Associated Issues of Ischemic Priapism in VS .NET

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Associated Issues of Ischemic Priapism
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1 Persistence and recurrence despite active intervention 2 Erectile dysfunction It is estimated that more than 25% of patients with priapism will have some degree of ED
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Non-Ischemic (High Flow) Priapism
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Non-ischemic or high- ow arterial priapism is a form of priapism typically caused by traumatic cavernosal artery laceration, or injury that enables unregulated ow of arterial blood directly into
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15 tivity in detecting the arterial lacunar stula that is seen angiographically on ultrasound (12 of 12 cases) In both the selective internal pudendal arteriography and perineal duplex study, the arterial lacunar stula was noted at the same location In fact, in one reported case where physical examination suggested incomplete return to accidity and postembolization due to recurrent stula, the negative perineal duplex Doppler ultrasound study correctly predicted the nal clinical outcome of complete priapism resolution and full erectile function Therefore if the follow-up clinical examination is equivocal for recurrence of the arterial lacunar stula, perineal duplex Doppler ultrasound may better predict the need for repeat arteriography and embolization The current algorithm for the management of non-ischemic priapism is seen in Fig 152 The algorithm emphasizes patient history, physical examination, pre-morbid and current erectile function status, and the use of perineal duplex Doppler ultrasonography for initial identi cation of the pathognomonic arterial lacunar stula If an active course of treatment is chosen, selective internal pudendal arteriography and embolization with autologous clot, with or without Gelfoam should be employed While complete detumescence is ideally seen immediately following selective embolization, partial tumescence at this time may be related to longstanding edema, reinforcing the concept that physical examination alone cannot be used to determine the endpoint of treatment or as the sole means of follow-up evaluation Serial perineal and penile duplex studies over the days and weeks postembolization should be part of the overall regimen to assure adequate resolution of the arterial lacunar stula If further intervention is required, perineal duplex studies can reduce the reliance upon multiple subsequent angiographic procedures and their associated risks
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the lacunar spaces of the corpora, bypassing the protective, high-resistance helicine arterioles This constant unregulated ow results in the pathognomonic arterial lacunar stula (ALF) of high- ow priapism The clinical characteristics of non-ischemic priapism typically include a pre-morbid history of trauma, delayed onset of priapism following the trauma, incomplete rigidity of the phallus compared to premorbid sexually-stimulated erectile rigidity, and a constant erection that is painless, non-tender, of persistent partial rigidity throughout the day and night, with the potential for increase to full rigidity with sexual stimulation Although spontaneous resolution may occur, with non-ischemic priapism the painless, partial erection will often continue unless active intervention is performed Selective internal pudendal arteriography has been the mainstay of diagnostic and therapeutic maneuvers for arterial priapism The pathognomonic arteriographic nding is of an arterial lacunar stula a characteristic intracavernosal cone-shaped blush of contrast at the site of the cavernosal artery laceration Unfortunately, these therapies have had little success in reversing the high- ow priapism state and are currently not recommended by the AUA guidelines for priapism therapy The current standard of intervention remains selective internal pudendal arteriography with transcatheter autologous clot embolization The goal of this therapy is to induce temporary occlusion of the cavernosal artery in order to allow the injured site to heal The temporary nature of this occlusion allows for the subsequent reestablishment of physiologically-controlled normal cavernosal blood ow, with preservation of erectile tissue viability and normal long-term erectile function This form of minimallyinvasive intervention has a high probability for resolution of the priapism with restoration of erectile potency compared to more invasive techniques, including permanent coil embolization and surgical ligation of the cavernosal artery Studies comparing perineal duplex ultrasound and concomitantly preformed selective internal pudendal arteriography have revealed excellent sensi-
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