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Priapism ppt
- 2. OVERVIEW ■ Definition ■ Types ■ Epidemiology and Pathophysiology ■ Evaluation and Diagnosis ■ Treatment
- 3. History Greek God PRIAPUS-God of fertility
- 4. 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. 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”
- 6. Ischemic Priapism (Veno-Occlusive, Low- Flow) Most common, accounting for more than 95% of all cases Persistent erection marked by rigidity of the corpora cavernosa Little or no cavernous arterial inflow Abnormal cavernous blood gases (hypoxic, hypercarbic and acidotic) Penile pain Rigid Erection Emergency
- 7. Histological Changes ■ 12 hours – corporal specimens show interstitial edema, progressing to destruction of sinusoidal endothelium ■ 24 hours – Exposure of the basement membrane and thrombocyte adherence ■ 48 hours – Thrombus can be found in the sinusoidal spaces, and smooth muscle necrosis
- 8. Nonischemic Priapism (Arterial, High- Flow) ■ Caused by unregulated cavernous arterial inflow ■ Corpora are tumescent but not rigid and the penis is not painful ■ History of blunt trauma to the penis or an iatrogenic needle injury is common ■ Arteriolar-sinusoidal fistula ■ Blood gases are not hypoxic or acidotic-non emergent
- 9. Stuttering Priapism (Intermittent) ■ Characterized by a pattern of recurrence ■ Recurrent unwanted and painful erections in men with sickle cell disease (SCD) ■ Patients typically awaken with an erection that persists for several hours ■ Becomes progressively painful secondary to ischemia ■ Any patient who has experienced ischemic priapism is at risk for stuttering priapism
- 10. Pathophysiology ■ Imbalance of vasoconstrictive and vasorelaxatory mechanisms predisposing the penis to hypoxia ■ Corporal smooth muscle cells are exposed to hypoxia, α- adrenergic stimulation fails to induce corporal smooth muscle contraction ■ Severe anoxia signifcantly impair corporal smooth muscle contractility & cause significant apoptosis of smooth muscle cells & ultimately fibrosis of the CC
- 11. ■ NO imbalance resulting in – aberrant molecular signaling – PDE5 dysregulation – adenosine overproduction – Reductions in Rho-kinase activity ■ Which translates into enhanced corporal smooth muscle relaxation and inhibition of vasoconstriction in the penis.
- 12. Etiology Hematologic Sickle cell disease Thalassemia Granulocytic leukemia Myeloid leukemia Lymphocytic leukemia Multiple myeloma Hemoglobin Olmsted variant Fat emboli associated with hyperalimentation Hemodialysis Glucose-6-phosphate dehydrogenase deficiency Genitourinary Straddle injury Coital injury Pelvic trauma Kick to penis or perineum Arteriovenous or arteriocavernous bypass surgery Urinary retention Recreational Drugs Alcohol, cocaine, crack cocaine, marijuana
- 13. Etiology Neurologic Syphilis Spinal cord injury Cauda equina compression Autonomic neuropathy Lumbar disk herniation Spinal stenosis Cerebral vascular accident Brain tumor Spinal anesthesia Cauda equina syndrome ■ Neoplastic – Sarcoma – Secondaries – Myeloma – Lymphoma – Penis, Prostate, urethra, testis, bladder, rectum, lung, kidney
- 14. Etiology HORMONES Gonadotropin-releasing hormone, testosterone INFECTIOUS (TOXIN- MEDIATED) CAUSES Scorpion sting, spider bite, rabies, malaria Prostatitis, Urethritis, Mumps, Syphilis METABOLIC CONDITIONS Amyloidosis, Fabry disease, gout, Diabetes, Nephrotic syndrome, Renal failure, Haemodialysis ■ ED pharmacotherapy – Oral sildenafil – Intraurethral alprostadil – Intracavernous agents – Papaverine, phentolamine, oral phosphodiesterase type 5 inhibitors
- 15. Pharmacologic Causes ■ α-ADRENERGIC RECEPTOR ANTAGONISTS – Prazosin, terazosin, doxazosin, tamsulosin ■ ANTIANXIETY AGENT – Hydroxyzine ■ ANTICOAGULANTS – Heparin, warfarin ■ ANTIHYPERTENSIVES – Hydralazine, guanethidine, propranolol ■ ANTIDEPRESSANTS AND ANTIPSYCHOTICS – Trazodone, bupropion, fluoxetine, sertraline, lithium, clozapine, risperidone, olanzapine, chlorpromazine, thioridazine, phenothiazines ■ ATTENTION- DEFICIT/HYPERACTIVITY DISORDER AGENTS – Methylphenidates – Atomoxetine
- 16. 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
- 17. 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 -- +
- 18. Piesis Sign ■ In young children with high flow priapism, perineal compression with the thumb will cause prompt detumescence, called Piesis sign-confirmatory
- 19. Investigations ■ Complete blood count, platelet count,WBC differential ■ Peripheral smear, reticulocyte count ■ Hb electrophoresis ■ Screening for psychoactive drugs and urine toxicology ■ Corporal Blood gas testing – Differentiates ischemic from nonischemic priapism. – Aspiration may be both diagnostic and therapeutic. – Initial penile aspirate will reveal dark deoxygenated blood with a “crankcase oil” appearance in ischemic priapism ■ Color duplex ultrasonography ■ Penile arteriography
- 20. Source PO2(mm hg) PCO2(mm hg) PH Normal arterial blood >90 <40 7.40 Normal venous blood 40 50 7.35 Ischemic priapism(first corporal aspirate) <30 HYPOXIA >60 HYPERCARBIA <7.25 ACIDOSIS TYPICAL BLOOD GAS VALUES
- 21. USG Imaging ■ Anatomic abnormalities Corporal fibrosis- white dots bilateral cavernous hematomas ( ) at∗ the base of the penis
- 22. 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
- 23. Color duplex ultrasonography Arterial-lacunar fistula due to rupture of the right cavernosal artery (arrowheads ) High flow priapism
- 24. 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)
- 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
- 26. Role Of MRI ■ Imaging of a well-established arteriolar-sinusoidal fistula ■ To demonstrate the presence and extent of tissue thrombus and corporal smooth muscle infarction ■ Imaging of corporal malignancy or metastasis
- 27. Differential diagnosis of priapism
- 28. Treatment ■ Management of ischemic episode- IMMEDIATE ■ > 4 hours – irrespective of etiology- Compartment syndrome ■ Oral agents are not recommended in the management of acute ischemic priapism (>4 hours)
- 29. Aspiration ■ Therapeutic- Decompresses and relieves pain ■ 36% resolution rate ■ Can flush with saline ■ A single, large-bore, 19- gauge needle inserted at penoscrotal junction at 3 or 9 o’clock position ■ Repeated until no more dark blood can be seen coming out from the corpora
- 30. 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
- 31. Drugs ■ Oral sympathomimetic drugs ■ Effectively reverse prolonged erection (<4 hours) initiated by ICI therapies ■ Aspiration followed by the ICI of sympathomimetic drugs ■ α-adrenergic agent- Metaraminol ■ Mixed α&βadrenergic agonists- Etilefrine, Phenylephrine &Epinephrine. ■ Pure β agonist-Terbutaline ■ α-adrenergic agent contract cavernous smooth muscles, allowing sinusoidal blood to egress from subtunical veins ■ β-adrenergic agent relaxes cavernous smooth muscle and dilate cavernous artery & promote oxygenated blood to enter cavernous spaces and washout deoxygenated blood
- 32. Drugs ■ Phenylephrine:100-200 mcg/ml dilution dose ■ Agent of choice ■ Use 1 mL of 200 mcg/mL solution via intracavernous injection in 1 hr.10 Doses ■ Erections > 4 hrs and < 12 hrs, cavernous aspiration, & irrigation with 10 mL of 1:1,000,000 solution of epinephrine ■ Let’s Stop This “Epi”demic! Preventing Errors with Epinephrine ■ 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 ■ Headache, dizziness, hypertension, reflex bradycardia, tachycardia, and irregular cardiac rhythms
- 33. Surgical Shunts ■ Failed intra cavernous treatment ■ Priapism lasting longer than 24 hours was associated with a 90% ED rate ■ Ischemic priapism >72 hrs duration ■ Cavernous thrombosis is evident and no blood can be aspirated from the corporal bodies ■ Surgical intervention may be preferable in patients with malignant or poorly controlled hypertension ■ Objective – Drain blood from cavernosa bypassing veno occlusive mechanism & reoxygenation of the cavernous smooth muscle
- 34. Shunt procedures are divided based on anatomic location ■ Percutaneous distal shunts—Ebbehoj, Winter, or T shunt – First because it is technically easier ■ Open distal shunt—Al-Ghorab or corporal snake ■ Combined T shunt and corporal snake maneuver—Zacharakis ■ Open proximal shunt ■ Saphenous vein—Grayhack and colleagues ■ Deep dorsal vein shunt
- 35. T shunt Less invasive Performed with local anesthetic in ER Creates a T-shaped shunt b/w the CC and glans penis. In T shunting a No. 10 blade is placed vertically through the glans 4 mm away from the meatus; blade pierces through the glans to the CC and is rotated 90 degrees away from the urethra and removed
- 36. TUNNEL (T)shunt Priapism >36 hrs, bilateral T shunt, with insertion of 20-Fr dilators into the fistula tract and into the CC down to the crus Technique traumatic and will require GA
- 37. Winter shunt ■ Distal corporo glanular shunt-with biopsy needle ■ EBBEHOJ shunt- scalpel used
- 38. AL- GHORAB SHUNT Distal caverno glanular shunt 2cms transverse Incision over glans Distal corpora excised as vent Most effective distal shunt Performed secondarily- invasive
- 39. Corporal Snake Maneuver ■ Modifcation of the Al-Ghorab shunt ■ Rather than excising a wedge of tunica and underlying CC muscle, a 7/8 Hegar dilator is advanced through each of the tunica windows proximally several cms to release blood and thrombus
- 40. Prevention shunt obstruction ■ Compressive penile dressings should be avoided ■ Patient should periodically squeeze and release the distal penis to “milk” the shunt maintaining patency ■ Anticoagulation – Preoperative aspirin 325 mg coupled with subcutaneous heparin 5000 units and post- operative aspirin 81 mg daily for 2 weeks
- 41. Quackels/Sachers shunt Proximal corpus cavernosum to spongiosum (CC-CS) shunt Trans-scrotal or transperineal approach Openings placed in staggered fashion Unilateral or Bilateral
- 42. Vein shunts GRAY HACK SHUNT- cavernoso Saphenous shunt BARRY SHUNT-cavernoso dorsal vein shunt
- 43. Penile Prosthesis ■ Untreated ischemic priapism or priapism refractory to interventions is severe fibrosis, penile length loss, and complete ED ■ Small-Carrion penile prosthesis through an infrapubic incision ■ Semirigid implants ■ “EARLY” implantation - two distinct advantages
- 44. ALGORITHM
- 45. 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
- 46. 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
- 47. ALGORITHM
- 48. 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
- 49. Stuttering Priapism ■ Single sympathomimetic intracorporal injection ■ oral and injectable α-adrenergic agonists ■ Terbutaline ■ Digoxin, ■ Antisickling agent hydroxycarbamide (hydroxyurea) ■ Estrogens ■ GnRH analogues ■ Antiandrogens, baclofen, gabapentin, and recently PDE5 inhibitors ■ Etilefrine - 100 mg in 24 hours at bed time ■ Goal of hormonal therapy in the prevention of stuttering priapism is to reduce serum testosterone to hypogonadal levels or block testosterone’s effects on the penis ■ Mean testosterone levels fall from baseline of 475 ng/dL to 275 ng/dL
- 50. 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
- 52. ■ Primary outcomes: – resolution of the priapism (flaccid penis for at least 24 hours), – recurrence of priapism (after 24 hours of flaccidity) – erectile dysfunction
- 53. 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
- 54. THANK YOU