Priapism

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Priapism

• 31st March 2003
• R Power

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Definition

• persistent erection not accompanied by sexual
  desire or stimulation
• gt 6 hours
• Corpora cavernosa only
• all age groups (including newborns)
• peak incidence 20 to 50yrs
• younger age group assoc with sickle cell
• usually pain (except in non-ischaemic type)

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Classification

• Low flow or Ischaemic (veno-occlusive)
• most common
• Painful sec to tissue ischaemia and smooth muscle
  hypoxia (compartment syndrome)
• Nonischaemic (arterial)
• less common
• upregulated cavernous inflow
• usually not fully erect and painless

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Low-flow priapism

• Low flow or Ischaemic (veno-occlusive)
• most common
• Penis fully erect (sludging of blood within)
• Painful sec to tissue ischaemia and smooth muscle
  hypoxia (compartment syndrome)
• blood gases from corpora - acidosis
• ? NO prostacyclin
• platelet aggregation and adhesion - thrombus
  formation and tissue damage

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Causes of low-flow priapism

• Intracavernosal pharmacotherapy
• 21 of cases of priapism - 207 patients
  papaverine (Nieminem et al.1995)
• PGE-1 alprostadil
• lt1 intracavernosal
• lt0.1 intraurethral
• extremely low incidence with oral agents
• Drugs
• cocaine, heparin withdrawal, trazadone,
  phenothiazines

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Causes of low-flow priapism

• Hyperviscosity syndromes (sickle-cell disease)
• 28 of all cases of priapism (most common cause
  in children)
• 42 incidence in adults with sickle-cell disease
• 64 incidence in boys with sickle-cell disease
• also affects with sickle-cell trait
• ? Assoc with testosterone
• Other haemoglobinopathies
• thrombophilia
• stutter priapism
• Recurrent episodes of priapism can result in
  enlarged penis, fibrotic corpora and ED

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Causes of low-flow priapism

• Neurological causes
• rare
• lumbar disc lesions, spinal stenosis, seizure
  disorders, cerebrovascular disease
• Post Trauma
• perineum, groin or penis usually cause high flow
  priapism but can cause low flow sec to haematoma
• Solid Tumours
• malignant infiltration of corpora
• Miscellaneous
• TPN, amyloid , rabies, appendicitis

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High-flow priapism

• Nonischaemic (arterial)
• less common
• Penile, perineal or pelvic trauma
• uncontrolled arterial inflow directly into the
  penile sinsoidal spaces
• usually penis not fully erect and painless
• often prolonged history
• normal local blood gases
• no risk of ischaemia and subsequent fibrosis

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Causes of High-flow priapism

• Trauma
• Very rarely sickle-cell disease
• Fabrys disease

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Management of Priapism

• Urological emergency
• Treat causal factor where identified
• goal is to abort the erection, thereby preventing
  permanent damage to the corpora (ED) and to
  relieve pain.
• Longer duration implies greater risk of impotence
• principle is to restore arterial inflow and
  venous outflow
• clinical history and drug history
• glans and corpus spongiosum rarely involved
• urinalysis
• haemoglobin S to outrule leukaemia
• ? Local blood gas measurments
• radionucleotide scanning - no longer performed
• colour doppler ultrasonography

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Medical management of low-flow priapism

• aspiration of the corpora with a 21G butterfly
  needle followed by an injection of phenylephrine
  (?1 adrenergic agonist) every 5 minutes until
  detumescence
• 10mg/ml phenylephrine in 19mls saline
• 100 effective if within 12 hours
• Oral terbutaline (?-adrenoceptor agonist) -
  5-10mg
• at best 36 response
• Sickle-cell - prompt and conservative as it
  recurs
• hydration, oxygenation, metabolic alkalinization
• aspiration and injection (as above)
• Stuttering priapism
• self injection of ?-adrenergic agent if sexually
  active (prophylactic digoxin) or oral
  ?-adrenergic agent (Etilefrine)
• antiandrogen if not to suppress nocturnal
  tumescence

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Surgical management of low-flow priapism

• Winter procedure using a Trucut needle
• create a shunt between glans and corpora
  cavernosa
• Ebbehoi procedure using a pointed scalpel blade
• El-Ghourab procedure
• excision of a piece of tunica albuginea
• 30 of above techniques fail
• direct cavernosal-spongiosum anastomosis
• corpora-saphenous shunt
• lower incidence of ED reported with Winter
  technique
• Intracavernosal thrombolytic agents ??

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Management of High-flow priapism

• Ice pack ? arterial spasm
• ?? spontaneous thrombosis
• Most cases require arteriography and embolisation
  of the internal pudendal artery or a branch

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Complications

• Untreated low-flow priapism leads to corporal
  fibrosis and impotence
• early complications
• acute hypertension, headache, palpitations,
  arythmias
• bleeding, haematoma, infection and urethral
  injury
• late complications
• fibrosis and impotence
• related to duration of priapism and aggressivness
  of treatment
• low-flow high incidence of ED if not treated
  within 12 hours
• high flow good prognosis (20 rate of ED)