Cavernosal Blood Research Articles

Veno-occlusive Priapism, An Undesirable Outcome of Warfarin Therapy: A Case Report

Background: Priapism is one of the urological emergencies requiring prompt medical or surgical intervention. The clinical diagnosis is made with adjunct cavernosal blood gas analysis and colour doppler ultrasound to determine the underlying aetiology; ischaemic or non-ischaemic, and the majority are veno-occlusive in origin (ischaemic). The occurrence of warfarin-induced priapism complicated with penile necrosis is a rare occurrence, and many cases are related to protein C deficiency. Case Presentation: We report a case of warfarin therapy initiation following a thromboembolic event as a sequela of Covid-19 infection, subsequently developed veno-occlusive priapism complicated with penile gangrene despite being in an overwarfarinized state. The penis was non-salvageable following the gangrenous event, even with prior cavernosal blood aspiration. Thrombophilia panel screening, which includes Protein C activity, was done, where the protein C activity was low, measuring 23%. Unfortunately, he succumbed to death due to severe cardiorespiratory complications before this blood result was ready. Discussion: Prompt diagnosis and treatment of priapism is needed to prevent loss of penile function. Priapism as a sequela of anticoagulant therapy should be suspected in a patient with recent anticoagulant initiation. Thus, immediate treatment can be administered to correct the underlying coagulation disorder. Conclusion: The development of veno-occlusive priapism and penile gangrene in a patient on warfarin therapy raises a concern about protein C deficiency.

HIGH FLOW PRIAPISM IN 7 YEARS-OLD BOY AFTER ACCIDENTALLY CONSUMING APHRODISIAC CHOCOLATE: A CASE REPORT

ABSTRACT
 Objective: This case report aimed to present our experience of conservative treatments for High Flow Priapism in children. Case(s) Report: A 7 years old boy presented with persistent and painless erections without sexual stimulation for 24 hours, the erection was first noticed when he woke up in the morning after accidentally consuming aphrodisiac chocolate 2 days before admitted to the hospital. There was no previous history of priapism and trauma or other risk factors. Discussion: Laboratory studies were within normal limits. Physical examination revealed a fully erect, nontender penile with rigid corpora cavernosa, soft glans, and erection hardness scale (EHS) 3. A cavernosal blood gas analysis was collected with the following values PH 7.41, pO2 117,7 mmHg, and pCO2 24, 8 mmHg. With diagnosis of High Flow Priapism, he was observed and got conservative treatments; ice and site-specific compression and after that EHS become 1. On follow-up after 2 months reported that patient had normal erections with no further episodes of priapism. Conclusion: High flow priapism in old boy after accidentally consuming aphrodisiac chocolate can managed by conservative therapy with favourable outcome.
 Keywords: Aphrodisiac chocolate, penile erection, priapism.

(244) Penoscrotal Decompression: A New Paradigm for Managing Prolonged Ischemic Priapism

Abstract Introduction Outcomes of men with delayed presentation of ischemic priapism (>24 hours) are poor. Management options include forming a proximal corporal shunt (poor evidence of efficacy) or immediate penile prosthesis placement with the associated increased risk of erosion and infection. Penoscrotal decompression (PSD) is thought to relieve the acute compartment syndrome of prolonged ischemic priapism (PIP) and restores perfusion. Experience is currently limited to 31 reported cases from several centers in North America. Objective To further assess the role and efficacy of PSD for PIP. Methods Retrospective review of men presenting with ischemic priapism. Only men following PSD were included. Ischemic priapism was confirmed by cavernosal blood gas and biopsy at time of decompression. Duration of ischemia, prior management and clinical outcomes were analyzed. Change in International Index of Erectile Function (IIEF) score was compared. Results Thirteen patients with a median age of 45 years (IQR 37-43) presented between July 2019 and June 2022. Median duration of PIP was 48 hours (IQR 38-56). Etiology of PIP was idiopathic in 5, iatrogenic or recreational drug-related in 6 and sickle-cell disease (SCD) in 2 men. All patients failed corporal aspiration, irrigation and intracavernosal phenylephrine and 2 failed distal corporo-glanular shunting (T-shunt and Winter shunt). All men had successful detumescence with 9 (69%) requiring bilateral PSD. Immediate pain relief was achieved in all but one man who had a very prolonged priapism (120 hours) where no fresh corporal bleeding was found despite bilateral PSD. He had chronic pain from SCD and was lost to follow-up following discharge. Another patient with SCD recurred within 24 hours following unilateral PSD and was successfully managed with intracavernosal phenylephrine. Only one man without SCD developed a recurrence of priapism the next day and he proceeded to insertion of a malleable penile prosthesis on day 2. There was no association between unilateral or bilateral PSD and recurrence of priapism. IIEF scores fell by a median of 12 (IQR 2.25-15.5) and 6 men developed severe erectile dysfunction. Four men have had a penile prosthesis inserted without complication (2x inflatable, 2x malleable) but 2 are awaiting surgery (one was cancelled due to anesthetic concerns). Follow-up was a median of 17.6 months (IQR 1.3 – 19.7) but 4 men were lost to follow-up. One man was unhappy with penile length following penile prosthesis. Conclusions In the first study outside of North America, PSD successfully relieved PIP in all patients with good pain relief for most (n=12, 92%). Six men developed severe refractory erectile dysfunction while 3 had recurrent priapism due to SCD (n=2) and cocaine abuse (n=1). This suggests that the lack of fresh corporal bleeding following PSD is a risk factor for failure and an immediate penile prosthesis should be considered. PSD averted the need for penile prosthesis insertion in 54% of men. PSD should be considered as a viable option for PIP. Disclosure No

(404) Early Experience of Penoscrotal Decompression for Refractory Ischemic Priapism and Its Impact on Sexual Function

Abstract Introduction Outcomes after distal shunting have low rates of success in cases of refractory ischemic priapism lasting more than 48 hours. Objective Our objectives are to report our institutional experience using penoscrotal decompression for the surgical treatment of prolonged and refractory ischaemic priapism. The primary end point is to assess priapism resolution in the patients. While the secondary end point is to assess erection recovery in those patients. Methods We prospectively evaluated refractory and prolonged ischemic priapism patients treated with proximal decompression from 2020-2022 at Alexandria Main University Hospital. Priapisms were confirmed as ischaemic based on clinical presentations, cavernosal blood gas abnormalities, and doppler ultrasound. Treatment with irrigation and injection of α-agonists in all patients had failed prior to PSD. Patient characteristics, peri-operative variables and outcomes, and changes in International Index of Erectile Function (IIEF) scores were evaluated. Results Thirteen patients with priapism who had treated with penoscrotal decompression from 2020 to 2022. Their age was 28-53 years. The duration of ischemic priapism was 48 hours to 10 days. Nine patients had previously undergone shunt surgery. All patients were successfully treated with Penscrotal deecompression without additional intervention and noted immediate relief of pain postoperatively. Of the 10 patients with documented sexual function status at last follow-up, six reported spontaneous erectile function adequate for penetration, while four reported erectile dysfunction. Conclusions Penoscrotal decompression proved to be an effective and safe way of managing refractory ischemic priapism. The technique showed to produce favorable results while maintaining adequate sexual function. Disclosure Yes, this is sponsored by industry/sponsor: alexandria main university hospital. Clarification Industry initiated, executed and funded study Any of the authors act as a consultant, employee or shareholder of an industry for: alexandria main university hospital.

(388) Primary Penile Squamouse Cell Cancer Related Malignant Priapism In A Cystectomized Patient: A Case Report

Abstract Introduction Priapism is a prolonged (> 4 hours) and unintended erection without sexual stimulation or sexual desire. Priapism due to neoplasms is called malignant priapism, which is a rare condition that tends to occur with corporeal metastasis of other pelvic area malignancies. Priapism due to primary penile malignancies is extremely rare. Objective In this article, we present the case of a patient who underwent total penectomy and bilateral inguinal lymphadenectomy due to malignant priapism related to primary penile squamous cell cancer (SCC), and who also underwent radical cystectomy (RC) and total urethrectomy due to urothelial carcinoma 19 and 2 years prior, respectively. Methods We prepared the patient's information to present. Results An 82-year-old male patient presented to an outpatient clinic with unintended erection and penile pain of about 48 hours’ duration and was on follow-up in our clinic because of urothelial carcinoma history. The patient’s history indicated that he underwent RC and orthotopic neobladder due to muscle-invasive urothelial cancer (UC) in the bladder. No tumor was observed in the final cystectomy pathology; therefore, no adjuvant therapy was given. Seventeen years after the RC operation, he presented with hematuria and a papillary lesion detected in the mid-urethra during cystourethroscopy. Since the biopsy result from this region was compatible with high-grade UC, he underwent total urethrectomy, neobladder resection, and ileal conduit. Urethrectomy pathology results were reported as UC invading the subepithelial stroma and lymphovascular area. Adjuvant MVAC (methotrexate, vinblastine, doxorubicin, and cisplatin) chemotherapy was administered. On follow-up 2 years after the urethrectomy operation, he presented with prolonged priapism. On examination, a cold and erect penis with a 1 cm diameter ulcerated lesion on the glans penis were observed. Hypoxia and hypercarbia were observed on the cavernosal blood gas examination, which was compatible with ischemic priapism. The hemogram was normal. On the emergent penile duplex Doppler ultrasound showed decreased blood flow and a mass on the proximal part of the penis. Subsequently, pelvic magnetic resonance imaging was performed and a mass was observed that was fully destructive to the cavernosal bodies and had irregularly circumscribed borders (Figure 1). Afterward, the patient underwent a total penectomy and bilateral inguinal lymphadenectomy. The pathology report from the penectomy material suggested that the tumor was compatible with moderately differentiated SCC. No sign of metastasis was observed in the lymph nodes. Extensive sampling of the tumor did not reveal any UC in situ, nor SCC in situ. The penis shaft was fully infiltrated by the tumor, with SCC morphology starting from the surgical margin and damaging all the structures of the penile body (Figure 2). The patient was transferred to the oncology clinic for additional treatment planning. Conclusions Despite being the most common primary malignancy of the penis, to the best of our knowledge priapism due to primary penile SCC has been reported only once in the literature. Although metastatic disease is typically thought to be the cause, when a patient with a history of pelvic malignancy presents with malignant priapism, it should be kept in mind that primary malignancies of the penis may also cause this condition. Disclosure No

ISCHEMIC PRIAPISM: A STARTLING THROMBOEMBOLIC COMPLICATION OF COVID-19

TYPE: Case Report TOPIC: Chest Infections INTRODUCTION: The coronavirus disease-2019 (COVID-19) is known to cause severe systemic inflammation leading to thrombotic complications. Deep vein venous thrombosis, pulmonary embolism and stroke are some of the most commonly reported. However, ischemic priapism has been rarely documented as a thromboembolic consequence. CASE PRESENTATION: A 39-year-old man with a history of hypertension and type 2 diabetes mellitus presented with a painful irreducible erection of six-hour duration. Physical exam revealed tachycardia and a tender, rigid penile shaft, with an engorged glans and corpus spongiosum. He denied prior episodes or penile trauma. Laboratory-work revealed an elevated D-Dimer and inflammatory markers, as well as a positive COVID PCR test. Further investigations showed no previous hematological diseases or medications with an elevated thromboembolic risk. He received epinephrine irrigation and cavernosal blood aspiration which resolved the priapism. Nonetheless, the erection recurred a few hours later and a heparin infusion was started. Despite being on heparin for 24 hours, the erection persisted, requiring surgical intervention via a corpora cavernosa - penis glans fistula. The erection resolved and he was discharged home. DISCUSSION: Priapism is a prolonged penile erection of more than four hours without sexual stimulation. Interestingly, COVID-19 induces thrombosis by the hypercoagulability, hyperviscosity, and endothelial dysfunction after the massive inflammatory response and free radical damage. Ischemic priapism is a medical emergency that prompts treatment with a-agonists and corporal blood aspiration if needed. Detumescence can be achieved surgically if the initial measures fail. CONCLUSIONS: This case highlights a rare complication of COVID-19. Early recognition and medical treatment can prevent irreversible complications. DISCLOSURE: Nothing to declare. KEYWORD: COVID-19 Ischemic Priapism

The Role of NGF and Its Receptor TrKA in Patients With Erectile Dysfunction

The aim of our study was to investigate the plasma NGF concentration and TrkA/p75NTR receptor expression on white blood cells (WBCs), in peripheral and corpus cavernosum blood isolated from patients with erectile dysfunction and metabolic syndrome (ED/MetS). This was a pilot case–control study. Inclusion criteria were as follows: men 18–65 years with ED and MetS and healthy subjects. The first sampling was performed at the level of the cubital vein (VC). Subsequently, 20 μg of intracavernous alprostadil was administered, and a second blood draw from the corpora cavernosa (CC) was performed once erection was achieved. Subsequently, the third blood sample was repeated at the level of the VC. We enrolled 8 cases with ED/MetS and 8 controls. There was no significant difference between the case and control group in terms of mean age (49.3 ± 5.9 and 53.13 ± 8.9, respectively). The case group had a lower IIEF score compared to the control group (14 ± 3.2 versus 27.3 ± 2.1; p < 0.05). Decreased NGF and TrKA expression on WBC and thiols were found in the plasma of ED/MetS patients compared to control. The study showed that patients with ED/MetS had a decrease in plasma NGF and thiol concentration, and they had a decrease in TrKA expression on WBCs.

Dorsal Artery Branches to the Corpora Cavernosa

ABSTRACT Introduction Understanding the penile arterial anatomy and its preservation is of interest to reconstructive and oncologic surgeons. The predominant cavernosal arterial supply is provided by the cavernous artery (CA) as it branches from the internal pudendal artery (IPA). Penile ultrasound and cavernosography have demonstrated the existence of accessory arteries originating from the dorsal artery of the penis (DA). Assessment of the arterial anatomy has largely been limited to imprecise ultrasound or invasive angiography. Objective To describe the anatomic findings relating to DA branching patterns in the penis among men undergoing CT cavernosography for evaluation of sexual dysfunction. Methods Images from CT cavernosography were reviewed in a sequential cohort of men. Imaging was reviewed to delineate the arterial anatomy with respect to the CA and DA branches distal to the pubic symphysis as noted by an absence of contrast in a linear hiatus within the corpora cavernosa. Data included the presence of an identifiable CA or DA branch, their diameters, the number of DA branches, distance from the pubic symphysis, and the approximate branching angle. Results 68 men had imaging available for analysis, 57 of whom underwent evaluation for ED and 37 for penile curvature. At least one CA was identifiable in 88% of men with a mean diameter of 1.66mm (Median 1.40, [IQR 1.30, 1.90]). DA perforating branches were identified in 90.8% of men, with a mean of 2.1 discrete branches per patient (Median 2, [IQR 1,3]). 26 men had penile doppler data available for comparison. Among those men, the mean CA diameter after injection was 1.51mm and the ratio between diameter measured on doppler and CT was 1.0. 4 patients had a DA branch identified on penile doppler and all had at least one DA branch identified on CT. 19 patients had at least one DA branch identified on CT which was not seen on penile doppler. In a subset of 33 patients with further CT data available for review, the mean number of DA branches identified was 2.24 (Median 2, [IQR 1,3]), with a mean DA branch diameter of 1.39mm (Median 1.40, [IQR 1, 1.70]). The first branch was identified at a mean of 2.06cm distal to the pubic symphysis with a branching angle of approximately 49.75 degrees, and the second branch was identified at a mean of 3.4cm distal to the pubic symphysis with a branching angle of approximately 50.62 degrees. Conclusions Dorsal artery contribution to the cavernosal blood supply may be more variable than previously thought. This is of interest to those performing penile doppler for assessment of blood flow given that it may be difficult to delineate the CA and DA in some patients. The impact of these DA branches on sexual function is not clear and warrants further investigation. Disclosure No

Tamsulosin and risk of priapism: A causality assessment using Austin Bradford Hill Criteria.

Tamsulosin hydrochloride, a selective alpha‐adrenergic blocking agent has been previously associated with priapism. Priapism is a medically serious condition that, if not intervened, can cause permanent erectile dysfunction. This study was conducted to investigate whether the association of tamsulosin and priapism is causal. All currently available evidence such as experimental, biological, toxicological, published studies, and safety data mined from the WHO global pharmacovigilance database was systematically organized into the Austin Bradford Hill causality assessment framework. In the international pharmacovigilance database, a strong association between tamsulosin and priapism (IC025 = 4.1; PRR025 = 19.9; ROR025 = 20) was observed. There were 122 cases of priapism associated with tamsulosin submitted to the database from 23 countries. In 87.7% of the cases, tamsulosin was reported as a ‘sole suspect,’ and in 50.8%, it was the only drug administered. In several patients, priapism resolved following discontinuation of tamsulosin and recurred after its reintroduction. Both in the published and unpublished data, for majority of the cases, the time to onset of priapism was within few days following the first intake of tamsulosin. Cases of priapism, particularly those published, were consistent in their clinical features with patients experiencing prolonged painful erection that required aspiration of cavernosal blood, irrigation of the corpora cavernosa, and treatment with vasopressors. Other alpha‐adrenergic blocking agents that are structurally analogous with tamsulosin have also been associated with priapism. In several cases, tamsulosin was used off‐label, for the treatment of ureteral calculi expulsion. Eight patients experienced priapism that ended up with serious complications such as ejaculation disorders and erectile dysfunction. The currently available totality of evidence suggests that the association of tamsulosin and priapism is causal. Healthcare professionals are therefore recommended to cautiously prescribe tamsulosin and ensure that consumers are aware of the potential risk of priapism.

Priapism in a patient with COVID-19: A case report

A pro-inflammatory response in patients with coronavirus disease provokes hypercoagulability and hyperviscosity, following an excessive liberation of acute phase reactants. Thromboembolic complications such as Deep Venous Thrombosis, Pulmonary Embolism, Stroke and Acute Coronary Syndrome were described from the beginning of the pandemic as possible manifestations of this new virus. Priapism is a medical urgency that demands quick assessment and timely treatment. A case of priapism is presented in a patient undergoing hospitalization for COVID-19. He was treated with cavernosal blood aspiration, irrigated with 0.90% w/v saline solution and intracavernosal injection of the sympathomimetic agent (adrenaline), with favorable response. Keywords: priapism; COVID-19; thrombosis.

Acute Ischemic Priapism: An AUA/SMSNA Guideline.

Priapism is a persistent penile erection that continues hours beyond, or is unrelated to, sexual stimulation and results in a prolonged and uncontrolled erection. Given its time-dependent and progressive nature, priapism is a situation that both urologists and emergency medicine practitioners must be familiar with and comfortable managing. Acute ischemic priapism, characterized by little or no cavernous blood flow and abnormal cavernous blood gases (ie, hypoxic, hypercarbic, acidotic) represents a medical emergency and may lead to cavernosal fibrosis and subsequent erectile dysfunction. A comprehensive search of the literature was performed by Emergency Care Research Institute for articles published between January 1, 1960 and May 1, 2020. Searches identified 2948 potentially relevant articles, and 2516 of these were excluded at the title or abstract level for not meeting inclusion criteria for any key question. Full texts for the remaining 432 articles were reviewed, and ultimately 137 unique articles were included in the report. This Guideline was developed to inform clinicians on the proper diagnosis and surgical and non-surgical treatment of patients with acute ischemic priapism. This Guideline addresses the role of imaging, adjunctive laboratory testing, early involvement of urologists when presenting to the emergency room, discussion of conservative therapies, enhanced data for patient counseling on risks of erectile dysfunction and surgical complications, specific recommendations on intracavernosal phenylephrine with or without irrigation, the inclusion of novel surgical techniques (eg, tunneling), and early penile prosthesis placement. All patients with priapism should be evaluated emergently to identify the sub-type of priapism (acute ischemic versus non-ischemic) and those with an acute ischemic event should be provided early intervention. Treatment of the acute ischemic patient must be based on patient objectives, available resources, and clinician experience. As such, a single pathway for managing the condition is oversimplified and no longer appropriate. Using a diversified approach, some men may be treated with intracavernosal injections of phenylephrine alone, others with aspiration/irrigation or distal shunting, and some may undergo non-emergent placement of a penile prosthesis.

Angiotensin-converting enzyme 2 (ACE2), angiotensin-(1-7) and Mas receptor in gonadal and reproductive functions.

Angiotensin (Ang)-(1-7) is an active peptide formed from Ang I or Ang-(1-9) by multiple proteolytic steps involving angiotensin-converting enzyme (ACE) 1 and other peptidases, or by a single cleavage of Ang II catalyzed chiefly by ACE2. The effects of Ang-(1-7) are mediated by the G protein-coupled receptor Mas (or Mas1), encoded by the protooncogene MAS. The reproductive system expresses ACE2 quite abundantly and therefore is able to generate Ang-(1-7) using precursor peptides produced locally or taken from circulation. In several mammalian species, Ang-(1-7) stimulates ovarian follicle growth, oocyte maturation and ovulation. The peptide is found in human endometrium, mostly during the secretory phase of menstrual cycle when the uterus is receptive to embryo implantation. Rat models and human observational studies suggest that Ang-(1-7) is part of the maternal adaptive response to pregnancy and its deficiency is associated with poor circulation in the placental bed. Knockout mice revealed a relevant participation of Mas-mediated stimulus to the maintenance of normal spermatogenesis, even though the animal can still reproduce without it. In addition, the vasorelaxant effect of Ang-(1-7) participates in the physiological mechanism of corpus cavernosum blood influx and penile erection. We conclude that preclinical evidence encourages the pursuit of treatments for female and male reproductive dysfunctions based on Mas agonists, starting with its natural ligand Ang-(1-7).

Penile curvature after Peyronie's disease surgery: What are the risk factors?

Surgery is the golden standard for the treatment of patients with Peyronie's disease in chronic phase (12-18months). Learning risk factors for post-surgical curvature (>20°) would aid both surgeon and patient in their decision-making process. The aim of this study was to investigate the risk factors for residual/recurrent curvatures. The clinical data of the patients, who underwent reconstructive surgery for PD between 1997 and 2016, were retrospectively reviewed. Follow-ups were performed via physical examination, surveys and phone calls. For shortening surgery (Nesbit/plication), initial bi-planar curvature was proved to be a predictor of post-operative curvature (p=.05). Lateral and ventral curvatures were associated with higher recurrence rates in patients who underwent grafting surgery (p=.01). In terms of baseline comorbidities, only diabetes mellitus had an association with curvature nonrecurrence for both shortening and lengthening surgeries (p<.05). Grafting surgery may be suggested to patients who had bi-planar curvatures instead of Nesbit surgery. Nesbit plication surgery may be preferred for patients with lateral and ventral curvatures instead of grafting surgery. Higher cavernosal blood pressures and more nocturnal erections of nondiabetic young patients might impede plication sutures and grafts and therefore increase penile curvature recurrence.

Favourable multi-institutional experience with penoscrotal decompression for prolonged ischaemic priapism.

To report our multi-institutional experience using penoscrotal decompression (PSD) for the surgical treatment of prolonged ischaemic priapism (PIP). We retrospectively reviewed clinical records for patients with PIP treated with PSD between 2017 and 2020. Priapisms were confirmed as ischaemic based on clinical presentations and cavernosal blood gas abnormalities. Treatment with irrigation and injection of α-agonists in all patients had failed prior to PSD. Patient characteristics, peri-operative variables and outcomes, and changes in International Index of Erectile Function (IIEF) scores were evaluated. We analysed 25 patients who underwent a total of 27 PSD procedures. The mean duration of priapism at initial presentation was 71.0h. Irrigations and injections in all patients had failed, while corporoglanular shunt treatment in 48.0% of patients (12/25) had also failed prior to PSD. Of the 10 patients who underwent unilateral PSD, two (20.0%) had priapism recurrence. Both were treated with bilateral PSD, with prompt and lasting detumescence. Among the 15 patients undergoing primary bilateral PSD, none had priapism recurrence. Of the 15 patients with documented sexual function status at last follow-up, nine (60%) reported spontaneous erectile function adequate for penetration, while six (40%) reported erectile dysfunction. The median (interquartile range) decrease in IIEF-5 score was 3.5 (0-6.75) points after PSD. Two patients underwent uneventful inflatable penile prosthesis placement following PSD. Penoscrotal decompression presents a simple, safe, highly effective and easily reproducible procedure for resolution of PIP. PSD should be considered as a viable salvage or alternative strategy to corporoglanular shunt procedures.

High flow priapism in 7 years-old boy after accidentally consuming aphrodisiac chocolate: a case report

Non-ischemic priapism (high-flow) is a persistent erection caused by unregulated cavernous arterial flow, characterized by a painless, persistent nonsexual erection that is not fully rigid and is caused by excess arterial blood flow into the corpora cavernosa. The cavernous environment does not become ischemic and cavernous blood gas does not show hypoxia, hypercarbia, or acidosis. This case report aimed to present our experience of conservative treatments for the treatment of High Flow Priapism. A 7 year old boy presented with persistent nonpainful erections without sexual stimulation for 24 hours. Patient felt the erection since he had been woken up in the morning. Patient had consumed aphrodisiac chocolate accidentally 2 days before admitted to the hospital. There was no previous history of priapism, no previous history of trauma or other risk factors. Laboratory studies were within normal limits. Physical examination revealed a fully erect, nontender penile with rigid corpora cavernosa, soft glans, and erection hardness scale (EHS) 3. A cavernosal blood gas analysis was collected with the following values PH 7.41, pO2 117,7 mmHg, and pCO2 24,8 mmHg. Diagnosis of High Flow Priapism was made. He was observed and treated with conservative measures; ice and site-specific compression. After that EHS become 1. On follow-up at 2 months, parents reported normal erections with no further episodes of priapism. In this report, we present the first documented case of high flow priapism in a 7 years old boy after consuming accidentally aphrodisiac chocolate in Saiful Anwar general hospital.

Anatomic and Functional Outcome Following Distal Shunt and Tunneling for Treatment İschemic Priapism: A Single-Center Experience

BackgroundIschemic priapism (IP) is a urologic emergency that requires early intervention. The main aim of IP treatment is to relieve the cavernosal pressure and provide erectile function. AimThe aim of this study was to determine the correlation between preoperative risk factors (patient’s age, duration of priapism, preoperative erectile function) and postoperative erectile dysfunction (ED). MethodsThis retrospective study consisted of 25 patients diagnosed with refractory IP between 2009–2017. The diagnosis of IP was confirmed by medical history, physical examination, and cavernosal blood gas analysis. All of the patients underwent the T-shunt procedure ± tunneling after a failed initial intervention. ResultsThe mean age at the time of the IP diagnosis was 46.84 years (range 23–77). The average follow-up time of the study population was 40.4 months (range 3–114), and the median time from the occurrence of IP to surgery was 58 hours (range 24–240). In all cases, rapid resolution of the erection was achieved with the T-shunt ± tunneling procedure. In 1 patient, priapism recurred after 12 hours. Postoperative ED was reported by 16 (84.21%) patients, with degrees of mild, mild to moderate, and severe in 6, 1, and 9 of these cases, respectively. During the follow-up, the mean International Index of Erectile Function–5 (IIEF-5) score was 12.68 (range 5–23). Only 3 (15.78%) patients achieved successful sexual intercourse without any treatment. 6 (31.5%) patients required the aid of phosphodiesterase type 5 inhibitors, and 1 (5.26%) patient required the aid of a vacuum erection device. The 9 (47.36%) patients with severe ED failed to respond to medical treatment and were considered candidates for a penile implant. According to Kendall’s tau-b correlation coefficient analysis, there was a positive correlation between the preoperative and postoperative IIEF-5 scores (P = .005), whereas the patient’s age and duration of priapism were negatively correlated with the postoperative IIEF-5 score (P = .016 and P = .046, respectively). Clinical ImplicationsTreatment options of IP should be discussed with patients in terms of both preoperative erectile function and the duration of priapism. Strengths & LimitationsThe small sample size and retrospective nature of this study were the main limitations. ConclusionsDespite high success and low complication rates of T-shunt surgery, the rate of undisturbed erectile function is only 14.6%. The patient’s age, the existence of preoperative ED, and the duration of priapism are associated with postoperative IIEF-5 scores.Ortaç M, Çevik G, Akdere H, et al. Anatomic and Functional Outcome Following Distal Shunt and Tunneling for Treatment İschemic Priapism: A Single-Center Experience. J Sex Med 2019;16:1290–1296.

Appropriate management of high-flow priapism based on color Doppler ultrasonography findings in pediatric patients: four case reports and a review of the literature

High-flow priapism in children is a very rare condition, and there is no clear consensus on its management. High-flow priapism is associated with increased cavernosal blood flow and broadly divided into two groups based on the presence or absence of arteriocavernous fistula in the corpora cavernosa. This study aimed to determine the appropriate management of high-flow priapism based on the existence of arteriocavernous fistula using penile color Doppler ultrasonography (CDU) findings in the pediatric population. The cases of four boys aged between 6 and 11 yearswith high-flow priapism treated between 2009 and 2017 are reported. Two boys had prior perineal trauma, one boy had blunt penile glans trauma, and one had no obvious cause for the condition. All boys initially underwent penile CDU and were treated conservatively or via selective arterial embolization depending upon the presence or absence of an arteriocavernous fistula. Penile CDU revealed an arteriocavernous fistula inside the corpus cavernosum penis in two of four boys and increased blood flow inside the corpus spongiosum in the remaining boys. The former two boys underwent selective arterial embolizationand one boy underwent repeated embolization because of remaining arteriocavernous fistula feeding from the contralateral cavernosal artery, whereas the boys with no arteriocavernous fistula on CDU were managed conservatively. All boys were successfully treated within 1 month, and they had normal morning erection and no evidence of recurrent priapism at the follow-up. Unlike low-flow priapism, high-flow priapism is not a medical emergency. Therefore, conservative therapy is an appropriate initial treatment, although selective arterial embolization can be effective for high-flow priapism with arteriocavernous fistula, with a success rate of 97% and no reported complications to date. Penile CDU is an imaging technique that can detect focal areas of turbulent flow with sensitivity close to 100%. This study has several limitations including a small number of cases, limited follow-up duration, and possibility of spontaneous arteriocavernous fistula closure in cases treated by arterial embolization. Penile CDU could be a reliable tool to diagnose high-flow priapism and detect the presence or absence of arteriocavernous fistula. Although conservative therapy remains the first choice, selective arterial embolization may be an early treatment option when CDU reveals an arteriocavernous fistula.

Aphrodisiac Activity of Ethanol Extract of Cratoxylum sumatranum (JACK) Blume Stems on Isolated Rat Corpus cavernosum

Cratoxylum sumatranum (Jack) Blume of the Hypericaceae family is known as “Bentaleng” by Dayak Benuaq. In ethnobotany, Cratoxylum sumatranum stems (CSS) is used as energy drink or aphrodisiac, but its effect has not been scientifically proven. Research objective to study the aphrodisiac activity of CSS extract by screening the aphrodisiac activity in vitro. Method: CSS was collected from Kutai Kertanegara Regency, East Kalimantan Province. Extraction was by maceration with ethanol solvent for three days. Re-maceration was done twice. In vitro screening of aphrodisiac activity used isolated rat corpus cavernosum. The organ was placed into a 10 mL chamber containing Krebs-Henselheit solution at pH 7.4, 37°C and aerated with carbogen gas. After acclimation, a contraction test was performed with phenylephrine solution and after reaching the peak of contraction at plateau the Control (solvent extract) or CSS ethanol extract was administerd at cumulatively increased concentration. Vasodilation activity was known if the contraction response was decreased after the extract’s administration and expressed in percent contraction with negative value. Results: CSS ethanol extract induce vasodilatory response on rat Corpus cavernosum blood vessels. Vasodilation activity is increasing with increasing concentration of extract given compared to Control. Conclusion the aphrodisiac activity of CSS ethanol extracts is directly through the vasodilation action mechanism on blood vessels in the rat corpus cavernosum.

429 The emergency treatment strategy and prognosis of priapism in a Chinese clinic

To explore the emergency treatment principles and prognosis of priapism in a Chinese andrology clinic. The medical records of 24 priapism patients in our emergency department were reviewed retrospectively. The mean age of the patients was 30.6 years (range from 18 to 48 years) with onset time from 4 h to 7 days. Among the 24 patients, twelve patients were caused by injection of vasoactive drugs, 4 patients were accompanied by hematological system diseases, 1 patient had repetitive sex intercourse, 5 patients experienced penile perineal trauma, and the rest 2 patients had no obvious causes. All patients received blood complete cells count, urine analysis, corpus cavernosum blood gas analysis and color Doppler ultrasonography, among which 18 patients were followed with a mean duration of 24 months ranging from 10 to 36 months. According to medical history, corpus cavernosum blood gas analysis and ultrasonography, 16 patients were diagnosed as ischemic priapism, 3 patients were stuttering priapism, and 5 patients were non-ischemic priapism. The venous type priapism patients received initial corpus cavernosum blood suction and α-adrenergic receptor agonist perfusion, whose corpus cavernosum was washed repetitively until its blood color returned to bright red. Ten ischemic priapism patients were recovered after corpus cavernosum blood irragation and α-adrenergic receptor agonist perfusion. The other 5 ineffective ischemic priapism patients received penile corpus cavernosum-glans shunt or penile corpus cavernosum-urethral corpus cavernosum shunt. The rest 1 ischemic priapism patient was treated by bilateral penile corpus cavernosum-great saphenous vein shunt. All 5 non-ischemic priapism patients recovered after 1 to 2 times of highly-selective internal pudendal arteriogram and embolism. Three stuttering priapism patients were received antiandrogen drugs, estrogen and PDE5 inhibitors, whose priapism frequency was ameliorated and controlled. Among the 18 patients under follow-ups, 5 non-ischemic priapism patients maintained erectile function, 10 ischemic priapism patients experienced obvious penile erectile dysfunction, of which 5 patients received penile prosthesis implantation, and 3 stuttering priapism patients maintained partial penile erection.

Ischaemic priapism: A clinical review.

Ischaemic priapism is a rare condition characterised by little or no cavernosal blood flow, pain and rigidity of the penis. Immediate intervention is required to restore blood flow, prevent necrosis and erectile dysfunction. This review was conducted to determine the best course of treatment and identify areas in current guidelines to which improvements could be made. PubMed, Ovid, MEDLINE (1946-December 2016) and the Cochrane Library were searched as sources for literature. Key studies in each of the areas of management were identified and analysed. A total of 45 articles were reviewed. The first step in treatment should be aspiration of corporeal blood. Further studies are needed to make firm recommendations as to whether irrigation should follow, as currently literature is inconclusive. If this fails to cause detumescence, sympathomimetics should be injected. The sympathomimetic of choice is phenylephrine as it is effective, specific and causes minimal cardiovascular side effects. It should be injected at a concentration of 100-500 μg/mL, with 1 mL being injected every 3-5 minutes for up to an hour (maximum 1mg in an hour). Surgical shunting is the next step, except in the cases of delayed priapism (48-72 hours duration) where immediate penile prosthesis insertion may be considered more appropriate. Distal shunts should be performed first, followed by proximal ones to minimise damage leading to erectile dysfunction. There exists little evidence recommending one shunting procedure over another. The final intervention is insertion of a penile prosthesis. Literature suggests that an inflatable prosthesis inserted immediately will yield the greatest patient satisfaction. A review of the literature has highlighted areas in which further research needs to be done to make conclusive recommendations, including whether irrigation should accompany aspiration and efficacy of shunting procedures. Further studies are required to ensure that patients receive the treatment most likely to cause detumescence and maintain erectile function.