Who Should Not Get a Penile Implant and Why?

Penile implants represent a third-line treatment option for erectile dysfunction (ED) and should only be considered in patients who have not responded to less invasive treatments such as oral medications, vacuum devices, or intracavernous injections¹. According to the 2025 EAU Guidelines, penile prosthesis implantation may be considered in patients who i) are not suitable for different pharmacotherapies or prefer a definitive therapy; and, ii) do not respond to other treatment modalities². Uncontrolled diabetes mellitus is a significant contraindication for penile implant surgery. The EAU Guidelines specifically identify diabetes as a risk factor for penile prostheses infection, highlighting the need for optimal patient selection³. While there are no randomized controlled trials determining the ideal threshold of glycated hemoglobin that is acceptable prior to implant surgery in diabetic patients, proper glycemic control is essential to minimize infection risk⁴. A large-cohort, multicentre analysis demonstrated that specific antibiotic combinations (vancomycin plus gentamicin) were most efficacious for implant preparation in diabetic patients to prevent postoperative infection⁵. Active infections anywhere in the body, particularly urinary tract or skin infections in the genital area, are absolute contraindications for penile implant surgery. The EAU Guidelines report that careful surgical techniques with appropriate antibiotic prophylaxis against Gram-positive and negative bacteria have reduced infection rates to 2-3% with primary implantation in low-risk patients and in high-volume centers⁶. However, this rate may increase significantly in patients with active infections, potentially leading to implant removal, tissue damage, and increased difficulty with future reimplantation. Psychological readiness is another critical factor in patient selection. The guidelines emphasize that focused psychosexual counseling may improve sexuality and sexual well-being in both patients and their partners after penile implant surgery⁷. Patients with unrealistic expectations, untreated psychiatric disorders, or body dysmorphic disorder may not be suitable candidates. The guidelines specifically mention that Penile Dysmorphic Disorder (PDD) patients may not benefit from invasive procedures and require clinical and psychological support instead⁸. Proper counseling about realistic outcomes is essential, as satisfaction rates are highest (92-100% in patients and 91-95% in partners) when appropriate counseling is provided⁹. Certain anatomical conditions may also present relative contraindications. Patients with significant penile fibrosis, severe Peyronie’s disease with extensive calcification, or prior complex urethral surgery may face higher technical challenges during implantation. Additionally, patients with impending erosion involving the distal corpora, urethra, or glans can occur in 1-6% of cases after surgery and represent potential complications that must be carefully evaluated¹⁰. Patients with significant vascular impairment, such as those with diabetes, are at higher risk for serious complications like glans ischemia and necrosis, reported in about 1.5% of patients¹¹. The EAU Guidelines also note that hypogonadism was independently associated with infection of the implant according to a retrospective analysis of a large insurance claim database in the US¹². Similarly, patients with spinal cord injury had higher risk of complications with up to 16% of cases reporting prosthesis infection in published series¹³. These patient populations require special consideration and potentially more aggressive perioperative management to minimize complications. In conclusion, while penile implants offer high satisfaction rates for properly selected patients with erectile dysfunction, careful patient selection is crucial to minimize complications and ensure optimal outcomes. Absolute contraindications include uncontrolled diabetes, active infections, and untreated psychological conditions, while relative contraindications include certain anatomical variations and medical conditions that increase surgical risk. A thorough preoperative assessment and appropriate patient counseling are essential components of the evaluation process.