Treatment Of Priapism Research Articles

Temporary Cavernosal–Cephalic Vein Shunt in Low-Flow Priapism Treatment

BackgroundSurgical shunting might be considered as the only option in the treatment of extended ischemic priapism that does not respond to aspiration and medication. ObjectiveA modified, simple, minimally invasive, and easily applicable artificial cavernosal–venous shunt technique for treating priapism is described in this report. Design, setting, and participantsA total of 15 patients with extended and nonresponsive low-flow priapism were treated with this technique between January 1998 and February 2007. InterventionWhen the conservative treatment of low-flow priapism does not yield the expected results, then the temporary cavernosal–cephalic vein shunt should be applied. The standard equipment required for this modified technique includes three angiocaths, two shorn blood serum sets, and saline solution with heparin. The blood in the cavernosa and the saline solution infusion are incorporated into the systemic circulation with the aid of serum sets and angiocaths. MeasurementsPriapism duration, history, causes, its relation with sexual stimulation, pain, and any prior management of priapism were assessed in all patients. A complete blood count and blood gases assessment were conducted in corporal aspirates, and duplex penile ultrasonography was performed, which showed attenuated blood flow in the cavernosal artery. Results and limitationsThis technique was applied in 15 patients. Complete detumescence was achieved in 13. In the two cases in whom the technique did not yield the expected results, there was a need for a sapheno–cavernosal shunt. These patients later complained of erectile dysfunction and penile pain that continued for 6 mo. Of the 13 patients in whom detumescence was achieved, 3 reported erectile dysfunction according to International Index of Erectile Function (IIEF) scores at the 12-mo follow-up. ConclusionsArtificial cavernosal–cephalic vein shunt in the treatment of priapism is simple, safe, effective, easily applicable, and warrants primary consideration when the second-line treatment of priapism is initiated.

Sickle Cell Disease Status and Outcomes of African-American Men Presenting with Priapism

Priapism is associated with sickle cell disease (SSD); however, few men receive education about this condition, which contributes to attenuated return of functional erections. To define the demographics, SSD status, and treatment outcomes of African-American men presenting with priapism. Demographics, medical history, self-report of sickle cell status, and outcome assessment using International Inventory of Erectile Function (IIEF) of men with priapism were retrospectively reviewed. A review of 39 cases of venocclusive priapism in African-American men was conducted. Charts were reviewed for demographics, medical history including SSD status by patient self-report, serum hemoglobin electrophoresis results, and priapism treatment and outcome. Mean duration of presenting priapism episode was 22 +/- 12 hours (6-70 hours). Eight percent of men had priapism for <12 hours, 59% 12-24 hours, 22% 24-36 hours, and 11% >36 hours. All patients with priapism events of >12 hours complained of reduction in erectile rigidity. No patients with priapism >36 hours duration had return of spontaneous functional erections, but 44% (24-36 hours), 78% (12-24 hours) and 100% (<12 hours) were able to generate functional erections with or without the use of sildenafil. Follow-up IIEF erectile function domain scores paralleled incidence of functional erections. Penile shunt surgery was required in 28%. Only 5% of men recalled learning that priapism was a complication of SSD. Six men denied a history of SSD; however, hemoglobin electrophoresis revealed abnormal hemoglobin S and elevated hemoglobin F levels in four of these men. The association of SSD and venocclusive priapism is well known in the medical community, yet few patients ever receive education regarding the emergency nature of the condition. The majority of men presents in a delayed fashion, and a significant proportion requires shunt surgery leading to long-term erectile dysfunction. Of those who denied having SSD, two-thirds had SSD by hemoglobin electrophoresis.

The Cochrane Library and sickle cell disease: an overview of reviews

AbstractBackgroundSickle cell disease is a genetically inherited red blood cell disorder which features pain as a predominant manifestation.ObjectivesTo review the evidence within Cochrane systematic reviews on the management of pain associated with vaso‐occlusive crises and priapism secondary to sickle cell disease in paediatric populations.MethodsThe Cochrane Library of Systematic Reviews was searched for all reviews that addressed interventions to relieve pain associated with sickle cell disease. Reviews that primarily addressed the reduction of sickle cell crises were excluded. Data were extracted from included reviews.ResultsThree reviews were included. One review examined pharmacological interventions to relieve pain associated with vaso‐occlusive pain crises. One trial in children reported a significant reduction in VAS scores associated with ketorolac administration versus pethidine, but another trial performed in adults showed no significant reduction in VAS scores when ketorolac was compared to placebo. Two trials found that parenterally delivered corticosteroids reduced the length of analgesic therapy compared to placebo, and another trial found that there was no difference in the pain scores of children when morphine was delivered either parenterally or orally. Two trials reported on long‐term psychological interventions to manage pain. One found that coping skills training in children resulted in a reduction in the tendency to report pain, while the other trial found that cognitive behavioural therapy in adolescents and adults resulted in a decrease in the emotional component of pain but not the sensory component. One review addressed the treatment of stuttering priapism in boys and men using stilboestrol, but included an insufficient number of patients to draw a conclusion.Authors' ConclusionsPharmacological interventions to treat vaso‐occlusive pain crises show mixed results in the use of ketorolac and no difference between parenteral versus oral administration of morphine. Psychological interventions for vaso‐occlusive crises demonstrated benefit in improving some components of pain. Evidence regarding treatment of priapism was weak. Further studies should employ multi‐centre trials and begin to address generalisability concerns by more focus in Africa, where the majority of patients with sickle cell disease reside. Copyright © 2008 The Cochrane Collaboration. Published by John Wiley &amp; Sons, Ltd. The Cochrane Collaboration

Priapism Associated With the Switch From Oral to Injectable Risperidone

Priapism is a rare, but serious, side effect of psychotropic medications. Psychotropic medication-induced priapism is believed to be caused by the alpha-adrenergic antagonism of these medications. Among the atypical antipsychotics, cases of priapism or prolonged erection have been associated with clozapine, olanzapine, risperidone, and quetiapine. Risperidone has primarily serotonergic, dopaminergic, and alpha-adrenergic antagonist properties. It has one of the highest affinities for the alpha1-adrenergic receptor blockade among the atypical antipsychotics. To date, there are 17 case reports of risperidone-associated priapism either in monotherapy or in combination with other psychotropics. To our knowledge, there are no published case reports of priapism on the injectable preparation of risperidone. We report a case of a 50-year-old man who developed priapism while being switched from the oral to the intramuscular preparation of risperidone. The importance of early recognition and intervention in cases of priapism is emphasized. The treatment of priapism with benztropine and other methods is discussed.

Investigational agents for sickle cell disease

Developments in the treatment of sickle cell disease (SCD) have not kept pace with advances in understanding the pathophysiology of this haemoglobinopathy. Drugs undergoing preclinical and clinical assessment for the therapy of these globin gene disorders are discussed in this article. Beginning with investigational agents for treatment of SCD as a whole, the discussion proceeds to drugs being developed for specific manifestations or iatrogenic complications. Despite being licensed in the USA, the prototype antisickling agent, hydroxycarbamide, has not attained worldwide clinical use because of concerns about long-term toxicity. The less toxic decitabine, which (as with hydroxycarbamide) increases fetal haemoglobin level, cannot be administered orally; therefore, the search continues for effective and safe antisickling drugs that can be taken orally. The naturally occurring benzaldehyde 5-hydroxymethyl-2-furfural has shown promising antisickling properties in vitro, and when administered to transgenic sickle mice. These effects are surpassed by the new synthetic pyridyl derivatives of benzaldehyde. Studies in humans with SCD are required to assess the clinical efficacy of these benzaldehydes. Niprisan, another antisickling agent with significant clinical efficacy and an attractive safety profile, is undergoing further development. The prospects of antiadhesion therapy in SCD are demonstrated by a recombinant protein containing the Fc fragment of IgG fused to the natural ligand for selectins: the conjugate significantly inhibited blood vessel occlusion in transgenic sickle mice. Whereas the orally administrable iron-chelating agent deferasirox is likely to increasingly take the place of desferioxamine (which can only be given parenterally), effective treatment of priapism in SCD remains a distressing challenge.

Myth: Blood transfusion is effective for sickle cell anemia—associated priapism

Priapism is a recognized complication of sickle cell anemia (SCA). When initial conventional treatments fail, simple or exchange blood transfusion has been advocated as a secondary intervention. However, recent literature suggests this may not be an effective therapy and may have significant neurologic sequelae. This paper reviews and summarizes the effectiveness and risks of blood transfusion compared with conventional priapism therapy. All relevant papers identified from a MEDLINE search were systematically examined for data related to the use of blood transfusion in the setting of priapism due to SCA. The effectiveness of conventional therapy was compared with transfusion therapy using the outcome of "time to detumescence" (TTD). In addition, papers documenting adverse neurologic sequela were reviewed and summarized. Forty-two case reports were identified containing complete information with regard to patient age and TTD. The mean TTD was 8.0 days with conventional therapy (n = 16) and 10.8 days with blood transfusion therapy (n = 26). Adverse neurologic sequelae from blood transfusion therapy was described in 9 cases, with long term outcomes ranging from complete resolution to severe residual deficits. The current literature does not support the contention that blood transfusion is an effective therapy in the treatment of priapism due to SCA, as defined by an acceleration of TTD. In fact, numerous reports suggest that serious neurologic sequelae may result from this treatment. We feel the routine use of this therapy cannot be recommended.

Case Report of Priapism in a Patient with Thalassemia Minor.

Background - Priapism is a urologic emergency caused by hematological problems in about 35% of cases. Its occurrence in sickle cell anemia, leukemia /other malignancies and primary thrombocythemias is well established. A very few case reports of priapism occurring in Thalassemia Intermedia especially after splenectomy have been documented in literature. Veno-occlusive priapism (low flow priapism) beyond 4hours is a compartment syndrome requiring emergent medical intervention. The most important late complication of priapism is fibrosis and impotence and their incidence is related to the duration and aggressiveness of treatment of priapism. We report a case of priapism in a patient of Thalassemia minor.Case report- A 42 year Asian male was referred from urology service for a hematologic work-up for recurrent episodes of priapism. He was admitted with a 24 hours-long episode of priapism. The history of priapism dates back to 1998, a few months after marriage, when he was admitted for the first episode of priapism and had a decompressive procedure. Since then, for 6 years, he had intermittent, 15 minutes to 1 hour episodes of penile erection. These episodes usually occur after midnight and were unrelated to sexual activity. He did not have any other medical problems and was not on any medications. He was not on any pro-erectile medications. He denied any history of masturbation. He denied any history of alcohol or illicit drug use. He was unaware of any family history of anemia. On physical examination, he did not have pallor, icterus, lymphadenopathy, skin ulcers or hepatosplenomegaly. The penis was circumcised without any trauma or necrosis. His hemoglobin was 10.5 g/dl, hematocrit 34%, MCV 65fl, RDW14.5 %, reticulocyte count 1.3%, platelets 274k/μl, and WBC 6.9k/μl. Peripheral smear showed poikilocytosis, hypochromia and microcytosis without any sickle cells or nucleated RBCs. Hemoglobin electrophoresis showed Hb A of 94%, Hb A2 of 5.6% and Hb F of 0.4%. His clinical picture, blood count, peripheral smear and electrophoresis were consistent with Thalassemia minor. He was managed by removal of inspissated blood and injection of phenylephrine into the corpora cavernosa. This was repeated a few times and the priapism was relieved and patient discharged.Conclusion- This is the first reported case of priapism in a patient with Thalassemia minor.

Intracavernous papaverine/phentolamine-induced priapism can be accurately predicted with color Doppler ultrasonography

Objectives To determine the value of penile duplex ultrasonography in predicting the occurrence of intracavernous drug-induced ischemic priapism directly after the rigid erection phase. Methods We evaluated 250 men with erectile dysfunction by color Doppler ultrasonography after the diagnostic injection of papaverine hydrochloride and phentolamine mesylate. Cavernosal artery waveforms were recorded, and peak systolic velocity (PSV) and end diastolic velocity (EDV) of the recorded waveforms were measured. In cases of priapism, color Doppler ultrasonography findings were evaluated to identify any finding that would predict priapism. Results In all, 41 patients experienced painful rigid erection for more than 1 hour after injection. All patients were divided into two groups. Group I included 16 patients who achieved full erection lasting less than 6 hours. Group II included 25 patients who achieved full erection lasting more than 6 hours. All patients of group I had PSV less than 61 cm/s and EDV of 0 to 2 cm/s. On the other hand, all patients of group II had PSV greater than 66 cm/s and EDV of 0 to 1 cm/s. These findings were accurate predictors of persistent erection requiring intervention in all 25 patients of group II and in none of the group I patients (100% specificity and sensitivity). Conclusions Our results show that during the first hour of penile color Doppler ultrasound study, PSV of 66 cm/s or more together with EDV of 0 cm/s is a reliable predictive factor for priapism. This finding is reliable enough that treatment for priapism should be initiated without further delay.

Priapism

There are three different types of priapism: low-flow, ischemic, anoxic or veno-occlusive priapism; high-flow, arterial or nonischemic priapism; and recurrent or stuttering priapism. To provide recommendations/guidelines concerning state-of-the-art knowledge for the diagnosis and treatment of priapism. An International Consultation in collaboration with the major urology and sexual medicine associations assembled over 200 multidisciplinary experts from 60 countries into 17 committees. Committee members established specific objectives and scopes for various male and female sexual medicine topics. The recommendations concerning state-of-the-art knowledge in the respective sexual medicine topic represent the opinion of experts from five continents developed in a process over a 2-year period. Concerning the Priapism Committee, there were 10 experts from six countries. Expert opinion was based on grading of evidence-based medical literature, widespread internal committee discussion, public presentation and debate. Concerning ischemic priapism, persistent cavernous smooth muscle relaxation and failure of contraction is a compartment syndrome with increasing intracavernosal anoxia, rising pCO2 and acidosis. Urgent medical attention should be sought for an erection lasting >4 hours; 90% with priapism >24 hours develop complete erectile dysfunction. After diagnosis and counselling, intracavernosal aspiration and alpha-blockers should precede surgical shunting. Concerning high-flow priapism (congenital, traumatic or iatrogenic), intervention is not urgent and often unnecessary. Definitive management is by selective embolization with autologous blood clot. Concerning recurrent/stuttering priapism, the pathophysiology may be central or local (sickle cell disease). Management needs to be individualized; androgen deprivation has proved useful but has adverse effects. There is need for prospective, clinical trials to define safe and effective management strategies for patients with low-flow, high-flow or recurrent priapism.

Successful management of stuttering priapism using home self-injections of the alpha-agonist metaraminol

Low-flow priapism can result in impotence if treatment is delayed, yet patients with recurrent priapism often suffer delay before therapy. We describe management of recurrent priapism using self-administered injections of intracavernosal metaraminol (Aramine, Merck), a long-acting vasoconstricting amine that is considered safer than epinephrine. The patient injects as often as once daily using 5-10 mg of drug. Our patient reports rapid detumescence and has not required emergency room visits since starting injections. He denies complications. Treatment of priapism using metaraminol has been suggested in the hospital setting; however, this is the first report of successful home self-administration of the drug.

Emergency evaluation and treatment of priapism

Priapism is a fairly uncommon presentation to the Emergency Department, but when it does present, it represents a true urologic emergency. Prompt treatment will decrease the risk of permanent sequelae including impotence. Treatment should be based on etiology and follow an organized approach. Various cases will arise when conservative management will not remedy the priapism and more aggressive measures will be needed, particularly if emergent urological consultation is not available. This article reviews the causes of priapism and systematically reviews techniques and procedures used to manage and treat priapism.

Treatment of priapism in pediatric patients with sickle cell disease

The available treatment options for priapism in pediatric (1-21 years of age) patients with sickle cell disease (SCD) are reviewed. Priapism is a complication of SCD that receives little attention, yet it is a particularly bothersome issue for many pediatric patients. Numerous therapeutic options have been attempted, including diethylstilbestrol, gonadotropin-releasing hormone analogues, various adrenergic agonists, and hydroxyurea. Few agents have actually been examined in a controlled clinical trial, making it difficult for practitioners to treat this complication. It is our recommendation that treatment should be conservative initially, with the patient being encouraged to urinate, exercise, increase his fluid intake, and take oral analgesics. If the episode of priapism persists beyond 2 hours, the patient should report to the emergency department for i.v. hydration and analgesics. If the episode persists beyond 4 hours, intracavernosal aspiration and instillation of an alpha-agonist should be performed and repeated as needed. If the priapism remains for longer than 12 hours, surgery should be considered for shunt placement. There is little evidence available regarding the definitive treatment of priapism, which affects a large number of pediatric patients with SCD. It is quite clear that more research is needed to determine what the best treatment options are for patients with this condition. Health care providers should educate their patients with SCD about the condition. Education, combined with more research of treatment options, may help patients avoid the damaging social, psychological, and medical implications of this bothersome and often embarrassing complication of SCD.

Of gods and leeches: treatment of priapism in the nineteenth century.

Of gods and leeches: treatment of priapism in the nineteenth century.

Of gods and leeches: treatment of priapism in the nineteenth century

Priapism is defined as a prolonged erection in the absence of sexual desire. The name derives from the Greek god Priapus who had an erect penis very much associated with sexual desire (Figure 1). It is written that his parents were Zeus and Aphrodite. When Hera, the wife of Zeus, heard of the pregnancy she cursed the child, such that, when the boy was born with oversized genitals, he was rejected by Aphrodite. The boy was brought up by shepherds who noticed that wherever they took him flowers would bloom and animals would copulate furiously. He thus became a god of fertility. Figure 1 The Feast of the Gods (detail). Giovanni Bellini and Titian 1514/1529. Priapus attempts to lift the skirt of the sleeping nymph Lotis. [National Gallery of Art, Washington, DC] I have looked for references to priapism in works from the nineteenth century—a time when medicine began to benefit from scientific method and the formal recording of experience.1 The Wellcome Trust's (London) History of Medicine database was used to find case reports published on priapism in journals of the 19th century. The selection, as will be seen, was mainly British. In addition, textbooks from the urogenital section of the Wellcome Library for the History and Understanding of Medicine were studied for recommendations on treatment of the condition. Ten case reports were discovered.2-11 The original journals for seven of these could be traced.2-8 Mention of the other three was made in textbooks and journals.9-11 All but two of the reports were published in the second half of the century.

The treatment of priapism--when and how?

Priapism is a condition first described by Tripe in 1845. It has been defined as a pathological condition of penile erection that persists beyond or is unrelated to sexual stimulation. Two variants of priapism have been well described. The ischemic priapism (also known as low-flow priapism) and nonischemic priapism (or high flow priapism) have unique and distinct causes. It is important to distinguish these two conditions as the treatment for each is different. This review will focus on the two types of priapism and the appropriate diagnostic work-up for each. As well, the medical and surgical treatment options for these two conditions will be described in detail. A third entity known as stuttering priapism will also be discussed as will its unique treatment alternatives.

Priapism: etiology, pathophysiology and management

The understanding of erectile physiology has improved the prompt diagnosis and treatment of priapism. Priapism is defined as prolonged and persistent erection of the penis without sexual stimulation and failure to subside despite orgasm. Numerous etiologies of this condition are considered. Among others a disturbed detumescence mechanism, which may due to excess release of contractile neurotransmitters, obstruction of draining venules, malfunction of the intrinsic detumescence mechanism or prolonged relaxation of intracavernosal smooth muscle are postulated. Treatment of priapism varies from a conservative medical to a drastic surgical approach. Two main types of priapism; veno-occlusive low flow (ischemic) and arterial high flow (non-ischemic), must be distinguished to choose the correct treatment option for each type. Patient history, physical examination, penile hemodynamics and corporeal metabolic blood quality provides distinction between a static or dynamic pathology. Priapism can be treated effectively with intracavernous vasoconstrictive agents or surgical shunting. Alternative options, such as intracavernous injection of methylene blue (MB) or selective penile arterial embolization (SPEA), for the management of high and low flow priapism are described and a survey on current treatment modalities is given.

American Urological Association Guideline On The Management of Priapism

priapism would eventually resolve on its own albeit with possible permanent damage to the penis. The literature reviewed for this guideline straddles both empirical and pathophysiology-based eras, and some of the reported positive responses to treatment may reflect the natural course of priapism rather than a true treatment success. In addition, the literature is bereft of followup data on patients with priapism. This document derives from a comprehensive review of the medical literature related to the management of priapism. As noted, deficiencies in this literature made it impossible to develop strict evidence-based guidelines. Most of the recommendations contained herein are based upon expert consensus following review of the literature. Where possible, expert consensus is supplemented with review of limited data. Because the literature review only considered reports of cases in which the duration of erections were longer than 4 hours, the recommendations made may not apply to erections of shorter duration. This guideline does not establish a fixed set of rules or define the legal standard of care for the treatment of priapism. Above all, it does not preempt physician judgment in individual cases. Variations in patient subpopulations, physician experience and available resources will necessarily influence choice of clinical strategy. Adherence to the recommendations presented in this document cannot assure a successful treatment outcome. The basis of each recommendation, consensus of the expert panel with or without data obtained by systematic review of evidence, is noted. A diagnostic and treatment algorithm is presented in the figure.

The incidence and management of priapism in Western Australia: a 16 year audit.

The objective of the study was to conduct a retrospective audit of patients who presented with priapism in Western Australia during the years 1985-2000. We searched the records of the teaching hospitals in metropolitan Perth and those of the Keogh Institute for Medical Research for the diagnostic code for priapism. A total of 82 episodes of priapism in 63 patients occurred over this 16 year period. In all, 62 episodes occurred after intracavernosal injections (ICI) and 20 were due to other causes. Treatment of priapism included simple aspiration of blood, intracavernosal injection of alpha-adrenergic agents and surgical shunt procedures. Priapism occurring outside the setting of ICI was more likely to require surgery; seven of 20 episodes. After ICI therapy, eight of 62 episodes required shunts. The use of prostaglandin E1 as the drug of choice in ICI therapy in 1989 led to a fall in the incidence of ICI-induced priapism. Priapism is a major side effect of ICI therapy and an uncommon, although important, side effect of other conditions. The incidence of priapism has fallen with the introduction of prostaglandin E1 monotherapy as the favoured drug for ICI therapy of erectile failure.

Methylene blue as a means of treatment for priapism caused by intracavernous injection to combat erectile dysfunction.

The authors observed priapism as a side effect occuring during the intracavernous treatment of erectile dysfunction. Earlier priapism had been treated with an intracavernous injection of sympatomimetics; unfortunately several complications and contraindications were found. Methylene blue was applied in the treatment of five patients. First a corpus cavernosum punction was performed and some blood was aspirated from the penis. Finally 100 mg of Methylthionin Chlorati was injected into the corpus cavernosum. A sufficient detumescence was observed in all of these cases. There were no complications. The method was applied effectively in two cases after an unsuccessful punction. The autors recommend intravenous methylene blue for the treatment of priapism. According to their experience this method is free of complications and as effective as a sympathomimetics treatment. As they think, it can be recommended in any manifestations of priapism because its force of action appears to be both chemically and biologically clear.

The etiology, diagnosis, and treatment of priapism: review of the American Foundation for Urologic Disease Consensus Panel Report.

Priapism is an important medical condition that requires immediate evaluation, and depending on etiology, may require emergency management. Based on the classification scheme offered by a recent consensus panel, priapism can be subdivided into ischemic and nonischemic types. The nonischemic type, usually the result of perineal trauma, can be treated with conservative therapy, whereas the nonischemic type, which arises from many varied causes, mandates immediate intervention. Corporal fibrosis and permanent erectile dysfunction can result from ischemic priapism that fails to resolve with therapy.