(325) Inflatable Penile Prosthesis Glans Ischemia Versus Severe Bruising: A Clinical Dilemma

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Abstract Introduction Glans ischemia and subsequent necrosis is a rare but devastating complication of inflatable penile prosthesis (IPP) placement. Differentiating true glans ischemia from severe ecchymosis is often difficult to distinguish, yet it remains paramount given the glans ischemia principle: “when in doubt, take it out.” Objective We present several clinical scenarios and associated postoperative images wherein there was concern for post-IPP glans ischemia based on initial clinical examination. In addition, we review pertinent clinical factors that can be used to help distinguish between greater than “average” glans ecchymosis and true ischemia. Methods We present four cases from 2025 and describe clinical factors likely responsible for increased glans discoloration. Results Traditional risk factors for glans ischemia are constrictive IPP wrap, vasculopathy, use of prolonged large bore catheters, and concomitant surgery (circumcision, distal counter-incision, urethral/neurovascular bundle mobilization). Case 1 was a patient with a history of radiation for prostate malignancy who had notably hypervascular corpora intraoperatively. On postoperative day (POD) #1, the urethral meatus was ecchymotic along with patchy ecchymosis throughout the glans. The Kerlix wrap can be seen around the penile shaft up to the corona. Removing the constrictive wrap and increasing room lighting revealed a well-vascularized glans with spotty ecchymosis likely from passage of the Keith needles during deployment. Case 2 was another patient examined on POD1 after uneventful IPP placement under local anesthesia. Note the similar level of ecchymosis involving the scrotum. Case 3 is another patient examined POD1 from a penoscrotal IPP that required multiple firing attempts with the Keith needle. Again, multifocal areas of patchy ecchymosis are interspersed with areas of normal appearing glans. The patient’s skin color was also similar in appearance to the areas of ecchymosis, requiring careful attention to detail to differentiate. Finally, Case 4 is an image on POD0 after uneventful IPP. The patient required several Keith needle passes because Furlow tool severed suture. Notably, decision was made to leave the penile implant in place in all cases. The penile wrap and/or catheter was removed and lighting was optimized to evaluate for clinical change. No patient reported paresthesia or pain out of proportion to the clinical examination. All glans were warm to the touch. Rates of glans bruising at POD3 for 298 implants performed since 2024 under local anesthesia, with bruising scored 0-4, were as follows: 0: 3.7% 1: 48.7%, 2: 25.5% 3: 21.1% 4: 0.3%. This demonstrates high rates of glans bruising with local anesthesia. We speculate that the increased rate of glans bruising may be attributed to the aggressive nature of the local anesthesia block, which can result in vasodilation and ecchymosis due to needle trauma and increased vascular permeability. Conclusions IPP cylinder deployment requiring multiple Keith needle punctures, constrictive post-op penile wrap, hypervascular corpora, exam/images with poor lighting, extensive bruising in other areas, and IPPs performed under local anesthesia appear may contribute to glans discoloration that mimics ischemia. A detailed physical exam and close clinical monitoring are essential when postoperative glans discoloration is observed. Disclosure No

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