Rare disorders of penile erection

Sleep-related painful erections: a survey-based analysis of patient-reported experiences with diagnosis and management

Sleep-related painful erection (SRPE) is a condition characterized by painful nocturnal erections and frequent nighttime awakenings; however, the pathophysiology is not well understood and existing literature consists mainly of case reports. We aimed to investigate the causes, treatments, and impact on quality of life among individuals affected by SRPE. An e-questionnaire comprising of 30 items was administered to a group of men with SRPE identified through social media in October of 2021. The survey collected information on demographics, clinical and social history, symptomatology, interventions and quality of life. 44 patients with SRPE completed surveys (70.9% response rate), with a mean age ± SD of 43.3 ± 12.8 years. Most respondents had no relevant medical history related to erectile function disorders. 43.2% of subjects reported sleep apnea, and 27.1% reported a mental health disorder or psychiatric medication use. Baclofen was the most common medication, but only 25% of patients found it beneficial. Sleep repositioning, oxygen device use and pelvic floor therapy were interventions that provided the most relief. Most patients did not require emergency department visits (93.2%); only a small number needed penile aspiration (n = 2). As reported by most respondents, SRPE significantly impacted patients' quality of life.

Priapism at Diagnosis of Pediatric Chronic Myeloid Leukemia: Data Derived from a Large Cohort of Children and Teenagers and a Narrative Review on Priapism Management

Pediatric chronic myeloid leukemia (CML) is a very rare malignancy (age-related incidence 0.1/100,000) typically presenting with leucocyte counts >100,000/µL. However, clinical signs of leukostasis are observed at diagnosis in only approximately 10% of all cases and among these, priapism is infrequent. Here, we analyze data from pediatric CML registries on the occurrence of priapism heralding diagnosis of CML in 16/491 (3.2%) boys (median age 13.5 years, range 4-18) with pediatric CML. In the cohort investigated, duration of priapism resulting in a diagnosis of CML was not reported in 5 patients, and in the remaining 11 patients, occurred as stuttering priapism over 3 months (n = 1), over 6 weeks (n = 1), over 1-2 weeks (n = 2), over several days (n = 2), or 24 h (n = 1), while the remaining 4 boys reported continuous erection lasting over 11-12 h. All patients exhibited splenomegaly and massive leukocytosis (median WBC 470,000/µL, range 236,700-899,000). Interventions to treat priapism were unknown in 5 patients, and in the remaining cohort, comprised intravenous fluids ± heparin (n = 2), penile puncture (n = 5) ± injection of sympathomimetics (n = 4) ± intracavernous shunt operation (n = 1) paralleled by leukocyte-reductive measures. Management without penile puncture by leukapheresis or exchange transfusion was performed in 3 boys. In total, 7 out 15 (47%) long-term survivors (median age 20 years, range 19-25) responded to a questionnaire. All had maintained full erectile function; however, 5/7 had presented with stuttering priapism while in the remaining 2 patients priapism had lasted <12 h until intervention. At its extreme, low-flow priapism lasting for longer than 24 h may result in partial or total impotence by erectile dysfunction. This physical disability can exert a large psychological impact on patients' lives. In a narrative review fashion, we analyzed the literature on priapism in boys with CML which is by categorization stuttering or persisting as mostly painful, ischemic (low-flow) priapism. Details on the pathophysiology are discussed on the background of the different blood rheology of hyperleukocytosis in acute and chronic leukemias. In addition to the data collected, instructive case vignettes demonstrate the diagnostic and treatment approaches and the outcome of boys presenting with priapism. An algorithm for management of priapism in a stepwise fashion is presented. All approaches must be performed in parallel with cytoreductive treatment of leukostasis in CML which comprises leukapheresis and exchange transfusions ± cytotoxic chemotherapy.

Epidemiology and treatment of priapism in sickle cell disease

Ischemic priapism is a common but underrecognized morbidity affecting about 33% of adult men with sickle cell disease (SCD). The onset of priapism occurs in the prepubertal period and tends to be recurrent with increasing age. Significantly, priapism is associated with an unrecognized high burden of mental duress and sexual dysfunctions. The diagnosis of priapism is clinical. Many episodes of priapism will resolve spontaneously, but when an episode lasts longer than 4 hours, the episode is considered a urologic emergency requiring quick intervention with either corporal aspiration or shunt surgery. Only 3 randomized clinical trials (stilbesterol, ephedrine or etilefrine, and sildenafil) have been conducted for secondary priapism prevention in SCD. All 3 trials were limited with small sample sizes, selection biases, and inconclusive results after completion. The current molecular understanding of the pathobiology of priapism suggests a relative nitric oxide (NO) deficiency secondary to chronic hemolysis in SCD and associated phosphodiesterase type 5 dysregulation. We posit an increase in NO levels will restore the normal homeostatic relationship between voluntary erection and detumescence. Currently, 2 randomized phase 2 trials (1 double-blind, placebo-controlled trial and 1 open-label, single-arm intervention) are being conducted for secondary priapism prevention in men at high risk for recurrent priapism (NCT03938454 and NCT05142254). We review the epidemiology and pathobiology of priapism, along with mechanistic therapeutic approaches for secondary prevention of priapism in SCD.

Improvement of associated symptoms using combined therapy in 44 patients with sleep-related painful erection during 1-year follow up

The current study was aimed at analysing the clinical features and efficacy of combined treatments in patients with sleep-related painful erection (SRPE). Patients who presented with SRPE were continuously enrolled from the outpatient clinic of Peking Union Medical College Hospital from 2015 to 2021. Demographic data, medical history, diagnostics, treatment options and their effectiveness on SRPE in the short and long therapeutic term were recorded. Individually designed combined therapy aimed at controlling SRPE-related symptoms and comorbidities (general health, pain, psychological and sleeping disorders, late-onset hypogonadism, and lower urinary tract symptoms) was used, and the effectiveness was evaluated. In total, 44 patients with an average age of 44.66 ± 7.96 years were enrolled. The median length of the delay in diagnosis was 1.5 years (range, 1 month to 27 years). Combined treatment aimed at controlling symptoms was used, the mean GAD-7, PHQ-9, PSQI and VAS scores were significantly decreased to 4.25 ± 3.44, 4.55 ± 2.86, 7.65 ± 3.06, and 2.90 ± 1.89 after treatment for 3 months. Moreover, the VAS ratings were significantly decreased at 1 year of follow-up (p < 0.001). SRPE mainly occurred in middle aged males, 79.55% (35/44) patients were more than 40 years old. The prevalence of anxiety, depression, poor sleep and nocturia is high in patients with SRPE. Combined treatments aimed at controlling these symptoms can be more effective.

Rare Disorders of Painful Erection: A Cohort Study of the Investigation and Management of Stuttering Priapism and Sleep-Related Painful Erection

BACKGROUND

A chief complaint of men with stuttering priapism (SP) and sleep-related painful erections (SRPE) is bothersome nocturnal erections that wake them up and result in poor sleep and daytime tiredness. SP and SRPE are rare entities that have similarities in their clinical features, but that require different treatment approaches.

AIM

The aim of this study was to describe the clinical features, investigations, and effective management options for men with SP and SRPE.

METHODS

Retrospective cohort study of 133 men with bothersome nocturnal painful erections that attended a tertiary andrology unit between 2004 and 2018. These men were divided into 3 groups. Group 1 (n = 62) contains men with sickle cell SP; group 2 (n = 40) has men with non-sickle cell SP and group 3 (n = 31) contains men with SRPE.

OUTCOME

To determine the effectiveness of medical and surgical treatments for men with SP and SRPE.

RESULTS

Hydroxyurea and automated exchange transfusion were the most effective treatment options in the sickle cell SP group. Hormonal manipulation and α-agonist therapies were effective in both SP cohorts (groups 1 and 2). Baclofen was the most effective therapy in men with SRPE. For men who failed medical management, implantation of a penile prosthesis resulted in complete resolution of the symptoms in men with SP (groups 1 and 2). Surgical management (penile prosthesis implantation and embolization) did not improve the patients' symptoms in the SRPE group.

CLINICAL IMPLICATIONS

This study differentiates between sickle cell SP, non-sickle cell SP, and SRPE and describes effective treatment options for each group.

STRENGTHS & LIMITATIONS

This is the largest cohort study for both SP and SRPE, respectively. Limitations include its retrospective nature and single-center experience.

CONCLUSION

Managing men in these 3 groups differently and in accordance with the proposed treatment pathway provides a more structured approach to the management of these rare conditions. Johnson M, McNeillis S, Chiriaco G, et al. Rare Disorders of Painful Erection: A Cohort Study of the Investigation and Management of Stuttering Priapism and Sleep-Related Painful Erection. J Sex Med 2021;18:376-384.