International Journal of Impotence Research (2003) 15, 152–155

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Original Research
Spontaneous tumescence after implantation of three-piece
hydraulic penile prostheses: a short-term experience
M Manning1, FJ Martı́nez, P Alken3 and K-P Jünemann2
1
Department of Urology, University-Hospital of the Justus-Liebig-University, Giessen, Germany; 2Department of Urology,
University Hospital of the Christian-Albrechts-University of Kiel, Germany; and 3Department of Urology, University
Hospital Mannheim, Carl-Ruprechts-University of Heidelberg, Germany

We evaluated spontaneous tumescence after penile prostheses implantation in a retrospective

study. A total of 32 patients with three-piece hydraulic implants (17 Mentor Alpha I, 15 AMS Ultrex
Plus) were enrolled. Consultation, personal interviews and questionnaires for both the patients and
their partners provided the necessary information. The average follow-up period was 29 months. In
total, 50 % of the patients reported spontaneous tumescence without activation of the implant and
one further patient (3%) claimed full rigid spontaneous erections. General satisfaction with the
prosthetic result was high at 91%. The following complications arose: one case of prosthesis
infection, one case of mechanical failure, one case of cylinder dislocation and two cases of
paraphimosis. A possible explanation for spontaneous tumescence after penile prosthesis
implantation is the elevated preload of the compressed rather than destructed cavernous tissue.
The artificial erection evoked by the prosthesis then takes the form of a normal physiological
reaction and/or a good objective ridigity, and could account for the high patient satisfaction rate
with three-piece hydraulic implants.
International Journal of Impotence Research (2003) 15, 152–155. doi:10.1038/sj.ijir.3900979

Keywords: erectile dysfunction; hydraulic three-piece penile implant; spontaneous tumescence;

corpus cavernosum

Introduction plantation, some patients report regular sponta-

In spite of the latest pharmacological developments
and advances in the treatment of erectile dysfunc-
tion, one group of patients still remain nonrespon-
ders to oral or intracarvernous pharmacological
therapy. The general alternative option for this
group is the surgical management of their impo-
tence. Vascular penile surgery is only successful in
certain selected groups of patients and therefore,
implantation of penile prosthesis is an alternative in
the unsuitable candidates for this type of surgery.
Although long-term satisfaction is high (up to over
90% after 4 y),1 a general point to be considered is
the destructive aspect of penile prosthesis implanta-
tion. It is a common belief that erectile tissue is
destroyed when the corpora cavernosa are dilated to
make room for the cylinders of the implant.
Surprisingly, subsequent to penile prosthesis im-
*Correspondence: FJ Martı́nez MD, PhD, Department of
Urology, University Hospital of the Christian-Albrechts-
University, D-24105 Kiel, Germany.
E-mail: fmartinez@urology.uni-kiel.de
Received 26 August 2002; revised 5 November 2002;
accepted 23 November 2002
neous tumescence. Although the remaining
functional cavernous tissue between the prosthetic
cylinder and the tunica albuginea plays an impor-
tant part in soft penile prosthesis implantation,2 the
same has not yet been evaluated for hydraulic three-
piece implants.
We investigated whether the corpora cavernosa
are still capable of tumescence or even spontaneous
erection after the implantation of hydraulic three-
piece prostheses.
Materials and methods
Patient population
A total of 32 patients were evaluated. Mean age at
the time of surgery was 56 y (41–71 y). All patients
had organic erectile failure (see Table 1) and were
nonresponders to intracavernous injection of papa-
verine/phentolamine (max. dose of 30 mg papaver-
ine + 1 mg phentolamine) and/or prostaglandin E1
(max. dose of 40 mg). The mean persistence of
impotence at penile prosthesis implantation was
7.4 y (1–20 y). Owing to the fact that a high number

Table 1 Origin of the erectile failure of the study patients
n=32
Diabetes mellitus
Arterial hypertonia
Hypercholesterolemia and obesity
Chronic renal failure
Multiple sclerosis
Neurogenic injuries after surgery or trauma
of patients in this cohort had a long persistent
erectile dysfunction of up to 20 y and since some
implants were done more than 8 y ago the IIEF
questionnaire could not be used because it was not
available at that time. Several patients, most of them
in other institutions, had already previous surgery
for erectile dysfunction: five penile revasculariza-
tion, five penile implants and one both revascular-
ization and implant.
Spontaneous tumescence after penile prostheses implantation
M Manning et al
153
ported full rigid erections without activation of the
prosthesis. In the remaining 47%, no spontaneous
action of the corpora cavernosa was experienced.
Out of the 17 patients reporting spontaneous
20
12
tumescence or erection, seven had a Mentor
14 Alpha-1 and 10 an AMS Ultrex Plus prosthesis. In
6 consequence, there was spontaneous tumescence in
2 41% (7/17) of the Mentor Alpha-1 patients and in
6 59% (10/15) of the AMS Ultrex Plus group (Table 2).
The mean frequency of the reported spontaneous
tumescence was 5 per month. Spontaneous tumes-
cence inadequate for sexual intercourse was experi-
enced by all patients except one, who reported full
erection.
Out of the 17 patients with spontaneous tumes-
cence or erection, preoperative cavernosography
gave evidence of pathology in 76.5% of the patients
and normal results in 23.5%. One of the patients
had a previous penile implant.

Surgical procedure General satisfaction

Penile prosthesis implantation was performed as a
standardized procedure. All patients were operated
by the same surgeon (KPJ). Intravenous antibiotic
treatment with ofloxacine commenced the day
before surgery and was then orally administered
for further 2 weeks, supplementary combined in the
first 5 days with gentamycin. Standardized washing
procedures were performed in the evening and
morning before surgery.
Three-piece hydraulic prosthesis were implanted
in all patients: 17 Mentor Alpha-1 and 15 AMS
Ultrex Plus. A penoscrotal approach was chosen for
all. The first activation of the prosthesis was made
under supervision of the surgeon at a mean period of
6 weeks after implantation.
Follow-up
In the Mentor Alpha-1 group, 53% of the patients (9/
17) were highly satisfied, 29% (5/17) were satisfied
and 18% (3/17) dissatisfied. In all, 47% of the AMS
Ultrex Plus group (7/15) were highly satisfied, 53%
(8/15) satisfied, no patients were completely dis-
satisfied (Table 3). Only three patients stated that
they would not choose penile prosthesis implanta-
tion again. The mean frequency of prosthesis
activation was 4.5 times per month in the Mentor
group and 6.4 times per month in the AMS group
(mean 5.45 times/month).
Satisfaction in the partner group did not signifi-
cantly differ from the patient group. Three partners
made no comment, 52% (15/29) were highly
satisfied, 38% (11/29) satisfied and 10% (3/29)
dissatisfied. General satisfaction is depicted in
Table 2.

Table 2 Spontaneous tumescence

In our retrospective study, follow-up data were
acquired by patient and partner questionnaires and Spontaneous Without
personal interviews. Physical examination was n=32 erection spontaneous erection
included. The mean follow-up was 29 months (6–
70 months). No patients were lost in the follow-up. AMS Ultrex plus 10 (59%) 5
Mentor Alpha-1 7 (41%) 10
In all 29 patient partners participate in the ques-
tionnaire, and 3 partners made no comment.

Table 3 General satisfaction

Results
Mentor AMS Female
n=32 Alpha-1 Ultrex Plus partner
Spontaneous tumescence
Highly satisfied 9 (53%) 7 (47%) 15 (51%)
Satisfied 5 (29%) 8 (53%) 11 (38%)
Spontaneous tumescence was reported by 16 of 32 Dissatisfied 3 (18%) 0 3 (10%)
patients (50%). One additional patient (3%) re-
International Journal of Impotence Research
 Spontaneous tumescence after penile prostheses implantation
M Manning et al
154
Table 4 Complications after three-piece hydraulic implants
Complications
Implant-associated infection+urethral lesion
Mechanical failure
Perforation of the cylinder
Paraphimoses
Complications
In the 32 patients, infection of the implant in
combination with urethral lesion arose in one,
mechanical failure of the prosthesis (pump failure)
in another and perforation of the cylinders in a
further patient. Successful revision was carried out
in all three cases. Less severe paraphimosis after
prosthesis implantation was observed in two pa-
tients (Table 4).
Discussion
Spontaneous tumescence
The achievement of spontaneous tumescence after
penile prosthesis implantation has already been
reported.3–5 In their pressure measurements made in
1992, Pescarori and Goldstein5 revealed that when
the three-piece hydraulic implants were activated,
the intraluminal pressure was much higher than
arterial pressure, thus resulting in compression of
the arteries and inhibition of the blood inflow.
The development of special penile implants (soft
implants) aimed at avoiding this adverse event. The
objective of the Subrini-type implant2 was to restore
erectile function by the initiation of a new hemody-
namic status in the corpora cavernosa. Dilation of
the cavernous bodies was performed prior to the
implantation of these soft cylinders. Once again, this
demonstrates that this surgical step is not identical
with complete cavernous body destruction.
In our patient population, over one-half (17
patients/53%) of the patients interviewed reported
spontaneous tumescence or even erection with
three-piece hydraulic implants. However, only one
patient reported spontaneous full, rigid erection and
therefore the ability to achieve spontaneous tumes-
cence should not be over-rated and should not
replace the function of the actual prosthesis. In all
remaining patients (n ¼ 16), tumescence was weak
and inadequate for vaginal penetration.
However, not only the corpus spongiosum with
the glans penis, but also the corpora cavernosa
together with the additional relaxation of the
corporal tissue, support in combination with the
activation of the prosthesis in the erectional func-
International Journal of Impotence Research
tion. Patients undergoing penile prosthesis implan-
tation should be informed of the possibility of
n additional physiological tumescence or rigidity of
the penis and should be encouraged to utilize
1
1
effectively this for sexual intercourse so that the
12 erection experienced resembles the normal physio-
2 logical type.
Hypothetical mechanism
Hypothetically, spontaneous tumescence after pe-
nile prosthesis implantation could be explained by
the elevated preload of likely compressed rather
than destructed cavernous tissue that allows the
easier induction of tumescence and erection.
Subrini et al2 postulated various factors involved
in the restoration of erectile function by soft penile
implants. The implant reduces the volume of the
cavernous body, which in turn leads to hemody-
namic effects. The compression of the cavernous
bodies between the implant and the tunica albugi-
nea significantly lowers the blood inflow necessary
for the attainment or maintenance of rigid erec-
tion.2,3
Another hypothesis favors an elevated preload
and easier venous compression as the underlying
mechanism of spontaneous tumescence with penile
implants.6 So in our study the patients with a
minimum of arterial blood inflow were able to
develop spontaneous penile tumescence after penile
prosthetic implantation. Of the 17 patients who
reported spontaneous tumescence, in 13 patients the
reason for their ED was an arteric vascularization
failure. In summary, the 50% patients with lack of
spontaneous erections were patients with reopera-
tion and caverno-venous failure. A possible expla-
nation could be scar formation that created caverno-
venous insufficience. The other 50% that did
develop tumescence, clearly demonstrate that the
dilatation of intracavernous smooth musculature
does not destroy erectile tissue, if it just pushes
the cavernous tissue aside during the operation.
This preserves partial erectile ability because the
intracavernous volume that has to be filled in order
to achieve an erection (intracavernous or penile
preload) is reduced, thus allowing the remaining/
surviving erectile tissue to relax and so to fill up the
cavernous or lacunar space, which in consequence
causes penile tumescence.
Interestingly, fibrosis of cavernous tissue does not
necessarily have a negative impact on spontaneous
tumescence. A total of 11 patients with previous
penile surgery were included in our series of 32
patients. One (previous penile prosthesis) of these
also reported regular spontaneous tumescence.
However, 10 out of these 11 males with previous
surgery (91%) did not experience tumescence,
whereas only five out of the remaining 21 patients

without previous penile surgery (24%) experienced
no spontaneous tumescence/erection at all. These
statistics positively predict an additional physiolo-
gical erectile component during sexual intercourse
in patients without previous surgery.
Consequences
During dilatation of the corpora cavernosa for penile
prostheses implantation, surgeons should be made
aware of the possibility of preserving the corpora
cavernosa tissue. Crude dilatation maneuvers
should be avoided for numerous reasons. On the
other hand, incomplete dilatation can cause severe
complications such as ill-fitting implants.
Satisfaction with three-piece penile implants
In our series, general satisfaction with three-piece
hydraulic penile implants was high (91%) and is
comparable with the latest published results of 65–
90%.6–8 Phenomenally, spontaneous tumescence
can transform the artificial erection with penile
implants into a more normal physiological erection,
which could explain the high satisfaction rate. The
partners were especially satisfied about the cosmetic
and functional results. Furthermore, the simple
manual handling of the prothesis was often men-
tioned in our questionnaire to be of high value for
the patients and their partners.
Conclusions
In all, 53% of patients report spontaneous tumes-
cence with three-piece hydraulic penile implants.
Spontaneous tumescence after penile prostheses implantation
M Manning et al
155
With one exception, this tumescence was inade-
quate for sexual intercourse in all of these patients.
We demonstrated that the destruction of cavernous
tissue during dilatation was incomplete and tumes-
cence, even with three-piece hydraulic implants,
was not completely prevented by the compressed
arteries in the remaining cavernous bodies. A more
normal physiological cavernous reaction (relaxa-
tion) improving the objective rigidity after prosthe-
sis implantation could be responsible for the
reported high satisfaction rate with this type of
implant. This phenomenal aspect will be addition-
ally enlightened in further investigations.
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International Journal of Impotence Research