Bulbar urethrocavernous fistula in setting of inflatable penile prosthesis: a case report

BACKGROUND: Urethral injury or erosion of an inflatable penile prosthetic (IPP) cylinder is a rare complication of IPP placement. It can present with varying symptoms and management can be difficult with risk for future complications. We present a patient with an eroded IPP who developed a secondary contralateral urethrocavernous fistula requiring repeat urethroplasty. We also describe the literature surrounding these complications and strategies to prevent them. CASE PRESENTATION: A 69-year-old man with poorly controlled diabetes presented to our clinic with 6 months of intermittent white urethral discharge first noted after IPP removal and replacement by an outside urologist for device malfunction. Office cystoscopy revealed an eroded right-sided prosthetic cylinder in the bulbar urethra. The patient was taken to the operating room for IPP explantation with closure of right corporal defect, left sided malleable prosthesis placement, and primary excision with anastomosis of his bulbar urethra. A catheter was left in place for two weeks postoperatively, at which time a peri-catheter retrograde urethrogram was performed which showed no evidence of contrast extravasation and his catheter was subsequently removed. Several months later, he presented with recurrent urethral discharge without evidence of recurrent erosion on cystoscopy with development of scrotal abscesses following office cystoscopy, concerning for an unidentified urethral defect. He returned to the operating room for scrotal exploration and was noted on cystoscopy to have a pinpoint fistula between his left corporal body and his bulbar urethra. He underwent left sided malleable prosthetic explant, and non-transecting bulbar urethroplasty. Peri-catheter retrograde urethrogram two weeks later showed no contrast extravasation and he has had no recurrence of urethral discharge or scrotal abscesses since. CONCLUSIONS: Urethral erosion and urethrocavernous fistula formation are rare complications of penile prosthesis placement. Risks are elevated in patients with corporal fibrosis, diabetes, those undergoing penile implant revision surgery, and those requiring prolonged urethral catheterization.