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Alternative Approaches to the Management of Priapism
SEXUAL FUNCTION AND DYSFUNCTION
studies have not defined potency clearly and, therefore, much of the information may not be as accurate and useful as one would prefer. Tom F.Lue, M.D.
Alternative Approaches to the Management of Priapism J. D. DEHOLL, P. A. SHIN,J. F. ANGLEAND W. D. STEERS, Departments of Urology and Radiology, University of Virginia School of Medicine, Charlottesville, Virginia Int. J. Impotence Res., 1 0 11-14, 1998
Herein we describe the use of intracavernous methylene blue (MB), a guanylate cyclase inhibitor, or internal pudendal artery embolization for the treatment of priapism. Eleven patients with priapism were treated from 1993-1996. Etiologies of priapism included PGEVpapaverine (3), trazodone (21, and sickle cell disease (11, in the other five cases the causes the cause was unknown. The average duration of priapism was 27 h for all patients (6-72 h). Five patients who failed intracavernous MB or an alpha-adrenergic agonist, underwent unilateral or bilateral pudendal artery embolization. The average duration of priapism for patients undergoing embolization was 43 h. Sixty-seven percent of the patients treated with MB responded with immediate detumescence. One-hundred percent of patients with priapism secondary to intracavernous injection therapy or trazodone responded. Of the five patients who underwent embolization, 40% achieved immediate pain relief and subsequent detumescence. The three non-responders exhibited a partial detumescence over 47-72 h. After follow-up of one year embolization available for only two patients revealed that one regained potency while the other remained impotent. These results confirmed that MB is effective for pharmacologically-induced priapism. Embolization is a less invasive option for refractory priapism, although results are less than satisfactory in men with priapism of several days duration.
Editorial Comment: The authors have proposed a new approach to the management of low flow priapism by intracavernous injection of methylene blue, a guanylate cyclase inhibitor that prevents the increase of cyclic guanosine monophosphate production in patients with priapism. Those patients in whom the conservative medical treatment failed underwent embolization of the internal pudendal arteries to relieve painful erections. The traditional treatment of low flow priapism is aspiration and intracavernous injection of an (Y adrenergic agonist solution. When there is a failure to respond shunting surgery is performed. The authors are to be congratulated for proposing such a drastic change from the traditional approach. Intracavernous injection of methylene blue to block guanosine cyclase activity is novel and rational. After aspiration of old blood in the corpora cavernosa, most of the time one would see a recurrence of priapism with fresh blood. This situation is an iatrogenic high flow priapism probably due to the release of large amounts of acidic products, such as endothelial derived relaxation factors or nitric oxide, which in turn stimulates the production of cyclic guanosine monophosphate and persistent muscle relaxation. Administration of methylene blue theoretically would stop this pathway and seems rational. Arterial embolization is somewhat more controversial. However, it is a standard treatment for patients with high flow priapism due to a ruptured cavernous artery or neurogenic priapism. Since the underlyhg pathology of low flow priapism is inadequate venous drainage, I would perform a shunting operation rather than embolization of the internal pudendal artery. Nevertheless, further studies are needed to investigate whether arterial embolization is a better approach than the traditional shunting procedure. Tom F.Lue, M.D.
Repetition of Color Doppler Ultrasonography: Is it Necessary? E. AKKUS, B. ALICI, H. O z m , S. ATAUS,M. BA~ISGIL AND H. HATTAT, Department of Urology, Sexual Dysfunctions Center, Cerrahpasa School of Medicine, Istanbul University, Istanbul, Turkey Int. J. Impotence Res., 1 0 51-55, 1998 The aim of the study was to determine whether any difference would occur in peak systolic velocity (PSV) and end diastolic velocity (EDV) measurements of color Doppler ultrasonography (CDU) between proximal and distal segments of the cavernous arteries obtained at different times. Twenty-six cases have undergone CDU three times in weekly intervals. PSV and EDV measurements of cavernous arteries were obtained both proximally and distally. The results have shown that statistically there was no difference between each measurement obtained on either sides at three different tests. (ANOVA PSV F(2-50) = 0.63, EDV F(2-50) = 0.81). Four of the 26 cases had different PSV results and six cases had different EDV results in three CDU tests. There was a statistical difference in measurements between proximal and distal segments of the
1947
studies have not defined potency clearly and, therefore, much of the information may not be as accurate and useful as one would prefer. Tom F.Lue, M.D.
Alternative Approaches to the Management of Priapism J. D. DEHOLL, P. A. SHIN,J. F. ANGLEAND W. D. STEERS, Departments of Urology and Radiology, University of Virginia School of Medicine, Charlottesville, Virginia Int. J. Impotence Res., 1 0 11-14, 1998
Herein we describe the use of intracavernous methylene blue (MB), a guanylate cyclase inhibitor, or internal pudendal artery embolization for the treatment of priapism. Eleven patients with priapism were treated from 1993-1996. Etiologies of priapism included PGEVpapaverine (3), trazodone (21, and sickle cell disease (11, in the other five cases the causes the cause was unknown. The average duration of priapism was 27 h for all patients (6-72 h). Five patients who failed intracavernous MB or an alpha-adrenergic agonist, underwent unilateral or bilateral pudendal artery embolization. The average duration of priapism for patients undergoing embolization was 43 h. Sixty-seven percent of the patients treated with MB responded with immediate detumescence. One-hundred percent of patients with priapism secondary to intracavernous injection therapy or trazodone responded. Of the five patients who underwent embolization, 40% achieved immediate pain relief and subsequent detumescence. The three non-responders exhibited a partial detumescence over 47-72 h. After follow-up of one year embolization available for only two patients revealed that one regained potency while the other remained impotent. These results confirmed that MB is effective for pharmacologically-induced priapism. Embolization is a less invasive option for refractory priapism, although results are less than satisfactory in men with priapism of several days duration.
Editorial Comment: The authors have proposed a new approach to the management of low flow priapism by intracavernous injection of methylene blue, a guanylate cyclase inhibitor that prevents the increase of cyclic guanosine monophosphate production in patients with priapism. Those patients in whom the conservative medical treatment failed underwent embolization of the internal pudendal arteries to relieve painful erections. The traditional treatment of low flow priapism is aspiration and intracavernous injection of an (Y adrenergic agonist solution. When there is a failure to respond shunting surgery is performed. The authors are to be congratulated for proposing such a drastic change from the traditional approach. Intracavernous injection of methylene blue to block guanosine cyclase activity is novel and rational. After aspiration of old blood in the corpora cavernosa, most of the time one would see a recurrence of priapism with fresh blood. This situation is an iatrogenic high flow priapism probably due to the release of large amounts of acidic products, such as endothelial derived relaxation factors or nitric oxide, which in turn stimulates the production of cyclic guanosine monophosphate and persistent muscle relaxation. Administration of methylene blue theoretically would stop this pathway and seems rational. Arterial embolization is somewhat more controversial. However, it is a standard treatment for patients with high flow priapism due to a ruptured cavernous artery or neurogenic priapism. Since the underlyhg pathology of low flow priapism is inadequate venous drainage, I would perform a shunting operation rather than embolization of the internal pudendal artery. Nevertheless, further studies are needed to investigate whether arterial embolization is a better approach than the traditional shunting procedure. Tom F.Lue, M.D.
Repetition of Color Doppler Ultrasonography: Is it Necessary? E. AKKUS, B. ALICI, H. O z m , S. ATAUS,M. BA~ISGIL AND H. HATTAT, Department of Urology, Sexual Dysfunctions Center, Cerrahpasa School of Medicine, Istanbul University, Istanbul, Turkey Int. J. Impotence Res., 1 0 51-55, 1998 The aim of the study was to determine whether any difference would occur in peak systolic velocity (PSV) and end diastolic velocity (EDV) measurements of color Doppler ultrasonography (CDU) between proximal and distal segments of the cavernous arteries obtained at different times. Twenty-six cases have undergone CDU three times in weekly intervals. PSV and EDV measurements of cavernous arteries were obtained both proximally and distally. The results have shown that statistically there was no difference between each measurement obtained on either sides at three different tests. (ANOVA PSV F(2-50) = 0.63, EDV F(2-50) = 0.81). Four of the 26 cases had different PSV results and six cases had different EDV results in three CDU tests. There was a statistical difference in measurements between proximal and distal segments of the
1947