Global Trends in Prevalence, Treatments, and Costs of Penile Prosthesis for Erectile Dysfunction in Men

Antimicrobial resistance and biofilm formation of penile prosthesis isolates: insights from in-vitro analysis

BACKGROUND

Inflatable penile prostheses (IPPs) have been shown to harbor biofilms in the presence and absence of infection despite exposure to various antimicrobials. Microbes persisting on IPPs following antibiotic exposure have not been adequately studied to assess biofilm formation capacity and antibiotic resistance.

AIM

In this study, we aimed to assess these properties of microbes obtained from explanted infected and non-infected IPPS using an in vitro model.

METHODS

35 bacterial isolates were grown and tested against various single-agent or multiple agent antibiotic regimens including: bacitracin, cefaclor, cefazolin, gentamicin, levofloxacin, trimethoprim-sulfamethoxazole, tobramycin, vancomycin, piperacillin/tazobactam, gentamicin + piperacillin/tazobactam, gentamicin + cefazolin, and gentamicin + vancomycin. Zones of inhibition were averaged for each sample site and species. Statistics were analyzed with Holm's corrected, one-sample t-tests against a null hypothesis of 0. Isolates were also allowed to form biofilms in a 96-well polyvinyl plate and absorbance was tested at 570 nm using a microplate reader.

OUTCOMES

Resistance was determined via clinical guidelines or previously established literature, and the mean and standard deviation of biofilm absorbance values were calculated and normalized to the optical density600 of the bacterial inoculum.

RESULTS

Every species tested was able to form robust biofilms with the exception of Staphylococcus warneri. As expected, most bacteria were resistant to common perioperative antimicrobial prophylaxis. Gentamicin dual therapy demonstrated somewhat greater efficacy.

STRENGTHS AND LIMITATIONS

This study examines a broad range of antimicrobials against clinically obtained bacterial isolates. However, not all species and antibiotics tested had standardized breakpoints, requiring the use of surrogate values from the literature. The microbes included in this study and their resistance genes are expectedly biased towards those that survived antibiotic exposure, and thus reflect the types of microbes which might "survive" in vivo exposure following revisional surgery.

CLINICAL TRANSLATION

Despite exposure to antimicrobials, bacteria isolated during penile prosthesis revision for both infected and non-infected cases exhibit biofilm forming capacity and extensive antibiotic resistance patterns in vitro. These microbes merit further investigation to understand when simple colonization vs re-infection might occur.

CONCLUSIONS

Although increasing evidence supports the concept that all IPPs harbor biofilms, even in the absence of infection, a deeper understanding of the characteristics of bacteria that survive revisional surgery is warranted. This study demonstrated extensive biofilm forming capabilities, and resistance patterns among bacteria isolated from both non-infected and infected IPP revision surgeries. Further investigation is warranted to determine why some devices become infected while others remain colonized but non-infected.

Search traffic for inflatable penile prosthesis increased following the COVID-19 pandemic in the United States: a Google Trends analysis

We aimed to determine the impact of the COVID-19 pandemic on search trends for inflatable penile implants in the US. Search trends for inflatable penile implants ranging from 2016 through 2023 were analyzed utilizing Google Trends. Associations between search trends and US Census Bureau data, including average household income and per capita income, were analyzed. Pre- and post- COVID-19, the interest in inflatable penile implants has been steadily increasing on average in the US. The average household income for counties with the highest interest in inflatable penile implants during the pre-COVID era was $53,136, whereas for the counties with the highest interest in inflatable penile implants in the post-COVID era, the average decreased to $50,940. Similarly, the average per capita median decreased from $35,209 to $34,547. Search traffic for inflatable penile prosthesis increased following the pandemic in the US. Nevertheless, post-pandemic, individuals with lower income levels showed no change in interest in penile implant searches compared to the pre-pandemic period. Understanding this steadiness in interest can inform healthcare professionals and policymakers to tailor interventions and educational efforts to reach a broader audience, ensuring equitable access to information and healthcare resources.

Preoperative counseling for penile implant surgery: standardized approach in a high-volume center of excellence

Shared-decision making is crucial in today's society. Although penile prosthesis surgery has had significant improvements regarding technique and materials over the last few decades - with the highest satisfaction rate in erectile dysfunction treatment at present time -, dissatisfaction can occur because of bad preoperative counseling with the creation of unrealistic expectations. This paper includes a small narrative review regarding the most important preoperative variables to be discussed in the preoperative setting. Literature search was conducted in December 2023 using PubMed. Additionally, our own standardized flowchart for preoperative counseling was added. The most important aspects of preoperative counseling include a description of the pathophysiology of erectile dysfunction as well as alternative treatments. Information should be given about which implant categories exist. Additionally, some information about the procedure itself as well as the financial aspect should be communicated. The most frequent and most important complications should be illustrated. Last but not least, the patient's expectations should be evaluated. Our added standardized flowchart with figure acts as a practical guideline for professionals as well as for patients. Our standardized approach for preoperative counseling emphasizes reasonable postoperative expectations aiming for a well-informed patient with high postoperative satisfaction. Our general strategy is to underpromise and overdeliver.

Does time of intraoperative exposure to the aerobiome increase microbial growth on inflatable penile prostheses?

Inflatable penile prosthesis (IPP) implantation is a surgical approach for the management of erectile dysfunction (ED). A feared complication is IPP infection, and increased operative time is a risk factor for infection. Exposure of an IPP implant to ambient air in the operating room (OR aerobiome) is thought to contribute to risk of infection from increased operative time, but this is not well-supported. The objective of this study was to evaluate if exposure to the OR aerobiome increased microbial colonization of IPPs. This was an ex vivo study using an uncoated IPP, observing standard surgical sterility and OR conditions. A sterile swab was collected every 30 min for 3 h from each IPP component. Positive controls consisted of swabs exposed to unprepped scrotal skin during in-office vasectomies. All swabs underwent quantitative polymerase chain reaction (qPCR) and next generation sequencing (NGS). Bioinformatic processing was carried out and taxonomic assignment was performed. No microbial growth was detected on any component of the IPPs at any time point, while positive control swabs all detected various skin flora, including bacterial and fungal growth. These findings suggest that exposure to the OR aerobiome does not increase the risk of IPP microbial colonization, at least within a 3-hour period. Further in vivo studies are needed.

Perioperative outcomes of penile prosthesis implantation in Germany: results from the GRAND study

We aimed to assess the recommended annual hospital volume for inflatable penile prosthesis implantation (PPI) and to provide evidence on perioperative outcomes of semi-rigid and inflatable PPI in Germany. We used the GeRmAn Nationwide inpatient Data (GRAND) from 2005 to 2021 and report the largest study to date with 7,222 patients. 6,818 (94.4%) patients underwent inflatable and 404 (5.6%) semi-rigid PPI. Inflatable PPI was significantly associated with shorter length of hospital stay (difference of 2.2 days, 95%CI: 1.6-2.7, p < 0.001), lower odds of perioperative urinary tract infections (5.5% versus 9.2%; OR: 0.58, 95%CI: 0.41-0.84, p = 0.003) and surgical wound infections (1% versus 2.5%; OR: 0.42, 95%CI: 0.22-0.88, p = 0.012) compared to semi-rigid PPI. Overall, 4255 (62.4%) inflatable PPIs were undertaken in low- ( < 20 PPI/year) and 2563 (37.6%) in high-volume ( ≥ 20 PPI/year) centers. High-volume centers were significantly associated with shorter length of hospital stay (difference of 1.4 days, 95%CI: 1.2-1.7, p < 0.001) compared to low-volume centers. Our findings suggest that inflatable PPI leads to a shorter length of hospital stay and lower rates of perioperative urinary tract and surgical wound infections compared to semi-rigid PPI. Patients undergoing surgery in high-volume centers for inflatable PPI are discharged earlier from the hospital.

Improved Health Care Utilization Among Men With Depression Undergoing Inflatable Penile Prosthesis in a U.S. Commercial Population

We evaluated depression-related health care resource utilization and antidepressant prescription medication utilization among commercially insured men in the United States who underwent inflatable penile prosthesis (IPP) implantation between January 1, 2007 and December 31, 2020, and who received a depression diagnosis in the year preceding the IPP procedure. A total of 11,177 patients received an IPP during the index period, 808 of whom were diagnosed with depression. A statistically significant reduction in overall depression-related health care visits occurred from pre- to post-IPP, decreasing from 4.9 to 3.8, p < .001. In addition, there was a significant reduction in depression-related inpatient visits (0.07 vs. 0.03, p = .02) and office visits (4.25 vs. 3.29, p < .001) from pre- to post-IPP. Of the 678 men who received an antidepressant medication within 1 year prior to their IPP date, 15% stopped antidepressant medication use entirely post-IPP. Among patients with continued antidepressant medication use post-IPP (n = 574), there was a significant decrease in the number of prescriptions (7.55 vs. 8.09, p < .0001) and refills (7.52 vs. 8.11, p = .0015), with a higher likelihood of discontinuation (17.6% vs. 10.5%, p < .0001) and a lower proportion of days covered (0.79 vs. 0.83, p = .0004) post-IPP compared with pre-IPP. In conclusion, IPP was associated with reduced depression-related health care utilization and antidepressant medication use among recipients. This suggests potential mental health benefits for IPP recipients beyond restoration of erectile function. Comprehensive insurance coverage for IPP, especially for men with depression, may be beneficial to both patients and insurers.

Long-term effects of combination treatment comprising low-intensity extracorporeal shockwave therapy and tadalafil for patients with erectile dysfunction: a retrospective study

This study retrospectively examined the effects of low-intensity extracorporeal shockwave therapy and tadalafil on erectile dysfunction patients. 116 patients got low-intensity extracorporeal shockwave therapy twice weekly for 3 weeks, 5 mg of tadalafil daily for 3 weeks, and adjuvant therapy for 6 months. Group A (1 year), Group B (2 years), Group C (3 years), and Group D (4+ years) were treated patients' follow-up groups. The patients' International Index of Erectile Function-5 (IIEF-5) scores were gathered at the start of treatment via face-to-face interviews and at the end of follow-ups by telephone conversations. IIEF-5 scores and the minimal clinically significant differences were the main outcomes. Mean follow-up length, age, and IIEF-5 scores of the patients were 2 ± 1.16 years, 47.34 ± 12.65 years, and 12.09 ± 3.66 points, respectively. Compared to baseline, treatment increased the median IIEF-5 scores of patients in groups A, B, C, and D by 7 [3-12], 6 [0-8], 7 [1-9], and 6.5 [2.5-10] points, respectively (p = 0.001). 71%, 63%, 65.8%, and 65% of treated patients in groups A, B, C, and D met the minimal clinically significant differences criteria (n = 77). Mild disease patients were 9.14 times more likely to respond to treatment than severe illness patients (OR, 9.14; 95% CI, 1.28-65.46; P = 0.02). Low-intensity extracorporeal shockwave therapy and 5 mg of tadalafil can treat erectile dysfunction for up to 4 years with sustained outcomes. This treatment is optimal for mild illnesses.

Penile Prosthetic Pump Reservoir Mimicking a Cecal Subepithelial Mass

Intestinal subepithelial lesions are often encountered during endoscopy. Etiologies can include lesions intrinsic or extrinsic to the gastrointestinal wall. They can present a diagnostic dilemma as simple mucosal biopsies are often nondiagnostic. The combination of characteristic radiographic, endoscopic, and endosonographic features can aid in a definitive diagnosis precluding the need for unnecessary tissue sampling of extrinsic compressive etiologies. The location of the space of Retzius which is the traditional site of penile prosthetic pump reservoir insertion can predispose to cecal compression. We present a rare case of a penile prosthetic pump reservoir presenting as a cecal subepithelial mass on endoscopy.

Nutritional aphrodisiacs: Biochemistry and Pharmacology

In 2022, the global prevalence of erectile dysfunction (ED) was estimated to be at least 150 million cases. This number is greatly suspected to be underestimate as most men withhold information about ED. Also, about 15% of world population have infertility troubles, and male factors are responsible for almost half of these cases. Studies have shown that the quality of semen has decreased in the past several decades owing to various health factors and environmental toxicants. The current medical interventions involve the inhibition of phosphodiesterase 5 which suffer from serious side effects and costly. One of the popular and most sought interventions are the natural and nutritional remedies as they are foods in essence and potentially with no harm to the body. Therefore, the goal of this paper is to provide a review of the most common nutritional aphrodisiacs with increasing libido and fertility highlighting the potential active constituents as well as the underlying mechanisms.

Overcoming barriers to immediate penile implant salvage surgery: a narrative review

BACKGROUND AND OBJECTIVE

Since immediate salvage (IS) surgery for infected penile prosthesis (PP) was introduced nearly 30 years ago, an abundance of evidence has emerged in support of its use. IS remains underutilized by the modern urologist despite its distinct advantages. While some medical literature proposes reasons for the underuse of IS, no comprehensive review attempts to address the numerous factors limiting its implementation. Our objective is to analyze the barriers to IS surgery for infected PP with the goal of expanding utilization of this technique through a practical and standardized approach for treating urologists.

METHODS

A narrative review of available English, peer-reviewed, medical literature relevant to the barriers to IS was completed. Searches were expanded to include literature from surgical specialties in general if hypothesized barriers were incompletely described in available PP publications.

KEY CONTENT AND FINDINGS

The major barriers that are likely contributing to the low rates of IS for PP surgery can be broadly classified into three major categories: institutional/systemic, medical/surgical, and patient preference. Institutional/systemically driven barriers include surgeon comfort with PP surgery, low national availability of urologists, inaccessibility of prosthetics or critical ancillary staff at the time of patient presentation and limited operating room (OR) access. Medical/surgical barriers primarily relate to reinfection fears, perceived contraindications to IS, and overall patient stability at the time of presentation. Patient preference factors inhibiting IS involve loss of trust in the medical team, psychosocial distress, dissatisfaction with the initial device prior to infection and anxiety regarding postoperative recovery. Many of the identified barriers can be overcome with increased surgical training, improved patient and surgeon understanding of PP infection, or precautionary planning.

CONCLUSIONS

Of the factors that contribute to low utilization of IS, many are misunderstood or unknown. Recognition of these barriers may equip urologists to provide better care to patients with prosthesis infection.

Sub-gluteal ligation of the internal pudendal vein for management of veno-occlusive erectile dysfunction (Shaeer's Vein Ligation-I): the cadaveric study

Vein ligation for veno-occlusive erectile dysfunction is being abandoned due to the recurrence rate. Among the reasons for failure is inability to ligate the deep system of veins; the internal pudendal vein. The vein exits the pelvis in the gluteal region, from the lesser sciatic foramen to the greater sciatic foramen, coursing over the ischial spine and sacro-spinous ligament, under the gluteus maximus. This work aims to verify feasibility of the first surgical procedure to ligate the internal pudendal vein through the gluteal approach. This cadaveric study involved five formalin-fixed cadavers. A surface anatomical landmark was designed to identify the ischial spine, at the intersection of two lines: a vertical line from posterior superior iliac spine to ischial tuberosity, and a horizontal line extending from sacro-coccygeal joint, laterally. An incision is cut encompassing the target point. Subcutaneous fat is dissected down to the gluteus maximus, which is split along the direction of its fibers. The vein can be found crossing over the ischial spine. "Shaeer's Vein Ligation - I" appears to be surgically feasible. A protocol for a surgical study is registered at clinicaltrials.gov, and is open for participation.

Management of urologic prosthetic reservoirs at the time of inguinal or pelvic surgery

INTRODUCTION

The artificial urinary sphincter and 3-piece inflatable penile prosthesis each require a fluid storage component and thus have components in the inguinal and pelvic regions. Because of this, patients with urologic prosthetics sometimes present challenges during future nonprosthetic operations. Presently, there is no established guideline for device management with ensuing inguinal or pelvic surgery.

AIMS

This article outlines concerns during pelvic and inguinal surgery for patients with an artificial urinary sphincter and/or inflatable penile prosthesis and proposes an algorithm for preoperative surgical planning and decision making.

METHODS

We conducted a narrative review of the literature on operative management of these prosthetic devices. Publications were identified by searching electronic databases. Only peer-reviewed publications available in English were considered for this review.

RESULTS

We review the important considerations as well as available options for operative management of these prosthetic devices during subsequent nonprosthetic surgery and highlight the advantages and disadvantages of each. Finally, we suggest a framework for helping surgeons determine which management strategy is most appropriate for their individual patients.

CONCLUSION

The best management strategy will differ depending on patient values, the planned surgery, and patient-specific factors. Surgeons should understand and counsel patients on all available options and encourage informed, shared decision making to determine the best individualized approach.

Erectile Dysfunction: Treatments, Advances and New Therapeutic Strategies

Erectile dysfunction (ED) is the inability to get and maintain an adequate penile erection for satisfactory sexual intercourse. Due to its negative impacts on men's life quality and increase during aging (40% of men between 40 and 70 years), ED has always attracted researchers of different disciplines, from urology, andrology and neuropharmacology to regenerative medicine, and vascular and prosthesis implant surgery. Locally and/or centrally acting drugs are used to treat ED, e.g., phosphodiesterase 5 inhibitors (first in the list) given orally, and phentolamine, prostaglandin E1 and papaverine injected intracavernously. Preclinical data also show that dopamine D4 receptor agonists, oxytocin and α-MSH analogues may have a role in ED treatment. However, since pro-erectile drugs are given on demand and are not always efficacious, new strategies are being tested for long lasting cures of ED. These include regenerative therapies, e.g., stem cells, plasma-enriched platelets and extracorporeal shock wave treatments to cure damaged erectile tissues. Although fascinating, these therapies are laborious, expensive and not easily reproducible. This leaves old vacuum erection devices and penile prostheses as the only way to get an artificial erection and sexual intercourse with intractable ED, with penile prosthesis used only by accurately selected patients.

Online Health Information for Penile Prosthesis Implants Lacks Quality and Is Unreadable to the Average US Patient

BACKGROUND

Online health information (OHI) has become widely accessible and affects patient decisions regarding their healthcare. The purpose of this study was to assess the readability, quality, and accuracy of information available to patients online about penile prosthesis implants (PPIs).

METHODS

We performed a Google search using the keywords "penile implant" and "penile prosthesis." The first 30 search results for both terms were analyzed, and advertisements, news articles, duplicates, and videos were excluded. Websites were categorized as institutional, commercial, and personal/patient support. Readability of each website was determined using the Flesch-Kincaid grade level (FKGL) readability formula within the readable tool. Quality was measured by Health On the Net (HON) certification status and the DISCERN scoring method. For website accuracy, a score of 1-4 (1=0-25%, 2=25-50%, 3=50-75%, and 4=75-100%) was assigned.

RESULTS

Forty-four websites met the criteria (23 institutional, 12 commercial, and 9 personal/patient support). The mean total FKGL score was 9.55. No statistical difference was detected between mean FKGL for each website category (p=0.69). Only eight websites (18%) scored ≤8th-grade reading level (average US adult level), while 36 (82%) were >8th-grade level. Mean total DISCERN sum score was 39.74/75, with no statistical difference in mean DISCERN score between website types (p=0.08). Over half (55%) of the websites were defined as "very poor" or "poor" quality by DISCERN scoring. Mean total overall quality rating was 2.67/5. HON certification was verified for only nine websites (20%). Twenty-five percent of websites were classified as 0-25% accurate, 23% were 25-50% accurate, 30% were 50-75% accurate, and 23% were 75-100% accurate.

CONCLUSION

Most information on the Internet about PPIs is reasonably accurate; however, the majority of websites are deficient in quality and unreadable to the average patient, irrespective of website type.

Management of male erectile dysfunction: From the past to the future

Erectile dysfunction is a common disease of the male reproductive system, which seriously affects the life quality of patients and their partners. At present, erectile dysfunction is considered as a social-psychological-physiological disease with complex etiology and various treatment methods. Oral PDE5I is the first-line treatment for erectile dysfunction with the advantages of high safety, good effect and non-invasiveness. But intracavernosal injection, hormonal replacement therapy, vacuum erection device, penile prosthesis implantation can also be alternative treatments for patients have organic erectile dysfunction or tolerance to PDE5I. With the rapid development of technologies, some new methods, such as low-intensity extracorporeal shock wave and stem cell injection therapy can even repair the organic damage of the corpora cavernosa. These are important directions for the treatment of male erectile dysfunction in the future. In this mini-review, we will introduce these therapies in detail.