What are the recommendations for a patient considering a penile implant for erectile dysfunction?

Penile Implant for Erectile Dysfunction

Penile prosthesis implantation is the gold standard definitive treatment for men with erectile dysfunction who have failed or cannot tolerate less invasive therapies (oral PDE5 inhibitors, intracavernosal injections, vacuum devices), and should be offered after thorough counseling about the irreversible nature of the procedure, potential complications, and realistic expectations. 1, 2, 3

Patient Selection Criteria

Medical Necessity Requirements

• Document failure of or contraindication to first-line pharmacologic therapy (PDE5 inhibitors like sildenafil, tadalafil) 4
• Confirm organic etiology of erectile dysfunction through appropriate diagnostic evaluation 4
• Trial or documented intolerance to second-line therapies (intracavernosal injections, intraurethral alprostadil, vacuum erection devices) before proceeding to prosthesis 4
• Absence of any active infections (systemic, cutaneous, or urinary tract) at time of surgery—this is an absolute contraindication 1, 2, 4

Critical Preoperative Counseling Points

Patients must understand these irreversible consequences before proceeding:

• The procedure is essentially irreversible and will likely reduce efficacy of subsequent therapies if device removal becomes necessary 2, 5
• Penile shortening compared to natural erections will occur 2
• Changes in penile sensation and configuration are possible 3
• Risk of mechanical failure requiring reoperation (6-16% at 5 years with modern devices) 2
• Risk of infection (now 1-2% with modern antibiotic-coated devices, but remains the most serious complication) 1, 2, 3
• Postoperative penile edema is normal and expected, typically resolving with supportive care over several weeks 5

Device Selection Algorithm

Three-Piece Inflatable Prosthesis (Gold Standard)

Recommend for most patients who have:

• Normal manual dexterity for pump operation 2, 6
• No contraindications to abdominal reservoir placement 6
• Desire for most natural appearance in flaccid and erect states 2, 6
• Peyronie's disease requiring curvature correction (allows for modeling to maximize correction) 2

Two-Piece Inflatable Prosthesis

Consider for patients with:

• Standard-sized penises without significant penile pathology 6
• Limited dexterity issues 6
• Need to avoid abdominal reservoir placement due to prior surgeries or potential complications 6

Malleable (Non-Inflatable) Prosthesis

Recommend for patients with:

• Significant manual dexterity limitations preventing pump operation 2, 6
• Need for length conservation in specific populations 6
• Preference for lower cost, better mechanical reliability, and no need for inflation/deflation training 1, 2

Infection Prevention Protocol

Critical Update on Antibiotic Prophylaxis

The traditional AUA-recommended regimen of vancomycin plus gentamicin alone is associated with HIGHER infection risk (HR: 2.7) compared to nonstandard regimens and should be reconsidered. 1

Recommended Prophylaxis Strategy

• Add antifungal prophylaxis to antibiotic regimen—associated with significantly lower infection risk (HR: 0.08) 1
• Consider triple antibiotic regimens (adding a third agent beyond vancomycin and gentamicin) rather than dual therapy alone 1
• Use antibiotic-impregnated or hydrophilic-coated devices—reduces infection rates from 1.61% to 0.68% (rifampin/minocycline coating) or from 2.07% to 1.06% (hydrophilic coating) 2

Additional Infection Prevention Measures

• Ensure patient is free of urinary tract infection preoperatively 1
• No dermatitis, wounds, or cutaneous lesions in operative area 1
• Shave operative area immediately prior to surgery, not earlier (small cuts may become infected) 1
• Administer broad-spectrum antibiotics providing Gram-negative and Gram-positive coverage before incision, continuing 24-48 hours postoperatively 1

Special Populations

Diabetes and Metabolic Syndrome

• Diabetes is associated with higher infection risk (HR: 1.9) 1
• Outcomes remain excellent with appropriate precautions—no significant difference in satisfaction scores compared to non-diabetic patients 7
• Consider antifungal prophylaxis particularly in this high-risk group 1

Post-Radical Prostatectomy

• Penile prosthesis is highly effective for iatrogenic erectile dysfunction following pelvic surgery 7
• Satisfaction rates equivalent to other etiologies of erectile dysfunction 7

Acute Ischemic Priapism

• For priapism lasting >36 hours, penile prosthesis placement may be considered to provide detumescence and preserve penile length 2

Common Pitfalls to Avoid

• Never proceed with surgery in presence of any active infection—violates clinical guidelines and increases infection risk dramatically 1, 2, 4
• Do not use vancomycin plus gentamicin alone without additional antimicrobial coverage—recent evidence shows this increases infection risk 1
• Do not skip antifungal prophylaxis in high-risk patients (diabetes, revision cases) 1
• Avoid shaving surgical site more than immediately before surgery—increases infection risk 1
• Do not implant prosthesis for premature ejaculation—risks far outweigh benefits for this indication 1

Technical Considerations

MRI Compatibility

• All currently manufactured penile implants in the United States are MRI-compatible at 1.5 Tesla field strength 1, 2
• Older devices (OmniPhase, Duraphase) are no longer marketed and had MRI contraindications 1

Concomitant Erectile Dysfunction and Premature Ejaculation

• If both conditions present, treat erectile dysfunction first—premature ejaculation may improve when ED is effectively treated 1