RECANALIZATION OF EMBOLIZED CAVERNOSAL ARTERY: RESTORING POTENCY IN THE PATIENT WITH HIGH FLOW PRIAPISM

Abstract

High flow priapism is an uncommon disease. Most cases are secondary to trauma. An arteriocavernous fistula caused by laceration of the cavernosal artery or one of its branches is the most common cause of this hemodynamic alteration. Immediate treatment with reduction of abnormal arterial flow is better possibly than other treatments. In addition, angiographic embolization is safe, selective and affords return to premorbid function and, therefore, it has been the most widely used. In our patient we evaluated the cavernosal blood gas analysis, and performed color Doppler ultrasonography and angiography for diagnosis, and superselective embolization of the internal pudendal artery with the autologous blood clots. The patient was followed with color Doppler ultrasonography and magnetic resonance imaging (MRI) 2 months after embolization. CASE REPORT A 17-year-old man presented with a 7-day history of sustained, painless and incomplete erection that occurred 3 days after blunt penile injury when he fell down on a bicycle. The erection did not subside and drainage of the corpora cavernosa with needle aspiration and several irrigations with 10 mg./ml. phenylephrine, which produced transient flaccidity, had been performed elsewhere. When referred to us, the penis was engorged with no tenderness, except bruising. A color Doppler scan showed abnormal arterial and venous flow in the corpora, and turbulent flow in the pseudoaneurysm. Peak systolic velocity was 30 cm. per second (end diastolic velocity of 3 cm. per second) in the right cavernosal artery and 52 cm. per second (end diastolic velocity of 6 cm. per second) in the left cavernosal artery before embolization. Blood gas analysis of the corpora cavernosa revealed a high oxygen partial pressure tension (93.8%) and oxygen saturation (97.1%). Superselective pudendal angiography performed with the patient under local anesthesia clearly demonstrated extravasation consistent with the presence of a pseudoaneurysm from a branch of the left cavernosal artery (fig. 1, A). Superselective embolization of the left internal pudendal artery with 3 ml. of autologous blood was performed. Repeat contrast injections confirmed a dramatic reduction in blood flow to the penis (fig. 1, B). The penis became gradually flaccid in the following 48 hours. During followup 2 months later, the patient stated that sexual arousal was associated with the return of erections, which were not complete. Physical examination revealed a ring-like fibrotic mass in the penile base but the lesion could not be differentiated as to whether it was in the tunica albuginea or intracavernosum. Color Doppler ultrasonography after injection with intracavernosal vasoactive agents revealed a well circumscribed hypoechoic mass that was no longer connected with the cavernosal artery, and there was no turbulent flow in the hypoechoic cystic mass (fig. 2, A).