Spontaneous detumescence and full restoration of erection in a patient with high-flow priapism with persistent arterial-lacunar fistula after repeated selective embolisation-A case report

High-flow priapism due to bilateral cavernous artery fistulas treated by unilateral embolization: A case report

BACKGROUND

High flow priapism (HFP) is a rare type of priapism. Perineal trauma is the most common cause of HFP. Trauma-induced penile artery injury may lead to an arterial-cavernosal fistula, whereas persistent irregular arterial blood flow entering the corpora cavernosum can cause a persistent penile erection. The routine treatment of HFP focuses on addressing the abnormal penile erectile status and avoiding post-treatment erectile dysfunction. Interventional embolization is an important therapeutic modality for HFP, and bilateral embolization therapy is currently the most commonly used technique for patients with bilateral cavernous artery fistulas; however, unilateral embolization therapy has yet to be reported.

CASE SUMMARY

Herein, we report of the case of a 26-year-old Chinese male who presented with a persistent abnormal erection for 12 h after perineal impact injury. Medical history, cavernous arterial blood gas analysis and radiological examinations led to a diagnosis of HFP caused by bilateral cavernous artery fistulas. We performed routine conservative treatment (compression therapy and ice application) for the patient after admission; however, 10 d later, his symptoms had not been relieved. After completion of the preoperative workup, right (severe side) selective perineal artery embolization was performed; the left cavernous artery fistula was left untreated. After postoperative continuation of conservative treatment for 72 h, the patient experienced complete penile thinning. The patient had no symptoms of erectile dysfunction over a follow-up period of 12 mo.

CONCLUSION

Compared with bilateral cavernous artery fistula embolization, we believe that unilateral cavernous artery fistula embolization can achieve positive clinical efficacy and reduce the risk of postoperative erectile dysfunction secondary to penile ischemia.

High-flow post-traumatic priapism with delayed presentation

Priapism is an urgent urological condition with varied aetiology that may be classified as low flow (ischaemic) or high flow (non-ischaemic). Diagnosis requires detailed clinical history and examination combined with appropriate investigations such as cavernosal blood gas sampling and penile Doppler ultrasound. In the case of high-flow priapism CT angiography can identify sources of abnormal arterial blood flow and cases may be managed conservatively, with surgery or through arterial embolisation. We detail a case of a young man presented 2 weeks after perineal trauma with high-flow priapism with an equivocal penile Doppler ultrasound. Cavernosal blood gas sampling was consistent with arterial blood and CT angiography was performed showing an arteriovenous fistula. The patient was then successfully managed with arterial embolisation resulting in detumescence and preserving sexual function.

An Update on Non-Ischemic Priapism

INTRODUCTION

Non-ischemic or high-flow priapism is derived from unregulated arterial inflow within the penis, which is significantly less common and, therefore, less well characterized than ischemic or low-flow priapism.

AIM

We collected the most recent available data and summarized the findings.

METHODS

All literature related to non-ischemic priapism from 2000-2018 from several databases was reviewed, and 105 articles, including any relevant referenced articles, were ultimately included.

MAIN OUTCOME METHODS

We evaluated modality success rates, need for repeat procedures, and effects on erectile function.

RESULTS

237 cases of non-ischemic priapism were evaluated. Approximately 27% of patients underwent observation or medical management as the first treatment modality, whereas 73% underwent intervention without observation or medical management beforehand. Angiographic embolization with temporary agents was the most common intervention and generally resulted in both moderate resolution of non-ischemic priapism and moderate preservation of baseline erectile function. Patients who underwent embolization with permanent agents experienced higher rates of resolution, as well as lower rates of erectile dysfunction (ED).

CONCLUSION

Most of the literature is in the form of case reports and small case series, thus limiting the quality and quantity of evidence available to draw decisive conclusions. However, from the available data, it is reasonable to presume that patients can undergo a trial of conservative management, then pursue embolization first with temporary agents. The analysis of the data demonstrated ED rates were higher with temporary agents than permanent agents. The literature quotes ED rates as low as 5% when using temporary agents and 39% with permanent agents. Our results were, in fact, the opposite, with higher ED rates when using temporary agents vs permanent (17-33% vs 8-17%). Further studies are required to better characterize the success and outcomes of angioembolization. Ingram AR, Stillings SA, Jenkins LC. An Update on Non-Ischemic Priapism. Sex Med Rev 2020;8:140-149.