Ultrasound guidance for real-time management of acute ischemic priapism.

Ischemic priapism is a relatively uncommon genitourinary condition that, if left untreated, can lead to permanent erectile dysfunction. Detumescence should ideally be attained within the first 36 h of onset to avoid irreversible fibrosis and necessary surgery. Opportunities to practice medical management of this condition are scarce, and the risk of iatrogenic injury of vessels, nerves, and urethra can be significant if performed blind. Visualizing these structures through ultrasonography can reduce the risk of injury and aid in the confirmation of drug delivery. This novel utilization of ultrasound guidance in active treatment can help improve physician confidence and success in managing this rare and urgent condition. To our knowledge, this is the first report of point-of-care ultrasound-guided penile nerve block used to manage pain associated with priapism. We present a 44-year-old male presenting with a painful erection lasting for eight hours. Penile doppler ultrasound was performed concurrent with medical management of priapism, with successful detumescence and discharge.

[Non-ischemic priapism (post-traumatic arteriovenous fistula of the right cavernous body) in the background of Landusy-Dejerine myopathy].

Landouzy-Dejerine myopathy (Facial-shoulder-shoulder myodystrophy) is a disease which causes weakness of the muscles of the shoulder girdle, back and hip muscles, which predisposes patients to an increased risk of injury and disability. The article presents a clinical observation of non-ischemic priapism, which developed as a result of perineal trauma with the formation of a fistula of the right cavernous body in a patient against the background of facial shoulder-shoulder myodystrophy. Methods for the differential diagnosis of this condition are also discussed.

The Diagnosis and Management of Recurrent Ischemic Priapism, Priapism in Sickle Cell Patients, and Non-Ischemic Priapism: An AUA/SMSNA Guideline.

PURPOSE: Priapism is a persistent penile erection that continues hours beyond, or is unrelated to, sexual stimulation and results in a prolonged and uncontrolled erection. Given its time-dependent and progressive nature, priapism is a situation that both urologists and emergency medicine practitioners must be familiar with and comfortable managing. METHODOLOGY: A comprehensive search of the literature on acute ischemic priapism and non-ischemic priapism (NIP) was performed by Emergency Care Research Institute for articles published between January 1, 1960 and May 1, 2020. A search of the literature on NIP, recurrent priapism, prolonged erection following intracavernosal vasoactive medication, and priapism in patients with sickle cell disease was conducted by Pacific Northwest Evidence-based Practice Center for articles published between 1946 and February 19, 2021. Searches identified 4117 potentially relevant articles, and 3437 of these were excluded at the title or abstract level for not meeting inclusion criteria. Full texts for the remaining 680 articles were ordered, and ultimately 203 unique articles were included in the report. RESULTS: This Guideline provides a clinical framework for the treatment (non-surgical and surgical) of NIP, recurrent ischemic priapism, and priapism in patients with sickle cell disease. The treatment of patients with a prolonged erection following intracavernosal vasoactive medication is also included. The AUA guideline on the diagnosis of priapism and the treatment of acute ischemic priapism was published in 2021. CONCLUSIONS: All patients with priapism should be evaluated emergently to identify the sub-type of priapism (acute ischemic versus non-ischemic) and those with an acute ischemic event should be provided early intervention when indicated. NIP is not an emergency and treatment must be based on patient objectives, available resources, and clinician experience. Management of recurrent ischemic priapism requires treatment of acute episodes and a focus on future prevention of an acute ischemic event. Sickle cell disease patients presenting with an acute ischemic priapism event should initially be managed with a focus on urologic relief of the erection; standard sickle cell assessment and interventions should be considered concurrent with urologic intervention. Treatment protocols for a prolonged, iatrogenic erection must be differentiated from protocols for true priapism.

Acute Ischemic Priapism: An AUA/SMSNA Guideline.

PURPOSE: Priapism is a persistent penile erection that continues hours beyond, or is unrelated to, sexual stimulation and results in a prolonged and uncontrolled erection. Given its time-dependent and progressive nature, priapism is a situation that both urologists and emergency medicine practitioners must be familiar with and comfortable managing. Acute ischemic priapism, characterized by little or no cavernous blood flow and abnormal cavernous blood gases (ie, hypoxic, hypercarbic, acidotic) represents a medical emergency and may lead to cavernosal fibrosis and subsequent erectile dysfunction. MATERIALS AND METHODS: A comprehensive search of the literature was performed by Emergency Care Research Institute for articles published between January 1, 1960 and May 1, 2020. Searches identified 2948 potentially relevant articles, and 2516 of these were excluded at the title or abstract level for not meeting inclusion criteria for any key question. Full texts for the remaining 432 articles were reviewed, and ultimately 137 unique articles were included in the report. RESULTS: This Guideline was developed to inform clinicians on the proper diagnosis and surgical and non-surgical treatment of patients with acute ischemic priapism. This Guideline addresses the role of imaging, adjunctive laboratory testing, early involvement of urologists when presenting to the emergency room, discussion of conservative therapies, enhanced data for patient counseling on risks of erectile dysfunction and surgical complications, specific recommendations on intracavernosal phenylephrine with or without irrigation, the inclusion of novel surgical techniques (eg, tunneling), and early penile prosthesis placement. CONCLUSIONS: All patients with priapism should be evaluated emergently to identify the sub-type of priapism (acute ischemic versus non-ischemic) and those with an acute ischemic event should be provided early intervention. Treatment of the acute ischemic patient must be based on patient objectives, available resources, and clinician experience. As such, a single pathway for managing the condition is oversimplified and no longer appropriate. Using a diversified approach, some men may be treated with intracavernosal injections of phenylephrine alone, others with aspiration/irrigation or distal shunting, and some may undergo non-emergent placement of a penile prosthesis.

Patient Education Is Associated With Reduced Delay to Presentation for Management of Ischemic Priapism: A Retrospective Review of 123 Men.

BACKGROUND: Adverse outcomes secondary to ischemic priapism (IP) are associated with time to presentation and management. AIM: To characterize patterns in presentation delay as a function of etiology and patient education regarding IP risk. METHODS: Following institutional review board approval, charts of IP patients presenting to our institution from 2010 to 2020 were reviewed. One episode of IP per patient was included for analysis. OUTCOMES: Priapism duration in patients presenting with IP. RESULTS: We identified 123 unique patients with IP. Common etiologies included erectogenic intracavernosal injection (24%), trazodone (16%), and other psychiatric medications (16%). Patients with sickle cell anemia or trait and intracavernosal injection-related IP presented sooner than idiopathic cases and those from psychiatric medication (P < .001). Etiology and provider education on IP risk were associated with presentation ≥ 24 hours. Upon multivariate analysis, only a lack of provider education was independently associated with presentation ≥ 24 hours. CLINICAL IMPLICATIONS: Men who received provider-based education on the risk of IP associated with their condition or medication regimen were more likely to seek prompt medical attention for IP and, therefore, less likely to require surgery. STRENGTHS & LIMITATIONS: This manuscript represents one of the largest series on priapism, an area of urologic practice in need of more evidence-based guidance. The numbers are not inflated by including multiple episodes per patient, and the data collected include etiology, time to presentation, and treatment. Limitations include a retrospective chart review study design at a single institution. CONCLUSION: Educational initiatives on the risk of IP associated with particular disease states and medications should target at-risk individuals, as well as prescribers of medications associated with IP. Dutta1 R, Matz1 EL, Overholt TL, et al. Patient Education Is Associated With Reduced Delay to Presentation for Management of Ischemic Priapism: A Retrospective Review of 123 Men. J Sex Med 2021;18:385-390.

Rare Disorders of Painful Erection: A Cohort Study of the Investigation and Management of Stuttering Priapism and Sleep-Related Painful Erection.

BACKGROUND: A chief complaint of men with stuttering priapism (SP) and sleep-related painful erections (SRPE) is bothersome nocturnal erections that wake them up and result in poor sleep and daytime tiredness. SP and SRPE are rare entities that have similarities in their clinical features, but that require different treatment approaches. AIM: The aim of this study was to describe the clinical features, investigations, and effective management options for men with SP and SRPE. METHODS: Retrospective cohort study of 133 men with bothersome nocturnal painful erections that attended a tertiary andrology unit between 2004 and 2018. These men were divided into 3 groups. Group 1 (n = 62) contains men with sickle cell SP; group 2 (n = 40) has men with non-sickle cell SP and group 3 (n = 31) contains men with SRPE. OUTCOME: To determine the effectiveness of medical and surgical treatments for men with SP and SRPE. RESULTS: Hydroxyurea and automated exchange transfusion were the most effective treatment options in the sickle cell SP group. Hormonal manipulation and α-agonist therapies were effective in both SP cohorts (groups 1 and 2). Baclofen was the most effective therapy in men with SRPE. For men who failed medical management, implantation of a penile prosthesis resulted in complete resolution of the symptoms in men with SP (groups 1 and 2). Surgical management (penile prosthesis implantation and embolization) did not improve the patients' symptoms in the SRPE group. CLINICAL IMPLICATIONS: This study differentiates between sickle cell SP, non-sickle cell SP, and SRPE and describes effective treatment options for each group. STRENGTHS & LIMITATIONS: This is the largest cohort study for both SP and SRPE, respectively. Limitations include its retrospective nature and single-center experience. CONCLUSION: Managing men in these 3 groups differently and in accordance with the proposed treatment pathway provides a more structured approach to the management of these rare conditions. Johnson M, McNeillis S, Chiriaco G, et al. Rare Disorders of Painful Erection: A Cohort Study of the Investigation and Management of Stuttering Priapism and Sleep-Related Painful Erection. J Sex Med 2021;18:376-384.

Risk Factors for Surgical Shunting in a Large Cohort With Ischemic Priapism.

BACKGROUND: Ischemic priapism is treated with a stepwise algorithm, but some patients may benefit from immediate shunt placement. AIM: To identify risk factors for surgical shunt placement in a large series of patients with ischemic priapism. METHODS: We identified all patients presenting to our institution with ischemic priapism from January 2010 to December 2018. Multivariable was performed to assess risk factors for surgical shunting. Receiver operating characteristic curve analysis (Youden Index) was used to assess which cutoff time for the duration of priapism was most predictive requiring shunting. OUTCOMES: We assess risk factors for surgical shunting and what duration of priapism was most predictive of requiring a shunt. RESULTS: We identified a total of 169 ischemic priapism encounters from 143 unique patients, of which 26 (15%) encounters resulted in a surgical shunt. Patients treated with a shunt had longer priapism durations than those without (median 36 vs 10 hours, P < .001). Independent predictors of a surgical shunt on multivariate logistic regression were the duration of priapism in hours (odds ratio: 1.05, 95% confidence interval: 1.02-1.10; P < .001) and history of prior priapism (odds ratio: 3.15, 95% confidence interval: 1.03-9.60; P = .045). Receiver operating characteristic curve analysis using priapism duration to predict the need for shunt generated an area under curve of 0.83. A duration of 24 hours correlated to a sensitivity of 0.77 and specificity of 0.90. CLINICAL IMPLICATIONS: These results can be used to counsel future patients and assist in the decision-making process for providers. STRENGTHS & LIMITATIONS: This is one of the largest series of priapism in the literature. Most (74%) of the priapism were due to intracavernosal injections so the results may not be generalizable to populations with different priapism etiologies. CONCLUSION: In this study of 169 priapism encounters, we found that the priapism duration and history of prior priapism were independent predictors of surgical shunt placement. These results can aid urologists in the counseling and decision-making process of these challenging cases. Zhao H, Dallas K, Masterson J, et al. Risk Factors for Surgical Shunting in a Large Cohort With Ischemic Priapism. J Sex Med 2020;17:2472-2477.

Anatomic and Functional Outcome Following Distal Shunt and Tunneling for Treatment Ischemic Priapism: A Single-Center Experience.

BACKGROUND: Ischemic priapism (IP) is a urologic emergency that requires early intervention. The main aim of IP treatment is to relieve the cavernosal pressure and provide erectile function. AIM: The aim of this study was to determine the correlation between preoperative risk factors (patient's age, duration of priapism, preoperative erectile function) and postoperative erectile dysfunction (ED). METHODS: This retrospective study consisted of 25 patients diagnosed with refractory IP between 2009-2017. The diagnosis of IP was confirmed by medical history, physical examination, and cavernosal blood gas analysis. All of the patients underwent the T-shunt procedure ± tunneling after a failed initial intervention. RESULTS: The mean age at the time of the IP diagnosis was 46.84 years (range 23-77). The average follow-up time of the study population was 40.4 months (range 3-114), and the median time from the occurrence of IP to surgery was 58 hours (range 24-240). In all cases, rapid resolution of the erection was achieved with the T-shunt ± tunneling procedure. In 1 patient, priapism recurred after 12 hours. Postoperative ED was reported by 16 (84.21%) patients, with degrees of mild, mild to moderate, and severe in 6, 1, and 9 of these cases, respectively. During the follow-up, the mean International Index of Erectile Function-5 (IIEF-5) score was 12.68 (range 5-23). Only 3 (15.78%) patients achieved successful sexual intercourse without any treatment. 6 (31.5%) patients required the aid of phosphodiesterase type 5 inhibitors, and 1 (5.26%) patient required the aid of a vacuum erection device. The 9 (47.36%) patients with severe ED failed to respond to medical treatment and were considered candidates for a penile implant. According to Kendall's tau-b correlation coefficient analysis, there was a positive correlation between the preoperative and postoperative IIEF-5 scores (P = .005), whereas the patient's age and duration of priapism were negatively correlated with the postoperative IIEF-5 score (P = .016 and P = .046, respectively). CLINICAL IMPLICATIONS: Treatment options of IP should be discussed with patients in terms of both preoperative erectile function and the duration of priapism. STRENGTHS & LIMITATIONS: The small sample size and retrospective nature of this study were the main limitations. CONCLUSIONS: Despite high success and low complication rates of T-shunt surgery, the rate of undisturbed erectile function is only 14.6%. The patient's age, the existence of preoperative ED, and the duration of priapism are associated with postoperative IIEF-5 scores. Ortaç M, Çevik G, Akdere H, et al. Anatomic and Functional Outcome Following Distal Shunt and Tunneling for Treatment Ischemic Priapism: A Single-Center Experience. J Sex Med 2019;16:1290-1296.

Penoscrotal Decompression-Promising New Treatment Paradigm for Refractory Ischemic Priapism.

BACKGROUND: For prolonged ischemic priapism, outcomes after distal shunt are poor, with only 30% success for priapic episodes lasting longer than 48 hours. AIM: To present a novel, glans-sparing approach of corporal decompression through a penoscrotal approach for cases of refractory ischemic priapism (RIP) after failed distal shunt procedures. METHODS: We describe the technique and present our initial experience with penoscrotal decompression (PSD) for treatment of RIP after failed distal shunt. We compared outcomes of patients with RIP undergoing surgical management using PSD or malleable penile prosthesis (MPP) placement after failed distal penile shunt procedures (2008-2017). OUTCOMES: Our initial experience showed favorable outcomes with PSD compared with early MPP placement in patients with RIP whose distal shunt failed. RESULTS: Of 14 patients with RIP undergoing surgical management after failed distal penile shunt procedures, all patients presented after a prolonged duration of priapism (median = 61 hours) after which the priapism was refractory to multiple prior treatments (median = 3, range = 1-75) including at least 1 distal shunt. MPP was inserted in 8 patients (57.1%), whereas the most recent 6 patients (42.9%) underwent PSD. All patients with PSD (6 of 6, 100%) were successfully treated with corporal decompression without additional intervention and noted immediate relief of pain postoperatively. In contrast, 37.5% of patients (3 of 8) undergoing MPP after failed distal shunt procedures required a total of 8 revision surgeries during a median follow-up of 41.5 months. The most common indications for revision surgery after MPP placement included distal (4 of 8, 50%) and impending lateral (2 of 8, 25%) extrusion. CLINICAL IMPLICATIONS: PSD is a simple, effective technique in the management of RIP after failed distal shunt procedures with fewer complications than MPP placement. STRENGTHS AND LIMITATIONS: Although PSD is effective in the management of RIP after failed distal shunt procedures, long-term assessment of erectile function and ease of future penile prosthetic implantation is needed. CONCLUSION: Corporal decompression resolves RIP through a glans-sparing approach and avoids the high complication rate of prosthetic insertion after failed distal shunt procedures. Fuchs JS, Shakir N, McKibben MJ, et al. Penoscrotal Decompression-Promising New Treatment Paradigm for Refractory Ischemic Priapism. J Sex Med 2018;15:797-802.

The Hemodynamic Effects of Intracavernosal Phenylephrine for the Treatment of Ischemic Priapism.

AIM: We sought to evaluate whether the administration of phenylephrine (PE) at concentrations higher than those described in guidelines resulted in any significant changes in vital signs or impacted outcomes. METHODS: After receiving institutional review board approval, we retrospectively reviewed the charts of patients presenting to our emergency department between May 1, 2014, and August 15, 2016, using International Classification of Diseases, Ninth Edition and Internation Classification of Disease, Tenth Edition diagnosis codes for priapism. Treatment was reviewed, including corporal aspiration/irrigation, injection of PE, and shunt procedures. Vital signs were compared before and after treatment with PE. Baseline variables were explored with categorical data analysis (chi-squared tests, t-tests, and Mann-Whitney nonparametric tests). Where feasible, linear regression was used to evaluate outcomes. MAIN OUTCOME MEASURE: Detumescence and changes in blood pressure and heart rate. RESULTS: We identified 74 different patient encounters of acute priapism. The median age was 36.5 years (interquartile range [IQR] = 27-47), and the median time to presentation was 5.4 hours (IQR = 4.0-9.6). 62 percent of cases were due to drug-induced priapism. In 58 (74%) encounters, patients received PE. The median dose of PE given was 1000 µg (IQR 500-2,000). Univariate regression found no association between PE dose and change in patient heart rate or blood pressure. A statistically significant decrease in heart rate (HR) (-4.2 BPM), systolic blood pressure (BP) (-1.8 mm Hg), and diastolic BP (-5.4 mm Hg) was noted. Fifty-three of 58 (91%) patients receiving PE experienced detumescence at the bedside, 2 required shunting in operating room, and 3 refused treatment and left against medical advice. No adverse events occurred. CONCLUSION: We frequently treat patients with high doses of PE and seldom notice adverse effects, typically resulting in resolution of priapism without any additional procedures. Careful administration of high doses of intracavernosal PE in patients presenting with priapism does not appear to significantly affect heart rate or blood pressure and may help prevent further ischemic damage and achieve detumescence effectively and efficiently. Sidhu AS, Wayne GF, Kim BJ, et al. The hemodynamic effects of intracavernosal phenylephrine for the treatment of ischemic priapism. J Sex Med 2018;15:990-996.

[Conservative management of traumatic priapism in paediatric patients]. / Manejo conservador del priapismo traumático en la edad pediátrica.

INTRODUCTION: High-flow priapism is infrequent in pediatric patients. It is mostly secondary to perineal trauma resulting in laceration of a penile artery and the formation of an arterio-cavernous fistula. It does not constitute a medical emergency in itself, and allows conservative management awaiting spontaneous resolution. CLINICAL CASE: A six-year-old boy with painless persistent erection preceded by perineal trauma. Ultrasound imaging confirmed the clinical suspicion of high flow priapism secondary to arterio-cavernous fistula. After adopting a conservative approach, the patient presented progressive detumescence, as well as ultrasound resolution one month after the episode. COMMENTS: In high-flow priapism, venous drainage of the penis is preserved. The classical approach in adults is based on therapeutic angiography, which presents greater technical complexity and the risk of iatrogenic hypoxia in pediatric patients.

INTRODUCCION: El priapismo de alto flujo es una entidad infrecuente en la edad pediátrica. Es, en su mayoría, secundario a traumatismo perineal que provoca la laceración de una arteria peneana y formación de una fístula arterio-cavernosa. No constituye una emergencia médica, permitiendo un manejo conservador a la espera de su resolución espontánea. CASO CLINICO: Niño de seis años con erección persistente e indolora tras traumatismo perineal. El diagnóstico ecográfico confirma la sospecha de priapismo de alto flujo secundario a fístula arteria-cavernosa. Tras manejo conservador, presenta detumescencia progresiva y resolución ecográfica al mes del episodio. COMENTARIOS: En el priapismo de alto flujo el drenaje venoso del pene se encuentra conservado. El manejo clásico en adultos se fundamenta en la angiografía terapéutica, de mayor complejidad técnica y riesgo de hipoxia iatrogénica en el paciente pediátrico.

Prevention of recurrent ischemic priapism with ketoconazole: evolution of a treatment protocol and patient outcomes.

INTRODUCTION: The management of recurrent ischemic priapism (RIP) is not clearly defined. Ketoconazole (KTZ) is used to treat RIP and produces a temporary hypogonadal state to suppress sleep-related erections (SREs), which often evolve into episodes of ischemic priapism in this population. AIM: We review our experience to prevent RIP using KTZ and present our outcomes using a decreased dose regimen. METHODS: A retrospective chart review and phone survey of 17 patients with RIP was performed. KTZ inhibits adrenal and gonadal testosterone production with a half-life of 8 hours. By suppressing testosterone levels, SREs are interrupted. We compared our previous protocol of three times daily (TID) KTZ dosing with prednisone for 6 months with our current regimen of initiating KTZ 200 mg TID with prednisone 5 mg daily for 2 weeks and then tapering to KTZ 200 mg nightly for 6 months. MAIN OUTCOME MEASURES: The primary outcome was the prevention of RIP using KTZ. Secondary outcomes included side effects secondary to KTZ use and patient satisfaction. RESULTS: All men experienced daily or almost daily episodes of prolonged, painful erections prior to starting KTZ. The mean number of emergency room (ER) visits per patient prior to starting KTZ was 6.5. No patient required an ER visit for RIP while on KTZ. Sixteen of 17 patients (94%) had complete resolution of priapism while on KTZ with effects noted immediately after starting therapy and no reported sexual side effects attributed to KTZ. One man stopped therapy after 4 days because of nausea/vomiting. Fourteen of 16 men eventually discontinued KTZ after a median duration of 7 months. Twenty-nine percent reported no recurrent priapic episodes after discontinuing. A total of 78.6% had partial or complete resolution of symptoms persisting after KTZ was discontinued with a mean post-treatment follow-up of 36.7 months. CONCLUSION: No reliable effective preventative therapy has been identified for RIP. In our relatively sizable single-center experience, KTZ appears to be a reasonably effective, safe, and inexpensive treatment to prevent RIP while preserving sexual function. We now recommend our tapered dose regimen listed above. After 6 months, we recommend stopping the medication as we have found a majority of patients will not need to resume nightly KTZ.

Refractory Ischemic Priapism Following Hemodialysis.

Priapism, characterized by prolonged and painful penile erection, is a rare urological emergency with diverse etiologies. We present a case of refractory ischemic priapism following hemodialysis in a 57-year-old male with a history of type II diabetes mellitus, hypertension, and end-stage renal disease. Despite standard conservative management, the patient's condition persisted, necessitating penile distal shunting through an intracorporeal dilatation plus Al-Ghorab corporoglandular shunt. Blood gas analysis of corpus cavernosum blood revealed severe acidosis and hypoxemia, emphasizing the systemic impact of ischemic priapism. The patient's history of erythropoietin injections and the administration of heparin during dialysis emerged as potential contributors to priapism. We discuss the complex interplay between erythropoietin, coagulation cascade, and heparin in the context of priapism development. The case underscores the need for further research to understand the specific mechanisms contributing to priapism in patients undergoing hemodialysis.

Rapid adoption of penoscrotal decompression for ischemic priapism in private practice.

Refractory ischemic priapism is a difficult to treat clinical entity for which there are a host of shunt procedures identified, but no singular agreed upon technique for surgical therapy. Recent literature describes success using a penoscrotal decompression technique that uses a similar dissection of a penoscrotal penile prosthesis placement. We demonstrate that this technique is easily applicable in the private practice setting as it uses a familiar setup to most general urologists in our case report.

Severe penile necrotizing infection with subsequent glandular gangrene after distal corporal aspiration and irrigation procedure for ischemic priapism.

Necrotizing penile infection following ischemic priapism takedown is a rare complication. A 60-year-old man presented with 1-week history of green and pink purulent discharge, penile swelling, and inability to void. Computed tomography demonstrated gas and fluid accumulation within the corporal bodies, suggestive for bilateral penile necrotizing corporal infection with possibility of intra-corporal abscesses. The patient underwent extensive serial surgical debridement of the penile and corporal tissues which was complicated with poly-microbial tissue cultures, growing Candida albicans and Staphylococcus epidermidis. Despite maximal penile drainage, glans penis gangrene was developed to level of mid penile shaft necessitating a partial penectomy.

Interventional radiology: Diagnosis and treatment of post-traumatic nonischemic priapism: A case report.

Priapism is defined as a form of erectile dysfunction characterized by a prolonged and involuntary penile erection, either partial or complete, occurring without sexual stimulation and lasting for more than 4 hours. Its incidence is estimated to be 0.5-0.9 cases per 100,000 people per year. The most frequent form is ischemic priapism, results from paralysis of the cavernous smooth muscles, which are unable to contract, leading to the stagnation of hypoxic blood within the sinusoidal spaces. Characterized by a painful rigid and sustainable erection. Non-ischemic priapism constitutes a rare entity, unlike the former, this type is typically painless. It is caused by an excessive influx of blood into the penis without a concomitant increase in outgoing blood flow. Blunt trauma is the most commonly reported etiology. And finally, recurrent priapism is characterized by recurrent episodes of prolonged erection and can be challenging to treat, often requiring long-term management to prevent recurrences. We report a case of high-flow priapism in a 10-year old child, secondary to a cavernous arterial fistula following a straddle injury during sports activity. It was suspected clinically and confirmed by ultrasound-Doppler, then successfully treated radiologically with highly selective embolization, with very satisfactory postoperative outcomes.

Contemporary management of ischemic priapism: A 12-year population-based analysis from a large US database.

BACKGROUND: Priapism is a urological condition characterized by a persistent erection. The management varies based on its subclassifications. Despite established clinical guidelines for ischemic priapism, there is a lack of large-scale research focused on patient characteristics and management strategies. OBJECTIVES: To analyze the contemporary management of ischemic priapism in the US, exploring patient demographics and clinical characteristics, as well as predictors of erectile dysfunction (ED) and penile prosthesis implantation (PPI). MATERIALS AND METHODS: We performed a retrospective analysis of the PearlDiver Mariner database, reviewing records from 2010-2021. Adult males diagnosed with ischemic priapism were included. Data analysis covered demographic, clinical variables, and management strategies. Predictors of de novo ED and PPI were evaluated using multivariable logistic regression analysis. RESULTS: Of 36,120 patients, most (93%) received only medical management, and a minority underwent surgical interventions (penile shunt surgery [PSS], PPI or both). Medical management was typically effective, as 67.08% of the patients in this group experienced only one episode of priapism. However, de novo ED occurred in 16.57% of these patients. The majority of patients undergoing PPI had an inflatable prosthesis (81%). Older age (odds ratio, OR 1.02), the presence of metabolic diseases (OR 1.39), neurogenic disorders (OR 1.72), solid pelvic malignancies (OR 1.09), and multiple episodes of priapism were identified as significant predictors of de novo ED (all p < 0.05). Similarly, age (OR 1.03), the presence of metabolic diseases (OR 1.23), solid pelvic malignancies (OR 1.99), and multiple episodes of priapism were associated with higher likelihood of PPI (all p < 0.05). CONCLUSION: Most cases of ischemic priapism are managed with the medical therapy. Less than 3% of patients with ischemic priapism receive PPI, and when this occurs an inflatable prosthesis is favored. Age, specific comorbidities, and multiple episodes of priapism appear to be significant predictors of ED and PPI.

Treatment of Refractory Idiopathic Ischemic Priapism: A Case Report and Literature Review.

Priapism is a medical condition characterized by a prolonged period of penile rigidity in the absence of external sexual stimulation. Three broad categories exist for this condition: ischemic (low venous flow), nonischemic (high arterial flow), and recurrent (stuttering). Ischemic priapism is a urological emergency necessitating immediate medical attention. This literature aims to highlight the importance of prompt workup and treatment of ischemic priapism in order to prevent irreversible damage to the penis, such as erectile dysfunction and impotence. This case report presents a 35-year-old patient who developed refractory ischemic priapism in the absence of an underlying causative agent. Fortunately, through pharmacological and surgical interventions, the patient was successfully treated with complete resolution of his symptoms.

Treatment of Refractory Ischemic Priapism: A Case Report and Literature Review.

Recurrent priapism is a rare and poorly known entity. It is defined by recurrent episodes of painful erections that last less than four hours. The etiology is similar to that of ischemic priapism. Episodes lasting more than four hours require immediate intervention to prevent penile fibrosis and subsequent erectile dysfunction. A 42-year-old male with no significant chronic-degenerative history was referred to our medical center from his second-level medical unit after a 56-hour history of ischemic priapism with the persistence of tumescence despite medical and surgical treatment. Upon interrogation, the patient reported stuttering (recurrent) episodes of painful erections lasting approximately three to four hours, not associated with sexual activity or arousal, in the past two years, with spontaneous resolution. He denied the use of psychotropics or drugs for erectile dysfunction. As a palliative measure, a left saphenous-cavernous (Grayhack) bypass was performed, with a 90% decrease in tumescence and total resolution of pain during the first 12 hours. There is little information and treatment recommendations for patients with recurrent priapism, and even less for patients who are refractory to conventional medical and surgical treatment. Recurrent or stuttering priapism is a condition with a low incidence and a pathophysiology compatible with low-flow priapism. It is difficult to treat and has a poor prognosis in terms of erectile function. Likewise, it is mostly associated with the use of psychotropic drugs such as cocaine and marijuana, medications for erectile dysfunction such as phosphodiesterase inhibitors, prostaglandin E1 analogues, and hematological malignancies such as sickle cell anemia and multiple myeloma. The aim of this article is to share our experience with a patient refractory to multiple medical and surgical treatments.

Gabapentin-Induced Priapism.

Priapism is defined as an erection that lasts longer than four hours, is unrelated to sexual interest or stimulation, and is unrelieved by orgasm. The ischemic subtype is a urologic emergency and is often caused by medication side effects, most notably selective serotonin reuptake inhibitors and trazodone. We present the case of ischemic priapism thought to be caused by the recent initiation of gabapentin.