pISSN: 2287-4208 / eISSN: 2287-4690 World J Mens Health 2016 April 34(1): 1-8 http://dx.doi.org/10.5534/wjmh.2016.34.1.1 Review Article

Clinical Management of Priapism: A Review

Kazuyoshi Shigehara, Mikio Namiki

Departments of Integrative Cancer Therapy and Urology, Kanazawa University Graduate School of Medical Science, Ishikawa, Japan

Priapism is defined as a persistent and painful erection lasting longer than four hours without sexual stimulation. Based on episode history and pathophysiology, priapism is classified into three subtypes: ischemic (low-flow), non-ischemic (high-flow), and stuttering priapism. Ischemic priapism is characterized by a persistent, painful erection with remarkable rigidity of the corpora cavernosa caused by a disorder of venous blood outflow from this tissue mass, and is similar to penile compartment syndrome. Stuttering priapism is characterized by a self-limited, recurrent, and intermittent erection, frequently occurring in patients with sickle cell disease. Non-ischemic priapism is characterized by a painless, persistent nonsexual erection that is not fully rigid and is caused by excess arterial blood flow into the corpora cavernosa. Because ischemic and non-ischemic priapism differ based on emergency status and treatment options, appropriate discrimination of each type of priapism is required to initiate adequate clinical management. The goal of management of priapism is to achieve detumescence of the persistent penile erection and to preserve erectile function after resolution of the priapism. To achieve successful management, urologists should address this emergency clinical condition. In the present article, we review the diagnosis and clinical management of the three types of priapism.

Key Word: Priapism, Penile erection

INTRODUCTION tients aged 40∼50 years [3]. Although the causes differ based on the clinical type of priapism, most cases are idio- Priapism is defined as a persistent and painful erection pathic (21%, alcohol drinking or drug abuse; 12%, peri- lasting longer than four hours without sexual stimulation, neal trauma; and 11%, sickle cell disease [SCD]) [5]. and usually needs emergency management [1]. Since the Based on episode history and pathophysiology, priap- first reported case by Tripe in 1845 [2], the etiology and ism is classified into three subtypes: ischemic (low-flow), clinical condition of priapism have been clarified gra- non-ischemic (high-flow), and stuttering (intermittent) dually. Some epidemiological studies have reported the priapism. Stuttering priapism is characterized by a re- incidence of priapism to be 0.3 to 1.0 per 100,000 males current and intermittent erection, frequently occurring in per year [2-4]. Typically, priapism occurs frequently in pa- a specific patient population with SCD, and is categorized

Received: Mar 2, 2016; Recised Mar 31, 2016; Accepted: Apr 2, 2016 Correspondence to: Kazuyoshi Shigehara Departments of Integrative Cancer Therapy and Urology, Kanazawa University Graduate School of Medical Science, 13-1, Takaramachi, Kanazawa, Ishikawa, 920-8641, Japan. Tel: +81-76-265-2393, Fax: +81-76-222-6726, E-mail: [email protected]

Copyright © 2016 Korean Society for Sexual Medicine and Andrology This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons. org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 2 World J Mens Health Vol. 34, No. 1, April 2016 as a self-limited ischemic priapism. As ischemic and non- 1. Ischemic priapism ischemic priapism differ based on treatment options and emergency status, it is important for urologists to discrim- Ischemic priapism, which accounts for 95% of all priap- inate between the types. ism cases, is the most common type [1]. It is characterized by a persistent, painful erection with remarkable rigidity of DIFFERENTIAL DIAGNOSIS the corpora cavernosa caused by a disorder of venous blood outflow from this tissue mass. Thus, penile tissue Differential diagnoses for ischemic and non-ischemic shows a hypoxic and acidotic condition, similar to penile priapism are indicated in Table 1, and a flowchart of each compartment syndrome, within the closed space of the treatment option is shown in Fig. 1. corpora cavernosa. Because it can lead to corporal tissue damage with time, emergency examination and manage-

Table 1. Differential diagnosis of priapism Variable Ischemic priapism (low flow) Non-ischemic priapism (high flow) Etiology Idiopathic, various drugs, corporal injections Antecedent trauma malignancies, SCD Symptoms Painful, remarkable rigidity, and complete Painless, not fully rigid, and incomplete erection erection

Corporal blood gas PO2≤30 mmHg, PCO2≥60 mmHg, pH≤7.25 PO2＞90 mmHg, PCO2＜40 mmHg, pH 7.40 analysis Compression signs Negative Positive Color Doppler A loss of cavernous blood flow Turbulent cavernous blood flow arteriolar-sinusoidal fistula CT scan Not commonly used Arteriocorporal fistula other pelvic injuries MRI Not commonly used Arteriocorporal fistula Angiography Not commonly used Arteriocorporal fistula, embolization SCD: sickle cell disease, CT: computed tomography, MRI: magnetic resonance imaging.

Fig. 1. Flowchart of treatment options for ischemic and non-ischemic pri- apism. CT: computed tomography, MRI: magnetic resonance imaging, 5-AR: 5-alpha reductase inhibitors. Kazuyoshi Shigehara and Mikio Namiki: Clinical Management of Priapism 3 ment are required; delayed treatment can result in com- chemic priapism is usually the result of antecedent trauma plete erectile dysfunction (ED) [1]. of the perineal or penile regions. It is induced by arterial The most common causes of priapism are iatrogenic, damage leading to arteriocorporal fistulas and occasion- such as intracarvernosal injections of prostaglandin E2 or ally to a trauma-associated pseudoaneurysm [11-13] con- papaverine hydrochloride and overdose administration of tributing to excess unregulated arterial flow to the corpora phosphodiesterase 5 (PDE5) inhibitors used in ED treat- cavernosa. In general, an incomplete and partially hard ment [1,6]. Some previous reports have stated that psychi- erection does not develop immediately after the trauma atric medications, alpha-1 blockers, leukemia, malignant but occurs later. lymphoma, malignancies (metastasis of the bladder, pros- In non-ischemic priapism, the corporeal blood gas anal- tate, and colorectal carcinoma of the corpora cavernosa), ysis reveals normal arterial blood gas values of PO2 ＞90

SCD, and idiopathic causes lead to the development of is- mmHg, PCO2 ＜40 mmHg, and pH 7.40 [2]. Perineal chemic priapism [2,5,7-9]. Possible mechanisms of this compression, which is also known as a compression sign type of priapism may be delay in corporal venous dilation, and results in obstruction of the causative arteriocorporal increase in blood stickiness, and direct venous invasion of fistulas, contributes to detumescence of the erection. malignancy. Compression sign is sometimes indicative of a diagnosis of The diagnosis of ischemic priapism can be made by a non-ischemic priapism, complementing a physical exami- cavernous blood gas analysis to confirm the storage of ve- nation [14]. CDU is also a common diagnostic tool and nous blood within the corpora cavernosa manifesting as a can show the unregulated and turbulent cavernosal arte- lower partial oxygen pressure (pO2; ＜30 mmHg), higher rial flow within the corpora cavernosa, suggestive of the partial carbon dioxide pressure (pCO2; ＞60 mmHg), and presence of arteriolar-sinusoidal fistula in most non-ische- a decline of pH (＜7.25) [2]. A cavernous blood gas analy- mic priapism cases [15]. Enhanced CT or CT angiography sis is recommended to distinguish non-ischemic from is- can be non-invasively and quickly performed, and these chemic priapism. In addition, a blood analysis should be are secondary recommended examinations for non-ische- performed for determining the cause of priapism and its mic priapism. In addition, localization of arteriocorporeal management, regardless of the type of priapism. Reticulocyte fistulas within the corpora cavernosa and the presence of counts and hemoglobin electrophoresis are informative other pelvic injuries can be determined [16]. for signifying the presence of SCD [2]. Color Doppler ul- Internal pudendal arteriography is not used for the ini- trasonography (CDU) is also a useful tool for screening is- tial diagnosis of priapism because of its invasiveness, but chemic priapism, which shows a loss of cavernous blood it is an essential examination for cavernosal arterial embo- flow without a cavernous arterial pulse [10]. Computed to- lization. The penile arteriography reveals outflow of the mography (CT) is not commonly used for the diagnosis of contrast medium into the corpora cavernosa from the arte- ischemic priapism, but CT should be performed for identi- rial–sinusoidal fistula. As there are some cases with bi- fying its etiology for management of the disease. lateral arteriocavernous fistula, internal pudendal arte- riography should be performed bilaterally. 2. Non-Ischemic priapism Magnetic resonance imaging (MRI) can also reveal ap- Non-ischemic priapism manifests as a painless, persis- parent findings of corpora cavernosa and the site of the ar- tent, partially rigid, and nonsexual erection. It is caused by teriocavernous fistula [1,5,17]. However, it is not com- excess blood flow from arteries into the corpora caver- monly used as a routine diagnostic tool because less in- nosa. As cavernous tissue shows a well-oxygenated con- formation regarding the usefulness of MRI is currently dition, non-ischemic priapism is not considered a medical available. emergency. 3. Stuttering priapism Non-ischemic priapism is generally less prevalent com- pared to ischemic priapism; however, it is relatively fre- Stuttering priapism is caused by SCD and is a recurrent quent in regions with rare prevalence of SCD [5]. Non-is- and intermittent painful erection. SCD is most prevalent in

www.wjmh.org 4 World J Mens Health Vol. 34, No. 1, April 2016 sub-Saharan Africa, tribal regions of India, and the Middle 1) Corporal aspiration East, whereas it is less prevalent in East Asia, including After penile anesthesia, a 19-gauge needle is used to Japan and Korea [18]. The lifetime incidence rate of priap- puncture the corpus cavernosum at the lateral shaft of the ism in the SCD population is as high as 42%, and these ep- penis to avoid damaging the urethra and the dorsal neuro- isodes result in ED in over 30% of cases [19]. In over 75% vascular bundle [5,21]. In cases of ischemic priapism, cor- of cases of stuttering priapism, patients with SCD experi- poral aspiration reveals dark venous blood initially and ence their first episode of priapism in their 20s, and con- should be continued until bright red oxygenated blood is versely, the most common cause of priapism occurring in aspirated [5]. When aspiration is difficult because of the in- children is SCD [19]. On the other hand, stuttering priap- creased viscosity of the blood within the corpus cav- ism may also be idiopathic or drug-induced and may fi- ernosum, cold saline irrigation can promote evacuation of nally lead to ischemic priapism, and the diagnosis and the viscous hypoxic blood [22]. Aspiration alone, with or clinical management are generally based on ischemic without corporal irrigation, has a success rate of approx- priapism. imately 30% [2,23]. A cause of stuttering priapism in men with SCD is sug- 2) Corporal injection of sympathomimetics gested by the relatively low PDE5 levels caused by less ac- If the corporal aspiration procedure is not successful, tivity of endothelial nitric oxide (NO), leading to the re- sympathomimetics should be instilled into the corpus lease of neuronal NO, which can contribute to abnormal cavernosa. Because of their low risk profile for any car- relaxation of the corpora cavernosa [20]. diovascular side effects, α-adrenergic agonists such as phenylephrine, with minimal β-adrenergic effects, should CLINICAL MANAGEMENT be used [2,23,24]. Continuous monitoring of vital signs during administration of these agents is important, espe- The goal of clinical management for priapism is to make cially in patients with cardiovascular diseases [24,25]. the continuous erection fade away and to preserve the Phenylephrine, which has been reported as the most com- ability to have erections in the future. Therefore, emer- monly used sympathomimetic, is diluted in normal saline gency evaluations to determine whether the priapism is is- to a concentration of 200∼500 μg/mL and given in 1-mL chemic or non-ischemic are required to initiate the appro- doses every 5∼10 minutes up to a maximal dose of 1 mg priate management. The differentiation can initially be until recovery from the continuous penile erection made based on the patient’s history and physical examina- [20,25]. Alternatively, ephedrine hydrochloride (5∼10 tion. Subsequently, confirmation must be obtained with mg), epinephrine (20∼80 μg), or norepinephrine (20∼ cavernous blood gas analysis and radiologic assessment. 80 μg) diluted in 5 mL of normal saline can also be used The objective in clinical management of ischemic priap- [23]. These sympathomimetics are less effective in pa- ism, which is an emergency that may result in permanent tients with ischemic priapism continuing over 6 hours be- ED, is to remove the compartment condition of the on- cause of the severe acidosis within the corpora cavernosa going cavernosal hypoxia. Conversely, non-ischemic [20]. Aspiration with the use of sympathomimetics, with or priapism is not a surgical emergency because of the ab- without corporal irrigation, can result in an increase in the sence of cavernosal hypoxia. The goal of intervention is efficacy rate for ischemic priapism of 43% to 81% [2,19]. solely to cure the persistent erection and to recover nor- 3) Surgical management mal erectile ability in response to sexual desire and Ischemic priapism continuing for more than 48 hours is activity. difficult to resolve by corporal aspiration, irrigation, and sympathomimetic injection. Thus, more immediate surgi- 1. Ischemic priapism cal shunting should be considered as another manage- Once the diagnosis of ischemic priapism has been ment option in such cases (Fig. 2). The goal of surgical made, emergency management is required. Less invasive shunting is to make an iatrogenic fistula to drain the intervention should be initiated. pooled deoxygenated blood from the corpora cavernosa. Kazuyoshi Shigehara and Mikio Namiki: Clinical Management of Priapism 5

Fig. 2. Schemes of surgical shunt- ing for the treatment of ischemic priapism. Data from Japanese So- ciety for Sexual Medicine (JSSM) Guidelines for Erectile Dysfunc- tion, Edition 2012 (JSSM, RichHill Medical Inc., Tokyo, Japan, p.87, 2012) with original copyright holder’s permission.

(1) Percutaneous distal shunting: A percutaneous dis- shunts (Quackels shunt) [33] and corpora-saphenous tal shunt, which is the procedure for creating a fistula be- shunts (Grayhack shunt) [34] can be considered, although tween the glans penis and corpora cavernosa, should be these procedures are associated with some complications attempted first, because it is easier to perform and has the including ED, local thrombus formation, and pulmonary fewest complications. Distal shunting is usually achieved embolism. The success rate of proximal shunts is 50% to by inserting a biopsy needle from the glans to the corpora 70% [2]. cavernosa (Winter’s shunt) [26], or a scalpel (Ebbehoj 4) Penile prosthesis shunt) [27]. Another type of shunting (T-shaped shunt) pro- Some previous reports mention the efficacy of a penile cedure involves inserting a scalpel into the corpora cav- prosthesis for patients with ischemic priapism not re- ernosa from the glans, followed by a 90o lateral rotation of sponding to conventional management [35,36]. As long- the scalpel and then pulling it out [28]. Pooled dark ve- term failure to treat low-flow priapism contributes to cav- nous blood and coagula should be removed out of the cor- ernosal fibrosis with resultant penile induration and short- pora cavernosa until bright red blood is revealed from the ening, immediate insertion of a penile prosthesis is recom- penile shunting wound. mended for maintaining penile length [35]. Rees et al [35] (2) Open distal shunting: The traditional surgical ap- suggest immediate penile prosthesis insertion in acute is- proach (Al-Ghorab shunting) is a dorsal subcoronal in- chemic priapism as a treatment option with minimal cision, which is performed by excising a piece of the tunica complications. albuginea at the tip of the corpus cavernosum [2,29,30]. 2. Stuttering priapism Burnett developed a technique involving dilatation of the cavernous tissue using a Hegar dilator (Burnett shunting) Stuttering priapism is a recurrent form of ischemic [31]. Some previous reports have noted that open distal priapism in which unwanted, painful erections occur re- shunting causes no more erectile failure than that caused peatedly with intervening periods of detumescence. by ischemic priapism itself, and shows excellent success Therefore, its medical management is generally equiv- rates even in patients who failed treatment with percuta- alent to that of ischemic priapism. For preventing re- neous distal shunting [29,32]. currence of stuttering priapism, hormonal therapy using (3) Proximal shunting: If distal shunts are un- gonadotropin-releasing hormone agonists, estrogens, an- successful, proximal shunts, such as corporospongiosal ti-androgens, and 5α-reductase inhibitors has been a suc-

www.wjmh.org 6 World J Mens Health Vol. 34, No. 1, April 2016 cessful medical management option [37]. term clinical observation [2,21,44]. Therefore, for cases Men with SCD have a defective PDE5 regulatory func- that fail to respond to conservative treatments, selective tion in the penis, resulting in abnormal relaxation of the angioembolization of the arterial–sinusoidal fistula should corpora cavernosa due to the release of neuronal NO [20]. be considered. Since Wear et al [45] reported a case with PDE5 inhibitors can contribute to improving unregulated non-ischemic priapism treated successfully by occlusion signaling of the NO pathway in patients with SCD, and of the left internal pudendal artery with an autologous clot, long-term efficacy of oral PDE5 inhibitors in men with several embolization materials, both temporary SCD-associated priapism without affecting normal erec- (autologous blood clot, absorbable gel, and gelatinous tile capacity has been shown [37,38]. The efficacy of PDE5 sponge) and permanent (metallic coil, n-butyl-2 cyanoa- inhibitors is usually seen within 2∼4 weeks. crylate, and polyvinyl alcohol particles), are currently In addition, insertion of a penile prosthesis for recurrent available [2,19,44-46]. Generally, temporary materials stuttering priapism in SCD has also been described as ef- are commonly used for first-line embolization because of fective in the long term [39,40]. the relatively lower subsequent incidence of ED [44-46]. Overall, angioembolization shows a high efficacy rate of 3. Non-ischemic priapism 90% [24,47,48], whereas there are reports of an unsat- As cavernous tissue shows a well-oxygenated condition isfactory curative rate of 60% to 70% by initial in non-ischemic priapism, it is not considered a medical embolization. A decrease in erectile function caused by emergency. Therefore, observation is recommended as embolism occurs in 32.0% of cases within 1 month after the initial management [2]. Some conservative treatments treatment, in 40.0% within 1∼3 months, in 16.0% within such as ice and site-specific compression to the injury are 3∼6 months, and in 12.0% after more than 6 months; fi- included as part of the observation therapy. Indeed, nally, permanent ED occurs in ＜10% of non-ischemic Hakim et al. described that ischemic priapism could be re- priapism cases. solved with no further management, and erectile function An autologous blood clot is the safest and ideal embo- of these patients could be retained sufficiently for sexual lism material because it causes only a temporary inter- intercourse with no negative sequelae [41]. A previous re- ruption of the blood flow feeding the fistula owing to its port suggested that observation can be recommended for premature lysis. Gel foam can also interrupt the arterial 6 weeks, and clinical symptoms and CDU should be blood flow temporarily, similar to a blood clot, and the ef- checked every 2 weeks [42]. However, insufficient in- fects usually last 5∼6 weeks after injection [46]. There- formation regarding conservative therapy has been avail- fore, temporary materials are initially preferred in most able. There has been no evidence to support the recom- cases. However, cases with arterial embolism using ab- mended duration of observation. Further discussion re- sorbable materials often have recurrence of priapism, with garding conservative treatment is likely to be required. the recurrence rate reported to be 30% to 40% [44-48]. Aspiration with or without injection of vasoconstrictive Permanent materials can contribute to a more durable agents is not recommended and should be used solely for occlusion than absorbable materials, which can achieve a the diagnosis of non-ischemic priapism [2]. Sympatho- lower recurrence of priapism. However, there is a risk of mimetic agents are not therapeutically effective but may post-interventional permanent ED, especially in cases of result in significant adverse effects to the cardiovascular bilateral fistula. The permanent materials should be alter- system. A temporary therapeutic response to intracaver- natively used for selected cases that fail to respond to treat- nous methylene blue, which is known to antagonize en- ment using primary temporary materials. A recent, im- dothelial-derived relaxation factors, has been reported proved technique of angiography has been shown to con- [2,43]. tribute to decreased development of ED by permanent em- Although 60% to 70% of cases with non-ischemic bolism, which has been reported to be equivalent to that priapism show spontaneous resolution, ED may occur in of temporary embolism [47,48]. approximately 30% of patients among those with long- Furthermore, hormonal agents such as anti-androgens, Kazuyoshi Shigehara and Mikio Namiki: Clinical Management of Priapism 7

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