Penile Implant Options, Who Knew?

Top 5 Things to Know When Choosing a Penile Implant

By Richard A. Santucci MD, FACS, HON FC Urol(SA)

Senior Surgeon, Crane Center for Transgender Surgery (Cranects.com)

Penile prostheses are medical devices placed into the phallus to allow intercourse, by stiffening the phallus enough for “intromission” (that’s “putting it in” lol).  They are made of highest quality medical silicone and are based on designs that have been modified and perfected over the years.

Types of Penile Prostheses

I strongly prefer the use of Coloplast penile prosthesis (I have no financial relationship with that company) because it is designed in a way that makes it ideal for use in transmen after Phalloplasty.  AMS also makes penile prostheses, and these are excellent, but have design features that make them ideal for cismen but less ideal after phalloplasty.

As of right now in the United States only two type of penile prosthesis are available: semirigid and inflatable.  The semirigid device (Coloplast Genesis™) is….rigid.  Its rigid all the time.  It is made up of a firm but flexible rod that can be placed in the “up” position for intercourse or in the “down” position to conceal it during everyday life.  The inflatable device (Coloplast Titan™) is a bit more complicated. It’s made up of three parts: 1) a reservoir of about 3 ounces that is placed under the muscles of your abdomen, which you usually can’t even feel since its hidden deep in your tissues.  2) a pump which is placed in the scrotum and because it is round and “testical-y” serves as one of the testicle prostheses c)a cylinder which goes into the phallus and does the actual stiffening.  The cylinder is only filled/stiffened for intercourse and the rest of the time its soft and unfilled for maximum concealability. 

We recently reported on every scientific report concerning penile prostheses after phalloplasty1 and in that review, 84% of folks chose an inflatable prosthesis and 16% chose a semirigid.

Both devices need to be strongly anchored to the underside of the pubic bone with special unbreakable sutures during surgery.  Most patients will choose to get a testicular prosthesis at the same time as the testicular prosthesis. 

My Top 5 Things to Know:

1. The semirigid prosthesis is considered “simpler” and may be slightly less prone to breakage than the more complicated inflatable prosthesis.  But this effect may not be very important: the total complication over long periods of follow-up comparing one or the other is very similar: 45% for inflatable and 42% for semi rigid1.  On the other hand, it’s possible that the more rigid semirigid device causes more distal erosion, as the hard silicone pushes every day towards the tip of the phallus it may work itself too far onto the phallus and require a surgery to replace it with a new device, sometimes months or years after the initial surgery…  Both devices have their costs and benefits and they are very similar in terms of how risky they are.

2. Placing medical silicone in the body is tricky, and all silicone implants have a certain risk of infection.  The rate of removal of a penile prosthesis in the first year of placement, usually from infection, is sky high (17% published rate).  We have an entire protocol to fight this high rate of infection and have been able to achieve MUCH lower rates of infection than the reported 17%.  SOME of those things are: a) find and treat any bacteria living in the urethra or urinary tract before surgery b) start oral prophylactic antibiotics before surgery and continue them after surgery c) give very strong intravenous antibiotics at the time of surgery, that have been previously scientifically proven to decrease infection d) soak the implants in different high strength antibiotic just before placement. This causes the device to “leach out” the antibiotic the coming days, decreasing infection e)fast and efficient surgery so that the time your wounds are open is less, which is proven to decreases complications f) special sterile prep of the skin just before surgery, using 3 different antimicrobial agents g) and more! 

3. A “semirigid” penile prosthesis really means “rigid….all the time”.  It’s important to know if your lifestyle will allow this. Like to jog? Wear a bathing suit?  Cycle?  A semi rigid prosthesis, causing an “erection for life” may be limiting to you.

4. Small, “surgically” clean surgeries can be done at the same time as the “super sterile” penile prosthesis surgery.  We routinely can safely do glansplasty, or redo glansplasty, penile plication and a few other genital surgeries at the same time.  Small clean surgeries done on other parts of your body (like top revisions) can also generally safely be performed the same day. It may be best to avoid doing surgeries that involve contaminated tissue at the same time as penile prosthesis, like major urethroplasty.  Penile liposuction, often used to decrease the size of phallus, is a NO NO on the same day as penile prosthesis.

5. The job of a penile prosthesis is to stiffen the phallus for purposes of intercourse—and it generally does that very well.  The implant will not greatly change the size, configuration, or much else about your phallus for good or bad.

Dr. Richard Santucci spent the last 18 years as one of the nation’s premier academic reconstructive urologist and now devotes his surgical talents full-time to transgender surgery at the Crane Center in Austin, Texas. Dr. Santucci offers Metoidioplasty, Phalloplasty, Orchiectomy, Vaginoplasty and Vulvoplasty.

Reference

The Rise of the Neophallus: A Systematic Review of Penile Prosthetic Outcomes and Complications in Gender-Affirming Surgery.  Rooker SA, Vyas KS, DiFilippo EC, Nolan IT, Morrison SD, Santucci RA. J Sex Med. 2019 May;16(5):661-672. doi: 10.1016/j.jsxm.2019.03.009. Epub 2019 Apr 5. PMID: 30956105