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Priapismus
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definition/background
Persistent painful purposeless erectionof the penis (or clitoris)
Frequently idiopathic Associated with some systemicdiseases
Sometimes seen after intra-cavernosalinjections
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Priapos (Priapus) was theGreek God of fertility who is
usually pictured with amassive erection.This painting was
discovered in the wall of atemple in Pompeii, destroyed
by the eruption of Mount Vesuvius in 79 AD. It shows
Priapos weighing his erection.
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Prostate Corpora cavernosa
Cross- section from The Visible Human Project
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Priapism - physiology
Penile erection generated by sensory stimulation of genitalia
spinal reflex arc - reflexogenicerectionafferent from penis through
pudendal nerve to sacral spinalerection center (S 2-S 3-S 4)efferent parasympathetic fibers
travel back in nervi erigentes and
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Priapism - physiologyPenile erection generatedby psychogenic stimuli
from higher braincenters
descend throughlateralcolumns andstimulatethoracolumbar andsacral spinalerectioncenters
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Priapism - physiology
Nitric oxide - an endogenous vasodilator- is released from nerve endings and
endothelial cells and binds to receptorson smooth muscle of corpora cavernosaCyclic guanosine monophosphate
(cGMP) is formed, relaxing smoothmuscle and allowing engorgement
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Priapism - physiology
Phosphodiesterase type 5 (PDE 5)catalyzes cGMP to GMP, leading to
reversal of the above processSildenafil (Viagra), a recently releaseddrug for erectile dysfunction, acts as a
PDE 5 inhibitor, helping to maintain aphysiologic erection
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Priapism - pathophysiology
Persistent erection of corporacavernosa due to disturbances in
detumescence mechanisms - i.e. inflow>> outflowCorpora spongiosum of the glans and
peri-urethral region unaffected
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Priapism - pathophysiology
Arterial high-flow - usually due torupture of cavernous artery and
unregulated flow into lacunar spaces -NOT generally painfulVeno-occlusive (low-flow) - full and
unremitting corporeal veno-occlusion
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Priapism - frequency
Internationally: no information availableIn the USA: High-flow rare, usually due to blunt
perineal injury or penetrating peniletrauma
Low-flow common in sludgingdisorders, especially sickle-celldisease (about 1/3 of males) andleukemic disorders
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Priapism - morbidity/mortality
Deaths have been reported in patientswith sickle cell disease and priapism,
but due to complications fromunderlying disease processMain morbidity is long-term impotence,
especially when diagnosis andtreatment are delayed
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Priapism - demographics
Race - no predilection (although sicklecell disease, of course, is a condition of
the African American population)Sex - disease of males. Clitoralpriapism has been described rarely
Age - all ages, but peak in sickle cellpatients between 19 & 21 years
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Priapism - history
Arterial high-flow priapism may be delayed after acute injury
may be due to vessel spasm, orformation of clot, which is reabsorbed
less tumescent than venous priapism
less painful than venous priapism good long-term prognosis
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Fractured penis
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Priapism - history
Veno-occlusive priapism painful erection, present for hours to
days ask abouttrauma
drugs - therapeutic and illicitself-injectionsexual stimulation
ast histor of similar or
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Priapism - causes
Most common -IDIOPATHICOther causesinclude leukemia multiple myeloma sickle cell disease tumor infiltration thalassemia
spinal cord injury
recentMycoplasmainfection
amyloidosis black widow
spider bites
carbon monoxidepoisoning
recent heparinuse
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Priapism - causes
Caverject self-injection Urethralsuppository
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Priapism - causes
Vacuum pumps andother sexual aids
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Priapism - causes
psychotropic drugs phenothiazines
butyrophenoneshydralazineprazosin, labetolol,phentolamine andother -blockerstestosteronemetoclopramide
calcium-channelblockersanti-coagulantstamoxifenomeprazolehydroxyzinecocaine, marijuana,and ethanol
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Phoneutria nigriventer - "armed spider"
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Priapism caused by Phoneutria bite
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Priapism - physical exam
Erect or semi-erect penis with a flaccidglans
Search for signs of traumaSearch for other possiblesigns of sludging - florid
skin, petechiae,conjunctival injection
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Priapism - work-up
Lab studies: If no predisposing factors, a complete
blood count may help identify apreviously undiagnosed leukemiaImaging studies:
Selective penile angiography may behelpful in high-flow priapism
CT scan - ?useful in segmental disease
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Priapism - treatment
Arterial priapism - 4 options Mechanical: iced compression
Pharmacologic: -agonists (watch outfor systemic blood pressure rise)
Surgical: fistula ligation (usually leads
to impotence) Selective embolization: new
procedure with varying degrees of
success
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Priapism - treatment
Priapism due to pharmacological agents terbutaline 5 mg po repeated in 15
minutes leads to resolution in about1/3 of patients intracavernous injection of -
adrenergicphenylephrine 100 to 500 mcg (put10 mg in 500cc NSS 20 mcg/ml.
Inject 10 to 20 cc every 5-10-
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Priapism - treatment
Low-flow due to sickle cell disease hydration
alkalinization analgesia possible exchange transfusion to get
Hgb > 10 gm% and HbS
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Priapism - treatment
Aspiration and irrigation for priapism lasting more than 2 hours
discuss with urologist if at all possible MUST warn patient treatment may
result in permanent impotence
conscious sedation may benecessary
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Priapism - treatment
Local anesthetic or penile blockInsert 19-g butterfly into engorged
corpus cavernosum through the glansinto the distal portionMilk out old blood
Irrigate with salineElastic wrap (Ace) to flaccid penis
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Priapism - complications
Impotence: about 50% incidence Younger patients seem to do better
Fibrosis: related to tissue ischemia Makes prosthesis placement difficultGangrene: due to ischemia andinfection Suprapubic catheter may help avoid
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Priapism - complications
Fourniers gangrene