Successful Penile Replantation and the Role of Postreplantation Sildenafil Therapy: Report of 2 Cases and Literature Review

Shibo Fu PhD; Dachao Zheng MM; Minkai Xie PhD; Haijun Yao MM; Zhong Wang PhD, MD

FIRST PUBLISHED: June 21, 2019 – Sexual Medicine 

DOI: https://doi.org/10.1016/j.esxm.2019.05.001

Introduction

Penile amputation can be successfully managed with microvascular replantation. However, most patients lose sexual function afterward, at least to some degree. Because the situation is rare, it is difficult to find clinical reports. This study describes the use of daily oral sildenafil therapy in two patients whose penises were surgically reattached.

Case 1

The first patient was 49 years old. His penis had been partially amputated with a knife.

“The bilateral corpus cavernosum was completely severed and the dorsal urethral wall was lacerated, but the urethral mucosa, testicles, and scrotum remained intact.”

The urethral wall, tunica albuginea, and midline septum were repaired. Neurovascular anastomosis began as the penile shaft was reattached.

The patient began taking oral sildenafil (50 mg/day) on postreplantation day 28. He was monitored for two days, then discharged. He continued with daily sildenafil for two months, then stopped when his erections recovered.

Follow-up appointments continued monthly. Six weeks into this period, the patient reported painful nocturnal tumescence, but this pain gradually decreased and resolved by the twelfth week.

Ninety-two days after replantation, the patient had his first intercourse, but said it was unsatisfying. The glans was numb.

Over the next three months, sensation and erection rigidity improved, and intercourse became more frequent.

The glans remained numb until three months after discharge, when the patient experienced mild formication for two weeks.

After 24 weeks, the patient had regained 70% of tactile sense, according to his own self report.

Case 2

The patient was a 31-year-old construction worker whose penis had been completely severed in a saw blade accident. The scrotum had been cut open, but spermatic cords remained intact. The distal penis had been kept at room temperature and was contaminated by sawdust. At the hospital, it was thoroughly cleaned and kept in ice chips.

Surgery began with debridement. The urethral mucosa, along with the urethral and penile cavernous bodies were repaired. An artery, two veins, and the dorsal penile nerve were anastomosed.

Patient developed edema and partial necrosis of the foreskin, successfully managed with a split-thicknes skin graft on the 10th day. The patient began PDE-5i therapy on postreplantation day 28 and was discharged on day 30.

The glans was numb and remained so during the patient’s first intercourse after surgery at 105 days. Sensation partially recovered, and the patient reported a sensation of “ants walking on a line,” which gradually resolved over 6 months. The patient said about 60% of his sensation had returned by this time.

Monthly follow up was planned for 6 months, followed by biannual follow up. The patient’s sexual function returned, and he did not continue follow up appointments after one year.

Discussion 

Before 2011, the functional recovery period for penile replantation patients at this medical center ranged from three months to over two years. The erection recovery rate was 77.5%.

The medical location began using PDE-5i therapy in penile replantation patients in 2011, with six patients undergoing this protocol since then. The post-2011 erectile function recovery rate has been 83.3%.

“Given the favorable prognosis of all 6 patients, we conclude that sildenafil may have value in accelerating the recovery of erectile function after replantation. At least our findings show that PDE-5i therapy does not induce adverse complications.”

However, prognosis can depend on several factors, including the “type of severance, warm ischemic time, quality of blood vessel anastomosis, postoperative venous congestion, and endothelial function.” More research is needed to learn more about PDE-5i therapy in penile replantation patients.