Penile implant surgery

Penile implant surgery is used in the treatment of impotence (erectile dysfunction). They can be very effective, but should be regarded as a treatment of last resort, to be used when other methods of treatment have failed.

This is because they have serious drawbacks and are irreversible. Once an implant has been put in, other methods of treatment will not work, even if the implant is removed.

There are two types of implant, the inflatable implant and the malleable (or semi-rigid implant).

Inflatable implants

The inflatable implant consists of two cylinders which are implanted inside the penis. They are connected to a reservoir which is implanted into the abdominal cavity just above the pubic bone and a pump which is implanted into the scrotum. All the parts are beneath the skin and are hidden from view, although the tubing which connects the pieces of the implant can sometimes be seen beneath the skin in the scrotum.

When the penis is flaccid (not erect) the cylinders are empty and the reservoir is full of fluid (sterile water or saline solution). If the pump is activated, fluid flows out the reservoir and into the cylinders, producing an artificial erection. When the erection is no longer required, a valve in the pump is activated and fluid flows back into the reservoir.

How is the pump activated and de-activated?

The pump is activated by squeezing it through the skin of the scrotum. The number of squeezes varies from patient to patient, but is often in the order of 10-20 times. To deactivate the pump, a small button on the pump is squeezed and the cylinders in the penis empty. Sometimes it is necessary to squeeze the penis directly at the same time, so some manual dexterity is needed to do this.

Malleable implants

Malleable implants are much simpler. They consist of two rods which are inserted into the penis. The rods are made of a special material which holds its position. The rods can be bent to make it easier to conceal them, and straightened when an erection is required.

The operation

The operation is performed under a general anaesthetic, and takes between 40 and 90 minutes. In most cases the only incision which is needed is a small cut at the base of the penis, where it joins the scrotum. Some patients having an inflatable implant will need a further incision in the groin to insert the reservoir, but this is not always necessary.

Patients having an inflatable implant normally have a catheter tube inserted after the operation, and a small drainage tube coming out the scrotum. These are removed the day after surgery and patients go home on that day or the day after. These tubes are not always necessary after a malleable implant and most patients can go home the day after surgery.

Which implant should I choose?

There is no doubt that inflatable implants give a better cosmetic result, particularly when the penis is flaccid (not erect). However, they are sometimes awkward to use and some patients find them very difficult. They are not advisable for anyone who does not have full use of his hands and is not motivated to learn to use the implant properly. The results which can be obtained with malleable implants are perfectly acceptable for most patients.

Are there any complications of the operation?

The biggest complication is infection, which occurs in about one in 20 cases. If the implant gets infected it has to be removed. Although it may be possible to insert another implant later this is not always possible, so if infection occurs it is a serious problem. Antibiotics are given routinely and sterile precautions are always taken, but never the less the infection risk remains.

Some bruising and swelling can be expected after surgery. This may take a couple of weeks to settle down. Pain can be a problem after the operation, and whilst it isn’t usually a major problem, there can be an ache which lasts for a few weeks.

Inflatable prostheses can undergo mechanical failure. This is rare but occurs in about 1 in 100 cases every year, so there is a one in 10 chance of failure in the first ten years after the operation. Usually the pump fails or the connecting tubing leaks. If this happens the implant can usually be replaced.

Occasionally malleable prosthesis can erode through the skin of the penis. This is rare.

Limitations of the operation

It is important to remember that these devices are not perfect.

The erection you will achieve with a prosthesis will not be as good as a natural erection, but it should be good enough for sexual activity. Most men will be able to have a normal orgasm (climax) afterwards but some men find that it is not possible.

Many men say the penis is not as large as it was before surgery. The shaft of the penis is normally restored to its previous length, but the glans of the penis (the head) is not enlarged by the operation. Furthermore the glans is sometimes relatively floppy, something which occasionally has to be corrected by further surgery. Patients who have suffered from Peyronie’s disease (bent penis) should bear in mind that the disease itself may have caused penile shortening, and all men should be aware that implants cannot be used to increase penile length in any way.

A rough guide to the eventual length of the penis after surgery is to hold the glans (head) of the penis tightly and stretch the penis as forcibly as possible. This “stretched penile length” is a reasonably accurate guide too the eventual length of the penis after surgery.

Malleable implants do not increase in length when they are inflated, only in girth (width).

The appearance when flaccid is perhaps the biggest problem with implants, particularly after a malleable implant

Should I have a penile prosthesis?

This is a very personal decision. Before you decide, make sure you have exhausted all other methods of treatment for your erectile problems, as once you have the operation there is no going back. Make sure you realise the limitations of these devices. If you have considered these things, and you want to me able to have sexual intercourse again, then there is no reason why you should not go ahead.

This information was written by Mr Mike Foster, a Birmingham Prostate Clinic consultant urologist specialising in penile implant surgery, operating on about 15 patients a year, with a total caseload of about 200 procedures.