At this point in my life I can say with confidence that I have seen a lot of penises. I have seen penises that are circumcised and uncircumcised. I have seen penises that are long, that are short, that are wide, that are narrow. I have seen penises with weird things growing off of them, with weird holes cut into them, that have been broken into a few different pieces, that have swollen up to three times their normal size. I have seen penises without any skin on them (protip: do not google image search “Fournier’s Gangrene”), penises turning green or black or purple, penises oozing pus. I have seen them cut open on the operating table, with insides splayed out like Prometheus on the rock.

In a similar vein, I have seen a lot of vaginas. Vaginas, being internal organs, are not as readily exhibited as penises, and require a great deal more assistance to display. No matter how good of a lover you think you are, I can guarantee you haven’t really seen a vagina until you’ve seen it in the OR. There are long labia, and short labia, and large clitorises, and small clitorises, and people with lots of hair and people with little hair, but once you pull the folds aside with a special surgical instrument called a Lone Star retractor (another thing you do not want to Google Image search), they all look mostly the same. There’s a lot of mucosal tissue, and eventually you get to a cervix. There’s not much modesty when you’re in the OR, legs in stirrups, draped in blue towels covering everything but your genitals, everything swabbed with iodine, two to three big surgical lights as bright as spotlights pointed directly at your crotch. Your face is totally covered. Your genitals are the star.

Americans feel weird about genitals. Are they supposed to have hair? How much? What color? Is it supposed to go up the shaft, or down into the labia minora? What are they supposed to look like? How big is big enough? How much skin is too much skin? And even if you reach a point in life where you feel comfortable with your genitals, there’s always some hesitancy about showing them to someone else, because you never know if that person might think something looks weird. This is America, and we’re weird about our junk. Usually genital aesthetics are confined to changing style or amount of hair, but more extreme options—from external pumps, implantable rods, or surgical nip & tuck of loose skin—still appear on side bars of all disreputable websites. Devices or surgeries to cosmetically alter the vagina are less common. While labioplasties (surgery to decrease the size of the labia majora or minora) are performed as surgical alterations to the vagina, most genital-modifying devices and surgeries are usually marketed to one specific group: people who want bigger penises.

The first penis surgery I ever saw was an implantable penile prosthesis (IPP, in surgical jargon). There are several different types of penile prostheses, but the two most common flavors are a pump or a malleable. The ‘pump’ is composed of two cylinders sewn into the shaft of the penis, connected by a suction line to a reservoir tucked away in the abdomen. This suction line is activated by means of a squeezeable plastic bulb (the pump itself), which is tucked down in the scrotal sack. A malleable is a lot simpler—just two malleable rods which get inserted. Bend down for everyday life, bend up for action.

The malleable kind

As a student, penis surgery was the first surgery I got really excited about. This sounds weird. Most urologic surgeries are done laproscopically, which means we cut holes in your belly, pump it full of air, and then stick a camera and surgical instruments inside and do the entire surgery on camera, video-game style. Laproscopic surgeries are good for patients—smaller incisions take less time to heal, require less pain medication, and usually have shorter hospital stays than open surgeries. However, when you’re a bright-eyed med student, sitting in the back of the operating room watching a screen for four hours does not feel like doing surgery. If you’re a student, you want open cases. Open cases are what laypeople picture when you think of surgery: someone is lying on a table with part of their body cut open, and surgeons standing around them with surgical tools, operating. If you’re a med student, you want to see real surgery, and that means open surgery. You want to be in there, holding back organs, watching blood spurt out of somebody’s abdomen and cauterizing the bleeders. I’m not saying that I want anyone to bleed profusely in the operating room, but if someone were to start spewing blood, I’ll be circling like a hawk with talons full of gauze. After watching a few days of mostly laproscopic surgeries, falling asleep in a darkened OR while people more important than me (trained surgeons) manipulated instruments inside someone else’s peritoneum, I wanted to get my hands dirty. So I signed up for the IPP.

If you’re thinking about getting a penis implant, here are some things you should know. They’re done by urologists. They are not a first-line therapy for erectile dysfunction; we only use them as a last resort, after Viagra, injections, and all other treatments fail. We more frequently use them in people who have traumatic injuries, or prostate cancer, or severe priapism (if you have an erection lasting six days, we might be seeing you). They only allow you to achieve an erection; they do not affect ejaculation or orgasm. They don’t make your penis larger; we specifically use an implant that will match the size of the organ you already have. They take around two hours, maybe as long as four or five. The surgery is covered by Medicare, as long as you have documented erectile dysfunction. You will lose a fair amount of blood—not as much as a car wreck with a long bone fracture, but more than a kidney transplant. Penises and scrotums have a lot of blood vessels.

If you’re thinking of DIYing some penis implants (never never never do this), the first thing you do is arrange the penis for surgery. To use a Lone Star retractor, you put about five or six hooks through the glans and the scrotal sac and pin them into place so you’re looking at the underside of the penis. You make a two or three inch incision in the scrotum, and then pull that incision open so you have a hole you can almost fit your hand through. You reach up through the inguinal ring (that’s the space where testicles descend out of the abdomen and into the scrotal sac), and you have to dissect away enough fascia (essentially the packing peanuts of your body, all the stuff between your organs) to make a pouch to hold the reservoir.

Then comes the fun part—you have to make space in the penis for the implants. To do this you take a series of dilators, metal rods of successively larger diameter, and shove them up each side of the shaft. Make sure you don’t hit the urethra, lest your quarry forfeit the cherished ability to urinate. To really get it in there, you have to hold the shaft up by the glans and shove as hard as you can to get the big metal rod all the way to the tip. Then repeat, only with another metal dilator which is larger around. After the hole in the shaft is large enough, you’ll have to put the implants up through the shaft. The implants also have to be anchored to something, so you take those same metal dilators and make two more holes, going through the scrotum down to the pelvic bone. Push the dilators to make sure they’re all the way down to pubic bone. Listen for the thump.

Then you begin to implant the prosthesis itself. To get the prosthesis up in the shaft, a threaded needle is attached to the top of the implant. Stick that needle up the shaft until it comes out of the glans, then pull on the thread to situate the inflatable cylinder all the way up the shaft, secured just under the glans. Insert the other end of the implant down next to the pubic bone, to anchor it. Repeat, inserting the shaft implant and bone anchor, for the other side. Then you insert the reservoir (which is just a plastic balloon filled with about a half cup of fluid) into that space you made in the abdomen. Attached to the implants is a little pump, which has a button in the middle. You take the tubing from the reservoir and hook it up to the pump, then hook up the tubing going from the pump to the implants.

To make sure it works, give it a squeeze. (This was the part my all-male operating staff made me do.) When you squeeze the pump, the inflatable cylinders fill with fluid, and up it goes. Push the button, and the fluid drains out of the cylinders back into the reservoir.  Down it goes. In the operating room, full of male staff, they made jokes about the device. “Look, you’ve got his attention,” they said, when the cylinders were full, and laughed. “Pull harder, it won’t bite,” they said, when I didn’t hold the shaft tightly enough during the catheter insertion. “It’s like a llama. It’ll just spit a little.” They laughed. I laughed, too. “His wife will be happier now,” our scrub nurse said.

As someone who appreciates a little misandry now and then, watching penis implants is grossly satisfying. Cut open the scrotum! Yeah! Shove big metal rods up the shaft! Oooh, that’s a lot of blood. But I was also upset. The first patient I saw get an IPP had lost his prostate to cancer, and was unable to ejaculate or achieve erection. Later in the week, I watched my second IPP—this time for a young man who took too much Viagra and got a blood clot in his superficial penile veins. The clot turned into scar, which would permanently disable his ability to achieve erection on his own, without the implant. In both cases insurance covered the surgeries.

Implantable penile prostheses are not just covered by insurance in case of disease or trauma, like the patients above. Medicare covers implantable devices for anyone who had documented history of erectile dysfunction. I live in a country where insurance will cover penis pumps if you can’t get it up, but not my birth control. The pleasure of middle aged men who can’t achieve an erection on their own is more important than my right as a woman to control hormones in my own body. 

Is it right? Is it right that insurance (and not just private insurance, but Medicare, government-funded insurance) will pay for penis surgery? Well, it’s okay for the first patient, because he had cancer. Cancer is bad. It took away his sex life. We’re just fixing the consequences of cancer. He’s a nice man, with a beautiful wife, who was always kind, and courteous, and his bones stuck out from his chemotherapy. But what about the guy who drunkenly took too much Viagra and got a blood clot in his penis? Unlike our cancer patient, he was terrible to us—rude to the nurses, mean to the doctors, always asking for increased pain medication. He kept cases of Mountain Dew in his room, and had already, before age 45, lost his top teeth. Does that change the way you think about his right to health care? What about the man the next week, who was going too hard from behind and ripped his corpus cavernosum? Is it right that most insurance will pay for a surgery so that he can engage in intercourse again, but won’t cover Plan B if I drunkenly use a condom wrong?

Maybe the comparison isn’t fair. But being able to generate an erection for sex is so important that it is covered by most insurance companies, and there is little controversy. It’s also complicated to parse out what is and isn’t covered—all private insurance is a little different, and government-funded Medicare part D (the part that pays for prescriptions) recently cut funding for all ED drugs, but Medicare will still pay for an implantable penile prosthesis for a patient with the same diagnosis. Earlier this year, when Hobby Lobby made a big stink about covering Plan B and IUDs, opponents were quick to point out that they still covered Viagra and vasectomies. But there was no Supreme Court case where these were challenged. There are no Christians lobbying Congress to cut Medicare funding for IPPs so older white men can get it up. There is little or no public controversy about who’s paying for men to have sex. No lobby group is trying to control male sexuality. When it comes to an IPP, no one is asking: “Well, did he have cancer? Or did he do this to himself?” because the male right to an erection is unquestioned. There is no other medical reason to get an IPP—it doesn’t, for example, stabilize mood swings, decrease the incidence of ovarian cysts, help prevent endometrial overgrowth, or even treat acne, all of which oral contraception pills do. Why does the controversy only come up when women and sex are involved?

The patient did well. The next day, in his hospital room, his wife thanked us as we signed his discharge paperwork. Later, the surgeon in charge of the case awkwardly admitted that he should be more professional, and that it was a bad idea to make lewd jokes in front of med students. He gave me a good grade. In the next case, instead of just holding retraction and mopping up blood with gauze, they let me attach the connectors to the pump—it sounds like a small gesture, but with an expensive surgical implantable device which requires correct connections to work properly, is way more important than wiping up the dirty spots. My urology rotation finished uneventfully. Every resident and attending I met asked me the same question: “What do you want to do?” And each time, I gave the same answer—gynecology. “It’s very similar,” they said. Unspoken but true, which I thought every time, was but urologists make more money. Eventually my sex drive came back, but I don’t know if I’ll ever be able to see a penis without thinking of what it looks like cut open. And I’ll never see penis enhancement spam the same way again.