High flow malignant priapism with isolated metastasis to the corpora cavernosa

Peno-scrotal metastasis of colorectal adenocarcinoma: A case report and review of the literature

INTRODUCTION

Colorectal cancer is the second most common cause of death worldwide and may present as metastatic disease involving the liver, lungs and bones, and pelvic organs. Penile and scrotal metastasis may occur secondary to primary tumors originating from the genito-urinary tract.

CASE PRESENTATION

We present a case of rectal adenocarcinoma metastatic to the penis and scrotum s/p chemotherapy and radiotherapy. His metastatic involvement was complicated by infections, necrosis and growth of maggots. Patient underwent wide excision and debridement of the metastatic deposits in the pubic, penile, scrotal and perineal region in addition to split-tissue skin graft from the right anterior thigh to cover the pubic region, the remainder of the penile shaft, and the scrotum.

CLINICAL DISCUSSION

Peno-scrotal metastasis secondary to rectal adenocarcinoma is a rare condition. It may present as malignant priapism, hematuria, obstructive urinary symptoms occurring when there is urethral involvement. The mechanism of metastasis may be due to retrograde venous flow from the vesical, pudendal, hemorrhoidal plexuses, and the prostatic venous plexus draining the cavernosal veins of the penis. Additionally, lymphatic involvement and spread may play an important role in the spread of the disease. Treatment of such conditions relies on chemotherapy and radiotherapy and surgery for local control and symptomatic treatment.

CONCLUSION

This article describes the rare occurrence of peno-scrotal metastasis of rectal adenocarcinoma and provides an overview on diagnosis, etiology, and management of the disease.

Symptom palliation with QUAD Shot radiation therapy to penile metastasis derived from descending colon cancer: a case report

A 54-year-old man was diagnosed with descending colon cancer with metastases in the liver, para-aortic lymph nodes, and penis, and chemotherapy was introduced after construction of a colostomy. The patient reported only mild penile pain at the time of diagnosis; however, the pain gradually worsened and interfered with his daily life. Opioids did not provide sufficient analgesia, and the patient developed dysuria and priapism. Through construction of a cystostomy, palliative radiotherapy with QUAD Shot regimen (14 Gy in 4 fractions twice-daily on 2 days repeated every 4 weeks) to the penile metastasis was started for pain relief and tumor shrinkage. The radiation rapidly improved the penile symptoms, enabling opioid reduction and cystostomy removal. The patient remained pain-free and able to urinate on his own until his death. Metastatic penile tumors are rare, especially those derived from colon cancer. Penile metastases occur mainly in the late stages of cancer and may impair the patient's quality of life. In such cases, palliative radiotherapy, especially with QUAD Shot regimen, is useful with short treatment time, durable symptom control, and little adverse effect, maintaining quality of life.

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.

Endovascular Interventional Radiology of the Urogenital Tract

Interventional radiology of the male urogenital system includes percutaneous and endovascular procedures, and these last consist mostly of transcatheter arterial embolizations. At the kidney level, arterial embolizations are performed mainly for palliative treatment of parenchymal tumors, for renal traumas and, less frequently, for arteriovenous fistulas and renal aneurysms and pseudoaneurysms. These latter may often require emergency intervention as they can cause renal or peri-renal hematomas or significant hematuria. Transcatheter arterial embolization is also an effective therapy for intractable severe bladder hematuria secondary to a number of neoplastic and inflammatory conditions in the pelvis, including unresectable bladder cancer and radiation-induced or cyclophosphamide-induced hemorrhagic cystitis. Endovascular interventional procedures for the penis are indicated for the treatment of post-traumatic priapism. In this article, we review the main endovascular radiological interventions of the male urogenital system, describing the technical aspects, results, and complications of each procedure at the various anatomical districts.

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.

Malignant priapism: Review of the report in three decades

Introduction:

Priapism is one of the few critical male urological emergencies. There are two main types of priapism, low flow/venous and high flow/arterial priapism. Malignant priapism is a rare subtype of low flow priapism usually secondary to pelvic malignancy, but other extra-pelvic primary cancers cannot be completely excluded.

Aim:

To assess and highlight the poor prognosis of malignant priapism, with a view to directing management towards both symptomatic relief and improving patients’ quality of life.

Method:

All reports of malignant priapism between 1998 and 2018 were searched and assessed focusing on the primary cancer, duration of complaint, associated symptoms, method of management and prognosis.

Conclusion:

Malignant priapism is a rare form of ischaemic priapism, resistant to successful therapies utilized in the management of other forms of ischaemic priapism. Urological cancers are the most common primaries implicated with the most commonly associated symptoms being pain and urinary symptoms. In the absence of any evidence based guidelines and reliably successful treatment options, clinicians should aim to employ supportive treatment strategies including adequate analgesia.

Level of evidence:

level4

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

INTRODUCTION

Priapism is rare yet has the potential to inflict significant suffering on patients, often with lasting consequences such as erectile dysfunction, corporal muscle necrosis, and a loss of sexual function. Although rare, it is a pathology that has received little focus in the literature, particularly that caused by malignancy, and it is in this form that the long-term prognosis becomes particularly poor.

AIM

This review looks at malignant priapism in detail moving from the etiology and pathogenesis through investigations and management to provide an up-to-date picture.

METHODS

In so doing, more than 30 articles are reviewed and examined from databases such as PubMed. Significant cases are provided as examples to provide a comprehensive review of a topic that receives little attention but can cause significant patient morbidity.

MAIN OUTCOME MEASURE

The main outcome measure was the use of aspiration, sympathomimetics, and surgery as the main treatment modalities and how each one is used with regard to both the underlying etiology of the priapism and also the prognosis. We look at the need for treatment and how that relates to quality of life and erectile function thereafter.

RESULTS

Solid tumor invasion-both primary and secondary-and hematologic malignancies represent the key etiologies of malignant priapism and aggressive treatment is needed. Recovery of erectile function can occur if intracavernosal phenylephrine is quickly administered or distal shunts are placed; however, the prognosis is often poor, and subsequent chemotherapy treatment is often required.

CONCLUSION

The importance of a clear history and examination cannot be understated, and although the prognosis is often poor, this review hopes to give clinicians better understanding to be able to recognize malignancy as a potential cause of priapism. Ralph O, Shroff N, Johnson MJ, et al. Malignancy: A Rare, Important and Poorly Understood Cause of Priapism. J Sex Med 2021; 9:312-319.

The Case Report of Priapus and a Modern Approach to an Ancient Affliction

INTRODUCTION

Priapism, taking its name from God Priapus, is total or partial erection lasting longer than 4 hours independent of sexual stimulus and can result in erectile dysfunction. There are three subtypes of priapism.

AIM

To review the three subtypes of priapism, their pathophysiology, current treatment options, and complications.

METHODS

The literature including priapism guidelines, review articles, and current trial studies was reviewed and the priapism type of God Priapus was investigated according to the mythology.

MAIN OUTCOME MEASURES

All three types of priapism were reviewed for etiology, diagnosis, and management. Medical and surgical treatment options were reviewed in relation to the current literature. Special emphasis concerned current treatment strategies and controversial surgical topics.

RESULTS

Ischemic priapism is the most common type, constituting 95% of all cases, and is an emergency. First-line treatments are blood aspiration and intracavernosal sympathomimetic drug injections. If these fail, then surgical shunt operations are recommended. A T-shunt combined with corporal tunneling is the currently popular option. Immediate penile prosthesis implantation is recommended for patients who present 48 to 72 hours after the onset of a priapism episode. High-flow priapism is caused by irregular arterial cavernosal blood flow, which usually occurs after a blunt perineal trauma. Antiandrogens and selective arterial embolization are the treatment options. Stuttering priapism is repetitive, self-limiting ischemic priapism and frequent in patients with sickle cell anemia. Ketoconazole is safe, cheap, and effective and appears to be a logical and suitable current treatment option to prevent further episodes, which is the primary treatment goal of stuttering priapism.

CONCLUSION

Priapism is a relatively common condition but not well known by clinicians. The lack and delay of treatment result in irreversible complications such as erectile dysfunction. Each type of priapism should be diagnosed and treated correctly with caution.

Embolization Treatment of High-Flow Priapism

Priapism is prolonged erection that persists beyond or is unrelated to sexual stimulation. There are two main types of priapism: high flow and low flow. The treatment of priapism will differ depending on the diagnosis of these two different types. In particular, interventional radiology plays a key role in treating patients with high-flow priapism. This article will review the diagnosis and treatment of the high-flow priapism.

[Emergencies of the external genital area]

BACKGROUND

In addition to epididymitis and testicular torsion, emergencies of the external genital are rare. Rapid diagnosis and therapy are essential so that immediate therapy can be provided, which is important for survival (Fournier gangrene) of the patient or for the preservation of erectile function (priapism and penile fracture). A detailed patient history and clinical examination are generally sufficient for correct diagnosis.

RESULTS

Under certain circumstances, it might be useful to perform ultrasound, computed tomography scan or magnetic resonance imaging or retrograde urethrography. A urine analysis is obligatory. In case of penetrating injuries and genital trauma in females, additional imaging should be performed because these are often associated with concomitant injuries of the rectum, vagina, or bladder. Special cases are gunshot wounds, in which caliber and type of weapon play an important role for the degree of damage, and animal or human bites. For animal bites, the risk for rabies infection and in case of a human bite the risk for transmission of HIV and hepatitis should be taken into consideration and post-exposure prophylaxis should possibly be offered.

Penile metastasis from rectal cancer by PET/CT

It is extremely rare for rectal tumors to metastasize to the penis, and when it occurs, it is associated with poor prognosis. The appearance of penile metastasis from rectal primary tumor on PET imaging has not been widely reported. We report a case of a 70-year-old man with previous history of treated stage III adenocarcinoma of the rectum 26 months ago. The restaging 18F-FDG PET/CT scan demonstrated a hypermetabolic mass at the base of his penile shaft. This lesion was confirmed on core biopsy to be a metastatic adenocarcinoma of colorectal origin consistent with the known primary rectal tumor.

Malignant priapism: Penile metastasis originating on a primary prostate adenocarcinoma

Malignant priapism is a definition invented in 1938 by Peacock, defined as a persistent erection, not related with sexual activity, caused by cavernous sinus and associated venous systems invasion with malignant cells. Penile secondary lesions are rare entities. Primary locations are usually the pelvic cavity organs, namely the prostate and the bladder as the most common ones. Priapism as a first manifestation of these kinds of lesions is even rarer. The aim was to present a 52-year-old patient harboring a penile metastasis that originated in the primary prostate adenocarcinoma, manifesting itself as a “common” priapism. The patient referred to the emergency room presenting with a priapism and nodules at the coronal sulcus, without previous similar episodes. His evolution until properly diagnosed was catastrophic with multiple lymph nodes, bone and organ involvement, and with his demise soon after from serious bleeding and congestive heart failure, almost 2 months after he first came to the emergency room. We review the literature concerning malignant priapism, diagnosis, and current treatment and survival perspectives.

Metastatic tumors of the penis: a report of 8 cases and review of the literature

The purpose of this study was to report the clinical characteristics, treatments, and outcomes of secondary penile cancers and review the literature of this rare condition.The records of 8 patients with metastatic penile cancer treated at our hospital from 2006 to 2013 were analyzed. A search of medical databases was conducted.Patient symptoms included penile mass (n = 7, 5 had concomitant pain) and acute urine retention (n = 1). The primary cancers included bladder, lung, gastric, liver, and prostate malignancies and 1 case of pulmonary epithelioid hemangioendothelioma. The longest time from diagnosis of the primary cancer to metastatic penile cancer was 16 years and the shortest was 7 months. Six patients were treated with phallectomy, 1 with resection of the mass, and 1 with only a biopsy because of advanced metastatic disease. Five patients are deceased at the time of this report, and the longest and shortest survival times (from the diagnosis of primary cancer to the death) were 16 years and 9 months, respectively. The literature review identified 17 cases reported since 2011, bringing the total number of reported cases to 480. Genitourinary cancer, primarily bladder and prostate, account for approximately 70 of the primary cancer sites and gastrointestinal cancers account for approximately 21%. Approximately half of the patients had died of their disease within 1 year of the diagnosis of penile metastasis.The prognosis of metastatic penile cancer is poor. Most primary cancers are in the urologic or gastrointestinal systems. Surgery and adjunctive therapy may improve symptoms, but fail to prolong survival.

Malignant priapism due to renal cancer: a case report of first manifestation of systemic spread

Introduction:

Malignant priapism due to cancers is a rare condition that only 30 cases of kidney cancers were reported.

Case Presentation:

We report on the first case of simultaneous penile, renal vein, vena cava, liver and ipslateral adrenal gland metastases from primary renal cancer in a 56-year-old man. The only complain of the patient was a history of painful priapism for one month. Corporoglanular shunt surgery was useless. Postoperative imaging showed extensive regional and distal metastases and tumor embolus in vena cava as well as renal and hepatic vein.

Conclusions:

Review of literature showed priapism being the first presentation in 20% to 50% of cases, almost all cases have shown very poor prognosis. This case report underscored the importance of investigation of primary tumors for patients with malignant priapism.

Malignant priapism secondary to isolated penile metastasis from a renal pelvic carcinoma

We report a case of isolated penile metastasis from renal pelvic carcinoma in a 69-year-old man with malignant priapism. The patient had radical resection of the renal pelvic carcinoma 2 months earlier with urothelial carcinoma (UC) and sarcomatoid differentiation histology. Physical examination showed no visible skin lesions, but a palpable hard nodule was present over the penile shaft. The imaging studies did not reveal other metastases. Cavernous-Glans shunt and nodule resection were performed, and histological examination showed metastasis UC with sarcomatoid differentiation. To our knowledge, we describe the first case of malignant priapism due to isolated penile metastasis of renal pelvic carcinoma.

Rare synchronous metastases of renal cell carcinoma

Renal cell carcinoma can metastasize to any region of the body. We review a patient who presents fourteen years after initial resection of the primary tumor with distant metastatic disease. This included spread to the bladder and penis that manifested as frank haematuria and malignant priapism respectively. We discuss the mechanism of spread and the management options available.

18F-FDG PET/CT in a case of malignant priapism secondary to metastasis from mucoid adenocarcinoma of the cecum

Metastatic tumors of the penis are rare, with priapism as the predominant symptom in a significant number of cases. The genitourinary tract and rectum are the most common primary sites. FDG PET/CT has established role in detection of distant metastasis in various malignancies. The authors describe a case of mucoid adenocarcinoma of cecum, presented with priapism after right hemicolectomy, where FDG PET/CT showed intense tracer uptake throughout the enlarged penis, which was later confirmed as metastatic adenocarcinoma by trucut biopsy.

Metachronous penile metastasis from rectal cancer after total pelvic exenteration

Despite its abundant vascularization and extensive circulatory communication with neighboring organs, metastases to the penis are a rare event. A 57-year-old male, who had undergone total pelvic exenteration for rectal cancer sixteen months earlier, demonstrated an abnormal uptake within his penis by positron emission tomography/computed tomography. A single elastic nodule of the middle penis shaft was noted deep within Bucks fascia. No other obvious recurrent site was noted except the penile lesion. Total penectomy was performed as a curative resection based on a diagnosis of isolated penile metastasis from rectal cancer. A histopathological examination revealed an increase of well differentiated adenocarcinoma in the corpus spongiosum consistent with his primary rectal tumor. The immunohistochemistry of the tumor cells demonstrated positive staining for cytokeratin 20 and negative staining for cytokeratin 7, which strongly supported a diagnosis of penile metastasis from the rectum. The patient is alive more than two years without any recurrence.

A review of penile metastasis

Penile cancer as primary disease is relatively rare in developed countries. The penis is a rare site of metastases in spite of its rich vascularization. Approximately 500 cases have been reported in the literature; almost 70% of primary lesions are of pelvic origin (from genitourinary or recto-sigmoid primary tumors). We describe a case of penile metastasis from lung cancer. The rarity of the event prompted us to also explore related reviews and discuss the incidence, physiopathology, diagnosis and therapy of penile secondary cancer.

Malignant priapism: a case report

BACKGROUND

Metastatic involvement of the penis is most commonly from a primary malignant genitourinary tumour. It is a rare phenomenon usually reflecting disseminated malignancy associated with a poor prognosis. Metastasis to the penis mimicking priapism is extremely rare, particularly in the absence of disseminated disease.

MATERIALS AND METHODS

We describe a case of painful priapism caused by a high-grade urothelial malignancy without disseminated disease.

CONCLUSION

Life expectancy is estimated at less than 1 year in these patients. Our patient remains in clinical and radiologic remission over 36 months from his original radical surgery.

Malignant priapism secondary to adenocarcinoma of the prostate

The authors report a case of an older gentleman with a history of metastatic prostate cancer who presented to the emergency department following 3 weeks of progressively intermittent and then continuous priapism. After an initial clinical workup, an MRI was performed of the pelvis for further evaluation of the patient's condition which demonstrated metastatic lesions within his corpora cavernosa. The patient underwent follow-up core-needle biopsy with pathologically proven metastasis.

Evaluation and management of priapism: 2009 update

Priapism is defined as a persistent penile erection (typically 4 h or longer) that is unrelated to sexual stimulation. Priapism can be classified as either ischemic or nonischemic. Ischemic priapism, the most common subtype, is typically accompanied by pain and is associated with a substantial risk of subsequent erectile dysfunction. Prompt medical attention is indicated in cases of ischemic priapism. The initial management of choice is corporal aspiration with injection of sympathomimetic agents. If medical management fails, a cavernosal shunt procedure is indicated. Stuttering (recurrent) ischemic priapism is a challenging and poorly understood condition; new management strategies currently under investigation may improve our ability to care for men with this condition. Nonischemic priapism occurs more rarely than ischemic priapism, and is most often the result of trauma. This subtype of priapism, which is generally not painful, is usually initially managed with conservative treatment.

High-flow priapism due to a malignant glomus tumor (glomangiosarcoma) of the corpus cavernosum

INTRODUCTION

The major cause of non-ischemic high-flow priapism is post-traumatic vascular injury leading to an arterio-lacunar fistula. However, rare causes such as tumors may induce priapism. This is the first report of a malignant glomus tumor localized in the corpora cavernosa.

AIM

The aim of this case is to emphasize the importance of the initial management of priapism and to suggest new tracks on the tests to be performed when the usual exams are not sufficient.

METHOD

We report the case of a hypervascular penile tumor responsible for high-flow priapism as the first clinical symptom of a metastatic glomus tumor. The persistent penile tumescence was initially considered to be a stuttering priapism and treated using an oral α-adrenergic as no provoking event nor fistula was found. After a 2-week reluctance, a penile magnetic resonance imaging (MRI) was performed.

RESULTS

The MRI showed a hypervascular lesion at the proximal part of the right corpora. The lesion was considered as a fistula, and a selective embolization was performed. Two weeks after embolization, the patient came back to the emergency room because of syncopes and dyspnea. Examination by cardiac ultrasound and chest computed tomography revealed the presence of cardiac, pulmonary, and subcutaneous malignant glomus tumors (glomangiosarcoma). Patient received three lines of chemotherapy, and the penile tumor was surgically removed because of persistent erectile dysfunction and perineal pain.

CONCLUSION

This case supports the use of corporal body blood gas analysis in difficult cases to discriminate high- and low-flow priapism and penile MRI when clinical history, physical examination, and aspiration are not contributory.

Priapism secondary to penile metastasis of rectal cancer

Metastatic penile carcinoma is rare and usually originates from genitourinary tumors. The presenting symptoms or signs have been described as nonspecific except for priapism. Rectal adenocarcinoma is a very unusual source of metastatic penile carcinoma. We report a case of metastatic penile carcinoma that originated from the rectum. Symptomatic improvement occurred with palliative radiotherapy.

Penile metastasis of cutaneous malignant melanoma: a true hematogenous spread?: Case report and review of the literature

Penile involvement has been implicated as a metastatic site in several tumors; approximately 300 cases have been reported. Of these, only two cases showed cutaneous melanoma as the primary site. Our patient presented with a painless mass on the penile shaft together with other distant metastases. A magnetic resonance image demonstrated two sites of deposit in the subcutaneous tissue on the radix penis, and fine needle aspiration cytology of the mass confirmed the presence of melanoma cells. The patient died of systemic disease without any further treatment for penile involvement. This unusual involvement is presented with a review of the related literature.

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.

Fine-needle aspiration of secondary malignancies of the penis: A report of three cases

Metastatic malignancy to the penis is an uncommon clinicopathologic entity, with only 300 cases reported since 1870. Of the reported cases, 75% were secondary to genitourinary primary tumors. Priapism is the most frequent symptom, although dysuria, ulceration, and node formation have also been described. We report three cases of penile metastatic involvement from primary tumors in the urinary bladder (two cases) and prostate (one case), respectively. Fine-needle aspiration (FNA) cytology from the penile nodules was performed in each case. The smears in all cases were highly cellular, and atypical neoplastic cells were observed singly, in clusters, or in papillary formations. The cells were pleomorphic with hyperchromatic nuclei and prominent nucleoli. Immunocytochemistry was performed for keratin 8 and 18 and prostatic-specific antigen (PSA). In conclusion, although it has rarely been used as a diagnostic tool, FNA of the penis can be proved effective and safe in diagnosing a suspected secondary malignancy.

Late penile metastasis from primary bladder carcinoma

We report a case of late penile metastasis from primary bladder carcinoma. Penile metastases are an extremely rare occurrence. The most striking feature of this case was that lung metastasis was diagnosed 7.5 years after the patient presented with primary bladder carcinoma and that metastasis to the penis was detected another 2.5 years later. No further urothelial carcinoma recurrence was observed during follow-up until the patient died of lung cancer 6 years after the occurrence of penile metastasis. The case is discussed with reference to published reports.