Penile implants for erectile dysfunction have been been continually improved and refined over the last 40 years. More than 300,000 cis gender and trans gender men have had penile implant surgery, with approximately 20,000 penile implant surgeries a year. 1

Expert Reviewed by Dr. Curtis CranePenile implants provide an erection by serving as a replacement for the spongy tissue (corpora cavernosum) inside the penis that normally fills with blood during an erection. They come in a variety of diameters and lengths.

Penile implant surgery is typically performed at stage 2 or 3 of a multi-stage phalloplasty (a minimum of nine months following stage 1.) Recovery time is typically 6 to 8 weeks. Patients can resume sexual activity after physician consultation.

Note On Terminology: Penile implants are also known as penile prosthetics. However a penis “prosthetic” or “prosthesis” commonly refers to a non-surgical “packer” — a polymer or silicone penis that’s worn in a harness or affixed with medical adhesive. Similarly, “erectile device,” which is also sometimes used interchangeably with “penile implant,” can refer to external devices that assist with erections via vacuum pressure, vascular constriction, nerve stimulation, stretching, etc. This article will use the term “penile implant” exclusively to describe those penile prosthetic devices that are surgically implanted.

Types of Penile Implants

There are three basic kinds of penile implants used in FTM phalloplasty: the non inflatable or semi-rigid implant (malleable and non-malleable), the 2-piece inflatable implant, and the 3-piece inflatable implant.

Non Inflatable Penis Implants

Non Inflatable Penis Implant

(Includes semi-rigid malleable and non-malleable rods.)

One or two bendable and “positionable” rods are inserted into the penis. The rods have an outer coating of silicone and inner stainless steel core or interlocking plastic joints. Non inflatable (or semi-rigid) implants are always firm. They can be bent into different positions for erect and flaccid states. These implants are used the least of all types, in approximately 10% of cases.2

Deflating Non Inflatable Penis ImplantHow it works: For an erection, simply bend the penis in the erect position. To end the erection, bend the penis down. Erections can be of various degrees depending on how the penis is bent.

Pros:

  • Easy to use: bend it up for an erection and bend it down when not in use.
  • Totally concealed in body
  • Simplest penile implant procedure
  • Least expensive
  • With fewer mechanical parts, these implants can last more than 20 years.

Cons:

  • Having a permanent semi-erection can feel and look awkward

Popular Brands of Semi-Rigid Penile Implants:

2-Piece Inflatable Penile Implants

2-Piece Inflatable Penile Implants - AMS AmbicorInflatable penile implants have two cylinders in the shaft of the penis, a reservoir that holds salt water, and a hydraulic pump to move the salt water from the reservoir to the cylinders, providing an erection.

The release valve on the pump drains the salt water out of the cylinders and back into the reservoir.

A 2-piece inflatable implant has the reservoir at the beginning of the cylinders (at the base of the penis) and the pump and release valve in the scrotum. These are used in about 15% of cases.3

Deflating 2-Piece Inflatable Penile ImplantHow it works: Gently squeeze the concealed pump in the scrotum several times. This moves the saline solution from the reservoir into the cylinders. As the cylinders fill, the penis becomes erect and firm. To end the erection, gently bend the penis down for 6-12 seconds. This transfers fluid back into the reservoir.

Pros:

  • Easy to use: pump it up for an erection, bend to deflate.
  • Totally concealed in body
  • Simplest inflatable penile implant procedure, least expensive surgery and implant.
  • More easily concealed under clothing than semi-rigid/non inflatable implant

Cons:

  • Requires some manual dexterity to inflate
  • Because only a small amount of fluid is transferred into the cylinders to obtain an erection, the penis is not as rigid as with a multi-component 3-piece inflatable penile implant.
  • The pump can be felt more in the scrotum to sex partners compared to the softer pump of the 3-piece inflatable implant

Popular Brands of 2-Piece Inflatable Penile Implants:

3-Piece Inflatable Penile Implants

3-Piece Inflatable Penile ImplantA 3-piece inflatable implant has the cylinders in the penis, the reservoir in the belly, and the pump and release valve in the scrotum. Compared to 2-piece inflatable implants, the reservoir in this type of implant is larger and separate from the cylinders. These are the most common of the penile implants, used in approximately 75% of cases.4

Inflating 3-Piece Inflatable Penile ImplantHow it works: Gently squeeze the concealed pump in the scrotum several times. This moves the saline solution from the reservoir into the cylinders. As the cylinders fill, the penis becomes erect and firm. To end the erection, simply press a “deflation site” on the pump. Deflating the cylinders transfers the fluid back to the reservoir and the penis becomes flaccid.

Pros:

  • Most closely resembles the process and “feel” of a non-assisted erection
  • Easy to use: pump it up for an erection, press the release valve to deflate
  • Easier to inflate than a 2-piece device due to larger, softer pump
  • Provides better rigidity of the two inflatable devices
  • Provides the best flaccidity of all implants when not in use
  • Creates the least amount of pressure on penile flesh when not in use, lessening risk of deterioration and thinning
  • Often more reliable than 2-piece penile implants
  • Totally concealed in body
  • More easily concealed under clothing than semi-rigid/non inflatable implant

Cons:

  • Requires some manual dexterity to inflate
  • Most involved implant surgery, most expensive surgery and implant.
  • More mechanical parts translates into a higher chance of mechanical failure compared to other implants. Can last as little as 3 years before needing replacement, though research has indicated that they can last 10-15 years.
  • Patients do not typically see any increase in length or girth due to the thickness of the flaps used to create the phallus
  • Highest complication rate. Most centers in Europe have stopped using this implant because, in some series, 50% of implants needed to be removed.

Popular Brands of 3-Piece Inflatable Penile Implants:

Factors In Choosing a Penile Implant

Choosing a type and brand of penile implant can be difficult as several factors need to be considered:

  • Age
  • Penis size: Overall size (including intra-operative measurement), ratio between the length to girth of penile shaft, ratio between penile length and size of scrotum, overall size of scrotum, size of glans penis.
  • History of previous implant, abdominal surgery, kidney transplant or other major pelvic surgery
  • Body type, incl. presence of a very prominent supra-pubic fat
  • Overall patient health and life expectancy
  • Costs

While the 3-piece inflatable penile implants are the most commonly used implants today, there are compelling reasons for trans men to consider the semi-rigid non-inflatable devices.

Dr. Curtis Crane is a reconstructive urologist and plastic surgeon who performs penile implant surgery in San Francisco. Dr. Crane prefers the semi-rigid implants for a number of reasons:

  • Over the long term, semi-rigid implants provide better rigidity compared to inflatable implants, which can lose rigidity over time.
  • Semi-rigid implants have a longer lifespan than inflatable implants (20+ years vs. 5-10 years.)
  • The semi-rigid implant and implant surgery are less expensive compared to inflatable implants.
  • Simpler implant surgery = reduced complication rates.
  • Unlike cisgender men, transsexual men do not generally get an increase of girth with inflatable implants.

Potential Complications

While improvements over the years have made the penile implant more reliable, no mechanical device is 100% free of malfunction, and that includes penile implants.

As with any surgical procedure, there always is the chance of post-operative infection. If the infection is severe, the implant must be removed.

Chronic pain may occasionally require removal of the implant.

Leakage from the cylinders can also require removal or replacement of the implant.

Less common complications include tissue erosion (particularly in the glans), implant malfunction (such as pump or reservoir failure) or defectiveness, and incorrect positioning or migration or the implant.

Journal Articles For Further Reading

Erectile Implants in Female-to-Male Transsexuals: Our Experience in 129 Patients
Piet B. Hoebeke, Karel Decaestecker, Matthias Beysens, Yasmin Opdenakker, Nicolaas Lumen and Stan M. Monstrey. European Urology, February 2010.

Novel technique for proximal anchoring of penile prostheses in female-to-male transsexual.
Large MC, Gottlieb LJ, Wille MA, DeWolfe M, Bales GT. Urology. 2009 Aug;74(2):419-21.

Penile implantation in Europe: successes and complications with 253 implants in Italy and Germany.
Natali A, Olianas R, Fisch M. J Sex Med. 2008 Jun;5(6):1503-12. doi: 10.1111/j.1743-6109.2008.00819.x. Epub 2008 Apr 10.
This report provides data on the most commonly used penile prostheses in cis gender men: the American Medical Systems [AMS] series: AMS 700CX, AMS Ambicor, and AMS 600-650.

Phalloplasty: a valuable treatment for males with penile insufficiency.
Lumen N, Monstrey S, Selvaggi G, Ceulemans P, De Cuypere G, Van Laecke E, Hoebeke P. Urology. 2008 Feb;71(2):272-6.

Long-term survival of inflatable penile prostheses: single surgical group experience with 2,384 first-time implants spanning two decades.
Wilson SK, Delk JR, Salem EA, Cleves MA. J Sex Med. 2007 Jul;4(4 Pt 1):1074-9.
Long-term revision-free survival, greater than 10 years has never been reported for inflatable penile prostheses. This is the first report on long-term reliability of inflatable penile prostheses. Fourteen different inflatables were examined including Mentor Alpha 1, Mentor Alpha NB, AMS 700 CX, and AMS 700 Ultrex. Researchers estimated that 60% of these virgin implants would survive 15 or more years without revision or extraction. Newer enhanced models are currently available, and even better long-term survival for these devices is predicted. (Note: Study looked at cis gender men.)

Obtaining rigidity in total phalloplasty: experience with 35 patients.
Hoebeke P, de Cuypere G, Ceulemans P, Monstrey S. J Urol. 2003 Jan;169(1):221-3.
The combination of a neourethra and erection prosthesis in a single neophallus in the female-to-male transsexual remains a challenge. In this report, experience with 35 patients is described, and 1- and 3-piece hydraulic models are compared.

Penile prosthesis implantation in a transsexual neophallus.
Tan HM. Asian J Androl. 2000 Dec;2(4):304-6.
Successful insertion of an inflatable prosthesis is described. The AMS CX prosthesis is used in a 45 year old transsexual, who had a large bulky neophallus constructed from the anterior abdominal subcutaneous fat 9 years previous.

More journal articles: Phallo.net, NIH.gov

Footnotes:
1. Source: Erectile Dysfunction Institute (EDI)
2. Source: EDI
3. Source: EDI
4. Source: EDI