Who is and isn't a candidate for a penile implant?
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.
Who is a good candidate for a penile implant?
The European guideline makes a strong recommendation for an implant when other treatments fail or when the patient prefers it. It finds enough evidence to recommend implants for men who do not respond to less invasive treatments, because of their high efficacy, safety and satisfaction.
The American guideline gives the man more room to choose. Every man with erectile dysfunction should be told about the implant option, and a man may reasonably begin with any treatment, however invasive. Implants have been used successfully in the general population and in many special groups of patients.
Why does an active infection delay surgery?
"Penile prosthetic surgery should not be performed in the presence of systemic, cutaneous, or urinary tract infection." Source 2, p. 32
An infected implant usually has to be removed, so an infection elsewhere in the body is treated before the operation. Even in good conditions, infection after a first implant affects 2% to 3% of low-risk men at high-volume centres. A 2008 AUA policy recommends antibiotics starting one hour before surgery and continuing for up to 24 hours after it. Other measures, such as antibiotics for more than 24 hours, shaving with clippers and chlorhexidine-alcohol skin preparation, might help prevent infection but lack definitive evidence.
Does diabetes rule out a penile implant?
Diabetes does not rule out an implant, but the two guidelines weigh it differently. The European guideline cites a large database study showing that diabetes is a risk factor for implant infection, which makes careful patient selection important. No randomised trial has set a blood sugar threshold that must be met before surgery.
The American guideline cites a systematic review that found no relevant current evidence of a higher infection risk in diabetic men, with most recent studies reporting rates of 2% or less since antibiotic-coated implants came into use. In one large study of diabetic men, a combination of the antibiotics vancomycin and gentamicin applied to the implant was the most effective at preventing infection.
What other conditions raise the risk?
Men with spinal cord injury carry a higher risk of complications, with prosthesis infection in up to 16% of cases in published series. Low testosterone was independently linked with implant infection in a large US insurance database.
Previous surgery and scarring also matter. A two-piece inflatable model may be considered when an abdominal reservoir carries risk, for example after extensive scarring or a kidney transplant. Men with scarring of the erectile tissue are told that an implant is unlikely to restore their earlier size, and serious complications such as erosion and loss of blood supply to the glans are more likely in men with significant vascular disease.