Corpus cavernosum abscess after Al-Ghorab shunt with Snake Maneuver for ischemic priapism treatment: Clinical and surgical treatments

Abstract

Corpus cavernosum abscess is a rare condition that can lead to permanent and debilitating consequences. This case reports a 58-year-old man who developed erectile dysfunction with no response to oral and intracavernous medications after the surgical treatment of a penile abscess.

1. Introduction

Corpus cavernosum abscess is a rare condition that can cause debilitating consequences. The corporal fibrosis that can evolve from this situation often results in erectile dysfunction and penile shortening. Only a few cases of corpus cavernosum abscess have been reported in the literature, especially as consequence of a modified Al-Ghorab shunt.¹ This report presents a case of corpora cavernosa abscess following an Al-Ghorab shunt associated with a Snake Maneuver to treat persistent ischemic priapism.

2. Case report

A 58-year-old male presented to the emergency room complaining of a prolonged and painful erection, three days after receiving an intracavernous prostaglandin injection. The case was first managed with drainage and saline irrigation of the corpus carvernosum, but detumescence was not achieved, considering the prolonged length of the priapism. An Al-Ghorab shunt with Snake Maneuver was then performed, achieving a complete resolution of the priapism, and the patient was discharged the next day.

At the first follow-up appointment the patient was asymptomatic, except for some residual edema of the penis. One month after the procedure, the patient evolved with penile pain, a diffuse swelling of the glans, penile shaft and purulent discharge from the surgical wound. The magnetic resonance imaging performed revealed a fluid collection filling both corpora cavernosa and some contrastation indicating an abscess (Fig. 1). Leukocytosis (16,900/mm3) and an increased CRP level(40,5mg/L) was found.

Fig. 1.

MRI images revealing a large fluid collection filling both corpora cavernosa, indicative of an abscess with an estimated volume of 72cm³.

The patient was submitted to drainage in the operating room. Metzenbaum scissor dissection was used to access and drain the fluid collections in the corpora cavernosa. Hegar dilators were used bilaterally to reach the entire extent of the corpus cavernosum and a penrose drain was kept in place for three days. Haemophilus parainfluenza was found in the culture examination of the abscess, which guided the antibiotic treatment with meropenem for seven days. The patient was discharged with significant improvement of the symptoms, after the end of the antibiotic treatment.

Six months after the procedure, the patient evolved with erectile dysfunction with no response to oral medications or intracavernous injections. As a next step, it was proposed a malleable penile prosthesis implant, which was performed eight months after the drainage. The procedure was carried out under spinal cord anesthesia through a large penoscrotal incision. Each corpus cavernosum was dissected and opened with a wide incision allowing dissection of its interior. The prosthesis was immersed in gentamicin before implantation, and the patient received a course of meropenem during anesthesia induction. He was discharged the next day with a prescription of ciprofloxacin for seven days. At the first week follow-up visit, the surgical incision was clean and there were no signs of infection. At present time, in a 6-month follow-up, the prosthesis is functional, well-placed, and there are no signs of infection or erosion.

3. Discussion

Corpus cavernosum abscess is a rare condition, with only a limited number of cases reported in the literature. The etiology can result from various conditions, and important risk factors include diabetes mellitus, HIV, and sexually transmitted diseases.^1,2

The diagnosis of corpus cavernosum infection relies on the patient's history and physical examination. The treatment should aim to minimize the incidence of complications, especially erectile dysfunction, penile curvature, and abscesses. There is no consensus on the optimal approach, but surgical incision and drainage followed by aspiration and antibiotic therapy are commonly employed.

It is important to emphasize that prolonged priapism causes significant impairment of cavernous circulation, which leads to local metabolic alterations such as hypoxia, hypercapnia, glycopenia, and acidosis. This environment combined with tissue damage caused by drainage procedures may increase the risk of infection. Ralph et al.³ reported a 6% infection rate in acute insertions of penile prosthesis while Wilson and Delk⁴ reported a 3% infection rate in virgin penile prosthesis insertions. In our case, an antibiotic dose was administered during the anesthesia induction, and he completed a 7-day course of oral antibiotics at the time of the first procedure, which could not prevent infection, though.

In this case, surgical drainage was essential due to the large abscess volume and the patient's history of surgical manipulation. Complete drainage of the abscess cavity is mandatory, which requires careful dissection over the abscess septa. The corpus cavernosum exploration using Hegar dilators had a crucial role in achieving the cavity entirely and safely, thanks to their blunt tip. The incision site above the previous incision was obvious in this case, and the MRI showed the abscess formation really close to it and no signs of urethral involvement. For patients without previous surgical procedures, especially those with urethral involvement, alternative access routes such as perineal or penile shaft approaches should be considered.

During the follow-up the patient needed a penile prosthesis, and he received detailed orientation about the procedure and the high risks of infection and extrusion. Previous literature shows that patients with previous surgeries and diabetic patients have a higher incidence of infection, prosthesis extrusion, and malfunction.⁵ The chosen prophylactic antibiotic was not routine, but it was chosen considering the abscess culture.

The follow-up is still short, but acknowledging the patient's background, it can be considered a good outcome, and a careful follow-up is required. A penile abscess is a rare condition, and prosthesis implantation after it is rarely done. Therefore, every reported case, along with the discussion and shared experiences increases the scarce knowledge about this condition and treatment options.

4. Conclusion

This case helps to raise awareness about penile infection and abscess after priapism and cavernosum shunt and shares experiences about the diagnosis and management of this rare condition.