Priapism Research Articles

(098) Does Early Implantation of Penile Prosthesis for Ischemic Priapism Associated with Decreased Complication Rate? A Systematic Review of Literature

Abstract Introduction Ischemic priapism (IP) is a prolonged undesired erection that accounts for >95% of all priapism episodes. Like compartment syndrome, it is characterized by diminished corporal blood flow and can lead to corporal fibrosis, penile shortening, and refractory erectile dysfunction. Penile prosthesis (PP) implantation is the treatment option in IP to treat the priapic episode and to preserve erectile function. However, no standardization exists regarding the optimal timing of PP implantation surgery. Objective The present review aims to systematically analyse the literature comparing early and delayed PP implantation in patients with IP. Methods A systematic search on PubMed, Scopus, and EMBASE databases were searched from inception to July 1st, 2023 and followed by hand searching. All the steps were performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. We assess the quality of evidence and the risk of bias in each included study. Results Three retrospective cohort studies comprising 199 subjects were included in this systematic review. All studies have different definitions of the timing of early PP implantation, ranging from within one week to ≤6 months from the onset of priapism. Despite different types of PP used, all studies agreed that early PP implantation results in lower intraoperative complications, such as corporeal perforation and urethral injury, greater preservation of penile length and girth, and a lower rate of prosthetic revision. On the other hand, the delayed insertion was linked to a longer surgical time because of challenges brought on by fibrotic tissue, with most of them also requiring a smaller cylinder. In regards to post-operative complication, the majority of studies demonstrated that delayed implantation would result in a higher rate of complication rate; however, one study demonstrated that early PP implantation had a higher likelihood of prosthesis erosion and infection, which was believed due to a higher rate of bacterial invasion during the earlier shunt surgeries. Conclusions The majority of current evidence favours early penile prosthesis insertion in term of lower complication rate for IP, especially the intraoperative complication, for IP, compared to the delayed implantation. Nevertheless, better quality evidence is still needed from RCT to determine the exact timing for early implantation, patient selection, and the best penile prosthesis types. Disclosure No.

(270) LISWT Before Penile Prosthesis Implantation Might Facilitate Dilation of Fibrotic Corpora

Abstract Introduction Severe corporeal fibrosis presents significant challenges in penile implant insertion. LISWT studies in rats and humans have suggested its ability to rejuvenate cavernous bodies through various mechanisms and growth factors. Objective This prompted our evaluation of LISWT's effectiveness in facilitating prosthesis implantation in patients with penile fibrosis, which are typically considered difficult cases. Methods A 34-year-old male smoker with a history of sickle cell disease, bilateral hip replacements, and splenectomy due to sickle cell crisis sought penile prosthesis implantation. He presented with severe erectile dysfunction and corporeal fibrosis following two ischemic priapism episodes caused by sickle cell disease, which were treated with distal shunts 4 and 1 years prior, respectively (Fig. 1). After obtaining consent, the patient underwent four cycles of LISWT, spaced one month apart. Each cycle consisted of four weekly sessions using the PiezoWave2 device from Richard WOLF with settings of 0.16mj/mm2 energy flux density, 6Hz frequency, and 10mm wave focus penetration depth. In each session, the patient received a total of 6000 shocks, distributed between the perineum, dorsum penis, and the lateral aspect of the penis. Results A month post-LISWT, the patient's Erection Hardness Score (EHS) improved from 0 to 1 following an intracavernous injection of 20 mcg of alprostadil (Fig. 2). Subsequently, he underwent a malleable penile implant procedure through the penoscrotal approach. Cavernosal dilation was successful up to 10mm using a Hegar dilator, with bilateral corporal measurements of 8cm proximally and 9cm distally. A Tactra malleable penile prosthesis (9.5mm girth and 17cm length) from Boston Scientific was implanted without complications (Fig. 3.A.B) Conclusions In cases of severe corporeal fibrosis, pre-treatment with LISWT may aid in the dilation of the corpora during penile prosthesis implantation, potentially reducing complications. Randomized studies are warranted to validate this indication Disclosure No.

Cocaine-related ischemic priapism. Systematic review and presentation of a single center series

IntroductionIschemic priapism is a medical emergency that, if not treated, could lead to permanent erectile dysfunction. The association between cocaine and priapism is well-known; however, data on patient characteristics, treatment, and outcomes is missing.This work aimed to answer the research question: What are the characteristics, management strategies, and erectile prognosis of patients consuming cocaine and presenting with priapism? MethodsWe conducted a systematic review according to PRISMA guidelines and described our case series. ResultsEight studies were selected for qualitative synthesis, presenting information on ten patients. In our case series, we showed information regarding four patients. From the systematic review, the mean presentation time was 42.6 h, and the mean number of procedures to solve priapism was 2,4; in our case series was 42.75 h and 2, respectively. ConclusionCocaine-related priapism might present with a delayed diagnosis, need more procedures to be managed, and have a worse prognosis. More extensive and prospective studies are required.

(039) Clinical Outcomes of Corporal Burnett “Snake” Maneuver Modification for Ischemic Priapism

Abstract Introduction The conventional approach for managing ischemic priapism (IP) involves a stepwise process that includes corporal aspiration and irrigation, intracavernosal sympathetic agent injection, shunt surgeries with or without snaking, and penile prosthesis implantation. It is crucial to determine the most appropriate surgical shunt procedure for patients who do not achieve detumescence with medical treatment, as complication rates are known to increase with ischemia time. Objective This study compared the effectiveness and clinical outcomes of distal penile shunt procedures with or without corporal Burnett "Snake" maneuver in patients presenting with IP. Methods We conducted a retrospective study involving patients who presented to our emergency department with IP and underwent surgical treatment at our institution between 2005 and 2021. The patients were divided into two groups: Group 1 (n = 26) underwent distal shunt + Burnett snake maneuver, and Group 2 (n = 56) underwent distal shunt-only. Clinical history, clinical parameters of IP, medical and surgical treatment details, and follow-up information, including IP recurrence, erectile function (EF), and complications, were determined through physician-patient interviews during preoperative assessment and postoperative visits. Successful priapism resolution was defined as pain relief, detumescence, and no further intervention required until discharge. Priapism recurrence was defined as a new presentation to the hospital with IP. EF was assessed before distal shunt surgeries and during post-op visits. EF was graded on a 4-point patient-reported scale: 1 = fully rigid, always capable of penetration, 2 = diminished erection, capable of penetration with phosphodiesterase-5 inhibitors, 3 = diminished erection, capable of penetration with intracavernosal/intraurethral injection or vacuum pump, 4 = insufficient erection despite non-surgical treatment methods. Results The patient's demographic characteristics are shown in Table 1. IP resolution was observed in 24 out of 26 patients (92.3%) in Group 1 and in 30 out of 56 patients (53.6%) in Group 2 (p < 0.001) with a single surgical intervention. IP recurrence was observed in 1 out of 24 patients (4.2%) in Group 1 and in 18 out of 30 patients (60%) in Group 2 among those successfully treated with a single surgical intervention (p < 0.001). When comparing the EF status between groups, 6 out of 14 patients (42.8%) in Group 1 compared to 13 out of 26 patients (50%) in Group 2 had functional preservation of EF (level 1 + level 2) after priapism surgery, among those successfully treated with a single surgical intervention which had EF data in their charts (p = 0.66). Conclusions Our study demonstrates that Burnett snake maneuver is more effective than distal shunt-only procedures in resolving acute IP. Furthermore, this technique shows greater success in preventing IP recurrences. Regarding EF recovery, Burnett snake maneuver is at least as successful as distal shunt-only procedures, even in cases with longer ischemia times. Disclosure No.

(019) Malignant Priapism: Case Report and Update on Management Protocols

Abstract Introduction Malignant priapism is a rare condition characterized by persistent erection resulting from the invasion or metastasis of a primary neoplasm. Penile metastases arise from the genitourinary tract 64% of the time (bladder: 28.6%, prostate: 27.9%, kidney: 6.9%, ureter: 0.5%) with colorectal adenocarcinoma, lung cancer, melanoma, and hematologic diseases comprising the remainder. Malignant priapism is reported to occur in 20-53% of patients with penile metastasis. The mechanism of malignant priapism remains unknown. The most accepted theory is an invasion of the corpus cavernosum as well as associated venous systems with malignant cells. This can occur from either hematogenous or lymphatic spread from the source tumor. Resulting derangement of arterial or veno-occlusive mechanism causes priapism. Both ischemic and non-ischemic priapism can occur. Objective While treatment guidelines for priapism in non-malignant cases have been established, there is currently no guideline for treating malignant priapism. This study aims to present three cases of malignant priapism resulting from advanced genitourinary cancers and evaluate the efficacy of palliative penectomy as a treatment modality for relieving symptoms associated with malignant priapism. Methods We conducted a retrospective analysis of three cases of malignant priapism associated with advanced genitourinary cancers. Data were collected from medical records, including patient demographics, primary tumor characteristics, clinical presentation, treatment modalities, complications, and outcomes. The main treatment approach utilized in all cases was palliative penectomy. Symptom relief and complications were assessed as primary outcomes. Results All three patients presented with progressive penile pain, and imaging studies confirmed the presence of metastatic disease involving the penile structures. Palliative penectomy was performed in all cases, resulting in sustained relief of symptoms. No major complications were reported during the surgical procedures. Follow-up assessments showed improved quality of life in terms of pain relief, but all patients died within a short period following penectomy owing to the advanced predisposing malignancy. (figure 1) Conclusions Treatment of malignant priapism needs to be individualized to the needs of the patient. No matter the primary or secondary nature of the disease, current data suggest that malignant priapism is associated with poor outcomes, and emphasis should be put on palliative care. Although new radiation techniques have shown favorable outcomes, penectomy should be considered the last resort in clinical management. Revisions to the existing management guidelines for priapism are necessary to address its occurrence in malignant contexts. (figure 2) Disclosure No.

Prolonged ischemic priapism in an adolescent with sickle cell anemia: Challenges of management

Introduction: Persistent penile erection lasting more than 4 hours and unrelated to sexual interest or stimulation is called priapism. Priapism is uncommon in children. Of the three widely accepted types: ischemic, non-ischemic, and stuttering priapism; ischemic priapism is the predominant type seen in children. A common cause of ischemic priapism in children is sickle cell disease. Ischemic priapism of prolonged duration is associated with a higher risk of complications especially irreversible loss of erectile function. It is a difficult clinical condition to manage and there are no established guidelines for its management in children. Adequate surgical treatment does not guarantee against the risk of devastating longterm sequelae. Case Report: We report a case of a 12-year-old boy with sickle cell anemia who presented after 48 hours of sustained painful penile erection. He required multiple surgical shunting procedures including distal corporoglanular shunt with tunneling of both corpora cavernosa with Hegar’s dilator to achieve detumescence. The management challenges encountered are highlighted. Conclusion: A potential role for anticoagulation and the use of low-dose hydroxyurea in the prevention of recurrent ischemic priapism in children with sickle cell anemia are advocated.

A novel technique for contained aspiration and irrigation of priapism

Abstract Background Ischemic priapism is a urological emergency requiring prompt corporal aspiration and irrigation, with risk of blood spillage that can place a significant biological hazard to the urologist and rest of emergency room staff. Aim The study sought to develop and validate a method for contained corporal aspiration that minimizes exposure to sharps and occupational hazards. Methods We used one large bore needle connected to a vacuum aspiration device and blood draw tubes for corporal aspiration and irrigation of ischemic priapism. Outcomes Feasibility of this method was assessed in 18 consecutive patients presenting to the emergency room with ischemic priapism. Clinical characteristics, resolution of priapism, and need for further interventions were documented. Results A total of 18 patients were treated using this technique. The mean time from onset to presentation was 12 hours. The etiology in all patients was recreational intracavernosal drug abuse, and 72% were HIV positive. Priapism completely resolved in all 18 patients. No patients required shunt procedures or further interventions to achieve detumescence. Clinical Implications This system can be used for safe management of ischemic priapism in any clinical scenario but is particularly beneficial to minimize exposure risk in the setting of increased risk of blood-borne infections. Strengths and Limitations This initial trial shows that this technique is safe and effective for cavernosal aspiration of ischemic priapism. Larger trials are required to validate this method. Conclusion Contained aspiration and irrigation of priapism can be used for effective management of ischemic priapism while minimizing health risks to urologists and emergency room staff.

Comment on: "Current opinions on the management of prolonged ischaemic priapism: does penoscrotal decompression outperform corporoglanular tunneling?"

Comment on: "Current opinions on the management of prolonged ischaemic priapism: does penoscrotal decompression outperform corporoglanular tunneling?"

Current opinions on the management of prolonged ischemic priapism: does penoscrotal decompression outperform corporoglanular tunneling?

Prolonged ischemic priapism presents a treatment challenge given the difficulty in achieving detumescence and effects on sexual function. To evaluate current practice patterns, an open, web-based multi-institutional survey querying surgeons' experience with and perceived efficacy of tunneling maneuvers (corporoglanular tunneling and penoscrotal decompression), as well as impressions of erectile recovery, was administered to members of societies specializing in male genital surgery. Following distribution, 141 responses were received. Tunneling procedures were the favored first-line surgical intervention in the prolonged setting (99/139, 71.2% tunneling vs. 14/139, 10.1% implant, p < .001). Although respondents were more likely to have performed corporoglanular tunneling than penoscrotal decompression (124/138, 89.9% vs. 86/137, 62.8%, p < .001), penoscrotal decompression was perceived as more effective among those who had performed both (47.3% Very or Extremely Effective for penoscrotal decompression vs. 18.7% for corporoglanular tunneling; p < .001). Many respondents who had performed both tunneling procedures felt that most regained meaningful sexual function after either corporoglanular tunneling or penoscrotal decompression (33/75, 44.0% vs. 33/74, 44.6%, p = .942). While further patient-centered investigation is warranted, this study suggests that penoscrotal decompression may outperform corporoglanular tunneling for prolonged priapism, and that recovery of sexual function may be higher than previously thought after tunneling procedures.

Randomized Controlled Double Blind Feasibility Trial of Tadalafil with Hydroxyurea Versus Hydroxyurea with Placebo for Secondary Prevention of Recurrent Priapism in Men with Sickle Cell Anemia: Pin Trial Final Results

Background: Recurrent ischemic priapism is a common complication of sickle cell anemia (SCA) with devastating sequelae of sexual dysfunction, reported at least once in 33% of men, with no evidence-based preventive treatment. Pre-clinical and observational studies with inadequate power have shown the potential benefits of phosphodiesterase-5 (PDE-5) inhibitors in preventing future priapism in transgenic mouse models and humans. Therefore, we hypothesized that a trial of PDE-5 inhibitor (tadalafil) for the prevention of priapism in men with SCA would be feasible, with an acceptable safety profile. Methods: We conducted a randomized, controlled, double-blind phase 2 feasibility trial to assess the composite primary outcome of recruitment, retention, and adherence rates of at least 75%. With a sample size of ³30 and an observed compliance rate of 83% and higher, we would obtain a lower bound of 75.6% or greater (above our lowest acceptable rate of 75% recruitment, retention, and adherence) using the Clopper-Pearson formula. The clinical outcomes were priapism rate (person-month), priapism pain intensity (1-5 Likert scale), priapism duration (minutes), and hospitalization for pain. The trial included men with SCA aged 18 to 40 years who had experienced a minimum of three priapism episodes, each lasting at least an hour, in the past 12 months, Figure 1. After satisfying the eligibility criteria and signing informed consent, the participants passed through a screening phase (2-4 weeks) and were subsequently randomized 1:1 into a treatment arm (tadalafil 5mg/day and hydroxyurea 20mg/kg/day) and standard care/placebo arm (hydroxyurea 20mg/kg/day and placebo). The treatment phase lasted 4 to 12 months, with priapism episodes tracked by: 1) daily text messages to each participant and 2) a paper diary to complement the daily text messages. The data was analyzed based on the intention to treat using negative binomial regression. The trial was approved by the IRB of Vanderbilt University Medical Center and Aminu Kano Teaching Hospital. The protocol was registered with Clinicaltrials.gov (NCT05142254) and PACTR (PACTR202105561969346). Results: The trial opened on 13th April 2022 and was stopped by the Data Safety and Monitoring Board on 12th June 2023 due to futility, based on the data as of 27 th February 2023. All 84 men approached for the trial consented to screening (100% recruitment rate), but only 64 (76.2%) met the eligibility criteria and were randomized, Figure 1. Thirty-two participants received the treatment in each arm. One participant was dropped by the investigator for non-compliance. Two participants (one in each arm) died before the trial completion (but none of the deaths was related to the investigational drugs), and 61 completed the trial (30 in the tadalafil arm and 31 in the placebo arm) The median age was 27.2 years and 23.3 years in the tadalafil and placebo arm, respectively, Table 1. The trial's retention rate and compliance rate to monthly visits were 98.6% and 97.4%, respectively. Based on pill count, the adherence rates to taladafil and hydroxyurea were 93% and 94%, respectively. The rates of priapism during the trial treatment period per month were 3.1 and 2.7 in the tadalafil and placebo arms, respectively; the incidence rate ratio (IRR) was 1.21 (95% CI: 0.52-2.80; p= 0.654). Serious adverse events, acute pain rate, hospitalizations, and emergency visits were not significantly different between the two arms. Conclusions: Our phase 2 trial's primary outcome results (recruitment, retention, and adherence rates) strongly support the feasibility of conducting a definitive phase RCT phase 3 trial for secondary priapism prevention in a low-resource setting where 50% of the global SCA births are located. Although not the primary intent of the phase 2 trial, we did not provide evidence that tadalafil with hydroxyurea was superior to hydroxyurea alone for secondary priapism prevention. We will continue to recommend a fixed dose of 20 mg/kg/day hydroxyurea therapy for secondary priapism prevention.

Case Report: Severe ischemic priapism as the clinical presentation in patient with chronic myeloid leukemia (CML) treated by proximal shunt

Background: Priapism refers to an erection of the penis that persists for four hours or more and is not associated with sexual arousal or stimulation. This condition is thought to be caused by abnormal production of blood cells in the bone marrow, which leads to the release of certain chemicals into the bloodstream. The current article presents a severe ischemic priapism case, and assesses and contrasts the documented instances of patients with chronic myelogenous leukemia (CML) who experienced priapism as their primary clinical symptom over the last two decades. Case presentation: The 21-year-old male patient presented with persistent and painful erections for three days. Further tests revealed he had CML and ischemic priapism. He was treated with distal shunting and proximal shunting with cytoreductive therapy to resolve the symptoms. Conclusions: Priapism is a medical emergency that can cause permanent damage to the erectile tissue if not treated promptly. Prolonged and painful erections can cause ischemia, leading to tissue damage and decreased function. If priapism is caused by an underlying medical condition; delaying treatment can allow the underlying condition to progress and become more difficult to treat.

Therapeutic Leukocytapheresis to relieve priapism due to leukostasis in CML patients: Our experience in a tertiary care centre

Hyperleukocytosis in leukemic patients may cause tumour lysis syndrome, disseminated intravascular coagulopathy, and leukostasis, resulting in decreased tissue perfusion and increasing the risk of mortality. Since the myeloid blasts are larger than lymphoid blasts and are less deformable, complications of leukostasis are seen more frequently in myeloid leukemia. Priapism is a less common complication associated with leukostasis in leukaemia patients that should be treated as soon as possible to avoid ischemic injuries. Although chemotherapeutic drugs such as hydroxyurea and imatinib are used to treat hyperleukocytosis in CML patients, leukocytapheresis (LCP) can achieve rapid cytoreduction. Prophylactic LCP could not offer any advantage over aggressive chemotherapy, but therapeutic leukocyte depletion has a proven role in patients having symptomatic leukostasis due to high tumour burden. Three patients with ischaemic priapism were reported at our institute's emergency department, where detumescence could not be achieved by distal shunting or aspiration with phenylephrine instillation. The procedure of therapeutic LCP was performed in all three patients on an emergency basis, which resolved painful priapism by rapid cytoreduction.

G6PD Deficiency: Exploring the Relationship with Different Medical Disorders

G6PD deficiency (G6PDD) is associated with oxidative stress resulting from an imbalance between reactive oxygen species (ROS) production and the body's ability to counteract. In this review, we explore the adverse effects of G6PDD on diverse physiological processes and disease outcomes. Past studies have demonstrated the association between G6PDD and various other diseases, indicating a link between G6PDD to heightened oxidative stress by accelerating virus replication, worsening infection severity, and weakening the body's defense mechanisms. Such stress is critical in the destruction of red blood cells (RBCs) during infections and has a detrimental impact on redox signaling, ultimately impacting cell health and promoting cancer development. Furthermore, it impairs endothelial function by lowering the nitric oxide (NO) level and increasing stress, resulting in detrimental cardiac consequences and reduced myocardial antioxidant capacity. Because ROS contributes to inflammation, this imbalance causes conditions such as early atherosclerosis. It also compromises the functionality of NO-regulated bronchodilators and conditions such as G6PDD exacerbate the risks of kidney damage. Elevated ROS levels can also induce harm in retinal tissues, blood vessels, brain cells, and Beta-cells, hence quickening the progression of diseases like Diabetic Retinopathy. Furthermore, oxidative stress plays a significant role in cerebral ischemic pathogenesis, contributing to neurodegenerative disorders. Additionally, decreased NADPH level is vital for NO synthesis as it can impact blood vessel relaxation and can potentially lead to ischaemic priapism. Investigating the association between G6PDD and other medical conditions is crucial as it helps to identify possible approaches to mitigate oxidative stress, thereby preventing associated complications and diseases, particularly in situations where current treatment options are insufficient.

Penile implants in low flow priapism.

Priapism is a persistent or prolonged erection, in the absence of sexual stimulation, that fails to subside. Prolonged ischaemic or low flow priapism is defined as a full or partial erection persisting for more than 4 h and unrelated to sexual interest or stimulation, characterised by little or no cavernous blood flow. Low flow priapism leads to progressive corporal fibrosis, which could, in turn, lead to long-lasting erectile dysfunction if left untreated. Penile prosthesis implantation is recognised as a management option in refractory and delayed low flow priapism for restoring erectile function with high patient satisfaction rates. However, the ensuing corporal fibrotic scarring poses a surgical challenge to clinicians, given the higher complication rates in this patient subset. Postoperative patient satisfaction has been closely linked to preoperative expectations and perceived loss of penile length. Therefore, thorough patient counselling concerning the risk and benefits of penile implants should be a priority for all clinicians. Moreover, there is a lack of consensus on the ideal prosthesis choice and procedural timing in refractory low flow priapism. In this review, we will examine the existing literature on penile implants in patients with priapism and discuss the options for managing complications associated with penile prosthesis surgery.

Management of Priapism: Results of a Nationwide Survey and Comparison with International Guidelines.

The aim of this study is to evaluate current urologic practice regarding the management of priapism in Turkey and compare with international guidelines. Urologists and urology residents were invited to an online survey consisting of 30 multiple-choice questions on priapism-related clinical practices that were consid- ered most important and relevant to practices by using Google Forms. Total number of responses was 340. Respondents reported that they recorded a detailed patient's medical history and physical examination findings (n = 340, 100%) and laboratory testing, which includes corporal blood gas analysis (n=323, 95%). Participants announced that they performed Doppler ultrasound for 1/4 cases (n = 106, 31%), but 22% of the participants (n=75) replied that they performed in >75% of cases. Participants (n=311, 91%) responded that the first-line treatment of ischemic priapism is decompression of the corpus cavernosum. Moreover, most respondents (n = 320, 94%) stated that sympathomimetic injection drugs should be applied as the second step. About three-quarters of respondents (n = 247, 73%) indicated adrenaline as their drug of choice. Phosphodiesterase type 5 inhibitors seems to be the most pre- ferred drug for stuttering priapism (n=141, 41%). Participants (n=284, 84%) replied that corpora-glanular shunts should be preferred as the first. A large number of par- ticipants (n = 239, 70%) declared that magnetic resonance imaging can be performed in cases with delayed (>24 hours) priapism to diagnose corporal necrosis. Most of the participants (84%) responded that penile prosthesis should be preferred to shunts in cases with delayed (>48 hours) priapism. It would be appropriate to improve the training offered by professional associations and to give more training time to the management of priapism during residency.

Priapism at Diagnosis of Pediatric Chronic Myeloid Leukemia: Data Derived from a Large Cohort of Children and Teenagers and a Narrative Review on Priapism Management.

Pediatric chronic myeloid leukemia (CML) is a very rare malignancy (age-related incidence 0.1/100,000) typically presenting with leucocyte counts >100,000/µL. However, clinical signs of leukostasis are observed at diagnosis in only approximately 10% of all cases and among these, priapism is infrequent. Here, we analyze data from pediatric CML registries on the occurrence of priapism heralding diagnosis of CML in 16/491 (3.2%) boys (median age 13.5 years, range 4-18) with pediatric CML. In the cohort investigated, duration of priapism resulting in a diagnosis of CML was not reported in 5 patients, and in the remaining 11 patients, occurred as stuttering priapism over 3 months (n = 1), over 6 weeks (n = 1), over 1-2 weeks (n = 2), over several days (n = 2), or 24 h (n = 1), while the remaining 4 boys reported continuous erection lasting over 11-12 h. All patients exhibited splenomegaly and massive leukocytosis (median WBC 470,000/µL, range 236,700-899,000). Interventions to treat priapism were unknown in 5 patients, and in the remaining cohort, comprised intravenous fluids ± heparin (n = 2), penile puncture (n = 5) ± injection of sympathomimetics (n = 4) ± intracavernous shunt operation (n = 1) paralleled by leukocyte-reductive measures. Management without penile puncture by leukapheresis or exchange transfusion was performed in 3 boys. In total, 7 out 15 (47%) long-term survivors (median age 20 years, range 19-25) responded to a questionnaire. All had maintained full erectile function; however, 5/7 had presented with stuttering priapism while in the remaining 2 patients priapism had lasted <12 h until intervention. At its extreme, low-flow priapism lasting for longer than 24 h may result in partial or total impotence by erectile dysfunction. This physical disability can exert a large psychological impact on patients' lives. In a narrative review fashion, we analyzed the literature on priapism in boys with CML which is by categorization stuttering or persisting as mostly painful, ischemic (low-flow) priapism. Details on the pathophysiology are discussed on the background of the different blood rheology of hyperleukocytosis in acute and chronic leukemias. In addition to the data collected, instructive case vignettes demonstrate the diagnostic and treatment approaches and the outcome of boys presenting with priapism. An algorithm for management of priapism in a stepwise fashion is presented. All approaches must be performed in parallel with cytoreductive treatment of leukostasis in CML which comprises leukapheresis and exchange transfusions ± cytotoxic chemotherapy.

Ischemic Priapism Leading to Penile Gangrene in A Patient with Phimosis: A Case Report and Review of the Literature

Ischemic Priapism Leading to Penile Gangrene in A Patient with Phimosis: A Case Report and Review of the Literature

Therapeutic outcomes and analysis of Doppler findings in 25 patients with non-ischemic priapism

Non-ischemic priapism (NiP) is painless partial tumescence caused by genital trauma and the formation of intracorporal arterio-venous fistula. This is a retrospective study of 25 men with NiP and reports the long-term erectile function and colour doppler ultrasound (CDUS) findings after treatment for NiP. Unstimulated CDUS was performed at diagnosis, 1 week and at last follow-up after treatment. CDUS traces were analysed: peak systolic velocity (PSV), end diastolic velocity (EDV), resistive index (RI) and mean velocity (MV) were calculated. Erectile function was assessed using the IIEF-EF questionnaire. At the last follow-up (median 24 months), 16 men had normal erectile function (64%): median IIEF-EF score 29 (IQR 28.5–30; σ2 2.78) and nine had erectile dysfunction (36%): median IIEF-EF score 17 (IQR 14–22; σ2 33.6). MV and EDV were statistically higher in those patients with erectile dysfunction at last follow-up compared to patients with normal erectile function: median MV 5.3 cm/s (IQR 2.4–10.5 cm/s; σ2 34) vs 2.95 cm/s (IQR 1.03-3.95; σ2 3.4) p < 0.002 and median EDV 4.0 cm/s (IQR 1.5–8.0; σ2 14.7) vs 0 cm/s (IQR 0–1.75; σ2 2.21) p < 0.004. Erectile dysfunction was observed in 36% of men treated for NiP and was associated with abnormal low resistance resting CDUS waveforms. Further investigation for persistent arteriovenous fistulation should be considered in these patients.

(381) Comparing Erectile Dysfunction (ED) Outcomes Following Priapism as an Adverse Effect of Intracavernosal Injectable Medications to Priapism due to Recreational use of Intracavernosal Injectable

Abstract Introduction Ischemic priapism is a urologic emergency which results in permanent erectile dysfunction if not managed immediately. We previously identified a large portion of ischemic priapism cases presenting to our institution caused by recreational use of intracavernosal injectable medications (ICI) for which patients did not have a prescription. Objective In the present study we identified a nearly equal number of men who presented with ischemic priapism as an adverse effect of ICI for which they did have a prescription. Our goal was to compare erectile function outcomes between these two populations in follow up. Methods Men presenting for ischemic priapism as an adverse effect of prescription ICI from January 2010 to December 2018 were contacted by mail, then via telephone. Standardized questions were asked of all participants on the topic of erectile dysfunction (five-item international index of erectile function (IIEF-5)). IIEF-5 results were compared to our previously described population of men with ischemic priapism caused by recreational use of ICI using the Student’s T-test of means. Results 13 men aged 23 – 68 (mean 51.9) were recruited. Ten men (77%) were white; the remaining three (23%) were black. All men confirmed diagnosis of ED prior to their priapism episodes and all men had their own prescription for ICI from a urologist. Seven men (54%) required phenylephrine irrigation, five (38%) achieved detumescence with cavernosal aspiration and saline irrigation alone, one (8%) required a distal shunt. Mean IIEF-5 for the population at time of phone interview was 12.5 (□ 7.4) signifying mild-moderate ED, which was not significantly different from the mean IIEF-5 of our priapism population due to recreational use of ICI (13.3 □ 4.0; p = 0.87; table 1). Conclusions Men who present with ischemic priapism as an adverse effect of prescription ICI appear to have similar functional outcomes compared to men with ischemic priapism due to recreational use of ICI as assessed by IIEF-5. This could also be interpreted as a better functional outcome considering that this population had pre-existing ED prior to their priapism episode and therefore did not lose erectile function. The adverse effect population also appears to require a shunt in the treatment of their priapism less frequently than the recreational ICI population. Disclosure No

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

Abstract Introduction Outcomes of men with delayed presentation of ischemic priapism (&amp;gt;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