priapism and peyronies disease.pptx

Pathology, Diagnosis, Management
of Priapism and Peyronies disease
Prepared by : Dr. Ibsa Daba(Urology Resident)
Addis Ababa Univeristy,Ethiopia
1
Priapism and Peyronies disease(Ibsa.D)

Outline
• Priapism
• Definition
• Classification
• Epidemiology
• Etiology
• Diagnosis
• Management
• Peyronies disease
• Natural history
• Penile anatomy
• Etiology
• Clinical features
• Diagnosis
• Management
2

Defining Priapism
• Priapism is a full or partial erection that continues more than 4 hours beyond
sexual stimulation and orgasm or is unrelated to sexual stimulation.
Classification
• 1.Ischemic priapism
• 2.Non ischemic priapism
• 3.Stuttering priapism
3

Classification
• Ischemic priapism (Veno-occlusive, Low flow)
 Is a persistent erection marked by rigidity of the corpora cavernosa (CC)
 There is little or no cavernous arterial inflow
 Analogous to compartment syndrome
• Non ischemic priapism (Arterial, High flow)
 Is a persistent erection caused by unregulated cavernous arterial inflow
 Typically, the corpora are tumescent but not rigid and the penis is not painful
• Stuttering priapism
 Is characterized by a pattern of recurrence
 Recurrent unwanted and painful erections in men with SCD,
 Can last for several hrs with intervening periods of detumescence 4

1. Etiology of Ischemic priapism
• Sexual stimulation or the administration of pharmacologic agents
• Hematologic dyscrasias are a major risk factor for ischemic priapism
• Priapism may occur in patients with excessive WBC counts(leukemia) malignant infilatration of penis
• Priapism secondary to metastatic infiltrating solid lesions is rare( peripheral nerve sheath tumor)
• Iatrogenic -Medications/Injections
• Intracavernous injection
• Oral Phosphodiesterase Type 5 Inhibitors,
• Medications for Attention-Deficit/ Hyperactivity Disorder,
5

2.Etiology of Stuttering priapism
• Patients with SCD may experience stuttering priapism from childhood
• Commonly reported precipitants of full-blown SCD priapism are;
• Stuttering nocturnal or early morning erections, dehydration, fever, and exposure to cold
• Sleep-related erections (SREs) take place during REM sleep
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3.Etiology of Nonischemic (Arterial, High-Flow) Priapism
• Due to Damaged artery or arteriole ruptures;
• the unregulated arterial inflow creates a arteriole-lacunar fistula
• The cause most commonly reported is a straddle injury to the crura.
• Other mechanisms
• include coital trauma,
• kicks to the penis or perineum,
• Pelvic fractures,
• birth canal trauma to the newborn male,
• needle lacerations,
• complications of penile diagnostics, and
• vascular erosions complicating metastatic infiltration of the corpor
• HFP has been described after iatrogenic injury from cold-knife urethrotomy , Nesbitt corporoplasty,
and deep dorsal vein arterialization
Priapism and Peyronies disease(Ibsa.D) 7

EVALUATION AND DIAGNOSIS OF PRIAPISM
Determine whether the underlying priapism
hemodynamics are ischemic or
nonischemic
• Non ischemic priapism
• no pain and
• the erection duration has not been accompanied by
progressive discomfort.
• Perineal trauma
• Chronic flaccidity
• Ischemia should be suspected
• progressive penile pain
• associated with the duration of erection;
• drug associated with priapism;
• Has SCD or another blood dyscrasia; or
• known neurologic condition, especially those
affecting the spinal cord

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Elements in Taking the History of Priapism
• Duration of erection(exam: rigid erection vs tumescense)
• Presence of pain
• Inciting event
• Persistent morning erection
• Pharmacologic erection
• Trauma to pelvis , perineum or penis
• Previous episodes of priapism
• Medications and recreational drugs
• Sickle cell disease(hemoglobinopathies, hypercoaguble staes
• Baseline erectile function
• Presence and duration of morning erection
• Use of PDE 5 inhibitors
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Physical Examination
• Inspection and palpation of the penis
• In ischemic priapism
• the corporal bodies will be completely rigid; and tender
• the glans penis and corpus spongiosum are not.
• non ischemic priapism should be suspected.
• nontender,
• tumescent,
• partially erect,
• Although malignancies rarely cause priapism,
• examination of the abdomen, testicles, perineum, rectum, and prostate may help identify a primary cancer.
• Malignant infiltration of the penis causes indurated nodules within or replacing corporal tissue.
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Laboratory Testing
• Complete blood count (CBC)
• WBC count with blood cell differential,
• Platelet count
• Coagulation profile
• In African-Americans, a sickle cell screening should be requested
• hemoglobin electrophoresis,
• reticulocyte count,
• lactate dehydrogenase)
• Urine and serum toxicology
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Corporal blood aspiration
• The corporal blood aspirate differentiates
ischemic from nonischemic priapism.
• Aspirate -send -Blood gas analysis sent
• Aspirate- inspect the blood
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Penile Imaging
CDU (color Doppler ultrasound
is an adjunct to the corporal aspirate in
differentiating ischemic from non
ischemic priapism.
• prolonged ischemic priapism
• no blood flow in the cavernous
arteries.
• non ischemic priapism have
• normal to high blood flow
velocities detectable in the cavernous
arteries;
MRI in priapism
Three possible roles for MRI to help in the
assessment of priapism;
1. Imaging of a well-established arteriolar-
sinusoidal fistula
2.Ischemic priapism to demonstrate the
presence and extent of tissue thrombus and
corporal smooth muscle infarction
3. Imaging the penis for corporal malignancy
or metastasis.

15

MEDICAL TREATMENTS
Ischemic Priapism
• Oral agents are not recommended in the management of acute
ischemic priapism (>4 hours)
• The recommended initial treatment is the decompressin of the
by aspiration
• Phenylephrine (200 µg) injected with an ultrafine needle and 1-
mL syringe may reverse the erection
• Followed by α-adrenergic injection or irrigation
16

SCD and hematologic malignancies
• Classically, treatment of SCD-induced ischemic priapism involved
• analgesics,
• hydration,
• oxygen,
• bicarbonate, and
• exchange transfusion.
• Unfortunately, acute neurologic complications may follow exchange transfusions.
• Reports from hematology centers suggest high success rates with use of
• Penile aspiration and injection
• Irrigation with intracavernous sympathomimetics
• SCD priapism
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Surgical management
• Surgical management of ischemic priapism is indicated
• After repeated penile aspirations and injections of sympathomimetics have failed
• If such an attempt has resulted in a significant cardiovascular side effect.
• Timing of surgical intervention
• 2004 International Consultation on Sexual Medicine in Paris recommended
• corporal aspiration and α-adrenergic agonists for at least
• 1 hour before consideration of shunting
• Early surgical intervention may be preferable in
• patients with malignant or poorly controlled hypertension or
• for men who are using monoamine oxidase inhibitor medications contraindicating α-adrenergic therapies.
18

Shunting
• Percutaneous distal shunts
• Ebbehoj, Winter, or, T shunt
• Open distal shunt
• Al-Ghorab or Corporal snake
• Open proximal shunt
• Quackles or Sacher
• Saphenous vein
• Grayhack
• Deep dorsal vein shunt
• Barry
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• The objective of shunt surgery is
reoxygenation of the cavernous smooth
muscle.
• The shared principle of shunt procedures is
to reestablish corporal inflow by relieving
venous outflow obstruction;
• creation of a fistula between the
• CC and glans penis,
• CC and corpus spongiosum, or
• CC and dorsal or saphenous veins.

1.T shunts (Percutaneous distal shunts )
• In T shunting a No. 10 blade is placed vertically through
the glans 4 mm away from the meatus;
• the blade pierces through the glans to the CC and is
rotated 90 degrees away from the urethra and removed
• Deoxygenated blood is milked out of the wound.
• The Al-Ghorab shunt requires the excision of
circular cone segments of the distal tunica
albuginea (5 × 5 mm)
• 2-cm transverse incision is made on the glans;
the distal tips of the rigid CC are incised and
grasped with 2-0 stay sutures or Kocher clamps.
20
2. Open distal shunt—Al-Ghorab

Corporal snake
21

3 Proximal shunt
• Proximal corpus cavernosum to
corpus spongiosum (CC-CS) shunt
procedures require a trans-scrotal or
transperineal approach .
22
4.Saphenous vein bypass or deep
dorsal vein shunt

Non-ischemic priapism management
• Arterial priapism is not an emergency.
• Spontaneous resolution or response to
conservative therapy has been reported in
up to 62% of published series
• The pathognomonic arteriographic finding
is an arteriolacunar fistula.
• Selective internal pudendal catheterization
and subsequent embolization have been
reported with various agents: microcoils ,
polyvinyl alcohol, N-butylcyanoacrylate, gel-
foam, and autologous blood clot.
• Surgical management with direct ligation of
fistula as a last resort
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Embolization
• The success rates with selective pudendal
artery catheterization followed by
embolization are high (89% to 100%),
regardless of the embolization material
used
24

Peyronies disease
25

Introduction
• PD is currently recognized as a wound-healing disorder of t
he tunica albuginea
• An injury to the penis activates an abnormal wound-healing
response
• The resulting scar or plaque is inelastic and therefore res
ults in penile deformity
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NATURAL HISTORY
• There are two phases
• 1. Active (acute) phase,
• painful erections and
• changing deformity of the penis.
• 2.Stable (chronic) phase,
• stabilization of the deformity and
• disappearance of painful erections
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Misconceptions
• 1.These include that PD is a rare disorder.
• In contrary the prevalence of PD is somewhere between 3% and 20%, and
• Higher DM and ED
• 2.PD has a reasonable likelihood of resolving spontaneously
• Full spontaneous resolution extremely rare
• If no treatment is offered it gets worsen
• 3. PD is a disorder that occurs only in middle-aged men.
• Multiple studies have demonstrated that it can occur in teenagers to men in their late 70s
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Associated condition
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PENILE ANATOMY AND PEYRONIE’S DISEASE
• The tunica albuginea
• oriented with an
• inner circular and
• outer longitudinal layer
• Functions include: structural support ,protection , part of veno-occlusive
mechanism
• The longitudinal layer of the tunica albuginea is
• thinnest at the 3 and 9 o’clock positions of the corpora;
• it is completely absent between the 5 and 7 o’clock positions
• Greater ease of dorsal buckling
• 60% to 70% of plaques are located on the dorsal aspect of the penis
30

Etiology
• Exact cause not yet defined
• Connective tissue disorders-duputyeran contracture
• Antecedent trauma has been reported in 16% to 40% of patients
• The proposed mechanism is that in the erect state,
• the pressures inside the penis can get quite high and
• acutely higher when external forces are placed on the penis during intercourse in particular.
• During sexual intercourse….
• sexual positioning,partner on the top
• Trauma to the flaccid penis may also trigger this process
31

Impact of wound healing in peyronies disease
• Remodeling phase in wound healing in the normal situation may last up to 1 or 2
years.
• The remodeling of an acute wound is tightly regulated by mechanisms that balance
the simultaneous degradation and synthesis of collagen and other ECM
macromolecules.
• Any alterations in this process may lead to abnormal wound healing
with excessive scarring

Clinical presentation
• Common presenting symptoms
 Penile pain
 Erect Deformity
 Palpable plaque
 ED
 torque pain
• Associated with pulling sensation of strong
erection
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History
 Onset was gradual or sudden
 Estimated time that symptoms began;
 Inciting event
 Direct external penile trauma to the flaccid or erect penis
 Instrumentation
 Personal or family history of other fibrotic disorders
including DD and Ledderhose

PD questionnaire (PDQ)-15 components
• (1) Peyronie’s psychological and physical symptoms (six items),
• (2) penile pain (three items), an
• (3) the effects of PD symptoms (six items)

Physical examination
• Kelami ( 1983 classification)
• 30 degree or less ---mild(39%)
• 31-60 degree---moderate(35%)
• >60---severe (13%)
• 12% had no curvature but did experience hourglass deformity
• Measurement by goniometer
• Photograph at home during erect form lateral and antero posterior
• Stretched penile length (SPL) is also a critical parameter to measure at
the initial consultation
• PD plaque can manifest in a variety of configurations including
• Cords;
• Simple nodules;
• Coinlike
• Irregular dumbbell shapes; or
• I-beam plaques
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Role of duplex ultrasound
• Identification of calcification during initial surveillance
in the flaccid state,
• Assessment of penile vascular flow parameters
after intracavernosal injection of vasoactive agent,
• Observation of the erectile response to the vasoactive injection
compared with the patient’s sexually induced erection at home.
• Provision of the best opportunity to objectively assess deformity
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Management
• Reassurance- if there is no difficulty or pain for the patient or his partner in accomplishing
penetrative sex.
• Oral agents
 Potaba, Vit E,Tamoxifen, Colchicine,- not recommended in AUA 2015,no benefit in reduction of plaque
 Pentoxyflline,-
 PDE5I-not recommended for PD

Intralesional – recommended in AUA 2015
• Verapamil
Predictors of success-
• younger age
• Curvature > 30 degree
Poor candidates
• Extensive calcification
• Curvature >90 degree
• Ventral curvature
• Nicardipine – not recommended in AUA 2015
• IFN alpha- recommended, minor side effects
• Clostridial collagenase
• Combination therapy
• Intralesional + oral agents +
traction therapy
• Intralesional + oral agents
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External force application
1. Electromotive : Verapamil +/- Dexamethasone-
2.ESWT
1. Direct damage to the penile plaque
2. Increases vascularity, induction of inflammatory rxn,
lysis of plaque potential benefit of ESWT with regard to pain reduction,
3.Penile traction –Traction therapy has the potential to be an effective nonsurgical treatment,
to recover lost length, reduce curvature, and enhance girth.
4.vacuum therapy-
5.Radiation therapy-
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Surgical management
40

Choice of surgery
• The primary determinants for the choice of surgical approach are based on two factors, including
• quality of the preoperative erection hardness and
• Severity of deformity, including curvature and indentation.
• In men who have rigidity that is adequate for coital activity with or without pharmacotherapy,
• tunica plication techniques and
• plaque incision or
• partial excision with grafting may be used
• Grafting procedures are recommended for those
• with more complex curves of greater than 60 to 70 degrees
• and/or a destabilizing hourglass resulting in a hinge effect
• PD and ED that is refractory to medical therapy,
• published algorithms have indicated that penile prosthesis placement is the procedure of choice
41

Surgical options( tunica shortening Procedures)
42
Nesbit procedure Yachia procedure
TAP Dot Procedure
A, The Nesbit procedure employs a transverse elliptical
incision of the tunica albuginea. B, This is done contralateral to the
area of greatest curvature. C, The defect is closed transversely with
permanent suture with or without the addition of absorbable suture.
The Yachia procedure employs a full-thickness vertical
incision (B) in the tunica albuginea contralateral to the area of
greatest curvature and is closed transversely (C) without removal of
tunica albuginea.
The dot procedure employs no incision. The tunica albuginea is plicated with
permanent suture using an extended Lembert-type suture placement
followingfour dots per plication. A, Suture placement for dorsal curve. B, Suture
placement for ventral curve.
tunica albuginea plication (TAP) procedure (A) employs a pair of
transverse parallel incisions (B) separated by 0.5 to 1.0 cm. The
incision is made through the longitudinal fibers but does not violate
the inner circular fibers of the tunic. C, The longitudinal fibers
between the two transverse incisions are removed to reduce the bulk

Tunica lengthening procedures
• Plaque incision and grafting (PIG) or partial plaque excision and
grafting (PEG)
• Greater complexity of disease
• Curvature > 60-70 degrees
• Shaft narrowing , hinging
• Extensive plaque calcification
• Strong pre-op erection is mandatory
• when he is asked directly, “If your penis was straight, would the
quality of rigidity that you currently have allow penetrative sex?”
43

Penile prosthesis
• Penile prosthesis
• In men with PD and concurrent ED refractory to PDE5 inhibitors
• ED +/- penile deformity sufficient to impair coitus

References
• Campbell Walsh 12th edition
• AUA guideline 2003 & 2015
• EUA guideline 2021
• Internet
45

Thank you
46

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