Medical management of ischemic stuttering priapism: a contemporary review of the literature

The effect of red blood cell disorders on male fertility and reproductive health

Male infertility is defined as a failure to conceive after 12 months of unprotected intercourse owing to suspected male reproductive factors. Non-malignant red blood cell disorders are systemic conditions that have been associated with male infertility with varying severity and strength of evidence. Hereditary haemoglobinopathies and bone marrow failure syndromes have been associated with hypothalamic-pituitary-gonadal axis dysfunction, hypogonadism, and abnormal sperm parameters. Bone marrow transplantation is a potential cure for these conditions, but exposes patients to potentially gonadotoxic chemotherapy and/or radiation that could further impair fertility. Iron imbalance might also reduce male fertility. Thus, disorders of hereditary iron overload can cause iron deposition in tissues that might result in hypogonadism and impaired spermatogenesis, whereas severe iron deficiency can propagate anaemias that decrease gonadotropin release and sperm counts. Reproductive urologists should be included in the comprehensive care of patients with red blood cell disorders, especially when gonadotoxic treatments are being considered, to ensure fertility concerns are appropriately evaluated and managed.

Management of Priapism: Results of a Nationwide Survey and Comparison with International Guidelines

OBJECTIVE

The aim of this study is to evaluate current urologic practice regarding the management of priapism in Turkey and compare with international guidelines.

METHODS

Urologists and urology residents were invited to an online survey consisting of 30 multiple-choice questions on priapism-related clinical practices that were consid- ered most important and relevant to practices by using Google Forms.

RESULTS

Total number of responses was 340. Respondents reported that they recorded a detailed patient's medical history and physical examination findings (n = 340, 100%) and laboratory testing, which includes corporal blood gas analysis (n=323, 95%). Participants announced that they performed Doppler ultrasound for 1/4 cases (n = 106, 31%), but 22% of the participants (n=75) replied that they performed in >75% of cases. Participants (n=311, 91%) responded that the first-line treatment of ischemic priapism is decompression of the corpus cavernosum. Moreover, most respondents (n = 320, 94%) stated that sympathomimetic injection drugs should be applied as the second step. About three-quarters of respondents (n = 247, 73%) indicated adrenaline as their drug of choice. Phosphodiesterase type 5 inhibitors seems to be the most pre- ferred drug for stuttering priapism (n=141, 41%). Participants (n=284, 84%) replied that corpora-glanular shunts should be preferred as the first. A large number of par- ticipants (n = 239, 70%) declared that magnetic resonance imaging can be performed in cases with delayed (>24 hours) priapism to diagnose corporal necrosis. Most of the participants (84%) responded that penile prosthesis should be preferred to shunts in cases with delayed (>48 hours) priapism.

CONCLUSION

It would be appropriate to improve the training offered by professional associations and to give more training time to the management of priapism during residency.

Stuttering Priapism in a Dog—First Report

Simple Summary

A 5-year-old recently castrated male Doberman dog presented for prolonged erection of one week’s duration with associated pain and dysuria. This was the fourth episode within a year. Each episode was associated with an unusual event, which was stressful for the dog. Castration performed two months prior to the final episode did not prevent recurrence. Due to tissue necrosis, penile amputation and urethrostomy had to be performed. To our knowledge, this case is the first report of a stuttering priapism in a dog. Stuttering priapism, also called recurrent or intermittent priapism, is a particular type of ischemic priapism described in humans that is characterized by repeated episodes of prolonged erections.

Abstract

A 5-year-old recently castrated male Doberman dog presented for prolonged erection of one week’s duration with associated pain and dysuria. This was the fourth episode within a year. Each episode was associated with an unusual event, which was stressful for the dog. Castration performed two months prior to the final episode did not prevent recurrence. Due to tissue necrosis, penile amputation and urethrostomy had to be performed. The dog recovered fully. Prolonged erection that persists beyond or that is unrelated to sexual stimulation is called “priapism”. This term refers to the Greek god Priapus, a god of fertility, memorialized in sculptures for his giant phallus. In humans, depending on the mechanism involved, priapism is classified as nonischemic or ischemic. Because prognosis and treatment are different, priapism must be determined to be nonischemic or ischemic. Nonischemic priapism is a rare condition observed when an increase in penile arterial blood flow overwhelms the capacity of venous drainage; it is often associated with penile trauma, and does not require medical intervention. Ischemic priapism is associated with decreased venous return. In humans, ischemic priapism accounts for 95% of cases, the majority of which are idiopathic. Ischemic priapism is a urological emergency; simple conservative measures such as aspiration of blood from the corpora cavernosa and intracavernosal injection of an adrenergic agent are often successful. Stuttering priapism, also called recurrent or intermittent priapism, is a particular form of ischemic priapism reported in humans that is characterized by repetitive episodes of prolonged erections. Management consists of treating each new episode as an episode of acute ischemic priapism, and preventing recurrence with oral medications such as dutasteride and/or baclofen, gabapentin, or tadalafil. To the authors’ knowledge, this case is the first report of stuttering priapism in a dog.

An update on the management algorithms of priapism during the last decade

Priapism is a persistent penile erection lasting longer than 4 hours, that needs emergency management. This disorder can induce irreversible erectile dysfunction. There are three subtypes of priapism: ischemic, non-ischemic, and stuttering priapism. If the patient has ischemic priapism (IP) of less than 24-hours (h) duration, the initial management should be a corporal blood aspiration followed by instillation of phenylephrine into the corpus cavernosum. If sympathomimetic fails or the patient has IP from 24 to 48h, surgical shunts should be performed. It is recommended that distal shunts should be attempted first. If distal shunt failed, proximal, venous shunt, or T-shunt with tunneling could be performed. If the patient had IP for 48 to 72h, proximal and venous shunt or T-shunt with tunneling is indicated, if those therapies failed, a penile prosthesis should be inserted. Non-ischemic priapism (NIP) is not a medical emergency and many patients will recover spontaneously. If the NIP does not resolve spontaneously within six months or the patient requests therapy, selective arterial embolization is indicated. The goal of the management of a patient with stuttering priapism (SP) is the prevention of future episodes. Phosphodiesterase type 5 (PDE5) inhibitor therapy is considered an effective tool to prevent stuttering episodes but it is not validated yet. The management of priapism should follow the guidelines as the future erectile function is dependent on its quick resolution. This review briefly discusses the types, pathophysiology, and diagnosis of priapism. It will discuss an updated approach to treat each type of priapism.

Presumptive Non-Ischemic Priapism in a Cat

A 14-year-old neutered male British shorthair cat presented with a 21-day history of persistent erection and dysuria, along with overgrooming of the perineal region. Mild palpation induced pain and rigid corpora cavernosa with flaccid glans were observed during physical examination. Ultrasonography of the penis did not detect significant blood flow in the penile cavernosal artery. The drawing of aspirate blood from cavernosal bodies for gas analysis was impossible because of the anatomically small penis size of cats. Conservative management, including topical steroid ointment, lidocaine gel, gabapentin, and diazepam, was prescribed for supportive management. The clinical signs resolved, and ultrasonographic examination of the penis revealed no abnormalities. The cat remains clinically well without recurrence during the 6 months after treatment. To our knowledge, this is the first report of non-ischemic priapism in a cat.

A Review of Antipsychotics and Priapism

INTRODUCTION

Pharmacologically induced priapism is now the most common cause of priapism, with approximately 50% of drug-related priapism being attributed to antipsychotic usage. The majority of pharmacologic priapism is believed to result in ischemic priapism (low flow), which may lead to irreversible complications, such as erectile dysfunction. It is imperative that prescribing physicians be aware of potentially inciting medications.

OBJECTIVES

To identify medications, specifically antipsychotics, associated with priapism and prolonged erections and understand the rates and treatment of these side effects.

METHODS

A PubMed search of all articles available on the database relating to priapism, prolonged erections, and antipsychotics was performed.

RESULTS

Various typical and atypical antipsychotic drugs (APDs) have been implicated in pharmacologically induced priapism. In addition to dopaminergic and serotoninergic receptors, APDs have affinities for a wide array of other receptors in the central nervous system, including histaminergic, noradrenergic, and cholinergic receptors. Although the exact mechanism is unknown, the most commonly proposed mechanism of priapism associated with APDs is α-adrenergic blockade in the corpora cavernosa of the penis. Priapism appears in only a small fraction of men using medications with α1-receptor-blocking properties, indicating differential sensitivities to the α-blocking effect among men, and/or additional risk factors that may contribute to the development of priapism. The best predictor for the subsequent development of priapism is a past history of having prolonged and painless erections. The acute management algorithm of APD-induced priapism is the same as for other causes of low-flow priapism.

CONCLUSION

Clinicians should educate patients treated with antipsychotics about the potential for priapism and its sequelae including permanent erectile dysfunction. Appropriate patient education will raise awareness, encourage early reporting, and help reduce the long-term consequences associated with priapism through early intervention. Hwang T, Shah T,Sadeghi-NejadH. A Review of Antipsychotics and Priapism. Sex Med Rev 2021;9:464-471.

[Priapism: Diagnosis and management]

OBJECTIVE

Our aim was to present a synthesis on the diagnosis and treatment of priapism.

METHODS

For this purpose, a literature search was performed through PubMed to analyze literature reviews and guidelines regarding priapism.

RESULTS

Priapism is an erection that persists more than 4hours. There are 3 types of priapism: ischemic priapism, non-ischemic priapism and recurrent (stuttering) priapism. Ischemic priapism, often idiopathic, is the most frequent. When diagnosed, an urgent management is required to limit erectile dysfunction. Sickle-cell patients are prone to have ischemic and stuttering priapism. Non-ischemic priapism usually occurs after perineal trauma. Priapism management depends on the type of priapism. Medical treatment (corporal aspiration and injection of sympathomimetics) then if failed, surgery are indicated for ischemic priapism. The persistence of a non-ischemic priapism most likely requires a radiologic embolization.

CONCLUSION

Priapism is a condition that often requires emergency treatment to spare erectile function. It appears crucial to know this condition and its management.

Daily tadalafil for the chronic phase of stuttering priapism: a case report

Background

Recurrent (stuttering) ischemic priapism is a challenging clinical condition. Frequent recurrences result in frequent hospital admissions whereas treatment with a shunting procedure often results in erectile dysfunction.

Case presentation

A 22-year-old man with stuttering idiopathic priapism developed erectile dysfunction (IIEF-5 score 12) following a Winter’s shunt; he was given tadalafil, 5 mg/daily, for 6 months. This treatment resulted in progressive restoration of erectile function in the 6 months following the shunt as well as in preventing recurrence of priapic episodes over a 24-month follow-up.

Conclusions

This is the first report in literature of chronic treatment of stuttering priapism with a phosphodiesterase-5 inhibitor being able not only to prevent recurrent priapic episodes but also to restore erectile function following a Winter’s shunt.

Contemporary best practice in the evaluation and management of stuttering priapism

Stuttering priapism is rare and under-investigated clinical entity. Although it shares similarities with ischaemic priapism, by definition, stuttering priapism has distinct characteristics that advocate for a different management in the clinical setting. Therefore, the management of stuttering priapism aims primarily to prevent recurrence rather than the resolution of spontaneous attacks. A multimodal approach and the individualization of each case are essential because of the diversity of the condition and the plethora of proposed therapeutic strategies. Understanding the underlying pathophysiology and familiarity with contemporary, past and emerging future agents and therapeutic options are required in order to provide an optimal solution for each patient. In addition, patient counselling and the option to combine therapeutic strategies and challenge second-line therapies are essential weapons in the armament of the urologist. Although further clinical trials and studies are mandatory in order to obtain solid data and provide recommendations, all therapeutic options are analysed, with specific interest in the potential advantages and disadvantages. A structured evaluation procedure is also described.

Clinical Management of Priapism: A Review

Priapism is defined as a persistent and painful erection lasting longer than four hours without sexual stimulation. Based on episode history and pathophysiology, priapism is classified into three subtypes: ischemic (low-flow), non-ischemic (high-flow), and stuttering priapism. Ischemic priapism is characterized by a persistent, painful erection with remarkable rigidity of the corpora cavernosa caused by a disorder of venous blood outflow from this tissue mass, and is similar to penile compartment syndrome. Stuttering priapism is characterized by a self-limited, recurrent, and intermittent erection, frequently occurring in patients with sickle cell disease. Non-ischemic priapism is characterized by a painless, persistent nonsexual erection that is not fully rigid and is caused by excess arterial blood flow into the corpora cavernosa. Because ischemic and non-ischemic priapism differ based on emergency status and treatment options, appropriate discrimination of each type of priapism is required to initiate adequate clinical management. The goal of management of priapism is to achieve detumescence of the persistent penile erection and to preserve erectile function after resolution of the priapism. To achieve successful management, urologists should address this emergency clinical condition. In the present article, we review the diagnosis and clinical management of the three types of 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.

[Priapism: Current diagnostics and therapy]

Priapism is characterized by involuntary persistent penile erection after or independent of sexual stimulation. The diagnostic clarification, including patient history, physical findings, duplex ultrasonography and analysis of blood gases is decisive for the underlying pathophysiology and the appropriate therapeutic procedure. Non-hypoxic and non-acidotic blood gas parameters enable a conservative approach, hypoxic, hypercarbic and acidotic parameters may lead to fibrosis of the corpora cavernosa and, in turn, to a loss of penile function. Low-flow or ischemic (veno-occlusive) priapism is an emergency situation and can lead to irreversible erectile dysfunction within 4 h. Treatment consists of blood aspiration and possibly intracavernosal injection of sympathomimetic drugs. A distal shunt is necessary in the case of treatment failure (in rare cases a proximal shunt). Management of recurrent priapism (stuttering) includes self-injection of sympathomimetic drugs and preventive long-term administration of erection inhibitory and erection promoting substances. This concept still needs to be validated. High-flow or non-ischemic priapism does not necessitate immediate treatment measures and should be kept under observation. In cases of a detectable fistula selective artery embolization is often a successful option.

Management of Recurrent Ischemic Priapism 2014: A Complex Condition with Devastating Consequences

INTRODUCTION

The management of recurrent ischemic priapism (RIP) is not clearly defined. Given the rarity of this condition, most treatment options are supported at best by level 3 or 4 evidence.

AIM

In this article, we review the current literature regarding the pathophysiology and management of RIP and discuss the risks and benefits associated with each option, which includes ketoconazole (KTZ), 5-α-reductase inhibitors and other hormonal therapies, phosphodiesterase type 5 (PDE5) inhibitors, intracavernosal sympathomimetic injection, oral sympathomimetic agents, and other investigational therapies.

METHODS

A comprehensive literature review was performed regarding the management options for RIP.

MAIN OUTCOME MEASURE

To examine the pathophysiology of RIP and evaluate the treatment options.

RESULTS

Multiple agents have been investigated to manage RIP. KTZ, finasteride, anti-androgens, gonadotropin-releasing hormone agonists, and estrogen have been shown to be effective in several reports, though some of these agents may have significant hormonal side effects. PDE5 inhibitors currently appear to be well tolerated in this patient population, though evidence of its efficacy is limited. Intracavernosal α-agonist therapy may be used to treat episodes of priapism after they occur. Very limited data suggest terbutaline, oral α-agonists, digoxin, hydroxyurea, and gabapentin may have a role in RIP management.

CONCLUSIONS

An ideal management strategy for RIP should focus on prevention of priapic episodes using an effective, well-tolerated, cost-effective medication. We currently have several proposed options, with varying efficacy rates and side effect profiles. While significant advancements in our understanding and management of stuttering priapism have been made within the past few years, clearly continuing research and clinical studies are needed to guide our management of this disease process. Hoeh MP and Levine LA. Management of recurrent ischemic priapism 2014: A complex condition with devastating consequences. Sex Med Rev 2015;3:24-35.

Management of priapism: an update for clinicians

Priapism is a prolonged erection that persists beyond or is unrelated to sexual stimulation. It is associated with significant morbidity: psychological, socioeconomic, and physical, including pain and potentially irreversible compromise of erectile function. There are three major types of priapism: ischemic, nonischemic, and stuttering. Establishing the type of priapism is paramount to safely and effectively treating these episodes. Ischemic priapism represents a urological emergency. Its treatment may involve aspiration/irrigation with sympathomimetic injections, surgical shunts, and as a last resort, penile prosthesis implantation. Nonischemic priapism results from continuous flow of arterial blood into the penis, most commonly related to penile trauma. This is not an emergency and may be managed conservatively initially, as most of these episodes are self-limiting. Stuttering priapism involves recurrent self-limiting episodes of ischemic priapism. The primary goal of therapy is prevention, but acute episodes should be managed in accordance with guidelines for ischemic priapism. In this paper we review the diagnosis and treatment of the three priapism variants, as well as discuss future targets of therapy and novel targets on the horizon.

Prostate cancer risk after anti-androgen treatment for priapism

BACKGROUND

Patients with recurrent ischemic priapism have historically been treated with anti-androgen therapy due to the limited available evidence for more targeted therapies to treat the underlying pathophysiologic mechanisms of this condition. We report a case in which anti-androgen therapy caused significant adverse side effects and likely masked this patient's elevated prostate-specific antigen (PSA) levels, which adversely impacted the timely diagnosis and treatment of his prostate cancer.

CASE REPORT

A 69-year-old man treated with anti-androgens for priapism initially developed unwanted anti-androgenic side effects such as gynecomastia, erectile dysfunction, and decreased libido. After decreasing his anti-androgen dosage and starting a specified regimen of phosphodiesterase type 5 inhibitor therapy, his serum PSA levels were found to be elevated. He was subsequently diagnosed with adenocarcinoma of the prostate and underwent a radical prostatectomy with the pathologic finding of high-grade, locally progressive disease.

CONCLUSION

Anti-androgen therapy carries significant complication risks, including the potential to alter the diagnosis and treatment of prostate cancer. Clinicians administering this therapy for priapism management should be aware of these possible risks.

Stuttering priapism in a patient with neurosyphilis

We recently encountered a case of stuttering priapism in a 41-year-old patient with neurosyphilis. Priapism very rarely has a neurogenic cause, and to our knowledge, priapism caused by neurosyphilis has not been reported previously in the literature. Our aim was to report this case and systematically review the related literature.

Unsatisfactory outcomes of prolonged ischemic priapism without early surgical shunts: our clinical experience and a review of the literature

Ischemic priapism is a rare occurrence which can cause severe erectile dysfunction (ED) without timely treatment. This retrospective study reports our experience in treating prolonged ischemic priapism and proposes our further considerations. In this paper, a total of nine patients with prolonged ischemic priapism underwent one to three types of surgical shunts, including nine Winter shunts, two Al-Ghorab shunts and one Grayhack shunt. During the follow-up visit (after a mean of 21.11 months), all patients' postoperative characters were recorded, except one patient lost for death. Six postoperative patients accepted a 25-mg oral administration of sildenafil citrate. The erectile function of the patients was evaluated by their postoperative 5-item version of International Index of Erectile Function Questionnaire (IIEF-5), which were later compared with their premorbid scores. All patients had complete resolutions, and none relapsed. The resolution rate was 100%. Seven patients were resolved with Winter shunts, one with an Al-Ghorab shunt and one with a Grayhack shunt. The mean hospital stay was 8.22 days. There was only one urethral fistula, and the incidence of postoperative ED was 66.67%. Four patients with more than a 72-h duration of priapism had no response to the long-term phosphodiesterase type 5 (PDE-5) inhibitor treatment. These results suggest that surgical shunts are an efficient approach to make the penis flaccid after prolonged priapism. However, the severe ED caused by prolonged duration is irreversible, and long-term PDE-5 inhibitor treatments are ineffective. Thus, we recommend early penile prosthesis surgeries for these patients.

Priapism is associated with sleep hypoxemia in sickle cell disease

PURPOSE

We assessed penile rigidity during sleep and the relationship of sleep abnormalities with priapism in adults with sickle cell disease.

MATERIALS AND METHODS

This was a case-control study of 18 patients with sickle cell disease and a history of priapism during the previous year, and 16 controls with sickle cell disease. Participants underwent overnight polysomnography and RigiScan® Plus recording to detect penile rigidity oscillations.

RESULTS

The priapism group (cases) showed a higher apnea-hypopnea index and oxyhemoglobin desaturation parameters than controls. A lower positive correlation between the apnea-hypopnea index and oxyhemoglobin desaturation time was observed in cases than in controls (Spearman coefficient ρ = 0.49, p = 0.05 vs ρ = 0.76, p <0.01), suggesting that desaturation events occurred independently of apnea. Two controls and 14 cases had a total sleep time that was greater than 10% with oxyhemoglobin saturation less than 90% but without CO(2) retention. Penile rigidity events were observed during rapid eye movement sleep and during stage 2 of nonrapid eye movement sleep, particularly in cases. The duration of penile rigidity events concomitant to respiratory events was higher in cases than in controls. Regression analysis revealed that the periodic limb movement and desaturation indexes were associated with priapism after adjusting for rapid eye movement sleep and lung involvement. Finally, oxyhemoglobin saturation less than 90% was associated with priapism after adjusting for lung involvement, hyperhemolysis and the apnea-hypopnea index.

CONCLUSIONS

Oxyhemoglobin desaturation during sleep was associated with priapism history. It may underlie the distribution pattern of penile rigidity events during sleep in these patients.