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Devices such as inflatable penile prostheses (IPP) can be used to achieve erectile rigidity after phalloplasty in assigned female at birth (AFAB) individuals. The approach to inserting an IPP in a neophallus is different and more challenging compared to that of an anatomical penis due to the absence of anatomical structures such as the corpora cavernosa, and the more tenuous blood supply of the neophallus and reconstructed urethra. In addition, the ideal surgical techniques and devices for use in the neophallus have not been defined. This review systematically summarises the literature on the insertion of IPP in the neophallus of individuals AFAB. In particular, the described techniques, types of devices used and peri-operative and patient-reported outcomes are emphasised. An initial search of the PubMed database was performed on 16 September 2022 and an updated search was performed on 26 May 2023. Overall, 185 articles were screened for eligibility and 15 studies fulfilled the inclusion criteria and were included in the analysis. Two studies reported outcomes on the zephyr surgical implant 475 FTM device and the others reported outcomes on the Boston Scientific AMS 600/700TM CX 3-piece inflatable, AMS AmbicorTM 2-piece inflatable, Coloplast Titan® or Dynaflex devices. Overall, 1106 IPPs were analysed. The infection rate was 4.2%–50%, with most studies reporting an infection rate of <30%. Mechanical failure or dysfunction occurred in 1.4%–36.4%, explantation was required in 3.3%–41.6%, and implant revision or replacement was performed in 6%–70%. Overall, 51.4%–90.6% of patients were satisfied and 77%–100% were engaging in sexual intercourse. An IPP in a neophallus is an acceptable option to achieve rigidity for sexual intercourse. However, this challenging procedure has good reports of patient and partner satisfaction despite significant risks of complications.

Injection of exogenous material into the penis and scrotum has been performed for augmentation purposes. Complications include cosmetic dissatisfaction, penile necrosis and lymphoedema. We report the complications and outcomes from a single centre with an updated systematic review of the literature. A retrospective review of all cases presenting with foreign substance injection into the genitalia, over a 10-year period was performed. Thirty-five patients with a mean (standard deviation (SD); range) age of 36.9 (±9.1; 22–61) years at presentation were included. The mean (SD; range) time between injection and presentation was 7.8 (±5.8; 1 day–20 years) years. The most common injected substance was silicone ( n  = 16, 45.7%) and liquid paraffin ( n  = 8, 22.9%). The penile shaft (94.3%) was the most injected site. The most common presentations were cosmetic dissatisfaction (57.1%) and pain and/or swelling (45.7%). Surgery was required in 32 (91.4%) cases. Primary procedures included local excision and primary closure ( n  = 19, 59.4%), circumcision ( n  = 5, 15.6%), excision with a split skin graft or a scrotal flap reconstruction ( n  = 5, 15.6%). Three (8.6%) patients presented with necrosis and required acute debridement. Overall, 18 patients had more than 1 procedure, and 8 patients required 3 or more procedures. A systematic search of the literature identified 887 articles of which 68 studies were included for analysis. The most common substance injected was paraffin (47.7%), followed by silicone (15.8%). The majority of patients (77.9%) presented with pain, swelling or penile deformity. 78.8% of the patients underwent surgical treatment, which included excision and primary closure with or without the use of skin grafts (85.1% of all procedures), the use of flaps (12.3%) and penile amputation ( n  = 2). Complications of foreign body injection into the male genitalia can be serious resulting in necrosis and autoamputation. Surgical intervention is often required to excise abnormal tissue to manage pain and improve cosmesis.

Genital gender affirmation surgery (gGAS) for individuals assigned female at birth (AFAB) is complex and requires the staged insertion of an erectile device to permit penetrative intercourse. This final stage of gGAS is challenging, owing to the variable anatomy and lack of supportive structures within the neophallus when compared with erectile device insertion for individuals assigned male at birth. There is a paucity in the literature at present regarding erectile device insertion in trans-sex AFAB patients. Hence, a narrative review following a literature review and supplemented by expert opinion from a high-volume centre of expertise is presented. The choices available for erectile device in this patient cohort are discussed. Principle surgical steps required for this complex surgery is outlined along with the recommended postoperative management of the patient. Postoperative outcomes and complications are also summarised in this fast-developing surgical procedure.

Purpose of Review Adult males with exstrophy-epispadias complex (EEC) are commonly dissatisfied with their genitalia and desire greater sexual normality. These patients have typically had several previous genital/pelvic procedures and there are specific considerations that must be taken into account if operative intervention is being considered. Genital reconstruction in the form of phalloplasty presents an option for improving sexual function. Recent Findings The majority of studies have focused on the radial free forearm flap (RFFF) phalloplasty with subsequent insertion of penile prosthesis (PP). Long-term cosmetic and functional satisfaction is high. Early urethral complications are common and PP-related complications are higher than in other patient populations. Summary Genital reconstruction is a safe procedure for EEC males with good long-term functional and cosmetic satisfaction. RFFF phalloplasty represents the most complete surgical option and should be considered in carefully selected patients.

Surgery for male factor infertility broadly involves either reconstructive techniques for obstructive azoospermia (OA) or sperm retrieval techniques for nonobstructive azoospermia (NOA). OA can occur at any site along the male reproductive tract. Approximately 6% of infertile men have an obstructive etiology for their infertility. Intratesticular obstruction at the level of the efferent ductules is rare and not amenable to microsurgical reconstruction. Ejaculatory duct obstruction (EDO) is due to stenosis of the ejaculatory ducts or obstruction secondary to congenital cysts, most commonly Mullerian duct cysts. NOA is caused by impaired spermatogenesis within the testicles. A combination of radiologic investigations and serum levels of follicle stimulating hormone (FSH), luteinizing hormone (LH) and testosterone will provide further information as to whether the underlying factor is NOA or OA. Obstructive azoospermia secondary to a vasectomy for sterilization is amenable to surgical reconstruction by performing a vasovasostomy.

This chapter gives an overview of genital reconstructive surgery that is available for trans-males in the UK, but the methods and rationales can be easily applied to any other country offering similar surgery. Some techniques that are not available in the UK have also been included for completeness. The discussion is specifically oriented to the various modifications of the techniques available for those patients identifying toward the male end of the spectrum of non-binary gender. The descriptions are based on real-world discussions and interviews with patients, and show how typical patient requests can be translated via surgical procedures to get the desired outcome.

The erect penis consists of two fibro-elastic tubes (tunica cavernosa), which are filled with blood under high pressure (100-200mmHg). If a shearing force is applied or the erect penis is suddenly bent, the intracavernosal pressure momentarily rises to supramaximal levels causing rupture of the tunica cavernosa.

Genitourethral emergencies may be secondary to ischemic, infective or traumatic conditions which require emergency surgery to minimize tissue damage and maintain long‐term function. Priapism is classified as ischemic (low flow), nonischemic (high flow) or intermittent (stuttering). Although poorly understood, recurrent priapism is common in patients with sickle cell disease although idiopathic stuttering priapism is now also increasingly recognized. Provided that the ischemic priapism is treated promptly, penile detumescence is successful and erectile function is preserved. A penile fracture is characterized by pain, swelling of the penile shaft, immediate detumescence and an audible “crack.” The significant swelling and ecchymosis is likened to an eggplant and is called the “aubergine sign.” If the hematoma is limited by Buck's fascia the swelling is restricted to the penile shaft.