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© 2021 The Authors. Société Internationale d'Urologie Journal, published by the Société Internationale d'Urologie, Canada.

Key Words Competing Interests Article Information

Prostatic artery embolization, penile tip 
necrosis, benign prostate hyperplasia, 
Embozene

None declared.

Patient Consent: Obtained.

Received on May 19, 2021 
Accepted on July 17, 2021 
Soc Int Urol J.2021;2(5):323–326

DOI: 10.48083/UCZQ9737

Prostatic artery embolization (PAE) is an emerging 
inter ventiona l radiologica l procedure performed 
under local anaesthesia, which provides an alternative 
treatment for benign prostatic hyperplasia (BPH) in 
patients whose preference or medical comorbidities 
preclude either a general anaesthetic or surgical 
intervention[1,2]. PAE has been shown to improve lower 
urinary tract symptoms (LUTS), although not with the 
same efficacy as a transurethral resection of prostate 
(TURP)[3–5]. The largest case series reported is of 630 
patients, in which 35% of patients reported an immediate 
improvement in symptoms, 82% had clinical success 
at medium-term follow-up (1 to 3 years), and 76% had 
clinical success at long-term follow-up (3 to 6.5 years)[3]. 
Reported complications following PAE include dysuria 
(16.9%) and frequency (11.6%), generally lasting no more 
than one week, and acute urinary retention (4.6%)[6]. 
Penile tip necrosis as a complication is reported as being 
exceedingly rare[3,4,6,7]. This paper describes 3 cases of 

penile tip necrosis following PAE to enable clinicians to 
readily identify the complication and manage patients 
appropriately.

The first patient was a 63-year-old man with significant 
medical comorbidities with an American Society of 
Anesthesiologists Physical Status Classification System 
(ASA) score of 4, who presented to emergency in acute 
urinary retention. He had a history of obstructive 
symptoms and had trialled pharmacotherapy to limited 
effect, with an International Prostate Symptom Score 
(IPSS) of 17. He had undergone a successful PAE 3 years 
earlier, which resulted in an improvement in his urinary 
flow with a voided volume of 156 mL, a peak flow rate 
of 15.1mL/sec, but a slightly elevated post-void residual 
volume of 85 mL. Following his re-presentation, he was 
referred back for consideration of repeating PAE. His 
prostate prior to the procedure measured 210 cc. A PAE 
via radial artery puncture was performed using 250 μm 

323SIUJ.ORG SIUJ  •  Volume 2, Number 5  •  September 2021

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Non-Target Embolization of the Glans Penis  
During Prostatic Artery Embolization

Cameron James Parkin,1,2,3 Cecile Pham,3,4 Amanda Chung,1,3,4,5 Stuart Menogue,4 Jules Catt,6,7  
Gavin Gottschalk,8 Cherie Wong,9 Venu Chalasani1,3,4,5

1 Department of Urology, Royal North Shore Hospital, Northern Sydney Local Health District, Australia 2 School of Medicine, The University of Notre Dame, Sydney, 
Australia 3 North Shore Urology Research Group, Royal North Shore Hospital, NSW, Australia 4 Department of Urology, Northern Beaches Hospital, NSW, Australia  
5 Faculty of Health and Medicine, University of Sydney, Australia 6 Department of Interventional Radiology, Liverpool Hospital, Australia 7 Department of Radiology, 
Prince of Wales Hospital, NSW, Australia  8 Chatswood Dermatology Centre, NSW, Australia  9 Department of Anatomical Pathology, Douglass Hanly Moir Pathology, 
Macquarie Park, Australia

Abstract

Prostatic artery embolization is becoming increasingly popular in the management of benign prostatic hyperplasia, 
particularly for patients with significant comorbidities that make them poor candidates for either general anaesthesia 
or surgical intervention. Penile tip necrosis as a complication following prostatic artery embolization is exceedingly 
rare, with only 4 cases previously reported in the world literature. It occurs as a result of the embolization material 
passing into and occluding collateral arterial networks such as those supplying the glans penis. This paper identifies 3 
further cases of penile tip necrosis, outlines its natural history, and proposes management strategies, so that clinicians 
can better identify and treat this condition.

http://SIUJ.org
mailto:Cameron.Parkin%40health.nsw.gov.au?subject=SIUJ


Abbreviations 
ASA  American Society of Anaesthesiologists Physical 

Status Classification System
BPH benign prostatic hyperplasia
IDC indwelling urethral catheter
IPSS International Prostate Symptom Score
LUTS lower urinary tract symptoms
PAE prostatic artery embolization
TURP transurethral resection of prostate

Embozene Microspheres. Pelvic angiography revealed 
the prostate arteries originating from the obturator 
arteries bilaterally. Small accessory pudendal arteries 
were identified originating from the obturator arteries, 
forming an arterial anastomosis between the prostate 
and penis (Figure 1). One week following the procedure, 
the patient noticed a rash developing over his glans 
penis. He was later referred to a dermatologist who noted 
full thickness epidermal necrosis and slough covering 
most of the glans (Figure 2a). The edge of the slough 
was lifted, and a punch biopsy performed. This revealed 
complete ulceration of the epithelium, inf lammation 
and non-refractile spherical foreign bodies within the 
arterioles of the tissue, correlating with Embozene 
Microspheres used during the PAE procedure (Figure 2b). 
Three months following the PAE procedure, the necrotic 
areas over the glans had completely healed (Figure 2c). 

These had been managed with regular dressings and 
daily 2% lignocaine ointment. The patient subsequently 
passed a trial of void.

The second patient was an 84-year-old man, with an 
ASA score of 4, who was referred for management of 
BPH in the context of failed medical management. He 
had been experiencing worsening LUTS over 5 years 
and had been dependent on an indwelling urethral 
catheter (IDC). A pre-procedural computed tomography 
angiogram of the pelvis had revealed both the left and 
the right prostatic arteries arising from a gluteopudendal 
trifurcation. A PAE was undertaken via puncture 
of the right femoral artery. The left prostatic artery 
was embolized with 250 μm Embozene Microspheres 
until complete stasis was achieved. No right-sided 

FIGURE 1. 

Pelvic angiography of a 63-year-old male (case 1) 
undergoing prostatic artery embolization, with a catheter 
placed in the left internal iliac artery. The left prostatic artery 
is derived from the left obturator artery which is also is 
supplying an accessory pudendal artery to the penis. 

FIGURE 2. 

Penile tip necrosis encountered following prostatic 
artery embolization: (A) A 63-year-old male (case 1) who 
developed penile tip necrosis 1 week following PAE;  
(B) Areas of necrosis over the glans were biopsied which 
revealed embolization of the Embozene Microspheres 
(circled) from the prostatic artery embolization within the 
vessels of the specimen, with surrounding inflammation 
and ulceration; (C) Three months following PAE, the areas 
of necrosis had completely healed; (D) An 84-year-old male 
(case 2) who developed penile tip necrosis day 7 post-
procedure. 

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embolization was performed secondary to significant 
stenosis at the origin of the right prostatic artery. The day 
following the procedure, the patient developed penile tip 
pain and erythema. This was initially treated with simple 
analgesia and lignocaine 2% topical gel. Pain persisted 
and patchy areas of necrosis developed over the glans 
penis (Figure 2d). The patient was continued on regular 
tablet analgesia and clotrimazole 1% topical cream. By 
postoperative day 19, the penile wounds had completely 
healed. The IDC was removed on postoperative day 60, 
and the patient was able to void spontaneously.

The final patient was a 77-year-old man who initially 
presented to emergency in acute clot retention. A 
cystoscopy revealed the cause of haematuria to be a grossly 
enlarged trilobar prostate with a prominent vascularised 
median lobe. Ultrasound revealed a prostatic volume 
of 176cc. He too had significant medical comorbidities 
and so was referred for PAE. Left radial artery access 
was obtained under local anaesthesia. Left internal iliac  
ar teriography revea led t he lef t prostatic ar ter y 
branching from the middle rectal artery (Figure  3a). 
The left prostatic artery was catheterized and embolized 
with 250 μm Embozene Microspheres. Right internal 
iliac arteriography revealed significant supply from 
an accessory pudendal artery (Figure  3b). The right 
prostatic artery was embolized with 250 μm Embozene 
Microspheres distal to the origin of the accessory 
pudendal artery. The patient presented to the emergency 
department on day 7 postoperatively with worsening 
penile pain. He was noted to have an area of necrosis on 
the glans penis, just ventral to the urethral meatus, which 
was exquisitely tender. He was admitted and managed 
conservatively. At 1-month follow-up, he had ongoing 
penile pain and had developed ulceration at the urethral 
meatus. He was commenced on chloramphenicol 1% 
topical ointment twice daily. The IDC was removed at 
time of review, and he was able to void spontaneously. 
At 6-month follow-up, the patient had no pain, and the 
ulceration of the glans penis had healed.

Penile tip necrosis as a result of prostate artery 
embolization is rare, occurring in < 1% of cases[5]. Non-
target embolization refers to the process in which the 
passage of the particles used to occlude the prostate 
arter y have passed into other arteria l networks 
supplying pelvic organs[5]. Penile tip necrosis is a result 
of non-target embolization in which, during PAE, 
these particles have likely passed from the prostatic 
artery into the pudendal circulation supplying the 
penis. Patients who are vasculopaths with resultant 
abundant pelvic collaterization are at greater risk of  
non-target embolization[5]. The arterial supply of the 
penis as a result can be highly variable, where it can 
derive from the internal pudendal artery directly, from 
an accessory pudendal artery, or from a combination 

of the 2[8]. The accessory pudendal artery typically is 
a branch of the internal obturator artery or inferior 
vesical artery; the latter also supplies the prostatic 
arteries more proximally, thus forming an anastomosis 
between the prostate and the penis[8]. Patients who have 
accessory pudendal arteries are at higher risk of penile 
complications following PAE as a result[9]. Bilhim et al., 
in a retrospective study of 186 patients who underwent 
PAE for lower urinary tract symptoms, identified 9 
patients (4.8%) who developed small skin lesions on 
the glans penis following PAE[9]. These were likely 
small areas of necrosis, all of which had spontaneously 
healed within 1 month of the procedure[9]. The pelvic 
angiography of these cases revealed that all patients who 
suffered from this minor complication had prominent 
accessory pudendal arteries[9]. Thus, for patients in 
whom accessory pudendal arteries are identified, care 
must be taken with the embolization technique to 
clearly identify the arterial anatomy to minimize the 
occurrence of non-target embolization[9].

In all 3 cases discussed, 250 μm Embozene Microspheres 
were used to occlude the prostatic arteries. Currently there 
is a wide variety in the size and composition of embolic 
agents available, with no consensus on a preferable agent. 
There is debate as to whether smaller particles, between 
100 μm and 300 μm, may predispose patients to non-
target embolization and recanalization of the arterial 
supply[10,11]. A small prospective randomised controlled 
trial has compared outcomes in 15 patients undergoing 
PAE who were embolized with smaller particles (100 μm 
to 300 μm) with outcomes in 15 patients embolized with 
larger particles (300 μm to 500 μm)[10]. Functionally, 

FIGURE 3. 

Three-dimensional reconstructions of a pelvic angiogram 
of a 77-year-old patient (case 3) undergoing prostatic artery 
embolization revealing selective catheterization of the left 
and right prostatic arteries (LPA & RPA – white arrows).  
(A) The left prostatic artery originated from the middle rectal 
artery; (B) The right prostatic artery was identified to  
originate from an accessory pudendal artery (red arrow) 
which is also seen supplying the penis. 

325SIUJ.ORG SIUJ  •  Volume 2, Number 5  •  September 2021

Non-Target Embolization of the Glans Penis During Prostatic Artery Embolization

http://SIUJ.org


both groups showed significant improvement in lower 
urinary tract symptoms as determined by mean IPSS 
scores. There were no major complications reported 
in either group, with no reports of penile tip necrosis. 
The patient cohort embolized with smaller agents did, 
however, report greater rates of complications, though 
these were not statistically significant (P = 0.066). These 
were mainly characterised by ejaculatory dysfunction 
and haematochezia.

As this is an uncommon occurrence following PAE, 
clinicians should still undertake a thorough clinical 
history and examination when approaching a new penile 
lesion. Penile lesions with similar appearance to that 
seen in these cases can be divided into benign, infective, 
inflammatory, and malignant aetiology. Penile biopsy 
should be reserved for those cases in which the diagnosis 
is unclear, or in which malignancy is suspected.

Given its low incidence, there are no guidelines 
on the prevention and management of penile tip 
necrosis following PAE. Although certainly alarming 
in appearance, all cases reported have healed in time. 
Current literature suggests that in addition to local 
wound care, patients should be commenced on regular 
acetylsalicylic acid to reduce platelet aggregation at the 
site of necrosis and tadalafil to reduce cytokine mediated 
inf lammation[5]. In the cases discussed, a stepwise 
analgesic regimen was followed, consisting of regular 
paracetamol, non-steroidal anti-inf lammatories, and 
topical local anaesthesia in the form of 2% lignocaine. 
When concurrent infection is suspected, use of topical 
antimicrobials such as 1% chloramphenicol should be 
considered.

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326 SIUJ  •  Volume 2, Number 5  • September 2021 SIUJ.ORG

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