A penile prosthesis is the definitive surgical treatment for erectile dysfunction refractory to or unsuitable for medical therapy, and for ED coexisting with Peyronie's deformity. It is irreversible — native erectile capacity is lost — but satisfaction is high, and the inflatable three-piece device is the most popular.
Indications and Contraindications
Indicated for ED that has failed or is unsuitable for conservative therapy, irreversible organic ED, refractory psychogenic ED, Peyronie's disease with coexisting ED and deformity, penile fibrosis, and phalloplasty. The absolute contraindications are active systemic, cutaneous, or urinary infection (relative: poorly controlled diabetes, immunosuppression, and limited motivation or unrealistic expectations).
Device Types
| Type | Features | Notes |
|---|---|---|
| Non-inflatable (semirigid rod) — malleable or positional | Paired solid cylinders, bent up/down | Cheap, easy to implant/use, low failure; but a constant erection (hard to conceal) and no girth change. Best for limited manual dexterity (~10% of implants) |
| 2-piece inflatable | Cylinders + scrotal pump (reservoir within the cylinders) | Avoids a separate reservoir — useful when the space of Retzius is hostile (colostomy, transplant, prior pelvic surgery); small/hard pump, less natural feel (~20%) |
| 3-piece inflatable | Cylinders + scrotal pump + separate reservoir | Most natural function (girth + length); the most popular (~70%) |
Pre-operative Evaluation and Technique
Counsel that the procedure is irreversible and that the stretched penile length is the maximum achievable length (warn about shortening and glans softening). Evaluate with ICI and penile Doppler. The device is placed through a scrotal or infrapubic incision (~1 inch): the corpora are dilated with Hegar dilators (avoid force — perforation risk), sized, and the cylinders placed; the reservoir sits in the space of Retzius (use submuscular placement after prior pelvic surgery, and empty the bladder first). Keep the device fully deflated (reservoir full) postoperatively to prevent auto-inflation, give perioperative antibiotics, and teach device use at ~4 weeks.
Complications
- Intraoperative — corporal perforation (most likely at the septum during dilation; prevent crossover with traction and scissors angled away from the midline) and urethral perforation (abandon the procedure and divert with a catheter; remove an inflatable device entirely). Poor distal support causes a drooping glans ("SST deformity") → glansplasty.
- Infection — 1–3% after a primary implant but 7–18% after revision; usually skin flora (S. epidermidis, S. aureus, Candida). Antibiotic-coated devices cut infection by 50–70%. Persistent pain or tethering at 3–4 weeks suggests infection; management is removal of all components, and a salvage washout-and-immediate-replacement preserves length but is contraindicated with Enterococcus, tissue necrosis, sepsis, DKA, or urethral erosion.
- Device malfunction (tubing cracks, leaks, pump failure) — replace the faulty component if early, but do a complete replacement after >2 years; ~50% of devices still function at 20 years.
- Erosion — remove all components and allow 8–12 weeks to heal. Pain only on inflation suggests oversized, buckling cylinders (confirm on an inflated MRI) → downsize.
Self-Test
1. What are the indications for a penile prosthesis? ED that has failed or is unsuitable for conservative therapy, irreversible organic ED, refractory psychogenic ED, Peyronie's disease with coexisting ED and deformity, and penile fibrosis.
2. What are the absolute contraindications? Active systemic, cutaneous, or urinary tract infection.
3. When is a 2-piece (rather than 3-piece) inflatable device useful, and who suits a semirigid rod? A 2-piece device when the space of Retzius is unavailable (colostomy, transplant, extensive pelvic surgery); a semirigid rod for men with limited manual dexterity.
4. What length should patients expect after surgery? Roughly the pre-operative stretched penile length — warn about some shortening and glans softening.
5. What are the infection rates, and the key preventive measure? 1–3% (primary) and 7–18% (revision); antibiotic-coated devices reduce infection by 50–70%, and infection mandates removal of all components.
6. Where is the reservoir placed, and how is auto-inflation prevented? In the space of Retzius (submuscular after prior pelvic surgery); keep the device fully deflated (reservoir full) postoperatively so the capsule forms around a full reservoir.