- UBC Urology Rounds

2013%04%02'
Urology Grand Rounds:
Contemporary Diagnosis and
Management of Priapism
Dr. Nathan Hoag (R4), Dept. of Urologic Sciences
Dr. Lindsay MacHan, Dept. of Radiology
March 27, 2013
Objectives
!  1. To review the clinical presentation and work up of
priapism.
!  2. To review the use of radiologic investigations and
interventions as they relate to priapism.
!  3. To review current and potential medical and
surgical treatments of priapism.
1'
2013%04%02'
Priapism
!  A pathologic condition of penile erection lasting
beyond, or unrelated to sexual stimulation
(persisting beyond 4 hours)
!  ~ 1-1.5 / 100,000 person years
!  One of the true urologic emergencies
!  2 pathologic and clinical sub-types
!  Low-Flow (Ischemic)
!  High-Flow (Non ischemic)
!  Plus “Stuttering priapism” (recurrent low-flow
priapism)
Priapism
!  Condition named after Priapus,
the Greek god of fertility.
!  Classically shown with a
“disproportionally large and
permanent erection.”
!  Description in the literature
credited to Hinman Sr in 1914
!  Hinman Jr proposed increased
viscosity, stasis, ischemic
theory behind priapism (1960).
2'
2013%04%02'
Priapism
Priapus: Greek god, or a greasy Greek?
6
687
It’s 2:16 AM
On call at St. Paul’s Hospital (of course)
6
Pager goes off
It’s the ER
Hi, is this urology?
I’ve got this guy
here with priapism,
what should I do?
Dr. Finkler has a patient with a 3
day erection after “experimenting
with some drugs”
3'
2013%04%02'
Case 1- “Perils of Pleasure”
!  43 yo M
!  “my boyfriend injected me with some trimix again,
and it’s been up for 3 days now”
!  Admits to “popping some Viagra, a little bit of
cocaine, and crystal meth”
!  PMHx: HIV +, 1 previous visits to ED for priapism
(under 6 hours, secondary to ICI), normal
erections.
Physical Exam
!  Fully rigid corporal bodies
!  Turgid glans and corpus spongiosum
!  ++ Painful
!  No evidence of trauma
!  Penile Blood Gases
!  pH 6.8, pCO2 120, pO2 6
4'
2013%04%02'
Priapism: History
!  Important to elicit:
!  Duration of erection*
!  Pain?
!  Previous hx of priapism and treatment
!  Use of drugs
!  History of pelvic/perineal trauma
!  History of sickle cell disease or other
hematological disorder
Priapism: Examination
!  Examine genitalia, perineum, abdomen for signs of
malignancy or trauma.
!  Corpora cavernosa typically affected while
spongiosum and glans spared.
!  Ischemic priapism often displays fully rigid
corporal bodies, while non-ischemic tends to be
tumescent, but not as rigid (due to preservation of
veno-occlusive mechanism)
5'
Color duplex Doppler ultrasonography (CDU) of the penis and
perineum is recommended in the evaluation of priapism. CDU is
an adjunct to the corporal aspirate in differentiating ischemic
from nonischemic priapism. Patients with prolonged ischemic priapism will have no blood flow in the cavernous
arteries; the return of the cavernous artery waveform will accompany successful detumescence. Patients with nonischemic
priapism have normal to high blood flow velocities detectable in the cavernous arteries; an effort should be made to localize
the characteristic blush of color emanating from the disrupted
cavernous artery/arteriole (Broderick, 2002). Examination of the
entire penile shaft and perineum is recommended; this can be
done with the patient supine but frog legged (Fig. 25–5). Penile
arteriography should be reserved for the management
!  Frompriapism,
AUA guideline
recommendations…
of high-flow
when embolization
is planned;
arteriography
is
too
invasive
as
a
diagnostic
!  CBC (infectious/hematological)procedure
to differentiate ischemic from nonischemic priapism
Reticulocyte
count
(elevated
in SCD)
(Burnett, ! 
2004).
The data from
penile
blood gas
assessments
become confusing
following
interventions.
Color
!  Urine tox screen (if suspected) Doppler
ultrasound should always be considered in the evaluaHgborelectrophoresis
r/otreatments
SCD)
tion of ! 
a full
partial erection(to
after
for
ischemic! priapism.
The
differential
diagnosis
includes
resolved
Penile blood gases
Diagnostic work-up
!  Colour doppler U/S
Table 25–4.
!  Penile arteriography
Normal arterial blood
(room air)
Normal mixed venous
blood (room air)
Ischemic priapism
(first corporal aspirate)
Key Points: Priapism Imaging
More on these
Dr. Machan
Typical Blood Gas Values
SOURCE
They describe eight patients with priapism following
ous injection (duration ≤7 hours), all of whom show
of cavernous arterial inflows with varied peak systol
and end-diastolic velocities. They concluded that m
2013%04%02'
with priapism following ICI (and
duration <7 hours) h
dynamic picture of mixed arteriogenic and veno-occ
pism. In their series, men with idiopathic ischemic pria
than 20 hours showed no detectible cavernous arteri
There have recently been reports on the use of ma
nance imaging in priapism. Kirkam and colleagues (2
that there are three possible roles for magnetic
imaging (MRI) to help in the assessment of pr
primary role would be in the imaging of a well-e
arteriolar-sinusoidal fistula (Kirkham, 2008). T
acknowledge a limitation of MRI is resolution; MRI c
onstrate small vessels as clearly as high-frequency Dop
raphy or angiography. The second would be in ischem
Po2 (mm Hg)
Pco2 (mm Hg)
pH
>90
<40
7.40
40
50
7.35
<30
>60
<7.25
Modified from Montague DK, Jarow J, Broderick GA, et al. American Urological
Association guideline on the management of priapism. J Urol 2003;170: 1318–24.
Color Doppler ultrasound (CDU) is an adjunct
poral aspirate in differentiating ischemic from no
from
priapism.
● CDU imaging should include corporal shaft and
neal assessment of the crural bodies when there
of penile trauma or straddle injury.
● CDU should always be considered in the evalu
persistent
High
Flow or partial erection after treatments fo
priapism.
penis
● Normal
Penile arteriography
is too invasive as a diagno
dure to differentiate ischemic from nonischemic
● MRI has three possible roles: imaging of a wellarteriolar-sinusoidal fistula, identifying corporal
and identifying corporal metastasis.
●
Erection physiology: Controlled by NO/cGMP signaling pathway
Incr cGMP
Activates GC
A
B
Figure 25-4. A, Initial corporal aspirate in ischemic priapism show dark, deoxygenated blood. Subsequent aspirations will show bri
blood as corpus cavernosum is reoxygenated by inflow. Empty syringes are from successive injections of phenylephrine. B, A butter
needle
NO !for
SMaspiration and injection should be placed at the penoscrotal junction. Initial failed efforts in the emergency room were d
distal placement of butterfly needle and failure to repeat aspirations.
Lue, NEJM 2000;342
6'
2013%04%02'
Priapism Pathophysiology –
Low Flow
!  Results from a derangement in penile
hemodynamics.
!  Veno-occlusive mechanism abnormality
!  Venous stasis, accumulation of deoxygenated blood
!  Impaired smooth muscle function, endothelial cell
dysfunction, PDE5 dysregulation
!  Up-regulation of pro-fibrotic growth factors (TGF )
!  Smooth muscle necrosis, collagen deposition,
penile fibrosis, ED*
Etiology- Ischemic Priapism
!  Hematologic (SCD, leukemia, asplenism, EPO,
TPN, Fabry’s)
!  Iatrogenic (ICI)
!  Neoplastic (Bladder/Prostate/Penile vs mets)
!  Neurologic (SCI, brain tumour, spinal anaesth,
syphilis, epilepsy)
!  Infectious (malaria, rabies, scorpion/spider bites)
7'
2013%04%02'
Etiology- Medications
! 
-blockers
!  Anti-coagulants (Heparin, warfarin)
!  Anti-depressants (Trazodone, SSRIs)
!  Anti-anxiety (hydroxizine)
!  Anti-psychotics
!  Anti-hypertensives (hydralazine, propanolol)
!  Recreational (alcohol, cocaine, marijuana)
!  Hormones (T, GNRH)
!  PDE5i
Management
!  Goal of management: Achieve detumescence and
preserve erectile function (prevent fibrosis)
!  Stepwise treatment algorithm of increasing
invasiveness
!  Concurrent management of any underlying disease
!  Evidence for treatments largely unclear, heavy
reliance on expert opinion and consensus
8'
MANAGEMENT OF PROSTAGLANDIN E 1-INDUCED
PROLONGED ERECTIONS
FRANKLIN C. LOWE, M.D.
JONATHAN P JAROW, M.D.
2013%04%02'
From the Departments of Urology, St. Luke’s/Roosevelt Hospital Center and
Columbia University College of Physicians and Surgeons, New York, New York,
and The Bowman Gray School of Medicine of Wake Forest University,
Winston-Salem, North Carolina
ABSTRACT-Prolonged
erections, priapism, secondary to pharmacologic stimulation are
usually treated by drainage of the corporeal bodies and irrigation with a sympathomimetic. To study the efficacy of oral medical therapy in the treatment of priapism, 75
patients with pharmaco
Ily induced (prostaglandin El) prolonged erections were
randomized to receive te
line, pseudoephedrine, or placebo. Detumescence occurred
in 36 percent, 28 percent, and 12 percent, respectively. Terbutaline was significantly
better than placebo (p < 0.05) in achieving detumescence. The results of this study suggest that oral terbutaline should be considered in the initial management of pharmacologically induced prolonged erections.
Medical management
!  Minimal evidence
The development of new nonsurgical therapies
and advances in surgical therapy has generated increased interest by patients and physicians in the
field of impotence. It is estimated that approximately 10 million American males and over 25
percent of men older than seventy-five years are
in
impotent. 1.2 Since Brindley3 first demonstrated
the 1980s that the intracorporeal
injection of phenoxybenzamine
could produce erections in men,
various vasoactive compounds have been used in
both the diagnostic evaluation and treatment of
impotent men. 4,5 The most commonly
utilized
agents today are papaverine, phentolamine,
and
prostaglandin E 1.
There are many potential complications
associated with pharmacologically
stimulated erections.
However, the most significant complication
is a
prolonged erection, or priapism, which is dose-related and most frequently observed in men with
neurogenic and psychogenic impotence.6 The incidence of these prolonged erections reported in
!  Pseudoephedrine not better than placebo
!  Terbulatine 36-42% vs 12-15% (p < 0.05) in 2
studies, no benefit in 1 study (Govier, J Urol 1994).
!  Methelyne Blue- 1 small study in 2002, 19/22
resolved with injection of MB.
International Journal of Impotence Research (2004) 16, 424–426
the literature ranges from 2 percent to 18 percent.6
The standard therapy for pharmacologically
induced prolonged erections is drainage and irrigation of the corpora with sympathomimetic
agents.738
Recent reports have suggested
that the oral
medications, pseudoephedrine
and terbutaline,‘O
are effective therapies for the reversal of pharmacologically induced prolonged erections. However,
the natural history of pharmacologic
erections is
not known, and the efficacy of these medications
has not been determined in a controlled fashion.
The purpose of this study was to determine whether pseudoephedrine
or terbutaline were superior
to placebo (sodium bicarbonate)
in reversing
pharmacologically
induced prolonged erections.
MATERIAL AND METHODS
Over a two-year period, 625 consecutive men
with erectile dysfunction received an intracorporeal injection of prostaglandin El as part of their
evaluation
or treatment.
The dosage
of
prostaglandin El ranged from 2 to 20 pg and was
4, 1993, accepted (with revisions): February
ADULT uRoLoGY
selected in an effort to avoid prolonged erections.
!  Possible use as an adjunct, if at all. ? For ICI
& 2004 Nature Publishing Group All rights reserved 0955-9930/04 $30.00
www.nature.com/ijir
Submitted:]anuary
15.1993
Oral terbutaline in the management of pharmacologically induced
prolonged erection
UROLOGY /
51
JULY1993 I VOLUME
42, NUMBER1
PLACEBO-CONTROLLED STUDY OF ORAL
TERBUTALINE AND PSEUDOEPHEDRINE IN
MANAGEMENT OF PROSTAGLANDIN E 1-INDUCED
PROLONGED ERECTIONS
S Priyadarshi
International
of Impotence
ResearchCollege
(2004) 16,
424–426 Jaipur, India
DepartmentJournal
of Urology,
SMS Medical
& Hospital,
& 2004 Nature Publishing Group All rights reserved 0955-9930/04 $30.00
www.nature.com/ijir
FRANKLIN C. LOWE, M.D.
Prolonged erection and priapism are common complications following intracavernosal injection of JONATHAN P JAROW, M.D.
vasoactive agents in the management of erectile dysfunction. It is usually treated by intracorporeal
drainage and irrigation with sympathomimetic agents. There is no established oral
. To of Urology, St. Luke’s/Roosevelt Hospital Center and
From therapy
the Departments
study the effect of oral terbutaline on prolonged erection following intracavernosal
Columbia injection
University of
College of Physicians and Surgeons, New York, New York,
vasoactive agent, a controlled randomized study was done in 68 patients. Detumescence
was Gray School of Medicine of Wake Forest University,
and The Bowman
achieved in 42 and 15% of the cases with oral terbutaline and placebo, respectively. Results of this Winston-Salem, North Carolina
study suggest that an initial trial with oral terbutaline for pharmacologically induced prolonged
erection may be successful.
International Journal of Impotence Research (2004) 16, 424–426. doi:10.1038/sj.ijir.3901180
ABSTRACT-Prolonged
erections, priapism, secondary to pharmacologic stimulation are
Published online 4 March 2004
usually treated by drainage of the corporeal bodies and irrigation with a sympath-
Oral terbutaline in the management of pharmacologically induced
prolonged erection
Keywords: priapism; prolonged erection; terbutaline
S Priyadarshi
Introduction
Materials and
omimetic. To study the efficacy of oral medical therapy in the treatment of priapism, 75
patients with pharmaco
Ily induced (prostaglandin El) prolonged erections were
randomized to receive te
line, pseudoephedrine, or placebo. Detumescence occurred
in 36 percent, 28 percent, and 12 percent, respectively. Terbutaline was significantly
better than placebo (p < 0.05) in achieving detumescence. The results of this study suggest that oral terbutaline should be considered in the initial management of pharmacomethods
logically induced prolonged erections.
Alpha Agonist/Irrigation
There has
beenMedical
a resurgence
of interest
the field of Jaipur,
DuringIndia
the last 3 y, 500 men with erectile dysfuncDepartment of Urology,
SMS
College
& inHospital,
impotence among both patients and physicians with
tion received intracorporeal injection of a bimix
The development
of new nonsurgical therapies
the literature ranges from 2 percent to 18 percent.6
the development of various surgical and nonsurgical
solution containing
papaverine
and chlorpromaand advances
in surgical therapy
has generated inThe standard therapy for pharmacologically
intherapies. Various vasoactive compounds as intrazine, as part ofcreased
their interest
evaluation
and and
treatment.
by patients
physicians The
in the
duced prolonged erections is drainage and irricorporeal injections
have been used in both the
dosage rangedfield
from
0.1 to 0.5
Patients
were
of impotence.
It isml.
estimated
that approxigation of the corpora with sympathomimetic
st
1
mately
10tomillion
American
males regarding
and overinjection
25
agents.738
diagnostic
evaluation
and treatment
impotence. complications
completely evaluated
make
a diagnosis
Prolonged
erection
and priapism
areofcommon
following
intracavernosal
of
of men dysfunction.
older than seventy-five
years are
Recent reports have suggested
that the oral
Pharmacologically induced erections have various
the aetiology percent
of erectile
It included
vasoactive
agents
in the management
of erectile
Itexamination,
is usually
treated
by serum
intracorporeal
1.2 Since Brindley3
first demonstrated
in
medications, pseudoephedrine
and terbutaline,‘O
impotent.
potential
complications
of which the most
signifi- dysfunction.
history, physical
urine
analysis,
the 1980s that the intracorporeal
injection of pheare effective therapies for the reversal of pharmaprolonged erection
or priapism.2 The agents.
testosterone,
prolactin
blood
biochemistry,
pharmadrainagecant
andis irrigation
with sympathomimetic
There
is
no
established
oral
therapy
.
To
noxybenzamine
could produce erections in men,
cologically induced prolonged erections. However,
incidence
erection ranges
2 to
cologic
erection
test and penile
duplex ultrasonothe natural
various vasoactiveintracavernosal
compounds have been used
in
study the
effect ofofprolonged
oral terbutaline
on from
prolonged
erection
following
injection
of history of pharmacologic erections is
18% depending upon the type of agent and the
graphy with pharmacologic
select of
not known, and the efficacy of these medications
both the diagnostic stimulation
evaluation and in
treatment
2
vasoactive
agent,
a
controlled
randomized
study
was
done
in
68
patients.
Detumescence
amount of dose used. The standard therapy for
patients. All patients
were4,5observed
in the office
impotent
men.
The most commonly
utilized
has was
not been determined in a controlled fashion.
The this
purpose of this study was to determine whethagents
today are
papaverine, Those
phentolamine,
and
erection
drainage
irrigation
until full and
detumescence
occurred.
patients
achievedsuch
in prolonged
42 and 15%
of isthe
casesand
with
oralofterbutaline
placebo,
respectively.
Results
of
er pseudoephedrine
or terbutaline were superior
prostaglandin
E 1. for more than 21 h were
the corporal bodies with sympathomimetic agents.3
with fullfor
erection
persisting
2
study suggest
that an initial trial with oral terbutaline
pharmacologically
induced
prolonged
to placebo (sodium bicarbonate)
in reversing
There are many potential complications
associThere is no established oral medication although
then treated with
oral
medication,
either
terbutaline
ated with pharmacologically
stimulated erections.
pharmacologically
induced prolonged erections.
erection some
mayrecent
be successful.
reports have suggested that pseudoe5 mg or placebo
(sodium
observedis a
However,
the bicarbonate)
most significant and
complication
phedrine
and terbutaline
may be effective
in reverMATERIAL AND METHODS
for 15
An additional
dosage
of 5 mg was
if
International
Journal
of4,5Impotence
Research
(2004)
16,min.
424–426.
prolonged doi:10.1038/sj.ijir.3901180
erection,
or priapism,
which given
is dose-resing such erections. This study was conducted to
detumescence lated
didandnot
15 min
Over a two-year period, 625 consecutive
men
most occur
frequentlyafter
observed
in menand
with
Published
onlinethe4 efficacy
Marchof2004
determine
oral terbutaline in pharwith erectile dysfunction received an intracorponeurogenicwith
and persistent
psychogenic impotence.6
The in30 min. Any patient
erection after
real injection of prostaglandin
El as part of their
of these
prolonged erections
reportedof in
macologically induced prolonged erection.
4 h received thecidence
standard
intracorporeal
irrigation
evaluation
or treatment.
The dosage
of
dilute adrenaline solution. Patients’ blood pressure
prostaglandin El ranged from 2 to 20 pg and was
4, 1993, accepted (with revisions): February
Keywords: priapism; prolonged erection; terbutaline
and pulse rate Submitted:]anuary
were monitored
during this period.
selected in an effort to avoid prolonged erections.
15.1993
!  1 step is corporal aspiration/irrigation
!  24-36% will resolve with aspiration alone
!  43-81% resolve with aspiration + sympathomimetic
injection (several case series)
!  Should be attempted before performing shunting
procedures
Introduction
Correspondence: S Priyadarshi Asst. Professor, Department of Urology, SMS Medical College & Hospital, C-80,
Gole market, Jawahar Nagar, Jaipur 302004, India.
E-mail: dr_shivam@hotmail.com
Received 15 December 2002; revised 3 September 2003;
accepted 5 November 2003
Results
UROLOGY
/ JULY1993 I VOLUME
42, NUMBER1
51
Materials and methods
!  Phenlyephrine is recommended
(AUA consensus
panel)
There has been a resurgence of interest in the field of
impotence among both patients and physicians with
the development of various surgical and nonsurgical
therapies. Various vasoactive compounds as intracorporeal injections have been used in both the
diagnostic evaluation and treatment of impotence.1
Pharmacologically induced erections have various
potential complications of which the most significant is prolonged erection or priapism.2 The
incidence of prolonged erection ranges from 2 to
18% depending upon the type of agent and the
amount of dose used.2 The standard therapy for
such prolonged erection is drainage and irrigation of
the corporal bodies with sympathomimetic agents.3
There is no established oral medication although
some recent reports have suggested that pseudoephedrine and terbutaline may be effective in reversing such erections.4,5 This study was conducted to
Of the 500 impotent patients receiving the intracorporeal injections, 68 (13. 6%) developed prolonged
During the last 3 y, 500 men with erectile dysfunction received intracorporeal injection of a bimix
solution containing papaverine and chlorpromazine, as part of their evaluation and treatment. The
dosage ranged from 0.1 to 0.5 ml. Patients were
completely evaluated to make a diagnosis regarding
the aetiology of erectile dysfunction. It included
history, physical examination, urine analysis, serum
testosterone, prolactin blood biochemistry, pharmacologic erection test and penile duplex ultrasonography with pharmacologic stimulation in select
patients. All patients were observed in the office
until full detumescence occurred. Those patients
with full erection persisting for more than 212 h were
then treated with oral medication, either terbutaline
5 mg or placebo (sodium bicarbonate) and observed
for 15 min. An additional dosage of 5 mg was given if
detumescence did not occur after 15 min and
9'
CHAPTER 25 ● Priapism
trauma or if the corporal aspirate reveals well-oxygenated
blood (Fig. 25–4A and B).
Penile Imaging
757
2013%04%02'
ischemia with penile edema, persistent ischemia, and conversion
to high-flow state. Chiou and colleagues (2009) have recommended
that to accurately categorize presentations as nonischemic or ischemic, careful interpretation of color Doppler ultrasound hemodynamics must be done in conjunction with the clinical assessment.
They describe eight patients with priapism following intracavernous injection (duration ≤7 hours), all of whom showed presence
of cavernous arterial inflows with varied peak systolic velocities
and end-diastolic velocities. They concluded that most patients
with priapism following ICI (and duration <7 hours) have a hemodynamic picture of mixed arteriogenic and veno-occlusive priapism. In their series, men with idiopathic ischemic priapism longer
than 20 hours showed no detectible cavernous arterial inflows.
There have recently been reports on the use of magnetic resonance imaging in priapism. Kirkam and colleagues (2008) noted
that there are three possible roles for magnetic resonance
imaging (MRI) to help in the assessment of priapism; the
primary role would be in the imaging of a well-established
arteriolar-sinusoidal fistula (Kirkham, 2008). The authors
acknowledge a limitation of MRI is resolution; MRI cannot demonstrate small vessels as clearly as high-frequency Doppler sonography or angiography. The second would be in ischemic priapism
Phenylephrine injection/
aspiration
Color duplex Doppler ultrasonography (CDU) of the penis and
perineum is recommended in the evaluation of priapism. CDU is
an adjunct to the corporal aspirate in differentiating ischemic
from nonischemic priapism. Patients with prolonged ischemic priapism will have no blood flow in the cavernous
arteries; the return of the cavernous artery waveform will accompany successful detumescence. Patients with nonischemic
priapism have normal to high blood flow velocities detectable in the cavernous arteries; an effort should be made to localize
the characteristic blush of color emanating from the disrupted
cavernous artery/arteriole (Broderick, 2002). Examination of the
entire penile shaft and perineum is recommended; this can be
done with the patient supine but frog legged (Fig. 25–5). Penile
arteriography should be reserved for the management
of high-flow priapism,
when embolization is planned;
100 cc minibag
arteriography is too invasive as a diagnostic procedure
to differentiate ischemic from nonischemic priapism
(Burnett, 2004). The data from penile blood gas assessments
become confusing following interventions. Color Doppler
ultrasound should always be considered in the evaluation of a full or partial erection after treatments for
ischemic priapism. The differential diagnosis includes resolved
!  100 mcg/ml conc.
!  Inject 1-2 ml q 3-5 min
!  Up to 1 hr before declaring
treatment failure (unlikely to work
if priapism > 48-72 hrs)
!  Aspirate between each injection,
pinching base of penis
Key Points: Priapism Imaging
!  Only one side necessary
Table 25–4.
●
●
Typical Blood Gas Values
SOURCE
Normal arterial blood
(room air)
Normal mixed venous
blood (room air)
Ischemic priapism
(first corporal aspirate)
Po2 (mm Hg)
Pco2 (mm Hg)
>90
<40
pH
7.40
40
50
7.35
<30
>60
<7.25
Modified from Montague DK, Jarow J, Broderick GA, et al. American Urological
Association guideline on the management of priapism. J Urol 2003;170: 1318–24.
A
●
●
●
Color Doppler ultrasound (CDU) is an adjunct to the corporal aspirate in differentiating ischemic from nonischemic
priapism.
CDU imaging should include corporal shaft and transperineal assessment of the crural bodies when there is a history
of penile trauma or straddle injury.
CDU should always be considered in the evaluation of a
persistent or partial erection after treatments for ischemic
priapism.
Penile arteriography is too invasive as a diagnostic procedure to differentiate ischemic from nonischemic priapism.
MRI has three possible roles: imaging of a well-established
arteriolar-sinusoidal fistula, identifying corporal thrombus,
and identifying corporal metastasis.
B
Figure 25-4. A, Initial corporal aspirate in ischemic priapism show dark, deoxygenated blood. Subsequent aspirations will show brighter
blood as corpus cavernosum is reoxygenated by inflow. Empty syringes are from successive injections of phenylephrine. B, A butterfly
needle for aspiration and injection should be placed at the penoscrotal junction. Initial failed efforts in the emergency room were due to
distal placement of butterfly needle and failure to repeat aspirations.
10'
2013%04%02'
Surgical Shunts
!  Shunts divided anatomically
! 
! 
! 
! 
! 
Distal (Winter, Ebbehoj, T-shunts)
Open distal (Al-Ghorab, Corporal snake)
Proximal (Quackles, Sacher)
Saphenous vein (Grayhack)
Deep dorsal vein shunt
!  Goal of shunting to reoxygenate cavernous smooth
muscle, create fistula between CC and (CS, glans,
veins)
Percutaneous distal shuntsWinter Shunt
CHAPTER 25 ● Priapism
763
and α-adrenergic agonists for at
of surgery (Pryor, 2004). Early
able in patients with malignant
n or for men who are using
medications contraindicating
hensive discussion and docuerectile function, duration of
urgery, and ED should be held
informed consent form signed
the longer an episode of
greater the likelihood of
n will be in the future. Pret priapism lasting longer than
ED rate (Pryor, 1982). Kulmala
% erectile function preservation
apism reversed in less than 24
f erectile function among men
days. Recommendations based
ction outcomes are few. One
le function outcomes by conl Index of Erectile Function).
ly documented 39 cases of SCD
ency department over 8 years;
erectile function status within
. Of the 39 African-American
d prior episodes of stuttering;
d with SCD; and only 5% had
were aware that priapism was a
~66% resolution
rate
Can be performed in ER, in theory
Figure 25–8. Winter shunt. A distal cavernoglanular shunt
procedure is depicted by the transglanular placement of a
large-bore needle or angiocatheter in the distal glans and corpus
cavernosum. (© Brady Urological Institute.)
A distal cavernoglanular shunt should be the first
choice of shunting procedures because it is technically
easier to perform than proximal shunting. Percutaneous
distal shunting is less invasive than open distal shunting
and can be performed with local anesthetic in the emer-
11'
2013%04%02'
Percutaneous distal shuntsEbbehoj Shunt
ET AL.
G A R C I A ET AL.
!  Transglanular
11 Blade
!  Passed several times
through glans to Surgery
CC
BJUI
Illustrated – Surgical Atlas
T-shunt with or without tunnelling for prolonged
!  Blood is milked out
of
ischaemic
priapism
764
SECTION VI ● Reproductive and Sexual Function
penis
BJU INTERNATIONAL
Maurice M. Garcia, Alan W. Shindel and Tom F. Lue
Department of Urology, University of California, San Francisco
!  Uni- vs. Bi-lateralILLUSTRATIONS by STEPHAN SPITZER, www.spitzer-illustration.com
~73% resolution
rate
A
PATHOPHYSIOLOGY OF PROLONGED
ISCHAEMIC PRIAPISM
Based on our clinical observations and findings
B from colour duplex ultrasonography beforeC
a
a
a
b
c
b
Figure 25–9. A, A No. 11 blade is used for an Ebbehoj
percutaneous
shunt,
and an
a No. 10 blade is used for a T shunt. B and
and after
shuntingcavernoglanular
procedures, we
present
C, Note the differences between the Ebbehoj and T shunts. In the Ebbehoj technique the No. 11 blade leaves a straight incision into the
illustrated
schematic
of the
pathophysiology
glans and corporus cavernosum. In the creation of
a T shunt the
No. 10 blade
is rotated
90 degrees after insertion and withdrawn. In both
the percutaneous techniques deoxygenated bloodofisischaemic
milked out priapism
of the open
wounds;
once
bright
red blood is seen, the skin is closed,
and the role of
leaving the deeper incision as the open fistula. In either procedure the maneuver may be repeated on the opposite corpora. (Courtesy of
conventional proximal and distal shunts.
Tom Lue.)
90°
b
d
1964). There are no data comparing bilateral (Sacher, 1972) and
unilateral CC-CS shunts (Quackles, 1964). Typically, bilateral
shunts are staggered; the right side and left side are separated by
Visualization of bright red blood in corporal aspirate
a distance
The
T-shunt
is
indicated
in casesofofat least 1 cm in an effort to minimize the risk of
Corporal blood gas
urethral stricture at the point of CC-CS communication (Fig.
ischaemic priapism that
are refractory to
Color Doppler ultrasound
25–12). In cases where proximal shunt fails, some have advocated
Measurement of intracavernous pressure
intracavernous injection
of diluted
α-bypass or deep dorsal vein shunt (Fig. 25–13A and
saphenous
vein
Penile compression maneuver (squeeze and release)
adrenergic medications.
ischaemic
B). In
A wedge
of tunica albuginea is removed and the vein is anastamosed end
to side
of CC. There are no comparative trials of vein
priapism of >3 days’ duration,
tissue
death
shunting for ischemic priapism. Authors have described a signifiand oedema can obstruct
blood flow from
urethral catheter is placed and lightly compressive dressing is cant risk of sapheno-femoral vein thrombus and pulmonary
the proximal to distalembolism
corpus cavernosum;
applied to the genitalia.
with vein shunting (Kandel, 1968).
in these
cases
a T-shunt alone might be
The key factors determining successful
surgical
reversal of ischemic priapism are evacuation
of
thrombus,
insufficient to restore penile circulation and
reestablishing cavernous inflow, and patency of shunt.
consideration must be given to placing a
Theoretically, larger open shunt procedures are likely to result in
T-shunt
with tunnelling of each
higher shunt patency rates; there are no data bilateral
comparing
percutaa rigid straight
neous and open distal shunts. The surgeon corpus
must becavernosum,
guided by using
Unfortunately
the natural history of untreated ischemic
familiarity with various techniques: percutaneous
shunting,
open
priapism
20–24
F urethral
sound
or dilator.or priapism refractory to interventions is
distal shunting, proximal shunting, and vein shunting. Although severe fibrosis, penile length loss, and complete ED (see
distal shunting can be performed with penile block and sedation Fig. 25–1). Kelami (1985) described the implantaion of the Smallin the emergency department, open shunting, especially that Carrion penile prosthesis through an infrapubic incision in the
PLANNING
AND PREPARATION
requiring passage of dilators into the CC, will likely
require general
management of postpriapic erectile dysfunction. Bertram and colanesthesia and an operating room suite. At the completion of the leagues (1985) described six postpriapic cases of penile prosthesis;
shunt, patency can be verified in the operating
room
and
subsefive patient
of six men
had successful implantation of semirigid prosthe• It is helpful to ask the
to describe
quently recovery room in a number of ways: bright oxygenated ses. Both groups described extensive corporal fibrosis and sugthe
quality
and
location
of
pain
before
blood should be seen emanating from the corporal bodies; intra- gested that semirigid implants were preferable because inflatable
starting
the procedure.
cavernous pressures should fall; the penis should
detumesce
and implants would not overcome the corporal fibrosis sufficiently to
refill with sequential compression and release;•and
Doppler
erect
thea penis.
Douglas and colleagues (1990) reported on penile
Thecolor
urologist
should
have
thorough
ultrasound will show resumption of cavernousdiscussion
artery inflow
(Lue,
prosthesis
in the
five SCD postpriapic men; they described a surgical
with the patient
about
2002; Nixon, 2003; Chiou, 2009) (TableET AL.25–5). Complications of technique of tunneling and corporal excavation. Inadvertent
indications, risks and benefits of the
shunting include penile edema, hematoma, infection, urethral damage to the tunica albuginea was common, as was subsequent
procedure. It is essential
to give ofa clear
fistula, penile necrosis, and pulmonary embolism.
migration
hardware; 11 additional procedures were required
explanation
the patient
that the
informs
The most commonly described proximal
shunt to
is the
following
initialhim
implants. The average time from priapism to
G Ain
R C1964
I A E T(Fig.
A L . 25–11).
unilateral shunt, described by Quackles
implant
in Douglas’s
was 4 years. Monga and colleagues
that
priapism
of prolonged
duration,
alone, series
is
Proximal corpus cavernosum to spongiosum (CC-CS) shunt pro- (1996) described implants in young SCD patients (six patients,
a risk factor for erectile dysfunction, and the
cedures require a transscrotal or transperineal approach (Quackles, average age 26); inflatable implants were placed to both treat ED
Table 25–5.
INDICATIONS
Assessing Corpora Cavernosa Shunt Patency
a
a
T-Shunt
b
b
Vertical incision 4mm lateral to meatus
Through glans to CC
Immediate Implantation
of Penile Prosthesis
T-shunt procedure might not modify that
risk. This discussion should be witnessed by a
BJUI
Surgery Illustrated – Surgical Atlas
T-shunt with or without tunnelling for prolonged ©
Turn 90° away from
urethra, remove
JOURNAL CO
MPILATION ©
1754
ischaemic
priapism
Milk out blood
2008 THE AUTHORS
2 0 0 8 B J U I N T E R N A T I O N A L | 1 0 2 , 1 7 5 4 – 1 7 6 4 | doi:10.1111/j.1464-410X.2008.08174.x
BJU INTERNATIONAL
Maurice M. Garcia, Alan W. Shindel and Tom F. Lue
Department of Urology, University of California, San Francisco
ILLUSTRATIONS by STEPHAN SPITZER, www.spitzer-illustration.com
PATHOPHYSIOLOGY OF PROLONGED
ISCHAEMIC PRIAPISM
Based on our clinical observations and findings
from colour duplex ultrasonography before
and after shunting procedures, we present an
illustrated schematic of the pathophysiology
of ischaemic priapism and the role of
conventional proximal and distal shunts.
a
a
12'
a
b
c
b
90°
d
b
METHODS
performed with the patient under
a localfor
anesthetic.
T-shunt
whom
followup, including erectile function,
was available.
After of
local
review
board review
and ap- Submitted for publication August 13, 2008.
Materials and Methods: We reviewed
theRecords
records
13institutional
patients
treated
the
Results:
were
available
for with
review
for
men
underwent
Study
receivedwho
institutional
review board ap- the
proval, records
were
reviewed of patients
treated with
the 13
Figure 2. Difference in size between number
T-shunt for whom followup, including
function,
was
available.
T-shunt
in whom
ultrasonography
wasJanuary
performed and2008.
forproval. blades.
shunt erectile
procedure
from
April
2006
to
In
most
cases
priapism h
whom followup was available. Followup consisted of an- * Correspondence: Northstar Urology, P. O.
Results: Records were availablelasted
for review
for
13
men
underwent
the T-irrigation/intracorporal
for more
than
24who
hours
and previous
administ
swering
the Sexual
Health Inventory
for Men and
self-Box 40,000, Vail, Colorado 81658 (telephone:
shunt procedure from April 2006
to of
January
2008.
Inofmost
casesbeen
priapism
had
assessment
penile sensation.
970-569-7725;
FAX: 970-569-7735;
Dr.w.und
tion
sympathomimetics
had
unsuccessful.
Ofskin
these
13 men e-mail:
6 had
The patient is prepped and penile/glans blocks with
closure, the patient is discharged ho
2013%04%02'
lasted for more than 24 hours and
previous
irrigation/intracorporal
administraxylocainedistal
or bupivacaine
are performed
with a 25
gaugebrant@gmail.com).
tion before
returns thepresentation
same shunt procedure
gone
unsuccessful
or proximal
shunt
procedures
tois op
interest
and/or
other with
relationship
needle.Of
Since
priapism
the underglans penis, the † Financial
tion of sympathomimetics had been unsuccessful.
these
13usually
menspares
6 had
opposite
side. In
patients
priapism la
service. All procedures
were
performed
only.
Caverno
Medical
Systems,
Coloplast
and follo
tips of the rigid cavernous
bodies are easilyusing
palpable. local
Awith American
3anesthetic
days we
create
a bilateral
T-shunt
gone unsuccessful distal or proximal shunt procedures
beforeplaced
presentation
to our
number
10 blade is in
the glansand
TIMM of
Medical.
a 20Fr dilator
or sounds through
the
blood flow was
restored
allvertically
but through
1 patient
another
required
a seco
it is anesthetic
fully within the cavernosum,
staying at least 4 ‡ Financial
glans to
the crus
on other
both relationship
sides. This crea
service. All procedures were performed usinguntil
local
only. Cavernous
interest
and/or
procedure. T-shunts
resulted
inof resolution
penile
pain
in
all
patients
and
mm away from
the opening
the meatus and of
thereby
ernous
tunnel
for
the
blood
to
flow
from
p
with PercSys and Ethicon.
blood flow was restored in all but 1 patientpreventing
and another
required
a blade
second
urethral injury
(fig. 1). The
is then rocorpora, and then via the shunt to the gl
but 2 had recovery
of
erectile
function.
§ Financial
interest and/or other relationship
tated 90 degrees
away
the urethra
andall
then reprocedure. T-shunts resulted in resolution of penile
pain in
allfrom
patients
and
with Lilly, Pfizer, American
Medical Systems,
blood,technique
often black withresults
an appearance
Conclusions: moved.
TheStagnant
T-shunt
in ofimmediate
resolution
of ischem
but 2 had recovery of erectile function.
Therapeutics and Bayer.
crankcase oil, is milked from the cavernosa-glandularAcordaRESULTS
penile
pain
and
rigidity.
Ultrasonography
confirms
that
blood
flow
is usua
to disclose.
After confirming
detumescence
glans is sutured ! Nothing
Conclusions: The T-shunt technique results inshunt.
immediate
resolution
of the
ischemic
Records
were available for review fo
withpreviously
an absorbable suture,
taking care
not to obliterate
¶ Financial
interestthe
and/or
other
relationship
restored
to
the
ischemic
corpora
cavernosa
after
the
procedure.
T
underwent
T-shunt
procedure
an
penile pain and rigidity. Ultrasonography confirms
blood
is usually
the deeper that
spongial
tissue flow
that constitutes
the shunt.with Bayer-GSK, Genix, Lilly ICOS, Medtronics,
equate
followup
between
April
2006 a
T-shaped
is width
simple
andprocedure.
reliable,
and
access
also
allows
for
proxim
Since the
of a standard
number
10 blade
from edge
restored to the previously ischemic
corporashunt
cavernosa
after
the
The
NexMed,
Pfizer,
Auxilium,
Geneve
Bio
Inc,
TAP,
The diagnosis of ischemic priapism
to rotational axis
is 4 observed
mm, this shouldsurprisingly
create a nominal excellent
We
recovery
of erec
Astellas,
Rinat, via
Biopharm
and American
Medical
made
history
and physical
ex
T-shaped shunt is simple andtrans-shunt
reliable, anddilation.
access
for scalpel
proximal
shunt
surfacealso
area ofallows
50 mm after
rotation and
Systems.
though
penile cavernous
blood gas aa
function.
Thisremoval
procedure
may
of corporal
circulation
(fig. 2). If the
penisfacilitate
remainsof
soft erectile
15recanalization
minutes after
Bilateral
if persists
returns
trans-shunt
dilation. Weorobserved
surprisingly
excellent
recovery
plex ultrasonography was used as
could make
proximalofshunts
obsolete.
Editor’s
Note:cases.
This2,3article
is the wer
function.
This procedure may facilitate
recanalization
corporal
circulation and
All procedures
equivocal
after
15 min
room
at our
urology
thirdthe
of emergency
5 published
in or
this
issue
could make proximal shunts obsolete.
ageultrasonography
ranged
from126
to 55credits
years. In a
for which
category
CME
Key Words: erectile dysfunction, priapism,
had Instructions
lasted for morefor
than 2
can priapism
be earned.
+/- corporal
dilatation
if > priapism, ultrasonography
17 hours to 14 days), and previous
Key Words:
erectile(esp
dysfunction,
obtaining credits are given with
Percutaneous distal shunts- T Shunt
! 
! 
2
36 hours)
intracorporal administration of sym
the questions
on pages 1970
andwere 6
had been unsuccessful.
There
1971.had undergone prior unsuccessful c
PRIAPISM is defined as an erection last!  Close with absorbable suture
! 
shunts before
presentation
o
structuraldular
changes
in the
penistoth
1 also had a failed cavernous-spon
PRIAPISM is defined as an erectioning
lastchanges
in the
penis that
longerstructural
than 4 hours
that
is not
may lead shunt.
to penile
fibrosis
and
sev
Three patients had preexis
1,2
whom
also had stuttering
priapism.
ing longer than 4 hours that is
not
may
to penile
fibrosis and
severe
associated
withlead
sexual
stimulation.
or complete
erectile
dysfunction.
C
etiology
of priapism 3 cases were d
13/13
with
resolution
(mean
1,2
associated with sexual stimulation.
or complete
erectileinto
dysfunction.
It is generally
classified
isch- Conservative drugs
management
is rarely
eff
(1 in combination
with atypica
post-op
SHIM 18.9)
medication),
1 was circumstanc
secondary to !-b
It is generally
classified into emic
isch- and nonischemic
servative management
is The
rarely effecetiologies.
tive except
in select
tion for lower urinary tract symptom
emic and nonischemic etiologies.
The
tive except the
in select
circumstances.
former,
comprising
majority
of
Interventions
may
include
aspirat
inappropriate use of a neighbor’s
intr
soactiveof
medication,
1 was due
to a nu
former, comprising the majority
of is considered
Interventions
may1. Incisions
include
aspiration
cases,
an Figure
emergency
due
and irrigation
the corpora,
inject
for
T-shunt
“male enhancement,” 2 were due to tr
cases, is considered an emergency
irrigation
of theascorpora,
todue
intense and
associated
pain,
well asinjection
of vasoconstrictive agents or surgi
to intense associated pain, as well as
of vasoconstrictive agents or surgical
T-Shaped Shunt and Intracavernous Tunneling for Prolonged
Ischemic Priapism 0022-5347/09/1814-1699/0 ®
0022-5347/09/1814-1699/0
Vol. 181, 1699-1705, April 2009
THE JOURNAL OF UROLOGY
Printed in U.S.A.
THE JOURNAL OF UROLOGY®
Copyright © 2009 by AMERICAN UROLOGICAL ASSOCIATION
William
O. Brant,*,†
M. Garcia,‡ Anthony J. Bella,§
Tom Chi! and
UROLOGICALMaurice
ASSOCIATION
DOI:10.1016/j.juro.2008.12.021
Copyright © 2009
by AMERICAN
Vol. 181, 1699-1705, April 2
Printed in U.
DOI:10.1016/j.juro.2008.12
www.jurology.com
1699
Tom F. Lue¶
From Northstar Urology, Vail, Colorado (WOB), University of Ottawa, Ontario, Canada (AJB), and University of California, San Francisco,
CHAPTER 25 ● Priapism
765
San Francisco, California (MMG, TC, TFL)
Purpose: Conservative management of prolonged ischemic priapism is rarely
effective. Interventions include corporal aspiration/irrigation, injection of vasoKey Points: Surgical Management
constrictive agents or surgical procedures. We describe a technique that fulfills
of Ischemic Priapism
several important criteria in the surgical management of ischemic priapism in
that immediate
resolution
of ischemic pain is achieved, a wide area, reliably
● Shunt surgery should be considered
for all cases
of ischemic
priapism (IP) failing aspiration
and intracavernous
injection
patent
shunt is created,
the procedure is technically simple and it may be
of α-adrenergics.
performed with the patient under a local anesthetic.
● Patients should be counseled
that erectile
function outMaterials
and Methods:
We reviewed the records of 13 patients treated with the
comes decline significantlyT-shunt
when IP for
has whom
lasted longer
thanincluding erectile function, was available.
followup,
24 hours and that complete
ED is anticipated
if IP persists
Results:
Records were
available for review for 13 men who underwent the Tfor longer than 36 hours. shunt procedure from April 2006 to January 2008. In most cases priapism had
● The objective of shunt surgery is reoxygenation of the cavlasted for more than 24 hours andAprevious irrigation/intracorporal administraernous smooth muscle.
tion of sympathomimetics had been unsuccessful. Of these 13 men 6 had under● The key factors determining successful surgical reversal of IP
gone unsuccessful distal or proximal shunt procedures before presentation to our
are evacuation of thrombus, patency of shunt, and resumpservice. All procedures were performed using local anesthetic only. Cavernous
tion of cavernous inflow.
blood flow was restored in all but 1 patient and another required a second
● A distal cavernoglanular shunt should be the first choice of
procedure. T-shunts resulted in resolution of penile pain in all patients and all
shunting procedures.
but is
2 had
of erectile
● Percutaneous distal shunting
less recovery
invasive than
open function.
Conclusions:
The T-shunt
technique results in immediate resolution of ischemic
distal shunting and may
be performed
with local
penile pain and rigidity. Ultrasonography confirms that blood flow is usually
anesthetics.
restored
to procedures
the previously
ischemic corpora cavernosa after the procedure. The
● There are a number of distal
shunting
and the
B
is simple
surgeon should be familiar T-shaped
with these shunt
procedures
and theirand reliable, and access also allows for proximal
trans-shunt dilation. We observed surprisingly excellent recovery of erectile
complications.
● Open distal shunting should
be considered
if percutaneous
function.
This procedure
may facilitate recanalization of corporal circulation and
shunting fails. There are no
comparative
trials ofshunts
safety, obsolete.
could
make proximal
Open Distal
Shunts- Al
Ghorab Shunt
!  Grasp w Kocher or 2-0,
excise 5x5mm of tunica
!  Compress/milk out blood
!  Foley, close
●
●
●
●
Abbreviations
and Acronyms
ED ! erectile dysfunction
SHIM ! Sexual Health Inventory
for Men
Submitted for publication August 13, 2008.
Study received institutional review board approval.
* Correspondence: Northstar Urology, P. O.
Box 40,000, Vail, Colorado 81658 (telephone:
970-569-7725; FAX: 970-569-7735; e-mail: Dr.w.
brant@gmail.com).
† Financial interest and/or other relationship
with American Medical Systems, Coloplast and
TIMM Medical.
‡ Financial interest and/or other relationship
with PercSys and Ethicon.
§ Financial interest and/or other relationship
with Lilly, Pfizer, American Medical Systems,
Acorda Therapeutics and Bayer.
! Nothing to disclose.
¶ Financial interest and/or other relationship
with Bayer-GSK, Genix, Lilly ICOS, Medtronics,
NexMed, Pfizer, Auxilium, Geneve Bio Inc, TAP,
Astellas, Rinat, Biopharm and American Medical
Systems.
Editor’s Note: This article is the
third of 5 published in this issue
for which category 1 CME credits
can be earned. Instructions for
obtaining credits are given with
the questions on pages 1970 and
1971.
efficacy, or erectile function outcomes for percutaneous
versus open distal shunting techniques.
Key Words: erectile dysfunction, priapism, ultrasonography
If distal shunting fails, then proximal shunting is recommended. Proximal shunting establishes a communication
between the corpora cavernosa and spongiosa at the base of
the penis. The surgeon must be aware of the unique anaPRIAPISM is defined as an erection laststructural changes in the penis that
tomic relationship between the corpus spongiosum and
ing longer than 4 hours that is not
may lead to penile fibrosis and severe
urethra.
1,2
associatedwith
withvein
sexual
stimulation.
or complete erectile dysfunction. ConShunting may also be accomplished
grafting
to
It is shunts
generally
into ischservative management is rarely effecthe corpora cavernosa. Venous
have classified
increased the
C
tive except in select circumstances.
risk of thromboembolism. emic and nonischemic etiologies. The
Following medical or surgical
reversal
of IP, penilethe
tumesformer,
comprising
majority of
Interventions may include aspiration
cence rather than complete
flaccidity
may be evident.
A
cases,
is considered
an emergency
due 25–10.and
irrigation
of the corpora,shunt
injection
Figure
A-C,
An open corporoglanular
is indicated
phenomenon of conversion
from IPassociated
to HFP has
been
to intense
pain,
as well
as
of vasoconstrictive
agents cavernous
or surgical
if percutaneous
shunting fails to reestablish
blood
described. In cases where the examination may be equivoinflow. The Al-Ghorab shunt requires the excision of circular cone
segments of the distal tunica albuginea (5 × 5 mm). (By permission
cal, color Doppler ultrasonography or cavernous blood gas
0022-5347/09/1814-1699/0
Vol.
181, 1699-1705,
April 2009 All
of Mayo Foundation for Medical
Education
and Research.
is recommended to demonstrate
patency
shunt ®and resPrinted in U.S.A.
THE JOURNAL
OF of
UROLOGY
rights reserved.)
www.jurology.com
toration of cavernous inflows.
DOI:10.1016/j.juro.2008.12.021
Copyright © 2009 by AMERICAN UROLOGICAL ASSOCIATION
After shunting, follow up with the patient on erectile functhrombus be triaged to immediate penile implant? What is clear
tion and any subsequent ED therapies.
is that any discussion pertaining to early prosthesis insertion
~74% resolution
rate
and circumvent ongoing episodes of stuttering priapism. They
suggested that both potency and recurrent episodes of ischemic
should be documented and include a comprehensive review of the
theoretic advantages and actual risks. Compared with prosthesis
insertion in a typical patient with erectile dysfunction, there are
significantly higher rates of complications noted in pria-
1699
13'
d 2009;6:1171–1176.
Robert L. Segal,* Nathaniel Readal, Phillip M. Piero
and Trinity
Bivalacqua
e: We provide long-term followup on a modification
of the J.
Al-Ghorab
distal
Abbreviations
orporoglanular shunt surgery for the treatment From
of ischemic
the Departmentpriapism.
of Urology, The James Buchanan Brady
Institute, T
andUrological
Acronyms
2013%04%02'
Baltimore, Maryland
als and Methods: We conducted a retrospective review of patients surgiDM2 ! diabetes me
eated for ischemic priapism at The Johns Hopkins Hospital from January
dysfu
metic administration, and
penile We
shunt
surgery,
Purpose:
provide
long-term
followupED
on!a erectile
modification
April 2012 with the Burnett
“Snake”
maneuver
of
the
Al-Ghorab
shunt.
applied serially as needed
[2,4].
By the latter, shunt
an surgery for IPP
penile
corporoglanular
the!treatment
inflatable of
peni
nic
medical
records
were
reviewed
to
collect
demographic
information
and
m refers to a pathologic disoropening is surgically created
in
the
tunica
albugMaterials and Methods: We conducted a retrospective re
ne
followup
was performed
to verify
outcomes.
com- at The Johns Hopkins
nrelated,
uncontrollably
persis- Open
inea
of Distal
the treatment
corporaShuntscavernosa
forCorporal
the
egress
of priapism
cally
treated
forPatients
ischemic
Accepted for publication
on.
disorder
is associated
trapped blood
various
[5–12],
and
theThe
SHIM
(Sexual
Health Inventory
forbyMen)
toapproaches
assess
erectile
2008
to April current
2012
with
the Burnett “Snake”
maneuver o
Study received institutio
“Snake”
Maneuver
anoxia
of the corpora cavernosa
in doing so, blood circulation
within
the
corporal
n.
Electronic medical records were reviewed
to collect demog
proval.
cause of the lack of blood ! 
circubodies
is restored
and telephone
metabolic followup
derangements
Modified
Al-Ghorab
Shunt
was
performed
to
verify
treatmentJohn
ou
: A total of 10 patients were
analyzed (age range 31 to
59 penis
years).
Mean
* Correspondence:
rological emergency, and can be
and painful sensations occurring
in
the
are
600 Northfor
Wolfe
St., Mar
pleted thewere
SHIMidiopathic
(Sexual Health
Men)
to
p
was 6.7
months
(range
0.57/8
toHegar
17). dilator
Priapism etiologies
(3), Inventory
! 
Insert
artment
syndrome
of the
penis.
relieved.
Maryland 21287-2162 (telep
several cm
function.
ne
(2),resolved
trazodone
cocaineThe
(3),efficacy
intracavernous
trimix (1)
m
is not
within and
4 hours,
of penile shuntinjection
surgery is of
controFAX: 410-614-3695;
e-mail:
Results: A total of 10 patients were analyzed
(age range
! 
Named
after
plumber’s
e is atcord
risk for
irreversible
struc- were
versial,
and reportswho
in thehad
medical
literature docunal
injury
(1). There
6
patients
previously
undergone
“snake”
followup was 6.7 months (range 0.5 to 17). Priapism etiolog
al damage
[1–3]. attempts at ment
variabledecompression
successes in resolving
major episodes
essful
surgical
priapism
and
priapism
trazodone
(2), mean
trazodone
and cocaine (3), intracavernous
! 
ED
likely
(though
natural
hx
ention
is
required
to
avert
of
ischemic
priapism
for
commonly
used
surgical
n was 75 hours (range
24
to
288).
Of
the
10
men
8
achieved
successful
is likely that of ED)
and spinal cord injury (1). There were 6 patients who had
quences of ischemic priapism.
shunting procedures [2,13,14].
However, penile
on of priapism with
no
recurrence.
There
were
2
men
with recurrent
unsuccessful
surgical
attempts at priapism decompressi
!  3/3 resolution
ensus guidelines, the treatment
shunt surgery remains immediately useful
to miti1171
duration
was
75
hours
(range
24 to 288). Of the 10 men
mthe
refractory
all management
who
were definitively
treated
with
inser2cmwith
Transverse
Incision
actions oftoaspiration
of
gate
the
pathologic
effects
associated
treat! ORIGINAL
1/3 erectile
function recovery
RESEARCH—SURGERY
resolution
priapism
with no recurrence. There were
an inflatable
prosthesis.
9 men presentations
6 had
normal
erectile
function
(partial 1/3)
orpora
cavernosa,penile
intracorporal
ment Of
refractory
of ofthe
disorder.
priapism
refractory
to
all
management who were definitiv
atively,
of whom
2 achieved
at least partial
erectile
function
postoperawith
or without
sympathomiInvestigators
have continued
to reevaluate
surgical
Corporal “Snake” Maneuver: Corporoglanular
Shunt
Surgical
tion of an inflatable penile prosthesis. Of 9 men 6 had n
Complications were sustained
byIschemic
2 men,
including wound infection with
Modification for
Priapism
preoperatively,
of whom 2 achieved at least partial erect
l Society for
Medicine
Sex
Med 2009;6:1171–1176
ecrosis
inSexual
1, and
an intraoperative urethralJtively.
injury
in
the
other
Complications
were with
sustained by 2 men, including
Arthur L. Burnett, MD, and Phillip M. Pierorazio, MD
uent urethrocutaneous
fistula
formation
and
wound
infection
with
skin
skin
necrosis
in
1,
and
an
intraoperative urethral inj
Department of Urology, The James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore,
MD, USA
s.
subsequent urethrocutaneous fistula formation and wou
DOI: 10.1111/j.1743-6109.2008.01176.x
necrosis.
sions: The modified Al-Ghorab corporoglanular
shunt using the Burnett
ABSTRACT
Conclusions:
modified Al-Ghorab
corporoglanular sh
maneuver is successful in resolving ischemic priapism, The
particularly
in
Current surgical Distal
shunting procedures for
majorsnake
ischemic priapism
do
not always is
effectively
resolve
maneuver
successful
in resolving ischemic pri
Open
ShuntsCorporal
efractory to first lineIntroduction.
management,
acute
presentations of this disorder. and in preventing further episodes of
cases
refractory
to
first
line
management,
and in prevent
Aim. To evaluate a modification of the Al-Ghorab distal penile corporoglanular shunt surgery for ischemic priapism.
m.
Methods. Three previously potent men (48, 43, 40 years of age) presented with major ischemic priapism episodes (5,
“Snake” Maneuver
priapism.
Erection; Erectile Dysfunction; Al-Ghorab
1173
Corporal “Snake” Maneuver
Figure 1 Technique of Al-Ghorab shunt with surgical modification. (A) Retrograde insertion of Hegar dilator into the distal
end of the right corpus cavernosum. (B) Hand motion for transcorporal advancement of the dilator.
Each tip is transfixed either with 2-0 suture or penis skin is done with 4-0 chromic sutures
grasped with a Kocher clamp, and a circular core (Figure 2). A urethral catheter is placed and
of tunica albuginea measuring approximately secured without tension, and a light sterile com5 mm in diameter is excised. Dark blood is im- pression dressing is applied to the genitalia.
mediately observed draining from the corporal
bodies. The modification entails the retrograde
Discussion
insertion of a size 7/8 Hegar dilator into each
corporal body through the tunical window and Major ischemic priapism is frequently refractory
advanced proximally several centimeters while to clinical management, and inappropriately or
applying a gentle boring motion to release con- unsuccessfully managed priapism of this particugested, viscous blood (Figure 1). After removal of lar form is met with the daunting course of slow
the instrument from the corpus cavernosum, pain resolution, penile deformity, and substantial
blood evacuation through the surgically formed erectile function loss. As these vexatious cases
even with aggressive early managechannel istofacilitated
by management
manual compressionincluding
of demonstrate,
2, and 6 days in duration, respectively), which were
refractory
clinical
sympathomimetic
1174
Burnett
and Pierorazio
penile shunt
the penis sequentially from a proximal to distal ment including performance of distal
intracavernosal treatments, intracorporal aspiration and direction.
saline Once
irrigation,
and penile shunt surgery attempts. We
the penis is flaccid (by clinical surgery, the problem can persist. They underoffered a surgical technique for facilitating corporal bloodjudgment
evacuation
by retrograde
insertionscore
of athecavernosal
dilator
need to continue
to develop effective
or other determinants
such as intracavsurgical management approaches, which can be
pressure monitoring),
closure of the glansincision.
through the excised tunical windows of the distal corporaernosal
cavernosa
after transglanular
!  Long-term
Key Words: fibrosis,follow-up
erectile(7dysfunction, penile erection
Key Words: fibrosis, erectile dysfunction, pen
Main Outcome Measures. Clinical evaluation of priapism resolution and erection recovery.
mo.)
J Sex Med 2009;6:1171–1176
Results. All men achieved successful resolution of priapism, with meaningful erection recovery assessable in one man.
Conclusions. The modified Al-Ghorab corporoglanular shunt surgery appears to offer an advantageous management approach to resolve ischemic priapism, particularly for cases refractory to first-line management. Burnett AL,
and Pierorazio PM. Corporal “snake” maneuver: Corporoglanular
shunt surgical modification for ischemic
SCHEMIC
priapism. J Sex Med 2009;6:1171–1176.
!  Successful
in manent penile
I
priapism, defined
as a perpriapism, defined as
a perstructural
and func8/10 pts (2 had
2,3
sistent
nonsexual
penile
erection,
is a
Key Words. Penis;
Dysfunction; Al-Ghorab
nonsexual penile erection,
is Erection;
a Erectiletional
Serious complicadamage.
1
IPP)
true urological emergency. If not
rological emergency.1 If not
tions including erectile dysfunction,
treated in a timely fashion, the erec!  Partial
pain, sustains
megaphallus,
in a timely fashion,Introduction
the
erec-erectilechronic penile
metic
and penile shunt
surgery, petileadministration,
tissue
acidosis
and anfunction in 2/8
applied4serially as needed [2,4]. By the latter, an
5
necrosis
sue sustains acidosis schemic
andpriapism
an-refers to a nile
and
penile
gangrene
pathologic disoropening
surgically
created in
tunica
albug-of arterial
oxiaisas
a result
ofthethe
lack
of sexually unrelated, uncontrollably persisinea of the corpora cavernosa for the egress of
I ! derarterial
2/10
had
a result of the lack of
can
result,
and
cause
severely
tent
penile
erection.
The disorder
is associated
trapped
blood bycan
various
approaches
[5–12],
and
circulation,
which
can
result
in perwith acidosis
and anoxia of the corpora cavernosa
in doing so, blood circulation within the corporal
complication
and penile
because of the lack
of blood circubodies isquality
restored and metabolic
derangements
ion, which can result
in pain
percompromised
of life.
Corporal Burnett “Snake” Surgical Maneuver for the Treatment
C
lation. It is a true urological emergency, and can be
manent penile
tional damage
tions includin
chronic penile
nile necrosis4
can result, an
compromised q
and painful sensations occurring in the penis are
0022-5347/13/1893-1025/0
a compartment
of the penis.
relieved.
ofconsidered
Ischemic
Priapism:syndrome
Long-Term
Followup
If ischemic priapism is not resolved within 4 hours,
The efficacy
of penile
surgery®is controTHE
JOURNAL
OF shunt
UROLOGY
the cavernosal tissue is at risk for irreversible struc- http://dx.doi.org/10.1016/j.juro.2012.08.245
versial, and reports in the medical literature docu13/1893-1025/0
Figure
2
Surgically
shunted
penis
in
sagittal
view.
(A)
Position
of
Hegar
dilator within
corpus cavernosum.
(B) Depiction
UROLOGICAL
AtheSSOCIATION
EDUCATION
AND RESEARCH, INC.
© 2013
bysuccesses
AMERICAN
Robert
L. Segal,*
Nathaniel
Readal, Phillip M. Pierorazio,
Arthur
L.
Burnett
tural and
functional
damage [1–3].
ment
variable
in resolving
major episodes
of corporal channel
with direction
of blood
drainage (arrows)
from corpus cavernosum,
through glans penis, and into corpus
and Prompt
Trinity J.intervention
Bivalacqua is required to spongiosum.
Vol.
189,
1025-1029,
March
2013
NAL OF UROLOGY®
avert
of ischemic priapism for commonly used surgical
thethedreaded
consequences
ischemic
priapism.
shunting
procedures
[2,13,14]. However, penile
From
Department of
Urology, The Jamesof
Buchanan
Brady Urological
Institute, The
Johns Hopkins
Medical Institutions,
EDUCATION
AND R
ESEARCH
, INC
.
Printed
in U.S.A.
AMERICAN UROLOGICAL ASSOCIATION
Baltimore,
Marylandto consensus guidelines, the treatment
administered shunt
when first-line
options
fail and invafrom the useful
corpora cavernosa,
According
surgery
remains
immediately
to miti- resulting in priapism
sive intervention
becomes
necessary.
recurrence. with treatapproach involves the actions of aspiration
of
gate
the
pathologic
effects
associated
The decision to apply our technique followed
We acknowledge that the technique was careblood from
the corpora
cavernosa,
ment
refractory
presentations
thein adisorder.
Purpose:
We provide
long-term
followupintracorporal
on a modification
of the
Al-Ghorab
distal
observations that
the standard
creation
of tunical Abbreviations
fully of
applied
select group of patients whose
openings
at
the
distal
corpora
cavernosa
alone
with
prior
medical andsurgical
surgical management for prisaline
irrigation
with
or
without
sympathomiInvestigators
have
continued
to
penile corporoglanular shunt surgery for the treatment of ischemic priapism.
and reevaluate
Acronyms
http://dx.
V
www.jurology.
any of the conventional distal penile shunt surger-
apism had clearly failed. A concern was whether
Materials and Methods: We conducted a retrospective
review
of patients
! diabetes
mellitus
ies is not always
successful
in causing surgithe egress of DM2
vigorous,
direct
intracorporal instrumentation
© 2009
International
Society
for Sexual
Medicine
J Sex Med
cally
treated
for ischemic
priapism
at The
Johnsthick
Hopkins
Hospital
and congested
bloodfrom
from January
the penis. Our
would2009;6:1171–1176
permanently and irreversibly damage the
ED ! erectile dysfunction
maneuver
conjures
up
a
plumber’s
job
to
unclog
erectile
tissue.
However,
we presumed that these
2008 to April 2012 with the Burnett “Snake” maneuver of the Al-Ghorab shunt.
accumulated debris from a water pipe using a IPPpatients
were penile
alreadyprosthesis
predisposed to severe erec! inflatable
Electronic medical records were reviewed to collect
demographic information and
plumber’s “snake” device. The mechanism of the
tile tissue impairment owing to their excessive,
telephone followup was performed to verify treatment
outcomes.
Patients
com-in the unabated ischemic episodes. In follow-up, as sugeffect may well
be that a channel
is formed
August 2,
2012.
for total blood
evacuation
from the Accepted
gested forbypublication
the erectile
function
recovery of our
pleted the SHIM (Sexual Health Inventory forerectile
Men)tissue
to assess
current
erectile
received
institutional
apcorporal body rather than just an exit site for Study
second
patient
and review
partialboard
recovery
of our third
function.
superficial blood release from this structure. Our proval.
patient, we learned that the maneuver does not
Results: A total of 10 patients were analyzed (age
to 59that
years).
Mean
Correspondence:exacerbate
Johns Hopkins
Hospital,tissue functional
secondrange
patient31
showed
creation
of tunical * necessarily
erectile
14'
2013%04%02'
Back to Case 1
!  Aspiration + phenylephrine injection unsuccessful
after 1 hour, Winter shunt unsuccessful in ER
!  Bilateral Ebbhoj, and T shunts unsuccessful in OR,
erection returned within 10 minutes.
We’re going
proximal boys!!!
Proximal Shunts- Quackles
Shunt
766
SECTION VI ● Reproductive and Sexual Function
!  CC – CS communication
!  Higher rates of ED with
proximal shunts
(selection?)
(Ralph, 2009). Mean dura
24 to 72 hours). All patien
and smooth muscle necro
tion of penile prosthesis in
priapism. Revision rates w
patients). The infection rat
related to multiple factors
ing penile interventions.
!  No data to compare univs. bilateral
Key Points: Surgical M
Priapism with Immedia
!  If bilateral = “Sachel”
!  Bilateral should be 1cm
●
apart
●
●
●
●
Figure 25–11. The proximal open shunt technique to establish
communication between the corpus spongiosum and corpus
cavernosum was first described by Quackles in 1964. (By
permission of Mayo Foundation for Medical Education and
Research. All rights reserved.)
●
The natural history o
interventions is sever
plete erectile dysfunc
The advantages of e
management of IP a
easier insertion.
Document baseline e
history of stuttering,
Consider penile pros
! The patient has fa
intracavernous inj
! The patient has fa
! Ischemia has been
Consider an MRI be
time of implant to
necrosis.
15'
There are higher rate
noted in priapism c
device migration, an
15
3d
Asp/IPT
65
Sickle
cell disease
Idiopathic
5
3d
Asp/IPT
6
30
Idiopathic
3d
Asp/IPT, Al-
7
57
Trazodone
3d
8
49
Idiopathic
4d
Asp/IPT, Winte
shunt
Asp/IPT, Winte
shunt
9
36
4d
10
44
Chronic myeloid
leukemia
Idiopathic
11
36
Idiopathic
5d
12
48
Trazodone
6d
13
41
6d
14
25
15
25
Psychiatric
medication
Chronic renal
failure
Idiopathic
16
33
Trauma
3 wk
Saphenous Vein ShuntGrayhack
!  Wedge of tunica excised
2013%04%02'Ghorab shun
4.5 d
!  Vein anastomosed end to
side to CC
!  No comparative trials on
vein shunting
!  High rates of thrombosis
and PE
!  10-69% rates of erectile
function recovery for
vascular shunts.
1 wk
8d
CHAPTER 25 ●
Asp/IPT, AlGhorab shun
Asp/IPT, Winte
shunt
Asp/IPT,
Winter,
Quackel
shunts
Asp/IPT, Winte
shunt
Asp/IPT
Asp/IPT, Winte
shunt
Sudafed
Terbutaline,
Asp/IPT
CD, cavernosal-dorsal vein; Asp/IPT, aspiration and intracavernosal phar
Function; Q, question.
* Erection-related IIEF questions. Q1, how often were you able to get an erec
sexual stimulation, how often were your erections hard enough for penetrat
were you able to penetrate (enter) your partner; Q4, during sexual intercourse
had penetrated (entered) your partner; Q5, during sexual intercourse, how
intercourse (each with scale of 0-5).
A
B a questionnaire assessing
tional Index of Erectile Function and
days (
priapi
the degree
spontaneous
erection,
information
about
suppleFigure 25–13. A, Venous
bypass toof
control
ischemic priapism
was first described
by Grayhack
in 1964.
The Grayhack shunt
mo
saphenous vein below
the junction
of the femoral
vein andor
anastamoses
the erection,
vein end to side
into the corpus
B, D
racav
mental
measures
to obtain
enhance
recurrent
epi-cavernosum.
vein (DDV) shunt with distal ligation of DDV and anastamosis of proximal DDV to corpus cavernosum. A wedge of tunica albug
4
removed. (By permission
Foundationand
for Medical
and Research.
All rights
reserved.) All
initia
sodesofofMayo
priapism,
moreEducation
necessary
surgical
procedures.
terven
saphenous vein graft penile CD shunt procedures were per9 had
formed by an experienced urologist (R.K.C.). The age of paCHAPTER 25 ● Priapism
767
Similar
have been
reported
(Sav
observation is recommended
this typeyears.
of priapism.
shunt
tients wasfor15-65
OneConservapatient was
a results
boy with
sickle
cellby others
tive measures include ice applied to the perineum and site-specific ander, 2006). Normal postembolization erectile fu
Male Sexual Dysfunction
giosal
disease. The age of the adult patients was 21-65 years. The
compression. Cavernous aspiration has only a diagnostic reported in 75% to 86% of patients (Cakan, 2006
Co
causes
of priapism
idiopathic
9 patients,
antidepressant
should be noted
that a single treatmen
role in high-flow
priapism.
Repeatedwere
aspirations,
injec-in It
tion carries
recurrence
rate of 30%
to 40
tion, and irrigation
with
intracavernous
sympathomiClinical Experience
and
Sexual
the
15
or other
psychiatric
medication
in 3 patients,
anda trauma,
sickle
metics have no role in the treatment of nonischemic 2002; Gandini, 2004; Ozturk, 2009). Although u
gently
cell disease, chronic
myeloblastic leukemia, and chronic renal
Function Outcome
of
Patients
With
cessful, embolization of HFP may require
priapism.
the em
v
failure in
1 patient
each.
patientThe
hadmost
developed
traumatic
notable side
effect of arterial
Patients demanding
immediate
relief
canOne
be offered
Priapism Treated
With
Penile
Cavernosal-Dorsal
erectile
dysfunction.
Although
selective arterial
embolization.
The pathognomonic
arteri
high-flow
priapism
of 3 weeks’arterioduration
before
surgery, and
theit was previous
nonpermanent
materials
less
graphic finding
isother
an arterial-lacunar
fistula;
aGraft
characteristic
intra- priapism
Vein Shunt Using
Saphenous
Vein
measu
15 patients
had
had ischemic
for embolization
32 hours to
8 cause
Deep Dorsal Vein Shunt-
cavernosal cone-shaped blush of contrast is seen at the site of the
Rei K. Chiou, Himanshu Aggarwal,
Adam
C. Mues,
Christopher
R. Chiou,
cavernous
artery
or arteriole
laceration
(Fig. 25–14). Selective
and Fleur L. Broughton
internal pudendal catheterization and subsequent embolization
UROLOGY 73 (3), 2009
have been
with various
agents:
microcoils,
polyvinyl
OBJECTIVES
To assess the outcome
of newreported
penile cavernosal-dorsal
vein
shunt using
a saphenous
vein graft.
Traditional surgeries
for priapism
have high failure rate
and subsequent
impotence. blood
alcohol,
N-butylcyanoacrylate,
gel-foam,
and autologous
METHODS
We reviewed the medical records of, and administered a questionnaire and the International
clot
(Kuefer,
2005).
Permanent
materials
pose
a
greater
theoretic
Index of Erectile Function to, 16 consecutive patients with priapism who had treated with the
risk of vein
erectile
many
recommend
of
penile cavernosal-dorsal
shuntdysfunction;
from
1997 to 2007.
Theirauthors
age was 15-65
years. Theuse
duration
9/13
had
erectile
recovery
of ischemic priapism
was 32 hours
to 8 days.
had previously
undergone
shunt Kim,
surgery
autologous
blood
clot Ten
andpatients
absorbable
gels (Pryor,
2004;
by other urologists.
Of the
16 patients,blood
5 returned
2007).
Autologous
clot the
hasquestionnaires.
a low risk of foreign body reacRESULTS
Priapism resolved or was improved after surgery in all 16 patients. One patient was lost to
for
sexual
activity
tion,
orenough
antigenicity;
it is afrom
temporary
occlusive
agent
and
should
follow-up. One6/9
pediatric
patient
was excluded
the analysis.
One patient
with
nonischemic
permit
recanalization
of the
cavernous
artery with
(Park,
2001).priapism
The
priapism continued
to have
sexual intercourse.
Of the
13 adult patients
ischemic
and follow-up for
!6.5 years,
had no erection,
1 hadartery
very little
erection, and 9 (69%)
success
rates3 patients
with selective
pudendal
catherterization
folhad erection. Of the 9 patients with erections possible, six had had sexual intercourse (Interlowed by embolization are quite high (89% to 100%), regardless
national Index of Erectile Function score 32-70) and 3 had not; 1 had a mental disorder, 1 was
of 1,
thetheembolization
material
used
(Kuefer,
2008).
in prison, and for
reason was unknown.
After
surgery,
color 2005;
DopplerNuman,
ultrasound
studies
CONCLUSIONS
nent ones (5% vs. 39%), recent reports employin
Index of Erectile Function in evaluation of postem
tile function describe similar rates of erectile dysfu
20% (Savoca, 2004; Alexander, 2006). Other r
effects include penile gangrene, gluteal ischemia,
nositis, and abscess of the perineum (Hakim, 1996
(Fig. 25–15).
Puppo (1985) compared perineal duplex ultras
tive internal pudendal arteriography showing exc
in detecting the arterial-lacunar fistula on ultraso
angiographically (12 of 12 cases). Several report
bined ultrasound-guided compression with s
embolization to increase success rates in the treatm
emic priapism (Hatzichristou, 2002; Bartsch, 2004
showed a patent shunt in all patients and restoration of cavernosal arterial flow in 12 of 13
patients studied.
A penile cavernosal-dorsal shunt appears effective for priapism. It resulted in priapism resolution
even in patients who had experienced a previous failed cavernosal-glandular shunt or cavernosalspongiosal shunt, with a high rate of sexual function preservation. UROLOGY 73: 556 –561,
2009. © 2009 Elsevier Inc.
P
riapism is a urologic emergency. It is traditionally
divided into ischemic (low-flow) and nonischemic
(high-flow) priapism, with each requiring different
management strategies. The management goal of ischB
emic priapism is to achieve detumescence and preserve as
much erectile function as possible. The initial treatment
us bypass to control ischemic priapism was first described by Grayhack in 1964. The Grayhack shuntfor
mobilizes
the
ischemic priapism
is usually aspiration and intracavhe junction of the femoral vein and anastamoses the vein end to side into the corpus cavernosum. ernous
B, Deep
dorsal
injection
of sympathomimetic drugs with or withdistal ligation of DDV and anastamosis of proximal DDV to corpus cavernosum. A wedge of tunica albuginea
is If this fails to resolve the priapism, some
out irrigation.
n of Mayo Foundation for Medical Education and Research. All rights reserved.)
form of cavernosal-glandular shunt (Winter or AlGhorab shunt) is commonly performed. Proximal shunting procedures using the Quackels (cavernosal-spongiosal)
or Grayhack (cavernosal-saphenous vein) technique are per-
mended for this type of priapism. Conservaice applied to the perineum and site-specific
ous aspiration has only a diagnostic
priapism. Repeated aspirations, injecn with intracavernous sympathomi-
4
Similar results have been reported by others (Savoca, 2004; Alexander, 2006). Normal postembolization erectile
function
has been
From
the Division of Urology,
Creighton University Medical Center and University of
NebraskaNuman,
Medical Center; 2008).
and Division of Urology, Department of Veterans Affairs
reported in 75% to 86% of patients (Cakan, 2006;
Nebraska Western Iowa Healthcare System, Omaha, Nebraska
It should be noted that a single treatment
embolizaReprint of
requests:
Rei K. Chiou, M.D., Ph.D., Division of Urology, Creighton
Center, 601 North 30th Street, Suite 3700, Omaha, NE 68131.
tion carries a recurrence rate of 30% toUniversity
40%Medical
(Ciampalani,
E-mail: chiou@creighton.edu
formed when distal shunting procedures have failed to
resolve the priapism. The efficacy of shunting procedures
in resolving priapism and the outcome of preserving
erectile function have varied among reports. Some investigators have reported very disappointing outcomes using
commonly performed shunting procedures.1 We have
previously reported on a new surgical technique involving the saphenous vein graft and the penile cavernosaldorsal vein (CD) shunt.2,3 In the present study, we have
reviewed our clinical experience of treating 16 patients
with priapism using this new shunt procedure and examined the sexual function outcome of these patients.
MATERIAL AND METHODS
We performed a retrospective chart review of 16 consecutive
patients with priapism who were treated with a penile CD shunt
from July 1997 to December 2007 (Table 1). In addition to
16'
EUROPEAN UROLOGY 56 (2009) 1033–1038
1035
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duration of the priapism.
engaging in sexual intercourse, no complications
!  Timing a challenge
International
Journal of Impotence
Research (2011)were
23, 158–164
corporal wash-out without a prosthesis being
inserted.
The corpora
the removal of an otherwise perfectly functioning inflatable
the others had not
shunt operations had been performed
(Fig. 4).>48
This manoeuvre
resulted
!  Min
hrs, up
to 3 weeks
resumed sexual activity
yet
due
to a variety
of reasons.
International
Journal
of Impotence
Research (2011)
23, 158–164
in rapid detumescence in all cases. The corpora were washed extensively
& 2011 Macmillannecrosis
Publishers Limited
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Histology confirmed
of the
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continuous closure of the corporotomy
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priapism:
our
and
sutures. The operation was easily
performed
andexperience
usually took <60
min. review of the literature
Table 2. Postoperative infections occurred in three patients
No drain was used and the catheter removed the following day. Patients
1
2
2
2
O Sedigh1, L Rolle1, CLA Negro1, C Ceruti1, M Timpano1,(6%)
E Galletto
, K each
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,
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hadARTICLE
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ORIGINAL
received intravenous antibiotics for 3 d 3and were then 3discharged on 1oral
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three
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1
SSCVD per l’ Andrologia, SCDU Urologia, AOU San Giovanni
Battista di Torino,
Torino, one
Italy; 2Infertility
and having had two shunt
operation,
with
patient
encouraged to cycle the device
early to prevent cylinder encasement
Reproductive Health Research Center, Reconstructive Urology, Shaheed Beheshti Medical Science University,
3
Tehran,
Iran
and
Hamad
Medical
Corporation
and
University
Hospital,
Doha,
Qatar
and subsequent deformity from the ensuing corporal fibrosis. Sexual
procedures. In all cases, the complication was managed
intercourse was allowed at 6 wk postoperatively.
by removing the implants, followed by a successful
Sexual Medicine
A cohort of 20 patients with delayed priapism reinsertion
who underwent of
treatment
at the Emergency
a 8malleable
prosthesis 6 mo later.
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our
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, C12
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was
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in
patients,
in 6 of , E Galletto , K Soltanzadeh , H A
Of these, 16 cases suffered from a low-flow priapism.
A total of surgery
6 cases were
managed
non3.
Results
3
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elective
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Prostheses were easily implanted in all patientsthese
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meanprocedure
operative timewas
of 94an
min.
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intraoperative complications and no infection were registered. All patients with an inflatable
prosthesis
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prosthesis. One patient
in
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t.com
complained
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in penile sensibility
All patientsinflatable
were
SSCVD
per Function
l’ Andrologia,
SCDU Urologia, AOU San Giovanni Battista di Torino, Torino, Italy; 2
satisfied with the results of surgery (International
Indexhad
of Erectile
Questionnaire-5,
who
an inflatable
penile
prosthesis
inserted developed
After
a value
of
j o u r n aintraoperative
l h o m e p a g ecomplications.
: w w w . e u r o pQ5
ea
nu
rmedian
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.follow-up
co
Reproductive
Health
Research
Center,
Urology, Shaheed Beheshti Medical Scienc
mean
allm
were
successfully
engaging
in
satisfactory
sexual
intercourses.
E U R O P E A N U R O L O G Y 5 6 3( 2 0 0 9 ) 1 0 3 3 – 1 0Reconstructive
38
significant were
loss of penile
length,
neither apical
erosion
nor deformity,
extrusion was recorded.
Early
a
penile
first
noticed
when
the and
device
was Hospital, Doha, Qatar
15.7 mo (4–60 mo), 96% of theNo
patients
fully
satisfied
Tehran,
Iran
and
Hamad
Medical
Corporation
University
a, prosthesis is a simple and a
of a penile
safe
procedure
in patientsa,with
ischemic
priapism, b, Rowland Rees a,
*,
Davidinsertion
J.
Ralph
,
Asif
Muneer
Alex
Freeman
Giulio
Garaffa
which failed
respondpatient
to conservative
Early insertion
of a first
prosthesis
helps at
to 6 wk postoperatively. A
inflated
for
the
time
with the results of the surgery,
withto one
onlymanagement.
a
a
maintain
adequate penile length,
resolve priapismMinhas
and, in the long term, it results in high
, Sukbinder
Andrew
N. Christopher
magnetic resonance imaging (MRI) scan of the penis
rates.penile curvature.
moderately satisfied due to asatisfaction
residual
International Journal of Impotence Research (2011) 23, 158–164; doi:10.1038/ijir.2011.23;
a
v
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but that who underwent treatment at the
St. Peter’s
Hospitals
and
Urology, London,
United Kingdom
Overall, 42 patients were
regularly
engaged
published
online
9The
June
2011in ofsexual
cohort
of 20 patients
with delayed
50 w
pts
wInstitute
refractory
ischemic
priapism
Department
j o u r n a(84%).
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pb a
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oneacademic
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between January 2002 and April 2010 w
intercourse
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Keywords: priapism of penis and clitoris; penile prosthesis; genital lengthening/girth enhancement
Of complication
these, 16 caseswas
suffered
from conservatively,
a low-flow priapism. A total of 6 cases were ma
inflating.
This
managed
!  43 received malleable
prosthesis
surgery
surgically,
10 required
shunt
surgery, and reduced
of these 5 were treated by early penile prosth
since the degree
of curvature
was
progressively
Article info
Prostheses were easily implanted in all patients with a mean operative time of
!  7 received IPP (wAbstract
less
edema)
unrelated
to, sexual
stimulation.
Typically,
only
Introduction
with
regular
cycling
of
the
device.
intraoperative
the corpora cavernosa
are affected. complications
Ischemic (veno- and no infection were registered. All patients with a
Sexual Medicine
The two
who
had
short
distally
longer
Article history:
Background:
Ischaemic
(IP),
which
is
refractory
tohad
conventional
medical
prosthesis
complained
a rods
reduction
in
penile
sensibility
that lasted 3 months. All pa
occlusive,
low patients
flow) priapism
priapism
is
a non-sexual,
Ischemic
priapism is a relatively rare sexualpersistent
erection
characterized
by
or no
function-threatening
andrological
emergency, with an
Accepted Duration
September
18, 2008
satisfied
with the
results
of the
surgery
(International
Index of Erectile Function Ques
and
surgical intervention,
results
in little
necrosis
corpus
cavernosum smooth
24-720h
(mean
209h)
implants
inserted
electively.
cavernous blood flow and abnormal cavernous
incidence of 1.5 per 100 000 person-year.1 Ischemic
Q5distal
mean
valuedevelop
4), acidotic).
and
all
were
successfully
Published
of from newborn to
muscle.
These
eventually
a variable
degree
of corporal
smooth in satisfactory sexual i
blood
gases patients
(hypoxic,
hypercarbic
and
Impending
erosion
occurred
in three
patients
with engaging
priapism
can online
occur atahead
all ages,
Nopresents
significant
loss
ofdysfunction
penile
length,
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apical erosion nor extrusion was reco
The fibrosis
corpora that
cavernosa
are rigid
and tender
to
print with
on October
1, 2008
elderly,
an undesirable,
rigid and painful erection,
muscle
as erectile
and
penile
shortening.
malleable
implants,
one
of
whom
had
undergone
the
palpation. Patients
typicallyofreport
pain. A
variety
which persists
in the absence
of sexual
stimulation,
96%
“fully
satisfied”
insertion
a penile
prosthesis
is a simple and safe procedure in patients with ischem
& 2011 Macmillan Publishers Limited All rights reserved 0955-9930/11
easily dilated with Hegar’s dilators, taking care distally when www.nature.com/ijir
previous
implant
reasons,
EUROP
E A N U R O Lfor
O G Y personal
56 (2009) 1
0 3 3 – 1 0 3 8and
Early insertion of inflatable prosthesis for intractable
priapism: our experience and review of the literature
! 
! 
The Immediate Insertion of a Penile Prosthesis for Acute
! 
To evaluate
thecontribute
long-term
of etiological
factors may
to outcome
failure of of patients who have undergone
not being relieved by either ejaculation or orgasm. Objectives:
Ischaemic Priapism
which
respond
toaconservative
management.
insertion of a prosthe
Keywords:
the detumescence
mechanism
intoprosthesis
this
condition.
American Urological Association guidelines
the immediate
insertion
offailed
a penile
as
treatment for an
acute episodeEarly
of
2,3
Ischemic priapism
is an emergency.
Resolution
of length,
maintain
adequate
penile
define
priapism
as a persistent penile erection, of
Ischaemic
priapism
IP refractory
to medical
therapy or shunt
surgery.
Sexual Medicine
ischemic priapism
is characterized
44 h in! 
duration,
that continuesrate
hours beyond,
or is
Revision
24%
satisfaction
rates.by the penis
Penile prosthesis
resolve priapism and, in the long term, it resu
returning
flaccid,
non-painful
However,
Design,
setting,
participants:
A total
of 50inpatients presented with prolonged
Table
2to–aand
Revision
surgery state.
performed.
International
Journal
of Impotence
Research (2011) 23, 158–164; doi:10.1038/
a
b penile edema,
a
many cases, persistent
ecchymosis
tissuesmooth
that
was
unresponsive
to
conventional
treatment.
Unsuccessful shunt surgery
David J. Ralph a,*, GiulioCorporal
, Asif Muneer a, IPAlex
, Rowland
Rees
Garaffa
and Freeman
partial erections
can
occur,
and it9may
mimic
published
online
June
2011,
Type
of
procedure
No.
of
Correspondence:
Dr
O
Sedigh,
ASO
San
Giovanni
Battista,
muscle
necrosis
had
been
performed
in
13
patients.
All
patients
had
evidence
ofpatients
cavernosal smooth
unresolved
priapism.
Resolution
of
priapism
can
be
a
a
per l’Andrologia, C.so
Bramante 88/90, Torino
, Sukbinder
Minhas
Andrew N. ChristopherSSCVD
verified
by measurement
of cavernous
blood gases
Fibrosis
muscle
necrosis
and, therefore,
underwent
an immediate insertion of a penile
10126,
Italy. of the corpora
orRemoval
blood flow
measurement
bypriapism
color duplex
of prosthesis
for infection
3
Keywords:
of ultrapenis and clitoris; penile
prosthesis; genital lengthening/girth e
E-mail:
dr.sedigh@libero.it
4
cavernosa
prosthesis
in exchange
the
acute
sonography.
a
Elective
to setting.
a three-piece device
6
We of
present
our experience
the treatment
of refractory
St. Peter’s Hospitals and The Institute
Urology,
London,inUnited
Kingdom
surgery
In the longMean
term,
up toduration
25% of patients
with in hours, intraoperative and postischemic
priapism
with
early
inflatable
penile
prosthesis
Measurements:
age,
of
priapism
Revisionpriapisms
for erosion
3
b
ischemic
induce erectile dysfunction.3
Department of Histopathology, UCLH,
United Kingdom
insertion.
operative
complications,
thepriapism
surgicalis outcome,
Cylinders
too short when
Indeed,
especially
not ade- and patients’ 2satisfaction were
Received 16 February 2011; revised 4 April 2011; accepted
quately
and
promptly
treated,
histopathological
30 April 2011; published online 9 June 2011
Autoinflation
1
recorded.
unrelated to, sexual stimulati
Fig. 2 – Severe oedema of the shaft after aspiration.
ResultsIntroduction
and limitations: A malleable penile prosthesis was inserted in 43 patients
a,
a
a
b
a
the corpora
cavernosa are affec
Abstract
and a three-piece inflatable implant in was inserted in 7 patients; a subsequent
Article info
occlusive,
low flow) priapism
Ischemic
priapism is a relatively rare sexualelective
exchange
in 6
a
a of a malleable to an inflatable device was performed
persistent erection characteriz
function-threatening andrological emergency, with
an
Article history:
Background: Ischaemicpatients.
priapism (IP), which is refractory to conventional
medical
1
cavernous
blood flow and a
Ischemic
incidence
offollow-up
1.5 per of100
000moperson-year.
After
a
median
15.7
(4–60
mo),
42
patients
had
already
Accepted September
18, 2008
and surgical intervention, results
in necrosis
of at
theall
corpus
cavernosum
smooth
a
blood
priapism
cansexual
occur
ages,
from infection
newborn
to
resumed
successful
intercourse.
Prosthesis
occurred
in threegases (hypoxic, hyperc
St. Peter’s Hospitals and The Institute of Urology, London,
United
Kingdom
Published online
ahead of
muscle. These patients eventually
a variable degree
ofpainful
corporal
smooth The corpora cavernosa are r
elderly, develop
with an undesirable,
rigid and
erection,
b
Department
of Histopathology, UCLH, United Kingdom patients (6%), which was managed by explantation and delayed reinsertion.
print on October
1, 2008
Patients typically re
which
in
the revision
absence
of sexual
stimulation,
muscle fibrosis that presents
as erectile
dysfunction
andsurgery.
penile
shortening.
A further
sixpersists
patients
needed
No
patient
complained palpation.
of penile
2,3
being
relieved
either
ejaculation
or orgasm.
Objectives: To evaluateshortening,
the not
long-term
outcome
of
patients
who96%.
have
undergone of etiological factors may con
and the
overall by
satisfaction
rate was
the detumescence mechanism
American
Urological
Association
guidelines
The
immediate
of a penile
for acute
Keywords:
the immediate insertionConclusions:
of a penile
prosthesis
asinsertion
a treatment
for anprosthesis
acute
episode
of refractory
Ischemic
define
priapism
as
a
persistent
penile
erection,
of
ischaemic
priapism
is
a
simple
and
successful
procedure
that
treats
the
acute priapism is an emerg
Abstract
Ischaemic priapism
Article info
IP refractory to medical
therapy
surgery.
ischemic
44ash or
in shunt
duration,
that continues
beyond,
is occur
episode
well
as the inevitable
erectile hours
dysfunction
thatorwill
with priapism is characte
The Immediate Insertion of a Penile Prosthesis for Acute
Ischaemic Priapism
David J. Ralph *, Giulio Garaffa , Asif Muneer , Alex Freeman , Rowland Rees ,
Andrew N. Christopher , Sukbinder Minhas
17'
2013%04%02'
Case 1
!  Patient achieved detumescence with Quackles
shunt
!  Partial recovery of erectile function
!  D/C home after 24h of sustained flaccidity
Ischemic Priapism- Outcomes
!  The longer the episode, the less likely for
preservation of erectile function
!  Pryor (1982)- > 24h = > 90% ED rate
!  Kulmala (1996)- < 24h = 92% erectile function
!  Bennett and Mulhall (2008)- 39 pts treated for
ischemic priapism
!  100% had spontaneous erections if < 12h
!  78% if between 12-24h
!  44% between 24-36h
!  0% if > 36h
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2013%04%02'
Research/Future therapies
Research/Future therapies
TGF-b1 neutralizing antibodies decrease the fibrotic effects of
ischemic priapism
International Journal of Impotence Research (2004) 16, 492–497
1
O Sanli , A Armagan
and A Kadioglu1*
1
1 Nature Publishing
1
2
& 2004
Group 1All
reserved
0955-9930/04
, E Kandirali
, B Ozerman2, I Ahmedov
, Srights
Solakoglu
, A Nurten
, M Tunç1$30.00
, V Uysal1
www.nature.com/ijir
1
Istanbul Faculty of Medicine, University of Istanbul, Istanbul, Turkey; and 2Institute of Experimental Medicine,
University of Istanbul, Istanbul, Turkey
The objective of this study was to evaluate the possible role of transforming growth factor beta 1
(TGF-b1) 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 þ ab (group 2), priapism with 24 h (group 3), priapism with 24 h þ 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-b1 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, histopatho-
19' fib
TGF-b1 neutralizing antibodies decrease the
ischemic priapism
2013%04%02'
Ischemic PriapismQuestions?
Case 2- “He’s back”
!  32 yo M
!  6 previous ED visits “low-flow priapism”
!  Always responded to irrigation/phenylephrine.
!  Denies drug use, no medications, negative
hematologic work-up, no history of trauma.
!  Diagnosed with recurrent idiopathic ischemic
priapism.
20'
2013%04%02'
Case 2
!  Presents with 5 hour history of painless erection.
!  Corporal bodies tumescent, but not fully erect
!  High-flow priapism suspected.
!  How many of past visits were high flow?
High-Flow Priapism
!  Persistent erection due to unregulated cavernosal
arterial inflow.
!  Typically corpora tumescent but not rigid.
!  Usually not painful.
!  Rare compared to LFP
!  Natural history is resolution (vs. ED)
21'
2013%04%02'
Etiology
!  Straddle injury
!  Coital trauma
!  Blunt trauma to penis/perineum
!  Pelvic fracture
!  Needle laceration
!  Vascular erosions (malignant)
!  Post procedure (DVIU, Nesbit)
Pathophysiology – High
Flow Priapism
!  Trauma/Injury leads to disruption of cavernous arterial
anatomy.
!  Creates arteriolar-sinusoidal fistula/shunt and increased
flow into cavernosa.
!  Veno-occlusive mechanism intact- Cavernous environment
does not become ischemic.
!  Once correctly diagnosed, does not require emergent
intervention.
!  62% resolve with conservative tx (ice, compression), no
studies comparing vs angiography
22'
to demonstrate the presence and extent of tissue thrombus and corporal smooth muscle infarction. Ralph (2009)
used MRI in the prospective management of 50 patients with
refractory ischemic priapism failing medical/surgical management
from 24 to 72 hours. Patients underwent MRI to characterize the
extent of smooth muscle necrosis before placement of penile prosthesis (Fig. 25–6A and B). The third role for MRI would be in the
imaging of corporal metastasis mimicking priapism, or
causing true ischemic priapism by obstruction of venous outflow.
MEDICAL TREATMENTS
Ischemic Priapism
Historically, first aid was applied by the patient or recommended
by a health practitioner unfamiliar with the hemodynamics of
priapism; these interventions included ejaculation, ice packs, cold
baths, and cold water enemas. Each of these remedies was thought
to end erection by inducing vasoconstriction. Some historical
reports advised voiding and exercise. Oral sympathomimetic drugs
(etilefrine, pseudoephedrine, phenylpropanolamine, and terbutaline) have been reported to effectively reverse prolonged erection
(<4 hours) initiated by intracavernous injection therapies with
efficacies of 28% to 36% (Lowe, 1993). Lowe and Jarow (1993)
compared oral terbutaline with pseudoephedrine or placebo in 75
patients with prolonged erection induced by intracavernous injection of Alprostadil; they reported detumescence in 38% of cases
following terbutaline, 28% following pseudoephedrine, and 12%
following placebo. In a follow-up study Priyadarshi (2004) specifically investigated the efficacy of oral terbutaline in the management of prolonged erection following intracavernous injections
(papaverine/chlorproamazine); he administered oral terbutaline
5 mg or placebo to men with persisting erection for more than 2.5
hours. Detumescence was acheieved in 42% and 15% of cases,
respectively, treated with terbutaline/placebo. Terbutaline treatment was unsuccessful in 58% of cases; all of those patients
responded to intracavernous injection of an α-adrenergic. In this
author’s experience, when diagnostic injections result in prolonged erections with duration from 2 to less than 4 hours, aspiration may not be necessary. An ultrafine needle and 1-mL syringe
(phenylephrine 200 µg) may be used for single injection of
α-adrenergic.
Oral agents are not recommended in the management
of acute ischemic priapism (>4 hours). The recommended
initial treatment of ischemic priapism is the decompression of the corpora cavernosa by aspiration. Aspiration
will immediately soften the erection and relieve pain.
Aspiration alone may relieve priapism in 36% of cases.
The AUA Guidelines Panel (2003) advised that there were not
sufficient data to conclude that aspiration followed by saline
intracorporal irrigation was any more effective than aspiration
alone (Montague, 2003). Subsequently, Ateyah (2005) reported
that a combination of corporal blood aspiration and cold saline
irrigation effectively terminated priapism in 66% of cases compared with aspiration alone (24%). Data to support the efficacy
of cold saline are limited. Aspiration should be repeated
until no more dark blood can be seen coming out from
the corpora and fresh bright red blood is obtained. This
process leads to a marked decrease in the intracavernous pressure, relieves pain, and resuscitates the corporal
environment removing anoxic, acidotic, and hypercarbic blood. A single, large-bore, 19-gauge needle should be
inserted at the peno-scrotal junction at 3 or 9 o’clock, to avoid
piercing the dorsal neurovascular bundle. The surgeon should
compress the penile shaft between the thumb and first digit,
just below the 19-gauge needle, aspirating the shaft until it is
soft. Leaving the needle in place, the shaft is permitted to refill.
Compression is reapplied and aspiration repeated. These maneuvers may need to be serially repeated. Several small, empty
syringes should be available (3-mL to 12-mL syringes).
Corporal aspiration, if unsuccessful, should be followed by α-adrenergic injection or irrigation. Aspiration
followed by the intracavernous injection of sympathomimetic drugs is recommended by the AUA Guidelines
Panel, 2003 (Montague, 2003). Sympathomimetic drugs (phenylephrine, etilephrine, ephedrine, epinephrine, norepinephrine,
metaraminol) cause cavernous smooth muscle (CSM) contraction.
In the laboratory, normal CSM preparations from humans, rabbits,
and rodents show concentration-dependent contractions on exposure to phenylephrine, if the corporal environment is well oxygenated and has a normal pH (Broderick, 1994; Muneer, 2008).
Broderick and Harkaway (1994) described time-dependent changes
in the corporal environment beginning within 6 hours of persistent erection (Broderick, 1994) in humans. Animal models of
2013%04%02'
Case 2- Colour Doppler
Ultrasound
Demonstrated
increased venous
flow to the distal/
proximal penis,
and increased
arterial flow in left
corporal body
A
B
Figure 25–5. A, Examination of the crural bodies is required when searching for arterial sinusoidal fistula following straddle injury. B, Color
Doppler image of arterial sinusoidal fistula of left cavernous artery.
Angiography
Angiography of left
pudendal artery
demonstrating fistula
between pudendal
artery and cavernosa.
Patient under went
angio-embolization of
left penile artery with
autologous blood and
gel foam with complete
resolution and normal
erectile function with 2
years follow up
23'
2013%04%02'
Treatment of High-Flow
Priapism
!  Expectant management (+/- ice, compresses)
!  Androgen blockade (Lue, 2010)
!  7/7 treated for 2-6 months leuprolide
!  Angiography/Embolization- preservation of erectile
function in 75-86%
!  More on this by Dr. MacHan
!  Surgical ligation of fistula
Radiology and Priapism
!  Thank you to Dr. MacHan
for speaking about the
radiologic aspects in
diagnosis and treatment
of priapism.
24'
2013%04%02'
Embolization For High
Flow Priapism
!
!
Lindsay!Machan,!MD!
University!of!British!Columbia!
!Vancouver,!British!Columbia!
T
h
e
!
!
i
m
a
!
High Flow Priapism
• 
Post injury
• 
• 
Straddle injury
Sexual misadventure
•  Rupture of a cavernosal artery
with unregulated flow into the
lacunar spaces
•  Painless
•  Distension cavernous bodies
•  Corpus spongiosum flaccid
25'
2013%04%02'
32 yr old carpenter
partial erection x 6 weeks
•  Gelfoam embolization
•  3 months – normal erectile function
36 yr old laborer pipe factory
partial erection x 3 ½ weeks
•  Steep RAO
•  Embo until flaccid
•  3 months – pharmacologic assisted
erections
26'
compared oral terbutaline with pseudoephedrine or placebo in 75
patients with prolonged erection induced by intracavernous injection of Alprostadil; they reported detumescence in 38% of cases
following terbutaline, 28% following pseudoephedrine, and 12%
following placebo. In a follow-up study Priyadarshi (2004) specifically investigated the efficacy of oral terbutaline in the management of prolonged erection following intracavernous injections
(papaverine/chlorproamazine); he administered oral terbutaline
5 mg or placebo to men with persisting erection for more than 2.5
hours. Detumescence was acheieved in 42% and 15% of cases,
respectively, treated with terbutaline/placebo. Terbutaline treatment was unsuccessful in 58% of cases; all of those patients
responded to intracavernous injection of an α-adrenergic. In this
author’s experience, when diagnostic injections result in prolonged erections with duration from 2 to less than 4 hours, aspiration may not be necessary. An ultrafine needle and 1-mL syringe
(phenylephrine 200 µg) may be used for single injection of
α-adrenergic.
33 yr old university professor
cycling injury
A
soft. Leaving the needle in place, th
Compression is reapplied and aspira
vers may need to be serially repe
syringes should be available (3-mL t
Corporal aspiration, if unsu
lowed by α-adrenergic injection
followed by the intracavernous
mimetic drugs is recommended
Panel, 2003 (Montague, 2003). Sym
ylephrine, etilephrine, ephedrine, ep
metaraminol) cause cavernous smoot
In the laboratory, normal CSM prepar
and rodents show concentration-depe
sure to phenylephrine, if the corporal
ated and has a normal pH (Brode
Broderick and Harkaway (1994) descri
in the corporal environment beginn
tent erection (Broderick, 1994) in
2013%04%02'
B
Figure 25–5. A, Examination of the crural bodies is required when searching for arterial sinusoidal fistula followin
Doppler image of arterial sinusoidal fistula of left cavernous artery.
33 yr old university professor
cycling injury
•  Gelfoam embo
•  Minimal recovery of erectile function @ 3 mo
27'
2013%04%02'
33 yr old university professor
cycling injury
46 yr old ski instructor
Straddle injury
Embolization with autologous blood clot
28'
2013%04%02'
UBC Experience
•  14 patients
–  21 – 53 years
–  2 days to 3 months post injury
• 
• 
• 
• 
Autologous clot – 4
Gelfoam – 5
Microcoils + gelfoam – 5
Detumescence - 9 / 10 recorded
UBC Experience
•  14 patients
–  21 – 53 years
–  2 days to 3 months post injury
•  FU on 8 patients
–  Spontaneous erections – 4
–  Pharmacologically assisted – 3
–  No erections - 1
29'
2013%04%02'
Embolic agents reported for
high flow priapism
• 
• 
• 
• 
• 
autologous clots
Gelfoam
N-butyl-cyanoacrylate
Microcoils
Recurrence of priapism 30–40% within 1
month*
Urology 2002;59:110–3
Priapism - treatment by
embolization - Bastuba et al*
• 
• 
• 
• 
7 patients
4 - 126 days
7 / 7 successfully embolized
6 / 7 regained full erectile function
–  2 weeks to 5 months
*JUrol 1994, 151:11231-1237
30'
2013%04%02'
5 year follow up embolization for
priapism
•  9 embolizations in 6 patients
–  traumatic 5
–  idiopathic 1
•  Gelfoam - 9 arteries
•  Gelfoam and microcoils – 1
•  Microcoils alone – 1
•  Baba et al Acta Radiol 2007
5 year follow up embolization for
priapism
•  No complications recorded
•  6 / 6
–  detumescence
–  normal erectile function
–  Baba et al Acta Radiol 2007
31'
2013%04%02'
Conclusion – Embolization for
high flow priapism
•  Embolize until detumescence
•  Temporary agents preferable
•  Return of erectile function possible
–  ?related to delay of Rx from injury
32'