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 semi­rigid 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 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 sexo­logist 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.