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Surgery may be considered as a third-line treatment option for men with erectile dysfunction (ED) who have failed to respond adequately to first- and second-line treatments.

Surgery in men with ED usually has one of three goals:

• to implant a device (penile proshesis) that can cause the penis to become erect
• to repair arteries with obstructions that block the flow of blood to the penis that cause impotence
• to block off veins that allow blood to leak from the penile tissues.

Implanted devices, known as prostheses, can restore erection in many men with impotence. In general, there are two major types of penile implants for the treatment of ED:

• Semirigid Penile Implants - Semirigid implants usually consist of paired, malleable silicone rods, which are inserted surgically into the corpus cavernosum, the twin chambers running the length of the penis. The user manually adjusts the position of the rods by bending them upwards prior to intercourse and then bending them back downwards after intercourse has been completed. Adjustment does not affect the width or length of the penis. In general, semirigid implants are cheaper and easier to position than inflatable penile implants. Examples of semirigid penile implants include:

  • AMS Malleable 600/650M models
  • Mentor Accuform

• Inflatable Penile Implants - Inflatable penile implants consist of two inflatable cylinders that are surgically implanted into the corpus cavernosum; a pump that is implanted into the scrotum; and a reservoir containing sterile saline solution that is implanted into the abdomen. The patient inflates the cylinders by pressing on the small pump, located under the skin in the scrotum, which transfers the saline solution from the reservoir into the two cylinders in the penis resulting in an erection. Inflatable penile implants are also equipped with a deactivation device that transfers the saline solution back into the reservoir in the abdomen after sexual intercourse has been completed. Sexual activity is usually restricted for a period of about 6 weeks after implantation of an inflatable penile implant. Examples of commercially available inflatable penile implants include:

  • Ambicor
  • AMS 700 CX
  • AMS 700 Ultrex

Possible problems with penile implants include mechanical breakdown of the prosthesis, penile pain, nerve damage, and infection. Mechanical problems with penile prostheses have diminished in recent years because of technological advances.

Revascularization surgery to repair arteries can reduce impotence caused by obstructions that block the flow of blood to the penis. The best candidates for such surgery are young men with discrete blockage of an artery because of an injury to the area or fracture of the pelvis. The procedure is less successful in older men with widespread blockage.

Surgery to veins that allow blood to leave the penis usually involves an opposite procedure - intentional blockage. Blocking off veins (ligation) can reduce the leakage of blood that diminishes rigidity of the penis during erection. However, experts have raised questions about this procedure's long-term effectiveness.