Inflatable Penile Prosthesis

Everybody asks about the cylinders. The reservoir is what decides the operation.

Two of the three components sit where you will never see them, one in the scrotum and one deep in the abdomen, and almost every interesting problem with these devices belongs to the one in the abdomen. Where a surgeon puts it, and how carefully, decides whether the thing works quietly for fifteen years or turns into a hernia repair. This page is about the machine.

The part nobody asks about

Men coming to a consultation on an inflatable prosthesis arrive with questions about the cylinders. How firm, how long, how natural, what a partner will feel. All fair questions and all easy to answer. Then the conversation turns to a soft silicone balloon roughly the size of a small orange that has to live somewhere inside the abdomen for the rest of the man's life, and the room goes quiet, because nobody had considered that part and nobody had been told it existed.

Nobody photographs the reservoir. No brochure leads with it. It shapes more of the operation than the two visible parts put together.

That balloon is the reservoir. It holds the fluid that makes everything work.

Look at what actually goes wrong with these devices over a lifetime and the reservoir is responsible for a disproportionate share of the surgical drama. It can herniate down into the groin. Sometimes it presses on a bladder. In rare and well documented cases it has found its way into the peritoneal cavity and caused a bowel obstruction. Far more often it sits there quietly for two decades and never announces itself, which is what happens in the overwhelming majority. The difference between those outcomes lies almost entirely in a decision made during the operation on where to put it, and that decision has changed substantially in the last ten years without most patients hearing a word of it.

Three components, three places, three failure modes

A three piece device is a closed hydraulic circuit. Fluid moves between two ends of it and nothing enters or leaves. Knowing which component sits where turns a frightening malfunction into something you can describe on the phone.

Each part fails in its own way. Cylinders wear at the points where they bend, so the classic late failure is a slow leak that leaves a device taking longer to firm up and softening on its own within the hour, a change that creeps in across months and gets blamed on age or on stress long before anybody thinks to test the machine. Tubing kinks or disconnects, which produces a device that will not inflate at all, and that failure arrives in a single day. The pump itself rarely breaks, though it can drift upward in the scrotum until it becomes hard to reach. Reservoirs behave unlike any of these, because a reservoir problem is a problem of position more than a problem of the part, and the damage lands on organs that have nothing to do with erections. One of those lists belongs on a clinic wall. The other belongs in the surgeon's plan before the first incision.

Narrow screens scroll this table sideways. Swipe or drag to reach every column.

Drag the table below sideways where a phone cuts off the last column.

How the hydraulics work

Twelve squeezes and one press

Squeezing the bulb of the pump draws fluid out of the reservoir and drives it along a tube into the two cylinders, a small volume with each squeeze, so a dozen or so gets the job done. Pressure inside the cylinders rises well beyond anything a natural erection produces, and implanted men commonly describe the result as firmer than they remember. Releasing works differently. A valve in the upper part of the pump has to be pressed and held for several seconds while the fluid runs back, and the penis softens over perhaps half a minute. None of the sequence is difficult, though it takes most men two or three weeks of practice before it stops requiring thought, and almost every man finds the deflation harder to learn than the inflation.

Deflated, the whole thing is meant to disappear. Cylinders sit soft inside the erectile bodies, tubing runs under the skin, and the pump reads as a third small structure in the scrotum that a man notices for a few weeks and then stops noticing. Nothing shows through clothing. Nothing causes trouble at an airport. A doctor examining the scrotum who has not been told will find it, and almost nobody else will, which is the answer to the question men worry over most beforehand and mention least afterward.

The reservoir problem

Why the traditional pocket stopped being obvious

For thirty years the reservoir went into the space of Retzius, a natural pocket behind the pubic bone and in front of the bladder, reached blindly with a finger through the same incision used for everything else. The technique worked because that pocket exists in an untouched pelvis and because the peritoneum, the membrane containing the bowel, lies safely above it. Then prostate surgery became common, and robotic prostate surgery more common still, and the pocket in question stopped being reliably present. Scarring obliterates it. The bladder sits differently afterward. Blind finger dissection in that situation can perforate a bladder, tear an iliac vein, or push a reservoir straight through into the abdominal cavity, and each of those has been reported often enough to change practice. A generation of men who had prostates removed in their fifties started arriving for implants in their sixties, and the anatomy those implants were designed around had gone.

Where the reservoir goes now

A single surgeon, ten years, and 561 first operations

The alternative is to place the reservoir higher, above the pubic bone, in the plane behind the abdominal muscles and well away from bladder and bowel. One American center compared the two directly across everything a single surgeon did between 2009 and 2019, excluding revisions, which left 561 first operations. The traditional pocket had been used in 131 of them and the high submuscular position in 430. Revision for a reservoir problem was needed in 6 of the 131 traditional cases, which is 4.6 percent, against 10 of the 430 high placements, which is 2.3 percent. That difference did not reach statistical significance, and the interesting part lies in what the problems were rather than how many there were. The traditional group produced one bladder erosion, two vascular injuries and three herniations. The high group produced nine herniations and one bowel obstruction, that last one occurring when a reservoir had gone into the peritoneal cavity by mistake.

Then the same surgeon changed his own technique partway through and the numbers moved sharply. Across 133 high placements done with his original method, 7 needed revision, which is 5.3 percent. Across the 297 done afterward with a refined five step protocol, 3 needed revision, which is 1.0 percent, and all three were herniations. That difference did reach significance.

Read that as a statement on technique and not on position. The same surgeon, the same placement, the same patients, a fivefold difference in reoperations.

So the useful question to put to a surgeon is never which position he prefers, phrased as a matter of philosophy, but how he performs the one he prefers and what his own reoperation rate looks like when he counts it. A published review of reservoir placement arrives at the same conclusion from the other direction, setting out each ectopic position, the anatomy behind it and the injuries reported when the dissection goes wrong, and ending with the observation that the decision belongs to the individual pelvis on the table. Prostate removed. Kidney transplanted. Mesh in the groin. Each of those rewrites the answer.

Feeling it, and why that settles

Moving the reservoir out from behind the pubic bone raises an obvious worry, which is that a balloon sitting under the abdominal wall might be felt or even seen. A German group measured exactly that in 142 men, half of whom had the high placement and half the traditional one. Among the 70 high placements, 45 men, which is 64.3 percent, could feel the reservoir by pressing on their own abdomen immediately after surgery.

In four out of five of those men the reservoir stopped being palpable by three months, once a fibrous capsule had formed around it and the tissues had settled. One man in the whole series of 142 said he could actually see it, and he was the thinnest man in the group.

Thin men should be told this beforehand. Being able to press on your own abdomen and locate a device is odd for a few weeks and unremarkable by the summer.

Auto inflation

Muscle squeezes whatever lies beneath it. Any reservoir tucked under the abdominal wall gets compressed every time those muscles contract, and if the pressure inside it climbs above the pressure sitting in the cylinders then fluid moves without anybody asking for it, which produces a device that firms up while a man coughs, lifts a suitcase, or does anything at all involving his abdominal wall. That was a genuine nuisance with early designs, and it remains the main engineering argument the traditional pocket still has in its favor.

Manufacturers answered it with a mechanical valve inside the reservoir that holds fluid in place until the pump actively draws on it. Reservoir shape changed too, from a simple sphere to flatter designs that distribute pressure differently under the muscle. Between those two changes the problem has largely gone, and that is what made high placement practical at all. Partial auto inflation still happens in a minority of men, settles for most of them as the capsule matures over the first months, and should be reported and not endured, since occasionally it signals a reservoir sitting in too tight a pocket.

Report it early either way. A device that fills itself is telling you something, and the fix is simpler in the first three months than in the third year.

The pump

Position matters more than the design of the pump itself. It needs to sit low and forward in the scrotum, below and in front of the testes, where a man can find it without a search and squeeze it without contorting. Placed too high it disappears behind the testes and becomes awkward to operate for the rest of its life, which is a mechanical failure of a kind that never shows up in device survival statistics.

Surgeons fix the pump in place with a stitch or with a carefully made pouch in the dartos layer, and both work. A pump that drifts upward over the years is uncommon and correctable with a small operation under local anesthetic. Anybody with limited hand strength should say so at the consultation, because pump design differs between manufacturers and one may suit those hands better than another.

The cylinders, and their length

Cylinders come in fixed lengths with rear extenders to fine tune the fit, and the surgeon measures the space with a purpose made instrument before choosing. Too short leaves the head of the penis unsupported when the device inflates. Too long presses on the tip from inside and eventually erodes. Neither error can be corrected without opening everything again, and an unhurried measurement matters more than any other minute of the operation. Diameter counts as a separate choice from length, settled on what the erectile bodies will accept after dilation and not on what anybody would prefer, since forcing a wide cylinder into a scarred body risks tearing the sheath and turning a straightforward implantation into a repair with a graft. Every man should also hear, before the operation and not after it, that an implant restores rigidity at whatever length the penis has now, and that years without erections or a long history of Peyronie's disease may already have taken some of that length, because the disappointment men report most commonly comes from expecting a device to give back something the disease removed.

In men whose penis has shortened badly, usually from severe Peyronie's disease or from years without erections, a technique exists to make the space longer rather than accepting it. The sheath is divided transversely, the halves slide apart to lengthen the shaft, and the defect is covered with a graft before cylinders go in. A small early series reported 12 men with significant atrophy or curvature beyond sixty degrees, seven of whom had this done, with mean curvature before surgery of 66 degrees, mean length gained of 2.6 centimeters, and no vascular complications at an average of fifteen months. One man was left with a residual fifteen degree bend. Those are small numbers from an experienced center and the technique carries a real risk of damaging blood supply to the head of the penis, so it belongs in a conversation and not on a price list. Few surgeons perform it regularly, and for most men a standard implantation at natural length serves better than extra centimeters bought at that risk.

The number you control

A multicenter study followed 902 implant procedures and asked a narrow question, which was whether blood sugar control predicts infection and where the line falls. It does, and the gradient is steeper than most people expect. Grouping men by their glycated hemoglobin produced infection rates of 1.3 percent below 6.5 percent, 1.5 percent between 6.5 and 7.5, 6.5 percent between 7.6 and 8.5, 14.7 percent between 8.6 and 9.5, and 22.4 percent above 9.5.

1. Have an HbA1c measured before anybody books a date, even where diabetes has never been diagnosed.
2. Where it sits above 8.5, spend three months bringing it down with your own family doctor and then have it measured again, because the two ends of that scale separate a risk of one in eighty from a risk of one in five.
3. Clear any urinary or skin infection first.
4. Stop smoking for the weeks either side of the operation, which helps the wound heal cleanly whatever else it does for you.

The number you do not control

The same analysis tested which factors independently predicted infection once everything else was accounted for. Age did not. Device type did not. The number of vascular risk factors did not. What did predict infection was Peyronie's disease, a high body mass index and a high HbA1c, and one factor ran in the protective direction, which was being operated on by a high volume surgeon.

Volume is the one item on that list that costs nothing to check and cannot be improved after the fact. A surgeon who implants forty of these a year has already met the scarred corpus that will not dilate, the pelvis full of mesh, the reservoir that refuses to sit where it should, and the device that has to come out at two in the morning, and he works with a theater team who hand him the right instrument without being asked for it, which is a large part of why operating time falls in experienced hands and why infection falls along with it. A surgeon who implants four a year reads the manual afresh each time. Neither sentence comments on anybody's ability. Both describe exposure, and exposure is what the analysis picked up when it found high volume protective after adjusting for everything else. The awkward part for a patient is that volume is almost never published, so it has to be requested directly, and the manner of the answer tells you nearly as much as the number does.

Columns run past the edge on a small screen. Slide the table across to read them.

1. How many inflatable devices do you implant in a year, and how many of those are revisions.
2. Where do you place the reservoir in a man who has had his prostate removed, and why there.
3. What is your own infection rate, and how do you know it.
4. Who does the operation if this device fails in ten years, and what happens if I am no longer in this country.

Write the answers down. Four straight answers from one surgeon are worth more than a hundred reviews, and a surgeon who treats those questions as reasonable has already shown you how the follow up will feel.

Recovery, and the cycling that matters

Swelling in the scrotum and shaft peaks around the third day and is the part men find alarming. It settles over two to three weeks with supportive underwear and gravity on your side. Most men go home the day after surgery with the device left deflated or barely inflated, and the first few weeks are mostly waiting.

This table also scrolls sideways on a narrow screen. Swipe or drag to reach every column.

Anybody traveling for this operation should have the activation session arranged before they fly home. Learning to work a pump from a written sheet or a video call is the commonest reason men arrive at a second opinion convinced their device is faulty when it is working perfectly.

Pain is moderate and short lived for most men, handled with simple analgesia and rarely needing anything stronger past the first week, and the thing men describe as worse than the pain is the strangeness of a swollen, bruised scrotum that looks alarming and is entirely ordinary. Wounds stay small. The stitches dissolve on their own. Driving comes back at around ten days, desk work at two weeks, and lifting at six. Anybody whose job is physical should plan the full six weeks instead of hoping, because a hernia torn through a healing abdominal wall, months after everything else has gone right, is a miserable way to lose a good result. The device stays deflated until the surgeon says otherwise, and squeezing the pump early to see whether it works is the commonest way men give themselves a problem.

What living with one is actually like

Most research on these devices measures whether they work and how often they break, which describes the machine and ignores the person carrying it. An Italian group built and validated a questionnaire to answer the other question, putting it to 69 men who had received three component hydraulic devices over a twelve year period and covering four separate domains of life, namely function, the personal, the relational and the social. Questionnaires of that kind get dismissed as soft, and the dismissal is lazy, because the choice a man faces here is never a choice on hydraulics but a choice on whether the rest of his life improves enough to justify an operation he cannot undo, and the only instrument capable of answering that is one that asks him directly. The numbers that came back repay a careful read.

The finding worth carrying into a consultation

Two results in that study deserve more attention than they get. The functional domain, meaning whether the device did what it was supposed to do mechanically, predicted overall quality of life better than anything else, which sounds obvious and is a useful corrective to the idea that this is mostly psychological. And more than half the men believed their partner was very satisfied, with the researchers finding that a partner's satisfaction shaped the man's own quality of life, his self image and how he related to the world outside the bedroom.

Bring them to the appointment. A partner who has heard a surgeon describe the deflated state in plain words expects something quite different afterward.

Take that last point as an argument for bringing your partner to the consultation. Their expectations end up inside your outcome, and the cheapest way to manage that is to let them ask their own questions of the surgeon rather than receive your summary of the answers.

Having this done in Istanbul

What we need before anybody books a date

• A recent HbA1c, whether or not you have ever been told you are diabetic, since the gradient described above applies to everybody.
• The operation note from any prostate, bladder, bowel or hernia surgery, because it decides where the reservoir can safely go.
• What you have already tried for this problem, at what dose, for how long, and what happened.
• Whether a kidney transplant sits in your pelvis, which changes the plan completely.
• Your full medication list, with anticoagulants and antiplatelet drugs named clearly.

A urologist reads all of it and writes back, at no charge and with no obligation, and the reply says plainly whether an inflatable device suits your anatomy or whether something else does. Seven languages are spoken here without an interpreter being booked, those being English, Arabic, French, Russian, Serbian, Romanian and Spanish, and any other language gets an interpreter arranged in advance. One coordinator takes your first message and stays attached to your case until discharge, then keeps answering on WhatsApp once you have flown home, which matters more for an implant than for most operations because the questions tend to arrive in week four rather than week one. A partner or relative sleeps beside you on a bed the ward provides. Hotel nights on either side of the admission, every transfer from the airport and back to it, and each trip between hotel and clinic are booked before you land. For a visa application, the invitation letter leaves our office roughly ten days ahead of your flight. Kitchen meals come halal, vegetarian or adjusted for diabetes, and a prayer room sits on the ward floor.

That reply arrives in writing. Nobody telephones afterward to press for a decision, and a fair number of the men we answer go on to choose something other than surgery.

Length of stay, flying home, and coming back

Plan seven to ten nights. That covers assessment and blood tests, the operation, one night on the ward, catheter removal on the first morning, and two wound reviews spaced across the week. Fitness to fly is signed off in writing at around day five to seven, and we do not leave that judgment to you. The device gets activated at four to six weeks, so either plan a short second visit for that or let us arrange the teaching session with a urologist near you, which we do at no extra charge and which we would rather organize than have anybody learn the sequence from a leaflet.

What moves the cost

We publish no figures here. The cost turns on which device goes in, whether scarring inside the erectile bodies makes the operation longer, whether a lengthening step is part of the plan, and how many nights the ward keeps you, and none of those can be settled until a urologist has read what you send. Any figure offered earlier than that has been picked to win an inquiry.

Inflatable penile prosthesis FAQ

Seven questions arrive in almost every first message we receive.

References

1. Baumgarten AS, Kavoussi M, VanDyke ME, Ortiz NM, Khouri RK, Ward EE, Hudak SJ, Morey AF. Avoiding deep pelvic complications using a five-step technique for high submuscular placement of inflatable penile prosthesis reservoirs. BJU International. 2020;126(4):457-463.
2. Osmonov D, Chomicz A, Tropmann-Frick M, Arndt KM, Jünemann KP. High-submuscular versus space of Retzius reservoir placement during implantation of inflatable penile implants. International Journal of Impotence Research. 2020;32(1):18-23.
3. Van Dyke M, Baumgarten AS, Ortiz N, Hudak SJ, Morey AF. State of the reservoir. Current concepts of penile implant reservoir placement and potential complications. Current Urology Reports. 2021;22(4):20.
4. Habous M, Tal R, Tealab A, Soliman T, Nassar M, Mekawi Z, Mahmoud S, Abdelwahab O, Elkhouly M, Kamr H, Remeah A, Binsaleh S, Ralph D, Mulhall J. Defining a glycated haemoglobin level that predicts increased risk of penile implant infection. BJU International. 2018;121(2):293-300.
5. Clavell-Hernández J, Wang R. Penile size restoration with nondegloving approach for Peyronie's disease. Initial experience. Journal of Sexual Medicine. 2018;15(10):1506-1513.
6. Caraceni E, Utizi L. A questionnaire for the evaluation of quality of life after penile prosthesis implant. Quality of life and sexuality with penile prosthesis. Journal of Sexual Medicine. 2014;11(4):1005-1012.