Priapism, a symptoms of claudication of the cauda equina in spinal stenosis

Abstract

Keywords: Priapism, Cauda Equina Syndrome, Spinal Stenosis Purpose: This paper was written following the authors clinical management of a patient whom had features of incomplete CES in combination with the symptom priapism. The literature regarding this phenomenon appeared sparse therefore the authors sought to improve their own understanding and share their findings. The aim was to discuss the relationship between spinal stenosis, cauda equina syndrome and priapism using available literature. The objective was to contribute to the evidence base and raise awareness of this rare clinical finding. Methods: A narrative review was completed with a structured search by a clinical librarian. A structured search of Medline, Embase and CINAHL was undertaken by a clinical librarian. In addition, the following resources were searched; BMJ Case Reports, UpToDate, BMJ Best Practice, TRIP Database, NHS Evidence and Google Advanced Search. The following search terms were utilised; cauda equine, cauda equina syndrome, spin* stenosis, lumbar stenosis, priapism and erection. For quality assurance, the authors used the revised SANRA tool. Results: This revealed 40 cases of intermittent priapism reported in the English literature. There appears to be an association with lumbar spine stenosis and priapism but there is a paucity of literature documenting cases of priapism as a feature of CES. Priapism can be an atypical presentation of lumbar spine stenosis/transient cauda equina compression. Increased intrathecal pressure secondary to direct compression and/or local nerve root ischemia at a stenotic level of the sacral cauda equina, this may lead to parasympathetic hyperactivity and subsequent priapism. Albeit transient, the manifestation of priapism suggests that the patient is experiencing sexual dysfunction from cauda equina compression and patients should be appropriately safety netted and managed depending upon their overall clinical picture. The literature appears to demonstrate decompressive surgery is a viable treatment option. Conclusion(s): Cases of priapism secondary to transient ischemia of the cauda equina nerve roots exist. Greater awareness of this clinical finding may help clinicians in their contextual reasoning in patients with suspected CES particularly in patients with suspected spinal stenosis. There is a paucity of literature on sexual dysfunction in patients with acute CES. It could also be beneficial for further research looking at the correlation between imaging and sexual dysfunction and priapism. Impact: This project may raise awareness of patients with priapism may have subcritical compression of the cauda equina; and that the increased mechanical pressure on the cauda equina induced by walking in patients with spinal stenosis may contribute to priapism as a transient autonomic disorder. These patients should be appropriately safety netted and managed according to their overall clinical picture. Funding acknowledgements: This work was not funded.