Introduction

The severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), responsible for COVID-19 disease, has been responsible for millions of hospital admissions around the world, many of them in the Intensive Care Units (ICU) [1]. In most cases, COVID-19 patients admitted to the ICU present with severe and frequently fatal respiratory disease, requiring invasive mechanical ventilation [2]. Prone positioning is an adjuvant treatment in patients with refractory hypoxemia, used in about fifty percent of patients with Acute Respiratory Distress Syndrome (ARDS) caused by COVID-19 infection [3]. It has been shown that putting patients with refractory hypoxemia in prone positioning, for twelve to sixteen hours a day improves mortality and some key physiologic parameters [4-6]. Nevertheless, prone positioning may be associated with several complications, including a higher risk of pressure-induced skin and soft tissue injury [7]. The presence of a semi rigid penile prosthesis might be overlooked in these cases, probably due to the low proportion of patients with these devices among the general ICU population. However, the proportion of individuals with penile prosthesis might be higher among elderly people with underlining cardiovascular comorbidities or diabetes mellitus, which are precisely the subgroup most reached by the severe forms of COVID-19. We report herein two cases of glans necrosis and spontaneous extrusion of penile prothesis in critically ill patients who required prone positioning in the scenario of SARS-CoV-2 severe infection.

Case 1

A 67-year-old man, obese, with a history of prostate cancer, diabetes mellitus and arterial hypertension was diagnosed with COVID-19 on November 5^th, 2020. The patient had been submitted to a semi-rigid penile prosthesis implantation 20 years ago, to treat an erectile dysfunction probably secondary to the diabetic vasculopathy. After a week with mild symptoms and out-of-hospital follow-up, his clinical condition deteriorated, and the patient was admitted to our Institution on November 13^th. Three days later, he was transferred from the ward to the ICU due to respiratory failure, needing prompt orotracheal intubation and invasive mechanical ventilation. The patient developed refractory hypoxemia and was put in prone position as a rescue therapy. Concomitantly, his hemodynamic condition deteriorated, with requirement of increasing doses of vasoactive drugs. On December 1^st, the urology team was called to evaluate a glans penis lesion observed during the ICU treatment and evidenced a necrotic lesion with 2 cm of diameter, with no sign of infection or secretions, suggesting aseptic necrosis. The penile prosthesis was well positioned with no sign of fractures or extrusions. It was recommended local care with daily cleaning and bandage. Four days later, the prosthesis spontaneously extruded. The material was collected and sent to microbiological culture. Additionally, a local debridement was performed. The wound course was uneventful with progressive improvement in the following weeks. However, on January 8^th, 2021, about one month later, the patient progressed with severe hypotension refractory to vasoactive drugs and, unfortunately, died. A complicating nosocomial infection was considered the most probable cause of death.

Case 2

A 67-year-old man, with a past medical history of arterial hypertension, diabetes mellitus and chronic coronary artery disease was admitted to the emergency room of a small city hospital on March 25^th, 2020 presenting dyspnea and diarrhea. He progressed to respiratory failure and need of orotracheal intubation with invasive mechanical ventilation within the following twelve hours. The patient had been submitted to implantation of a semi-rigid penile prosthesis a few years ago to treat a severe erectile dysfunction supposedly secondary to diabetes mellitus associated vasculopathy. He was transferred to the ICU of our institution on March 27^th and had the diagnosis of SARS-CoV-2 infection confirmed at the same day. Shortly after, he progressed with refractory hypoxemia and was submitted to a trial of prone positioning, with good response and repeated the strategy in the three subsequent days. On the April 5^th, the urology team was called to evaluate a necrotic lesion of 1cm of diameter on the glans penis, suggestive of aseptic necrosis. The penile prosthesis was well positioned with no sign of fractures or extrusions. It was recommended local care with daily cleaning and bandage. The patients had a favorable clinical course and was extubated three days later, being transferred to the ward afterwards. The glans lesion became progressively worse despite adequate local care (Figure 1). The penile prosthesis was spontaneously extruded, with requirement of surgical debridement and a partial penectomy (Figure 2). The post-operative period was uneventful, and the patient was discharged to home on May 9^th, 2020, 45 days after hospital admission.

Figure 1: Necrotic lesion of 1cm of diameter on the glans penis, suggestive of aseptic necrosis.