Cryoablation of the Penile Nerves for Chronic Penile Pain

Introduction

There is not an adequate amount of data or literature available on the prevalence of chronic penile pain. Chronic penile pain is pain in the penis that may be recurrent or persistent and can be spontaneous or produced by some physical activity, sexual dysfunction, and lower urinary tract infection. The pain does not occur primarily inside the urethra. Estimates suggest that 7 % of males suffering from Peyronie’s disease (a noncancerous disease caused by fibrous scar tissue formed on the penis and leads to curved and painful erections) complain of pain when the penis is flaccid. The management of chronic penile pain is not completely understood even after the causes of this pain are excluded. Cryoablation of the penile nerves has been considered one of the treatment options for this condition. This treatment is based on the successful management of chronic scrotal content pain through ultrasound-guided targeted cryoablation (UTC).

What Is Chronic Penile Pain?

Penile pain is pain or discomfort in the shaft, base, or head of the penis. Sometimes it can affect the foreskin. The intensity of this pain can differ depending on the underlying condition due to which this pain is experienced. This pain can be accompanied by a burning or itching sensation. Chronic penile pain can affect men of any age group and can occur as a result of a disease or accident.

Immediate attention must be given to any kind of penile pain, especially if it occurs during erection, hinders urination, or is accompanied by discharge, redness, sores, or swelling. In case of an accident or injury, the pain can be sudden and severe. On the contrary, in the case of a disease, the pain may be mild initially and become worse gradually.

What Is Cryoablation?

Cryoablation is a procedure that is used to kill or destroy diseased tissue or abnormal cells. This procedure is employed for the treatment of skin disorders and cancer through extremely cold gas. It is also known as cryotherapy or cryosurgery and is usually less invasive and safer than surgery to remove the affected cells or tissue.

The different types of cryoablation include:

• Surgically (performed inside the body through a large open incision or cut).

• Percutaneously (inside the body through a small hole or puncture).

• Topically (performed on the surface of the skin).

Which Nerve Is Involved in Cryoablation?

The dorsal nerve of the penis (DNP) supplies the sensory innervation of the penis and the glans. It is the terminal branch of the pudendal nerve. The dorsal nerve of the penis (DNP) moves along the inferior ischial ramus before it enters the urogenital diaphragm and joins the penile shaft located below the inferior pubic ligament. The dorsal nerve of the penis (DNP) also provides afferent fibers to the following structures:

• Urethral mucosa (epithelium extending from the neck of the bladder to the external urethral meatus).

• Corpus spongiosum (mass of spongy tissue around the male urethra within the penis).

The dorsal nerve of the penis (DNP) plays a vital role in the ejaculation reflex as it receives somatosensory impulses from the glans. The dorsal nerve of the penis (DNP) is primarily involved in somatosensory function with a little motor component.

The afferent fibers of this nerve lead to the transmission of sensory signals to the central nervous system causing a normal sensation and erectile or ejaculatory reflex in men.

What Are the Risks and Benefits of Cryoablation?

Cryoablation of the penile nerves can lead to the risk of sensory loss and erectile dysfunction as the dorsal nerve of the penis (DNP) plays a vital role in erection, penile sensation, and ejaculation.

Possible damage to the neurovascular bundle is another risk associated with cryoablation procedures for chronic penile pain, and it may lead to the formation of a hematoma. Generally, there is a risk for hematoma formation with superficial procedures in the surrounding structures. To limit this risk, ultrasound guidance is used as it helps to manage the ice ball expansion close to these structures.

The patients must be made aware of the potential risks and benefits of this procedure, including permanent erectile dysfunction and hematoma formation. To achieve the desired results, another cryoablation procedure can be performed, or prescribing oral medications like Gabapentin should be considered. Not continuing any further treatment is also an option that can be considered. In case of positive results of the treatment, the patient reports a significant reduction in penile pain after cryoablation.

What Are the Other Treatment Options for Penile Pain?

Treatment for penile pain depends on the condition or disease:

• In Peyronie’s disease (a noncancerous disease caused by fibrous scar tissue formed on the penis and leads to curved and painful erections), the administration of injections helps to reduce or soften plaques. In severe cases, these plaques can be removed surgically.

• In the case of priapism (prolonged and painful erection lasting for more than four hours without any sexual stimulation), the blood can be drained from the penis with a needle as it helps to decrease an erection. Certain medications may also help lower the blood flowing into the penis.

• Antibiotics are used to treat urinary tract infections (UTIs) and some sexually transmitted infections (STIs) like gonorrhea, chlamydia, and syphilis. These antibiotics can also be used to treat balanitis.

• To reduce herpes outbreaks, antiviral medications can be used.

• In the case of phimosis (a condition characterized by a tight foreskin that can not be stretched back over the head of the penis, normally seen in an uncircumcised child), steroid creams can be rubbed on the penis. However, in some cases, surgery is essential.

• In paraphimosis (a condition characterized by a urologic emergency occurring in uncircumcised males causing entrapment of foreskin behind the glans penis), icing the head of the penis helps to reduce swelling. The swelling can also be decreased by putting pressure on the head of the penis. Medications can also be injected into the penis to help it drain, and small cuts in the foreskin can also be made to decrease swelling.

• In the case of penile cancer, the surgeon can remove cancerous parts of the penis, followed by radiation treatment or chemotherapy.

Conclusion

There is not much data available to support the best treatment available for the management of chronic penile pain. However, cryoablation of the penile nerve is considered a potential treatment option where this pain cannot be managed by other methods including medical therapy.