Priapism

Priapism is a prolonged pathological erection that is not associated with sexual arousal, and lasts more than 4 hours, not durable after intercourse.

[1], [2], [3], [4]

Epidemiology

The prevalence of priapism is 0.11-0.40% among patients of urological clinics.

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Symptoms of the priapism

Symptoms of priapism are different, and depend on the pathogenetic type.

Ischemic priapism

The ischemic (veno-inclusive, low-flow) variant constitutes 95% of cases of priapism. This is usually a rigid painful erection that occurs as a result of stagnation of blood and a decrease in the partial pressure of oxygen in the cavernous bodies of the penis (pO2 <30 mmHg. PCO2> 60 mmHg pH <7.3) . This type of priapism is characterized by a minimum blood flow velocity in the cavernous bodies or complete stopping of it. In the development of this disease, assistance must be provided urgently. In the absence of treatment, the outcome of ischemic priapism becomes fibrous cavernous tissue of the penis, proceeding with a clinical picture of erectile dysfunction (impotence).

Ultrastructural changes in the cavernous tissue of the penis develop after 12 hours, and after a day the lesions become irreversible. With a duration of priapism over 24 h, erectile dysfunction develops in 89% of cases.

Various blood diseases ( leukemia, sickle-cell anemia, erythrocytosis) can lead to ischemic priapism , neoplastic CNS processes, narcotic and alcohol intoxication. Priapism develops in 30% of patients with prostate cancer, 30% of the bladder and 11% of patients  with kidney cancer. Sometimes priapism occurs with malaria and rabies, often in an acute period. Priapism can also be triggered by the use of various medications (psychotropic drugs, androgens, antidepressants, alpha-blockers, antihypertensives, anticoagulants), including injectable intracavernoscopy (pharmacological priapism).

Non-ischemic priapism

Non-ischemic (arterial, high-flow) priapism develops, usually as a result of damage to the cavernous arteries of the penis or as a result of a perineal or penile injury that leads to the formation of an arteriolacunary fistula. This type of priapism is not accompanied by acidosis and does not require urgent provision of emergency medical care. The prognosis from the position of preservation of the erectile function is favorable. Symptoms of non-ischemic priapism include a permanent incomplete rigidity of the penis, developing, usually, a few hours after the injury. Against the background of sexual or genital stimulation, a full-fledged erect erection develops. Pain is absent. In some cases, spontaneous resolution of priapism can occur several days or months after the onset.

In a number of cases, the etiological factor in the development of both ischemic and nonischemic priapism can not be established, and then we are talking about the idiopathic form of priapism.

Recurrent Priapism

Recurrent (recurrent, nightly intermittent) priapism is a type of ischemic priapism. With this type of priapism, painful long erections alternate with short periods of detumescence. This type of priapism is poorly understood, occurs in diseases of the central nervous system and the peripheral nervous system, blood diseases, and can also be psychogenic.

Diagnostics of the priapism

Diagnosis of priapism is not difficult and is based on anamnestic data, examination data and palpation of the penis.

With intermittent priapism, complex diagnostics with the study of the central nervous system and the peripheral nervous system is necessary.

Laboratory diagnostics

• Clinical blood test.
• Determination of the gas composition of blood in the cavernous bodies of the penis.
• Dopplerography of the vessels of the penis, which in the case of non-ischemic priapism makes it possible to detect the presence of arterial fistula.

Differential diagnosis of priapism conducts on the basis of anamnesis, clinical data (examination of external genital organs), instrumental and laboratory studies.

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Treatment of the priapism

Treatment of priapism (non-ischemic form) can be expectant, or it may consist of performing selective arteriography with embolization of arterial fistula. In the future, the choice of treatment depends on the state of the erectile function.

Treatment of priapism (ischemic form) consists in carrying out complex emergency measures, primarily involving aspiration-irrigation therapy with the introduction of intracavernous alpha-adrenomimetics (epinephrine, phenylephrine norepinephrine), which increase the probability of arresting priapism in 43-81% of observations. It is advisable to use anticoagulants and sedatives concomitantly. Priapism, which develops against the background of blood diseases, is often stopped with active treatment of the underlying disease. During the entire period of conservative treatment of priapism, it is necessary to control blood pressure, heart rate, in some cases, an ECG is performed continuously. Trying to stop priapism with aspiration-irrigation therapy should be at least 1 hour.

Of course, it is necessary to take into account the duration of priapism - the effectiveness of conservative measures is minimal after 48 hours or more from the moment of onset of the disease.

Operative treatment of priapism

In the absence of the effect of conservative treatment, surgical treatment of priapism is shown, the principle of which is the creation of adequate venous drainage from the cavernous bodies of the penis. Most often, drainage is carried out through intact spongiform bodies with a preserved venous outflow.

• Percutaneous bypass (distal shunt). The essence of the method is the formation of a fistula between cavernous bodies and a spongy body. Operative intervention is performed under local anesthesia. A biopsy needle (Winter technique) or a scalpel (Ebbehoj technique) perform a puncture in the apical zone of cavernous bodies.
• Open shunting (distal shunt) - Al-Ghorab technique. In fact, this is a modification of the operation Winter. Under general anesthesia parallel to the coronal sulcus on the dorsal surface of the glans penis, access to the apical sections of the cavernous bodies. Acute way to form holes with a diameter of 5 mm. Cavernous bodies are washed with a solution of sodium heparin.
• The proximal shunt is the Quackles technique. This type of shunting is performed when the imposition of a distal spondyocavernous fistula is ineffective. Under the general anesthesia with the pre-installation of a urethral catheter, the midline (transverse scrotal or perineal) is the secretion of the belly shell of the cavernous bodies. Bilaterally, cavernous bodies are bilaterally formed into elliptical windows. A similar window is formed in the spongy body of the urethra. Cavernous bodies are washed with a solution of sodium heparin and form a spongiocavernous fistula.
• Sapheno-cavernous anastomosis is the technique of Grayhack. They are used quite rarely when the proximal shunt is ineffective.

Further management at priapism

In the postoperative period, patients with priapism should be prescribed anti-inflammatory and anticoagulant therapy with active monitoring of clotting rates during the day. In a remote postoperative period, it is advisable to carry out complex rehabilitation measures aimed at improving the perfusion of cavernous bodies, in order to prevent the development of erectile dysfunction (impotence).

Treatment of priapism (intermittent form) is a complex task, since priapism and its etiological and pathogenetic aspects have not been studied sufficiently. There are data on the successful use of therapeutic doses of digoxin and gonadotropic hormones. In several cases, complex treatment of priapism, including psychopharmacological and physiotherapy treatment and psychotherapy, is not unsuccessful.