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The medico legal aspect of priapism and its associated diagnostic and therapeutic interventions remains important in our litigious society The physician should explain to the patient the natural history of
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Priapism the disease and the extremely high risk of developing erectile dysfunction, early or late, despite active or no intervention Discussion should include the advantages and potential disadvantages of the various
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treatment alternatives, as well as the risks associated with no treatment at all Documentation of this, in addition to any prior erectile dysfunction, and all counseling sessions, should be meticulous
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PRIAPISM (erection > 4 hours)
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History and physical examination
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Simultaneous treatment of any underlying disease (eg sickle cell crisis)
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Cavernous aspiration with blood gas or Doppler ultrasound
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ISCHEMIC
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NON-ISCHEMIC
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Aspiration with or without aspiration
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Consider expectant management Phenylephrine
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*Distal shunting
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*Arteriography and embolization with autologous clot/Gelfoam
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*Repeat shunt procedure or consider proximal shunting
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*If persists, repeat perineal Doppler ultrasound
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*Consider surgical procedure
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Fig 151 Management algorithm for priapism
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15
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Suspicion of arterial priapism
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History of penile or perineal trauma
Constant, painless erection
Bright red corporal blood aspiration with high oxygen tension
Perineal duplex Doppler ultrasound arterial lacunar fistula visualized
Active intervention
Expectant management "watchful waiting"
Diagnostic pudendal arteriogram arterial lacunar fistula visualized (+) Selective embolization with autologous clot (add Gelfoam if recurrent) (-)
Follow-up perineal duplex Doppler ultrasound (-)
What is the integrity of erectile hemodynamics Has cavernosal artery laceration healed Has cavernosal artery flow returned Is there evidence of cavernosal leak
Perineal duplex study
Penile duplex Doppler
(+) Arterial lacunar fistula (-) Continue observation Consider further therapies: -Tension band / vacuum device -Intracavernosal pharmacotherapy -Inflatable penile prosthesis
Fig 152 Patient management algorithm based on study group data
Abnormal
Normal
Dynamic infusion Pharmacocavernosometry and cavernosography Abnormal Normal Continue observation
Priapism
Suggested Reading
1 Witt MA, Goldstein I, Tejada IS, Green eld A, Krane RK Traumatic laceration of intracavernosal arteries: the pathophysiology of non-ischemic, high- ow, arterial priapism J Urol 1990;143:129 2 Bastuba MD, Saenz de Tejada I, Dinlenc CZ, Sarazen A, Krane RJ, Goldstein I Arterial priapism: diagnosis, treatment and long-term follow-up J Urol 1994;151:1231 3 El-Bahnasawy M, Dawood A, Farouk A Low-Flow priapism: risk factors for erectile dysfunction BJU Int 2002;89:285 4 Brock G, Breza J, Lue TF, Tanagho EA High- ow priapism: a spectrum of disease J Urol 1993;150: 968 5 Hauri D, Spycher M, Bruhlmann W Erection and priapism: a new physiopathological concept Urol Int 1983;38:138 6 Krane RJ, Goldstein I, Tejada IS Impotence N Engl J Med 1989;321:1648 7 Lue TF, Hellstrom WJG, McAnich JW, Tanagho E Priapism: a rede ned approach to diagnosis and treatment J Urol 1986;136:104 8 Dahm P, Rao D, Donatucci C Antiandrogens in the treatment of priapism Urology 2002;59:138 9 Levine L, Guss S Gonadotropin-releasing hormone analogues in the treatment of sickle cell anemiaassociated priapism J Urol 1993;150:475 10 Rourke K, Fischler A, Jordan G Treatment of recurrent idiopathic priapism J Urol 2002;168:2552 11 Bookstein JJ Penile angiography: The last angiographic frontier AJR 1988;150:47 12 Ji MX, He NS, Wang P, Chen G Use of selective embolization of the bilateral cavernous arteries for posttraumatic arterial priapism J Urol 1994;151:1641 13 Wheeler GW Angiography in post-traumatic priapism: A case report AJR 1973;119:119
14 Gudinchet F, Fournier D, Jichlinski P, Meyrat B Traumatic priapism in a child: evaluation with color- ow Doppler sonography J Urol 1992;148:380 15 Feldstein VA Post-traumatic high- ow priapism evaluation with color ow Doppler sonography J Ultrasound Med 1993;12:589 16 Walker TG, Grant PW, Goldstein I, Krane RJ, Green eld A High- ow priapism: treatment with super-selective transcatheter embolization Radiology 1990;174:1053 17 Steers WD, Selby JBJ Use of methylene blue and selective embolization of the pudendal artery for high- ow priapism refractory to medical and surgical treatments J Urol 1991;146:1361 18 Puppo P, Belgrano E, Germinale F, Bottino P, Giuliani L Angiographic treatment of high- ow priapism Eur Urol 1985;11:397 19 Levine FJ, Tejada IS, Payton TR, Goldstein I Recurrent prolonged erections and priapism as a sequela of priapism: pathophysiology and management J Urol 1991;145:764 20 Crummy JB, Ishizuka J, Madsen PO Post-traumatic priapism: successful treatment with autologous clot embolization AJR 1979;133:329 21 Berger R, Billups K, Brock G, Broderick GA, Dhabuwala CB, Goldstein I, Hakim LS, Hellstrom W, Honig S, Levine LA, Lue T, Munarriz R, Montague DK, Mulcahy JJ, Nehra A, Rogers ZR, Rosen R, Seftel AD, Shabsigh R, Steers W AFUD Thought Leader Panel for evaluation and treatment of priapism Int J Impot Res 2001;13 (Suppl5):S39 43 22 Guideline on the Management of Priapism American Urologic Association, 2003 23 Hakim LS, Kulaksizoglu H, Mulligan R, Green eld A, Goldstein I Evolving concepts in the diagnosis and treatment of arterial high ow priapism J Urol 1996 Feb;155(2):541 8