Medical management of ischemic stuttering priapism: a contemporary review of the literature

Priapism is defined as a prolonged and persistent erection of the penis without sexual stimulation. This is a poorly understood disease process with little information on the pathophysiology of this erectile disorder. Complications from this disorder are devastating due to the irreversible erectile damage and resultant erectile dysfunction (ED). Stuttering priapism, though relatively rare, affects a high prevalence of men with sickle-cell disease (SCD) and presents a challenging problem with guidelines for treatment lacking or resulting in permanent ED. The mechanisms involved in the development of priapism in this cohort are poorly characterized; therefore, medical management of priapism represents a therapeutic challenge to urologists. Additional research is warranted, so we can effectively target treatments for these patients with prevention as the goal. This review gives an introduction to stuttering priapism and its clinical significance, specifically with regards to the patient with SCD. Additionally, the proposed mechanisms behind its pathophysiology and a summary of the current and future targets for medical management are discussed.     

Clinical course linkage among different priapism subtypes: Dilemma in the management strategies

Objectives: Priapism is a rare condition whose management differs according to the etiology. We report the clinical course of three forms of priapism to assess the feasibility and safety of recent management strategies. Methods: The study included eight patients complaining of persistent erection for ≥4 h who were treated in our institution between January 1996 and July 2007. Results: Overall, we categorized 12 cases of priapism in eight patients divided as follows: five cases of ischemic priapism (IP), three of stuttering priapism (SP), and four of non‐ischemic priapism (NIP). Two of five IP patients needed a shunt procedure, which led to the subsequent erectile dysfunction. The other three were treated successfully with a corporal injection of sympathomimetic agents and subsequently suffered from SP. One of the three SP patients suffered from mimicked NIP with increased arterial blood flow during the initial treatment for IP. Four of the NIP patients including the mimicked one achieved complete detumescence, through arterial embolization in two and conservative management in two. Conclusions: Current management seems effective and safe in the short‐term. However, the long‐term outcome of the treatment for IP is still disappointing. Careful long‐term observation is needed for an appropriate management.     

远端分流术治疗缺血性阴茎异常勃起随访分析

目的:回顾本院收治的缺血性阴茎异常勃起(IP)的临床资料和随访结果,为合理治疗IP提供依据。方法:分析自2004年至2010年收治的IP的临床资料,并通过电话和门诊就诊的方式随访。结果:8例IP就诊前均在外院接受过不同方式的减压治疗,失败后转入本院。年龄平均34.5岁,缺血时间平均84.5 h(36¹32 h)。在本院行阴茎海绵体穿刺抽吸冲洗后完全疲软1例,部分疲软7例;进一步行Al-Ghorab分流术,成功2例,失败5例。对失败者施行T型分流术,5例完全疲软。成功随访5例,2例中度ED,3例完全性ED。与中度ED相比,完全性ED者缺血时间较长。结论:减压治疗失败后,早期尝试T型分流术可提高IP治疗的成功率。     

反复发作缺血性阴茎异常勃起(1例报告并文献复习)

目的探讨反复发作缺血性阴茎异常勃起的临床特点。方法分析复发性阴茎异常勃起1例,结合相关文献复习。结果反复发作夜间阴茎异常勃起16个月患者,临床检查确诊为复发性缺血性异常勃起,采用5a还原酶抑制剂保列治联合5羟色胺再摄取抑制剂左洛复治疗5d后,异常勃起未复发。继续服用保列治治疗,随访4个月异常勃起无复发,勃起功能正常。结论复发性缺血性阴茎异常勃起临床罕见,采用5a还原酶抑制剂联合5羟色胺再摄取抑制剂治疗具有一定的效果。     

Insights of priapism mechanism and rationale treatment for recurrent priapism

Priapism is defined as abnormal prolonged penile erection occurring beyond or unrelated to sexual interest. The disorder is enigmatic yet devastating because of its elusive etiology, irreversible erectile tissue damage, and resultant erectile dysfunction （ED）. Current management strategies suffer from a poor understanding of the pathophysiology, especially at the molecular level. The traditional treatments are based more on empirical rather than evidence-based knowledge. The outcomes for restoration of normal erectile function are poor, especially for stuttering priapism. Therefore, it is critical to understand priapism from a molecular level, to formulate treatment strategies and to establish rational prevention strategies for high-risk populations, such as sickle cell disease （SCD） patients and cases of the stuttering variant. This review focuses on the recent advances at the molecular level in priapism and penile erection, and applies the recent knowledge to the treatment of stuttering priapism.     

Unsatisfactory outcomes of prolonged ischemic priapism without early surgical shunts: our clinical experience and a review of the literature

Ischemic priapism is a rare occurrence which can cause severe erectile dysfunction (ED) without timely treatment. This retrospective study reports our experience in treating prolonged ischemic priapism and proposes our further considerations. In this paper, a total of nine patients with prolonged ischemic priapism underwent one to three types of surgical shunts, including nine Winter shunts, two Al-Ghorab shunts and one Grayhack shunt. During the follow-up visit (after a mean of 21.11 months), all patients'' postoperative characters were recorded, except one patient lost for death. Six postoperative patients accepted a 25-mg oral administration of sildenafil citrate. The erectile function of the patients was evaluated by their postoperative 5-item version of International Index of Erectile Function Questionnaire (IIEF-5), which were later compared with their premorbid scores. All patients had complete resolutions, and none relapsed. The resolution rate was 100%. Seven patients were resolved with Winter shunts, one with an Al-Ghorab shunt and one with a Grayhack shunt. The mean hospital stay was 8.22 days. There was only one urethral fistula, and the incidence of postoperative ED was 66.67%. Four patients with more than a 72-h duration of priapism had no response to the long-term phosphodiesterase type 5 (PDE-5) inhibitor treatment. These results suggest that surgical shunts are an efficient approach to make the penis flaccid after prolonged priapism. However, the severe ED caused by prolonged duration is irreversible, and long-term PDE-5 inhibitor treatments are ineffective. Thus, we recommend early penile prosthesis surgeries for these patients.     

A rare cause of recurrent priapism: hereditary angioedema

Hereditary angioedema is a rare disease, which is caused by deficiency of compleman c1 esterase inhibitor regulatory protein in the compleman system. Priapism is involuntary, painful and prolonged erection of penis more than 4 h without sexual desire. In this case report, we elucidated a patient diagnosed with hereditary angioedema while he had recurrent priapism.     

A case report on idiopathic recurrent priapism

Idiopathic recurrent priapism is a difficult problem to treat and a potentially devastating condition that may result in irreversible penile fibrosis. We present the case of a patient who, during a period of 10 years, had recurrent episodes of idiopathic priapism and we show that therapeutic options do exist for the management.     

An alternative noninvasive approach for the treatment of high-flow priapism in a child: duplex ultrasound-guided compression

We are presenting a 5-year-old boy with a traumatic high-flow priapism developed after a straddle injury and successfully treated by compression and simultaneous monitoring with a duplex ultrasound probe. We believe that this may be an alternative method against conventional treatment modalities including conservative follow-up, sympathomimetic drug administration, percutaneous embolization of the fistula, and surgical ligation.     

A new cause of ischaemic priapism: Synthetic cannabinoids

Priapism is a urological emergency that needs early intervention and may lead to irreversible cavernosal damage. Ischaemic priapism is the most common type, which is frequently idiopathic and commonly associated with haematological diseases, medications or recreational drugs. Synthetic cannabinoids (SCs) have been increasingly used all over the world, particularly among young‐adult population. SCs can cause severe adverse effects on several organ systems. However, there are no studies in the literature which have stated the possible relationship between using of SCs and priapism. We present a case of 28‐year‐old man who was diagnosed with a 58‐hr lasting priapism after regular administrations of SCs. The priapism did not resolve neither after applying aspiration with irrigation nor shunt surgery. Finally, penile prosthesis implantation was performed as last treatment option. The SCs have been increasingly used among young population in recent years; therefore, new SC‐related ischaemic priapism cases might be encountered in the emergency departments.     

Acenocoumarol associated priapism: report of a case

We report on a 20-year-old man presenting with priapism while receiving oral acenocoumarol for the treatment of deep vein thrombosis. To the authors' knowledge, it is the first reported case of acenocoumarol-associated priapism.     

9例阴茎异常勃起诊治体会

目的 探讨阴茎异常勃起的诊断和治疗方法.方法 回顾性分析9例阴茎异常勃起患者的诊治过程.结果 9例患者均通过病史、体检、海绵体抽吸血气分析及多普勒超声检查确诊.经镇静、局部冷敷、海绵体抽吸血液、海绵体内注射药物及手术等不同方法治疗后,8例缺血性阴茎异常勃起患者中5例完全消退,3例部分消退;1例非缺血性阴茎异常勃起患者部分消退.5例随访6个月,其中4例出现ED.结论 阴茎海绵体血气分析、海绵体彩色多普勒检查对阴茎异常勃起有重要诊断价值,早期及正确应用海绵体注射药物和阴茎海绵体尿道海绵体分流术加术中冲洗是治疗缺血性阴茎异常勃起的可靠方法,但是由于大多数病人持续勃起时间较长,ED的发生率偏高.     

Post-traumatic high flow priapism: A case report

A case of post-traumatic high flow priapism in a 32-year-old man is reported. The diagnosis was based on cavernous blood gas analysis and left internal pudendal arteriography. He was treated by unilateral super-selective embolization of the fistula with coils and gelatin sponge. At 1 month after embolization, erectile function had recovered, as demonstrated by measurement of nocturnal penile tumescence.     

New aspects in the treatment of priapism

Recent advances in the understanding of erectile physiology have improved the prompt diagnosis and treatment of priapism. During initial assessment, the physician must distinguish between veno-occlusive low flow (ischemic) and arterial high flow (nonischemic) in order to choose the correct treatment option for each type of priapism. Patient history, physical examination, penile haemodynamics and corporeal metabolic blood quality assist the distinction between static and dynamic priapism. Normally, priapism is effectively treated with intracavernous vasoconstrictive agents or surgical shunting. However, when these two methods fail, subsequent treatment procedures are a matter for debate. Alternative options, such as intracavernous injection of methylene blue or selective penile arterial embolization, for the management of high and low flow priapism are described and a survey of current treatment modalities is presented.     

The use of high‐resolution magnetic resonance imaging in the management of patients presenting with priapism

Study Type – Diagnosis (exploratory cohort)
Level of Evidence 2b OBJECTIVE To investigate the use of magnetic resonance imaging (MRI) of the penis during an episode of priapism and assess the viability of the corpus cavernosum (CC) smooth muscle, as prolonged ischaemic priapism is associated with a high rate of long‐term erectile dysfunction (ED), and the viability of CC smooth muscle influences the subsequent management in ischaemic priapism. PATIENTS AND METHODS The study was set in a single centre based in a large university teaching hospital. We investigated the correlation of T2‐weighted gadolinium‐ enhanced MRI with the histology from CC biopsies in the same patients. In all, 38 patients (mean age 42 years) presenting with priapism over a 3‐year period had MRI of the penis. The scans were reported by two dedicated uro‐radiologists who graded the MR images as showing viable or nonviable erectile tissue. One pathologist assessed the CC biopsies for necrosis. The findings were then correlated. Where no biopsies were taken a clinical follow‐up was used to assess erectile function. RESULTS In 23 patients undergoing both a CC biopsy and MRI, the sensitivity of MRI in predicting nonviable smooth muscle was 100%. In a further 10 patients MRI showed nonviable CC smooth muscle, but no biopsy was taken in these patients; on clinical follow‐up all of these patients subsequently developed ED. In a further five patients the imaging showed viable smooth muscle and these patients subsequently maintained erectile function on clinical follow up. CONCLUSIONS Penile MRI provides an accurate imaging method to assess smooth muscle viability in patients presenting with priapism.     

Partial priapism secondary to tamsulosin: a case report and review of the literature

Partial priapism is also called partial segmental thrombosis of the corpus cavernosum. It is a rare pathology, and its aetiology, physiopathology and treatment are still not completely understood. To our knowledge, partial priapism due to alpha blockers has not been reported previously in the literature. In this study, a successfully treated case of partial priapism occurring after the usage of alpha blocker is presented and discussed in light of the related literature.