Use of Methylene Blue and Selective Embolization of the Pudendal Artery for High Flow Priapism Refractory to Medical and Surgical Treatments

Abstract

High flow priapism is often treated effectively with intracavernous vasoconstrictive agents or surgical shunting. If these maneuvers fail treatment is unclear. A 21-year-old black man, who had failed previous pharmacological and surgical therapies, temporarily (8 hours) responded to intracavernous methylene blue, which is known to antagonize endothelial derived relaxation factor. Recurrent priapism was managed successfully by embolization of the left internal pudendal artery with absorbable gelatin sponge. Review of the literature reveals that only 7 patients have been managed with arterial embolization and our case represents the first in which intracavernous methylene blue produced detumescence.

Priapism

“…Therefore, observation has been considered as an option with the hope of spontaneous detumescence. Methylene blue which blocks the effect of nitric oxide has been tried in high¯ow states that are not due to cavernosal artery injury with some success, 34 but its use is discouraged because of the possibility of penile necrosis and formation of necrotic abscesses. 54,55 High¯ow priapism in the case of sickle cell disease is best treated with conservative measures in the same manner as low¯ow sickle cell priapism.…”

Highly selective embolization of bilateral cavernous arteries for post-traumatic penile arterial priapism

“…4,5 In case of permanent occlusion good vascularization of a single cavernous artery frequently ensures sufficient potency and the forming of collateral circulation is known to have a substantial attribution to good potency. 4,5,10 In conclusion; resorbable material, like gelfoam is the embolic agent of choice for bilateral arteriocavernous fistulas, however, sometimes occlusion can only be achieved with microcoils.…”

“…3,8,10 Transient gluteal pain is a clinical sign indicative for ischemia caused by this procedure. 10 In our case we awaited the result of the embolization on the left side, it did not resolve the priapism. We then embolized the right side which resulted in an immediate detumescence of the erect penis.…”

Priapism pathophysiology: clues to prevention

“…Pharmaceutical approaches described to offer benefit include: intracorporal thrombolytic agents, which would support the pathogenic roles of blood stasis and thrombosis, 57,58 oral diethylstilbestrol, which by exerting antiandrogenic effects would imply that androgens permit aberrant penile erection; 35 systemic injections of gonadotropin-releasing hormone analogues, which because they are also anti-androgenic would further hypotheses about the pathogenic role of androgens; 59,60 lidocaine as a penile anesthetic block, which is considered to work by blunting sensory input conveyed in the dorsal nerve of the penis of reflexive erectile pathways; 61 oral and intracorporal alpha-adrenergic agonists, which exert contractile effects on erectile tissue, thus indicating the likely pathogenic role of uncontrolled non-adrenergic factors; 24,60,62,63 intracorporal methylene blue, an antagonist of the nitric oxide/ cyclic guanosine monophosphate/protein kinase G effector mechanism of corporal smooth muscle relaxation, pointing to a possible pathogenic role of this biochemical pathway. 64,65 Basic science investigation Basic research in the field has consisted mainly of identifying and evaluating animal models featuring priapic behavior and molecular studies that suggest possible mechanisms for the disorder. Transgenic mouse models of sickle cell disease display priapism supporting the idea that disturbed penile vascular homeostasis associated with the hematologic disease is pathophysiologic.…”

“…Presently, current pharmacologic treatment successes support the roles of androgenic suppressive agents, 59,60 adrenergic agonist therapies, 24,60,62,63 and effectors of the nitric oxide-dependent erection regulatory pathway in the penis such as methylene blue. 64,65 As promising as these therapies have been, they still warrant certain considerations such as when they should be administered, whether they can be administered with minimal penile trauma and without causing adverse extra-penile effects, and whether they can be offered with a regimen that does not impair natural erections long term.…”