Episodes Of Priapism Research Articles

Priapisme sous antipsychotiques et défis de prise en charge : à propos d’un cas

Priapism is a persistent, and often painful, penile erection, lasting more than 3 hours, not usually associated with sexual stimuli. It is a urological emergency that can cause serious complications. Drugs are responsible of the onset of 25 to 40% of cases of priapism. Several classes of medication are involved: antidepressants, antihypertensives, anticoagulants, alpha-blockers and some psychoactive substances (alcohol, cocaine, cannabis...). However, about 50% of drug related priapism is due to antipsychotics (AP). Clinicians should be aware of this rare side effect because of the severity of its complications and the difficulty of its management, especially in non-stabilized psychotic patients. We report a case of a 22-year-old male Moroccan patient, diagnosed with schizophrenia, who had been admitted for the first time to a psychiatric hospital for management of a psychotic episode. First, he received 15 mg per day of haloperidol, and seven days later he developed priapism. The patient was immediately referred for urological care. Aspiration and irrigation of the corpora cavernosa was proposed, but could not be performed because of patient refusal, and the erection resolved spontaneously after 10 hours. Haloperidol was stopped, and four days later the patient was switched to 10mg per day of olanzapine. After 10 days of treatment, he developed a second episode of priapism, and olanzapine was also stopped. A cavernosal aspiration-irrigation was performed in emergency; which resulted in the partial detumescence of the penis. Two days later, and despite therapeutic abstention, the patient presented another episode of priapism. The indication of a revascularization of the corpora cavernosa was proposed, but again the patient refused the surgery. Finally, the patient was administered 400mg/day of amisulpride, with a favorable outcome. Priapism disappeared after a month with the installation of fibrosis and partial loss of erectile function. The precise mechanisms of the role of AP in the occurrence of priapism are not all known and a multifactor etiology seems the most likely. Neuromuscular hypothesis is the most mentioned, involving the blocking action of alpha1-adrenergic receptors of the corpora cavernosa for which most of AP have an affinity. The occurrence of priapism in a psychotic patient, especially during periods of decompensation, raises a number of challenges for the medical staff. First, the non-recognition by the patient of this side effect, and its potentially severe consequences. Second, the absence of link between dose and duration of AP treatment on one side, and the onset of priapism on the other, which makes it hard to predict. The third challenge is the choice and initiation of another AP. The literature reveals many cases of priapism in both conventional and atypical AP, the presence of a predisposition to this type of incident has been reported. However, few authors have focused on alternatives to provide for these patients. Amisulpride is currently the only molecule that does not have alpha-adrenergic affinity and is therefore preferred in these cases. Priapism is a rare but serious adverse event of AP medication. Informing patient about the risk of priapism would help to report it early and prevent erectile dysfunction. Switching to another AP with less alpha1-blocking properties is generally recommended.

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.

Randomized Controlled Trial of Sildenafil for Preventing Recurrent Ischemic Priapism in Sickle Cell Disease

BackgroundSuccessful preventive therapy for ischemic priapism, a disorder of penile erection with major physical and psychologic consequences, is limited. We conducted a randomized, double-blind, placebo-controlled clinical trial to assess the efficacy and safety of sildenafil by a systematic dosing protocol to prevent recurrent ischemic priapism associated with sickle cell disease. MethodsThirteen patients with sickle cell disease reporting priapism recurrences at least twice weekly were randomized to receive sildenafil 50 mg or placebo daily, unassociated with sleep or sexual activity, for 8 weeks, followed by open-label use of this sildenafil regimen for an additional 8 weeks. ResultsPriapism frequency reduction by 50% did not differ between sildenafil and placebo groups by intention-to-treat or per protocol analyses (P = 1.0). However, during open-label assessment, 5 of 8 patients (62.5%) by intention-to-treat analysis and 2 of 3 patients (66.7%) by per protocol analysis met this primary efficacy outcome. No significant differences were found between study groups in rates of adverse effects, although major priapism episodes were decreased 4-fold in patients monitored “on-treatment.” ConclusionsSildenafil use by systematic dosing may offer a strategy to prevent recurrent ischemic priapism in patients with sickle cell disease.

Oral Phosphodiesterase Type 5 Inhibitors in Recurrent Priapism Complicating Thalassemia Intermedia: A Case Report

Recurrent priapism is a rare, serious and difficult to treat complication of some hematological disorders, for which no standard therapy exists. This study reports a case of a 42-year-old man with thalassemia intermedia complicated by recurrent episodes of priapism. To prevent priapism recurrences, a trial of PDE5is use was initiated. One day after initiation of a PDE5i (25 mg sildenafil repeated every 8 hours), priapism was improved. For 3 weeks, the patient reported improvement, without experiencing any episodes of priapism and a normal physiologic erectile function. Four weeks after treatment he experienced priapism reoccurrence and doubling of the Sildenafil was not effective. Gonadotropin-releasing hormone agonist initiated and one week after initiatin of new drug he improved. He was free of priapism episodes for more than 2 years afterward. PDE5 deregulation seems to be an underling pathologic mechanism of recurrent priapism at least in thalassemia intermedia patients. It appears that PDE5is may have a role in the management of such patients and further testing in clinical trials is needed.

A case of priapism with risperidone.

Priapism is a urologic emergency defined as a prolonged, possibly painful, penile erection. There are several known causes of priapism including psychotropic medications. One of the mechanisms by which antipsychotics are believed to induce priapism is through alpha-1 antagonism. This is case of a 50-year-old male with a history of schizophrenia with previous priapism related to trazodone, who presents with new onset priapism associated with risperidone. In this case, the treatment of priapism includes discontinuation of the offending agent and drainage of the corpus cavernosum twice along with intracavernosal phenylephrine injections. It is important to educate patients on priapism as a possible side effect of medications. It is also important to consider previous episodes of medication-induced priapism when prescribing psychotropic medications as this may increase the patient's future risk of priapism.

Prevention of Recurrent Ischemic Priapism with Ketoconazole: Evolution of a Treatment Protocol and Patient Outcomes

The management of recurrent ischemic priapism (RIP) is not clearly defined. Ketoconazole (KTZ) is used to treat RIP and produces a temporary hypogonadal state to suppress sleep-related erections (SREs), which often evolve into episodes of ischemic priapism in this population. We review our experience to prevent RIP using KTZ and present our outcomes using a decreased dose regimen. A retrospective chart review and phone survey of 17 patients with RIP was performed. KTZ inhibits adrenal and gonadal testosterone production with a half-life of 8 hours. By suppressing testosterone levels, SREs are interrupted. We compared our previous protocol of three times daily (TID) KTZ dosing with prednisone for 6 months with our current regimen of initiating KTZ 200 mg TID with prednisone 5 mg daily for 2 weeks and then tapering to KTZ 200 mg nightly for 6 months. The primary outcome was the prevention of RIP using KTZ. Secondary outcomes included side effects secondary to KTZ use and patient satisfaction. All men experienced daily or almost daily episodes of prolonged, painful erections prior to starting KTZ. The mean number of emergency room (ER) visits per patient prior to starting KTZ was 6.5. No patient required an ER visit for RIP while on KTZ. Sixteen of 17 patients (94%) had complete resolution of priapism while on KTZ with effects noted immediately after starting therapy and no reported sexual side effects attributed to KTZ. One man stopped therapy after 4 days because of nausea/vomiting. Fourteen of 16 men eventually discontinued KTZ after a median duration of 7 months. Twenty-nine percent reported no recurrent priapic episodes after discontinuing. A total of 78.6% had partial or complete resolution of symptoms persisting after KTZ was discontinued with a mean post-treatment follow-up of 36.7 months. No reliable effective preventative therapy has been identified for RIP. In our relatively sizable single-center experience, KTZ appears to be a reasonably effective, safe, and inexpensive treatment to prevent RIP while preserving sexual function. We now recommend our tapered dose regimen listed above. After 6 months, we recommend stopping the medication as we have found a majority of patients will not need to resume nightly KTZ.

Testosterone replacement therapy does not promote priapism in hypogonadal men with sickle cell disease: 12‐month safety report

Hypogonadism, which is highly prevalent in men with sickle cell disease (SCD), affects quality of life and causes great morbidity. The safety of testosterone replacement therapy (TRT) in SCD in relation to priapism episodes is relatively unknown. Our aim was to monitor the safety of TRT in a cohort of seven hypogonadal men with SCD. Testosterone undecanoate (Nebido) 1 g was administered intramuscularly to adult men with homozygous SCD (Hb SS) having hypogonadism [serum total testosterone ≤12.0 nmol/L (346 ng/dL), reference range 12.5-38.1 nmol/L (360-1098 ng/dL)] for 12 months. Serum total testosterone, haemoglobin, haematocrit, renal and liver function tests, glucose and PSA measurements were done at baseline and 12-month follow-up. Trough serum total testosterone, haemoglobin and haematocrit were measured three monthly. Priapism events and adverse drug events were assessed every 3 months. International Index of Erectile Function (IIEF), Androgen Deficiency in the Ageing Male (ADAM) and World Health Organization Quality of Life (WHOQOL) questionnaires were administered at baseline, 6 and 12 months. Seven men with a mean age of 34.4 years were treated. Median total testosterone increased from 10.6 to 11.2 nmol/L (p = 0.46). Median serum lactate dehydrogenase levels decreased from 1445 to 1143.5 IU/L (p < 0.05), while all other laboratory indices remained stable. Injection site pain was the most frequently reported adverse event, with no increases in painful crises, hypersensitivity or oedema. After TRT, there was no significant increase in priapism frequency. Median questionnaire scores were increased for the IIEF (46-68, p = 0.018), reduced for ADAM (5.0-2.0, p = 0.016) and unchanged for WHOQOL (98-103, p = 0.086). TRT using testosterone undecanoate with eugonadal intent for hypogonadism appears to be safe in men with SCD. This treatment does not appear to promote priapism occurrences and rather it possibly improves sexual function. Future prospective evaluations in larger groups of hypogonadal men with SCD are necessary to confirm these findings.

Anxiety related to sexual abuse: a case of recurrent priapism

Recurrent priapism is notoriously difficult to treat and very distressing to the sufferer. There is little literature about emotional contributors to this condition. We report a case of a man with sexual abuse and severe anxiety who responded acutely to emotion-focused treatment with persistent cessation of severe recurrent priapism episodes. A second case treated with the same method had a similar response to treatment. Emotional factors may be relevant in certain cases of recurrent priapism and these factors warrant clinical management and formal study.

Ziprasidone-Induced Ischemic Priapism Requiring Surgical Intervention

To the Editor: This is a case of ischemic priapism necessitating surgical intervention for a patient on ziprasidone treatment. Case report. Mr A, a 50-year-old white man with bipolar I disorder (DSM-IV criteria), had been treated with a combination of ziprasidone and divalproex sodium for the last 6 years. The dose of ziprasidone was 60 mg in the morning and 80 mg at night, which had been his regimen for several years. The patient received advice from his psychiatrist that he should coingest ziprasidone with food to improve the bioavailability. However, the following day (that is, following an ingestion of 80 mg at bedtime and 60 mg in the morning of ziprasidone with food), he presented with a persistent painful penile erection lasting 10 hours. Mr A was treated with corpora cavernosal drainage and irrigation with phenylephrine injection. Owing to lack of improvement, a proximal Winter shunt with corpora cavernosal drain instillation and a second phenylephrine injection was attempted; however, this was unsuccessful. Spontaneous flaccidity was obtained after 3 days. Urologists recommended balloon pump implantation after 6 to 12 months for ischemia-induced impotence. They concluded ziprasidone as the likely etiology of the ischemic priapism. The patient had a history of erectile dysfunction treated with as-required sildenafil 100 mg. The last dose was taken 72 hours prior to the onset of priapism. Subsequent to this treatment with sildenafil, the patient had normally functioning erection, ejaculation, and ensuing flaccidity of his penis following sexual activity. Additionally, the patient reported a 2-hour episode of priapism 5 months prior to the current episode, which resolved spontaneously and was unrelated to sildenafil use. Priapism is a urologic emergency, with some patients developing impotence despite medical interventions.1 PubMed search with terms ziprasidone OR Geodon AND priapism found only 1 previous report concerning ziprasidone use and ischemic priapism requiring surgical intervention.2 Priapism, though uncommon, is referenced as a possible side effect with ziprasidone. Ziprasidone has an antagonist action on α1 receptors,3 and this action is ostensibly culpable in priapismic reactions. There can be up to a 2-fold increase in bioavailability when ziprasidone is ingested with food, and, hence, patients are normally advised to ingest this medication with at least a 500-calorie dietary intake for better absorption.4 This patient had a prolonged history of fasted-state ziprasidone administration, which upon correction elicited a rapid dose-dependent α1-mediated ischemic-priapismic reaction to amplified drug concentrations, mandating emergent surgical interventions. Phosphodiesterase inhibitors, too, can cause prolonged erection5; in this patient’s case, sildenafil is unlikely to have been the cause for 2 primary reasons. Firstly, sildenafil has a short half-life of 3 to 4 hours,6 and the duration between sildenafil use and priapism onset was 72 hours. Secondly, there was a return to normal flaccidity following the sexual act when sildenafil was last used. Up to 50% of patients with priapism have a history of prolonged erection.7 In this case, an episode of self-resolving prolonged erection was followed by ischemic priapism 5 months later. We recommend that clinicians educate patients and monitor for sexual side effects not only following initiation and dose increments of ziprasidone, but also during any conditions that promote bioavailability. From this case, we suggest close follow-up or medication switching in those patients who experienced an episode of self-resolving priapism on ziprasidone treatment to prevent adverse reactions such as ischemic priapism and its associated morbidities.

Transient Distal Penile Corporoglanular Shunt as an Adjunct to Aspiration and Irrigation Procedures in the Treatment of Early Ischemic Priapism

PurposeIschemic priapism, a compartment syndrome, requires urgent treatment in order to nourish the corpora cavernosa. As the first step, aspiration of blood and irrigation of the cavernosal bodies is performed to prevent fibrotic activity and secure erectile capability. During aspiration, there are risks of cardiovascular side effects of adrenergic agonists. We aimed to evaluate a transient distal penile corporoglanular shunt technique in place of aspiration and irrigation techniques for treatment of early ischemic priapism.Materials and MethodsA transient distal penile shunt was applied to 15 patients with early ischemic priapism between January 2011 and May 2012. Priapism duration, history, causes, pain, and any prior management of priapism were assessed in all patients. A complete blood count and penile Doppler ultrasonography were performed, which showed attenuated blood flow in the cavernosal artery. A sterile closed system blood collection set, which has two needles and tubing, was used for the transient distal penile shunt.ResultsTen of 15 patients with early ischemic priapism were successfully treated with this transient shunt technique. No additional procedures were needed after the resolution of rigidity in the 10 successfully treated patients.ConclusionsThe transient nature of this technique is an advantage over aspiration and irrigation in the treatment of early ischemic priapism. Our results indicate that the technique can be offered for patients with an ischemic priapism episode of no more than 7 hours.

Erectile Function Significant Enough for Penetration During Sexual Intercourse after Removal of Inflatable Penile Prosthesis

Fifty-two-year-old male with history of multiple insults to his erectile tissue, including insertion and removal of penile implant, presents with significant partial erectile function, substantial enough for anal penetration during sexual intercourse. Erectile function rigid enough for anal penetration, let alone any erectile function after removal of an inflatable penile prosthesis (IPP), is rare. This article, to our knowledge, is the first case of a patient who has undergone multiple insults to his erectile tissue, including an episode of ischemic priapism followed by implantation and removal of an IPP, who presents with erectile function sufficient enough for coitus. Outcome measured via standardized patient questionnaires and penile Doppler following injection of Trimix. An objective measure of the patient's erectile function was performed via penile Doppler. Penile Doppler after 10-mcg injection of Trimix revealed numerous perforating vessels from the corpora spongiosum providing blood flow to the corpora cavernosa. The patient obtained approximately 60-70% rigid erection. To our knowledge, and after thorough review of the literature, we could not find any reports of erectile function significant enough to take part in sexual intercourse and penetration after removal of a three-piece IPP. The implant usually disrupts the normal anatomy which allows for cavernosal arterial vasodilation and increased blood flow into the corpora. Following dilation of the corpora the cylinders are inserted and inflated, and the smooth muscle that makes up the corpora cavernosum is compressed against the wall of the tunica albuginea. Theoretically, the remaining smooth muscle tissue may retain some of its physiologic function, adding some additional girth to the penis with an already activated IPP during sexual intercourse.

Finasteride for recurrent priapism in children and adolescents: a report on 5 cases

Recurrent priapism is prevalent in children. Different medications have been used to avoid new episodes, however, there is no consensus regarding the best option. The use of finasteride to treat priapism in adults has already been tested. The aim of the present study was to test the hypothesis that a low dose of finasteride would be effective in preventing recurrent priapism in children. Since 2007, five children and adolescents with recurrent episodes of priapism have been treated with finasteride in our department, and the medical records of these patients were reviewed for this study. In four cases, the dose used was 1 mg a day, while the remaining patient used 1 mg twice a day. Prior to initiating finasteride treatment, one patient reported having had 6 episodes of acute priapism, while the remaining patients had more than 10 episodes. One of the patients reported having stuttering priapism almost daily. With a mean follow-up of 20 months, four patients had no episodes and only one patient complained of sporadic and shorter duration episodes. These initial results suggest that a low daily dose of finasteride appears to represent an effective and safe form of treatment for recurrent priapism in children and adolescents with SCD. However, in order to confirm these initial findings, studies with a large population and a control group are essential.

Corporal Burnett “Snake” Surgical Maneuver for the Treatment of Ischemic Priapism: Long-Term Followup

We provide long-term followup on a modification of the Al-Ghorab distal penile corporoglanular shunt surgery for the treatment of ischemic priapism. We conducted a retrospective review of patients surgically treated for ischemic priapism at The Johns Hopkins Hospital from January 2008 to April 2012 with the Burnett "Snake" maneuver of the Al-Ghorab shunt. Electronic medical records were reviewed to collect demographic information and telephone followup was performed to verify treatment outcomes. Patients completed the SHIM (Sexual Health Inventory for Men) to assess current erectile function. A total of 10 patients were analyzed (age range 31 to 59 years). Mean followup was 6.7 months (range 0.5 to 17). Priapism etiologies were idiopathic (3), trazodone (2), trazodone and cocaine (3), intracavernous injection of trimix (1) and spinal cord injury (1). There were 6 patients who had previously undergone unsuccessful surgical attempts at priapism decompression and mean priapism duration was 75 hours (range 24 to 288). Of the 10 men 8 achieved successful resolution of priapism with no recurrence. There were 2 men with recurrent priapism refractory to all management who were definitively treated with insertion of an inflatable penile prosthesis. Of 9 men 6 had normal erectile function preoperatively, of whom 2 achieved at least partial erectile function postoperatively. Complications were sustained by 2 men, including wound infection with skin necrosis in 1, and an intraoperative urethral injury in the other with subsequent urethrocutaneous fistula formation and wound infection with skin necrosis. The modified Al-Ghorab corporoglanular shunt using the Burnett snake maneuver is successful in resolving ischemic priapism, particularly in cases refractory to first line management, and in preventing further episodes of priapism.

Stuttering Priapism: Insights into Pathogenesis and Management

Priapism is defined as a persistent, painful erection that continues beyond, or is unrelated to, sexual stimulation. It may be categorized as either ischemic (low/absent flow) or nonischemic (high flow). Stuttering priapism is a variant of the ischemic type that is characterized by repetitive, transient, painful, self-limiting episodes of priapism. It is associated with various hematological disorders, including sickle cell disease and pharmacological treatments. The consequences of ineffective treatment of priapism are erectile dysfunction and impaired quality of life due to chronic pain and physical disfigurement. Many of the existing medical therapeutic options for treatment of stuttering priapism are nonmechanistic and associated with significant adverse effects. However, the scientific knowledge of stuttering priapism has transitioned in the past few years, from a condition that is poorly understood to one that has borne a burst of evolving molecular science. In this review, the pathophysiology of priapism is discussed, with particular emphasis on new molecular effectors and mechanisms. Novel treatment methods, as well as potential future agents, based on the emerging molecular evidence are discussed.

809 TESTOSTERONE DEFICIENCY IS A POSSIBLE RISK FACTOR FOR PRIAPISM ASSOCIATED WITH SICKLE CELL DISEASE

You have accessJournal of UrologySexual Function/Dysfunction/Andrology: Basic Research I1 Apr 2012809 TESTOSTERONE DEFICIENCY IS A POSSIBLE RISK FACTOR FOR PRIAPISM ASSOCIATED WITH SICKLE CELL DISEASE Belinda Morrison, Marvin Reid, Wendy Madden, Zhaoyong Feng, and Arthur Burnett Belinda MorrisonBelinda Morrison Kingston 7, Jamaica More articles by this author , Marvin ReidMarvin Reid Kingston 7, Jamaica More articles by this author , Wendy MaddenWendy Madden Kingston, Jamaica More articles by this author , Zhaoyong FengZhaoyong Feng Baltimore, MD More articles by this author , and Arthur BurnettArthur Burnett Baltimore, MD More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.898AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Priapism has a high incidence in sickle cell disease (SCD). Testosterone deficiency has been recognized in adolescent and adult males with SCD. We sought to determine the association of testosterone deficiency and priapism in adult men with SCD. METHODS A cross-sectional study of 50 adult men with homozygous S SCD was performed. All patients had early morning blood taken for total and free testosterone, FSH, LH, prolactin, lipid levels, LDH and hematological indices. Patients completed an interviewer administered questionnaire regarding priapism frequency, duration and treatment. Hypogonadism was defined as serum total testosterone < 12 nmol/L. The association of testosterone deficiency and priapism was determined. RESULTS Priapism was noted in 24 (48%) patients and was most frequently seen in men between ages 18-25 years. Mean age of the study population was 34.2 ± 8.9 years, and there was no difference in age based on history of priapism. Hypogonadism was assessed in 6 of 24 (25%) patients with priapism. There was no difference in mean total testosterone levels in patients with and without a history of priapism (16.7± 4.9 nmol/L and 15.4±5.9 nmol/L, respectively). Similarly, there was no difference in serum LH and FSH levels based on history of priapism. Of the patients who reported a history of priapism, there was no difference in frequency, number and duration of priapism episodes relative to total or free testosterone levels. There was a trend towards an association of free testosterone levels (p = 0.09) and duration of priapism episodes >30 min (p=0.09). CONCLUSIONS Hypogonadism is prevalent in patients with SCD. There is a 25% risk association of hypogonadism and priapism. Prospectively gathered data is needed to define the priapism profile of SCD patients with hypogonadism. Table 1. Responses to priapism questionnaire in study patients Frequency (%) History of priapism 48 Age of onset of priapism (yrs) 13-17 36 18–25 59 >25 5 Precipitating activity Sleep 95 Intercourse 5 Frequency of priapism episodes Daily 9 Alternate days 14 Once weekly 18 Once monthly 14 Other 45 Duration of priapism episodes <30 min 41 1 hour 32 2 hours 9 2–5 hours 9 >5 hours 9 Table 2. Laboratory values of patients with priapism Variable (Normal range) Mean values in patients with priapism Mean values in patients without priapism Age (yrs) 32.6±1.7 35.8±1.7 Haemoglobin (Hb) (14.0-18.0 g/dl) 7.8±1.8 7.9±1.8 LH (0-25 IU/L) 7.4±2.3 8.1±2.4 FSH (0-20 IU/L) 7.2±4.6 7.2±4.8 Total Testosterone (12.5-38.1 nMol/L) 16.7±4.9 15.4±5.9 Free Testosterone (194.4-936.1 pMol/L) 327.0±135.3 287.8±108.0 © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e330-e331 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Belinda Morrison Kingston 7, Jamaica More articles by this author Marvin Reid Kingston 7, Jamaica More articles by this author Wendy Madden Kingston, Jamaica More articles by this author Zhaoyong Feng Baltimore, MD More articles by this author Arthur Burnett Baltimore, MD More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Acute management of priapism in men

What's known on the subject? and What does the study add? Priapism is a rare event. However, various medications and medical conditions may increase the risk. Priapism can be ischaemic, non-ischaemic or stuttering. It is paramount to distinguish the type of priapism, as misdiagnosis may lead to significant morbidity. Ischaemic priapism represents a compartment syndrome of the penis and is therefore a medical emergency. A delay in management may significantly affect future erectile function. Stuttering priapism represents recurrent subacute episodes of ischaemic priapism, which may lead to erectile dysfunction. Thus episodes must be minimised. Non-ischaemic priapism is not a medical emergency. However, misdiagnosis and injection with sympathomimetic agents can result in system absorption and toxicity. This review article provides a summary of the evaluation and management of priapism. Furthermore, a step by step flow chart is provided to guide the clinician through the assessment and management of this complex issue. To review the literature regarding ischaemic, non-ischaemic and stuttering priapism. To provide management recommendations. A Medline search was carried out to identify all relevant papers with management guidelines for priapism. Ischaemic priapism represents a compartment syndrome of the penis and urgent intervention is required to decrease the risk of erectile dysfunction. Non-ischaemic priapism is not a medical emergency; however, it can result in erectile dysfunction. The treatment objective for stuttering priapism is to reduce future episodes with systemic treatments, whilst treating each ischaemic episode as an emergency. Priapism is a complex condition that requires expert care to prevent complications and irreversible erectile dysfunction.

Priapism in Antipsychotic Drug Use: A Rare but Important Side Effect

Priapism is a rare but important side effect of antipsychotic drugs which may evolve into a urological emergency. Most antipsychotic drugs are alpha-1 adrenergic antagonists, which is thought to be the principal mechanism involved in antipsychotic-induced priapism. Other aetiologies exist, however. A case is presented with multiple episodes of priapism during the use of several different antipsychotic drugs. The case is representative of many patients treated with antipsychotic drugs, as there were hyperprolactinemia, and illicit drug use, which are known causes of priapism. Moreover, the patient used combinations of antipsychotic drugs. The case thus illustrates the etiological complexity which could delay a diagnosis of antipsychotic-induced priapism, and the problem of establishing a link between priapism and one particular ingredient of a drug combination. The case presents how a treatment regimen was finally established balancing antipsychotic efficacy to acceptable side effects and offers guidance to physicians regarding how antipsychotic-induced priapism may be resolved.

269 PARACRINE HEDGEHOG STIMULATES ANDROGEN PRODUCTION FROM PROSTATE STROMAL FIBROBLASTS

apism in children with HbS in order to determine if outcomes differed in patients who did and did not receive SMT. RESULTS: From July 2004 to July 2009, 15 patients with HbS (8HbSS, 3 HbSC, 3 HbSbeta thalassemia, 1 HbSF) experienced 20 priapism episodes. One patient experienced 2 episodes and 2 patients experienced 3 episodes each. 1 patient had undergone prior surgical shunting. Mean age at presentation was 13.2 years (range 1.5 17.8). Hematocrit at presentation was higher in patients with HbSbeta thalassemia (30.2) and HbSC (27) than in patients with HbSS (25.9) or HbSF (23.9). Mean episode duration at presentation was 38.2 hours (range 2.0 384); erections waxed and waned in 8 episodes and were continuous in 12. 7/20 (35%) episodes were associated with acute chest syndrome (ACS); these patients had lower room air oxygen saturation (92.7% vs 98.8%; p 0.04). All patients received treatment directed at the hemoglobinopathy with aggressive hydration (18/20 episodes), narcotic pain medication (19/20 episodes), and/or high-flow oxygen (5/20 episodes). No single therapeutic agent was associated with significant improvement in time to detumescence. Resolution of the priapism mirrored overall improvement in patients with ACS. In 5/20 (25%) episodes, patients required transfusion of packed red blood cells. One episode (5%) required a distal shunt after medical management failed. In 11 (55%) episodes, patients received adjunctive SMT; hematocrit (p 0.23) and episode duration at presentation (p 0.31) were similar in patients with and without SMT. Time to episode resolution was longer in patients who received SMT (76.8 vs 36.8 hours, p 0.09); however, the 1 patient who required shunting did not receive SMT. CONCLUSIONS: In patients with HbS, priapism is often a manifestation of the underlying disease process and rarely requires surgical intervention. Hemoglobinopathy directed therapy should be individually tailored for patients with HbS associated priapism, as no single agent has been shown to improve outcome. SMT use may be associated with delayed resolution of HbS associated priapism.

A Case of Relapsing Priapism Associated With Long-Acting Injectable Risperidone

To the Editor: Priapism is a well-documented side effect of antipsychotic medications, including the atypical antipsychotic risperidone.1 Wang et al2 report a case involving a patient taking the long-acting injectable form of risperidone (Risperdal Consta, Janssen Pharmaceutica). In that case, the patient developed a series of prolonged, self-resolving erections of less than 5 hours' duration following the first injection. This was followed by 2 episodes of frank priapism requiring emergency treatment. The authors did not emphasize the challenges of treating relapsing priapism that resolves only after the drug has been cleared from the system. We present a second report of relapsing priapism following administration of long-acting injectable risperidone and draw special attention to the difficulties of recurrent treatment. Case report. Mr A, a 49-year-old man, presented in March 2006 to our emergency department with priapism that had persisted for the previous 16 hours. His history was significant for paranoid schizophrenia, which had initially been treated with fluphenazine 37.5 mg/d orally. Because of lack of compliance, he was switched to long-acting injectable risperidone every 2 weeks. He had a remote history of alcohol, cocaine, and marijuana abuse but denied ingestion of any illicit drugs or alcohol concurrent with the use of antipsychotic medications. A toxicology screen was negative. Mr A developed priapism 1 week after his third injection of risperidone. The patient was on no medications other than risperidone at the time he developed priapism. Blood aspirated from the corpora cavernosa of the erect penis was dark and thus consistent with ischemic priapism. The patient was treated with aspiration of blood from the corpora cavernosa followed by irrigation with dilute phenylephrine solution with resultant complete detumescence. The patient returned to the emergency department an additional 3 times with relapsing priapism over the next 7 days. Each episode of priapism rapidly and completely responded to phenylephrine injections of the corpora. Mr A was switched back to oral fluphenazine and experienced no further episodes of priapism over the subsequent 18 months. He was subsequently lost to follow-up. Although numerous cases of risperidone-related priapism have been reported,2 little attention has been drawn to relapsing priapism caused by the long-acting injectable form. Clinicians and patients should be aware that such priapism may return even after repeated pharmacologic treatments because of the drug's sustained release, and appropriate plans should be made for follow-up. Presumably, the risk of relapse decreases over a several-week period of time as the risperidone is excreted from the body. This case also illustrates the broader point that long-acting antipsychotics can have a variety of long-lasting adverse effects, including more persistent forms of neuroleptic malignant syndrome and acute dystonic reactions.3 These risks, however, must be weighed against the added convenience that long-acting injectable antipsychotics may offer patients.4

Le priapisme : une complication pédiatrique grave de la maladie de Fabry

Fabry disease is an X-linked recessive lysosomal storage disorder caused by α-galactosidase A deficiency. Although the disease presents in childhood, diagnosis is often delayed to adulthood or missed, presumably due to the lack of specificity of the symptoms and to the absence of major complication during the paediatric years. We report a 9-year-old boy known to have a Fabry disease who presented an episode of priapism. Successful treatment was achieved by repeated corporeal aspiration under general anaesthesia. This case is the fifth report of priapism in children with Fabry disease, suggesting that priapism may be a severe vascular complication of the disease during infancy. This report emphasizes the importance of an early diagnosis and treatment of Fabry disease, including enzyme replacement therapy, to prevent major disease-associated morbidity and to optimize patient outcomes.