madman
Super Moderator
Watch starting at 31 minutes to watch Dallas (a gay porn star) who does an excellent testimonial.
Introductions and Program Overview
- Webinar Focus: Penile prosthesis considerations in the MSM (men who have sex with men) population—a rarely addressed topic in this format.
- Moderators: Dr. Chris Nelson (psychiatry, Memorial Sloan Kettering, SMSNA treasurer) and Dr. Yaofei.
- Speakers:
- Dr. Justin Law (urologist, Kaiser Permanente, LGBTQ+ sexual health interest)
- Dr. Jake Miller (urology resident, UC Irvine, research on ED and MSM)
- Jim Walker/Dallas Teal (former broadcaster, gay adult film actor, penile implant recipient, patient advocate)
- Program Structure:
- Dr. Law: Erectile dysfunction (ED) considerations in MSM.
- Dr. Miller: Penile prosthesis considerations in MSM.
- Dr. Nelson & Jim Walker: Patient perspective discussion on prosthesis expectations and satisfaction.
Erectile Dysfunction in MSM: Epidemiology and Predictors (Dr. Law)
- Definition: MSM = men who have sex with men; only 44.5% identify as gay/homosexual.
- Clinical Practice: Importance of asking about both sexual orientation and gender of sexual partners.
- Prevalence:
- 79% of MSM report at least one sexual dysfunction (ED, premature ejaculation, etc.).
- 45% report ED specifically.
- Homosexual men have 1.5x higher odds of reporting ED than heterosexual men.
- Hypothesized Causes:
- Psychological stress: social stigmatization, discrimination, internalized homonegativity, shame.
- Relationship/partner stability issues, competition, insecurities.
- Predictors of ED in MSM (Shinwan et al., 2012, n=2,700):
- Older age, HIV positive status, lower urinary tract symptoms, prior ED medication use, lack of stable partner.
- HIV-related ED: possibly due to androgen deficiency, immunosuppression, or antiretroviral therapy.
- Assessment:
- Sexual practices and preferences: sexual position (top/insertive, bottom/receptive, versatile) impacts management.
- Erection importance varies by activity (penetration, self-image, masturbation, oral sex).
- Erection as a sign of masculinity/arousal.
- ED Treatment in MSM:
- Similar to men who have sex with women, with key caveats.
- Address psychogenic factors: psychological stress, relationship instability, self-esteem, body dysmorphia.
- Referral to mental health providers may help.
- Assess recreational drug use, especially chemsex/party and play (10.3% prevalence in MSM).
- Caution: Intracavernosal injections in stimulant users due to priapism risk.
- Penile prosthesis as an option for refractory ED (to be discussed further by Dr. Miller).
Penile Prosthesis in MSM: Satisfaction, Biomechanics, and Safety (Dr. Miller)
- Prevalence: High sexual dysfunction in MSM, but limited data on IPP (inflatable penile prosthesis) outcomes.
- Medication Use:
- 16–29% of gay/bisexual men use PDE5 inhibitors (Viagra, Cialis), but little data on progression to IPP.
- UCI Multi-Center Study:
- 49 MSM from 7 centers in 5 countries, all with AMS or Coloplast implants.
- 21 primary implantations, no postoperative infections, 1 revision (non-infectious) at 15-month follow-up.
- Median EDITS score: 93.2/100; Quality of Life: 72/80 (higher than historical averages).
- Device Complications:
- Dissatisfaction often linked to device malfunction.
- Anal penetrative sex may expose prosthesis to higher forces due to sphincter/pelvic muscle tone.
- Biomechanical Studies:
- Ansari et al.: Device buckling at 980g axial force.
- Henry et al.: Buckling at 1,500g (patient-inflated); no buckling when surgeon-inflated.
- Cadaver/ex vivo: Buckling at up to 6,100g (cadaver), 5–8 newtons (ex vivo).
- Anal vs. Vaginal Penetration Forces:
- Vaginal: 500–1,500g (Karakin et al., 1980s).
- Anal: UCI study—average 3,000g (range 2,600–4,200g), 2–6x higher than vaginal.
- Anal penetration forces can exceed buckling thresholds, especially with suboptimal inflation.
- Counseling Recommendations:
- MSM (and any patient) engaging in anal penetration should be counseled on device risks.
- Emphasize proper inflation technique; demonstrate and have patient practice in clinic.
- More research needed on long-term outcomes and device durability in MSM.
Culturally Sensitive Sexual History Taking
- Sample Questions for MSM:
- "Do you have sexual intercourse with male or female partners?"
- If male: "What are your sexual preferences/positions (top, bottom, versatile)?"
- "How important are erections for your sexual activity?"
- For Men Who Have Sex with Women:
- Ask about anal penetration and sexual practices; erection strength requirements may differ.
- Intake Forms: Can help gather sensitive information non-verbally; patients can skip if uncomfortable.
- Provider Approach: Comfort and openness are key; normalize discussions about sexual practices and relationship structures.
Surgeon Counseling for MSM Undergoing IPP
- Preoperative Counseling Should Address:
- Higher forces during anal penetration may increase risk of device trauma/malfunction.
- Advise patients to monitor for device issues and report changes.
- Demonstrate and supervise device inflation to ensure proper technique.
- Reinforce at first postoperative visit; ensure patient can fully inflate device.
Patient Perspective: Jim Walker/Dallas Teal
- Peer Resource: Acts as a peer resource for men with ED and penile implants; receives 30–60 weekly inquiries globally.
- Barriers: Many men are reluctant to discuss ED or prosthesis with healthcare providers; peer support is often first contact.
- Personal Journey:
- ED began at age 28; HIV positive; tried oral meds, then daily tri-mix injections for adult film work.
- Excessive injectable use led to penile damage (loss of sensitivity, curvature).
- Underwent IPP after medical consultation; reports high satisfaction.
- Device Use and Limitations:
- Advises "respect your device"—avoid positions/devices (e.g., constriction rings) that stress the implant.
- Avoids reverse cowboy/cowgirl and squatting-on-top positions due to buckling risk.
- Has experienced buckling with partners inexperienced in receptive anal sex; recommends patience and alternatives.
- Not concerned about future revisions; trusts device and provider.
- Integration into Sexual Activity:
- Prefers term "bionic" over "prosthetic" to reduce stigma.
- Integrates inflation discreetly during foreplay; partners often unaware of implant.
- Encourages confidence and openness; partner reactions are generally positive or curious.
- Advice to Providers:
- Understand and inquire about patients' sexual practices and relationship structures.
- Avoid assumptions (e.g., asking gay men about wives).
- Cultural competence is more important than provider's own orientation.
- Outreach could include presence at LGBTQ+ events or online platforms for anonymous Q&A.
Relationship Structures and Sexual Practices in MSM
- Open Relationships/Non-Monogamy: Common in long-term MSM couples; frequency varies.
- Sex Outside Relationship: Some couples engage regularly or occasionally; throuples and other arrangements exist.
- Provider Role: Normalize and inquire about these practices without judgment.
- Chemsex: Prevalent; can impact ED and treatment choices.
Community Engagement and Outreach
- Self-Treatment: Many MSM self-treat or seek advice from peers rather than providers.
- Provider Outreach Suggestions:
- Display inclusive symbols (e.g., rainbow flag) in clinics.
- Register in LGBTQ+ friendly provider directories (e.g., GLMA).
- Consider semi-anonymous online outreach or Q&A platforms.
- Engage with community events or websites frequented by MSM.
Postoperative and Partner Satisfaction Data
- Survey Timing: Satisfaction surveys best administered at 3+ months post-IPP, after recovery.
- Partner Satisfaction: No published data on partner satisfaction with IPP in MSM; only patient satisfaction and some data on ED in MSM.
- Future Research: Partner satisfaction is an area for future research.
Postoperative Use and Recovery
- Standard Protocol: Device cycling starts at 2 weeks post-op; sexual activity (including anal penetration) permitted at 6 weeks.
- Patient Guidance: Advise patients to start gently; most are cautious initially due to soreness.
- Risks: Some patients may attempt use earlier, risking complications.
Barriers to Care and Recommendations
- Barriers: MSM may avoid seeking care due to stigma, lack of provider understanding, or fear of disclosure.
- Provider Role: Foster inclusive, nonjudgmental environments and proactively address sexual health with all patients.
- Peer Support: Visible community advocates (like Jim Walker) play a crucial role in education and destigmatization.
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