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Priapism: Evaluation of Treatment Regimens
Vol. 112, ,July
THE .JocRNAL OF UROLOGY
Printed in U.S.A.
Copyright© 1974 by The Williams & Wilkins Co.
PRIAPISM: EVALUATION OF TREATMENT REGIMENS MOHAMMED E. DARWISH, BASSEM ATASSI
AND
SAMUEL S. CLARK*
From the Divisions of Urology, University of Illinois and West Side Veterans Administration Hospitals, Chicago, Illinois
done in 4 1 and a corporospongiosum shunt was done in 4, with 5 episodes of priapism. 2 - 4 Complications to management of these 21 episodes of priapism consisted of an arteriovenous fistula in i, pulmonary embolism in l 5 and urethrocutaneous fistula in 1 (14.3 per cent).
Priapism is a rare disease that presents a major treatment dilemma because of lack of a clear understanding of the pathophysiology. It is a disease of persistent, painful penile erection not necessarily related to sexual desire or stimulation and occurs in relatively young, sexually active male subjects. If left untreated priapism frequently results in impotence. While most cases are classified as idiopathic some are associated with specific disease entities, such as sickle cell trait, sickle cell anemia, leukemia, tumors of the lower urinary tract, inflammatory diseases of the prostate and trauma. A review of our patients seen during the last 7 years is presented herein.
RESULTS
There were 21 episodes of priapism reported in which flaccidity was ultimately reached in all, while only 10 (48 per cent) retained sexual potency (see figure). DISCUSSION
In order to intelligently treat this challenging condition, a clear understanding of the pathophysiology of priapism is essential. In 1930 Stieve 6 described muscular pillars or cushions within the vascular walls of the penis which were confirmed histologically in 1952 by Conti. 7 They postulated that these "polsters" acted as arterial and venous valves under the influence of the lumbar sympathetic nerves, which inhibited vasoconstriction and sacral parasympathetic nerves and caused arteriolar vasodilatation. In 1960 Hinman accepted this principle and indicated that the persistent erection led to increased carbon dioxide tension, hypoxia and, ultimately, fibrosis of the corpora cavernosa. s Newman and associates challenged this concept, suggesting that the primary etiological factor in erection, and thus in priapism, is the arterial flow rate. 9 Using a Doppler flowmeter Malvar and
MATERIALS AND METHODS
There were 22 patients with 23 episodes of priapism seen at our hospitals in 5,600 urological admissions from 1965 to 1972, an incidence of 0.4 per cent. Of these 22 patients 20 were available for review, consisting of 21 episodes of priapism. The age range of patients was from 10 to 61 years, with an average of 35.5 years, and the population consisted of 3 white and 17 black patients. Underlying causative factors were found in 9 patients, including 5 with sickle cell anemia, 3 with sickle cell trait and 1 with acute prostatitis. The remaining 11 patients had idiopathic priapism. Duration of symptoms prior to seeking medical advice varied from 16 to 144 hours, with an average of 65 hours. The presenting symptoms consisted of painful erection in 21 cases, edema of the penis in 4, difficulty in urination in 2 and dysuria with urethral discharge in 1. The presenting physical findings consisted of induration of the corpora cavernosa bilaterally in all patients while the glans penis and corpus spongiosum were not involved. Treatment was conservative in 20 of the 21 episodes which consisted of a various combination of sedation, general or spinal anesthesia, local ice packs or systemic hormonal treatment with estrogen. In 18 patients the corpora cavernosa were aspirated through a large needle, using local saline and heparin irrigations. Of the 8 patients with 9 episodes of priapism a corporosaphenous shunt was
1 Grayhack, J. T., McCullough, W., O'Conor, V. J., Jr. and Trippel, 0.: Venous bypass to control priapism. Invest. Urol., 1: 509, 1964. 2 Quackels, R.: Cure of a patient suffering from priapism by cavernospongiosa anastomosis. Acta Urol. Belg., 32: 5, 1964. 3 Falk, D. and Loos, D. C.: Spongiocavernosum shunt in the surgical treatment of idiopathic persistent priapism. J. Urol., 108: 101, 1972. 4 Sacher, E. C., Sayegh, E., Frensilli, F., Crum, P. and Akers, R.: Cavernospongiosum shunt in the treatment of priapism. J. Urol., 108: 97, 1972. 'Kandel, G. L., Bender, L. I. and Grove, J. S.: Pulmonary embolism: a complication of corpus-saphenous shunt for priapism. J. Urol., 99: 196, 1968. 6 Stieve, H.: Harn and Gesclachtsapparat. In: Handbuch der Mikroskopischen Anatomie des Menschen. Edited by W. V. Mollendorff. Berlin: Springer-Verlag, 1930. 7 Conti, G.: L'erection du penis humain et ses bases morphologico-vasculaires. Acta Anat., 14: 217, 1952. 8 Hinman, F., Jr.: Priapism: reasons for failure and therapy. J. Urol., 83: 420, 1960. 'Newman, H. F., Northup, J. D. and Devlin, J.: Mechanism of human penile erection. Invest. Urol., l: 350, 1964.
Accepted for publication December 28, 1973. Read at annual meeting of North Central Section, American Urological Association, Acapulco, Mexico, November 11-18, 1973. * Requests for reprints: University of Illinois Hospital, Post Office Box 6998, Chicago, Illinois 60680. 92
93
PRIAPISM
PROCEDURES
RESULTS Flaccid
Conservative Management 20 pts.
Potent
Impotent
2 (10%) ~ l (10%)
0
1 ( s%)
t
Needle Aspiration 18 pts.
l
7
~ Second
Aspi ration 3 pts. ~
~4(22%)
6 ( 33%)
0
3 ( 7 s%)
0
3
Operative Management 8 pts.
~ Corporosaphenous Shunt
4 pts.
---1)
"'
Second Corporosaphenous Shunt l pt. ~
Corporospongiosum Shunt 4 pts.
4 (100%) ~ 3 (75%)
0
l (100%) ~ l (100%)
0
l
(2s%)
l
Recurrent Priapism (30 days) with Second Corporospongiosum Shunt l pt.
0
TOTALS 21
21 ( 1 o0%)
l O ( 48%)
9 ( 4 3%)
2 ( 9%)
Twenty-one episodes of priapism in 20 patients
associates were able to determine in 2 cases of priapism that the arterial flow rate during the state of erection was extremely high. 10 After treatment the flow rate subsided to normal levels in 1 patient who remained potent and decreased to less than normal levels in the other who became impotent. They suggested that the cause of persistent erection appeared to be a continuously high arterial flow rate rather than venous obstruction. In the Leriche syndrome impotence is the rule, mounting clinical evidence that arterial flow is of paramount importance in developing an erection of the penis. We postulate then that it is the increase in penile arterial flow which is not adequately handled
the venous drainage system that permits a state of erection to occur. Newman and associates have suggested that once erection does occur the fiow rate can be diminished while erection maintained. 9 However, Mal var and associates have shown that the flow rate is consistently throughout the state of priapism. 10 Ideally, treat. ment should then be directed at the high arterial flow rate but, since this is impractical, mm;t. treatment regimens have been directed at increm,ing the venous drainage. Treatment can be either conservative 1s sedation, regional or general anesthesia, hormonal. hypotensive, topical ice packs or pressure dress ings, anticoagulants and fibrolysins) 11 or openI··
10 Malvar, T., Baron, T. and Clark, S.S.: Assessment of potency with the Doppler flowmeter. Urology, 2: 396, 1973.
11 Grace, D. A. and Winter, C. C.: Priapism: an appraisal of management of twenty-three patients. J. Urol., 99: 301, 1968.
94
DARWISH, ATASSI AND CLARK
tive (ligation of the arterial flow and venous shunts). i-•. 12 Conservative management is directed nonspecifically at the disease and not at the pathophysiological factors and has resulted predictably in a poor success rate. Of our 20 patients, only 2 became flaccid and only 1 is now potent. This would appear to be the experience of others. 11 Hinman has shown that untreated priapism will ultimately resolve with a high rate of impotence. 8 Our success rate with non-specific treatment may simply be nothing more than that which can be accomplished by watchful waiting. Therefore, specific therapy should be used early in this disease if one expects to improve on the failure rate of the conservative management regimens. Early and adequate operative intervention has been advocated by many authors. 5 • 8 • 13 - 15 However, authors such as Grace and Winter, 11 and Hamm and Waterhouse 16 advocated delayed or conservative management based on the variable natural history of priapism. A conservative needle aspiration technique was used on 18 patients-only 56 per cent became flaccid and only 22 per cent of those remained potent. Therefore, we advocate early operative intervention. According to the hypothesis proposed, direct arterial ligation would appear to be the most logical operative approach. However, Newman and associates were not able to demonstrate that manipulation of the internal pudendal arteries led to a definitive erection but, rather, to penile edema when the flow rate was increased. 9 This suggests that direct manipulation of the pudendal arteries will not be successful. If the hypothesis is correct then a venous shunting procedure which does not close or which is not involved in the erection mechanism will lead to impotence since it allows the arterial flow to pass through the penile erectile tissue too rapidly to cause the pooling effect normally seen in a state of 12 Fortuiio, R. F. and Carrillo, R.: Gangrene of the penis following cavernospongiosum shunt in a case of priapism. J. Urol., 108: 752, 1972. 13 Garrett, R. A. and Rhamy, D. E.: Priapism: management with corpus-saphenous shunt. J. Urol., 95: 65, 1966. 14 Howe, G. E., Prentiss, R. J., Cole, J. W. and Masters, R.H.: Priapism: a surgical emergency. J. Urol., 101: 576, 1969. 15 Eadie, D. G. and Brock, T. P.: Corpus saphenous by-pass in the treatment of priapism. Brit. J. Surg., 57: 172, 1970. 16 Hamm, F. C. and Waterhouse, K.: Injuries of the genital tract. In: Urology, 3rd ed. Edited by M. F. Campbell and J. H. Harrison. Philadelphia: W. B. Saunders Co., chapt. 23, p. 870, 1970.
erection. The corporosaphenous shunt, while increasing venous drainage from the penis and allowing the erection to subside, does require phlebothrombosis to take place prior to successful return of potency. However, the cavernospongiosum shunt diverts to a structure (corpus spongiosum) which is a normal component of an erection and does not require phlebothrombosis to close the shunt in order for an erection to occur. Furthermore, with the cavernospongiosum shunt, there is no direct communication to the systemic circulation as there is in the corporosaphenous shunt procedure, thus obviating the possibility of systemic embolism. Four of our patients had a corporosaphenous shunt (3 bilaterally and 1 unilaterally) and a repeat corporosaphenous shunt was necessary in the unilateral case. The results were a flaccid penis in all patients but potency in only 1. In the 4 patients who had a corporospongiosum shunt all patients became flaccid with 3 maintaining potency and 1 being unknown owing to his young age. One of these patients had a second episode of priapism 30 days after treatment and was again treated with a corporospongiosum shunt, resulting in a flaccid penis with potency. The definition of potency in the literature is ill-defined, thus making a literature review impossible to assess. Klein and associates 17 while seriously questioning the ability of the corporosaphenous shunt to achieve flaccidity, reviewed 29 cases reporting presumed potency rate of 14 while Sacher and associates• reported a 75 per cent potency rate in 12 patients with a corporospongiosum shunt. We had a 25 per cent potency rate in our corporosaphenous shunts and an 80 per cent potency rate in our corporospongiosum shunts. CONCLUSION
From our experience as well as others we believe that a perfect method of treatment for priapism has not been described. Of the available methods of direct attack on the problem, it would seem that cavernospongiosum shunt offers the most logical and simplest procedure to directly intervene in the vasculature of the penis. The complication rates reported are low and the success rates are relatively high for this procedure. It should probably be done early and can be done either unilaterally or bilaterally. If the disease recurs a second procedure can be performed with expected success. 17 Klein, L. A., Hall, R. L. and Smith, R. B.: Surgical treatment of priapism: with a note on heparin-induced priapism. J. Urol., 108: 104, 1972.
THE .JocRNAL OF UROLOGY
Printed in U.S.A.
Copyright© 1974 by The Williams & Wilkins Co.
PRIAPISM: EVALUATION OF TREATMENT REGIMENS MOHAMMED E. DARWISH, BASSEM ATASSI
AND
SAMUEL S. CLARK*
From the Divisions of Urology, University of Illinois and West Side Veterans Administration Hospitals, Chicago, Illinois
done in 4 1 and a corporospongiosum shunt was done in 4, with 5 episodes of priapism. 2 - 4 Complications to management of these 21 episodes of priapism consisted of an arteriovenous fistula in i, pulmonary embolism in l 5 and urethrocutaneous fistula in 1 (14.3 per cent).
Priapism is a rare disease that presents a major treatment dilemma because of lack of a clear understanding of the pathophysiology. It is a disease of persistent, painful penile erection not necessarily related to sexual desire or stimulation and occurs in relatively young, sexually active male subjects. If left untreated priapism frequently results in impotence. While most cases are classified as idiopathic some are associated with specific disease entities, such as sickle cell trait, sickle cell anemia, leukemia, tumors of the lower urinary tract, inflammatory diseases of the prostate and trauma. A review of our patients seen during the last 7 years is presented herein.
RESULTS
There were 21 episodes of priapism reported in which flaccidity was ultimately reached in all, while only 10 (48 per cent) retained sexual potency (see figure). DISCUSSION
In order to intelligently treat this challenging condition, a clear understanding of the pathophysiology of priapism is essential. In 1930 Stieve 6 described muscular pillars or cushions within the vascular walls of the penis which were confirmed histologically in 1952 by Conti. 7 They postulated that these "polsters" acted as arterial and venous valves under the influence of the lumbar sympathetic nerves, which inhibited vasoconstriction and sacral parasympathetic nerves and caused arteriolar vasodilatation. In 1960 Hinman accepted this principle and indicated that the persistent erection led to increased carbon dioxide tension, hypoxia and, ultimately, fibrosis of the corpora cavernosa. s Newman and associates challenged this concept, suggesting that the primary etiological factor in erection, and thus in priapism, is the arterial flow rate. 9 Using a Doppler flowmeter Malvar and
MATERIALS AND METHODS
There were 22 patients with 23 episodes of priapism seen at our hospitals in 5,600 urological admissions from 1965 to 1972, an incidence of 0.4 per cent. Of these 22 patients 20 were available for review, consisting of 21 episodes of priapism. The age range of patients was from 10 to 61 years, with an average of 35.5 years, and the population consisted of 3 white and 17 black patients. Underlying causative factors were found in 9 patients, including 5 with sickle cell anemia, 3 with sickle cell trait and 1 with acute prostatitis. The remaining 11 patients had idiopathic priapism. Duration of symptoms prior to seeking medical advice varied from 16 to 144 hours, with an average of 65 hours. The presenting symptoms consisted of painful erection in 21 cases, edema of the penis in 4, difficulty in urination in 2 and dysuria with urethral discharge in 1. The presenting physical findings consisted of induration of the corpora cavernosa bilaterally in all patients while the glans penis and corpus spongiosum were not involved. Treatment was conservative in 20 of the 21 episodes which consisted of a various combination of sedation, general or spinal anesthesia, local ice packs or systemic hormonal treatment with estrogen. In 18 patients the corpora cavernosa were aspirated through a large needle, using local saline and heparin irrigations. Of the 8 patients with 9 episodes of priapism a corporosaphenous shunt was
1 Grayhack, J. T., McCullough, W., O'Conor, V. J., Jr. and Trippel, 0.: Venous bypass to control priapism. Invest. Urol., 1: 509, 1964. 2 Quackels, R.: Cure of a patient suffering from priapism by cavernospongiosa anastomosis. Acta Urol. Belg., 32: 5, 1964. 3 Falk, D. and Loos, D. C.: Spongiocavernosum shunt in the surgical treatment of idiopathic persistent priapism. J. Urol., 108: 101, 1972. 4 Sacher, E. C., Sayegh, E., Frensilli, F., Crum, P. and Akers, R.: Cavernospongiosum shunt in the treatment of priapism. J. Urol., 108: 97, 1972. 'Kandel, G. L., Bender, L. I. and Grove, J. S.: Pulmonary embolism: a complication of corpus-saphenous shunt for priapism. J. Urol., 99: 196, 1968. 6 Stieve, H.: Harn and Gesclachtsapparat. In: Handbuch der Mikroskopischen Anatomie des Menschen. Edited by W. V. Mollendorff. Berlin: Springer-Verlag, 1930. 7 Conti, G.: L'erection du penis humain et ses bases morphologico-vasculaires. Acta Anat., 14: 217, 1952. 8 Hinman, F., Jr.: Priapism: reasons for failure and therapy. J. Urol., 83: 420, 1960. 'Newman, H. F., Northup, J. D. and Devlin, J.: Mechanism of human penile erection. Invest. Urol., l: 350, 1964.
Accepted for publication December 28, 1973. Read at annual meeting of North Central Section, American Urological Association, Acapulco, Mexico, November 11-18, 1973. * Requests for reprints: University of Illinois Hospital, Post Office Box 6998, Chicago, Illinois 60680. 92
93
PRIAPISM
PROCEDURES
RESULTS Flaccid
Conservative Management 20 pts.
Potent
Impotent
2 (10%) ~ l (10%)
0
1 ( s%)
t
Needle Aspiration 18 pts.
l
7
~ Second
Aspi ration 3 pts. ~
~4(22%)
6 ( 33%)
0
3 ( 7 s%)
0
3
Operative Management 8 pts.
~ Corporosaphenous Shunt
4 pts.
---1)
"'
Second Corporosaphenous Shunt l pt. ~
Corporospongiosum Shunt 4 pts.
4 (100%) ~ 3 (75%)
0
l (100%) ~ l (100%)
0
l
(2s%)
l
Recurrent Priapism (30 days) with Second Corporospongiosum Shunt l pt.
0
TOTALS 21
21 ( 1 o0%)
l O ( 48%)
9 ( 4 3%)
2 ( 9%)
Twenty-one episodes of priapism in 20 patients
associates were able to determine in 2 cases of priapism that the arterial flow rate during the state of erection was extremely high. 10 After treatment the flow rate subsided to normal levels in 1 patient who remained potent and decreased to less than normal levels in the other who became impotent. They suggested that the cause of persistent erection appeared to be a continuously high arterial flow rate rather than venous obstruction. In the Leriche syndrome impotence is the rule, mounting clinical evidence that arterial flow is of paramount importance in developing an erection of the penis. We postulate then that it is the increase in penile arterial flow which is not adequately handled
the venous drainage system that permits a state of erection to occur. Newman and associates have suggested that once erection does occur the fiow rate can be diminished while erection maintained. 9 However, Mal var and associates have shown that the flow rate is consistently throughout the state of priapism. 10 Ideally, treat. ment should then be directed at the high arterial flow rate but, since this is impractical, mm;t. treatment regimens have been directed at increm,ing the venous drainage. Treatment can be either conservative 1s sedation, regional or general anesthesia, hormonal. hypotensive, topical ice packs or pressure dress ings, anticoagulants and fibrolysins) 11 or openI··
10 Malvar, T., Baron, T. and Clark, S.S.: Assessment of potency with the Doppler flowmeter. Urology, 2: 396, 1973.
11 Grace, D. A. and Winter, C. C.: Priapism: an appraisal of management of twenty-three patients. J. Urol., 99: 301, 1968.
94
DARWISH, ATASSI AND CLARK
tive (ligation of the arterial flow and venous shunts). i-•. 12 Conservative management is directed nonspecifically at the disease and not at the pathophysiological factors and has resulted predictably in a poor success rate. Of our 20 patients, only 2 became flaccid and only 1 is now potent. This would appear to be the experience of others. 11 Hinman has shown that untreated priapism will ultimately resolve with a high rate of impotence. 8 Our success rate with non-specific treatment may simply be nothing more than that which can be accomplished by watchful waiting. Therefore, specific therapy should be used early in this disease if one expects to improve on the failure rate of the conservative management regimens. Early and adequate operative intervention has been advocated by many authors. 5 • 8 • 13 - 15 However, authors such as Grace and Winter, 11 and Hamm and Waterhouse 16 advocated delayed or conservative management based on the variable natural history of priapism. A conservative needle aspiration technique was used on 18 patients-only 56 per cent became flaccid and only 22 per cent of those remained potent. Therefore, we advocate early operative intervention. According to the hypothesis proposed, direct arterial ligation would appear to be the most logical operative approach. However, Newman and associates were not able to demonstrate that manipulation of the internal pudendal arteries led to a definitive erection but, rather, to penile edema when the flow rate was increased. 9 This suggests that direct manipulation of the pudendal arteries will not be successful. If the hypothesis is correct then a venous shunting procedure which does not close or which is not involved in the erection mechanism will lead to impotence since it allows the arterial flow to pass through the penile erectile tissue too rapidly to cause the pooling effect normally seen in a state of 12 Fortuiio, R. F. and Carrillo, R.: Gangrene of the penis following cavernospongiosum shunt in a case of priapism. J. Urol., 108: 752, 1972. 13 Garrett, R. A. and Rhamy, D. E.: Priapism: management with corpus-saphenous shunt. J. Urol., 95: 65, 1966. 14 Howe, G. E., Prentiss, R. J., Cole, J. W. and Masters, R.H.: Priapism: a surgical emergency. J. Urol., 101: 576, 1969. 15 Eadie, D. G. and Brock, T. P.: Corpus saphenous by-pass in the treatment of priapism. Brit. J. Surg., 57: 172, 1970. 16 Hamm, F. C. and Waterhouse, K.: Injuries of the genital tract. In: Urology, 3rd ed. Edited by M. F. Campbell and J. H. Harrison. Philadelphia: W. B. Saunders Co., chapt. 23, p. 870, 1970.
erection. The corporosaphenous shunt, while increasing venous drainage from the penis and allowing the erection to subside, does require phlebothrombosis to take place prior to successful return of potency. However, the cavernospongiosum shunt diverts to a structure (corpus spongiosum) which is a normal component of an erection and does not require phlebothrombosis to close the shunt in order for an erection to occur. Furthermore, with the cavernospongiosum shunt, there is no direct communication to the systemic circulation as there is in the corporosaphenous shunt procedure, thus obviating the possibility of systemic embolism. Four of our patients had a corporosaphenous shunt (3 bilaterally and 1 unilaterally) and a repeat corporosaphenous shunt was necessary in the unilateral case. The results were a flaccid penis in all patients but potency in only 1. In the 4 patients who had a corporospongiosum shunt all patients became flaccid with 3 maintaining potency and 1 being unknown owing to his young age. One of these patients had a second episode of priapism 30 days after treatment and was again treated with a corporospongiosum shunt, resulting in a flaccid penis with potency. The definition of potency in the literature is ill-defined, thus making a literature review impossible to assess. Klein and associates 17 while seriously questioning the ability of the corporosaphenous shunt to achieve flaccidity, reviewed 29 cases reporting presumed potency rate of 14 while Sacher and associates• reported a 75 per cent potency rate in 12 patients with a corporospongiosum shunt. We had a 25 per cent potency rate in our corporosaphenous shunts and an 80 per cent potency rate in our corporospongiosum shunts. CONCLUSION
From our experience as well as others we believe that a perfect method of treatment for priapism has not been described. Of the available methods of direct attack on the problem, it would seem that cavernospongiosum shunt offers the most logical and simplest procedure to directly intervene in the vasculature of the penis. The complication rates reported are low and the success rates are relatively high for this procedure. It should probably be done early and can be done either unilaterally or bilaterally. If the disease recurs a second procedure can be performed with expected success. 17 Klein, L. A., Hall, R. L. and Smith, R. B.: Surgical treatment of priapism: with a note on heparin-induced priapism. J. Urol., 108: 104, 1972.