Embolization Of Internal Pudendal Artery Research Articles

Internal pudendal artery embolization: A minimally invasive approach for bulbar artery pseudoaneurysm.

We report a case of 20-year-old young male with hematuria caused by bulbar artery pseudoaneurysm. There was neither history of trauma nor prior bladder catheterization. Nontraumatic, non-iatrogenic bulbar artery pseudoaneurysm is a very rare cause of hematuria. Endovascular management by gel foam embolization after selective catheterization of bulbar branch of internal pudendal artery was done. The reason behind gel foam embolization was that gel foam provides temporary arterial occlusion to allow time for mucosal healing and so erectile function will not be affected.

Hematospermia: An Unusual Cause of Urology Emergency

Hematospermia is a distressing disorder in sexually active men resulting in great concern to the patient. We report an unusual case of hematospermia with an atypical presentation, involving a 54-year-old man presented with acute urinary retention after sexual intercourse. Although the causes are widely known, arteriovenous malformation as the cause of this disorder has not much been reported in the literature. Transcatheter embolization of internal pudendal artery is a promising option for hematospermia caused by arterial fistula or bleeding.

Post traumatic prepubertal high-flow priapism: a rare occurrence

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

Disseminated Intravascular Coagulation Following Transrectal Ultrasound Guided Prostate Biopsy

A 69-year-old otherwise healthy male who was not taking any medication presented with acute urinary retention and prostate specific antigen 75 g/l (normal 0 to 4). Eight transrectal ultrasound (TRUS) guided prostate biopsies were performed uneventfully. Blood work on the day of the procedure, including hemoglobin, platelets, prothrombin time, partial thromboplastin time and international normalized ratio, was normal. The patient was given 500 mg ciprofloxacin orally the night before and the morning of the procedure. Ten hours after the procedure he presented with progressively worsening rectal bleeding and became hemodynamically unstable. Physical examination revealed massive rectal bleeding. Blood work showed hemoglobin 115 gm/l (normal 140 to 180), platelets 80 10/l (130 to 400), white blood count 15.2 10/l (4.8 to 10.8), prothrombin time greater than 240 seconds (13.0 to 15.8), partial thromboplastin time greater than 240 seconds (35.0 to 46.8), fibrinogen less than 0.5 gm/l (1.94 to 3.82) and D-dimer greater than 4.0 g/l (0 to 0.5). Urine and blood cultures were later found to be negative. The patient was subsequently examined while under anesthesia. The source of bleeding was poorly visualized and the rectum was packed. Angiography and right internal pudendal artery embolization were done (see figure). He was transferred to the intensive care unit and treated for DIC. Intensive care unit course was complicated by acute renal failure, pulmonary edema and atrial fibrillation. Nevertheless, he completely recovered and was discharged from the hospital after 3 weeks. Pathological evaluation showed adenocarcinoma of the prostate Gleason 9/10 in all specimens. The patient had diffuse bone metastases and was started on hormonal therapy. Three months later he was asymptomatic and prostate specific antigen was 6 g/l.

RECANALIZATION OF EMBOLIZED CAVERNOSAL ARTERY: RESTORING POTENCY IN THE PATIENT WITH HIGH FLOW PRIAPISM

High flow priapism is an uncommon disease. Most cases are secondary to trauma. An arteriocavernous fistula caused by laceration of the cavernosal artery or one of its branches is the most common cause of this hemodynamic alteration. Immediate treatment with reduction of abnormal arterial flow is better possibly than other treatments. In addition, angiographic embolization is safe, selective and affords return to premorbid function and, therefore, it has been the most widely used. In our patient we evaluated the cavernosal blood gas analysis, and performed color Doppler ultrasonography and angiography for diagnosis, and superselective embolization of the internal pudendal artery with the autologous blood clots. The patient was followed with color Doppler ultrasonography and magnetic resonance imaging (MRI) 2 months after embolization. CASE REPORT A 17-year-old man presented with a 7-day history of sustained, painless and incomplete erection that occurred 3 days after blunt penile injury when he fell down on a bicycle. The erection did not subside and drainage of the corpora cavernosa with needle aspiration and several irrigations with 10 mg./ml. phenylephrine, which produced transient flaccidity, had been performed elsewhere. When referred to us, the penis was engorged with no tenderness, except bruising. A color Doppler scan showed abnormal arterial and venous flow in the corpora, and turbulent flow in the pseudoaneurysm. Peak systolic velocity was 30 cm. per second (end diastolic velocity of 3 cm. per second) in the right cavernosal artery and 52 cm. per second (end diastolic velocity of 6 cm. per second) in the left cavernosal artery before embolization. Blood gas analysis of the corpora cavernosa revealed a high oxygen partial pressure tension (93.8%) and oxygen saturation (97.1%). Superselective pudendal angiography performed with the patient under local anesthesia clearly demonstrated extravasation consistent with the presence of a pseudoaneurysm from a branch of the left cavernosal artery (fig. 1, A). Superselective embolization of the left internal pudendal artery with 3 ml. of autologous blood was performed. Repeat contrast injections confirmed a dramatic reduction in blood flow to the penis (fig. 1, B). The penis became gradually flaccid in the following 48 hours. During followup 2 months later, the patient stated that sexual arousal was associated with the return of erections, which were not complete. Physical examination revealed a ring-like fibrotic mass in the penile base but the lesion could not be differentiated as to whether it was in the tunica albuginea or intracavernosum. Color Doppler ultrasonography after injection with intracavernosal vasoactive agents revealed a well circumscribed hypoechoic mass that was no longer connected with the cavernosal artery, and there was no turbulent flow in the hypoechoic cystic mass (fig. 2, A).

Alternative Approaches to the Management of Priapism

Herein we describe the use of intracavernous methylene blue (MB), a guanylate cyclase inhibitor, or internal pudendal artery embolization for the treatment of priapism. Eleven patients with priapism were treated from 1993-1996. Etiologies of priapism included PGE1/papaverine (3), trazodone (2), and sickle cell disease (1), in the other five cases the causes the cause was unknown. The average duration of priapism was 27 h for all patients (6-72 h). Five patients who failed intracavernous MB or an alpha-adrenergic agonist, underwent unilateral or bilateral pudendal artery embolization. The average duration of priapism for patients undergoing embolization was 43 h. Sixty-seven percent of the patients treated with MB responded with immediate detumescence. One-hundred percent of patients with priapism secondary to intracavernous injection therapy or trazodone responded. Of the five patients who underwent embolization, 40% achieved immediate pain relief and subsequent detumescence. The three non-responders exhibited a partial detumescence over 47-72 h. After follow-up of one year embolization available for only two patients revealed that one regained potency while the other remained impotent. These results confirmed that MB is effective for pharmacologically-induced priapism. Embolization is a less invasive option for refractory priapism, although results are less than satisfactory in men with priapism of several days duration.

Alternative approaches to the management of priapism.

Herein we describe the use of intracavernous methylene blue (MB), a guanylate cyclase inhibitor, or internal pudendal artery embolization for the treatment of priapism. Eleven patients with priapism were treated from 1993-1996. Etiologies of priapism included PGE1/papaverine (3), trazodone (2), and sickle cell disease (1), in the other five cases the causes the cause was unknown. The average duration of priapism was 27 h for all patients (6-72 h). Five patients who failed intracavernous MB or an alpha-adrenergic agonist, underwent unilateral or bilateral pudendal artery embolization. The average duration of priapism for patients undergoing embolization was 43 h. Sixty-seven percent of the patients treated with MB responded with immediate detumescence. One-hundred percent of patients with priapism secondary to intracavernous injection therapy or trazodone responded. Of the five patients who underwent embolization, 40% achieved immediate pain relief and subsequent detumescence. The three non-responders exhibited a partial detumescence over 47-72 h. After follow-up of one year embolization available for only two patients revealed that one regained potency while the other remained impotent. These results confirmed that MB is effective for pharmacologically-induced priapism. Embolization is a less invasive option for refractory priapism, although results are less than satisfactory in men with priapism of several days duration.