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Treating erectile dysfunction with penile implants

Posted By Nancy Ferrari On March 11, 2009 @ 2:45 pm In ED,Prostate Knowledge | Comments Disabled

Penile implants, an option patients with erectile dysfunction probably hear little about, might offer a lasting and satisfying cure. Abraham Morgentaler, M.D., director of Men’s Health Boston, explains how.

Thanks to Viagra’s introduction more than a decade ago, erectile dysfunction has become fodder for comedians, talk shows, and mainstream media. And there’s clearly a market for Viagra (sildenafil) and its cousins, Cialis (tadalafil) and Levitra (vardenafil): the American Urological Association estimates that ED, as it’s become known, affects 25 million American men.

All three medications have helped a significant number of men achieve an erection firm enough for intercourse. A 2001 study of Viagra’s long-term effectiveness reported an overall success rate of 69%. The success rates for Cialis and Levitra were similar — 59% and 69%, respectively. However, the response can depend on what caused the ED in the first place. Men who have vascular problems as a result of diabetes or heart disease find that the drugs work only about half of the time. Response rates are lower — just 30% — for men who’ve had a radical prostatectomy.

Men who cannot take the ED medications or find them ineffective do have other options. For example, injections, penile bands, and vacuum erection devices can help men with ED achieve and sustain an erection. Yet many men and their partners find that using these aids requires planning and eliminates spontaneity, or that they produce less-than-satisfactory results.

For these men, a penile implant, also called a penile prosthesis, may be the best option. Men with an implant can have an erection at any time — and maintain it for as long as they want — without the use of medication or other devices, allowing for greater spontaneity. Broadly speaking, there are two types of implants:

  • Inflatable implants. These may have a two- or three-piece design. Three-piece implants consist of a fluid-filled reservoir in the abdomen, a pump with a release valve in the scrotum, and two inflatable cylinders in the penis (see Figure 1). Squeezing the pump transfers fluid from the reservoir into the cylinders, causing an erection. Pushing the release valve drains the fluid back into the abdominal reservoir. Two-piece implants combine the fluid-filled reservoir and the pump in the scrotum (see Figure 2). Bending the penis returns the fluid to the reservoir.
  • Semirigid, or malleable, rods. As the name implies, this type of implant consists of bendable rods, usually constructed of braided stainless steel wires or articulating plastic disks, covered with silicone (see Figure 3). The rods are bent upward to have sex and pointed down to conceal the device under clothing. This type of implant is always firm.

Figure 1: Three-piece inflatable penile implant

To create an erection with a three-piece penile implant, repeatedly squeeze the pump bulb implanted in the scrotum. This transfers fluid from the abdominal reservoir to the inflatable cylinders. Pushing the release valve sends fluid back to the reservoir and returns the penis to its flaccid state (see inset).

Figure 2: Two-piece inflatable penile implant

To create an erection with a two-piece penile implant, repeatedly squeeze the pump bulb. Bending the penis transfers fluid from the inflatable cylinders back to the pump bulb and returns the penis to its flaccid state (see inset).

Figure 3: Semirigid (malleable) penile implant

The semirigid, or malleable, penile implant always remains firm. Bend the rods upward for sexual intercourse; point them down to conceal the implant under clothing (see inset).

Most patients choose an inflatable device because the penis looks more natural — both when erect and when flaccid — than with semirigid rods. Inflatable implants expand the girth of the penis, creating a firmer-feeling erection; depending on the model, the penis may also lengthen. One downside to inflatable implants is the risk of mechanical trouble, which can run from the merely inconvenient or embarrassing (unintended inflation, for example) to the relatively serious (a leaky reservoir that requires surgical repair or an overly large implant that breaks through the skin).

Some patients opt for malleable devices because they are easier to manipulate than inflatable implants, which require some manual dexterity. As far as the surgery goes, a single incision makes them simpler to insert. But because the rods always remain firm, they’re harder to conceal. (For a comparison of the advantages and disadvantages of each type, see Table 1.)

Table 1: Penile implants compared

Implant type Advantages Disadvantages Notes/comments
3-piece inflatable
  • Acts and feels more like a natural erection than other models.
  • Requires more manual dexterity than other implants.
  • Chance of unintended erection, depending on the model.
  • Possibility of leakage or malfunction.
  • Most expensive type of implant.
  • Requires the most extensive surgery of all implants.
  • Inflate/deflate device inserted in scrotum. Squeeze the pump to inflate and press the release valve to deflate.
  • Fluid reservoir inserted in abdomen.
  • Lock-out valve on some models prevents unintended inflation.
2-piece inflatable
  • Penis looks more natural in erect and flaccid states than the semirigid implant.
  • Easier to operate than the 3-piece implant.
  • No abdominal incision.
  • Possibility of leakage or malfunction.
  • Squeeze and release the pump several times to move fluid into penile cylinders. Bending and holding the penis causes cylinders to soften.
  • Penis does not deflate as fully as with 3-piece implant.
Semirigid, or malleable, rods
  • Easy to use, especially for those with limited dexterity.
  • Requires the least extensive surgery.
  • Fewest parts, so less chance of malfunction.
  • Least expensive type of implant.
  • Constantly firm.
  • Not as easy to conceal as 2- and 3-piece implants.
  • For intercourse, lift the penis and make the rods as straight as possible.
  • Some models can be bent in multiple places to fit more comfortably under clothing.

Various textbooks and Web sites claim that three-piece inflatable implants are the most popular option because they produce the most natural-looking erection and the greatest flaccidity, making them easier to conceal. Although one Web site estimates that 70% of patients opt for a three-piece device, about 90% of my patients choose a two-piece implant. That’s mainly because they are easier to inflate and deflate than three-piece models. And sometimes (though not always), previous radiation therapy or abdominal surgery, such as a kidney transplant or radical prostatectomy, makes surgery to place the abdominal reservoir difficult and risky; a two-piece device may be best in these circumstances. True, flaccidity may not be as complete with a two-piece implant as with a three-piece, but many of my patients tell me that they appreciate having a fuller-looking penis.

Regardless of the model chosen, patients and their partners report a high degree of satisfaction with penile implants over all. One study found no significant difference in patient satisfaction between the malleable and inflatable implants, though the patients’ partners reported greater satisfaction with the inflatable implants. Of 425 men in a British study of penile implants, most of whom had the malleable variety, 89% could have sexual intercourse, and 81% were satisfied with the implant results. (For details on these and other studies, see “Patient satisfaction,” below.)

Patient satisfaction

Brinkman MJ, Henry GD, Wilson SK, et al. A Survey of Patients with Inflatable Penile Prostheses for Satisfaction. Journal of Urology 2005;174:253–57. PMID: 15947649.

Lux M, Reyes-Vallejo L, Morgentaler A, Levine LA. Outcomes and Satisfaction Rates for the Redesigned 2-Piece Penile Prosthesis. Journal of Urology 2007;177:262–66. PMID: 17162061.

Minervini A, Ralph DJ, Pryor JP. Outcome of Penile Prosthesis Implantation for Treating Erectile Dysfunction: Experience with 504 Procedures. BJU International 2006;97:129–133. PMID: 16336342.

Montorsi F, Rigatti P, Carmignani G, et al. AMS Three-Piece Inflatable Implants for Erectile Dysfunction: A Long-Term Multi-Institutional Study in 200 Consecutive Patients. European Urology 2000;37:50–55. PMID: 10671785.

Specific implant models have received high marks, too. A recent analysis of satisfaction rates for a two-piece penile implant pegged patient satisfaction at 85% and partner satisfaction at 76%. Of the patients, 86% said that they would recommend the prosthesis to a friend in a similar situation or undergo the procedure again. An Italian study of 200 patients who received a three-piece implant and 120 partners found that 92% of patients and 96% of partners were satisfied with their sexual activity. And anecdotally, dozens and dozens of my patients have said, “Doc, I wish I had gotten an implant years ago.”

What held them back? Most of the men I talk to say that penile implants were never presented to them as an option. The number of urologists who regularly perform implant surgery is limited. Many may claim that they do the procedure, but most perform only a few a year, hardly enough to keep their skills sharp. As a result, they don’t suggest it to patients, or they downplay the possibility when asked.

The other significant hurdle is psychological. Patients who have had a radical prostatectomy often say that the thought of another surgery discourages them. Other patients fear having something artificial in their body or worry that the implant will look and feel unnatural. And for others, puritanical thinking creates an internal moral struggle: Is it okay to undergo surgery just to have sex? What will my friends think? I often remind people that heart patients have implanted devices like pacemakers and defibrillators, which are considered perfectly normal. And let’s not forget how much of our personal identity is tied to our sexuality.

I am certainly not suggesting that people can take the decision lightly. To the contrary, it requires a lot of thought. The procedure itself cannot be reversed, eliminating the possibility that natural erections will return, even if the implant is removed. And as with all surgeries, patients are at risk of infection. The infection rate is about on par with that of other surgical procedures — about 1% to 3% of patients develop an infection. Rates are higher among patients with immune system disorders and chronic health conditions, such as diabetes. Mechanical failure may also occur, though improvements to implants have made problems less common. A recent analysis of 455 patients with a three-piece device estimated that more than 81% of devices were free of mechanical trouble after 10 years.

The procedure itself takes about one to two hours. While you are under either general or spinal anesthesia, the surgeon will make an incision where the penis meets the scrotum, or alternatively, above the penis, just above the pubic bone. Next, the surgeon will stretch the spongy tissue that lines the corpora cavernosa (see Figure 4), the side-by-side chambers that run the length of the penis, to determine the correct-size prosthesis. After flushing the area with an antibiotic solution, he or she will seat the implant cylinders in the corpora cavernosa. If you are getting a two-piece inflatable implant, the pump and valve mechanism will be inserted in your scrotum. For a three-piece device, the fluid reservoir will be placed into the abdomen.

Figure 4: Anatomy of the penis

During penile implant surgery, the surgeon inserts the device’s cylinders in the corpora cavernosa, side-by-side chambers that run the length of the penis. For inflatable implants, the surgeon inserts the pump and valve mechanism in the scrotum.

Your doctor will give you antibiotics both before and after surgery. The intensity and duration of postoperative pain may vary. Most men will need to take narcotics for about a week after surgery to relieve the pain. After that, pain can usually be managed with a nonsteroidal anti-inflammatory agent such as ibuprofen or acetaminophen.

My more-motivated patients go home the same day as surgery, but most will spend a night in the hospital. Strenuous physical activity should be avoided for about a month; sexual activity can resume in about four to six weeks, depending on the type of implant.

Patients and their partners are generally more satisfied with the results if they know what to expect from a penile implant. If at all possible, you and your partner should meet with the doctor together before surgery. Make sure you both understand the risks and benefits of the procedure and how the prosthesis works. A few other points to keep in mind:

  • While an implant can cause an erection, it won’t increase desire or sensation.
  • Some men complain that their penis is shorter after surgery than it was when they had erections naturally.
  • An implant will generally preserve the ability to have an orgasm and ejaculate, but it will not restore these abilities if they are already absent.
  • Don’t expect an implant to solve relationship problems. If you and your partner need to resolve conflicts, talk with a psychologist or psychiatrist.
  • Share your feelings with your partner and be sensitive to your partner’s concerns. Some partners feel that their sexual pleasure is diminished by the fact that they aren’t involved in creating an erection.

As I mentioned earlier, finding a qualified doctor to perform a penile implant might be tricky. Most large hospitals and academic medical centers will have at least one or two urologists on staff who specialize in sexual dysfunction. Your primary care provider may be able to refer you to a colleague. The Sexual Medicine Society of North America offers a physician finder on its Web site, www.sexhealthmatters.org. The Erectile Dysfunction Institute and the Society for Urologic Prosthetic Surgeons also list physicians on their Web site, www.edcure.org/edi_sups.aspx. Medicare and most, though not all, commercial insurance plans cover the diagnosis and medically necessary treatment of ED, which includes the implantation of a penile prosthesis. Some insurance plans may specifically exclude coverage for penile prostheses or cover only certain types, such as the semirigid device. Talk with your physician and insurance carrier to find out exactly what’s covered before making a treatment decision.

If you have ED, you know how trying it can be. The important thing to realize is that just about any man with erection problems can be successfully treated and can have satisfying sexual activity again. Penile implants have allowed many men to regain the ability to achieve an erection and have sex — and restore intimacy in their relationships. For single men who have been afraid to date because they are embarrassed by their ED, penile prosthesis surgery may bestow the self-confidence they need to find a wonderful, supportive partner.

Don’t let ED stand in the way of enjoying your life. If things aren’t working out the way you’d like, consult an expert.

Originally published Jan. 1, 2008; last reviewed April 22, 2011.

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