An Update on Non-Ischemic Priapism

Abstract

Introduction Non-ischemic or high-flow priapism is derived from unregulated arterial inflow within the penis, which is significantly less common and, therefore, less well characterized than ischemic or low-flow priapism. Aim We collected the most recent available data and summarized the findings. Methods All literature related to non-ischemic priapism from 2000–2018 from several databases was reviewed, and 105 articles, including any relevant referenced articles, were ultimately included. Main Outcome Methods We evaluated modality success rates, need for repeat procedures, and effects on erectile function. Results 237 cases of non-ischemic priapism were evaluated. Approximately 27% of patients underwent observation or medical management as the first treatment modality, whereas 73% underwent intervention without observation or medical management beforehand. Angiographic embolization with temporary agents was the most common intervention and generally resulted in both moderate resolution of non-ischemic priapism and moderate preservation of baseline erectile function. Patients who underwent embolization with permanent agents experienced higher rates of resolution, as well as lower rates of erectile dysfunction (ED). Conclusion Most of the literature is in the form of case reports and small case series, thus limiting the quality and quantity of evidence available to draw decisive conclusions. However, from the available data, it is reasonable to presume that patients can undergo a trial of conservative management, then pursue embolization first with temporary agents. The analysis of the data demonstrated ED rates were higher with temporary agents than permanent agents. The literature quotes ED rates as low as 5% when using temporary agents and 39% with permanent agents. Our results were, in fact, the opposite, with higher ED rates when using temporary agents vs permanent (17–33% vs 8–17%). Further studies are required to better characterize the success and outcomes of angioembolization.

Malignant Priapism – What Do We Know About It?

“…CT examination may be used at a later stage in order to scan for priapism etiological factors, especially if we suspect an underlying malignancy. MRI is very useful because it provides high quality images of the penile tissues, therefore offering essential information about the viability of the cavernosal smooth muscle fibers and it also allows us to appreciate the patient's outcome in terms of regaining a normal erectile function (10,23). Internal pudendal arteriography is usually used in NIP cases in order to detect an arterio-cavernosal fistula.…”

“…Considering the fact that this type of priapism does not require emergency treatment, the first-line approach consists of conservative measures such as observation (periodic clinical and CDU assessment), perineal ice packs and compression, as well as androgen deprivation therapy (gonadotropin releasing hormone agonists and antiandrogens) that aims at reducing the frequency of nocturnal penile erections, which favor the persistence of the arteriocavernosal fistula (25, 29). If the conservative treatment fails, the next step implies angiography with selective fistula embolisation using either temporary agents (autologous blood clot or absorbable gel foam) or permanent materials such as metallic coils or synthetic agents (ethylene-vinyl alcohol and N-butyl-cyanoacrylate) (21,23,30).…”

Presumptive Non-Ischemic Priapism in a Cat

“…Priapism is a penile erection lasting more than 4 h in the absence of sexual stimulation and can be classified into non-ischemic (high-flow, arterial), ischemic (low-flow, venoocclusive), and stuttering (recurrent, intermittent) subtypes [1][2][3][4][5]. Ischemic priapism is a medical emergency associated with acidosis, hypoxemia, and glucopenia within the corpus cavernosum, while the non-ischemic kind is a persistent erection resulting from unregulated arterial inflow, commonly caused by trauma, and characterized by a partially erect penis with low pain severity [1][2][3].…”

“…Continuous ischemic priapism induces permanent smooth muscle necrosis and fibrosis, which can cause smooth muscle dysfunction in the corpus cavernosum [6]. Stuttering (recurrent) priapism refers to the recurrent and painful erection and shows similar rigidity and severity of pain to that observed with ischemic priapism, but the length of erection time is relatively short [1][2][3][4][5]. Sickle cell disease is reportedly the most common causes of stuttering priapism in humans [1,2,7].…”

“…In human medicine, the European Association of Urology (EAU) and the American Urology Association (AUA) have established a diagnosis and distinguished the subtypes [1][2][3]. A thorough medical and trauma history and the onset of clinical signs are essential for the diagnosis and classification of priapism [1,2,5]. Physical examination should include the entire penis and perineal region, and rigidity, color, and scale of pain should be accurately evaluated [1][2][3][4][5].…”