Can men with diabetes (Diabetes Mellitus) be considered for a penile implant?

Can Men with Diabetes Get a Penile Implant?

Yes, men with diabetes can and should be considered for penile implant surgery when indicated for erectile dysfunction, though they face a modestly increased infection risk (1.5-fold higher) that can be substantially mitigated with antibiotic-impregnated prostheses and optimized glycemic control. 1, 2

Diabetes as an Indication, Not a Contraindication

• Diabetes is one of the most common causes of erectile dysfunction requiring penile prosthesis implantation, affecting 35-90% of diabetic men through multiple mechanisms including autonomic neuropathy, vascular disease, and endothelial dysfunction. 3
• Penile prosthesis represents the definitive surgical solution when first-line treatments (PDE5 inhibitors) fail in diabetic patients with ED. 4, 5
• Diabetes itself does not preclude penile implant surgery—it is a recognized indication that requires specific perioperative management strategies. 5

Infection Risk: The Primary Concern

Quantifying the Risk

• Meta-analysis demonstrates that diabetes increases penile prosthesis infection risk with an odds ratio of 1.53 (95% CI 1.15-2.04), meaning diabetic men have approximately 50% higher infection rates than non-diabetic men. 1
• Contemporary infection rates in diabetic patients range from 1.47% to 4.17% depending on prosthesis type and surgical technique. 2
• All infections in one prospective study occurred exclusively in the diabetic subgroup (5 of 32 diabetics, 0 of 58 non-diabetics), highlighting diabetes as the dominant infection risk factor. 6

The Glycemic Control Controversy

The evidence on HbA1c thresholds is contradictory, requiring clinical judgment:

• One 1992 prospective study found that poorly controlled diabetics (HbA1c >11.5%) had a 31% infection rate versus 5% in controlled diabetics (HbA1c <11.5%), suggesting a critical threshold. 6
• However, a larger 2018 retrospective study of 300 diabetic patients found no significant association between HbA1c levels and infection risk, with 0.9% infection rate in HbA1c ≤9% versus 0% in HbA1c >9%. 7
• Given this conflicting evidence, the prudent approach is to optimize glycemic control preoperatively (target HbA1c <8%) while recognizing that HbA1c alone should not exclude diabetic candidates from surgery. 6, 7

Risk Mitigation Strategies

Antibiotic-Impregnated Prostheses: The Game-Changer

• Use of minocycline/rifampin-impregnated inflatable penile prostheses reduces 7-year infection rates in diabetic men from 4.24% to 1.62% (log-rank p <0.0001). 2
• This represents a 62% relative risk reduction in infection-related revisions over 7 years of follow-up in the largest known database of diabetic IPP recipients. 2
• Antibiotic-impregnated prostheses should be considered standard of care for all diabetic patients undergoing penile implant surgery. 2

Preoperative Optimization Algorithm

Step 1: Glycemic Assessment

• Measure HbA1c within 30 days of planned surgery. 6
• If HbA1c >8%, delay elective surgery for 3 months of intensive diabetes management. 6
• Recheck HbA1c before proceeding—target <8% for optimal outcomes. 6

Step 2: Cardiovascular Risk Stratification

• Categorize patients using Princeton Consensus criteria before any ED treatment, as ED predicts coronary artery disease. 4, 3
• Obtain cardiac clearance for high-risk patients before proceeding with surgery. 4

Step 3: Complication Screening

• Screen for diabetic complications that may affect surgical outcomes: peripheral neuropathy, autonomic neuropathy, peripheral arterial disease, and nephropathy. 3
• Measure testosterone levels in men with symptoms of hypogonadism, as low testosterone is common in diabetic men and may affect outcomes. 4, 8

Surgical Considerations for Diabetic Patients

• Diabetic patients require meticulous surgical technique with strict adherence to sterile protocols given their inherently higher infection susceptibility. 5
• Corporal fibrosis may be more prevalent in diabetic men with long-standing ED, potentially complicating implantation and requiring specialized techniques. 5
• Despite these challenges, penile prosthesis implantation remains an effective and safe treatment option for diabetic men when proper perioperative management is employed. 5

Postoperative Management

• Maintain tight glycemic control in the immediate postoperative period, as hyperglycemia impairs wound healing and immune function. 6
• Extended antibiotic prophylaxis may be warranted in diabetic patients, though specific duration recommendations vary by institution. 2
• Long-term follow-up is essential, as infection-related revisions can occur years after initial implantation. 2

Key Clinical Pitfalls to Avoid

• Do not deny penile implant surgery to diabetic men based solely on their diabetes diagnosis—this represents appropriate definitive treatment for refractory ED. 5
• Do not rely exclusively on HbA1c cutoffs to exclude candidates, as the evidence is conflicting; instead, use HbA1c as one factor in comprehensive risk assessment. 6, 7
• Do not use non-impregnated prostheses in diabetic patients when antibiotic-impregnated options are available, as this unnecessarily increases infection risk by 2.6-fold. 2
• Do not proceed without cardiovascular risk assessment, as ED in diabetic men signals systemic vascular disease requiring evaluation. 4, 3