Better Sex: Penile Implants for Erectile Dysfunction

Better Man Clinics: What exactly is a penile implant or penile prosthesis?

Marah Hehemann, MD: So, a penile prosthesis is a surgical implant at the core, just like a breast implant or a knee implant that you get when that body part is not functioning optimally. When your knee has arthritis, and you can’t do your daily functions, you might get a knee replacement. I like to think of a penile implant just like that. It allows you to get back that part of your life and that part of your quality of life through a surgical implant. There are a few different kinds, a few different brands that companies make, and globally they are different. So, the implants that we have here in the United States may not be used in Israel, for instance, due to device approvals. But largely, they’re all surgical implants that allow a man to have an erection again where, prior to surgery, he may not have been able to have one.

Better Man Clinics: Now, aside from the different brands, I understand there are different types of penile implants that guys ask a lot about. What are the different types of penile implants?

Marah Hehemann, MD: When I talk about a penile prosthesis, I break it down into a decision tree. The largest difference between the different types is whether or not the implant can change from soft to rigid or whether it always stays rigid to some extent. On the one hand there are the semi-rigid implants, also known as malleable implants. They’re bendable rods, allowing a man to have an erection that he bends up when needed and bends back down when no longer needed. The other type is the inflatable penile prosthesis, with two variations: a two-piece, which includes cylinders and a small pump in the scrotum, and a three-piece, with cylinders, a pump, and a reservoir. These implants are activated when needed for sexual activity but otherwise are not rigid.  These are considered the gold standard in the United States.

Better Man Clinics: So, with the semi-rigid penile implant, you’re always rigid to some extent, but you can bend it down. For the inflatable implant, the penis is not rigid unless you pump it up, correct?

Marah Hehemann, MD: Exactly. The semi-rigid is bendable, and the inflatable appears natural when not in use and can be pumped up as needed.

Better Man Clinics: What are the relative advantages and disadvantages of the semi-rigid versus the inflatable penile implants?

Marah Hehemann, MD: The major advantage of the inflatable device, considered the gold standard, is that it’s a physiological, natural feeling way to achieve an erection. It simulates the hydraulic mechanism of a natural erection. As a result, it feels very natural in both the flaccid and erect states. However, the downside of the inflatable implant is that it requires hand function to pump it up. For men with poor hand function, the semi-rigid might be preferable, although it may not provide the same rigidity for sex as the inflatable device.

Better Man Clinics: When you say “pump it up,” are they pumping the penis? What are men pumping exactly to get that erection with an inflatable prosthesis?

Marah Hehemann, MD: There are three parts to an inflatable penile implant.  The first part is the reservoir, which stores the fluid that is moved into the penis to create an erection.  Men with an inflatable prosthesis don’t really interact with the reservoir because it is “tucked away” in a location where men don’t really feel or see it.  The second part of the prosthesis includes the two cylinders, which are placed in the natural erectile chambers of the penis.  These are the chambers that fill with blood during a natural erection.  These cylinders, similarly, get filled up with fluid (stored in the reservoir) during an erection.  The third part of the inflatable implant is the pump. The pump is placed in the scrotum, and it inflates the cylinders inside the penis (by forcing fluid to move into the cylinders from the reservoir), simulating a natural erection. This pump is squeezed to actively pump fluid from the reservoir to the cylinders, much the same way as those Reebok sneakers of the 1990s were pumped up.  Everything is contained internally, and when deflated, it’s not noticeable.

Better Man Clinics: Does sex feel natural with an implant in place?

Marah Hehemann, MD: The implants don’t change the sensation of the skin and having sex, but they give back rigidity. The nerves to the penis in terms of sensation should not be changed. However, the feeling of the head of the penis might be slightly different as it’s not made of the same spongy tissue as the erectile cylinders.  As a result, it may not get as totally rigid and may feel a little less hard and a little colder.

Better Man Clinics: Do penile implants impact achieving orgasm, climax, or ejaculation?

Marah Hehemann, MD: No, the implants won’t change a man’s ability to achieve orgasm or ejaculation. However, underlying conditions like vascular disease or the aftermath of prostate cancer treatment might affect these functions.

Better Man Clinics: Another concern often brought up, specifically with the semi-rigid implant, is its impact on urination, especially for guys with prostate issues. Does a penile implant make it more difficult to urinate with those rods in place?

Marah Hehemann, MD: No, the cylinders of the implant are located separate from the urine tube, so it should not affect urinary function.

Better Man Clinics: Can a penile implant increase the length or girth of the penis?

Marah Hehemann, MD: No, penile implants cannot make the penis longer. The implant gives back the rigidity and girth of a full erect penis but does not alter its natural length.

Better Man Clinics:  Can a penile implant ever be used as an initial treatment option without trying other options first?

Marah Hehemann, MD: It is my strong feeling, supported by the guidelines of the American Urological Association, that you do not need to fail other therapies to be a candidate for a penile implant.  I put it on the table for everyone.  Anyone who is a good surgical candidate who can undergo a one hour minimally invasive surgery can be a candidate for an implant.  It is the only technique that we have that can restore erections for guys who want spontaneity with their partner and can get on demand erections without having to deal with the rigmarole of taking pills or using vacuum devices or injections.

Better Man Clinics:   Are there any guys for whom a penile prosthesis should never be an option?

Marah Hehemann, MD: Young guys with erectile dysfunction related to performance anxiety or life stressors might consider other strategies first. Additionally, those with incorrect assumptions about gaining size from the implant should be informed. It’s essential to set realistic expectations before undergoing irreversible surgery.

Better Man Clinics: Is a penile implant irreversible? What happens if you have a prosthesis placed and, eventually, you have it removed? What are your options for managing erectile dysfunction afterwards? Can you go back to other treatments like Viagra or injections? Or is the only option another prosthesis in that situation?

Marah Hehemann, MD: Once a man has an implant put in, he cannot go back to the other options. So that’s incredibly important to know. It is an incredible treatment, a kind of final amazing solution, but it is not reversible. So, if an implant is put in and it needs to be revised or replaced, my guidance is to not let any surgeon take it out without putting one directly back in. And that’s the guidance that men should go forward with if they have an implant put in.

Better Man Clinics: What are the risks of penile implants at the time of surgery? What can potentially go wrong during the surgery itself?

Marah Hehemann, MD:  In experienced hands, someone who does a lot of these procedures annually, it is a very safe surgery. However, there are just things that can occur during any event in the most experienced of hands. First, the structures we’re working around, like the urethra, the bladder, and parts of the pelvis, can be injured during surgery. That is a very low risk because we’re always very careful about keeping those important structures safe. But that is something that can occur. The other thing that can occur during surgery is misplacement of the components of the implant. Specifically, we get into the question of whether the cylinders of the implant are placed exactly in those erectile chambers. Sometimes, in placing the cylinders within the penis, we may accidentally cross over, meaning putting the cylinder from the right side into the left side. There are ways that this can be corrected, especially in very experienced hands. So, at the time of surgery, those are some of the worst-case scenarios, extremely rare circumstances. Usually, this is, as I mentioned, a one-hour surgery. I perform this as an outpatient surgery for most men, and it’s very safe.

Better Man Clinics: Does a penile implant surgery require general anesthesia?

Marah Hehemann, MD: It does in my hands and in those of most implanters. With the majority of surgeons who do this procedure in the United States, the patient is put to sleep. The procedure takes anywhere from an hour to an hour and a half. And most surgeons let guys go home either the same day or just the morning after surgery.

Better Man Clinics: Is there any preparation required for patients prior to penile implant surgery?

Marah Hehemann, MD: In terms of preparation for surgery, most surgeons would want their patients to do things like using an antibacterial soap wash for either a week before surgery (or at least a few days before). It kind of depends on the surgeon. But usually, that’s the main preparation. Doctors typically like to remove the pubic hair just to get a clear field to do our implant. And we like to do that ourselves. It’s been shown to be safer and reduce infection when we do it ourselves.

Better Man Clinics: What actually happens during penile implant surgery? You mentioned that you make a little incision, either around the scrotum or just above the penis. And I think you mentioned that people wouldn’t be able to really tell you had surgery based on those incisions. Is that correct? How is the penile implant surgery actually performed?

Marah Hehemann, MD: Yeah, absolutely. So those are the two main approaches, the two main ways we do the surgery. And either way it goes, you would never know that you had a scar there. They are very well-concealed cosmetic procedures. So, first, that small opening is made. The next step is to measure the inside of the erectile body so that the correct size of the cylinder for the penile implant is chosen in order to provide the most length and the most rigidity. And, so, there are some game-time decisions that need to be made. We don’t pick the size beforehand because we need to measure the penis from the inside, and the penis in men goes out of the body and it actually also goes back inside the body too. And so that measurement that we get when we’re in the operating room is used to choose the length of the implant. That’s measured, and then we place the reservoir, the cylinders, and the pump, and then the implant is connected so the fluid can move through. Then it’s closed up. That’s really kind of the surgery in a nutshell.

Better Man Clinics: So, to review, the reservoir is just a container that stores the fluid when the penis is not erect.  You squeeze the pump (located in the scrotum) to actually move the water or fluid from that reservoir into those cylinders within the penis to give you an erection. And, when you’re done, you push a button on the pump, and the fluid goes back in the reservoir and the erection goes down.  Is that correct?

Marah Hehemann, MD: Yeah, exactly. It’s just movement of the fluid inside which is sterile saline. So, it’s saltwater.  It is very safe and, if it ever were to leak out, it is totally not harmful at all.

Better Man Clinics: What kind of pain should someone expect immediately after penile implant surgery?

Marah Hehemann, MD: So, in our field, most surgeons are working without any use of narcotics or very little use of narcotics. We have developed ways to get around having lots of pain after surgery and needing those strong pain medicines by giving other types of medications either before the surgery or during the surgery. I do tell patients that every guy is different so there’s no way that I can tell whether you are going to have pain for two weeks or you’re going to have just mild discomfort for two weeks. It’s hard for me to know that for sure. But it is a surgical procedure. So having some discomfort is expected. For the first two weeks, you may have some discomfort and may be walking around a little more gingerly. But many patients don’t require strong pain medications like narcotics.

Better Man Clinics: How soon after a penile implant surgery do guys usually return to work?

Marah Hehemann, MD: It depends entirely on what a guy does for work. If you are working from home behind a desk, I would say maybe take a couple of days off, just to be comfortable and so you can recuperate. However, if you were to be doing more hands-on labor type of work, you would probably want to take about two weeks off.

Better Man Clinics: Is there some type of rehab that needs to occur before guys can resume sexual activity?

Marah Hehemann, MD: As I mentioned, each surgeon may have different nuanced, specific instructions for what to do after surgery. There is just a little bit of rehab that goes after surgery which involves learning how to feel for the pump inside the scrotum and how to press the pump button.  Your surgeon or their staff will explain at what point you should be expected to do that and how to do it. One of our goals is to make sure everyone is super comfortable with things. Also, directly after surgery, we want to make sure that that pump is well-positioned down in the scrotum.  In order to ensure that this is the case, most surgeons will want you to do just very gentle exercises of pulling that pump down into the bottom of the scrotum. Then, a few weeks after surgery, the surgeon may want you to start inflating and deflating the penile prosthesis.

Better Man Clinics: How soon after a penile implant surgery can guys resume sexual activity?

Marah Hehemann, MD: Depending on the surgeon and the surgery, most guys can resume sexual activity in 3-6 weeks after a penile implant surgery.  There is a healing period, and for a lot of guys who end up with an implant, they’ve been having challenges with ED for some time. And so, hopefully, that four weeks won’t feel too long. I think it’s actually a pretty rapid recovery but there is a little bit of a waiting period afterwards.

Better Man Clinics: What type of complications or long-term issues do guys sometimes experience with penile implants?

Marah Hehemann, MD: There are two complications that are innate to any type of implant that we put in the body, whether it’s a knee, a breast, or the penile implant. One is that it’s a foreign body and it can become infected. As these implants have evolved, the risk of infection has come down because of some amazing technology that has been adopted by the manufacturers. They have established ways to get antibiotics absorbed onto the device in order to reduce infection. In general, for most high volume implanters who perform a lot of these implants every year, the infection rate is about 1%. If the implant were to become infected, it may mean taking it out and putting a new one back. It may also mean IV antibiotics. The second risk that is inherent to any implant is that it can experience mechanical dysfunction or mechanical failure. The risk of that in the short term (in the first five years) is extremely low. There was a study that came out in 2019 that showed that the vast majority (two-thirds to three-quarters) of these inflatable implants last over 10 years. The semi-rigid devices shouldn’t have any mechanical dysfunction because they don’t have the same fluid mechanisms. When an implant breaks down, it usually involves fluid leaking out of the device. As a result, what you’ll notice is just that the implant stops working. It’s not an emergency, but you will need a surgeon to take a look and probably switch out either one part of the implant or the whole thing, depending on how old it is.

Better Man Clinics:  A malleable or semi-rigid penile implant does not have the complex hydraulic mechanisms of an inflatable penile prosthesis.  What is the life span of a semi rigid penile implant?

Marah Hehemann, MD: The semi-rigid or the malleable implants have an amazing lifespan that can be decades.  However, there are some other challenges with the malleable or semi-rigid penile implants.  The one primary challenge is that, because the malleable prosthesis is a rigid structure that sits inside of you, it may want to come out due to the constant pressure it places on the tissues around it.  So, erosion of the implant out through the skin is the one sort of unique risk for semi-rigid implants over time.  That risk is not really as present in the inflatable implant.  It can happen with the inflatable implant, but is more commonly seen with the semi-rigid implants.

Better Man Clinics: Can a semi-rigid penile implant be exchanged if it erodes out of the skin?

Marah Hehemann, MD: Yes, the semi-rigid implant can be swapped out, and there are strategies that implanters can use to make that really safe as well.

Better Man Clinics: Do most or all urologists perform penile implant surgery? Or should penile implants really be kept in the hands of an expert or specialist in implant surgery?

Marah Hehemann, MD: The data shows that the best outcomes in terms of lowest risk of infection, best satisfaction, and best safety profile usually comes from surgeons who perform a lot of these penile implants. That is really the same for any procedure. So yes, I do think that when you’re thinking about getting a penile implant, the safest approach is to find someone who is an expert and who has the training in these implants and who does a lot of them.

Better Man Clinics: What questions should a guy ask a prospective surgeon who will be performing his penile implant surgery?

Marah Hehemann, MD: I think some of the questions are:

1. “Do you have training in this type of implant surgery?”
2. “How many implants do you typically perform per year”

Most urologists are going to be honest people and want the best care for their patients. They should be honest in answering those type of questions. There are also some online resources that list the vetted, experienced implanters. The device companies have websites that list doctors and groups in the region who are designated centers of excellence. These are surgeons that perform a lot of these type of penile implants.

Better Man Clinics: What is an acceptable or desirable number of cases that penile implant surgeons should be performing to be considered experienced?

Marah Hehemann, MD: I think that anyone who’s doing more than 20 implants a year, or has the training in many, many implants per year would be considered a high volume surgeon. There are surgeons out there who are performing hundreds of implants a year. They are fantastic surgeons. However, does that mean you need to go fly down, East Coast if you’re on the West Coast to have them perform the surgery for you? No, there are people who are well trained in your region. You just have to use those resources to find the best person. It is also important to feel really comfortable with your surgeon and make sure that you have a good relationship with them and trust them. You need to have a good understanding of what to expect from your conversations with them. You want to feel really comfortable with the person who is going to do your penile implant surgery.