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Ch.

25 Priapism
Presented by:

1.Dorsal artery 2.Carvernosal(Deep) artery 3.Bulbourethral artery

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)

Stuttering Priapism (Intermittent) Nonischemic Priapism (Arterial, High-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

Stuttering Priapism (Intermittent)


Stuttering priapism characterizes a pattern of recurrence. The term has historically described recurrent unwanted and painful erections in men with sickle cell disease (SCD) Patients typically awaken with an erection that persists for several hours. Males with SCD may experience stuttering priapism from childhood

Nonischemic Priapism (Arterial, High-Flow)


Nonischemic priapism is a persistent erection caused by unregulated cavernous arterial inflow. Typically, the corpora are tumescent but not rigid and the penis is not painful A history of blunt trauma to the penis or an iatrogenic needle injury is common.

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.

Etiology of Ischemic Priapism


Ischemic priapism accounts for the majority of cases described in the literature.
The erection of ischemic priapism may begin with sexual stimulation or the administration of pharmacologic agents. Once an erection persists beyond 4 hours and is not relieved by cessation of sexual stimulation or orgasm, the physiologic phenomena of ischemic priapism have begun Population:0.34~1.5 per 100,000 person-years The etiology of priapism was identified as idiopathic in the majority, and 21% of cases were associated with alcohol or drug use/abuse, 12% with perineal trauma, and 11% with SCD

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

Etiology of Stuttering (Intermittent) Priapism


Patients typically awaken with an erection that persists up to 4 hours and becomes progressively painful secondary to ischemia. SCD patients may experience stuttering priapism from childhood.

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

Etiology and Pathophysiology of Nonischemic (Arterial, High-Flow) Priapism


Nonischemic priapism is much rarer than ischemic priapism, and the etiology is largely attributed to trauma (be blunt or penetrating) Resulting in laceration of the cavernous artery or one of its branches within the corpora

The most common cause is a straddle injury to the crura


Described following iatrogenic injury: cold-knife urethrotomy, Nesbitt corporoplasty, and penile revascularization procedures. (ischemia high flow) Sustained partial erection may develop 24 hours following perineal or penile blunt trauma

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.

Evaluation and diagnosis of priapism


History taking (DD:ischemia/nonischemia) Inspection and palpation of 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 corporal blood aspirate differentiates ischemic from nonischemic priapism


Aspiration may be both diagnostic and therapeutic

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

Medical Tx for Ischemic Priapism


Oral agents are not recommended in the management of acute ischemic priapism (>4 hours)
The recommended initial treatment of ischemic priapism is the decompression of the corpora cavernosa by aspiration. Aspiration will immediately soften the erection and relieve pain. Aspiration alone may relieve priapism in 36% of cases.
not sufficient data to conclude that aspiration followed by saline intracorporal irrigation was any more effective than aspiration alone Aspiration should be repeated until no more dark blood can be seen coming out from the corpora and fresh bright red blood is obtained

Corporal aspiration, if unsuccessful, should be followed by -adrenergic injection or irrigation.


Aspiration followed by the intracavernous injection of sympathomimetic drugs is recommended by the AUA Guidelines Panel, 2003
Sympathomimetic drugs cause cavernous smooth muscle (CSM) contraction Phenylephrine is a selective 1-adrenergic receptor agonist without -mediated ionotropic Phenylephrine can be concentrated as 200 g/mL in saline and administered intermittently as 0.5 mL to 1.0 mL, every 5 to 10 minutes to a maximum dosage of 1 mg.

Blood pressure monitoring is recommended if repeated sympathomimetic dosing is given.

Medical Management of Stuttering Priapism


The goals of managing a patient with stuttering priapism include prevention of future episodes, preservation of erectile function
oral -adrenergics at limited daily dosing should be considered in the management of stuttering priapism; drug therapy is typically initiated at bedtime.

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.

Phophodiesterase Type 5 (PDE5) Inhibitors


management of patients (adults and children) with SP associated with hemoglobinopathies PDE5 inhibitor therapy alleviates recurrent priapism episodes in men with SCD-associated priapism without affecting normal erectile capacity Dosing should be initiated under conditions of complete penile flaccidity, not during a stuttering episode

Surgical management of ischemic priapism


Surgical management of ischemic priapism is indicated after repeated penile aspirations and injections of sympathomimetics have failed or if such an attempt has resulted in a significant cardiovascular side effect.

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

Open distal shunt

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.

Immediate Implantation of Penile Prosthesis


The natural history of untreated ischemic priapism or priapism refractory to interventions is severe fibrosis, penile length loss, and complete ED Penile prosthesis in the acute management of ischemic priapism had two distinct advantages
corporal fibrosis is not yet established penile length may be preserved

Consider penile prosthesis if:


The patient has failed aspiration and sympathomimetic intracavernous injection. The patient has failed distal and proximal shunting. Ischemia has been present for longer than 36 hours

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.

Interventional angiography in the management of arterial priapism


Arterial priapism is not an emergency. Spontaneous resolution or response to conservative therapy has been reported in up to 62% of published series Persistent partial erection from HFP may be evident for months to years, without adverse impact on erectile function

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

1.Patients demanding immediate relief can be offered selective arterial embolization


2. A characteristic intracavernosal cone-shaped blush of contrast is seen at the site of the cavernous artery or arteriole laceration 3. selective pudendal artery catherterization 4. Overall success rates with embolization are high, although a single treatment carries a recurrence rate of 30% to 40% 5. Although ultimately successful, embolization of HFP may require retreatment. The most notable side effect is erectile dysfunction. 6. Where angio-embolization fails or is contraindicated, surgical ligation is reasonable 7. a pseudocapsule around the fistula has developed, surgical ligation has been reported to be successful.

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