INTRODUCTION — Erectile dysfunction (ED) affects approximately 50 million American men each year. The introduction of oral phosphodiesterase inhibitors revolutionized the care of these patients, but surgery still has a clear role when these inhibitors and other approaches fail or are contraindicated.
The surgical management of erectile dysfunction, including implantation of penile prostheses and penile vascular (arterial and venous) reconstruction, is reviewed here. The correction of curvature abnormalities (ie, Peyronie's disease) and other aspects of erectile dysfunction are discussed elsewhere.
●(See "Epidemiology and etiologies of male sexual dysfunction".)
●(See "Evaluation of male sexual dysfunction".)
●(See "Treatment of male sexual dysfunction".)
●(See "Surgical management of Peyronie's disease".)
INDICATIONS — Surgical management of erectile dysfunction (ED) should be reserved for men who cannot use, or who have not responded to, first- and second-line therapies. (See "Treatment of male sexual dysfunction", section on 'General principles'.)
Patients with curvature abnormalities (ie, Peyronie's disease) with ED or significant risk factors for future ED are candidates for the placement of a penile prosthesis at the time of their reconstructive surgery. (See "Surgical management of Peyronie's disease".)
Contraindications — Implantation of a penile prosthesis is contraindicated in the presence of infection (eg, systemic, pulmonary, urinary tract, cutaneous). The penis and scrotum must be free of any dermatitis, wounds, or other cutaneous lesions.
PREOPERATIVE PREPARATION — A thorough review of the patient's medical and surgical history, and a physical examination including a complete urologic examination, should be performed. History and physical examination are directed at evaluating the efficacy of previous nonsurgical treatments, identifying medical risk factors or other conditions (eg, infection) that may contraindicate the procedure, and confirming the presence and nature of erectile dysfunction.
The patient's manual dexterity must be considered when choosing the type of penile implant. If the patient cannot operate his device, he must have a willing and able partner who can assist him. Semirigid devices generally require less manual dexterity to operate. (See 'Choice of implant' below.)
The author performs a penile duplex ultrasound study following intracorporeal injection of a vasodilating agent to assess tumescence and vascular flow prior to placement of a penile prosthesis. This study assesses the tumescence, length, and girth of the penis, which help guide the choice of implant. The presence of vascular insufficiency and penile curvature can also be determined.
For men who are potential candidates for penile revascularization, a preoperative pelvic and penile arteriogram is necessary to determine the location and severity of vascular obstruction. (See "Evaluation of male sexual dysfunction".)
Medical risk evaluation — Most men with erectile dysfunction not due to sequelae of trauma will have been screened for cardiovascular disease, such as hyperlipidemia, hypertension, and diabetes, prior to institution of medical therapy. Repeat evaluation may be needed prior to surgery since erectile dysfunction is often a marker of cardiovascular disease [1-4]. (See "Evaluation of male sexual dysfunction" and "Evaluation of cardiac risk prior to noncardiac surgery".)
Men with significant cardiovascular disease are not good candidates for penile revascularization; however, if their cardiac risk is not high, they may be a candidate for a penile implant. (See 'Penile prostheses' below and 'Penile revascularization' below.)
Diabetes mellitus is associated with a higher risk of perioperative infection. While improving control of diabetes mellitus before surgery has reduced the risk of infection for some surgeries, a consistent benefit for patients undergoing penile implants has not been found [5-8]. (See "Perioperative management of blood glucose in adults with diabetes mellitus".)
Patients should avoid taking aspirin and nonsteroidal anti-inflammatory medications for seven days prior to the procedure as these may increase the risk of postoperative bleeding. (See "Perioperative medication management", section on 'Medications affecting hemostasis'.)
Antimicrobial prophylaxis — Antibiotic prophylaxis with activity against flora of the skin and genitourinary tract should be administered within one hour of incision [9]. Appropriate choices are given in the table (table 1). While the American Urological Association guidelines suggest that prophylaxis should be discontinued within 24 hours of the procedure, these guidelines are not specific to the placement of prostheses [9]. Some surgeons also administer an antifungal agent, such as amphotericin, preoperatively, as approximately 11 percent of cultures identified at time of penile explantation for infection identify Candida albicans [10]. Oral antibiotics are administered for one week following placement of a penile implant. The author typically uses oral amoxicillin/clavulanate, cephalexin, or levofloxacin. (See "Antimicrobial prophylaxis for prevention of surgical site infection in adults", section on 'Genitourinary surgery'.)
Patient counseling — A thorough preoperative discussion is essential and should review preparation, complications, and outcomes of surgery.
The patient considering prosthesis implantation should be informed of the potential complications, which include but are not limited to wound infection, urethral and bladder injury, penile shortening, impaired sensation, mechanical failure (ie, inflatable implants), or the potential need for reoperation due to implant erosion or infection. (See 'Implant complications' below.)
ANATOMY — The penis is composed of three cylindrical masses (two corpora cavernosa, corpora spongiosum) bounded by fibrous tissue and covered with skin (figure 1). The tunica surrounds the corpora cavernosa and is composed of collagen arranged in circular and longitudinal layers. The inner circumferential layer contains intracavernosal pillars that help tether the corporal bodies, limiting overexpansion. The outer longitudinal collagen fibers run from the glans penis to the proximal crura at the base of the penis.
The main arterial vascular supply is derived from the internal pudendal artery, which is a branch of the internal iliac artery. The internal pudendal becomes the common penile artery, which branches into the dorsal, bulbourethral, and cavernous arteries. The cavernous or cavernosal artery supplies the helicine arterioles supplying the spongy trabecular tissues that store and trap blood during an erection.
The cavernosal tissue is drained by venules that coalesce to form subtunical venules before exiting the tunica albuginea as emissary veins. The emissary veins run obliquely between the inner and outer layers of the tunica. These veins drain the corporal bodies; a septum between the corporal bodies allows vascular communication between them. The emissary veins unite, forming the circumflex, periurethral, and superficial dorsal veins.
Erectile physiology is discussed in detail elsewhere. (See "Epidemiology and etiologies of male sexual dysfunction", section on 'Erectile physiology'.)
PENILE PROSTHESES — Penile prostheses have been used for the treatment of erectile dysfunction since the 1950s. The first implants consisted of rib cartilage, modeled after the os penis of some animals. Subcutaneous acrylic splints, polyethylene rods, and pure silicone implants were used in the past. A major advance in prosthetic surgery has been the placement of devices within the paired corpora cavernosa, providing improved cosmetic and functional results [11-15].
Early inflatable prosthetic models were plagued by mechanical dysfunction, aneurysm formation, and S-shaped deformities [16]. Over time, inflatable devices have become more dependable, with high rates of patient satisfaction. Following the introduction of sildenafil in 1998, the use of penile prostheses dropped considerably. However, the subsequent development of tolerance to medical therapy led to a rebound in the number of implanted penile prostheses that exceeded pre-1998 levels [17].
Types — Two types of penile implants are commercially available, with inflatable prosthetics accounting for the majority of implants [18].
Semirigid — Semirigid rods have been available for several decades. They are easy to use but result in a permanent erection (picture 1). Although semirigid devices continue to be used successfully, they make up fewer than 10 percent of all implanted penile prostheses [19].
The mechanical reliability of malleable devices is excellent, and they are easy to implant via subcoronal, penoscrotal, or infrapubic incisions. Because they are malleable, the penis can be bent down close to the body to be less noticeable under clothing. Malleable prostheses bend with relative ease, but they may have some springback. This means that they have some "memory" as to their original shape and will return to some degree to their original straight position. The degree of springback determines the ease of concealment for the patient.
Inflatable — The inflatable prostheses are designed to approximate the rigidity and flaccidity of the normally functioning penis. These devices consist of two hollow cylinders placed within the corpora cavernosa, a saline reservoir and pump (figure 2) [20]. Designs and materials for inflatable penile prostheses have continued to improve over time with high rates of patient satisfaction (>90 percent) [18,21-30].
Inflatable prostheses are generally available in two- or three-piece designs [18].
●Two-piece – Two-piece penile prostheses are comprised of intracavernosal cylinders attached to a small scrotal pump (picture 2). Inflation of the device is achieved by squeezing the pump, which redistributes saline from a reservoir in the rear of the cylinders to the front of the cylinders, creating rigidity in the outward aspect of the corpora cavernosa, thus creating an erection. Deflation is accomplished by bending the cylinders (and the penis), which activates a valve allowing fluid to return to the reservoir area. In the flaccid state, the two-piece prosthesis appears fuller than a multicomponent device, because less fluid is transferred to the smaller reservoir area.
The main advantage of the two-piece prosthesis is simplified operative placement because of the integrated reservoir (ie, no need to fill or connect). The two-piece implant is particularly useful when prior pelvic or inguinal surgery prevents the placement of a separate reservoir. Another advantage is the ease of deflation, which requires less dexterity and digital sensitivity than multicomponent devices [14].
Patient satisfaction has been shown to be as high as 96 percent and mechanical failure rates less than 5 percent over a five-year period [14,21].
●Three-piece – The three-piece implant consists of penile cylinders, a scrotal pump, and a reservoir (picture 3). Erection is achieved by repeatedly squeezing the pump; each compression transfers fluid from the reservoir to the intracorporeal cylinders until adequate rigidity is achieved (figure 2). Pressing a valve mechanism in the scrotal pump causes fluid to flow from the cylinders back to the reservoir.
●Variations – Special designs provide increased length in addition to width, and rear tip extenders can be added to the back of the cylinders to modify length further. Other designs are available to accommodate fibrotic corpora or the shortened penis. Some penile prostheses have smaller reservoirs; others have a lockout valve to prevent cylinder autoinflation (ie, fluid unintentionally transferred from reservoir to cylinders) [24,31].
Autoinflation is typically due to compression on the reservoir (ie, abdominal straining) and causes partial unintended erections, which may be socially awkward. By preventing autoinflation, the lockout valve also permits the surgeon to place the reservoir in sites prone to the effects of increased abdominal pressure, such as an epigastric, subcutaneous, or subrectus location.
Antimicrobial-coated implants — Antibiotic coatings provide an effective way to reduce the risk of perioperative infection and are available with some inflatable prostheses. InhibiZone is a US Food and Drug Administration (FDA)-approved surface treatment of rifampin and minocycline [28,32]. Resist combines an antibiotic solution of gentamicin and bacitracin [33]. These coatings are impregnated onto the external silicone surfaces of the implanted components. Another approach coats the implant with a hydrophilic coating that reduces bacterial adherence and absorbs antibiotics when the implant is immersed in antibiotic-containing solution [34].
Several retrospective studies have reported significant reductions in infection rates with antibiotic-treated implants compared with nontreated implants [32,33,35].
Choice of implant — In most cases, the choice of prosthesis type is a personal one based upon the patient's preference and perception of function and cosmesis. As a general rule, most men prefer the more natural capabilities of inflatable prostheses.
Other factors may be important in specialized populations:
●Older men, especially those with limited mental or manual dexterity, should be offered a semirigid or two-piece inflatable implant because manipulating the pump and deflation mechanisms of three-piece inflatable devices may be challenging.
●Patients with diminished sensation in the penis (ie, spinal cord injury) should be offered an inflatable device to decrease the potential for skin or urethral erosion due to prolonged excessive pressure on the rods [36,37].
Technique — The placement of penile prostheses is usually performed as an outpatient procedure under general, spinal, or epidural anesthesia, but it can be also be performed with local anesthesia and monitored sedation [38,39]. Following the procedure, the patient is instructed not to use the device for four to six weeks to ensure adequate healing.
Placement of these devices can be performed through a penoscrotal, infrapubic, or subcoronal approach. The operative area is shaved immediately prior to surgery and the skin prepared. (See "Overview of control measures for prevention of surgical site infection in adults".)
Corporotomies are made in the corpora cavernosa, which are then dilated and measured. The appropriate-sized device is chosen, both in terms of length and diameter. The pump is placed in the scrotum. If a three-piece device is chosen, the reservoir is typically placed preperitoneally behind the rectus muscle, either through the external inguinal ring or via a separate lower abdominal incision. Reservoirs can also be placed ectopically and above the transversalis fascia.
Considerations for Peyronie's disease — Either a two- or three-piece prosthesis can be used in the management of Peyronie's disease. For men with significant plaques and curvature, a "modeling" procedure may be performed in which the tunical plaque is fractured over an inflated cylinder at the time of implantation. In this procedure, the penis is forcibly bent in a direction opposite the curvature [40]. Bending pressure is maintained on the penis for 90 seconds. When successful, the modeling procedure results in splitting and rupturing of the fibrotic plaques.
If the plaque is not able to be fractured, then a combination of plaque incision and grafting may be performed [40]. (See "Surgical management of Peyronie's disease", section on 'Grafting'.)
Implant complications — The most serious complication of penile prosthesis implantation is infection; however, mechanical failure can also occur, with surgical revision required in 5 to 15 percent of men over one to seven years [19,21-23,41].
Infection — Implant infection occurs in approximately 3 percent of cases; patients with diabetes, spinal cord injury, or previous implants have infection rates up to 10 percent [5,6,42]. Infection usually occurs within three months of implantation [43].
Most implant infections occur as a result of intraoperative contamination with normal skin flora such as Staphylococcus epidermidis; these organisms have been isolated from 30 to 50 percent of infected prostheses [5,44,45]. Aerobic gram-negative organisms, such as Proteus, Pseudomonas, Escherichia coli, and Serratia, also cause implant infections. Cases of infection due to Candida albicans, mycobacteria, and gonococci can occur [43,46,47].
The risk of implant infections can be reduced with meticulous attention to sterile technique and delay of implantation until after adequate treatment of any known infections [48]. Antibiotic-coated prostheses may also be useful for prevention of infection. (See 'Antimicrobial-coated implants' above.)
Clinical manifestations include penile pain, erythema, and induration over the prosthesis or device extrusion. Subclinical infections manifest most commonly with chronic penile pain [49].
Management of suspected infection usually requires surgical exploration. Early culture, debridement, and irrigation facilitate microbiological diagnosis and may reduce the likelihood that a biofilm will form on the implants [50-52]. Material from the wound should be sent for gram stain and culture with sensitivity. If the wound gram stain is negative (ie, no organisms, no white cells), the site should be thoroughly irrigated, the prosthesis can be left in place, and the wound can be closed [42,51]. The presence of frank purulence usually necessitates removal of the entire device and vigorous wound irrigation.
Empiric therapy prior to the return of culture results should cover both gram-positive skin flora and aerobic enteric bacterial flora (eg, E. coli, Klebsiella spp). Appropriate empiric regimens include vancomycin (table 2) and either ceftriaxone (1 g IV daily) or ciprofloxacin (400 mg IV every 12 hours or 500 to 750 mg orally twice daily). Antibiotic selection should be tailored to culture and sensitivity results when available.
The duration of therapy depends on individual circumstances:
●For eradication of infection following implant removal, 7 to 14 days of therapy is usually effective. Reimplantation of a new prosthesis can be considered a minimum of three months after treatment is completed if there are no ongoing signs of infection [53].
●For implant salvage, the duration of therapy depends upon the clinical response to therapy [42]. Treatment with parenteral therapy is indicated until signs of infection have resolved, and many clinicians transition to oral antibiotics; the duration of oral treatment depends on the clinical scenario. In these cases, it is important to have a definitive microbiological diagnosis to guide decisions about route and duration of treatment.
PENILE REVASCULARIZATION — The most commonly performed technique for penile revascularization involves anastomosis of the inferior epigastric artery to the dorsal penile artery (dorsal artery arterialization). The original technique, which is less often performed, uses the dorsal penile vein as the distal target (dorsal vein arterialization).
Arterial revascularization relies on the inferior epigastric artery. A paramedian abdominal incision is made and the inferior epigastric vessels dissected from the lower surface of the rectus muscle. The inferior epigastric artery is then anastomosed to the deep penile artery (Hauri technique) [45].
Penile dorsal artery arterialization requires microsurgical skill and is generally performed in specialized centers [48,54-57]. An analysis of 25 trials identified risk factors associated with failure of penile revascularization, which include smoking, diabetes mellitus, hypertension, hyperlipidemia, history of radiation therapy, coronary artery disease, alcohol abuse, obesity, cavernosal fibrosis, and distal arterial disease [58].
Postoperative complications may include penile edema, penile numbness, and penile shortening due to scar entrapment.
Reasonable success rates for penile revascularization are achieved in young, nonsmoking, otherwise healthy men who have recently acquired erectile dysfunction due to a focal arterial occlusion [54,55,58-64]. Only 6 to 7 percent of men with vascular erectile dysfunction are candidates for penile revascularization with these restricted criteria [48]. Long-term success rates range from 50 to 67 percent [54,55,61,64].
Techniques to improve the veno-occlusive mechanism with ligation of the dorsal, cavernous, and crural veins were popular toward the end of the 20th century due to encouraging early results; however, efficacy beyond six months was minimal, and these procedures have been largely abandoned in favor of medical therapies with phosphodiesterase-5 (PDE-5) inhibitors [57,59].
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Male sexual dysfunction".)
SUMMARY AND RECOMMENDATIONS
●Several surgical procedures may help men with erectile dysfunction who do not respond to pharmacologic therapy and for select patients with Peyronie's disease. The cause of the erectile dysfunction and the general health of the individual should determine the type of procedure. Our recommendations are consistent with clinical guidelines published by the American Urological Association [56].
●Penile prosthesis implantation has the highest satisfaction rates of all treatment options, including pharmacologic therapy, for erectile dysfunction. Prostheses have allowed men to have effective, reliable, and cosmetically acceptable erections as well as an acceptable appearance when flaccid. (See 'Penile prostheses' above.)
●In most cases, the choice regarding the type of prosthesis is made on the basis of cosmesis and function. As a rule, men prefer the capability of inflatable prostheses to mimic the normal penis, both for its usual state of flaccidity and for its ability to become rigid for sexual activity. (See 'Inflatable' above.)
●In contrast, older men, especially those with limited mental or manual dexterity, may prefer a semirigid rod or two-piece device, since it may be challenging to manipulate the pump and deflation mechanisms of the three-piece inflatable devices. (See 'Semirigid' above.)
●Penile implant infection is the most serious complication of penile implants and most often requires complete removal of the device and intravenous antibiotic therapy. Penile implant salvage can be considered in select cases. (See 'Infection' above.)
●For most men with vascular erectile dysfunction, we suggest avoiding penile arterial revascularization given the low success rates and long-term complications (Grade 2B). (See 'Penile revascularization' above.)
●Penile arterial revascularization (performed at a specialty center) may be reasonable for young, nonsmoking, otherwise healthy men without evidence of generalized vascular disease, diabetes, or hypertension who have recently acquired erectile dysfunction secondary to a focal arterial occlusion. (See 'Penile revascularization' above.)
●For men with erectile dysfunction with veno-occlusive disease, we suggest not performing penile venous surgery given the low success rates and the availability of effective oral medications such as phosphodiesterase-5 (PDE-5) inhibitors (Grade 2B). (See 'Penile revascularization' above.)
