Depression and Anxiety are Associated with Increased Complications after Penile Prosthesis Surgery

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We aimed to determine if depression/anxiety increased complication rates in penile prosthesis surgery. All penile prosthesis cases by a single surgeon at our institution from 2020–2022 were reviewed. Data was collected on demographics, medical/psychiatric history, intraoperative details, and post-operative outcomes. Fisher’s exact test was used to compare complications amongst patients when sorted by categorical variables. Complications were analyzed as time to event outcomes using Kaplan-Meier methods. Multivariable logistic regression was used to measure the effect of mental health on complications while controlling for potential confounders. 284 penile prosthesis cases were performed. Anxiety/depression was significantly associated with post operative complications (p = 0.002) and infection (p = 0.025). Anxiety/depression is independently associated with increased complications in a multivariable logistic regression model including age, BMI, diabetes, primary surgery, smoking status, and correctly holding anticoagulation. Survival analysis showed that anxiety and depression both resulted in faster times to complication and re-operation (all p < 0.05). This is the first study assessing the impact of mental health on penile prosthesis outcomes. Urologists should consider mental health when evaluating patients for prosthesis surgery, and mental health treatment prior to surgery may improve outcomes. Health sciences/Diseases/Urogenital diseases/Erectile dysfunction Health sciences/Risk factors Health sciences/Health care/Therapeutics/Surgery Health sciences/Health care/Therapeutics/Adverse effects Figures Figure 1 Figure 2 Introduction Surgical site complications are a cause for concern after inflatable penile prosthesis (IPP) placement. Poor wound healing may predispose to tissue and/or device infection. The rate of infection after IPP placement is reportedly 0.68–1.06% at 6–12 months postoperatively, but other studies report rates up to 3% 1,2 . Infections account for approximately half of complications in the immediate postoperative period per the national surgical quality improvement program 3 . Prosthetic infections can be challenging to eradicate, potentially due to biofilm development, and often involve an extended duration of antibiotics and device removal 4 . There is a well-established link between psychologic distress and poor wound healing 5 . Increased pro-inflammatory cytokines have been shown in patients with experimentally-induced blisters after hostile marital interactions, with poorer wound healing in those categorized as having more hostile relationship patterns 6 . A large-scale observational study involving thousands of patients undergoing hip replacement, hernia repair, and varicose vein procedures found that patients with moderate anxiety or depression had an increased probability of wound complications 7 . The same study also showed an association between anxiety or depression with readmission rates and duration of stay. In a review of psychological variables and early surgical recovery, trait and state anxiety were found to be associated with impaired wound healing and postoperative complications 8 . Interestingly, an empathic and patient-centered approach to anxious surgical patients has been shown to improve postoperative recovery and wound healing 9 . There is a paucity of data directly examining the relationship between depression or anxiety in the outcomes following penile prosthesis surgery. The object of this study is to assess for correlation between a preoperative diagnosis of depression or anxiety and complication rates after penile prosthesis surgery, with the goal of developing quality improvement studies and initiatives. Methods After obtaining institutional review board approval, our prospectively collected database of prosthetic urology cases was retrospectively reviewed for cases performed from 2020–2022. Procedures were classified as either primary placement of prosthesis or secondary surgery, which included removal with replacement and revision. Revision was defined as any operation including exchange of components, while replacement was defined as replacing the entire device. Complications were defined by Clavien-Dindo classification and identified based on documentation by urologists or emergency room physicians. Time to complication was defined as number of days from date of surgery. Follow-up was based upon last in-person assessment. Presence of preoperative diagnoses of depression or anxiety was determined by chart review for the related ICD codes or clinical documentation by a provider prior to the surgery. Patients were further classified as having received treatment for anxiety/depression if they reported taking a selective serotonin reuptake inhibitor (SSRI), serotonin norepinephrine reuptake inhibitor (SNRI), atypical antidepressant, or tricyclic antidepressant at the time of their procedure. As contemporary management of depression and anxiety follows similar clinical algorithms, the presence of associated medications was not used to define presence of either condition. Preoperative presence of depression or anxiety, as well as treatment for these conditions, was determined separately for each procedure if patients had multiple operations. Descriptive statistics for continuous and categorical values were calculated. Fisher’s exact test was used to compare the distribution of complications and reoperation based on preoperative mental health status and whether patients received medical management of mental health. Similar analyses were repeated for primary and secondary surgeries. Survival analysis was conducted using Kaplan Meier curves and compared using the Log-rank (Mantel-Cox) test. Patients were censored at time of complication or at last follow up if no complication occurred. Multivariable logistic regression was used to analyze the impact of having a history of treatment or diagnosis of anxiety/depression upon incidence of postoperative complication, controlling for confounding factors such as age, body mass index (BMI), diabetes, smoking status, whether the surgery was primary, and whether anticoagulation was held prior to procedure. Hazard ratios and odds ratios are reported with 95% confidence intervals (CI) and p-values of 0.05 were used for all analyses. Results 284 cases were identified, with 194 (68.3%) in white patients, 77 (27.1%) in African American patients, and 13 (4.6%) in patients of unknown/other race. 222 (78.2%) surgeries were primary procedures, and 62 (21.8%) surgeries were replacement/revision procedures. The mean age at time of surgery was 64.17 years old (37–86 years old) and mean BMI was 30.17 kg/m 2 (18.11–46.17 kg/m 2 ). 33 (11.6%) patients were smokers or had quit within 6 weeks of surgery. 118 (41.5%) patients had diabetes at time of surgery. 84.2% of patients held blood thinners prior to surgery. Median follow up was 248 days. 26/284 (9.2%) of all operations had complications, with 7 Clavien 1 complications, 5 Clavien 2 complications, and 14 Clavien 3b complications. 10 cases had some type of postoperative infection (3.5%), and 14 (4.9%) required re-operation/revision. Non-infectious complications included 4 reservoir malfunctions, 1 pump malfunction, 1 cylinder malfunction, 1 unknown malfunction, 1 hematoma, 2 cylinder herniations, 1 reservoir erosion, and 5 miscellaneous complaints including inflammation, pain, and/or poor wound healing. The rate of complication in primary surgery was 7.2% (16/222), while the rate of complication in revision or replacement surgery was significantly higher at 16.1% (10/62) (p = 0.044). Of the 10 cases of postoperative infection, none of these occurred within 30 days of surgery. 4/10 (40%) were superficial wound concerns managed with antibiotics and no need for additional surgery. Of the 6 cases that had subsequent surgery for infectious concerns, 3/6 were able to retain a device based on operative findings. Of the 3 cases that required full device removal, one involved a combination procedure with IPP and artificial urinary sphincter placement, and the rest (2/3) consisted of primary IPP placement with one removed between 2 and 3 months postoperatively, and the other at over 90 days after surgery. Thus, 1/222 (0.5%) primary implant placements required removal for infection within 90 days. 76 patients (26.7%) had either a diagnosis of depression or anxiety prior to penile prosthesis surgery, with 52 (18.3%) patients diagnosed with anxiety and 71 (25%) patients diagnosed with depression. Diagnoses of either condition were seen in 56 (25.2%) and 20 (32.2%) of patients undergoing primary or replacement/revision, respectively. Mean age was significantly younger among patients with depression or anxiety (62 vs 65 years; p = 0.025). Mean BMI was higher among patients with depression or anxiety (31.08 vs 29.84), though not statistically significant. There was no association between depression or anxiety and a diagnosis of diabetes or tobacco history (see Table 1). Presence of either mental health condition (depression or anxiety) was associated with a significantly higher likelihood of postoperative complication (18.42% vs 5.77%, OR 3.688; p = 0.002). Depression (OR = 4.114, p = 0.001) and anxiety (OR 3.881, p = 0.002) were also separately associated with the higher rate of overall complications. There was no association between depression and complications after primary surgery, but a significant association was found after replacement or revision (OR = 7, p = 0.009). Unlike depression, anxiety was significantly associated with complication regardless if primary surgery (OR 3.035, p = 0.0464) or replacement/revision (OR 6.429, p = 0.0177). Patients with depression or anxiety had a higher infection rate at 7.89% compared to 1.92% in patients without either diagnosis, corresponding to a OR of 4.371 (p = 0.0252). Both depression (OR 4.823, p = 0.0179) and anxiety (OR 4.83, p = 0.0208) were separately found to be associated with increased rates of postoperative infection. Survival analysis found that patients with either depression or anxiety had a significantly increased risk of complication and a shorter time to complication. A diagnosis of depression was associated with a hazard ratio (HR) of 5.14 for having a complication (p = 0.0004; Fig. 1 a), and an average time to complication of 121.2 days versus 208.8 days for those without depression. A diagnosis of anxiety was associated with a hazard ratio of 5.68 for complication (p = 0.0008; Fig. 1 b), and an average time to complication of 147 days versus 172.4 days for those with no anxiety. Multivariable logistic regression was performed to assess the association of multiple confounding factors with complication, showing that having a diagnosis of anxiety or depression was the sole independent predictor of complication with an OR of 3.113 (95% CI: 1.283–7.608). Conversely, patients without evidence of these mental health conditions or those who had filled a prescription for active treatment prior to surgery had no significantly increased risk of complication compared to those with untreated anxiety/depression. There was no significant relationship between medical treatment of depression or anxiety preoperatively and subsequent complication when only patients with relevant diagnoses were analyzed. Survival analysis found no difference in time to complication or risk of complication in patients treated for depression or anxiety versus those that were not. The subset of patients with anxiety had a significantly increased risk of reoperation after primary surgery (OR 4.944, p = 0.037), but not after replacement or revision. Interestingly, when examining the subset of patients with depression, there was no significant association with reoperation after primary surgery or removal/replacement. Similarly, patients who had their anxiety or depression managed by medication did not have a significant increase in reoperation compared to those managed without prescription medication. Survival analysis showed that both patients with anxiety and patients with depression had shorter times to reoperation than patients without either diagnosis. Depression was associated with a HR of 3.675 for re-operation (p = 0.0343), with an average time to reoperation of 160 days compared to 383 days for those without (Fig. 2 a). Anxiety was associated with a HR of 5.509 for reoperation (p = 0.0145), with an average time to reoperation of 181.2 days compared to 339.25 days for those without (Fig. 2 b). Patients medically treated for depression or anxiety did not have a significant difference in time to reoperation than patients that did not receive treatment. Discussion Depression and anxiety are commonly comorbid with erectile dysfunction (ED), and the onset of ED often precipitates poor mental health 10 . Both depression and anxiety have been linked to poor surgical outcomes, with a large review finding increased wound complications in patients with moderate depression or anxiety across four of the most common surgical procedures performed in England 7 . Though postoperative complications present a major source of morbidity in penile prosthesis surgery and often lead to reoperation 11 , the association between preoperative anxiety and depression and outcomes after IPP placement/revision has not been explored in the literature until now. We found that over a quarter of men undergoing these operations had depression or anxiety, and that these specific patients had a significantly greater rate of surgical complications. The prevalence of depression among men with ED is high, and the relationship is thought to be bi-directional 12 . The Massachusetts Male Aging Study established that 12% of patients that developed ED had pre-existing depression 13 . Similarly, a large Finnish study found that 7% of men with new onset ED had depression 14 . ED appeared to have an even stronger association with developing depression, with rates of onset as high as 46% in a cohort of young males 15 . Our study was consistent with this data as 25% of our patients had a diagnosis of depression, though the temporal relationship of depression and ED is unknown. The data regarding the relationship between anxiety and ED is less robust, as generalized anxiety disorder is often coupled with depression in analysis. Jern et al and Manolo et al both identified that symptoms of anxiety and depression were associated with poor erectile function 10 , 16 . A cross-sectional survey of Chinese ED patients found 79.82% suffered from anxiety 17 . A retrospective study of ED patients in India found that 23.4% had some kind of anxiety disorder, mostly predating ED 18 . Our data showed that 18.3% of our patients had anxiety, though our cohort was clearly different with respect to age and nationality. Notably, panic disorder and post-traumatic stress disorder are also linked to ED, with a recent literature review finding the prevalence of ED to be from 2-36.2% in panic disorder and from 3–85% in PTSD 19 . The overall complication rate of primary penile prosthesis surgery has been reported as around 5% 11 , but may be as high as 25% for revision cases 20 . However, these rates may not account for device malfunction, which may occur in up to 17.5% over 10 years 1 , 21 . Infection is often the most feared complication given the risk of device loss, and has been reported after 1–3% of cases in the era of antibiotic coatings and washouts 2 . Our data in this relatively short window of collection is similar to existing data, with a 7.2% and 16.1% complication rate for primary and revision/replacement cases, respectively. The overall infection rate was 3.5%, but only 0.5% of primary implantation surgery infections were severe enough to require removal. Malfunction was seen in only 2.5% and may reflect the length of follow-up. With respect to reoperation rates, estimates range from 11–15% over 5–10 years 22 . While our reoperation rate of 4.9% may appear due to the length of follow-up, it is lower than that reported in studies with similar follow-up 23 , 24 . We found a significant association between depression and anxiety with postoperative infection. This mirrors similar findings among other types of prosthetic surgery. In hip and knee replacements, depression and anxiety have been linked to increased risk of both superficial and prosthetic infections in primary and revision procedures 25 , 26 . The proposed hypothesis underlying these findings is that depression results in the release of pro-inflammatory cytokines while decreasing immune cell functions, consequently impeding wound healing and predisposing patients to infection 27 . Depression was also associated with infection after ventricular assist device implantation, which was attributed to poor compliance with device care 28 . These hypotheses may also explain the increased risk of penile prosthesis infection in the setting of depression or anxiety, though shared comorbidities between depression/anxiety and device infection may present confounding factors. Our results also suggest a relationship between depression and anxiety and the need for reoperation, though the association with anxiety is more robust. Of note, a similar relationship between mental health and reoperation has been established for orthopedic prosthesis as well 25 . Infection and device malfunction are the most common reasons for penile prosthesis revision 22 and also account for the majority of complications in this study. Though the association between psychological factors and infection have been discussed, it is unclear if there is any association between mental health and reports of device malfunction. Depression and anxiety prior to surgery are associated with worse pain control and increased analgesic requirements 29 , which may make patients more sensitive to a malfunctioning prosthesis. Depression in elderly patients is also a risk factor for progression to mild cognitive impairment 30 . As most penile prosthesis recipients are elderly, depression-related cognitive impairment could contribute to reported malfunction rates as a function of device misuse. The findings in this study suggest preoperative depression and anxiety negatively affect long-term outcomes of penile prosthesis surgery. The postoperative complication and infection rate in patients with anxiety or depression are comparable to those reported for risk factors such as spinal cord injury and diabetes 31 – 33 . The current consensus in preventing complications in the preoperative setting is to screen for relevant risk factors and to optimize their management 34 . Identification and management of depression and anxiety could potentially improve outcomes in nearly a quarter of prosthetic cases, as studies suggest optimizing mental health improves recovery 9 . Given that depression is associated with increased length of stay, readmission rates, and overall cost of care, preoperative efforts may reduce the burden on health care systems 35 , 36 . This study has multiple limitations, some of which have already been highlighted. It is retrospective from a single tertiary care center with a relatively small sample size, and thus results may not be fully generalizable to other practice settings. There was also relatively little psychiatric history that could be gleaned through chart review outside of diagnosis and medication usage. As depression and anxiety are best managed through a combination of medication and therapy, we were unable to fully assess whether patients were adequately managed preoperatively, and we lack a definition of what fully ‘optimized’ would entail. This may account for the lack of association between recorded treatment of mental health conditions and our outcomes. Conclusion In summary, diagnoses of depression and/or anxiety are common among men undergoing penile prosthesis surgery, and are associated with increased complications, infections, and reoperation. Though this association has been reported by other surgical subspecialties, this study is, to our knowledge, the first to establish such a relationship in penile prosthesis recipients. Appropriate pre-operative mental health screening and management of depression and anxiety represent an opportunity for urologists to potentially improve patient outcomes. Further study will be needed to determine optimal assessments and therapeutic targets prior to surgery. Declarations Data Availability: Data generated for this study can be found within the published article. Additional data is available from the corresponding author upon request. Author Contributions: All the authors were involved in editing the final manuscript and have approved the final version. MX designed the study, collected data, performed statistical analysis and drafted the manuscript. RT designed the study, performed the operations, and gave feedback on the study design and manuscript. CP performed statistical analysis, provided feedback on the study design and collected data. DW provided feedback on the manuscript and collected data. MN, RR and ME all collected data. Funding: This study was funded by the Wake Forest Department of Urology Ethical Approval: This study was approved under by IRB under IRB00042919. 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Hip Pelvis 2024; 36: 204–210. Table 1 Table 1: Demographic characteristics of patient population at time of surgery Characteristic Total Depression/Anxiety P value Yes No Prosthesis surgery 284 76 (26.76%) 208 (73.24%) Primary surgery 222 (78.17%) 56 (19.72%) 166 (58.45%) Removal/replacement 55 (19.37%) 18 (6.34%) 37 (13.03%) Revision 7 (2.46%) 2 (0.7%) 5 (2.76%) Mean Age (years) 62.16 64.92 0.025 Mean BMI (kg/m 2 ) 31.08 29.84 0.075 Current Smoker 0.4 Yes 33 (11.62%) 11 (3.87%) 22 (7.75%) No 247 (86.97%) 63 (22.18%) 184 (64.79%) Unknown 4 (1.41%) 2 (0.7%) 2 (0.7%) Diabetes 0.587 Yes 118 (41.55%) 34 (11.97%) 84 (29.58%) No 166 (58.55%) 42 (14.79%) 124 (43.66%) Additional Declarations There is NO conflict of interest to disclose. Cite Share Download PDF Status: Published Journal Publication published 06 Aug, 2025 Read the published version in International Journal of Impotence Research → Version 1 posted Editorial decision: revise 12 May, 2025 Review # 2 received at journal 20 Apr, 2025 Reviewer # 2 agreed at journal 16 Apr, 2025 Review # 1 received at journal 27 Mar, 2025 Reviewer # 1 agreed at journal 25 Mar, 2025 Reviewers invited by journal 25 Mar, 2025 Submission checks completed at journal 21 Mar, 2025 Editor assigned by journal 20 Mar, 2025 First submitted to journal 20 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6273246","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":433633582,"identity":"aa821ac5-336d-4477-ad0f-c8f00c000a93","order_by":0,"name":"Mark Xu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0UlEQVRIiWNgGAWjYLCCDwwMBgwSQMYDhgNAMoGwDsYZMC0JCURqYeYhSYtu+xkzads2O2N+6eaDHxJ/3GHgZ88xwKvF7ExamnRuW7KZ5JxjyRIJCc8YJHveENByg/mYdO42ZhuDGzkGQC2HGUAMAloY26Qtt9Xb2N/I//wDpMWesBagLYzbDpsZSOSwQWyRIOyXZMvef8eNJW6kmVkkpB3mkTjzrAC/luNnDG/8OFNt2D8j+fGNDzaH5fjbkzfg1YIBeEhTPgpGwSgYBaMAKwAApIBIxdQwY00AAAAASUVORK5CYII=","orcid":"","institution":"Wake Forest Baptist Health","correspondingAuthor":true,"prefix":"","firstName":"Mark","middleName":"","lastName":"Xu","suffix":""},{"id":433633583,"identity":"7dcae5d3-6e05-4e53-a1e3-25976ef5b522","order_by":1,"name":"Connor Policastro","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Connor","middleName":"","lastName":"Policastro","suffix":""},{"id":433633584,"identity":"ef342acc-b03a-4c33-85d5-d75ff57687e4","order_by":2,"name":"Dylan Wolff","email":"","orcid":"https://orcid.org/0000-0003-4897-9732","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Dylan","middleName":"","lastName":"Wolff","suffix":""},{"id":433633585,"identity":"b55ef0b0-b8d0-45ef-934d-588fa000bf5b","order_by":3,"name":"Mary Namugosa","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Mary","middleName":"","lastName":"Namugosa","suffix":""},{"id":433633586,"identity":"bce7528f-8258-4f42-a4b3-8d6d602561f0","order_by":4,"name":"Rory Ritts","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Rory","middleName":"","lastName":"Ritts","suffix":""},{"id":433633587,"identity":"a930565a-63c4-4750-a4e6-df7a67359b33","order_by":5,"name":"Megan Escott","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Megan","middleName":"","lastName":"Escott","suffix":""},{"id":433633588,"identity":"abc7498a-48c7-4791-b8ba-0b2d87b45155","order_by":6,"name":"Ryan Terlecki","email":"","orcid":"https://orcid.org/0000-0002-7003-0497","institution":"Wake Forest Baptist Health","correspondingAuthor":false,"prefix":"","firstName":"Ryan","middleName":"","lastName":"Terlecki","suffix":""}],"badges":[],"createdAt":"2025-03-21 02:10:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6273246/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6273246/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1038/s41443-025-01149-9","type":"published","date":"2025-08-06T04:00:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":80050827,"identity":"974137a7-55a0-4c44-b7df-cfc1d161e8da","added_by":"auto","created_at":"2025-04-07 10:22:28","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":123233,"visible":true,"origin":"","legend":"\u003cp\u003ea) Survivorship free of complication for patients with depression versus those without\u003c/p\u003e\n\u003cp\u003eb) Survivorship free of complication for patients with anxiety versus those without\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-6273246/v1/095e1b22512a2864f39dbd4b.png"},{"id":80051751,"identity":"d13463ee-2687-4f1b-8f67-290496b70381","added_by":"auto","created_at":"2025-04-07 10:30:28","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":117939,"visible":true,"origin":"","legend":"\u003cp\u003ea) Survivorship free of reoperation for patients with depression versus those without\u003c/p\u003e\n\u003cp\u003eb) Survivorship free of reoperation for patients with anxiety versus those without\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-6273246/v1/f0525a13b3128d5f27acb434.png"},{"id":88509447,"identity":"08454eb4-5bfe-4524-bc66-b364eaafff38","added_by":"auto","created_at":"2025-08-07 07:49:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":574734,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6273246/v1/68c323f0-1f1d-4de8-9f27-45400677e3af.pdf"}],"financialInterests":"There is \u003cb\u003eNO\u003c/b\u003e conflict of interest to disclose.","formattedTitle":"Depression and Anxiety are Associated with Increased Complications after Penile Prosthesis Surgery","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSurgical site complications are a cause for concern after inflatable penile prosthesis (IPP) placement. Poor wound healing may predispose to tissue and/or device infection. The rate of infection after IPP placement is reportedly 0.68\u0026ndash;1.06% at 6\u0026ndash;12 months postoperatively, but other studies report rates up to 3%\u003csup\u003e1,2\u003c/sup\u003e. Infections account for approximately half of complications in the immediate postoperative period per the national surgical quality improvement program\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. Prosthetic infections can be challenging to eradicate, potentially due to biofilm development, and often involve an extended duration of antibiotics and device removal\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThere is a well-established link between psychologic distress and poor wound healing\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. Increased pro-inflammatory cytokines have been shown in patients with experimentally-induced blisters after hostile marital interactions, with poorer wound healing in those categorized as having more hostile relationship patterns\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. A large-scale observational study involving thousands of patients undergoing hip replacement, hernia repair, and varicose vein procedures found that patients with moderate anxiety or depression had an increased probability of wound complications\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. The same study also showed an association between anxiety or depression with readmission rates and duration of stay. In a review of psychological variables and early surgical recovery, trait and state anxiety were found to be associated with impaired wound healing and postoperative complications\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. Interestingly, an empathic and patient-centered approach to anxious surgical patients has been shown to improve postoperative recovery and wound healing\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThere is a paucity of data directly examining the relationship between depression or anxiety in the outcomes following penile prosthesis surgery. The object of this study is to assess for correlation between a preoperative diagnosis of depression or anxiety and complication rates after penile prosthesis surgery, with the goal of developing quality improvement studies and initiatives.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e After obtaining institutional review board approval, our prospectively collected database of prosthetic urology cases was retrospectively reviewed for cases performed from 2020\u0026ndash;2022. Procedures were classified as either primary placement of prosthesis or secondary surgery, which included removal with replacement and revision. Revision was defined as any operation including exchange of components, while replacement was defined as replacing the entire device. Complications were defined by Clavien-Dindo classification and identified based on documentation by urologists or emergency room physicians. Time to complication was defined as number of days from date of surgery. Follow-up was based upon last in-person assessment.\u003c/p\u003e \u003cp\u003ePresence of preoperative diagnoses of depression or anxiety was determined by chart review for the related ICD codes or clinical documentation by a provider prior to the surgery. Patients were further classified as having received treatment for anxiety/depression if they reported taking a selective serotonin reuptake inhibitor (SSRI), serotonin norepinephrine reuptake inhibitor (SNRI), atypical antidepressant, or tricyclic antidepressant at the time of their procedure. As contemporary management of depression and anxiety follows similar clinical algorithms, the presence of associated medications was not used to define presence of either condition. Preoperative presence of depression or anxiety, as well as treatment for these conditions, was determined separately for each procedure if patients had multiple operations.\u003c/p\u003e \u003cp\u003eDescriptive statistics for continuous and categorical values were calculated. Fisher\u0026rsquo;s exact test was used to compare the distribution of complications and reoperation based on preoperative mental health status and whether patients received medical management of mental health. Similar analyses were repeated for primary and secondary surgeries. Survival analysis was conducted using Kaplan Meier curves and compared using the Log-rank (Mantel-Cox) test. Patients were censored at time of complication or at last follow up if no complication occurred. Multivariable logistic regression was used to analyze the impact of having a history of treatment or diagnosis of anxiety/depression upon incidence of postoperative complication, controlling for confounding factors such as age, body mass index (BMI), diabetes, smoking status, whether the surgery was primary, and whether anticoagulation was held prior to procedure. Hazard ratios and odds ratios are reported with 95% confidence intervals (CI) and p-values of 0.05 were used for all analyses.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e284 cases were identified, with 194 (68.3%) in white patients, 77 (27.1%) in African American patients, and 13 (4.6%) in patients of unknown/other race. 222 (78.2%) surgeries were primary procedures, and 62 (21.8%) surgeries were replacement/revision procedures. The mean age at time of surgery was 64.17 years old (37\u0026ndash;86 years old) and mean BMI was 30.17 kg/m\u003csup\u003e2\u003c/sup\u003e (18.11\u0026ndash;46.17 kg/m\u003csup\u003e2\u003c/sup\u003e). 33 (11.6%) patients were smokers or had quit within 6 weeks of surgery. 118 (41.5%) patients had diabetes at time of surgery. 84.2% of patients held blood thinners prior to surgery. Median follow up was 248 days. 26/284 (9.2%) of all operations had complications, with 7 Clavien 1 complications, 5 Clavien 2 complications, and 14 Clavien 3b complications. 10 cases had some type of postoperative infection (3.5%), and 14 (4.9%) required re-operation/revision. Non-infectious complications included 4 reservoir malfunctions, 1 pump malfunction, 1 cylinder malfunction, 1 unknown malfunction, 1 hematoma, 2 cylinder herniations, 1 reservoir erosion, and 5 miscellaneous complaints including inflammation, pain, and/or poor wound healing. The rate of complication in primary surgery was 7.2% (16/222), while the rate of complication in revision or replacement surgery was significantly higher at 16.1% (10/62) (p\u0026thinsp;=\u0026thinsp;0.044).\u003c/p\u003e \u003cp\u003eOf the 10 cases of postoperative infection, none of these occurred within 30 days of surgery. 4/10 (40%) were superficial wound concerns managed with antibiotics and no need for additional surgery. Of the 6 cases that had subsequent surgery for infectious concerns, 3/6 were able to retain a device based on operative findings. Of the 3 cases that required full device removal, one involved a combination procedure with IPP and artificial urinary sphincter placement, and the rest (2/3) consisted of primary IPP placement with one removed between 2 and 3 months postoperatively, and the other at over 90 days after surgery. Thus, 1/222 (0.5%) primary implant placements required removal for infection within 90 days.\u003c/p\u003e \u003cp\u003e76 patients (26.7%) had either a diagnosis of depression or anxiety prior to penile prosthesis surgery, with 52 (18.3%) patients diagnosed with anxiety and 71 (25%) patients diagnosed with depression. Diagnoses of either condition were seen in 56 (25.2%) and 20 (32.2%) of patients undergoing primary or replacement/revision, respectively. Mean age was significantly younger among patients with depression or anxiety (62 vs 65 years; p\u0026thinsp;=\u0026thinsp;0.025). Mean BMI was higher among patients with depression or anxiety (31.08 vs 29.84), though not statistically significant. There was no association between depression or anxiety and a diagnosis of diabetes or tobacco history (see Table\u0026nbsp;1).\u003c/p\u003e \u003cp\u003ePresence of either mental health condition (depression or anxiety) was associated with a significantly higher likelihood of postoperative complication (18.42% vs 5.77%, OR 3.688; p\u0026thinsp;=\u0026thinsp;0.002). Depression (OR\u0026thinsp;=\u0026thinsp;4.114, p\u0026thinsp;=\u0026thinsp;0.001) and anxiety (OR 3.881, p\u0026thinsp;=\u0026thinsp;0.002) were also separately associated with the higher rate of overall complications. There was no association between depression and complications after primary surgery, but a significant association was found after replacement or revision (OR\u0026thinsp;=\u0026thinsp;7, p\u0026thinsp;=\u0026thinsp;0.009). Unlike depression, anxiety was significantly associated with complication regardless if primary surgery (OR 3.035, p\u0026thinsp;=\u0026thinsp;0.0464) or replacement/revision (OR 6.429, p\u0026thinsp;=\u0026thinsp;0.0177). Patients with depression or anxiety had a higher infection rate at 7.89% compared to 1.92% in patients without either diagnosis, corresponding to a OR of 4.371 (p\u0026thinsp;=\u0026thinsp;0.0252). Both depression (OR 4.823, p\u0026thinsp;=\u0026thinsp;0.0179) and anxiety (OR 4.83, p\u0026thinsp;=\u0026thinsp;0.0208) were separately found to be associated with increased rates of postoperative infection.\u003c/p\u003e \u003cp\u003eSurvival analysis found that patients with either depression or anxiety had a significantly increased risk of complication and a shorter time to complication. A diagnosis of depression was associated with a hazard ratio (HR) of 5.14 for having a complication (p\u0026thinsp;=\u0026thinsp;0.0004; Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ea), and an average time to complication of 121.2 days versus 208.8 days for those without depression. A diagnosis of anxiety was associated with a hazard ratio of 5.68 for complication (p\u0026thinsp;=\u0026thinsp;0.0008; Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eb), and an average time to complication of 147 days versus 172.4 days for those with no anxiety. Multivariable logistic regression was performed to assess the association of multiple confounding factors with complication, showing that having a diagnosis of anxiety or depression was the sole independent predictor of complication with an OR of 3.113 (95% CI: 1.283\u0026ndash;7.608).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eConversely, patients without evidence of these mental health conditions or those who had filled a prescription for active treatment prior to surgery had no significantly increased risk of complication compared to those with untreated anxiety/depression. There was no significant relationship between medical treatment of depression or anxiety preoperatively and subsequent complication when only patients with relevant diagnoses were analyzed. Survival analysis found no difference in time to complication or risk of complication in patients treated for depression or anxiety versus those that were not.\u003c/p\u003e \u003cp\u003eThe subset of patients with anxiety had a significantly increased risk of reoperation after primary surgery (OR 4.944, p\u0026thinsp;=\u0026thinsp;0.037), but not after replacement or revision. Interestingly, when examining the subset of patients with depression, there was no significant association with reoperation after primary surgery or removal/replacement. Similarly, patients who had their anxiety or depression managed by medication did not have a significant increase in reoperation compared to those managed without prescription medication.\u003c/p\u003e \u003cp\u003eSurvival analysis showed that both patients with anxiety and patients with depression had shorter times to reoperation than patients without either diagnosis. Depression was associated with a HR of 3.675 for re-operation (p\u0026thinsp;=\u0026thinsp;0.0343), with an average time to reoperation of 160 days compared to 383 days for those without (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ea). Anxiety was associated with a HR of 5.509 for reoperation (p\u0026thinsp;=\u0026thinsp;0.0145), with an average time to reoperation of 181.2 days compared to 339.25 days for those without (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eb). Patients medically treated for depression or anxiety did not have a significant difference in time to reoperation than patients that did not receive treatment.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eDepression and anxiety are commonly comorbid with erectile dysfunction (ED), and the onset of ED often precipitates poor mental health\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. Both depression and anxiety have been linked to poor surgical outcomes, with a large review finding increased wound complications in patients with moderate depression or anxiety across four of the most common surgical procedures performed in England\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. Though postoperative complications present a major source of morbidity in penile prosthesis surgery and often lead to reoperation\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e, the association between preoperative anxiety and depression and outcomes after IPP placement/revision has not been explored in the literature until now. We found that over a quarter of men undergoing these operations had depression or anxiety, and that these specific patients had a significantly greater rate of surgical complications.\u003c/p\u003e \u003cp\u003eThe prevalence of depression among men with ED is high, and the relationship is thought to be bi-directional\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. The Massachusetts Male Aging Study established that 12% of patients that developed ED had pre-existing depression\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. Similarly, a large Finnish study found that 7% of men with new onset ED had depression\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. ED appeared to have an even stronger association with developing depression, with rates of onset as high as 46% in a cohort of young males\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. Our study was consistent with this data as 25% of our patients had a diagnosis of depression, though the temporal relationship of depression and ED is unknown.\u003c/p\u003e \u003cp\u003eThe data regarding the relationship between anxiety and ED is less robust, as generalized anxiety disorder is often coupled with depression in analysis. Jern et al and Manolo et al both identified that symptoms of anxiety and depression were associated with poor erectile function\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. A cross-sectional survey of Chinese ED patients found 79.82% suffered from anxiety\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. A retrospective study of ED patients in India found that 23.4% had some kind of anxiety disorder, mostly predating ED\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. Our data showed that 18.3% of our patients had anxiety, though our cohort was clearly different with respect to age and nationality. Notably, panic disorder and post-traumatic stress disorder are also linked to ED, with a recent literature review finding the prevalence of ED to be from 2-36.2% in panic disorder and from 3\u0026ndash;85% in PTSD\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe overall complication rate of primary penile prosthesis surgery has been reported as around 5%\u003csup\u003e11\u003c/sup\u003e, but may be as high as 25% for revision cases\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. However, these rates may not account for device malfunction, which may occur in up to 17.5% over 10 years\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e. Infection is often the most feared complication given the risk of device loss, and has been reported after 1\u0026ndash;3% of cases in the era of antibiotic coatings and washouts\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. Our data in this relatively short window of collection is similar to existing data, with a 7.2% and 16.1% complication rate for primary and revision/replacement cases, respectively. The overall infection rate was 3.5%, but only 0.5% of primary implantation surgery infections were severe enough to require removal. Malfunction was seen in only 2.5% and may reflect the length of follow-up. With respect to reoperation rates, estimates range from 11\u0026ndash;15% over 5\u0026ndash;10 years\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. While our reoperation rate of 4.9% may appear due to the length of follow-up, it is lower than that reported in studies with similar follow-up\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e,\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eWe found a significant association between depression and anxiety with postoperative infection. This mirrors similar findings among other types of prosthetic surgery. In hip and knee replacements, depression and anxiety have been linked to increased risk of both superficial and prosthetic infections in primary and revision procedures\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e,\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. The proposed hypothesis underlying these findings is that depression results in the release of pro-inflammatory cytokines while decreasing immune cell functions, consequently impeding wound healing and predisposing patients to infection\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e. Depression was also associated with infection after ventricular assist device implantation, which was attributed to poor compliance with device care\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e. These hypotheses may also explain the increased risk of penile prosthesis infection in the setting of depression or anxiety, though shared comorbidities between depression/anxiety and device infection may present confounding factors.\u003c/p\u003e \u003cp\u003eOur results also suggest a relationship between depression and anxiety and the need for reoperation, though the association with anxiety is more robust. Of note, a similar relationship between mental health and reoperation has been established for orthopedic prosthesis as well\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. Infection and device malfunction are the most common reasons for penile prosthesis revision\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e and also account for the majority of complications in this study. Though the association between psychological factors and infection have been discussed, it is unclear if there is any association between mental health and reports of device malfunction. Depression and anxiety prior to surgery are associated with worse pain control and increased analgesic requirements\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e, which may make patients more sensitive to a malfunctioning prosthesis. Depression in elderly patients is also a risk factor for progression to mild cognitive impairment\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e. As most penile prosthesis recipients are elderly, depression-related cognitive impairment could contribute to reported malfunction rates as a function of device misuse.\u003c/p\u003e \u003cp\u003eThe findings in this study suggest preoperative depression and anxiety negatively affect long-term outcomes of penile prosthesis surgery. The postoperative complication and infection rate in patients with anxiety or depression are comparable to those reported for risk factors such as spinal cord injury and diabetes\u003csup\u003e\u003cspan additionalcitationids=\"CR32\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e. The current consensus in preventing complications in the preoperative setting is to screen for relevant risk factors and to optimize their management\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e. Identification and management of depression and anxiety could potentially improve outcomes in nearly a quarter of prosthetic cases, as studies suggest optimizing mental health improves recovery\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. Given that depression is associated with increased length of stay, readmission rates, and overall cost of care, preoperative efforts may reduce the burden on health care systems\u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e,\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThis study has multiple limitations, some of which have already been highlighted. It is retrospective from a single tertiary care center with a relatively small sample size, and thus results may not be fully generalizable to other practice settings. There was also relatively little psychiatric history that could be gleaned through chart review outside of diagnosis and medication usage. As depression and anxiety are best managed through a combination of medication and therapy, we were unable to fully assess whether patients were adequately managed preoperatively, and we lack a definition of what fully \u0026lsquo;optimized\u0026rsquo; would entail. This may account for the lack of association between recorded treatment of mental health conditions and our outcomes.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn summary, diagnoses of depression and/or anxiety are common among men undergoing penile prosthesis surgery, and are associated with increased complications, infections, and reoperation. Though this association has been reported by other surgical subspecialties, this study is, to our knowledge, the first to establish such a relationship in penile prosthesis recipients. Appropriate pre-operative mental health screening and management of depression and anxiety represent an opportunity for urologists to potentially improve patient outcomes. Further study will be needed to determine optimal assessments and therapeutic targets prior to surgery.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData Availability:\u0026nbsp;\u003c/strong\u003eData generated for this study can be found within the published article. Additional data is available from the corresponding author upon request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u0026nbsp;\u003c/strong\u003eAll the authors were involved in editing the final manuscript and have approved the final version. MX designed the study, collected data, performed statistical analysis and drafted the manuscript. RT designed the study, performed the operations, and gave feedback on the study design and manuscript. CP performed statistical analysis, provided feedback on the study design and collected data. DW provided feedback on the manuscript and collected data. MN, RR and ME all collected data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThis study was funded by the Wake Forest Department of Urology\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval:\u0026nbsp;\u003c/strong\u003eThis study was approved under by IRB under IRB00042919. All patients gave written consent for their anonymized data to be used in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests:\u003c/strong\u003e None of the authors have any conflicts of interest to disclose\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSadeghi-Nejad H. Penile prosthesis surgery: a review of prosthetic devices and associated complications. J Sex Med 2007; 4: 296\u0026ndash;309.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWilson SK, Zumbe J, Henry GD, Salem EA, Delk JR, Cleves MA. Infection reduction using antibiotic-coated inflatable penile prosthesis. 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J Sex Marital Ther 2012; 38: 349\u0026ndash;364.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYang Y, Song Y, Lu Y, Xu Y, Liu L, Liu X. Associations between erectile dysfunction and psychological disorders (depression and anxiety): A cross-sectional study in a Chinese population. Andrologia 2019; 51: e13395.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRajkumar RP, Kumaran AK. Depression and anxiety in men with sexual dysfunction: a retrospective study. Compr Psychiatry 2015; 60: 114\u0026ndash;118.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVelurajah R, Brunckhorst O, Waqar M, McMullen I, Ahmed K. Erectile dysfunction in patients with anxiety disorders: a systematic review. 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J Sex Med 2016; 13: 129\u0026ndash;133.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGaffney CD, Fainberg J, Punjani N, Aboukhshaba A, Pierce H, Patel N \u003cem\u003eet al.\u003c/em\u003e Immune Deficiency Does Not Increase Inflatable Penile Prosthesis Reoperation Rates. J Sex Med 2021; 18: 1427\u0026ndash;1433.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrewal S, Vetter J, Brandes SB, Strope SA. A population-based analysis of contemporary rates of reoperation for penile prosthesis procedures. Urology 2014; 84: 112\u0026ndash;116.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarmer JR, Wyles CC, Duong SQ, Morgan Iii RJ, Maradit-Kremers H, Abdel MP. Depression and anxiety are associated with an increased risk of infection, revision, and reoperation following total hip or knee arthroplasty. Bone Jt J 2023; 105-B: 526\u0026ndash;533.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWilson JM, Farley KX, Erens GA, Bradbury TL, Guild GN. Preoperative Depression Is Associated With Increased Risk Following Revision Total Joint Arthroplasty. J Arthroplasty 2020; 35: 1048\u0026ndash;1053.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGhoneim MM, O\u0026rsquo;Hara MW. Depression and postoperative complications: an overview. BMC Surg 2016; 16: 5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGordon RJ, Weinberg AD, Pagani FD, Slaughter MS, Pappas PS, Naka Y \u003cem\u003eet al.\u003c/em\u003e Prospective, multicenter study of ventricular assist device infections. Circulation 2013; 127: 691\u0026ndash;702.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTaenzer P, Melzack R, Jeans ME. Influence of psychological factors on postoperative pain, mood and analgesic requirements. Pain 1986; 24: 331\u0026ndash;342.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSteenland K, Karnes C, Seals R, Carnevale C, Hermida A, Levey A. Late-life depression as a risk factor for mild cognitive impairment or Alzheimer\u0026rsquo;s disease in 30 US Alzheimer\u0026rsquo;s disease centers. J Alzheimers Dis JAD 2012; 31: 265\u0026ndash;275.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePang KH, Muneer A, Alnajjar HM. A Systematic Review of Penile Prosthesis Insertion in Patients With Spinal Cord Injury. Sex Med Rev 2022; 10: 468\u0026ndash;477.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGon LM, de Campos CCC, Voris BRI, Passeri LA, Fregonesi A, Riccetto CLZ. A systematic review of penile prosthesis infection and meta-analysis of diabetes mellitus role. BMC Urol 2021; 21: 35.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTienforti D, Totaro M, Spagnolo L, Di Giulio F, Castellini C, Felzani G \u003cem\u003eet al.\u003c/em\u003e Infection rate of penile prosthesis implants in men with spinal cord injury: a meta-analysis of available evidence. Int J Impot Res 2024; 36: 206\u0026ndash;213.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrimley SC, Yousif A, Kim J, Hellstrom WJG. Tips and tricks in the management of inflatable penile prosthesis infection: A review. Arab J Urol 2021; 19: 346\u0026ndash;352.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSumbal R, Murtaza M, Sumbal A, Farooq A, Ali Baig MM, Qadar LT. Relationship Between Mental Health Disorders and Readmissions Following Total Joint Arthroplasty: A Systematic Review and Meta-Analysis. J Arthroplasty 2023; 38: 188\u0026ndash;193.e1.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePortnoy AR, Chen S, Tabbaa A, Magruder ML, Kang K, Razi AE. Complications and Healthcare Cost of Total Hip Arthroplasty in Patients with Depressive Disorder. Hip Pelvis 2024; 36: 204\u0026ndash;210.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Table 1","content":"\u003cp\u003eTable 1: Demographic characteristics of patient population at time of surgery\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"708\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 209px;\"\u003e\n \u003cp\u003eCharacteristic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 304px;\"\u003e\n \u003cp\u003eDepression/Anxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 317px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 209px;\"\u003e\n \u003cp\u003eProsthesis surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 108px;\"\u003e\n \u003cp\u003e284\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 141px;\"\u003e\n \u003cp\u003e76 (26.76%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 163px;\"\u003e\n \u003cp\u003e208 (73.24%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 209px;\"\u003e\n \u003cp\u003ePrimary surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 108px;\"\u003e\n \u003cp\u003e222 (78.17%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 141px;\"\u003e\n \u003cp\u003e56 (19.72%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 163px;\"\u003e\n \u003cp\u003e166 (58.45%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 209px;\"\u003e\n \u003cp\u003eRemoval/replacement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 108px;\"\u003e\n \u003cp\u003e55 (19.37%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 141px;\"\u003e\n \u003cp\u003e18 (6.34%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 163px;\"\u003e\n \u003cp\u003e37 (13.03%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 209px;\"\u003e\n \u003cp\u003eRevision\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 108px;\"\u003e\n \u003cp\u003e7 (2.46%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 141px;\"\u003e\n \u003cp\u003e2 (0.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 163px;\"\u003e\n \u003cp\u003e5 (2.76%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 209px;\"\u003e\n \u003cp\u003eMean Age (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 141px;\"\u003e\n \u003cp\u003e62.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 163px;\"\u003e\n \u003cp\u003e64.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e0.025\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 209px;\"\u003e\n \u003cp\u003eMean BMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 141px;\"\u003e\n \u003cp\u003e31.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 163px;\"\u003e\n \u003cp\u003e29.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e0.075\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 209px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 141px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 163px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 209px;\"\u003e\n \u003cp\u003eCurrent Smoker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 141px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 163px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 209px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 108px;\"\u003e\n \u003cp\u003e33 (11.62%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 141px;\"\u003e\n \u003cp\u003e11 (3.87%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 163px;\"\u003e\n \u003cp\u003e22 (7.75%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 209px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 108px;\"\u003e\n \u003cp\u003e247 (86.97%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 141px;\"\u003e\n \u003cp\u003e63 (22.18%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 163px;\"\u003e\n \u003cp\u003e184 (64.79%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 209px;\"\u003e\n \u003cp\u003eUnknown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 108px;\"\u003e\n \u003cp\u003e4 (1.41%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 141px;\"\u003e\n \u003cp\u003e2 (0.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 163px;\"\u003e\n \u003cp\u003e2 (0.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 209px;\"\u003e\n \u003cp\u003eDiabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 141px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 163px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e0.587\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 209px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 108px;\"\u003e\n \u003cp\u003e118 (41.55%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 141px;\"\u003e\n \u003cp\u003e34 (11.97%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 163px;\"\u003e\n \u003cp\u003e84 (29.58%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 209px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 108px;\"\u003e\n \u003cp\u003e166 (58.55%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 141px;\"\u003e\n \u003cp\u003e42 (14.79%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 163px;\"\u003e\n \u003cp\u003e124 (43.66%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-impotence-research","isNatureJournal":false,"hasQc":false,"allowDirectSubmit":false,"externalIdentity":"ijir","sideBox":"Learn more about [International Journal of Impotence Research](http://www.nature.com/ijir/)","snPcode":"41443","submissionUrl":"https://mts-ijir.nature.com/cgi-bin/main.plex","title":"International Journal of Impotence Research","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"ejp","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6273246/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6273246/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eDepression and anxiety are often comorbid with erectile dysfunction and are linked to worse surgical outcomes. We aimed to determine if depression/anxiety increased complication rates in penile prosthesis surgery. All penile prosthesis cases by a single surgeon at our institution from 2020\u0026ndash;2022 were reviewed. Data was collected on demographics, medical/psychiatric history, intraoperative details, and post-operative outcomes. Fisher\u0026rsquo;s exact test was used to compare complications amongst patients when sorted by categorical variables. Complications were analyzed as time to event outcomes using Kaplan-Meier methods. Multivariable logistic regression was used to measure the effect of mental health on complications while controlling for potential confounders. 284 penile prosthesis cases were performed. Anxiety/depression was significantly associated with post operative complications (p\u0026thinsp;=\u0026thinsp;0.002) and infection (p\u0026thinsp;=\u0026thinsp;0.025). Anxiety/depression is independently associated with increased complications in a multivariable logistic regression model including age, BMI, diabetes, primary surgery, smoking status, and correctly holding anticoagulation. Survival analysis showed that anxiety and depression both resulted in faster times to complication and re-operation (all p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). This is the first study assessing the impact of mental health on penile prosthesis outcomes. Urologists should consider mental health when evaluating patients for prosthesis surgery, and mental health treatment prior to surgery may improve outcomes.\u003c/p\u003e","manuscriptTitle":"Depression and Anxiety are Associated with Increased Complications after Penile Prosthesis Surgery","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-07 10:14:23","doi":"10.21203/rs.3.rs-6273246/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"revise","date":"2025-05-12T13:01:03+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"This content is not available.","date":"2025-04-20T23:16:04+00:00","index":2,"fulltext":"This content is not available."},{"type":"reviewerAgreed","content":"This content is not available.","date":"2025-04-16T21:18:17+00:00","index":2,"fulltext":"This content is not available."},{"type":"editorInvitedReview","content":"This content is not available.","date":"2025-03-27T17:30:38+00:00","index":1,"fulltext":"This content is not available."},{"type":"reviewerAgreed","content":"This content is not available.","date":"2025-03-25T09:56:50+00:00","index":1,"fulltext":"This content is not available."},{"type":"reviewersInvited","content":"","date":"2025-03-25T08:58:02+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-21T10:15:14+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-03-21T02:06:27+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Journal of Impotence Research","date":"2025-03-21T02:06:26+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-impotence-research","isNatureJournal":false,"hasQc":false,"allowDirectSubmit":false,"externalIdentity":"ijir","sideBox":"Learn more about [International Journal of Impotence Research](http://www.nature.com/ijir/)","snPcode":"41443","submissionUrl":"https://mts-ijir.nature.com/cgi-bin/main.plex","title":"International Journal of Impotence Research","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"ejp","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"1837fae2-c058-4382-afb1-db3748e16dea","owner":[],"postedDate":"April 7th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":46171765,"name":"Health sciences/Diseases/Urogenital diseases/Erectile dysfunction"},{"id":46171766,"name":"Health sciences/Risk factors"},{"id":46171767,"name":"Health sciences/Health care/Therapeutics/Surgery"},{"id":46171768,"name":"Health sciences/Health care/Therapeutics/Adverse effects"}],"tags":[],"updatedAt":"2025-08-07T07:34:09+00:00","versionOfRecord":{"articleIdentity":"rs-6273246","link":"https://doi.org/10.1038/s41443-025-01149-9","journal":{"identity":"international-journal-of-impotence-research","isVorOnly":false,"title":"International Journal of Impotence Research"},"publishedOn":"2025-08-06 04:00:00","publishedOnDateReadable":"August 6th, 2025"},"versionCreatedAt":"2025-04-07 10:14:23","video":"","vorDoi":"10.1038/s41443-025-01149-9","vorDoiUrl":"https://doi.org/10.1038/s41443-025-01149-9","workflowStages":[]},"version":"v1","identity":"rs-6273246","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6273246","identity":"rs-6273246","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}