Acute Infection following Injection of Penile Bulking Agent

Introduction: Dissatisfaction of penile girth is an increasing phenomenon. We have noticed an increased number of patients presenting with complications following injection of bulking agents into the penis. In both the medical and non-medical setting, commonly injected bulking agents include paraffin, petroleum jelly, mineral oil, cod liver oil, metallic mercury, and petroleum jelly. Case reports from the literature have demonstrated various methods of injection, as well as shortand long-term complications, including foreign body reactions leading to penile scarring, skin necrosis, abscess formation, and Fournier’s gangrene. Here we present case of an acute, severe subcutaneous penile infection following injection of an unknown bulking agent. Case Report: A 38-year old uncircumcised Hispanic male presented to clinic with severe penile pain, edema, and erythema two days after undergoing injection of a penile bulking agent. His urologic history was significant only for bulbomembranous urethroplasty for urethral stricture (perineal trauma) disease five years prior. The patient reported visiting a clinic in Tijuana, Mexico where a thick clear gel was injected in four different areas subcutaneously in the penis. He noted subjective increased girth. Later that night, however, after a spontaneous erection, he experienced “sudden pain and swelling,” which continued to worsen until presentation at clinic. He denied any voiding difficulty or dysuria. He was febrile to 38.0°C and hemodynamically stable. His physical exam revealed a marked swollen penile shaft and prepuce with fluctuance and cellulitis spreading into the suprapubic area. The preputial skin was not reducible. He was admitted and started on broad-spectrum intravenous antibiotics. His labs revealed leukocytosis (WBC = 16,000). He was taken to the operating room a dorsal slit, abscess drainage, bilateral subcutaneous penrose drain placement, and catheter placement. Copious amounts of purulent fluid and thick gel-like substance were expressed. Over the next two days, the wound continued to drain purulent fluid. His WBC normalized and his pain significantly improved. The penile edema also improved dramatically. Intraoperative biopsy revealed extensive acute inflammation and abscess formation with fibrovascular tissue, but no evidence of necrosis. The patient was discharged on hospital day six, with plans for follow-up in one week to second-stage surgical planning. Discussion: Prospective reports of subcutaneous penile injections are limited and report results at short follow-up. Sequential subcutaneous injections of micro-droplets of liquid silicone 324 men resulted in short-term increase of 27% of penile girth with no significant complications at 24 months. The use of injectable hyaluronic acid gel in 50 patients showed significant enlargement in circumference lasting 18 months. These studies showed no complications at 18-24 months. While these positive results from medical centers performing penile injection exist, many disastrous complications of this practice in the nonmedical setting have been reported. Often, these complications require extensive resection and reconstruction with local skin flaps or graft reconstruction. With reported complications occuring beyond three years after injection, it is likely that complications are underreported. This case report offers a management strategy of an acute infectious complication after injection. Conclusion: Subcutaneous penile injections with bulking agents may commonly be administered by non-medical personnel. This practice harbors a poorly-defined risk of infectious complications, which can be severely disfiguring. Public awareness of the complications of bulking agents needs to be promoted. Source of Funding: None