Priapism in acute spinal cord injury

Priapism caused by partial deficiency of tetrahydrobiopterin through hypofunction of the sympathetic neurons in sepiapterin reductase gene-disrupted mice

6R-L-erythro-5,6,7,8-tetrahydrobiopterin (BH4) is an essential cofactor for aromatic L-amino acid hydroxylases, including tyrosine hydroxylase (TH), alkylglycerol monooxygenase, and three types of nitric oxide (NO) synthases (NOS). Sepiapterin reductase (SPR) catalyzes the third step of BH4 biosynthesis. SPR gene-disrupted (Spr-/- ) mice exhibit a dystonic posture, low body weight, hyperphenylalaninemia, and unstable hypertension with endothelial dysfunction. In this study, we found that Spr-/- mice suffered from a high incidence of severe priapism. Their erections persisted for months. The biopterin, BH4, and norepinephrine contents, and TH protein levels in the penile tissue of Spr-/- mice without and with priapism were significantly reduced compared to those of Spr+/+ mice. In contrast, their neural NOS (nNOS) protein levels were increased, and the cyclic guanosine monophosphate (cGMP) levels were remarkably elevated in the penises of Spr-/- mice with priapism. The symptoms were relieved by repeated administration of BH4. The biopterin, BH4, and norepinephrine contents were increased in penile homogenates from BH4-supplemented Spr-/- mice, and the TH protein levels tended to increase, and their nitrite plus nitrate levels were significantly lower than those of vehicle-treated Spr-/- mice and were approximately the same as vehicle- and BH4-supplemented Spr+/+ mice. Thus, we deduced that the priapism of Spr-/- mice is primarily caused by hypofunction of the sympathetic neurons due to cofactor depletion and the loss of TH protein and, further, dysregulation of the NO/cGMP signaling pathway, which would be caused by disinhibition of nNOS-containing neurons and/or abnormal catabolism of cyclic nucleotides is suggested.

Priapism after spinal cord injury - a case report and review of the literature

Involuntary unwanted erections are extremely rare after spinal cord injury (SCI). A sudden loss of sympathetic tone to the pelvic vasculature following SCI causes an increase in the parasympathetic tone and uncontrolled arterial blood flow into the penile sinusoidal spaces. When occurring immediately after an acute SCI, it is generally self-limiting and settles within a few hours. In contrast, recurrent, unwanted erections in patients with chronic SCI are more unpredictable in frequency and duration and may require treatment. We present a case of recurrent involuntary unwanted erections in a patient with chronic SCI after a stab wound to his neck and review the pathophysiology and available management options.

An arrow that missed the mark: a pediatric case report of remarkable neurologic improvement following penetrating spinal cord injury

Penetrating spinal cord injuries are rare in children but result in devastating impacts on long-term morbidity and mortality-with little known about the recovery capacity in this age group. We present the case of an eight-year-old child who sustained a penetrating injury through the right anterior thorax. Thoracic CT showed the arrow tip extending through the spinal canal at T6. Neurologic examination revealed no motor or sensory function below T6. The arrow was surgically removed without complications through an anterior-only approach. MRI on post-operative day (POD) 4 showed focal T2 hyperintensity at the T6 spinal cord. Patient was discharged on POD33 with an American Spinal Injury Association (ASIA)-D score and trace voluntary control over bowel and bladder function. Remarkably, four months later, he had near normal bowel and bladder function, with near-intact lower extremity strength and self-sustained ambulation. Follow-up imaging revealed hemicord formation at the level of injury. We review our case of penetrating spinal cord injury in a child and similar reports in the literature. Penetrating thoracic spinal cord trauma portends poor clinical outcomes, particularly when employing available adult prognostic spinal cord injury scoring metrics. Incomplete spinal cord injury, and often-associated spinal shock, can mimic a complete injury-as in our patient, which improved to near-complete motor and sensory restoration of function and resulted in the formation of a split hemicord. This case represents a unique penetrating spinal cord injury with remarkable neurologic recovery, which would advocate against definitive early prognostication in the pediatric population.

High flow or low flow? An unusual case of ischemic priapism following gunshot wound to the cervical spinal cord

Ischemic priapism has rarely been reported in the setting of acute spinal cord injury. Herein, we present a 25 year-old male with cavernous blood gas evidence of ischemic priapism following a traumatic gunshot wound with a retained bullet fragment in the third cervical vertebra. The patient received definitive treatment with corporal aspiration and irrigation, with no evidence of priapism recurrence. This unusual case emphasizes the critical importance of obtaining a cavernous blood gas, even when a common cause of non-ischemic priapism is apparent. Suspicion for ischemic priapism must be maintained, especially in the setting of multiple known risk factors.

Recurrent priapism in spinal cord injury: A case report

Context: Recurrent priapism is characterized by repetitive episodes of erections which are unrelated to sexual interest or stimulation. It is extremely rare in patients with spinal cord injury (SCI). There are a number of conservative agents used in the treatment.Findings: We describe the case of a 20-year-old male with cervical-5 American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade A tetraplegia as a result of a diving accident 2 years ago. He declared that the recurrent penile erections occurred up to 15-20 times day and night every day and lasted up to 20 min each time unrelated to sexual interest or stimulation. He was prescribed baclofen 10 mg, twice daily. The frequency and duration of erections decreased to 3-5 times/day lasting for about 5 min each and the patient reported a high treatment satisfaction.Conclusion: The presentation of this case is to remind clinicians this rare but distressing condition of recurrent priapism seen in men with complete spinal cord lesions and to summarize the use of medications, most commonly baclofen, to alleviate the condition.

Traumatic Injuries to the Spinal Cord and Peripheral Nervous System

Both blunt and penetrating trauma can cause injuries to the peripheral and central nervous systems. Emergency providers must maintain a high index of suspicion, especially in the setting of polytrauma. There are 2 major classifications of peripheral nerve injuries (PNIs). Some PNIs are classically associated with certain traumatic mechanisms. Most closed PNIs are managed conservatively, whereas sharp nerve transections require specialist consultation for urgent repair. Spinal cord injuries almost universally require computed tomography imaging; some require emergent magnetic resonance imaging. Providers should work to minimize secondary injury. Surgical specialists are needed for closed reduction, surgical decompression, or stabilization.

Emergency Management of Traumatic Spinal Cord Injuries

Spinal cord trauma constitutes one of the main causes of mortality and morbidity in young adults around the world, with an estimated 2 to 3 new cases for every 100,000 population. Road traffic accidents, falls from high heights, sports injuries, and violent actions are common causes of spinal cord injuries. There is no “gold standard” for the diagnosis of spinal cord traumatic injuries; however, the rational use of conventional radiologic test, computed tomography scan, and magnetic resonance imaging (MRI) will allow to identify almost all clinically relevant injuries. MRI is recommended according to surgeon’s criteria, who after evaluating the specific characteristics of the injury will determine its usefulness. Therapeutic strategies need to be directed to maintain airway, breathing and circulation, maintenance of mean arterial pressure prevention of hypotension, and assessment of other associated injuries. Intensive treatment must be focused on the prevention and management of ventilatory and cardiovascular abnormalities related to muscle weakness and loss of autonomic innervation.

An Update on Non-Ischemic Priapism

INTRODUCTION

Non-ischemic or high-flow priapism is derived from unregulated arterial inflow within the penis, which is significantly less common and, therefore, less well characterized than ischemic or low-flow priapism.

AIM

We collected the most recent available data and summarized the findings.

METHODS

All literature related to non-ischemic priapism from 2000-2018 from several databases was reviewed, and 105 articles, including any relevant referenced articles, were ultimately included.

MAIN OUTCOME METHODS

We evaluated modality success rates, need for repeat procedures, and effects on erectile function.

RESULTS

237 cases of non-ischemic priapism were evaluated. Approximately 27% of patients underwent observation or medical management as the first treatment modality, whereas 73% underwent intervention without observation or medical management beforehand. Angiographic embolization with temporary agents was the most common intervention and generally resulted in both moderate resolution of non-ischemic priapism and moderate preservation of baseline erectile function. Patients who underwent embolization with permanent agents experienced higher rates of resolution, as well as lower rates of erectile dysfunction (ED).

CONCLUSION

Most of the literature is in the form of case reports and small case series, thus limiting the quality and quantity of evidence available to draw decisive conclusions. However, from the available data, it is reasonable to presume that patients can undergo a trial of conservative management, then pursue embolization first with temporary agents. The analysis of the data demonstrated ED rates were higher with temporary agents than permanent agents. The literature quotes ED rates as low as 5% when using temporary agents and 39% with permanent agents. Our results were, in fact, the opposite, with higher ED rates when using temporary agents vs permanent (17-33% vs 8-17%). Further studies are required to better characterize the success and outcomes of angioembolization. Ingram AR, Stillings SA, Jenkins LC. An Update on Non-Ischemic Priapism. Sex Med Rev 2020;8:140-149.

Spontaneous detumescence and full restoration of erection in a patient with high-flow priapism with persistent arterial-lacunar fistula after repeated selective embolisation-A case report

High-flow priapism is a rare condition mainly caused by perineal trauma. Laceration of cavernosal artery results in a formation of arterial-lacunar fistula with unregulated blood flow causing prolonged erection. We present a case of a 25-year-old man with high-flow priapism and concurrent erectile dysfunction treated with repeated selective embolisation with only a partial effect. When no further embolisation was possible, we assumed on conservative management even through the fistula was still present. Spontaneous detumescence occurred 9 months, and erectile function has fully restored 24 months after the injury. To the best of our knowledge, spontaneous detumescence with full restoration of erection even through the persistent arterial-lacunar fistula has not been reported previously. Therefore, we propose conservative approach after embolisation to be an option.

Through Clinical Observation: The History of Priapism After Spinal Cord Injuries

Since ancient times, physicians of antiquity noted the occurrence of priapism in some spinal cord injuries. Although priests saw it as a consequence of curses and witchcraft, after clinical observations of the Middle Ages and Renaissance, the first medical hypotheses emerged in the 17th-19th centuries completed and argued by neuroscience and neurology developed in the European laboratories and hospitals. This study aims to present a short overview of the history of clinical observations of posttraumatic male priapism after spinal cord injuries since antiquity until the beginning of the 20th century.

Advances in the understanding of priapism

Priapism, a persistent penile erection lasting longer than 4 hours and unrelated to sexual activity, is one of the most common emergencies treated by urologists. Priapism can be categorized as ischemic, recurrent ischemic (stuttering), and non-ischemic. Advances in understanding the pathophysiology of various types of priapism have led to targeted management strategies. This review aims to provide an up-to-date picture of the pathophysiology and management of priapism. A search of Medline and PubMed for relevant publications using the term "priapism" was performed. In addition to the "classical" articles, emphasis was placed on publications from January 2013 to September 2016 to evaluate the most recent literature available. Though advances in both basic and clinical research continue and effective treatment options are available, methods for the prevention of priapism continue to be elusive.

Update on traumatic acute spinal cord injury. Part 2

The aim of treatment in acute traumatic spinal cord injury is to preserve residual neurologic function, avoid secondary injury, and restore spinal alignment and stability. In this second part of the review, we describe the management of spinal cord injury focusing on issues related to short-term respiratory management, where the preservation of diaphragmatic function is a priority, with prediction of the duration of mechanical ventilation and the need for tracheostomy. Surgical assessment of spinal injuries based on updated criteria is discussed, taking into account that although the type of intervention depends on the surgical team, nowadays treatment should afford early spinal decompression and stabilization. Within a comprehensive strategy in spinal cord injury, it is essential to identify and properly treat patient anxiety and pain associated to spinal cord injury, as well as to prevent and ensure the early diagnosis of complications secondary to spinal cord injury (thromboembolic disease, gastrointestinal and urinary disorders, pressure ulcers).

The Case Report of Priapus and a Modern Approach to an Ancient Affliction

INTRODUCTION

Priapism, taking its name from God Priapus, is total or partial erection lasting longer than 4 hours independent of sexual stimulus and can result in erectile dysfunction. There are three subtypes of priapism.

AIM

To review the three subtypes of priapism, their pathophysiology, current treatment options, and complications.

METHODS

The literature including priapism guidelines, review articles, and current trial studies was reviewed and the priapism type of God Priapus was investigated according to the mythology.

MAIN OUTCOME MEASURES

All three types of priapism were reviewed for etiology, diagnosis, and management. Medical and surgical treatment options were reviewed in relation to the current literature. Special emphasis concerned current treatment strategies and controversial surgical topics.

RESULTS

Ischemic priapism is the most common type, constituting 95% of all cases, and is an emergency. First-line treatments are blood aspiration and intracavernosal sympathomimetic drug injections. If these fail, then surgical shunt operations are recommended. A T-shunt combined with corporal tunneling is the currently popular option. Immediate penile prosthesis implantation is recommended for patients who present 48 to 72 hours after the onset of a priapism episode. High-flow priapism is caused by irregular arterial cavernosal blood flow, which usually occurs after a blunt perineal trauma. Antiandrogens and selective arterial embolization are the treatment options. Stuttering priapism is repetitive, self-limiting ischemic priapism and frequent in patients with sickle cell anemia. Ketoconazole is safe, cheap, and effective and appears to be a logical and suitable current treatment option to prevent further episodes, which is the primary treatment goal of stuttering priapism.

CONCLUSION

Priapism is a relatively common condition but not well known by clinicians. The lack and delay of treatment result in irreversible complications such as erectile dysfunction. Each type of priapism should be diagnosed and treated correctly with caution.

[Emergencies of the external genital area]

BACKGROUND

In addition to epididymitis and testicular torsion, emergencies of the external genital are rare. Rapid diagnosis and therapy are essential so that immediate therapy can be provided, which is important for survival (Fournier gangrene) of the patient or for the preservation of erectile function (priapism and penile fracture). A detailed patient history and clinical examination are generally sufficient for correct diagnosis.

RESULTS

Under certain circumstances, it might be useful to perform ultrasound, computed tomography scan or magnetic resonance imaging or retrograde urethrography. A urine analysis is obligatory. In case of penetrating injuries and genital trauma in females, additional imaging should be performed because these are often associated with concomitant injuries of the rectum, vagina, or bladder. Special cases are gunshot wounds, in which caliber and type of weapon play an important role for the degree of damage, and animal or human bites. For animal bites, the risk for rabies infection and in case of a human bite the risk for transmission of HIV and hepatitis should be taken into consideration and post-exposure prophylaxis should possibly be offered.