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The European guideline does not describe a loss of penile girth as a normal part of ageing. It gives reference values, with a mean erect circumference of 11.66 cm, and shows how far size worries differ from reality. In one study, 84% of women were satisfied with their partner's size, while only 55% of men were satisfied with their own.

An erection that does not go away without sexual stimulation is called priapism. The common ischaemic type becomes a medical emergency once it lasts beyond four hours, because irreversible damage to the erectile tissue begins about 48 hours after onset. Draining the trapped blood combined with a vessel-narrowing injection resolves 80% to 100% of cases.

No clinical guideline sets a normal length of time for an erection during sex. The closest measure is an overnight test, in which an erection of at least 60% rigidity lasting 10 minutes or more shows that the physical erection mechanism works. Losing the erection after ejaculation is normal, while an erection lasting beyond four hours without arousal needs urgent care.

Most erectile dysfunction has more than one cause, so the European guideline advises caution with a strict split into physical and psychological types and suggests the terms primary organic and primary psychogenic instead. Physical causes include vascular, hormonal and nerve problems. In one German study, erectile dysfunction affected 19.2% of men aged 30 to 80.

When a partner regularly cannot get or keep an erection firm enough for sex, it is erectile dysfunction, and most cases have more than one cause. Erectile dysfunction affects the quality of life of both partners, so guidelines include the partner in assessment and treatment. Partner satisfaction after implant surgery is reported at 91% to 95%.

An erection that repeatedly fades before or during sex, rather than now and then, fits the definition of erectile dysfunction, the persistent inability to get and keep an erection firm enough for satisfactory sex. Losing the erection soon after ejaculation is normal. Treatments work well, and alprostadil injections are effective in more than 70% of men.

Erectile dysfunction can be an early warning sign of heart and blood vessel disease. In a study of 965 men without heart disease, younger men with erectile dysfunction, especially those under 50, had a higher Framingham cardiovascular risk score. Guidelines therefore treat erectile dysfunction as a risk marker that warrants a check of heart risk factors.

A smaller or weaker erection is most often a sign of erectile dysfunction, which affected 19.2% of men aged 30 to 80 in one German study and becomes more common with age. Treatment for prostate cancer and conditions that scar the erectile tissue can also change penile size. Guidelines do not link erection size to hydration.

A penile implant makes the shaft rigid but does not generally enhance orgasm or ejaculation, and it has no direct effect on sex drive. Changes in orgasm are more often linked to the cause of the erectile dysfunction, such as prostate cancer treatment. Satisfaction with implant surgery still reaches 92% to 100% in patients with appropriate counselling.

Tablets for erectile dysfunction are not needed for rigidity once an implant is in place, because the implant makes the shaft firm. After surgery, PDE5 inhibitor tablets and alprostadil have been used to improve warmth, sensation and swelling of the glans, but the evidence is too limited to guide practice. PDE5 inhibitors must never be combined with nitrates.

Recovery after penile implant surgery usually involves some pain, which in the experience of the American guideline panel resolves within one to three months. Early problems such as swelling or bruising occur in a mean of 3.4% of men and are rarely serious. When the device is first used depends on healing and on the surgeon, because no universal post-operative protocol exists.

In a small group of young men whose erectile dysfunction follows pelvic or perineal trauma, surgery to restore arterial blood flow has a 60% to 70% long-term success rate. For most men, blood vessel damage is not repaired directly, and treatment focuses on risk factors, PDE5 inhibitor tablets and other options. Surgery on the penile veins is not recommended.

Penile traction is the one lengthening approach the European guideline supports, as a conservative option. In one study, wearing a traction device for at least four hours a day for six months added 1.7 cm to stretched length. The guideline recommends against implants, penile disassembly and the sliding technique for lengthening, and against hormones after puberty.

Lifestyle change can improve erections in some men. Physical activity, particularly aerobic exercise, weight loss and treatment of heart risk factors may improve sexual function, and guidelines recommend starting these changes before or alongside other treatment. Supplements help little, and L-arginine raised erectile function scores by only 2.74 points in one meta-analysis.

A penile implant can make the erect penis slightly shorter than an erection produced with medication before surgery. In one study the loss averaged 0.74 cm one year after surgery. Most men feel some shortening, but in another study measured length did not change significantly, and in some men with Peyronie's disease stretched length increased.

Neither the European nor the American guideline for erectile dysfunction includes massage among its treatments. The options they do recommend range from lifestyle change and PDE5 inhibitor tablets to injections, vacuum devices and implants, and implant surgery reaches 92% to 100% patient satisfaction. Pelvic floor muscle training, a different approach, shows early promise after prostate surgery.

An inflatable penile prosthesis works by moving fluid from a reservoir into two cylinders inside the penis when a pump in the scrotum is pressed, and a release mechanism empties them afterwards. A semi-rigid prosthesis has no fluid and is bent into position by hand. Satisfaction with implant surgery reaches 92% to 100% when patients are properly counselled.

With an inflatable implant, an erection is produced by pressing a pump in the scrotum, which fills two cylinders in the penis with fluid until the shaft is firm, and a release mechanism ends it. A semi-rigid implant stays firm and is bent upward by hand. Satisfaction with implant surgery reaches 92% to 100% in patients and 91% to 95% in partners.

Most penile implants keep working for many years. A meta-analysis found that 93.3% were still working at one year, 87.2% at five years, 76.8% at ten years and 52.9% at twenty years. Implants that stop working early usually do so because of mechanical failure or infection, and a further operation can replace the device.

Neither the European nor the American guideline sets an age limit or an ideal age for a penile implant. Candidacy rests on whether other treatments have worked and on the man's preference. Age still shapes the discussion, because 76.8% of implants are still working at ten years and 52.9% at twenty, so a younger man is more likely to need a replacement.

A penile implant is a device placed inside the penis during surgery to treat erectile dysfunction that has not responded to other treatment, or when a man prefers a definitive option. Implants are either inflatable or semi-rigid. Infection affects 2% to 3% of first implants in low-risk men at high-volume centres, and 76.8% of devices still work after ten years.

The main drawbacks of a penile prosthesis are the risks of surgery, infection in 2% to 3% of first implants at high-volume centres, mechanical failure over time and the fact that the choice is best regarded as irreversible. Satisfaction is still among the highest of any treatment for erectile dysfunction, at 92% to 100% of patients.

Clinical guidelines do not give a price for a penile implant, and the cost depends on the country, the hospital, the device and the insurance plan. Guidelines do treat cost as a real factor in the decision. Treatment costs are among the most common barriers to ED treatment, while satisfaction with implant surgery reaches 92% to 100% of patients.

Guidelines do not name a single best treatment for erectile dysfunction. The European guideline tailors the choice to invasiveness, efficacy, safety, cost and the man's preference, with PDE5 inhibitor tablets as first-line therapy. Penile implants have one of the highest satisfaction rates of any option, at 92% to 100% of patients, and are recommended when other treatments fail or by preference.

A penile implant is an option for men whose erectile dysfunction has not responded to other treatment, or who prefer a definitive treatment. Surgery is not performed while there is an infection in the body, on the skin or in the urinary tract. Risk factors such as spinal cord injury, with infection rates of up to 16%, are weighed rather than ruling surgery out.

Insurance cover for a penile implant depends on the plan, not on clinical guidelines. At one US tertiary centre in 2016 and 2017, Medicare insured 39.5% of men seeking an inflatable implant, while 48.0% of men with commercial insurance could not obtain the device because of plan exclusions or denials, despite a medical need for it.