Penis priapism

Penis priapism

1. Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai

1

2. Moderators:
Professors:
Prof. Dr. G. Sivasankar, M.S., M.Ch.,
Prof. Dr. A. Senthilvel, M.S., M.Ch.,

Asst Professors:
Dr. J. Sivabalan, M.S., M.Ch.,
Dr. R. Bhargavi, M.S., M.Ch.,
Dr. S. Raju, M.S., M.Ch.,
Dr. K. Muthurathinam, M.S., M.Ch.,
Dr. D. Tamilselvan, M.S., M.Ch.,
Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH and KMC, Chennai. 2

3. History
Fresco of Greek God PRIAPUS
3 Dept of Urology, GRH and KMC, Chennai.

4. Physiology of erection
4 Dept of Urology, GRH and KMC, Chennai.

5. Definition
Persistent penile erection that continues hours
beyond, or is unrelated to, sexual stimulation
The guideline definition is restricted to only erections
of greater than four hours duration
Typically, only the corpora cavernosa are affected
5 Dept of Urology, GRH and KMC, Chennai.

6. DEFINITION
AUA Committee-“Multifactorial entity of genital organ
tumescence or rigidity, that develops and persists in a
pathologically uncontrolled fashion for any duration
without sexual purpose”
Clitoris /spongiosum may also become tumescent
6 Dept of Urology, GRH and KMC, Chennai.

7. Pathophysiology
Priapism -disturbances in the
mechanism of detumescence due to
excess release of contractile
neurotransmitter
malfunction of the intrinsic
detumescence mechanism
obstruction of draining venules
prolonged relaxation of
intracavernous smooth muscle
7 Dept of Urology, GRH and KMC, Chennai.

8. Sub types
Ischemic (veno-occlusive, low flow) little or no
cavernous blood flow and abnormal cavernous
blood gases (hypoxic, hypercarbic and acidotic)-
emergency
Nonischemic (arterial, high flow) priapism -
unregulated cavernous arterial inflow; blood gases
are not hypoxic or acidotic-non emergent
Stuttering (intermittent) priapism is a recurrent
form of ischemic priapism in which unwanted
painful erections occur repeatedly with
intervening periods of detumescence,< 3 hrs
8 Dept of Urology, GRH and KMC, Chennai.

9. Sub types
Refractory– immediately recurrent non ischemic
erectile state after treatment of ischemic priapism
due to arterial filling- no trauma
Pseudopriapism –penile rigidity and edema
caused by superficial nodular metastases /semi-
rigid prosthesis
Idiopathic -50% cases, ischemic model
Congenital/ neonatal- forceps delivery,
respiratory distress syndrome, umbilical artery
catheterisation, polycythaemia, congenital syphilis
9 Dept of Urology, GRH and KMC, Chennai.

10. Etiology
Hematologic
Sickle cell disease
23%adult,63%pediatric
Thalassemia
Leukemia-CML 50%
Polycythemia,PNH
Hemophilia,HSP
Coagulopathies
Corpora cavernosal
thrombosis
Asplenia
Traumatic
Spinal cord injury
Pelvic ,penile, perineal
trauma- onset delayed
Intra cavernosal
injection
Arterial anastomosis to
corpora
Scorpion and snake
venom
10 Dept of Urology, GRH and KMC, Chennai.

11. Etiology
Neurologic
Herniated lumbar disc
Regional/general
anesthesia
Spinal cord tumor or
compression
Multiple sclerosis
Brain tumors
Ruptured cerebral
aneurysm
Syphilis
Epilepsy
Neoplastic
Sarcoma
Secondaries
Myeloma
Lymphoma
Paraneoplastic
Penile, urethral,
bladder,prostate, kidney
cancer
11 Dept of Urology, GRH and KMC, Chennai.

12. Etiology
Infective
Prostatitis
Urethritis
Mumps
Syphilis
Rabies
Malaria
Atypical pneumonia
Pharmacologic
NTG, α blockers
Verapamil/theophylline
Haloperidol
Chlorpromazine
Imipramine/SSRI
Heparin/warfarin
Erythropoietin,Androgens
Alcohol/cocaine
Tacrolimus

12 Dept of Urology, GRH and KMC, Chennai.

13. Etiology
Metabolic
Amyloidosis
Fabry's disease
Gout
Diabetes
Nephrotic syndrome
Renal failure
Haemodialysis
Hyperlipedaemic total
parenteral nutrition
ED pharmacotherapy
Oral sildenafil
Intraurethral alprostadil
Intracavernous agents
Young men, neurologic
illness, better erectile
function –at risk
13 Dept of Urology, GRH and KMC, Chennai.

14. HISTORY
Duration of erection
Degree of pain
Previous history of priapism and its treatment
Erectile function status
Use of drugs : antihypertensives; anticoagulants;
antidepressants and other psychoactive drugs;
alcohol, marijuana, cocaine,cannabis
Vasoactive agents used for intracavernous
injection
History of trauma- perineal straddle injury
History of sickle cell disease or other hematologic
abnormality
14 Dept of Urology, GRH and KMC, Chennai.

15. Examination
Ischaemic Nonischaemic
Corpora cavernosa fully rigid
+ --
Penile pain
+ --
Abnormal cavernous blood gases

+ --
Blood abnormalities and
hematologic malignancy
+ --
Recent intracavernous vasoactive
drug injections
+ --
Chronic, well-tolerated tumescence
without full rigidity
-- +
Perineal trauma
-- +






15 Dept of Urology, GRH and KMC, Chennai.

16. Piesis Sign
In young children with high flow priapism, perineal
compression with the thumb will cause prompt
detumescence, called Piesis sign-confirmatory
Usefulness in an adult is questioned
16 Dept of Urology, GRH and KMC, Chennai.

17. Investigations
Complete blood count, platelet count,WBC
differential
Peripheral smear, reticulocyte count
Hb electrophoresis
Screening for psychoactive drugs and urine
toxicology
Blood gas testing
Color duplex ultrasonography
Penile arteriography
17 Dept of Urology, GRH and KMC, Chennai.

18. Pre hospital care
Ice packs to the perineum and penis
Asking the patient to walk up stairs-mechansim -
arterial steal phenomenon.
External perineal compression may also be a useful
temporizing measure
18 Dept of Urology, GRH and KMC, Chennai.

19. Cavernosal Blood Gas Analysis
Flaccid
penis
Low flow
mm Hg
High flow
mm Hg
Colour of
blood
Dark red Bright red
pO2 40 <30 >90
pCO2 50 >60 <40
pH 7.35 <7.25 7.4
19 Dept of Urology, GRH and KMC, Chennai.

20. USG Imaging
Anatomic
abnormalities
Corporal fibrosis- white dots
bilateral cavernous hematomas (∗) at the
base of the penis
20 Dept of Urology, GRH and KMC, Chennai.

21. Color duplex ultrasonography
Performed in the lithotomy
or frogleg position
Scanning perineum first and
then along the entire shaft of
the penis
Screening test for
anatomical abnormalities--
cavernous.A fistula or
pseudoaneurysm in
nonischemic priapism
Examine perineal corpora
cavernosa
Low flow priapism
21 Dept of Urology, GRH and KMC, Chennai.

22. Color duplex ultrasonography

Arterial-lacunar fistula due to rupture
of the right cavernosal artery
(arrowheads )
High flow priapism
22 Dept of Urology, GRH and KMC, Chennai.

23. Angiography
Adjunctive study
Identify site of cavernous
artery fistula (ruptured
helicine artery)
Performed as part of an
embolization procedure
arterial-lacunar fistula due to rupture of the
right cavernosal artery (arrowheads)
23 Dept of Urology, GRH and KMC, Chennai.

24. Cavernosography
Not used routinely
Delayed cases –sinus
thrombosis
Evaluation of post
episode erectile function
Prior to surgery – fistula
closure
Irreversible fibrosis of corpora
cavernosa on cavernosography
24 Dept of Urology, GRH and KMC, Chennai.

25. Differentiating features
High flow Low flow
pO2 >90 mm Hg <30 mm Hg
pCO2 <40 mmHg >>60mmHg
pH >7.4 <7.2
Pain -- +
Pulsation + -
Palpation Elastic Sturdy
Arterial inflow Present Absent
Venous outflow Open Closed
Viscosity low High 25 Dept of Urology, GRH and KMC, Chennai.

26. Natural history
Resolution = non painful flaccid state
90% of men with ischemic priapism> 24 hrs – cannot
perform intercourse
Erectile dysfunction rate of 35% with systemic
treatment only
26 Dept of Urology, GRH and KMC, Chennai.

27. Treatment
Management of ischemic episode- IMMEDIATE
> 4 hours – irrespective of etiology- Compartment
syndrome
27 Dept of Urology, GRH and KMC, Chennai.

28. Aspiration
Therapeutic-
decompresses and relieves
pain
Combined with blood gas
sampling (non
Heparinized)
30% resolution rate
Can flush with saline
Aspirate 20-30 mL of blood
from either the 2-o'clock or
10-o'clock position while
milking the shaft
28 Dept of Urology, GRH and KMC, Chennai.

29. Aspiration with irrigation
Alpha adrenergic agent- phenylephrine
 α1 agonist, 100-200ug every 5-10 min
Epinephrine- 10-20ug every 5 to 10 min
Transglanular –less hematoma and facilitate blood
drainage after catheter removal
Trans corporal-proximally and distally
Blood evacuation needed for drug to be effective
Resolution-58% with injection, 77% with
combined
29 Dept of Urology, GRH and KMC, Chennai.

30. Drugs
Phenylephrine:100-500
mcg/dose, up to 10 doses
Use 10-20 mL of 20
mcg/mL solution via
intracavernous injection
q5-10min
Pseudoephedrine :- 60-120
mg PO may be given in
cases of priapism of short
duration (2-4 h)
Terbutaline -5 mg PO,
repeated after 15 min; 0.25-
0.5 mg SC,not in children
Methylene blue: Second
messenger inhibitory
effect, affecting muscle
relaxation
1-2 mg/kg IV slowly over 5
min ,not in children
30 Dept of Urology, GRH and KMC, Chennai.

31. Surgical Shunts
Failed intra cavernous treatment
Ischemic priapism 48-72 hrs duration
Objective –drain blood from cavernosa bypassing veno
occlusive mechanism
31 Dept of Urology, GRH and KMC, Chennai.

32. Winter shunt
Distal corporo glanular
shunt-with biopsy
needle
EBBEHOJ shunt-
scalpel used
32 Dept of Urology, GRH and KMC, Chennai.

33. EL- GHORAB SHUNT
Distal caverno glanular
shunt
Incision over glans
Distal corpora excised
as vent
Most effective distal
shunt
Performed secondarily-
invasive
33 Dept of Urology, GRH and KMC, Chennai.

34. Quackels/Sachers shunt
Proximal caverno
spongiosal shunt
Openings placed in
staggered fashion
Bilateral
communication
34 Dept of Urology, GRH and KMC, Chennai.

35. Vein shunts
GRAY HACK SHUNT- cavernoso
Saphenous shunt
BARRY shunt-cavernoso dorsal
vein shunt
35 Dept of Urology, GRH and KMC, Chennai.

36. TUNNEL (T)shunt
No .10 scalpel, 4 m
away from urethra
Blade rotated 90deg
away
50 sq.mm area
removed
Priapism >3 d, bilateral
T shunt, with insertion
of 20 fr sounds into
corpora
36 Dept of Urology, GRH and KMC, Chennai.

37. Prolonged ischemic priapism
LUE’S approach: a 3-step duration dependent
approach
Stage1< 24 h, Evacuation of old blood + diluted α
adrenergic agent;
Stage2- 1–2 d, T-shunt
Stage3> 3 d, T-shunt + tunnelling

Can Urol Assoc J. 2009 August; 3(4): 312–313
37 Dept of Urology, GRH and KMC, Chennai.

38. Outcomes
AUA panel data -resolution rate- 74% for Al-Ghorab,
73% for Ebbehøj, 66% for Winter, 77% for Quackels,
and 76% for Grayhack procedures
Erectile dysfunction rates are higher for the proximal
shunts, Quackels and Grayhack (about 50%) than for
the distal shunts (25% or less)
38 Dept of Urology, GRH and KMC, Chennai.

39. Non ischemic priapism
62%resolve with observation
Duration does not affect outcome
Selective arterial embolization-75% resolution
Non permanent material- clot/gel(5%ED)
Permanent-Coil, PVP, alcohol-(39%ED)
Penile exploration + doppler guided ligation-
last resort-63%resolution, 50%ED
39 Dept of Urology, GRH and KMC, Chennai.

40. Treatment algorithm
40 Dept of Urology, GRH and KMC, Chennai.

41. Hematologic priapism
Sickle cell disease- hydration, oxygenation, and
systemic alkalinisation to prevent further sickling
Corporeal aspiration and intracavernous α agonists
should be given as soon as possible
Hypertransfusion –selective cases - neurological
side effects
Leukaemia- treatment with leukopheresis after
failing aspiration may be necessary
41 Dept of Urology, GRH and KMC, Chennai.

42. Recurrent priapism
Treat each episode as for
ischemic cases
Prevent recurrence-
Self injection phenylephrine
Gonadotrophins-LHRH
Agonist 7.5mg/month
Anti androgens-bicalutamide
50 mg
Baclofen(20-40mg OD),
digoxin(0.25 mg)
Terbutaline
42 Dept of Urology, GRH and KMC, Chennai.

43. Miscellaneous therapies
Hydroxyurea-sickle cell disease
Methylene blue for high flow
Streptokinase, t-PA for ischemic priapism
43 Dept of Urology, GRH and KMC, Chennai.

44. Primary outcomes:
resolution of the priapism (flaccid penis for at least 24
hours),
recurrence of priapism (after 24 hours of flaccidity)
erectile dysfunction
44 Dept of Urology, GRH and KMC, Chennai.

45. Future
Clinical studies of priapism should
 Documentation of pre-priapism erectile function
 Time from onset of priapism to initial treatment
and time to each subsequent treatment
Measurement of sexual function after resolution
using a standardized instrument for one year
Using contemporary validated instruments for
assessing quality of life
45 Dept of Urology, GRH and KMC, Chennai.

46. 46 Dept of Urology, GRH and KMC, Chennai.