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INTRACAVERNOSAL PHENYLEPHRINE FOR RECURRENT PRIAPISM: SELF-ADMINISTRATION BY DRUG DELIVERY IMPLANT
0022-5347/01/1655-1632/0 THE JOURNAL OF UROLOGY® Copyright © 2001 by AMERICAN UROLOGICAL ASSOCIATION, INC.®
Vol. 165, 1632, May 2001 Printed in U.S.A.
INTRACAVERNOSAL PHENYLEPHRINE FOR RECURRENT PRIAPISM: SELF-ADMINISTRATION BY DRUG DELIVERY IMPLANT DAVID J. RALPH,* EDOARDO S. PESCATORI,† GILES S. BRINDLEY
AND
JOHN P. PRYOR
From the Institute of Urology, University College London, London, United Kingdom KEY WORDS: penis, priapism; phenylephrine; infusion pumps, implantable
We describe an original technique to manage recurrent priapism refractory to oral treatment. CASE REPORT
A 28-year-old white man presented with a 3-year history of painful, nocturnal, prolonged erections. These erections occurred every night and lasted from 1 to 6 hours. Medical history included circumcision. The patient did not take any medication, and physical examination was normal. The etiology of the prolonged erections was unknown in that all hematological evaluations were normal and Doppler ultrasound excluded an arteriovenous malformation. Nocturnal penile tumescence monitoring confirmed a prolonged erection lasting for 4 hours. Treatment with 2.5 mg. procyclidine 3 times daily1 was unsuccessful as was 100 mg. cyproterone acetate taken at night. The surgical implantation of a penile drug delivery system to delivery phenylephrine was offered to the patient.2 Through a lateral penoscrotal incision the Brindley‡ drug delivery implant was placed with the cannula inserted into the lateral aspect of the right corpus cavernosum and sutured to the tunica albuginea with a nonabsorbable suture (see figure). The combined pump/reservoir was filled with Accepted for publication December 8, 2000. * Requests for reprints: The Institute of Urology and Nephrology, 48 Riding House St., London, United Kingdom W1W 7EY. † Current address: Cattedra di Urologia, Modena University, Modena, Italy, 41.100. ‡Brindley Surgical Devices, London, United Kingdom.
saline and positioned in a dependent position in the scrotum. The patient was discharged home the next day. At 1-month followup the saline solution in the reservoir was withdrawn and phenylephrine solution was instilled percutaneously. After an initial titration period, 50 mg. phenylephrine solution (10 mg./ml.) diluted with normal saline to a volume of 8 ml. was percutaneously instilled into the reservoir. The patient was instructed on how to squeeze the pump so that 1 squeeze delivered 0.13 ml. (0.8 mg.) phenylephrine solution into the corpus cavernosum. The patient used the device for 4 months and was successful in reversing the prolonged painful erections. DISCUSSION
Recurrent priapism is a rare condition that may cause significant pain and distress. Oral therapy with terbutaline, pseudoephedrine or digoxin is usually successful3 but when priapism persists, self-injection with ␣-adrenergic agents has been advocated.4 The latter is less than ideal, as the patient must always carry a syringe, needle and medication. More than 10 years have passed since the first report of an implantable drug delivery system for erectile dysfunction,5 and the latest version of such a device can be used for at least 3 years.2 A capsule may form around the intracavernous cannula but it seems that the infused drug can diffuse through this capsule into the erectile tissue. Therefore this side effect may delay the effect of the drug and this delayed onset of action increases with time. To our knowledge we report the first case describing the use of a drug delivery implant for the treatment of recurrent low flow priapism. At followup this approach appeared to be safe, effective and well accepted by our patient. REFERENCES
Latest version of Brindley penile drug delivery implant. Intracavernosal cannula segment (a) is 18 mm. long, has longitudinal ribs and longitudinal slit to facilitate corporeal insertion. Metal coated segment (b) allows placement of securing sutures. Reservoir (c) holds maximum volume of 8 ml. Compressing area (d) allows intracavernosal delivery of 0.13 ml. fluid with each squirt.
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1. Pryor, J. P. and Hehir, M.: The management of priapism. Br J Urol, 54: 751, 1982 2. Ralph, D. J., Brindley, G. and Pryor, J. P.: Penile drug delivery implants: long term followup. Presented at the second European Society of Impotence Research meeting, Amsterdam, The Netherlands, 1997 3. Lowe, F. C. and Jarrow, J. P.: Placebo-controlled study of oral terbutaline and pseudoephedrine in management of prostaglandin E1-induced prolonged erections. Urology, 42: 51, 1993 4. Levine, F. J., Saenz de Tejada, I., Payton, T. R. et al: Recurrent prolonged erections and priapism as a sequela of priapism: pathophysiology and management. J Urol, 145: 764, 1991 5. Desai, K. M., Gingell, J. C. and Floyd, T. J.: Preliminary report of a new concept in the treatment of erectile impotence using an implantable drug delivery system. Br J Urol, 60: 267, 1987
Vol. 165, 1632, May 2001 Printed in U.S.A.
INTRACAVERNOSAL PHENYLEPHRINE FOR RECURRENT PRIAPISM: SELF-ADMINISTRATION BY DRUG DELIVERY IMPLANT DAVID J. RALPH,* EDOARDO S. PESCATORI,† GILES S. BRINDLEY
AND
JOHN P. PRYOR
From the Institute of Urology, University College London, London, United Kingdom KEY WORDS: penis, priapism; phenylephrine; infusion pumps, implantable
We describe an original technique to manage recurrent priapism refractory to oral treatment. CASE REPORT
A 28-year-old white man presented with a 3-year history of painful, nocturnal, prolonged erections. These erections occurred every night and lasted from 1 to 6 hours. Medical history included circumcision. The patient did not take any medication, and physical examination was normal. The etiology of the prolonged erections was unknown in that all hematological evaluations were normal and Doppler ultrasound excluded an arteriovenous malformation. Nocturnal penile tumescence monitoring confirmed a prolonged erection lasting for 4 hours. Treatment with 2.5 mg. procyclidine 3 times daily1 was unsuccessful as was 100 mg. cyproterone acetate taken at night. The surgical implantation of a penile drug delivery system to delivery phenylephrine was offered to the patient.2 Through a lateral penoscrotal incision the Brindley‡ drug delivery implant was placed with the cannula inserted into the lateral aspect of the right corpus cavernosum and sutured to the tunica albuginea with a nonabsorbable suture (see figure). The combined pump/reservoir was filled with Accepted for publication December 8, 2000. * Requests for reprints: The Institute of Urology and Nephrology, 48 Riding House St., London, United Kingdom W1W 7EY. † Current address: Cattedra di Urologia, Modena University, Modena, Italy, 41.100. ‡Brindley Surgical Devices, London, United Kingdom.
saline and positioned in a dependent position in the scrotum. The patient was discharged home the next day. At 1-month followup the saline solution in the reservoir was withdrawn and phenylephrine solution was instilled percutaneously. After an initial titration period, 50 mg. phenylephrine solution (10 mg./ml.) diluted with normal saline to a volume of 8 ml. was percutaneously instilled into the reservoir. The patient was instructed on how to squeeze the pump so that 1 squeeze delivered 0.13 ml. (0.8 mg.) phenylephrine solution into the corpus cavernosum. The patient used the device for 4 months and was successful in reversing the prolonged painful erections. DISCUSSION
Recurrent priapism is a rare condition that may cause significant pain and distress. Oral therapy with terbutaline, pseudoephedrine or digoxin is usually successful3 but when priapism persists, self-injection with ␣-adrenergic agents has been advocated.4 The latter is less than ideal, as the patient must always carry a syringe, needle and medication. More than 10 years have passed since the first report of an implantable drug delivery system for erectile dysfunction,5 and the latest version of such a device can be used for at least 3 years.2 A capsule may form around the intracavernous cannula but it seems that the infused drug can diffuse through this capsule into the erectile tissue. Therefore this side effect may delay the effect of the drug and this delayed onset of action increases with time. To our knowledge we report the first case describing the use of a drug delivery implant for the treatment of recurrent low flow priapism. At followup this approach appeared to be safe, effective and well accepted by our patient. REFERENCES
Latest version of Brindley penile drug delivery implant. Intracavernosal cannula segment (a) is 18 mm. long, has longitudinal ribs and longitudinal slit to facilitate corporeal insertion. Metal coated segment (b) allows placement of securing sutures. Reservoir (c) holds maximum volume of 8 ml. Compressing area (d) allows intracavernosal delivery of 0.13 ml. fluid with each squirt.
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1. Pryor, J. P. and Hehir, M.: The management of priapism. Br J Urol, 54: 751, 1982 2. Ralph, D. J., Brindley, G. and Pryor, J. P.: Penile drug delivery implants: long term followup. Presented at the second European Society of Impotence Research meeting, Amsterdam, The Netherlands, 1997 3. Lowe, F. C. and Jarrow, J. P.: Placebo-controlled study of oral terbutaline and pseudoephedrine in management of prostaglandin E1-induced prolonged erections. Urology, 42: 51, 1993 4. Levine, F. J., Saenz de Tejada, I., Payton, T. R. et al: Recurrent prolonged erections and priapism as a sequela of priapism: pathophysiology and management. J Urol, 145: 764, 1991 5. Desai, K. M., Gingell, J. C. and Floyd, T. J.: Preliminary report of a new concept in the treatment of erectile impotence using an implantable drug delivery system. Br J Urol, 60: 267, 1987