A 25-year-old male presented with a painful, sustained erection for 2 days. His history included splenomegaly. Examination found an erect, tender penis and enlarged spleen. Tests showed leukemia. Dark blood was aspirated from his cavernosa, and distal shunts were created to drain blood and induce flaccidity. He was diagnosed with ischemic priapism caused by leukemia-induced sickle cell disease and thrombocytosis. Distal shunting successfully treated his priapism.

1. MAHAR NAVEED SARWAR
RESIDENT UROLOGIST
WARD # 19, JPMC

2.  25 years old male no known comorbids, presented to
us in emergency with
 c/o
 Painful sustained erection for 2 days
Erection was spontaneous and severely painful. it did not relieved
with analgesics
There was no history of trauma to genitelia
No significant drug history
No significant addiction history
There was past history of splenomegaly

3.  Young male of average height and built, well
oriented to time person and place
Vitals:
•Pulse = 97/min
•B.P = 120/90mmhg
•R/R = 18/min
•Temp = 98.6:F
Sub-vitals:
Anemia = absent
Jaundice = absent
Cyanosis = absent
Clubbing = absent
Dehyd: = absent
L/Nodes = N/P
Edema = absent

4.  Abdominal examination:
◦ Spleen was palpable 3 finger breadth below the level of
umbilicus
◦ Rest of the examination was unremarkable
 Local examination:
◦ Fully erect, congested and mildly tender penis
◦ No sign of trauma

5.  Hb = 12.4 gm%
 PLT = 449000
 TLC = 161000
 Myelocytes = 07%
 Promyelocytes = 14%
 Na+ = 135
 K+ = 4.2
 U = 35
 Cr = 0.9

6.  Under G.A clotted dark blood aspirated from
cavernosa
 distal shunts created between corpora cavernosa
and corpus spongiosum
 Phenylephrine injected into the corpora until
penis became flaccid
 Next morning pt shifted to Oncology for the
management of leukemia.

7.  DEFINATION:
◦ Priapism is a full or partial erection that continues more
than 4 hours beyond sexual stimulation and orgasm or
is unrelated to sexual stimulation
 TYPES:
◦ LOW FLOW(ISCHEMIC):
◦ HIGH FLOW(NONISCHEMIC)

8.  Common than non-ischemic
 Results from veno-occlusion
 Its rigid and very painful
 Blood flow will be decreased
 Blood in cavernosa will show hypoxia,hypercarbia
and acidosis

9.  Its post traumatic
 Unregulated arterial blood flow
 Semi-rigid and painless erection
 Cavernosal blood shows arterial values

10.  Itracorporal injection therapy
◦ PGE
◦ Papavarin
 Thromboembolism
◦ Sickle cell disease
◦ Leukemia
◦ Fat emboli
 Drugs
 TPN
 Alcohol intoxication
 Recreational therapy e.g.: cocaine
 Malignant infiltration of cavernosa
 Infection
◦ Malaria, rabies, scorpion sting
 Neurogenic causes
◦ Spinal Cord lesions
◦ Autonomic neuropathy
◦ Anesthesia

11.  Detailed history (specially past medical history)
 Examination
 Investigation
◦ Full blood count and peripheral blood films
◦ ABGs of aspirated cavernous blood
 Ischemic priapism  hypoxia,hypercarbia and acidosis
 Non ischemic priapism  normal arterial or mixed arterial-
venous picture
◦ Duplex Doppler ultrasound of penis
 Ischemic priapism  Decreased flow
 Non ischemic priapism  Increased flow
◦ Urine and serum toxicology

12.  Decompression by aspiration followed by
injection of sympathomimetics into corpora
cavernosa
 Phenylephrine is the drug of choice
◦ Highly α1 selective without β-mediated ionotropic and
chronotropic effects
◦ Diluting it in N/S at concentration of 100 to 500 Ug/ml
and giving 1ml every 5 minutes
◦ maximum 1mg of Phenylephrine can be injected
◦ Serial monitoring of B.P and Pulse

13.  Percutanous distal shunts:
◦ Ebbehoj
◦ Winter
◦ T-shunt (Brant)
 Open distal shunt
◦ Al-Ghorab
◦ Corporal Snake (Burnett)
 Open proximal shunt
◦ Quackles
 Saphenous vein
◦ Grayhack
◦ Deep dorsal vein shunt

18.  Its not an emergency
 Start expectant management with cool bathing
and ice packing  vasospasm and thrombosis
 Arteriography and selective embolisation of the
internal pudendal artery or its branches
 Ligation of the site of fistulae