Penile Implant Journal for treating 40 degree bend with calcified plaque

[rakeshgupta2021]

Background

I am a 60 year old Indian male. I developed the problem  2 years ago in  the first half 2019. I discovered it when I woke up one day with a hardon but there was a bend, and I could feel a hard  scar/plaque about the size of a nickel somewhere between the base and the middle of the penis. The size and shape of the plaque has not changed  since then. This points to penile injury being the possible cause. I can't remember any incident from the past where the penis hurt. So, I am not 100% sure it is penile injury.

I was able to have vaginal sex then although I started feeling the erections were not as strong. I checked out a lot of material including this forum. I looked into a lot of potential treatments that are out there, and many of them have varying records of success.  For example, I tried DMSO/Iodine. I tried herbal pills that provide improved blood flow. Some of the treatments helped with the blood flow and helped keep the sex life and erections going. Over time, the erections became weaker. Fast forward 2 years I could get only weak erections,  and I could only cum through blow jobs. It was not easy to have vaginal sex for more than a minute. The erection would deflate from the pain.

I went to see Dr. Karpman around Oct of 2019. He injected the erection inducing medicine. He felt the plaque. He did the ultrasound.  He said the bend was 40 degrees with calciified/hard plaque, and there was hour glassing. He suggested two possible treatments -  a) Xiaflex, or b) Excision/Grafting plus implant. His preferred treatment for me was excision/grafting plus an implant. In his experience, only excision/grafting had poor results as the healing of the excision/graft area  needed a lot of discipline and hard work from the patient to have erections so the healing happened in the right way. He said he would do Xiaflex if I wanted to try a non surgical method, but he warned that Xiaflex has poor results against calcified/hard plaques (he said there are studies on this). I went home dazed, realizing that nothing I tried worked so far, and the logically the only option left appeared to be surgery.  I was also concerned that a surgeon would obviously recommend a surgical option, and I wanted to make my decision in a careful manner.  I wanted to think more about this. I sat on the problem after that for 2 years (part of it due to wanting to avoid procedures when covid was rampant), and realized around August 2021 that I need to make the moves to solve this  problem  I went back to see Dr. Karpman again, and discussed the options again. Finally, I decided to go with surgery.

Takeaway: Go see a good urologist ASAP when you have a problem. Time is not going to make the situation better. Hope is not an answer.


Pre Surgery Discussion with the Surgeon

This meeting happened 8 days before the surgery.

I was able to talk to a forum member prior to this meeting, and realized that there were 2 viable surgery options actually:
1. Excision/Grafting with Implant
2. Implant only..if the penis straightens
3. Excision/Grafting without Implant (this appeared to have a very high chance of failure given it required).


I discussed options 1 and 2 with Dr. Karpman, and we agreed that he will do the implant first, and if the penis has less than a 10 degree bend, to not do the excision/grafting.  If the bend was more than 10 degrees, I asked him to go ahead with the excision/grafting.  He did warn me that he prefers option 1, and option 2 is not totally clean as the plaque will still be there. He was not sure how the plaque will behave in the future, and if it will cause pain (erection, intercourse, etc.).Dr. Karpman also mentioned that he will keep me overnight in the hospital. He also said he was going to use Coloplast,and that the Boston Scientific LGX 700 was not a fit for my situation (I am not able to recollect the reason).

Takeaway: Some of the people on this forum know quite a lot. There is a lot of information on this forum. Educate yourself and you will make the right decision for yourself.

(I cannot emphasize enough the tremendous service some of the forum members like Hawk provide. They take so much of their personal time to help out the rest of us that have  run into this problem)


Pre Surgery Preparations at Home

I made sure I cleaned all surfaces  in the kichen, bedroom, living room and bathroom with Lysol spray.  I sprayed the sofa with the same spray, and also ensured I was going to use clean sheets, towels and clothes. This was to reduce the chance of any infection post surgery. I will keep following this routine after I come back from surgery.

Takeaway: Do everything you have to do to reduce the chances of an infection.


Day 1 - Day of Surgery

I went to the hospital and checked in. I spoke with Dr. Karpman briefly, and was taken into the OR. I came out of anesthesia possibly 3 hours later. Dr. Karpman came by to say the surgery went well, and that the penis had a very small bend with the implant inserted. So, he did not do the excision/grafting. The pain was severe in the area of the surgery, and I made sure I took as much pain medicine as I was allowed during my time at the hospital. The pain was quite severe, and I felt depressed thinking this was what was in store for me the next 3 weeks.  (Fortunately, it did not turn out that way)

Day 2 - Day of Discharge

They removed the catheter, the bandage around the penis, the blood drain from the wound, etc.  in the morning.The catheter removal was painful, but not as painful as I had imagined given some of the implant journeys I read.

Dr. Karpman came in the morning and spent some time explaining that I have to put in the hard work now. He was going to send me 70% inflated, and asked that I do the following important things till I see him in a week
1. Hot tub soaking at least 2 times a day for 30 mins starting Day 5. This was so there was increased blood flow to the area of surgery and around, and this would lead to better healing. (Please note that they used ice packs on Day 1 and Day 2 to reduce the inflammation from the surgery. So, it appears there is a switchover point and time between reducing inflammation through ice packs and improved healing through heat. If anybody has any opinion on this, please comment)
2. Pulling down on the implant apparatus in the scrotum without activating the inflation/deflation to ensure that the implant apparatus  settles/heals at the bottom of the scrotum (2 times a day)
3. Post the 1 week post op visit, he said I would need to cycle the erections 2 times a day for 30 min.

I was discharged around noon, and the drive home was 1 hr. and painful with the bumps in the road causing pain. Based on this experience, I believe that a long road trip home may not be a good idea this soon after a surgery. I think it would be better to stay at a hotel nearby for a couple of days. It is probably a good idea to avoid any additional  physical trauma in the immediate aftermath of the surgery.

Day 3

I had a lot of pain. I took the opioid pain killers to manage the pain (maximum allowed by the prescription..4 per day).

Day 4

I showered as this was allowed starting this day. Pain came down as well.  I was down to 2 opioid pain pills for the day.

Day 5

There is slight pain, bordering more on the discomfort side. I did not take any pain medicines today. Also, did hot tub soaking today. I am able to walk up and down the stairs. I did some walking inside the house on one level.

(More to follow)

[Roddy]

Hi Rakeshgupta

Welcome to the Implant Forum. What an excellent introduction to your own journal - so well written and organised. I love your 'take away thoughts' sections. Good luck with your recovery, which sounds as though it's going well so far, and stay ahead of the pain at all times once you start cycling. I too was sent home 75-80% inflated and I know it's not easy walking around the house with a hard on for 10 days! I remember sleeping was particularly difficult due to my erection.

Keep your spirits up as the end result is mind-blowing from the hell you've been through for the last few years. Please read the journals of the guys on here as they are a treasure chest of information and will keep you going if things get dark for you.

Looking forward to your next posts.

Roddy

[Mikel7]

Keep us posted and a quick recovery !  

[Hawk]

I agree with Roddy,  What a great, well-written introductory post.  I am so glad you advocated for yourself and encouraged Dr. Karpman to try the implant BEFORE excision/grafting.  You are so much better off both recovery-wise and with the initial risk of surgical issues such as infection.

Dr. Karpman is to be commended for listening to a patient's concerns and modifying his surgical plan to include both his expertise and the patient's input.

Please keep the journal progressing.  We would all prefer updates to help others.  All your entries do not have to be masterpieces like the first entry.  Just let people know how this progresses as you heal and the impact it has on your life.

[tshug]

rakeshgupta2021, nice detailed post! You and I are both in the recovery mode. I had my revision implant done last Tuesday and I'm in day 5 now and progressing well.

I hope your recovery continues to go well too. I have a post going also with my recovery and hopefully both yours and mine will help others going through this.

tshug

[rakeshgupta2021]

Thanks, all.

So far, my implant journey seems to be going well. I was very apprehensive about how painful it would be,  especially after reading Merrix's journal.  The difference may be related to overall health/response to surgery, prior treatments on the penis and their effects on this surgery.

Here I am at Day 6, and the only pain/discomfort I have is when urinating, and that I am walking around in the house with an erection. The implant appears to be a very viable path and should probably be one of the top options. However, I think it requires you to go through a whole process psychologically of accepting the implant.

I bought sweatpants 2-3 sizes larger, and a hoodie to use if I am going to walk outside. I will try to go for a walk outside today. I will also use the jockstrap they sent me home with to provide some support while I am walking (and avoid adding stress to the area).

[rakeshgupta2021]

Days 6 to 9

Steady recovery. 2 hot tub soaks every day. Completing the antibiotic prescription. No pain meds.
Urinating is almost normal and painless (even with the 70% inflation that I have now)

The pain that I felt when I pressed on the plaque area is gone. This was a big fear for me, because if the pain is there, I would need to go for excision/grafting later.  Will review this pain aspect with the doctor on a full erection.

Went for a 2 mile walk on Day 9 on flat ground. I think I would not have been difficult if the terrain had some climbing.

Day 10 is the follow up meeting with Dr. Karpman, and another follow up likely after 3 weeks.

[Hawk]

A great report.  You are on your way and far ahead of where you would be now if you had both an implant and excision/grafting.

If you know your first inflation/deflation will be by the doctor, save a pain poll for that day.  No one has ever inflated my penis other than me, but I read the accounts and can imagine the discomfort of having someone else inflate you because they are getting no feedback of discomfort as they pump.  

[Waveboy]

Great information. Great that your didn't need / hope you don't need graph/ cutting plaque. I had that and that has been the toughest part of surgery healing for me.

Yes I would suggest to others as you did stay couple nights in hotel room. No road trips.
Keep us updated!

As far as feeling someone else inflating / deflating. My doctor just checked mine to make sure working and I go back in 10 days for education. But the only discomfort is holding the deflate button down if the doctor doesn't know he has the edge of your ball squeezing it. If I do it myself I will know what is between finger and deflate button. But when he pumped up I didn't feel that.

[rakeshgupta2021]

Day 10 Update


I met Dr. Karpman today, and we cycled the inflation/deflation 2 times - once by him and once by me. He said I am recovering well. He said the next 90 days are critical for the healing and that I do the inflation/deflation cycling.

He suggested that I

• Do the inflation/deflation cycling atleast 2 times
• Keep the penis inflated for 30 min atleast each time.  
• need to do this for 90 days
• More times I can do this in a day, the better

Dr. Karpman said I got a 18cm+2cm RTE. He could not use the 20 cm due to the plaque constricting. However, the penis nowhere near the 18cm or 20 cm length

I will see him in 2 weeks. I will post my next update on this thread then.

[JB999]

Rake, funny, I had my first follow up today with Dr Karpman, I'm 8 days post-op.  How did it go today?  Any issues?

[Hawk]

You two might have been in the waiting room together

[rakeshgupta2021]

@JB9999 ...Congrats on your surgery. We may have been in there in the waiting room at the same time. How is your recovery coming along?

There were no issues. Dr. Karpman said everything is coming along well. Now, I have to do the daily work for the next 3 months.

[JB999]

Lol, yes, but with that busy office.......  Recovery from surgery itself has been great. Other than day/night of surgery, have had no pain, no issues.  Except for enlarged prostate being aggravated by the surgery, and subsequent urination issues, everything is great.  Now need a second surgery for the bph.  Glad to hear yours is going well

[rakeshgupta2021]

I have been working on my inflation/deflation since the doctor's visit.
I am confident that I am reaching full inflation. However, I am not so sure I am getting full deflation.
Can somebody tell some signs of full deflation. I have a Coloplast.


Also, what does the implant length imply in terms of the erection size I will achieve.

[Roddy]

Full deflation can be something of a worry for sure. Not long after I was implanted there was extensive talk on the forum about the possibility of tissue erosion from not properly deflating. This made me kind of paranoid if I'm being honest as I had got used to still having what we call here in the UK a 'semi' and what you guys in the US call a 'chubbi' (am I miles wrong on that one? 🤣) when I had deflated. It never really went properly soft again like a natural floppy. I got into the habit of simply deflating with my right hand and squeezing my penis with my left hand at the same time. This is what I still do now.

I also remember being pretty gutted at the 5 inches I was left with on full pump weeks after the op. I kept faith with what I had read from the other journals - that daily cycling for at least half an hour, would restore length and girth in time. I'm glad I continued to cycle as I stopped this once I had reached 6.25 inches again. I became more concerned with longevity of the implant than making it back to 7 inches where I was before extreme peyronies had robbed me of 2 inches. So, in summary, if what you are saying is that you are disheartened by the length you're at just now, don't be. Just keep cycling to the max, daily, for 6 months to a year and you'll get back what you've lost.

Hope that helps ease your mind?

Roddy

[Hawk]

Walking around constantly with a semi or chub (we use both terms in the U.S.) can potentially cause erosion.  What is more important is that deflation is as important at this stage as inflation because both stretch the forming scar capsule.  One stretched the penis, the other the reservoir capsule.   When you TOTALLY deflate a brand new Titan, your penis should be somewhat misshapen. When you feel your penis with the thumb and index finger, you should feel be able to feel a flat cylinder on each side.  You should be able to walk up the cylinder with your thumb and index finger.  You should feel a "dog ear," which is just a term for a folded cylinder at some point along the way. Without fluid, the retracting penis makes the cylinder fold or crimp.  You can feel the semi-sharp corners of the fold, like a dog with half of his ear erect and half bent down.

IF you can get the Titan "one-touch" to work (most can't at this stage), then you can:
squeeze the deflate button with one hand,
turn loose of the pump
Squeeze the penis with your hand, and it will deflate without touching the pump again.

A better way to do it is:
Squeeze the deflate button
Turn loose
squeeze the penis using the ball of each thumb like a vise
You can roll your hands from the ball of the hand to the knife-edge of the hand.

That vise-like rolling action will milk all fluid from the penis.

I seemed to have a little auto inflation early on. Auto inflation is the result of the reservoir capsule not getting stretched by total deflation.  So I totally deflated my penis and then wrapped it snug in Coban wrap to keep it constricted when not inflating.  I only had to do that for about 36 hours, and it seemed to resolve my issue totally.

Determining the size of a penis from an implant size is difficult.  I have a 22cm Titan, and after 6 months of cycling, I reached 7"  VERY firmly bone-pressed with very full inflation.

[JB999]

Great info Hawk, thank you.  I start cycling next week, so am learning all I can beforehand.

[rakeshgupta2021]

Things appear to be progressing well on my recovery.

Normally, before the surgery, I had big balls. Now, with the implant, I feel like my balls have become much bigger. The scrotum is the size of a tennis ball  now.

Did the people with the implants experience an increase in the ball size.

I see the doctor in another 10 days for the 3 week follow up.

[Hawk]

You have a small addition to the scrotum so you have to increase a little but what you are experiencing has to be swelling that has not totally resolved.

I know you got a Coloplast but was it the Titan or a different model?  Also, remind us of the size and whether there were Rear tip Extenders (RTE's)

[rakeshgupta2021]

It is a Titan Coloplast 18cm plus 2cm RTE.

[rakeshgupta2021]

Regarding Cycling to full inflation and deflation...the doctor advised that I should go to full inflation and keep it inflated for atleast 30 min 2 times a day. From reading the forums, it appears that the benefit is more if you can keep it inflated longer and more number of times.

Is the above correct?

[Hawk]

The longer time the better.  I personally would accomplish this with longer sessions NOT more sessions.  The more sessions, the more wear on the pump.

That does not mean in the beginning weeks I would not do multiple times a day but I personally would not and did not do that for months.

[rakeshgupta2021]

I had a 3 week post surgery follow up today with Dr. Karpman. Next follow up in 3 months.
Dr. Karpman said it is healing well, and cleared me for sex. My scrotum is still bigger than I what I think it should be. He suggested continuing with ibuprofen 600mg/3 times a day for the next 3 months.

When I asked why he picked Coloplast vs LGX, he said Coloplast is the only implant approved for Peyronies because of the strength of the material.

https://www.coloplastmd.com/diseases/peyronies-disease/

[JB999]

Rake, we are on the same timeline.  Back to your post on 11/14 re: deflation, how is that going, better?  I can deflate to the point where I am comfortable in underwear, but I seem to auto inflate a little.  Leaves me too inflated for comfort.  I've tried deflating again, holding pressure, briefly hitting the inflate valve.  To no avail.  I auto inflate back to the same hardness it seems no matter what.  Curious if you or anyone has dealt with this.  I would like to deflate more than I am currently  

[Hawk]

No doctor ever told me to do this but Dr. Eid did tell me the importance of stretching the reservoir very early so the scar capsule formed to accommodate all the fluid.  He said If I did not that only surgery could correct the problem.

Due to that advice, when I experienced some auto inflation at about 3 weeks I immediately took action.  I would TOTALLY deflate and immediately wrap my deflated penis very snugly with  Coban self-adherent wrap.  I only had to do it for 2 days and nights to resolve the issue.

[JB999]

Thank you Hawk.  I have some of that wrap, I will try it!

[rakeshgupta2021]

I have the left half of my scrotum inflamed/bigger and lumpy and  heavier. The doctor insisted that the pump must have slipped on one of my inflation/deflation cycles and hit the testes hard, and that it should it resolve over time. I don't remember ever banging the pump into the testes.

Other than this issue, I feel like most of the other trauma has healed well.

Anybody else run into the swollen scrotum problem after 4 weeks?

[Hawk]

Smacking a testicle with a flying pump hard enough to cause swelling would be an UNFORGETTABLE incident.  I have been dropped to the floor with a work-related strike to a testicle (pre-implant) and it never caused swelling.  There is no way the swelling is from a rubber pump bulb giving you a startling, uncomfortable, pop to the testicle.

I would monitor this very closely.  Is this the side of the scrotum the pump is in or the other side?

I would try heat and cold and if it gets the least bit worse, insist on a fast appointment.  

[rakeshgupta2021]

The right half of the scrotum is normal. It is as before.
The left half of the scrotum is where the pump is, and the swelling and lumpy pieces from the swelling are there. Also, I feel a dull ache on the Left hand side of the scrotum (probably because of the weight of the pump and the inflammation).

I wish I had written down in detail how my scrotum felt before the surgery. I don't have a baseline to compare to.The right half could serve as a baseline, though.

In any case, do people feel the weight of the pump in their scrotum (3 weeks, 3 months, 1 year after surgery)

[Hawk]

Rakeshgupta, 6 - 9 months after surgery you cannot tell you have an implant no matter how you move.  There is NO sign of having an implant except if you feel with your hands.  In fact, at least 90% of the awareness is gone after 3 months.

If you read the journals you will see that no one complains about a swelled scrotum a month after surgery.  No one says they feel "lumpy pieces from the swelling there" at ANY stage after the surgery.

You really should read all the journals from the day of surgery to 4 weeks.  It would not take that long.

I am a little concerned about an infection.  Can you feel all the detail on the pump such as the ridges on the pump bulb?  If you get an infection those details cannot be felt.  Can you slide the scrotum skin back and forth over the pump bulb?  If it is stuck to the pump bulb, that is a sign of infection.  Infection ALWAYS starts at the pump.

[rakeshgupta2021]

Does anybody have any picture of how the IPP apparatus (pump, deflation button, tubes) are typically laid out inside the scrotum. It appears that the tubes into the cylinders in the penis and the tubes to the storage pouch are right in the center but hugging the skin ( in my case)

[Hawk]

Was your surgical approach Peno-scrotal or retro-pubic?

[rakeshgupta2021]

Infrapubic. The only cut is a horizontal cut above the penis

[JB999]

Rake, has this issue improved for you?

[rakeshgupta2021]

No. I still have lumps in the left hand side. Painless by themselves, but due to the weight of the lumps and the pump weight..the whole thing is  mild grade painful. Most likely some hematoma/hematocele. They keep saying I must have done something to bump the testes hard, and I keep saying NO - I would know if I did it.  They have given me a stronger anti inflammatory medicine. I am also using a jockstrap.

They scheduled an office visit this week, and I was disappointed to hear that the ultrasound person comes only on Mondays. They scheduled an ultrasound now for next week. So, I have to go in again.

I will have to wait till the ultrasound is done.

@JB...how are you doing?

Question to others : should I use the jockstrap during the daytime and while sleeping?

[JB999]

Sorry it's not better.  I have what Karpman called a hematoma, in my sack.  It feels like a soft but kind of rigid small piece of felt.  It's not painful however, so that part is all good, it's not impacting my lump.  My left testicle is up higher and out front way more than my right.  I think it's the tubing behind and below pulling it up and out.  Do you have anything lie that?  It's not painful in itself, but I have to be careful to not smack myself!  I also look lopsided right now, was told to give it time.

[rakeshgupta2021]

yeah...it is mess there for me with tubing, the inflation bulb, and the lump, and thickness from inflammation all packed in on the Left side of the scrotum.

strange that you also got a hematoma in your nut sack just like me...(and I will know for sure after the ultrasound on Monday)

[rakeshgupta2021]

Regarding the tubing question, the tubing is right in the middle, and forms its own shape that it holds.

[JB999]

Same for me. Tubing in the middle, but seems to come back up and under more on my left.  Good luck at that next appt

[Hawk]

Strange but I have never thought about or noticed tubing in my scrotum.  I just checked and with a little effort, I can feel 1/2 inch of straight tubing above my pump.  Tubing is routed differently with a retropubic approach however but you should not feel a scrotum full of tubing.

[rakeshgupta2021]

The tubing is quite prominent in my case, and it looks like, in JBs case too.

The results from the ultrasound came back regarding my left side scrotum being thicker and lumpy - it is hydrocele. I am going to give this some time, and see how to get it resolved. Having heavy balls is not exactly a good situation for the long term. There is hydrocele on both sides, but the left side decided to become bigger and lumpier.

[Hawk]

IS this expected to resolve?  Is it being treated?  Any time frame?

[Hawk]

You asked about a diagram of tubing etc., for an implant.  I am sure if you search you can find such diagrams. However, you might have to be persistent to find one for your specific approach (infrapubic).

There is no doubt that the detectability of the tubing depends on a few factors such as the approach, whether RTE's are used, and the surgeon's skill.

In general infra-pubic approach is somewhat more detectable, and RTE makes the tubing more detectable because they move the base of the implant where the tubes connect further forward.  Having said that, most men are very satisfied with either approach.

[rakeshgupta2021]

Need to meet the doctor again regarding the hydrocele to discuss the options. Surgery for hydrocele appears to be the only viable path from what I have seen.

I might have had a mild and stable case of hydrocele before the IPP, but now it is bigger, but still (hopefully) stable. However, the size/weight is uncomfortable, so needs to be addressed if it does not change.

I feel like the warm baths  in the days post surgery may have something to do with the increase in size. The progression of the hydrocele stopped after I stopped the warm baths. Also, some trauma from messing with the pump would have played a role.

[rakeshgupta2021]

Based on my experience, if you are considering IPP, it is best to fix some of the issues you may be having in the penis/scrotum area (eg: hydrocele) before the IPP. I think you would want IPP to be the last surgery. The hydrocele makes it harder for the use of the pump and deflation...

I don't know if if fixing the hydrocele in the same surgery as the IPP surgery would be a good idea, as it adds to the overall trauma in one surgery session, but it is worth discussing with the surgeon.

[Hawk]

I admit to total ignorance on this issue.  I have never encountered this problem or posted about this issue.  

[rakeshgupta2021]

I met Dr. Karpman.  There's a decent sized hydrocele on both sides (from increase in size post the surgery). He said that it is best to wait two months to see if the hydrocele will come down.  If it does not, then he would consider doing a hydrocele surgery.

He said that the chances of infection are higher from the hydrocele surgery because of the pump inside. So, he has to take extra precautions like having me stay overnight with antibiotic drip. For context, usually this is a 'simple' outpatient surgery.

So, it seems like it would have been better to deal with issues like hydrocele before the IPP. Unfortunately, I didn't think of this. Nor the doctor.

I assume that no one on this forum ever ran into this IPP/hydrocele combination:)

[Hawk]

It is the first instance I know of.  Hopefully this will self-resolve and you won't need to deal with it.

[LightAtTheEndOfTheTunnel]

What if you don't have a tub to soak in? I only have a standup shower