Manhood: The Rise and Fall of the Penis (36 page)

The penis bone also occasionally crops up in literature. Henry Miller, the first serious modern writer to give an honest account of his tur -

bulent love life, mentions it in
Tropic of Cancer
, in his colourful style: O Tania, where now is that warm cunt of yours, those fat, heavy garters, those soft, bulging thighs? There is a bone in my prick six inches long. I will ream out every wrinkle in your cunt, Tania, big with seed . . . I shoot hot bolts into you, Tania, I make your ovaries incandescent. Your Sylvester is a little jealous now? He feels something, does he? He feels the remnants of my big prick. I have set the shores a little wider. I have ironed out the wrinkles. After me you can take on stallions, bulls, rams, drakes, St. Bernards.

This fantasy is not a degradation of women, far from it. It is modern man’s painfully transparent anxiety: sexual envy and fear of having too small a penis.

The use of genuine rib cartilage as a penis prosthesis proved inadequate in the long term: the material was eventually reabsorbed by the body. For this reason synthetic prostheses were developed in the 1950s.

To begin with these were inserted in the penis, but outside the erectile tissue compartments. This had in fact been tried thousands of years previously in China: with chicken bones. The problem was that in time x-ray photo of a

dog’s baculum.

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The inflatable

erection pros -

thesis.

Reservoir

Cylinders

Pump

the chicken bone bored through the skin, and initially the same thing happened with the subcutaneously inserted prostheses. For that reason the technique was modified; in 1960 Beheri described the operating technique still current today in which two plastic cylinders, which may or may not be inflatable, are placed in the erectile tissue compartments and as it were fill them; this procedure entails the permanent loss of the spongiform erectile tissue.

The implanting of a prosthetic is an irrevocable step, since it involves the sacrificing of the penis’s own capacity to swell. Even given optimum information it is often difficult for patients and their partners to imagine in advance what living with a penile prosthesis will be like.

Talking to a patient who has already been through a similar procedure –

usually a very effective way of briefing patients – is generally not feasible, often due in large part to false modesty on both sides. In this way things remain veiled in secrecy. We find this in the novel
The Story
of R
(1990) by the Italian writer Gaia Servadio, in which her main character, a rich businesswoman, tells her adored young lover the following about a penile prosthesis:

‘I shouldn’t be telling you these things, but the Baron’s just come back from Bulgaria where he had plastic surgery done to his . . . yes, well, eh, you know what I’m talking about! A small internal pump so that with a bit of manipulation, he can get it up. Apparently it’s a painful operation, but many people have it done. I mean, what is one to do? When a man’s reached the age of seventy, he knows everything there is to know about sex, but he can’t do anything about it any more. For women it’s different, eh?’

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‘But once the pump’s been inserted, what can a man do?

Can he still have orgasms?’

Well, that is possible, since experiencing an orgasm is not in itself dependent on an erection. Experience shows, though, that most men are very attached to an orgasm with an erect penis. As regards the quality of orgasm, this is never reduced after the implantation of a prosthesis.

There are various kinds of prosthesis on the market. The semi-rigid type consists of two flexible plastic cylinders, one of which is placed in each erectile tissue compartment. For aesthetic reasons it is sensible to carry out a circumcision at the same time. After implantation the penis is constantly in an erect state, but its flexibility is such that it can be hidden under clothing. It could be compared to the bendability of an old-fashioned desk lamp. The much more expensive inflatable prosthesis has the advantage that the penis remains flaccid when ‘at rest’, and that a natural erection is simulated. The prosthesis comprises two inflatable cylinders. As with the semi-rigid prosthesis, the cylinders are placed in the erectile tissue compartments. The length of the cylinders is not decided until the operation is in progress, and this requires great precision. If they are too long there is a danger that the casing of the erectile tissue compartment will be perforated. If they are too short the so-called ‘Concorde phenomenon’ may occur, that is, the glans may droop during an erection. The cylinders in the erectile tissue compartments are linked to a pump in the scrotum and with a fluid reservoir in the abdominal cavity. When an erection is required, the cylinders can be filled with fluid by squeezing the pump. Some dexterity is required to operate the prosthesis. Scientific research has shown that penile prostheses cause few problems in daily life. In the case of semi-rigid prostheses it is not always possible to camouflage the penis properly, and for that reason tight swimming trunks are not recommended.

More than three-quarters of patients who have had an operation are satisfied. The principal reasons for dissatisfaction mentioned are the impossibility of intercourse (especially after implantation of a semi-rigid prosthesis) and the absence of an orgasm. Almost all patients would have the operation again. This obviously means that even a defective restitution of the capacity for erection can be seen as a successful restoration of the battered sense of male self-esteem.

It is important to gain a clear picture before the operation of the pattern of expectations of both the patient and his partner. This is not work for a urologist alone, and preferably there should always be a sexologist involved. Unfortunately it does sometimes transpire that it would have been better if a patient had not had the operation. A practical example: a 50-year-old man had had impotence problems for a 190

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considerable time. Based on the evidence of various tests the urologist was convinced that these were psychological in origin, and consequently referred the patient to a sexologist. It soon became apparent that the man involved had a rather unhappy prehistory. He married young, but divorced a few years later and shortly afterwards entered into a homosexual relationship. Later he nevertheless felt more attracted to women. After having led a rather wild life up to then, things became calmer. He curbed his excessive drinking and married a somewhat older woman. Unfortunately this relationship also went wrong: his wife fell in love with a member of the choir at the church they had joined, and the marriage foundered.

The patient, undeterred, embarked on a new relationship, but now unfortunately his penis let him down. And what happened? The sexo -

logist he consulted could not help him, but referred him back to the urologist with the request that he be taught to give himself intrapenile injections. That soon proved a failure: haemorrhages, complaints of pain, and so on. A vacuum pump did not help. Only after a great deal of humming and hawing was the patient prepared to return to the sexologist, and his new partner refused to accompany him. Finally, at the patient’s insistence, it was decided to implant a prosthesis, the semi-rigid type, since the urologist felt the patient was probably not dextrous enough to operate an inflatable prosthesis, and also to reduce costs (since hospitals have to keep within budget). Fortunately the procedure was completed without complications.

However, during a follow-up check the patient expressed his dissatisfaction at the final outcome of the operation. He did not tell his daughter about the operation and said that he saw her looking at his crotch while he was holding his granddaughter on his lap. He was convinced that his daughter saw his ‘erect’ penis and hence had started avoiding him. This story is hard to argue with, and might be grounds for discontinuing the implantation of semi-rigid prostheses.

Viagra

Strange as it may seem, the medicine that broke all sales records was a fluke. At the pharmaceuticals group Pfizer researchers were looking for a new medication for cardiovascular disease. One substance reviewed was sildenafil, the active component of the Viagra pill. There was considerable hope that it would be possible to use it to combat chest pains (angina pectoris), but in clinical tests in the 1990s the drug seemed to be a flop. Researchers detected little of the intended effect on the heart and the group saw little hope of a return on its investment. Then, strangely enough, reports came in from test subjects of unforeseen, but 191

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definitely pleasant side-effects. The strength of the drug Viagra lay not in the ribcage, but in the penis: long-lasting, hard erections and more stamina in lovemaking. A number of test subjects flatly refused to return their supply of the drug at the end of the research period and one of them even satisfied his need by breaking into the research lab. It slowly began to dawn on those concerned that with sildenafil the solution to a problem affecting men all over the world had fallen into their lap.

Once the desire has been awakened and the stage of foreplay is reached, an erection pill can do its work. Between twenty and 30 minutes after the drug has been taken the erection-causing action kicks in.

How do sildenafil and the more modern pde5 inhibitors work? With the right mood and in the right circumstances nerve impulses from the brain stimulate the production of cyclic guanosine monophosphate (cgmp) in the penis. As a result the smooth muscle cells of the spongiform network in the erectile tissue compartments relax. (When the penis is flaccid, the smooth muscle cells are on the contrary taut.) The penis finds rest only in erection, in sex and, for by far the longest periods, each night during rem sleep.

When cgmp is released into the erectile tissue compartments there is a dilation of the arteries, and more blood flows in. At the same time the increasing volume of blood forces the exiting veins shut, retaining blood in the penis and causing an erection.

The enzyme phosphodiesterase 5 (pde5) breaks down cgmp, so that the erection is not maintained and the blood flows away as fast as it enters. This the point at which pde5 inhibitors like sildenafil (Viagra), vardenafil (Levitra) and tadalafil (Cialis) help by neutralizing the erection killer phosphodiestarase 5. Cialis has the longer effect, 36 hours, and is also called ‘the weekend pill’, offering the advantage that intercourse does not have to happen soon after taking the pill: one can wait until Saturday or even Sunday – an important consideration, knowing that many women dislike making love to order. pde5 inhibitors protect cgmp, then, so that blood remains longer in the erectile tissue compartments. pde5 inhibitors act not only in the penis, but also in varying degrees in the other pde receptors. By 2007 twelve of these had been identified. The most common side-effects of pde5 inhibitors are headache, a reddish complexion, a full feeling in the stomach region, a bluish haze in front of the eyes, dizziness and skin rashes. In these loca-tions pde inhibitors with a different number have been pinpointed. The pde5 inhibitors, for example, act to a minor extent on the pde6

receptors in the retina. In addition it is important that pde5 inhibitors should not be taken at the same time as medication containing nitrate; this can cause sharp drops in blood pressure. Since 2006 sildenafil has 192

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had one other official use: the drug can lower blood pressure in the pul-monary circulation. Raised blood pressure in the blood vessels of the lung is life-threatening and sometimes very difficult to treat.

At the end of 2006 banner headlines announced that British doctors had saved the life of a premature baby with Viagra. The doctors administered the drug to a little boy, who at birth weighed only 780 g and was struggling with one non-functioning lung. The medication opened tiny blood vessels in his lungs, allowing oxygen to be absorbed by his blood in spite of this. The parents of baby Lewis, who had been born in August 2006, feared for his life and had even prepared for the funeral – but in December they were able to take him home!