ABSTRACT
Objectives
To culturally adapt and psychometrically validate an Arabic version of the Satisfaction Survey for Inflatable Penile Implant (SSIPI-AR) for assessing patient satisfaction after inflatable penile prosthesis (IPP) implantation among Arabic-speaking men.
Methods
We performed a cross-cultural translation and validation study of the 16-item SSIPI using forward translation, synthesis, back-translation, expert committee review, and pilot testing. Adult Arabic-speaking men (≥18 years) who had undergone IPP implantation 6 months to 5 years prior were recruited. Participants completed the SSIPI-AR at baseline and again after 2 weeks. Construct validity was evaluated using exploratory factor analysis (EFA). Reliability was assessed via internal consistency (Cronbach’s alpha) and test – retest reliability (intraclass correlation coefficient, ICC). Satisfaction was summarized using total and domain scores.
Results
Fifty men were included (mean age 57.5 ± 10.5 years). EFA supported retention of all 16 items with acceptable sampling adequacy (KMO = 0.505) and a significant Bartlett’s test (p < 0.001). Four factors explained 81.83% of total variance: Implant Functionality and Usability (6 items), Overall Sexual Confidence and Satisfaction (5 items), Penile Appearance and Regret (3 items), and Concealability and Flaccid Appearance (2 items). Internal consistency was high for the total scale (Cronbach’s alpha = 0.897) and subscales (0.816–0.924). Test – retest reliability was excellent (total ICC = 0.985; subscale ICCs 0.958–0.990; all p < 0.001). Mean total satisfaction was 75.31/80 (94.13%), with domain satisfaction ranging from 90.27% (appearance/regret) to 94.45% (sexual confidence/satisfaction).
Conclusions
The SSIPI-AR demonstrates strong construct validity, high internal consistency, and excellent test – retest reliability, supporting its use as a brief, culturally appropriate, implant-specific patient-reported outcome measure for quantifying satisfaction after IPP implantation in Arabic-speaking populations.
KEYWORDS: Satisfaction, penile prosthesis, SSIPI, Arabic, translation, validation
Introduction
Erectile dysfunction (ED) is defined as the persistent inability to achieve and/or maintain a penile erection of sufficient rigidity for satisfactory sexual activity for more than 3 months [1]. ED becomes more common with advancing age. Global estimates indicate that over 150 million men were affected in the mid-1990 s, and the burden was projected to reach approximately 322 million by 2025 [2,3]. This increase is thought to parallel longer life expectancy and the rising prevalence of comorbidities and established risk factors for ED [4]. In their global review, Kessler et al. reported that population-based prevalence estimates vary markedly across regions ranging from 3% to 76.5% and are largely due to differences in age structure, ED definitions, and assessment methods [5]. In Qatar, ED prevalence was estimated at 54.5% among men older than 40 years, with significant associated risk factors including age, diabetes, hypertension, and coronary artery disease [6].
Penile prosthesis (PP) implantation is an established treatment for men with ED who have an inadequate response to medical therapy, cannot tolerate pharmacotherapy, or who prefer a definitive, long-term solution. The AUA ED guideline emphasizes patient counseling and shared decision-making and supports consideration of PP implantation as a valid option, rather than positioning it strictly as a ‘last resort’ after exhausting all medical therapies [7].
Globally, penile implant surgery has shown a steady increase, with an average annual growth rate of 8.1% between 2006 and the end of 2010. During this period, 39,430 implants were recorded by AMS and 23,583 by Coloplast [8]. A systematic review identified 27 studies reporting a total of 447,204 PP surgeries performed between 1988 and 2019 [9].
Satisfaction following inflatable penile prosthesis (IPP) implantation is a central outcome in contemporary ED care, complementing traditional surgical endpoints such as complications and device survival. While published series generally report high patient and partner satisfaction, comparisons across studies remain challenging because satisfaction is frequently measured using non-uniform instruments or center-specific assessments. For example, a Barcelona tertiary referral center (Italy/Spain) with 576 PP implants performed between 2008 and 2018 reported 82% patient satisfaction and 88.3% partner satisfaction, but relied on internal outcome assessment rather than a widely validated satisfaction questionnaire [10]. Likewise, a recent Jordan-led study including patients from eight Middle Eastern countries (2018–2023) reported an 89% satisfaction rate using the Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) after penile implant surgery [11].
To capture outcomes beyond erectile function alone, satisfaction is commonly evaluated using validated instruments such as the International Index of Erectile Function (IIEF), the EDITS, and implant-related quality-of-life tools (e.g. QoLSPP). However, these measures were not developed specifically as IPP satisfaction instruments, and may not fully reflect domains unique to prosthesis users (e.g. device usability, concealability, rigidity adequacy, and partner-related perspectives).
In 2021, the Satisfaction Survey for Inflatable Penile Implants (SSIPI) was introduced as the first validated English-language patient-reported outcome measure (PROM) designed specifically to assess satisfaction with IPP, enabling standardized and systematic collection of satisfaction data in both clinical practice and research [12]. Nevertheless, SSIPI is currently validated in English [12], French [13], and Spanish [14] limiting its applicability in Arabic-speaking settings and underscoring the need for a culturally appropriate Arabic translation and validation.
To this date, SSIPI was not translated and culturally adapted to Arabic language. We elected to translate and validate SSIPI to Arabic language, as it is a simple, short and strongly validated questionnaire. When translated to Arabic language, this questionnaire will serve as an important tool to evaluate outcome of the IPP and assess satisfaction of the patients and address their concerns. Once established and published, it can be utilized in 22 Arabic-speaking countries, where many patients do not speak or read English. We expect that the Arabic version, that will be translated and validated following the guidelines for cross-cultural adaptation of health-related QoL measures [15], will yield a good reliability and validity as was noted in the original version.
Materials and methods
Study design and procedures
This was a cross-cultural translation and psychometric validation study designed to translate the SSIPI into Arabic (SSIPI-AR) and to evaluate its validity and reliability among Arabic-speaking men who previously underwent IPP implantation. Participants completed the SSIPI-AR at enrollment and again two weeks later to assess test-retest reliability. In parallel, relevant sociodemographic, clinical, and prosthesis-related variables were collected using a standardized data collection sheet, including prosthesis characteristics and postoperative complications (e.g. infection, erosion, explantation, and reimplantation). Complications were ascertained through structured review of the electronic medical record (clinic documentation, emergency visits, admissions, and operative notes when applicable), and supplemented by focused history taking for events managed outside the treating institution.
Setting and sample
Participants were recruited from andrology clinics at the Ambulatory Care Center, Hamad Medical Corporation (HMC), Qatar, during routine follow-up visits. Adult Arabic-speaking men (≥18 years) who had undergone IPP implantation 6 months to 5 years prior to enrollment were eligible. This postoperative interval was intentionally selected to align with the timeframe used in the original validation study of the SSIPI [12]. The lower limit of 6 months was chosen to allow adequate postoperative recovery, resolution of acute surgical discomfort, and sufficient experience with device use before satisfaction assessment, while the upper limit of 5 years was intended to include patients still likely to be actively using the prosthesis while limiting the influence of very long-term recall bias and late device-related factors. Exclusion criteria included prior repeat surgery (explantation and reimplantation) and presence of an actively infected, malfunctioning, or eroded prosthesis at the time of assessment.
Translation and validation procedure
The translation and cultural adaptation process followed a standardized forward translation, synthesis, back-translation, and expert committee review approach to ensure conceptual equivalence and cross-dialect comprehensibility.
Translation (forward translation and synthesis)
The original English SSIPI was independently forward-translated into Arabic by two urologists and an externally certified medical translator whose native language was Arabic. The translated versions were reviewed and reconciled in a consensus meeting to generate a single synthesized Arabic draft using clear, patient-friendly language.
Back-translation and reconciliation
The synthesized Arabic draft was back-translated into English by two independent urologists and an externally certified medical translator whose native language was English and who were blinded to the original wording. The back-translated version was compared with the original SSIPI, and discrepancies were resolved through consensus to confirm conceptual equivalence and linguistic accuracy.
An expert committee then reviewed the pre-final Arabic version, comprising at least four andrologists and two independent expert urologists from different Arabic-speaking countries, to evaluate feasibility, formatting, style, and clarity across dialects and accents. The committee produced the final SSIPI-AR version for psychometric testing (Appendix 1).
Pilot testing
Pilot testing was conducted through interviews with a small number of patients who had undergone IPP implantation at least six months earlier. Feedback focused on clarity, comprehension, and acceptability of wording and response options. Minor linguistic refinements were made where necessary before finalizing the SSIPI-AR for field administration.
Construct validity assessment
Construct validity was evaluated by examining the underlying factor structure of the SSIPI-AR using exploratory factor analysis (EFA) with principal component analysis (PCA) and a rotated solution, enabling identification of latent domains and supporting derivation of total and subscale scores.
Reliability assessment
Internal consistency reliability was assessed for the total SSIPI-AR scale and its subscales using Cronbach’s alpha and item-total correlations, with an alpha value > 0.70 considered acceptable [16]. Test – retest reliability was assessed by re-administering the SSIPI-AR two weeks after baseline completion and calculating the intraclass correlation coefficient (ICC).
Ethical considerations
The study protocol was reviewed and approved by the Medical Research Center (MRC), Hamad Medical Corporation, Qatar. The study was conducted in accordance with the Declaration of Helsinki, Good Clinical Practice (GCP), and applicable Ministry of Public Health regulations in Qatar. Written informed consent was obtained from all participants prior to enrollment.
Statistical analysis
IBM SPSS version 26.0 was used to analyze the data. The sociodemographic and clinical characteristics of the patients were analyzed using descriptive statistics. Categorical variables were reported as frequencies and percentages, whereas continuous variables were reported as means with standard deviations (±SD).
EFA with PCA utilizing a rotated matrix was performed to validate the structure of the SSIPI-AR. The Kaiser-Meyer-Olkin (KMO) measure and Bartlett’s test of sphericity were computed to verify the sampling adequacy and the data suitability for factor analysis. Factors with eigenvalues greater than one were retained in the model, and utilized to determine the final SSIPI-AR structure and overall score.
Thereafter, the correlation between each factor and the corresponding latent factor and the overall survey scale was evaluated using Pearson’s correlation. Moreover, Cronbach’s alpha was measured to assess the internal consistency and reliability of the entire scale as well as its subscales. The intraclass correlation coefficient (ICC) was computed to verify test-retest reliability. Results were presented with a 95% confidence interval (CI), and a P value of less than 0.05 with a 5% margin of error was considered statistically significant.
Finally, the SSIPI-AR total and subscale scores were used to assess patient satisfaction with the inflatable penile implant. Mean satisfaction scores and standard deviations were computed, and satisfaction percentages were obtained by dividing the mean score by the highest possible score for each scale.
Results
Demographic and clinical characteristics
A total of 50 patients with IPP were included in the study. The average age of participants was 57.5 years (±10.49), and their average body mass index (BMI) was 28.6 kg/m2 (±4.54). The majority (82%) had completed high school, while only 18% had a university degree. With respect to comorbidities, 78% had been diagnosed with diabetes mellitus, and 60% had been diagnosed with hypertension. Less frequently, 8% and 2%, respectively, had ischemic heart disease and chronic kidney disease. The average number of comorbidities per patient was 5.48 (±0.89). The detailed demographic and clinical characteristics of patients are shown in Table 1.
Table 1.
Demographic and clinical characteristics.
| Variable | Mean or Frequency | SD or Percentage |
|---|---|---|
| Age (years) | 57.52 | 10.49 |
| Weight (Kg) | 84.42 | 17.07 |
| Height (Cm) | 171.24 | 7.64 |
| BMI (Kg/m2) | 28.63 | 4.54 |
| Level of Education | ||
| High Secondary School | 41 | 82% |
| University | 9 | 18% |
| Comorbidities | ||
| Diabetes Mellitus | ||
| No | 11 | 22% |
| Yes | 39 | 78% |
| Hypertension | ||
| No | 20 | 40% |
| Yes | 30 | 60% |
| Ischemic Heart Disease | ||
| No | 46 | 92% |
| Yes | 4 | 8% |
| Chronic Kidney Disease | ||
| No | 49 | 98% |
| Yes | 1 | 2% |
| Total Number of Comorbidities | 5.48 | 0.89 |
| Time between Surgery and Completion of Questionnaire (months) | 14.78 | 4.26 |
SD: Standard Deviation; BMI: Body Mass Index.
Validation of the SSIPI-AR
Factor analysis
Factor analysis with PCA was conducted to assess the structure validity of the SSIPI-AR for measuring satisfaction with inflatable penile implant. All 16 items could be extracted with Varimax rotation. None of the variables exhibited low factor loading (<0.3), low communality (<0.3), or over-correlation (>0.9). The KMO measure of sampling adequacy was 0.505, indicating an acceptable model. Additionally, the Bartlett’s test of sphericity was highly significant (p < 0.001).
The analysis revealed a solution of four factors with Eigenvalues greater than one, and explaining 81.83% of the total variance. Factor 1 comprised 6 items capturing the Implant Functionality and Usability (IFU) domain, with factor loading ranging from 0.534 to 0.897. Factor 2 included 5 items covering the Overall Sexual Confidence and Satisfaction (OCS) domain, with factor loading ranging from 0.557 to 0.933. Factor 3 had 3 items related to Penile Appearance and Regret (PAR) domain, with factor loading ranging from 0.729 to 0.963. Lastly, factor 4 included 2 factors presenting the Concealability and Flaccid Appearance (CFA) domain, with factor loading ranging from 0.839 to 0.908. The Varimax rotated component matrix of the SSIPI-AR is reported in Table 2.
Table 2.
Varimax rotated component matrix of the SSIPI-AR.
| Item Number | Factor | Factor 1 | Factor 2 | Factor 3 | Factor 4 | Communalities |
|---|---|---|---|---|---|---|
| 5 | How bothered are you by the pain or discomfort when the implant is activated/inflated? | 0.897 | 0.849 | |||
| 15 | How satisfied are you with the ease of use of your penile implant? | 0.882 | 0.803 | |||
| 6 | When the implant is inflated, how often does the pain or discomfort limit your ability to use the implant? | 0.881 | 0.880 | |||
| 16 | How satisfied are you with the spontaneity of the erection with the penile implant? | 0.792 | 0.878 | |||
| 14 | How often did the penile implant provide an erection suitable for sexual intercourse? | 0.746 | 0.838 | |||
| 13 | How often have you had difficulty using the pump in your scrotum to inflate or deflate the device? | 0.534 | 0.540 | |||
| 1 | When you attempted sexual intercourse using the penile implant, how often was it satisfactory for you? | 0.933 | 0.945 | |||
| 3 | How confident have you been about your ability to engage in sexual activity with the penile implant? | 0.927 | 0.937 | |||
| 2 | Overall, how satisfied have you been with the penile implant? | 0.877 | 0.873 | |||
| 7 | How satisfied are you with the naturalness of your erection with the penile implant when activated/inflated? | 0.751 | 0.861 | |||
| 12 | How satisfied are you with the location of the pump in your scrotum? | 0.557 | 0.400 | |||
| 9 | How satisfied are you with the girth/width of your erection with the penile implant when activated/inflated? | 0.963 | 0.947 | |||
| 8 | How satisfied are you with the length of your penis with the penile implant activated/inflated? | 0.915 | 0.914 | |||
| 4 | Have you experienced any regret about having a penile implant placed? | 0.729 | 0.741 | |||
| 11 | How satisfied are you with your ability to conceal the implant in its inactivated/deflated state? | 0.908 | 0.901 | |||
| 10 | How satisfied are you with the naturalness of your penis when the penile implant is inactivated/deflated? | 0.839 | 0.785 | |||
| Percentage of variance explained = 81.83% | 26.27% | 24.42% | 17.12% | 14.03% | ||
| Cronbach’s alpha = 0.897 | 0.924 | 0.888 | 0.871 | 0.816 |
Factor 1 = Implant Functionality and Usability (IFU); Factor 2 = Overall Sexual Confidence and Satisfaction (OCS); Factor 3 = Penile Appearance and Regret (PAR); Factor 4 = Concealability and Flaccid Appearance (CFA); Kaiser – Meyer – Olkin (KMO) = 0.505. Bartlett’s test of sphericity: p < 0.001.
Internal consistency
The SSIPI-AR had a high internal consistency for assessing satisfaction with inflatable penile implant indicated by a Cronbach’s alpha of 0.897. The 4-factor domains also demonstrated high Cronbach’s alpha ranging from 0.816 to 0.924 (Table 2). All items of the SSIPI-AR exhibited highly significant correlations with the full scale and the subsequent subscales (factor domains) (all p < 0.01). The Pearson correlation coefficients ranged from 0.469 to 0.822. The correlations of the SSIPI-AR items with the full scale and subscales are shown in Table 3.
Table 3.
Pearson correlation of the SSIPI-AR items with full scale and corresponding subscales.
| Item Number | Item | IFU* | OCS* | PAR* | CFA* | SSIPI-AR* |
|---|---|---|---|---|---|---|
| IFU1 | How bothered are you by the pain or discomfort when the implant is activated/inflated? | 0.886** | 0.681** | |||
| IFU2 | How satisfied are you with the ease of use of your penile implant? | 0.836** | 0.585** | |||
| IFU3 | When the implant is inflated, how often does the pain or discomfort limit your ability to use the implant? | 0.926** | 0.683** | |||
| IFU4 | How satisfied are you with the spontaneity of the erection with the penile implant? | 0.920** | 0.822** | |||
| IFU5 | How often did the penile implant provide an erection suitable for sexual intercourse? | 0.885** | 0.788** | |||
| IFU6 | How often have you had difficulty using the pump in your scrotum to inflate or deflate the device? | 0.720** | 0.599** | |||
| OCS1 | When you attempted sexual intercourse using the penile implant, how often was it satisfactory for you? | 0.936** | 0.721** | |||
| OCS2 | How confident have you been about your ability to engage in sexual activity with the penile implant? | 0.933** | 0.719** | |||
| OCS3 | Overall, how satisfied have you been with the penile implant? | 0.898** | 0.728** | |||
| OCS4 | How satisfied are you with the naturalness of your erection with the penile implant when activated/inflated? | 0.874** | 0.760** | |||
| OCS5 | How satisfied are you with the location of the pump in your scrotum? | 0.634** | 0.469** | |||
| PAR1 | How satisfied are you with the girth/width of your erection with the penile implant when activated/inflated? | 0.946** | 0.526** | |||
| PAR2 | How satisfied are you with the length of your penis with the penile implant activated/inflated? | 0.929** | 0.631** | |||
| PAR3 | Have you experienced any regret about having a penile implant placed? | 0.795** | 0.725** | |||
| CFA1 | How satisfied are you with your ability to conceal the implant in its inactivated/deflated state? | 0.914** | 0.559** | |||
| CFA2 | How satisfied are you with the naturalness of your penis when the penile implant is inactivated/deflated? | 0.924** | 0.499** | |||
| IFU | 0.799** | |||||
| OCS | 0.804** | |||||
| PAR | 0.697** | |||||
| CFA | 0.561** |
*IFU: Implant Functionality and Usability; OCS: Overall Sexual Confidence and Satisfaction; PAR: Penile Appearance and Regret; CFA: Concealability and Flaccid Appearance; SSIPI-AR: Satisfaction Survey for Inflatable Penile Implant Arabic Version. **p < 0.01.
Test-retest reliability
The ICCs for the scores of the SSIPI-AR total score and its subscale scores, initially and after 2 weeks, were measured to evaluate test-retest reliability. The overall SSIPI-AR score displayed an ICC of 0.985, while the ICC values for the subscale scores varied from 0.958 to 0.990. Excellent test-retest reliability was demonstrated by all values being statistically very highly significant (p < 0.001) for both the entire SSIPI-AR and its latent factors. Table 4 presents the ICC for the SSIPI-AR total and subscale scores at test and retest.
Table 4.
Intraclass correlation coefficient for the SSIPI-AR total and subscale scores at test and retest.
| Scale/Subscale | Intraclass Correlation Coefficient | 95% Confidence Interval |
P value | |
|---|---|---|---|---|
| Lower Bound | Upper Bound | |||
| SSIPI-AR* | 0.985 | 0.973 | 0.992 | <0.001 |
| IFU* | 0.971 | 0.949 | 0.983 | <0.001 |
| OCS* | 0.990 | 0.982 | 0.994 | <0.001 |
| PAR* | 0.973 | 0.954 | 0.985 | <0.001 |
| CFA* | 0.958 | 0.928 | 0.976 | <0.001 |
*SSIPI-AR: Satisfaction Survey for Inflatable Penile Implant Arabic Version; IFU: Implant Functionality and Usability; OCS: Overall Sexual Confidence and Satisfaction; PAR: Penile Appearance and Regret; CFA: Concealability and Flaccid Appearance.
Assessment of satisfaction
Table 5 reports patient satisfaction with IPP as measured by the SSIPI-AR total score and its subscale scores. The mean total satisfaction score was 75.31 out of a maximum of 80, reflecting a satisfaction rate of 94.13%. High mean scores were also observed across all subscales, with satisfaction percentages ranging from 90.27% (PAR) to 94.45% (OCS).
Table 5.
Assessment of patient satisfaction using the SSIPI-AR total and subscale scores.
| Scale/Subscale | Mean Score | SD | % of the Mean | Minimum | Maximum |
|---|---|---|---|---|---|
| SSIPI-AR* | 75.31 | 8.05 | 94.13 | 47.00 | 80.00 |
| IFU* | 28.82 | 3.19 | 92.97 | 15.00 | 31.00 |
| OCS* | 23.61 | 3.10 | 94.45 | 14.00 | 25.00 |
| PAR* | 13.54 | 3.00 | 90.27 | 3.00 | 15.00 |
| CFA* | 9.22 | 1.66 | 92.20 | 4.00 | 10.00 |
*SSIPI-AR: Satisfaction Survey for Inflatable Penile Implant Arabic Version; IFU: Implant Functionality and Usability; OCS: Overall Sexual Confidence and Satisfaction; PAR: Penile Appearance and Regret; CFA: Concealability and Flaccid Appearance; SD: Standard Deviation.
Discussion
This study validated the Arabic version of the 16-item SSIPI-AR, aiming to evaluate its psychometric properties in measuring patient satisfaction with penile implants. The results clearly support the survey’s strong validity and reliability. With solid validity measures and high internal consistency, the SSIPI-AR proves to be a valuable tool for use in both clinical practice and research. In addition, the present study highlighted a high level of overall patient satisfaction with IPP.
The current study successfully validated the SSIPI-AR, a brief and practical tool designed to measure patient satisfaction after penile implant surgery. This Arabic version was adapted from the original English survey developed by Salter and colleagues [12], which itself was based on the longer 37-item SSIPI. The goal was to create a clear, culturally appropriate instrument that patients could easily understand and complete in their native language.
The current findings demonstrate that the SSIPI-AR is reliable, as reflected by a high Cronbach’s alpha for both the overall survey scale and its subscales [17]. Using EFA, we identified a 4-factor structure that organizes the items into meaningful domains.
The domains identified in our Arabic cohort closely represent the core concepts that drive satisfaction after IPP surgery. First, the IFU domain integrates pain/discomfort during activation and the practical mechanics of operating the device, conceptually reflecting whether the device is usable for intercourse in real life [18]. Second, the OCS domain captures a broader, patient-centered outcome including successful and satisfying intercourse, restored sexual confidence, and reduced performance-related anxiety, which are recognized as multidimensional determinants of satisfaction following IPP [19].
Third, the PAR domain links perceived penile dimensions (girth/length) with regret, which is clinically important because perceived size concerns are common after IPP and often reflect expectation gaps when counseling does not address length perception or glans engorgement limitations [20]. Finally, the CFA domain addresses how natural the penis looks when deflated and how well it can be concealed, factors that can shape social comfort, body confidence, and willingness to use the device beyond sexual performance [21].
Interestingly, the factor structure identified by the current study differed from the theoretical model proposed by Salter and colleagues [12], who categorized the SSIPI into four domains: overall satisfaction, pain, appearance, and function. Given the small sample size of the current study (n = 50), we opted for EFA rather than testing an existing model with CFA. This allowed to explore the underlying dimensions of the survey without being constrained by prior assumptions. In contrast, Salter and colleagues used CFA to test their theoretical model, reporting a Comparative Fit Index (CFI) of 0.92, a Tucker-Lewis Index (TLI) of 0.86, and a Root Mean Square Error of Approximation (RMSEA) of 0.10 [12]. While a CFI of 0.92 suggests an acceptable fit, the TLI falls below the commonly accepted threshold of 0.90, and an RMSEA of 0.10 indicates a poor fit, as values above 0.08 are generally considered suboptimal [22]. These results suggest that the theoretical structure proposed by Salter and colleagues yields a mixed model fit and may not fully capture the complexity of patient experiences with penile implants.
Furthermore, the current use of EFA is supported by methodological literature that emphasizes its suitability in early stages of instrument validation, especially when adapting tools to new languages or cultural settings and when theoretical models have yet to be confirmed [23]. EFA allows for the identification of latent structures based on the data itself, which can be especially valuable when adapting instruments across different languages and cultures [24]. However, we acknowledge that the inability to perform CFA on our proposed structure, due to limited sample size, is a limitation of this study. Future research with larger samples is necessary to confirm the factor structure identified through EFA and to further validate the SSIPI-AR. Such studies would benefit from employing CFA to test the stability and generalizability of the proposed model across diverse populations.
The SSIPI-AR showed excellent internal consistency, with a Cronbach’s alpha of 0.897, closely aligning with the original English version (0.970) [12]. Notably, the Cronbach’s alpha values for the SSIPI-AR subdomains were slightly higher than those reported for the English version, suggesting robust reliability across domains. Reproducibility was further confirmed by the highly significant correlations between each individual item and the overall survey scale. In terms of test-retest reliability, the SSIPI-AR also performed excellent with an ICC of the total score of 0.985, and between 0.958 to 0.990 for the subdomain scores. All these values were highly significant (p < 0.001), reflecting excellent consistency over time. These results are in line with standard reliability thresholds, where ICC values above 0.90 indicate excellent stability [25]. Taken together, these findings affirm that the SSIPI-AR is a reliable and stable instrument for repeated assessments.
The ability to perform repeated, standardized satisfaction assessments is particularly important in penile implant care because satisfaction is dynamic rather than static. Patient experience can evolve with increasing familiarity with device cycling, changes in partner factors, and delayed issues such as mechanical concerns, discomfort with inflation, concealability challenges, or shifting expectations over time. Regular satisfaction measurement therefore serves several purposes: (i) it enables early identification of modifiable problems (e.g. pain during inflation, difficulty using the pump, or dissatisfaction with concealability) that may respond to targeted education, technique coaching, analgesic strategies, or adjunctive counseling; (ii) it facilitates structured postoperative counseling focused on expectation alignment and partner communication, particularly around appearance and perceived length; and (iii) it provides an objective framework for quality improvement and benchmarking across surgeons, centers, device types, and patient subgroups. Importantly, prior literature has emphasized that satisfaction assessment after penile prosthesis surgery has historically relied on heterogeneous tools and non-standardized approaches, limiting comparability across studies and settings, and supporting the need for validated, implant-specific instruments that can be applied longitudinally [12,26].
In addition to strong psychometric performance, our cohort demonstrated high satisfaction levels as measured by the SSIPI-AR total and subscale scores. The mean total score was 75.31/80 (94.13%), with consistently high subscale satisfaction across domains, ranging from 90.27% (PAR) to 94.45% (OCS). These findings reinforce that, for appropriately selected patients, IPP surgery can deliver durable, patient-perceived benefit across both functional and psychosocial dimensions, consistent with prior reports of high post-implant satisfaction [11,27].
When interpreted by domain, the slightly lower mean score in PAR compared with the other domains is clinically meaningful and aligns with the broader implant literature emphasizing that appearance- and size-related perceptions are common sources of postoperative concern and may influence decisional regret [27,28]. In contrast, high scores in OCS suggest that many patients experience restoration of sexual self-efficacy and satisfaction, which may represent the primary ‘value outcome’ of implantation from the patient perspective.
Cross-study comparisons should be made cautiously due to differences in study design, timing of assessment, eligibility criteria, and reporting metrics (mean vs median). For example, the French evaluation of SSIPI outcomes reported a median total SSIPI score of 66 (IQR 60–73) in a cohort of 59 patients, with high pain subscale scores (median 10/10) and comparatively lower appearance scores (median 23/30) [13]. In addition, satisfaction was assessed across a relatively broad postoperative interval (6 months to 5 years), which was intentionally selected to align with the timeframe used in the original SSIPI validation study. Although 6 months is a clinically reasonable lower threshold that allows adequate recovery and sufficient experience with device use, satisfaction after IPP implantation may still evolve over time [29]; therefore, variation in the interval from surgery to assessment may have contributed to response variability. Future studies with larger, more heterogeneous Arabic-speaking samples, including revision cases and broader complication profiles, will be helpful to better characterize satisfaction distributions, domain ‘floor/ceiling’ behavior, and predictors of lower satisfaction, particularly within the appearance/regret construct.
Strengths and limitations
This study is the first to validate a patient satisfaction survey specifically for Arabic-speaking patients with penile implants, making it a valuable and timely contribution to the field. A major strength lies in its data-driven approach, rather than relying on a predefined theoretical model. The structure of the SSIPI-AR emerged from the data itself, offering a more authentic representation of patients’ experiences. The validation process was thorough, covering key psychometric aspects to ensure the tool is valid, reliable, consistent, and reproducible. On the other hand, a few limitations should be acknowledged. The small sample size restricted our ability to perform CFA on the newly proposed structure and prevented deeper multivariable analysis to explore what influences patient satisfaction. In addition, the absence of established comparator instruments prevented formal assessment of convergent validity and limited the breadth of validation evidence. Our eligibility criteria excluded patients with prior explantation/reimplantation and those with active infection, erosion, or device malfunction at assessment. This was consistent with the study objective of evaluating SSIPI-AR performance and satisfaction in patients with a functioning implant. However, this approach may have favored patients with more favorable postoperative outcomes, contributed to higher satisfaction scores, and limited generalizability to patients with major complications or revision surgery. Moreover, the absence of additional independent measures such as comparisons of satisfaction with other erectile dysfunction treatments or assessments of self-esteem limited our ability to examine convergent validity. Future research with larger and more varied samples is needed to address these limitations.
Supplementary Material
Acknowledgments
Open Access funding provided by the Qatar National Library.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Supplementary material
Supplemental data for this article can be accessed online at https://doi.org/10.1080/20905998.2026.2648366
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