Simply put, a penile implant is a device that that allows a man to have an erection "on demand," when he has trouble doing so naturally. ED is the inability to achieve or maintain an erection firm enough for sexual intercourse.
The decline of implant use concerns some doctors, who say penile implants have the highest rate of patient satisfaction among all ED treatments.
"It's like starting a car; you just turn it on when you're ready," said Dr. Darius Paduch, study author and director of Sexual Health and Medicine at Weill Cornell Medical College in New York City. "The guys love it."
Researchers found that the number of men diagnosed with erectile dysfunction increased 165% over the 10-year study period, while the use of penile implants declined, with 4.6% of men with ED getting a penile implant in 2002 and 2.3% of men opting for an implant in 2010. The study's finding tha t penile implants are on the downturn resulted from an analysis of 1,763,260 men using Medicare public use files from 2001 to 2010.
"When medications like Viagra and Cialis don't work, we then present all the remaining options to the patient as a 'second line,' including penile implants and injections," said Dr. Drogo Montague, director of the Center for Genitourinary Reconstruction in the Glickman Urological & Kidney Institute at the Cleveland Clinic, and professor of surgery at the Cleveland Clinic Lerner College of Medicine. "Penile prosthesis is the only thing that works for almost every man with ED -- unlike injections and pills."
Penile implants were most utilized by men from 65 to 74 who had other existing medical conditions, according to the study. Men from the South and West were more likely to get a penile implant than men from other parts of the country. It's believed that this concentration is because of the higher prevalence of obesity, a condition linked to ED, in those areas of the country, according to Paduch.
Surgical techniques for inserting penile prostheses have also improved over time. A growing number of operations are now outpatient procedures, which means men can leave the hospital the same day as the surgery.
The rise of ED treatment alternatives
While the discovery of ED treatments such as Viagra and intracavernosol injection (a shot a man gives himself to induce an erection) is blamed for the falling popularity of penile implants, it's also possible that medical providers are choosing simpler treatments in lieu of complex surgical procedures.
"There's a real need for penile prosthesis, but this isn't generally recognized by the public and even some medical professionals," said Montague. "Not being able to have intercourse has been shown in numerous studies to cause low self-esteem depression."
According to Montague, it's common for men with ED to give up hope when better-known treatm ents -- medicines such as Viagra and penile injections -- don't work. He said men should be given all of the options early on in treatment, including penile prosthesis.
Dr. Tom Lue, professor and vice chair of Urology at UC San Francisco, emphasized the patient's lifestyle when treating ED.
"Number one is education," said Lue. "That's better than any surgery."
He said he focuses holistic treatments, then prescribes medication if the problem isn't solved. For instance, Lue said men experiencing daily, chronic stress can experience erectile dysfunction as a result. "Surgery is a last resort," said Lue. "Penile implants are much more invasive and have a higher rate of complication, especially for patients with underlying conditions like obesity and high blood pressure."
Penile implants: An 'on demand' erection for men
Penile implants, invented in 1973, were once considered the gold standard of ED treatment before the widespread use of Viagra and ot her treatments.
There are two main types of penile implants, each with advantages and disadvantages. The patient and his doctor decide what's best after considering factors such as age, overall penis size and ratio between the visible and internal portions of the penis.
An inflatable penile prosthesis is the most common type of implant. When a man is ready for sex, he squeezes a pump implanted in the scrotum, which transfers saline solution from a reservoir behind the groin to cylinders in the shaft, taking the penis from soft to hard.
"It takes a couple of minutes, depending on how hard you squeeze the pump," said Montague. "The bigger the penis, the longer it takes."
The other type of implant is a semi-rigid penile prosthesis, which is an implanted device composed of two malleable stainless steel wires surrounded by silicone. In essence, the penis is always erect and is manually bent up or down depending on the man's needs.
Experts say men with penile implants report higher levels of satisfaction compared to those using medications or injections partly because the implant is part of the body and is not visible from the outside. Penile implants have no impact on pleasure sensation, and ejaculation also functions normally, according to experts.
Erectile dysfunction cases are increasing
Over the past 10 years, erectile dysfunction has almost doubled, according to Paduch. "This is partly due to the increased prevalence of obesity and diabetes, but also because patients and doctors are more knowledgeable."
Paduch also notes that ED awareness has benefited from lots of publicity, thanks to television advertising for medications such as Viagra.
Broadly, erectile dysfunction can be either organic -- meaning physiological -- or psychological, or a combination of both.
One study estimates that nearly 20% of all men over the age of 20 in the United States live with erectile dysfunction.
Th e prevalence of erectile dysfunction is highly correlated not only with age, but also with cardiovascular risk factors. "Anything that is bad for your heart is also bad for your penis," said Paduch. That's why lifestyle changes such as smoking cessation, increased exercise and weight loss have shown to help treat erectile dysfunction, especially as men age.
But aging alone isn't a sentence for ED, said Montague. "Men who are healthy are not expected to lose erectile function solely on the basis of age. However, with each decade of life there is a higher and higher rate of men with ED because of age-related disorders ... which pile up and can cause erection problems."
Paduch said men shouldn't be afraid to discuss any sexual problems with their physician.
"We approach the issue in a matter-of-fact way, so most patients are not embarrassed, as you might think they would be."