Acute management of priapism in men

US of the Penis: Beyond Erectile Dysfunction

High-frequency US, with a linear transducer and gray-scale, color, and spectral Doppler US techniques, is the primary imaging modality for evaluation of the penis. It can allow delineation of anatomy and assessment of dynamic blood flow; it is easily available and noninvasive or minimally invasive; it is cost effective; and it is well tolerated by patients. US assessment after pharmacologic induction of erection is an additional tool in assessing patients with suspected vasculogenic impotence, and also in selected patients with penile trauma and suspected Peyronie disease. Penile injuries, life-threatening infections, and vascular conditions such as priapism warrant rapid diagnosis to prevent long-term morbidities due to clinical misdiagnosis or delayed treatment. US can facilitate a timely diagnosis in these emergency conditions, even at the point of care such as the emergency department, which can facilitate timely treatment. In addition, color and spectral Doppler US are valuable applications in the follow-up of patients treated with endovascular revascularization procedures for vasculogenic erectile dysfunction. Image optimization and attention to meticulous techniques including Doppler US is vital to improve diagnostic accuracy. Radiologists should be familiar with the detailed US anatomy, pathophysiologic characteristics, scanning techniques, potential pitfalls, and US manifestations of a wide spectrum of vascular and nonvascular penile conditions to suggest an accurate diagnosis and direct further management. The authors review a range of common and uncommon abnormalities of the penis, highlight their key US features, discuss differential diagnosis considerations, and briefly review management. ©RSNA, 2024 Supplemental material is available for this article.

An Experimental Rat Model Study: Is There Any Effect of Syringic Acid on Ischemia-Reperfusion Injury in Priapism?

Purpose The purpose of this research is to examine the impact of syringic acid on ischemia-reperfusion injury in cavernosal tissue, utilizing a rat model of induced priapism. Materials and methods A total of 24 rats were allocated into three groups. Group 1 was designated as the control group, while Group 2 underwent ischemia-reperfusion injury assessment using the priapism model. Group 3 underwent the same procedures as Group 2, with the addition of intraperitoneal administration of syringic acid (100 mg/kg) 60 min after priapism initiation. All rats underwent penectomy, and sufficient blood samples were collected. Histopathological assessment of penile cavernosal tissue involved grading tissue damage, inflammation, vasocongestion, desquamation, and edema on a scale of 0-3 (0: normal, 1: mild, 2: moderate, 3: severe). Result Significant differences were observed among the three groups in terms of IL-1 beta and TNF-alpha levels (p=0.001 and p<0.001, respectively). IL-1 beta and TNF-alpha levels in Group 2 were found to be significantly higher than Group 3 (p=0.003 and p=0.004). There was also a significant difference among the three groups in terms of median MDA levels (p<0.001). Furthermore, the median MDA level in Group 2 was found to be significantly higher than that in Group 3 (p<0.001). While significant differences were observed among the three groups in terms of median SOD and GSH-px levels, no significant difference was found among the groups in terms of median PC levels (p=0.004, p= 0.048, and p=0.159, respectively). In direct microscopic examination, a significant improvement in pathological scores was noted in Group 3 compared to Group 2 (p<0.001). Conclusion Syringic acid demonstrated protective properties against ischemia-reperfusion injury caused by priapism in cavernosal tissue.

3D-printed procedural task trainer for the aspiration of penile corpus cavernosa in ischaemic priapism

OBJECTIVE

The development and initial clinical assessment of a novel 3D-printed procedural task trainer for the aspiration of penile corpus cavernosa in ischaemic priapism.

METHODS

A task trainer for the aspiration of penile corpus cavernosa was designed and manufactured using commercially available 3D printing equipment. The trainer was assessed in two separate training sessions led by faculty investigators. Participants in the sessions were asked to complete a post-procedure survey with regards to the utility and realism of the task trainer.

RESULTS

The participants (n = 14) covered a broad spectrum of clinician types. The trainer was perceived by the participants as being anatomically realistic, and especially while under drapes provided a reasonable facsimile of real clinical setup. The trainer proved resilient to multiple attempts at aspiration by multiple participants.

CONCLUSIONS

Participant and facilitator feedback indicates that the task trainer is a useful platform to train for what is a low frequency, but high stakes, procedure. Small numbers of participants preclude statistical rigour and certainty regarding overall performance of the trainer. However, the uniformity in the responses would suggest that this is indeed a task trainer that is 'fit for purpose'.

Is urgent surgical management necessary for priapism in pediatric patients with hematologic conditions?

INTRODUCTION

Acute priapism is usually considered a medical emergency that warrants prompt urologic evaluation and treatment. Efforts have been made to determine the optimal management strategy for pediatric priapism.

OBJECTIVE

The aim of this study is to assess differences in conservative, minimally-invasive, and operative management of acute priapism in the pediatric population.

STUDY DESIGN

A retrospective study of pediatric patients with acute priapism from 2015 to 2021 at a single tertiary care children's hospital was conducted. Conservative, minimally-invasive, and operative approaches for the priapism episodes during these hospital encounters were analyzed.

RESULTS

Thirty-nine patients were identified with a total of 61 cases of acute pediatric priapism were evaluated in the study period. Eight-three percent of patients were African-Americans, and 72% of patients had a history of sickle cell disease. Oxygen therapy (P = 0.001) and hydration with intravenous fluids (P = 0.00318) were more commonly utilized for hematologic-associated cases compared to other etiologies. For priapism episodes of hematologic etiology, 18 (40.0%) and 18 (40.0%) patients received phenylephrine injection and aspiration/irrigation (e.g., minimally-invasive therapy), respectively, while for the other causes of priapism, three (18.8%) and four (25.0%) received phenylephrine injection and aspiration/irrigation (e.g., minimally-invasive), respectively. Conservative and minimally-invasive treatment resulted in complete resolution of priapism in 27 (60%) and 16 (35.5%) patients with hematologic-associated priapism while 12 (75%) and 1 (6.3%) patients with other etiologies had resolution of priapism with conservative and minimally-invasive treatment, respectively. One patient received shunting in the hematologic group while two patients received shunting in the non-hematologic group (P = 0.1031).

DISCUSSION

Hematologic disorders are the most common causes of priapism in children and adolescents. An overwhelming majority of priapism events in the pediatric population can be managed with conservative therapies including oxygenation and intravenous hydration as well as minimally-invasive procedures such as corporal aspiration, irrigation and/or injections. The utilization of corporal shunting, anesthesia, and hospital resources is infrequently necessary for pediatric priapism episodes.

CONCLUSION

While urgent surgical management is often performed in the adult population, a minimally-invasive management strategy can be implemented in the pediatric population where an extended period of conservative management that avoids operative management and general anesthesia is effective.

Effectiveness of the caverno-dorsal vein shunt (Barry shunt) on prolonged ischaemic priapism and its effect on the post-operative long-term erectile function

Ischaemic priapism is the most common form of priapism and requires urgent treatment. In this study, we evaluated the effectiveness of the caverno-dorsal vein shunt on resolution of ischaemic priapism and on the post-operative long-term erectile function in patients presenting with priapism. The study included 10 patients admitted to our hospital for priapism between 2010 and 2018. The median age of the patients was 31 (24-66) years. The median priapism time was 13.5 (7-38) hours. The blood gas measurements were taken from the corpus cavernosum, and the drainage of the corpus cavernosum was performed as an emergency intervention. Then, the corpus cavernosum was irrigated with 0.01% adrenaline 5 times in 20-min intervals. The caverno-dorsal vein shunt procedure was performed in cases without regression of priapism. Two months after, the operation shunt was closed. Detumescence occurred in all patients. Eight of 10 patients maintained their erectile function. In 2 patients, severe erectile dysfunction occurred at post-operative 2 months following a priapism attack and penile prosthesis implantation was performed in these 2 patients. Our study showed that caverno-dorsal vein shunt procedure is effective in providing detumescence and maintaining potency in cases with ischaemic priapism. In our opinion, caverno-dorsal vein shunt can be considered as the first treatment of choice for refractory low-flow priapism.

Priapism from Recreational Intracavernosal Injections in a High-Risk Metropolitan Community

INTRODUCTION

Recreational use of intracavernosal injections (ICIs) is a high-risk behavior that involves sharing of these agents by men without physician regulation.

AIM

To characterize the etiologies and outcomes of priapism at a Los Angeles metropolitan medical center to better understand patterns of usage of recreational ICIs and the public health implications of such practices.

METHODS

With institutional review board approval, we retrospectively reviewed all cases of priapism presenting to the emergency room of a Los Angeles tertiary medical center from 2010 to 2018. We compared outcomes between patients who presented with priapism after recreational ICI and patients who presented with other etiologies.

MAIN OUTCOME MEASURE

We describe patient characteristics, etiologies, and treatments of priapism at our institution.

RESULTS

We identified 169 priapism encounters by 143 unique patients. Recreational ICIs accounted for 82 of the 169 priapism encounters (49%). Patients who used recreational injections were younger than those who presented with other etiologies (43.5 years vs 47.5 years; P = .048) and had delayed presentations (median, 12 hours vs 8 hours; P < .0001). There was no statistical difference across groups in the proportion of patients requiring operative intervention (14.6% of recreational ICI users vs 16.1% of all other patients; P = .23). A total of 36 out of 72 patients who used recreational ICIs (50%) were HIV+.

CLINICAL IMPLICATIONS

Our study adds to the relatively sparse literature on priapism outcomes. We identify and describe a high-risk population that uses recreational intracavernosal injections.

STRENGTHS & LIMITATIONS

To our knowledge, this is the largest series of priapism encounters. However, the data are retrospective from a single institution, and there is a lack of long-term follow up.

CONCLUSION

A large proportion of priapism visits at our institution were attributed to recreational use of ICIs. This is a high-risk patient population that may not be aware of the risks of recreational ICIs and the consequences of priapism. Further effort should be made to increase public and physician awareness of this harmful practice. Zhao H, Berdahl C, Bresee C, et al. Priapism from Recreational Intracavernosal Injections in a High-Risk Metropolitan Community. J Sex Med 2019;16:1650-1654.

Priapisme veineux aigu aux urgences : procédure fondée sur une revue systématique de la littérature

Le priapisme veineux aigu (PVA) est urgent en raison de séquelles érectiles éventuelles. Sa rareté et l’absence de procédure expliquent des traitements encore inégaux, peu normés.

Objectif : Optimiser la prise en charge initiale d’un PVA grâce à une procédure décisionnelle, adaptée aux urgentistes.

Matériel et méthode : Une revue systématique de la littérature recense les algorithmes schématisés ainsi que des articles de revue et mises au point récents. Les critères diagnostiques et thérapeutiques ont été analysés puis comparés pour vérifier s’ils répondaient aux besoins. La validation de cette procédure par des experts a été recherchée. Résultats : L’originalité de notre procédure réside dans sa cible (urgentistes), sa hiérarchisation, « Que faire ? Comment faire ? Quand faire ? Qui fait ? », de façon graduée et séquentielle via une chronologie détaillée, et une priorité donnée à la gazométrie caverneuse, fil conducteur de la prise en charge, facilement disponible. À cela s’ajoutent des tableaux, des check-lists (contexte étiologique et souffrance ischémique), des schémas descriptifs des traitements médicaux indiqués en première ligne (technique, matériel de ponction décompressive et d’injection intracaverneuse d’alpha-stimulant), critères de recours à l’urologue, suivi et hospitalisation. Cette procédure a été validée par le conseil scientifique du réseau nord-alpin des Urgences, le comité d’andrologie et médecine sexuelle de l’Association française d’urologie.

Conclusion : Facile à utiliser, cette procédure inédite répond à un réel besoin. Son appropriation et sa diffusion s’inscrivent dans une démarche qualité adaptée au parcours de soins du PVA en France afin de prévenir les séquelles érectiles de cette urgence affectant majoritairement des sujets jeunes.

Acute penile trauma: imaging features in the emergency setting

In an emergency department, penile traumas are uncommon and a prompt diagnosis is necessary. Penile injury may result from penetrating and non-penetrating trauma. Non-penetrating injuries can produce cavernosal hematomas or fractures: if not treated promptly, these lesions can result in fibrosis or erectile dysfunction. Penile traumatic lesions need a clinical approach first, but a radiological study is often required: ultrasonography with color and spectral Doppler study is usually the first approach. In some cases, magnetic resonance imaging may be performed to better recognize even small discontinuity of the tunica albuginea. Radiologists have to be aware of the various radiological patterns of penile traumatic lesions, in order to establish a prompt and correct diagnosis.

The management of stuttering priapism

INTRODUCTION

Stuttering priapism is a variation of ischemic priapism, generally transient and self-limiting, occurring during sleep and lasting less than 3-4 hours. It may progress to episodes of complete ischemic priapism in approximately one third of cases, necessitating emergent intervention.

EVIDENCE ACQUISITION

This review aims to provide an up-to-date picture of the pathophysiology and management of stuttering priapism. A search using Medline and EMBASE for relevant publications using the terms "priapism", "stuttering", "diagnosis", "treatment", "fibrosis", was performed.

EVIDENCE SYNTHESIS

Stuttering priapism shares its etiologies with ischemic priapism and a large number of diseases or clinical situations have risk association for developing the disorder. The most common causes are sickle cell disease or other hematologic and coagulative dyscrasias especially in children. In the adult population, idiopathic priapism occurring without any discernible cause is considered to be the most common form in adults. The medical management of priapism represents a therapeutic challenge to urologists. Unfortunately, although numerous medical treatment options have been reported, the majority are through small trials or anecdotal reports. Understanding the underlying pathophysiology and understanding the current and emerging future agents and therapeutic options are mandatory in order to provide the best solution for each patient.

CONCLUSIONS

The goal of management of priapism is to achieve detumescence of the persistent erection in order to preserve erectile function. 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.

Penile emergencies: a review of the main conditions

Acute penile conditions, which typically have a traumatic, vascular, or infectious etiology, are rather uncommon and often require prompt medical evaluation. Penile emergencies can be treated conservatively or surgically, and their management often relies on the results of imaging examinations. Because of its high spatial resolution and wide availability, as well as the fact that it does not involve the use of ionizing radiation, ultrasound is the imaging modality of choice in the initial evaluation of penile emergencies. Inconclusive cases can be further evaluated with magnetic resonance imaging. The main purpose of this pictorial essay is to review the main penile emergencies, by presenting illustrative cases, focusing on radiologic findings, and discussing the roles played by the various imaging methods.

Sexual concerns after Spinal Cord Injury: An update on management

BACKGROUND

Spinal Cord Injury (SCI) causes neurological impairment with resultant neurogenic sexual dysfunction which can compound preexisting psychological and medical sexual concerns. Understanding these concerns is important in managing the lifelong needs of persons with SCIs.

OBJECTIVES

To provide an overview of the impact of SCI on sexuality along with a framework for treatment of sexual concerns. To briefly review male infertility and its treatments and pregnancy in females after SCI.

METHODS

Interdisciplinary literature review and synthesis of information.

RESULTS

The average age at SCI is increased, thus persons with SCIs may have preexisting sexual concerns. Sexual activity and satisfaction are decreased after SCI. Psychogenic sexual arousal is related to remaining sensation in the T11-L2 dermatomes. Orgasm occurs in approximately 50% of persons with SCIs with all injuries except subjects with complete lower motor neuron (LMN) injuries affecting the lowest sacral segments A structured approach to treatment including assessing preinjury function, determining the impact of injury, education, assessing and treating iatrogenic sexual dysfunction and treatment of concomitant problems is recommended. Basic and advanced methods to improve sexual arousal and orgasm are discussed and treatment of anejaculation and issues associated with pregnancy and SCI are reviewed.

CONCLUSIONS

Sexual satisfaction is impaired after SCI; however, education and new therapies can improve responsiveness. Future research is warranted to improve sexual function and fertility potential in persons with SCIs.

Priapism as the initial sign in hematologic disease: Case report and literature review

INTRODUCTION

Priapism is an uncommon sign and sometimes considered a diagnosis challenge into systemic disease; this is defined as ≥4 h continuous penile erection, without sexual stimulation. We state that this work has been reported in line with the SCARE criteria PRESENTATION OF CASE: A Mexican 52-year-old man was brought to the emergency room with priapism of six days of evolution. His medical history reported fatigue and waxy pallor had begun a month ago, the rest of interrogation was unremarked. Hyperleukocitosis (>250,000 cells/ml) was documented on his preoperative evaluation, the initial step was hematology consultation due to malignance suspicion, followed by corpora cavernosa drainage-irrigation and surgery penis shunts. After of procedure, we realized bone marrow aspiration, kariotype and cytogenetic analysis, histopathological and moleculars assay reported myeloid hyperplasia compatible with acute phase CML and Philadelphia translocation t(9:22) (q34;q11.2) with P210 BCR-ABL1 fusion transcriber, patient was discharged with dasatinib for maintenance phase. Actually, he has a satisfactory evolution without relapses.

DISCUSSION

The majority of reported cases shows the individual importance of hematological diseases in priapism as it is shown in the analysis of the literature of 10 years (2006-2016) that we made. It is imperative to consider the type of priapism, and the genetic and demographic patient aspects due to the early and correct approach improves the short and long term outcome of the hematological patients.

CONCLUSION

Priapism is an uncommon sign of systemic disease. In the presence of warning signs, malignancy should be considered until proven otherwise.

Penile Doppler ultrasonography revisited

Penile Doppler ultrasonography is a high-performing, noninvasive or minimally-invasive imaging modality that allows the depiction of the normal anatomy and macroscopic pathologic changes in real time. Moreover, functional changes in penile blood flow, as seen in erectile dysfunction (ED), can be analyzed using color Doppler ultrasonography (CDUS). This review article describes the normal sonographic anatomy of the penis, the sonographic technique for evaluating ED, the normal phases of erection, and the various causes of ED. Additionally, we describe the interpretation of different parameters and findings on penile CDUS for the diagnosis and classification of ED, priapism, and Peyronie disease.

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.

Noninvasive treatments for iatrogenic priapism: Do they really work? A prospective multicenter study

Objectives:

Intracorporeal injections (ICIs) of vasoactive substances during penile Doppler ultrasound (PDU) are a common investigation for erectile dysfunction (ED) diagnosis. ICI can be responsible of priapism, a pathological condition of prolonged penile erection not related to sexual stimulation. The aim of our study is to investigate the effectiveness of physical exercise and medical treatment as noninvasive therapy to restore detumescence in prolonged erections after ICI.

Materials and Methods:

Data were prospectively collected on men undergoing PDU in three urological centers. Three hundred and sixty-nine patients underwent PDU for the investigation of ED. All the participants received an ICI of quadrimix; prostaglandine E1, papaverine, phentolamine, and atropine. The data of the patients have been analyzed to record their comorbidities, results of PDU, and the complications encountered.

Results:

Fifty-three patients (14.4%) developed prolonged erections. Physical exercise alone was successful in reversing prolonged erection within 30 min in 21 (39.6%) patients. Out of the remaining 32 patients, oral salbutamol induced detumescence in 18 (34%) within the observation period of 60 min. Nonresponders were managed successfully with aspiration and irrigation of corpora with saline (11 patients, 20.75%) or with Phenylephrine (three patients, 5.66%).

Conclusions:

Physical exercise and oral salbutamol are safe and effective in restoring detumescence of pharmacologically-induced priapism. Noninvasive therapy may save a significant number of these patients an invasive treatment.

A case of priapism with risperidone

Priapism is a urologic emergency defined as a prolonged, possibly painful, penile erection. There are several known causes of priapism including psychotropic medications. One of the mechanisms by which antipsychotics are believed to induce priapism is through alpha-1 antagonism. This is case of a 50-year-old male with a history of schizophrenia with previous priapism related to trazodone, who presents with new onset priapism associated with risperidone. In this case, the treatment of priapism includes discontinuation of the offending agent and drainage of the corpus cavernosum twice along with intracavernosal phenylephrine injections. It is important to educate patients on priapism as a possible side effect of medications. It is also important to consider previous episodes of medication-induced priapism when prescribing psychotropic medications as this may increase the patient's future risk of priapism.

Urethrocutaneous fistula post-Al-Ghorab shunt

Priapism is a rare event that may be induced by clinical conditions and medications. Ischemic priapism (IP) is a compartment syndrome of the penis, and it constitutes a medical emergency that may cause significant morbidity on the erectile function in particular. We report a case of a 30-year-old male in his fourth episode of priapism. The aspiration and washing of the corpora cavernosa with saline solution were performed, followed by washing with adrenaline solution without resolution of the condition. Treatment was followed by the performance of the Al-Ghorab shunt procedure with dorsal incision of the glans. During follow-up, an area of necrosis distal to the incision was detected, and after the catheter removal on postoperative day 14, the patient developed a glandular dorsal urethrocutaneous fistula and meatal stenosis. The meatal stenosis was corrected by Johanson urethroplasty with a neo-meatus at the coronal sulcus, along with resection and debridement of the fistula tract and a three-layer closure.

The effect of pentoxifylline on penile cavernosal tissues in ischemic priapism-induced rat model

INTRODUCTION

Priapism is defined as persisting (>4 h), painful and abnormal tumescence that can occur without sexual stimulation. Three subtypes priapisms are seen-the non-ischemic priapism, intermittent and the ischemic priapism. In ischemic priapism, there is an abnormality in the veno-occlusive mechanism, resulting in venous stasis and accumulation of deoxygenated blood within the penile cavernosal tissue. Cavernosal tissue necrosis develops after extended period of ischemia and is eventually replaced by fibrotic tissue. It may results in erectile dysfunction if not treated promptly. Although, standard treatment of the ischemic priapism is penile aspiration and intracavernosal alpha-adrenergic agents, new oral agents have been investigated to reduce the cavernosal damage. In this study, the effect of different doses of pentoxifylline on cavernosal tissues was evaluated.

MATERIALS AND METHODS

Thirty-six male Wistar albino rats, age 5.5-6 months and weighing 250-300 g, were used in this study. The rats were randomly divided into five groups. In Group 1 (n = 7), the control group, only penectomy was performed. In Group 2 (n = 8), after 1 h of ischemic priapism, penectomy was performed. Group 3 (n = 7) received daily a 10 mg oral pentoxifylline for 4 weeks after 1 h of ischemic priapism, group 4 (n = 7) received a daily 30 mg oral pentoxifylline for 4 weeks after 1 h of ischemic priapism, and group 5 (n = 7) received a daily 100 mg oral pentoxifylline for 4 weeks after 1 h of ischemic priapism. At the completion of a 4-week period, penile tissues were obtained. Before penile tissues were obtained, intracavernosal pressures measured with electrical field stimulation and smooth muscle collagen ratio were evaluated pathologically.

RESULTS

Electrical field stimulation-induced intracavernosal relaxation decreased in group 2 compared with group 1 (p < 0.05). Electrical field stimulation-induced relaxation enhanced in the group 3, 4 and 5 compared to group 2 (p < 0.05). In group 2, the collagen density was significantly higher than group 1. Administration of pentoxifylline reduced the collagen density caused by ischemic priapism in groups 3, 4 and 5 compared with group 2.

CONCLUSION

The results of the present study showed that ischemic priapism caused damage in the penile tissues of rats, and treatment with pentoxifylline reduced the harmful effects of ischemic priapism.

Atypical Presentation of Priapism in a Patient With Acute Iliocaval Deep Venous Thrombosis Secondary to May-Thurner Syndrome

We report on a 42-year-old male who presented with priapism, severe scrotal swelling, and left lower extremity pain and swelling. Initial management of priapism failed, and he was noted to have both cavernosal and glandular venous obstruction. Computed tomography (CT) was performed and identified extensive acute thrombosis involving the distal inferior vena cava and the left iliac veins. Pharmacomechanical thrombolysis (PMT) was started over the course of two days. At completion of thrombolysis, the culprit lesion in the left common iliac vein was treated with angioplasty and stenting. His postoperative course was uneventful, and his priapism as well as the scrotal and leg swelling improved. He was discharged home on full anticoagulation. To our knowledge, this is the first available description of this rare presentation along with a literature review of the underlying vascular etiology for priapism.