A 75-year-old diabetic male presented to urology clinic complaining of mechanical malfunctioning of 2-piece penile prosthesis which was inserted on 2007. Patient developed colon cancer and underwent laparoscopic resection of colon in 2015 followed by chemotherapy for one year. He was considered in remission, and there was no contraindication for penile prosthesis exchange after oncologic clearance was granted. Standard preparation for penile prosthesis exchange was done including full history, clinical examination including inguinal region to exclude inguinal hernia, and local examination for external genitalia looking for penile and scrotal skin to exclude any skin infections, boil, rash or open wound. Removal of the 2-piece prosthesis and substitution of a 3-piece inflatable prosthesis were performed with antiseptic solution washout of the implant spaces. The patient had smooth postoperative period and discharged on the first postoperative day on broad spectrum antibiotics after partial deflation of penile prosthesis and instructed not to inflate the device for 4 weeks and to resume sexual intercourse 6 weeks later.
The patient’s postoperative follow-up was smooth with no complications, and the wound healed uneventfully. At 4 weeks, he was trained in prosthesis operation and cleared for use of the prosthesis.
After an additional 5 months of time, the patient presented to emergency department complaining of painful scrotal swelling and inability to inflate prosthesis due to tenderness with mild dysuria without history of fever. Physical examination found normal vital signs, and local examination showed scrotal wall thickening, redness, and increased warmth. Notably, the pump was tethered to the most dependent area of scrotum (Figs. 1 and 2).
The patient urgently admitted to the urology ward for assessment of possible penile prosthesis infection, and laboratory and imaging studies were requested. Parenteral broad spectrum antibiotics were given. Laboratory values were normal apart from high C-reactive protein 99 (WBC 8.8, ESR 61, serum creatinine 96Mmol/l, HbA1c 8.1%, urine microscopy showed leukocytes 10 with no growth urine culture).
Scrotal US demonstrated that approximately 4.4 × 2.4 × 2.1 cm sized collection with dense echoes is seen at the proximal aspect of scrotal portion of the prosthesis. Collection is seen to extend over the prosthesis to distal aspect of the scrotum with a maximum thickness of 10 mm. No evidence of collection was seen in penis. Diffuse scrotal wall edema is seen. Both testis and epididymis appear normal. Minimal free fluid is seen in both tunica vaginalis sacs (Figs. 3 and 4).
The patient did not improve clinically after 4 days of antibiotic therapy. He was still complaining of scrotal pain, tenderness, and swelling and, furthermore, increasing trend of C-reactive protein level but afebrile throughout.
Pelvic and penis MRI demonstrated that significant soft tissue enhancement was seen in scrotal soft tissue, tunica albuginea, around the pump and prosthesis which is likely representing ongoing infective process (Fig. 5).
The patient had not mentioned that he had contracted brucellosis infection during a trip to Saudi Arabia one and half months ago. It was reported later when his family provided documentation. Blood sample for brucellosis titers was taken. At the time of admission, patient had received incomplete treatment for brucellosis. With all these new findings beside that imaging was not convincing of an abscess formation and after consulting infectious disease team, the patient was considered as a brucellosis relapse and treated accordingly with anti-brucellosis antibiotics (Rifampicin + Tetracycline).
After 48 h of starting brucellosis-specific antibiotics, there was a dramatic clinical improvement in pain and complete resolution of scrotal swelling. After 96 h, the patient was discharged to home on oral antibiotics for 6 weeks with outpatient follow-up in urology and infectious disease clinics. The patient is presently infection free 1 year later. Recent control scrotal US showed no more fluid collection noticed, normal both testes and epididymis, pump and reservoir seen without radiological picture of inflammation around them. The patient and family were happy with the management approach which preventing him from surgical intervention with related risk of anesthesia at this age, in addition to financial sequelae of penile prosthesis removal and implantation later on once, and he wrote official appreciation letter and compliment feedback through patient and visitor service center.