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Preoperative Evaluation for Penile Prosthesis Implantation

Penile implants have among the highest satisfaction rates of any treatment for erectile dysfunction, and those rates depend on patient selection and on expectations set before the first incision. Implanting the wrong patient is the most avoidable error in prosthetic urology.[1][2]

The Decision to Implant​

Penile implantation is an option after shared decision-making, including for men who prefer it without first trying less invasive treatments. Discuss PDE5 inhibitors, intraurethral alprostadil, vacuum erection devices, intracavernosal injections, and prostheses according to the patient's goals.[1][3] Three pathways in which early implantation is reasonable are:

  • Peyronie's disease with medically refractory ED or high risk of postoperative ED. The prosthesis treats ED; assess residual deformity after cylinder placement and add modeling, plication, or grafting when needed.[37]
  • Corporal fibrosis. Ischemic priapism, prior infection or prior prosthesis explantation can make dilation harder. AUA/SMSNA permits considering a prosthesis for untreated acute ischemic priapism >36 hours or failure of shunting, with or without tunneling . If an erection persists after shunting, confirm persistent ischemia with corporal blood gas or color duplex Doppler before another operation . Early placement may limit fibrosis-associated shortening; discuss its risks and benefits against delayed placement .[24]
  • Patient preference for a definitive, on-demand solution. This is a valid indication when the patient has been adequately counseled, even if they have not formally "failed" medical therapy

See penile-implants index for the indication list.

Patient Selection: the CURSED Framework​

The CURSED Patient mnemonic was proposed by Trost, Baum and Hellstrom, from a review of the urologic and cosmetic-surgery literature, to identify seven traits that may indicate a psychologically challenging patient at increased risk of postoperative dissatisfaction: Compulsive/obsessive, Unrealistic, Revision, Surgeon shopping, Entitled, Denial and Psychiatric. Denial and psychiatric disorder are two separate traits in the original formulation, not one combined trait.[4]

LetterTraitWhat it looks like in clinic
CCompulsive / obsessiveRepetitive preoccupation with minor perceived changes in penile anatomy, sensation, or function that interferes with daily activities
UUnrealistic expectationsAssumes an implant restores natural erections or guarantees greater length, sensation, or orgasm; it supplies rigidity.[4][44]
RRevision / previously operated elsewhereExplanted or revised at another institution; seeking a different outcome from a different surgeon
SSurgeon shoppingRepeated consultations with a fixed list of desired outcomes, marked praise of a new surgeon, or quick criticism after an undesired result
EEntitled / demandingInterrupts, dismisses nurses and support staff, makes demands about the perioperative experience
DDenialDenial of prior erectile function or current disease status
PPsychiatric disorderUntreated major depression, body dysmorphic disorder, or active psychiatric decompensation

None of these is an absolute contraindication. Each warrants additional counseling time and documentation. When several traits cluster, a deferred decision or referral to another surgeon is considered. Unrealistic expectations and revision surgery are among the traits Trost and colleagues list as indicating higher risk of dissatisfaction, and a mixed-method study of 47 men found that 79% were satisfied with their implant.[4][5]

The partner conversation​

Older selected three-piece IPP series summarized by Trost and Bernal reported partner satisfaction of 91–95%; a later meta-analysis of 39 studies and 4,381 female partners estimated pooled satisfaction at 76% (95% CI 74–77; I² 90.24%).[4][6][45] Partner dissatisfaction is a recognized determinant of patient dissatisfaction.[4][6][45] Where possible, the partner attends at least one preoperative visit, handles the demonstration device and takes part in the consent discussion. In a 2019 retrospective comparison of 883 men (349 malleable, 26 two-piece and 508 three-piece implants; mean follow-up 68 months), couples' satisfaction was significantly higher with three-piece than with malleable devices, with no difference by brand; 27 malleable recipients (7.7%) later switched to a three-piece device because of dissatisfaction, versus 1 (0.2%) switch in the other direction.[20]

Medical Optimization​

Diabetes​

Diabetes is the most extensively studied modifiable risk factor for prosthesis infection. In a multicenter retrospective cohort of 5,261 patients, diabetes was an independent risk factor (OR 1.68).[7] Infection rates rose with HbA1c in a prospective multicenter cohort of 902 implants (1.3% below 6.5% and 22.4% above 9.5%), where an HbA1c of 8.5% predicted infection with 80% sensitivity and 65% specificity.[12] A 2026 meta-analysis, primarily of retrospective studies, found infection rates more than twice as high in studies with mean HbA1c of 8% or higher (9.1% vs 3.8%).[13] No randomized trial has validated a cutoff. Common practice:

  • HbA1c <8.5% was a proposed infection-risk threshold in Habous 2018, whose cohort was predominantly malleable implants.[12]
  • HbA1c <7% is the ADA's general goal for many nonpregnant adults when achievable without severe hypoglycemia or hypoglycemia affecting health or quality of life (6.3a, grade A).[31]
  • For adults with diabetes undergoing elective surgery, the Endocrine Society conditionally suggests HbA1c <8% when feasible and blood glucose 100–180 mg/dL 1–4 hours before surgery; when that HbA1c target is infeasible, the glucose target still applies.[34]
  • Hold SGLT2 inhibitors before scheduled surgery to reduce perioperative ketoacidosis risk: stop canagliflozin, dapagliflozin, and empagliflozin at least 3 days before surgery, and ertugliflozin at least 4 days before surgery.[36]

Fructosamine (2–3 week glycemic average) can be used as an adjunct in patients with hemoglobinopathies or when a more recent glycemic snapshot is needed.

Obesity and metabolic syndrome​

Obesity increases operative difficulty (deeper scrotum, harder reservoir access). In the 26-case fungal infection series cited by the review, 18/26 (69%) had diabetes and 22/26 (85%) were overweight or obese.[8][46] BMI >30 warrants additional counseling on technical difficulty and infection risk. A retrospective claims cohort of 18,475 IPP recipients reported three-year coded infection in 5.2% of those with recorded obesity versus 3.0% with no identified risk factors (univariate HR 1.76, 95% CI 1.28–2.43).[47] In a revision candidate with BMI >40, weight reduction before reimplantation is a reasonable consideration.

MRSA screening and decolonization​

Nasal MRSA carriage is more frequent in healthcare workers, dialysis patients and those with recent hospitalization. An orthopedic preoperative decolonization program used a nasal swab and, for S. aureus carriers, 2% nasal mupirocin twice daily plus daily 4% chlorhexidine body wash for 5 days.[32] This is institutional practice. The AUA best practice statement does not address decolonization for implant surgery; for clean implanted devices its Table V lists an aminoglycoside or aztreonam paired with a first- or second-generation cephalosporin or vancomycin.[9][51]

Smoking​

Smoking cessation for at least 4 weeks preoperatively is commonly advised. A single-center retrospective series of 137 patients associated smoking with explantation.[14]

Hypogonadism​

Symptomatic men with serum testosterone <300 ng/dL are evaluated for hypogonadism, and treatment can be started before or alongside implantation. The decision to continue testosterone around implantation is individualized: a retrospective database study found more coded IPP infections among hypogonadal patients receiving testosterone than among those not receiving it (7.0% versus 3.9%; RR 1.9, 95% CI 1.002–3.5).[38] In the TRAVERSE trial, testosterone was noninferior to placebo for major adverse cardiac events but was associated with more atrial fibrillation, acute kidney injury and pulmonary embolism, so thrombotic history is reviewed.[15]

Anticoagulation​

Warfarin, DOACs, and dual antiplatelet therapy require individualized perioperative plans coordinated with the prescribing clinician. One penile-implant center reports operating on patients taking aspirin 81 mg after individualized bleeding and thrombosis assessment.[35] Scrotal hematoma is a risk with uncorrected anticoagulation, and hematoma has been associated with infection in some series.

Physical Examination​

  • Penile length in stretched and flaccid states. Length is documented in clinic and shared with the patient, so later concerns about shortening have a baseline
  • Corporal integrity. Ask about prior intracavernosal injection therapy and palpate for Peyronie’s plaques, prior surgery scars (especially Nesbit / plication), and fibrosis from priapism or infection. In a retrospective cohort of 2,540 primary IPPs, 36 (1.4%) had intraoperative crossover, corporal perforation, or urethral injury; prior injection therapy was associated with this composite (adjusted OR 2.11).[48]
  • Scrotal anatomy and dartos thickness. The pump sits between the dartos layers; excessively thick or tethered scrota change operative planning
  • Manual dexterity. Assess the patient’s ability to operate the selected pump and hand strength when device operation is uncertain. In a prospective study of 29 IPP recipients, stronger grip was associated with less difficulty using the pump at three months.[33][39]
  • Abdominal wall. Prior low-transverse scars (Pfannenstiel, open prostatectomy, cystectomy, appendectomy, hernia mesh) make virgin space of Retzius reservoir placement riskier and push toward ectopic placement
  • Inguinal canal patency. Patent processus vaginalis or known inguinal hernia changes reservoir strategy; a reservoir should not be placed through a hernia defect
  • Penile sensation. Biothesiometry, applying a standardized vibratory stimulus to marked dorsal, ventral and shaft sites and recording the first-perceived-vibration threshold against normative values, is one office technique for this and has been used to document sensory change after plaque incision and grafting for Peyronie's disease; there is no standardized protocol and little evidence that the result itself changes ED or implant management, so a normal history and exam remain the baseline documentation for most patients.[18][19]
  • Meatus and urethra. Meatal stenosis or unrecognized stricture can affect postoperative catheterization decisions

Special Preoperative Considerations​

Prior pelvic / lower abdominal surgery​

A patient with prior radical prostatectomy, cystectomy, pelvic radiation, renal transplant, or extensive hernia mesh is not a candidate for reflexive space-of-Retzius reservoir placement. Preoperative planning includes:

  • Review of operative notes where available
  • Consider an ectopic subrectus reservoir in a plane superficial to the transversalis fascia; choose access and pocket height for the patient's anatomy rather than using the arcuate line alone to define the plane.[28]
  • Consideration of a two-piece device that avoids a separate abdominal reservoir (AMS Ambicor; Rigicon Infla2P where available, as it is not sold in the United States).[49]
  • Discussion of malleable prosthesis for the highest-risk abdomens

In a matched retrospective cohort of 26 solid-organ transplant recipients (kidney, liver, heart or kidney-pancreas) and 26 age-matched controls, infection occurred in 4% versus 0% (P = 1.00) and reoperation in 11.5% versus 11.5% (P = 1.00), with no difference in reoperation rate between two-piece and three-piece devices. A 2025 systematic review reports more reservoir-related complications in pelvic-organ transplant recipients with three-piece devices; reservoir planning therefore depends on graft location and the altered pelvic anatomy.[21][22][30]

See reservoir placement for technical options.

Peyronie's disease with ED​

Patients with Peyronie's require preoperative documentation of curvature direction, degree, and deformity complexity (hourglass, hinge, notch, indentation). Decision-making includes whether intraoperative modeling alone will suffice, whether plication is planned at time of implant, and whether a tunica albuginea incision or grafting step is anticipated.[10]

Prior prosthesis explantation​

A patient whose prior device was explanted for infection is at the highest risk of infection. Previous IPP infection was an independent risk factor for infection in the multicenter cohort (OR 4.67).[7] Practice for these patients includes:

  • After infected-device explantation without immediate salvage, treat the infection and confirm clinical healing before reimplantation. The AUA guideline describes healing over six weeks to six months, and a published pathway describes reimplantation at approximately 6–12 weeks; longer delay can increase corporal fibrosis and shortening.[3][40]
  • Documentation of infection clearance (white count, ESR/CRP, and clinical exam)
  • Preoperative imaging in selected cases (pelvic MRI to assess retained reservoir fragments, residual abscess)
  • Counseling that reinfection remains a substantial risk despite best practice
  • Consideration of malleable rather than inflatable reimplantation in the highest-risk scenarios

Post-radiation​

Prior pelvic radiation may alter tissue planes relevant to reservoir placement. In a 2025 multicenter retrospective cohort of 3,530 primary IPPs (211 with prior radiation), propensity-matched intraoperative complications were more frequent after radiation (4.3% versus 0.9%), particularly distal crossover; no statistically significant difference in postoperative complications or reoperations was detected over 24 months.[50] In a retrospective comparison of 101 radiation-exposed patients and 153 prostatectomy controls, any-complication rates among the 87 and 148 with outcome data were 16/87 (18.4%) and 17/148 (11.5%) at median five years (P = 0.141).[27] Reimplantation timing is determined by the indication, tissue condition and any active infection.

Phalloplasty / neophallus​

Placement in a neophallus differs fundamentally: there are no native corpora, erosion rates are higher, and dedicated neocorporal techniques (wrapped cylinders, dedicated designs or malleable devices) are used. This is covered in the gender-affirming surgery section.

Laboratory and Imaging​

Routine labs: CBC, BMP, HbA1c and a coagulation profile when anticoagulated. Assess for symptomatic UTI and obtain urinalysis or culture when clinically indicated; treat active infection before implantation. Routine urine-culture and asymptomatic-bacteriuria protocols vary by institution; the 2026 French guideline does not recommend routine preoperative culture for penile prosthesis implantation.[26] HIV and hepatitis screening is selective, where clinically appropriate.

Review voiding symptoms and history of retention alongside the routine history. Postoperative catheterization in a man with unrecognized outlet obstruction raises erosion and infection concerns.[23] For Coloplast Titan and Titan Touch, unresolved urination problems such as elevated residual urine due to bladder-outlet obstruction or neurogenic bladder are a labeled contraindication; assess the planned device’s current instructions before implantation.[33]

Imaging is not routinely indicated for primary IPP. Selective use:

  • Penile duplex ultrasound. Where the ED etiology is unclear or venous leak is suspected
  • Pelvic MRI. For complex Peyronie's with atypical curvature, for revision cases with suspected reservoir migration or abscess, and occasionally for neophallus planning
  • CT abdomen/pelvis. Revision cases with suspected retained reservoir or tubing, or where abdominal anatomy is substantially altered
  • Cystoscopy. Reserved for a clinical indication, such as assessing urethral patency or prostatic enlargement when bladder-outlet obstruction is a concern[23]

Informed Consent — What Is Unique​

Beyond the generic surgical consent elements, IPP implantation requires specific disclosures:

  • Reliable natural erections should not be expected after implantation. Corporal dilation and cylinder placement alter erectile tissue, and removal does not reliably restore preimplant erectile function. In a retrospective series of 32 three-piece recipients at mean 29 months, 16 reported spontaneous tumescence without device activation and one further patient reported full rigidity.[41][42]
  • Length is what it is. The implant will not make the penis longer than its maximum stretched state. Many patients report subjective shortening after surgery even with length-expanding cylinders.
  • Orgasm, ejaculation and sensation. Document each separately before surgery and discuss expectations against that baseline. Ejaculation and orgasm are distinct; removal of the prostate and seminal vesicles usually markedly reduces or abolishes antegrade ejaculation, and radiotherapy for prostate cancer can also impair it. Orgasm can occur without ejaculation.[25] For a man being implanted after radical prostatectomy, use the separate orgasmic-function data: in a prospective cohort of 499 men, orgasmic function was worse at a median 36 months in 60% and recovery plateaued at 15 to 21 months, with younger age (50 or younger), bilateral nerve sparing and better preoperative erectile function and desire predicting a better outcome.[16] Reports after radiation therapy for prostate cancer describe reduced orgasm intensity and altered ejaculation.[16][17]
  • The device is mechanical and can fail. In a series of 2,384 first-time implants spanning two decades, revision-free survival for all reasons was 68.5% at 10 years and 59.7% at 15 years; newer mechanically enhanced models had better mechanical survival in that series.[11]
  • Infection risk was 1.9% overall in a multicenter cohort, and is higher in diabetic patients, revision cases and patients with prior infection.[7] Infection typically mandates explantation.
  • The penis will feel different. The cylinders provide shaft rigidity but do not directly inflate the glans; glans engorgement varies, and some men report a soft glans despite full device inflation.[29]
  • Partner involvement. Partner expectations are reviewed again in consent.
  • Activation timing. Usually 4–6 weeks postop; patients anticipating a specific upcoming event (wedding, vacation) should plan accordingly.

Many high-volume implanters have patients watch a manufacturer-provided device video and handle a demo device during the consent visit, a practice intended to reduce postoperative dissatisfaction and medicolegal exposure.

Preoperative Infection-Prevention Bundle​

The infection-prevention protocol begins weeks before the case. See the infection article for evidence base. The preop elements are:

  • Glycemic optimization. Review HbA1c and discuss infection risk; 8.5% is a proposed risk threshold from a cohort dominated by malleable implants.[12][13]
  • S. aureus nasal screening and decolonization of carriers when required by the local protocol (institutional practice).[32]
  • Smoking cessation ≥4 weeks
  • Chlorhexidine body wash the night before and the morning of surgery, performed by the patient
  • No shaving at home. Hair is clipped in the OR
  • Check device contraindications. Defer implantation for active infection according to the selected device label, examine genital and operative-site skin, and check material and antibiotic-coating allergies.[33][43] AMS 700 InhibiZone is contraindicated with rifampin, minocycline or other tetracycline sensitivity and systemic lupus erythematosus; Coloplast Titan lists active infection and silicone sensitivity.[33][43]
  • Preoperative antibiotics per institutional protocol. AUA Table V lists an aminoglycoside or aztreonam paired with a first- or second-generation cephalosporin or vancomycin for less than 24 hours; the statement text advises no doses after wound closure.[9] In a retrospective multicenter cohort of 4,161 primary IPPs, vancomycin plus gentamicin alone had similar crude infection rates to other regimens (1.0% versus 1.2%) but higher adjusted risk (HR 2.7, 95% CI 1.4–5.4).[52] Perioperative intravenous antifungal use was associated with lower infection risk in another retrospective cohort (OR 0.22).[7]

Documentation Essentials​

A prosthetic urology clinic note before the OR booking should contain:

  • Failed or contraindicated medical therapy trials (with dose, duration, response)
  • Baseline SHIM / IIEF score
  • Stretched and flaccid penile length
  • Partner discussion summary
  • Specific device selected and rationale (3-piece, 2-piece or malleable; brand)
  • Risk factors acknowledged (diabetes, radiation, prior surgery, revision status)
  • Document the specific expectations or psychosocial concerns discussed.[4]
  • All major complications discussed by name
  • Patient's stated expectations (verbatim quotes are protective)

See Also​

Videos​

Penile Prostheses: Complications, Patient Selection and Advanced Maneuvers
SMSNA (2023)

References​

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