The inflatable penile prosthesis—the ultimate treatment for severe erectile dysfunction

Erectile dysfunction (ED) is a long-standing condition that benefits from modern treatments. For those seeking medical attention for ED, it brings a significant negative impact on health-related quality of life and self-esteem. The penile prosthesis represents the last option in the therapeutic hierarchy for this condition, and the last decades have seen major improvements in both mechanics, durability and safety of this implant. Herein, this review highlights the most commonly used penile prosthetic devices, the surgical techniques involved, and the current evidence supporting their safety and effectiveness. Data from the literature consistently supports the inflatable penile prosthesis as the ultimate treatment for ED, despite its irreversible nature, arising from the destruction of the natural tissue involved in erection. We conclude that the penile prosthesis should be offered as the last alternative treatment, only for regaining erectile function but not for the enlargement of the penis.

Penile prosthesis; Erectile dysfunction; Penile implant

[1] Salonia A, Bettocchi C, Capogrosso P, Carvalho J, Corona G, Hatzichristodoulou G, et al. EAU guidelines on sexual and reproductive health. EAU Guidelines. EAU Annual Congress Milan: Milan. 2023.

[2] Jorissen C, De Bruyna H, Baten E, Van Renterghem K. Clinical outcome: patient and partner satisfaction after penile implant surgery. Current Urology. 2019; 13: 94–100.

[3] Falcone M, Garaffa G, Gillo A, Dente D, Christopher AN, Ralph DJ. Outcomes of inflatable penile prosthesis insertion in 247 patients completing female to male gender reassignment surgery. BJU International. 2018; 121: 139–144.

[4] Osmonov D, Christopher AN, Blecher GA, Falcone M, Soave A, Dahlem R, et al. Clinical recommendations from the European society for sexual medicine exploring partner expectations, satisfaction in male and phalloplasty cohorts, the impact of penile length, girth and implant type, reservoir placement, and the influence of comorbidities and social circumstances. The Journal of Sexual Medicine. 2020; 17: 210–237.

[5] Wilson SK, Chung E, Langford B, Schlesinger R, Koca O, Simsek A, et al. First safety outcomes for rigicon conticlassic® artificial urinary sphincter. International Journal of Impotence Research. 2024; 36: 829–832.

[6] Vakalopoulos I, Kampantais S, Ioannidis S, Laskaridis L, Dimopoulos P, Toutziaris C, et al. High patient satisfaction after inflatable penile prostheses implantation correlates with female partner satisfaction. The Journal of Sexual Medicine. 2013; 10: 2774–2781.

[7] Patel N, Golan R, Halpern JA, Sun T, Asafu-Adjei AD, Chughtai B, et al. A contemporary analysis of dual inflatable penile prosthesis and artificial urinary sphincter outcomes. Journal of Urology. 2019; 201: 141–146.

[8] Pyrgidis N, Barham DW, Hammad M, Sokolakis I, Hatzichristodoulou G, Lentz AC, et al. Synchronous surgical management of erectile dysfunction and stress urinary incontinence: a systematic review and meta-analysis of reoperation rates. Sexual Medicine Reviews. 2022; 10: 782–790.

[9] Carson CC III. Efficacy of antibiotic impregnation of inflatable penile prostheses in decreasing infection in original implants. Journal of Urology. 2004; 171: 1611–1614.

[10] Wilson SK, Carson CC, Cleves MA, Delk JR 2nd. Quantifying risk of penile prosthesis infection with elevated glycosylated hemoglobin. Journal of Urology. 1998; 159: 1537–1539; discussion 1539–1540.

[11] Mulcahy JJ, Carson CC III. Long-term infection rates in diabetic patients implanted with antibiotic-impregnated versus nonimpregnated inflatable penile prostheses: 7-year outcomes. European Urology. 2011; 60: 167–172.

[12] Ciftci S, Nemut T, Culha MM, Yilmaz H, Ustuner M, Yavuz Y, et al. Non-infected penile prosthesis cultures during revision surgery; comparison between antibiotic coated and non-coated devices. International Brazilian Journal of Urology. 2016; 42: 1183–1189.

[13] Chanyi RM, Alzubaidi R, Leung EJY, Wilcox HB, Brock GB, Burton JP. Inflatable penile prostheses implantation: does antibiotic exposure matter? Sexual Medicine. 2018; 6: 248–254.

[14] Lipsky MJ, Onyeji I, Golan R, Munarriz R, Kashanian JA, Stember DS, et al. Diabetes is a risk factor for inflatable penile prosthesis infection: analysis of a large statewide database. Sexual Medicine. 2019; 7: 35–40.

[15] Mandava SH, Serefoglu EC, Freier MT, Wilson SK, Hellstrom WJ. Infection retardant coated inflatable penile prostheses decrease the incidence of infection: a systematic review and meta-analysis. Journal of Urology. 2012; 188: 1855–1860.

[16] Yeung LL, Grewal S, Bullock A, Lai HH, Brandes SB. A comparison of chlorhexidine-alcohol versus povidone-iodine for eliminating skin flora before genitourinary prosthetic surgery: a randomized controlled trial. Journal of Urology. 2013; 189: 136–140.

[17] Levine LA, Becher EF, Bella AJ, Brant WO, Kohler TS, Martinez-Salamanca JI, et al. Penile prosthesis surgery: current recommendations from the international consultation on sexual medicine. The Journal of Sexual Medicine. 2016; 13: 489–518.

[18] AUA. Urologic Procedures and Antimicrobial Prophylaxis (2019). 2019. Available at: https://www.auanet.org/guidelines/urologic-procedures-and-antimicrobial-prophylaxis-(2019) (Accessed: 19 March 2021).

[19] Wosnitzer MS, Greenfield JM. Antibiotic patterns with inflatable penile prosthesis insertion. The Journal of Sexual Medicine. 2011; 8: 1521–1528.

[20] Barham DW, Pyrgidis N, Gross MS, Hammad M, Swerdloff D, Miller J, et al. AUA-recommended antibiotic prophylaxis for primary penile implantation results in a higher, not lower, risk for postoperative infection: a multicenter analysis. Journal of Urology. 2023; 209: 399–409.

[21] Palmisano F, Boeri L, Cristini C, Antonini G, Spinelli MG, Franco G, et al. Comparison of infrapubic vs penoscrotal approaches for 3-piece inflatable penile prosthesis placement: do we have a winner? Sexual Medicine Reviews. 2018; 6: 631–639.

[22] Wallen JJ, Madiraju SK, Wang R, Henry GD. Implementation of length expanding inflatable penile prosthesis is not sufficient to prevent postsurgical penile shortening. Asian Journal of Andrology. 2019; 21: 98–100.

[23] Karpman E. Management of distal & proximal penile prosthesis crossover. The Journal of Sexual Medicine. 2016; 13: 1008–1012.

[24] Yang DY, Kohler TS. Damage control considerations during IPP surgery. Current Urology Reports. 2019; 20: 10.

[25] Pearlman AM, Terlecki RP. Proximal corporal perforation during penile prosthesis surgery: prevention, recognition, and review of historical and novel management strategies. The Journal of Sexual Medicine. 2018; 15: 1055–1060.

[26] Frydman V, Pinar U, Abdessater M, Akakpo W, Grande P, Audouin M, et al. Long-term outcomes after penile prosthesis placement for the management of erectile dysfunction: a single-centre experience. Basic and Clinical Andrology. 2021; 31: 4.

[27] Bellaiche J, Gonzalez Serrano A, Larre S. Survival and associated factors with long-term survival of penile prosthesis. Progrès en Urologie. 2021; 31: 374–380. (In French)

[28] Wilson SK, Delk JR, Salem EA, Cleves MA. Long-term survival of inflatable penile prostheses: single surgical group experience with 2,384 first-time implants spanning two decades. The Journal of Sexual Medicine. 2007; 4: 1074–1079.

[29] Miller LE, Khera M, Bhattacharyya S, Patel M, Nitschelm K, Burnett AL. Long-term survival rates of inflatable penile prostheses: systematic review and meta-analysis. Urology. 2022; 166: 6–10.

[30] O'Rourke TK Jr, Erbella A, Zhang Y, Wosnitzer MS. Prevention, identification, and management of post-operative penile implant complications of infection, hematoma, and device malfunction. Translational Andrology and Urology. 2017; 6: S832–S848.

[31] Garber BB, Bickell M. Delayed postoperative hematoma formation after inflatable penile prosthesis implantation. The Journal of Sexual Medicine. 2015; 12: 265–269.

[32] Wang R, Howard GE, Hoang A, Yuan JH, Lin HC, Dai YT. Prospective and long-term evaluation of erect penile length obtained with inflatable penile prosthesis to that induced by intracavernosal injection. Asian Journal of Andrology. 2009; 11: 411–415.

[33] Deveci S, Martin D, Parker M, Mulhall JP. Penile length alterations following penile prosthesis surgery. European Urology. 2007; 51: 1128–1131.

[34] Xie D, Nicholas M, Gheiler V, Perito D, Siano L, Kislinger I, et al. A prospective evaluation of penile measures and glans penis sensory changes after penile prosthetic surgery. Translational Andrology and Urology. 2017; 6: 529–533.

[35] Miranda-Sousa A, Keating M, Moreira S, Baker M, Carrion R. Concomitant ventral phalloplasty during penile implant surgery: a novel procedure that optimizes patient satisfaction and their perception of phallic length after penile implant surgery. The Journal of Sexual Medicine. 2007; 4: 1494–1499.

[36] Lee KC, Brock GB. Strategies for maintaining penile size following penile implant. Translational Andrology and Urology. 2013; 2: 67–73.

[37] Narang GL, Figler BD, Coward RM. Preoperative counseling and expectation management for inflatable penile prosthesis implantation. Translational Andrology and Urology. 2017; 6: S869–S880.

[38] Henry GD, Laborde E. A review of surgical techniques for impending distal erosion and intraoperative penile implant complications: part 2 of a three-part review series on penile prosthetic surgery. The Journal of Sexual Medicine. 2012; 9: 927–936.

[39] Mirheydar H, Zhou T, Chang DC, Hsieh TC. Reoperation rates for penile prosthetic surgery. The Journal of Sexual Medicine. 2016; 13: 129–133.

[40] Grewal S, Vetter J, Brandes SB, Strope SA. A population-based analysis of contemporary rates of reoperation for penile prosthesis procedures. Urology. 2014; 84: 112–116.

[41] Chung E, Van CT, Wilson I, Cartmill RA. Penile prosthesis implantation for the treatment for male erectile dysfunction: clinical outcomes and lessons learnt after 955 procedures. World Journal of Urology. 2013; 31: 591–595.

[42] Eid JF, Wilson SK, Cleves M, Salem EA. Coated implants and “no touch” surgical technique decreases risk of infection in inflatable penile prosthesis implantation to 0.46%. Urology. 2012; 79: 1310–1315.

[43] Henry GD. The Henry Mummy Wrap™ and the Henry Finger Sweep™ surgical techniques. The Journal of Sexual Medicine. 2009; 6: 619–622.

[44] Baird BA, Parikh K, Broderick G. Penile implant infection factors: a contemporary narrative review of literature. Translational Andrology and Urology. 2021; 10: 3873–3884.

[45] Wilson SK, Costerton JW. Biofilm and penile prosthesis infections in the era of the coated implants: a review. The Journal of Sexual Medicine. 2012; 9: 44–53.

[46] Lopategui DM, Balise RR, Bouzoubaa LA, Wilson SK, Kava BR. The impact of immediate salvage surgery on corporeal length preservation in patients presenting with penile implant infections. The Journal of Urology. 2018; 200: 171–177.

[47] Mulcahy JJ. Long term experience with salvage of infected penile implants. The Journal of Urology. 2000; 163: 481–482.

[48] Pan S, Rodriguez D, Thirumavalavan N, Gross MS, Eid JF, Mulcahy J, et al. The use of antiseptic solutions in the prevention and management of penile prosthesis infections: a review of the cytotoxic and microbiological effects of common irrigation solutions. The Journal of Sexual Medicine. 2019; 16: 781–790.