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BackTable / Urology / Article
Penile Implant Infection Signs & Treatment
Quynh-Chi Dang • Jan 5, 2022 • 2.3k hits
It is important to know penile implant infection signs because it is a treatable complication after surgery. The penile implant can be removed or replaced after a washout procedure. Additionally, patients with penile implant infections should be started on culture-specific antibiotics. Urologist and penile implant specialist Dr. Jonathan Clavell shares his advice when looking for penile implant infection signs and his advice for penile implant infection treatment on the BackTable Urology Podcast.
We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable Urology Brief
• There are three penile implant infection treatment options: (1) removal, (2) removal and replacement with another 3-piece inflatable prosthesis, or (3) removal and replacement with a malleable prosthesis.
• A penile implant infection means that the corporas must be cleaned out through a washout procedure. Dr. Clavell recommends using Irrisept with 0.05% chlorhexidine or Clorpactin.
• It is recommended for surgeons to send cultures of the penile implant infection for identification and susceptibility analysis. Culture-specific antibiotics are always preferred, but broad spectrum antibiotics and antifungals can be used as alternative options.
• Dr. Clavell removes penile implants if there is extrusion through the glans. He usually replaces or only partially removes the implant in the case of extrusion through the urethra.
Table of Contents
(1) Penile Implant Infection Treatment Options
(2) Penile Implant Infection Washout Procedure & Antibiotic Selection
(3) Penile Implant Extrusion Through the Glans or Urethra
Penile Implant Infection Treatment Options
Gross puss is one of the most definitive penile implant infection signs. There are three penile implant infection treatment options. First, the surgeon can remove the three-piece inflatable prosthesis and place a new prosthesis, which has a 50% success rate. Second, the surgeon can replace the three-piece prosthesis with a malleable penile implant. Finally, the surgeon can remove the prosthesis without replacing it with another implant. Dr. Clavell recommends discussing the three different penile implant infection treatment options with the patient as well as assessing uncontrollable risk factors, like diabetes, which lower the success rate of a replacement penile prosthesis after penile implant infection.
[Dr. Jose Silva]
There's always talk about infection versus erosion, and it’s a fine line. I mean, as long as the patient doesn't have any systemic symptoms, I'm not gonna put in a new implant. Let's say that the pump is eroding through a scrotum. When do you make the decision to just exchange everything at that moment? Or do you just take it out and then come back on another occasion?
[Dr. Jonathan Clavell]
I mean, it really depends on how bad that infection is. If there's gross pus leaking out, I usually try to take everything out. Then I would have a conversation before the surgery with the patient about the risks. For any patient who has an infection, I tell them that we have three options. I can take everything out and come back another day. Also, I can take everything out and place a malleable, right? But you have about a 15, 20% chance that this is going to fail. And then I can also take everything out, replace it with a three-piece inflatable implant again, but you have about a 50% chance at best that this can work or that this is going to eventually work. And usually I let the patients decide as long as they're aware of what they're getting themselves into.
It is possible to replace it with a three-piece. I've done it before and they've done well, of course, in these patients, I will, I need to make sure what infection we're dealing with based on what the culture has shown. And I will keep them on antibiotics probably for a little bit longer, maybe two or three weeks, rather than just one week afterwards.
Also, evaluate the risk factors. If this guy's like an uncontrolled diabetic, don't shoot yourself in the foot. If the guy's healthy and doesn't have any risk factors for infection, then it's something that we can definitely consider.
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Penile Implant Infection Washout Procedure & Antibiotic Selection
Regardless of the penile implant infection treatment option, the urologist must perform a washout procedure to clean out the corpora. Dr. Clavell uses Irrisept, which contains 0.05% chlorhexidine, but also recommends Clorpactin. He does not recommend using hydrogen peroxide or betadine, as they can damage tissues.
If a replacement penile prosthesis will be placed in the future, a carrion cast can be used to create extracapsular space to ensure that the new implant will not make contact with the previous surgical capsule. The cast, which prevents the corpora from collapsing while waiting for replacement surgery, is made of a combination of a stimulant and antibiotics.
Dr. Clavell recommends sending cultures for identification and susceptibility analysis immediately. If broad spectrum antibiotics must be used, he recommends combining vancomycin, zosyn, and an antifungal.
[Dr. Jose Silva]
And in those cases you do a wash out, you try to remove the biofilm. What techniques do you use to clean those corpora?
[Dr. Jonathan Clavell]
So I do a wash out. I use Irrisept which has chlorhexidine. It's like, I think it's like 0.05%. I use Irisept with antibiotic solution. I'm just basically alternating both. I have a really good friend who uses another solution called clorpactin. It's basically like bleach, but tissue friendly.
I want to use that in the hospitals where I work. They just don't have it available yet. As soon as we have it available, I'm definitely going to start using it. I do not use betadine. I do not use hydrogen peroxide. I believe these will damage the tissues, and they're really not that great.
So again, I use whatever is available. but again, it's just a matter of actually irrigating those tissues more than what you're actually irrigating with. So the most important thing is you make sure that you wash out everything very well.
And I place the implant within that same surgical capsule inside the corporas. There is a doctor from Egypt who also uses the extra capsular tunneling. So he’s basically creating a new space behind that capsule in order to avoid contact of the new implant with the surgical capsule.
And that's something that works for him in several cases that he published. So again, there's multiple things that we can try. For example, another thing for these infected IPPs, he makes a carrion cast, which is basically like a spacer, using a solution called stimulant, which is calcium sulfate. And you can actually combine it with an antibiotic solution. So it's like a powder that you just combine it with vancomycin or tobramycin or whatever other powder antibiotic, you mix everything together, you get the water in, or saline, and it will create, uh, this paste that forms like a cast. And this cast usually dissolves within six weeks.
So basically you can leave that cast in there and come back six weeks later. So we will create a, like a spacer inside to make sure that the corporal tissue doesn't collapse and start causing fibrosis. So whenever you come back, it's going to be easier for you to get an implant. That being said, it's easier said than done.
I believe that right now he's working on a new protocol to see how he can optimize that. You have like a five minute window, to get that cast in and it will create a mess if you don’t do it quickly.
[Dr. Jose Silva]
…What broad-spectrum antibiotic will you give them?
[Dr. Jonathan Clavell]
So I usually try to keep them on something similar, of course. If you have a guy who comes into your office with pus, get a culture right there in your office and send it out, so you know what you're dealing with. That way, you can tailor your antibiotics to cover for that bacteria specifically. If it's still broad spectrum, I would still do the regular vancomycin and gentamicin.
Sometimes I combine vancomycin and zosyn, instead of the gentamycin, and I also put in an antifungal. Again, you can also get these fungal infections if we're not paying attention to it. The first thing that I do is, as soon as I make my incision, get a swab of that tissue or send a little bit of that biofilm tissue out for culture to make sure that you know what you're dealing with–just in case that you have to come back in the future to get an implant in. Knowing what bacteria was in there and what resistance that bacteria had is helpful.
Penile Implant Extrusion Through the Glans or Urethra
It is possible for a penile implant to extrude distally through the glans or laterally into the urethra. Dr. Clavell avoids replacing an implant if the previous one has extruded through the glans. However, if the implant has extruded into the urethra and there are no penile implant infection signs, he is comfortable with replacing the penile implant. In some cases where only one cylinder on one side is affected, he sometimes removes the problematic cylinder and leaves the normal cylinder on the unaffected side alone. Although these patients do not have a full three-piece implant, they can still regain some erectile function.
[Dr. Jose Silva]
And for those cases that you have extrusion through either the glans or the urethra, will you put another implant at the same time? Or will you close the defect and come back at another time?
[Dr. Jonathan Clavell]
Depends. Again, this is all my opinion, so do not take this as scripture. I mean, these cases are extremely rare. If there is a complete extrusion and complete erosion that I can actually see the implant–if it's through the glans, it is very unlikely that I will place an implant in again if it's in contact with the urethra. I would not do it–again this is just me. I would not place an implant back in on that side. If it's like, you know, on the actual side of the shaft and there are no gross penile implant infection signs, I would just take everything out and place an implant in and just close it. And I would just keep that implant deflated until everything heals.
Let's say that it eroded into the urethra but there are no gross signs of infection, and only one side has eroded. You can take that side out and just leave that other side. Let's say that the right side eroded, you can leave the left implant that left cylinder inside.
And sometimes you can actually get away with it. And I've seen guys in my office again, not my patients, but guys who've had implants done before that have one cylinder and they're happy with it. So again, they can still be functional with one cylinder. Sometimes it's just a matter of setting proper expectations and telling them, “Hey, man, we just want to get you functional. This is not for you to be, you know, feeling like when you were 20 years old. We’re just trying to get you functional and we can always come back and fight another day.”
[Dr. Jose Silva]
And I think talking about expectations at first is the most important part, because they always see the videos on YouTube that show great erections, just like when they were 20 years old.
And, hey, that's not true. I mean, like I said, it's just a matter of being functional. Are you doing drainage on those patients? Let's say you do a wash out. You put in a new implant. Do you leave in a drain?
[Dr. Jonathan Clavell]
Yes, I will do that for those patients. I definitely will. I mean, even if I don't leave an implant in, I would leave a drain in for several days. Because again, you are washing them out a lot. You're using a lot of fluid. You want to make sure that you set yourself up for success. You don't want these guys to have edema and then, you know, the edema accumulates into a pocket, and then you have a pocket of fluid that could potentially get infected.
So for those, I would usually just leave a drain in.
Podcast Contributors
Dr. Jonathan Clavell
Dr. Jonathan Clavell is a high-volume prosthetic urology surgeon and assistant professor of urology at UT Health Science Center Houston.
Dr. Jose Silva
Dr. Jose Silva is a board certified urologist practicing in Central Florida.
Cite This Podcast
BackTable, LLC (Producer). (2021, November 24). Ep. 23 – Complex Penile Implants [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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