Surgical Penile Implants

Surgical implantation of a penile prosthesis is one option for erectile dysfunction which involves inserting an implant into the erectile tissue. Different types exist including malleable (semi-rigid) and inflatable (hydraulic).

Discussion

There are no RCT studies in this area. Penile prostheses have been used for over 25 years to treat ED, penile retraction (or a combination of both) or for improvement in urinary management in selected men with SCI. Generally, for ED, this option was considered after failure of more conservative treatments, including ICI of vasoactive substances, vacuum devices and, more recently, oral PDE5i. Five case-series reports and one cohort study in over 500 men with SCI have revealed a high level of satisfaction with the use of penile prostheses for the treatment of ED, making intercourse possible in almost 85%, as well as resolution of urinary management issues in 90% of patients. In addition, in one study (Zermann et al. 2006), 67% of females interviewed were satisfied with results of treatment of their partner’s ED. Inflatable prostheses (although more expensive) are often preferred over semi-rigid malleable prosthesis as the semi-rigid prosthesis is more difficult to conceal due to the permanence of the erection. These factors, although affecting preference, have not altered the overall satisfaction rates associated with malleable prostheses (Kim et al. 2008).

However, serious complications may occur in about 10% of patients, including infection (4-8%) and perforations depending on implant type (9-18% of semi-rigid devices vs 0-2.7% of semi-flexible/inflatable devices). It has been suggested that the insertion of smaller diameter prosthesis in patients performing clean intermittent catheterizations is more appropriate to reduce the resistance at the time of catheter insertion and potential urethral erosion. Results of two larger studies (Gross et al. 1996; Zermann et al. 2006) have shown that improvements over the last 10 years in device design (with the introduction of softer implant materials), surgical approach (infrapubic rather than subcoronal) and infection control measures (broad-spectrum antibiotic prophylaxis and whole body disinfection) have dramatically reduced the likelihood of these complications occurring. Under these improved circumstances, implantation of a penile prosthesis appears to be a relatively safe and viable option, perhaps best reserved for when reversible ED therapies have failed or for those men (or their partners) who find other alternatives, such as intracavernosal injections unacceptable. This decision requires careful consideration in view of the fact that if explanation of penile prosthesis is necessary, the person may no longer be a candidate for other treatment options, such as ICI or a VCD, due to possible extensive penile damage and scarring.

Conclusion

There is level 4 evidence (Kim et al. 2008; Zermann et al. 2006; Gross et al. 1996) which suggests the use of penile prostheses as treatment for erectile dysfunction (ED) in men with SCI when other ED treatments have failed.