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Original articles

Primary erectile dysfunction: detection and management of concomitant congenital penile curvature upon penile prosthesis implantation

Shaeer, Osama; Shaeer, Kamal

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doi: 10.1097/01.XHA.0000399338.45570.92
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Abstract

Introduction

Primary erectile dysfunction (ED) is the absence of full, sustained erections since early childhood or puberty. In a series of 67 eugonadal patients, primary ED was attributed to psychogenic factors in 16% and organic causes in 85% patients, namely neurological (18%), arteriogenic (52%), and venogenic (52%). Concomitant psychogenic abnormalities were found in 68% of patients with organic primary ED [1].

The condition may imply implantation of a penile prosthesis. As the patient may have never experienced a rigid erection, he is unable to report on the possibly existing congenital penile curvature (without hypospadias), which afflicts approximately 4–10% of men [2]. Upon implantation, and during calibrating the corpora cavernosa and choosing the suitable length of implant, the problem of curvature is not recognized. Only after insertion of the rods the curvature is revealed. The least favorable option then is to ignore the problem with the consequent compromised esthetics and functionality, with the exception of cases of mild curvature, where the shortening that occurs by the default implantation procedure may mask the curvature. Another option is to extract the implant cylinders and to shorten them (in the same session) such that the longer aspect of the penis is equal to the shorter aspect, with the consequent shortening and increased infection rate attributed to increased operative manipulation and time. A third option is to extract the cylinders and correct curvature in the same procedure, which is also not without drawbacks: The straightened corpora cavernosa are different in length from the presized cylinders, longer or shorter according to the technique used to correct curvature. Adding rear tip pieces or shortening the cylinders may not necessarily meet the new length required. After correction of curvature, artificial erection is needed to judge whether or not correction is adequate, and this cannot be performed considering the corporotomies that leak saline used to induce artificial erection. Finally, as correction of curvature is performed after the implant has been unsealed, inserted, and then extracted, the procedure is rendered much longer and more complex than originally planned, with the prosthesis exposed, possibly increasing the risk of infection.

Therefore, evaluation of anatomical deformities before the procedure may help to avoid unfavorable outcome or unnecessary difficulty and increased risk for infection upon implantation of penile prosthesis in cases of primary ED. This study describes a method to evaluate congenital curvature in cases of primary ED before surgery and to correct curvature upon prosthesis implantation, even before calibration of the corpora cavernosa.

Materials and methods

Workup for patients complaining of primary ED includes the routine history taking, local and general examination, blood sugar measurement, hormonal profile, escalating to Duplex examination, and nocturnal penile tumescence measurement in selected cases. Studies such as canvernometry and cavernosography can be performed in cases suspicious of having venogenic impotence. In patients where ED proves to be of organic nature, it is difficult to judge straightness of the penis considering failure to attain the fully erect state, even with intracorporal injection of vasoactive drugs.

A work-around is to induce artificial erection by basal compression and saline infusion. A tourniquet applied to the base of the penis and saline infusion through a butterfly needle can induce full erection, allowing the surgeon, and the patient, to witness the curvature, if any, to determine the severity, direction, point of maximum curvature, and other relevant information. Although this can be performed intraoperatively before the skin incision, it may be of value to perform it before surgery with the aim of prospective planning as well as thorough patient counseling as to the details of his condition and those of the intended procedure. In some cases, the patient finds the tourniquet (such as a vacuum device constriction band) uncomfortable. In such cases, manual compression of the base of the penis by the patient or physician can be adequate. Afterward, it is recommended to delay the procedure for at least 5 days with administration of oral antibiotic treatment as prophylaxis against the minor possibility of infection introduced by this procedure. Surgery is restricted to patients with primary ED of proven organic etiology, resistant to medical treatment. Only for those patients testing for curvature is performed. A written informed consent was obtained before surgery.

Preoperative testing was used for detection of anatomical abnormalities in 16 patients presenting with primary ED attributed to venous leakage and resistant to medical treatment, including phosphodiesterase inhibitors. Age range was 24±2 years. One patient was diabetic. From among 16 cases, four cases with ventral curvature of 30° or more were spotted: 30° (two cases), 40° (one case), and 50° (one case). In addition, three more cases exhibited mild ventral curvature of less than 30°, and two cases exhibited lateral curvature of approximately 10°. Patients with a ventral curvature of 30° and above requested correction of curvature along with implantation.

The procedure starts with induction of artificial erection in the same way described earlier (Fig. 1). In this study, an intestinal clamp is used to compress the base of the penis, being noncrushing, and it does not compress the corpus spongiosum as the blades diverge distally. Having determined the degree and direction of curvature (30° ventrally in the case at hand) as well as the point of maximum curvature, which is marked by inserting a needle, a penoscrotal incision is cut. The penis is everted out through the incision, and the point of maximum curvature previously marked is exposed (Fig. 2). Chordee, if any, is excised. A cruciate corporotomy incision is cut through the tunica albuginea of the corpus cavernosum over the point of maximum curvature (Fig. 3). In most cases, this gaping incision is sufficient to correct curvature. This is checked by covering the corporotomy with sterile surgical glove material sutured to its edges, by reinducing artificial erection, and by deciding if there is a need for further incisions.

Figure 1
Figure 1:
Artificial erection demonstrating the degree and direction of curvature as well as the point of maximum curvature.
Figure 2
Figure 2:
The point of maximum curvature is exposed through the penoscrotal incision.
Figure 3
Figure 3:
One or more cruciate corporotomy incisions correct curvature.

The graft for closing the corporotomies is harvested from the tunica vaginalis of the testis through the same skin incision (Fig. 4). Many alternatives exist including synthetic vascular graft material. The harvested graft is kept in saline up to the stage of sealing the corporotomies.

Figure 4
Figure 4:
Harvesting the tunica vaginalis graft.

Dilatation of the corpora cavernosa, calibration, and prosthesis implantation proceeds as usual. Having laid in the prosthesis, the corporotomies are sealed by the tunica vaginalis graft sutured to their edges using Vicryl 3 suture material (Ethicon, USA) (Fig. 5). For this purpose and in cases where the corporotomies are distal, the penis may be everted out of the incision once more to expose the corporotomies (Fig. 5). It is not necessary to overlay a Dartos flap for nourishing the graft, considering that Dartos will already be coated to the graft and immobilized by leaving the prosthesis in the erect state for 2 weeks. Dartos layers and skin are closed. Prosthesis of a suitable length is implanted into a straight penis (Fig. 6). The postoperative period is no different than regular implantation cases, except that sexual intercourse is delayed for 3 months after implantation as a safety margin until graft take and stabilization. Although a semirigid prosthesis was implanted in this series due to financial and availability considerations, the technique is applicable with inflatable prosthesis as well. All patients commenced sexual intercourse successfully.

Figure 5
Figure 5:
Sealing the corporotomies with the tunica vaginalis graft: a, Corporotomy half-closed showing the prosthesis; b, Corporotomy fully closed.
Figure 6
Figure 6:
Prosthesis implanted in a straight penis.

Results

In all four cases, curvature was fully corrected, and prosthesis was successfully implanted and followed for 6–8 months. Two out of four patients exhibited edema overlying the sites of the corporotomies, resolving spontaneously in 3–4 weeks.

All patients commenced sexual intercourse successfully.

Discussion

A curved penis may make coital relationship difficult, painful, and sometimes impossible, according to the degree and direction. Lateral curvature has the highest negative impact on coitus, followed by ventral and lastly dorsal curvature. Milder degrees of curvature may not affect sexual function but can compromise satisfaction with body image.

In severe cases of primary ED, patients with curvature may not report it but rather report their sole complaint, that is, impotence. Only in milder cases with average erection that rapidly fades, in cases partially responding to itracavernous injection of vasoactive drugs, or in cases improving with medical treatment, this curvature may be reported. Otherwise, it is the duty of the physician to recognize the presence of the unreported curvature, especially if implantation of a penile prosthesis is intended. The only way to detect curvature in such cases is by induction of artificial erection by saline infusion against a base tourniquet. In case the patient does not tolerate preoperative testing, consent for correction of possible curvature can be obtained instead.

Correction of penile curvature can be achieved by several surgical techniques. Counter shortening (plication) is a simple procedure with no impact on erectile function and is the mainstay in correcting stand-alone congenital penile curvature, which nevertheless inherently results in shortening [3]. Incision and grafting can correct any degree of curvature without compromising length, but is known for causing ED due to venous leakage [4], not to mention the possibility of graft contraction [5]. Corporal rotation can correct curvature with neither shortening nor ED, yet, is only applicable in isolated dorsal or ventral curvature and not in lateral curvature [6].

In cases where implantation of a penile prosthesis is intended, venous leakage is not a concern, and immobilization by the erect implant also works against graft contraction. It is capable of correcting any degree of curvature in any direction without shortening and can be performed through the same penoscrotal incision, in contrast to dorsal plication and corporal rotation, which require dorsal access.

In Peyronie's disease-induced curvature, the penis can be straightened by manual modeling [7] or by merely inflating the implant for extended periods acting as a tissue expander. There is no literature evidence that this could be the case with congenital curvature where curvature is a structural abnormality rather than a resilient fibrous tissue that can yield to molding. Similarly, in cases of congenital curvature with normal erectile function, straightening by physical manipulation (as with manual modeling or coitus) was not reported as a method of correcting curvature and hence the motivation to correct curvature upon implantation [8,9].

To achieve equality of rods and to conceal curvature, the prosthesis is shortened. Deciding not to shorten the implant, such that it acts as a tissue expander, may lead to anterior perforation as with any oversized implant and will leave the patient with unanticipated curvature. If this option is to be considered, the patient should be informed and consenting beforehand, and hence the importance of preoperative evaluation.

In addition to modeling [7], correction of Peyronie's-induced curvature after implantation was reported by either placation [8] or by plaque incision/grafting [9]. This study describes correction of curvature before calibrating the corpora cavernosa, in contrast to the previous techniques, avoiding unnecessary prolongation and complexity of the procedure and higher risk of infection in case unanticipated curvature is encountered and corrected after implantation. Correction is double checked by reinducing artificial erection before implantation, ensuring straightness. This gives the real length of the corpora and allows placement of the suitable length of prosthesis in a straight penis, avoiding unnecessary disappointment in case curvature is ignored. Evaluation of anatomical deformities with artificial erection can be a routine part of the workout for patients with primary ED for prosthesis implantation.

Conclusion

Congenital curvature can coexist with primary ED (nine out of 16 patients in this series); yet, it is not reported by the patient who has never experienced a rigid erection sufficient to reveal the curvature. Preoperative detection of curvature is of value for patient counseling and planning for the procedure. Correction of curvature before implantation (in the same session) can help implanting the suitable length of prosthesis in a straight penis, without undue complexity and risk of infection.

Acknowledgements

This study is self-funded. There is no proprietary of interest to declare.

References

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