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Shaker H, Said NOE, ElSaeed KO. Combination of pregabalin and Amitriptyline in management of chronic idiopathic pain following penile prosthesis implantation: a pilot study. Basic Clin Androl 2024; 34:7. [PMID: 38565989 PMCID: PMC10986100 DOI: 10.1186/s12610-024-00223-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 03/16/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Chronic post-penile prosthesis pain is de novo pain persisting > 2 months post-operatively. This pain is inadequately reported, poorly understood and undermanaged. The purpose of this current pilot study was to improvise a medical approach to alleviate the condition and assess the combination of Pregabalin and Amitriptyline in its management. RESULTS The study enrolled 9 patients complaining of idiopathic penile, pelvic, or scrotal pain persisting > 2 months after penile prosthesis implantation. Patients were prescribed pregabalin 75mg/12h (escalated after 1 week to 150mg/12h upon demand) and Amitriptyline 25mg once daily for 3 months. The pain was reassessed after 10, 30 and 100 days. The dose of pregabalin required and the side effects of the medication were noted. Findings revealed a significant decrease in pain duration (p = 0.007), frequency (p < 0.001), and intensity (p < 0.001); in glanular (p = 0.008), shaft pain (p = 0.046) but not scrotal (p = 0.112). Moreover, a significant decrease was found in sharp pain (p = 0.003) and pain aggravated by touch (p = 0.008) but not aching pain (p = 0.277). Additionally, significant improvement was reported in QoL (p < 0.001) and dose escalation of pregabalin to 150mg/12h was required in only 1 case (11%). CONCLUSION The combination of pregabalin and amitriptyline is very effective in the management of chronic idiopathic pain following penile prosthesis implantation. However, due to the ambiguity and lack of reporting of the condition, we recommend a multicentric contribution to acknowledge the condition, and weigh its prevalence accurately, whilst evaluating the efficacy of our approach. This study received ethical approval from Ain Shams University Research Ethics Committee (REC) FWA 000017585, on 04/13/2023 (REC-FMASU@med.asu.edu.eg). TRIAL REGISTRATION no FMASU R98/2023.
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Affiliation(s)
- Hassan Shaker
- Urology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Nouran Omar El Said
- Pharmacy Practice & Clinical Pharmacy, Faculty of Pharmacy, Future University in Egypt, Cairo, Egypt
| | - Karim Omar ElSaeed
- Urology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt.
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Xiang A, Braun AE, Chang C, Swerdloff D, Gross MS, Simhan J. Penoscrotal inflatable penile prosthesis recipients often fully recover from pain at two weeks following placement. Int J Impot Res 2024:10.1038/s41443-024-00871-0. [PMID: 38561424 DOI: 10.1038/s41443-024-00871-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 12/19/2023] [Accepted: 03/04/2024] [Indexed: 04/04/2024]
Abstract
The symptoms and duration of pain following inflatable penile prosthesis (IPP) surgery remains poorly understood. We characterize postoperative pain following penoscrotal 3-piece inflatable penile prosthesis placement in patients managed with a standardized pain management protocol. This is a single-center prospective analysis of 96 virginal penoscrotal 3-piece IPP recipients (9/2019 to 9/2021) excluding patients with chronic pain, IPPs performed with alternative approaches or concomitantly with other surgeries and those with infections. Standardized pain questionnaire was performed by phone on post-operative day (POD) 2, 7, 14, and 30. The primary outcome was self-reported pain scores, measured by pain score 0-10 (0 = no pain, 10 = unbearable, "worst pain you have ever felt") at various locations (incision, penile, scrotal, abdominal) over the first 30 days postoperatively. A majority of pain reported was outside the scrotal area with 67.6% of complaints in the shaft, glans, abdomen and incision. From POD2 to POD30, there was a significant decrease in severe pain from 46.2 to 11.1% (p = 0.05) with an increase in mild pain from 23.1 to 62.4% (p = 0.05). Roughly half of the participants (47.9%, n = 46) reported no pain by POD14. Penoscrotal IPP recipients often fully recover from pain at the two-week period following surgery and those with lingering discomfort predominantly complain of penile shaft and glans pain.
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Affiliation(s)
- Alice Xiang
- Department of Urology, Jefferson Einstein Healthcare Network, Philadelphia, PA, USA
- Department of Urology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Avery E Braun
- Department of Urology, Jefferson Einstein Healthcare Network, Philadelphia, PA, USA
- Department of Urology, Fox Chase Cancer Center, Philadelphia, PA, USA
- Department of Urology, University California of San Francisco, San Francisco, CA, USA
| | - Chrystal Chang
- Department of Urology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Daniel Swerdloff
- Department of Urology, Jefferson Einstein Healthcare Network, Philadelphia, PA, USA
| | - Martin S Gross
- Section of Urology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Jay Simhan
- Department of Urology, Fox Chase Cancer Center, Philadelphia, PA, USA.
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Anderson DJ, Cao DY, Zhou J, McDonald M, Razzak AN, Hasoon J, Viswanath O, Kaye AD, Urits I. Opioids in Urology: How Well Are We Preventing Opioid Dependence and How Can We Do Better? Health Psychol Res 2022; 10:38243. [PMID: 36118983 PMCID: PMC9476236 DOI: 10.52965/001c.38243] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023] Open
Abstract
Urologic procedures (both open and minimally invasive) can cause pain due to the surgery itself, devices placed, and post-operative issues. Thus, pain management is important for every post-procedure recovery period. Opioid use post-surgery is common and often over-prescribed contributing to persistent use by patients. In this article, we review the extent of opioid use in pediatric urologic procedures, vasectomy, endourologic procedures, penile implantation, urogynecologic procedures, prostatectomy, nephrectomy, cystectomy, and scrotal/testicular cancer surgery. Generally, we have found that institutions do not have a standardized protocol with a set regimen to prescribe opioids, resulting in more opioids being prescribed than needed and patients not properly disposing of their unused prescriptions. However, many institutions recognize their opioid overuse and are implementing new multimodal opioid-sparing analgesics methods such as non-opioid peri-operative medications, minimally invasive robotic surgery, and nerve blocks or local anesthetics with varying degrees of success. By shedding light on these opioid-free methods and prescription protocols, along with improved patient education and counselling, we hope to bring awareness to institutions and decrease unnecessary opioid use.
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Affiliation(s)
| | - David Y Cao
- School of Medicine, Medical College of Wisconsin
| | - Jessica Zhou
- School of Medicine, Medical College of Wisconsin
| | - Matthew McDonald
- School of Medicine, Rocky Vista University College of Osteopathic Medicine
| | | | - Jamal Hasoon
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School
| | - Omar Viswanath
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School; Valley Anesthesiology and Pain Consultants, Envision Physician Services; Department of Anesthesiology, University of Arizona College of Medicine Phoenix; Department of Anesthesiology, Creighton University School of Medicine
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health
| | - Ivan Urits
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School; Department of Anesthesiology, Louisiana State University Health Shreveport
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Chung E, Bettocchi C, Egydio P, Love C, Osmonov D, Park S, Ralph D, Xin ZC, Brock G. The International Penile Prosthesis Implant Consensus Forum: clinical recommendations and surgical principles on the inflatable 3-piece penile prosthesis implant. Nat Rev Urol 2022; 19:534-546. [PMID: 35711059 DOI: 10.1038/s41585-022-00607-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2022] [Indexed: 01/06/2023]
Abstract
Despite significant scientific advances in the modern three-piece inflatable penile prosthesis implant surgery, it is not without surgical risks and can carry additional cosmetic and psychosocial consequences in poorly selected and consented individuals. To address this problem, an international group of key opinion leaders and high-volume prosthetic surgeons reviewed the current guidelines and clinical evidence, discussed their experiences, and formed a consensus regarding inflatable penile prosthesis surgery. The findings of this consensus panel were presented at the 17th biennial Asia Pacific Society of Sexual Medicine scientific meeting. The experts concluded that proper patient selection, informed consent and strict adherence to safe surgical principles are important to optimize clinical outcomes. Furthermore, most intraoperative complications, if recognized, can be addressed intraoperatively to enable placement of the device at the time of initial surgery. Men with significant corporal fibrosis due to Peyronie's disease, prior prosthesis explantation and priapism, and men who have undergone construction of a neophallus, as well as men who receive concurrent continence surgery, are complex cases requiring additional care and advanced techniques to obtain optimal surgical outcomes. Variability in patient care - in terms of postoperative antibiotic use, pain management, scrotal care, and cycling of the penile prosthesis implant - must be reduced to enable optimization and assessment of outcomes across patient groups.
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Affiliation(s)
- Eric Chung
- AndroUrology Centre, Brisbane, Queensland, Australia.
- University of Queensland, Princess Alexandra Hospital, Brisbane, Queensland, Australia.
- AndroUrology Centre and Macquarie University Hospital, Sydney, New South Wales, Australia.
- AndroUrology Centre, Sydney, New South Wales, Australia.
| | | | | | - Chris Love
- Urology South, Level 2, Holmesglen Private Hospital, Moorabbin, Victoria, Australia
| | | | - Sean Park
- Sewum Prosthetic Urology Center of Excellence, Seoul, Korea
| | - David Ralph
- Institute of Urology, University College London Hospital, London, UK
| | - Zhong Cheng Xin
- Andrology Center, Peking University First Hospital, Beijing, China
| | - Gerald Brock
- University of Western Ontario, London, Ontario, Canada
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Ellis JL, Sudhakar A, Simhan J. Enhanced recovery strategies after penile implantation: a narrative review. Transl Androl Urol 2021; 10:2648-2657. [PMID: 34295750 PMCID: PMC8261412 DOI: 10.21037/tau-20-1220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 11/02/2020] [Indexed: 12/03/2022] Open
Abstract
Optimizing pain management strategies in penile implantation has historically been a challenge to urologists assuming care of patients post-operatively. In addition to the complex pathophysiology of male genital pain, the responsibility of opioid stewardship in the face of the ongoing narcotics epidemic presents its own set of challenges to experienced implanters. Recent innovations in pre- and intra-operative analgesia have provided some improvement in patient-reported pain outcomes. When used together in protocols spanning each phase of operative care, multimodal analgesia (MMA) regimens provide superior patient pain control and successfully decrease opioid usage compared to traditional opioid-based pain control. This review will systematically present literature that discusses interventions in the preoperative and intraoperative spaces aimed at optimally controlling pain. We will also highlight surgical techniques that have been demonstrated to help ameliorate post-operative pain in penile implant recipients. We will discuss the impact of MMA protocols across urology and further explore its larger impact on reducing opioid burden in the ongoing epidemic.
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Affiliation(s)
- Jeffrey L Ellis
- Department of Urology, Einstein Healthcare Network, Philadelphia, PA, USA
| | - Architha Sudhakar
- Department of Urology, Einstein Healthcare Network, Philadelphia, PA, USA
| | - Jay Simhan
- Department of Urology, Einstein Healthcare Network, Philadelphia, PA, USA.,Division of Urologic Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
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Abstract
PURPOSE OF REVIEW To review the most recent literature citing opioid-sparing multimodal analgesic strategies used to manage perioperative pain in patients who underwent inflatable penile prosthesis (IPP) surgery and to provide the penile implant surgeon a variety of non-opioid-based pain management strategies for IPP management. RECENT FINDINGS Interventions performed in the pre-operative, intraoperative, and post-operative arenas have all been shown to effectively lower pain scores and reduce opioid consumption. Certain surgical techniques performed during IPP surgery have helped with post-operative discomfort patients may feel after surgery. Multimodal analgesia (MMA) protocols adopted from other surgical fields and other urologic subspecialties that are implemented in IPP surgery have promising results with regard to post-operative pain control and opioid consumption. Protocols that implement a combination of refined surgical technique and multimodal analgesia offer substantial benefit to patients undergoing IPP surgery. Further work is needed to assess long-term pain control and opioid use in patients that undergo IPP surgery using these innovative strategies.
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Britton CJ, Findlay BL, Parikh N, Kohler T, Helo S, Ziegelmann MJ. Long-acting liposomal bupivacaine and postoperative opioid use after Peyronie's disease surgery: a pilot study. Transl Androl Urol 2021; 10:174-183. [PMID: 33532307 PMCID: PMC7844478 DOI: 10.21037/tau-20-871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background Novel strategies have been proposed to minimize postoperative opioid use, yet many patients experience significant pain after penile surgery. Our objective was to evaluate postoperative opioid use in patients undergoing penile ring block with long-acting liposomal bupivacaine (LB; Exparel) during surgery for Peyronie's disease (PD). Methods We identified patients who underwent tunica albuginea plication (TAP) and plaque excision/grafting (PEG) for PD between July 2019 and September 2020. Intraoperatively, a ring block was administered at the penile base penis with 20 cc of LB. Patients were instructed to use over the counter pain medications as first line treatment for postoperative pain, and opioids were available for severe breakthrough pain as needed [7.5 oral morphine equivalents (OME) =5 mg oxycodone]. Opioid use was assessed during the first five days postoperatively. Results In total, 28 patients met inclusion criteria including 18/28 (64%) who underwent TAP and 10/28 (36%) who underwent PEG. Median patient age was 56 years (IGR 51;61). Median postoperative 10-point visual analogue pain score was 0 (range 0-3). Duration of penile anesthesia ranged from 1.5-4 days. In total, 9/28 patients (32%) utilized opioids during the first five days postoperatively (range 7.5-75 OME). Two patients (7%) required opioids during the first two days after surgery. 27/28 (96%) were satisfied or highly satisfied with postoperative pain control. Conclusions Intraoperative penile ring block with LB resulted in excellent pain control with local anesthetic duration of 1.5-4 days. The majority of patients did not require any opioids during the early postoperative period. Further study comparing outcomes with shorter-acting local anesthetics is necessary to balance pain control benefits with additional cost.
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Affiliation(s)
| | | | - Niki Parikh
- Department of Urology, Mayo Clinic, Rochester, MN, USA
| | - Tobias Kohler
- Department of Urology, Mayo Clinic, Rochester, MN, USA
| | - Sevann Helo
- Department of Urology, Mayo Clinic, Rochester, MN, USA
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Rodríguez-Cabero M, González J. Current clues for better analgesic prescription after urologic surgery. Transl Androl Urol 2020; 9:2462-2466. [PMID: 33457216 PMCID: PMC7807356 DOI: 10.21037/tau-20-937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
| | - Javier González
- Servicio de Urología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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Fraile Poblador A, Díaz Pérez D, Hevia Palacios M, Burgos Revilla F. Analysis of preoperative and postoperative expectations of penile implant candidates. Actas Urol Esp 2020; 44:345-350. [PMID: 32354643 DOI: 10.1016/j.acuro.2020.01.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 01/24/2020] [Indexed: 12/25/2022]
Abstract
Penile prosthesis implantation is a good option for the treatment of refractory erectile dysfunction. However, the patient's expectations, among other factors, condition his satisfaction after surgery. This review article aims to present the scientific evidence available concerning patient satisfaction with penile prosthesis surgery.
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Commentary on Postoperative penile prosthesis pain: is it worse in diabetic patients? Int J Impot Res 2020; 33:380-381. [PMID: 32203429 PMCID: PMC8055533 DOI: 10.1038/s41443-020-0252-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 02/22/2020] [Accepted: 03/05/2020] [Indexed: 11/08/2022]
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