Pseudo-Priapism! Forgotten Semirigid Penile Prosthesis

Letter to the Editor Pseudo-priapism! Forgotten semirigid penile prosthesis

S Basu1*, CS Biyani1, SS Karamuri2 and T Shah1

1Department of Urology, Bradford Royal Inﬁrmary, Bradford, UK; and 2Department of Radiology, St James’ Hospital, Leeds, UK

Priapism is an undue and sustained erection in the absence of sexual stimulus. In the elderly population drug induced, thromboembolic and malignant aetiologies are common. This report demonstrates that in elderly demented patients, penile prosthesis should be considered in the differential diagnosis of such a condition. A plain X-ray of the pelvic region incorporating the penis could prove very useful, particularly in the absence of a proper history. International Journal of Impotence Research (2002) 14, 418–419. doi:10.1038=sj.ijir.3900870

Keywords: priapism; penile prosthesis; penile-doppler; corpus cavernosum

Introduction the complaint of a nonresolving erection of 2 weeks duration with moderate pain. This patient had been a long-term sufferer of chronic obstructive airway Priapism is a sustained erection in the absence of a disease (COAD), rheumatoid arthritis, non-insulin sexual stimulus. By far the majority of the cases are dependant diabetes mellitus (NIDDM) hypertension, the result of a veno-occlusive event in the corpora- Parkinson’s disease and dementia. General exam- 1 cavernosa, particularly due to pharmacotherapy. ination was unremarkable. Penile examination Pain is a predominant feature, unless an arterial showed a tender red and erythematosus glans, a pathology is implicated, where there is a history of firm or semi-rigid rather than a hard penis and the trauma present. In the elderly population along with absence of any paraphimosis. Due to the painful the cause mentioned already, antipsychotic-medica- nature a urethral catheter was inserted. Full blood tion, hyperviscosity syndromes and malignancies count (FBC), urea and electrolytes (U&E), C-reactive are some of the other factors implicated in the protein (CRP) and glucose where all within normal causes of priapism. With the increasing size of the range. Rectal examination did not reveal any elderly population, there however is a demented prostatic abnormality and prostate-specific antigen subgroup where proper history may not be available (PSA) was normal for age. Attempted aspiration of and the presence of a semi-rigid prosthesis must the corpora for cavernosal blood was unsuccessful be regarded as one of the differential diagnoses so was phenylephrine injection and the needle met in a case of priapism. We report an unusual case with stiff resistance. Abdominal ultrasound re- of priapism, which presented non-acutely and vealed no abnormality. Penile-doppler ultrasound turned out to be a penile prosthesis in the process was performed which revealed echo-poor cavernosa of erosion into the urethra in an elderly demented with bright echogenic tubular areas in between individual. suggestive of calcification within an infarcted corpus. It was thus reported as an (Figure 1) end stage irreversible infarction of corpora cavernosa. Case report After discussion with the family, a decision was taken to manage the patient conservatively with pain relief and a suprapubic catheter. While he was A 72-year-old male resident of a nursing home was still in hospital, awaiting discharge, his ex-wife referred to the on-call urology team by his GP, with visited his GP and told him that he had a penile prosthesis implanted 10 y previously in one of the *Correspondence: S Basu, Department of Urology, Bradford Royal Infirmary, Duckworth Lane, Bradford, BD9 6RJ, UK. regional hospitals. A straight film of the pelvis was E-mail: [email protected] requested, and this showed (Figure 2) the shadow of Received 9 January 2002; accepted 6 March 2002 the prosthesis, with metal clips anchoring them. He Letter to the Editor SBasuet al 419 was discharged home. Two weeks later he was readmitted with erosion of the prosthesis through his urethra and subsequent extrusion.

Discussion and conclusion

In the case of elderly nursing home residents, proper history may not be available until a suitable time, as a sizeable number of the population can be demented. Priapism in itself is a urological emergency as its persistence beyond 24 h increases the chances of widespread smooth muscle necrosis and subsequent impotence.2 Two types of priapism have been described, high-flow or arterial and low-flow or venous. In the case of venous=low-flow priapism, cavernosal blood gas analysis together with colour- coded penile Doppler ultrasound scan showing minimal arterial flow and distended corpora cavernosa clinches the diagnosis.3 In this case inability to aspirate blood from the cavernosa together with extensive fibrosis on penile ultrasound was not corroborative of a low-flow priapism, hence in the absence of a proper history, a definitive conclusion was not possible. This case turned out to be one of a penile prosthesis in the process of erosion and extrusion. The Doppler finding of calcifications and a well organised tubular echogenic area within the corpora did not definitely resemble that of a penile Figure 1 Ultrasound of penis: transverse and longitudinal prosthesis hence the straight X-ray of the pelvis section images showing echo-poor corpora cavernosa with showing the penile region did play a significant part echogenic areas which appear elongated on longitudinal section. in clinching the diagnosis. There has been a previous report of perineal pain caused by leftover rear-tip extenders from a removed penile prosthesis, which was discovered as a scout abdominal film.4 Penile prosthesis if followed-up for more than 5 year will have a 5% re-operation rate for mechanical failure,5 and in the case of demented elderly individuals it only complicates the picture. A straight X-ray of the pelvis should not be omitted and a semirigid penile prosthesis should be considered when evaluating such patients present- ing with similar problems.

References

1 Erectile dysfunction: current investigation and management. Mosby-Wolfe Medical Communication: London, 1998. 2 Spycher MA, Hauri D. The ultrastructure of erectile tissue in priapism. J Urol 1986; 135: 142 – 147. 3 Broch G et al. Nitric oxide synthase: a new diagnostic tool for neurogenic impotence. Urology 1993; 141: 412. 4 Stein A, Shotland Y, Lurie A. Malleable penile prosthesis removal leaving behind the rear tip extenders: a clinical presentation. Urol Int 1993; 50: 119 – 120. Figure 2 Radiograph of penile area showing long and spiraling 5 Lewis RW. Long-term results of penile prosthetic implanta- nature of the implant. tions. Urol Clin North Am 1995; 22: 847 – 863.

International Journal of Impotence Research