Overview of Penile Prosthesis
A penile prosthesis, also known as a penile implant, is a medical device that is surgically inserted into the penis to treat erectile dysfunction (ED). It is typically considered when other treatments for ED have been unsuccessful. The main goal of a penile prosthesis is to provide an erection that is sufficient for sexual intercourse. There are two main types of penile prostheses: inflatable implants and malleable (or semi-rigid) implants.
Inflatable Implants
Inflatable penile implants are the most commonly used type of penile prosthesis. They consist of a pump, two cylinders, and a reservoir containing saline solution. The cylinders are implanted in the penis, the pump is placed in the scrotum, and the reservoir is implanted in the abdomen. When the pump is squeezed, saline solution is transferred from the reservoir into the cylinders, causing an erection. To deflate the penis, a release valve on the pump is pressed, allowing the saline to flow back into the reservoir.
Malleable (Semi-rigid) Implants
Malleable implants consist of two bendable rods that are surgically implanted into the erection chambers of the penis. This type of implant allows the penis to be positioned as needed for sexual intercourse and then bent away from the body for concealment under clothing when not in use. Malleable implants are simpler and have fewer parts than inflatable implants, making them a good option for men with limited manual dexterity.
Advantages and Disadvantages
The choice between an inflatable or malleable penile prosthesis depends on patient and partner satisfaction, cosmetic considerations, and the patient’s health status.
Advantages of Penile Prosthesis:
- Provides a solution for men who have not had success with other ED treatments.
- High patient and partner satisfaction rates.
- Allows for control over the timing and duration of an erection.
Disadvantages of Penile Prosthesis:
- Involves surgery, which comes with risks such as infection.
- May require replacement or repair over time due to wear or malfunction.
- Can cause a permanent change in the natural state of the penis; if removed, normal erectile function is unlikely to return.
Surgical Considerations
The surgery to implant a penile prosthesis is usually done under general anesthesia. It typically involves a short hospital stay or may be performed on an outpatient basis. Recovery time varies, with most men able to return to normal activities within a few weeks and to sexual activity within 4 to 6 weeks.
Components of a Penile Prosthesis
The components of a penile prosthesis vary depending on the type of implant chosen: inflatable or malleable (semi-rigid). Each type is designed to mimic the appearance and function of a natural erection as closely as possible. Here’s a breakdown of the components for each type:
Inflatable Penile Prosthesis
Inflatable penile implants are the most advanced type of penile prosthesis and consist of several key components:
- Cylinders: Two cylinders are inserted into the penis’s erection chambers (corpora cavernosa). These cylinders are inflated to create an erection and deflated to return the penis to a flaccid state.
- Pump: The pump is implanted in the scrotum between the testicles. This component allows the patient to control the inflation and deflation of the cylinders. Squeezing the pump moves saline solution from the reservoir into the cylinders to create an erection.
- Reservoir: A saline solution reservoir is implanted in the abdomen. It stores the saline solution that is transferred to the cylinders to create an erection. When the erection is no longer desired, the saline is returned to the reservoir.
- Tubing: Connects the cylinders, pump, and reservoir. The tubing allows the saline solution to move between the reservoir and the cylinders when the pump is activated or deactivated.
Malleable (Semi-Rigid) Penile Prosthesis
Malleable penile implants are simpler in design and consist of the following components:
- Rods: Two bendable rods are surgically inserted into the penis’s erection chambers. These rods are made of a flexible core covered with a silicone sheath, allowing them to be bent into an erect position for sexual intercourse and then back down when not in use.
Unlike inflatable implants, malleable implants do not have a pump, reservoir, or tubing, as they do not require inflation or deflation. The simplicity of this design makes it a durable and less complex option, though it offers less natural-feeling erections than the inflatable type.
Choosing the Right Implant
The choice between an inflatable and a malleable penile prosthesis depends on several factors, including the patient’s preference, health condition, manual dexterity, and the specific recommendations of the treating physician. Inflatable implants tend to provide a more natural erection and flaccidity, making them more popular despite their complexity. Malleable implants, on the other hand, are often recommended for men who prefer a simpler, more straightforward device or for whom manual dexterity is a concern.
Medical indications for considering a penile prosthesis
The decision to consider a penile prosthesis, also known as a penile implant, is typically reserved for men with erectile dysfunction (ED) who have not responded to less invasive treatments. Medical indications for considering a penile prosthesis include:
1. Refractory Erectile Dysfunction
This is the primary indication for a penile prosthesis. It includes men who have not had success with, or cannot tolerate, other treatments such as oral medications (e.g., phosphodiesterase type 5 inhibitors), penile injections, vacuum erection devices, or intraurethral suppositories.
2. Peyronie’s Disease with Erectile Dysfunction
Peyronie’s disease can cause abnormal curvature, pain, and erectile dysfunction in men. When accompanied by refractory ED, a penile prosthesis may be considered to correct the curvature and restore erectile function, especially if the curvature prevents satisfactory sexual intercourse.
3. Penile Fibrosis
Severe penile fibrosis, which may result from Peyronie’s disease, priapism (prolonged erection), penile trauma, or previous surgeries, can lead to erectile dysfunction that is unresponsive to conservative treatments. In such cases, a penile implant can help achieve an erection suitable for intercourse.
4. Postpriapism Erectile Dysfunction
Priapism, if not treated promptly, can lead to ischemic damage to the penile tissue, resulting in fibrosis and subsequent ED. A penile prosthesis may be considered for men who develop ED following an episode of priapism.
5. Complex Urological Conditions
Men with complex urological conditions, such as those undergoing reconstruction after pelvic trauma or those with congenital penile anomalies that lead to ED, may be candidates for a penile implant.
6. Psychological Impact
Men for whom erectile dysfunction has a significant negative impact on their psychological well-being, relationships, or quality of life, and who have not benefited from other forms of therapy, may also consider a penile prosthesis.
7. Contraindications and Considerations
It’s important to note that while penile implants offer a high degree of satisfaction, they are considered a last resort after other treatments have failed or are not suitable. Patients should have realistic expectations and understand the potential risks and benefits. Contraindications include uncontrolled diabetes, active urogenital infections, and unrealistic patient expectations.
Before proceeding with a penile prosthesis, a thorough evaluation by a healthcare professional specializing in male sexual dysfunction is necessary. This evaluation will help to ensure that the patient is a suitable candidate for the procedure and to discuss the type of implant that would best suit the individual’s needs and lifestyle.
Comparison with Other ED Treatments
Erectile dysfunction (ED) can be treated through various methods, each with its own advantages and disadvantages. The decision on which treatment to pursue often depends on the cause of ED, the patient’s overall health, personal preferences, and the severity of the condition. Here’s a comparison of a penile prosthesis with other ED treatments:
1. Oral Medications
- Examples: Sildenafil (Viagra), Tadalafil (Cialis), Vardenafil (Levitra), Avanafil (Stendra)
- Pros: Non-invasive, easy to use, effective for many men
- Cons: May cause side effects (e.g., headache, flushing, upset stomach), contraindicated with certain medications (e.g., nitrates), not effective for all men
- Comparison: Oral medications are the first-line treatment for ED. They are less invasive than a penile prosthesis but also less effective in cases of severe ED or when medical conditions prevent their use.
2. Vacuum Erection Devices
- Pros: Non-invasive, can be effective for various causes of ED
- Cons: May be cumbersome to use, can cause bruising or numbness, erections may look unnatural or be cold to the touch
- Comparison: Vacuum devices are a non-invasive option but may not provide as satisfactory an erection as a penile prosthesis. They require planning and can disrupt spontaneity.
3. Penile Injections
- Examples: Alprostadil, Bi-mix, Tri-mix
- Pros: Effective for many men who do not respond to oral medications
- Cons: Injections may be painful, risk of priapism (prolonged erection), may cause scarring
- Comparison: Penile injections are more invasive than oral medications and less invasive than a prostheses. They can be effective when oral medications fail but require the patient to be comfortable with self-injection.
4. Intraurethral Suppositories
- Example: Alprostadil urethral suppository (MUSE)
- Pros: Less invasive than injections
- Cons: May cause discomfort, less effective than injections or oral medications
- Comparison: A less invasive option compared to injections and penile prostheses but often less effective and can be uncomfortable to use.
5. Penile Prosthesis
- Pros: High satisfaction rates, allows for spontaneous erections, effective in severe cases of ED
- Cons: Invasive (requires surgery), risk of infection or mechanical failure, irreversible
- Comparison: A penile prosthesis is often considered a last resort when other treatments have failed. It is the most invasive option but also offers the potential for the highest satisfaction among men who do not respond to or cannot use other treatments.