Penile Implant Surgery: Everything You Need to Know

Penile implant surgery is an operation in which a prosthesis is implanted into the penis for the treatment of erectile dysfunction (ED) that isn't improving with nonsurgical treatment. This is a major surgical procedure that's done to help regain sexual function. Though there are less-invasive treatments, such as vascular (artery or vein) repair or the use of vacuum erectile dysfunction devices, this surgery is considered the gold standard approach for difficult cases. It will take several weeks to recover after a penile implant, and you will have to learn how to use the implant after you heal from surgery. Most patients and their partners are satisfied with the results of a penile implant.

Types of Erectile Dysfunction Surgery

If medications, lifestyle management, injections, or the use of erectile dysfunction devices don't achieve results, penile implant surgery will be considered among several surgical options. Here's a quick comparative breakdown:

• Penile implant surgery is considered the gold-standard approach to erectile dysfunction as it reliably creates a rigid shaft. Despite some risks, including post-surgical infection and prosthetic failure, this treatment is over 90 percent effective. Unlike its counterparts, this treatment takes on a broader range of cases and is by far the most popular option.
• Arterial revascularization, in which arteries supplying blood to the penis are reworked, can be a good option in some cases. However, it's unlikely to help in cases of ED due to insufficient blood circulation due to issues like smoking, high cholesterol and blood pressure, and diabetes mellitus.
• Venous surgery is indicated when the dysfunction arises due to veins in the penis being unable to trap sufficient blood to maintain the erection. This condition, known as venous leak, is treated by removing sections of veins to improve trapping. It has mixed results and is generally reserved for younger men with congenital or traumatic erectile dysfunction.
  

What Is Penile Implant Surgery?

Penile implant surgery is the placement of a prosthesis into the penis. The prosthesis will make it so the penis can become erect, but it will not enlarge its size. The implant should not diminish any sensation that you feel in your penis; it's not intended to increase sensation either.

The surgery involves general or local anesthesia and an incision on your penis so your surgeon can insert the device.

There are two types of implants: inflatable and noninflatable.

Inflatable Implants

Inflatable penile implants don't inflate with air. Instead, they are filled with fluid from a reservoir that is implanted in the body. The pump is usually implanted in the scrotum.

Two-piece implants and three-piece implants each have their advantages:

• Two-piece implants are simpler and easier to use. However, there is usually a trade-off between the firmness of the erection and how flaccid the penis can become. People who have a two-piece implant tend to be more satisfied with their penis in the flaccid or the erect state, but not both. This is because the small size of the one-piece fluid pump and reservoir doesn't allow for major adjustments.
• Three-piece implants, in contrast, are slightly more complex. In addition to the prosthesis and pump, they also contain a separate reservoir. The added parts allow for several benefits. The flaccid penis is fully flaccid since there is a valve to release pressure in the penis when an erection is no longer wanted. The additional reservoir space also allows erections with this device to be firmer than those with the two-piece implant.

An inflatable penile implant needs to be pumped to an erect position by squeezing the pump so the reservoir will send fluid to the penis. The penis can be manually deflated by placing pressure that sends fluid back to the reservoir.

Noninflatable Implants

Noninflatable implants are semi-rigid tubes that can be bent to the desired shape. You can point your penis down for everyday use or position it up for sexual intercourse.

There are several different types of noninflatable implants with varying trade-offs. Some offer more stiffness for sex. However, that may come with the potential for more discomfort at other times.

Contraindications

A penile prosthesis isn't right for everyone, and some conditions can make the procedure risky or unlikely to be effective.

If you have a bladder infection, you will need to postpone your surgery until after the infection is treated and resolved. If you have chronic bladder or pelvic infections, however, this procedure may be ill-advised; chances of a severe surgical infection or device contamination can make this surgery very risky for you.

Additionally, a penile implant might not be right for you if you've had significant trauma to your penis or urethra (the small tube through which urine travels) and damage has not been repaired.

If you have a sexually transmitted disease with open wounds, you and a doctor will need to make sure it is fully treated and that you are not exposed to further infections in the pelvic area before your surgery.

Potential Risks

There are some risks of penile implant surgery, including surgical complications and potential problems with inadequate function of the device after it is placed.

Potential post-operative issues include:

• Infection
• Bleeding
• Changes in a sensation of the penis due to nerve damage
• Injury to the urethra
• Shortening of the penis
• Problems with the implant function

Purpose of Penile Implant Surgery

Penile implants are a type of treatment that can help those with erectile problems, which can occur due to a number of issues such as aging, hormone deficiency, and Peyronie's disease (a disease in which fibrous tissue thickens in the penis).

Erectile dysfunction is diagnosed based on your medical history, a physical examination to determine whether you have any anatomical changes, and possibly hormone tests that measure testosterone, as low testosterone can contribute to erectile dysfunction. You might also have diagnostic imaging tests to identify possible issues that could be causing your erectile problems such as prostate enlargement, bladder issues, spine disease, or tumors.

A penile implant can also help people who have had a phalloplasty (a gender-affirming surgical construction of a penis for transgender men, transmasculine nonbinary people, or cisgender men who have lost their penis) have an erection.

Conservative Management

Nonsurgical treatments for erectile dysfunction can be effective for many. Generally, it is recommended that you try conservative therapies before attempting penile prosthesis. Approaches include:

• Oral medication (testosterone or drugs like Viagra)
• Penile injections
• Shock wave therapy

This is typically not a prerequisite for a penile implant surgery after phalloplasty, however.

You might consider a noninvasive erection assistance device, which doesn't require surgery. There are several popular choices:

• Penile rings are elastic bands worn around the penis to prevent the backflow of blood after an erection. They're used after the penis has achieved an initial erection.
• Vacuum pumps use suction to create an erection. The penis is lubricated and placed inside a tube. The air is then extracted using a manual pump, promoting blood flow to the region. Once erect, a penile ring is placed around the shaft.
• External erectile prostheses include penis sleeves, which are hollow, specially shaped devices worn over the penis. These, and devices like the Elator or Erektor (which rely on fitted rings and rods), stimulate an erection and help some men achieve orgasm during sex.

How to Prepare

Once you have decided that you want to have a penile implant, a urologist will talk to you about selecting the type of implant that's most suitable for your condition as well as your personal preferences.

You can expect to have a small scar from the incision, and a doctor will show you exactly where your scar will be and where your implant will be placed.

Location

You will have your procedure in a surgical operating room that is located in a hospital or surgical center.

A penile implant is an outpatient procedure, so you will come to your appointment from home and likely go home on the same day of surgery.

What to Wear

You can wear anything comfortable to your surgery appointment. Loose pants are a good choice, as you will have bandages on your pelvis and your surgical area will be swollen after surgery.

Food and Drink

You should abstain from eating and drinking after midnight on the night before your surgery.

Medications

A doctor will discuss medication adjustments with you. Generally, it is advised to reduce or stop blood thinners several days prior to surgery. You also might need to adjust the dose of any diabetes medication or anti-inflammatory medications that you regularly take. Follow your doctor's instructions.

What to Bring

When you go to your surgery appointment, bring your identification, medical insurance information, and a form of payment if you will pay for a portion of your procedure.

You should have someone with you who can drive you home after your surgery because you will be sore and possibly groggy.

Pre-Op Lifestyle Changes

You should not need to make adjustments in your lifestyle prior to your procedure.

What to Expect on the Day of Surgery

You will go in to register for your procedure and sign a consent form prior to your surgery.

You may have preliminary blood tests, including a chemistry panel and complete blood count (CBC). Issues like abnormal electrolyte levels (measured by a chemistry panel) or a high white blood cell count may signal an acute illness that could necessitate postponing your surgery.

You will have to go to a pre-surgical area where you will change into a surgical gown. You will have your temperature, blood pressure, and pulse checked. Your nurse will place an intravenous (IV, in a vein) catheter, most likely in your arm or hand.

Your surgeon will check you and may examine your penis and the surrounding area to ensure that there are no problems such as an infection prior to your surgery.

You might receive one dose of prophylactic IV antibiotic medication before your procedure to reduce the risk of infection.

You may be asked to use the bathroom before being taken to the operating room.

Before the Surgery

Once you are in the operating room, you will have a urinary catheter placed in your urethra to collect urine during your surgery. For some people, this process is slightly uncomfortable for a few minutes, although many people don't feel it.

You will not be able to feel any pain during your surgery. You will have light anesthetic medication injected into your IV, and this should make you sleepy.

In addition to your light IV anesthetic, there are other pain control methods that can be used during penile implant surgery:

• You might also have local anesthesia, with numbing medication injected with a needle around your groin and penis.
• You may have general anesthesia, which involves IV medications that put you to sleep and paralyze your muscles. If you have general anesthesia, you will have a breathing tube placed in your throat so that you can have mechanical breathing assistance during your surgery.

You will likely have your heart rate, blood pressure, and oxygen saturation monitored throughout your procedure.

During the Surgery

Your pubic hair will be shaved, possibly as your anesthesia is getting started. Your penis, scrotum, and surrounding area will be cleansed with an antiseptic solution. Your surgeon will place a drape over your body, exposing only your penis and a small area around it where the incision will be made.

Your surgeon will make an incision in the skin that can range from 1 inch to 4 inches in length, depending on how much access is needed for insertion of the implant.

Typically, the incision is made at the top of your penis near your pelvic bone on the ventral side (the side facing down when the penis is flaccid and facing up when the penis is erect). The incision can be made on the dorsal side, however.

Your surgeon will cut the tissue below the skin to access the area behind your corpus cavernosum. This is the erectile tissue that runs down the ventral side of your penis.

• Your surgeon might gently expand the area behind your corpus cavernosum with a surgical device.
• If you have scar tissue or growths, they may need to be resected.
• Your implant will be positioned directly behind the corpus cavernosum toward the side that is deeper in your penis and further from your skin.
• You may also have another incision near your scrotum for the placement of a reservoir and pump if you are having an inflatable prosthesis.

Throughout your procedure, all bleeding must be well controlled and blood in the surgical area must be meticulously removed so it won't accumulate in your penis after the incision is closed.

Once your procedure is complete, you will have sutures placed to close the deep layers that were cut and another set of superficial sutures to close your skin. The surgical area will be cleaned and covered with bandages and gauze.

Your IV anesthesia medication will be stopped. If you've had general anesthesia, it will be reversed and your breathing tube will be removed. The medical team will ensure that you can breathe on your own before you leave the operating room to go to the post-operative recovery area.

After the Surgery

You might still be groggy from the anesthetic while in the post-operative area.

You will have your urinary catheter in place for approximately 12 to 24 hours after surgery. Your medical team will watch for excessive blood in the urine or cloudiness (a sign of infection).

The medical team will monitor your pain level as the anesthetic medication is wearing off and give you pain medication as needed.

When it's clear that you are stable, you will be sent home, probably with your catheter still in place.

Recovery

It will take several weeks to fully recover from having a penile implant.

In the first few weeks after your surgery, you will have swelling and pain in and around your penis. Your medical team will explain what's normal and what's not.

You may need to go for a follow-up appointment the day after your surgery so you can have your catheter removed. Your surgical area will also be checked at this time to ensure that swelling is going down.

After a few weeks, you will have your sutures removed. The doctor will let you know when you can start resuming normal activities and using your penile implant for sexual activity.

Healing

As you are recovering, you will need to take care of your surgical wound. You will be given instructions regarding the cleaning of your wound and whether you need to keep it dry.

Constipation can increase pain, and you might need to take a laxative to keep your stools soft. You will also need to follow instructions regarding cleaning yourself properly after a bowel movement to prevent contamination of your surgical wound.

You can use an ice pack to reduce swelling. Be sure not to place the ice pack directly on your skin. If you need to, you can take your pain medication as prescribed. It's important that you take any antibiotics a doctor has prescribed as well; don't stop a course early even if you are feeling well.

Signs of post-operative complications that you should look out for include:

• Increasing swelling
• Blood in the urine
• Cloudy urine
• Painful urination
• Increasing pain in the surgical area
• Warmth, redness, or tenderness
• Fever or chills

Coping With Recovery

You will have to rest in bed for several days after your surgery, but the doctor will recommend that you walk for about 15 minutes a few times a day to prevent complications of inactivity such as a bladder infection, blood clots, or pressure sores. It can help to have some extra help around the house during this time.

After a few days, you can advance your walking as tolerated and as directed by a doctor.

Using Your Implant

You will need to learn how to use your prosthesis. This process is more complicated if you have an inflatable device.

You will receive instructions from the medical team, and you should ask any questions you have to make sure you fully understand what to do. Some inflatable prostheses require preparation by inflating them every day for several weeks before they are ready for use.

Possible Future Surgeries

In general, penile implant surgery is intended to be a one-time procedure. However, some who get an implant will need a replacement or revision at some point in the future if the implant becomes dislodged or damaged, such as due to a traumatic injury.

If you have a surgical complication, such as damage to any area in or around the penis or a severe infection, you may need additional surgery to resolve the issue.

Lifestyle Adjustments

After you heal, you should be able to engage in sexual activity and normal physical activities.

As you begin to have sexual activity with your implant, you will become familiar with the timing, size, and firmness of your erections. You may also consider discussing these changes and adjustments with your partner.

Surgery is generally reserved for "refractory" cases of erectile dysfunction, which are those that are resistant to treatment. This can arise in several cases:

• Lack of response to treatment: Lifestyle modifications, medications, or other noninvasive treatments don't resolve the issue.
• Peyronie's disease: This disease, characterized by extreme bending of the penis during erections, leads to painful sex and dysfunction. Other treatments will not resolve this issue.
• Trauma: Penile implants are considered in cases of erectile dysfunction due to damage to the nervous system, as in traumatic brain injury (TBI) or spinal cord injury.

The efficacy of erectile dysfunction varies based on type:

• Penile implant surgery is considered the gold standard for restoring function in cases of erectile dysfunction. Over 90 percent of patients are highly satisfied with the procedure, and complications or mechanical failures are rare. Infection rates among postoperative patients have been found to be only about 2 percent.
• Arterial revascularization may not be effective in some cases and has best results for younger men with erectile dysfunction due to pelvic trauma. There's a chance of complications after surgery. Up to 13 percent of patients experience glans hyperemia, in which there's too much blood in the head (or "glans") of the penis.
• Venous surgery also has more limited applications, with older men having an increased risk of complications. Applied in the correct circumstances, researchers have found success rates of up to 83 percent within a year of surgery, with these numbers consistently dropping in subsequent follow-up.
  

A Word From Verywell

If you're considering a penile prosthesis, talk to a doctor who is familiar with the risks and benefits of this surgery. It is important to discuss potential side effects and less-invasive alternatives before choosing this surgery. It is also a good idea to investigate the different types of implants as you are considering this procedure.