The penis is made of three cylindrical bodies of endothelium-lined cavernous spaces: the paired dorsolateral corpora cavernosa, and the single, ventral, and midline corpus spongiosum (1). The corpora cavernous is covered with tunica albuginea, a skinny membrane that with about 2 mm thickness in the time of flaccid penis and 0.25 mm in the erection time (2, 3). The principle of erection has not been understood completely yet. Having a normal male sexual function is completely dependent on a normal erection. Male erectile dysfunction is the steady or frequent incapability to attain and/or keep a penile erection enough for sexual performance (4). Epidemiological studies pointed that erectile dysfunction is a general problem in aging males and it has been expected that by 2025 it will influence about 350 million men all over the world (5).In addition to age, some psychological, neurological, hormonal, arterial, or cavernosal impairment and more frequently, a combination of these factors can result in erectile dysfunction. Here we represent a very rare case of abnormal cavernous which results in erectile dysfunction and our novel therapy recommendation.
We present a case of a 23-years married man referred to the department of urology and complained about sexual dysfunction because despite the erection he was not able to perform coitus. The informed consent was completed by the patient to report the case, and the case was reported based on CARE guidelines
The patient complaint about was the inability to perform coitus because of not having a rigid straight erection and he had described to his surgeon that his penis had ventral deviation.
This erectile dysfunction had been reported by the patient six months before as well, and at that time the urologist had misdiagnosed the ventral chordee. Nesbit operation had been done over the patient as a useful procedure for the correction of congenital or acquired chordee. Unfortunately, because of the lack of rigidity in the cavernous, the surgeon was made to have several plication sutures during surgery with no beneficial result. During the surgery, we found out that the tunica albuginea of the penis did not have enough strength. Also, in preoperative physical examination, we induce erection with the injection of intracavernous papaverine and we could bend the penis in every direction despite the patient had enough erection (Figure 1).
Figure 1. The patient's penis was bent in the position of third/fourth from distal in spite of having a normal erection.
In the color-doppler ultra-sonography, no evidence of tunica albuginea abnormality of cavernous was seen. Moreover, no Peyronie's plaque or fibrosis was reported. The usual approach for the treatment of similar complications is implanting a penile prosthesis.
In our technique, considering that lack of penis rigidity can be the result of cavernous smooth musculature abnormality, multiple vascular meshes were placed to increase the strength of surrounding tunica albuginea. During the surgery, first, the penis was degloved and then the erection was induced by papaverine injection. We confirmed the lack of rigidity of the cavernous in the middle shaft of the penis. After that, the erection has removed and all neurovascular bundles (NVB) from the dorsal, lateral, and urethra from the ventral were released. With the injection of the normal saline artificial erection was created and all leakage was sealed meticulously (Figure 2).
Figure 2. Several steps of placing a penile implant surgery (1 to 3).
Our prior plan for surgery was using mesh completely all-around cavernous. But during surgery, we observed it is not necessary to place mesh on the urethral bed. The surgery continued by placing multiple vascular meshes in the form of circular and longitudinal and the urethral bed left without mesh.
For the inner layer of mesh, we used GORTEX vascular mesh to have enough strength and we placed them with enough distance between meshes to not restrict increase length during a normal erection.
The outer layer of mesh is formed by placing longitudinal DACRON vascular mesh to fill up the gaps between GORTEX and saving the normal function of erection via their flexible nature of DACRON mesh. The logic behind the technique is based on the difference between a balloon and a tire. Both of them are flexible when they are flat, but when they are inflated, their rigidity is not equal because of the different strengths of the material.
Finally, the skin was repaired by Monocryl and the patient was discharged after one week of having a foley catheter and ten days of medication (Figure 3).
Figure 3. The status of the patient after three months.
Follow-up after two and six weeks showed a significant improvement in the patient. After one year the patient had no problem and our result of the surgery was completely satisfying (Figure 4). We suggest that our new technique of surgery takes the place of penile implant for such cases.
Figure 4. One year after surgery
Some problems like Peyronie's disease, trauma, or having previous surgery can have resulted in acquired curvature of the penis (6). In our 23 years old patient with no history of trauma or related disease despite having an erection, was not able to do coitus because his penis bent.
The abnormality of penis cavernosa ranges from congenital disease to acquired disease such as Peyronies disease, trauma, etc. The first and straight treatment for our patient was using the penile prosthesis. But with considering the underlying pathology of our patient we decided to perform a new surgery technique. To increase the strength of tunica albuginea, we used vascular mesh instead if allograft material because we need to cover the large surface of the cavernous. Although using vascular meshes may have the same complication as penile prosthesis such as the possibility of infection but still, normal erection function remains intact. The result of our novel treatment is promising with significant benefit for the patient.
The plication procedures for Peyronie's disease and some other penile deformities are suggested as well (7-9). Implanting penile prosthesis as a new type of paired sponge-filled silicon prostheses can be another treatment surgical strategy (10, 11). In our case, the plication procedures were not effective and the surgeon was made to think about another surgical method. We choose to place multiple vascular meshes in which the mechanism of its action is partially the same as implanting a penile prosthesis. The result of our novel treatment strategy was completely satisfying with no remaining complications for the patient. In comparison to the prosthesis, the expenses of meshes are lower. More than that if the prosthesis is the inflatable one the patients will be dependent on some accessory instrument and the self-confidence of patients decreases (12). Meshes are suggested as the treatment strategy before the prosthesis. That means if meshes do not work the final surgery substitution method can be prosthesis but if the prosthesis failed the other substitute is not available.
So there are some difficulties connected to the other surgical methods like infectious complications involving placement of a penile prosthesis (13, 14). One-year follow-up of our case after established that using of multiple vascular meshes had not any complications like inflatable or infection. We suggested this method with high efficacy and safety in patients like our case. After a one-year follow-up of our patient he had does not have any complications. After a one-year follow-up of our patient he had does not have any complications.
Taken everything into the consideration, our technique with vascular mesh can be considered as the most efficient method to improve the cavernous strength.
All authors contributed equally.
Special thanks to Urology Research Center (URC), Tehran University of Medical Sciences, Tehran, Iran.
Conflict of interest
All authors claim that there is no competing interest.
There is no funding.
All authors ensured our manuscript reporting adheres to CARE guidelines for reporting of case reports.
ED Erectile dysfunction
NVB Neurovascular bundle