Emergency evaluation and treatment of priapism

Cases of Patients Treated in Countries With Limited Resources and Discussed by Experts of the International CML Foundation (iCMLf)-Case No. 1: A Boy Presenting With Priapism and Loss of Vision

Pediatric chronic myeloid leukemia (pCML) is a rare malignancy accounting for only 2%-3% of all childhood leukemias. Due to this rarity, familiarity with pCML is limited among most pediatric practitioners, including even pediatric hemato-oncologists. In low- and middle-income countries (LMICs), limited financial resources and limited data specific to pCML represent obstacles that healthcare providers must face in diagnosing and treating this rare condition in children. The International CML Foundation (iCMLf) is improving outcomes for people with CML in these countries where resources, diagnostics, and access to medicines may be limited (https://www.cml-foundation.org/lmic-programs.html). Virtual meetings with the purpose of teaching participating pediatricians from LMICs of defined geographical regions were organised by the iCMLf in 2023. At a virtual meeting of the South Asia region, the case of a 14-year-old Indian boy was presented diagnosed with CML in a chronic phase complicated by priapism and loss of vision in his left eye due to hyperleukocytosis. Key aspects of this case are discussed in-depth from the perspective of (i) a pediatric hemato-oncologist practicing in a high-income country, (ii) a pediatric hemato-oncologist practicing in a LMIC, (iii) an adult CML hematologist, and (iv) from the iCMLf in improving the care of children with CML worldwide. Thus by discussing a multifaceted complicated case of pCML in written form as well as pointing to the pediatric module of the iCMLf Knowledge Centre will hopefully contribute to minimize existing knowledge gaps in a rare pediatric malignancy.

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.

Emergency Department Utilization for Patients Living With Sickle Cell Disease: Psychosocial Predictors of Health Care Behaviors

Study objective

Individuals living with sickle cell disease (SCD) often require urgent care; however, some patients hesitate to present to the emergency department (ED), which may increase the risk of serious clinical complications. Our study aims to examine psychosocial, clinical, and demographic factors associated with delaying ED care.

Methods

This was a cross-sectional study of 267 adults with SCD from the national INSIGHTS Study. The binary outcome variable asked whether, in the past 12 months, participants had delayed going to an ED when they thought they needed care. Logistic regression was performed with clinical, demographic, and psychosocial measures.

Results

Approximately 67% of the participants reported delaying ED care. Individuals who delayed care were more likely to have reported higher stigma experiences (odds ratio [OR]=1.09; 95% confidence interval [CI] 1.03 to 1.16), more frequent pain episodes (OR=1.15; 95% CI 1.01 to 1.32), lower health care satisfaction (OR= 0.74; 95% CI 0.59 to 0.94), and more frequent ED visits (OR=6.07; 95% CI 1.18 to 31.19). Disease severity and demographics, including sex, age, and health insurance status, were not significantly associated with delay in care.

Conclusion

Psychosocial factors, including disease stigma and previous negative health care experiences, are associated with delay of ED care in this SCD cohort. There is a need to further investigate the influence of psychosocial factors on the health care–seeking behaviors of SCD patients, as well as the downstream consequences of these behaviors on morbidity and mortality. The resulting knowledge can contribute to efforts to improve health care experiences and patient-provider relationships in the SCD community.

Pharmacologically-induced Recreational Priapism: Case Report and Review

Introduction

Priapism, a time-sensitive urologic emergency, is associated with hematologic disorders, malignancies, trauma, pharmaceuticals, and recreational drugs.

Case Report

A 51-year-old male presented with 36 hours of priapism after recreational use of nonprescribed pharmaceuticals including an oral phosphodiesterase inhibitor and intracorporally injected erectile medications, together with unspecified quantities of cocaine and alcohol. Venous blood gas confirmed ischemic priapism. Detumescence was achieved with intracavernosal phenylephrine injection, aspiration, and irrigation.

Conclusion

This case highlights the risk that recreational use of vasoactive medications by patients who seek to prolong sexual activity may lead to delayed presentation for ischemic priapism.

Ziprasidone-induced priapism requiring surgical treatment

Both typical and atypical antipsychotic psychotropics have been reported to cause ischemic priapism presumptively secondary to alpha1-adrenergic blockade. This condition is a urologic emergency for if not evaluated and treated appropriately, long-term sequelae include erectile dysfunction and impotence. This paper addresses the first reported case of priapism requiring surgical intervention presumed to be secondary to ziprasidone. Increased clinician and patient education regarding priapism is required in order to minimize this adverse event and to maximize immediate treatment.

Perspectives on Priapism Education in Emergency Medicine

INTRODUCTION

Priapism is a urologic emergency managed by both emergency medicine (EM) providers and urologists. Attitudes regarding its management and understanding of education of non-urology trainees in this area are poorly defined.

AIM

The aim of this study was to describe attitudes toward priapism management among multiple stakeholders and define the current state of priapism education among EM residency programs.

METHODS

Surveys were developed and distributed online to EM residency leadership, EM residents, and urology providers. Each solicited attitudes and preferences regarding independent priapism management by EM providers. EM residents were further queried about their educational and clinical experiences in priapism management, and EM residency leadership were surveyed about their educational curricula. Responses among all 3 groups were compared using Fisher's exact tests.

MAIN OUTCOME MEASURE

Quantitative and descriptive responses were solicited regarding EM providers' management of acute ischemic priapism and current priapism curricula for EM residents.

RESULTS

91 EM residency program directors and assistant program directors (31.6% of programs), 227 EM residents (14.7% of programs), and 94 urologists (6.3% of survey recipients) responded. All geographic regions and all years of EM training were represented. Over 90% of all surveyed groups felt that EM providers should independently manage priapism in practice. 17% of senior EM residents felt "not at all" confident in managing priapism; and 25.5% had never primarily managed this entity in training. 81% of programs had a formalized priapism curriculum, of which 19% included treatment simulation. However, 36% of residents felt that current curricula were insufficient.

CLINICAL IMPLICATIONS

Widespread approval from both EM providers and urologists support EM-based management for uncomplicated cases of acute ischemic priapism. Current educational curricula for EM trainees may not be sufficient to prepare them to manage this entity in practice.

STRENGTHS & LIMITATIONS

This is the first study to examine provider attitudes toward EM-based management of priapism and assess the current state of education in this area with input from all key stakeholders. This survey was limited in its scope and the response rate was lower than desired.

CONCLUSION

Urologists support independent priapism management by EM providers, but an educational gap remains for EM trainees who do not feel adequately trained to manage this independently in practice. Dai JC, Franzen DS, Lendvay TS, et al. Perspectives on Priapism Education in Emergency Medicine. J Sex Med 2020;17:159-162.

Prognostic Factors and Outcome of Management of Ischemic Priapism in Zaria, Nigeria

OBJECTIVES

The objective of this study was to determine the nuances of management, prognostic factors, and outcome of ischemic priapism in patients seen at Ahmadu Bello University Teaching Hospital, Zaria, Nigeria.

PATIENTS AND METHODS

We retrospectively studied the case notes of all patients managed for ischemic priapism in the Ahmadu Bello University Teaching Hospital, Zaria, over a period of 10 years (2006-2015). The data extracted included patients' age, occupation, duration of painful penile erection, and previous episodes. Addition information including precipitating factors, hemoglobin genotype, treatment, and complications was also retrieved. Data obtained were analyzed using SPSS version 20.

RESULTS

The records of a total of forty patients managed for priapism over the period under review were retrieved. Thirty-three (82.5%) of these patients had an operative intervention. The mean age was 23.7 years with a range of 8-53 years. Sixty percent of patients were young adults in their third decade of life. The minimum duration of erection at presentation was 18 h and a maximum period of 10 days with a mean of 105.5 h (4 days). Thirty-three patients (82.5%) had sickle cell anemia (HbSS). Erectile dysfunction (ED) accounted for 60% of all forms of postpriapism complications. Five patients (12.5%) had residual tumescence from fibrosis, and three patients had recurrence outside the immediate postoperative period. Duration of symptoms before surgical intervention, SSA and previous episodes were the most important prognostic factors.

CONCLUSION

Priapism is a disease of the young, mostly sickle cell anemic patients. Late presentation remains the norm in our environment, hence a higher incidence of ED. The distal penile shunt is an effective means of achieving detumescence even with failed conservative management. Favorable outcome is highly dependent on the duration of erection and early intervention.

Recurrent priapism from therapeutic quetiapine

Priapism is rarely related to use of non-erectile related medications. The objective was to educate about the multiple possible causes of priapism and to provide treatment recommendations for the different types of priapism. We present the case of a 43-year-old African American male with a history of schizoaffective disorder who presented to our emergency department multiple times over a three year period with priapism, each episode related to the ingestion of quetiapine. Following penile aspiration and intercavernosal injection of phenylephrine, this patient had resolution of his priapism. This case demonstrates an unusual case of recurrent priapism.

Biochemical and genetic markers of erectile dysfunction

Erectile dysfunction (ED) is a very common pathology, affecting over 150 million men worldwide. The pathogenesis is typically multifactorial, involving a kaleidoscope of organic, endocrine, and psychogenic factors. In general, ED is divided into organic and psychogenic impotence, but most men with organic etiologies have an associated psychogenic component. Given the high frequency of this pathology, the identification of biochemical and genetic correlates and/or markers is of pivotal interest not only for treating preciously these patients and preventing serious psychological consequences but also for the high risk for occult cardiovascular disease (CVD) that often accompanies or follows this pathology. A variety of cardiovascular risk factors have been associated with both the onset and the severity of ED, including markers of endothelial function, thrombosis, and especially dyslipidemia, so that their measurement should now be considered as an important part of the increased global cardiometabolic risk profile in patients with ED. While nitric oxide (NO), asymmetric dimethylarginine (ADMA), and endothelin (ET) hold some promises as biochemical markers of both CVD and ED, there are several technical and clinical drawbacks that make their measurement overall meaningless in the clinical practice. As regards genetic polymorphisms, controversial results have been provided so far. Although some genetic markers were consistently associated with ED, other studies failed to demonstrate significant associations, highlighting a substantial bias in standardization of methodologies and patient enrolment. Nevertheless, further research in this area should be encouraged, since the first promising evidence that gene therapy might be effective to restore the decline in ED has been provided in the animal model.

A minimally invasive temporary cavernoso-saphenous shunt in the management of priapism after failed conservative treatment

Priapism is an urological emergency with detrimental consequences, if not managed expeditiously. Though a rare condition with an incidence between 0.3 and 1.5 per 100,000 population, its management options are limited and decision making could be challenging. We present a case of late presenting priapism for which the initial routine clinical care (aspiration, intracavernosal injection, and distal shunt) failed to relieve erection. Subsequently, the patient was successfully treated by a temporary cavernoso-saphenous shunt using carotid shunt and repeated heparin flushes. This novel surgical treatment offers an alternate method of relieving priapism, avoiding the long-term undesired effects associated with permanent proximal shunts such as cavernoso-venous grafts. Moreover, interval flushes (and/or repeated aspirations) with heparin ensures patency of this new shunt during the perioperative period. The patient recovered without any complications and the shunt was removed after one week. He has regained partial erection, however refused to have further treatment. Temporary cavernoso-saphenous shunt using carotid shunt offers an alternate option of management of priapism in patients with failed initial conservative treatment and distal shunts.

Successful use of terbutaline in persistent priapism in a 12-year-old boy with chronic myeloid leukemia

A 12-year-old boy had been suffering from intermittent episodes of penile erection for 2 weeks. For the last 2 days, however, the patient had been having sustained priapism and had to be admitted in a private hospital for management. Investigations revealed high total leukocyte counts. He was referred to the authors' hospital where a diagnosis of chronic myeloid leukemia was made. He was started on intravenous hydration, hydroxyurea, and allopurinol. Imatinib was added 2 days later. The parents refused surgical intervention. Despite a reduction in the counts the priapism persisted and the pain was unresponsive to opioids. Administration of terbutaline was associated with a successful outcome resulting in relief from pain within 20 min. The priapism also resolved completely in 1 day.

Stuttering priapism complicating warfarin therapy in a patient with protein C deficiency

Priapism is a rare disorder defined as a persistent penile erection that continues hours beyond, or is unrelated to, sexual stimulation. There are two types of priapism; ischemic low-flow type or non-ischemic high flow, with differing etiologies. Priapism associated with thrombophilia is a well-recognized entity. However, the pathogenesis of this association is not fully understood. We report a rare case of recurrent (stuttering) priapism in a patient with protein C deficiency while maintained on Warfarin therapy. This therapy was also complicated by Warfarin-induced skin necrosis.

Priapism in the Oncology Setting

CASE STUDY

N.L. is a 20-year-old Caucasian man with no significant medical history. He presented to the hospital with a two-day history of feeling ill with intermittent nausea, vomiting, blurred vision, and headache. He also noted slurred speech and left-upper-quadrant fullness for almost a month.

Counseling Patients About Sexual Issues

In recent years, the frequency of antidepressant drug-induced sexual dysfunction has increased, along with the use of new drugs for the treatment of erectile dysfunction and premature ejaculation. It has thus become common for pharmacists to counsel patients about sexual issues. Pharmacists must not only become knowledgeable about these drugs and their indications, but they must also become skilled and comfortable with counseling patients and answering questions from both patients and other health care providers. In addition to therapeutic information, pharmacists' discussions with patients should take into account factors that contribute to treatment nonadherence and treatment failure. Patient education is essential to ensure optimum outcomes for pharmacologic treatments for both erectile dysfunction and premature ejaculation. Improper use of phosphodiesterase-5 inhibitor drugs for erectile dysfunction accounts for most nonresponsiveness and discontinuation of treatment. Drug-induced sexual dysfunction is common with some psychotropic drugs. Up to 50% of men will experience delayed ejaculation, and at least 30% of men and women will experience anorgasmia from antidepressant drugs with serotonin agonist activity. Trazodone is the drug most commonly associated with the rare but very serious adverse effect of priapism. The pharmacist who is both competent and comfortable discussing sexual function and dysfunction with patients can make positive contributions to their therapeutic outcomes as well as their quality of life.

Sexual dysfunction and cardiac risk (the Second Princeton Consensus Conference)

Recent studies have highlighted the relation between erectile dysfunction (ED) and cardiovascular disease. In particular, the role of endothelial dysfunction and nitric oxide in ED and atherosclerotic disease has been elucidated. Given the large number of men receiving medical treatment for ED, concerns regarding the risk for sexual activity triggering acute cardiovascular events and potential risks of adverse or unanticipated drug interactions need to be addressed. A risk stratification algorithm was developed by the First Princeton Consensus Panel to evaluate the degree of cardiovascular risk associated with sexual activity for men with varying degrees of cardiovascular disease. Patients were assigned to 3 categories: low, intermediate (including those requiring further evaluation), and high risk. This consensus study from the Second Princeton Consensus Conference corroborates and clarifies the algorithm and emphasizes the importance of risk factor evaluation and management for all patients with ED. The panel reviewed recent safety and drug interaction data for 3 phosphodiesterase (PDE)-5 inhibitors (sildenafil, tadalafil, vardenafil), with emphasis on the safety of these agents in men with ED and concomitant cardiovascular disease. Increasing evidence supports the role of lifestyle intervention in ED, specifically weight loss and increased physical activity, particularly in patients with ED and concomitant cardiovascular disease. Special management recommendations for patients taking PDE-5 inhibitors who present at the emergency department and other emergency medical situations are described. Finally, further research on the role of PDE-5 inhibition in treating patients with other medical or cardiovascular disorders is recommended.

Sexual dysfunction and cardiac risk (the Second Princeton Consensus Conference)

Recent studies have highlighted the relation between erectile dysfunction (ED) and cardiovascular disease. In particular, the role of endothelial dysfunction and nitric oxide in ED and atherosclerotic disease has been elucidated. Given the large number of men receiving medical treatment for ED, concerns regarding the risk for sexual activity triggering acute cardiovascular events and potential risks of adverse or unanticipated drug interactions need to be addressed. A risk stratification algorithm was developed by the First Princeton Consensus Panel to evaluate the degree of cardiovascular risk associated with sexual activity for men with varying degrees of cardiovascular disease. Patients were assigned to 3 categories: low, intermediate (including those requiring further evaluation), and high risk. This consensus study from the Second Princeton Consensus Conference corroborates and clarifies the algorithm and emphasizes the importance of risk factor evaluation and management for all patients with ED. The panel reviewed recent safety and drug interaction data for 3 phosphodiesterase (PDE)-5 inhibitors (sildenafil, tadalafil, vardenafil), with emphasis on the safety of these agents in men with ED and concomitant cardiovascular disease. Increasing evidence supports the role of lifestyle intervention in ED, specifically weight loss and increased physical activity, particularly in patients with ED and concomitant cardiovascular disease. Special management recommendations for patients taking PDE-5 inhibitors who present at the emergency department and other emergency medical situations are described. Finally, further research on the role of PDE-5 inhibition in treating patients with other medical or cardiovascular disorders is recommended.