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PRIAPISM

PRIAPISM . Mohammad Hamad Alkandari Urology Board, R3 13/02/2014 Adan Hospital. Priapus Priapos. OUTLINE . Definition Mechanism of erection. Types AUA gidelines Introduction Evaluation Recommendations Procedures

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PRIAPISM

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  1. PRIAPISM Mohammad Hamad Alkandari Urology Board, R3 13/02/2014 Adan Hospital

  2. Priapus Priapos

  3. OUTLINE • Definition • Mechanism of erection. • Types • AUA gidelines • Introduction • Evaluation • Recommendations • Procedures • New shunting techniques • Home messages

  4. Definition • Must: • Sustained penile erection > 4 hours. • Absence of both physical & psychological stimulation. • Usually: • Painful. • Tumescence is restricted to the corpora cavernosa.

  5. Mechanism Of Erection • Erection thus involves: sinusoidal relaxation, arterial dilation, and venous compression

  6. Types • Ischemic (veno-occlusive): • Emergency. • Low cavernous blood flow • Hypoxic • Hypercapnic • Acidotic. • Corpora are rigid & tender. • Etiology: • Idiopathic • SCD. HOW? • Medications • Leukemia • Malignancies • Other hemoglobinopathies

  7. Ischemic • Persistent penile edema, ecchymosis and partial erections may mimic unresolved priapism. • Resolution confirmed with. • Measurement of cavernous blood gases • Blood flow by color duplex U/S.

  8. Types II. Nonischemic(arterial) • Uninhibited cavernous arterial inflow. • neither fully rigid nor painful. • Normal cavernosal blood gases. • Etiology: • Perineal trauma, straddle injury. • cavernous artery/corpora cavernosa fistula. • Fabry disease • SCD • Resolution  completely flaccid penis.

  9. Types III. Stuttering (intermittent): • Recurrent form of ischemic • With intervening periods of detumescence. • Lasting less than 2 hours. • Idiopathic > SCD • Fourth type?

  10. Types IV. Neonatal: • Spontaneously resolving. • Resolves in 2 to 6 days • Without adverse results. • Etiology: • Idiopatheic • Birth trauma • Polycythemia

  11. Introduction • Relatively uncommon • No solid EBM on Rx outcomes. • Medical emergency • Not always require immediate intervention • Ischemic  progressive fibrosis & ED. • Some treatment modalities  ED! • Step-wise pattern with increasing invasiveness & risk.

  12. Evaluation

  13. History • Duration of erection • Degree of pain • Previous h/o priapism &its treatment • Drugs! • History of trauma • History of SCD or other hematologic diseases. • Examination?

  14. Examination • General • Abdomen & pelvis • External genitalia • Perineum. • Investigations?

  15. Investigations • CBC • WBC & differential • Plt • Hb • Reticulocytes  electrophoresis • Toxicology +/- • Cavernosal blood gas, or D. • Before? • Color duplex US

  16. Blood Gas • Nonischemic = normal ABG • Normal flacid penis = normal mixed venous.

  17. Recommendation #1 • In order to initiate appropriate management, the physician must determine whether the priapism is ischemic or nonischemic. [Based on Panel consensus.]

  18. Ischemic Priapism • Management’s delay = inevitable damage. • Treat the condition IMMIDIATELY! • Treat the cause concurrently. • SCD systemic Rx  resolution of Priapism in up to 35%. • Step-wise Rx: • Aspiration • Intracavernous alpha-adrenergics • Irrigation/evacuation • Shunting

  19. Recommendation #2 • In patients with an underlying disorder, such as sickle cell disease or hematologic malignancy, systemic treatment of the underlying disorder should not be undertaken as the only treatment for ischemic priapism. The ischemic priapism requires intracavernous treatment, and this should be administered concurrently. [Based on Panel consensus.]

  20. Recommendation #3 • Management of ischemic priapism should progress in a step-wise fashion to achieve resolution as promptly as possible. Initial intervention may utilize therapeutic aspiration (with or without irrigation) or intracavernous injection of sympathomimetics. [Based on Panel consensus and review of limited data.]

  21. Sympathomimetics • Causes detumescence. • Resolution if used alone: • Sympathomimetics: 43-81% • ED is less as well. • Aspiration: 24-36% • A+B:  77% • Recurrence rate is (?)

  22. Recommendation #4 • If ischemic priapism persists following aspiration/irrigation, intracavernous injection of sympathomimetic drugs should be performed. Repeated sympathomimetic injections should be performed prior to initiating surgical intervention. [Based on Panel consensus and review of limited data.]

  23. Aspiration • first step after insertion of 19 or 21 gauge needle into the corpus cavernosum for diagnostic purposes. • Why not after the injection?

  24. Recommendation #5 • For intracavernous injection of a sympathomimetic agent, the Panel recommends use of phenylephrine because this agent minimizes the risk of cardiovascular side effects that are more common for other sympathomimetic medications. [Based on Panel consensus and review of limited data.]

  25. Phenylephrine • Sympathomimetics: • Alpha  blood vessels • Beta  heart • Highest resolution rate, 81%. • Least CV side effects. • alpha1-selective adrenergic agonist. • Administration?

  26. Recommendation #6 • For intracavernous injections in adult patients, phenylephrine should be diluted with normal saline to a concentration of 100 to 500 mcg/mL, and 1 mL injections made every 3 to 5 minutes for approximately one hour, before deciding that the treatment will not be successful. Lower concentrations in smaller volumes should be used in children and patients with severe cardiovascular disease. [Based on Panel consensus.]

  27. Phenylephrine Formula • Dilute it with NS. • Concentration of 100 to 500 mcg/ml • One ml injections every 3-5 minutes • For 1 hour. • Chlidren & CVD pts: lower dose. • Failure?

  28. Recommendation #7 • During and following intracavernous injection of sympathomimetic drugs, the physician should observe patients for subjective symptoms and objective findings consistent with known undesirable effects of these agents: acute hypertension, headache, reflex bradycardia, tachycardia, palpitations, and cardiac arrhythmia. In patients with high cardiovascular risk, blood pressure and electrocardiogram monitoring are recommended. [Based on Panel consensus.]

  29. When to D/C? • Acute hypertension • Headache • Reflex bradycardia • Tachycardia • Palpitations • Arrhythmia

  30. Recommendation #8 • The use of surgical shunts for the treatment of ischemic priapism should be considered only after a trial of intracavernous injection of sympathomimetics has failed. [Based on Panel consensus.]

  31. Shunting • Unwanted, but necessary sometimes! • To re-establish circulation of the corpora cavernosa. • Duration of priapism α failure of injections • 48 hrs! • Different types.

  32. Recommendation #9 • A cavernoglanular (CORPOROGLANULAR) shunt should be the first choice of the shunting procedures because it is the easiest to perform and has the fewest complications. This shunting procedure can be performed with a large biopsy needle (Winter) or a scalpel (Ebbehøj) inserted percutaneously through the glans. It can also be performed by excising a piece of the tunica albuginea at the tip of the corpus cavernosum (Al-Ghorab). Proximal shunting using the Quackels or Grayhackprocedures may be warranted if more distal shunting procedures have failed to relieve the priapism. [Based on Panel consensus and review of limited data.]

  33. Shunting Procedures • Distal (corporoglanular): • Winter • Ebbehøj • Al Ghorab • Excision of both tips of the corpora cavernosa. • Most invasive & effective. • Proximal: • Quackels (corporospongiosal) • Grayhack (corporosaphenous) • ED rates are higher with proximal shunts. • Shunts usually close with time. If not?

  34. Biopsy needle (Winter) • Scalpel (Ebbehøj)

  35. Ghorab

  36. Quackels (corporospongiosal)

  37. Grayhack (corporosaphenous)

  38. About The Study • 36-month period (2009-2012) • 45 patients • Prolonged ischemic priapism. • All patients had an unsuccessful primary Rx. • Underwent: • T-shunt • Intracavernoustunneling (Snake) • with cavernous muscle biopsies.

  39. Steps • Failure of intracavernoussympathomimetics, & aspiration/irrigation. • G.A. • B/L T-shunts of the glans • No. 10 scalpel  • Intracavernous tunneling • size 8 Hegar dilator • to the proximal limit of the corpus cavernosum.

  40. Cont. • Corporal blood drainage & penile decompression. • Corporal wash with N.S. • Intracavernous phenylephrine injection. • Biopsies before tunneling.

  41. Conclusions  • Success α duration of priapism. • Studies report that if priapism lasts <24 hrs92% success. • although ED is still present in 50%. • If priapism >48 hours: • technique usually fails • corporal fibrosis due to smooth muscle necrosis. • T-shunt is a useful technique in early priapism (<48 hours).

  42. Complications Of Shunting ..

  43. Complications • Failure • ED • Urethral fistulae • Purulent cavernositis • PE, following which procedure?

  44. Recommendation #10 • Oral systemic therapy is not indicated for the treatment of ischemic priapism. [Based on Panel consensus and review of limited data.]

  45. Nonischemic Priapism • Uncommon. • Spontaneous resolution in up to 62%. • Despite the usual late presentations (up to yrs) • ED in 1/3 of patients.

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