Penile prosthesis: what it is, when it is implanted, how it works

A penile prosthesis is a surgical implant that definitively resolves erectile dysfunction when medical and physical therapies have not produced satisfactory results. International guidelines place it as third-line therapy: implantation follows the failure of oral therapy (first line) and intracavernous therapy (second line). It carries the highest satisfaction rate of all ED treatments, and it is also an irreversible choice.

When a penile prosthesis is implanted

Prosthetic implantation is never a first choice; it is the final step of a pathway:

• First line: oral PDE5 inhibitors
• Second line: alprostadil by intracavernous injection, transurethral device or topical cream, optionally with a vacuum device
• Third line: penile prosthesis implantation

The typical candidate is a man with severe organic erectile dysfunction: long-standing diabetes, the aftermath of radical pelvic surgery (in particular radical prostatectomy for prostate cancer), advanced vascular damage, or severe Peyronie's disease associated with erectile failure.

Types of penile prosthesis

In the past there were rigid prostheses, inserted into the corpora cavernosa but difficult to conceal, since the penis remained permanently erect. Two categories are used today:

Semi-rigid (malleable) prostheses

Two semi-rigid cylinders inserted into the corpora cavernosa. The penis is positioned manually. They are simpler, with fewer mechanical components, but less concealable than the hydraulic models.

Hydraulic (inflatable) prostheses

These are today's reference solution, available in two configurations:

• Two-piece: two cylinders in the corpora cavernosa and a pump placed in the scrotum
• Three-piece: two cylinders, the scrotal pump and a small abdominal reservoir

A hydraulic prosthesis is completely concealed when the penis is flaccid. Activated by a very simple manual mechanism on the scrotal pump, it produces an erection comparable to a natural one, to the full satisfaction of both partners.

A prosthesis removes neither orgasm nor ejaculation

This is the most common fear, and it is unfounded. A penile prosthesis replaces the mechanism of erection, not penile sensitivity or orgasmic function. The implant acts on the corpora cavernosa, not on the nerves responsible for penile sensation or on the mechanisms of ejaculation. The patient retains penile sensitivity and reaches orgasm and ejaculation exactly as with a natural erection.

The procedure

• Anaesthesia: general
• Surgical approach: an incision at the penoscrotal angle, or a suprapubic approach
• Scar: small, 3–4 cm, the only visible sign of the implant; over time it becomes almost imperceptible
• Hospital stay: minimal, a few days

Risks and complications

Like any prosthetic implant, the penile prosthesis carries possible complications, which should be known before surgery rather than after:

• Implant infection: the most feared complication, since it may require removal of the prosthesis. The risk is higher in diabetic patients and in revision surgery
• Mechanical failure: hydraulic prostheses are mechanical devices with a finite lifespan; a malfunction may require replacement
• Erosion of the tissue by the cylinders, a rare event

Penile prosthetic surgery requires specific experience: the management of complications and of implants in difficult situations is a distinct competence. Prof. Natali has published on these topics, including European series of penile implants and the management of complications of penile prosthesis surgery.

Frequently asked questions about the penile prosthesis

Is a penile prosthesis visible?

No. Hydraulic prostheses are completely concealed when the penis is flaccid. The only visible sign is a small 3–4 cm scar at the penoscrotal angle or in the suprapubic area, which becomes almost imperceptible over time.

Is there still pleasure with a prosthesis? Is ejaculation possible?

Yes. The prosthesis replaces the mechanism of erection, not penile sensitivity or orgasmic function. The patient reaches orgasm and ejaculates as if the erection were natural.

Is a penile prosthesis reversible?

No. The implant permanently occupies the corpora cavernosa, and after surgery a return to drug therapy is no longer possible. This is precisely why it is a third-line therapy: the prosthesis comes after the other options have been tried, and the decision is taken with the specialist and shared with the partner.

How long does a penile prosthesis last?

Hydraulic prostheses are mechanical devices with a finite lifespan: a failure may require replacement after some years. Actual longevity depends on the model, on use and on the individual patient, and is one of the points to discuss with the surgeon before implantation.

How long is the hospital stay?

The hospital stay is minimal, a few days. The procedure is performed under general anaesthesia.

Who is the ideal candidate?

A man with severe organic erectile dysfunction who has not responded to first- and second-line therapy, and who has been properly informed about the irreversibility of the implant and its possible complications. Careful preoperative assessment of the patient is an integral part of a successful outcome.

Would you like to know whether you are a candidate for an implant? Ask Prof. Natali for a consultation or book an appointment at his practices in Florence and Empoli, Italy.

The information on this page is provided for general educational purposes and does not replace a medical examination, which remains the only diagnostic tool for correct and effective treatment.