C Penile : Patient O N Teaching and Perioperative Care T I N Susanne A. Quallich U Dana A. Ohl I N G rectile dysfunction (ED) As more options become available for treating is defined as “the inabili- (ED), more men are seeking treatment. Despite excellent efficacy of ty to achieve and main- available medical management, a percentage of these patients will be E tain an erection suffi- refractory to the less invasive options for treatment, leaving the sur- D Ecient to permit satisfactory sexu- gical implantation of a penile prosthesis as their remaining option for al activity” (Droller et al., 1992). U Some estimates indicate that ED definitive treatment of ED. The patient seeking penile prosthesis C surgery faces many challenges as he proceeds through the periop- affects as many as 10 to 20 mil- A lion men in the United States, erative processes. A thorough understanding of indications, preop- with this number increasing up erative assessment and teaching, intraoperative procedure, and T to 30 million if men with mild to postoperative care and teaching for the patient receiving a penile I moderate ED are included prosthesis will enable him to achieve the best possible outcome. O (Feldman, Goldstein, & Hatzich- risou, 1994). N Treatment of ED is a quality Objectives of life issue. ED has been associ- This educational activity is designed for nurses and other health ated with depression, anxiety care professionals who care for and educate patients regarding penile regarding sexual function, poor prosthesis. The multiple choice examination that follows is designed to self-image and self-esteem, and test your achievement of the following educational objectives. After can affect the quality of the rela- studying this offering, you will be able to: tionship with a patient’s partner 1. Describe the indications for a penile prosthesis. (Bates, 2001; Meredith, 1995). 2. Discuss several preoperative management issues unique to the Successful treatment of ED can patient receiving a penile prosthesis. restore a man’s confidence in his 3. Identify the risks of penile prosthesis surgery. sexual potency as well as 4. Discuss the postoperative care for the patient having prosthesis improve his quality of life. surgery. In the era of established and 5. Develop a plan of care for the patient having surgery for a popular oral erectogenic agents, penile prosthesis. and with new oral agents becom- ing available, it might be expect- sildenafil citrate (Viagra®), inter- the less-invasive treatments for ed that the indications and need ested in a vacuum erection ED. As more and more men con- for implantable penile prosthe- device, or will respond to phar- tinue to seek care for ED, it is ses as a treatment for ED would macologic injections designed to important to be familiar with the be declining. However, not all produce an erection. As the pop- concepts specific to penile pros- men with ED are candidates for ulation continues to age, and thesis surgery, its risks, and its with the acceptance of ED as a unique perioperative manage- Susanne A. Quallich, APRN, BC, NP- topic that can be readily dis- ment issues. C, CUNP, is a Nurse Practitioner, cussed between patient and Section of Urology, Ann Arbor Veterans’ provider, the number of penile History of the Penile Affairs Health System, Ann Arbor, MI. prostheses that are implanted has Prosthesis remained relatively steady (Stan- Surgery for ED was first Dana A. Ohl, MD, is an Associate Professor of Urology, Head, Division ley, Bivalacqua, & Hellstrom, reported at the turn of the centu- of Andrology and Microsugery, 2000). A penile prosthesis ry, although it typically involved University of Michigan Medical remains the primary option for penile revascularization proce- Center, Ann Arbor, MI. many patients who have failed dures only (Virag, 1989). The first

UROLOGIC NURSING / April 2002 / Volume 22 Number 2 81 C Figure 1. implantable erectile device was introduced in 1966 O AMS Malleable 650™ and was a single rigid device implanted beneath the Penile Prosthesis fascia of the penis. This device was unsatisfactory N in both appearance and function to patient and sur- T geon alike. Subsequent improvements involved the I development of various types of paired rods that were implanted into the corpora cavernosa. These N later devices were still suboptimal because they U could not be easily concealed and did not mimic I natural erectile function. In 1972, American Medical Systems (AMS) N developed the first inflatable prosthesis: a three-piece G device with two cylinders, a scrotal pump, and an abdominal fluid reservoir (Scott, Bradley, & Timm, Figure 2. E 1973). It rapidly became the mainstay of treating all AMS Ambicor® types of ED with the exception of psychogenic ED. D Penile Prosthesis Mentor first introduced its version of the three-piece U prosthesis in 1983. These early devices and others C that followed it, however, were plagued by various mechanical problems that often required surgical A revision or complete replacement of the device. T Several implantable penile devices have come I and gone in the last 30 years, including the AMS Hydroflex, AMS Dynaflex, Omniphase, Surgitek O Flexi-Flate and Flexi-Flate II, Finney Flexirod I and N Flexirod II, Surgitek Uni-Flate 1000, and Mentor Mark II. It is possible to care for patients who still have some of these previous models implanted; although due to their malfunctions, many have been replaced with a current model. Ideal Penile Prosthesis Figure 3. AMS 700 Several criteria define the “ideal” penile prosthe- Penile Prosthesis sis. Cosmetically, the device should resemble a nat- ural erection as closely as possible. It should also resemble a flaccid penis when the device is not in use and should feel normal when palpated. The prosthe- sis should preserve the shape of the penis at all times and should be convenient and easy to use to allow for spontaneity. The model of prosthesis that most close- ly fulfills these criteria is the three-piece inflatable prosthesis. Selecting a penile prosthesis for a particular patient depends on a variety of factors. It may be determined by patient preference or the cost of the device if the surgery is not covered by insurance. Device selection can also be guided by a history of previous abdominal or inguinal surgeries, the manu- al dexterity of the patient, the existing comorbidities of the patient, and surgeon preference.

Photos courtesy of American Medical Systems, Inc., Types of Penile Prostheses Currently Available Minnetonka, MN (www.visitAMS.com) Malleable. Malleable penile prostheses are avail- able from several companies: AMS (Malleable 650 [see Figure 1]), Mentor (Small-Carrion, Malleable), and CE Series Posttest appears Timm Medical Technologies (Dura II). A malleable prothesis may be made of pure silicone rubber and on pages 93-95. may have an intertwined central or metallic core. The

82 UROLOGIC NURSING / April 2002 / Volume 22 Number 2 Table 1. C Types of Available Inflatable Penile Prostheses O N Device Length Specific Device Description Expansion Material Indications Comments T I AMS Ambicor Two-piece No Silicone Previous mesh inflatable inguinal hernia N repair, kidney U transplant patients I N AMS 700CX Three-piece No Silicone Peyronie’s dis- Also with G inflatable ease, long nar- Inhibizone row penis, previ- coating ous distal cylin- E der erosion D AMS 700CXM Three-piece No Silicone Fibrosis, reim- Also with U inflatable plantation after Inhibizone infection coating C A AMS 700 Ultrex Three-piece Yes Silicone None; can be Also with or Ultrex Plus inflatable used in most sit- Inhibizone T uations coating I O Mentor Three-piece No Bioflex S/P radical Nonrefluxing Alpha 1 inflatable (polyurethane) or reservoir valve N cystectomy

Mentor Alpha 1 Three-piece No Bioflex Peyronie’s Nonrefluxing Narrow Base inflatable (polyurethane) disease, reservoir valve reimplantation after infection

Dura II consists of a series of artic- (Lewis, 1998). Malleable prothe- mesh as the result of previous ulating discs that allow a pro- ses are implanted less frequently inguinal hernia repairs may be nounced bend and can aid in con- due to better mechanical reliabili- presented with this type of device cealing the device. ty of the three-piece inflatable as an option. This type of prosthe- Malleable prostheses are the prosthesis. sis also involves a single step for least expensive of the three pros- Two-piece inflatable. The cur- deflation. There is no significant thesis types and are the least com- rently available two-piece inflat- mechanical advantage to the two- plicated to place surgically. The able prosthesis (AMS Ambicor [see piece prosthesis, however, when malleable prosthesis has the low- Figure 2]) contains a combination compared with the three-piece est incidence of wear-induced scrotal pump/reservoir, but does (Dubocq, Tefilli, Gheiler, Haikun, failure because it has no mechan- not present as natural a flaccid & Dhabuwala, 1998; Kabalin & ical parts. This type of prosthesis state as a three-piece prosthesis Kuo, 1997). is more suitable for holding a con- (Kabalin & Kuo, 1997). Three-piece inflatable. The dom catheter in place as it pro- The two-piece model will not three-piece inflatable penile pros- vides a constant semi-rigid sup- provide any significant increase theses (AMS 700 Ultrex or Ultrex port. Its drawbacks include the in girth. The main advantage to Plus [see Figure 3], AMS 700CX, fact that it can be difficult to con- this particular prosthesis is the AMS 700CXM, Mentor Alpha I ceal because it is always firm, it lack of the suprapubic reservoir, and Alpha I narrow base [see does not alter penile length, and it which also results in the more Figure 4]) provide the most natur- does not alter penile girth. A high- rapid placement of the device by al approximation of a patient’s er incidence of erosion is also the surgeon. Patients who have original erectile function (Gold- seen with this type of prosthesis had extensive surgery to the stein et al., 1997). Inflatable de- because it is always semi-rigid inguinal regions or who have vices are compared in Table 1.

UROLOGIC NURSING / April 2002 / Volume 22 Number 2 83 C Figure 4. Indications for Penile to the compression of the reser- O Mentor Alpha 1 Prosthesis voir from postoperative scarring There are several reasons a following prostatectomy. N man may be offered a penile pros- Radiation therapy. Many T thesis as an option for treating his patients with cancer I ED. Men who are diagnosed with treated with external beam radia- organic ED and who have failed tion will develop impotence over N first and second-line pharmaco- time. This is due to the damage U logic management may be offered that occurs to the neurovascular I a penile prosthesis as definitive bundles as well as corporal fibro- N treatment for their continued sis that occurs (Dubocq, Bianco, erectile dysfunction. Because this Maralani, Forman, & Dhabuwala, G is an elective surgery that is not 1997). These patients may not without risks, it is vital to estab- respond to the first and second- E lish what a particular patient’s line pharmacologic treatments goals are in seeking surgical treat- and may be offered a penile pros- D ment for his ED. thesis, although they are at a U During the discussion the slightly increased risk of infection C patient must be told that once an from the tissue and vascular dam- implant is placed, pharmacologic age caused by the radiation A treatment will usually not work. (Wilson & Delk, 1995). T The patient and his partner must . Patients I understand that implantation who have undergone a radical The three-piece device allows damages the corpora cavernosa cystoprostatectomy can also be O the patient the most control over and should be used only after all candidates for prostheses. These N his erection and the most natural other options have been explored. patients will typically experience appearance both inflated and It is imperative that the patient ED similar to that seen with the deflated. Although giving the best understands the ramifications of a prostatectomy patients. This is inflation, a three-piece device will penile prosthesis from the start again due to the removal of the not, however, recreate the length and that there is no turning back and varying of patient’s native erection. The after the prosthesis has been degrees of preservation of the neu- AMS Ultrex provides a slight implanted. rovascular bundles. increase in penile girth with infla- Radical prostatectomy. Men Other surgical procedures. tion as well as the potential for the who have undergone a radical Patients who have had any major greatest increase in length due to prostatectomy are frequently can- abdominal surgery such as the an expansion in length of up to didates for a penile prosthesis. repair of an abdominal aortic 20% (Montague, Angermeier, & The strongest predictor of potency aneurysm or colon resection are Lakin, 1996). The Mentor Alpha I after a prostatectomy is preopera- also candidates for a penile pros- has a unique nonrefluxing reser- tive sexual function, but potency thesis for treatment of ED. voir valve that is often preferred is also influenced by patient age, Peyronie’s disease. Peyronie’s for patients who have had previ- comorbidities, and the ability of disease is a benign condition that ous abdominal surgery. the surgeon to spare either one or often presents as a painful erec- Regardless of the model, how- both of the neurovascular bundles tion, a curved erect penis, and poor ever, the patient needs good man- (Lue, 2000). Patients will have a erection distal to the curved area. ual dexterity to work the scrotal “dry” orgasm (no ejaculate), as the This curvature is caused by a pump that inflates and deflates seminal vesicles are also removed fibrous plaque along the shaft of any three-piece prosthesis. The along with the prostate. the penis, can occur anywhere nature of these devices also cre- Because sexual function can along the length of the shaft, and ates a higher risk of mechanical improve in the 6 to 12 months fol- can be so severe that it prevents failure. AMS has recently added lowing surgery (Presti, 2000), a vaginal intercourse. Patients may the Inhibizone (minocycline penile prosthesis is not typically also complain of some degree of hydrochloride and rifampin) coat- discussed until at least 12 months . Some men ing to its three-piece inflatable after the surgery. In this case, may experience remission of the models to add further protection some surgeons prefer to offer the disease and resolution of the against infection. Both AMS and Mentor three-piece prosthesis plaque. For those who do not gain Mentor provide kits for implanta- because of its lock-out reservoir relief from noninvasive treat- tion via the penoscrotal and infra- valve. This valve will prevent the ments or do not experience remis- pubic approach. autoinflation of the prosthesis due sion, and have poor rigidity of

84 UROLOGIC NURSING / April 2002 / Volume 22 Number 2 erection, implantation of a three- management preoperatively. treatment option, but the patient C piece inflatable prosthesis with Lack of manual dexterity. won’t be able to go back to most O intraoperative “modeling” is the Any patient considering surgery options after a prosthesis has been preferred treatment (Wilson & for a prosthesis also needs to be implanted. N Delk, 1994). The implantation of evaluated for his level of manual Penile prosthesis surgery is T the prosthesis allows for the dexterity. While this is of less con- an elective surgical procedure, I straightening of the penis intraop- cern with a malleable prosthesis, and as such, time must be taken to eratively without incising the a patient who desires a three- insure that the client is medically N Peyronie’s plaque. After the inser- piece inflatable prosthesis must optimized. As ED rarely exists in a U tion and inflation of the prosthesis possess sufficient manual dexteri- vacuum, the medical manage- I “fractures” the plaque, this “mod- ty to be able to manipulate the ment of a patient’s comorbidities eling” of the plaque allows the pump after it is placed in the scro- can be challenging. Many condi- N penis to be straight when the pros- tum (Lewis, 1998). This is also a tions, such as cardiovascular dis- G thesis is inflated after healing is consideration with the two-piece ease, can increase a patient’s risk complete. inflatable prosthesis, unless in for surgery. Routine preoperative E either case the patient’s partner is evaluation will include a urinaly- Contraindications to committed to taking responsibili- sis and culture, baseline chemis- D Implantation of Penile ty for inflating the prosthesis. tries, complete blood count, coag- U Prosthesis ulation studies, electrocardio- C Infection. Patients who have Preoperative Evaluation gram, and a chest film in patients active urinary tract infections Throughout the preoperative over age 50. A glycosolated hemo- A (UTI) at the time of surgery are at process, patients and their part- globin and albumin may be added T increased risk for infection of the ners should be given multiple at the provider’s discretion. I prosthesis postoperatively despite opportunities to ask questions Uncircumcised males should the use of broad-spectrum antibi- and express any concerns they undergo a prior to O otics in the holding area (Jarow, may have regarding the surgery. considering prosthesis surgery if N 1996; Montague et al., 1996). Men This particular surgery is unique they have a history of recurrent with active UTIs should have their in that the preoperative discus- balanitis or posthitis or apparent surgery delayed until a clean uri- sion must include not only a dis- poor hygiene. This will eliminate nalysis can be documented within cussion of basic surgical princi- a potential source of postoperative approximately 2 weeks of the pro- ples, but discussion of a patient’s infection. If a phimosis or paraphi- posed operative date. sexual function, previous ED mosis is noted on the preoperative An active infection anywhere treatment failures, and the pro- examination, the patient will also in the body can also increase the jected improvement of his sexual be advised to pursue a circumci- risk of postoperative infection of function. It may be necessary at sion or dorsal slit prior to implan- the prosthesis. Infections should times to involve the patient in tation of a prosthesis. This will be eradicated prior to surgery. counseling with a sex therapist or prevent any potential complica- This includes, but is not limited psychologist who specializes in tions due to the swelling of the to, diabetic foot infections, peri- treating patients with sexual dys- penile shaft immediately after odontal disease, and any lesion function. This can help uncover surgery. In both instances, these that would be within the opera- any issues the patient or couple additional procedures would only tive field (Jarow, 1996). may have regarding the nature of delay the implantation of the Diabetes. Some investigators their sexual relationship and help prosthesis until the incision sites have reported that a glycosolated prevent unrealistic expectations are healed. hemoglobin greater than 11.5% from either party about the post- presents an increased risk for operative function of the prosthe- Preoperative Counseling postoperative infection (Bishop et sis. When counseling the patient al., 1992). But other investigators Preoperative discussion will considering a penile prosthesis, it have shown that this does not also include a review of the vari- is important to include the conclusively increase the risk for ous types of prostheses and the patient’s significant other to help postoperative infection (Jarow, indications, benefits, potential avoid unrealistic expectations 1996; Wilson, Carson, Cleves, & problems, and side effects for regarding the results of the Delk, 1998). The role of diabetes each. Some patients will have an surgery. Patients and their part- in postoperative penile prosthesis expressed preference for one type ners must be informed that the infections may be due to its well- over another and should be sup- erections created by an inflatable documented impact on healing ported in their choice of device. penile prosthesis will be approxi- time, the microvascular changes it The nurse must clearly outline mately one to two centimeters causes over time, or poor diabetes that a penile prosthesis is a good shorter than their native erection.

UROLOGIC NURSING / April 2002 / Volume 22 Number 2 85 C Table 2. invasive procedure such as a cys- O Preoperative Instructions for Penile Prosthesis Surgery toscopy, colonoscopy, or teeth cleaning. N ◆ Stop taking aspirin, ibuprofen (Motrin®, Advil®), and naproxen T (Naprosyn®) 7 days before your surgery date. These drugs can thin Risks of Penile Prosthesis I your blood. Surgery ◆ If you take the blood thinner warfarin sodium (Coumadin®), you will Penile prosthesis surgery car- N be given special instructions about when to stop this medication. ries with it some unique risks due U ◆ You will be given separate instructions about which medications you in part to a foreign object being I may take the morning of surgery. implanted into the human body. N ◆ Do not shave your groin for the 2 weeks before your surgery date. Recovery after this surgery can be This prevents any nicks to your skin that can provide an entrance for further complicated by the fact G bacteria. that ED is commonly seen in ◆ You will be given four chlorhexidine (Hibiclens®) sponges, which patients with existing comorbidi- E have special antibiotic soap. Use two to bathe or shower the night ties that can prolong and compli- before surgery: use one to clean your entire body, and one to clean cate healing. These risks should D your groin. The morning of surgery, bathe or shower again, using be reviewed with the patient as U one sponge to clean your entire body, and one to clean your groin. often as possible prior to surgery C to ensure that the patient is famil- iar with them, and also because A this is an elective surgery. These T This is because the cylinders of of the incision could cause dam- risks are a dynamic group of I the prosthesis only extend the age to the incision and loss of its potential postoperative complica- length of the corpora cavernosa containment structures. Resum- tions, which can themselves be O and therefore provide firmness ing sexual activity will be dis- interrelated and which can be N throughout the length of the cor- cussed at a later postoperative devastating both physically and pora only. In contrast, a natural visit. After 6 weeks, most patients psychologically to the patient. erection would also create firm- are sufficiently healed to resume Infection is the primary risk of ness throughout the glans of the sexual activity after being in- this particular surgery. This is penis as both the corpora caver- structed in the use of their pros- more commonly seen with nosa and corpora spongiosium fill thesis. patients who have diabetes or a with blood. This loss of length is Once the appropriate device spinal cord injury, or who have the primary reason for dissatisfac- has been determined, patients had repeat prosthesis surgery tion with prosthesis surgery, and should be given the opportunity where there has been a delay the patient should be reminded to to examine a model of the pros- between the removal of a prosthe- expect this difference in length. thesis they will have implanted. sis and the reimplantation of This will reinforce preoperative another one. Infection commonly Preoperative Teaching teaching regarding the prosthesis presents within the first 12 weeks If any type of prosthesis must components and their role in the after implantation and is thought be removed, the patient must be function of the prosthesis as a to originate at the time of surgery cautioned that the likelihood of whole. It should also be men- (Knoll, 1998). The patient may response to any of the pharmaco- tioned that the model prosthesis complain of pain, swelling, logic methods of producing an is not representative of the pros- induration, or erythema of the erection is small (Mulcahy, 2000). thesis that will be implanted. or the shaft of the penis. The patient must also be informed Each patient is carefully mea- He may also complain of drainage that if the prosthesis is removed sured intraoperatively to ensure from the incision site, a discharge for any reason, repeat surgery to that the prosthesis implanted is from the scrotum if the pump has implant another prosthesis carries correctly sized. eroded through the scrotal skin, or with it a slightly increased infec- The patient and his partner drainage from the if there tion risk as compared with the should also be given clear written has been erosion of a cylinder. original implantation surgery. instructions detailing their roles The patient and his partner The patient planning to pro- in the immediate preparation the should be instructed to report any ceed with prosthesis surgery, night before surgery (see Table 2). of these clinical manifestations to regardless of the type of implant, In addition, the patient and his the surgeon immediately. must be cautioned against sexual partner should be taught about There are two methods by activity of any kind for 6 to 8 untoward side effects and what to which an infected prosthesis may weeks after the surgery. Use of the look for as well as the need to take be addressed. The first is a con- prosthesis prior to proper healing prophylactic antibiotics before an servative approach to simply

86 UROLOGIC NURSING / April 2002 / Volume 22 Number 2 remove the prosthesis, treat the undergo repeated urethral instru- rected by surgical release of the C patient with an appropriate com- mentation or who are on a regi- capsule by overdistension and O bination of antibiotics, and docu- men of clean intermittent cathe- does not necessarily require that ment that the infection is eradicat- terization may be at higher risk for the entire device be replaced. N ed before attempting to implant erosion due to the potential for T another prosthesis. The drawback repeated trauma to the urethra. Immediate Preoperative I to this approach is that the corpo- Incorrect sizing of the cylin- Patient Preparation ra can scar during the intervening ders can present with what is Patients scheduled to receive N period of time if it is greater than termed an SST deformity (after a penile prosthesis should have a U 4 to 6 weeks. This can result in a the Concorde aircraft), or a down- documented clean urinalysis with- I more challenging second surgery, ward hooking of the glans when in the 2 weeks prior to the surgery which can also increase the sub- the cylinders are inflated. This date. If a documented urinalysis is N sequent risk of infection; the would require surgery to replace not available, one may be ordered G resulting scarring can also cause the cylinders and correct the as part of the preoperative orders. the patient to lose an additional deformity. Incorrect cylinder siz- The patient should be made aware E one-half to one inch of the length ing can also contribute to postop- that the surgeon may chose to can- of his erection (Mulcahy, 2000; erative pain. cel the surgery if the urinalysis is D Wilson & Delk, 1995). This The typical life span of an suspicious for an infection. The U approach can also lead to pro- inflatable prosthesis is given as 8 patient must be instructed to C longed postoperative pain due to to 10 years of “regular use.” While shower the night before and morn- the additional dissection of the there exists no clear definition of ing of surgery with chlorhexidine A tunica albuginea that may be “regular use,” the incidence of soap that is provided to him. T required (Lewis, 1998). mechanical failure is approxi- Antibiotics, such as van- I The second option for mately 8.5% (Dubocq et al., 1998) comycin followed by gentamicin, addressing the infection is a pros- and can be seen several years after will be given in the holding area O thesis salvage protocol. This the original implantation. Often to provide broad-spectrum cover- N involves removal of the infected mechanical failure presents as age against common skin flora prosthesis, aggressive irrigation of complaints of the prosthesis not and gram-negative bacteria. The the tissues with seven antibiotic inflating correctly or fully when specific antibiotics will be sur- and antiseptic solutions, redrap- previously it had functioned as geon and/or facility dependent. ing the patient, rescrubbing and intended. This can indicate a The patient’s genital area should regowning by the surgical team, leakage of fluid from the system or be carefully inspected in the hold- and the implantation of a second a rupture of one of the cylinders. ing area to confirm the absence of prosthesis during a single opera- While it is possible to replace lesions which could be a source tion (Furlow & Goldwasser, 1987; only the failed part (if it can be for infection. Mulcahy, 2000). Because there is determined), many surgeons will no time delay between the prefer to replace the entire pros- Surgical Procedure implantation of the two prosthe- thesis. The possibility of mechan- The patient is shaved in the ses, length of erection is preserved ical failure must be discussed operating room to prevent poten- and there is no scar tissue that can with the patient and his partner. tial exposure to skin pathogens. potentially complicate a second Prolonged postoperative pain After a 10-minute Betadine® surgery. can indicate a subclinical infec- scrub of the surgical field, the The cylinders of the prosthe- tion. Complaints may include patient is draped with paper sis can erode through the corpora penile pain with inflation of the drapes (paper drapes are used as cavernosa and into the urethra, prosthesis, pain to the side of the wet cloth is permeable to bacte- which can also result in infection. scrotum in which the pump is ria). The surgical team scrubs for Erosion can be caused by the placed, swelling, erythema, and 10 minutes and dons paper incorrect sizing of the cylinders possible groin pain to the side in gowns. It is also recommended intraoperatively or by unrecog- which the reservoir is placed. This that the scrub technician or nurse nized damage to the urethra dur- can be treated with oral or intra- stay in the operating room for the ing the dilation of the corpora venous antibiotics, but usually duration of the case. Traffic in the (Montague et al., 1996). The requires prosthesis removal. surgical suite should be limited to patient may complain of pain to Over time, a capsule will form prevent contamination. The pros- the shaft of the penis along the around the prosthesis compo- thesis is assembled on a separate side with the erosion, or drainage nents. But it is also possible that a stand and soaked in a solution from the urethra. The prosthesis thick capsule may form around consisting of two antibiotics, such must be removed to provide the the reservoir, leading to autoinfla- as 50,000 U of bacitracin and 160 urethra time to heal. Patients who tion of the device. This can be cor- mg of gentamicin in 1,000 mL of

UROLOGIC NURSING / April 2002 / Volume 22 Number 2 87 C normal saline. This mixture will and the pump is placed. The Discharge Instructions O again be surgeon and/or facility external inguinal ring is then A Foley catheter will be in dependent. The new AMS bluntly dissected, the inguinal place and will be removed the N Inhibizone prostheses, which do floor is pierced, and the reservoir morning following surgery. The T not require soaking in antibiotic is placed in the retropubic space patient may be discharged once I solution prior to implantation, are and filled. The connections he is able to void. The wound the exception to this procedure. between the pump and the reser- should be checked every 2 hours N A penile prosthesis can be voir and between the pump and to evaluate for excessive drainage U implanted under general, region- the two cylinders are made. The to the dressing. The patient may I al, or local anesthesia. The first prosthesis is inflated to confirm also have a drain placed in the N step of the surgery itself is the that it is functional and then fully scrotum which will be removed placement of the Foley catheter. If deflated (although in some cases prior to discharge. G the catheter cannot be placed, the it may be left partially inflated to Since the reasons for this surgery will be aborted, as the promote hemostasis). The skin surgery are usually kept quiet by E inability to insert the catheter can incision is closed with absorbable the patient, he may receive little be an indication that the patient suture, and the penis is placed in family support while in the hospi- D has a vesical neck contracture or a an upward position on the tal or during the initial postopera- U urethral stricture. Either of these abdomen. A dressing is applied to tive period. Nursing staff will C conditions would require surgical the penis, antibiotic ointment and have an important support role, correction and appropriate post- sterile fluffs are applied to the especially with the patient who is A operative healing time before incision, and a mesh brief is not involved in a relationship. T implantation of a prosthesis can placed on the patient. Opportunities for the patient to I be rescheduled. The surgical procedure for a discuss his feelings regarding the The prosthesis can be malleable prosthesis would be surgery and his recovery should O implanted via an infrapubic or complete following the insertion be encouraged. N penoscrotal approach. The infra- of the cylinders. Implantation of a On discharge, the patient will pubic approach allows the sur- two-piece inflatable device would receive a prescription for 7 days of geon to place the reservoir for a conclude following placement of a broad-spectrum antibiotic. He three-piece prosthesis under the combination pump/reservoir will also be given a modest supply direct vision but provides limited in the scrotum. of pain medication as well as a exposure of the corpora. The stool softener. Common postoper- penoscrotal approach allows for Postoperative Management ative complaints should also be better visualization of the corpora Patients undergoing implan- discussed with the patient, but requires blind placement of tation of a three-piece penile including bruising and edema to the reservoir through the external prosthesis are commonly kept in the genitals, discomfort when sit- inguinal ring. The surgical the hospital overnight for a full ting, discomfort with patient’s approach will be influenced by 24 hours of intravenous antibi- usual clothing, or discomfort with the patient’s surgical history and otics, although in some centers, . The patient should also the surgeon’s preference. implantation of any type of pros- be instructed in the usual signs The implantation of a three- thesis may be considered outpa- and symptoms of infection at the piece prosthesis via the penoscro- tient surgery. Pain medications incision site: pain, erythema, tal approach begins with a vertical are ordered on an as-needed swelling, and drainage. incision at the penoscrotal junc- basis. Ice bags may be used to ele- Prosthesis patients must also tion. After dissecting to the tunica vate the scrotum and can provide be instructed to contact their urol- albuginea, parallel corporotomies some relief from any discomfort, ogy clinic if they notice hema- are made between preplaced rows but should only be used for 15 turia, have difficulty starting their of closure sutures, and the corpo- minutes at a time. Patients may stream, or experience any dysuria ra cavernosa are dilated in prepa- find that the use of a scrotal roll due to the proximity of the ure- ration for the insertion of the will decrease any discomfort thra to the corpora cavernosa. cylinders. Once the corpora caver- related to the surgery as it may Specific written discharge in- nosa are measured and the correct alleviate the swelling of the scro- structions should be given to each size for the prosthesis chosen, the tum. A small towel can be rolled patient (see Table 3), as well as a cylinders are inserted into the cor- up and placed under the scrotum copy of the company’s patient pora and the corporotomies are when lying down or resting. information pamphlet for the spe- closed. The cylinders are filled Patients may also be encouraged cific type of prosthesis the patient with isotonic normal saline. to limit the amount of standing has had implanted. Next, a pouch for the pump is for the first few days to minimize When discharged, patients created midline in the scrotum scrotal swelling. with inflatable penile prostheses

88 UROLOGIC NURSING / April 2002 / Volume 22 Number 2 Table 3. C Postoperative Instructions for Penile Prosthesis Surgery O Activity Special Considerations N Avoid heavy lifting (greater than 5 pounds) or stren- Follow special instructions your doctor has given T uous activity prior to your postoperative appointment. you that are particular to the type of prosthesis you This causes increased abdominal pressure and puts have. I stress on the incision. If you need to brace yourself to If your scrotum is swollen, wear a scrotal support, N pick up an object, it is too heavy. limit standing for extended periods, and when resting, U elevate your scrotum on a towel roll. Sexual Activity Avoid constipation to prevent straining; increase I It is recommended that sexual activity should be roughage in your diet, drink prune juice or orange juice, N avoided for 6 weeks after surgery. Use of the prothesis or take Milk of Magnesia® or other over-the-counter lax- prior to proper healing of the incision could cause dam- ative if necessary. You will be prescribed a stool soften- G age to the incision and result in potential infection of the er when you are discharged. It is recommended that you prothesis. Your doctor will inform you at a postoperative drink 6 to 8 glasses of water a day to enhance the effec- visit of when you will be able to resume sexual activity. tiveness of the stool softener. Should constipation E become a problem that is not relieved, call the Urology D Clothing Service. Wear loose-fitting briefs or shorts and avoid wear- U ing clothing that is too tight. Your penis may be taped to Reasons to Call Your Doctor C your abdomen to promote proper healing. ◆ Increased scrotal or penile swelling. A ◆ Drainage from you incision. T Bathing ◆ You may shower if you wish. Gently wash the inci- Skin around your incision is warmer than else- I sion with soap and water, rinse thoroughly, and pat dry. where. This will keep your incision clean, dry, and free of bac- ◆ Difficulty passing your urine or starting a stream. O teria. ◆ Blood in your urine. N ◆ Nausea and vomiting. Incision Care It is extremely important that you carefully monitor ◆ Severe pain that is not relieved by your pain your incision for signs of redness, swelling, or drainage. medication. It is also important to keep the incision clean. ◆ Chills or fever of 101 or more degrees F.

Carry your prosthesis identification card in your You will be given an appointment to return approx- wallet at all times. imately 6 weeks after your surgery. At this time, the doctor will check your prosthesis and will dis- cuss with you resuming sexual activity.

must be cautioned against inflat- weeks after the surgery. If there is Reported rates of patient satis- ing the device prematurely, as this no tenderness or pain at the site of faction for patients receiving can damage the corporotomy clo- the scrotal pump, the patient can penile prostheses are high, 80% to sure or reopen the incision. All be shown how to inflate the pros- 90%, when compared with other penile prosthesis patients must be thesis. He should also be encour- ED interventions (Kabalin & Kuo, strongly cautioned against using aged to inflate the prosthesis at 1997; Tefilli et al., 1998). There the prosthesis for sexual activity least twice a day, whether he are reported increases in the fre- of any kind for at least 6 weeks. If plans to engage in sexual activity quency of intercourse, satisfaction the prosthesis is used before the or not. This will help him become with intercourse, and improve- incision has healed, the incision familiar with the degree of manu- ments in self-image. The prosthe- may reopen and place the entire al dexterity required to activate sis is a reliable device that works system at risk for infection, or the the device. If there is no pain asso- without need for arousal, in con- entire containment of the cylin- ciated with the fully inflated pros- trast to some pharmacologic treat- ders may be lost. thesis, he may be instructed to ments. Therefore, its efficacy is resume sexual activity. The unrelated to a patient’s level of Followup Appointment patient may use a water-soluble anxiety. Most patients can be instruct- lubricant when resuming inter- However, because patients ed in the use of their prosthesis at course as early attempts may pro- with a penile prosthesis can initi- the initial postoperative visit 6 voke anxiety. ate and sustain sexual activity

UROLOGIC NURSING / April 2002 / Volume 22 Number 2 89 C without being aroused, it may be the anti-reflux reservoir valve, will increase. Both pharmacologic O possible for them to exhaust those patients who have a Mentor and surgical options for treating themselves before reaching Alpha I prosthesis can also have an erectile dysfunction will continue N orgasm (Montague et al., 1996). MRI scan safely (Shellock et al., to improve. The option of a penile T The patient with a prosthesis 1993). The only prostheses for prosthesis will remain as a defini- I should be reminded that while which an MRI scan is not recom- tive, albeit invasive, treatment for the implant will enable him to mended are the Dacomed those patients who fail or who are N have intercourse, it will not affect Duraphase and OmniPhase not candidates for primary and U his libido. Penile prostheses also (Shellock et al., 1993). Patients secondary pharmacologic treat- I do not affect orgasm, penile sen- may still have either of these mod- ments. ¥ sation, ejaculation, or urination. els implanted despite the fact that N The primary complaint of they are no longer available. References G patients who have had a prosthe- Patients with any type of Bates, P. (2001). Management of men with reproductive disorders. In J. Black, J. sis implanted is the loss of length penile prosthesis should be cau- Hawks, & A. Keene (Eds.), Medical-sur- E to their erection, which under- tioned about engaging in any con- gical nursing: Clinical management for scores the importance of dis- tact sports during which they may positive outcomes (6th ed.) (pp.945- D cussing this point prior to surgery. sustain injury to the groin. Such 977). Philadelphia: Saunders. Loss of length is due to a simple injury can potentially damage the Bishop, J.R, Moul, J.W., Sihelnik, S.A., U Peppas, D.S., Gormley, T.S., & Mc- C fact of anatomy: the corpora cav- components of the prosthesis. Leod, D.G. (1992). Use of glycosylated ernosa, where the cylinders are Men with a penile prosthesis hemoglobin to identify diabetics at A implanted, do not extend the should also be encouraged to carry high risk for penile prosthesis infec- T entire length of the penis and so a prosthesis identification card or tions. The Journal of Urology, 147, 386-388. I the cylinders do not provide any MedicAlert bracelet at all times. Droller, M.J., et al. (1992). National firmness to the glans when inflat- This will help prevent the misin- Institutes of Health Consensus O ed. Many patients also complain terpretation of a pelvic x-ray and Statement, Impotence. Bethesda, MD: N about the softness of the glans, misdiagnosis of in the NIH. which is inherent to an erection case of the patient with a malleable Dubocq, F., Tefilli, M.V., Gheiler, E.L., Haikun, L., & Dhabuwala, C.B. (1998). produced by a prosthesis. This prosthesis. The patient should also Long-term mechanical reliability of occurs because the cylinders do be reminded that he will need pro- multicomponent inflatable penile not extend into the glans and also phylactic antibiotics with any prosthesis: Comparison of device sur- because there is decreased blood invasive procedure. vival. Urology, 52(2), 277-281. Dubocq, F.M., Bianco, F.J., Maralani, S. J., flow to the penis commonly seen Forman, J.D., & Dhabuwala, C.B. with impotence. Conclusions (1997). Outcome analysis of penile Another possible outcome of Management of erectile dys- implant surgery after external beam prosthetic surgery is the rejection function is a significant quality of radiation for . The of the patient by his partner. If their life and self-esteem issue, especial- Journal of Urology, 158(5), 1787- 1790. Feldman, H.A., Goldstein, I., & relationship has existed without ly as ED can be the result of a Hatzichrisou, D.G. (1994). Impotence physical intimacy for an extended malignancy or other chronic med- and its medical and psychological cor- period of time, or if the partner did ical condition and can impact the relates: Results of the Massachusetts not enjoy intercourse, the surgery patient’s social functioning. The male aging study. The Journal of Urology, 151(1), 54-61. can add a significant strain to their device reliability, increased rigidi- Furlow, W.L., & Goldwasser, B. (1987). relationship. This illustrates why it ty, patient and partner satisfaction, Salvage of the eroded inflatable penile is vital to include both patient and and natural appearance, both prosthesis: A new concept. The partner in decision making and inflated and deflated, of the penile Journal of Urology, 138, 481-482. education preoperatively. Patient prosthesis characterize it as a Goldstein, I., Newman, L., Baum, N., Brooks, Chaikin, L., Goldberg, K., satisfaction, good surgical out- definitive treatment for ED for McBride, A., & Krane, R.J. (1997). come, and device reliability have many men. A penile prosthesis is Safety and efficacy outcome of Mentor all been studied, but few studies one method of successfully manag- Alpha-1 inflatable penile prosthesis have addressed this particular ing ED and results in the improve- implantation for impotence treatment. The Journal of Urology, 157, 833-839. aspect of postoperative outcome ment of a patient’s self-image, but Jarow, J.P. (1996). Risk factors for penile involving the penile prosthesis. this can also be complicated as a prosthetic infection. The Journal of Patients who have any of the patient prepares for this elective Urology, 156, 402-404. three-piece inflatable prostheses surgical procedure. Kabalin, J.N., & Kuo, J.C. (1997). Long-term available from AMS can safely As the population continues to followup of patient satisfaction with the Dynaflex self-contained inflatable have a magnetic resonance imag- age, and as increasing numbers of penile prosthesis. The Journal of ing (MRI) scan (Shellock, Morisoli, men continue to seek treatment for Urology, 158(2), 456-459. & Kanal, 1993). Despite the pres- ED, referrals to urologists for man- ence of the metallic components of aging this multi-faceted condition continued on page 92

90 UROLOGIC NURSING / April 2002 / Volume 22 Number 2 Penile Prosthesis continued from page 90 Knoll, L.D. (1998). Penile prosthetic infec- tion: Management by delayed and immediate salvage techniques. Urology, 52(2), 287-290. Lewis, R. (1998). Surgery for erectile dys- function. In P.C. Walsh, A.B. Retik, T.A. Stamey, & E.D. Vaughn (Eds.), Campbell’s urology (7th ed.) (pp. 1215-1236). Philadelphia: Saunders. Lue, T.F. (2000). Male sexual dysfunction. In E.A. Tanagho, & J.W. McAnincho (Eds.), Smith’s general urology (15th ed.) (pp. 788-810). New York: Lange Medical Books. Meredith, C.E. (1995). Erectile dysfunction. In K.A. Karlowicz (Ed.), Urologic nurs- ing: Principles and practice (pp. 332- 359). Philadelphia: Saunders. Montague, D.K., Angermeier, K.W., & Lakin, M.M. (1996). Penile prosthesis implantation. In F.F. Marshall (Ed.), Textbook of operative urology (pp. 712-719). Philadelphia: Saunders. Mulcahy, J.J. (2000). Long-term experience with salvage of infected penile pros- thesis. The Journal of Urology, 163(2), 481. Presti, J.C. (2000). Neoplasms of the prostate gland. In E.A. Tanagho, & J.W. McAnincho (Eds.), Smith’s general urology (15th ed.) (pp. 399-421). New York: Lange Medical Books. Scott, F.B., Bradley, W.E., & Timm, G.W. (1973). Management of erectile impo- tence: Use of implantable inflatable prosthesis. Urology, 2, 80-82. Shellock, F.G., Morisoli, S., & Kanal, E. (1993). MRI procedures and biomed- ical implants, materials, and devices: 1993 update. Radiology, 189, 587-599. Stanley, G.E., Bivalacqua, T.J., & Hellstrom, J.G. (2000). Penile prosthetic trends in the era of effective oral erectogenic agents. Southern Medical Journal, 93(12), 1153-2000. Tefilli, M.C., Dubocq, F., Rajpurkar, A., Gheiler, E.L., Tiguert, R., Barton, C., Li, H., & Dhabuwala, C.B. (1998). Assessment of psychosexual adjust- ment after insertion of inflatable penile prosthesis. Urology, 52(6), 1106- 1112. Virag, R. (1989). Revascularization of the penis. In E.D. Whitehead (Ed.), Current operative urology (pp. 287- 296). Philadelphia: Lippincott. Wilson, S.K., & Delk, J.R. (1994) A new treatment for Peyronie’s disease: Modeling the penis over an inflatable penile prosthesis. The Journal of Urology, 152, 1121-1123. Wilson, S.K., & Delk, J.R. (1995). Inflatable penile implant: Predisposing factors and treatment suggestions. The Journal of Urology, 153(3), 659-661. Wilson, S.K., Carson, C.C., Cleves, M.A., & Delk, J.R. (1998). Quantifying risk of penile prosthesis infection with ele- vated glycosolated hemoglobin. The Journal of Urology, 159(5), 1537-1539.

92 UROLOGIC NURSING / April 2002 / Volume 22 Number 2 C Penile Prosthesis Case Study O Susanne A. Quallich N Dana A. Ohl T I N History enteric-coated aspirin, and sim- ly. There were also no diabetic U A.H. is a 64-year-old gentle- vastatin (Zocor®). A.H. and his foot ulcers that might provide a I wife have been married for 35 source of infection. He was given man who has been followed in N urology clinic for management of years. a prescription for cephalexin his organic erectile dysfunction (Keflex®) 500 mg QID, which he G (ED). He had been successfully Preoperative Evaluation was instructed to begin taking 7 After discussion of other pos- days prior to surgery. A.H. was treated with sildenafil citrate E (Viagra®) 100 mg until he was sible interventions for treating his encouraged to maintain tight started on sublingual nitroglycerin ED (vacuum erection device and glycemic control to prevent infec- D for management of his coronary penile prosthesis), A.H. and his tion and promote healing, and to U artery disease (CAD). A.H. was wife decided to proceed with the stop taking aspirin 7 days before C then prescribed alprostadil evaluation for a three-piece inflat- his surgery, which was scheduled (Caverject®) to manage his ED, but able prosthesis. They were coun- for 10 days later. A lately has found that even the seled on the following points: T Surgery maximum dose, 40 mcg, does not that the length of the natural erec- I produce an erection that is satis- tion will be shortened by 1 to 2 Examination of A.H.’s groin factory for intercourse. cm; there is a slightly higher risk in the preoperative holding area O A.H. has a medical history to prosthesis surgery because a showed that he was free of any N that is significant for Type 2 (non- foreign body is being implanted; lesions. A.H. underwent an insulin dependent) diabetes melli- that should the prosthesis have to uneventful placement of an AMS tus, CAD with two-vessel angio- be removed, the chances that 700 Ultrex prosthesis with plasty 14 months ago, hyperten- A.H. will respond to Caverject Inhibizone coating, placed via the sion, and benign prostatic hyper- again is small; and the expected penoscrotal approach with reser- trophy (BPH). He has no allergies lifespan of the device is 8 to 10 voir placement through the right to food or medication. A.H.’s sur- years. external inguinal canal. A.H. was gical history is significant for two The preoperative evaluation able to void without difficulty left inguinal hernia repairs, the for A.H. showed that his laborato- when the Foley catheter was second which required mesh. His ry values were all within normal removed the following morning. social history is remarkable for 60 limits, with the exception of his He was then discharged home pack years of smoking, which he glycosolated hemoglobin at 8.7%. after 24 hours of intravenous quit when diagnosed with dia- His urinalysis was also within antibiotics with written postoper- betes 6 years ago, and is negative normal limits, again with the ative instructions and the manu- for both alcohol and illicit drug exception of a small amount of facturer’s patient education use. His current medications glucose. The chest x-ray showed brochure. include glyburide (Diabeta®), met- no active disease and his preoper- formin (Glucophage®), sublingual ative ECG showed normal sinus Followup nitroglycerin, prazosin (Mini- rhythm, with inferior T-wave Two weeks later at his initial press®), lisinopril (Zestril®), abnormalities consistent with his postoperative visit, A.H. com- medical history. A.H. also plained of soreness to his scro- demonstrated adequate manual tum. On physical examination, Susanne A. Quallich, APRN, BC, dexterity to operate the pump on his scrotum was slightly edema- NP-C, CUNP, is a Nurse Practitioner, the prosthesis model in the clinic. tous and ecchymotic, his sutures Section of Urology, Ann Arbor Physical examination showed were intact, and there was no evi- Veterans’ Affairs Health System, Ann A.H. to be a mildly obese male, dence of infection. He was Arbor, MI. who was circumcised, with no instructed to manage this sore- evidence of open areas or lesions ness with local treatments, such Dana A. Ohl, MD, is an Associate to the penis, scrotum, or inguinal as ice bags to the scrotum, a scro- Professor of Urology, Head, Division area; however, there were several tal roll to elevate his scrotum, and of Andrology and Microsugery, University of Michigan Medical small areas of folliculitis noted to to minimize extended periods of Center, Ann Arbor, MI. his medial upper thighs bilateral- continued on page 92

UROLOGIC NURSING / April 2002 / Volume 22 Number 2 91 Case Study techniques were demonstrated to continued from page 91 both the patient and his wife, and A.H. was advised to inflate and standing or sitting. He was also deflate the prosthesis two to three encouraged to use over-the- times a day to help him become counter pain medications as proficient with its use. A.H. left needed, and to contact the urolo- the clinic able to correctly use the gy clinic for any changes in his prosthesis, and he and his wife condition, such as a fever greater were also advised that they might than 100 degrees F, drainage from find a water-soluble lubricant the incision, or an increase in helpful during their initial pain. attempts at intercourse. At his second postoperative A.H. subsequently returned visit 6 weeks after his surgery, to the urology clinic several A.H. had no complaints, stating months later for routine followup that his soreness had resolved a of his BPH. He reported that few days after the previous visit. while it initially took some time His incision was well healed, and to become familiar with the use of he had no tenderness to palpation the prosthesis, he is very pleased of his scrotum, penis, or right with the outcome of his surgery. inguinal region. He was instruct- He and his wife have been able to ed to begin to use his prosthesis; return to spontaneous sexual the initial inflation of the prosthe- activity, something that they had sis was done without any com- found difficult when he was plaints of pain from the patient. using alprostadil (Caverject). ¥ Proper inflation and deflation

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