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Penile Prosthesis Infection — Evolution, Evidence, and Modern Controversies

Inflatable penile prosthesis (IPP) implantation is one of the most patient-satisfying procedures in all of urology, with sustained satisfaction rates above 90% in modern series. Infection remains its most feared complication. An infected device almost always means explantation, cavernosal fibrosis, penile shortening, prolonged morbidity, a return to the operating room, and significant patient distress. Understanding how infection rates have fallen, what continues to drive that decline, and where the current controversies sit is essential for any prosthetic urologist beginning independent practice in 2026.

The contemporary infection rate sits at approximately 1.9% across primary and revision cases combined in the largest modern multicenter cohort to date.[1] Real-world hospital data from a 2025 analysis confirms this range (1.9–3.1%), with most infections occurring within the first six months and a steep gradient by risk profile — patients with three or more risk factors face rates as high as 5.6%.[2] This represents a roughly five-fold improvement over the pre-coating era, when infection rates of 8–15% were typical for primary implantation and 10–18% for revision surgery.

See also: Penile Implants overview, Inflatable Penile Prosthesis (biomaterial), Artificial Urinary Sphincter.

Historical Evolution​

The trajectory of IPP infection over the last fifty years follows three inflection points.

Pre-coating era (1970s–2001)​

First-generation inflatable devices carried infection rates in the 8–11% range, dropping into the 3–5% range by the early 2000s through gradual improvements in perioperative antibiotic protocols, sterile technique, and patient selection.[3] Coagulase-negative Staphylococcus — particularly S. epidermidis — dominated the microbial profile. Infections were framed as failures of sterile technique, a paradigm that would shift substantially with the recognition of biofilm biology.

Antibiotic-coating era (2001–2002)​

The second and most dramatic inflection came with the introduction of antibiotic-impregnated devices.

  • American Medical Systems (now Boston Scientific) released the InhibiZone coating — a factory-applied combination of rifampin and minocycline that elutes locally over 24–72 hours after implantation.[4][5]
  • Mentor (now Coloplast) followed in 2002 with the hydrophilic Titan, which uses a polyvinylpyrrolidone surface that absorbs whatever antibiotic solution the surgeon chooses to dip the device in immediately before placement.[6]

Carson's 2004 manufacturer-database analysis of InhibiZone showed infection reduction from 1.61% (uncoated) to 0.68% (coated) at six months.[4] Wolter and Hellstrom's 2004 Titan data showed reduction from 2.07% to 1.06% at one year.[6] Long-term follow-up out to 7.7 years confirmed the durability of these gains.[5][7]

From 2003 onward, virtually every IPP sold in the United States has been coated, and infection rates dropped by approximately 50% across the field.

No-touch + antifungal era (2015–present)​

The third inflection, more gradual and ongoing, came over the last decade through three convergent forces:

  • Widespread adoption of the no-touch surgical technique
  • Recognition of the biofilm paradigm
  • Emerging understanding that antifungal coverage matters

Modern infection rates in high-volume implanter series now hover around 1%, with Eid's published no-touch series reporting rates as low as 0.46%.[8]

The Microbial Landscape Shift​

The success of antibiotic coatings has paradoxically created a new problem. By largely eliminating infections from indolent gram-positive organisms — particularly coagulase-negative Staphylococcus — coatings have left behind a residual infection population dominated by more virulent and harder-to-cover organisms.

Gross and colleagues' 2017 multicenter analysis of penile prosthesis cultures was a landmark in this recognition:[9]

  • MRSA accounts for approximately 10% of contemporary IPP infections
  • Gram-negative organisms have become more prominent
  • Fungi — predominantly Candida albicans and C. glabrata — now account for up to 11% of infections

A subsequent dedicated review of fungal IPP infections found that 83% occur in diabetic or obese patients.[10]

This shift has significant implications for prophylaxis. The antibiotic regimens recommended by guidelines extrapolated from orthopedic and general surgery literature — which targeted the older microbial spectrum — are increasingly mismatched to the bugs that now actually cause IPP infections.

Drivers of Decline (Ranked by Impact)​

Five major factors have driven the decline, in roughly the following order of impact:

1. Antibiotic-coated devices​

The single largest gain. The roughly 50% relative reduction associated with both InhibiZone and hydrophilic Titan dipping protocols is durable and reproducible across multiple series.

2. The no-touch technique​

Developed by J. François Eid, this uses an adhesive barrier drape after skin preparation to ensure that neither the surgeon's gloves nor the implant ever contacts the patient's skin during placement. Combined with separate gloves and instruments for skin and device-handling phases, frequent glove changes, and minimization of operative time and OR traffic, this protocol has produced the lowest published infection rates in the field (0.46%).[8]

3. Modern skin antisepsis​

2% chlorhexidine gluconate in 70% isopropyl alcohol (ChloraPrep) replacing povidone-iodine offers faster bactericidal onset and longer residual activity. A 2025 prospective cohort study using ChloraPrep skin preparation combined with fibrin sealant hemostasis and no drain placement reported zero infections in 103 primary IPP cases compared with 3.5% in historical povidone-iodine controls.[11]

4. Patient optimization​

  • Glycemic control — HbA1c targets generally below 8.5% (no validated cutoff exists)
  • MRSA nasal screening and decolonization with mupirocin and chlorhexidine body washes for known carriers
  • Smoking cessation for at least four weeks preoperatively

Diabetes is associated with approximately 1.7-fold increased infection risk in multivariable analysis.[1]

5. Center-of-excellence effect​

Real and consistent — high-volume implanters outperform lower-volume operators across virtually every metric, including infection rate. This is one of the most important factors a patient can ask about when selecting a surgeon.

6. Antibiotic stewardship​

Specifically, the recognition that single-dose perioperative prophylaxis is sufficient and that extended IV courses or postoperative oral antibiotics provide no benefit — the most recent refinement, supported by 2025 PUMP collaborative data.[1]

The AUA Guideline Controversy​

The American Urological Association published its Best Practice Statement on Urologic Procedures and Antimicrobial Prophylaxis in 2008, with subsequent updates in 2019 and 2020.[12] For prosthetic cases, including IPP placement, the recommendation has been an aminoglycoside (typically gentamicin) plus either vancomycin or a first- or second-generation cephalosporin.

These recommendations were extrapolated from orthopedic and general surgery literature because, at the time of original publication, no IPP-specific prosthetic urology data existed to guide the choice.

Practice adoption​

Brant and colleagues' national cohort analysis showed a 42% relative increase in adoption of vancomycin-plus-gentamicin regimens following the 2008 publication.[13] Vancomycin plus gentamicin became the dominant regimen across U.S. prosthetic urology practice — despite no level-1 evidence supporting it for IPP surgery specifically.

The PUMP reassessment​

In 2021, the Prosthetic Urology Multi-Institutional Partnership (PUMP) was formed across 18 institutions in North America, Europe, and Korea. It has produced the most consequential challenge to the AUA recommendation to date.

Barham et al., 2023 (J Urol, 4,161 primary IPP cases) delivered the central finding: vancomycin plus gentamicin alone was associated with a 2.7-fold higher infection risk than nonstandard regimens (HR 2.7, 95% CI 1.4–5.4, p=0.004).[14]

Abou Chawareb et al., 2025 (5,261 patients across 16 centers) confirmed and extended these findings:[1]

  • IV antifungal use was independently associated with significantly lower infection risk (OR 0.22, p<0.001)
  • Postoperative oral antibiotics and prolonged IV antibiotic prophylaxis beyond 24 hours showed no protective effect
  • Diabetes (OR 1.68) and prior IPP infection (OR 4.67) remained the dominant patient-level risk factors

A parallel multicenter investigation focused specifically on diabetic patients showed similar findings: AUA-adherent prophylaxis resulted in 5.6% infection rates compared with 1.9% for nonstandard regimens.[15] Effective nonstandard alternatives included vancomycin-gentamicin-fluoroquinolone, clindamycin-fluoroquinolone, and vancomycin-fluoroquinolone combinations.

The AUA Best Practice Statement has not yet been updated to reflect this body of evidence. The 2025 Sexual Medicine Reviews publication from the 5th International Consultation on Sexual Medicine offers the most current expert-consensus document and serves as the modern counterpoint to the AUA BPS.[16]

Antifungal Prophylaxis — the Strongest Modifiable Signal​

The 92% reduction in infection risk associated with adding an antifungal to antibacterial coverage in the 2023 PUMP analysis is the strongest single signal in the modern IPP infection literature.[14] The 2025 follow-up study reproduced this finding (OR 0.22 for IV antifungal use).[1]

A systematic review focused specifically on antifungal prophylaxis concluded that fungal infections represent a significant proportion of contemporary IPP infections and that antifungal prophylaxis is warranted.[17] A comprehensive 2024 review supports routine antifungal use, particularly in high-risk populations.[10]

Fluconazole 400 mg IV given preoperatively is the most commonly used regimen. Amphotericin B serves as an alternative, particularly when non-albicans Candida coverage is a concern.

Adoption patterns​

A 2025 multicenter survey of SMSNA, SUPS, and GURS members found antifungal use in:[18]

  • 25.9% of primary cases
  • 72.3% of diabetic cases
  • 65.2% of salvage cases
  • 48.2% of revision cases

Recent bench data confirm that adding antifungal agents to dipping solutions does not compromise antibacterial efficacy on hydrophilic surfaces.[19]

The Modern Antibiotic Regimen​

There is no universally agreed best regimen, and the PUMP investigators have been explicit that no randomized controlled trial has identified one — establishing the optimal regimen would require thousands of patients. The most defensible contemporary approach involves five principles:

Principle 1 — Tailor to your local antibiogram​

When the PUMP investigators applied this principle to three surgeons at three different institutions, they found three different ideal regimens. Pulling your institution's Candida and gram-negative resistance data should be a first step in any new practice.

Principle 2 — Cover MRSA, gram-negatives broadly, and Candida​

A reasonable contemporary regimen:

AgentCoverage
VancomycinMRSA + gram-positive
Gram-negative agent*Gram-negatives
Fluconazole 400 mg IVCandida

*Gram-negative options: gentamicin, piperacillin-tazobactam, or ceftriaxone — depending on local sensitivity patterns. The Gross group's adopted regimen is vancomycin + piperacillin-tazobactam + fluconazole.[10]

Principle 3 — Single perioperative dose, stopped within 24 hours​

2025 PUMP data show no benefit to extended IV courses or postoperative oral antibiotics.[1] This aligns with broader antimicrobial stewardship principles and avoids unnecessary contribution to resistance and microbiome disruption.

Principle 4 — Timing within 60 minutes of incision​

For cefazolin or cephalosporin-based regimens. Vancomycin requires longer infusion and should be started earlier.

Principle 5 — Skip routine postoperative oral antibiotics​

Multiple studies have now confirmed that this practice provides no protective benefit and may actively promote antimicrobial resistance and gut microbiome disruption.[1][20]

Dipping Solutions — Device-Specific​

The choice of dipping or irrigation solution is fundamentally device-specific.

AMS 700 InhibiZone​

The manufacturer's instructions for use prohibit dipping in any antibiotic solution because the rifampin-minocycline coating is applied during manufacture and dipping strips it off. The factory-applied elution is the entire mechanism of the device's intrinsic infection protection, and adding solution would undermine it.

Surgeons should restrict themselves to copious irrigation of the surgical field around the device with:

  • Sterile saline
  • Antibiotic-fortified saline (vancomycin and gentamicin)
  • Or — based on bench compatibility data — 0.05% chlorhexidine gluconate (see Irrisept discussion below)

Coloplast Titan (hydrophilic)​

Dipping for at least 30 seconds immediately before placement is essential. The most-evidenced cocktail, supported by Towe et al.'s 2020 head-to-head analysis in diabetic patients, is vancomycin 1 g/L plus gentamicin 80–160 mg/L.[21] This combination produced significantly lower infection rates (1.4%) compared with:

  • Rifampin-gentamicin
  • Bacitracin-polymyxin-gentamicin
  • Trimethoprim-sulfamethoxazole-gentamicin

(up to 6.4% infection rate in the diabetic primary-implant subgroup).

Antifungal agents — fluconazole or amphotericin B — can be added to the dipping solution in high-risk patients without compromising antibacterial activity.[19]

Irrigation — What NOT to Use​

Several solutions historically used in IPP surgery should now be avoided in the wound:

Povidone-iodine (Betadine) wound irrigation​

Associated with markedly increased infection rates. Manka et al.'s case-control study found a 9 to 16.9-fold increased infection risk with 5% betadine irrigation compared with antibiotic-fortified saline.[22] Povidone-iodine remains appropriate for skin preparation but should not be used as wound irrigation.

Hydrogen peroxide​

Despite its historical inclusion in the original Mulcahy salvage washout protocol, now generally avoided due to:

  • Documented tissue cytotoxicity
  • Impaired wound healing
  • Well-recognized risk of corporal air embolism[22]

Bacitracin-polymyxin and TMP-SMX-gentamicin combinations​

As primary dipping solutions, shown inferior to vancomycin-gentamicin in head-to-head analysis on hydrophilic devices.[21]

0.05% chlorhexidine gluconate (Irrisept) on hydrophilic devices​

The most important new addition to this list — discussed in detail below.

Irrisept — Introduction and Mechanism​

Irrisept is a self-pressurized lavage bottle containing 0.05% chlorhexidine gluconate in sterile water. It is FDA-cleared as an antimicrobial wound irrigation device. It first gained traction in orthopedic and breast reconstructive surgery and migrated into prosthetic urology over the last five years.

The proposed advantages of CHG irrigation in IPP surgery are mechanistically appealing:

  • The cationic CHG molecule binds to anionic components of microbial cell walls, disrupting membrane integrity and causing rapid cell death across a broad spectrum — gram-positive bacteria, gram-negatives, anaerobes, fungi (including Candida), and enveloped viruses[23]
  • The mechanical jet lavage adds physical biofilm disruption
  • Low tissue toxicity
  • Not absorbed systemically in clinically meaningful amounts
  • Does not promote antibiotic resistance — an attractive profile in an era of antimicrobial stewardship

Irrisept Evidence — InhibiZone (AMS) Devices​

Broadly favorable.

  • Karpman & Griggs 2023 (in vitro) — effective microbial reduction across the modern IPP infection spectrum, including aerobes, anaerobes, and fungi.[23]
  • Lim et al. 2024 (bench study) — confirmed that the InhibiZone surface retains its antimicrobial activity following exposure to 0.05% CHG; the coating is not stripped or degraded.[24]
  • Razdan et al. (small salvage series, 4 corporal Irrisept washout cases) — zero infections. Hypothesis-generating only.[25]

Ivan et al. 2026 (J Sex Med, 761 InhibiZone IPP cases) — the most important dataset to date — found no difference in infection rates between 0.05% CHG and conventional antibiotic irrigation (1.9% vs 2.0%, p=0.9).[26] This is the largest real-world data set to date examining CHG with InhibiZone devices, and it supports continued use of 0.05% CHG as wound and field irrigation in this device category.

Irrisept Evidence — Hydrophilic Titan Devices: The 2026 Pivot​

The data for 0.05% CHG with hydrophilic Coloplast Titan devices tells a fundamentally different story, and represents the most important recent shift in IPP infection prevention practice.

Ivan et al. 2026 (J Urol, 2,150 hydrophilic IPP cases) found that 0.05% CHG use was associated with significantly higher infection rates compared with antibiotic-only irrigation:[27]

SubgroupCHGAntibiotic-only
Overall hydrophilic IPP4.6%2.1% (p<0.05)
Revision surgery12%—

The conclusion was clear: caution with 0.05% CHG use is warranted in hydrophilic IPP surgery pending prospective evaluation.

This finding is corroborated by two complementary studies:

  • Helo et al. 2025 (J Sex Med) identified CHG application, diabetes, revision surgery, and extended operative time as independent risk factors for IPP infection — a stack of compounding risks that should give pause whenever multiple are present.[28]
  • Simhal et al. 2024 (in vitro) provides the mechanistic explanation: vancomycin-gentamicin dipping confers approximately 5.5 log microbial reduction on hydrophilic surfaces, while 0.05% CHG alone provides only approximately 1.5 log reduction.[29]

Why the Device-Specific Difference?​

The two coating chemistries respond completely differently to CHG irrigation.

InhibiZone​

Uses rifampin and minocycline covalently bonded to the silicone surface during manufacture. CHG irrigation does not chemically displace these antibiotics, and bench studies confirm that InhibiZone retains its kill activity after CHG exposure.

The net effect on an InhibiZone device is additive: CHG adds biofilm disruption and broad-spectrum coverage without degrading the device's intrinsic protection.

Hydrophilic Titan​

The antibiotic protection on a Titan comes entirely from the surgeon-applied dip absorbed by the polyvinylpyrrolidone coating. CHG appears to displace these bound antibiotics from the hydrophilic surface, washing off the protective layer the surgeon worked to apply.

The net effect on a Titan is subtractive: CHG removes the most important defensive layer of the device. The Simhal in-vitro data quantify this — 5.5 log reduction with the antibiotic dip vs 1.5 log with CHG alone.[29]

Practical implication: for hydrophilic Titan devices, avoid 0.05% CHG irrigation pending prospective randomized data, particularly in revision and salvage cases where infection risk is already elevated.

Revision and Salvage​

Revision and salvage surgery carry substantially higher infection risk than primary implantation. Historical revision infection rates reached 10–13%, though modern washout-protocol revisions have brought this down to approximately 3% in experienced hands. Prior IPP infection is the single largest patient-level risk factor for subsequent infection (OR ~4.7).[1]

Modified-Mulcahy salvage washout protocol​

  1. Explant all components
  2. Sequential antiseptic washes (avoid hydrogen peroxide and excess betadine in modern practice)
  3. Change all gloves and instruments
  4. Re-prep and re-drape the field
  5. Replace with a new antibiotic-coated implant

Contemporary considerations (2026)​

  • Capsule and pseudocapsule cultures sent routinely (with next-generation sequencing where available)
  • Fresh antibiotic-coated device used even in presumed non-infectious revisions
  • Antifungal coverage added routinely in salvage and revision settings
  • 0.05% CHG specifically avoided in revisions involving hydrophilic devices, given the 12% infection rate observed in this subgroup in the Ivan 2026 cohort[27]

Practical Synthesis — What to Do in 2026​

Preoperatively​

  • MRSA screening with mupirocin and chlorhexidine decolonization in carriers
  • Glycemic control (HbA1c target generally <8.5%)
  • Smoking cessation ≥4 weeks
  • ChloraPrep skin antisepsis

Perioperative antibiotics​

  • Vancomycin + gram-negative agent (per local antibiogram) + fluconazole 400 mg IV
  • Single dose, stopped within 24 hours
  • Skip postoperative oral antibiotics

Device selection​

  • Always include an antibiotic coating
  • InhibiZone — do not dip
  • Titan — dip vancomycin 1 g/L + gentamicin 80 mg/L for ≥30 sec, add antifungal in high-risk patients

Surgical technique​

  • No-touch barrier drape protocol
  • Frequent glove changes
  • Minimize OR traffic and operative time
  • Copious antibiotic-saline irrigation throughout

Irrisept use — device-specific​

DeviceCHG (Irrisept)
AMS 700 InhibiZoneAppears safe
Coloplast Titan (hydrophilic)Avoid based on 2026 data
Revision of hydrophilic IPPEspecially avoid (12% infection signal)

Use vancomycin-gentamicin-fortified saline irrigation for hydrophilic cases instead.

Postoperatively​

  • Avoid prolonged IV antibiotics
  • Skip routine oral antibiotics
  • Build your own personal infection registry from day one — the PUMP investigators generated the data that is now reshaping the field by tracking their own outcomes. You can do the same.

Future Directions​

  • The AUA Best Practice Statement is overdue for revision given the body of evidence directly contradicting current recommendations
  • NCT06489431 — Irrisept vs traditional antibiotic irrigation for virgin penile prosthesis placement, active Phase III RCT at Rush University; readout 2026–2027
  • Optimal antifungal strategy (universal vs risk-targeted) remains debated, with stewardship concerns about Candida resistance pushing back against the strong PUMP signal favoring routine use
  • Next-generation sequencing of biofilms is revealing distinct microbiome signatures that may eventually enable individualized salvage protocols
  • Surface engineering beyond antibiotics — anti-adhesion coatings, silver, hydrogels, quorum-sensing inhibitors — represents the likely next leap. The next major gain in IPP infection reduction may not be antimicrobial; it may be anti-biofilm.

Bottom Line​

Penile prosthesis infection rates have fallen from 8–15% in the 1970s to approximately 1% in modern primary cases, driven principally by antibiotic-coated devices, the no-touch surgical technique, modern skin antisepsis, patient optimization, and high-volume implantation.

The microbial landscape has shifted toward MRSA, gram-negatives, and fungi — a shift that has rendered the AUA-recommended vancomycin-plus-gentamicin regimen not merely outdated but actively associated with higher infection risk than nonstandard alternatives.

Antifungal prophylaxis is the single largest modifiable signal in the contemporary IPP infection literature, with a 92% reduction in infection risk in the largest multicenter analysis.

Irrisept is device-specific: safe and likely beneficial with InhibiZone-coated AMS devices, but harmful with hydrophilic Coloplast Titan devices because it displaces the surgeon-applied antibiotic dip.

Tailoring everything to local antibiogram data and building a personal infection registry remain the most important things any prosthetic urologist can do in 2026.

References​

1. Abou Chawareb E, Hammad MAM, Azad B, et al. Perioperative Antimicrobial Strategies in Inflatable Penile Prosthesis Surgery: Associations Between Antifungals, Oral Antibiotics, and Intravenous Antibiotic Duration, and Infection Outcomes. J Urol. 2025;214(6):642–653. doi:10.1097/JU.0000000000004716

2. Brant W, Sato R, Rojanasarot S, et al. Infection Rates and Risk Factors Following Inflatable Penile Prosthetic Implantation: An Analysis of Real-World Hospital Data. J Sex Med. 2025;22:qdaf224. doi:10.1093/jsxmed/qdaf224

3. Wilson SK, Costerton JW. Biofilm and Penile Prosthesis Infections in the Era of Coated Implants: A Review. J Sex Med. 2012;9(1):44–53. doi:10.1111/j.1743-6109.2011.02428.x

4. Carson CC. Efficacy of Antibiotic Impregnation of Inflatable Penile Prostheses in Decreasing Infection in Original Implants. J Urol. 2004;171(4):1611–1614. doi:10.1097/01.ju.0000118245.66976.e1

5. Carson CC III, Mulcahy JJ, Harsch MR. Long-Term Infection Outcomes After Original Antibiotic Impregnated Inflatable Penile Prosthesis Implants: Up to 7.7 Years of Follow-Up. J Urol. 2011;185(2):614–618. doi:10.1016/j.juro.2010.09.094

6. Wolter CE, Hellstrom WJG. The Hydrophilic-Coated Inflatable Penile Prosthesis: 1-Year Experience. J Sex Med. 2004;1(2):221–224. doi:10.1111/j.1743-6109.2004.04032.x

7. Serefoglu EC, Mandava SH, Gokce A, et al. Long-Term Revision Rate Due to Infection in Hydrophilic-Coated Inflatable Penile Prostheses: 11-Year Follow-Up. J Sex Med. 2012;9(8):2182–2186. doi:10.1111/j.1743-6109.2012.02830.x

8. Eid JF. Penile Implant: Review of a "No-Touch" Technique. Sex Med Rev. 2016;4(3):294–300. doi:10.1016/j.sxmr.2016.01.002

9. Gross MS, Phillips EA, Carrasquillo RJ, et al. Multicenter Investigation of the Micro-organisms Involved in Penile Prosthesis Infection: An Analysis of the Efficacy of the AUA and EAU Guidelines for Penile Prosthesis Prophylaxis. J Sex Med. 2017;14(3):455–463. doi:10.1016/j.jsxm.2017.01.007

10. Natsos A, Tatanis V, Lekkou A, et al. Unveiling the Hidden Perils: A Comprehensive Review of Fungal Infections in Inflatable Penile Prosthesis Surgery. J Pers Med. 2024;14(6):644. doi:10.3390/jpm14060644

11. Fathollahi A, Razdan S, Razdan S. Zero Infection Protocol in Inflatable Penile Prosthesis Surgery: A Prospective Cohort Study Using Chlorhexidine-Alcohol Skin Preparation and Fibrin Sealant Hemostasis. Int J Impot Res. 2025. doi:10.1038/s41443-025-01174-8

12. Lightner DJ, Wymer K, Sanchez J, Kavoussi L. Best Practice Statement on Urologic Procedures and Antimicrobial Prophylaxis. J Urol. 2020;203(2):351–356. doi:10.1097/JU.0000000000000509

13. Brant A, Lewicki P, Punjani N, et al. Trends in Antimicrobial Prophylaxis for Inflatable Penile Prosthesis Surgery From a Large National Cohort. Urology. 2023;172:131–137. doi:10.1016/j.urology.2022.11.010

14. Barham DW, Pyrgidis N, Gross MS, et al. AUA-recommended Antibiotic Prophylaxis for Primary Penile Implantation Results in a Higher, Not Lower, Risk for Postoperative Infection: A Multicenter Analysis. J Urol. 2023;209(2):399–409. doi:10.1097/JU.0000000000003071

15. Rezaee ME, Towe M, Osman MM, et al. A Multicenter Investigation Examining American Urological Association Recommended Antibiotic Prophylaxis vs Nonstandard Prophylaxis in Preventing Device Infections in Penile Prosthesis Surgery in Diabetic Patients. J Urol. 2020;204(5):969–975. doi:10.1097/JU.0000000000001158

16. Köhler T, Munarriz R, Parker J, et al. Penile Prosthesis for Erectile Dysfunction: Recommendations from the 5th International Consultation on Sexual Medicine. Sex Med Rev. 2025;13(2):144–171. doi:10.1093/sxmrev/qeaf001

17. Zheng AS, Foley S, Nair R, Acher P. Is There a Role for Antifungal Prophylaxis in Patients Undergoing Penile Prosthesis Surgery? A Systematic Review. J Sex Med. 2022;19(5):842–849.

18. Abou Chawareb E, Barham DW, Hammad MAM, et al. Multicenter Examination of Contemporary Penile Prosthesis Surgery Infection Prophylaxis Practices. J Sex Med. 2025;22(8):1531–1533. doi:10.1093/jsxmed/qdaf145

19. Im B, Giordano A, Winslow A, Hickok N, Chung P. Addition of Antifungal Agents to Antibiotic Solutions Does Not Diminish the Antibacterial Properties of Penile Prosthesis Hydrophilic Surface Dips. J Sex Med. 2026;23(2). doi:10.1093/jsxmed/qdaf372

20. Dropkin BM, Chisholm LP, Dallmer JD, et al. Penile Prosthesis Insertion in the Era of Antibiotic Stewardship — Are Postoperative Antibiotics Necessary? J Urol. 2020;203(3):611–614. doi:10.1097/JU.0000000000000578

21. Towe M, Huynh LM, Osman MM, et al. Impact of Antimicrobial Dipping Solutions on Postoperative Infection Rates in Patients With Diabetes Undergoing Primary Insertion of a Coloplast Titan Inflatable Penile Prosthesis. J Sex Med. 2020;17(10):2077–2083. doi:10.1016/j.jsxm.2020.07.009

22. Bole R, Habashy E, Yang D, et al. Timing and Causative Organisms Associated With Modern Inflatable Penile Prosthesis Infection: An Institutional Retrospective. J Sex Med. 2023;20(1):107–112. doi:10.1093/jsxmed/qdac001

23. Karpman E, Griggs R, Twomey C, Henry GD. Dipping Titan Implants in Irrisept Solution (0.05% Chlorhexidine Gluconate) and Exposure to Various Aerobic, Anaerobic, and Fungal Species. J Sex Med. 2023;20(7):1025–1031. doi:10.1093/jsxmed/qdad055

24. Lim R, Liang J, Bole R, et al. Minocycline-Rifampin-Impregnated Penile Prosthesis Surfaces Retain Antimicrobial Activity Following Irrigation With 0.05% Chlorhexidine Gluconate and Antibiotic Solutions. J Sex Med. 2024.

25. Razdan S, Siegal AR, Celtik KE, Carrion R, Valenzuela RJ. Three-Piece Penile Prosthesis Salvage With Chlorhexidine Gluconate and Length Preservation: Our Technique and Outcomes. Asian J Androl. 2026;28(1):9–15.

26. Ivan SJ, Abou Chawareb E, Hammad M, et al. 0.05% Chlorhexidine Gluconate Is Not Associated With Infection in Antibiotic Impregnated Inflatable Penile Prosthesis Surgery: Results From a Large Multi-Institutional Collaborative. J Sex Med. 2026;23(1):qdaf368. doi:10.1093/jsxmed/qdaf368

27. Ivan SJ, Abou Chawareb E, Hammad M, et al. Intraoperative 0.05% Chlorhexidine Gluconate Utilization Is Associated With an Increased Incidence of Infection in Hydrophilic Inflatable Penile Prosthesis Surgery: A Multi-Institutional Cohort Study. J Urol. 2026;215(4):460–471. doi:10.1097/JU.0000000000004853

28. Helo S, Bonakdar Hashemi M, Ziegelmann MJ, et al. Chlorhexidine Gluconate Application, Diabetes, Revision Surgery, and Extended Operative Time Increase Risk for Penile Implant Infection. J Sex Med. 2025;22:508–516. doi:10.1093/jsxmed/qdaf009

29. Simhal R, Im BH, Shah S, et al. Antibiotic Dip and Irrigation Solutions Confer Increased Antimicrobial Efficacy of Inflatable Penile Prosthesis Hydrophilic Surfaces Compared With 0.05% Chlorhexidine Gluconate. J Sex Med. 2024;21(9):816–822. doi:10.1093/jsxmed/qdae073