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25 Priapism
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Definition: Priapism is a full or partial erection that continues more than 4 hours beyond sexual stimulation and orgasm or is unrelated to sexual stimulation. Three types:
Ischemic Priapism (Veno-Occlusive, Low-Flow)
Ischemic Priapism
Ischemic priapism is a persistent erection marked by rigidity of the corpora cavernosa and little or no cavernous arterial inflow. In ischemic priapism there are time-dependent changes in the corporal metabolic environment with progressive hypoxia, hypercarbia, and acidosis. The patient typically complains of penile pain after 6 to 8 hours, and the examination reveals a rigid erection The condition is analogous to a muscle compartment syndrome Interventions beyond 48 to 72 hours of onset may help relieve erection and pain but have little benefit in preserving potency. Ischemic priapism is an emergency. When left untreated, resolution may take days and erectile dysfunction (ED) invariably results
A disruption of the cavernous arterial anatomy creating an arteriolar-sinusoidal fistula The cavernous environment does not become ischemic and cavernous blood gases do not show hypoxia, hypercarbia, or acidosis. This type of priapism, once properly diagnosed, does not require emergent intervention.
The term priapism has its origin in reference to the Greek god Priapus, who was worshipped as a god of fertility and protector of horticulture. Priapus is memorialized in sculptures for his giant phallus.
Hematologic dyscrasias are a major risk factor for ischemic priapism. Priapism has been described as a complication of SCD, thalasssemia, hemoglobin Olmsted, and thrombophilia
In most case reports of metastatic priapism, the primary malignancy is genitourinary (prostate and bladder) SCD priapism has traditionally been ascribed to stagnation of blood within the sinusoids of the corpora cavernosa during physiologic erection, secondary to obstruction of venous outflow by sickled erythrocytes the incidence of priapism in men with homozygous sickle cell (SS) disease was 42% (another paper: 6.4% )
The sickle cell genetic mutation is the result of a single amino acid substitution in the beta-globin subunit of haemoglobin. The clinical features are seen in homozygous SCD patients: chronic hemolysis, vascular occlusion, tissue ischemia, and end-organ damage.
Source: KingNet Alprostadil : Prostaglnadin E1PGE1- Cyclodextrin PGE1 Alprostadil PapaverinePhentolamine Pa-PaverinePhentolamine
Any patient who has experienced ischemic priapism is at risk for stuttering priapism.
Patients with stuttering priapism will experience repeated painful intermittent attacks up to several hours before remission
Molecular basis
In the penis the vascular endothelium is a source of vaso-relaxing factors such as NO and adenosine, as well as vaso-constrictor factors such as RhoA/Rho-kinase. (nitric oxide/cGMP signaling ) PDE type 5 enzyme degrade the cyclic nucleotide cGMP A direct result of NO imbalance resulting in aberrant molecular signaling, PDE5 dysregulation, adenosine overproduction, and reductions in Rho-kinase activity, translating into enhanced corporal smooth muscle relaxation and inhibition of vasoconstriction in the penis.
Laboratory Testing
Evaluation should include a CBC, WBC with blood cell differential, platelet count, and coagulation profile to assess anemia, rule out infection, detect hematologic abnormalities, and ensure that the patient can safely tolerate surgical interventions In African-Americans a sickle cell prep and hemoglobin electrophoresis should be requested A corporal blood gas by aspiration is recommended in the emergency evaluation of priapism.
The initial corporal apirate may be sent for blood gas testing to document pH, PO2, and PCO2
Color duplex Doppler ultrasonography should be initiated if the history suggests penile/perineal trauma or if the corporal aspirate reveals well-oxygenated blood
A single, large-bore, 19-gauge needle should be inserted at the peno-scrotal junction at 3 or 9 oclock, to avoid piercing the dorsal neurovascular bundle
Penile Imaging
Color duplex Doppler ultrasonography (CDU) of the penis and perineum is recommended in the evaluation of priapism Penile arteriography should be reserved for the management of high-flow priapism, when embolization is planned
arteriography is too invasive as a diagnostic procedure to differentiate ischemic from nonischemic priapism
1.CDU imaging should include corporal shaft and transperineal assessment of the crural bodies when there is a history of penile trauma or straddle injury. 2.CDU should always be considered in the evaluation of a persistent or partial erection after treatments for ischemic priapism.
MRI has three possible roles: 1.imaging of a well-established arteriolar-sinusoidal fistula 2.identifying corporal thrombus and corporal smooth muscle infarction 3. identifying corporal metastasis
Hormonal Therapies
The primary action of systemic hormonal therapy in stuttering priapism is the suppression of the androgenic effects on penile erection. GnRH agonists, antiandrogens, diethylstilbestrol may affect libido, may affect fertility, cause gynecomastia, cause hot flushes, promote osteoporosis, and worsen sexual function.
Baclofen
Studies in both rats and humans suggest that baclofen inhibits penile erection and ejaculation, through GABA receptor activity.
Recommended corporal aspiration and -adrenergic agonists for at least 1 hour before consideration of surgery
the longer an episode of ischemic priapism lasts, the greater the likelihood of compromised erectile function will be in the future (priapism lasting longer than 24 hours was associated with a 90% ED rate ) expert opinion stated that shunting is to be considered for ischemic priapism events lasting 72 hours or less.
The objective of shunt surgery is reoxygenation of the cavernous smooth muscle The shared principle of shunt procedures is to reestablish corporal inflow by relieving venous outflow obstruction This requires creation of a fistula between the corpora cavernosa (CC) and glans penis, CC and corpus sponsigosum, or CC and dorsal/ saphenous veins.
1.A distal cavernoglanular shunt should be the first choice of shunting procedures because it is technically easier to perform than proximal shunting. 2.Percutaneous distal shunting is less invasive than open distal shunting and can be performed with local anesthetic in the emergency department. 1.Percutaneous distal shuntsEbbehoj (1974), Winter (1976), or T-shunt (Brant, 2009) 2.Open distal shunt 3.Open proximal shunt 4.Saphenous vein 5.Deep dorsal vein shunt
1.The key factors determining successful surgical reversal of ischemic priapism are evacuation of thrombus, reestablishing cavernous inflow, and patency of shunt.
2.A unilateral shunt is often effective. Bilateral shunts are used only if necessary
1.There are no comparative trials of safety, efficacy, or erectile function outcomes for percutaneous versus open distal shunting techniques *Percutaneous distal shunts*
Ebbehoj vs
T-shunt
1.The most commonly described proximal shunt is the unilateral shunt, described by Quackles in 1964 2. Proximal corpus cavernosum to spongiosa (CC-CS) shunt procedures require a transscrotal or transperineal approach
3. at least 1 cm in an effort to minimize the risk of urethral stricture at the point of CC-CS communication
1.In cases where proximal shunt fails, some have advocated saphenous vein bypass or deep dorsal vein shunt. A wedge of tunica albuginea is removed and the vein is anastamosed end to side of CC 2.Venous shunts have increased the risk of thromboembolism.
Compared with prosthesis insertion in a typical patient with erectile dysfunction, there are significantly higher rates of complications noted in priapism cases:
infection, urethral injury, device migration, device erosion, and revision surgeries.
Initial observation is recommended for this type of priapism. (ice applied to the perineum )
Cavernous aspiration has only a diagnostic role in high-flow priapism.
Repeated aspirations, injection, and irrigation with intracavernous sympathomimetics have no role in the treatment of nonischemic priapism