Penile prosthetic surgery

What is penile prosthetic surgery?

Penile prosthetic surgery involves fitting an artificial implant inside your penis to allow you to have an erection firm enough for sexual activity. It's used when other treatments for erectile dysfunction haven't worked, and the whole device stays inside your body.

What conditions does it treat?

This surgery is generally considered once other treatments haven't worked, for:

• erectile dysfunction that hasn't responded to tablets, injections, vacuum devices or urethral pellets
• Peyronie's disease (curvature of the penis) where this is also affecting erectile function
• priapism, a prolonged and painful erection, that has failed to respond to other treatments and caused lasting damage
• as part of surgery to construct a penis for some people having gender-affirming treatment.

What are the benefits?

A penile implant restores the ability to have an erection firm enough for sex, whenever you wish, for as long as you wish and as often as you wish. It doesn't affect your desire for sex, the sensation on the skin of your penis, or your ability to reach orgasm and ejaculate.

Satisfaction is generally high, with figures ranging from around 80% to 95% of men and partners satisfied with the results. Implants are also durable, typically lasting 10 to 15 years, with some estimates suggesting up to 20, before needing replacement, and the effect is purely mechanical, so it works regardless of arousal, hormones or stimulation.

Are there different types or surgical approaches?

There are three main types of implant:

• malleable (semi-rigid) implants: two bendable rods that stay permanently semi-firm and are simply positioned up or down; quick to fit, rarely go wrong mechanically, and useful for men with other health problems or limited hand dexterity
• three-piece inflatable implants: the most commonly used type, with two cylinders in the penis, a pump in the scrotum and a fluid reservoir in the abdomen; more natural when soft, though the extra parts bring a slightly higher, still small, chance of a mechanical problem
• two-piece inflatable implants: a pump and cylinders without a separate abdominal reservoir; useful if previous pelvic or abdominal surgery makes reservoir placement difficult, though they don't go as fully soft when deflated.

Before considering surgery, most men will have already tried alternatives such as tablets, penile injections, vacuum erection devices, urethral pellets or psychosexual counselling; it's worth discussing with your surgeon any of these you haven't yet tried.

What happens before the procedure?

You'll have a full discussion with your surgeon and specialist nurse about which type of implant suits you, including being shown how each looks and works. It's important to tell the team about:

• any implanted devices you already have, such as a pacemaker, joint replacement or heart valve
• any regular blood-thinning medicines, such as warfarin, aspirin, clopidogrel, rivaroxaban or dabigatran
• any allergies, particularly to antibiotics or skin cleaning solutions
• a current or past MRSA infection.

You'll usually be admitted on the day of surgery, having showered beforehand, and your general health, blood pressure and pulse will be checked, along with confirmation that you can empty your bladder without significant problems. An antibiotic injection is given before the procedure, the area is shaved and cleaned with antiseptic, and you'll be asked to stop eating and drinking beforehand as instructed; stopping smoking in advance, if you can, helps with healing.

What happens during the procedure?

1. You're given a general anaesthetic, so you're asleep throughout, though occasionally a spinal anaesthetic is used instead.
2. A catheter is passed through the penis into the bladder.
3. A cut is made where the penis and scrotum meet, or occasionally elsewhere; most of the operation is done through this one cut.
4. The inside of the shaft is gently stretched to the right size, and the correctly sized implant is fitted.
5. For an inflatable device, a pump is positioned in the scrotum and a fluid reservoir placed in the abdomen, sometimes through a separate small cut, and the system is filled with fluid and tested while you're still asleep.
6. The cuts are closed, usually with dissolvable stitches, often with a small drain and a firm dressing; you may have a catheter overnight.

The operation typically takes 1 to 2 hours, occasionally longer for a more complex case.

What does recovery look like?

In hospital

If an inflatable device is used, it may be left inflated overnight to reduce bleeding, then deflated before you go home; the first deflation can feel a little odd, which is normal. A catheter and any wound drain are usually removed the morning after surgery.

Most men stay in hospital for around one night, though some go home the same day. You'll be given a discharge summary, a course of antibiotics to take home, and advice on your recovery before you leave.

At home

Swelling and bruising of the penis and scrotum for several days, sometimes up to 10 days, is expected, along with discomfort for a couple of weeks that settles with the painkillers you're given. Keep the area clean and dry as advised.

An outpatient appointment 2 to 3 weeks after surgery teaches you how to bend or inflate and deflate the device, with further reviews typically at 6 weeks and again at 3 months. Guidance on resuming sexual activity varies between 4 and 6 weeks depending on the centre, so follow your own surgeon's advice.

If you ever need abdominal, groin or pelvic surgery in future, you must tell the surgeon you have an inflatable penile implant, so they can avoid damaging it. Contact your team if you develop a high temperature, increasing redness, throbbing or discharge at the wound.

What are the risks and complications?

As with any operation, there are risks to be aware of:

• bruising and swelling of the penis: almost all patients
• infection: about 1 to 3 in 100 for a first-time operation, rising to 6 to 10 in 100 for a repeat, complex, or priapism-related procedure; infection usually means the whole device has to be removed
• mechanical failure of an inflatable device within 10 years: about 1 in 20
• erosion of the device through the skin, needing further surgery: about 1 in 20 to 1 in 50
• drooping of the head of the penis: about 1 in 10 to 1 in 50
• injury to the bladder, bowel or nearby blood vessels, or a hole in the erectile tissue during surgery, occasionally preventing the implant being fitted: about 1 in 50 to 1 in 250
• temporary or permanent numbness of the head of the penis, from nerve irritation: uncommon
• needing a catheter to help pass urine for a short time afterwards: fairly common, reported in around a quarter of patients in some studies
• slight shortening of the penis compared with a natural erection, and the head of the penis not becoming as hard: possible
• serious anaesthetic or heart and circulation problems, such as a blood clot, chest infection, stroke or heart attack: about 1 in 50 to 1 in 250; your anaesthetist can estimate your own risk
• a general hospital-acquired infection risk, such as MRSA, of around 8 in 100, higher for some patients.