Erectile Dysfunction - Treatment

Introduction

What factors determine which treatment a doctor recommends for ED patients?

Erectile dysfunction has many causes, both physical and psychological. Initial management for ED depends on the possible cause of the disorder in each individual patient. Treatment options for ED have significantly improved over the past few years and new research and medications continue to increase treatment choices. Treatments offered depend on the expertise of the physician you see. For example, a urologist may offer you a greater scope of treatments than a family physician.

Deciding which treatment is best depends on a number of factors, including:

• Whether the cause of a patient's ED is physical, psychological or both
• The presence of other medical conditions
• The possibility of interaction with other medications
• Which option is most likely to be effective for a particular patient
• The preferences of the man and his partner

Physical issues that may cause varying degrees of sexual dysfunction include: injury or surgery; underlying medical conditions, such as diabetes and/or cardiovascular disease; lifestyle issues, such as smoking and the use of alcohol or other substances; and side effects of medications used to treat other conditions. Psychological issues that can lead to ED include performance anxiety, stress or secondary sexual dysfunctions (premature, delayed and/or retrograde ejaculation).

While the first step of good medical practice is to alter controllable risk factors (such as smoking, obesity, and alcohol abuse; stress, fatigue, depression; the adjustment of prescription medications etc.), most patients with ED will need an additional form of treatment. Therapies currently available include: sexual counseling and education, oral medications, injection therapy, vacuum devices and surgical treatments.

To determine an optimal treatment plan, physicians, patients and partners must have open and honest discussions of all available options. The process of care model outlines the general approach to treatment. First-line therapy includes (1) an attempt to correct controllable risk factors (2) addressing overt psychological issues (For example, if ED commences during the first relationship after a divorce, after being widowed or where obvious confidence issues are not being helped by medical therapies, such as a sex psychologist) (3) oral therapy (pills), which at this time is limited to the use of PDE5 inhibitors, such as sildenafil citrate (Viagra®), vardenafil hydrochloride (Levitra®) and tadalafil (Cialis®).

Second-line treatment includes the use of vacuum devices, intra-urethral (urine channel) suppositories and penile injection (intracavernosal) therapy and is typically reserved for men who have failed pills or have significant side effects and cannot tolerate these medications. Third-line therapy is for patients who have explored first- and second-line therapy and includes vascular surgery for very specific populations of men and penile implant (prosthesis) surgery.

Is treatment for ED covered by insurance? Are the medicines covered?

Treatment and medicine coverage by healthcare insurance varies from one insurance provider to the next, as well as from one plan to the next. It is best to contact the individual provider in order to determine whether the prescribed treatment(s) for ED is covered by insurance.

What non-surgical treatments are available for ED?

The most common non-surgical treatments for ED include:

• Counseling/Psychotherapy/Sex Therapy
• Oral medications
• Penile (intracavernosal) injections
• Vacuum devices
• Intra-urethral suppositories

What is involved in Counseling/Psychotherapy/Sex Therapy?

Seeking psychological treatment is very common in the treatment of ED since ED can be both due to, and the cause of, psychological stress, sexual anxiety and/or other mental health and personal issues.

Psychological treatments often involve counseling or talk therapy and include talking about relationships and experiences with a mental or sexual health professional. Therapists can help find effective ways of coping with many of these problems. Therapists can offer practical strategies that can help reduce sexual anxiety and encourage communication around sexual issues. Often, meeting with a therapist, as few as three or four times, can be very helpful. For many couples affected by ED, talking with a therapist together may produce the best results, as good communication among partners can also help solve problems in an intimate relationship that might be contributing to ED and increasing sexual anxiety.

The risks and benefits of all treatment options should be discussed with a doctor before any mode of treatment is chosen, as patient and partner satisfaction is the primary goal.

Does taking vitamins or other dietary supplements help treat or prevent ED?

Many dietary supplements, such as herbs, vitamins, and minerals, have become increasingly popular as ways to treat medical conditions and improve health. Some are even labeled and marketed as promoting sexual health and improving ED. Don't assume "natural" products are safe and effective to use, as they are not usually reviewed and/or approved by regulatory health agencies such as the U.S. Food and Drug Administration (FDA). There is very little clinical evidence to determine whether dietary supplements provide benefits to people with ED. It is best to discuss the individual risks and benefits of any dietary supplements with your physician before taking them, as some may interact with current prescriptions or complicate current medical conditions.

It is worth noting that in ED drug trials, there is a 30% placebo response rate, meaning that 30% of men on a placebo (sugar pill) claim an improvement in their erectile function. Two important caveats: first, some male health supplements contain androgens (testosterone, DHEA, androstenedione), which may be inappropriate for some men, and second, it has been shown that some of these "all natural" supplements actually contain drugs such as sildenafil citrate (Viagra®) and tadalafil (Cialis®). One of the reasons many men choose to try such supplements is that they are not permitted to use the prescription medications sildenafil citrate (Viagra®), vardenafil hydrochloride (Levitra®) and tadalafil (Cialis®), because they use or possess nitroglycerin-containing medications. Combining these two types of medications may result in life-threatening blood pressure changes. So be cautious when purchasing or using 'all natural' supplements, as they may actually not be 'all natural.'

Self-injection

What types of injections are used to treat ED?

Oral medications don't work for everyone. Many men may be prescribed medicines that go directly, via injection, into the penis. Injection therapy may use a single drug or a combination of drugs. Single drug injection therapy uses alprostadil, a type of prostaglandinE1 (PGE1), and is called either Caverject® or Edex®. Combination therapies, called "bi-mix" (for 2 drugs mixtures) or "tri-mix" (for 3 drugs mixtures), are a mixture of either two, or all three, of the following most commonly used drugs: papaverine, phentolamine and/or alprostadil. Not all bi-mix or tri-mix medications are identical - the amount of the individual drugs may vary from pharmacy to pharmacy.

Alprostadil is a vasoactive agent that is a synthetic version of the chemical prostaglandin E. This chemical helps relax the smooth muscle tissue in the penis to enhance blood flow needed for an erection.

Papaverine and phentolamine also belong to this group of medicines called vasodilators (drugs that relax smooth muscle tissue, causing arteries to open and allowing an influx of blood flow).

Most men who do not respond to oral drug therapies used to treat ED find injection therapies to be effective. Success rates with self-injection are roughly 85 percent of patients. Injections may also be helpful for men who are taking other medications, such as oral nitrates, that should not be used at the same time as some oral medications for ED.

Is the use of injections to treat ED new?

Injection therapy for the treatment of ED is not a new treatment. It was first introduced in the early 1980s. Papavarine was the first substance used and studied extensively in the 1980s. Injection therapies are still in widespread use for the treatment of ED and are a safe and reliable alternative to other ED treatments.

Only Caverject and Edex are FDA approved for use. Compounding pharmacies mix the other combination therapies and because no specific pharmaceutical company has the licensing rights to the combinations, FDA studies have never been conducted, and likely never will, to determine their exact safety and reliability. These combination agents, however, have been used for more than a decade longer than Caverject and Edex and are just as safe and probably more effective in most men.

How are the injections administered?

Penile injections should be coordinated by a urologist. Injection treatments involve the injection of medication into the base of the penis (the part of the shaft furthest from the head of the penis) approximately 5-10 minutes before sexual activity. The injected medication causes blood vessels within the penis to widen, or dilate, which increases blood flow to the penis and causes an erection. Erections from injection therapies are commonly 30 minutes in duration. The needle used is a 29-gauge needle (tiny - like that used by diabetics injecting insulin for sugar control). Most men describe the sensation like 'pulling a hair out of the back of their hand'.

Although the thought of an injection can be unpleasant, injection is a quick and easy technique to learn. The injection method is highly successful letting many men experience an erection rigid enough for intercourse. Injections should not be used more than 3 times per week. Patients need to be trained in the technique of penile injections and these training sessions also allow the physician to figure out a safe starting dose of injection medication.

It is always best to speak with a physician or trained health professional to discuss the proper use of any prescribed treatment.

What are the side effects of injections used to treat ED?

The greatest concern about using injection therapy is the possibility of developing prolonged erections (lasting longer than 4-6 hours). This condition is known as priapism and can cause permanent damage to the erection tissue of the penis. Priapism can be avoided by carefully dosing the medication, which should be coordinated by your urologist (see Fact Card on Avoiding And Treating Priapism).

In general, minor side effects that may occur with penile injection therapy include:

• Mild bruising over the site of injection: this can be avoided by pressing over the injection site for 3 minutes (6 minutes if you are using a blood thinner).
• Penile pain: while uncommon, this occurs more commonly in men using alprostadil containing injection agents. It is most common in men with diabetes and following radical prostatectomy surgery.
• Swelling at the site of injection: this usually happens when some of the medication is discharged under the skin and usually occurs with poor technique.

How much do the injections cost?

The cost per injection for alprostadil (Caverject or Edex) alone can be expensive if insurance carriers do not cover it. The injection mixtures of alprostadil, phentolamine and/or papavarine, are generally less expensive option. Treatment and medication coverage by healthcare insurance varies from one insurance provider to the next, as well as from one plan to the next. Therefore, it is best to contact the individual provider in order to determine which treatments for ED are covered by insurance.

Vacuum devices

What are vacuum devices and how do they work to treat ED?

Vacuum erection devices (VED), also called vacuum constriction devices (VCD), are commonly used, have been FDA approved and have been utilized for nearly a century. Several medical equipment companies have created specially designed devices to limit the amount of pressure that is built up in the cylinder, reducing the chance of pressure-induced penile injury. Some devices have been developed and are available (mainly via the Internet) that are not FDA approved and should not be used without consulting a doctor.

The basic units of FDA approved VED/VCD are:

• a clear plastic cylinder with an opening at one end that is placed over the penis.
• a pump that is connected to the cylinder that draws air out to create a vacuum. The pump may be hand or battery operated. The vacuum reduces air pressure in the cylinder and an increase in blood flow to the penis. FDA approved cylinders have pop-off valves, which limit the amount of pressure.
• an elastic ring. Once an erection is achieved, an elastic ring is placed around the base of the penis. The elastic helps maintain the erection by reducing blood flow out of the penis. The rings come in different shapes, sizes, and most importantly tightness for individual fit. Most manufacturers recommend use of the elastic ring for no more than 30 minutes to minimize the risk of injury.

VEDs/VCDs are effective, but some men find them to be cumbersome and that they get in the way of sexual spontaneity. With proper instruction, roughly 80 percent of men who use.
VEDs/VCDs achieve a functional erection.

How much does a vacuum device cost?

VEDs/VCDs usually cost anywhere from $300 to $500. For example, the battery-powered versions tend to be more expensive. There are several devices currently on the market, some of which can be obtained without a prescription.

Coverage of these devices by healthcare insurance varies depending on the insurance provider and plan. It is best to contact the individual provider concerning cost or coverage.

What are the risks involved with using a vacuum device?

The risk of side effects is low and usually minor. Possible problems associated with the constriction band may include bruising, skin irritation, pain or discomfort, numbness and/or loss of sensitivity. Other common side effects with VEDs/VCDs include a sensation that the penis is cold and pinched scrotal tissue from the constriction ring.

Transurethral agents

What is a "transurethral agent"?

Transurethral agents, also called intra-urethral agents, are ED treatments whose mode of administration is insertion into the urine channel, known as the urethra. The only FDA-approved urethral suppository is called MUSE® (Medicated Urethral System for Erection), which contains the drug alprostadil (also used in the injectable drugs, Caverject and Edex).

How are urethral suppositories inserted?

A tiny medicated pellet, roughly the size of a grain of rice, is inserted approximately one inch into the opening at the top of the penis, while the man is standing, using an applicator. Once effectively inserted, the tissue of the penis absorbs the suppository. To help aid insertion and administration of the suppository into the urethra, lubrication can be achieved by inserting the pellet directly following urination. To minimize leaking and promote absorption, the patient is also instructed to hold the penis upright and massage gently and to stand, sit or walk for 5 to 10 minutes while the medication is being absorbed and an erection develops.

How do urethral suppositories work?

Alprostadil (MUSE) belongs to a group of medicines called vasodilators that increase blood flow by causing blood vessels to expand. Once MUSE is inserted and absorbed into the tissue immediately surrounding the urethra (the corpus spongiosum) it is transferred into the erectile chambers (corpora cavernosa) through small veins. The medicine then causes the erectile tissue to relax and allows blood flow to increase. This increased blood flow causes an erection.

MUSE is prescribed in one of four dose strengths (125, 250, 500, and 1000 mg), although the lower doses tend not to be effective in the average man with ED. MUSE is usually only recommended as a single daily dose.1

MUSE usually begins creating an erection in about five-to-10 minutes. Sexual activity should be attempted within 10 to 30 minutes after using the medicine. It is not uncommon for the erection to continue after ejaculation,1 although loss of the erection is expected within one hour. A doctor should determine the correct dose of MUSE.

How effective are urethral suppositories?

MUSE has an average overall success rate of 35%, in achieving an erection sufficiently rigid for sex. While urethral suppositories are often less intimidating to men than injecting medicines into the penis, it can still be a complex process and should be taught in the clinician's office before a man begins to use MUSE at home.

What are the side effects or potential complications of urethral suppositories?

The most common side effects are pain and minor discomfort in the penis and perineum (area between scrotum and rectum) and dizziness. These side effects are reported in less than 5% and 2% of men, respectively, and often go away during treatment as the body adjusts to the medicine. Because of the potential for dizziness, it is often recommended that the first dose of the agent, particularly 500 or 1000 mgs, be given in the physician's office.

Rare side effects that can occur requiring a doctor's immediate attention include an erection continuing for over four hours (known as priapism) or an erection becoming painful.

When using alprostadil in its suppository form, it is important to use a condom when having sexual intercourse with a pregnant female. Although harm to the fetus is unlikely, using a condom will protect the fetus from exposure to this medicine. If a woman can become pregnant, use of contraceptive methods is recommended because the effects of this medicine on early pregnancy are not known.

What is the cost of urethral suppositories?

Depending on the dose of MUSE prescribed, it may cost anywhere from $125 to $175 for six urethral suppositories. The cost of treatment with healthcare coverage varies according to provider or plan.

Vascular surgery

What is vascular surgery?

Vascular surgery attempts to restore penile blood flow that has been reduced by correcting a blockage or leakage in blood flow to the penis in order to improve a man's ability to get and maintain a natural erection.

Vascular surgeries can include:

• Repairing leaking veins that prevent a man from keeping an erection
• Bypass operations to re-route blood past blocked arteries to the penis
• Blocking off veins that allow blood to leave penile tissue.

What is artery bypass surgery used for ED?

Artery bypass surgery, also known as penile revascularization, is a treatment for ED that is designed to bypass blocked arteries that limit blood flow to the penis thus causing ED. In this surgery, an artery is transfered from another area of the body (usually the abdomen), to a penile artery in an effort to create a new path for bloodflow to the penis that bypasses the blocked or injured vessel. Therefore, the specific objective of artery bypass surgery is to increase artery blood flow to the erection tissue of the penis.

This procedure is most commonly used in men who have experienced a penile vessel injury caused by events such as trauma, pelvic facture or surgery.

Artery bypass surgery is a treatment that has the potential to permanently cure patients of ED, allowing men to spontaneously develop erections without the need for any ED medications or internal/external devices.

Who are candidates for penile revascularization?

Young men who have ED secondary to traumatic occlusion of the erectile artery(ies) and who have no other vascular risk factors (eg. diabetes, hypertension, hypercholesterolemia, or significant cigarette smoking) represent the ideal patient population for penile vascular surgery. The investigation and preoperative evaluation of these patients are aimed at ensuring 1) normal hormonal status, 2) normal neurologic function, and 3) the documentation of poor blood flow and the absence venous leak. All young patients with a history suggestive of trauma-associated ED (particularly patients who have experienced pelvic fracture or perineal trauma) can be considered candidates for penile vascular surgery.

What form of patient evaluation is required?

All patients considered candidates for penile revascularization should have a routine hormone evaluation to ensure adequate circulating levels of testosterone. In addition, a nocturnal penile tumescence and rigidity analysis (NPTR) should be performed to rule out neurogenic and psychogenic erectile dysfunction. Finally, a blood flow assessment with duplex Doppler penile ultrasonography or dynamic infusion cavernosometry/cavernosography (DICC) is required. Following testing, if the patient has a diagnosis of pure arterial insufficiency, an arteriogram is performed to show the arterial anatomy and confirm the location of the blockage. The arteriogram should demonstrate several findings to ensure optimal results from penile revasularization. These findings include: 1) a blockage of the common penile or cavernosal artery at a point that is amenable to bypass 2) at least one donor (inferior epigastric) artery of sufficient length and caliber to reach the top surface of the penis and the recipient artery 3) communicating branches passing from the dorsal artery into the erection chamber (corpus cavernosum) on at least one side, preferably the side of the occlusion.

What does the surgery involve?

There are many variations of this procedure, which is beyond the scope of this section. The operation takes approximately 4-6 hours. The patient is asleep under general anesthesia. In the most commonly and probably most successful approach to penile revascularization, the donor artery is harvested for the abdomen. The inferior epigastric artery is a blood vessel that supplies blood to one of the abdominal muscles. Removing this artery has no effect on the health of this muscle. This blood vessel harvesting requires an incision on the belly. The artery is detached from its upper attachment and swung down onto the top surface of the penis by tunneling it through the hernia ring. There is a second incision on the scrotum or penis. Once on the top of the penis the inferior epigastric artery is attached to the recipient artery the surface artery of the penis (dorsal artery). Patients routinely stay in hospital a single night, miss one week from work and need to avoid physical exertion including sexual activity for several weeks after surgery.

How successful is penile revascularization?

The medical literature indicates that there are some men who are cured of their ED by this operation. The success is based on how appropriate a candidate the patient is for the surgery and the experience and training of the surgery. There are few centers in the world that would be considered centers of excellence for this operation. This is not an operation that should be routinely performed by a urologist or surgeon who has not received special training in this form of microsurgery. Most medical papers published suggest that approximately 50% of men will be cured at 2-5 years after surgery. Besides this group there are men who are improved but who still require the use of erection medicines after surgery.

What is vein ligation surgery for ED?

Sometimes veins in the penis can leak, preventing it from staying erect. Venous ligation surgery attempts to correct this problem by blocking off veins (ligation) that normally allow blood to leave the penis. By creating an intentional blockage in blood flow out of the penis, this reduction in the leakage of blood is aimed at increasing the rigidity of the penis during an erection. Leakage of blood from the penis is the result of damage to the structure of the erection tissue. Thus, this form of surgery does not address the underlying cause but more the symptoms of leakage. To date, there is no evidence that vein ligation surgery has success in the long-term cure of ED due to venous leak. Thus, most authorities currently do not advocate venous ligation surgery. There is one group of men in whom there is renewed interest in such surgery. Preliminary evidence suggests that young men who have a specific form of leak (isolate crural venous leak) may benefit from a specific form of surgery (crural ligation/exclusion surgery). Patients are candidates for this surgery if they have this special form of leak proven usually requiring a test called cavernosography. At this time, very few centers in the USA have experience in this procedure.

Penile implants

What are penile implants (prostheses)?

Penile prostheses, or penile implants, are an important treatment option for men with ED who have an established medical cause for ED, fail to respond to nonsurgical treatments (such as oral medications, vacuum devices, injection therapy etc.) and who are motivated to have surgery to improve erectile function. Penile implant requires a permanent surgical procedure that cannot be reversed. It is important that men talk to their doctor about the advantages and possible drawbacks of having the procedure.

This procedure replaces the spongy tissue (corpora cavernosum) inside the penis with rigid, semirigid, or inflatable cylinders (depending on which type of penile implant is chosen). In all penile prostheses, the surgically inserted components are totally concealed within the body. After a penile implant, when a man desires an erection, he is able to produce a rigid erection on demand that enables him to have sexual relations. Penile implants do not typically lengthen the penis.

What types of implants are available?

There are diverse forms of penile implant options that can be categorized into two main types of implants, each of which come in a variety of diameters and lengths.

• Semi-rigid malleable (positionable) rods (also known as non-hydraulic)
• Inflatable (also referred to as hydraulic), which include two- and three-piece implants

Semi-rigid malleable (positionable) rods

Malleable models are not often used, nowadays only making up about 10% of devices impanted. Certain men should avoid this device (such as men with spinal cord injury, diabetics, and men who have had penile irradiation). The malleable penile implant requires surgical insertion of a pair of flexible rods within the erection chambers of the penis. The rods have an outer coating of silicone and inner stainless steel core or interlocking plastic joints. These joints enable the man to place the penis in either the erect or flaccid position. This type of implant produces a constant penile rigidity that merely needs to be lifted up, or bent, into the erect position to achieve an erection and sexual intimacy, or in the downward position for urination. As he does so, the rods inside his penis bend. Malleable penile implants can be bent in more than one place to create the desired erection. Three malleable devices exist at this time (AMS Malleable 650 and Dura-II devices, and the Mentor Acu-Form prosthesis).

Inflatable Devices

Both of the types of hydraulic, inflatable devices have hollow cylinders that are implanted within the erection chambers of the penis. In order to create an erection, these inflatable devices use a pump to transfer fluid (saline) into the cylinders via tubing. As fluid is pumped into these cylinders, they expand to enlarge or "erect" the penis. The two and three-piece penile implants differ in their location of fluid storage, mainly how this fluid is then transferred out of the cylinders when an erection is no longer desired also is different.

• 2-piece inflatable implants - This is the simpler of the two types of inflatable device, accounting for approximately 15% of penile implants used worldwide. In the two-component penile prostheses, one component is the paired cylinders and the second component is the fluid-filled internal pump located inside the scrotum. Compression of the pump results in transfer of fluid from the back part of the cylinders and pump into the middle portion, resulting in rigidity. To end the erection with a two-component penile prosthesis, the penis is gently bent down for 5-10 seconds at its mid-shaft, resulting in the fluid being returned to the fluid-filled pump. The AMS 2-piece device (Ambicor), is the only currently available 2-piece. The advantage of this device is that it is easier to deflate and may be a better device for older men or men with poor manual dexterity. The disadvantage of this device is that in the flaccid state it always contains some fluid and thus the penis will always appear "full" (similar to the penile form after a man has a hot shower).
• 3-piece inflatable implants - The most commonly used inflatable device is the three-piece inflatable implant, accounting for approximately 75% of penile implants. This device has paired cylinders and a small scrotal pump, but in addition this device also has a fluid reservoir (which is placed behind the abdominal wall muscles) that is filled with saline solution. Thus, all parts of the device are internal. With these three-component devices, a larger volume of fluid is pumped into the cylinders for an erection by squeezing the concealed pump in the scrotum several times in order to move the fluid from this concealed reservoir into the cylinders that are in the penis. As the cylinders fill, the penis becomes erect and firm. When the erection is no longer desired, a release valve on the pump (in the scrotum) is simply pressed to transfer the fluid back into the reservoir and out from the cylinders, causing the penis to become flaccid. There are five different 3-piece devices available to address most implant situations. The advantage of a 3-piece device is that it is completely flaccid in the deflated state. It does however require some training to learn how to deflate the device.

One major difference between the hydraulic, inflatable prosthesis and the semi-rigid malleable penile implant is that the inflatable prosthesis has a more natural feeling since they allow for control of rigidity and size. The semi-rigid devices have the advantage of being the simplest of the penile implants and are the cheaper option. The disadvantages include a constantly rigid penis that resembles neither normal erection nor flaccidity, which makes it difficult to conceal under tighter fitting clothing as well as an increased risk for device erosion.

The pros and cons of each treatment option should be carefully discussed with the treating physician to make the best-informed choice and to ensure that the patient has realistic expectations about their treatment results.

What is involved in inserting a penile implant?

The surgical approach differs according to which implant is used, the history of the patient and the surgeon's preference. During surgery, which is done under anesthesia, the penile implant is inserted through an incision made in the penis, lower abdomen, or scrotum (depending on which type of penile device is being implanted). A thin, flexible tube is inserted briefly up the urethra and into the bladder to drain urine.

Usually one small surgical cut is made either above the penis where it joins the abdomen or under the penis where it joins the scrotum. In this procedure no tissue is removed and blood loss is usually small, therefore blood transfusions are almost never required. Patients may go home the same day of surgery or spend one night in the hospital. The operation takes approximately one hour to perform.

Most men have pain, some swelling and bruising after penile prosthesis implantation for about 2-4 weeks, for which oral pain medication is used and routinely helpful. Men are instructed not to use the prosthesis for sexual activity one month after surgery.

Neither the operation to implant a prosthesis, nor the device itself, should interfere with sensation, orgasm or ejaculation.

How effective are penile implants as a treatment for ED?

Long-term clinical data show that penile implants are highly effective and reliable, in fact about 90%-95% of inflatable prosthesis implants produce erections suitable for intercourse. Studies also find a very high degree of satisfaction by both users and their partners. Satisfaction rates with the prosthesis are typically 80%-90% and the vast majority of men say they would choose the surgery again. Studies indicate that men who undergo implant surgery report a dramatic improvement in erectile function for both noninflatable and inflatable implants. Other research has found that satisfaction rates increase drastically after 6-12 months of use, with the most significant improvements reported in the second half of their first year following implant surgery.

Men using penile implants also report that erections created by implants seem more natural than ones from other, nonsurgical methods. They also say that penile implants offer spontaneity by allowing them to control when an erection will occur, as well as providing consistency, and rigidity.

Penile prostheses do increase hardness of the shaft of the penis, but that they do not routinely lengthen the penis.

What are the possible complications of penile implants?

The main risks are infection, erosion and mechanical failure. If infection occurs, removal of the prosthesis will most likely have to occur in order to eliminate the infection. Historically, after removing the prosthesis, re-implantation of another device has been postponed for several months.

Currently, salvage implant surgery removes the infected device and replaces it with a new device at the same time. The results of this approach suggest that 80% of the salvage implants do not get infected again. The advantage of this approach is that it avoids the penile shortening that occurs in the penis that has had an implant removed without being replaced.

Erosion, when the tissue around the implant is damaged and the device pushes through the skin, is often associated with infection and often necessitates removal of the device.

While post-operative complications of penile implant surgery are not common, mechanical failure is more likely to occur with inflatable than with rod prostheses. The most common cause of failure in these devices is leakage from the cylinders, causing the fluid present to leak into the body (these prostheses contain normal saline that is usually absorbed without harm). After mechanical failure, another operation for prosthesis replacement or repair is necessary if the man wants to remain sexually active. This occurs in 15-30% of men within 10-15 years after the original implant has been placed.

Other, less common mechanical complications include the implant being positioned incorrectly inflating spontaneously (auto-inflation).

When inserted, penile prosthesis does not change sensation on the skin of the penis or a man's ability to reach orgasm, and ejaculation is not affected. But, once a penile prosthesis is put in, it may destroy the ability to naturally get an erection.

As with all medical procedures, it is important to discuss the possible risks and complications involved in penile implant surgery with a physician in order to determine which procedure is best.

What is the cost of a penile implant?/ Will insurance cover this procedure?

The cost of penile implants (including device, medical procedure, and after-care) usually ranges from $15,000 - $20,000. The cost of treatment with healthcare coverage varies. However, insurance coverage for these operations is often good, since there is usually a medical cause of the ED. But, it is best to contact the individual provider in order to determine if urethral suppositories are covered by insurance and their individual cost to the patient.