A penile prosthesis is a medical device implanted into the penis to treat erectile dysfunction (ED). It is typically considered when other treatments, such as oral medications and injections, are ineffective. While penile prostheses can significantly improve quality of life, they also come with potential complications, the most serious of which is infection. It is essential to be aware of the infection risks and implement preventive measures to ensure patient safety and optimal outcomes.

Prevelance of prosthesis infection

Penile prosthesis infections are rare, occurring in approximately 1-3% of primary implantations. However, the risk can be higher in certain populations, such as those with diabetes, spinal cord injuries, or immunocompromised states. Revisions or secondary implantations carry a slightly higher infection risk, estimated around 3-5%.

Risk factors for infection

Infection is a serious complication associated with penile prosthesis implantation. Here are the primary risk factors for infection in penile prosthesis implantation:

Diabetes

• Hyperglycemia: Poor blood glucose control can impair wound healing and immune response, increasing the risk of infection.
• Elevated HbA1C levels: This indicates poorer long-term control of blood glucose levels in diabetic patients. Poorly controlled diabetes is associated with impaired wound healing, compromised immune function, and increased susceptibility to infections, including those related to surgical implants like penile prostheses.
• Microvascular Complications: Diabetes can cause poor circulation, leading to reduced delivery of immune cells to the surgical site.

Obesity

• Increased Surgical Time: Obesity can complicate the surgical procedure, leading to longer operating times and greater exposure to potential contaminants.
• Poor Wound Healing: Excess adipose tissue can impair healing processes and increase the risk of postoperative infections.

Immunocompromised State

• Chronic Conditions: Conditions like HIV/AIDS, chronic kidney disease, or use of immunosuppressive medications (e.g., corticosteroids, chemotherapy) can compromise the immune system.
• Reduced Defense Mechanisms: An impaired immune system is less effective at fighting off infections.

History of Infections

• Previous Surgical Infections: A history of infections at the surgical site or other urological infections can increase susceptibility.
• Recurrent Urinary Tract Infections (UTIs): Frequent UTIs can introduce bacteria into the penile region, increasing the infection risk for the prosthesis.

Smoking

• Impaired Circulation: Smoking can lead to vasoconstriction, reducing blood flow and oxygen delivery to the surgical site.
• Delayed Healing: Tobacco use is associated with slower wound healing and increased susceptibility to infections.

Surgical Factors

• Surgical Technique: Non-sterile techniques or intraoperative contamination can introduce pathogens.
• Surgical Experience: Surgeons with less experience in penile prosthesis implantation may have higher rates of postoperative complications, including infection.

Concurrent Medical Conditions

• Cardiovascular Disease: Conditions like hypertension and peripheral artery disease can impair healing and increase infection risk.
• Chronic Inflammatory Diseases: Conditions such as rheumatoid arthritis or inflammatory bowel disease can affect immune function.

Hospital Environment

• Nosocomial Infections: Hospital-acquired infections due to resistant bacteria can complicate the postoperative period.
• Sterility Protocols: Lapses in hospital sterility protocols can increase the risk of infection during surgery.

Chronic renal failure

• Chronic renal failure is a risk factor for penile prosthesis infection due to its association with impaired immune function and poor wound healing.

Organ transplantation

• Organ transplantation is a risk factor for penile prosthesis infection because of the use of immunosuppressive medications, which weaken the immune system.

Paraplegic patients

• Paraplegia (spinal cord injuria) is a risk factor for penile prosthesis infection due to potential complications like poor circulation and higher susceptibility to infections.

Age

• Older Age: Advanced age can be associated with a decline in immune function and slower healing processes.

Prevention of infection

Preventing infection in penile prosthesis implantation is critical to ensure the success of the procedure and the well-being of the patient. Here are key strategies to prevent infections associated with penile prostheses:

Preoperative Measures

• Patient Screening and Optimization:
  • Diabetes Management: Ensure tight glycemic control in diabetic patients to improve immune function and wound healing.
  • Address Comorbidities: Optimize the management of other chronic conditions such as hypertension, cardiovascular disease, and obesity.
  • Smoking Cessation: Advise patients to stop smoking well before the surgery to enhance healing and reduce infection risk.
  • Urinary Tract Health: Treat any existing urinary tract infections (UTIs) before surgery to reduce bacterial load.
• Preoperative Antibiotics:
  • Prophylactic Antibiotics: Administer broad-spectrum antibiotics prior to surgery to reduce the risk of bacterial contamination during the procedure.

Intraoperative Measures

• Aseptic Technique:
  • Sterile Environment: Maintain a sterile operating environment with strict aseptic techniques to minimize the risk of contamination.
  • Minimize Operating Time: Reduce surgical duration to lower the risk of intraoperative exposure to bacteria.
• Use of Antibiotic-Coated Implants:
  • Antibiotic/Hydrophilic Coatings: Utilize penile prostheses with antibiotic or hydrophilic coatings that reduce bacterial colonization on the implant surface.
• Surgical Expertise:
  • Experienced Surgeons: Ensure that the procedure is performed by experienced surgeons who are skilled in penile prosthesis implantation to reduce complications.

Postoperative Measures

• Postoperative Antibiotics:
  • Extended Antibiotic Prophylaxis: Continue antibiotics postoperatively as recommended to prevent early infections.
• Wound Care:
  • Proper Dressing: Use sterile dressings and maintain a clean surgical site to promote healing and prevent infection.
  • Monitoring for Signs of Infection: Regularly check the surgical site for signs of infection such as redness, swelling, increased pain, or discharge.
• Patient Education:
  • Hygiene Instructions: Educate patients on proper hygiene practices to keep the surgical site clean.
  • Early Reporting: Instruct patients to report any signs of infection immediately for prompt intervention.

Follow-Up Care

• Regular Follow-Up Visits:
  • Scheduled Check-Ups: Arrange regular follow-up appointments to monitor the healing process and detect any early signs of complications.
  • Prompt Intervention: Address any complications or infections quickly to prevent the progression of infection.
• Long-Term Monitoring:
  • Late Infection Vigilance: Remain vigilant for signs of late infections, even months to years after the procedure, as they can occur and require immediate attention.

Treatment of infection

Infections following penile prosthesis implantation, while relatively rare, are serious complications that require prompt and effective treatment. The approach to managing these infections depends on the timing, severity, and the patient’s overall condition.

Early Infections (Within 4-6 Weeks Post-Surgery)

• Antibiotic Therapy:
  • Empiric Treatment: Initiate broad-spectrum intravenous antibiotics immediately upon suspicion of infection. Common choices include vancomycin combined with a third-generation cephalosporin or aminoglycoside to cover both Gram-positive and Gram-negative organisms.
  • Culture-Specific Therapy: Adjust antibiotic regimen based on culture and sensitivity results from wound swabs or aspirates.
• Surgical Intervention:
  • Irrigation and Debridement: For localized infections, perform surgical irrigation and debridement to remove infected tissue and biofilm from the prosthesis. Salvage of the implant may be possible if the infection is detected early.
  • Explantation: If the infection is extensive or the implant salvage is not feasible, remove the prosthesis. This involves debridement of all infected and necrotic tissues.
• Temporary Management:
  • Drain Placement: After explantation, place surgical drains to manage infection and fluid accumulation.
  • Antibiotic Spacer: Consider using an antibiotic spacer to maintain penile length and shape, and to deliver local antibiotic therapy.

Late Infections (Beyond 6 Weeks Post-Surgery)

• Antibiotic Therapy:
  • Prolonged Antibiotic Use: Initiate prolonged antibiotic therapy tailored to the pathogen identified. Oral antibiotics may be used based on the severity of the infection and patient’s response to initial treatment.
• Surgical Management:
  • Explantation and Delayed Reimplantation: Remove the infected prosthesis and thoroughly debride the infected tissue. Reimplantation of a new prosthesis is typically delayed for several months until the infection has completely resolved and tissues have healed.
  • Two-Stage Procedure: A two-stage approach may be employed, where an antibiotic spacer is initially placed, followed by definitive implant placement once the infection is cleared.

Management of Biofilm-Associated Infections

• Biofilm Considerations: Biofilm formation on the prosthesis surface can make infections particularly difficult to eradicate, often necessitating implant removal.
• Antimicrobial Strategies: Use high-dose, long-duration antimicrobial therapy targeting biofilm-producing bacteria.

Supportive Care

• Pain Management: Provide adequate pain relief through medications to manage discomfort associated with infection and surgical procedures.
• Nutritional Support: Ensure the patient has adequate nutrition to support immune function and healing.

Patient Education and Follow-Up

• Infection Signs: Educate patients on recognizing early signs of infection, including increased redness, swelling, pain, fever, or discharge.
• Follow-Up Appointments: Schedule regular follow-up visits to monitor healing and ensure complete resolution of the infection.
• Preventive Measures: Discuss strategies to prevent future infections, such as maintaining good hygiene and managing underlying health conditions effectively.

Summary

Infection is a serious complication of penile prosthesis implantation that can lead to significant patient morbidity and may require the removal of the device. Overall, successful management of penile prosthesis infections relies on early detection, appropriate antibiotic use, surgical intervention when necessary, and comprehensive patient care and education.

Prof. Dr. Emin ÖZBEK

Urologist

Istanbul- TURKIYE