Ischemic priapism is an organ-threatening event. It presents as a rigid and painful erection despite the absence of any sexual stimulation. In up to 60% of cases of ischemic priapism no precipitating factor is identified. However, medications such as intra-cavernosal agents, anti-psychotics, anti-hypertensives, as well as illicit drug use and hematological disorders have been implicated in ischemic priapism. Management of a prolonged priapism is challenging. It is usually refractory to aspiration, intra-carvenosal phenylephrine, and even surgical shunting. The corpora carvenosa can be irreversibly replaced by dense fibrosis after 6 hours of ischemia. This may result in a shortened, indurated, non-erectile penis. We present and describe the surgical technique of a case of prolonged ischemic priapism treated with early implantation of penile prosthesis.
Yeng Kwang Tay, Dan Spernat, Sree Appu, Christopher Love
Submitted Septebmer 30, 2011 - Accepted for Publication March 9, 2012
KEYWORDS: Priapism, penile prosthesis, early insertion
CITATION: UroToday Int J. 2012 June;5(3):art 28. http://dx.doi.org/10.3834/uij.1944-5784.2012.06.15
Ischemic priapism is an organ-threatening event. It presents as a rigid and painful erection despite the absence of any sexual stimulation. Ischemic priapism is commonly associated with intracavernosal agents to treat erectile dysfunction . Less commonly, anti-hypertensives, anti-psychotics, illicit agents such as cocaine, medical conditions such as blood dyscrasias, and sickle cell anemia may cause it. The management of prolonged priapism (greater than 24 hours) is difficult. Irreversible damage is evident even after 6 hours of ischemia , and in our experience the priapism is usually irreversible by the time patients present to our tertiary referral center.
The sequelae of unresolved priapism are penile fibrosis and total erectile dysfunction, treatable only by later implantation of a penile prosthesis. This is a technically difficult procedure with a high complication rate and often leaves a cosmetically and functionally poor result, particularly because of the severe shortening associated with the fibrosis.
A 51-year-old man presented to our tertiary referral center with an 8-day history of ischemic priapism. He had no history of erectile dysfunction nor had he had any previous episodes of priapism. There were no inciting events noted in the history. He had presented several days earlier at a peripheral hospital where aspiration was attempted. This failed to relieve his priapism and he was discharged home with analgesia.
When he presented to our tertiary referral center he was in severe pain and had no detumescence for 8 days. Initially, he was managed with attempt at aspiration and an injection of phenylephrine as per the American Urological Association guidelines. As this failed to relieve his priapism, a distal shunt (Winter shunt) was performed. Unfortunately, this also failed to relieve his priapism. The patient was admitted to the ward for analgesia and taken to theater the following morning for placement of a malleable penile prosthesis.
Under a general anesthetic, the corpora were exposed via a penoscrotal incision. Bilateral 3 cm corporotomies were performed with minimal bleeding from the ischemic cavernous tissue. Dilatation was achieved with a single pass of a Furlow tool proximally and distally on each side, followed by a 12 Hegar dilator. Following this, 12 mm by 21 cm Coloplast (Minneapolis, USA) malleable rods were inserted. The procedure was uneventful, and even after 8 days of priapism there was minimal fibrosis and no difficulty dilating the corpora cavernosa. The total operative time was 20 minutes. Additionally, the previously performed Winter shunt did not impede the placement of the prosthesis. The patient was discharged home on postoperative day 2 with minimal pain. He was reviewed at 4 weeks postoperatively, and his wound has healed completely without any evidence of complications. The 6-month follow-up confirmed excellent patient satisfaction without any difficulties achieving successful sexual intercourse. The patient was offered placement of a 3-piece inflatable penile prosthesis; however, due to satisfaction with the malleable device the patient has declined this.
Of patients who have priapism lasting for more than 24 hours, 90% experience impotence [1,4]. Dense fibrosis of the corpora cavernosa occurs with extended priapism and complicates the later insertion of penile prostheses . Early implantation before the development of dense fibrosis might give more satisfactory results . Furthermore, the placement of a malleable prosthesis acts to prevent fibrosis and scarring of the corpora cavernosa, thus maintaining penile length . Early implantation of penile prosthesis also permits early return of sexual activity . As highlighted by Deveci et al., the loss of penile length is closely associated with lower satisfaction rates and lower International Index of Erectile Function scores . An alternative would be to place an inflatable penile prosthesis acutely. However, regular cycling of the device is required to prevent fibrosis and penile deformity . This may be difficult for the patient to perform due to pain and swelling.
Some studies have reported difficulties with migration of penile prostheses after aggressive Winter shunt with the potential for distal extrusion of the prosthesis necessitating additional procedures . Others, however, have reported no increased incidence of extrusion through the weakened tip of the corpora cavernosa . To prevent this theoretical increased risk we recommend performing a Winter shunt with a “Tru-cut” biopsy needle as used for transrectal prostate biopsy to prevent loss of large areas of distal corpora cavernosa. Additionally, Ralph et al. have reported an increased infection risk (6%) in patients with shunt surgery . Once the tissues have settled the patient can be considered for placement of an inflatable penile prosthesis. In fact, early penile prosthesis insertion is technically easier with low complication rates . It can also prevent extended or double corporotomies, which is often unavoidable in cases with dense corporal fibrosis .
- Douglas, L., H. Fletcher, et al. (1990). “Penile prostheses in the management of impotence in sickle cell disease.” Br J Urol 65(5): 533-535.
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- Sedigh, O., L. Rolle, et al. (2011). “Early insertion of inflatable prosthesis for intractable ischemic priapism: our experience and review of the literature.” Int J Impot Res 23(4): 158-164.
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- Salem, E. A. and O. El Aasser (2010). “Management of ischemic priapism by penile prosthesis insertion: prevention of distal erosion.” J Urol 183(6): 2300-2303.
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- Ralph, D. J., G. Garaffa, et al. (2009). “The immediate insertion of a penile prosthesis for acute ischaemic priapism.” Eur Urol 56(6): 1033-1038.
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- Deveci, S., D. Martin, et al. (2007). “Penile length alterations following penile prosthesis surgery.” Eur Urol 51(4): 1128-1131.
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- Kabalin, J. N. (1994). “Corporeal fibrosis as a result of priapism prohibiting function of self-contained inflatable penile prosthesis.” Urology 43(3): 401-403.