PRIAPISM

MCHS (LL CAMPUS

PRIAPISM
OBJECTIVES
Describe the condition
Aetiology
Pathophysiology
Clinical features
Investigation
Management
DESCRIPTION
 Priapism is a pathologic condition involving
involuntary, prolonged erection which is
unrelated to sexual stimulation lasting for
more than 4 hrs and unrelieved by
ejaculation.
 This condition is a urologic emergency and
early intervention allows the best chance for
functional recovery
 Incidence is bimodal – 5-10 yrs and 20-50
yrs.
DESCRIPTION CONT..
 Pain is a common descriptor, perceived to
be a consequence of genital tissue ischemia
and increased pressure generated within the
corporal bodies.
 Classified as

1) Ischemic (low flow)

2) Non-ischemic (high flow)
ETIOLOGY
Idiopathic
The most common cause of priapism in the adult
population involves agents used to treat erectile
dysfunction.
The most common cause in children is sickle cell
disease (SCD), accounts for 65% of cases.
 Leukemia
 Direct trauma: penile ,Perineal & scrotal
Recreational drugs. i.e. Cocaine and Alcohol
ETIOLOGY CONT.
Neurologic Conditions: such as
syphilis, brain tumors, epilepsy and brain
and spinal cord injury.
Malignant Neoplasm: Local primary or
metastatic neoplastic processes are also
known to carry priapism risks
ETIOLOGY CONT.
 Pharmacologic causes like
Antihypertensives.
 Psychotropic drugs like the typicals
(chlorpromazine, fluphenazine, and
atypicals like clozapine,risperidone
and aripiprazole
 Antidepressive agents like fluoxetine,
citalopram and trazodone
PATHOPHYSIOLOGY
 Vascular stasis in the penis and decreased
venous outflow from the organ are the
primary circumstances that may cause
priapism.
 Fistula formation (cavernous artery and
lacunar spaces of the cavernous tissue),
which allows blood to bypass the normal
cavernous arteriolar bed.
 Unregulated or disrupted arterial inflow,
allowing a lot of well-oxygenated blood in
the corpora.
LOW-FLOW PRIAPISM
Low-flow priapism may be due to any of the
following:
1) An excessive release of
neurotransmitters
2) Blockage of draining venules (e.g.,
mechanical interference in sickle
cell crisis or leukemia
LOW-FLOW PRIAPISM
During these episodes, a veno-occlusive
effect impedes venous outflow of the
corpora cavernosa.
This increases pressure within the
corporal bodies, facilitating accumulation
of blood that stagnates in the corporal
sinusoid.
LOW-FLOW PRIAPISM
Eventually, this contributes and exposes
the penile tissues to an environment that
is so hypoxic and acidic.
Increasing pressure within the corporal
bodies creates rigidity and a painful
erection
LOW-FLOW PRIAPISM
Persistent tissue ischemia lasting longer
than 24 hours can result in endothelial and
smooth-muscle cell destruction and penile
fibrosis.
Tissue ischemia that lasts for over 48 hours
may lead to smooth-muscle necrosis.
With delay of treatment, the irreversible
sequlae can lead to varying degrees of
permanent erectile dysfunction.
 LOW-FLOW PRIAPISM
 Prolonged low-flow priapism leads to a painful
ischemic state, which can cause fibrosis of the
corporeal smooth muscle and artery
thrombosis.
 The degree of ischemia depends on number
of veins involved and the duration of
occlusion.
 Light-microscopy studies conducted
demonstrated that corporeal tissue becomes
thickened, edematous, and fibrotic after days
of priapism.
FEATURES OF LOW-FLOW
PRIAPISM
This condition is generally painful.
Patients are sexually inactive
No history of trauma
No evidence of trauma
Rigid erection
Ischemic corpora: As indicated by
dark blood upon corporeal aspiration
 HIGH FLOW PRIAPISM
High-flow priapism is the result of
uncontrolled arterial inflow from a fistula
between the cavernousa artery and the
corpus cavernous.
This is generally secondary to blunt or
penetrating injury to the penis or
perineum causing rupture of a cavernous
artery.
CROSS SECTION OF
PENIS
FEATURES OF HIGH-FLOW
PRIAPISM
This type of priapism is generally not painful .
Adequate arterial flow
Well-oxygenated corpora
Evidence of trauma: Blunt or penetrating injury to
the penis or perineum.
The patient may be sexually active
Chronic recurrent presentation
Delay between trauma and the onset of priapism
INVESTIGATIONS

 FBC
 Grouping and x-match
 Penile blood gas (PBG) measurement
 Penile Doppler ultrasonography: locate fistulas
in high-flow priapism
 Pelvic angiography: To help confirm the fistula’s
location after introducing a dye IV)
 Computed tomography (CT) scanning
MANAGEMENT
 Detumescence is the goal of
treatment, managed through a
process of aspiration followed by
intracavernous drug therapy
 Historically, priapism was managed by
nonmedical interventions such as
ejaculation, exercise, ice packs, and
cold baths to induce vasoconstriction
and possibly providing pain relief.
MANAGEMENT
These remedies have achieved varying
levels of success.
However, they lack evidence and do not
correlate with the hemodynamics of
priapism.
MANAGEMENT (LOW-
FLOW PRIAPISM)
Supportive care
Identify and treat reversible causes.
Intracavernosal phenylephrine (Neo-
synephrine) is the drug of choice and first-
line treatment for low-flow priapism. NOTE:
always put patients on cardiac moniter when
giving Intracarvenosa injections. (ICI)
Aspiration of the corpora cavernousa
followed by saline irrigation.
INTRACARVENOSA
INJECTIONS (ICI)
EPINEPHYLINE/
PHENYLEPHRINE ADRENALINE

 Dilute a  Give 1-2mls of

concentration of (1:100 000)
100-500mcg per 1 strength
ml. adrenaline.
 Give every 3-5  Administer it every
minutes up to a 20 minutes up to
maximum of 1mg amaximum of five
in an hour. times
GENERAL MANAGEMENT
(LOW-FLOW PRIAPISM)
Key steps in the management of low-
flow priapism include the following:
Oxygenation
Analgesics (e.g. intravenous
morphine)
Hydration
Transfusion if prolonged periods of
ischemia have occurred
Emergent surgical decompression
DECOMPRESSION
PROCESS
Ischemic priapism of more than 4 hours in
duration implies a compartment syndrome,
decompression of the corpora cavernousa is
recommended for counteracting the ischemic
effects.
1. Dorsal nerve block and ring block
2. Transglanular intracorporal needle
insertion with an angiocatheter (16- or 18-
gauge).
3. Evacuation of blood and irrigation of the
corpora cavernousa
PENILE IRRIGATION
PENILE IRRIGATION
PROGNOSIS

Prognosis depends on the :

Duration of symptoms
The patient's age
Underlying pathology.
It is reported that 92% less than 24 hours
remain potent, while only 22% of patients
with priapism that lasted longer than 7
days remained potent.
PROGNOSIS
 In general, vaso-occlusive priapism
poses a higher risk of impotence than
high-flow arterial priapism.
 Sickle cell disease appears to
particularly increase risk.
 Infection can complicate priapism.
 NOTE: This is a urological emergency
!!!!!!!
THANK YOU ALL