Penile prosthesis

Penile prosthesis implantation represents the ultimate option for the treatment of end-stage erectile dysfunction (ED). Originally developed in the 1970’s, and refined in the following decades, penile implants now represent a durable and safe solution for men when all conservative treatment options have failed or are contraindicated. Modern prostheses have a high mechanical reliability, are associated with low infection rates which translates into high patient satisfaction. The satisfaction rates are higher than any other treatment modality.

Indications

Any patient with Erectile dysfunction that fails to respond to oral medication, penile injections , vacuum devices or any other modality.
Patients where conservative therapy is contraindicated eg:
- a. Viagra, Cialis, Levitra, Spedra when taking Nitrate containing drugs
- b. Caverjet/Viridal - in patients on Warfarin, history of priapism
- c. Vacuum devices – anticoagulants
Patient choice after trying other treatments
Advanced Peyronie’s Disease
Following penile or pelvic trauma
Priapism
Buried penis
In conjunction with penile reconstruction.

Introduction to penile implants

David Ralph introduces penile implants

Patient Assessment & Counseling

Patients considered for penile prosthesis implantation should have a thorough physical and psychological assessment to ensure that surgery is the appropriate option for them. While implant surgery is quite effective at achieving functional goals, patients need to undergo adequate counseling regarding what to realistically expect from this procedure and possible complications. Penile prosthesis implantation usually represents the final step of a long diagnostic and therapeutic pathway, when all the spectrum of medical treatments has proved ineffective or not suitable.

When penile prosthesis implantation is contemplated, the patient’s preference as well as lifestyle, body habitus and previous medical history will often determine the best device option for the patient. It is important to review all device options with the patient to give him enough time to absorb and process all of the information to make a decision. In these conversations, patients should be shown samples of the various devices in order to allow them to appreciate the texture of the cylinders and familiarize themselves with the shape of the pump. Adequate preoperative counseling and management of patient’s expectations play a very important role in determining postoperative patient’s satisfaction rates.

Internet advertising can often be misleading and produce unrealistic expectations. Patients need to be fully aware that the goal of penile prosthesis implantation is to guarantee a straight and rigid penis for penetrative sexual intercourse with preservation of sensation and orgasmic function.

Occasionally there maybe reduced glans engorgement that will need additional medical treatment. Penile prosthesis implantation will not increase the length of the penis or restore the length loss due to Peyronie’s Disease, fibrosis or long lasting ED.

Patients also need to be aware that penile prosthesis implantation represents the last resort and is irreversible, as it causes permanent damage to the muscle of the inside of the penis. The inflatable implants last 10 -15 years depending on use after which they will need to be changed.

Check list:

Tried/been offered all other therapies
Handled all of the implant types
Expectations met
Complications discussed
Able to meet and discuss with other patients
Possible psychosexual counseling
Partner in agreement

Common questions that should be asked

Will it feel different during sexual intercourse?
Does a penile prosthesis allow for some romantic spontaneity?
How will my penis look?
How long will I be in the hospital?
Will anyone be able to tell that I have an implant?

Types of penile prostheses

Coloplast Corporation and American Medical Systems (AMS) produce the most widely used penile prostheses. Both companies produce inflatable and malleable penile prosthesis.

A malleable prosthesis gives a semirigid erection at all times. The penis is maneuvered into position for intercourse and bent either alongside the inner thigh or under the trouser belt for concelement when not needed.

An inflatable prosthesis involves the transfer of fluid into the penis when an erection is desired, and then back into a reservoir when a flaccid penis is needed. In a 3 piece device, the fluid is stored in the reservoir which is hidden in the pelvis. By squeezing the pump that is within the scrotum, fluid is then transferred into the cylinders within the penis to become erect. Once finished, a release button on the pump is pressed to allow the fluid to return to the resevoir and deflate the penis.

In general, young and physically active patients with good dexterity and a larger penis are better served with 3 piece inflatable penile prosthesis, since this type of device allows excellent girth expansion and rigidity and during deflation allows the penis to be easily concealed. On the other hand, in older patients, where concealment of the penis is not an issue and poor dexterity is more common, a malleable penile prosthesis might be the better choice.

A 2 piece device is also available which has a mixture of attributed and is reserved for those who have had extensive abdominal surgery to avoid the placement of a reservoir.

Penile implants: Types

David Ralph discusses the types of penile implant available

Diagram showing the types of penile prostheses