And now for the perhaps shocking news: there are times when Viagra, Cialis and Levitra are of no help at all for treating erectile dysfunction. You have all been persuaded to believe that Viagra and the other PDE-5 inhibitors will always be able to help, even if only a little. Unfortunately, that's not true. There are times when the degree of damage is too great for a "natural" solution. And let's be clear. In relative terms, the use of and the others allows the body to respond to sexual stimulation as it was designed to do. Viagra simply removes a physical barrier to a natural erection.

This means we are into the surgical options. The first to mention is vascular reconstructive surgery. In a small number of cases, the surgeon may be able to reconstruct the arteries so that blood will flow more freely into the corpus cavernosum. Alternatively, surgery may help those suffering from venous leakages. When the blood inflates the corpus cavernosum, it compresses the veins that allow the blood to drain out of the penis. If the compression is inadequate, the blood will not be retained inside the corpus and the erection will deflate. Unfortunately, the surgical theories have mostly failed in practice. Only about 5% of those having reconstructive surgery have found improved performance. This surgery is expensive. It is a long and difficult operation, and any incision can cause nerve damage. So it is not often used today.

Thus, when all else has failed or is not acceptable for some reason, we come to the somewhat radical solution of implanting a penile prosthesis.

How does this work?
There are three tubes in the penile shaft. Running along the bottom of the penis, the urethra drains the urine from the bladder out of the body through the penis. Along the top of the penis, the two more substantial tubes run side-by-side. They are designed to work in much the same way as the tyre on a car, i.e. with an inner and outer tube. So when the inner tubes fill with blood, they push against the outer tubes and, as the volume of blood increases, lift the penis into an erect position.

Since the 1930s, medical researchers have been experimenting with implants to mimic this process of inflation and create the effect of an erection. We therefore have more than seventy years of experience among more than one million men to draw on. Two different approaches have come to dominate. One range of implants remains semi-rigid. These devices are easy to implant and very rarely fail mechanically. The problem, however, is that they produce a permanent erection which can be difficult to conceal. Although they may be flexed up and down, most have limited mobility. The Dura II manufactured by American Medical Systems (AMS) has a more sophisticated system relying on interlocking disks strung on a central cable under tension which offers greater control over positioning, but may have an increased risk of mechanical failure.

The others are hydraulic, e.g. Dynaflex and CXM, and inflate, relying on a pump contained inside the scrotum to transfer fluid (almost always water) from a reservoir inside the abdomen. These devices may have:

1.one, rod-like inflatable chamber which is hinged;
2.a two chamber system, e.g. the Ambicor; or
3.a three chamber system. All these systems replace the original corpa cavernosa. Today's three-piece inflatable devices produced by AMS and Mentor Corporation offer flaccidity and erections that approach the natural state. Whichever system you opt for, you should expect some pain and discomfort for five or six weeks following surgery. And, once installed, the implants cannot replace the "real thing". Thus, if you have already lost your libido, it will not return. Similarly, if the nerve damage had caused a loss of sensation, or you were unable to achieve orgasm or ejaculation, prosthetics will not restore those functions.So what are the advantages of this technology? Well, when the oral medications such as Viagra, and have failed, the convenience factors of the alternatives become important. Implants are safe and work no matter what the original cause of the ED. They are particularly useful to treat cases of damage following priapism and Peyronie's Disease, fibrosis after injections, and to restore function after surgery for prostate cancer. So long as the partners are counselled on the strengths and weaknesses of the systems available, they provide satisfaction in more than 90% of all cases. Once installed, there are no further costs and they require no further maintenance (only about 3% of all installed devices ever need attention). From a psychological point of view, there is no external equipment to distract - as in the case of injections and vacuum devices. Equally, there is no need to remember to bring the Viagra, Cialis or Levitra along. If you are in the mood, you can simply act without having to wait for the medication to take effect.
Nevertheless, there are disadvantages to consider. This is a once-and-for-all procedure. Once the implant has been installed, it is no longer possible for a natural erection to occur. It is always possible that, as science develops, different non-invasive procedures may become available. One may solve the ED problem you have. If your view is that a more natural form of treatment is better, then you may decide to wait. On the issue of informed consent, there are always risks in surgery involving an anaesthetic. In particular and despite a coating of antibiotics to modern implants, you will learn there is a small risk of infection following the surgery. This is relatively rare, but if it does occur and irrigation fails, the only response is to remove the prosthesis. However, once installed, there are three more general complaints.

1.Because the erection is not being caused "naturally", the systems only produce hardness in the body of the penis. Neither system affects the head of the penis which remains soft. This can feel unsatisfactory and make penetration uncomfortable.
2.The body of the penis does not warm as in the natural erection which can feel strange to your partner.
3.The surgery can sometimes produce a shorter penis which you and your partner may find unsatisfactory.
Finally, let's dispose of one more general worry that some of you may have. There have been a number of problems with the safety of some silicone implants, e.g. in breast enhancements. None of the inflatable prostheses use any form of silicone as the fluid.