Priapism Pp t

8/11/2019 Priapism Pp t

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Priapismus


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definition/background

Persistent painful purposeless erectionof the penis (or clitoris)

Frequently idiopathic Associated with some systemicdiseases

Sometimes seen after intra-cavernosalinjections


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Priapos (Priapus) was theGreek God of fertility who is

usually pictured with amassive erection.This painting was

discovered in the wall of atemple in Pompeii, destroyed

by the eruption of Mount Vesuvius in 79 AD. It shows

Priapos weighing his erection.


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Prostate Corpora cavernosa

Cross- section from The Visible Human Project


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Priapism - physiology

Penile erection generated by sensory stimulation of genitalia

spinal reflex arc - reflexogenicerectionafferent from penis through

pudendal nerve to sacral spinalerection center (S 2-S 3-S 4)efferent parasympathetic fibers

travel back in nervi erigentes and


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Priapism - physiologyPenile erection generatedby psychogenic stimuli

from higher braincenters

descend throughlateralcolumns andstimulatethoracolumbar andsacral spinalerectioncenters


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Nitric oxide - an endogenous vasodilator- is released from nerve endings and

endothelial cells and binds to receptorson smooth muscle of corpora cavernosaCyclic guanosine monophosphate

(cGMP) is formed, relaxing smoothmuscle and allowing engorgement


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Phosphodiesterase type 5 (PDE 5)catalyzes cGMP to GMP, leading to

reversal of the above processSildenafil (Viagra), a recently releaseddrug for erectile dysfunction, acts as a

PDE 5 inhibitor, helping to maintain aphysiologic erection


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Priapism - pathophysiology

Persistent erection of corporacavernosa due to disturbances in

detumescence mechanisms - i.e. inflow>> outflowCorpora spongiosum of the glans and

peri-urethral region unaffected


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Priapism - pathophysiology

Arterial high-flow - usually due torupture of cavernous artery and

unregulated flow into lacunar spaces -NOT generally painfulVeno-occlusive (low-flow) - full and

unremitting corporeal veno-occlusion


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Priapism - frequency

Internationally: no information availableIn the USA: High-flow rare, usually due to blunt

perineal injury or penetrating peniletrauma

Low-flow common in sludgingdisorders, especially sickle-celldisease (about 1/3 of males) andleukemic disorders


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Priapism - morbidity/mortality

Deaths have been reported in patientswith sickle cell disease and priapism,

but due to complications fromunderlying disease processMain morbidity is long-term impotence,

especially when diagnosis andtreatment are delayed


15/36Sickle Cell Disease


16/36Chronic Lymphocytic Leukemia (CLL)


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Priapism - demographics

Race - no predilection (although sicklecell disease, of course, is a condition of

the African American population)Sex - disease of males. Clitoralpriapism has been described rarely

Age - all ages, but peak in sickle cellpatients between 19 & 21 years


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Priapism - history

Arterial high-flow priapism may be delayed after acute injury

may be due to vessel spasm, orformation of clot, which is reabsorbed

less tumescent than venous priapism

less painful than venous priapism good long-term prognosis


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Fractured penis


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Priapism - history

Veno-occlusive priapism painful erection, present for hours to

days ask abouttrauma

drugs - therapeutic and illicitself-injectionsexual stimulation

ast histor of similar or


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Priapism - causes

Most common -IDIOPATHICOther causesinclude leukemia multiple myeloma sickle cell disease tumor infiltration thalassemia

spinal cord injury

recentMycoplasmainfection

amyloidosis black widow

spider bites

carbon monoxidepoisoning

recent heparinuse

-


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Priapism - causes

Caverject self-injection Urethralsuppository


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Priapism - causes

Vacuum pumps andother sexual aids


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Priapism - causes

psychotropic drugs phenothiazines

butyrophenoneshydralazineprazosin, labetolol,phentolamine andother -blockerstestosteronemetoclopramide

calcium-channelblockersanti-coagulantstamoxifenomeprazolehydroxyzinecocaine, marijuana,and ethanol


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Phoneutria nigriventer - "armed spider"


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Priapism caused by Phoneutria bite


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Priapism - physical exam

Erect or semi-erect penis with a flaccidglans

Search for signs of traumaSearch for other possiblesigns of sludging - florid

skin, petechiae,conjunctival injection


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Priapism - work-up

Lab studies: If no predisposing factors, a complete

blood count may help identify apreviously undiagnosed leukemiaImaging studies:

Selective penile angiography may behelpful in high-flow priapism

CT scan - ?useful in segmental disease


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Priapism - treatment

Arterial priapism - 4 options Mechanical: iced compression

Pharmacologic: -agonists (watch outfor systemic blood pressure rise)

Surgical: fistula ligation (usually leads

to impotence) Selective embolization: new

procedure with varying degrees of

success


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Priapism due to pharmacological agents terbutaline 5 mg po repeated in 15

minutes leads to resolution in about1/3 of patients intracavernous injection of -

adrenergicphenylephrine 100 to 500 mcg (put10 mg in 500cc NSS 20 mcg/ml.

Inject 10 to 20 cc every 5-10-


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Low-flow due to sickle cell disease hydration

alkalinization analgesia possible exchange transfusion to get

Hgb > 10 gm% and HbS


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Aspiration and irrigation for priapism lasting more than 2 hours

discuss with urologist if at all possible MUST warn patient treatment may

result in permanent impotence

conscious sedation may benecessary


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Local anesthetic or penile blockInsert 19-g butterfly into engorged

corpus cavernosum through the glansinto the distal portionMilk out old blood

Irrigate with salineElastic wrap (Ace) to flaccid penis


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Priapism - complications

Impotence: about 50% incidence Younger patients seem to do better

Fibrosis: related to tissue ischemia Makes prosthesis placement difficultGangrene: due to ischemia andinfection Suprapubic catheter may help avoid


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Priapism - complications

Fourniers gangrene

Priapism Pp t

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