Surgical and minimally invasive treatment of ischaemic and non-ischaemic priapism: a systematic review by the EAU Sexual and Reproductive Health Guidelines panel

Comparative efficacy of gelatin sponge, microcoils, and nbca in arterial gastrointestinal bleeding: a retrospective study

BACKGROUND

Arterial gastrointestinal bleeding poses a serious threat to life that requires timely and effective intervention. This study evaluated the effectiveness of three different embolization strategies: the use of gelatin sponge alone, in combination with microcoils, and in combination with n-butyl cyanoacrylate (NBCA).

METHODS

This retrospective study included 68 patients with acute arterial gastrointestinal bleeding (Forrest F1), categorized into three embolization groups: gelatin sponge alone (n = 23), gelatin sponge + microcoils (*n* = 23), and gelatin sponge + NBCA (n = 22). Clinical success was defined as complete hemostasis without rebleeding within 30 days. Multivariate analysis adjusted for age, NSAID use, and bleeding site.

RESULTS

The gelatin sponge + NBCA group achieved 100% clinical success, significantly higher than gelatin sponge + microcoils (91.30%) and gelatin sponge alone (65.22%) (P < 0.001). Rebleeding rates were lowest with NBCA (0% vs. 34.78% for gelatin sponge alone; P < 0.001), and complication rates favored NBCA (13.6% vs. 47.8%; P = 0.013). Multivariate analysis confirmed the superiority of combination strategies, with gelatin sponge + NBCA showing the highest odds of success (adjusted OR = 24.12, 95% CI: 2.98-195.21, P = 0.003). Subgroup analyses revealed no significant interaction between embolic strategy and bleeding site (P > 0.05), though upper GI cases trended toward higher success rates (92.3-100%) compared to lower GI (80-100%).

CONCLUSION

The study underscores the superiority of combination embolic strategies over the application of gelatin sponge alone for managing arterial gastrointestinal bleeding. The addition of microcoils and NBCA to gelatin sponge enhances both the efficacy and durability of embolic interventions, suggesting their preferential use in clinical practice to optimize patient outcomes.

Current evidence on the management of ischaemic priapism post-shunting: a narrative review

When ischaemic priapism becomes unresponsive to aspiration-irrigation and shunting, poor outcomes for priapism resolution and functional recovery are expected. This study reviews the strategies to improve the outcomes for priapism patients after shunting, based on a comprehensive literature-search on PubMed, Cochrane Library, and EMBASE. Erectile dysfunction is common after shunting, particularly in cases of pre-existing erectile dysfunction, older age, recurrent priapism, or necrosis detected by magnetic resonance imaging. Distal shunts are typically adopted as first-line options. Systemic anticoagulation may prevent thrombus-formation, which may lead to recurrence of ischaemic priapism. Both selective and non-selective phosphodiesterase type 5 inhibitors may enhance erectile function recovery and prevent priapism recurrence. A repeat penile blood gas analysis can help determine whether there has been a conversion to non-ischaemic priapism if shunts fail. Proximal shunts and the penoscrotal decompression can be considered when distal shunting does not result in complete detumescence. Early malleable penile prosthesis implantation is an option after shunting failure. Use of vacuum erection device regimens should be encouraged after shunting to minimize penile fibrosis, especially when late penile prosthesis implantation is needed due to erectile dysfunction previously unresponsive to medical management. More evidence is needed to achieve consensus regarding the optimal management of ischaemic priapism after shunting, and surgical innovation should continue to refine the current techniques.

Surgical illustrative review of the treatment of ischaemic priapism

Ischemic priapism is a condition where there is prolonged and painful erection of the penis that is not associated with sexual stimulation. When initial bedside management fails to achieve detumescence, surgical management is indicated. This article is an illustrative review of historic and modern surgical techniques for the management of ischemic priapism including distal shunting techniques (Winter's, T-Shunt, Al-Ghorab, and Burnett's), proximal shunting techniques (Quackles, Barry), and penoscrotal decompression.

Priapism Presentations in a Saudi Arabian Emergency Department: A Retrospective Study at a Tertiary Care Hospital

OBJECTIVES

To examine the distribution, clinical characteristics, and management of priapism in a Saudi Arabian tertiary care setting to provide a regional perspective.

SUBJECTS AND METHODS

This retrospective chart review included 29 male patients presenting with priapism at a tertiary care hospital in Riyadh, Saudi Arabia, from January 2011 to June 2023. Data were collected on patient demographics, clinical presentation, treatment modalities, and outcomes.

RESULTS

The study found recurrent episodes of priapism in many patients, with a significant number associated with hematological diseases, notably sickle cell disease. Most treatments involved non-surgical methods. A notable finding was the correlation between the duration of priapism episodes and the likelihood of hospital admissions, suggesting that prolonged episodes often required more extensive medical attention.

CONCLUSIONS

Priapism often presents as a chronic and recurrent condition requiring personalized management strategies. This study emphasizes the importance of recognizing regional occurrence patterns to enhance the management of priapism and suggests a need for further research in regions where this condition is less common.

Trends and outcomes of hospitalized patients with priapism in Germany: results from the GRAND study

We aimed to provide evidence on the trends and in-hospital outcomes of patients with low- and high-flow priapism through the largest study in the field. We used the GeRmAn Nationwide inpatient Data (GRAND), provided by the Research Data Center of the Federal Bureau of Statistics (2008-2021), and performed multiple patient-level analyses. We included 6,588 men with low-flow and 729 with high-flow priapism. Among patients with low-flow priapism, 156 (2.4%) suffered from sickle cell disease, and 1,477 (22.4%) patients required shunt surgery. Of them, only 37 (2.5%) received a concomitant penile prosthesis implantation (30 inflatable and 7 semi-rigid prosthesis). In Germany, the total number of patients with low-flow priapism requiring hospital stay has steadily increased, while the number of patients with high-flow priapism requiring hospital stay has decreased in the last years. Among patients with high-flow priapism, 136 (18.7%) required selective artery embolization. In men with low-flow priapism, sickle cell disease was associated with high rates of exchange transfusion (OR: 21, 95% CI: 14-31, p < 0.001). The length of hospital stay (p = 0.06) and the intensive care unit admissions (p = 0.9) did not differ between patients with low-flow priapism due to sickle cell disease versus other causes of low-flow priapism. Accordingly, in men with high-flow priapism, embolization was not associated with worse outcomes in terms of length of hospital stay (p > 0.9), transfusion (p = 0.8), and intensive care unit admission (p = 0.5). Low-flow priapism is an absolute emergency that requires shunt surgery in more than one-fifth of all patients requiring hospital stay. On the contrary, high-flow priapism is still managed, in most cases, conservatively.

Evaluating the management trends for priapism and assessing the risk of priapism after in-office intracavernosal injections: a cross-sectional analysis

We describe the management trends of patients suffering from any priapism and evaluate the risks of developing priapism after intracavernosal injections (ICI) performed in office. We queried TriNetX for two separate male adult cohorts - those presenting with any priapism based on International Classification of Disease code, N48.3 (priapism) and those who underwent ICI in office based on Current Procedural Terminology code, 54235 (injection of corpora cavernosa with pharmacologic agent[s]). We evaluated treatment options for these patients after any priapism and described demographic risks for developing priapism after ICI performed in office. There were 17,545 priapism encounters and 26,104 usages of ICI in the office. Most common treatment for any priapism was corporal irrigation/injection of medications (11.3%). Patients presenting with priapism after ICI were younger (age > 65 years, OR 0.44 [95% CI 0.38-0.51], p < 0.01) and had a higher prevalence of mood disorders (20% vs 14%), behavioral disorders (7% vs 2%) and sickle cell disease (6% vs <1%). They were less likely to have diabetes (14% vs 22%), hypertension (33% vs 40%), prostate cancer (13% vs 25%) or have taken sildenafil or tadalafil (29-30% vs 35-38%). For patients administering ICI, proper screening and counseling of priapism is important to reduce complications.

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.

Diagnosis and Management of Priapism

This JAMA Clinical Guidelines Synopsis summarizes the 2022 American Urological Association/Sexual Medicine Society of North America guidelines on diagnosis and management of priapism.

Priapism at Diagnosis of Pediatric Chronic Myeloid Leukemia: Data Derived from a Large Cohort of Children and Teenagers and a Narrative Review on Priapism Management

Pediatric chronic myeloid leukemia (CML) is a very rare malignancy (age-related incidence 0.1/100,000) typically presenting with leucocyte counts >100,000/µL. However, clinical signs of leukostasis are observed at diagnosis in only approximately 10% of all cases and among these, priapism is infrequent. Here, we analyze data from pediatric CML registries on the occurrence of priapism heralding diagnosis of CML in 16/491 (3.2%) boys (median age 13.5 years, range 4-18) with pediatric CML. In the cohort investigated, duration of priapism resulting in a diagnosis of CML was not reported in 5 patients, and in the remaining 11 patients, occurred as stuttering priapism over 3 months (n = 1), over 6 weeks (n = 1), over 1-2 weeks (n = 2), over several days (n = 2), or 24 h (n = 1), while the remaining 4 boys reported continuous erection lasting over 11-12 h. All patients exhibited splenomegaly and massive leukocytosis (median WBC 470,000/µL, range 236,700-899,000). Interventions to treat priapism were unknown in 5 patients, and in the remaining cohort, comprised intravenous fluids ± heparin (n = 2), penile puncture (n = 5) ± injection of sympathomimetics (n = 4) ± intracavernous shunt operation (n = 1) paralleled by leukocyte-reductive measures. Management without penile puncture by leukapheresis or exchange transfusion was performed in 3 boys. In total, 7 out 15 (47%) long-term survivors (median age 20 years, range 19-25) responded to a questionnaire. All had maintained full erectile function; however, 5/7 had presented with stuttering priapism while in the remaining 2 patients priapism had lasted <12 h until intervention. At its extreme, low-flow priapism lasting for longer than 24 h may result in partial or total impotence by erectile dysfunction. This physical disability can exert a large psychological impact on patients' lives. In a narrative review fashion, we analyzed the literature on priapism in boys with CML which is by categorization stuttering or persisting as mostly painful, ischemic (low-flow) priapism. Details on the pathophysiology are discussed on the background of the different blood rheology of hyperleukocytosis in acute and chronic leukemias. In addition to the data collected, instructive case vignettes demonstrate the diagnostic and treatment approaches and the outcome of boys presenting with priapism. An algorithm for management of priapism in a stepwise fashion is presented. All approaches must be performed in parallel with cytoreductive treatment of leukostasis in CML which comprises leukapheresis and exchange transfusions ± cytotoxic chemotherapy.