Surgical Techniques: Distal Cavernosum–Glans Shunts for Ischemic Priapism

Abstract

Priapism is a pathological condition of a penile erection that persists beyond or is unrelated to sexual stimulation. It is an important medical condition that requires evaluation and may require emergency management. Ischemic priapism is the most common form of priapism; it is usually a painful, rigid erection characterized clinically by absent cavernous blood flow. Ischemic priapism beyond 4 hours is a compartment syndrome requiring emergent medical intervention. Potential consequences are irreversible corporal fibrosis and permanent erectile dysfunction. Initial assessment of priapism involves history and physical (penile) examination, assessment of corporal blood flow status by visual inspection (color, consistency) of corporal aspirate, corporal blood gas (pH, PO2, PCO2), or color duplex ultrasound. After adequate penile anesthesia via penile block, aspiration with or without injection of an adrenergic agonist is used initially to induce detumescence. Monitoring of vital signs is recommended in patients with a history of cardiovascular diseases. As in all ischemic compartment conditions, rapid intervention is a necessity. Aspiration + administration of an adrenergic agonist are highly recommended before any surgical treatment. Treatments initiated beyond 72 hours may have benefits in relieving unwanted erection and associated pain, but have little documented benefit in potency preservation. Three possible outcomes can result from the aspiration + adrenergic agonist combination after a reasonable dosage and duration (e.g., 20 mg of diluted phenylephrine over 1 hour): complete resolution, partial resolution, and no resolution. Complete resolution (completely flaccid penis) often occurs in priapisms of less than 24-hour duration, although occasionally it may occur in those of longer duration. In cases of complete resolution, instructions are provided to the patient for management of possible recurrence and follow-up visits. Partial resolution (of less than 75% rigidity with a compressible penis) should be regarded as a borderline situation. When in doubt, color duplex ultrasound can be used to confirm the flow in the cavernous arteries. In such cases, inpatient observation is recommended and interval physical examination of penis and/or interval assessment of cavernosal arterial blood flow status by color duplex ultrasound. Adrenergic agonists may be administered, by intracavernous injection or orally, on an interval basis to maintain detumescence. No resolution (more than 75% rigidity) or recurrent priapism after a transient detumescence is a common outcome in priapisms of more than 24-hour duration, despite repeated adrenergic agonist administration. Absence of cavernous arterial flow can be confirmed with color duplex ultrasound if necessary. This condition is due to interstitial edema as well as smooth muscle and endothelial cell dysfunction. In such cases, the patient should be managed by a percutaneous cavernosum–glans surgical shunt procedure. Adrenergic agonist irrigation Baseline