Transplants, Implants, and Other Penises of Last Resort
he AMS Malleable 650 Penile Prosthesis is a high-profit item with a steady demand. You could do worse, in life, than to be an AMS sales rep. On the downside, your sales patter would need to include the phrase “better concealment with less springback.” You would have to listen to yourself saying “The enhanced rigidity reduces the possibility of buckling during intercourse.” There would be days, perhaps even most days, when you would find yourself in a group of strangers, holding a silicone penile implant up to the fly of your chinos.
For the AMS sales rep visiting Dr. Hsu’s office at the Microsurgical Potency Reconstruction and Research Center, today is one of those days. Worse, it’s a day when the strangers are myself and Dr. Hsu’s wiseacre colleague Alice Wen. Alice is serving as my interpreter. The rep is demonstrating how you get erect with a set of 650s—one in each erectile
chamber—inside your penis. It happens faster than the real deal. You just bend it into position like a gooseneck lamp.
There are also inflatable, rather than malleable, models. Here you don’t bend the penis, you pump it up. The surgeon implants a small bladder of saline (or air) above the pubis bone. This gets pumped into the implant by means of a hollow, squeezable bulb implanted in the scrotum and attached to the prosthesis by a plastic tube. Inflatables are more popular because—unlike a malleable implant— they enlarge the girth of the penis, as would happen in an unaided erection. To many men, it seems more natural— except, of course, for the scrotum-squeezing aspect of the event.
“So who does the pumping?” Alice is making what psychologists call the distress face. “Anyone” is the answer. Whoever wants to. The guy, his date. Very occasionally, a visiting stranger. Sex researcher Cindy Meston tells a story about the time Irwin Goldstein, then at Boston University’s Center for Sexual Medicine, made her pump up one of his post-ops. “I was in Boston for a conference. I had the flu, I was throwing up all morning. Irwin was all excited about this new pump he’d installed: You have to see this, Cindy!’ He drags me over to his office, and there’s this enormous man with no pants on. Irwin’s going, ‘Go on, Cindy, pump it up!’ And I’m going, ‘Oh, no, Irwin, please, not today. . . .’ ”
Who would have this done? “It’s fairly popular,” says Goldstein, a urologist who is the editor of theJournal of Sexual Medicine. (The global total, to date, for AMS implantations is 250,000.) “But it’s a third-line therapy.” In other
words, doctors try less radical treatments first. Implant surgery is intended for men whose erectile tissue is irreparably damaged and fibrous. Because if it wasn’t that way before the operation, it will be afterward. The prosthesis basically reams the erectile tissue on the way in.
Despite the reaming, an implant recipient can have orgasms and ejaculate. “The rigidity function—which is now being borne by the implants—has nothing to do with desire and orgasm,” explains Goldstein. Erection, orgasm, and ejaculation are independent events. A man can have an orgasm—or even multiple orgasms—without ejaculation, and he can have an orgasm and/or ejaculation without an erection. An implant only affects erection. Goldstein: “If you can play the piano before the implant, you can play the piano after the implant.”
Most prosthesis patients are older men. In about twenty minutes, Dr. Hsu will be inserting the AMS 650 into a seventy-year-old man whom I will call Mr. Wang. The reason for the operation sits in the waiting room: the new wife. Mrs. Wang is forty.
he first time an implant—basically a strip of cartilage— was installed in the penis of an impotent man was 1952.
The patient is described—this being the Journal of the South Carolina Medical Association—as “a 23-year-old Negro veteran of World War II.” Ironically, the young man became impotent as a result of being the opposite of impotent. Three months before, he had shown up at the veterans hospital with an erection that had refused to go down for two days and two nights. The doctors surgically drained the corpora cavernosa, and the operation resulted in a constricting scar in his erectile tissue, such that it was no longer living up to its name. Insult to injury, when he returned to complain about his impotence, the doctors refused to take him at his word. They had him masturbate in front of them. When this “failed to cause any visible or palpable erection of the penis,” Dr. Buford S. Chappell signed him up for the world’s first penile implant. Chappell does not specify who—or what—the cartilage came from. Nor does he mention whether the patient knew he was a guinea pig.
You got the sense that Chappell’s summation—“He has ejaculations although intercourse is not as pleasant as before”—wore a heavy sugar-coat. Chappell included an After drawing of the penis, which “now hung in a semierect position that allowed the comfortable wearing of clothing.” Based on the drawing, it was difficult to imagine wearing anything other than a caftan comfortably, and then only if you were comfortable with constantly appearing to have an erection, something that if I were a young African – American man in South Carolina in 1952,1 might not be.
lice and I are joining Dr. Hsu in the operating room today. Mr. Wang is resting with his eyes closed. The operation is being done with local anesthesia, backed up by acupuncture. The penis is in good hands: Dr. Hsu has done more than a hundred prosthetic implantations. “Exactly one hundred eighteen,” he says, vigorously scrubbing his hands and forearms at the sink in the corner of the operating room. “Only two extrusions.” Alice raises her eyebrows above her surgical mask. “You mean it. . .”
Dr. Hsu holds his hands up in front of a nurse for gloving, a word I can no longer, since chapter 6, type happily. He nods. Meaning it pokes through the end of the penis. This tends to happen during vigorous sex in certain positions. “That’s why we tell patients: No woman on top.”
“Ohhh, no.” This from Alice.
Dr. Hsu makes a short incision where the pubic hair would be if the patient hadn’t been shaved. (This way the incision scar is hidden; implants can also be inserted through the tip of the penis.) He picks up a steel rod of approximately the same dimensions as the implant. This rod, called a Hegar’s dilator, will be used to stretch each corpus cavernosum to ready it for the implant. It slides in fairly easily, though not as easily as I would have preferred, catching here and there and requiring a firm push.
Dr. Hsu’s nurse is unwrapping the second implant, for the other erectile chamber. This one does not go gently. The insertion is done in two stages. One end is submerged down to the pubis bone. That leaves several inches of implant sticking out of the incision like a flagpole upon conquered lands. Dr. Hsu hairpins the protruding part in half and then tries to feed the remaining end into the incision and push it toward the organ’s tip, straightening it as it enters. It seems to be stuck. There’s a kinked inch of implant protruding from the fleshy incision. Dr. Hsu presses on the kinked rod. The novelist Martin Amis once described an impotent character’s attempts at intercourse as being like trying to feed an oyster into a parking meter. This is like trying to put a parking meter into an oyster.
Dr. Hsu pulls out the 650 and starts anew. Alice has stopped watching. Mr. Wang, incredibly, is napping. This time it goes in with minimal wrangle, and Dr. Hsu sews up the incision. It looks like a penis again, but longer and fatter than it was an hour ago. Dr. Hsu does a dry run, making sure the implant bends properly and holds its erect position. He bends it up into the familiar silhouette, and then lets go of it. It stays as he left it, a cooperative flesh Gumby limb. Then he pushes it down out of the way, like those exercise gizmos that can be stowed flat under the bed. Mr. Wang won’t become erect, he’ll just suddenly be erect. His hydraulics have been swapped for an on/off toggle.
What Mr. Wang has sacrificed today is his organ’s natural retractability. The adjective flaccid will never again apply. In its place are the adjectives bulky and conspicuous. Mr. Wang will appear to be going through life at half-mast.
Too bad he doesn’t have a pair of underwear that exerts significant inward retentive pressure. I am borrowing the wording of the team of inventors listed on the patent for Men’s Underwear with Penile Envelope. The patent nowhere states that either of the inventors—who share a last name—had a semirigid penile implant that was causing embarrassing trouser bulge. Nor does it state that the other inventor exerted significant pressure to do something about it. I am, as they say, thinking outside the penile envelope. Just guessing.
Mr. Wang’s penis resembles a normal erection, but I find myself wondering if it feels that way. Does it feel like a blood-engorged penis, or does it feel like a penis with two silicone rods in it?
“May I squeeze it?”
Alice looks at Dr. Hsu. Dr. Hsu looks at the patient, whose head is hidden behind a green curtain of surgical sheeting. He is awake now, but he speaks no English and his crotch is still numb. He’ll never know. Dr. Hsu steps away from the operating table and pulls a pair of latex gloves from a box on a counter behind him.
“Mary, you have traveled a long way. You can do whatever you want.”
It does not feel entirely penislike, but at the same time, it does not feel inferior. It’s sort of bionic-seeming.
Though the exterior lacks the steely feel of a true erection, the interior is hard, harder even than a natural erection. And so it stays until everyone is finished. I can understand why, for someone who has exhausted all other possibilities, implants could be a welcome relief. So are they? And what do the ladies have to say?
In one study, 76 percent of the men were satisfied with the rigidity of their new, malleable organ. Another survey, of 350 men with inflatable implants, showed a satisfaction rate of 69 percent. In another, similarly sized study, 83 percent were satisfied—but only 70 percent of their partners were. (“Because they want to go on top,” surmises Alice Wen.) The most common complaints were that the implant caused pain or that it looked unnatural. Women occasionally complained that the head of the man’s penis was cold (a condition known as “cold glans syndrome”).
Obviously, satisfaction rates vary depending on the type and brand of implant. Less obviously, satisfaction rates vary depending on which one of a man’s wives is weighing in. In a study entitled “Satisfaction with the Malleable
Penile Prosthesis Among Couples from the Middle East,” some of the men—who hailed from Libya, Egypt, Sudan, Yemen, Algeria, and Saudi Arabia—had either two or three wives. Table 4, a journal table quite unlike any other, lists the men’s and women’s assessments in separate columns, and is split crosswise into sections for “З-Wives Polygamy” and “2-Wives Polygamy” While in six of the nine polygamous couples, the men basically agreed with their wives, three couples’ assessments bespoke stormy days in the marital tent.
Polygamy No. 4, for instance. The man reported being “satisfied,” as did one of his wives. The other two wives were, respectively, “dissatisfied” and “very dissatisfied” with the implant, “to the point of strong desire to remove it.” I pictured wives two and three whispering conspiratorially, kitchen knives hidden beneath their abayas. You may add to the general climate of marital discord the fact that 64 percent of the men had kept the operation a secret from their wives—possibly because 94 percent of the men hadn’t been told by their surgeon that their erections would be unnatural. The capper: A couple of years after the men’s surgeries, Viagra became available in most of these countries.
The careless reader might be tempted to draw a conclusion from the preceding paragraphs, and that is that polygamy causes erectile dysfunction. Ли contraire! In 2005, anthropologist Ben Campbell traveled from Boston University to the far fringes of Kenya to chat with Ariaal tribesmen about their erectile function. One of the things he discovered was that men with multiple wives had lower rates of age-related erectile decline. Of course, this is not to say that an extra wife will prevent you from developing ED. It is far more plausible that a man whose penis is in working order is more likely to take on the sexual freight of multiple wives. Compared, that is, to an impotent man. Who would have to be mad, or maybe Libyan.
ather than shore up a broken penis, might it be possible to simply install a new one? If a hand or face can be transplanted, why not a penis? Surgeons have, in fact, considered it. Danish surgeon Bjoern Volkmer said in an email that the topic came up some months ago with regard to a young patient whose penis had been partially amputated to remove a malignancy. One problem, Volkmer said, is that erectile tissue can react to trauma by growing the same sort of tough, nonelastic, fibrous tissue that contributes to impotence. This includes the trauma of attack by one’s own immune system, an inevitable side effect of transplanting someone else’s tissue into or onto your body. Immunosuppressive drugs would mitigate, but apparently not prevent, the. problem. (The other, larger hurdle, with cancer amputations, is that the immunosuppressive drugs needed to protect the new penis would leave the patient defenseless against the cancer.)
But if you happen to be impotent because someone has cut off your penis, then the microsurgeons can help you. The world’s most experienced penis reattachment surgeons can be found in Thailand, where, during the 1970s, an estimated one hundred vengeful Thai wives, spurred by media coverage of a prominent 1973 case, sliced off the penises of their adulterous husbands as they slept. When a suitably equipped microsurgeon was on hand to reattach the errant appendage, the men were able to resume philandering within a matter of months. Though probably with reduced success: The penises, though operative, were shorter, numb, and often only partway erectable.
The most serious complication, in the Thai attacks, was infection. Two of the wives flushed the penises down the toilet, forcing their husbands to grope for their lost manhood inside the septic tank. (Incredibly, both were found, cleaned, cleaned some more, and reattached.) More commonly, the women would hurl the penis out the window. In the cases described in “Surgical Management of an Epidemic of Penile Amputations in Siam,” all the recovered penises were “grossly contaminated.”
Better that than eaten by livestock. Many rural Thai homes are elevated on pilings, with the family’s pigs, chickens, and ducks tending to mill about seeking shade in the space underneath. It is not, oddly, the pigs, but rather the ducks, that the castrated Thai must worry about. The paper does not provide the exact number of penises eaten by ducks, but the author says there have been enough over the years to prompt the coining of a popular saying: “I better get home or the ducks will have something to eat.”
And then there are the castrations wherein the blade and the stalk belong to the same man. One of the Thai case reports was that of a husband whose wife had complained about his failings in bed, whereupon he walked into the bathroom and severed his penis with a straightedge razor. (While the Thai women in the article almost without exception used kitchen knives, the autocastrating male tends to reach for his razor. Or, in the case of one Thai farmer, a shovel.) The remorseful wife rushed both husband and penis to the emergency room—the latter wrapped, like an exotic lunch, inside a banana leaf.
A small but unsettling subset of autocastrations are the product of religious delusion. The New Testament contains a troublesome passage about celibacy (Matthew 19:12). In the passage, Jesus is ticking off all the kinds of eunuchs in the world. “There are eunuchs born that way from their mother’s womb, there are eunuchs made so by men, and there are eunuchs who have made themselves that way for the sake of the Kingdom of Heaven.” In 1985, a thirty-one-year-old Australian man added himself to the last category. It was an especially tragic case, as this man was already more celibate than many priests. He had never had sex, never had a girlfriend (or boyfriend). He lived with his parents, where, quoting the case report, “every spare moment was spent sitting in his room reading the Bible from cover to cover.”
Except for the occasional five or ten moments that he devoted, with tremendous guilt, to masturbating. Worried that the keys to the Kingdom would be withdrawn, or the locks changed or however that works, he decided to atone. Employing the skills he had picked up while castrating bulls on his father’s farm as a boy, he opened his scrotum with a razor, cut out his testicles, and flushed them down the toilet. The author of the case report interprets the disposal as a sign of resolve; ambivalent autocastrators often “bring their organs with them to the hospital.” Indeed, this man made no effort to retrieve his testes and voiced no regret for the act. He also refused testosterone replacement therapy, and has no doubt made great strides in the church choir.
I will leave you with the story of a fifty-six-year-old government officer in India who told emergency room doctors that he had cut off his penis in order to cure a longstanding case of incontinence. One of the physicians, who wrote up the case for the Indian Journal of Psychiatry, suspected deeper mental turmoil was at play, as the patient had earlier jumped into a well, in what was ruled an attempted suicide. Though given this man’s flair for therapeutic overkill, it’s possible he was merely thirsty.
A penis amputation is not a cure for incontinence but it was, for one perplexed seventy-year-old man, a cure for his impotence. The newly invigorated member was a phantom.
Phantom limbs are a common consequence of arm and leg amputations; owing to peculiarities of the nervous system, the sensations that existed in the limb beforehand often persist after the surgery. Occasionally, this happens with mastectomies—the phantom breast even seeming to “swell” at certain times of the month—and with penectomies (seven of twelve cases, according to one survey). Phantom expert V S. Ramachandran, of the Brain and Perceptual Process Laboratory at the University of California, San Diego, once had a patient with a phantom appendix. So painful was it that he had trouble believing his surgeon had removed the real one.
In the case of the seventy-year-old, the phantom erection was so vivid that the man would bend over and “check for its presence.” It must have been a bittersweet victory: to feel erections after two years of impotence, yet have no penis with which to take advantage of them. It’s a urological rendering of the O. Henry story about the woman who cuts off her long hair and sells it to buy her husband a watch fob for Christmas—not knowing that he has pawned his watch to buy a set of combs for her hair.
The phantom erections eventually stopped when the penis amputee, at seventy-four, was shot in the back and paralyzed from the waist down.