management of infected penuma implant: case report
TRANSCRIPT
Journal of Case Reports and Images in Urology 6, 2021.
J Case Rep Images Urol 2021;6:100014Z15KO2021. www.ijcriurology.com
Olson et al. 1
CASE REPORT OPEN ACCESS
Management of infected Penuma implant: Case report
Kathleen M Olson, Adri M Durant, Aqsa Khan
ABSTRACT
The Penuma implant is a subcutaneous silicone penile implant for penile enhancement that has been FDA approved since 2004. We report the case of a 42-year-old male with infected Penuma implant several months after revision surgery. It was identified on physical exam and imaging and managed with intravenous (IV) antibiotics and explantation.
Keywords: Infected prosthesis, Penile implant, Recon-struction
How to cite this article
Olson KM, Durant AM, Khan A. Management of infected Penuma implant: Case report. J Case Rep Images Urol 2021;6:100014Z15KO2021.
Article ID: 100014Z15KO2021
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doi: 10.5348/100014Z15KO2021CR
INTRODUCTION
Erectile dysfunction (ED) and penile enhancement are not new topics to the urologic community. The first written description of ED dates back to the 8th Century
Kathleen M Olson1, Adri M Durant1, Aqsa Khan1
Affiliation: 1Department of Urology, Mayo Clinic Arizona, Phoenix, AZ, USA.Corresponding Author: Kathleen M Olson, MD, 5777 E Mayo Blvd, Phoenix, AZ 85054, USA; Email: [email protected]
Received: 09 November 2020Accepted: 12 February 2021Published: 22 March 2021
BC and the first acrylic implant was performed in the US 1952 [1, 2]. Through the years, our surgical management of ED has evolved into a successful practice due to the development of the inflatable penile prosthesis (IPP). However, the field of penile implants and augments is not limited to the IPP. Patients have access to many new devices that claim to augment and enhance the penis while maintaining erectile function, but the American Urologic Association (AUA) does not consider penile augmentation a safe or efficacious procedure and specifically counsels against the use of subcutaneous fat injections and division of the suspensory ligament [3]. No official statements have been made regarding silicone implants placed within the connective tissue of the penis despite FDA approval for these implants. One such device that has appeared on the market is the Penuma, a crescent-shaped silicone implant placed between Dartos and Buck’s fascia through an infrapubic approach which spans the length of the penis. Complications associated with these devices include seroma, scarring, and infection [4, 5]. There is a paucity of experience and recommendations treating infectious complications related to this device. In this case report, we describe the surgical management of an infected Penuma implant.
CASE REPORT
The patient was a 42-year-old male with non-contributory past medical history who underwent silicon sleeve penile implant for penile enlargement. After this initial procedure, the patient had chronic penile pain exacerbated by erections and developed an area of firmness at the glans which severely affected his social and sexual health. Revision surgery was performed three years later with goal to resize the implant for better outcome. After implant revision, he developed acute on chronic penile pain. Several months after the revision procedure he developed significant penoscrotal edema, erythema and nausea, vomiting, fever, and chills causing him to seek medical care.
Upon presentation to the emergency department he was tachycardic but was otherwise hemodynamically stable. His physical exam demonstrated significant edema and erythema of the phallus with palpable fluctuance around implant that extended from his infrapubic incision to the glans of the penis. Rectal exam revealed
CASE REPORT PEER REVIEWED | OPEN ACCESS
Journal of Case Reports and Images in Urology 6, 2021.
Olson et al. 2J Case Rep Images Urol 2021;6:100014Z15KO2021. www.ijcriurology.com
a normal prostate without tenderness and no pelvic floor discomfort. His lab work showed leukocytosis of 13.4/L, normal basic metabolic panel, and normal urinalysis. CT scan performed without contrast showed edema of the scrotum and penis with fluid collection around implant (Figure 1). He was admitted to the hospital and started on broad-spectrum antibiotics (Zosyn and Vancomycin) with IV fluids for resuscitation.
The following day, the patient was taken to the operating room (OR) for explant of silicon penile implant and washout. Incision was made through his prior infrapubic surgical site and dissection was directed toward implant. Capsule was identified and entered with immediate release of purulent fluid. Culture later showed Staphylococcus aureus resistant to ampicillin, clindamycin, and penicillin as well as Cutibacterium acne. The cavity was opened laterally to the distal end of the implant on both sides. The proximal end of the implant was delivered through the incision and mesh and permanent suture anchoring the implant to the distal penis was visualized. The Penuma was then removed through incision after cutting sutures (Figure 2). The mesh was not removed as it was deeply imbedded in the penile tissue. The risks of leaving the mesh in place include pain and infection; however, removal would have led to greater tissue damage and possibly more chronic pain. We decreased the infection risk by using the following steps: the implant cavity was copiously irrigated with double antibiotic solution and half inch Penrose
drain was placed into the capsule, exiting just lateral to incision. The subcutaneous tissue was closed with 2-0 vicryl interrupted and epidermis was approximated with surgical staples.
Post-operatively, the patient felt much improved. His penile pain and swelling had considerably decreased. His leukocytosis had resolved. He was discharged to home on a two week course of Bactrim and Keflex with drain in place and plan for close follow-up for drain and staple removal. He has not had further infections since explantation. The patient endorsed erectile dysfunction following Penuma explantation, which he did not have an issue with pre-operatively, and was started on sildenafil.
DISCUSSION
Approved by the FDA in 2004, thousands of Penuma silicone implants have been placed to date [6]. These numbers will likely continue to climb due to increasing public awareness. In a single institutional retrospective study, infections occurred in 3.2% of patients receiving Penuma implants. Of those with infections, 61% required explantation of the device. The infection and explantation rate may be higher than reported in this retrospective study due to incomplete cohort response to surveys [4]. A small case series reported by Furr et al. described removal of silicone implants for penile enhancement due to intractable pain and infection in four cases [5]. Of note, these patients had long-term complications related to fibrosis with curvature and shortening leading to erectile dysfunction [5].
Increased vigilance with regard to sterile technique and prophylactic measures is needed with penile silicone implants. Addition of antibiotic coatings to these devices is under investigation and likely to be beneficial as similar application to IPPs was found to significantly reduce infections [5, 7]. Furthermore, increased number and standardized recommendations for antibiotic irrigations should be encouraged as well as adherence to the AUA guidelines on antimicrobial prophylaxis involving implanted prosthesis [8]. This case study details treatment principles similar to infected IPPs with prompt identification, explantation, and broad-spectrum antibiotics being the mainstays of treatment. Finally, patients thinking of undergoing this cosmetic procedure need to be counseled on the risks of potentially life-threatening infection, chronic pain, iatrogenic erectile dysfunction (ED), and penile disfigurement.
CONCLUSION
Subcutaneous silicone penile implants are gaining popularity due to FDA approval. However, this cosmetic procedure may have underreported rates of side effects including infection, chronic pain, iatrogenic ED, and penile disfigurement. Infected subcutaneous penile
Figure 1: Radiographic images at time of presentation. Left: Soft tissue edema and induration consistent with cellulitis. Implant noted to extend cranially beyond corpora cavernosa. Right: Fluid collection around implant with soft tissue edema consistent with abscess.
Figure 2: Intraoperative photos. (A) Incision made through prior scar in the infrapubic region. (B) Distal aspect of implant sutured to underlying connecting tissue and mesh with permanent suture. (C) Post-operative image showing intact implant and drain positioning.
Journal of Case Reports and Images in Urology 6, 2021.
Olson et al. 3J Case Rep Images Urol 2021;6:100014Z15KO2021. www.ijcriurology.com
implants should be treated similarly to other infected urologic prostheses with antibiotics and explantation. Patients may need long-term follow-up for management of other complications such as ED or fibrosis.
REFERENCES
1. Le B, Burnett AL. Evolution of penile prosthetic devices. Korean J Urol 2015;56(3):179–86.
2. Rodriguez KM, Pastuszak AW. A history of penile implants. Transl Androl Urol 2017;6(Suppl 5):S851–7.
3. Penile Augmentation Surgery. American Urological Association. Available at: https://www.auanet.org/guidelines/penile-augmentation-surgery
4. Elist JJ, Valenzuela R, Hillelsohn J, Feng T, Hosseini A. A single-surgeon retrospective and preliminary evaluation of the safety and effectiveness of the Penuma silicone sleeve implant for elective cosmetic correction of the flaccid penis. J Sex Med 2018;15(9):1216–23.
5. Furr J, Hebert K, Wisenbaugh E. Complications of genital enlargement surgery. J Sex Med 2018;15(12):1811–7.
6. 510(k) Premarket Notification. [Available at: https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm?id=K042380]
7. Mandava SH, Serefoglu EC, Freier MT, Wilson SK, Hellstrom WJG. Infection retardant coated inflatable penile prostheses decrease the incidence of infection: A systematic review and meta-analysis. J Urol 2012;188(5):1855–60.
8. Wolf JS Jr, Bennett CJ, Dmochowski RR, et al. Best practice policy statement on urologic surgery antimicrobial prophylaxis. J Urol 2008;179(4):1379–90.
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Author ContributionsKathleen M Olson – Conception of the work, Design of the work, Acquisition of data, Analysis of data, Interpretation of data, Drafting the work, Revising the work critically for important intellectual content, Final approval of the version to be published, Agree to be accountable for all
aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved
Adri M Durant – Acquisition of data, Analysis of data, Drafting the work, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved
Aqsa Khan – Conception of the work, Interpretation of data, Revising the work critically for important intellectual content, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved
Guarantor of SubmissionThe corresponding author is the guarantor of submission.
Source of SupportNone.
Consent StatementWritten informed consent was obtained from the patient for publication of this article.
Conflict of InterestAuthors declare no conflict of interest.
Data AvailabilityAll relevant data are within the paper and its Supporting Information files.
Copyright© 2021 Kathleen M Olson et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information.
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