Reprod Dom Anim 45, 558563 (2010); doi: 10.1111/j.1439-0531.2008.01257.

x ISSN 0936-6768

Case Report Priapism Secondary to Perineal Abscess in a Dog A Case Report

A Martins-Bessa1, T Santos2, J Machado2, R Pinelas2, MA Pires3 and R Payan-Carreira3
1

Veterinary Sciences Department; 2Veterinary Teaching Hospital; 3CECAV, University of Tras-os-Montes and Alto Douro, Vila Real, Portugal

Contents
A 7-year-old intact male Boxer was referred to our services at the Veterinary Teaching Hospital of the University of Trasos-Montes and Alto Douro, suering from a persistently erect penis (including the bulbus glandis) that had been exposed for several days. Radiographic and ultrasonographic examinations detected a 5.0 3.5 cm mass located dorso-laterally to the urinary bladder. The microbial culture of the mass revealed Staphylococcus spp. At that time, we suspected the involvement of an abscess in the origin of the priapism. Medical and surgical treatments were promptly instituted, which allowed for penile withdrawal into the prepuce; however, the resolution of the penile erection was not accomplished in the following days and penile amputation was required. Histological evaluation of the excised penis revealed extensive infarction of the erectile tissue of the pars longa and bulbus glandis, and also of the blood vessels of the penis. Following penile amputation and antimicrobial therapy, the animal fully recovered. Ultimately, the animal died as a consequence of gastric torsion. At necropsy, some lesions compatible with a previous perforation of the intestinal wall were recorded. The data gathered from the anamnesis, the physical and imaging examinations, along with the post-mortem ndings, allowed us to conclude that in this clinical case the primary cause of priapism was a perineal abscess due to bowel perforation.

conrmation of the hypothesis that had been proposed as the origin of the priapism: an extended perineal abscess induced by bowel perforation.

Case Report
A 7-year-old intact male Boxer weighing 27.6 kg was referred for consultation to the Reproductive Medicine Service at the Veterinary Teaching Hospital of the University of Tras-os-Montes and Alto Douro (Portugal) with history of dysuria, stranguria and haematuria (which had led to repeated bladder catheterization) as well as persistent penile exposure and oedema which had been present for 7 days. On admission the dog evidenced signs of lameness in its hind limbs, suggestive of a painful perineal condition. The physical examination failed to reveal any obvious abnormalities other than the persistently erect penis, that included the bulbus glandis (Fig. 1a), and incapacity to withdraw the penis into the prepuce. Oedema was also detected, extending from the post-scrotal area to the internal face of the hindlimbs, with local rubor and elevated temperature. A radiographic examination of the caudal abdomen revealed the presence of a slightly radiodense mass located dorsocaudally to the urinary bladder (UB) (Fig. 1b). For the ultrasonographic (US) examination a Philips HD3 scanner (Philips Medical System, Andover, MA, USA) was used, with a 59 MHz linear-array and a 24 MHz convex transducers. The US examination revealed a markedly distended UB and prostatic urethra (Fig. 2a). The ultrasonograms of the prostate revealed a normal size, echogenicity, shape and symmetry. A poorly-delimited mass with heterogeneous echogenicity (Fig. 2b) was identied dorso-caudally to the UB, measuring about 5.0 cm in length and 3.5 cm in width. Penile US examination revealed a markedly increased size of the erectile structures and a reduction of the overall echogenicity of the penile structures when compared to normal US images (Fig. 2c,d; PayanCarreira and Bessa 2008). The US images collected at the bulbus glandis (Fig. 2d) showed the urethra surrounded by a clearly evident and slightly echogenic corpus spongiosum, enclosed by the os penis identied as a V-shaped, hyperechogenic structure. A pronounced increase in the erectile tissue (ET) of pars longa and bulbus glandis size was shown, along with a reduction of its echogenicity. A change to a coarse granular pattern of irregular echogenicity and the absence of small anechogenic spaces that correspond to the sinusoids (Fig. 2d) was also observed.

Introduction
Priapism is a prolonged and painful penile erection not initiated by sexual stimuli, resulting from a disturbance in the normal regulatory mechanisms that initiate and maintain penile accidity (Harmon and Nehra 1997). In man, priapism has been most frequently described as a result of the use of intracavernous vasoactive drugs (such as papaverine) (Lue et al. 1986), a systemic disease (such as haemoglobinopathy) (Fowler et al. 1991) or penile metastasis from urogenital tumors (Morga Egea et al. 2000). Priapism is rarely described in association with medullar compression (Lorenzini et al. 2001) or as an adverse eect of antipsychotic medication (Compton and Miller 2001). Priapism is an uncommon condition in veterinary medicine (Oyamada et al. 1997), but a few case reports have been described in dogs (Orima et al. 1989; Guilford et al. 1990; Rogers et al. 2002), cats (Orima et al. 1989; Gunn-Moore et al. 1995) and horses (Blanchard et al. 1991; Oyamada et al. 1997; Van Harreveld and Gaughan 1999). The present report describes the clinical and pathological ndings of a case of priapism that developed as a consequence of a perineal abscess in a 7-yearold dog. The patient later died from causes unrelated to the case described here, and the necropsy allowed for the

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(a)

(b)

Fig. 1. Priapism in a 7-year-old male Boxer. (a) At admission, the penis was persistently erect and had been exposed for 7 days. A penile mucosal erosion and congestion was evident, as well as peri-scrotal oedema. (b) On the latero-lateral abdominal radiography, a radiodense mass (arrows heads) dorso-caudal to the distended urinary bladder (UB) is present. Ventrally, the cranial border of the prostate gland (P) can be detected

A serum chemistry prole revealed markedly increased BUN, alkaline phosphatase and creatinin, and the complete blood count exhibited leukocytosis with neutrophilia (Table 1). After decompression of the UB, a sample of the mass was obtained by ne needle aspiration, for cytological examination and culture. Cytological examination of the mass revealed a predominance of neutrophils and the presence of bacteria, indicative of an abscess. Staphylococcus spp. was isolated from the bacteriological culture. Cytological examination of the urine sediment was consistent with chronic cystitis. The dierential diagnosis of penile exposition included priapism, paraphimosis and penile paralysis. Data obtained during clinical evaluation and by X-ray and US examination were highly suggestive of priapism. The existence of oedema in the post-scrotal area could be associated with compression at a caudal level of the internal pudendal vessels veins or at the dorsal level of the vein of the penis. The compression exerted at those points could also explain the impairment of penile venous drainage, which could be responsible for the priapism. Medical treatment was initiated with intravenous uids (0.9% saline) and anti-biotherapy: Enrooxacin (Baytril; Bayer HealthCare, Carnaxide, Bayer Portugal) in association with Clindamycin (Antirobe; Pzer Portugal, Porto Salvo, Portugal) in a dosage of 5 mg kg i.v. and 11 mg kg p.o. q12h, respectively. Non-steroidal anti-inammatory medication was also administered, using meloxicam (Metacam; Boehringer Ingelheim, Vetlima, Portugal) at initial 0.2 mg kg s.c. dosage on the rst day, followed by a maintenance dosage of 0.1 mg kg day s.c. Priapism was managed using cold compresses locally with saline and hypertonic solutions several times a day. As the patient failed to respond promptly to this treatment, surgery was performed on day 2 to enlarge the diameter of the preputial orice. The animal was pre-medicated with 0.2 mg kg butorphanol (Turbogesic; Fort Dodge Veterinaria SA, Girona, Spain) intravenously and anaesthesia was induced with intravenous administration of 4 mg kg propofol (Propofol Lipuro; Braun, Melsungen, Germany); this was

followed by an inltration of 2 ml lidocaine 1% (Linca na; Braun) around the incision line and anaesthesia was maintained with boluses of 2 mg kg propofol as needed (total of 8 mg kg). Penis retraction into the preputial cavity was then achieved. Nevertheless, resolution of the persistent erection was not accomplished during the following days and, also due to the onset of necrosis of the penis, a penile amputation with prescrotal urethrostomy and orchiectomy was performed on day 4. The procedure was initiated by pre-medicating the patient with 0.4 mg kg butorphanol and 0.4 mg kg diazepam (Bialzepam; Bial, Sao Mamede do Coronado, Portugal) intravenously, where anaesthesia was induced with intravenous injection of 4 mg kg propofol; after intubation, anaesthesia was maintained with 1.52.2% isourane (IsoFlo; Abbott Laboratories, Barcelona, Spain) in 100% oxygen. Gradual improvements in micturition and in urinary tract condition were observed as the animal became ambulatory. The dog was followed with routine checkups in the internal medicine services for an additional 2 months. The penis and prepuce were submitted to standard methods of preparation for histological examination after xation in 10% buered formalin solution. The tissues were then processed for inclusion in paran, sectioned at 2 lm and stained with haematoxylin and eosin (H&E). Microscopical examination revealed penile infarction, with extended necrosis, haemorrhage and multiple thrombi. Compression of the urethra was also observed, which was reduced to a cleft. The skin of the prepuce was normal. The ET of both pars longa and bulbus glandis evidenced multiple large-sized thrombi, features compatible with a chronic process, and extended necrosis (Fig. 3ac). Sections obtained at the preputial cavity entrance revealed that this space was relled by granulation tissue with marked inltration by neutrophils. Two months after its last visit to our Hospital the animal suddenly died as a consequence of gastric dilatation and torsion of intestine and spleen. At necropsy, the volvulus involving the intestine, spleen and stomach was the most relevant nding. The

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(a)

(b)

(c)

(d)

Fig. 2. Ultrasonograms obtained at admission. Images (a) and (b) were obtained using a 24 MHz convex transducer. (a) Longitudinal ultrasonogram of the prostate gland. The prostatic parenchyma surrounds a distended prostatic urethra (U). (b) Ultrasonogram of the mass dorso-lateral to the bladder: a heterogeneous mass (arrows) dorso-caudal to the UB is seen. Images (c) and (d) were obtained using a 59 MHz linear transducer. (c) Ultrasonogram performed in a healthy male of a similar weight at the level of the bulbus glandis. The os penis (asterisks), evidenced as a V-shaped hyperechogenic structure surrounds the corpus spongiosum and the urethra (arrow), the bulbus erectile tissue (ET) is demonstrated as a structure of a coarse granular pattern of irregular echogenicity (arrowhead). (d) In the diseased dog, on the ultrasonograms obtained at the bulbus glandis a slightly echogenic corpus spongiosum (arrow) surrounding the urethra is evidenced, along with a pronounced increase in size of the bulbus the ET, which also showed a decrease in echogenicity (arrowhead) Table 1. Haematological and serum biochemical values on patients admission
Parameter Complete blood count Red blood cells (RBC) (1012 l) Packed cell volume (fraction of RBC) White blood cells (WBC) (109 l) Neutrophils (fraction of WBC) Eosinophils (fraction of WBC) Lymphocytes (fraction of WBC) Monocytes (fraction of WBC) Serum biochemistry Alkaline phosphatase (U l) Alanine aminotransferase (U l) Total protein (g l) Albumin (g l) Blood urea nitrogen (mmol l) Creatinin (lmol l) Value Reference range

6.26 0.46 21.4 0.90 0.07 0.69 0.27 816 70 56 29 39.63 230.72

5.58.5 0.370.55 6.117.4 0.60.7 0.020.1 0.120.3 0.030.1 10.6100.7 8.257.5 5080 2235 2.039.71 54.81153.82

abdominal and pelvic areas were carefully examined as they were previously suspected to be the location of the abscess. No evidence of the previous abscess remained, but a closer examination of the colon demonstrated the existence of a serosal wall scar compatible with a prior perforation of the colonic wall (Fig. 3d). We concluded, therefore, that bowel perforation was the most probable cause of abscess formation in the pelvic area. It had subsequently caused priapism, secondary to compression and impairment of venous drainage of the penis into the internal pudendal veins.

Discussion
Even though several causes for priapism have been reported in animals (mainly horses) and humans, many of the exact mechanisms for the dierent aetiologies of

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(a)

(b)

(c)

(d)

Fig. 3. Anatomopathological evaluation of the excised penis and prepuce (ac). (a) At gross examination, on transverse sections of the excised penis and prepuce, infarctation of the ET of pars longa is clearly demonstrated, together with the corpus spongiosum engorgement, which substantially reduces the lumen of the urethra (U). The asterisk indicates the os penis. (b) On the microphotograph histological evaluation of cross-sections obtained at pars longa penis level, revealed that the urethral (U) lumen is reduced to a cleft and the thromboembolism of the corpus spongiosum is evident (H&E; scale bar = 300 lm, small mu, Greek, m). (c) Besides the reduced lumen of the urethra (U), several thrombi in the ET of the pars longa are observed (H&E; scale bar = 300 lm, small mu, Greek, m). (d) At necropsy, a scar lesion on the colon serosa was found (arrowhead), compatible with a previous lesion that could be associated with the abscess

priapism are unknown in domestic animals (Rochat 2001). In horses, priapism occurs most commonly after administration of a-adrenergic blocking agents such as phenotiazine-derivative tranquilizers (Shumacher and Vaughan 1988). Tumour metastasis (Blanchard et al. 1991) or spinal nematodiasis with associated parenchymal destruction of the spinal cord (Oyamada et al. 1997) are seldom primary causes in this species. Priapism is an uncommon condition in cats and dogs (Gunn-Moore et al. 1995). The most important causes of dog priapism are spinal cord injuries leading to the stimulation of the erection centre or the pelvic nerves (Orima et al. 1989). It has also been reported in association with penile thromboembolic lesions (Johnston et al. 2001), genitourinary infections and constipation (Papazoglou 2004) or associated to multifocal distemper encephalomyelitis (Guilford et al. 1990). Priapism secondary to a penile metastasis has also been reported in a dog (Rogers et al. 2002). In the present

case it was probably the development of an abscess in the pelvic cavity, which later extended to the pelvic area that impaired blood drainage from the glans penis by compression. During initial evaluation the origin of the abscess in this area was not possible to determine. Although bowel perforation is a suitable explanation for the presence of this abscess, anamnesis and clinical signs did not support this, so further studies were not performed to rule out this hypothesis. The pattern of blood ow to the penis that occurs during normal erection is altered in priapism (Rochat 2001). The associated vascular stasis in the penile corpus cavernosum results in sickling of erythrocytes that occlude the venous outow and bring about trabecular oedema (Pauwels et al. 2005). If prolonged, priapism leads to irreversible thrombosis of the cavernous spaces (Blanchard et al. 1991). In the case reported here, the existence of the abscess remained undetected for several days, and when the patient was presented for consulta-

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A Martins-Bessa, T Santos, J Machado, R Pinelas, MA Pires and R Payan-Carreira

tion in our Hospital the recorded anamnesis from the referring clinic included a week-long history of recurrent penile exposure due to oedema and the need for multiple bladder catheterizations. Along with oedema, the rubor and raised local temperature in the postscrotal and perineal area were also detected during clinical examination. Taken together, these facts pointed to a chronic situation that would pre-dispose this animal to be non-responsive regarding clinical resolution of the priapism. Repetitive and prolonged exposition of the penis from the preputial cavity, in this case, also induced abrasion and necrosis of the penile mucosa, as is described for sustained priapism (Rochat 2001). The goal of the priapism therapy is to restore normal circulation in the corpus cavernosum (Van Harreveld and Gaughan 1999). A prompt diagnosis of the specic cause is crucial in order to institute the appropriate therapy (Rochat 2001) and to preserve the penis from severe injury, desiccation, ischemia, necrosis and urethral obstruction (Johnston et al. 2001). Nevertheless, the choice of an eective method to treat priapism is demanding, because precise causes in most patients are not well-dened (Wilson et al. 1991). Pharmacological treatment with benztropine mesylate is successful in horses, but should be administered early after onset of priapism, when venous drainage in the cavernous space is still preserved (Wilson et al. 1991). In horses, the ushing of the corpus cavernosum penis with heparinized saline solution to remove clotted blood which impairs venous return and blood circulation from the cavernous tissue has better success rates when applied shortly after the onset of the situation (Van Harreveld and Gaughan 1999). This procedure is reserved for when pharmacological therapy fails (Rochat 2001). In this case, conservative methods of treatment failed to achieve detumescence. An early detection of the compression induced by the abscess mass was mandatory for achieving an eective withdraw of the penis and to oppose the tendency for thrombi formation in the penis. Decompression through surgical methods such as the tunica albuginea incision, which includes the incision of the bulbus glandis as well as the pars longa (Orima et al. 1989), was not attempted, as decompression is usually successful without permanent damage provided the treatment is done within 12 h of the onset of the situation (Kalsi et al. 2002), which was not the case. In the present report, as palliative measures failed, a penile amputation was performed to avoid extensive penile necrosis. The pathophysiology of priapism in dog has been poorly described, so the relative risks and benets of the application of spongiosum-cavernous shunts in the treatment of priapism are unknown (Rochat 2001). Some evidence points to the hypothesis that dog priapism preferentially involves the engorgement of the corpus spongiosum (Rochat 2001), contrary to other species. Even in the case that both ET are aected, it should be expected that the shunting procedures would be of little benet in the dog (Rochat 2001). In the present case, the prolonged priapism led to irreversible thrombosis of the cavernous spaces, haemorrhagic lesions and necrosis, which compromised the

subsequent normal function of the penis. The postmortem ndings pointed to a denitive explanation of the perineal abscess that subsequently caused priapism, probably through a penile vascular obstruction associated with impaired venous outow. In the case described here, from the physical, imaging examinations and postmortem ndings it was concluded that the primary cause of the priapism was most probably the perineal abscess that followed bowel perforation. Acknowledgement
The authors wish to thank Raquel Souto for the English revision of the manuscript.

Author contributions
A. Martins-Bessa carried out the ultrasonographic examinations, participated in the clinical follow-up and drafted the manuscript. T. Santos and J. Machado performed the pre-and post-surgical follow-up of the animal, including X-rays and blood analysis. R. Pinelas performed the surgical interventions. MA Pires carried out the necropsy and all the anatomopathological analysis and help to draft the manuscript. R. Payan-Carreira helped with ultrasonographic examinations, coordinated the clinical follow-up and drafted the manuscript.

References
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Priapism Secondary to Perineal Abscess in a Dog Oyamada T, Miyajima K, Kimura Y, Kikuchi M, Nakanishi S, Yoshikawa H, 1997: Priapism possibly caused by spinal nematodiasis in a stallion. J Equine Sci 8, 101107. Papazoglou LG, 2004: Diseases and surgery of the canine penis and prepuce. In: Congress Proceedings Online, 29th World Congress WSAVA, 6th9th October, Rhodes, Greece [http://www.vin.com/proceedings/Proceedings.plx? CID=WSAVA2004&O=Generic]. Accessed in June 16, 2008. Pauwels F, Schumacher J, Varner D, 2005: Priapism in horses. Compendium Cont Edu Pract Vet 27, 311315. Payan-Carreira R, Bessa AC, 2008: Application of B-mode ultrasonography in the assessment of the dog penis. Anim Reprod Sci 106, 174180. Rochat MC, 2001: Priapism: a review. Theriogenology 56, 713722. Rogers L, Lopez A, Gillis A, 2002: Priapism secondary to penile metastasis in a dog. Can Vet J 43, 547549.

563 Shumacher J, Vaughan JT, 1988: Surgery of the penis and prepuce. Vet Clin North Am Equine Pract 4, 473491. Van Harreveld PD, Gaughan EM, 1999: Partial phallectomy to treat priapism in a horse. Aust Vet J 77, 167169. Wilson DV, Nickels FA, Williams MA, 1991: Pharmacologic treatment of priapism in two horses. J Am Vet Med Assoc 199, 11831184.

Submitted: 22 Jul 2008 Authors address (for correspondence): Ana Celeste Martins-Bessa, Department of Veterinary Sciences, University of Tras-os-Montes and Alto Douro, Apart. 1013; 5001-801 Vila Real, Portugal. E-mail: abessa@utad.pt

2008 The Authors. Journal compilation 2008 Blackwell Verlag

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