Penile Implant Surgery

At a glance

• What it is: Surgical placement of an inflatable penile prosthesis (IPP) - two soft cylinders inside the natural erection tissue of the penis, a small pump in the scrotum, and a saline reservoir tucked inside the abdomen. The patient inflates and deflates the device on demand.^6,7
• Who it suits: Men with persistent erectile dysfunction in whom oral tablets (PDE5 inhibitors), vacuum erection devices and intra-cavernosal injection therapy have not given a satisfactory result, or are unsuitable - including many men after radical prostatectomy, pelvic radiotherapy, severe Peyronie’s disease, or significant vascular or neurogenic ED.^6,7
• What the evidence shows: Inflatable penile prostheses have the highest patient and partner satisfaction of any treatment for erectile dysfunction in the published literature (typically reported as 90-95% or above), with infection rates of approximately 1-3% and long-term mechanical reliability of around 80-95% at 10 years for the modern three-piece devices.^3,4,5,8,9
• Where Urology NSW sits: Dr Raji Kooner has performed inflatable penile prosthesis surgery for many years and considers it an under-recognised option for men whose erectile dysfunction has not responded to less invasive treatment. Suitability, the device options, and the specific risks of implant surgery are discussed in detail at consultation.

What is a penile (inflatable) prosthesis?

The penis contains two cylinders of spongy tissue called the corpora cavernosa. During a normal erection, these fill with blood under pressure and the penis becomes rigid; when the erection ends, the blood drains out. An inflatable penile prosthesis replicates the same mechanism mechanically.^6,7

A modern three-piece inflatable penile prosthesis has three components, all hidden under the skin once healed:

• Two cylinders placed inside the corpora cavernosa, along the length of the penis.
• A small pump sitting in the scrotum, between the testicles, with a deflate button on top.
• A saline reservoir placed in the lower abdomen, behind the abdominal wall.

To get an erection, the patient repeatedly squeezes the scrotal pump. Saline moves from the reservoir into the cylinders and the penis becomes firm. The erection can be maintained for as long as desired, and is not affected by tiredness, alcohol or stress in the way a natural erection is. When finished, pressing the deflate button on the pump returns the saline to the reservoir and the cylinders soften.⁶

Two-piece (combined pump and reservoir in the scrotum) and malleable (semi-rigid, no pump) implants exist as alternatives in selected men where a three-piece device is not feasible (for example after extensive abdominal or pelvic surgery), but the three-piece IPP gives the most natural-feeling rigid and flaccid states and is the device used in the great majority of cases internationally.⁶

Implant types at a glance

The choice of device is individualised at consultation, taking into account the patient’s anatomy, prior abdominal or pelvic surgery, body habitus, manual dexterity, and personal preferences.

Where a penile implant fits in erectile dysfunction treatment

Erectile dysfunction is common - around 40% of Australian men are affected to some degree¹ - and most men respond well to one of the simpler treatment options. International guidelines (American Urological Association, European Association of Urology) describe a stepped approach:^6,7

1. First line: oral PDE5 inhibitors (sildenafil, tadalafil, vardenafil), modification of cardiovascular and metabolic risk factors, and pelvic-floor work.
2. Second line: vacuum erection devices, and intra-cavernosal or intra-urethral prostaglandin therapy (such as alprostadil / Caverject).
3. Third line: surgical placement of a penile prosthesis. For carefully selected men this can also be a first choice if the simpler treatments are clearly unlikely to be effective.^6,7

A penile prosthesis is generally considered after a structured trial of the simpler options has not given a satisfactory result. Dr Kooner’s view, supported by the published literature, is that this option is under-recognised in Australia given how reliably it works for the right patient.²

Who is suitable?

An inflatable penile prosthesis is most often considered for:

• Men with persistent erectile dysfunction despite a structured trial of PDE5 inhibitors, vacuum therapy and injection therapy.^6,7
• Men with erectile dysfunction after radical prostatectomy, pelvic radiotherapy or other pelvic surgery, particularly where nerve damage means oral medication and injection therapy are unlikely to restore reliable erections.⁶ See Sexual rehabilitation after prostatectomy.
• Men with severe vasculogenic erectile dysfunction (significant vascular disease) or with diabetes and severe diabetic ED.
• Men with significant Peyronie’s disease where the curvature and erectile dysfunction together make a prosthesis with intra-operative correction the most reliable option.
• Men in whom oral PDE5 inhibitors are unsafe or contraindicated (for example men on long-acting nitrate therapy for cardiac disease).

A penile prosthesis is usually not the first option for:

• Men whose erectile dysfunction has not yet been worked up with a basic medical assessment, cardiovascular risk review and a structured trial of less invasive treatment.^6,7
• Men with active infection (urinary, skin or systemic) - this needs to be treated before any implant surgery is considered, because of the infection risk.⁵
• Men with poorly controlled diabetes, where blood glucose control needs to be optimised first to reduce the risk of infection.⁵
• Men whose primary problem is loss of libido, ejaculation, sensation, fertility or relationship issues rather than erectile rigidity itself - an implant treats erection only.

Each recommendation is made with the individual patient (and partner where appropriate) after a full history, examination, and review of medical and surgical history, current medications, and previous treatment trials.

How is the operation performed?

1. Anaesthesia. The operation is performed under a general or spinal anaesthetic. Antibiotics are given intravenously at induction, in line with the published infection-prevention protocols (the Mulcahy / AUA implant protocol).^5,6
2. Skin preparation. Careful preparation of the skin of the scrotum, penis and lower abdomen, with a chlorhexidine or povidone-iodine scrub. A specific shave is performed in theatre rather than the night before, to reduce the risk of bacterial colonisation of small skin nicks.⁵
3. Incision. A single small incision is made either at the top of the scrotum where it joins the penis (a penoscrotal approach), or just above the penis (an infrapubic approach). The choice is individualised; the penoscrotal approach gives good access to the corpora and the scrotum for pump placement and is the most common approach worldwide.⁶
4. Cylinder placement. A small opening is made in each corpus cavernosum. The corpora are gently dilated to the appropriate length, measured carefully, and the two cylinders of the prosthesis are placed inside.⁶
5. Pump placement. A pocket is created in the scrotum between the testicles, and the pump is placed there.
6. Reservoir placement. The saline reservoir is placed behind the abdominal wall in the lower abdomen, usually through the same incision (or via a small separate access if the anatomy requires).
7. Connection and testing. The three components are connected and the device is tested intra-operatively by inflating and deflating it to confirm that the cylinders fill correctly and that the pump and reservoir work as expected.
8. Closure. The incision is closed in layers with absorbable sutures. A waterproof dressing is applied and the penis is taped up to the abdomen for the first 24 hours to reduce swelling.

The whole operation typically takes one to two hours. Most centres use the modern infection-reducing pathway (intra-operative re-prep, no-touch insertion technique, antibiotic-coated device, peri-operative diabetic control) which has reduced reported infection rates.⁵

What to expect: hospital stay and early recovery

Length of stay. Most men go home the same day or after one overnight stay, depending on individual circumstances and the time of surgery.

Catheter. A urinary catheter is usually placed during surgery and either removed before discharge or the next morning.

Pain. Pain is moderate for the first few days and is well controlled with regular paracetamol, a short course of anti-inflammatories and a small supply of stronger pain relief if needed. Bruising and swelling of the scrotum and lower penis are normal in the first one to two weeks and settle gradually.

Wound and dressing. The single small incision is closed with absorbable sutures and covered with a waterproof dressing that allows showering after 24-48 hours. The penis is usually taped lightly upward to the abdomen for the first day to reduce swelling.

Device handling. Most surgeons leave the device deflated for the first few weeks while the tissues heal. At a follow-up visit (typically four to six weeks after surgery), the device is partly inflated and the patient is taught how to operate the pump. From that point, daily partial inflation is recommended for a short period to help the body settle around the cylinders.⁶

Return to activity. Walking from the day after surgery; light desk-type work usually within one to two weeks. Avoid heavy lifting and cycling for approximately four to six weeks while the deep layers heal.

Sexual activity. Sexual activity is typically resumed approximately six weeks after surgery, once the operating surgeon has confirmed that the wound has healed and the device is working correctly.

Outcomes

Patient and partner satisfaction

Across multiple published series and registries, inflatable penile prostheses have the highest patient and partner satisfaction of any treatment for erectile dysfunction. Reported satisfaction is typically around 90-95% or above for both patients and partners.^3,4,8,9 The Manfredi 2021 review summarised the available satisfaction literature; the PROPPER multicentre prosthesis registry described real-world contemporary practice.^4,9

Mechanical reliability

Modern three-piece inflatable penile prostheses are mechanically robust. Long-term series of the AMS 700CX and current-generation devices report mechanical-failure-free survival of approximately 80-95% at 10 years.⁸ When mechanical failure does occur, the device can usually be replaced at a further operation.

What an implant does and does not do

• It restores reliable, on-demand penile rigidity sufficient for penetrative sexual activity.^3,4
• It does not change desire (libido), sensation, ability to orgasm, or fertility on its own.
• It does not enlarge the penis. The implant fills the existing corpora; many men feel slightly shorter than they were before surgery, which is partly due to how the natural erection tissue settles after the corpora are dilated. The published literature describes this as a real but usually mild effect.⁶
• The natural erection tissue is altered during the operation. After a penile prosthesis, going back to tablets, vacuum or injection therapy is not possible.⁶

Risks and complications

Every patient is counselled on the following risks before surgery.

• Infection. The most important specific risk of any prosthesis. Modern protocols (intravenous prophylactic antibiotics, antibiotic-coated devices, no-touch technique, theatre re-prep, optimised diabetic control) have reduced infection rates to approximately 1-3% in published series.⁵ If an implant becomes infected, it usually has to be removed; a replacement device can often be placed at the same operation (a "salvage" reimplant) or as a separate procedure later, depending on circumstances.⁵
• Mechanical failure. Like any mechanical device, the prosthesis can fail over time. Modern devices have long-term reliability of around 80-95% at 10 years.⁸ Replacement surgery is usually possible.
• Erosion or extrusion. Uncommon; the cylinders, pump or reservoir can erode through the surrounding tissue if there is unrecognised infection, urethral injury at surgery, or chronic pressure (for example a long-term indwelling catheter against a cylinder). Treatment usually means removing the affected component.
• Penile shortening or change in glans sensation. Some men feel slightly shorter than before surgery, and a small proportion notice reduced sensation in the glans. These are usually mild.
• Bleeding and bruising. Some bruising and swelling of the scrotum and penis is universal in the first one to two weeks; significant bleeding requiring a return to theatre is uncommon.
• Scrotal discomfort or auto-inflation. Some men experience scrotal scar discomfort that settles with time. Older two-piece designs were associated with auto-inflation (the device partly inflating on its own) when intra-abdominal pressure rose; modern lock-out reservoirs have largely resolved this.⁶
• Urinary problems. Temporary difficulty passing urine after catheter removal is uncommon and usually settles. A urinary tract infection is treated with antibiotics.
• General surgical risks. Bleeding, infection at the incision, and the usual risks of any operation under general anaesthesia (chest infection, deep vein thrombosis, pulmonary embolism) - all uncommon and reduced by standard peri-operative care.

Penile implants after radical prostatectomy and pelvic surgery

Erectile dysfunction is common after radical prostatectomy and after pelvic radiotherapy, particularly when the neurovascular bundles cannot be fully spared. A structured rehabilitation programme using PDE5 inhibitors (and, where needed, vacuum therapy or intra-cavernosal injections) is started early after surgery; this is described on the Sexual rehabilitation after prostatectomy page.

A penile prosthesis is considered when post-operative recovery has plateaued and the simpler treatments have not given a satisfactory result. International guidelines support penile prosthesis surgery as an effective and well-accepted option in this group.^6,7 Surgery is usually delayed until at least 6-12 months after the prostate or pelvic operation, to allow tissues to settle and to give nerve recovery a fair chance.

Penile implants at Urology NSW

Dr Raji Kooner has performed inflatable penile prosthesis surgery for many years and considers it an under-recognised option for men whose erectile dysfunction has not responded to less invasive treatment.² The decision to proceed is made jointly with the patient (and partner where appropriate) after a full work-up, including review of medical history and previous treatments, and a clear discussion of the irreversibility of the procedure, the satisfaction figures, and the specific risks of implant surgery.

For background on non-surgical treatment of erectile dysfunction, see Erectile dysfunction. For the implant-based treatment of stress urinary incontinence (the artificial urinary sphincter, AUS), see Artificial urinary sphincter. Both procedures are part of the Urological prosthetics service.

Patients who would like to discuss whether a penile implant is appropriate for them are welcome to contact the practice to arrange a consultation or request a second opinion.

Frequently asked questions

Will anyone be able to tell I have an implant?

No. The whole device is inside the body. When the cylinders are deflated, the penis hangs naturally; when inflated, it is rigid. There are no external parts and no visible scar in most cases once the small incision has healed.

Is the erection natural?

The erection looks and feels close to natural during use. It is created mechanically, so it does not depend on arousal, blood flow or medication and can be maintained for as long as you want. Sensation, orgasm and ejaculation depend on your own nerves and on whatever surgery or condition led to the erectile dysfunction in the first place; the implant does not change those.

What does it feel like to operate?

The pump in the scrotum is squeezed several times to inflate the cylinders. A separate deflate button on the pump returns the fluid to the reservoir. Most men learn to use the device confidently within a few sessions of practice.

Is it permanent? Can I change my mind?

The natural erection tissue is altered during the operation. Once an implant has been placed, going back to tablets, vacuum therapy or injection therapy is not possible.⁶ The implant itself can be removed, but the erection cannot be expected to return to its pre-implant state. For this reason, an implant is usually considered after the simpler options have been tried.

How long does the device last?

Modern three-piece devices are reported to be mechanically reliable in approximately 80-95% of cases at 10 years.⁸ If the device wears out or fails, replacement surgery is usually possible.

Will I be longer or shorter after surgery?

The implant fills the existing corpora; it does not enlarge the penis. Many men feel slightly shorter than they were before surgery, which is partly due to how the natural erection tissue settles after the corpora are dilated. The published literature describes this as a real but usually mild effect.⁶

What about my partner?

Partner satisfaction is also high in the published literature when the patient is satisfied with the device.^4,9 Where appropriate, the consultation includes the partner; the operation itself, the recovery and how the device is used are best understood together.

Will I be able to have spontaneous erections?

No. An implant gives you an on-demand erection, not a spontaneous one - you inflate the device by squeezing the scrotal pump when you want an erection, and deflate it when you are finished. If you can still get spontaneous erections that are firm enough for intercourse without an implant, you should think carefully about whether surgery is the right step, because the operation alters the natural erection tissue and is not reversible.^6,7

Will I still be able to orgasm and ejaculate?

An implant treats erection only. Sensation, the ability to reach orgasm, and ejaculation depend on your own nerves and on whatever condition led to the erectile dysfunction in the first place. If you could orgasm before the operation, you should still be able to orgasm afterwards. If you have had a radical prostatectomy, you will not produce semen at orgasm because the prostate and seminal vesicles have been removed.

Is the device safe with MRI scanners and airport security?

Modern inflatable penile prostheses are widely labelled as MR Conditional by the manufacturer, meaning they are safe to scan under specified MRI conditions; the practice will give you an implant card that you should show to the radiology team before any scan. The device contains a small amount of metal but does not normally trigger airport security walk-through detectors. If a hand-held scanner does detect it, the implant card explains what the device is.

Is the procedure covered by Medicare and private health insurance?

Penile prosthesis surgery is generally covered by private health insurance for erectile dysfunction that has not responded to non-surgical treatment, subject to your level of cover and waiting periods. The total cost is typically made up of:

• Hospital fees (theatre time, ward bed, nursing) - billed by the hospital and usually covered by your private health fund.
• Anaesthetist’s fee - billed separately by the anaesthetist; private health funds typically cover most or all of this.
• Surgeon’s fee - billed by the practice; an out-of-pocket gap may apply, depending on your fund.
• The implant device - billed by the hospital and listed on the Prostheses List, with private health funds typically covering the listed price.

Medicare item numbers are available for the surgical procedure where the eligibility criteria are met. The practice will provide a written estimate of fees, including any expected gap, before surgery.