C.C. Wang, J.H. Chen, S.P.

Liu, et al

POST-TRAUMATIC, HIGH-FLOW PRIAPISM TREATED WITH SELECTIVE CAVERNOUS ARTERY EMBOLIZATION AND INTRACAVERNOUS STREPTOKINASE IRRIGATION: A CASE REPORT
Chung-Cheng Wang, Jyh-Horng Chen, Shih-Ping Liu, Jyi-Jyh Hung,1 Po-Chin Liang,1 and Ju-Ton Hsieh

Abstract: A 54-year-old man developed priapism shortly after a blunt perineal trauma. An arteriocavernous fistula caused the high-flow priapism, and was detected on both color Doppler sonography and selective phaloarteriography. Selective embolization of the left cavernous artery with Gelfoam was performed to seal the fistula, resulting in immediate detumescence. However, the penis remained firm despite returning to almost normal size. No fistula was detected by subsequent color Doppler sonography and phaloarteriography examination. Intracavernous irrigation with 200,000 U streptokinase was applied to treat residual firmness 2 weeks after embolization. Successful sexual intercourse was reported 3 months later. The combination of selective cavernous artery embolization and intracavernous streptokinase irrigation was effective for the treatment of the high-flow priapism in this case.

(J Formos Med Assoc 2000;99:9524) Key words:

embolization high-flow priapism streptokinase

Priapism, an uncommon condition of prolonged penile erection, is usually caused by abnormal venous outflow from the corpora cavernosa (low-flow priapism) [1]. Direct arterial injuries may induce uncontrollable arterial inflow resulting in high-flow priapism. Different treatment strategies are needed for low- and highflow priapism [2, 3]. We report a case of high-flow priapism successfully treated by selective cavernous artery embolization and intracavernous streptokinase irrigation.

Case Report
A 54-year-old sexually-active man suffered from priapism shortly after an episode of straddle trauma, when he fell on the edge of a ditch, suffering a hard blow to his perineum. No gross hematuria or dysuria was experienced. He visited our urology clinic because of prolonged penile erection 70 days later. Physical examination revealed a painless,

indurated mass (1.5 x 1.5 cm) at the peno-scrotal junction and persistent penile erection. Urinalysis, complete blood count, prothrombin time, partial thromboplastin time, biochemical studies, and chest roentgenography showed nothing abnormal. Color Doppler sonography of the penis disclosed a homogenous, hypoechoic lesion (1.8 x 1.2 cm) near the junction of the penile cruses, receiving extensive blood flow from the left cavernous artery. The peak arterial velocity in the left cavernous artery proximal to the mass was 98.2 cm/s (Fig. 1). Selective left internal pudendal arteriography revealed disruption of the left proximal cavernous artery resulting in arteriocavernous fistula formation and a large pseudoaneurysm of the sinusoidal space (Fig. 2A). Transarterial embolization (TAE) with Gelfoam strip was performed on the left cavernous artery. A post-TAE film showed disappearance of the arteriocavernous fistula without injury to the urethral artery (Fig. 2B). Immediate detumescence of the penis was noted after TAE. However, the penis retained an abnormally firm consistency despite returning to almost normal size. Subsequent phaloarteriography and color Doppler sonography did not detect the fistula 2 days later. The penis remained abnormally firm in the flaccid state 2 weeks after TAE. Intracavernous irrigation with 200,000 U

Departments of Urology and 1Radiology, National Taiwan University Hospital, Taipei, Received: 16 February 2000. Revised: 10 March 2000. Accepted: 11 April 2000. Reprint requests and correspondence to: Dr. Ju-Ton Hsieh, Department of Urology, National Taiwan University Hospital, 7 Chung-Shan South Road, Taipei, Taiwan.

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Embolization and Intracavernous Streptokinase Irrigation for High-flow Priapism

Fig. 1. Color Doppler ultrasound reveals a 1.8 x 1.2-cm hypoechoic lesion in the proximal corpus cavernosum. High blood flow is also shown (arrow).

streptokinase (Hoechst, Frankfurt, Germany) was performed, resulting in a mild reduction in penile firmness. No fever or penile pain resulted from the irrigation. Successful sexual intercourse was reported 3 months after treatment, even though his penis retained a mild abnormal firmness in the flaccid state.

Discussion
Priapism is the occurrence of persistent penile erection unassociated with sexual arousal. It is characterized by

tumescence of the corpora cavernosa associated with a flaccid corpus spongiosum and glans penis. The mechanism of high-flow arterial priapism has been proposed as unregulated arterial inflow bypassing the protective, highly resistant helicine arteries, thereby entering the lacunar spaces directly. The lacunar spaces distend, but, in the absence of neurologic stimulation, compression of the subtunical venules against the tunica albuginea is incomplete [4]. Unlike low-flow priapism, adequate venous outflow is still preserved in high-flow priapism, and blood stasis, hypoxia, and tissue damage are prevented [3]. Accurate differentiation between high- and lowflow priapism is mandatory for an appropriate therapeutic approach. Diagnostic modalities include a history of trauma, penile aspiration with blood gas determination, Doppler sonography, and phaloarteriography [5]. A history of significant trauma to the perineum prior to the occurrence of priapism, the absence of severe erection pain, and corporal aspiration of bright red blood imply arterial priapism. Delayed presentation of high-flow priapism is not uncommon because of lack of discomfort [6]. Treatments for arterial priapism include mechanical, pharmacologic, surgical, and radiologic options [79]. Mechanical intervention consists of external compression of the perineum with local application of ice for a few hours. However, this maneuver is often unsuccessful owing to the lack of precise location to stop the proximal arterial inflow. Intracavernous irrigation with vasoactive agents results in only transient or incomplete resolution of arterial priapism. Conventional shunting procedures do not achieve detumescence in arterial priapism and should be avoided. Surgical ligation of the affected vessel offers precise control of the bleeding vessel and can be

Fig. 2. A) Selective left internal pudendal arteriography reveals disruption of the left cavernous artery, forming an arteriosinusoidal fistula and a large pseudoaneurysm in the sinusoidal space. B) The post-transarterial embolization film shows the disappearance of the arteriosinusoidal fistula and that the urethral artery is still patent. J Formos Med Assoc 2000 Vol 99 No 12

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reserved for patients who are allergic to contrast media or in whom embolization is unsuccessful. Selective arterial embolization can be performed with the use of Gelfoam, coil, bucrylate, or autologous blood. In our patient, we used Gelfoam as the embolization material and erectile function was preserved after treatment. This is not surprising since a previous study indicated that a high percentage of erectile function preservation could be achieved after TAE treatment [10]. In addition to aspiration and irrigation of the corpora cavernosa, local fibrinolysis with streptokinase has been shown to be effective as an adjuvant treatment for low-flow priapism; it removes the fibrin and thrombosis deposited in the corpora cavernosa [11, 12]. The long duration of high-flow priapism in this case made it possible that some fibrin had deposited in the corpus cavernosum. In spite of embolization treatment, the penis retained an abnormally firm consistency in the flaccid state and made subsequent streptokinase irrigation necessary. Local fibrinolytic therapy after arterial embolization for high-flow priapism has not been previously reported. This treatment was effective and without any systemic adverse effects. In conclusion, the combination of selective cavernous artery embolization and the empiric use of intracavernous streptokinase irrigation was effective for the treatment of high-flow priapism in our patient.

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