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Migration of malleable penile prosthesis

We reported a case of rectal migration of malleable penile prosthesis passed out as hard bowel motion without patient recognition.


INTRODUCTION
Erectile dysfunction (ED) is defined as the inability to achieve or maintain an erection sufficient for satisfactory sexual performance. [1] Condition usually affects older men with chronic medical illnesses (e.g., diabetes, chronic renal disease, and cardiovascular disease).
Management is often started with pharmacological agents (PDE5 inhibitor) or intracorporeal injections and ends by penile prosthesis (PP) insertion in patients who responded poorly to the previous measures.
Complication of PP insertion varies, including infections, pain, or device malfunction (commonly with inflatable type). [2] Erosion, S-shaped deformity, and poor glans support happen less commonly. [2] Migration of malleable PP device to a nearby tissue or structure is a rare complication, with few cases reported in the literature.

CASE REPORT
Here, we reported a case of a 72-year-old diabetic patient, presented with a 3-year history of ED. He tried PDE5 inhibitor and intracavernosal injection without satisfactory response. He had previous removal of infected AMS Ambicor inflatable PP 3 months following insertion.

Presentation
The patient was admitted electively for insertion of malleable PP 6 months following the removal of the previously infected prosthesis.
Diabetes was well controlled preoperatively.
Malleable AMS Spectra size 9.5 mm, 20 cm long PP was inserted through a subcoronal incision under aseptic technique, with antibiotic cover pre-, intra-, and post-operatively. The insertion was difficult due to previous surgery. The two rods of the prosthesis were situated at the same level at the distal glandular ends.
The trial of voiding on day 2 and day 5 postoperatively failed following catheter removal. Urethral catheter was reinserted. He had mild perineal pain with mild tenderness over the end of the left rod without evidence of swelling or inflammation.

Investigations
The perineal ultrasound did not show evidence of collection or corporal perforation. Pelvic MRI was inconclusive due to metal rod artifact.
Diagnostic flexible cystoscopy showed mucosal urethral injury at distal left side of the penile urethra (attributed to repeated catheterization), bilateral enlarged prostatic lobes, and trabeculated bladder. Suprapubic catheter was inserted.
On the next day, he was stable, discharged, and booked for ascending urethrogram as an outpatient.
He was seen at the outpatient clinic 3 weeks following surgery complaining of mild perineal pain. Examination revealed mild perineal tenderness, subcutaneous abscess at the left root of the penis, and minimal pus discharge at the urethral meatus. The left rod piece of the PP was not felt, while the right one was in place. The patient did not see or notice passage of abnormal hard piece, apart from hard bowel motion which he usually has every now and then.
Ascending urethrogram [ Figures 1 and 2] demonstrated that the left rod of the PP was missing and also revealed communication between the urethra and the rectum where the contrast was leaking.
He was admitted, the left penile root subcutaneous abscess drained, and left corporal irrigation through the urethral fistula was done. Swab culture grew Escherichia coli.
The right corpora with the remaining rod was intact and left in situ.
Postoperatively, the patient was stable, improved on antibiotics, and discharged with the suprapubic catheter.

Follow-up retrograde urethrogram [Figures 3 and 4]
3 weeks later showed intact normal urethra, and no contrast leakage, indicating closure of the fistula.
Suprapubic catheter clamped and removed following his normal micturition. Three months later, he was not satisfied with the remaining rod as he could not use it, and hence, it was removed.

DISCUSSION
Migration rod of malleable PP is rarely reported in the literature, we know only two reported cases. All other reported cases were reservoir migration of inflatable PP.   Kucukturkmen et al. [3] reported a late complication of malleable PP rod migrating to buttock area.
Ogreden et al. [4] reported a case of migration to the thigh.
Our case represents another site for possible migration of rod of malleable PP where it migrates to the rectum as confirmed by contrast leaking to rectum in ascending urethrogram study. The patient is an old man with frequent constipation. He did not see or notice passage of any abnormal object. He may consider the passage of the PP rod as his usual hard bowel motion.
The rarity of this condition added more challenge in our case and made our case report worth publishing.

Financial support and sponsorship
Nil.

Conflicts of interest
There are no conflicts of interest.