Case Of Priapism Research Articles

High-flow priapism as a complication of a veno-occlusive priapism: two case reports

The presentation of two cases of veno-occlusive priapism, in patients of 36 and 58 years, in whom the different medical and surgical techniques employed, failed. The suspicion that high-flow priapism had been provoked by said surgical intervention was confirmed by bilateral arteriographs of the pudendal artery. The treatment, selective embolisation of the affected cavernosal artery with reabsorbable material, led to a rapid return of penile detumescence.

Priapism due to sacrococcygeal chordoma metastasis treated with radiation therapy

We are reporting the first case of priapism due to a sacrococcygeal chordoma metastasis treated with radiation therapy as palliative treatment.

38-Year-Old Man With Priapism and a History of Paranoid Schizophrenia

38-Year-Old Man With Priapism and a History of Paranoid Schizophrenia

Priapismo de alto flujo y larga evolución. Presentación de un caso y propuesta de algoritmo diagnóstico y tratamiento

High-flow priapism is an infrequent pathology in Urology, specially long term cases as the one we present. Literature is scarce and both diagnostic methods and treatment have remained unchanged for many yearsWe present a high flow priapism case that has lasted for 30 years, but which is well tolerated and even desired by the “patient”. Furthermore, we propose a new diagnostic algorithm and treatment

Priapismo secundario a reacción leucemoide paraneoplásica en paciente con cáncer de vejiga

Priapism Following Paraneoplastic Leukemoid Reaction In A Patient With Bladder CancerPriapism associated with solid tumours is usually produced by penile metastasis or direct tumour infiltration of the corpora cavernosa. Neoplasias are responsible for between 3-8% of all cases of priapism, and in 80% of cases the primary tumour has a genito-urinary origin.Leukemoid reaction is an haematological disorder characterized by a leukocytosis of over 50000/μl, which develops reactively with different pathological processes such as severe inflammation, disseminated infections, intoxications and tumours.The pathophysiologic mechanism that explains priapism following leukemoid reaction is an intravascular obstruction due to blood hyperviscosity, leading to a blood stasis in the cavernosa veins, and impeding the drainage of the corpora cavernosa.We present a case of priapism in a patient with locally advanced bladder cancer, which was probably the result of blood hyperviscosity produced by a paraneoplastic leukemoid reaction.

Carcinoma transicional y priapismo metastático

Malignant priapism is rare and usually secondary to genitourinary tumors. The prognosis is poor since it generally indicates the presence of multiorgan metastasis.A case of malignant priapism or priapism secondary to penile metastasis from transitional carcinoma is presented and the literature is reviewed.

Novel Technique in the Management of Low Flow Priapism

Priapism is a urological emergency that requires prompt attention. Most cases of priapism are categorized as “low flow” (LF), and if detumescence is successful within 12 hours potency is often preserved. However, after 24 hours widespread cellular damage and fibrosis occur, and future erections are often not possible.1 A low threshold for invasive management should be adhered to. We describe a technique of corporeal irrigations that may obviate the need for more invasive shunts. CASE REPORT A 39-year-old black man presented emergently for the third time within 2 months with a diagnosis of priapism. He had previously undergone successful saline irrigations and -agonist injection therapy. Unlike his previous visits, he had waited approximately 40 hours before presenting for evaluation. The patient had a history of paranoid schizophrenia requiring risperidone, and recreational cocaine and marijuana use. On examination he was in mild distress with a painful erect penis and palpable fibrosis. The glans was soft and there was no evidence of perineal trauma. Laboratory values were within normal limits, including a hematocrit of 41%. While preparing for corporeal irrigations, the patient was placed on oxygen and given oral pseudoephedrine and terbutaline, and had an ice pack applied to the genitalia. The blood gas from the penis was pH 6.68, oxygen pressure 9 and carbon dioxide pressure 144. Without improvement after these conservative measures saline irrigations using an 18 gauge needle inserted at the base of the penis were started. Approximately 300 cc dark blood was removed. Phenylephrine was also injected at a dose of 200 g/cc. Unsustained detumescence was observed, so a Winter shunt was performed at the bedside. A transient period of detumescence occurred for several hours but on the following day the penis was again painfully erect. At that time 1 gm intravenous cefazolin was administered, and 18 gauge needles were inserted into each corpus cavernosum in the perineum and distally through the glans into the corpora cavernosa a technique previously described by Jarow 2 (fig. 1). Saline was injected proximally and removed distally through each needle. After 60 cc irrigation there was prompt detumescence. After 24 hours of observation the patient maintained a flaccid, fibrotic state (fig. 2). He was discharged home with an oral antibiotic, and at followup 6 months later he was impotent. DISCUSSION Priapism has an incidence of 1.5 per 100,000 and can be caused by either LF or “high flow” state.3 Corporeal irrigations with saline and -agonist therapy can successfully manage most episodes of LF priapism. However, management of this disease process can be frustrating, leading to invasive distal and more invasive proximal shunt procedures. In our experience some patients who present with painful priapism, especially those who wait more than 24 hours before treatment, can be difficult to treat even with a distal shunt procedure. We hypothesize that these patients are incompletely irrigated. More specifically, the distal corpus cavernosum is irrigated well from the base of penis to the glans but not from the base of the penis down to the perineum. Using our technique, we believe the entire corpus cavernosum can be irrigated with saline. It has been reported that risperidone and drug use can cause LF priapism. 1, 4 We instructed the patient at multiple visits to discontinue these agents but he refused. We also investigated the possibility of sickle cell disease. However, the hemoglobin electrophoresis was negative. We recommend using intravenous antibiotics in preparation for this procedure to decrease the chances of perineal wound infections, especially in those who have diabetes. Moreover, we believe this technique should be performed when the more traditional distal irrigations fail and before any shunt procedures.

Tricorporal priapism in a patient with metastatic esophageal cancer

Tricorporal priapism refers to priapism involving the corpora cavernosa and spongiosum. It is exceedingly rare and, depending on the etiology, may be difficult or impossible to treat. We present a case of tricorporal priapism in a patient with metastatic esophageal cancer and complete thrombosis of all venous vasculature below the level of the renal veins. Ultimate management consisted of comfort measures and minimizing the risk of infection. In this case of tricorporal ischemic priapism, the recognized treatment options for ischemic priapism were not applicable, because no viable shunt targets were available. The treating urologist should be aware of this potential clinical entity and be prepared to offer conservative management.

Priapisme et infection pulmonaire chez l’enfant

Priapism is a rare urologic emergency in pediatric population. It is usually a consequence of sickle cell disease. Leukemia is another important cause of priapism in children. We present a case of priapism associated with an acute pulmonary infection. To our knowledge, this is the second case describing this association. In the other reported case, pulmonary infection was related to Mycoplasma Pneumoniae. The hypothesis is that infection with Mycoplasma Pneumoniae can produce a hypercoagulable state, especially in selected areas of the circulation.

Priapism Secondary To Hypertriglyceridemia

Various etiologies of priapism have been described, including sickle-cell disease, cocaine abuse, hematological malignancies, penile metastases, trauma, intracavernous injection therapy for erectile dysfunction and oral medications. Nevertheless, many cases of priapism are classified as idiopathic. We report a case of priapism secondary to hypertriglyceridemia, and recommend screening patients with a serum lipid profile if an obvious etiology cannot be identified. CASE REPORT A 33-year-old black male with diet controlled diabetes mellitus presented with a painful erection 18 hours in duration. The patient had woken in the morning with an erection unrelated to sexual stimulation. He denied a history of sickle cell anemia, cocaine abuse or penile trauma, and he was not taking any medications. The patient reported occasional marijuana and heavy alcohol use. He described a previous episode of priapism approximately 3 months prior that had lasted 8 hours but resolved without intervention. Physical examination confirmed classic low flow priapism that was extremely tender to palpation. Laboratory evaluation revealed a serum white blood count of 10.8 10 9 /l., hematocrit 42.4% and platelet count 248 10 9 /l., all of which were within normal limits. A sickle cell screening panel was negative. Blood glucose level was 109 mg./dl. (normal 65 to 110) and serum creatinine 1.3 mg./dl. (0.7 to 1.4). Urine toxicology screen was positive only for cannabinoids. It is noteworthy that during the blood collection process the phlebotomist observed a thick white layer on top of the blood drawn in the chemistry tube. This finding prompted measurement of serum triglyceride, which was increased to 2,041 mg./dl. (normal 40 to 160). Liver function tests were within normal limits. Corporeal blood gas demonstrated a pH of 6.95, partial carbon dioxide pressure 93 mm. Hg and partial oxygen pressure 16 mm. Hg. The patient was treated with multiple intracavernous injections of 250 to 500 g. phenylephrine, cavernous aspiration and cavernous irrigation with saline. Aspiration of corporeal blood showed a fatty layering similar to that seen in the blood collection tube. Complete detumescence was achieved with these treatments. Endocrinology consultation for evaluation of hypertriglyceridemia was obtained, and treatment was started with gemfibrozil. Serum lipid profile was obtained the next day, and revealed total cholesterol 393 mg./dl. (normal 80 to 220), high density lipoprotein 41.6 mg./dl. (35.0 to 68.0) and repeat triglyceride level 856 mg./dl. (40 to 160). DISCUSSION Previous reports have described an association of priapism with total parenteral nutrition.1, 2 It is hypothesized that the lipid emulsion is the precipitating factor. To our knowledge this case of priapism secondary to hypertriglyceridemia unrelated to total parenteral nutrition represents the first such case reported in the English literature. Hypertriglyceridemia may cause sludging of blood, hypercoagulability and fat embolus leading to venous outlet obstruction of the corpora cavernosa. Investigators have demonstrated distortion of erythrocyte morphology, increased erythrocyte aggregation and adhesiveness, and decreased capillary flow associated with the intravenous infusion of fat.3 Our patient presented with a serum triglyceride level more than 12 times the upper limit of normal. It was postulated that the hypertriglyceridemia was related to pancreatic insufficiency secondary to alcohol abuse, although the patient might have had an undiagnosed familial disease. Urine toxicology screen confirmed the use of marijuana but we do not believe that marijuana use is an etiological factor in priapism. In addition, we are unaware of any case reports associating marijuana with priapism. Since many cases of priapism have an unidentifiable etiology, we believe a serum lipid profile screen is indicated in the diagnostic evaluation. REFERENCES

Management of priapism in the newborn

We report a case of priapism in a newborn and the results of a review of the publications on neonatal priapism. A preterm newborn developed idiopathic priapism on the first day after birth. The priapism disappeared after 4 days of observation. Periods with normal penile erection were reported at follow-up after 20 months. The results of the literature review also advocate management by observation alone.

Priapism Associated with Hemoglobin C Trait

Priapism constitutes a urological emergency in which alterations to the normal physiological process leading to penile erection result in a prolonged painful erection. One hemoglobinopathy, sickle cell anemia, is linked with priapism in 11% of cases.1 Hemoglobin C is an abnormal hemoglobin distinct from hemoglobin S, which is found in sickle cell disorders. Hemoglobin C disease occurs in patients who are homozygous for the gene, while hemoglobin C trait occurs those who are heterozygous for the hemoglobin C gene. Hemoglobin C trait is uncommon and there is a paucity of literature regarding clinical findings in patients with this blood dyscrasia. We report a case of priapism associated with hemoglobin C trait.

PRIAPISM IN A 15-YEAR-OLD BOY WITH CONGENITAL DYSERYTHROPOIETIC ANEMIA TYPE II (HEREDITARY ERYTHROBLASTIC MULTINUCLEARITY WITH POSITIVE ACIDIFIED SERUM LYSIS TEST)

Congenital dyserythropoietic anemia encompasses a group of related disorders characterized by ineffective erythropoiesis, bone marrow erythroblastic multinuclearity and secondary hemochromatosis. Type II, the most common variation, is called hereditary erythroblastic multinuclearity with positive acidified serum lysis test (HEMPAS). To our knowledge this is the first reported case of priapism associated with HEMPAS.

Efficacy of exchange blood transfusion in the management of priapism in patients with sickle cell disease in northeast Nigeria

Background: Thirteen cases of priapism seen in adult patients with sickle cell disease (SCD) were treated by exchange blood transfusion (EBT) at the University of Maiduguri Teaching Hospital during a five-year period (1996-2000). Each patient was scheduled to receive a total of 12-unit exchange, but due to voluntary donor blood scarcity and differences in affordability of commercial donors only 1 (7.7%) patient could receive 10 units, 3 (23.1%) patients had 8 units each, and 9 (69.2%) patients received 7 units each. Method: EBT was carried out manually in all cases and the mean number of units exchanged, the mean levels of Hb S and the mean levels of haematocrit were determined before the start of EBT (pre-EBT) and at the time of achieving complete detumescence. Result: The exchange procedures were started with mean pre- EBT levels of 95% of Hb S and 0.24L/L of haematocrit; complete detumescence was achieved in all cases after an average of 6 units were exchanged by which time the mean Hb S level had fallen to 50.3% and the haematocrit had risen to a mean level of 0.28L/L. Conclusion: EBT was successful in achieving complete detumescence and at much higher Hb S level (50.3%) than was earlier recommended. EBT is therefore effective in treating priapism in SCD and should be offered to such patients in order to avoid surgery, the risks of general anaesthesia in SCD and the possibility of postoperative impotence. Keywords: Sickle cell disease, Priapism, Exchange blood transfusion. Nig. J. of Surgical Research Vol.4(1-2) 2002: 22-27

Arterial priapism and cycling: a new worrisome reality?

Arterial priapism is a rare condition caused by the traumatic formation of an arteriolacunar fistula. We report 2 cases of arterial priapism after cycling injuries. Both patients sustained a violent perineal trauma against the top tube on the bicycle. In both cases, penile detumescence was obtained by superselective arteriographic embolization of the fistula with gelatin sponge or microcoil. The fistula was monolateral in the first case and bilateral in the second. Cycling should be considered a possible risk factor for arterial priapism as it is for urethritis, prostatitis, hematuria, testicular torsion, scrotal and penile numbness, and erectile dysfunction.

Priapism from quetiapine overdose: first report and proposal of mechanism

We report a case of priapism occurring after an overdose of the newly approved atypical antipsychotic quetiapine. A review of its previously published receptor-binding studies suggests that alpha-adrenergic blockade may be the responsible mechanism. To our knowledge, this is the first report of priapism associated with quetiapine, and we recommend the inclusion of priapism in its list of potential adverse effects in cases of overdose.

Priapism Associated With Conventional and Atypical Antipsychotic Medications

Priapism is a prolonged, usually painful, and persistent penile erection not usually associated with sexual stimuli, resulting from a disturbance in the normal regulatory mechanisms that initiate and maintain penile flaccidity. This infrequent adverse event of antipsychotic medication use requires emergency evaluation and has potentially serious long-term sequelae including erectile dysfunction. Clinicians prescribing antipsychotic medications should be aware of this rare but serious adverse event. A computerized search, using the MEDLINE database (1966-summer 2000), located cases of priapism associated with most conventional antipsychotics as well as with clozapine, risperidone, and olanzapine. The search included no restrictions on languages. Keywords included priapism combined with antipsychotic agents and the names of the currently available atypical antipsychotics. Twenty-nine publications were located using these parameters. Additional publications were reviewed for general background on pathophysiology, evaluation, and management. The quality of the evidence reviewed is limited by the observational and uncontrolled nature of case reports, case series. and review articles. Psychotropic-induced priapism is currently believed to be caused by the alpha1-adrenergic antagonism of these medications. Detumescence is sympathetically mediated, and alpha1-adrenergic antagonism (within the corpora cavernosa) inhibits detumescence. The propensity of individual antipsychotics to induce priapism can presumably be estimated on the basis of alpha1adrenergic blockade affinities. Of the conventional antipsychotics, chlorpromazine and thioridazine have the greatest alpha1-adrenergic affinity and have been most frequently reported to be associated with priapism. Of the atypical antipsychotics, risperidone has greater alpha1-adrenergic affinity, although 3 of the 5 currently U.S. Food and Drug Administration (FDA)-approved atypicals have been reported to be associated with priapism. Virtually all antipsychotic medications have been reported to rarely cause priapism due to their alpha-adrenergic antagonism. This adverse event should be considered a urologic emergency. Clinicians should be familiar with this infrequent serious adverse event of antipsychotic medications.

THE PREDICTION OF PAPAVERINE INDUCED PRIAPISM BY COLOR DOPPLER SONOGRAPHY

We identified color Doppler sonography findings that are useful for predicting priapism in patients after the intracavernous injection of diagnostic papaverine. We evaluated 72 men with erectile dysfunction by color Doppler sonography after the diagnostic injection of papaverine. Cavernous artery waveforms were recorded, and peak systolic and diastolic velocity of the recorded waveforms was measured. In cases of priapism color Doppler sonography findings were retrospectively evaluated to identify any finding that would predict priapism. Priapism was observed in 8 of the 72 patients (11.1%). In 6 of 8 priapism cases there was no blood flow in the cavernous artery during or after adequate erection, including after minutes 5, 10 and 20 in 3, 1 and 2, respectively. This absence of encoding was not relieved even after all stimuli were removed. In 2 patients who later presented with complaints of priapism the Doppler study was completed normally and all parameters were acquired without any cessation of blood flow in the cavernous artery. The persistent disappearance of color and pulse encoding in the cavernous artery predicted priapism with 75% sensitivity, 100% specificity, a positive and negative predictive value of 100% and 96.9%, respectively, and 97% accuracy. The persistence of absent blood flow in the cavernous artery even after the elimination of all stimuli during penile color Doppler ultrasound is a reliable predictor of priapism. The finding is accurate enough to initiate treatment for priapism to avoid further delay.

The Incidence of Pharmacologically Induced Priapism in the Diagnostic and Therapeutic Management of 685 Men with Erectile Dysfunction

Objective: To evaluate the incidence of pharmacologically induced priapism in the diagnostic and therapeutic management of erectile dysfunction. Patients and Methods: Over a period of 7 years, 685 men were investigated for erectile failure. They underwent a simple test with vaso-active drugs, and the nonresponders were further investigated. Eventually, 83 men began autoinjections and 45 still continue. Results: Eight (1.2%) cases of priapism presented during the simple test with vaso-active drugs in these patients, while none occurred during self-injection treatment. Three were prolonged erections induced by prostaglandin E₁ (PGE₁) and 5 by papaverine (Pap). Six were treated safely with intracavernosal injection of etilephrine without blood aspiration. Conclusion: Priapism is always a potential phenomenon where no individual, no particular drug and no specific dose are completely safe. It may be caused even with 5 µg of PGE₁ or 7.5 mg of Pap. Auto-injection therapy however is a safe kind of treatment in well-experienced patients. Careful regulation of the doses and practice in the use of vaso-active drugs may reduce the priapism rate.

Traitement chirurgical du priapisme par la ponction-drainage balanique à «ciel ouvert » sur 26 patients de race noire

The surgical treatment of the priapism is complex and requires various techniques for diversion of the corpora cavernosa with significant morbidity. For the last 15 years, the author have been using a simple transglandular cavernosal spongiosum shunt technique, which satisfies the requirements of functional surgery: restoration of anatomy, reduced morbidity, facility to learn. This article is intended to precisely describe the surgical technique and to present the results based on a personal series of 26 cases of priapism operated with this technique in black patients (19 adults and seven children) in the context of sickle-cell anaemia.