Surgical treatment and outcomes of acute and chronic ulcers on the penis following injection of foreign substances.

In this paper, we present our experience with acute and chronic penile ulcers resulting from injection of an exogenous substance and their surgical treatment.

[Clinical case of penile fracture].

A clinical case of a penile fracture as a result of an unsuccessful sexual intercourse, which later required surgical treatment in the form of corporoplasty with opening and draining of the hematoma, is discussed in the article. Penile fracture is a rare urological emergency that requires immediate medical attention to avoid long-term complications, including penile curvature and erectile dysfunction.

Subcoronal Incision for Inflatable Penile Prosthesis Does Not Risk Glans Necrosis.

PURPOSE: Glans vascular compromise had previously been considered a rare but devastating complication of the subcoronal incision for inflatable penile prosthesis surgery. Here, we describe the largest series of subcoronal implants to date to assess contemporary complication rates. MATERIALS AND METHODS: A retrospective review of subcoronal prosthesis placements by a single surgeon from Seoul, South Korea, was performed. Patients were randomly assigned either Coloplast Titan or AMS 700 device per institutional practice. RESULTS: A total of 898 patients who underwent subcoronal implants from May 2015 to March 2022 were analyzed. Median follow-up was 41 months (IQR 40). Preoperative patient comorbidities included diabetes (36.6%) and Peyronie's disease (4%). The most common complication was transient distal penile edema (74.7%). Transient incisional paresthesia (20.6%) was more common in patients with diabetes (31.9% vs 13.9%, P < .01). Five cases (0.5%) of distal penile skin necrosis were reported in patients who had previously been circumcised. Of these, 3 were managed successfully with wet-to-dry dressing, 1 required skin grafting, and 1 required device explant. Device infection without incisional compromise occurred in 2 cases (0.2%). There were no instances of glans necrosis or ischemia observed in this cohort. Of the first-time implants (817, 90.9%), most (62.3%) were successfully completed under local anesthetic alone, with the remainder of surgeries completed with the addition of adjunctive conscious sedation. CONCLUSIONS: Subcoronal incision for first-time or revision penile implant surgery is not a risk factor for glans ischemia or necrosis and can be safely completed under local anesthetic with or without conscious sedation.

Timing and causative organisms associated with modern inflatable penile prosthesis infection: an institutional retrospective.

BACKGROUND: The advent of antibiotic-coated devices has reduced the rate of inflatable penile prosthesis (IPP) infections; however, this may have altered microbial profiles when infections do occur. AIM: To describe the timing and causative organisms behind infection of infection retardant-coated IPPs in the context of our institution's perioperative antimicrobial protocols. METHODS: We retrospectively reviewed all patients undergoing IPP placement at our institution from January 2014 to January 2022. In all patients, perioperative antibiotic administration was congruent with American Urological Association guidelines. Boston Scientific devices are impregnated with InhibiZone (rifampin and minocycline), and all Coloplast devices were soaked in rifampin and gentamicin. Intraoperative irrigation was performed with betadine 5% irrigation prior to November 2016 and with vancomycin-gentamicin solution afterward. Cases involving prosthesis infection were identified, and variables were extracted from the medical record. Descriptive and comparative statistics were tabulated to identify clinical characteristics, including patient comorbidities, prophylaxis regimen, symptom onset, and intraoperative culture result. We previously reported an increased infection risk with Betadine irrigation and stratified results accordingly. OUTCOMES: The primary outcome was time to infectious symptoms, while the secondary outcome was description of device cultures at the time of explantation. RESULTS: A total of 1071 patients underwent IPP placement over 8 years with an overall infection rate of 2.6% (28/1071). After discontinuation of Betadine, the overall infection rate was significantly lower at 0.9% (8/919) with a relative risk of 16.9 with Betadine (P < .0001). Primary procedures represented 46.4% (13/28). Of 28 patients with infection, only 1 had no identified risk factors; the remainder included Betadine at 71% (20/28), revision/salvage procedure at 53.6% (15/28), and diabetes at 50% (14/28). Median time to symptoms was 36 days (IQR, 26-52); almost 30% of patients had systemic symptoms. Organisms with high virulence, or ability to cause disease, were found in 90.5% (19/21) of positive cultures. CLINICAL IMPLICATIONS: Our study revealed a median time to symptoms of just over 1 month. Risk factors for infection were Betadine 5% irrigation, diabetes, and revision/salvage cases. Over 90% causative organisms were virulent, demonstrating a microbial profile trend since antibiotic coating development. STRENGTHS AND LIMITATIONS: The large prospectively maintained database is a strength along with the ability to follow specific changes in perioperative protocols. The retrospective nature of the study is a limitation as well as the low infection rate, which limits certain subanalyses from being performed. CONCLUSION: IPP infections present in a delayed manner despite the rising virulence of infecting organisms. These findings highlight areas for improvement in perioperative protocols in the contemporary prosthetics era.

Smile Incision-Modified Technique for Better Scrotal Outcome in Surgical Management of Penile Paraffinoma.

INTRODUCTION: Penile augmentation with foreign material injection is used to increase penile length, girth, or both. Most of these individuals develop complications due to an abnormal mass formation known as penile paraffinoma. Multiple surgical techniques for restoring penile function and correcting near-normal penile shape have been developed, but prior techniques have some post-operative complications. METHODS: We explained the smile incision-modified technique for penile paraffinoma reconstruction using illustrations to describe step-by-step procedures. This study aimed to describe our modified surgical technique for reconstruction to correct complications due to disastrous consequences of failed penile augmentation. RESULTS: A total of 16 patients aged 28-66 years (mean: 44.25 ± 2.63) were operated with a smile incision-modified technique from January 2017 until December 2020 in Semarang Dr. Kariadi tertiary hospital. There were no intraoperative complications observed. We found hematoma in 3 patients in a 1-week follow-up. After 2 weeks of post-operative surgery, all patients had no skin dehiscence or necrosis. Cosmetic appearance and functional improvement after reconstruction were acceptable by all patients. CONCLUSION: Penile paraffinoma reconstruction using the smile incision-modified technique was a feasible and effective technique to manage penile paraffinoma patients with good esthetic results and minor complications.

[A Case of Penile Calciphylaxis in a Hemodialysis Patient].

In the present case of a 56-year-old male, hemodialysis was introduced from December 20XX-2 due to chronic renal failure caused by diabetic nephropathy. In February 20XX, a glans penis ulcer was observed. It gradually expanded. Angiography conducted in April revealed complete occlusion of the left internal pudendal artery and poor visualization of the bilateral penile arteries. Given the high risk of obstruction, endovascular treatment was not conducted. The glans penis ulcer continued to expand, and maintenance dialysis became difficult due to intractable pain. Opioids were introduced, but the pain could not be controlled. In May 20XX, the patient was referred to our department for surgical treatment, and partial penile resection was performed. The patient was diagnosed with penile calciphylaxis based on clinical findings and pathological diagnosis. After the surgery, the pain subsided considerably, and the patient is being followed on an out-patient basis.

Prevention of Penile Prosthesis Infection.

INTRODUCTION: Management protocols for treatment of severe erectile dysfunction have changed little in the last 20 years. Most algorithms consider penile prostheses as the last option of treatment in patients who have failed medical management. Despite multiple advances in current devices, prosthetic infection remains the most feared complication by implanting surgeons and patients. This report tries to make a compilation of the factors that can be impacted to prevent penile implant infections, and to make penile implantation a safer and more reliable way to solve an erection deficit. PURPOSE OF REVIEW: List events related to the surgical act (pre-operative, intra-operative, and post-operative) that are related to the risk of infection to contextualize possible actions/measures used to avoid prosthetic infection. RECENT FINDINGS: The impact of coated implants on reduction of infection rates. The recommendation to use chlorhexidine-based solutions over iodine solution for preoperative skin preps. Appears to be no difference in infection rates according to the approach chosen by the surgeon (infrapubic vs penoscrotal). The change in the microbial colonies that are colonizing implants in recent years are dramatic. Lack of evidence of which solutions to use for salvage or revision washout surgery: Chemical eradication or mechanical lavage cleansing?. Despite the importance of metabolic control in the literature, there is a disparity in exact glycemic values ​prior to the intervention in our literature. Factors such as preparation of the operative site, presence of comorbidities or previous surgeries, surgical time, or additional maneuvers during surgery can negatively impact the final result of penile prosthetic surgery.

Bulbar urethrocavernous fistula in setting of inflatable penile prosthesis: a case report.

BACKGROUND: Urethral injury or erosion of an inflatable penile prosthetic (IPP) cylinder is a rare complication of IPP placement. It can present with varying symptoms and management can be difficult with risk for future complications. We present a patient with an eroded IPP who developed a secondary contralateral urethrocavernous fistula requiring repeat urethroplasty. We also describe the literature surrounding these complications and strategies to prevent them. CASE PRESENTATION: A 69-year-old man with poorly controlled diabetes presented to our clinic with 6 months of intermittent white urethral discharge first noted after IPP removal and replacement by an outside urologist for device malfunction. Office cystoscopy revealed an eroded right-sided prosthetic cylinder in the bulbar urethra. The patient was taken to the operating room for IPP explantation with closure of right corporal defect, left sided malleable prosthesis placement, and primary excision with anastomosis of his bulbar urethra. A catheter was left in place for two weeks postoperatively, at which time a peri-catheter retrograde urethrogram was performed which showed no evidence of contrast extravasation and his catheter was subsequently removed. Several months later, he presented with recurrent urethral discharge without evidence of recurrent erosion on cystoscopy with development of scrotal abscesses following office cystoscopy, concerning for an unidentified urethral defect. He returned to the operating room for scrotal exploration and was noted on cystoscopy to have a pinpoint fistula between his left corporal body and his bulbar urethra. He underwent left sided malleable prosthetic explant, and non-transecting bulbar urethroplasty. Peri-catheter retrograde urethrogram two weeks later showed no contrast extravasation and he has had no recurrence of urethral discharge or scrotal abscesses since. CONCLUSIONS: Urethral erosion and urethrocavernous fistula formation are rare complications of penile prosthesis placement. Risks are elevated in patients with corporal fibrosis, diabetes, those undergoing penile implant revision surgery, and those requiring prolonged urethral catheterization.

A Review on Penile Length and Girth Issues in Penile Prosthetic Surgery.

PURPOSE OF REVIEW: The goal of this paper is to understand the reasons behind penile length and girth issues after penile prosthesis surgery and review the literature for current strategies employed to decrease these issues. RECENT FINDINGS: Measurement inconsistencies triggering further studies have shown there is a real loss of penile length and girth after prosthesis surgery. There have been varying hypotheses of why this happens, and numerous approaches have been proposed to help combat this in the preoperative, intraoperative, and postoperative settings. Erectile dysfunction prevalence is expected to increase; therefore it is important for urologists to understand the treatment options, including prosthesis surgery. Numerous techniques have been hypothesized and studied in smaller settings in the preoperative, intraoperative, and postoperative settings with regard to prosthetics surgery. However, larger studies are still needed to confirm these findings in order to help to counsel and educate patients preoperatively in addition to employing tactics to help minimize penile shortening.

Sexual Dysfunction Among Men Who Have Sex with Men: a Review Article.

PURPOSE OF REVIEW: The goal of this review article is to evaluate sexual dysfunction among men who have sex with men (MSM). RECENT FINDINGS: Men who have sex with men are commonly affected by sexual dysfunction. Often sexual dysfunction in MSM will significantly impact their psychological well-being perhaps even more than their heterosexual counterparts. Despite the frequency and high impact of sexual dysfunction in MSM, access to appropriate care may be limited. It is important for urologists, especially sexual medicine clinicians, to be aware of and comfortable with differences in sexual practices of MSM. Penile pathology in this patient population will negatively affect their quality of life and well-being. Therefore, it is important to properly assess and treat these patients.

Penile Necrosis as a Presenting Sign of Purpura Fulminans Mimicking Fournier's Gangrene.

ABSTRACT: We report the case of a 63-year-old white man who, 3 days after stent removal of endoscopic drainage of pancreatic cysts, developed a penile necrosis due to purpura fulminans (PF) that has been misdiagnosed as Fournier's gangrene. Penile necrosis was rapidly followed by a lethal multiorgan failure due to disseminated intravascular coagulopathy (DIC), triggered by the subsequent development of a severe acute pancreatitis. PF describes a rare syndrome involving intravascular thrombosis and hemorrhagic infarction of the skin. Although reports of penile necrosis secondary to various causes are documented in the literature, penile necrosis secondary to PF in the setting of acute pancreatitis is a rare event. Histopathologic studies of the skin showing an occlusive nonvasculitic vasculopathy are the first step to achieve an accurate diagnosis.

[Penile glans amputation during circumcision: causes, treatments and preventive measures].

INTRODUCTION: Penile glans amputation during circumcision is a rare but potentially devastating complication. The mechanism and causes are poorly understood and incomprehensible. It is important to identify the causes of these complications, to suggest a mechanism and to propose prevention measures. MATERIALS: Between 2005 and 2019, six patients with penile glans amputationafter circumcision were analyzed. All were operated without medical evidence, for religious reasons. THE RESULTS: The operations were performed by local anesthesia, at home - in 5 patients, in 1 child - at polyclinic. All children were circumcised by scalpel with guillotine method, without visualization of glans. Partial amputation of penile glans was observed in 2 children (33.3%). Complete cut-off of the glans at the level of the coronal sulcus was revealed in 4 boys (66.6%). Meatoplasty with urethral mobilizations was performed 2 patients (33.3%) with partial amputation. The tops of corpus cavernous was covered of with the remnants of the skin of penile shaft in two boys (33.3%). Glansplasty was performed in 2 other patients (33/3%), using a labial mucosa graft to reconstruct the shape of glans and glanular groove. The follow up have showed meatostenosis in two boys (33.3%) in the first 2 months after surgery. One child required repeated meatoplasty (16.6%), another had a recovery of normal urine flow rates after urethral dilatation and stenting (4 weeks). CONCLUSION: Visual control of the glans position during circumcision will prevent the amputation. "Guillotine" techniques including, Mogen clamp-type devices, are considered potentially dangerous. Circumcision in newborns, without general anesthesia, in the presence of swelling of the foreskin have an increased risk of glans damage. Preliminary examination of the glans and adequate release of preputial adhesions help to prevent complication of circumcision and to identify combined malformations (hypospadia, epispadia, concealed penis.).

Management of post-circumcision necrosis of the penis: the medicolegal aspect.

PURPOSE: To perform a medical evaluation of penile necrosis causes and treatment approaches by examining patients who had penile necrosis after circumcision surgery. METHODS: A total of 24 patients with penile necrosis after circumcision surgery, who presented at various hospitals in Turkey between September 2003 and April 2013 and whose cases were being reviewed at the Institution of Forensic Medicine with regard to malpractice, were evaluated retrospectively. RESULTS: The mean age of the patients was 5 ± 3.7 years, and the mean time of the necrosis diagnosis after circumcision was 5.2 ± 6.3 days. In etiologic terms, the predictive factors were monopolar cautery use in ten (41.6%) patients, post-circumcision infection in eight (33.3%), compartment syndrome due to post-circumcision dressing in three (12.5%), local anesthetic agent used for dorsal nerve blockage in two (8.3%), and methemoglobinemia in one (4.1%) patient. The first approaches to necrosis treatment were surgical intervention in 15 (62.5%) patients, hyperbaric oxygen treatment (HBOT) in 6 (25%), the conservative approach in 2 (8.3%), and HBOT plus surgical intervention in 1 (4.1%) patient. CONCLUSION: Penile necrosis is a preventable complication that requires early intervention. The current study will be helpful in preventing penile necrosis and in guiding surgeons in approaches following its occurrence.

Urethral injury in penile fracture: a narrative review.

OBJECTIVE: To present the evolution and the recent data on the etiology, diagnosis, management and outcomes of penile fracture (PF) with concomitant urethral injury. MATERIALS AND METHODS: We searched the Pubmed database between 1998 and 2019 using the following key words: "penile fracture", "fracture of penis", "trauma to penis", "rupture of corpora cavernosa", "urethral injury", "urethral rupture" and "urethral reconstruction". RESULTS: The incidence of urethral lesion in patients with PF varies by geographic region and etiology. Blood in the meatus, hematuria and voiding symptoms are highly indicative of urethral rupture. The diagnosis of PF is eminently clinical and complementary exams are not necessary. The treatment consists of urethral reconstruction and the most common complications found are urethral stenosis and urethrocutaneous fistula. CONCLUSION: PF is an uncommon urological emergency, particularly in cases with urethral involvement. Urethral injury should be suspected in the presence of suggestive clinical signs, and diagnosis is usually clinical. Urgent urethral reconstruction is man-datory and produces satisfactory results with low levels of complications.

Haemophilus parainfluenzae-related cellulitis of the penis following tearing of a short frenulum.

INTRODUCTION: Infectious cellulitis is a common disease, mostly affecting the lower extremities and the face but only rarely the genitalia. OBSERVATION: A 24-year-old male patient presented with acute erythematous edema of the penile shaft and foreskin present for 48hours. Gentle retraction of the foreskin revealed a short frenulum with a small area (2-3mm) of erosion. He had had unprotected genital and orogenital sex three days before with his usual female partner and reported tearing of the frenulum during intercourse. Ampicillin-sensitive Haemophilus parainfluenzae was isolated from the swab taken from the erosion of the frenulum. Clinical remission was obtained following oral administration of amoxicillin and clavulanic acid. DISCUSSION: We describe not only the first case of Haemophilus parainfluenzae-associated cellulitis of the penis but also the first report of penile cellulitis following erosion of a short frenulum during sexual intercourse.

Complications and Management of Penile Girth Enhancement with Acellular Dermal Matrix.

INTRODUCTION: Acellular dermal matrix (ADM) is a common filler used widely in clinical practice to increase penile girth for cosmetic reasons, but there are few studies on its complications. AIM: The aim of this study was to investigate and analyze the complications of penile girth enhancement (PGE) with ADM. METHODS: The medical records of 78 patients who underwent PGE with ADM between June 2016 and January 2019 were retrospectively reviewed. MAIN OUTCOME MEASURE: Related complications and their subsequent management were summarized and analyzed. RESULTS: 78 patients (mean age 31.14 years [21-66 years]) received PGE with ADM. At the 3-month follow-up, the penile circumference was increased by 1.1 (0.5-2.1) cm on average. There were 47 patients with erectile discomfort, 12 with delayed healing, 10 with unobvious augmentation effect, 8 with wound hematoma, 7 with prepuce edema, 4 with wound infection, and 3 patients with skin necrosis of the dorsal side. 7 patients eventually underwent ADM removal. CLINICAL IMPLICATIONS: These adverse complications indicate that ADM should be used with caution for PGE. STRENGTH & LIMITATIONS: This study adds important data, as there are few published reports on the complications of PGE with ADM. However, this study did not compare postoperative complications with ADM to those seen with other filler material. CONCLUSION: Even with standardized surgical methods and rigorous postoperative care, complications of PGE using ADM are severe, which indicates that it is not an ideal or safe method for PGE. Xu T, Zhang G, Bai W, et al. Complications and Management of Penile Girth Enhancement with Acellular Dermal Matrix. J Sex Med 2019;16:2011-2017.

Penile lymphoedema: approach to investigation and management.

BACKGROUND: Penile lymphoedema (with and without cellulitis) is a rare, often chronic, clinically heterogeneous entity with an uncertain pathogenesis and an important differential diagnosis. It creates significant physical and psychosexual morbidity, and presents considerable therapeutic challenges. The existing literature is limited. AIM: To describe and share our updated cumulative experience of a cohort of patients with penile lymphoedema. METHODS: This was a retrospective review of the case records of patients with chronic penile lymphoedema seen in two dedicated male genital dermatology clinics between January 2011 and July 2016. RESULTS: In total, 41 cases were identified. Over a third had Crohn disease (CD) (which was occult in one-third of these), and over a third had serological evidence of streptococcal infection. All patients responded to systemic antibiotics and specialized urological surgery circumcision and excision). CONCLUSIONS: Penile lymphoedema should be investigated to exclude underlying pathology especially CD and streptococcal infection. Treatment with antibiotics should be considered early and long term to try to preserve the foreskin: most patients are uncircumcised. Some patients may benefit from a course or courses of oral steroids. The development of gross dysfunction of the prepuce usually dictates circumcision and excision of lymphoedematous tissue once the situation is medically stabilized.

Suspensory ligament release combined with acellular dermal matrix filler in infrapubic space: A new method for penile length augmentation.

Until now, no reliable method is recognised in treating buried penis. This study explored a new method of penile length augmentation using acellular dermal matrix filler in infrapubic space combined with liposuction and penile suspensory release. Patients with "small-sized penis" received penile length augmentation procedure including suprapubic liposuction, penile suspensory ligament release and insertion of folded acellular dermal matrix between corpora cavernosa and pubis symphysis. Their penile length from tip to skin was measured pre-operatively and post-operatively. The post-operative complications and patients' satisfaction were also recorded. Fifteen adult male patients were included with the mean age of 33.2 ± 4.6 years old and BMI of 28.9 ± 5.3 kg/m2 . The average amount of liposuction was 430 ± 90.0 ml. The average penile length measured pre-operatively and post-operatively (on table and 3 months afterwards) was 3.0 ± 1.3 cm, 7.3 ± 2.1 cm and 5.4 ± 1.8 cm. The penile length has significantly increased by 4.3 ± 1.6 cm (on table) and 2.4 ± 0.8 cm (3 months post-operatively; p < 0.05). The post-operative complications included oedema of penis, ecchymosis of lower abdomen and poor wound healing. No patient was dissatisfied with the appearance and function. The new method using acellular dermal matrix combined with liposuction and penile suspensory ligament release is safe and effective. The method could be applied to selected patients with buried penis.

Unusual Case of Penile Ecchymosis.

Hirudin is a potent anticoagulant found in the salivary glands of several species of leeches. We report a case of direct hirudin exposure after suspected leech bite causing significant penile ecchymosis. Diagnosis was not apparent on initial evaluation but made after a thorough history was obtained and the leech was found in the lining of his swim trunks, which he left at home. Although this presentation mimics several other potentially serious conditions, treatment is largely observational with anticipated rapid improvement over the course of hours without intervention.