Currently available options for patients with ED include, in addition to sextherapies, oral pharmacotherapy, intraurethral and intracavernous PGE1, vacuum devices and penile implants. Phosphodiesterase 5 inhibitors offer the less invasive and the most manageable option but their efficacy is limited in patients with severe organic factors. Intraurethral and intracavernous PGE1 and vacuum devices represent powerful second line therapies. However some patients fail with PGE1 and vacuum and should be referred to urologists for penile implants.

The first penile implant procedure has been described in 1936 by Bogoras who inserted a section of rib cartilage into a reconstructed penis. Penile prosthetic surgery became popular in the early 1970s when Scott introduced the first inflatable penile prosthesis. Numerous papers in the last recent years have stigmatized visible improvements in materials and surgical techniques. Antibioprophyllaxy, use of specific surgical areas and sterile ways have produced very significant reductions in complications rates as infections, cylinders extrusions and urethral perforations. Patients with working devices have reported very high satisfaction, better quality of life and improvements in self esteem and partner relationship. However some studies indicate reasonable level of satisfaction post-operatively, although success rate in term of satisfaction are not as high as success rate in term of a good surgical result. Presumably, the patient or couple who is dissatisfied post-operatively yet has a good surgical result did not have expectations met. Ideally, penile prosthesis implantation should include at least one preoperatively counseling visit with a sex therapist and one or more visits as needed postoperatively.

Some surgeons and particularly some urologists are interested in and well trained on penile surgery. However, country differences in penile implants surgical activities can be very important. Thus, the ratio for penile prosthesis implantations between US and France is close to 1 to 10. Such variation cannot be explained only by cultural differences and lead us to consider that penile implants image is not very positive in France. It is never easy for the patients and their general practitioners to accept the proposition of prosthetic implantations. It is common in France that, when sex therapists give information to the patient or couple, when they explain that there are various treatment options for erectile dysfunction, they don’t include penile prosthesis implantation or they discussed very strongly of complications. Sometimes, the patient is referred to a urologists that decline the prosthetic surgery because of insufficient training. Urologists and sexologists organized a round table in the French sexological meeting in Marseille on 2006. As it has been previously reported in UK, only a few French surgeons implanted more than 10 or 20 prostheses per year. They decided together that the first step to develop penile prosthesis implantations in France was to increase the surgical level of French urologists. A national 2 years post-graduate training and academic certification has been proposed. First sessions will start on November 2008. The program include not only surgical indications and techniques but also sexological evaluation and management of the couple.