Priapism

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Priapism

  1. 1. Priapism By Dr. Waleed Dawood
  2. 2. Definition • persistent erection not accompanied by sexual desire or stimulation • > 6 hours • Corpora cavernosa only • all age groups (including newborns) • peak incidence 20 to 50yrs • younger age group assoc with sickle cell • usually pain (except in non-ischaemic type)
  3. 3. Classification • Low flow or Ischaemic (veno-occlusive) – most common – Painful sec to tissue ischaemia and smooth muscle hypoxia (compartment syndrome) • Nonischaemic (arterial) – less common – upregulated cavernous inflow – usually not fully erect and painless
  4. 4. Low-flow priapism • Low flow or Ischaemic (veno-occlusive) – most common – Penis fully erect (sludging of blood within) – Painful tissue ischaemia and smooth muscle hypoxia (compartment syndrome) – blood gases from corpora - acidosis ↓ NO & prostacyclin – platelet aggregation and adhesion - thrombus formation and tissue damage
  5. 5. Causes of low-flow priapism • Intracavernosal pharmacotherapy – 21% of cases of priapism – extremely low incidence with oral agents • Drugs – cocaine, heparin withdrawal, trazadone, phenothiazines
  6. 6. Causes of low-flow priapism • Hyperviscosity syndromes (sickle-cell disease) – 28% of all cases of priapism (most common cause in children) – 42% incidence in adults with sickle-cell disease – 64% incidence in boys with sickle-cell disease – also affects with sickle-cell trait • Other haemoglobinopathies – thrombophilia – “stutter priapism” • Recurrent episodes of priapism can result in enlarged penis, fibrotic corpora and ED
  7. 7. Causes of low-flow priapism • Neurological causes – rare – lumbar disc lesions, spinal stenosis, seizure disorders, cerebrovascular disease • Post Trauma – perineum, groin or penis usually cause high flow priapism but can cause low flow sec to haematoma • Solid Tumours – malignant infiltration of corpora • Miscellaneous – TPN, amyloid
  8. 8. High-flow priapism • Nonischaemic (arterial) – less common – Penile, perineal or pelvic trauma – uncontrolled arterial inflow directly into the penile sinsoidal spaces – usually penis not fully erect and painless – often prolonged history – normal local blood gases – no risk of ischaemia and subsequent fibrosis
  9. 9. Causes of High-flow priapism • Trauma • Very rarely sickle-cell disease
  10. 10. Management of Priapism • Urological emergency • Treat causal factor where identified • goal is to abort the erection, thereby preventing permanent damage to the corpora (ED) and to relieve pain. • Longer duration implies greater risk of impotence • principle is to restore arterial inflow and venous outflow • clinical history and drug history • glans and corpus spongiosum rarely involved • urinalysis • haemoglobin S to outrule leukaemia • ? Local blood gas measurments • colour doppler ultrasonography
  11. 11. Medical management of low-flow priapism • aspiration of the corpora with a 21G butterfly needle followed by an injection of phenylephrine (α1 adrenergic agonist) every 5 minutes until detumescence – 10mg/ml phenylephrine in 19mls saline – 100% effective if within 12 hours • Oral terbutaline (β-adrenoceptor agonist) - 5-10mg – at best 36% response • Sickle-cell - prompt and conservative as it recurs – hydration, oxygenation, metabolic alkalinization – aspiration and injection (as above) • Stuttering priapism – self injection of α-adrenergic agent if sexually active (prophylactic digoxin) or oral α-adrenergic agent (Etilefrine) – antiandrogen if not to suppress nocturnal tumescence
  12. 12. Surgical management of low- flow priapism • Winter procedure using a Trucut needle – create a shunt between glans and corpora cavernosa • Ebbehoj procedure using a pointed scalpel blade • El-Ghourab procedure – excision of a piece of tunica albuginea • 30% of above techniques fail – direct cavernosal-spongiosum anastomosis – corpora-saphenous shunt
  13. 13. Management of High-flow priapism • Ice pack → arterial spasm • ?? spontaneous thrombosis • Most cases require arteriography and embolisation of the internal pudendal artery or a branch
  14. 14. Complications • Untreated low-flow priapism leads to corporal fibrosis and impotence • early complications: – acute hypertension, headache, palpitations, arythmias – bleeding, haematoma, infection and urethral injury • late complications: – fibrosis and impotence – related to duration of priapism and aggressivness of treatment – low-flow : high incidence of ED if not treated within 12 hours – high flow : good prognosis (20% rate of ED)

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