Malignancy: A Rare, Important and Poorly Understood Cause of Priapism

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.

Primary Penile Squamous Cell Cancer-Related Malignant Priapism in a Cystectomized Patient: A Case Report

Priapism is one of the most common urologic emergencies and is characterized by a prolonged and painful erectile state unrelated to sexual stimulation or sexual desire. Neoplasm-associated priapism is a rare condition and is usually caused by corporeal metastases of other pelvic area malignancies. Primary penile malignancy-related malignant priapism is extremely rare. In this reported case, an 82-year-old male presented with priapism. The penile doppler ultrasound and pelvic magnetic resonance imaging were compatible with ischemic priapism and corporal mass. Subsequently, the patient underwent total penectomy and bilateral superficial inguinal lymphadenectomy. The pathology report was consistent with primary penile squamous cell cancer (SCC), so the patient underwent adjuvant radiotherapy. However, he developed multiple metastases and could survive for about six months. The patient had undergone radical cystectomy (RC) and urethrectomy 19 and 2 years ago due to urothelial carcinoma, respectively. To the best of our knowledge, this is the second case of malignant priapism due to primary penile SCC and represents one of the longest urethral recurrence periods after RC. When a patient presents with malignant priapism, primary penile malignancies should be considered in differential diagnosis, even if the patient has a history of pelvic area malignancies.

Priapism mimic: penile metastasis from hepatocellular carcinoma

We describe the case of a metastatic penile tumour of hepatocellular origin treated with surgical resection.

Malignant Priapism - What Do We Know About It?

Malignancy as an etiological factor involved in priapism pathogenesis is rare. Malignant priapism (MP) can arise as a result of penile tumor invasion, either from primary penile tumors or from metastatic penile tumors, or due to hematological malignancies. Non-urological penile metastases are associated with significant worse prognosis compared to urological penile metastases, the appearance of priapism in such cases affecting even more the prognosis and the survival of these patients. Patients diagnosed with hematological malignancies and priapism present significant higher survival rates compared to those who develop MP in the context of a non-hematological malignancy, this being related to the fact that hematological malignancies are more sensitive to chemo- and radiotherapy. Most malignant priapism cases are ischemic; therefore the management should be based on the initial steps of the IP therapeutic protocol. Considering the trigger factor that has led to the priapic event specific oncologic treatment can be added as well.