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\begin{document}

\title{A strategy for salvaging shrinkage soft glans penis and impending
prosthesis loss in patients with a penile implant}



\author[1]{Geng-Long Hsu}%
\author[2]{Chung Cho-Hsing}%
\author[1]{Cheng-Hsing Hsieh}%
\author[3]{Ta-Chin Lin}%
\author[4]{Jeff Chueh}%
\affil[1]{Hsu's Andrology}%
\affil[2]{Taipei Medical University}%
\affil[3]{National Defense Medical Center}%
\affil[4]{National Taiwan University Hospital}%


\vspace{-1em}



  
  \date{June 02, 2024}


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\textbf{Key Clinical Message}

A shrined soft glans syndrome is~expected in patients with penile
implantation.~We sought to remind surgeons how to prevent soft glans
penis. Although avoiding prosthesis extrusion was recommended earlier,
inadvertent ignorance is persistent, so the appropriate cylinder
position and novel enhancement of the glans penis were
reiterated.\textbf{~}

\textbf{Keywords}

Penile implant, penile glans enhancement, penile venous stripping,
prosthesis extrusion, soft glans syndrome, shrinkage glans penis

\textbf{INTRODUCTION}

In 1998, the first agent of PDE-5 inhibitor was available to treat
patients who have erectile dysfunction regardless of varied underlying
causes (ED).\textsuperscript{1} Subsequently, this type of agent opened
the era of medical treatment as the first line of options for these
awkward diseases.\textsuperscript{2,3} The second-line varied treatment
strategy will be resorted if patients are poorly responsive to the
oral~PDE-5 inhibitors.\textsuperscript{4} These second-line options
include vacuum constriction devices, vasodilator intracorporeal
injection, endovascular therapies entailing sclerotherapy, and
controversial penile vascular surgery.\textsuperscript{5} Although no
sustainable scientific support exists, resulting in none that the
Federal Drug Administration has proved in the United States, recent
popularity has soared among marketers. There are many, such as
extracorporeal shock wave therapy (ESWT) supported by randomized
studies,\textsuperscript{6} platelet-rich plasma (PRP) injection, stem
cell injection, etc. Still,~the penile implant remains a golden solution
for those patients whose erection dysfunction has been
refractory.\textsuperscript{7}

Some complications in this golden standard option appear unavoidable,
such as shrined soft glans syndrome, mechanical failure, intracorporeal
infection, and prosthesis extrusion, which is the most
hazardous.\textsuperscript{8} These issues might suffer psychologically,
but not just physically, for patients who underwent a prior penile
implant, particularly the most typical issue of soft glans syndrome
complained about by their sexual partner. We report an example case of
suffering from soft glans syndrome with impending prosthesis loss in his
sixth journey of penile implantation. However, he is unaware of an
imminent prosthesis loss on the patient's side. Given appropriate
housing, a penile implant was published in 1994;\textsuperscript{9} this
surgery niche has not been popularly recognized in the urology
profession; we sought to report this case in solving the shrinkage soft
glans syndrome and implant malposition with a novel enhancement
strategy,\textsuperscript{10} in addition to~repositioning the implant
on an ambulatory basis.

\textbf{2~CASE HISTORY AND EXAMINATION SUPPLEMENTED WITH X-RAYS}

A 42-year-old truck driver has~suffered soft glans syndrome and glans
shrinkage in the last two years after his sixth penile implant performed
elsewhere in 2021. Subsequently, he enjoyed the intromission sex per two
days afterward. Soft glans syndrome and a shrunk glans size are
aggravated gradually, intolerable conspicuous complaints from his female
partner.~He started his sixth journey with the penile implant at the age
of 27 when a penile implant with a three-piece inflatable (AMS 700) type
was made in 2008 elsewhere. It was removed because of an early infection
followed by a mechanical failure, which made him commit the first
suicide attempt. Then, a malleable type (Spectra) penile implant was
made in another medical center elsewhere. He consulted us with an
incomplete hinge because of uncomfortable pressures resulting from the
prosthesis's hinging attempt despite reassurance made for many months by
his attending surgeon.~An extra extender was disclosed by KUB (Fig. A,
B), which was removed by our salvage surgery (Fig. 1 C, D). A malleable
implant should be inconvenient for holding heavy boxes during his
professional work; he receives an inflatable, malleable, inflatable
(Fig. 1 E, F), and a malleable type of implant, respectively, in
different medical institutes, from age 36 to 40. In 2021, a suicide
attempt sustained and traumatized his left hip joint, which was fixed by
three nails. It resulted from no sexual function and fewer job
opportunities, which was improved in late 2021. then, a single malleable
implant was housed in his right corpus cavernosum; meanwhile, he was
told that the left-side corpus was too fibrotic, narrowing to be
implanted elsewhere.

\textbf{3 FURTHER INVESTIGATION AND TREATMENT}

In December 2023, he was referred for solving soft glans syndrome and
gradual shrinkage of glans diameter, and an impending prosthesis loss
was noted during a physical examination (Fig. 2A). He requested never to
touch his implant but just the solution for glans enhancement.~A
glanography was conducted after a \# 19 G scalp needle was fixed at the
dorsal aspect of the glans penis with Anterior-Posterior (Fig. 2 B) and
lateral view X-ray (Fig. 2 C). A venous complex was demonstrated by
bulks of the deep dorsal vein (DDV), two cavernosal veins (CVs, curved
arrow) complex (curved arrow in inserted right lower), and the corpus
spongiosum (double-headed arrow). Under acupuncture-assisted local
anesthesia,\textsuperscript{11}~neither electrocautery nor a suction
apparatus was used. The salvage surgery was blueprinted with our proper
position to the sub-room above the corpora cavernosa (Fig. 2D). Penile
venous stripping was made, entailing the DDV and CVs being stripped,
during which 29 ligations were made for the retro-coronal plexus using
6-0 nylon at the exit of every emissary's vein, venous ligation was
performed at the penile hilum with 5-0 nylon. Then, a 3.5 cm
longitudinal tunic incision, corporotomy, was performed along the right
corpus cavernosum to relocate the implant appropriately, followed by a
tunic fashion with 6-0 nylon.

\textbf{FOLLOW-UP X-RAY}

An uneventful postoperative course exists, and he presents us with
gratifying glans enhancement diameter. The postoperative glanography was
performed (Fig. 2 E, F). An increment of the diameter of the glans penis
was 25.0\%, diameter from preoperative 30.0mm to postoperative 37.5mm.
He drove himself home immediately postoperatively with an uneventful
course. He was gratified and shifted from a tractor-trailer driver to a
bus driver profession with no necessity of weight withholding and
enjoying his harmonious family life.

\textbf{5 DISCUSSION}

Given human erection is a natural hydraulic phenomenon, insufficient
erection rigidity might also be a natural course in a male's life if
erectile dysfunction (ED) is strictly defined as over 25 \% of
sustaining an ability to attain or maintain a rigid erection for
satisfactory coitus. Particularly, the primary impotence will ruin one's
life psychologically and physically, as in this
case.\textsuperscript{12} It, unfortunately, conspicuously does so in a
young man while active sex is granted.\textsuperscript{13} In primary
ED, the penile implant remains the final and golden solution for ED men.
A penile implant is an old strategy for providing necessary rigidity
that sustains no weaning, even in the era of oral medication for
treating elusive ED.\textsuperscript{14} As in the De Novo penile
fibro-vascular assembly, the sinusoids of the glans penis are
independent of that of the corpus spongiosum;\textsuperscript{15} after
that, a ligation of its marked drainage veins is a natural way for glans
enhancement.

Given~just~evidence can speak volumes and~only~practice can test the
truth, should medical practice be exceptional? Both penile venous
stripping and factual enhancement of the glans penis are not above
controversy; along with prostrated research, both strategies seem to
sustainably long-term benefits.~In addition, the innovative penile
fibrous anatomy was explored several decades ago. This was an
anatomy-based penile implant that could prevent the traditional soft and
shrinkage glans penis.\textsuperscript{16}~A further reiteration appears
necessary, conspicuously in the exclusively natural method, without the
necessity of artificial materials for enhancement purposes.

\textbf{6 CONCLUSION}

Despite this, it is expected to encounter shrinkage soft glans syndrome
in patients who have undergone penile implants. It is preventable
intraoperatively and treatable if soft glans syndrome exists. So does an
inappropriate location of penile prosthesis.

\textbf{ACKNOWLEDGMENT}

We want to thank Director Hsiu-Chen Lu~for her preparation of photos for
this manuscript.



\textbf{CONFLICTS OF INTEREST}

None of the contributing authors have any conflict of interest,
including specific commercial interests, relationships, and affiliations
relevant to the subject matter or materials discussed in the manuscript.

\textbf{AUTHORS CONTRIBUTION~}

G L Hsu:~surgery, study concept, data collection, data interpretation,
authoring the full manuscripts. C H Chung: working on~the above issues,
including acquisition, and recruiting the imaging. C H Hsieh:~data
collection, analysis, interpretation, acquiring, and then composing the
photos. T C Lin: Surgery fellowship in playing assistant role. J SC
Chueh: Edited the paper and led the team.

\textbf{DATA AVAILABILITY STATEMENT}

The data for this case report were taken from the case clinical records
and anonymized. Written patient consent was gained for this case report.

\textbf{REFERENCES}

1.~~~~FDA approves oral therapy for erectile dysfunction.~\emph{Am J
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2.~~Bivalacqua TJ, Champion HC, Hellstrom WJ, Kadowitz PJ.
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3.~~~~Moncada Iribarren I, S\selectlanguage{ngerman}áenz de Tejada I. Pharmacological treatment
of erectile dysfunction.~\emph{Curr Opin Urol} . 1999;9(6):547-551.
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4.~~~~Vardi Y, Appel B, Jacob G, Massarwi O, Gruenwald I. Can
low-intensity extracorporeal shockwave therapy improve erectile
function? A 6-month follow-up pilot study in patients with organic
erectile dysfunction.~\emph{Eur Urol} . 2010;58(2):243-248.
doi:10.1016/j.eururo.2010.04.004

5.~~~~Huang PC, Hsu GL. Vascular Surgery for Erectile Dysfunction. In
Skinner MK editor.~\emph{Encyclopedia of Reproduction} . 2018;
(4):427--436. Academic Press:
Elsevier.~\emph{http://dx.doi.org/10.1016/B978-0-12-801238-3.64804-3}

6.~~~~Olsen AB, Persiani M, Boie S, Hanna M, Lund L. Can low-intensity
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doi:10.3109/21681805.2014.984326

7.~~~~Frydman V, Pinar U, Abdessater M, et al. Long-term outcomes after
penile prosthesis placement for the Management of Erectile Dysfunction:
a single-Centre experience.~\emph{Basic Clin Androl} . 2021;31(1):4.
Published 2021 Mar 4. doi:10.1186/s12610-021-00123-x

8.~~~Bettocchi C, Ditonno P, Palumbo F, et al. Penile prosthesis: what
should we do about complications?~\emph{Adv Urol} . 2008;2008:573560.
doi:10.1155/2008/573560

9.~~~~Hsu GL, Brock G, Martínez-Piñeiro L, von Heyden B, Lue TF, Tanagho
EA. Anatomy and strength of the tunica albuginea: its relevance to
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doi:10.1016/s0022-5347(17)35214-x

10.~~Hsu GL, Hill JW, Hsieh CH, Liu SP, Hsu CY. Venous ligation: a novel
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implantation.~\emph{Biomed Res Int} . 2014;2014:923171.
doi:10.1155/2014/923171

11.~~Hsu GL, Zaid UX, Hsieh CH, Huang SJ. Acupuncture assisted local
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2013;2(4):291-300. doi:10.3978/j.issn.2223-4683.2013.12.02

12.~~Sheng Z. Psychological consequences of erectile
dysfunction.~\emph{Trends in Urology \& Men's Health} ~2021; 12:19--22.

13.~~Capogrosso P, Colicchia M, Ventimiglia E, et al. One patient out of
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14.~~Montague DK. Penile prosthesis implantation in the era of medical
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15.~~Hsu GL, Lu HC. Penis Structure---Erection. In M. K. Skinner
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16. Hsu GL, Chen HS, Huang SJ. Does tunica anatomy matter in penile
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doi:10.3978/j.issn.2223-4683.2014.03.04

\textbf{Legends}

\textbf{Figure 1.~} X-ray imaging on penile implant journeys of this
42-year-old truck driver. A. The penis was putting downward; an
Anterior-Posterior pelvic film disclosed an extender of the penile
prosthesis was left in the right corpus cavernosum (dark arrow in the
inserted film, right bottom), which obscured the clear space between two
cylinders, its medial location implicated why incomplete hinging
malleable implant, resulting from eliciting pain by compression. B.
Further film disclosed the extender (arrow in the inserted film) making
a space competition on his penoscrotal region while the penis was
directed upward. C. After~salvaging surgery,~an AP view showed no more
extender; note the film comparison with that in A. D. Again, it showed
no extender compared to the film in B. E. In his fourth penile implant
with three pieces of inflatable type, the pump activator was ready to
erose the scrotal skin (inserted left) and the proximal tip of the
implant (dark asterisk in inserted right). F. Similar finding was noted
when the penis was filmed in a lateral position for comparison with that
in E.

\textbf{Figure 2:} Photo and imaging evidence with surgery illustration
of anatomy blueprint in this 42-year-old man. A. Photo of the
implementing prosthesis extrusion via urethral meatus (white
arrow).~Note patient's fingers were holding his penis. B. While the
penis was positioned downward,~via a 19G scalp needle (curved arrow)
inserted in the left lateral aspect of the glans penis, a glanography
was conducted via contrast medium injection (white cross), then an
Anterior-Posterior pelvic film disclosed a single malleable penile
prosthesis was shown in the right corpus cavernosum (white arrow) and
three nails for treating his traumatic hip joint resulting from a
suicide attempt (hollow arrow). C. Glanography was obtained in a
30-degree right oblique view while the contrast medium was injected.
Note the~erection-related venous plexus was distributed on the dorsal
aspect of the corpora cavernosa, and the corpus spongiosum~(curved
double arrow).~ The implant (white arrow) was ready to extrude~through
the urethral meatus. D. The anatomy illustration for reinsertion of the
mislocated implant, salvaging the penile implantation, was made
following the novel strategies for glans enhancement. E. In a 30-degree
right oblique view, appropriate implant location and significant glans
enhancement after the penile venous stripping. Note that the
erection-related venous plexus was no longer seen and, meanwhile, the
corpus~spongiosum~(curved double arrow)~was~playing a more~significant
role of venous drainage route, compared to those in the C. F. As the
penis was downward, in the glanography in injecting (white cross), the
sustainable implant and significant glans enhancement in physiologically
hemodynamic, compared with those in B.\selectlanguage{english}
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