A Multi-institutional Assessment of Multimodal Analgesia in Penile
Implant Recipients Demonstrates Dramatic Reduction in Pain Scores
and Narcotic Usage

Jacob Lucas DO; Martin Gross MD; Faysal Yafi MD; Kenneth DeLay MD; Sarah Christianson DO; Farouk M. El-Khatib MD; Mahdi Osman BS; and Jay Simhan MD

FIRST PUBLISHED: December 19, 2019 – The Journal of Sexual Medicine

DOI: https://doi.org/10.1016/j.jsxm.2019.11.267

Introduction

In the United States, the opioid epidemic is a serious public health crisis. As a result, clinicians are encouraged to find nonopioid-based pain management protocols, but such strategies have not been widely studied in urology.

The current study investigated perioperative pain control and narcotic usage in men undergoing inflatable penile prosthesis (IPP) implantation. Opioid-based pain management was compared to a multimodal analgesia (MMA) protocol.

Material and Methods

Implant-related data were collected from four medical sites. Patients were excluded if they received 2-piece inflatable or malleable implants. Those undergoing Mulcahy salvage or concomitant procedures were also excluded, as were men who were allergic or had a sensitivity to any medication used in the MMA protocol. None of the men were taking MMA medications for chronic pain.

Two cohorts were compared.

From November 2015 to June 2017, 100 (average age 64) received opioid-only pain management as follows:

Between July 2017 and December 2018, 103 men (average age 63) received MMA management as follows:

The study’s primary outcome was postoperative narcotic usage as measured in total morphine equivalents (TMEs). Secondary outcomes were visual analog scores (VAS) of pain. Three reference time periods were used:

Postanesthesia care unit (PACU)
Postoperative day 0 (POD0)
Postoperative day 1 (POD1)

Results

Median postoperative VAS scores were “significantly lower” in the MMA group at all time points.

MMA patients also used fewer narcotics during these times compared to the opioid-only group. The following table represents median TMEs:

None of the patients experienced adverse side effects related to pain medication.

At discharge, patients in the MMA group were prescribed fewer narcotics (an average of 20 tablets) than the opioid-only group (an average of 30 tablets). Approximately 11% of the men in the MMA group needed narcotic refills, compared to 28% of the opioid-only group.

Discussion

Narcotic reduction as shown in this study has “important public health considerations” and might play a role in mitigating the U.S. opioid epidemic.

In addition, using an MMA approach “avoids some of the well-known adverse medication effects of opioids and opiates” such as “ileus, constipation, urinary retention, respiratory depression, and dependence.”

The drugs used in the MMA protocol had favorable safety profiles. They were also less expensive than those in the opioid-only protocol.

The study’s retrospective design and the potential for patient recall bias were identified as limitations.

Conclusion

“Our standardized regimen, consisting of non-opioid medications targeting several pain pathways, produces excellent pain control with a significant reduction in total narcotic consumption over the entire postoperative recovery period.”