Caverject Intra-cavernosal Injections for Erectile Dysfunction

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Prostaglandin Injections:

  • ED where medications have failed
  • You’re not keen on the Vacurect pump
  • Not keen on a penile implant

No if you are not scared of needles, this may be the way to go.

Caverject Impulse

Male Anatomy

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Male anatomy

16 DOT ‘Nesbitt’ Plication

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Correction of penile chordee / curvature.

Why is it done?

  • To treat an acquired deviation of an erect penis.
  • Usually occurs in males 55-65 years of age.
  • Can be associated with previous penile trauma, usually no associated history.
  • A dorsal (up) curvature is more common than a ventral (down) one. Can also deviate to the side.
  • Pain is usually the presenting symptom with a gradually worsening curvature.
  • The curvature may be so bad that penetration becomes impossible.
  • Associated with the connective tissue disorder: Dupuytren’s Contracture, which is an auto-immune disease.
  • Worse cases may require a penile prosthesis.

Pre-requirements

  • An informed consent is required from the patient/ parents.
  • Patients are informed that this may shorten the penis to the length of the shorter side of the penis, usually 2-3 cm.
  • In patients who wish to preserve penile length, a lengthening technique using buccal mucosa may be indicated and will be referred to a colleague.
  • Patients may not eat or drink from 6-8 hours prior to surgery according to age.
  • Any anti-coagulants such as Warfarin or Aspirin must be stopped 7 days prior to surgery. Clexane injections may be substituted.
  • Be prepared for an overnight stay.

How is it done?

  • This procedure is done under general anesthetic.
  • Supine position.
  • The foreskin is loosened proximal to the glans with a circumferential incision and the whole penile skin is retracted to the base of the penis.
  • An artificial erection will be induced by injecting a sterile saline solution into the penile corpora cavernosa with a tourniquet around the base.
  • Non-dissolvable sutures will be placed on the sides opposite to the diseased areas in an attempt to pull the erect penis into a straight alignment.
  • Occasionally a circumcision may result due to complications with this technique, yet foreskin preservation is attempted.
  • If there is a dorsal curvature, ventral sutures are laced and the penis pulled in upright position, therefore sutures are always placed on the opposite site avoiding vital structures such as.
  • An indwelling catheter will be inserted until you are awake.
  • A dressing is then applied, which should be removed after 72 hours.
  • A local anesthetic is injected at the base of the penis as a penile block thus giving post-operative pain relief for the next 4-6 hours.

What to expect after the procedure?

  • Any anesthetic has its risks, and the anesthetist will explain such risks.
  • Bleeding is a common complication.
  • A hematoma (blood collection under the skin) may form and needs to be reviewed by Dr Schoeman as soon as possible. Bruising is normal.
  • Sutures may tear loose with vigorous use of erect penis, and the procedure may then require revision.
  • An infection of the wound may occur and requires immediate attention.
  • Necrosis of the foreskin and some penile skin can occur in rare circumstances. This may require skin-grafting.
  • DANGER SIGNS: A wound that swells immediately, fever, and puss. Contact Dr Schoeman or the hospital immediately as this occurs in up to 15–20% of all cases.

What next?

  • Dressings should be kept dry for the initial 72 hours after surgery and soaked off in a bath thereafter.
  • The dressing may sometimes adhere to the wound causing slight bleeding on removal. Don’t panic, the bleeding will stop.
  • The catheter will be removed as soon as you are awake, or if there are concerns, the following morning.
  • On discharge, a prescription may be issued for patients to collect.
  • Patients should schedule a follow-up appointment with Dr Schoeman 2 weeks after the procedure.
  • There will be signs of bruising for at least 10 days.
  • Refrain from using your erect penis for 6 weeks.
  • The suture-line will be hard and indurated for at least 8-10 weeks.
  • Sick leave will be granted for 10 days.
  • Please direct all further queries to Dr Schoeman’s rooms.
  • PLEASE CONTACT THE HOSPITAL DIRECTLY WITH ANY POST-OPERATIVE CONCERNS AND RETURN TO THE HOSPITAL IMMEDIATELY SHOULD THERE BE ANY SIGNS OF SEPSIS.

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Wes 16 Dot Nesbitt Plication

Cauterization of Penile Condylomata

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Fulguration of penile condyloma, with penile block

Why is it done?

  • One of the non-medical treatment options for condylomas (genital warts)..

How is it done?

  • This procedure is done under local or general anaesthetic.
  • Supine position.
  • The foreskin may be the only affected area and therefore a circumcision is done.
  • Otherwise, the affected area is exposed and cleaned.
  • The affected lesions are cauterized, including the root of the wart.
  • Due to charring, and good hemostasis, no sutures are required.
  • Hemostatic dressings are placed.
  • Specimen is sent to a histopathologist.
  • An indwelling catheter may be inserted if the biopsy area involves the meatus of your urethra.
  • A dressing is then applied, which should be removed after 72 hours.
  • A local anesthetic is injected at the base of the penis as a penile block thus giving post-operative pain relief for the next 4-6 hours.

What to expect after the procedure?

  • Any anesthetic has its risks, and the anesthetist will explain such risks.
  • Bleeding is an uncommon complication.
  • Eschar may loosen with vigorous use of erect penis and could lead to bleeding.
  • An infection of the wound may occur and requires immediate attention.
  • DANGER SIGNS: A wound that swells immediately, fever, and puss. Contact Dr Schoeman or the hospital immediately as this occurs in up to 15–20% of all cases.

What next?

  • Dressings should be kept dry for the initial 72 hours after surgery and soaked off in a bath thereafter.
  • The dressing may sometimes adhere to the wound causing slight bleeding on removal. Don’t panic, the bleeding will stop.
  • The catheter will be removed as soon as you are awake, or if there are concerns, the following morning.
  • Patients should schedule a follow-up appointment with Dr Schoeman 4-6 weeks after the procedure.
  • There will be signs of bruising for at least 10 days.
  • Refrain from using your erect penis for 6 weeks.
  • Sick leave will be granted for a few days.
  • Please direct all further queries to Dr Schoeman’s rooms.
  • PLEASE CONTACT THE HOSPITAL DIRECTLY WITH ANY POST-OPERATIVE CONCERNS AND RETURN TO THE HOSPITAL IMMEDIATELY SHOULD THERE BE ANY SIGNS OF SEPSIS.

 

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Wes Cauterization of Penile Condylomata

Caverject Intra-Cavernosal Injections

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Intra cavernous injections for erectile dysfunction, demonstrating and teaching self-administration.

Why is it done?

    • A treatment option for erectile dysfunction.
    • Usually when oral techniques have failed ie Viagra, Levitra and Cialis.
    • Or where the patient wishes to skip the oral phase for something more effective.
    • ED can occur from the age of 40.
    • Risk factors:
      • Older.
      • Overweight.
      • Diabetic,
      • Hypertensive,
      • Cardiac issues.
    • An alternative is a Vacuum Pump Device.
    • Worse cases may require a penile prosthesis.

How is it done?

  • This procedure is done at home.
  • You will be given a ‘hands-on’ instruction.
  • An effective dose will be determined.
  • A pre-made-up syringe with a determined dose is made ready prior to the injection.
  • The penis is pulled away from your body with the non-dominant hand.
  • The injection site is cleaned with an alcohol wipe.
  • Caverject is injected at the base of the corpora cavernosa at an angle of 45 degrees with the shaft. See hand-out.
  • Allow 5 minutes for an erection to be obtained.
  • The erection lasts approximately 20 minutes.

What next?

  • Once the correct the dose has been established.
  • You feel comfortable using the injections.
  • A repeat script will be issued.
  • Your GP will continue with the medication.
  • Dr Michael Gillman, Men’s Health Physician is a fantastic alternative.

Complications?

  • Dose too high for the individual.
  • Prolonged painful erection.
  • If erection lasts longer than 4-6 hours, it becomes an emergency, and you are required to visit your local Emergency Department.
  • This will be drained with a syringe.
  • A surgical bypass my be done with possible erectile dysfunction as complication.

 

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Wes Caverject Intra-Cavernosal Injections

Circumcision

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Surgical removal of foreskin with penile block for post-operative pain relief

Why is it done?

  • Religious reasons.
  • Health reasons.
  • Personal reasons.
  • Medical reasons:
    • Narrowing of foreskin -phimosis.
    • Foreskin stuck behind head of penis – paraphimosis.
    • Severe infection of the foreskin and head of penis -balanoposthitis.
    • Cancer of the foreskin – SCC.
    • Trauma.

How is it done?

  • This is done under general anesthetic or penile block.
  • A cut is made at the level of the glans penis, circumferentially around the penis, through the skin.
  • The foreskin is then retracted, and a second incision is made circumferentially around the base of the glans penis.
  • The skin between the 2 incisions is then surgically removed.
  • Dissolvable sutures are then placed between the 2 remaining edges.
  • A Jelonet and Bactroban dressing is then placed tightly around the penis, still allowing urine to pass through the end.
  • A local anesthetic is injected into the base of the penis thus giving post-operative pain relief for the next 4-6 hours.

Unfortunately, no infants younger than 12 months can be operated on in any of the private hospitals ONLY at Children’s Hospital.

 

What to expect after the procedure

  • Any anesthetic has its risks, and the anesthetist will explain such risks.
  • Bleeding is a common complication.
  • With any subsequent erections post operatively, the sutures may pull out causing an opening of the wound with subsequent bleeding.
  • An infection of the wound can occur if the dressings are left on too long.
  • If the dressing has been applied too tightly, or if there is any discomfort, please remove the dressing immediately. If some hemorrhaging re-occurs, REDO the dressing!
  • In very young patients, the foreskin may still be attached to the head of the penis, thus leaving a raw and red glans penis after surgery. Keep the affected area clean and apply ointment as prescribed.
  • NB! Each person is unique and for this reason symptoms may vary!

What next?

  • The dressing should be removed in a bath 48 hours after the procedure.
  • The dressing should be soaked until it comes off with ease.
  • The dressing may sometimes adhere to the wound causing slight bleeding on removal. Don’t panic the bleeding will stop.
  • As soon as the dressing has been removed, Bactroban (or similar) ointment should be applied on the wound twice a day.
  • This may not be required if the foreskin was not adhered to the glans penis.
  • On discharge a prescription may be issued for the patient to collect.
  • A follow-up appointment should be scheduled to see Dr Schoeman within 2 weeks.
  • Please don’t hesitate to direct all pre-operative queries to Dr Schoeman’s rooms.
  • PLEASE CONTACT THE HOSPITAL WITH ANY POST-OPERATIVE CONCERNS AND RETURN TO THE HOSPITAL IMMEDIATELY SHOULD THERE BE ANY SIGNS OF SEPSIS.

 

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Wes Circumcision

Dorsal Slit Procedure

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Opening of foreskin where a phimosis exists, yet foreskin preservation is a requirement. Also done initially with severe septic para-phimosis as interim procedure until sepsis is cleared and a circumcision is possible

Why is it done?

  • Paraphimosis: foreskin stuck behind head of penis.
  • Foreskin preserving.

How is it done?

  • This is done under general anesthetic or a penile block.
  • A vertical cut is made through the tightest part of the para-phimosis, and the foreskin is than able to be covered over the meatus.
  • The incision is then closed by opposing edges in the horizontal plane.
  • Dissolvable sutures are placed between the 2 remaining edges.
  • A local anesthetic is injected into the base of the penis thus giving post-operative pain relief for the next 4-6 hours.

What to expect after the procedure

  • Any anesthetic has its risks, and the anesthetist will explain such risks.
  • Minor bleeding.
  • With any subsequent erections post operatively, the sutures may pull out causing an opening of the wound with subsequent bleeding.
  • An infection of the wound can occur if the dressings are left on too long.
  • If the dressing has been applied too tightly, or if there is any discomfort, please remove the dressing immediately. If some hemorrhaging re-occurs, REDO the dressing!
  • In very young patients, the foreskin may still be attached to the head of the penis, thus leaving a raw and red glans penis after surgery. Keep the affected area clean and apply ointment as prescribed.
  • NB! Each person is unique and for this reason symptoms may vary!

What next?

  • The dressing should be removed in a bath 48 hours after the procedure.
  • The dressing should be soaked until it comes off with ease.
  • The dressing may sometimes adhere to the wound causing slight bleeding on removal. Don’t panic the bleeding will stop.
  • As soon as the dressing has been removed, Bactroban (or similar) ointment should be applied on the wound twice a day.
  • This may not be required if the foreskin was not adhered to the glans penis.
  • On discharge a prescription may be issued for the patient to collect.
  • A follow-up appointment should be scheduled to see Dr Schoeman within 2 weeks.
  • Please don’t hesitate to direct all pre-operative queries to Dr Schoeman’s rooms.
  • PLEASE CONTACT THE HOSPITAL WITH ANY POST-OPERATIVE CONCERNS AND RETURN TO THE HOSPITAL IMMEDIATELY SHOULD THERE BE ANY SIGNS OF SEPSIS.

 

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Wes Dorsal Slit procedure

Partial Penectomy

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Partial amputation of penis with penile block for postoperative pain management.

Why is it done?

  • Confirmed penis cancer, only infiltrating the distal penis.
  • No lymph nodes involved.

How is it done?

  • This procedure is done under general anesthetic.
  • Supine position.
  • The foreskin may be the only affected area and therefore a circumcision is done.
  • Otherwise, the affected area is exposed and cleaned.
  • The affected lesions, usually including the glans is then removed surgically.
  • A 1-2 cm clear surgical margin should be obtained, with sufficient penile length to allow effective urination.
  • The urethral meatus is reconstructed.
  • Hemostatic dressings are placed.
  • Specimen is sent to a histopathologist.
  • An indwelling catheter will be inserted.
  • A dressing is then applied, which should be removed after 72 hours.
  • A local anesthetic is injected at the base of the penis as a penile block thus giving post-operative pain relief for the next 4-6 hours.

What to expect after the procedure?

  • Any anesthetic has its risks, and the anesthetist will explain such risks.
  • Bleeding can occur.
  • Your catheter will be removed on Day 3.
  • Long-term risk of a meatal stenosis.
  • An infection of the wound may occur and requires immediate attention.
  • DANGER SIGNS: A wound that swells immediately, fever, and puss. Contact Dr Schoeman or the hospital immediately as this occurs in up to 15–20% of all cases.

What next?

  • Dressings should be kept dry for the initial 72 hours after surgery and soaked off in a bath thereafter.
  • The dressing may sometimes adhere to the wound causing slight bleeding on removal. Don’t panic, the bleeding will stop.
  • The catheter will be removed after 3 days
  • Patients should schedule a follow-up appointment with Dr Schoeman 4-6 weeks after the procedure.
  • At this stage: if you have any inguinal lymph nodes are palpated, you will be placed on antibiotics. This will be reviewed in 6 weeks.
  • Depending on the staging of the Penile Cancer, Inguinal Node dissection will be scheduled.
  • If your nodes are positive for cancer, Radiation and Chemotherapy will be discussed by an Oncologist.
  • There will be signs of bruising for at least 10 days.
  • Refrain from using your erect penis for 6 weeks.
  • PLEASE CONTACT THE HOSPITAL DIRECTLY WITH ANY POST-OPERATIVE CONCERNS AND RETURN TO THE HOSPITAL IMMEDIATELY SHOULD THERE BE ANY SIGNS OF SEPSIS.

 

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Wes Penectomy Partial

Penile Biopsy

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Biopsy of penile skin / lesion to confirm or exclude penile cancer

 

Why is it done?

  • To confirm/ exclude the presence of malignancy
  • To find the best effective treatment option for this lesion

How is it done?

  • This procedure is done under local or general anesthetic.
  • Supine position.
  • The foreskin may be the only affected area and therefore a circumcision is done.
  • Otherwise, the affected area is exposed and cleaned.
  • If it is a large area, a wedge resection of an area close to normal skin is done.
  • Otherwise, a complete excision biopsy is done.
  • Hemostatic sutures are placed.
  • Hemostatic dressings are placed
  • Specimen is sent to a histopathologist.
  • An in catheter may be inserted if the biopsy area involves the meatus of your urethra.
  • A dressing is then applied, which should be removed after 72 hours.
  • A local anesthetic is injected at the base of the penis as a penile block thus giving post-operative pain relief for the next 4-6 hours.

What to expect after the procedure?

  • Any anesthetic has its risks, and the anesthetist will explain such risks.
  • Bleeding is a common complication.
  • A hematoma (blood collection under the skin). Bruising is normal.
  • Sutures may tear loose with vigorous use of erect penis, and the procedure may then require revision.
  • An infection of the wound may occur and requires immediate attention.
  • DANGER SIGNS: A wound that swells immediately, fever, and puss. Contact Dr Schoeman or the hospital immediately as this occurs in up to 15–20% of all cases.

What next?

  • Dressings should be kept dry for the initial 72 hours after surgery and soaked off in a bath thereafter.
  • The dressing may sometimes adhere to the wound causing slight bleeding on removal. Don’t panic, the bleeding will stop.
  • Patients should schedule a follow-up appointment with Dr Schoeman 2 weeks after the procedure.
  • There will be signs of bruising for at least 10 days.
  • Refrain from using your erect penis for 3-4 weeks.
  • The suture-line will be hard and indurated for at least 8-10 weeks.
  • PLEASE CONTACT THE HOSPITAL DIRECTLY WITH ANY POST-OPERATIVE CONCERNS AND RETURN TO THE HOSPITAL IMMEDIATELY SHOULD THERE BE ANY SIGNS OF SEPSIS.

 

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Wes Penile lesion exision Biopsy

Penile Fracture Repair

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Repair of a ruptured Corpora Cavernosa which may sometimes involve a repair of the urethra as well.

 

How does this occur?

  • Classically seen in guys turning over onto an erect penis in their sleep.
  • Vigorous sex where the erect penis slips out and is re-inserted outside the desired orifice, causing a bend and snap in the corpora cavernosa with a loud snap sound signifying a tear of the CC.
  • Occurs at any age.
  • Sudden severe swelling of penis turning blue, looking like an eggplant.
  • Pain occurs at the time of incident.
  • This requires acute attention, therefore make your way to an emergency department as soon as possible.

What to do?

  • URGENT.
  • Make your way to ED ASAP
  • An ultrasound is done to isolate the tear in the Corpora.

How is it fixed?

  • This fixed under general anesthetic.
  • Supine position (on your back), sterile procedure.
  • An incision is done over the isolated spot.
  • The corpora is sutured with non-dissolving sutures.
  • Where the area is not seen on ultrasound, the foreskin is loosened under the glans with a circumferential incision and the whole penile skin is retracted to the base of the penis.
  • Occasionally a circumcision may result due to complications with this technique, yet foreskin preservation is attempted.
  • An indwelling catheter will be inserted until the swelling is better.
  • A dressing is then applied, which should be removed after 72 hours.

What to expect after the procedure?

  • Any anesthetic has its risks, and the anesthetist will explain such risks.
  • Bleeding is a common complication.
  • A hematoma (blood collection under the skin) is present and will take some time to settle. Bruising is normal.
  • Sutures may tear loose with vigorous use of erect penis, and the procedure may then require revision.
  • An infection of the wound may occur and requires immediate attention.
  • Necrosis of the foreskin can occur in rare circumstances.
  • DANGER SIGNS: A wound that swells immediately, fever, and puss. Contact Dr Schoeman or the hospital immediately as this occurs in up to 15–20% of all cases.

What next?

  • Dressings should be kept dry for the initial 72 hours after surgery and soaked off in a bath thereafter.
  • The dressing may sometimes adhere to the wound causing slight bleeding on removal. Don’t panic, the bleeding will stop.
  • The catheter will be removed as soon as you are awake, or if there are concerns, the following morning.
  • Patients should schedule a follow-up appointment with Dr Schoeman 2 weeks after the procedure.
  • There will be signs of bruising for at least 10 days.
  • Refrain from using your erect penis for 6 weeks.
  • The suture-line will be hard and indurated for at least 8-10 weeks.
  • PLEASE CONTACT THE HOSPITAL DIRECTLY WITH ANY POST-OPERATIVE CONCERNS AND RETURN TO THE HOSPITAL IMMEDIATELY SHOULD THERE BE ANY SIGNS OF SEPSIS.

 

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Wes Penile Fracture Repair