Management of Priapism: A Contemporary Review

Priapism in children: an experience of the modified Winter procedure

BACKGROUND

Priapism in children is a rare disease, which seldom presents during the pediatric surgery practice. It is, however, a surgical and urological emergency. Early diagnosis and prompt management can prevent the devastating sequelae of this potentially fatal condition.

MATERIALS AND METHODS

A prospective study was conducted between March 1st, 2007 and February 28th, 2019 at the Department of Pediatric Surgery, Khyber Teaching hospital, Peshawar. All the patients between 3 and 15 years of age, with the diagnosis of priapism, were enrolled in the study with ethical approval.

RESULTS

A total of ten patients were enrolled in the study period from March 1st, 2007 to February 28th, 2019. The age ranged between 3 and 15 years and the mean age of presentation was 8 years. The mean duration of symptoms was 4 h. The mean hospital stay was 4 days. The modified Winter procedure by creating a corporoglanular shunt was performed in all cases. Successful detumescence was achieved in eight patients, while two patients needed further detumescence and manual evacuation. Symptomatic relief was achieved in all the children.

CONCLUSION

Priparism in children is a rare urological emergency that can lead to permanent erectile dysfunction if prompt medical intervention is not done. The modified Winter procedure technically is a less invasive procedure to achieve satisfactory clinical outcome in terms of achieving good erectile functions.

Analysis of the Causes of Newborn Priapism: A Retrospective Clinical Study

Priapism is a rare condition in the newborn. The aim of this study was to investigate the demographic, etiologic and clinical features of neonatal priapism. We retrospectively analysed the data of 11 patients diagnosed with neonatal priapism in the neonatal intensive care unit between 2000 and 2019. Priapism was defined as an erection in the neonatal period, lasting more than 4 hours. Etiological examinations revealed polycythemia in one (9.09%) patient, D-dimer elevation in three patients, and heterozygous methyltetrahydrofolate 667 gene mutations in one patient. Other patients were considered idiopathic. Detumescence was achieved in all 11 (100%) patients during the follow-up period. The median hospitalization duration was 6 (IQR [4, 8]; range, 2-9) days. The median follow-up duration was 38 (IQR [30, 42]; range, 13-94) months for patients followed-up in our hospital after discharge. Neonatal priapism is a rare condition. Successful treatment results can be achieved with conservative methods. Data acquired from our study showed that diseases with a tendency to hypercoagulation belong to the etiology by damaging penile microcirculation and make the response to conservative treatment more challenging.

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.

A population-based analysis of predictors of penile surgical intervention among inpatients with acute priapism

While consensus exists regarding risk factors for priapism, predictors of operative intervention are less well established. We assessed patient and hospital-level predictors associated with penile surgical intervention (PSI) for patients admitted with acute priapism, as well as length of stay (LOS) and total hospital charges using the National Inpatient Sample (2010-2015). Inpatients with acute priapism were stratified by PSI, defined as penile shunts, incisions, and placement of penile prostheses, exclusive of irrigation procedures. Survey-weighted logistic regression models were utilized to assess predictors of PSI. Negative binomial regression and generalized linear models with logarithmic transformation were used to compare PSI to LOS and total hospital charges, respectively. Among 14,529 weighted hospitalizations, 4,953 underwent PSI. Non-Medicare insurances, substance abuse, and ≥3 Elixhauser comorbidities had increased odds of PSI. Conversely, Black patients, sickle cell disease, alcohol abuse, neurologic diseases, malignancies, and teaching hospitals had lower odds. PSI coincided with shorter median LOS (adjusted IRR: 0.62; p < 0.001) and lower ratio of the mean hospital charges (adjusted Ratio: 0.49; p < 0.001). Additional subgroup analysis revealed penile incisions and shunts primarily associated with reduced LOS (adjusted IRR: 0.66; p < 0.001) and total hospital charges (adjusted Ratio: 0.49; p < 0.001). Further work is required to understand predictors of poor outcomes in these populations.

Management of Priapism: 2021 Update

Priapism is defined as a persistent penile erection lasting more than 4 hours. Priapism is a rare condition but when present it requires prompt evaluation and definitive diagnosis. Priapism has 2 pathophysiologic subtypes: ischemic and nonischemic. Ischemic priapism accounts for a majority of cases reported. Ischemic priapism is a urologic emergency and requires intervention to alleviate pain and prevent irreversible damage to erectile tissues. This article highlights current guidelines and the contemporary literature on priapism.

Immediate insertion of a soft penile prosthesis as a new option for a safe and cost-effective treatment of refractory ischemic priapism

OBJECTIVE

The aim of this study is to assess the management of refractory ischemic priapism (IP) by the immediate insertion of a soft penile prosthesis (sPP).

PATIENTS AND METHODS

We identified men affected by IP who underwent early sPP placement from May 2017 to October 2019. All patients underwent a detailed medical history review; intraoperative, postoperative features and adverse events were recorded. We evaluated the penile lengthening and bending, presence of complementary erection, ability to have sexual intercourse, postoperative sexual life satisfaction (International Index of Erectile Function [IIEF] questionnaire - question number 5). A cost-analysis was included.

RESULTS

A total of six patients were identified. Median time (range) since onset was 78 (48-108) hours with a mean age (SD) of 33 (6.9) years. Median operative time (range) was 82 minutes (62-180). No complications were recorded. Median follow- up was 9 months (range 3-17). No significant loss of penile length, neither penile angulation was recorded. Despite a transient reduction of penile sensitivity, all patients reported satisfactory sexual intercourse (mean score question number 5 from IIEF-5 of 4). The cost of sPP was € 1769,00 with a surgeryrelated reimbursement fee from the National Health System of € 3856,75.

CONCLUSIONS

The insertion of a sPP for patients with refractory IP results in immediate pain relief, preservation of sexual function and penile size, with a higher surgery reproducibility in an emergency. In addition to this, financial and resource burdens of IP on the health-care system can be potentially reduced.

Do Antifungals and Local Anesthetic Affect the Efficacy of Antibiotic Dipping Solution?

BACKGROUND

The rates of infection after inflatable penile prosthesis (IPP) range from 1% to 3%; however, with changes in antibiotic practice intraoperatively and the incorporation of local anesthetic dips, it is unclear whether this incidence of infection is affected.

AIM

To evaluate whether the utilization of local anesthetic dips and antifungal solutions affect the efficacy of previously established dips across multiple species and strains.

METHODS

Strains of four different species of bacteria and one fungus were prepared in a standardized confluency. A standardized, and sterile protocol was used to punch out 6mm circular discs from the reservoir of a Coloplast Titan device. The discs were submerged in a standardized concentration of antimicrobials (combinations of Bactrim, Rifampin + Gentamicin, Vancomycin, Zosyn, and Amphotericin B) and plated. The zone of inhibition (ZOI) was measured at 24, 48, and 72 hours. Five repetitions of each organism was performed (>1700 discs), and the mean ZOI was calculated. Saline and DMSO were used as control on each plate.

OUTCOMES

Main outcome was the ZOI identified with each antibiotic solution, and the secondary outcome was the efficacy of the antibiotic over the course of 72 hours.

RESULTS

Difference in antibiotic efficacy was seen when each bacterial species was evaluated separately, with rifampin and gentamicin having less efficacy towards all organisms other than S. epidermidis. When looking specifically at the Candida species, amphotericin B was significantly better than other antibiotic solutions. In regards to efficacy of antibiotics over 72 hours, all treatment groups showed a decrease in ZOI over time. However, treatment groups that included rifampin demonstrated the ability to inhibit S. aureus and S. epidermidis over the 72-hour period.

CLINICAL IMPLICATIONS

To improve clinical practice and alleviate concerns that incorporation of local anesthetic and antifungals may decrease the efficacy of antibiotic solutions.

STRENGTHS AND LIMITATIONS

A major strength of the study is that it is the most robust and scientifically sound study performed on this topic with approximately 1700 repetitions. It is also the first study of its kind to include a wide spectrum of bacterial and fungal strains and antibiotic solutions along with temporal data on drug elution over a 72-hour period. A limitation of the study is the in vitro model, and this needs to be validated in a clinical setting.

CONCLUSIONS

Dipping prosthetics in antifungal and local anesthetic does not decrease the efficacy of the antimicrobials. The drug elution capabilities of the hydrophilic coating lasts primarily for 24-48hours. Mishra K, Bukavina L, Long L, et al. Do Antifungals and Local Anesthetic Affect the Efficacy of Antibiotic Dipping Solution?. J Sex Med 2021;18:966-973.

Medical treatment of recurrent ischaemic priapism: a review of current molecular therapeutics and a new clinical management paradigm

OBJECTIVES

To examine the current molecular therapeutics in the medical treatment of recurrent ischemic priapism (RIP). To propose a stepwise clinical management paradigm for the treatment of RIP.

METHODS

We performed a literature search using the PubMed database for the terms 'recurrent ischemic priapism' and 'stuttering priapism' up until December 2020. We assessed pre-clinical and clinical studies regarding medical management of RIP and molecular pathophysiology. Case series and randomized trials were evaluated by study quality and patient outcomes to determine a potential clinical management scheme.

RESULTS

Recent research has fostered an improved understanding of the underlying molecular pathophysiology of RIP that has paved the way forward for developing new therapeutic agents. Medications targeting neurovascular, hormonal and haematological mechanisms associated with RIP show great promise towards remedying this condition. A host of therapeutic agents operating across different mechanistic directions may be implemented according to a clinical management scheme to potentially optimize RIP outcomes.

CONCLUSION

RIP remains a medically neglected condition with current management focused on treating the acute condition rather than modulating the course of disease. Continued research into the molecular mechanisms of RIP and standardized clinical pathways can improve the quality of care for patients suffering from this condition.

Current Status for Semirigid Penile Prosthetic Devices

PURPOSE OF REVIEW

The goal of this paper was to evaluate the current use of semirigid penile prosthesis (SRPP), surgical techniques for insertion of SRPP, and how to prevent and approach surgical complications.

RECENT FINDINGS

SRPP is a valid option for those who are refractory to medical therapy for erectile dysfunction (ED) and even more appropriate for specific subsets of patient populations. It is important for urologists to know which patient population SRPP is preferred for. Several studies have shown good patient outcomes and patient satisfaction with those who underwent SRPP.