If oral medications for erectile dysfunction do not work, surgery to implant a penile prosthesis is also an option. The penile prosthesis is a silicone device is implanted into the penis that allows the patient to have intercourse while preserving normal sensation. It does require surgery, although the surgery is usually done as an outpatient procedure or with an overnight stay accompanied by only mild discomfort for patients.
There are three kinds of penile prosthesis: the 3 piece inflatable penile prosthesis, the malleable penile prosthesis and the 2 piece inflatable penile prosthesis.
We most commonly use the three piece inflatable penile prosthesis. This surgically placed prosthesis consists of a scrotal pump, inflatable cylinders and a small reservoir to hold fluid. When a patient wants to have an erection he squeezes the scrotal pump to inflate the prosthesis and gets a very hard erection. Normal sensation remains and patients often are thankful that they can have an erection like when they were young. When the patient no longer wants to have the erection, he can push on a small button on the pump and the penis will become soft again.
Most patients love the rock-hard firmness, the duration and sensation of their erection and are generally very satisfied with the 3-piece penile prosthesis. In addition to this, when the penis is down, the flaccid penis appears normal. Sometimes, patients report that their partners still have no idea they have a prosthesis in!
An alternative to the three piece penile prothesis is a malleable penile prothesis. The malleable penile prosthesis involves two semi-rigid cylinders that are implanted into the penis without a pump or reservoir. When the patient wants to have an erection, he bends the penis up – when the patient no longer wants to have an erection he can bend the penis back down. Typically the erection is firm enough for intercourse and like the three piece penile prosthesis sensation remains normal. The advantage to the malleable prothesis is that it is very easy to use for patients who may have trouble with their hands and the surgery itself can be quickly done. The disadvantage to the malleable prosthesis (or what is called a semi-rigid prosthesis) is that the erection tends not to be as hard as a three piece penile prothesis and when they are non-erect, the penis is not completely soft.
A third alternative to the three piece and malleable prostheses is the two piece inflatable prosthesis. There is no reservoir and the patient just has a scrotal pump which transfers fluid into penile cylinders when they want to have erection. This is an option for some patient and combines the benefits of the three piece penile prosthesis as well as the malleable prosthesis, but also some of the disadvantageous of both. The patient would not have as rigid erection with the two piece prosthesis as they would have with three piece and they are not as completely soft when they are done with their erection.
Although the surgery is generally considered very safe there are risks. Patients can have some discomfort and bruising at the incision site. The device can malfunction or breakdown but usually it lasts for between 10 to 15 years. One of the major risks is the possibility that the penile prosthesis can erode or become infected. This risk less than 5%.
If the prosthesis itself has become infected, antibiotics will prevent the need for surgery to remove the prosthesis. Often, a new prosthesis can be implanted at the time of surgery to remove the infected one.
We typically have the patient clean themselves with a special soap the night before and morning of surgery. In addition antibiotics are started before surgery and continued after surgery. During the surgery extra care is taken to minimize any chance the prosthesis would be exposed to residual bacteria on the skin and minimize its exposure to air.
There is typically some swelling around the penis and scrotum. Dressings usually come off 2 days after surgery. A scrotal support or jock-strap will help decrease some of the swelling. Usually the device can be activated and used at around 6-8 weeks after the surgery.
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