Arterial Priapism Research Articles

Diagnosis and X-ray endovascular methods of treatment of arterial priapism in children

Diagnosis and X-ray endovascular methods of treatment of arterial priapism in children

Эмболизация артериокавернозной фистулы при артериальном приапизме: клинический случай

Arterial priapism occurs much less frequently than venous (non-ischemic, low-flow) priapism. Considering the absence of ischemia of the cavernous bodies in arterial priapism, emergency surgical intervention is usually not indicated, and a wait-and-see approach is acceptable. In the absence of spontaneous resolution of arterial priapism, invasive treatment may be performed upon the patient’s desire. Currently, the method of choice is super-selective embolization of branches of the internal pudendal, cavernous, or helical artery. This article presents a clinical case of arterial priapism, in which super-selective embolization of the cavernous artery with PVA (polyvinyl alcohol) embolization agent was performed, resulting in complete resolution of priapism after the operation.

Posttraumatic Arterial Priapism Treated with Superselective Embolization: Our Clinical Experience and a Review of the Literature.

To present 12 cases of arterial priapism treated by superselective embolization and propose our management algorithm for this condition. Between February 2013 and May 2018, 12 cases of arterial priapism caused by blunt trauma were treated by superselective embolization. The mean age of patients was 36years (25-47years). All of the patients had normal sexual capability before priapism (IIEF-5 scores 24-25). All patients were treated with superselective embolization after more than 3weeks of simple conservative treatment had failed. All cases but one used a gelatin sponge as embolic agent. A microcoil was added in one case in which the gelatin sponge failed to occlude the pseudoaneurysm. After superselective embolization, ice pack and "observation" treatments continued. The sexual capability of the patients was evaluated by IIEF-5 scores at 6months and 12months postoperatively. The mean follow-up period was 27.2months (13-48months). Three patients achieved complete detumescence immediately. Nine cases needed 2-17days to return to a flaccid nonpainful state. No patient underwent a second embolization. The time needed to improve erectile function was from 7days to 4months. There has been no recurrence. Eleven patients treated with gelatin sponge have normal erectile function, while one patient treated with additional microcoil embolization had mild erectile dysfunction. Superselective embolization of the fistula is an effective option for arterial priapism. Absorbable agents should be used. Superselective arterial embolization should be considered after 3weeks of conservative treatment. Patients should undergo another 3weeks of "observation" treatment before repeated intervention.

Cycling Trauma as a Cause of Arterial Priapism in Children and Teenagers.

Bicycle riding has multiple beneficial cardiovascular effects; however, it is a well-documented source of significant urologic injuries. Priapism is a rare condition in children, and occurs primarily because of congenital hematologic diseases or adverse drug reactions. A pediatric clinical case and literature review of a high-flow priapism secondary to cycling trauma is described here to highlight their etiopathologic correlation. Bicycle riding trauma is a rare but possible cause of high-flow priapism in children, and a high index of suspicion should ensure appropriate management.

217 Posttraumatic Arterial Priapism Treated With Superselective Embolization: Our Clinical Experience

We presented five cases of arterial priapism treated by superselective embolization and evaluate erectile function at a long-term follow up. Between Feb 2011 and May 2014, five cases of arterial priapism caused by perineal or penile blunt trauma were treated by superselective embolization. The mean age of patients was 35 years (25–47 years). All patients underwent a series of examinations. All of the five patients had normal sexual capabilities before priapism (IIEF-5 scores of 24-25). All patients had failed with simple conservative treatments which lasting more than 3 weeks (21-30 days). All patients treated with superselective embolization. All cases but one used gelatin sponge as embolic agent. One case the gelatin sponge failed to occlude the pseudoaneurysm, and then micro-coil was added. After superselective embolization, ice pack and 'observation' treatments continued. Sexual capabilities of the patients were evaluated by IIEF-5 scores at 6 months and 12 months postoperatively.

Nonischemic Priapism Following Penile Tattooing

To our knowledge, here we report the first case of nonischemic priapism following penile tattooing. To report the first case of nonischemic priapism following penile tattooing. A case with tattooing-induced priapism is presented including subjective reporting, physical examination, and laboratory/radiologic evaluations. A 21-year-old man, presented with partially rigid penis of 3-month duration. On examination, the penis was half rigid, with a tattoo on its dorsal surface, and a smaller tattoo on the glans (Figure 1). The patient initially stated that the tattoo had been created years ago, but later admitted that he had it created just before the occurrence of priapism. A traditional tattooist created the tattoo manually, using a handheld needle. Bleeding from deep penile tissue for several days complicated the tattooing. Known etiologies of priapism were investigated and ruled out. Specifically, perineal injury, leukemia, sickle cell trait, thalassemia, urinary tract infection, neurogenic, neoplastic, infectious, toxic, and pharmacological causes were actively investigated and ruled out. There was no history of alcohol consumption or smoking. Aspirated penile blood was bright red. Cavernous blood gas measurements confirmed high oxygen and low carbon dioxide content, diagnostic of arterial priapism. There was no embolization facility in Kermanshah. In fact, there are few experts in superselective embolization in Iran. We referred the patient for superselective embolization. However, he underwent a nonindicated Sacher procedure. Predictably, the procedure was unsuccessful. At present, the patient continues to have priapism. Because of the painless nature of erections, moderately good preservation of erectile function during intercourses, and disappointment with former surgery, the patient declined further therapies, and he lives with his condition. Tattooing should be added to the etiologies of nonischemic priapism. Considering this case, we discourage penile tattooing.

Evaluation and management of priapism in a newborn: A case report and review of the literature

Idiopathic neonatal priapism is a rare and poorly understood phenomenon. The case of an otherwise healthy premature male newborn who was noted to have a persistent penile erection on the first day of life is presented. A Doppler ultrasound of the penis was performed, along with the first-ever cavernous blood gas analysis reported in a newborn. These investigations indicated that the presentation was consistent with nonischemic (arterial or high-flow) priapism. The patient was managed conservatively and the erection resolved fully on the sixth day of life. A review of the existing literature identified polycythemia as the most common identifiable cause of priapism in newborns, but the majority of cases are idiopathic. In most instances, observation alone is appropriate and spontaneous detumescence occurs. There are no published reports of erectile impairment following neonatal priapism, which suggests that this condition is relatively benign in the absence of other disease states.

Use of Magnetic Resonance Angiography in Diagnosis and Decision Making of Post-Traumatic, High-Flow Priapism

The ideal imaging modality should demonstrate the presence or absence of a clinically significant, causative vascular lesion that, in high-flow arterial priapism, may need intervention. We report a 22-year-old male with post-traumatic arterial priapism. Color Doppler ultrasound could not reliably identify a significant vascular lesion. Magnetic resonance angiography (MRA) demonstrated the presence of a cavernous artery pseudoaneurysm. Based on this finding, embolization was decided, with a successful outcome. Contrast-enhanced MRA appears to be a useful, noninvasive diagnostic tool for decision making in cases of high-flow priapism.

Posttraumatic Nonischemic Priapism Treated with Autologous Blood Clot Embolization

High-flow arterial priapism is rare and characterized by a prolonged nonpainful erection. Autologous clot embolization allows complete resolution of the problem in most of the cases. To review our experience with superselective transcatheter embolization in the treatment of nonischemic priapism. Advances in the understanding of the nonischemic priapism with the aid of newer techniques have altered the current management of nonischemic priapism. Between 2002 and 2006, 11 patients underwent superselective transcatheter embolization of nonischemic priapism with blunt trauma to the penis or perineum. All patients underwent diagnostic evaluation with color-flow Doppler ultrasound and superselective pudendal arteriography, revealing bilateral arteriocorporal fistula and pseudoaneurysm in two cases, bilateral arteriocorporal fistula in one case, unilateral arteriocorporal fistula in one case, and unilateral arteriocorporal fistula and pseudoaneurysm in seven cases. Autologous blood clot was used as an embolization agent in all cases combined with microcatheter guidance. The procedure was technically successful in all cases. In three (27.2%) cases, a second embolization was required due to recurrence of priapism. In all patients, erectile function was restored within 6 weeks of the procedure. Follow-ups at 6 and 12 months after the last procedure revealed that full erectile capacity was restored in 10 of 11 patients, and these patients did not experience further recurrence of priapism. One patient reported a slight decrease in the quality of his penile erection. Our experience revealed that superselective transcatheter embolization and transient occlusion of the fistula with autologous blood clot is an effective therapy for the treatment of nonischemic priapism. Furthermore, recovery of erectile function due to recanalization of the occluded vessel occurred weeks after the procedure.

The Use of Transcatheter Superselective Embolization to Treat High Flow Priapism (Arteriocavernosal Fistula) Caused by Straddle Injury

A28-year-old white male presented with persistent partial erections after an industrial straddle injury 5 months earlier. Immediately following the injury the patient experienced moderate perineal and penile pain with extensive bruising and a small laceration on the perineum. There was no evidence of urethral bleeding at the time of injury. The pain eventually subsided but the patient experienced chronic unwanted erections that were approximately 30% to 40% of full rigidity. The patient was unable to achieve an erection adequate for sexual penetration despite a normal libido. He reported no nocturnal erectile activity or urinary complaints. The patient had a supportive spouse. Otherwise all medical history was noncontributory. The patient was a well developed male with a moderate degree of anxiety. Genitourinary examination revealed moderate rigidity and slight tenderness along the left corporal body with a soft glans. The remaining physical examination was unremarkable. Results from the penile color duplex Doppler ultrasound study revealed 60 cm per second inflow in the left cavernosal artery with a corresponding 24 cm per second venous outflow. There was approximately 80% tumescence with 40% rigidity of the penis during the study. Based on history and Doppler study, diagnosis was left high flow priapism with a venous leakage component, and a pudendal arteriogram with possible embolization was scheduled. Superselective injection of the deep penile artery showed a deep penile arteriocavernosal fistula (part A of figure, arrow) causing massive opacification of the corporum cavernosum (part A of figure, arrowhead). To protect the glans penis against inadvertent embolization which could cause loss of sensitivity, a 0.014 platinum guide wire was temporarily placed into the dorsal penile artery (part B of figure, arrow) through a double lumen catheter while embolizing the fistula through the microcatheter advanced through the second lumen. Following superselective embolization of the fistula with AMICAR® enforced autologous blood clot, salutary occlusion of the fistula with no further opacification of the corpora was observed (part C of figure). Upon successful occlusion the penis became soft and rapidly collapsed. High flow priapism is a rare form that occurs with unregulated inflow of arterial blood into the corpora through an arteriocavernosal fistula, and is usually preceded by some form of perineal or penile trauma. Because there is perfusion of well oxygenated blood, high flow priapism (arterial priapism) is nonpainful, nonischemic and not an acute urological emergency. Thus, there is time for initial pharmacological therapeutic modalities. For high flow priapism refractory to this conservative management, radiological transcatheter superselective embolization has become the treatment of choice. 1 Selective embolization can be conducted using a variety of agents including autologous blood clot, metallic microcoils, gel foam and N-butyl cyanoacrylate. 2 Although there is a paucity of data, current theory suggests that embolization should be done with temporary occlusive agents to prevent irreversible changes in erectile function. Thus, autologous blood clots have become the mainstay of treatment for high flow priapism, with long-term followup rates of resolution at 100% and restoration of erectile function at 86%. 3

Post traumatic prepubertal high-flow priapism: a rare occurrence

High-flow or arterial priapism is an uncommon condition resulting from perineal or penile trauma. The classical features are a painless erection of the cavernous bodies while the corpus spongiosum stays flaccid. This case highlights a 11-year-old boy who presented with painless semi rigid erection of 3 days duration following a blunt skateboard injury to his perineum. Following failed conservative treatment, the patient underwent bilateral internal pudendal angiography with localization and embolization. Follow up in 1 month showed patient to have normal nocturnal and reflexogenic erections. Medical and surgical treatments for high-flow priapism have been described in literature with varying degree of success and complications. The current accepted standard of care is pelvic angiography and super-selective embolization of internal pudendal artery.

The modern approach to high-flow priapism

Priapism is defined as persistent unwanted erection that is not associated with sexual desire or sexual stimulation. Low-flow, high-flow, and stuttering priapism are the three types of priapism. High-flow priapism (arterial priapism) is a rare condition resulting from penile or perineal trauma leading to consistent painless semi-erection. Clinical evaluation of high-flow priapism is based on medical history, blood gas analysis of the cavernous blood, color Doppler ultrasonography, and arteriography. Several treatment options have been used for this rare entity. Surgical and conservative management strategies had been used in the past with controversial results. The modern approach to treatment of high-flow priapism is selective and/or supraselective embolization of the arteriocavernous fistula combined with angiography and color Doppler ultrasonography. This approach is the first line and gold standard in treatment of high-flow priapism.

Evaluation of patients after treatment of arterial priapism with selective micro-embolization

Arterial (high-flow) priapism is characterized by a prolonged non-painful erection without sexual arousal as a result of unregulated inflow of blood to the corpus cavernosum. Treatment is based on decreasing this elevated inflow, primarily by means of selective arteriography and embolization. The aim of this study was to evaluate the treatment of patients with arterial priapism. In the period between 1990 and 2004, 10 patients with arterial priapism were admitted to our department. The mean age when priapism developed was 32 years (range 11-62 years). Eight patients were treated with selective embolization, one was operated on and one refused treatment. Nine patients completed a standardized questionnaire which included the International Index of Erectile Function (IIEF-5). The mean follow-up time after treatment was 70 months. All patients treated with selective embolization achieved reduced tumescence. Six out of eight patients had an improved IIEF-5 score after treatment. In nine men, the etiology of the arterial priapism was perineal trauma. In one case, an anomaly with an accessory artery to the corpus cavernosum was diagnosed, which required surgery, and in one case recurrence of the priapism necessitated a second embolization. Selective embolization results in reduced tumescence and an improvement in erectile function in patients with arterial priapism. Trauma to the perineum was the main etiology in this study.

Management strategy for arterial priapism: therapeutic dilemmas.

We present 7 cases of arterial high flow priapism and propose management algorithms for the condition. We studied 2 children and 5 adults with posttraumatic arterial priapism. Blood gas analysis and color Doppler ultrasonography of the corpora cavernosa confirmed the diagnosis in 4 adults, while 1 patient had already undergone cavernous artery ligation in elsewhere. In the children perineal compression resulted in detumescence, a sign that is proposed to be indicative of the diagnosis of arterial priapism (piesis sign) complementing physical examination. Mechanical compressive force was applied to the perineum of 1 boy, while the other received a watchful waiting program. All adults participated in an observation regimen except 1, who decided to undergo immediate embolization of the internal pudendal artery. Perineal compression led to the resolution of priapism in 1 child, while spontaneous resolution was noted in the other. An adult noticed spontaneous penile detumescence 3 to 4 months after trauma, which was attributable to site specific venous leakage and decreased, inflow in the contralateral cavernous artery. The patient underwent venous surgery and is on an intracavernous injection regimen. Successful embolization of the internal pudendal artery was performed immediately in 1 man and in the other 4 months after trauma due to social inconvenience. Adult patient 3 is still on the watchful waiting protocol (42 months), while the one who underwent cavernous artery ligation is receiving treatment for erectile dysfunction. Absent of long-term damaging effects of arterial priapism on erectile tissue combined with the possibility of spontaneous resolution or progressive concomitant hemodynamic abnormalities associated with blunt perineal trauma are suggestive of the introduction of an observation period in the management algorithm of high flow priapism. Such a period may help avoid unnecessary intervention and determine the impact of priapism on patient personal life. Perineal compression may be also added as part of the physical examination as a sign specifically indicative of arterial priapism.

Is the combination of superselective transcatheter autologous clot embolization and duplex sonography-guided compression therapy useful treatment option for the patients with high-flow priapism?

The aim of this study was to report feasibility, benefit and complications of superselective transcatheter autologous clot embolizations and duplex sonography-guided compression therapy in four patients with delayed post-traumatic high-flow priapism. Medical records of four consecutive patients diagnosed with delayed post-traumatic high-flow priapism (arterial priapism) were reviewed. High-flow priapism occurred mean 41.8 (6-92) h after the trauma developed. The patients were presented to hospital mean 8.3 (5-15) days after priapism occurred. The patients were assessed by penile color flow Doppler sonography. After the pathologically increased, arterial flow or arteriocavernosal fistula was seen, combination therapy with superselective transcatheter autologous clot embolizations and duplex sonography-guided compression was performed. If complete detumescence could not be achieved, this therapy was applied in the following day. In patients who had resistance to the second embolization, superselective embolization with microcoil was performed. Follow-up included penile color flow Doppler sonography at the following day, 1 month and 3 months after the procedure. International Impotence Symptoms Score (IIEF) was obtained during the follow-up. The treatment was successful in one, partially successful in one and not successful in two of the four patients. This therapy was reperformed to the latter three patients. After the treatment, high-flow priapism disappeared in one of the three patients and embolization with methalic microcoil was needed to perform to the other two patients. At 1 day after the treatment, color flow Doppler sonography and physical examinations were normal in all four patients. In the 1st and 3rd months of the follow-up, color flow Doppler sonography and the NPT tests were normal in three of the four patients. Slight erectile dysfunction was detected in one patient. Combination of superselective transcatheter autologous clot embolizations and duplex sonography-guided compression therapy may be considered as one of the first-line treatment options in adult patients with delayed post-traumatic high-flow priapism.

Manejo diagnóstico y terapéutico del priapismo: nuestra experiencia

Introduction The aim of this article was to determine the prevalence and management of ischemic and arterial priapism in our center (Fundació Puigvert). Methods We retrospectively evaluated the charts of 69 patients (mean age: 56.3 ± 4.5 years, range: 22-75 years) who attended our emergency room complaining of erection for more than 4 hours between January 1998 and December 2001. Results Sixty-five patients were diagnosed with ischemic priapism (mean duration: 7.19 ± 1.52 hours; range: 4-48). Sixty-four had previously undergone intracavernosal injection with vasoactive drugs as diagnosis or treatment for erectile dysfunction. One patient was diagnosed with malignant priapism (with bowel adenocarcinoma as the primary tumour). The therapeutic management of ischemic priapisms consisted of simple cavernosal aspiration (6 patients), aspiration plus irrigation with saline solution (22 patients) and aspiration plus irrigation with saline solution and irrigation with etilefrine solution (36 patients). Four patients were diagnosed with non-ischemic or arterial priapism. Of these, two had a history of perineal trauma while riding mountain bikes. One experienced complete detumescence with symptomatic treatment (ice, local compression, analgesics) and the other three patients were successfully treated with embolization with titanium coils. Discussion All patients who attended the emergency room and received a diagnosis of ischemic priapism had previously undergone either diagnostic or therapeutic intracavernosal injection with vasoactive drugs for erectile dysfunction. Other causes of ischemic priapism such as the use of cocaine, trazodone or hemoglobin disorders or idiopathic causes were not frequent in our center. Management of arterial priapisms through embolization of arteriolacunar fistula was effective and produced no complications.

The surgical management of priapism

Priapism is defined as a pathologic condition in which penile erection persists beyond, or is unrelated to, sexual stimulation. Despite advances in the knowledge of erectile pathophysiology, priapism remains a diagnostic and therapeutic enigma. Cavernosal blood gas analysis and color Doppler ultrasonography aid in the differentiation between arterial and ischemic types. Aspiration therapy, shunt surgery, and implant surgery should be used to effect detumescence and preserve long-term sexual function in ischemic priapism. Internal pudendal angiography with selective embolization should be used to diagnose and treat arterial priapism.

Priapismo arterial de alto flujo secundario a fístula arterio-cavernosa bilateral post-traumática. embolización supraselectiva con coágulo autólogo

High-Flow Arterial Priapism For Postraumatic Bilateral Arterial-Cavernous Fistula. Highly Selective Embolization Using Autologous Blood ClotHigh flow arterial priapism is rare and characterized to a prolonged non-painful partial erection. Arteriocavernous fistula, rarely bilateral, is associated with penile or perineal trauma (genitoperineal area). Review of the literature, in only eleven cases this fistula is bilateral. Diferents treatments with non common norm has been used. We report a case of a 27 years old male who presented high folw priapism secondary to bilateral postraumatic arterio-cavernous fistula. Autologous blood clot was used for fistulas embolization to minimize the risk of impotence in this young patient. No complications was registered. Eight months later the patient had normal erectile function and no fistula was detected on ultrasonography doppler. We consider arteriography with highly selective embolization using reabsorbable agents obtains the best results, the least risks and complications in this process.

Resolución de un caso de priapismo arterial secundario a fístula arteriocavernosa bilateral mediante embolización selectiva con material reabsorbible

Priapism is defined as persistent erection without sexual stimulus. The new classifications make a distinction between venooclusive low flow priapism, isquemic and arterial high flow priapism, non isquemic. The perineal or penis trauma are responsible the most of cases arterial priapism, formation of an arteriocavernous fistula. The diagnosis is clinical, blood gas analysis and colour Doppler ultrasonography of the corpora cavernosa confirmed the diagnosis. The arteriography with selective embolization constitutes a safe and effective therapeutic method.We report one case of arterial priapism secondary to bilateral arteriocavernous fistula resolved with selective embolization using reabsorbible material.

Priapism of the Glans and Corpus Spongiosum. Report of two cases with angiography

Priapism, whether of the arterial or veno-occlusive type, mainly affects the cavernous bodies, leaving the low-pressure system in glans and corpus spongiosum soft without urethral compression. In the present 2 case reports, the pathologically increased pressure primarily affected the corpus spongiosum. One had arterial priapism following penile revascularization and the other veno-occlusive priapism due to thrombosis of the internal pelvic veins. Both had ulcerations of the glans and urinary retention requiring suprapubic catheterization. Arteriography revealed the disease mechanism in both, and led to embolization in 1.