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Erectile dysfunction and penile prosthesis


What is ED?

Erectile dysfunction (ED) consists of an insufficient erection of the penis and, as a consequence, difficulty in penetration and unsatisfactory sexual intercourse.

ED can have many degrees, from a situation in which the penis achieves an erection but not as “rigid as before” to a complete absence of an erection. It is usually a progressive phenomenon in which the patient gradually notices that he does not achieve the usual hardness or that the erections do not last long enough to have a satisfactory relationship.

What are the causes of erectile dysfunction?

The most common causes of this pathology are vascular causes. The penis is an organ with a complex and important vascular network. To understand it, the corpora cavernosa are two cylinders that fill with blood and are subsequently emptied when the erection is lost.

Source: Asociación Española de Urología (

Knowing this, we can classify the causes of ED into the following:

– Age. The simple fact of getting older causes, as in the rest of the body, alterations in the penis at the level of blood vessels, cholesterol and triglyceride deposits, which make circulation difficult and an adequate erection is not achieved.

– Diseases such as diabetes, hypertension or cardiovascular disease are common causes of erectile dysfunction.

– Peyronie’s disease is a special entity because it causes curvature of the penis due to fibrous plaques that form in the albuginea of the corpus cavernosum, which causes it to curve when having an erection. It is common for patients with this problem to also present with erectile dysfunction.

– Previous surgeries, fundamentally radical prostatectomy performed on patients with prostate cancer. In addition, surgeries that affect the vessels and nerves that go to the penis, such as radical cystectomy for bladder cancer or colon and rectal cancer surgeries, can produce these types of alterations.

– Genetic factors. There is a group of generally young patients who have rarely had an erection and who present this problem possibly because there is some alteration that causes their penile erectile system to not function properly.

How is erectile dysfunction diagnosed?

The diagnosis is made based on the patient’s symptoms, in most cases we use questionnaires that the patient fills out and they give us a lot of information, the most common are the International Index of Erectile Function (IIEF).

Additionally, other analytical studies can be performed, especially hormonal ones, as well as glucose, cholesterol or triglyceride control. Doppler ultrasound can inform us of the arterial and venous flow that an erect patient presents and is requested in selected cases.

How is erectile dysfunction treated?

Depending on the cause of erectile dysfunction and your preferences, we will offer you a variety of treatments suitable for different patient profiles.

In general, the first line of treatment will be oral treatments:

Oral treatments:

There are 4 active ingredients that can be prescribed orally. The choice of one or the other and the dose to be administered is based on the sexual profile of each patient, dose needs and preferences for use:

  1. Sildenafil (Viagra)
  2. Tadalafil (Cialis, Citax)
  3. Vardenafil (Levitra)
  4. Avanafil (Expedra)


All four have a similar mechanism of action, increasing the blood flow that enters the penis and allowing a firmer and longer-lasting erection to be achieved in response to a stimulus.

If you take one of these medications in the absence of sexual stimulation, an erection will not occur automatically. There needs to be sexual stimulation for its mechanism to activate. Oral medications to treat erectile dysfunction are not aphrodisiacs, do not cause arousal, and are not necessary for men who do not have erection problems.

Although they are very well tolerated in some patients, they can cause side effects that should be identified. The most common are redness, nasal congestion, headache, visual disturbances, back pain and abdominal discomfort.

Intracavernosal injections. Alprostadil (Caverject)

In cases where oral medication fails or has no response, injection of alprostadil into the corpora cavernosa can be used.

Initially, the use of this alternative seems like an invasive and bloody method and some patients are wary of its use. However, with proper explanation and instruction, the success and satisfaction rate is very high.

Using a very fine needle, alprostadil (Caverject) is injected into the base or side of the penis. Each injection is dosed to create an erection that lasts no more than an hour. As the needle used is very fine, the pain at the injection site is usually very mild. Side effects may include minor bleeding from the injection, prolonged erection (priapism), and, rarely, fibrous tissue formation at the injection site.

If you are a candidate for this treatment, Dr Puche will instruct and explain to you in the same consultation how to choose the dose, prepare and administer the injection in an absolutely safe way.

Penis prosthesis. Is it an alternative for me?

The choice to place a penile prosthesis can be made in patients with erectile dysfunction in whom: 

– Oral medication has failed or generates side effects.

– Intracavernosal injections have no effect or generate side effects.

– Or, in those patients who do not want to rely on pills or injections to achieve an adequate erection.

This treatment involves surgically placing a device on both sides of the inside of the penis. There are different types of prostheses on the market and the choice of each one should be discussed in the consultation according to the preferences and individual situation of each patient. Each prosthesis has characteristics that adapt better or worse to the needs and sexual profile of each patient. Dr Puche will guide you and provide all the necessary information to make the most correct decision and choose the prosthesis that best suits your needs.

Simply put, there are two types of penile prostheses:

  1. Malleable penile prosthesis. They are the simplest form of prosthesis. They consist of two separate silicone cylinders with the ability to be “placed” in the desired position. Both cylinders are consistent enough to achieve adequate penetration. Its main disadvantage compared to hydraulic prostheses is that the penis is always in a state of rigidity. They are a good option for patients with neurological problems or manual mobility problems.
  2. Hydraulic penile prosthesis. In this case there are also two cylinders but they are hollow and these are filled through a hydraulic mechanism that is activated at the patient’s will when he wants to achieve an erection.

In turn, hydraulic prostheses can be:

  • Of two components: Its mechanism is simpler than the three-component one and although the cylinders allow inflation and emptying, the penis does not achieve a state of complete laxity with this system.
  • Three-component: They are the most advanced prostheses with the greatest functionality. The erection achieved is very natural and complete and, when the mechanism is deactivated, the state of laxity is also complete, not appearing to have the device implanted.

It is important to know that, with the correct indication, the placement of a penile prosthesis has been shown to achieve satisfaction rates of 92% among patients and 96% among their partners 

Appearance of a 3-component hydraulic penile prosthesis. The yellow coating is an antibiotic coating that is used to reduce the rate of infections

In the following video you can see schematically how an AMS 700 inflatable penis prosthesis works.

How does Dr Puche perform penile prosthesis implant surgery?

Appearance of a 3-component hydraulic penile prosthesis. The yellow coating is an antibiotic coating that is used to reduce the rate of infections

In the following video you can see schematically how an AMS 700 inflatable penis prosthesis works.

Depending on the patient’s history and characteristics, penile prosthesis implantation can be performed using various techniques and incisions. In my case, except in special circumstances, I always follow the same technique and perform the implant through a penoscrotal incision (between the base of the penis and the scrotum).

– Surgery can be performed with spinal anesthesia (from the waist down) or general anesthesia depending on the patient’s characteristics.

– The duration of the surgery is usually between 1-2 hours.

– At the end, a bandage is placed on the penis that remains for 24 hours.

– Normally the patient is discharged on the same day or the next day depending on the time at which the intervention is performed (less than 24 hours after admission).

– In order to use the prosthesis normally, it is usually necessary to wait at least 6-8 weeks.

** It is important to know that, as with any intervention, there may be complications such as urinary retention, or the appearance of hematomas or edema, which will not lead to long-term problems. However, the most feared complication is prosthetic infection, which can lead to its removal. To minimize this possibility, I always follow a strict perioperative infection prevention protocol. Still, this complication can occur in approximately 5% of patients.

How long does a penile prosthesis last?

Normally it is estimated that about 10 years. Although this is variable and is probably more so with more modern prostheses. When this occurs, there is the possibility of replacing it with a new one with a surgery very similar to the first.

The implantation of penile prostheses by expert surgeons reduces the complications associated with the intervention. Dr Puche is currently the coordinator of the Reconstructive Urology Unit at the Virgen de las Nieves Hospital in Granada and has extensive experience in the placement of this type of devices.


1.- Montorsi F, Rigatti P, Carmignani G, et al. AMS three-piece inflatable implants for erectile dysfunction: a long-term multi-institutional study in 200 consecutive patients. Eur Urol. 2000 Jan;37(1):50-5.

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