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)