








































This is an open access article under the terms of a license that permits non-commercial use, provided the original work is properly cited.  
© 2021 The Authors. Société Internationale d'Urologie Journal, published by the Société Internationale d'Urologie, Canada.

Key Words Competing Interests Article Information

Penile prosthesis, infection, erectile 
dysfunction, salvage surgery, revision 
prosthesis

None declared. Received on August 8, 2021 
Accepted on August 27, 2021

Soc Int Urol J.2021;2(6):380–381

DOI: https://doi:10.48083/GVCC5010

380 SIUJ  •  Volume 2, Number 6  •  November 2021 SIUJ.ORG

COMMENTARY

Expert Roundtable Discussion on Penile Prosthesis 
Infection Prevention Measures
Eric Chung,1, 2 Martin S. Gross,3 Koenraad van Renterghem,4 Jay Simhan5

1 University of Queensland, Princess Alexandra Hospital, Brisbane, Australia 2 AndroUrology Centre, Brisbane and Sydney, Australia 3 Dartmouth-Hitchcock Medical 
Center, Lebanon, United States 4 Department of Urology, Jessa Hospital and Hasselt University, Hasselt, Belgium 5 Einstein Medical Center, Philadelphia, United States

Inflatable penile prosthesis (IPP) implantation remains the standard of care for men with medical-refractory erectile 
dysfunction. However, IPP infection remains one of the most consequential complications of penile prosthesis 
surgery[1,2]. Apart from the patient morbidity and explant of the infected device, infection can also be associated 
with significant corporal fibrosis with ensuing reduction in penile size and more difficult re-implantation, as well 
as adverse psychosexual and socioeconomic effects[3,4]. The incidence of IPP infection has decreased over the last 
decade because of better surgical care pathways coupled with antibiotic-coated prostheses and surgical technique 
improvements[5].

IPP infection should be differentiated from infection of the surgical site alone[4]. Most implant infections usually 
occur within the first 6 weeks because of bacterial contamination at the time of surgery. In contrast, chronic infections 
or infections occurring after 6 weeks are often subclinical, with patients presenting with chronic pain around the 
device components or device extrusion[6].

The following commentary is a summary of the experts’ round table discussion by key opinion leaders and 
high-volume surgeons from North America, Europe, and Asia Pacific regions at the recent Société Internationale 
d'Urologie (SIU) Academy educational webinar. Contemporary literature and clinical evidence regarding the preven-
tion and management of penile implant infection were discussed[2,6,7]. A detailed analysis of all relevant studies, 
including a full surgical description, is not feasible in this commentary.

1. Primary Penile Implant Infection
Modifications of preoperative and perioperative risk factors with appropriate use of antibiotic coverage and modern 
IPP have significantly reduced infection rates over the years. Pre-existing medical comorbidities such as diabetes, 
smoking status, immunosuppression, radiation history, neurological disorder, previous pelvic surgery, older age, 
and obesity have all been shown to increase the risk of peri-prosthetic infection[2–4,6–9], and optimisation of 
these risk factors might mitigate IPP infection. All patients should undergo routine preoperative urine microscopy 
tests and skin checks. Appropriate precautions to minimize contamination by common skin organisms include 
a preoperative shower with an antibacterial agent, intraoperative hair removal and use of alcoholic formulations 
for skin preparation[6,7]. Perioperative antibiotic prophylaxis, ideally given at least 1 hour before surgery, and the 
use of antibiotic-coated devices have been well documented to minimize intraoperative infection risk[2,6,7]. While 
the nature of intravenous antibiotics is likely dependent on local institution antibiotics policy, the combination of 
antibiotics covering both gram-positive and gram-negative bacteria is preferred. The co-administration of an 
antifungal is usually reserved for patients with obesity or poorly controlled diabetes, or in certain geographical 
locations, or in the setting of salvaging an infected IPP[2,3]. The group consensus recommendation to augment 
coverage with antifungals is in contradistinction to existing antimicrobial recommendations of the American 
Urological Association and the European Association of Urology but is felt to be necessary given contemporary 
studies that have demonstrated the prevalence of fungal organisms in these high-risk penile implant populations.



Standard surgical protocols such as appropriate full 
protective surgical attire and limiting the number of 
staff and traffic within the operating room should be 
instituted[7]. Attention to surgical wound sterility with 
a small surgical field, the use of antibiotic solution irri-
gation and minimizing device-skin contact, have been 
described to improve surgical sterility[6,7]. There is 
currently no evidence to suggest that a particular surgi-
cal approach has a higher infection risk[1].

Postoperative antimicrobial prophylaxis is often given 
especially in high-risk groups (eg, people with diabetes) 
although this remains a surgeon preference. Patients 
are advised to maintain high standards of hygiene and 
refrain from sexual activity in the first 4 to 6 weeks after 
surgery. Any signs of impending infection such as fever 
or early cellulitis should be brought to the attention of 
the surgeon immediately.

2. Revision Penile Implant Infection
Patients with pre-existing risk factors will always have 
a higher risk of IPP infection after revision surgery 
compared with after primary surgery[3,6]. Those 
operated on for impending device component erosion 
are at increased risk of infection, especially if the revision 
surgery requires additional or complex procedures such 
as graft reconstruction[3].

In revision surgery, aggressive irrigation of all surgical 
sites and excision of pseudo-capsule may remove bacte-
rial seeding within the biofilm, which is often responsi-
ble for delayed device infection[2,4,7]. Any device that 
is older than 5 years should ideally be exchanged at the 
revision surgery. The existing reservoir can be retained 
in the absence of infection or eroded penile prosthetic 
component if the defunctionalized reservoir is located 
within the extraperitoneal and retropubic space[6,7], 

but needs to be emptied and capped to prevent fluid 
accumulation and subsequent risk of infection[1]. Many 
surgeons will prescribe postoperative antibiotics for 
patients in revision and salvage cases.

3. Salvage Penile Implant Infection
In the early stage of IPP infection, a trial course of 
intravenous antibiotics with or without antifungal 
may be appropriate in the absence of systemic sepsis 
or purulent discharge[1,2]. However, the decision 
for surgical intervention should be made if there 
is a progression of sepsis or evidence of device 
extrusion[1,3,4]. The decision to conserve an IPP or not 
depends on the patient’s presentation and clinical status, 
the timeline and onset of infection, and response to the 
antibiotic treatment[10].

While explant of the infected device without salvage 
remains the safest option, salvage protocol with revi-
sion penile prosthesis implant can be carried out if there 
is an absence of tissue necrosis and purulence in the 
corporal bodies or scrotum[1–3,7]. In the salvage cases, 
all components of the device should be removed with 
aggressive mechanical lavage based on various versions 
of Mulcahy’s washout protocols using a series of antisep-
tic solutions consisting of half-strength povidone-iodine, 
half-strength hydrogen peroxide, and combination anti-
biotic agents. An immediate device replacement impor-
tantly preserves sexual function and penile length and 
further prevents corporal fibrosis. A malleable implant 
is a simpler and cheaper alternative to IPP that can be 
used at the time of salvage surgery and facilitate eventual 
conversion to inflatable implant in the near or long-term 
future[1]. For a delayed re-implantation, use of a vacuum 
erection device may help in obtaining good results and 
reducing fibrosis and the shortening of the penis.

References

1. Levine L A, Becher E, Bella A, Brant WO, Kohler TS,  Martinez-
Salamanca JI. Penile prosthesis surgery: current recommendations 
from the International Consultation on Sexual Medicine. J Sex 
Med.2016;13:489–518.  DOI: 10.1016/j.jsxm.2016.01.017

2. Swanton AR, Munarriz RM, Gross MS. Updates in penile prosthesis 
infections. Asian J Androl.2020;22(1):28-33.

3. Chung E. Penile prosthesis implant in the special populations: 
diabetics, neurogenic conditions, fibrotic cases, concurrent urinary 
incontinence, and salvage implants. Asian J Androl.2020;22(1):39-44.

4. Al-Shaiji TF, Yaiesh SM, Al-Terki AE, Alhajeri FM. Infected penile 
prosthesis: literature review highlighting the status quo of prevention 
and management. Aging Male.2020;23(5):447-456.

5. Chung E. Penile prosthesis implant: Scientific advances and 
technological innovations over the last four decades. Transl Androl 
Urol.2017;6(1):37-45.

6. Hebert KJ, Kohler TS. Penile prosthesis infection: myths and realities. 
World J Mens Health.2019;37(3):276-87

7. Best JC, Clavijo RI. Best practices for infection prevention in penile 
prosthesis surgery. Curr Opin Urol.2020;30(3):302-308.

8. Gon LM, de Campos CCC, Voris BR, Passeri LA, Fregonesi A, Zanettini 
Riccetto CL. A systematic review of penile prosthesis infection 
and meta-analysis of diabetes role. BMC Urol.2021;21:35. DOI:  
https://doi.org/10.1186/s12894-020-00730-2

9. Carrasquillo RJ, Munarriz RM, Gross MS. Infection prevention 
considerations for complex penile prosthesis recipients. Curr Urol 
Rep.2019;20(3):12.

10. Barlotta R, Foote C, Simhan J. Penile prosthesis salvage: Review 
of past and current practices. Curr Sex Health Rep.2019;11:185-189.

381SIUJ.ORG SIUJ  •  Volume 2, Number 6  •  November 2021

Expert Roundtable Discussion on Penile Prosthesis Infection Prevention Measures


