Maintaining penile size following penile implant

Insertion of a penile prosthetic implant (PPI) is typically reserved as the last line of treatment for drug-refractory erectile dysfunction (ED). Loss of penile length as a result of penile prosthesis placement is the most common postoperative patient complaint shown to reduce overall satisfaction with the procedure. There are several reasons for this

Objective loss of penile size

Conditions causing tunical scarring (Peyronie’s disease)

Corporal fibrosis or loss of cavernous smooth muscle (ischemic priapism, previous radical prostatectomy)

Subjective loss of penile size

Increased prepubic fat distributionLoss of glanular engorgement

Long history of ED with inaccurate recollection of erect penile size

Firstly, the pathology behind the severe ED such as Peyronie’s disease, neglected ischemic priapism, loss of cavernosal smooth muscle and previous radical prostatectomy may have resulted in tunical scarring or fibrosis that severely limits the elasticity of the tunica albuginea. While not apparent in a flaccid penis, it becomes obvious after a PPI has been inserted and inflated.

Secondly, many patients who underwent PPI insertion may have a history of ED lasting many months or years. This could affect the accuracy of their recollection of what their penile sizes were prior to the onset of their condition.

Thirdly, an inflated PPI fills up only the corporal bodies of the penis and has no impact on glanular engorgement, which is a physiological phenomenon in normal erections. This lack of glanular swelling may contribute to the perception of decreased penile size.

Fourthly, men who require PPI are usually in the older age group. As a man ages or puts on weight, the fat in the prepubic region has a tendency to increase and engulf the penile shaft. This phenomenon of a partially “buried penis” may affect the patient’s perception of penile length after PPI.

As with other sexual dysfunction therapies, the outcome of PPI surgery are largely dependent on patient and partner satisfaction. Most frequent implanters will realize that perceived inadequacy of penile size, be it penile girth or penile length, are practical issues that need to be addressed in clinical practice, and may be best suited for a full discussion pre-operatively, to set realistic expectations.

Patient’s perception of decreased penile size after PPI can negatively influence overall satisfaction and sexual quality of life measures. Strategies to preserve and potentially increase penile size are of great importance to all implanters. The strategies in this review target 3 stages of patient care; pre-insertion, intraoperative and post-insertion. Besides traction therapies and surgeries to enhance perceived penile size, refinements in the surgical approach to allow greater conservation of cavernosal smooth muscle and optimal sizing of the implant cylinders are simple ways to optimize penile length. A direct comparison of treatment outcomes evaluating the various approaches is not currently possible, owing to divergent study techniques across the small numbers of small studies with limited reported measures. The implanting surgeon can best serve his patient by adopting a combination of different strategies that are individualized and specific to the patient’s needs.

We are hopeful that advancements in stem cell technology may one day allow surgeons to pre-operatively increase cavernosal smooth muscle content and improve tunica albuginea elasticity, which are the bane of contemporary penile shortening after PPI.