Post-Papavarine Injection Priapism:Management

A 35 year old gentleman presented with painful persistent penile erection after the injection of papavarine for penile doppler evaluation .The penile doppler and the intra-corporal injection were given 12 hours before.He had erection lasting for almost 12 hours before he presented to us.

The examination revealed tender turgid erecion with glans also rigid.

He was taken up for immediate intra-corporal aspiration with 21 G scalp vein.About 200 ml dark blood was evacuated followed which red blood started coming.

Then Phenyl Epinephrine (1 ml in 20 ml----500 mcg) was injected and kept for 5 moin.Then the rigidity was seen to subside.

But the tumuscence was still there.

One more dose was given and then the scalp vein was again clamped.Now this time the penis has become totally flaccid





PRIAPISM:

Priapism is erection that persists beyond or unrelated to sexual activity. It is of two types
Low flow-This is because of priapism due to lack of outflow leading to congestion of blood in corpora and subsequent decrease in arterial flow leading to ischemia. In this there is anoxia of smooth muscle component of corpora.
PRIAPISM IS AN EMERGENCY. Any delay in the treatement will result in corporal ischemia and fibrosis. This will lead to permanent erectile dysfunction and penile deformity.
High Flow: This is due to trauma to perineum causing arteriovenous fistula and increased flow. This is not an emergency.
History-Detailed history regarding Intracavernosal Injection of Vasoactive agents, Hematological diseases, substance abuse, perineal trauma should be taken. The duration and any accompanying pain should be inquired. Any past history of priapism should be inquired.
Clinical examination-

Very Important to feel for any Malignant induration (metastases causing priapism), Bruit in perineum (trauma related high flow priapism). These obviously pinpoint to aetiology and help in treatment.
Invstigations:
1) Duplex Doppler Ultrasound-to differentiate between low and high flow priapism. Duplex ultrasound will reveal low flow and constricted cavernosal artery while in high flow the flow will be turbulent indicative of arteriovenous fistula.
2) Cavernosal Blood gas Analysis (Important) Ph< 7.25, pCO2>60,pO2>30 (Low Flow).The arterial blood gas picture is reverse in High Flow variant. This is an important necessary tool because it definitively pinpoints the type of priapism. It involves aspiration of blood from the corpora and sending it to ABG analyser(usually present in ICU)
Management

Low flow variety
1) Hematological disorders-Always hydrate the patient first
2) If Priapism less than 4 hours-Intracavernosal Injection of Phenylephrine bolus 500mcg repeated after 5 minutes. Importantly patient’s vitals should be kept on monitoring.
3) If priapism more than 4 hours-Drain one corpora with 21 G scalp vein with aspiration to remove old anoxic blood and inject a bolus of Phenylephrine ( 1 ml of Phenylephrine with 19 ml Normal saline mixture).The scalp vein should be clamped for 5 minutes. Repeat the procedure if there is no response.
4) Alternatively drain the corpora with 20 G scalp vein passively and let the blood drain out on its own. Initially the drained blood is dark anoxic slowly once the smooth muscle component of the corpora recovers red blood oozes out and that is the end-point of the drainage.

5) No response-------Send to Andrologist for Performance of corpora-glanular shunt (AL GHORAB SHUNT) .This procedure is simple .It can be done under penile block anaesthesia. It involves peroration of the corpora cavernosa through spongiosum (glans).This is followed by dilatation of the fenestration by Hegar´s dilator. The aim is to allow drainage of anoxic cavernosal blood into relatively supple spongiosum. The glans wound is then closed .This procedure is safe and quick.

High flow variety:
Initially conservative treatment like application of pressure packing, ice packing, use of adrenergic agents as written above. If these measures fail then Internal pudental angiography and angioembolisation is the treatment.
Stuttering Priapism:
Many patients, especially children, have a pattern of multiple short episodes over a period of days or several weeks. The priapism is often normal flow and prognosis is generally good and therapy is conservative. If the episode lasts longer and turns painful; then it should be like low flow variety. The long term prevention can be done with Baclofen 40 mg at the bed time.