Treatment of Penile Erosion
Penile erosion requires immediate complete surgical removal of the eroded device, with management tailored to the underlying cause—whether from penile prosthesis, artificial urinary sphincter (AUS), or urethral sling—followed by a mandatory healing period before considering any replacement procedure. 1, 2
Immediate Surgical Management
For Penile Prosthesis Erosion
- Complete explantation of the eroded prosthesis is mandatory and should not be managed conservatively, as erosion can lead to infection, abscess formation, and sepsis 1, 2
- Cystoscopy must be performed to visualize the full extent of erosion into the urethra or bladder 1, 2
- Cross-sectional imaging (CT or ultrasound) should be obtained to evaluate for abscess formation and rule out sepsis 1, 2
Intraoperative Urethral Management Options
The approach to the urethral defect depends on the size and tissue quality at the time of explantation:
- For small urethral defects (<5mm): Urethral catheter drainage alone may be sufficient 1
- For moderate defects: In situ urethroplasty can be performed if local tissue quality permits 1
- For large circumferential defects: Anastomotic urethroplasty may be required 1
- The degree of inflammation, induration, and fibrosis at the erosion site will guide the surgical approach 1
Post-Explantation Management
Mandatory Healing Period
- A waiting period of 3-6 months is essential before considering any replacement prosthesis to allow tissue healing and reduce infection risk 2
- During this period, monitor for urethral fistula, urethral diverticula, or stricture formation 1
Future Prosthesis Considerations
- Synthetic mesh should never be used for any future incontinence surgery in patients with a history of urethral erosion 2
- For patients requiring future incontinence management, autologous fascial pubovaginal sling is the preferred option given the history of urethral surgery and erosion 2
- If considering penile prosthesis reimplantation, inflatable devices are preferred over malleable/semi-rigid devices, as they remain soft when deflated and cause less constant urethral pressure 3
Special Considerations and Risk Factors
Radiation History
- Radiation causes small vessel obliteration and endarteritis, resulting in ischemic tissue changes that make the urethra more vulnerable to erosion 1
- Radiated patients have a relative risk of 2.97 for prosthesis erosion compared to non-radiated patients 1
- The transcorporal approach is an independent risk factor for erosion in radiated patients 1
Catheterization-Related Erosion
- Patients with indwelling urethral catheters or performing intermittent clean catheterization have a 56% incidence of urethral erosion after penile prosthesis placement 3
- Erosion typically presents as a late complication, occurring several months after implantation in 80% of cases 3
- For patients requiring chronic catheterization who desire a penile prosthesis, construct a perineal urethrostomy or insert a suprapubic tube to avoid urethral trauma 3
Salvage Techniques for Impending Erosion
- For impending erosion (prosthesis visible but not yet fully eroded), extracapsular reimplantation with cylinder reseating may be attempted as a salvage procedure to avoid complete explantation 4
- This technique is only appropriate when erosion is caught early, before full urethral perforation or infection develops 4
Critical Pitfalls to Avoid
- Never attempt conservative management of established erosion—complete removal is mandatory 2
- Do not reimplant any prosthesis before the 3-6 month healing period, as premature reimplantation significantly increases infection risk 2
- Avoid placing indwelling urethral catheters in patients with penile prostheses whenever possible, as friction and inflammation from catheterization are major etiological factors for erosion 3
- Always send all removed tissue for pathological examination to rule out occult malignancy, particularly in cases with chronic inflammation 5