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Many men with ED have limited success with medications, and many men are unsure that they will be able to have intercourse successfully on any given day. Because of the uncertainty of success, and to prevent disappointment for their partners and themselves, many men are reluctant to initiate sex. A device implanted into the penis, known as a penile prosthesis, can restore erections in most men with ED. Many men don't realize until after penile implant surgery that they had been avoiding sexual relations because they feared that they would be unsuccessful. After implant surgery men are confident that they will be able to have intercourse successfully whenever they wish to.
Figure 1. With an inflatable implant, erection is produced by squeezing a small pump implanted in a scrotum. The pump causes fluid to flow from a reservoir residing in the lower pelvis to two cylinders residing in the penis. The cylinders expand to create the erection.
Penile prosthesis surgery has been performed for more than 30 years since it was developed at Baylor College of Medicine in Houston by Brantley Scott, M.D. The surgical techniques and implant devices have undergone a number of improvements over the years, so that it is now a very reliable and satisfying treatment for men with ED. Most men try less invasive approaches before they have implant surgery, but more than 80% of men who have surgery are very satisfied with the results.
The urologists at MBUA are the most experienced in the Santa Cruz and Monterey area with this type of surgery. Dr. Rosen trained in Houston with the inventor of the inflatable penile prosthesis, and all of the doctors have many years of experience. We recently hosted a visit by Steve Wilson, M.D., one of the highest-volume implant surgeons in the world, and had an opportunity to learn some of his techniques. We have many satisfied patients who are able to share their experience with men interested in the surgery.
There are two main types of penile implants, inflatable and malleable (also called semi-rigid). Inflatable implants consist of paired cylinders, which are surgically inserted inside the penis and can be expanded using pressurized fluid (see figures 1 and 2). Tubes connect the cylinders to a fluid reservoir and a pump, which are also surgically implanted. The patient inflates the cylinders by pressing on the small pump, located under the skin in the scrotum. Inflatable implants expand the length and width of the penis when the device is inflated. They also leave the penis in a more natural state when not inflated. MBUA urologists recommend impantation of prostheses from Mentor Corporation or American Medical Systems.
Figure 2. An inflatable penile prosthesis has 3 components; 2 paired cylinders, a pump, and a reservoir.
Malleable implants consist of paired rods, which are inserted surgically into the corpora cavernosa. The patient manually adjusts the position of the penis and, therefore the rods, by bending the penis straight to have intercourse and down when he is dressed. Adjustment does not affect the width or length of the penis. This type of implant has no moving parts so it is very reliable, but it does not provide as realistic an erection as the inflatable penile implant.
After penile prosthesis surgery, men are able to have intercourse with confidence that they will be able to have an adequate erection. The pump in the scrotum is pumped until the penis is hard enough for intercourse, and men keep an erection until they decide to deflate the prosthesis. There is no pain during pumping of the device. The feeling of the erect penis may be slightly different than a natural erection because the penis is filled by the prosthesis, not blood, but it should not feel any different to the sexual partner. The feeling of climax, or orgasm, is exactly the same as it was with a natural erection. The overwhelming majority of men are extrememly satisfied with the results of penile implant surgery. We have a number of patients who are willing to share their experience with men who are considering this type of treatment.
Penile implant surgery is performed as outpatient surgery; patients do not need to stay in the hospital. The surgery is performed under spinal or general anesthesia. An incision is made accross the top of the scrotum at the base of the penis, and in most men the entire operation is performed through this one incision. In some men who have had previous surgery it may be necessary to make a small incision in the groin area to place the reservoir that holds the fluid. The prosthesis is left inflated overnight after surgery and a catheter is left in the penis so that men do not need to urinate. The prosthesis is deflated in the office the next day and the catheter is removed. We recommend that men place an ice pack on the penis and scrotum for the first 2-4 hours after they go home from surgery. Men will take antibiotic tablets for 4-5 days after surgery, and will usually use pain medication for the first 2 weeks. Most men say that the pain level after this type of surgery is moderate. It is common to have some bruising and swelling of the penis and scrotum after surgery, and it will resolve like a bruise anywhere else in the body. When the swelling and tenderness of the pump have decreased the patient will be taught how to inflate and deflate the prosthesis twice a day. Men are usually able to start to have intercourse 6-8 weeks after surgery, but it is not uncommon to have some discomfort for up to 12 weeks.
The main risk of penile implant surgery is infection of the device. The overall infection rate is less than 5%, but it is slightly higher in men with diabetes. Men who require revision or replacement of the prosthesis have an 8-10% risk of infection. If a patient has infection of the device it is initially treated with oral medications, but it some cases the prosthesis needs to be removed and a new one placed during the same operation or later.
The implant devices have become very reliable, but with time they can have mechanical malfunction; 85% or more are working well 5 years after implant and 67% are working at 10 years. If there is mechanical malfunction an operation is performed to replace the device.
In rare cases there can be an injury to the urethra during surgery, and this may require that the surgery be stopped. There have also been rare cases of erosion of the prosthesis through the skin; these cases are usually caused by infection.