Gülhane Týp Dergisi 2007; 49: 40-41 OLGU SUNUMU/CASE REPORT © Gülhane Askeri Týp Akademisi 2007

Broken needle in the penis as a complication of intracavernous injection therapy

Ýlker Akyol (*), Cüneyt Adayener (*), Temuçin Þenkul (*), Kenan Karademir (*), Kadir Baykal (*), Cüneyt Ýþeri (*)

Case Report Summary visi uygulayan hastanýn penisinde iðne A 74-year-old male applied to the emer- palpe edilebiliyor ve direkt grafide iðne A 74-year-old male applied to the gency room having a broken needle in his penisin dorsolateralinde görülebiliyordu. emergency room (ER) having a bro- penis. He has been on intracavernous in- Ýðne, lokal anestezi altýnda çýkarýldý ve ken needle in his penis. He has been jection therapy for erectile dysfunction operasyon yerinde komplikasyon geliþme- and the needle had been broken in that di. Hastaya, erektil iþlev bozukluðu için on intracavernous injection therapy morning. The needle was felt under the oral tedaviye geçmesi önerildi. Erektil (ICIT) for erectile dysfunction (ED) soft tissue in his penis and it could be iþlev bozukluðunda intrakavernöz enjek- for the past month and he did an seen on the direct radiography within the siyon tedavisi önerilen hastalarýn el injection that morning in the way that dorsolateral part of the penis. The nee- becerileri dikkatlice deðerlendirilmeli ve dle was removed under local anesthesia doðru enjeksiyon tekniðinin önemi vurgu- he had been taught. The patient and there was no complication at the lanmalýdýr. reported that the needle of the syr- operation site. The patient was advised Anahtar kelimeler: El becerisi, erektil inge was broken as he pulled it out of to switch to oral medication for his erec- disfonksiyon, intrakavernöz enjeksiyon tile dysfunction. Manual dexterity of the the corpus cavernosum, and the distal patients to whom intracavernous injec- part of the needle was stuck in his tion therapy is advised for erectile dys- Introduction penis. Physical examination revealed function should be evaluated cautiously, and the importance of correct injection A number of agents, either alone a small area of hyperemia on the left technique should be stressed. or in combination, have long been dorsolateral side of the penis and the Key words: Manual dexterity, erectile used in erectile dysfunction for intra- needle was felt under the soft tissue. dysfunction, intracavernous injection cavernous injection therapy; though A direct radiography showed a linear Özet this was not without serious adverse opacity lying obliquely from outside Ýntrakavernöz enjeksiyon tedavisinin effects such as priapism, corporeal to deep inside of the corpus caver- komplikasyonu olarak penis içinde fibrosis, systemic side effects due to nosum of the penis (Figure 1). We kýrýlmýþ iðne Yetmiþ dört yaþýndaki erkek hasta, ilk- vasodilatory action (e.g. hypotension, decided to take the foreign object out yardým servisine penisinin içinde kýrýlmýþ tachycardia, pallor, dizziness), painful and went on with a skin incision bir iðne olduðunu ifade ederek baþvurdu. erection, pain in the injection site and under local anesthesia. The broken Erektil iþlev bozukluðu nedeniyle kendi kendine intrakavernöz enjeksiyon teda- hematoma/ecchymosis (1). Rather part of the needle was found under high patient drop out rates have also dartos fascia and taken out. This was been reported due to various reasons a 28 gauge needle. There was no *Department of Urology, GATA Haydarpaþa Teaching Hospital such as unnaturalness of the treat- bleeding at the site immediately after ment, and the above-mentioned ad- the removal of the needle. Subcu- Reprint request: Dr. Cüneyt Adayener, GATA Haydarpaþa Eðitim Hastanesi Üroloji Servisi, verse effects associated with the pro- taneous tissue was closed with run- Üsküdar-34668, Ýstanbul cedure (1). We herein report a rather ning sutures in two layers and the E-mail: [email protected] unusual complication of intracav- skin was closed with chromic sutures. Date submitted: June 01, 2006 ernous injection therapy. A tight bandage was applied so as not Accepted: September 29, 2006

40 to obstruct urine flow and this was tion elsewhere and was from a lower As a conclusion, whenever an removed on the next day. After one sociocultural level. The attending ICIT is to be started in a patient with week, there was no hematoma nor physician might have chosen injec- ED, manual dexterity should be con- active bleeding at the surgery site. tion therapy as the firstline treatment sidered in the first place and the The patient was advised to switch to due to the above-mentioned eco- importance of the correct injection oral medication. nomical concerns, yet underestimat- technique must be stressed. ing the importance of patient capabil- ity before starting such a treatment. References The oblique needle track in the lon- 1. Evaluation and nonsurgical manage- gitudinal direction suggested that the ment of erectile dysfunction and pri- apism. In: Walsh PC, Retik AB, patient's injection technique was Vaughan ED, Wein AJ (eds). Camp- wrong. We figured that he inserted bell's Urology. WB Saunders Com- the needle obliquely causing it to pany, 2002: 1619-1663. travel within the corpus cavernosum 2. Greenstein A, Sofer M, Chen J. more than needed, and after complet- Delayed retrieval of fragment after ing the injection, he pulled the needle breakage during intracavernous self-injection. J Urol 1997; 157: 953. Figure 1. White arrow showing the needle syringe back in an improper direction within the penis (lateral) 3. Moemen MN, Hamed HA, Kamel II, which exerted a bending force on the Shamloul RM, Ghanem HM. Clinical Discussion needle which caused it to break and sonographic assessment of the side The advent of phosphodiesterase before it came out of the penis. effects of intracavernous injection of (PDE) inhibitors has cut down on the Needle breakage is a very rare vasoactive substances. Int J Impot Res 2004; 16: 143-145. prescription of intracavernous injec- complication of ICIT and there are a 4. Park NC, Park HJ. Management of tion therapy and gained popularity few case reports in the literature (2- intracavernosal needle breakage during rapidly. However PDE inhibitors are 6). It appears that broken part of the self-injection of vasoactive agent. Int J often not covered by insurance poli- needle may be deep inside of the cor- Impot Res 2003; 15 (Suppl 6): 64. cies as opposed to less expensive pus cavernosum, and one may not be 5. Mark SD, Gray JM: Iatrogenic penile alternative agents used for ICIT. On able to feel and remove it at first; foreign body. Br J Urol 1991; 67: 555. 6. Beer SJ, See WA. Intracorporeal nee- the other hand, ICIT, being a rather however, needle may be found at a dle breakage: An unusual complication invasive procedure, requires manual more superficial location and may be of papaverine injection therapy. J Urol dexterity. Our case got his prescrip- removed later on (2). 1992; 147: 148-150.

Cilt 49 · Sayý 1 · Gülhane TD Broken needle in the penis · 41