When medical therapy fails along with combination therapy, or if medical therapy is contraindicated, the next step in the treatment of erectile dysfunction involves the placement of a penile prosthesis. Once again, a man must have the cardiovascular health to tolerate sexual activity prior to the placement of the prosthesis.
There are several considerations and counseling points that must be discussed with the patient prior to intervention. This leads into the discussion of types of prosthesis available. The three most commonly used on the market today are the following: malleable prosthesis, two-piece inflatable prosthesis, and the three-piece inflatable prosthesis.
The surgical procedures are performed while the patient is asleep with anesthesia. This can be done by general anesthesia (placing a breathing tube into the lungs and delivering air while you sleep) or by spinal anesthesia. Spinal anesthesia involves placing a needle into the spine in the back that gives a medicine to make the skin and tissues numb from the belly button down to the toes. A sedative medication is then given so the patient will not be aware of what's happening. They are not totally asleep, but they will not be aware of the surgery taking place (called a "twilight" sleep). The choice of anesthesia depends on what other medical conditions (lung or heart problems) the patient may have, and this is a conversation that the patient will have with the anesthesiologist.
A malleable prosthesis is the simplest of the three penile implants both from a patient's and a surgeon's perspective. There are two rods that are inserted into the corporeal bodies of the penis. To review, the penis is composed of three "tubes." Two of those tubes are responsible for erections, called the corporeal bodies. The third is the tube that the male urinates through, called the urethra. When the prosthesis is placed, the corporeal bodies are "hollowed out," to make room for the prosthesis.
The malleable penile prosthesis is always hard or erect. When a patient is not using the prosthesis, it must be tucked between the legs in order to conceal it. The benefit of this device is that there is little effort involved in the "activation." If the patient wants to have sex, the penis is straightened out and sex can occur that instant. The other types require some form of activation (that will be described later). This simplicity has the downside of being less like a normal penis in that it never truly gets soft. Because of this, some men feel that it is uncomfortable .
The two- and three-piece inflatable prostheses combat this by having a pump mechanism that is used to fill the prosthesis. These will be discussed in the next entry.