Intermittent priapism associated with lumbar spinal stenosis

Priapism, a symptom of claudication of the cauda equina in spinal stenosis

Priapism is defined as a persistent penile erection in the absence of sexual arousal. This symptom has been documented in patients with spinal stenosis although it is considered a rare finding. The European Association of Urology guidelines on priapism [Salonia et al., 2014] list cauda equina syndrome and spinal stenosis as causative factors for ischemic priapism although the literature describing this phenomenon appears sparse. Priapism can be a rare symptom of lumbar spine stenosis/transient cauda equina compression. This presentation is complex and believed to be a parasympathetic mediated autonomic disorder. This article discusses the relationship between spinal stenosis, cauda equina syndrome and priapism using available literature. Greater awareness of this clinical finding may help clinicians in their clinical decision making. In patients with suspected cauda equina syndrome, subjective enquiry regarding the symptom priapism may add to the patients overall clinical picture.

Walking-Evoked Erection in Patients with Lumbar Degenerative Diseases: Eight Cases and Review of the Literature

Study Design

Narrative review with a case illustration.

Purpose

The purpose of this study was to evaluate the pathogenesis and outcome of therapy for walking-evoked erection in patients with lumbar degenerative diseases.

Overview of Literature

Cauda equina compression due to lumbar degenerative diseases rarely cause a walking-evoked erection; however, no review has been undertaken of walking-evoked erection in patients with lumbar degenerative diseases.

Methods

A total of 1,570 male patients with lumbar degenerative diseases, who underwent surgery between April 2003 and June 2017, were evaluated; from these patients, participants with walking-evoked erection were selected. Preoperative clinical data of walking-evoked erection, paresthesia, and bladder and bowel function were assessed. In our study, the neurological status and the erectile function of each participant were retrospectively evaluated before and after surgery using the Japanese Orthopedic Association score and the Overactive Bladder Symptom Score.

Results

Among the 1,570 male patients screened in our department, eight patients (0.51%, 8/1,570) presented with walking-evoked erection accompanied by cauda equina symptoms. In six of the patients, the erectile symptoms were associated with paresthesia in the genitalia or perianal region. Of the six patients evaluated for bladder dysfunction, all were diagnosed with prostatic hyperplasia, while four were diagnosed with an overactive bladder. In all patients, walking-evoked erection disappeared entirely after surgery.

Conclusions

This study comprises the first review of walking-evoked erection in patients with lumbar degenerative diseases. We speculate that sensory input, such as paresthesia in the genitalia or perianal region stimulates the pelvic or perineal nerves through the pudendal nerve and induces reflexogenic erections.

Isolated intermittent neurogenic priapism: an unusual presentation in degenerative lumbar spinal stenosis

Priapism is a relatively uncommon clinical presentation. The well-recognised causes are sickle cell anaemia and the use of medications, such as vasoactive erectile agents. Infrequently, it could be the result of lumbar spinal stenosis. The authors reported an elderly man with 1-year history of isolated intermittent priapism aggravated by walking. MRI showed lumbosacral spondylosis with severe stenosis at the level of L4-L5. Total laminectomy of L4 and L5 was done, resulting in a rapid and complete resolution of symptom without recurrence during the follow-up time of 10 years.

Priapism

Priapism is a relatively uncommon condition that may present as a medical emergency associated with significant pain and anxiety in the veno-occlusive or low-flow variant. Pharmacologic advances and, specifically, the availability of intracavemosal alpha-agonist therapy have dramatically improved the prospects of resolution for patients with low-flow priapism presenting within the first few hours of the acute episode. High-flow priapism is not considered an emergency and treatment measures are typically conservative aimed at preservation of potency. Urologists, radiologists, and other health care personnel caring for the patient with priapism must be familiar with various etiologic factors implicated in low-flow and high-flow priapism to formulate a logical step-care approach. Differentiation of the low-flow from the high-flow state is perhaps the most critical initial diagnostic challenge that determines the sequence of further interventions including surgical shunts in low-flow priapism refractory to medical therapy.

Priapism: etiology and management

Priapism is a urologic emergency. All patients should receive prompt urologic consultation. Management is based on prompt recognition, differentiation between low- and high-flow priapism, reversal of any potential precipitating factors, and the use of corporal aspiration/irrigation combined with intracavernosal alpha-agonist injection therapy. It cannot be over-emphasized that severely prolonged erections are associated with the development of irreversible problems with erectile function and, therefore, immediate and aggressive management is mandatory.