Cavernous Blood Research Articles

312 Endogenous Vasoactive Peptides in the Control of Penile Erectile Tissue: Is there a Role of Arginine-Vasopressin (AVP)?

The role of the adrenergic system in mediating the constant tone of corpus cavernosum (CC) smooth musculature during penile flaccidity and in returning the erect penis into the flaccid state is well established. However, it is not yet known whether additional non-adrenergic, non-cholinergic (NANC) transmitters are involved in this process. Arginine-Vasopressin (AVP, ADH), a pituitary peptide hormone with vasoconstrictor properties, has been assumed to be an important mediator contributing to such a control. The present study was conducted in order to determine whether there is a role of AVP in controlling CC smooth muscle tension. Plasma levels of AVP (ng/L) were determined in the systemic and cavernous blood of 25 healthy adult male volunteers who were exposed to visual and tactile erotic stimuli in order to elicit penile tumescence and erection. Whole blood was aspirated from the CC and a cubital vein. Following the separation of plasma volumes, AVP was quantified by means of radioimmunometric methods (RIA). The effects of AVP (0.1 nM - 100 nM) on isolated human penile erectile tissue at basal tension were examined using the tissue bath technique.

Algorithm for the Diagnosis and Treatment of Penile Injury

Injuries of the external genital organs in men are most often found in active age with a predominance of closed injuries and require careful implementation of the entire necessary amount of diagnostic and therapeutic measures, active surgical tactics aimed at preventing distant cavernous blood flow disturbances, the development of fibrotic changes in the cavernous tissue, protein membrane and stricture of the penile urethra.

183 Levels of Transforming Growth Factor ß1 (TGF ß1) in the Systemic and Cavernous Blood of Healthy Males during different Penile Conditions

183 Levels of Transforming Growth Factor ß1 (TGF ß1) in the Systemic and Cavernous Blood of Healthy Males during different Penile Conditions

Course of transforming growth factor ß1 in the systemic and cavernous blood of healthy males through different penile conditions.

Studies on erectile dysfunction (ED) have revealed a relationship between smooth muscle atrophy and the accumulation of collagen in the corpus cavernosum (CC). Transforming growth factor ß1 (TGF ß1) is a cytokine which has been proposed to be involved in the fibrotic process in the CC. We aimed to evaluate the course of TGF ß1 in the systemic and cavernous blood of 17 healthy males through different phases of the sexual arousal response (exemplified by the penile conditions flaccidity, tumescence, rigidity and detumescence). An enzyme-linked immunoassay was used to measure the concentration of TGF ß1 (ng/ml) in both the systemic and cavernous blood at the stages of flaccidity, tumescence and detumescence. TGF levels were significantly higher in the cavernous compartment than in the systemic blood. A linear decrease was evident in the cavernous blood when the flaccid penis became tumescent (24.3±14.5 to 13.9±6.5) and rigid (to 8.7±3.1). At detumescence, TGF increased to 18.3±10.4. In contrast, the levels in the systemic circulation remained unchanged. The results are in support of the hypothesis that the concentration of TGF ß1 in the CC is regulated by adequate blood flow and oxygenation.

Diagnostic Value of Plasma Pentraxin3- Level For Diagnosis of Erectile Dysfunction.

Erectile dysfunction (ED) is a sexual dysfunction described as the inability to develop or maintain an erection of the penis adequate for sexual intercourse, and its prevalence increases with age. Seen as a common sexual disorder worldwide, organic causes are the underlying reason for 80 percent of ED cases, with the most characteristic pathology responsible for organic ED being atherosclerosis. This study investigates the diagnostic value of plasma PTX-3 levels in arterial ED. This study included a total of 45 patients who were admitted to the urology and cardiologyoutpatient clinics of the Medical Faculty of Canakkale Onsekiz Mart University (COMU) and consented to participate in this study. Patients were categorized into three equal groups in number: (1) patients with ED diagnosed with coronary artery disease (CAD) (15 patients in total); (2) patients with ED not having coronary artery disease or any other equivalent diseases (diabetes mellitus, hypertension and hyperlipidemia) (15 patients in total);and (3) ordinary patients with no ED (15 patients in total). An interview was conducted at the andrology polyclinic with each patient in order to ascertain detailed information on their medical and sexual history and on demographic characteristics. All patients were also administered the International Index of Erectile Function (IIEF) questionnaire. The findings from this study investigating the diagnostic value of plasma PTX-3 levels in ED were statistically significant for two comparisons: the differences between the peripheral blood and cavernous blood values of the patient groups (group 1 and 2) and the control group (group 3), and the differences between the peripheral blood and cavernous blood values of group 2 (patients with ED who do not have CAD) and the control group (group 3). As PTX-3 is more specific than the formerly recognized biochemical markers in endothelial dysfunction, it can be used in the diagnosis of vascular originated ED.

070 Penile prosthesis placement in the setting of prolonged refractory ischemic priapism: a single institution experience

Erectile dysfunction is a well-known complication of prolonged ischemic priapism. The purpose of this study is to present and analyze our institution’s experience of immediate penile prosthesis (PP) placement in the setting of prolonged ischemic priapism refractory to irrigation and/or shunting procedures. A total of 18 patients presented with prolonged ischemic priapism unresponsive to conventional management between 2011 and 2017 at a single institution. All patients had evidence of ischemic priapism on cavernous blood gas. Each patient experienced priapism for greater than 24 hours and had failed conservative management including corporal aspiration and irrigation +/- phenylephrine. Eight patients (44.4%) underwent unsuccessful shunting procedures prior to surgery. A semi-rigid PP was placed in 16 patients and a three-piece inflatable PP was placed in 2 patients. Mean patient age was 43.9 years old (20-62 years old). 4 patients (22.2%) developed prosthetic infection, all requiring surgical intervention. Mean follow up was 4.8 months (1-36 months). At last follow up, 15 patients (83.3%) have a PP in place. All 15 patients are sexually active and satisfied with their overall result.

Is β-endorphin significant in the control of the male sexual response?

It has been assumed that β-endorphin, belonging to the family of opiodergic neuropeptides, might facilitate the inhibition of the male sexual response; however, its role in the control of the penile erectile tissue remains to be elucidated. This study aimed to evaluate in healthy men the course of β-endorphin in the systemic and cavernous blood through different stages of sexual arousal. Thirty-four (34) men were exposed to erotic stimuli to induce penile tumescence and rigidity. Blood was aspirated from the corpus cavernosum and a cubital vein during the penile conditions flaccidity, tumescence, rigidity and detumescence. Plasma levels of β-endorphin were determined by means of radioimmunometric methods. The effects of β-endorphin on isolated human penile erectile tissue were investigated in vitro. β-endorphin did not induce a contractile response of the cavernous tissue or reverse the contraction induced by noradrenaline. β-endorphin decreased in the systemic blood when the penis became tumescent and rigid and increased during detumescence. In the cavernous blood, no alterations in β-endorphin concentrations were observed. The drop in β-endorphin observed during tumescence and rigidity seems likely to reflect the inhibition of the opioidergic input with the beginning of sexual arousal.

The Case Files

FigureFigureFigureA 41-year-old man with a past medical history of bipolar disorder, PTSD, and alcohol abuse presented to the emergency department for an erection that wouldn't go away. He said his erection had persisted for 28 hours and was starting to be painful. He had taken trazodone the day before but was unable to recall the dosage. He denied any erectile dysfunction in the past when he was on trazodone a year before. Physical examination showed an uncomfortable-appearing man lying supine in bed but in no acute distress. The physical exam was normal except for the genitourinary exam, which revealed an erect penis without any visible discoloration, trauma, or tenderness. Management was started by a urologist. The patient was given local anesthesia, and phenylephrine was injected locally into each corpora. No result was observed. Then corporal aspiration with a 19-gauge needle on either side of the corpora was performed. Prior to starting the procedure, the patient's blood pressure was recorded at 144/93 mm Hg, with a hemoglobin level of 14.0 g/dl. During the procedure, he began to have chills and became tremulous and diaphoretic. His blood pressure dropped to 75/50 mm Hg and his hemoglobin level to 10.3 g/dl. He was given normal saline bolus, transfused one unit of packed red blood cells type O (Rh negative), and started on ciprofloxacin 500 mg BID. After the procedure, he continued to complain of lightheadedness, looked pale, and was shivering. His blood pressure was 80/49 mm Hg. A second 1L bolus of normal saline and a second unit of packed red blood cells were given, and his blood pressure rose to 101/65 mm Hg. After detumescence and cessation of bleeding through the penis, he was admitted to the hospital for continued observation. The patient said he did not experience adverse reactions to trazodone when he took it previously. Trazodone is an antidepressant that works by acting as a serotonin (5-HT2) inhibitor. Trazodone-induced priapism is estimated to occur in one in 1,000 to one in 10,000 patients with doses ranging from 50 to 400 mg. (J Clin Psychiatry 1990;51[10]:430.) Priapism is a persistent erection for more than four hours in the absence of sexual stimulation. A total of 32,462 cases of priapism were reported in the United States between 2006 and 2009. (J Urol 2013;190[4]:1275.) It can occur in any age group, but incidence is most common in children between 5 to 10 and adults between 20 to 50. (Postgrad Med J 2006;82[964]:89.) Low-flow priapism is associated with pain, decreased cavernous blood flow, and corporal rigidity. Risk factors include sickle cell disease or trait, medications, cocaine use, antidepressants, and total parenteral nutrition. (Urol Clin North Am 2007;34[4]:631.) Many antidepressants and antipsychotics are known to cause priapism, such as bupropion, fluoxetine, sertraline, lithium, clozapine, risperidone, olanzapine, chlorpromazine, and thioridazine. Priapism is a known but uncommon side effect of trazodone. Priapism can be divided into low-flow (ischemic) and high-flow (nonischemic) priapism. Trazodone results in low-flow priapism, which causes inadequate drainage of blood from the penis and an erect penis. Treatment of ischemic priapism can involve corporal aspiration, placement of a penile surgical shunt to establish a fistula to allow an outflow channel from corpora cavernosa and implantation of a penile prosthesis. (Blood 2015;125[23]:3551; Korean J Urol 2013;54[12]:816.) Corporal aspiration resulting in blood loss can cause hemorrhagic shock, which requires proper implementation of resuscitative strategy. Low-flow priapism requires rapid detumescence to prevent long-term effects, and it involves aspiration with intracavernous alpha agonist (phenylephrine) injection. The patient's hemoglobin level dropped from 14 mg/dL to 10 mg/dL over the course of an hour. Sudden drop in intravascular volume results in hypovolemic shock with symptoms of hypotension, tachycardia, tachypnea, cool, clammy skin, feelings of lightheadedness, and abnormal mental status. Managing hemorrhagic shock requires fluid resuscitation through crystalloid, blood transfusion, hemorrhage control, and preventing trauma-related coagulopathy. Crystalloid is used to allow for maintenance of preload, while blood transfusion helps improve tissue oxygenation. Transfusion and crystalloid help prevent the mechanisms of traumatic coagulopathy such as loss-dilution, excessive activation of coagulation, hypothermia, metabolic acidosis, and anemia. Without aggressive fluid repletion, the patient remains susceptible to tissue hypoxia, inflammation, and end-organ damage. The patient had presented with priapism, but addressing his primary complaint resulted in shifting his treatment priority to hemorrhagic shock. Hemorrhage is a major cause of preventable death after trauma, or in this case, corporal aspiration. Hemorrhagic shock limits oxygen delivery, resulting in tissues hypoxia, inflammation, and organ dysfunction.

Preoperative EUS-guided tattooing of the pancreas with a minuscule amount of marking solution utilizing a newly designed injector

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. Zargooshi J, Rahmanian E, Motaee H, and Kohzadi M. Nonischemic priapism following penile tattooing. J Sex Med 2012;9:844–848.

Designed angiopoietin-1 variant, COMP-angiopoietin-1, rescues erectile function through healthy cavernous angiogenesis in a hypercholesterolemic mouse.

Despite the advent of oral phosphodiesterase-5 inhibitors, curative treatment for erectile dysfunction (ED) remains unavailable. Recently, the link between ED and cardiovascular disease was unveiled and the main etiology of ED was found to be vasculogenic. Therefore, neovascularization is a promising strategy for curing ED. Angiopoietin-1 (Ang1) is an angiogenic growth factor that promotes the generation of stable and functional vasculature. Here, we demonstrate that local delivery of the soluble, stable, and potent Ang1 variant, COMP-Ang1 gene or protein, into the penises of hypercholesterolemic mice increases cavernous angiogenesis, eNOS phosphorylation, and cGMP expression, resulting in full recovery of erectile function and cavernous blood flow up to 8 weeks after treatment. COMP-Ang1-induced promotion of cavernous angiogenesis and erectile function was abolished in Nos3-/- mice and in the presence of the NOS inhibitor, L-NAME. COMP-Ang1 also restored the integrity of endothelial cell-cell junction by down-regulating the expression of histone deacetylase 2 in the penis of hypercholesterolemic mice and in primary cultured mouse cavernous endothelial cells. These findings constitute a new paradigm toward curative treatment of both cavernous angiopathy and ED.

Intramuscular hemangioma mimicking synovial sarcoma on fine-needle aspiration cytology

A 13-year-old boy presented to our hospital with clinical complaint of lump in knee joint and associated pain for 6 years. Fine-needle aspiration cytology was done and cytology smears showed biphasic pattern composed of spindle cells, epithelial elements, and numerous mast cells. Hence, it was reported as synovial sarcoma and histopathology was advised. Lump was excised successfully. Histopathological sections showed numerous capillary sized blood vessels, cavernous blood vessels, thick walled blood vessels present between skeletal muscle, and adipose tissue. Hence, the diagnosis of intramuscular haemangioma was made. Follow-up was done for 1 year. No recurrence or complications were seen.

A case of umbilical cord hemangioma

We report a rare case of an umbilical cord hemangioma. The umbilical cord consisted of Capillaries and cavernous blood vessels and the hemangioma stressed umbilical arteries and vein. At 40 weeks of gestation, it resulted in intrauterine death of the fetus. Microscopically, there were lots of vessels with various thicknesses in the umbilical cord. Autopsy shows evidences of smothering. These findings indicate there may be a causal connection between the umbilical cord hemangioma and fetal death because of the impaired umbilical circulation.

Priapism following continuous thoracic epidural anaesthesia: emergency or a benign condition?

Priapism is a rare complication of epidural anaesthesia, and the pathophysiology is poorly understood. In general, 95% of all priapism episodes are ischemic because of decreased penile blood flow, and therefore requires immediate treatment. A case is reported of a 45-year-old male patient in which a clear relation is demonstrated between continuous thoracic epidural analgesia and priapism after transabdominal nephrectomy. The level of epidural anaesthesia supports the theory that the erection is a consequence of increased penile blood flow, thus a relatively harmless condition. However, confirmation by serial cavernous blood gas analysis or colour duplex ultrasonography is mandatory. Until this hypothesis is confirmed, termination of epidural infusion is advised as a primary treatment.

Penile rehabilitation with a vacuum erectile device in an animal model is related to an antihypoxic mechanism: blood gas evidence

Our previous study showed that vacuum erectile device (VED) therapy has improved erectile function in rats with bilateral cavernous nerve crush (BCNC) injuries. This study was designed to explore the mechanism of VED in penile rehabilitation by analyzing cavernous oxygen saturation (SO2) and to examine the effect of VED therapy on preventing penile shrinkage after BCNC. Thirty adult Sprague-Dawley rats were randomly assigned into three groups: group 1, sham surgery; group 2, BCNC; and group 3, BCNC+VED. Penile length and diameter were measured on a weekly basis. After 4 weeks of therapy, the penile blood was extracted by three methods for blood gas analysis (BGA): method 1, cavernous blood was aspirated at the flaccid state; method 2, cavernous blood was aspirated at the traction state; and method 3, cavernous blood was aspirated immediately after applying VED. SO2 values were tested by the blood gas analyzer. The results showed that VED therapy is effective in preventing penile shrinkage induced by BCNC (Penile shortening: BCNC group 1.9±1.1 mm; VED group 0.3±1.0 mm; P<0.01. Penile diameter reduction: BCNC group 0.28±0.14 mm; VED group 0.04±0.14 mm; P<0.01). The mean SO2±s.d. values were increased by VED application (88.25%±4.94%) compared to the flaccid (76.53%±4.16%) or traction groups (78.93%±2.56%) (P<0.05). The calculated blood constructs in the corpus cavernosum right after VED application were 62% arterial and 38% venous blood. These findings suggest that VED therapy can effectively preserve penile size in rats with BCNC injury. The beneficial effect of VED therapy is related to antihypoxia by increasing cavernous blood SO2.

Periosteal spindle cell hemangioma of the fibula: a case report

Spindle cell hemangioma is a rare benign tumor characterized by cavernous blood vessels and spindle cell proliferation. It typically arises in the subcutis of the distal extremities, particularly in the hand. Spindle cell hemangioma of periosteal origin is extremely rare, and our extensive literature search did not find any reports of this condition. We report here a case of spindle cell hemangioma of periosteal origin arising from the right fibula of a 49-year-old woman. Pathological examination of a needle biopsy specimen indicated the possibility of low-grade spindle cell sarcoma, and the patient underwent resection of the fibular diaphysis with a wide margin. Subsequent examination of the surgical specimen revealed a diagnosis of periosteal spindle cell hemangioma. Follow-up examination at 10 months showed no evidence of local recurrence or metastasis. A large tissue sample was required for definitive diagnosis in this case. Spindle cell hemangioma behaves in a benign fashion, but recurrence occurs in about 60% of cases. Excision of the fibula was a reasonable course of management in this case because these patients usually maintain good function. Reports of additional cases will be required to determine the most appropriate treatment for this tumor.

Intracavernosal injections in the diagnosis and treatment of PDE-5 resistant erectile dysfunction.

Dupplex Doppler study after intracavernosal injection (ICI) of vasoactive drugs is a valuable tool in the evaluation of vascular status in patients suffering from erectile dysfunction [1]. Normal erection after ICI suggests sufficient venous occlusion. Persistent diastolic cavernous blood flow measured by end–diastolic velocity (EDV) despite adequate arterial inflow measured by peak systolic velocity (PSV) suggests insufficient veno–occlusive mechanism which results in venous leakage [1]. EDV >5 cm/s and resistive index (RI) less than 0.75 have been universally accepted as pathologic reflecting venous outflow, though controversies exist about normal values of PSV. EAU recommends considering PSV of >30 cm/s, EDV 0.8 as normal while some authors consider PSV values between 25 and 35 and EDV between 5 and 7 cm/s as grey zone [1, 2, 3]. Dupplex Doppler studies have some limitations. The tests may be false negative in up to 20% with borderline arterial inflow (25–35 cm/s) [1]. Repeated duplex Doppler examinations revealed normal vascular status in a significant number of patients [4]. Moreover, several studies showed that EDV and RI in patients with repeated unsatisfactory reactions to intracavernous prostaglandin injection are poor predictors of venous leakage and should not replace dynamic pharmacocavernosometry/cavernosography (DPCC) in the investigation of vasculogenic impotence [5]. Cavernosography definitely has its place in diagnosing cavernosal venous leakage and is considered the gold standard by some authors [3, 4]. False positive results of duplex Doppler studies may be due to e.g. anxiety during the examination, which can resolve with repeated administration out of the office. The authors [6] present a concept of repeated ICI in patients with erectile dysfunction resistant to oral and intracavernosal therapy and EDV >5 cm/s on duplex Doppler examination, which suggests that at least part of those men suffered from venous leakage. No pharmacocavernosometry studies were done, which may however reflect common daily practice. Repeated self–administered ICI resulted in symptomatic improvement and reduction in mean EDV and increase in RI, while no significant difference in mean PSV was noted. Those patients who responded to therapy were generally younger and had worse erection quality before start of the study, which may have resulted in bigger potential for improvement and better quality of cavernous tissue. Improvement in EDV was noted in 21 patients and 10 of them reached EDV <5 cm/s which was considered normal. Possible explanation of that finding is discussed in the article. Despite that, only six men with EDV <5 cm/s during duplex Doppler examination after the treatment reported improvement in erectile response after ICI including three who regained spontaneous erections without injections. It would therefore be interesting to look at PSV values in responders and non–responders before and after the treatment, as differences in PSV changes between those groups could reflect existence of mixed vasculogenic pathology and arterial insufficiency component. Despite those considerations, an idea of repeated self–administered ICI in treatment of men with erectile dysfunction and abnormal EDV during dupplex Doppler studies seems to be interesting. Such an approach would be helpful to identify a group of non–responders who should then be referred to angiografic imaging as potential candidates for vascular surgery. Further studies including pharmacocavernosometry/pharmacocavernosography are needed to verify the role of repeated self–administered ICI in the treatment of erectile dysfunction due to cavernosal venous leakage.

Standard Operating Procedures for Priapism

To provide standard operating procedures for the diagnosis and management of priapism. Review of the literature. Reduction of priapism and preservation of erectile function. Priapism is a persistent penile erection that continues hours beyond, or is unrelated to, sexual stimulation. Priapism requires prompt evaluation and usually requires emergency management. There are two types of priapism: (i) ischemic (veno-occlusive or low flow), which is found in 95% of cases, and (ii) nonischemic (arterial or high flow). Stuttering (intermittent) priapism is a recurrent form of ischemic priapism. To initiate appropriate management, the physician must determine whether the priapism is ischemic or nonischemic. Necessary diagnostic steps are an accurate history, physical examination, and cavernous blood gas analysis and/or color duplex ultrasonography of the corpora cavernosa. Management of ischemic priapism should achieve resolution as promptly as possible. Initial treatment is therapeutic aspiration with or without irrigation of the corpora. If this fails, intracavernous injection of sympathomimetic drugs is the next step. Surgical shunts should be performed if nonsurgical treatment has failed. The initial management of nonischemic priapism should be observation. Selective arterial embolization is recommended for the management of nonischemic priapism in patients who request treatment. The goal of management for a patient with recurrent (stuttering) priapism is prevention of future episodes. Management of priapism has become increasingly successful as scientific understanding of the pathophysiology and molecular biology of priapism improves. The key to further success in the treatment of priapism is basic research of this uncommon but potentially devastating condition.

Intraosseous spindle cell hemangioma of the calcaneus: a case report and review of the literature

Spindle cell hemangioma, a rare benign tumor characterized by cavernous blood vessels and spindled areas, typically arises in the subcutis of the distal extremities, particularly the hand. The case of intraosseous spindle cell hemangioma is extremely rare, and only 1 case arises in the frontal bone has been reported previously. We describe herein a case of intraosseous spindle cell hemangioma occurring in the left calcaneus in a 65-year-old woman. The patient was successfully treated by the operation. The present case is instructive especially in the differential diagnosis of primary bone tumor structured by spindle cells, for which the possibility of spindle cell hemangioma should be considered.

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.

Is there a significance of histamine in the control of the human male sexual response?

Although histamine has been suggested to be involved in the control of male sexual function, including the induction of penile erection, its role in the human corpus cavernosum penis is still poorly understood. The aim of our study was to evaluate the course of histamine plasma levels through different stages of sexual arousal in the systemic and cavernous blood of healthy male subjects. Thirty four (34) healthy men were exposed to erotic stimuli to elicit penile erection. Blood was aspirated from the corpus cavernosum and a cubital vein during the penile conditions flaccidity, tumescence, rigidity and detumescence. Blood was also collected in the post-ejaculatory period. Plasma levels of histamine (ng ml(-1)) were determined by means of a radioimmunoassay. Histamine slightly decreased in the cavernous blood when the penis became tumescent. During rigidity, histamine decreased further but remained unaltered in the phase of detumescence and after ejaculation. In the systemic circulation, no alterations were observed with the initiation or termination of penile erection, whereas a significant drop was registered following ejaculation. Results are not in favour of the hypothesis of an excitatory role of histamine in the control of penile erection. Nevertheless, the amine might mediate biological events during the post-ejaculatory period.