priapism

1. PRIAPISM
Sukhdev, CMC Vellore

2. Etymology
• God of fertility and flora
• Son of Zeus

3. Definition
• Full or partial erection
• Beyond 4 hours
• Related or unrelated to sexual stimulation and orgasm

4. Classification
• Ischemic(veno occlusive or low flow)
• Non ischemic(Arterial or high flow)
• Stuttering(intermittent)
• Partial

5. Ischemic priapism
• Akin to compartment syndrome
• Rigidity with minimal/absent cavernosal artery inflow
• So, anaerobic milieu – hypoxia, hypercarbia, acidosis
• >48 hours – gradual destruction of CC smooth muscle
• >48 hours – thrombus > smooth muscle necrosis > ED

6. Non ischemic priapism
• Increased cavernosal arterial inflow
• Similar to an AV fistula limb
• CC are tumescent but not rigid owing to intact venous drainage
• Usually follows blunt injury to penis/perineum, iatrogenic needle
injury
• CC environment is not anaerobic
• Does not require emergent intervention

7. Stuttering priapism
• Recurrent prolonged erection episodes
• Can progress to ischemic priapism
• Common in SCD
• Stuttering priapism ischemic priapism

8. Epidemiology
• Ischemic priapism – 95% of cases
• Lifetime risk of priapism in sickle cell disease patient : 29-42%
• Risk of priapism after ICI of erectogenic agents : 0.4-35%(risk more
with papaverine than alprostadil)
• Rare in men who take PDE5i

9. • Stuttering priapism  ischemic priapism Non ischemic priapism

10. Partial priapism
• Priapism limited to crura only
• Very rare
• Aka idiopathic partial thrombosis of penis
• Bicycle riding, erectogenic agents, hematological diseases – have
been implicated

11. Aetiology
• Idiopathic in majority
• Drugs
• Blood dyscrasias
• Trauma
• Malignancy – GU cancers with local infiltration

13. Sickle cell disease and Priapism
• Sickled erythrocytes causing venous obstruction
• 1/3rd of priapism cases have SCD as the cause
• Mean age of onset of priapism in SCD = 15 years
• Precipitating events : sexual arousal, sleep, fever and dehydration, cold weather
Pathophysiology:
• Sickled RBCs release arginase, which converts arginine to ornithine and so, NO’s source is lost
• Oxidant radicals also remove NO
So, combo of NO scavenging and decreased production
The same pathophysiology is implicated in pulmonary hypertension, stroke – ASPEN
syndrome(Association of SCD, Priapism, Exchange transfusions and Neurological events)

14. Non ischemic priapism
• Aka arterial/High flow priapism
• Rarer than ischemic priapism
• MCC is trauma – either blunt or penetrating
• Also reported after EIU
Pathophysiology:
• Cavernosal artery laceration which leaks into sinusoids => arteriosinusoidal fistula
• Delay between trauma and HF priapism
• Nocturnal erection dislodges clot>arterial inflow leads to fistula and
pseudocapsule formation
• Also occurs post Rx of LF priapism; the iatrogenic trauma creates a fistula

15. Molecular pathophysiology
• NO imbalance leading to ↑cGMP due to reduced PDE5 and ↓Rho
khinase activity leading to decreased smooth contraction

16. Clinical features
Goal – to differentiate ischemic vs non ischemic priapism

17. Ischemic priapism Non ischemic priapism
Incidence 95% <5%
Clinical features Painful Painless
Rigid Tumescent
Previous episodes of stuttering
priapism can be present
Previous episodes rare
Association Associated with hematological
abnormalities
Associated with trauma
Diagnosis Hypercarbia, hypoxia, acidotic Normal ABG
Intervention Emergency Elective

18. Corporeal blood gas analysis
pO2 pCO2 pH
Ischemic priapism <30 >60 <7.25
Non ischemic priapism >90 <40 7.4

19. Colour doppler
HFP CDU LFP CDU

20. Other lab investigations
• CBC for hematological abnormalities
• Urine and serum toxicology assay for psychoactive drugs

21. Treatment
• Medical management
• Surgical management

22. Medical management
• Oral
• Intracavernosal
• Oral medications have no role in ischemic priapism
• Role only in stuttering priapism

23. • ICI of vasoconstrictors
• Aspiration
• Aspiration + ICI of vasoconstrictors

24. ICI of vasoconstrictors
• Intracavernosal injection of vasoconstrictors alone is most useful
when ICI of erectogenic agents are given(diagnostic/therapeutic) and
when the duration of erection is >1 hour but not >4 hours
• Phenylephrine 200 µg injected with an ultrafine needle into the
corporal bodies

25. Aspiration
• Aspiration alone may alleviate priapism in 1/3rd of cases
Technique of aspiration:
• Single large bore 19/18G needle inserted at 3 or 9 O clock at
penoscrotal junction(to avoid DVC)
• Shaft should be held between thumb and index finger just below the
needle
• Compress the shaft and aspirate blood. Then release the shaft
pressure to refill and aspirate again
• Repeat till the blood is bright red in colour

27. • Intracorporeal isotonic saline irrigation
• Replace the volume of blood aspirated

28. ICI of vasoconstrictors

29. Phenylephrine
• Diluted to 100-200 µg/ml
• 1 ml injected every 5 minutes till a maximum of 1000 µg
• Penile shaft is compressed below the needle during injection and
aspiration of blood done between injections
• Monitor patient’s BP due to sympathomimetic effects of the drug

30. Surgical management of ischemic priapism
• After failed ICI adrenergics at least for an hour(International
consultation on sexual medicine, 2004)
• Or can be used in patients who have contraindications for alpha
adrenergics(elderly, patients on MAO inibitors)
• Priapism lasting longer than 24 hours – 90% ED
• International society for Sexual medicine recommends shunting for
LFP of 72 hours or less
• Shunt surgeries done after 36 hours only relieves pain without any
benefit on erectile function

31. Objectives of shunting
• To shunt across the venous obstruction
The shunting can be to:
• Glans/Corpus spongiosum
• Deep dorsal vein
• Saphenous vein

32. Winter’s shunt
• Insertion of Trucut© needle through the glans into the corpus
cavernosum on both sides
• Easiest
• Least successful

34. Ebbehoj and T shunts
Ebbehoj shunt:
• 11 blade used to make a percutaneous cavernosoglanular shunt
T shunt:
• 10 blade inserted into glans and rotated 900 to make a T shunt
Better done under ultrasound guidance to avoid urethral injury

36. • Winter, Ebberhoj and T shunt can be done under penile block
• Deoxygenated blood milked out and glans closed if necessary with
absorbable sutures
• Patient can be discharged if the penis remains flaccid for 15 minutes

37. Al Ghorab Shunt
• Open cavernosoglanular shunt
• Requires GA

38. Al Ghorab shunt

39. Burnett corporal snake technique
• Less invasive than Al ghorab
• Combination of T shunt and Al ghorab
• T shunts made and 20Fr dilators inserted down to the crura

40. Burnett corporal snake technique

41. Open proximal corporospongiosal shunt/
Quackles shunt
• Trans scrotal or perineal approach
• If done bilaterally, should be done in a
staggered fashion to avoid urethral stricture
formation

42. Open proximal corporospongiosal shunt/
Quackles shunt

43. Venocorporal shunt/Grayhack shunt
• Grayhack shunt is done to GSV
• Can also be done to deep dorsal vein

45. Post operative care
Like AV fistula care
• Avoid compressive dressings to penis
• Patient should periodically compress and release the distal penis to
maintain the patency of the shunt created
• Anticoagulation(Heparin/aspirin)

46. Complications of shunting
• Penile hematoma
• Infection
• Urethral stricture
• Urethral fistula
• Penile necrosis
• Pulmonary embolism
• High flow priapism

47. Immediate penile prosthesis insertion
• Priapism lasting longer than 36 hours
• MRI evidence of corporal fibrosis/smooth muscle necrosis
• Failure of distal/proximal shunts
Merits:
• Fibrosis has not fully established which makes the procedure easy
• Penile length is preserved
Demerits:
• Higher complication rate
• Device extrusion higher, especially in region of previous shunting

48. Management of HFP
• HFP is not an emergency
• It is nothing but a vascular fistula
• 2/3rd will spontaneously resolve
• And so, only priapism type where conservative management can be
tried – Ice application to perineum
• Aspiration, ICI have no role in the treatment of LFP

49. Arterial embolisation
• Patients demanding immediate relief can be subjected to
angioembolisation
• Recurrence rate of 30%
• So, may require retreatment

50. Surgical management
• Transcorporal ligation of the fistula under doppler guidance
• Indicated when patient demands immediate relief

51. Management of stuttering priapism
• Oral adrenergics
• Hormonal therapies
• Ketoconazole
• 5α reductase inhibitors
• Baclofen
• PDE5i
• ICI of adrenergics at home

52. Oral adrenergics
• Etilefrine
• 100 mg/ day maximum
• Started at 25 mg at bedtime and increased up to 100 mg/day
• Only FDA approved drug for stuttering priapism

53. PDE5i and stuttering priapism
• Seems counterintuitive
• But regular PDE5i can cause PDE5 upregulation and can decrease
cGMP levels( Burnett et al, 2006)
• Should not be started during a priapism episode
• Efficacy seen after a week or more

54. ?PRIAPISM
↓
Rigid and painful/tender Non tender and tumescent but not rigid
↓ ↓
Ischemic Non ischemic
↓ ↓
Hematology consult ← Previous similar episodes of stuttering priapism
Examination
History for blood dyscrasias
Previous trauma history
↓ ↓
CDU and blood gas analysis
↓ ↓
Ischemic Non ischemic
↓ ↓
Document baseline IIEF score
↓ ↓
Cavernosal aspiration Conservative vs
angioembolisation/fistula closure
↓
Normal saline irrigation
↓
ICI of adrenergics for an hour
← ←
↓
↓
↓ ↓
Success Failure → Percutaneous distal shunt under LA
Complete detumescence Partial detumescence ↑ ↓
↓ ↓ ↑
Discharge IP and CDU/corporal
gas repeat
→ ↑ Open distal shunt under GA:
 Al ghorab
 Corporal snake if clots could not be evacuated by al
ghorab
↓
Proximal shunt
↓
MRI
↓
Corporal fibrosis
↓
+ -
Immediate penile prosthesis Observation

55. Priapism after ICI
• If it less than 1 hour, ICI of phenylephrine alone is enough
• If more than 4 hours, treat as in ischemic priapism

56. Summary
• Differentiate priapism clinically and along with CDU/corporal blood
gas analysis
• Because the entire treatment pathway varies
• Because ischemic – emergency; non ischemic – elective
• Treatment of ischemic priapism is aspiration and fistula(shunt
)creation
• Treatment of non ischemic priapism is fistula closure

57. References
• Campbell 11th edition
• Priapism EAU guidelines
• Urological emergencies – a practical guide, Hunter and McAninch
• Outcome and erectile function following treatment of priapism: an
institutional experience, Pal et al, 2015