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Injection technique to induce penile erection
INJECTION TECHNIQUE
TO INDUCE
PENILE ERECTION R. F. GITTES,
M.D.
A. P. MCLAUGHLIN,
III, M.D.
From the Division of Urology, Department of Surgery, University of California at San Diego, California
Documenting a penile deformity during erection preoperatively has heretofore been an awkward procedure. Polaroid photography in the privacy of the patient’s home has been advocated and used. l However, during surgical treatment under anesthesia there has not been any reliable technique for inducing erections. It has been true in our experience that reflex erections occurred usually when least desired by the urologist. We have devised a simple technique to reproduce an erection, both before and during surgery: a soft rubber tourniquet is applied to the base of the penis, and the corpora are filled by injection with heparinized saline. Office Technique When a patient is seen with a complaint of penile deformity from Peyronie’s disease or con-
genital curvature, his problem is documented photographically in the office (Fig. 1). We apply a tourniquet to the base, inject a bleb of lidocaine (Xylocaine) in the dorsal skin of the shaft of the penis, and plunge a 21-gauge scalp vein needle obliquely into one corpus cavernosum. Normal saline with added heparin (10 mg. or 1,000 units per 100 cc.) is slowly injected by hand pressure with a large syringe until a full erection is achieved, usually after 60 to 100 cc. in adults. The known communications between the corpora cavernosa usually make it possible to fill both corpora with the single needle. The patient is asked to confirm the accuracy of the erection reproduced and photographs are taken close up from several directions. The tourniquet and then the needle are removed, and finger pressure is maintained over the puncture site for five
FIGURE 1. Diagrammatic illustration of office technique, with Penrose drain tourniquet at base of penis and percutaneous injection of one corpus cavernosum. Inset shows one of several views (right lateral) of the deformity in patient with Pe yonie’s disease. Reproduction of the erection is perfectly accurate according to patient.
UROLo<:Y
I
OCTOBEH
1974
/ VOLUME
IV, NUMBEH
4
473
FIGURE 2. illustration of operating room technique. After placement of a patch of dermis to replace diseased plaque, a pair of needles are inserted directly into corpora and heparinized saline injected as before. In spite of leakage through suture line, enough turgor is achieved to confirm adequacy of repair. Technique is even more effective when corpora are watertight, as in confirming the elimination of chordee in epispadias repairs. inset shows postoperative rel sub in the patient shown in Figure 1, again by reproducing erection in office.
minutes. The patient is warned that some ecchymosis will result around the injection site. The absorbed heparin dose is of no consequence. Operating
Room Technique
During surgical treatment for chordee and hypospadias, Peyronie’s disease,2J or congenital curvature of the penis ,* it is our practice to circumcise the penile skin just proximal to the corona and dissect it back to expose the corpora. A tourniquet is then applied at the base, and a 19-gauge scalp vein needle is stuck into the body of one of the exposed corpora cavernosa. Heparinized saline may be injected repeatedly, and a full erection is reproduced before and after the repair to make sure it is just right (Fig. 2). In the cases of congenital curvature in which we intend to use the Nesbit technique, we find it useful to plicate Bucks fascia and the underlying tunica albuginea with Allis forceps in two or more spots and again reproduce the erection.* If a satisfactory straightening is noted, we know just how much fascia to excise, namely, the amount caught in the Allis clamps. The saline injection does, of course, require a reasonably watertight repair of Bucks fascia, but a little loss into the surgical field is of no consequence. If leakage is present, we prefer to insert two needles, one in each corpus cavernosum, to insure symmetric filling pressure and avoid factitious deformity due to unequal filling of the two corpora (Fig. 2).
474
There has been no significant complication from this technique. Initially, there was difficulty with subcutaneous extravasation of fluid when repeated intrasurgical punctures of the corpora were done through the skin. However, dissection of the skin away from the penile shaft and direct injection into the exposed corpora as described has prevented that problem. Summary A new technique is described for reproducing a full penile erection by injecting heparinized saline into a corpus cavernosum with a scalp vein needle. It is used in the office and during surgical procedures to permit photographic documentation of penile malformations and ascertain their complete repair.
225 West Dickinson Street San Diego, California 92103 (DR. GI’ITES) References POUTASSE,E.: Personal communication, 1971. PEARMAN,R. 0.: Treatment of organic impotence by implantation ofapenile prosthesis, J. Urol. 97: 716 (1967). HORTON, C. E., and DEVINE, C. J., JR.: Peyronie’s disease, Plast. Reconstr. Surg. 52: 503 (1973). NESBIT, R. M.: Congenital curvature of the phallus: report of three cases with description of corrective operation, J. Urol. 93: 230 (1965).
UROLOGY / OCTOBER 1974 / VOLUME IV, NUMBER4
TO INDUCE
PENILE ERECTION R. F. GITTES,
M.D.
A. P. MCLAUGHLIN,
III, M.D.
From the Division of Urology, Department of Surgery, University of California at San Diego, California
Documenting a penile deformity during erection preoperatively has heretofore been an awkward procedure. Polaroid photography in the privacy of the patient’s home has been advocated and used. l However, during surgical treatment under anesthesia there has not been any reliable technique for inducing erections. It has been true in our experience that reflex erections occurred usually when least desired by the urologist. We have devised a simple technique to reproduce an erection, both before and during surgery: a soft rubber tourniquet is applied to the base of the penis, and the corpora are filled by injection with heparinized saline. Office Technique When a patient is seen with a complaint of penile deformity from Peyronie’s disease or con-
genital curvature, his problem is documented photographically in the office (Fig. 1). We apply a tourniquet to the base, inject a bleb of lidocaine (Xylocaine) in the dorsal skin of the shaft of the penis, and plunge a 21-gauge scalp vein needle obliquely into one corpus cavernosum. Normal saline with added heparin (10 mg. or 1,000 units per 100 cc.) is slowly injected by hand pressure with a large syringe until a full erection is achieved, usually after 60 to 100 cc. in adults. The known communications between the corpora cavernosa usually make it possible to fill both corpora with the single needle. The patient is asked to confirm the accuracy of the erection reproduced and photographs are taken close up from several directions. The tourniquet and then the needle are removed, and finger pressure is maintained over the puncture site for five
FIGURE 1. Diagrammatic illustration of office technique, with Penrose drain tourniquet at base of penis and percutaneous injection of one corpus cavernosum. Inset shows one of several views (right lateral) of the deformity in patient with Pe yonie’s disease. Reproduction of the erection is perfectly accurate according to patient.
UROLo<:Y
I
OCTOBEH
1974
/ VOLUME
IV, NUMBEH
4
473
FIGURE 2. illustration of operating room technique. After placement of a patch of dermis to replace diseased plaque, a pair of needles are inserted directly into corpora and heparinized saline injected as before. In spite of leakage through suture line, enough turgor is achieved to confirm adequacy of repair. Technique is even more effective when corpora are watertight, as in confirming the elimination of chordee in epispadias repairs. inset shows postoperative rel sub in the patient shown in Figure 1, again by reproducing erection in office.
minutes. The patient is warned that some ecchymosis will result around the injection site. The absorbed heparin dose is of no consequence. Operating
Room Technique
During surgical treatment for chordee and hypospadias, Peyronie’s disease,2J or congenital curvature of the penis ,* it is our practice to circumcise the penile skin just proximal to the corona and dissect it back to expose the corpora. A tourniquet is then applied at the base, and a 19-gauge scalp vein needle is stuck into the body of one of the exposed corpora cavernosa. Heparinized saline may be injected repeatedly, and a full erection is reproduced before and after the repair to make sure it is just right (Fig. 2). In the cases of congenital curvature in which we intend to use the Nesbit technique, we find it useful to plicate Bucks fascia and the underlying tunica albuginea with Allis forceps in two or more spots and again reproduce the erection.* If a satisfactory straightening is noted, we know just how much fascia to excise, namely, the amount caught in the Allis clamps. The saline injection does, of course, require a reasonably watertight repair of Bucks fascia, but a little loss into the surgical field is of no consequence. If leakage is present, we prefer to insert two needles, one in each corpus cavernosum, to insure symmetric filling pressure and avoid factitious deformity due to unequal filling of the two corpora (Fig. 2).
474
There has been no significant complication from this technique. Initially, there was difficulty with subcutaneous extravasation of fluid when repeated intrasurgical punctures of the corpora were done through the skin. However, dissection of the skin away from the penile shaft and direct injection into the exposed corpora as described has prevented that problem. Summary A new technique is described for reproducing a full penile erection by injecting heparinized saline into a corpus cavernosum with a scalp vein needle. It is used in the office and during surgical procedures to permit photographic documentation of penile malformations and ascertain their complete repair.
225 West Dickinson Street San Diego, California 92103 (DR. GI’ITES) References POUTASSE,E.: Personal communication, 1971. PEARMAN,R. 0.: Treatment of organic impotence by implantation ofapenile prosthesis, J. Urol. 97: 716 (1967). HORTON, C. E., and DEVINE, C. J., JR.: Peyronie’s disease, Plast. Reconstr. Surg. 52: 503 (1973). NESBIT, R. M.: Congenital curvature of the phallus: report of three cases with description of corrective operation, J. Urol. 93: 230 (1965).
UROLOGY / OCTOBER 1974 / VOLUME IV, NUMBER4