inflatable penile prosthesis, for sexual intercourse. so for the patientto be satisfied having intercourse. um, it's something that is very, very common. it'sestimated that about 30 million american men have some type of ed. and it's a spectrum,it's not all or none. meaning, you can have mild, moderate to severe. and so it's a spectrumof a condition. um, and i think that that's
important to understand. when we look at reasons for problems witherectile dysfunction, there are lots of reasons but the bottom line, sort of the take homemessage is that, typically there's a disease state, or what we call organic, as opposedto, in the mind. a lot of guys wanna think that, okay, gosh it's my mind, that is theproblem, that i can't get erections. but generally it's a reason. it's a physical cause. andso you can see on here, vascular... um... getting an erection is normal blood flow,so anything that's going to cause vascular disease, um heart disease, ah... high bloodpressure, that kind of stuff, can affect it. ah diabetes... diabetes is very common herein san antonio. and diabetes is a disease
of both blood vessels and nerves. and so thatcan cause trouble. and then medicines and obviously medicinescan influence it a little bit. but i always tell patients... you know a lot of patientsare... they say, well, you know i was fine, and then they put me on some medicine formy high blood pressure and then i started to have trouble with erections. ah, it's importantto be treated for high blood pressure, 'cause as i tell patients, i mean if you have a stroke,and it doesn't matter if you have an erection or not. and so i think it's important to takethe medicines that your, your regular doctor has given you to treat the condition. andso that's important. so we look at restoration or return of erectilefunction... ah, there are a lot of different
options for patients that are out there. and so i think everybody is familiar withthe pills or oral therapy. viagra came out in 1998, and so it's amazing what it's done.and it's also amazing what their lawyers have done because the patent is still protected,so there is no generic viagra. none of these medicines are generic, and so they're expensive. i disagree with this slide a little bit. ah,the oral medicines work in about 65% of patients as opposed to what they say on here, 70, 80%.and really a lot of it just depends on how bad the blood vessel disease is. so if somebodyhas diabetes and high blood pressure, heart disease, treated for high cholesterol, thechances of the medicine, falls off. maybe
it only works about 20 or 30%. if someonehas been treated for prostate cancer, maybe that... you know, again that number is less.and so it depends. there's not sort of one, uniform percentage of patients that respondto the medicines. a lot of it just depends on, on what medical condition that they have. so the way that these medicines work, is thatthe patient takes them. there are some instructions and also some precautions. ah, the patientneeds to have stimulation. so you can't take it and then just sort of wait around and hopethat an erection comes up. you actually have to be stimulated. ah you take it typicallyan hour or two before anticipated sexual activity. and then there's a window where the medicineswork. so you have to plan. ah cialis, that
window is a little bit longer. um, but ingeneral, you have to plan when you want to use it. never take more than once a day. andagain, some of the medicines can be affected by, by food, and so, particularly viagra andlevitra, food can affect it. what are the side effects of the medicines?well they're all fairly common, but they're short-lived. and so you can have some headache,facial flushing, ah maybe a stuffy nose, a little nasal congestion, that kind of stuff.the only contraindication, meaning, who can't take this medicines? if the individual ison nitrates. and so nitrates is a heart medicine and so... really it's safe for any other medicine.blood pressure medicines, beta blockers, diabetes medicines, all that stuff and so the medicines...and it's been studied, because viagra's been
out since 1998, it's really been studied inevery group and with all sorts of medicines. some precautions, alpha blockers, those aremedicines used to help guys urinate a little bit better. so patients want to be on stableprostate medicine. um, and then again, if there is some question about the heart conditionof the patient and the patient needs to talks to their... their cardiologist and just sortof see if they're okay to be sexually active. and it's just like, you know, are they okayto exercise? so it's the same type of question. and so these are the things, and that's whyit's important that the individual, um, ah, ah see their physician, um to get prescribedthe medicine so they can be counseled on how to take it correctly. and then also giventhe proper instructions, and so that's important.
so, what else is out there? um, and then letme say, the pills average $20, $25 for one pill. um, and so, just as your baseline. so what else is out there? well the othersome other options are the vacuum erection device. ah, one of my patients, his wife refersto this as the mood killer. it's a very cumbersome, bulky, ah, device. and you can see on here,um, there's a vacuum, it's a cylinder that goes over the penis. and then the vacuum drawsblood into the penis, and then when the penis is full, there's a little constrictive bandthat's placed around the penis. and so, um, it does take some time to kinda set up andyou... you can see the side effects listed here. it can cause some bruising, maybe somediscomfort. um, the erection also isn't warm.
and so some of the women don't like that andso... ah, but nonetheless, it's out there and... you know i put all these things on here, notto tell you which one is better. but just so you know there are choices. so, for somepeople, the vacuum erection device is... they like it. well that's great. i mean it doesn'tmatter to me. and some people the pills work and they like it. well that's great too. buti think it's important to know what's out there. and um, just so you're educated. another, ah, um treatment option is a, isa, a suppository. and basically what that is, it's a little pellet, it's about the sizeof a grain of rice that goes inside the urine
channel. and muse stands for um, this medicatedurethral suppository for erection. but another patient... you know i learn all these thingsfrom patients. muse doesn't work that well and he says that muse stands for, "maybe we'llsee an erection." um, it only works in about 40% of patients. and it's expensive, it'sabout $30 for one little pellet, one treatment. so no needles are needed. you get an erectionin 10-15 minutes. you got to refrigerate it. but again, um, it's expensive and doesn'thave a great efficacy rate, um, only in about 30 or 40% of patients. these are some of the side effects. but reallythe big one is probably urethral burning and irritation. so just like if you've gottensoap inside your urethra, the urine channel,
that's maybe that's what it feels like. ahand so ah... nonetheless, so for some people, muse is what they prefer. ah, we don't writea lot of prescriptions for muse, to be quite honest. there are some patients that havetried it and like it. and so i'll refill it. but as far as you know, starting out withtherapy, um, it's really not a great option for patients. also we have here, injection therapy, and...and um, so caverject as listed on here is a widely used agent. there's other types ofinjection therapy that we use, ah there's stuff that we get from a compounding pharmacythat we teach patients. and so, you know, when you see some of the advertisements inthe newspaper, the men's solution and that
kind of stuff, they guarantee an erection,they pretty much put everybody on injection therapy. so they're not going to try differenttreatment options. they're not going to try... okay, let's try the pills. and if that doesn'twork, then, you know, we can try injections. and if that doesn't work, then we can trysomething else. there there's just basically one answer. and so... because they can sellthat stuff to you. and so they actually... i've heard that it's actually pretty expensivefor a vial. the injection therapy has been out... theconcept has been out since 1982 or so. and we have lots of patients on injection therapy.and there are patients that fail oral medicine, and we'll go ahead and put them on injectiontherapy. and so, we do the teaching in our
office. it's actually very cost effective.now we get our injection medicine made generally at one of the local compounding pharmacies,so it's really only about 2-$3 per erection. so it's just getting over the hurdle of puttinga needle into the penis. guys have to get over. but um, the efficacy, effectiveness of injection,may be about 80%. remember where i said pills were about 65%. muse is about 40%. so thatkind of gives you an idea of... of... of where everything kinda fits in. but you can seeon here i mean you got to put a needle in. you've got to inject it right into the erectiletissue. you get an erection. it's about 10 minutes to get an erection.
these are some of the side effects, you canget some scar tissue, ah, it can be painful. if guys have been treated for prostate cancer,they always complain of some discomfort when they use injection therapy. so ah, so thereare some issues with it. but all treatments are going to have some side effects. i meanthat's just the way it is. so now penile implants. so, what are penileimplants? and um, i have a great slide that's kind of pokes fun at it, but we're not allowedto use it anymore. so anyway, penile implants have actually been out for a long time, sosince 1972. and ah, it was actually invented at baylor, one of my professors, brantleyscott, was the guy that came up with this. which is really pretty amazing. he also cameup with the artificial sphincter, um. and
he was originally from san antonio, i meanthere's a lot of texas roots to this. so, so the device has been out for over 40 years,which is amazing. and ah and um, so this slide needs to updated. um, it is an operation, ah, but it's... thesurgery has evolved. so when i was a resident and learned how to do the surgery, it wasa 2-3 hour operation. you know for a first time patient, patients were in the hospitalfor 4, 5 days. and it was a big deal. complications were greater. now, it's an outpatient operation.so today i did one artificial urinary sphincter and then three penile implants and so... onthe virgin patients, meaning, who have not had surgery before, it's 30 minutes, theygo home the same day. and so big difference
from... from years ago. excellent patient, partner satisfaction...lots of studies we've done, a bunch of studies ourselves, and um, it does demonstrate, ah,that. these are ah, when you look at ah, patientsatisfaction ah, now this is actually a two-piece device, but again, at the end of the day,it's the same concept. patients and partners are happy with this and you know, there'sa lot of positives to it. mr. king will get up here and kind of give you his feeling aboutit but, you know the spontaneity of it. um, and again, they're fairly durable devices. now some people think that there's somethinghanging out the body. that people can tell
you have an implant inside you. that's quitethe contrary. i mean nobody knows, um, you can't tell. i mean, even looking at somebody,even when it's deflated, with the type of device i tend to put in. if the individualhas good use of their hands, called the inflatable device. and so that's a device where there'sa pump in the scrotum. and on here, you know, just kind of backingup, let me just go over the diagram. there's a little reservoir here that holds sterilesaline. um, inside the penis, the erection chamber, or the cylinder, and then down inthe scrotum, between the testicles is the pump. so everything is underneath the skin.there's a little incision, maybe about an inch or so, and everything is put in throughthat.
so the device is, think of hydraulics, it'sfilled with water and that's essentially how it works, ah with the device. and so as longas the individual has good use of their hands, they're able to get the inflatable device.and when they want to use it, they inflate it, it provides good rigidity. they can leaveit up as long as they want. when they're done they let it down. you can use it, you know,five times a day. and there's no limit, once the patient has healed up for this. and thenagain, as i said, when it's deflated, the cylinders are soft, it looks soft and youcan hardly tell that anybody has anything inside of them. and there's different types of cylinders,and everyone asks, well, you know, how do
you measure? and this and that... well everyonehas a different sized penis of course, and so we measure and put in what's appropriatefor the individual. and um, so that's how that... that works. we keep all this stuffin the hospital so we have plenty of, ah, choices for patients. so this is a long-term solution. so thesedevices, as i tell patients, they're meant to last 15-20 years, when we put them in.um, ah the companies that make them they do provide the patient with a warranty, generallyfor the lifetime of the patient. and i always joke that it's just for parts, it's not forlabor, so... um, but you can use it anytime you want. spontaneous, ah, again... um, andgood patient satisfaction. it doesn't affect
ejaculation or orgasm, really has no... norole with that. that's separate. so risks. again, everything has risks. justlike the shots have risks, the pills have risks, everything has risks. um, so it's importantthing to understand. probably the biggest thing that people are afraid of, infection.and so you know, i think now days, some of the enhancements with the device they're coatedwith antibiotics. i think that was probably the best thing. that's been, i guess about10 years. and that's really deceased the infection rate. so in a non-diabetic, the infectionrate is less than 1%, which is i think, amazing. i mean that's less than hips and knees thatthe orthopedic physicians put in. so i think that right there, is fairly amazing.
um, it does, as it says on here, will makenatural and spontaneous erections impossible. but you know patients always they always question,well if it doesn't work, can i go back to what i had? and i tell them, i mean what didyou have before? i mean the guys that are getting implants have ed. alright, so we'renot putting implants in patients that, you know they take viagra and it works great orthey're happy on shots. i mean, they have erectile dysfunction, and generally they don'trespond to any other treatment. so they're looking to be treated. and so that's why weput it in. um, you can get some shortening with the device.a lot of it just depends on... again everyone's penis is different. how elastic or stretchablethe penis is. ah some patients will complain
of some loss of length, some don't. and allthat stuff is determined by physical exam. and there are things that we do before surgery,to help stretch up the penis, um, if that's a big concern of patients. and again, thisis where seeing somebody with some experience in this um, ah process can help you to getgood satisfaction, um. mechanical failures we talked about, and thenpain. but again this goes back to... um, and the risks have to be put on here. i thinkit's important. if you look at patient satisfaction, in excessof 90, 95% and that's been over the years. and so that's not anything that's new thatjust kind of popped up. and that's... various studies all over the u.s. and outside of thecountry, um, that patients like it. so certainly
if something had all these horrible risks,we wouldn't still be putting in the implants. and so ah, that's a possible thing, ah. is it covered by insurance or medicare? itactually is. medicare covers it. at least for now, i joke. and ah, it is covered bymedicare, tricare, really most insurances cover it. it's rare that insurances don't.um, for those that are self-pay, it's expensive so, you know, fifteen, eighteen thousand dollars.and i do have some patients that... pay. um, but in general, most of the patients, themajority, the overwhelming majority of patients, um their insurance covers it. their medicareand what have you, cover it. so it is covered by insurance, and if here is a problem withthe device, um, again, um, insurance will
cover for it to be fixed, and corrected, andthis and that. ah, obviously the company doesn't guaranteeinsurance coverage and that's something that the practice does. we have people, that'sall they do, they figure out authorization and everything else and, counsel the patienton what their piece, if they decide to get an implant, is gonna be. you know, what theircomponent is. so not every urologist is a prosthetic urologist.um, ah, and you know, as we said, i mean, you know i've been doing prosthetic urology,really since i got out of training so, now we're coming up on 20 years, which is sortof a scary number. but, ah, i've been fortunate enough to do it. i really like it. and becausei really like it and i've done a lot, i've
gotten pretty accomplished at it and so...and i think it's important to get good outcomes, to see somebody that's experienced in it.because, you know, there are little nuances, just with any surgery. um, i don't do cancerrobotic surgery. we have people here that do that stuff and... and ah. or we have peoplethat take out kidneys. i mean again, fortunately in our group we have all these specialiststhat can concentrate and focus. and so today, like i said, i mean i did four prostheticcases. that' a lot of cases, when you ask the ams people... i mean that's, and thathappens every week. um, tuesday is my day. and so we stay fairly busy. and so it's importantto seek somebody with some experience in this and ah, um to get a good result, i think thatthat's key.
so again, erectile dysfunction is very common.a lot of great treatment options. penile implant is a solution and especially if you're nonresponsiveto the other therapies. but get the partner involved, no question about it. and, and feelfree... we just opened up our men's health and wellness clinic. it's just at the endof the parking lot, so i'm very excited about that. so, it's an environment for men, um...obviously the wives can come with their husband. but ah... but you know the way that the dã©coris set up and once the patients get in the back, there are just guys taking care of them,so... it's a sensitive subject, no question
about it, and so we try and make the environment,um geared towards guys where they can feel comfortable talking to us. the people i workwith, my team, um, they've been with me...
chris now, a number of years and so ah...does a great job and so, i think that that's really part of it as well. i mean the feedbackwe get from patients.