Evaluating the appropriateness of penile prosthesis in non-organic erectile dysfunction and premature ejaculation: a Delphi consensus among penile implant surgeons

Abstract

Background: Non-organic erectile dysfunction (ED) and premature ejaculation (PE) are common conditions for which European Association of Urology guidelines lack specific recommendations on penile prosthesis implantation (PPI).

Aim: To establish expert consensus on the role of PPI in non-organic ED and PE using the Delphi method.

Methods: A panel of 24 international penile implant surgeons with significant experience in PPI participated in a 3-round Delphi consensus between February and May 2025. Participants were mainly European-based (Italy, n = 16; Turkey, n = 4; United Kingdom, n = 2; Spain, n = 1; Germany, n = 1). Two online questionnaire rounds were followed by a final virtual meeting. Topics included diagnostics, treatment hierarchy, indications for PPI, ethical concerns, surgical risks, patient satisfaction, partner's involvement, and follow-up strategies. Consensus was defined as ≥75% agreement or disagreement on Likert-scale items.

Outcomes: Expert consensus was reached on all 53 items, including the ones regarding the appropriateness of PPI in non-organic ED and PE.

Results: Experts agreed on the importance of thorough psychosexological assessment, standardized diagnostic tools, and exhausting conservative treatments before considering PPI in non-organic ED. Seventy-five percent supported PPI as a last-resort option in non-organic ED, provided psychological evaluation and informed consent protocols are in place. In contrast, the panel rejected PPI as a treatment for pure PE due to insufficient evidence and lack of clinical experience. Emphasis was placed on ethical safeguards, long-term follow-up, and partner involvement in decision-making.

Clinical implications: These findings suggest that, under strict conditions, PPI may have a role in treatment-resistant non-organic ED but not in pure PE.

Strengths and limitations: Limitations include the inherent subjectivity of the Delphi methodology and the restricted representativeness of the panel, which was mainly European-based and composed exclusively of urologists specializing in penile implants.

Conclusion: Selective use of PPI in non-organic ED is supported by expert consensus, while its use in pure PE is not; updated guidelines and further research are warranted.

Keywords: consensus; erectile dysfunction; penile prosthesis; premature ejaculation; psychosexual disorders.