Penile Implant, Erection, and Surgery Considerations
Medically reviewed by Matthew Wosnitzer, MD
A penile implant is a device surgically inserted into the penis to treat erectile dysfunction (ED). There are two forms of implants, one that is inflatable and another that consists of a malleable rod you can bend. Various penile prosthetics are approved by the Food and Drug Administration (FDA) for implantation and come in different sizes and materials.
While effective in enabling an erection suitable for sexual intercourse, penile implant surgery carries significant risks, including the risk of infection, chronic pain, penile deformity, and a need for repeat surgery.
This article weighs the risks and benefits of penile implant surgery. It also explains what types of penile implants are available and what is involved in the surgery. It describes alternatives to penile implant surgery if faced with severe erectile dysfunction.
Other Reasons for a Penile Implant
Erectile dysfunction is the primary, but not sole, reason for a penile implant. Other reasons include:
Treatment of severe Peyronie's disease
Gender-affirming surgery used in tandem with phalloplasty for transgender men
Repair of a traumatic or disfiguring penile injury, such as a penile fracture
Related: How Common Is Erectile Dysfunction?
Illustration by Zoe Hansen for Verywell Health
Penile Implant Pros and Cons
Erectile dysfunction is a condition that affects roughly 1 in 4 people with penises in the United States. Penile implant surgery is typically pursued when all other conservative options fail to improve ED.
Advantages
Penile implants are becoming an increasingly common procedure, particularly in the United States, where the vast majority of surgeries are performed. Due to their increasing safety, some urologists in the United States perform more than 100 procedures yearly.
Advantages of penile implant surgery include:
Ability to achieve an erection "on demand"
Reduced sexual performance anxiety
Ease of use
Generally high satisfaction rates (80% or more, according to some studies)
Avoidance of ED medication risks or side effects
Low surgical failure rates
Ease of implantation (with surgeries generally taking 90 minutes or less)
Low rate of postoperative complications (generally less than 0.1% for initial surgery)
Medicare and many private insurance plans cover the procedure if medically indicated
Disadvantages
As with all surgeries, there are risks to penile implant surgery. Results and satisfaction can vary from person to person, and complications, while rare, can be very serious.
Disadvantages of penile implant surgery include:
Out-of-pocket costs between $10,000 and $20,000 without insurance
High co-pay or coinsurance costs, even with coverage
High rate of insurance denial (as high as 48% according to one study)
Implants do not improve penile sensitivity
Implants do not necessarily improve length or diameter of the penis
A 6% to 13% risk of repeat surgery due to device deterioration and other causes
A high rate of complications with repeat surgery (7% infectious and 22% noninfectious)
Surgical errors can also sometimes occur. For example, oversized devices can lead to chronic pain and damage to the urethra and other penile structures. On the flip side, undersized devices can lead to "floppy glans syndrome," in which the penis is distorted and unable to get fully erect.
Both cases may require revision surgery, which, in turn, can place you at an increased risk of complications.
Can a Penile Implant Make You Bigger?
Although some people pursue a penile implant for aesthetic reasons, the devices are not able to increase the length of the penis. If anything, the surgery may slightly shorten the penis due to the contraction of tissues as the penis heals.
An inflatable penile implant may increase girth, but using an inappropriately large device is likely to cause more harm than good, leading to chronic pain, tissue damage, and the need for revision surgery.
Related: Do Penis Enlargement Treatments Work?
Types of Penile Implants and Sizing
The FDA approves many different devices for use in penile implant surgery. They fall under two broad categories: malleable prosthetics and inflatable implants.
Malleable Prosthetics
These were among the first devices used back in the 1960s for penile implant surgery. Also known as non-inflatable penile prosthetics, the devices are implanted into the shaft (corpora) of the penis. They can be bent upward to place the penis in an erect position or downward when not in use.
The two main types are:
Soft implants that are made solely of malleable silicone
Semirigid implants consisting of one or two coiled metal rods coated with silicone
Malleable penile prostheses are advantageous as they can often be trimmed to size to adjust for the penis length. Moreover, they tend to last longer than inflatable implants because they have fewer moving parts.
On the downside, these solid devices can constantly rub against the urethra and other structures of the penis, causing tissue erosion and damage. Because they keep the penis slightly rigid all the time, malleable implants may also be uncomfortable and difficult to conceal under clothing.
Inflatable Implants
Inflatable implants are a more recent innovation. They consist of two soft silicone cylinders that are implanted into the corpora cavernosa (pair of spongelike erectile tissue forming the penis) and filled with sterile saline to achieve an erection.
The cylinders are attached to a pump implanted inside the scrotum. The saline is held in a reservoir implanted either behind the lower abdominal muscles or the tissues of the lower abdominal cavity (called the retroperitoneal space).
When the implant is not in use, a valve inside the scrotum can release the fluid and return the penis to its flaccid (soft) state.
Three-piece inflatable implants are considered the gold standard for penile implant surgery as they afford a more "realistic" erection while reducing the risk of erosion. In the United States, they have largely replaced malleable implants due to a lower rate of infections and higher rates of user satisfaction.
Even so, they tend to have a shorter life than malleable implants and a greater risk of mechanical failure.
Related: Anatomy and Function of the Penis
Preparing for Penile Implant Surgery
As increasingly commonplace as penile implant surgery has become, certain preparations and precautions are needed to ensure the best possible outcome.
Preoperative Preparations
A comprehensive evaluation is needed to ensure that you are a candidate for surgery. While there are few absolute contraindications to the procedure, people with an active infection or unresolved urinary problems (such as neurogenic bladder or bladder outlet obstruction) would need to be treated before the surgery can proceed.
A detailed review of your medical and surgical history is important as it can influence the choice of device. With an inflatable implant, for instance, certain abdominal or pelvic procedures (such as prostate surgery or colorectal radiation) can limit where the saline reservoir is placed if there is extensive scarring or adhesions.
To properly size the device, the stretched length and girth of your penis would be evaluated.
As part of the workup, your surgeon would discuss the risks and benefits of the procedure and provide you with a realistic expectation of what the implant can and cannot do.
Tips for Avoiding Complications
Smokers would be advised to quit cigarettes to aid with wound healing and reduce the risk of postoperative infection.
Blood sugar control would be stressed to people with diabetes as a hemoglobin A1c reading than greater than 8.5% is linked to an increased risk of infection following penile implant surgery.
Related: How to Speed Recovery From Surgery
How Penile Implant Surgery Is Performed
Penile implant surgery is performed under general anesthesia by a urologist (a specialist of the male reproductive tract).
To reduce the risk of infection, antibiotics are delivered intravenously (into a vein) immediately before the surgery. Further decreasing the risk are newer silicone implants impregnated (filled) with antibiotics or made with special coatings that are immersed in antibiotics before surgery.
Once the patient has been placed on the operating table and provided anesthesia, a Foley catheter is inserted into the urethra to drain the bladder.
After that, the placement of the implant remains largely the same (with additional steps if a three-piece inflatable pump is used), as follows:
An incision is made on the underside of the penis near the scrotum for an inflatable implant and the top of the penis near the pelvis for a malleable implant.
The fibrous membrane surrounding the shaft called the tunica albuginea, is cut and spread open with retractors.
A long device called a dilator is pushed into the underlying tissues to create a long channel to place the implant.
The corpora cavernosa are dilated using a variety of techniques.
The implant is inserted into the space. (If an inflatable implant is used, saline would be pumped into the device to ensure that it works and there are no leaks.)
The incision is closed with sutures (stitches).
Next, an incision is made in the scrotum near the base of the penis to place the saline pump.
The opening is widened, and tubing from the implant is connected to the pump.
The pump is gently placed in the scrotum.
Next, an incision is made near the spermatic cord (the tube that receives sperm from the testicles) to place the attached reservoir.
After widening the opening, the reservoir is filled with saline and positioned in place.
The internal and external incisions are closed with sutures.
The Foley catheter is removed, and the person is wheeled to recovery.
Penile Implant Post-Op and Recovery
While penile implant surgery has long been performed as an inpatient procedure, around 70% are done on an outpatient basis in the United States. Advances in "no-hands" surgery and antibiotic-impregnated devices have contributed to the decline in inpatient procedures.
Pain is common and sometimes extreme after penile implant surgery, and it is not uncommon for surgeons to prescribe a short course of opioid painkillers to help reduce pain. Over time, these can be transitioned to non-opioid painkillers and eventually over-the-counter drugs like Tylenol (acetaminophen). Occasional ice application can also help ease scrotal pain.
Once home, you would be advised to stay off your feet as much as possible and to avoid any heavy lifting for two to four weeks. It may be in your best interest to book off work for at least two weeks.
You can usually shower 48 hours after surgery, but need to keep the wound dry and change the dressing. During healing, keep the penis pointed upward toward the belly button unless your surgeon tells you otherwise.
Your surgeon will usually schedule a follow-up visit five days after surgery to check that the wound is healing properly and to ensure that the implant, pump, and reservoir are correctly positioned.
Once the sterile dressing is no longer needed, an athletic supporter (jockstrap), compression shorts, or tight mesh underwear should be worn to support the testicles and avoid movements that can disrupt the wound.
Most people can return to work within two weeks, but you would be advised to avoid sex for six weeks to ensure that the implant is securely placed and less likely to shift or migrate.
When to Seek Medical Care
Although rare, infection can occur after penile implant surgery, especially if you don't follow your surgeon's care instructions.
Call your care team immediately if you experience:
High fever with chills
Increasing swelling, pain, redness, or heat
A whitish or yellowish discharge from the wound
Opening of the wound (wound dehiscence)
Related: Is Sudden Erectile Dysfunction Serious?
Living With a Penile Implant
If a penile implant is properly cared for, it may last you the rest of your life. But this largely depends on the device you choose and your age at the time of surgery.
Of the two types, malleable implants tend to last longer. However, they are also more likely to cause pain and postoperative complications, making them a less attractive option for many people.
By contrast, an inflatable penile implant may only last for around 15 years. Though this may not be a problem for people over 60 who most commonly pursue implant surgery, it can make this option less attractive to younger people faced with the likelihood of revision surgery in the future.
According to a 2019 study in the Journal of Sexual Medicine, of 149 people implanted with an inflatable prosthetic, 41% were still using it after 20 years. Of those who experienced problems, 79% were due to mechanical failure, such as leaks or cracks.
To this end, care needs to be taken to avoid damaging the implant, irrespective of the type. This may include:
Altering sex practices and avoiding "rough" sex
Wearing a solid athletic cup during sports
Limiting activities that place repetitive stress on the perineum (the space between the anus and penis), such as horseback riding or mountain biking
Seeing your urologist immediately if you have an injury to the groin or genitals
Related: Living Well With Erectile Dysfunction
Alternatives to Erectile Dysfunction Surgery
Generally speaking, penile implant surgery is considered a last resort when all other conservative options fail. Even if you are eager to pursue treatment, your insurance provider may not cover the procedure until other, less invasive options have been reasonably explored.
These include alternatives like:
Traditional PDE5 inhibitors like Viagra (sildenafil) or Cialis (tadalafil)
Injectable vasodilators like Trimix (alprostadil/phentolamine/papaverine)
Vacuum erection devices (VEDs) approved by the American Urological Association and covered by most health insurance
Testosterone replacement therapy may also help overcome ED if you are diagnosed with hypogonadism (low testosterone).
You may also need to consider if there are psychological causes for your ED (referred to as psychogenic erectile dysfunction). This is especially true if you are younger and in otherwise good health.
Insurers are generally reluctant to approve penile implants for younger people unless there is a clear-cut medical cause, such as multiple sclerosis or a spinal cord injury.
Related: Causes of Erectile Dysfunction In Young Men
Summary
Penile implant surgery is an invasive procedure sometimes used to treat erectile dysfunction when conservative options fail. It involves the implantation of either a solid malleable implant or an inflatable saline implant into the shaft of the penis.
While inflatable implants are considered the gold standard, they have a life span of roughly 15 to 20 years due to mechanical failure. Malleable implants that you manually bend have a longer life but also a higher rate of postoperative complications, including chronic pain and infection.
Read Next: Uncommon Causes of Erectile Dysfunction
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