1) A 42-year-old man presented with a painful erection lasting 8 hours with no known cause. Physical examination and tests revealed rigid corpus cavernosum and low blood flow. He was diagnosed with idiopathic low-flow priapism and treated with drainage of blood from the corpus cavernosum and flushing with saline. 2) A 35-year-old man experienced penile pain and swelling after sexual intercourse. Examination found a penile deformity and fracture that was surgically repaired by evacuating the hematoma and closing the tunica albuginea defect. 3) The document discusses rare urology cases, including definitions, presentations, evaluations

1. Rare cases in Urology
Dr. Aung Ko Htet
Department of Urology
DSGH (1/1000)
17.5.2023 (Wednesday)

2. Case (1)
42 years old man presented with a 8 hours history
of a painful erection

3. History
• first episode
• not related to sexual stimulation or desire
• no trauma
• no pharmacotherapy for ED
• no antipsychotics drug
• no history of sickle cell disease or leukaemia
• no previous surgery or urethral instrumentation
• no immunosuppression
• no known malignancy
• no intracavernous injection therapy

4. Physical Examinations
• Rigid & tender corpus
cavernosum
• Soft glans penis & corpus
spongiosum
• No evidence of trauma or
haematoma
• DRE - NAD
• Aspiration - the dark
blood (+)

5. Laboratory investigations
1. Baseline blood tests
2. Renal function assessment
3. Electrolytes
4. Cavernous blood gas analysis
• PaO2 – 12 mmHg
• PaCO2 – 72 mmHg
• pH – 7.1

6. Imaging
Penile doppler USG
• No flow in the cavernosal arteries and
corpus cavernosum

7. Diagnosis
IDIOPATHIC LOW-FLOW PRIAPISM

8. Procedure
Making incisions at
the glans penis

9. Procedure
Squeezing &
evacuation of the
sludged blood

10. Procedure
Squeezing &
evacuation of the
sludged blood

11. Procedure
Flushing the corpous
cavernosum with 0.9%
N/S & administration of
adrenergic agent

12. Post-procedure management
• To maintain continuous fistula drainage,
pressure was exerted on the shaft of the
penis (every 15 min).

13. Background Theory
Definition
• Prolonged, unwanted erection, in the
absence of sexual desire or stimulus,
lasting >4 hours
Incidence
• 1.5/100,000
• Peak at ages 5-10 & 20-50

14. Anatomy

15. Classifications
Low-flow (ischaemic) priapism (90%)
• due to veno-occlusion
• most common form
• painful, rigid erection, with absent or low cavernosal blood flow
• >4h requires emergency intervention
• blood gas analysis shows hypoxia and acidosis
High-flow (non-ischaemic) priapism (10%)
• due to unregulated arterial blood flow
• presenting with a semi-rigid, painless erection
• usually due to trauma and subsequent AV fistula development
• usually self-limiting
• blood gas analysis - similar results to arterial blood
Recurrent (stuttering) priapism
• most commonly seen in sickle cell disease
• usually high flow, but may change to low flow with anoxia

16. Aetiology
Primary (idiopathic)
Secondary
• Intracavernosal injection therapy – papaverine, PGE1
• Drugs – α-blockers, antidepressants, antipsychotics,
psychotrophics, tranquilizers, anxiolytics, anticoagulants,
recreational drugs, alcohol excess, TPN
• Thromboembolic – sickle cell disease, leukaemia,
thalassaemia, fat emboli
• Neurogenic – spinal cord lesion, autonomic neuropathy,
anaesthesia
• Trauma – penile or perineal injury (resulting in cavernosal artery
laceration or arteriovenous fistula formation)
• Infection – malaria, rabies, scorpion sting, genitourinary sepsis
• Others – prostate or bladder cancer extending into penis,
amyloidosis.

17. Aetiology

18. Pathophysiology
Priapism lasting for 12 hours
• At 24 hours – trabecular interstitial
oedema followed by destruction of
sinusoidal endothelium and exposure of
the basement membrane
• At 48 hours – sinusoidal thrombi, smooth
muscle cell necrosis, and fibrosis

19. Management
Low-flow priapism
• Decompress urgently with aspiration of blood from the corpora.
• If no change after 10min, proceed to intracavernosal injection of α1-
adrenergic agonist.
• Oral terbutaline may be effective treatment for intracavernosal
injection-related cases.
• Sickle cell disease requires, aggressive rehydration, oxygenation,
analgesia, and haematological input (consider exchange transfusion).
• If aspiration and phenylephrine fails after 1 hour, surgical intervention
is attempted with shunt and biopsy.
• Corporosaphenous shunting can be considered where the long
saphenous vein is tunnelled and anastomosed onto the corpora
cavernosum.
• If this fails or patients present late (after 48–72 hours), discuss the
insertion of a penile prosthesis. This will treat both the priapism and
inevitable ED and avoids the difficulty and high complication rates of
delayed insertion into a fibrotic penis.

20. Management
High-flow priapism
• Conservative treatment is recommended in most cases.
• Traumatic or delayed presentations require arteriography and either
selective or internal pudendal artery embolization with autologous
blood clot or fat.
• Ligation of fistula may be required.
Recurrent priapism
• Optimize haematological management of sickle cell disease to reduce
frequency of attacks.
• Regular oral alpha agonists such as etylephrine can be helpful and/or
androgen suppression (i.e. cyproterone acetate).
• Complications – 90% of priapism lasting >24 hours develop complete
ED.

21. Management
Sickle cell disease
• Massive blood transfusion, exchange blood
transfusion or both
• Hyperbaric O2 therapy
Leukaemia
• Chemotherapy

22. Complications
• Impotence/ Erectile dysfunction
• Deformity

23. Case (2)
35 years old man presented with acute penile pain
and swelling following sexual intercourse

24. History
• “cracking sound” during coitus
• immediate detumescence
• f/b deformed painful penile swelling

25. Physical Examinations
• Clinical diagnosis
• Penis was swollen and bruised
(resembling an aubergine)
• No bruising (at lower abdominal
wall, perineum and scrotum)
• A tender, palpable defect was felt
over the site of the tear in the tunica
albuginea.
• No blood at the meatus
• No haematuria & dysuria
• No AROU

26. Investigations
Penile USG
• Site of tunica tear
• Haematoma (+)
Lab investigations
• Baseline blood test – NAD

27. Diagnosis
PENILE FRACTURE

28. Management
Urological emergency

29. Surgical exploration
• Supine position
• Subcoronal incision
• Deglove the penis
• Enter Buck fascia using a
longitudinal incision
• Evacuate the blood clot and define the injury
• Penile fracture (~1 cm)
• Freshen the edges of the tunica albuginea with
Metzenbaum scissors
• Close with interrupted 3/0 polydioxanone suture
• Close ventral incisions with reapproximation of the
Dartos muscle using a running suture (3/0 Vicryl)
• The skin was closed.

30. Post-operative care
Patients avoid sexual intercourse for 6
weeks after repair.

31. Background Theory
Definition
• Rupture of the tunica albuginea of the erect penis (i.e.
rupture of one or both corpora cavernosa ± rupture of the
corpus spongiosum with rupture of the urethra).

32. Pathophysiology
• The tunica albuginea is 2 mm thick in the flaccid
state and 0.25 mm during erection and is
vulnerable to rupture if the penis is forcibly bent.
• The patient usually reports a sudden ‘snapping’
or ‘popping’ sound and/or sensation with sudden
penile pain and detumescence of the erection.
• The penis is swollen and bruised, sometimes
resembling an aubergine.
• If Buck’s fascia has ruptured, bruising extends
onto the lower abdominal wall and into the
perineum and scrotum. A tender, palpable defect
may be felt over the site of the tear in the tunica
albuginea.
• If the urethra is damaged, there may be blood at
the meatus or haematuria and pain on voiding or
urinary retention.

33. Treatment
Conservative
• application of cold compresses to the penis
• analgesics and anti-inflammatory drugs
• abstinence from sexual activity for 6–8 weeks to allow healing
Surgery
The main goals of treatment are to restore or maintain the
ability to have erections and preserve urinary function.
• expose the fracture site in the tunica albuginea
• evacuate the haematoma
• close the defect in the tunica
• lower complication rate, less chance of penile scar tissue and
prolonged penile pain

34. Surgical repair
• Expose the fracture site by degloving the penis via a circumcising
incision around the subcoronal sulcus or by an incision directly over
the defect, if palpable.
• A degloving incision allows better exposure of the urethra for
associated urethral injuries.
• Alternatively, use a midline incision extending distally from the midline
raphe of the scrotum along the shaft of the penis.
• Close the defect in the tunica with absorbable sutures or by
nonabsorbable sutures.
• Non-absorbable sutures may possibly be associated with prolonged
post-operative pain.
• Leave a urethral catheter.
• Repair a urethral rupture, if present, with a spatulated single or two-
layer urethral anastomosis and splint repair with a urethral catheter for
3 weeks.

35. Thank you!