HIGH FLOW PRIAPISM COMPLICATING VENO-OCCLUSIVE PRIAPISM: PATHOPHYSIOLOGY OF RECURRENT IDIOPATHIC PRIAPISM?

Abstract

Of the several known forms of priapism veno-occlusive priapism is the most common.' High flow priapism is uncommon and usually follows trauma to the perineum.2 More than 20 cases have been reported and the majority of patients have been treated with angiographic embolization.2 Idiopathic recurrent priapism occasionally follows treatment of veno-occlusive priapism and is a diagnostic and therapeutic challenge.3 We report on 2 patients with recurrent idiopathic priapism aRer treatment for veno-occlusive priapism. Diagnostic testing revealed a high flow cavernosal arterial state without evidence of a cavernosal-sinusoidal fistula. Arteriographic embolization with absorbable gelatin sponge resulted in complete resolution. This high flow state may represent a variant of traumatic high flow priapism or it may be the pathophysiology of recurrent idiopathic priapism and may be best treated with angiographic embolization. CASE REPORTS Case 1. A 33-year-old black man with no medical history presented with a painful erection 24 hours in duration. He denied any drug use and had no history of trauma or sickle cell disease. Corporeal aspiration revealed dark crankcase oil like blood. He was initially treated with intracorporeal imgation using saline and then 2 to 3 doses of 300 pg. phenylephrine, which resulted in partial detumescence. However, the erection returned within 15 minutes. A Winter shunt procedure was performed without resolution of the priapism. A glans spongiosum to corpus cavernosum shunt (El-Ghorab shunt) was then created. The shunt provided for partial detumescence. The priapism returned 6 hours postoperatively. Color duplex ultrasound of the penis revealed a high flow state, which was most significant in the right cavernosal (68 cm. per second) and dorsal (63 cm. per second) arteries. An internal pudendal arteriogram revealed a common cavernosal trunk, originating from the right internal pudendal artery. There was no separate cavernosal artery originating from the left internal pudendal artery and no evidence of a cavernosal-sinusoidal fistula. Angiographic embolization of the cavernosal trunk with absorbable gelatin sponge pledgets resulted in immediate detumescence. The penis remained detumescent without any spontaneous erections 4 weeks after embolization. minutes the erection returned. A bedside Winter shunt pro