2. Moderators:
Professors:
Prof. Dr. G. Sivasankar, M.S., M.Ch.,
Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
Dr. J. Sivabalan, M.S., M.Ch.,
Dr. R. Bhargavi, M.S., M.Ch.,
Dr. S. Raju, M.S., M.Ch.,
Dr. K. Muthurathinam, M.S., M.Ch.,
Dr. D. Tamilselvan, M.S., M.Ch.,
Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH and KMC, Chennai. 2
5. Definition
Persistent penile erection that continues hours
beyond, or is unrelated to, sexual stimulation
The guideline definition is restricted to only erections
of greater than four hours duration
Typically, only the corpora cavernosa are affected
5
Dept of Urology, GRH and KMC, Chennai.
6. DEFINITION
AUA Committee-“Multifactorial entity of genital organ
tumescence or rigidity, that develops and persists in a
pathologically uncontrolled fashion for any duration
without sexual purpose”
Clitoris /spongiosum may also become tumescent
6
Dept of Urology, GRH and KMC, Chennai.
7. Pathophysiology
Priapism -disturbances in the
mechanism of detumescence due to
excess release of contractile
neurotransmitter
malfunction of the intrinsic
detumescence mechanism
obstruction of draining venules
prolonged relaxation of
intracavernous smooth muscle
7
Dept of Urology, GRH and KMC, Chennai.
8. Sub types
Ischemic (veno-occlusive, low flow) little or no
cavernous blood flow and abnormal cavernous
blood gases (hypoxic, hypercarbic and acidotic)-
emergency
Nonischemic (arterial, high flow) priapism -
unregulated cavernous arterial inflow; blood gases
are not hypoxic or acidotic-non emergent
Stuttering (intermittent) priapism is a recurrent
form of ischemic priapism in which unwanted
painful erections occur repeatedly with
intervening periods of detumescence,< 3 hrs
8
Dept of Urology, GRH and KMC, Chennai.
9. Sub types
Refractory– immediately recurrent non ischemic
erectile state after treatment of ischemic priapism
due to arterial filling- no trauma
Pseudopriapism –penile rigidity and edema
caused by superficial nodular metastases /semi-
rigid prosthesis
Idiopathic -50% cases, ischemic model
Congenital/ neonatal- forceps delivery,
respiratory distress syndrome, umbilical artery
catheterisation, polycythaemia, congenital syphilis
9
Dept of Urology, GRH and KMC, Chennai.
13. Etiology
Metabolic
Amyloidosis
Fabry's disease
Gout
Diabetes
Nephrotic syndrome
Renal failure
Haemodialysis
Hyperlipedaemic total
parenteral nutrition
ED pharmacotherapy
Oral sildenafil
Intraurethral alprostadil
Intracavernous agents
Young men, neurologic
illness, better erectile
function –at risk
13
Dept of Urology, GRH and KMC, Chennai.
14. HISTORY
Duration of erection
Degree of pain
Previous history of priapism and its treatment
Erectile function status
Use of drugs : antihypertensives; anticoagulants;
antidepressants and other psychoactive drugs;
alcohol, marijuana, cocaine,cannabis
Vasoactive agents used for intracavernous
injection
History of trauma- perineal straddle injury
History of sickle cell disease or other hematologic
abnormality
14
Dept of Urology, GRH and KMC, Chennai.
15. Examination Ischaemic Nonischaemic
Corpora cavernosa fully rigid
+ --
Penile pain
+ --
Abnormal cavernous blood gases
+ --
Blood abnormalities and
hematologic malignancy
+ --
Recent intracavernous vasoactive
drug injections
+ --
Chronic, well-tolerated tumescence
without full rigidity
-- +
Perineal trauma
-- + 15
Dept of Urology, GRH and KMC, Chennai.
16. Piesis Sign
In young children with high flow priapism, perineal
compression with the thumb will cause prompt
detumescence, called Piesis sign-confirmatory
Usefulness in an adult is questioned
16
Dept of Urology, GRH and KMC, Chennai.
17. Investigations
Complete blood count, platelet count,WBC
differential
Peripheral smear, reticulocyte count
Hb electrophoresis
Screening for psychoactive drugs and urine
toxicology
Blood gas testing
Color duplex ultrasonography
Penile arteriography
17
Dept of Urology, GRH and KMC, Chennai.
18. Pre hospital care
Ice packs to the perineum and penis
Asking the patient to walk up stairs-mechansim -
arterial steal phenomenon.
External perineal compression may also be a useful
temporizing measure
18
Dept of Urology, GRH and KMC, Chennai.
19. Cavernosal Blood Gas Analysis
Flaccid
penis
Low flow
mm Hg
High flow
mm Hg
Colour of
blood
Dark red Bright red
pO2 40 <30 >90
pCO2 50 >60 <40
pH 7.35 <7.25 7.4
19
Dept of Urology, GRH and KMC, Chennai.
21. Color duplex ultrasonography
Performed in the lithotomy
or frogleg position
Scanning perineum first and
then along the entire shaft of
the penis
Screening test for
anatomical abnormalities--
cavernous.A fistula or
pseudoaneurysm in
nonischemic priapism
Examine perineal corpora
cavernosa
Low flow priapism
21
Dept of Urology, GRH and KMC, Chennai.
23. Angiography
Adjunctive study
Identify site of cavernous
artery fistula (ruptured
helicine artery)
Performed as part of an
embolization procedure
arterial-lacunar fistula due to rupture of the
right cavernosal artery (arrowheads)
23
Dept of Urology, GRH and KMC, Chennai.
24. Cavernosography
Not used routinely
Delayed cases –sinus
thrombosis
Evaluation of post
episode erectile function
Prior to surgery – fistula
closure
Irreversible fibrosis of corpora
cavernosa on cavernosography
24
Dept of Urology, GRH and KMC, Chennai.
25. Differentiating features
High flow Low flow
pO2 >90 mm Hg <30 mm Hg
pCO2 <40 mmHg >>60mmHg
pH >7.4 <7.2
Pain -- +
Pulsation + -
Palpation Elastic Sturdy
Arterial inflow Present Absent
Venous outflow Open Closed
Viscosity low High 25
Dept of Urology, GRH and KMC, Chennai.
26. Natural history
Resolution = non painful flaccid state
90% of men with ischemic priapism> 24 hrs – cannot
perform intercourse
Erectile dysfunction rate of 35% with systemic
treatment only
26
Dept of Urology, GRH and KMC, Chennai.
27. Treatment
Management of ischemic episode- IMMEDIATE
> 4 hours – irrespective of etiology- Compartment
syndrome
27
Dept of Urology, GRH and KMC, Chennai.
28. Aspiration
Therapeutic-
decompresses and relieves
pain
Combined with blood gas
sampling (non
Heparinized)
30% resolution rate
Can flush with saline
Aspirate 20-30 mL of blood
from either the 2-o'clock or
10-o'clock position while
milking the shaft
28
Dept of Urology, GRH and KMC, Chennai.
29. Aspiration with irrigation
Alpha adrenergic agent- phenylephrine
α1 agonist, 100-200ug every 5-10 min
Epinephrine- 10-20ug every 5 to 10 min
Transglanular –less hematoma and facilitate blood
drainage after catheter removal
Trans corporal-proximally and distally
Blood evacuation needed for drug to be effective
Resolution-58% with injection, 77% with
combined
29
Dept of Urology, GRH and KMC, Chennai.
30. Drugs
Phenylephrine:100-500
mcg/dose, up to 10 doses
Use 10-20 mL of 20
mcg/mL solution via
intracavernous injection
q5-10min
Pseudoephedrine :- 60-120
mg PO may be given in
cases of priapism of short
duration (2-4 h)
Terbutaline -5 mg PO,
repeated after 15 min; 0.25-
0.5 mg SC,not in children
Methylene blue: Second
messenger inhibitory
effect, affecting muscle
relaxation
1-2 mg/kg IV slowly over 5
min ,not in children
30
Dept of Urology, GRH and KMC, Chennai.
31. Surgical Shunts
Failed intra cavernous treatment
Ischemic priapism 48-72 hrs duration
Objective –drain blood from cavernosa bypassing veno
occlusive mechanism
31
Dept of Urology, GRH and KMC, Chennai.
32. Winter shunt
Distal corporo glanular
shunt-with biopsy
needle
EBBEHOJ shunt-
scalpel used
32
Dept of Urology, GRH and KMC, Chennai.
33. EL- GHORAB SHUNT
Distal caverno glanular
shunt
Incision over glans
Distal corpora excised
as vent
Most effective distal
shunt
Performed secondarily-
invasive
33
Dept of Urology, GRH and KMC, Chennai.
34. Quackels/Sachers shunt
Proximal caverno
spongiosal shunt
Openings placed in
staggered fashion
Bilateral
communication
34
Dept of Urology, GRH and KMC, Chennai.
35. Vein shunts
GRAY HACK SHUNT- cavernoso
Saphenous shunt
BARRY shunt-cavernoso dorsal
vein shunt
35
Dept of Urology, GRH and KMC, Chennai.
36. TUNNEL (T)shunt
No .10 scalpel, 4 m
away from urethra
Blade rotated 90deg
away
50 sq.mm area
removed
Priapism >3 d, bilateral
T shunt, with insertion
of 20 fr sounds into
corpora
36
Dept of Urology, GRH and KMC, Chennai.
37. Prolonged ischemic priapism
LUE’S approach: a 3-step duration dependent
approach
Stage1< 24 h, Evacuation of old blood + diluted α
adrenergic agent;
Stage2- 1–2 d, T-shunt
Stage3> 3 d, T-shunt + tunnelling
Can Urol Assoc J. 2009 August; 3(4): 312–313
37
Dept of Urology, GRH and KMC, Chennai.
38. Outcomes
AUA panel data -resolution rate- 74% for Al-Ghorab,
73% for Ebbehøj, 66% for Winter, 77% for Quackels,
and 76% for Grayhack procedures
Erectile dysfunction rates are higher for the proximal
shunts, Quackels and Grayhack (about 50%) than for
the distal shunts (25% or less)
38
Dept of Urology, GRH and KMC, Chennai.
39. Non ischemic priapism
62%resolve with observation
Duration does not affect outcome
Selective arterial embolization-75% resolution
Non permanent material- clot/gel(5%ED)
Permanent-Coil, PVP, alcohol-(39%ED)
Penile exploration + doppler guided ligation-
last resort-63%resolution, 50%ED
39
Dept of Urology, GRH and KMC, Chennai.
41. Hematologic priapism
Sickle cell disease- hydration, oxygenation, and
systemic alkalinisation to prevent further sickling
Corporeal aspiration and intracavernous α agonists
should be given as soon as possible
Hypertransfusion –selective cases - neurological
side effects
Leukaemia- treatment with leukopheresis after
failing aspiration may be necessary
41
Dept of Urology, GRH and KMC, Chennai.
42. Recurrent priapism
Treat each episode as for
ischemic cases
Prevent recurrence-
Self injection phenylephrine
Gonadotrophins-LHRH
Agonist 7.5mg/month
Anti androgens-bicalutamide
50 mg
Baclofen(20-40mg OD),
digoxin(0.25 mg)
Terbutaline
42
Dept of Urology, GRH and KMC, Chennai.
44. Primary outcomes:
resolution of the priapism (flaccid penis for at least 24
hours),
recurrence of priapism (after 24 hours of flaccidity)
erectile dysfunction
44
Dept of Urology, GRH and KMC, Chennai.
45. Future
Clinical studies of priapism should
Documentation of pre-priapism erectile function
Time from onset of priapism to initial treatment
and time to each subsequent treatment
Measurement of sexual function after resolution
using a standardized instrument for one year
Using contemporary validated instruments for
assessing quality of life
45
Dept of Urology, GRH and KMC, Chennai.
