Clinical Practice Patterns for Surgical Shunts and Penile Prosthesis Placement in Men With Priapism: A Retrospective Large Claims Database Analysis

INTRODUCTION

The objective of this study was to assess the rates of surgical shunting and prosthesis placement for acute ischemic priapism using a large multi-institutional claims database.

METHODS

A US claims database network (TriNetX Diamond Network) was queried from 2010 to 2020. We constructed a cohort of men ages ≥ 16 years who (1) had a diagnosis of priapism and (2) underwent an irrigation of the corpora cavernosa for priapism. We assessed the number of men who then had a surgical penile shunt or penile prosthesis placement. Demographics, time to surgical procedure, and order of procedures were collected.

RESULTS

A total of 6392 men were identified with the diagnosis of priapism and the procedure of corpora cavernosal irrigation. Of these men, 693 (11%) proceeded to surgical shunt. One hundred forty-four men (2%) underwent initial penile prosthesis placement. Of the men undergoing initial penile prosthesis, only 17 of 144 (12%) cases occurred within the first month of corpora cavernosal irrigation. Finally, when assessing choice of initial shunts vs initial penile prosthesis before and after 2015, overall rates of initial shunt (10.0% vs 8.5%, P < .0001) and initial prosthesis (3.1% vs 2.1%, P < .0001) were lower after 2015 when compared with rates prior to 2015.

CONCLUSIONS

In this US claims-based analysis of men presenting with ischemic priapism and treated with initial irrigation, a small percentage (11%) of men went on to receive surgical shunting, and only 2% received an initial prosthesis. Men receiving initial prostheses were more likely to have more comorbidities, and overall surgical management of priapism has decreased over time.

Oral phosphodiesterase type 5 inhibitors and priapism: A VigiBase analysis

PURPOSE

To explore the differences of priapism events among a diverse cohort taking erectogenic medicines (i.e., phosphodiesterase type 5 inhibitors [PDE5i] and intracavernousal drugs).

METHODS

We queried the World Health Organization global database of individual case safety reports (VigiBase) for records of the adverse drug reactions (ADR) with sildenafil, tadalafil, avanafil, vardenafil, papaverine, and alprostadil. Disproportionality analyses (case/non-case approach) were performed to assess the reporting odds ratio (ROR) of priapism reporting in PDE5i consumers compared to intracavernousal drug recipients.

RESULTS

From a total of 133 819 ADR events for erectogenic medications, 632 were priapism (PDE5is: n = 550, 0.41%; intracavernousal drugs: n = 82, 9.92%). Priapism disproportionality signals from intracavernousal drugs were 25 times stronger than PDE5is (ROR = 34.7; confidence interval [CI] 95%: 27.12-43.94 vs. ROR = 1.38; 95% CI: 1.24-1.54). For all PDE5i agents, the 12-17 years age group had the highest ROR (9.49, 95% CI: 3.76-19.93) followed by 2-11 years (4.31, 95% CI: 1.57-9.4). Disproportionality signals for consumers under 18 for both all PDE5is as a whole (ROR = 4.57, 95% CI: 2.48-7.73) and sildenafil (ROR = 4.89, 95% CI: 2.51-8.62) were stronger than individuals 18 or older (ROR = 1.06, 95% CI: 0.93-1.21 and ROR = 1.08, 95% CI: 0.91-1.26, respectively).

CONCLUSIONS

PDE5i use shows disproportionate priapism signals which are higher in young patients.

Association between priapism and HIV disease and treatment

BACKGROUND

Priapism, a urologic emergency, has known associations with certain medical conditions. Many cases are idiopathic, suggesting an opportunity to identify novel risk factors.

AIM

We sought to identify medical conditions and pharmaceutical treatments that are associated with priapism using data-mining techniques.

METHODS

Using deidentified data in a large insurance claims database, we identified all men (age ≥20 years) with a diagnosis of priapism from 2003 to 2020 and matched them to cohorts of men with other diseases of male genitalia: erectile dysfunction, Peyronie disease, and premature ejaculation. All medical diagnoses and prescriptions used prior to first disease diagnosis were examined. Predictors were selected by random forest, and conditional multivariate logistic regressions were applied to assess the risks of each predictor.

OUTCOMES

We identified novel relationships of HIV and some HIV treatments with priapism and confirmed existing associations.

RESULTS

An overall 10 459 men with priapism were identified and matched 1:1 to the 3 control groups. After multivariable adjustment, men with priapism had high associations of hereditary anemias (odds ratio [OR], 3.99; 95% CI, 2.73-5.82), use of vasodilating agents (OR, 2.45; 95% CI, 2.01-2.98), use of HIV medications (OR, 1.95; 95% CI, 1.36-2.79), and use of antipsychotic medications (OR, 1.90; 95% CI, 1.52-2.38) as compared with erectile dysfunction controls. Similar patterns were noted when compared with premature ejaculation and Peyronie disease controls.

CLINICAL IMPLICATIONS

HIV and its treatment are associated with priapism, which may affect patient counseling.

STRENGTHS AND LIMITATIONS

To our knowledge, this is the first study to identify risk factors for priapism utilizing machine learning. All men in our series were commercially insured, which limits the generalizability of our findings.

CONCLUSION

Using data-mining techniques, we confirmed existing associations with priapism (eg, hemolytic anemias, antipsychotics) and identified novel relationships (eg, HIV disease and treatment).

Epidemiology and treatment of priapism in sickle cell disease

Ischemic priapism is a common but underrecognized morbidity affecting about 33% of adult men with sickle cell disease (SCD). The onset of priapism occurs in the prepubertal period and tends to be recurrent with increasing age. Significantly, priapism is associated with an unrecognized high burden of mental duress and sexual dysfunctions. The diagnosis of priapism is clinical. Many episodes of priapism will resolve spontaneously, but when an episode lasts longer than 4 hours, the episode is considered a urologic emergency requiring quick intervention with either corporal aspiration or shunt surgery. Only 3 randomized clinical trials (stilbesterol, ephedrine or etilefrine, and sildenafil) have been conducted for secondary priapism prevention in SCD. All 3 trials were limited with small sample sizes, selection biases, and inconclusive results after completion. The current molecular understanding of the pathobiology of priapism suggests a relative nitric oxide (NO) deficiency secondary to chronic hemolysis in SCD and associated phosphodiesterase type 5 dysregulation. We posit an increase in NO levels will restore the normal homeostatic relationship between voluntary erection and detumescence. Currently, 2 randomized phase 2 trials (1 double-blind, placebo-controlled trial and 1 open-label, single-arm intervention) are being conducted for secondary priapism prevention in men at high risk for recurrent priapism (NCT03938454 and NCT05142254). We review the epidemiology and pathobiology of priapism, along with mechanistic therapeutic approaches for secondary prevention of priapism in SCD.

Clinical Vignettes Part I

Patients with sickle cell disease and/or (rarely) trait are at increased risk for developing recurrent episodes of priapism, also known as stuttering priapism, and major ischemic priapism. Treatment of acute ischemic priapism is reactive; whereas ideal management consists of preventative approaches to ultimately promote the best improvement in patient's quality of life. Leg ulcers in patients with sickle cell disease (SCD) are quite common, with ∼20 % of patients with HBSS reporting either having an active or a past ucler. They can be confused with venous ulcers, with lower extremity hyperpigmentation confounding further the diagnosis. Several factors believed to contribute to the development of leg ulcers in patients with SCD are discussed in this article. Sickle cell liver disease (SCLD) occurs because of a wide variety of insults to the liver that happen during the lifetime of these patients. SCLD includes a range of complications of the hepatobiliary system and is increasing in prevalence with the aging adult sickle population. Liver nodular regenerative hyperplasia (NRH) is more common than realized and underappreciated as a diagnosis and requires liver biopsy with reticulin staining. Undiagnosed, the insidious damage from liver NRH can lead to noncirrhotic portal hypertension or cirrhosis.

Low nitric oxide level is implicated in sickle cell disease and its complications in Ghana

BACKGROUND

Nitric oxide (NO) plays a fundamental role in maintaining normal vasomotor tone. Recent clinical and experimental data suggest that NO may play a role in the pathogenesis and therapy of sickle cell disease (SCD). The aim of this study was to determine NO metabolites (NOx) in SCD patients at steady state and in vaso-occlusive crisis (VOC), as well as those with hemolytic clinical sub-phenotype that includes leg ulcers and priapism.

METHODOLOGY

This was a case-control cross-sectional study conducted on a total of 694 subjects including 148 comparison group HbAA, 208 HbSS SCD patients in steady state, 82 HbSC SCD patients in steady state, 156 HbSS SCD patients in VOC, 34 HbSC SCD patients in VOC, 34 HbSS SCD patients in post VOC, 21 HbSS SCD patients with leg ulcer and 11 HbSS SCD patients with priapism, with age ranging from 15 to 65 years. Laboratory diagnosis of SCD was done at the Sickle Cell Clinic of the Korle-Bu Teaching Hospital. Plasma nitric oxide metabolites were measured using Griess reagent system by ELISA method.

RESULTS

Mean NOx of 59.66±0.75 µMol/L in the comparison group was significantly different from those in steady state (P=0.02). During VOC, there was a significant reduction in mean NOx levels to 6.08±0.81 µMol/L (P<0.001). Mean NOx levels were however, significantly higher (50.97±1.68 µMol/L) (P<0.001) in the immediate postcrisis period. The mean NOx levels in the leg ulcer (21.70±1.18 µMol/L) (P<0.001) and priapism (28.97±1.27 µMol/L) (P<0.001) patients were significantly low as compared to the SCD patients in the steady state and comparison group.

CONCLUSION

This study presents the first report on plasma NOx levels in SCD complication in Ghanaian SCD patients and confirms reduced plasma NOx levels in SCD patients in general.

Emergency Department Visits and Inpatient Admissions Associated with Priapism among Males with Sickle Cell Disease in the United States, 2006-2010

People with sickle cell disease (SCD) suffer from numerous acute complications that can result in multiple hospitalizations and emergency department (ED) and outpatient care visits. Priapism, a prolonged unwanted erection of the penis not due to sexual stimulation, is a serious complication among males with SCD. Variations in estimates of prevalence make it difficult to accurately assess the burden of this complication of SCD. We analyzed data from the Nationwide Emergency Department Sample (NEDS), a product of the Healthcare Cost and Utilization Project, for the years 2006 through 2010 to measure the numbers of ED visits and to examine patterns of subsequent hospitalizations associated with priapism among male patients with SCD. We find that among ED visits associated with males with SCD, those prompted by priapism are more likely to result in hospitalization than are those associated with pain.

External validation of a prediction model for penile prosthesis implantation for erectile dysfunction management

INTRODUCTION

Penile prosthesis implantation (PPI) is the definitive surgical treatment for erectile dysfunction (ED), yet it is often delayed for a variety of reasons. From commercial and Medicare claims data, we previously developed a tool for determining a patient's likelihood of eventually receiving PPI. We validated this instrument's utility by comparing cohorts receiving surgical (PPI) versus non-surgical ED management at a single institution.

MATERIAL AND METHODS

The prediction model was based on a logistic regression incorporating claims data on demographics, comorbidities and ED therapy. A risk score is calculated from the model as the product of relative risks for the individual variables. The current validation was a retrospective analysis of ED patients seen at this institution from January to December 2012. Inclusion criteria included ED diagnosis and either first-time PPI or non-surgical treatment (controls). Risk scores for patients receiving PPI were compared to those of non-surgical controls.

RESULTS

We established a cohort of 60 PPI patients (mean age 54.4 ± 9.5) and compared them with 120 non-PPI patients (mean age 53.4 ± 11.2 years). The median score of the PPI cohort was 5.7 (IQR 2.8-9.9) versus the non-PPI cohort's 1.8 (IQR 0.9-5.5) (p < 0.0001). The area under the receiver operator characteristic curve for predicting eventual PPI was 0.72 (95% CI, 0.64-0.79) (p < 0.0001).

CONCLUSION

The prediction model risk-stratified men who ultimately underwent PPI compared to non-surgically managed controls. This external validation study suggests that the prediction model may be used on an individual patient basis to support a recommendation of PPI for managing ED.

[Clinical and therapeutic aspects of priapism at CHU Gabriel Touré: study of 36 cases]

Le priapisme est une érection prolongée douloureuse et irréductible survenant en dehors de toute stimulation sexuelle et n'aboutissant pas à une éjaculation. C'est une urgence urologique. Au Mali, la drépanocytose, une pathologie endémique joue un rôle de premier plan parmi les étiologies. L'objectif de cette étude est d'analyser les aspects cliniques et thérapeutiques du priapisme. Nous avons réalisé une étude rétrospective de type descriptive portant sur 36 cas de priapisme colligés au service d'urologie du CHU Gabriel Touré sur une période de 6 ans et 4 mois. L’âge moyen de nos patients était de 17 ans. Les tranches d’âge les plus représentées étaient comprises entre (11-20 ans) et (21-30 ans) soit 58%. 11 patients soit 31 % avaient eu un antécédent d’érection prolongée; le délai de consultation à partir du premier signe du priapisme était retardé, 31 % des patients étaient venus dans les 24-72h. Sur les 34 patients qui avaient fait l’électrophorèse de l'hémoglobine, 31 patients soit 91 % étaient porteurs d'hémoglobine anormale S et ou C. 32 patients soit 89% de nos patients avaient eu une ponction des corps caverneux. La détumescence a été obtenue le même jour chez 61 % des patients. Chez 11 patients soit 31 %, l’érection était bonne. Le priapisme est une urgence urologique, dont la fréquence est élevée dans la population drépanocytaire. La drépanocytose était la principale cause dans notre pays, tout praticien doit systématiquement y penser avant toute autre étiologie.

Priapism in homozygous sickle cell patients: important clinical and laboratory associations

OBJECTIVE

To evaluate the relationship between the occurrence of priapism and important steady-state clinical and laboratory parameters in homozygous sickle cell disease (SCD).

SUBJECTS AND METHODS

Steady-state clinical and laboratory data were obtained from the medical records of 126 male patients seen in the clinic over a 7-year period. Estimated prevalence rates, correlation coefficients and independent t tests were calculated to assess the relationship between priapism and several important clinical and laboratory indices. Patient data on age, haemoglobin concentrations, the frequency of crises per annum, leucocyte counts, platelet counts, serum bilirubin and aspartate transaminase were evaluated.

RESULTS

The prevalence of priapism was determined to be 21.4%, and 22.2% of those affected had erectile dysfunction. There was a significant positive correlation between priapism and older age (p = 0.049) and lower leucocyte counts (p = 0.008). There was no significant relationship with other clinical or laboratory indices.

CONCLUSION

About 1 in 4 of all homozygous older SCD patients had priapism, and an approximately similar ratio developed erectile dysfunction; they also had lower steady-state leucocyte counts. Other clinical and laboratory indicators of disease severity in SCD did not positively correlate with the occurrence of priapism, and this may imply an alternative pathogenetic mechanism.

Outcome of management of acute prolonged priapism in patients with homozygous sickle cell disease

BACKGROUND

Priapism is a persistent, often painful, purposeless penile erection, which amy or may not be associated with sexual desire, excitement stimulation, or intercourse.

OBJECTIVE

To present the outcome of management of acute prolonged priapism in patients with homozygous sickle cell disease.

METHODS

Fifty-four patients seen over a 20-year period were studied. Of these, 35 were treated surgically with Ebbehoj's cavernosa-glandular shunt while 19 were treated conservatively. The information documented for each patient included age, haemoglobin genotype, duration of priapism before treatment , time of onset, previous history of priapism and possible aetiological factors.

RESULTS

The age range 2.5-38 years with a mean of 20.56 + or - 9.33 years. The potency rate in those treated conservatively was 47.37% while it was 70.37% in those treated surgically. The potency rate in those treated conservatively was 47.37% while it was 70.37% in those treated surgically. The potency rate decreased with increasing duration of priapism before treatment. Those treated within three days had a significantly better outcome than those treated after three days. (chi(2)=4.2986, P=0.038). The potency rate also decreased with increasing age at onset but there was no statistically significant difference between the potency rate in the age groups.

CONCLUSION

Surgical treatment of acute prolonged priapism may be associated with a higher potency rate compared to conservative treatment. There is an inverse relationship between the potency rate and duration of priapism before treatment and age at onset of Priapism. Acute prolonged priapism is a common cause of impotence in patients with homozygous sickle cell disease.

[Priapism in sickle cell anaemia in Senegal: prevalence, attitudes and knowledge]

We interviewed 108 sickle cell anaemia patients aged 5 years older on priapism, and 113 healthy subjects in a control group. They were recruited in the out-patient consultation of the two sickle cell anemia care units of the Fann teaching hospital in Dakar. Ten cases of priapism were identified, all in the group of sickle cell patients (the difference is significant, p = 0.004). Prevalence of priapism was 9.3%. Actuarial probability of having priapism was 8.3% by 10 years of age, and 38.9% +/- 5.7 by 20 years of age. Before the interview, only 10.2% of the sickle cell patients and 8% in the control group knew about priapism, and most of them were unaware of its association with sickle cell disease (75% of sickle cell anaemia patients and 80% of control subjects). This lack of information should be improved by an educational program.

Priapism in sickle cell disease

Priapism, an unwanted painful erection of the penis, is a little discussed but common complication of sickle cell disease. What is known about the prevalence of priapism, efficacy of management approaches, and outcome is drawn primarily from retrospective and single-center reports. Priapism occurs in two patterns: prolonged and stuttering (ie, recurrent brief episodes that resolve spontaneously). If priapism persists for 4 hours or more without detumescence, the patient is at risk for irreversible ischemic penile injury, which may terminate in fibrosis and impotence. Large multicenter studies examining the epidemiology and current treatments and well-organized trials of novel therapies are urgently needed for patients who have sickle cell disease and priapism.

[Sickle-cell crisis in the child and teenager in Brazzaville, Congo. A retrospective study of 587 cases]

Using files related to children admitted at the Brazzaville teaching hospital (Congo) between May 1995 and May 2002, the authors have studied the part of sickle cell crisis (SCC) in the sickle cell disease, have assessed the epidemiological particularities, the relation between some clinical, biological factors as well as the severity of the disease. On the whole, 587 SCC have been observed in homozygous SS children aged 6 to 17. The distribution was as follows: painful osteo-articular crisis (58.6%), abdominal crisis (23.5%), acute chest syndrome (14%), neurological strokes (3.2%) and priapism (0.7%). The neurological strokes (75%) and the hand-foot syndrome (77.8%) were predominant in male. As regards the interaction age-localization of the crisis, the hand-foot syndrome mainly concerned children under five, long bones and rachis impairment those aged 11 to 15; abdominal and neurological crisis were observed especially before the age of 10, the acute chest syndrome after 10 (68.3%). Malaria (48.9%) and bacterial or viral infections (24.5%) proved to be the triggering factors when these are identified (188 cases). SCC occurred in 67.5% of the cases during the hot and rainy seasons. Moreover the haemoglobin F rate above 10% was correlated with a low prevalence of SCC, in particular the potentially severe crisis, revealing at the same time its protective value. These results show that SCC, by their frequency and/or their severity constitute a major handicap when the vital prognosis is not involved. Rigorous health habits, appropriate vaccination programme, adequate malarial prophylaxis, optimal transfusional strategy and especially the use of hydroxyurea, prove to be urgent preventive measures to put into practice. Their efficient implementation will provide a better quality of life to the sickle cell patient and will decrease the risks of severe crisis.

The incidence and management of priapism in Western Australia: a 16 year audit

The objective of the study was to conduct a retrospective audit of patients who presented with priapism in Western Australia during the years 1985-2000. We searched the records of the teaching hospitals in metropolitan Perth and those of the Keogh Institute for Medical Research for the diagnostic code for priapism. A total of 82 episodes of priapism in 63 patients occurred over this 16 year period. In all, 62 episodes occurred after intracavernosal injections (ICI) and 20 were due to other causes. Treatment of priapism included simple aspiration of blood, intracavernosal injection of alpha-adrenergic agents and surgical shunt procedures. Priapism occurring outside the setting of ICI was more likely to require surgery; seven of 20 episodes. After ICI therapy, eight of 62 episodes required shunts. The use of prostaglandin E1 as the drug of choice in ICI therapy in 1989 led to a fall in the incidence of ICI-induced priapism. Priapism is a major side effect of ICI therapy and an uncommon, although important, side effect of other conditions. The incidence of priapism has fallen with the introduction of prostaglandin E1 monotherapy as the favoured drug for ICI therapy of erectile failure.

Priapism caused by infection and an inflammatory process in the pelvic region

Priapism caused by an inflammatory process is rare. We report on a 25-year-old man with priapism due to an infiltration in the pelvic region, enclosing the right sacral plexus. Blood cultures revealed Staphylococcus aureus to be the causal organism. Treatment consisted of parenteral antibiotics, aspiration of the corpora cavernosa and injection of epinephrine, resulting in a flaccid penis and full recovery of potency after 3 weeks. A literature review was conducted for infection and inflammatory processes as a cause for priapism.

Priapism in sickle-cell disease; incidence, risk factors and complications - an international multicentre study

OBJECTIVE

To define the incidence, risk factors and complications of priapism in a large population of patients with sickle-cell anaemia in five centres in the UK and Nigeria, as priapism is common among these patients, but the precise characteristics of the condition in this population are poorly documented.

PATIENTS AND METHODS

A questionnaire was developed and administered to patients with sickle-cell disease. Questions were designed to define the incidence, nature, precipitants, duration, treatment and complications of priapism. A distinction was made between acute (severe) priapism and the recurrent, 'stuttering' type.

RESULTS

The questionnaire was completed by 130 patients (mean age 25 years, sd 11, range 4-66) from the five centres; 102 (78%) were homozygous Hb SS genotype, 19 (15%) were Hb SC genotype and two (1.5%) were Hb Salpha-thalassaemia. Of the patients, 46 (35%) reported a history of priapism, and of these, 33 (72%) had a history of stuttering priapism, while 24 (52%) had had an acute episode of priapism. The mean age of onset of priapism was 15 years, with 75% of patients having the first episode before their 20th birthday. Sexual activity was the most frequent precipitating factor, with fever and/or dehydration being the next most common. Of the 46 patients, 10 (21%) with a history of priapism reported having erectile dysfunction. A similar proportion reported dissatisfaction with sexual intercourse, including a fear of engaging in sexual activity.

CONCLUSION

The incidence of priapism among patients with sickle-cell anaemia is high (35%). The implications of priapism for erectile and sexual function are significant and documented in this large series. The treatment of this condition in these patients remains unstandardised. This study highlights the need for an increased awareness of the problems associated with priapism among patients, families and medical professionals.

The etiology, diagnosis, and treatment of priapism: review of the American Foundation for Urologic Disease Consensus Panel Report

Priapism is an important medical condition that requires immediate evaluation, and depending on etiology, may require emergency management. Based on the classification scheme offered by a recent consensus panel, priapism can be subdivided into ischemic and nonischemic types. The nonischemic type, usually the result of perineal trauma, can be treated with conservative therapy, whereas the nonischemic type, which arises from many varied causes, mandates immediate intervention. Corporal fibrosis and permanent erectile dysfunction can result from ischemic priapism that fails to resolve with therapy.

Priapism in sickle cell anemia in Togo: prevalence and knowledge of this complication

Prevalence of priapism and knowledge on this disease was assessed by interviewing a group of 114 sickle cell anemia patients, 5 years and older, considered to be genotypically homogenous (Benin or #19 haplotype). Prevalence of priapism in homozygous sickle cell patients was 26.3% (30/114) and that of the control group of subjects with Hb AA was 2% (2/102) (the difference was very significant: p = 5.10-7). Actuarial probability of having priapism by 20 years of age was 69 +/- 8.5%. Few homozygous patients without a history of priapism (15.8%) have heard about priapism. This lack of knowledge, added to low accessibility of a health care system, may explain the high rate of impotence (31.6%). The results of this study led us to plan a large program of infonnation about priapism and sickle cell disease in the Togolese population.

Prepubertal high flow priapism: incidence, diagnosis and treatment

PURPOSE

We reviewed the literature of the last 40 years and report our experience with treating high flow priapism with fistula embolization in prepubertal boys.

MATERIALS AND METHODS

Two boys had blunt perineal trauma and 1 had penile trauma (ages 6, 6 and 10 years). Painless priapism developed within 24 hours and lasted for 4 to 7 days before the patients presented to the hospital. Primary diagnosis was made on color Doppler ultrasound. When high flow priapism was diagnosed angiography of the internal iliac artery and embolization of the arteriocavernosal fistula were performed. Mean followup was 26 months.

RESULTS

Color Doppler ultrasound revealed bilateral arteriocavernosal fistulas in 2 boys and a unilateral fistula in 1. Angiography showed fistulas of the branches of the internal pudendal artery in 2 patients and fistulas of the bulbourethral artery in 1. Microcoils were used in the bulbourethral artery and a gelatin sponge was used in other penile arteries. Complete detumescence with restored erectile function was achieved in all cases.

CONCLUSIONS

High flow priapism in children can be diagnosed easily by typical clinical features combined with color Doppler ultrasound. In children with posttraumatic priapism embolization of the arteriocavernosal fistula is superior to surgical or medical procedures and should be the first line therapy. Embolization using microcoils for bulbourethral arteries and a gelatin sponge for other penile arteries has proved to be safe and successful therapy.

Incidence of priapism in the general population

OBJECTIVES

To assess the incidence of priapism in the general population.

METHODS

We conducted a population-based retrospective cohort study within a general practitioners research database. Our study population comprised all male patients with permanent registration status with a general practitioner. All patients with an International Classification for Primary Care code for penile problems (Y01, Y04, Y08) were identified. In addition, a free text search on priapism and painful erection was conducted. The computerized medical records from all potential patients were reviewed, and we requested additional information from the general practitioner if priapism was suspected.

RESULTS

The total study cohort comprised 145,071 men, with a total follow-up of 341,133 person-years. Five patients developed a first occurrence of priapism during the follow-up period, corresponding to an overall incidence rate of 1.5 per 100,000 person-years (95% confidence interval 0.2 to 2.8). The incidence rate in men 40 years old and older was 2.9 per 100,000 person-years (95% confidence interval 0.1 to 5.7). No cause of priapism was apparent in 2 patients, 2 cases occurred after intracavernous injection of vasodilators, and 1 patient experienced priapism because of sickle cell disease.

CONCLUSIONS

The incidence of priapism is low but seems higher than was previously assumed.

Priapism associated with conventional and atypical antipsychotic medications: a review

BACKGROUND

Priapism is a prolonged, usually painful, and persistent penile erection not usually associated with sexual stimuli, resulting from a disturbance in the normal regulatory mechanisms that initiate and maintain penile flaccidity. This infrequent adverse event of antipsychotic medication use requires emergency evaluation and has potentially serious long-term sequelae including erectile dysfunction. Clinicians prescribing antipsychotic medications should be aware of this rare but serious adverse event.

METHOD

A computerized search, using the MEDLINE database (1966-summer 2000), located cases of priapism associated with most conventional antipsychotics as well as with clozapine, risperidone, and olanzapine. The search included no restrictions on languages. Keywords included priapism combined with antipsychotic agents and the names of the currently available atypical antipsychotics. Twenty-nine publications were located using these parameters. Additional publications were reviewed for general background on pathophysiology, evaluation, and management. The quality of the evidence reviewed is limited by the observational and uncontrolled nature of case reports, case series. and review articles.

RESULTS

Psychotropic-induced priapism is currently believed to be caused by the alpha1-adrenergic antagonism of these medications. Detumescence is sympathetically mediated, and alpha1-adrenergic antagonism (within the corpora cavernosa) inhibits detumescence. The propensity of individual antipsychotics to induce priapism can presumably be estimated on the basis of alpha1adrenergic blockade affinities. Of the conventional antipsychotics, chlorpromazine and thioridazine have the greatest alpha1-adrenergic affinity and have been most frequently reported to be associated with priapism. Of the atypical antipsychotics, risperidone has greater alpha1-adrenergic affinity, although 3 of the 5 currently U.S. Food and Drug Administration (FDA)-approved atypicals have been reported to be associated with priapism.

CONCLUSION

Virtually all antipsychotic medications have been reported to rarely cause priapism due to their alpha-adrenergic antagonism. This adverse event should be considered a urologic emergency. Clinicians should be familiar with this infrequent serious adverse event of antipsychotic medications.

[Incidence of priapism at the Marqués de Valdecilla University Hospital in Santander]

OBJECTIVE

Our experience in the management of priapism, its etiology, blood gas changes, treatment and outcome are presented.

METHODS

The records of patients that had been treated at the Urology services of our hospital over the last 8 years were reviewed. During this period, patients with erectile dysfunction were treated according to a protocol.

RESULTS

There were 9 episodes of priapism in 8 patients; all cases were low flow and the patients were aged 37-71 years. The duration of the prolonged erection ranged from 4 to 72 hours. Of these 9 cases, the etiology was intracavernosal PGE in 7, after trazodone administration in one case, and unknown in one case. Intracavernosal metoxamine was administered in all cases with excellent results, except one case that required a saphenous-cavernosal shunt and another case that was initially treated with adrenalin also with good results.

CONCLUSIONS

Since intracavernosal agents have been utilized in the treatment of erectile dysfunction, priapism has become a more frequent urological emergency. Although a lower incidence has been reported for PGE, the dose should be well adjusted to avoid a higher incidence.

The incidence of pharmacologically induced priapism in the diagnostic and therapeutic management of 685 men with erectile dysfunction

OBJECTIVE

To evaluate the incidence of pharmacologically induced priapism in the diagnostic and therapeutic management of erectile dysfunction.

PATIENTS AND METHODS

Over a period of 7 years, 685 men were investigated for erectile failure. They underwent a simple test with vaso-active drugs, and the nonresponders were further investigated. Eventually, 83 men began autoinjections and 45 still continue.

RESULTS

Eight (1.2%) cases of priapism presented during the simple test with vaso-active drugs in these patients, while none occurred during self-injection treatment. Three were prolonged erections induced by prostaglandin E1 (PGE1) and 5 by papaverine (Pap). Six were treated safely with intracavernosal injection of etilephrine without blood aspiration.

CONCLUSION

Priapism is always a potential phenomenon where no individual, no particular drug and no specific dose are completely safe. It may be caused even with 5 microg of PGE1 or 7.5 mg of Pap. Auto-injection therapy however is a safe kind of treatment in well-experienced patients. Careful regulation of the doses and practice in the use of vaso-active drugs may reduce the priapism rate.

Priapism in adult Nigerians

OBJECTIVES

To review the presentation and treatment of adult Nigerians with priapism.

PATIENTS AND METHODS

Thirty-five men (mean age 35 years, range 20-54) were seen over a 12-year period. All patients underwent an immediate modified or conventional cavernospongiosus shunt and were assessed at 2, 6 and 12 weeks after discharge for erection, orgasm and fibrosis of corpora cavernosa.

RESULTS

Ten patients initially presented to traditional healers and 13 presented early to qualified medical practitioners, and were managed conservatively. As a result, 21 of the 35 patients presented to the author's hospital 6-10 days after the onset of erection. Many did not realise that priapism was abnormal, or had no money to attend hospital. After surgical treatment detumescence was obtained in all patients and maintained. At 12 weeks, 14 patients had normal erections, 13 reduced erections and eight no erections. A local aphrodisiac was identified as the commonest predisposing factor, followed by sickle-cell disease.

CONCLUSION

This study shows clearly that even if a patient with priapism presents late, vigorous treatment in the form of an adequate shunt should be undertaken as soon as possible, as this is the only chance the patient has to regain potency.

Prevalence of priapism in children and adolescents with sickle cell anemia

A questionnaire survey was conducted of patients with homozygous sickle cell anemia (Hb SS) and sickle cell beta(0)-thalassemia (Hb S-beta(0)) between 5 and 20 years of age to determine the prevalence and characteristics (number of episodes, timing, duration, cause, or precipitating event) of priapism. Ninety-eight male patients or their parents were surveyed by the same male investigator using a structured verbal interview, which was modified according to the age of the patient. Ninety-four patients had Hb SS and four Hb S-beta(0) thalassemia. Eleven (11%) patients were known to have experienced priapism previously. In response to the questionnaire, 16 of the remaining 87 (18%) patients reported having had priapism on one or more occasions. The actuarial probability of experiencing priapism by 20 years of age was 89% (+/- 9%). The mean age at the initial episode was 12 years, the mean number of episodes per patient was 15.7 (median, 1; range, 1-100), and the mean duration of an episode was 125 minutes. Episodes typically occurred around 4:00 am, and 75% of the patients surveyed had at least one episode starting during sleep or upon awakening from sleep. The prevalence of priapism in children and adolescents with SCA is much higher than previously described. Since early intervention and treatment may prevent irreversible penile fibrosis and impotence, patients and parents should be educated about this complication in advance of its occurrence.

Priapism: an appraisal of surgical treatment

The surgical outcome in 66 patients with priapism who presented at the University College Hospital, Ibadan, over a ten-year period was evaluated. Operative procedures carried out included bilateral cavernostomies in 23 patients, caverno-glandular shunts in 11, caverno spongiosal shunt in 18 and caverno-saphenous shunt in 1. Complete detumescence was achieved immediately postoperatively in all patients, however, this was not maintained. Some turgidity recurred after twenty-four hours in all patients. In 12 patients with recurrence of turgidity, 8 had flaccid penis after. Long-term results and follow up in these patients are scanty due to default, but of the 12 that were followed up for a period ranging from 2 months to 2 years, 6 are still able to achieve and maintain an erection, while 6 had no erection at all. Two of five patients who had conservative treatment are able to achieve and maintain an erection. The outcome of surgical treatment appears to be superior to conservative treatment. Bilaterial cavernostomies appear to be effective, but when this fails a shunt procedure should be carried out.

[Management of priapism induced by PGE1]

OBJECTIVE

To review the literature on priapism following intracavernous injection of PGE1, its management and the physiopathological mechanisms involved.

METHODS/RESULTS

The literature on PGE1-induced priapism available on Medline is reviewed and two cases treated at our hospital are described. The diagnostic and therapeutic algorithms are presented. The relationship between drug use and priapism is difficult to establish since patients with the same history who received the same dose of Alprostatil did not develop priapism.

CONCLUSIONS

Although infrequent, treatment must be instituted urgently since there is generally low flow.

Preservation of potency after treatment for priapism

Impotence is the most serious complication of priapism. In order to study its incidence and risk factors, the final outcomes of 124 cases of priapism in previously potent patients were analyzed and correlated with the duration of symptoms, age of the patients, aetiology and modality of treatment. Thirty-nine per cent of the patients became impotent. The duration of symptoms before treatment correlated markedly with the risk of impotence, in that 92% of those whose priapism had lasted less than 24 h remained potent but only 22% of those for whom it had lasted longer than 7 days. The younger the patients the better the prognosis, so that 88% of those younger than 30 years preserved their potency but only 40% of those older than 50 years. The prognosis was poorest when heparin therapy or a combination of alcohol drinking and psychopharmaceuticals was the aetiological factor behind priapism. Only 31% of patients preserved their potency after conservative treatment for priapism, whereas 69% of those treated with small glandocorporeal shunts did so. Priapism is an emergency state, in which immediate procedures are necessary to ensure detumescence as soon as possible. If puncture with lavation and intracorporeal injection of alpha-sympathomimetics does not restore detumescence, small glandocorporeal shunts should be performed.

Priapism, its incidence and seasonal distribution in Finland

Priapism is regarded as an uncommon disease in white populations, although no previous research has been done into its incidence in a certain geographical area. All cases of priapism in Finland during the years 1975-90 are reviewed here. Its incidence varied from 0.34 to 0.52/100,000 males per year, being very stable during the whole period of 16 years, when cases due to intracorporeal injections for treatment of impotence are excluded. Typical patients were 40-50 years old, and the incidence was higher in the eastern part of the country. Most cases of priapism were seen during the lighter half of the year, between March and August (65%). The use of intracorporeally injected vasoactive drugs for impotence increased the incidence more than two-fold.

Multisystem damage associated with tricorporal priapism in sickle cell disease

PURPOSE

Priapism is an uncommon but debilitating complication of sickle cell disease (SCD). Recent observations among adult males regarding the abysmal failure of medical and surgical therapy encouraged us to review our 25-year experience identifying the prognostic features that might determine outcome.

PATIENTS AND METHODS

As part of a prospective 25-year longitudinal demographic and clinical cohort study, a subset of 38 (8.2%) patients with priapism were identified among a cohort of 461 men with SCD. The patients with priapism were compared with the nonaffected men with respect to severity of disease expression, hematologic status, beta s globin gene haplotype, and the incidence of sickle-related major organ failure. The influence of the treatment modalities on outcome was also evaluated.

RESULTS

Priapism occurred as a single episode in 24 patients, and in 14 as temporally clustered repeat episodes. Eighty-seven percent of those with priapism had sickle cell anemia (SS), an increased risk as compared with other variants of SCD (p = < 0.05). There were two distinct age-related patterns of disease expression. Eight patients were prepubertal; they experienced shorter episodes, involvement of the corpora cavernosa only, few recurrent episodes, and a good prognosis for future erectile function. Non-surgical therapy in children was associated with excellent results. In contrast, the 29 postpubertal adults often had involvement of the corpora cavernosa and corpus spongiosa (tricorporal disease) and half had prolonged episodes that lasted longer than 8 days. One pubescent patient had repeated episodes and became impotent. Prolonged or repeated episodes eventuated in impotence in 56%. Surgical intervention was not beneficial. Sickle cell-related organ failure such as stroke, chronic restrictive lung disease, chronic renal failure, and nonhealing leg ulcers was observed more frequently in men who had priapism. Death occurred in nine adult patients (25%) within 5 years of the first episode of priapism.

CONCLUSION

Priapism in adult males identifies those at high risk for other sickle cell-related organ failure syndromes and, as such, is another complication indicative of severe disease. The dismal prognosis in SS adults requires better understanding of the precise pathophysiology of low-flow tricorporal priapism. Clarification of the mechanisms inducing the priapic state should lead to specific therapeutic maneuvers and an improved prognosis for this disabling condition.

[Treatment of impotence with intracavernous auto-injections: moxisylyte diminishes the risks compared to papaverine]

The alpha-blocking agent Moxisylyte was tested in auto-intracavernous injections (auto-ICI) in 72 impotent patients. The side-effects were compared to those observed in a group of 34 impotent patients treated with auto-ICI of Papaverine during the same period of time. The Moxisylyte auto-ICI improved 83% of the patients including 68% reporting a complete and durable success. Moxisylyte proved to be safer due to a reduced rate of prolonged erections (1.3% of the patients versus 8.8% with Papaverine) and corporeal fibrosis (1.3% versus 32% with Papaverine). Though less potent than Papaverine, and often seeming insufficient when tested in the office, this type of alpha-blocking agent could be tried in a first time in most candidates to auto-ICI before resorting to Papaverine or Prostaglandin E1 if it fails.

Relief of sickle cell priapism by hydralazine. Report of a case

We report a 16-year-old Tanner IV male with homozygous hemoglobin S who presented with recurrent episodes of priapism unresponsive to standard therapy with hydration, analgesia, and exchange transfusion. He had a complete resolution of his symptoms with hydralazine therapy. We therefore suggest a trial of vasodilator therapy for recurrent sickle cell priapism before attempting surgical therapy.

Priapism associated with asplenic state

Priapism may be primary (idiopathic) or secondary to sickle cell anemia, trauma, leukemia, drugs, venous thromboembolic diseases, and other less common disorders. This study concerns 21 patients with priapism treated during a period of ten years. Nine patients (43%) had sickle cell anemia. Of the 12 individuals (57%) classified as idiopathic, 3 (25%) had previously undergone surgical splenectomy for benign conditions. Considering the propensity for this unusual condition to develop in patients with hemoglobinopathy-induced hyposplenism, the possibility of a relationship between the asplenic state and priapism is considered.

Priapism in the newborn

The authors describe a rare case of priapism in a newborn infant. Treatment with intravenous ketamine hydrochloride produced rapid detumescence. The literature is reviewed with respect to priapism in the newborn and its management, and the authors propose injection of ketamine hydrochloride as an alternative method of management for this condition in newborn infants.

Risk factors for papaverine-induced priapism

Intracorporeal administration of papaverine hydrochloride is frequently used in the diagnosis and treatment of impotence. Priapism is the most serious potential complication of its use. The historical characteristics of 400 consecutive men receiving a standardized dose of papaverine were reviewed in an effort to determine the risk factors for prolonged erections. Younger men (p less than 0.0001) with better baseline erectile function (p less than 0.023) were more likely to have priapism. Despite use of a significantly lower dose, patients with overt neurological disease also had an increased rate of priapism. Patients with a history of coronary artery disease had a significantly lower risk of priapism (p less than 0.05). Patients with a final diagnosis of either psychogenic or neurogenic impotence had a much greater risk of priapism than those with vasculogenic impotence (p less than 0.001). The initial dosage in pharmacological erection therapy may be adjusted according to these risk factors. However, not all patients with psychogenic or neurogenic impotence had priapism and some patients with vascular disease did have priapism. Therefore, all impotent patients are potentially at risk for pharmacologically induced priapism.

[Case report of priapism in a 4 year old child]

The authors report a case of idiopathic priapism in a 4 year old boy. This is an exceptional disease at this age, which was treated urgently by creating a cavernosospongiosum fistula with a rapidly favourable clinical course. The prognosis appears to be related to the rapidity of treatment. Although aetiological treatment can be proposed in the case of priapism due to haematological malignancies, only surgical treatment appears to be truly effective in the other forms.

Incidence, possible causes and followup of idiopathic prolonged penile erection in the newborn

From 1974 to 1988, 4 cases of neonatal idiopathic prolonged penile erection were recorded, for an incidence of 0.15 per thousand or 1 case for 6,673 male newborns. Our first patient was case 7 described in the literature and the first observed in 1 of nonidentical twins. Followup for 2 to 8 years revealed no urogenital problems but a longer period (at least until puberty) is needed. Clinical and etiological aspects of this entity are discussed. Many of the etiological factors cited as possible causes of prolonged erection at this patient age represent only predisposing conditions for the occurrence of penile erection. Because of the spontaneous disappearance of prolonged penile erection, observation rather than surgical or medical management is advocated for the newborn. Only in selected patients should the limit of expectation, and the best time for and type of surgical intervention be established.

Circannual rhythmicity in the occurrence of idiopathic priapism in north-western India

A group of 26 patients who were operated upon for idiopathic priapism between 1972 and 1986 were classified according to the date on which they attended hospital. During the same 15-year period 150 patients with penile cancer were treated and they served as controls. The data were analysed for circannual rhythmicity (365.25 days = 360 degrees and 0 degrees = 22 December. This revealed a significant circannual rhythmicity in the occurrence of idiopathic priapism, with the acrophase located on 2 August. There was a significantly higher incidence of idiopathic priapism between April and September.

Priapism and dialysis

Ninety-three dialysis units located in the tri-state area were surveyed for the prevalence of priapism. Seventeen of 3,337 male patients experienced an episode of priapism. All of these episodes occurred either during or 2-7 h after dialysis, suggesting a cause-and-effect relationship. The use of heparin during dialysis seemed to play a role in its induction; none of the patients on peritoneal dialysis experienced priapism, and heparin was not used in their exchanges. Eleven of 17 patients also received androgen therapy which might have been a contributing factor. Additional considerations included dialysis-induced hypoxemia and acidosis which have been known to precipitate priapism in patients with sickle cell disease or trait. In our study, 2 of 10 patients, including our case report, were black males with sickle cell trait. The calculated prevalence in the male population is 1:196, and in blacks and Caucasians 1:128 and 1:293, respectively. Except for 2 cases of sickle cell trait in the 10 black males, no particular subpopulation at risk was identified. In view of the absence of a proven etiologic agent and the relatively low prevalence of priapism we do not recommend changes in dialysate, anticoagulant, or the use of androgen therapy.

Priapism: review of 34 cases

One hundred ninety-seven cases of priapism have been recorded in the medical files of Charity Hospital Louisiana in New Orleans from 1938-1982. One hundred seventy-two adults and 25 children were registered in this series. Ninety-three per cent of the patients with priapism were black, and 86 patients of this group underwent 93 surgical procedures. The cases of 34 patients treated between July 1, 1981, and December 31, 1982, were thoroughly reviewed. Sixteen patients had a previous history of priapism. Average delay between onset of symptoms and presentation to the hospital for treatment was thirty hours. Sickle cell screens were obtained in 28 patients and were positive in 17. Twenty-nine patients were initially treated conservatively, with 17 priapisms eventually resolving, but the remaining 12 patients required surgical intervention. Overall, 50 per cent of the 34 patients had surgery. All of the surgical cases resolved satisfactorily with the Winter procedure. Complications with this procedure were uncommon, but postoperative bandaging was the chief cause of morbidity. Follow-up for at least six months revealed comparable sexual potency (80-83%) in either conservatively or surgically managed patients.

Priapism in association with sickle cell anemia in Saudi Arabia

A questionnaire study of 42 Saudi patients with sickle cell anemia revealed that none of them had ever suffered from priapism. A comparison of hematological parameters between Jamaican priapism patients and Saudi non-priapism patients suggested that high Hb F levels and hypochromic microcytosis in Saudi patients might play an important role in preventing this complication.