we went to examine him the i mean he had the penis but it was just skin like everything was

Starting point is 00:15:38 kind of like separated away from his body i'm like well i cannot place the tissue was fragile all it sounds like yeah i mean this is like an anomaly so that ever that's why it's like as long as you have a penis that's attached to your body you are a candidate for the penile implant okay okay and so i'm assuming that for those who might have difficulty with healing like some you know immune issues or as you're saying the tissue fragility or just not being able to take be able to for the body to take on the implant i i would assume that that is a conversation that yeah i I mean, but those are very rare situations. And I've had guys who are, for example, on immunosuppressive therapy, that they're on

Starting point is 00:16:17 chemotherapy, for example, or they might be like a methotrexate or some steroids. And yes, I mean, they might have delayed wound healing. But again, it is in the hands of an experienced surgeon. Most of the time, we're able to do it. Right now, I have a guy who's healing from his surgery. I mean, he's probably about four or five weeks out. And I was the third surgeon he talked to. And the other two surgeons that were like, oh, we cannot do it because you're on these, you know, steroid medications.

Starting point is 00:16:44 He has rheumatoid arthritis and he's on both methotrexate and also prednisone. And many surgeons were like, oh, we cannot do this. The same thing happens with guys who, for example, who are transplant patients. There aren't all these immunosuppression medications just to make sure that they do not reject their organs, you know, their transplant organ. And we can still, you know, place an implant. And they have done very well. And even with a three-piece inflatable penile prosthesis, I mean, it is something that we can do. So again, Matt, it all depends on the experience of your surgeon, but these things tend not to be a contraindication for this procedure.

Starting point is 00:17:23 Okay, awesome. Well, thank you for clarifying that because those are some big questions going up in my mind. So is there, in your opinion, is there any potential disadvantage of a penile implant? yeah let's yeah there's only one true disadvantage and we already you know dabbled into this and again it's that there is no going back uh if for some reason you don't like the implant we can take it out uh but pills or injections will not work you know once the implant is removed so again there is no going back and again some listeners might get scared of that but let's be honest to ourselves i mean if you are considered a pnl implant it is because you're not happy with your erections. Your erections are failing you. You want to have sex, but you're not able to either

Starting point is 00:18:09 gain or maintain an erection. And you have probably tried another treatment, if not all treatments already. So when we think there's no going back, we need to ask ourselves, what are we going back to? Is it failure? Then maybe, again, maybe with the penile implant, we have everything to gain and nothing to lose. I mean, there's another minor disadvantage. That's the one true disadvantage, right? There's no going back. Another minor disadvantage is that the implant, it does not engorge the head of the penis. So if a man has problems getting the glands engorged, the implant will not fix that. And that can sometimes be fixed with pills or a gel. But for example, whenever I see a man who, you know, who is considering a penile implant,

Starting point is 00:18:55 I tell them whenever us men, whenever we have sex, like our sexual experience in our penis is the following. We have five things. The penis gets hard, right? The head of the penis gets engorged with blood, you know, gets sensitive. You have sensation, right? We enjoy while we're having sex. You have the orgasm, which we know it happens in our brain, doesn't happen in our penis. And we have the ejaculation, which is the fluid that's coming out, right?

Starting point is 00:19:23 So all, and I tell them all those mechanisms are different. We're only fixing one, only getting your penis hard. We're not getting blood flowing into the head of your penis. We're not affecting your sensation. Cause again, we're nowhere near the nerves that give sensation. We're not going to affect your orgasm. We're not going to affect your ejaculation. So if you have a young man who has, or somebody who has a young partner and I'm like, Hey,

Starting point is 00:19:46 we're interested in, in having kids in the future, the implant will not prevent you from having kids in the future. okay this is an implant not a transplant it is still your penis it is still your body we're just facilitating your penis to get hard that's it it will still your penis will not feel dead your penis because i have guys like hey doc what will happen with my libidos like some you know if my partner touches me will i still feel like things want to start it's like yeah i mean you might still feel warmness in your penis you might still feel that the head of the penis gets engorged, but the only way you will be able to get it hard once you have an implant is with you.

Starting point is 00:20:27 I mean, if you have an inflatable implant is with you pumping it up. Okay. If you're not pumping it up, it will not be hard enough for penetrative intercourse. But again, all the, all those other things, all those other four things, it's still on the man's body. Okay. No, that's interesting. So if you have a guy who has severe cardiovascular disease, for example, he had, uh you know heart like severe heart coronary severe coronary artery disease or he has some you know severe vascular issues and he's not able to engorge the head of the penis uh he's you know that that might be a disadvantage for them so so there are some men for example that tell me doc when i'm having sex i enjoy it i'm able to orgasm but i but i feel like the head of my penis is cold

Starting point is 00:21:11 and for those men something something that we can do is we can give him a pill you give him Viagra, Cialis, or one of these medications. There's also gels that they can put in through their urethra, and that can help engorge the head of the penis. And sometimes that can deliver blood flow to the head of the penis. So that's, again, there's ways to fix that disadvantage. That's why I call it a minor disadvantage. And another disadvantage is some men think that, again, that the implant can make the

Starting point is 00:21:39 penis smaller. So let's talk about that. Yes, let's talk about that. Okay. um and again so so yeah i mean there are reports and there's multiple studies showing that men say that after the penile implant the penis is smaller smaller and i truly believe that to not be true okay and i'll explain whenever a man gets a penile implant most of the time these are these tend to be older men um you know men in their you know 50s 60s 70s 80s 90s sometimes um

Starting point is 00:22:12 And again, these tend to be men who've had erectile dysfunction for a long period of time. Their bodies have changed. So now we're gaining weight. We have a fat pad and we fantasize of what our penis used to be. And we're like, yeah, I've had, I mean, these are concerts I have with guys like, Doc, I used to grab it with two hands before and now I can only grab with one. And I'm like, yeah, but you're comparing your 70 year old penis whenever you've had

Starting point is 00:22:40 erectile dysfunction for 20 plus years and the last time you had a good erection was seven years ago you're comparing that to when you were 20 years old and again the implant we can only get it as big as to what you bring in that day to the surgery so the implant really doesn't get the penis smaller erectile dysfunction gets the penis smaller Peyronie's disease which by the way we can you can invite me another day we can talk about that one and Peyronie's disease again it's it's it's just a for a dose of you who do not know what this is um you might have watched the carrot commercials and people don't understand what the carrot commercial is about um it's a disease that can happen inside within the penis that's formed scar tissue and then the penis is

Starting point is 00:23:25 not able to stretch and that can cause uh shortening of the penis it can also cause deformities and or curvature in the penis but anyway so these two conditions are the ones that usually cause the penis to shrink the analogy that i usually use to my patients the following if you go to the gym every single day and you're stretching out your muscle you're exercising your muscles your muscles will grow if you stop exercising for six years and then all of a sudden you want to go back to the gym your muscles are not going to be what they used to be six years ago when you were having those regular uh you know those regular exercises the same thing happens with the penis when people might think oh but doc i'm not having sex every day how you know how did

Starting point is 00:24:06 my penis stay healthy throughout my first 30 years well do as we sleep we have nocturnal erections and that's how the way the how our bodies keep our penises healthy and once we start having vasculogenic erectile dysfunction right now the psychogenic but the vasculogenic erectile dysfunction once we start having that we start lacking those nocturnal erections we're not having those regular stretches as we uh like we used to have at night and therefore our penises can start decreasing in size okay um so what can a man do in order to regain or retry to recover that size before they get an implant that's when a vacuum erection device comes into play and usually what i tell my patients is the following it's like if you've had erectile dysfunction for a long time

Starting point is 00:24:55 and you are really concerned about your size, one thing that you could consider is using a vacuum erection device every single day, probably for at least, you know, at least three to four weeks before your surgery. And we're kind of like training your penis where it's marathon. You cannot go to a marathon without training. And what I tell them is like, Hey, we're going to get your penis to bootcamp. And then we're going to try to get you. And then the day of the surgery will be your marathon race. The other thing that we as surgeons, at least, you know, many experts what we do now in order for us to give men their best size, the biggest size that they can possibly get, is we try to induce an erection right before the surgery. So the first thing that

Starting point is 00:25:40 we do before this, at least me, the first thing that I do whenever I do a surgery is I will stick a needle inside the penis and I will start infusing with saline just to stretch the penis out, right? Because most men, we are growers, not necessarily showers. So we want that penis to grow as much as possible. And while it's on stretch, that's when we place it on traction. And that's where we make our measurements. And that's the way that most of us are able to keep the size with the implant. The other thing that needs to be, you know, now that we're talking about size and penile implants is that most men, whenever we measure our penises, we always measure our penises whenever we are erect right so one like we discussed before the implant does not engorge

Starting point is 00:26:28 the head of the penis so when whenever we whenever the guy wakes up and he you know takes the bandages off the first thing that they do is stick a ruler and try to measure it right um so what i tell them is like hey whenever you do that you have to take into consideration that we're not accounting for that glance engorgement so sometimes i have guys like hey doc i'm you know you i'm half a half an inch shorter. Like you shorted me. I'm like, let's talk when you get aroused. And then usually we talk two months later and they're like, you know what, that I'm actually a little bit longer and wider than what I used to be. And I'm like, I told you if men were not satisfied, this wouldn't be something that us sexual health experts, when it comes to urology would be offering our

Starting point is 00:27:12 patients. I mean, the reason we enjoy performing these procedures is because men and their partners tend to be very satisfied with the results. Oh, awesome. So, oh my gosh, so many questions for you, Dr. Clavel. So many. Where do I start? So a couple of things that I, one about using toys, sex toys. Are there any no-nos completely?

Starting point is 00:27:36 Can you potentially damage or hurt the surgery or the inflatable? Great question. Great question. So again, these are two cylinders. again we're talking now again about the inflatable implant these are two cylinders that are placed inside the the shaft of the penis and what really it just really doesn't give rigidity to the penis what gives rigidity to the to the penis is a sheath that's around those two cylinders so again your those that implant is still protected and to answer your question in layman's terms it's like

Starting point is 00:28:12 there's nothing that's off label. There's nothing that's out of the question in terms of what you can experience when it comes to sex. I usually tell men, it's like, you can probably smash it with a hammer. It's probably not going to break it. I mean, I'm pretty sure no one can smash it with a hammer. But the one thing that you cannot do is stick a needle into the penis, right? Because if you stick a needle, the fluid will leak out. Also in the area of the reservoir, also in the area of the pump so try to keep needles or knives anything sharp that can stab inside and leak the fluid out but for example one of the things that men are concerned about is like whenever we see the you know sildenafil like viagra commercials usually there's a comment it's like oh if you

Starting point is 00:28:55 have an erection that lasts for more than four hours you have to go to the emergency room with the implant that doesn't happen right um so with the implant that i have guys i have a patient for example who comes in to see me once a year he's in his 70s and he comes in once a year it's always right before he goes on a cruise and he's like doc pump me up to the max because you can get it stronger than i you have a stronger grip than than i do and we pump him up to the max and he and he keeps the erection for the full week believe it or not so again we do not encourage that uh But this is something that you can have sex for how long you want to. You can reach orgasm three times and you're still be it will be able to continue.

Starting point is 00:29:41 Because, again, the one thing that the one benefit that the implant will give a man who has one is that you have complete 100 percent control of your erection. You get it hard when you want to. You get it down when you want to. those days that you're having sex with your female partner and she tells you i was disclosed you're that's not going to happen anymore you can continue going at it even if you reach orgasm so that's why both men and their partners again be it female or male it doesn't matter but usually both men and their partners are extremely satisfied with this okay so my second question then is you you're mentioning arousal so there's mental arousal or subjective arousal and then genital arousal i did hear you say that okay once the implant is in there it it really just the

Starting point is 00:30:34 function is the hardness right which is going to be more of a mechanical process does the the that person's physiology in relation to the erectile process is there any synergistic or complementary assist within the implant or does that completely go off the table so again it all depends on i mean the arousal process again starts with the brain right uh you know we get aroused at the level of the brain and then there's you know signals between the brain your spine the blood vessels and the penis so again that connection is probably not going to happen because again you're you're not having blood flow to bring in i mean you're still having blood flow to to get inside your penis, but it's just not hard enough for you to get it to penetrative intercourse. But all the

Starting point is 00:31:23 arousal process will still be intact. I mean, you will still be, you know, if you have a high libido, you will still continue to have a high libido. If you have a low libido, you will continue to probably have a low libido. Again, this does not affect libido. This does not affect sensation most of the time. This does not affect orgasm most of the time. I mean, I have some men who tell me dog it takes me a little bit longer to reach an orgasm and usually it's that again when the penis is like super super hard sometimes you lose some sensitivity because then the nerves are being stretched out that's why for example guys who have a you know 60 to 80 percent erection is still strong enough for them to probably have sex but sometimes they tell me say hey doc i have a

Starting point is 00:32:06 little premature ejaculation i used to last anywhere between five to ten minutes and now i'm lasting two minutes and it's usually because again the less rigid the penis gets the more sensitive sensitive it can sometimes get and you can reach an orgasm a little bit quicker the other thing is with age sensation decreases so i have many men who are in their late 70s or early 80s and they have the implant they're like hey doc you know it takes me a little bit longer for to reach orgasm i enjoy everything but it takes me sometimes 15 20 minutes or 30 minutes to reach an orgasm and what we do is we try to find ways be it with vibrators be it with medications to help with lens engorgement or sometimes even medications that can work at the

Starting point is 00:32:52 level of the brain to actually help them improve their arousal and hopefully be able to reach an orgasm so again this these all these other mechanisms are completely different so those should still be intact the arousal will still be there we're just helping you to be able to get an an erection. That's it. We're not doing anything else. Okay. Okay. So how often do folks who have prostate cancer, prostate cancer prostatectomies come for the penile implant? Because I can imagine that's one of the biggest, I would say, downfalls of having potentially a prostate cancer treatment is the detrimental effects on sexual function. Definitely. I mean, this is a specific population that i'm very you know passionate about helping um i did my subspecialty training

Starting point is 00:33:46 like my penile implant surgery training most of it was at md anderson cancer center here in houston texas um so it was uh for me i was super honored to be able to help all these guys who have prostate cancer so yeah i mean erectile dysfunction is a very common uh side effect of radical prostatectomy whenever the prostate gets removed, and also for radiation, and also for guys who have their oral hormonal therapy to keep their prostate cancer under control. So again, therapies for prostate cancer can definitely affect the erectile function of a man. And this is a very high volume population who gets these procedures. You usually want to tell a man, again, if you had good strong erections before your prostatectomy it's like hey and you had a nerve sparing

Starting point is 00:34:36 prostatectomy uh sometimes those nerves can recover uh there is good research data showing that after a year that is that tends to be uh less common for it to be able to recuperate so in the first year it sounds like hey it's really up to you you can wait to you know you don't have to jump the gun and get the penile implant right away we can try other ways to rehabilitate the penis we call it penile rehabilitation with a vacuum erection device with pills we try to give them injections and the good thing about the injections again the injection bypasses all that mechanism that was disrupted by the surgery um so the the injection direct goes directly inside the penis will bring blood flow directly inside the penis and the guy should be able to have an

Starting point is 00:35:26 erection with, with the injections after the radical prostatectomy, if they had good erections before. So just like with any other man, I tell him like, Hey, these are all your options. We decide what you, what you think is best for you. It all depends on your level of urgency. Uh, just yesterday I was having a conversation with a guy who had a, he had his prostate removed back in April. So it's been seven months. He's still, he still hasn't recovered. Uh, you know, his nerves haven't recovered. He's still has erectile dysfunction. He's like, doc, I want to wait because I've been through so much in the past year. And I'm like, wait, I mean, we can try this,

Starting point is 00:35:59 try the injections for now, let's see how you do. And whenever you're ready, I'm here for you. Again, we're not here to push therapies to a patient. We're here to facilitate the tools that we know that can help them. And the guy, I mean, this is purely elective. So the guy decides whatever he wants to do. But to answer your question, because I get carried away.

Starting point is 00:36:20 There's no worries. So to answer your question, I mean, guys who have radical prostatectomy are excellent candidates for this there are excellent candidates for this and they can still you know reach orgasm their orgasms will be different right their pelvic floor has been altered whenever they removed their their process or their orgasm will be different they're not going to be able to ejaculate there are some men that say that their orgasms are more intense after their prostate gets removed. And I think it's probably from some changes in their pelvic floor muscles, right? And there are some men who sometimes can have pain whenever they

Starting point is 00:36:59 have an orgasm. And that's when experts like yourself can come in to help them be able to reach a satisfactory level of sexual pleasure. Yeah, no, that's wonderful. Thank you for sharing your passion uh and and so that's this got me thinking about another population that which may or may not be you know part of your wheelhouse but for those who are transitioning like so um gender affirming surgeries um phalloplasties where does the penile implant come into play for for those types of surgeries so i mean that is not completely out of my wheelhouse uh but yeah I mean, for basically any, uh, you know, woman who's transitioned into a man or any trans man, uh, who wants to achieve, uh, sexual intercourse, the PLM plan can be done. Um, it, it's not as straightforward of a procedure as with a guy who, you know, as a, uh, natural man who had an erection, uh, or who has a penis with two chambers.

Starting point is 00:38:02 Cause again, with giving them that whenever they have a new phallus, uh, the chamber inside that phallus is different, right? this is something that was usually they usually get it from the forearm and we need to create that chamber so instead of placing two cylinders most of the time what we do is we place one cylinder and we try to anchor it you know to the bone to make sure that it has enough axial rigidity for them to be able to achieve intercourse but yes we still use the inflatable implant at least i've never seen a malleable implant placed on a on a trans man but it is definitely still possible if they want to achieve sexual intercourse. Okay, awesome. Thank you for answering that question. So what should someone look for when choosing a potential surgeon for a penile

Starting point is 00:38:56 implant? I mean, that's a great question and something that's probably a little bit hard to answer, right? But usually what I tell men who call our office is, I mean, to be honest, my most honest recommendation would be to look for someone who you trust if you do not trust your surgeon that is not a good way to start I mean look for someone with experience ideally right I mean don't always take the easy way out I get many patients who went with a you know local urologist that that was the closest to them that the urologist even tells them like hey I don't feel comfortable doing these surgeries I mean I've done them before but I would recommend you to go to someone else and they're like oh no doc I mean you're my doctor and I want you to do my

Starting point is 00:39:42 surgery and they're like okay I'll do it and then once they do it they're not happy they're not satisfied and then they come back to see me for me to fix them right and usually the first surgery tends to be the easiest surgery right so usually again I would say try to look for somebody who has experience uh i believe that it is not out of the question or it's not it's not it's not disrespectful for you to ask your surgeon how comfortable he or she feels doing a surgery um i mean you can ask them how many have you done in the past year how many have you done in this month how many do you do a year uh because again sometimes you have will have a surgeon was like oh i've done 500 of these but the last one was 10 years ago ah yeah good point so try to find

Starting point is 00:40:29 somebody again who you trust um that's probably the most important thing and try to find somebody who feels comfortable doing this like i have guys who i i mean i treat other conditions for neurology and i have guys who sometimes come in it's like hey doc i mean you diagnosed me with prostate cancer i want you to take my prostate out and i'm like sir if i was you if you were my father i wouldn't trust myself taking your prostate out i know i can do it but it's just been so long since i've since i've taken a process out that i i believe that the best thing for you is to find somebody who does this on a regular basis and that way you can have the best outcome possible because yes the penile implant is a functional surgery right this is not a cosmetic surgery i've

Starting point is 00:41:13 had guys who come in and they're like doc i just want to be able to last longer i want an implant i'm like that is not the right candidate for this this is something this is something a procedure that we offer for men who have erectile dysfunction, not somebody who's looking for a cosmetic implant, right? However, this is also, in a sense, this is also a cosmetic surgery. We want to give, you know, guys are very jealous about their penises and we want to give them the best outcome possible so that they can feel comfortable and finally be able to, instead of focusing on their penis and being worried about their penis failing, they can focus on their partners. They can focus on the relationship. They can regain that confidence. I mean, usually what

Starting point is 00:41:58 I tell guys, what we try to do is try to provide hope for them. We try to get guys who feel hopeless. We try to get them to be hopeful. We want them to feel worthy of their relationships. And we want them to kind of like stop thinking about their penis. We want them to feel like when they were 20 years old. And sometimes I have couples who are in their seventies and they're like doc i feel like when i was 30 years old again not physically of course but mentally emotionally with their partners now it's like doc now we can actually focus on each other rather than having 20 minutes to focus on the penis for it to start working right so yeah when it comes to looking for a potential surgeon look for somebody who you trust somebody

Starting point is 00:42:40 who feels comfortable somebody who's very well familiarized with not only how to perform the surgery but also how to manage complications we didn't even talk about complications today no but we can briefly if you want to because i actually did have a question about expectations for healing so after you have the pinot implant what is the what is the guidelines for the healing process and does there need to be any rehabilitation around that afterwards yeah for the for the actual surgery i mean and you've just finished out that surgery you find you find try to find a surgeon who who again feels comfortable uh not only performing the surgery but also managing complications, right?

Starting point is 00:43:20 Because again, if something goes wrong, you want to make sure that you have somebody who you can trust to take care of whatever happens. And again, usually most, I mean, there's multiple, multiple, there is probably hundreds of experienced surgeons, at least here in the United States, because sometimes I have guys like a doctor, there's only three surgeons and you're one of them.

Starting point is 00:43:40 Like, no, I mean, there's multiple surgeons around the United States who feel extremely comfortable performing these surgeries and also managing complications. It's just a matter of just trying to find them. And again, find somebody who you trust. Now let's talk about the complications. Ask me the question again. Yes, please tell me what are some of the complications that may arise from a penile implant surgery? So, I mean, when it comes to complications, the most common risk that can happen is infection. In the hands of an experienced surgeon, this risk is usually less than 2%, meaning again, 98% of men do not have any infections. There are many surgeons out there

Starting point is 00:44:24 that have their complication, that their infection risk at less than 1%. So again, and how do we prevent these infections from happening? Again, we make sure that we're completely sterile during the field. These implants now have antibiotic coating or they have, one of them has an antibiotic coating already installed in it or impregnated in it. The other implant has a hydrophilic coating that is able to absorb solutions and antibiotic solutions and antibacterial solutions. And we can install the implant while it's already coated with that antibiotic solution. And yeah, I mean, usually, again, that's probably the most common risk or complication. But even after an infection, there are ways for us to be able to restore an erection later on.

Starting point is 00:45:10 Also, the device can fail. I mean, this is a medical device. So this, if you are young and you're getting an implant, this will very likely fail at some point. Most implants last between 10 to 15 years. But I've seen implants that I've seen guys who've been 18, 19 years out with their implants and it still works. So again, and I've also seen guys who fail within a year. So again, this is usually I tell guys, it's like a car, like you buy it brand new and you can get an amazing car that will last you for 20 years and you can get a, you know, a lemon that will last you for six months. It also depends also in wear and tear, right?

Starting point is 00:45:50 So if you are extremely active with the implant, the implant again can even can probably last a little bit less than a car that you're only driving once a month, right? So yeah, so the device can malfunction and also the device can be misplaced, which is why it is important that men seek help from an expert. I guess sometimes the implant can be undersized, it can be oversized, sometimes it's not placed in the right position, and then the implant can kind of start like poking towards the side. So that's very important that you seek help from an expert, right? Rather than go to somebody who's not experienced performing these procedures, because that's

Starting point is 00:46:31 how we can avoid these complications however all these things that i talked to you about for example if the implant fails that it malfunctions that it stops working eventually we can always go back and replace it with a new one oh okay and that doesn't that the tissue around the implant depends right so sometimes the tissues with time i mean sometimes the tissues can get weaker and weaker but again most of the time in the hands of a well-experienced surgeon we're able to get something in to be functional okay it's probably not going to be as you know the tissues are not going to be as healthy like the you know three months out of your first surgery right but i've had for example uh probably about six months ago i had a guy who i did his 10th revision

Starting point is 00:47:16 and it worked and it worked so again there there are you know there are some surgeons who there there's one study that says like oh after the fifth implant everybody gets infected uh like that's not going to work that's not true so again i did a 10th revision on a patient who's still functional and he's still very happy wow this is awesome i had this conversation i swear you're right we could probably talk for three hours on this stuff um so okay my promise last question no uh again i i have all the time that you need so healing let's talk about our expectations for healing time frames um is there a ramping process of using the dividylis? What is this conversation like with your patients?

Starting point is 00:48:00 So usually the recovery, I tell guys, is usually between three to six weeks. I mean, there are surgeons that are able to get their patients to start using the implant for sex at three weeks. So the way this works, again, we place it, if we're talking about the inflatable implant, right? Because the malleable implant, you just place it and you wait for the incision to heal. Once the incision is healed, you use it. But with the inflatable implant, it's a little bit different. So there are some surgeons that will place the implant and we keep it partially inflated for, again, anywhere between two to six weeks. And then once the man is able, you know, once the patient is able to cycle the implant, that they feel comfortable to both inflate and

Starting point is 00:48:41 deflate, they can start exercising the tissues. And by cycling, we mean, again, you inflate it to the max, you keep it there for sometimes, again, it can be five to 30 minutes, and then you deflate it, right? And that's what we call cycling. And that's most of the time what's able to keep the chambers as expanded as possible. Because as soon as we place any implant in your body, except if we place it in your abdomen, but if we place a breast implant, if we place the knee replacement or a hip, your body will create a capsule around that implant. And that's the way the body protects itself from attacking the actual implant okay so there's going to be a capsule there's going to be place uh that's going to start forming around the implant and we want

Starting point is 00:49:24 that capsule to be as expanded as possible to be able to maximize the girth for the patient and also the length for the patient so what we what we tell the patients okay we're going to place an implant we might leave it chubby that's what i call it a chubby uh so we leave it like around 60%. So you'll expand it enough that it will keep the form and shape of the penis. That's not going to be like super flat, but not rigid enough that they're not able to get it inside their pants while they recover. So the body will start creating that capsule. And then once you start cycling, we're going to try to expand that capsule as it starts to form. Usually that capsule takes about six months to a year for that to form, but most of it forms within the first three months.

Starting point is 00:50:07 So what I tell a guy is the following, hey, we're going to keep you partially inflated for, my patients is usually four to six weeks. And how do we determine who's four weeks and who's six weeks? It all depends on the specific guy, right? On the specific patient. There are patients that take a little bit longer. So I tell them, set your mindset for six weeks so you don't get frustrated when you're at four weeks. by telling them, so set your mind for six weeks. At six weeks, we're going to start psyching that implant every single day. Every single day, I want you to get it hard and then deflate it. And you're going to do that for at least three months. However, if you're super motivated and you want to really maximize that, continue doing that for six months to a year. And what we know, and it's very common for guys who regularly cycle their implants

Starting point is 00:50:52 and they usually come back and they tell us like, hey doc, I'm actually a little bit bigger than what I even used to be. The implant kind of like expanded the tissues a little bit more than what I used to have when I had a natural erection. But again, those are the guys who are extremely motivated. And most of the time, whenever that implant fails, we have to go back for whatever reason, most of the time we're able to get them a little bit longer.

Starting point is 00:51:15 The implant that we can place in the future can be a little bit longer. So again, the implant from the inside can continue to expand the tissues. Healing, three to six weeks, we just have to wait for that incision to heal. The only things that men cannot do is, usually I tell them three things during those six weeks, you cannot lift anything heavier than 10 pounds. Why? We have a reservoir that's going to be in your abdomen, and we get that through the inguinal ring, so through the groin.

Starting point is 00:51:41 So if the man starts lifting things that are heavy or creating pressure in their core, that reservoir will migrate down into the scrotum, and then we have to go back and reposition it. But again, after six weeks, the capsule is already, you know, most of the capsule has been already been formed and most times they are able to get back to a regular life. I have guys who are bodybuilders and they have implants and everything worked well. So, and they're lifting 600 pounds, so they're going to be fine. And then, so that's one thing. The other things I usually encourage my patients to not submerge in water while the incision

Starting point is 00:52:15 is still healing. My wife is a dermatologist. so she's like yeah you try to keep the incisions you know you can keep them moist but don't soak them um and then the other thing is that i try to discourage sexual intercourse uh for the first you know usually four to six weeks there's many you know younger guys you know guys in their 30s or 40s that get implants usually they're able to cycle their implants a little bit sooner and usually what i tell them though is i try to be gentle initially while you're having sex because you're still healing from the inside you want to make sure that the stitches that we place inside

Starting point is 00:52:50 that that uh those chambers inside your penis that those heal before you start doing you know crazy positions that are going to disrupt your penis um so again it's very rare for for you know sex to damage the implant there is no positions that are again that are out of bounds when it comes to this everything's game you can get as creative as you as you want to but while you're healing again during those first six weeks try to be gentle issue i tell guys like hey the first time you have sex with this is going to be like the first time you had sex you're both going to be like look at each other it's like everything okay is it doesn't hurt okay no okay okay well let's continue and then as you feel comfortable going at it off you go off to the races and you

Starting point is 00:53:37 can have a very, very successful sex life. Oh, that's awesome. Thank you so much, Dr. Clavel. And so my mind has been blown and I have learned so much on today from you. Thank you so much for sharing your knowledge with me and the audience. And I mean, wow, it's your wealth of knowledge and certainly clearly an expert in your field. So how could folks connect with you if they wanted to reach out to you connect with you on social media so we have i mean we try to be in all social media platforms uh uh the twitter i usually use it for networking with other experts i don't use it mostly for you know for listeners and and and patients to communicate with me uh but certainly through facebook um through i have a facebook channel it's clavel urology it's clavel c-l-a-v-e-l-l

Starting point is 00:54:27 i'm pretty sure like you can get it in the description of this podcast and everything else So it's Clavel Urology. And I also have Instagram and YouTube channels. So Instagram and YouTube is usually Clavel Uro. That's also my Twitter handle. So if you want to find us through there, again, you can always communicate with us. I'm, I'm an open book. I try to respond to everybody who posts comments on my YouTube videos as much as I can, as time allows. And again, we want you to feel as, if you're listening to this and you're considering an implant, we want you to feel as comfortable as you can. I want you to feel at peace. I know that nobody initially wants an implant. Most of the time, whenever we are considering an implant is because we think we need it, right? So I want you to feel at peace with your decision. I want you to be stress-free. I want you to be relaxed. And my goal is for you

Starting point is 00:55:22 to feel comfortable and for you to be motivated and for you to be confident again. So, so yeah, I mean, YouTube is, there's a lot of information. You can even watch how I perform the surgeries, how I fix, you know, complex situations, how I fix curvatures. I mean, I'm an open book and you can watch step by step if you watch those videos you can probably go into the operating room and assist me doing the surgery so again if there's there's a lot of information on how to prepare for surgery how to what to expect after your surgery now I'm actually working on a video because I get men from all over the world to get these surgeries done and I find myself kind of like talking like answering the same questions about the logistics of traveling and that's my

Starting point is 00:56:11 upcoming videos coming hopefully soon um and there's you can even see patient testimonials uh there we had a recent video of a couple who kind of like shared their experience uh both a man and a woman sharing their experience of how was how their journey trying to get over erectile dysfunction worked um and you there's so much information online not even in my channel alone there's multiple channels out there um if you guys really want to learn more about what men really go through uh boston scientific which is one of the companies that make implants they recently launched a mini docuseries of five episodes seven minutes each free you know very quick uh and very short so for those who have short attention span and it's a it's called the

Starting point is 00:57:01 hard series h-a-r-d series and you can look at it you look it up online you can put like you know heart series boston scientific or heart series erectile dysfunction i'm pretty sure you can find it on google and you'll see five episodes of five guys that struggled with erectile dysfunction because of different uh causes right there's people who had diabetes there's people who had prostate cancer uh for example my patient in that episode i mean in the episode that we that we launched it was a young guy in his 40s completely healthy but he had problems specifically in his penis and and they shared their stories of how they were able to overcome erectile dysfunction with this with this surgery how this surgery transformed their sexual life so again there's

Starting point is 00:57:45 a lot of information out there uh i'm more than happy to communicate with you guys and if you guys want to schedule appointments with me i can just look up online you'll be able to find me we have a website as well um it's very easy to remember it's houstonmentshealth.com so we're in houston texas uh so it's houstonmentshealth.com but i'm not from houston i'm from puerto rico so but yeah it's houstonmentshealth.com and you can find a lot also a lot of information about these procedures uh about me if you want to like see like what we've done um again i'm very passionate about this topic i give conferences about this topic i train doctors how to do these surgeries. And we have men from all over the world who travel to get these surgeries done.

Starting point is 00:58:28 And I'm available. I try to help as much as I can, my patients as much as I can. And I'm excited to be a part of this journey for these men who need these procedures. Thank you, Dr. Clavel. Yes, clearly you're so generous with your time and your resources. And we will make sure to link all of those fabulous resources in the show notes for people and in the YouTube description below. So no worries on that. Thank you so, so very much again for your wisdom. I have learned so much.

Starting point is 00:59:03 So thank you again. Thank you for the invitation. And if there's other questions that arise when you post this in your platforms and we need to give some tune-ups and go back on some topics, I'm more than happy to come back and help you out. Because again, my goal, again, is for people to be educated.

Starting point is 00:59:26 And there's a lot of misconceptions out there, a lot of myths when it comes to these procedures. And we need, you know, people, right, couples to learn more about these options that are available for them. Absolutely. Well, thank you again. And to all of our listeners and viewers, thank you so much for being here. As always, in loving wellness for your pelvis, this is Dr. Susie. See ya.

Starting point is 00:59:48 thanks for listening to today's episode be sure to visit my website drsusieg.com for show notes and related resources on today's topic if you like what you're hearing head on over to youtube and subscribe to my channel on my youtube channel you'll find content related to sex pelvic health and expert interviews for men if you got a question or a topic that you'd like me to answer on my channel be sure to type it in the comment box below

In Your Pants with Dr. Susie G - Penis implant surgery for erectile dysfunction

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