PRIAPISM

MAHAR NAVEED SARWARRESIDENT UROLOGIST

WARD # 19, JPMC

25 years old male no known comorbids, presented to us in emergency with

c/o Painful sustained erection for 2 days

Erection was spontaneous and severely painful. it did not relieved with analgesics

There was no history of trauma to geniteliaNo significant drug historyNo significant addiction historyThere was past history of splenomegaly

CASE SUMMARRY

Young male of average height and built, well oriented to time person and place

ON EXAMINATION

Vitals:•Pulse = 97/min•B.P = 120/90mmhg•R/R = 18/min•Temp = 98.6⁰F

Sub-vitals:Anemia = absentJaundice = absentCyanosis = absentClubbing = absentDehyd: = absentL/Nodes = N/PEdema = absent

Abdominal examination:◦ Spleen was palpable 3 finger breadth below the level of

umbilicus◦ Rest of the examination was unremarkable

Local examination:◦ Fully erect, congested and mildly tender penis◦ No sign of trauma

EXAMINATION:

Hb = 12.4 gm% PLT = 449000 TLC = 161000 Myelocytes = 07% Promyelocytes = 14% Na+ = 135 K+ = 4.2 U = 35 Cr = 0.9

INVESTIGATIONS

Under G.A clotted dark blood aspirated from cavernosa

distal shunts created between corpora cavernosa and corpus spongiosum

Phenylephrine injected into the corpora until penis became flaccid

Next morning pt shifted to Oncology for the management of leukemia.

Diagnosis of ischemic priapism secondary to leukemia established

DEFINATION:◦ Priapism is a full or partial erection that continues more

than 4 hours beyond sexual stimulation and orgasm or is unrelated to sexual stimulation

TYPES:◦ LOW FLOW(ISCHEMIC):

◦ HIGH FLOW(NONISCHEMIC)

PRIAPSIM

Common than non-ischemic

Results from veno-occlusion

Its rigid and very painful

Blood flow will be decreased Blood in cavernosa will show hypoxia,hypercarbia

and acidosis

LOW FLOW (ISCHEMIC PRIAPISM)

Its post traumatic

Unregulated arterial blood flow

Semi-rigid and painless erection

Cavernosal blood shows arterial values

HIGH FLOW(NON-ISCHEMIC)

Itracorporal injection therapy◦ PGE◦ Papavarin

Thromboembolism◦ Sickle cell disease◦ Leukemia◦ Fat emboli

Drugs TPN Alcohol intoxication Recreational therapy e.g.: cocaine Malignant infiltration of cavernosa Infection

◦ Malaria, rabies, scorpion sting Neurogenic causes

◦ Spinal Cord lesions◦ Autonomic neuropathy◦ Anesthesia

ETIOLOGY

Detailed history (specially past medical history) Examination Investigation◦ Full blood count and peripheral blood films◦ ABGs of aspirated cavernous blood

Ischemic priapism hypoxia,hypercarbia and acidosis Non ischemic priapism normal arterial or mixed arterial-

venous picture◦ Duplex Doppler ultrasound of penis

Ischemic priapism Decreased flow Non ischemic priapism Increased flow

◦ Urine and serum toxicology

EVALUATION

Decompression by aspiration followed by injection of sympathomimetics into corpora cavernosa

Phenylephrine is the drug of choice◦ Highly α1 selective without β-mediated ionotropic and

chronotropic effects◦ Diluting it in N/S at concentration of 100 to 500 Ug/ml

and giving 1ml every 5 minutes◦maximum 1mg of Phenylephrine can be injected◦ Serial monitoring of B.P and Pulse

MEDICAL MANAGEMENT

Percutanous distal shunts:◦ Ebbehoj◦ Winter◦ T-shunt (Brant)

Open distal shunt◦ Al-Ghorab◦ Corporal Snake (Burnett)

Open proximal shunt◦ Quackles

Saphenous vein◦ Grayhack◦ Deep dorsal vein shunt

SURGICAL MANAGEMENT FOR ISCHEMIC PRIAPISM

PERCUTANEOUS SHUNTS

  Al-Ghorab shunt

PROXIMAL OPEN SHUNT (Quackles)

Grayhack shunt

Its not an emergency

Start expectant management with cool bathing and ice packing vasospasm and thrombosis

Arteriography and selective embolisation of the internal pudendal artery or its branches

Ligation of the site of fistulae

SURGICAL MANAGEMENT FOR NON-ISCHEMIC PRIAPISM