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Salmonella Infection of a Penile Prosthesis
1487
Salmonella Infection of a Penile Prosthesis Justin Sausville, MD,* Gopal Gupta, MD,* Graeme Forrest, MD,† and Toby Chai, MD* *Division of Urology, Department of Surgery and †Division of Infectious Diseases, Department of Medicine, University of Maryland Medical Center, Baltimore, MD, USA DOI: 10.1111/j.1743-6109.2008.01013.x
ABSTRACT
Introduction. Patients with erectile dysfunction (ED) who have failed oral or intracavernosal erectogenic therapy may benefit from inflatable penile prosthesis (IPP) placement. Such individuals commonly include patients with diabetes mellitus or chronic renal insufficiency. Complications of IPP placement include erosion and infection. Most often, infection of IPPs involves skin flora that are hypothesized to be introduced at the time of device placement and persist as a biofilm, causing clinical infection as a result of failure of containment by host defense mechanisms. Aim. In this report, we describe a renal transplant patient with a Salmonella infection of an IPP following a diarrheal illness. To our knowledge, this organism has not been implicated in penile prosthesis infection. Main Outcome Measures. The clinical course of, and microbiological data pertinent to, this patient are summarized. Additionally, a limited literature review was undertaken and is here summarized. Methods. Retrospective review of medical record documentation. Results. This patient was found to have a Salmonella infection of his IPP with ensuing device erosion. Following urgent device removal and culture-specific antibiotic therapy, he was discharged from the hospital at his baseline functional status and renal function. Conclusions. This is the first report of which we are aware in which Salmonella penile prosthesis infection is described. While this man’s immunocompromised status may have made him more vulnerable to device infection, the literature is generally supportive of IPP placement in the transplant population when other modes of ED treatment have failed. Moreover, we postulate a hematogenous mechanism for device seeding in this patient. Sausville J, Gupta G, Forrest G, and Chai T. Salmonella infection of a penile prosthesis. J Sex Med 2009;6:1487–1490. Key Words. Salmonella; Penile Prosthesis; Renal Transplant; Erectile Dysfunction
Introduction
almonella spp. are known for their ability to infect the native abdominal aorta as well as valvular prostheses [1,2] and have been implicated in infections of orthopedic prostheses [3]. They are also causative agents of some primary psoas, liver, and retropharyngeal abscesses [4–6]. We now present a case of a Salmonella enterica serovar Litchfield infection of an inflatable penile prosthesis (IPP) associated with a recent diarrheal illness.
S
Case Presentation
A 73-year-old African American man with past medical history of diabetes and hypertension © 2008 International Society for Sexual Medicine
underwent a radical prostatectomy in 1994 for prostatic adenocarcinoma. Subsequently, he developed end stage renal disease and received a cadaveric renal transplant in 2001 without complications. His immunosuppression regimen consisted of mycophenolate mofetil, tacrolimus, and prednisone. The patient had erectile dysfunction refractory to medical therapy and in 2006 he underwent a successful implantation of a three-piece IPP, with the reservoir placed in the space of Retzius, paired cavernosal cylinders, and a pump placed in a subdartos pouch. In November 2007, the patient was admitted to an outside hospital with a 1 week history of gross hematuria and decreasing urine output and was J Sex Med 2009;6:1487–1490
1488 found to be in acute renal failure with a creatinine of 11.6 mg/dL. At the outside hospital, a Foley catheter was placed. A urine culture grew >105 CFU/mL pan-sensitive Salmonella spp. He was given intravenous ampicillin and transferred to our institution. On transfer, the patient complained of dysuria in addition to symptoms already mentioned. He described watery diarrhea associated with nausea and vomiting in August 2007. Stool cultures had been sent during that episode; they were negative, as were fecal leukocytes. He also complained of diffuse lower abdominal pain. He denied any foreign travel; he has a dog, and is a retired automobile mechanic. He acknowledged a penchant for eating undercooked eggs. Physical examination revealed an afebrile and hemodynamically stable older man in no distress. His abdomen was soft and nontender. Genitourinary examination showed a Foley catheter draining dark yellow urine. He was diffusely tender over his entire scrotum, as well as along the lateral aspects of his penis. He was oriented to person but not place or time. Laboratory studies included a creatinine of 9.9 mg/dL and a white blood cell count of 10.3 K/mcL. A scrotal ultrasound was performed demonstrating echogenic fluid surrounding the pump portion of the IPP. The patient was taken urgently to the operating room for IPP removal. Findings at operation included erosion of the distal end of the left cavernosal cylinder into the penile urethra (Figure 1). Additionally, the cylinders, pump, and associated tubing were surrounded by extensive grossly purulent fluid. The IPP was removed in its entirety, and the spaces it had occupied were copiously pulse-
Figure 1 Intraoperative photograph from this case showing cylinder from IPP eroding into penile urethra (T. Chai, personal communication).
J Sex Med 2009;6:1487–1490
Sausville et al. lavaged. The wound was primarily closed, and a drain was left. A Foley catheter was placed. Blood and urine cultures were negative. The abscess fluid grew Salmonella enterica serovar Litchfield sensitive to all antibiotics tested. The patient’s ensuing hospital course was notable for hemodialysis for 1 week as well as respiratory distress requiring mechanical ventilation and an upper extremity deep venous thrombosis. The scrotal drain was removed on postoperative day 3, and the wound healed well. The Foley catheter was removed on postoperative day 12. His renal function improved to baseline, and he was discharged home on ciprofloxacin. Discussion
We present a case of Salmonella infection of an IPP in an immunocompromised individual with device erosion. IPPs are widely accepted for treatment of ED for which medical management has failed. Prosthesis infection necessitates device excision; its incidence is estimated at 1–3% for a first implant [7]. Typical manifestations include edema, fever, and erythema overlying IPP components or possibly device erosion, although late infections may run a subacute course characterized by persistent pain [7]. A variety of organisms have been implicated, notably Staphylococcus epidermidis, cultured in up to 56% of explanted devices [8]. To our knowledge, there is no description in the literature of a penile prosthesis infection by Salmonella. Evidence suggests that most infective organisms are introduced at the time of implantation and persist via biofilm formation [9]. This finding has led to the development of antibiotic-coated IPPs that may reduce the risk of infection [10]. Hematogenous seeding of penile prostheses has been regarded as a secondary mechanism of infection. Carson and Robertson reported six cases of prosthesis infections in which distant infective events, blood cultures, and prosthesis cultures coincided [11]. A subsequent study in rats failed to demonstrate colonization of prosthesis material with distant inoculation of S. epidermidis [12], though the offending organisms in Carson’s original report were others in five of six cases. We postulate that this patient’s IPP was seeded with Salmonella during an episode of bacteremia at the time of his diarrheal illness. Alternatively, the organism could have been sequestered in his reticuloendothelial system [13] and infected the
1489
Salmonella Infection of Penile Prosthesis IPP during a subsequent episode of bacteremia. After infection of the prosthesis, erosion led to the clinical manifestation of gross hematuria. IPP erosion has been reported in the setting of urethral catheterization [14]. However, we feel that erosion in this patient was related to his device infection, as he had hematuria prior to catheterization and he had no recent history of urethral instrumentation. A general question raised by this report pertains to the appropriateness of IPP placement in the organ transplant population, given these patients’ immunosuppression. Cuellar and Sklar reported a series of 46 prosthesis implantations in kidney and pancreas recipients. They found no increased incidence of infection, but there were significantly more mechanical complications, which were felt to be due to repeated retroperitoneal exploration with ensuing compromise of the reservoir [15]. The series of Lasaponara et al. included five transplant patients who received IPPs without complications [15]. Conversely, there is at least one report of Fournier’s gangrene in a transplant patient with an IPP [16]. Barry proposes IPPs as third line treatment after failure of oral and injected erectogenics. This approach is concordant with Lasaponara et al’s findings that the majority of patients responded to oral or injected therapy [16]. Barry further specifies criteria for consideration of IPP placement that include stable allograft function, use of the least immunosuppression that is compatible with allograft protection, and use of a prosthesis without an intra-abdominal reservoir component [17]. Moreover, as Sadeghi-Najad notes, stringent perioperative and intraoperative measures to prevent device infection are generally regarded as indispensable [18]. Following these principles may result in better outcomes, but penile prosthesis implantation will never be an inconsequential procedure in the challenging renal transplant population. Corresponding Author: Justin Sausville, MD, University of Maryland Medical Center, Division of Urology, 22 S. Greene St., Baltimore MD 21201, USA. Tel: 410328-5570; Fax: 410-328-1716; E-mail: jsausville@ smail.umaryland.edu Conflict of Interest: None declared
Statement of Authorship
Category 1 (a) Conception and Design Justin Sausville; Gopal Gupta; Toby Chai
(b) Acquisition of Data Justin Sausville; Gopal Gupta; Toby Chai (c) Analysis and Interpretation of Data Justin Sausville; Gopal Gupta; Toby Chai; Graeme Forrest
Category 2 (a) Drafting the Article Justin Sausville; Gopal Gupta (b) Revising It for Intellectual Content Justin Sausville; Gopal Gupta; Toby Chai
Category 3 (a) Final Approval of the Completed Article Justin Sausville; Gopal Gupta; Toby Chai; Graeme Forrest
References
1 Katz SG, Andros G, Kohl RD. Salmonella infections of the abdominal aorta. Surg Gynecol Obstet 1992;175:102–6. 2 Gönen C, Topeli A, Cetinkaya YS. Prosthetic valve endocarditis caused by Salmonella enteritidis. Scand J Infect Dis 2004;36:72–5. 3 Day LJ, Qayuum QJ, Kauffman CA. Salmonella prosthetic joint septic arthritis. Clin Microbiol Infect 2002;8:427–30. 4 Hsu RB, Lin FY. Psoas abscess in patients with an infected aortic aneurysm. J Vasc Surg 2007;2:230– 35. 5 Chow YP, Changchien CS, Chiu KW, Kuo CM, Kuo FY, Kuo CH. Salmonellosis with liver abscess mimicking hepatocellular carcinoma in a diabetic and cirrhotic patient: case report and review of the literature. Liver Int 2006;4:498–501. 6 Su FH, Chen PT, Chiu YC, Chen JW. Salmonella retropharyngeal abscess in a child: case report and literature review. Padiatr Infect Dis J 2003;22:833– 6. 7 Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds.) Walsh-Campbell Urology, 9th edition. Philadelphia: Saunders-Elsevier; 2007:788– 901. 8 Carson CC. Diagnosis, treatment, and prevention of penile prosthesis infection. Int J Impot Res 2003;15:S139–46. 9 Silverstein A, Donatucci CF. Bacterial biofilms and implantable prosthetic devices. Int J Impot Res 2003;15:S150–4. 10 Wilson SK, et al. Infection reduction using antibiotic-coated inflatable penile prostheses. Urology 2007;70:337–40. 11 Carson CC, Robertson CN. Late hematogenous infections of penile prostheses. J Urol 1988. 12 Culha M, Acar O, Mutlu B, Ozdemar S, Mutlu N, Koemuer O, Goekalp A. Prosthesis culture 6 J Sex Med 2009;6:1487–1490
1490 months after implantation and the effect of haematogenous seeding in a rat model. Int J Impot Res 2004;16:231–4. 13 Kotton CN, Hohmann EL. Pathogenesis of Salmonella gastroenteritis. Available at: http://www.utdol. com/utd/content/topic.do?topicKey=gi_infec/4758 (accessed January 21, 2008). 14 Hisasue S, Sato Y, Horita H, Adachi H, Suzuki N, Kato R, Suzuki K, Itoh N, Tsukamoto T. Erosion of a penile prosthesis due to an indwelling urethral catheter as a late complication. Int J Urol 2002; 9:525–7.
J Sex Med 2009;6:1487–1490
Sausville et al. 15 Cuellar DC, Sklar GN. Penile prosthesis in the organ transplant recipient. Urology 2001;57:138–41. 16 Lasaponara F, Paradiso M, Milan MG, Morabito F, Sedigh O, Graziano ME, Abbona A, Piccoli GB, Rossetti M, Mezza E, Ferrando U. Erectile dysfunction after kidney transplantation: Our 22 years of experience. Trans Proc 2004;36:502–4. 17 Barry JM. Treating erectile dysfunction in renal transplant recipients. Drugs 2007;67:975–83. 18 Sadeghi-Nejad H. Penile prosthesis surgery: A review of prosthetic devices and associated complications. J Sex Med 2007;4:296–309.
Salmonella Infection of a Penile Prosthesis Justin Sausville, MD,* Gopal Gupta, MD,* Graeme Forrest, MD,† and Toby Chai, MD* *Division of Urology, Department of Surgery and †Division of Infectious Diseases, Department of Medicine, University of Maryland Medical Center, Baltimore, MD, USA DOI: 10.1111/j.1743-6109.2008.01013.x
ABSTRACT
Introduction. Patients with erectile dysfunction (ED) who have failed oral or intracavernosal erectogenic therapy may benefit from inflatable penile prosthesis (IPP) placement. Such individuals commonly include patients with diabetes mellitus or chronic renal insufficiency. Complications of IPP placement include erosion and infection. Most often, infection of IPPs involves skin flora that are hypothesized to be introduced at the time of device placement and persist as a biofilm, causing clinical infection as a result of failure of containment by host defense mechanisms. Aim. In this report, we describe a renal transplant patient with a Salmonella infection of an IPP following a diarrheal illness. To our knowledge, this organism has not been implicated in penile prosthesis infection. Main Outcome Measures. The clinical course of, and microbiological data pertinent to, this patient are summarized. Additionally, a limited literature review was undertaken and is here summarized. Methods. Retrospective review of medical record documentation. Results. This patient was found to have a Salmonella infection of his IPP with ensuing device erosion. Following urgent device removal and culture-specific antibiotic therapy, he was discharged from the hospital at his baseline functional status and renal function. Conclusions. This is the first report of which we are aware in which Salmonella penile prosthesis infection is described. While this man’s immunocompromised status may have made him more vulnerable to device infection, the literature is generally supportive of IPP placement in the transplant population when other modes of ED treatment have failed. Moreover, we postulate a hematogenous mechanism for device seeding in this patient. Sausville J, Gupta G, Forrest G, and Chai T. Salmonella infection of a penile prosthesis. J Sex Med 2009;6:1487–1490. Key Words. Salmonella; Penile Prosthesis; Renal Transplant; Erectile Dysfunction
Introduction
almonella spp. are known for their ability to infect the native abdominal aorta as well as valvular prostheses [1,2] and have been implicated in infections of orthopedic prostheses [3]. They are also causative agents of some primary psoas, liver, and retropharyngeal abscesses [4–6]. We now present a case of a Salmonella enterica serovar Litchfield infection of an inflatable penile prosthesis (IPP) associated with a recent diarrheal illness.
S
Case Presentation
A 73-year-old African American man with past medical history of diabetes and hypertension © 2008 International Society for Sexual Medicine
underwent a radical prostatectomy in 1994 for prostatic adenocarcinoma. Subsequently, he developed end stage renal disease and received a cadaveric renal transplant in 2001 without complications. His immunosuppression regimen consisted of mycophenolate mofetil, tacrolimus, and prednisone. The patient had erectile dysfunction refractory to medical therapy and in 2006 he underwent a successful implantation of a three-piece IPP, with the reservoir placed in the space of Retzius, paired cavernosal cylinders, and a pump placed in a subdartos pouch. In November 2007, the patient was admitted to an outside hospital with a 1 week history of gross hematuria and decreasing urine output and was J Sex Med 2009;6:1487–1490
1488 found to be in acute renal failure with a creatinine of 11.6 mg/dL. At the outside hospital, a Foley catheter was placed. A urine culture grew >105 CFU/mL pan-sensitive Salmonella spp. He was given intravenous ampicillin and transferred to our institution. On transfer, the patient complained of dysuria in addition to symptoms already mentioned. He described watery diarrhea associated with nausea and vomiting in August 2007. Stool cultures had been sent during that episode; they were negative, as were fecal leukocytes. He also complained of diffuse lower abdominal pain. He denied any foreign travel; he has a dog, and is a retired automobile mechanic. He acknowledged a penchant for eating undercooked eggs. Physical examination revealed an afebrile and hemodynamically stable older man in no distress. His abdomen was soft and nontender. Genitourinary examination showed a Foley catheter draining dark yellow urine. He was diffusely tender over his entire scrotum, as well as along the lateral aspects of his penis. He was oriented to person but not place or time. Laboratory studies included a creatinine of 9.9 mg/dL and a white blood cell count of 10.3 K/mcL. A scrotal ultrasound was performed demonstrating echogenic fluid surrounding the pump portion of the IPP. The patient was taken urgently to the operating room for IPP removal. Findings at operation included erosion of the distal end of the left cavernosal cylinder into the penile urethra (Figure 1). Additionally, the cylinders, pump, and associated tubing were surrounded by extensive grossly purulent fluid. The IPP was removed in its entirety, and the spaces it had occupied were copiously pulse-
Figure 1 Intraoperative photograph from this case showing cylinder from IPP eroding into penile urethra (T. Chai, personal communication).
J Sex Med 2009;6:1487–1490
Sausville et al. lavaged. The wound was primarily closed, and a drain was left. A Foley catheter was placed. Blood and urine cultures were negative. The abscess fluid grew Salmonella enterica serovar Litchfield sensitive to all antibiotics tested. The patient’s ensuing hospital course was notable for hemodialysis for 1 week as well as respiratory distress requiring mechanical ventilation and an upper extremity deep venous thrombosis. The scrotal drain was removed on postoperative day 3, and the wound healed well. The Foley catheter was removed on postoperative day 12. His renal function improved to baseline, and he was discharged home on ciprofloxacin. Discussion
We present a case of Salmonella infection of an IPP in an immunocompromised individual with device erosion. IPPs are widely accepted for treatment of ED for which medical management has failed. Prosthesis infection necessitates device excision; its incidence is estimated at 1–3% for a first implant [7]. Typical manifestations include edema, fever, and erythema overlying IPP components or possibly device erosion, although late infections may run a subacute course characterized by persistent pain [7]. A variety of organisms have been implicated, notably Staphylococcus epidermidis, cultured in up to 56% of explanted devices [8]. To our knowledge, there is no description in the literature of a penile prosthesis infection by Salmonella. Evidence suggests that most infective organisms are introduced at the time of implantation and persist via biofilm formation [9]. This finding has led to the development of antibiotic-coated IPPs that may reduce the risk of infection [10]. Hematogenous seeding of penile prostheses has been regarded as a secondary mechanism of infection. Carson and Robertson reported six cases of prosthesis infections in which distant infective events, blood cultures, and prosthesis cultures coincided [11]. A subsequent study in rats failed to demonstrate colonization of prosthesis material with distant inoculation of S. epidermidis [12], though the offending organisms in Carson’s original report were others in five of six cases. We postulate that this patient’s IPP was seeded with Salmonella during an episode of bacteremia at the time of his diarrheal illness. Alternatively, the organism could have been sequestered in his reticuloendothelial system [13] and infected the
1489
Salmonella Infection of Penile Prosthesis IPP during a subsequent episode of bacteremia. After infection of the prosthesis, erosion led to the clinical manifestation of gross hematuria. IPP erosion has been reported in the setting of urethral catheterization [14]. However, we feel that erosion in this patient was related to his device infection, as he had hematuria prior to catheterization and he had no recent history of urethral instrumentation. A general question raised by this report pertains to the appropriateness of IPP placement in the organ transplant population, given these patients’ immunosuppression. Cuellar and Sklar reported a series of 46 prosthesis implantations in kidney and pancreas recipients. They found no increased incidence of infection, but there were significantly more mechanical complications, which were felt to be due to repeated retroperitoneal exploration with ensuing compromise of the reservoir [15]. The series of Lasaponara et al. included five transplant patients who received IPPs without complications [15]. Conversely, there is at least one report of Fournier’s gangrene in a transplant patient with an IPP [16]. Barry proposes IPPs as third line treatment after failure of oral and injected erectogenics. This approach is concordant with Lasaponara et al’s findings that the majority of patients responded to oral or injected therapy [16]. Barry further specifies criteria for consideration of IPP placement that include stable allograft function, use of the least immunosuppression that is compatible with allograft protection, and use of a prosthesis without an intra-abdominal reservoir component [17]. Moreover, as Sadeghi-Najad notes, stringent perioperative and intraoperative measures to prevent device infection are generally regarded as indispensable [18]. Following these principles may result in better outcomes, but penile prosthesis implantation will never be an inconsequential procedure in the challenging renal transplant population. Corresponding Author: Justin Sausville, MD, University of Maryland Medical Center, Division of Urology, 22 S. Greene St., Baltimore MD 21201, USA. Tel: 410328-5570; Fax: 410-328-1716; E-mail: jsausville@ smail.umaryland.edu Conflict of Interest: None declared
Statement of Authorship
Category 1 (a) Conception and Design Justin Sausville; Gopal Gupta; Toby Chai
(b) Acquisition of Data Justin Sausville; Gopal Gupta; Toby Chai (c) Analysis and Interpretation of Data Justin Sausville; Gopal Gupta; Toby Chai; Graeme Forrest
Category 2 (a) Drafting the Article Justin Sausville; Gopal Gupta (b) Revising It for Intellectual Content Justin Sausville; Gopal Gupta; Toby Chai
Category 3 (a) Final Approval of the Completed Article Justin Sausville; Gopal Gupta; Toby Chai; Graeme Forrest
References
1 Katz SG, Andros G, Kohl RD. Salmonella infections of the abdominal aorta. Surg Gynecol Obstet 1992;175:102–6. 2 Gönen C, Topeli A, Cetinkaya YS. Prosthetic valve endocarditis caused by Salmonella enteritidis. Scand J Infect Dis 2004;36:72–5. 3 Day LJ, Qayuum QJ, Kauffman CA. Salmonella prosthetic joint septic arthritis. Clin Microbiol Infect 2002;8:427–30. 4 Hsu RB, Lin FY. Psoas abscess in patients with an infected aortic aneurysm. J Vasc Surg 2007;2:230– 35. 5 Chow YP, Changchien CS, Chiu KW, Kuo CM, Kuo FY, Kuo CH. Salmonellosis with liver abscess mimicking hepatocellular carcinoma in a diabetic and cirrhotic patient: case report and review of the literature. Liver Int 2006;4:498–501. 6 Su FH, Chen PT, Chiu YC, Chen JW. Salmonella retropharyngeal abscess in a child: case report and literature review. Padiatr Infect Dis J 2003;22:833– 6. 7 Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds.) Walsh-Campbell Urology, 9th edition. Philadelphia: Saunders-Elsevier; 2007:788– 901. 8 Carson CC. Diagnosis, treatment, and prevention of penile prosthesis infection. Int J Impot Res 2003;15:S139–46. 9 Silverstein A, Donatucci CF. Bacterial biofilms and implantable prosthetic devices. Int J Impot Res 2003;15:S150–4. 10 Wilson SK, et al. Infection reduction using antibiotic-coated inflatable penile prostheses. Urology 2007;70:337–40. 11 Carson CC, Robertson CN. Late hematogenous infections of penile prostheses. J Urol 1988. 12 Culha M, Acar O, Mutlu B, Ozdemar S, Mutlu N, Koemuer O, Goekalp A. Prosthesis culture 6 J Sex Med 2009;6:1487–1490
1490 months after implantation and the effect of haematogenous seeding in a rat model. Int J Impot Res 2004;16:231–4. 13 Kotton CN, Hohmann EL. Pathogenesis of Salmonella gastroenteritis. Available at: http://www.utdol. com/utd/content/topic.do?topicKey=gi_infec/4758 (accessed January 21, 2008). 14 Hisasue S, Sato Y, Horita H, Adachi H, Suzuki N, Kato R, Suzuki K, Itoh N, Tsukamoto T. Erosion of a penile prosthesis due to an indwelling urethral catheter as a late complication. Int J Urol 2002; 9:525–7.
J Sex Med 2009;6:1487–1490
Sausville et al. 15 Cuellar DC, Sklar GN. Penile prosthesis in the organ transplant recipient. Urology 2001;57:138–41. 16 Lasaponara F, Paradiso M, Milan MG, Morabito F, Sedigh O, Graziano ME, Abbona A, Piccoli GB, Rossetti M, Mezza E, Ferrando U. Erectile dysfunction after kidney transplantation: Our 22 years of experience. Trans Proc 2004;36:502–4. 17 Barry JM. Treating erectile dysfunction in renal transplant recipients. Drugs 2007;67:975–83. 18 Sadeghi-Nejad H. Penile prosthesis surgery: A review of prosthetic devices and associated complications. J Sex Med 2007;4:296–309.