Pain Management in Penile Prosthetic Surgery: A Review of the Literature
Lael Reinstatler, MD, MPH; Kevin Shee, BS; Martin S. Gross, MD
ONLINE: July 20, 2017 – Sexual Medicine Reviews
While medical literature has addressed pain management for some urologic procedures (such as cystectomies and radical prostatectomies), little has been documented concerning pain management in penile prosthetics.
Because such surgery is elective, pain management information is important for men weighing this decision.
The current study reviewed perioperative and postoperative pain management strategies for men receiving penile prostheses (PPs).
Penile Prosthetic Devices
The two types of PPs in use today are either inflatable or semirigid. The 3-piece inflatable version (IPP) is the most frequent implant used today.
Penile Prosthetic Techniques
PPs are generally implanted using one of two methods: the infra-pubic approach and the penoscrotal approach. Most surgeries are done as same-day or overnight-stay procedures.
Pain control for penile surgery has been widely studied. Some authors have recommended a crural block for PP insertion.
Pathophysiology of Penile and Scrotal Pain
Pain is classified as acute or chronic, but the pathophysiology of chronic penile and scrotal pain is not well understood.
Acute penile pain stems from the somatosensory peripheral nerve pathways. Three of the major nerve blocks used for penile surgery target three major nodes in these pathways: the dorsal nerve of the penis, the pudendal nerve, and the S2 to S4 roots (caudal block).
There is no standard protocol for the management of scrotal pain.
Local Anesthetics in IPP Implantation
Local anesthetics are frequently used and are classified according to their duration of action. Examples include the following:
- Very short acting: Chloroproicaine (15-30 minutes)
- Short acting: Lidocaine (30-120 minutes)
- Intermediate acting: Mepivacaine (60-140 minutes)
- Long acting Bupivacaine (120-240 minutes)
Newer formulations of longer-acting anesthetics have been effective, but can be cost prohibitive.
Intraoperative Pain Management
Men receiving a PP undergo general, spinal, or local anesthesia. The literature shows high success rates for local anesthesia. In the 1990s and 2000s, the pudendal nerve block became a popular method.
An “infra-pubic space” block was investigated and deemed effective, but researchers considered the pudendal block to be the better option.
Overall, studies addressing local anesthetic options for PP surgery have been small and research involving more patients is needed.
Postoperative Pain Management
There is not much information about pain management after PP surgery. No large studies exist on this topic. The largest, which involved 131 patients, found that giving a dorsal penile nerve block relieves immediate postoperative pain, but is not effective for the long term.
Another study involved 56 men who were not given narcotic prescriptions after discharge. Instead, they were instructed to take non-steroidal anti-inflammatory drugs. Sixteen patients needed narcotics at the 2-day follow-up, but by the 10th day, none needed narcotics.
Penile Prosthetic Outcomes
Up to 13% of men have complications from surgery, the authors found. The most common adverse effects are mechanical failure and infection. Chronic pain can occur, but does not usually lead to device removal.
Some men experience pain as they learn to operate their implant.
“Intraoperative pain management has been well described for PP implantation,” the authors concluded. “Postoperative pain management has not been examined closely.”
They added that preoperative pain management might affect postoperative pain control and warrants further research.