Priapism. From Priapus to the present time

The genitourinary system in ancient Greece: a historical perspective

The Ancient Greeks were great innovators in all academic fields, including medicine. Hippocrates of Kos, the Father of Medicine, established many terms for the genitourinary (GU) system, such as nephros, urethra, urogenital, and adenocarcinoma. According to Hesiod's Theogony, Aphrodite, the goddess of love and beauty, was born off the coast of Kythera, from the foam produced by Uranus's genitals, after his son Cronus had thrown them into to the sea. In this review, we present the etymology of the GU vocabulary, review the Ancient Greeks' understanding of the GU system and the origins of Greek myths related to the male genitals.

An Experimental Rat Model Study: Is There Any Effect of Syringic Acid on Ischemia-Reperfusion Injury in Priapism?

Purpose The purpose of this research is to examine the impact of syringic acid on ischemia-reperfusion injury in cavernosal tissue, utilizing a rat model of induced priapism. Materials and methods A total of 24 rats were allocated into three groups. Group 1 was designated as the control group, while Group 2 underwent ischemia-reperfusion injury assessment using the priapism model. Group 3 underwent the same procedures as Group 2, with the addition of intraperitoneal administration of syringic acid (100 mg/kg) 60 min after priapism initiation. All rats underwent penectomy, and sufficient blood samples were collected. Histopathological assessment of penile cavernosal tissue involved grading tissue damage, inflammation, vasocongestion, desquamation, and edema on a scale of 0-3 (0: normal, 1: mild, 2: moderate, 3: severe). Result Significant differences were observed among the three groups in terms of IL-1 beta and TNF-alpha levels (p=0.001 and p<0.001, respectively). IL-1 beta and TNF-alpha levels in Group 2 were found to be significantly higher than Group 3 (p=0.003 and p=0.004). There was also a significant difference among the three groups in terms of median MDA levels (p<0.001). Furthermore, the median MDA level in Group 2 was found to be significantly higher than that in Group 3 (p<0.001). While significant differences were observed among the three groups in terms of median SOD and GSH-px levels, no significant difference was found among the groups in terms of median PC levels (p=0.004, p= 0.048, and p=0.159, respectively). In direct microscopic examination, a significant improvement in pathological scores was noted in Group 3 compared to Group 2 (p<0.001). Conclusion Syringic acid demonstrated protective properties against ischemia-reperfusion injury caused by priapism in cavernosal tissue.

Treatment of Refractory Ischemic Priapism: A Case Report and Literature Review

Recurrent priapism is a rare and poorly known entity. It is defined by recurrent episodes of painful erections that last less than four hours. The etiology is similar to that of ischemic priapism. Episodes lasting more than four hours require immediate intervention to prevent penile fibrosis and subsequent erectile dysfunction. A 42-year-old male with no significant chronic-degenerative history was referred to our medical center from his second-level medical unit after a 56-hour history of ischemic priapism with the persistence of tumescence despite medical and surgical treatment. Upon interrogation, the patient reported stuttering (recurrent) episodes of painful erections lasting approximately three to four hours, not associated with sexual activity or arousal, in the past two years, with spontaneous resolution. He denied the use of psychotropics or drugs for erectile dysfunction. As a palliative measure, a left saphenous-cavernous (Grayhack) bypass was performed, with a 90% decrease in tumescence and total resolution of pain during the first 12 hours. There is little information and treatment recommendations for patients with recurrent priapism, and even less for patients who are refractory to conventional medical and surgical treatment. Recurrent or stuttering priapism is a condition with a low incidence and a pathophysiology compatible with low-flow priapism. It is difficult to treat and has a poor prognosis in terms of erectile function. Likewise, it is mostly associated with the use of psychotropic drugs such as cocaine and marijuana, medications for erectile dysfunction such as phosphodiesterase inhibitors, prostaglandin E1 analogues, and hematological malignancies such as sickle cell anemia and multiple myeloma. The aim of this article is to share our experience with a patient refractory to multiple medical and surgical treatments.

An update on the management algorithms of priapism during the last decade

Priapism is a persistent penile erection lasting longer than 4 hours, that needs emergency management. This disorder can induce irreversible erectile dysfunction. There are three subtypes of priapism: ischemic, non-ischemic, and stuttering priapism. If the patient has ischemic priapism (IP) of less than 24-hours (h) duration, the initial management should be a corporal blood aspiration followed by instillation of phenylephrine into the corpus cavernosum. If sympathomimetic fails or the patient has IP from 24 to 48h, surgical shunts should be performed. It is recommended that distal shunts should be attempted first. If distal shunt failed, proximal, venous shunt, or T-shunt with tunneling could be performed. If the patient had IP for 48 to 72h, proximal and venous shunt or T-shunt with tunneling is indicated, if those therapies failed, a penile prosthesis should be inserted. Non-ischemic priapism (NIP) is not a medical emergency and many patients will recover spontaneously. If the NIP does not resolve spontaneously within six months or the patient requests therapy, selective arterial embolization is indicated. The goal of the management of a patient with stuttering priapism (SP) is the prevention of future episodes. Phosphodiesterase type 5 (PDE5) inhibitor therapy is considered an effective tool to prevent stuttering episodes but it is not validated yet. The management of priapism should follow the guidelines as the future erectile function is dependent on its quick resolution. This review briefly discusses the types, pathophysiology, and diagnosis of priapism. It will discuss an updated approach to treat each type of priapism.

Pathophysiology and Grayscale Ultrasonography of Penile Corporal Fibrosis

INTRODUCTION

Penile corporal fibrosis may occur secondary to explantation of an infected penile prosthesis, severe penile trauma, refractory low-flow priapism, Peyronie's disease, or chronic intra-cavernous injection of vasoactive drugs. Other etiologies of corporal fibrosis, presenting primarily with erectile dysfunction, can develop in chronic smokers, hypertensive patients, alcoholics, diabetics, and after radical prostatectomy. Corporal erectile tissue fibrosis is a significant pathophysiologic component of erectile dysfunction; however, current ultrasound-based penile imaging protocols do not directly assess it.

OBJECTIVE

To determine if grayscale ultrasonography (US) is a suitable imaging modality to identify and assess penile corporal erectile tissue fibrosis.

METHODS

A PubMed literature review was performed for studies that detailed ultrasonographic methods and findings of pathologies causing penile corporal fibrosis. Our main outcome measure was the ultrasonographic findings of pathologies causing penile corporal fibrosis.

RESULTS

Grayscale US demonstrates the capability to detect and localize the fibrotic changes of the corpora cavernosa. Ultrasonographic findings capture penile corporal tissue heterogeneity including diffuse, circumscribed, or localized patterns.

CONCLUSION

Overall, grayscale US may be a useful and convenient imaging modality to assess penile corporal fibrosis secondary to explantation of an infected penile prosthesis, priapism, penile trauma, chronic intra-cavernous injection of vasoactive drugs, diabetes, Peyronie's disease, and vascular disease. While limited by the skill and knowledge of the US operator, the combined knowledge of pathophysiology and US may help clinicians identify and manage the underlying etiology of penile corporal fibrosis. Kim J, Drury R, Morenas R et al. Pathophysiology and Grayscale Ultrasonography of Penile Corporal Fibrosis. Sex Med Rev 2022;10:99-107.

Shear wave elastography as a new, non-invasive diagnostic modality for the diagnosis of penile elasticity: a prospective multicenter study

Objective:

Shear wave elastosonography (SWE) could be used to evaluate the elasticity of penile tissue. Few studies in the literature, however, have investigated its use in patients with erectile dysfunction (ED) or have attempted to correlate findings with International Index of Erectile Function (IIEF-5) scores. The primary aim of this study was to evaluate the characteristics of erectile tissue using SWE and to determine possible relationships with IIEF-5 and Erection Hardness Scale (EHS) scores. The secondary aim was to establish a cut-off SWE examination value over which cavernous tissue stiffness could contribute to a subsequent organic alteration.

Methods:

This prospective study included male patients 18−80 years of age who attended two general andrology clinics and underwent SWE. Subjects were divided into groups according to IIEF-5 score, and correlations between SWE and IIEF-5 and EHS questionnaire scores were explored.

Results:

A total of 270 subjects (mean age 46.7 ± 16.9 years) were included. ED was reflected by low IIEF-5 and EHS scores and a decrease in the mean elasticity of the corpora cavernosa according to SWE, although the difference between the left and right corpora cavernosa was not statistically significant. No statistically significant correlation was found between measurements of the corpora cavernosa (in kPa) and age. The optimal cut-off identified was 24.75 kPa.

Conclusion:

Results demonstrated that the mean elasticity of the corpora cavernosa according to SWE was correlated with IIEF-5 score and EHS score.

Acute penile trauma: imaging features in the emergency setting

In an emergency department, penile traumas are uncommon and a prompt diagnosis is necessary. Penile injury may result from penetrating and non-penetrating trauma. Non-penetrating injuries can produce cavernosal hematomas or fractures: if not treated promptly, these lesions can result in fibrosis or erectile dysfunction. Penile traumatic lesions need a clinical approach first, but a radiological study is often required: ultrasonography with color and spectral Doppler study is usually the first approach. In some cases, magnetic resonance imaging may be performed to better recognize even small discontinuity of the tunica albuginea. Radiologists have to be aware of the various radiological patterns of penile traumatic lesions, in order to establish a prompt and correct diagnosis.

Postoperative drug-induced priapism

We presented a case of a postoperative patient with low-flow priapism, possibly initiated by propofol-based anaesthesia or epidural anaesthesia. The delay in diagnosing priapism resulted in emergency interventions with a partially successful effect and eventually permanent erectile dysfunction. Due to the delay in treatment, erectile dysfunction ensued and was manageable with medication; hence, the patient decided against a penile prosthesis.

High-flow priapism treated with superselective transcatheter embolization using polyvinyl alcohol particles

OBJECTIVES

Priapism is a persistent erection of the penis not associated with sexual stimulation. High-flow priapism is caused by unregulated arterial inflow, usually preceded by perineal or penile blunt trauma and formation of an arterial-lacunar fistula. We present a case of high-flow priapism in a 13-year-old patient managed with polyvinyl alcohol particles.

METHODS

After obtaining informed consent of the parents of the minor, diagnosis was made with penile Color Doppler Ultrasound and confirmed with flush angiography. Selective arterial embolization was performed with the use of polyvinyl alcohol particles.

RESULTS

Complete detumescence was achieved without compromising the patient's erectile function.

CONCLUSIONS

The use of permanent occlusive agents like polyvinyl alcohol particles for embolization shows good occlusion rates compared to temporary agents. More studies are needed to find the safer and better agent for the treatment of high flow priapism without compromising erectile function.

Ultrasound Emergencies of the Male Pelvis

Male pelvic emergencies are uncommon, and symptoms typically include scrotal pain, scrotal enlargement, or a palpable scrotal mass or all of these. Ultrasound is often the first-line modality for evaluation of male pelvic emergencies, which may be stratified into vascular, infectious, or traumatic causes. Entities such as testicular torsion, Fournier gangrene, and testicular dislocation are surgical emergencies and should not be missed or misdiagnosed, as this may cause a significant delay in urgently necessary treatment. Radiologists need to be familiar with the role of imaging as well as the key characteristic imaging findings of these injuries to direct the appropriate management.

Intracavernosal metaraminol bitartrate for treatment of priapism resulting from circumcision: a case report

Introduction

Priapism is an uncommon disorder of involuntary prolonged erection beyond sexual excitement or desire. Herein, we present a rare case of priapism resulting from traditional circumcision under regional anesthesia with dorsal penile nerve block by xylocaine, which was successfully treated by intracavernosal injection of metaraminol bitartrate.

Case description

A 37-year-old man visited our out-patient department for a penile erection, which had been observed during the surgery, lasting for 21 days. 10 days after circumcision, he accepted simple corporeal aspiration in another hospital but it had no effect. In our hospital, he was injected intracavernosally twice a day, with 2 mg metaraminol bitartrate diluted in 1 ml normal saline every time. Complete resolution of penile tumescence was achieved after injection for 7 days, no complications were observed.

Discussion and evaluation

Priapism developed following circumcision is very uncommon. This particular case was diagnosed as high-flow non-ischemic priapism, and is the first reported event of priapism resulting from circumcision which was finally successfully treated with the efficient and minimally invasive method of intracavernosal injection of metaraminol bitartrate.

Conclusions

Intracavernous injection of metaramino bitartrate might be a simple, effective and safe method for relief of priapism associated with circumcision. Yet, more clinical studies are needed to validate the effectiveness of intracavernosal metaramino bitartrate for post-circumcision priapism.

Management of priapism in adult men

This study aims to present the management of priapism in adult men in Port Harcourt, Nigeria. All patients who presented with priapism in 2 hospitals in Port Harcourt from July 2007 to April 2014 were prospectively studied. Treatment was assigned based on clinical presentation. Data analyzed included: age on clinical presentation, risk factor, mode, and outcome of management. There were 18 patients aged 17 to 60 years (median age: 30 years). Three patients (16.7%) presented with stuttering priapism. Most of the patients presented after 24 hours of onset. Sixteen patients (89.9%) had hematological disorders. Five patients (27.8%) took suspected aphrodisiac medications. Seven patients (38.9%) were managed conservatively. The rest achieved detumescence following glandulo-cavernous shunting. Erectile function after treatment was satisfactory in 5 patients (27.8%). The commonest cause of priapism in Port Harcourt was hematological disorder. Most of the patients presented late. Prevalence of erectile dysfunction after treatment was high.

Second pathways in the pathophysiology of ischemic priapism and treatment alternatives

OBJECTIVE

To evaluate the early therapeutic alternatives such as bosentan, an endothelin receptor blocker, theophylline, an adenosin receptor blocker, and a nonselective phosphodiesterase enzyme inhibitor, zinc protoporphyrin (ZnPP), a heme oxygenase 1 inhibitor, for the therapy of ischemic priapism in the rat models.

METHODS

Twenty-four Sprague-Dawley rats were randomly divided into 4 equal groups: control group, ZnPP group, bosentan group, and theophylline group. Erection was provided by vacuum constriction method and maintained for 4 hours for achieving the priapism in all groups. The rats in the control group were administered 1 mL/kg saline intraperitoneally (ip). The rats in group 2 were administered 25 mg/kg ZnPP ip. The rats in group 3 were administered 0.25 mg/kg bosentan ip. The rats in group 4 were administered 100 mg/kg theophylline ip. Six rats from each group were decapitated after 6 hours of drug administration. Then endothelin 1, adenosine deaminase, heme oxygenase 1 enzymatic activity, and apoptosis index in the cavernous tissues were estimated.

RESULTS

Cavernous tissue endothelin 1, adenosine deaminase, heme oxygenase 1 enzymatic activity levels, and apoptosis index were significantly decreased in bosentan, theophylline, and ZnPP-treated rats compared with the controls.

CONCLUSION

Inhibition of priapism induced apoptosis with bosentan, theophylline, and ZnPP seems promising on preserving erectile function.

Korean Society for Sexual Medicine and Andrology (KSSMA) Guideline on Erectile Dysfunction

In February 2011, the Korean Society for Sexual Medicine and Andrology (KSSMA) realized the necessity of developing a guideline on erectile dysfunction (ED) appropriate for the local context, and established a committee for the development of a guideline on ED. As many international guidelines based on objective evidence are available, the committee decided to adapt these guidelines for local needs instead of developing a new guideline. Considering the extensive research activities on ED in Korea, data with a high level of evidence among those reported by Korean researchers have been collected and included in the guideline development process. The latest KSSMA guideline on ED has been developed for urologists. The KSSMA hopes that this guideline will help urologists in clinical practice.

Priapism: pathophysiology and the role of the radiologist

Priapism is defined as a penile erection that persists for 4 h or longer and is unrelated to sexual activity. Its identification is important as lack of timely treatment (particularly of the low flow/ischaemic subgroup) can result in persisting erectile dysfunction as a consequence of irreversible corporal fibrosis. This review describes the physiology and anatomy of the normal erection, the aetiology and pathophysiology of the different types of priapism, and the role of the radiologist in the management of the condition. The treatment of iatrogenic priapism following intracavernosal injection of pharmacostimulant is discussed.

In vitro and in vivo animal models in priapism research

INTRODUCTION

Priapism is an enigmatic yet devastating clinical phenomenon. In the last two decades, the use of various animal models to study this disorder has dramatically advanced our understanding of this mysterious disorder.

AIM

This report reviews various animal models used to study ischemic priapism and informs basic science researchers the broad view of priapism research.

METHODS

Retrospective review of pertinent literature from the last two decades via PubMed search using the keywords "ischemic priapism" and "priapism model."

MAIN OUTCOME MEASURES

  Findings on the animal models used in ischemic priapism research and its advantages and limitations.

RESULTS

In vitro and in vivo animal models varying from dogs, cats, rabbits, rats to mice were used in priapism research. In vitro models included: (i) corpora cavernosa smooth muscle (CCSM) strip in organ bath; (ii) corporal tissue binding assay; (iii) CCSM cell culture under hypoxia/anoxia. In vivo models could be categorized as: (i) pharmacologically induced by corpus cavernosum medicine injection; (ii) ventilation induced by tidal volume control; (iii) mechanical induced by a constrictor band placed around the base of the penis combined with induced erection; (iv) genetic engineered by intracorporal gene transfer, transgenic, or gene knock-out.

CONCLUSIONS

The ischemic priapism animal models are shifting from pharmaceutically or mechanically induced to genetically engineered. The knowledge generated by those models is enhancing our understanding and management of this clinical challenge.

High-flow priapism complicating ischemic priapism following iatrogenic laceration of the dorsal artery during a Winter procedure

We report a case of a patient who developed high-flow priapism following a Winter procedure performed for the treatment of low-flow ischemic priapism. During the creation of bilateral cavernosal-glandular shunts, the tip of the left dorsal artery was accidentally lacerated. A fistula developed through the shunt between the torn artery and the cavernosal sinusoids of the tip of the left corpus cavernosum. Gray-scale and Doppler sonography and angiography allowed diagnosis and guided the therapeutic approach.

Intracavernous epinephrine: a minimally invasive treatment for priapism in the emergency department

Priapism is the prolonged erection of the penis in the absence of sexual arousal. A 45-year-old man, an admitted frequent cocaine user, presented to the Emergency Department (ED) on two separate occasions with a history of priapism after cocaine use. The management options in the ED, as exemplified by four individual case reports, in particular the use of a minimally invasive method of intracorporal epinephrine instillation, are discussed.

Post traumatic prepubertal high-flow priapism: a rare occurrence

High-flow or arterial priapism is an uncommon condition resulting from perineal or penile trauma. The classical features are a painless erection of the cavernous bodies while the corpus spongiosum stays flaccid. This case highlights a 11-year-old boy who presented with painless semi rigid erection of 3 days duration following a blunt skateboard injury to his perineum. Following failed conservative treatment, the patient underwent bilateral internal pudendal angiography with localization and embolization. Follow up in 1 month showed patient to have normal nocturnal and reflexogenic erections. Medical and surgical treatments for high-flow priapism have been described in literature with varying degree of success and complications. The current accepted standard of care is pelvic angiography and super-selective embolization of internal pudendal artery.

Post-surgical high-flow priapism treated by embolization

Perineal and penile traumas are the commonest cause of high-flow priapism. The clinical symptom of this disease is generally a prolonged, painless, and semirigid penile erection without any other urogenital symptoms. In contrast, high-flow priapism is a quite uncommon condition after transurethral surgery and it may be presented with an unusual clinical manifestation. Herein, we report the first case of priapism associated with massive urethral hemorrhage requiring blood transfusion after internal urethrotomy. High-flow priapism was successfully treated by autologous clot embolization and the priapism associated with massive urethral hemorrhage resolved.

Low-flow priapism needs recognition and early correct treatment

Low-flow priapism is a rare condition whereby there is a persistent, painful erection. The patient often presents late because of embarrassment. Failure to recognise this as an emergency and instigate immediate treatment may lead to cavernosal tissue ischaemia, fibrosis and subsequent long-term impotence. A case of low-flow priapism, that demonstrated a lack of urgency and understanding is discussed. An internet-based literature search provided a treatment regimen with resolution of tumescence.

Case report: Avoidance of palpable corporal fibrosis due to priapism with upregulators of nitric oxide

INTRODUCTION

Recent evidence suggests that blocking inducible nitric oxide (NO) synthase in the penis may exacerbate fibrotic processes and that application of medications known to increase NO in tissues may prevent fibrosis.

AIM

To report the use of an antifibrotic regimen consisting of medications known to upregulate NO production in two patients with refractory priapism.

METHODS

Two patients presented with priapism of greater than 48-hour duration. After corporal aspiration/irrigation and shunting procedures failed, both were prescribed a daily antifibrotic regimen comprising the phosphodiesterase inhibitors pentoxifylline and sildenafil, and the NO precursor, L-arginine.

RESULTS

At 1 year, both patients were found to have supple corpora without evidence of corporal fibrosis.

CONCLUSIONS

An antifibrotic regimen consisting of upregulators of NO production may ameliorate the corporal fibrosis associated with recalcitrant priapism.

Priapism associated with routine use of quetiapine: case report and review of the literature

We report a case of priapism occurring in a patient taking a standard daily dose of the atypical antipsychotic quetiapine (Seroquel). To our knowledge, this represents the second published report associating quetiapine with priapism, and the first to associate priapism with routine dosing of the drug. Previously published studies have suggested that alpha-adrenergic blockade may be the mechanism of action for this side effect. We report successful management in this case with cavernosal aspiration followed by intracavernosal injection of phenylephrine.

Conservative management of priapism in acute spinal cord injury

OBJECTIVES

To perform a retrospective chart review of priapism as a complication of spinal cord injury and review the management and follow-up. Priapism is a known complication of acute spinal cord injury, but little has been written concerning the management of this condition.

METHODS

A retrospective chart review (1992 through 2002) was performed for all patients with a diagnosis of priapism. Of these patients, 6 had priapism in the setting of acute spinal cord injury without pelvic trauma. We reviewed the management of the priapism in these cases, and follow-up was attempted in each case.

RESULTS

Of the 6 patients with spinal cord injury-related priapism, 4 had spinal cord injury located at C5-C7, 1 at C5-C6, and 1 at T12. The prolonged erections were managed conservatively in 4 patients and irrigated with intracorporeal phenylephrine in 2. All patients with corporal blood gas measurement (n = 4) had nonischemic priapism. All 4 patients who underwent no intervention had the priapism resolve within 5 hours. Four patients (two treated conservatively and two who underwent irrigation) had recurrent episodes during the same admission that resolved spontaneously. Long-term outcomes were obtained by telephone from all 6 patients. Of the 6 patients, 5 had maintained spontaneous erections to date (range 3 to 10 years).

CONCLUSIONS

The results of our study have shown that priapism related to acute spinal cord injury is nonischemic and may be managed conservatively because of the high likelihood of resolution. Corporal blood gas measurement is important because the results can guide further management decisions. Our results suggests that conservative management of priapism related to spinal cord injury has a low rate of causing long-term erectile dysfunction.

Color Doppler US of the Postoperative Penis: Anatomy and Surgical Complications

A number of surgical procedures that significantly change the penile anatomy and vasculature can be used to manage pathologic conditions of the penis (eg, congenital and acquired deformities, erectile dysfunction, priapism). Phallic reconstruction surgery can be used for sex reassignment and after penile amputation or for correction of congenital malformations. Color Doppler ultrasonography (US) clearly depicts the normal penile anatomy and postoperative changes (eg, changes of the tunica albuginea, extraalbugineal pathologic fluid collections, cavernosal tissue changes produced by scars and fibrosis). It is also effective in evaluating surgery-related complications and determining the causes of erectile dysfunction and other unsatisfactory long-term results. Moreover, color Doppler US of the penile vessels and vascular anastomoses following revascularization allows direct evaluation of flow characteristics, shunt patency, and venous engorgement. Color Doppler US is the imaging modality of choice in evaluating patients who have undergone penile surgery.

TGF-beta1 neutralizing antibodies decrease the fibrotic effects of ischemic priapism

The objective of this study was to evaluate the possible role of transforming growth factor beta 1 (TGF-beta1) antibodies (ab) for the prevention of fibrotic effects of priapism in a rat model. In total, 30 adult Sprague-Dawley rats were divided into five groups. Priapism with 6 h (group 1), priapism with 6 h+ab (group 2), priapism with 24 h (group 3), priapism with 24 h+ab (group 4) and control (group 5). Priapism was induced with a vacuum erection device and a rubber band was placed at the base of the erect penis. At 1 h after the initiation of priapism, TGF-beta1 antibodies were given intracavernosaly. All rats underwent electrical stimulation of the cavernous nerve after 8 weeks. Intracavernous and systemic blood pressures were measured during the procedure. Rats in group 1 showed significantly higher (intracavernosal pressure (ICP) pressures to cavernous nerve stimulation and had higher ICP/BP ratios when compared to other groups. Similarly, histopathologic examination revealed less fibrosis in group 2, compared with the other groups. Consequently, TGF-beta1 antibodies antagonise the fibrotic effects of TGF-beta1, especially in cases with duration of priapism less than 6 h.

Priapism--a review of the medical management

Priapism is characterised by the presence of prolonged, often painful penile erection in the absence of a sexual stimulus. This rare condition has a range of aetiologies, but is most common following self-administration of injection therapy for impotence. Priapism may be classified into high- and low-flow states. Low-flow priapism is an emergency ischaemic condition requiring prompt recognition and treatment to avoid devastating long-term complications of erectile dysfunction. Wide-ranging medical therapies are covered in this review. Diagnostic and treatment algorithms are suggested in light of the current available literature.

Clinical and sonographic assessment of the side effects of intracavernous injection of vasoactive substances

The objective of this study is to evaluate the side effects of intracavernous vasoactive agents on clinical and sonographic basis. Two groups of patients were included, group I included 168 ED patients trained on self-injection therapy using one of the three protocols. Protocol A: papaverine; protocol B: PGE1; and protocol C: trimix (papaverine, phentolamine and PGE1). Patients were followed up clinically, sonographically and by laboratory investigations for 6 months to evaluate the occurrence of side effects. Group II included 21 patients presenting to our department for the first time with a complication of intracavernous injection pharmacotherapy (ICI) initiated elsewhere. In all, 168 patients of group I completed the study. Patients on papaverine had the highest incidence of complications concerning prolonged erection, subcutaneous hematoma and penile fibrosis. Postinjection penile pain was observed more with groups B and C than group A. No systemic side effects were reported. Duplex ultrasound was beneficial in detecting mild clinically impalpable fibrosis. In total, 10 patients of group II presented with prolonged erection, seven with penile fibrosis, three with cavernositis and one with intracavernous needle breakage. We conclude that although ICI therapy is an effective second-line treatment option, patients on a self-injection program should be followed up both clinically and sonographically both at the initiation phase and on regular follow-up visits.

Priapism

Priapism is a relatively uncommon condition that may present as a medical emergency associated with significant pain and anxiety in the veno-occlusive or low-flow variant. Pharmacologic advances and, specifically, the availability of intracavemosal alpha-agonist therapy have dramatically improved the prospects of resolution for patients with low-flow priapism presenting within the first few hours of the acute episode. High-flow priapism is not considered an emergency and treatment measures are typically conservative aimed at preservation of potency. Urologists, radiologists, and other health care personnel caring for the patient with priapism must be familiar with various etiologic factors implicated in low-flow and high-flow priapism to formulate a logical step-care approach. Differentiation of the low-flow from the high-flow state is perhaps the most critical initial diagnostic challenge that determines the sequence of further interventions including surgical shunts in low-flow priapism refractory to medical therapy.

The value of penile duplex in the prediction of intracavernous drug-induced priapism

The aim of this work is to assess the value of penile duplex in the prediction of intracavernous drug-induced ischemic priapism. A total of 400 patients with erectile dysfunction were evaluated before and after diagnostic intracavernous injection of a trimix solution (papaverine+phentolamine+PGE1) using color Doppler sonography. In all, 29 patients experienced sustained rigid erections for more than an hour. Patients were further divided into two groups. Group A included patients with spontaneous resolution of their rigid erection within 3 h (10/29) and group B included patients with priapism (19/29) that did not resolve within 3 h. In group A, patients had minimal cavernous artery blood flow within the first hour postinjection, that increased with relief of their erection. Group B patients had no blood flow in their cavernous artery an hour after intracavernous injection and for 6 h later. The disappearance of blood flow in the cavernous artery after an hour of sustained rigid erection predicted priapism with 100% specificity and sensitivity. The persistent absence of cavernous artery blood flow for more than an hour, as detected by color Doppler ultrasound, is an objective predictor of priapism. This may guide early intervention to resolve the prolonged erection.

Idiopathic priapism in a young boy

We report a case of recurrent priapism in a boy. There were no recurrences during or after oral treatment with Bricanyl (terbutaline).

Tricorporal priapism in a patient with metastatic esophageal cancer

Tricorporal priapism refers to priapism involving the corpora cavernosa and spongiosum. It is exceedingly rare and, depending on the etiology, may be difficult or impossible to treat. We present a case of tricorporal priapism in a patient with metastatic esophageal cancer and complete thrombosis of all venous vasculature below the level of the renal veins. Ultimate management consisted of comfort measures and minimizing the risk of infection. In this case of tricorporal ischemic priapism, the recognized treatment options for ischemic priapism were not applicable, because no viable shunt targets were available. The treating urologist should be aware of this potential clinical entity and be prepared to offer conservative management.

Color Doppler imaging of posttraumatic priapism before and after selective embolization

High-flow priapism usually follows perineal or penile trauma with disruption of an intracavernosal artery. Angiographic embolization of the lacerated artery is currently considered the treatment of choice. The contribution of gray-scale and color Doppler ultrasonography (US) in diagnosis and treatment of 10 patients with high-flow priapism was investigated. In patients with recent arterial laceration, the cavernous tissue surrounding the arterial-sinusoidal fistula appears as a hypoechoic region with undefined margins. In long-standing priapism, this area is usually more regular and circumscribed, mimicking a pseudoaneurysm. Color Doppler US is highly sensitive for detection of the arterial-sinusoidal fistula that causes extravasation of blood from the lacerated cavernosal artery. After angiography, color Doppler US allows confirmation of both successful embolization by demonstrating disappearance or size reduction of the fistula and unsuccessful treatment by demonstrating patency of collateral feeding vessels or early recanalization of the embolized artery. Limitations of color Doppler US include underestimation of the number of accessory feeding vessels, which may become patent only after embolization of the main vascular supply, and difficulty in recognizing vessels that feed the fistula from the opposite side.

Management of low-flow priapism using the Winter procedure: a case report

Priapism is a prolonged penile erection that is unrelated to sexual stimulation. Low-flow priapism has been associated with sickle cell disease and other hemoglobinopathies, neoplastic syndrome, anticoagulant therapy, psychotropic medication, and idiopathic causes. We report the successful treatment of idiopathic low-flow priapism using the Winter procedure. Initial treatment consisted of aspiration and intracavernous irrigation with iced saline and a vasoconstrictive agent, but in vain. We then performed the Winter procedure, in which fistulas between the corpora cavernosa and the glans penis were created. This resulted in the simultaneous detumescence of the penis, without complication. The erectile function of the penis was normal 1 year after the procedure. This case shows that idiopathic low-flow priapism can be successfully treated using the Winter procedure when conservative treatment fails.

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.