A Systematic Review on Ischemic Priapism and Immediate Implantation: Do We Need More Data?

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.

Epidemiology and treatment of priapism in sickle cell disease

Ischemic priapism is a common but underrecognized morbidity affecting about 33% of adult men with sickle cell disease (SCD). The onset of priapism occurs in the prepubertal period and tends to be recurrent with increasing age. Significantly, priapism is associated with an unrecognized high burden of mental duress and sexual dysfunctions. The diagnosis of priapism is clinical. Many episodes of priapism will resolve spontaneously, but when an episode lasts longer than 4 hours, the episode is considered a urologic emergency requiring quick intervention with either corporal aspiration or shunt surgery. Only 3 randomized clinical trials (stilbesterol, ephedrine or etilefrine, and sildenafil) have been conducted for secondary priapism prevention in SCD. All 3 trials were limited with small sample sizes, selection biases, and inconclusive results after completion. The current molecular understanding of the pathobiology of priapism suggests a relative nitric oxide (NO) deficiency secondary to chronic hemolysis in SCD and associated phosphodiesterase type 5 dysregulation. We posit an increase in NO levels will restore the normal homeostatic relationship between voluntary erection and detumescence. Currently, 2 randomized phase 2 trials (1 double-blind, placebo-controlled trial and 1 open-label, single-arm intervention) are being conducted for secondary priapism prevention in men at high risk for recurrent priapism (NCT03938454 and NCT05142254). We review the epidemiology and pathobiology of priapism, along with mechanistic therapeutic approaches for secondary prevention of priapism in SCD.

Review of Ischemic and Non-ischemic Priapism

PURPOSE OF REVIEW

Priapism is a rare condition that has different presentations, etiologies, pathophysiology, and treatment algorithms. It can be associated with significant patient distress and sexual dysfunction. We aim to examine the most up-to-date literature and guidelines in the management of this condition.

RECENT FINDINGS

Priapism is a challenging condition to manage for urologists, since the etiology is often multi-factorial and the suggested treatment algorithms are based on small studies and expert anecdotal experience, perhaps due to the rarity of the disorder. Ischemic priapism of less than 24 h can be managed non-surgically in most cases with excellent results. Ischemic priapism of more than 36 h is frequently associated with permanent erectile dysfunction. Management of prolonged priapism with penile shunting still may result in poor erectile function, so penile prosthesis can be discussed in these scenarios.

Penile Prosthesis Implantation in Refractory Ischaemic Priapism: Patient Selection and Special Considerations

Ischemic priapism accounts for more than 95% of all priapic episodes. It has to be considered a urological emergency because its time extension may lead to necrosis of smooth muscle cells of the corpora cavernosa, resulting in a complete erectile dysfunction, penile shortening and loss of girth. In the present systematic review, we perform an up-to-date literature search for patients suffering from refractory ischemic priapism who undergo penile prosthesis implantation with particular interests to the patients characteristics. The conservative management of the priapic episode consists of a sympathomimetic agent in the first istance. Failure or recurrence of priapism following these conservative measures is an indication for surgical management. Shunt procedures between the corpora cavernosa and the neighbouring structures are often used first line; however, in refractory ischemic priapism the success rate is minimal. In such cases (>48 h) an indication of immediate placement of a penile prosthesis could be the best solution.

[Non-infectious emergencies of the lower urinary tract and genitals]

INTRODUCTION

The objective of this narrative review was to report the most relevant data on the contemporary management of the main non-infectious emergencies of the lower urinary tract and genital organs.

METHODS

A narrative synthesis of the articles (French, English) available on the Pubmed database was carried out in June 2021. A request to the health surveillance network for emergencies and deaths (SurSaUD®, Santé Publique France) revealed original data on the epidemiology of non-infectious lower urinary tract and genital organs emergencies.

RESULTS

Non-infectious emergencies of the low urinary tract and genital organs represent a large panel of traumatic and non-traumatic situations, which constitute the 3rd reasons in urology for a consultation at the emergency department after, infectious disease (1st) and non-traumatic/non-infectious emergencies of the upper urinary tract (2nd). Hematuria is the 3rd urological reason for men for a consultation at the emergency department. Globally, pelvic trauma and genital traumatism mainly concern men. These emergencies rarely affect the prognosis but can be integrated into more complete situations which are likely to impact their treatment, particularly in multiple traumas.

CONCLUSIONS

In this article we report the epidemiology and the principles of management of non-infectious emergencies of the lower urinary tract and genital organs.

Penile Doppler ultrasound study in priapism: A systematic review

BACKGROUND

Penile Doppler ultrasound (PDU) is suggested to be an alternative to blood gas analysis (BGA) from the corpora cavernosa in differentiating between high- and low-flow priapisms, with limited supportive evidence.

AIM

To compare penile Doppler ultrasound study and blood gas analysis in the diagnosis of priapism, through a systematic review of the literature.

METHODS

Studies were identified by literature search of Medline, Scopus, Cochrane and ClinicalTrials.Gov. Studies were included if their participants had priapism evaluated by Penile Doppler ultrasound, and reported data on the blood gas analysis or pudendal artery angiography (PAA). Two authors independently extracted the articles using predetermined datasets, including indicators of quality.

OUTCOMES

Correlation of penile Doppler ultrasound with blood gas analysis and pudendal artery angiography.

RESULTS

Twelve studies were included. Three studies compared Penile Doppler ultrasound to blood gas analysis and pudendal artery angiography. Penile Doppler ultrasound was used as adjunctive to blood gas analysis to differentiate low flow from high flow priapism, guidance for embolization, etiological diagnosis in three studies. Compared to pudendal artery angiography, penile Doppler ultrasound had a sensitivity of 40-100% and a specificity of 73%, to localize vascular injury and anatomical abnormalities (two studies). Penile Doppler ultrasound was also used for the follow-up after the treatment of priapism (two studies). No study reported an impact on functional results or a delay of management due to penile Doppler ultrasound use.

CLINICAL TRANSLATION

We reviewed evidence on penile Doppler ultrasound study in priapism. Penile Doppler ultrasound study performance was comparable to blood gas from corpus cavernosum. It is recommended to use doppler as an alternative diagnostic tool.

STRENGTHS & LIMITATIONS

Our systematic review had limitations. Firstly, the number of cases in the included studies was small. Secondly, these studies were all retrospective. Lastly, few data were reported with regards to hemodynamic parameters of penile Doppler ultrasound, and the majority of studies did not describe these in detail.

CONCLUSIONS

Evidence supports that penile Doppler ultrasound is a reliable way for differentiating high-flow and low-flow priapism. We recommend penile Doppler ultrasound study as an alternative of blood gas analysis from corpus cavernosum, especially when the latter is not available.

LEVEL OF EVIDENCE

3.

Priapism and Sickle Cell Disease: Special Considerations in Etiology, Management, and Prevention

Sickle cell disease (SCD) is an inherited medical condition where sickled red blood cells cause vaso-occlusive crisis. One major complication of SCD is priapism, defined as an erection of the penis lasting over four hours beyond sexual stimulation or orgasm. SCD priapism is caused by sickled erythrocytes obstructing venous outflow and can lead to permanent erectile dysfunction. This article reviews the pathology, physiology, and management of SCD priapism, including potential novel therapeutic agents.

Premature Ejaculation patients and their partners: arriving at a clinical profile for a real optimization of the treatment

The aim of the study is to extrapolate clinical features of Premature Ejaculation (PE) patients and female partners of men affected with PE, in order to get a profile that can be of assistance for physicians within the dynamics of a couple, one of which is a PE patient. An observational, non-interventional, cross-sectional epidemiological study entitled IPER (Italian Premature Ejaculation Research) was conducted and included two different cohorts of subjects that were randomly sampled from a patient dataset of selected General Practitioners: 1. IPER-M sub-cohort (1.104 subjects) was made of male subjects in which they were then distinguished patients with or without PE based on the score of the PEDT questionnaire; IPER-F sub-cohort (1.109 subjects) was made of female subjects from an independent sample of women (therefore not the partners of the IPER-M males) in which they then distinguished those partners of a male subject with PE or not. In addition to an identical general questionnaire to explore demographic aspects and habits, each subcohort was then evaluated using validated questionnaires. No differences were noted between PE+/PE- patients in terms of alcohol consumption, smoking habits, physical activity nor stress condition in everyday life, employment, socio-economic class and marital status. While the prevalence of PE proportionally increased with age, excluding the 50-59 and 70-80 years decades, in the IPER-M group an overall statistically significant difference for the mean age between the PE+ and PE- groups (p = 0.002) was detected, but without reaching any difference amongst the different age classes in the IPER-F group. The PE+ patients reported a significantly lower frequency rate of sexual intercourse, worse QoL (p = 0.006 and p < 0.0001, respectively), and increased anxiety status (p < 0.0001 for both subgroups). This study shows that, rather than talking with a patient affected by PE it would be advisable to introduce the concept of couple counseling with the person patient and his partner, because it is only through classification of both partners as one couple and a full understanding of their mutual sexual experience that PE treatment can be optimized and its results measured accurately.

Current Status for Semirigid Penile Prosthetic Devices

PURPOSE OF REVIEW

The goal of this paper was to evaluate the current use of semirigid penile prosthesis (SRPP), surgical techniques for insertion of SRPP, and how to prevent and approach surgical complications.

RECENT FINDINGS

SRPP is a valid option for those who are refractory to medical therapy for erectile dysfunction (ED) and even more appropriate for specific subsets of patient populations. It is important for urologists to know which patient population SRPP is preferred for. Several studies have shown good patient outcomes and patient satisfaction with those who underwent SRPP.

Two-piece inflatable and semi-rigid penile implants: an effective alternative?

Penile prostheses (PPs) are an excellent treatment to be considered for patients suffering from erectile dysfunction (ED), refractory to oral medications, or unwilling to consider intracavernosal injections or other therapeutic strategies. Nowadays the market is dominated by three-piece inflatable penile prosthesis (IPP), which are considered the best option available. However, in some specific cases three-piece IPP may be superseded by semi-rigid penile prosthesis (SRPP) and two-piece IPP. Despite the advantages of these implants, the literature is quite scarce, not robust and rarely takes into consideration the partner's satisfaction. This clearly affects the strength of our conviction. Most of the studies confirm that SRPPs and two-piece IPPs can be considered a valid alternative in patients with hand dexterity issues, refractory ischaemic priapism, neophallus and in cases of complex anatomies. In addition, the ease of placement and the high confidence level of surgeons make them a powerful tool in the armamentarium of urologists.