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Recurrent partial priapism
RECURRENT PARTIAL PRIAPISM JAMES
E. GOTTESMAN,
M.D.
From the Department of Surgery, Division of Urology, UCLA School of Medicine, and Wadsworth Veterans Administration Hospital, Los Angeles, California
ABSTRACT - Exploration of an unusual case of a painful, recurrent, perineal mass revealed partial priapism of the right corpora cavernosa. Etiology is speculative and no definitive therapy is offfled.
A thirty-four-year-old Caucasian man was admitted to the Wadsworth Veterans Administration Hospital after experiencing four days of a painful perineal mass. He reported a ten-year history of infrequent but severe episodes of right perineal pain and swelling. These periodic recurrences, which numbered about ten, occurred after prolonged sexual activities and usually resolved within twenty-four to forty-eight hours. Previous diagnoses of prostatitis were tendered post facto by other physicians and treated with antibiotics. Four days prior to admission, and again after prolonged sexual activity, his malady recurred but did not resolve. Sulfisoxazole (Gantrisin) was started on the second day prior to admission along with analgesics, with little benefit. The patient had no urologic symptoms other than a decrease
in the caliber of his urinary stream. Past medical history was unremarkable. Physical examination revealed a normal, flaccid penis and descended testicles. A rock-hard, banana-sized, painful mass was present in the right perineum (Fig. 1A). His prostate was soft and nontender, but the base of the mass could be felt rectally to the right of the membranous urethra. Urinalysis, urine cultures, chemistry, and coagulation studies were all normal. Intravenous pyelogram and retrograde urethrogram were within normal limits. Three days of sitz baths, bedrest, and analgesics did little to afford relief. The mass persisted and was explored on the fourth hospital day. Results of panendoscopy and cystoscopy were unremarkable. The right ischiocavernosus muscle
FIGURE 1. (A) Outline of right perineal mass. (B) Incision and drainage of right corpora cavernosa with release of material resembling crankcase oil.
UROLOGY
/ MAY 1976 / VOLUME
VII. NUMBER
5
519
was draped over the mass, appearing to involve the corresponding corpora cavernosa. Incision into the mass released 30 cc. of material resembling crankcase oil, followed by immediate detumescence of the mass (Fig. 1B). Specimens were taken for culture and biopsy. The corporeal cavity was irrigated with saline, which reproduced the mass effect, and the corpora was then closed with 3-O Dexon. Postoperatively, the mass (somewhat smaller and less painful) recurred but eventually resolved over the next three weeks. The biopsy showed mild, nonspecific inflammation of the corporeal wall. All cultures were negative. At one month, the patient was again having normal sexual relations with no postoperative pain or swelling.
This patient represents recurrent priapism in an isolated segment of corpora, not communicating with the distal ipsilateral corpora or the opposite side. Possibly, a post-traumatic or postinflammatory process occurred which caused occlusion and segregation of the proximal right corpora. A cavernosogram might have had some diagnostic benefit, but this area of corpora is poorly visualized with conventional techniques and interpretation would be difficult. The likelihood of recurrence in this patient is high, but in view of his unwillingness to risk impotency, more aggressive surgical therapy was not indicated.
Los
Comment Trauma, prolonged intercourse, blood dyscrasias, leukemia, sickle cell disease, central nervous system irritation, heparinization, prostatitis, lues, metastatic tumors, systemic infections, and drug ingestion have all been associated with priapism. 1-4However, in 46 to 50 per cent of the cases investigated no causative process could be identified. Treatment ranges from various conservative maneuvers to operative shunting procedures. Impotence occurs in a large percentage of these cases regardless of what treatment plan is used. 5sr
520
University of California Angeles, California 90024
References 1. HINMAN, F., JR.: Priapism: reasons for failure of therapy, J. Urol. 83: 420 (1960). 2. KLEIN, L., HALL, R., and SMITH, R.: Surgical treatment of priapism, with a note on heparin-induced priapism, ibid. 108: 104 (1972). JORDAN,W. P., JR.: Hydroceles and varicoceles, Surg. Clin. North Am. 45: 1535 (1965). RUBIN, S. 0.: Priapism as a probable sequel to medication, J. Urol. Nephrol. 2: 81 (1968). LA ROCQUE,M. A., and COSGROVE,M. D.: Priapism: a review of 46 cases, J. Urol. 112: 770 (1974). GRACE, D. A., and WINTER, C. C.: Priapism: appraisal of management of 23 patients, ibid. 99: 301 (1968).
UROLOGY /
MAY 1976 I VOLUME VII, NUMBER 5
E. GOTTESMAN,
M.D.
From the Department of Surgery, Division of Urology, UCLA School of Medicine, and Wadsworth Veterans Administration Hospital, Los Angeles, California
ABSTRACT - Exploration of an unusual case of a painful, recurrent, perineal mass revealed partial priapism of the right corpora cavernosa. Etiology is speculative and no definitive therapy is offfled.
A thirty-four-year-old Caucasian man was admitted to the Wadsworth Veterans Administration Hospital after experiencing four days of a painful perineal mass. He reported a ten-year history of infrequent but severe episodes of right perineal pain and swelling. These periodic recurrences, which numbered about ten, occurred after prolonged sexual activities and usually resolved within twenty-four to forty-eight hours. Previous diagnoses of prostatitis were tendered post facto by other physicians and treated with antibiotics. Four days prior to admission, and again after prolonged sexual activity, his malady recurred but did not resolve. Sulfisoxazole (Gantrisin) was started on the second day prior to admission along with analgesics, with little benefit. The patient had no urologic symptoms other than a decrease
in the caliber of his urinary stream. Past medical history was unremarkable. Physical examination revealed a normal, flaccid penis and descended testicles. A rock-hard, banana-sized, painful mass was present in the right perineum (Fig. 1A). His prostate was soft and nontender, but the base of the mass could be felt rectally to the right of the membranous urethra. Urinalysis, urine cultures, chemistry, and coagulation studies were all normal. Intravenous pyelogram and retrograde urethrogram were within normal limits. Three days of sitz baths, bedrest, and analgesics did little to afford relief. The mass persisted and was explored on the fourth hospital day. Results of panendoscopy and cystoscopy were unremarkable. The right ischiocavernosus muscle
FIGURE 1. (A) Outline of right perineal mass. (B) Incision and drainage of right corpora cavernosa with release of material resembling crankcase oil.
UROLOGY
/ MAY 1976 / VOLUME
VII. NUMBER
5
519
was draped over the mass, appearing to involve the corresponding corpora cavernosa. Incision into the mass released 30 cc. of material resembling crankcase oil, followed by immediate detumescence of the mass (Fig. 1B). Specimens were taken for culture and biopsy. The corporeal cavity was irrigated with saline, which reproduced the mass effect, and the corpora was then closed with 3-O Dexon. Postoperatively, the mass (somewhat smaller and less painful) recurred but eventually resolved over the next three weeks. The biopsy showed mild, nonspecific inflammation of the corporeal wall. All cultures were negative. At one month, the patient was again having normal sexual relations with no postoperative pain or swelling.
This patient represents recurrent priapism in an isolated segment of corpora, not communicating with the distal ipsilateral corpora or the opposite side. Possibly, a post-traumatic or postinflammatory process occurred which caused occlusion and segregation of the proximal right corpora. A cavernosogram might have had some diagnostic benefit, but this area of corpora is poorly visualized with conventional techniques and interpretation would be difficult. The likelihood of recurrence in this patient is high, but in view of his unwillingness to risk impotency, more aggressive surgical therapy was not indicated.
Los
Comment Trauma, prolonged intercourse, blood dyscrasias, leukemia, sickle cell disease, central nervous system irritation, heparinization, prostatitis, lues, metastatic tumors, systemic infections, and drug ingestion have all been associated with priapism. 1-4However, in 46 to 50 per cent of the cases investigated no causative process could be identified. Treatment ranges from various conservative maneuvers to operative shunting procedures. Impotence occurs in a large percentage of these cases regardless of what treatment plan is used. 5sr
520
University of California Angeles, California 90024
References 1. HINMAN, F., JR.: Priapism: reasons for failure of therapy, J. Urol. 83: 420 (1960). 2. KLEIN, L., HALL, R., and SMITH, R.: Surgical treatment of priapism, with a note on heparin-induced priapism, ibid. 108: 104 (1972). JORDAN,W. P., JR.: Hydroceles and varicoceles, Surg. Clin. North Am. 45: 1535 (1965). RUBIN, S. 0.: Priapism as a probable sequel to medication, J. Urol. Nephrol. 2: 81 (1968). LA ROCQUE,M. A., and COSGROVE,M. D.: Priapism: a review of 46 cases, J. Urol. 112: 770 (1974). GRACE, D. A., and WINTER, C. C.: Priapism: appraisal of management of 23 patients, ibid. 99: 301 (1968).
UROLOGY /
MAY 1976 I VOLUME VII, NUMBER 5