The 23rd ESSM Congress was successfully delivered in a virtual format between 17^th to 19^th February 2022. My brief was to summarise updates on the surgical treatment of sexual dysfunction. The main themes were on penile implants, Peyronie’s disease and penile augmentation.

Penile prosthesis insertion

Dr Daniar Osmonov presented a step by step video of inflatable penile prosthesis insertion. He emphasised the importance of a >1.5cm corporotomy to allow easy insertion of the cylinders. Cross-over (distal or proximal) or urethral perforation should be checked for. Implanters should stay lateral while dilating but stay medial when placing a reservoir!

Dr Javier Romero Otero discussed adjunctive techniques to improve penile length and girth during penile prosthesis insertion. On the dorsal aspect, options include liposuction, abdominoplasty or division of the suspensory ligament. Ventrally, scrotoplasty can be considered. Variants of the sliding technique can be used for penile lengthening.

Professor Koenraad van Renterghem discussed the results of a recent multicentre study on corporotomy length. A more proximal corporotomy means a shorter rear-tip extender is needed, less intracorporal tubing and less likelihood for “Maserati” penis. He also offered insights into different reservoir placement options and encouraged recruitment in the multi-centre PHOENIX trial under the auspices of the European Association of Urology Research Foundation.

In a submitted abstract, Schifano et al compared two brands of inflatable penile prosthesis (Boston Scientific and Coloplast) using retrospective data from the Italian Multi-institutional National Registry of Penile Prostheses (INSIST-ED). A total of 1529 procedures were recorded between 2014-2021 with complete Quality of Life and Sexuality with Penile Prosthesis (QoLSPP) questionnaire at 1-year follow-up in 207 patients. High volume implanters were more likely to choose Boston Scientific devices but importantly, complication rates and QoLSPP scores were similar for both manufacturers.

Penile implant infection

Penile prosthesis infection featured strongly in this Congress including the Boston Scientific and Coloplast sponsored sessions. Professor Ignacio Moncada’s excellent talk reminded us that prevention of device infection is key. However, the level of evidence that guides our practice remains poor. Studies are difficult in this area due to the low rates of device infection, publication bias, difficulties with follow-up and confounding factors like colonising bacteria in the biofilm¹.

Professor Koenraad van Renterghem expanded on the concept of a biofilm. A biofilm is induced by bacteria that adhere to the device before or during implantation. The bacteria secrete an adhesive substance that irreversibly attaches it to the device. More extracellular polymers are secreted and a biomatrix is completed within 46 hours². Microcolonies of bacteria then break off to seed further colonisation. Biofilms allow bacteria to resist antibiotic concentrations up to 1000x that of free-floating bacteria.

The risk of device infection is influenced by host factors and pathogen factors. Host factors that reduce the risk of device infection include smoking cessation 4 weeks prior to surgery and the clearance of nasal Staphylococcus aureus prior to surgery. Diabetes, and especially poor diabetic control, increases the risk of infection. Previous spinal cord injury and a low CD4 count (<300) in men with HIV are also risk factors.

Obese men (though the risk of fungal infection is higher in obese men) and those who are immunosuppressed or with concomitant fungal infection of the groin may not have a higher risk of device infection. However, device manufacturers advise deferring patients with a superficial infection or abscess whilst the American Urological Association guidelines recommend testing and treatment of a positive urine culture.

Pathogen factors relate to factors that reduce the burden of pathogens (bacteria and fungi) on the device. Infection risk is reduced by using an alcoholic chlorhexidine skin preparation³, on the day hair removal using clippers (razors preferred for penoscrotal approach)⁴, parenteral antibiotics prior to surgery and antibiotic coated devices. High volume surgeons and by association, a shorter operative time also reduces the risk of infection. The “no touch technique” or avoiding contact of the device to skin may also beneficial⁵. The use of a scrotal drain, surgical approach (infrapubic versus penoscrotal) and concomitant circumcision does not affect the risk of infection.

Several speakers highlighted a seminal paper by Gross et al showing that fungal infections represent 12% of all penile prosthesis infections, mostly in diabetic or overweight patients⁶. Antifungal prophylaxis (fluconaxole) should be considered for these patients.

Professor David Ralph continued the discussion on diabetic patients. A diabetic has an odds ratio of 1.53 (95% CI 1.15-2.04) for developing device infection⁷. In addition, diabetics are more likely to have a phimosis or Peyronie’s disease and corporal fibrosis that may complication penile prosthesis insertion. They are also likely to have central obesity and are at higher risk for penile gangrene, which is a devastating complication of penile prosthesis insertion.

Dr Agustin Fraile followed with a presentation on preventing infection during revision penile prosthetic surgery. The presence of a biofilm surrounding the device may explain the higher associated risk of infection (10-18%)⁸. He also reminded us of the immediate (Mulcahy) salvage surgery for an infected penile prosthesis⁹. Salvage with a malleable prosthesis may be more successful and this can then be exchanged for an inflatable device several months later if desired by the patient¹⁰. Dr Fraile then showed a video of the challenging insertion of a penile prosthesis following previous explant for infection.

In a moment of candour during question time, several speakers confessed that they no longer do a full 10-minute pre-operative skin scrub. However, all speakers emphasised that a scrotal drain is very important to reduce the risk of haematoma and should be used routinely.

Penile augmentation

The last day of the conference started with an excellent session on penile augmentation. Dr Cobi Reisman started the session with a great talk on penile size. He discussed the seminal systematic review and penile size nomogram by Veale et al (table 1)¹³. Stretched penile length was strongly correlated with the erect penile length but there was no correlation between the erect and flaccid penis size.

Table 1: Mean length and girth in up to 15 521 men depending on penile state

He reminded us that while 45% of men wished they had a larger penis, women were mostly unconcerned about their partner’s penile size. Penile length was unimportant for 77% of survey respondents while girth was not important to 68%¹⁴. Interestingly, there was a preference for slightly greater penile length and girth in a casual partner compared to a long-term partner¹⁵. Data is limited in men who have sex with men but penis size may be a more important consideration in this cohort.

In his talk, Dr Nuno Tomada defined micropenis as a normally developed penis that is <2.5 standard deviations below the mean size in SPL for age (<7.5cm). Small penis syndrome is when one feels uncomfortable about penis size despite the absence of micropenis. Body dysmorphic disorder (BDD) represents a pre-occupation with one or more perceived flaws (not apparent to others) to the extent that one hides or attempts to fix it. BDD can be associated with depression and suicidal ideation. Penile dysmorphic syndrome are men with BDD due to concern of the size or shape of their penis.

Penile augmentation could be considered in men with micropenis or even those with small penis syndrome but Dr Tomada cautioned that men with high surgical risk, unrealistic expectations or are psychologically unstable should be excluded from penile augmentation. Men with BDD should also not be offered treatment.

Penile hypoplasia (shortening) is associated with medical conditions like Peyronie’s disease and iatrogenic causes like radical prostatectomy or pelvic radiotherapy. Apparent hypoplasia can either be due to a hidden penis (due to abdominal fat or cutaneous relaxation of the abdomen) or buried penis where the penile shaft is beneath the suprapubic skin due to obesity or radical circumcision. These men may benefit from treatment.

Lastly, men seek penile augmentation is to improve their self-perception and to address psychological distress related to penis size. Some also want to improve sexual function and enjoyment for their partner and themselves¹⁶. Nevertheless, Dr Tomada stressed that psychological counselling and sex education should be offered prior to any consideration for penile augmentation.

See you all in Rotterdam for ESSM 2023 from the 15^th till 18^th of February.

References

1. Kohler TS, Wen L, Wilson SK. Penile implant infection prevention part 1: what is fact and what is fiction? Wilson’s Workshop #9. International Journal of Impotence Research. 2020;33(8):785-792.
2. Wilson SK, Gross MS. Biofilm and penile prosthesis infections in the era of coated implants: 2021 update. International Journal of Impotence Research. 2021;13:13.
3. Yeung LL, Grewal S, Bullock A, Lai HH, Brandes SB. A comparison of chlorhexidine-alcohol versus povidone-iodine for eliminating skin flora before genitourinary prosthetic surgery: a randomized controlled trial. J Urol. 2013;189(1):136-140.
4. Tanner J, Melen K. Preoperative hair removal to reduce surgical site infection. [Review]. 2021;1:Cd004122.
5. Eid JF, Wilson SK, Cleves M, Salem EA. Coated implants and “no touch” surgical technique decreases risk of infection in inflatable penile prosthesis implantation to 0.46%. Urology. 2012;79(6):1310-1315.
6. Gross MS, Phillips EA, Carrasquillo RJ, et al. Multicenter Investigation of the Micro-Organisms Involved in Penile Prosthesis Infection: An Analysis of the Efficacy of the AUA and EAU Guidelines for Penile Prosthesis Prophylaxis. Journal of Sexual Medicine. 2017;14(3):455-463.
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8. Henry GD, Wilson SK, Delk JR, 2nd, et al. Penile prosthesis cultures during revision surgery: a multicenter study. J Urol. 2004;172(1):153-156.
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10. Gross MS, Phillips EA, Balen A, et al. The Malleable Implant Salvage Technique: Infection Outcomes after Mulcahy Salvage Procedure and Replacement of Infected Inflatable Penile Prosthesis with Malleable Prosthesis. J Urol. 2016;195(3):694-697.
11. Cocci A, Ralph D, Djinovic R, et al. Surgical outcomes after collagenase Clostridium histolyticum failure in patients with Peyronie’s disease in a multicenter clinical study. Sci. 2021;11(1):166.
12. Trost L, Huang H, Han X, Burudpakdee C, Hu Y. Penile surgery for patients with Peyronie’s disease initially treated with collagenase clostridium histolyticum or surgery: a claims database analysis. International Journal of Impotence Research. 2022;10:10.
13. Veale D, Miles S, Bramley S, Muir G, Hodsoll J. Am I normal? A systematic review and construction of nomograms for flaccid and erect penis length and circumference in up to 15,521 men. BJU Int. 2015;115(6):978-986.
14. Francken AB, van de Wiel HB, van Driel MF, Weijmar Schultz WC. What importance do women attribute to the size of the penis? Eur Urol. 2002;42(5):426-431.
15. Prause N, Park J, Leung S, Miller G. Women’s Preferences for Penis Size: A New Research Method Using Selection among 3D Models. PLoS ONE. 2015;10(9):e0133079.
16. Sharp G, Oates J. Nonsurgical Medical Penile Girth Augmentation: A Retrospective Study of Psychological and Psychosexual Outcomes. Aesthet. 2019;39(3):306-316.