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Priapism 31st March 2003 R Power.

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1 Priapism 31st March 2003 R Power

2 Definition persistent erection not accompanied by sexual desire or stimulation > 6 hours Corpora cavernosa only all age groups (including newborns) peak incidence 20 to 50yrs younger age group assoc with sickle cell usually pain (except in non-ischaemic type)

3 Classification Low flow or Ischaemic (veno-occlusive)
most common Painful sec to tissue ischaemia and smooth muscle hypoxia (compartment syndrome) Nonischaemic (arterial) less common upregulated cavernous inflow usually not fully erect and painless

4 Low-flow priapism Low flow or Ischaemic (veno-occlusive) most common
Penis fully erect (sludging of blood within) Painful sec to tissue ischaemia and smooth muscle hypoxia (compartment syndrome) blood gases from corpora - acidosis  NO & prostacyclin platelet aggregation and adhesion - thrombus formation and tissue damage

5 Causes of low-flow priapism
Intracavernosal pharmacotherapy 21% of cases of priapism patients papaverine (Nieminem et al.1995) PGE-1 alprostadil <1% intracavernosal <0.1% intraurethral extremely low incidence with oral agents Drugs cocaine, heparin withdrawal, trazadone, phenothiazines

6 Causes of low-flow priapism
Hyperviscosity syndromes (sickle-cell disease) 28% of all cases of priapism (most common cause in children) 42% incidence in adults with sickle-cell disease 64% incidence in boys with sickle-cell disease also affects with sickle-cell trait ? Assoc with testosterone Other haemoglobinopathies thrombophilia “stutter priapism” Recurrent episodes of priapism can result in enlarged penis, fibrotic corpora and ED

7 Causes of low-flow priapism
Neurological causes rare lumbar disc lesions, spinal stenosis, seizure disorders, cerebrovascular disease Post Trauma perineum, groin or penis usually cause high flow priapism but can cause low flow sec to haematoma Solid Tumours malignant infiltration of corpora Miscellaneous TPN, amyloid , rabies, appendicitis

8 High-flow priapism Nonischaemic (arterial) less common
Penile, perineal or pelvic trauma uncontrolled arterial inflow directly into the penile sinsoidal spaces usually penis not fully erect and painless often prolonged history normal local blood gases no risk of ischaemia and subsequent fibrosis

9 Causes of High-flow priapism
Trauma Very rarely sickle-cell disease Fabry`s disease

10 Management of Priapism
Urological emergency Treat causal factor where identified goal is to abort the erection, thereby preventing permanent damage to the corpora (ED) and to relieve pain. Longer duration implies greater risk of impotence principle is to restore arterial inflow and venous outflow clinical history and drug history glans and corpus spongiosum rarely involved urinalysis haemoglobin S to outrule leukaemia ? Local blood gas measurments radionucleotide scanning - no longer performed colour doppler ultrasonography

11 Medical management of low-flow priapism
aspiration of the corpora with a 21G butterfly needle followed by an injection of phenylephrine (1 adrenergic agonist) every 5 minutes until detumescence 10mg/ml phenylephrine in 19mls saline 100% effective if within 12 hours Oral terbutaline (-adrenoceptor agonist) mg at best 36% response Sickle-cell - prompt and conservative as it recurs hydration, oxygenation, metabolic alkalinization aspiration and injection (as above) Stuttering priapism self injection of -adrenergic agent if sexually active (prophylactic digoxin) or oral -adrenergic agent (Etilefrine) antiandrogen if not to suppress nocturnal tumescence

12 Surgical management of low-flow priapism
Winter procedure using a Trucut needle create a shunt between glans and corpora cavernosa Ebbehoi procedure using a pointed scalpel blade El-Ghourab procedure excision of a piece of tunica albuginea 30% of above techniques fail direct cavernosal-spongiosum anastomosis corpora-saphenous shunt lower incidence of ED reported with Winter technique Intracavernosal thrombolytic agents ??

13 Management of High-flow priapism
Ice pack  arterial spasm ?? spontaneous thrombosis Most cases require arteriography and embolisation of the internal pudendal artery or a branch

14 Complications Untreated low-flow priapism leads to corporal fibrosis and impotence early complications: acute hypertension, headache, palpitations, arythmias bleeding, haematoma, infection and urethral injury late complications: fibrosis and impotence related to duration of priapism and aggressivness of treatment low-flow : high incidence of ED if not treated within 12 hours high flow : good prognosis (20% rate of ED)

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