Percutaneous temporary embolization of the internal pudendal arteries in idiopathic priapism: 2 additional cases

[History of high-flow priapism: 1960-2005]

High-flow priapism caused by a pathological arterial influx to the cavernous bodies was first described by F.B. Burt in 1960. The pathophysiological differentiation of high- and low-flow priapism was developed in 1983. The development of diagnostic tools for differentiation of different forms of priapism and the progress in the therapy of high-flow priapism from arterial ligation to supraselective embolization is presented.

Changing diagnostic and therapeutic concepts in high-flow priapism

High-flow priapism (HFP) is defined as pathological increased arterial influx into the cavernosal bodies. Since 1960, 202 cases have been published in the literature. This study evaluates the effect of the changing diagnostic and therapeutic concepts. The data of 202 cases of HFP was evaluated regarding diagnostic and therapeutic procedures and long-term results. Success was defined as restored erectile function without recurrent priapism. The major etiology of HFP is trauma, especially in children or young adults; in older men, HFP is a rare event mainly caused by malignoma. Cavernosal blood-gas analysis, color-Doppler ultrasound and angiography were the most effective diagnostic tools to distinguish high- from low-flow priapism. The success rate was 20% for shunt operations and 89% for arterial embolization. In conclusion, embolization was effective in the majority of cases of traumatic HFP, while shunt surgery remained disappointing. For HFP caused by inherited diseases and malignoma conservative therapy is mandatory.

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.

Post-traumatic high-flow priapism: management by superselective transcatheter autologous clot embolization and duplex sonography-guided compression

High-flow priapism is caused by uncontrolled arterial inflow into the penis, often from direct arterial trauma. We report a case of arterial or high-flow priapism that was treated with a combination of selective transcatheter autologous clot embolization and duplex sonography-guided compression therapy. Sonography showed a pulsatile, anechoic area at the base of the penis inside the left corpus cavernosum after blunt perineal trauma, and color Doppler examination revealed an arteriosinusoidal fistula. Autologous clot embolization was only partially successful, and 3 sessions of ultrasound-guided compression therapy were necessary to achieve complete thrombus formation in the fistulous tract, which became isoechoic a day after compression therapy.

Selective embolization of bilateral arterial cavernous fistulas for posttraumatic penile arterial priapism

A 22-year-old man suffered a hiking accident with perineal trauma and developed a nonpainful priapism secondary to bilateral arterial-cavernosal fistulas. To minimize the risk of impotence in this young patient, successive selective embolizations with autologous blood clot were performed to close the fistulas. This led to an uncomplicated full recovery. No fistula was detectable on Doppler ultrasonography at 1-year follow-up. Review of the literature confirms the safety of embolization with autologous clot.

Treatment of posttraumatic chronic high-flow priapisms by superselective embolization of cavernous artery with autologous clot

Two cases of high-flow priapism that occurred after blunt perineal trauma and lasted for 35 days (case 1) and 40 days (case 2) were successfully treated by embolization of the lacerated cavernous arteries with autologous clots. Cavernous arterial blushes were demonstrated on selective internal pudendal arteriograms in both cases. Case 1 with left cavernous arterial laceration restored 80% of premorbid erectile function with successful intercourse 4 months after superselective embolization. In case 2 with bilateral cavernous arterial lacerations, premorbid erectile function was fully resumed 2 months after bilateral embolization of the cavernous arteries at intervals of 15 days. None developed local or systemic complications.

Embolization therapy in two subtypes of priapism

Two subtypes of priapism have been described based on the pathophysiologic mechanism. The more common type, termed stasis priapism, is characterized by a low flow state in which inadequate venous outflow creates an acidotic hypoxic environment leading to a painful prolonged erection. The other less common subtype, high flow priapism, is arteriogenic. We used embolization therapy in one case with long lasting stasis priapism and in the other with high flow priapism due to bilateral arteriosinusoidal fistulae in the penis. In both cases we used polyvinyl alcohol for embolization and sexual potency preservation. Priapism is the persistence of erection that does not result from sexual desire. Hauri et al. described two variants of priapism. In high flow priapism (non-ischaemic) there is unregulated arterial inflow to the lacunar spaces due to a lacerated cavernous artery associated with previous perineal and penile trauma. In stasis priapism, the second type, the basic abnormality could be due to a more pronounced or prolonged blood entrapment inside the vascular spaces of the corpora cavernosa sustained by an unknown cause. There are many treatment methods especially for low flow ischaemic variant. We report two different kinds of priapism and embolization therapy in both of them with polyvinyl alcohol.

Conservative management of high-flow priapism

High-flow priapism most frequently occurs as a result of penile trauma with subsequent unchecked arterial flow into the corpora cavernosa. An improved understanding of its underlying pathophysiology has allowed a more selective therapeutic approach, usually with preservation of potency. We report on 4 cases of traumatic high-flow priapism seen over a 5-year period. The patients were managed successfully with conservative treatment consisting of observation after arteriography or percutaneous duplex ultrasound-guided autologous clot embolization where tortuous vessels prevented selective embolization. No patient required surgical repair and hospitalization was brief (0 to 2 days). The use of color duplex ultrasonography provided a noninvasive modality for establishing the site of the injury and allowed serial follow-up evaluation. When conservative measures failed, the color duplex ultrasound study confirmed the presence of the ruptured cavernous artery and allowed percutaneous autologous clot embolization in 1 patient. Long-term follow-up (1 to 4 years) of these patients revealed a return to their preinjury state of erectile function.

Arterial priapism: diagnosis, treatment and long-term followup

We report on the long-term followup of 7 patients 11 to 50 years old treated for arterial priapism following perineal or penile trauma with arteriographic evidence of contrast medium extravasating from a lacerated cavernous artery into surrounding erectile tissue lacunae (an arterial-lacunar fistula). All patients underwent medical record review and completed a mailed questionnaire. The priapism erections were described as devoid of pain or tenderness, incompletely but constantly rigid and able to increase rigidity with sexual stimulation. Bright red corporeal aspirates were observed in all cases. Color flow Doppler ultrasound findings of focal areas of high flow turbulence correlated with diagnostic arteriography (correlation coefficient 1.00). Initial treatment by mechanical or pharmacological means was unsuccessful when performed. Superselective transcatheter embolization of the ipsilateral common penile artery resolved the priapism in all cases. The interval from onset to resolution of priapism was 4 to 126 days. Full erectile function return was delayed from 2 weeks to 5 months, most likely from resolving clot lysis. Full erection quality was restored in 6 of 7 patients with persistent function and restored frequency of intercourse at 6 to 67 months. Reestablished cavernous artery flow in previously embolized arteries was demonstrated on followup ultrasonography. Surgical treatment was not required in any case. We conclude that arterial priapism occurs in the absence of neurogenic-mediated relaxation, and is sustained by high oxygen tension and shear stress associated with the cavernous artery laceration. Embolization therapy offers effective management of the pathophysiology with high preservation of premorbid erectile function.

High flow priapism after blunt perineal trauma: resolution with bucrylate embolization

We report on 2 patients (ages 21 and 33 years) with high flow priapism secondary to arteriocavernous fistula produced by perineal injury. Both cases were satisfactorily resolved by super-selective embolization of the fistula with bucrylate. Diagnosis was based on the results of gasometry in cavernous blood, color Doppler ultrasound and arteriography. Erectile function after 24 and 30 months of treatment, respectively, was normal in both patients. Review of the literature revealed that only 13 patients have been managed with arterial embolization. To our knowledge our report represents the first in which intracavernous bucrylate embolization produced detumescence with preservation of erectile function.

Delayed high flow priapism: pathophysiology and management

Two cases of the management and pathophysiology of high flow arterial priapism are presented. Both cases were post-traumatic with delayed onset of priapism and both had angiographically diagnosed arteriocorporeal fistulas. Case 1 was managed with selective cavernous artery ligation and case 2 resolved spontaneously, both with excellent return of premorbid levels of erectile function. We propose that the pathophysiological mechanism involves injury to the intracavernous artery, causing ischemic necrosis. After a delay the arterial segment blows out, leading to unregulated blood flow into the corpus cavernosum. Management with surgical ligation is highly selective and nondisruptive to unaffected vessels, offering precise control of the bleeding vessel.

Use of methylene blue and selective embolization of the pudendal artery for high flow priapism refractory to medical and surgical treatments

High flow priapism is often treated effectively with intracavernous vasoconstrictive agents or surgical shunting. If these maneuvers fail treatment is unclear. A 21-year-old black man, who had failed previous pharmacological and surgical therapies, temporarily (8 hours) responded to intracavernous methylene blue, which is known to antagonize endothelial derived relaxation factor. Recurrent priapism was managed successfully by embolization of the left internal pudendal artery with absorbable gelatin sponge. Review of the literature reveals that only 7 patients have been managed with arterial embolization and our case represents the first in which intracavernous methylene blue produced detumescence.

Priapism in childhood

Priapism is a rare condition in childhood; the majority of reported cases are in boys with sickle cell disease, where conservative management is often appropriate. Our experience with 4 cases, with differing aetiologies, and a review of the literature highlight the need for aggressive therapy when conservative measures fail.

Intracorporeal cavernosa streptokinase as adjuvant therapy in the delayed treatment of idiopathic priapism

Late treatment of priapism may be associated with unsuccessful aspiration and irrigation of the corpora cavernosa. In such cases intracorporeal instillation of streptokinase resulted in dramatic improvement in detumescence. A subsequent venous shunt procedure achieved good results.