Erectile dysfunction (ED) is the inability to attain and/or maintain an erection sufficient for sexual intercourse. Fifty percent of men aged 40–70 years will be affected by ED. This may result in a significant deterioration in their quality of life and relationships. It is often associated with conditions affecting vascular circulation such as diabetes mellitus, hyperlipidaemia, smoking, obesity and hypertension. However, it may also be due to conditions affecting nerve innervation (pelvic surgery) or smooth muscle. Montorsi et al. provided the first significant evidence linking ED with cardiovascular disease [1]. In their landmark paper, 50% with acute chest pain and proven coronary artery disease also reported ED. Subsequent studies have strengthened their findings and ED should now be considered to precede a cardiovascular event by 3–5 years [2–5]. The reduction of risk factors associated with vascular disease may improve erectile function [6]. The second large group of men who will experience ED are those undergoing pelvic surgery; this group is increasing in numbers every year.

The treatment of ED consists of medical and surgical therapies. The medical treatment of ED was revolutionised in the 1990s with the development and marketing of Sildenafil which was the first phosphodiesterase-5 inhibitors (PDE5i) . This group of drugs has an estimated efficacy of 60% [7]. Second line treatment includes intracavernosal or intraurethral alprostadil and vacuum devices. Men who fail or do not tolerate medical therapies should be offered the insertion of a penile prosthesis (PP) . Prostheses have undergone a variety of innovations since they were first described in 1936 [8]. The 1973 hydraulic silicon prosthesis developed by Scott forms the basis of the modern day PP [8]. The modern day PP has a satisfaction rate of over 80% with complication rates of less than 10% [9–16]. Penile prosthesis implantation results in a significantly higher satisfaction and sexual frequency when compared with Sildenafil, vacuum device and injection therapy [17].

There are currently three types of penile prosthesis available which are manufactured by American Medical Systems (AMS) Boston Scientific and Coloplast. The prosthesis available may be classified as (Table 13.1):

This is vitally important and ideally should take place in a dedicated clinic. Patients’ and their partners’ expectations must be managed to ensure they are aware that the implant will only produce rigidity to enable penetrative sexual intercourse but will not increase penile length and should be considered irreversible. It is therefore important that all other options have been attempted and failed prior to proceeding to PP. The different types of PP are demonstrated and the patient is offered the opportunity to discuss the procedure with a patient who has already had a PP implanted. The session is also useful for the clinician as an opportunity to assess:

These factors will enable the clinician to individualise the type of implant chosen. Patients must be counselled about all the potential risks associated with the procedure.

All patients are reviewed pre-operatively in the Pre-assessment clinic where routine investigations are performed and in high risk patients, a review by a consultant anaesthetist is undertaken. Men with diabetes are optimised to reduce their risk of post-operative infections. In rare circumstances the procedure may be performed under a local anaesthetic (Table 13.2).